THE AUSTRALIAN
MEDICAL JOURNAL.
AUGUST, 1876.
" Maldon, July 11, 1876.
" The President of the Medical Society of Victoria, Melbourne.—
Dear Sir,—In a case of accidental poisoning from chloroform, in which a considerable quantity had been swallowed, I found that the inhalation of liquor ammoniac proved most valuable, restoring the patient to consciousness after other means had been tried in vain.
" I therefore beg, through you, to suggest that a similar method of treatment be tried in cases of poisoning from snake bite, as it is easy, simple, and, in competent hands, safe.
" I am, dear Sir, yours truly
" JOHN O'NEILL, M.D."
NEW MEMBER.
Dr. Talbot, of Brunswick, was elected a member.
EXHIBITS.
The honorary secretary exhibited a sample of preserved goats' milk, forwarded by Mr. Joseph Sullivan, with the subjoined descrip- tion of its preparation :—" Bran is boiled in water, and the water then used to boil rice in. The starch is then extracted from the
VOL. XXI.
MEDICAL SOCIETY OF VICTORIA.
ORDINARY MONTHLY MEETING.
WEDNESDAY, AUGUST 2, 1876.
(117 Collins Street East.)
Present : Dr. Day, Dr. Neild, Dr. P. Smith, Mr. Ralph, Dr.
Molloy, Mr. Kennedy, Dr. Williams, Mr. Barker, Dr. Pinnock, Dr. Blair, Dr. Ryan, Dr. Graham, Dr. Martin, Dr. Bleasdale, Dr.
Jonasson, Dr. McMillan, Mr. Morton, and Mr. Fitzgerald.
CORRESPONDENCE.
The following letter was read :—
246 Medical Society of Victoria. [Aug.
Tice, sugar added, mixed with goats' milk, and the compound formed into a powder, with a small quantity of calcium, to assist digestion."' Dr. MARTIN, speaking of the preparation exhibited, remarked that, as infants did not digest farinaceous food until the age of four months, there was an objection to the presence of bran and rice in this powder. If goats' milk were necessary to be used at all, let it be supplied in a concentrated form as milk only. The Anglo-Swiss milk was of this kind. He thought they should have been furnished with more of the rationale, and a less crude description of the mode of its preparation.
Dr. BLAIR thought Dr. Martin knew no more of the Anglo-Swiss preparation than this one. This one, moreover, was a local product, and deserved encouragement. It was something more than a mere mixture of milk and rice powder.
Dr. BLEASDALE believed Bloor's preparation had been found -useful, and the composition of it was known. He (Dr. B.) had lately been over Guest's biscuit factory, and had seen some dyspeptic biscuits, and he had suggested some modification in the way of malt flour, which had been found useful. In these foods the introduction of a natural ferment might take the place of the saliva of the young child. In the Appennines, the sweet chestnut supplied a consider - able source of food, and a curious fact was ascertained—that the youngest children could be brought up upon chestnut-flour. It might be a question as to how far goats' milk could supply mothers milk. Indeed, there was much discrepancy of testimony on this subject.
Dr. MARTIN mentioned, incidentally, that Mr. Guest was ready to make any kind of biscuit for dietetic purposes.
Dr. MOLLOY and Dr. SMITH suggested that there should be some testing of the preparation.
Dr. RYAN'S experience of the Anglo-Swiss milk had been such as to satisfy him of its value. He did not think it contained any farinaceous matter whatever.
Dr. Martin, Dr. Smith, Dr. Bleasdale, and Dr. Blair, were appointed a committee to examine and report upon the preparation at the next meeting of the Society.
Dr. PINNOCK exhibited a portable lamp, adapted for microscopic, ophthalmoscopic, laryngoscopic, or spectacular work, and described it by quoting as follows, from the last edition of " Carpenter on the Microscope" :—" It is adjusted to any height, is capable of being packed in a small compass, and of being carried in any position .without spilling the liquid it burns. This desideratum is now -supplied by Mr. Swift, who has devoted much ingenuity to the construction of such a lamp, the special difficulty being to prevent leakage, from the passage through which the wick rises, without interfering with the ascent of the fluid. The lamp is mounted on a telescope-pillar, which supports it steadily at any height, from 4
1876.] Treatment of Scarlet Fever. 247
to 12 inches, and this is screwed into a tripod foot. By pushing the telescope-pillar, unscrewing the tripod, and inverting it over the chimney, the lamp can be packed in a tube 7i inches long, and 1- 3g inch in diameter. It gives a good bright flame, and burns for hours. The size of the receiver might of course be increased, so as to enable the lamp to burn longer, but this would add to the bulk of its case."
Dr. PINNOCK remarked that he had suggested to the inventor of the lamp a contrivance by means of which a much more powerful light might be obtained, consisting of a metal flat projecting ring, which could be slipped over the lamp chimney, resting on the projecting portion just above the glass. A small screw depended from its under surface, and on to this a conductor was screwed, which could be brought directly in front of the glass at will by rotating the ring. By means of the ordinary laryngoscopic reflector attached to the forehead, by an elastic band round the head, a brilliant light might be thrown on to any required spot. The price of the lamp was £1 10s.
TREATMENT OF SCARLET FEVER BY PER-OXIDE OF HYDROGEN AS UNCTION.
The honorary secretary read the following letter, received some time ago by Dr. Day, from Dr. Moffitt, of Sydney :-
" 135 Castlereagh-street, Sydney, 2nd March, 1876.
" Dr. DAY.—Dear Sir,—Some two or three months ago I noticed in the public papers an account of your mode of treating scarla- tina, and, having had a fatal case under the mode I usually adopt in treating the disease, I made inquiries of one of our leading chemists here (Mr. Watt) whether the ozone ether could be obtained in Sydney, and, finding that he had a good supply, I made up my mind to give it a trial, using the ordinary disinfectants in the sick room and passages—on which you will see my paper in the N. S. W. Medical Gazette, of which I send you copies.
" I have treated altogether ten cases, two of which were adults.
A man, aged 58, on whom the eruption came out very well—the gargle, ' two drachms of the ozone ether to eight ounces of water, with half an ounce of glycerine,' speedily relieved the throat ; the directions were, to use it when required, and to swallow a little afterwards. The ointment, one drachm to the ounce of lard, gave great relief to the irritation of the skin, and was very much liked by the patient, who was glad to have it applied three times a day.
The other case was a mother nursing her children through the disease. She got scarlatinal sore throat of a most distressing character ; the gargle used freely every second hour completely relieved her in twelve hours, and she did not suffer again from that cause, although she was in close attendance on her children for the next three weeks. The other eight cases were young persons and children. In two of the cases the eruption did not come out well,
s2
248 Medical Society of Victoria. [Aug.
and as they could not gargle, I gave a teaspoonful of the gargle to be swallowed every hour, with the happiest results. The ointment was also used. In the other six cases the eruption came out well ; the same routine was followed with them. I observed the applica- tion of the ointment was specially grateful in every case, and the little patients often asked to have it applied when they felt the irritation of the skin coming on, which was complied with in every case. From my observation of this mode of treating the disease, I consider one of the best things in connection with it, is the com- parative immunity of the attendants from catching the disease. I believe the danger of taking the disease is reduced to a minimum.
