MEDICAL MATTERS IN VICTORIA. 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 THE ANNUAL ADDRESS.

confine ourselves to what is truly beneficial to

humanity and advantageous to ourselves as a By J. E Neild, M.D., Ch.B., Melbourne, brotherhood, having the health of the comRetiring President Victorian Branch B.M.A. munity in our collective keeping.

Looking back upon the past year, and limitRead at the Annual Meeting of the Victorian Branch ing our reflections principally to local matters, of the British Medical Association.

although, nevertheless possessing an interest common to all scientific workers, we find our

selves embarrassed by the multitude of subjects We have had a quiet year, but then there which claim our retrospective attention. It is have been few of us to quarrel, even if we had hardly too much to say that the question of been so inclined.

sanitation stands foremost in the list. Those We have met in Council and we have met in who, like myself, have a considerable burden of monthly meeting, and the unity of our gather- years upon their shoulders, can remember very ings has been maintained, consequently there well the time when, practically, no attention has been an agreement in discussion, which I was given to the observance of conditions neces. can only describe as beautiful.

sary to the prevention of disease and the We thus close the year at peace with all men preservation of health. The physician was for the present, and, our minds being undis- regarded by most people as a man to look wise, turbed by pyrexial influences, we can the more feel pulses, and give large quantities of medicalmly apply ourselves to the work of passing, cine; and he himself, with rare exceptions, in brief review, some of the matters which have limited himself to the exercise of these simple occupied the attention of the profession during duties. Hygiene, as we now know it, possessed the year now nearing its close.

no meaning to the average mind. Boards of But before doing so I would ask you to health had no substantive existence, and those pardon me if I parenthetically digress by members of the profession who busied themsaying a few words about myself.

selves about water supply, the regular removal When, some eighteen months ago, I was of filth, the purification of streams, the conasked to take the position of President of the struction of dwellings in which light and pure Victorian Branch of the British Medical Asso-air were provided for, and in which houseciation I was indisposed to do so, not because refuse was regularly removed, were looked upon I felt no interest in the success of the Branch, as doctrinaires or as eccentric faddists. So in the planting of which, I may say, I took a also with reference to the wholesomeness of prominent part twenty years ago, and of which food and drink. Adulteration was openly pracI had been Honorary Secretary and President, tised, and only nominally punished, and the but because I had virtually for some time public, who suffered both in health and pocket, ceased to occupy any official position in its or- were slow to believe that any harm came to ganisation. I was reminded that there had them from these frauds. Even at this day, recently occurred a sort of cataclysm in the among educated and otherwise intelligent Branch, and that the integrity of the Association people, there is still an incomprehensiblo disrewas imperilled, and that I, as one of the gard of the danger incurred by the consumption founders, might be able to restore its cohesion of poisonous food, although the risks they run and strength. I therefore acceded to the are pointed out by the profession. request made to me, and I can but say that In respect of diet as an adjunct to strictly I have done

medical treatment, there has come about a The charming courtesy of those who have great change. There was a time, and that not attended the meetings during the year has been so long ago, when patients were allowed to eat beyond reproach, and to them I offer my very what they pleased, both as to quality and quangrateful thanks, and I can only regret that the tity, and though some measure of reform has Branch should have been concerned in a matter been accomplished in this matter, the reform which, regarded from any point of view, added is not complete either in adults or children. nothing to its dignity, its reputation, or its Young people are allowed to stuff themselves usefulness.

to their heart's content and to their stomach's

my best.

com

discomfort, and especially in the case of infants It would be superfluous at this day to speak the practice of overfeeding, and wrong feeding, of the microscope as an adjunct in diagnosis. continues to exist. The number of artificial It is so indispensable in certain bacteriological foods that are crammed into the alimentary enquiries that the wonder is certain forms of canals of these unfortunate creatures add disease could formerly be treated otherwise greatly to the infantile mortality, as I have than empirically. And here it is only right to

I reason to know from the number of necropsies speak of the progress which has recently been I have performed since the Infant Life Protec- made with the pathology of tuberculosis, and tion Act came into force.

more especially to express satisfaction at the In strictly medical, or, as it would be more consequent results of this enquiry in the treatcorrect to term it, drug treatment there has ment of that disease which I need hardly say is been a great change of late years. Many of now, or at least should be, conducted on printhe old preparations have been swept away and ciples wholly different from those formerly new ones substituted, not always, as I think, regarded as indispensable. I am not sure, howwith advantage. And here I may remark that ever, that the inclusion of non-medical persons the enormous number of pills, tabloids, ovoids, in the committees appointed to manage the and other forms in which nearly every drug is proposed consumptive sanatoria is an unnow manufactured by the wholesale druggists, mixed advantage; for while their intentions has unquestionably extended the consumption might be beyond cavil, their amateur efforts of medicine in these forms, more especially by might work mischief. The special instruction the general public, who, knowing both the of nurses, however, both in these and cognate nature and the quantity of the drug they are institutions, might possibly act as valuable swallowing, are enabled to treat themselves counteracting influences. without the interposition either of the doctor Touching the subject of our hospitals, there is or the pharmacist. Nevertheless, the quack not much new to be said save that the still thrives ; and he thrives because of his Contagious Diseases Hospital is not mystery. He demonstrates practically the truth pleted, and apparently is not likely to be of the very old adage, Omne ignotum pro mirifico. completed. Such portion of it as is finished

