INTERCOLONIAL
MEDICAL JOURNAL OF AUSTRALASIA.
VOL. VII. No. I. JANUARY 20, 1902.
1 h Artirleo.
HOSPITAL MANAGEMENT IN RELATION TO THE MEDICAL PROFESSION.
By W. MOORE, M.D., M.S.
As the President of the Society is away from the State, the usual address could not be given, and as the President has promised to give the Society an address on his return, it was not thought advis- able that any attempt should be made to supply the place of the usual address of the retiring President. At the same time, it was thought that members would scarcely care to settle to the ordinary routine work of our regular meetings. Under these circumstances, it was suggested that I might read a paper on Hospital Management in Relation to the Medical Profession. This matter is one of great and, I venture to think, of growing importance. At the same time, it must be borne in mind that it is one of great difficulty. The question has to be looked at from the point of view of the man in the street, as well as from that of the medical practitioner. Then, again, it must be remembered that the point of view of the hospital surgeon and physician may not be the same as that of the general practitioner.
I have said that I think that this question is one of growing importance. Certain changes that have in recent years been intro- duced into our hospital system, and certain changes in the con- ditions under which we live, will in all probability bring about a very considerable alteration in the conditions under which our hospitals are maintained. Until a few years ago, the Melbourne Hospital would have scouted the proposal to charge the indigent sick and injured for the services rendered to them by it. But somehow it was decided to make all out-patients pay a registration fee of a shilling a month, and it was found that this small fee brought in a considerable sum of money. This was done, at any rate partly, with the view of keeping away from the Hospital certain
1 B
2 Intercolonial Medical Journal. Jan. 20, 1902
undesirable people, loafers, who were not thought to benefit, or to be benefited by, the institution. Then, of course, it was found that the Out-patient Department, though of so much less importance, and though costing so much less, than the In-patient Department, brought into the coffers of the Hospital a much larger sum of money.
So it was decided to take a fee from every in-patient from whom it could be obtained. And this is the present practice.
Now, the medical profession cannot insist too strongly on the fact that public hospitals are maintained for the treatment of the sick and injured poor ; for the treatment of those who are so poor that, under the added misfortune of sickness or injury, they are dependent, for the treatment necessary to bring them back to health again, on their better-off fellow citizens. It is for the treatment of such cases that the surgeons and physicians give, free of charge, their services, and not for the treatment of those who can afford to pay for those services, either at their hands, or at the hands of some other practi- tioner. And it is for the treatment of such cases, we take it, that the charitable public give of their means, and not for the treatment of those who are as well, or almost as well, able to pay as they are themselves. And further, there is nothing more likely to dry up the sources of charitable support than the feeling that funds are being misapplied, and can there be a much worse misapplication of funds, given for the relief of the poor and needy, than their diversion for the benefit of those who are not poor and needy ? And we venture to think that the hospitals are in the end, by enforcing payment from patients, likely to lose more than they gain by the patient's contributions. But there is a greater objection to the taking of fees from patients than those mentioned, and it is this—when payment is looked for, those who can pay are almost certain to get the prefer- ence over those who cannot. That this is a very real and no imagined danger, I am sure many of you can bear me out.
Further, in the Out-patient Department at the Melbourne Hospital, it has happened over and over again to me and to my colleagues that a patient has not presented himself for treatment for some time, and when questioned as to the reason, has replied—" I had not the money." Of course we know the Hospital authorities do not intend this ; it may even be said that it is the patient's own fault, but I cannot admit that. If it is the established custom to demand a fee, then, even though on satisfactory evidence given the fee is remitted, there will be numbers of very sensitive, but very poor and very sick
Inter. Med. Jn1.1 Hospital Management. 3,
Jan. 20, 1902 J
people who, rather than go and make full revelations as to their dire poverty, will go without the treatment they stand in such extreme need of. And these are the very people for whom the out-patient physicians and surgeons give their time and knowledge and skill ; and these are the people for whose benefit our well-to-do fellow- citizens give of their substance, and not for those who can give r/-, and even as much as 5/-, or 'oh or 15/- a week, these latter sums in many cases being much more than the actual cost of the treatment (medicines or dressings supplied), medical attendance excepted.
Again, it undoubtedly frequently happens that when the poor patient pays to the Hospital 2/6, or even IF a week, he has to go without something that would be of great assistance in restoring him to health. For instance, a girl or young man is suffering from phthisis. The friends manage to keep the patient somehow ; they cannot afford certain articles of food that to such people in ordinary health would be luxuries, but which, to the afflicted one, are really necessaries. Then comes the extreme hardship of taking i/-, 2/6, or 5/- a week, for that money might well have gone towards supply- ing these necessary medical comforts.
Yet another objection, and this purely from the hospital physician and surgeon's point of view, is that when as much as 5/-, and still more if 0/- or 15/- a week is charged, such patients naturally consider that they are paying a fee for the services of the doctor, whereas the doctor is treating them, from his point of view, as suit- able subjects for charitable relief. It is in connection with these cases that soreness very naturally arises on the part of the general practitioner. These are the patients who can pay him fees, whose friends may be still better able to pay fees, and he thus finds himself being deprived of a considerable portion of his livelihood. The Hospital, supported by the gratuitous services of its Medical and Surgical Staff, thus becomes a strong competitor of the general practitioner, and that is certainly in no way the intention of those members of the profession who give their services to the Hospital.
Then, too, when patients pay a certain sum, no matter how small, they consider that they are paying for what they get ; if the sum is
of
considerable amount, enough or almost enough to cover the cost of maintenance, medical treatment being free, they consider they are doing all that is required of them. They find that for this small sum they have been well treated, have had good nursing, and skilful medical or surgical attendance. Consequently, when ill again, they1B 2
4 Intercolonial Medical Journal, Jan. 20, 1902
naturally return for the same cheap but good attention ; and they recommend their friends to do the same. But the medical man is not paid. The very individual who does the most for the patient gets nothing ; he does it as an act of charity, on the supposition that the patient is unable to pay for nursing and medical advice. It is very easy to suggest that the medical staff of a hospital should participate in the fees paid by patients. But even if this benefaction were agreed to—a thing very unlikely in the impecunious condition of most of our hospitals—it would be most unfair. For then you would have a small favoured section of the medical profession, endowed by the Government and supported by charitable subscriptions, com- peting on these advantageous terms with the rest of the profession.
This has always seemed to me a great objection to the taking of
" paying " patients, as distinct from the " contributing " patients just spoken of, into our hospitals.
I readily admit that something may be said in favour of enforcing payment from all patients who can pay, but I maintain that the objections far outweigh the advantages. Some years ago there might have been more reason for receiving certain fairly well-to-do people into a hospital, and accepting a donation from them, because there was not then the same accommodation for the treatment of such cases outside as there is now. Accident cases are almost always, and frequently wrongly and unnecessarily, taken into the hospital, and kept there until practically well, thus generally excluding other and suitable patients. And no doubt the hospital benefits considerably by such cases, but I maintain that they should be sent out of hospital at the earliest possible moment compatible with safety, in order to make room for some poor person who may be sick or injured.
It will be at once apparent how strongly this question of accepting payment bears on the question of the adequacy or inadequacy of our hospital accommodation. If we are providing accommodation for a considerable number of people who can pay in addition to those who cannot, then of course much more accommodation will be required.
