Full text of "Medical Journal of Australia"

THE

MEDICAL JOURNAL

OF AUSTRALIA

IN TWO VOLUMES ANNUALLY

DS/28

17.1

The following issue(s) is/are missing and
unobtainable

Date of collating . . . ./. . .&gt;. .&lt;:. .* .

-1946

) JUNE

(Sydney), F.R.A.C.P., F.R.A.C.S.

SYDNEY

AUSTRALASIAN MEDICAL PUBLISHING COMPANY- LIMITED
1946

THE

MEDICAL JOURNAL

OF AUSTRALIA

IN TWO VOLUMES ANNUALLY

Volume I- 1946

JANUARY TO JUNE

EDITOR:

MERVYN ARCHDALL, M.D., Ch.M. (Sydney), F.R.A.C.P., F.R.A.C.S.

SYDNEY

AUSTRALASIAN MEDICAL PUBLISHING COMPANY. LIMITED
1946

KEY TO DATES AND PAGE NUMBERS.

Number.

Date.

Pages.

January 5

1 to 32

January 12

33 to 64

January 19

65 to 96

January 26

97 to 132

February 2

133 to 168

February 9

169 to 204

February 16

205 to 240

February 23

241 to 276

March 2

277 to 312

March 9

313 to 348

March 16

349 to 384

March 23

385 to 420

March 30

421 to 456

April 6

457 to 492

April 13

4!&gt;3 to 536

April 20

537 to 572

April 27

573 to 608

May 4

609 to 644

May 11

645 to 680

May 18

681 to 716

May 25

717 to 752

June 1

753 to 7S8

June 8

789 to 824

June 15

825 to 860

June 22

861 to 896

June 29

897 to 932

VOL. I, 1946.

INDEX TO THE MEDICAL JOURNAL OF AUSTRALIA.

INDEX TO VOLUME I, 1946.

JANUARY TO JUNE

In this index (C.C.) indicates current comment : ((&gt;) indicates an original article; (R) indicates a report of case; (rev.), a review.

Page
A

Abbie, A. A. Anatomy in the Medical

Curriculum (O) 152

Abdomen, Gunshot Wounds of the,
Early Results in a Short Series
of Cases of, by T. F. Rose, A.
Newson and D. Watson (O) . . 180

Abnormalities, Congenital, in Infants
following Infectious Diseases
during Pregnancy, with Special
Reference to Rubella : A Third
Series of Cases, by C. Swan and
A. L. Tpstevin (O) 645

Aborigines in the Northern Terri
tory, A Sociological Study of the,
and their Eye Diseases, by M.
Schneider (O) 99

Abortion, Childbirth and, Infections
due to Streptococcus Hsemolyticus
Group A following, Stained
Smears for the Rapid Diagnosis
of, by H. M. Butler (O) .... 437

Abscess, Putrid Lung, by C. .T.

Officer Brown (O) 107

Abstracts from Medical Literature
Authors

Abrahamsen, D 343

Adams, M. L., Frobisher and

Kuhns 780

Allan, J. H 522

Allen, A. C., and Spitz 484

Altwie-Werber, E., Loewe and

Rosenblatt 161

Anderson, w. A. D., Pinkerton

and Smiley 88

Appleton, A. B 88!)

Armstrong, C. D., Bloomfield and

Kirby 376

Atkinson, J. D., and Wilson . . 376

Atkinson, W. B., and Elftman . . 89

Aynsley, T. R 305

Babudieri, B., and Bietti 304

Bacsich, P., and Wyburn 485

Bagby, J. W 812

Baker, R. D 888

Banerjee, S 121

Banner, E. A., arid Dockerty ti:!4, 888

Barach, A. L., ct alii 342

Barbara, D. A 343

Beikenstein, N., and Gold .... 343

Bennett, A. E 343

Bietti, G. B 304

Bigelow, R. R., Bruschwig and

Ricketts 194

Bishop, G. H 485

Blain, A. W., and De Matteis . . 596

Blair, H. A., and Wedd 924

Blair, J. E., and Buchman .... 597
Blank, I. H., Lane, Rockwood

and Sawyer 812

Bloch, K., and Rittenberg .. 121.925

Blomfield, L. B., and Clark 89

Bloomfield, A. L., Armstrong and

Kirby 376

Blum, G., and Wakeley 342

Bodian, D., and Howe 781

Bogen, E., and Margraves 413

Boisvert, I 1 ., Rantz and Spink . . 252

Borak, J., and Taylor 449

Blumgart, H. L 161

Boyd, R. W 377

Bridgman, C. S., and Smith . . 889

Britton, S. W., and Kline 924

Brown, J. B., and Orians 925

Brown, P. N., Salk, Pearson,

Smyth and Francis 781

Bruschwig, A., Ricketts and

Bigelow 194

Buchman, J., and Blair 597

Bugbee, H. G 25

Burke, G., and Canter 161

Burrows, A., Russell and May . . 24

Buschke, F., and Cantril 449

Camiel, M. R 852

Camp, J. D., and Moreton 57

Page

Abstracts from Medical Literature
Continued.

Authors Continued.

Candel, S., and Wheelock 556

Canter, M. M., and Burke 161

Cantril, S. T., and Buschke .... 449

Caro, M. R., and Stubenrauch . . 412

Castillo, J. C., and Stiff 523

Clark, W r . B. Le Gros, and Blom
field 89

Clarkson, J., and Lederman .... 853

Clayton, S. G 232

Cleveland, D., and Kindwall .... 343

Cohen, H. M., and Pfaff 412

Collom, S. A., and Ewing .... 596

Comfort, M. W., and Kelsey . . 88

Corber, A. A 233

Costello, M. J., and Landy 24

Counceller, V. S., and Pratt . . 25

Couper, E. C. Ross 672

Crimm, P. D., and Westra 556

Curtis, A. C., Teitelbaum and

Goldhamer 88

Custer, M. D., and Waugh 597

Cutting, W. C., and Dobson ... 744

Daland, E. M 597

Daly, D 745

Davalos, A 813

Davies, D. V 485

Davies, J. A. V., and Hutchings 672

Davison, C., and Demuth 889

Dawson, A. B 89

De Matteis, A., and Blain 596

Demuth, E. L., and Davison .... 889
Denny, E. R., Khallenberger and

Pyle 744

De^wiler, S. R 889

Dick, T. B. S 745

DiLeone, R., and Waterman . . 449

Dixon, G. J., and Dick 745

Dobes, W. L., Franke and

Romano 812

Dobson, L., and Cutting 744

Dockerty, B., and Banner 888

Dockerty, M. B.

And Banner 634

Hodgson and Muspey 634

Ducharme, P 448

Dudley, M. G., and Walton .... 781

Dyer, H. F 635

Eaton, R. M., et alii 597

Edlin, J. V., Johnson, HIetko and

Heilbrunn 744

Eggers, S. W. N 673

Eichwald, M., and Singletary . . 852

Elbel, E. R., and Green 924

Elftman, H., and Atkinson .... 89

Eller, G. H., and Frobisher 780

Elliott, H. W., and Norris .... 120

Elliott, S. D 376

Emmel, V. M 89

Enders, J. F 780

Epstein, B. S 448

Erickson, L., Taylor, Henschel

and Keys 522

Ewing, W. M. D., and Collom .. 596

Falk, A., and Nicholson 557

Farmer, C. J., Hagens and Karp 305

Feinberg, S. M., and Friedlaender 744
Feldman. W. H., Hinshaw and

Pfuetze 556

Field, J. B., ct alii 523

Fields, H 233

Fitzpatrick, F. K 780

Flippin, H. F.

Reinhold and Phillips 342

Zintel, Nichols. Wiley and

Rhoades 744

Florey, M. E., McFarlan and

Mann 304

Forbes. W. H., Sargent and

Roughton 120

Francis, T., junior. Salk, Pear
son. Brown and Smyth 781

Franke, A. G., Dobes and

Romano 812

Page

Abstracts from Medical Literature

Continued.
Authors Continued.

Freed, S. C 160

Freeman, W., and Watts 343

Friedlaender, S., and Feinberg . . 744
Friedman, A. P., and Merritt . . 342

Friedman, N. B 484

Frobisher, M., junior

Adams and Kuhns 780

And Eller 780

Frost, K., and Obermayer .... 412
Galindo, P., Hammon and Reeves 781

Gardner, J., et alii 925

Gates, O., and Warren 888

Gericke, O. L 744

Gibson, D. M 377

Gillan, R. U 304

Gold, L., and Beikenstein .... 343

Goldberg, L. C. . . 812

Golden, R., and Ducharme .... 448
Goldhamer, S. M., Teitelbaum

and Curtis 88

Goldstein, J 709

Goodall, J. R 233

Goodof, I. 1 88

Gordon, H. H 812

Gorro, A. P 813

Gortner, W. A 121

Goyanna, R., and Greene 813

Graham, M. P., and Small 597

Gralnick, A 745

Gratzek, F. R., and Stenstrom . . 57

Gray, D. J 89

Green, E. L., and Elbel 924

Green, M. J., and Hamburger 376, 780
Greene, L. F 413

And Goyanna 813

Groat, R. A., Rambach, junior,

and Windle 596

Grolnick, M., and Loewe 376

Hagens, E. W., Karp and Farmer 305
Hale, C. H., and Robbins . . 56, 448

Hall, A 70S

Hall, I. Simpson 709

Halperin, M. H., McFarland and

Niven 522

Hamburger, M., junior

Hamburger and Green . . 376, 780

I uck and Robertson 377

Puck, Robertson and Hurst . 377

Hamburger, V. C 376

Hammon, W. McD., Reeves and

Galindo 781

Hansson, C. J 57

Hauser, I. J., and Work 305

Heilbrunn, O., Edlin, Johnson

and HIetko 744

Helwig, F. C., and Read 160

Hemphill, J. E., and Reeves . . 57

Henderson, J 412

Hendry, A. M 253

Henschel, A., Taylor, Erickson

and Keys 522

Herrin, R. C., and Meek 522

Herzog, E. G 253

Hilding, A. C 708

Hinshaw, H. C., Feldman and

Pfuetze

Hirshfeld, J. W

HIetko, P., Edlin, Johnson and

Heilbrunn

Hodgson, J. E., Dockerty

Mussey

Hogan, G. F

Hone, E. L., et alii

Horn. R. C., Pendergrass and

Lafferty

Howe H. A., and Bodian

Howell. T. H

Hurst, V., Puck, Hamburger and

Robertson

Hutchings, G., and Davies

Hutter, A. M., and Parkes ....

Jackman, J., and Luhert

Jaffe, H. L

and

556
195

744

634
557

925

781
5 5 7

377

672

233

852

INDEX TO THE MEDICAL JOURNAL OP 1 AUSTRALIA.

VOL. I, 1946.

I age
Abstracts from Medical Literature

Continued.
Authors Continued.

Johnson, B. C., et alii 523

Johnson, H. K., and Larsener . . 343

Johnson, H. W 635

Johnson, R. H., Edlin, Hletko

and Heilbrunn 744

Kaplan. K. B 889

Karp. M., Hagens and Farmer . . 305

Kay, &lt;;. A., and Williams 120

Keeper, C. S 342

Keitzer, W. A., Nesbit and Lynn 813
Kelsey, M. P., and Comfort .... 88

Kennedy, C., and Palmer 121

Kerr, W. J., and Ralston 924

Keys, A., Taylor, Erickson and

Henschel 522

Kickham, C. J. E 413

Kindwall, J. A., and Cleveland . 343
Kirby, W. M., Bloomfield and

Armstrong 376

Klein, B. V., and Stettin 523

Kline, R. F., and Britton 924

Krieg, E. G 634

Kuhns, W. J., Frobisher and

Adams 780

KunMler, W. E 557

Kuyper, A. C 523

Laestar, C. H., and Phemister . 194
Lafferty, J. O., Pendergrass and

Horn 56

Lam, C. R 57

Landy, S., and Costello 24

Lane, C. G., Rockwoocl, Sawyer

and Blank 812

Larsener, R., and Johnson . . . 343
Lederman, M., and Clarkson . . 853

Lehr, D 813

Leslie, A., and Silverman 744

Leuceutia, T 853

Levinson, S. O., Milzer and Lewin 781
Lewin, P., Levinson and Milzer 781

Lewis, B. O., and Sodeman 744

Light. R. U., and Prentice 596

Limarzi, L. R., and Wolff 233

Loewe, L.

Altwie-Werber and Rosenblatt 161

And Grolnick 376

Lubert, M., and Jackman 56

Lucic, H 708

Luecke, R. W., and Pearson ... 121
Lynn, J. M., Nesbit and Keitzer 813
MacFarland, M. L., and McHenry 523

Maegraith, B. G., et alii 557

Magoun, H. W., and Wilson . . . 889
Mandeville, F. B., and Nelson . . 25
Mann, I., Florey and McFarlan 304

Manter, J. T 889

Margraves, R. D., and Bcgen . . . 413

Marks, M. B 252

Maroun, T., and Monnerot-

Dumaine 484

Martin, H., and Reese ! 304

Martinez, D., and Visscher . . 522

Mapsie, F. M 194

Mathe, C. P . . . . 25

May, H. B., Burrows and Russell 24

McAdam, I. W. J 597

McCarty, M 376

McClosrky, W. T., and Smith . . 377

McCulloch, C 708

McCutchan, G. R 160

McDonald, J. R., Moersch and

Tinney 888

McFarlan, A. M., Florey and

Mann 304

McFarland, R. A., Halperin and

Niven 522

McHenry. E. W., and Mac
Farland 523

McLoughlin, C. J., and Paulin . 342

McShan, W. H., et alii 925

Meek, W. J.. and Herrin 522

Meekison, D. M 673

Merritt, H. H., and Friedman 342

Mills, C. A., et alii 925

Milzer, A., Levinson and Lewin 781

Mitchell, H. H., et, alii 121

Moersch, F. P., and Stark 745

Moersch, H. J., Tinney and

McDonald 888

Moeys, E. J., and Tordoir .... . 673

Mohanty, J. K 161

Monnerot-Dumaine, M., and

Maroun 484

Moore, T 813

Morehead, R. P., and Woodruff . 888
Moreton, R. D., and Camp .... 57

Morrison, L. M 556

Morton, D. G., and Newgard .... 232

Morton, J 195

Munger, A 852

Page

Abstracts from Medical Literature

Continued.
Authors Continued.

Murphy, R. J., Romansky and

Rittmann 160

Murray, N. A 88

Mussey, R. D., Hodgson and

Dockerty 634

Nelson, C. M., and Mandeville . . 25
Nesbit, R. M., Keitzer and Lynn 813

Newgard, K., and Morton 232

Nichols, A. C., Zintel, Flippin,

Wiley and Rhoades 744

Nicholson, C S89

Nicholson, J. H., and Falk 557

Niven, J. I., McFarland and

Halperin 522

Norrie, E. R., and Elliott 120

Novak, E., and Stevenson 484

Noyes, R. W 634

Obermayer, M. E., and Frost . . 412

Olsen, A. M., and Tinney 5C7

Ordstrand, V., Thomas and

Tomlinson 557

Orians, B. M., and Brown 925

Osten, J. M., et alii 925

Ostow, M 745

Overholt. R. H 161

Page, I. H., and Taylor 161

Palmer, L., and Kennedy 121

1 arkes, J., and Hutter 233

Paterscn, M. T 745

Paul, H. E., et alii _.. 121

Paulin, J. E., and McLoughlin . 342

Peacher. W. G 744

Pearson, H. E., Salk, Brown,

Smyth and Francis 781

Pearson. P. B., and Luecke .. 121
Pendergrass, E. P., Lafferty and

Horn 56

Pendergrass, R. C 56

Perkins, J. F., junior 924

Perry, C. B 557

Peterkin, C. A. Grant 24

Peterson, L. W 195

Pfaff, R. O., and Cohen 412

Pfahler, G. E 853

Pfuetze, K. H., Hinshaw and

Feldman 556

Phemister, D. B., and Laestar . 194
Phillips, F., Reinhold and Flippin 342

Pick, J. F 195

Pinkerton, H., Smiley and

Anderson 88 i

Poth, E. J 194

Potter, E. L 635 |

Pratt, J. H., and Counceller . . 25
Prentice, H. R., and Light .... 596

Proom, H 376

Puck, T. T.

Hamburger and Robertson . . 377

And Hurst 377

Pugh, D. G 56

Pyle, H. D., Shallenbrger and

Denny 744

Ralston, H. J., and Kerr 924

Rambach, W. A., junior, Groat

and Windle 596

Ransohoff, N. S 342

Rantz, L. A., Spink and Boisvert 252

Read, J. T., and Helwig 160

Reese, A. B., and Martin 304

Reese, E. C 194

Reeves, R. J., and Hemphill . . 57
Reeves, W. C., Hammon and

Galindo 781

Reinhold, J. G., Phillips and

Flippin 342

Resenberg, R. . . . T 343

Resnick, L 233

Revens, W. S 160

Rhoades, J. E., Zintel, Flippin,

Nichols and Wiley 744

Rhoden, A. E 484

Rice, E. E., et alii 121

Ricketts, J. T., Bruschwig and

Bigelow 194

Rittenberg, D., and Bloch . . 121, 925
Rittmann, G. E., Romansky and

Murphy 160

Robbins, L. L., and Hale ... 56, 448
Robertson, O. H., Hamburger

and Puck 377

Robinson, S. S., and Tasker .... 812
Rockwood, E. M., Lane, Sawyer

and Blank 812

Rogers, H. M 88

Romano, D., Franke and Dobes . 812
Romansky, M. J., Murphy and

Rittmann 160

Rosenblatt, R., Loewe and

Altwie-Werber 161

Rosenwasser, H 305

Page
Abstracts from Medical Literature

Continued.
Authors Continued.

Ross, S. G 252

Rothbard, S 376

Roughton, F. J. W., Forbes and

Sargent 120

Ruben, J. A., and Tipson 925

Russell, B., Burrows and May . . 24
Russell, W. O., Stowell and

Sachs KS8

Sachs, E., Stowell and Russell 888
Salk, J. E., Pearson, Brown,

Smith and Francis 781

Sarett, H. P 523

Sargent, F., Forbes and Roughton 120
Sawyer, C. S., Lane, Rockwood

and Blank 812

Schachter, R. J 120

Scharrer, E 89

Senturia, B. H 709

Shallenberger, P. L., Denny and

Pyle 744

Phalom, E. S 556

Shorr, E 413

Silber, R. H 523

Silverman, D. N., and Leslie . . 744

Simpson, S. A., and Young 485

Singer, R 709

Singletary, W. V., and Eichwald 852

Small, J. M., and Graham .... 597
Smiley, W. L., Pinkerton and

Anderson 88

Smith, G. Harvey 232

Smith, K. U.. and Bridgman .... 889

Smith, M. I., and McClosky 377

Smyth. C. J., Salk, Pearson,

Brown and Francis 781

Snell, A. C 304

Snyder, J. C., and Wheeler .... 780

Sodeman, W. A., and Lewis . . . 744

Spealman, C. R 924

Speed, J. S 253

Spink, W. W., Rantz and

Boisvert 252

Spitz, S., and Allen 484

Stark, F. M., and Moersch ... 745

Stenstrom, K. W., and Gratzek . 57

Stetten, D 121

And Klein 523

Steven, R. A 161

Stevenson, R. R., and Novak . . 484

Stiff, H. A., and Castillo 523

Stocker, F. W 708

Stowell, R. E., Sachs and Russell 888

Stubenrauch, C. H., and Caro .. 412

Sunderland, S 89

Tasker, S., and Robinson 812

Taylor, H. K., and Borak ..... 449
Taylor. H. L., Erickson, Henschel

and Keys 522

Taylor, R. D., and Page 161

Teitelbaum, M., Curtis and Gold-

hamer 88

Tenennt, W 448, 673

Thomas, J. W., Ordstrand and

Tomlinson 557

Thome, F. C 745

Tinney, W. S.

And Olsen 557

Moersch and McDonald 888

Tipson, R. S., and Ruben 925

Tomlinson, C., Thomas and

Ordstrand 557

Tomnkins, P 634

Tordcir, B. M., and Moeys .... 673

Tuhy, J. E., and Welch 596

Turnbull, J. A 161

Van Buskirk. C 485

Van Harreveld. A 522

Vastine, J. H. and M. F 25

Vaughan, W. W 56

Visscher, M. B., and Martinez . 522

Wagman, O. H 70S

Wakeley, C. P. G., and Blum . . 342

Walker-Taylor, P. N 161

Walls, E. W 485

Walton, C. H. A., and Dudley . . 7 81

Warren, S., and Gates 888

Waterman, G. W., and DiLoone 449

Watts. .T. W., and Freeman . . 343

Waugh, J. M., and Custer .... 597

\Vedd, A. M., and Blair 924

Weinstein, L., and Wesselhoeft . 557

Welch, C. S., and Tuhy 596

Welch, P. B 556

Wesselhoeft, C., and Weinstein . 557

Westra, J. J., and Crimm .... 556

Wheeler, C. M., and Snyder . . 780

Wheelock, M. C., and Candel . . 556

Wiener, A. S 781

Williams, R. H., and Kay .... 120
Wiley, M. M., Zintel, Flippin,

Nichols and Rhoades 744

Vol.. 1, 1946.

INDEX TO THE MEDICAL JOURNAL OF AUSTRALIA.

Page
Abstracts from Medical Literature

Continued.
Authors Continued.

Wilson, A. K $52

Wilson, G. S., and Atkinson . . :!7(i
Wilson, W. C., and Magoun .. 889
W indie. W. F., Groat and

Rambach 59G

Wolf, A. V 120

Wolff, J., and Liniarzi 233

Woodruff, \V. JO., and Morehead S88

Woolley, D. W 121

Work, \V. P., and Hauser 305

Wyburn, G. M., and Bacsich .. 485
Voting-, J. Z., and Simpson .... 485

Xachary, K. B 590

Zintel, II. A., Flippjn, Nichols.

Wiley and Rhoades 744

Bacteriology and Immunology 370, 780
Body .Louse, Human, Experi
mental Infection of the, with

Typhus Strains 780

Carriers, Dangerous, of Haemo-

lytic Streptococci 780

Diphtheria in Baltimore 780

Endocarditis. Bacterial -

And Penicillin 37(j

Subacute, 1 m m u n o 1 o g i c a 1

Studies in :&gt;,7G

Mumps. Immunity in 780

Penicilllnase 376

I neumococcal Types, Transfor
mation of 370

1th Sensitization, Test for 781

Staphylococcus Aureus, Phage

Typing of 370

Streptococci

Group A, Bacteriostatic Effect
of Human Serum on . . 370

Group A, Proteolytic Enzyme

Ihemolytic, Dangerous Car
riers of

Typhus, Kickettsial Agglutina
tion in

Biochemistry 121, 523,

Acetic Acid

Alloxan ] 21,

Anoxia

Biotin 121,

Body Composition

Bone Formation

Calcium Pantothenatc

Cholinc

DDT

Endocrine Tissues

Fatty Acids

Fatty Liver

Folic Acid

(Jalacto.sc

&lt; ilycogenesis

Haematopoiesis

Human Milk Fat

Lipidea

Pantothenie Acid

Plasma Fibrinogen

Thiamin Requirements

Vitamin E

Vitamins in Muscle

Wound Healing

Dermatology &gt; (, U 2,

Dermatitis Exfoliativa following

Arsphenamine Therapy

Dermatoses of the Hands

Ihemangioendothelioma of ill 1

Skin

fehthyosis, Treatment of

Lupus Krythematosus

Penicillin

Allergic Reactions during the
Administration of

In Dermatological Therapy ..

In the Treatment of Cutaneous

Disease

Skin, Colloid Degeneration of the
Sulphonamides, Skin Eruptions

due to the Application of

Sycosis Barbae. The Treatment of,

with Penicillin Cream

Tropical Disease, A, Resembling

Lichen J Maims

Vitamin Therapy in Dermatology

( iymecology 232.

Chorionepithelioma, Extragenital

KMrophy of the Bladder with
1 rocidentia

Fallopian Tube, Surgical Ob
struction of the

Granulosa-Cell Tumour of the
Ovary

Haemorrhage, Vaginal, in Women
Aged Over Fort\ Years ....

370

925
121
925
925
925
121
523
523
121
523
925
925
523
523
121
523
925
925
121
523
523
925
121
121
121

S12

112
812
812

S12
812

24
24

812
412

634
233

232
034
634

034

Page
Abstracts from Medical Literature

Continued.
( lynaecoiogy Continued.

Ovulation. Basal Body Tempera
ture Graphs as an Index to .. 034
Theca-Cell Tumours of the Ovary 034
Tuberculosis and Cancer of the

Uterus, Coexisting 232

Uterine Polypi 232

Hygiene 377, 781

Encephalitis, An Epidemiological

Study of 781

Fungous Spores, Air-Borne, in

Manitoba 7S1

Influenza Vaccination, Effect of,

One Year Later 781

I oliomyelitis

Experimental, E f f e c t of
Fatigue, Chilling and Mech
anical Trauma on Resistance

to 781

Transmission of, The, to
Rhesus Monkeys by Acci
dental Laboratory Infection 781
Streptomycin and "Promin" in

Experimental Tuberculosis . . 377
Triethylene Glycol Vapour in

Hospital Wards 377

Tuberculosis. Prevention of .... 377
X-Ray Survey. An, of Healthy
Troops in Canada 377

Medicine 1 GO, 550

Allergy, Respiratory, and Un
resolved Pneumonia 101

Arterial Thickening 557

Bronchiectasis 557

Feeding Reflex, Gastric, Distur
bances (if the 55G

Gonorrhoea, The Treatment of,

with Penicillin in Oil 100

Haemorrhage, Impending Cerebral 101
Hypertension, Malignant, Cured

by Nephrectomy 557

Meningitis, Purulent, Hypertonfc
Solutions in the Treatment of 550

Mononucleosis, Infectious 100

Myocardial Infarction. Acute,
The Relation ot Effort to

Attacks of 101

Myocarditis, Acute 556

Night Cramps 557

Oleothorax in the Treatment of

Tuberculous Empyema 550

I aracentesis of the Chest 557

Penicillin, The Rectal Adminis
tration of 101

Peptic Ulcer 550

Pleural Effusion 557

Pneumonia, Non-Tuberculous,

Complicating Tuberculosis . . 557
Premenstrual Distress, The
Treatment of, and the Andro-

gens loo

Pruritus Ani 100

Scarlet Fever 557

Simmond s Disease, The Treat
ment of, with Male Sex Hor
mones 101

Sprue, Carbohydrate Absorption

in 557

Thiouraeil Therapy in Thyreo-

to.xicosis 100

Tuberculosis 550

Pulmonary, Lobectomy and

Pneumoneetomy for 161

Ulcer

Peptic, .Etiology of 101

Tropical 101

Whooping Cough, Maternal Blood
in 101

Morphology Nil, 485, 889

Anastomoses, Arterial, Efficiency

of Intramuscular 89

Argentattin Cells of the Stomach 89
Blood Vessels of Nervous Tissue SO
Carrying Angle of Human Arm 89
Cells, Absorbing, of the Small

Intestine $9

I i pus Callosum, Perception and

the Ns :&gt;

Extensor D gitorum Communis,

Insirt oiis of 889

Hamstring Muscles. Anomalous S9
Heart, Human. Conducting Sys
tem in 485

Light, Mechanical Ucsponses of

K .-tina to SS9

Lungs. Arteries and Veins of the 889
Meningeal Relations nf Hypo
physis v.i

Muscles, Intel-osseous, of the
Human Foot SS9

Page
Abstracts from Medical Literature

Continued.
Morphology Continued.

Nerve Regeneration, The Effect
of Interference with Blood

Supply on 485

Nerve. The Seventh Cranial

(Facial) 485

Nerves, Visceral and Somatic,

Regeneration of 485

Olivary Nucleus, The Inferior . 889
1 civic Brim, Female, Two Main

Diameters of 889

Skin, Regeneration of 485

Sleep Centres in the Cortex .... 889
Synovial Fluid, The Cell Con
tent of 485

Neurology and Psychiatry . . . 342,

Alcoholic Personality, Neurotic
Character Structure of the . .

Alcoholism, Chronic, The Con
ditioned Aversion Treatment
in

Criminal Behaviour, Psycho-
dynamics in

Cup, Physiological, of the Optic
Disk, The Depth of the, and
Mental Ability

Delirium Tremens, Psychogenesis
in

Electroshock Treatment. A
Fatality Incident to

Headache following Injuries to
the Head

Lobotomy, Prefrontal

Lupus Erythematosus, Acute
Disseminate, Central Nervous
System in

Organic Deterioration

Radiculitis, Acute Brachial ....

Sclerosis, Primary Lateral ....

Senile and Arteriosclerotic Men
tal Patient, Problems of the .

"Shock" Therapies, An Evalua
tion of the

Speech Disorders in the Second
World War

Torticollis, Spasmodic

"Tridione", The Anticonvulsant
Action of

Obstetrics 233,

Anaemia in Pregnancy

Infection, Uterine Defence
Mechanism against

Penicillin, The Transmission of,
through the Placenta

Placenta Praevia, The Conserva
tive Management of

"Prostigmin" as a Test for Early
Pregnancy

Stilboestrol, The Influence of, on
Lactation . . . ...

Toxaemia of Pregnancy, Late . . .

Vitamin K Administered during
Labcur, The Effect on Infant
Mortality of

Ophthalmology 304,

Blepharitis, Marginal

Blinking

Cataract Incisions, Closure of .

Corneal Ulcers, Insulin Treat
ment of . . . .

Disciform Degeneration of the
Macula

Eclipse Blindness

Glaucoma, Diathermy for

Hypotropia

Injuries, Perforating

Lysbzyme

Retinoblastoma, Bilateral

Strabismus Treated Orthopti
c-ally

Orthopaedic Surgery 253,

Air Arthrography in the Diag
nosis of Torn Semilunar Car
tilage

Colics Fractures, Treatment of

Ma limited

Dislocation, Chronic, of the Base
of the Metacarpal of the

Thumb

Fractures

Kunt seller Method, The, of

Treatment of

of Long Bones, The Treat
ment of Non-Union or De
layed Union of

Oateoarthritia as an Ortho
paedic Problem

Plasmocytoma of Bone

744
343

745
343
745
342

&gt; ,J *J

745
343
745
745

744
745

635
233

708
304

708
708

305

708

70S
7ns
708
304
304
304

INDEX TO THE MEDICAL JOURNAL OF AUSTRALIA.

VOL. I, 1946.

Page

Abstracts from Medical Literature -
Continued.

Oto-Rhino-Laryngology 305, 709

Acetylsalicylic Acid: A Probable
Cause for Secondary Post-
Tonsillectomy Haemorrhage . . 709
Aircraft Noise, Effect of, on

Hearing 709

Fenestration of the Labyrinth . . 709
Otitis, External, Treatment of . 709
Penicillin Therapy by Inhalation 305

Sinusitis arid Penicillin 305

Thrombophlebitis, Lateral Sinus 305

Paediatrics 252, G72

Neo-Natal Life, Sonic Problems

of 252

Penicillin in infections of Infancy 672
Penicillin Treatment

Of Oral Inflammations in

Childhood 252

Of Pneumococcus Meningitis

in Infants 672

Rheumatic Fever, The Treatment
of, with Penicillin 252

Pathology 88,484,888

Adenoma of the Bronchus 888

Burns, Internal Lesions in 888

Carcinoma of the Uterus, The

Vaginal Smear in Diagnosis of 888
Chorionepithelioma, Primary In-
tracranial, with Metastases to

the Lungs 888

Endarteritis, Subacute Bacterial
(Streptococcus Viridans) Pul
monary 484

Glomerulosclerosis, Intercapillary 88
Liver Function Tests, The Com
parative Value of Several .... 88
Lymphoma, Solitary Giant Fol-
licular, of the Vermiform

Appendix 888

Myasthenia Gravis, Tumours of

(he Thymus in 88

Neutropenia, Primary Splenic . . 88
Occlusion of the Hepatic Veins 88

Paraganglioma, Malignant 484

Pneumonia, Giant-Cell, with In
clusions 88

Scrub Typhus (Tsutsugamushi

Disease) and Other Riekett-

sial Diseases, A Comparative

Study of the Pathology of . . 484

Sweat Gland Tumours of the

Vulva 484

Theca-Cell Tumours of the

Ovary 888

Trench Foot, The Pathology of . 484

Physical Therapy 57,449,853

Anaesthesia, Refrigeration 57

Carcinoma

Cervical, Treated by Inter
stitial Radium Implanta
tion 44 J

Mammary, Survival after X-

Ray Therapy of 57

Of the Oesophagus, Radium

Treatment of 853

Hsemangioma, The Treatment of 853
Marie-Striimpell Disease, Ront-
gen irradiation in the Treat
ment of 57

Rontgen Therapy of Bladder

Carcinomata 449

Sarcoma, Kaposi s 57

Ureteral Obstruction, The Ques
tion of, by Irradiation 853

X-Ray Therapy in Advanced

Rheumatoid Arthritis 449

Physiology 120, 522, 924

Anoxia, Age, Sex, Carbohydrate,
Adrenal Cortex and Other

Factors in 924

Arsenic Trioxide, Tolerance to,

in the Albino Rat 120

Arsenite, The Effect of, on the

Respiration of Rat Tissues .. 120
Blood Flow in Hands, Effect of
Ambient Air Temperature and

of Hand Temperature on 924

Blood Volume of Normal Young
Men, The Effect of Bed Rest

on the 522

Calcification, Traumatic : A Pre
cipitating Factor in "Bends"

Pain 522

Carbon Monoxide Uptake, The

Rate of, by Man 120

Cholinesterase, Use of, in Shock 120
Dehydrating Effect, The, of Con
tinuously Administered Water 120
Muscle Fibres, Degenerated, Re-
innervation of, by Adjacent
Functioning Motor Units . . 522

Page

Abstracts from Medical Literature
Continued.

Physiology Continued.

Nerves, Afferent, Excited by In
testinal Distension ......... 522

Pulse Reaction to Step-Up Exer
cise on Benches of Different
Heights

924
924

Shivering, Role of Proprioceptors
in ........................

Skin Temperature Responses to
Local Heating, Observations
wn ........................

Ihiourea, Absorption, Distribu
tion and Excretion of .......

Vascular Responses of the Nasal
Mucosa to Thermal Stimuli . .

Venous Return, The Action of
Cardiac Ejection on ......... 924

Visual Thresholds as an Index
of the Modification of Anoxia
by Glucose ............... 522

522
120
924

Radiology .............. ,-&gt;(;, 44^

Amoeblasis, The Clinical Signifi
cance of Deformity of the
Caecum in .................

Calcification in the Ascending
Aorta ....... ..............

Carcinoma of the Prostate,

Treatment of, by Irradiation .
Collapse of the Lung, Lobar and

Segmental .................

Radiographic Appearance of
Fistula, Arterio-Venous, Cardiac

Changes in ................

Gastritis, Antral, Radiological

and Gastroscopic Findings in
Gaucher a Disease, The Early

Radiological Diagnosis of . .
Leontiasis Ossea, A Probable Ex

planation for : Fibrous Dys-

plasia of the Skull .......

Necrosis, Radiation, of the Cal-

varium .................

CEsophagea] Displacement, Atypi

cal, with Left Atrial Dilatation
Osteoma, Osteoid, of Bone .
Pulmonary Infiltrations, Tran

sient Successive (Loffler s Syn

drome) ................ \

Rontgen Examination in Con

genital Intestinal Obstructive

Defeats in Infants .......

Rontgenology of the Draining

Bronchi from Tuberculous

Cavltiea .................

Sarcoma and Chondrosarcoma,

Ostcogenic .................

, 852

448
50

852

56
448

448

448
852

852

N "-gery ................... 194,

Acrylic Resin for the Closure of

Skull Defects
Burns-

Local Treatment of .........

Metabolic Changes, after The
Cancer of the Breast .......

Concussion of the Spinal Cord
Dermoplasty of War Wounds of

the Lower Part of the Leg ..
Gelatin Sponge and Thrombin ..
Goitre, Substernal and Intra-

thoracic .........

Heparin, The Use of , In" the

Abdomen ...........

CErtema and Ecchymosis, Pul

monary. after Hemorrhage .
Pancreatitis, Acute ...........

Penicillin

In Acute Osteomyelitis ...

In the Treatment of Chronic
Osteomyelitis ............

Penicillin Therapy in Fracture

of the Femur ....
Removal, Total, of the Pancreas

.uid Other Organs and Tissues
Scgmental Resection, Primary in

the L -&gt;ft Side of the Colon
Shock, The Causation of ......

Su: cinylsulphathiaz o 1 e and

Phthalylsulphathiazole in Colmi

Surgery .............. j jM

Thenar Palsy ............. . . ] 59 fi

Wound Infection. Prophylaxis

of ................... ..... iy5

Wounds, Sucking, of the Chest 596

Theraneutics ............... ;!42. 744

Aetinomycosie ............... 744

Ainu lii Hepatitis ............ 744

"Diodoquin" ................. 744

Penicillin ................ ;&gt;4&lt;&gt;

Treatment, The. of Subacute
Bacterial Endocarditis with 342

596
597

194
195
597
596

195
596

596
194

597
195

."&gt; 9 7
597
590
191

597

191

Page

Abstracts from Medical Literature
Continued.

Therapeutics Continued.

Penicillin Aerosol, Inhalation of,
by Patients with Bronchial
Asthma, Chronic Bronchitis,
Bronchiectasis and Lung Ab
scess ............... 349

Poliomyelitis ............. . 342

Privine Hydrochloride ...... . . 744

Streptomycin, A Study of ... 744
Suicide by Ingestion of Amphet
amine Sulphate ............ 744

Sulphadiazine 42

U.F.I ............... :::::::::: 342

Vincent s Angina ............ 744

Urology ................ 25 413 813

Aluminium Hydroxide Gels in

Renal Calculus ............ 413

Anuria ..... ................. 25

Spinal Analgesia in Treatment
of .................... 4i3

Nephrolithotcmy for Recurrent

Branching Calculi ......... 25

Prostatic Adenomectomy, Perineal 813
Prostatic Resection, Trans-

urethral ............. 413

Pyuria, Abacxerial, True Infec

tive ...................... 813

Renal Pelvis and Ureter, Dupli

cation of .............. 813

Subcutaneous Urcgraphy ...... 25

Sulphacetamide in Urinary Tract

Infections .................. 813

Testicle, Rupture of the ...... . 25

Tuberculosis, Renal, 1 rognosis of 813
Ureteric Obstruction in Children 413
Uretero-Intestinal Anastomosis,

Bilateral .................. 813

Wilms Tumour of the Kidney . . 25

A }- A. F ......................... 884

Abt, I. A ......................... 884

Achalasia, CEsophageal ....... 816

Adams, D. Monk The Spelling of

\\ ords ....................... 34,-,

Addison s Suprarenal Syndrome of
Primary Pituitary Origin, A Case
of, by W. R. Lang (R) ...... 335

Address. An

By A. V. Meehan (O) ....... 133

By A. C. Thomas (O) .......... 573

Changing Face, The, of Medical
Practice in Tasmania, by G. M.
W. demons (O) ............ 609

Politics and the Medical Profes
sion, by J. Dale (O) ......... 65

Post -War Rehabilitation of Science
The, by J. G. Wagner (O) .... 97

Adenoids, Tonsils and, A Method for
the Removal of, under Local
Anaesthesia with the Patient in
the Recumbent Position, by R
H. Bettington (O) ............ 882

Adrenal Haemorrhage in Erythro-

blastosis ..................... 103

Advertisements for Permanent Posi-
. _ t. 0118 -. ..................... 566

Afibrinpgensemia, Congenital (C.C.) 375
Agglutinin, The Anti-O, in Human
Blood with the Report of a Case
of its Occurrence, bv N R
Henry (O) ..........

Aird, I ................

Akhurst, T. A. F .....

Albaugh, C. H .........

Albrect ......................... .

Allan, George, Death of ...... . . . . .

Allergy. Clinical, of the Upper
Respiratory Tract, The Botany of
Toowoomba and Environs and
its Relation to, by C. R Morton
(O) .......... * .............. 585

Amberson, J. Burns .............. 920

American Journal of Obstetrics and

Gynecology, The .............. 411

Amoebiasis, Occult, in Ex-Prisoners

of War. by C. E. M. Gunther . . 490

395
303
234
23
923
453

Amoebic Pericarditis (C.C.)

Amputation, Local, of Gangrenous
Toes in the Presence of Glyco-
suria and Senility, bv N. C. Joel

159

298
C69

Amsden, H. H ....................

Amyotonia Congenita (Oppenheim s

Disease) ..................... 854

Anaemia ......................... 814

Aplastie ....................... 814

Hypoplastic ................... 815

Anaesthesia

Hypnosis as a Substitute for. Some
Observations Concerning the Use
of, by R. L. H. Sampimon and
M. F. A. Woodruff (O) ....... 393

VOL. I, 1946.

INDEX TO THE MEDICAL JOURNAL OF AUSTRALIA.

Page
Anaesthesia Continued.

In Childbirth 198

Local, A Method for the Removal
of Tonsils and Adenoids under,
with the Patient in the Recum
bent Position, by K. H. Betting-
ton (O) 882

Spinal, and Chloroform : A Com
parison of Mortality

By C. E. Corlette (O) .. 545,892

By S. V. Marshall 750

By J. E. Thomas 750

Analgesia- -

In Labour 197

Spinal

By J. Oldham (O) 432

"Non-Take", by 1 . Gill 606

Anastomosis, Intestinal, The Preven-

vention of Leakage after (C.C.) 887
Anatomy

In the Medical Curriculum, by A.

A. Abbie (O) 152

Introduction to the Study of, An :
The Tissues of the Body, by W.

E. Le Gros Clark (rev.) 479

Anderson, A. J 157

Anderson, D. The Placing of X-Ray

Films in Envelopes 930

Anderson, G 638, 641, 712

North and Wilson

Resistance, The. of Hsemophilus
Influenzas to the Action of
Penicillin, with Special Refer
ence to Type B Strains (O) . . 626
Treatment, The, of Hsemophilus
Influenzse Meningitis with Sul-
phonamides in Conjunction
with Hsemophilus Influenzse,
Type B, Rabbit Antiserum (O) 215
Anderson, George Murray, Death of

608, 786

Anderson, G. W., ct alii (Global Epi-
diiniology: A Geography of
Disease and Sanitation) (rev.) 591

Anderson, J. Ringland 675

Anderson, P. M. A Note on the Use
of Penicillin in the Laboratory
Diagnosis of Whooping-Cough

(O) 244

Anderson, S. G. A Note on T\vo
Laboratory Infections with the
Virus of Newcastle Disease of

Fowls (R) 371

Aneurysm, Traumatic Arterio-Venous,
of the Femoral Blood Vessels,
by G. C. V. Thompson (O) .... 104

Angina

Ludwig s, A Case of, by V. Bulteau

(R) 514

Pectoris (C.C.) 632

Anniversary, A Twenty-Fifth (C.C.) 411

Anorexia Nervosa 310

Anoxia, Renal Failure and, by J.

Walker Tomb 63

Anti-Cancer Council of Victoria, The 571

Anus, Imperf orate 129

Appendicectomy, A Jungle, by N. M.

Kater (R) 443

Arachnoiditis, Basal 928

Araneidism (C.C.) 811

Archer, V. W. (The Osseous System :
A Handbook of Roentgen Diag
nosis) (rev.) _. 666

Arden, F. Rupture of the Liver in
the New-Born : Recovery after
Blood Transfusion and Lapar-

otomy (R) 187

Armstrong, W. D 86

Armytage, J. E., and Rountree Hos
pital Blankets as a Source of

Infection (O) 5U3

Arteriosclerosis, Hypertensive, with

Retinal Changes 378

Arthritis

Acute Suppurative, of the Hip . . 162
Rheumatoid, Muscular Lesions in
(C.C.) 670

Artificial Respiration Explained, by

F. C. Eye (note) 516

Ascorbic Acid in the Milk of Mel
bourne Women, by D. Winikoff
(O) 205

Aseptic Technique, Points in 201

Ashby, E 249

Aspinall, Andrew Eric and Archibald

John, Deaths of 238

Association professionellc inter-

natioiiale des metlecins 633

"Atebrin" and Dermatitis : An In
quiry

By "Inquirer" 60 ,

By N. Paul 715

Atelectasis, Congenital 854

Page

Atkinson, N. Preliminary Report mi
Strains of Salmonella Blegdam
Causing Infections in Humans in

New Guinea (O)

Atomic Energy in the Coming Era,

by D. Dietz (rev.)

Atlas of Surgical Approaches to
Bones and Joints, by T. Nicola

( rev. )

Aub, J. C

Australasian Medical Publishing
Company, Limited .... 127,558,
Australia and Science : The Univer
sity of Sydney and Scientists

By A. J. Canny

By N. E. Goldsworthy

By D. R. Moore

By F. W. Simpson
(Leading Article)

Australian and New Zealand Associa
tion for the Advancement of

Science

Australian Army Medical Curps,
Rates of Pay for Part-Time

Duties in the

Australian Broadcasting Commission
Australian Medical Board Proceed
ings

New South Wales .... 31,64,454,
490, (ill.

Queensland 64, 276, 384,

455. 491, 679,

Tasmania 455, 491,

Australian Pharmaceutical Formulary

Aviation NeurOrPsychiatry, by R. N.

Ironside and I. R. C. Batchelor

( rev. )

381
346

IIS
417
249

823

819
896
567

480

Bacille Calmette Gtierin, by J

Murphy

Bacillus Proteus OXK, The Use &lt;&gt;f
a Polysaccharide of, in the
Diagnosis of Scrub Typhus, by
1 . de Burgh (O)

Backache

In Soldiers, by D. Slurkey (&lt;&gt;)
Low

By A. E. Lee (O)

By E. Murphy (O)

Back Pain, Low, by A. V. Meehan
(O)

Bacteria in Relation to the Milk
Supply: A Practical Guide for
the Commercial Bacteriologist .
by C. H. Chalmers (rev.)

Bacterial Cell, The: In Its Relation
to Problems of Virulence. Im
munity and Chemotherapy, by R.
J. Dubos, with an addendum by
C. F. Robinow (rev.)

Bailey. H. (Demonstrations of Opera
tive Surgery for Nurses) (rev.)

Ball, L. Volkmaim s Ischsemic Con-
tracture of the Forearm (R)

Bancroft, Joseph, Memorial Lecture

Banks-Smith, R. G

Barach, A. L

Barber, A. Politics and the Medical
Profession

Barbour. J. R. Fractures of the Car
pal Scaphoid (O)

Basic Wage. The Shortage of Nurses
and Social Medicine

By M. C. DeGaris

By E. S. Meyers (O)

Balchelor, I. II. C., and Ironside
(Aviation Neuro-Psychiatry )
(rev.)

Battles, M. G

Bauer, L. H

Bayon, H. P

"Beach Foot", by E. Pockley

Bearham, G

Begg, J 00,62,130,163,

Bell, G

Bell, Hocking versus

Bell, W. J., junior

Benson, L. Blood Loss in Ctesarean
Section (O)

Bergman

Beriberi. Yaws and : A Warning, by
C. M. Deland

Berli ier, F

Bellinger, H. F., and Jacobs A Con-
tribulion to the Problem of Mas-
culinization (O)

Bettington, R. H.

And Vincent Report on a Series
of Cases of Sinusitis Treated by
Chemotherapy at an Australian
General Hospital (O)

838

I I

47!l

5 1 5
516

224
127
674
193

416
352

785
548

480
595
302
340
346
200
855
230
254
445

842

810

676

1 18

358

Page

Bettington, R. H. Continued.

Metl?cd, A, for the Removal of
Tonsils and Adenoids under Local
Ansesihesia wiih the Patient in
the Recumbent Position (O)

. 520,

882

i: \;in, Mr. A 520, 742

Beveridye, R. L 118

Beveridge, W. I. B., Campbell and
Lied Pleuropneumo n i a - L i k e
Organisms in Cases of Non-
Gonococcal Urethritis in Man and
in Normal Female Genitalia (O) 17H
Bickart, D. A Case of Intractable

Constipation 166

liiei.tiell, F., and Prescott (The Vita
mins in Medicine) (rev.) 552

Bicrring, W. L 740

Bicuspid Aortic Valve 163

Bisho,; Harman Prize, The Katherine 675

Bishci;, W. A 54

Black. D. A. K 373

Black, G. H. Barnaul 675

Black. R. H 234

Blackburn, C. R. Bickerton 234

Bladder, Urinary, Intraperitoneal

Rupture of the 380

Blanch, M 27, 28

Blankets, Hospital

As a Source of Infection, by 1 . M.
Rountree and J. E. Armytage

(O) 503

Treatment of, The, with Oil Emul
sions and the Bactericidal Action
of Fixanol C" (Cetyl 1 yri-
diiiium Bromide), by P. M.

Rountree (O)

Blashki, E. P

Legacy Club, The

"Blast" Injury of the Spinal Cord,
Report of a Fatal Case of, by

D. Leslie (R) 188

Blaubaum, P. E 130

Congenital Fibrocystic Disease of

the Pancreas (O)

"Blood", A Journal Devoted to

Hasmatology (C.C.)

Blood Group Frequencies

in Hollanders, by J. J. Graydon,
R. T. Simmons and E. F. Woods

(O) 576

In Papuans, Further Observations
on the Rh and Hr Factors and
the, by R. T. Simmons, J. J.
Graydcn and E. F. Woods (O) 537

Blood Groups

In Tasmania, by C. Duncan (O) . 475
In ihe Maori, by J. J. Graydon and

11. T. Simmons (O) ... 135

Blcod. Human, The Anti-O Agglu-
tinin in, with the Report of a
Ca.se cf its Occurrence, by N. R.
Henry (O) 395

Blood Loss

In Csesarean Section

By L. Benson (O) 812

By K. H. Broome 930

Some Efrects of, on Healthy Males,
by R. J. Walsh and A. K. Sewell

(O) 73

Boas. E. P 193

Bcile au-GiaiH, J. C., and Gates (A

Handbook for Dissectors) (rev.) 704

Bone as Human Food (C.C.) 595

Bone? and ..chits, Atlas of Surgical
Approaches to, by T. Nice a

(rev.) sos

Books Received 32, 64. 96,

168, 204, 240, 276, 312. 120.

456, 492, 536, 572. 008, 680,

716, 752, 787. 824, 860. 81Mi. 932

Botany, The, of Toowoomba and

Environs and ;ts Relation to

Clinical Allergy of the Upper

Respiratory Tract, by C. R.

Morton (O) ~&gt; s "&gt;

Bourne, A. W.

And Williams (Recent Advances in
Obstetrics and * -ynsecology )

(rev.) 2:1:

(Synopsis of Obstetrics and Gynae
cology) (rev.) 6GC

Bcurne, O. H 921

Bowden, K. M. Spontaneous Rupture
cf the Spleen, with Notes 1111 Two

Cases (O) 506

Bowel, Congenital Deformity of the s5i
I .oNvkcr. Cedrie Victor, Death of .. S23

r.nys. C. V sT

Braddon. P. D. Columnar-Celled
( areinoma of the Rectum
Treated by Radon : Preliminary
Report Sixteen Months after
Treatment (R) 477

Mil

INDEX TO THE MEDICAL JOURNAL OF AUSTRALIA.

VOL. I, 1946.

Page

Brain Disease, Organic : 1 ossibly

Cerebral Tumour ............. 309

Brain, W. R., and Strauss (Uecent
Advances in Neurology and
Neurppsychiatry) (rev.) ...... 371

Brait.hwaite, P. Treatment of Gun
shot Wounds of the Chest in the
Field by Penicillin Therapy .... 4 is

Bray, George AVilliam, Death of . . 489

Britain, Great -

Future Health Services in ...... 487

(C.C.) ...................... 482

National Health Service Bill of . . 524
By S. Siedlecky ............... 898

(Leading Article) ........... 517

Reporf, A, on a Comprehensive
Dental Service from (Leading
Article) . . , .................. 593

British Medical Agency of New South

Wales. Limited ............... 602

British Medical Agency of Queens
land, Proprietary, Limited.
Queensland Medical Finance,
Proprietary, Limited ......... 12(i

British Medical Association

Federal Council ............ 12G, 600

Advertisements for Permanent

Positions ................... 566

Appointment of Office Bearers . . 558
Australasian Medical Publishing

Company, Limited ......... 558

Australian Naval Medical Ser

vices ...................... 566

Australian Pharmaceutical For

mulary ................... 567

Brochure for Public Circulation 562
Commonwealth Employees Com
pensation Act ............... 505

Commonwealth Serum Labora

tories, Products from the .... 565
Compulsory Health Insurance . . 562
Conditions of Service Committee 568
Constitution of the Federal

Council and Autonomy of the

Branches in Australia ...... 559

Contract Practice ............ 561

Control of Medical Practitioners

of Recent Graduation ...... 570

Date and Place of Next Meeting 570
Deafness, Post-Rubella ........ 565

Decorations Received by Medical

Officers of the Australian

Armed Forces ............... 55S

Drugs, The Nomenclature of . . 567
Emergency Medical Service . . 569
Federal Common Form of Agree

ment ..................... 561

Federal Medical War Relief

Fund ..................... 559

Federal Organization Fund ..... 559

Fees for Medical Examinations 567
Fees for the Examination of

Recruits to the Army ...... 570

Finance ..................... 558

And the Western Australian
Branch ................. 560

High-Frequency Apparatus, Re

strictions on .............. 570

Hospital Services ............ 563

MacCallum. Dr. F., Illness of . 559
Medical Officers Relief Fund

(Federal) .................. 558

Medical Planning ............. 562

Medical Registration ......... 561

Meeting of the Federal Council

553,
National Health and Medical

Research Council .........

Xeti-e . 27, 59,162,236,273,310,

344, 380, 414, 450, 486, 530, 570,

603, 636, 675, 710, 782, 816, 855,

Ophthalmic Practitioners, Short

age of ....................

Opticians and ( (ptometrists, The

Teaching of, in any Branch of

Ophthalmology .............

organization of" the Profession .
Overseas Travelling Fellowships
Pharmaceutical Benefits Act

1944 ......................

Port-Graduate Facilities in the

United States ..............

1 rinciples-

Fundamental, of the Medical
Profession ....

Of Medical Ethics ........ .

Professional Rooms for Civilian

Medical Practitioners
Proprietary Medicines Investiga

tion Committee ............

Publicity Committee ........ 1

Quarantine Officers. Appointment

927
569

567
559
558

562
567

562

570

565
559

564

Page

British Medical Association Con-
tinned.
Federal ( ouncil Continued.

Rates of Pay for Part-Time
Dui c.s in the Australian Army
Medical Corps

569

ReestabliBhment and Reemploy-

ment Act, 1945 566

Refugee Medical Practitioners

i ro 1 1 Europe 558

Rehabilitation of Medical Officers

in Liie Armed Forces 568

Release "of Medical Officers from

the Services 570

Repatriation Commission .... 568

Representatives 558

Retirement, The -

Of Dr. T. A. Price and Dr.

H. C. Colville 558

Of Surgeon Captain W. J. Carr
and Air Vice-Marshal T. JO.

V. Hurley 558

Of the Chairman of the Medi
cal Equipment Control Com
mittee 570

Salaries of Commonwealth Medi
cal Officers 564

Special Groups 559

Specialist, Definition of a 565

Telephone Directories 567

Unemployment and Sickness

P.enefits Act, 1944 56f,

Votes of Thanks 570

War Emergency Organization . . 568
Katherine Bishop Harman Prize . . 675
New South Wales Branch-
Hooks Added to the Jjibrary .... 855
British Medical Agency of New

South Wales, Limited 602

Child Health. Chair of, at the

I niversity of Sydney 60J

Amendment of By-Laws 600

Annual Meeting 59S

Of Delegates 600

Annual Report &lt;;f the Council . . 598
Australasian Medical Publishing

Company, Limited 600

Chiropodists, Recognition of ... 601

Coal Inquiry 601

Congratulations 598

Constitution of ( ouncil 600

Contract Practice 601

( Y.uncil 599

lOlection of Office-Bearers 603

l-\(K ral Council of the British
Medical Association in Aus
tralia 600

Council Organization

Medical War Relief

600

600
602
601
603

603
599

599

Federal

Fund
Federal

Fund

Financial Statement

Hospital Policy

In.-(,ming President s Address ..

Induction of President

Library

Local Associations of Members,

Affiliated

Medical P.vnefhs Fund of New

South Wales 601

.Medical Finance Limited 602

Medical Sociology and Research,

Department of 601

Meet ings 598

Sckuiific 26, 58, 306,

378, 814, 854, 926

.M mbershin 598

Pathological Services, Compre
hensive, f. r New South Wales (in]
Pharmaceutical Benefits Act,

1944 601

Premises Revenue Account .... 602
Rehabilitation f Medical Officers

of tlh Arn-ed Forces 600

Representatives 598

Resident -Medical Officers

Salaries (HU

Roll of I lonour 5 US

Sandes, Francis Pereival 59S

Special Grotius for the Study of

Snecial P.ranches of Medical

Knowledge 600

X-Ray Set-vices in North Coast

Towns of X. \v South Wales 6(i|
Gphthalmological Society of Aus
tralia

Annual Meeting 674

i resident s Address 674

Qii HMis find Branch

Affiliated Local Associations .... 126

Annual Meeting 122

Annual Jtcport of Council 122

Australasian Medical Publishing

Company, Limited 127

Page

British Medical Association Con
tinued.

Queensland Branch Continued.
Bancroft, Joseph, Memorial Lec
ture 127

British Medical Agency of
Queensland. Prop r i e t a r y.
Jvimited. Queensland Medical
Finance, Proprietary, Limited 126
British Medieal Association
(Queensland Branch) Mem
orial Fund 125

Building Subcommittee 125

Election

Of Auditors 127

Of Office-Bearers 127

Ethics Committee 122,127

Federal Council 126

Federal Medical War Relief

Fund 123

Finance

Financial Statements

Hospital Matters

Induction of 1 resident

Jackson Lecture

Library 1 22

Licences under Alien Do; tors
(National Security) Regula
tions 121

Limbs, Artificial, Supply of 124

Linen for Doctors Surgeries .. 123

Liquid Fuel Supplies 123

Lodges 125

Medical Fees Tribunal 125

Meetings

Council 122

Scientific 122

Membership 122

Alt morial Roll 127

Motor-Car Tires and Accessories 123

Newsletter. Monthly 123

Obituary 122

Office-Bearers and Councillors . . 122
Organization Subcommittee .... 124
Pharmaceutical Benefits Act,

1944 126

President s Address i 29

Profession, The, and the Public 129
Queensland Medical Coordina
tion Committee 123

Queensland Medieal War Benefit

Fund 123

Rationing 123

Rehabilitation of Members of the

Armed Services 123

Repatriation Commission : Medi
eal Benefits for Dependants of

! ec eased Soldiers 123

Representation 123

Roll of Honour 122

Social 127

University of Queensland i - &gt;

Votes of Thanks 1 2!i

War Emergency Organization .. 123
Representative Meeting in London.

The Special 746

P.y II. Hunter 715

(Leading Article) 741

South Australian Branch: Sliort-
;ige tit Hospital Accommodation

in South Australia 344

Tasmanian Branch

Meeting. Annual 636

Victorian I! ranch

Annual Meeting 90

Annual Report of the Council . 90
Appointment of Subcommittees . 90
Attendances at Council Meetings 90

Business of Council 91

Election 90

Federal Council 92

Honours Conferred by His
Majesty the King for Services
Rendered during the Present

War 91

Installation of the President for

1946 92

Library of the Medieal Society of

Victoria 92

Meetings of the Branch 91

.Melbourne Permanent Post-
Graduate Committee 92

Mem.H rship Roll 90

Mollison, Dr. C. H.. Retirement
&gt; ! , from the Office of Honorary

Treasurer 92

Notice 344

President s Address 92

Roll of Honour 91

Votes of Thanks 92

Brody, J. A Case of Tick Typhus

in North Queensland (R) 511

Broncho-Pulmonpry Segments, The,

in Skiagrams.; of the Chest (C.C.) 670

VOL. I, 1946.

INDEX TO THK MEDICAL JOURNAL OF AUSTRALIA.

1 age
Broomc. K. I 1. -Blood Loss in

Cspsarean Section 1)30

Broster, L. K. (Endocrine Man : A
Study in the Surgery of Sex,
with a foreword by P. C.

-Mitchell) (rev.) 84

Broughton Hall Psychiatric Clinic . 306
Brown, A. E. Too Many Doctors? GOG

Brown, C. J. Officer 27, 29, 61

Putrid Lung Abscess (()) 107

Some Notes on the Treatment of

Pulmonary Tuberculosis (()) . . 825
Brown, D. A. Poliomyelitis: A

Question of Diagnosis 822

Brown, G. W., and Draper Staphy-
lococcal Enteritis in Children

(O) 4G9

Brown, J. Poverty, Housing and

Health 29

Browne, F. J 704

Bruce, James Whitson Kemp, Death

of . 132

Brues, A. M 707

Bryce, L 712

Buchanan, George Arthur, Death of 716

Bull, C 2?,

Bulteau, A.

Poverty, Housing and Health ... 29
[ leers in the Mouth: An Appeal

for Help 418

Bulteau, V. A Case of Ludwig s

Angina (R) 514

Burgess, J. N 4 8 G, 487

Burma and Siam ; Clinical Lessons
from Prisoner of War Hospitals
in the Par East, by A. E. Coates

(O) 753

Burnet, F. M 192

(Virus as Organism: Evolutionary

and Ecological Aspects of Some

Human Virus Diseases) (rev.) 372

Burnet, J. (Outlines of Industrial

Medicine, Legislation and

Hygiene) (rev.) 20

Burniston, G. G. Medical Rehabilita
tion: Its Organization in the
Royal Air Force and the Royal
Australian Air Force (O) .... 620

Burns, C. M 26

Burns Complicated by Haematemesis
and Melena. Report on a Case of.

by J. A. Marsden (R) 551

Burrett, A. F. Research at the

Kanematsu Institute 782

Burrows, H. (Biological Actions of

Sex Hormones) (rev.) 920

Burt, L. I. Treatment of Suppura-
tive Tenosynovitis in the Fingers

(O) 399

Butler, A. G. War and Humanism 165
Butler, H. M. Stained Smears for
the Rapid Diagnosis of Infec
tions due to Streptococcus Haemo-
lyticus Group A following Child
birth and Abortion (O) 437

Buzzard, 1 534

Byrne, K. Ma a -ia . 930

Caesarean Section, Blood Loss in

By L. Benson (O) 842

By K. H. Broome 930

Caffey, J. (Pediatric X-Ray Diag
nosis : A Textbook for Students
and Practitioners of Pediatrics.
Surgery and Rad ology) (rev.) 807
Calculus, Renal, Hydroncphrosis and

Hydroureter 163

Callagher, H. C. Placenta Praevia .. 571

Oallender. S. T 743

, Cameron, C,. R., Profe~r-or, is

Honoured (C.C.) 671

Campbell, A. D., Beveridge and
Lind Pleuropneumonia-Like Or
ganisms in Cases rf Non-Gono-
coccal Urethritis in Man and in
Normal Female Goim -lia (O) .. 179
Campbell, Alice Pritchaio. I&gt;i ; i:i of 311

Campbell, K 60.451.675.710.712

Clinical Aspects of Foetal Erythro-

blastosis (O) 68fi

Canada

And the United States. Recent
Experiences in, by H. M. .lames

(O) 827

Post-War Plans for Nutrition in . . 93

Canada Letter 236, 604, 929

i .nicer, Early Diagnosir and Early
Treatment of, The: A Publicity

Campaign 571

Canny, A. J 631

Australia and Science: The Uni
versity of Sydney and Scientists 381
Research at tbo K ancmatsu Insti
tute 642, 895

Page
Captivity. the Singapore, Medical

Aspects of, by C. Harvey (O) . . 769
Carbon Monoxide Metabolized in the

Body, Is? (C.C.) ". 483

Carcinoma

Adrenal, Causing Precocity 60

Columnar-Celled, of the Rectum
Treated by Radon: Preliminary
Report, Sixteen Months after
Treatment, by P. I). Braddon

(U) *. 477

Of the Bladder with Bilateral
Transplantation of Ureters . . . 379

ovarian in a Foetus (C.C.) 707

Cardiac Disease, Diagnostic Methods

in (C.C.) 886

Carr, Surgeon Captain W. .T.
And Air Vice-Marshal T. E. V.

Hurley, The Retirement of 558

Retiremtnt of, The (Leading

Article) 117

Castle, W. B 920

Casualties, Battle, Plasma Protein
Estimations in, by T. E. Wilson

(O) 153

Cataract Operation, Premedication

and Cooperation in 674

Cataract, Secondary, The Treatment

of 674

Gates, H. A., and Boileau-Grant (A

Handbook for Dissectors) (rev.) 704
Caughey, J. E., and Porteous An
Epidemic of Poliomyelitis Occur
ring among Troops in the Middle

East (O) 5

Cell, The Bacterial : In its Relation
to Problems of Virulence, Im
munity and Chemotherapy, by
R. J. Dubos, with an Addendum
by C. F. Robinow (rev.) .... 515
Centenaries of "Forty-Five", by H.

Stitton (O) 421

Central Hospital, Melbourne The

By C. H. Dickson 30

By C. L. McVilly 203

Cerebral Trauma and its Mechanisms

(Leading Article) 885

Chair of Child Health at the Uni
versity of Sydney 601

Chalmers, C. H. (Bacteria in Rela
tion to the Milk Supply : A Prac
tical Guide for the Commercial

Bacteriologist) (rev.) 479

Chambers, C. H., and Thompson
Chylangioma of the Mesentery,
with Report of a Case, and a
Brief Discussion of Mesenteric

Cysts (O) 210

Chest Examination : The Correlation
of Physical and X-Ray Findings
in Diseases of the Lung, by R.
R. Trail, with foreword by W.
L. Langdon-Brown (rev.) .... 703
Chest, Introduction to Diseases of

the, by J. Maxwell (rev.) 228

Chesterman, J. T. (The Treatment of
Acute Intestinal Obstruction)

(rev.) 156

Child, Pre-School, in Australia, The

Health of (C.C.) 374

Childbirth

And Abortion, Infections due to
Streptococcus Haeniplyticus Group
A following, Stained Smears for
the Rapid Diagnosis of, by H. M.

Butler (O) 437

Control of Pain in, by C. B. Lull
and R. A. Kingston, with an
introduction by N. W. Vaux

(rev.) 40S

Childhood, Nutrition and Chemical
Growth in, by I. G. Macy, with
a foreword by L. Reynolds and
a supplement by J. O. Holmes

(rev.) 884

Children s Hospital, Melbourne ..27,
59, 92,129,162,450,
486, 636, 675, 710, 890, 928
Survey from the, A : Coeliac
Disease, by G. E. M. Scott (O) 659

Chiropodists, Recognition of 601

Chiropody, The Essentials of, by C.

A. Pratt (rev.) 408

(Chloroform, Spinal Anaesthesia and :
A Comparison of Mortality

By C. E. Corlette (O) .. 545,892

By S. V. Marshall 750

By J. E. Thomas 750

Chloroma 163

Chondritis of the Patella, by N.

Little and C. Hudson (O) .... 398
Chorea

Chronic Progressive 30S

I luntington s 308

1 age
Chorioretinitis, Toxoplasmic En-

cephalomyelitis and 674

Christie, R.

And North Acquired Resistance of
Staphylococci to the Action of

Penicillin (O) 176

And Simmons Penicillin Sensi
tivity of Streptococci Mostly of
Groups A, B, C and G (O) .... 349
Chromoblastomycosis, with Reports of
Two Cases Occurring in Queens
land, by W. J. Saxton, F.
Hatcher and E. H. Derrick (O) 695
Chylangioma of the Mesentery, with
Report of a Case and a Brief
Discussion cf Mesenteric Cysts,
by G. C. V. Thompson and C, H.

Chambers (O) 210

Clark, F. J.

Recent Advances in the Surgical
Treatment of Lumbar Interver-
tebral Disk Disease (O) ... 49, 417

Trigeminal Neuralgia 895

Clark, W. E. Le Gros (The Tissues of
the Body : An Introduction to the
Study of Anatomy) (rev.) .... 479
Clayton, George Edward Burdekin,

Death of 716

Cleland, J. B 817

Acceptable Words : Quotations with

a Medical Bearing (O) 876

And Hamilton A Case of Ab
dominal Lymphangioendothelioma
or Peritoneal Mesothelioma (R) 477

Moulds in the Lungs (R) 247

Unknown Foreign Bodies in the

Lung (R) 225

Clements, F. W 374

demons, G. M. W 636

( hanging Face, The, cf Medical
Practice in Tasmania -An Ad
dress (O) 609

Climatic Factors and the Nutrition of

Herbage Plants 817

Cloward, R. B 118

Clune, F. Pacific Parade (note) . . 704

Coal Inquiry 601

Coates, A. E.- Clinical Lessons from
Prisoner of War Hospitals in the
Far East (Burma and Siam)

(O) 753

Cobb, S 300

Cobley, J. F. C. C 555

And Wilson Report of a Case of
Salmonella Blegdam Septicaemia
and Suppurative Pericarditis

with Recovery (R) 439

Cceliac Disease, A Survey from the
Children s Hospital, Melbourne,

by G. E. M. Scott (O) 659

Cceliac Syndrome 675

Cold Haemagglutinins, The Clinical

Significance of (C.C.) 743

Colquhoun, J 486, 890, 891

Colville, H. C 130

Commodore, The, by C. S. Forester

(note) H6

Commonwealth Employees Compen
sation Act 565

Commonwealth Serum Laboratories,

Products from the 565

Congresses, The Australian and New
Zealand Association for the Ad
vancement of Science 823

Constipation, Intractable, A Case of

By D. Bickart 166

By A. E. Lee 165

Contact Lenses 671

Contracture, Volkmann s Ischsemic,

of the Forearm, by L. Ball (R) 224
Control of Medical Practitioners of

Recent Graduation 570

Convalescence after Surgical Pro
cedures (C.C.) 594

Convulsive Therapy in Forward
Areas, Psychotic Casualties in
New Guinea, with Special Refer
ence to the Use of, by D. Ross

(O) 830

Conybeare, J. J 408, 776

Coordination Committee, Queensland

Medical 123

Cope, 779

Copeman, W. s. C 373

Corcoran, A. C., and Page (Arterial
Hypertension: Its Diagnosis and

Treatment) (rev.) 83

Corkill, A. B., Pollock and Smith
The Value of Biochemical Tests
in the Interpretation of Jaundice

(O) 617

Corlette, C. E. Spinal Anaesthesia
and Chloroform : A Comparison

of Mortality 892

(O) 545

INDEX TO THE MEDICAL JOURNAL OF AUSTRALIA.

VOL. I, 1946.

i age

( urn : pondi licf .

Ad&lt; inai .v. The, of Medical Train
ing-, by K. J. I!. Davis 275

Amierobic Pyuria, by J. Mo ik .... 7S5

.\u iiriii and Dermatitis: An In
quiry

By "Inquirer" 607

By N. Paul 715

Australia and Science: The Uni
versity of Sydney and Scientists --

My A. .1. Canny 381

My X. 10. Goldsworthy -".4(i

My !&gt;. K. Moore 41 S

By F. W. Simpson 417

Bacille Calmctte &lt; im-riii. by J. A.
K. Murphy 930

Basic Wage, The. Shortage of
Nurses and Social Medicine, by
M. C. DeGaris 7X5

"Beach Foot", by E. Pockley 346

Blood Loss in Csesarean Section,
by K. H. Broome 930

Can Epilepsy be Cured?, by R. S.
Ellery 30

Case, A, of Intractable Constipa
tion

By I). Bickart 165

By A. E. Lee 165

Central Hospital, Melbourne, The

By C. H. Dickson 30

By C. L. McVilly 203

Congenital Fibrocystic Disease of
the Pancreas, by L. Dods 929

Digestion, The, of Dogs and Chronic
Osteomyelitis, by "Curious" .... 275

Disclaimer, A, by A. W. Morrow 678

Epidemic Polyarthritis, by .7. R.
Nimmo 380

Federal Medical War Relief Fund,
The

By W. F. Simmons 418

By M. Thornton 41 S

Functional Disorders

By W. S. Dawson 21 5

By A. A. Pain Mil

Future, The, of Medical Practice,
by C. H. Jaede 823

Honorary Medical Staffs, by C. C.
McKellar 894

Inguinal Hernia and its Repair

By C. Craig 274, 678

By L S. Loewenthal 381

Intervertebral Disk, The

By W. H. Godby 237

By D. Miller 346

By M. A. Radcliffe-Taylor . 2: ,7, 454

Late Herbert Michael Moran, The,
by E. H. Molesworth 311

Legacy Club, The, by E. P. Blashki 63

Malaria

By K. Byrne 930

By M. R. Finlayson and .7. McF.
Rossell 784

National Health Service Bill of
Great Britain, The. by S.
Siedlecky 893

"Non-Take" Spinal Analgesia, by
P. Gill 606

Observations on Psychoses Occur
ring in Service Personnel in For
ward Areas, by F. W. Graham . . 785

Obstetric Bulletins, by B. T. Mayes 275

Occult Amoebiasis in Ex-Prisoners
of War, by C. E. M. Gunther .. 490

On the Prickly Heat

By J. P. O.Brien 164

By C. White 382

Organization of a Profession, by
E. S. Meyers 784

Pharmaceutical Benefits Act, The.
1944, by L. R. Jury 893

Placenta Prsevia

By H. C. Gallagher 571

By B. T. Mayes 715

By J. N. R. Stephen 490, 893

Placing, The, of X-Ray Films in
Envelopes, by D. Anderson .... 930

Poliomyelitis? : A Question of Diag
nosis, by D. A. Brown 822

Politics and the Medical Pro
fession

By A. Barber 416

By P. G. Dane 417,784

By E. P. Dark 534, 929

By C. O Day 273

By N. Pern 416, 677

Poverty, Housing and Health

By J. Brown 29

By A. Bulteau 29

Professor Ralph Stockman, by M.
Kelly 822

Psychiatric Programme for Peace,
A, by C. I. McLaren 677

Page
( nrrespondence- -Continued.

Psychotherapy, by A. A. Pain ... s.v.i
!;&gt;(, , Advances in the Diagnosis
and Treatment of Lumbar Inter-
vertebral Disk Disease

By F. Clark 417

By D. Miller 274

;:.v .7. H. Young 382

Renal Failure and Anoxia, by J.

Walker Tomb 63

Research -

At Sydney Hospital, by Is. Rose 75(i
At the Kanematsu Institute

By A. F. Burrett 782

By A. J. Canny 642, 895

By J. C. Eccles 641

By W. W. Ingram 783

By T. H. Vickers 642

Services Medical Officers" Associa
tion of New South Wales, by J.

M. Yeates 785

Special Representative Meeting in

London, The, by H. Hunter .... 715
Spelling of Words, The, by D. Monk

Adams 345

Spinal Anaesthesia and Chloroform :
A Comparison of Mortality

My ( . I-:. Corlette . . . 892

By S. V. Marshall 750

By J. E. Thomas 750

Spondylitis Ankylopoietica-

By K. Hasiett Frazor 453, 677

By "Froach Eilean" 535

Surgical and Applied Anatomy of
the Inguinal Region, by E. S.

Meyers 237

"Thio" Drugs in Thyreotoxicosis,
by H. R. (I. Poate and S. L.

Spencer 750

Too Many Doctors?, by A. E. Brown 606
Toothache and Folk-Lore, by P. G.

Dane : . 275

Treatment of Gunshot Wounds of
the Chest in the Field by Peni
cillin Therapy, by P. Braithwaite 418
Treatment of Scabies, The, by J.

G. Morris 380

Treatment, The. of Inguinal Hernia.

by C. Craig 345

Trigeminal Neuralgia

By F. .7. Clark 895

By A. Lyons 750

Tsutsugamushi Disease : A Warn
ing, by J. T. Gunther 419

Tuberculosis Patients and Hos
pitals

By A. H. Penington 237

By D. B. P tt 30

I leers in the Mouth. An Appeal
for Help

By A. Bulteau 418

By L. Hewitt 418

My B. Hiller 490

By "M.B. B.S." 274

By F. F. McMahon 715

By E. M. Murphy 5:1 I

By I. Roxon-Ropschitz : ,s2

Unusual Case of Malaria, An

By N. Cunningham 453

By R. F. Matthews 380

Use, The, and Misuse of Tetanus

Antitoxin, by S. Sheldon 131

War and Humanism, by A. G.

Butler 165

Wounds Caused by Small Fish

By H. Flecker 534

By K. F. D. Sweetman 345

Yaws and Beriberi : A Warning, by

C. M. Delar.d ". 676

Correspondence, Special

Canada Letter 236, 604, 929

London Letter 603

New Zealand Letter 344, 676

Corrigendum 348

Cosh, John Inglis Clark, Death of .. 311

Cottrell, J. D 669

Counseling, Personality Factors in,
by C. A. Curran, preface by M.
J. Ready, introduction by C. R.

Rogers (rev.) SO 7

Counsell. W. D 674

Craig, C.

Inguinal Hernia and its Repair

274,678
Treatment, The, of Inguinal Hernia 345

Cricket Match 491

Crooke, Robert Warren, Death of . . 895
Crosse, V. M. (The Premature Baby,
with a foreword by L. G. Par
sons) (rev.) 20

Crowther, W. E. L. H 7S6

Case, A. of So-Called Hydro
phobia : A Matter of Diagnosis
(O) 69

Page

&lt; i uxatto, H. and. K 810

Croydon Obstetric Service (C.C.) .. 554
Ciimmine, H. G., and Laidley The
Empirical Use of Penicillin for a
Sulphonamide-Resistant Patient

(R) 476

Cunningham, N. An Unusual Case

of Malaria 453

Curd, F. H. S 229

"Curious" The Digestion of Dogs

and Chronic Osteomyelitis .... 275
Curran, C. A. (Personality Factors
in Counseling, preface by M. J.
Ready, introduction by C. R.

Rogers) (rev.) 807

Curran, D., and Guttmann (Psycho
logical Medicine : A Short Intro
duction to Psychiatry, with an
Appendix on Psychiatry Associ
ated with War Conditions, with
a foreword by J. J. Conybeare)
(rev.) 776

Current Comment

Action of Iodine in Graves s Disease 779

Amoebic Pericarditis 159

Angina Pectoris 632

Annals of the Montevideo Faculty

of Medicine 158

Araneidism 811

Arterial Embolism and Thrombosis

in Infancy 87

Availability, The, of Vitamins in
Various Foods and Pharmaceuti
cal Products 410

"Blood", A Journal Devoted to

Hsematology 743

Bone as Human Food 595

Mrain, The, of Dr. Robert Ley ... 447
Broncho-Pulmonary Segments, The,
in Skiagrams of the Chest .... 670

Cerebral Hydatid Cyst 446

Clinical Significance, The, of Cold

Hsemagglutinins 743

Complete Obstetric Service, A .... 554

Congenital Afibrinogenaemia 375

Congenital Defects in Infants after
Maternal Rubella : Further Re
ports and Discussions 23

Convalescence after Surgical Pro
cedures 594

Diagnostic Methods in Cardiac

Disease 886

Dr. J. G. Hunter Flies to England 595
Droplet Spray Infection and Res
pirator y Activity 447

Effect of Emetine on the Heart, The 669

Epistaxis 669

Kxcretion of Iron 303

Kxperimental Study, An, on Pan
creatic Secretion and Division of

the Pancreas 4x:!

lOye Signs in Graves s Disease. The 521

Fat Embolism 671

Foams and Living Tissues Si;

Future Health Services in Great

Britain 482

Health, The, of the Pre-School

Child in Australia 373

Heart Sounds in Health 158

Hypertensin 810

Index to "The Medical Journal of

Australia" 447

International Medical Conference,

An 633

Is Carbon Monoxide Metabolized in

the Body? 483

Jean-Paul Marat : Visionarv or

Villain? " 340

Lesions of the Mouth and Iron

Deficiency &50

ht-ssons from Spinach 922

Medical Annual, The :!41

Medical Education and Medical
Practice in Germany during the

War 923

Medical History, The, of the War

of 1939-1945 633

Modern Treatment in Acute

Nephritis 742

Murmurs from Turbulent Flow . . 339
Muscular Lesions in Rheumatoid

Arthritis 670

New York Festschrift, A 193

Ovarian Carcinoma in a Foetus . . 707

Penicillin and the Skin 411

Placebo, The 887

Porphyria 250

Post -War Germany: A Psychiatric

Problem ] I n

Prevention, The

Of Influenza 192

Of Leakage after Intestinal

Anastomosis 887

Of Sunburn 375

Vol.. I, 1946.

INDEX TO THE MEDICAL JOURNAL OF AUSTRALIA.

Page
Current Comment Continued.

Problem, The, of Early Pulmonary

Tuberculosis ~7S

Professor G. it. Cameron is

Honoured 671

Prognosis, The, in Subarachnoid

Haemorrhage 22

Pulmonary Eosinophilosis 55

Results, The, of Prefrontal Leu-

cotomy 1 1 s

Retropubic and Extravesical Pros
tatectomy , 230

Sleep Paralysis 811

"Stevens-Johnson Syndrome, The" 193
Thoracic Complications of Typhoid

and Salmonella Infections 55."&gt;

Tick Paralysis 339

Toothache and" Folk-Lore 54

Toxic Factors in Experimental

Shock 707

Toxicity of Thiouracil, The 850

Transient Disturbances following

Head Wounds 706

Twenty-Fifth Anniversary, A .... 411
Two Causes of Pain in the Right

Iliac Fossa 303

Ulcer Problem, The 632

Unusual CKstrogen Reaction in a

Boy 595

Unusual Recto-Vesical Injury, An 743

Currie, J. R 630

Cyst, Hydatid, Cerebral (C.C.) .... 446
Cystic Disease, Congenital

Of the Kidneys 450

Of the Lung 450

Cysts, Mesenteric, Chylangioma of
the Mesentery, with Report of
a Case, and a Brief Discussion
of, by G. C. V. Thompson and
C. H . Chambers (O) 210

Daoryocystostomy, Endonasal, West s
Operation, Some Notes on, by

G. A. D. McArthur (O) 508

Dale, J 90, 92

An Address -Politics and the

Medical Profession (O) 05

Dameshek, W 743

Danber, D. V 193

Dandy, W. E 53

Dane, P. G.

Politics and the Medical Profession

417, 784

Toothache and Folk-Lore 275

Dangerous Drugs Regulations of

Victoria 382

Danielson, R W 23

Darby, W. J 850

Dark, E. P. Politics and the Medical

Profession 534, 929

Darling, H. C. R 823

Davey, D. G 229

Davies, Harold Whitridge, Death of 859

Da vies, J. H. Twiston 411.

Davis, K. J. B. The Adequacy of

Medical Training 275

Dawson, W. S. Functional Disorders 275

Day, A 93

"DDT" Poisoning in Man, by I. M.
Mackerras and R. F. K. West

(R) 400

Deafness. Post-Rubella 565

Death, Sudden, following Initial In-
t jection of a Mercurial Diuretic,

by A. Murphy (R) 589

de Burgh, P. M.

Notes on Field s Stain (O) 544

Use, The, of a Polysaccharide of
Bacillus Proteus OXK in the
Diagnosis of Scrub Typhus (O) 81
Defects, Congenital, in Infants, after
Maternal Rubella : Further Re
ports and Discussions (C.C.) . . 23
Deformities

Among Recruits, An Analysis of,
with Remarks on Sub-Standard
Types, by W. E. Roberts (O) . 360

Multiple Congenital 450

Deformity, Congenital, of the Bowel 854
DeOaris, M. C. The Basic Wage,
Shortage of Nurses and Social

Medicine 785

Deland, C. M. Yaws and Beriberi :

A Warning 676

Delohery, H. J., and Miller Staphy-
lococcal Meningitis and Ventric.u-
litis: Cure by Penicillin (R) .. 512
Dementia

Paralytica 306

Presenile 309

Denny-Brown, D 250

Page

Dental Service, a Comprehensive, A
Ucport from Great Britain on
( Leading Article)

Dental Students, Essentials of Sur
gery for, by J. C. Ross (rev.) ..

Derham, A. P 451, 452, 890,

Dermatitis, "Atebrin" and : An
Inquiry

By "Inquirer"

By X. Paul

Dermatology, An Introduction to,
with a Chapter on the Theory
and Technique of X-Ray and
Radium Therapy, by E. H.
Molesworth, with a Foreword to
the First Edition by J. Jadas-
sohn (rev.)

Derrick, E. H

Aiute Porphyria, with Reports of

Two Fatal Cases (O)

Saxton and Hatcher Chromo-
blastomycosis, with Reports of
Two Cases Occurring in Queens
land (O)

Deutpeh, H. (The Psychology of
Women : A Psychoanalytic Inter
pretation, with a foreword by S.
Cobb) (rev.)

Devine, J

Diabetes Mellitus with Hyperlipsemia
and Hypercholesterolaemia, by A.
M. Henderson (R)

Diarv for the Month 32, 64, 96, 132,
168, 204, 240, 276, 312, 348, 384,
420, 456, 492, 536, 572, 608, 644,
680, 716, 752, 788, 824, 860, 896,

Dick, B. M., and Illingworth (A
Text-Book of Surgical Path
ology) (rev.)

Dick, G. F

Dickson, C. H. The Central Hospital,
Melbourne

Dietary Deficiencies and Oral Struc
tures (Leading Article)

Dietetics, Tropical, Nutrition and, by
L. Nicholls (rev.)

Dietz, D. (Atomic Energy in the
Coming Era) (rev.)

Discipline, Clinical (Leading Article)

Disclaimer, A, by A. W. Morrow . .

Diseases

Infectious, During Pregnancy, Con
genital Abnormalities in Infants
following, with Special Refer
ence to Rubella : A Third Series
of Cases, by C. Swan and A. L.

Tostevin (O)

Of the Chest, Introduction to, by

J. Maxwell (rev. )

Of the Lung, The Correlation of
Physical and X-Ray Findings in :
Chest Examination, by R. R.
Trail, with foreword by W. L.

Langdon-Brown (rev.)

Virus, Some Human, Evolutionary
and Ecological Aspects of : Virus
as Organism, by F. M. Burnet

(rev.)

Disk Disease, Lumbar Intervertebral
Recent Advances in the Diagnosis
and Treatment cf

By F. Clark

By D. Miller

By J. H. Young

(O)

Recent Advances in the Surgical
Treatment of, by F. J. Clark

(O)

Disk, The Intervertebral

By W. H. Godby

By D. Miller

By M. A. Radeliffe-Taylor . . 237,

(Leading Article)

Dislocation, Congenital, of the Hip . .

Dissectors, A Handbook for, by J. C.

Boileau-Grant and H. A. Gates

(rev.)

Diuretic, Mercurial, Sudden Death
following Initial Injection of a,

by A. Murphy (R)

Dixon, K

Dixon, Mr. Justice

Doctors, Too Many?, by A. E. Brown

Dods, L

Congenital Fibrocystic Disease of

the Pancreas

Dogs, The Digestion of, and Chronic
Osteomyelitis, by Curious" ....
Doherty M. K., Sirl and Ring
(Modern Practical Nursing Pro
cedures ) ( rev. )

ITOmbrain, A. W

Donald, W. D

Donaldson, G. M. M

372

928

607
715

227
157

241

695

300

887

513

932

336

920

516

629

409
678

645

228

703

372

417

274

382

237

346

454

589
411
267
606
814

929

630
674
339
375

Page

Dowling. I . G. Epidemic Poly
arthritis (O) 245

Downes, H. R 849

Downing, H. F 703

Dowson-Weisskopf, A. B. (Industrial
Nursing : Its Aims and Practice,
with a foreword by E. Summer-
skill) (rev.) 84

Draper, F., and Brown -Staphylo-

coccal Enteritis in Children (O) 469
Drinker, C. K. (Pulmonary Edema
and Inflammation : An Analysis
of Processes Involved in the For
mation and Removal of Pul
monary Transudates and Ex-

udates) (rev.) 739

Droplet Spray Infection and Respira
tory Activity (C.C.) 447

Drugs, The Nomenclature of 567

Dubos, R. J. (The Bacterial Cell :
In its Relation to Problems of
Virulence, Immunity and Chemo
therapy, with an addendum by

C. F. Robinow) (rev.) 515

Dubos, R. T 707

Duguid, J. P 447

Duhig, J. V 157

Duncan, C. Blood Groups in Tas
mania (O) 475

Dunlop. E. E. Clinical Lessons from
Prisoner of War Hospitals in the

Far East (O) 761

Dunn, S. R 234

Uccles, J. C 631

Research at the Kanematsu Insti
tute 641

Ectodermal Dysplasia, Congenital . . 815

Eddy, C. E. The .Fiftieth Anniver
sary of the Discovery of X Rays
(O) 138

Edema, Pulmonary, and Inflamma
tion : An Analysis of Processes
Involved in the Formation and
Removal of Pulmonary Trans
udates and Exudates, by C. K.
Drinker (rev. ) 739

Editorial Notices . . 32, 64, 96, 132,
168, 204, 240, 276, 312, 348, 384,
420, 456, 492, 536, 572, 608, 644,
680, 716, 752, 788, 824, 860, 896, 932

Edman, P 810

Education, Medical, and Medical
Practice in Germany during the
War (C.C.) 923

Edwards, A. T 926

Some Remarks on Psychotic, Ex-
Servicemen (O) 738

Edwards, J. G 239

Electrocardiograms 378

Ellery, R. S.

Can Epilepsy be Cured? 30

(Psychiatric Aspects of Modern

Warfare) (rev.) 189

Psychiatric Programme for Peace,

A (O) 457

Embelton, D. M., and Jones -Volvulus
of the Small Bowel, with Report
of a Case Treated by Resection
with Recovery (O) 144

Embolism

Arterial, and Thrombosis in In
fancy (C.C.) 87

Fat (C.C.) 671

Emergency Medical Service, The . . 569
Emetine, The Effect of, on the Heart

(C.C.) 669

Encephalitis

Lethargica, A Syndrome Resem
bling Disseminated Sclerosis as a

Sequel to 308

Post-Varicellal. A Case of, showing
Bilateral Softening of the Neo-
striatum and Terminal "Tet-
anoid Chorea" (Gowers), by C.
Swan (R) 697

Endocrine Man : A Study in the Sur
gery of Sex, by L. R. Broster,
with a foreword by P. C. Mitchell
(rev.) 84

p:ndocrinology

Neurology, Psychiatry and, The
1945 Year Book of, edited by H.

H. Reese et alii (rev.) 919

Of Woman, by E. C. Hamblen
(rev.) 665

Entamoeba Histolytica, The Detection
of the Cysts of, in the Faeces by
Microscopic Examination, by A.
T. Marsden (O) 915

XII

INDEX TO THE MEDICAL JOURNAL OF AUSTRALIA.

VOL. I, 1946.

i "age

Enteric Fever clue to Bacterium
Enteritidis Var. Blegdam (Sal
monella Blegdam) : A Series of
Fifty Cases in Australian Soldiers
from New Guinea, by F. Fenner

and A. V. Jackson (O) 313

Enteritis, Staphylococcal, in Chil
dren, by F. Draper and (5. \V.

Brown (O) 469

Eosinophilosis, Pulmonary (C.C.) .. 55

Epidemiology, Global : A Geography

of Disease and Sanitation, by

J. S. Simmons, T. F. Whayne,

G. W. Anderson, H. M. Horack

and collaborators (rev.) 591

Epilepsy Can Epilepsy lie Cured?, by

R. S. Ellery 30

Epiphyses, 1 remature Union of ... 486
Episiotomy and Perineal Repair . . 200

Epistaxis (C.C.) 669

Ercole, Q. N 234

Erythroblastosis

Adrenal Haemorrhage in 163

Foetal 710

Clinical Aspects of, by K. Camp
bell (O) 686

Ethics, Medical, The Principles cf . . 570

Eusterman, G. B 920

Evans, C. Lovatt (Principles of
Human Physiology, with section
on the special senses by H.

Hartridge) (rev.) 704

Eve, F. C. (ArLJficial Respiration

Explained) (note) 516

Evidence at Inquests, Medical Prac
titioners and 345

Examinations, Rypins Medical Licen-
sure : Topical Summaries, Ques
tions and Answers, edited by W.

L. Bierring (rev.) 740

Exophthalmos, Unilateral Pulsating,
due to a Defect of the Orbital

Wall 674

Exposure, Extensile, Applied to Limb

Surgery, by A. K. Henry (rev.) 444
Ex-Servicemen, Psychotic, Some Re
marks on, by A. T. Edwards (O) 738
Eye Diseases A Sociological Study
cf the Aborigines in the Northern
Territory and their, by M.

Schneider (O) . 99

Eyes (Leading Article) 705

Fagan, K. J. Surgical Experiences

as a Prisoner of War (O) 775

Fairley, N. Hamilton 229, 234

Fantl, P. The Bleeding Tendency
in Obstructive Jaundice : Diag
nosis and Management (O) ... 547

Fass, E 809

Fat Embolism (C.C.) 671

Feddersen, A. S 533

Federal Medical War Relief Fund
123, 312, 419, 455, 492, 536,
559, 572, 600, G07, 644, 680,

716, 751, 788, 824, 859, 932

By W. F. Simmons 418

By M. Thornton 418

(Leading Article) 229

Fees for Medical Examinations .... 567
Fellowships, Overseas Travelling,

383, 558

Femur and Fibula, Congenital Ab
sence of 26

Fenn 483

Fenner, F., and Jackson Enteric
Fever, due to Bacterium Enteri-
tidis Var. Blegdam (Salmonella
Blegdam) : A Series cf Fifty
Cases in Australian Soldiers

from New Guinea (O) 313

Festschrift, A New York (C.C.) .. 193
Fetherston Memorial Lecture, The

R. H., by A. M. Wilson (O) . . . . 1
Fibrocystic Disease

Congenital, of the Pancreas

By P. E. Blaubaum (O) 833

By L. Dods 929

Pseldoarthrosis of the Tibia due to 26
Fibula, Femur and, Congenital

Absence of 26

Fielding, J. W.

Further Observations on Rat

Leprosy (O) 681

Observations on Human Lejrosy:
Infection of Rats with Human

Excretai Organisms (O) 578

Fieid s Stain, Notes on. by P. M. de

Burgh (O) 544

Fincke 922

Finlayson, M. R., and Rossell

.Malaria 784

Firor, \V. B

Fischer, A. E

Fish, Small, Wounds Caused by

By H. Flecker

By K. F. D. Sweetman

"Fixanol C" (Cetyl Pyridinium Bro
mide), Bactericidal Action of,
The Treatment of Hospital
Blankets with (Ml Emulsions and
the, by P. M. Rountree (()) ....

Flecker, H. -Wounds Caused by
Small Fish

Fluids, Intravenous Administration
of, A Trocar and Cannula for
the, by R. V. Pratt (O)

Fly nn. R. Congenital Stricture of
the Oesophagus (R)

Foams and Living Tissues (C.C.) ..

Foley, The Honourable T. A

Folk-Lore, Toothache and (C.C.) . .

Food Consumption in Australia
(Leading Article)

Food Shortage, The World (Leading
Article)

Food, The Relationship of, to Health,
by M. Hutchings (O)

Foot, Beach, by E. Pockley

Foreign Bodies. Unknown, in the
Lung, by J. B. Cleland (R) ....

Forester, C. S. (The Commodore)
(note)

Forster, W

Foster-Carter, A. F

Fracture of the Pelvis Complicated
by Intrapelvic Rupture of the
Urethra

Fractures

Compound, of the Extremities,
due to Gunshot Wounds : The
Early Results of Treatment in
the Field Aided by Penicillin
Therapy, by T. F. Rose and A.

Newscn (O)

Of the Carpal Scaphoid, by J. R.
Barbour (O)

Francis, T., junior

Frank, R. T

Frayne, Ernest John, Death of ....

Frazer, E. Haslett

Spondylitis Ankylopcietica . . 453,

Freedberg, A. S

Freund, H.

age

66t;

193

53 1

345

539
534

702
86

157
54

21
921

225

116
640
670

379

age

,ss:;

"Froach Eilean" Spondylitis Anky-

lopoietica

Fryberg, A

Fuller-ton, Alexander Young, Death

Functional Disorders

By W. S. Dawson

By A. A. Pain

Fungi, Exploring the Higher

Gabriel, W. B. (The Principles and
Practice of Rectal Surgery)
( rev. )

Gaha, T. R. Latent Primary Breast
Tumour (R)

Game, J. A Case of Periarteritis
(Pclyarteritis) Nodosa (R) ....

Gangrenous Toes, Local Amputation
of, in the Presence cf Glyco-
suria and Senility, by N. C. Joel
(R)

Gardner, B., Woodward et alii (Ob
stetric Management and Nursing)
( rev. )

Gardner, H

Gargoylism

Germany

Medical Education and Medical
Practice in, during the war

(C.C.)

Post-War: A Psychiatric Problem
(C.C.)

Gill, P. "Non-Take" Spinal Anal
gesia

Gillcspie, W. P

&lt; Jilmour, W

Glaister, .1. (Medical Jurisprudence
and Toxicology) (rev.)

Glaucoma, Traumatic, Monocular
Chronic

Godby, W. H. The Inrervertebral
Disk

Goddard, T. H

Goldswcrthy, N. E. Australia and
Science : The University of
Sydney and Scientists

Gonorrhoea, Penicillin Therapy in the
Treatment of, The Results of,
by S. Siedlecky (O)

Goodeli, H

352
192
193
895
58
677
632
670

535
157

490

275
131
817

228
590
295

298

923
119

606
703
670

480

671

237
636

346

Graham, E. A

Graham, F. W. Observation!) on

Psychoses Occurring in Service
Personnel in Forward Areas .. 785
Graham, Walter Robert, Death of . . 32
&lt; ira ves s Disease

Action of Iodine in, The (C.C.) .. 779

Eye Signs in, The (C.C.) 521

Gniydon, J. J.
And Simmons

Blood Groups in the Maori (O)
Rh Blood Types, The, and their

Reactions (O)

Simmons and Woods

Blood Group Frequencies in Hol
landers (O) 576

Further Observations on the Rh
and Hr Factor?, and the Blood
Group Frequencies in Papuans

(O) 537

Green Armour, by (). White (note) . 516

Green, J 202,711

Greene, J. A 303

Greenhill, J. P 884

Greenwood, Mr 741

Gregersen, M. 1 483

Gregg, N. McAlister 674

Gregory, T. S 234

Grier, R. C., junior ::::!

Grieve, J. W 60,61,93,675,890

Griffiths, G 488, 670

Grinker, R. R., and Spiegel- (War

Neuroses) (rev.) 630

Groat, R. E 87

Grove, J. L. Tetanus Treated with

Penicillin ; Recovery (R) 22i

Groves, H. (Synopsis of Surgery,
edited by C. P. G. Wakeley)

(rev.) * 190

Growth, Chemical, Nutrition and, in
Childhood, by I. G. Macy, with
a foreword by L. Reynolds and
a supplement by J. O. Holmes

(rev.) 884

Gunblast, Experimental Observations
on the Aural Effects of, by N. E. .

Murray and G. Reid (O) 611

Gunther, C. E. M.

New Conceptions of Malaria Con
trol (O) 510

Occult Amoebiasis in Ex-Prisoners

of War 490

Gunther, J. T. Tsutsugamushi

Disease : A Warning 419

Guthrie, D. (A History of Medicine)

(rev.) 1 ::

Guttmann, E., and Curran (Psycho
logical Medicine : A Short Intro
duction to Psychiatry, with an
Appendix on Psychiatry Associ
ated with War Conditions, with
a foreword by J. .]. Conybeare)

(rev.) 776

i Iwynne, F. J 670

Gymnastics, Medical, Massage and,
by M. V. L^ce, with a foreword

by J. MenneH (rev.) 24S

Gynaecological D&gt;crders, The Symp
tomatic Diagnosis and Treat
ment of, by M. M. White, with
a foreword by F. J. Browne

(rev.) 704

( lyna^cology

Obstetrics and, The 1945 Year Book
of, edited by J. P. Greenhill

(rev.) 884

Recent Advances in Obstetrics and,
by A. W. Bourne and L. H.

Williams (rev.) 299

Synopsis of Obstetrics and, by A.
W. Bourne (rev.) 666

Hsemagglutinins, Cold, The Clinical

Significance of (C.C.) 743

Hsemangiomata of the Lower Limb 26

Ifa?matology, "Blood", A Journal

Devoted to (C.C.) 743

Ilfemor.hiius Influenzse -

Ilesistaree of. The, to the Action
of Penicillin, with Special Refer
ence to Type B Strains, by E. A.
North, H. Wilson and G.

Anderson (O) L 626

Type B. Rabbit Antiserum, The
Treatment of Hremophilus In-
fluenzse Meningitis with Sul-
phonamides in Conjunction with,
by E. A. North, H. Wilson and
G. Anderson (O) 215

Hnemorrhage, Subarachnoid, The

Prognosis in (C.C.) 22

Vol.. I, 1946.

INDEX TO THE MEDICAL JOURNAL OF AUSTRALIA.

xin

llahn, P. F

Hair and Scalp, The. by A. Savill
(rev.)

llaidano. J. S

Hales, G. M. B

Hall, R. D. MeKeUar A Short Note
on the Changing Outlook in
Osteomyelitis brought about by
the Introduction of Penicillin (R)

Hallarr, K 28,451,480.

Hai ows, B. ... 28, 59, 00, 01,480.

Hajrblen, E. C. (Edocrlnology of
Wo.man) (rev.)

Hamilton, I.

And Cleland A Case of Abdominal
Lymphangioendothelloma or Peri
toneal Mosothelioma (R)

And Hardy Hernia through the
Foramen of Winslow Emerging
through the Castro-Hepatic
Omentum (R)

Hamilton. J. Bruce

Hardle, David, Death of

Hardy, J. K. S., and Hamilton
Hernia through the Foramen of
Winslow Emerging through the
Castro-Hepatic Omentum (R) ..

Hartr rtge, H

Harvey, C. Medical Aspects of The
Singapore Captivity (O)

Hatcher, P., Saxton and Derrick
Chromoblastomycosis, with Re
ports of Two Cases Occurring in
Queensland (O)

Hawker. R. W. Studies in Nicotinic
Acid (O)

I lay. Arthur, Death of

I layden, F

Hayes, W. Ivon i?6. 532,

Hay ward, G. W

Head Wounds. Transient Distur
bances following (C.C.)

Health

Of the Pre-School Child in Aus
tralia, The (C.C.)

Poverty, Housing and

By J. Brown

By A. Bulteau

Relationship of Food to. The, bv
M. Hutehings (O)

Health Education Council, Queens
land

Health Legislation in the United
States of America, Discussions
on (Leading Article)

Health Service Bill of Great Britain,

The National

(Leading Article)

Health Services, Future, in Great

Britain

(C.C.)

Heart Sounds in Health (C.O.)

Heath. C. W. (What People Are: A
Study of Normal Young Men)
(rev.)

Heliner

Hemivertebra, Spondylolisthesis and

Henderson, A. M. A Case of Dia
betes Mellitus with Hyper-
lipsemia and Hyperchclesterol-
aemia (R)

Henderson, J. L

Henry, A. K. (Extensile Exposure
Applied to Limb Surgery) (rev.)

Henry, N. R.

And Simmons Studies on Rh Iso-

Immunlzatlon (O)

Anti-O Agglutinin in Human Blood,
The, with the Report of a Case
of its Occurrence (O)

Herbage Plants, Climatic Factors and
the Nutrition of

TTerndon, R. F. (An Introduction to
Essential Hypertension) (rev.) .

Hernia

i Diaphragmatic

Inguinal

And its Repair

By C. Craig 274,

By L. S. Loewenthal

By H. Turnbull (O)

Treatment of. The

l ..\ ( . Craig

By F. V. Stonham (O)

Through the Foramen of Winslow
Emerging through the Gastro-
llenatic Omentum, by I. Hamilton
and J. E. S. Hardy (R)

HIS
483

854

401

-1ST
1ST

805

07-i

S05
704

872

533

53 I

009

374

2!)
29

TOO
124

524
517

487
482
158

444

Sit)
20

513
375

444

395
817
740

078
381
109

345

185

Hes^

Hewitt. L.- -Ulcers in the Mouth: An
Apopal for Help

Hewitt, \v. E

1 licks, .1. I &gt;. Lipomata o| the UteruHJ
with Report of n Case (O)

Page

1 1 igli-Freque.i&gt;ey Apparatus. The

Restrictions on 570

Hill, A 201

Hiller, B. I lcers in the Mouth: An

Appeal for Help 41)0

Hingston, II. A., and Lull (Control
i rain in Childbirth, with an
introduction by X. W. Vaux)
(rev.) 408

Hirschfeld, iOugen, Death of 931

Hirst, G. K 193

Historical Records 125

History, The Medical, of the War of

1!C;9-1SI45 (C.C.) 033

Hochberg, M 4 1 o, 11 1

Hocking versus Bell 254

Hollanders, Blood Group Frequencies
in., by .i. .1. Graydon, R. T. Sim
mons and 10. F. Woods (&lt;&gt;) .... 570

llelmes, J. O SSI

Honours, The Order of Saint John

of Jerusalem 1 li 1

Hookworm Disease in Australian
Soldiers, with Reports of Cases,
by C. B. Sangster (O) 3S5

Horark. H. M., ct alii (Global Epi
demiology: A Geography of
Disease and Sanitation) (rev.) . 591

Hormones, Sex, Biological Actions

of, by H. Burrows (rev.) 920

Horn, H. \Y 122

I lospital

Broughton Hall Psychiatric Clinic 300
Central Hospital, Melbourne, The

By C. II. Dickson 3o

By C. L. McVilly 20: 1 ,

Children s Hospital, Melbourne . 27.

59, 92, 129, 102, 450,

ISt;, 030. 075, 710, 890, 928

Survey from the, A: Coeliac

Disease, by G. E. M. Scott

(O) 059

Lewisham Hospital, Sydney 20

Royal Alexandra Hospital for

Children 814, 854

Sydney Hospital 378, 631

Research at, by N. Rose 750

Women s Hospital, Melbourne, Ob
stetrical Staff of the 190, 530

Hospital Accommodation. Shortage

of, in South Australia 344

Hospital Benefits Act, 1945 125

Hospital Blankets

As a Source of Infection, by P. M.
Rountree and J. JO. Armytage

(O) 503

Treatment of, The, with Oil Emul
sions and the Bactericidal Action
of "Fixanol C" (Cetyl I yri-
dinium Bromide), by I 1 . M.
Rountree (O) " 539

Hospital Color and Decoration, by R.

I . Sloan (note) 190

Hospitals

Slatting of. The: A Statement from

England (Leading Article) 777

Tuberculosis I atients and

By A. H. Penington

I .y D. B. I itt

Hospitals Act Amended

Housing

And Health, Poverty

By J. Brown 29

By A. Bulteau 29

Community, The Sociological As
pects of. by I. B. Scbirc (O) .. 327

Howard, R 451, 180. 040

Hoyle, C 070

Hudson, C., and Little Chondrit is of

the Patella (O) 398

Hudson. Catherine, and Hytten- The
Tuberculin 1 atch Test: A Com
parison with the Mantoux Test
(O)

Human Body after Death, The Study
of the, by K. Inglis (O)

Humanism. War and, by A. G. Butler

Hunter. H. The Special Representa
tive Meeting in London

Hunter, J. G- 553.

Dr.. Flies to England (C.C.) ....

Hunting-ton s Chorea

Hurley, Air Vice-Marshal T. 10. V.,
The Retirement of Surgeon
Captain W. J. Carr and 558

Hurst. A 53

Hurwitz, D 23

Hutehings. J 202

And Wheildon Post-Abort ional
Tetanus with Recovery (R) . . . 404

Hutehings, M. The Relationship of

Food to Health (O) 790

Huxlable, C .452

475

222
L65

715
741

595
308

Page

Huyck, ,|.H 339

Hydalid Cyst, Cerebral (C.C.) 440

Hydronephrosis and Hydroureier,

Renal Calculus 1(53

Hydrophobia, A Case of So-Called:
A Matter of Diagnosis, by W. E.

L. H. Crowther (O) 09

Hydrourcter, Renal Calculus, Hyclro-

nephrosis and 103

Hygiene, Industrial Medicine, Legis
lation and, Outlines of, by J.
Burnel (rev.) 20

I lyndman. O. R 53

I 1 yperchoieeterolaemia, Hyperlipsemia

and, A Case of Diabetes Mellitus
with, by A. M. Henderson (R) 513

Hypertensin (C.C.) 810

I lypertension

Arterial: Us Diagm:s ; s and Treat
ment, by I. H. Page and A. C.

Corcoran (rev.) 83

Essential. Ai 1 [htrodliction to, by
R. F. Herndon (rev.) 740

Hypnosis as a Substitute for Anses-
ihesia. Some observations Con
cerning the Use cf, by It. L. H.
Sampimon and M. F. A. Wo idruff
(O) 393

Hypotonia, Generalized: A Case fcr

Diagnosis 451

Hytten, F. E., and Hudson The
Tuberculin Patch Test : A Com
parison with the Mantoux Test
(O) 475

Illingworth, C. F. W., and Dick (A
Text-Book of Surgical Path
ology) (rev.)

Index to "The Medical Journal of
Australia" (C.C.)

Industrial Nursing: Its Aims and
I ractice. by A. B. Dovvson-
Weisskopf. with a foreword by
10. Summerskil] (rev.) 84

Infection, Droplet Spray, and Res
piratory Activity (C.C.) 447

Infections

Due to Streptococcus Hfemolyticus
Group A following Childbirth
and Abortion, Stained Smears for
the Rapid Diagnosis of, by H. M.

Butler (O) 437

Tendon Sheath, of the Hard, Peni
cillin Therapy for, by J. A.
Marsden (O)

Infectious Disease, Acute, Nursing in,
by F. V. G. Scholes (rev.) .....

Inflammation. Pulmonary Edema
and: An Analysis of Processes
Involved in the Formation and
Removal of Pulmonary Trans-
udates and Exudates, by C. K.
Drinker (rev. ) 739

Influenza, The Prevention of (C.C.) 192

Ingclfinger, F. J 067

Inglis, K 239

Study, The, of the Human Body
after Death (O) 222

Ingram. W. W. Research at the

Kaneinatsu Institute 7*3

Inguinal Region, The Surgical and
Applied Anatomy of the, by E.
S. Meyers 237

Injuries, Acute,, of the Head: Their
Diagnosis. Treat inent. Complica
tions and Sequels, by G. F.
Rowbotham (rev.) 20

Injury- -

"Blast", of the Spina! Cord, Report
of a Faial Case of, by D. Leslie

(R) * : ss

Recto- Vesical, An Unusual (C.C.) 713
Inoculations. Prophylactic, Some
Complications and Sequelae of the,

by M. Kelly (O)

"Inquirer" -- "Atebrin" and De
nial it is: An Inquiry

Intel-vertebral Disk Disease, Lumbar
Recent Advances in the Diagnosis
and Treatment of

By F. Clark 417

By D. Miller 274

By J. H. Young 382

(O) 45

Recent Advances in the Surgical
Treatment of, by F. J. Clark

(O) : 49

Intervertebral Disk, The

By W. H. Godby 237

By D. Miller 340

By M. A. Radcliffe-Taylor .. 237.454
(Leading Article) 53

XIV

INDEX TO TIIK MKDK. AL .JOl RNAL OF AUSTRALIA.

VOL. I, 1946.

Page

Intussusception, Bowel Resection for inn
Iodine in i Iraves s Disease, The

Action of (C.C.) 779

Iris Prolapse 674

Iron Deficiency, Lesions of the Mouth

and (C.C.) 850

Iron, Excretion of (O.C. ) 303

Ironside, R. N., and Batehelor

(Aviation Neuro-Psychia try)

(rev.) 480

Tso-Agglutinin, An Immune Anti-M,

in Human Serum, by R. J.

Walsh (II) H5

Jackson, A. V., and Fenner Enteric
Fever due to Bacterium Enteri-
tidis Var. Blegdam (Salmonella
Blegdam) : A Series of Fifty
Cases in Australian Soldiers
from New Guinea (O)

Jackson Lecture

Jacobs. H., and Bettinger A Con
tribution to the Problem of Mas-
culinization (O)

Jadassohn, J

Jaede. C. H. The Future of Medical
Practice

James, H. M. Recent Experiences in
Canada and the United States
(O)

Japan, Experiences as a Prisoner of
War in, by S. E. L. Stening (O)

313

127

227

823

827
773

547

617

487

298
193
531

SOS

141
3 Of.

117

ir,7

Jaundice

Obstructive, The Bleeding Ten
dency in : Diagnosis and Manage
ment, by P. Fantl (O)

Value, The, of Biochemical Tests
in the Interpretation of, by A.
B. Corkill, D. J. Pollock and Cr.
E. Smith (O)

Jens, J

Joel, N. C. Local Amputation of
Gangrenous Toes in the Presence
of Glycosuria and Senility (R) .

