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Full text of "Medical Journal of Australia"

b 



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 . . . ./. . .>. .<:. .* . 



-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. 


1 


January 5 


1 to 32 


2 


January 12 


33 to 64 


3 


January 19 


65 to 96 


4 


January 26 


97 to 132 


5 


February 2 


133 to 168 


6 


February 9 


169 to 204 


7 


February 16 


205 to 240 


8 


February 23 


241 to 276 


9 


March 2 


277 to 312 


10 


March 9 


313 to 348 


11 


March 16 


349 to 384 


12 


March 23 


385 to 420 


13 


March 30 


421 to 456 


14 


April 6 


457 to 492 


15 


April 13 


4!>3 to 536 


16 


April 20 


537 to 572 


17 


April 27 


573 to 608 


18 


May 4 


609 to 644 


19 


May 11 


645 to 680 


20 


May 18 


681 to 716 


21 


May 25 


717 to 752 


22 


June 1 


753 to 7S8 


23 


June 8 


789 to 824 


24 


June 15 


825 to 860 


25 


June 22 


861 to 896 


26 


June 29 


897 to 932 





VOL. I, 1946. 



INDEX TO THE MEDICAL JOURNAL OF AUSTRALIA. 



ni 



INDEX TO VOLUME I, 1946. 

JANUARY TO JUNE 



In this index (C.C.) indicates current comment : ((>) 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 

56 

781 
5 5 7 

377 

672 

233 

56 

852 



IV 



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, <;. 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 :>,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 

< ilycogenesis 

Haematopoiesis 

Human Milk Fat 

Lipidea 

Pantothenie Acid 

Plasma Fibrinogen 

Thiamin Requirements 

Vitamin E 

Vitamins in Muscle 

Wound Healing 

Dermatology > (, 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 :> 

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 

744 
343 

745 
343 
745 
342 

> ,J *J 



745 
343 
745 
745 



744 
745 



635 
233 



708 
304 

708 
708 

305 

708 

70S 
7ns 
708 
304 
304 
304 



VI 



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 .............. ,->(;, 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 

56 

5G 

448 



448 
852 



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 ->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 ................ ;>4<> 

Treatment, The. of Subacute 
Bacterial Endocarditis with 342 



596 
597 

194 
195 
597 
596 

195 
596 

596 
194 

597 
195 

."> 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. 



vn 



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 



B 



R. 



Bacille Calmette Gtierin, by J 

Murphy 

Bacillus Proteus OXK, The Use <>f 
a Polysaccharide of, in the 
Diagnosis of Scrub Typhus, by 
1 . de Burgh (O) 

Backache 

In Soldiers, by D. Slurkey (<>) 
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) 



81 

838 



12 

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 



LO 



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) ~> s "> 

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 <;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 - > 

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 
> ! , 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. 



IX 



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>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< 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 !>. K. Moore 41 S 

By F. W. Simpson 417 

Bacille Calmctte < 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 
!;>(, , 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 

< 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. 



XI 



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."> 

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 

D 

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 

30 

85 

516 

629 

409 
678 



645 

228 



703 



372 



417 

274 

382 

45 



49 

237 

346 

454 

53 



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 



F 

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 

of 

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 

< 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 
< 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>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 

H 

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 



p 

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 

95 



S05 
704 



872 

90 

533 

53 I 

009 



374 



2!) 
29 



TOO 
124 



524 
517 

487 
482 
158 



444 

Sit) 
20 



513 
375 



444 



395 
817 
740 

27 



078 
381 
109 

345 

185 



Hes^ 



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

Hewitt, \v. E 

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



Page 

1 1 igli-Freque.i>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 (<>) .... 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 



10 

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 



K 

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 > 
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 ** :>> 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" :> > : >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 >. 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 

M 

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. 



xv 



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> 

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 

20 

920 

443 

20 

336 



408 
849 
254 
273 

133 

40 



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 

N 

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 

O 

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>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 >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 

P 

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 

30 

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 

Q 

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<., 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> 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 

< 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<. 
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 



XX 



INDEX TO THE MEDICAL JOUKN AL 



AUSTRALIA, 



VOL. 1, 1940. 