And here I would like to say a word or two on this subject of the adequacy of the hospital accommodation in Melbourne. If only suitable cases were admitted into our hospitals, if the beds were reserved solely for the poor when they are sick, and if other cases not suitable on medical grounds were excluded, then I think that the hospital accommodation would be found to be quite
Inter. Med..1n1.1 Hospital Management. 5
Jan. 20, 1902
adequate. And it certainly does seem somewhat strange to see members of the medical profession, even though at the same time they be members of the medical staff of a hospital, strongly advo- cating the increase of hospital accommodation. I think also that
some thought should be given to the other side of the question—to the number of hospitals and of hospital beds that a community is able to maintain. A community, especially if it has been educated to go to hospital in every case of illness or accident, may easily be able to fill 1200 beds ; but that same community may not be able, or may be unwilling, to maintain more than 800 ; and this side of the question should surely receive due consideration.
In my opinion, the building of the Infectious Diseases Hospital as a separate institution was simply a hideous blunder, and I have less hesitation in saying this now because, at the time the money was being raised to build it, I told the then Mayor of Melbourne what my opinion was, adding that it was simply saddling the community wish the maintenance of another large hospital. This was the opinion of my friend, Dr. C. H. Molloy, at that time the Medical Superintendent of the Melbourne Hospital. Had the necessary wards been built in connection with the " Alfred " or some other hospital, the cost would not have been anything like what it has been ; there would thus have been a considerable endowment towards maintenance, and by using the officers and machinery of the establishment with which it was connected, the cost of mainten- ance would have been greatly lessened. This, however, is a little away from my subject.
There are several other matters in connection with hospitals that we may now with advantage consider for a little while. The most important of these is the mode of election of the honorary medical officers at the Melbourne and Women's Hospitals. It is strange that here in Melbourne we should continue a system of election which in England has been abandoned in every large hospital. This question has been discussed both here and else- where, but it would seem that the machinery to be put in motion to effect a change requires more energy than this community can spare.
Also, it seems to me that on other occasions the strongest part of the attack has not been directed against the most vulnerable part of system. The chief fault has been found with the electoral body, and elaborate and impracticable schemes have been suggested for preventing the creation of faggot votes ; various other electoral bodies
6 Intercolonial Medical Journal. Jan. 20, 1902
have been named, e.g., it has been even proposed that the Council of the University should act with the Committee of the Melbourne Hospital in the election of the Medical Staff. But I for one would have far less confidence in such a body than in the present one, for I feel sure that with such a small body errors would be much more likely than is the case at present. The great fault is in the tenure of office, or in the fact that every four years all the staff, eighteen in number, have to stand for election. Think what that means ! The eight men who have for four or more years held the position of In-door Physicians and Surgeons, and who by virtue of that fact should be, and almost certainly are, the leaders in the profession in the State, have to submit themselves for election to a huge constitu- ency, and may be, until recently they have almost always been, opposed by ambitious juniors, or by rivals from another hospital, or by some physician or surgeon of standing who may have settled in Melbourne. On each side there are four places to be filled. There may be only one new candidate, or there may be more. But any one of the old staff may lose his place. Consequently, every man's hand is against every other man, and thus a nice and peaceful and happy state is apt to be engendered in the relations of these leaders in the profession one to another. In the Out-patient Department there are ten positions, and here of late the competition has been more keen than for the senior positions, and the same state of things prevails.
Now, it has for many years seemed to me that such a scheme as was agreed to more than twelve years ago by the Melbourne Hospital Staff, at a largely attended meeting of that body, would meet all the circumstances better than any other. By this scheme, it was proposed that the in-door staff should hold office for fifteen years, or until the age of 6o was reached. That all vacancies in the in-door staff should be filled by promotion from the out-door staff, promotion being by seniority, and seniority being determined by length of continuous service ; in the case of the lengths of service being equal, the position to go to the officer highest on the poll at the election. Then every vacancy on the out-door staff should be filled by election by the subscribers and life governors as at present.
" Thus," I can imagine someone saying, " perpetuating the present iniquitous system." The iniquity of the present system is that eighteen vacancies have to be filled at the same time ; that the men holding these positions are all well-known men, many of them
Inter. Med. &Al Hospital Management. 7
Jan. 20, 1902
among the best known men in the profession in the city ; and also that the candidates aspiring to hold the positions are in many cases well-known men also ; that men who have done their work honestly and well have repeatedly to stand for election ; that their work counts for practically nothing in the election ; that all the devices of the electioneering candidate have to be resorted to, and this by perhaps about thirty prominent members of the profession all at the same time. The great advantages of the plan suggested are that the election would be to fill only one vacancy at a time ; that the candidates for this position, seeing that they would have to wait ten or twelve years at least for a vacancy on the in-door staff, would almost necessarily be young and comparatively unknown men, but men of sound training, and willing to wait patiently and work.
There would certainly not be more than three or four candidates ; they would not be likely to be in the position to put on many votes, or to influence many governors ; they would be little known to the general public or to the subscribers to the Hospital. But they would, as a rule, be well-known to the medical profession, and as each member of the profession has his considerable circle of friends, any young man who was specially able, or who had specially devoted himself to any particular work, would get the almost unanimous support of the Medical Profession, and would almost certainly be elected, even though he were almost unknown to the general public.
As a matter of fact, in my own knowledge, this has been shown to be the case. Many years ago, casual vacancies on the Out-patient Staff at the Melbourne Hospital were filled by election by the subscribers and life governors. On one occasion, there were two candidates for a position on the Out-patient Medical Staff. One of the candidates was a man who had been in practice for some time here, but who was unlikely to get any support from the medical profession ; his opponent was a very young man, not particularly able, but very painstaking and trustworthy, who had recently been a Resident at the Hospital, and was very highly thought of by the Honorary Staff, but who probably did not know a dozen voters out- side the profession. Yet he got in fairly easily. At the next general election, his opponent was elected in the general scramble. By this system, no one but a well-qualified man would be likely to be a candidate.
Think for yourselves, who under such conditions would be the candidates at the present moment for a vacancy at the Melbourne
8 Inlercolonial Medical Journal. Jan. 20, 1902
Hospital, either on the surgical or the medical side. And when you have selected the candidates, I think you will agree with me in saying that it would matter very little to patients at the Hospital, or to the general public, which furnishes private patients, who got the position ; though, of course, it might matter a greal deal to the candidates.
Again, once a man was elected to the Out-patient Staff, he would know that his tenure of office was secure, and so he would be able to devote himself specially to medical or to surgical practice, really giving for some years all his best powers to hospital work, to the investigation and treatment of disease, and to the teaching of students. Under present conditions he cannot do that. He has to devote himself mainly to securing a general practice as a sure means of livelihood, because he knows that at the next general election he may be rejected.
We know the objection that will at once be urged against this system—that it makes each hospital a close borough, that there is no means of getting rid of inefficient or neglectful officers. In the first place, we think that there should be some method of getting rid of such an officer. We see no reason why the Committee should not have the power of suspension and dismissal, to be followed by a special election by the governors to fill the vacancy thus caused.
Here, again, no doubt the medical profession would really be the judges. If, in their opinion, their colleague had been harshly used, he would certainly be returned. If he had been distinctly and badly in the wrong, I think he would be rejected. At any rate, I feel sure that the chance of his rejection would be much greater than is the chance of rejection now in the case of a man neglectful or incom- petent. In times past there have been men who should have been got rid of, but their electioneering capabilities were much too good to permit of that ; whilst at times able men, who performed their duties most conscientiously, have been rejected. Many men, especially medical men, object to the election of the Medical Staff being left in the hands of the subscribers and life-governors, because they cannot judge of the candidates' capabilities and quali- fications. Neither could any other electoral body, except one wholly medical, and such an one is impossible, and would probably not be desirable if it were possible of attainment. And any smaller electoral body would be much more likely to be " worked " than would the large body of subscribers and life-governors. In
Inter. Med. Jul."