Johnson, F. C

Johnstone, J. W 196,

Joints. Atlas of Surgical Approaches
to Bones and, by T. Nicola (rev.)

Jones, P.. and Embelton Volvulus
of the Small Bowel, with Report
of a Case Treated by Resection
with Recovery (O)

Jones, S. Evan

Journal, The, and the Recent Indus
trial Unrest (Leading Article) .

Julius, S

Jurisprudence, Medical, and Toxi
cology, by J. Glaister (rev.) ....

Jury. L. R. The Pharmaceutical
Benefits Act. 1944

Kanematsu Institute

Research at the

By A. F. Burrett

By A. J. Canny 642,

By J. C. Eccles

By W. W. Ingram

By T. H. Vickers

Kaplan, I. L

Kater, N. M. A Jungle Appendicec-

tomy (R)

Katz, L,. N

Kelly, M.

Professor Ralph Stockman

Some Complications and Sequelae
of the Prophylactic Inoculations

(O)

Kennedy. F

Kennedy, R. T.

Remarkable "Dr." Spencer, The

(O) 149

Young Dr. Storch of Adelong (O) 362

Kepner. R. De M 11 S

Keratitis, Vitamin C (Ascorbic Acid)

in 675

Kern, F., junior 159

Kersley, G. D. (Outlines of Physical

Methods in Medicine) (rev.) . . 336

Kety. S. S 707

Kinsella, V. J 535

Kirk, N. T 808

Knox, O. M. (Principles of Pediatrics

and Pediatric Nursing) (rev.) . 703

Kohlstaedt 810

Kosmak, G. AV 411

Kruse, H. D 669

631

782
896

641

i S &gt;
642
666

S22

800
84

I age

Labour

Analgesia in 1 97

.Management of, The 1 9!i

Progress of, The, and Palpation . . 196

Symposium on 196

Third Stage of. Management of the 199

Uterine Pains in 196

Lace, M. V. (Massage and Medical
Gymnastics, with a foreword by

J. Mennell) (rev.) 24S

Laidley, J. W. S., and Cummine The
Empirical Use of Penicillin for a
Sulphonamide-Resistant Patient

(R) 476

Lang, W. R. A Case of Addison s
Suprarenal Syndrome of Primary

Pituitary Origin (R) 3

Langdon-Brown, W 703

Langley, Francis Ernest, Death of . . 490
Latham, Mr. Justice, Chief Justice . 254
Law, T. Boyd Penicillin in Pre-
Operative and Post-Operative

Ophthalmic Surgery (R) 442

Lawrence, J. H 483

Lawson, R. S. Report of a Case of

Ami Tobic Pyuria (R) 550

Leading Articles

Australia and Science: The Uni
versity of Sydney and Scientists 249
Cerebral Trauma and its Mechan-

o o ,~

isms Boo

Clinical Discipline 409

Dietary Deficiencies and Oral

Structures 85

Discussions on Health. Legislation
in the United States of America 301

Eyes 705

Federal Medical War Relief Fund,

The 229

Food Consumption in Australia . . 21
Heavy Blow, A, to Medical

Research ** :&gt;&gt; 1

Institute, An, of Medical Research

for Queensland 157

Intervertebral Disk, The 53

Journal, The, and the Recent Indus
trial Unrest 1 1 "

Meeting, The, of the Federal

Council 553

National Health Service Bill of

Great Britain, The 517

Overseas Travel for Australian

Students 191

Paludrine" 229

Parenteral I se of Vitamins, The . . 667

Peace and the Individual 481

Report, A

From Great Britain on a Com
prehensive Dental Service . . . 593
On the Remuneration of General

Practitioners 809

Research in Medical History .... 445
Retirement. The, of Surgeon Cap
tain W. J. Carr 117

Special Representative Meeting in

London. The 741

Staffing of Hospitals, The : A State
ment from England 777

"Story, The, of a Great Achieve
ment" :&gt; &gt; : &gt;7

Treatment, The, of Rheumatism by

Dehydration 373

Women in Medicine 849

World Food Shortage, The 921

Lead Poisoning 124, 816

Leakage after Intestinal Anastomosis,

The Prevention of (C.C.) 88 1 !

Lee, A. E.

Case, A, of Intractable Constipation 165

Low Backache (O) 42

Lee, D. H. K 157

Lee, R. 1 302

Legacy Club, The, by E. P. Blashki 63
Legislation and Hygiene. Outlines of
Industrial Medicine, by J. Burnet

(rev.) 20

Leichtentritt, B 670

Lemerle, T. H 234

Lemmon, W. M. . . 197

Leprosy

Human, Observations on : Infection
of Rats with Human Excretal
Organisms, by J. W. Fielding
(O) , 578

Rat, Further Observations on, by
J. W. Fielding (O) 681

Report. A. of Nine Cases among
Natives of the Mount Hagen
Area in New Guinea, by N.
Shlimovitz (R) 369

I age
Leslie, D. R.

Case, A, of Gunshot Wound of the

Large and Small Intestines (R) MM;
Report of a Fatal Case of "Blast"

Injury of the Soinal Cord (R) . . 188
L Estrange, Guy Stuart, Death of .. 204
Leucotomy, 1 refrontal, The Results

of (C.C.) 118

Lewis, F. T 86, 87

Lewis, N. D. C 919

Lewisham Hospital, Sydney 26

Ley, Dr. Robert, The Brain of (C.C.) 447

Limbs, Artificial, Supply of 124

Line!, I . E., Beveridge and Camp
bell Pleuropneumonia-Like Or
ganisms in Cases of Non-
Gonococcal Urethritis in Man and
in Normal Female Genitalia (O) 179

Linen for Doctors Surgeries 123

Lipomata of the Uterus, with Report

of a Case, by J. 1 &gt;. Hicks (O) 184

Liquid Fuel Supplies 123

Liquor Reform Society 124

Little, A. G., junior 303

Little, N 58, 59

And Hudson Chondritis of the

Patella (O) 398

Some Further Observations on

Sciatica (O) 33

Liver, Rupture of the, in the New-
Born : Recovery after Blood
Transfusion and Laparotomy, by

F. Arden (R) 187

Loewenthal, L. S. Inguinal Hernia

and its Repair 381

London Letter 603

Long, J. C 23

Lowsley, O. S. (The 1945 Year Book

of Uroloay) (rev.) 776

Lcwther, F. de L 849

Luckiesh, M 375

Ludwig s Angina, A Case of, by V.

Bulteau (R) 514

Lull. C. B., and Kingston (Control of
Pain in Childbirth, with an intro
duction by N. W. Vaux) (rev.) 408
Liii -.;. Diseases of the. The Correla
tion of Physical and X-Ray
Findings in : Chest Examination,
by R. R. Trail, with a foreword
by W. L. Langdon-Brown (rev.) 703
Lung Abscess, Putrid, by C. J.

Officer Brown (O) 107

Lymphangioendothelioma, Abdominal,
or Peritoneal Mesothelioma. A
Case of, by I. Hamilton and J.

B. Cleland (R) 477

Lyons, A. Trigeminal Neuralgia . . 750

Lyons, R 631

Lyttleton, O, The Right Honourable 337

MacCallum, P 92

Mace, L. M 483

Macindoe, N. M 674

Mackerras, I. M., and West "DDT"

Poisoning in Man (R) 400

Mackerras, M. J 234

Mackie, M. A 533

MacLaurin, C 340

Macnamara, J 640,641,712

Macpherson, M 374

Mary, I. G. (Nutrition and Chemical
Growth in Childhood, with a fore
word by L. Reynolds and a
supplement by J. O. Holmes)

(rev.) 884

Magee, C. G 23

Malaria

By K. Byrne 930

By M. R. Finlayson and J. McF.

Rossell 784

Unusual Case of, An

By X. Cunningham 453

By R. F. Matthews 380

Malaria Control, New Conceptions of,

by C. E. M. Gunther (O) .... 510
Malaya and Thailand, Observations
by a Pathologist during Three
and a Half Years as a Prisoner
of War in. by A. T. H. Marsden

(O) . 766

Malosetti, H. E 159

Mantoux Test, The The Tuberculin
Patch Test : A Comparison with
the by Catherine Hudson and

F. E. Hytten (O) 475

Maori, Blood Groups in the, by J. J.

Graydon and R. T. Simmons (O) 135
Marat Jean-Paul: Visionary or Vil
lain? (C.C.) 340

Marble, H. C 54

Marks, A 816

Marlev, H. W. H 157

VOL. I, 1946.

INDEX TO THE MEDICAL JOURNAL OF AUSTRALIA.

Page

Marrack, J. K., Panton and May

(Clinical Pathology) (rev.) .... 848

Marsden, A. T. H.

Detection, The, of the Cysts of
Entamceba Histolytica in the
Faeces by Microscopic Examina
tion (O) 915

Observations by a Pathologist
during Three and a Half Years
as a Prisoner of War in Malaya
and Thailand (()) 76U

Marsden, J. A.

Penicillin Therapy for Tendon
Sheath Infections of the Hand

(O) 435

Report on a Case of Burns Com
plicated by Haematemesis and

Melena (R) 551

Marshall, C. E. Chronic Vesiculitis
as a Factor in the Production of
Non-Gonococcal Urethral Dis
charges (O) 846

Marshall, S. V. -Spinal Anaesthesia
and Chloroform : A Comparison

of Mortality 750

Marvin 87

Masculinization, A Contribution to

the Problem of, by H. F.

Bettinger and H. Jacobs (O) .. 10

Massage and Medical Gymnastics, by

M. V. Lace, with a foreword by

J. Mennell (rev.) 248

Massler, M 85

Masten, M. G 919

Matthews, R. F. An Unusual Case

of Malaria 380

Matzke 87

Maun, M. E 670

Maxwell, J. (Introduction to Diseases

of the Chest) (rev.) 228

May, H. B., Panton and Marrack

(Clinical Pathology) (rev.) .. 848

Mayock, R. L 594

Mayer-Gross, W 118

Ma yes, B. T.

Obstetric Bulletins 275

Placenta Prsevia 715

"M.B., B.S." Ulcers in the Mouth :

An Appeal for Help 274

McArthur, G. A. D. Some Notes on
West s Operation (Endonasal

Dacryocystostomy ) (O) 508

McCance, R. A 303

McCarthy, C. M 92(5, 927

Rehabilitation, The, of War

Neurotics (O) 910

McCulloch. R. N. Studies in the

Control of Scrub Typhus (O) . . 717

McCutcheon, A 129

McDonald, C. G 674

McDonald, Edward, Death of 9f&gt;

McKellar, C. C. Honorary Medical

Staffs 894

McKillop, W. J 203

McLachlan, A. E. W. (Handbook of
Diagnosis and Treatment of

Venereal Disease) (rev.) 336

McLaren, C. I. A Psychiatric Pro
gramme for Peace 677

McLaren, W. W 450, 451

McLean, George, Death of 240

McLean, J 711

McLorinan, H 93, 638, 641

Report, A, on Sixteen Cases of

Supraglottic CEdema (O) 220

McMahon, F. F. Ulcers in the

Mouth : An Appeal for Help . . 715

McTiernan, Mr. Justice 271

McVilly. C. L. The Central Hospital.

Melbourne 203

Means, J. H 779

Medical Annual, The (C.C.) 341

Medical Appointments 96, 204,

276, 348, 384, 420, 456, 492, 536, 572,
608, 644, 680, 716, 752, 788, 860, 896, 932
Important Notice . 32, 64, 96, 132,
168, 204", 240, 276, 312, 348, 384,
420, 456, 492, 536, 572, 608, 644,
680, 716, 752, 788, 824, 860, 896, 932
Medical Benefits Fund of New South

Wales 601

Medical Conference, An International

(C.C.) 633

Medical Curriculum. Anatomy in the,

by A. A. Abbie (O) 152

Medical Defence Society of Queens
land 816

Medical Education and Medical Prac
tice in Germany during the War

(C.C.) 923

Medical Finance Limited 602

Medical History, Research in (Lead
ing Article) 445

Page

Medical Officers, Certain Service, The
Training Prior to Discharge of

30,
Medical Practice

Dangerous Drugs Regulations of

Victoria

Future of, The, by C. H. Jaede . .

In Tasmania, The Changing Face

of, An Address, by G. M. W.

demons (O)

Medical Practitioners and Evidence

at Inquests

Police Offences (Amendment) Act

of New South Wales

Supply, The, of Motor-Cars

Medical Prizes The Stawell Prize . .
Medical Profession, Politics and the

An Address, by J. Dale (O)

By A. Barber

By P. G. Dane 417,

By E. I . Dark 534,

By G. O Day

By N. Pern 416,

Medical Sciences Club of South Aus
tralia

Medical Societies

Medical Defence Society of Queens
land

Medical Sciences Club of South

Australia

Medico-Legal Society of Victoria,

The

Melbourne Psediatric Society . . 27,

59, 92,129,162,450,

486, 636, 675, 710, 890,

Obstetrical Society of the Women s

Hospital, Melbourne 196,

Public Medical Officers Association

of New South Wales, The

Medical Staffs, Honorary, by C. C.

McKellar

Medical Students, The Selection of,
in Relation to the Needs of a
Community and the Facilities
Available for Instruction, by

Lambert Rogers

Medical Training, The Adequacy of

By K. J. B. Davis

By B. Williams (O)

Medicine-

For Nurses, by W. G. Sears (rev.)
General, The 1945 Year Book of,
bv G. F. Dick et alii

240

382

823

609
345

of, A, by D. Guthrie

edited
(rev.)
History
(rev.)

Industrial, Legislation and Hygiene,

Outlines of. by J. Burnet (rev.)

Outlines of Physical Methods in,

by G. D. Kersley (rev.)

Psychological, A Short Introduction
to Psychiatry, with an Appendix
on Psychiatry Associated with
War Conditions, by D. Curran
and E. Guttmann, with a fore
word by J. J. Conybeare (rev.)
Social, The Basic Wage, Shortage
of Nurses and

By M. C. DeGaris

By E. S. Meyers (O)

Textbook of, by Various Authors,
edited by J. J. Conybeare (rev.)

Women in (Leading Article)

Medico-Legal Hooking versus Bell
Medico-Legal Society of Victoria, The
Meehan, A. V.

Address, An (O)

Low Back Pain (O)

Melbourne Paediatric Society . . 27,

59, 92, 129, 162, 450,

486, 636, 675, 710, 890,

Melbourne Permanent Post-Graduate

Committee (see Post-Oraduate

Work)

Mello-Leitao. C

Melnick, D 410,

Memorial, A, to the Late Professor

James Thomas Wilson

Men, Normal Young, A Study of:
What People Are, by C. W.

Heath (rev.)

Meningitis

And Ventriculitis, Staphylococcal :
Cure by Penicillin, by D. Miller

and H. J. Delohery (R)

Hsemophilus Influenzae, The Treat
ment of. with Sulphonamides in
Conjunction with Haemophilus
Influenzae, Type B, Rabbit Anti-
serum, by E. A. North, H. Wilson

and G. Anderson (O)

Purulent, of Infancy and Child
hood : A Twelve Months Survey
of the Results of Treatment by
Penicillin, by E. K. Turner (O)

65
416
784
929
273
677

817

816
817
273

928
530
414
894

162

275
147

920

443

336

408
849
254
273

133

928

811
411

348
444

512

215
14

Page

Mennell, J 248

Mennell, J. B. (Physical Treatment
by Movement, Manipulation and

Massage) (rev.) . . . 444

Meschan, I. A Radiographic Analysis

for Spondylolisthesis (O) 465

Mesothelioma, Peritoneal, Abdominal
Lymphangioendothelioma or, A
Case of, by I. Hamilton and J.

B. Cleland (R) 477

Meyers, E. S.

Basic Wage, The, Shortage of

Nurses and Social Medicine (O) 548
Organization of a Profession .... 784
Surgical and Applied Anatomy,

The, of the Inguinal Region .... 237
Michaelis, L. S. (Anatomical Atlas

of Orthopaedic Operations) (rev.) 848
Milk of Melbourne Women, Ascorbic

Acid in the, by D. Winikoff (O) 205
Milk Supply, Bacteria in Relation to
the : A Practical Guide for the
Commercial Bacteriologist, by C.

H. Chalmers (rev.) 479

Miller, D 58

And Delohery Staphylococ c a 1
.Meningitis and Ventriculitis:

Cure by Penicillin (R) 512

Intervertebral Disk, The 346

Recent Advances in the Diagnosis
and Treatment of Lumbar Inter-
vertebral Disk Disease 274

Miller, J. B 746

Millin, T 230

Minor, G. R 555

Minot, G. R 743, 920

Mitchell, 1 . C 84

Mitral Stenosis, Early 814

Molcsworth, E. H 415

(An Introduction to Dermatology,
with a Chapter on the Theory
and Technique of X-Ray and
Radium Therapy, with a Fore
word to the First Edition by J.

Jadassohn) (rev.) 227

Late Herbert Michael Moran, The 311
Mollison, Dr. C. H., Retirement of,
from the Office of Honorary

Treasurer 92

Moncrieff, A 479

Money, R. A 58, 59, 707

Sciatica (O) 37

Monk, I. Amicrobic Pyuria 785

Montevideo Faculty of Medicine,

Annals of the (C.C.) 158

Moore, D. R. Australia and Science :
The University of Sydney and

Scientists 418

Moore, F. D 779, 851

Moore, J. N. P 118

Moran, Herbert Michael

Death of 415, 535

The Late, by E. H. Molesworth . . 311
Morris, J. G. The Treatment of

Scabies 380

Morris, J. Newman Medical Aspects
of Red Cross in the Second
World War The Sir Richard

Stawell Oration (O) 169

Morrison, G 533

Morrow, A. W. A Disclaimer 678

Morton, C. R. The Botany of Too-
woomba and Environs and its
Relation to Clinical Allergy of
the Upper Respiratory Tract (O) 585

Moschowitz, E 193

Motor-Cars, The Supply of 95

Motor-Car Tires and Accessories .... 123
Moulds in the Lungs, by J. B.

Cleland (R) 247

Mouth, Lesions of the, and Iron

Deficiency (C.C.) 850

Muecke, Roy LePage, Death of .... 311
Murmurs from Turbulent Flow (C.C.) 339

Murphy, A 157

Sudden Death following Initial
Injection of a Mercurial Diuretic

(R) 589

Murphy, E. Low Backache (O) ... 44
Murphy, E. M. Ulcers in the Mouth :

An Appeal for Help

Murphy, J. A. R. Bacille Calmette

Gurin

Murray, N. E., and Reid Experi
mental Observations on the
Aural Effects of Gunblast (O) . 611

Murray, Senator 302

Muscular Atrophy, Peroneal 379

Nathanson, I. T 707

National Health and Medical Re
search Council, The 561

XVI

INDEX TO THK MKDICAL JOURNAL OF AUSTRALIA.

VOL. I, 1946.

Page

National Health Service Bill of Great

I .ritain, The 524, 740

By S. Siecllofky 891!

(Leading Ari cle) 517

Naval Medical Services, The Aus
tralian 566

Naval, Military and Air Force
Appointments . . . 3i, 132, 166, 203,
275, 311, 347, 453, 605, 643,
675, 712, 747. 782, 818, 857, 891

Casualties 31 , 64,168.419,

491, 606, 782, 891

Decorations 380, 419, 571

Training, The, Prior to Discharge
of Certain Service Medical

Officers 30, 240

Neil, J. Hardie 670

Nelson, T. Y 707

Nephritis, Acute, Modern Treatment

in (C.C.) 742

Nervous Diseases, The Diagnosis of,

by J. Purves-Stewart (rev.) .. 739

X( rvous System

Central, Early Diagnosis in
Tumours of the, by W. Lister
Reid (O)

Diseases ot the, by F. M. R. Walshe
(rev.) I

Neuralgia, Trigeminal

By F. J. Clark

By A. Lyons

865
52

895
750

Neurology

And Neuropsychiatry, Recent Ad
vances in, by W. R. Brain and

E. B. Strauss (rev.) 371

Psychiatry and Endocrinology,
The 1945 Year Book of, edited
by H. H. Reese et alii (rev.) .. 919
Neuropathology, Textbook of, by A.

Weil (rev.) 299

Neuro-Psychiatry, Aviation, by R. N.
Ironside and I. R. C. Batchelor

(rev.) 480

Neuroses, War, by R. R. Orinker and

J. P. Spiegel (rev.) 630

Neurosurgical Patient, The : His
Problems of Diagnosis and Care,

by C. W. Rand (rev.) 247

Neurosyphilis 306

Tabetic Form with Optic Atrophy 306

Tabo-Paretic Type 307

Neurotics, War, The Rehabilitation

of 926

By C. M. McCarthy (O) 910

By H, H. Willis (O) 912

Newcastle Disease of Fowl:-, Virus
of, A Note on Two Laboratory
Infections with the, by S. G.
Anderson (R) . 371

New Guinea- -

Enteric, Fever due to Bacterium
Enteritidis var. Blegdam (Sal
monella Blegdam) : A Series of
Fifty Cases in Australian
Soldiers from, by F. Fenner and
A. V. Jackson (O) 313

Leprosy : A Report of Nine Cases
among Natives of the Mount
Hagen Area in, by N. Shlimovltz
(R) . 369

Salmonella Blegdam Causing Infec
tions in Humans in, Preliminary
Report on Strains of, by N.

Atkinson (O) 326

New-land, H 558

Newson, A., and Rose -

Compound Fractures of the Ex
tremities due to Gunshot
Wounds : The Early Results of
Treatment in the Field Aided by

Penicillin Therapy (O) . . 330

Early Results of the Treatment of

Gunshot Wounds of Limb Joints

Aided by Penicillin Therapy (O) 75

Suture of Deep Soft Tissue War

Wounds Aided by Penicillin

Therapy (O) 364

Treatment of Gunshot Wounds of
the Chest in the Field Aided by

Penicillin Therapy (O) 290

And Watson Early Results in a
Short Series of Cases of Gun
shot Wounds of the Abdomen

(O) 180

Newton, A 570

New Zealand Letter 344, 676

Nicholls, L. (Tropical Nutrition and

Dietetics) (rev.) 51fi

Nicola, T. (Atlas of Surgical Ap
proaches to Bones and Joints)
(rev.) SOS

Page
Nicotinic Acid, Studies in. by It. W.

Hawker (O) 872

Nightingale, H. J 671

Nimmo, J. R. -Epidemic Polyarthritis 380
Nissen, R. (Duodenal and Jejunal
Peptic Ulcer : Technic of Resec
tion, with a Foreword by O. H.

Wangensteen) (rev.) 189

Noble, R. A 31

Nominations and Elections 32,

64, 168, 203, 240, 311. 347, 383,
420, 455, 492. 536, 571, 607, 644,
679, 716, 751, 787, 824, 859, 895, 931

North, E. A.

And Christie Acquired Resistance
of Staphylococci to the Action

of Penicillin (O) 176

Wilson and Anderson

Resistance, The, of Haempphilus
Influenzse to the Action of
Penicillin, with Special Refer
ence to Type B Strains (O) 626
Treatment, The, of Haemophilus
Influenzas Meningitis with Sul-
phonamides in Conjunction
with Hasmophilus Influenzas,
Type B, Rabbit Antiserum (O) 215
Northern Territory, A Sociological
Study of the Aborigines in the,
and their Eye Diseases, by M.

Schneider (O) 99

Notes on Books, Current Journals and

New Appliances
Artificial Respiration Explained,

by F. C. Eve 516

Commodore, The, by C. S. Forester 116
Green Armour, by O. White .... 516
Hospital Color and Decoration, by

R. P. Sloan 190

Pacific Parade, by F. Clune 704

Talk 552

Notice 204, 456, 572,

747, 752, 788, 896
Special Representative Meeting in

May 536

Nuffield Medical Endowment 895

Nurses

Demonstrations of Operative Sur
gery for, by H. Bailey (rev.) .. 516
Medicine for, by W. G. Sears (rev.) 20
Shortage of, and Social Medicine,
The Basic Wage

By M. C. DeGaris 785

By E. S". Meyers (O) 548

Nursing

In Acute Infectious Disease, by F.

V. G. Scholes (rev.) 300

Industrial : Its Aims and Prac
tice, by A. B. Dowson-Weisskopf,
with a, foreword by E. Summer-
skill (rev.) 84

Obstetric Management and, by H.
L. Woodward, B. Gardner et

alii (rev.) 703

Pediatric, Principles of Pediatrics

and, by C. M. Knox (rev.) .... 703
Nursing Procedures, Modern Prac
tical, by M. K. Doherty, M. B.
Sirl and O. I. Ring (rev.) .... 630

Nutrition

And Chemical Growth in Childhood,
by I. G. Macy, with a foreword
by L. Reynolds and a supplement

by J. O. Holmes (rev.) 884

And Dietetics, Tropical, by L.

Nicholls (rev.) 516

Post-W T ar Plans for, in Canada . . 93

Nutt, A. L 707

Nye, L. J. J. The Saliva Factor in

Peptic Ulceration (O) 114

Obituary

Allan, George 453

Anderson, George Murray . . 608, 786
Aspinall. Andrew Eric, and Archi
bald John 238

Bowker, Cedric Victor 823

Bray, George William 489

Bruce, James Whitson Kemp 132

Buchanan, George Arthur 716

Campbell, Alice Pritchard 311

Clayton, George Edward Burdekin 716

Cosh, John Inglis Clark 311

Crooke, Robert Warren 895

Davies, Harold Whitridge 859

Frayne, Ernest John 895

Fullerton, Alexander Young 490

Graham. Walter Robert 32

Hardie, David 95

Hay, Arthur 96

I -age
Obituary Continued.

1 I irschfeld, Eugen 931

Langley, Francis Ernest 490

L Estrange, Guy Stuart 204

McDonald, Edward 96

McLean, George 240

Moran, Herbert Michael .... 415, 535

Muecke, Roy LePage 311

I igdon, Douglas Clelland 451

l 61ya, Eugene 823

Retallack, Cyrus Bath 859

Rogerson, Edward 752

Hosebery, Sidney Solomon 204

Smith, Redford John Wright .... 716

Sutcliffe, Ernest Weston 859

Tennent. Joseph Thorn 536. 823

Van Someren, George Arbuthnot . . 716

Vickers, Wilfred 384

Wilkinson, William Camac . . 204, 488

Wilson, James Thomas 31

Wright-Smith, Redford John 931

O Brien, J. P. On the Prickly Heat 164
Obstetrical Society of the Women s

Hospital, Melbourne 196, 530

Obstetric Bulletins, by B. T. Mayes 275
Obstetric -Management and Nursing,
by H. L. Woodward, B. Gardner

et alii (rev.) 703

Obstetric Service, A Complete (C.C.) 554

( )l&gt;stetrics

And Gynaecology

Recent Advances in, by A. W.
Bourne and L. H. Williams

(rev.) 299

Synopsis of, by A. W. Bourne

(rev.) 666

And Gynecology, The 1945 Year
Book of, edited by J. P. Greenhill
(rev.) 884

Obstruction

Intestinal, Acute, The Treatment
of, by J. T. Chesterman (rev.) 156

Pyloric, without Tumour 59

Occipito-Posterior Positions, Some
Points in the .-Etiology and

Mechanism of 531

Occipito-Posterior Presentation, The

Management of the 532

Occiput, Posterior Position of the . . 530
Points in Statistics and /Etiology . 530

Ocular Syndrome, An 674

O Day, G.- Politics and the Medical

Profession ...._. 273

CEclema (see also Edema)

Supraglottic, A Report on Sixteen
Cases of, by H. McLorinan (O) 220

CBsophagus, Congenital Stricture of

the, by R. Flynn (R) 702

Oestrogen Reaction, Unusual, in a

Boy (C.C.) 595

Ohler, W. R 23

Oldham, J. Spinal Analgesia (O) .. 432

ophthalmic Practitioners, The Short
age of 569

ophthalmic Surgery, Penicillin in
Pre-Operative and Post-Opera
tive, by T. Boyd Law (R) ... 442

Ophthalmological Society of Aus
tralia (British Medical Associa
tion) 747

Oppenheim s Disease, Amyotonia

Congenita 854

Opticians and Optometrists, The
Teaching of, in any Branch of
Ophthalmology 567

Oral Structures, Dietary Deficiencies

and (Leading Article) S5

Organization of a Profession, by 1C.

S. Meyers 784

Orthopaedic Operations, Anatomical
Atlas of, by L. S. Michaelis
(rev.) . . . . 848

Oser, B. L 410, 411

i &gt;sseous System, The : A Handbook
of Roentgen Diagnosis, by V. W.
Archer (rev.) tit! 6

Osteomyelitis

Chronic, The Digestion of Dogs

and. by Curious" 275

Of the Acetabulum S54

Short Note, A, on the Changing

Outlook in, brought about by the

Introduction of Penicillin, by R.

D. McKellar Hall (R) 401

Pacific Parade, by F. Clune (note) 704

I age S10

Page, I. H., and Corcoran (Arterial
Hypertension : Its Diagnosis and
Treatment) (rev.) S3

VOL. I, 1946.

INDEX TO THE MEDICAL JOURNAL OF AUSTRALIA.

xvii

Page
1 ain, A. A.

Functional Disorders 131

I sychotherapy 859

Pain

Control of, in Childbirth, by C. B.
Lull and It. A. Kingston, with
an introduction by N. W. Vaux

(rev.) 408

In the Right Iliac Fossa, Two
Causes of (C.C.) 303

"Paludrine"

(Leading Article) 229

(M.488S) in Australia, Researches
on 234

Pancreas

Congenital Fibrocystic Disease of
the

By 1 . E. Blaubaum (O) 833

By L. Dods 929

Division of the, An Experimental
Study on Pancreatic Secretion

and (C.C.)

1 anton, P. N., Marrack and May

(Clinical Pathology) (rev.) ..

Papataci Fever, The Clinical Picture

of, especially in Palestine, by A.

Sandier (O) 789

Papuans, Further Observations on
the Rh and Hr Factors, and the
Blood Group Frequencies in, by
R. T. Simmons, J. J. Graydon and

E. F. Woods (O) 537

Paralysis

Sleep (C.C.) 811

Tick (C.C.) 339

Parr, L. J. A., and Shipton Spondy-

litis Ankylopoietica (O) 277

Parsons, L. G 20

Patella, Chondritis of the, by X.

Little and C. Hudson (O) ... 398

Pathological Exhibits 103

Pathological Services for New South

Wales, Comprehensive 601

Pathology

Clinical, by P. N. 1 anton, J. R.

Marrack and H. B. May (rev.) 848
Surgical, A Text-Book of. by C.

F. W. Illingvvorth and B M.
Dick (rev. ) 33G

Paul, X. "Atebrin" and Dermatitis :

An Inquiry 715

Paykoc. Z. V 743

Peace

And the Individual (Leading

Article) 481

Psychiatric Programme for, A

By R. S. Ellery (O) 457

By C. 1. McLaren 077

Peacock, W 779

Pediatric X-Ray Diagnosis: A Text
book for Students and Prac
titioners of Pediatrics, Surgery
and Radiology, by J. Caffey
(rev.) 807

Pediatrics

Principles of, and Pediatric Nurs
ing, by C. M. Knox (rev.) .... 703

Year Book of, The 1945, edited by
I. A. Abt, with the collaboration
of A. F. Abt (rev.) 884

I enicillin

Acquired Resistance of Staphylo-
cocci to the Action of, by E. A.
North and R. Christie (O) .... 170

And the Skin (C.C.) 411

Empirical Use of, The, for a Sul-
phonamide-Resistant Patient, by
H. G. Cummine and J. W. S.
Laidley (R) 476

In I re-Operative and Post-Opera
tive Ophthalmic Surgery, by T.
IJoyd Law (R) 442

In the Laboratory Diagnosis of
Whooping-cough, A Note on the
1 se of. by I 1 . M. Anderson (O) 244

Purulent Meningitis of Infancy and
Childhood: A Twelve Months
Survey of the Results of Treat
ment by, by E. K. Turner (O) 14

Resistance, The^ of Htemophilus
Influenza to the Action of Peni
cillin, with Special Reference to
Type B Strains, by E. A. Xorth,
H. Wilson and G. Anderson (O) 626

Septic Thrombosis of the Cavernous
Sinus Treated with Penicillin . . 674

Short Note, A, on the Changing
Outlook in Osteomyelitis brought
about by the Introduction of, by
R. D. McKellar Hall (R) 401

Page

Penicillin Continued.

Staphylpcoccal Meningitis and Ven-
triculitis : Cure by, by D. Miller

and H. J. Delohery (R)

Tetanus Treated with : Recovery,
by J. L. Grove (R)

Penicillin Sensitivity of Streptococci
Mostly of Groups A, B, (.. and
G, by R. T. Simmons and R.
Christie (O)

Penicillin Therapy

Compound Fractures of the Ex
tremities due to Gunshot
Wounds : The Early Results of
Treatment in the Field Aided by,
by T. F. Rose and A. Xevvson

(O)

Early Results of the Treatment
of Gunshot Wounds of Limb
Joints Aided by, by T. F. Rose

and A. Xewson (O)

For Tendon Sheath Infections of
the Hand, by J. A. Marsden

(O)

In the Treatment of Gonorrhoea,
The Results of, by S. Siedlecky

(O)

Suture of Deep Soft Tissues War
Wounds Aided by, by T. F. Rose

and A. Xewson (O)

Treatment of Gunshot Wounds of
the Chest in the Field by, by P.

Braithwaite

Treatment of Gunshot Wounds of
the Chest in the Field Aided by,
by T. F. Rose and A. Newson
(O)

Penington, A. H. Tuberculosis
Patients and Hospitals

Pepper, p. H. Perry

Periarteritis (Polyarteritis) Xodosa,
A Case of, by J. Game (R) ....

Pericarditis

Amojbic (C.C.)

Suppurative, with Recovery, Re
port of a Case of Salmonella
Blegdam Septicaemia and, by
J. F. C. C. Cobley and T. E.
Wilson (R)

Perineal Repair, Episiotomy and ....

Pern, X. Politics and the Medical
Profession 416,

Personality Factors in Counseling,
by C. A. Curran, preface by M.
J. Ready, introduction by C. R.
Rogers ( rev. )

Pett, L. B

Pharmaceutical Benefits Act, 1944,

The 91, 126, 562,

By L. R. Jury

Photographs, Clinical

Physical Methods in Medicine, Out
lines of, by G. D. Kersley (rev.)

Physical Treatment by Movement,
Manipulation and Massage, by
J. B. Mennell (rev.)

Physiology, Human, Principles of, by
C. Lovatt Evans ; with section
of the special senses by H. Hart-
ridge (rev.)

Pickering, E. W

1 igdon, Douglas Clelland, Death of .

Pink Disease

Pitt, D. B. Tuberculous Patients and
Hospitals ._

Placebo, The (C.C. )

Placenta Praevia

By H. C. Gallagher

By B. T. Mayes

By J. X. R. Stephen 490,

By R. H. Syred (O)

Plant, A

Plasma Protein Estimations in Battle
Casualties, by T. E. Wilson (O)

Pleuropneumonia-Like Organisms in
Cases of Xon-Gonococcal Ure-
thritis in Man and in X ormal
Female Genitalia, by W. I. B.
Beveridge, A. D. Campbell and
P. E. Lind (O)

Pneumothorax, Artificial, Pulmonary
Tuberculosis Treated by

Poate, II. R. G

And Spencer "Thio" Drugs in

Thyreotoxicosis

(O)

Pockley, E. "Beach Foot"

Poisoning

D.D.T., in Man, by I. M. Mackerras

and R. F. K. West (R)

Lead 124,

Police Offences (Amendment) Act of
New- South Wales

330

75
435
904
364
418

290

237

887

295
159

439
200

677

807
93

601

893

378

441

704
632
451
816

887

571
715
894
357
193

153

179

378

779

750
493
346

400
816

1 age

Poliomyelitis 636

Acute Anterior 124

Epidemic of, An, Occurring among

Troops in the Middle East, by

J. E. Caughey and W. M.

I orteous (O) 5

Paralysis, Mild, Early Detection of iin
Question of Diagnosis, A, by D. A.

Brown 822

Virus of, The j.. . . 638

Politics and the Medical Profession
Address, An, by J. Dale (O) .... 65

By A. Barbtr 416

By P. G. Dane 417,784

By E. 1 . Dark 534, 929

By G. O Day ". 273

By N. Pern 416, 677

Pollock, D. J., Corkill and Smith
The Value of Biochemical Tests
in the Interpretation of Jaun
dice (O) 617

Polya, Eugene, Death of 823

Polyarteritis Periarteritis Xodosa,

A Case or, by J. Game (R) .... 295

Polyarthritis, Epidemic

By P. G. Dowling (O) 245

By J. R. Ximmo 380

Pontine Degeneration, Progressive . 309

Pope, A 707

Pope, K. S 234

Porphyria

Acute, with Reports of Two Fatal
Cases, by E. H. Derrick (O) . . 241

(C.C.) 250

Porteus. S. D 118

Porteous, W. M., and Caughey An
Epidemic of Poliomyelitis Occur
ring among Troops in the Middle

East (O) 5

Post-Graduate Facilities in the

United States 567

Post-Graduate Medical Education
Committee of the University of
Queensland (see Post-Graduate
Work )

Post-Graduate Work

Melbourne Permanent Post-Gradu
ate Committee 92

Course at Geelong 535

Course on Anaesthesia in Mel
bourne 535

Courses at Melbourne during

1946 for Medical Graduates .. 62
Course at the Women s Hospital 751

Programme for March 203

Programme for April 383

Programme for June 643

Programme for July 821

Refresher Course for General

Practitioners in Melbourne ... 714
Xew South Wales Post-Graduate

Committee in Medicine 203

Annual General Course in Syd
ney: Programme for April .. 455

Course at Armidale 751

Course in Advanced Medicine at

Sydney 737

Course in Clinical Pathology at

Sydney . . 895

Course in Gynaecology and Ob
stetrics at Sydney 821

Courses in Sydney 311

Film Afternoon at Sydney . . 348,

679, 859
Film Programme at Sydney . . 535

Lectures at Sydney 859

Programme of Courses in Sydney

for 1946 " 607

Overseas Travelling Fellowships . 383
Post-Graduate Committee in Medi
cine of the University of Ade
laide
Course on Heart Disease at

Adelaide G79

Post -Graduate Study in England . 63
University of Queensland Post-
Graduate Medical Education
i Committee
Courses in Obstetrics and Gyna--

cology at Brisbane 931

Courses in Queensland in 1946 .. 131
General Revision Course at

Brisbane . 273

Lectures in the Principles of

Pathology 27;!

Post-Graduate Week in Brisbane

i!43, 678
Poverty, Housing and Health

P.y J. Urown 29

P.y A. Multeau 29

XV111

INDEX TO THE MEDICAL JOURNAL OF AUSTRALIA.

VOL. I, 1946.

Page

. 928
. 303

J o\vell, M. L

Power, M. H

Practitioners

General, Remuneration of, A

Report on the (Leading Article) 809
Medical, and Evidence at Inquests 345

I ratt, C. A. (The Essentials of

Chiropody) (rev.) 408

I ratt, R. V. A Trocar and Cannula
for the Intravenous Administra
tion of Fluids (O) 629

Pratt-Thomas, H. R 483

Precocity, Adrenal Carcinoma

Causing GO

Pregnancy, Infectious Diseases dur
ing, with Special Reference to
Rubella, Congenital Abnor
malities in Infants following: A
Third Series of Cases, by C.
Swan and A. L. Tostevln (O) . . 645

Premature Baby, The, by V. M.
Crosse, with a foreword by L. (J.
Parsons (rev.) 20

Prescott, F., and Bicknell (The

Vitamins in Medicine) (rev.) .. 552

Price, E 636, 641

Prickly Heat, On the

By J. P. O Brien 164

By C. White 382

Priestly, F. R 345

Prisoner of War

In Japan, Experiences as a, by

S. E. L. Stening (O) 773

In Malaya and Thailand, Observa
tions by a Pathologist during
Three and a Half Years as a, by

A. T. H. Marsden (O) 700

Sumo Medical Experiences as a. by

N. H. Rose (O) ..772

Surgical Experiences as a, by K.

J. Fagan (O) 775

Prisoner of War Hospitals in the Far
East

Clinical Lessons from (Burma
and Siam), by A. E. Coates

(O) 753

By E. E. Dunlop (O) 761

Proprietary Medicines Investigation

Committee . . : 565

Prostatectomy, Retropubic and Extra-

vesical (C.C.) 230

Pseudoarthrosis, Congenital, of the

Tibia due to Fibrocystic Disease 26
Psychiatric Aspects of Modern War
fare, by R. S. Ellery (rev.) 189

Psychiatric Programme for Peace, A

By R. S. Ellery (O) 457

By C. I. McLaren 677

Psychiatry

And Endocrinology. The 1945 Year
J5ook of Neurology, edited by H.
H. Reese et alii (rev.) 919

Short Introduction to, A, with an
Appendix on Psychiatry Associ
ated with War Conditions :
Psychological Medicine, by D.
Curran and E. Guttmann, with
a foreword by J. J. Conybeare
(rev.) 776

Psychology

In General Practice, edited by A.

Moncrieff (rev.) 479

Of Women, The: A Psychoanalytic
Interpretation, by H. Deutsch,
with a foreword by S. Cobb

(rev.) 300

Psychosis, Conf visional 310

1 syehoses Occurring in Service Per
sonnel in Forward Areas, Obser
vations on

By F. W. Graham 785

By H. J. B. Stephens (O) . . 145

Psychotherapy, by A. A. Pain 859

Psychotic Casualties in New Guinea,
with Special Reference to the
Use of Convulsive Therapy in
Forward Areas, by D. Ross (O) 830
Psychotic Ex-Servicemen, Some Re
marks on, by A. T. Edwards (O) 738

Public Health

Early Diagnosis and Early Treat
ment, The, of Cancer : A Pub
licity Campaign 571

Future Health Services in Great

Britain 487

National Health Service Bill of

Great Britain, The 524

Post-War Plans for Nutrition in

Canada 93

Public Medical Officers Association

of New South Wales, The 414

Page

Pugh, L. G. C 373

Pulmonary Edema and Inflammation :

An Analysis of Processes In
volved in the Formation and
Removal of Pulmonary Trans-
udates and Exudates, by C. K.
Drinker (rev.) 739

Purves-Stewart, J. The Diagnosis of

Nervous Diseases) (rev.) 739

Pyrexia, Prolonged 814

Pyuria, Amicrobic-

By I. Monk 785

Peocrt of a Case of, by R. S.
Lawson (R) 550

Queensland Health Education Council 124
Quarantine Officers, The Appointment

of 564

Queensland, An Institute of Medical

Research for (Leading Article) 157
Quotations wuh a Medical Bearing :

Acceptable Words, by J. B.

Cleland (O) 876

Radcliffe-Taylor, M. A. The Inter-
vertebral Disk 237, 454

Radiology, Year Book of, The 1945;
Diagnosis : edited by C. A.
Waters ; associate editor, W. B.
Firor ; Therapeutics : edited by I.

L. Kaplan (rev.) 666

Ralston 339

Ramfrez, F 446

Rand, C. W. (The Neurosurgical
Patient : His Problems of Diag
nosis and Care) (rev.) 247

Rapopcrt, M 742

Rationing 123

Rawlings, W. J 533

Rawson, R. W 779

Ready, M. J 807

Recto-Vesical Injury, An Unusual

(C.C.) 743

Rectum, Columnar-Celled Carcinoma
of the, Treated by Radon : Pre
liminary Report, Sixteen Months
after Treatment, by 1 . D.

Braddon (R) 477

Red Cross, Medical Aspects of, in
the Second World War, The Sir
Richard Stawell Oration, by J.

New : man Morris (O) 169

Reese, H. H 919

Reestablishment and Reemployment

Act, 1945, The 566

Reflexes, The Examination of : A
Simplification^ by R. Wartenberg,
foreword by F. Kennedy (rev.) 84
Refugee Medical Practitioners from

Europe 558

Registration, Medical 561

Rehabilitation

Medical : Its Organization in the
Royal Air Force and the Royal
Australian Air Force, by G. G.

Burniston (O) 620

Of Medical Officers of the Armed

Forces 568, 600

Of Members of the Armed Services 123

Of War Neurotics 926

By C. M. McCarthy 910

By H. H. Willis 912

Reid, G., and Murray Experimental
Observations on the Aural
Effects of Gunblast (O) 611

Reid, J. S. C 742

Reid, W. Lister Early Diagnosis in
Tumours of the Central Nervous
System (O) 865

Release, The, of Medical Officers from

the Services 570

Remuneration of General Prac
titioners, A Report on the (Lead
ing Article) 809

Renal Failure and Anoxia, by J.

Walker Tomb 63

Repatriation Commission 568

Medical Benefits for Dependants of
Deceased Soldiers 123

Representative Meeting, The Special,

in London (Leading Article) . . 741

Research

At Sydney Hospital, by N. Rose . . 750
At the Kanematsu Institute

By A. F. Burrett 782

By A. J. Canny 642, 894

By J. C. Eccles 641

By W. W. Ingram 783

By T. H. Vickers 642

Page

Research Continued.

In Medical History (Leading

445

631

Article)

Medical

Heavy Blow t&lt;., A (Leading

Article)

Institute of, An, for Queensland

(Leading Article) 157

Resident Medical Officers Salaries . 601
Respiration. Artificial, Explained, by

F. C. Eve (note) 516

Respiratory Activity, Droplet Spray

Infection and (C.C.) 447

Retallack, Cyrus Bath, Death of .... 859

Reviews

Acute Injuries of the Head : Their
Diagnosis, Treatment, Complica
tions and Sequels, by G. F.
Rowbotham 20

Anatomical Atlas of Orthopaedic
Operations, by L. S. Michaelis . 848

Arterial Hypertension : Its Diag
nosis and Treatment, by I. H.
Page and A. C. Corcoran 83

Atlas of Surgical Approaches to
Bones and Joints, by T. Nicola,
with a Foreword by N. T. Kirk 808

Atomic Energy in the Coining Era,
by p. Dietz . 629

Aviation Neuro-Psvchiatry, by R.
N. Ironside and I. R. C. Batchelor 480

Bacteria in Relation to the Milk
Supply : A Practical Guide for
The Commercial Bacteriologist,
by C. H. Chalmers 479

Bacterial Cell, The : In its Relation
to Problems of Virulence, Im
munity and Chemotherapy, by
R. J. Dubos, with an addendum
by C. F. Robinow 515

Biological Actions of Sex Hor
mones, by H. Burrows 920

Chest Examination : The Correla
tion of Physical and X-Ray Find
ings in Diseases of the Lung, by
R. R. Trail, with a foreword by
W. L. Langdon-Brown 703

Clinical Pathology, by P. N. Pan-
ton, J. R. Marrack and H. B.
May 84S

Control of Pain in Childbirth, by
C. Lull and R. A. Kingston, with
an introduction by N. W. Vaux 408

Demonstrations of Operative Sur
gery for Nurses, by H. Bailey . . 516

Diagnosis, The, of Nervous
Diseases, by J. Purves-Stewart . 739

Diseases of the Nervous System, by
F. M. H. Walshe 52

Duodenal and Jejunal Peptic
Ulceration ; Technic of Resection,
by R. Nissen, with a Foreword
by O. H. Wangensteen 189

Endocrine Man : A Study in the
Surgery of Sex, by L. R. Broster,
with a foreword by P. C. Mitchell 84

Endocrinology of Woman, by E.
C. Hamblen 665

Essentials

Of Chiropody, The, by C. A.

Pratt 408

Of Surgery for Dental Students,
by J. C. Ross 372

Examination of Reflexes, The : A
Simplification, by R. Wartenberg,
foreword by F. Kennedy 84

Extensile Exposure Applied to
Limb Surgery, by A. K. Henry 444

Global Epidemiology : A Geography
of Disease and Sanitation, by J.
S. Simmons, T. F. Whayne, G.
W. Anderson, H. M. Horack and
collaborators 591

Hair and Scalp, The, by A. Savill 408

Handbook

For Dissectors, A. by J. C.

Boileau-Grant and H. A. Cates 704
Of Diagnosis and Treatment of
Venereal Disease, by A. E. W.
McLachlan 336

History of Medicine, A, by D.
Guthrie 443

Industrial Nursing: Its Aims and
Practice, by A. P. Dowson-
Weisskopf, with a foreword by
E. Summerskill 84

Introduction

To Clinical Surgery. An : Sur
gical Wherefores and There-
fores, by C. F. M. Saint .... 848

Vol.. 1, 1946.

IXDKX TO THK MKDICAL JOURNAL OF AUSTRALIA.

XIX

Page

lie views Continued.

Jntnxlui-t ion- Continued.

Ti&gt; Dermatology. An, with a
Chapter on the Theory and
Technique of X-Kay and
Radium Therapy, by E. H.
Molesworth, with a foreword
to the First Edition by J.

Jadassohn 227

To Diseases of the Chest, by

J. Maxwell 228

To Essential Hypertension, An
by It. F. Hernclon 740

Manual, A, of Tuberculosis, Clinical
and Administrative, by 10. A.
I nderwood, with an introduction
by J. K. Currie 630

Massage and Medical Gymnastics,
by M. V. .Lace, with a foreword
by J. Mennell 248

Medical Jurisprudence and Toxi
cology, by J. Glaister ISO

Medicine for Nurses, by W. G.
Sears 20

Modern 1 ractical Nursing Pro
cedures, by M. K. Doherty, M.
B. Sirl and O. I. King 030

Neuroaiirgical Patient, The : His
i roblcnis of Diagnosis and Care,
by C. W. Kami :

.Nursing in Acute infectious
Disease, by F. V. G. Scholes . .

Nutrition and Chemical Growth in
Childhood, by 1. G. Macy. with
a foreword by L. Reynolds and
a supplement by J. O. Holmes . . 884

Obstetric Management and Nurs
ing, by H. L. \Vood\yard and B.
Gardner, with a section on home
deliveries l.y \V. i . Gillespie and
also a section on diseases of the
newly born by 11. F. Downing 703

&lt; isseous System, The : A Handbook
of Roentgen Diagnosis, by V. \V.
Archer 066

Outlines of industrial Medicine,
.Legislation and Hygiene, by .1.
Burnet

Cialmes of I hysical Methods in
Medicine, by (i. D. Kersley ....

Pcdiairie X-Ray Diagnosis: A
Textbook for Students and Prac
titioners of Pediatrics, Surgery
and Radiology, by J. Cafl ey .... 807

Personality Factors in Counseling,
by C. A. Curran, preface by M.
J. Ready, introduction by C. R.
Rogers _. 807

Physical Treatment by Movement,
Manipulation and Massage, by
J. B. Mennell 444

Premature Baby, The, by V. M.
Crosse, with a foreword by L. c&lt;.
Parsons 20

Principles

And Practice, The, of Rectal

Surgery, by W. B. Gabriel . . 228
Of Human Physiology (originally
"Starling s Princples of Human
Physiology ), by C. Lovatt
Evans, with section on the
special senses by H. Hartridge 704
Of Pediatrics and Pediatric
Nursing, by C. M. Knox 703

Psychiatric Aspects of Modern
Warfare, by R. S. Ellery 180

Psychological Medicine: A Short
Introduction to Psychiatry, with
an Appendix on Psychiatry Asso
ciated with War Conditions, by
D. Curran and E. Guttmann,
with a foreword by J. J. Cony-
beare 776

Psychology in General Practice,
edited by A. Moncrieff 471)

Psychology of Women, The: A
Psychoanalytic Interpretation, by
II. Deutsch. with a foreword by
S. Cobb 3 mi

Pulmonary Edema and Inflamma
tion: An Analysis of Processes
involved in the Formation and
Removal of Pulmonary Trans-
udates and Exudatos. by C. K.
Drinker 739

Recent Advances

In Neurology and Neuropsychi-
atry, by W. R. Brain and 10. B.

Strauss 371

In Obstetrics and Gynaecology,
by A. W. Bourne and L. H.
Williams 299

Page
Reviews Continued.

Rypins Medical Liicensure Exam
inations: Topical Summaries,
Questions and Answers, edited by

W. L. Bierring 740

Symptomatic Diagnosis and Treat
ment, The, of Gynaecological Dis
orders, by M. M. White, with a

foreword by F. J. Browne 704

Synopsis

Of Obstetrics and Gynaecology,

by A. W. Bourne 066

Of Surgery, by H. Groves, edited

by C. 1 . G. Wakeley 190

Text-Book. A, of Surgical Path
ology, by C. F. W. Illingwortn

and B. M. Dick ._. 336

Textbook

( f Medicine, by Various Authors,

edited by J. J. Conybeare .... 408
Of Neuropathology, by A. Weil 299
Tissues of the Body, The : An In
troduction to the Study of
Anatomy, by W. E. Le Gros

Clark 479

Treatment, The, of Acute Intes
tinal Obstruction, by J. T.

Chest erman 156

Tropical Nutrition and Dietetics, by

L. Nicholls 510

Virus as Organism : Evolutionary
and Ecological Aspects of Some
Human Virus Diseases, by F. M.

Kurnel 372

Vitamins in Medicine, The, by F.

Bicknell and F. Prescott 552

Wai- Neuroses, by R. R. Grinker

and J. P. Spiegel 630

What People Are : A Study of
Normal Young Men. by C. W.

Heath 444

Year Book, The 1945

of Genera) Medicine, edited by
G. F. Dick, J. Burns Amber-
son, G. R. Minot, W. B. Castle,
\V. D. Stroud and G. B. Eust er
man 920

Of General Surgery, edited by 10.

A. Graham 883

Of Neurology, Psychiatry and
Endocrinology ; Neurology
edited by H. H. Reese and M.
G. Masten ; Psychiatry- edited
by N. D. C. Lewis; Endocrin
ology edited by E. L. Sevring-

haus 919

Of Obstetrics and Gynecology,

edited by J. 1 . Greenhill .... SS4
Of Pediatrics, edited by I. A. Abt.
with the collaboration of A.

F. Abt 884

Of Radiology; Diagnosis: edited
l:y C. A. Waters, associate
(ditor W. B. Firor ; Thera
peutics : edited by I. L. Kaplan 666
Of Urology, by O. S. Lowsley . . 776

Reynolds 339

Reynolds. L 884

Rh and Hr Factors, Further Obser
vations on the, and the Blood
Group Frequencies in Papuans,
by R. T. Simmons, J. J. Graydon

a nd E. F. Woods (O) 537

Rh Blood Types, The, and their
Reactions, by J. J. Graydon and

R. T. SimiiK ns (O) 861

Rheumatism, The Treatment of, by

Dehydration (Leading Article) . 373
Rheumatoid Arthritis, Muscular

Lesions in (C.C.) 670

Rh Iso-Immunization, Studies on, by
N. R. Henry and R. T. Simmons

(O) 897

Rich, Mr. Justice 25-1

Uiddcll, C. B 779

Ring, O. I., Doherty and Sirl (Modern
Practical Nursing Procedures)

(rev.) 630

Riseman. J. E. F 032

Robert. A 86

Rol ei-ls, K. G 674

Roberts, \V. E. An Analysis of
Deformities among Recruits, with
Remarks on Sub-Standard Types

(O) 30o

Roller (sen. E. Graeme 674

"Robin May" Memorial Fund. The . . 7SS

Robinow, C. K 515

Rogers. C. R 807

Rogers. Lambert The Selection of
Medical Students in Relation to
the Nteds of a Community and
the Facilities Available for In
struction 162

Page

Rogerson, Edward, Death of 752

Rolleston, J. D 54

Rome, R. M 199

Rooms, Professional, for Civilian

Medical Practitioners 569

Root, W. S 483

Rose, N. H. Some Medical Experi
ences as a Prisoner of War (O) 772
Rose, N. Research at Sydney Hos
pital 750

Rose, T. F.
And Newson

Compound Fractures of the Ex
tremities due to Gunshot
Wounds : The Early Results of
Treatment in the Field Aided
by Penicillin Therapy (O) . . 330
Early Results of the Treatment
of Gunshot Wounds of Limb
Joints Aided by Penicillin

Therapy (O) 75

Suture of Deep Soft Tissue War
Wounds Aided by Penicillin

Therapy (O) 304

Treatment of Gunshot Wounds of
the Chest in the Field, Aided
by Penicillin Therapy (O) . . . 290
Bilateral Trigger Thumb in Infants

(R) 18

Newson and Watson

Early Results in a Short Series
of Cases of Gunshot Wounds

of the Abdomen (O) 180

Rosebery, Sidney Solomon, Death of 204
Ross, D. Psychotic Casualties in
New Guinea, with Special Refer
ence to the Use of Convulsive
Therapy in Forward Areas (O) 830

Ross, F. L 229

Ross, I. Clunies 340

Ross, J. C. (Essentials of Surgery
for Dental Students) (rev.)

372

784
250
483

Rossell, J. McF., and Finlayson

Malaria

Roth, N

Roughtor, F. J. W

Rountree. P. M.

And Armytage Hospital Blankets

as a Source of Infection (O) . . 503
Treatment, The, of Hospital Blan
kets with Oil Emulsions and the
Bactericidal Action of "Fixanol
C" (Cetvl Pyridinium Bromide)

(O) 539

Rowbotham, G. F. (Acute Injuries
of the Head : Their Diagnosis,
Treatment, Complications and

Sequels) (rev.) 20

Roxon-Ropschitz, I. Ulcers in the

Mouth : An Appeal for Help .... 382
Royal Alexandra Hospital for Chil
dren 814, 854

Royal Australasian College of Physi
cians

Annual Meeting 491, 820

Examination for Membership 29
Royal Australasian College of Sur
geons

Examination for Fellowship . . 94
George Adlington Syme Scholar
ship, 1946 786

Gordon Craig Scholarships 29,678
Meetings of the Courts of

Examiners 130

Post-Graduate Course in Sur
gery, A 130

Royal College of Obstetricians and
Gynaecologists Examination for

Membership 131, 678

Rubella

Congenital Abnormalities in Infants
following. Infectious Diseases
during Pregnancy, with Special
Reference to : A Third Series of
Cases, by C. Swan and A. L.

Tostevin (O) 645

Maternal, Congenital Defects in
Infants after : Further Reports

and Discussions (C.C.) 23

Rubin, M. 1 742

Rundle, F. F 521

Rupture

Intra pelvic, of the Urethra, Frac
ture of the Pelvis Complicated

by ;;79

Intraperitcneal, of the Urinary

Bladder 380

Of the Liver in the New-Born :
Recovery after Blood Transfusion
and Laparotomy, by F. Arclen

(R) 187

Six ntaneous, of the Spleen, with
Notes on Two Cases, by K. M.
Bowden (O) 506

INDEX TO THE MEDICAL JOUKN AL

AUSTRALIA,

VOL. 1, 1940.

Page

Russell, W. Ritchie TOG

Ryan, H &lt;&gt;74

Ryle, J. A 409

Rypins Medical Lie-ensure Examina-
lion.s : Topical Summaries, Ques-
tion.s and Answers, edited by \V.
L. Bierring (rev.) 740

Saint, C. F. M. (An Introduction to
Clinical Surgery : Surgical Where
fores and Therefores) (rev.) . . 848

Salaries-. The, of Commonwealth

Medical Orticers 564

Saliva Factor, The, in Peptic t" Itera
tion, by L. J. J. Nye (O) 1 14

Salmonella Blegdam

Causing Jn lections in Humans in
New Guinea, Preliminary Report
on Strains of, by X. Atkinson

(O) 326

Enteric Fever due to Bacterium
Enteriti lis Var. Blegdam : A
Series of Fifty Cases in Aus
tralian Soldiers from New
Guinea, by F. Fenner and A. V.

Jackson (O) &lt; I &gt;

Salmonella Blegdam Septicaemia and
Suppurative Pericarditis with
Recovery, Report of a Case of.
by J. F. .C. C. Cobley and T. 10.

Wilson (R) i:!!i

Salmonella Infections, Typhoid and,

Thoracic Complications of (&lt; .&lt; .) 555

Saltau, W. D 1 J! . 533

Sampimon, R. L. H., ar.d Woodruff
Some Observations Concerning
the Use of Hypnosis as a Sub
stitute for Anaesthesia (O) ... 393

Sanderson, 1 . H 632

Sandes, Francis Percival 598

Sandfly Fever (see Papataci Fever)
Sandier, A. The Clinical Picture 9f
Fapataci Fever, especially in

Palestine (O) 789

Sangster, C. B. Hookworm Disease
in Australian Soldiers, with

Reports of Cases (O) 385

Sarcoidosia 674

Savill. A. (The Hair and Scalp)

(rev.) 408

Saxton, W. J., Hatcher and Derrick
Chromoblastoniyeosis, with Re
ports of Two Cases Occurring in

Queensland (O) 695

Scabies, The Treatment of, by J. G.

Morris 380

Scalp. The Hair and, by A. Savill

(rev.) 408

Scaphoid. Carpal, Fractures of the,

by J. R. Barbour (O) 352

Scarborough, II 375

Schneider, M. A Sociological Study
of the Ab( rigines in the North
ern Territory and their Eye

Diseases (O) 99

Sclu.larships, Cordon Craig 29. 678

Schcles, F. V. G. (Nursing in Acute

Infectious Disease) (rev.) .... 300

Schour, 1 85

Schroeder 923

Srhrneder, A. 11 446

Schweit/.ei , A 481

Seiarra, D 250

Sciatica 58

By R. A. -Money (O) 37

Some Further Observations on. by
N. Little (O) . 33

Science

Australia t;nd : The University of
Sydney and Scientists

By A. J. Canny 3X1

By N. 10. Goldsworthy 316

I .y [;. R. Moore 418

By F. W. Simpson 417

(Leading Article) 249

Post-War Rehabilitation of. The
An Address, by J. G. Wagner

(O) 97

Scleroderma 92, 855

Sclerosis, Disseminated 26, 307

Syndrome Resembling, A. as a
Sequel to Encephalitis Lethargica 308

Scott, G . 487

Scott. G. 10. M 675

Cceliac Disease: A Survey from the
Children s Hospital. Melbourne

(O) 659

Scott, Kaye 890

Scrub Tvphus. Studies in the Control

of, by R. N. McCulloch (O) . . 717
Scurvy 816

Page

Sears, W. G. (Medicine for Nurses)

(rev.) 20

Sebire, 1. B. The Sociological As
pects of Community Housing
(O) 327

Sen, S 742

Septicaemia, Salmonella Blegdam, Re
port of a Cuse of, and Suppura-
tive Pericarditis with Recovery,
by . F. C. C. Cobley and T. E.
Wilson (R) 439

Serum, Hum:&gt;:i, An Immune Anti-M
Iso-Agglutinin in, by R. J. Walsh

Services Medical Officers Association

of New South Wales

By J. M. Veates

Sevringhaus, E. L

Sewell, A. K., and Walsh Some
Effects of Blood Loss on Healthy

Males (O)

Sex Hormones, Biological Action of,

by H. Burrows (rev.)

Sheldon, S. The Use and Misuse of

Tetanus Antitoxin

Sherman

Shipton, E., and Parr Spondylitis

Ankylopoietica (O)

Shlimovitz, N. Leprosy : A Report
of Nine Cases among Natives
of the Mount Hagen Area in New

Guinea (R)

Shock. Experimental, Toxic Factors

in (C.C.)

Short, A. 11

Siam, Burma and ; Clinical Lessons
from Prisoner of War Hospitals
in the Far East, by A. E. Coates

(O)

Siedlecky, S.

National Health Service Bill of

Great Britain, The

Results, The, of Penicillin Therapy
in the Treatment of Gonorrhoea

(O)

Simmons, J. S., et alii (Global Epi
demiology: A Geography of
Disease and Sanitation) (rev.) .
Simmons. R. T.

And Christie Penicillin Sensitivity
of Streptococci Mostly of Groups

A, B, C and G (O)

And Graydon

Blood Groups in the Maori (O)
Rh Blood Types, The, and their

Reactions (O)

And Henry Studies on Rh Iso-

Immunization (O)

Graydon and Woods

Blood Group Frequencies in

ll&lt; llanders (O)

Further Observations on the Rh
and Hr Factors, and the Blood
Group Frequencies in Papuans

(O)

Simmons, W. F

Federal Medical War Relief Fund,

The

Simpson, F. W. Australia and
Science: The University of Syd
ney and Scientists

Simpson, G 198,

Singapore Captivity, Medical Aspects

of the, bv C. Harvey (O)

Sinn, H 28, 450,

Sinuses, Tuberculous

Sinusitis Treated by Chemotherapy
at an Australian General Hos
pital, Report on a Series of Cases
of. by R. H. Bettington and G.

K. Vincent (O)

Sir], M. I ... Doherty and Ring (.Modern
Practical Nursing Procedures)

(rev.)

Skin, Penicillin and the (C.C.)

Sleep Paralysis (C.C.)

Sloan, R. I . (Hospital Color and

Decoration) (note)

Smith. E. Temple

Smith. G. E., Corkill and Pollock
The Value of Biochemical Tests
in the Interpretation of Jaundice

(O)

Smith, H

H. Fairfield

Redford John Wright, Death

1J5

788
785
919

920

131
922

707
341

753
890
904
591

Smith,
Smith.
Smith,

Smithy, H. G

Soldiers, Backache in. by 1 &gt;. Stuekey

(O)

Solis-Cohen. M

Sollmann, T

4L7
530

769
451

378

630
411
811

190
671

617
712
916
743

716
483

838
158
375

926

234

Page

Southby, R 28, 60, 129, 130,

533, 610, 710, 712, 890

Souttar, H. S

Spearman, H. L. 379

Special Article

Researches on 1 aludrinc (M.4888)

in Australia

.-^lection, The. of Medical Students
in Relation to the Needs of a
Community and the Facilities
Available lor Instruction, by

Lambert Rogers 162

S|v..-i;iiist, The De-&gt; .)ition of a 565

Spelling of Words. The, by D. Monk

Adams 345

Silencer , "Dr. ", The Remarkable, by

R. T. Kennedy (O) 149

Spencer, S. L 379, 779

Ai;d Pcate "Thio" Drugs in

Thyreotoxicosis 750

(O)

Speiis, W. ("The Spens Report") ..
Spiegel. J. P., and Grinker (War

Neuroses) (rev.)

Spinach, Lessons from (C.C.)

Spinal Anaesthesia and Chloroform:
A Comparison of Mortality

By C. E. Corlette 892

(O) 545

By S. V. Marshall 750

By J. E. Thomas 750

Spinal Analgesia

By J. Oldham (O)

"Nou- Take", by I . Gill

Spleen, Spontaneous Rupture of the,
with Notes on Two Cases, by K.

M. Bowden (O)

Spondylitis Ankylopoietica

By E. Hasleii Frazer 453,

By "Froacn Eilean"

By L. J. A. I arr and E. Shipton
(O)

Spondylolisthesis

And Hemivertebra

Radiographic Analysis ol, A, by

I. Mesehan (O)

Spriggs, E

Springthorpe, G

Stain, Fields. Notes on, by I . M.

de Burgh (O)

Sla-ibury, J. B

Staphylococcal Enteritis in Children,

by F. Draper and G. W. Brown

(b)

Staphylococcal Meningitis and Ven-
triculitis : Cure by Penicillin, by

D. Miller and H. J. Delohery

(R)

Staphylococci, Acquired Resistance
of, to the Action of Pei.icillin, by

E. A. North and R. Christie (O)

Stark, A. W. B

Starke, Mr. Justice

"Starling s Principles of Human

Physiology", ace Principles of
Human Physiology, by C. Lovait
10 vans (rev.)

Starr, I

Stats, D

Stawell Oratioi:, The Sir Richard
Medical Aspects of Red Cross
in the Second World War, by
J. Newman Morris (O)

Stawell Prize. The

Steindler, A

Steiner, G

Si ining, S. E. L. Experiences as a
Prisoner of War in Japan (O) . .

Stephen, J. N. R

Placenta Prtevia

Stephen, R. L

Stephens. II. H 27, 2S. 59, 92,

129. L30, 16?, 163, 450. ISii. 641,

Stephens. H. J. B.- -&lt; M.servalior.s on
Psychoses Occurring in Service
Personnel in Forward Areas (O)

493

809

630
922

432

6U6

677
535

277

465
779
640

544
339

469

176
SID
264

704
594
743

169
751

670

773
894
490

855

(175

St.

A. M.

Syndrome,
Ralph,

The"

bv M.

"Stevens-Johnson
(C.C.)

Stockman, Professor

Kelly

Stokes. E. H

Stokes, H. L

Stenham. F. V. The Treatment

Inguinal Hernia (O)

Storch, Young Dr., of Adeloiig, by

R. T. Kennedy (O)

"Story, The, of a Great Achieve
ment" (Leading Article)

Strauss, E. B., and Brain (Recent

Advances in Neurology and

Neuropsychiatry) (rev.)

145

1 . 3

193

822

378
451

185
162
137

VOL. I, 1946.

INDEX TO THE MEDICAL JOURNAL OF AUSTRALIA.

xxi

Page

Streptococci, Mostly of Groups A, B,
C and G, Penicillin Sensitivity of,
by R. T. Simmons and R.

Christie (O) 349

Stricture, Congenital, of the CEso-

phagus, by R. Flynn (R) 702

Stroud, W. D 920

Stuart-Harris, C. H 411

Stuckey, D. Backache in Soldiers

(O) 838

Sudeck s Post-Traumatic Bone Dys
trophy 480

Sulphonamides in Conjunction with
Haemophilus Influenzas, Type B,
Rabbit Antiserum, The Treat
ment of Hsemophilus Influenzas
Meningitis with, by E. A. North,
H. Wilson and G. Anderson (O) 215
Sulphonamide-Resistant Patient, The
Empirical Use of Penicillin for
a, by H. G. Cummine and J. W.

S. Laidley (R) 476

Summerskill, E 84

Sunburn, The Prevention of (C.C.) . . 375

Surgery

Clinical, An Introduction to : Sur
gical Wherefores and Therefores,
by C. F. M. Saint (rev.) 848

Essentials of, for Dental Students,
by J. C. Ross (rev.) 372

General, The 1945 Year Book of,
edited by E. A. Graham (rev.) . 883

Limb, Extensile Exposure Applied
to, by A. K. Henry (rev.) 444

Operative, Demonstrations of, for
Nurses, by H. Bailey (rev.) .... 516

Ophthalmic, Penicillin in Pre-
Operative and Post-Operative, by
T. Boyd Law (R) *. 442

Rectal, The Principles and Prac
tice of, by W. B. Gabriel (rev.) 228

Synopsis of, by H. GroveSj edited

by C. P. G. Wakeley (rev.) 190

Sutcliffe, Ernest Weston, Death of . . 859

Sutherland, B. M 202

Sutton, H. Centenaries of "Forty-
Five" (O) 421

Swan, C.

And Tosteyin Congenital Abnor
malities in Infants following In
fectious Diseases during Preg
nancy, with Special Reference to
Rubella : A Third Series of Cases

(O) 64f&gt;

Case, A, of Poet-Varicella! En
cephalitis showing Bilateral
Softening of the Neostriatum and
Terminal "Tetanoid Chorea"

(Gowers) (R) 697

Swan, M. S. A 234

Sweetman, K. F. D. Wounds Caused

by Small Fish 345

Sydney Hospital 378, 631

Research at, by N. Rose 750

Syme Scholarship, 1946, George

Adlington 78(5

Symonds, C. P 22

Syphilis, Gastric 378

Syred, R. H. Placenta Prsevia (O) 3.~&lt;2

Tait, L. G 816

Talk (note) 552

Taylor 339

Taylor, A. H 375

Taylor, G. C 157

Taylor, R. J 814

Tedeschi, C. D 885

Telephone Directories 567

Telfer, A. C 379

Tendon Sheath Infections of the
Hand, Penicillin Therapy for, by

J. A. Marsden (O) . 435

Tennent, Joseph Thorn, Death of 536, 823
Tenosynovitis, Suppurative, in the
Fingers, Treatment of, by L. I.

Burt (O) 399

"Tetanoid Chorea" (Gowers), A Case
of Post-Varicellal Encephalitis
showing Bilateral Softening of
the Neostriatum and, by C. Swan

(R) . 697

Tetanus

PoBt-Abortional, with Recovery, by
J. Hutchings and A. Wheildon

(R) 404

Treated with Penicillin ; Recovery,

by J. L. Grove (R) 22(i

Tetanus Antitoxin, The Use and Mis
use of, by S. Sheldon 131

Page

Thailand, Malaya and, Observations
by a Pathologist during Three
and a Half Years as a Prisoner
of War in, by A. T. H. Marsden

(O) 766

"Thio" Drugs in Thyreotoxicosis, by

H. R. G. Poate and S. L. Spencer 750
(O) 493

Thiouracil

Thyreotoxicosis Treated with 27

Toxicity of. The (C.C.) 850

Thomas, A. C 603, 926, 927

Address, An (O) 573

Thomas, J. E. Spinal Anaesthesia
and Chloroform : A Comparison

of Mortality 750

Thomas, R. C 554

Thompson, G. C. V.

And Chambers Chylangioma of
the Mesentery, with Report of a
Case, and a Brief Discussion of

Mesenteric Cysts (O) 210

Traumatic Arterio-Venous Aneu-
rysm of the Femoral Blood
Vessels (O) 104

Thornton, M. The Federal Medical

War Relief Fund 418

Thrombosis

In Infancy, Arterial Embolism and

(C.C.) 87

Septic, of the Cavernous Sinus
Treated with Penicillin 674

Thyreotoxicosis -
"Thio" Drugs in

By H. R. G. Poate and S. L.

Spencer

(O)

Treated with Thiouracil

Tibbetts, D. M

Tick Paralysis (C.C. )

Tick Typhus in North Queensland, A

Case of, by J. Brody (R)

Tidy, H. .

750
493
27
707
339

511
341
810
337

Tigerstedt

Times, The

Tissues of the Body, The : An Intro
duction to the Study of Anatomy,
by W. E. Le Gros Clark (rev.) 479

Tivey, E. A 58, 59, 59S

Tobias, C. A 483

Tomb, J. Walker Renal Failure and

Anoxia 63

Tonge, J. 1 234

Tonsils and Adenoids, A Method for
the Removal of, under Local
Anaesthesia with the Patient in
the Recumbent Position, by R.
H. Bettington (O) 882

Toothache and Folk-Lore

By I . G. Dane 275

(C.C.) 54

Toowoomba and Environs, The
Botany of, and its Relation to
Clinical Allergy of the Upper
Respiratory Tract, by C. R.
Atorton (O) 585

Torrents, E 446

Tostevin, A. L., and Swan Congenital
Abnormalities in Infants follow
ing Infectious Diseases during
Pregnancy, with Special Refer
ence to Rubella : A Third Series
of Cases (O) 645

Toxicology, Medical Jurisprudence

and, by J. Glaister (rev.) 480

Toxoplasmic Encephalomyelitis and

Chorioretinitis 674

Trail, R. R 778

(Chest Examination : The Correla
tion of Physical and X-Ray
Findings in Diseases of the Lung,
with a foreword by W. L.
Langdon-Brown) (rev.) 703

Training

Medical, The Adequacy of

By K. J. B. Davis 275

By B. "Williams (O) 147

Prior to Discharge, The. of Certain
Medical Officers 30, 240

Transposition of Viscera 129

Trauma, Cerebral, and its Mechan
isms (Leading Article) 885

Travel, Overseas, for Australian

Students (Leading Article) .... 191

Treatment, Physical, by Movement,
Manipulation and Massage, by
J. B. Mennell (rev.) 444

Trigeminal Neuralgia

Ry F. J. Clark 895

By A. Lyons 750

Page
Trigger Thumb, Bilateral, in Infants,

by T. F. Rose (R) 18

Trikojus, V 779

Trocar and Cannula, A, for the
Intravenous Administration of
Fluids, by R. V. Pratt (O) ... 629

True, E 196, 203

Truman, President 301

Trumble, H. C 817

Tsutsugamushi Disease, A W T arning,

by J. T. Gunther 419

Tuberculin Patch Test, The: A Com
parison with the Mantoux Test,
by Catherine Hudson and F. E.
Hytten (O) 475

Tuberculosis

Manual of, A, Clinical and Ad
ministrative, by E. A. Under
wood, with an introduction by
J. R. Currie (rev.) 630

Pulmonary

Early, The Problem of (C.C.) .. 778
Some Xotes on the Treatment of,

by C. J. Officer Brown (O) . . 825
Treated by Artificial Pneumo-

thorax 378

Tuberculosis Patients and Hospitals

By A. H. Penington ._ 237

By D. B. Pitt ". 30

Tuberculous Sinuses 378

Tumour

Breast, Latent Primary, by T. R.

Gaha (R) 590

Of Bone 890

Of the Axilla 854

Possibly Cerebral : Organic Brain

Disease 309

Wilms s 379

Tumours of the Central Nervous
System, Early Diagnosis in, by

W. Lister Reid (O) 865

Tunbridge, E. B 927

Turbulent Flow, Murmurs from

(C.C.) 339

Turnbull, H. Inguinal Hernia and

its Repair (O) 109

Turner, E. K. Purulent Meningitis
of Infancy and Childhood : A
Twelve Months Survey of the
Results of Treatment by Peni
cillin (O) 14

Typhoid and Salmonella Infections,

Thoracic Complications of (C.C.) 555

Typhus
Scrub

Studies in the Control of, by

R. N. McCulloch (O) 717

Use, The, of a Polysaccharide
of Bacillus Proteus OXK in
the Diagnosis of, by P. de

Burgh (O) 81

Tick, in North Queensland, A Case
of, by J. Brody (R) 511

U
Ulcer

Peptic, Duodenal and Jejunal :
Technic of Resection, by R.
Nissen, with a foreword by O.

H. Wangensteen (rev.) 189

Problem, The (C.C.) 632

Ulceration, Peptic

Duodenal and Jejunai: Technic of
Resection, by R. Nissen, with a
Foreword by O. H. Wangensteen

(rev.) 189

Saliva Factor in, The, by L. J. J.

Nye (O) 114

Ulcers in the Mouth : An Appeal for
Help-
By A. Bulteau 418

By L. Hewitt 418

By B. Hiller 490

By "M.B., B.S." 274

By F. F. McMahon 715

By E. M. Murphy 534

By I. Roxon-Ropschitz 382

Underwood, E. A. (A Manual of
Tuberculosis, Clinical and Ad
ministrative, with an introduc
tion by J. R. Currie) (rev.) .... 630
Unemployment and Sickness Benefits

Act, 1944, The 565

United States of America

Discussions on Health Legislation

in the (Leading Article) 301

Recent Experiences in Canada and

the. by H. M. James (O) 827

University Intelligence University of
Melbourne : Nuffleld Medical "En
dowment 895

XX11

INDEX TO THE MEDICAL JOURNAL OF AUSTRALIA.

VOL. I, 1946.

Page

University of Queensland 127

University of Queensland Post-
Graduate Medical Education
Committee (sec Post-Graduate
Work)
University of Sydney

And Scientists : Australia and
Science

By A. J. Canny 381

By N. E. Golds-worthy 346

By D. K. Moore 418

By P. W. Simpson 417

(Leading Article) 249

Chair of Child Health at the 601

Ureters, Bilateral Transplantation of
the, Carcinoma of the Bladder

with 379

Urethral Discharges. Non-Gonococcal,
Chronic Vesiculitis as a Factor
in the Production of, by C. E.

Marshall (O) 846

Urethritis, Non-Gonococcal

In Australian Troops Stationed in

Borneo, by S. Williams (O) . . 693
In Man, Pleuropneumonia-Like
Organisms in Cases of, and in
Normal Female Genitalia, by W.
I. B. Beveridge, A. D. Campbell

and P. E. Lind (O) 179

Urology, The 1945 Year Book of, by

O. S. Lowsley (rev.) 776

van der Heide, C 811

Van Someren, George Arbuthnot,

Death of 716

Vascular Diseases and their Relation
ship to the Eye 674

Vaux, N. W 408

Venereal Disease, Handbook of Diag
nosis and Treatment of, by A.

E. W. McLachlan (rev.) 336

Ventriculitis, Meningitis and, Staphy-
lococcal : Cure by Penicillin, by
D. Miller and H. J. Delohery (R) 512
Vesiculitis, Chronic, as a Factor in
the Production of Non-Gonococcal
Urethral Discharges, by C. E.

Marshall (O) 846

Vickers, T. H. Research at the

Kanematsu Institute 642

Vickers, Wilfred, Death of 384

Vickery, D. G. R 854

Vincent, G. K., and Bettington
Report on a Series of Cases of
Sinusitis Treated by Chemo
therapy at an Australian General

Hospital (O) 358

Virilism, Adrenal 379

Virus

As Organism : Evolutionary and
Ecological Aspects of Some
Human Virus Diseases, by F. M.

Burnet (rev.) 372

Of Newcastle Disease of Fowls.
The, A Note on Two Laboratory
Infections with, by S. G. Ander
son (R) 371

Viswanathan, R 55

Vitamin C (Ascorbic Acid) in Kera-

titis 675

Vitamins

Availability of, The, in Various
Foods and Pharmaceutical Pro
ducts (C.C.) 410

In Medicine, The, by F. Bicknell

and F. Prescott (rev.) 552

Parenteral Use of, The (Leading
Article) 667

Volkmann s Ischaemic Contracture of

the Forearm, by L. Ball (R) . . 224

Volvulus of the Small Bowel, with
Report of a Case Treated by
Resection with Recovery, by D.
M. Embelton and P. Jones " (O) 144

von Ries, J. . 595

Waddy, R. G 674

Wagner, J. G 127, 129

Address, An The Post- War Re
habilitation of Science (O) .... 97

Wagner, Senator 302

Wait, L 61, 92, 93, 451

Wakefield, E. G .303

Wakeley, C. P. O .190

Walch, J. H. B 9fi

Walsh, R. J.

And Sewell Some Effects of Blood

Loss on Healthy Males (O) .... 73
Immune Anti-M Iso-Agglutinin,
An, in Human Serum (R) 115

Page
Walshe, F. M. R. (Diseases of the

Nervous System) (rev.) 52

Recovery (R) 439

Waltz, A. D 742

Wangensteen, O. H 189, 633

War

And Humanism, by A. G. Butler . 165
Germany during the, Medical Edu
cation and Medical Practice in

(C.C.) 923

Madical Aspects of Red Cross in
the Second World The Sir
Richard Stawell Oration, by J.

Newman Morris (O) 169

Of 1039-1945, The Medical History

of the (C.C.) ~. 633

War Neuroses, by R. R. Grinker and

J. P. Spiegel (rev.) 630

War Neurotics, The Rehabilitation of 926

By C. M. McCarthy (O) 910

By H. H. Willis (O) 912

Warfare, Psychiatric Aspects of

Mod3rn, by R. S. Ellery (rev.) 189

Warren, S 671

\Vartenberg, R. (The Examination of
Reflexes : A Simplification, fore
word by F. Kennedy) (rev.) .. 84

Wasserman, L. R 743

Waters, C. A 666

Watson, D., Rose and Newson Early
Results in a Short Series of
Cases of Gunshot Wounds of the

Abdomen (O) 180

Watson, H. Preston 58

Webster, R 163,636,641,710

Weil, A. (Textbook of Neuropath-

ology) (rev.) . ... 299

Weinberg, J 811

Wenner, R 595

Wesley, C. H 854

West, R. F. K., and Mackerras,

D.D.T. Poisoning in Man (R) . . 400
West s Operation (Endonasal Dacryo-
cystostomy), Some Notes on, by
G. A. D. McArthur (O) .... . 508
Whayne, T. F., et alii (Global Epi
demiology : A Geography of
Disease and Sanitation) (rev.) 591
Wheildon, A., and Hutchings Post-
Abortional Tetanus with Re
covery (R) 404

Whitaker, J. G 129, 162, 163,

450, 487, 891, 929
White, C. On the Prickly Heat . . 382

White, M. L 555

White, M. M. (The Symptomatic
Diagnosis and Treatment of
Gynaecological Disorders, with a
foreword by F. J. Browne) (rev.) 704
White, O. (Green Armour) (note) . . 516
White Paper on Health Service in

Great Britain 524

Whooping-Cough, Penicillin in the
Laboratory Diagnosis of, A Note
on the Use of, by P. M. Ander
son (O) 244

Widdowson, E. W 303

Wilkinson, William Camac, Death of

204, 488

Willcocks, G. C 230

Williams, B 926

Adequacy of Medical Training. The

(O) 147

Williams, D 674

Williams, L. H., and Bourne (Recent
Advances in Obstetrics and

Gynaecology) (rev.) 299

Williams, S. Non-Gonococcal Ure
thritis in Australian Troops

Stationed in Borneo (O) 693

Willink, Mr 741

Willis, H. H 926,927

Rehabilitation, The, of War Neu
rotics (O) 912

Willius, F. A 886

Wilms s Tumour 379

Wilson, A. M 530, 533

The R. H. Fetherston Memorial

Lecture (O) : . 1

Wilson, C. W 521

Wilson, H., North and Anderson
Resistance, The, of Heemophilus
Influenzae to the Action of Peni
cillin, with Special Reference to

Type B Strains (O) 626

Treatment, The, of Haemophilus
Influenzae Meningitis with Sul-
phonamides in Conjunction with
Haemophilus Influenzae, Type B,
Rabbit Antiserum (O) 215

Wilson, James Thomas

Death of 31

Memorial, A, to the Late 348

Memorial, A, to the Late Professor 384

Page

Wilson, T. E 555

And Cobley Report of a Case of

Salmonella Blegdam Septicaemia

and Suppurative Pericarditis with

Plasma Protein Estimations in

Battle Casualties (O) 153

Winikoff, D 923

Ascorbic Acid in the Milk of Mel
bourne Women (O) 205

Winkle, W. J., et alii 851

Wittwer, S. H 922, 923

Wolf, G. A., junior 23

Wolff, H. G 23

Wolkin, J 53

Women

In Medicine (Leading Article) . 849
Psychology of, The : A Psycho
analytic Interpretation, by H.
Deutsch, with a foreword by S.

Cobb (rev.) 300

Women s Hospital, Melbourne, Obstet
rical Society of the 196, 530

Woodland, L. J 26

Woodruff, M. F. A., and Sampimon
Some Observations Concerning
the Use of Hypnosis as a Sub
stitute for Anaesthesia (O) ... 393
Woods, E. F., Graydon and Simmons
Blood Group Frequencies in Hol
landers (O) . . . ., 576

Further Observations on the Rh
and Hr Factors, and the Blood
Group Frequencies in Papuans

(O) 537

Woodward, H. L., Gardner et alii
(Obstetric Management and

Nurssing) (rev.) 703

Words, Acceptable : Quotations with
a Medical Bearing, by J. B.

Cleland (O) 876

Wound, Gunshot, of the Large and
Small Intestines, A Case of, by

D. R. Leslie (R) 406

Wounds

Caused by Small Fish, by H.

Flecker 534

Gunshot

Of the Abdomen, Early Results
in a Short Series of Cases of,
by T. F. Rose, A. Newson and

D. Watson (O) ISO

Of the Chest, Treatment of, in
the Field Aided by Penicillin
Therapy

By P. Braithwaite 418

By T. F. Rose and A.

Newson (O) 290

Compound Fractures of the Ex
tremities due to : The Early
Results of Treatment in the
Field Aided by Penicillin
Therapy, by T. F. Rose and

A. Newson (O) 330

Of Limb Joints, Early Results
of the Treatment of, Aided by
Penicillin Therapy, by T. F.
Rose and A. Newson (O) .... 75
Head, Transient Disturbances fol
lowing (C.C.) 706

War, Deep Soft Tissue, Suture of,
Aided by Penicillin Therapy, by
T. F. Rose and A. Newson (O) 364

Wright. L. E. A 631

Wright-Smith. Redford John, Death

of 931

Wynn, A 533

X-Ray Diagnosis, Pediatric : A Text
book for Students and Prac
titioners of Pediatrics, Surgery
and Radiology, by J. Caffey
(rev.) 807

X-Ray Films, The Placing of, in

Envelopes, by D. Anderson 930

X-Ray Services in North Coast

Towns of New South Wales .... 601

X Rays, The Fiftieth Anniversary of
the Discovery of, by C. E. Eddy
(O) " 138

Yaws and Beriberi : A Warning, by

C. M. Deland 676

Year Book, The 1945

Of General Medicine, edited by G.

F. Dick et alii (rev.) 920

Of General Surgery, edited by E.

A. Graham (rev.) 883

Of Neurology, Psychiatry and

Endocrinology, edited by H. H.

Reese et nlii (rev.) 919

VOL. I, 1946.

INDEX TO THE MEDICAL JOURNAL OF AUSTRALIA.

XXlll

Page
Year Book Continued.

Of Obstetrics and Gynecology,

edited by J. I . Greenhill (rev.) 884
Of Radiology ; Diagnosis : edited by
C. A. Waters, associate editor,
W B. Piror ; Therapeutics :
edited by I. L. Kaplan (rev.) . . GGG
Of Urology, by O. S. Lowsley (rev.) 770

Page

Yeates, J. M. Services Medical
Officers Association of New
South Wales 785

Young, J. H. Recent Advances in the
Diagnosis and Treatment of
Lumbar Intervertebral Disk

Disease 382

(O) 45

Page

743

Zamecnik, P. C

707

Ziegler E E

707

Kiillintrj r. R. M.

. 923

INDEX TO ILLUSTRATIONS.

Page

Ascorbic Acid in the Milk of Mel
bourne Women, by D. Winikpff . 203

Aspinall, Andrew Eric and Archibald

John 238

Blankets, Hospital, as a Source of
Infection, by 1 . M. Rountree and
J. E. Armytage 503

Cresarean Section, Blood Loss in, by

L. Benson 842

Chylangioma of the Mesentery, with
Report of a Case, and a Brief
Discussion of Mesenteric Cysts,
by G. C. V. Thompson and C. H.
Chambers 210

Coeliac Disease : A Survey from the
Children s Hospital, Melbourne,
by G. E. M. Scott 659

Deformities among Recruits, An
Analysis of, with Remarks on
Sub-Standard Types, by W. E.
Roberts 360

Diabetes Mellitus, A Case of, with
Hyperlipaemia and Hypercholes-
terolaemia, by A. M. Henderson 513

Disk Disease, Lumbar Intervertebral,
Recent Advances in the Diag
nosis and Treatment of, by J. H.
Young 45

Enteric Fever due to Bacterium
Enteritidis Var. Blegdam (Sal
monella Blegdam) : A Series of
Fifty Cases in Australian
Soldiers from New Guinea, by
F. Fenner and A. V. Jackson . . 313

Fibrocystic Disease, Congenital, of

the Pancreas, by P. E. Blaubaum 833

Foreign Bodies, Unknown, in the

Lung, by J. B. Cleland 225

Gunblast, Experimental Observations
on the Aural Effects of, by N. E.
Murray and G. Reid 611

Hardie, David 95

Hookworm Disease in Australian
Soldiers, with Reports of Cases,
by C. B. Sangster 385

Human Body after Death, The Study

of the, by K. Inglis 222

Page

Hydrophobia, A Case of So-Called :
A Matter of Diagnosis, by W. E.
L. H. Crowther 69

Leprosy, A Report of Nine Cases
among Natives of the Mount
Hagen Area in New Guinea, by
N. Shlimovitz 3G9

Lipomata of the Uterus, with Report

of a Case, by J. D. Hicks 184

Lymphangioendothelioma, Abdominal,
or Peritonea! Mesothelioma, A
Case of, by I. Hamilton and J.
B. Cleland 477

Masculinization, A Contribution to
the Problem of, by H. F.
Bettinger and H. Jacobs 10

Meningitis, Purulent, of Infancy and
Childhood : A Twelve Months
Survey of the Results of Treat
ment by Penicillin, by E. K.
Turner 14

Moran, Herbert Michael 415

Moulds in the Lungs, by J. B.

Cleland 247

Penicillin Therapy for Tendon Sheath
Infections of the Hand, by J. A.
Marsden 435

Periarteritis (Polyarteritis) Nodosa,

A Case of, by J. Game 295

I igdon, Douglas Clelland 452

Poliomyelitis, An Epidemic of, Occur
ring among Troops in the Middle
East, by J. E. Caughey and W.
M. Porteous 5

Prisoner of War Hospitals in the Far
East (Burma and Siam), Clinical
Lessons from, by A. E. Coates 753

Prisoner of War Hospitals in the Far
East, Clinical Lessons from, by
E. E. Dunlop 761

Prisoner of War in Malaya and Thai
land, Observations by a Path
ologist during Three and a Half
Years as a, by A. T. H. Marsden 76 G

Psychotic Ex-Servicemen, Some Re
marks on, by A. T. Edwards . . 738

Page

Salmonella Blegdam Septicaemia and
Suppurative Pericarditis with
Recovery, Report of a Case of,
by J. F. C. C. Cobley and T. E.
Wilson 439

Sciatica

By R. A. Money 37

Some Further Observations on, by
N. Little 33

Spondylitis Ankylopoietica, by L. J.

A. Parr and E. Shipton 277

Spondylolisthesis, A Radiographic

Analysis of, by I. Meschan .... 4G5

Stricture, Congenital, of the GBso-

phagus, by R. Flynn 702

"Thio" Drugs in Thyreotoxicosis, by

H. R. G. Poate and S. L. Spencer 493

Trocar and Cannula, A, for the Intra
venous Administration of Fluids,
by R. V. Pratt 629

Tumour, Latent Primary Breast, by

T. R. Gaha 590

Typhus, Scrub, Studies in the Control

of, by R. N. McCulloch 717

Volkmann s Ischsemic Contracture of

the Forearm, by L. Ball 224

Wilkinson, William Camac 488

X Rays, The Fiftieth Anniversary of

the Discovery of, by C. E. Eddy 138

SPECIAL PLATES.

Chromoblastomycosis, with Reports
of Two Cases Occurring in
Queensland, by W. J. Saxton,
F. Hatcher and E. H. Derrick

facing page 696

Encephalitis, Post-Varicellal, A Case
of, Showing Bilateral Softening
of the Neostriatum and Terminal
"Tetanoid Chorea" (Gowers), by
C. Swan facing page 697

Stricture, Congenital, of the CEso-

phagus, by R. Flynn, facing page 702

Reglttertd at the G.P.O., Sydney, for Transmission by Post as a Newspaper. Published Weekly. Price 1s.

THE

MEDICAL Km JOURNAL

OF AUSTRALIA

VOL. I. 33RD YEAR. SYDNEY, SATURDAY, JANUARY 26, 1946. No. 4.

COMMONWEALTH OF AUSTRALIA. DEPARTMENT OF HEALTH.

PENICILLIN

COMMONWEALTH

PENICILLIN "COMMONWEALTH" (THE CALCIUM SALT OF PENICILLIN)
IS AVAILABLE IN THE FOLLOWING SIZES AT THE PRICES SHOWN

1 ampoule containing 100,000 Oxford units 10/6

This quantity i sufficient for a series of parenteral doe.
(Available also in boxes holding 5 ampoules.)

1 ampoule containing 15,000 Oxford units 5/6

This quantity is intended for a single parenteral done.
(Available also in boxes holding 6 ampoules.)

1 ampoule containing 5,000 Oxford units 4/6

This quantity is intended primarily for dilution and local application, but may be used

for parenteral injection if desired.
(Available also in boxes holding 6 ampoules.)

The Medical Profession is notified that the Control of Penicillin Order, promulgated in the Commonwealth of
Australia Gazette, No. 85, of 3rd May, 1944, has been revoked.

The Penicillin Order published in Gaeotte No. 189 of 20th September, 1944, and in THB MBDICAL JOUKHAL ov
AUSTRALIA of 30th September, 1944, relaxes the conditions under which Penicillin may be supplied for the treatment
of members of the civilian population.

To obtain Penicillin a Medical Practitioner must apply in the form of certificate set out in the Order to the Senior
Commonwealth Medical Officer in the State concerned. The signature of a colleagrue is no longer required.

The addresses of the Senior Commonwealth Medical Officers are: NEW SOUTH WALES, Customs House,
Circular Quay, Sydney; VICTORIA, A.C.A. Building, 118 Queen Street, Melbourne; SOUTH AUSTRALIA,
C.M.L. Building, 41-47 King William Street, Adelaide; WESTERN AUSTRALIA, 4th Floor, G.P.O., Perth;
TASMANIA, Commonwealth Health Laboratory, Launceston; QUEENSLAND, Anzac Square, Adelaide Street.
Brisbane.

COMMONWEALTH SERUM LABORATORIES

PARKVILLE, N.2, VICTORIA, AUSTRALIA

THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER. JANUARY 26, 1946.

ANDREW S PHARMACEUTICAL PREPARATIONS

TUBERCULIN PATCH TEST

(Vollmer) L e d e r I e

ANDREW S LABORATORIES presents a simple and convenient
device to the Australian Medical Profession in introducing and
distributing the

TUBERCULIN PATCH TEST (Vollmer) Lederle

It represents a reliable, safe and painless test, in a stable form
which avoids the use of needles or any instrument, saves time,
as it may be applied by a nurse acting under the direction of
a physician. The VOLLMER PATCH TEST is a valuable
method for use in any public health campaign. It is of
particular value for testing

infants and pre-school age children

The test is made by the application of a strip of adhesive tape
(with tuberculin-treated squares) to the skin, showing a
reaction on removal of the tape after 48 hours.

Further instructions are given in the leaflet attached to each
packing distributed by our Laboratories.

ANDREW S LABORATORIES, SYDNEY

MANUFACTURERS OF DRUGS AND FINE CHEMICALS

LACTOGEN AND VI-LACTOGEN . . . and why they
are the most easily digested of all prepared foods for infants

When our research laboratories were developing the
new Spray Process Lactogen and Vi-Lactogen, they
thought and worked with the single purpose of making
them the best of all prepared foods for infants.
Specifically, the important advan
tages gained by adopting the exclu
sive Spray Process of manufacture

1. Forms a softer, finer curd, more
easily assimilated by baby s
delicate stomach.

2. The soft, finely divided Lactogen
and Vi-Lactogen curd is far more
readily digestible.

3. Fat separation is avoided during
feeding.

Photograph shows fine, uniform texture of Lactogen
curd.

Based on the scientific fact that all milk, in the process
of digestion, forms a curd, and that the ease or

difficulty of digestion is dependent upon the size and
toughness of the curd formed, the ultimate aim of our
laboratories was to produce a baby food that -would form
the softest and finest of curds, and at the same time,
retain the full nourishing qualities necessary to baby s
growth and development. Lactogen and Vi-Lactogen,
made by the new exclusive Spray Process, forms a
softer, finer curd of uniform texture, making them the
easiest of all prepared foods for infants to digest. In
addition, both foods are modified with added cream
and lactose so that baby can quickly assimilate all the
nutritive goodness. Whether used as supplementary
to, or wholly as a substitute for, breast milk, Lactogen
and Vi-Lactogen can be recommended as safe, alterna
tive foods of the highest quality. Vi-Lactogen . . .
modified more closely to breast milk composition, is
intended for the young baby. Lacto
gen, -with its higher protein content,
is the ideal food as baby grows older.

LACTOGEN

AND

VI-LACTOGEN

Nestle s Product

THE MEDICAL JOURNAL OF AUSTRALIA

VOL. I. 33itD YEAR.

SYDNEY, SATTKDAY, JANUARY 26, 1946.

No. 4.

Table of Contents.

[The Whole of the Literary Matter in THE MEDICAL JOURNAL OF AUSTRALIA is Copyright.]

ORIGINAL ARTICLES-

An Address The

Page.
Post-War Rehabilitation of

Science, by J. G. Wagner, B.Sc., M.B., Ch.M. . . 97
A Sociological Study of the Aborigines in the

Northern Territory and their Eye Diseases, by

Michael Schneider 99

Traumatic Arterio-Venous Aneurysm of the

Femoral Blood Vessels, by George C. V.

Thompson, F.R.C.S 104

Putrid Lung Abscess, by C. J. Officer Brown . . . . 107
Inguinal Hernia and its Repair, by Harley Turnbull 109
The Saliva Factor in Peptic Ulceration, by L,. J. J.

Nye 114

REPORTS OF CASES

An Immune Anti-M Iso-Agglutinin in Human

Serum, by R. J. Walsh 115

NOTES ON BOOKS, CURRENT JOURNALS AND NEW
APPLIANCES

The Commodore 116

LEADING ARTICLES

The Retirement of Surgeon Captain W. J. Carr
The Journal and the Recent Industrial Unrest

CURRENT COMMENT

The Results of Prefrontal Leuchotomy
Post-War Germany: A Psychiatric Problem . .

ABSTRACTS FROM MEDICAL LITERATURE

Physiology

Biochemistry

118

120
121

BRITISH MEDICAL ASSOCIATION NEWS Pago.
Annual Meeting 122

MEDICAL SOCIETIES

Melbourne Paediatric Society 129

THE ROYAL AUSTRALASIAN COLLEGE OF
SURGEONS

A Post-Graduate Course in Surgery . .
Meetings of the Courts of Examiners

130
130

THE ROYAL COLLEGE OF OBSTETRICIANS AND
GYNAECOLOGISTS

Examination for Membership 131

POST-GRADUATE "WORK

Courses in Queensland in 1946 131

CORRESPONDENCE

The Use and Misuse of Tetanus Antitoxin . .
Functional Disorders

. . 131
131

NAVAL, MILITARY AND AIR FORCE

Appointments 132

OBITUARY

James Whitson Keinp Bruce 132

\ DIARY FOR THE MONTH 132

I MEDICAL APPOINTMENTS: IMPORTANT NOTICE .. 132

EDITORIAL NOTICES . 132

THE POST-WAR REHABILITATION OF SCIENCE.

By J. G. WAGNER, B.Sc., M.B., Ch.M.,

President of the Queensland Branch of the British
Medical Association.

THE year 1945 will be entered in the annals of world
history as that which marked the fall of the tyranny of
the Axis, and the victory of the United Nations as
champions of democracy, over the evil powers of their
enemies. No one who witnessed the exuberant and spon
taneous joy of "V.P." day and compared it with the
restrained celebration of "V.E." day a few months earlier,
could doubt that the attainment of victory and the restora
tion ef peace had long been the earnest hope of all our
people. And though the present universal turmoil appears
to deny the world s aspirations towards freedom, yet in
itself it is an expression of the freedom that has been
restored, even though the celebrations savour too strongly
of the time-honoured folly of cutting off one s nose to spite
one s face. Even if at present the omens are unpropitious,
the building of a structure that will place war outside the
pale of civilization and allow mankind to devote its energies
to the proper pursuit of the arts of peace, must surely
be one of man s noblest aims, to be pursued equally by
all peoples. There still remain enemies to be conquered,
enemies whose conquest will require all man s skill and
knowledge and energy. These enemies are poverty and
ignorance, crime and disease.

Even more than its predecessor, World War II has been
remarkable for the use made by the belligerent nations

1 Read at the annual meeting of the Queensland Branch of
the British Medical Association on December 14, 1945.

of available scientific knowledge, and the development of
scientific research to provide new methods for the
prosecution of the war in all its aspects. The range of
this activity is so vast that oae person could hardly be
familiar with more than a .small portion of it. When we
think of such things as magnetic mines, "degaussing",
"radar", jet propulsion of aeroplanes, improvement of
fuels for internal combustion, synthetic rubber, tanks,
landing craft, bulldozers, camouflage, bombsights, "Fido",
"Pluto" and a thousand and one things culminating in the
development of the atomic bomb, we begin to realize how
far the application of science to war has proceeded in
these fields. In the domain of medicine we are more
familiar with the developments that have taken place.
The use of sulphonamides and of penicillin in the treatment
of wounds and illness, the modern treatment of shock, the
application of blood transfusion, the control of malaria,
to quote but a few these are stories whose romance is
well known to us.

That the application of science to war has been
reasonably effective is all the more remarkable when
it is remembered that we have not yet completely shaken
off the domination of ignorance amongst men in high
military and political command. There is cause for
thankfulness that the bad old days of the Crimean and
South African campaigns are almost entirely gone. How
otherwise could our troops have survived in New Guinea
and Borneo? No tribute can be too great to the efficiency
and devotion of the medical services in these areas, and to
the enlightened leadership which allowed them to function.
Nevertheless, it happens only too frequently that the
scientific expert who knows how to perform a particular
task is frustrated by a higher authority, fully charged
with ignorance and its concomitant inferiority complex.
For example, in World War I, although the importation
of fruit had been recommended as essential by the scientific
advisers to the British Board of Trade, the British Govern
ment showed clearly that it had not learnt the lessons in

THK MEDICAL JOURNAL OF AUSTRALIA.

.TANTAKY 26, 1946.

nutrition taught by Captain Cook in the eighteenth
century. In Germany at the same time the importance
of vitamins was not realized by government authorities,
and the population was stricken with deficiency diseases
and lowered morale on the home front, together with an
enormous increase in the incidence of tuberculosis. Such
instances could be multiplied a thousandfold.

But now the war is over. The time has come to beat
the swords of war into the ploughshares of peace. The
problems of rehabilitation are before us, involving the
reestablishment of men and women in useful civilian and
peace-time activity. No phase of this problem is more
important than the rehabilitation of science, by which I
mean the harnessing of all our scientific knowledge to
the problems of peace, and the enlargement of that
knowledge by intensive research. How, then, can we
achieve this objective? The answer is that it can be done
only by an intelligent appreciation by political leaders in
every country of the scope of science, in regard to both
the fullness of its knowledge and the shortcomings of its
ignorance which indicate the need for research. The
inevitable consequence of this state of mind would be
a determination to use science to the full for the better
ment of mankind without fear of political consequences.

In making this plea one must admit that already much
has been done; but in the field of medical science, and in
Australia, much remains to be done. For example, the
measures taken for the treatment of patients suffering
from tuberculosis on the one hand, and for the eradication
of tuberculosis from the community on the other, would
be no credit to a prehistoric civilization which could not
be expected to know any better. It is true that in
Brisbane a sanatorium will shortly be built, and this is
a step in the right direction. At present the compulsory
notification of tuberculosis as an infectious disease has
no value except from a statistical point of view. Surely
the role of a government in this matter is to obtain the
advice of its experts and to follow that advice to provide
facilities for a survey of the population, for accurate
diagnosis, for adequate treatment, and above all for main
tenance of the sufferer and his dependants as long as is
necessary. In the matter of prevention, why should the
infective patient not be isolated? How incongruous to
allow an infective patient to broadcast tubercle bacilli
throughout the community when the leprosy patient is
compelled to submit to strict isolation! Surely it is just
as culpable to allow tuberculous milk to be distributed,
when we know how to prevent this risk. The presence
of arsenic in fruit and vegetables rightly is a mutter for
strict and constant supervision; the danger of the tubercle
bacillus in milk demands equal vigilance.

In many parts of Australia, mosquitoes cause consider
able discomfort and ill-health. Filarial infection is more
widespread than is generally realized, dengue epidemics are
familiar to all of us, malaria is common in the north and
occurs in non-tropical areas. Some day we may have to
grapple with yellow fever. It is years now since the town
of Toowoomba was persuaded to undertake intensive
mosquito control and proved that such an idea was no more
than practical common sense; but progress in this respect
in other areas is still in its elementary stages. The amount
of money spent on mosquito nets, mosquito spirals and
sprays all more or less ineffective as far as the main
problem is concerned would go far towards the cost of a
thoroughly efficient mosquito control organization, and
increased industrial efficiency and decreased loss of work
and wages must also be regarded as an offset against the
cost. Here again we have failed to use our proved
knowledge to our immediate advantage.

Some day, perhaps soon, in this age of rapid transport,
smallpox will descend on Australian communities in whole
sale fashion. Outside that large number of discharged
service personnel who have had the boon of compulsory
vaccination, there is an enormous pool of susceptible popu
lation through which an epidemic of smallpox would rage
with devastating effect, and yet there is no public con
science in favour of compulsory vaccination for civilians.

The problem of venereal disease in the community is one
of major importance, and yet one in which a determined

effort in the application of known methods of prevention
and treatment would reduce the incidence to a minor
figure. It only requires public opinion and political leader
ship to decide firmly enough its policy in such a matter
to enable experts to carry out measures adequate for the
purpose.

In the matter of "quack" and patent medicine advertising,
untold harm is done to a long-suffering public by their
pathetic belief in the printed and spoken word. The impact
of the old familiar advertisement in the Press, and particu
larly of the newer blaring radio broadcast, is so powerful
that it is easy to understand its effect on gullible people.
But it is not so easy to understand why an intelligent
government, with skilled advisers to inform it, will allow
its citizens to be robbed in pocket and damaged in health
by the application of these confidence methods. In this
field there are signs of a movement towards better things.
I refer to the censorship established by the Australian
Press over medical advertising, and I have heard of the
banishment of worthless preparations from the Queensland
market by government activity. But much more remains
to be done before we can claim that we as a community are
using our knowledge for the public benefit.

Passing to the matter of research, we come to a field so
vast as to be intimidating; yet science need not be over
awed any more than General MacArthur was when faced
with the problem of the Pacific. Every giant has chinks in
his armour. The MacArthurs of science infallibly find them
and proceed to topple the monster. What is needed every
where is for governments to choose their MacArthurs and
Mountbattens, their Montgomery s and Eisenhowers, and
provide them with the means to carry out their campaigns.
This, of course, needs money, and as finance is alleged to
be the test of good government, criticism of apparently
wasteful expenditure will lead to the downfall of any
government, unless it can be shown that the money so
spent provides a direct benefit in hard cash for the
electors. The parliamentary candidate needs to be able to
show such concrete things as schools and bridges and
hospitals to say nothing of financial grants to this section
or that which have been provided by himself and his
party, and, moreover, he needs to be able to promise more
and bigger and better things for the future. And whilst
politicians and public give lip service to research in their
more expansive moments, she remains a Cinderella when
budgets are being framed.

I am aware that the British Government is making
extensive plans for research, that in Australia the National
Health and Medical Research Council and the Council for
Scientific and Industrial Research are well-grown strip
lings, and that the Queensland Medical Research Institute
is in its prenatal stage. All this is good; but in general,
ten times the amount of money proposed could be well
spent on scientific research and room would still be left
for more.

And while we are speaking about money, let us not forget
about men as the chief instruments of research. These are
no ordinary men. They conform to no regular pattern.
They are flowers of such rare blossom that it is wicked to
allow them to waste their sweetness. Yet here in Australia
we have examples of research men of proved merit con
demned to spend their days in useful routine work, when
all they need is the opportunity to go on with research
work already planned. Imagine Melba in the village choir!
Imagine Phar Lap in the plough!

Think of the research work to be done in medicine, and
do not forget the need for research in pure science, in
agriculture, in forestry, in engineering, and in almost every
sphere of human activity the gathering of knowledge and
its application for the benefit of mankind.

One field of research requiring development is that con
cerned with hours of work in industry. So far this has
always been a political matter; but the nation can no
longer afford it as a political plaything. For every human
activity there must be an optimum number of hours of
work per week, when regard is paid to the welfare of
the worker, the output of industry, the needs of the
public and every other pertinent factor. This is a question
that can and should be determined by scientific method.

JANUARY 26, 1946.

THE MEDICAL JOUttNAL OF AUSTRALIA.

In similar fashion the determination of the basic wage
lies within the province of the science of mathematics
rather than that of legal disputation. Basic needs in food,
clothing, housing et cetera are known factors, and together
make a total which, like a scientific law, is correct in all
circumstances and under all conditions.

There is a phrase that is frequently quoted to the effect
that the expert should be "on tap, but not on top". Such
a saying may be true when experts such as the water
diviner command high salaries in the departments by
which they are employed, and when their advice is pre
ferred to that of the trained and experienced geologist,
or in the medical field when addle-pated and psychopathic
pseudo-experts are placed in charge of important activities
for which they are utterly unfitted. Appointments such as
these arise because the true expert is on tap, but not on top.
If we have to wait until general public opinion is
sufficiently well informed in matters of this kind, many
generations will have lived and died before the community
gets the benefit of that scientific knowledge which is at
present available to us.

We have an example of this attitude in the persistent
refusal in Queensland to appoint as members of hospital
boards doctors and nurses who may well be regarded as
experts in hospital affairs and in matters relating to the
care of the sick. I do not hold that hospital boards
should be composed entirely of doctors and nurses
(although such a plan might well be an improvement on
the present set-up); in my opinion the composition of a
hospital board would be vastly improved, in the public
interest, by the appointment of doctors and nurses to it.
But these, being experts, are unfit to be on top, they must
merely be on tap. In these circumstances it is fortunate
that such expert advice as is on tap usually commands a
good hearing, though this is not always so. (I am
reminded of the story of the dominating husband, who pro
pounded to his wife an infallible formula for domestic
harmony; he agreed that she should have her way when
ever they were in agreement.)

In short, until such time as the conduct of human
activities with a scientific basis is placed in the hands of
men and women who by virtue of sound training and
experience fully understand the problems with which they
have to deal, we can expect nothing but retardation of
normal progress in the rehabilitation of science.