Page 

Russell, W. Ritchie TOG 

Ryan, H <>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) < I > 

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 (< .< .) 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:>: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< 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 

R 

Redford John Wright, Death 



1J5 

788 
785 
919 



920 



131 
922 



707 
341 



753 
890 
904 
591 



Smith, 
Smith. 
Smith, 

of 

Smithy, H. G 

Soldiers, Backache in. by 1 >. 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-> .)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.- -< 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. 



Of 



"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> 

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.~<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 

V 

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 

W 

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 

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 


z 




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 



II 



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 



98 



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. 



99 



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 <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 <3) ). There are 
probably between 200 and 300 lepers amongst the northern 
tribes distributed almost entirely in the coastal regions 
(Kirkland< 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 <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. 

<2 > 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. 

<a) C. Cook : "Epidemiology of Leprosy in Australia", Com 
monwealth of Australia, Department of Health, Service Publica 
tion Number 38, 1927, page 28. 

<4) W. B. Kirkland : Personal communication. 

(5 > J. Andrews : Personal communication. 

<"> W. B. Kirkland : Personal communication. 

<7) "Hanson s Tropical Diseases", Eleventh Edition, 1942, page 
634. 

<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 <: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>) 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. <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 <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. 

> J. S. Horsley and I. A. Bigger: "Operative Surgery", Fifth 
Edition, Volume I, 1940, page 151. 

<2 > E. Holman : "Arterio-Venous Aneurysm", 1937, page 48. 

< 3 > 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. 

< 4) H. Bailey : "Surgery of Modern Warfare", Second Edition, 
Volume 1, 1942, page 250. 

(B > 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. 

< 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. 

<7) L. Rogers : "Physiological Considerations in Vascular 
Surgery : Ligation of Main Arteries of Limbs", THE MEDICAL 
JOURNAL OF AUSTRALIA, May 19, 1945, page 517. 

<H > 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. 

<8> 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 


of 


.iEtiological Factor. 


Abscesses. 


Dental operations . . 


7 




Parturition 








6 




Abdominal operations 








5 




Ear, nose and throat oper 


ations 






3 




Foreign bodies 








2 




Carcinoma of the lung 








1 




Unknown 








1 




"Pneumonia" et cetera 








16 





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- 



JANUARY 26, 1946. THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER. 



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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 




86 


8 


9-3% 


Fascial repair 




39 


6 


15-4% 


Other methods : 










Bassini 


n 








Fowler 


6 r 


17 


3 


17-6% 


McArthur 


3 








Bloodgood 


ij 









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 


52 



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> 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. 

<u S. Wolf and H. G. Wolff : "Human Gastric Function". 
> 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 <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 <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 

nl 

positive reactions and T> 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 > 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 > 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. 

< 4 > 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. 



ix 




ZERO HOUR 



BLACK OF NIGHT. A ringing phone . . . another call to 
arms. Instinctively, the doctor answers. For him it is the 
zero hour. An accident at an industrial plant. A worker 
seriously injured. Once again begins a battle in the war 
that never ends . . . the crusade against disease . . . man s 
untiring enemy. 

And science marches by the doctor s side . . . helps fight 
the foe with modern weapons. Take radiography ... a 
good example. Radiographs may save the worker s life 
. . . help chart a course that leads to successful treat 
ment and a speedier recovery. 



TODAY the satisfactory diagnostic radiograph is the rule 
rather than the exception. One reason is that radiographers 
recognize that a sharp, contrasty negative depends to a 
large extent upon highly efficient intensifying screens. 
Screen care and replacement are important. Screens that 
are dirty, scratched or stained produce inferior results. 

Examine screens regularly. Replace worn screens. Ample 
stocks of Patterson Screens are available. Patterson Screen 
Division of E. I. du Pont de Nemours & Co. (Inc.) 



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THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER. JANTAKY 20, 1940. 




TREATMENT 



YEAR BOOK, 1945 

Edited by Cecil P. G. Wakeley, C.B., D.Sc., F.R.C.S., 

F.R.S.E. 