Jan. 20. 1902' Hospital Management. 9
addition to that, I think that the privilege of electing the members of the Honorary Medical Staff as vacancies arise, but not the whole Staff, every four years, or even every seven, or every ten years, is one that subscribers may fairly and reasonably claim.
Another very important matter is the question of the presence of medical men on the committee of a hospital. It surely is an extra- ordinary thing that on most of our hospital committees there are no medical men. These institutions are intended for the treatment of the sick poor. Medical men devote their lives to the treatment of the sick ; it is their life work. Therefore the knowledge possessed by medical men should be of the greatest value in the management of these institutions ; and yet, here in Melbourne, it appears to be generally accepted that the management can be better effected without the expert knowledge of members of the medical profession.
At the Melbourne Hospital, at one time, medical men did sit on the committee, in fact, a former member of the staff, who had been rejected at a general election, became the President of the Hospital.
It is very easy to see how such an arrangement might be a failure without invalidating the claim that medical men should have seats on the committee, and more particularly, that certain members of the staff should have seats there. In England there are still a few, it would appear a very few, hospitals on whose managing committees the medical staff is not represented. The National Hospital for the paralysed and epileptic was one of these. In the early part of the past year a serious dispute arose between the staff and the com- mittee, and the cause of the trouble was really the want of any representation of the medical staff on the committee. The Practi- tioner took advantage of this occasion to publish a special Hospital Management number. It obtained papers from many laymen connected in various ways with the management of hospitals, and also a number of medical men on the staffs of various hospitals, both in London and the provinces. And it certainly was remark- able to find how almost unanimous was the opinion that the medical
staff should have " adequate direct representation " on the com- mittee of management. Strangely enough, the one man who thought that the better plan of management was by a lay committee and a separate medical board, was a hospital secretary. It may seem to many that the method of allowing the staff to hold their own meetings, and report and recommend to the committee of lay managers, should serve all the purposes required. But a report is
10 Intercolonial Medical Journal. Jan. 20, 1902
generally of little use unless one at least of its framers is there to explain it and to engineer it through the committee. Besides, to the majority of ordinary questions that come before a hospital com- mittee there is a medical side, by virtue of which the advice of an expert would be of great value.
Dr. Bristowe, for many years on the staff of St. Thomas' Hospital, and a great authority on hospital management, held the opinion very strongly that several members of the medical staff should have seats on the committee of management of the hospital, but he said he did not care whether they had votes or not, in fact, he thought it better that they should not ; for it was his opinion that, if the medical men could not persuade a majority of the lay members of the committee to agree with them, then they were either wrong in their contention, or they had not taken sufficient trouble in presenting their case.
There is, I think, much in this view, though of course it presumes that the lay members are all single-minded in their service of the hospital. It certainly seems to me that the staff of a hospital like the Melbourne Hospital should elect two or more of its members, to represent it on the committee of management. And it would probably also be a very good thing if one medical man at least, not connected with the staff of the hospital, would secure a seat at the hands of the subscribers. Then probably it would not be such a very difficult matter to find out where the leakage occurs that causes the Melbourne Hospital to spend more per bed in the treatment of its patients than any other hospital in Australia, at the same time probably supplying less than most of the others in the way of conveniences for treatment.
There is another very important matter in connection with hospital management, and one in which I fear that even here I may find very little support for the .views I strongly hold. The managing body must have an executive officer to carry out its instructions, &c., and here in Melbourne that officer is practically always a layman. In a book on the Johns Hopkins Hospital, Baltimore, I found this statement — " There must be but one executive head in a general hospital, and he must be held rigidly responsible to the governing Board. He should be selected for his intimate familiarity with all the details of hospital administration, and for his known executive ability. Experience has also amply proved that he should be a medical man, who has been thoroughly trained in hospital practice. His title should be that of superin-
Inter. Med. JnI.1 Hospital Management. 11
Jan. 20, 1902
tendent ' or medical superintendent,' and he should have general charge of the entire establishment. It should be his duty to enforce all rules and regulations, and all offices and employes should be under his control under the rules. He should have no direction whatever of the medical and surgical treatment of the patients, except in cases of emergency." That is a clear and definite state- ment. There was little doubt in the writer's mind as to the correctness of his views. Yet here in Melbourne we studiously avoid adopting the course so plainly stated to be the correct one.
Indeed, the opposite course is so systematically followed that it would seem to be held by governing bodies that the only correct practice is to have a layman for their executive head. In one hospital that I know something about, there has lately been an opportunity to make the doctor the head, but almost every member of the Committee scouts the idea as preposterous. The arguments used against the doctor being the executive head, are such as these
—The idea of a medical man attending to the growing of cabbages ; medical men are always such bad business men. Now, really they are not always ; no doubt frequently they are, because they are professional men, and not business men, and probably in proportion as they are good professional men, in like proportion are they business men. But I know of no reason why, even from that point of view, a medical man should not manage a hospital as well as any other man or woman, if it was his business to do so, and there are very many other reasons why he should manage it much better than any other man or woman. The Secretary would be the secretary, and would attend to all the details of the office, but he would not be the manager, the head of the institution ; the Medical Superintendent would be the manager. The Matron would attend to the nurses and their duties, but the Medical Superintendent would be her superior officer, and she would be responsible to him. The House Steward would attend to the details of his office, and be responsible to the Medical Superintendent, and through him, of course, to the Committee. The Medical Superintendent would be the channel of communication between the Committee and the Staff, honorary and other. He would attend all meetings of Committee, and would explain and advise on any matters that might need elucidation.
This system is adopted at the General Hospital, Brisbane, with the result that it is probably the best managed hospital in Australia.
There, if funds will not permit the patients to be treated in the best
12 Intercolonial Medical yournal.
way possible, and the grounds to be maintained in a state of perfection, the appearance of the grounds is sacrificed, and not the well-being of the patients. In the two large Hospitals in Sydney, much the same system prevailed a few years ago when I made enquiries into the matter, and I have no reason to think that any change has been made since.
Thus, if my arguments are of any value, it must be admitted that the hospitals in Melbourne, and the Melbourne Hospital in particular, present grave errors in the principles on which they are managed. And it is my firm conviction that, if the medical profes- sion chose to take united action, almost the whole of these defects could be remedied. In most things the Melbourne Hospital, as the largest and the most central hospital, and as the place where the medical students attend, sets the example. Consequently, if any reform is attempted, the Melbourne Hospital should first be dealt with. And it has always seemed to me that the first thing necessary there is to change the system of electing the Medical Staff. That done, it would then be possible to have a united Staff, and with the Staff united, any reform that it thought necessary could readily be effected. The Staff would obtain adequate representation on the Committee ; would advocate the principle of making the Medical Superintendent the Manager, and all other reforms would then be mere matters of detail.
These are questions of supreme importance to the medical profes- sion, and we should devote to them more thought and much more activity than we do. Whilst appearing to be serving our own interests, we would be benefiting the whole community, not only the poor and needy when sick and injured, but also our better-off fellow-citizens when they are in similar trouble.