There has been no second case in any of the houses where this treatment has been fairly used, with one exception, and that was clearly traced to a child, who had escaped where this treatment was adopted, and was thought to be safe, going into a neighbour's house, where no precautions were taken; she caught the disease there and brought it home. She was immediately put under the ozone treatment, and has made a good recovery. I have not lost a case since I commenced your treatment, and I have fully made up my mind to persevere in it and give it a fair trial, and I may, perhaps, report any further cases I may have in my practice, which is principally among the upper and middle classes. I have been thinking, if this mode of treating the disease is equally effective in the hands of other medical men, scarlatina, like small-pox, might be stamped out altogether. The great difficulty would be with the clubs. Before a Sanitary Commission lately held in Sydney, I advised the erection of a temporary hospital of wood in a healthy locality, to which all voluntary patients should be removed, and those who would not avail themselves of this aid should be com- pelled to hoist a yellow flag, with Scarlatina' printed on it, and to keep it up under the surveillance of the police, until a doctor's certificate was given that the house was free from disease ; and that no person suffering from scarlatina should be allowed to go abroad, or be seen in any place where people congregate, or in any con- veyance of a public kind, under a heavy penalty. That close cabs of a special colour, and without lining of any kind, should be appointed to take patients to the hospital, and when the scarlatina is ascertained to be completely stamped out, the hospital should be burned. I believe, with the aid of your ozone treatment' being made compulsory in all cases, and the strict enforcement of the above sanitary laws, scarlatina would soon become a thing of the past.
" Having used your treatment with the above results, I feel that am bound in honour to make this acknowledgment, and congratulate you on being the first to find out so effective a remedy for this dire disease, which every year has carried off so many hundreds of our young people, and many heads of families, especially mothers, in the shape of puerperal scarlatina,' one of the most fatal diseases with which I am acquainted.
1876.] DR. P. SMITH on the Registration, of Disease. 249
" If you have any printed matter respecting the ozone treatment I would feel greatly obliged for a copy.
" Believe me very truly and faithfully yours,
" A. MOFFITT: 7 Mr. RALPH had had one case of scarlatina, in which he had used the ozonic ether with glycerine, and had also employed it as a spray.
Dr. MARTIN inquired if lard was essential for the introduction of the per-oxide.
Dr. DAY : Not necessarily so, but he thought it had the advantage of oil. The cocoa-butter was still better.
Dr. RYAN would ask Dr. Day his opinion as to how the poison was got rid of ?
Dr. DAY : Chiefly by the skin and mucous membrane. He administered it internally, therefore.
Dr. MOLLOY had used the ozonized lard with a somewhat varying benefit. He had not, however, found it a universal preventative as regards others. In fact, some who had no such protection were less subject to its influences. He preferred the lard to the oil.
Dr. DAY urged the use of the lard thoroughly three times a day.
As infection did not extend beyond a short distance, it seemed rational to effect oxidation of the poison immediately on its leaving the body.
Dr. MOLLOY drew the attention of Dr. Day to the extensive use of the ozonized lard in Clerkenwell, London.
A conversation ensued, the purport of which was the effect of ozonized lard in limiting the activity of the poison, the general .experience being conclusive to that proposition.
The next paper read was as follows :-
ON THE REGISTRATION OF DISEASE.
BY PATRICK SMITH, M.D.,
Resident Medical Officer of the Yarra Bend Lunatic Asylum.
By disease registration, I would understand the registration by medical men of all cases of sickness occurring in their practice, the locality, &c., being also specified, just in the same way and by the same machinery as causes of death are now registered. If all cases of sickness were to be thus registered, the undertaking would at first sight seem a most formidable and costly one for any state to undertake. Its formidable character would, I believe, on closer examination disappear, and the cost would be as nothing compared with the saving of life likely to be effected. I fear public opinion is not yet ripe for sanctioning such a measure, but I think that the registration of all epidemic disease is inevitable in a not very distant future.
250 Medical ,Society of Victoria. [Aug.
It is needless for me to point out the immense benefits that have already accrued from our present system of registration of deaths, births, &c., of how much legislation such data have been the basis, and of what advantage to the national health. We are thankful for what we have got, but we now need an extension of the system.
We need something more exact than the mere registration of the causes of death, viz., registration of disease or sickness. At the present time the State, as far as its knowledge of the extent to which sickness may prevail, has been compared to that of a commander-in-chief who knows, indeed, how many of his men have been killed, but does not know how many have been put hors de combat, and therefore is ignorant of his available strength. It is true that a certain ratio does exist between the number of deaths from any disease and the number of cases. But this ratio holds good only in a few instances, and medical science above all things demands exactness in its data.
As an illustration of what we lose in our knowledge of certain diseases by the registration of the causes of death only, I quote from the Lancet the following :—" Taking the group of rheumatic diseases, more suffering is caused by it among all ranks of the community and more protracted disability to labour (and consequent public loss) than by any other class of maladies except that of the respiratory organs. Yet, as rheumatism and gout are seldom directly fatal, they attract comparatively little attention in our sanitary statistics." As in this instance so in many others ; the ratio between the number of deaths and cases of sickness may be said practically to have no existence. If in our own colony we take the instance of hydatid disease it is seldom assigned as the direct cause of death, and we know nothing at all of the extent to which it prevails by our Registrar-General's returns. How important it is to have accurate knowledge on the point I need not say.
But disease-registration is one of those matters which, strictly, does not concern the medical man, which would in many cases tend to the curtailing of his practice, and which is distinctly the function of the State. Nevertheless, the art of preventing disease has been so readily taken on as part of his duty by the medical man, that it has come to be looked upon as his function as much as the cure of disease ; only with this difference, that for the latter he is supposed to be entitled to be paid, for the former not.
I shall briefly state what seems a few of the advantages to be derived from accurate disease returns.
(1.) The cost of any particular disease could be estimated.
Few men outside our profession seem to have any comprehension of the expense to the State of disease. The social economist, however, who might regard as next to nothing the suffering caused by any disease, and the agony of mind arising from friends and relatives killed by it, inasmuch as pain and grief have no money value, would stand aghast at the direct money loss. If, for instance, the direct money loss caused by the epidemics of measles and scarlet
1876.] DR. P. SMITH on the Registration of Disease. 251 fever which have lately visited the colony could be accurately estimated (as they can be approximately), I feel convinced that the most rigid utilitarian would grudge no expense for any attempt to prevent the recurrence of these maladies. The expenditure of a large sum of money, even with the bare chance of such prevention, could not be considered ill spent. But at present we can give no very definite idea of the cost, since, apart from disease-registration, we do not know the number of cases.