A year-book of modern diagnostic methods and treatment designed to 
greet members of the medical services returning from the forces and to 
enable the busy practitioner to keep abreast of current medical opinion. 
IIIIIlllllllllIIHIIM 

"A galaxy of brilliant contributors. . . . The subject matter has been 
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Ulster Medical Journal. 

iiiraiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii 



SELECTION FROM CONTENTS 



The Nature and Treatment of War-Time Malaria Relapses 

"Sir Philip Manson-Bahr, C.M.G., D.S.O., M.D., F.R.C.P. 
Hydatid Disease Mainly from the Clinical Standpoint. 

Sir Louis Barnett, C.M.G., F.R.C.S., F.R.A.C.S. 
The Treatment of Injuries to Peripheral Nerves. 

H. W. S. Wright, M.S., F.R.C.S. 



The Treatment of Karly Phthisis in the Young Soldier. 

James Watt, M.A., M.D., D.P.H. 

The Management of the Young; Diabetic in War Time. 

G. M. Wauchope, B.Sc., M.D., M.R.C.P. 

The Treatment of Peptic Ulcer in War Time. 

A. Morton Gill, M.D., M.R.C.P. 



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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 !>, 



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<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 ~> 
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 


s. 

10 


10 

10 


d. s. 

9 


5 

o gg7 \i 


d. 

2 







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 


3 


g 


55 


11 


9 


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 



2 





388 5 


10,239 4 1 


10,239 4 


1 









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>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. 











s. 


d. s. d. 




s. d. s. d. 


November 15, 1945. 


November 15, 1945. 




To 


Branch Expenses 
Library Expenditure 


947 
60 


16 

17 


8 


By Branch and Organization Fund 
Subscriptions 


2,176 3 




Depreciation of Office Equipment . . 


8 


16 


9 


,, Interest 












1017 11 








Federal Council 








scribed Stock 


.") S 1 2 




Contribution to Expenses 
Special Contribution to Council 


464 


5 





Australasian Medical Publishing 
Company, Limited, Debentures 


2 15 




Expenses 


500 


1 2 


^> 




60 16 










Q i; A i - ( 


Q. 1 f ~\* t -f- -n v,l 


5 Cv 


,, 


Expenses, B.M.A. House 






, > -t 11 O 


,. oct ie or iNuintion I ampniets . . 


t> D 




Rates, Land Tax, Insurance, 














Repairs and Sundries 


156 


5 


;; 








Cleaning 


78 














Depreciation, Building 


48 


17 


5 










283 


2 


S 






Less Rents Received 


249 


















J 9 g I 




n 


Net Surplus for Year 












Transferred to Accumulation 






j 






Account 






225 11 8 












2,242 2 10 




2.242 2 10 



JANUARY 20, 19<>. 



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>, 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 



58 



2 15 



s. d. 



L9 



:>,,600 9 



2 



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 


6 





599 


1 





464 


5 





500 


12 


6 


706 


4 


6 


100 


12 


7 


55 


11 


2 


29 


11 


2 


28 


6 


3 


23 


5 


6 


4 


5 


6 



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 >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<>. 



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> 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>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. 6 

FEB. 7 

FEB. 8 

FEB. 12 

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. 



XI 



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, 
>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 > 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^ 

u 



ompanu 
1 <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 




C. 

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. 




11 



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). 



4. 

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 



TH 




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. 



IV 



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 



1. 



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 



VI 



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 



172 



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 



174 



THE MEDICAL JOURNAL OF AUSTRALIA. 



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 


5 


+ + + + + 


8948 








2,000 


5 


+ + + + S 


8948 








1,000 


5 


+ + + + s 


8948 








500 


5 


8 S 8 8 8 


8988 








4,000 


5 


+ + + + + 


8988 








2,000 


5 


+ + + + + 


8988 








1,000 


5 


+ + S S S 


8988 








500 


5 


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. 




A 


S948 


0-6 unit 1 


4,000 


Nil 


10 


++++++++++ 


B 


S948 


0-6 unit 


4,000 


25,000 


10 


ssssssssss 


C 


S988 


10 units 


4,000 


Nil 


10 


++++++++++ 


D 


S988 


10 units 


4,000 


25,000 


10 


++++++++++ 



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 


5 


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 



FEBRUARY 9, 1946. THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER. 



