NOVEMBER, 1924.
No. 115.
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The Walter and Eliza Hall Re- search Institute .
"Stranger than Fiction," or "What Does the Mob Say ?" . . • Editorial ..
Business Page
"The Meaning and Value of Life"
Some Urological Clinics of America Woes of a Woman Student . ..
Constipation
Lumps . •
The Phenomenon of "Abstinence Symptoms in Narcotic Drug Addiction"
'Sweet are the Uses of Advertise- ment" ..
Suicide ..
S.R.C. Elections
Some Thyroid Disorders
Henry Charles Varley, M.B. et Ch.B. ..
Ladies' Letter . Commentaries
Cases for Commentary
Page 101 103 106 108 109 110 114 115 117
118 121 122 124 125 127 130 131 133
Discipline—An Explanation On Dit
Experience ..
The Decision ..
Duds and Derelicts ..
Specula Correspondence M.S.S. Ball ..
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153 154 155 157
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100
the Zpeculuin
No. 115. NOVEMBER, 1924
Che Walter anb Eli3a *tall 1Researcb institute.
By Dr. C. H. KELLAWAY, Director.
It is fitting that the first thing to strike the eye of a visitor on entering the
\\ alter and Eliza Hall Institute should he a brass tablet erected to the memory of Dr. C. G. M. Mathison, for he was the first Director of the Clinical Labora- tories now included in the Institute, and he it was who prepared the plans of the present building. At the end of 1913 he came from London to take up the position of special Clinical Physiologist and Pathologist to the Melbourne Hos- pital, the Pathological Block of which was just then being rebuilt. A number of medical men interested themselves in obtaining subscriptions to a clinical research fund for the purpose of purchasing apparatus and providing assistants for Dr. Mathison, for which no provision had originally been made. However, before anything further could be done the war had broken out, and Dr. Mathi- son left immediately for the front.
Some two years later, at the instance of Professor Sir Harry Allen, then Honorary Pathologist to the Melbourne Hospital, the trustees of the Walter and Eliza Hall Estate set aside an annual sum of £2500 for the purposes of Medical Research. With this endowment a third floor and basement with animal houses were added to the new Pathological Block of the Hospital, and by 1916 the southern wing of this building had been transformed into a set of fine labora- tories suitable for all modern pathological requirements. It was then named the
"Walter and Eliza Hall Institute for Research in Pathology and Bacteriology,"
and placed under the control of a Board consisting of representatives of the Wal- ter and Eliza Hall Trustees, the Council of the University of Melbourne, and the Committee of the Medical Staff of the Melbourne Hospital. The annual payment from the Trust was subsequently raised to £2600, and the Melbourne Hospital Clinical Fund also contributes £500 per annum. The present members of the Board are :—Mr. A. T. Danks (Chairman), Sir Leo Cussen, Sir John Monash, Sir Harry Allen, Mr. C. Lort Smith (Hon. Treasurer), and Dr. C. H. Mollison.
As so many men were on active service abroad in 1916, it was thought inad- visable to try and obtain a permanent staff immediately, and Sir Harry Allen was appointed Honorary Director, with a part-time assistant. For eighteen months the top floor was occupied by the Director of the Commonwealth Serum Institute and his staff, while the Commonwealth Serum Laboratories were in
101
course of erection. In 1919 Dr. S. W. Patterson, a graduate of the University of Melbourne, was appointed Director of the Institute, and he immediately pro- ceeded to collect a permanent staff and fully equip the laboratories with the required apparatus, most of which he had ordered before leaving England. For three years he did most valuable work at the Institute, and laid down the prin- ciples on which it is still run. The staff of the Institute is available to co-operate with the Honorary Physicians and Surgeons in carrying out special investigations of problems, and to help in elucidating obscure cases, and a certain amount of teaching is also undertaken. Lecture demonstrations on clinical chemistry, bac- teriology and blood work to fifth year medical students are given by the Director during two terms, and there is a pathological museum containing several hundred macroscopic and microscopic specimens housed in the Institute, which is available for tutorial demonstrations and for individual study. The Director and his staff are also available for post-graduate teaching, which is carried out under the auspices of the Melbourne Permanent Post-graduate Committee. While the Institute is very closely associated with the Melbourne Hospital—the two resi- dent clinical pathologists of the hospital working in the Institute laboratories under the supervision of the Director—it is available for investigation of medical problems arising in all parts of the State. Routine pathological investigations for medical practitioners are not made, but specimens having to do with researches going on in the Institute are welcomed. Where these specimens are from paying patients, any fee sent in is placed to the credit of the Apparatus Fund of the Institute.