But to go further in this matter of direction of the
nation s activities, I submit that on the topmost rung of
national affairs, there is a lack of the necessary leaven of
science in the parliaments and cabinets of Commonwealth
and States. The absence of a scientific outlook at this
level is something that we can ill afford. We have little
enough to boast about in the general level of intelligence
quite apart from scientific training of those whom we
honour with the duty of representing us in our national
councils. The most that we appear to achieve is a group
of people who, by virtue of greater or less experience, and
by association with their subordinate technical advisers,
blossom forth as experts in their own right, and begin to
rush in with their own expert opinions where their sub
ordinates have feared to tread. So it happens that men
and women of science for all practical purposes are dis
franchised, since their influence as electors is nil, their
influence as technical advisers is minimal, and their
influence in parliaments and cabinets is infinitesimal.

The responsibility for this state of affairs lies heavily on
scientists themselves. It is their public duty to take an
active interest in politics, to make themselves available as
political candidates, however much they may shrink from
the hurly-burly and from other sacrifiices entailed.

Thirty-three years have elapsed since the University of
Queensland produced its first graduates, who now have j
attained some degree of maturity. How far have they been j
able to influence the public life of Queensland? On the
face of it, very little. Yet it would be saddening to think ;
that their unseen influence in the community had not been !
a source of great benefit. This, however, is not enough. |
We cannot expect intelligent government until a sufficient j
number of intelligent, well-trained men and women apply ,

their faculties to the problems of government. We cannot
expect a scientific outlook on scientific problems where
there is no scientific training, and without these conditions
no government can use science for the benefit of the
governed to its fullest capacity.

Democracy has triumphed; let it go forward hand in
hand with science towards a greater future for mankind.

A SOCIOLOGICAL STUDY OF THE ABORIGINES IN

THE NORTHERN TERRITORY AND THEIR

EYE DISEASES.

By MICHAEL SCHNEIDER,
Major, Australian Army Medical Corps.

The Sociological and Psychological Background.
DISTRIBUTED over an area of about 500.000 square miles,
comprising the Northern Territory, are some 15,000 full-
blooded aborigines. A number estimated at about 6,000
and classified nomadic have had very little contact with,
and live outside of, European influence. Approximately
50% of these are to be found in Arnhem Land. Approxi
mately a further 6,000 live in supervised camps, and the
remaining 3,000 or thereabouts are in regular employment.
The nomadic group live the way of their ancestors. Free
and fearless, they roam in their tribal country eking out
an existence on what can be gathered from the soil, the
plants and water, and by the chase. They have no know
ledge whatsoever of food production and conservation.
Those residing in supervised camps have become almost
entirely dependent on the white man for their existence.
At intervals a primitive urge to go "walkabout" compels
them to disappear into the trackless wastes and bush, and
to live the way of their ancestors. The third group,
classified as in regular employment, occupy a social position
somewhere between the nomadic and the supervised cainp
inhabitants. They are employed chiefly on cattle .stations
as cattle musterers, gardeners, goat herders, hewers of
wood and drawers of water. In return for their services
they are provided with a ration of flour, sugar, tea, tobacco,
a little beef, and a lot of offal. At times, which in the
northern areas correspond to the monsoonal wet season,
many station managers send them into the bush to live
in their primitive way, in country largely depleted of food
and game owing to the invasion of the white man s cattle.
Native habitations are never clean, and those connected
with cattle stations are extraordinarily filthy and squalid.
Some three or four feet high, constructed of any available
local material boughs, odd pieces of iron sheets, bags,
scraps of canvas, with the earth as a floor and the roof a
sloping extension of the walls they provide but slight pro
tection against the elements. Scraps of food lie on the
ground and adorn the forks of adjacent trees and shrubs or
the roof of the wurlie. Innumerable lean, flea-infested dogs
slink about uneasily. There is no pretence at sanitation,
and water may be in a distant stream or billabong. In
these surroundings the aborigines squat, or lie on dirty
blankets or canvas or on the ground. Clothing if worn
is never washed. In the dry areas flies are clustered
over scraps of food, refuse, dogs and human beings alike,
and add to the general misery.

In the nomadic state the natives move from one site
to another in their search for food, asd the elements
cleanse the vacated sites.

During the last six or seven decades, more and more
tribal hunting grounds have been alienated from the
aborigines and occupied by pastoralists. The consequent
competition between cattle and native animals has invari
ably led to a considerable reduction in the number of the
latter. Spearing of cattle is denied to the natives, and with
game becoming progressively more depleted, the erstwhile
possessors of the land have been compelled either to seek
help from the cattle station managers or to perish. This has
produced a gradual drift from the independent free nomadic

100

THE MEDICAL JOURNAL OF AUSTRALIA.

JANUARY 26, 1946.

state to that of subservience to the white man. This drift
has been considerably accelerated during the war by the
army in its search for local labour.

As a nomad the aboriginal has a dignified bearing and
behaviour indicative of freedom and independence. Once
he has sold his birthright for a mess of potage by accepting
the white man s dole, his character changes completely.
His face betrays his servility and shame, and his eyes
reveal his fears and doubts. Some few aborigines can
adapt themselves to our world, but the vast majority
fail hopelessly. This failure cannot be entirely ascribed
to the white man s lack of interest, greed, intolerance
or fears. Many teachers have attempted to educate them
and missionaries to Christianize them, and at the present
time unionists wish to enlist them under the same wage
awards as white men.

It is the aboriginal himself who is unable to "make the
grade". Not only is he unable to adopt our mode of life,
but the mere attempt spells annihilation and extinction
for him. Separated from us by countless generations of
evolution, he has a simple, child-like mind which cannot
assimilate what we have to offer. His mind has developed
on an entirely different evolutionary scheme; it is a
scheme in which his environmental economy is all-
important. He has become a part of it. From his earliest
years all his activities, physical and mental, have been
related to it. The plants and trees, animals and birds,
the fish and streams and waterholes, the rocks and hills,
the clouds and rain, the wind, the stars, the sun and moon,
all are of the greatest significance to him, not only in his
sole practical avocation of food gathering, but still more
so in his totemic existence. Of much greater importance
to him than actual parents are his totemic forebears who
created these natural objects. These natural objects form
an integral part of his life and his conception of the
future world. They are the basis of his health and
happiness, his beliefs and his survival. He has struck a
balance with nature in the same manner as our unique
fauna and flora have done. When he is severed from this
association, his psychological make-up never recovers, his
joy and happiness disappear, his life becomes empty and
purposeless, and he declines and degenerates into a pitiable
outcast.

No matter how well-meant and willing our efforts, we
cannot obviate this decay. The native simply cannot bridge
the gulf separating his world from ours. This decay is not
obvious to him. He begins by adopting a passive attitude
to our world, and this is rapidly followed by indifference
to his personal welfare, to his survival, and to the survival
of his race. His lubra in consequence practises abortion
and infanticide, neither of which is countenanced in the
nomadic state, with perhaps the exception of multiple
births, in which case the environmental economy may exact
a relevant ruling. Furthermore, when he is in this stage
of decay he seeks the few small pleasures which he
associates with the white man flour, tea, tobacco, calico,
knives, hatchets and in some instances opium and alcohol.
He accepts the comparatively poor food doled out to him
and passively abandons the food, environment and social
structure more suited to his existence. Being incapable
of abstract thought, he cannot assess the comparative
advantages and defects of the two states.

The white man s attitude to his black employees can
be summed up by the statement that it is motivated by gain,
but is otherwise one of complete indifference. This applies
almost universally. Few cattle stations would be solvent
but for the cheap source of labour supplied by the natives.
All too frequently in return the native is not viewed as an
indispensable servant, but is despised and spurned, and
tolerated only if he is able-bodied and useful. This indict
ment must be modified in the case of many cattle owners
who support non-working dependants of their black
employees. Unfortunately, ill-advised legislation tends to
penalize employers who adopt this humane practice.

This, then, briefly outlines the sociological and psycho
logical background of the aboriginal in the Northern
Territory. The impressions thus penned were formed
during a sojourn of some twenty-one months in the area
with Australian general hospitals. It was during the

period when the Australian Army Medical Corps included
the aborigines in its care. Excursions were made to
various localities along the Stuart Highway (Alice Springs
to Darwin), to the large rivers Roper, Victoria, Daly,
Adelaide and Katherine. Natives were examined where
they were found, and in particular at the cattle, police and
mission stations, and at Army native camps; occasionally
also the roaming food-gatherer was examined.

Of the general diseases encountered very little will be
mentioned, apart from the enumeration of those most
commonly seen, with a note on their frequency rate. The
eye diseases were noted more carefully.

General Diseases.

Yaws.

Yaws or serologically allied disease (Cleland &lt;2) ), has
probably been with aborigines from time immemorial.
Its incidence is remarkably high.

In a series of 38 consecutive cases among adults examined
serologically in one month at an Australian general
hospital, the blood of 36 yielded the Kline reaction. Of
11 infants and children examined in the same series the
blood of two yielded the Kline reaction.

Leprosy.

Leprosy was introduced by Chinese indented labourers
towards the end of the last century (Cook &lt;3) ). There are
probably between 200 and 300 lepers amongst the northern
tribes distributed almost entirely in the coastal regions
(Kirkland&lt; 4) ).

Malaria.

Malaria may have been introduced to the Arnhem Land
coast by Macassars prior to its occupation by white men.
Matthew Flinders wrote of "ague" amongst the natives on
this coastline. Because of the absence of intertribal con
course it is highly improbable that the disease extended
inland. It was probably introduced into the area between
Darwin and Katherine by miners from New Guinea during
the mining boom at the latter end of last century and the
early part of the present century. Its incidence is not
high. Benign tertian malaria is endemic, and occasional
epidemics of malignant tertian malaria occur and are
associated with a high mortality rate.

Hookicorm.

In the higher rainfall areas north of the Roper River
it is assumed, owing to the frequency of eosinophilia, that
intestinal parasites must be common. Some 50% of subjects
with eosinophilia pass ova of hookworm in the faeces
(Andrews 09 ). The disease is highly endemic along the
coastline, around the northern coastal streams and in
adjoining islands. It leads to a greater degree of morbidity
and mortality than is generally realized. Apart from the
deaths more directly ascribed to the anaemic condition
itself, the profound secondary anaemia resulting from the
infection renders many subjects prone to certain inter-
current diseases, to which they succumb.

Tuberculosis.

Pulmonary tuberculosis is found in a moderate number
of cases fewer than one would expect in a people with
no knowledge of cleanliness and hygiene. Their outdoor
mode of life may be a modifying factor. Extvapulmonary
tuberculous infections are fairly common (Kirkland &lt;0) ).
This may be ascribed to the fact that bovine tuberculosis
is common amongst cattle in some parts of the Northern
Territory, and natives almost invariably eat their food
only partly cooked.

Eye Conditions.
The Conjunctiva.

One commonly finds collections of dark brown pigment in
the conjunctiva of the lids and bulbs of adults. They
tend to be localized into the larger accumulations in the
areas normally exposed when the eyes are open. The
caruncle and plica semilunaris sometimes share in this

.TAXI: Ait v L O, 194G.

THE MEDICAL JOURNAL OF AUSTRALIA.

lavish distribution of pigment. Because infants and
children are devoid of these collections of pigment, they
must be classified as acquired. Occasionally a complete
ring of pigment surrounds the cornea, usually but not
invariably separated by a space of about one millimetre
from the limbus. These rings are from 1-0 to 1-5 milli
metres in width.

The Iris.

The colour of the iris is always dark, varying between
chocolate-brown and almost black. Owing to lack of con
trast between iris and pupil, it is difficult to define the
pupillary edge in daylight.

The Fundus.

The fundi are almost invariably of a uniform slaty-
pink colour, and chorioidal vessels cannot be seen. By
contrast, the optic nerve head is apparently, but not
actually, paler than in Europeans. Rarely, the fundus
background is of a paler shade of pink or red resembling
the colour in European eyes.

Visual Acuity.

Tested with the Snellen illiterate chart, the visual acuity
as a whole approximates that of Europeans. Of a series
of 48 subjects taken at random, 33 had a visual acuity
of Ve in each eye, and four managed 6 /.v A further six
registered 8 / G in one eye, and the remaining five had a
visual acuity of less than % i n either eye. The impairment
of vision in these had resulted from trachomatous corneal
lesions. In the field, however, an aboriginal leaves us far
behind in perceptive powers. He recognizes objects at
many times the distance at which the white man can
recognize them, and his ability to recognize and follow
tracks and footprints leaves us bewildered. The extra
ordinary performances of black-trackers would be largely
discredited and classified as figments of fiction, but that
they are commonly accepted in legal practice. These feats
are not due to any advantage in visual acuity with which
the aboriginal is often credited, but are the result of
training and careful observation and of the accurate inter
pretation of natural phenomena so closely related to his
survival.

Refractive Errors.

Tests for errors of refraction were performed after
routine instillations of homatropine and cocaine (2%).
All eyes exempt from deep or extensive superficial corneal
disease were hypermetropic. The largest error discovered
was three diopters, and the majority varied between 0-25
and 1-5 diopters. Hypermetropic astigmatism varying
between 0-5 and 1-0 diopter was seen in about 30% of
subjects. In no instance was myopia found in an eye free
from corneal disease.

Lid Diseases.

Chalazion is not uncommon and chiefly affects young
adults. The incidence approximates that in whites.
Blepharitis and hordeolum, however, are rare.

Naso-lachrymal Duct.

Chronic dacryocystitis in association with old, active,
severe trachoma is not uncommon. In several instances
it had produced a diverticulum of the sac in the lower lid,
extending as far out as the external eanthus. In one
subject the distended sac readily held 2-5 cubic centimetres
of saline solution. No evidence of rupture through the
skin indicating acute dacrocystitis was found in any
subject.

Conjunctival Disease.

Pterygium is somewhat rare. In a series of 574 subjects
it was present in 17, and is therefore considerably less
common than in a similar number of whites residing in
the Northern Territory. It never encroaches more than
about two millimetres on the cornea.

Mucopurulent conjunctivitis is prevalent amongst
children, and is usually associated with profuse nasal

discharge and a tendency to bronchitis. The organisms
most commonly found on culture media were Koch-Weeks
bacilli and pneumococci.

No attempt at cleansing the conjunctival sacs is ever
made by the mother, and the discharge collects on the
lashes in hard, stiff pencils.

The Cornea.

Variations in diameter of the cornea are similar to
those in European eyes. Arcus senilis is not uncommon
in the elderly. Owing to their outdoor life in thick high
grass and bush, the natives in the northern areas occasion
ally present corneal abrasions.

The corneal lesions of trachoma will be dealt with under
a later heading.

Uveal Disease.

The aborigines appear to be remarkably free from dis
orders of the uveal tract. No frank case of acute iritis or
cyclitis was observed on external examination, nor was any
evidence of chorioiditis found in the fundi of 86 subjects
examined ophthalmoscopically. Iris atrophy with mydriatic-
resistant pupils was evident in several lepers. Popular
opinion among white people in the Northern Territory
maintains that the natives are largely infected with
gonorrhoea. In refutation of this common belief, it may
be stated that no evidence of gonococcal eye disease was
found, nor could gonococcal focal infection be suspected in
the absence of uveal inflammation.

Ocular Manifestation of Yaws.

If it is assumed that infection by Treponema pertenue
immunizes a people against infection by Treponema
pallidum m , then syphilis is not likely to be encountered in
the aborigines, and it is probable that the following cases
may be listed as presenting unusual manifestations of yaws.

CASE I. Aiden was aged about thirty years; he belonged
to the Djappada tribe, in the Wyndham area. He had optic
atrophy and central retinitis. He was admitted to hospital
with right-sided hemiplegia of recent origin. The blood
yielded both the Kline and the Wassermann reactions
("++"). An accompanying impairment of visual acuity (right
eye, 8 / 18 ; left eye Veo). also of recent origin, was due to optic
atrophy, and in the left eye it was also partly due to central
retinitis. The cerebro-spinal fluid was under normal pres
sure, contained globulin and ten cells per cubic millimetre, and
yielded a paretic type of gold curve and a "doubtful positive"
reaction to the Wassermann test. The patient intimated
that his lubra and two children were well. Rapid reduction
in the paralysis and some improvement in the visual acuity
followed initial treatment by potassium iodide and mercury,
later supplemented by "Novarsenobillon".

CASE II. Topsy, aged about twenty years, belonged to the
Rimburrunga tribe in lower Arnhem Land. She had bilateral
interstitial keratitis and keratoconus in the left eye. This
lubra had uniform grey opacities in the deeper layers of the
cornese associated with deep blood vessels. In the right
eye the grey area occupied approximately the upper half,
the lower margin being convex downwards. The lesion In
the left cornea resembled that In the right, but extended
further down and occupied all but a narrow zone about 1-5
millimetres wide inferiorly. A considerable degree of kerato
conus was superimposed in the left eye. The blood reacted
to the Kline test ("++").

CASE III. Blind Maggie, aged about twenty-five years,
belonged to the Nowla tribe in the Victoria River area. She
had optic atrophy. She stated that she had been blind "long
time" and that the blindness had "come slow". Her pupils
were 5-0 millimetres in diameter and Inactive. She was
completely blind without perception of light. The fundi
presented clearly denned, greyish-white disks, with no altera
tion in their level, the blood vessels appeared to be normal
and the fundus colour was a little paler than is usual in
aborigines. These conditions were combined with ataxla,
disturbance of balance, flaccid arms and legs, absent deep
reflexes and a positive ("+ + +") reaction of the blood to the
Kline test.

CASE IV. An infant, aged about two months, belonged to
the Ngullican tribe in the Roper River area. He had Inter
stitial keratitis. The blood of both parents and the infant
reacted to the Kline test. Both cornese of the child were
opaque and of a generalized pale-grey colour, amongst

102

THE MEDICAL JOURNAL OF AUSTRALIA.

JAXUAKY 26, 1940.

which numerous rounded, yellowish-grey plaques were dis
tributed. The subsequent history is not known, as the
family disappeared silently and suddenly into the bush soon
after treatment was initiated.

Cases III and IV have been described by Binns lsl .

Trachoma.

As may be expected in a people living in close personal
contact with each other, without the slightest notion of
personal cleanliness and hygiene, trachoma has a re
markably high incidence. Of a total of 574 subjects, 520
(91%) presented evidence of trachoma in one of its stages.

The most remarkable feature of the disease in the
Northern Territory is the extraordinary influence that
climate bears on its severity. In the southern areas of
the Northern Territory, rarely free from wind and dust,
the disease is severe. In the northern areas, comparatively
free from wind and dust, the disease is mild and complica
tions are rare. The incidence rate is practically identical
in the two areas thus subdivided climatologically.

The bush fly Musca vetustissima is so prevalent in the
interior dry areas that outdoor life is a most trying
experience. The flies have a predilection for one s eyes j
and are most persistent in their endeavours, and it becomes j
necessary to wipe them from one s lids times without
number. The aboriginal placidly ignores flies, and one
usually finds a group clustered about his eyelids. In
the northern areas these flies are practically absent a
few are seen in the winter months, but never in large
numbers.

The incidence rate of trachoma is practically identical
in the fly-ridden and the fly-free areas, and one may there- j
fore conclude that flies play a minor role, if any, in the !
dissemination of the disease.

The chief vehicle of transference of the organism of
trachoma in the aboriginal is almost certainly the human
finger. It is a common experience to observe a lubra j
wiping the secretion from her eyes with her fingers, and !
a moment later repeating the manipulation on her child s I
eyes, wiping any excess on to some part of her body or
thighs.

Corneal Conditions in Trachoma. In both severe and mild j
cases of trachoma in the aborigines, one frequently finds j
a crescent-shaped infiltration or degeneration of the cornea !
contiguous with the sclerotic. The lesions appear during |
the stage of healing and are apparently permanent. They
have a sharply defined border, are greyish-white to olive-
brown in colour, and may contain small collections of
dark brown pigment and both superficial and deep blood !
vessels. Their length varies from 7-0 to 12-0 millimetres,
they taper at each end, and the diameter in the middle
varies from 1-0 to 3-5 millimetres. They are most usually
situated on the upper border of the cornea, but may occur
on the upper and lower borders, or occupy the whole
circumference. Being contiguous with the sclerotic and
opaque, they distort the outline of the cornea to super
ficial examination, so that if they are present above and
below, the cornea appears to be horizontally oval. Irregular
mantles of pannus may coexist and extend beyond the
margins of these degenerated areas. The lesions were
found in 101 (22%) of 463 sufferers from trachoma. In
11 eyes the crescents contained Herbert s pits clear,
circular areas varying from one to two millimetres in
diameter, most of them discrete but others merging with
neighbouring pits. They varied in number from a solitary
pit to as many as nine, and if they were multiple they
described an arc in the area of crescentic degeneration.
In two subjects a narrow pigmented line described an arc
in the crescentic area.

Severe Trachoma. Severe trachoma is found in the dry,
dusty, windy interior country. It conforms to the classical
description of the disease, in that it begins in early child
hood and terminates with the grave, producing more
suffering than any other disease, and is accompanied by
progressive impairment of vision and not infrequently
blindness. Of a series of 140 consecutive subjects
examined, 11 were blind in both eyes, 13 were blind in one
eye, 41 presented cornea! opacities which considerably

impaired the visual acuity, and 31 had pronounced
entropion which in 25 instances had resulted in trichiasis.
Phthisis bulbi was found in five eyes. In nine cases there
was an associated chronic dacrocystitis with considerable
enlargement of the lachrymal sac, and symblepharon was
present in two subjects. Pannus, visible to the naked eye,
was present in all severe active cases of trachoma, and in
two cases the grey mantle extended over the whole cornea.
History taking, apart from its amusement value to a
bystanding colleague, is usually valueless. An aboriginal
cannot think in abstract terms, and time is of no sig
nificance to him. When he is questioned, his averted face
remains expressionless until he discovers whether one
wishes him to reply in the affirmative or negative, and then
his desire to please outweighs his respect (if any) for
scientific investigation.

The following will serve as illustrative cases of severe
trachoma.

Judy, aged about fifty-five years, belonged to the Wadamar
tribe. The conjunctives of her lids were red and considerably
swollen and speckled with areas of pigmentation. Scarring
in irregular patches coexisted with small collections of
follicles. Both lachrymal sacs contained a large quantity of
foul-smelling pus, which welled from the inferior puncta
on pressure over the enlarged sacs. Her right eye was
shrunken and the edge of its calcified lens projected some
two millimetres from an anterior perforation of the cornea.
(The lens was readily removed with a blunt curette.) Her
left eye presented early senile cataract and much pannus.

January, aged about twenty years, belonged to the
Ngeinman tribe. A series of well-defined scars on his throat
indicated an ineffectual attempt at suicide. Both his eyes
presented severe, active trachoma with many large follicles
on greatly swollen, hyperplastic and reddened conjunctiva.
Grey mantles of pannus with numerous blood vessels
extended downwards to cover half of his corneae. In the
upper area occupied by pannus in each eye was a greyish-
white crescent, tapering at both ends, about 7-0 millimetres
long and 3-5 millimetres wide in its middle. The crescent
in the left eye contained a solitary Herbert s pit.

Joe, aged about seventy years, belonged to the Billi-ngarra
tribe. His trachoma was characterized by a few follicles,
some scarring and much swelling and redness of the con
junctiva of the lids. He had entropion and trichiasis. His
left eye was quite blind from a dense white opacity of the
whole of the cornea. His right cornea presented a dense
central scar containing a horizontal pigmented line. The
visual acuity in this eye was poor. An optical iridectomy
would help Joe.

Charlie, aged about seventy-five years, belonged to the
Ngeinman tribe. He was completely blind from trachoma.
Both cornese presented dense opacities undergoing calcareous
degeneration, and blood vessels. His lids were distorted,
with the production of trichiasis, and follicles, areas of
epithelial hyperplasia partly pigmented, and irregular scars
on his tarsal conjunctivas were present.

Charlie was conducted by Joe (mentioned above) in the
manner invariably used by natives when leading their
blind. Joe s visual acuity was just sufficient for him to
avoid large obstacles and pitfalls, and he led Charlie at
the end of a stout cudgel some five feet long. They pro
ceeded in single file, one at each end of the stick held
loosely and horizontally by their sides.

Mary Anne, aged about forty-five years, belonged to the
Ngongalli tribe. Her trachoma had produced entropion,
distichiasis and trichiasis, and isolated scars on the cornese.
She was the only native examined who practised epilation
for the relief of trichiasis. She did this by pulling the lid
away from the eyeball, and then removing the offending
lashes between the index finger and thumb of the same
hand. Although performed without the aid of a mirror or
an instrument, the procedure was highly successful, in that
no lashes were rubbing on her cornese, although many were
projecting about half a millimetre from the lid.

Nellie, aged about sixty years, belonged to the Djamindjang
tribe. She was blind in both eyes from trachoma. The
right eye was affected by phthisis bulbi and the left by
keratectasia involving the whole of a densely opaque cornea.
Trichiasis involved both upper and lower lids, and had
produced spastic entropion of the lower lids.

Mild Trachoma. As has been previously mentioned
mild trachoma has a climatological distribution, and in
general belongs to the comparatively wind and dust free

JANUARY 26, 1940.

THE MEDICAL JOURNAL OF AUSTRALIA.

103

areas north of the Roper River. The incidence rate is
practically identical with that of severe trachoma about
90% of all persons. None of them complained even of dis
comfort, although this may be ascribed to the natural
stoicism of the natives. In no case was photophobia,
excessive lachrymation or active corneal ulceration present.
Slight ptosis was observed in a fair proportion of subjects
with pannus and follicles. Pannus was present in all
with follicles and epithelial hyperplasia. Most of the
children had early trachoma manifested by pannus, red
swollen conjunctiva of the lids containing follicles, and
a little hyperplasia. Fine cicatrices were found in those
who had attained the age of ten or twelve years, and adults
presented little evidence of preexisting trachoma apart
from fine scarring of the tarsal conjunctiva, and in a
large proportion of cases the areas of crescentic degenera
tion previously described.

The following will serve as illustrative cases.

Biblingi, aged about thirty years, belonged to the Ngandi
tribe. Fine scars were irregularly distributed over the |
tarsal conjunctiva of both eyes. Pannus could not be seen
with the naked eye, but with a x 10 loupe small blood vessel
loops could be followed on to the corneal epithelium. No
other abnormality was detected about his eyes.

Cobiyaryack, aged about twelve years, belonged to the
Nungabuya tribe. He presented slight ptosis, and a few
small follicles were present in a slightly reddened area over
the tarsal conjunctiva of each eye. Small areas of scar
tissue were distributed irregularly. A crescentic grey area
of corneal degeneration was present on the upper border
of each cornea; each was about 7-0 millimetres in length
and 2-5 millimetres wide in the centre, and tapered at the
ends.

Ironstone, aged about thirty years, belonged to the Rimbur-
runga tribe. Faint scarring, which produced a pale bluish
discoloration of the tarsal conjunctiva in each eye, and a
series of greyish-white crescents of degeneration in the j
peripheral area of the cornea, were the only remaining
evidence of previous trachoma.

Paddy, aged about twenty-five years, belonged to the
Melville Island tribe. His tarsal conjunctiva had become
scarred, with the production of an ivory-white, smooth,
glistening surface. There was no distortion of the lids or
entropion. His cornese presented a few fine invading blood
vessel loops above, and in the left eye he had an olive-green
crescent of corneal degeneration about nine millimetres long
and two millimetres wide in its middle.

Don, aged about twenty years, belonged to the Millingimbi
tribe. His lashes were unusually long. The conjunctiva of
his upper lids was reddened and contained small irregular
areas of cicatrization. The cornese appeared clear.

Treatment of the Diseases of the Aborigines.

As has previously been intimated, the natives of the
Northern Territory are readily divisible into three socio
logical groups: (a) the supervised camp group, (b) those
in regular employment, and (c) the nomadic group.

The inhabitants of supervised camps, largely treated
with contempt by their supervisors, with no hope of ever
being accepted in the white man s society, and with no
pride in their ancestry, are rapidly diminishing in numbers.
Their medical problem is a self-terminating one they are
doomed to early extinction. Medical care in the meantime
should be, and actually is, based on that provided for
white communities including treatment in hospitals. A
similar attitude is adopted to those employed on cattle
stations in the vicinity of towns.

As for the nomadic group, and those employed on out
lying cattle stations, we cannot approach these too
cautiously. On the outlying cattle stations a semblance
of the black man s primitive patriarchal family life is
still maintained, and for that reason these natives should
be treated in the same manner as the nomadic people.
It is for the latter, however the nomads that a special
plea is made. Previous experience shows us clearly that
there is no surer way of exterminating them, even if we
cure them individually of their physical ills, than by
collecting them in the vicinity of white people. They
cannot be separated from their highly adapted primitive
existence from the only world they know and survive.
There is no alternative. This factor must form the basis

of our approach to them, or better by far that we leave
them alone. Therefore as a general principle treatment
in hospital cannot be countenanced. These remarks do
not apply to the comparatively small numbers of lepers
and those suffering from tuberculosis, who must be segre
gated.

If the nomadic people in Arnhem Land, estimated at some
3,000 individuals, were left completely to themselves; if
we strictly excluded not only pearlers and beachcombers,
who under the pretext of seeking water land on its shores
to satisfy their lust, and the "poor whites" roaming in
the area, but also all manner of teachers and missionaries,
often well-intentioned but ill-informed; if these were
excluded, there is no reason why the aborigines should
not survive through hundreds of years. They have done
so through countless forgotten ages, and it is only when
we thrust ourselves upon them with our "civilization"
that they leave their virtuous primitive life, adopt our
vices, and end miserably.

All missionaries in the Northern Territory cannot be
included in this generalization. A few intelligent men
do exist teachers in the true sense, who do not allow
religious zeal to subjugate their respect for aboriginal
customs and habits. Fully cognizant of the havoc and
destruction created by fellow-missionaries, these few stand
preeminent in their helpful, unselfish and commonsense
attitude. They rate physical welfare as at least equal in
importance with spiritual welfare, and realize that the
uncontaminated black man is more virtuous than the
white.

The natives in Arnhem Land live in barren, inhospitable
country, which fortunately for them has not been inviting
enough for white men to occupy. How long this state of
affairs will continue is unpredictable. Even now certain
ignorant and misguided people maintain that lack of
development of Arnhem Land is one of the reasons why
the Northern Territory has failed economically in the past.
They have formulated the most extraordinary and fantastic
schemes for its so-called development. Let us call a halt to
these dreamers and at the same time preserve the aboriginal
in his last stronghold. Arnhem Land cannot be utilized
economically by the white man, so why destroy the black
man in it?

The problem confronting us, therefore, is primarily, the
prevention of their racial extinction, and secondarily, the
treatment of their diseases. The former is dependent on
wise and humane administration; the latter presents no
insuperable difficulties. The medical care of the aborigines
who live the primitive food-gathering, patriarchal family
existence could be maintained by mobile medical units.
A mobile medical unit would consist of a medical officer,
with special training in the treatment of trachoma and
aboriginal diseases, a guide-interpreter, with special know
ledge of native customs and habits, for each district, and
an orderly. The unit would have at its disposal two motor
vehicles, one of which would be fitted out with the neces
sary medical, surgical and laboratory equipment for the
diagnosis and treatment of the diseases commonly found.
It would visit suitable areas in the reserves in rotation.
The unit could control yaws, malaria, trachoma and
probably hookworm, determine the diagnosis of leprosy
and tuberculosis, act in an advisory capacity on matters
of personal hygiene and cleanliness in fixed native encamp
ments, and indicate the mode of procedure for treatment
of disease for the periods intervening between visits.
This approach would not "detribalize" the aboriginal or
interfere with his mode of life, and the medical officers
would receive the confidence of the natives, who would
readily submit to treatment. The white custodians of
aborigines would also welcome it, and their active coopera
tion would be assured.

Treatment in hospitals for natives other than those who
had been "detribalized" would, as has been previously
mentioned, spell death and destruction to them. Quite
apart from this aspect, there are other factors that would
render such a plan infeasible and ineffective. The large
number of sufferers from yaws and trachoma alone could
not be coped with by any transport unit over the trackless
areas involved, nor would air transport be adequate; and

THE MEDICAL JOURNAL OF AUSTRALIA.

JAM-AKY 26, 1916.

the aborigines, with their innate fear of any other than
their tribal grounds, even if successfully collected, would
quietly take to the bush and disappear.

A modification of the approach that a mobile medical unit
would employ, and more suited to the difficult terrain and
vast distances, was in force prior to the outbreak of the
war against Japan, through the medium of the Aerial
Medical Service. This service visited the cattle, mission
and police stations at regular intervals. The large number
of sufferers from the complications of trachoma alone
indicates that the service had insufficient medical officers
at its disposal. Its activities will be enlarged in the post
war period, more medical officers and more aircraft will
be engaged, and it is anticipated that this service will be
able to cope with the large number of sick natives in the
various stations under its supervision.

Summary.

1. The sociological and psychological background of the
aborigines in the Northern Territory is briefly outlined.

2. Their common diseases are enumerated.

3. A survey of their eye conditions and diseases is
presented.

4. The prevalence of trachoma is stressed.

5. The climatological influence on the severity of
trachoma is pointed out.

6. The frequent occurrence of a crescentic-shaped de
generation of the cornea in trachoma is mentioned, and
the macroscopic appearance is described.

7. A note on the mode of transfer of the infecting
organism of trachoma is tendered.

8. The theory that flies act as vectors of trachoma is
discredited.

9. Suggestions concerning a medical officer s approach to
the aborigines are outlined.

10. The formation of mobile medical units in the
Northern Territory is recommended.

11. A plea that Arnhem Land be maintained as an in
violate aboriginal reserve is added.

Acknowledgements.

I am indebted to the Director-General of Medical
Services of the Australian Military Forces for permission
to publish this paper. Appreciation is expressed for the
helpful criticism of Lieutenant-Colonel W. B. Kirkland and
Chaplain W. S. Chaseling. My thanks are due to many
kind and hospitable white residents on the cattle, mission
and police stations in the Northern Territory, who made
the investigation work both simple and pleasant.

References.

(1) "Official Year Book of the Commonwealth of Australia",
Number 34, 1941, page 307.

&lt;2 &gt; E. C. Black and J. B. Cleland : "Pathological Lesions in
Australian Aborigines, Central Australia (Granites), and
Flinders Range", The Journal of Tropical Medicine and Hygiene,
Volume XLJ, 1938, page 69.

&lt;a) C. Cook : "Epidemiology of Leprosy in Australia", Com
monwealth of Australia, Department of Health, Service Publica
tion Number 38, 1927, page 28.

&lt;4) W. B. Kirkland : Personal communication.

(5 &gt; J. Andrews : Personal communication.

&lt;"&gt; W. B. Kirkland : Personal communication.

&lt;7) "Hanson s Tropical Diseases", Eleventh Edition, 1942, page
634.

&lt;R) R. T. Binns : "A Study of Diseases of Australian Natives
in the Northern Territory", THE MEDICAL JOURNAL OF AUS
TRALIA, Volume I, 1945, page 421.

TRAUMATIC ARTERIO-VENOUS ANEURYSM OF THE
FEMORAL BLOOD VESSELS.

By GEORGE C. V. THOMPSON, F.R.C.S. (Edinburgh),

Surgical Registrar of a Royal Australian Air

Force Hospital.

TRAUMATIC arterio-venous communications most fre
quently result from wounds of an artery and an accom
panying vein by a penetrating projectile of the nature of
a rifle bullet or a bomb fragment, or as a result of stab

wounds. Thus it is to be expected that larger numbers
of arterio-venous aneurysms will occur in war-time and
that opportunities will be presented for the study of their
clinical features.

The common sites for arterio-venous communications of
traumatic origin are in exposed situations in which an
artery and vein are in contact over long distances. It is
not surprising that the most common vessels which sustain
injuries resulting in the development of arterio-venous
aneurysms are the femoral, axillary, brachial, popliteal,
carotid and subclavian vessels, the frequency being some
what in that order. The most commonly encountered
arterio-venous aneurysms are those of the femoral vessels.

The type of communication between the artery and the
vein depends upon the degree of wounding of the vessels,
the amount of perivascular hsematoma formation and the
relative positions of the arterial and venous wounds. A
small foreign body passing between an artery and its
accompanying vein may cause only a small puncture of
both artery and vein, with a minimal extravasation of
blood into the tissues, because the proximity of the
openings allows the blood extravasated from the artery to
follow a pathway of little resistance through the venous
puncture rather than to dissect tissue planes. A fistula is
thus established without the formation of an intervening
aneurysmal sac; either this may be a direct communication
between artery and vein or an arterio-venous fistula united
by a small channel may result. Such communications
constitute an aneurysmal varix. If the vascular damage is
greater than this, or if the wounding of the vessels is
such that the openings of the artery and vein are at the
same level although not contiguous, as may happen in
tangential wounds of blood vessels, blood is extruded into
the tissues and forms a hsematoma, which finally communi
cates with the venous opening. The organization of the
track thus formed gives rise to an arterio-venous com
munication in which an aneurysmal sac is an integral
part. This constitutes an arterio-venous aneurysm.

Reports of Cases.

In a recent case it was most instructive to watch the
formation of an arterio-venous aneurysm during the first
few days after injury to the femoral vessels. Such a
patient (Case I) was recently examined after he had
sustained a gunshot wound of the femoral region; a large
thigh hsematoma developed, which was rapidly reduced in
size, and at the same time the classical signs of an arterio-
venous communication became evident. The clinical con
dition and progress of this particular patient will be briefly
quoted.

CASE I. On November 9, 1944, B.N.M., an officer of the
Royal Australian Air Force, was injured by a rifle bullet
which penetrated his left thigh in the region of the apex of
the femoral triangle of Scarpa. He was examined almost
immediately; at this time his pulse rate was 60 per minute
and his blood pressure was 120 millimetres of mercury,
systolic, and 70 millimetres, diastolic. Three hours later, on
his admission to hospital, examination revealed that the
entry wound was a quarter of an inch in diameter and was
situated three and a half inches below Poupart s ligament,
just lateral to the femoral artery. A slightly larger exit
wound was situated in the gluteal region, two inches from
the mid-line of the body. The pulsations of the femoral and
popliteal arteries were readily palpable, but pulsations of
the posterior tibial and dorsalis pedis arteries were palpable
only with difficulty. There was a large hsematoma over the
thigh, which rapidly subsided during the next twenty-four
hours.

Two days after the accident a pulsation and thrill were
noticed for the first time over the femoral artery. These
features extended as far as Poupart s ligament and were
associated with an audible bruit; but no obvious localized
pulsating mass was recognizable as a distinct entity, apart
from the generalized effusion of blood into the thigh muscles
and tissues. Neither at this nor at any subsequent time did
venous engorgement or oedema of the leg appear.

During the next few days the thrill, pulsation and bruit
became more localized over the femoral region, and the
thrill now actually extended proximal to Poupart s ligament.
Proximal compression of the artery by digital pressure over
its course at Poupart s ligament controlled the thrill, but
unfortunately no record of the effect on pulse rate or blood

JA.MAKY L ii, 1940.

THE MEDICAL JOURNAL OF AUSTRALIA.

105

pressure was kept. No undue general symptoms or signs of
cardiac involvement were noted. About five weeks after
injury some deficiency of circulation in the foot occurred,
with transient colour changes.

On October 31 exploration of the area was carried out
under general anaesthesia, and a communication of the
aneurysmal type was found between the femoral artery and
vein immediately distal to the origin of the profunda femoris
artery. Ligation of the artery and vein proximal and distal
to the site of communication was carried out, followed by
excision of the aneurysm. After operation the foot became
cold, and cyanosis of the toes and forefoot was pronounced.
This condition lasted for a week, at the end of which time
the foot became warmer and pulsations reappeared in the
posterior tibial artery. Within a month of operation this
officer had begun walking and after another month s con
valescence he could play sport and walk moderate distances
without undue discomfort. Four months after injury a
medical board considered that he "had recovered all normal
usage of the leg and was fit for duties in the capacity of a
pilot".

The arterio-venous fistula having been established, there
gradually appear changes in the liinb circulation, in the
calibre of the vessels, and in the thickness of their walls,
and especially in the lower extremity, varicosity of the
superficial veins occurs. The pathological changes in the
vessels and in the blood flow have been described by
Horsley and Bigger. (1) There is considerable difference of
blood pressure between artery and vein, resulting in
rapid flow through the fistula and very little prospect of
spontaneous cure by clotting. The ease of blood flow
through the fistula allows a proportion of the blood in the
limb to be returned to the heart without taking part in
the limb nutrition, and eventually may cause cardiac
enlargement. Changes occur in the artery, which becomes
smaller distal to the fistula, owing to the reduced blood
flow, and dilated proximal to the fistula, so that it is able
to convey the blood needed to nourish the limb and to
accommodate the extra blood short-circuited back to the
heart. The veins become dilated distally as far as the first
valve, and proximally as far as the vena cava or even the
heart. If the venous valves become incompetent, vari
cosity of the veins ensues, the nutrition of the limb suffers,
and ulceration or eczema may supervene. As a result of
their dilatation the veins become thickened, so that it is
difficult from examination of their wall at operation to
distinguish artery from vein. These features are more
evident in long-standing cases. This was recently seen
in the case of a patient who had an arterio-venous
aneurysm of the femoral vessels of three years duration.
The clinical history of this patient (Case II) is also briefly
recorded.

CASE II. On July 22, 1942, W.G.M., a Royal Australian Air
Force corporal, was accidentally injured by a 0-22 rifle bullet,
which entered the medial aspect of his left thigh and was
recovered from the region of his left anterior superior iliac
spine at operation under local anaesthesia on the same day.
At this time he had a certain amount of extravasation of
blood in the medial aspect of his thigh, and during con
valescence a swelling was noted in the groin, which had an
"emphysematous" sensation to palpation. No record was
made of any damage to the main blood vessels, nor was
aneurysm suggested, although it appears probable that early
features were making themselves evident at this stage. The
patient did not report for medical examination for two years,
at which time he fainted on duty. The medical records
state that examination revealed no abnormality except for
varicose veins in his left leg.

On April 25, 1945, the patient reported at the unit sick
parade on account of swelling of his left ankle and dilated
veins in his left leg. He said that the veins of the leg had
gradually become more prominent since the date of his
accident and had been accompanied by the slow development
of o?dema. Clinical examination revealed dilatation of the
superficial veins below the knee, with considerable tor
tuosity accompanied by "pitting" oedema and a small ulcera
tion surrounded by low-grade cellulitis at an area of recent
bruising. In the upper half of the thigh a thrill and bruit
were present, localized over the femoral vessels, but no
aneurysm could be palpated. The thrill and bruit could
readily be followed to a point three inches proximal to
Poupart s ligament. The pulse rate was 80 per minute; the
systolic blood pressure was 170 millimetres of mercury and
the diastolic pressure 70 millimetres. The pulse was of the

typical "water-hammer" or Corrigan type. The apex beat
of the heart was displaced laterally, being palpable five
inches from the mid-line of the sternum. Control of the
blood flow through the arterio-venous communication by
pressure over the femoral artery resulted in a fall of pulse
rate to 70 per minute, and investigation of the blood pressure
revealed a less pronounced pulse pressure; the systolic blood
pressure was unchanged, but the diastolic pressure rose to
110 millimetres of mercury. An X-ray examination of the
heart showed slight enlargement in all cardiac diameters;
this confirmed the findings on clinical examination, as well
as revealing engorged pulmonary blood vessel markings
throughout the lung fields.

On June 7 operation on the femoral arterio-venous
aneurysm was performed by a consultant surgeon. After
control of the vessels, the aneurysmal communication
between the femoral vessels was found to be just distal to
the origin of the profunda femoris artery. Ligation of the
femoral artery and vein proximal and distal to the
aneurysmal area was followed by excision of the sac after
several small communicating vessels had been ligated and
divided. A small blood transfusion was given, as no evidence
of cardiac embarrassment had occurred as a result of
ligation. Immediately after operation the pulse rate was
76 per minute, and the systolic blood pressure was 130
millimetres of mercury and the diastolic pressure 84 milli
metres.

Since operation little variation has occurred in these
figures. There were no circulatory changes in the foot
after operation, the dorsalis pedis and posterior tibial arteries
being palpable at all times. The heart size rapidly decreased,
and one week after operation the apex beat was four and a
quarter inches from the mid-line. One month after opera
tion the heart was clinically normal, the apex beat being
in the normal situation. On July 10 X-ray examination of
the chest revealed a decrease in the size of the cardiac
shadow compared with the film taken prior to operation,
and considerable reduction in the congestive changes in the
lung fields. At this time the patient was considered fit for
discharge from hospital to have a short convalescence prior
to return to his normal duties.

Discussion.

It will be noted that the clinical signs and symptoms of
a femoral arterio-venous aneurysm, as exemplified by the
two cases quoted, differ according to the length of time
that has elapsed since the fistula was established. An
important feature to remember is that the signs of an
arterio-venous aneurysm may appear immediately after
the accident, or they may not become evident until after
the lapse of some days or weeks. In the first case quoted
the signs did not become manifest for a day or so. This
may be explained by the fact that absorption of the peri-
vascular hsematoma allows signs of the fistula to be found
or that the channels become more patent as swelling
subsides. To the signs of the local condition are added
general signs and symptoms in long-standing cases or in
cases in which the fistulous openings are very large. At
the same time nutritional changes in the limb may be
evident.

When a wound has occurred in the region of the femoral
vessels, a careful study of the exit and entry sites will
often lead one to suspect injury to those vessels. In all
such cases a careful examination should be made at that
time, and on several subsequent occasions, to exclude
vascular damage and the development of an arterio-venous
connexion. The formation of a large hasmatoma in the
soft tissues does not necessarily occur in those instances
in which a contiguous artery and vein are injured. The
venous opening permits rapid return to the circulation of
extravasated arterial blood, and so tissue distension is
prevented from occurring. According to the nature of
the fistulous communication, a swelling may or may not
be palpable. If the fistula communicates through a large
sac, a swelling may be palpable. Such a swelling, if
present, is usually pulsatile; but in the majority of femoral
arterio-venous aneurysms the sac is too small to be detected
on clinical examination.

The two most characteristic features of an arterio-venous
aneurysm are palpable thrill and an accompanying loud
characteristic bruit, which is probably most aptly described
as of a "machinery" type. The thrill is pronounced over
a considerable distance along the course of the vessels

10G

THE MEDICAL JOURNAL OF AUSTRALIA.

JANUARY 26, 1046.

concerned in the fistulous communication. The nature of
the bruit is such that it is continuous throughout the whole
cardiac cycle but is accentuated in systole. In the cases
encountered the prominent feature noted was that the
thrill had its maximum intensity a considerable distance
proximal to the site of the vascular injury, and although
the femoral injury was below the origin of the projunda
femoris artery, the site of maximum thrill and
pulsation was proximal to Poupart s ligament along the
course of the external iliac vessels. It appeared as if
the most obvious thrill was on the venous efferent limb
from the fistulous opening. The distal transmission of
the thrill was less pronounced than its proximal
projection. The vascular bruit was heard most readily
over the vessels and was maximal over the area of
greatest thrill and at the fistulous site. The bruit had
extensive transmission in both directions, and could be
heard not only over the feet, but also along the vessels
proximally for long distances. The thrill and bruit are
continuous with systolic accentuation, but both can be
abolished by compression of the femoral artery proximal
to the site of the arterio-venous aneurysm.

At the same time, it will be noticed that as a result of
the compression there is a reduction in pulse rate, a
lowering of the systolic blood pressure (often after a
rise for a couple of beats, in experimental studies), or
a rise of the diastolic blood pressure. This has been
designated as Branham s sign; but Holman (21 credits
Nicholadoni with observing as early as 1875 the slowing
of the pulse rate on arterial compression proximal to the
vascular communication.

Other local features are signs of venous dilatation and
back pressure in the legs, with large dilated varicose
veins, oedema of the legs and trophic tissue changes,
giving rise to eczema and ulceration. It is rare for
pulsation to be noticed in the veins of the limb distal to
the fistula. The oedema of the legs rapidly disappears
when the part is elevated.

The deficient circulation of the leg accompanying some
arterio-venous aneurysms gives rise to symptoms of
fatigue after exercise, in addition to oedema and to trophic
changes. Actual gangrene or ischsemia are, however, rare
sequelae.

In long-standing femoral arterio-venous aneurysms, as
in other peripheral aneurysms of long duration, and
provided that the fistula is sufficiently large, there
develop various signs and symptoms of cardiac
embarrassment. Symptoms such as dyspnoea, tachycardia
on exertion, faintness and a sense of cardiac discomfort
are complained of, and ultimately, the condition
progresses until signs of cardiac enlargement appear or
even death may ensue. In occasional cases cardiac failure
rapidly supervenes, as was described by Mason, Graham
and Bush &lt;:l) and quoted by H. Bailey. (41 The rapidity of
the return of the heart to normal size and of the pulse
pressure to normal are striking cardio-vascular features
after operation for closure of the fistula. The cardio
vascular changes occurring after an arterio-venous fistula
have been tabulated by Tarnower, Lattin and Adie. (r&gt;) In
brief, the effects are: (i) acceleration of the pulse rate;
(ii) elevation of the systolic blood pressure and fall of
the diastolic pressure; this feature gives rise to the
water-hammer pulse, capillary pulsation and exaggerated
pulse pressure ; (iii) increased cardiac output with
decreased stroke output; (iv) engorged pulmonary vessels;
(v) increased circulating blood volume; (vi) cardiac
enlargement; (vii) changes in the electrocardiographic
tracings; (viii) increased venous pressure and circulation
time, when cardiac decompensation occurs.

The circulatory effects are dependent upon the size of
the fistula, the size of the blood vessels involved, the dis
tance of the fistula from the heart and the volume and
force within the artery which is short-circuited, as well as
upon the age of the patient and the presence or absence
of preexisting cardiac disease.

A careful consideration of the signs and symptoms makes
the diagnosis of arterio-venous aneurysm of Uie femoral
or other peripheral vessels moderately certain in nearly
all cases. The differential diagnosis from a simple

aneurysm, however, is extremely important from the point
of view of treatment. Ligation of the artery is all that is
required for the cure of a simple aneurysm; but this not
only fails to relieve the symptoms or produce a cure of
an arterio-venous aneurysm, but may actually precipitate
gangrene of the limb. The main difference between the
two conditions is, firstly, that the arterio-venous aneurysm
has a continuous thrill and bruit, with systolic intensifica
tion, while an aneurysm shows these features in systole
only; and, secondly, digital compression of the artery
proximally slows the pulse rate and affects the blood
pressure in the presence of an arterio-venous fistula, but
not in the case of a simple aneurysm.

Treatment.

The problem of treatment of arterio-venous aneurysms
involves a discussion of the nature of any operative pro
cedure and of the time at which operation should be
undertaken. It is generally agreed that, as only a small
number of arterio-venous fistulae close spontaneously,
operation is indicated, but that, except in a few cases in
which early repair may be attempted or in which cardiac
failure is developing, operative procedures should be
deferred until an efficient circulation has been established
by the collateral blood vessels of the limb.

Holman/ 8 who has extensively studied arterio-venous
fistula?, discusses the treatment of these conditions accord
ing to whether the fistula is recent or of long standing.
In a case in which an injury to a large artery is suspected,
bed rest is indicated. If an enlarging hsematoma of the
limb threatens the blood supply of the extremity, immediate
operation is indicated. The procedure adopted is the
temporary control of the affected vessels and evacuation
of the hsematoma; in the absence of infection the vein is
ligated, and after the edges of the arterial rent have been
trimmed, suture of the artery is the ideal procedure. It
is found that this is not possible in many cases, and
ligation of the artery has to be carried out. The collateral
circulation is encouraged by blood transfusion, and in
some cases sympathectomy has been recommended. The
use of blood transfusion needs careful consideration, how
ever, since closure of the fistula, in any but the most
recent cases, increases the circulating blood volume and
causes further cardiac embarrassment.

If diagnosis is delayed and primary treatment has not
been adopted, operation is postponed until an efficient col
lateral circulation has been established. This period of
delay should be six weeks at least, and perferably about
three or four months. At the end of this time, not only
has the circulation had time to establish an adequate
alternative route, but the local trauma has subsided, the
vessels have healed, and dissection is less difficult than
in the indurated tissues. The development of progressive
cardiac symptoms or any local complication may necessitate
operative interference at any time. In the event of
cardiac insufficiency, bed rest and frequent digital com
pression of the fistula are recommended before operation.
Adequate post-operative rest is also indicated in these
cases, to allow the heart to compensate for the increased
diastolic pressure which results from the closure of the
fistula, and which in some cases may cause some further
cardiac embarrassment, requiring venesection for its relief.
The normal effect of closing the fistula, however, is to open
up the capillaries of the collateral circulation in a manner
similar to that observed in limbs after ligation of a main
artery when a blood transfusion is given to the patient.
In this condition the closure of the fistula makes available
the blood previously short-circuited through the fistula for
use in the general circulation.

The operation performed on these arterio-venous fistulae
of the femoral vessels is usually proximal and distal liga
tion of the vein and artery involved in the anastomosis,
together with all the branches that may intervene between
the points of ligation. The further procedures adopted
depend on the circumstances, either excision of the sac or
its obliteration being carried out. These procedures can
be accomplished only with adequate exposure and complete
control of the main vessels above and below the field of
operation. In the case of the femoral vessels this involves

JA.M-AKY 26, 194(5.

THK MEDICAL JOURNAL OF AUSTRALIA.

107

control of the external iliac vessels and of the lower parts
of the femoral vessels as early stages of the operation.
The vessels can be controlled by special clamps or by
small pieces of rubber tubing encircling the vessels and
having a cord loosely tied in readiness should control
become necessary. It must be emphasized that proximal
ligation of the artery alone is inadequate to cure the
condition and is almost certain to precipitate gangrene of
the leg.

In special circumstances it may be possible to carry out
a more surgically sound procedure, aiming at reconstruc
tion of the arterial lumen, by such procedures as those of
Matas and Bickham, which have been described by H.
Bailey. &lt;4) The vein of the arterio-venous aneurysm or
aneurysmal varix is freely opened, after control of the
vessels, and the fistula is closed by sutures inserted from
within the lumen of the vein. The aneurysmal sac and
segment of the vein are then excised, no attempt being
made at reconstituting the venous lumen in any circum
stances. The ideal procedure is not readily applicable;
it needs special technique and atraumatic needles threaded
with fine silk impregnated with paraffin, and precautions
must be adopted to prevent vascular clotting by the use of
sodium citrate solution locally or of heparin. If this
procedure is successful, the limb receives its blood supply
through the reconstructed artery.

After operation careful nursing is necessary to aid the
limb to return to normal and to establish an efficient
circulation as quickly as possible. Rogers " briefly sum
marizes the essential features by advising that attention
be paid to the posture of the limb, so that its metabolism
is reduced and the peripheral vessels are relaxed. The
limb circulation should be aided by gravity and the limb
is therefore extended in a position approximating to heart
level. The leg is cooled; this lowers its metabolism and
its demand on a blood supply. Rogers recommends the
use of ice, but in the cases quoted, exposure of the leg to
ordinary room temperatures was all that was considered
necessary; warming of the legs by hot-water bottles or
other heat sources was avoided. The peripheral vessels
generally are relaxed by the application of warmth to the
body, with the exception of the injured leg, and thus the
establishment of collateral circulation to the limb is aided.
There is not, however, universal agreement about the
cooling of the leg, although present opinion is gradually
swinging towards cooling rather than heating of the limb
during the stage when the collateral circulation is being
established. Reichert &lt;8) found that, after ligation of an
artery of the previously amputated and resutured limb of
a laboratory animal, the limb would live if kept warm,
but became gangrenous if allowed to be chilled. The
experiment did not appear to be conclusive, and further
clinical experience on the subject of freezing or cooling of
a limb suffering from vascular damage or ligation is
necessary before a conclusion can be reached.

The immediate results of treatment by quadruple ligation
and excision of the fistulous area are excellent. The
return of the heart to normal size and the improvement
in the pulse rate and blood pressure are dramatic. The
collateral circulation is usually sufficient to supply the
needs of the limb, provided that operation has been delayed
for an adequate time after injury. However, Bigger 19
has further investigated some of these cases in which
ligations of main vessels of the extremities have been
carried out for arterio-venous aneurysms. He has found
that there is definite evidence that the circulation is
inadequate for sustained muscular activity, and stresses
the fact that this important observation has not received
the attention which is its due. As an example is quoted a
case in which a superficial femoral ligation was performed
for arterio-venous fistula, and in which the leg easily tires
and the foot is cold. In the series of cases quoted, after
ligation of a main vessel for arterio-venous fistula, there
was no instance of serious acute circulatory difficulty, but
all the patients had evidence of persistent circulatory
deficiency. Bigger concludes that, although a patient with
arterio-venous fistula has little chance of gangrene after
resection of a main artery, even the common femoral or
popliteal, yet "such a patient appears to be as prone to

chronic circulatory difficulty as one having ligation of the
corresponding vessel for arterial aneurysm". It is too
early yet to assess the terminal results of the cases quoted
in this paper, but a "follow-up" appears to be well worth
while at a later stage.

Summary.

1. Two cases of femoral arterio-venous aneurysm of the
superficial femoral vessels are reported, to demonstrate the
development of an arterio-venous fistula, and also to show
the late results in a long-standing case with classical local
and cardio-vascular signs.

2. The characters of the thrill and bruit present in
arterio-venous fistula are set out and their extensive
conduction is described. The cardio-vascular features
generally are discussed.

3. The importance of differential diagnosis from arterial
simple aneurysm is stressed.

4. The advantage of delay before operative treatment in
most cases is mentioned, and the operative procedures
adopted are briefly reviewed.

5. The rationale of post-operative treatment is described.

6. The prognosis of femoral arterio-venous aneurysm
treated by quadruple ligation and excision is good in
respect of immediate results, but signs of chronic circu
latory inadequacy are apt to develop, limiting return to
full activity in some cases.

Acknowledgement.

I wish to thank Air Vice-Marshal T. E. V. Hurley,
Director-General of Medical Services, Royal Australian Air
Force, for permission to publish this paper.

References.

&gt; J. S. Horsley and I. A. Bigger: "Operative Surgery", Fifth
Edition, Volume I, 1940, page 151.

&lt;2 &gt; E. Holman : "Arterio-Venous Aneurysm", 1937, page 48.

&lt; 3 &gt; J. M. Mason, G. S. Graham and J. D. Bush : "Early Cardiac
Decompensation in Traumatic Arterio-Venous Aneurysms",
Annals of Surgery, Volume CVII, June, 1938, page 1029.

&lt; 4) H. Bailey : "Surgery of Modern Warfare", Second Edition,
Volume 1, 1942, page 250.

(B &gt; H. Tarnower, B. Lattin and S. G. Adie : "The Successful
Closure of an Arterio-Venous Aneurysm Involving the Left
Innominate Vein and Left Common Carotid Artery", Annals
of Surgery, Volume CXVI, November, 1942, page 700.

&lt; 6) E. Holman : "The Immediate and Late Treatment of an
Arterio-Venous Fistula", The Australian and New Zealand
Journal of Surgery, Volume XIV, October, 1944, page 83.

&lt;7) L. Rogers : "Physiological Considerations in Vascular
Surgery : Ligation of Main Arteries of Limbs", THE MEDICAL
JOURNAL OF AUSTRALIA, May 19, 1945, page 517.

&lt;H &gt; F. L. Reichert : "The Importance of Circulatory Balance in
the Survival of Replanted Limbs", Biilletin of the Johns
Hopkins Hospital, Volume XLIX, August, 1931, page 86.

&lt;8&gt; I. A. Bigger : "Treatment of Traumatic Aneurysms and
Arterio-Venous Fistulas", Archives of Surgery, Volume XLIX,
September, 1944, page 170.

PUTRID LUNG ABCESS.

By C. J. OFFICER BROWN,
Melbourne.

PUTRID lung abscess is a serious and by no means
infrequent complication of surgical operations and par
turition. Since 1939 I have operated on 41 patients for
lung abscesses, 21 of which followed operation or par
turition (Table I).

The common factor in all these 21 cases was general
anaesthesia; in most cases the anaesthesia was "trouble
some", or post-operative vomiting occurred. Some patients
had recovered too soon from anaesthesia in a dental
operation, and anaesthesia was reinduced when the patient
had his mouth full of blood and saliva. In one case teeth
and tonsils, and in another tonsils and antra, were dealt
with at the same operation. In yet another case, although
the patient was not seen to vomit, some dried vomitus
was noticed on the pillow. Post-operative lung abscesses
1 result from the inhalation of blood, pns or debris, and it

108

THE MEDICAL JOURNAL OF AUSTRALIA.

JANUARY 26, 1946.

can be shown by bronchoscopy that some blood always
enters the trachea during any operation on the nose or
mouth unless special measures are taken to prevent it.
Even in a conscious patient the laryngeal reflex is not
the complete protection it is often assumed to be. Lipiodol
introduced into the pharynx of a sleeping patient can be
demonstrated radiologically in the lungs next morning,
and heavy sedation is quite sufficient to put the laryngeal
reflex off its guard.

If the patient is lying on his back, inhaled material
tends to gravitate into the bronchus to the apex of a lower
lobe usually in the right lung and if he is lying on his
side it flows first into the upper lobe bronchus of the lower
lung. These facts can readily be demonstrated with lipiodol
under the X-ray screen. Post-operative abscesses are most
common in the apices of the lower lobes and in the upper
lobes.

After regional block anaesthesia inhalation may occur
while the patient is "sleeping it off", and heavy sedation
should be avoided in these cases.

TABLE I.

Number

.iEtiological Factor.

Abscesses.

Dental operations . .

Parturition

Abdominal operations

Ear, nose and throat oper

ations

Foreign bodies

Carcinoma of the lung

Unknown

"Pneumonia" et cetera

Total

It is recognized that some blood is aspirated into the
lungs in the majority of mouth and nose operations, but
in most cases this is coughed up and causes no trouble.
In some cases a small bronchus becomes blocked by the
inhaled material, and the corresponding segment of lung
becomes atelectatic; with infection added, a localized
pneumonitis develops, and this is the explanation of many
cases of post-operative pneumonia. When the infecting
organisms are necrotizing dental anaerobes or similar
types, a putrid lung abscess results.

The segment of atelectatic lung always abuts on the
visceral pleura, and infection excites an intense pleural
reaction and adhesions form over the area of reaction.
Since the greater part of the surface of the lung is in
contact with the chest wall, in most cases these adhesions
fix the site of the abscess to the chest wall. This does
not happen if the abscess reaches the pleura on the dia
phragmatic or mediastinal surfaces of the lung, or in a
fissure. In all other cases there is an area of adhesions
through which the abscess can be drained without
opening the free pleural space. This area is sealed
off early and the adhesions are firm within two or three
weeks of the onset of the abscess. The area of fusion may
be limited and is often not more than an inch or two in
any direction; but with accurate localization it Ls usually
adequate for approach to the abscess.

Cavitation always occurs in seven to ten days from the
onset, and in acute abscesses the cavity is found to average
about two inches in diameter, and is solitary, spherical and
unilocular. It contains pus, debris and sloughs, and after
a few days opens into a bronchus; this allows the exit
of the foul gases which cause the putrid smell and taste,
even before any pus is evacuated. As the bronchial opening
enlarges, pus and sloughs may be evacuated and spon
taneous cure may result.

In most cases bronchial drainage is inadequate and the
process tends to become subacute. Fibrosis develops in the
wall of the abscess and in the adjacent lung, local extensions
occur causing multiloculation, and "spillover" into adjacent
bronchi results in satellite abscesses and bronchiectasis. At
this stage drainage is useless, and the only hope of cure is

by extirpation of the diseased portion of the lung. At any
stage the abscess may perforate into the pleural cavity,
causing a localized or generalized pyopneumothorax. Cere
bral abscesses may result from blood spread, and amyloid
disease may develop from long-continued suppuration.
"Spillover" into other parts of the lung may cause
suppurative pneumonia or other abscesses.

Acute, subacute and chronic stages shade into one
another; but it is helpful to separate them arbitrarily.
For practical purposes a abscess less than six weeks old
is acute, from six weeks to three months it may be con
sidered subacute, and after three months it is considered
chronic.

Symptoms.

After operation there is usually an incubation period
of a few days, followed by the onset of illness with flushes,
chilliness and rigors. Pain in the chest indicates the site
of pleural involvement, and localized tenderness may be
elicited over this area. A cough develops, and although
at first it is dry and irritating and non-productive, in a
short time usually ten or twelve days from the onset
the patient begins to expectorate foul pus in increasing
amounts. Some days before expectoration commences a
foul odour may be noticed in the breath, and this is diag
nostic of the presence of a lung abscess. Haemoptysis
frequently occurs. The maximal interval between operation
and onset is probably fourteen days.

Prophylaxis.

Dentists and surgeons are usually held responsible for the
development of post-operative lung abscesses, but the real
blame in most cases lies with the anaesthetist. No operation
on the mouth or throat, involving general anaesthesia,
should be performed unless the patient is in a well-equipped
hospital. The operation should always be performed with
the patient in the prone position, and when it is likely
that aspiration will occur, the anaesthetic should be
administered through an endotracheal tube and the
pharynx should be packed or otherwise shut off. In any
operation, if aspiration does occur or is suspected, the
air passages should be cleared at the end of operation
by tracheal suction or bronchoscopy, and in the post
operative period, if atelectasis develops, active measures
should be taken to overcome it. First the patient should
be given morphine, laid on the sound side and vigorously
thumped and rolled about. This may start a fit of coughing
with the expulsion of a plug of mucus or blood clot, which
will be followed by reexpansion of the collapsed area. If
it fails, tracheal suction with a catheter may be tried or
bronchoscopy may be used. Bronchoscopy, although some
what terrifying to a sick patient, is undoubtedly the best
method, and should be looked on as an essential accomplish
ment for any specialist anaesthetist. I make it a routine
measure after all operations to insist that the patient takes
regular deep breaths and coughs, even if it hurts, because
sputum retention is the commonest cause of post-operative
chest complications.

No operation of election should be performed in the
presence of dental infection, and dental inspection should
be a routine measure before operation in all hospitals.

Management.

The majority of acute abscesses require surgical drainage,
just as surely as operation is required for the treatment
of acute appendicitis. Both conditions may resolve spon
taneously; but the decision whether to operate or not and
when to operate is entirely the province of the surgeon,
who should be called in as soon as a lung abscess is
suspected. It is obvious that complete resolution is much
more likely to occur if the infection can -be controlled in
the acute stage before secondary changes have developed
in the surrounding lung. If drainage has to be attempted,
it is much more likely to succeed in the acute unilocular
stage than when the cavity is multilocular and the
surrounding lung fibrotic and honeycombed. Once the
condition of chronic pulmonary suppuration has been
reached, although drainage may bring about some improve-

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THE MEDICAL JOURNAL OF AUSTRALIA.

109

ment in selected cases in which large, poorly-drained pus-
containing cavities are present, cure is rarely possible
except by extirpation.

Probably about 30% of putrid abscesses resolve spon
taneously, and it is reasonable to be conservative for a
few weeks in cases in which abscesses are apparently
draining well into a bronchus, when the course is not
very acute and the cavity is only moderate in size.
Penicillin should be used for these patients and will help
if bronchial drainage is sufficient. Unless resolution is
progressing satisfactorily, drainage should never be
delayed beyond six weeks, and if symptoms recur after
apparent resolution the abscess should be drained without
further delay. Resolution must be assessed on the
disappearance of clinical symptoms (rise in temperature,
cough, sputum) and the clearing of X-ray signs. Until the
X-ray findings are normal relapse is likely, and the patient
should never be discharged from hospital. Good X-ray
films must be taken every week during the period of
observation, and if there is any evidence of deterioration
extra films should be taken at once. Clinical examination
is of little value, and the progress of the lesion can be
followed only by radiological methods. Films should be
taken in two planes, and various intensities and exposures
should be used in an attempt to demonstrate a cavity, if
one is not readily visible. Because cavities appear and
disappear in the films in accordance with their content of
pus or air, sufficient films should be taken for accurate
localization on the first occasion when a cavity is demon
strated. Accurate localization is the sine qua non for
successful drainage.

Non-operative treatment consists of "wait and see", with
supportive regime, drugs and postural drainage. Broncho-
scopy should generally be used once, to exclude the presence
of a foreign body or a carcinoma or other obstruction in a
bronchus. It is occasionally of value in improving drain
age, especially in the case of abscesses in the basal parts
of the lower lobes. Bronchoscopy should be carried out
by the surgeon, because the information obtained helps in
localizing the abscess and determining when and how to
operate; it should not be repeated unless it has obviously
improved drainage, or in an emergency, when a sudden
flooding of the bronchial tree has occurred and aspiration
is necessary to relieve respiratory distress.

Sulphonamides are useless for putrid infections. Penicillin
is efficient in controlling them, provided drainage is
adequate, but it is useless without effective drainage. It
should be used for twenty-four hours before operation and
for as long as seems necessary after operation. Penicillin
prevents the sloughing of the surfaces of the wound and
hastens the disappearance of the putrid odour after
operation, and it seems likely that it reduces the risk of
"spillover" suppurative pneumonia and possibly cerebral i
abscess in the immediate post-operative period, when \
coughing is painful and retention of secretions difficult to
prevent.

With accurate localization nearly every lung abscess can
be approached through the adherent area and drained in
one stage. If the pleura is inadvertently opened, a two-stage
operation may be necessary; but this has happened in
only a fe\v of my cases.

Drainage should be carried out at once in the case of
all hyperacute abscesses and all abscesses with excep
tionally large cavities, and in the case of an acute abscess
that has not responded satisfactorily to a few weeks
delay. It may be tried for subacute and chronic abscesses
with large, poorly-drained cavities associated with copious
sputum. Often in these cases lobectomy will be needed;
but the risk of the major operation may be reduced by
preliminary drainage, to reduce the volume of sputum and
improve the patient s condition.

Lobectomy is the only treatment for the patient who
has passed into the stage of chronic pulmonary suppuration
with multiple cavitation and bronchiectasis. Many of
these people are reasonably well, but have persistent cough
and sputum, and in my experience they have all been cured
by lobectomy. Contrasted to these is a small group of
patients whose infection is diffused through a lobe with
multiple small cavities and much fibrosis. They are febrile

and toxasmic and losing ground, but there is no cavity that
can be drained, and lobectomy seems to offer them their
best chance of recovery. Lobectomy was performed on
five of my patients suffering from this condition. The
first, in 1940, died on the operating table from suffocation
by the cheesy pus squeezed from the lobe as it was being
freed. Improved methods of anaesthesia and operation
that we now use would have prevented this, and recently
Dr. R. H. Orton piloted an even more troublesome patient
through a successful three-hour lobectomy by repeated
bronchial suction and bronchoscopy during the operation.
The next two patients survived the operation, but
succumbed to putrid infection a few weeks later. Penicillin
would probably have saved these two. The last two have
done well. One is cured and the other is convalescent.

Results.

The results have been as follows. From 1939 to 1941,
10 patients had lung abscesses drained; two patients were
cured and eight died. From 1942 onwards, 16 patients had
lung abscesses drained; 11 patients were cured, one died,
the condition of two was improved and they were later
cured by lobectomy, one contracted tuberculosis, and the
condition of one was not improved. Lobectomy for car
buncle of the lung was carried out in five cases; one
patient was cured, one is convalescent and three died.
Lobectomy for chronic suppuration after a lung abscess
was carried out in 13 cases; all the patients were cured.
Thus, of 18 patients submitted to lobectomy, three died.

In three of the cases in tbe 1942 and after group two
separate abscesses were drained. In one case recovery
followed drainage of a complicating localized pyopneumo-
thorax, and in another recovery followed a first-stage
operation in which rib resection was performed and the
cavity was not found, the wound being packed and closed
to allow further localization. Penicillin had been used
for some days before operation without response, and its
administration was continued after operation. The
patient s temperature became normal, and after an initial
increase, cough and sputum disappeared and he made a
complete recovery without further operation.

Acknowledgements.

I should like to express my indebtedness to the writings
of Neuhof and Touroff and their associates. From them
I obtained an understanding of the pathology and manage
ment of lung abscesses, and I have had opportunity to
confirm the accuracy of the principles they enunciate. At
the Mount Sinai Hospital in the last sixteen years these
men have operated on 172 patients suffering from acute
putrid lung abscess, with four deaths.

Bibliography.

Arthur S. W. Touroff and Harold Neuhof : "The Differentia
tion between Acute Putrid and Non-Putrid Pulmonarv
Abscess", The Journal of Thoracic Surgery, Volume X, August,
1941, page 618.

H. Neuhof : "Acute Putrid Abscess of the Lung", Surgery,
Gynecology and Obstetrics, Volume LXXX, April, 1945, page
351.

INGUINAL HERNIA AND ITS REPAIR.

By HARLEY TURNBULL,

Lieutenant-Colonel, Auslralain Army Medical Corps,
Australian Imperial Force.

THE Bassini operation is standing its trial. English
surgery in particular has been vehement in its condemna
tion, and unequivocably demands the death of the Bassini
technique. The operation was first described by Bassini
in 1889, and for fifty-five years it has been accepted. If it
is to be condemned, the evidence on which it is sentenced
must be irrefutable and irreproachable. Those who
wilfully destroy must of necessity rebuild, and the new
edifice must be finer and better.

110

THE MEDICAL JOURNAL OF AUSTRALIA.

JANUARY 26, 1946.

The objections to the Bassini operation are based on
the statistics of recurrences, and a dogma which depends
on statistics must always be suspect. An article by
Edwards in The British Journal of Surgery of October, 1943,
is typical of this trend in the surgical treatment of hernia,
and is an example of the ever-increasing number of articles
over the last ten years damning the Bassini operation.
Edwards draws attention to the alarming recurrence rate,
and dogmatically states that it is due to a blind adherence
to the Bassini technique. He quotes figures which were
published by Max Page in 1943, and he bases his conclusions
largely on them. They are the results of 142 operations
performed in 1943. These figures are shown in Table I:

TABLK I.
After Edwards.

Number of

Recurrence

Operation.

Performances.

Recurrences.

Rate.

Bxcision of sac

9-3%

Fascial repair

15-4%

Other methods :

Bassini

Fowler

6 r

17-6%

McArthur

Bloodgood

The striking fact is the low number of Bassini operations
on which Edwards bases his opinion; the McArthur and
Bloodgood operations are only slight variations of the
Bassini operation and can be classed as a Bassini operation,
so that the total is 11 operations out of 142. The Fowler
operation can by no means be called a Bassini modification,
so that the given numbers included in "other methods"
should be 11 Bassini and six Fowler operations. The
recurrences were three a rate of 17-6%. There is no
mention of the type of operation the Bassini or the Fowler
in which the recurrences were observed. These figures
are thus unfair to the Bassini technique. As they stand in
the article by Edwards they are valueless, for there are
three fallacies, one of which has been mentioned. Other
important fallacies are as follows: (i) the operations were
performed by different men, who must vary in skill, tech
nique and judgement; (ii) much vital information is
omitted the age of the patient, his general physique, the
type of hernia, the suture material, the type of anaesthesia,
pulmonary complications, sepsis, the period of incapacity
(that is, the length of stay in bed), the length of con
valescence, and the period before hard work was resumed.
Without full information the figures are unintelligible, and
surgeons would be ill-advised to discard Bassini s operation
on a spurious deduction from such figures.

To illustrate how treacherous and misleading figures
without detail can be, the following two hypothetical cases
may be put forward. The first patient has a large scrotal
hernia of some years standing; the sac is thickened, fibrous
and adherent, and there is gross distortion of the
anatomical planes. The second patient is a young man,
whose tissues are firm and tonic; the hernia is small and
a bubonocele, the hernial ring, is small and there is no
distortion of the tissues. The first patient undergoes a
Bassini operation and the hernia recurs; the second has
the sac excised and the hernia does not recur. Is it
justifiable to state that the Bassini operation is no good
and should be discarded without considering the difference
in the two types of hernia and the relative difficulty of the
two operations? Excision of the sac can be performed
only in selected cases, and the recurrence rate should be
lowest in such a group. What is to be done with the other
cases? It is postulated that there are only two operations
that can be performed the Bassini operation or a fascial
repair. On the quoted figures, which by no means give
the true position, the recurrence rates were respectively
17% and 15%. The rate may well have been much lower
for the Bassini operation alone, for with it are included
six Fowler operations. Is it wise to state on these figures
that fascial repair should replace the Bassini operation,
as Edwards states? Edwards s final words are that early
hernia should be treated by excision of the sac with

tightening of the internal ring; all other herniae should be
treated by fascial repair; the Bassini operation and its
modifications must be abandoned.

There is no evidence here for a prima facie case against
the Bassini operation. Each surgeon must form his own
opinion, but that opinion must be impartial, and founded
on rock, not sand. The provocative opposition to the
Bassini operation has stimulated an interest which must
result in progress, for the treatment of hernia is not so
satisfactory as it should be. It is of great importance
now because the number of operations for hernia performed
on servicemen is large. The combined loss of man-hours
from these cases is enormous, and this loss is substantially
increased if the recurrence rate is high.

Ogilvie, of England, for a long time has been a bitter
opponent of the Bassini operation. His main arguments
against the operation are three: (i) suture of the conjoint
tendon to the inguinal ligament means a muscle working
out of place; (ii) the abdominal wall is weakened; (iii)
recurrence is favoured rather than prevented. These
statements must be considered in detail, and the answer
is found in the anatomy of the inguinal region.

The lowest fibres of the internal oblique arise from the
lateral two-thirds of the inguinal ligament, and with the
lower fibres of the transversus abdominis form the conjoint
tendon. The union results in a sickle-shaped fold, which
is inserted into the pubic crest and the medial three-
quarters of an inch of the ilio-pectineal line. The direction
of the fibres is downwards and medial. When the muscle
contracts, it must do so in the direction of its fibres
that is downwards and medially. This results in the lower
border s becoming straight, taut and approximated closer
to the inguinal ligament. The natural action of the con
joint tendon is thus to draw itself downwards on
contraction. In muscular people the conjoint tendon as
such exists only at its insertion, and the muscle of the
internal oblique and transversus is often so low that it
abuts against the inguinal ligament in its natural position.

When the conjoint tendon is sutured to the inguinal
ligament, as in the Bassini operation, the tendon is put in
a position that is a slight exaggeration of the normal, and
it is sutured in the direction of its pull. If unabsorbable
sutures are used, fibrous union does occur between the
two structures, despite statements to the contrary. Casti-
gators of Bassini state that this fibrous union is not
sound, will not withstand strain and has been achieved
by the destruction of the muscle fibres. It is asserted
that the insertion of sutures into the conjoint tendon to
anchor it to the inguinal ligament strangles the blood
supply, and causes a traumatic necrosis of the muscle
fibres and their replacement by fibrous tissue. Is this
strictly true? How often is it found that the lower inch
or so of the conjoint tendon is completely devoid of muscle,
and is a flat sheet of fibrous tissue of tendinous com
position? Tendon is practically avascular, so how can a
blood supply be strangled that does not exist? And how
can fibrous tissue be changed into fibrous tissue?

When the tendon is sutured to the medial two-fifths of
the inguinal ligament, its normal position is only slightly
changed, as is the direction of the pull of its fibres; should
not this union be considered an extension of the insertion
of the tendon? If this is so, then the abdommal wall should
be strengthened, for the tendon has a greater purchase.
If the conjoint tendon is firmly attached to the inguinal
ligament, and if the ilio-hypogastric and the ilio-inguinal
nerves are intact, when the internal oblique contracts
there can be no increased weakness of the abdominal wall.

If the Bassini operation weakens the abdominal wall,
then recurrence when it takes place should be through the
weakest spot, which is not at the internal ring but at
Hesselbach s triangle. Recurrences should accordingly be
direct rather than indirect. Experience shows that,
irrespective of the original type of hernia, 66% of the
recurrences are indirect; this proves that the wall cannot
be weakened by the operation.

Antagonists of Bassini point to the good results achieved
in children by simple ligation and excision of the sac,
using this fact as an argument against mechanical repair.

JANUARY 26, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

Ill

They overlook the basic principles that in children the
tissues are firm and tonic, that there is no anatomical
distortion, that the sphincteric action of the internal ring
is unimpaired, and, what is more important, that the
older the child grows, the less is the chance of recurrence.
In the child the size of the internal ring compared to the
area of the abdominal wall is relatively much greater than
in the adult. As the child ages, the size of the internal
ring diminishes, owing to a "step-up" in the area and
bulk of the abdominal wall, until man s estate is reached.
Therefore the tendency to recurrence progressively
diminishes as the child develops. Heavy work, stress
and strain are potent factors in causing recurrence; but
the child s musculature is not subjected to the same degree
of strain as is the adult s, so that after operation the
passing of the years permits Nature to effect a permanent
cure.

These are the answers to the three statements by
Ogilvie: the muscle is not working out of place, the
abdominal wall is not weakened, and recurrence is not
made easier.

Those who would discard the Bassini operation must of
necessity put forward much weightier evidence than they
have done. The Bassini operation is not suitable for
every hernia, but it should be retained for those cases
in which it is suitable a decision for which the operating
surgeon alone must be responsible.

ANATOMY OF INGUINAL HERNIA.

The anatomy of the inguinal region reveals in part the
secret of success or recurrence. The inguinal canal is
1-5 inches long, and being cone-shaped, consists of an
apex, a base and anterior and posterior walls. It runs
obliquely from above downwards and medially. The apex
is a finger s breadth above the mid-point of the inguinal
ligament corresponding to the position of the internal
ring. The anterior wall is formed throughout by the
external oblique and the posterior wall throughout by the
transversalis fascia, and placed between these two are the
internal oblique and conjoint tendon, which encircle the
canal, taking part in the formation of both anterior and
posterior walls. The strength of the canal depends on
the internal oblique. Anteriorly this muscle covers the
lateral third of the canal including the internal ring and
thus forms a part of the anterior wall; it then curves round
as the conjoint tendon, and owing to the obliquity of the
canal, it forms a posterior relation of the medial third
of the canal. Where it forms the posterior wall the
internal oblique has joined with the transversus abdominis
to form the conjoint tendon. The floor is formed by the
grooved surface of the inguinal ligament and by the
lacunar ligament, which is the area of insertion of the
inguinal ligament on to the ilio-pectineal line. The external
ring is triangular in shape, admits the tip of the finger
and is formed by the pillars of the external oblique. The
floor of the canal is further strengthened by the trans-
vesalis fascia and by the insertion of the reflex inguinal
ligament from the opposite external oblique into the ilio-
pectineal line. Consideration must be given to the internal
oblique and to the conjoint tendon, for these constitute
the real strength of the canal.

Owing to the obliquity of the canal and the sickle shape
of the conjoint tendon, when the internal oblique contracts
it has a two-fold action, and the canal is compressed by
two opposing forces. The internal oblique compresses the
lateral third of the canal and internal ring backwards;
the conjoint tendon compresses the medial third of the
canal from behind forwards. The double action results in
the formation of the two potential sphincters one at the
internal ring and lateral portion of the canal, the other
at the external ring and medial portion of the canal. This
opposing action explains why a bubonocele is retained in
the canal for a variable period. It breaks through the
first sphincter and the internal ring, and is then delayed
by the second sphincter at the external ring.

In the construction of the canal are two points of weak
ness: one is of necessity the internal ring; the other is
the area just medial to the inferior epigastric vessels and

lateral to the pubic tubercle. It is at these two points
that hernia occurs. Therefore, any operation must be
designed to reinforce these two areas; otherwise it will
fail.

RELATIVE FREQUENCY OF HERNIA.

Of hernia? 75% are indirect, 25% direct. Recurrence
rates for both types of hernia are variously estimated
from 0% to 30%. The 0% figure can be discarded. The
average figure is probably about 15% and will vary with
the skill of the surgeon. Of the recurrences, 60% to 70%
are indirect. This fact requires careful thought. It means
that three-quarters of all herniae are indirect and three-
quarters of the recurrences are indirect that is that in
75% of the recurrences the original hernia is reproduced.
One most important fact is thus brought to light, for it is
obvious that at operation for both types of hernia the
surgeon has failed to deal adequately with the internal ring.
The explanation why most herniae recur as indirect hernia?
is simple and is indirectly wrapped up in the internal ring.
In my experience, fully 66% of the so-called direct herniae
have no claims whatever to be called direct herniae, for
the hernia is a combination hernia with both direct and
indirect sacs. This calls for a revision of the nomenclature
and of the relative frequency of the various types of hernia.
The figures should read: indirect hernia 75%, combination
hernia 15%, direct hernia 10%. In 66% of the direct
hernia?, if a search is made at the beginning of the
spermatic cord at the internal ring, a small indirect sac
will be found. This is never more than an inch long, is
very fragile, is non-adherent and has never been filled
with contents. If this fact is not recognized at operation
for direct hernia and the search is not made for the
indirect sac, then the seed is sown for the growth of an
indirect recurrent hernia, and the operation has been a
failure. This explains the frequent recurrence of so-called
direct hernise as indirect herniae. The funicular hernia
of Ogilvie is not a separate hernia, but a direct hernia
which has come through a small aperture in the posterior
wall of the inguinal canal just lateral to the pubic tubercle.

CAUSES OF RECURRENCES.

All indirect herniae are congenital, and Nature has fallen
down on her job. It is thus beyond our means to prevent
the occurrence of hernia; but by adequate operation
planned on physiological and anatomical grounds the
condition can usually be cured and recurrences largely
prevented. The causes of recurrence in general can be
labelled in most cases as bad surgery, due to ignorance of
the condition, and these causes can be grouped under
the following headings.

Poor Technique.

Poor technique covers a multitude of sins brutal
handling of the tissue, tearing instead of cutting and
stripping, faulty haemostasis, inadequate treatment of the
sac, missing of the sac, insertion of sutures under too great
a tension, faulty knots, injury of the ilio-hypogastric and
ilio-inguinal nerves, incomplete kowledge of the mechanics
of hernia, a lax aseptic technique, and lastly, tedious
surgery.

Ill-Advised Operation.

If the surgeon has a faulty conception of the mechanics
of hernia formation, he cannot perform the appropriate
operation required for each type. He fits the patient to a
standard operation and does not plan his operation to fit the
patient.

Faulty Pre-Operative Supervision.

The general physique of the patient is important. A
repair should not be performed during a period of ill-
health, and all general diseases should be eradicated. Tone
less, atrophic tissues must be rebuilt, muscles strengthened
and the patient s general condition improved. Complacency
in repair of hernia cannot be tolerated. The best time to
operate on a hernia is when it first occurs. Too often does
the medical man say: "Yes, you have a rupture, but it does
not matter much, you can have it fixed up if it troubles

112

THE MEDICAL JOURNAL OF AUSTRALIA.

JANUARY 26, 1946.

you." Apart from subjecting the patient to the complica
tions of hernia, the medical man must remember that a
hernia is never stationary all the time it is increasing in
size and insidiously causing greater and greater anatomical
distortion, and the cure is gradually passing from a simple
to a more difficult operation with the greater chance of
recurrence. In the case of the large, irreducible, scrotal
hernia the patient should be put to bed for a period of
time in a moderate Trendelenburg position, and compres
sion spica bandages should be used; often the hernia will
be spontaneously reduced. If this occurs, the elastic tissues
will take up and a difficult operation will be made easier.

Faulty Suture Material.

In a mechanical repair operation the tissues are sutured
under slight tension, otherwise a firm repair will not result.
Therefore, as the tissues are sutured under some tension,
they must be firmly anchored until union occurs. In the
case of tissues that are relatively avascular (such as
fibrous and tendinous tissues), this apposition must be
maintained for a much longer period than in the case of
tissues with a good blood supply. Success in these cases
thus depends on the sutures, which must be non-irritating
and unabsorbable. Silk, thread or stainless steel wire are
the sutures to use, and the best of all is silk. This applies
also to chromicized gut. Silk is the ideal suture, and it
must be used for the whole operation ; bleeding points must
be tied with it and it must be used in each stage of the
repair. Catgut should not be used in combination with
silk. The dictum that Halstead gave to the world long ago
still holds good that if silk is used it must be used alone,
and not in conjunction with catgut.

In the use of silk there are three points that are to be
remembered. The knot must be a surgical knot that is,
a double twist in the first part completed as a reef knot
or else a triple knot. Silk thicker than necessary must
not be used, and lastly, if the knot is tied as advised, it
will not slip and the threads should be cut directly on the
knot, so that long ends are avoided.

Post-Operative Complications.

Despite every effort, post-operative complications will
occur. The aim should always be to prevent them and
thus minimize their occurrence.

Pulmonary Complications

Pulmonary complications are common, irrespective of the
type of anaesthesia used, and as such favour recurrence.
Careful pre-operative care should be given, particularly to
the heavy smoker. Nicotine before operation is a potent
cause of trouble after operation. Heavy smoking results in
rhinitis, sinusitis, pharyngitis and a "dirty" mouth. The
soil is thus present in which the seed may grow. Smoking
should be stopped, or at least reduced to a minimum, for
two weeks prior to operation. If this is done, upper
respiratory infection will largely subside, the "dirty"
mouth will become clean and the possibility of pulmonary
complications will be lessened.

The anaesthesia used is of no importance; complications
occur equally after any form. My own preference is for
spinal anaesthesia, for it gives perfect relaxation and avoids
post-operative vomiting.

Sepsis.

If sepsis occurs, recurrence is almost inevitable. Sepsis
causes redema, tension, inflammation, hyperaemia, cutting-
out of sutures and delayed healing. It can be avoided by
adequate skin preparation, the use of side towels, careful
surgical technique and perfect hsemostasis.

Complications Due to Faulty Post-Operative Care.

A common cause of recurrence is to allow the patient up
too soon. Bodily activity must be eliminated until healing
occurs. If this is not done, the whole strain of the
abdominal wall is taken by the sutures, in which case the
surgeon asks too much. Relatively avascular tissues, such
as fibrous tissues and tendon, require three times as long

for healing as vascular tissues, such as muscle. In respect
of a hernia operation, the period of stay in bed is thus
obvious. After the simple excision of the sac the only
fibrous tissue sutured is the external oblique; therefore
the stay in bed must be two weeks. When a mechanical
repair is performed, such as a Bassini operation, the stay
in bed must be longer a minimum period of three weeks.
For most patients with poor physique and large herniae, the
stay in bed must be four weeks. If a post-operative com
plication occurs particularly sepsis the rest period is
i proportionately longer. The time in bed can be profitably
i employed by the institution of gentle abdominal exercises
! starting not before the beginning of the third week. No
j lifting is to be done for a minimal period of two months
from the time the patient is allowed out of bed, and during
this period the patient takes gentle physical training. At
the end of three months from the time of operation the
patient makes a start on heavy work, and this is increased
over the next month. By the end of four months there are
no restrictions. Should the work be very heavy during
this fourth month, a light abdominal belt should be pre
scribed in order to take the general abdominal strain.

How is Hernia to be Treated f

There are only two hernia operations that should ever
be performed: (i) simple excision of the sac with tighten
ing of the transversalis fascia; (ii) a modified Bassini
repair, alone or combined with fascial graft. All other
operations are superfluous.

Simple Excision of the Sac.

Simple excision of the sac is the operation of choice for
early, small, indirect hernia. The cases must be carefully
selected. The patient is usually young and his abdominal
muscles are firm, tonic and well developed. No anatomical
distortion must be present, which means that the hernia
must be of short duration. The sac is ligated and excised
just above the neck, the spermatic cord is not dislocated
from its bed, the transversalis fascia is tightened and the
internal ring is narrowed until it fits snugly around the
cord.

Modified Bassini Repair.

The modified Bassini repair operation must be performed
in all cases that do not come into the above-mentioned
class namely, all direct herniae, all combined herniae and
all indirect herniae that are chronic, large and adherent.
In short, it must be performed in all cases in which there
is any distortion of the abdominal wall, however slight it
may be, and it must always be performed in the case of
recurrent hernia.

Technique of the Modified, Bassini Repair.
The original operation of Bassini is never strictly
followed by the writer. The broad principles are the same,
but the scope of the operation is enlarged in order to
strengthen the weak points on the canal.

The incision is made through the skin and fascia, and

skin towels are sutured on; a four-inch incision is made in

the external oblique in the direction of its fibres. This

incision must come well forward over the pubic tubercle,

which must be exposed, and free access must be given to

repair this weak point in the abdominal wall. This

incision goes through the external ring, and the edges of

the divided external oblique are picked up with haemostats

| and widely retracted. The upper portion is stripped up

| with the finger from the internal oblique to the point of

its union with that muscle. The lower portion with the

i inguinal ligament is carefully cleaned on its proximal and

; distal surfaces. The ilio-hypogastric and ilio-inguinal

! nerves are picked up and held out of the way. The

spermatic cord is then freed from the surrounding tissues

just above the pubic tubercle by passing the fingers from

i side to side underneath it, and a piece of gauze is then

| passed through so that the cord can be elevated when

I necessary. The bulk of the cord is not displaced. The

cremasteric fascia is incised longitudinally and the edges

| are retracted. The sac will then be found on the antero-

medial aspect of the cord.

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THE MEDICAL JOURNAL OF AUSTRALIA.

113

The fundus of the sac is picked up with a haemostat, and
the sac is freed by being stripped with gauze on the finger
and by occasional touches with the scalpel. When the sac
is freed as far as possible, it is opened at the fundus, and a
finger is inserted and used as a foundation on which to
strip with the finger of the other hand. The sac must be
freed until the area above the neck is clear, as indicated
by its collar of extraperitoneal fat. This area above the
neck is transfixed with two separate sutures of silk. These
sutures are passed from either side, and each pierces the
sac so that about three-quarters of the sac is enclosed in
each bite and the sutures are so placed that they inter
lock. These sutures are tied and a second single trans
fixion suture is tied just distal to the first. The redundant
portion of the sac is removed. On excision of the sac the
stump will retract deep down, and this is the first reason
why the sac must be tied high. The second reason is to
ensure that all the sac is removed.

The incised cremasteric fascia is now united with a few
interrupted silk sutures cut directly on the knot. In the
freeing of the sac up so high, there is one important fact
to remember: often the bladder is closely opposed to the
neck of the sac, particularly in the case of large hernise.
Unless this is remembered and care is displayed, trouble
some haemorrhage may occur from veins on the bladder
wall. If the bladder cannot be identified and abnormal
haemorrhage occurs, then it is certain that the bladder wall
is being traumatized. Do not expect to see rich red
muscle fibres; the fibres are pale and anaemic, and close
inspection must be made in order to identify them as
muscle. Should excess haemorrhage occur, then nothing
further is done until it has been absolutely controlled (this
control is sometimes difficult). If haemorrhage is not
controlled, a frequent result is the development of a large
extraperitoneal haematoma, which takes many weeks to
absorb and often suppurates. A scalpel should never be
used in this area, otherwise puncture of the bladder will
result. The danger of puncturing the bladder is not in
committing it, but in not recognizing that it has been done.
If the bladder is cut into, the opening is doubly sutured
and at the conclusion of the operation an in-dwelling
urethral catheter is inserted and left for seven days, fluids
are "pushed" and a sulphonamide is given.

The next step is completely to free the under-surface of
the conjoint tendon from the tratisversalis fascia until it
can be grasped as a separate entity. This freeing of the
conjoint tendon is important, for in most cases it permits
the tendon to be sutured to the inguinal ligament without
tension. The two points of weakness in this area are at
the internal ring and just lateral to the pubic tubercle;
the repair must aim at strengthening these two points.

The first step is to strengthen and tighten the trans-
versalis fascia. This is done either by a purse-string
suture or by interrupted silk sutures. The internal ring
is now narrowed by interrupted sutures placed on the
infero-medial surface until the ring is comfortably tight
and admits only the tip of the finger.

The next detail in technique is to suture the neigh
bouring lateral border of the rectus sheath, the area of the
linea semilunaris, to the periosteum of the pubic tubercle.
The needle must be felt to bite in and the suture grip
hard. This is the most important stitch in the whole
repair. It fixes the most medial point of the conjoint
tendon and relaxes the rest of the tendon, enabling it to
be sutured to the inguinal ligament without tension.
Rarely it will be found in placing this stitch that the
tension is too great; if so, the suture must be taken out,
and a semilunar fold of the anterior rectus sheath hinged
on the lateral border of the muscle must be brought down
and sutured in a similar way to the periosteum of the
pubic tubercle and the commencement of the inguinal
ligament. This effectively shuts off the weak point in
this area.

Vertical mattress sutures of silk are then used for the
repair. The fibres of the inguinal ligament run longi
tudinally. Thus sutures must not be inserted parallel to
the fibres, but across them; otherwise they will tear out,
split, mutilate and weaken the ligament, and so weaken

the repair. The second important point in the application
of these sutures is that they must be tied on the distal
surface of the inguinal ligament that is, on the femoral
triangle side. This permits the conjoint tendon to be
brought into the greatest possible contact with the inguinal
ligament, and the sutures can be tied more securely and a
sounder repair results. The conjoint tendon is stitched to
the inguinal ligament by interrupted sutures until it fits
snugly under the cord emerging from the internal ring.
One or two sutures are now inserted above the cord uniting
the internal oblique to the inguinal ligament. This is an
important step in strengthening the internal ring, for the
repair is now firm all round the emerging cord. In all,
about seven sutures are required.

The two nerves are now replaced and the external oblique
is repaired with interrupted "figure of eight" sutures. The
external oblique may be redundant; this is often the case
in big hernia. If this is so, it is overlapped after the
method of Mayo. If it is considered that the repair should
be further strengthened, fascial strips should be used from
the external oblique and plaited into the repair. This
method of using the external oblique fascia will be
described later.

This is the modified Bassini operation which the writer
considers should be performed in all cases in which the
operation is indicated.

Direct Hernia Repair.

Except for the method of dealing with the sac the opera
tion of repair for direct hernia is the same as the modified
Bassini operation described. An ever-present danger in
these hernise is the close proximity of the bladder; but
despite this close association the sac must be completely
freed until the surrounding peritoneum is taut. If haemor
rhage occurs (which it often does), nothing further is done
until it is controlled. If the sac is large, it must be treated
in the same way as an indirect sac, and the redundant
portion must be removed. Occasionally it is found that
when the sac is freed it is small. In these cases the sac
should be opened, surrounded by a purse-string suture
under direct vision and then invaginated.

It is of the utmost importance in dealing with a direct
sac to see whether there is an indirect extension into the
base of the cord. If so, the two sacs are converted into
one large direct sac by pulling the indirect out into the
direct sac. On no account are the inferior epigastric vessels
to be divided, as is advocated by some surgeons. They form
an important stanchion in the strength of the posterior
wall.

In the case of large scrotal herniae of the indirect type
(the sacs of which are adherent and thickened), after the
repair has been performed, the bottom of the scrotum must
be opened and a tube inserted to provide drainage, for
these herniae often ooze after operation. If drainage is not
provided, blood or serum tracks down into the scrotum, the
haemorrhage being concealed. A scrotal haematoma will
result, which may reach an alarming size, burying the
penis. If adequate drainage has not been provided and this
complication occurs, the blood must be rapidly aspirated.
But blood clots quickly, and usually by the time the
trouble is discovered aspiration is impossible because of
soft clot. The only thing to do then is to incise the
bottom of the scrotum, turn out all clot either mechanically
or by flushing with saline solution, and establish drainage.
In elderly men with large herniae it is justifiable to remove
the testis and cord in order to obtain a sounder repair.
The patient should always be warned of this possibility
before operation.

Gallic s Operation and Fascial Repair.

In the opinion of the writer there is no place in hernia
repair for the operation practised by Gallic. There are
several objections to the operation. The method of getting
the fascial strips is unnecessary and time-consuming, and
time is a factor in recurrence. The fasciotome Should
never be used, as it leaves a weakness in the thigh despite
assertions to the contrary by its advocates. It causes a
muscle hernia which is unsightly and constitutes a weak-

114

THE MEDICAL JOURNAL OF AUSTRALIA.

JANUARY 26, 1946.

ness. Haemorrhage cannot be controlled, and a haematoma
sometimes occurs. A final objection is that some patients
for long afterwards complain of pain over this area. A
first axiom in surgery is never to replace one wrong by
another.

If the surgeon wants to take fascia from the thigh, he
should do it by the open approach. He should cut down
on the fascia, strip off the required amount, then suture
the gap in the muscle sheath so that no harm will result.
This method of obtaining fascia is seldom, if ever, needed.
In the case of large hernias of long standing, when the
tissues are stretched, attenuated and distorted, a fascial
repair should be used in addition to the modified Bassini
repair; but a fascial repair should not be used alone. In
these cases the external oblique is always redundant, and
this muscle will provide all the fascia that is required.
A long skin incision is used in the direction of the fibres
of the external oblique, the repair is performed as advo
cated, and strips of fascia are then obtained from both
upper and lower borders of the tendon. These strips must
be left anchored at one end. The beginning of the suture
is thus anchored, greater security being obtained with no
waste of fascia. The strips should be thin enough to be
threaded through a large non-cutting needle, and they
should be darned into the modified Bassini repair already
performed. Their insertion must be through the conjoint
tendon and inguinal ligament anterior to sutures used in
the Bassini repair. If this is done, the inguinal ligament
will not be mutilated, a double repair will be effected and
added security will be given. Fascial sutures must never
be inserted under tension. The Gallic needle should never
be used for introducing the fascial strips; it is cumber
some, it has a cutting point, it is far too big, and it irre
trievably damages the inguinal ligament and is one cause
of weakening the abdominal repair.

It is impossible in some cases to diagnose the type of
hernia, and operation alone will reveal whether the hernia
is indirect or direct. It is well to remember also that in
older people if bilateral hernia is present it is usually
direct. As a final injunction, the successful repair of a
hernia is a difficult operation. The patient with a hernia
is not a guinea-pig on whom the budding surgeon should
learn the first principles of surgical practice.

SURGICAL TREATMENT OF HERNIA IN AUSTRALIA.

Hernia is a common condition, and post-operatively
requires a prolonged period of rehabilitation. Loss in
wages, expenses incurred, compensation and loss of
effective working hours are considerable. The importance
of securing a permanent cure at the first operation is thus
evident. In Australia most general practitioners carry out
their own hernia operations, and this form of surgery is
not the sole prerogative of specialist surgeons. The opera
tion performed is invariably a Bassini modification, and
the results represent the individual efforts of many
surgeons good, bad and indifferent. The following figures
are offered for contemplation, in order that the importance
of this condition may be appreciated. The operations were
performed in only one of the many military hospitals in
Australia a hospital to which the writer was attached.

Seven hundred operations were performed, of which 52
were for recurrent herniae a percentage of 7-5. Whilst
not a strictly accurate assumption, it can be stated that
this figure of 7-5% approximately represents the recurrence

TABLE II.

Period.

Inguinal Hernia Operation?.

Primary
Hernia.

Recurrent
Hernia.

January 7 to December 31, 1943
January 7 to June 30, 1944

419

229

41
11

Total

648

rate in Australia, where the Bassini operation is univer
sally performed for all herniae except those not associated
with anatomical distortion of tissue planes. Further, the
recurrence rate in troops is probably higher than in
civilians, because of the increased severity of their work.
In this case the percentage recurrence rate in civilians is
probably lower. These figures are striking from another
viewpoint. Seven hundred hernia operations, performed
in one hospital over a period of eighteen months, meant
the complete immobilization of a full battalion of men for
a period of three months. If the whole Australian Imperial
Force is considered and, further, the whole Allied
services the loss of fighting personnel from this condition
alone is appalling.

In the Australian Imperial Force the approximate recur
rence rate is 7-5%. In the civilian populace it is probably
lower. How, then, can the opponents of Bassini fairly
insist that his operation be discarded?

SUMMARY.

1. The aim of this paper is an attempt to answer the
critics of Bassini.

2. The evidence given by the opponents in condemnation
of the operation has been considered in detail.

3. Reasons have been given for retention of the opera
tion reasons built on the sound foundation of anatomy,
physiology and results.

4. Herniae in general have been discussed and a form of
treatment has been recommended.

CONCLUSION.

The Bassini operation must not die. It must be retained
in surgery until such time as the ideal is found. To
abandon the operation would be a retrograde step in the
repair of hernias, and recurrences would inevitably
increase.

ACKNOWLEDGEMENT.

This paper is published by permission of Major-General
S. R. Burston, Director-General of Medical Services,
Australian Imperial Force.

THE SALIVA FACTOR IN PEPTIC ULCERATION.

By L. J. J. NYE,
Brisbane.

IN the aetiology and treatment of peptic ulcer many
theories have been advanced and have had enthusiastic
support for some years, but eventually have been dis
carded because they have failed to stand up to the
therapeutic test. It is, however, now believed with good
reason that ulcers are caused by peptic digestion of the
gastric mucosa by the hydrochloric acid of the gastric
juice. The question which must be asked is, why doee
the mucosa in certain subjects at certain times lose its
capacity to defend itself against this ever-present and
natural secretion? Is it due to some factor or factors in
the lives of these subjects which cause an increase in the
production of hydrochloric acid? Is it due to alteration in
the quantity and quality of the protective mucus which
is adherent to the mucosa? Is it some pathological process
or decreased resistance in the mucosa itself? Is it caused
by eating coarse food too rapidly, or do all the above-
mentioned factors play a part?

It is well known that many sufferers from duodenal
ulcer have been in the habit of "bolting" their food, and
it is of interest to speculate whether this may be one of
the setiological factors, for in addition to failure to pulp
the food, there is insufficient time for it to become mixed
with saliva. The pulping of the food with the teeth is
not the only purpose of chewing; the thorough mixing
with saliva plays a much more important part in digestion
than is usually believed. It is well known, for instance,

JANUARY 26, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

115

that persons fed through a gastrostomy tube digest their
food better and gain in weight if the food is first chewed
in the mouth and mixed thoroughly with saliva before
being injected into the stomach. Moreover, many dys
peptics know that, if they eat mince meat, it is not well
tolerated unless it is well mixed with saliva before being
swallowed. Another interesting observation is that most
people can obtain relief from heartburn, flatulence and
hyperacidity merely by swallowing saliva.

This suggests that the saliva factor in dyspepsia is
worthy of more careful consideration than has been given
to it in the past. It has not been fully established how
saliva aids in digestion. It is believed that in the actual
process of digestion saliva plays an insignificant part.
There are no enzymes in saliva that could convert proteins
or fats into absorbable forms; but polysaccharides are
converted to disaccharides by the ptyalin.

Opinions have been put forward suggesting the presence
of some hormone in saliva which has some regulating
effect on carbohydrate metabolism as well as some influence
on gastric secretion; but the evidence presented in favour
of this hypothetical hormone is conflicting.

It is possible that mucus is an important factor. There
is a variable amount of mucin in saliva, and although
it is not known how it acts, mucin has been shown to be
an important aid in the treatment of peptic ulceration.
Possibly it has direct action on the secretory tubules as
well as a neutralizing effect.

It must be remembered also that the gastric mucosa is
covered by a protective layer of viscous tenacious mucus
with a pH between 4-0 and 7-0; this protects the mucosa
from the highly acid gastric juice, which has a pH of
perhaps less than 2-0. There is also a certain amount of
evidence to show that in peptic ulcer patients an inade
quate amount of mucus is secreted, both in the gastric
mucosa and in the saliva. Wolf and Wolff, (1) working on
their man with a permanent gastric fistula, showed the
importance of mucus in controlling gastric acidity and
preventing ulceration. They found that, when the mucus
secretion was continuously removed by suction from the
wall of the stomach, there soon appeared a tiny erosion
which rapidly developed into a typical peptic ulcer. If
mucus was allowed to flow again on this surface it would
soon heal.

The recent work on lysozyme, which is a powerful
bacteria-dissolving substance found in egg white and
saliva, suggests that it may serve the important purpose
of defending the gastric mucosa against bacterial invasion.
It is significant, too, that the amount of lysozyme in the
saliva varies not only in different subjects, but in the
same subject at different times.

The neutralizing effect of the salivary fluid is also
important. In a series of 22 patients with dyspeptic symp
toms it was found that the pH of fasting gastric juice
varied between 4-2 and 6-9, the average being 5-4. The
pH of the saliva taken at the same time varied between
6-1 and 6-9, the average being 6-5, and in all cases the
salivary pH was higher than that of the gastric juice.

The salivary glands have both sympathetic and para-
sympathetic innervation. The flow of saliva is not con
tinuous, but is regulated by the nervous system and
depends on certain food, chemical and emotional stimuli.
It is a matter of common experience for the mouth to
become moist at the smell of food or dry during certain
emotional states. Wolf and Wolff found the average
accumulation of saliva during the three hours of a
"control" morning was 40 millilitres; but one day, when
the subject was depressed, it was only 10 millilitres, and
later, during a day of intense resentment, it was 72
millilitres.

Babkin (a&gt; refers to Baxter s work in his laboratory;
Baxter, after section of the auriculo-temporal (secretory)
nerve root, found that the salivary glands were able to
secrete saliva nearly normal not only in quantity, but also
in chemical composition. Babkin then makes the following
statement:

It would be risky to suggest that the sympathetic
supply is alone responsible for such remarkable and
specific actions on the part of the glands to different
stimuli. It seems more likely there are other nerve
channels through which parasympathctic impulses may
reach the glands.

Babkin further states that in certain circumstances the
sympathetic and parasympathetic nerves act not antagon
istically but synergically.

In animals undoubtedly there are positive salivary con
ditioned reflexes (alimentary, sexual et cetera) which
increase or decrease the response of the glands to certain
stimuli. In dogs the ordinary phenomenon is the inhibition
of salivary secretion in case of fear and even at the sight
of anything unusual (the so-called "orienting" reaction).

However it acts, there is evidence to show that more
consideration should be given to the question of the
quantity, quality and effective utilization of saliva in the
dyspepsias. In order to take full advantage of certain
qualities inherent in saliva, it would appear that in the
treatment of all dyspepsias the thorough mixing of all
food with saliva is essential and alkaline lozenges should
be effective not only for their neutralizing effect, but
because they stimulate a flow of saliva which also has an
antidyspeptic effect, for it has been shown that the presence
of alkali in the mouth evokes a copious secretion of saliva
rich in mucin, and the act of sucking also increases the
flow.

I have experimented with satisfactory results with
lozenges made of calcium carbonate, magnesium carbonate,
sodium citrate and sugar. Not only do they give relief
in hyperacidity, heartburn and flatulence in most cases,
but the amount of alkali needed for this purpose is much
less than when the usual alkaline powder is used. Further
more, the lozenges are a much more convenient form of
medication, as they can be carried in the pocket or kept
in a box at the bedside.

Conclusion.

This article does not claim to have propounded any new
definite conclusions. It merely submits a theory which it
is believed may add something to the knowledge of treat
ment of dyspepsia and peptic ulceration and may serve
as a stimulus to further experimentation.

References.

&lt;u S. Wolf and H. G. Wolff : "Human Gastric Function".
&gt; A. Babkin : "Secretory Mechanism of Gastric Glands",
page 520.

Deports: of Cases,

AN IMMUNE ANTI-M ISO-AGGLUTININ IN
HUMAN SERUM.

By R. J. WALSH,

Major, Australian Army Medical Corps,
Australia.

THE agglutinogens M and N are of medico-legal interest,
but are not usually considered in blood transfusion work.
The anti-M and anti-N iso-agglutinins are only rarely found
in human serum. The anti-M agglutinin has been reported
on seven occasions and the anti-N agglutinin once. Wiener"
states that in four instances the anti-M agglutinins were
of natural occurrence and were not produced by iso-
immunization. The references to these reports are not
available to the writer. Wiener and Forer &lt;2) have recorded
the finding of a serum which contained an anti-M agglutinin
as well as an anti-Rh agglutinin. Clinical details of this
patient are not recorded, but Wiener (1) states that the
agglutinins were produced as a result of iso-immunization
from blood transfusion. Wiener* 3 reported a further patient,
a woman, in whose serum an anti-M agglutinin was found.
This patient had received a transfusion of blood one month
previously, and no abnormal agglutinin was detected at the

116

THE MEDICAL JOURNAL OF AUSTRALIA.

JANUARY 26, 1946.

time. The patient described by Paterson, Race and Taylor w
had never received a transfusion of blood, and although she
had four children, none had suffered from haemolytic disease
of the newborn. The four children all possessed the
agglutinogen M. The serum in which the anti-M agglutinin
was detected was obtained from the mother four months
after the last child was born. It is impossible in this case
to determine whether the anti-M agglutinin was natural in
occurrence or whether it was produced by immunization of
the mother with the foetus s red blood cells during pregnancy.

Singer &lt;5) has reported the only serum in which an anti-N
agglutinin has been found; he considers that the agglutinin
was the result of iso-immunization following a transfusion
of MN blood seven days previously. As the agglutinin in
this case could not be detected by the usual methods of
cross-matching, there would appear to be little justification
for the assumption. The anti-N agglutinin could have been
of natural occurrence.

A further instance of a human serum containing an anti-M
agglutinin is now reported. Although there is no absolute
proof, it seems probable that the agglutinin resulted from
iso -immunization.

Clinical Record.