Messrs. Warner and Webster, of 240 Swanston Street, beg to notify that they have secured the sole Agency for Messrs. Arnold Bros., the well-known Surgical Instrument Manufacturers of England.
Jan. 20, ]902
Jan. 20.led.
1902 J Am
pu
tation under Spinal Cocaine Ancestkesia. 13Inter. b JnI.1
(ritnicat attb 4clopitat litecorbo.
" Imperat, ecce, suis nova nostra Australia doctis, Quod discis, comites, jussus ab arte, dote."
AMPUTATION THROUGH THE MIDDLE OF THE THIGH, UNDER THE AN/ESTHESIA RESULT- ING FROM THE INJECTION OF COCAINE INTO THE LUMBAR SUB—ARACHNOID SPACE.
By ROBERT H. RITCHIE, M.B., B.S. Melb.
Surgeon to the Horsham Hospital.
W. R., mt. 78, admitted to the Horsham Hospital on November 4, Igor. Patient had been under treatment for heart disease for some months as an out-patient. On admission, he complained of great shortness of breath, swelling of the feet and legs, frequent micturition, with very much straining during the act. The apex beat was displaced to the left and downwards, the heart's action exceedingly irregular, the sounds faint, and a bruit with the first sound at the mitral area. The pulse was at times almost imper- ceptible, and the arteries very cordy. There was marked oedema of the feet and legs. The prostate was very large, and the bladder reached half-way to the umbilicus, over-flow incontinence being pre- sent. Patient was put on a mixture with digitalis, and the urine drawn off regularly. He improved considerably, the breathing getting comfortable, and the oedema disappearing.
On the afternoon of November 21, patient not having been out of bed since admission, he complained of great pain in the right foot and right calf, and the foot was noticed to be cold. Next morn- ing, the foot and ankle had a bluish livid appearance, and the usual changes of appearance accompanying gangrene set in, the gangrene extending upwards to about two inches below the knee-joint. The toes and foot soon mummified, but above, the gangrene was of the moist type, bull forming and breaking, with a discharge of blood- stained serum. As the patient was very restless, and at times, from pain, not accountable for his actions, he frequently tore all dressings off, and putrefactive organisms gained admission, making the limb very offensive. •However, by frequent changes of dressings this was overcome. The pain, loss of sleep, and mental distress had a
14 Intercolonial Medical Journal. Jan. 20, 1902
very bad effect on his general health. His appetite went off, and the left foot and leg became once more cedematous. As the dis- organised condition of his heart made it impossible to administer any general anesthetic to allow of amputation, I decided to inject a solution of cocaine into the spinal canal, and amputate through the thigh under the anasthesia resulting from this. The patient, on having the possible risks pointed out to him, was quite willing to have the operation performed.
The evening preceding the day of operation, the gangrenous limb was enveloped with wool and bandaged up to the knee. The skin of the thigh was then very carefully disinfected and covered with a lysol foment. The skin in the lumbar region was similarly prepared and also covered with a foment. These foments were left on till the time of operation. The greatest care was taken in the sterilisation of all the instruments to be used, and among these was a Luer's all glass syringe, with a needle about 3.÷ inches long.
The morning of the operation (January 7) the patient was placed on the operating table in a sitting position and bending forward across his knees. The foment was taken off his back, and the spines of the third and fourth lumbar vertebrm located. A small quantity of a sterilised 2 per cent. solution of eucaine was then injected into the skin about a quarter of an inch to the right of the midline, and midway between the level of the third and fourth lumbar spines.
With a scalpel a nick was made in the area of skin so rendered insensitive, and the point of the needle of the Luer's syringe was then inserted in this small incision, and the needle pushed in a direction upwards, forwards, and inwards. Two or three attempts were made without entering the spinal canal, so a similar injection of eucaine was made in the skin at a corresponding spot to the left of the spine, and at the first attempt the needle passed into the spinal canal. It required fairly firm pressure to make the needle travel through the tissues, and the absence of resistance felt directly the needle entered the spinal canal was very noticeable, and at the same time cerebro-spinal fluid began to drip from the needle. The needle being left in situ, the glass syringe was loaded with 3o ms. of sterilised water, in which gr. of cocaine hydrochlorate had been dissolved. About thirty drops of cerebro-spinal fluid having been allowed to drip away, the syringe was fitted to the needle and the 3o ms. of cocaine solution slowly injected. The syringe and needle were left in position, so that more cocaine solution could be injected
Jan. 20, 1902
Inter. Med. Ja Amputation under Spinal Cocaine Anesthesia. 15 if it was found that gr.+ was not sufficient. After waiting ten minutes, the skin of the patient's foot was pinched, and he said he could feel it quite distinctly. The same procedure was repeated frequently, the skin of the foot, calf and thigh being pinched, and each time the patient said he could feel it quite plainly, and could locate the site of the pinch. It struck me twenty minutes after the injection that, though aware of the pressure of a pinch, he might not be to pain, so without letting him see what I was doing I made a small incision with a scalpel in the left calf, right through the skin ; blood came freely from the wound, but patient did not stir, and on being asked if he felt anything, said he did not. To make sure he was quite insensitive to pain, I removed the foment from the right thigh, and commenced the incision for cutting the anterior flap, patient assuring me he could feel no pain whatever, though he knew I was touching his leg. Being now satisfied, I withdrew the needle from the spinal canal, closing the punctures with collodion. The patient was then placed on his hack with a towel over his face. A tourniquet was applied round the thigh high up, and the amputation proceeded with. A long anterior and a short posterior flap were cut out, and the femur divided a little above the middle. A conversation was kept up with the patient all the time, and to every question his answer was that he was not feeling the slightest pain. When the femur was being sawn through, he said he could hear the saw, and knew the bone was being divided, but could feel no pain. The femoral artery and vein were both thrombosed, and the cut muscles were of a brownish colour. Ligatures having been applied to all the vessels, the tourniquet was removed. There was such slight oozing as a result of this that, taken in conjunction with the throm-
bosis of the main vessels, and the colour of the muscles, the chances of the flaps sloughing seemed very great. The flaps were brought together by silkworm-gut sutures without any drainage, and the stump dressed with plain sterilised gauze.
About two hours after the operation, patient began to complain of abdominal pain ; he became very excited with it, shouting out very much, though he would quieten when spoken to. He had a very bad night, restless and moaning, and refusing to take any nourishment or stimulant He took a little water, but each time it caused vomiting, the vomit being thin black fluid. The bowels acted during the night ; he still complained of the pain in abdomen in the morning. No pain in stump. Pulse very irregular, and much
16
Intercolonial Medical Journal. Jan. 20, 1902weaker than it was. About r i o'clock on the morning after the operation he went to sleep, and slept till night. On waking, he took nourishment well, and though there was occasional vomiting, he rapidly regained his former strength, and gave no further cause for anxiety. The wound healed by first intention, without any sign of sloughing of the flaps. He is now in perfect comfort, eating well and sleeping well. The cedema has disappeared from the left leg, and his pulse is much stronger than it was before operation.
Remarks.—The
most scrupulous care was taken to guard against any infection of the spinal meninges and of the stump, and consider- ing the condition of the limb, the union by first intention of the flaps was most satisfactory. One loophole for the entrance of germs was the hydrochlorate of cocaine, as it cannot be sterilised by boil- ing the solution without decomposing. I used one of Parke, Davis and Co.'s gr. tabloids, a tube of which I had in my hypodermic case for many months, and when the length of time that must have passed since it was placed in the tube was considered, it seemed hardly probable any living organism would be adhering to it. Still, there was a chance of infection in this way. Cocaine hydrochlorate solution may be sterilised by raising to a temperature of 8o° C.
for three days in succession, but I had no means of doing this.