In 1923 Dr. Patterson resigned in order to take an appointment on the staff of Duff House, and Dr. C. H. Kellaway, the present Director, also a graduate of the Melbourne University, was appointed to succeed him. During the time which elapsed before Dr. Kellaway's arrival from London, Mr. H. Dew, F.R.C.S., acted as Director. The present staff consists of the following:—
Dr. C. H. Kellaway.—Director.
Miss M. Cowen, B.Sc.—Bio-chemistry.
Miss C. Maudsley, B.Sc.—Electrocardiography.
Miss F. E. Williams.—Bacteriology and Serology.
Dr. G. F. S. Davies.—(Honorary.) Part-time Workers.
Mr. H. Dew, M.B., B.S., F.R.C.S. (Eng.).—Hydatid Disease.
Dr. J. F. Chambers, M.B., B.S., M.R.C.P. (Lond.) ( Honorary).—
Metabolism
Dr. W. W. S. Johnston, M.D.—Venereal Disease.
Hospital Workers.
Dr. F. M. Burnet, M.D., B.S.—Senior Resident Pathologist.
Dr. K. Daly, M.B., B.S.—Pathological Registrar.
Miss B. Splatt, B.Sc.--Biochemist.
In addition to this staff two Research Scholars work in the laboratories—
the Cancer Research Scholar (at present Dr. M. B. Wanliss) and the Clinical Research Scholar.
During its short life of four years a good deal of interesting and valuable research work has been done at the Institute. The work of Hamilton Fairley on helminthic infestations, and more particularly his observations on hydatid
THE SPECULUM 103
disease, and his standardisation of his methods of serological diagnosis, both for hydatid disease and for syphilis, are among the most important contributions.
Patterson's work with Miss Williams on dysentery and respiratory infections in Australia has also been very valuable ; and Dew's observations on dysentery and amoebic abscess of the liver, on morphology and development of the hydatid parasite, and his recent work on tumours of the testis, which was awarded the Jacksonian Prize of the College of Surgeons, are some of the most notable con- tributions of the Institute to the advance of medical science.
Although a fine room has been provided for a library on the top floor of the Institute, until recently the reading matter has been limited to a small collection of the late Dr. G. C. M. Mathison's books and journals, which were very generously given to the Institute by his mother, and to a few journals which have been taken regularly. But the Edward Wilson Trustees have just given £3000 for the purpose of forming a small library, and a considerable amount of energy is being devoted to the matter of collecting books and journals which will be useful for reference purposes. In connection with this the Institute is very much indebted to Sir Henry Maudsley, Dr. Hume Turnbull, Dr. Ivan Connor, Dr. Alan Newton, Dr. Lawton, Dr. A. Cowen, the Secretary of the British Medical Asso- ciation in Brisbane, and many other people who have so generously donated back numbers of their medical periodicals. With gifts such as these it is felt that in the course of a year or so the Institute will have a really useful working library.
At present the work of the Institute is spread over a fairly wide field. Dr.
Burnet is doing interesting work on bacteriophages, Miss Williams is turning her attention to tissue culture, Dr. Dew is continuing his interesting work on morphology and histogenesis of hydatid disease in man, and the Director, with Dr. Davies, is working on the problem of albuminuria. The electrocardiographic department, under the guidance of Dr. Turnbull and the skill of Miss Maudsley, is doing valuable work, and Dr. S. 0. Cowen and Miss Cowen are still engaged with the problem of bile pigment metabolism in relation to blood disease.
•••• ,
%tranger than fiction," or "Ultbat Goes the (nob eav?"