The patient, a female, aged sixty-two years, had suffered
since 1939 from a blood dyscrasia diagnosed as pernicious
anaemia. Since that time response to liver and iron therapy
had been unsatisfactory, and between 1939 and 1943 she
received at least seven blood transfusions. No details of
these transfusions are available; but the blood donors have
been compatible on all cross-matching tests. Difficulty of
administration has been frequently encountered, as the
patient s superficial veins are extremely small. Her elbows,
forearm and legs have numerous scars due to incisions over
the veins. In June, 1943, she received three transfusions of
blood. The first was discontinued after 200 mils had been
administered because of a rigor; 600 mils of blood were given
on the second and third occasions, the second transfusion
being without incident and the third associated with a slight
transient rigor. On February 15, 1944, she was again
admitted to hospital with a remission of anaemia, and was
given blood transfusions on two occasions. The second
transfusion was administered intrasternally, because no
suitable vein could be found. After 400 mils had been given
the transfusion was discontinued, because the patient became
cold, broke out into a sweat and complained of pain in the
chest. No jaundice was noted and no haemoglobinuria was
found. A further transfusion was contemplated on March 13,
1944, but a gross incompatibility was detected on cross-
matching tests with blood of a homologous group.

Investigation.

An investigation was carried out. Blood was obtained with
difficulty from a vein. A suspension of red blood cells in
2-6% sodium citrate solution was made and serum of icteric
tinge was separated. When the cells were tested, the
patient s blood was found to belong to group A, subgroup A 2 ,
and to group N, and the cells were Rh-positive. Her serum
agglutinated all group B cells and the majority of group A
cells, both subgroups A t and A 2 , and group O cells that were
available. The Rh factor could not have been involved,
because some Rh-negative as well as Rh-positive cells were
agglutinated. Agglutination was distinct to the naked eye,
and large clumps of agglutinated cells appeared within five
minutes of the mixing of the serum and cells on a slide at
room temperature. It was also obvious when the mixture
was made in test tubes and incubated at 37 C. The serum
wae then mixed on a slide with equal parts of a citrate
suspension of red blood cells of the following known
constitution:

OMN Rh + 4 samples, all positive (+)

OM Rh + 4 samples, all positive (+)

AM Rh + 1 sample, positive (+)

OM Rh - 1 sample, positive (+)

ON Rh + 5 samples, all negative (-)

By the application of Fisher s formula (quoted by Paterson,
a! 6!

Race and Taylor) , where a represents the number of

positive reactions and T&gt; the number of failures to react in
a total number n tested, it can be calculated that the odds
in favour of the antibody s being anti-M are 3,002 to one.

Complete absorption of the antibody was effected with an
equal volume of washed OM cells. This absorbed serum did
not agglutinate M or MN cells. The antibody was titrated
against OM and OMN cells by allowing a mixture of the
cells and serially diluted serum to remain in contact for one

hour at room temperature. Readings were made with the
naked eye after the cell-serum mixtures had been trans
ferred from tubes to a flashed opal glass slide. The titre
was found to be 1 in 32 in both instances.

Discussion.

It seems unlikely that the anti-M agglutinin could have
been of natural occurrence, since in that case it would
almost certainly have been detected earlier in cross-matching
tests. If, however, it was present in small amounts and
was overlooked, it must certainly have increased in titre as
a result of immunization. It appears much more probable
that the agglutinin was the direct result of iso-immunization
from previous transfusions, but the blood groups of previous
donors are not known. It is statistically improbable that all
belonged to group N. The possibility that the antigenic
stimulus was provided by a foetus the only two pregnancies
had occurred forty-six and thirty-two years earlier cannot
be overlooked; but it is not at all likely that an immune
antbody would have survived in the blood stream for thirty-
two years. There is no evidence that either child suffered
from hsemolytic disease of the newborn.

Acknowledgements.

The assistance of Dr. A. H. Tebbutt is gratefully
acknowledged. Facilities for the investigation were provided
by the New South Wales Red Cross Blood Transfusion
Service. The Director-General of Medical Services has
given permission for publication of the report.

References.

(1 &gt; A. S. Wiener : "Blood Groups and Transfusion", Third
Edition, 1943.

(2) A. S. Wiener and S. Forer : "A Human Serum Containing
Four Distinct Iso-Agglutinins", Proceedings of the Society of
Experimental Biology and Medicine, Volume XLVII, June, 1941,
page 215.

(:i &gt; A. S. Wiener : "Haemolytic Transfusion Reactions : Pre
vention, with Special Reference to the Rh and Cross Match
Tests", American Journal of Clinical Pathology, Volume XII,
June, 1942, page 302.

&lt; 4 &gt; J. L. Hamilton Paterson, R. R. Race and G. L. Taylor : "A
Case of Human Iso-Agglutinin Anti M", British Medical Journal,
Volume II, July 11, 1942, page 37.

(5) E. Singer: "Iso-immunization against Blood Factor N",
THE MEDICAL. JOURNAL, OF AUSTRALIA, Volume II, July 10, 1943,
page 29.

THE COMMODORE.

WE have at last been privileged to make the acquaintance
of that versatile sailor, Captain Sir Horatio Hornblower,
R.N., and we feel that the introduction has been too long
delayed. 1 In fact, it is almost impossible to believe that
the gallant captain is an apocryphal figure. In his book,
C. S. Forester has skilfully outlined a background of inter
national politics, life at sea and military operations, begin
ning a short time before Napoleon Buonaparte s fateful
attack on Russia. Hornblower is given a delicate mission in
and around the Baltic, and, as commodore in command of a
squadron of the Royal Navy, sets out to carry it out. It is
unnecessary to go into detail of how he does so; Captain
Sir Horatio Hornblower, we learn, is famous for ingenuity
and luck. The characters are living people and the tale is
exciting and well told; but obviously it is merely the vehicle
by which the reader is given a true appreciation of the very
human and lovable hero. To his comrades and subordinates
he appears a man of unswerving decision and iron will; we
are privileged to observe the mental and emotional processes
which go on behind the scenes to know how this outwardly
rock-like man conquers his genuine fear of the huge
responsibility that is laid upon him. At the close of the
book, Hornblower, his mission accomplished with something
more than the success expected of him, is left, obviously
about to suffer from a serious illness, which may be plague.
Let us hope that Mr. Forester will take pity on his readers
and not leave them in suspense for another six years the
period that elapsed between the previous "Hornblower" novel
and "The Commodore".

1 "The Commodore", by C. S. Forester; 1945. Sydney: Angus
and Robertson, Limited ; London : Michael Joseph, Limited.
1\" x 5", pp. 270. Price: 8s. 6d.

JANUARY 26, 1946. THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER.

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THE MEDICAL JOURNAL OF AUSTRALIA.

117

SATURDAY, JANUARY 26, 1946.

All articles submitted for publication in this journal should
be typed with double or treble spacing. Carbon copies should
not be sent. Authors are requested to avoid the use of
abbreviations and not to underline either words or phrases.

References to articles and books should be carefully
checked. In a reference the following information should
be given without abbreviation: initials of author, surname
of author, full title of article, name of journal, volume, full
date (month, day and year), number of the first page of the
article. If a reference is made to an abstract of a paper, the
name of the original journal, together with that of the
journal in which the abstract has appeared, should be given
with full date in each instance.

Authors who are not accustomed to preparing drawings
or photographic prints for reproduction are invited to seek
the advice of the Editor.

THE RETIREMENT OF SURGEON CAPTAIN
W. J. CARR.

EVERYONE will agree that the head of a service, par
ticularly of a medical service, sets the standard of efficiency
and devotion to duty of its members. This has been shown
over and over again in the war to which we refer as having
just ended. Australian doctors have good reason to be
proud of the medical services of the sea, land and air
which they joined willingly and in such large numbers.
That they will acknowledge their own and the country s
indebtedness to the medical dii ectors there is no shadow
of doubt. Of the three services, that of the Navy is the
only one which before the war could be said to have a
staff of permanent medical officers. In 1933 the Royal
Australian Naval Medical Service had 28 medical officers;
of these, 15 were permanent officers, 11 belonged to the
Royal Australian Naval Reserve, one belonged to the Royal
Australian Naval Volunteer Reserve, and one was on loan
to the Royal Navy. It was this service which Surgeon
Captain W. J. Carr was called on to control at the out
break of war. On January 31, 1946, he is to retire from
the command. The occasion should not be allowed to pass
without comment; Captain Carr has served the Common
wealth and the Empire with the utmost devotion and in
the best tradition of the "Silent Service", and this should j
be acknowledged.

With the outbreak of war the Royal Australian Navy
increased its number of ships and the number of its
fighting personnel. The number of medical officers
increased with the number of ships and men. Security
reasons made it undesirable to refer to new ships as
they were commissioned, but it may be remarked that the
appointments to the navy were promulgated without inter
ruption in the Commonwealth of Australia Gazette. In
the year 1945 the Royal Australian Naval Medical Service

comprised 110 medical officers. Of these, 14 were per
manent medical officers; 83 belonged to the Royal
Australian Naval Reserve, and six to the Royal Australian
Naval Volunteer Reserve; seven were on loan to the Royal
Navy. In other words, the administrative duties of the
director of the service and his responsibilities had grown
enormously. The advent of the Royal Navy to Australian
waters threw extra work onto Captain Carr s shoulders.
To him was allotted the task of working out the plan
for the posting of the British Pacific Fleet s medical
establishment in Australia. He made all the hospital
arrangements and also those for the supply of medical
equipment. This was in August, 1944, and with the small-
ness of his staff (he has only one medical staff officer) the
extra work was no sinecure. Through the six years of
war Surgeon Captain Carr has thus carried a steadily
growing burden of work and responsibility. The medical
profession of Australia and those outside its ranks who
have given any thought to the subject cannot understand
why no promotion has come to him. By every standard
known to the non-naval observer promotion has been
earned. In any case it is ridiculous that so important a
service as the medical service of the Royal Australian
Navy should carry with it no rank higher than that of
captain. This rank is the equivalent of colonel in the
army. We maintain that Surgeon Captain Carr should
on his retirement be promoted to the rank of surgeon-
rear-admiral and that the promotion should be dated from
January, 1945, when the main body of the Pacific Fleet
came to Australia. But whether the parsimonious Royal
Australian Navy does what it should do in this matter or
not, it should be known in naval and non-naval circles
that the medical profession of the Commonwealth holds
Surgeon Captain Carr in high esteem, is grateful to him
for consistent first-class work, and wishes him peace and
contentment in his retirement.

THE JOURNAL AND THE RECENT INDUSTRIAL
UNREST.

THE last few months of the year 1945 and January of
1946 have been very difficult for those concerned in the
production of THE MEDICAL JOURNAL OF AUSTRALIA. Now
that the acuteness of the difficult period has passed, it
has been thought that a short statement should be made
for the information of readers. At the beginning of the
war the manager of the journal was faced with the demand
for economy in the use of paper. Certain restrictions were
imposed under National Security Regulations in regard to
the use of paper and other matters. These have been faith
fully observed. There is no need to quote details of the
amounts by which paper had to be reduced "or of the
difficulties in securing an adequate supply of paper. What
is important is that readers should appreciate how valuable
for them has been the reduction in the size of type which
was undertaken in August, 1940. An eight-point type was
substituted for what had previously been printed in ten-
point, and seven-point type for what had been eight-point.
The effect of the change in type was that the amount of
letterpress available to readers was practically unchanged.
As the war progressed and medical officers in the services
recorded their observations, an increasing number of con-

118

THE MEDICAL JOURNAL OF AUSTRALIA.

JANUARY 26, 1946.

tributions were sent to this journal. These papers and
the reports on the use of new medicaments and new
methods of treatment had often the unfortunate result of
creating a long latent period before articles could be
published. The dispute in the printing industry which
began in September last accentuated all these troubles and
difficulties.

When publication was resumed on December 1, 1945, it
was quite impossible to make up the loss in the number
of issues of the journal, and the issue of December 1 was
designated "Numbers 12 to 22 inclusive". After two issues
had appeared the strike originating in the mining and
ironworkers industry occurred. At first, since THE
MEDICAL JOURNAL OF AUSTRALIA is registered as a weekly
newspaper, publication was not affected, but before long
the use of electricity and gas for all but daily newspapers
was prohibited and publication ceased for a second time.
Since work was resumed in the New Year the journals
held up by the second interruption of publication have been
published as quickly as possible and it is hoped that
normal running will continue.

In spite of the large hiatus in the latter months of 1945,
the volume for the second half of that year included 516
pages. When we remember that Volume II of 1943 con
tained 532 pages of reading matter with 25 pages of
supplement, the second volume for 1945, affected by the
large hiatus, does not appear so discreditable. Before the
break last September the intention was to return to the
use of ten-point and eight-point type in January, 1946.
This change-over has been postponed and in a week or
two some additional pages of reading matter will be
published in each issue. In this way some of the accumu
lated material will appear. The return to larger type will
be made as soon as conditions justify the change. In the
meantime it is hoped that readers will continue their
forbearance with the war-time type.

THE RESULTS OP PREFRONTAL LEUCHOTOMY.

IN May, 1944, a good deal of space was given in these
columns to the subject of psycho-surgery. The development
of the operation of prefrontal leuchotomy, or prefrontal
lobotomy, was traced and special reference was made to
work by W. Freeman and J. W. Watts. It was pointed out
that, though in certain circumstances the patient s con
dition was improved and he was able as a result of the
operation to lead a more or less equable life, the condition
produced was final "once one cuts, there is no return".
The general conclusion stated was that the place of the
method in the treatment of persons suffering from
abnormal mental states had not been determined and that
the greatest caution should be displayed in the selection
of patients to be subjected to it. For these reasons it
will be of interest to refer to two recent reports on the
results of the operation.

The first report is based on 100 cases and is by F.
Berliner, R. L. Beveridge, W. Mayer-Gross and J. N. P.
Moore, who write from the Department of Clinical
Research, Crichton, Dumfries. 1 At the time when these
authors wrote, the first fifty of their one hundred patients
had been operated on for at least fifteen months and it
was concluded that the outcome in these cases was more
or less settled. The second fifty had been operated on for

1 The Lancet, September 15, 1945.

less than fifteen months, some of them for less than two
months, and consequently the results could not be regarded
as final. The series included 49 male and 51 female
patients; the average age was 36 years and the range 19
to 53 years. The criterion for the selection of patients
for operation was the presence of a clinical picture of
"mental tension" a concept which, we are told, is hard
to define. "It may be thought of as a persistent emotional
change sustaining and to some extent determining the
clinical picture. Such a change is always of an unpleasant
quality, invariably distressing, and sometimes intolerable
to the patient. Its presence is shown by irritability, rage,
fear, or other forms of emotional excitation; insomnia,
and on the motor side, restlessness, aggressiveness, destruc-
tiveness, or impulsive behaviour." Of the 100 patients, 88
suffered from schizophrenia (54 were catatonics) ; the
remainder included four patients with melancholia, five
with severe obsessional states, two epileptics and a general
paretic, who, after fever treatment, developed chronic hal
lucinations. Judged by ordinary prognostic standards, all
the patients were hopeless chronic invalids. All of them
had failed to respond to treatment other than operation.
Of the patients with schizophrenia, 24 are described as
"recovered", 13 as "much improved", and 23 as "improved".
Of the four with melancholia, one fell into each of these
three groups, and the fourth died. Of five with obsessional
illness, four "recovered" and one was "much improved".
These workers point out that it is unwise to evaluate the
results of a new form of therapy without controls, but
they regard their results as encouraging and add that they
fully warrant the use of the operation in suitable cases.
With this most readers will agree.

The second report comes from S. D. Porteus and R. De M.
Kepner, of the Psychological Clinic of the University of
Hawaii. It deals with twenty patients who have been
treated at the Territorial Hospital for Mental Disorders,
Hawaii, where Porteus is the psychological consultant and
Kepner the clinical director. The operations were per
formed by R. B. Cloward, consultant neurosurgeon of the
institution. The report is a monograph of 115 pages. (It
has also been published in Genetic Psychology Monographs,
Volume XXIX, 1944, page 3.) The detailed histories of
the twenty cases are so full of interest that they will be
read, or should be read, by all psychiatrists interested in
the subject. Porteus and Kepner examined their subjects
by psychological tests; they used a modification of the
Binet test and also the Porteus maze test. In some
instances the results of the tests did not favour operation,
but since there were no established criteria for the selec
tion of patients, operation was carried out in spite of the
findings. Eleven of the twenty patients studied manifested
some degree of improvement; two improved to such an
extent that they were able to be released from hospital.
In nine of the eleven cases the psychological recommenda
tion "on the basis of present experience" would have been
favourable to operation. In seven of the nine cases in
which no improvement occurred, the recommendation
would have been adverse. This means that in 16 of the
20 cases the prognosis based on various psychological
considerations was justified. Porteus and Kepner think
that with more experience the percentage of accurate
prognoses would increase. They state the following guiding
principles in selection.

1. The elimination from the list of prospective
lobotomy patients of the mentally defective on the
ground that the operation cannot put into the brain what
was never there.

2. The elimination of the mentally deteriorated on
the grounds that the operation cannot restore what is
already lost.

3. A reasonably high maze test record is a favorable
sign, the reason being that, if planning capacity is
diminished, as it almost certainly will be after operation,
the individual will retain enough to enable him to
function satisfactorily in community life.

4. One conclusion, admittedly somewhat tentative, is
that hebephrenia should be considered a contraindication
for operation. This feature of behavior is probably to be

- interpreted as an emotional retrogression, similar in its
unfavorable implication to mental deterioration.

JANUARY 26, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

ll J

5. Theoretically, certain catatonic types, because of
the strong tendency to stereotyped reactions in post-
lobotomy behavior, would also not be considered good
prospects.

6. Another presumption is that manic-depressives
exhibiting cyclical changes in mood are not good risks.
The operation cannot be expected to bring about
opposite results in the same patient.

7. One commonly dependable post-operative index of
the surgical adequacy of the operation is decline in
maze test ability. The results of several reoperations
will show whether this indication is completely reliable.

Porteus and Kepner have found that the general diag
nostic label is not of great assistance in the selection of
patients for operation. Their group of patients does not
represent fairly the types for whom lobotomy is recom
mended and they point out that success has been attained
in various types of psychosis. One point of considerable
interest is that among the criminal insane operated on
were three individuals whose collective convictions
included three killings and five stabbings. The condition
of all three was improved and one was discharged as
being no longer a menace to the community.

It would be possible to discuss both these reports in
much greater detail, but for our present purpose this is
not necessary. Two points should be mentioned. The first
is that apparently social adjustment after this operation
has been performed may take a considerable time. Freeman
and Watts, who are probably more entitled than any other
workers to express an opinion, have described the process
of adjustment as slow and as extending even into the
second year afer operation, or longer than that. The
second point is that sometimes a second operation may be
needed if the first has not done what is to be expected.
This is an aspect that will probably be discussed by future
workers. In the meantime all who are interested in the
subject will agree with Porteus and Kepner that the
application of the procedure should not become widespread
until careful and continued psychological and psychiatric
studies of its effects have been undertaken. There is some
thing to be said for their idea that a neuropsychological
institute should be established where such investigations
could be carried out, though others will hold that a special
institution is not required.

POST-WAR GERMANY: A PSYCHIATRIC PROBLEM.

IN April, May and June, 1944, there took place a
conference at the College of Physicians and Surgeons,
Columbia University, New York City, on "Germany After
the War". The participants in this discussion represented
a wide selection from experts in anthropology, sociology,
psychology, psychiatry, education, economic and political
science and other studies. The conclusions reached were
presented and individual sections discussed at the annual
meeting this year of the New York Regional Division of
the American Orthopsychiatric Association. An excellent
account of the deliberations has been published. 1 The
analyses given and the recommendations submitted make
rather grim reading, for the seriousness of the situation
in the Germany of today and the Germany of tomorrow
is disclosed with convincing realism of detail. There can
be no question that Americans have been profoundly
shocked at the change which Germany underwent between
the two world wars. For many years Germans had been
excellent colonists in the United States of America,
industrious and intelligent and soon imbibing the
American spirit; furthermore, American intellectuals
sought inspiration from German universities and many
looked upon Germany as their spiritual home. It is true
that Germany resorted to harsh measures in World War I,
but these were of military origin and purpose and had
what excuse military operations can claim. Then came the

American Journal of Orthopsychiatry , July, 1945.

promulgation of Nazi doctrine and the horrified Americans,
as well as the citizens of the British Empire, discovered
in the German people an insulting assumption of racial
superiority which did not hesitate at endeavouring to
exterminate a whole people, a contempt for democracy,
a proclamation of a new order to supersede all previous
orders, and the resort to a technique of lies, subterfuges
and world-wide spying and infiltration. The conference
emphasized strongly the fact that the measures to be
taken with post-war Germany must not be confined to the
military, political and economic spheres, for most impor
tant of all are a psychiatric analysis and based upon this
a treatment directed towards an abnormal and deeply
entrenched psychology. A whole generation of Germans
has been poisoned in moral fibre and in intellectual free
dom by cunning propaganda lavished on them during
their impressionable years. The boys of the Hitler
Youth Movement, who were fourteen to eighteen years of
age in 1933, when the toxicity had reached full potency,
are now twenty-six to thirty years of age, and it is with
these perverted adults that the Allies must deal. In
another article in the same journal, "Children under the
Nazi System", there is a cold, unbiased, but none the less
terrible description of the devilish devices used to win
over boys to the doctrine that the master race must be on
top and it mattered not by what methods this was
attained. Youngsters were encouraged to sneer at old-
fashioned parents and to regard the home as of no
account; girls were for pleasure and procreation, while
marriage was "not a biological necessity". In the main
report some concepts are given which Germans tenaciously
hold and which have been causative in the headlong rush
into degeneracy. Chief amongst these are the doctrine of
German superiority, the right of Germans to dominate all
other groups which must be regarded as enemies, the
apotheosis of the military cult and the application of
military methods to civil life, and particularly to educa
tion. Each of these must be destroyed beyond recovery
and the process may take a long time. We are warned
that the reaction of English-speaking democracies to any
particular form of treatment must not be taken as indicat
ing what the Germans will do in a similar position. The
British and Americans would, for example, accept a
remission of a penalty with gratitude; the Germans with
contempt, as it would in their view imply stupidity or
weakness in the victor. In fact, a strong plea is made
for "putting the boot in", to use a local expression, in
dealing with the conquered Teutons. An illustration
which might have been given in this discussion is that
after Versailles it was hoped to transform the German
army into something different and yet retain the former
corps of officers. What happened was that a new German
army arose more brutal than the old. 1 If democracy is to
be saved, then the German military system must be
destroyed to its minutest rootlet. Education must be
forcibly overhauled and reformed and freedom should be
restored to Press, radio, stage, film and Church. The
imposition of a superficial form of democratic govern
ment would be of little service so long as the poison
remains in the soul of the people. To rebuild German
character will be a long business; it may be impossible,
but it must be tried. If it fails, then the means of doing
harm must be taken away from the nation collectively
and individually. The report makes it clear that the
problem of post-war Germany is essentially a problem in
mental pathology; the country must be shielded from the
libido of desperate adolescents whose degenerate actions
should be kept under with a strong hand. The reading
of these measured analyses and recommendations gives
the feeling that there is little hope for betterment in
German manhood today, for the poison cannot be expelled
or neutralized by an arsenical or sulphonamide drug, nor
can the devils be exorcised by kindly treatment. It is to
be hoped that the report of these American deliberations
will be placed in the hands of the Allied statesmen in
whose responsibility the control of Germany now rests.

( The Times Literary Supplement, August 18, 1945, page 387.

120

THE MEDICAL JOURNAL OF AUSTRALIA.

JANUARY 26, 1946.

from
Literature,

PHYSIOLOGY.

The Rate of Carbon Monoxide
Uptake by Man.

W. H. FORBES, F. SARGENT AND F. J. W.
ROUGHTON (The American Journal of
Physiology, April, 1945) present new
data for the rate of carbon monoxide
uptake by normal men at sea level,
when exposed to air containing various
percentages of carbon monoxide (0-01
to 2-0) for various times. The subjects
were at rest, engaged in light activity,
light work or hard work. A composite
chart is given for calculating the
average individual increase In per
centage of carboxyhaamoglobin in the
blood with time, at varying carbon
monoxide pressure and varying ventila
tion rate. Particular individuals may,
however, vary consistently by as much
as 20% from the data in the chart,
which may, therefore, in practical cases,
often be replaced by much simpler
approximate equations given in the text.
Variations in the ratio of tidal air to
dead space, and in the value of the
diffusion constant of the lungs, appear
to be responsible for the differences
between individuals in the rate of
carbon monoxide uptake. The observed
rates of carbon monoxide uptake are
lower than the average rates of most
previous observers: the difference is
attributed partly to more accurate
estimation of carboxyhsemoglobin (by
the Scholander-Roughton technique)
and partly to adequate allowance for
the blank carbon monoxide already
present in the blood before the exposure.
Lowering of the total barometric pres
sure (down to 140 millimetres of
mercury) is without effect on the rate
of carbon monoxide uptake, provided
the partial pressure of carbon monoxide
in the trachea is kept constant and cor
rection is made for any increase in
ventilation rate due to hypoxia. In
creasing the oxygen from 20% to 98%
at sea level decreases the rate of carbon
monoxide uptake: the effect is more
pronounced in hard work than at rest.
This decrease occurs because the rate
of reaction of carbon monoxide with
haemoglobin is inversely proportional to
the oxygen pressure.

The Dehydrating Effect of

Continuously Administered

Water.

A. V. WOLF (The American Journal of
Physiology, April, 1945) recalls that
other authors have shown that the
quantity of water lost in diuresis due
to water excess may be greater than
the quantity taken in. The author
studied this dehydrating effect in man.
Ten young subjects were taken and a
fixed amount of water varying from 20
to 200 millilitres was drunk every ten
minutes. The intake of water was con
tinued for periods up to seven hours.
A steady state of water intake under
the conditions of these experiments on
man results in a total output of fluid
larger than the intake, and if con
tinued, leads to the production of
negative water loads. The urinary out
put alone was 8% greater than the

intake rate. The ratio of rate of
chloride excretion to the rate of excess
water excretion is equal to the normal
plasma concentration in the steady
state, and the equation of steady state
is calculated. The threshold of appear
ance and the threshold of retention are
defined and are illustrated for chloride.
In renal excretion, the regulation of
concentration of plasma chloride takes
precedence over the regulation of body
volume, when water is drunk.

Use of Cholinesterase in Shock.

R. J. SCHACHTER (The American
Journal of Physiology, April, 1945)
reports that surgical shock was pro
duced in 66 anaesthetized dogs by exces
sive haemorrhage or manipulation of
the intestines. When permanent shock
levels of blood pressure were demon
strated to be present, treatment con
sisting of restoration of blood volume
or of injection of cholinesterase
was attempted. The dogs in haemor
rhage shock responded well to beef
plasma, administered in appropriate
volumes, by recovering from shock. The
dogs in traumatic shock were benefited
by plasma only temporarily. When
the dogs in traumatic shock were given
intravenous injections of cholinesterase,
the blood pressure nearly always (16
out of 18 dogs) returned to normal and
remained there for the duration of the
experiment.

Absorption, Distribution and
Excretion of Thiourea.

R. H. WILLIAMS AND G. A. KAY (The
American Journal of Physiology, May,
1945) state that in addition to the
recently demonstrated antithyreoidal
action of thiourea, the use of this sub
stance in the measurement of renal
function and in the estimation of the
total body water has been considered.
They have modified the methods to
allow determination of thiourea in any
of the fluids and tissues of the body.
They also state that thiourea is rapidly
absorbed from the gastro-intestinal
tract and is rapidly distributed through
out the tissues and fluids of the body;
its concentration in the tissues varies
widely. The distribution of thiourea
correlates poorly with the water content
of body fluids and tissues; the apparent
volume of distribution far exceeds the
actual content of body water. The sub
stance is broken down in the body in
a rapid and inconstant manner. No
thiourea is excreted in the stools, but
it appears in the urine within thirty
minutes of ingestion. None of the
substance is usually found in the urine
forty-eight hours after cessation of
therapy. In patients with nephritis
there is a distinct impairment in the
excretion of thiourea.

The Effect of Arsenite on the
Respiration of Rat Tissues.

H. W. ELLIOTT AND E. R. NORRIS (The
American Journal of Physiology, May,
1945) state that rats given 25 milli
grammes of arsenic trioxide as a solu
tion of sodium arsenite per kilogram
body weight may die in fifteen minutes
with the characteristic symptoms.
Animals on lower but still lethal doses
may develop the same syndrome in the
course of a twenty-four hour period.
Rats may be adapted to arsenic trioxide

by the injection of sublethal doses over
a long period of time. While normal
rats show a fall in temperature when
injected with solutions of sodium
arsenite, adapted rats show much less
or no drop in body temperature. The
hypothermia follows immediately after
the injection of arsenic and may be due
to a direct effect on the temperature-
regulating centre in the hypothalamus,
to some action on the vasodilator
centres, or to a lowering of the
basal metabolic rate which might con
ceivably be due to reduction of the
respiratory rate of the individual body
tissues. With the object of determining
the cause of the hypothermia, studies
were made of the effects of arsenic
trioxide on cerebral cortex, diaphragm,
kidney, cortex and liver. By tissue
respiration studies, action-concentration
curves of arsenic trioxide have been
prepared for cerebral cortex, diaphragm,
kidney cortex and liver in the albino
rat. Fatal doses of arsenic trioxide
administered subcutaneously in vivo
have no effect on cerebral cortex
respiration, cause reduction of dia
phragm and kidney respiration, and
induce stimulation of liver respiration.
Fatal doses of arsenic trioxide adminis
tered intraperitoneally in vivo have no
effect on cerebral cortex respiration, and
cause reduction of diaphragm, kidney
cortex and liver respiration. The
absence of effect on the cerebral cortex
respiration while the respiration of the
muscle tissue of the diaphragm is
reduced would suggest that the
hypothermia of arsenic poisoning is
influenced more by a decreased rate of
energy metabolism of the individual
tissues than by a direct effect on the
temperature-regulating centre in the
central nervous system.

Tolerance to Arsenic Trioxide in
the Albino Rat.

E. R. NORRIS AND H. W. ELLIOTT (The
American Journal of Physiology, May,
1945) discuss some of the work which
has been done concerning tolerance to
arsenic. There seems no doubt that
the arsenic eater may ingest quantities
of arsenic trioxide which would be
poisonous to the normal individual.
However, the ability of the individual
or laboratory animal to acquire a true
tolerance to arsenic trioxide either as
a solid or in solution as sodium arsenite
has been questioned by several investi
gators. The general belief was that no
tolerance could be developed to arsenic
in solution, but that with solid arsenic
the tolerance is due to diminished
absorption. In the course of studies
made by the authors on the detoxifica
tion of arsenic by rats it was desired to
administer the largest doses that could
be safely given. Solutions of sodium
arsenite were injected intraperitoneally.
When a group of rats had been injected
with sublethal doses for three weeks it
was found that the dose could be in
creased to a level which invariably
killed normal animals without pro
ducing toxic effects. Attention was
then given to this aspect of the
question, and the authors showed that
rats acquire a true systemic tolerance
to arsenic trioxide in solution, injected
intraperitoneally as sodium arsenite.
The toxicity of a dosage of arsenic
trioxide and the progress of adaptation
have been demonstrated by studying
the hypothermia after injection. The

JANUAKY 2(i, 1946. THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER.

ZERO HOUR

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121

tolerance to injected arsenic trioxide
was shown not to be due to decreased
rate of absorption from the body cavity.

BIOCHEMISTRY.

Alloxan.

S. BANERJEE (The Journal of Bio
logical Chemistry. May, 1945) has
reported on the hypoglycsemic action of
alloxan. Hypoglycsemic convulsions
were not observed when alloxan (200
milligrammes per kilogram) was
injected intravenously into three
partially pancreatectomized rabbits. All
three animals survived and developed
hyperglycaemia and glycosuria on the
following day. Three normal rabbits
with the pancreas intact died of hypo-
glycffimic convulsions within varying
periods after the intravenous injection
of alloxan. The alloxan hypoglycsemia
is suggested to be due to the release
of preformed insulin from the necrosed
islets and not to stimulation of the
islet tissue.

Vitamin E.

D. W. WOOLLEY (The Journal of
Biological Chemistry, June, 1945) has
studied some biological effects produced
by the quinone of a-tocopherol.
Administration of dZ-a-tocopherol quinone
to pregnant mice causes haemorrhage
in the reproductive system and resorp-
tive termination of pregnancy during
the last week of gestation. Similar
amounts of the compound were without
detectable effect on non-pregnant mice.
No permanent damage was done to the
ability to reproduce. The action of
the quinone was not prevented by large
doses of a-tocopherol acetate, but was
negated by small amounts of 2-methyl-l,
4-naphthoquinone (vitamin K). The
quinone was viewed as a structural
analogue of both vitamin E and vitamin
K. 3, 3 -methylenebis (4-hydroxy-
coumarin), which caused signs (re
versible by vitamin K) similar to those
seen in vitamin K deficiency, did not
produce resorption or vaginal haemor
rhage in pregnant mice. The quinone
was much more effective when given
intraperitoneally than when given
orally.

Lipides.

\V. A. GRTNER (The Journal of Bio
logical Chemistry, June, 1945) has in
vestigated the lipide fractions of 438
foetuses, representing 66 litters and
covering 70% of the gestation period of
the pig. The water content of the pig
foetus exhibits two rapid falls during
growth, a phenomenon previously cor
related with changes in the foetal
kidneys. The total lipide and lipide to
protein ratio remain constant for a
large part of the embryonic growth
period. Evidence is presented that a
considerable portion of the non-
phospholipide fatty acids, often con
sidered "neutral fat", is actually present
in unesterified (free) form. On a dry
weight basis, the phospholipide content
is at a maximum in the very young
foetus, which has twice as much of this
lipide as does the foetus at term. The
phospholipide fatty acids, in common
with the other acid fractions, have an
average iodine number of 82. The
unsaponifiable lipides in the dry solids

progressively decrease in their per
centage content during embryonic
growth, the total and free cholesterol
fractions roughly paralleling this fall.
At no time is there any notable ten
dency for cholesterol to appear in ester
form. The foetal glycerides gradually
increase, beginning about the middle of
the gestation period, but even at term
they account for only a minor part of
the total lipide substance. Considerable
differences exist in the development of
the lipides in the foetal pig in com
parison with the foetal rabbit.

Galactose.

D. STETTEN (The Journal of Biological
Chemistry, June, 1945) has studied the
glycogen turnover in the liver and
carcass of rats fed with galactose.
When rats were fed with galactose
instead of glucose as the sole dietary
sugar, less glycogen was recovered from
their tissues, especially from their
livers. The rate at which deuterium
was incorporated into this glycogen
from deuterium oxide in the body fluid
was at least as rapid as when glucose
was fed. Prom the maximal isotope
concentrations in the glycogen it could
be shown that the animal can convert
galactose into glycogen without labiliza-
tion of all of the carbon-bound
hydrogen. The galactose excreted in the
urine when galactose is fed to male
rats receiving deuterium oxide is
essentially free of deuterium. This
finding provides a confirmation of the
non-exchangeable nature of the carbon-
bound hydrogen of hexose.

Choline.

R. W. LUECKE AND P. B. PEARSON

(The Journal of Biological Chemistry,
May, 1945) have studied the effect of
the ingestion of excessive quantities of
choline on the amount in tissues and
urine. The ingestion of forty grammes
of choline chloride daily for a period of
six days did not increase either the free
or total choline content of the liver,
kidney or plasma. The choline recovered
in the urine on any single day during
choline feeding ranged from 0-7% to
2-5% of the choline ingested by sheep.
The amount excreted in the urine of
dogs ingesting five grammes daily was
approximately 0-5% of the amount
ingested. The ingestion of choline is
accompanied by an increase in urinary
nitrogen. The increment in urinary
nitrogen is virtually equivalent to the
choline nitrogen ingested. Betaine
hydrochloride administered per os is
not excreted in urine as choline or
betaine.

Wound Healing.

H. E. PAUL et alii (Archives of Bio
chemistry, June, 1945) have found that
the thiamin content of repair tissue in
skin wounds at the stage of rapid
healing is approximately double that of
normal skin. The average thiamin con
tent of normal rat skin has been
determined to be 0-57 microgramme per
gramme in animals in the latter half
of life.

Biotin.

C. KENNEDY AND L. PALMER (Archives
of Biochemistry, June, 1945) have pro
duced evidence that biotin is one of
the factors needed for successful gesta
tion and the birth of viable young in

the rat and is probably a necessary
factor in lactation; however, as folic
acid was not included in the ration,
the effect of biotin on lactation is not
positively known.

Body Composition.

H. H. MITCHELL et alii (The Journal
of Biological Chemistry, May, 1945)
have studied the chemical composition
of the adult human body, thirty-five
years of age, with reference to moisture,
ether extract, protein (N x 6-25), total
ash, calcium, phosphorus and gross
energy. Individual analyses of the
skeleton, musculature, skin and many
visceral organs are reported. The data
from this material have been considered
in connexion with the requirements of
calcium for growth on the assumption
that the integration of calcium
accretions during the growing period
will equal the calcium content of the
adult organism.

Vitamins in Muscle.

E. E. RICE et alii (Archives of Bio
chemistry, June, 1945) have investigated
the distribution and comparative con
tent of certain B-complex vitamins in
pork muscular tissues. The thiamin,
riboflavin, niacin and pantothenic acid
contents of 24 pork muscles have been
determined for each of several animals.
It has been shown that the vitamin
content of the muscles in a single
animal vary as much as 200% to 300%.
Muscles which are high in a vitamin
in one pig tend to be high in other
animals of this species. Muscles con
taining relatively much thiamin usually
contain high levels of niacin, but
relatively low levels of riboflavin and
pantothenic acid. Although there are
indications that the activity or function
of the muscle may be responsible for
the variations in vitamin content, no
definite conclusions to this effect can
be drawn on the basis of the present
data.

Acetic Acid.

THE formation of acetic acid in the
rat has been studied quantitatively by
K. Bloch and D. Rittenberg (The
Journal of Biological Chemistry, June,
1945). The acetylation of foreign amines
by acetic acid was studied. By
employing acetate labelled with C 13 as
well as deuterium, it has been shown
that no loss of deuterium due to
exchange reactions occurs in the
acetylation of reaction. Acetic acid is
an effective acetylating agent for para-
aminobenzoic acid, d- and I-phenyl-
amino-butyric acids and sulphanilamide.
Evidence is presented to show that
acetic acid is the only acetlyating
agent for the aromatic amines,
sulphanilamide and para-aminobenzoic
acid. Acetic acid is the major source of
acetyl groups in the acetylation of
phenylamino-butyric acid, which, how
ever, can also be acetylated by a
mechanism probably involving pyruvic
acid. From the dilution of the acetate
fed it is calculated that 15 to 20 milli-
molls of acetic acid are formed daily
per 100 grammes of rat tissue. It is
suggested that the major part of this
acetate arises from the oxidation of
fatty acids. It is estimated that at
least half the carbon atoms of
cholesterol are derived from acetate.

THE MEDICAL JOURNAL OF AUSTRALIA.

JANUARY !&gt;,

British Q^eDical association r^etos.

ANNUAL MEETING.

THE annual meeting of the Queensland Branch of the
British Medical Association was held at B.M.A. House,
Wickham Terrace, Brisbane, on December 14, 1945, DR. H. W.
HORN, the President, in the chair.

ANNUAL REPORT OK COUNCIL

The annual report of the Council, which had previously
been circulated among members, was taken as read on the
motion of Dr. C. C. Minty, seconded by Dr. D. Gifford Croll,
and adopted on the motion of Dr. C. C. Minty, seconded by
Dr. Alex Murphy. The annual report is as follows.

The Council has pleasure in presenting the following report
of the work of the Branch for the year ending November 15,
1945.

Membership.

The membership of the Branch is 641 and 3 complimentary
members, as against 623 last year, making a gain of 18.
Forty-five honorary associate members were elected during
the year.

The gains were: new members, 43; transferred from other
Branches, 2 ; members reinstated, 1.

The losses were: members transferred to other Branches,
13; deceased, 12; resignations, 3.

The following members of the Branch completed fifty
years of membership of the British Medical Association at
the end of the year 1944: Dr. W. Wallis Hoare, Dr. J. A.
Goldsmid.

There is a total of 146 members engaged on full-time duty
with His Majesty s Forces.

Honours have been conferred by His Majesty the King
on the following members for services rendered during the
war: O.B.E., Lieutenant-Colonel Arnold W. Robertson;
Military Cross, Captain H. Glynn Connolly. Mentioned in
Dispatches: Lieutenant-Colonel P. W. Hopkins, Lieutenant-
Colonel W. E. E. Langford, Lieutenant-Colonel L. McD.
Outridge, Lieutenant-Colonel J. H. Thorpe, Lieutenant-
Colonel L. G. Hill, Lieutenant-Colonel R. G. Quinn. A letter
of congratulation was sent to these members.

We are glad to extend a warm welcome to the following
members who have been prisoners of war: Major B. L. W.
Clarke, Major Clive Uhr, Captain C. R. R. Huxtable, M.C.,
Captain C. R. Boyce, prisoners of war in Japanese hands,
and Captain L. Pelham Sapsford, who was a prisoner of war
in Germany.

Obituary.

The Branch has sustained a loss by death of the following
members: Dr. Clive L. Paine, Dr. A. C. F. Halford, Dr.
R. Graham Brown, Dr. R. A. McWilliam Robinson, Dr. W. A.
Fraser, Dr. Alan R. East, Dr. J. E. Overstead, Dr. St. A. W. L.
McDowall, Dr. F. W. Harlin, Dr. Eric Meikle.

It is with regret that we record the death of Sir David
Hardie, M.D., which has just occurred. Sir David Hardie
had been a member of the Association for over fifty years
and he was a past president of the Branch.

Roll of Honour.

Captain Benjamin Hooper died on active service. Captain
D. G. Picone and Captain P. M. Davidson died whilst
prisoners of war in Japanese hands.

Meetings.

In addition to the annual meeting, twelve meetings of the
Branch were held, two of which were special meetings, one
being held to give members an opportunity of hearing the
views of the Federal Council on the Pharmaceutical Benefits
Act, given by the General Secretary, Dr. J. G. Hunter, and
the other an address by Dr. C. I. McLaren.

The average attendance was forty-one.

Council.

Twenty-one meetings were held. The record of attendances
of the Council is as follows:

Dr. H. W. Horn (President) 21

Dr. J. G. Wagner (President-Elect and Honorary

Treasurer) 20

Dr. L. P. Winterbotham (Past President) . . . . 14

Dr. Norman Sherwood (Honorary Secretary) . . 20

Dr. C. C. Minty (Chairman of Committees) . . 20
Dr. J. G. Avery (Honorary Secretary of Com
mittees) 16

Dr. Felix Arden (Councillor)

Dr. E. W. Casey (Councillor)

Dr. R. B. Charlton (Councillor)

Dr. D. Gifford Croll (Councillor)

Dr. Milton Geaney (Councillor)

Dr. L. T. Jobbins (Councillor)

Dr. Alan E. Lee (Councillor and Federal Council

representative)

Dr. F. W. R. Lukin (Councillor)

Dr. J. G. Morris (Councillor)

Dr. Mervyn S. Patterson (Councillor)

16
18
13
20
18
13

20
14
16
15

Dr. T. A. Price (Councillor and Federal Council
representative) 8

Dr. W. H. Steel (Councillor) 16

Scientific.

February. Clinical meeting in conjunction with the Mater
Misericordiee Public Hospital Clinical Society.

March. Dr. L. J. J. Nye: "The Management of Duodenal
Ulcer."

April. Dr. P. A. Earnshaw: "The Problem of the Under
weight Child."

May. Discussion of the profession s attitude to the
Pharmaceutical Benefits Act.

June. Brigadier N. Hamilton Fairley: "Tropical Medical
Research in the Australian Army" (Joseph Bancroft
Memorial Lecture).

July. Dr. Neville G. Button: "A Surgeon Visits the U.S.A."

July (Special). A talk by Dr. J. G. Hunter, General
Secretary of the Federal Council, on the Pharma
ceutical Benefits Act.

August. Symposium on backache. The opening speakers
were Dr. A. V. Meehan, Dr. Ellis Murphy and Dr.
Alan E. Lee.

August (Special). Dr. C. I. McLaren: "A Medical
Psychologist in the Far East."

September. Dr. S. Julius: "The History of Medicine in
Soviet Russia" (Jackson Lecture).

October. Major John F. Williams: "The Working of a
Child Guidance Clinic."

November. Clinical meeting in conjunction with the
Brisbane General Hospital Clinical Society.

Office-Bearers and Councillors.

Dr. J. G. Wagner was elected President-Elect for the
ensuing year and Dr. Norman Sherwood was elected
Honorary Secretary.

The following office-bearers were elected by the Council:

Honorary Treasurer: Dr. J. G. Wagner.

Chairman of Committees: Dr. C. C. Minty.

Honorary Secretary of Committees: Dr. J. G. Avery.

Honorary Librarian: Dr. Neville G. Button.

Assistant Honorary Librarian: Dr. Konrad Hirschfeld.

Dr. Mervyn Patterson, Dr. J. G. Avery, Dr. Robin Charlton
and Dr. L. T. Jobbins are not seeking reelection for 1946, and
the Council wishes to record its appreciation of the services
rendered by them.

Ethics Committee.

At the annual meeting of the Branch held on December 13,
1944, the following were elected members of the Ethics Com
mittee: Dr. Alex. Marks, C.B.E., D.S.O., V.D., Dr. G. P.
Dixon, C.B.E., V.D., Surgeon Commander Gavin Cameron,
Dr. M. Graham Button, Dr. L. J. J. Nye. The ex-offlcio
members of the Ethics Committee consist of the President,
President-Elect, the Honorary Treasurer and the Honorary
Secretary for the time being in office.

Two meetings of the committee were held to deal with a
complaint received regarding a member of the Branch.

Library.

During the year seventy-eight books were borrowed from
the library by thirty-three members.

Arrangements have been made to receive the reports of
the Medical Research Council of England as they are
published.

The only addition to the library this year is "Pre-School
Centres of Australia", by J. H. L. Cumpston and Christine
Heinig.

Leave of absence.

JANUARY 26, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

123

Representation.

The Branch was represented as follows during the year:
Council of the British Medical Association: Professor

R. J. A. Berry.
Federal Council of the British Medical Association in

Australia: Dr. T. A. Price and Dr. Alan E. Lee.
Federal Council Contract Practice Committee: Dr. L. P.

Winterbotham.
Australasian Medical Publishing Company, Limited: Dr.

D. Gifford Croll, director; Dr. T. A. Price and Dr.

Alan E. Lee, members.

Medical Officers Relief Fund (Federal) : Queensland Com
mittee, Dr. D. Gifford Croll, Dr. G. P. Dixon, Dr. W. H.

Steel.

Medical Assessment Tribunal: Dr. A. H. Marks.
Queensland Medical Board: Dr. D. Gifford Croll, Dr. J. G.

Wagner, Dr. Felix Arden.
Queensland Post-Graduate Medical Education Committee:

Dr. S. F. McDonald and Dr. Alan E. Lee.
Queensland Medical Coordination Committee: Dr. F. W. R.

Lukin.

Queensland Radium Institute: Dr. Alan E. Lee.
Queensland Nutrition Council: Dr. P. A. Earnshaw, Dr.

Noel M. Gutteridge.
Queensland Bush Nursing Association: Dr. L. Bedford

Elwell.
Queensland Council of Social Agencies, Board of Studies:

Dr. C. C. Minty.

Flying Doctor Service of Australia: Dr. Harold Crawford.
Red Cross Blood Transfusion Service Committee: Dr.

Milton Geaney.

Red Cross Society Appeal Committee: Dr. L. J. J. Nye.
The Surf Life Saving Association of Australia, Queensland

State Centre: Dr. F. W. R. Lukin.
Physical Fitness Association of Queensland: Dr. E. S.

Meyers and Dr. Harold Crawford.

The Editor of THE MEDICAL JOURNAL OF AUSTRALIA was
represented by Dr. Felix Arden.

War Emergency Organization.
Rehabilitation of Members of the Armed Seri-ices.

The special subcommittee of the Branch appointed to deal
with this important matter consists of the following mem
bers: Dr. J. G. Wagner, Dr. F. W. R. Lukin, Dr. C. C. Minty,
Dr. Ellis Murphy, Dr. T. V. Stubbs Brown, and the ex-officio
members of the Council.

The Council has been watchful of the interests of members
returning from the services in regard to the provision of
facilities for post-graduate study and hospital experience, and
also in placement in civilian practice. Such members have
been urged to seek the advice of the Rehabilitation Sub
committee, and everything possible will be done to assist
them in all their problems.

Dr. Ellis Murphy has been appointed to act as the repre
sentative of the Queensland Post-Graduate Medical Education
Committee on the Rehabilitation Subcommittee of the
Branch, and Dr. Stubbs Brown is the nominee of the Society
of Returned Medical Officers of Queensland.

In June last the President attended a meeting of repre
sentatives of the Universities Commission with the local
Advisory Committee to that commission, at which details
regarding rehabilitation of medical officers were discussed,
and the general principles of medical education to be per
mitted and paid for by the Universities Commission were
defined.

The question of facilities for post-graduate work outside
Australia being made available to medical officers discharged
from the armed forces, on terms to be arranged, had been
under discussion by the Federal Council of the British
Medical Association. The Branch Council has expressed
itself in favour of the suggestion.

The Branch Council has also endorsed a recommendation
made to the Federal Council that there should be open com
petition between the medical agencies regarding ex-service
practitioners who are seeking avenues of practice.

Queensland Medical Coordination Committee.

Dr. F. W. R. Lukin was again reappointed representative
of the Branch on the Queensland Medical Coordination Com
mittee for the year 1945.

The Branch Council has endorsed the opinion of the
Federal Council that the present set-up of State Medical
Coordination Committees under Commonwealth control
should continue for the time being.

Repatriation Commission: Medical Benefits for Dependants
of Deceased Soldiers.

An agreement between the Repatriation Commission and
the Federal Council has now been reached, after having
been under discussion for several years. The terms of the
agreement should be satisfactory to the medical profession.

Payment for service to dependants of deceased soldiers
will be on a sliding scale determined by the nominal wage
index each year, with a differentiation for metropolitan and
extra-metropolitan areas. For the purposes of the agreement
the metropolitan area has been extended to include
Toowoomba, Maryborough, Rockhampton and Ipswich.

It is understood that beneficiaries may receive treatment
directly by agreement with the Repatriation Department
without the intermediary of a lodge. Also that benefits
must be taken up within six months without submitting to
medical examination. After the expiration of that time a
medical examination is necessary.

Queensland Medical War Benefit Fund.

The Queensland Medical War Benefit Fund was renewed
for a further period of twelve months, which expires on
April 30, 1946.

The future of the fund is undecided at present.

Federal Medical War Relief Fund.

It is proposed by the Federal Council to establish a Federal
Medical War Relief Fund to assist members of the medical
profession who have been disabled, and the dependants of
those who have died as a result of enemy action or of sickness
contracted whilst serving in the armed forces. Also to issue
loans, with or without interest, to medical men, who, as a
result of enemy action, may require temporary financial
assistance.

The fund is to be established by donations from members
of the profession in Australia, and an effort is to be made in
each State to secure as large initial donations as possible.

The control of the fund will be in the hands of trustees
appointed by the Federal Council, and a local committee of
management has been appointed in each State.

It was decided by the Branch Council to appoint the same
personnel as the trustees of the Queensland Medical War
Benefit Fund as the local committee of management for the
Federal Medical War Relief Fund in this State, namely, Dr.
J. G. Wagner, Dr. F. W. R. Lukin, Dr. J. G. Avery, Dr. Milton
Geaney and Dr. J. V. Duhig.

An appeal is to be launched shortly for donations to the
fund.

Rationing.

Although the war has ended, the supply of certain foods
necessary for special classes of the community is still a
matter for medical certification, but the position has eased
somewhat in this regard.

Liquid Fuel Supplies.

The subcommittee appointed to deal with petrol require
ments of metropolitan members has continued its useful
work with the able assistance of Mr. F. K. Davis. Dr. L. P.
Winterbotham is chairman, and the other members are Dr.
Alec Paterson, Dr. A. G. Anderson and Dr. J. G. Avery.

Motor-Car Tires and Accessories.

Members have also been assisted by Mr. F. K. Davis in
obtaining necessary new tires and retreads et cetera, in order
to maintain efficient transport to enable them to carry out
their professional duties.

Linen for Doctors Surgeries.

Through a subcommittee consisting of Dr. L. P. Winter
botham, Dr. J. G. Avery and Dr. Alec Paterson, members
are enabled to obtain adequate supplies and replenishments
of linen for their surgeries; returned service medical officers
particularly appreciate the assistance given in this matter.

Monthly Newsletter.

The monthly newsletter, which was originally sent only to
members in the forces to keep them in touch with current
events, is now circulated to all members of the Branch,
although it does not necessarily represent the views of the
Council.

The members of the Publicity Committee responsible for
the compilation of the newsletters are to be congratulated
upon their excellent work and variety of expression.

124

THE MEDICAL JOURNAL OF AUSTRALIA.

JAM-AKY 2&lt;J.

Supply of Artificial Limbs.

Attention was drawn to the serious position existing in
Queensland in connexion with the supply of artificial limbs.
It is almost impossible for a patient with an amputation to
obtain an artificial limb. The matter was referred to the
Chairman of the Medical Equipment Control Committee, who
promised that all possible steps would be taken to remedy
the position.

Licencees under Alien Doctors (National Security)
Regulations.

At the meeting of the Federal Council held in Melbourne
on October 15, 1945, it was decided to recommend to the
Branches that, unless their country of origin provides
registration of graduates of the State concerned upon con
ditions no less onerous than those existing in such State, the
registration of alien doctors whose licences will have expired
be opposed.

Organization Subcommittee.

Personnel: Dr. Alan E. Lee, Dr. W. H. Steel, Dr. Robin
Charlton. Dr. Felix Arden, Dr. E. W. Casey, Dr. J. G. Morris,
Dr. L. T. Jobbins and the ex-officio members of the Council.

This subcommittee is vested with power to act in matters
which came before it, provided they are not questions of
policy or of a controversial nature.

During the year 24 meetings were held, and recommenda
tions were made to the Council on matters which were not
dealt with directly by the subcommittee.

The following is a record of some of the important subjects
considered by the subcommittee.

Workers Compensation Schedule of Fees. A schedule of
medical fees for attendance on injured workers, as agreed
between the Council of the Branch and the Insurance Com
missioner, and endorsed by the State Treasurer, has been
published and circulated to the profession. This schedule
came into operation as from April 1, 1945, and appears to be
working satisfactorily.

The fees are applicable to treatment of injured workers in
their home, at the doctor s surgery or in a private hospital.
In ordinary cases of injury to workers the Insurance Com
missioner is responsible for payment of medical fees not
exceeding 25, but no responsibility is accepted by him for
private hospital fees, except in special circumstances where
no public hospital accommodation is available, or for injured
workers who are covered by a lodge agreement, or other con
tributory scheme. The sympathetic cooperation of the
Insurance Commissioner in all matters under dispute must
be fully acknowledged.

Unemployment and Sickness Benefits Act. Regarding the
question of medical certificates required under the provision
of this act, members have been advised, where information of
a confidential nature has to be disclosed, to give the
certificate to the patient concerned or obtain the written
consent of the patient to furnish the information to the
Social Service Department.

Medical Certificates. It is a matter of congratulation to
the profession that during the year there has been very little
need for the functioning of the subcommittee appointed to
deal with such matters.

The members of the subcommittee are Dr. H. W. Horn
and Dr. L. P. Winterbotham.

General Health Policy of the Branch. In view of the
importance of the health of the community which is receiving
the attention of the Government and other bodies, a special
subcommittee was appointed to draw up a general health
policy for the Branch, which was adopted by the Council in
August. Copies have been sent to the Federal Council, other
State Branches, and to local medical associations of the
Queensland Branch.

Queensland Institute of Medical Research. A letter was
sent to the Minister for Health and Home Affairs con
gratulating him upon the establishment of an Institute of
Medical Research, as outlined in the Press, and assuring him
of the full cooperation of the Association.

Queensland Health Education Council. The Queensland
Health Education Council, which was instituted by an Order
in Council of the Governor during the year, has superseded
the Queensland Cancer Trust, and its activities have been
extended to "educate the public in health matters generally".

The medical members appointed by the Government include
Dr. Alan E. Lee, Dr. L. M. McKillop, Dr. Konrad Hirschfeld,
Dr. E. H. Derrick and Dr. A. B. Fryberg.

A conference of interested bodies was held on August 7
to discuss the best avenues for the expenditure of public

money on health education of the general public, at which
the Branch was represented by Dr. Harold Crawford. Sub
sequently recommendations drawn up by a subcommittee
were submitted to the Health Education Council, and a copy
of the general health policy of the Branch was forwarded.

Operations Performed on a Minor. In response to an
inquiry for a statement as to the legal responsibility of the
profession in connexion with an operation performed on a
minor, a reply was received from the Minister for Health
and Home Affairs. It was stated that the Solicitor-General
advises that parents under Queensland law have full control
of infants within the meaning of our Children s Protection
Act, 1896, and an operation on such an infant would be an
I assault. On the other hand, if the parent s refusal of consent
were perverse, such parent might be guilty of an offence
under the act, or even of manslaughter.

Lead Poisoning. No improvement in the position with
regard to lead in paint has been achieved. It is contended
by the Master Painters Association that, while the Federal
Government permits paint to be manufactured with lead as
a pigment, the painters have no alternative but to use it.
Dr. L. J. J. Nye addressed the Master Painters Association
on the incidence of lead poisoning in Queensland. Sub
sequently at a joint conference between representatives of
, the Master Painters, Signwriters and Decorators Association
of Queensland and representatives of the Operative Painters
Union, it was decided to ask the British Medical Association
to join them in a deputation to the Minister for Health in an
endeavour to clarify the position with regard to the quantity
of lead being used in the manufacture of paint. A reply was
sent stating that we are only too pleased to cooperate, and
Dr. D. Gifford Croll and Dr. L. J. J. Nye will represent the
Branch at the deputation to the Minister.

Acute Anterior Poliomyelitis. At the suggestion of the
Minister for Health, a conference was held on March 9 to
make recommendations for the prevention of the spread of
this disease, at which the Association was represented by
the President, Dr. H. W. Horn. The recommendations were
as follows: That consultants should be made available and
that patients be isolated for fourteen days. If a case occurs
in a school child, all children in the class are to be isolated
at home. Contacts under fourteen years of age are to be
isolated at home for fourteen days. Power to control children
i at theatres, picture shows et cetera to be obtained. The
treatment will depend upon the medical practitioner in
charge of the case, and the wish of the parents.

Peters-Arctic Delicacy Company, Limited, Staff Super
annuation Scheme. A letter was received from the trustees
of the scheme, stating that they are desirous of instituting
a free medical examination for each member of the super-

. annuation scheme, in addition to the welfare benefits already
provided, and requesting advice on the matter. A conference

of representatives of both bodies was held, and subsequently
a medical officer was appointed to whom a fee of one guinea
is to be paid for each individual examination, and the scheme
will also meet the cost of any further examination by a

, specialist where necessary. All members of the scheme are

| invited to submit to free medical overhaul.

Liquor Reform Society. At a conference of organizations
interested in liquor reform which was held in July, a session
was organized by the Council to present the scientific angle
to the public. Dr. L. P. Winterbotham acted as chairman of
the session and the speakers were Professor John Bostock
and Dr. F. W. R. Lukin.

Health Inspectors Association : Annual Conference. The
President, Dr. H. W. Horn, accepted an invitation to attend
the annual conference of the Health Inspectors Association,
and delivered an address at the opening meeting on Tuesday,
August 21. These annual conferences have been in abeyance
for some yearg owing to the war.

Assistants in Doctors Surgeries. The question of salaries
paid to trained nurses in doctors surgeries was raised by
the Australasian Trained Nurses Association at the request
of their members concerned, with a view to having the
amount increased to 5 9s. per week as provided in the award
for registered nui-ses employed in industrial and commercial
establishments.

A reply was sent to the effect that the Council is in
favour of adequate salaries being paid, but it is not in a.
position to bind doctors in their individual contracts with
trained nurses.

An application is to be made to the Industrial Arbitration
Court by the Federated Clerks Union to have receptionists in
doctors surgeries brought under the conditions of the clerks
award. The claim will be opposed by the Association.

JANUARY 26, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

125

Historical Records. With the object of collecting and pre
serving medical records of the early part of this century In
Queensland, a subcommittee has been appointed comprising
Dr. E. S. Meyers, Dr. Harold Love and Professor John
Bostock.

Queensland Surf Life Saving Association. It has come to
the notice of the Council that a member was acting as
honorary medical officer to a surf life saving club, and it
was pointed out to him that the holding of such an appoint
ment was an infringement of By-law 51, namely: "No mem
ber of the Association shall act as Honorary Medical Officer
of any athletic, sporting, racing or similar body." The
member subsequently resigned from the position.

Dr. F. W. R. Lukin holds appointment as honorary medical
officer to the Queensland State Centre of the Surf Life
Saving Association and liaison officer between the Queens
land Branch of the British Medical Association and that
organization, to which position he was nominated by the
Council. This does not involve giving free treatment to
members of the Surf Life Saving Association.

Hospital Matters.

The Hospital Subcommittee did not function this year,
and matters concerning hospitals have been dealt with by
the Organization Subcommittee.

Hospitals Act Amended. The Hospital Act Amendment
Act came into force during the year, and all efforts to have
medical representation on hospital boards have been
unsuccessful. The Part-Time Medical Officers Association
of the Brisbane and South Coast Hospitals Board has also
approached the Minister for Health and Home Affairs
regarding the matter.

The Brisbane and South Coast Hospitals Board, as
reconstituted, consists of eight members appointed by the
Government and one by the seventeen local authorities in
the board s area. The majority of the appointees are govern
ment departmental officers and union officials.

Hospital Policy of the Branch. During the year the
hospital policy of the Branch was revised to meet altered
conditions. The planning of hospitals in the past was largely
influenced by the fact that public hospitals were regarded as
places for treatment of the sick poor, but this function has
almost disappeared in Queensland, and public hospitals are
used to a great extent by the whole community. Only about
20% of hospital patients in Queensland use private hospitals.
It is considered, therefore, that hospitals should be divided
into three classes, (i) community hospitals, (ii) base hos
pitals, (iii) special hospitals, and the first requirement for
an improved hospital system in Queensland is decentraliza
tion. The amended hospital policy of the Branch is based on
these lines, and copies have been sent to interested bodies
and to members who had submitted comments on the draft
policy which was circularized to all members of the Branch.

Lack of Hospital Accommodation. A conference of
interested parties was arranged by the Council of the British
Medical Association to consider what steps could be taken
to improve the position of shortage of hospital accommoda
tion. Further private hospitals have had to close down
owing to lack of nursing and domestic staff. The only
solution appears to be to make more beds available and
provision of adequate staff.

Annual Leave for Hospital Medical Officers. This matter
has been taken up with the Department of Health and Home
Affairs, in view of the fact that some hospital boards include
a clause in their by-laws making it necessary for the medical
officer of the hospital to provide a locum tenens at his own
expense for four weeks annual holiday. It is considered that
the cost of a locum tenens for the period of four weeks
should be borne by the hospital board.

Hospital Benefits Act, 1945. The Federal Council met the
Acting Minister for Health, Senator Keane, and other
departmental officials on October 16 to discuss the Hospitals
Benefits Act, 1945, when the policy of the Federal Council
was placed before them.

The question of the retention of honorary medical service
to public hospitals in the event of the abolition of the means
test is under consideration by the Branches.

Lodges

The Joint Committee of representatives of the Friendly
Societies Medical and Hospital Council and lodge medical
officers met on three occasions. The representatives of the
Branch are: Dr. L. P. Winterbotham, Dr. H. W. Horn, Dr.
T. A. Price, Dr. F. W. R. Lukin.

Capitation Fee: Metropolitan Area. Approval was

i granted by the Prices Commissioner for payment of increased

capitation fees to medical officers in accordance with the

sliding scale laid down in the agreement between the

I Friendly Societies Medical and Hospital Council and the

1 British Medical Association. The capitation fee for the

year commencing July 1, 1945, was computed by the

Government Statistician as 33s. 6d. for adult male members.

Capitation Fee: Country Areas. The Council has expressed

the opinion that the rate for country areas should be a 25%

; increase on the metropolitan rate.

The Bundaberg Local Association suggested that the lodge

| rates should be compulsorily fixed by the Branch Council,

and not left to local associations or lodge medical officers, as

at present provided in the by-laws, which it is considered

i should be amended. This suggestion has been referred to

the local associations for their comment.

Federal Common Form of Agreement. At the last meeting
of the Federal Council it was decided that the time has
arrived for the implementation of the agreement, and a
communication is being forwarded to the Federal Council of
the Friendly Societies Association asking whether the
friendly societies throughout Australia are prepared to
accept the Common Form subject to agreement being reached
in regard to rates which will be on a sliding scale.

Building Subcommittee.

Personnel: Dr. D. Gifford Croll, Dr. M. Graham Sutton,
Dr. S. F. McDonald, and the ex-officio members of the
Council. The activities of the subcommittee have been
resuscitated with the object of considering the question of
j the erection of a new building on the Wickham Terrace
site.

Medical Fees Tribunal.

Personnel: Dr. G. P. Dixon (Chairman), Dr. Alan Lee
(Honorary Secretary), Dr. J. G. Wagner, Dr. D. Gifford Croll,
Dr. H. S. McLelland, Dr. S. F, McDonald.

Four cases were dealt with during the year, in two of
which the verdict given was: "That the fee charged was fair
and just." In the third case, in which a fee of 6 6s. had
been charged, the finding was: "That the fee charged was
higher than was warranted and that the just fee for such
service was 4 4s." In the fourth case a fee of 80 was
charged for an operation, including assistant and anaesthetic
fees and drugs. The finding of the tribunal was: "That the
! fee was considerably higher than was warranted and that a
just fee for such service was 38 17s.

British Medical Association (Queensland Branch)
Memorial Fund.

The indenture has been drawn by our solicitors, and the
I President, Honorary Treasurer and Honorary Secretary, for
i the time being in office, have been appointed trustees.

The purposes of the fund are as follows:

1. To provide prizes commemorating distinguished mem
bers of the Queensland Branch of the British Medical
Association for meritorious students in the University of

i Queensland in the Faculty of Medicine.

2. To provide volumes commemorating distinguished mem-
| bers of the Queensland Branch of the British Medical

Association to the library of the said Branch endorsed with
such commemoration on the fly leaf of such volume signed
by the President for the time being of the Branch.

3. To provide a British Medical Association Memorial Roll
to be kept in conjunction with such Memorial Fund. The
name of a deceased member shall be entered in such
Memorial Roll on the instructions of the Council of the said
Branch, so that such Memorial Roll may be read by the

j President for the time being of such Branch at every annual
meeting of the Branch.

4. To provide for any other kind of memorial to dis
tinguished members of the said Branch that the trustees
may detei-mine at the request of the Council of the said
Branch.

5. The name of a deceased member of the said Branch
shall not be inscribed on the Memorial Roll unless: (a) Not

j less than three friends of the deceased member make
application to the trustees that his name be inscribed. (&)
The Council of the said Branch certify the deceased member
to have been a distinguished and honourable member of the
Queensland Branch of the British Medical Association and of

i the medical profession, (c) The sum of not less than twenty-
five pounds to be paid into the Memorial Fund by the friends

1 of such deceased member at the time of such application.

126

THE MEDICAL JOURNAL OF AUSTRALIA.

JANUAUY 26, 1946.

With the concurrence of its trustees, the Eustace Russell
Memorial Fund has been added to the Memorial Fund of the
Branch.

The following is a list of the foundation members to be
entered on the Memorial Roll: Joseph Bancroft, Kearsey
Cannan, Ernest Sandford Jackson, John Mowbray Thomson,
Charles Ferdinand Marks, William Nathaniel Robertson,
Donald Allan Cameron, Francis Washington Everard Hare,
William Frederick Taylor, Peter Bancroft, Joseph Espie
Dods, James O Neil Mayne, James Barr McLean, Hugh Bell,
Eustace Russell.

The Council has also approved of the following names
being entered on the Memorial Roll: John Lockhart Gibson,
Kenneth Joseph Gilmore Wilson.

, Affiliated Local Associations.

Rockhampton Local Medical Association.

The membership of the Association is as follows: President, !
Dr. F. C. Wooster; Honorary Secretary, Dr. R. Palmerston j
Rundle;; other members are Dr. E. R. Watkins, Dr. Paul E. !
Voss, Dr. D. B. Walker, Dr. C. N. Matheson, Dr. Adah Stuart,
Dr. W. E. Hasker, Dr. Doris Skyring, Dr. Vincent T. J. ;
Lynch, Dr. Bruce Gordon, Dr. N. C. Talbot, Dr. J. C. Ross,
Dr. B. R. V. Forbes.

Two meetings were held during the year. The first, which
was preceded by a dinner and followed by supper, consisted
of medical films and an address by the President of the ,
Queensland Branch, Dr. H. W. Horn. The second meeting
included an address by Dr. A. G. S. Cooper on "Indications
for Radium and X-Ray Therapy".

R. PALMERSTON RUNDLE,

Honorary Secretary-

Bundaberg Local Medical Association.

The membership of the Association is as follows: Dr. E.
Schmidt (President), Dr. I. C. Hains (Honorary Secretary-
Treasurer), Dr. Duncan Fowles, Dr. L. McKeon, Dr. A. W.
Graham.

We have to report for the year just past that the Associa- |
tion of members is developing along the direction of
strengthening the ties between the members. Regular
meetings are held and discussion is free, and careful records :
are kept of all proceedings, and there is general unanimity on
decisions made.

During this term we have had the pleasure of addresses j
by Dr. A. G. S. Cooper, of the Queensland Radium Institute,
Brisbane, who addressed us on radium and radio-
therapeutics. We greatly appreciated the detailed informa
tion given on this important subject, also by Professor J. V.
Duhig, of the Queensland University, who more recently, ;
at short notice, addressed us on various matters of patho
logical and biochemical interest. These lectures we feel are
very important inasmuch as the spoken word is a vast help
in augmenting what is learnt by experience, as also the
written word. We trust, therefore, that in the days to come
we may have more such addresses or lectures, particularly
as air travel is now so convenient and space has been greatly
diminished accordingly.

I. C. HAINS,

Honorary Secretary.

Maryborough Local Medical Association.

Several meetings have been held during the year to discuss I
lodge capitation fees, the annual meeting being held on
October 14, 1945.

Office-bearers elected are: President, Dr. A. J. Kennedy; !
Honorary Secretary, Dr. O. E. Nothling; other members are i
Dr. D. T. Rushton Smith, Dr. K. H. Hooper, Dr. Egmont
Theile, Dr. Alice M. Theile.

It was resolved at the annual meeting to draw up a j
constitution and submit a draft to the members in one |
month s time.

EGMONT THEILE,

For the Honorary Secretary.

Townaville Local Medical Association.

The annual meeting of this Association was held on
August 16, 1945.

Election of officers was as follows: President, Dr.
W. B. Chapman; Honorary Secretary-Treasurer, Dr. L.
Halberstater; the other members are Dr. H. A. Sundstrup, i
Dr. John Breinl, Dr. A. G. Bennett, Dr. V. F. A. O Neill, Dr.

F. R. Tod Stevens, Dr. G. H. Moore, Dr. Beatrice Nelson, Dr.
W. J. Chapman.

It was decided to undertake negotiations with the lodges
for variation of fees. Negotiations are proceeding.

L. HALBERSTATER,

Honorary Secretary.

Other Local Medical Associations.

The Cairns and Kingaroy Local Medical Associations
report that, owing to the war position, they are unable to
hold meetings.

British Medical Agency of Queensland, Proprietary,

Limited. Queensland Medical Finance, Proprietary,

Limited.

After five years service with the Royal Australian Navy,
Mr. S. N. Cobbold resumed the managership of the agency
and the secretaryship of the Queensland Medical Finance,
Proprietary, Limited, in September last. He subsequently
made a tour of south-eastern Queensland with a view to
assisting members released from the armed forces to
reestablish themselves in civilian practice.

Mr. F. K. Davis, who was acting manager and secretary
of the two companies respectively, is remaining on as
assistant to Mr. Cobbold, and will still carry on all services
to members hitherto attended to by him.

Whilst extending a welcome to Mr. Cobbold and wishing
him every success in the future, the Council desires to
place on record its appreciation and thanks to Mr. Davis
for the able manner in which he carried out his duties and
assistance to members during the difficult period of the war
years.

During the year a Ford sedan car has been purchased by
the agency and is available to members on a "Drive Your
self" basis. It is for use at such times as members own
cars are out of commission, and has proved a very useful
service.

Pharmaceutical Benefit s Act, 1944.

The implementation of the Pharmaceutical Benefits Act
by the Commonwealth Government is still a matter for
conjecture, as its validity has been tested in the Victorian
courts by the Attorney-General of that State. The verdict
is awaited with interest.

In October last an unsatisfactory conference took place
between the Federal Council of the British Medical Associa
tion and the Acting Minister for Health. At the conference
the Minister was asked whether the Government was pre
pared to meet the four objections of the Federal Council to
the act. Upon a negative reply being received, the Minister
was informed that the Federal Council s policy of non-
cooperation with the Government would continue.

Members of the Branch will be advised further on the
matter in the event of the implementation of the act being
proclaimed.

In July, Dr. J. G. Hunter, General Secretary of the Federal
Council, visited Queensland with the object of informing
members of the Branch of the latest developments in con
nexion with the Pharmaceutical Benefits Act. He addressed
members at an extraordinary general meeting of the Branch,
and, accompanied by Dr. Alan Lee, he made a tour of south
western Queensland, and contacted practically all the medical
practitioners in the various towns visited, either individually
or at meetings, and placed before them the views of the
Federal Council on the act. In addition, he addressed repre
sentatives of the Trades and Labour Council concerning the
views of the organized profession in relation to the Pharma
ceutical Benefits Act.

Federal Council.

During the year two meetings of the Federal Council were
held in Melbourne, at which the Branch was represented by
Dr. Alan Lee and Dr. Thos. A. Price at the first meeting, and
at the second meeting by Dr. Alan Lee and Dr. D. Gifford
Croll (replacing Dr. Price, who was unable to attend). A
record of the proceedings of the meetings is published in
THE MEDICAL JOURNAL OF AUSTRALIA.

We were pleased to have a visit from the General Secre
tary of the Federal Council, Dr. J. G. Hunter, in July last.

The Pharmaceutical Benefits Act, 1944, is referred to in
another part of this report, and the question of the general
medical services is still in statu quo. Both these subjects
are of major interest to the medical profession at present
and have occupied a great deal of time and thought by the
Federal Council.

JANUARY 26,

THE MEDICAL JOURNAL OF AUSTRALIA.

127

Many other matters of great importance were dealt with
by the Federal Council at its meetings.

A special contribution of 500 was forwarded to the Federal
Council by the Branch for organization expenses. This
amount was taken from the organization fund of the Branch.

Australasian Medical Publishing Company, Limited.

We are pleased to state that the directors of the company
have once again decided to continue the generous rebate to
the Branches of ten shillings for each member who has
totally relinquished civil practice as at December 31, 1945,
for continuous full-time service in His Majesty s Forces.

"The Medical Journal of Australia."

Owing to a printers strike in New South Wales, publica
tion of the journal has been temporarily suspended as from
September 15, and members have been deprived of their
copies for a period of nine weeks. This is the first time
that THE MEDICAL JOURNAL OK AUSTRALIA has ever failed to
put in its weekly appearance.

Lists of members of the Branches of the British Medical
Association in Australia, published by the Australasian
Medical Publishing Company, Limited, are now available at
the Branch office.

University of Queensland.

British Medical Association (Queensland Branch) : Queens
land Medical Students Loan Fund. The personnel of the
committee of administration is as follows: Dr. C. A.
Thelander (chairman), Professor H. J. Wilkinson, Dr. E. S.
Meyers, Dr. Alex Murphy, Dr. Arnold Robertson (a repre
sentative of the University of Queensland Medical Society,
nominated annually by the society) and the ex-officio mem
bers of the Council. The President attended a meeting of
medical students on May 8, when the objects of the loan
fund were put before them. The fund now stands at
346 Os. 4d., and during the year 15 Is. was donated by
medical students and 55 18s. 9d. by members of the Branch.

Faculty of Medicine. At meetings of the faculty of
medicine the Branch is represented by the President, upon
the nomination of the Senate. This provides a valuable
liaison between the Association and the faculty of medicine.
An, important matter under discussion during the year was
the revised medical curriculum, soon to be embarked upon
at this university.

Queensland Post-Graduate Medical Education Committee.
This committee is working in close relationship with the
British Medical Association in regard to the rehabilitation
of medical officers returned from the services, and is taking
an active part in the educational aspect of the matter.

University of Queensland Medical Society. Dr. W. H. Steel
has been appointed to act as liaison officer between the
Branch Council and the society. Assistance was rendered
in obtaining non-medical books for the society s library to
be established for the use of undergraduate members, and
several members of the Branch donated suitable books for
this purpose.

Harold Plant Memorial Prize, 1945. This prize was
awarded to Desmond Neville Bottcher, and was presented
to him by the President of the Branch at the Jackson Lecture
held on September 7.

Eustace Russell Memorial Prize, 1945. The winner of this
prize was Donald Nicholson O Reilly, and was presented by
the President of the Branch at the Jackson Lecture on
September 7.

William Nathaniel Robertson Medal, 1945. Advice was
received from the Registrar of the University of Queensland
that this medal was won by Desmond Neville Bottcher.

Joseph Bancroft Memorial Lecture.

Brigadier N. Hamilton Fairley, O.B.E., M.D., F.R.S.,
delivered the 1945 Joseph Bancroft Memorial Lecture on
Friday, June 1, in the Medical School Hall on the subject
of "Tropical Medical Research in the Australian Army".
There was an attendance of 51 members and visitors. A
vote of thanks to the lecturer was moved by Dr. Ellis
Murphy and seconded by Dr. C. C. Minty. At the conclusion
of the lecture the President presented the Bancroft Memorial
Medal to Brigadier Fairley.

Jackson Lecture.

On Friday, September 7, the Jackson Lecture, which is
given annually in memory of the late Ernest Sandford
Jackson, was delivered by Dr. S. Julius, his subject being
"The History of Medicine in Soviet Russia".

Social.

Council Dinner. Prior to the Bancroft Lecture, the Presi
dent and members of the Council entertained the lecturer,
Brigadier N. Hamilton Fairley, at dinner at the Belle Vue
Hotel on Friday, June 1. Other guests at the dinner were
Surgeon Captain Lambert Rogers, Commander in Chief,
British Pacific Headquarters; Surgeon Captain C. Keating,
Medical Officer in Charge, Royal Naval Hospital, Brisbane;
Surgeon Commander Gavin Cameron, Senior Medical Officer,
Royal Australian Navy, Brisbane; Colonel K. B. Fraser,
D.D.M.S., Headquarters, Queensland L. of C. Area; Wing
Commander Wicks, D.P.M.O., R.A.A.F., Brisbane; Dr. Ellis
Murphy, Chairman, Queensland State Committee, Royal
Australasian College of Physicians; Dr. J. J. Power, Chair
man, Queensland State Committee, Royal Australasian- Col
lege of Surgeons; Dr. S. F. McDonald.

Dinner to Returned Prisoners of War Members.- One of
the most enjoyable functions ever held by the Branch was"
a dinner party at Lennon s Hotel on November 15, to give
members an opportunity of extending a welcome to Major
B. L. W. Clarke, Major Clive Uhr, Captain C. R. Huxtable,
M.C., Captain Clive Boyce and Captain L. P. Sapsford.
Seventy-five members of the Branch were present.

Finance.

It will be noted from the balance sheet that the net surplus
for the year was 225 11s. 8d.

Conclusion.

It must be appreciated that this report to the members
mirrors only in part the enormous volume of business dealt
with by the Council in the year now past.

The document would be incomplete without reference to
the ready spirit of cooperation shown by all, whether at
council meetings, on committees, or in other matters where
personal sacrifice of time and energy has been called upon
in the interests of the public or the profession.

Nor would the efficient working of our organization have
been possible without the diligence and ability of the Secre
tary (Mrs. Spooner) and her staff, in which respect the
Queensland Branch is indeed fortunate.

In the presentation of the report I have no hesitation in
commending the work of your representatives at all times.

(Signed) H. W. HORN,

President.

BALANCE SHEET AND FINANCIAL STATEMENT.

The balance sheet and financial statement for the year
ended November 15, 1945, were taken as read and adopted
on the motion of Dr. J. G. Wagner, seconded by Dr. A. E.
Lee. The statements are published herewith.

ELECTION OF OFFICE-BEARERS.

The President announced the results of the election of
office-bearers and members of the Council.
President : Dr. J. G. Wagner.
President - Elect : Dr. Horace Johnson.
Past President: Dr. H. W. Horn.
Honorary Secretary: Dr. Norman Sherwood.
Councillors: Dr. H. W. Anderson, Dr. Felix Arden, Dr.

R. V. Adamson, Dr. T. V. Stubbs Brown, Dr. E. W.

Casey, Dr. D. Gifford Croll, Dr. Milton Geaney, Dr.

Alan E. Lee, Dr. F. W. R. Lukin, Dr. C. C. Minty, Dr.

J. G. Morris, Dr. T. A. Price, Dr. W. H. Steel, Dr. L. P.

Winterbotham.

ETHICS COMMITTEE.

Dr. M. Graham Button, Dr. L. J. J. Nye, Dr. S. F.
McDonald, Dr. J. J. Power, Dr. R. G. Quinn, Dr. J. G. Avery
and Dr. G. P. Dixon were elected members of the Ethics
Committee.

ELECTION OF AUDITORS.

Messrs. R. G. Groom and Company were reelected auditors
on the motion of Dr. J. G. Wagner, seconded by Dr. Robin
Charlton.

MEMORIAL ROLL.

The President read the Memorial Roll of the Branch and
gave a list of the foundation members as follows: Joseph
Bancroft, Kearsey Cannan, Ernest Sandford Jackson, John
Mowbray Thomson, Charles Ferdinand Marks, William
Nathaniel Robertson, Donald Allan Cameron, William
Frederick Taylor, Peter Bancroft. Joseph Espie Dods, James

ll S

THE MEDICAL JOURNAL OF AUSTRALIA.

JAM-AKY 20, 1946.

QUEENSLAND BRANCH OF THE BRITISH MEDICAL ASSOCIATION (INCORPORATED).
Balance Sheet as at November 15, 1945.

LIABILITIES.
s. d. s. d.
Fixed Liabilities
Loan from Queensland Medical Land
Investment Company, Limited . . 4,650
Current Liabilities-
Subscriptions for Remittance to :
British Medical Association,
London 28 16 ~&gt;
Australasian Medical Publishing
Company, Limited, Sydney . . 27

KC 1 C C

ASSETS.

Fixed Assets, at cost, less deprecia
tion
Land and Buildings B.M.A. House
Library

2,428
150

84
4

d. s.

o gg7 \i

Typewriters, Bookcases, Balopticon
and Furniture
Bancroft Medals and Collar

Queensland Medical Land Invest-

2,975

j 909 n

Association Funds
Accumulation Account .
Sinking Fund
Reserve for Dinners,
ments, etc.

. . . 5,116 14 5
388 5, :;
Entertain-
28 8

Shares of 1 each paid to 10s.
each at cost

British Medical Agency of Queens
land Proprietary, Limited 257
Shares of 1 each, fully paid-

257

- 5,533 7 8

Australian Consolidated Inscribed
Stock
31%, maturing 1959
3J%, maturing 1960

Australasian Medical Publishing
Company, Limited
5% Debentures at cost

Current Assets
English, Scottish and Australian
Bank, Limited Credit Balance,
Current Account
Sundry Debtors

1,500
300

1 800

1,478
608
6
4

2
8
3

Electric Light Deposit
Cash in Hand

Sinking Fund Investments
Australian Consolidated Inscribed
Stock
280: 33%, maturing 1951, at cost
90: 31%, maturing 1960 ..
Commonwealth Savings Bank, Bris
bane Credit Balance

O ||QC 7

278
90

388 5

10,239 4 1

10,239 4

We have compared the above Balance Sheet with the Books, Accounts and Vouchers of the Queensland Branch of the
British Medical Association (Incorporated), and have obtained all the information and explanations we have required. The
Register of Members and other records which the Company is required to keep by the Companies Acts of 1941-1942, or by
its Articles, have, in our opinion, been properly kept.

In our opinion, the Balance Sheet is properly drawn up to exhibit a true and correct view of the state of the Association s
affairs as at 15th November, 1945, according to the best of our information and the explanations given us. and as shown l&gt;v
the books of the Association.

R. G. GROOM & COMPANY.

Chartered Accountants (Aust. ),

Auditors.
Brisbane, 18th November, 1945.

(Sgd.) J. a. WAGNER, .

Honorary Treasurer.

QUEENSLAND BRANCH OF THE BRITISH MEDICAL ASSOCIATION (INCORPORATED).
Revenue Account for Twelve Months ended November 15, 1945.

EXPENDITURE.

REVENUE.

d. s. d.

s. d. s. d.

November 15, 1945.

Branch Expenses
Library Expenditure

947
60

By Branch and Organization Fund
Subscriptions

2,176 3

Depreciation of Office Equipment . .

,, Interest

1017 11

Federal Council

scribed Stock

.") S 1 2

Contribution to Expenses
Special Contribution to Council

464

Australasian Medical Publishing
Company, Limited, Debentures

2 15

Expenses

500

1 2

^&gt;

60 16

Q i; A i - (

Q. 1 f ~\* t -f- -n v,l

5 Cv

Expenses, B.M.A. House

, &gt; -t 11 O

,. oct ie or iNuintion I ampniets . .

t&gt; D

Rates, Land Tax, Insurance,

Repairs and Sundries

156

;;

Cleaning

Depreciation, Building

283

Less Rents Received

249

J 9 g I

Net Surplus for Year

Transferred to Accumulation

Account

225 11 8

2,242 2 10

2.242 2 10

JANUARY 20, 19&lt;&gt;.

THE MEDICAL JOURNAL OF AUSTRALIA.

129

QUEENSLAND BRANCH OF THE BRITISH MEDICAL ASSOCIATION (INCORPORATED).

GENERAL FUND.
Statement of Receipts and Payments for Twelve Months ended November 15, 1945.

RECEIPTS.

November 16, 1944.

To Funds at November lt&gt;, 1944
English, Scottish and Australian
Bank, Limited Current Ac
count

Cash in Hand

1,161
1

November 15, 1945
To Subscriptions

For Remittance to British Medi
cal Association, London . . 828 17 ;!
For Remittance to THE MEDICAL

JOURNAL OF AUSTRALIA, Sydney "95 12
Queensland Branch Subscriptions 1,091 it
Organization Fund. Queensland

Branch 1,084 11 :!

s. d.

4 8
14 11
1,162

General
Rent :

British Medical Agency of
Queensland Proprietary,

Limited, Part Payment Ar
rears . . . . 250

Basement, Garage

and Room . . 28

A.T.N.A 800

Medical Defence

Society . . . . 500

Sale of Nutrition Pamphlets . .

Interest on Commonwealth In
scribed Stock . . . . ....

Australasian Medical Publishing
Company, Limited Interest on
Debentures

291

2 15

s. d.

:&gt;,,600 9

5,120 11 8

PAYMENTS.

November 15, 1945.

By Amounts remitted on account of

Subscriptions Collected to
British Medical Association,

London

Australasian Medical Publishing
Company, Limited. Sydney . .

., Federal Council

Contribution to Expenses
Special Contribution to Council
Expenses

,, Branch Expenses

Salaries, Audit and Honoraria . .
Postages and Duty Stamps
Printing and Stationery
Bank Charges, Meeting Expenses

and Sundries

Telephone Rental and Calls

Travelling Expenses

Electric Light

,. B.M.A. House Expenses

Rates to December 31, 1945
Cleaners Wages, Insurance, Re
pairs and Maintenance
State Land Tax

s. d.

128 16 8

94 9 10
10 18 I)

Library Expenditure

Funds at November 15, 1945

English, Scottish and Australian

Bank, Limited, Brisbane . . 1,478 3 11

Cash in Hand 439

s. d.

831

599

464

500

706

100

1,430

234
60

17 7

1,482 7 8

5,120 11 8

O Neil Mayne, John Barr McLean, Hugh Bell, Eustace
Russell, Thomas Lane Bancroft.

The President announced that the following names had
been added to the roll during the year: Kenneth Joseph
Gilmore Wilson, John Lockhart Gibson.

INDUCTION OF PRESIDENT.

Dr. H. W. Horn then inducted Dr. J. G. Wagner to the
chair.

PRESIDENT S ADDRESS.
Dr. J. G. Wagner read his address (see page 97).

TIIK PROFESSION AND THE PUBLIC.

The following motion was carried at the instance of the
President :

That this annual meeting of the Queensland
Branch of the British Medical Association places on
record its sincere appreciation of the coopei ation
given to members of the profession by the civilian
public during the war years. Without that coopera
tion medical practice would have been chaotic.
It was decided that a copy of the resolution should be
sent to the Press.

VOTES OF THANKS.

Votes of thanks were passed to the retiring members of
Council, the Honorary Secretary and the office staff for
their work during the year.

C0eDical Societies.

MELBOURNE 1VEDIATRIC SOCIETY.

A MEETING of the Melbourne Pzediatric Society was held
on August 8, 1945, at the Children s Hospital, Carlton, DR.
H. DOUGLAS STEPHENS, the Acting President, in the chair.

Transposition of Viscera.

DR. ALAN MCCUTCHEON showed a male patient, aged five
years and eleven months. The child had first attended the

| out-patient department in July, 1943, with a distended
i abdomen and complaining of coldness and blueness of the
extremities. Consanguinity of his parents was established.
He next attended the hospital on April 14, 1945, when he was
noted to be mentally retarded, and a few rhonchi were
audible in the right lung. The heart appeared to be on
the right side and the liver on the left side. He had attended
at intervals with frequent colds, anorexia and nocturnal
enuresis. Dr. McCutcheon showed X-ray films taken at
these visits. A barium meal examination was carried out
on June 1, 1945; this revealed dexiocardia, congestion of the
base of the left lung and transposition of the gastro
intestinal tract. A cholecystogram was taken on July 11,
1945. The gall-bladder, which lay on the left side, was seen
to be of normal size and position. It filled with the dye,
concentrated it well and contracted after a fatty meal. In
none of the films were there any shadows of gall-stones,
and there was no evidence of abnormality of the gall-bladder.
Dr. McCutcheon said that he was hoping to have a broncho-
gram taken later, to determine whether transposition of the
lungs as well as of the other viscera was present. Dr.
McCutcheon wondered w r hether the consanguinity of the
parents might have been a factor in the anomaly in this
instance. He had observed, when dealing with such children
in institutions, that they were frequently retarded physically
or mentally or in both ways.

DR. ROBERT SOUTHBY said that Dr. McCutcheon had covered
the ground so fully that there remained little to add. In a
plain X-ray film, confusion between dexiocardia and trans
position of the viscera might arise, or even between these
conditions and a displaced heart. The electrocardiogram
w r as looked upon as revealing the most pathognomonic sign.
This showed inversion of all the deflections in Lead I. Dr.
Southby said that the patient should wear a disk disclosing
his anomaly in case an abdominal operation was contem
plated in later years. Dr. Southby asked whether Dr.
McCutcheon had observed dexiocardia or transposition of
the viscera in offspring of consanguineous parents.

Dr. McCutcheon, in reply, said that he had not previously
observed this anomaly in children of consanguineous
parents. He intended to study the electrocardiogram and
the bronchogram.

Imperforate Anus.

DR. J. G. WHITAKER showed a male child, aged four months,
who had an imperforate anus. The confinement had been

130

THE MEDICAL JOURNAL OF AUSTRALIA.

JANUARY 26, 1946.

normal, and after two days it was noted that the baby was
having no bowel actions and that the abdomen was becoming
increasingly distended. Rectal examination revealed an anal
canal only one inch in length, with what felt like a solid
block of tissue above. A sigmoid colostomy had been estab
lished, and when the baby recovered from this operation,
X-ray investigation of the defect with barium filling from
the colostomy revealed a probable atresia of the rectum
about one to one and a half inches in length. After some
difficulty in the feeding of the baby had been overcome, the
child was transferred to the Children s Hospital at the age
of eight weeks. Examination on his admission to the hos
pital revealed an infected colostomy wound with a pin-point
stoma in the left iliac fossa, and the anal canal was patent
for a distance of one to one and a half inches. The rest of
the examination revealed no abnormality, except that the
baby showed general signs of malnutrition. Soon after
wards, the colostomy opening was dilated with Spencer Wells
forceps and bowel irrigations were begun; also daily dilata
tion of the opening with Hegar s dilators was instituted. A
few days later the child was examined bimanually under
general anaesthesia by Dr. Whitaker. A finger in the anal
canal was separated from the finger above in the descending
loop of the colostomy by a deficiency in the lumen of the
rectum, the precise thickness of which was difficult to
estimate, but was adjudged to be about one inch in length.
The future treatment of the baby appeared to be one of
three possibilities: (a) the establishment of a permanent
palliative colostomy, probably in the transverse colon, owing
to inadequacy of left iliac colostomy; (b) laparotomy and
inspection of the bowel from above, to see whether any
reconstitution would be possible; (c) the insertion of a pair
of forceps up through the resisting tissue in the roof of the
anal canal, in the hope that this would recanalize the
deficiency. Dr. Whitaker said that the above-mentioned
propositions had been explained to the parents of the baby
and the risks made clear, and advice to allow laparotomy and
attempted reconstitution of the bowel if possible had been
given. Permission was obtained, and at laparotomy the
following features were noted and the lumen of the gut was
reconstituted. The distal loop of the sigmoid colon was
found to be hypertrophied and dilated to almost adult size,
and passed downwards to end suddenly where the rectum
became extraperitoneal. At this stage a pair of Spencer
Wells forceps was introduced per rectum and pushed
upwards, and guided by the operator s hand from above,
was pushed through the obstructing tissue till it was
palpated within the lumen of the lower sigmoid colon above.
The sigmoid colon was opened, and a length of rubber tubing
was grasped in the forceps, pulled through the opening and
made to issue through the anus. This end of the tube was
sutured to the skin around the anus. The opening in the
sigmoid colon was closed and oversewn, a drain tube was
placed in the pelvis and the abdominal wound was closed.
The child had made satisfactory progress after operation.
Liquid faeces were passed through the rectal tube on the
first day, while the iliac colostomy functioned normally and
continued to do so for three days, when the tube slipped
from the rectum as the restraining sutures sloughed from
the perineal skin. It was found that the tube could be
replaced easily, and so it was removed completely, and daily
dilatation of the reconstituted gut was commenced. From
that time the child had passed semi-solid, normal-sized
stools per rectum, and dilators up to Hegar s Number 13
could be passed with ease. The colostomy had not yet
closed. The abdominal wound was almost healed. The child
was apparently healthy and making progress. Dr. Whitaker
said that only time would determine the ultimate outlook.

DR. JOHN BEGG sought information on the treatment of
patients with imperforate anus. He had been injudicious
enough to operate on such a patient. The child was left
with a perineal anus, but no hope of a satisfactory sphincter
mechanism. The alternative of a permanent colostomy
offered little solace, though perhaps it was preferable to a
perineal anus. Dr. Begg wondered whether such patients
should be treated surgically or allowed to die.

DR. H. C. COLVILLE quoted a recent unusual experience of
his own. He said that five years earlier he had examined
a baby two hours after birth; the baby had an imperforate
anus, as well as a rudimentary tail. Dr. Colville observed
that there was a pronounced bulge in the perineum when
the baby cried. He punctured the bulging area, and was
rewarded by a free flow of cerebro-spinal fluid. He hastily
closed this opening and explored the perineum, until he
found the rectum and brought it down and sutured it to the
region of the anus. At the time of the meeting the child
was five years old, and presented the problem raised by
Dr. Begg. It could be said that this child was certainly not

the "write off" that Dr. Begg had visualized; he was a fine,
sturdy little boy, and needed dilatation only at intervals.
By careful training, in which the child was encouraged
to empty his bowels at a definite time each day, much had
been accomplished. During the remainder of the day there
was a slight fa?cal stain only. Some degree of sphincteric
control did develop, though anatomically no sphincter
existed. Dr. Colville said that he was wondering whether
greater sphincteric control developed in later life, and
whether anyone had attempted to construct a sphincter
from the adjacent muscles, such as the glutei.

DR. ROBERT SOUTHBY said that he was interested in a boy
who had had a colostomy established when he was a few
hours old. The boy went through school and later joined
his father in business. He died at the age of twenty years
from streptococcal septicaemia, after a full life of com
parative comfort.

DR. PETER BLAUBAUM asked whether the Injection of dye
to determine the size of the block of tissue constituting the
atresia was a safe procedure.

DR. H. DOUGLAS STEPHENS said that he was not nearly so
pessimistic as Dr. Begg about imperforate anus; the out
look was hopeful if a bulge could be visualized in the
perineum when the baby strained. It was Dr. Stephens s
belief that the operative treatment outlined by Ladd and
Gross was best. He had removed the coccyx and made an
artificial anus posterior to the usual site, but had not found
it satisfactory. In some cases it was better to establish a
colostomy and drainage. The ultimate result in these cases
was interesting. Dr. Stephens said that a few weeks earlier
a strong man had walked into his office and told him that
he (Dr. Stephens) had operated on him at the Children s
Hospital twenty years earlier for imperforate anus. Two
years later Dr. Stephens had again operated on him for an
inguinal hernia. Later he had found out that he had
congenital heart disease. The man was a butcher, and his
bowels were open every day. Dr. Stephens said that he
asked to see the patient s perineum, and succeeded in passing
a Number 22 Hegar s dilator without much difficulty.

(To be continued.)

CI)c

3u0ttaiasian College
of Burgeons*

A POST-GRADUATE COURSE IN SURGERY.

THE Royal Australasian College of Surgeons will conduct
| in Melbourne a post-graduate course. It will begin on
March 4 and conclude on May 31, 1946. The course is
I suitable for all graduates who wish to undertake post-
i graduate study in surgery, and is not designed solely for
j those desiring to present themselves for senior surgical
j qualifications.

Lectures will be delivered at Prince Henry s Hospital from
I 2 to 3.30 o clock p.m. on Mondays, Wednesdays and Fridays.
Lecture demonstrations will be held on Tuesdays and
Thursdays from 2 to 4 o clock p.m. From March 5 to April 2
inclusive the demonstrations will take place at the Alfred
Hospital; from April 4 to April 23 the venue will be Saint
Vincent s Hospital; on April 25 the Children s Hospital; from
April 3 to May 23 the Royal Melbourne Hospital.

Lectures and lecture demonstrations will be arranged in
the surgical specialities. These will be announced in detail
following the receipt of entries which close on January 31.
1946.

Twenty-four lectures and lecture demonstrations in
pathology will also be arranged.

MEETINGS OF THE COURTS OF EXAMINERS.

THE next meeting of the Courts of Examiners of the Royal
Australasian College of Surgeons for the Primary Examina
tion for Fellowship of the College will be held in Melbourne.
Australia, and in Dunedin, New Zealand, probably early in
June, 1946.

The next meeting of the Court of Examiners for the Final
Examination for Fellowship of the College will be held at the
College in Melbourne in the first week in June, 1946.

Candidates who desire to present themselves at either of
these meetings should apply to the Censor-in-Chief for

JANUARY -G, 194(5.

THE MEDICAL JOURNAL OF AUSTRALIA.

131

permission to do so on or before April 1, 1946. The
appropriate forms are available from the Secretary of the
Royal Australasian College of Surgeons, Spring Street,
Melbourne, C.I.

Hopal College of &gt;b$tetrician$ anD

EXAMINATION FOR MEMBERSHIP.

CANDIDATES who have not indicated their intention to sit
for the examination for membership of the Royal College of
Obstetricians and Gynaecologists are asked to do so as soon
as possible. All inquiries should be addressed to Professor
R. Marshall Allan at the University of Melbourne.

COURSES IN QUEENSLAND IN 194&lt;&gt;.

THE University of Queensland Post-Graduate Medical
Education Committee announces that the following courses
will be held in 1946.

General Revision Course.

The general revision course is of thirteen weeks duration
and will be repeated twice during the year, so that there
will be continuous clinical lecture demonstrations throughout
1946. In this way, any service medical officer granted three
months pre-discharge training, any ex-service medical officer
granted three months post-discharge rehabilitation training
or any post-graduate training to attend a general refresher
course, by joining the class at any time during the year and
attending the sessions set out in the time-table to be
circulated, will cover the five parts of the course.

Part I: Paediatrics, of three weeks duration, commencing
on Monday, February 4, 1946.

Part II: Medicine, of three weeks duration, commencing
on Monday, February 25, 1946.

Part III: Obstetrics and gynaecology, of two weeks dura
tion, commencing on Monday, March 18, 1946.

Part IV: Surgery, of three weeks duration, commencing
on Monday, April 1, 1946.

Part V: The specialities, of two weeks duration, com
mencing on Monday, April 22, 1946.

Three or four lecture demonstrations will be held each
week, in the afternoon or evening, during each part of the
course. The time and place of each lecture will be indicated
on a detailed programme shortly to be circulated.

Course II, a repetition of Course I, will commence on
Monday, May 6, 1946.

Senior Course in Medicine.

The senior course in medicine is suitable for candidates
preparing themselves for the M.R.A.C.P. and M.D. examina
tions. This will be run concurrently with Part II (medicine)
of the general revision course, which will be supplemented
by lecture demonstrations in pathology, clinical rounds in the
medical wards et cetera.

Anatomy and Principles of Pathology.

This course is suitable for candidates preparing themselves
for the M.S. (Part I). This is term III of the course, parts
I and II of which were held in 1945. Term III will com
mence sometime in March, on a date to be announced later.
Term III (anatomy) will cover the anatomy of the
extremities, in ten evening courses, each of which is of two
hours duration. The "Principles of Pathology" will also be
covered in ten lectures. The fees for this course will be
7 7s. per subject per term, providing nine members take
the full course.

Bancroft Oration and Post-Graduate Week.

The Bancroft Oration will bt&gt; delivered on June 7, 1946,
and will be followed by post-graduate week, June 7 to 14,

Week-End Courses in Country Centres.

Week-end courses to be held in country centres will be
announced later.

Post-graduate students are welcome at the medical school
library for study purposes. Books and journals may not be
removed from the library.

Service medical officers and ex-service medical officers
desiring further information on post-graduate study should
communicate with Dr. P. H. Macindoe, Medical School,
Herston Road, Brisbane (telephone: BO 534).

Correspondence.

THE USE AND MISUSE OF TETANUS ANTITOXIN.

SIR: A pamphlet, wrapped round each container of anti
toxin, is issued by the Commonwealth Serum Laboratories,
in which it is set out, under the heading, Directions for Use:
If the subcutaneous route is chosen the most favourable
position for injection is under the loose skin of the lower
abdomen." In Sydney and suburbs this direction seems to
me to be almost universally ignored. The upper arm is the
site selected, with the almost inevitable result that the
unfortunate patient experiences a more or less severe
reaction; the reaction frequently is so severe that he is
disabled and suffers much more from the treatment than
from the original injury. My experience is that such
reaction and incapacity do not eventuate if the proper
site is chosen for the injection.

While no one questions the expediency of administering
tetanus antitoxin in cases of penetrating wounds, such as
puncture by nails in the feet or puncture by cargo hooks
and in lacerated, contused or dirty wounds, it does, however,
seem to me unnecessary and overdoing it to follow the same
procedure in ordinary clean-cut quite superficial wounds.
Having in mind that the tetanus bacillus is anaerobic, it
would be more appropriate to administer antitetanic serum
to everybody who runs a rose thorn into their finger or
pricks it with a needle or pin. Like so many other useful
remedies, it is overdone.

Some years ago I had occasion to investigate the morbidity
and fatal cases from tetanus in New South Wales; the
statistics showed that the principal incidence was in children
under ten years of age who contracted it from penetrating
wounds in bare feet. In adults frequently the origin and
mode of infection were not discovered. It was also found
that it was as common in clerks as in fellmongers and there
were several cases after septic abortion. I have known more
than twenty sheep die from it after shearing in one shed,
and the infection was traced to a particular tar pot that was
used for dressing the wounds caused at shearing.

I have been prompted to write this note in the hope that
a little more discretion and horse-sense may be exercised
in administering the antitoxin, because I have seen such a
number of cases of suffering and disability from its misuse.

Yours, etc.,

STRATFORD SHELDON, M.B., Ch.M., B.Sc.
28, O Connell Street,
Sydney,

December 12, 1946.

FUNCTIONAL DISORDERS.

SIR: Half the patients seen in general practice have

nothing organically wrong with them. This opinion has

been frequently expressed and statistically confirmed by

I J. B. Barton. These patients are suffering from functional

! disorders of various kinds, including neurasthenia, anxiety

I states, functional dyspepsia, cardiac, gastric, ocular, bladder,

! genital and other neuroses, stammering, writer s cramp,

: behaviour disorders, globus, hysterical aphonia, conversion

I hysteria with backache or pains in the limbs, coccydynia,

I frigidity, epileptiform attacks and many other conditions.

| We have been accumstomed to prescribing "nerve tonics",

alkaline powders, bromide or phenobarbital, changing their

glasses, or ordering a holiday, with indifferent results.

Recently Evan Jones, of Sydney, Bostock, of Brisbane,
T. A. Ross in England, Kraines in America and others have
indicated that most of these illnesses respond dramatically

THE MEDICAL JOURNAL OF AUSTRALIA.

.JANUARY 1&gt;6, 1946.

to psychotherapy, and experience has shown that some can
be cured in an hour.

Although these cases comprise half the work of the
general practitioner, our medical periodicals are almost silent
on the subject, and this letter is an appeal for more articles
on the functional disorders in this journal.

142, Concord Road,
Concord,

New South Wales.
January 19, 1946.

Yours, etc.,

A. A. 1 AIN.

, S^ilitarp anD air jforce.

APPOINTMENTS.

THE undermentioned appointments, changes et cetera have
been promulgated in the Commonwealth of Australia Gazette,
Number 9, of January 17, 1946.

PERMANENT NAVAL FORCES OF THE COMMONWEALTH

( SEA-GOING FORCES).

To be Surgeon Captain. Surgeon Commander Denis
Adrian Pritchard.

AUSTRALIAN ARMY MEDICAL CORPS.

NX34968 Lieutenant-Colonel R. F. K. West relinquishes
command of 3rd/14th Australian Field Ambulance, 7th
November, 1945.

The following officers are placed upon the Regimental
Supernumerary List: SX1464 Lieutenant-Colonel R. G.
Champion de Crespigny, 7th November, 1945, and WX3416
Major (Temporary Lieutenant-Colonel) G. C. Moss, 8th
November, 1945.

WX3330 Colonel (Temporary Brigadier) A. L. Dawkins,
O.B.E., E.D., relinquishes the rank of Temporary Brigadier
and is transferred to the Reserve of Officers (Australian
Army Medical Corps) with the rank of Colonel and is
granted the rank of Honorary Brigadier, 14th November,
1945.

VB116930 Local Lieutenant-Colonel F. S. Gorrill ceases to
be seconded and relinquishes the rank of Local Lieutenant-
Colonel and ceases to be attached to the Australian Military
Forces, 24th October, 1945.

2nd/6th Australian General Hospital. VX65536 Captain
J. M. McCracken is placed upon the Regimental Super
numerary List, 27th August, 1945.

102nd Australian Casualty Clearing Station (Australian
Imperial Force). NX107907 Major R. C. Scobie is placed
upon the Regimental Supernumerary List, 16th November,
1945.

Q273987 Honorary Captain L. I. Burt is appointed from the
Reserve of Officers (Australian Army Medical Corps) and to
be Captain, 22nd October, 1945.

New South Wales Lines of Communication Area: To be
Honorary Captain, 16th November, 1945. James Lincoln
Kelly.

ROYAL AUSTRALIAN AIR FORCE.
Citizen Air Force: Medical Branch.

The probationary appointments of the following Flight
Lieutenants are confirmed with effect from the dates
indicated: C. F. Bellemore (267567), 13th March, 1944,
D. A. S. Morgan (287465), 19th September, 1945. (Ex. Min.
No. 5 Approved llth January, 1946.)

Ofcituarp,

JAMES WHITSON KEMP BRUCE.

WE regret to announce the death of Dr. James Whitson
Kemp Bruce, which occurred on January 22, 1946, at North
Sydney, New South Wales.

Diarp for tije

JAN. 31
FEB. 1
FEB. 5

FEB. 6

FEB. 7

FEB. 8

FEB. 12

FEB. 19

FEB. 21
FEB. 21
FEB. 22
FEB. 26
FEB. 27
FEB. 28
MARCH
MARCH
MARCH

.South Auptrnlian Branch, B.M.A. : Scientific Meeting.

Queensland Branch, B.M.A. : Branch Meeting.

New South Wales Branch, B.M.A. : Organization and

Science Committee.

Victorian Branch, B.M.A. : Branch Meeting.
Western Australian Branch, B.M.A. : Council Meeting.
South Australian Branch, B.M.A. : Council Meeting.
. Queensland Branch, B.M.A. : Council Meeting.
Tasmanian Branch, B.M.A. : Ordinary Meeting.
New South Wales Branch, B.M.A. : Executive and

Finance Committee.
. New South Wales Branch, B.M.A. : Medical Politics

Committee.

South Australian Branch, B.M.A. : Council Meeting.
Victorian Branch, B.M.A. : Executive Meeting.
-Queensland Branch, B.M.A. : Council Meeting.
New South Wales Branch, B.M.A. : Ethics Committee.
Victorian Branch, B.M.A. : Council Meeting.
South Australian Branch, B.M.A. : Scientific Meeting.
1. Queensland Branch, B.M.A. : Branch Meeting.
2. Tasmanian Branch, B.M.A. : Annual Meeting.
5. New South Wales Branch, B.M.A. : Organization

and Science Committee.

Qietiical appointments: important Notice*

MEDICAL PRACTITIONERS are requested not to apply for any
appointment mentioned below without having first communicated
with the Honorary Secretary of the Branch concerned, or with
the Medical Secretary of the British Medical Association,
Tavistock Square, London, W.C.I.

New South Wales Branch (Honorary Secretary, 135, Macquarie
Street, Sydney): Australian Natives Association; Ashlield
and District United Friendly Societies Dispensary ; Balmain
United Friendly Societies Dispensary ; Leichhardt and
Petersham United Friendly Societies Dispensary; Man
chester Unity Medical and Dispensing Institute, Oxford
Street, Sydney ; North Sydney Friendly Societies Dis
pensary Limited ; People s Prudential Assurance Company
Limited ; Phoenix Mutual Provident Society.

Victorian Branch (Honorary Secretary, Medical Society Hall,
East Melbourne): Associated Medical Services Limited;
all Institutes or Medical Dispensaries ; Australian Prudential
Association, Proprietary, Limited ; Federated Mutual
Medical Benefit Society ; Mutual National Provident Club ;
National Provident Association ; Hospital or other appoint
ments outside Victoria.

Queensland Branch (Honorary Secretary, B.M.A. House, 225,
Wickham Terrace, Brisbane, B.I 7) : Brisbane Associated
Friendly Societies Medical Institute ; Bundaberg Medical
Institute. Members accepting LODGE appointments and
those desiring to accept appointments to any COUNTRY
HOSPITAL or position outside Australia are advised, in
their own interests, to submit a copy of their Agreement
to the Counsil before signing.

South Australian Branch (Honorary Secretary, 178, North
Terrace, Adelaide) : All Lodge appointments in South
Australia ; all Contract Practice appointments in South
Australia.

Western Australian Branch (Honorary Secretary, 205, Saint
George s Terrace, Perth): Wiluna Hospital; all Contract
Practice appointments in Western Australia. All Public
Health Department appointments.

OBDitorial

MANUSCRIPTS forwarded to the office of this journal cannot
under any circumstances be returned. Original articles for
warded for publication are understood to be offered to THE
MEDICAL JOURNAL OF AUSTRALIA alone, unless the contrary be
stated.

All communications should be addressed to the Editor, THE
MEDICAL JOURNAL OF AUSTRALIA, The Printing House, Seamer
Street, Glebe, New South Wales. (Telephones: MW 2651-2).

Members and subscribers are requested to notify the Manager,
THE MEDICAL JOURNAL OF" AUSTRALIA, Seamer Street, Glebe,
New South Wales, without delay, of any irregularity in the
delivery of this journal. The management cannot accept any
responsibility or recognize any claim arising out of non-receipt
of journals unless such a notification is received within one
month.

SUBSCRIPTION RATES Medical students and others not
receiving THE MEDICAL JOURNAL OK AUSTRALIA in virtue of
membership of the Branches of the British Medical Association
in the Commonwealth can become subscribers to the journal by
applying to the Manager or through the usual agents and book
sellers. Subscriptions can commence at the beginning of any
quarter and are renewable on December 31. The rates are 2
for Australia and 2 5s. abroad per annum payable in advance.

JANUARY 26, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER.

Medical Practices, etc.

Medical.