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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> 

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> 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. <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> 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 > 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 > 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 > M. E. De Bakey and B. N. Carter : "Current Considerations 
of War Surgery", Annals of Surgery, Volume CXXI, May, 1945, 
page 545. 

<4> 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. 

<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 > J. C. Boileau Grant : "A Method of Anatomy", Third 
Edition, 1944, page 275. 

(8 > 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. 

< 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 > 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. 

<l:l > 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, <2>( " >(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 <8) that the fat cells 
come from a specially differentiated connective tissue. 
Baniecki <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. 



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185 



References. 

< l > P. L. Hitter and S. W. Stringer : "Lipoma of Uterus", The 
American Journal of Obstetrics and Gynecology, Volume XL., 
1940, page 501. 

(2 > J. H. M. Knox : "Lipomyoma of the Uterus", The Bulletin 
of the Johns Hopkins Hospital. Volume XII, 1901, page 38. 

<:1 > 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. 

<G > 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. 

< e) A. C. Starry : "Fatty Tumours of the Uterus", Surgery, 
Gynecology and Obstetrics, Volume XLI, 1925, page 642. 

(7 > 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. 



186 



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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 (<) 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, (<)) from a review 
of the literature, concluded that prophylaxis, diagnosis and 
treatment were alike unsatisfactory. Tow C7> 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. 

> H. Ehrenfest: "Birth Injuries of the Child", 1931, page 286. 

< 2) Palmer : Medical Research Council of the Privy Council, 
Special Report Series Number 118, 1928; quoted by Ehrenfest, 
loco citato. 

<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. 

<*> C. Berkeley, V. Bonney and D. MacLeod : "The Abnormal 
in Obstetrics", 1938, page 422. 

<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. 

<7 > 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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Cbe Medical journal of aumalia 



SATURDAY, FEBRUARY 9, 1946. 



All articles submitted for publication in this journal should 
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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 



198 



THE MEDICAL JOURNAL OF AUSTRALIA. 



FEKRI-ARY 9, 194(>. 



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 



200 



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FEBRUARY 9, 1946. 



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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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 



202 



THE MEDICAL JOURNAL OF AUSTRALIA. 



FEBRUARY 9, 1946. 



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" >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 
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. 



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 ; 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. 

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.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. 

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. 



dBDitotial Notices, 



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 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. 



xv 



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> 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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ELECTRICAL IN 

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Diploma Scientific Chiropody. 



Ediswan Electric Convulsion 
Therapy Apparatus. 
Infra-Red Generators. 
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Equipment Hire Service. 
Further Particulars: 
STORER-HARRISON X-RAY 
COMPANY 

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PERCIVAL D. OLLE 

M.S.R., B.P.A., N.R. (Eng.)t 
PHYSIO-THERAPIST. 

Short and Ultra-Short Wave, 
6 to 20 Metres. At rooms only. 
Ultra-Violet, Infra-Red, Dia 
thermy, Iontophoresis. 
Physical injuries treated. 

"Wemfoury", 

42 Elizabeth Street, Ashfleld. 
Telephone; UA 1097.. . 



QUEENSLAND 
MEDICAL PRACTICES 



Brisbane, outer suburb, old estab 
lished, every facility, income 3,500, 
comfortable house, ideal situation. 
Goodwill and property 4,500. 
Country town, cool climate, pros 
perous district, income 4,000, 
shared hospital appointment. Good 
will 2,500, very modern brick 
home, every convenience, 5,500. 
Country town (solo), death 
vacancy, excellent district, com 
fortable home (either sell or rent). 
Widow will also sell instruments, 
library and furniture. 
Country town (three men), income 
1,900, excellent hospital facilities, 
goodwill 1,200, comfortable ten- 
roomed house on lease 3 week. 
Country town, prosperous dairying 
district, income from practice and 
private hospital over 5,000. Price, 
including property and hospital 
goodwill and furniture and fixtures, 
3,750. 

Will lease for nine months with 
option to purchase old-established 
general practice. Income over 
4,000, good country town, every 
facility. Owner qualifying for 
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. 



0f 



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 
Practices 

Advice and recommenda 
tion rendered to enquirers. 



INSURANCES 

Fire, Life, Sickness and Acci 
dent, Motor Car, Workers Com 
pensation, etc. 

