MEDICAL MATTERS IN VICTORIA.

THE ANNUAL ADDRESS.

By J. E Neild, M.D.. Ch. B., Melbourne, Retiring President Victorian Branch B.M.A.

As a scientific body a wide field is open to us for the exercise of our legitimate functions, and I can but hope that for the future we shall confine ourselves to what is truly beneficial to humanity and advantageous to ourselves as a brotherhood, having the health of the community in our collective keeping.

Looking back upon the past year, and limit

of the British Medical Association.

WE have had a quiet year, but then there have been few of us to quarrel, even if we had been so inclined.

We have met in Council and we have met in monthly meeting, and the unity of our gather ings has been maintained, consequently there has been an agreement in discussion, which I can only describe as beautiful.

We thus close the year at peace with all men for the present, and, our minds being undisturbed by pyrexial influences, we can the more calmly apply ourselves to the work of passing, in brief review, some of the matters which have occupied the attention of the profession during the year now nearing its close.

But before doing so I would ask you to pardon me if I parenthetically digress by saying a few words about myself.

When, some eighteen months ago, I was asked to take the position of President of the Victorian Branch of the British Medical Association I was indisposed to do so, not because I felt no interest in the success of the Branch, in the planting of which, I may say, I took a prominent part twenty years ago, and of which I had been Honorary Secretary and President, but because I had virtually for some time ceased to occupy any official position in its organisation. I was reminded that there had recently occurred a sort of cataclysm in the Branch, and that the integrity of the Association was imperilled, and that I, as one of the founders, might be able to restore its cohesion and strength. I therefore acceded to the request made to me, and I can but say that I have done my best.

The charming courtesy of those who have attended the meetings during the year has been beyond reproach, and to them I offer my very grateful thanks, and I can only regret that the Branch should have been concerned in a matter which, regarded from any point of view, added nothing to its dignity, its reputation, or its usefulness.

although, nevertheless possessing an interest common to all scientific workers, we find ourselves embarrassed by the multitude of subjects which claim our retrospective attention. It is hardly too much to say that the question of sanitation stands foremost in the list. Those who, like myself, have a considerable burden of years upon their shoulders, can remember very well the time when, practically, no attention was given to the observance of conditions neces sary to the prevention of disease and the preservation of health. The physician was regarded by most people as a man to look wise, feel pulses, and give large quantities of medicine; and he himself, with rare exceptions, limited himself to the exercise of these simple duties. Hygiene, as we now know it, possessed no meaning to the average mind. Boards of health had no substantive existence, and those members of the profession who busied themselves about water supply, the regular removal of filth, the purification of streams, the construction of dwellings in which light and pure air were provided for, and in which houserefuse was regularly removed, were looked upon as doctrinaires or as eccentric faddists. also with reference to the wholesomeness of food and drink. Adulteration was openly practised, and only nominally punished, and the public, who suffered both in health and pocket, were slow to believe that any harm came to them from these frauds. Even at this day, among educated and otherwise intelligent people, there is still an incomprehensible disregard of the danger incurred by the consumption of poisonous food, although the risks they run are pointed out by the profession.

So

In respect of diet as an adjunct to strictly medical treatment, there has come about a great change. There was a time, and that not so long ago, when patients were allowed to eat what they pleased, both as to quality and quantity, and though some measure of reform has been accomplished in this matter, the reform is not complete either in adults or children. Young people are allowed to stuff themselves to their heart's content and to their stomach's

discomfort, and especially in the case of infants the practice of overfeeding, and wrong feeding, continues to exist. The number of artificial foods that are crammed into the alimentary canals of these unfortunate creatures add greatly to the infantile mortality, as I have reason to know from the number of necropsies I have performed since the Infant Life Protection Act came into force.

In strictly medical, or, as it would be more correct to term it, drug treatment there has been a great change of late years. Many of the old preparations have been swept away and new ones substituted, not always, as I think, with advantage. And here I may remark that the enormous number of pills, tabloids, ovoids, and other forms in which nearly every drug is now manufactured by the wholesale druggists, has unquestionably extended the consumption of medicine in these forms, more especially by the general public, who, knowing both the nature and the quantity of the drug they are swallowing, are enabled to treat themselves without the interposition either of the doctor or the pharmacist. Nevertheless, the quack still thrives; and he thrives because of his mystery. He demonstrates practically the truth of the very old adage, Omne ignotum pro mirifico. The treatment of certain diseases by what is comprehensively known as the serum method, appears to maintain the favour with which it was at first received. Its efficacy has been enthusiastically proclaimed, but, at the risk of being pronounced unreasonably sceptical, I am obliged to declare that I cannot but regard this treatment as still only on its trial. If it is found to maintain the specific virtues with which it is credited so much the better. Up to the present I cannot but regard it as requiring confirmatory evidence in many cases. Of surgical antisepsis as propounded by its apostle, Lord Lister, there is no need to speak with hesitation. Its success has been established without question, and it has changed completely both the method and the results of operative surgery. With anesthesia and asepsis in operative surgery, chirurgical procedure has been made possible in cases which, little more than half a century ago, were past the limits of recovery, and which it was regarded as criminal to treat with the knife. Conservative surgery has thus been made possible where it was formerly not attempted by the most experienced surgeons. The Röntgen light, moreover, has lent a valuable aid in diagnosing conditions of an obscure kind, which could not be made clear save by much suffering and mutilation.