By X.Y.
Some little time ago I became greatly interested in a conductor on the Brunswick line. Some peculiarities which distinguished him from the rest of the Melbourne tram-men convinced me that he had not been brought up to his present calling. For example, he never said, "Fez, pies," nor did he give a handful of halfpennies by way of change when offered two bob for a tuppenny fare, while his cry of "Miner Kerv" was utterly lacking in distinction. One day, by chance, I got into conversation with him. We were both laughing at a stout professor who was chasing the tram, and apparently using vile language because it did not stop for him. In answer to my discreet enquiries he confessed that there had been a mystery in his life, and a few days later, over a pint of beer
4 4
(to be meticulously accurate, several pints and a few whiskies), he confided to me the following pathetic story.
•
No, laddie, you were right. My mother never raised her boy to be a trammie.
I was destined, like yourself, for the noble profession of medicine. Signs were not lacking, even in my childhood days, of that genius for anatomy which was later to win me fame. I have distinct recollections of chastisement incurred by calling one of my mother's friends, a Mrs. Levy, "hook-nose," and another, Alderman Burnstein, "big-belly"—an early and remarkable instance of interest in anatomical variations. I shall pass lightly over my schooldays and my first year at the Shop, for it was not until I entered the dissecting room that my triumphs commenced. I at once realised that I had found my true vocation.
The hydatid of Morgagni, the duct of Santorini, from the first enthralled me far more than a night at the Black Rock Palais or form at the Bijou. My demon- strator, Mr. Bailes, was so upset by my completing his statement, "This muscle arises from the—" with the correct "inferior angle and vertebral border of the scapula," that he forgot his lines, and was unable to proceed with the demon- stration. In the prosector's examination I obtained 99%, losing one mark by what was undoubtedly a low trick on the part of the examiner. He asked what muscles were responsible for expulsion of the last drops of urine, expecting the answer, "Opponens pollicis and Flexor digitorum brevis." In third year, by dint of swotting all the points in the text book which the professor of anatomy had announced as "extremely important," and also the remaining half-page, I beat my previous record. Hospital work was to me a tedious distraction, and six years after entering the University I returned to it as Professor of Anatomy, beino-
6 then 21 years of age.
A year later I met my fate. She was Senior Demonstrator in the Physiology School, and no one could repulse an enquiring pupil with more aplomb. To other eyes than mine she may not have seemed beautiful. Undoubtedly the left acromion was approximately 3.7254 millimetres higher than the right ; she suf- fered also from chronic inflammation of the subcutaneous burea of the olecranon ("miner's elbow," to use the antiquated nomenclature of my hospital colleagues), but these slight blemishes were more than compensated by the delicate knobs on her external occipital protuberance (inion)—f or shingling was then endemic
—and the truly wsthetic manner in which the subcutaneous layer of adipose tissue rounded off her exquisite corners.
After a short but passionate courtship, conducted mainly in the cafeteria and round the lake at lunch time, we married. No pair were ever more devoted.
Though she was a physiologist, I an anatomist, each duly appreciated the other's triumphs. When
_
I demonstrated by the examination of 367 cadavers that the percentage of cases in which the M. Palmaris Longus was absent was 11.1(where Le Double has given 11.2), she was as delighted as if I had taken her to the M.S.S. jazz rattle. Nor was I lacking in appreciation when she proved conclusively that a guinea pig could not sustain life on a diet of wood shavings and turpentine in a Torricellian vacuum owing to deficiency in Vitamin P (fat soluble).
But one thing was lacking. We were blessed with no children. No doubt these were adequate reasons, both anatomical and physiological, which it is hardly necessary to detail in these days when "Married Love" is found in every Sunday school library. So passed some pleasant years. Happy, happy days, but tragedy was soon to follow.
fl
THE SPECULUM. 105 My wife had just concluded a most delicate research. Heaven knows how many pairs of my socks went undarned, how many dickies unwashed, while she pursued the search for truth. From a discarded Ford, two billiard halls, and a pair of pink suspenders, she constructed a most ingenious sphygmomanometer.