1. Unopposed country practice,
excellent climate, south N.S.W.
Average cash take 1,200. Good
public hospital. Premium 1,000.

2. Unopposed subsidized practice,
northern N.S.W. Cash take 1,100.

Residence to rent. Price 600.

Wanted.

Ophthalmic assistantship wanted by
doctor keen to specialize.

All Enquiries Confidential.
GOYDER, SON & CO.,

Medical Agents,

Cutht-art House, lie Czistlereagh
Street, Sydney. BW 7149.

After Hours: JA 72OJJ.

The name of Goyder has been

associated with Medical Agency

since 1902.

Australian Physiotherapy
Association

(Australasian Massage

Association)
NEW SOUTH WALES

Massage, Remedial Exercises and

Medical Electricity.
Occupational Therapy.

Members are fully trained in
these subjects and work only under
the direction of a registered medical
practitioner.

Further information obtainable
from the General Secretary.

MISS E. P. EVANS,

Manchester Unity Building, 185

Elizabeth Street, Sydney.

(MA 2031.)

A PPLICATIONS are invited for
** the position of Medical Prac
titioner for Kimba District in South
Australia. Practice covers a radius
of approximately 35 miles.
Guarantee by District Council of
1,000 p.a. Well-equipped govern
ment subsidized hospital at Kimba.
Further particulars may be
obtained from the Secretary, Kimba
Hospital, Kimba, S.A.

RENWICK HOSPITAL, FOR
INFANTS, SUMMER HILL.

; Applications, on prescribed form.

j are invited for the position of
Resident Medical Officer. Salary at
the rate of 4 p.w. Vacancy March.
Particulars, Medical Superinten
dent. W. B. ROOD. Secretary,
Benevolent Society of N.S.W.,
General Offices, Thomas Street,
Sydney.

YTf ANTED TO PURCHASE,
&gt;T General Practice in or near
Sydney. Cash available. Particu
lars to Dr. A. B.C., this Office.

SPEECH THERAPY.

Remedial Treatment for
Reading, Writing, Speech

and Voice Disorders.

MISS WRAY, A.S.S.T., London.

Speech Therapist to R.A.H.C.,

Sydney.

1 Marqaarir Street, Sydney.
Phone &gt; B 4460.

Service for Doctors

Watson House, BJigh Street,

Sydney.
Telephone: BW4433.

No. 590. Radiological practice in
base hospital town. Goodwill and
X-ray plant for sale. Professional
rooms and private residence to
rent. Scope increase takings.
No. 591. Assistant required, view
partnership, large Sydney outer
suburban practice. Opportunity
young married ex-service surgeon,
Prot.

No. 586. Unopposed north-western
district, N.S.W., country practice,
taking 2,000. Excellent hospital.
Substantial appointments. Brick
house to rent. Goodwill for sale.
Pre-war takings over 3,000.
No. 574. N.S.W. country practice,
opposed, taking over 2,000.
Appointments worth 350. Mids.
70. Large district intermediate
hospital. Goodwill for sale.

Modern house to rent. Oppor
tunity young married ex-service
practitioner.

No. 5(J7. Base hospital town,
E.N.T. Practice taking 2,750 p.a.
Goodwill and modern residence for
sale.

Locum tenens available for short
term, suburban or country work,
from February 4.

Particulars in Confidence.

\VATSON VICTOR

LIMITED

LICENSED BUSINESS AGENTS

Watson Honoe, Rlich Street,

Sydney.

Branch** In all Capital Cltlea of
Australia and Nerr Zealand.

ROYAL HOBART HOSPITAL, :
RE-ORGANIZATION MEDICAL,
STAFF. Following the re-organiza
tion of medical staff, applications
are invited from fully qualified
and registered medical prac
titioners for the following posts.
Medical Registrar: Commencing
salary 750, rising to 800 per
annum in second year. Duties
include the supervision, investiga
tor and treatment of all
medical cases admitted to hospital,
also the work and case recording
of junior resident medical officers,
according to the wishes of the
Superintendent and honorary
physician in charge of the beds.
Applicants to have held the post
of a senior resident medical officer
in a hospital and interested in
medicine. The post is suitable for
one working for his M.R.A.C.P.
Senior Resident Medical Officer: At
least two years hospital experience
necessary. Duties include the
supervision, investigation and
treatment of obstetrical and
gynaecological Oases under the
honorary obstetricians and gynae
cologists to the hospital. Com
mencing salary 550 per annum
plus board and residence. Accom
modation for single men living out
allowance payable to married men.
Applications stating age, experience
and qualifications, together with
copies of recent testimonials, and
clearly stating position sought,
close with the undersigned on
February 20, 1946. Successful
applicants to commence duty March
15, 1946. H. M. WRIGHT. Secre
tary, Box 495, G.P.O., Hobart.

FOR SALE, Practice, North Shore
Line. Takings about 3,000.
Modern house for sale. Moderate
lodge list. No surgery undertaken.
Apply "P.B.", c.o. THE MEDICAL
JOURNAL OF AUSTRALIA, Seamer St.,
Glebe, Sydney, N.S.W.

/COMMONWEALTH DEPART-
VV MENT OF HEALTH : Vacancy
for Chief Medical Officer (Exempt),
Darwin, N.T. CONDITIONS OP
SERVICE. Salary Range: 1,202 to
1,352 (annual increments of 50).
The above salary is inclusive of
cost of living adjustment, which at
present is 40 per annum. In
addition, district allowance of 100
p.a. (married) or 80 p.a. (single)
is payable. Duties: He will be
responsible, under the Director-
General of Health, for all medical
services in the Northern Territory,
the control of hospitals, the leper
station, quarantine, aerial medical
services, and public health
generally. He should possess sound
professional knowledge, be a good
administrator, and possess a
diploma in public health or tropical
medicine. Hours of Duty: No fixed
hours. The Chief Medical Officer is
not regarded as eligible for special
monetary compensation for over
time, Sunday or holiday duty. No
right of private practice. No
superannuation. Motor-car trans
port provided ; or mileage allow
ance at Public Service rates, if
using own car. Housing and
furniture deductions from salary at
Public Service rates: (a) if
occupying departmental quarters in
Darwin, the deduction of rent to be
at the rate of 10% of the minimum
salary of the position. Furniture:
Rented on the basis of 10% of the
purchase price in all cases where
official furniture is provided. Fares:
Fares to the Northern Territory
will be paid by the department, but,
in the event of the appointee not
remaining in the service for at
least six months, he may be re
quired to refund the fare paid on
his behalf. Recreation Leave:
Thirty-six (36) days per annum
exclusive of Sundays and holidays,
which may be allowed to accumu
late for three consecutive years.
Recreation leave to be granted in
respect of each completed twelve
months continuous employment.
Travelling Time for Recreation
Leave: Seven (7) days each way.
This travelling time is the maxi
mum period which may be allowed,
irrespective of the locality in
which the employee spends recrea
tion leave or whether leave is
accumulated or enjoyed annually,
provided that where a lesser period
is occupied in travelling, the travel
ling time should be correspondingly
reduced. Sick Leave : In accor
dance with Public Service con
ditions. Engagements may be
terminated at any time without
notice by the Director-General of
Health on the grounds of mis
behaviour or inefficiency ; otherwise
it may be terminated by one
month s notice in writing by either
the Director-General of Health or
the appointee. Preference will be
accorded to persons with the neces
sary qualifications, in accordance
with the provisions of the Re-
establishment and Employment Act
(No. 11 of 1945). Applications
showing full name, date and place
of birth, war service (if any) and
full details of qualifications and
experience should be forwarded to
reach the Director-General of
Health, Canberra, A.C.T., on or
before 9th February, 1946.

FOR PRIVATE SALE, X-Ray
Practice in convenient country
centre. For further particulars
apply XYZ, c.o. THE MEDICAL.
JOURNAL OF AUSTRALIA. Seainer
Street, Glebe. Sydney, N.S.W.

EXPERIENCED PRAC

TITIONER wants to buy
suburban practice, preferably
partnership, in Adelaide. All in
formation confidential. Apply to
No. 94, c.o. THE MEDICAL JOURNAL
OP AUSTRALIA. Seamer Street,
Glebe, Sydney, N.S.W.

STORER-HARRISON
X-RAY COMPANY

FOR EVERYTHING

ELECTRICAL IN

MEDICINE

Ediswan Electric Convulsion
Therapy Apparatus.
Infra-Red Generators.
Ultra-Violet Lamps.
Short-Wave Diathermy.
Surgical Diathermy.
Faradic/Galvanic Apparatus.
X-Ray Apparatus.
X-Ray Accessories.
Equipment Hire Service.

Further Particulars:

STORER-HARRISON X-RAY

COMPANY

67 Hunter Street, Sydney
BW5122 BW 7277

A UCKLAND HOSPITAL

-tX BOARD, NEW ZEALAND.
Applications addressed to the
undersigned and closing on the 28th
day of February, 1946, are invited
from Registered Medical Prac
titioners of the British Empire of
at least ten years standing and
having wide clinical and adminis
trative experience, for appointment
as Superintendent-in-Chief of the
Board s institutions at a salary of
2,000 per annum, payable monthly,
rising by annual increments of 50
to a maximum of 2,250 living out
(New Zealand currency). The
Board s institutions include four
major hospitals accommodating
2,600 patients, with other hospitals
in course of planning. The position
will be wholly administrative. Con
ditions of appointment, accompany
ing explanatory memorandum and
official form of application may be
obtained on request to the Secre
tary, P.O. Box 2200, Auckland, New
Zealand. Applications should be
endorsed on envelope "Superinten
dent-in-Chief". R. F. GALBRAITH.
Secretary.

/COMMONWEALTH OF AUS-
^ TRALIA, DEPARTMENT OF
HEALTH : Vacancies for Position
of Medical Officer. Applications
are invited for appointment to the
positions of Medical Officer, Com
monwealth Department of Health.
Salary range is 720 to 864
(standard), subject to cost of
living adjustments, which raises the
salary at the present time to 760
to 904 (actual). The annual
ncrements are 36. The position
will be exempt from the provisions
of the Commonwealth Public
Service Act. A number of positions
are in the laboratory services of
the department, for which a course
of training is provided after
appointment. Applicants must be
medical graduates between 25 and
35 years of age, should produce
evidence of sound professional
knowledge, and be prepared to per
form duty anywhere in Australia.
Preference will be accorded to
persons with the necessary quali
fications in accordance with the
provisions of the Re-establishment
and Employment Act (No. 11 of
1945). Applications showing full
name, marital status, and date and
place of birth should be forwarded
to the Director-General of Health,
Canberra, A.C.T.

Xll

THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER. JANUARY 26, 1946.

FOR SYMPTOMATIC RELIEF

AND TREATMENT OF PEPTIC ULCER

Following the investigation of Mutch (B.M.J., October, 1937), the thera
peutic value of Hydrated Magnesium Trisilicate was established. Having a
ratio of MgO to SiO 2 of 1 to 2.24, Trinesium Stearns is in exactly the form
advocated by Mutch. Clinical tests have established the efficacy of Trinesium
in the management and treatment of peptic ulcer. It provides protection
against the corrosion of the ulcer bed, together with continuous control of
hyperacidity and sustained adsorbent action.

In combination with the gastric juices Trinesium forms a silica gel over the
ulcer, thus providing mechanical protection for the ulcer. By its neutralising
action and its potent adsorbing power, Trinesium can create a pepsin-free
and acid-free zone. This guards the raw ulcer area from further irritation and
corrosion due to digestive activities.

Mutch found that with Magnesium Irisilicate, a minimal amount of mineral
base controls hyperchlorhydria continuously.

Samples ana further literature on 1 rinesium will he
gladly sent to the medical profession on request to
Frederick Stearns & Company Division, Box 3286,
G.P.O., Sydney.

Trinesium

STEARNS

ANTACID Trinesium relieves
gastric Hyperacidity within a few
minutes. The single dose will
control excess acid for the entire
:.- period of gastric digestion.

ADSORPTIVE Mutch reports
that, as an adsorbent. Magnesium
Trisilicate "far transcends bis
muth salts, magnesia, aluminium
hydroxide or other medicaments
in common use. .

ANTIPEPTIC The silica gel
formed by Trinesium provides
mechanical protection for stomach
ulcers. It subdues pain and in
flammation and help? to achieve
healing

DOSAGE Trinesium
(Hydrated Magnesium Trisili
cate) is available in bottles con
taining l5 oz., and in tablet form.
Average dose is 21 grains (one
level teaspoonful).

rredi

reaenci

Stearns^

ompanu
1 &lt;7

ivision

SYDNEY, AUSTRALIA

Wholly set up, printed and published at the Printing House, Seamer Street, Glebe, Sydney, N.S.W., by ARTHUR FREDERICK ROOTS
SIMPSON, of B airholm Street, Strathfield, New South Wales, on behalf of the AUSTRALASIAN MEDICAL PUBLISHING COMPANY

LIMITED, Seamer Street, Glebe, Sydney, New South Wales.

Registered at the G.P.O., Sydney, for Transmission by Post as a Newspaper.

Published Weekly.

Price 1s.

THE

MEDICAL

JOURNAL

OF AUSTRALIA

VOL. I. 33RD YEAR.

SYDNEY, SATURDAY, FEBRUARY 9, 1946.

No. 6.

FOR SYMPTOMATIC RELIEF

AND TREATMENT OF PEPTIC ULCER

Following the investigation of Mutch (B.M.J., October, 1937), the thera
peutic value of Hydrated Magnesium Trisilicate was established Having a
ratio of MgO to SiO 2 of 1 to 2.24, Trinesium Stearns is in exactly the form
advocated by Mutch. Clinical tests have established the efficacy of Trinesium
in the management and treatment of peptic ulcer. It provides protection
against the corrosion of the ulcer bed, together with continuous control of
hyperacidity and sustained adsorbent action.

Mutch found that with Magnesium Trisilicate, a minimal amount of mineral
base controls hyperchlorhydria continuously.

Samples and further literature on Trinesium will be
gladly sent to the medical profession on request to
Frederick Stearns & Company Division, Box 3286,
G.P.O., Sydney.

Trinesium

STEARNS

L y T

7),

wision

SYDNEY. AUSTRALIA

FACTS ABOUT
TRINESIUM

ANTACID Trinesium relieves
gastric hyperacidity within a few
minutes. The single dose will
control excess acid for the entire
period of gastric digestion.

ADSORPTIVE Mutch reports
that, as an adsorbent. Magnesium
Trisilicate far transcends bis
muth salts, magnesia, aluminium
hydroxide or other medicaments
in common use.

ANTIPEPTIC The silica gel
formed by Trinesium provides
mechanical protection for stomach
ulcers. It subdues pain and in
flammation and helps to achieve
healing.

THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER. FEBRUARY 9, 1946.

For the local treatment of IMPETIGO

CONTAGIOSA and various
other skin infections

Efficiently distri
butes medication.

Carries medication
into intimate con
tact with lesion.

Contains no grease.
(Water miscible-base).

Helps to prevent
spread of infection.

Alulotion contains 5% ammoniated
mercury colloidally dispersed in a base
of aluminium hydroxide gel and kaolin.
It is a greaseless, water-miscible lotion
which is clean, convenient and effica
cious for local treatment of various
cutaneous infections. Clinical tests
have proved that the use of Alulotion
noticeably reduces healing time.

INDICATIONS: For local treatment of impe
tigo contagiosa, ecthyma, folliculitis and the
secondary infections associated with eczema,
seborrheic dermatitis and dermatitis due to
irritants.

ALULOTION

INCORPORATED

{S INC. N U.S.A.

44 Bridge Street, Sydney

AMMONIATED MERCURY with KAOLIN

FEBRUARY 9, 1946. THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER.

111

British Medical Insurance
Co. of Vic. Ltd.

Founded in the interests of the Medical Profession,

surplus profits are devoted to the Medical Society of

Victoria.

All Classes of Insurance Transacted:

FIRE Homes, Cars, Furniture, Equipment.
BURGLARY Contents of Homes, Instruments,

Cars, Jewellery, Furs.

WORKERS COMPENSATION. PERSONAL,

LUGGAGE, PERSONAL ACCIDENT. COM
PULSORY THIRD PARTY. WAR DAMAGE.

DIRECTORATE OF THE B.M.I.

Dr. C. H. Mollison (Chairman), Dr. L. Latham,

Dr. J. Newman Morris, Dr. F. Kingsley Norris,

Mr. T. E. V. Hurley.

THE BRITISH MEDICAL INSURANCE CO, OF VIC. LTD.

389-395 Little Flinders Street, Melbourne, C.I.
Phone: M 1871 (9 linen).

H. K. LEWIS & CO. LTD.

THE SYMPTOMATIC DIAGNOSIS AND TREAT
MENT OF GYNAECOLOGICAL DISORDERS

By M. MOORE WHITE, M.D.Lond., M.B., B.S.,
P.R.C.S.Eng., M.R.C.O.G., with a Foreword by
F. J. BROWNE, M.D.Aberd., D.Sc., F.R.C.P.Edin.,
F.R.C.O.G. Second Edition. Fully illustrated.
Demy 8vo. 16s. net, postage 2d. (Just published.)

THE SULPHONAMIDES IN THEORY AND
PRACTICE

By J. STEWART LAWRENCE, M.D.Ed., M.B.,
Ch.B., M.R.C.P., Demy 8vo. 9s. net, postage 7d.
(Just published.)

ANATOMY AND PHYSIOLOGY FOR NURSES

By J. L. HAMILTON PATERSON, M.D.Lond., M.B.,
B.S., M.R.C.P., M.R.C.S. With 93 Illustrations.
Demy 8vo. 9s. net, postage 7d. (Just published.)

A GUIDE TO HUMAN PARASITOLOGY

For Medical Practitioners

By D. B. BLACKLOCK, M.D.Edin., D.P.H.Lond.,

D.T.M.Liverp., and T. SOUTHWELL, D.Sc., Ph.D.

Fourth Edition. With 2 Coloured Plates and 122

Text Illustrations. Royal 8vo. 15s. net, postage 9d.

LONDON: 136 GOWER STREET, W.C.1
Cablegrams: Publicavit, Westcent, London

ANDREW S PHARMACEUTICAL PREPARATIONS

for therapy and in the pre^operative management of
thyrotoxicosis, for patients with exophthalmic or adenomatous
goitres, primary and secondary hyperthyroidism

Packed in bottles of 50 and 100 tablets of 0.05 grm.

, ,, 50 0.2

Dosage in pre-operative management . . .

from 0.2 to 0.6 grm. a day.
Maintenance dosage . . .

from 0.05 to 0.2 grm. a day.

THIOUREA

in bottles of 100 tablets
of 0.25 grm.

Literature and further information provided on request from the manufacturers

ANDREW S LABORATORIES, SYDNEY

MANUFACTURERS OF DRUGS AND FINE CHEMICALS:

Adrenalin Synthetic Hexoestrol Sulfaguanidine Analytical Reagents

Cholesterol Sodium Desoxycholate Thiouracil pH-Indicators

Dehydrocholic Acid Stibophen Thiourea Spot Test Reagents, etc.,

Stilboestrol Lecithin (Brain) D.D.T.

THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER. FEBRUARY 9, 1946.

SALINE THERAPY

in relation to
INEFFICIENT DEF/ECATION

Carefully controlled clinical tests conducted a
few years ago in England established the value
of a small regular dose of the simple mixture of
salts in Kruschen Salts, in the prophylaxis and
treatment of colon stasis and dyschezia. This
mixture comprises:

SODIUM SULPHATE
SODIUM CHLORIDE
MAGNESIUM SULPHATE
POTASSIUM SULPHATE
POTASSIUM CHLORIDE

Summary of conclusions:

Authorities recognize the widespread preva
lence of a condition known as dyschezia
inefficient defaecation, which may or may not
be associated with frank constipation.

2. This condition arises largely as a result of
present-day life low residue diets, paucity
of fluid intake, sedentary occupations and
lack of bodily exercise.

3. Experimental and clinical work demon
strates clearly the importance of controlling
the withdrawal of water from the faeces in
the intestine.

4. Carefully-controlled clinical tests proved
that a small daily dose (1-2 grammes as
much as will lie on a sixpence) of Kruschen
Salts, brought up the water content of the
faeces to normal and ensured regular, physio
logically satisfactory emptying of the bowel.

5. This effect is due to the indiffusible ions
released by Kruschen Salts in solution,
which attract and retain sufficient water in
the faeces by osmotic pressure.

6. In the treatment and prophylaxis of this
ubiquitous condition, the regular daily dose
of Kruschen Salts is the method of choice
its action accords with normal physiological
processes; it contains no "drugs" and is
neither injurious nor habit-forming.

KRUSCHEN SALTS

E. Griffiths Hughes Ltd.

Established 1156.

GOLD MEDAL, International Congress of Medicine,

191S.

Brand Ethooaln *

Hydrochloride.

3 HE ORIGINAL. PREPARATION.
Ellh Trade Mark If*. 37*477 (IMC).

COCAINE-FREE Local AMMthetle.

Despite the war, NOVOCAIN
preparations are, and will continue
to be, available in all forms, viz.:

Solutions In Ampoules, 1 or. and 2 ox. Bottles,
Stoppered or Rubber Capped. Tablets IB

various sizes, and Powder.

THE SAFEST AND MOST RELIABLE LOCAL

ANAESTHETIC.
Six to seven times less toxic than Cocaine.

Literature and Pall Technique ea Reejveat.

Sold Under Acreement.

THE SACCHARIN CORPORATION, Limited

M M ALFORD GROTE. SNARESBROOK. I O.1DOH. K.18
Telephones WAN8TKAD X3S7.

Australian Aeent: J. L. Brown eV Co.,
1SS William Street, Melbourne, C.I.

Made in Australia

simnniTE

INSUFFLATION POWDER

and

VAGINAL SUPPOSITORIES

provide an effective treatment for
vaginitis of any origin. SIMANITE
products are non-irritant and non-
toxic.

CARTER & CO. (AUST.) PTY. LTD.

267 Clarence Street, Sydney.

335 Flinders Lane, Melbourne.

Agents :

GRADWELL BROS., W. RAMSAY PTY. LTD.,

Brisbane. Adelaide.

S. VAN DAL & CO.,
Perth.

FEBRUARY 9, 1946. THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER.

ANAHMIN

The Active Haemopoietic Fraction of Liver.

The exceptionally high anti-anaemic potency of Anahaemin B.D.H. is sometimes not
realised by physicians who therefore tend to administer unnecessarily large doses or to
administer Anahaemin at unnecessarily short intervals. In consequence a proportion of
the material is wasted and the cost of treatment becomes excessive. Further, the patient
is subjected to the administration of larger or more frequent injections than are required for
effective treatment. It is important to realise, therefore, that even moderately severe cases
of pernicious anaemia usually require an initial dose of not more than 2 c.c. followed by
1 c.c. every seven to ten days until the blood count is normal. Doses of 1 c.c. to 2 c.c.
monthly provide adequate maintenance in most cases.

Thus, although the cost per ampoule of Anahaemin may seem to be high, the cost of
treatment over a period is low.

Stocks of Anahamin B.D.H. are held by leading pharmacists throughout
the Commonwealth, and full particulars are obtainable from

THE BRITISH DRUG HOUSES (Australia, Pty.) LTD.

250 Pitt Street Sydney

Anan/Aus/462

THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER. FEBRUARY 9, 1946.

Zephiran is a germicide of high bacteri
cidal and bacteriostatic potency. In proper
dilutions it is non-irritating and relatively
non-toxic to tissue cells.

Zephiran possesses detergent, keratolytic
and emulsifying properties, which favour
penetration of tissue surfaces, hence
removing dirt, skin fats and desquamating
skin.

INDICATIONS

Zephiran is widely employed for
skin and mucous membrane anti
sepsis for pre-operative disinfec
tion of skin, for vaginal instillation
and irrigation, etc., and for the dis
infection of hands and instruments.

HOW SUPPLIED

Zephiran is available as a stan
dardised 10% aqueous solution
called Zephiran Concentrate.

Bottles of 4 oz. and 40 oz. either

(A) aromatic and colourless
or

(B) blue-tinted and odourless

BRAND OF ALKYLDIMETHYLBENZYLAMMONIUM CHLORIDES

BAYER PHARMA PTY. LTD., SYDNEY

Distributors: FASSETT & JOHNSON LTD., 36-40 Chalmers Street, Sydney

THE MEDICAL JOURNAL OF AUSTRALIA

VOL. I. 33RD YEAR.

SYDNEY, SATURDAY, FEBRUARY 9, 1946.

No. 6.

Table of Contents.

[The Whole of the Literary Matter in THE MEDICAL JOURNAL OF AUSTRALIA i* Copyright.!

ORIGINAL, ARTICLES Page.

The Sir Richard Stawell Oration Medical Aspects

of Red Cross in the Second World War, by

J. Newman Morris . . ..-.. 169

Acquired Resistance of Staphylococci to the Action

of Penicillin, by E. A. North and R. Christie . . 176
Pleuropneumonia-like Organisms in Cases of Non-

gonococcal Urethritis in Man and in Normal

Female Genitalia, by W. I. B. Bereridge, A. D.

Campbell and Patricia E. Lind 179

Early Results in a Short Series of Cases of Gunshot

Wounds of the Abdomen, by Thomas F. Rose,

Arthur Newson and Donald Watson 180

Lipomata of the Uterus, with Report of a Case,

by J. D. Hicks 184

The Treatment of Ing-uinal Hernia, by Franklyn V.

Stonham 185

REPORTS OF CASES

Rupture of the Liver in the New-Born: Recovery
after Blood Transfusion and Laparotomy, by

Felix Arden, M.D., M.R.C.P 187

. Report of a Fatal Case of "Blast" Injury of the

Spinal Cord, by D. Leslie 188

REVIEWS

Psychiatry and Modern War 189

The Surgery of Peptic Ulceration 189

Synopsis of Surgery 190

NOTES ON BOOKS, CURRENT JOURNALS AND NEW
APPLIANCES

The Decoration of Hospitals- 190

LEADING ARTICLES

Overseas Travel for Australian Students 191

CURRENT COMMENT Page.

The Prevention of Influenza 192

"The Stevens-Johnson Syndrome" 193

A New York Festschrift 193

ABSTRACTS FROM MEDICAL LITERATURE

Surgery 194

MEDICAL SOCIETIES

Obstetrical Society of the Women s Hospital,

Melbourne 196

POST-GRADUATE WORK

The New South Wales Post-Oraduate Committee in

Medicine 203

The Melbourne Permanent Post-Graduate Com
mittee s Programme for March . . . ^ . . . . 203

CORRESPONDENCE

The Central Hospital, Melbourne 203

NOMINATIONS AND ELECTIONS 203

NAVAL, MILITARY AND AIR FORCE

Appointments 203

OBITUARY

Guy Stuart L Estrange 204

Sidney Solomon Rosebery 204

William Camac Wilkinson 204

NOTICE 204

MEDICAL APPOINTMENTS 204

BOOKS RECEIVED 204

DIARY FOR THE MONTH 204

MEDICAL APPOINTMENTS: IMPORTANT NOTICE .. 204
EDITORIAL NOTICES . 204

Cfte ^it iaictjatti ^tatoeli Station. 1

MEDICAL ASPECTS OF RED CROSS IN THE SECOND
WORLD WAR.

By J. NEWMAN MORRIS,
Melbourne.

THE Sir Richard Stawell Oration was established by its
founder to preserve the memory of one of the greatest of
Australian doctors, whose death occurred just ten years ago.
Six of those years have seen the greatest world war of all
time the aftermath of the war in which Sir Richard
Stawell rendered such distinguished service. In the war
just ended he has been represented by his only son, Dr.
John Stawell.

I was a student of Stawell s and that was a great
privilege. After more than forty years I still remember
the awed hush of expectancy and excitement when word
went round the hospital that "Dicky s here". Then would
follow a clinical demonstration, unequalled by any teacher
I have ever seen at work. After I graduated, Stawell
became to me the ideal physician, one to whom I could go
in confidence, in consultation or in great relief for help
in sickness in my own family. To those who had the
honour and privilege to know Stawell as leader, colleague,
doctor or friend, it is not necessary to stress the qualities
of the man. He has become a tradition of that generation.
For those who were denied that privilege, perhaps the

1 Delivered at a meeting of the Victorian Branch of the
British Medical Association on October 17, 1945. Received
for publication January 18. 1946.

picture of "the Chief" in "In Hospital", by William Ernest
Henley, will serve in some degree:

His brow spreads large and placid, and his eye

Is deep and bright with steady looks that still.

Soft lines of tranquil thought his face fulfil.

His face at once benign and proud and shy.

If envy scant, if ignorance deny

His faultless patience, his unyielding will.

Beautiful gentleness and splendid skill,

Innumerable gratitudes reply.

His wise, rare smile is sweet with certainties.

And seems in all his patients to compel

Such love and faith as failure cannot quell.

We hold him for another Heracles,

Battling with custom, prejudice, disease,

As once the son of Zeus with Death and Hell.

May his influence and example long pervade and glorify
the traditions of Victorian and Australian medicine!

When my fellow trustees did me the honour of asking me
to deliver the tenth Sir Richard Stawell Oration, it was
suggested that I should speak of the work of the Australian
Red Cross Society in the late war. Stawell found time to
take part in voluntary organizations related to the work
of the medical profession, and it is not inappropriate that
the war work of the largest voluntary organization in
Australia should be the theme of a Stawell oration.

The second world war, which ended with the surrender
of the Japanese forces on August 15, 1945, presented the
Red Cross movement with even greater opportunities for
service than the first world war. But its true functions
have not been generally appreciated. Because of the
manner of its origin eighty-one years ago, and of its close
association with the work of the medical services, the Red
Cross Society stands apart from philanthropic organizations
whose services cover the welfare of fit and well troops. At
the conclusion of the war of 1914 to 1918 the countries

170

THE MEDICAL JOURNAL OF AUSTRALIA.

FEBRUARY 9, 1946.

signing the League of Nations Covenant pledged themselves
to encourage the formation of national Red Cross societies
which would devote their energies towards the prevention
of disease, the improvement of health and the mitigation of
suffering, while maintaining their traditional purpose of
organizing to give free voluntary aid to the sick and
wounded in war. The International Red Cross Committee
grants recognition only to such national societies as receive
approval from their governments and are recognized as
official auxiliaries to the medical services of the armed
forces. The Australian Red Cross Society, founded on
August 13, 1914, and granted a Royal Charter in 1941,
conforms to these necessary conditions.

BASIS OF MEDICINE.

There is a close affinity between the purpose of medical
practice and the objects of the Red Cross Society. It has
been said that the primary objects of the medical profession
are to prevent and cure disease, to ease pain and to save
life. "Medicine", wrote Sir William Osier, "arose out of
the primal sympathy of man with man, out of the desire
to help those in sorrow and sickness", and "the basis of
medicine is sympathy and the desire to help others, and
whatever is done with this end must be called Medicine ".
The presence of this sympathy can be traced through
recorded history. The Order of Saint John of Jerusalem
organized aid for the sick and wounded from the twelfth
century on. The first convention for the protection of
wounded in battle was devised by the British physician
General Sir John Pringle, during the War of the Austrian
Succession in 1742. But Florence Nightingale and Henri
Dunant are mainly responsible for the modern organization
of voluntary aid in the care of war casualties.

DEFINITION OF FUNCTIONS.

No specific definition of the purposes of an official
auxiliary has been laid down. These were developed on
the experience of past wars and in consultation between
army medical directorates and Red Cross officials. But
as the Red Cross Society is recognized by governments
as the official voluntary auxiliary of the medical services,
it is clear that the functions and purposes of the Red Cross
must conform to those of the services.

In "The Australian Army Medical Services in the 1914-
1918 War", Colonel A. Graham Butler defines the army
medical service as a highly complex social group, "at once
a technical military service, exactly organized, established
and trained for maintaining the army s strength for the
achievement of victory; a scientifically equipped social
service, cooperating with the various civil agencies in
effecting the repair and reenablement of the war-damaged
soldier, and a fully accredited humane agency for pro
moting and cooperating in the alleviation of suffering".
This is a wide definition and seems to call for the assis
tance of such a voluntary auxiliary as the Red Cross,
especially in relation to the two last-mentioned purposes.
It can and should be said, in relation to the Second World
War, that the medical services have in a most distinguished
manner fulfilled all the purposes set out by Butler. Many
of Stawell s students and successors have shared in this
fine record, which would have greatly delighted him. How
proud, for example, would he have been of Neil Fairley
and his associates in their winning fight against tropical
diseases, which contributed so greatly to the ultimate
victory of the Allied forces! And with what admiration
would he have learnt of the magnificent deeds of Coates,
Brennan, Dunlop, Hunt and others in Japanese prison
camps, or of Le Souef, Moore and many doctors in European
prison camps! The service nurses share in the medical
achievements of the war, and no greater epic of heroism
exists than the courageous manner in which Australian
nurses met their deaths in Sumatra at the hands of a
murderous and inhuman foe. The reputation of our medical
and nursing services stands deservedly high throughout
the world. The Red Cross Society has been proud to
assist them in every operational area as far forward as
the regimental aid posts.

Butler listed the overseas activities of the society in
the First World War, broadly as follows:

1. Provision of material: (a) extra equipment, stores,
foodstuffs and so forth, for the use of the medical services;
(6) extra comforts for the patients themselves, in par
ticular tobacco; (c) means of transport, as ambulance
wagons; (d) furnishings for convalescent homes and
hostels; (e) other material.

2. Provision of facilities for reparative and vocational
training and for recreation.

3. Visitation of patients in hospitals.

4. As an agency for the Australian Comforts Fund, as
far as comforts for the medical services, especially the
nursing service, were concerned.

5. Non-medical activities under the Geneva Convention
and Hague agreements: (a) action in respect of prisoners
of war; (6) the tracing of missing soldiers and communica
tion with their relatives.

Except with reference to the Australian Comforts Fund,
that description could be adopted in relation to the recent
war. The society strictly limited its services to the sick
and wounded and prisoners of war, although it provided
group comforts for the nursing personnel. In accordance
with its international obligations it also rendered aid to
enemy prisoners of war who were under the care of
Australian doctors. Many of the comforts issued were
produced by the devoted labour of tens of thousands of
workers amongst the three thousand branches of the
society spread throughout the Commonwealth and its
dependencies. The service was rendered by a field force
consisting of five hundred men and women. Most of the
men had served as combatants, whilst the women, known
variously as hospital visitors and field hospital officers,
were specially selected and trained. Each military hospital
had attached to it Red Cross officers and other ranks, all
incorporated in the army and subject to military law. In
the mainland hospitals the service was supplemented* by
voluntary Red Cross unattached workers. This personal
service was given also on hospital ships, ambulance trains
and aerodromes.

ORGANIZATION.

Owing to the location in Melbourne of defence head
quarters, the Red Cross Society has always had its central
body in this city. It is controlled by a national council
elected by State divisions of the society, together with
some ex-officio and coopted members. The ex-officio mem
bers include the directors-general of the medical services
of the armed forces. Until the outbreak of war, Major-
General R. M. Downes, then Director-General Medical
Services of the Army and the Royal Australian Air Force,
was chairman, and he was succeeded by Dr. Victor Hurley,
who later became Director-General Medical Services of the
Royal Australian Air Force.

The first committee appointed at the outbreak of war
was the Medical Services Committee, which included not
only ex-officio medical members of the council, but the
Principal Medical Officer of the Repatriation Department,
the Commonwealth Director-General of Health and other
medical men of prominence. It is now under the able
guidance of Dr. W. W. S. Johnston as chairman and Dr.
G. Robinson as Director. Similar committees exist in State
divisions. There has been definite medical guidance in
the affairs of the society.

PRE-WAR PREPARATIONS.

Soon after the Munich crisis in September, 1938, the
International Red Cross Committee warned all national
Red Cross societies to organize to a war-time level, and
the Australian Red Cross Society appointed a planning
committee under the leadership of Dr. Victor Hurley. A
"Red Cross War Book" was prepared with the approval
of the Director-General Medical Services of the army, and
the plans were put into operation at the declaration of war.
The chapters of the war book described the authority
under which the society acts, both nationally and inter
nationally, and dealt in detail with the various matters
of interest in the society s activity, such as stores, per
sonnel, transport, auxiliary hospitals, inquiry work and

FEBRUARY 9, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

171

service to prisoners of war, while one chapter dealt with
the details of hospital improvisation and blood transfusion.

EQUIPMENT IN SERVICE HOSPITALS.

Although much thought had been given to the war-time
needs of this country, Australia was unprepared when
hostilities commenced. This was true of the medical ser
vices, which had few whole-time officers and little or no
hospital accommodation or equipment. In July, 1938, the
Commonwealth Government set up a committee under the
chairmanship of Major-General R. M. Downes to coordinate
all matters relating to the medical needs of the country,
military and civilian, in the event of war within Australia.
The information acquired by that body indicated that a
considerable amount of the needs must be met at first by
a process of improvisation.

None of the excellent camp hospitals and magnificent
base hospitals now existing had been erected. Little
expenditure had been incurred to prepare for a national
emergency that might not happen. Even in the early
months of mobilization expenditure seemed to be niggardly
in regard to the medical needs of the forces, and permission
to acquire equipment was apt to be subject to long delays.
It was then that the Red Cross Society, untrammelled by
regulations, played a significant part in assisting the
medical services.

The society commenced its war service without funds,
but with a certain small amount of stores remaining from
the war of 1914 to 1918. Public support was soon forth
coming, money donated amounting ultimately to more
than 12,000,000. The Stores Department, on the basis of
previous experience and in consultation with army medical
officers, compiled a list of some eight hundred items of
equipment, hospital furnishings, clothing and comforts
considered suitable to supplement the official equipment
scale for the care of sick and wounded. As military hos
pitals became organized, specific requests from individual
medical officers became frequent. Official issue of items
desired by them but outside the adopted scale was refused
or delayed, and the Red Cross Society provided a more
rapid channel of approach. It was soon found necessary,
both by the Equipment Control Officer and by the society,
to reach an understanding and to arrive at a formula.

Every establishment has an official scale of issues which
is based upon experienced opinion as to needs. It is a
minimum scale rather than a maximum scale, and, being
official, is applied in strict accordance with regulations.
The Red Cross Society is not . responsible for providing
basic equipment for hospitals. Only if the need is one
of immediate urgency should supplies which should be
issued by the authorities be sent to hospitals. The Red
Cross Society should, it was determined, supplement the
scale only when by its so doing increased efficiency of
service could be given, or when urgency required official
rules to be ignored, or when rapid replacements were
essential owing to war casualties. It was laid down as a
general principle that the funds of the society were not
expended upon equipment which the State should provide
as a necessity.

Experimental Equipment.

It is not always easy to amend an official scale nor to
add to it. Improved instruments may be desired or are
devised by medical officers, but no provision is made for
experimental expenditure. Here the Red Cross Society was
able to help. The most noticeable example was in mobile
units, for blood transfusion, for surgical teams, for bac
teriological work. The unit is constructed at the expense
of the society. If it proves worthy of use, it may or may
not become an official issue. Requests for such equipment
always had official endorsement, and the blueprints were
prepared and the construction supervised by service medical
officers. For example, early in the war a mobile trans
fusion train was constructed at the request of the then
Transfusion Officer, Colonel Ian Wood, and the Equipment
Control Officer, Colonel Wallace Ross, both of whom super
vised the construction. Intense interest was aroused in
this first unit, which was shipped to the Middle East, but

sad to relate, never arrived there. Four such units were
later built.

Each suggestion was considered carefully and subjected to
the tests laid down. Special orthopaedic fracture apparatus
was constructed for one hospital, and clinical photographic
equipment for another, whilst plaster bandage machines,
sterile water units and portable X-ray units were made
and supplied in the early years of the war to the navy,
army and air force medical establishments. Tools for
repairing instruments were asked for and given, as no
adequate official provision was made at the time, and this
gift proved of great value in the Middle East and led to
similar requests from other hospitals. A giant magnet
was requested by an oculist of a general hospital. None
was available, so an effective instrument was made in
Australia, under the supervision of the oculist himself.

Other Equipment.

Libraries for the staffs of military medical units were
not liberally allowed for in the early days, and the society
took some part in meeting this need. This service was also
aided by the British Medical Insurance Company of
Victoria.

Care was taken, as far as possible, to refrain from
catering for the special hobbies of individual officers, who
desired to have at their disposal all the apparatus they
had been accustomed to using in their civilian work, instead
of adapting themselves to official equipment scales. Medical
officers found that asking officially and getting things
were generally quite unrelated happenings, so they applied
to the Red Cross.

Ownership of Equipment.

The matter of ownership of equipment issued to hospitals
by the society created some difficulty. After the previous
war, some individual officers claimed the society s gifts
for their own use, and the late Sir Neville Howse charac
terized this as a great abuse. It was decided to adopt the
principle for the war that all equipment would be issued
to the unit on loan, remaining the property of the society.
The final i*esult of this action, no doubt, will cause some
problems when the goods are called in.

Comforts.

Red Cross stores in operational areas contained large
reserve stocks of prepared dressings, rolls of old linen
(favoured by nurses), rolls of gauze, leno for plaster
work, and bandages. These were included on the basis
of previous experience and were the product of organized
teams, including former members of the Australian Army
Nursing Service. There is evidence to prove that at
times they were a very present help in time of trouble.
But most of the hospital equipment was provided for the
direct benefit of the patients themselves and was legiti
mately classed as "comforts". The men were frequently
under the misconception that they were normal issues.
The main idea was that the men must not suffer, and if
the society could in any reasonable way lessen the
suffering and aid in hastening recovery, it had a duty
to do in which it must not fail. Many of the comforts
could have been regarded as essential, but they just were
not provided officially, although they were certainly valued
on behalf of the patients by medical officers and nurses
alike. -The items were numerous, ranging from personal
requisites to furniture and floor coverings.

It may be thought that all food requirements for
patients in medical establishments would at all times be
adequately catered for and available. Medical comforts
and light diets in the early days of the war could, it was
stated, be obtained if asked for, although not laid down
on a definite scale as an issue. No service that the Red
Cross Society provided was more useful than its "light
diets". In every theatre of operations they were declared
by hospital staffs to have proved essential, while in the
New Guinea 1 campaigns they were of life-saving value. In
the last year of the war the society was officially requested
to cease issuing these light foods, and medical officers and
nurses were ordered not to use them, as official scales were

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THE MEDICAL JOURNAL OF AUSTRALIA.

FEBRUARY 9, 1946.

adequate. But even then the society s stores were used.
Florence Nightingale once said: "It is one thing to have
goods in the quarter-master s store, but it is another matter
to get them." Even the fresh eggs and fruit sent by the
society via Royal Australian Air Force planes to various
points in New Guinea failed to meet all the needs for
these articles. The total list of articles made available
by the society reads like the stock list of a general store.

SPECIAL REQUESTS FOB RED CROSS SERVICE.

While no special functions are laid down for the
Australian Red Cross Society as an official auxiliary, its
existence provides an organization to which the medical
corps can direct specific requests for aid. Much of the
war work done by the society followed requests of this
nature, such as the establishment of convalescent homes,
the employment of medical social workers, and the
provision of blood serum and of a rehabilitation service
in hospitals.

Convalescent Homes.

Dunant s improvised voluntary aid on the battlefield of
Solferino included the utilization of a village church as
a casualty hospital, and ever since then the establishment
of auxiliary hospitals in war time has been a recognized
objective in Red Cross work. This service is included in
the Royal Charter of the Australian Red Cross Society.
The British Red Cross War Organization in both world
wars conducted many such institutions, although neither
the Canadian nor the American society was called on in
this regard. Towards the end of 1939, after a conference of
deputy directors of medical services from the several
military districts, the Director-General Medical Services
.requested the society to establish convalescent homes for
the after-care of service patients. The first and largest
convalescent home was opened in Victoria at "Stonnington"
in May, 1940, with a bed capacity of 150. Thirty-two such
homes were ultimately opened in Australia, as well as one
at Port Moresby and one at Colombo, and a rest home for
nurses at Jerusalem. A contract was let for the erection of
a convalescent home for the Eighth Division in Malaya, and
work had just started when the Japanese forces overran
the Malay Peninsula.

Eight of the homes accommodated women only, one
was for officers and one was devoted solely to the rehabilita
tion of psychiatric patients. The society was responsible
for the selection and equipping of the buildings and for
the staffing of the homes. Trained nurses were appointed
in charge of whole-time or part-time Red Cross aids or
voluntary aids. Amenities, handcraft materials and
instruction, and apparatus for physical therapy were also
supplied, subject to approval by the Deputy Director
Medical Services. The Australian Army Medical Corps
was responsible for medical care and records, admissions
and discharges, and discipline. The convalescent homes
were thus organized as part of the military hospital
system; they were conducted by the Ked Cross Society,
but for all practical purposes were under the control of
the Director-General Medical Services and his staff. For
a great part of the war there were available 1,357 beds,
supplementary to those in the various base hospitals. The
stay of the men was usually relatively short, and the
treatment given was essentially that applicable to recovery
of medical and surgical patients no longer confined to
bed. No training or "hardening up" was carried out as
in a convalescent depot, and the type of care given, with
its relaxation of the discipline of a regular service hospital,
proved beneficial to the thousands of military patients
who were accommodated, while the homes provided a
useful reserve of beds for the medical officers.

Blood Transfusion Service.

Transfusion of blood and blood derivatives assumed
large proportions in the resuscitation of battle casualties,
and it has been assigned a high priority as "a life-saving
procedure. Tor ten years prior to the outbreak of war, a
blood transfusion service was a Red Cross activity in
Australia. Commencing in Melbourne in 1929, on the

suggestion of the late Lieutenant-Colonel E. L. Cooper,
then medical superintendent of the Royal Melbourne
Hospital, it spread gradually to divisions in Western
Australia, Queensland and Tasmania, and during the war,
to New South Wales and South Australia. Recently a
service has been established in the Northern Territory.

The pioneer service in, Victoria, under the direction of
Dr. Lucy Bryce, commenced by organizing blood donors
for individual transfusions; the service also undertook
testing and grouping of blood. In 1938 it set up a blood
bank, the first in Australia. As the threat of war
developed, an emergency service was instituted on the
initiative of Dr. Bryce and Colonel Ian Wood. Early in
1940 pooled blood was obtained from these emergency
donors and processed into liquid serum, for the first time
in Australia, at the Commonwealth Serum Laboratories.
Until the middle of 1942 all the serum sent from Australia
to the Middle East and Malaya came from this source.

In July, 1942, Major-General F. A. Maguire and Colonel
C. H. Kellaway requested the society to cooperate with
the Australian Army Medical Corps on a national basis
in developing a transfusion service to meet all military
and civilian needs. At that time invasion of Australia
was imminent. Combined army and Red Cross units were
formed in each State, and an elaborate scheme of organiza
tion was developed to deal with any civilian casualties
consequent upon enemy action. A large and active service
was set up at the Sydney Hospital, which provided the
greater part of the serum for service purposes. However,
serum was produced also in Queensland and Western
Australia, as well as in Victoria. Plants for drying serum
were set up in Sydney and Adelaide, and for small-scale
experimental work in Melbourne. "Pooled serum, wet and
dry, thus provided, has been available for civilian as well
as for service needs, and has been supplied to the Royal
Navy and the Royal Australian Navy, to the Allied
forces and to merchant service vessels, as well as to New
Zealand, Fiji, Samoa and the Flying Doctor service.

The Red Cross Blood Transfusion Service has
endeavoured to meet all needs and to keep pace with
progress, and other aspects may be summarized as follows.

1. Donors with high-titre serum (anti-A and anti-B)
were selected for use in blood group tests. Serum from
these donors, which is processed at the Commonwealth
Serum Laboratories, was used for the testing of many
thousands of members of the defence forces.

2. Panels of "Rfr-negative" donors were established and
suitable anti-Rh serum was provided. In a consultative
capacity, especially in Victoria, New South Wales and
Western Australia, the Red Cross service has been able
to enlist the cooperation of obstetricians and paediatricians,
thus securing satisfactory supplies of serum for processing.

3. Special products, such as red cell suspensions and
concentrated serum, have been supplied for therapeutic
purposes on an experimental basis in recognized clinical
schools. .

4. Original investigations have been published from
time to time in medical and scientific journals by Red
Cross medical officers and technicians.

5. Individual donors are supplied to practitioners who
prefer to take blood from donors immediately before
use or to employ special methods.

6. From the latter end of 1942, whole blood, Group O,
was sent by air transport from the Queensland and New
South Wales services, in specially designed ice-boxes, for
use in military hospitals, both Australian and Allied, in
the South-West Pacific area.

7. Blood banks have been set up in civilian hospitals
in many towns in Australia and suitable stocks of serum
are maintained in many country hospitals. The Red Cross
Transport Service has frequently been used to meet rapid
emergency needs, both in cities and in the country. This
has proved of special value in such disasters as the bush-
fires in Victoria in 1944.

8. In order to investigate the newer developments in
transfusion work, the society sent Dr. Lucy Bryce and
Miss M. Bick to the United States of America early this

FEBRUARY 9, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

173

year. Miss Bick is at present working in the laboratories
of Professor Cohn, in Boston, on the technique of serum
fractioning and the study of the increasing value of
serum globulins.

The general coordination of these transfusion services
and the formulation of national policy is vested in a
National Blood Transfusion Committee within the Medical
Services department of the society. The committee includes
senior officers of the defence medical services, pathologists,
and transfusion and refrigeration experts froni all States
of the Commonwealth. A technical subcommittee exists
to deal in detail with, keep abreast of, and report on
scientific and technical problems and developments. These
committees meet several times each year.

The society has determined to continue for the benefit
of civilians the widened basis of operations developed to
meet war-time needs, provided financial support is forth
coming and the interest and cooperation of donors can
be maintained. This latter factor is the essential basic
consideration, and time only will tell whether this sacri
fice of blood by tens of thousands of Australians, so
readily available in periods of national emergency and
danger, will be equally available for life-saving and
preventive purposes in the quieter days of peace.

The service is a costly one to organize and maintain,
and no charge is made by the Red Cross Society for any
help it gives. Doctors who use the service freely have
never been prominent in helping to keep it going or in
obtaining donors. Blood transfusion has become an
essential factor in meeting resuscitation and other needs.
It is assuming greater importance in the prevention and
treatment of some of the infectious diseases. It must be
organized on a permanent basis, and it is thought that
the Red Cross Society is the best body to continue the
work. Already the Victorian Division, in cooperation with
the Royal Melbourne Hospital, is building a Red Cross
donor centre and associated laboratories, and similar
expenditure is contemplated in other parts of Australia.
This is being done in the hope that the wonderful volun
tary service and the sustained devotion of donors, so
freely offered to save the lives of the fighting forces, may
be available to preserve these men, their wives and
children, during the long years of civilian reconstruction.

The medical profession should be the most energetic
helpers of the society in this life-saving enterprise. Prob
ably also the society will be compelled to request a
government subsidy to take care of financial aspects if
the blood and serum are to continue to be supplied free
of cost to the patient.

Rehabilitation of Disabled Service Personnel.

Towards the end of the war of 1914 to 1918 the then
newly constituted Repatriation Commission requested the
Red Cross Society to provide facilities for occupational
therapy. The service then started was maintained in
repatriation institutions in the years between the two world
wars. Materials and workshops were provided, together
with instructors, by means of which the men in hospitals,
sanatoria and mental institutions learned the methods of
basket-making, cabinet work and other craft work, not
only as a diversion but as an aid to restoration of health.

During the Middle East campaign, at the request of the
army, the Red Cross women hospital visitors commenced
handcraft instruction which served to some extent as
occupational therapy, under the direction of medical
officers.

In March, 1941, the Adjutant-General asked the Red
Cross to participate in rehabilitation work within Aus
tralia. The society was asked to act as agent for the
Army Education Service, and as liaison between the
medical officer and education service and between the
patient and the education service, and also to provide
handcrafts for relief of tedium. Medical social workers
were appointed as liaison officers and to supervise and
coordinate the handcraft work. Similar functions were
also accepted on behalf of the Royal Australian Air
Force Rehabilitation Section.

Although it was appreciated that, where hospital
patients were concerned, medical social workers could
suitably perform a liaison function for the education
service, the desirability of the direct importance of medical
social work as part of medical treatment was apparent
from the outset, and the Directors-General of Medical
Services of the Army and the Royal Australian Air Force
considered this early in 1943. They decided that medical
social work should be one of the facilities afforded by
their medical directorates, believing that more flexibility
could be achieved if such workers were not enlisted
service personnel. Accordingly it was decided that they
should be Red Cross personnel working under the com
manding officers of hospitals. The Director-General Medical
Services, Royal Australian Air Force, further expressed
the view that Red Cross medical social workers could give
continuity where medical officers wished to have a "follow-
up" of patients after their discharge from hospital.

In July, 1943, an army instruction made Red Cross
medical social workers directly responsible to the medical
services and no longer required them to function as agents
for the education service. At the same time Red Cross
handcraft workers were made responsible to army occupa
tional therapists. Instructions from the army and the
Royal Australian Air Force gave Red Cross medical social
work an official position in hospitals. Similar work was
undertaken for the navy. This set-up allowed greater
specialization in medical social case work under the
medical officers direction. In military hospitals, Where
matters that confront the civilian almoner (such as
arranging for special diets or other matters often affected
by the need for financial aid) do not arise, the patient as
an individual becomes more isolated as the main subject
of medical social work. Attention is then directed ta
problems of psychological adjustment to illness or dis
ability, when the medical officer considers this will con
tribute to the patient s recovery and to securing the
constructive acceptance of the patient s situation by his
family. Perhaps for such reasons Red Cross medical social
workers are most used in psychiatric cases and in those
in which mental disturbance is associated with some other
condition. In the obtaining of social histories at the
medical officer s request the national set-up of the Red
Cross service allows information to be easily obtained
from other States when necessary. This is done on a
considerable scale at one large psychiatric unit (114th
Australian General Hospital). Medical social workers
may also assist with post-discharge plans for those leaving
the services and provide follow-up investigations under
medical guidance. At large hospitals it has been found
that rapid turnover in staff and patients makes attention
to individual problems difficult.

At the end of 1943, it was apparent that there was a
great need for some care to be given to service personnel
discharged as medically unfit but not accepted for
benefits from the Repatriation Commission; the policy
| of the society was changed to provide case work service
for this class. Previously only those accepted by the
commission had been within the scope of Red Cross
service. Thus Red Cross social service is now available
to all service members in hospital and dischai ged on
medical grounds. For the latter, social service departments
of the Red Cross are established in all capital cities.

Service in both the hospital and the post-discharge
fields is carried out in cooperation with other agencies,
it being recognized that the Red Cross Society is
responsible for the sick and wounded and those discharged
as medically unfit. Commonwealth departments are now
beginning to develop a trained social worker staff, but
as the supply of workers that are even now needed will
not be available, close liaison will be necessary.

The society has accepted a proposal from the Director-
General of Manpower for the seconding of Red Cross
social workers for individual follow-up of selected disabled
ex-service personnel at a stated period after their first
placement through the Commonwealth Employment
Service. The object is to prevent serious maladjustments
which might prove difficult to eradicate, and also to provide

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FEBRUARY 9, 1946.

the opportunity to explore individual needs as a basis
for further development from that stage.

In November, 1944, "Gilbulla" Rehabilitation Farm was
established by the society in New South Wales. This is
a residential rehabilitation centre for men who, after
medical treatment, have some residual difficulty, either
organic or psychological, through which they are not yet
fit to take up training or return to a civilian job.
Cooperation with the Repatriation Commission and the
Commonwealth Department of Social Services is j
maintained.

Beginning with a proposal from the army in 1943, that
the society should help to meet the extreme shortage of
trained workers by subsidizing students in medical social
work, the Red Cross Society has developed a scholarship
scheme in social service, through which 48 students have
undertaken training. This number includes three senior
workers who have been granted scholarships to the Mental
Health Course of the University of London. As a further
contribution to the development of what is a young
profession in Australia, the society has agreed to provide
for a period subsidies to the Universities of Sydney,
Melbourne and Adelaide, to improve training facilities in
social work.

In 1932 the Victorian Council of Social Training was
formed. Sir Richard Stawell was its first chairman, and
showed great interest in what was then a new form of
training. When he retired he asked me to succeed him.
Now this body is merged with the Board of Social Studies
at the University of Melbourne. It is certain that
Stawell would have been delighted with the progress
of the organization which he so ably started and with
the valuable contribution made by trained social workers
during the war.

HAXDCRAKT SKKVICE.

The handcraft service was developed as a separate
operation. In general hospitals in Australia, Red Cross |
activity in. this regard comprised, under the scheme
approved by the Adjutant-General and the Director-
General Medical Services, assistance to the occupational
therapists who were appointed by the forces, to the
extent that medical officers may call upon Red Cross for
assistance in doing everything possible to relieve the
tedium of patients in hospital.

The organization of this service was placed in the
hands^of a well-trained director of handcrafts. She was
responsible also for the teaching of Red Cross hospital
officers, each of whom was required to undergo a fixed
minimum period of training. Training centres were set
up in each State with a central school in Melbourne.
The director was required also to maintain a steady flow
of materials to forward areas and base hospitals alike.
Owing to the few suitably trained occupational therapists,
some hospitals were without the service of these valuable
officers, while in forward areas Red Cross officers were
responsible only for providing diversional therapy. The
absence of occupational therapy departments often led
medical officers to rely on Red Cross workers to carry
out prescribed remedial work. This development laid
on the Red Cross Society the obligation to give to its field
hospital officers the best possible training in handcraft
work.

The development of the handcraft service during the
war was proof of its value to patients in hospitals from
base to forward areas. In the base areas it was guided
by professional handcraft workers, aided by teams of
voluntary workers. Its remedial value, apart from the
relief of tedium, was soon apparent.

The standard of work required was decided by the need
of patients and by medical advisers who knew what was
best for each patient. Experience showed, for example,
that a craft like weaving, with many fields to be explored,
was far more valuable to a long-term patient than to a
short-term patient, keeping him mentally alert as well as
fully occupied. Leather work, with stimulus of new
designs of varied articles, and leather plaiting could be
carried on by the patient when he was discharged from

hospital and returned to his unit located in some areas
like the Northern Territory, where tedium and boredom
were prevalent. The improvised work-bench was
encouraged to utilize resources at hand (for instance, in
North Queensland the lawyer vine was used for all types
and sizes of baskets, and in New Guinea pearl shell or
scrap duralumin was employed); this was preferable to
the sending forward of quantities of scarce and expensive
fancy materials, which would be out of reach of the
patient when he was discharged.

The popularity of this scheme created difficulties, and
it had to be controlled by being confined largely to men
referred by medical officers or ward sisters. Many stories
have been told of how patients have been working hard
on some activity, yet the handcraft worker or field
hospital officer has not known how to do the work
herself. One patient could teach string knotting to a
group, and gradually this would spread from ward to
ward until many were so occupied. It is certainly not
handcraft ability that is the most important attribute of
the Red Cross officer, but initiative to develop an idea
where she sees it an idea not always her own. Far
more benefit may be gained by the patient who has not
only employed himself, but also is thinking of others. It
was proved time and again that simply distributing
materials was of little value. The advice and comment
that went with the first job enabled the patient completing
another to say: "I never thought I could do this."

The value of this stimulus to a bored patient s interest
needs little emphasis and it is a service that needs for
its application women, well trained ami well selected, able
to fit into the hospital atmosphere, and ready to follow
medical guidance in achieving more rapid recovery for the
patient. It is a service for which medical and nursing
staffs, immersed in their all-absorbing duties, have not
the time. There is no doubt that, carried out in the
efficient way that characterized it, this service left a
lasting impression on the men and women who were laid
aside in service hospitals during the war.

The society employed 80 full-time handcraft workers
and 363 part-time voluntary assistants in Australia. These
figures d"o not include those hospital visitors or field
hospital officers in charge of handcrafts in both divisional
and forward areas, of whom there were more than 50
carrying out this service wherever hospitals were set up.

Psychiatric Problems.

Probably in no other war have the psychiatric problems
of members of the armed forces received so much real
attention from the battlefield to the period of return to
civilian existence. Much has been written on this subject,
some of it of first-class importance, some of it based on
misconceptions and ignorance.

Early in the war some public concern was expressed at
the apparent lack of treatment facilities in Australia for
this class of patient, and the society was approached to
do something about it. As a result the council offered the
Director-General Medical Services any assistance in its
power of which he might care to make use. One of the
first results of this offer was the appointment by the
Victorian Division of a trained psychiatric social worker
at the Heidelberg Military Hospital. The appointment
of a psychiatric sub-committee Lieutenant-Colonel H.
Maudsley and Major John Williams was made to the
National Medical Services Committee, whose advice and
guidance were constantly sought and freely given. A Red
Cross convalescent home at Kew, Victoria, with a bed
capacity of 100, was set aside to accommodate patients
referred from the psychiatric wards at Heidelberg, the
society furnishing the home with every facility needed
for the rehabilitation of the patients. The home
"Rockingham" achieved successful results under skilled
medical supervision.

TRANSPORT.

In some countries transport of wounded is mainly,
sometimes entirely, a responsibilty of the Red Cross
organization, a notable example being the United Kingdom,

FEBRUARY 9, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

175

where a large fleet of ambulances is maintained by the
Red Cross Society under military direction. The Australian
society laid its plans to render this service if this country
was invaded. It was known that at least up to July,
1938, the army had only two ambulances, apart from borne
horse-drawn vehicles of ancient type, while the navy had
one ambulance and part use of another. It was soon
obvious that the society would not be expected to provide
an ambulance service, and early in 1940 it was decided to
present ambulances as gifts to the various medical
services. Altogether 200 were presented through this
Red Cross channel, many of them being shipped to the
Middle East, where they were subsequently handed to the
British Red Cross.

A considerable volume of transport service was
rendered, however, in all States, in meeting convoys of
wounded, sick and prisoners of war arriving by ship",
aeroplane or ambulance train. Amenities not otherwise
available were also placed on air ambulances at each
landing place, while every hospital ship and ambulance
train was accompanied by Red Cross representatives
attached to the medical units in charge.

MEDICAL CONTROL OF RED CROSS SERVICK TO
PRISONERS OF WAR.

The most widely known service rendered by the Red
Cross Society in the late war was the provision of food
parcels, invalid foods and medical supplies for prisoners of
war. Where this help was able to be given fully, it was a
valuable aid in maintaining health and morale and some
times even life itself. The story gives point to the
status of the Red Cross Society and the neutral Inter
national Red Cross Committee. The Prisoners of Wai-
Code, formulated by the International Red Cross Com
mittee, and signed and ratified by most countries in 1929,
has little reference ta. the Red Cross, whose only duty
under the code is to establish an information bureau.
There is a reference to undefined Red Cross welfare
work, which must not be impeded, but the responsibility
for caring for the basic needs of prisoners of war is
placed on the captor nation, supervised by so-called
"protecting powers".

British and American authorities fully carried out the
obligations imposed on them in the care of enemy prisoners
of war, but unfortunately, Germany, Italy, Japan and their
allies failed to do so. Hence the vital need for Red Cross
aid. Germany, and to a lesser extent Italy, permitted this
aid to be given to a surprising extent, and it was carried
out largely on a cooperative basis, by national Red Cross
organizations, through the International Red Cross
Committee. Shipping difficulties, distance and danger from
enemy action were factors which caused the Australian Red
Cross Society to pay to have food parcels packed by the
Canadian Red Cross and to purchase other assistance
from the British organization.

The least known aspect of this vital service is the
close and expert medical supervision of the contents of
the standard food parcels supplied by the Red Cross
Society. This work was done by medical officers of the
British War Office. Similar analyses were made in Canada
and in the United States, and the procedure was closely
followed by our own medical department. The nutritive
value of the main basic commodities and their alternatives
were estimated in terms of Calories, protein, calcium,
iron, vitamins A, B and C, riboflavin and nicotinic acid.
Calculations were made of the nutritive value of foods
in each standard parcel, and the average value of each
parcel was arrived at. From this was calculated the
average value per week and per day. On figures supplied
by the War Office the standard German and Italian
prisoners of war ration was analysed. The fiures obtained,
added to those obtained from the analysis of standard
food parcels, gave the available food values per man per
day, which were compared with optimum requirements.
From these calculations shortages in various constituents
were estimated as well as some excess values. It was
possjble to control by this means the amount of fortifica
tion necessary in various food commodities. Similar

analyses of Japanese rations were made by the Ministry
of Food, based on data supplied by the International Red
Cross delegates. Compared with optimum requirements,
there were, as might be expected, considerable deficiencies.

Immediately on the outbreak of war with Japan the
Medical Service Committee of the Australian Red Cross
Society, in anticipation of the capture of Australians, and
in the false belief that the Japanese would permit the
Red Cross service to operate as in Europe, devised a food
parcel having regard to the basic national foods of Japan.
This parcel was later accepted with slight modifications
by the medical officers of the British War Office. The small
amount of relief permitted subsequently by Japan is too
well known.

Similar medical advice controlled the contents of invalid
food parcels, which were accompanied by detailed direc
tions as to their appropriate use. Medical and surgical
equipment, drugs, dressings and special appliances not
provided in sufficient quantities or variety by captor
countries were dispatched through the International Red
Cross" Committee, largely on requisition sent by medical
officers in prisoner-of-war camps.

Blinded prisoners were provided with appropriate equip
ment and instruction on the lines adopted at Saint
Dunstan s Hospital, while a similar service was rendered
to those who had become deaf. Textbooks were sent to
medical officers, while the education service provided had
definite medical value in prison camps.

The excellent results obtained in the maintenance of
health amongst prisoners of war in Europe where Red
Cross aid was available can be largely attributed to the
close association of the medical profession in this service.

Although the" Japanese authorities at the outset
announced tl^at they would observe the Geneva Con
vention, no such regular service was ever permitted.
Large quantities of food parcels and medical supplies
were prepared under close medical supervision, but very
little of this ever reached the prison camps.

EDUCATION IN NUTRITION.

When, in 1942, food rationing was commenced in this
country, the society felt that it should assist in order
that the best use should be made of the more limited
food supplies. Although Australia was never really short
of food, there has always been too much malnutrition.

It had been urged by the National Health and Medical
Research Council that a widespread national campaign
should be initiated to ensure a complete and adequate
supervision over the diet of the community, and that this
provided important work for the Women s organizations
throughout Australia. From every survey made it has
been shown that varying degrees of malnutrition exist in
Australia and that much ill health, both physical and
mental, is due to the inadequacy of our diet. Bad dietary
habits may be the result of economic hardship; but a
great deal of the blame can be attributed to ignorance on
the part of many persons as to food needs and food values.

The Nutrition Service of the Australian Red Cross
Society was therefore inaugurated to assist the Common
wealth Government in the task of disseminating know
ledge of the principles of nutrition to the Australian
people. In an effort to educate men, women and children
as to what constitutes a "balanced diet", the Australian
Red Cross Society arranged for nutrition campaigns to
be conducted in the various States of the Commonwealth.
This work was commenced more than eighteen months
ago, and since then the society has slowly enlarged its
sphere of activities to meet the needs of the Australian,
community.

A Red Cross National Nutrition Committee was formed
within the medical department. It included medical
specialists and trained dietitians, nominated by their pro
fessional organization. Two trained dietitians were
appointed to the staff at national headquarters. As they
work in cooperation with the Commonwealth Department
of Health and the State Nutrition Committee, their
activities are confined to those spheres not being adequately-
dealt with by other authorities.

176

THE MEDICAL JOURNAL OF AUSTRALIA.

FEBRUARY 9, 1946.

Elementary nutrition courses have been conducted in
cities and in many country towns. To these, members of
the public, Red Cross personnel and representatives from
different women s organizations are invited. In addition,
the dietitians visit schools, teachers colleges, parents
associations, women s organizations and youth clubs, giving
single talks on nutrition. Pamphlets, posters, charts and
strip films have been prepared to assist the programme,
and efforts are being made to arouse interest in nutrition
problems affecting the health and welfare of the Australian
people. For those unable to attend lectures, broadcast
talks have been arranged, and from time to time articles
are published in the city and country Press dealing with
"food facts" with which all should be familiar.

Through these activities it has been possible to make
contact with a large section of the public. However, the
work is only in its infancy at present; but it is hoped
to extend it considerably in the near future, as it is
thought that by doing so the Red Cross will be performing
a valuable service, particularly in the post-war years.

EDUCATION IN HOME MANAGEMENT.

The society has also sponsored a course of lectures in
"home management, as it is considered that the greatest
contribution women can make to the peace and happiness
of the post-war world is to foster the art of home-making.
The primary object of the course is to stimulate the wives
and relatives of returning men to prepare themselves to
become better housewives and home-makers, so that the
best possible conditions will be available for their menfolk
after their long absence. Through the willing cooperation
and help of the domestic science schools in Victoria, a
series of ten lectures and demonstrations has been given
in Melbourne and some country areas. The subjects dealt
with have included cookery, laundry work, housewifery,
budgeting, marketing and nutrition. It is hoped shortly
to establish this project in New South Wales and Queens
land and to enlarge upon it so as to include various other
subjects which will prove useful to all home-makers, both
men and women.

An interesting phase of this campaign of education has
been the experiment being conducted at the Royal Mel
bourne Hospital by the Victorian Division on the sug
gestion of Dr. Ivan Maxwell. A qualified dietitian has
been installed in quarters provided ,by the board of
management, solely to give instruction in home food
management to patients and their friends referred by
medical and other officers. This dietitian has no relation
to the dietetic treatment prescribed for patients.

OTHER ACTIVITIES.

Other activities were carried on during the war and are
still being conducted. The limits of time and space debar
more than a brief mention of some of them, and as the
Chairman of the American Red Cross recently remarked,
"medical and health problems touch virtually every aspect
of Red Cross activities". The Red Cross Society is a
permanent organization and two points form its basic
principles succour for all victims of war without dis
tinction, and the struggle against human suffering in all
its forms.

The service has been available to all civilian sufferers
from the war to merchant seamen, civilian internees,
people evacuated to this country from enemy-occupied
territories, and the inhabitants of devastated countries in
Europe and Asia. While medical supplies, clothing, food
and other commodities and financial aid were sent to the
United Kingdom and on the Continent to France, Norway,
Poland, Yugo-Slavia, Czechoslovakia, Russia and Albania,
special aid was rendered to Greece and Crete and to
countries liberated from the Japanese. Large relief ship
ments and specialist teams of relief workers were sent
to the people of Greece, in recognition, not only of their
great need, but of their kindness to Australian soldiers.

For the relief of liberated prisoners of war and internees
in Asiatic and Pacific territories, many tons of relief goods
have been sent. A relief ship was chartered and loaded

with 4,500 tons of goods; it resembled a floating warehouse.
These were the first supplies available in these areas
other than the Philippines, and at the present moment the
society s workers are distributing them in Singapore,
Saigon, Hong-Kong, Shanghai and Borneo and in Australian
territories.

Medical supplies have been sent to China, and requests
are coming in even now each day almost for more and
more aid, especially in Dutch islands and in French
Indo-China.

Civilian needs within Australia during the war absorbed
much of the society s attention. Disasters such as bush-
fires and epidemics, shortage of nursing staffs in hospitals,
and assistance in tuberculosis clinics, in promoting mass
radiography and in immunization schemes, have taxed the
available service to the utmost, as did the now almost
forgotten civil defence measures when invasion threatened
this country.

Conclusion.

A sincere tribute is offered to the hundreds of thousands
of Australians, mainly women, who by their sacrifice and
work, mostly given anonymously, carried on so vigorously
this vast constructive and practical organization of sym
pathy and aid to those who suffered during the war.

Although peace of a sort has come to this earth, much
work in the field of social service remains yet to be done.
The Red Cross is the name and emblem of a great labour
of love and mutual aid, in which all nations have been
brought together. It embodies the idea of brotherly help,
systematic, truly neutral, remote from national, religious
and social differences, voluntarily enlisted in the struggle
against human suffering. It is inconceivable that such a
united will to help in all times of need should be per
mitted to disintegrate because fighting has ceased. Recently
a soldier wrote: "May the Red Cross go on for ever." It
will so long as humanity needs it. The universal applica
tion of its spirit throughout the world surely would do
more for permanent peace than the political systems. But
Dr. Huber, the great President of the International Red
Cross, has said:

To see in the pacification of the world by the rule of
justice the supreme goal of all politics and to work
towards that goal with energy and confidence, does not
mean that we should shut our eyes to the fact that
recourse to violence has not yet been made impossible,
human instincts being what they are, demoniac and
nature bound still. This being so, we must still stand
ready to help when the need arises so that in the midst
of awful havoc, the Red Cross on the white field may
continue to bear aloft the symbol of fraternity.

The Australian Red Cross Society will carry on and will
value the continued and extending assistance of the
medical profession.

ACQUIRED RESISTANCE OF STAPHYLOCOCCI TO
THE ACTION OF PENICILLIN.

By E. A. NORTH and R. CHEISTIE,

From the Commonwealth Serum Laboratories,
Melbourne.

SPINK, Hall and Ferris (1945) failed to find a strain of
staphylococcus not previously exposed to penicillin that
was not inhibited by one unit of penicillin per millilitre,
although more than 100 strains were tested. This is in
accord with our own findings (North and Christie, 1945),
that whilst naturally occurring penicillin-resistant staphy-
lococci are at the most rare, a large proportion of the
strains isolated from wounds in patients undergoing pro
longed penicillin treatment showed considerable resistance
as judged by standard sensitivity tests. There was, how
ever, no definite evidence to indicate whether the resistant
strains were the direct descendants of sensitive organisms

FEBRUARY 9, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

177

TABLE I.
Characteriftics of Staphylococci Itolated from Leg Wound of Patient W33.

Date
Isolated.

Serial
Number of
Strain.

Coagulase
Formation.

Fibrinolysis.

Haemolysis. 1

Pigment
Formation. 1

Mannitol
Fermentation.

Serological
Typing.*

Penicillin
Resistance.*

7.6.45
15.6.45
21.6.45

S948
S962
8938

+
+
+

+
+

a
$

Aureus + + + +
Aureus + -f- + +
Aureus + + + +

+ 1
+1

+ 1

III-VI
III-VI
Ill-ATI

0-6 unit
2-5 unite
10 units

1 Haemolysis is recorded as observed on 5% sheep blood agar.

* Pigment is graded with regard to intensity ("Aureus + + + +" indicates intense pigment formation).

* The "+" sign indicates fermentation, and the numeral the day on which fermentation is complete.

* The Roman numerals indicate the type sera which cause agglutination.

* Resistance is recorded as the highest concentration in units per millilitre of penicillin in broth in which growth is apparent (even if slight) after twenty-
four hours.

already in the wounds or were the result of cross-infection,
either with naturally resistant strains or with odd strains
that had acquired resistance and had become disseminated
through the wards.

In the course of further work (to be published) some
penicillin-resistant Staphylococci were encountered which
with little reasonable doubt could be regarded as variants
of sensitive parent organisms, which had developed their
resistance to penicillin in vivo. The finding of such vari
ants enabled us to compare the reactions, particularly in
laboratory animals, of the variants which had developed
resistance to penicillin in vivo with variants which had
acquired resistance in vitro.

The observations recorded in this communication con
firm the general conclusions reached by Spink, Hall and
Ferris (1945) with regard to the difference between
variants whose resistance has been developed in vivo and
variants whose resistance has been developed in vitro.
They also show that the former retain full pathogenicity
as judged by animal experiments, and that the penicillin
resistance demonstrated by tests in vitro can also be shown
in tests in laboratory animals that is, in vivo.

Materials and Methods.

Penicillin-Resistant Variants of Normally Sensitive

Strain Developed in Vivo.

Three cultures, S948, S962 and S988, were isolated on the
dates shown in Table I. This table also shows their
various biological and metabolic characteristics. Sero
logical typing was done by slide agglutination (Christie
and Keogh, 1940), whilst tests for penicillin resistance
were carried out as previously described (North and
Christie, 1945). S962 and S988 are regarded as true
penicillin-resistant variants of S948.

In the animal experiments to be described, the reactions
of S988 were compared with those of S948.

Penicillin-Resistant Variants of Standard Sensitive
Strain F.D.A. 209, Developed in Vitro.

Penicillin-resistant variants of standard sensitive strain
F.D.A. 209 were developed in vitro by daily subculturing
of strain F.D.A. 209 in increasing concentrations of peni
cillin in nutrient broth. As the strain developed increasing
resistance, agar slopes were inoculated from the tube
containing the highest concentration of penicillin in
which growth occurred. Such cultures were preserved
under paraffin for future reference and testing, and were
designated F.D.A. 209/1, F.D.A. 209/10, and so on, up to
F.D.A. 209/160, the denominator indicating the highest
unitage of penicillin per millilitre of broth in which the
variant would grow.

Mouse Pathogenicity Tests.

Mouse pathogenicity tests were carried out as previously
described (North and Christie, 1945), except that a range
of dosages was employed to find the actual killing effect
of the strains compared. The dose was always made up to
a volume of one millilitre with normal saline solutisn,
and its strength was estimated by the use of Burroughs
Wellcome standard opacity tubes.

Comparison of Results of Penicillin Therapy in Staphy-

lococcal Infections in Mice with Sensitive (S948)

and Resistant (#988) Strains.

The infecting dose was that used in our standard mouse
pathogenicity test (4,000,000,000 organisms), and the
penicillin dosage was based on the report of Warmer and
Amluxen (1945), in which they found that it was necessary
to give 200 units per gramme of body weight every one
and a half hours to maintain a concentration of one unit
per millilitre. Further details will be given when the
actual experiment is being described.

Standard Biochemical Tests.

Tests for coagulase production, fibrinolysis, haemolysis,
pigment formation and penicillin sensitivity were carried
out as described previously (North and Christie, 1945;
Christie, North and Parkin, 1945).

Results.

Comparison of the pathogenicity for mice of strains S948
(penicillin-sensitive) and S988 (penicillin-resistant) shows
(Table II) that their killing power is identical within
the limits of experimental error. Further reference to
Table I shows that this similarity is combined with only
one observable difference resistance to penicillin as tested
in vitro.

TABLE II.

Effect on Mice of Living Cultures of Penicillin-Sensitive Stapkylococcut, 5948,
and of Penicillin-Resistant Variant, S988.

Culture.

Number of
Organisms.
(Millions.)

Number of
Mice.

Result After
Twenty-four
Hours. 1

S948

4,000

+ + + + +

8948

2,000

+ + + + S

8948

1,000

+ + + + s

8948

500

8 S 8 8 8

8988

4,000

+ + + + +

8988

2,000

+ + + + +

8988

1,000

+ + S S S

8988

500

8 S 8 S 8

x The symbol "+" indicates death ; "S" indicates survival of mouse.

Once the fact was established that S948 and S988 were
equally lethal for mice, the ability or otherwise of peni
cillin to prevent death in mice was investigated. Four
groups of mice, A, B, C and D, each consisting of ten
animals of equal weight (20 grammes), were used. Groups
A and C were left untreated, whilst the mice of groups
B and D were given 4,000 units of penicillin intraperi-
toneally at 8.45 a.m. and again at 10.15 a.m. Mice of
groups A and B were then infected with S948 organisms
intraperitoneally, and mice of groups C and D with S988
organisms (penicillin-resistant variants). The order of
infecting the mice was such that the penicillin-treated
animals received the living Staphylococci fifteen to twenty
minutes after the second dose of penicillin. The mice in
groups B and D received a further 17,000 units spread
over three doses at intervals of three hours, the first dose
being given one hour after the infection with Staphylococci.

178

THE MEDICAL JOURNAL OF AUSTRALIA.

FEBRUARY 9, 1946.

TABLE III.
Demonstration of Penicillin Resistance in Staphylococci by Mouse Inoculation.

Strain of

Penicillin

Number of

Total Units

Group of

Infecting

Resistance Organisms.

of Penicillin

Number of

Result. 1

Mice.

Staphylococci.

in Vitro.

(Millions.)

Administered.

Mice.

S948

0-6 unit 1

4,000

Nil

++++++++++

S948

0-6 unit

4,000

25,000

ssssssssss

S988

10 units

4,000

Nil

++++++++++

S988

10 units

4,000

25,000

++++++++++

1 The result was read twenty-four hours after the mice were infected intraperitoneally, and seventeen hours after groups B and D had their final doses of
penicillin. The symbol "+" indicates death; "S" indicates survival of meuse.

1 The standard penicillin-sensitive strain F.D.A. 209 used as a control when resistance was being estimated in vitro gave the same result as 8948.

The penicillin solution used contained 25,000 units per
millilitre, and each mouse treated received one millilitre
in divided doses.

The result of this experiment (Table III) is similar
to that of one recorded by Warmer and Amluxen (1945),
in that penicillin saved the mice infected with a penicillin-
sensitive strain, whilst similar treatment failed to protect
mice against infection with a penicillin-resistant staphylo-
coccus. Our experiment is of added interest, since the
resistant staphylococcus is almost certainly a direct descen
dant of the sensitive strain S948.

The penicillin-resistant variant F.D.A. 209/160, developed
in vitro, was found to differ considerably from the parent
strain F.D.A. 209 in its biological and metabolic charac
teristics. It grew poorly on nutrient agar and the colonies
were smaller than the usual staphylococcal colonies. Little
pigment was formed, and some /3 haemolysis was evident
on sheep s blood and agar. Mannitol fermentation was only
slightly slower, but the variant still produced coagulase,
although not so rapidly as F.D.A. 209. On the other hand,
in poorness of growth, reduced size of colonies and almost
complete lack of opacity in colonies, it could not be said
to resemble closely any strain pathogen or non-pathogen
that we have isolated from living tissues.

On repeated subculture in nutrient broth of strain
F.D.A./160, its characteristics reverted to those of the
parent strain, including its sensitivity to penicillin. The
same alteration in characteristics was shown by the less
resistant variants F.D.A./l and F.D.A./10. These changes
did not run parallel with increased resistance to penicillin;
they appeared to precede it.

The killing doses in mice of living cultures of F.D.A. 209
and its resistant variants, particularly F.D.A. 209/160,
were investigated with the result shown in Table IV. It
will be noticed that strain F.D.A. 209 kills within exactly

TABLE IV.

Fatal Dose for Mice of Living Culture of Standard Penicillin-Sensitive Strain

F.D.A. 209 and of Three Variants with Resistance to Penicillin developed

in Vitro.

Culture.

Infecting Dose.
(Millions of
Organisms.)

Number of
Mice.

Result After
Twenty-four
Hours. 2

F.D.A. 209 1 .
F.D.A. 209 ..
F.D.A. 209 ..
F.D.A 209

3,000
2,000
1,000
500

5
5
5
5

S S S S S

F.D.A. 209/160
F.D.A. 209/160
F.D.A. 209/160
F.D.A. 209/160

32,000
16,000
8,000
4,000

2
6
7
5

+ +

-f + S S S S
S S S S S S S
S S S S S

F.D.A. 209/10
F.D.A. 209/10

6,000
4,000

1
5

S
S S S S S

F.D.A. 209/1

4,000

S S S S S

1 For particulars of F.D.A. 209 and its variants, see text.
Symbol "+" indicates death; "S" indicates survival of mo

the same range as S948 and S988 (see Tables II and IV),
whilst F.D.A. 209/160 is almost completely avirulent.
(Suspensions of killed organisms from non-pathogenic
strains are lethal for mice in doses of 100,000,000,000.)

The killing power of strain F.D.A. 209/10 was not tested
in a higher dosage than 6,000,000,000, as many non-patho
genic strains cause mice to appear ill with this dosage.
After injection of organisms F.D.A. 209/10 the mice
remained perfectly well.

A rabbit was injected intravenously with one millilitre
of a twenty-four hour broth culture of F.D.A. 209/160. On
the day following the injection the rabbit looked perfectly
well. An attempt to recover the organism from the blood
was successful, and the staphylococcus was found to be
still resistant to 160 units of penicillin per millilitre.
Further attempts at blood culture failed, and the rabbit
suffered no apparent ill effects.

As a further check on the validity of the results
obtained in mice, 0-5 millilitre of a twenty-four hour broth
culture of F.D.A. 209 was injected intravenously into a
rabbit, which died within twenty hours. Another rabbit
similarly dosed with a culture of F.D.A. 209/10 remained
perfectly well.

It has been shown that a penicillin inhibitor can be
extracted from Staphylococci that have acquired resistance
in vivo (Spink, Hall and Ferris, 1945), but not from
resistant variants developed in vitro. By two methods,
both differing from that referred to by Spink et alii, we
have confirmed this.

Selected strains were grown overnight in broth, and
penicillin was added in graded amounts to quantities of
10 millilitres of the sterile filtrates. The tubes were then
inoculated with the standard sensitive strain, F.D.A. 209,
and reincubated. Growth occurred in the two filtrates
from resistant strains developed in vivo, when the peni
cillin concentration was as high as 2-5 units per millilitre.
With the filtrates from the standard sensitive strain itself
and from a resistant variant (F.D.A. 209/160) developed
in vitro, the highest concentration of penicillin in which
growth occurred was 1/32 unit per millilitre. .

Two resistant strains developed in vivo and one developed
in vitro were "spot inoculated" on the centre of nutrient
agar plates containing 2-5 units of penicillin per millilitre
and incubated overnight. A streak inoculum of the
standard sensitive strain (F.D.A. 209) was then made
across the medium, passing close to each central colony.
On further incubation growth from the streak inoculum
of the sensitive strain occurred near the colonies of the
resistant strains developed in vivo. No growth occurred
near the colony of the resistant variant (F.D.A. 209/160)
developed in vitro.

Discussion.

Spink, Ferris and Vivino (1944) stated that "probably
of considerable clinical importance is that an increased
resistance to penicillin is accompanied by the development
of strains which are more susceptible to the bactericidal
action of whole blood, and possibly to the other defence
mechanisms of the host". This conclusion appears to have
been based mainly on experiments conducted on resistant
variants developed in vitro, and Spink and his associates
(1945) have recently modified this view. They now con
sider that the resistance to penicillin which has been
developed by in vitro methods is only a temporary charac
teristic of the organisms, whilst resistance acquired in
vivo as a result of therapy with penicillin appears to be
a more permanently acquired property. They state that

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FEBRUARY 9, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

179

the organisms which have become resistant to penicillin
in ihe human body are as resistant to the bactericidal
action of human blood as the penicillin-sensitive parent
strains in other words, they retain their full patho-
genicity.

Our results tend to confirm the later views of Spink and
his associates, especially with regard to the invasiveness
of the strains which have developed resistance in the
human body. In our experience it has not been easy to
trace the direct development of resistance in a strain in
infected war wounds. However, there is little room for
doubt in the instance recorded by us, as strains sero-
logically resembling S948, S962 and S988 are uncommon.

So far there is little evidence that these resistant
strains developed in vivo have been a major cause of
failures with penicillin. However, Anderson, Howard and
Rammelkamp (1944), reporting on the penicillin treatment
of a series of patients suffering from chronic osteomye
litis, tested the sensitivity of the organisms before therapy;
at intervals the organisms which persisted in the lesions
were tested again. In two cases cultural examinations
made a year after completion of penicilin therapy showed
the organisms to be still resistant to penicillin.

Six resistant strains isolated from infected wounds
treated with penicillin have been subcultured in this
laboratory every day in nutrient broth for a period of
thirty days. At the end of that time they showed the
same resistance to penicillin as at the beginning, and they
also showed all their former properties indicating full
pathogenicity and invasiveness. One of these strains was
three times subjected to animal passage, being given intra
venously to a rabbit and recovered post mortem; after
the third passage its resistance to penicillin as tested in
vitro had not altered.

Warmer and Amluxen (1945), in experiments (already
referred to) using mice, found that a penicillin-resistant
haemolytic staphylococcus proved to be resistant to con
centrations of penicillin in vivo comparable with those
in vitro. The strain which was isolated from an abscess
following osteomyelitis treated with penicillin was found
by laboratory tests to be resistant to concentrations of
penicillin below 10 units per millilitre. The experiment
(see Table III) carried out by us, and based on Warmer
and Amluxen s report, completely confirmed their findings.

Evidence such as that contained in the reports of Spink
et alii (1945), Anderson et alii (1944), Warmer and
Amluxen (1945), together with our own experience, sug
gests that penicillin-resistant staphylococci may become a
clinical problem of the future.

Conclusions.

1. Penicillin-resistant staphylococci developed in vivo
are as highly pathogenic for laboratory animals as the
sensitive parent organisms.

2. Resistant variants developed in vitro are not patho
genic for laboratory animals.

3. Staphylococci in which resistance has been developed
in the human body following penicillin treatment kill
mice in spite of the administration of large amounts of
penicilliH.

Bibliography.

D. G. Anderson, L. G. Howard and C. H. Rammelkamp :
"Penicillin in the Treatment of Chronic Osteomyelitis. Report
of 40 Cases", Archives of Surgery, Volume XLIX, October,
1944, page 245.

R. Christie and E. V. Keogh : "Physiological and Serological
Characteristics of Staphylococci of Human Origin", The Journal
of Pathology and Bacteriology, Volume LI, 1940, page 189.

R. Christie, E. A. North and B. J. Parkin : "Criteria of
Pathogenicity in Staphylococci", 1945 (to be published).

E. A. North and R. Christie : "Observations on Sensitivity of
Staphylococci to Penicillin", THE MEDICAL JOURNAL OF AUS
TRALIA, Volume II, July 14, 1945, page 44.

W. W. Spink, U. Ferris and J. J. Vivino : "Antibacterial
Effect of Whole Blood upon Strains of Staphylococci Sensitive
and Resistant to Penicillin", Proceedings of the Society of
Experimental Biology and Medicine, Volume LV, 1944, page 210.

W. W. Spink, W. H. Hall and U. Ferris : "Clinical Significance
of Staphylococci with Natural or Acquired Resistance to the
Sulphonamides and to Penicillin", The Journal of the American
Medical Association, Volume CXXVIII, June 23, 1945, page 555.

H. Warmer and J. Amluxen : "Comparison of In Vitro and
In Vivo Penicillin Resistance of a Strain of Hsemolytic Staphy
lococcus Aureus", The Journal of Laboratory and Clinical
Medicine, Volume XXX, May, 1945, page 419.

PLEUROPNEUMONIA-LIKE ORGANISMS IN CASES OF

NON-GONOCOCCAL URETHRITIS IN MAN AND IN

NORMAL FEMALE GENITALIA.

By W. I. B. BEVERIDGE, A. D. CAMPBELL and

PATRICIA E. LIND,

From the Walter and Eliza Hall Institute of Research

in Pathology and Medicine, and the Animal Health

Research Laboratory, Council for Scientific

and Industrial Research, Melbourne.

DI-RIXG the present war, about half of the cases of
urethritis among men in the Australian armed services
have been non-gonococcal. Most of these cases of so-called
non-specific urethritis conform to the following fairly
well-defined disease entity: the discharge is usually serous
or milky and small in amount, little or no pain occurs on
urination, there is no definite response to penicillin or
sulphonamides, and in smears are found polymorpho-
nuclear and epithelial cells. There is always a history of
venereal contact, the incubation period being between
seven and twenty-one days in two-thirds of our cases.

Complement Fixation Tests.

In 1940 Dienes reported the isolation of pleuropneumonia-
like organisms from the cervix of five women, and later
he and Smith (1942) isolated these organisms from 23 of
77 cervical swabs from women and from four men suffering
from prostatitis. Klieneberger-Nobel (1945) cultivated
pleuropneumonia-like organisms from the vagina of from
14% to 40% of women, some of whom were suffering from
venereal disease and some of whom were apparently
normal.

In 1943, Beveridge, seeking the cause of non-specific
urethritis, isolated pleuropneumonia-like organisms from
four of twenty-four patients. This led Dr. A. Neave
Kingsbury (personal communication) to carry out comple
ment fixation tests with serum from patients with venereal
disease, using antigen prepared by one of us (A.D.C.) from
the bovine pleuropneumonia organism. Kingsbury obtained
a number of positive reactions, but there was no clear
association between the results of the tests and the
patient s clinical condition. We had a similar experience
using antigen prepared from the bovine organism.

Antigen for complement fixation tests was prepared from
two strains of pleuropneumonia-like organisms isolated
from patients suffering from non-specific urethritis. The
technique of the tests and the preparation of the antigen
were as used for bovine contagious pleuropneumonia
(Campbell and Turner, 1936; Campbell, 1938). In the first
few batches of serum there was a striking correlation
between the results of the tests and the clinical condition;
of 62 specimens of serum from patients suffering from
non-specific urethritis in New South Wales, 57 gave positive
results, whereas only seven positive results were obtained
from 98 specimens of serum from normal blood donors in
Melbourne. However, subsequently only 22 positive results
were obtained with 66 specimens of serum from patients
suffering from non-specific urethritis in Victoria, and 44
positive results were obtained among 158 specimens of
serum sent in for Wassermann testing. The majority of
the last-mentioned subjects presumably were not suffering
from non-specific urethritis.

Cultural Investigations.

Since publication of the earlier series of cultural studies
by Beveridge mentioned above, Johnston and McEwin
(1945) isolated two strains from cases of non-specific
urethritis in South Australia. Urethral smears from each
of these patients contained cytoplasmic inclusions, which
these authors suggested might be manifestations of either
the pleuropneumonia-like organism or a virus. Dr. S. E.
Williams (personal communication) has observed similar
inclusions in smears from patients suffering from non
specific urethritis. He also saw extracellular forms, and
considered that those inside and outside the cells were
pleuropneumonia-like organisms, as they closely resembled
such organisms seen in smears from mouse lung.

180

THE MEDICAL JOURNAL OF AUSTRALIA.

FEBRUARY 9, 1946.

We have recently culturally examined 70 urethral wash
ings from patients suffering from non-specific urethritis
by means of the semi-solid medium previously described
(Beveridge, 1943), with the modification that only one tube
was sown with each specimen and penicillin was added
to a concentration of about 20 units per millilitre. Pleuro-
pneumonia-like organisms were isolated from 14, and in
most of these instances they were present in large numbers
in the primary culture. Attempts at culture of the
organisms from 67 normal male medical students yielded
no positive results. Dr. Ella Macknight cooperated in the
investigation by examining 11 women from whom men had
contracted the disease. These women all had some erosion
of the cervix, usualy of mild degree. Cultures of pleuro-
pneumonia-like organisms were obtained from three of 11
swabs from the cervix of these women. Dr. Macknight also
collected swabs from the cervix and vulva of 101 appar
ently normal women attending the gynaecological clinic of
a public hospital. Positive cultures were obtained from 17
of these women. In three instances the organisms were
grown from the vulva and not from the cervix, in two from
the cervix and not from the vulva, and in seven from
both; in the remaining five instances the region was
unspecified. There were no obvious cultural differences
between the strains from the normal women and those
from women suffering from non-specific urethritis.

Investigation of Respiratory Infections.

Since there was such poor correlation between the results
of the serological tests and the clinical condition of the
genital tract, investigations were undertaken in an attempt
to trace the origin of the positive serological reactions.

Eighteen specimens of serum from 72 patients suffering
from febrile upper respiratory tract infections gave posi
tive results to complement fixation tests against antigen
made from pleuropneumonia-like organisms isolated from
patients suffering from urethritis. In ten instances serum
taken at the time of infection gave negative results, while
that obtained from the same person during convalescence
gave a positive response to complement fixation tests.
However, in four instances the reverse occurred.

Seventeen specimens of serum from 24 patients with
atypical pneumonia yielded positive results.

Attempts were made to grow pleuropneumonia-like
organisms from material from four patients suffering from
atypical pneumonia, from 57 washings from infected antra,
and from 70 excised tonsils. No cultures were obtained.

Discussion.

The results of both cultural and serological studies
have failed to clarify the significance of pleuropneumonia-
like organisms in non-specific urethritis as seen in Aus
tralian servicemen.

For the present we must leave out of consideration the
results of the complement fixation tests, which are con
fusing. The positive reactions may be non-specific or may
be due to infection with pleuropneumonia-like organisms
in some part of the body other than the urethra.

The main objections to the hypothesis that non-specific
urethritis is principally or wholly due to infection with
pleuropneumonia-like organisms are (i) the failure to
obtain a growth of the organisms in 80% of cases and (ii)
their presence in about 20% of normal women.

1. It was not possible, in the circumstances in which
the work was done, to make repeated attempts at culture
from the same subject. Pleuropneumonia-like organisms
are relatively delicate, and it is easy to imagine circum
stances in which they might fail to appear in culture
although they were primarily responsible for the clinical
condition. Such factors might account, at least to some
extent, for the rather small proportion of positive results
we obtained.

2. The existence of pleuropneumonia-like organisms in
the genital tract of a considerable proportion of women
showing no clinical evidence of infection cannot be
regarded as evidence against the view that this group of
organisms is responsible for non-specific urethritis in the
male. It would be in line with general concepts of the

ecology of bacteria of low potential pathogenicity for
example, pneumococci and meningococci in the throats to
find such a state of affairs. Non-specific urethritis in the
male is often, perhaps usually, so trivial that it would
be likely to escape attention in civil life.

Certainly no conclusion is justified on the present evi
dence; but all the facts available are nevertheless con
sistent with the tentative hypothesis that the disease is,
in the majority of cases, the result of infection by pleuro
pneumonia-like organisms.

Summary.

Complement fixation tests against pleuropneumonia-like
organisms isolated from urethritis produced positive
reactions with a proportion of specimens of serum from
persons suffering from various complaints, but there was
no clear correlation with any clinical condition. These
organisms were isolated in 20% of cases of non-specific
urethritis among males and from 17% of swabs from the
genital tract of normal women. None were detected in
normal men. The interpretation of these results is
discussed.

Acknowledgements.

These investigations were carried out in collaboration
with the Australian Army and the Royal Australian Air
Force. We are indebted to Major C. G. B. Colquhoun, to
Squadron-Leader K. McLean, and to Lieutenant A. Stewart
for selection of cases.

Bibliography.

W. I. B. Beveridge : "Isolation of Pleuropneumonia-Like
Organisms from the Male Urethra", THE MEDICAL JOURNAL OF
AUSTRALIA, Volume II, 1943, page 279.

A. D. Campbell : "Contagious Bovine Pleuropneumonia : A
Report on the Use of New Antigens for the Complement-
Fixation and Agglutination Tests", The Journal of the Council
for Scientific and Industrial Research, Volume II, 1938, page
112.

A. D. Campbell and A. W. Turner : "Studies on Contagious
Pleuropneumonia of Cattle : II. A Complement Fixation Reaction
for the Diagnosis of Contagious Bovine Pleuropneumonia",
Council for Scientific and Industrial Research, Australia,
Bulletin Number 97, 1936, page 11.

L. Dienes : "Cultivation of Pleuropneumonia-Like Organisms
from Female Genital Organs", Proceedings of the Society for
Experimental Biology and Medicine, Volume XL1V, 1940, page
46S.

L. Dienes and W. E. Smith : "Relationship of Pleuro
pneumonia-Like Organisms to Infections of the -Human Genital
Tract", Proceedings of the Society for Experimental Biology and
Medicine, Volume L, 1942, page 99.

G. A. W. Johnston and J. McEwin : "Non-Gonococcal Ure
thritis : Considerations of ^Etiology ; Findings in Two Cases",
THE MEDICAL JOURNAL OF AUSTRALIA, Volume I, 1945, page 369.

E. Klieneberger-Nobel : "Pleuropneumonia-Like Organisms in
the Human Vagina", The Lancet, Volume II, July 14, 1945,
page 46.

EARLY RESULTS IN A SHORT SERIES OF CASES OF
GUNSHOT WOUNDS OF THE ABDOMEN.

By THOMAS F. ROSE,
Major, Australian Army Medical Corps,

ARTHUR NEWSON,
Major, Australian Army Medical Corps,

AND

DONALD WATSON,
Major, Australian Army Medical Corps.

IT is the purpose of this communication to present the
early results in 27 cases of gunshot wounds of the abdomen
sustained in a recent campaign in the South-West Pacific
Area. These patients were treated in a forward surgical
unit attached to a field ambulance, the time lag between
receipt of the wound and operation averaging eight hours
(varying from four to sixteen hours). Rifle bullets were
the cause of the wound in eight instances, machine-gun
bullets in three, fragments of mortar bombs in six, frag-

FEBRUARY 9, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

181

ments of high explosives in five, fragments of grenades in
three and fragments of landmines in two.

Eighteen patients had bowel perforations, whereas nine
had involvement of solid viscera only seven had involve
ment of the liver, and one had involvement of the spleen
and one of the kidney. There were two abdomino-thoracic
wounds in the former group one on the right side involv
ing the liver, duodenum and jejunum, and one on the left
involving the descending colon and three in the latter
group, two involving the liver and one the spleen. The
abdominal lesion was the major in these cases, the chest
injury being simply a perforation of the lower lobe of the
lung associated with a hsemopneumothorax. In one instance
the chest wound was sucking in character.

Seven patients had associated wounds, four having
multiple wounds of the extremities, one a sucking chest
wound, one a pulmonary and abdominal blast effect, and
one a penetrating brain wound.

RESUSCITATION.

Blood loss is the predominating feature in abdominal
wounds, because of the extensive haemorrhage into the
peritoneal cavity and into the mesenteric and retroperi-
toneal tissues, apart from that due to any associated
injuries. The subsequent circulatory deficiency causes
anoxia of vital organs, which rapidly leads to an irrever
sible state of decompensated shock u) unless early and rapid
transfusions of blood ai"e given.

Replacement therapy with stored or fresh group O blood
was accordingly commenced immediately on the patient s
arrival, whether he appeared to require it or not. Each
patient received an average of four litres, usually two
before, one during and one immediately after operation.
Since the best results are achieved by rapid transfusions
of whole blood and by early operation, the first two litres
were given at the rate of fifteen minutes each or even
faster if this was considered necessary. Ogilvie m) points
out that there is no limit to the amount or rate of trans
fusions in cases of severe blood loss, and in this series no
untoward effects were seen from this quick, massive form
of transfusion.

As a consequence, those patients who required abdominal
exploration were fit for operation on an average one hour
after the commencement of resuscitation. However, one
patient with extensive abdominal injuries, who appeared
to be adequately resuscitated with three litres of blood,
died during operation eight hours after receipt of the
wound, and another with a badly shattered liver died
six hours after receipt of the wound whilst being
resuscitated.

DIAGNOSIS AND OPERATIVE TECHNIQUE.

Diagnosis and operative technique have been discussed
in numerous articles, more especially by Gordon Gordon-
Taylor and W. H. Ogilvie, and do not need recapitulation
here.

Twenty-three patients, including three with abdomino-
thoracic wounds, required abdominal exploration, whilst
two with simple perforating abdomino-thoracic wounds
involving the liver and lung and one with a perforating
wound of the left kidney responded to conservative
measures. The chest lesions in the cases of abdomino-
thoracic wound required only suture of a sucking wound
in one case and repeated aspiration of a haemothorax with
penicillin instillation in four cases. These last patients
had an expanded lung and a dry pleural cavity within ten
days.

Tetanus toxoid and gas-gangrene antiserum were given
to all patients.

AFTER-TREATMENT.

All patients who required operation had the stomach
drained by a Ryle s tube until peristalsis was audible,
usually on about the fourth day. During this time a daily
amount of four litres of fluid, mostly serum to help supply
protein, was given intravenously to ensure a daily excretion
of 1,200 to 1,500 millilitres of urine and to make up loss of

fluid by sweating. Once the Ryle s tube was removed,
intravenous infusions gave place to feeding by mouth.

Blood haemoglobin estimations and red cell counts were
performed every third day, and if the level of haemoglobin
fell below 80%, further transfusions were given to correct
the anaemia.

PENICILLIN.

Penicillin is most valuable in gunshot wounds of the
abdomen."" Its purpose is twofold firstly to prevent or
localize infection in the parietes and any associated wounds,
and secondly, to prevent or localize peritonitis, as it is
now known that streptococci and staphylococci are con
taminants of the peritoneum in these cases. tt&gt;

Intramuscular penicillin therapy was commenced imme
diately on the patient s arrival, amounts of 15,000 units
being given every three hours. The average amount given
was 720,000 units, though it was much higher when other
injuries were present.

Penicillin, in the form of penicillin-sulphanilamide
powder, was used locally in the abdominal wall and asso
ciated wounds, but it was not used in the peritoneal cavity.

CONVALESCENCE.

All patients held in the forward unit were fit for evacua
tion usually two or three weeks after operation. Evacua
tion was by a sea trip of sixty miles, and as it was noticed
that "abdominal" patients were liable to seasickness, this
trip was always postponed if the seas were rough. A
sudden storm at sea made one patient seasick, and as a
result he almost died from an attack of acute confusional
insanity lasting fourteen days.

RESULTS.

Eight of the nine patients with solid viscera injuries
only recovered, and nine of the eighteen patients with bowel
perforation recovered. Four of the five patients with
abdomino-thoracic wounds included in the above figures
survived.

Recoveries.

The patients who recovered are divided into two groups,
(i) those with solid viscera injuries only and (ii) those
with bowel perforations.

Solid Viscera Injuries Only (Eight Cases).

Six patients had an uneventful convalescence. Three of
these had sustained perforating abdomino-thoracic wounds,
two on the right side with liver perforations which did not
require operation, and one on the left with a ruptured
spleen requiring splenectomy. In two cases, a large foreign
body lodged superficially in the liver and was removed at
operation; one of these patients had a sucking chest wound
in addition. One patient had a perforating wound of the
left kidney which did not require operation. An excretion
pyelogram three weeks later revealed a normal kidney.

Two patients had post-operative complications. One, who
had a large foreign body removed from the liver, developed
j a superficial wound infection due to a penicillin-sensitive
Staphylococcus aureus and Bacillus proteus; this rapidly
yielded to treatment. The other had a badly damaged liver
due to a rifle bullet s traversing it from side to side. Three
pieces of liver lying free in the abdominal cavity were
removed and the abdomen was drained. This patient
developed atelectasis of the lower lobe of the right lung,
and a biliary fistula through both the drainage and
laparotomy wounds lasting twenty-seven days. A ventral
hernia developed in the last-mentioned wound and was
repaired five weeks later.

Three months after receipt of the wound, six patients
were back in their unit doing the same work as pre
viously. Two months after receipt of the wound another
was in a convalescent depot, and another was still in
hospital convalescing from a ventral hernia repair.

Comment. None of the patients with liver wounds
became jaundiced, and none developed an infection of the
liver, at least not during the follow-up period. It is
possible, of course, for liver infections to occur months

182

THE MEDICAL JOURNAL OF AUSTRALIA.

FEBRUARY 9, 1946.

after receipt of a wound, so that the prognosis must be
guarded. M) This favourable outcome may be due in great
part to penicillin and also to the removal of all approach
able foreign bodies. No patient developed choleperitoneum,
but one had a biliary fistula which probably prevented its
occurrence. It is wise to establish drainage in all cases
of severe liver injury as a precaution against this
complication.

Bowel Perforations (Nine Cases).

Five patients had an uneventful convalescence. The first
had a perforated liver and a large tear in the upper part
of the jejunum. The second had four jejunal perforations
and a large retroperitoneal haemorrhage. The third had an
abdomino-thoracic wound with a perforated lung and two
small perforations of the descending colon, which were
sutured. The fourth had a small perforation of the
ascending colon, which was sutured, and a large tear in
the transverse colon, which was exteriorized as a loop
coloetomy, and a perforated liver.

Three months after receipt of the wound the first three
patients had for a month been back in their unit doing
their usual work. The fourth was discharged from the
army back to his civil occupation (clerk). The fifth was
in hospital two months after receipt of his wound, about
to have his colostomy closed.

The four remaining patients had post-operative compli
cations, two due to pulmonary emboli and two due to
infection.

The pulmonary emboli involved the lower lobe of the
right lung in both patients. The first, who had a tangential
tear of the greater curvature of the stomach and a large
tear of the mesenteric border of the first jejunal loop
involving the mesentery, suffered a single embolus on the
eighteenth day, from which he made an uneventful
recovery. The second, who had three jejunal perforations
and a badly lacerated mesentery, 1 suffered an embolus on
the fourth and again on the fourteenth day. Recovery was
uneventful, and two months later he was well and in a
convalescent depot.

Both of these patients had severe mesenteric damage, for
which ligature of divided jejunal vessels was necessary.
Such damage is a frequent cause of pulmonary emboli and
a common cause of death in cases of gunshot wound of the
abdomen.

In two cases intraperitoneal infection developed.

The first patient, a native, sustained seven jejunal tears
and a badly lacerated mesentery. Suture was performed six
hours after receipt of the wound, but the foreign body was
not found. Paralytic ileus developed and caused a rupture
of the abdomen on the fifth day; the abdomen was success
fully sutured. On the tenth day, a pelvic abscess (Bacterium
coli) was drained through the rectum. When examined three
months later, the patient was back on the "carrier line".

The second patient had two ileal perforations and wide
spread mesenteric and retroperitoneal haemorrhage. He was
not examined until sixteen hours after receipt of the wound,
when early peritonitis was already present. A pelvic abscess,
from which a penicillin-sensitive haemolytic streptococcus was
isolated, developed on the eighth day and was drained
through the wound, which became infected by the same
organism. A ventral hernia developed, which was repaired
two months later. Two months later still, the patient was
well in a convalescent depot.

This last patient shows the value of penicillin in peri
toneal infection. Though its use was commenced too late
to prevent a streptococcal infection, penicillin undoubtedly
localized it.

Deaths (Ten Cases).

Nine patients with bowel perforations and one with a
shattered liver died. Full autopsies were performed, but
there were no facilities for microscopic examination of the
organs.

The results in cases of gunshot wound of the abdomen
depend largely on circumstances beyond the surgeon s

1 It may be noted, in passing, that a missile may cause
tangential wounds of the bowel, so that an unequal number
of perforations is not uncommon.

control. A series of cases in which the majority of
wounds are due to high explosives or bombs will have a
greater mortality rate than one in which rifle bullets are
the cause of the wounds, especially if associated injuries
are present as well. The earlier patients reach the
surgeon, the higher will be the proportion of seriously
injured patients received and hence the higher the
mortality rate. (B&gt; Delay in receiving patients brings peri
tonitis, but it eliminates the worst cases ; ao) for instance,
Rohlf and Snyder (U) operated on their patients on an
average eighteen hours after receipt of the wound, and
only 20 deaths occurred in 98 cases.

Irreversible Shock Due to Anoxia of Vital Organs.

The cause of death in these severe cases is anoxia of
vital organs due to the deficient circulation resulting from
blood loss. Though blood transfusions have enabled men
to survive injuries which would have been fatal in the last
war, nevertheless there is still a small proportion of cases
in which adequate resuscitation is without avail, because
an irreversible state of shock exists, probably due to irre
parable damage to cells of the liver, brain, adrenals, bowels
and kidneys. &lt;a)U)

This state may cause death shortly after receipt of the
wound, as in three cases in this series. The first patient
died whilst being resuscitated from a badly shattered liver.
The second, who had an abdomino-thoracic wound with
gross involvement of lung, diaphragm and liver, a perfora
tion of the duodenum and eight perforations of the jejunum,
died during operation eight hours after receipt of the
wound, having apparently been adequately resuscitated.
The third patient had a shattered left sacro-iliac joint, a
torn internal iliac vein, a perforated rectum and six jejunal
perforations. Haemorrhage was controlled by packing, the
perforations of the jejunum and rectum were sutured and
a proximal colostomy was performed. In spite of a trans
fusion of five litres of blood, commenced eight hours after
receipt of the wound, the patient died twenty-four hours
later. During this time he was rational and passed a litre
of normal urine.

Traumatic Urcemia.

Should the kidneys be the chief organs affected by
anoxia, the syndrome of traumatic uraemia occurs. tt)aj&gt; In
this, anoxia causes irreversible changes in the kidneys, the
tubules being mainly affected as in the "crush syndrome".
It may occur in any severe injury, and does not require a
crush injury or gross muscle damage for its appearance."*
No myohaemoglobin is excreted, and pigmented casts are
absent from the urine.

Clinically the patient responds to resuscitation sufficiently
to stand operation and appears to do well for a few days.
Gradually, however, a uraemic state develops, with vomiting,
rising blood urea level and diminishing urinary excretion,
until finally anuria supervenes and the patient dies in
coma about the eighth day. Albumin, blood and casts
are found in the urine.

Two patients in this series died of traumatic uraemic.
They showed no evidence of transfusion incompatibility,
blackwater fever or "sulphanilamide kidney". (Both had
penicillin-sulphanilamide powder insufflated into the
parietal wounds, but no sulphonamide was administered
systemically.) Unfortunately, there were no facilities for
blood urea estimations. Autopsy in both instances dis
closed that all wounds were healing well and there was
no evidence of infection. All organs, including the kidneys,
appeared to be grossly normal.

One patient was hit by multiple mortar fragments, which
caused severe damage to the abdominal wall with eviscera
tion of the stomach, small bowel and transverse colon. There
was a large tear in the greater curvature of the stomach,
through which a recent meal had escaped into the lesser sac
and the great omentum. There were five holes in the
jejunum, and the right side of the colon was in ribbons. The
lower pole of the right kidney was lacerated, and much retro-
peritoneal haemorrhage had occurred.