It would be superfluous at this day to speak of the microscope as an adjunct in diagnosis. It is so indispensable in certain bacteriological enquiries that the wonder is certain forms of disease could formerly be treated otherwise than empirically. And here it is only right to speak of the progress which has recently been made with the pathology of tuberculosis, and more especially to express satisfaction at the consequent results of this enquiry in the treatment of that disease which I need hardly say is now, or at least should be, conducted on principles wholly different from those formerly regarded as indispensable. I am not sure, however, that the inclusion of non-medical persons in the committees appointed to manage the proposed consumptive sanatoria is an unmixed advantage; for while their intentions might be beyond cavil, their amateur efforts might work mischief. The special instruction of nurses, however, beth in these and cognate institutions, might possibly act as valuable counteracting influences.

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Touching the subject of our hospitals, there is not much new to be said save that the Contagious Diseases Hospital is not pleted, and apparently is not likely to be completed. Such portion of it as is finished stands in the grounds of the Yarra Bend Asylum, a mournful memento of the scriptural warning of what happens to persons who commence to build houses without first sitting down and counting the cost thereof. The Government will tell us it is no affair of theirs to provide the money for its completion, and the public will say we contributed twenty thousand pounds, and that should have been sufficient to complete it, and everybody will write or want to write to the newspapers to say what should be done. Meantime the feverstricken people are dying, and we shall wish we were ruled by an autocrat who could order things on the sic volo sic jubeo principle; and we shall also wish we had a new general hospital in place of the patchwork institution which should have been razed twenty years ago. From hospitals we may speak of medical schools. and our own Medical School of the University necessarily claims chiefest attention. It has recently undergone some changes, some of them not for the better, but at any rate it is nevertheless still the most flourishing department of our principal seat of learning. It will probably suffer in common with the other sections as the result of the financial cloud which has shadowed the chest; and by the time this has passed away we shall perhaps have learnt wisdom sufficient to look more

In one there were stones in the gall bladder in the common hepatic and also the right and left hepatic ducts. The common hepatic duct was opened and stones some fifteen in number were removed. In the fourth stones were removed from the common hepatic and common bile duct.

The fatal case I have already mentioned occurred in a woman of 54 with malignant disease of the gall bladder. She had intermittent jaundice and very great pain. I thought that I might be able to relieve her by getting rid of the stones. I was not aware that she was suffering from malignant disease before I operated. At half past one she was seen by Dr. Heggaton and seemed well with a pulse of 104, and she died shortly after three. In none of these cases did I make any attempt to suture the bile duct. In three of them so matted were the surrounding structures it would have been impossible to do so. In the other two it was possible. A rubber drainage tube was placed with one end on the opening in the duct, and outside and inside this tube were placed gauze drainage wicks. If septic symptoms had subsided the drainage was discarded after a few days when a firm lymph track had been established.

It is well known that linear incision of a mucous track like the urethra heals with a fine linear scar, and is not followed by stricture. Arguing from this I acted as I did, nor have I had any reason to be disappointed with the result.

Suture is unnecessary and often impossible. It requires a larger incision, necessitates a greater amount of handling and materially prolongs the operation. Suture also offers a fair chance of diminishing the calibre of the duct. These cases necessitating choledochotomy are often associated with a pathological condition of the bile ducts due to backward pressure and infective processes, so that drainage, free drainage of the ducts is an absolute necessity and a sound surgical procedure.

Even in those cases where men have sutured, the duct leakage has frequently taken place, and in some cases where suture has been adopted without drainage, leakage has occurred and has been followed by death. It is evident then that suture of the duct is not necessary, and unless it be backed up by good drainage, it is likely to be productive of fatal results. Mayo reports eleven cases of choledochotomy. In four he sutured and drained, and in the re maining seven he did not suture. All recovered.