Unfortunately the subject rarely survived the application of the instrument, so the results were negative. She refused to consider my suggestion, which was to replace the Ford with a 1914 model Hup., fearing even more fatal results. She abandoned this line of research, and turned her attention to a determination of the intoxication index of the various brands of liquor offered for sale in Mel- bourne hotels. I willingly consented to collaborate.
All went swimmingly for a time. During the second fortnight of the test she brought home a sample of the wine technically known as "pinkie," surrep- titiously obtained from a carafe on a table in the Fitz. After dinner she gave me the usual dose, and sat down, paper and pencil in hand, to note the effects of the drug. The taste was somewhat alarming, but I soon noticed in myself symptoms of unusual mental activity. A work I had been perusing that morning came vividly to my mind. The author had given a revolutionary account of the distribution of the branches of the superior cervical ganglion. I felt that I must satisfy myself immediately by actual dissection, and, in lively and exhilarated tones, explained my difficulties to my wife, suggesting that I should carry out on her the slight incisions necessary. She at first demurred, but a smart tap on the head with the poker procured her silent consent. Quickly I fetched my scalpel and forceps, made my incisions, and exposed the ganglion.
All this had taken some little time, and, just as I had succeeded in satisfying myself that the author was correct, the effects of the pinkie began to wear off.
The scalpel slipped from my trembling fingers, its point pierced the internal jugular vein, a bubble of air must have entered, for in a few seconds my wife was dead!
What pen could describe my anguish? I fled the house, taking with me all the cash and valuables I could carry, and buried myself in the mountain fast- nesses of Ferntree Gully, where I managed to elude the police. At the end of a year the hue and cry had died down, and my appearance was so altered that I decided to risk returning to the city, where I was lucky enough to obtain my present job. It has its advantages. I see quite a lot of the merry medical stu- dents, who are almost as clever at avoiding paying each other's tram fares as at dodging lectures on the. C.N.S. But my heart is far away. All day long the question rings in my ears—"Was it murder on my part—or suicide on hers ?"
for remember, sir, she gave me pinkie.
•
"That is my story, sir. Thank you, mine's the same again." It wasn't. I cast at him a reproachful look and the remains of my beer and left that bar for ever.
Frosh (entering chemist's shop) : "I want some acid, please."
Chemist : "What sort of acid—sulphuric, nitric---?"
Frosh : "Dunno the name of it, but the sort you put on girls."
Sir Harry Allen.
We regretfully have to announce that Sir Harry Allen has not yet recovered from the illness which laid him low early this year. Past and present members of the M.S.S., and more especially those who remember him as teacher and friend of their student days, join in earnest hopes that he may be restored in some measure at least to his former health and vigour at no distant date. To Lady Allen and his family we extend our most cordial sympathy during this trying period.
Obstetrics.
In the "Correspondence" column appears a letter complaining of the present teaching system in this subject, together with suggestions for improvement.
We are able to announce that this whole matter has been laid before the Special Obstetric Commission by the Chairman of the M.S.S., at the express request of the Commission.
Clinical Surgery Prize.
Messrs. Ramsay, Reaby Pty. Ltd. have presented to the M.S.S. a prize of surgical instruments to the value of £10 for clinical surgery in the Final Honour Examination. The prize is to be given annually. On behalf of the M.S.S. we desire to accord our heartiest thanks to the firm for their outstanding generosity.
Library.
The old Medical Library has been moved into infinitely more suitable quar- ters in the old Anatomy Museum. Under the capable guidance of Professor Osborne all literature of interest to medical students is being gathered into this central spot. An especial feature, we understand, is to be made of current scientific journals. Only those who have had experience of "hunting up references" under the old regime will appreciate the immense benefit this will confer on future generations.
Med. School and Hospital.
High hopes were entertained early in the year that the Melbourne Hospital was to be moved nearer to the University, and that the Trustees of the Rocke- feller Foundation might then be prevailed upon to give some assistance in the erection of a new and up-to-date Medical School. But it was not to be. The Melbourne still stands at the corner of Swanston and Lonsdale Streets, a good mile from the University, and the Trustees of the Foundation refuse absolutely to do anything for a Medical School that is not situated practically in a hospital.