Resuscitation was commenced four hours after receipt of
the wound, and an hour and a half later the parietal wound
was excised, the stomach and small bowel perforations were
sutured, the omentum was resected and a right hemi-

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183

colectomy was performed. The kidney did not require
surgical intervention.

The patient did well at first, but he became drowsy on the
fifth day and died in coma on the eighth day. His blood
pressure rose to 150 millimetres of mercury, systolic, and
100 millimetres, diastolic, on the fifth day, but slowly dropped
to normal.

In the first twenty-four hours this patient received six
litres of blood (including that used for resuscitation) and two
litres of serum. Thereafter he had four litres of serum per
day. (In such cases of renal damage, large quantities of
saline solution given intravenously will do no good in fact,
they only dilute the blood and tissue fluids. (8) ) He passed 800
millilitres of urine in the first twenty-four hours, a daily
average of 1,200 millilitres in the next five days, 500 milli
litres on the sixth day, 100 millilitres on the seventh day, and
none on the day of his death. Hsematuria was present from
the damaged kidney from the first, but twenty-six hours
after operation, epithelial, granular, hyaline and blood casts
appeared and were present in all specimens.

Another patient was hit by a burst of machine-gun bullets.
one of which caused four perforations of the terminal portion
of the ileum and the others widespread muscle damage of
both legs, thighs and buttocks. Resuscitation was com
menced seven hours after receipt of the wound, and an hour
later his wounds were excised and the bowel was repaired.
He did well until the fourth day, when he became drowsy,
and he died in coma on the eighth day. His blood pressure
always remained at about 110 millimetres of mercury, systolic,
and 80 millimetres, diastolic.

He received four litres of blood and two of serum in the
first twenty-four hours, and then four litres of serum per
day. He passed an average of 1,200 millilitres of urine per
day until the sixth day, when he passed only 200 millilitres.
On the seventh and eighth days he passed no urine at all.
Albumin and epithelial, granular, hyaline casts and blood
appeared in the urine sixteen hours after operation, and were
thereafter present in every specimen.

Disturbance of the Heat-Regulating Mechanism.

One patient died in coma with hyperpyrexia. It is prob
able that anoxia caused irreversible changes in the heat-
regulating centres of the brain, so that a condition similar
to heatstroke arose. (In this instance, the weather, though
humid, was not excessively hot.) There was no evidence
of cerebral malaria. He had been receiving routine suppres-
sive "Atebrin" treatment, and was also given ten grains
of quinine intravenously for five doses, but these measures
made no difference to his condition.

A high-explosive fragment caused a large tear in the
greater curvature of this patient s stomach and divided the
right gastro-epiploic vessels, so that he lost a great deal of
blood. He was resuscitated with five litres of blood, and
operation was performed four hours after receipt of the
wound.

Although he had an adequate fluid intake of four litres of
serum a day and passed two litres and more of normal urine
per day, his temperature rapidly rose to a constant level of
107 P. in spite of all efforts to lower it, and he became
unconscious. The significant feature was that he never
sweated after operation, except on the third day, whon there
was a slight skin action and his temperature dropped to
103 F. He then became conscious, but was confused. Never
theless, he again stopped sweating, the temperature rose to
107 F., and he died on the fourth day.

Autopsy disclosed that all organs, including the brain, were
grossly normal. There was no infection of the abdominal
cavity.

Fcccal Peritonitis.

There were two deaths from peritonitis due to contamina
tion of a haemoperitoneum with liquid faeces, which had
escaped from a perforation of the colon. In one case the
damaged bowel was exteriorized, and in the other it was
resected and a gun-barrel colostomy was performed. Both
patients died on the fourth day from Bacterium coli
peritonitis. It is well known that this type of peritonitis
is most lethal in its effects, and penicillin cannot improve
the prognosis because of the wide faecal contamination of
the peritoneal cavity.

Associated Injuries.

One patient, who had a perforated small bowel and colon
treated respectively by suture and colostomy, died from

an associated penetrating wound of the left ceerbral hemi
sphere caused by a machine-gun bullet. He was admitted
to hospital in coma, and died eighteen hours later without
recovering consciousness.

Congenital Absence of the Right Kidney.

One patient was most unfortunate, in that he had only a
left kidney, his right kidney and ureter being congenitally
absent a condition which occurs only once in 700 indi
viduals. " A bullet shattered his spleen and left kidney and
perforated the splenic flexure of his colon. Splenectomy,
nephrectomy and exteriorization of the damaged colon were
performed. He passed no urine at all after operation, lapsed
into coma and died on the sixth day. An autopsy disclosed
the absence of the right kidney and ureter.

SUMMARY.

1. Twenty-seven cases of gunshot wounds of the abdomen
are discussed. Eighteen patients had bowel perforations
and nine solid viscera involvement only. Nine of the
former and eight of the latter survived.

2. Irreversible shock due to anoxia of vital organs
caused six deaths, three shortly after receipt of the wound
ing and three later, two from traumatic uraemia and one
from hyperpyrexia. Faecal peritonitis caused two deaths,
associated brain injury one and destruction of a single
kidney another.

3. Of the 17 patients who survived, six had post
operative complications, two having pulmonary emboli, two
abdominal abscesses, one a biliary fistula and one a wound
infection. Two of these developed a ventral hernia
through the laparotomy wound, in one case due to
infection and in one to a biliary fistula.

4. At the end of three months ten patients were back
in their unit doing the same work as previously, most of
them having been back about a month, three were in a
convalescent depot, and one was discharged from the army
fit for sedentary work a month after his colostomy had
been closed. Two were still in hospital two months
after receipt of the wound, one about to have a colostomy
closed and one convalescing from repair of a ventral
hernia. One was still in hospital six weeks after receipt
of the wound, about to go to a convalescent depot.

ACKNOWLEDGEMENT.

We wish to thank the Director-General of Medical
Services, Australian Military Forces, Major-General S. R.
Burston, for permission to publish this report.

REFKRENCES.

n &gt; S. O. Aylett and A. P. Alsop : "Surgery and Anaesthesia of
War Wounds of the Abdomen", British Medical Journal, Volume
I, 1945, page 547.

(2 &gt; E. H. Darmady, A. H. Siddons, T. C. Corson, C. D.
Langton, Z. Vitek, A. W. Badenoch and J. C. Scott : "Traumatic
Uraemia. Reports on Eight Cases", The Lancet. Volume II
December 23, 1944, page 809.

(:i &gt; M. E. De Bakey and B. N. Carter : "Current Considerations
of War Surgery", Annals of Surgery, Volume CXXI, May, 1945,
page 545.

&lt;4&gt; J. E. Dunphy : "The Therapy of Shock", Post-Graduatr
Medical Journal, Volume XXI, April, 1945, page 112.

(6) "Traumatic Anuria", The Lancet. Volume I, February 24
1945, page 244.

&lt;e) G. Gordon-Taylor : "Second Thoughts of the Abdominal
Surgery of Total War. A Review of 1,300 Cases", The British
Journal of Surgery, Volume XXXII, October, 1944, page 126

(7 &gt; J. C. Boileau Grant : "A Method of Anatomy", Third
Edition, 1944, page 275.

(8 &gt; H. Harkins, O. Cope, E. Evans, R. Phillips and D. Richards:
"The Fluid and Nutritional Therapy of Burns", The Journal of
the American Medical Association, Volume CXXVIII, June 16,
1945, page 475.

&lt; B) A. G. Lowdon : "War Wounds of the Abdomen. Report of
Sixty-Four Cases Treated by Laparotomy", Edinburgh Medical
Journal, Volume LI, June, 1944, page 257.

(10) W. H. Ogilvie : "Abdominal Wounds in the Western
Desert", Surgery, Gynecology and Obstetrics, Volume LXXVIII
March, 1944, page 225.

(11 &gt; W. H. Ogilvie : "Some Applications of the Surgical Lessons
of War to Civil Practice", British Medical Journal, Volume I,
1945, page 619.

U2) C. G. Parsons : "Traumatic Uraemia", British Medical
Journal, Volume I, 1945, page 180.

&lt;l:l &gt; E. L. Rohlf and J. M. Snyder : "Surgical Experiences in
Abdominal Wounds in North African Campaign", Surgery,
Gynecology and Obstetrics, Volume LXXIX, September, 1944,
page 286.

184

THE MEDICAL JOURNAL OF AUSTRALIA.

FEBRUARY 9, 1046.

LIPOMATA OF THE UTERUS, WITH REPORT
OF A CASE.

By J. D. HICKS,

From the Department of Pathology, Prince Henry s
Hospital, Melborirne.

A TUMOUK of the uterus containing fat cells is of con
siderable interest, in that less than fifty such tumours are
recorded in the literature/ 1 and some speculation is
excited as to the origin of fatty tissue in an organ where
fat is not usually present where, in fact, it is practically
never seen.

Under the heading of "lipomata", or fatty tumours, are
described tumours which consist almost solely of adipose
tissue, as well as others with a varying admixture of
fibrous, myomatous and fibromyomatous elements. About
one-third of the reported specimens appear to be simple
lipomata, and the majority contain a good deal of fibrous
tissue or smooth muscle.

A small percentage of the tumours containing fat are
sarcomatous in nature, the malignant activity being found
more in muscle cells than in the fat.

The clinical history of patients with fatty tumours, and
their age group, symptoms, signs and prognosis, are
similar to those of patients with fibromyomata. The dis
covery of fat within the fibroid is a surprise awaiting the
pathologist, and it may not be obvious until microscopic
preparations have been examined.

The majority of the tumours are found in the fundus
uteri; a few occur in the cervix or as small polypi.
Commonly five to fifteen centimetres in diameter, they are
at times very small. The presence of fat may be suspected
by the pale yellow colour of the tumour or by its soft
consistency, which is in considerable contrast to the firm,
whorled surface of a fibroid tumour, sometimes pinkish,
sometimes pearly in colour.

Individual tumours may vary in the amount of fat they
contain from one area to another; but the larger tumours
are more likely to contain greater proportions of fibrous
or muscular tissue.

Few suggestions as to the origin of the fat cells have
been put forward, beyond those which had already been
expressed forty years ago, &lt;2&gt;( " &gt;(1) and little evidence has been
gathered towards a complete or satisfactory explanation.

There are three possible sources of the fat cells in these
tumours. They may arise from cells which retain the
potentiality of differentiating into fat cells that is, from
the totipotent primitive mesenchymal cell or from uni-
potent cells in embryonic rests of Cohnheim. Perhaps, also,
an occasional lipoblast may have migrated into the uterus
along with blood vessels and nerves, there to indulge a
tumour-producing propensity. Secondly, there may be a
metaplasia of already differentiated cells in the uterus, a
transformation of connective tissue or of fibrous or mus
cular tissue into fat. Finally, connective tissue cells, or
muscle cells, of uterine origin may undergo fatty degenera
tion. The occurrence of tiny fat droplets in connective
tissue or muscle cells in some of the tumours containing
large fat cells suggests to one author"" that the latter
may have arisen by way of fatty degeneration of the
normal tissue elements, but to another &lt;8) that the fat cells
come from a specially differentiated connective tissue.
Baniecki &lt;7) hints at a possible relationship with diabetes
mellitus.

It can hardly be thought that a true liporna is a degenera
tion of muscle or connective tissue cells, but rather it is
a proliferation of fat cells, whether their precursors in the
substance of the uterus are totipotent cells of the primitive
mesoderm or awakened embryonic rests. In the majority
of the tumours in which fibrous tissue and smooth muscle
play a large part, these cells are healthy and show little
degenerative change; they do not resemble the cells of
fibromyomata in which fatty degeneration has taken place.
I have found no mention of the presence of fat cells in

an otherwise normal uterus, but on two occasions I have
seen a small group of typical fat cells on routine examina
tion of sections, once from the cervix and once from the
fundus uteri. No abnormality in those sections could
suggest a reason for the presence of the cells.

The mixed mesodermal tumours of the uterus, with
their striated muscle and cartilage, illustrate the diversity
of tissues which may arise within the uterus, and the
production of a simple tissue such as fat should not be
deemed beyond the capabilities of this organ. It seems
reasonable to attribute the fat cells of the true lipomata
and of most of the fibromyolipomata to cells laid down in
the Anlage of the uterus, which have retained the poten
tiality of developing into mature adipose tissue.

Report of a Case.

M.N., a married woman, aged fifty-seven years, was
admitted to hospital in January, 1941. She had been
attending the out-patient department with a complaint of
indigestion; a test "meal examination revealed hypochlor-
hydria, and subsequent administration of hydrochloric acid
gave her some relief. All her five children were well. The
menopause had occurred three years previously, after which
she had had no further blood loss until seven weeks prior
to her admission to hospital, when she had noticed a slight
spotting of blood. On examination of the patient, the uterus
was found to be enlarged to about the size of a pregnancy
of four months duration. Recently she had experienced some
frequency of micturition, but no scalding. Total hysterec
tomy was performed by Dr. L. S. Kidd, and the specimen
was sent to the pathology department with the label
"fibroma". The Fallopian tubes and the ovaries did not
appear to be diseased.

On pathological examination, the uterus presented a

smooth, rounded appearance. On bisection the specimen was

seen to consist of a rounded tumour seven centimetres in

diameter, the muscular wall of the uterus being stretched

thinly round it. The tumour lay in the anterior wall of

the uterus, a long, curved, narrow cavity running upwards

behind the mass. Only part of the cervix was present. The

tumour itself was pale in colour, with a yellowish tint. It

was slightly lobulated, and the surface was smoother than

a fibromyoma and did not show the firm, tight whorls of

! that type of tumour. The consistency was soft, much softer

; than that of a fibroid tumour, but firmer than that of normal

| adipose tissue.

Microscopic examination revealed the presence of a large
j amount of normal fat tissue, supported by a fibrous frame-
I work (Figure I). While fat comprised about 70% of the

FIGURE I.

Showing the relative proportions of fat and fibrous tissue
in a typical field.

tumour, and fat cells were seen in every low-power field,
fibrous tissue predominated in some areas. After differential
staining, smooth muscle fibres were identified, but only in
the walls of blood vessels and not as part of the tumour
itself. A diagnosis of lipofibroma of the uterus was made.

Acknowledgements.

I wish to thank Dr. L. S. Kidd for his permission to
report this case, and Mr. G. Aubrey-Crowe for the drawing.

FEBRUARY 9, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

185

References.

&lt; l &gt; P. L. Hitter and S. W. Stringer : "Lipoma of Uterus", The
American Journal of Obstetrics and Gynecology, Volume XL.,
1940, page 501.

(2 &gt; J. H. M. Knox : "Lipomyoma of the Uterus", The Bulletin
of the Johns Hopkins Hospital. Volume XII, 1901, page 38.

&lt;:1 &gt; A. Sitzenfrey : "Drei seltene Geschwiilste" , Zeitschrift fur
Geburtshiilfe und Gynakologie, Volume LXVII, 1901, page 32.

(4) A. G. Ellis: "Lipoma of the Uterus", Surgery, Gynecology
and Obstetrics, Volume III, 1906, page 658.

&lt;G &gt; H. Williamson and R. St. L,. Brockman : "Fibro-Myo-
Lipomata of Uterus", The Journal of Obstetrics and Gynaecology
of the British Empire. Volume XXVIII, 1921, page 290.

&lt; e) A. C. Starry : "Fatty Tumours of the Uterus", Surgery,
Gynecology and Obstetrics, Volume XLI, 1925, page 642.

(7 &gt; H. Baniecki : "Lipomyom des Uterus und Diabetes Mellitua",
Archiv fur pathologische Anatomic und Physiologic, Volume
CCL.XXXVII, 1932, page 483.

THE TREATMENT OF INGUINAL HERNIA.

By FRANKLYN V. STONHAM,

Lieutenant-Colonel, Indian Medical Service; Officer

in Charge of tJie Surgical Division of a

General Hospital.

INGUINAL HERNIA is one of the commonest of surgical
disorders which requires treatment by operation. The
Bassini operation, which was introduced in 1888, is one of
the most important milestones in surgical progress. As
Professor Grey Turner is often in the habit of pointing out,
the surgical treatment of hernia has in the past been of
the utmost importance, since so much of our modern
surgical knowledge and operative technique has been built
up around hernia operations. The Bassini operation since
its introduction has undoubtedly cured millions of suf
ferers; but the results have fallen short of 100%, and the
operation has therefore undergone innumerable modifica
tions. In fact, if one inspects the records of any hospital,
one will usually see the procedure employed entered on
the documents as "modified Bassini operation". The
soundness of the Bassini operation was first contested in
1899 by R. Hamilton Russell, who held that all hernise
were congenital in origin that is to say that the sac has
been present always and has remained a potential source
of hernia until increased intraabdominal pressure has
forced something into it and caused it to become distended
and clinically evident. Hamilton Russell held that weak
ness of the musculature had primarily nothing to do with
the production of the hernia, but was secondary to its
presence. Russell regarded the inguinal canal as a
sphincter normally in a state of tonus which increased
reflexly when the intraabdominal tension was raised by
physical exertion straining, micturition, coughing et
cetera. That is to say, the muscles contract isometrically.
That a process of peritoneum passes through the inguinal
canal into the scrotum, which should close before birth,
is accepted by embryologists; but Russell s contention that
femoral hernia, direct hernia and herniae in other sites are
all due to a preformed sac depending upon a process of
peritoneum following the blood vessels which emerge from
the abdomen has been disputed, and the weight of opinion
is now against it. Russell therefore concluded that since
the presence of the sac was the primary cause of the
hernia, removal of the sac alone was sufficient to effect
cure, and that any meddling with the mechanism of the
inguinal canal was not only superfluous but actually
harmful, since attempts to close the canal by suturing the
conjoined tendon to Poupart s ligament would be likely
to cause atrophy of the former structure and thus favour
recurrence or the development of a direct hernia. Russell s
theory was vigorously attacked at the time when it was
put forward, especially on embryological grounds by Sir
Arthur Keith, and surgery has been slow to adopt the
Russell principle in operations. Russell practised surgery
at Melbourne, and while a number of Australian surgeons
follow his procedure, others prefer the Bassini technique
or one of its modfiications, holding that recurrences follow
the Russell operation and that they have seen recurrences
in patients who had actually been operated upon by

Hamilton Russell himself. Recently, however, there has
been rather a swing back to simple excision of the sac as
opposed to more complicated procedures, there being no
substantial evidence to support any claim for a lower rate
of recurrence from such procedures. Philip Turner has
advocated simple removal of the sac in children without
division of the external ring. The soundness of the Bassini
operation has also been challenged by Ogilvie and others,
and recently Brandon (1945) in a carefully considered
paper has emphasized the value of simple excision of the
sac in suitably chosen cases. Brandon quotes Saint
Thomas s Hospital statistics, which rather tend to suggest
that simple excision of the sac is followed by a recurrence
rate of approximately half that of the alternative proce
dures which are now popular namely, the operation
associated with the names of Bassini, Fowler, McArthur,
Bloodgood and Gallie.

Caution should be exercised, however, in the acceptance
of any hernia statistics at their face value, since other
factors than the technique employed may contribute to
failure. This point will be discussed below. Moreover, it
is in the apparently less favourable type of case that the
surgeon is often tempted to employ one of the more
ambitious procedures. There is much truth in what
Hamilton Russell used to say, when he emphasized that
much more could be learnt from one case carefully and
minutely studied than from all the statistics which were
ever published. The essence of the matter is that while
simple excision of the sac suffices for the vast majority of
indirect herniae, each case should be carefully considered
on its merits, and the procedure adopted should be varied
according to what is demanded by the conditions found.
In other words, no single stereotyped operation will meet
the needs of every case in every set of circumstances.

Causes of Recurrence.

1. The Bassini operation is faulty in principle and inter
feres with the efficiency of the sphincteric mechanism of
the inguinal canal. Exposure demands dislocation of the
cord and unnecessary trauma. Suture of the conjoined
tendon to Poupart s ligament may be followed by atrophy,
especially if large bites of tissue are taken and the sutures
are tightly tied. In any case, as Wakeley (1940) points
out, it is difficult to secure any sound union between
muscle and tendon. In by far the majority of instances in
which an operation for recurrence is performed, explora
tion reveals that the original operation was of the Bassini
type.

2. Failure carefully to isolate the sac and remove the
whole of it appears to be a potent factor in the production
of recurrence. In carrying out operations for recurrence
it is not uncommon to find what appears to have been
the original neck in situ and a nodular mass indicating
the site of the original ligature below it. The operator
had evidently relied on his attempts to obliterate the canal
to prevent recurrence. As Edwards (1943) puts it, "the
original hernia is reproduced".

3. The use of catgut is probably a fairly common con
tributing factor. The tissues of some patients have the
faculty of digesting catgut quickly, and sutures, especially
when tied with some degree of tension, tend to give way.
This may be one of the reasons why the recurrence rate
after the Bassini operation is not higher than it is. Catgut
also causes a tissue reaction, and in addition, to borrow a
term from Leriche, "subinfection" if not actual suppura
tion. This is especially likely to develop under tropical
conditions, and it is not uncommon to find at a subsequent
operation for recurrence that the incision in the external
oblique aponeurosis has become undone. Unabsorbable
sutures are preferable, and with careful technique the
risk of a persistent sinus is negligible. I have abandoned
silk in favour of fine braided nylon ("Deknatel"), and
with this material more than two hundred hernia opera
tions have been carried out in tropical climates without
the slightest trouble in securing primary healing; further,
as far as can be ascertained, there has been no subsequent
evidence of sinuses or "stitch abscesses". Interrupted
sutures are to be preferred, but as Haxton (1945) points
out, continuous nylon sutures can be used with impunity.

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FEBRUARY 9, 1946.

4. A history of ineffective and inadequate after-treatment
can be obtained in a large proportion of cases in which
recurrence has followed within a year or so of the original
operation. This occurs in military practice, and it is due
either to failure on the part of the surgeon to give instruc
tions that no severe physical exertion or weight-lifting
be indulged in for at least three months, or, more com
monly, to the surgeon s instructions having been dis
regarded. The loading of heavy boxes onto a truck is
apt to be regarded by some people as "light work". In
civil practice the patient, who may be a labourer, may
himself be at fault.

5. Unskilled operating is often held to be a frequent
source of recurrence, and it is stated that the recurrence
rate is likely to be high in institutions where hernia
operations are relegated to inexperienced house surgeons.
The obvious remedy is not to take this class of work
out of their hands, but to teach them to do it properly.

6. Complicated operations usually defeat their own object.
Operations which distort normal anatomy, like Halstead s
and Schmeiden s, are fundamentally unsound; recurrences
follow, and it is questionable whether a more simple pro
cedure would not have been better in the first instance.
Recently I have seen a patient who had undergone a
bilateral Halstead operation eight months previously, which
was followed by bilateral recurrence and bilateral testicular
atrophy. Recurrences follow the Gallic operation. This
operation has a distinct sphere of usefulness; but the
idea of using "living" sutures has captivated surgical
imagination, and the procedure is often used as a routine
measure for cases in which it is not required, and the
operation is thus likely to be brought into disrepute.
Fascial sutures are not without disadvantages. They
require careful fixation with silk, and the large needle
used to insert the minflicts appreciable trauma. Fascial
sutures do not grow and "become incorporated in the
tissues". At operations for recurrence they can be seen
apparently unaltered by any growth. Silk or nylon would
in many instances have been equally effective.

When recurrences follow one of the more complicated
"repairs" the surgeon is often faced with a difficult prob
lem. When recurrence follows simple removal of the sac
the surgeon has undamaged tissues to deal with at the
subsequent operation, and this is in itself a strong argu
ment in favour of the latter procedure.

7. Failure to suture the fascia transversalis has been
cited as an omission which may favour recurrence. While
this fascia may be found to be a strong sheet of tissue in
cadaver dissections, it is a variable structure. When the
sac is isolated by gauze dissection and twisted before the
ligature is applied, the defect in the fascia is probably
sufficiently approximated to allow it to heal over without
sutures. W. J. Lytle (1945), who has made careful
anatomical studies of the inguinal canal, recommends that
the internal ring be narrowed by sutures inserted from
below upwards, but admits that twisting of the sac prior
to ligature probably draws the fascia transversalis together
sufficiently to produce a narrowing of the ring. In many
herniae it is difficult to find anything but some filmy tissue,
and dissection and retraction necessary to suture firmer
material may do more harm than good. The influence of
the fascia transversalis in preventing recurrence is prob
ably not of great importance. The principal offender is
the sac itself acting as a dilator.

8. Errors in diagnosis may lead to pseudo-recurrence.
A sac may be bilobed and only one loculus may be removed.
Inguinal sacs have occasionally been removed when the
patient has actually been suffering from a femoral hernia.
The importance of precise diagnosis cannot be over
emphasized. When a patient states that his hernia recurred
soon after his discharge from hospital, it is probable that
the wrong sac was removed.

9. Patients suffering from chronic cough, stricture, pros-
tatic enlargement or severe chronic constipation are
unfavourable subjects for operation. Operations upon very
old people, or upon those of poor physique with tissues of
poor quality, and upon the very obese, may be expected
to have a somewhat higher recurrence rate. Previous

suppurative inguinal adenitis may considerably weaken the
tissues.

Operation for Inguinal Hernia.
Anaesthesia.

If one wishes to ascertain the competency of the sphinc-
teric action of the inguinal canal, it is obvious that its
action must be actually witnessed. Local infiltration with
"Novocain" enables the contraction and any descent of
the conjoined tendon to be seen and felt. Local infiltration,
moreover, permits the patient to cough, and the sac can
readily be found and its limits determined. Local infiltra
tion has two disadvantages. One is the fact that the
healing powers of the tissue are slightly interfered with
and there is a small addition to the risk of infection, and
the other is the fact that traction on the peritoneum during
the manipulations necessary for isolation and high ligature
of the sac sometimes causes pain and vomiting.

Spinal analgesia lacks these drawbacks, and I now use
it as a routine method. Six to eight millilitres of a 1 in
1,500 solution of "Nupercaine" are injected moderately
slowly into the spinal theca, and the patient is turned face
down at once with a small pillow under the epigastrium
and kept face down for seven minutes. The table is tilted
to 10 of "head-down" position, and this tilt is maintained
during operation. This gives satisfactory anaesthesia of
the sensory roots, while voluntary movement of the
abdomen and legs is retained. The patient is able to con
tract the abdomen and to cough.

Operative Technique.

The drapes are arranged so that one towel clip is on
the anterior superior iliac spine and another is just above
the root of the penis. The incision is three and a half
inches long; it commences three-quarters of an inch lateral
to the penis and half an inch below and parallel with the
edge of the upper towel. The skin, fascia of Camper and
fascia of Scarpa are incised in the same line. Branches
of the superficial inferior epigastric and the superficial
external pudendal vessels are caught and ligated, and other
small bleeding points are seized in fine-pointed haemostats
and twisted at the conclusion of the operation. Skin towels
are then clipped to the edges of the incision, the instru
ments are discarded and gloves are sluiced in antiseptic
lotion. The external ring is then sought and two small
Kocher forceps are clipped on to it for subsequent identifica
tion, and the external oblique aponeurosis is incised in the
direction of its fibres, which is roughly the same as that
of the wound. It is not necessary extensively to clear the
aponeurosis of fascia. The cut edges are retracted upwards
and downwards by being clipped with tissue forceps. If
it is remembered that the sac of an indirect hernia passes
from above downwards in front of the contents of the
cord, it is easily found. Without disturbance of the cord,
an incision is made parallel with and at the upper part
of the cord, passing through the cremaster, the cremasteric
fascia and the infundibuliform fascia which, incidentally,
may exhibit more than one distinct layer and the sac is
exposed. The patient is then asked to cough, and the
extent of the sac can be seen. The sac is then seized with
forceps and isolated as far as possible by sharp knife
dissection, the isolation of the neck being completed by
gauze stripping. If the sac is large and adherent, the
distal portion need not be dissected out. If it is cut off
and incised longitudinally, the subsequent development of a
funicular hydrocele need not be feared. The sac is opened
to ensure that it is empty, twisted, transfixed and ligated
flush with the peritoneum. When released, it retracts into
the abdomen out of sight.

The patient is again asked to contract the abdominal wall
or to cough. The efficacy of the removal of the sac is
inspected and the physiological action of the conjoined
tendon observed. If as in the majority of cases both
appear satisfactory, nothing more is done and the wound is
closed. A few interrupted sutures close the incision in
the infundibuliform and cremasteric fascia, and the
external oblique aponeurosis is then examined for slackness.
If none is present, the aponeurosis is united with inter-

FEBRUARY 9, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

187

rupted sutures one-quarter of an inch apart or else by a
continuous stitch. If slackness is present, excess is taken
up by overlapping of the edges with interrupted sutures.
If the external ring previously examined was found to be
large, it is reduced by sutures to normal proportions that
is to say, to a size at which it just admits the tip of the
finger. The external oblique thus braces up the deeper
muscles and allows them to shorten. The skin incision is
closed by four sutures, one-quarter inch from the edge,
passing through all layers down to the deep fascia, and
intermediate sutures unite the skin edges.

Before the external ring is examined the gloved hands
are washed with antiseptic solution; but otherwise "no-
touch" technique is observed throughout. If it is necessary
to handle the tissues, they are seized with gauze. Tying
with forceps and the use of the Singer suturing instrument
completely eliminate the risk of contaminating the suture
material.

Fine braided nylon thread is used throughout, and ends
are cut short over triple knots. If the neck of the sac
seems rather bulky for fine material, to save trouble the
thread is put in double.

Alter- Treat ment.

The patient is kept strictly in bed for twenty-one days
after operation, and deep breathing exercises are carried
out from the start to maintain the tone of the abdominal
musculature. The more elaborate exercises preferred by
physical therapists are not essential. The stitches are
taken out when the wound has healed that is to say, in
about five or six days. The patient is allowed up on the
twenty-first afternoon and permitted to walk about. He is
discharged from hospital a day or so later, and emphatically
warned against strenuous exertion, especially the lifting
of weights, for three months; otherwise normal activity
and sport are unrestricted. Double herniae may be repaired
at one sitting with a complete change of gloves and instru
ments. A. K. Henry s approach through a mid-line incision
with extraperitoneal ligature of both sacs is more difficult,
but the principle is much the same.

Difficult HernicB.

Less favourable herniae for operation comprise very large
inguinal herniae with stretching and atrophy of the
surrounding tissues; direct hernia, in which atrophy is
nearly always present; and recurrent hernia. To minimize
the risk of recurrence something more than simple removal
of the sac is necessary. The proportion of cases in which
a more elaborate operation is required varies according
to the type of practice. For routine practice in civilized
countries, simple removal of the sac should suffice in at
least 90% of cases; but amongst backward communities,
especially in oriental countries, one finds a larger propor
tion of the neglected type of hernia. For these patients it
is doubtful whether any stereotyped "cookery-book" type of
operation can be relied upon for every type of hernia and
in every circumstance, and the operation should be "tailor
made" to suit the needs of the individual patient. Surgical
ingenuity can select one of a number of procedures. In
Bloodgood s operation a flap of fascia is turned down from
the anterior rectus sheath and sutured to Poupart s liga
ment. There may be difficulty in securing a large enough
flap, and a weak spot in the abdominal wall is left. Philip
Turner s patch can sometimes be used with advantage. A
flap of fascia lata hinged on Poupart s ligament is turned
up under the latter structure and sutured to the trans-
versalis fascia, or better still, with very slight tension to
the conjoined tendon. The flap may require a separate
incision, but it can be obtained by stripping down and
retraction a somewhat bloody procedure, as many small
vessels are present. This, again, has disadvantages. A
weak part is left from which the fascia has been taken,
and it may be impossible to get enough fascia. There is
also some risk of injuring the femoral nerve and vessels.
A free fascia lata graft may be used instead.

Gallie s fascia lata repair may be employed with advan
tage in certain cases. However, large amounts of fascia
lata cannot be taken with complete impunity, as the

resulting defect may itself subsequently worry the patient.
For large hernial defects a silk lattice or floss-silk darn
may be the only course open. The slight risk of infection
in these cases, in which a large amount of foreign material
is introduced, cannot be dismissed lightly. In the event
of such a misfortune the results are truly disastrous, and
the unfortunate patient may spend many months in
hospital.

Recently Mair has claimed success in the use of whole-
skin grafts to close hernial defects. Apparently he has had
no trouble with sepsis, and the epithelial elements of the
skin seem to disappear.

Lately there has been some tendency to revert to
McGavin s silver-wire filigree. This method never enjoyed
wide popularity, and any unfortunate supervention of
sepsis left the surgeon with an extremely difficult problem.
However, it seems that in successful cases the cure has
been permanent and complications have been infrequent
(Grey Turner, 1943). This operation may in the future
have a limited but distinct scope, especially since new
metals like vitallium and tantalium, which are much more
readily accepted by the tissues, are available.

Summary.

1. The case for simple excision of the sac to cure
oblique inguinal hernia has been stated.

2. The causes of recurrent hernia have been discussed.

3. The value of local and spinal anaesthesia in deter
mining what procedure is indicated in hernia operations
has been given emphasis.

4. The technique of an operation based on Hamilton
Russell s operation has been described in detail.

Bibliography.

W. J. M. Brandon : "Inguinal Hernia ; House that Bassini
Built", The Lancet, Volume I, February 10, 1945, page 167.

H. C. Edwards : "Inguinal Hernia", The British Journal of
Surgery, Volume XXXI, October, 1943, page 172.

H. Haxton : "Nylon for Buried Sutures", The British Medical
Journal, Volume I, January 6, 1945, page 12.

W. J. Lytle : "The Internal Inguinal Ring", The British
Journal of Surgery, Volume XXXII, April, 1945, page 441.

G. B. Mair : "Preliminary Report on the Use of Whole Skin-
Grafts as a Substitute for Fascial Sutures in the Treatment of
Herniae", The British Journal of Surgery, Volume XXXII,
January, 1945, page 381.

R. Hamilton Russell: The Lancet, Volume II, 1899, page 1353 ;
also personal communications.

F. V. Stonham : "Nylon", The Indian Medical Gazette, Volume
LXXVII, 1942, page 283.

D. C. Turner and G. Grey Turner : "Modern Operative
Surgery", 1943, page 1049.

R. P. Rowlands and P. Turner : "The Operations of Surgery".
Eighth Edition, 1937, page 27.

C. P. G. Wakeley : "Treatment of Certain Types of External
Herniae", The Lancet, Volume I, May 4, 1940, page 822.

of Ca0es,

RUPTURE OF THE LIVER IN THE NEW-BORN:

RECOVERY AFTER BLOOD TRANSFUSION

AND LAPAROTOMY.

By FELIX ARDEN, M.D., M.R.C.P.,

Medical Superintendent, Brisbane Children s
Hospital, Brisbane.

THE following case is reported in view of the compara
tive rarity of the condition and because recovery from
it appears to be exceptional.

Clinical Record.

R.E., a male infant, aged two days, was admitted to the
Brisbane Children s Hospital at 2 p.m. on December 29,
1944, because of pallor, breathlessness and inability to
suck. These symptoms had first appeared that morning,
approximately thirty-six hours after the child s birth. The
child had been born at full term; he weighed nine pounds

188

THE MEDICAL JOURNAL OF AUSTRALIA.

FEBRUARY 9, 1946.

and had presented by the vertex. The obstetrician in
attendance had been obliged to use forceps for the head
and had experienced some difficulty with the shoulders,
but had exerted no force on the trunk. Resuscitation had
not been required. None of the mother s four previous
confinements had been easy, as her pelvic measurements
were small. Her first baby weighed ten pounds and was
stillborn; the other three needed instrumental delivery.

When first examined the infant was noticeably pale and
looked ill. His breathing was hurried (88 respirations to
the minute), but not laboured. The temperature was
100-2 F. No other abnormality was discovered at the
initial examination, and a provisional diagnosis of pneu
monia was made. During the next two hours the baby s
condition deteriorated rapidly. By 4 p.m. he was much
paler and had grown restless. His breathing had become
gasping and typical of air-hunger. The pulse was almost
imperceptible. His abdomen was found to be slightly
distended and dull on percussion all over the right side
and in the left flank. It was now reasonably certain that
the child had a massive intraperitoneal haemorrhage.

Blood transfusion was started immediately, stored group
blood from the hospital blood bank being used without
a delay for cross-typing. The large amount of 200 mils
of blood was given rapidly and another 100 mils were
added during the next four hours. One mil of a vitamin K
preparation was injected intramuscularly. The trans
fusion was of immediate benefit; the infant s colour
returned and his distress abated; but his abdomen
remained distended and dull on percussion in the flanks.

Operation was performed at 8 p.m. under anaesthesia
with ether given by the "open" method combined with
local infiltration of the abdominal wall. On the assumption
that the liver was the most likely organ to be involved,
the abdomen was opened by a right upper paramedian
incision. The peritoneal cavity was found distended with
blood and blood clot, and exploration revealed a deep
fissure, two inches long, in the antero-superior surface
of the right lobe of the liver close to the mid-line. Blood
was oozing freely from the torn liver substance.

Owing to the friability of the liver, attempted closure
of the gap with mattress sutures proved unsatisfactory.
However, the fissure was so fortunately placed that it
was possible to suture the torn edges of the liver capsule
to the cut edges of the parietal peritoneum. This had
the effect of shutting off the peritoneal cavity from the
source of the bleeding and rendered the oozing laceration
in the liver subject to control by external pressure. A
strip of the right rectus abdominis muscle, with a pedicle
at the lower end, was placed in the fissure in the liver
substance and the abdominal wall was closed. No gauze
packing was used. Firm pressure was applied by strapping
over dressings.

The haemoglobin value, estimated just before the blood
transfusion, was 52%. Four days after the operation it
was 95% (100% = 13-8 grammes of haemoglobin per 100
mils).

Apart from some post-operative vomiting and slight
delay in wound healing, the baby made an uneventful
recovery and was discharged from hospital in good health
fourteen days later. When examined at the age of seven
months he was in magnificent condition and weighed
20 pounds.

Comment.

The comparative rarity of rupture of the liver in the
new-born has been mentioned. Nevertheless, the "Quarterly
Cumulative Index Medicus" refers to seven case reports in
the past seven years, and the condition is described in
a few obstetric text-books. There is a good account in
Ehrenfest s monograph on birth injuries. (1) He quotes
Palmer/ 2 who, investigating the cause of 144 fcetal deaths,
found five cases of liver injury, three in which deep
tears were present, and two in which the lesions were
merely subcapsular haemorrhages. Several writers quote
Lundquist/ who encountered at post-mortem examination
five deep parenchymatous injuries of the liver among 49
instances of intraabdominal haemorrhage in the newly
born. No doubt the condition is sometimes overlooked

and would be met more often if more post-mortem exam
inations were made.

With regard to the causation, it is surprising that the
large friable liver of the new-born, which often projects
well below the protecting ribs, is not ruptured more often.
Extraction of the trunk during breech delivery and the
application of strong fundal pressure are quoted by
Berkeley, Bonney and MacLeod (&lt;) as possible ways in which
the liver may be injured. To this list accidental blows
on the mother s or child s abdomen and vigorous attempts
at resuscitation must be added. The most interesting
setiological fact, however, is that in some well-attested
cases (for example, Berry s 5 ) the condition appears as a
spontaneous one, the trauma incidental to normal delivery
sometimes being enough to produce the damage. This
was almost the case in the present instance.

The delay in the onset of symptoms is characteristic.
To quote Ehrenf est : (1)

Prom the viewpoint of diagnosis it is striking that
infants, eventually dying from a ruptured liver,
apparently as a rule seem perfectly normal for approxi
mately the first three days of life. Symptoms of serious
illness do not manifest themselves until a considerable
amount of extravasated blood has reached the peritoneaJ
cavity. Then death is prone to occur suddenly and
unexpectedly.

It seems likely that a subcapsular haematoma forms
first and that urgent symptoms supervene only when the
capsule eventually gives way.

Rupture of the liver in the new-born has always been
regarded as a fatal condition. Schmitt, (&lt;)) from a review
of the literature, concluded that prophylaxis, diagnosis and
treatment were alike unsatisfactory. Tow C7&gt; said of these
cases: "Most children who survive the first twelve hours
appear fairly normal for a couple of days. Then they
suddenly become ill, go into shock and die within a few
hours without presenting any local physical signs."
Ehrenfest, in his account of the disease, quotes a number
of cases, all fatal. He refers to the "usually quite
unexpected discovery (at post-mortem examination) that
the liver has been injured". He does not mention survival.
The available literature records only fatal cases, the
diagnosis being made post mortem.

The infant whose recovery after blood transfusion and
laparotomy is here reported was in the following ways
fortunate: he was vigorous and above average weight; he
came under observation in time; and the fissure in his
liver was in an accessible place.

References.

&gt; H. Ehrenfest: "Birth Injuries of the Child", 1931, page 286.

&lt; 2) Palmer : Medical Research Council of the Privy Council,
Special Report Series Number 118, 1928; quoted by Ehrenfest,
loco citato.

&lt;3) B. Lundquist : "Intrathoracic and Intraabdominal Haemor
rhages in the Newly Born", Acta obstetricia et gynecologica
Scandinavica, Volume IX, 1930, page 331 ; quoted by Ehrenfest,
Tow et alii.

&lt;*&gt; C. Berkeley, V. Bonney and D. MacLeod : "The Abnormal
in Obstetrics", 1938, page 422.

&lt;6) J. A. Berry : "Fatal Haemorrhage from the Liver In an
Infant Five Days Old", British Medical Journal, Volume I,
1926, page 825.

(8) F. T. Schmitt : "Etiology of Rupture of the Liver in the
New Born", Zeitschrift fur Gebnrtshiilfe und Gynakologie,
Volume CXIV, 1936, page 70 ; abstracted in American Journal
of Diseases of Children, Volume LIV, 1937, page 864.

&lt;7 &gt; A. Tow: "Diseases of the New Born", 1937, page 108.

REPORT OF A FATAL CASE OF "BLAST" INJURY
OF THE SPINAL CORD.

By D. LESLIK,
Major, Australian Army Medical Corps.

IT is realized that the data with regard to this case are
incomplete in many details, but none the less it may be of
interest in showing the serious effects which can be
produced by bomb blast injury of the spinal cord without
apparent bony lesion.

FEBRUARY 9, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

189

Clinical Record.

The patient, aged twenty-one years, was admitted to an
Australian general hospital on the evening of October 10,
1943, uraemic, unable to give a history, and with a tempera
ture of 106 F. He had no external wound but a large
bed sore. He appeared to be anaesthetic to the level of
the sixth cervical vertebra, and did not move legs or
trunk. There were occasional weak movements of the
shoulder girdle, but otherwise no movement of the arms.
His bladder was distended to the umbilicus.

From the notes accompanying the patient it appeared
that he had been injured by bomb blast on October 1
(nine days previously) and that his symptoms and signs
developed at once and gradually increased. Thus, when
he was examined by his regimental medical officer, he could
feel and localize pin pricks in both legs, but when examined
at the field ambulance later during the same day he
could not do so. He had no plantar response of any sort
from the outset. His bladder was catheterized on
October 9 at the field ambulance, and he was then evacu
ated, his bladder being catheterized at least once more
during evacuation. It was reported on the day of injury
that he had no tenderness or palpable abnormality of the
skull or spine. Records showed he had received 76 grammes
of sulphaguanidine.

On his admission to hospital, suprapubic cystostomy was
performed without anaesthesia and gross cystitis was seen
to be present. His condition did not improve and he died
ten hours after admission to hospital.

Post-Mortem Examination.

Post-mortem examination revealed bilateral pyelo
nephritis, it being possible to express pus from the apices
of the pyramids of both kidneys. With regard to the
central nervous system, the pathologist reported that the
brain was normal. In the middle to lower part of the
cervical portion of the spinal cord there was an area
extending for about one and a half inches in which a
brownish discoloration and considerable loss of normal
texture were present. The area appeared necrotic and
softened. The cord was frozen and cut into sections.
Above and below the area of softening the cord was a
little congested, but there was no sign of old or recent
haemorrhage; otherwise it appeared normal. No deformity
of the bony vertebral canal was seen during the removal
of the cord. No X-ray picture was taken.

Comment.

It is regretted that two important pieces of information
were not available an X-ray picture of the cervical part
of the spine and a history from the patient himself as
to the nature of the trauma -whether the injury was
purely one of blast or whether there was some other
factor such as a fall or a blow.

PSYCHIATRY AND MODERN WAR.

DR. R. S. ELLERY has a well-earned reputation for dealing
entertainingly with controversial matters. It is maintained
in "Psychiatric Aspects of Modern Warfare". 1

In his opening chapter he draws attention to the frailty
and fallibility of the human spirit. We must keep our feet
on the earth of reality, for is not man "this featherless biped
with brains this monarch of misrule this sinner-saint of
creation! In his intellect how like a god! in his behaviour
how like a hyena!" and "Men and women may reverence
truth in the abstract, but when the feelings are stirred they
will always incline to the cock and bull".

The author pleads for the debunking of war. Good people
allow themselves to be stampeded into war through ultra-
nationalism. "The bad people are politicians and members

1 "Psychiatric A spools of Modern Warfare", by R. S Ellery.
M.D., F.R.A.C.P. ; 1945. Melbourne: Reed and Harris.
8J" x 5J", pp. 191, with 8 illustrations. Price: 12s. 6d.

of political groups industrialists, financiers and speculators
who put the pursuit of personal profit above any considera
tions of justice and decency, and who, for their own selfish
interests, never scruple to exploit the ill-balanced emotions
of men for the most base and ignoble ends." Among them
are included the great German and Japanese dictators who
by a perverted psychology give "men and women a belief not
in goodness, but in greatness".

In order to underline the brutishness of war, the book is
illustrated by a series of drawings by Goya, brilliantly
conceived and executed more than a century ago. With
the Japanese atrocities before us, we have the realization
that sadism in war is not a new phenomenon.

This book was written for a nation in arms. Although
the end of hostilities has not altered the main thesis, it has
shifted the viewpoint. Dr. Ellery, in showing the great
need for psychiatrists, emphasizes the necessity for the
psychiatric overhaul of recruits. Rightly he stresses the view
that in the production of neurosis and psychoneurosis "the
precipitating factors difficulties in adjustment, fear, fatigue,
trauma and other noxious accompaniments of war produce
psychiatric casualties chiefly among those who are pre
disposed".

In regard to the forms of mental disease and the types
of treatment the outlook is conventional. As the disease is
a reaction of the whole organism, prognosis and treatment
must be based on broad lines.

There is a plea for a psychiatric consultation centre to
which men could go for frank and homely discussions of
their emotional problems. Running through the pages of
this book is the emphasis upon the need for a background
of faith. Man for his mental health must have a feeling of
present and future security. Dr. Ellery points out that in
a changing world, some religious props are losing their hold.
"Our anxiety arises from the loosening of those emotional
bonds which once existed between man and his celestial
God-image." The author holds that: "A new faith must be
found a new formula devised for the re-direction and sub
limation of aggressive instincts. This may come through
psychology and the keener understanding of the human
mind." With this theme there can be little disagreement,
though there is a very considerable doubt as to the ideal
type of ideology.

No consideration of war would be complete without men
tion of its aftermath. In a later edition Dr. Ellery should
amplify this. More could be said of the unconscious pension
hunter. Dr. Ellery hints at the emotional unrest which we
are today seeing in a world-wide series of strikes when many
are hungry and homeless. He foresees the inescapable
results of juvenile mismanagement which is worthy of
repetition.

Society s shabby treatment of its war-time adolescents
will demand a reckoning in the near future.
Psychiatrists, educators and social workers will have
to be prepared to handle that great batch of emotional
problems which will follow in the wake of war, arising
out of the defective or precocious development of youth.
They will have to meet aggressions undisciplined and
rebelliousness which flouts authority, frustrations and
maladaptations which have led to neurotic incapacity,
conduct disorders incidental to deficient education, and
damaged personalities taking refuse in dependency.

The book has a useful glossary of psychological terms and
is written so as to be easily understandable by the non-
medical reader. The field of psychiatry is enormous, its
toilers are few, its needs are great. Only by the wider
diffusion of such knowledge shall we achieve progress. This
interesting book points the way.

THE SURGERY OF PEPTIC ULCERATION.

NISSEN S recent work on the technique of resection in
duodenal and jejunal peptic ulcer is an intensely interesting
study. 1 As Wangensteen points out in his foreword, although
remarkable reductions are being effected in the mortality
of appendicitis and intestinal obstruction, the mortality of
peptic ulcer has remained uninfluenced by therapeutic pro
cedures during the last three decades. Though in the past

1 "Duodenal and Jejunal Peptic Ulcer : Technic of Resection",
by Rudolf Nissen, M.D., with a Foreword by Owen H
Wangensteen, M.D., Ph.D.; 1945. New York: Grune and
Stratton. 8J" x 5J", pp. 144, with 123 illustrations. Price:
$4.75.

190

THE MEDICAL JOURNAL OF AUSTRALIA.

FEBRUARY 9, 1946.

SYNOPSIS OF SURGERY.

THE twelfth edition of "A Synopsis of Surgery" has been
produced despite wartime disturbances. 1 It is unnecessary
to argue the merits and defects of synopses, but these are
manifest in this production. If one wants a summary of the
salient features of some important disease it can be found
here. Most of the summaries are excellent and representative
of solid English teaching. This book would be of value to
those with a photographic type of memory who do not need
to know the reasons for statements. In this book there is
a noted absence of explanations. Perhaps these are out of
place in a synopsis, but such omissions detract from its
value; for example, in the discussion of the treatment of
crush syndrome the physiological basis of treatment is not
mentioned. This encourages "vain repetition" on the part of
students. Many other instances of this kind could be cited.

Brevity may be the excuse for a dogmatism which is a
universal and deplorable failing. That "ether is only rarely
used as a sole anaesthetic agent" is open to question. It
may help the examination student to be given a rule of
thumb, as in the treatment of fractured scaphoid, but it
would be better surgery for him to use his judgement, being
guided by the X-ray appearance, as well as by the length
of history. Experience with thyreotoxicosis makes most
surgeons less and less inclined to group all cases into two
varieties, primary thyreotoxicosis and toxic adenoma.

Proportion and correct emphasis are difficult to achieve.
Yet "it seems hardly appropriate to devote two-thirds of a
page to burns and more than two pages to the operative

1 "Synopsis of Surgery", by Hey Groves, edited by Cecil P. G.
Wakeley, C.B., D.Sc., F.R.C.S., F.R.S.E., F.A.C.S., F.R.A.C.S. ;
Twelfth Edition; 1945. Bristol: John Wright and Sons Limited.
71" x 5", pp. 640, with many illustrations. Price: 25s. net.

the distrust of physicians in the ability of surgeons to
overcome the ulcer diathesis of a patient with a duodenal
ulcer has not been without foundation, this surgical
empiricism is now coming to an end. The problem facing
the surgeon is, of course, twofold, in that he must not only
maintain a low mortality rate for his operations, but at the
same time he must complete a procedure which will rarely
be followed by jejunal ulceration. Because the mortality
rate is the more immediately pressing of these two require
ments, surgeons who feel that they must abandon gastro-
enterostomy because of its high incidence of subsequent
stomal ulceration, have been attracted towards the exclusion
forms of gastrectomy. Nissen, however, regards retention
of the pyloric antrum as incompatible with cure of the ulcer
diathesis, and maintains that the secondary ulceration rate
in these operations is little if any less than that which follows
simple gastro-jejunostomy.

The main purpose of his book is to show that even in the
presence of formidable penetrating duodenal ulcers it is
possible to make a partial gastrectomy which includes
removal of the pyloric antrum, and yet to keep the mortality
rate under 3%. The secret of success is related to the safe
closure of the duodenal stump, and with the help of numerous
illustrations the author describes a procedure which includes
three essential stages, namely, adequate mobilization of the
anterior duodenal wall, ample exposure of the crater and
avoidance of any surgical manipulations of the posterior
duodenal watt.

Nissen s account of the surgery of recurrent jejunal ulcer
is largely related to those cases which are a sequel to
exclusion operations; and he stresses the point that excision
of the excluded segment is still a prerequisite if further
ulceration is to be avoided. Where the condition of the
patient will permit, the desirable operation for such an ulcer
will include removal of the pyloric antrum, closure of the
duodenal stump, resection of the anastomotic ulcer with
further gastrectomy, and reestablishment of a new stoma.
Where such an operation entails undue risks, removal of
the excluded segment with or without jejunal feeding for
two months will sometimes obviate the necessity for further
surgery.

Contrary to the usual practice of the English-speaking
surgeons, Nissen advocates an entero-anastomosis in all
ante-colic resections, and holds that the resultant absence
of alkaline duodenal contents in the region of the main
anastomosis does not increase the liability to subsequent
ulceration.

As stated above, this is an intensely interesting study by |
a master of gastric surgery, and its contents should be |
known to every surgeon who aspires to cure a patient of
his peptic-ulcer diathesis.

treatment of cleft palate, nearly two pages to hydatid cysts
and a page to internal peritoneal hernise.

All textbooks which have taken a reasonable amount of
time to prepare are in danger of being out of date by the
time they are published. This book is at a disadvantage
because there is only a very brief mention of penicillin
which has so radically altered the outlook in surgery and
medicine. It would appear to have been possible to
incorporate more details of experiences with this form of
therapy. Sulphonamide therapy is recommended frequently,
but with rare mention of dosage, for example, in the treat
ment of erysipelas. This is important, and the precautions
that must be taken are worthy of consideration. The use
of sulphonamides has greatly reduced the instance of strepto-
coccal septicaemia, and yet the statement is made that
Streptococcus pyogenes is the causative organism in more
than half the cases. There are several other statements
which are out of date. In the discussion on asepsis we
read that the operator and all who have to speak must wear
a mask while in the theatre. Surely it is time that the
silent assistants wore one also. In a list of antiseptics,
alcohol in the form of "surgical spirit" receives first mention
and high commendation. Sulphonamides and penicillin are
last on the list. "B.I. P.P." receives a mention and "Flavine"
is recommended. Brandy is also given per rectum, (perhaps
justifiably). Thiourea and thiouracil are not mentioned. One
wonders how often avulsion of the phrenic nerve for pul
monary tuberculosis is done now. To us who do not see
much tuberculosis of bone the classification of different types
of caries as given appears antiquated and unnecessary.
Intracranial haemorrhage is treated in the same old way
with most emphasis on the extradural variety. Surely it
is time that this fault was eradicated from textbooks. Non
specific urethritis is still incorrectly said to be rare.

Minor errors are always likely to occur in a comprehensive
textbook, especially if prepared in a hurry. Nicola s opera
tion is called "Nichol s operation". On page thirty Figures X
and XI should be reversed. In the former it is obvious
that the incision for infection of the sheath of the flexor
policis long-its muscle has cut the nerve supply to the thenar
muscles. More important statements with which many
would not agree are that the treatment of spondylolisthesis
is by operation (no other treatment is suggested), that
"regional ileitis" does not affect the caecum, and that up to
twenty minims of Lugol s iodine are needed three times a,
day in the treatment of thyreotoxicosis.

J!2ote0 on Books, Current Journals ana
Jfteto appliances

THE DECORATION OF HOSPITALS.

RAYMOND SLOAN, in "Hospital Color and Decoration", has a
lot of very new and interesting things to tell the reader on
an interesting subject. 1 Writing in an informal style, the
author takes the reader on a "conducted tour" through every
section of a hospital, including quarters for medical, nursing
and domestic staffs. Mr. Sloan rightly lays great stress
on the thei-apeutic value of pleasant and cheerful sur
roundings; some of his proposals for private rooms, however,
sound a bit too exuberant and too glamorous for the
average Australian patient, and there is a slight shudder
at the idea of a guardian angels and silver stars as wall
and ceiling decorations in the nursery. His pages on colour
and decoration in public wards are particularly good, and
could be studied by the authorities of all hospitals where the
bleak uniformity of an institution is the rule. He has many
suggestions. Amongst many good ones, are his ideas on
furnishing the entrance hall and waiting rooms to create
favourable first impressions and to remove many of the
patient s misapprehensions; the arrangement of coffee shops
and small gardens; and the fitting of cubicle curtains run
ning on rods hung from the ceiling to take the place of
the clumsy screen. The author illustrates his points
liberally with photographs and line drawings, but has failed
to include one of the corridor. This he admits to be the
"hospital stepchild" and a problem one, too, and here a
photograph would have been of help. This book can be well
studied, but Mr. Sloan s advice should be noted that the
decoration of a hospital is a job for an expert, not an amateur.

1 "Hospital Color and Decoration", by Raymond P. Sloan ; 1944,
Chicago : Physicians Record Company. Sydney : Angus and
Robertson Limited. 9J" x 1", pp. 272, with many illustrations.
Price: 32s. 6d.

FEBRUARY 9, 1946. THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER.

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THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER. FEBRUARY 9, 1946.

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191

Cbe Medical journal of aumalia

SATURDAY, FEBRUARY 9, 1946.

Authors who are not accustomed to preparing drawings
or photographic prints for reproduction are invited to seek
the advice of the Editor.

OVERSEAS TRAVEL FOR AUSTRALIAN STUDENTS.

IN the course of an address delivered before the British
Medical Association at Montreal in 1897 under the title
"British Medicine in Greater Britain", the late William
Osier said that in certain aspects the "Australasian Settle
ments presented the most interesting problems of Greater
Britain". He used the following words: "More homogeneous,
thoroughly British, isolated, distant, they must work out
their destiny with a less stringent environment, than, for
example, surrounds the English in Canada. The traditions
are more uniform and of whatever character have filtered
through British channels. . . . What the maturity will
show cannot be predicted, but the vigorous infancy is full
of crescent promise." That was nearly fifty years ago.
Those who have lived in the world of medicine during this
period have been rarely privileged; they have seen many
discoveries and have watched their application in the
fight against disease and the alleviation of human
suffering; they have witnessed a reawakening in the value
of research and its intensified pursuit in every branch
of medical science; and unless they have been quite torpid,
they have probably helped to bring about a widening of
outlook and the placing of fresh emphasis on such aspects
as the mental action and reaction in bodily disease and
the varied problems of sociological medicine and other
avenues of preventive medicine. This means that they
have been taking a part in the evolution of science in
relation to man, and this, it must be remembered, is bound
up with the social evolution which is even now taking
place, and has been in progress for the last few centuries.
Osier pointed out that evolution advanced by such slow
and imperceptible degrees that to those who were part of
it the finger of time seldom seemed to move. Even the
great epochs, he held, were seldom apparent to par
ticipators. None of those who have been engaged in the
practice of medicine during the last fifty years can have
failed to be conscious of its recent developments; they
probably realized that the changes would be far-reaching,

but many could not or would not see them as part of an
orderly evolutionary process. This last fact, incidentally,
is one of the great difficulties in the making of plans for
the future in either the medical or social sphere. Con
fining our attention for the moment to the sphere of
medicine, we should probably be correct in the contention
that development in what Osier called the Australasian
Settlements has been much as he would have expected it
to be. Osier spoke in Montreal, a city of two languages,
French being spoken as well as English because so many
of the people are French Canadians. The words "more
homogeneous" applied to Australia are therefore justified.
Medicine in Australia has also been thoroughly British
the early teachers in Australian medical schools were
trained in Britain and they have left the British stamp on
the Australian-born teachers who have succeeded them. The
words "isolated" and "distant" do not apply with the same
force today as they did in 1897. In the past if Australia
did appear to be a step behind in the adoption of some
scientific advance perfected in Britain, on the Continent
of Europe or in America, the lag was probably occasioned
by distance or isolation. During recent years distance has
for most practical purposes been almost eliminated, but
isolation is a potential danger and measures must con
tinually be taken to guard against it. Isolation is not
caused only by distance separating centres of activity or
persons from one another; it may be the result of subtle
factors of mind and possibly of habit.

In the pursuit of medical science, the student, that is,
the practitioner, who cuts himself off from scientific
collaboration and discussion with his fellows, however self-
sufficient he may think himself to be, faces a life of
deprivation and his atrophy must after a shorter or longer
period of time become apparent. But there is another side
to the picture. If we suppose that every practitioner
makes the best possible use of his facilities for scientific
advancement and that the medical community is united in
its scientific endeavour, something will still be lacking.
No scientific community can thrive in isolation, particu
larly if it is young; stimulating infusions from other
scientific communities are needed from time to time.
Stimuli may be received in various ways, but the one on
which we wish to lay stress is the paying of visits to other
countries by individual practitioners. In the early days
of Australia medicine was indeed "thoroughly British".
Australian medicine is slowly building up its own tradition,
but it is still largely influenced by British medicine and
the influence has been to a great extent absorbed by
individual practitioners in their individual comings and
goings rather than by groups of persons. Central Europe
and latterly America have also attracted the medical
traveller. While on the one hand it has for many years
been almost looked on as essential for a practitioner to
study on the other side of the world if he wished to
specialize in a particular branch of medicine, sound argu
ments have lately been advanced in favour of the provision
of means by which special skill may be acquired within
the borders of the Commonwealth. This is a condition
which should be made possible for all the specialties. It
would, however, deprive the future specialist of the
enormous benefit that can be gained from overseas travel
and study. In any case practitioners other than would-be
specialists are no different from the latter in their ability
to benefit in this way. In the past medical practitioners
seeking to enlarge their experience overseas have had to

192

THE MEDICAL JOURNAL OF AUSTRALIA.

FEBRUARY 9, 1946.

travel at their own expense and in many cases have had
to save from their earnings to gain the money needed. At
the present time with the high cost of living and the
excessive burden of taxation it appears that very few prac
titioners will be able to save for this purpose and the only
people able to spend time at clinical schools in the old
seats of learning will be those possessed of inherited
wealth. If this state of affairs does arise it will be a
serious loss to individuals, but this loss will be thrown
back onto the community the community always suffers
in the long run if anything is allowed to happen which
lowers the efficiency of its servants. There are several
ways in which the situation may be met. One would be
by the making of reciprocal arrangements with teaching
hospitals in Great Britain and America for the establish
ment of resident posts to be held for a period by overseas
graduates. Another method that might be considered
would be the creation of travelling fellowships by the
extension of the present scheme by which the fees of
certain students with living allowances are met by the
State, the students most likely to profit being selected after
exhaustive inquiry into every aspect of their qualifications
and attainments. Some young graduates might be able
to find appointments overseas if nothing more than the
cost of travelling was provided. The travelling fellowships
established by the Nuffield Foundation, the Rockefeller
Foundation and the Carnegie Trust, and advertised
recently in this journal by the National Health and
Medical Research Council, are valuable, but they cover only
a short period and are intended more especially for those
likely to be engaged in clinical teaching.

Medicine is not the only sphere in which the provision
of overseas experience for young Australians will be useful
to Australia in the future. The Chancellor of the Univer
sity of Melbourne, writing in the University Gazette of
May 24, 1945, outlined a proposal for the establishment of
travelling scholarships between universities in Britain,
America and Australia as a means of dispelling the ignor
ance displayed by the people of one country of the ways
of life and thought of another. He holds and many will
agree with him that this ignorance is one of the causes
of international misunderstanding. If the world is to live
at peace in the future, the peoples of the different nations
will need to understand and to trust one another. Australia
has seen a good deal of American and British service men
during the last few years. The friendships that have been
made, the trust that has been engendered, are worth
fostering. The Chancellor mentioned the design of Cecil
Rhodes who founded the scholarships known to all
Australians. He thinks that a somewhat similar design
might be adopted by Britain, America and Australia. This
is a statesman-like suggestion that should be given serious
consideration by the Commonwealth authorities.

On the medical side we think that a body such as the
Federal Council of the British Medical Association in
Australia should appoint a subcommittee to report on the
matter. When this has been done, the question will have to
be further pursued. It is really part of post-graduate educa
tion and both it and the proposal made by the Chancellor
of the University of Melbourne ought to be dealt with when
other post-war educational matters are considered. On a
previous occasion we expressed the opinion that a Royal
Commission on Education should be constituted as a post
war measure; the time is ripe for this to be done.

Current Comment

THE PREVENTION OF INFLUENZA.

THE threat of epidemic disease has throughout the
ages followed in the wake of war. Indeed as Zinsser
writes: "Armies have crumbled into rabbles under the
onslaught ... of dysentery and typhoid bacilli"; so that
in the technique of what we are pleased to call "modern"
warfare, the anticipation and prevention of infection
are logical contributions to victory.

Early in the war the Office of the Surgeon-General
United States Army set up in its Preventive Medicine
Service a Commission on influenza under the direction
of Thomas Francis, junior, and a comprehensive plan
was developed for the field trial of vaccination against
influenza, in which use was made of the large aggrega
tion of young adults in training centres under reasonably
controlled conditions. It was decided to rely on a single
injection of concentrated material, timing the inoculations
as far as possible to precede an expected outbreak, and to
inject alternate subjects with control material of similar
volume. The centres of investigation were in Minnesota,
Iowa, California, Michigan and New York, and each team
of workers have assembled and recorded their results. 1

The vaccine was prepared from standard strains A and B,

and the A virus was composed of equal amounts of strains

PR8 and Weiss. The latter was a recently isolated strain

from an apparently sporadic case in 1943, and was included

in the hope that it might more nearly resemble strains

likely to be infective in the community, also because it had

been found that it produced good antibody response. Each

dose of 1-0 millilitre contained concentrate from 5-0

millilitres of allantoic virus B, and 2-5 millilitres each of

PR8 and Weiss, and was injected subcutaneously.

Vaccination was carried out in the different centres

between October 19 and December 4, 1943, and washings

were taken and cultivated for virus during the period;

every tenth subject was bled at intervals of ten days, for

i antibody titre, and in some cases three months later.

j Virus was first isolated on November 17, although serum

: antibody rises had indicated that virus was in the various

communities earlier, and about this time a sharp rise in

j the general incidence of respiratory disease was also

j noticed. In all groups a total of 5,989 persons were

I vaccinated, and 5,923 received the control injection.

The overall results showed that the incidence of

| influenza amongst the inoculated was 2% and amongst the

controls 8%, so that the vaccine had appreciably affected

the incidence of the disease, showing a protective

influence from the single dose given roughly eight days

before the disease became noticeable. The tests on

i paired sera from control subjects showed that while there

was evidence of influenza A in the community, only in

! a single instance in the New York series was there a

I rise in B virus titre of antibody, and no B virus was

isolated during the course of the investigation. Findings

in the different centres vary, and it is interesting to

| compare them. In Iowa, where the whole programme of

vaccination was not complete when cases began to occur,

the incidence amongst controls was five times that amongst

the vaccinated, while in California, where six weeks

elapsed, the controls showed only twice the incidence

shown by the test subjects; here a strain of virus isolated

during the epidemic, "Olson", was used as antigen for the

hsemagglutination tests, and the antibody demonstrated

by its use was a much lower titre than that towards PR8

and Weiss. These diagnostic isolations of virus were

carried out by the amniotic method, and in view of the

recent demonstration by Burnet and his co-workers of the

differences in reactivity in "0" and "D" virus, there may

be an explanation of this result. 2 In Minnesota note was

taken of the finding that in a vaccinated subject whose

paired sera had shown good antibody rise, the later

1 American Journal of Hygiene, July, 1945.
- The Australian Journal of Experimental Biology and Medical
Science. June, 1945, page 151.

FEBRUARY 9, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

193

occurrence of clinical infection, proven by virus isolation,
did not stimulate further antibody response.

The associated rise of winter respiratory infections was
carefully watched; /3-hsemolytic streptococci made their
appearance, but did not influence the influenza group in
any detectable way, while of 11 patients in New York
classified as suffering from atypical pneumonia, seven
showed definite evidence of influenza A, and were all
control subjects, suggesting that the virus could produce
pneumonia. The duration of immunity as measured by
antibody response was tested as far as practicable up to
four months after inoculation, and although there were
exceptions, the general level of antibody remained higher
than that initially found. As is well known, the subjects
with lower antibody showed better rise after inoculation but
the level fell again; those with higher antibody level showed
less response and less fall.

In the thoughtful discussion contributed by G. K. Hirst
and his group 1 it is suggested that the relation of serum
antibody and resistance to clinical influenza needs further
explanation, and they point out that an increase in the
general attack rate would in all probability minimize the
value of vaccination. Moreover, the good result obtained
in the centre where cases began to occur eight days after
completion of the programme indicated a possible optimum
time, a finding which could be made useful in further
experiments.

In Australia the constant flow of experimental evidence
on influenza virus from the Walter and Eliza Hall Institute
provokes a keen interest in the results of this large scale
experiment. Professor Burnet suggests that the local
implantation of virus on the respiratory mucosa may well
be an explanation for the lack of influence of high anti
body titre. According to this suggestion, the virus becomes
attached to the susceptible cell from the situation where
the least possible antibcdy effect can be produced. At the
same time his recently described technique to differentiate
virus in the "0" phase from the derivative phase of
established laboratory strains difference in hsemagglutin-
ability of fowl and guinea-pig red cells and inability to
infect the allantoic cavity may call for revision of the
significance of methods of primary isolation of virus. The
usefulness of the practice of giving a single dose of con
centrated vaccine to susceptible age groups assembled as
in army training camps, however, seems to be well
substantiated by the results recorded here.

"THE STEVENS-JOHNSON SYNDROME.

IN 1922, A. M. Stevens and F. C. Johnson described "a
new eruptive fever associated with stomatitis and oph
thalmia". 3 They reported two cases. The earliest symptoms
were weakness, and soreness of the mouth and eyes. In
a short time purulent conjunctivitis became apparent, and
on the third day reddish spots appeared on the back of the
neck. The eruption spread until only feet, hands and scalp
were free of it.

The trunk, arms and thighs were thickly set with
discrete, oval, brownish purple papular lesions, varying
in size from 0-5 to 2 cm. in the longest diameter. A
few of the largest spots showed a yellowish, dry,
necrotic center. There was no vesicle nor pustule forma
tion; no induration about the papule; no areola and the
skin between the lesions seemed to be perfectly normal.
The forearms and legs showed what seemed to be the
more recent lesions. These were less raised, of brownish
color, paling somewhat on pressure, and more closely set
than were those of the trunk and thighs.

The lips were cracked and bleeding and encrusted; the
tongue was swollen, bright red and fissured; and the
buccal mucous membrane was "inflamed with small bullous
lesions which rapidly broke down, leaving a raw and angry
surface". The eyelids were redematous. Thick pus streamed
from the palpeberal fissures. One patient was blinded; the

1 The Journal of the American Medical Association Volume
CXXIV, 1944, page 982.

2 American Journal of Diseases of Children, December, 1922.

other was left with a corneal opacity. One patient s spleen
was palpable. It is of interest to note that his tonsils had
been removed a few months previously and that he had
been in hospital for fourteen weeks thereafter suffering
from fever and splenomegaly and that Staphylococcus aureus
had been cultured from the blood. The course of the illness
was that of a severe and protracted fever. The leucocyte count
was low at the height of the illness. In one case a pure culture
of Staphylococcus aureus was obtained from a necrotic
lesion. No other significant bacteriological findings were
recorded. Stevens and Johnson presented strong arguments
in favour of their view that it was a separate clinical entity.
Since their report a number of cases have been recorded
under such names as "erythema multiforme bullosum with
involvement of mucous membranes of eyes and mouth",
"erythema multiforme exudativum with ophthalmia and
stomatitis" et cetera. The latest report comes from Simon
Kove, a medical officer of the United States Army. 1 His
two patients were young men. The first suffered from
membranous stomatitis, purulent conjunctivitis and inflam
mation of the urethral meatus; but he had no exanthem.
Sulphadiazine was given early. The temperature subsided
by lysis and reached normal by the sixth day. The oral
mucous membrane had sloughed away by the tenth day,
and by the seventeenth day the mouth was normal. The
occular discharge ceased on the seventh day; but con
junctivitis persisted till the seventeenth day. The second
patient s illness was severer and more prolonged. It com
menced with parotitis. Numerous vesicular and ery-
thematous lesions appeared. Sulphadiazine and penicillin
were given. In each case the leucocyte count was raised
(10,000 to 14,000 per cubic millimetre) at the commence
ment of the illness, but remained below 10,000 thereafter,
and in the second case was as low as 5,800. Kove, bearing
in mind the second patient s mumps, suggests that a virus
may be the causal agent.

The main and possibly the primary lesions in this
syndrome are stomatitis and conjunctivitis. The exanthem
appears to be secondary; possibly it occurs only when
infection of the blood stream is heavy. Perhaps the early
administration of Sulphadiazine was sufficient to limit it in
Kove s cases. Oral and ophthalmic surgeons and dermatolo
gists should be on the lookout for the disease. Possibly it
is not so rare as we have been led to believe.

A NEW YORK FESTSCHRIFT.

Tin: issue of the Journal of the Mount Sinai Hospital,
New York, for May-June, 1945, is dedicated to Dr. Eli
Moschowitz on his sixty-fifth birthday. It is said of Dr.
Moschowitz in a foreword that no member of the staff of
the Mount Sinai Hospital in this generation has com
manded the respect and devotion of his associates in quite
the same degree, and he is described as "physician,
scientist, scholar, traveller, epicure, bibliophile, magician
and lover of music and the arts". He has been a prolific
and versatile writer in the field of clinical medicine. His
monograph on the hyperkinetic diseases was the subject
of comment in this journal on February 26, 1944. Dr.
Moschowitz s latest monograph on "The Biology of
Obesity" might well have application to the special number
of the Journal of the Mount Sinai Hospital, for instead of
the usual slender publication it is a stout volume of 814
pages. It is "healthy fat", however, and may well give
much pleasure to the recipient. Among many interesting
contributions are articles on cup-shaped nipples as a stigma
of infertility, by R. T. Frank; on the continuous
immobilization of the chest and diaphragm in the treat
ment of pulmonary tuberculosis, by A. L. Barach; on the
relationship of the arcus senilis to coronary arterial
disease, by E. P. Boas; on the Kenny treatment of polio
myelitis, by A. E. Fischer; on the pathogenesis of athero
sclerosis, by L. N. Katz and D. V. Danber; and on a
homunculus discovered in a dermoid cyst of the ovary, by
A. Plant. There are 75 articles in all.

1 The American Journal of the Medical Sciences, November,

i y 4 o,

194

THE MEDICAL JOURNAL OF AUSTRALIA.

FEBRUARY 9, 1946.

abstracts from
Literature*

SURGERY.

Total Removal of the Pancreas and

Other Organs and Tissues.
A. BRUSCHWIQ, J. T. RICKETTS AND
R. R. BIGELOW (Surgery, Oynecology
and Obstetrics, March, 1945) report a
case of total pancreatectomy, total
gastrectomy, total duodenectomy,
splenectomy, left adrenalectomy and
omentectomy in a diabetic patient, with
recovery. The patient was a white
male, aged fifty-three years, who was
seen first in February, 1944, and was
complaining of steatorrhoea, loss of
weight and polyphagia. After examina
tion it was decided that he was severely
diabetic, and it was found that he
required 60 to 90 units of insulin daily.
Under treatment he regained 37 of the
50 pounds in weight which he had
previously lost. X-ray examinations of
his alimentary tract revealed no
abnormality. He was discharged from
hospital in May, being readmitted three
months later with jaundice and right
upper abdominal pain. Exploratory
laparotomy was performed in Sep
tember, 1944, and a carcinoma was
found in the body and tail of the
pancreas, with extension into the
stomach and left adrenal gland, and
numerous metastases in the greater
omentum. The omentum was resected
first, and then the stomach, duodenum,
pancreas, spleen and left adrenal.
CEsophago-jejunostomy and choledocho-
jejunostomy were performed. An
entero-anastomosis was carried out.
The operation was performed in five
hours and forty-three minutes, during
which time the patient received 2,800
millilitres of blood, and 300 millilitres of
saline and 800 of gelatin solution. It
is stated that there was no shock at
any time, and that the post-operative
course was smooth. Details of the
management are given. The pancreas
when examined showed degenerative
insular changes typical of diabetes, and
carcinoma arising from duct epithelium.
The patient was ambulatory ten weeks
after the operation, but then developed
metastases within the abdomen and died
one month later.

The Use of Heparin in the Abdomen.

F. M. MASSIE (Annals of Surgery,
April, 1945) discusses the intra-
abdominal use of heparin in the pre
vention of peritoneal adhesions. He
first reviews the work of Lehman and
BoyB. These investigators administered
heparin before closing the abdomen
after dividing adhesions, and then by
paracentesis every twelve hours for
three days; results in fourteen patients
were reported. The author has tried a
modification of this method in seven
cases. All patients had shown a ten
dency to reform adhesions in number
and density far above the average, and
to develop intestinal obstruction. He
thinks that heparin seems to offer a
better outlook in this type of condition
than anything used up to now, but
quotes and endorses the view of
Lehman and Boys, that "the use of
heparin should be limited to cases of
obstruction due to adhesions, and par
ticularly to cases In which previous

operations have been performed for
obstruction; in other words heparin
should be used only in that group of
desperate cases in which one is willing
to accept the hazard of an insufficiently
tried method in preference to a future
risk of significant proportions". The
one important and essential contra
indication is the presence of an oozing
peritoneum after adhesions have been
divided, and heparin should not be used
when granulation or subacute inflam
matory tissue is present. Minor dangers
attending the use of heparin are infec
tion and delayed wound healing, but
the chief danger is haemorrhage. Blood
coagulation and bleeding time should
be estimated, but the author has
obtained better guidance from clinical
observation, together with estimations
of blood pressure and haemoglobin.
Should haemorrhage occur, it can be
checked by blood transfusion and by
discontinuance of the heparin, but this
will mean abandoning the attempt
to prevent the reestablishment of
adhesions. The author reports seven
cases in which heparin was used intra-
peritoneally.

Succinylsulphathiazole and Phthalyl-
sulphathiazole in Colon Surgery.

E. J. POTH (Surgery, June, 1945) dis
cusses the value of Succinylsulpha
thiazole and phthalylsulphathiazole
(referred to briefly as "sulphasuxidine"
and "sulphathalidine") in the prepara
tion of the colon for surgery. Both
drugs lower the count of coliform
organisms in the fasces very consider
ably, but there are some differences
between the two drugs; the former will
reduce the count to about 100 organisms
per gramme of faeces, and cause the
stools to become semifluid, small in
bulk, mucoid and relatively odourless.
Sulphathalidine is more effective in
reducing the colonic flora, but the faeces
become tenacious and stringy, and there
is less efficient mechanical emptying of
the bowel unless enemata and purges
are used. Sulphathalidine is the more
effective drug in the presence of diar
rhoea. Average dosages are 3-0 grammes
every four hours for sulphasuxidine and
1-5 grammes every four hours for
sulphathalidine. Among several thousand
patients there has been one fatality,
which was due to agranulocytosis.
Some minor toxic effects are described,
and the author points out that there
is a possibility, through misunder
standing, that the patients may be given
sulphathiazole when succinylsulpha-
thiazole has been ordered. The larger
dosage renders such an error dangerous.
An occasional patient with an ulcerat
ing condition of the colon shows an
increased tendency to bleeding while
being prepared with sulphasuxidine.
For routine pre-operative preparation a
saline purge is first administered and
the patient is then put on a diet with
a high protein content and a low
residue. One or other of the drugs is
given, in the dosages mentioned above,
for a period of seven days. If an
anastomosis has been performed, the
drug is continued after operation. Poth
concludes that sulphasuxidine and
sulphathalidine help to bring about
a satisfactory bacteriological and
mechanical preparation of the bowel for
surgical operation. With the proper
alteration of bacterial flora, the
preservation of blood supply by the
avoidance of tension and the proper

placement of sutures become more
important than the chance soiling of
tissues by the modified contents of the
bowel. The drugs, when properly used,
contribute to a lowering of operative
mortality, and make an occasional pro
cedure possible which might otherwise
not be feasible.

Local Treatment of Burns.

E. C. REESE (The American Journal
of Surgery, March, 1945) reports his
experiences in the treatment of 39
cases of burns. Local treatment con
sisted of the application of a trans
parent film with a methylcellulose base,
and containing 20% of sulphanilamide
and 10% of sulphacetamide. Before
application of the film the burned area
was cleansed with neutral soap, strict
aseptic precautions being observed.
Pressure dressings were applied over
the film, and were removed after four
or five days to permit inspection of
the burn through the film. The film
was not removed until healing was
complete, unless any portion had
become macerated. This was then
replaced by new film. General sup
portive measures were also employed.
The author found the results were
satisfactory and the patients very
comfortable. He considers that the
method is deserving of wider use.

The Causation of Shock.

DALLAS B. PHEMISTER AND CARL H.
LAESTAR (Annals of Surgery, June, 1945)
discuss the causation of surgical shock.
"Working on the theory that nerve
stimuli from the site of injury or opera
tion produce shock, they have made
attempts to prevent shock by nerve
block. Swingle and his co-workers
deduced that a flow of nociceptive nerve
stimuli from an area subjected to
trauma played an important part in the
production of shock, and that if spinal
anaesthesia was used the incidence and
severity of shock were greatly reduced.
The authors refer to a series of experi
ments on dogs by Swingle and his co-
workers, designed to test theories as
to the effect of trauma in producing
shock. The animals were anaesthetized
with ether, and then a 2% solution of
procaine was injected at the level of
the third or fourth lumbar vertebra, the
amount varying with the weight. Both
hind legs were subjected to trauma
with a mallet, after which the ether
was withdrawn and the spinal anaes
thesia continued. The authors arranged
a further series of experiments to
determine how much of this reported
protection against limb trauma was due
to blockage of sensory nerves preventing
the flow of presumable nociceptive
stimuli from the field of trauma and how
much due to the block of vasomotor and
motor nerves with resultant temporary
fall in blood pressure reducing the
amount of haemorrhage. The technique of
the authors own method is described
and detailed tables of the results are set
out. No evidence was obtained from
these limb trauma experiments either
that a flow of nociceptive stimuli from
the injured field or that toxin formation
is an important contributing factor in
the initiation of any circulatory impair
ment or shock which followed. The
animals in which the trauma was
applied soon after the administration of
spinal anaesthesia were protected from
shock principally by the blockage of the
vasomotor and motor nerves, which

FEBRUARY 9, 1946. THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER.

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THE MEDICAL JOURNAL OF AUSTRALIA.

195

greatly lowered the blood pressure and
limited the haemorrhage to an amount
that was too small to produce shock,
instead of by the blockage of afferent
impulses. The maintenance of such a
low blood pressure by spinal anaesthesia
for the prevention of shock during an
operation on man is contraindicated, as
the amount of anaesthesia required
would be too great. In all of the experi
ments in which shock developed, the
local blood loss was large and consti
tuted the outstanding causative factor.
There appears to be no indication for the
renewal of efforts to prevent shock by
the blockage of afferent nerve impulses
through the use of local or spinal anaes
thesia. Indications for the use of local
or spinal anaesthesia in shock are based
on other grounds.

Prophylaxis of Wound Infection.

L. W. PETERSON (Archives of Surgery,
April, 1945) discusses methods of
cleansing wounds as set out in medical
literature. Believing that the germicidal
properties of soap are unquestionable
and that the irritative properties of
soap in wounds are neither great nor
damaging, the author conducted a
series of experiments to establish the
.superiority of soap and water over other
means of cleansing wounds. He allowed
a culture of pyogenic organisms to
remain in the wound for a definite time;
the effects of mixtures of green and
white soaps, the effects of scrubbing,
the combined effects of scrubbing and
soaps and the effects of irrigation with
isotonic saline solution were studied.
Photomicrographs of biopsy specimens
after the various treatments illustrate
the article. There is no doubt as to the
efficacy of the various soaps as
germicidal agents. However, in these
experiments, when the soaps were
placed in actual contact with the
uncontaminated fresh wounds, they pro
duced a definite but slight irritation.
This was noted only on microscopic
examination ; gross examination re
vealed no difference between control
wounds and wounds into which soap
had been placed. However, in wounds
which were contaminated by a given
amount of a culture of Staphylococcus
aureus placed within their depths and
then exposed to soap, there was definite
increase in signs of infection over those
found in the control wounds not exposed
to soap; "green" soap was found more
irritating than "white" soap. The
harmful effect of mechanical washing
of the wounds is in direct proportion
to the coarseness of the material used.
These experiments indicated that of the
various methods studied, the cleansing
of contaminated wounds by a gentle
irrigation with isotonic solution of
sodium chloride is the most effective
prophylaxis of wound infection. Con
taminated wounds treated by this gentle
irrigation healed with less evidence of
infection than did control contaminated
wounds subjected to no treatment other
than closure at the specified time. Best
results were obtained by irrigating the
wounds with 1,000 millilitres of saline
solution with no scrubbing, but with
the force of the stream used as the
washing mechanism.

Acute Pancreatitis.

JOHN MORTON (Xurgery, April, 1945)
deals with the need for rapid diagnosis
of acute pancreatitis. He emphasizes

the value of Somogyi s rapid method of
estimating the amyloclastic activity of
the blood amylase; this test may be
reported upon in twenty minutes. The
test measures the reaction time, not
the reducing power, of the blood
diastase. Under normal conditions the
pancreas, salivary glands and liver do
not - contribute to the blood diastase
level, but acute pathological changes in
the pancreas or salivary gland may
cause a temporary effusion from these
glands into the blood stream. Aspirated
fluid from the peritoneal cavity is
useful, and in acute pancreatitis gives
high readings. Acute pancreatitis can
be diagnosed only very rarely without
the blood amylase test. The author
quotes a series of diagnoses ranging
from perforated ulcer, cholecystitis,
empyema of the gall-bladder, to the
acute crisis of pernicious anaemia; in
all these cases improvement could have
been effected by the application of the
test. He states that acute pancreatitis
must be considered in all cases of
sudden severe epigastric pain. The
serum amylase test is of the greatest
value in deciding if the pancreas is
involved. There are two distinct types
of acute pancreatitis, acute oedematous
and pancreatic necrosis. Acute

cedematous pancreatitis can be diag
nosed by the serum amylase test and
the rapid improvement under conserva
tive treatment. Pancreatic necrosis
must be suspected when the patient
fails to make improvement within a
few days. In acute oedematous
pancreatitis operation should be
deferred until the reaction has subsided.
Acute 03dematous pancreatitis is fol
lowed by chronic pancreatitis fre
quently, as is demonstrated at late
operation. Pancreatic necrosis is fol
lowed in a proportion of those who
survive by abscess, diabetes and pseudo-
cysts. Conservative treatment of
pancreatic necrosis or pancreatic
abscess is disastrous. When diagnosis
of either condition is suspected, opera
tion is indicated as soon as the patient
can be properly prepared for it. Biliary
tract disease should be treated after
acute pancreatitis if it has played a
part in the onset. Any surgical
manipulation about the lower end of
the common bile duct or the head of
the pancreas is likely to be followed by
post-operative acute pancreatic oedema.
This can be demonstrated by the
amylase test. There is a considerable
danger of this in the resection of
posterior duodenal ulcer perforating
into the pancreas. It carries a
mortality which should be taken into
consideration in any series of duodenal
ulcer resections. The author s case
reports were selected to illustrate points
made in this discussion.

Dermoplasty of War Wounds of the
Lower Part of the Leg.

J. F. PICK (The American Journal of
Surgery, July, 1945) describes a method
of covering areas denuded of skin after
excision of diseased soft parts and bone.
The author claims that eight to ten
months time is gained in the manage
ment of severe injuries of the lower
part of the leg and that the results are
better from the functional, anatomical
and cosmetic points of view. The
basis of the method is the combination
of the double pedicled flap, with a
reduction in the circumference of the
leg, and the secondary use of full thick

ness skin over the small residual
surgically created area. The method is
applied to the management of compound
fractures of the leg by the open method.
Great care is taken in the pre-operative
treatment by means of scrubbing and
irrigation with Dakin s solution coupled
with packing, keeping the wound moist,
and the use of general measures to
J produce an aseptic field. The first step
| in the author s method consists in
taking an exact copy of the defect by
means of an 3C-ray film cleaned of its
sensitized coat. After it has been cut
accurately on the wound surface, the
pattern is turned to one side or the
other to see which offers the best tissue.
The whole of the affected soft parts
are then excised, care being taken to
avoid disseminating any of the debris
into the surgically uncontaminated
areas around and underneath. Any
bone protruding into the wound is
excised with the soft parts to avoid
leaving excrescences under the flap.
This may leave a very deep defect quite
unsuitable for ordinary skin grafting.
It is of no consequence that only
tendons and bone appear in the bottom
I of the wound. An important and neces
sary step inv, cutting the flap by a single
incision approximately parallel to the
long axis of the limb, is to cut only
half-way through the fat, and then to
separate the fat into two layers. This
separation is carried out by sharp dis
section under the whole of the flap
and under its upper and lower
extremities. The fat remaining is now
fashioned into fat pedicle flaps to cover
the underlying bone and tendon ct
cetera. The double pedicled flap is now
moved over the defect. To reduce the
new raw surface produced by moving
the flap, the author sacrifices some of
the undisturbed fat over the muscles.
In two of the author s cases the whole
of the lower part of the leg was stripped
of fat, so that it was possible to close
the wound without any subsequent skin
grafting. The areas left on each side
of the flap are then covered with full
thickness grafts. Two punctures are
made in the skin to permit drainage
from the most dependent part. The
dressing is done by covering the whole
area with 3% scarlet red ointment;
over this is placed a layer of cotton
wool moist with saline solution, and
over this dry cotton wool. Care is taken
not to apply too much pressure. The
leg is elevated and the whole dressing
is left undisturbed for fourteen days.

The Metabolic Changes after Burns.

J. W. HIRSHFELD et alii (Archives of
Surgery, April, 1945) report the results
of the investigation of loss of nitrogen
by 23 burned patients. The intake was
carefully compared with loss by way of
vomitus, faeces, urine and wound
exudate. All patients excreted large
quantities of nitrogen in the urine, and,
except for a few who received large
quantities of carbohydrate and protein,
lost considerable weight. It was possible
to prevent or to decrease a negative
nitrogen balance by feeding with diets
high in calorific value and protein con
tent. These diets, however, were poorly
tolerated during the first few days after
injury. Most burned patients suffer from
anorexia and will not consume an
adequate diet, hence after the stage of
shock has passed special care must be
taken to ensure that they eat sufficient
food to maintain proper nutrition.

196

THE MEDICAL JOURNAL OF AUSTRALIA. FEBRUARY 9, 1946.

30eDical Societies.

OBSTETRICAL SOCIETY OF THE WOMEN S
HOSPITAL, MELBOURNE.

A MEETING of the Obstetrical Society of the Women s Hos
pital, Melbourne, was held on May 16, 1945, at the hospital,
DR. ELLIOTT TRUE in the chair. The meeting took the form
of a symposium on the conduct of labour by members of the
obstetrical staff of the hospital.

Symposium on Labour.
Uterine Pains in Labour.

DR. W. I. HAYES discussed pains in labour. He said that
labour was the extrusion of the child from the uterus and
vagina until its complete expulsion into the outside world.
When this was progressive and effected by a succession of
normal uterine and abdominal contractions, the labour was
normal, even though an abnormal presentation or foetal
mechanism might be present. It was important to realize
that there was an intimate relationship between the pains
and the progress of the child. When progress was normal,
the pains were normal, and conversely, when pains were
normal, normal progress was taking place. Thus, there were
two criteria by which a labour might be judged first, the
progress of the child, and secondly, the pattern of uterine
activity; but of the two, the latter was the more delicate,
became evident earlier, and was therefore the more
important.

Dr. Hayes then said that uterine contractions during
labour varied in rhythm, in duration, in intensity and in
character, according to the stage of labour at which they
occurred. Each contraction slowly increased to an acme of
height, which was maintained for a certain time, and then
the contraction slowly subsided. During the stage of taking
up or shortening of the cervix, the pains lasted three to five
seconds, recurred at intervals of fifteen minutes to one hour,
and were usually felt solely in the abdomen; but during the
stage of cervical dilatation, the pains lasted twenty to
twenty-five seconds, recurred every three to five minutes,
and beginning in the back, passed round to the front. In
the second stage of labour, the stage of descent or expulsion,
the uterine contractions lasted forty to fifty seconds,
recurred every five to seven minutes, were typically
"bearing down" in character, and were assisted by voluntary
contractions of the abdominal musculature. In every case,
the labour pains should be studied from time to time, to
determine whether they conformed to the normal pattern.
The patient must be asked to notify the onset of a con
traction, the uterus should be palpated, the demeanour of
the patient should be closely observed, the duration of the
complete contraction should be ascertained by timing with
a watch, and then the onset of the next contraction should
be awaited, so that the interval between pains might be
known. If the patient was in a certain stage of labour, and
had the type of contraction corresponding to that stage, then
the labour was normal and normal progress was taking
place; but if the pains characteristic of one stage occurred
outside that stage for example, if second-stage pains
appeared before the cervix was almost fully dilated, or first-
stage pains occurred during the stage of expulsion then the
labour was abnormal, and progress was not taking place.
Except in the rare instance of true uterine inertia, the
character of the contraction always reflected the progress
of the child against the resistance offered to it by the pelvis
and birth canal.

Dr. Hayes went on to discuss abnormal labour pains, in
contrast with those of normal labour. He said that true
uterine inertia, the cause of which was still unknown, was
attended by infrequent, short, weak and ^ineffective con
tractions, which were present throughout all stages of the
labour. Primary uterine inertia was due either to a reflex
spasm of the circular muscle of the cervix, from apprehen
sion or fear, or to lack of pressure by the presenting part
on the internal os, as in disproportion, full bladder, placenta
prceina et cetera,. In each case, the pains at the onset of
labour were vague, infrequent and irregular. Secondary
uterine inertia, though usually but erroneously thought to be
the result of uterine fatigue, was initially due to obstruction
to the child s progress. Hyperactivity of the uterine action,
giving rise to contractions which were stronger, longer and
more freq*uent than normal, and which were likely to lead
to a state of impending rupture of the uterus, was also
the result of obstruction; but in this case, the child was
attempting to pass through a partly dilated cervix, and this

provided the stimulus which intensified the forces of labour.
In precipitate labour, the contractions during the first stage
gave rise to little or no pain, and the acceleration of the
second stage followed from a combination of reduced
resistance with an overwhelming desire to bear down. In
conclusion, Dr. Hayes said that for many years the
mechanical factors of labour had been unduly stressed at
the expense of the physiological factors. It was hoped that,
in future, more attention would be paid to the latter, and
that their importance would be more fully appreciated.

The Progress of- Labour and Palpation.

DR. J. W. JOHNSTONE said that he wished to turn attention
from the physiological forces of labour, or engines of
delivery, to the purely mechanical side how the foetus was
moving along the birth canal, and the clinical determination
of the progress of labour by external palpation. 1 Except in
cases of gross cephalo-pelvic disproportion, it was not pos
sible to predict the outcome of labour until the process was
well established. In the complex physiological mechanism
of labour, the uncertain factors were the strength of the
pains, the relaxation of the pelvis, the moulding of the
head, the altered disposition of the soft parts, and the
physical and mental fortitude of the patient. Although pre
liminary warning signals of impending disaster might be
present, every labour became more or less a test of labour.
As Hippocrates himself had said: "Experience is fallacious
and judgement difficult." Dr. Johnstone pointed out that
the putting of the foetal head through the pelvis had not
the same mathematical precision as the passing of a marble
through a wedding ring, in which case it went through or it
did not. The pelvis itself was moderately fixed, but by no
means circular. The all-important plane of the inlet was
inclined at 55, with the forward-projecting but inaccessible
promontory not much below the navel, so that the head
passed down and back into the bed. Although buried in the
substance of the mons, Veneris and obscured by the origin
of the rectus muscle, the symphysis pubis was the out
standing landmark on palpation of the pelvic brim. Its
sloping surface formed the whole anterior wall ef the bony
pelvis. It was the arch or bridge under which the head must
ride. Dr. Johnstone, referring to the foetal head, pointed
out that this was unlike the marble, in that it was com
pressible in substance and ovoid in shape. The general
contour of the occipital pole was spherical, the sub-
occipito-bregmatic and biparietal diameters each being three
and three-quarter inches. Projecting forward out of this
occipital sphere, and lagging behind it in the flexed head, was
the sincipital sphere, slightly less in diameter. The main
art in obstetrics was to estimate the disposition of this ovoid
body with respect to the sloping upper pelvic strait. Some
would say that this was about as satisfactory as playing
snooker on a tilted table and using elliptical billiard balls.

The terms "attitude", "lie", "presentation" and "position"
of the foetus relative to the mother were familiar to every
one. Dr. Johnstone said that he wished to draw attention
to another relationship, even more important but not so
generally understood. This was first described by Miiller as
the station of the foetus the level of the presenting part,
its degree of engagement, how far it had descended on the
curve of Carus in other words, its relationship to the
symphysis. It was usual to speak of a floating head when
the head was freely mobile above the inlet. In the ntulti-
gravida the head often remained high until the cervix was
well dilated and the membranes ruptured. When present in
a primiffravida at the onset of labour, floating head was a
warning signal of possible disproportion, as lightening and
fixity usually occurred some weeks before. The head was
said to.be becoming fixed when moderate pressure would not
displace it, but the biparietal diameter had not yet passed
the region of the inlet. It was engaged when its greatest
horizontal plane, passing through the parietal bosses, had
passed the plane of the inlet.

Referring to palpation, Dr. Johnstone said that one had to
ask what landmarks there were on the foetus by which
descent could be judged. Descent of the foetal heart sounds
provided only a vague and unreliable estimate. The anterior
shoulder was the only point sufficiently defined on the foetal
body to be used as a landmark. When the head was com
pletely above the brim, it was four or five inches over the
pubis, and when fully engaged it was about two inches
above the pubis. After anterior rotation it approached the
mid-line while descending. It was the fcetal head, however,
that provided the main estimate of descent and disproportion,
and the methods used were the first and second pelvic grips

1 Dr. Johnstone s discussion was illustrated by a number of
lantern slides.

FEBRUARY 9, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

197

and their modifications. In performing the first pelvic grip,
It was best to begin by palpating the symphysis pubis and
its upper margin. The ulnar border of the right hand was
then placed on the pubis and a wide grasp of the head was
taken in the spread hand. Its ovoid contour, with the
forward-projecting and upward-lagging sincipital pro
tuberances, was determined. This sincipital pole would lie
to one or other side of the pelvis and to the back or front
according to position. In the flexed head the sinciput was
the last to disappear, and in posterior positions its projection
forwards over the pubis was likely to lead to an erroneous
diagnosis of disproportion. This first pelvic grip of Pawlic
could also be used to determine fixity, by rocking the head
from side to side. Again, by reversing the grip and holding
the head down on the brim with the left hand from above,
it was possible to estimate overhang over the pubis. The
second pelvic grip was performed by turning to face the
patient s feet, and by sinking the fingers into the iliac fossae,
it was possible further to palpate and outline the head and
to rock it from side to side, in or over the brim. The grip
could also be modified, as described by Miiller and by
Windeyer, to determine disproportion and overlap. If the
head was pushed down onto the pubis and back onto the
promontory, a "sighter" could be taken with the fingers
from the most forwardly projecting portion of the head onto
the pubis. It was well again to remember the inclination of
the brim, and to recollect that the head therefore went down
and back into the bed. When the sinciput had disappeared
from deep palpation in the iliac fossa, one could begin to
feel for the emerging head by deep palpation through the
soft tissues of the ischio-rectal fossa lateral to the vulva.
In the labour ward post-anal palpation was preferred. The
patient was turned on her left side and the parts were
covered with a towel, and during a contraction the fingers
were pressed slowly and deeply into the tissues behind the
anus and in front of the coccyx. When the firm resistance
of the head could be felt from below, the end of labour was
usually in sight. Later the perineum would bulge during
a contraction, the anus would begin to open, exposing a
length of its red anterior wall, and then the hairy scalp
would part the pillars of the labia as the head was crowned.
Dr. Johnstone said that by using these methods of external
palpation, which could be often repeated and carried no
risk, it was possible to determine the clinical progress of
labour, and in most labours to dispense with internal
examination. While undoubtedly vaginal examination pro
vided much additional data, particularly with regard to the
dilatation of the soft parts, in normal labour vaginal
examination should be resorted to only when there was
doubt about continued advance. The important question of
what was the station of the head had to be asked many
times in every labour such questions as how much of the
head was still above the pelvic brim, had the critical point
been reached, and whether the parietal bosses had passed
the conjugata vera with the lowermost level of the head at
the ischial spine plane. It was this ability to recognize the
changing station or progressive descent of the head which
constituted a great part of obstetrical art. Conversely, it
was the inability to recognize the lack of advance in spite
of good contractions which distinguished the blind midwife
from the truly observant accoucheur.

Analgesia in Labour.

DR. W. M. LEMMON discussed the relief of pain in labour.
Dr. Lemmon said that it was almost a century since Sir
James Simpson, in 1847, used ether for that purpose and
subsequently replaced it by chloroform. In 1902 von
Steinbuckel introduced the combination of morphine and
scopolamine, and this was the commencement of a long list
of drugs and combinations of drugs which were used to
alleviate the suffering of the parturient. Kotz and Kaufman
in 1944 had reviewed the methods in current use in American
clinics, and had found that in spite of individual variations
there were six basic methods: (a) the use of paraldehyde;
(ft) the rectal use of an ether in oil mixture; (c) the rectal
administration of "Pentothal Sodium"; (d) the use of
morphine and scopolamine; (e) the use of the barbiturates;
(/) continuous caudal anaesthesia. A surprising omission
from this list was the use of chloral hydrate in combination
with potassium bromide, which had been found most useful
in the early stages of labour.

Discussing paraldehyde, Dr. Lemmon said that, given
rectally or orally, it resulted in satisfactory analgesia and
amnesia in 85% or more of cases if it was used in combina
tion with morphine or barbiturates, but was not nearly so
useful alone. Rosenfield and Dividoff in 1935 used paraldehyde
in combination with "Nembutal" in a series of 300 cases; but
the dosages used six to thirteen grains of "Nembutal" and

six to twelve drachms of paraldehyde were much above
what was now regarded as safe. Kotz and Kaufman used it
also with morphine, the average dose being 11/60 of a
grain of morphine and 17-5 drachms of paraldehyde. The
nauseous taste and odour of paraldehyde limited its useful
ness when given by mouth, and rectal administration of
analgesics was not favoured in Melbourne because of soiling
of the field and the tendency to proctitis. In spite of this,
paraldehyde was one of the least toxic of drugs, with a large
margin of safety between the therapeutic and toxic doses,
and it justified more extensive employment than at present.

Dr. Lemmon went on to say that the rectal administration
of oil and ether mixtures in combination with barbiturates
or morphine and scopolamine, as suggested by Gwathmey,
was credited with satisfactory results, but had not been used
to any extent in the Women s Hospital. Special supervision
was necessary, and this limited the usefulness of the method.
"Pentothal Sodium" given rectally had been reported on
with favour, especially for multiparce, but the method had
not been used in the hospital. Morphine and scopolamine,
the first of the analgesics employed, although suffering at
times a temporary eclipse, had stood the test of time.
Experience in the method was necessary for good results,
but when this was present, it was most satisfactory for
primigravidce, the duration of whose labour was such that
the child was unlikely to be born within four hours of the
initial injection. If it was born within this time, the
depression of the foetal respiratory centre by the morphine
was sufficient to cause concern in the resuscitation of the
child. Experience would indicate that the greatest danger
lay between one and three and a half hours after the
injection of morphine, and this greatly limited the usefulness
of the method for multiparce.

Dr. Lemmon went on to describe what he considered the
most useful routine. Early in labour, chloral hydrate and
potassium bromide, thirty grains of each, were given by
mouth. When the cervix had been taken up and the os was
beginning to dilate, hyoscine compound A or B was given,
according to the estimate of probable progress. Two hours
later one two-hundredth of a grain of scopolamine was given,
and this dose was repeated every two hours or less often
if the patient did not appear to require such dosage. The
room should be darkened, and disturbance of the patient
minimized. For this reason memory tests which entailed
disturbing the patient twice should be used sparingly. A
substitute for such tests, which had been found useful when
one was in doubt, was to ask the patient to oppose the two
index fingers about six inches in front of the eyes. If this
was easily and quickly performed, further scopolamine was
required. Various substitutes for morphine in this method
had been used from time to time for example, heroin or
"Dilaudid" without great benefit, although heroin was used
much more than morphine as a routine sedative in the
hospital. The latest substitute suggested was demerol hydro-
chloride, which had just become available on the Australian
market under the name of "Pethidine". This drug had
properties analogous to both the morphine and atropine
series, and had apparently little depressant action on the
fcetal respiration. Schumann had reported 1,000 cases in
which the drugs were given to primigravidce and multiparce,
the later receiving the drugs by the intravenous route when
ever it was estimated that delivery within two hours was
likely. In this series the administration of demerol was
repeated with that of the scopolamine at intervals of four
hours. Results quoted were satisfactory, and reports from
Britain by Gallen and Prescott confirmed this finding.
Further experience with the drug should prove of interest.

Dr. Lemmon went on to say that barbiturates had a great
vogue in the last decade, and numerous members of the
group had been tried; but the most generally useful appeared
to be "Nembutal". It had been used alone and in combination
with other drugs, notably scopolamine and paraldehyde.
Early American reports gave large doses, up to fifteen grains
or more, with an initial dose of four and a half to six
grains repeated as required; but later reports reduced the
maximum total dosage to nine grains. Lundgren and Bruce,
in 1940, experimented with "Nembutal" and scopolamine,
"Nembutal" and paraldehyde, and "Nembutal" alone, and
found the combination with scopolamine the most effective.
Their maximum dose was six to seven and a half grains of
"Nembutal" with 1/150 grain of scopolamine, which is more
in keeping with experience in this country.

Dr. Lemmon then outlined what he considered the most
useful method for primigravidce. Early in labour chloral
hydrate and potassium bromide, thirty grains of each, were
given. When the cervix had taken up and the os was
beginning to dilate, three grains of "Nembutal" were given,
followed in half to three-quarters of an hour by 1/150 grain

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FEKRI-ARY 9, 194(&gt;.

of scopolamine. The administration of "Nembutal", one and
a half grains, alone or with scopolamine (1/200 grain) might
be repeated as required at intervals of three or four hours;
but the maximum total dose of "Nembutal" should not exceed
seven and a half grains. For multiparce, "Nembutal" might
be used in the reduced dosages now employed, as the same
depression of the foetal respiratory centre did not occur as
with morphine; but the dosage should be less for example,
one and a half grains as an initial dose, followed in half an
hour by another one and a half grains if the effect was
insufficient. Scopolamine, 1/150 grain, might be given -at
any time from one hour after the initial dose. This amount
was often sufficient, but another 1-5 grains of "Nembutal"
might be given in three or four hours if necessary. This
had been found to be a useful routine method of sedation
for multiparce.

Dr. Lemmon then said that the barbiturates had certain
disadvantages; for example, restlessness and even delirium
were noted at times, and certain people were abnormally
susceptible to them. But in spite of these drawbacks they
were widely used at present, and were still among the most
useful analgesics in labour.

Referring to continuous caudal anaesthesia, Dr. Lemmon
said that in the last few years continuous caudal anaesthesia
had been given an extensive trial in America. Two tech
niques had been used: (a) repeated injections through a
malleable needle; (ft) continuous drip administration through
a ureteral catheter inserted through a number 13 gauge
needle, the needle being then withdrawn. The solutions used
had been "Metycaine", 1-5% in isotonic saline solution, and
procaine, 1% in isotonic saline solution. The injection was
made into the sacral canal below the dural sac. The amount
of solution injected was forty mils, and repeated injections
of twenty mils every thirty to forty minutes to maintain
anaesthesia were advised. The analgesia was perfect in "the
majority of cases, but the risks were ma ny, and fatalities
and "close calls" had been so numerous that the method had
been abandoned in many clinics. The main danger was the
injection of the solution into the subarachnoid space, and
the suggested safeguards (a) aspiration of the needle prior
to injection and (b) preliminary injection of eight mils of
solution, with a delay to see whether symptoms of spinal
anaesthesia ensued seemed to be uncertain, as fatalities
had occurred in spite of their employment. Infection was
also a danger, and deaths had been reported. Intravenous
injection of the drug, which could not always be avoided,
might also prove fatal. The necessity for the constant
attendance of a specially trained anaesthetist proved yet
another disadvantage. In conclusion, Dr. Lemmon said
that Greenhill s final remarks in "The 1943 Year Book of
Obstetrics and Gynecology" were worthy of quotation: "At
the risk of being called an ultra conservative, I believe
that, despite its auspicious start, continuous caudal anaes
thesia will not become part of our general obstetric
armamentarium."

Anaesthesia in Childbirth.

DR. G. SIMPSON gave a demonstration of anaesthetic
apparatus. Discussing anaesthesia in childbirth, he said
that the pioneer and outstanding personality in this field
was Sir .lames Young Simpson, of Edinbui gh, who against
great opposition obtained recognition of the case for anaes
thesia in childbirth. Not only did Simpson establish the
value and effectiveness of obstetric anaesthesia, but he
established the right of women to demand relief of pain
during labour a right not now challenged in any quarter.
It was the practice in the Women s Hospital for delivery to
give anaesthetics to all women. The problem of anaesthesia
in labour was one still requiring much research and investi
gation. There had been too much tendency to regard a
half-hearted surgical anaesthesia as being all that was
required. The problem was closely bound to that of analgesia
and sedatives in labour. It was not practicable to have an
anaesthetist continuously present throughout labour, so the
problem was concerned with the search for an anaesthetic
that could be given by an untrained person, by a midwife,
or by the patient herself. The conditions required were:
(i) painless childbirth, (ii) no harm to mother or child,
(iii) the possibility of administration by an unskilled person.
The Midwives Regulations in Victoria gave rather negative
assistance. Article 40 made the following statement: "No
midwife shall (c) administer an anaesthetic to a patient
unless under the personal supervision of, and in the
immediate presence of a legally qualified medical prac
titioner."

Dr. Simpson went on to say that the ideal anaesthetic agent
and method of administration answering all requirements

had not yet been found, but by various surgical anaesthetics
and other means satisfactory relief could be given in all
but exceptional cases. It was well established, but not
satisfactorily explained, that women in labour took anaes
thetics well. Anaesthetic death had hardly to be considered,
and this allowed for carelessness, which was bad. There was
no excuse for commencing the administration of an anaes
thetic without proper resuscitation measures available
oxygen, "Coramine", mouth gag et cetera.

Referring to surgical anaesthetics in general use, Dr.
Simpson first discussed chloroform. He said that this was
Sir James Young Simpson s anaesthetic, in use now for
nearly 100 years and still in the front rank. It might be
given on an open mask or folded towel (rag and bottle
method). It might also be given by means of an inhaler.
With a Junker inhaler it might be self-administered. When
the patient was anaesthetized, she stopped pumping and got
no more. It had also been given in capsules, which were
broken by the patient and inhaled. The dangers of chloro
form were well known. They were (i) acute chloroform
poisoning, (ii) delayed chloroform poisoning, (iii) burning
of the face from contact with liquid chloroform, and (iv) the
danger of post-partum haemorrhage due to uterine relaxa
tion; moreover, chloroform was not to be used in toxaemia,
heart disease or shock, nor was it to be used carelessly, and
free air and airway must always be maintained. The
advantages of chloroform were: (i) quick, pleasant, easy
induction; (ii) quick analgesia, with no struggling in induc
tion; 4t was particularly useful for patients under sedation
with hyoscine; (iii) no mucous secretion; (iv) good relaxa
tion, which was necessary for manipulations for example,
internal version; (v) ease of transport, as small amounts
were required; (vi) non-inflammability it could be used in
bedrooms with open fires; (vii) safety of use in pulmonary
tuberculosis. For some reason chloroform in Victoria was
discredited and seldom used. The hospital was blamed for
discouraging its use; but that was not their present teaching.
Chloroform was used for all primiparce and for induction
of anaesthesia in most cases in the labour ward, except when
it was contraindicated. The position was well summed up in
the following terms by a special committee of the Royal
College of Obstetricians and Gynaecologists appointed in 1933
to investigate the use of analgesics in midwifery:

Chloroform by any method should not be used by
midwives acting alone. This conclusion has been reached
with regret, but both immediate and delayed dangers,
which are well recognized, occurred in this investigation,
and it is not possible fully to guard against such occur
rences if the administration is in inexperienced hands.

This finding should not, however, be taken as
prejudicing the use of chloroform by registered medical
practitioners, who, aware of the dangers, can take pre
cautions to lessen the risks.

Dr. Simpson said that the falling off in the use of chloroform
was a mistake and a pity; but its reintroduction would
require careful training of those who were now used to
pouring on ether ad libitum without fear of consequence.

Dr. Simpson went on to say that at present ether was the
most used anaesthetic. It was considered safe and fool
proof; but although there was little risk of overdose, there
were real dangers of post-anaesthetic pulmonary complica
tions. Ether might be given by open mask or by vapourizing
machine. Two vapourizers were available the ether machine
and the Oxford vapourizer. These both allowed safe
administration by the midwife or by the patient herself. The
dangers of ether were mainly due to inhalation of mucus
or vomitus. The patient was often badly prepared, not
having been starved, and having had no preliminary atropine.
She might be "fighting mad" from hyoscine. She was lying
in the left lateral position a bad position for anaesthesia.
If massive pulmonary collapse occurred, the correct treat
ment was immediate bronchoscopy and aspiration of bronchi.