COPYING, TYPING 

Duplicating, MSS., Meeting 
Notices, etc. 



_. . . ( B 4159 

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 
vices and radiopaque plaque 
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 
Two and D.ouble Three X-Ray 
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 



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1, Wimpole Street, LONDON, W.I 

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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. 




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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 
< ;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. <! 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 .,>I-KK.\,-I, VXD PTY. LTD.. 
l i:, \Vickham Terrac, . lirishane. 
i: 9597. 



COMMONWEALTH OF AUS- 
V> 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 *>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 




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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 



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CALCIUM 

FOR PROLONGED THERAPY 
FOR GREATER SOLUBILITY 

EACH DRACHM CONTAINS 20 GRAINS OF CALCIUM 
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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 

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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 <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, <5)<8) 
has been denied by Wachholder," 1 by Ferdinand, (8) by 
Muller/ 9 by Neuweiler <10> 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> Gedd and 
Kjelberg <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 <12) ), although during lactation the body 
appears to store vitamin C for longer periods than usual 
(Baumann and Rappolt " ). To quote from Baumann : <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, <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 


milligrammes 




Baumann 181 


50 


8 to 14 







milligrammes 


milligrammes 


Chu, Woo and Sung 1 " . . 


82 


Adequate 




milligrammes 




Ingalls et oKi " 1 .. 





28 4 to 5 
milligrammes 


Ingalls" 





20 to 40 
milligrammes 


4 


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 " 


70 





4 


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> 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 <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. 


I. 


II. 


III. 


IV. 


V. 




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> 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. 


I. 


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 <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 


43 


6th . 


3-41 


45 


7th 


4-13 


47 


8th . 


4-12 


29 


9th . 


4-13 


17 


10th . 


3-79 


22 



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 <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, <31> Schlemmer et a/ii, (as) 
Kasahara and Kawashima, (32) Wachholder/" de Haas and 
Meulemans <;!3) and Stoerr <34> 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, <2S) Kasahara 
and Kawashima, (32) and Wachholder and Correns (:io) noticed 
a fall in ascwbic acid value of milk while the lactation 
proceeded. Bleyer, <31) Neuweiler, <35) Winkler and Heins, (36> 
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 


45 


48 


37 


30 


20 


18 


11 


14 


9 


8 


6 


5 


1 


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 


50 


October 


3-51 


54 


November 


4-18 


65 


December 


4-00 


24 


January 


4-10 


23 



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 


47 


October 


3-68 


33 


November 


3-28 


38 


December 


3-82 


32 


January 


3-75 


37 


February 


3-56 


71 



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 <: 7) 
(London), 5-6 milligrammes per centum (135 samples); 
Kasahara and Kawashima <38> (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 <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, <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. 

< 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. 

<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. 

<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. 

< 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 

< 18 > G. Gaethgens and E. Werner : "Administration of Vitamin 
C to Nursing Mothers", Archiv fiir Gynakologie, Volume CLXV, 

1937, page 63. 

< 19 > 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. 

< 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. 

<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. 

< 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. 

< aj > 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. 

<a>) 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. 

<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. 

< :i2) M. Kasahara and K. Kawashima : "Beitrag zur Kenntnis 
des Vitamin C Gehalts in der Colostralmilch", Klinische Wochen 
schrift, Volume XV, 1936, page 1279. 

<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. 

<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 > 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. 

<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. 

<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. 

<* 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> 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. 

**> 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. 

<" 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. 



<> 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 > Sapegno and Mado : Archivio italiano di pediatria e 
puericultura, Volume II, 1934, page 724 ; quoted by Elmby, 
loco citato. 

< 17 > 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> 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. 

<" 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, <3> 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> 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 <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 <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 <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 <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. 

(c) Dermoid inclusions (very rare). 

(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 <17> 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>) 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 >, 
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 > 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 <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 >) 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 <: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 <9) 
found it in the third decade. The female sex seems to 
be more commonly affected than the male. 

Warfield <: " 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. 



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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> 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 > C. W. Plynn : "Mesenteric Cysts, with Report of a Case 
of Cystic Lymphangioma", Annals of Surgery, Volume XCI, 
April, 1930, page 505. 

<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. 