At least it must be so close that clinicians and students can pass from hospital to lecture theatre or laboratory without having to change their coats.
., ci
(a. Ir rjr.
er inf
ce:
One day in last September, A day I well remember,
I was walking down the street quite full of pride, When my heart began to flutter,
So I lay down in the gutter,
And a pig came and lay down by my side.
As I lay down in that gutter, My heart still in a flutter,
A lady passing by was heard to say :
"You can always •tell who boozes By the company he chooses."
And the pig got up and slowly walked away.
THE SPECULUM. 107
The Trustees are quite right. The late. Sir William Osier was never tired of emphasising the fact that the Hospital is the Medical School. Some things the student has, unfortunately, to learn in the lecture theatre, but he learns the great bulk of what is to be his life's work 'in the wards of the Hospital, and until the two are one we shall go on having the same old complaints from the new- comer to the Hospital : "That's not what they taught us at the University."
Contributors.
The Editor desires to thank his contributors for their efforts towards the success of this number of the "Speculum," more especially those graduates who have managed to devote some of their all too small leisure to the benefit of the younger generation.
There is, however, a type of person who seems to take a personal delight in waylaying the Editor on his way to a clinic—or morning tea—to ask, "When is the 'Spec.' coming out ?" Contributions from such are conspicuous by their absence. The Editor desires to announce his intention of exerting all his influence concerning these parasites, with a view to "making their houses a dungheap and their names a hissing and a by-word among all generations for ever." So now you know.
BUSINESS PAGE.
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The following, having paid the required subscription, have been elected as life members :— Dr. J. Newman Morris.
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THE SPECULUM. 109
"the Meaning ant) Oatne of
On Friday, July 4th, Professor Gunn delivered an address with the above title, under the auspices of the Medical Students' branch of the S.C.U. There was a large and appreciative audience, though, owing to an unfortunate lack of clearness in the announcements of the lecture, many of those present were under the misapprehension that the address was one of the series on medical subjects arranged by the University branch of the M.S.S. •
After briefly referring to the value of such meeting for interchange of ideas between the different faculties (among which the "Meds." had a reputation for exclusiveness), Professor Gunn emphasised the obvious fact, that the University is a training ground for life. Life, he stated, should be real and earnest, not a mere pursuit of pleasure. It was, in the words of John Stuart Mill, "better to be a man dissatisfied than a pig satisfied." There were higher things in life than having a "good time." (Applause.)
The lecturer maintained that there was scope for greater co-operation between physiologists and psychologists, for matter and mind were intimately related. Nevertheless, in his opinion, man was more than an animal, and there was a constant conflict between his instinctive desires and his moral ambitions.
In the Victorian era, instinct was sacrificed to morality. At the present time there was, perhaps, an excessive reaction. In his opinion, it was impossible to harmonise the two sides of man's nature.
Man as a self-conscious animal was capable of self-criticism, and had there- fore constructed a scale of moral values. Mankind had not yet decided what things were ultimately worth while ; music and art, for instance, or the Christian idea of the supreme value of human personality. Such movements as the S.C.U., by promoting discussion, helped the adolescent to decide what things in life were important for him. Such a decision had to be made, and should not be postponed.
Professor Gunn therefore urged his audience to join a branch of the S.C.U., giving his personal assurance that they would derive great benefit from its activities, such as Bible study.
On Friday, June 20th, the first of a series of lectures arranged by the University Branch was delivered by Sir George Syme, the president of the M.S.S., in the new anatomy theatre.
The speaker expressed his pleasure at being asked to address the medical students on a subject so intimately connected with their future welfare. He said that medical ethics constituted a rule for the conduct of the practitioner in his professional capacity. Such a rule was imperative, since medicine was a profession, not a trade. There were, for example, no "butcher's ethics." (Faint cheers from the back benches.) The proper attitude for a doctor, in no matter what circumstances, was summed up in the golden rule, "Do unto others as you would be done by." Since, however, that was subject to wide and varying inter- pretations, it was safer for the young doctor to join the local branch of the B.M.A. immediately after registration. In two pamphlets which would be handed to him he would find a mass of detailed instructions as to what was and was not professional in conduct. The speaker quoted from his own experience instructive examples of the difficulties which were likely to arise if these regulations were not observed.