Eucaine, the solution of which stands boiling well without decom-
position, has in many cases proved unsatisfactory. As regards
the technique of the operation, I learned most from an article
in the
Lancetfor January r2th, 1901, p. 137. Most patients
are said to feel tingling and itching sensations in the legs, but
my patient did not. As regards the most frequent symptoms
after the operation, my patient had vomiting, but no headache
and no rise of temperature. The evening of the day after the
operation the temperature was 99°, but on no other occasion
was it above normal. He retained complete control over his
bladder and rectum. It is recommended that the penetrating sharp-
ened portion of the needle should be very short, and with such a
needle there would be less chance of injuring the nerves of the cauda
equina. It would seem clear that it is only the sensation to pain
that is abolished in this method. The patient seemed to know he
was being handled, and where he was being handled, but could not
feel the slightest pain. The patient was given several drinks of
brandy and water while on the operating table, and on being put
Inter. Med. Jnl. 1 Foreign Body in Bronchus. 17
Jan. 20, 190: j
back to bed, strychnine injections were given every four hours for several days. He was also given champagne.
I am indebted to Dr. Cookson for watching the patient while I was operating. He states that no noticeable alteration occurred in the pulse, save on division of the femur, when it became for a few minutes more feeble, and that at the end of the operation the pulse was practically as strong as at the beginning.
CASE OF FOREIGN BODY IN THE BRONCHUS- TRACHEOTOMY—RECOVERY.
By A. GEOFFREY OWEN, M.B., B.S. Melb.
Late House Surgeon, Melbourne Hospital.
House Surgeon, Melbourne Children's Hospital.
In the Intercolonial Medical yournal of Australasia of March 20, 1898, Dr. Lendon, of Adelaide, reported a case of foreign body in the bronchus, and at the same time drew up an appendix of all the reported Australian cases of this condition, eleven in all—four of which ended fatally, the remaining seven recovering—the foreign bodies being coughed up in four of the latter cases, and removed by tracheotomy in the other three. The rarity and importance of the condition make the' following additional case of sufficient clinical interest to be reported in detail :-
T. C., mot. 8, was brought to the Out-patient Department of the Melbourne Children's Hospital, on the afternoon of January 13, by his mother, who gave the following history of his condition :—About ten o'clock in the morning the boy had been sucking a pine seed, when suddenly "the seed went down the wrong way ; " several severe paroxysmal attacks of coughing followed, accompanied by vomiting, and the child was much exhausted. He was taken to a doctor, who immediately sent him to. the Hospital. At the Out-patient Depart- ment, he was seen by Dr. Stephens, who made the following note of his condition :— " Child much exhausted ; laryngeal cough ; vesicular murmur diminished over right side of chest, especially at upper part ; numerous rhonchi over right side of chest, fewer on left side." He was admitted to the wards under the charge of Dr. Bennie. On the way up, he had a severe attack of coughing, which exhausted him greatly.
On examination in the wards, I was surprised to find the physical signs had undergone a marked change. There was now good
1c
18 Intercolonial Medical Journal. Tan. 20, 1902
vesicular murmur over the whole of the right chest, but at the left base there was almost complete loss of breath sounds, and a slightly dull note on percussion, while over the front of the left chest the vesicular murmur was markedly diminished. The change in the physical signs was a conclusive proof that the seed had left the right, and was now lodged in the left bronchus, completely blocking the subdivision going to the left base, and partially blocking the entry of air into the rest of the lung. The shifting of the physical signs from one side to the other has been noted on more than one occasion, and was well marked in a case reported by Dr. Stawell (Intercolonial Medical Journal of Australasia 1895), of an orange pip in the bronchus. In consideration of the child's exhausted con- dition, it was decided not to try any interference that evening. In anticipation of tracheotomy, the neck was surgically prepared and dressed, and the tracheotomy instruments placed ready at hand for any emergency. The mother brought with her a duplicate seed from the same cone, which the boy stated to be exactly the same size as the one he had been sucking (it was afterwards proved to correspond exactly), and its measurements were—length inch, circumference round broadest part
.4
inch. It will be seen from this that the seed would be quite capable of completely blocking up one of the main subdivisions of the bronchus of a child of eight years old. A comparison of the seed measurements with that of the " retention swell " of an O'Dwyer's intubation tube for a child of eight (one inch in circum- ference), shows there to be only * inch difference between the two, which proved that in the event of the seed being coughed into the glottis, it would almost completely obstruct the entry of air. A further consideration of the measurement caused us to wonder how the seed managed to pass through the glottis, seeing how difficult it is at times to introduce the intubation tube when one wishes to do so, and how easy it is to pass the tube into the cesophagus when wishing to intubate the larynx.The boy passed a good night, with only two moderately severe fits of coughing, and on examination of the chest it was found that the signs had again altered. The obstruction was still on the left side, but there was now found almost complete loss of the vesicular murmur over the left chest anteriorly, with some dulness, while at the base the breath sounds were diminished, showing that the seed had lodged in a different subdivision of the bronchus. Later on in
Inter. Med. Jr11.1 Foreign Body in Bronchus. 19
Jan. 20, 1902
the morning an attempt was made to dislodge the seed. All prepara- tions having been made for an immediate tracheotomy, the boy was then inverted, slapped on the back, and shaken without any result.
Coughing was then encouraged by tickling the back of the throat, but with no avail, and an examination of the chest showed the body to be in exactly the same position as previously. The signs had not altered on the evening of the i4th, the boy remained fairly comfort- able, and had been very little troubled with coughing ; there were numerous rhonchi to be heard all over the chest, especially on the left side, but there were no indications of definite inflammatory reaction in the lungs. The question of tracheotomy at this stage was considered, but it was felt that, as long as the body remained lodged and fixed in the bronchial subdivision, little good could come from the operation. In the event of one failing to secure the seed at the operation on inserting a tracheotomy tube, rapid death may occur from sudden complete blockage of the tube, and this actually happened in a case of this kind which I well remember, at the Adelaide Children's Hospital (Swift, Australasian Medical Gazette 1897).
On the evening of the 15th, the boy was very comfortable when seen on my late round, but a few minutes after this I received an urgent message from the night sister, and hastening to the ward, found the boy cyanosed, and struggling for breath, hardly any air entering the chest. He was rapidly placed on the ward table, and while Dr. White kindly administered oxygen, I performed a rapid tracheotomy, which was followed by marked relief. At each breath the end of the seed could be seen presenting at the upper end of the tracheal wound, and attempts were made to get the seed out
" end on " with forceps, but without success, so in order to avoid bruising the tracheal wound, the latter was enlarged, when the seed was immediately coughed out. In view of the large opening in the trachea, I thought it advisable to put in a tube for forty-eight hours, and not to attempt immediate suture of the whole of the wound.
The boy was placed in a steam tent, and from that time onwards the progress of the case was uneventful, the tube being removed in thirty-six hours, and no emphysema following. The main part of the wound healed by first intention, and the stitches were removed in five days, the opening left by the tube rapidly closing in.
1 c 2
20 Intercolonial Medical Journal. Jan, 20, 1902
On the 21st the boy was allowed up. His voice had returned, and his lungs were quite clear, except for an occasional rhonchus at the bases.