<e > A. N. Collins and G. L. Berdez : "Chyle Cysts of the 
Mesentery", Archives of Surgery, Volume XXVIII, February, 
1934, page 335. 

(10 > 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 > 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. 

"> 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. 

<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. 

<16> C. N. Dowd : "Mesenteric Cysts", Annals of Surgery, 
Volume XXXII, October, 1900, page 515. 

<17) E. W. Petersen : "Cysts of the Mesentery", Annals of 
Surgery, Volume CXII, July, 1940, page 80. 

(18 > 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. 

<ai > 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 > 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 *> 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. 

*> 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 


78 


69 


69 





39 


705 


Children s Hospital, Boston, 1933-1936 ; 


















Fothergill (1937) 


31 


27 


51 


38 


36 





38 


221 


Children s Hospital, Washington, D.C. 


















Lindsay, Rice and Sellnger (1940) 


205 


180 


100 


73 


50 


5 


29 


642 


Bureau of Laboratories, Department of 


















Health, New York. Neal, Jackson and 


















Applebaum (1934) 


961 


1,216 


111 


209 


203 


27 





2,727 


Hospital for Sick Children, Toronto. Silver- 


















thorne (1943) 


368 


236 


153 


148 


170 


25 





1,100 


Royal Alexandra Hospital for Children, 


















Sydney, 1 1934-1944 


120 


291 


118 


86 


38 


13 


78 


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 



1 


8 
4 






9 
6 


1 



84 
73 


1 
1 




Total 


56 





52 





22 


1 


12 





15 


1 


157 


2 


1-2 


Sulphonamides : 
Royal Alexandra Hospital 
for Children, Sydney . . 
Children s Hospital, Mel 
bourne 


27 
24 


3 
1 


22 
24 


5 
4 


14 

7 


6 



8 
6 


4 
1 


15 
3 


8 
1 


86 
64 


26 

7 




Total 


51 


4 


46 


9 


21 


6 


14 


5 


18 


9 


150 


33 


22-0 


Sulphonamides and serum : 
Royal Alexandra Hospital 
for Children, Sydney . . 
Children s Hospital, Mel 
bourne . . . . . A 
Other Australian Hospitals 


4 

14 
19 




3 
10 


1 

16 
4 




10 
3 


2 

10 
1 


1 

8 
1 


1 

4 
1 


1 

4 

1 


2 


2 


2 


2 


10 

44 

27 


4 

25 
17 




Total 


37 


13 


21 


13 


13 


10 


6 


6 


4 


4 


81 


46 


56-8 


Total 


144 


119 


56 


32 


37 


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 








Royal 














Alexandra 








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 










Patients 




(P). 1 








i 


Treated. 














1 


Treated. 














i 




























* 


Patients 


Re 
coveries 


Patients 


Re 
coveries 




Number 


.1 
1 


Patients 


Re 
coveries. 


Patients 


Re 
coveries 


Patients 


1 

di 




Number 


i! 




24 .. 


49 


8 


48 


5 


97 


13 


13 -4 


5 





30 


13 


23 


13 


58 


26 


44-8 


0-00002 


d over 


, 37 


18 


16 


2 


53 


20 


37-7 


5 


4 


14 


12 


4 


4 


23 


20 


86-9 


0-00007 


Potal . . 


86 


26 


64 




150 


3:5 


22-0 


10 


4 


44 


25 


27 


17 


81 


46 


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. 




I 


0-05 


+ 


O 1 














II 


0-1 


+ 


-(- 














III 


0-15 


+ : + 


+ 











IV 


0-2 1 + i + 


+ 


+ 








V 


0-25 


+ 


+ 


-f 


+ 


+ 





Milligrammes per centum of sugar 


Over 


40 to 


30 to 


20 to 


10 to 


10 




50 


50 


40 


30 


20 





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. 

< 15 
15 to 25 
25 to 40 
Over 40 



Antibody Nitrogen Indicated, 

Mg. 

100 

75 

50 

25 



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 



FEBRUARY 16, 1946. THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER. 