I shall next direct your attention to the

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acutely septic cases. There were eight, and two of them died. One, a man of 38 years, became suddenly ill with rigors. He was ill for about ten days before I saw him. He was slightly jaundiced and tender over the gall bladder and hepatic region. He had no gall stones, and though I drained his gall bladder bile never flowed freely, and his condition was in no wise abated. He merely became less jaundiced, and died in about three weeks time. There was no post-mortem I do not know what was the origin of the attack-it was probably intestinal. A man of 50 years had an attack of biliary colic twenty years ago, and another six years after that. During the past twelve months the attacks have been very much more frequent. He was continuously ill for three weeks before admission. He had rigors about every eighteen hours after he was admitted to hospital. was operated on the third day after admission. I admit that this was three days lost. On the last day he for the first time showed some slight jaundice. He had very marked tenderness over the gall bladder. His pulse was 130, and his temperature 102°, and he looked very ill indeed. After some difficulty his gall bladder was found deeply situated and hidden by omentum and transverse colon. It was extremely small, and distended with gas in the upper part, so that I was almost persuaded that I was dealing with intestine. On opening it gas escaped, and in the lower part there was about a teaspoonful of very fœtid pus. No gall stones could be found. He recovered rapidly, but returned in two months' time with dragging pains and a history of a rigor. I opened, and found no evidence of gall stones in the ducts, but there were necessarily many adhesions which I separated. He at the present time looks well, but he still has pain which he asserts is not at all like the old trouble, and is, I believe, to be attributed to adhesions, inasmuch as he is gradually getting better. Harris states that this often occurs for some time after operating on shrunken gall bladders. In one other case did I experience a like result. The pains left gradually and have not returned after eighteen months. Four other cases were operated on, when rigors and high temperature, and offensive purulent material and gall stones were found in the gall bladder. One of the patients with malignant disease of the head of the pancreas gave a history of old attacks of biliary colic, and no stones were present. She was extremely jaundiced. The other was slightly jaundiced, but the pancreas was involved. affected by pressure only,

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whole of the bile duct

was

It certainly seems odd that in these two cases there was a history of old standing biliary colic, and the presence of gall stones is said to have a marked effect on the production of cancer and chronic inflammatory affections in this region. Both of these patients died a few months afterwards.

A young unmarried woman, aged 22 years, gave a history of attacks of colicky pain in the epigastrium for the last eight or nine years. These attacks lasted for one and a half to three hours, and came at intervals of from two to six weeks. The pain was felt radiating out from the epigastrium. She was never jaundiced. The attacks so far as she knew bore no relation to her meals or to food taken. On the day following the attack practically all symptoms of it had vanished. On opening the gall bladder I found the fundus about twice the normal size, elongated and sagging downward. The bile was thick and treacley; the cystic duct was dilated in its upper part. A No. 4 sound could be passed. No gall stones were present. Part of the fundus was cut off and the raw edge was attached to the abdominal wall. I judged that by shortening and straightening the gall bladder, the bile could the more easily escape, as the thickened condition was probably due to stasis. Since then, five months ago, the patient has been quite well. This case showed a fair amount of intermittency, but the symptoms of the case I am about to mention were of a fairly mild, but persistent character. He was a man sixteen stone in weight and 33 years of age. For the past six months he had been troubled with more or less pain in the region of the gall bladder, and for the last six weeks he had been jaundiced; the jaundice gradually increasing in degree. He had, I learned, a slight and varying temperature all through, and for a short period before operation it had ranged as high as 102°. His gall bladder held about half a pint of thick bile, which was not purulent. There were no gall stones, and only a few adhesions about the neck of the gall bladder. The gall bladder was drained and the temperature and jaundice subsided. He left hospital in two months time quite well. A few weeks after this he became ill with a profuse and frequent diarrhoea, and in the interval preceding this he complained greatly of his want of appetite and his weakness. I saw him a few hours before death, I could discover neither sign nor symptom of liver trouble. No post mortem could be obtained, but I was very much inclined to think that both illnesses originated in some intestinal condition of a septic character.

I hope I do not assume too much when I say that there is a common impression held by many that the intense pain of biliary colic is due to the effort on the part of the biliary passages to expel gall stones. This is, probably, in the great majority of cases, a totally erroneous view, and most likely the correct one is that each of the attacks represents an attack of cholecystitis. Owing to the inflamed condition of the mucous membrane of the gall bladder, and particularly the bile passages, there is a resistance to the outflow of the bile and mucoid secretion. The increase in tension thus occasioned immediately excites within the tender gall bladder a reflex spasm, a biliary colic.

Spasm of the urinary bladder will take place when ulcer or acute cystitis is present. Attacks of renal colic are not uncommon in cases where the stone does not engage the ureter. A man may have stone in the kidney for years without giving rise to any pain whatever. How often, on the other hand, has a kidney been cut down upon for spasmodic colicky attacks, a marked symptom of stone when no stone has been present. We can only infer then that these attacks of pain are due not necessarily to a blocking obstruction, but to a reflex spasm, brought on by perhaps an amount of interference sufficient to produce but a slight increase in the pressure on the irritated epithelial surface behind it.

The very fact that, in some, biliary colic has been present in a marked degree when no gall stones have been present, is sufficient to induce one to believe that other conditions besides gall stones must bear a causal relation to the colic. This may be due to inspissated bile and to pressure from without, but considering the number of cases in which varying degrees of an ulcerative process have been found, there is a strong presumptive evidence that pathological changes in the mucous membrane or the wall of the gall bladder are a very strong factor in the production of biliary colic.

Naunyn and Stolz state that the bile is not absolutely aseptic, but that organisms and usually bacillus coli, are few in number, very attenuated and only obtained by sowing the culture medium with large quantities of biliary fluid. If streptococci are carefully introduced into a normal gall bladder they are got rid of fairly quickly, but if the mucous membrane is injured, or if the outflow of bile is obstructed, the organisms present multiply and probably a fresh invasion takes place, for bacillus coli almost always predominates.

Attacks of biliary colic, of cholecystitis, or of