But (2) it would be possible to localise at least some diseases by means of registration.
Any system of disease-registration would, of course, include the locality of its occurrence. But the subject of disease-localisation is so wide that I cannot indicate, even in the most general way, the sanitary and social revolution that it would create. If it were shown that scarlet or typhoid, or diphtheria or dysentery was in the habit of selecting certain portions of this city or suburbs, or certain inland towns or disticts, as its favourite residence, it would be impossible to avoid the conclusion that the disease originated there, or that it was attracted thither by suitable soil. Inquiry would be straightway directed into the drainage, sewerage, water-supply, house foundations, overcrowding, or general filth of the neighbour- hood. The de novo or other origin of disease might be thus settled.
Assuming, then, that it would be possible to localise diseases of some kinds, it would then be an easy matter to construct disease- maps of our city as well as country districts.
Supposing such a map based on disease-registration returns, authorised, say, by our Central Board of Health, could be purchased at any of our booksellers, or could be hung up at the town halls, city and suburban, or in any other public place for reference ; heads of families and others on the look-out for houses would thus have some idea of the healthiness or the reverse of the various districts of the city and suburbs. If a person in search of a house saw by the colouring of the map that certain streets in Collingwood were the habitats of diarrhoea or of typhoid, that other localities in Carlton
or North Melbourne were seldom without scarlet fever or diphtheria,
would he, unless urged by dire necessity, take up his abode there I Any approach to such a state of things would at once stir up the owners of property, who, being touched in their tenderest part, the pocket, would in time stir up the various corporations to thorough draining and systematic cleansing. The property-owners under these circumstances might also attend to the proper ventilation and general cleanliness of their houses. The byeways, right-of-ways,
&c., of our city, and even of our suburbs, are in many parts crowded with dwellings in such a manner as to defy belief, in those who are less familiar with them than medical men. The effects at present we cannot estimate, and probably shall be unable to do until some pestilence overtakes us. On such a condition of things, disease-registration would at once tell.
252 Medical Society of Victoria. [Aug.
But further, it would be possible by means of disease-localisation, in a manner which we cannot do at all at present, to institute comparisons between the health of dwellers in the city and in the country, on highlands and on flats, on clay subsoils and sandy, between the health of a community in wet seasons and seasons of drought, &c. These seem to me a few, and but a few, of the results that would be obtainable by disease-localisation, and if it were possible to proceed no further, take no further action on such facts, they would be worth collecting.
The advantages arising from disease returns that I have above mentioned, hold good in regard to general disease-registration, but in a much greater degree to epidemic diseases. It is in those in- fectious diseases which, allowed to gather to a head, become epidemics, that disease-registration would be able to effect most.
All are agreed that if an attempt is to be made at all to limit, not to say stamp out, an infectious disease which may ultimately become epidemic, it must be by dealing with the very earliest cases of its occurrence. As matters at present stand, a death by scarlet fever or measles is the first intimation that the sanitary authorities have that these diseases have appeared in any locality. But before a death has occurred by it, a fever may have propagated itself, and made a score of centres whence to radiate over a whole community.
If infectious diseases, as some think, can be originated de novo, yet as each case becomes a centre of indefinite propagation, it might be possible, by early disinfection and isolation to at least limit the spread of the disease, so that it should not assume epidemic proportions.
If, on the other hand, they are in this colony simply imported, then, indeed, by securing early and complete isolation and disinfec- tion, the stamping out of them would be quite possible.
But the question arises " How is the opportunity of dealing at the earliest moment with infectious diseases to be secured, and who is to deal with them ? "
The registration of all diseases, though giving much valuable information, yet supplies less that could be taken advantage of than that of epidemic diseases. It is in these, chiefly, that prompt action could be taken, and taken with success. Behind the registrar there would, of necessity, be some organisation to carry out preventive measures. Where registration of disease exists—for I am sketching no Utopian or merely paper project—the proceeding is something like this. Every medical man in whose practice any case of infectious or self-propagating disease occurs, is bound by law to give information of the same—register it, if you will—to the local health officer within, say twenty-four hours of his diagnosing the disease, specifying disease, locality, street, and house. The local health officer will visit the house, advise the removal to a hospital for infectious diseases. He will take in hand, through his subordinates, to disinfect by heat the infected bedding, furniture,
&c. He may also inquire into the local causes, if any, of the fever.
1876.] DR. P. SMITH on the Registration of Disease. 253 In case of no hospital being available for such cases, he may give directions as to isolation and recommend experienced nurses.
Some such proceeding in case of infectious diseases is at this moment, and has been for many years, in practice in some conti- nental States. I may mention, on the authority of the Lancet and British Medical Journal, two kingdoms where this amount of civilisation has been reached, viz. Holland and Denmark.
I am met with the objection that the States of the Continent are too paternal altogether, and that the citizens have been accustomed to have the liberty of the subject interfered with in a way that no British community would tolerate. I have then merely to state what may be news to some, that in the 17th clause of the New Zealand Medical Act, it is made a condition of the right of any medical man to practise in that colony, that within a specified time after the recognition of any infectious disease he shall register the same with an officer appointed for the purpose. (I refer you to the Lancet of 26th September, 1874.)
With what authority (or if any) the person with whom the registration is effected is armed for the removal of the infected 'person, or dealing with him in any preventive way, I have been unable to discover, either as regards New Zealand or the Continent.
The introduction of it in New Zealand is doubtless with the view of following up the registration by some such proceeding as above described, and the fact has encouraged me more than anything else to bring the matter before the Society. It is just possible that it may be easier to make such an innovation at an early period of our national existence than it would be later.
What is possible for individuals ought to be possible for States.
During an epidemic of small-pox in Salford in 1873-74, the Manchester and Salford Sanitary Association, at its own expense, engaged twenty-nine medical men in the district where the disease was prevalent, to report each case occurring in their practice at the office of the association. The payment was 2s. 6d. for each case so registered. Armed with no authority at all, but relying on per-
suasion, the employes of the association communicated with the family of the person affected with the disease, offering to remove him to the Small-pox Hospital, to disinfect all clothing, &c., with which he had been in contact, and, failing that, to provide skilled nurses who could carry out isolation and disinfection so as to lessen the chance of spreading the disease.
These measures were said to have greatly limited the ravages of the disease ; and it is not difficult of credence.
The failure of complete success has been in the want of power to Compel removal to a situation where complete isolation could be effected.
In the commencement of an epidemic the carrying out of some such plan would, I think, be the means of stamping it out, provided compulsory removal were possible. I cannot help thinking that if a few comfortable cottages were provided for the reception of fever
254 Medical Society of Victoria. [Aug. 1 cases, where the sick could be nursed till recovery much as in their
own homes, it would not require more than persuasion to induce
parents with fever-stricken children to go there. If the conse- 1 quences involved in the few first cases of an infectious disease being
allowed to become an epidemic were taken into account, it would behove any community to make it worth while for an infected family to remain in quarantine till danger was over. The education of most communities in matters sanitary will have, in the opinion of most of you, to be conducted for a long time ere such arrange- ments would be readily acquiesced in. The State may be slow to make the experiment of attempting to stamp out an epidemic at its commencement—for any other period of its existence stamping out need not be tried. Yet I appeal to you, whether wilder and less feasible experiments, and far more costly, have not been under- taken in this Victoria of ours, and with far less humane objects in view.