My thanks are due to Dr. Bennie for his courtesy in allowing me to publish this case.
c 'Onterrotonial
.0our11a1 of Australasia.
JANUARY zo, 1902.
THE AN/ESTHETIC QUESTION.
To the majority of people, the fact of being thrown into the sleep of. anaesthesia is, in itself, sufficiently terrifying, but during the last few weeks the anxiety of those who are called upon either to administer or to be subjected to the influence of chloroform has been aggravated by reports of fatal accidents that have occurred during the administration of that anxsthetic.
While it is recognised that in the event of this dis- aster occurring the fullest inquiry is demanded, and while we would disclaim either the necessity or the desire for any approach to concealment, we would point out that the public is in no way benefited, but on the contrary, suffers through the prominence that has been given to that matter in the daily press dur- ing the last few weeks. Especially must the strongest exception be taken to the utterly ridiculous expres- sions on the subject that have been given by ignorant laymen.
It avails little to point out that, from the nature of
anxsthesia, and from the fact that it is a process in
which the central nervous system is profoundly en-
Inter. Med. Jn1.1
Jac. 20, 1902 The Ancesthetic Question. 21
gaged, a certain amount of risk is, and so far as we are able to judge, always will be inseparably associated with it ; it is beside the question to plead that a slight risk is the price that has to be paid for the inestimable blessing of oblivion while the surgeon is at work, for no sane man could regard the price as high. It is however, an obviously legitimate demand that the price to be paid in the shape of risk shall be the lowest possible, and that the danger of anaesthesia shall be reduced to the ultimate minimum.
The time seems opportune for raising the question whether, in our community, something may not yet be done in this direction ; and it is scarcely necessary to add that the question implies the suggestion to review once more the conflicting claims of chloroform and ether as general anaesthetics.
While it is now universally admitted that, on the
whole, ether is the safer anaesthetic of the two, the
fact remains that, in this city, chloroform is the an ae s-
thetic most frequently chosen. Probably the chief
reason for the retention of chloroform as the chief
anaesthetic is to be found in the prevalent opinion
that it is greatly to be preferred in abdominal opera-
tions, and seeing how predominating the number of
operations on the abdomen has of late years become,
and if we add to the abdominal operations whole groups
of others for which chloroform is considered more
appropriate, it is clear that the sphere of ether will
be somewhat restricted, and the confidence of the
administrator will be naturally given to the agent
with which he is most familiar. It is, however, im-
possible to resist the conclusion that the capacity for
safely administering chloroform is not to be acquired
by everybody with equal facility, and it is perfectly
22 Intercolonial Medical Journal. Jan, 20, 1902
well recognised in the profession that the results achieved by different administrators vary enormously, and that the difference is not by any means a question merely of practice and experience.
Granted that chloroform can be administered in such a way as to be almost free from danger, it does not therefore follow that it is as suitable as any other agent for general and indiscriminate use. What is required is a drug that will be safe, not in the hands of a good administrator, but in those of a bad one ; and if ether satisfies this latter requirement better than chloroform, it seems to be the duty of all of us to endeavour to substitute the safer ans- thetic for that which has been proved to carry with it a risk which we wish to
seediminished. On the other hand, it would appear that the advantages of chloroform in abdominal work have been somewhat over-estimated, and there seems to be a general trend of opinion among surgeons who have great experience in operating on the abdomen, that after all, ether can by a little good management, be made to answer quite as well as its rival anxsthetic in this depart- ment of surgery.
On the whole, the indications would seem to suggest that it would be well for the profession in this country to make a more extended use of ether than has hitherto been done, and to endeavour, by increased familiarity with, and perfection in the method of administration, to render its use as convenient and satisfactory as that of chloroform, for the majority of cases in which an anesthetic is required.
Reference has been made to the increased use of
chloroform brought about by the extension of abdo-
minal surgery. The increased fatality from chloroform
IjiaitnerioMe1(19.02n1.1 Intercolonial Medical Congress of Australasia. 23
-
anmsthesia may not be unconnected with this same extension. In abdominal operations the anwsthetic is pushed to its utmost, to produce complete relaxation, and it may be that the anaesthetist has thus acquired a wrong standard of the degree of anxsthesia neces- sary, and in all cases deems it necessary to maintain the same degree of complete relaxation ; and the surgeon also, is apt to demand it. It very often happens, generally probably, that the surgeon is much the senior, and dominates the position. The an ae s- thetist should be absolutely independent, and use his own discretion and judgment in the administration.
His position is a most responsible one, and is generally very inadequately remunerated.
qt Intaroloniat 1 Oita' ongtess of ustralasia.
SIXTH SESSION.
To BE HELD IN HOBART, TASMANIA, FEBRUARY 17TH TO 22ND, 1902.
Patron :—His Excellency the Right Honourable Earl of Hope- toun, P.C., K.T., G.C.M.G.
Vice-Patron:—Sir Thomas N. FitzGerald, F.R.C.S. Irel., C.B., Melbourne.
With the Special Countenance and support of The Hon. N. E.
Lewis, C.M.G., Premier of Tasmania, and His Majesty's Ministers in 'Tasmania.
President of Congress :—Gamaliel Henry Butler, M.R.C.S. Eng., M.L.C., Hobart.
Retiring President :— John Thomson, M.B., C.M. Edin., Brisbane.
Vice-Presidents of Congress : Past Presidents—Joseph Cooke Verco, M.D. Lond., F.R.C.S. Eng. ; Sir Thomas Naghten FitzGerald, C.B., F.R.C.S.I. ; P. Sydney Jones, M.D. Lond.,
24 Intercolonial Medical Journal. Jan. 20, 1902
F.R.C.S. Eng. ; Ferd Campion Batchelor, M.D. Durh ; John Thomson, M.B., C.M. Edin. Past Treasurers—W. T. Hayward, M.R.C.S. Eng. ; J. 0. Closs, M.D. Edin. ; the late T. Chambers, F.R.C.P. Edin. ; H. Astles, M.D. St. And. ; W. F. Taylor, M.D.
Kingst. Past General Secretaries—B. Poulton, M.D. Melb. ; Professor H. B. Allen, M.D. Melb.; Professor T. P. Anderson Stuart, M.D. Edin. ; S. T. Knaggs, M.D. Aberd. ; Professor J. H.
Scott, M.D. Edin. ; Louis Edward Barnett, M.D. Edin., F.R.C.S.
Eng. ; Wilton Love, M.B., C.M. Edin. Past Presidents of Sections—John Williams, M.D. Edin. ; Joseph Forman, M.R.C.S..
Eng. ; H. T. Whittell, M.D. Aberd. ; Hon. W. F. Taylor, M.D.
Kingst., M.L.0 ; E. C. Stirling, M.D. Camb., F.R.S. ; Hon. H.
Norman MacLaurin, M.D. Edin., LL.D., M.L.C. ; W. C.
Wilkinson, M.D. Lond. ; Mark J. Symonds, M.D. Edin. ; F..
Norton Manning, M.D. St. And. ; James Patrick Ryan, L.R.C.S.I. ; Wm. Snowball, M.D. Melb. ; Walter Balls-Headley, M.D. Camb. ; Alfred Austin Lendon, M.D. Lond. ; H. M.