Referring to nitrous oxide, Dr. Simpson said that during
the first World War a combination of nitrous oxide and
oxygen was established as the safest surgical anaesthetic
agent. It was not thought of in obstetrics because of its
cost and because of the unsuitability of machines for
administration. What was required in labour was an inter
mittent anaesthetic to be given when the pains occurred.
This was provided by the McKesson machine or with the
Australian "Austox D.M.". The "Austox" machine had
been on the market since about 1930. It was a most
satisfactory machine for the administration of nitrous oxide
and air or oxygen during labour. Its only disadvantage was
lack of portability, due not so much to weight as to the
essential awkwardness of its disarticulated parts. In 1932
Dr. R. J. Minnitt, at the request of the Liverpool Maternity

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199

Hospital, had undertaken to investigate means of giving relief
for the pains of childbirth. The result of Dr. Minnitt s
research was the Minnitt machine, first made available in
September, 1933, which allowed self-administration of nitrous
oxide and air in a fixed concentration of 45% of gas. Wide
publicity had been given to the Minnitt machine and to this
method of obstetric analgesia, which until the war was being
used extensively in England. In the investigation by the
Royal College of Obstetricians and Gynaecologists in 1934,
3,865 cases of anaesthesia by the Minnitt method were
included. It was considered that there was no added risk
to mother or child, but satisfactory analgesia was claimed
in only 77%. However, in a series of 1,025 cases presented
by Minnitt himself between 1933 and 1935, 92% of satis
factory results were claimed. The committee of the Royal
College of Obstetricians and Gynaecologists in its report
concluded that: "Gas and air administration by the Minnitt
apparatus is safe and satisfactory, although the apparatus
is expensive and gas costly. It is recommended that its
use be extended." Dr. Simpson went on to say that while
nitrous oxide and air were suitable for analgesia and anaes
thesia in most normal cases, the concentration of nitrous
oxide given did not allow deep anaesthesia and was inadequate
in some cases for normal delivery. It was insufficient for
forceps deliveries. After three or four breaths of pure
nitrous oxide had been inhaled, analgesia was produced in
sixteen seconds. Labour pains lasted for only half a minute
to one minute, so to obtain any effect it was most essential
to commence the administration of nitrous oxide and air
just before the pain started. This required training of the
patient. Minnitt advocated training before confinement, so
that the mask might be applied to the face and. the inhala
tion commenced without delay. It also precluded the use
of other sedatives, which dulled the pain and prevented the
patient from making an early start with the anaesthetic.
If nitrous oxide and oxygen were used, 5% of oxygen would
keep the patient free from cyanosis if only three or four
breaths were taken. This mixture, if inhaled at the first
indication of pain, would give analgesia and a short sleep
after the pain was over. In the second stage the patient
should hold the last breath and bear down. It was important
to take deep breaths. The percentage of oxygen must be
increased if longer periods of anaesthesia were required.
When necessary ether might be introduced to deepen anaes
thesia. A puff of pure oxygen might be given after delivery
fully to oxygenate the baby. The advantages of the method
were that it did no harm to mother or baby, and did not
slow but in fact quickened labour. It was the best anaes
thetic for toxaemic or shocked patients, and was also suitable
in pulmonary tuberculosis. While in the analgesic state
the mother was fully cooperative, but anaesthesia could easily
be deepened as required. The disadvantages of the method
were the awkward equipment, the danger that gas cylinders
might be empty when required, the fact that the mechanical
apparatus might not be understood by the staff, and the cost.
Much greater use should be made of gas, and in the larger
maternity hospitals the apparatus should be understood by
the staff and used more frequently.

Dr. Simpson then said that spinal anaesthesia was not used
at the hospital, and he could see no case for its use. Intra
venous anaesthesia had only special application for example,
for manual removal of the placenta in severe shock or in
tuberculosis. Local anaesthesia had an application in certain
cases only, for example, in breech deliveries episiotomy was
performed under local anaesthesia so that the full pushing
power of the mother might be preserved. The common
misuse of anaesthetics was in the giving of too little or too
much. In one labour ward there was a text: "My grace is
sufficient for thee." This was not appreciated by most
patients. Patients were sometimes told by their experienced
friends to yell their hardest or they would not get an
anaesthetic. That was surely a discredit to obstetricians. On
the other hand, an anaesthetic was abused if it was used
merely to hold back a normal delivery till the obstetrician
could arrive to be a witness. Light anaesthesia was best
except for intrauterine manipulations.

Dr. Simpson said that no survey of anaesthesia would be
complete without reference to training in relaxation before
confinement, which it was held allowed painless childbirth,
or to hypnotism, which appeared to be much used in Russia.
Hypnotism would seem to hold great attraction at the present
time, for it could be administered satisfactorily by telephone.
There was thus a wide range of tried and tested anaesthetic
agents from which to choose. There were indications, contra
indications and dangers. The method of administration and
the working of apparatus must be understood by both
obstetricians and midwives. Whatever method was employed,

the aim was a healthy baby and an undamaged mother, and
further, a mother whose comment would be, How marvel
lous it is to have a baby" not, was was often heard, "Never
again".

The Management of Labour.

DR. R. M. ROME dealt with some points in the management
of labour and the delivery of the child. He stressed the
importance of full instruction of the patient as to what to
expect when labour commenced and as to when she should
proceed to hospital. In the case of the primipara, the patient
should go to hospital when pains occurred regularly at
intervals of approximately fifteen or twenty minutes. A.
multiparous patient should be admitted to hospital if the
membranes ruptured, or at the first sign of abdominal dis
comfort associated with uterine contractions. Occasionally
difficulty was experienced in ascertaining whether labour had
commenced. In "true labour", pains commenced in the back
and were usually associated with a "show" of blood, and
throughout their duration the uterus was firmer and more
prominent in outline. Rupture of the membranes was often
difficult to detect, but if it had occurred the hair of the
fo?tus could sometimes be felt and slight displacement of the
head would produce a gush of liquor amnii. Indicators were
sometimes useful, particularly bromthymol blue (0-2% in
alcohol), which gave an alkaline reaction if liquor had swept
through the vagina. Smears from the vagina could be
shown by the Sudan method to contain fat from the vernix.

During the first stage of labour the patient should be
encouraged to walk about and could be occupied with reading
and knitting until the pains become more severe, when she
should be kept in bed. The pains during the first stage
were usually short and not of the "bearing down" variety.
The patient should not be permitted to attempt to hurry
labour along by pulling on a towel or pushing against part
of the bed. Sleep should be encouraged (with the aid of
sedatives) during night-time.

During the second stage the pains were more frequent,
each lasted longer and they are associated with "bearing
down". The patient should be confined to bed and sedatives
and anaesthesia might be used.

Dr. Rome mentioned several points concerning delivery
of the baby, which he said were useful when remembered
by the practitioner. There was little chance of finding the
chin until the anterior fontanelle was clear of the perineum,
and it was often found to one or other side between the
anus and coccyx. If difficulty was experienced, the Ritgen
manoeuvre might be helpful. In the delivery of the head,
the perineum should not be touched by the fingers, and an
attempt to deliver the head between pains was always
associated with less damage to the soft parts of the mother.
Delivery of the anterior shoulder might be difficult, but it
was often of advantage to apply pressure in Kristeller
fashion,- or better still, to apply pressure above the pubis in
a caudal and backward direction. If this proved unsuccessful,
it was sometimes helpful to turn the patient quickly into
the dorsal position. Dr. Rome also mentioned the importance
of diet during labour. He said that the average patient
required 2,000 Calories and 3,000 mils of fluid per day during
labour, but solid food was best avoided. An adequate intake
of food and fluid was necessary to maintain the strength of
the mother, to forestall acidosis and to aid in the prevention
of obstetric shock.

Management of the Third Stage of Labour.

DR. W. D. SALTAU said that there should be no need to
emphasize the importance of the proper management of the
third stage of labour, not only on account of the maternal
mortality associated with the accidents of this stage, but
also because of the effects on the immediate and sometimes
the remote well-being of the patient. Proper management
promoted a smoother convalescence during the puerperium,
and the patient was less liable to infection and she nursed
her baby better. Retention of pieces of placenta and mem
brane might be the cause of puerperal infection, resistance
to which was lowered by any severe grade of anaemia. There
was no question that excessive haemorrhage might be pro
duced by improper conduct of the third stage, and quite
rightly this was mentioned in the textbooks as the most
frequent cause of post-partum haemorrhage. There was a
certain amount of blood loss associated with the normal third
stage, but the aim of the obstetrician should be to limit this
to the absolute minimum. Whitridge Williams found that
in 1,000 consecutive spontaneous labours the average blood
loss was 343 mils. Any loss exceeding 600 mils should be
considered abnormal.

Dr. Saltau briefly reviewed the phenomena that took place
immediately after the end of the second stage. He said

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that there was a pronounced sudden reduction in the size
of the uterus due to retraction with thickening in the
muscular wall of the uterus. This caused constriction and
kinking of the vessels in the placental site. Until con
tractions returned, one largely depended on these phenomena
for the control of haemorrhage in the early part of the third
stage. Once contractions recurred, whether immediately or
within a few minutes, one had a reinforcement of Nature s
method for limitation of haemorrhage in the early third
stage. If these functions were not efficient, then this was
the time when there was apt to be some over-distension of
the uterus with blood, and Dr. Saltau thought that it was at
this stage that some control of the fundus was indicated.
The sudden diminution in the size of the uterus predisposed
to separation of the placenta from its attachment, and with
the oozing of blood from the placental site, this led to the
formation of the retroplacental clot. This represented the
so-called Schultze mechanism in placental separation, when
the placenta tended to present at the vulva by its foetal
surface. In this case there was frequently little or no
haemorrhage until the stage of expulsion. Whether the
placenta separated by this method, or by the Duncan method
involving separation at its edge and a rolling-up into the
longitudinal axis of the uterus, was immaterial as far as
the management of the third stage was concerned. However,
the latter method was more likely to be accompanied by
slight continuous haemorrhage until the placenta was away.
Dr. Saltau said that obstetricians had had it drilled into
them that the essential part- of the management of the third
stage was the control of the fundus that the hand should
rest lightly on the fundus to elicit information as to whether
the uterus was contracting or whether the fundus was filling
up. If the control of the fundus was limited to this light
pressure, no harm was likely to result; but there was always
the temptation to do something more. On occasions, perhaps
whilst the obstetrician was sucking mucus from the baby s
mouth or tying the cord, he had asked sisters what the
fundus was doing, only to note with apprehension that
instead of lightly palpating it, they made a grab at an
apparently elusive fundus, and then if it eluded them, made
another grab and perhaps proceeded to massage it at the
same time. The light pressure became converted into
unnecessary meddlesome interference. As he had pointed
out before, in the early minutes of the third stage they
were depending for control of haemorrhage on muscular
retraction with constriction of vessels, and there was also
the formation of the retroplacental clot of the Schulze
mechanism to be considered ; so it could readily be
appreciated that unnatural interference with the uterine
function at this stage might be a menace. Apart from the"-
following-down of the fundus when the baby was born and
the maintenance of light pressure for the first minute or
two of the third stage, Dr. Saltau said that he sometimes
wondered whether this so-called control of the fundus was
really necessary. Unless the patient was obese the fundus
could usually be visualized, and one could note the amount
of external haemorrhage. If necessary, intermittent light
palpation of the fundus should suffice. As to the actual
expulsion of the placenta, if the usual textbook signs of
placental separation were present fresh haemorrhage,
lengthening of the cord, increased mobility of and rise in
level of the fundus then all was well, and the placenta
could be expressed by the so-called Dublin method in the
average time of fifteen to thirty minutes or sometimes less;
this was in contrast to Credg s method, which was the
squeezing from the uterus of a placenta which might be
still partly attached. Thus, within reasonable limits, and
in the absence of continuous haemorrhage, they should wait
until some of these signs of placental separation were
present. However, an American professor of obstetrics,
Leroy Calkin, of Kansas University, from the observation of
two signs which he stated had not been previously
emphasized (i) an alteration in the shape of the uterus
from a flattening to a more globular shape, and (ii) a
slight escape of blood maintained that the placenta in
almost 70% of cases separated in five minutes or less, and
pointed out that this was in sharp contrast to the older idea
of fifteen, twenty or thirty minutes for the duration of the
third stage. He suggested expulsion of the placenta when
these signs were present, rather than a delay for the
lengthening of the cord et cetera. By the original method
formulated by him in 1861, Cred expressed the placenta
with the first contraction of the uterus in four to eight
minutes. This was rightly condemned by his fellow
obstetricians as being unphysiological. They stated that the
uterus emptied too rapidly, it filled with clots, the tendency
to late haemorrhage was increased, the primary haemorrhage
was great and retention of fragments of placenta and mem

brane was more common. With these observations Dr.
Saltau thought all were in agreement. At the other extreme,
Ahlfeld, in 1882, proposed a purely expectant plan of treat
ment. The uterus was not touched unless in the case of
profuse haemorrhage, the patient was placed over a hole
in the mattress, and the escaping blood was caught in a
funnel and led to a graduated vessel under the bed. The
obstetrician sat at her bedside watching her face, counting
her pulse and occasionally taking note of the amount of
blood lost. If the placenta did not come away in two hours,
the patient was asked to bear down, and if she did not expel
it, then it was expressed. Dr. Saltau thought that the busy
modern obstetrician could hardly be expected to fall in with
these ideas, so the happy medium was adopted of expression
by the Dublin method, usually within half an hour. In the
large majority of cases the third stage could be terminated
in this way after good contraction and provided that some,,
if not all, of the signs of placental separation were present.
No manipulation or interference with the fundus should be
carried out until these signs were present, unless, of course,
haemorrhage occurred, when the fundus should be massaged
to stimulate contractions. Dr. Saltau went on to ask how
long they were to wait, in the absence of undue haemorrhage
and without the recognized signs of placental separation. At
the end of half an hour he thought it permissible to massage
the fundus and see if the placenta would come away. If
not, one had to be patient and wait; but even if there was
still no haemorrhage after an hour, he considered it a fair
thing to try a Cred6 expression. If this was unsuccessful,
then one was probably dealing with the problem of the
retained placenta, and this problem, along with that of
post-partum haemorrhage earlier in the third stage, was
really outside the scope of the discussion. The early
obstetricians occasionally resorted to pulling on the cord
at the same time as they exerted pressure on the fundus.
This procedure had naturally been discarded at the present
time; but Dr. Saltau thought that when the placenta could
be seen in the vagina, to lift it out by the cord, provided the
fundus was under control, was not without its advantages.
He had*" the impression that the membranes came away
better, and there might be this added advantage. One noticed
that occasionally when the placenta was pushed right out
ahead of the contracting fundns, the uterus tended to settle
into the pelvis. This seemed to lead to imperfect contraction,
control and massage of the fundus became more difficult, and
he had seen further haemorrhage associated with this con
dition which might have been avoided. One had to remember,
too, the extra strain on the uterine supports, which tended
to result from too forcible pushing down of the fundus. With
regard to the delivery of the membranes. Dr. Saltau did not
think it mattered much whether they were twisted or gently
levered out by a see-saw movement; but the main thing was;
patience.

Dr. Saltau then said that there was one other thing which
should be avoided after the placenta had been expelled.
Quite correctly one made sure that the uterus was firm by
suitable massage; but sometimes one saw sisters continuing
to massage a fundus which was already firm. This did more
harm than good. Once the fundus was in good contraction,,
it should be left alone. If there was much subsequent relaxa
tion, it could be massaged at intervals and any clots expelled.
The importance of preservation of warmth of the patient
could not be unduly stressed. Too often obstetricians tended
to allow the patient to become cold whilst they were waiting
for the termination of the third stage. In most labour wards
there was a sterile catheter on the instrument tray, and even
if there was no obvious collection of urine in the bladder,
it never did any harm whilst one was waiting for placental
separation to swab the vulva and pass the catheter. It
eased one s mind as to a possible cause of delay in the third
stage. The routine administration of pituitrin and
occasionally ergometrine was wise, especially in these days,
of busy labour wards and shortage of staff. One could leave
one s patient with an easier mind. There should be no need
to mention the routine inspection of placenta and membranes,
and perineum for laceration. In the event of incomplete
membranes or retained placental fragments, the only indica
tion for exploration of the uterus was the proved placenta
succenturiata.

Episiotomy and Perineal Repair.

DR. G. BEARHAM said that one aim of the obstetrician
should be to starve the gynaecologist. He said that the
woman s perineum and vagina should, after childbirth, be
as near as possible anatomically to what it was immediately
before conception. To attain this end he thought it necessary
that during delivery the head should not be allowed to
traumatize the perineum. He did not permit the head to*

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THE MEDICAL JOURNAL OF AUSTRALIA.

201

stretch the perineum for longer than an hour in a primi-
gravida or half an hour in a multigravida, and if he noticed
that with each contraction as the head impinged on the
perineum there was a trickle of blood running over the
perineal edge, then unless delivery was effected after an
episiotomy, the perineum would be badly torn. Dr. Bearham
said that sometimes he was able to deliver a comparatively
large head in a primiffravida without any obvious perineal
tear, only to find later that the woman complained of stress
incontinence. This was due to submucous tearing of the
pubo-cervical fascia in the anterior vaginal wall, with a
resultant laxity of the bladder and urethral supports. During
delivery of the head, on occasions, he had noticed a crack
appearing in the skin of the perineum between the perineal
edge and the anus. In these cases, to avoid a deep uncon
trolled perineal laceration, he performed an episiotomy. He
had found that by performing an episiotomy either in
anticipation of an inevitable perineal tear, or when a tear
had commenced, or if the perineum was being stretched to
such a degree that the underlying fascia was likely to be
torn, he had been able to give the patient a nearly normal
vagina and perineum post partum. Dr. Bearham said that
he had always performed an episiotomy at the equivalent
situation on the perineum of 5 o clock or 7 o clock on a
watch face. As a rule he took the incision down to muscle,
but not through muscle; only rarely was it necessary to
incise the muscle. The episiotomy was performed by inserting
the blunt-pointed blade of a sharp pair of scissors beneath
the appropriate part of the pei ineum between the foetal
head and the perineum, and then cutting. This is done after
an appropriate antiseptic, such as Bonney s blue, had been
applied to the perineum. He had found that if the perineum
was rigid and good contractions were occurring, hot sterile
moist flannels applied to the perineum would reduce its
rigidity and often save the necessity of a forceps delivery-

Dr. Bearham said that, in a forceps delivery, before
applying the blades, if the perineum was rigid, he always
hooked the gloved lubricated index and middle fingers of his
right hand over the edge of the perineum, and gently but
firmly, with a side-to-side rocking motion of the hand, ironed
out the perineum. Too much force should not be used in this
manoeuvre, or else the object of delivery of the fcetus without
damage to the perineum would be defeated. As the lubricant,
he preferred sterile glycerin to anything else. In his
experience he had found that lacerations often completed
the third stage of labour (a) in the cervix, (6) running on
either side or both sides of the urethral orifice and about
a quarter to half an inch lateral to the urethral orifice,
(c) running from the perineum towards the vaginal vault
in the postero-lateral vaginal wall, (d) involving the
perineum. The last-mentioned tears of the perineum could
be divided into three degrees: (a) a first degree tear, which
involved only the skin of the perineum and mucous mem
brane of the posterior vaginal wall; this tear meant that
some fibres of the levator fascia had been torn; (b) a second
degree tear, which extended down to the muscle, but did
not involve the muscle; (c) a third degree tear, which
involved the muscle and extended into the rectum. In Dr.
Bearham s opinion it was necessary always after completion
of the third stage of labour carefully to examine the
perineum and vagina for any evidence of tears, and if any
were found, to repair them immediately. In his opinion, if
a laceration of the cervix was accompanied by severe
bruising of the cervical tissue, unless haemorrhage occurred
from this area, it was best not sutured, but repaired some
months later, as the bruised area generally sloughed. How
ever, if haemorrhage from the cervix was obvious, this had
to be controlled by sutures. Tears involving the labia
minora or running lateral to the urethral orifice had to be
sutured with interrupted sutures, so as to bring the torn
edges into apposition. Number 2 plain gut was the best
suture material for tears of this type. Tears involving the
posterior vaginal wall should be sutured with interrupted
Number 2 chromicized gut sutures.

Dr. Bearham said that in dealing with first, second and
third degree tears of the perineum he found it necessary to
bring the torn tissues accurately together in layers, using
Number 2 chromicized gut for interrupted sutures. He
found it best to do this with the patient in the lithotomy
position or in the dorsal position with the legs abducted
and flexed, as in these positions, particularly the former, it
was easier to obtain correct apposition of the tissues,
although in the case of first and second degree tears the
left lateral position was used by many. Although many
obstetricians did not worry about suturing first degree tears,
he thought that they should be sutured. In the third degree
tear the rectal mucous membrane should be sutured with
Interrupted sutures of Number 2 plain gut. The sphincter

should be sutured with a figure-of-eight suture in two layers
of Number 2 chromicized gut. The remainder of the torn
muscle should be sutured edge to edge with interrupted
sutures of Number 2 chromicized gut. Torn fascia, mucous
membrane and skin should be sutured layer to layer with
interrupted sutures of Number 2 chromicized gut. In
suturing an episiotomy incision, Dr. Bearham always used a
similar technique, employing interrupted sutures with
Number 2 chromicized gut, and although this method took
longer than a repair took when silk-worm gut was used,
the end-result justified the extra time. As an antiseptic he
always used Bonney s blue, as it was in his opinion more
effective as an antiseptic and less irritating to the vulva
than any other antiseptic. By way of after-treatment he
always ordered a perineal toilet consisting of a wash-down
with an aqueous solution of "Zephiran" (1 in 100) or "Dettol"
(1 in 20), followed by drying of the suture line by dabbing
it with sterile swabs and then either Bonney s blue, or spirit,
after the patient voided urine, defaecated or needed a perineal
toilet. When a third degree tear was present he confined
the bowels for six days, giving a non-residual diet, and on
the night before they were to be opened; he gave one ounce
of paraffin oil and two drachms of milk of magnesia by
mouth, and five ounces of olive oil or olive oil substitute by
rectum, and on the morning on which the bowels were to be
opened an enema.

Points in Aseptic Technique.

DR. ARTHUR HILL discussed the aseptic conduct of labour.
He said that although the attainment of complete asepsis
might be impossible, an attempt should be made to approach
it. The development of a sound aseptic technique required
attention to detail. Dr. Hill stressed the following points.
Whenever possible the delivery should take place in a single
room, well ventilated and accessible to sunlight. All basins,
sheets, towels, gowns, packs, swabs, masks, gloves and
instruments employed during labour must be sterile.
Efficient masking should be carried out by everyone who
entered the delivery room. An efficient mask must have a
sufficient number of layers of a material capable of arresting
droplets, and should be worn to cover the nose and mouth,
pass well under the chin and fit closely to the cheeks. The
Jessop hospital mask fulfilled all these conditions, but
almost without exception the locally made masks he had
examined were deficient on one or more counts. A general
tightening up of masking technique was .essential if pre-
ventible infections during labour by group A hsemolytic
streptococci were to be eliminated. A wise precaution was
the application of "Dettol" cream to the patient s hands every
three hours; this minimized the risk that the patient might
infect herself with her hands during pains. Vaginal examina
tions should be reduced to a minimum and were rarely
necessary in uncomplicated labour. Obstetricians should rely
only on antiseptics of proven worth, used in adequate
strength. The two best at present available for obstetric
use were "Dettol" and "Zephiran" concentrate, the former to
be used in a strength not less than one part in three of
water, and the latter in a strength of at least one teaspoonful
to the pint of water. Some minutes should be allowed for
the antiseptic to act before one proceeded to examination or
delivery. All soap must be washed from the operative field
before "Zephiran" was applied.

At delivery the accoucheur should wear a cap and sterile
mask, long-sleeved gown and gloves. After the external
genitalia and surrotmding area had been cleansed with swabs
soaked in "Zephiran", the guards were applied. When the
patient was in the left lateral position (as was generally
adopted in Victoria), it was sufficient to apply one obstetric
sheet, folded to at least double thickness, to cover the whole
of the left lower limb below the vulva. This obstetric sheet
should be of thick material, finely woven, and an excellent
size was six feet by three feet six inches. Sheets were
to be used in preference to multiple towels, which were almost
always inefficient. It was important to remember that a
soaked sheet or towel meant an unsterile sheet or towel.
Delivery should be conducted with the accoucheur facing the
vulva, and using his right hand to prevent too early exten
sion or expulsion of the foetal head and his left hand to
control the chin. By this method it was not necessary to
fasten sterile guards around the patient s right leg or over
her abdomen. The old domiciliary method of encircling the
patient s right thigh with the accoucheur s left arm and
forearm was unnecessarily cumbersome, almost inevitably
destroyed asepsis, and, except when the patient was
extremely difficult to control, should be abandoned. A
perineal pad or double thickness of sheeting should be used
to protect the left hand from the post-anal skin, and a
similar protection should guard the hand from faecal

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contamination when the perineum .was being wiped back
over the child s face.

After delivery, the child s respiratory passages could
generally be cleared effectively by alternating the
manreuvres of suspending the child vertically from its feet
and wiping out its naso-pharynx with gauze on the gloved
finger. When aspiration of the naso-pharynx was indicated,
it was best to employ a mechanical aspirator or delegate the
duty to an assistant. When the accoucheur himself orally
performed aspiration with a mucous catheter, this should be
done on a separate sheet or towel away from the mother, and
at its completion, if asepsis was to be maintained, the
accoucheur must remask and rewash himself and reapply
sterile gown and gloves.

When the umbilical cord was being ligated, the ligature on
the maternal side was best applied inside the vagina, and the
cord was then divided between the maternal and foetal
ligatures and discarded. The cord was then out of the way
during the suturing, and the risk of carrying infection from
the anus to the perineum and vulva with movement of the
cord was eliminated.

Before repair of a laceration or episiotomy wound, the
genital and surrounding areas should once more be cleansed
with swabs soaked in "Zephiran" solution, and one such swab
could be placed temporarily inside the wound so as to cover
its surfaces. A fresh sterile sheet or towel, folded longi
tudinally to double thickness, was now placed across the left
thigh and folded back on itself so as to cover the lower part
of the perineum and the anus. Towel clips fastened this
sheet or towel to the left thigh, the perineum and the right
buttock, so limiting the area of operative exposure and
excluding the anus. A vaginal pack or rolled perineal pad,
wrung out of "Zephiran" solution, was now used to plug
the vagina deep to the wound, and suturing was then
carried on in a dry field.

If 0-25 milligramme of ergometrine was injected intra
muscularly at the time of delivery of the fretal head, the
third stage of labour was commonly completed with the
patient still in the left lateral position and before perineal
repair had been commenced. At whatever time, however, it
became necessary for the obstetrician to "take over" from
the nurse and transfer his hand to the uterine fundus, he
should place a sterile towel, folded to double thickness,
between his hand and the patient s abdomen.

At conclusion .of the third stage the accoucheur himself
should complete the patient s toilet cleansing the vulva,
applying the sterile pads and assisting to change the bedding
and apply the abdominal binder. He must not delegate these
important duties to an assistant. Like the wise surgeon, he
must leave the field of action only when to his personal
satisfaction the wound site had been adequately cleansed,
closed and covered.

Comments.

DR. JOHN GREEN congratulated the speakers on the excel
lent combination of the physiological and clinical aspects
of labour. He was attracted by the suggestion of Dr. Hayes
that in labour progress and pains were complementary not
only did unsatisfactory pains give poor progress, but
conversely, poor progress might lead to unsatisfactory
uterine action. Dr. Green felt that if the labour pains could
be rectified, progress might then become more satisfactory.
He described a lazy uterus, a tired uterus and an erratic
uterus. For the lazy uterus the use of restrogens was
helpful, for the tired uterus a good dose of morphine was
often followed by a revival of good contractions, and in the
type of case associated with short, sharp pains, in which the
uterus seemed to hug the baby, an antispasmodic such as
"Spasmalgin" -was a help.

With regard to sedatives, Dr. Green said that in a routine
way he used morphine and hyoscine for primiparce and
"Nembutal" for multiparce. For the primipara chloral
hydrate and potassium bromide could be combined with the
sedative if the patient was restless, and it was given as a
routine measure to a multipara just before the first dose of
"Nembutal". Dr. Green knew that hyoscine was given with
the barbiturates, but was uneasy concerning this combina
tion. Ether could be used as an analgesic towards the end of
labour, and it was possible in many cases to ease pain and
yet obtain some cooperation from the patient. Nitrous
oxide and oxygen could be delightful for the patient, but
self-administration could not be guaranteed. Nitrous oxide
and oxygen had the great merit of not diminishing the power
of the uterine contraction. This indicated the positive use
for nitrous oxide, as distinct from its comfort effect, for
those patients who lacked the physical and mental fortitude

referred to by Dr. Johnstone. In the case of such patients,
who cried out for sedatives and yet went easily "out of
labour", Dr. Green stopped all sedatives, relying on nitrous
oxide and oxygen to ease the pain and allow progress to
take place. With regard to continuous caudal anaesthesia,
Dr. Green said that he could not resist referring, perhaps
I unfairly in his ignorance, to the comment of Howard James
on spinal anaesthesia for tonsillectomy. Howard James quoted
the remarks of Dr. Samuel Johnson on being shown a dog
walking on two legs: "Sir, I perceive that it can be done, but
it is not well done, the wonder is that it should be done at
all."

Dr. Green said that he, like Dr. Bearham, employed
episiotomy rather frequently, for he recollected several cases
in which he had, so to speak, saved the perineum at the cost
of overstretching the outlet. He thought that if forceps
were not applied prematurely, the elaborate episiotomy of
De Lee would not often be necessary. Contrary to the
usual procedure, Dr. Green did his suturing with a couple
of non-absorbable sutures, thereby minimizing anaesthesia
and perhaps helping the third stage. He thought that the
modern sedative plus anaesthetic management of labour
increased the incidence of trouble post partum. In this
connexion he reminded the meeting of the value of injection
of the cord in cases in which the third stage was trouble
some. For this reason he queried the suggestion made by
Dr. Hill of cutting the cord inside the vagina; otherwise he
reaffirmed the respect he had always held for the advanced
theoretical and practical views of Dr. Hill on the prevention
of sepsis.

DR. B. M. SUTHERLAND congratulated the speakers. He said
that their discussions of the modern trends in obstetrics
took his mind back to the old days, when patients were
delivered in the home with untrained assistance and the
practice of midwifery was not so pleasant. The introduction
of the baby bonus had made it possible for mothers to enter
hospital, and the speakers from the Women s Hospital had
the advantage of every assistance and facility. In those
days chloroform was the anaesthetic of choice, and he believed
it still to be most useful. It was given a few drops at a
time at the bedside, in much the same way as nitrous oxide
and oxygen were given now. It had the advantage of making
the patient quiet quickly, which was not so when ether was
used. Dr. Sutherland had first commenced using morphine
and hyoscine in 1907. The advantage of hyoscine was that
it relieved the memory of events. It did not matter which
qf the numerous sedatives and anaesthetics was used, pro
vided the attendant knew and attained proficiency in the
one used. He thought caudal anaesthesia had only a limited
use in large centres, and was not suited for general use or
in the country.

For the young obstetrician the first I equirement was to
attain proficiency by practice in external palpation, using
the different grips as outlined by Dr. Johnstone in deter
mining the occiput and sinciput. If there was any doubt
about external palpation, it was better -to obtain all the
information by one complete vaginal examination with proper
surgical aseptic technique, and if necessary using an
anaesthetic.

Dr. Sutherland pointed out a type of tear not mentioned by
Dr. Bearham, in which the recto-vaginal septum and vaginal
mucosa were transversely torn an inch or more within the
vagina. It was the common practice at the time of Dr.
Worrall and others to use silk-worm gut in all vaginal work
including the cervix. Although brought up in this school,
Dr. Sutherland had commenced using catgut exclusively in
1908. He had no cause for regret, and his patients were
more comfortable, so that he now regarded silk-worm gut
as out of date. Ironing out the perineum and careful
watching of the third stage were essential parts of mid
wifery. Injection of the cord for retained placenta promised
to be a valuable procedure, and Dr. Sutherland hoped that
the hospital would bring forth its own statistics on the
subject without referring to outside sources. The hospital
produced a comprehensive medical report, which could to
advantage be brought to notice more frequently.

DR. W. E. HEWITT said that he had been interested in
injection of the umbilical cord with saline solution, 500 mils
of hot sterile saline solution being injected by an ear syringe
at the end of twenty minutes to half an hour. In forty cases
he had found that the placenta almost invariably separated.
There were two exceptions one patient had had a manual
removal previously, and the other was a primipara with an
atonic uterus.

DR. J. HUTCHINGS said that at the Queen Victoria Hospital,
injection of the cord as a routine measure immediately after

FEBRUARY 9, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

203

delivery had been tried in several hundred cases. The
method used was by means of a French needle connected
by rubber tubing to a milk bottle containing saline solution,
which was displaced by air injected with a Higginson s
syringe. It was found that the third stage was so shortened
that the nurses were given a bad impression of its duration
and did not obtain experience in its management. When the
placenta was partially separated, the saline solution tended
to run away rather than distend the placenta; but the
result of the hot intrauterine douche was still effective. It
failed in only a few cases, but the incidence of manual
removal was much reduced.

DR. W. J. McKiLLOP considered that heroin was the most
efficacious narcotic in labour; the patients settled down well,
labour was quicker and fewer babies needed resuscitation
than after the use of morphine. It was his opinion that
rectal examination was a valuable means of assessing the
progress of labour. In suture of the perineum he preferred
catgut to non-absorbable material.

Dr. Elliott True, from the chair, expressed regret at the
absence of Professor Marshall Allan owing to illness. Dr.
True agreed with Dr. Sutherland that the hospital had
valuable statistics on record, and asked members who were
interested to write in any suggestions which the hospital
staff would be pleased to discuss at some future meeting.
He drew attention to the fact that there was a difference
between hyoscine and scopolamine, scopolamine being the
better, as it had less tendency to make the patient maniacal.
He did not like the term "fixation of the presenting part", as
it implied that it was not possible to "unfix" it. He thought
"engaged" and "not engaged" were sufficient. In inviting
the members to supper, Dr. True said that one definition of
a symposium he had been able to find was that it was a
banquet interspersed with intellectual discussion of a high
standing.

Postgraduate

THE NEW SOUTH WALES POST-GRADUATE
COMMITTEE IN MEDICINE.

PRINTED copies of the handbook "Facts about Rehabilitation
for Medical Officers in the Services", compiled by the New
South Wales Post-Graduate Committee in Medicine in con
junction with the New South Wales Branch of the British
Medical Association, are now available on application to the
Post-Graduate Committee, 131, Macquarie Street, Sydney, or
to the New South Wales Branch of the British Medical
Association, 135, Macquarie Street, Sydney.

For information on lectures for medical graduates applica
tion should be made to the Secretary, 131, Macquarie Street,
Sydney. Telephones: BW 7483 and B 4606.

Attention is drawn to the following courses: course in
gynaecology, February 18 to 22, 1946; course in obstetrics,
February 25 to March 8, 1946; course in paediatrics, March 11
to 20, 1946 ; advanced course in surgery, continuing to March
30, 1946; advanced course in medicine, continuing to March
15, 1946.

These courses are available to all practitioners, and
candidates desiring to enrol are requested to make early
application, as the numbers will be limited.

THE MELBOURNE PERMANENT POST-GRADUATE
COMMITTEE S PROGRAMME FOR MARCH.

THE Melbourne Permanent Post-Graduate Committee
announces the following programme for March, 1946.

University Classes.

University courses preparatory to the examinations for
Part I of M.D. and M.S., and, if sufficient numbers present,
for Part I of D.G.O., D.L.O., D.O., D.P.M., D.T V R.E. and
D.D.R. will commence on March 13. The fee for each of
these courses is thirty guineas.

Modern Methods and Technique in Teaching.

A course of five lecture demonstrations in teaching
methods and technique will commence on March 14 at
8.15 o clock p.m., and will continue on Thursday evenings
until April 11 at the Melbourne University Arts Building.
There will be no fee t" &gt;i" this course.

Continuous Refresher Course.

Refresher classes, commenced in February, will be con-
I tinued on Mondays, Tuesdays, Thursdays and Fridays of
each week at the Royal Melbourne, Alfred, Saint Vincent s
I and Children s Hospitals. This course is for service and
i ex-service medical officers.

Course for M.D. (Part II) and M.R.A.C.P. Examinations.

The series of clinical lecture demonstrations designed for
| a higher qualification in medicine will be continued on
Tuesday afternoons from 2.15 o cleck p.m.: March 5, by
Colonel H. H. Turnbull on "Aortic and Coronary Disease";
March 12, by Dr. L. B. Cox on "Paraplegia" ; March 19, by
Dr. J. Horan on "Peptic Ulcer"; March 26, by Dr. E. G.
Robertson on "Epilepsy".

Enrolments for courses should be made with the Secretary,
Post-Graduate Committee, College of Surgeons, Spring Street,
Melbourne, C.I, two weeks before the commencement of each
course.

Correspondence.

THE CENTRAL HOSPITAL, MELBOURNE.

SIR: In your issue of January 5, 1946, you published a
letter from Dr. C. H. Dickson, Secretary of the Victorian
Branch of the British Medical Association, with a resolution
of the Victorian Branch Council regarding Central Hospital.

The management of the hospital wishes to record its
appreciation of the cooperation of the British Medical
Association and to advise that this hospital will not have an
out-patient department, and it is a feature of policy that all
cases admitted on the recommendation of private prac
titioners should be referred back to them on discharge.
Detailed clinical reports will be forwarded to the patient s
medical attendant on discharge, and it is the earnest desire
of the medical staff of Central Hospital to assist private
practitioners in every possible way with details of investiga
tions and treatment carried out at the hospital.

The general section of Central Hospital will be opened
progressively as nursing staff becomes available, and it is
anticipated that a medical ward will first be ready to receive
patients on or about March 1, 1946. Beds for this ward may
be booked through the Medical Director at any date hence
forth.

Yours, etc.,

C. L. McViLLY, Administrator.

Central Hospital,

172, Lonsdale Street, .
Melbourne, C.I.

January 30, 1946.

nomination* and election**

THE undermentioned have applied for election as members
of the New South Wales Branch of the British Medical
Association:

Colman, Jack, M.B., B.S., 1943 (Univ. Sydney), 81,

Freddy s Road, Bexley.
Duval, Ferdinand, M.B., B.S., 1937 (Univ. Sydney), 135,

Macquarie Street, Sydney.
Harker, Andrew Jenning, M.B., B.S., 1939 (Univ.

Sydney), 7, Rawson Street, Epping.
Fisher, Gerard Maxwell, M.B., B.S., 1942 (Univ. Sydney),

NX200861, Captain, 101 A.G.H., Australia.
Schuster, Elizabeth Mary, M.B., B.S., 1945 (Univ.

Sydney), Broken Hill and District Hospital, Broken

Hill, New South Wales.
Kirtle, Patricia, M.B., 1931 (Univ. Sydney), Broughton

Hall, Leichhardt.
Taylor, John Lindsay, M.B., B.S., 1939 (Univ. Sydney),

Prince Henry Hospital, Little Bay.

, Qiilitarp anD air JForce.

APPOINTMENTS.

THE undermentioned appointments, changes et cetera have
been promulgated in the Cominonwealth of Australia Gazette,
Number 18, of January 31, 1946.

204

THE MEDICAL JOURNAL OF AUSTRALIA.

FEBRUARY 9, 1946.

ROYAL AUSTRALIAN AIR FORCE.
Citizen Air Force: Medical Branch.

The probationary appointments of the following Flight
Lieutenants are confirmed: F. A. J. Hetherington (6381),
J. N. Brown (267083), J. Kargotich (297400), K. G. Howsam
(257504), M. J. Etheridge (257503), D. Hemming-Jones
(277460), T. H. Gavin (277462).

Flight Lieutenant L. Kowadlo (257662) is transferred from
the Reserve to the Active Force for full-time duties with
effect from the 29th August, 1945.

SD&ituatp*

GUY STUART L ESTRANGE.

WE regret to announce the death of Dr. Guy Stuart
L Estrange, which occurred on January 31, 1946, at
Toowoomba, Queensland.

SIDNEY SOLOMON ROSEBERY.

WE regret to announce the death of Dr. Sidney Solomon
Rosebery, which occurred on February 1, 1946, at Sydney.

WILLIAM CAMAC WILKINSON.

WE regret to announce the death of Dr. William Camac
Wilkinson, which occurred on February 3, 1946, at Virginia
Water, England.

NOTICE.

THE annual cricket match between the members of the
Australian Dental Association and the British Medical
Association in New South Wales will take place at the
Sydney Cricket Ground on Wednesday, March 6, 1946.
Medical men desiring to play should communicate without
delay with Dr. Walter L. Calov, 157, Macquarie Street,
Sydney.

appointments.

In pursuance of the provisions of The Queensland Institute
of Medical Research Act of 1945, Sir Raphael W. Cilento has
been appointed chairman, Dr. Abraham Fryberg has been
appointed deputy chairman, and Dr. Aubrey D. D. Pye, Dr.
George C. Taylor and Dr. Thomas V. Stubbs have been
appointed members of the Council of the Queensland Institute
of Medical Research.

Dr. E. S. A. Meyers has been appointed Medical Officer
of Health of the South Coast Health District of New South
Wales.

TBoobs HeceifceD.

"Green Armour", by Osmar White; 1945. Sydney, London:
Angus and Robertson, Limited. 8J" x 5J", pp. 256. Price:
10s. 6d.

"War Neuroses", by Roy R. Grinker, Lieutenant-Colonel,
M.C., and John P. Spiegel, Major, M.C., Army Air Forces;
1945. Philadelphia, Toronto: The Blakiston Company 9" x 6"
pp. 155. Price: $2.75.

"The Red Centre : Man and Beast in the Heart of Australia",
by H. H. Finlayson ; 1945. Sydney, London: Angus and
Robertson Limited. 1\" x 5", pp. 154, with illustrations. Price:
Is. 6d.

"Global Epidemiology : A Geography of Disease and Sanita
tion", by James S. Simmons, B.S., M.D., Ph.D., Dr.P.H., Sc.D.
(Hon.), Tom F. Whayne, A.B., M.D., Gaylord West Anderson,
A.B., M.D., Dr.P.H., Harold M. Horack, B.S., M.D., and col
laborators ; Volume One : Part One, India and the Far East ;
Part Two, The Pacific Area; 1944. London: William Heineman.
Limited. 10" x 7". pp. 534. Price: 30s. net.

Diarp for tte

FEB. 12
FEB. 12

FEB. 19

FEB. 21
FEB. 21
FEB. 22
FEB. 26
FEB. 27
FEB. 28
MARCH
MARCH
MARCH

MARCH
MARCH

MARCH

Tasmanian Branch, B.M.A. : Ordinary Meeting.

New South Wales Branch, B.M.A. : Executive and

Finance Committee.
New South Wales Branch, B.M.A. : Medical Politics

Committee.

South Australian Branch, B.M.A. : Council Meeting.
Victorian Branch, B.M.A. : Executive Meeting.
Queensland Branch, B.M.A. : Council Meeting.
New South Wales Branch, B.M.A. : Ethics Committee.
Victorian Branch, B.M.A. : Council Meeting.
South Australian Branch, B.M.A. : Scientific Meeting.
1. Queensland Branch, B.M.A. : Branch Meeting.
2. Tasmanian Branch, B.M.A. : Annual Meeting.
5. Federal Council, B.M.A., in Australia : Meeting at

Sydney.
5. New South Wales Branch, B.M.A. : Organization

and Science Committee.
6. Western Australian Branch, B.M.A. : Council

Meeting.

6. Victorian Branch, B.M.A. : Branch Meeting.
7. New South Wales Branch, B.M.A. : Special Groups

Committee.
7. South Australian Branch, B.M.A. : Council Meeting.

appointments: 3mpottant Notice.

New South Wales Branch (Honorary Secretary, 135, Macquarie
Street, Sydney) : Australian Natives Association ; Ashfield
and District United Friendly Societies Dispensary ; Balmain
United Friendly Societies Dispensary ; Leichhardt and
Petersham United Friendly Societies Dispensary ; Man
chester Unity Medical and Dispensing Institute, Oxford
Street, Sydney ; North Sydney Friendly Societies Dis
pensary Limited ; People s Prudential Assurance Company
Limited ; Phoenix Mutual Provident Society.

Queensland Branch (Honorary Secretary, B.M.A. House, 225,
Wickham Terrace, Brisbane, B.17) : Brisbane Associated
Friendly Societies Medical Institute ; Bundaberg Medical
Institute. Members accepting LODGE appointments and
those desiring to accept appointments to any COUNTRY
HOSPITAL or position outside Australia are advised, in
their own interests, to submit a copy of their Agreement
to the Counsil before signing.

South Australian Branch (Honorary Secretary, 178, North
Terrace, Adelaide) : All Lodge appointments in South
Australia ; all Contract Practice appointments in South
Australia.

dBDitotial Notices,

All communications should be addressed to the Editor, THE
MEDICAL JOURNAL OF AUSTRALIA, The Printing House, Seamer
Street, Glebe, New South Wales. (Telephones: MW 2651-2).

SUBSCRIPTION RATES Medical students and others not
receiving THE MEDICAL JOURNAL OF AUSTRALIA in virtue of
membership of the Branches of the British Medical Association
in the Commonwealth can become subscribers to the journal by
applying to the Manager or through the usual agents and book
sellers. Subscriptions can commence at the beginning of any
quarter and are renewable on December 31. The rates are 2
for Australia and 2 5s. abroad per artfaum payable in advance.

FEBRUARY 9, 1946.

SYDNEY HOSPITAL, : HON.
MEDICAL STAFF. Applica
tions are invited for the following
appointments: (a) 0ne Honorary
Assistant Physician. (b) Should
one of the present Honorary
Relieving Assistant Physicians be
appointed Honorary Assistant
Physician, there will be vacancies
for two Honorary Relieving Assis
tant Physicians, (c) Two Honorary
Relieving Assistant Ophthalmic
Surgeons. (d) Two Honorary
Anaesthetists. (e) Should two of
the present Honorary Assistant
Anaesthetists be appointed Honorary
Anaesthetists, there will be
vacancies for two Honorary Assis
tant Anaesthetists and one Honorary
Relieving Assistant Anaesthetist.
Honorary Clinical Assistants. (a)
Medical: 14 Clinical Assistants, 2
Relieving Clinical Assistants. (b)
Surgical : 5 Clinical Assistants, 1
Relieving Clinical Assistant. (c)
Gynaecology : 2 Clinical Assistants.
(d) Orthopaedic: 2 Clinical Assis-
tants. (e) Dermatology: 2 Clinical
Assistants. Applications f9r the
foregoing appointments will be
received on the following terms and
conditions: (1) Honorary Medical
Staff: Term, 1st April, 1946, to 31st
December, 1949. (2) Honorary
Clinical Assistants : Term, 1st April,
1946, to 31st December, 1946. (3)
Should any successful applicant
(except Clinical Assistants) who is
still on war service be unable to
take up the appointment on the
due date, the Board will grant leave
until his return. (4) All applicants
(except as stated in condition (5))
must complete a Sydney Hospital
application form, and should
attach copies of three credentials.
Forms are available from the
Medical Superintendent, who will
also give particulars of duties.
(5) Recent unsuccessful applicants
for other appointments may, by

THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER.

letter, indicate they wish their
prior application endorsed for any
of the foregoing new vacancies,
without the necessity of sub
mitting an entirely new application.
(6) Applicants applying for the
senior positions where there are
also junior vacancies, are recom
mended to specifically state they
are willing to accept a junior
appointment, if unsuccessful in the
senior vacancies ; ptherwise&gt; they
will not be considered for the
junior appointments. (7) Canvas
sing of members of the Board will
disqualify. (8) Applications, which
close on 4th March, 1946, at 5 p.m.,
to be addressed, "The President,
Sydney Hospital, Sydney", and
envelopes endorsed "Hon. Medical
Staff Application". A. F. BURRETT,
Secretary. ,

LADY DOCTOR, six years ex
perience G.P., hospitals, re
quires assistantship or long term
locum in the metropolian area,
Sydney. Apply No. 43, c.o. THE
MEDICAL JOURNAL, OF AUSTRALIA,
Seamer St., Glebe, Sydney, N.S.W.

ROOMS in busy Sydney centre,
excellent position, available for
specialist. Apply No. 99, c.o. this
office.

STOKER-HARRISON
X-RAY COMPANY

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QUEENSLAND
MEDICAL PRACTICES

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lished, every facility, income 3,500,
comfortable house, ideal situation.
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goodwill 1,200, comfortable ten-
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Country town, prosperous dairying
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specialist diploma.
We have other attractive oppor
tunities and welcome inquiries,
particularly from ex-service men.

DAVID W. REID

Medical Agent,
MEDICAL, AND SURGICAL,
REQUISITES PTY. LTD.
Wickham Terrace, Brisbane

Telegrams: "Measure", Brisbane.
Phones: B 0294, B 0295, M 7450.

BRITISH MEDICAL AGENCY OF QUEENSLAND PTY. LTD.

B.M.A. HOUSE, 225 WICKHAM TERRACE, BRISBANE, B 17

Doctors desiring Practices, Partnerships, Assistantships or Locums should apply now for advice and/or

particulars.

S. N. COBBOLD, Manager, B 9597. After hours F 9533. Telegrams: "Medicine", Brisbane.

MEDICAL PRACTITIONER required for country
practice. Guaranteed 800 per annum. House for
sale or rental. .

COUNTRY PRACTICE. Cash takings 1,850. For sale,
1,400. House 1,100.

TASMANIAN CITY PRACTICE for sale, 3,000. House

for sale or rental. SUBURBAN AND COUNTRY assistants required.

PARTICULARS IN CONFIDENCE
340 Swanston Street, Melbourne. Telegrams: "Medagency", Melb. Phone*: FJ 4123, 4124. After hour*: LF 3110.

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. B.M.A. HOUSE, 135-137 MACQUARIE STREET, SYDNEY

CONSULT YOUR OWN AGENCY ON ALL MEDICAL AGENCY SERVICES

Sales and Purchases of
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Advice and recommenda
tion rendered to enquirers.

INSURANCES

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pensation, etc.

COPYING, TYPING

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telephone* | XA 2644 (After Hour.) Telegrams: "Locumten. Sydney".

Financial Assistance

available in approved

cases to facilitate

transfers.

C. R. STRANGE,
Manager and Secretary.

XVI

THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER. FEBRUARY 9, 1946.

The Decker CULDOSCOPE

A NEW INSTRUMENT FOR ACCURATE DIAGNOSTIC
PROCEDURES IN THE FEMALE PELVIS . . . .

"T HE Decker Culdoscope consists of a right angle vision telescope,
trocar and cannula especially designed to facilitate puncture of the
cul-de-sac, and a set of three cervical cones and flexible tube with Luer
lock connectors. With this instrument accurate visual diagnosis may
be made, as all organs of the female pelvis are readily observed when
patient is in the knee-chest posture as illustrated. This instrument also
enables the operator to procure a photographic record of the appear
ance of the pelvic organs.

Camula through

WatVic Apparatus for Pelvimetry

For Anterior/Posterior position
(Thom/Torpin method). In
cludes adjustable fittings, arms,
localizing pointers, locking de
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suitably perforated.

For Lateral position (Thorn/
Torpin method). Includes base,
adjustable members, metal bar
suitably perforated and fitted
with spirit level.

Back Rest and Foot Rest
arranged to fit WatVic Double
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Tables. Adjustable.

For full particulars phone or Write nearest WatVic Showrooms.

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Sydney, Melbourne, Brisbane, Adelaide, Perth, Wellington, Auckland, Christchurch.

FEBRUARY 9, 1946. THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER.

xvn

ANTISEPSIS

Prevention or Cure

Streptococcus pyogenes and B.coli, even in the presence
of pus, are killed within two minutes by a two per cent.
solution . . . moreover, when Dettol is dried on the skin it
confers protection for several hours against contamination
by haemolytic streptococci.

/. Obstet. Gyn*c, 193*. 40. 966.

In the advance of medicine war has always been the
great catalyst. Today we see a quickening of the tempo
of research into the chemotherapy of infections the
ynthesis of ever more effective compounds for enhanc
ing the body s resistance to bacterial invasion.

But in the operating theatre, in the labour ward, wher
ever the battle against infection is fought, there can be
no relaxation in the ritual of antisepsis no compromise
in the principle that the greatest triumph over infection
lies in its prevention.

At this time more than ever the chosen weapon in the
first offensive line is Dettol the general purposes

antiseptic that has virtually superseded all others in
hospitals throughout the Empire. In Britain s great
lying-in hospital, Queen Charlotte s, the introduc
tion of this product was followed by the decline of
over 50% in hamolytic streptococcal infection
long before effective chemotherapeutic means for
combating the fully developed infections became
available. Experiments have shown that Dettol not
only destroys pathogenic bacteria but renders the
kin immune to reinfection for a period measured
in hours. Moreover, it retains high bactericidal
potency in the presence of blood, pus and other
organic matter; and, being non-caustic, it is applic
able at full strength to raw wounds and surfaces
without causing pain or inhibiting the natural
processes of repair.

Every extension in the use of Dettol, in the hos
pital and the home, for the protection of the
patient and the doctor, reduces the incidence of
infections which call for curative measures. Cure is
more spectacular than prevention but prevention is
still better than cure.

R E CK ITT

2908

& COLMAN (AUSTRALIA) LIMITED, (PHARMACEUTICAL DEPARTMENT), SYDNEY

Fellowship of
Postgraduate Medicine

1, Wimpole Street, LONDON, W.I

Telephone: Langham 4266.

should be consulted regarding all Postgraduate
instruction. ANNUAL MEMBERSHIP
SUBSCRIPTION 1 Is. permits Members,
on payment of the requisite fees, to attend the
SPECIAL COURSES arranged periodically
in almost every subject (including Courses for the
M.R.C.P. and F.R.C.S. Final Examinations).

The Post Graduate Medical Journal (published
monthly) , giving details, in addition to matters of
Clinical and Practical interest, is included in the
Membership subscription, or may be subscribed
to separately at 12s. per annum, post free, by
practitioners whilst resident overseas.

D-H-A

+T d

FELTON GRIMWADE & DUERDINS
PTY. LTD.

S4S FLINDERS LANK, MELBOURNE, C.I

XV111

THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER. FEBRUARY 9, 1946.

The perfect finish and even impregnation of the c Cellona J Plaster of Paris
Bandage ensure a light cast of great strength. To facilitate the making
of large casts, Cellona is also supplied in widths of i8",24" and 36".

Cellona

PLASTER OF PARIS BANDAGES

TRADE MARK

WHOLESALE DISTRIBUTORS

MELBOURNE : Felton, Grimwade & Duerdins Pty. Ltd. SYDNEY : Elliotts & Australian Drug Pty. Ltd.

ADELAIDE : A. M. Bickford & Sons Ltd. PERTH : Felton, Grimwade & Bickford Ltd*

BRISBANE, ROCKHAMPTON & TOWNSVILLE : Taylors, Elliotts Pty. Ltd.

HOBART & LAUNCESTON, TASMANIA : L. Fairthorne & Son Pty. Ltd.

AUCKLAND, CHRISTCHURCH, DUNEDIN, WELLINGTON : Kempthorne, Prosser & Co. s New Zealand

Drug Co. Ltd. .

E6 Made in England by T. J. Smith & Nephew Ltd., Hull

Price 1s.

FEBRUARY 9, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER.

RENEVOLENT SOCIETY OP
-D NEW SOUTH WALES. Ap
plications are invited from medical
practitioners for the following
appointments which have become
vacant through effluxion of time in
accordance with the by-laws.
Closing date 28th February, 1946.
Royal Hospital for Women, Pad-
dington : Hon. Obstetrician and
Gynaecologist (retiring, Dr. H. A.
Ridler), Hon. Assist. Obstetricians
and Gynaecologists (retiring, Drs.
T. H. Small and G. G. L. Stening),
Hon. Psychiatrist (retiring, Dr. J.
McGeorge). Renwick Hospital for
Infants, Summer Hill: Hon.
Physician (retiring, Dr. V. Con-
rick), Hon. Urologist (retiring, Dr.
C. Edwards), Hon. Anaesthetists
\feiiring, Drs. K. M. Locke and
P. L. Jobson), Hon. Radiologist
(retiring, Dr. M. Dalgarno). Hon.
Dental Surgeon to above hospitals
(retiring, Dr. W. J. Wearn).
"Scarba", Bondi: Hon. Visiting
Medical Officer (retiring, Dr. V.
Rich). All the above are eligible
for, but not entitled to, re-election.
W. B. ROOD, Secretary, General
Offices, Thomas Street, Sydney.

MAREEBA HOSPITALS BOARD.
Applications are invited for the
position of Resident Medical Officer.
Salary 600 per annum, plus 2 2s.
per week living allowance and
reimbursement of all reasonable
expenses incurred whilst visiting
subsidiary hospitals. Furnished
quarters available at Mareeba Hos
pital for sing-ie applicant. Duties
consist of visiting Board s sub
sidiary hospitals at Mt. Molloy,
Chillagoe and Mt. Mulligan
periodically (such visits requiring
about one week out of every four)
and generally assisting Medical
Superintendent when at main hos
pital, Mareeba. Duties to com
mence as soon as possible. Full
fares to Mareeba refunded after 12
months service. Applications,

closing at 5 p.m. on 19th February,
1946, to be addressed to F. H. Jay,
Secretary, P.O. Box 27, Mareeba,
N. Qld. Applicants are advised to
send applications per air mail
owing to possibility of disruption of
I train services through floods.

T7ICTORIAN EYE AND EAR
HOSPITAL. Applications are
invited for appointment t^ the
Honorary Surgical and Medical
Staff of the above hospital :
Honorary Ophthalmic Surgeons,
Honorary Aural Surgeons,
Honorary Assistant Ophthalmic
Surgeons, Honorary Assistant Aural
Surgeons, , Honorary Clinical
Assistants (Ophthalmic), Honorary
Clinical Assistants (Aural). Ap
plication forms may be had on
application to the undersigned. All
applications to be lodged by not
later than 23rd March, 1946. J.
MILLER, Manager and Secretary.

T7ICTORIAN EYE AND EAR
N HOSPITAL. Applications are
invited for the (temporary) position
of Anaesthetist at the hospital. Re
muneration 2 2s. per session.
Applications to be lodged by the
15th February. Forms of applica
tion may be had on application to
the undersigned. J. MILLER,
Manager and Secretary.

ROYAL HOSPITAL FOR
WOMEN, PADDINGTON

volent Society of New South
Wales). Applications on pre
scribed form are invited for
Resident Medical Officer. Term for
lhn:e months, commencing 1st.
April, 1940. Salary at the rate of
&lt; ;mvassing of directors
is prohibited. Applications close
-March. 1946. --W. B. ROOD.
Secretary, General offices, Thomas
Street. Sydney.

Watson House, Bligh Street,

Sydney.
Telephone: BW4433.

Principals, Please Note. We have
a number of young married prac
titioners, mostly ex-services, who
are anxious to enter general prac
tice in the city or country as
assistants or junior partners, and
who reside in the following Sydney
suburbs : Balmoral, Bellevue Hill,
Bondi, Chatswood, Cronulla, Gordon,
Mosman, Roseville, Rose Bay and
Wollstonecraft.

Vendors, Please Note. We have a
number of ex-service doctors who
are cash buyers for suburban or
country practices, goodwill and
property, with residence, for ex
change in the following Sydney
suburbs : Bondi, Chatswood, Gordon,
Rose Bay, Bellevue Hill and
Balmoral.

Particulars in Confidence.

WATSON VICTOR

LIMITED

LICENSED BUSINESS AGENTS
Watson Howae, Bllg-a itr**t,

sy*ey.

Hranohe. ! all Capital Clt.e* (
Aa.tr.il. &lt;! New ZcaUm*.

A PPLICATIONS are invited for
-"- the position of Medical Prac
titioner for Klmba District in South
Australia. Practice covers a radius
of approximately 35 miles.
Guarantee by District Council of
1,000 p. a. Well-equipped govern
ment subsidized hospital at Kimba.
Further particulars may be
obtained from the Secretary, Kimba
Hospital, Kimba, S.A.

RENWICK HOSPITAL FOR
INFANTS, SUMMER HIL,L.
Applications, on prescribed form,
are invited for the position of
Resident Medical Officer. Salary at
the rate of 4 p.w. Vacancy March.
Particulars, Medical Superinten
dent. W. B. ROOD. Secretary,
Benevolent Society of N.S.W.,
General Offices, Thomas Street.
Sydney.

MICROSCOPE for sale. Mono
cular. Four eyepieces and four
objectives, including oil immersion
lens. Moving stage. Centering
condenser. 50. Apply to No. 100,
c.o. THE MEDICAL JOURNAL OF AUS
TRALIA. Seamer Street, Glebe,
Sydney, N.S.W.

FOR SALE, Harvard Examination
Chair, Surgical and Ear, Nose
and Throat Instruments, two
Surgical Instrument Cases, one
Table with drawers for dressings,
Leitz microscope. BROWN, 10
Church Street, Randwick, FX 2572.

ST. GEORGE DISTRICT HOS
PITAL, KOGARAH, SYDNEY
(325 Beds). Applications are in
vited for the temporary honorary
positions of Consulting Obstet
rician, Assistant Surgeon and
.Morbid Anatomist until most
service medical officers have been
demobilized. Applications close
Monday. 18th February, 1946.
C. D. MclNTYRE, Secretary.

WK S T E R N ELECTRIC
STKTiiMsroi K (portable),
new batteries, in first -class con
dition, for sale. Submit offer.
Particulars from linrnsii MI:DICAL
AGENCY OF .,&gt;I-KK.\,-I, VXD PTY. LTD..
l i:, \Vickham Terrac, . lirishane.
i: 9597.

COMMONWEALTH OF AUS-
V&gt; TRALIA, NATIONAL HEALTH
AND MEDICAL RESEARCH
COUNCIL: Nuffield Foundation,
Rockefeller Foundation and
Carnegie Trust Fellowships.

Applications are called for Over
seas Travelling Fellowships spon
sored by the above Bodies.
Applications must reach the Chair
man, National Health and Medical
Research Council, Department of
Health, Canberra, not later than
1st March, 1946, and be set ou; in
the following form : name .of
foundation or trust; name If
applicant and marital s ^ at *&gt;4Fellow
details of academic record; details* *ff 1 }5
of service record^ contributions to
literature; details of any teaching
or research appointments ; arrange
ments, if any, made for a teaching
or research post on return to Aus
tralia ; subject of proposed study or
research in detail ; department,
university, college, hospital or clinic
where it is proposed the work will
be carried out ; names and addresses
of not more than three referees,
resident in Australia, to whom
reference can be made for con
fidential reports ; financial assis
tance required ; approximate date
at which Fellowship could be taken
up. The following are the particu
lars and conditions associated with
the individual grants :

The Nuffield Foundation (Nuffield
Dominion Medical Fellowships). 1.
The Nuffield Foundation has made
available a total sum of 6,000 for
the award of Nuffield Dominion
Medical Fellowships to Australians
in the years 1946 and 1947. 2. The
purpose of these Fellowships is to
enable some medically qualified
persons from Australia to obtain
in the United Kingdom such post
graduate training and experience
as may be necessary to prepare
them to undertake, subsequently,
medical teaching and research
work on their return to Australia.
3. The Fellowships will be awarded
by the trustees of the Foundation
on the recommendation of a special
selection committee appointed by
the National Health and Medical
Research Council. 4. The Fellow
ships will be open to persons of
either sex who are nationals of
Australia, who hold recognized
medical qualifications, and whose
talents and personal inclinations
afford good promise of their ability
to advance knowledge and educa
tion in some branch of medicine.
5. Preference will be given to
candidates who have served as
medical officers with the armed and
auxiliary fores of the Crown. 6. A
Fellow will be expected to resume
residence in Australia on the com
pletion of his Fellowship. 7. So
far as possible the amount of any
award and the conditions attached
to it will be adjusted to the needs
of the recipient, having regard to
the purpose for which the Fellow
ships are offered,- 8. The annual
value of a Fellowship will be
between 300 and 800. The travel
ling expenses incurred by the Fel
low in coming to the United
Kingdom and returning to his own
country will be paid in addition.
If a Fellow wishes to be accom
panied by his wife, he may apply
for the payment of his wife s
travelling expenses as well. 9. A
Fellowship will be tenable for one
or two years. 10. Except with the
express permission of the trustees
of the Foundation, a Fellow may
not hold any other award con
currently with his Fellowship. 11. A
Fellow \\ill lie required tn carry
out, at institutions approved by tin-
trustees of the Foundation, a pro
gramme, of work and training
similarly approved. Other \\rK.
paid or unpaid, may not be under
taken without the permission of the
trustees. 12. A Fellow wii.
reiiuired to submit to the trustees i

at the end of each year s
of his Fellowship a report
work during that year. 1.
the trustees at any time
a Fellow neglects or li
the obligations of his
they shall have pow
to terminate his Ff*

Rockefeller Fr
Rockefeller Foui
available a sum.
Rockefeller Found!

for the year ,

for approximately
The understanding
of these

salaried
appointm
teaching and

one year upon return to Australia.
These appointments need not be
necessarily full time, but a greater
part of the time is to be devoted
to teaching and research, either
clinical or associated with the basic
sciences. There are no restrictions
as to the subject of study, nor the
country to which the Fellow is
sent. The selection of applicants
is to be made by an Overseas
Travelling Fellowship Committee
appointed by the National Health
and Medical Research Council.

Carneyie Trust. The Carnegie
Trust has made available the sum
of ?25,000 for one year. This will
allow for approximately eight Fel
lowships. Fellowships are avail
able to demobilized medical officers
for the purpose of travel and study
in the U.S.A. for a period of six
months. This is particularly
applicable to clinical teachers who
have served in the medical services
of the armed forces. There are no
other special conditions. The
selection of applicants is to be
made by an Overseas Travelling
Fellowship Committee of the
National Health and Medical
Research Council.

Commonwealth Fund
York (Pan-American
Bureau). - - The Commonwealth
Fund will consider up to five
Fellowships, up to 5,000 dollars
each for on* year, for advanced
work or study. Grants are sub
ject to the condition that the
appointee returns to an academic
position in Australia at the cessa
tion of his Fellowship. The
appointments will be made by the
Commonwealth Fund on merits of
application. Applications will be
forwarded to the Commonwealth
Fund through the Overseas Travel
ling Fellowship Committee.

Taxation. Copies of a ruling on
the taxation requirements of
persons appointed to Overseas
Travelling Fellowships are available
on request to the Director-General,
Commonwealth Department of
Health, Canberra.

of New
Sanitary

WANTED, practice, Sydney
suburban or outer suburban,
cash. S.P. c.o. this journal.

one portable ether
nachine, suitable obstetrics,
perfect order. 15. LM 3088. B.
CATHER, 457 Parramatta Road,
Leichhardt, N.S.W.

TT OR SALE,

-T

SPEECH THERAPY.

Remedial Treatment for

Reading-, Writing", Speech

and Voice Disorders.

MISS WIIAY, A.S.S.T., London.
Speech Therapist to R.A.H.C.,

Sydney.

li. Jl Macquarie Street, Sydney.
Phone: B -1G50.

THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER. FEBRUARY 9, 1946.

The medication of choice in Peptic ulcer

Prompt relief from pain

Superior weight gain during treatment

Rapid healing of ulcer

Fewer Recurrences

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Wholly set up, printed and published at the Printing House, Seamer Street, Glebe, Sydney, N.S.W., by ARTHUR FREDERICK ROOTS
SIMPSON, of Fairholm Street, Strathfield, New South Wales, on behalf of the AUSTRALASIAN MEDICAL PUBLISHING COMPANY

LIMITED. Seamer Street, Glebe, Sydney, New South Wales.

Registered at the G.P.O., Sydney, for Transmission by Post as a Newspaper. Published Weekly. Price 1s.

THE

MEDICAL mm JOURNAL

OF AUSTRALIA

VOL. I. 33RD YEAR. SYDNEY, SATURDAY, FEBRUARY 16, 1946. N. 7.

COMMONWEALTH OF AUSTRALIA. DEPARTMENT OF HEALTH.

PENICILLIN

COMMONWEALTH

PENICILLIN "COMMONWEALTH" (THE CALCIUM SALT OF PENICILLIN)
IS AVAILABLE IN THE FOLLOWING SIZES AT THE PRICES SHOWN

1 ampoule containing 100,000 Oxford units . . 10/6

This quantity is sufficient for a series of parenteral doie.
(Available also,. in boxes holding 5 ampoules.)

1 ampoule containing 15,000 Oxford units 5/6

This quantity is intended for a single parenteral dose.
(Available also in boxes holding 6 ampoules.)

1 ampoule containing 5,000 Oxford units 4/6

This quantity is intended primarily for dilution and local application, but may be used

for parenteral injection if desired.
(Available also in boxes holding 6 ampoules.)

The Medical Profession IB notified that the Control of Penicillin Order, promulgated in the Commonwealth of
Australia Gaeette, No. 85, of 3rd May, 1944, ha* ben revoked.

The Penicillin Order published in Oaeettc No. 189 of 20th September, 1944, and in THH MBDICAL JOURNAL or
AUSTRALIA of 30th September, 1944, relaxes the conditions under which Penicillin may be supplied for the treatment
of members of the civilian population.

To obtain Penicillin a Medical Practitioner must apply in the form of certificate set out in the order to the Senior
Commonwealth Medical Officer in the State concerned. The signature of a colleague is no longer required.

The addresses of the Senior Commonwealth Medical Officers are: NEW SOUTH WALES, Customs House,
Circular Quay. Sydney; VICTORIA, A.C.A. Building, 118 Queen Street, Melbourne; SOUTH AUSTRALIA,
C.M.L. Building, 41-47 King William Street, Adelaide; WESTERN AUSTRALIA, 4th Floor, G.P.O., Perth;
TASMANIA, Commonwealth Health Laboratory, Launceston; QUEENSLAND, Anzac Square, Adelaide Street,
Brisbane.

COMMONWEALTH SERUM LABORATORIES

PARKVILLE, N.2, VICTORIA, AUSTRALIA

THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER. FEBRUARY 16, 1946.

THE ORIGINAL EFFERVESCENT CALCIUM

. ^-

HAMILTON S
CALCIUM

FOR PROLONGED THERAPY
FOR GREATER SOLUBILITY

EACH DRACHM CONTAINS 20 GRAINS OF CALCIUM
GLUCONATE WITH VITAMINS A AND D

AVAILABLE IN 2{ OZ. AND 15 OZ. PACKAGES

THE HAMILTON LABORATORIES LTD.

ADELAIDE AUSTRALIA

JUST PUBLISHED

72 pages (9x7 inches): over 1,000 entries.
TWO SHILLINGS

AN INDEX OF MODERN
REMEDIES

(Third Series)

By WILLIAM MAIR, M.P.S., F.C.S.,
F.R.S.E.

From the foreword by DR. JOHN H. GADDUM,
F.R.S., Professor of Materia Medica and Pharma
cology in the University of Edinburgh: "The book is
thoroughly up to date. It contains information not
readily available in any other form, about all the
drugs mentioned in the Supplements to the B.P. and
B.P.C., and the names of Substances approved by the
General Medical Council. No one who is interested
can be without this book; everyone can afford to buy
it."

1 Copy Two Shillings

3 Copies in one Parcel 5/6

6 10/9

12 . . 21 /-

All post free at home or abroad.

Each copy in an envelope ready for delivery or posting.
Remittance with all orders, to the Publishers:

THE SCOTTISH CHEMIST,

240 Albert Drive, Glasgow, S.I

Qu i n o I o r
Compound
Ointment

SQUIBB

A N ointment of proved value in staphylo-
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barbae, sycosis vulgaris, tinea sycosis and such
dermatological conditions as Impetigo con-
tagiosa. Prolonged antiseptic action and
noteworthy properties of promoting tissue
repair make Quinolor a valuable aid in cases
where its use is indicated.

Distributors for Australia

S. HOFFNUNG & CO. LTD.

SYDNEY

FEBRUARY 16, 1946. THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER.

111

Vihs

COMPLEX

SINGLE

FACTORS

IN VITAMIN THERAPY

The established interdependence of members of
the vitamin B Complex often constitutes a limiting
factor in successful sub-clinical vitamin therapy,
where preparations providing only a single mem
ber of the Vitamin B Complex are prescribed.

Yitos is one of the richest known sources ot
Vitamin B , B, and E and also provides significant
amounts of several other components of the B
Complex, e.g., Riboflavin, Niacin and Pantothenic
Acid, combined with 30% Protein of high bio
logical value.

Vitos Vitamin Abstracts.

Williams, R. J. "Water Soluble Vitamins"

Ann. Rev. Biochem, XII.

The complex relationship existing between the vari
ous components of the B complex is discussed with
due stress being laid on the fact that the effects
produced by any one member are often dependent
on the supply of others.

Prepared under scientific laboratory control and
guaranteed to contain no synthetic vitamin admixture.

H. L. BUSSELL & CO. PTY. LTD.

20-32 MEAGHER STREET, SYDNEY

The "General

on the home front

THE DOCTOR at home shoulders a greater burden than
ever before. Charged with responsibility of winning the
never-ending war against disease, he must now fight many
a battle almost single-handed.

But, thanks to the contributions of scientific progress,
modern weapons are a constant aid in placing victory within
his grasp. Take fluoroscopy and radiography, for example
. . . both point the way to positive diagnosis. They
eliminate doubt and uncertainty . . . permit a safer, surer
course of action that leads to speedier recovery.

Screen care is important. Intensifying screens that are
dirty, scratched or stained increase exposure time and
produce faulty negatives. To insure clear, sharp, contrasty

radiographs the kind needed for accurate diagnosis

replace damaged, worn screens now. Patterson Screen
Division of E. I. du Pont de Nemours & Co. (Inc.).

Patterson Screen Division

Distributors for Australia and New Zealand:

WATSON VICTOR LIMITED

Watson House, Bligh Street, Sydney

Melbourne, C.I 117 Collins Street

Brisbane, B.10 105 Eagle Street

Adelaide 9 Gresham Street

Wellington, N.Z Kelvin Chambers, 16 The Terrace

Auckland, N.Z Lister Buildings, Victoria Street

Perth 295 St. George s Terrace

THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER. FEBRUARY 16, 1946.

Laboratory
Control . . .

The goodness of Sanitarium Weet-
bix and Granose Whole Wheat Breakfast
Biscuits, Bixies Whole Wheat Flakes and
other equally famous Sanitarium Health
Food products is not left to chance. To
the contrary every stage of manufacture
is carefully controlled by stringent labora
tory tests that fully safeguard the food
value of the finished products. Their in
clusion in light nourishing diets, therefore,
can be recommended with confidence.

SANITARIUM HEALTH FOOD CO.

Rapid and

effective

treatment

IN the treatment of rickets the
oral administration of CoUoscl
Otlrhim with Vitamin D is widely
recommended. In a number of
tests on rats in which rickets had
been induced, complete cures have
been effected in a few days simply
by the use of this preparation.

Cottosol Cakium with Vitamin
D contains i per cent, (approx.)
of a colloidal calcium salt of fatty
acids standardised to contain 250
international units per tcaspoon-
ful of Vitamin D.

CKnieml Literature 0n

Cakium with Vkamm D k
applied in 4 oz., 10 oe. aad 20 OK.
beetle* and in rials of 25 and 100
capaukMr sugar-coated tablet* (each
ooe fluid ittacfam) tor oral adminrt-
tntwn. Atoo for sobcutaneoiu
|ctioo in ampoules (boio of ix) of
| I and a c.c., and 1 5 and 30C.C. viab.

tettfc VITAMIN D

Stocks held by the Associated House*
of the Drug Houses of Australia Ltd.

THE CROOKES LABORATORIES

(British Colloids Lid.)

PARK ROYAL. LONDON, N.W.IO

ENGLAND

Ml 96 - 14 JJ

FEBRUARY 16, 1946. THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER.

In Qastric Hyperacidity

CAL-BIS-NATE

The composition of Cal-Bis-Natc is simple and rational.
Its effectiveness, however, rests "in no little measure on
the fact that the ingredients are matched for density
and are held together in a colloidal base. This means
uniform dispersion one dose is the same as the next.
\Vhepher it is a simple gastric hyperacidity with sour
eructations, or a more severe condition of gastric ulcer,
with its burning, stabbing, pressing pain, Cal-Bis-Nate
affords quick, prolonged and safe relief, uncomplicated
by the dangers and discomforts of gaseous distension.

A trial supply will gladly be sent on request.

WILLIAM R. WARNER & CO. PTY. LTD.. 508-528 RILEY STREET. -SYDNEY, N.S.W

It is easy to relieve constipation by the use of a purgative,
but this does not remove the cause, so the trouble inevitably
recurs.

VERACOLATE is a physiological evacuant, for it contains
the bile salts sodium taurocholate and sodium glycocholate
which are the natural laxatives of the intestinal c^nal.
A mild vegetable laxative and a carminative are added to
initiate peristaltic action and increase gastric tone. Veracolate
Tablets, therefore, relieve constipation and at the same
time overcome the dyspepsia, biliousness and sallow com
plexion associated with biliary stasis. Veracolate encourages
all the digestive activities to return to healthy normality.

VERACOLATE

TABLETS

WILLIAM R. WARNER & CO. PTY. LTD.. 508-528 RILEY STREET. SYDNEY. N.S.W.

THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER. FKUKIAKY 16, 1946.

EOCAL

SUPPLIED IN BOTTLES OF
100 AND 1,000 TABLETS

Each tablet contains:

DI-CALCIUM PHOSPHATE . . gr. 7.5
FERROUS SULPHATE . . gr. 0.33

VITAMIN B, . 100 I.U.

VITAMIN D . 400 I.U.

PRICE TO PATIENTS

6 -

100 TABLETS

PER

VOL. I. 33RD YEAR.

SYDNEY, SATURDAY, FEBRUARY 16, 1946.

No. 7.

Table of Contents.

[The Whole of the Literary Matter in THE MEDICAL JOURNAL, OF AUSTRALIA Im Copyright.]

ORIGINAL ARTICLES Page.

Ascorbic Acid in the Milk of Melbourne Women, by

Dora Winikoff, M.Sc 205

Chylangioma of the Mesentery, with Report of a
Case, and a Brief Discussion of Mesenteric
Cysts, by G. C. V. Thompson, F.R.C.S., and
C. H. Chambers, M.B., B.S 210

The Treatment of Hsemophilus Influenzae Menin
gitis with Sulphonamides in Conjunction with
Hsemophilus Influenzse, Type B, Rabbit Anti-
serum, by E. A. North, Harold Wilson and G.
Anderson 215

A Report on Sixteen Cases of Supraglottie CEdema,

by H. McLorinan 220

The Study of the Human Body after Death, by

Keith Inglis, M.D 222

REPORTS OF CASES

Volkmann s Ischaemic Contracture of the Forearm,

by Leonard Ball, F.R.C.S., F.R.A.C.S 224

Unknown Foreign Bodies in the Lung, by J. B.

Cleland 225

Tetanus Treated with Penicillin; Recovery, by

John L. Grove 226

REVIEWS

Dermatology 227

Surgery of the Rectum 228

Diseases of the Chest 228

LEADING ARTICLES

"Paludrine" . . . .

The Federal Medical War Relief Fund .

229
229

CURRENT COMMENT Page.

Retropubic and Extravesical Prostatectomy . . . . 230

ABSTRACTS FROM MEDICAL LITERATURE

Gynaecology 232

Obstetrics 233

SPECIAL ARTICLE

Researches on "Paludrine" (M.4888) in Australia

BRITISH MEDICAL ASSOCIATION NEWS

Notice

234
236

236

SPECIAL CORRESPONDENCE

CaYiada Letter

CORRESPONDENCE

Tuberculosis Patients and Hospitals 237

The Intervertebral Disk . . . ." 237

The Surgical and Applied Anatomy of the Inguinal

Region 237

OBITUARY

Andrew Eric Aspinall and Archibald John Aspinall 238
George McLean 240

NAVAL, MILITARY AND AIR FORCE

The Training Prior to Discharge of Certain Service

Medical Officers 240

NOMINATIONS AND ELECTIONS 240

BOOKS RECEIVED 240

DIARY FOR THE MONTH 240

MEDICAL APPOINTMENTS: IMPORTANT NOTICE .. 248
EDITORIAL NOTICES . 240

ASCORBIC ACID IN THE MILK OF MELBOURNE
WOMEN.

By DORA WINIKOFF, M.Sc. (Cracow),

From the Department of Biochemistry, University
of Melbourne.

As a sequel to the work on the mineral content of breast
milk/ 1 an investigation was carried out on the ascorbic
acid content of maternal milk in the Melbourne area.

Literature.

In man, according to Boyle," normal ascorbic acid
nutrition is essential for the maintenance of the tissues by
which the teeth are attached to the jaws. Loosening of the
teeth in ascorbic acid deficiency is the result of atrophy
of such tissues. This author also considered such sub-
optimal ascorbic acid nutrition to be an underlying factor
in the production of systemic pyorrhoea. Moreover, in
infants and children receiving enough vitamin C for pro
tection against scurvy, there may still develop a condition
of latent or subacute scurvy accompanied by more or less
severe injury to the teeth ( Smith &lt;3) ). It thus becomes
apparent that larger quantities of vitamin C are required
for good nutrition than for the prevention of scurvy. For
this reason, and in view of the widespread occurrence of
dental caries in this country, there is an urgent necessity
to safeguard the proper vitamin C nutrition of infants and
children.

It has been proved beyond any doubt that artificially
fed infants need a vitamin C supplement as early as the
first week of life, owing to the low content of this vitamin
in cow s milk compared with that in human milk. The
practice of giving even breast-fed children orange juice
after the first six months has also been adopted in this

country. The question arises, however, whether in all
cases there is an adequate vitamin C intake during the
first six months of breast feeding.

The possibility that the infant has the ability of syn
thesizing vitamin C up to its tenth month of life, as
suggested by Rohmer and Bezssonoff 4 and by Stoerr, &lt;5)&lt;8)
has been denied by Wachholder," 1 by Ferdinand, (8) by
Muller/ 9 by Neuweiler &lt;10&gt; and others, who express the
opinion that although after birth the infant possesses a
store of vitamin C which enables it to cover the deficit for
some time, its only source of intake is breast milk.

According to Elmby et alii, (u} Baumann 121 and others,
the ascorbic acid content of milk follows closely that of
blood, which in turn is completely dependent on the diet
of the nursing mother (Baumann and Rappolt, (1:1&gt; Gedd and
Kjelberg &lt;14) ).

Numerous experiments have been carried out to raise
the ascorbic acid level in milk by means of a high vitamin
C intake, either in the food or by the administration of the
synthetic vitamin. The general belief is that the lactating
mother has no special storage capacity for vitamin C once
the saturation point has been reached (Neuweiler 15 Chu
et aZii, (113) Baumann &lt;12) ), although during lactation the body
appears to store vitamin C for longer periods than usual
(Baumann and Rappolt " ). To quote from Baumann : &lt;12)

There is no lower threshold for secretion from blood
into milk and it goes on until the maternal organism is
greatly depleted, but there is an upper limit of about
8 mg. per cent, in milk. There is no upper limit for
secretion into urine, but there Is a lower limit about
1-1-4 nag. per cent, in blood.

However, with regard to the question of the ascorbic acid
level in milk in the case of a deficiency in the diet,
Laurin (17) and Widenbauer and Rappolt (see Laurin"")
think that the amount available can if necessary be
supplied to the child by means of breast milk, even at the
cost of the mother s own need of this vitamin. Gaehtgens

206

THE MEDICAL JOURNAL OF AUSTRALIA.

FEBRUARY 16, 1946.

and Werner, &lt;1S) on the other hand, express the opinion that
when the daily requirements are not covered the mother s
organism becomes depleted during gestation, but during
lactation the infant is the sufferer, since the ascorbic acid
content of the milk falls and the mother is thereby
protected.

In view of this controversy it seems to be advisable to
supplement the possible deficiency in milk by giving orange
juice or other easily assimilated source of vitamin C
direct to the infant rather than to the mother. However,
as Smith (:i) recommends, no harm is done if the intake
of the nursing mother is doubled during the period of
considerable drain on her resources.

Daily Requirements of Mother and Infant.

The Technical Committee on Nutrition of the League of
Nations 09 has estimated the vitamin C requirements of
artificially fed infants to be five to fifteen milligrammes
per day. The majority of investigators, however, taking
the average vitamin C intake of a breast-fed infant nursed
by a mother receiving a satisfactory diet, consider this
amount inadequate. Young 1211 and Hess and Benjamin 221
recommend the daily allowance of 7-5 to 20 milligrammes
to prevent avitaminosis, whilst Wachholder (7) considers
10 to 15 milligrammes per day as an absolute minimum.
Smith, " summarizing the results of several investigators,
estimates Ihe daily requirements of an infant as five to
eight milligrammes of ascorbic acid per kilogram of body
weight, based on a daily intake during the first few months
of 500 to 1,000 mils of milk with an ascorbic acid content
within the range of four to seven milligrammes per
centum. A concentration below four milligrammes per
centum is regarded by this author and others as an
indication of vitamin C deficiency in the tissues of lac-
tating women.

Table I shows the respective daily intakes of mother and
infant and the percentage of ascorbic acid in milk as
given by different authors.

TABLK I.

Daily Intake of

Ascorbic Acid. Ascorbic

Author.

Acid in Milk.

(Milligrammes

Mother.

Infant.

per Centum.)

Widenbauer and Kuhner

80 to 100
milligrammes

40 to 50
milligrammes

De Haas and Meulemans""

Adequate

40 4 to 5
milligrammes

Toverud" 01 . .

100

25 to 30 6 to 7

milligrammes

Baumann 181

8 to 14

milligrammes

Chu, Woo and Sung 1 " . .

Adequate

milligrammes

Ingalls et oKi " 1 ..

28 4 to 5
milligrammes

Ingalls"

20 to 40
milligrammes

Selleg and King "

40 to 50
milligrammes

6 to 8

Braestrup 1 "

Adequate

- 3 to 8

milligrammes

per kilogram

of body

weight

Bessey 1 " 1

Adequate

20 to 40

milligrammes

Baumann 1 "

milligrammes

Materials and Methods.

The investigation was carried out during the spring and
summer of 1942-1943. The samples were taken at the
Women s Hospital, Melbourne, and at several baby health
centres and homes for mothers and babies. They repre
sented mostly the lower and middle income groups.

The source of material and the method of collection of
milk samples were the same as in the previous work. u)
Milk was collected in small, brown, glass-stoppered bottles,
transferred to a black box and immediately taken to the
laboratory. The estimation was carried out not later than
two hours after collection. 1

Tillman s method of estimation, as modified by Bessey,* 2 "
was used, but as the end-point presented considerable dif
ficulties, Kuhn s (24&gt; back titration with Mohr s salt solution
was applied and gave satisfactory results. 2

Reagents.

The ascorbic acid solution was prepared as follows:
0-002 to 0-004 gramme was made up to 100 millilitres with
3% metaphosphoric acid solution.

The 2-6-dichlorophenol-indophenol was made up as fol
lows: 0-01 gramme was dissolved in hot water. After
cooling, 10 millilitres of phosphate buffer solution at pH 6-8
were added and the total volume was made up to 100 milli
litres. The buffer solution consisted of 15-45 millilitres
of 0-2 molar sodium phosphate solution and 4-55 millilitres
of 0-1 molar citric acid solution kept over chloroform.

Mohr s stock solution was prepared in the following
way: 0-1 gramme of ammonium ferrous sulphate (C.P.)
was dissolved in water with two millilitres of concentrated
sulphuric acid and made up to 100 millilitres. For titration
10 millilitres of the stock solution were diluted to 100
millilitres.

All reagents were made up freshly as required with
glass-distilled water and kept in brown bottles in a
refrigerator.

The dye solution was standardized every day according
to the method of Bessey and King &lt;25) with pure ascorbic
acid solution, pH 1-5 to 2-0. (According to King/* 6 the
pH of the end-point should be kept below 3-5 to obtain
satisfactory results.)

The Mohr s salt solution was in turn standardized every
day against the dye, as described by Lorenz and Arnold. 373

Technique.

To five millilitres of milk (in duplicate) five millilitres
of metaphosphoric acid were added and titrated with the
dye solution from a microburette till the appearance of
the first pink colour. An excess of dye was then added and
the back titration with -Mohr s salt solution was carried
out drop by drop till the pink colour completely dis
appeared. As the Mohr s salt solution was prepared so that
10 millilitres corresponded to three to four millilitres of
dye, the accuracy of estimating the end-point was greatly
increased.

1 To estimate the loss of vitamin C caused by cool storage,
several samples were mixed with equal volume of a 3%
solution of metaphosphoric acid, placed in a blackened, evacu
ated desiccator, and left for twenty-four hours in a refrigerator.
Under these conditions the less of vitamin C was from 2%
to 7%.

2 As the full description of Kuhn s method was unobtainable,
the details of this modification had to be worked out by. the
writer.

TABLE II.
Variations in Ascorbic Acid Content of Different Portions of the Same Milk. (Milligrammes per Centum.)

Number of Sample.

Type of Milk.

II.

III.

IV.

VI.

VII.

vni.

IX.

First milk
Middle milk
End milk

0-84
0-78
0-79

4-02
3-68
3-66

6-15
5-93

1-58
1 55
1-49

"6-52
6-57
6-49

3-67
3-65

5-22

5-78

3-95
3-73
3-70

3-35
3-42

FEBRUARY 16, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

207

Preliminary Work.

As many authors point out, there are great variations
in the ascorbic acid content of milk occurring one day
and from day to day. Differences have also been found
in milk from different breasts and in various portions of
the same milk. In view of this variability preliminary
tests were made to ascertain whether the method of col
lecting and sampling caused any additional errors.

Nine milk samples were taken in two or three portions,
as the first, the middle, and the end milk. The results
given in Table II show certain fluctuations; but the state
ment by Schlemmer et aZii (2s&gt; that the end milk is richer
in vitamin C than the first or middle milk was not sub
stantiated. There was also no significant difference
between portions of milk taken from different breasts, as
is indicated in Table III.

TABLE III.

Variation in Ascorbic Acid Content of Milk from Different Breatts (Milligrammes
per Centum.)

Sample.

Breast.

II.

III.

IV.

Left

4-02

6-57

4-08

3-53

Right

4-19

6-49

4-12

3-65

The day-to-day variations in individual samples were
considerable, but they were much smaller when taken as
averages of a number of samples (see Table IV). These
samples were taken during the colostral period between
the fifth and tenth days. Apart from the results on the
sixth day the differences were small. Selleg and King &lt;29)
obtained similar results.

TABLE IV.

Day-to-day Variations Taken on a Number of
Samples (Colostral Period).

Mean Value of

Day

Ascorbic Acid.

Kumber of

Post Partum.

(Milligrammes

Samples.

per Centum.)

5th

3-91

6th .

3-41

7th

4-13

8th .

4-12

9th .

4-13

10th .

3-79

Main Investigation.

Over 500 samples of milk from normal and abnormal
women were examined. They included (i) colostral and
(ii) mature milk.

Colostral Period.

Two hundred and eight samples from 186 normal mothers
were examined between the fifth and tenth days post
partum. From some of the patients several samples were
taken on different days, always at the same feeding time.

The ascorbic acid content of milk ranged from 0-86 to
7-40 milligrammes per centum, the mean value being 3-87

milligrammes per centum and the standard deviation being
1-45. The frequency distribution curve had a normal
appearance.

Fifty samples from 36 mothers suffering from toxaemia,
albuminuria or post-partum eclampsia and from women
whose babies had been born prematurely, were taken
between the third and eleventh days after confinement.
The mean value, which was 3-94 milligrammes per centum
for all cases, and 4-00 milligrammes per centum for the
23 cases of prematurity, did not differ greatly from the
mean for normal cases (contrary to Elmby &lt;u) and
Correns, (:!0) who investigated only a small number of cases).
The results did not include the figures of 9-37 milligrammes
per .centum and 6-30 milligrammes per centum (average
of three estimations) obtained from two patients kept on
a diet rich in vitamin C.

Mature Milk.

Samples numbering 261 from 186 normal mothers were
taken at intervals of one month throughout the whole
remaining period of lactation. The ascorbic acid content
ranged from 0-39 to 7-74 milligrammes per centum. The
mean value for the whole period was 3-67 milligrammes
per centum. A single sample with ascorbic acid content
of 9-37 milligrammes per centum (see above) was not
included. The frequency distribution curve had a normal
appearance.

The mean value for individual months of lactation (see
Table V) rose slightly from the colostral period, remained
constant during the first and second months, then gradu
ally fell, and after reaching its lowest level during the
sixth month, slowly rose again and regained its former
level during the ninth and tenth months. Although its
range of variations (2-99 to 4-01 milligrammes per centum)
was small in comparison with that of individual samples,
the results were statistically examined by the application
of the t-test. The mean values for each of the first
two months were identical. The differences between these
values and those for each successive month up to the sixth
proved to be statistically significant. This indicated a fall
in ascorbic acid value of -milk with the progress of lacta
tion. The seasonal variations could not be mainly respon
sible for this fall, as in every group of samples taken
during the same stage of lactation several were taken
during each of the calendar months of spring and summer.
The rise after the sixth month could be explained by the
fact that the child, being put on "educational diet", con
sumed less breast milk, and the concentration of ascorbic
acid rose with the decrease in volume secreted, which
automatically followed the smaller intake by the child.

The mean value for colostral milk was slightly higher
than that for the mature milk taken as a whole, but not
in comparison with each individual month of lactation.
Among overseas workers, Bleyer, &lt;31&gt; Schlemmer et a/ii, (as)
Kasahara and Kawashima, (32) Wachholder/" de Haas and
Meulemans &lt;;!3) and Stoerr &lt;34&gt; found the ascorbic acid con
tent higher in colostrum than in mature mHk, while
Neuweiler (3B) and Winkler and Heins (38) could find no dif
ference in the two values. Schlemmer et aJn, &lt;2S) Kasahara
and Kawashima, (32) and Wachholder and Correns (:io) noticed
a fall in ascwbic acid value of milk while the lactation
proceeded. Bleyer, &lt;31) Neuweiler, &lt;35) Winkler and Heins, (36&gt;
on the other hand, consider the level to be constant, pro
vided that there is no vitamin C deficiency in the mother s
diet.

TABLE V.
The Ascorbic Acid Content of Milk According to the Month of Lactation:

Month.

1st

2nd

3rd

4th

5th

6th

7th

8th

9th

10th

llth

12th

13th

Ascorbic acid (milligrammes per
centum)

4-00

4-01

3-31

3-12

3-28

2-99

3-37

3-21

4-03

3-91

3-60

4-76

4-59

Number of samples

Standard deviation

1-60

1-69

1-33

1-21

1-04

1-11

1-23

1-13

1-39

1-00

1-60

208

THE MEDICAL JOURNAL OF AUSTRALIA.

FEBRUARY 16, 1946.

Seasonal Changes.

To obtain a picture of the seasonal fluctuation the results
were regrouped according to the calendar month. Colostral
and mature milk, however, was treated separately as
representing different time intervals in lactation periods
(see Tables VI and VII).

TABLE VI.

The Ascorbic Acid Content of Colostral Milk During
the Spring and Summer Months.

Ascorbic Acid.

Month.

(Milligrammes

Number of

per Centum.)

Samples.

September

4-41

October

3-51

November

4-18

December

4-00

January

4-10

TABLE VII.

The Ascorbic Acid Content of Mature Milk During
the Spring and, Summer Months.

Ascorbic Acid.

Month.

(Milligrammes

Number of

per Centum.)

Samples.

September

4-12

October

3-68

November

3-28

December

3-82

January

3-75

February

3-56

The ascorbic acid content was lowest in October for
colostral milk and in November for mature milk, while in
both it was highest in September. The colostral period,
which represented a large number of samples taken at the
same stage of lactation, was chosen for statistical analysis.
This revealed a significant difference between the mean
values for September and October and for October and
November, while the differences between the other months
were not statistically significant.

MEAN 3.67

MEAN 3. 87

0113^5
ASCORBIC

7 8

AGIO (AI,LLIGMMES pe cer )
FlGURI I.

Frequency distribution histiograms.

There is no real scarcity of fruit and vegetables through
out the year in the Melbourne area; but during the month
of October, 1942, owing to war conditions, citrus fruits
and green vegetables were in short supply, while potatoes
were not available until the middle of November, when
the new crop arrived. This coincided with the significant
drop in ascorbic acid value. Although no estimations were
made during the winter months in the course of this
investigation, it might be expected lhat under normal con
ditions the values during this period would have fallen
to the level of October, 1942, or below.

Discussion and Conclusion.

During the last decade numerous publications have
appeared in the scientific literature concerning the vitamin
C content of breast milk in different countries. Unfor
tunately, owing to war conditions, many of these publica
tions have been available only by title or in the form of
short abstracts. Furthermore, as many of the authors
based their results on a small number of samples, only
those publications were selected which could give reliable
information on the vitamin C level of breast milk in their
respective countries.

The results are summarized below.

Colostral Milk.

The figures recorded were as follows: Selleg and King/* 1
5-5 milligrammes per centum (53 samples) ; Gaehtgens
and Werner, us) 1-8 to 7-6 milligrammes per centum (set
groups of 10 to 20 samples); Kasahara and Kawashima/ 321
7-0 to 8-0 milligrammes per centum (122 samples).

Mature Milk.

The figures recorded were as follows: Harris and Ray &lt;: 7)
(London), 5-6 milligrammes per centum (135 samples);
Kasahara and Kawashima &lt;38&gt; (Japan), 4-5 milligrammes
per centum ("a number"); Laurin (I7) (Sweden), 3-0 to
7-0 milligrammes per centum (55 samples); Gedd and
Kjelberg (14) ( Gotten rJUrg), 3-9 milligrammes per centum
(421 samples); Ingalls et alii (United States of
America), 4-5 milligrammes per centum ("a number");
El-Gholmy (40) (Cairo), 3-8 milligrammes per centum (140
samples); Isono (41) (Japan), 3-5 milligrammes per centum
(57 samples).

In addition, a few other publications were selected in
which the results, although based on a small number of
samples or given without the number of samples examined,
were nevertheless of some interest. They are as follows:
Braestrup and Lieck 421 (Copenhagen), 2-0 to 6-0 milli
grammes per centum; Traversaro and Quesada &lt;w (Argen
tina), 5-0 milligrammes per centum (six samples) ; de Haas
and Meulemans (:w (Batavia), 4-0 to 5-0 milligrammes per
centum (native women), 6-0 to 7-0 milligrammes per
centum (European women); Cimmino (44) (Italy), 2-7 milli
grammes (five samples) ; Concepcion and Gargaritano 10
(Philippines), 4-0 to 5-0 milligrammes per centum;
Sapegno and Mado (4C) (Turin), 4-0 to 5-0 milligrammes per
centum; Chakraborty 47 (Calcutta), 5-0 milligrammes per
centum; Kroker C4S) and Elmby/ 11 who give respectively
2-2 to 4-2 milligrammes per centum for low income groups
and 8-7 milligrammes and over 7-0 milligrammes per
centum for high income groups.

Seasonal Changes.

All authors agree that the vitamin C value of milk under
goes certain seasonal variations, particularly in countries
where there is a shortage of fresh fruit and vegetables in
winter-time. Sinkko, &lt;4u) in Finland, who investigated the
ascorbic acid content of the milk of ten women through
out the year, found that it was low in winter-time. High
values were obtained in August and September, but there
was a fall in October and November; the lowest value of
1-76 milligrammes per centum was reached in February,
as compared with 4-63 milligrammes per centum in Sep
tember. The variations in the infant mortality rate during
the year are correlated by Sinkko with the seasonal varia
tions in the content of breast milk. Winkler and Heins" 81
found the values to be 4-6 to 6-6 milligrammes per centum
in summer and 2-9 to 5-2 milligrammes per centum in
winter, and Gedd and Kjelberg (I4) (Gottenburg) found the
values to be 4-2 milligrammes per centum in autumn and
3:6 milligrammes per centum in spring. Baumann (1J!)
(Switzerland) reported for the period from November to
January a range of 2-5 to 3-0 milligrammes per centum,
and for the period from June to October (summer) 4-0 to
7-5 milligrammes per centum. He noticed an unexpected
rise after January (February to May, 3-5 to 5-7 milli
grammes per centum) due to the arrival of imported
citrus fruit. Ferdinand^ (Rostock, Germany) found
values of 3-5 milligrammes per centum for winter and

FEBRUARY 16, 1946.

THE MEDICAL JOT7RHAL OF AUSTRALIA.

209

2-1 milligrammes per centum for early spring, while
Correns (30) (Rostock) found values of 3-93 milligrammes
per centum for summer. The results for summer and
winter in Rostock were thus not greatly different, owing
to the availability of a good supply of food rich in vitamin
C. The low values for early spring would coincide with
the period in central Europe during which fresh greens
or other sources of the vitamin are scarce.

Comment.

Compared with most of the reliable overseas reports,
the average ascorbic acid content of breast milk in the
Melbourne area, ranging from 3-0 to 4-0 milligrammes per
centum throughout the whole lactation period, is low even
during the summer months.

According to Ingalls, (ao) Smith (:f) and others, in order to
assure a daily supply of 20 to 40 milligrammes, which is
essential for adequate nutrition of the infant, the ascorbic
acid content of milk must not fall below the level of
4-0 milligrammes per centum. In the Melbourne area the
average value just reached this level only during the first
two months of lactation. During the remaining four
months until the infant began, or should have begun, to
receive the orange juice, the level was found to decline to
2-99 milligrammes per centum.

The frequency distribution histograms (Figure I) reveal
that in about 50% of cases during the colostral period
and in about 60% in the later stages the level was below
4-0 milligrammes per centum. This means that more than
half of the breast-fed infants in the lower and medium
income groups received a diet deficient in vitamin C even
during the summer months, while those babies receiving
pooled mother s milk or cow s milk supplement had an
even lower vitamin intake. The histograms also indicate
that a large portion of the adult female population had a
subclinical vitamin C deficiency.

Therefore it seems to be of great importance to give
both the mother and the breast-fed infant orange juice or
synthetic vitamin C as early as the first few weeks after
the mother s confinement.

Summary.

1. Preliminary work was carried out as follows. (a)
Nine milk samples were examined in two or three portions.
The end milk was not richer in ascorbic acid than the
middle or first milk, (b) Four milk samples were taken
from both breasts and found to have the same ascorbic
acid content within the limits of experimental error.
(c) A number of samples was studied during the colostral
period on six consecutive days. The differences between
the averages of a number of samples were much smaller
than the day-to-day variations in individual samples.

-2. During the colostral period 208 samples from 186
healthy mothers were examined between the fifth and
tenth days post partum. The ascorbic acid content of milk
ranged from 0-86 to 7-40 milligrammes per centum, the
mean value being 3-87 milligrammes per-^centum and the
standard deviation 1-45.

3. Fifty milk samples from 36 mothers suffering from
toxaemia, albuminuria and post-partum eclampsia, and
from mothers of premature infants, were examined between
the third and eleventh days post partum. The mean value
was 3-94 milligrammes per centum for all the women and
4-00 milligrammes per centum for the 23 with premature
infants. These figures do not differ greatly from the values
for normal women.

4. Samples numbering 261 from 186 healthy mothers
were taken at intervals of one month during the whole
period of lactation. The ascorbic acid content ranged from
0-39 to 7-74 milligrammes per centum. The mean value
for the whole period was 3-67 milligrammes per centum.
The mean values for individual months rose slightly from
the colostral period, remained constant during the first
and second months and gradually fell, reaching the lowest
level of 2-99 milligrammes per centum during the sixth
month, and then rose again.

5. The differences between the third, fourth, fifth and
sixth months as compared with the first two mouths proved

to be statistically significant, indicating a fall in ascorbic
acid leveL with the progress of lactation up to the sixth
month.

6. The mean value for colostral milk was slightly higher
than that for the mature milk taken as a whole, but not
iiPcomparison with the figures for each individual month
of lactation.

7. The results, regrouped according to the calendar
month, have shown a significant fall in vitamin G content
for colostral milk in October and for mature milk in
November, which coincided with the shortage of potatoes
and fresh vegetables.

8. The average ascorbic acid content of milk in the
Melbourne area, ranging from 3-0 to 4-0 milligrammes per
centum, was low in comparison with the figures obtained
in other countries.

9. The frequency distribution histograms revealed that
from 50% to 60% of breast-fed babies in the lower and
middle income groups did not receive an adequate amount
of vitamin C during their first six months of life, as 4-0
milligrammes per centum is considered the minimum
ascorbic acid concentration in milk necessary for normal
nutrition.

10. The writer considers that it is urgent to administer
some vitamin C supplement even to breast-fed babies as
early as the first few weeks of life.

Acknowledgements.

The writer wishes to thank Dr. V. Scantlebury-Brown,
Dr. H. Kincade, and Dr. K. Campbell for advice and prac
tical .assistance, also Dr. M. Mackie and the staff of the
Women s Hospital; Sister E. Smith, Sister Kramer, Sister
Murphy, Sister Leany and Mrs. Hancock, of the baby
health centres; the matrons and staff of the "Carlton
Home", "Kiddish" and "The Haven" for facilities in col
lecting samples; and Professor V. M. Trikcjus for criticism
and advice.

References.

(I) D. Winikoff : "Calcium, Magnesium and Phosphorus in
the Milk of Australian Women", THE MEDICAL JOURNAL OF
AUSTRALIA, Volume II, 1944, page 660.

&lt; 2) P. Boyle : "Vitamin C and Dental Caries", The Journal of
Pediatrics, Volume XII, 1938, page 415.

(3) S. L. Smith : "Human Requirements of Vitamin C", The
Journal of the American Medical Association, Volume CXI, 1938,
page 1753.

(4) P. Rohmer and N. Bezssonoff: La Nature, Volume II,
1934, page 142 ; quoted by Wachholder, loco citato.

&lt;5) P. Rohmer, N. Bezssonoff and E. Stoerr : "La teneur
particulierement elevee du liquide cephalorachidien en vitamine
C chez le premature et le nouveau-ne normal", Comptes rendus
des seances de la Societe de biologic de Paris, Volume CXXI,
1936, page 987; quoted by Muller, loco citato.

" P. Rohmer, N. Bezssonoff and E. Stoerr : "L influence des
facteurs non alimentaires sur la synthese de la vitamine C par
I organisme animal", Comptes rendus des seances de la Societe
de biologic, Volume CXVIII, 1935, page 58 ; quoted by Ferdinand,
loco citato.

(7) K. Wachholder : "Die Versorgung des Sduglings mit
Vitamin C", Klinische Wochenschrift, Volume XV, 1936, page
593.

(5) H. Ferdinand: "Der Vitamin C Gehalt der Fraiienmilch
und der Kuhmilch in der Friihjahrmonaten", Klinische Wochen
schrift, Volume XV, 1936, page 1311.

&lt;8) J. Muller: "Der Vitamin C Austausch zwischen Mutter und
Fetus", Klinische Wochenschrift, Volume XVIII, 1939, page 299.

do) -yy Neuweiler : "Vitamin C Metabolism of Newborn
Children", Zeitschrift fur Vitaminforschung, Volume VI, 1937,
page 75 ; quoted in Nutrition Abstracts and Reviews, Volume
VII, 1937-1938, page 181.

(II) A. Elmby and P. Becker-Christensen : "Cber das Verhalten
der Ascorbinsdure in der Schtvangerschaft unter der Geburt,
wiihreiid das Wochenbetts und in ersten Lebenstagen des*
Kindes", KHnische Wochenschrift, Volume XVII, 1938, page
1432.

(12) rp Baumann : "Vitamin C Metabolism of Lactating Women.
Physiological and Pathological Degree of Saturation of the
Human Organism with Vitamin C", Jahrbuch der Kinderheil-
kunde, Volume CL, 1937, page 193 ; quoted in Nutrition
Abstracts and Reviews, Volume VII, 1937-193S, page 1083.

as) T Baumann and L. Rappolt : "Vitamin C Metabolism",
Zeitschrift fur Vitaminforschung, Volume VI, 1937, page 1 ;
quoted in Nutrition Abstracts and Reviews. Volume VII, 1937-
1938, page 181.

&lt; u) E. Gedd and K. Kjelberg : "The Vitamin C Content in the
Breast Milk of Mothers in Gothenburg", Acta Pediatrica.
Volume XXVI, 1939, page 177.

(i.-,) -vv. Neuweiler : "Die Vitamin der Milch unter besonderem
Beriicksicht der Fraiienmilch", 1936 ; quoted by Gedd and
Kjelberg", loco citato.

210

THE MEDICAL JOURNAL OF AUSTRALIA.

FEBRUARY 16, 1946.

da) p. T. Chu, T. Woo and C. Sung : "A Study of Vitamin C
Metabolism in Lactating Mothers", Chinese Journal of Physi
ology, Volume XIII, 1938, page 383 ; quoted in Nutrition
Abstracts and Reviews, Volume VIII, 1938-1939, page 1086.

(17) I. Laurin : "Some Ascorbic Acid Saturation Tests on
Infants", Lecture to the South Swedish Pediatric Society, 1937;
quoted by Gedd and Kjelberg, loco citato. 4

&lt; 18 &gt; G. Gaethgens and E. Werner : "Administration of Vitamin
C to Nursing Mothers", Archiv fiir Gynakologie, Volume CLXV,

1937, page 63.

&lt; 19 &gt; Report of the Technical Committee on Nutrition of the
League of Nations, December, 1937 ; quoted by Smith, loco
citato, and Ingalls, loco citato.

(a -p. H. Ingalls : "Ascorbic Acid Requirements in Early
Infancy", The New England Journal of Medicine, Volume
CCXVIII, 1938, page 872; quoted in Nutrition Abstracts and
Reviews, Volume VIII, 1938-1939, page 1080.

(21) Z. Jung: Zeitschrift fiir Vitaminforschung, Volume I,
1932, page 294 ; quoted by Wachholder, loco citato.

&lt; 22) A. P. Hess and H. R. Benjamin : "Urinary Excretion of
Vitamin C", Proceedings of the Society for Experimental Biology
and Medicine, Volume XXXI, 1934, page 855 ; quoted by
Wachholder, loco citato.

(2i) O. A. Bessey : "Use and Abuse of Vitamin C Determina
tion", The Journal of Pediatrics, Volume XII, 1938, page 415.

&lt;24) A. Kuhn : "The Technique of Vitamin C Estimation by
Dichlorophenolindophenol Method", Klinische Wochenschrift,
Volume XX, 1941, page 1174; quoted in Nutrition Abstracts and
Reviews, Volume XI, 1941-1942, page 576.

&lt; K) O. A. Bessey and C. G. King : "The Distribution of Vitamin
C in Plant and Animal Tissues and its Determination", The
Journal of Biological Chemistry, Volume GUI, 1933, page 687.

&lt; aj &gt; C. G. King : "Chemical Methods for Determination of
Vitamin C", Industrial and Engineering Chemistry, Analytical
Edition, Volume XIII, 1941, page 13.

(27) A. J. Lorenz and L. J. Arnold: "Standardisation of 2,6-
Dichlorophenol-indophenql with Ferrous Compounds", Industrial
and Engineering Chemistry, Analytical Edition, Volume X,

1938, page 687.

(28) p. Schlemmer, B. Bleyer and H. Cahermann : "Studien iiber
biochemische Aktivatoren der Milch", Biochemische Zeitschrift,
Volume CCLIV, 1932, page 187.

&lt;a&gt;) E. Selleg and C. G. King : "The Vitamin C Content of
Human Milk and its Variation with Diet", The Journal of
Nutrition , Volume II, 1936, page 599.

&lt;30) A. E. Correns : "Die Vitamin C Gehalt der Frauenmilch
und der Kuhmilch im Sommer", Klinische Wochenschrift, Volume
XVI, 1937, page 81.

(:!1) B. Bleyer : "Die Bestimmung von Vitamin C Antiscorbutic
in Milch", Miinchener medisinische Wochenschrift, Volume
LXXX, 1933, page 257 ; quoted in Nutrition Abstracts and
Reviews, Volume III, 1933-1934, page 420.

&lt; :i2) M. Kasahara and K. Kawashima : "Beitrag zur Kenntnis
des Vitamin C Gehalts in der Colostralmilch", Klinische Wochen
schrift, Volume XV, 1936, page 1279.

&lt;33 J. H. de Haas and O. Meulemans : "The Ascorbic Acid
(Vitamin C) Content of Mother s Milk in Batavia", The Indian
Journal of Pediatrics, Volume III, 1936, page .216 ; quoted in
Nutrition Abstracts and Reviews, Volume VI, 1936-1937, page
976.

&lt;34) E. Stoerr : "Milk as a Source of Vitamin C, Human and
Cow s, Raw and Heated. Seasonal Variations, etc.", Revue
frangaise de pediatrie, Volume XII, 1936, page 427 ; quoted in
Nutrition Abstracts and Reviews, Volume V, 1936-1937, page
660.