The question of expense of such registrations compared with the expense of one epidemic would be as nothing. If every medical man in the colony were to be in the employ of the government as far as the registration of epidemic disease is concerned, and if he were to be paid for such, the comparative cost would be utterly trifling, and the direct gain to the community, as well as to science, would be very great.. A complete division of the colony into registration districts, each with its health-officer and assistants, would seem to some impracticable. But I have already pointed out that, quoad infectious diseases, Holland and Denmark are in this position, and Manchester, Edinburgh, Brighton, and many other cities in England are at this moment attempting to get into it Nor, after all, would such arrangement be unheard of. In the days, of the Roman Emperors Theodosius and Justinian the archiato populares, or State physicians, were appointed, to the number of ten in the largest towns, one to each division or sub-division ; seven in towns of the second order, and five in the smaller. These collec- tively formed a college, whose duty it was to attend to the public health. It is impossible for me to enter into all the difficulties of detail in carrying out the registration of infectious diseases. I see many. I only point to the fact that other countries have overcome them, and so might we. To show that attempts are being made in England to initiate such a system, I give a reference to this subject in the Lancet :-
Dr. Taaffe, medical officer of health for Brighton, in his last Annual Report (1874-75) says :—" The movement now on foot foF securing the intimation to the officer of health of all cases of infec- tious disease, is one well worthy of support. By that means a know - ledge would be obtained of not only every unhealthy locality, but of every unhealthy street, and every unhealthy house where these diseases are fostered and encouraged by sanitary defects. During 1874-76 ninety houses where infectious diseases occurred were inspected in Brighton with the best results, and in no instance was there ail'
1876.] DR. P. SMITH on the Registration of Disease. 255 clashing with the interests of private medical practitioners, but, on the other hand, the work was carried on with mutual good feeling between myself and the medical attendants. At the same time the strictest secresy surrounded all the proceedings. Nor was the course adopted objected to on the part of heads of families, who invariably felt that the medical officer of health was their friend, and that his interference was for their own and the public good.
Incalculable benefit must ensue from the knowledge thus obtained."
The whole subject of epidemiology not only possesses claims upon es as medical men, but is of no ordinary interest and importance.
The question as to the etiology of the spreading diseases seems to roe to be in a fair way to receive an answer through this study. If a few careful observers among the medical men in each of the Australian colonies were to chronicle the first appearance, origin, and course of epidemics, their connection with or contemporaneous- ness with epizootic, or epiphytecs, and insect or other plagues, it would be possible in such way greatly to increase our knowledge of them, and perhaps to do something in our own way to solve the problem of their etiology. If this were done, it would then be an easy matter to ascertain whether our Australian epidemics were contemporaneous in appearance with those in Europe.
Dr. BLEASD ALE observed that, in connection with the Central Board of Health, this subject had been considered.
Dr WILLIAMS regarded the proposition in connection with hospital practice as impracticable. As to out-door hospital practice, he believed it to be, as described by Dr. Youl, an exchange for the spread of diseases. Until patients could be treated in their own districts, the returns would be necessarily imperfect. Another mode of spreading zymotics, especially scarlet fever, was through the in- Patients, who were regularly visited by their friends.
The PRESIDENT, during 26 years had kept a register of all the epidemics, and he had accumulated much valuable information.
Fle was strongly in favour of the establishment of such a system.
He thought we should get at a better conception of the causation of disease, more especially by observing in connection with it the Changes in the condition of terrestrial magnetism. Where there was a balance of magnetism, diseases were well known to be lessened in intensity. Then as to locality, the existence of an alkaline soil had been found to increase the activity of cholera. A system of registration would afford us more exact data in this respect.
Dr. SMITH, in ,reply to Dr. Williams, thought the hospital cases would represent so small a proportion as not to affect the common result. He thought a branch of this society might take up specially the subject of epidemiology. We had advantages here which did not obtain at home. The influence of general causes was shown by the fact of the lower animals being coincidently affected.
ALTERATION OF RULES.
Dr. NEILD moved and it was carried, " That the following be added to the rules of the Society, viz.:—In Rule 3, after the word ' ordinary,' that the word corresponding be inserted. That in Rule 5, the following sentence be added, after the word required Candidates for election as corresponding members shall be members of the profession living out of the colony. They shall be legally - qualified medical practitioners in the country where they reside, and nature of their qualification shall be stated at the time of their nomination. They shall pay an entrance-fee of one guinea, but shall be exempt from the annual subscription. In all other particu- lars they shall be subject to the same conditions as ordinary members.
Town or country members leaving the colony may become correspond - ing members by signifying their wish to the committee, and they shall thereupon be relieved from any further payment of subscriptions."
ON THE PARASITIC THEORY OF DISEASE The influence of living organisms, and especially of those belong- ing to the vegetable kingdom, in the production of diseased con- ditions in man and the lower animals, as well as in the more high 19 organised plants, has excited much attention during the last feW, years. Long ago, of course, the opinion was frequently expressed that minute organisms, animal or vegetable, were probably the cause of certain diseases ; but it is only within a comparatively recent period that anything more than theoretical considerations could be brought to bear on the question. During the last twee/
years particularly, there has been a growing accumulation of observa - tions and experiments bearing on the subject, sufficient to can/
conviction to most minds that a good many diseases in human beings are directly caused, and not merely accompanied, by the presence of vegetable organisms of different kinds. Facts are Al° being accumulated on a large scale, and in all probability a oil;
siderable time must elapse before many points that are still doubtful can be placed beyond dispute. The importance of the subject is s°
obvious as scarcely to need insisting on. A rational treatment 0,, any disease must always be dependent on a knowledge of its ,causation ; and so long as we are in the dark about the agents of
influences which originate or keep up diseased conditions, our efforts in the way of prevention and cure, however apparently successful;
must always bear the taint of uncertainty. If vegetable parasite can be shown to be the essential cause of certain diseases, th e
greater call and encouragement have we to devote increased ate
°, tion to the prevention of them by the use of all hygienic measures' -and, above all, by t' a free and careful use of those agents knovittr,
disinfectants, the best of which have been clearly shown to act Di 1 256 DR. JAMIESON on the Parasitic Theory of Disease. [Aug.
1876.] 'DR. JAMIESON on the Parasitic Theory of Disease. 257:
destroying the minute forms of vegetable life which are active in bringing about processes of putrefaction and fermentation. But in addition to its aid as a guide in the scientific application of pre- ventive measures, I hope to be able to show that the theory under consideration has been fruitful in the suggestion of measures for the cure of disease, when it has already taken root ; and that if the establishment of this new doctrine has the effect of banishing some forms of treatment which have been long in vogue, it has helped us toward the use of others calculated to be more effectual.