O'Hara, F.R.C.S.I. ; Jas. Jackson, M.D. Lond. ; J. W. Spring- thorpe, M.D. Melb. ; Arch. Watson, M.D. Paris ; R. Scot Skirving, M.B., C.M. Edin. ; A. MacCormick, M.D. Edin. ; M. U. O'Sullivan, L.R.C.P. and S. Edin; H. Lindo Ferguson, M.D. Dub., F.R.C.S.I. ; J. Ashburton Thompson, M.D. Brux., D.P.H. Cantab.
Treasurer :—J. Edgar Wolfhagen, M.B., C.M. Edin., Macquarie Street, Hobart.
General Secretary :—Gregory Sprott, M.D. Glasg., Macquarie Street, Hobart.
SECTION
1.—MEDICINE.
President :— James Jamieson, M.D., M.Ch., Lecturer on Medicine, University of Melbourne.
Vice-Presidents :—A. Jarvie Hood, M.B., C.M. Glasg., Sydney ; Geo. T. Howard, B.A., M.D. Melb., Melbourne ; Walter Fell, M.A., M.D. Oxon., Wellington ; H. Swift, M.D. Cantab., Adelaide;
Peter Bancroft, M.B., M.Ch. Syd., Brisbane ; T. H. Lovegrove, M.R.C.S. Eng., Perth.
Secretaries :—A. H. Clarke, M.R.C.S. Eng., Macquarie Street,.
Hobart ; Chas. Parker, M.B. Edin., St. John Street, Launceston.
Inter. Med. Jai
Jan. 20, 1902 Intercolonial Medical Congress of Australasia.
SECTION II.—SURGERY.
President •—Louis Edward Barnett, M.B., F.R.C.S. Eng., Lecturer on Surgery, University of Otago, N .Z .
Vice-Presidents :—Wm. Chisholm, M.D. Lond., M.R.C.S. Eng., Sydney ; G. A. Syme, M.B., F.R.C.S. Eng., Melbourne ; T. Hope Lewis, M.R.C.S. Eng., Auckland ; Frank Tratman, M.D. Lond., M.R.C.S. Eng., Perth ; G. Herbert Hopkins, F.R.C.S. Eng., L.R.C.P. Lond., Brisbane ; Benjamin Poulton, M.D., M.R.C.S.
Eng., Adelaide.
Secretaries :— F. J. Drake, M.B. Melb., Harrington Street,,, , Hobart ; Geo. E. Clemons, M.D. Edin., Cameron Street, Launceston.
SECTION III.—DISEASES OF THE EYE, EAR, THROAT, AND NOSE.
President :—T. K. Hamilton, M.D., F.R.C.S.I., Victoria Square, Adelaide.
Vice-Presidents :—Thos. S. Kirkland, M.D. Glasg., F.R.C.S.
Edin., Sydney ; Chas. L. M. Iredell, M.R.C.S. Eng., L.R.C.P..
Edin., Melbourne ; Wm. M. Stenhouse, M.D., M.Ch. Glasg., Dunedin ; Edward L. Gault, M.B. Melb., Melbourne ; A. Francis, M•B•, B.Ch. Cantab., Brisbane ; Henry T. Kelsall, M.D. Lond., M.R.C.S. Eng., Perth.
Secretaries :—C. E. Barnard, M.D. Aber., Macquarie Street, Hobart ; G. H. Hogg, George Street, Launceston.
SECTION IV.—MIDWIFERY AND DISEASES OF WOMEN.
President :—Ralph Worrall, M.D., M.Ch., Gynmcologist, Sydney Hospital, Sydney.
Vice-Presidents :—H. C. Taylor Young, M.D., M.Ch., Sydney ; F. W. W. Morton, L.R.C.P. & S., L.M. Edin., Melbourne ; Arthur F. Davenport, M.B. Lond., M.R.C.S. Eng., Melbourne ; A. J. H. Saw, M.D. Carob., Perth ; F. Glynn Connolly, M.R.C.P.
Lond., M.R.C.S. Eng., Brisbane.
Secretaries :—J. Edgar Wolfhagen, M.B. Edin., Macquarie Street, Hobart ; J. G. Johnson, M.R.C.S. Eng., L.R.C.P. Lond., Evandale.
26 Intercolonial Medical Journal. Jan. 20, 1902
SECTION V.—PUBLIC HEALTH
(INCLUDING STATE MEDICINE, FORENSIC MEDICINE, PSYCHOLOGICAL MEDICINE, AND DEMOGRAPHY).
President :—D. Astley Gresswell, M.A., M.D., D.P.H. Cantab., President of Board of Health, Victoria.
Vice-Presidents :— F. Tidswell, M.B. Syd., D.P.H. Cantab., Sydney ; Thomas Cherry, M.D., M.S., Melbourne ; B. Burnett Ham, M.R.C.S. Eng., L.R.C.P. Lond., D.P.H., Brisbane ; A. C.
F. Halford, M.D. Melb., Brisbane ; T. Mailler Kendall, L.R.C.P.
& S. Edin., Sydney ; J. V. McCreery, L.R.C.S. Irel., Melbourne.
Secretaries :—W. W. Giblin, M.R.C.S. Eng., Macquarie Street, Hobart ; J. T. Wilson, M.B. Eng., Cameron Street, Launceston.
SECTION VI.—ANATOMY, PHYSIOLOGY, PATHOLOGY (INCLUDING BACTERIOLOGY), AND PHARMACOLOGY.
President :—J. H. Scott, M.D., C.M., Professor of Anatomy and Physiology, University of Otago, N.Z.
Vice-Presidents :—Sydney Jamieson, B.A. Syd., M.B., M. Ch.
Edin., Sydney ; Edward Jennings, M.R.C.S. Eng., L.R.C.P. Lond., Christchurch, N.Z. ; J. Atkin Wheeler, M.B. Lond., M.R.C.S.
Eng., Toowong, Queensland ; W. R. Cavenagh Mainwaring, M.B., B. Ch., Adelaide, S.A. ; W. P. Seed, M.R.C.S. Eng., L.R.C.P.
Lond., Coolgardie, W.A.
Secretaries :—E. T. MacGowan, M.B. Melb., General Hospital, Hobart ; J. Ramsay, M.B. Melb., General Hospital, Launceston.
EXECUTIVE COMMITTEE.
. The President ; Treasurer ; General Secretary ; C. E. Barnard, M.D. ; A. H. Clarke, M.R.C.S. Eng. ; E. L. Crowther, M.D. ; E. J. Crouch, M.R.C.S. Eng. ; F. J. Drake, M.B. ; W. W. Giblin, M.R.C.S. Eng. ; E. W. J. Ireland, M.B. ; D. H. E. Lines, M.B. ; E. T. MacGowan, M.B. ; R. G. Scott, M.B. ; C. C. Walch, M.B. ; J. E. Wolfhagen, M.B.
District Members of Executive Committee :—Geo. M. Anderson, M.B., Franklin ; G. E. Butler, M.R.C.S. Eng., Zeehan ; G. E.
Clemons, M.D., Launceston ; G. H. Hogg, M.D., Launceston ; C. Joyce, M.B., Beaconsfield ; W. G. Maddox, M.R.C.S. Eng., Launceston ; J. McCall, M.B., Ulverston ; W. H. MacFarlane,
Ijiainte.roMied9o2Jnl. 1 Intercolonial Medical Congress of Australasia. 27 M.D., New Norfolk ; Chas. Parker, M.B., Launceston ; C. J.
Pike, M.B., Launceston ; J. Ramsay, M.B., Hospital, Launceston.