IX 



Pharyngitis and 



effective therapy 

with ARGYROL 



BRAND SILVER 

ARGYROL has proved its value for controlling 
infections of (he nose and throat. Many eminent 
authorities have noted that the best results are 
obtained when ARGYROL is specified in all pre 
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reasons for this. The silver in ARGYROL is in a 
much finer state of colloidal dispersion, also there is 
a far greater degree of Brownian movement, which 
logically must result in greater therapeutic activity. 
This is not true of ordinary mild silver proteins, for 
ARGYROL is the only silver salt that does not tend 
to become irritating with increased concentration. 
SPECIFY ARGYROL IN ALL PRESCRIPTIONS. 



Paint thoroughly with 
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ARGYROL. It often 
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are first systematically swabbed 
with the ARGYROL - soaked 
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nd the lower part of the pharynx. 



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Vitamin E in the Menopause 



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oestrogens and at the same time a safer method for combating menopausal flushes. 

In a letter to the Editor (R.M.J., October 23, 1943) a well-known authority on Vitamin E, in referring to 
the above-mentioned article, stated that, believing this vitamin to be a potent anti-oestrogen, he administered 
Ephynal in large doses to menopausal women and he believed his results would compare favourably with 
those of physicians describing ocstrogens. 

A further report has just been published (Amer. journ. Obst. & Gj/i., July, 1945). The investigation covered 
a period of six months and 25 patients ranging in age from 22 to 55 years. 



"First reports of experimental use of this drug were 
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of the hot flushes and drenching perspiration, and a 
definite change for the better in their mood and outlook 
. . . Of these 25 patients seven reported complete relief of 



symptoms on dosages of 10 to 20 mg. daily over periods 
of from one to three weeks. Sixteen patients reported 
very marked relief on 10 to 20 mg. daily over periods of 
from two to six weeks. A great reduction in the number 
of hot flushes per day was evident promptly upon taking 
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Sole Agents in Australia : F. H. Faulding & Co. Ltd., 98, Castlereagh Street, Redfern Park, Sydney, N.S.W. 



THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER. FEBRUARY 16, 1940. 



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IODO-SALVE (IODISED BALMOSA) 

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FBBKI-ARY 16, 1946. 



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 


9 

4 


8 


\ 


2 0-038 
2 0-5 



to 2 
25 and 


4 

over 


45 

17 


17 
15 


9 

4 


7 
8 


4 2 0-033 
2 2 0-5 

1 


Total 


62 


32 


13 


10 


6 


4 


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> 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*" <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. 



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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. 

<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. 

<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<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> 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 



FKBRUARY 16, 1946. THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER. 



xi 




Rapid Healing OF PEPTIC ULCER 

Healing of peptic ulcer at a rapid rate is the rule with Amphojel (Colloidal 
Aluminium Hydroxide Gel-Wyeth) Roentgenological re-examination after ten 
days of treatment often shows complete disappearance of the ulcer niche, f 



tWOLDMAN, E. F., and POLAN, C. G.: The 
Value of Colloidal Aluminium Hydroxide in 
the Treatment of Peptic Ulcer: A Review of 
407 Consecutive Cases, AM. J. M. Sc. 198: 
155-164 (August) 1939. 



AMPHOJEL 

Colloidal Aluminium Hydroxide Gel 
The Medication of Choice in Peptic Ulcer 




INCORPORATED 

INC. IN U.S.A. 

44 Bndg. Str.et. Sydney 




Prompt relief from pain 
RAPID HEALING OF ULCER 

Fewer recurrences 

Less need for restricted 
diet 

No alkalosis; no secondary 
acid rise 



xii THE MEDICAL JOURNAL OF AUSTRALIA ADVERTISER. FEBRUARY 16, 194fi. 



PROMIN 



Promin (Sodium p:p -diamino-diphenylsulphone-N:N - 
di- (dextrose sulphonate) is one of the few chemotherapeutic 
agents shown io be capable of inhibiting the tubercle bacillus. 

Applied topically, 5 per cent. PROMIN JELLY has been 
used with encouraging results in the treatment of superficial 
tuberculous lesions ("British Medical Journal", December 
26, 1942) and for the treatment of lupus, especially of the 
ulcerative type. 

Promin Jelly is available in 2-oz. glass jars. 



Further details 
will be supplied on request. 



Parke, Davis & Company, Limited 



(INC. IN U.S.A.) 

SYDNEY 



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