In discussing the subject, the plan which I propose to adopt is, to state first of all the general grounds derived from ordinary clinical experience, for holding that the acute contagions diseases, generally called zymotic, are caused by some contagium,
1. It is certain that the poison which produces these diseases has the property of multiplying to an indefinite extent. A portion of the contagium which produces scarlet fever, so minute as to be incapable of being weighed exactly even with the most delicate balance, may bring on that disease in one individual in some per- fectly isolated community, and in a short time, from that one, the disease may spread to thousands, every one of whom has in his, system an amount of the poison sufficient to allow of its transmission to a considerable number of healthy persons susceptible to its influence. Only an organised being can possibly be supposed to reproduce itself in this way.
2. It may be said of all these diseases, that they have a period of incubation. This period in many of them is very well defined, and its existence is best, if not only, to be explained on the supposition that the contagium requires a certain time to multiply and spread over the body, before it can unfold its full activity.
3. The amount of the contagium of any of the zymotic diseases required to produce that disease in a healthy person, might almost be said to be infinitely minute, when compared with a full dose of even the most powerful poison known to the chemist. Delafond has shown that anthrax can be imparted to a healthy animal, by means of the fortieth part of a drop of the blood of one which is diseased ; and, indeed, Davaine, whose name is specially associated.
with the study of this disease, has asserted that anthrax can be inoculated with a fluid which contains only one millionth of a drop of diseased blood. We are all acquainted with the almost infinitesimal quantity of lymph required for the production of the vaccine disease. Compare with any of these the dose even of such an active poison as hydrocyanic acid, necessary to produce dangerous symptoms, and it will be at once apparent that, in the contagium of the zymotic diseases, we have to do with something quite different from any known chemical poison.
4. Chemists have not been able to discover in the bodies of men or animals suffering from a zymotic disease, any substance with
258 Du. JAMIESON on the Parasitic Theory of Disease. [Aug.
well-defined chemical properties which is capable of again producing the disease. The amount of the contagium present in the body, when the disease is at its height, must be considerable, and yet, in spite of the perfection which analytical chemistry has attained, and the very minute quantities of such poisons as strychnine which can be detected in mixed organic matters, there has been no approach made to the discovery of specific organic poisons in measles, scarlatina,
&c. For the present, I leave out of consideration the substance called sepsin, as, whatever may be its relation to septicaemia and other forms of putrid poisoning, these diseases are not included among the zymotic infectious diseases.
5. The action of disinfectants in destroying the fixed contagia of epidemic diseases is to be explained only on the supposition that they actually kill, or at least put a stop to the functional activities of minute organisms. The observed effect of some of the best disinfectants in checking fermentation and putrefaction, by destroy - ing the minute organisms, which are at work in carrying on these processes, indicates how they act in preventing the spread of epidemic disease. More particularly, the effect of heat in destroying the germs of disease, suggests the conclusion that it operates by killing minute organisms, as we could scarcely expect exposure to a temperature equal to, or even a little higher than, that of boiling water, to be so effectual in annulling the properties of a definite organic compound, not an organised structure or living organism
Other points might, perhaps, be adduced tending to the same conclusion as those which have just been discussed ; but I am unwilling at this early stage of the argument, to introduce anything that can easily be made a subject of dispute. Those which have been adduced are tolerably cogent, though it must be allowed that some at least of them might possibly admit of another interpretation ,than that which has been here given to them. It seems advisable, however, to refer to any such differences further on, and rather to continue with the presentation of proofs and arguments which are admitted by nearly all authorities of any weight.
This argument for the view that the zymotic diseases are caused by the presence of living organisms in the body of the person -affected, so far as it is based on what may be called hypothetical grounds, may fitly be concluded by a comparison of their phenomena with the life-history of a microscopic organism, the growth of which can be observed with the naked eye. This is the remarkable parasite described by Ehrenberg under the name Hones prodigiosa, and by Cohn as Micrococcus prodigiosus. It is that which forms a red growth on articles of food, on which it can easily be cultivated for the sake of experiment. If we call the spread of this organism on food, and the changes which it produces there the disease, then the direct transplantation of the organism may be called the infection, or introduction of the contagium. But the organists requires for its growth a suitable substratum, containing sufficient organic nitrogenous matter. This may be called the general predtt
1876.] DR. JAMIESON on the Parasitic Theory of Disease. 259 position. But it is not a matter of indifference in what condition the substratum, or article of food, is presented. On raw meat the red growth does not form, but on boiled meat it grows luxuriantly, and best of all on that which has been freshly cooked. This may be called the special or individual predisposition, or the varying degree of susceptibility to the action of the disease shown by different individuals, or by the same individual at different times.
The slight difference in the character of the nutritive substratum, which permits, or prevents the growth of a fungus, is shown by the circumstance that a parasite, which thrives in the material supplied to it by the structures of the solanum tuberosum, perishes when it is placed on those of the solanum niyrum. How easily a very slight addition of foreign matter may render a nutritive substance unfit to support a fungus which usually thrives in it is strikingly shown by the researches of Dr. J. Schroeter, who found that no fermentation took place in a solution of grape sugar mixed with yeast, when carbolic acid was added in the proportion of only one in fifty thousand (1 : 50,000). These facts seem to throw a glimmer of light on the at present inexplicable cases met with during all epidemics, of persons seeming to enjoy at one time a perfect immunity from the invasion of a disease, to which they soon after prove quite susceptible. But returning to the red mould, we find that after its implantation it does not spread to almost any per- ceptible extent for the first two days. This may be called the period of incubation, after which it grows rapidly for several days ; and at the same time the substance on which it spreads assumes a dirty grey colour, and emits an unpleasant odour. These phenomena might be called the symptoms and morbid products, just as, in a case of any zymotic disease, there are specific signs, and morbid secretions, and other products. After the growth of the micrococcus has continued for some time, it either dries up or perishes under the the formation of other organisms. This may be called the subsidence of the disease. To complete the analogy between the life history of this organism and the characteristic features of some zymotics, it must be said that there have been seasons when it assumed quite the proportions of an epidemic, though it is not generally abundant.
Thus in 1819 it was common over a great part of Lombardy. In the Botanical Institute at Breslau, the micrococcus prodigiosus was extensively cultivated in 1869, and even after its intentional multiplication was stopped, it appeared spontaneously on articles of food during half a year. A year after the cultivation had been stopped, Professor Cohn could not produce the red growth, and obtained it only by introducing it from without in 1872. This might almost be regarded as a history of the progress and decline of an epidemic outbreak of measles or scarlatina.