Local Secretaries :—South Australia : J. B. Gunson, M.B. Adel., Angas Street, Adelaide. Victoria : George Adlington Syme, M.B.
Melb., F.R.C.S. Eng., 82 Collins Street East, Melbourne. New South Wales : Philip Ed. Muskett, L.R.C.P. & S. Edin., 143 Elizabeth Street, Sydney. New Zealand : Professor John H.
Scott, M.D. Edin., The University of Otago, Dunedin. West Australia : Athelstan J. H. Saw, M.D. Camb., St. George's Terrace, Perth. Queensland : Wilton Love, M.B. Edin., Wick- ham Terrace, Brisbane.
PROCEEDINGS OF CONGRESS.
On Monday, February ,7th, the Congress will meet at the Town Hall, Hobart, at li a.m., to transact business, and at 8.3o p.m.
His Excellency the Governor will open Congress. The President, the Hon. G. H. Butler, will also welcome members, but owing to the death of the late President, already alluded to, and the limited time at his disposal before meeting of Congress, the customary
Presidential Inaugural Address will not be delivered.
Besides the ordinary work of the Sections, two evenings will be devoted to the general Discussion on Cancer. The Discussion, which will be opened by Professor H. B. Allen, Melbourne University, promises to be one of the most important and interesting features of the Congress.
It is expected that, if time permits on the second evening, a motion will be moved, that the time is opportune to form an Australasian Medical Association with a permanent Council, in lieu of the present Intercolonial Medical Congress of Australasia.
After obtaining the opinions of the various Medical Societies, the Committee decided it would be extremely difficult to frame a constitution for such an Association that would meet with the approval of even a majority of them. Probably, after the subject has been ventilated, Congress may take further steps if thought desirable.
As important discussions are to take place in the Public Health Section on Quarantine, Plague, &c., the Mayors of the capital cities of the Australian States have been asked to send their Medical Officers of Health, and it is anticipated that a large number of Public Health experts will be present.
28 Intercolonial Medical Journal. Jan. 20,190s
At the request of the Committee, the Premier of Tasmania has invited the other State Governments to send representatives, and already some of the States have appointed their delegates.
The work of the Sectional Secretaries will be materially assisted if members will forward short abstracts of their papers before the last week in January, and also provide the Secretaries with a type- written copy of their papers, when Congress meets, for purposes of publication. Members intending to be present at the Congress are requested to inform the General Secretary to that effect at their earliest convenience, and should apply at once to the local
Secretary for their membership tickets.
Members on arrival in Hobart are requested to sign the roll at the Town Hall, and to state whether they are accompanied by a lady.
The railway authorities of Victoria, New South Wales, South Australia, West Australia, and Queensland have agreed to allow single fares for the double journey to members (and one lady) attending Congress, conditionally that at least six persons avail themselves of the concession ; New Zealand promises excursion fares. To obtain the above concession it will be necessary for members to communicate with the local Secretary of their State or Colony, who will issue certificates.
The Tasmanian Government has promised half fares over all Government railways to members and their wives. The produc- tion of Membership Ticket will be necessary to obtain the conces - sion on Tasmanian railways.
Steamship Reductions.—The A.U.S.N. Co. grants 20 per cent.
reduction on return fares for members and their wives. The Union S.S. Co. and Huddart Parker Co. will allow to per cent.
reduction on return tickets. In order to secure these reductions, it will be necessary for members to present their Congress tickets, countersigned by the local Secretary of their State.
A glance at the programme of entertainments shows the desire of the Committee, namely, that the social functions should not overshadow the scientific work of the Congress.
It has been suggested that after the Congress is over, a special trip round the north and north-west coast of Tasmania might meet with favour.
Provided a sufficient number intimate their intention of taking the trip, a special train will leave Hobart on Monday, February
Inter. Med. Jai
•Jan. 20, 1902 Intercolonial Medical Congress of Australasia. 29
24, allowing visitors time to see Launceston and suburbs. Stop- pages will also be made at Longford, Deloraine, Devonport, Ulverstone, and Emu Bay, and every opportunity given to visitors to see the country.
Some members of the Executive Committee will accompany the party. The return fare will be about sos. per head, and it is expected Hobart will be reached on Wednesday night or Thursday morning.
Those wishing to take this trip should notify the General Secre- tary as soon as possible, so that suitable arrangements may be made for the reception of visitors at the various places of call.
DAILY PROGRAMME.
SUNDAY, FEBRUARY I6TH.
II a.m.--A Congress Sermon will be preached before members at St. David's Cathedral. Preacher, Rev. Reginald Stephen, M.A., Sub-Warden, Trinity College, Melbourne.
7 P.m.—Special Service will be held in St. Andrew's Presbyterian Church, Bathurst Street. Preacher, Rev. James Scott, D.D.
MONDAY, I 7TH.
10 a.m. to 5 p.m.—Enrolment of Members and issue of Tickets,
&c., in the Town Hall.
II a.m.—General Meeting of Congress at the Town Hall, for the purpose of receiving the Report of the Executive Com- mittee, and for the despatch of such business as may be brought forward.
3'3 0 p.m.—Afternoon Tea at Elwick or Botanical Gardens.
8'30 P.m.—Opening of Congress by His Excellency the Governor, and President's Welcome to Members.
9.3 0 p.m.—Reception by President and Mrs. G. H. Butler at the Royal Society's Rooms.
TUESDAY, I8TH.
50 a.m.—Presidential Address in Medicine.
0.45 a.m.—Meeting of Sections.
2 P.m.—Marine Excursion given by the Union Steamship Co.
8.30 p.m.—Discussion on Cancer, to be opened by Prof. H. B.
Allen, Melbourne.
30 Intercolonial Medical Journal, Jan. 20,1002.
WEDNESDAY, 19TH.
io a.m.—Presidential Address in Surgery.
10.45 a.m.—Meeting of Sections.
12.30 p.m.—Drive to High Peak, and Luncheon given by the President and Tasmanian Members of Congress.
THURSDAY, 20TH.
io a.m.—Presidential Address in Public Health.
io.45 a.m.—Meeting of Sections.
3.3o p.m.—Garden party at Government House.
9 p.m.—Reception at Town Hall by the Hon. the Premier and Mrs. N. E. Lewis.
FRIDAY, 2I ST.
io a.m.—Presidential Address in Midwifery and Gynaecology.
10.45 a.m.—Meeting of Sections.
2 p.m.—Special Trip to Salmon Ponds, with a Reception by His.
Worship the Mayor and Mrs. Geo. Kerr.
8.3o p.m.—Discussion on Cancer continued. Resolution re for- mation of an Australian Medical Association.
SATURDAY, 22ND.
ro a.m.—Final Meeting of Sections.
a.m.—Closing of Congress. Election of next President. Time and place of next Congress to be settled.
3 p.m.—Fishing Excursion. Bowling Match, Hobart Bowling Green. Golf Matches at the Newlands and Sandy Bay Links.
The Committees of the Tasmanian, Hobart, and Athenaeum Clubs invite Members of the Congress to be Honorary Members during their stay in Hobart.
piteitral goriet) a Ir7i dor Ia.
ANNUAL MEETING.
WEDNESDAY, JANUARY 8, 1902.
(Hall of the Society, 8 p.m.) The Vice-President (Dr. W. MooRE) in the chair.
The minutes of the last Annual Meeting were read and confirmed.
Dr. W. Snowball was unanimously elected an honorary member of the Society. While proposing him, Dr. J. W. BARRETT said that