(s) ~w Neuweiler : "Vitamin C Content of Human Milk", Zeit
schrift fur Vitaminforschung,- Volume IV, 1935, page 39; quoted
in Nutrition Abstracts and Reviews, Volume V, 1935-1936,
page 91.

W6) H. Winkler and E. Heins : "Der Askorbinsduregehalt der
Frauenmilch im Sommer und Winter", Zeitschrift fiir die
Geburtshiilfe und Gynakologie, Volume CXVII, 1938, page 148;
quoted by Gedd and Kjelberg, loco citato.

7 &gt; L. J. Harris and S. N. Ray : "Diagnosis of Vitamin C Sub-
nutrition by Urine Analysis. Antiscorbutic Value of Human
Milk", The Lancet, Volume I, 1935, page 171.

&lt;38) M. Kasahara and K. Kawashima : "Seasonal Variations in
the Vitamin C Content of Human Milk", Zeitschrift fur Kinder-
heilkunde, Volume LVIII, 1936, page 191 ; quoted in Nutrition
Abstracts and Reviews, Volume VI, 1936-1937, page 660.

&lt;aw T . H. Ingalls, R. Draper and H. M. Teel : "Vitamin C in
Human Pregnancy and Lactation. (2) Studies during Lacta
tion", American Journal of Diseases of Children, Volume LVI,
1938, pages 1004 and 1011 ; quoted in Nutrition Abstracts and
Reviews, Volume VIII, 1938-1939, page 1085.

&lt;* P. A. El-Gholmy : "The Ascorbic Acid Content of Human
Milk and the State of Vitamin C Nutrition of Children Attending
the Child Welfare Centre, Fouad I Hospital", M.D. Thesis,
Fouad I University, Cairo, Egypt; quoted in Nutrition Abstracts
and Reviews, Volume IX, 1939-1940, page 729.

(4I&gt; S. Isono : "Arakawa Reaction and Vitamin C Content of
Human Milk", Tohoku Journal of Experimental Medicine,
Volume XXXV, 1939, page 480.

(42) p w Braestrup and H. Lieck : "Biological Estimation of
Vitamin C in Breast Milk", Hospitalstiden.de, Volume LXXXI,
1938, page 913; quoted in Nutrition Abstracts and Reviews,
Volume VIII, 1938-1939, page 652.

**&gt; J. C. Traversaro and R. Quesada : "Vitamin C in Human
Milk", Revista de la Asociacion bioquimica argentina, Volume
III, 1938, page 7 ; quoted in Nutrition Abstracts and Reviews,
Volume VIII, 1938-1939, page 1087.

&lt;" A. Cimmino : "Vitamin C in Human and Cow s Milk and
the Milk of Other Mammals", Quaderni della Nutrizione,
Volume V, 1938, page 239 ; quoted in Nutrition Abstracts and
Reviews, Volume VIII, 1938-1939, page 696.

&lt;&gt; I. Concepcion and M. L. Gargaritano : "Studies on Vitamin
C", The Journal of the Philippine Islands Medical Association,
1939, page 19; quoted in Nutrition Abstracts and Reviews,
Volume IX, 1939-1940, page 93.

(46 &gt; Sapegno and Mado : Archivio italiano di pediatria e
puericultura, Volume II, 1934, page 724 ; quoted by Elmby,
loco citato.

&lt; 17 &gt; R. K. Chakraborty : "Vitamin C Content of Some Indian
Food-Materials", The Indian Journal of Medical Research,
Volume XXIII, 1935, page 347; quoted by Elmby, loco citato.

(4s&gt; j\ Kroker : "Vitamin C in Cow s and Human Milk", Milch-
wirtschaft Forschungen, Volume XIX, 1938, page 318 ; quoted
in Nutrition Abstracts and Reviews, Volume VIII, 1938-1939,
page 652.

&lt;" E. I. Sinkko : "Relation between Infantile Mortality and
Variations in the Vitamin C Content of the Mother s Milk at
Various Seasons of the Year in Finland", Acta Pediatrica,
Volume XXI, 1937, page 407; quoted in Nutrition Abstracts and
Reviews, Volume VIII, 1938-1939, page 201.

(50) K. Utheim-Toverud : "The Vitamin C Requirements of
Pregnant and Lactating Women", Zeitschrift fur Vitamin
forschung, Volume VIII, 1939, page 237 ; quoted in Nutrition
Abstracts and Reviews, Volume IX, 1939-1940, page 189.

CHYLANGIOMA OF THE MESENTERY, WITH REPORT

OF A CASE, AND A BRIEF DISCUSSION OF

MESENTERIC CYSTS.

By G. C. V. THOMPSON, F.R.C.S. (Edinburgh),
Squadron Leader, Royal Australian Air Force,

and

C. H. CHAMBERS, M.B., B.S.,
Flight Lieutenant, Royal Australian Air Force.

(From the Surgical Division of a Royal Australian
Air Force Hospital.)

A CHYLANGIOMA of the mesentery has been defined by
Ewing (1) as a cavernous lymphangioma containing milky
fluid, which arises from congenital or acquired obstruction
of the lacteal vessels. Chylangioma constitutes one type
of true mesenteric cyst, in that it conforms to the definition
of a mesenteric cyst given by Higgins and Lloyd/ 2 who
held that mesenteric cysts were cysts which occurred in
or near the mesentery, which were not malignant, dermoid
or parasitic, and which did not arise from any normally
placed retroperitoneal organ.

Great interest has been shown in the study of mesenteric
cysts since the discovery at autopsy, by Benevieni, of the
first recorded mesenteric cyst in 1507. The history of
the knowledge accumulated in respect to cysts of mes
enteric origin is extensively reported; the reviews of
Warfield, &lt;3&gt; Swartley, U) and Roller 5 may be quoted as
adequately summarizing the historical aspect.

Of all the abdominal tumours, Flynn (0) considers those
of the mesentery to be the rarest. Mesenteric cysts are
uncommon, Wai-field estimating that only about 500 cases
of mesenteric cyst have been reported in the literature.
Among these cases, Slocum (7&gt; states that less than 300 true
mesenteric cysts have been reported, and that the number
of true chylous cysts of the mesentery of sufficient size to
cause symptoms would be no greater than 200. Parsons,* 8
after reviewing the literature, states that there are records
of only ten cases of mesenteric cyst with gross and micro
scopic appearances of true proliferating cystic lymph
angioma, although the criteria on which this assertion is
made are not definitely enumerated in the article. It
appears to us that the condition is more common than
these figures lead one to believe, but, because lymph-
angiomata (or chylangiomata) are still rare, we venture
to report a case of this type of cyst which we regard as a
true chylangioma.

The frequency with which mesenteric cysts are found
can be judged from a review of the medical literature
which contains statistical surveys. At the University of
Minnesota, Collins and Berdez (8) found no case of mes
enteric cyst in 15,000 autopsies, and only two cases of
chyle cysts were found in the clinical records of 200,000
cases. These figures are comparable with the records of

FEBRUARY 16, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

211

the Mayo Clinic, where Crisp and Judd &lt;10) found the
histories of eight cases of cysts amongst 25 mesenteric
tumours in 820,000 admissions. Alesen (11) was able to find
no case of mesenteric cyst recorded at the Los Angeles
General Hospital between 1912 and 1929; but during the
following five-year period one case was recorded in 188,921
admissions ( Roller (5) ). The average statistics, of which a
long series has now accumulated, give the relative fre
quency of mesenteric cysts as approximating to one in
every 100,000 admissions.

Review of available Australian literature covering the
last twenty years has shown little reference to mesenteric
cysts in Australia. Phillips &lt;12) failed to find any case
amongst 19,788 admissions to the Alfred Hospital, Mel
bourne, during the years from 1930 to 1933, or in 4,000
post-mortem examinations performed at that hospital since
1914. Three mesenteric cysts have been recorded in
Australian medical journals during this time. In 1927
Lee (i:i) reported a mesenteric cyst simulating post-partum
dilatation of the stomach; in 1928 Wade and Steigrad &lt;14)
recorded a case of lymphatic mesenteric cyst; and in 1935
Ross 05 described an enterogenous cyst in an infant.

Recently, at a Royal Australian Air Force hospital, a
case of chylangioma, or cavernous lymphangioma con
taining chyle, was investigated by us and an exploratory
operation was carried out. No other case of mesenteric
cyst has been recprded in 13,744 admissions to this
hospital. Because of the rarity of this type of mesenteric
cyst, the case history will be briefly given and can be
used as a basis for discussion of mesenteric cysts generally.

Report of a Case.

An airman of the Royal Australian Air Force, A.J.H.,
aged twenty years, first reported in June, 1944, that he had
noticed an epigastric "lump", which was associated with
some vague abdominal discomfort. The examining medical
officer could feel a tumour mass in the epigastrium, which
appeared to have a diameter of three inches. Further ques
tioning elicited a history of three days persistent umbilical
pain, anorexia and nausea, but no vomiting. A curious
feature was the complaint of persistent lumbar backache.
Inquiry into the past history revealed no significant features.
The patient was admitted to hospital at this time with a
normal temperature and pulse rate, but with a "dirty"
tongue and "heavy" breath. Abdominal examination revealed
tenderness above and to the right of the umbilicus, with
some abdominal rigidity. At this time the mass could not be
palpated, although two days later a cystic, freely movable
mass could be felt in the left lower quadrant of the abdomen.
Shortly afterwards the tumour apparently disappeared, and
repeated palpation gave negative results. An outstanding
feature of the cyst has been its free mobility at all times,
and a tendency to disappear, probably due to its being
moved to a position under cover of the costal arch. The
blood film was normal, and there was a slight decrease in
the haemoglobin value (93%). The Casoni test, the hydatid
complement fixation test, the Wassermann test, a plain
X-ray examination of the abdomen, and an opaque meal
examination of the gastro-intestinal tract were all carried
out with negative results.

In December, 1944, he was readmitted to hospital with
some joint pains, which were considered to be of mild
rheumatic nature. Once again the mass was palpable, but,
being in the left loin, was considered probably renal in
origin. Electrocardiograph tracings, a blood count, and
estimation of the blood sedimentation rate gave normal
results. X-ray films of the renal tract revealed an enlarged
left renal shadow, which was, however, considered to be
within normal limits, and no opaque calculi. Excretion
pyelography revealed the dye excretion, the renal calyces,
the pelvis and the ureter to be normal. After a month in
hospital the patient was returned to duty, the mass being
indefinitely palpable below the left costal margin and being
considered possibly a kidney.

On June 1, 1945, the patient was readmitted to hospital
with pain in the upper part of the abdomen and in the
lumbar region, identical with that experienced a year
previously. He was also aware of a freely mobile epigastric
tumour. Clinical examination gave negative results, except
for the presence of a smooth, freely movable, cystic mass
about four inches in diameter, with regular outline, and
situated in the umbilical region. While freely mobile, the
mass could most easily be displaced into the right upper
quadrant of the abdomen. The clinical diagnosis was

between a mesenteric cyst and a hydatid cyst. The Casoni
test was repeated with negative results. Microscopic exam
ination of the urine revealed no siginificant features. A
blood examination showed that the haemoglobin value was
12-6 grammes per 100 mils (90%), the red blood cells
numbered 4,670,000 per cubic millimetre, and the white blood
cells numbered 8,700 per cubic millimetre, 66% being neutro-
phile polymorphonuclear cells, 23% being lymphocytes, 7%
monocytes and 4% eosihophile polymorphonuclear cells.

Operation, performed on June 7, 1945, revealed a large,
fleshy, irregularly rounded, well-differentiated tumour arising
in the mesentery in the region of the duodeno-jejunal
junction and the upper part of the jejunum, and extending
towards its posterior attachment, thereby surrounding the
superior mesenteric artery. The tumour was mottled, with
pale pink and creamy-yellow areas throughout. The mesen
tery of the jejunum was widely separated by the tumour,
which had extended in such a manner that it had formed a
gutter that partly surrounded the jejunum over its proxi
mal eight inches. There was no evidence that the tumour
had infiltrated surrounding tissues, no obstruction to the
lumen of the bowel was evident, although some thickening
of the bowel wall over the first ten or twelve inches
occurred, and a small number of the lacteals draining the
area were thickened, dilated and filled with a material
resembling clotted chyle or fat. The mass was of varying
Consistence, being formed of fleshy masses separated by
cystic spaces, varying in size from the size of a pin s head
to that of a golf ball; the whole area had a typical spongy
appearance. The tumour, which was more extensive than
clinical examination had led us to believe, was not invading
surrounding structures, but its removal was considered to
be technically impossible because of its relationship to the
superior mesenteric artery, and marsupialization would not
drain the cyst. Aspiration was carried out as a palliative
procedure, no gastro-jejunal anastomosis being deemed
necessary, as obstruction of the lumen of the jejunum
appeared to be a most unlikely development for a con
siderable time. A biopsy specimen of the tumour mass was
taken to confirm the diagnosis of chylous cyst of the mesen
tery. The abdomen was closed after operation.

The fluid obtained from the cystic spaces was milky,
contained fat globules, and was partly pale piiak from blood
staining. The pathological report on the fluid was that the
specimen of fluid was milky and blood-stained, and on
microscopic examination was found to contain red blood
cells, a few lymphocytes and granular material which
resembled fat. The microscopic appearance of the biopsy
specimen (see Figure I) revealed adipose tissue, in which

FIGURE I.

Photomicrograph of biopsy specimen of the chylangioma,
showing a network of lymph spaces lined by flattened
endothelium and surrounded by irregularly arranged,
smooth muscle fasciculi. (Haemotoxylin and eosin stain,
x 105.)

some small blood vessels, irregularly shaped spaces and
smooth muscle fibres were present. The spaces were lined by
flattened endothelium and contained a small quantity of
granular eosinophilic material and a few scattered red cells.
The smooth muscle was irregularly arranged around these
spaces, particularly the larger space visible in the section,
and here the fibres tended to be grouped into interweaving
fascic.uli in the walls of the space. The pathologist s opinion

212

THE MEDICAL JOURNAL OF AUSTRALIA.

FEBRUARY 16, 1946.

was that these histological findings, taken in conjunction
with .the character of the aspirated fluid, indicated the
diagnosis of chylangioma.

Convalescence was uneventful, and although a mass,
smaller and less mobile than formerly, is still palpable in
the lower part of the epigastrium, the patient is symptom-
free and has returned to his pre-service occupation.

Discussion.

The classification of mesenteric cysts is confused, and
no uniform opinion is noted amongst many schemes pro
pounded. Moynihan in 1897 produced a simple classifica
tion, which was succeeded by the classification of Dowd, 1 "
who stressed the embryonic origin of many cysts. Sub
sequent classifications have been a modification or ampli
fication of these earlier schemes.

Roller &lt;5) gives the following scheme as a basis for
classification of mesenteric cysts:

1. Embryocytomata or embryonic inclusion tumours.

(a) Urogenital remnants derived from sequestrated
portions of Wolffian or Miillerian ducts.

(&) Cystic dermoids and teratomata resulting from
sequestration of remnants of the developing
genital glands.

(d) Enterocystomata arising from sequestration of
either an intestinal diverticulum or the vitelline
duct.

2. Chylous cysts, which are considered by Ewing to be

chyle angiomata and by Dowd to be chylous secretion
into preformed cysts.

3. Bacterial or parasitic cysts, such as occur as cystic

formations in tuberculous glands or hydatid cysts.

4. Traumatic cysts, arising from haematomata in the mes

entery or developing around a foreign body.

5. Angiomata of blood or lymph vessels. The latter would

be lymphangiomata and should therefore be classified
with the chylous cysts above.

6. Gas cysts, which are included with reservation.

In the classification which Petersen &lt;17&gt; proposes, the
primary distinction is made between embryonic cysts and
pseudo-cysts, which are grouped thus:

1. Embryonic.

(a) Cysts arising from embryonic remnants and

sequestrated tissue: (i) serous, (ii) chylous, (iii)

sanguineous, (iv) dermoid.
(Z&gt;) Cysts of intestinal origin: (i) by sequestration

from the bowel during development; (ii) arising

from Meckel s diverticulum.
(c) Cysts arising from urogenital organs (germinal

epithelium, ovary, Wolffian body or Miillerian

duct).

2. Pseudo-cysts.

(a) Of infective origin.

(ft) Cystic malignant disease.

However, for the purpose of study, and as a basis for
discussion, the simple classification of Ewing appears
adequate. He concisely divides mesenteric cysts into four
groups, as follows: (i) lymphatic or chylous, (ii) enteric,
(iii) urogenital, (iv) dermoid and teratoid.

It will be noted that cysts of neighbouring organs,
encysted haematomata, malignant cysts, infective cysts and
hydatid cysts are excluded, and that gas cysts, which are
rare, of disputed aetiology, and considered by many to be
due to gas formation in dilated lymph or chylous channels,
are not classified.

Dermoids and teratoid tumours are extremely rare in the
mesentery, although they can occur at any point from the
cceliac axis to the pelvis. Their origin is disputed, but
two main views are held. Wilms considers that they arise
from imperfect closure of embryonic abdominal plates,
but others consider that they arise from an ovarian basis.
In the mesentery these tumours differ in no way from
similar dermoids and teratoids of other situations.

Cysts of urogenital origin are but rarely found amongst
mesenteric cysts and form an ill-defined group. In a
discussion on retroperitoneal cysts, Handfield- Jones (1S &gt;,
traces ttye origin of cysts in relation to the embryonic
urogenital system. It is quite conceivable that mesenteric

cysts could arise by displacement of remnants of the
Wolffian system into the developing mesentery. Cysts
of urogenital origin are usually large, thin-walled
cysts, ^ned by low columnar epithelium and having a
fibrous tissue wall. In the cyst is found a clear, serous
fluid, of low specific gravity, and containing pseudo-mucin.
Cysts of urogenital origin are difficult to distinguish from
cysts of mesocolic origin, to which attention has been
- drawn by Handfield-Jones, who related their origin to
islands of peritoneum which failed to disappear during
the process of development and fixation of the colon.

Enteric cysts form a definite group of mesenteric cysts.
Dowd 10 focused attention on the origin of mesenteric
cysts from remnants of the Wolffian body, but also admitted
that some cysts might arise from intestinal diverticula.
Evidence is now conclusive that enterogenous cysts arise
in this manner. Miller 19 reports a case in which an
enteric cyst could be seen developing from the intestinal
wall, and there is abundant evidence that intestinal diver
ticula may arise in the bowel of the embryo. If such a
diverticulum, lying between the layers of the mesentery,
becomes separated, it readily forms a potential mesenteric
cyst. Such a cyst has usually a single cavity and a wall
resembling that of the intestine; it even contains layers
of smooth muscle, a mucosa with crypts, and a lining of
cylindrical, cuboid or stratified epithelium. Evans 30
states that all cysts found in the abdomen, in the thorax or
at the umbilicus, having the structure of gut, must have
been derived from the primitive intestinal tract and are
developmental enterogenous cysts. These cysts can arise
from a diverticulum of embryonic entoderm in this manner,
but another source is in relation to the vitello-intestinal
tract. The situation of the vitello-intestinal tract in
relation to the mesentery is subject to considerable varia
tions, and it is not uncommon for remnants of the vitello-
intestinal tract to become separated between the layers
of the mesentery, and to give rise to typical enteric mes
enteric cysts. It appears probable that cysts arising from
vitelline duct remnants would be found towards the lower
portion of the small intestine, while those arising from
the formation of intestinal diverticula would appear at the
upper end.

Chylous or lymphatic cysts have caused a large amount
of discussion in medical literature. Many authors, includ
ing Dowd, 10 Warfield, -" and Higgins and Lloyd, (2 &gt; regard
chylous or lymphatic mesenteric cysts as not arising from
obstruction of lymphatics, but as accumulations in pre
existing cysts. However, there seems to be considerable
reliable evidence that lymphatic or chylous cysts exist as
distinct entities and that they are mostly of embryonic
origin, although some may be acquired. The former are
the true chylangiomata and the latter are due to obstruc
tion to lymphatic vessels. It is, however, not always easy
to distinguish between the lymphangiomatous and the
lymphangiectatic variety.

Chylous cysts form large, usually multilocular tumours,
or sometimes occur as numerous small swellings of v the
mesentery, the intestine, the omentum or retroperitoneal
organs. Chylangioma can be considered as a tumour of
lymph vessels, consisting of endothelial cells and connec
tive tissue, both of which take part in the neoplastic
process. The condition is considered of embryonic origin,
even though signs and symptoms may not be present until
adolescence or adult life. The tumour consists of an anas
tomosing network of lymph spaces supported by thin walls
or thick septa, lined by endothelium, with chylous con
tents or more inspissated fatty material, and often blood
stained. The endothelium lining the cavernous lymph
spaces may be flattened, or in places it may be hyperplasUc,
proliferating and heaped up into layers. In some speci
mens evidence of the formation of new lymphatic channels
can be observed as an outgrowth of endothelium into the
connective tissue and its subsequent canalization. It is
possible in cysts with tense contents for the endothelial
lining to be distributed in a patchy fashjon. The walls of
the lymph spaces may be thin or thick septa; they are
composed of fibrous tissue, in which may be found many
small round cells, lymph follicles and dilated lymph

FEBRUARY 16, 1946.

THE MEDICAL. JOURNAL OF AUSTRALIA.

213

spaces on many occasions. Some elastic tissue and
bundles of smooth muscle may be present in the walls,
and giant cells are found about fatty detritus. The
presence of smooth muscle in the wall, being a feature
common to chylangiomata and enteric cysts, may make
their recognition difficult.

The contents of chylangiomatous cysts rarely appear to
have been analysed or correlated with the contents of
mesenteric cysts whose pathology is known. It appears
as if all analyses have been made on "typical" mesenteric
cysts of unstated aetiology, and no examination of fluid
from a chylous lymphangioma (chylangioma) appears to
have been made and compared with that of fluid from a
lymphangioma containing clear fluid. Higgins and Lloyd 2
state that "typical" fluid from a mesenteric cyst is pale,
clear, straw-coloured fluid with a specific gravity of 1015
to 1016, contains large amounts of albumin, and is
alkaline in reaction; blood, cell debris and cholesterin are
also usually present. Ross and Mead &lt;21) analysed "chyle-
like" and amber fluid from mesenteric cysts, but stated
that the sample was not chyle, which consists of lymph
containing fat globules, but that it consisted of fluid, the
milky appearance of which was due to protein loosely
bound with lipoid material, particularly lecithin. The
composition of the two samples varied little, except in
respect to fat and cholesterol; both contained 94-3% water,
5-7 % solids and approximately 3-8% total protein. The
fat (ether-soluble) content in the chylous fluid was
0-27% as compared with 0-73% in the amber fluid, and the
cholesterol content was 0-178% in the chylous fluid as
against 0-38% in the amber fluid. Messer 221 analysed the
fluid from a chylous cyst in a patient operated upon by
Slocum, (7) comparing its composition with that of chyle,
chylous effusion and the contents of chylous cysts reported
by other authors. Once again considerable disparity exists
in the chemical composition, and no constant feature
appears in the analyses of the four authors quoted. The
fat content varied from 4-5% to 35-8%, and the protein
content from 1-97% to 8-51% in the analysis of the mes
enteric cystic fluid. In this series it is again uncertain
whether the contents of the chylous cysts should be con
sidered as those of chylangiomata. Messer believed the
disparity to be due to variation of the degree of effusion
or to differential absorption of the stagnant fluid. The
particular specimen examined was a creamy fluid, which
on standing separated out, a tenacious creamy sludge being
produced. One pronounced feature of chylous fluid that
should be noted is its resistance to accidental contamina
tion by bacteria; a specimen remains sterile for long
periods in the absence of precautions to avoid entry of
bacteria. This is rather surprising, in view of the rela
tively high protein content; it suggests that the fluid has a
bacteriostatic effect.

Macroscopically, chylangiomata are well differentiated
from surrounding tissues, having a capsule which varies
with the size of_ the cysts, with their situation, and
according to whether they are pedunculated or sessile,
or whether they project between the layers of the mes
entery. The tumour may be a single cyst or a multilocular
cyst with cystic spaces of varying size; it may be entirely
cystic or partly fleshy.

Chylangiomata are considered benign tumours, whose
embryonic origin is stressed by Klemm and Rittner (as
quoted by Ewing (1 &gt;) and by Murbach, Lewison and
Diebert/ 2 " who pointed out that lymphangiomata occurred
most frequently at the primitive centres of origin of lymph
tissue in the embryo.

Acquired dilatation of lymphatic vessels of the intestinal
tract can give rise to mesenteric cysts, and such dilatations
are included in the definition of chylangiomata outlined
at the commencement of this paper. That obstruction of
lymphatics can give rise to cysts has been challenged on
the grounds that the rich anastomosis of lymphatics would
not permit this occurrence. However, there are some
grounds for the belief that it is possible, and there is no
doubt that lymph stasis influences the course of many
congenital lymphangiomata and that cystic dilatation does
occur in the newly formed lymph vessels of proliferating

cystic lymphangiomata. In some cases the dilatation with
cyst formation appears to involve chiefly the lymph nodes.
Such a condition would be comparable with the condition
described by Hill, (24) to which he has given the name of
mesenteric chyladenectasis. He noted that, while excessive
dilatation of lymph-node sinuses to form multilocular or
single cysts was rare, dilatation of mesenteric gland nodes
with inspissated chyle was extremely rare. This dilata
tion, to which the term "chyladenectasis" has been given,
has been variously attributed to obstruction of the lym
phatics or the lymphatic duct, to infarction of efferent
lymph vessels, to obstruction of the thoracic duct and iliac
veins simultaneously, to chronic desquamative lymph
angitis, and to inflammatory change altering the local
lymphatic circulation. Cystic changes are present in the
lymph nodes, which have the character of lymph-gland
medullary sinuses, with no true endothelial lining, and
absence of smooth muscle around the cystic channels. Hill
states that chyladenectasis should be considered in cases
of multilocular, multiple cysts located in the mesentery,
particularly in adults, and not involving the intestinal wall.
The characters of these cysts are the presence of chylous
or fatty material in dilated lymph-node sinuses without
complete endothelial lining, absence of smooth muscle in
the cyst walls, and suitable obstruction to chylous drainage.
The differentiation of mesenteric cysts into their various
groups is not easy on either anatomical or pathological
grounds; but it may be stated that the presence of smooth
muscle, epithelial lining of intestinal type and perhaps
goblet-cell formation suggests enteric cysts; endothelial
lining suggests chylangioma; high columnar epithelium
and pseudo-mucin, hair or teeth, suggest origin from
primitive sex organ ancestry (War field &lt;:i) ).

Mesenteric cysts occur at any age, but the maximum
incidence appears to be in early adult life. There is
general agreement on this, although Higgins and Lloyd 12
state that the maximum incidence is between the ages of
ten and twenty years, while Warfield (: " found the greatest
incidence in the fourth decade, and Collins and Berdez &lt;9)
found it in the third decade. The female sex seems to
be more commonly affected than the male.

Warfield &lt;: " has stated the distribution of mesenteric
cysts reported in the literature in their relation to the
intestine; but, unfortunately; no statistics appear to be
available as to the location of various pathological types
of cysts in relation to the bowel. It was found that cysts of
the small intestinal mesentery were slightly more frequent
than those of the large bowel; that 1-5% occurred at the
duodeno-jejunal junction; that cysts of the ileum were
almost three times as common as cysts in the jejunum;
and that the three divisions of the colon had approxi
mately an equal number of cysts in relation to them.

The symptoms arising from mesenteric cysts are in
no way pathognomonic; it is often the onset of an acute
surgical complication that first draws attention to the
condition. In uncomplicated cases the patient presents for
examination with the complaint of a palpable tumour or
of abdominal distension. The tumour varies in size, but
characteristically it is smooth, rounded or lobulated, some
what centrally situated in the abdomen; perhaps its most
prominent feature is its extreme mobility, especially in a
transverse direction. In favourable circumstances the
fluctuant or fluid nature of the cyst contents can be
demonstrated. The second important feature which draws
the patient s attention to his condition is pain; this is
nearly always present, even in the absence of complica
tions which almost invariably are accompanied by severe
pain. The pain may be generalized over the abdomen or
may be confined to the tumour itself. In the latter case
particularly, localized tenderness may be elicited. It is
stated that pain is more frequently present in mesenteric
cysts than in any other cystic abdominal tumour. The
reason for this is not apparent, although the curious
lumbar pain in the case quoted was probably due to drag
or tension on the mesentery. The site, nature and cause
of pain in uncomplicated mesenteric cysts do not appear
to have received much attention in the literature.

Other symptoms, such as malaise, anorexia, nausea or
occasional vomiting are not prominent features, but are

214

THE MEDICAL JOURNAL OF AUSTRALIA.

FEBRUARY 16, 1946.

more common in mesenteric cysts than in those of retro-
peritoneal regions. Fatigue and loss of weight and
strength may occur, but these are only of minor grade;
the rapid loss of weight, which Moynihan thought was a
feature of chylous cysts, does not appear to be a constant
finding.

The classical clinical signs were considered to be the
prominence of a fluctuant tumour towards the umbilical
region, great mobility in a transverse direction, and the
presence of a "zone of resonance around and a belt of
resonance across the cyst". The last-mentioned sign must
be most inconstant, apparently has no sound logical basis,
and is rarely mentioned by modern writers. The features
of the palpable tumour have already been mentioned,
except that the percussion note over the tumour may be
dull, and variable bands of resonance as described above
not be present. Tenderness over the cyst is frequently
found even in the absence of complications.

The usual history, physical signs .and symptoms pre
sented in a case of mesenteric cyst are those of complica
tions which may arise and will be discussed no further.

In a review of cysts of the omentum, of the mesentery,
and of retroperitoneal origin, Berger and Rothenberg, (25)
reviewing eighteen cases, of which five were cases of
mesenteric cyst, found that eight patients had sought
treatment for acute surgical conditions, that eight patients
complained of a mass only, and that two-thirds of the
patients had had pain; four of the five patients with mes
enteric cysts had complained of pain and had a palpable
tumour also.

The diagnosis of mesenteric cyst is primarily one of
correlating the physical signs of a freely mobile cyst in
the abdomen with the knowledge that, although they are
rare, mesenteric cysts occur and must be considered in a
differential diagnosis. Their final diagnosis is made by
elimination of other conditions.

In the matter of diagnosis, the intelligent use of X-ray
facilities greatly helps in arriving at a correct opinion.
Hinkel (a8) states that valuable information concerning
location of a cyst can be obtained by palpation under an
X-ray screen after the administration of barium orally
or rectally, or in both ways, noting indentation of viscera,
their mobility and other features. A plain X-ray film of
the abdomen occasionally outlines the shadow of a mes
enteric cyst, particularly if calcification is occurring in its
wall. Excretion pyelography establishes the relation of
a cyst to the renal tract and is helpful in differential
diagnosis. It has been suggested that pneumoperitoneum
methods may help in the localization and identification
of a mesenteric cyst.

The differential diagnosis of mesenteric cysts is from
ovarian cysts, retroperitoneal tumours, pancreatic cysts,
hydronephrosis, hydatid cysts, bowel tumours, pregnant
uterus et cetera.

Complications which may occur in mesenteric cysts are
numerous and give rise to serious conditions whose signs
and symptoms overshadow those of the original cyst and
for which treatment of a surgical nature is urgently
required. Briefly, the complications may be stated as
follows.

1. Intestinal obstruction, which occurs in 30% to 50%
of cases and has a high mortality rate. The mechanism of
the obstruction is variable, symptoms arising from vol
vulus, angulation of the bowel, adhesions, intussusception,
or stenosis of the bowel by pressure from the cyst.

2. Peritonitis, which may develop as a complication of
intestinal obstruction or of rupture of the cyst.

3. Haemorrhage into a mesenteric cyst, which may have
acute symptoms and prove fatal. It is also common for
a minor grade of haemorrhage to occur into a cyst, par
ticularly of the chylangiomatous type, giving rise to the
pink colour of the contents, but to no other symptoms.

4. Rupture of the cyst, either spontaneously or, more
frequently, as a result of trauma of minor or gross degree.

5. Torsion, which may occur, but is infrequent.

6. Incarceration of a cyst in the pelvis; this has been
mentioned, but must be a rare complication.

The question of malignant changes occurring in mes
enteric cysts is an important one, but malignancy appears
to be exceedingly rare. It may, therefore, be considered
that mesenteric cysts are benign tumours, and the prog
nosis will depend upon the size, the location and the site
of attachment of the cyst, upon the presence of complica
tions, such as intestinal obstruction and peritonitis, with
their high mortality, and, finally, upon the type of operative
procedure necessary for the treatment of the condition.
The malignant changes that have been described are of a
sarcomatous or carcinomatous nature, but very few cases
indeed have been reported.

The treatment of mesenteric cysts, without complications,
has become standardized and can be considered in four
sections, as follows.

1. Enucleation of the cyst is without doubt the ideal
procedure. It is most frequently employed and is accom
panied by the lowest mortality rate of any curative pro
cedure. Dense adhesions render the operation difficult,
and at all times care must be taken to avoid injury to
the vascular channels to the bowel.

2. In many instances it is found that enucleation is
impossible because of adhesions to the bowel wall, the
situation of the tumour, or liability of a loop of bowel to
gangrene from damage to vessels in the mesentery. In
such cases resection of the tumour and a portion of the
bowel is the method of treatment. The mortality rate of
this procedure is greater than that of the enucleation opera
tion and is higher still in the presence of complications.

3. In certain circumstances it is impossible to perform
either of these operations, and so opening, drainage and
marsupialization of the cyst to the abdominal wall are
the only feasible procedures. Despite many objections to
this method, it has a place in the treatment of mesenteric
cysts, it is fairly safe and, given sufficient time, it results
in the obliteration of the cyst with final cure. The objec
tions on the grounds of persistent sinus formation, non-
obliteration of the cavity and the greater incidence of
intestinal obstruction, are more theoretical than real.

4. Aspiration alone is not a satisfactory method of
treatment, but it may be used as a preliminary stage in
radical surgical treatment. It was used in the case
quoted in this paper, with the full realization of the limita
tions of the method, because radical excision or marsupial
ization was impossible, and in the absence of obstruction,
anastomosis of the bowel was not indicated.

It will be noted that all procedures for relief of the
condition are based upon recognition of the benign nature
of the usual mesenteric cyst and must be modified in the
case of the uncommon malignant cyst.

Cysts complicated by intestinal obstruction, peritonitis,
rupture, or the other rarer conditions, primarily demand
the standard treatment for these disorders, the decision in
respect to the cyst and the line of treatment to be
adopted being made at the time of operation. The mor
tality rate is higher by virtue of the complications, but
apart from this fact the treatment is along routine lines
and needs no further comment.

Summary.

1. A case of chylangioma of the mesentery at the
duodeno-jejunal junction is reported. The cyst had the
features of a true tumour of the lacteals, and is sufficiently
uncommon to be of interest, especially in view of the
infrequency in the literature of reports of mesenteric
cysts of any type.

2. The confused classification of mesenteric cysts is
discussed, and an attempt has been made briefly to describe
common types of mesenteric cysts.

3. The clinical signs, symptoms, diagnosis and treatment
of mesenteric cysts are briefly stated.

4. Mesenteric cysts must be more common than appears
from perusal of the literature, which, from lack of
material, presents an inadequate basis for investigation
of the subject. A plea is therefore made for further case
reports, so that data can be collected for elucidation of the
problem of the nature, frequency and origin of cysts in
relation to the peritoneum and mesentery.

FEBRUARY 16, 1946. THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER.

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DISTRIBUTORS: FASSETT & JOHNSON LTD., CHALMERS STREET, SYDNEY

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THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER. FEBRUARY 16, 1946.

Nutritive Food Tonic

Each 10 grammes (approximately 2

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Vitamin A .
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300 Int. Units
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1,000 Int. Units

Together with dextrose and calcium phosphate
in a chocolate base.

For the treatment of those vague
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nervous exhaustion, sleeplessness,
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In debility following severe illness,
and for those cases
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of the normal diet.

During pregnancy and
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As a stimulant for sub
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In 5 and 10 oz. jars and
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FEBRUARY 16, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

215

Acknowledgements.

We are indebted to Air Vice-Marshal T. E. V. Hurley,
Director-General of Medical Services, Royal Australian Air
Force, for permission to publish this article. We also
wish to thank Professor S. Sunderland, Professor of
Anatomy, University of Melbourne, for the photomicro
graph of the specimen, and Major F. R. Magarey for the
pathological reports.

References.

(1) J. Ewing: "Neoplastic Diseases", Fourth Edition, 1942.

(Z) T. T. Higgins and E. I. Lloyd : "Mesenteric Cysts : With a
Report of Two Cases", The British Journal of Surgery, Volume
XII, July, 1924, page 95.

(:!) J. O. Warfleld : "A Study of Mesenteric Cysts", Annals of
Surgery, Volume XCVI, September, 1932, page 329.

(4&gt; W. B. Swartley : "Mesenteric Cysts", Annals of Surgery,
Volume LXXXV, June, 1927, page 886.

(5) C. S. Roller : "Mesenteric Cysts", Surgery, Gynecology and
Obstetrics, Volume LX, June, 1935, page 1128.

(8 &gt; C. W. Plynn : "Mesenteric Cysts, with Report of a Case
of Cystic Lymphangioma", Annals of Surgery, Volume XCI,
April, 1930, page 505.

&lt;7) M. A. Slocum : "Surgical Treatment of Chylous Mesenteric
Cyst by Marsupialization", The American Journal of Surgery,
Volume XLJ, September, 1938, page 464.

(s) E. O. Parsons : "True Proliferating Cystic Lymphangioma
of the Mesentery", Annals of Surgery, Volume GUI, April,
1936. page 595.

&lt;e &gt; A. N. Collins and G. L. Berdez : "Chyle Cysts of the
Mesentery", Archives of Surgery, Volume XXVIII, February,
1934, page 335.

(10 &gt; E. S. Judd and N. W. Crisp : "Primary Tumours of the
Mesentery", Proceedings of the Staff Meetings of the Mayo
Clinic, Volume VII, September 21, 1932, page 555.

m) L. A. Alesen : "Mesenteric Chylous Cysts", California and
Western Medicine, Volume XXX, April, 1929, page 261.

(I2 &gt; H. A. Phillips : "Spindle-Celled Mesenteric Tumours ; with
Remarks on Similar Retro-Peritoneal Tumours", The British
Journal of Surgery, Volume XXI, April, 1934, page 637.

"&gt; A. E. Lee : "Mesenteric Cyst Simulating Acute Post-
Partum Dilatation of the Stomach", THE MEDICAL JOURNAL OF
AUSTRALIA, Volume I, January 15, 1927, page 83.

&lt;14) R. B. Wade and J. Steigrad : "A Case of Mesenteric Cyst",
THE MEDICAL JOURNAL OP AUSTRALIA, Volume I, April 14, 1928.
page 465.

(1B) K. Ross : "Enterogenous Cyst in an Infant", THE MEJDICAL
JOURNAL OP AUSTRALIA, Volume II, July 13, 1935, page 53.

&lt;16&gt; C. N. Dowd : "Mesenteric Cysts", Annals of Surgery,
Volume XXXII, October, 1900, page 515.

&lt;17) E. W. Petersen : "Cysts of the Mesentery", Annals of
Surgery, Volume CXII, July, 1940, page 80.

(18 &gt; R. M. Handfield-Jones : "Retro-Peritoneal Cysts : Their
Pathology, Diagnosis and Treatment", The British Journal of
Surgery, Volume XII, July, 1924, page 119.

(ie) R T Miller : "Enterogenous Mesenteric Cysts", The
Bulletin of the Johns Hopkins Hospital, Volume XXIV, October
1913, page 316.

(20) A. Evans : "Developmental Enterogenous Cysts and Diver-
ticula", The British Journal of Surgery, Volume XVII Julv
1929, page 34.

&lt;ai &gt; D. Ross and C. I. Mead : "Mesenteric Cysts : With Report
of a Case", The Canadian Medical Association Journal, Volume
XXX, March, 1934, page 262.

(2a &gt; F. C. Messer : "Analysis of Fluid from a Chylous Mes
enteric Cyst", The Journal of Laboratory, and Clinical Medicine,
Volume XXIII, March, 1938, page 596.

* C. F. Murbach, E. F. Lewison and G. A. Diebert : "Lymph
angioma of the Abdomen", The American Journal of Suraer-a,
Volume LXVIII, June, 1945, page 391.

(2 *&gt; J. M. Hill : "Mesenteric Chyladenectasis", The American
Journal of Pathology, Volume XIII, March, 1937, page 267

* L. Berger and R. E. Rothenberg : "Cysts of the Omentum,
Mesentery and Retro-Peritoneum", Surgery, Volume V April
1939, page 522.

*&gt; C. L. Hinkel : "Mesenteric Cysts : Their Roentgen Diag
nosis", The American Journal of Roentgenoloav Volume
XLVIII, August, 1942, page 167.

THE TREATMENT OF H^EMOPHILUS INFLUENZvE
MENINGITIS WITH SULPHONAMIDES IN CON
JUNCTION WITH H^EMOPHILUS INFLUENZA,
TYPE B, .RABBIT ANTISERUM.

By E. A. NQPTH, HAROLD WILSON and G. ANDERSON.

From the Commonwealth Serum Laboratories,
Melbourne.

OF the several forms of infectious meningitis in children,
that caused by Hcemophilus influenza is common and
deadly. In spite of the various papers which have
appeared on this disease, its importance does not seem to

be widely perceived, and so it may be desirable to mention
some points about it before discussing its treatment with
sulphonamides in conjunction with Hcemophilus influenza
rabbit antiserum, which is the subject of this report.

Frequency.

The frequency of Hatmophilus influenza* meningitis
among other kinds of infectious meningitis in children
at home and abroad may be gathered from Table I. It is
indistinguishable clinically from other kinds of infectious
meningitis. The diagnosis is reached as a result of
bacteriological examination of the cerebro-spinal fluid, and
there is reason to think that Hcemophilus influenza whe_n
present is not always identified. The disease may there
fore be commoner than is believed. Suggestions will be
made under the heading "Bacteriological Diagnosis" below,
which should help to obviate this error.

Age Incidence.

Hwmophilus influenza; meningitis is about three times
more frequent in children aged under two years than in
older children (Fothergill and Wright, 1933; Wilkes-Weiss
and Huntington, 1936). Of the 388 children who are
included in the present report, 68% were aged under two
years; the number within each year of age is shown in
the bottom line of Table II. The disease is rare in adults.

Mortality.

Alexander s (1943) estimate that, before the introduction
of specific treatment, 92% to 100% of affected children
died is supported by Neal et alii (1934), who reported that
four children (3-5%) had recovered out of 111 (all children
died out of 62 who were aged less than two years).
Alexander s estimate is also supported by Wilkes-Weiss and
Huntington (1936), who found among 500 reported cases
only nine recoveries out of 373 children aged under two
years (2-4% recovered), and 26 recoveries out of 127
aged over two years (20-5% recovered), and by Silverthorne
(1943), who reported one recovery among 70 cases. Knouf
et alii (1942), Neter (1942), and Johnson and Fousek
(1943) have reported that all the children in their smaller
series (19, 37 and 22 children respectively) died under
non-specific treatment. Aleman (1940) found that 15
children (3-2%) recovered out of 478, aged under two
years, whose cases were on record on were in her own
experience. In the present series two children (1-2%)
recovered out of 157 of all ages who received no specific
treatment (Table II); they were aged respectively between
two and three years and over four years. Children aged
twenty-five months or over numbered 50; of these, there
fore, 4-0% recovered.

In the case of children aged less than two years, death
is so common under expectant treatment that recovery of
even a few such children after other treatment may
reasonably be attributed to it.

Specific Treatment.

Pittman s (1930, 1931) differentiation of Hvmophilus
influenza; into six serological types, a to /, and her dis
covery that one type, type ft, is responsible for practically
all cases of meningitis, led to the preparation of type-
specific Hcemophilus influenza; horse antiserum. Unfor
tunately, the clinical results of its use either alone or
together with complement (Ward and Wright, 1932;
Wright and Ward, 1932; Ward and Fothergill, 1932;
Fothergill and Blackfan, 1935) or sulphonamides were
disappointing (Pittman, 1933, 1/18 j 1 Wilkes-Weiss and
Huntington, 1936, 1/19; Fothergill, 1937, 31/201; Lindsay
et alii, 1940, 9/37; Knouf et alii, 1942, 1/32; Silverthorne,
1943, 8/36).

Meanwhile, sulphonamides were found to inhibit the
growth of Hcemophilus influenza in vitro and in vivo
(Pittman, 1939, 1942; Alexander, 1943). Clinical reports

1 In fractions following authors names, the denominator
indicates the number of children treated, the numerator the
number that recovered.

216

THE MEDICAL JOURNAL OF AUSTRALIA.

FEBRUARY 16, 1946.

TABLE I.
Relative Frequencies of the Various Kinds of Infectious Meningitis in Children.

Number of Cases in which Organism was Isolated.

Source.

Tubercle
Bacillus.

Meningo-
coccus.

HcemopMus
influenzee.

Pneumo-
coccus.

Strepto
coccus.

Staphylo-
coccus.

Others.

Total.

Children s Hospital, Boston, 1920-1931 ;

Fotherglll and Sweet (1932)

290

160

705

Children s Hospital, Boston, 1933-1936 ;

Fothergill (1937)

221

Children s Hospital, Washington, D.C.

Lindsay, Rice and Sellnger (1940)

205

180

100

642

Bureau of Laboratories, Department of

Health, New York. Neal, Jackson and

Applebaum (1934)

961

1,216

111

209

203

2,727

Hospital for Sick Children, Toronto. Silver-

thorne (1943)

368

236

153

148

170

1,100

Royal Alexandra Hospital for Children,

Sydney, 1 1934-1944

120

291

118

744

By courtesy of the Medical Superintendent.

TABLE II.

The Numbers of Children According to Age who Received no Specific Treatment (up to 1937^ or who were Treated with
Sulphonamides (from 1937 Onwards), or with Sulphonamides in Conjunction with Hcemophihis Influenzas, Type B, Rabbit Anti-
serum (from 1943 Onivards), and the Numbers who Recovered.

Form of Treatment.

Age in Months.

All Ages.

to 12

13 to 24

25 to 36

37 to 48

49 and Over.

Total
Chil
dren
Treated.

Number
of
Re
coveries.

Per
centage.

Patients.

Re
coveries.

Patients.

Re
coveries.

Patients.

Re
coveries.

Patients.

Re
coveries.

Patients.

Re
coveries.

No specific treatment :
Royal Alexandra Hospital
for Children, Sydney 1 . .
Children s Hospital, Mel
bourne 1

26
30

30
22

11
11

8
4

9
6

84
73

1
1

Total

157

1-2

Sulphonamides :
Royal Alexandra Hospital
for Children, Sydney . .
Children s Hospital, Mel
bourne

27
24

3
1

22
24

5
4

8
6

4
1

15
3

8
1

86
64

Total

150

22-0

Sulphonamides and serum :
Royal Alexandra Hospital
for Children, Sydney . .
Children s Hospital, Mel
bourne . . . . . A
Other Australian Hospitals

14
19

3
10

16
4

10
3

10
1

8
1

4
1

25
17

Total

56-8

Total

144

119

388

1 From figures supplied by courtesy of the medical superintendents.

of its use covered 59 children, of whom 23 (38-9%)
recovered (Hamilton and Neff, 1939, 1/1; Sirlin and
London, 1940, 1/1; Jacoby, 1941, 1/1; Neter, 1942, 1/3;
Knouf et alii, 1942, 1/13; Sako et alii, 1942, 5/7; Davies,
1943, 4/20; Moir, 1943, 2/4; Hall and Spink, 1943, 2/2;
Silverthorne, 1943, 3/5; Cooperstock, 1944, 2/2). Unfor
tunately, with the exception of Davies s, these reports
referred only to single children or to small series of
children whose ages were not always given. In a disease
in which death under expectant treatment is usual, reports
of a new treatment, when based upon small numbers,
tend to comprise an unduly high proportion of recoveries;
success is more apt to be recorded than failure. Neverthe
less, children evidently were saved by Sulphonamides,
though a recovery rate so high as 38-9% should hardly
be expected in statistically adequate series comprising a
due proportion of younger in relation to older children.
Alexander et alii (1942) found that only 12% recovered
of 50 children recorded in the literature and from their
own experience. Aleman (1940) has reviewed the earlier
reports and found 10 patients (12-2%) recovered out of

82 treated with sulphanilamide and five recovered out of
18 treated with sulphapyridine.

Finally, Hcemophilus influenza rabbit antiserum was
introduced by Alexander (1939). In contrast to Hcemo-
philus influenzce horse antiserum, its efficacy in conjunction
with Sulphonamides was reported consistently (Neter,
1942, 4/7; Scott and Bruce, 1942, 1/1; Scully and Menten,
1942, 5/9; Grunthal and Winters, 1943, 2/2; Johnson and
Fousek, 1943, 17/20; Alexander, 1943, 57/75; Hall and
Spink, 1943, 2/2; Silverthorne, 1943, 3/10; Birdsong et
alii, 1944, 7/8; Boisvert et alii, 1944, 22/26; Nicholson,
1944, 2/4; Turner, 1945, 10/20). One hundred and thirty-
two children (71-7%) recovered out of the 184 comprised
in these reports, most of which are open to the criticisms
raised against similar meagre reports of the use of Sul
phonamides. They include, however, four less inadequate
series of 20 or more children, of whom 106 (75-2%)
recovered out of 141. Evidently further reduction in the
mortality rate followed the addition of Htemophilus
influenza? rabbit antiserum to Sulphonamides.

FEBRUARY 16, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

217

Penicillin is not efficacious in Hcemophilus influenzas
infections.

The Present Series.

The data relating to children in the present series who
received no specific treatment or who were treated with
sulphonamides were provided from the records of the
Children s Hospital, Melbourne, and of the Royal Alexandra
Hospital for Children, Sydney, by courtesy of the respec
tive medical superintendents. For generous cooperation
in supplying all information required for this report we
are grateful to them, and also to some fourteen physicians,
in the course of whose hospital or private practice in
various places children were treated by sulphonamides in
conjunction with Hcemophilus influenzas, type b, rabbit
antiserum.

The serum was prepared in rabbits at the Commonwealth
Serum Laboratories against strains of Hcemophilus
influenzce, type b, isolated from cerebro-spinal fluid. It was
treated to reduce its toxicity to human beings (Goodner
et alii, 1937), but it was not concentrated; it was estimated
to contain not less than one milligramme of antibody
nitrogen per mil (Alexander and Heidelberger, 1940) on
the basis of its precipitin titre and by mouse protection
tests (Seidman et alii, 1942). It was issued to any
physician who required it, who used it at his discretion;
it was thus submitted to a field trial in unselected patients
under ordinary conditions.

In Table II are shown respectively the numbers of
children according to age who received no specific treat
ment (up to 1937) or who were treated with sulphonamides
(from 1937 onwards) or with sulphonamides in conjunction
with Hcemophilus influenzce, type ft, rabbit antiserum (from
1943 onwards), and the numbers who recovered. The
independent results from the two widely separated hos
pitals are shown separately. All children are shown in
the table, including some who were moribund or were
already suffering from hydrocephalus when treatment was
begun; no one is omitted; the table therefore includes
the four children previously reported from the Children s
Hospital, Melbourne, by Nicholson (1944), and the 29
reported by Turner (1945).

Of 157 children who received no specific treatment, two
(1-2%) recovered. On the other hand, of 150 who were
treated with sulphonamides, 33 (22%) recovered, and of
81 who were treated with sulphonamides in conjunction
with Hcemophilus influenza:, type b, rabbit antiserum, 46
(56-8%) recovered. The improvement under treatment
with sulphonamides, and the further improvement under
treatment with sulphonamides in conjunction with rabbit
serum is obviously highly significant (P - 0-0000002).

Discussion.

Influence of Age on Prognosis.

The influence of age on prognosis in children who
received no specific treatment has been referred to under
the heading "Mortality" above. Under treatment with
sulphonamides and under treatment with sulphonamides
in conjunction with rabbit serum the recovery rate
improved with each year of age (Table II). The influence
of age on prognosis is more clearly shown in Table III,
in which the results of treatment with sulphonamides or
with sulphonamides in conjunction with rabbit serum are
arranged within the age groups from birth to twenty-four
months and twenty-five months or over. Under each plan
of treatment the recovery rate is higher in the higher
age group.

As is shown in the last column of Table III, there is a
highly significant difference in the survival rate among
children treated with sulphonamides and serum as com
pared with those treated with sulphonamides alone. The
significance in the under twenty-four months age group
is greater than in the higher age group, but this is because
the former group is the larger.

If one assumes that the data presented represent a fair
valuation of the efficacy of the two methods of treatment,
the addition of serum is capable of saving the lives of
about 30 out of 100 children whose ages vary from birth
to twenty-four months, of almost 50 out of 100 children
aged twenty-five months or over, and of 35 out of 100
children in both groups combined, all of whom would die
if treated with sulphonamides alone.

A difference is noticeable in the results obtained in the
two hospitals in children aged twenty-five months or more
who were treated with sulphonamides. This is the only
difference of any significance (P lies between 0-02 and
0-05) noticeable in the results obtained in the two hos
pitals; in all other groups their results were similar.
It seems to provide a further example of the better
prognosis in older as compared with younger children,
since it is probably to be explained, at least in part, by
the preponderance in the Sydney group as compared with
the Melbourne group of children who were aged forty-
nine months or over (Table II) 15 out of 37 in Sydney
as compared with three out of 16 in Melbourne.

Principles and Practice of Treatment.

The disease, though usually fatal, varies much in inten
sity. It may progress slowly for weeks or appear so
suddenly (Hertzog et alii, 1944) as to give little oppor
tunity for treatment.

Experimental and clinical evidence suggests that, though
sulphonamides inhibit Hcemophilus influenzcr, recovery

TABLE III.

The Numbers of Children who were Treated with Sulphonamides or with Sulphonamide.s in Conjunction with Hcemophttus influenzce, Type B, Rabbit Antuerum,
and the Numbers who Recovered within the Age-Groups to 24 Months and 25 Months and Over.

Sulphonamides.

Sulphonamides and Serum.

Royal

Alexandra

Hospital

Children s

Total

Hospital

Children s

Other

Total

for

Hospital,

Number of

for

Hospital,

Australian

Number of

ge in
onths.

Children,
Sydney.

Melbourne.

Total
Number of

Recoveries.

Children,
Sydney.

Melbourne.

Hospitals.

Total
Number of

Recoveries.

Probability
Factor

Patients

(P). 1

Treated.

Patients

Re
coveries

Patients

Re
coveries

Number

.1
1

Patients

Re
coveries.

Patients

Re
coveries

Patients

Number

24 ..

13 -4

44-8

0-00002

d over

, 37

37-7

86-9

0-00007

Potal . .

150

3:5

22-0

56-8

0-0000002

1 When P = 0-01, the odds are one in 100 that the difference in results (whatever that may be) is due to chance. Values of 0-05 or less are here regarded
statistically significant, and values of 005 or less as highly significant.

218

THE MEDICAL JOURNAL OP AUSTRALIA.

FEBRUARY 16, 1946.

depends essentially upon immunity, that is, domination of
antibody over antigen. The antibody is either produced
naturally or injected therapeutically. The principle of
treatment, therefore, as recognized by Alexander and her
associates (1942, 1943) is to inhibit invasion by means of
one of the sulphonamides until a bacteriological diagnosis
has been reached and specific antibody can be injected
sufficient to reinforce whatever natural antibody may be
produced.

For a discussion of the principles and practice of
modern treatment, the reader is referred to the papers
just mentioned, on which many of the following remarks
are based. Alexander attributes any improvement in her
results which may have occurred since the experimental
year 1938-1939 chiefly to careful control of the concentra
tion of sulphonamide and antibody in the patient s blood.

The dose of serum, which is expressed in milligrammes
of antibody nitrogen, should correspond to the severity
of the infection as judged by the glucose content of the
cerebro-spinal fluid or by the concentration of specific
polysaccharide (antigen) in the body fluids. Alexander
gives a good rough-and-ready method of estimating the
glucose content of the cerebro-spinal fluid for this purpose:
to one mil of Benedict s solution in each of five test tubes
are added fbe quantities of cerebro-spinal fluid shown in
Table IV, the concentration of glucose in the cerebro-
spinal fluid being estimated according to the volume of
fluid required to reduce the Benedict s solution.

TABLE IV.

A Qitalitative Test for Estimating the Amount of Sugar in Cerebro-Spinal Fluid
in Milligrammes per Centum. (Alexander et alii, 1942 : Alexander, 1943.)

Mil of

Tube

Cerebro-

Reduction of Benedict s

Number.

Spinal

Solution (1-0 Mil).

Fluid.

0-05

O 1

0-1

-(-

III

0-15

+ : +

0-2 1 + i +

0-25

-f

Milligrammes per centum of sugar

Over

40 to

30 to

20 to

10 to

1 "+" = Reduction of Benedict s solution; "0" = no reduction of
Benedict s solution.

The concentration of specific polysaccharide (precipi-
tinogen) is estimated by observing the time taken for the
precipitate to appear when cerebro-spinal fluid, clarified
if necessary by centrifugation, is carefully layered over
Haimophilus influenza antiserum in a test tube of small
(three to five millimetre) calibre; its appearance within
ten minutes is held by Alexander to indicate severe infec
tion requiring a correspondingly large dose of serum.
Alexander s schedule of doses in relation to the glucose
content of the cerebro-spinal fluid is as follows:

Spinal-Fluid Sugar, Mg.
per 100 c.c.

&lt; 15
15 to 25
25 to 40
Over 40

Antibody Nitrogen Indicated,

Mg.

100

In the present series most of the children who recovered
after intravenous injection of the serum were given from
30 to 180 mils, the average total amount being about 130
mils, which was rarely given in more than two doses.
As has already been mentioned, the serum was not
concentrated.

On the other hand, the seven infants aged under two
years (average, eleven months) who recovered after intra
muscular administration of serum (see Table V) received
an average total dose of 90 mils (minimum 30 mils, maxi
mum 120 mils), the greatest amount given at any one time
being 60 mils (to three patients).

Twelve hours after injection of the serum, which
Alexander recommends should be given intravenously

along with continuous infusion of glucose solution, tests
are applied to ascertain whether its dose was sufficient to
ensure circulation of free antibody. During the first week
enough free antibody should be present in the patient s
serum, when this is diluted 1 in 10 and added to a sus
pension of Ha mophilus influenza , to cause capsular
swelling. Organisms present in the cerebro-spinal fluid
(in which they may be preserved by the addition of
formalin, 0-4%), if numerous enough, may be used for this
purpose, or a young four to six hours culture in Levinthal
broth can be used if organisms are not available in suf
ficient numbers in the cerebro-spinal fluid. We have
had little experience of this use of the Quellung reaction,
but we believe that in hands less practised than those
of Alexander and her colleagues it may be misleading.
At the Children s Hospital, Melbourne, before the decision
is made to give a further dose of serum, lumbar puncture
is generally performed and attention is paid among other
signs to the glucose content of the cerebro-spinal fluid;
a low glucose content suggests that a further dose of
serum is necessary.

Boisvert et alii (1944) report that they have injected
the serum intramuscularly into five children, four of whom,
all aged less than twenty-one months, recovered. In the
present series the numbers within the age groups from
birth to twenty-four months and twenty-five months or
over who were given the serum intravenously, intra
muscularly or by both routes are shown in Table V, in
which the better recovery rate after intramuscular injec
tion in the age group from birth to twenty-four months
is significant (P = 0-033). It may be thought that the
serum was given intramuscularly to such children as
were not acutely ill,. and that it was given intravenously
to those who were acutely or desperately ill. The clinical
histories do not suggest that this was so; the disease
was described by physicians as severe in six of the seven
children who recovered in the age group from birth to
twenty-four months. No fixed rule can be formed on the
evidence available. To some children it would seem
imperative to give the serum intravenously. To others a
delay of four to six hours before maximum concentration
of circulating antibody is reached would not seem 4o be
of crucial importance. It may well be that an initial
dose of serum intravenously followed up by a further
amount intramuscularly will be found the most generally
efficacious. Intrathecal injection of the serum is not
recommended.

Alexander attributes the disappointing results of treat
ment in infants, particularly those aged under seven
months, to late diagnosis. Meningitis is harder to recog
nize early in infants tkan in older children whose calvaria
are rigid, and the physician may be reluctant to submit
to lumbar puncture a baby who shows none of the text
book signs of meningitis. It is probably noteworthy, too,
that the blood of young children after the age of two
months lacks bactericidal power against Hamophilus
influenza , which is not usually demonstrable until after
the third year (Fothergill and Wright, 1933). To judge
from the well-known difficulty of immunizing young
children, such natural antibody is not readily provoked
in young children in response to infection. The delay
in beginning specific treatment which results from late
diagnosis may well be more dangerous therefore to young
than to older children. -

Bacteriological Diagnosis.

The following suggestions are put forward, "especially
for those in remote country districts, in the hope that
they will facilitate the rapid identification of Ha mophilus
influenza , type b.

As soon as meningitis is suspected, one of the sulphon
amides should be given, lumbar puncture should be per
formed, and a Gram-stained smear should be prepared
from a portion of the centrifuged deposit of cerebro-spinal
fluid. If small Gram-negative rods or cocco-bacilli are
found, a presumptive diagnosis of influenzal meningitis
may be made and serum given. The identity of the
organism may be tested by the Quellung reaction, although

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THE MEDICAL JOURNAL OF AUSTRALIA.

219

TABLE V.

The Number of Children Treated with Sulphonamides in Conjunction with Hcemophilus influenza;, Type B, Rabbit Antiserum, into Whom the Serum was Injected
Intravenously or Intramuscularly or by Both Routes, and the Numbers who Recovered tvithin the Age-groups to 24 Months and 25 Months and Over.

Age in Months.

Intravenous Administration.

Intramuscular Administration.

Both Intravenous and
Intramuscular Administration.

Probability Factor :
Intramuscular versus
Intravenous
Administration.

Patients.

Recoveries.

Patients.

Recoveries.

Patients.

Recoveries.

to 24 . . . . 45
25 and over . . . . 17

17
15

2 0-038
2 0-5

to 2
25 and

over

17
15

7
8

4 2 0-033
2 2 0-5

Total

0-063

this is not advised in the. case of those without experience
of the technique.

The diagnosis may be confirmed within a few minutes
in severe cases by the carrying out of a precipitin test
on the clear supernatant fluid (Fothergill, 1937), as
described above. Failure to elicit this reaction does not,
however, exclude influenzal meningitis, and an attempt
should always be made to grow the organisms from the
remainder of the centrifuged deposit.

The only easily prepared medium on which Hemophilus
influenza; grows freely is chocolate (cooked blood) agar
(it grows very poorly on blood agar and ascitic agar).
Chocolate agar, when prepared as follows, gives an early
and abundant growth. Two mils of red blood cells from
defibrinated horse blood (after the supernatant serum
has been decanted) are added to 15 mils of melted nutrient
agar at 56 C. and mixed, and the whole is heated for
ten minutes at 78 C. The medium is then poured into
plates and allowed to cool before it is inoculated from
the remaining portion of the centrifuged deposit. If
growth occurs, there is sufficient within twenty-four hours
on which to carry out confirmatory tests, or the culture
may be forwarded to a bacteriological laboratory for
identification.

Three points are worth remembering: firstly, Ha mo-
philus influenza is a common cause of meningitis in young
children, and influenzal meningitis is almost invariably
associated with one serological type, type 6; secondly,
Hwmophilus influenzw will not grow freely on any of the
more commonly used media except chocolate agar; and
thirdly, although it grows luxuriantly on this medium, it
will die within perhaps four days or so if not sub-cultured.

In such a grievous disease as Ha mophilus influenza
meningitis, even the moderate success here recorded is
heartening. It should encourage the physician to continue
treatment with one of the sulphonamides, which was
probably begun on first suspicion of infection, and urgently
to seek a bacteriological diagnosis in order that he may
immediately reinforce whatever natural antibody may be
present by injecting specific artificial antibody contained
in rabbit serum.

Summary.

1. Hwmophilus influenza meningitis is usually third to
tuberculous and meningococcal meningitis among other
kinds of infectious meningitis in children. It is about
three times more frequent in children aged under two
years than in older children. It is rare in adults. Nearly
all children aged under two years who receive no specific
treatment die; a few older children recover (in the present
series 4% aged over two years). Practically all cases are
due to one serological type of Hcemophilus influenza ,
type b.

2. Of 157 children of all ages who received no specific
treatment, two (1-2%) recovered; of 150 who were treated
with sulphonamides, 32 (22-0%) recovered); of 81 who
were treated with sulphonamides in conjunction with
Hamophilus influenza , type &, rabbit antiserum, 46
(56-8%) recovered.

3. Recovery under treatment was more frequent with
each year of age. The worse prognosis in very young
children was probably due to delay in the commencement
of specific treatment resulting from late diagnosis, in
consequence of the difficulty of recognizing meningitis
early in very young children without resorting to lumbar
puncture. It was possibly due also to the absence of
natural antibody from the blood of young children and
to their relatively poor immune response to infection.

4. One of the sulphonamides should be given. A bacterio
logical diagnosis should be urgently sought, and specific
antibody contained in rabbit serum should be injected
immediately the diagnosis is reached.

Acknowledgements.

Our indebtedness to members of the staff of different
hospitals, both honorary physicians and other workers,
has already been acknowledged in the text. We also wish
to acknowledge the advice and help of Mr. J. J. Graydon,
M.Sc., of these laboratories, particularly in assessing the
statistical values of the results obtained. Finally, we
desire to record our appreciation of the skill and
enthusiasm of members of the staff of these laboratories,
particularly of Mrs. M. Green and Miss O. Coe, without
whose wholehearted cooperation sufficient serum for these
clinical trials could not have been produced.

Bibliography.

R. Airman : "Influenzal Meningitis", New Orleans Medical
ana Surgical Journal. Volume XCIII, July, 1940, page 25.

H. E. Alexander: "Type B Anti-Influenzal Rabbit Serum for
Iherapeutic Purposes", Proceedings of the Society for Experi
mental Biology and Medicine. Volume XL, February, 1939 page
"Experimental Basis for Treatment of Hemophilus
inriuenzae Infections", American Journal of Diseases of Children
Volume LXVI, August, 1943, page 160; "Treatment of Hemo-
pniius Influenzse Infections and of Meningococcic and Pneumo-
coccic Meningitis", American Journal of Diseases of Children,
Volume LXVI, August, 1943, page 172.

H. E. Alexander, C. Ellis and G. Leidy : "Treatment of Type
bpecific Hemophilus Influenza; Infections in Infancy and Child
hood , The Journal of Pediatrics. Volume XX, June, 1942, page
673.

H E. Alexander and M. Heidelberger : "Chemical Studies on
Bacterial Agglutination: V. Agglutinin and Precipitin Content
of Antisera to Hemophilus Influenzas, Type B", The Journal of
Experimental Medicine. Volume LXXI, January, 1940, page 1.

McL. Birdsong, W. W. Waddell and B. W. Whitehead
Influenzal Meningitis". American Journal of Diseases of
Children. Volume LXVII, March, 1944, page 194.

P. L. Boisvert, M. D. Fousek and M. F. Grossman "Intra
muscular Administration of Anti-Hemophilus Influenzse Type b
Rabbit Serum : Report of its Use in Three Cases of Influenzal
Meningitis", The Journal of the American Medical Association
Volume CXXIV, January 22, 1944, page 220.

M. Cooperstock: "Influenzal Meningitis in Siblings", imerican
Journal of Diseases of Children. Volume LXV11I, October 1944
page 269.

J. N&gt; P. Davies : "Pfeiffer s Bacillus Meningitis. Response to
Chemotherapy", The Lancet, Volume I, May 1, 1943, page 553.

Le R. D. Fothergill: "Hemophilus Influenzse (Pfeiffer Bacillus)
Meningitis and its Specific Treatment", The New England
Journal of Medicine. Volume CCXVI, April 8, 1937, page 587.

Le R. D. Fothergill and K. D. Blackfan : "Complement in the
Serum Treatment of Meningococcus Meningiis", The Journal of
Pediatrics. Volume VII, 1935, page 731.

Le R. D. Fothergill and L. K. Sweet : "Meningitis in Infants
and Children, with Special Reference to Age-Incidence and
Bacteriological Diagnosis", The Journal of Pediatrics Volume
II, 1932, page 696.

220

THE MEDICAL JOURNAL OF AUSTRALIA.

FEBRUARY 16, 1946.

Le R. D. Fothergill and J. Wright : "Influenzal Meningitis.
The Relation of Age Incidence to the Bactericidal Power of
the Blood against the Causal Organism", The Journal of
Immunology, Volume XXIV, April, 1933, page 273.

K. Goodner, F. L. Horsfall and R. J. Dubos : "Type-Specific
Antipneumococcus Rabbit Serum for Therapeutic Purposes ; Pro
duction, Processing and Standardization", The Journal of
Immunology, Volume XXXIII, October, 1937, page 279.

R. M. Greenthal and K. J. Winters : "Influenzal Meningitis :
Report of Two Cases", Archives of Pediatrics, Volume LX,
February, 1943, page 69.

W. H. Hall and W. W. Spink : "Sulfamerazine : Clinical
Evaluation in 116 Cases", The Journal of the American Medical
Association, Volume CXXIII, September 18, 1943, page 125.

T. R. Hamilton and F. C. Neff : "Influenzal Meningitis with
Bacteremia Treated with Sulfapyridine : Recovery", The Journal
of the American Medical Association. Volume CXIII, September
16, 1939, page 1123.

A. J. Hertzog, I. L. Cameron and A. E. Karlstrom : "Influenzal
Meningitis in Brothers", The Journal of the American Medical
Association, Volume CXXIV, February 19, 1944, page 502.

N. M. Jacoby : "Pfeiffer s Bacillus Meningitis : Recovery with
Chemotherapy", The Lancet, Volume II, December 20, 1941,
page 753.

R. D. Johnson and M. D. Fousek : "A Study of the Spread of
H. Influenzas, Type B", The Journal of Bacteriology, Volume
XLV, February, 1943, page 197.

E. G. Knouf, W. J. Mitchell and P. M. Hamilton : "Survey of
Influenzal Meningitis over a Ten-Year Period (1931-41)", The
Journal of the American Medical Association, Volume CXIX,
June 27, 1942, page 687.

J. W. Lindsay, E. C. Rice and M. A. Selinger : "The Treatment
of Meningitis due to Hemophilus Influenzas (Pfeiffer s Bacillus)",
The Journal of Pediatrics, Volume XVII, August, 1940, page 220.

R. A. Moir : "Response of Pfeiffer s Bacillus Meningitis to
Sulphapyridine", The Lancet. Volume I, May 1, 1943, page 556.

J. B. Neal, H. W. Jackson and E. Applebaum : "Meningitis
due to the Influenza Bacillus of Pfeiffer (Hemophilus
Influenzas) : Study of 1 1 1 Cases with 4 Recoveries", The Journal
of the American Medical Association, Volume CII, February 17,
1934, page 513.

E. Neter : "Observations on Hemophilus Influenzas (Type B)
Meningitis of Children", The Journal of Pediatrics, Volume XX,
June, 1942, page 699.

A. G. Nicholson : "Meningitis due to Hasmophilus Influenzas :
Review of Treatment", THE MEDICAL JOURNAL, OF AUSTRALIA,
Volume I, April 8, 1944, page 320.

M. Pittman : "The S and R Forms of Hasmophilus
Influenzas", Proceedings of the Society for Experimental Biology
and Medicine, Volume XXVII, 1930, page 299 ; "Variation and
Type Specificity in the Bacterial Species Hsemophilus Influenzas",
The Journal of Experimental Medicine, Volume LIII, April, 1931,
page 471 ; "The Action of Type-Specific Hasmophilus Influenzas
Antiserum", The Journal of Experimental Medicine, Volume
LVIII, December, 1933, page 683 ; "The Protection of Mice
against Hemophilus Influenzas (Non-Type-Specific) with Sulfa
pyridine", Public Health Reports, Volume LIV, September 29,
1939, page 1769 ; "Antibacterial Action of Several Sulfonamide
Compounds on Hemophilus Influenzas, Type B" Public Health
Reports, Volume LVII, December 11, 1942, page 1899.

W. Sako, C. A. Stewart and J. Fleet: "Treatment of Influenzal
Meningitis with Sulfadiazine : Preliminary Report", The Journal
of the American Medical Association, Volume CXIX, May 23,
1942, page 327.

E. P. Scott and J. W. Bruce : "Influenzal Meningitis : Report
of a Case with Recovery", The Journal of Pediatrics, Volume
XX, April, 1942, page 499.

J. P. Scully and M. L. Menten : "Treatment of Influenzal
Meningitis with Anti-Influenzal Rabbit Serum and Sulfapyri
dine", The Journal of Pediatrics, Volume XXI, August, 1942,
page 198.

L. R. Seidman, J. H. Dingle and L. D. Fothergill : "The Identi
fication of Precipitin with Mouse-Protective Antibody with
Reference to the Evaluation of Anti-H. Influenzas Sera", The
Journal of Bacteriology, Volume XLIII, January, 1942, page 97.

N. Silverthorne : "Meningitis in Childhood", The Canadian
Medical Association Journal, Volume XLVIII, March, 1943,
page 218.

E. M. Sirlin and A. H. London : "Influenzal Meningitis : Case
Report", The Journal of Pediatrics, Volume XVII, August, 1940,
page 228.

E. K. Turner : "A Further Report on the Treatment at the
Children s Hospital, Melbourne, of Influenzal Meningitis with
Sulphonamides and Type-Specific Serum", THE MEDICAL JOURNAL
OF AUSTRALIA, Volume I, March 3, 1945, page 219.

H. K. Ward and Le R. D. Fothergill : "Influenzal Meningitis
Treated with Specific Antiserum a,nd Complement : Report of
5 Cases", American Journal of Diseases of Children. Volume
XLIII, April, 1932, page 873.

H. K. Ward and J. Wright : "Studies on Influenzal Meningitis :
I. The Problems of Specific Therapy", The Journal of Experi
mental Medicine, Volume LV, February, 1932, page 223.

D. Wilkes-Weiss and R. W. Huntington : "The Treatment of
Influenzal Meningitis with Immune Serum", The Journal of
Pediatrics, Volume IX, October, 1936, page 462.

J. Wright and H. K. Ward: "Studies on Influenzal Menin
gitis : II. The Problem of Virulence and Resistance", The Journal
of Experimental Medicine, Volume LV, February, 1932, page 235.

A REPORT ON SIXTEEN CASES OF SUPRAGLOTTIC
(EDEMA.

By H.

Queen s Memorial Infectious Diseases Hospital,
Fairfield, Victoria.

In 1941, Sinclair described ten cases of acute laryngitis
caused by Hasmophilus influenza- and associated with bac-
terisemia. In 1943, du Bois and C. Anderson Aldrich (2)
reported four similar cases. It is the purpose of this
paper to describe sixteen cases occurring at the Queen s
Memorial Infectious Diseases Hospital, Fairfield, over a
period of eighteen months during 1944 and 1945, the
general clinical picture of which was similar to that
described by the above writers. There were, however,
certain variations to which reference will be made.

Fifteen of the patients were children, the youngest being
aged two years and the oldest ten years. The remaining
patient was an adult male, aged thirty-three years. There
were two deaths, one of which occurred in the ambulance
while the patient was on the way to hospital. All patients
except one were examined within twelve hours of the
onset of illness, and all were seriously ill with signs of
severe respiratory obstruction. In nine instances trache
otomy was necessary, and in three a complicating purulent
meningitis developed after a short interval.

The main clinical features were as follows.

1. There was a sudden onset of difficult, obstructed
breathing in a previously well child. Grave symptoms
developed within a few hours of the onset. There appeared
to be no doubt that, in the cases at present under review,
the obstruction was supraglottic and not subglottic, and
was caused solely by enormous swelling of the epiglottis
and aryepiglottic folds. This swelling was so great as to
reduce the glottic opening to a narrow slit. There was no
true laryngeal stridor, the voice was not hoarse, and the
cough wheh present was not croupy. Both inspiration and
expiration were difficult; but the expiratory obstruction
appeared to be the greater. Expiration was always accom
panied by a sound like a deep-seated snore. It was present
in all cases and was considered to be a sign of great value
in the diagnosis.

2. Prostration was always a prominent feature. Sinclair
described the condition as "shock" for want -of a better
word. He makes the following statement: "This appear
ance of shock seemed out of all proportion to the relatively
short duration of the obstructive symptoms." A recent
article suggests an explanation for this prostration.
Saphir reports five fatal cases of laryngeal oedema in
which acute myocarditis was found at autopsy.

3. The swollen, hard epiglottis and aryepiglottic folds
could be easily palpated by passing a finger down the
throat. Direct laryngoscopy was never necessary to con
firm the diagnosis.

The history of a typical case is as follows:

A boy, L.H., aged four years, was admitted to hospital
with a history of difficult breathing of three hours duration.
Other members of the household had suffered colds, but
this child had been well prior to the attack. No previous
attacks of asthma or other allergic signs had been noted.

On his admission to hospital, the child was pale and list
less. A prpnounced expiratory snore was noted. The voice
was not hoarse, but it had a slightly "strangled" character.
There was a slight cough, but it was not croupy. The throat
was reddened, but the fauces were not swollen. A view
of the swollen and congested epiglottis could be obtained
by the use of the tongue depressor, and the diagnosis was
confirmed by digital examination.. Two hours after his
admission to hospital that is, five hours after the onset
prostration became more marked, pallor had increased and
slight cyanosis of the lips was evident. Tracheotomy was
performed under local anaesthesia. During the operation
respiration ceased, necessitating hurried opening of the
trachea and artificial respiration. A small amount of muco-
purulent secretion was then expelled. The epithelial surface

FEBRUARY 16, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

221

of the trachea appeared normal. Breathing Vas vgreatly
relieved and the colour improved. Prostration persisted for
twenty-four hours, and the child was disinclined to swallow
fluids. His temperature on admission to hospital was 103 F.
This subsided gradually, but did not return to normal for
seven days. By the fourth day the oeaema of the epiglottis
had subsided sufficiently to permit removal of the trache
otomy tube. Recovery was then uneventful.

The only adult patient, a man, aged thirty-three years,
was able to give a clear account of the symptoms of onset.

At the evening meal he noticed some pain on swallowing.
His own^description was that there was a painful lump in
the middle of the throat. This appeared to become larger
;ind more painful during the evening until it affected his
breathing. He spent a restless , night and at times became
very distressed. He was admitted to hospital early the
next morning. The clinical picture was typical, but pain
was a more prominent feature and prostration was not so
pronounced as in the case previously described. The cervical
glands were tender, and "some oedema of the tissues
of the neck was present. He survived the dangerous period
without operative interference and made an uneventful
recovery.

Complications.

Three children developed purulent meningitis after the
initial symptoms of obstruction had been relieved. In the
first case meningitis was not diagnosed until fourteen
days after the onset of illness, although indefinite menin-
geal symptoms appeared some days earlier. The second
case of meningitis was diagnosed ten days and the third
seven days after the onset of the obstructive symptoms.

Bacteriology.

Jackson " has described a condition called angioneurotic
oedema of the glottis, in which the epiglottis is similarly
swollen and cedematous. However, the absence of any
previous allergic signs and the lack of response to adrena
line would appear to make this an unlikely explanation.
The writers previously mentioned*" &lt;2) have shown that
the causative organism was Hatmophilus influenza in the
cases reported by them. The positive cultural findings in
the blood would appear to be an adequate explanation of
the prostration which occurred.

It must be admitted that the bacteriological findings in
the present series have not been so happy or conclusive.
At the time when most of these cases were investigated
the literature on the subjct was not known, and no special
effort was made to cultivate Hatmophilus influenza* either
from the throat or from the blood. Even after the finding
of this organism in the cerebro-spinal fluid in two cases,
it was thought that it was probably a secondary invader
becoming active after the primary lesion.

Cultural examination of throat swabbings as a rule
produced a growth of normal inhabitants of the respiratory
tract, namely, green streptococci, Gram-negative diplococci
and occasionally staphylococci. Swabs of throats were
investigated by two other laboratories independently, with
similar inconclusive results. An attempt to isolate a
virus was also unsuccessful.

However, in view of the conclusive findings of the
writers previously mentioned, and of the similarity of
the clinical picture, it is reasonable to suggest that
Hcemophilus influenza was associated with the condition.
This opinion is strengthened by the fact that two of the
three cases of meningitis which developed were due to
Ha-mophilus influenza: Type B. In the third case a profuse
growth of pneumobacillus of Friedlander was obtained
from the throat, the trachea and the cerebro-spinal fluid.
There may be still some doubt, of course, whether this
was the primary cause of the original lesion.

Differential Diagnosis.

All sixteen patients were admitted to hospital with the
provisional diagnosis of laryngeal diphtheria. To those
accustomed to dealing with this disease the difference is
obvious. The dramatic suddenness of the onset, the
absence of true laryngeal signs and the absence of mem
brane are important points.

The condition known as laryngo-tracheo-bronchitis may
present some difficulty. In this disease, which is frequently
staphylococcal in origin, the onset may be rapid; but the
obstruction is subglottic and due to thick, tenacious mucus
in the larynx and trachea. There is no swelling of the
epiglottis. Cases of asthma should not present any trouble,
but retropharyngeal abscess may be difficult to exclude
until a complete examination is made.

Confirmation of the diagnosis of oedema of the supra-
glottic region can be made with certainty either by direct
vision or by digital examination. The latter method is to
be preferred as being more rapid and certain and less
distressing to the patient.

Treatment.

Tracheotomy was shown to be a life-saving operation in
this condition. Intubation with O Dwyer s tubes was
attempted in a few early cases, but was never successful.
It was performed with great difficulty owing to the
narrowed glottic opening, and when it was accomplished
the swollen epiglottis closed over the top of the tube.
Indications for tracheotomy were obvious distress, prostra
tion, pallor or cyanosis. So long as the colour remained
good and the child appeared to have plenty of fight,
tracheotomy was deferred. At the first sign of change of
colour or development of signs of exhaustion, operation
was performed without delay. The operation presented
no special difficulty if carried out early, but if it was
delayed until prostration had become severe, collapse was
likely to occur during the operation. Speed was then
essential. One patient died after operation as the result
of an incompletely controlled haemorrhage into the trachea.
As a rule the post-operative management was not difficult.
Unless the wound became infected there was little dis
charge from the tube. In this regard the nursing was
much simpler than in laryngo-tracheo-bronchitis or laryn
geal diphtheria, in which blockage of the tube is frequent.
The average time for retention of the tube was five days;
but in no case was it more than a week. The wound
always healed readily.

Sulphonamides were given in every case, in the form of
sulphathiazole, sulphadiazine or sulphamerazine. Peni
cillin was also used in some cases, but as the probable
organism is penicillin-resistant, it is doubtful whether
this measure played any useful part in the treatment.

All patients were treated in a steam tent before and
after operation, and oxygen was used freely.

Most patients developed some degree of anaemia before
recovery was complete; but transfusion was necessary in
only one case. This was in the case of the child who
developed meningitis due to Friendlander s bacillus, an
infection which was controlled only after two prolonged
courses of sulphadiazine.

Hcemophilus influenza rabbit antiserum was used only
in the three cases in which meningitis developed. It was
undoubtedly a factor in the patients subsequent recovery.
Whether its use early in the disease would have accelerated
the recovery of the other patients or pi-evented the onset
of meningitis is still open to doubt.

Summary. .

Sixteen patients were admitted to the hospital over a
period of eighteen months with a condition of cedema of
the supraglottic region particularly affecting the epiglottis
and the aryepiglottic folds. The clinical picture was one
of severe prostration and rapidly developing respiratory
obstruction caused by partial occlusion of the glottic
opening. There were two deaths, one of which occurred
in the ambulance before the patient s admission to
hospital.

In nine cases tracheotomy was necessary. This is con
sidered to be a life-saving operation in this condition, and
the importance of its early performance is stressed.

The role of Hcemophilus influenza- as the causative
organism is discussed.

Purulent meningitis is a possible complication of the
condition.

222

THE MEDICAL JOURNAL OF AUSTRALIA.

FEBRUARY 16, 1946.

References.

U) S. E. Sinclair : "Hasmophilus Influenza Type B in Acute
Laryngitis with Bacteremia", The Journal of the American
Medical Association, Volume CXVII, 1941, page 170.

&lt;a) P. G. du Bois and C. A. Aldrich : "Haemophilus Influenza
Type B Laryngitis with Bacteremia ; Report of Four Cases",
Journal of Pediatrics, Volume XXIII, 1943, page 184.

&lt;3) O. Saphir : "Laryngeal Edema, Myocarditis and Unexpected
Death (Early Acute Laryngotracheobronchitis)", The American
Journal of the Medical Sciences. Volume CCX, September, 1945,
page 296.

(4) C. Jackson and C. L. Jackson : "Diseases and Injuries of
the Larynx", Second Edition, 1942, page 82.

THE STUDY OF THE HUMAN BODY AFTER DEATH. 1

By KEITH INGLIS, M.D.,
From the Department of Pathology, University of Sydney.

"MEN fear death as children fear to go in the dark", said
Francis Bacon, and added: "It is as natural to die as to
be born."

Throughout history study of the human body after death
has been hampered by superstition a"nd religious prejudice.
This study has two main purposes: (i) anatomical, (ii)
pathological. Knowledge of the normal anatomical struc
ture of the body is an essential background for medical
practice; knowledge of alterations wrought by disease is
essential not only to establish the cause of death, but also
for an understanding of the processes of disease in general.

Chronologically considerations of anatomy preceded those
of pathology. In the time of Hippocrates (460 to 370 B.C.),
anatomical knowledge was mainly gained from the dismem
berment of animals slaughtered for sacrifices, and Aristotle
(384 to 322 B.C.), a pupil of Plato, taught anatomy by the
dissection of animals.

Dissection of the human body was first conducted on a
fairy large scale at Alexandria in about 300 B.C. Three
factors helped to establish anatomy as an independent
science in Alexandria namely, the practice of embalming
the body, a lessening of religious prejudice, and the
encouragement of the Ptolemies.

Galen (131 to 201 A.D.) followed the traditions of the
Alexandrians, but he had not their opportunities of dis
secting the human body. A long period of darkness
followed Galen, and though there were occasional flashes
of light, it was not until the time of Vesalius (1514 to
1564) that anatomy in the modern sense came to be
revealed. Vesalius had difficulty in obtaining bodies for
study, and it has been said that he secured his first human
skeleton by stealing the remains of a hanged and roasted
thief, outside the walls of Louvain (Ball).

When today you cross the Arno by the Ponte Vecchio
and enter the heart of Florence, where the "David" of
Michelangelo (1475 to 1564) is on one side and the
"Perseus" of Cellini (1500 to 1571) on the other, you feel
that you are in the atmosphere of the famous Florentine
artist anatomists. Leonardo da Vinci (1452 to 1519) and
Michelangelo did much of their dissecting in Florence and
were among the artists who put new life into the study
of anatomy.

Late in the sixteenth century, and at the commencement
of the seventeenth, Fabricius (1537 to 1619) worked and
taught at Padua, where Harvey was a pupil (1599 to 1603).
During the eighteenth century an important factor in
the advance of medicine was the presence in Great Britain
of private schools of anatomy and surgery, especially that
in Great Windmill Street, where William Hunter and John
Hunter worked and taught anatomy, pathology and
surgery.. In the early nineteenth century the activities of
the resurrectionists, especially in Edinburgh, became a
matter of grave public concern, culminating in the
murders committed by Burke and Hare. Burke at his

1 Read at the annual meeting of the Section of Neurology,
Psychiatry and Neurosurgery of the New South Wales Branch
of the British Medical Association on December 6, 1945.

trial was found guilty and addressed by the Lord Justice-
Clerk as follows:

Your sentence shall be put into execution in the usual
way, but accompanied with the statutory attendant of
the punishment of the crime of murder, viz., that your
body should be publicly dissected and anatomized.

In pursuance of the sentence of the court, Alexander
Monro Tertius publicly dissected the body, and the follow
ing day not less than 25,000 persons viewed the remains of
the murderer (Ball). In 1832 the Anatomy Act was passed,
and body-snatching became a thing of the past. The act
repealed the direction that the bodies of murderers should
be dissected (Goodman).

An interesting historical review relating to "the supply
of bodies for dissection" is presented by Goodman in the
Arris and Gale Lecture (1944). Goodman discusses recent
trends, the present position and the prospects for the future
in Great Britain. In regard t&lt;T-the causes of diminution in
supply he makes the following statement:

The long-term cause which has been operating with
gradually increasing- force over the past 100 years is, of
course, the improvement in the social and financial
position of the poorest classes. Improvements in real
wages, social legislation, and philanthropic efforts have
all played their part, and there is little reason to expect
that this process will not continue indeed, certain
aspects of social legislation "already adopted in principle
by the Government may be expected to have most
important effects on supplies.

The same holds true for Australia, and unless some
radical change is effected, the present lamentable situation
with its inevitable lowering in standards of medical
knowledge will become even worse than it is now. In my
opinion the way to meet the situation is by educating
public opinion along the right lines. I have great confi
dence in the commonsense and fairness of the man and
woman in the street, and if they have the right example
to follow I am sure they can be relied on to follow it.
These people should be encouraged, by example as well as
by precept, to leave written statements (accompanied by
written consent of next-of-kin) expressing willingness for
their bodies to be studied after death either by patho
logical post-mortem examination or by anatomical dis
section. The example should be set by medical men, who
are familiar with the problem, and who know precisely
what is involved.

It was not until the time of Morgagni (1682 to 1771)
that the human body was seriously studi ed after death
from the point of view of pathology. The standard text
book prior to Morgagni s "De Sedibus et Causis Morborum"
was -Bonet s "Sepulchretum Anatomicum", which included
a large collection of post-mortem reports from the sixteenth
and seventeenth centuries. Morgagni s great book pub
lished in 1761 correlated clinical signs with pathological
changes in the organs. Bichat (1771 to 1802), who laid
the foundation of pathological histology, stressed the
importance of tissues as contrasted with organs in the
study of lesions in the body. As Long puts it: "Bichat
formed the connecting link be.tween Morgagni, who had so
greatly influenced the teaching of organ pathology, and
Virchow, who developed the concept of a pathology of
cells." Facilities for the study of the human body from
the point of view of pathology have greatly improved
during recent years.

In the eighteenth century Morgagni worked in the
Anatomical Theatre of Fabricius at Padua, which was built
in 1594, and except for minor alterations remains
unchanged to the present day. In this theatre there is a
small area on the floor for the autopsy table, and six
tiers completely surround the room. These tiers extend
from floor almost to ceiling and are so narrow that
onlookers must stand.

In the first half of the nineteenth century Rokitansky,
working in Vienna, was an outstanding pathologist. Nine
years ago the lecture theatre in Vienna, which seemed very
old, had the autopsy table in front of the seats, which
provided sitting accommodation for large numbers; those
sitting at the back, however, were at a great disadvantage,

FEBRUARY 16, 194H.

THE MEDICAL JOURNAL OF AUSTRALIA.

223

because they were very little higher than those in front, and
were too far from the body. In some American hospitals,
about fifteen years ago, movable structures made of iron
piping were wheeled around the autopsy table to form
three sides of a square. This arrangement provided sitting
accommodation for considerable numbers of students and
gave a good view of the autopsy table, but the "seats"
were not very comfortable.

A few years ago Lord Nuffield made a gift to the Royal
Prince Alfred Hospital, Sydney, and this money, with
more added, was used in building and equipping the Lord
Nuffield Theatre of Pathology in the basement of the new
Medical School of the University of Sydney. The amphi
theatre is arranged to provide comfortable sitting accom
modation for about eighty students, which corresponds to
half the total number of students in an average year. A
special system of lighting has been installed (in addition
to that over the table), and when specimens removed from
the body are held up to view under a bright light, the
students in the back row are only about eight feet from
them. Facilities for cutting immediate frozen sections are
provided, and students participate in performing the

The same advice, in the main, holds good at the present
day, and yet in our large metropolitan hospitals it is not
unusual for a medical officer to fail to see the post-mortem
examination of the body of a patient who dies while under
his care, and a radiologist rarely seeks confirmation of a
doubtful diagnosis in the autopsy room. For country prac
titioners the opportunity of checking clinical diagnosis by
post-mortem examination seldom arises.

When a doctor does not ascertain what lesions were
present in the body of one of his patients who dies, ,such
a doctor may remain ignorant of the fact that some of
the opinions he formed from clinical observation were
entirely erroneous. This calls to mind the occasion
referred to by Plato in "The Apology for Socrates", when
Socrates approached a man who seemed wise to not a few
but particularly to himself, and, after questioning him,
went away saying: "This man imagines he knows, with
out really knowing. I, knowing nothing, do not even
suppose that I know. On this point, at any rate, I appear
to be a little wiser than he."

It used to be the custom to have a motto over the
entrance portal to the post-mortem room in a hospital. At

FIGURE I.

Lord Nuffield Theatre of Pathology (main theatre). The special system of illumination
the amphitheatre had not been installed when this photograph was taken.

front of

examination of the body. Cooling of the cabinet in which
the bodies are kept is adjusted to prevent decomposition
but not to destroy the cellular structure of the tissues.

A small chapel is in communication with the main
theatre; in one end of this chapel is a viewing chamber,
where the body is placed on a bier behind a large plate-
glass window for inspection by friends of the deceased;
a velvet curtain covers this window when the viewing
chamber is not in use. Every endeavour has been made
to show consideration for the relatives, and to make it
clear to students that the term "dead-house" is obsolete
and has been replaced by "theatre of pathology", a science
laboratory where an endeavour is made to unravel the
mysteries of disease.

Great advances have been made during recent years in
diagnosis, but it still remains true that at a few autopsies
the clinical diagnosis is shown to be completely wrong,
and at a rather larger number partly wrong; even when
the clinical diagnosis is confirmed, important abnormalities
are often found which were unsuspected during life.
Nearly a century and a half ago Bichat said:

You may take notes, for twenty years, from morning
to night at the bedside of the sick, upon the diseases of
the heart, the lungs, the gastric viscera, etc., and al!
will be to you only a confusion of symptoms, which,
not being united in one point, will necessarily present
only a train of incoherent phenomena. Open a few
bodies, this obscurity will soon disappear.

the Royal Prince Alfred Hospital the motto was "In caelo
quies", and at the Sydney Hospital "Etiam mortui
prosumns". It is true that even though dead we are of
use, and indeed that is the theme of the present address;
nevertheless it was thought that the public display of this
motto might offend the sensibilities of some people, and it
was not painted over the entrance to the new autopsy
room in the Kanematsu Institute at the Sydney Hospital.

There appears recently to have been an awakening of
interest on the part of some of our younger physicians in
the study of diseased organs and tissues after death, and
this is a hopeful sign for the future. I understand that
it is proposed to establish more departments of pathology
in country centres in this state, and these will prove a
boon to country practitioners in their service to the people.
The opinion has been expressed that the pathologists in
these country centres should not be required to do work
which calls for a knowledge of pathological histology,
because of the need for long experience to gain confidence
in this field of study. I do not concur in this opinion;
no autopsy is "complete without histological study of some
organs and tissues, and sometimes the diagnosis cannot
be determined until microscopic evidence is available, and
even then occasionally remains uncertain. The perform
ance of autopsies in large country centres is most desir
able, as it is an important step in the direction of insti
tuting clinical pathological meetings among groups of
practitioners who are far removed from the metropolis.

224

THE MEDICAL JOURNAL OF AUSTRALIA.

FEBRUARY 16, 1046.

While the encouragement of autopsies in widely separated
centres is advocated, it must be recognized that some
centralization of these activities is necessary in order that
those who do the work may have enough practice to gain
the requisite experience. An autopsy that is badly done
might be better left undone. This calls to mind a request
which came to the Department of Pathology of the Univer
sity recently, that some attendants from a mental hospital
should visit the Lord Nu ffield Theatre of Pathology to
pick up the essentials of post-mortem technique; I under
stand that a visit on one afternoon was contemplated.
This, request is reminiscent of the story which has been
attributed to an eminent British bacteriologist. It is said
that a young doctor called at this bacteriologist s labora
tory to learn bacteriological technique while the wife of
the young man waited in his motor car down in the street.

Bodies and museum specimens should be strictly anony
mous so far as students are concerned; this rule is observed
in all medical institutions of repute. Mixed medical
museums are a mistake. Medical museums should be
either for laymen or for scientists; those for scientists
should not be open to laymen. -

In the mental hospitals of New South Wales there are
some 12,000 patients. In the larger institutions more
laboratory facilities should be provided, and the number of
autopsies performed should be greatly increased. The
standard of service rendered by medical officers attached
to mental hospitals would be raised considerably if they
were given facilities for more extensive scientific investiga
tion of the diseases from which their patients suffer.

Heports of Cases,

VOLKMANN S ISCH^EMIC CONTRACTURE OF THE
FOREARM.

By LEONARD BALL, F.R.C.S., F.R.A.C.S.,
Melbourne.

that a haematoma might be present which could be
evacuated.

At operation an incision was made along the entire
length of the anterior surface of the forearm and the
deep fascia was incised, considerable bulging of the
muscles being produced. The brachio-radialis appeared
normal and was retracted to the radial side. The musculus
flexor digitorum sublimis (humeral head) appeared normal

ISCH.^MIC contracture has long been looked upon as a
sequel to tight bandaging or splinting, resulting in venous
obstruction, although Volkmann himself, writing in 1881,
considered it due to "a continuous stoppage of arterial,
blood". u) A tight plaster cast may cause arterial obstruc
tion, and further theories as to the production of ischaemic
contracture are as follows: (i) contusion of a main
artery, (ii) traumatic arterial spasm, (iii) arterial throm
bosis or embolism, (iv) traumatic aneurysm or arterio-
venous aneurysm. The condition most commonly follows
suparcondylar fractures of the humerus, when the brachial
artery may be injured or stretched across the lower end
of the humerus.

The following, case, occurring in a young lad suffering
from a fracture of his olecranon without displacement,
who had no treatment prior to the onset of his ischgemia,
is of interest from both the medico-legal and the clinical
aspects.

Clinical Record.

J.M.O N., aged seventeen years, fell from a- tram on to
his right elbow at about midnight on June 4, 1944. His
arm was painful, but not unduly so, and he slept fitfully
through the night; but in the morning he had considerable
pain in the forearm and was admitted to the Alfred
Hospital at about 11 a.m.

On examination the forearm was seen to be tense,
swollen and painful, and appeared fluctuant; complete
anaesthesia was present from just above the wrist joint
to the fingers. The swelling of the forearm did not involve
the hand. There was complete paralysis of the muscles
of the forearm and hand, and the radial and ulnar pulses
were palpable and of good volume. On June 4, after
consultation with Mr. Balcombe Quick and Mr. Fay
Maclure, it was decided to open the forearm, in the hope

FIGURE I.

Showing level of anaesthesia on the patient s admission,
to hospital on June 5, 1944.

and was retracted to the ulnar side; thus the radial head
of origin of the muscle was exposed. This latter was
paler than normal and did not bleed easily, nor did it
contract readily on stimulation. The muscle fibres were
split and the musculus flexor digilorum profundus was
exposed; this appeared normal, except that it was infil
trated with blood, presumably from the fractured

FIGURE II.
Showing level of anaesthesia on September 1, 1944.

olecranon. No attempt was made to suture the incision,
and indeed, on account of the tension of the forearm, it
would have been impossible to do so. The wound was
dressed with "Vaseline" gauze.

On his return to the ward the patient s arm was kept
elevated in a sling suspended from a framework above the
bed, this being the position of greatest comfort for him.
There was no evidence of post-operative infection, and
on June 12 (one week after operation) the wound was

FEBRUARY 16, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

225

dressed, when it was found that the swelling was con
siderably reduced and some passive movement of the
wrist joint was possible. On June 19, at the next dressing,
the swelling of the forearm had subsided still further,
but there was considerable evidence of trophic changes
in the fingers, especially on the dorsum of the proximal
interphalangeal joints, where blisters were present. Com
plete anaesthesia was still found to exist.

FIGURE III.
Showing level of anaesthesia on February 1, 1945.

The wound of the forearm healed without incident, and
the hand and forearm gradually assumed the position
typical of a Volkmann s ischaemic contracture. Attempts
were made to prevent this deformity by splinting, but
these had to be abandoned owing to the trophic changes
in the fingers and hand, the slightest pressure causing
blisters. The area of anaesthesia gradually became smaller,
as is shown in Figures I, II, III and IV.

FIGURE IV.
Showing level of anaesthesia in July, 1945.

Although no special attention was directed to the
fracture of the olecranon in fact, the forearm was flexed
on the arm during the period of treatment the fracture
united perfectly without any disability of the elbow
joint.

Comment.

Although this patient developed a typical Volkmann s
contraGjure (as shown in Figure VI), yet at operation
the ischaemic process seemed to be limited to the radial
head of his musculus flexor digitorum sublimis. However,
other structures were involved, as was shown by the com
plete paralysis of his forearm and fingers and the total

anaesthesia distal to his wrist. The anaesthesia slowly
disappeared, and also presumably the motor nerve supply
to the forearm muscles improved. The result may have
been improved by an excision of this muscle, or perhaps a
detachment of its origin at the time of the original
operation.

FIGURE V.

Photograph taken in September, 1944, showing developing
ischaemic contracture and trophic changes.

FIGURE VI.

Photograph taken in June, 1945, showing fully developed
Volkmann s contracture.

It is fortunate for the doctor concerned that he did not
examine the patient earlier, as it is probable that any
treatment directed toward the fractufed olecranon would
have been blamed, or at least been considered a con
tributory factor, in the development of his ischaemic con
tracture.

Reference.

(1&gt; R. Watson-Jones : "Fractures and Injuries", Third Edition,
Volume I, page 121.

UNKNOWN FOREIGN BODIES IN THE LUNG.

By J. B.

Marks Professor of Pathology, University of
Adelaide.

A WOMAN, aged thirty-three years, suffering from schizo
phrenia, died at a mental hospital at 7.30 p.m. on July 23.
1944. She had always been thin. She had suddenly

226

THE MEDICAL JOURNAL OF AUSTRALIA.

AKY 16, 1946.

become ill on the day on which she died, suffering from
dyspnoea, a flushed face and physical signs of a pneumonic
state. In the lower and anterior part of the upper lobe
of the right lung was a red, consolidated area, one and a
half inches (3-7 centimetres) in diameter, with pale specks
in it, possibly minute abscesses. In the lower lobe of
the right lung a superficial dark hsemorrhagic-looking
patch was seen.

Microscopic examination of the affected lung revealed
considerable consolidation, the alveoli being filled with
coagulated exudate, red cells or polymorphonuclear cells, or
in some places loosely with macrophages. Embedded here
and there in the consolidated areas, and usually in groups,
were a number of foreign bodies. These were oval in
shape and varied in size (some measurements being 52^
evidently cross section) from 83(U, by 66/u to 116/i by 83/u.
There appeared to be a thin capsule which stained a
reddish colour with hsematoxylin and eosin, and the
contents seemed divided into about 10 or 12 spaces by
reddish, irregular septa giving a vague honeycomb or
reticular appearance. Sometimes these spaces looked as
though they were independent oval structures. In one case
the contents, which seemed to comprise four irregular
elongated bodies, had shrunk, leaving apparently a cap
sule behind. With iodine a faint blue tint appeared.
The bodies were quite unlike pollen grains. Professor
T. Harvey Johnston did not recognize them as of animal
origin (for example, ova) and Professor J. G: Wood con
sidered that they were not vegetable in nature. Can
anyone suggest what these bodies are from this description
and the s*epia wash drawing (Figure I)?

FIGURE I.
Drawing showing foreign bodies in lung, nature unknown.

Most of the bodies lay in what had been alveolar spaces,
though some were amongst exudate and degenerated
polymorphonuclear cells in small bronchioles. Those in the
alveoli were usually surrounded by a ring of condensed
nuclei, many of which were from polymorphonuclear cells,
though, where organization of the exudate was taking
place, some belonged to fibroblasts. Occasionally macro
phages had united round a body in an alveolar space to
form small foreign-body giant cells. The bodies were
irregularly distributed in the sections, and in one low-
power field 12 were counted; but in considerable areas
of consolidated lung none were found. If these bodies
were not responsible for the condition in the lungs as a
whole, they certainly played an important subsidiary part.

TETANUS TREATED WITH PENICILLIN; RECOVERY.

By JOHN L. GROVE,
Launceston, Tasmania.

Clinical Record.

THE patient, a male, aged twenty-four years, had been
healthy except for chronic otitis media; this in 1940 spread
to the left mastoid and gave rise to meningitis, which
responded to sulphonamide therapy. He was perfectly
well until five days before his admission to hospital. He
is a motor truck driver, and on that day noticed that any
heavy lifting gave rise to pain low in the centre of the
front of his chest. This was not severe, and he was able
to carry on with his work. Four days before his admis
sion to hospital the symptoms were unaltered, except that
at lunch time he had one sudden, severe, cramp-like pain
in the chest, of short duration. He still worked and slept
well that night. He suffered from no general malaise and
no stiffness anywhere. Three days before his admission
to hospital he was having fairly frequent attacks of cramp
in the chest and abdomen, and was unable to work. He
remained in bed and called a medical practitioner, who
could detect no abnormality and considered the condition
dyspeptic. That night he had several spasms of increasing
severity and frequency, and these continued for the next
two days and nights. By the morning of his admission to
hospital, on May 13, 1944, he had become exhausted and
called another medical practitioner, who found him gravely
ill. He was admitted to a private hospital with a pro
visional diagnosis of acute appendicitis, and was examined
by me at midday, by which time the diagnosis had become
obvious.

On examination, the patient was sweating profusely and
had a furred tongue and most offensive breath. Board-
like rigidity of the abdomen was present, and any attempt
at palpation brought on typical generalized tetanic spasms.
His temperature was 101-6 F., his pulse rate was 124 per
minute, and his respirations numbered 28 per minute.
There was no wound except a small puncture on the right,
hand.

A diagnosis of tetanus was made and confirmed by a
surgeon called in consultation in view of the provisional
diagnosis mentioned above. Treatment with penicillin and
serum was commenced immediately. Penicillin was given
intramuscularly in doses of 20,000 units every three hours.
The patient complained that the penicillin injections were
painful, until the site was changed from the buttock and
thigh to the deltoid, where the injections seemed to be quite
painless. (This site, moreover, involves minimum disturb
ance of the patient.) Penicillin treatment was continued
for teti days with a 25% reduction in dosage on the fifth
day, a total of 1,710,000 units being used. Serum was given
both intravenously and intramuscularly for the first three
days, and thereafter intramuscularly only. Serum therapy
was continued for twelve days, a total of 270,080 units
being given. The nursing staff expressed the opinion that
a definite improvement seemed to follow each dose of
serum.

A variety of sedatives was used. "Avertin" was the sheet
anchor. Twelve doses were given during the first nine
days in hospital, the total used being 62-1 mils. At first
the "Avertin" gave from six to eight hours sleep with
freedom from spasms, the period of relief gradually
diminishing to about four hours. The only disadvantage
of "Avertin" seems to be that while the patient is under
its influence, it is difficult to keep up fluid intake. This
had been noted in previous cases in which "Avertin" was
used. In order to keep up fluid intake, it was necessary
to give for periods between doses of "Avertin" a drug which
gave a measure of control of spasms with at least reason
able freedom from pain, and yet allowed cooperation from
the patient. Morphine filled this need well and gave rise
to no anxiety. A total of four and five-twelfth grains was
given. Morphine was on occasion combined with hyoscine,
of which a total of one-tenth of a grain was given.
"Nembutal" was tried on three occasions, but gave no

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FEBRUARY 16, 1946.

THE MEDICAL JOURNAL OF AUSTRALIA.

227

relief. "Sodium Amytal" was found useful after the fifth
day and toward the end of the illness, when spasms were
decreasing in severity and number, it was used in place of
"Avertin"; 87 grains of this drug were used in all.
"Sodium Amytal" seems to have a place in the treatment
of tetanus, but does not appear to be as useful as "Avertin"
in the severe stages.

Spasms, which were precipitated by the slightest
stimulus for example, a motor car passing down the
street outside the hospital continued until the thirteenth
day in hospital; 252 spasms were recorded. This is a
conservative estimate, as no record was kept on the first
day, and for some reason the staff did not usually record
spasms occurring as the result of the naturally frequent
attention to the patient. Abdominal rigidity persisted till
the sixteenth day. The jaw stiffness persisted till after the
patient s discharge from hospital on the nineteenth day.
Even on the seventeenth day he could open his mouth
only half to two-thirds of the normal extent.

His temperature ranged between 99 and 101-6 F. for
the first six days and then gradually fell, remaining normal
after the sixteenth day in hospital. The pulse rate, apart
from that recorded during spasms, did not rise above 120
per minute, and it gradually settled with the temperature.
The respiration rate was 44 per minute on the third day
in hospital, and this also gradually fell with the
temperature.

The urinary output for the first twelve days totalled 303
ounces, whereas the fluid intake was 819 ounces. The
tremendous loss of fluid mainly by perspiration is one of
the features of severe tetanus. In this case there was a
loss of over three gallons of fluid in twelve days (not
counting the actual loss of weight of ten pounds during
the illness), and this bears out the need for strict attention
to intake if dehydration is to be avoided. Diet was fluid
until the fourteenth day (the last spasm occurred on the
thirteenth day), when semi-solids were started. He was
able to eat meat on the seventeenth day despite some
residual stiffness of the jaw.

The bowels, which had last acted two days before his
admission to hospital, remained unopened until the ninth
day in hospital. Enemata were given twice without success
and on each occasion seemed to make his condition
temporarily worse. Finally the bowels opened into the bed
in response to the last dose of "Avertin".

Comment.

While no conclusions can be drawn from one case, it
was thought that an analysis of the records of previous
patients treated in Launceston might be of interest.
Records of 16 other patients since 1930 were traced; of
these, seven recovered. The ages ranged from two to
seventy-three years. The incubation period (which could
not be determined in five cases) averaged five days in the
fatal cases and eleven days in the others. The period of
onset (that is, the period between the first symptom and
the first spasm, which was not known in three cases)
averaged 2-4 days in fatal cases and 2-5 in others.

Only two of the other patients who recovered could be
classed with this patient as severely affected. In one of
these cases the incubation period was 18 days, and although
388 spasms were recorded over eleven days, the patient s
condition never gave rise to anxiety, his temperature being
normal by the fourth day and remaining so. In the other
case, in which the incubation period was unknown, the
patient had spasms for six days and the initial tempera
ture of 98-8 F. returned to normal after the second day
in hospital.

It would seem fair to state that the case described is
probably the most severe case of the series in which
recovery occurred. As handicap additional to the severity
of the disease, the patient was nursed in a private hospital
by a staff none of whom had previously nursed a patient
suffering from tetanus, and unfortunately in a noisy room.
The patient had a rapid convalescence and has remained
at his work since, apparently none the worse for his illness.

DERMATOLOGY.

AFTER a period of seven years, Dr. E. H. Molesworth has?
presented a second edition of "An Introduction to Derma
tology". 1 The first edition was reviewed at some length in
this journal on April 10, 1937. Despite the difficulties
associated with the war, Molesworth has found sufficient
time and energy to produce a volume which is distinctly
better than its predecessor. There has been some rearrange
ment in the subject matter. The chapters have been divided
into seventeen instead of thirteen, and the number of
illustrations has been increased by eleven. Molesworth
admits the collaboration and influence of several overseas
authorities, perhaps the best known being Dr. Frederick
Goldschlag, late of Poland. In addition, Dr. R. Kaye Scott,
of Melbourne, has brought the section on radium right up
to date. However, as in the first edition, it is the pen of
the experienced and dogmatic Molesworth which dominates,
and this is as it should be.

Many dermatological authors include so many treatments
(without indicating their personal preference) that an
inexperienced practitioner may be at a loss to know just
what to prescribe. This is far from the case with the -author
under review. His book is easy to read and the treatments
are clear-cut.

Molesworth makes no claim that his textbook is complete.
There are certain omissions, some of which are certain to be
included in the next edition. It will now be convenient to
enumerate some of them. (i) There is no reference to
penicillin. This is, of course, explained by the fact that the
book was in the press before this great therapeutic agent
was available, (ii) As a textbook for students there should
be one or two illustrations in a chapter dealing with the
anatomy of the skin, (iii) There should be a special chapter
devoted to drug Eruptions. Certain eruptions due to the
absorption of drugs are described here and there in the text,
but the book would be far more complete with this inclusion,
(iv) There is no reference to Thorium X, which has recently
been advised for port-wine stains and tinea of the nails,
(v) "Mouse plague" has been omitted from an excellent
article devoted to fungous infection. Outbreaks of this form
of tinea are not uncommon in certain of the wheat areas in
Australia, (vi) Very little has been written concerning skin
diseases under tropical war conditions. There is no descrip
tion of a fairly common condition known by such na