It will probably be allowed by most persons, that the general grounds applying to all the acute infectious diseases, as now stated with considerable fulness, are sufficient to show the great probability that living organisms are important agents in the causation of
260 DR. JAMIESON on the Parasitic Theory of Disease. [Aug..
these diseases. Of course the argument from analogy is subject to fallacies, and can scarcely by itself carry conviction to the mind, particularly when the regular inductive method of collecting facts, by observation and experiment of a direct kind, can be followed. I will now, therefore, go on to a consideration of some of these positive proofs ; and the results to which we have attained at the end of this theoretical discussion, may be useful in turning the scale in a doubtful case, care being taken not to lay undue stress on them. I do not think that it is denied by any one whose opinion is of the slightest value, that vegetable parasites can take up their abode on or in animals, or other plants, can live and multiply at their expense, and produce diseased conditions of some sort by their mere presence. It is easy to understand that the morbid phenomena associated with the presence of fungi, have been more thoroughly investigated and the relations of cause and effect more definitively settled, in the case of plants and insects, than in man, or even in the higher animals ; and so it has long been agreed among botanists that the potato disease and the grape disease, both of which have been so widespread and destructive, are caused respectively by the Peronospora infestans and the Oidium Tuckeri. The manner in which the fungus invades the healthy plant, spreads into and destroys its structures, and whilst rooted in them fructifies, and by the production of spores supplies the elements whereby the fungus extends its ravages, has been well ascertained. Certain destructive diseases of insects have also been shown as clearly to be of parasitic origin. Thus the disease of silkworms, known as the muscardine, depends on the growth in the living animal of the fungus known as Botrytis bassiana. The common house-fly is also subject to a disease caused by the growth in it during life of the Empusa muscce. These diseases are caused by well-developed fungi, whose life history has been fully wrought out, and which multiply by means of spores.
Another disease affecting the silkworm has been more destructive even than the muscardine, and a few years ago almost destroyed the valuable and important industry of silk production in France and other countries of Europe. I refer to the disease known as pebrine.
It has been made the subject of a very thorough series of investiga - tions by Pasteur, who has shown that it is due to the development of minute organisms in the worm. This disease differs, however, from those' already instanced in this, that these morbific organisms are not fully developed fungi, with distinction of structures and organs of reproduction, but merely minute corpuscles seen by the help of the microscope in immense numbers in the blood and tissues of the worm. (An interesting sketch of the results of Pasteur's investigations is given by Professor Tyndall, in Nature, 7th July, 1870.) The disease has a special interest for Victorians, because its ravages compelled the silk cultivators in France and elsewhere to look abroad for a supply of healthy eggs, and so led to the attempt now being made to establish silk farms in this colony. The disease has also a special importance in its bearings on our subject, since it
1876.] Dn. JAMIESON on the Parasitic Theory of Disease. 261 is more analogous to the zymotic diseases in men than any of the others previously mentioned.
There are some diseases in human beings which are unmistakably due to the presence of fully developed fungi. These are the well- known diseases of the skin, favus, herpes tonsurans, and pityriasis versicolor, caused respectively by the parasitic growths known as the Achorion Schoenleinii, Trichophyton tonsurans, and Microsporon furfur. These fungi have not been fully studied, and as they do not produce true spores, it is supposed that they may pass through another stage of development outside of the body on some suitable substratum. It has even been attempted to show that they are merely forms of the widely diffused moulds, penicillium, aspergillus, and mucor ; but this has not been satisfactorily established. Be this as it may, they form reproductive cells, which are the means of communicating the disease from one individual to another. These diseases are strictly local, confining themselves to the epidermis almost invariably, and producing their effects perhaps solely as local irritants.
The mucous membrane of various parts and especially of the mouth in young children, is frequently the seat of the disease known as thrush, due to the presence of the Oidium albicans, a true fungus like those affecting the skin. It, too, is generally purely a local disease, seldom extending more deeply than the middle layer of the mucous membrane, though cases have been observed in which the mycelium threads pierced the walls of the blood-vessels. Professor Zenker of Erlangen has even observed a case in which portions of the mycelium had been carried away by the current of blood, and, as impacted emboli, had become the centres of numerous small abscesses of the brain. Such accidents, of course, must be very unusual, and all these four parasitic diseases, except for their local effects, might be described as insignificant, seldom occasioning constitutional symptoms, and then only from the local irritation acting powerfully on a susceptible subject. There is another parasitic disease, which, though like these, essentially local, differs completely in its extent and severity. This is the Madura foot, a remarkable affection, which has been investigated and described by Dr. H. Vandyke Carter in a work published by Messrs. Churchill, under the title " On Mycetoma, or the Fungus Disease of India ; London, 1874." The disease affects the feet almost invariably, though cases have been known in which it had its seat in the hand.
The fungus has been described by Berkeley, and named the Chionyphe Carteri. It spreads through all the tissues of the limb, even penetrating the bone, and is formed in masses, sometimes as large as a musket ball, which, when examined microscopically, are found to consist mainly of minute bodies, supposed by Carter to be a bacterium, and named by him B. rubescens. When these are cultivated on a suitable substratum they produce the fully developed chionyphe. Carter does not claim to have settled the whole question, and especially the history of the fungus outside of the
262 DR. POLITZER on the Treatment of [Aug human body is not known. By what means, chemical or mechanical, it pierces and destroys hard structures like bone has not been properly shown. Pathologically the disease is important as forming a kind of transition from the superficial parasitic affections of the skin and mucous membrane, already described, and those constitu- tional affections which only present as their assumed cause, the minute organisms variously known as bacteria, micrococci, torulw,
&c., which, though by some suspected to be the spores or germs of higher fungi, have not been proved to be such in a way that satisfies the botanists who have made this branch of science their special study.
So far our subject, though associated with some difficulties, has had to do with matters which in the main may be looked on as settled. With regard to the diseases which have come under consideration, the pathologists and botanists are in accord ; and if there may possibly even now be a few who obstinately insist that in favus, and the other superficial affections, the fungus is a mere accident, it is surely impossible for any sane man, who weighs the statements of Carter, to hold that the chionyphe merely finds its food in the diseased structures, and has no share in causing the frightful ravages seen in cases of Madura Foot.
In the part of our subject which we have next to consider, almost every point has been made matter of dispute. The diseases in which the constitutional symptoms are, as a rule, most prominent, will, therefore, require a fuller treatment, though it will not be possible to discuss the present state of opinion in all of them. Our space will allow only of a bare statement of conclusions in most of them, without an account of the grounds on which those conclusions are based.
Warrnambool. JAMES JAMIESON, M.D.
( To be continued.)
ON THE TREATMENT OF CHRONIC TYMPANIC OTORRHcEA.
By PROFESSOR DR. ADAM POLITZER,
Principal of the Clinic for Aural Diseases in the Imperial General Hospital of Vienna.
Translated by JAMES T. RUDALL,
Fellow by Examination of the Royal College of Surgeons of England.