The treatment of certain diseases by what is stands in the grounds of the Yarra Bend comprehensively known as the serum method, Asylum, a mournful memento of the scriptural appears to maintain the favour with which it warning of what happens to persons who comwas at first received. Its efficacy has been mence to build houses without first sitting enthusiastically proclaimed, but, at the risk of down and counting the cost thereof. The being pronounced unreasonably sceptical, I am Government will tell us it is no affair of theirs obliged to declare that I cannot but regard this to provide the money for its conipletion, and treatment as still only on its trial. If it is the public will say we contributed twenty thoufound to maintain the specific virtues with sand pounds, and that should have been suffiwhich it is credited so much the better. Up to cient to complete it, and everybody will write the present I cannot but regard it as requiring or want to write to the newspapers to say confirmatory evidence in many cases.

what should be done. Meantime the fever. gical antisepsis as propounded by its apostle, stricken people are dying, and we shall wish we Lord Lister, there is no need to speak with were ruled by an autocrat who could order hesitation. Its success has been established things on the sic volo sic jubeo principle; and without question, and it has changed completely we shall also wish we had a new general both the method and the results of operative hospital in place of the patchwork institution surgery. With anesthesia and asepsis in opera- which ld hav been razed twenty years tive surgery, chirurgical procedure has been ago. From hospitals we may speak of medical made possible in cases which, little more than schools, and our own Medical School of the half a century ago, were past the limits of University necessarily claims chiefest attention. recovery, and which it was regarded as It has recently undergone some changes, some criminal to treat with the knife. Conservative of them not for the better, but at any rate it is surgery has thus been made possible where it nevertheless still the most flourishing departwas formerly not attempted by the most ment of our principal seat of learning: It will experienced surgeons. The Röntgen light, more probably suffer in common with the other over, has lent a valuable aid in diagnosing sections as the result of the financial cloud conditions of an obscure kind, which could not which has shadowed the chest; and by the be made clear save by much suffering and muti- time this has passed away we shall prrhaps lation.

have learnt wisdom sufficient to look more

Of sur

5

cases

2 cases

acute

sharply after the internal management of our care can but surmise what the condition is, public institutions.

and at times remains in doubt how or why his Once in this great city we had but one patient has recovered. medical society, now

we have four.

I do In this series of cases I have purposely only not know if this large number of medical included those in which the symptoms usually brotherhoods has enlarged the fraternal feeling associated with gallstone disease were present. which characterised the bulk of the profession That is to say, there were attacks of biliary forty years ago ; I question if it has. There is colic and in some cases jaundice as well. talk of forming a large medical association out I have divided them under the following of a union of the separate societies. This headings, but I shall speak only of those cases association, as I understand, is to take the which present features of special interest. place of the Congress which occasionally meets.

I recovered

2 in common hepatic But I also think it will not prove the success

1 maligCholedochotomy

duct

nant died predicted for it; matters were better left as

for gall stones, 1 in right and left he they are. Then as to medical books and

patic and common he. recovered periodicals. Of these we have a superfluity.

patic duct They tell one much that one already knows,

2 in common bile duct recovered and much more that one does not want to Rupture of gall

Rupture of gall{1 patient, aged 73, gall{ recovered

} know. It is true that the best of us are willing

bladder to be students all our lives, if only those who

2 recovered Malignant di

dying a essaying to teach us will tell us things that are sease of head of

few months worth knowing, but it is not always that they

the pancreas

after do.

14 acute suppurative

2 recovered And now I have to apologise for mention

cholecystitis and

2 died ing a number of matters with which you are all

cholangitis

5 familiar; but it is not a bad thing sometimes

suppurative cholecystitis

5 recovered

Cholecystotomy briefly to go over trudden ground, if only to be

17 cases

3 severe pericholecystitis 3 recovered sure that we are making at least some headway.

and impacted gall stones / In our copy books we used to write Non progredi

4 simple uncomplicated.. 4 recovered est regredi, and this adage, although common

1 distended gall bladder
colic, no gall stone

1 recovered

} place and old, is still true, and will

continue to be true; and I trust that, with our progress,

1 attachment of floating

kidney to, common bile ( 1 recovered there will also be good fellowship, good feeling, Biliary colic due

duct and enduring good faith in one another.