[Dr. Politzer is well known as one of the most eminent aural surgeons of the present day. He has published an excellent treatise
" On the Membrana Tympani in Health and Disease," which has
1876.] Chronic Tympanic Otorrhcea. 263 been ably translated into English by Drs. Matthewson and Newton, Assistant-Surgeons of the Brooklyn Eye and Ear Hospital. He also devised a very ingenious method of clearing the Eustachian tube and inflating the tympanum, to which in this colony I first called attention, now more than nine years ago. (Australian Medical Journal, No. 75, July 1867.) At that time I had seen no descrip- tion of, or reference to, the method in the English language, and I had had few cases in which I could put it to the test of practice.
Since then, abundant opportunities of using it have been afforded to me, and I regard it as the most valuable contribution to aural surgery for many years past. The paper, of which a translation here follows, appeared in a Vienna medical periodical a few months ago.
—J.T.R.]
Among the most powerful remedies which have hitherto been employed in the treatment of chronic suppuration of the middle ear, is undoubtedly the nitrate of silver, and the concentrated solutions of it, used for cauterizing the diseased tympanic mucous membrane.
The employment of this remedy, in strong concentration, by pencilling, was practised by Frank (in 1866) and White (1866); but the merit of having made generally known the caustic treatment by nitrate of silver belongs to Schwartze, who, in the year 1868, pub- lished his experience of the action of concentrated solutions of nitrate of silver in chronic middle otorrhcea, in a short notice, " The Caustic Treatment of Suppurative Aural Catarrh.* Since that time I have used the remedy in a large number of cases, and I here give a resume of my experience of it.
In my essay " On the choice of Astringents in Suppurative Aural Catarrh" (Wiener lied. Presse, 1866) I had already pointed out that weak solutions of nitrate of silver proved of very little use in chronic suppurations, and that, on the other hand, by using concen- trated solutions, we are sometimes able to cure growths in the external auditory passage, and on the outer surface of the membrane of the drum. Afterwards, when, on the proposal of Schwartze, I also employed concentrated solutions of nitrate of silver in purulent catarrh of the middle ear, unaccompanied by granulations, I found in my trials with solutions of different strength, that generally still stronger solutions than those specified by Schwartze (1.0-2.5 grm.
to 35.0 grm. water) were more effective, and I now generally use a solution of nitrate of silver one part in ten parts of distilled water.
In the employment of this remedy the following precautions are to be taken :—Before all, it is necessary to drive the secretion out of the middle ear, by my method or by the catheter, into the external meatus, then by repeated syringing with lukewarm water to wash the secretion out of the passage, and to remove the water remaining behind in the ear by inclining the head to one side and passing a plug of cotton wool into the auditory meatus.
* " A.rchiv f. Ohrenheilkuncle," Bd. 4, p. 1, Juni 1868.
T 2
DR. POLITZER on the Treatment of [Aug.
In this way only is it possible for the remedy to come into immediate contact with the diseased membrane of the middle ear, as by insufficient cleansing of the ear the silver solution combines with the secretion remaining behind, as albuminate of silver, with- out acting at all on the mucous membrane of the tympanum.
From ten to fifteen drops suffice for cauterizing the lining of the middle ear, to be poured by means of a glass or horn spoon into the auditory passage, the head being inclined towards the opposite side.* In extensive destruction of the membrana tympani, the solution will pass into the tympanum by the mere force of gravi- tation, without difficulty. In small perforations, on the contrary, it is necessary, while the head is in the lateral position described, to let air pass through the middle ear by my method, or according to the proposal of Schwartze, to press the tragus backwards over the external auditory opening, by which the fluid in the meatus will be compressed and will sometimes pass through the Eustachian tube slightly into the fauces. While the fluid in the tympanic cavity rarely calls forth a painful burning sensation in the ear, the entrance of a few drops through the Eustachian tube into the fauces is almost always accompanied with an unpleasant burning feeling in the throat, which often lasts for several hours.
In rare cases, where from much swelling of the mucous membrane of the Eustachian tube, some of the fluid does not easily flow into the faucial cavity upon pressing the tragus into the lumen of the external meatus, I have observed a more or less pronounced vertigo, induced by the increased pressure on the labyrinth. Such vertigo, as is known, occurs also from forcible syringing into the external meatus, in cases of perforated membrana tympani, since the sudden overloading of the plate of the stapes and the membrane of the fenestra rotunda by the impressing stream, produces a momentary increase of pressure in the labyrinth. The simplest means of quickly relieving this vertigo is an inflation by my method, upon which the vertigo either vanishes immediately, or is considerably lessened.
For the formation of a proper slough, it is sufficient to leave the fluid in contact with the diseased parts from one to two minutes. If the solution is sooner removed from the ear, we find indeed that the deeper parts, the remains of the drum membrane and the visible part of the inner wall of the drum are covered with a similar light grey layer, as in the effectual slough formation, after longer action of the caustic. But this grey layer is formed merely by a combination of the silver solution with the epithelium and mucus of the lining membrane of the drum, without the structure of the mucous mem- brane itself becoming essentially altered by the remedy. These seeming superficial sloughs are in a few hours completely cast off, whilst the sloughs occurring after longer action of the caustic, are often not detached from the tissue until after twenty-four hours or even more.
* A glass pipette will be fofind the most convenient instillment—Trans•
265
.4.876.] Chronic Tympanic Otorrhwa.
After the action of the silver solution on the diseased parts, the superfluous quantity of it is to be removed from the ear by syringing.
The employment of a solution of common salt to neutralise the superfluous nitrate of silver, I consider unnecessary, and I generally use plain warm water. After the cauterization, even when a solution of salt has been used immediately for neutralisation, the secretion contains so much silver, that frequently dark brown spots are produced on the skin of the ear and its neighbourhood, by which the patients are compelled for several days to avoid all social intercourse.
To prevent the occurrence of these spots, we may smear the auricle and the outer part of the cartilaginous meatus with a thin layer of fat ; or, immediately after using the caustic, the auricle and the neighbourhood of the ear may be washed with a weak solution of iodide of potassium, and the skin then be gently wiped dry. The latter method is specially recommended, if the employment of the caustic solution is left to the patient himself or to his relatives.*
As regards the influence of concentrated solution of caustic in diminishing and curing purulent discharge from the middle ear, it depends less on the duration of the mischief, than on the state of the diseased mucous membrane and the general health of the patient.
For we often observe a rapid diminution of the discharge in a short time after the use of the caustic, even in otorrhcea of years' standing ; whilst in other cases, when the suppurative process has only lasted a few months, the secretion of pus is not diminished even after long use of the remedy. Moreover, the remedy acts more quickly and certainly in cases of genuine inflammation of the middle ear where the organism is healthy, than in those suppurations which have come on in the course of scarlatina, of scrofula, and tuberculosis. Further, the effect of the remedy will be more certain if in the course of the suppuration in the middle ear, no overgrowths and granulations of the mucous membrane have formed. Nevertheless, among my cases I have noted a considerable number in which the membrana tympani,
or the exposed inner wall of the tympanum, was covered with close pressed granulations, from the size of a hemp seed to that of a millet seed, which, after repeated use of the concentrated caustic solution, completely vanished, so that after the suppuration had ceased, the promontory appeared quite smooth and of a pale yellow colour.