1 pressure of enlarged

You will observe that there are seven cases A SERIES OF TWENTY-SEVEN CASES OF

in all, three of whom died. Two died because OPERATION ON THE GALL BLADDER

the acute septic conditions for which operation AND BILE DUCTS.

was conducted had already poisoned them, and By H. V. C. Hinder, M.B., Ch.M. Syd., associated with malignant disease died

Lecturer in Clinical Surgery, and Hon: rather suddenly from a cause I was not precisely Surgeon, Prince Alfred Hospital, Sydney. able to ascertain, but judging from the en

feebled condition of the patient, I should say In looking over my histories of operation cases, that very probably she died from pulmonary I noticed that there was a considerable number thrombosis. of cases which had a more or less direct relation Interesting as I am sure you would find the to the gall bladder and bile ducts, and some of histories of these cases, I feel that I must them, too, with such perplexing histories and confine myself to those which have a more or associated with such peculiar conditions, that 1 less direct bearing on the remarks which I felt that here was to be found material for would wish to make in connection with the opening up a profitable discussion on a subject subject of cholecystitis. which comes within the ken of every professional Cases of choledochotomy are difficult as a rule man.

and I feel that it would be unjust to my The surgeon has a certain advantage over the surgical colleagues were I to pass over them physician in that he has greater opportunities without comment. for intra abdominal examination in those In two of the five cases of choledochotomy serious cases which

recover, whereas the the gall stones were found in the common bile physician, unless the patient dies under his duct, and were extracted by incising the duct.

to

(portal glands, syphilitic} 1 recovered

one

In one there were stones in the gall bladder in acutely septic cases. There were eight, and the common hepatic and also the right and left two of them died. One, a man of 38 years, hepatic ducts. The common hepatic duct was became suddenly ill with rigors. He was ill for opened and stones some fifteen in number were about ten days before I saw him. He was slightly removed. In the fourth stones were removed jaundiced and tender over the gall bladder and from the common hepatic and common bile hepatic region. He had no gall stones, and duct.

though I drained his gall bladder bile never The fatal case I have already mentioned flowed freely, and his condition was in no wise occurred in a woman of 54 with malignant abated. He merely became less jaundiced, and disease of the gall bladder. She had inter- died in about three weeks time. There was no mittent jaundice and very great pain. I post-mortem I do not know what was the thought that I might be able to relieve her by origin of the attack-it was probably intestinal. getting rid of the stones. I was not aware A man of 50 years had an attack of biliary that she was suffering from malignant disease colic twenty years ago, and another six years before I operated. At half past one she was after that. During the past twelve months the seen by Dr. Heggaton and seemed well with attacks have been very much more frequent. a pulse of 104, and she died shortly after three. He was continuously ill for three weeks before

In none of these cases did I make any admission. He had rigors about every eighteen attempt to suture the bile duct. In three of hours after he was admitted to hospital. He them so matted were the surrounding structures was operated on the third day after admission. it would have been impossible to do so. In the I admit that this was three days lost. On the other two it was possible. A rubber drainage last day he for the first time showed some slight tube was placed with one end on the opening jaundice. He had very marked tenderness in the duct, and outside and inside this tube over the gall bladder. His pulse was 130, were placed gauze drainage wicks. If septic and his temperature 102°, and he looked very symptoms had subsided the drainage was ill indeed. After some difficulty his gall discarded after a few days when a firm lymph bladder was found deeply situated and hidden track had been established.

by omentum and transverse colon. It was It is well known that linear incision of a extremely small

, and distended with gas in the mucous track like the urethra heals with a fine upper part, so that I was almost persuaded that linear scar, and is not followed by stricture. I was dealing with intestine. On opening it Arguing from this I acted as I did, nor have I gas escaped, and in the lower part there was had any reason to be disappointed with the about a teaspoonful of very fætid pus. No gall result.

stones could be found. He recovered rapidly, Suture is unnecessary and often impossible. but returned in two months' time with dragging It requires a larger incision, necessitates a pains and a history of a rigor. I opened, and greater amount of handling and materially found no evidence of gall stones in the ducts, prolongs the operation. Suture also offers a but there were necessarily many

adhesions fair chance of diminishing the calibre of the duct. which I separated. He at the present time

These cases necessitating choledochotomy are looks well, but he still has pain which he often associated with a pathological condition asserts is not at all like the old trouble, and is, of the bile ducts due to backward pressure and I believe, to be attributed to adhesions, infective processes, so that drainage, free drain inasmuch as he is gradually getting better. age of the ducts is an absoluto necessity and a Harris states that this often occurs for some sound surgical procedure.

time after operating on shrunken gall bladders. Even in those cases where men have sutured, In one other case did I experience a like result. the duct leakage has frequently taken place, The pains left gradually and have not returned and in some

cases where suture has been after eighteen months. Four other cases were adopted without drainage, leakage has occurred operated on, when rigors and high temperature, and has been followed by death. It is evident and offensive purulent material and gall stones then that suture of the duct is not necessary, and were found in the gall bladder. One of the unless it be backed up by good drainage, it is patients with malignant disease of the head of likely to be productive of fatal results. Mayo the pancreas gave a history of old attacks of reports eleven cases of choledochotomy. In biliary colic, and no stones were present. She four he sutured and drained, and in the re. was extremely jaundiced. The other was maining seven he did not suture. All slightly jaundiced, but

whole the recovered.

pancreas was involved.

The bile duct was I shall next direct your attention to the affected by pressure only.

was

It certainly seems odd that in these two I hope I do not assume too much when I say cases there was a history of old standing biliary that there is a common impression held by colic, and the presence of gall stones is said to many that the intense pain of biliary colic is have a marked effect on the production of due to the effort on the part of the biliary cancer and chronic inflammatory affections in passages to expel gall stones. This is, prothis region. Both of these patients died a few bably, in the great majority of cases, a totally months afterwards.

erroneous view, and most likely the correct one A young unmarried woman, aged 22 years, is that each of the attacks represents an attack gave a history of attacks of colicky pain in the of cholecystitis. Owing to the inflamed condiepigastrium for the last eight or nine years. tion of the mucous membrane of the gall These attacks lasted for one and a half to three bladder, and particularly the bile passages, hours, and came at intervals of from two to there is a resistance to the outflow of the bile six weeks. The pain was felt radiating out and mucoid secretion. The increase in from the epigastrium. She was never jaundiced. tension thus occasioned immediately excites The attacks so far as she knew bore no relation within the tender gall bladder a reflex spasm, to her meals or to food taken. On the day a biliary colic. following the attack practically all symptoms of Spasm of the urinary bladder will take place it had vanished. On opening the gall bladder when ulcer or acute cystitis is present. Attacks I found the fundus about twice the normal of renal colic are not uncommon in cases where size, elongated and sagging downward. The the stone does not engage the ureter. A man bile was thick and treacley ; the cystic duct may have stone in the kidney for years without

dilated in its upper part. A No. 4 giving rise to any pain whatever. How often, sound could be passed. No gall stones were on the other hand, has a kidney been cut down present. Part of the fundus was cut off and upon for spasmodic colicky attacks, a marked the raw edge was attached to the abdominal symptom of stone when no stone has been wall. I judged that by shortening and present. We can only infer then that these straightening the gall bladder, the bile could attacks of pain are due not necessarily to a the more easily escape, as the thickened con- blocking obstruction, but to a reflex spasm, dition was probably due to stasis. Since then, brought on by perhaps an amount of interfive months ago, the patient has been quite well. ference sufficient to produce but a slight

This case showed a fair amount of inter-increase in the pressure on the irritated epimittency, but the symptoms of the case I am thelial surface behind it. about to mention were of a fairly mild, but The very fact that, in some, biliary colic has persistent character. He was a man sixteen been present in a marked degree when no gall stone in weight and 33 years

For the stones have been present, is sufficient to induce past six months he had been troubled with one to believe that other conditions besides more or less pain in the region of the gall gall stones must bear a causal relation to the bladder, and for the last six weeks he had been colic. This may be due to inspissated bile and jaundiced; the jaundice gradually increasing to pressure from without, but considering the in degree. He had, I learned, a slight and number of cases in which varying degrees of an varying temperature all through, and for a ulcerative process have been found, there is a short period before operation it had ranged as strong presumptive evidence that pathological high as 102°. His gall bladder held about half changes in the mucous membrane or the wall a pint of thick bile, which was not purulent. of the gall bladder are a very strong factor in There were no gall stones, and only a few ad- the production of biliary colic. hesions about the neck of the gall bladder. Naunyn and Stolz state that the bile is The gall bladder was drained and the tempera- | not absolutely aseptic, but that organisms and ture and jaundice subsided. He left hospital usually bacillus coli, are few in number, very in two months time quite well. A few weeks attenuated and only obtained by sowing the after this he became ill with a profuse and culture medium with large quantities of biliary frequent diarrhea, and in the interval preced- Auid. If streptococci are carefully introduced ing this he complained greatly of his want of into a normal gall bladder they are got rid of appetite and his weakness. I saw him a few fairly quickly, but if the mucous membrane is hours before death, I could discover neither injured, or if the outflow of bile is obstructed, sign nor symptom of liver trouble. No post the organisms present multiply and probably a mortem could be obtained, but I was very much fresh invasion takes place, for bacillus coli inclined to think that both illnesses originated in almost always predominates. some intestinal condition of a septic character. Attacks of biliary colic, of cholecystitis, or of

of age.