I cannot, however, confirm the assertion of Schwartze, that by the cauterization of the mucous membrane of the middle ear, a nearly certain success, will be obtained in every case uncomplicated by the formation of granulations. For in more than half of the cases -where no granulation on the middle ear could be proved, the purulent secretion was either not lessened at all, or only to a certain 'degree, and not completely stopped after longer use.
Now, in a large number of cases where, after repeated (8-10) cauterizations of the membrane of the middle ear, the secretion
* I cannot help thinking that it would be dangerous to delegate the use of Lthis remedy to non-professional hands.—Trans.
gry
266 DR. POLITZER on the Treatment of Otorrhaa. [Aug.
was either not at all, or only in a small degree diminished, I have observed a rapid diminution or complete removal of the otorrhoea, through the blowing of powdered alum into the external meatus.
In my memoir " On the choice of Astringents," I have already expressed myself relative to the effect of this remedy, that in numerous cases of ear-disease, after repeated use of powdered alum, the secretion has entirely ceased, with partial or complete restoration of hearing, and that the success was the more brilliant, as in the cases referred to, the otorrhcea persisted for months or years, and could not be cured by zinc or lead solutions or other remedies. I have besides observed that frequently the powdered alum, used in the first place, diminished the secretion slightly or not at all, but - that a remarkable diminution of the discharge occurred if a zinc or lead lotion had been dropped in a few times before the employment of the alum. But the effect of the powdered alum is yet more striking, if, previous to using it, cauterization of the mucous mem- brane of the tympanum had preceded ; and the cases are not rare in which, after previous caustic treatment, an otorrhcea of years' duration has completely stopped after a single inflation of powdered crude alum.
From my experience I must, therefore, point out the consecutive and combined use of the concentrated caustic solution and the powdered alum, as the most effectual method of treatment of chronic tympanic otorrhcea, and I usually follow up the caustic treatment - by the employment of powdered alum, when, after eight or ten applications of the caustic solution, the discharge is only little or not at all diminished.
The powder may be blown in by means of a suitable short tube or quill, fitted to an elastic bottle, or by means of Stork's laryngeal insufflator. Care must be taken that the point of the instrument is pretty accurately directed against the region of the membrane, tympani, otherwise the powder will not reach the diseased parts, but will be blown against the wall of the meatus. It is therefore to the purpose, immediately after using the remedy, to satisfy one- self by the speculum that the powder has reached the membrane tympani, or with large perforations the cavity of the drum, in which case the surface visible looks snow-white.* If the secretion is not too profuse, the insufflated powder mass remains in the ear at least two days. If upon examination on the third day it is found that the powder has remained quite dry, or that it has partially fallen out of the ear, and that the diseased parts are no longer moist, but have become dry, it is not recommended to syringe out the ear, because the secretion can be again excited by the water pressing into the tympanum. We rather desist from all efforts by the external meatus, for when the secretion has stopped, the powder gradually crumbles and falls out of the passage of itself. If on examination, however, the insufflated powder mass is seen moistened through, the
• In blowing powders into the ear, I always first introduce a speculum.—
Trans.
1876.] The Hospital for Sick Children. 267 meatus is to be syringed out, in order to remove the lumps formed by the alum powder and the secretion.
As experience shows that sometimes, on the day after syringing the ear, the secretion has quite ceased, so it is prudent not to repeat the insuffiation of the powder immediately after the syringing is finished, but only on the following day, in case the secretion still continues. We must point out as especially important that the insuffiation must only be repeated after we are convinced by the speculum of the complete removal of the often firm-sticking lumps formed by the secretion and the alum powder ; and it is sometimes necessary, when strong syringing is not sufficient, to remove the firm-sticking masses by careful manipulation with the probe.
Australian
ci $1 Itbiral
AUGUST 1876.
THE HOSPITAL FOR SICK CHILDREN.
The seventh annual meeting of the contributors of the Hospital for Sick Children had an encouraging significance, in that it was held in the building lately the residence of Sir Redmond Barry, and purchased of him for the purpose of being transformed into a hospital. The progress of this institution, since its first establishment by Dr. Wm. Smith, affords an agreeable evidence of what can be done by the steady co-operation of a few determined persons working together, keeping the object of their exertion well before them, and not allowing themselves to be moved from the attainment of their object by any considerations outside the main issue. The very modest way in which the hospital began, and the opposition which from influential sources confronted it, might easily enough have discouraged less energetic advocates. No doubt a good deal of its success has been owing to the circumstance that the managing committee has been composed for the most part of ladies having a social position, likely to aid the institution in the early difficulties of a new career. Still better, they have not been afraid of the real work necessary to be done ; but have shown a business capacity fully equal to the labour and administration required. No doubt, in such a hospital a ladies' committee was peculiarly indicated, quite as appro-i priately indeed, as in the Lying-in Hospital, but the success which has distinguished both these charities can hardly help suggesting a connection in the nature of cause and effect
268 Co-operative Statistics. [Aug.
between such a committee and such a success. It might be a startling proposition to make, to recommend that the female element should preponderate in the committees of all our charitable institutions, but if we are to be guided by results, it seems difficult to avoid such a conclusion.
The new hospital, containing accommodation for fifty beds, will permit of a much larger extension of its useful- ness than has hitherto been possible, and looking at it from
a
purely medical point of view, it is not unreasonable toexpect
that, with this larger field of usefulness, some records bearing upon the diseases of children and their treatment will be furnished as the result of the experience of the staff There is a good opportunity for supplying information of this. kind, and it ought not to be neglected, considering how large a proportion of every-day practice consists of the diseases of children. At the annual meeting, Dr. Wigg proposed that clinical lectures should be regularly given to the students of the University, and to this suggestion there can be but one response. For it has been said, and with more than the appearance of truth, that the excessive mor- tality of children in this colony is in no respect the result of climatic influence, but is altogether the consequence of causes of a social nature. The remarkable freedomfrom
disease and the low rate of mortality in the Protestant Orphan Asylum at Emerald Hill, seem to corroborate this view ; so that it would be possible, one would think, to ascertain, by observations made in this hospital, how far the advantages enjoyed by the children in the asylum, are due to the better conditions of health in which they are found.
In every way, then, the termination of the first seven years of existence of the Hospital for Sick-Children is full of hopefulness, and its newer and larger sphere of operations represents a prospect of usefulness both to the public and to
the
profession which justifies sanguine expectationi.CO-OPERATIVE STATISTICS.
The following circular and forms were some months ago issued from the Central Board of Health :
" CENTRAL BOARD OF HEALTH,
"Melbourne, 3rd June, 1876.
" SIR,-I have the honour, by direction of the Central Board of Health, to call your attention to certain circulars which the Board, on the respective