In conclusion, Sir George dwelt on the necessity for the strictest observance of the Hippocratic oath of secrecy. Facts concerning patients elicited in the
course of medical practice should never be divulged except by direction of a judge in a court of law.
Mr. Melville, in a brief speech, thanked Sir George on behalf of those present for his instructive and interesting address, which, judging from the applause and from subsequent discussions, was highly appreciated by the listeners.
%ome Virological Clinics of America.
By "CYSTOSCOPE."
On returning from a short visit to the chief urological centres of the United States, it may be of interest to give some description of those special departments of the American General Hospitals which deal with urinary surgery. It is hoped to describe their organisation and equipment, without dealing with the scientific and technical side of their work.
Owing to circumstances of wind and weather, which landed us at Provi- dence, Rhode Is., the first centre visited came to be Boston, the capital of New England, and perhaps the most famous University city in America. Here at the Peter Bent Brigham Hospital, which provides the greater part of the clinical teaching of the medical school of Harvard University, the surgical chief is Dr.
Harvey Cushing, and the urologist is Dr. W. C. Quinby. Each holds the dual position of surgeon to the hospital and professor or associate professor at the medical school. The organisation of this hospital, essentially a teaching one, follows largely that of its parent, the Johns Hopkins Hospital at Baltimore, which is older by twenty years. In each a combination of English and Con- tinental methods of hospital management is found. Firstly, each service, of which the urological is an example, is organised into a head, a group of associates or assistants, and a staff of house surgeons, and is supplied with requisite clinical laboratories in charge of trained technicians. Secondly, the student is regarded as an integral part of the organisation, as essential as the intern, and taking his share as surgical dresser or clinical clerk. Further, each service has its own out- patient department, consulting and examination rooms, and ward accommodation, both public and private. The arrangement by which there is a complete staff gathered under one roof, organised and equipped to carry out the investigation and treatment of patients in the public wards, and at the same time free to see and treat private patients in the same building, seemed to work easily and fairly.
The whole working day of each member of the staff is thus spent in the insti- tution; the gain in efficiency and the economy of time and material are of value as much to the patient as to the surgeon.
The visitor from Australia found in Dr. Quinby a delightful host. Under his guidance one was enabled to see the Medical School and University buildings of Harvard, also the Massachusetts General Hospital, where in the Bullfinch theatre ether was first administered as a general anaesthetic. Its museum con- tains Bigelow's operating chair and the early ether-masks of dome-shaped glass.
Lunch at the Brigham Hospital was a cheery meal, at which the talk, led by Professor Cushing, turned largely on the problems of medical education and the medical curriculum, which seems to be as interesting and ever-changing a subject
THE SPECULUM. 111 with them as it is with us. The story of how they got their new medical school is interesting. When the need for a new building arose, Mr. J. P. Morgan was approached directly, and asked if he would provide the necessary funds—some ten million dollars. Mr. Morgan's reply was to engage a staff of experts for one year, who were to examine the plans, to consider the need for the building, and to investigate the aims and record of the school. It was only when fully satisfied on these points that the financier gave the money and the new school was built.
Such gifts, as well as endowments and grants, are a feature of the hospitals and medical schools throughout America. That potent force, public opinion, has been so well educated in this respect in Boston that it is said no man who has money dies without leaving a large part of what he has to bequeath to some form of public charity.
At Baltimore, the next point on what is known as the "urological circle,"
some five days were spent at the Brady Institute of Urology. This is one of the three special departments which have been added to the Johns Hopkins Hospital, and is again an example of public-spirited benefaction on the part of its founder, Mr. James Buchanan Brady. In the words of Dr. Young, who originated the plans for the institute, and who has been its director since its foundation: "The aim has been to construct and maintain a self-contained unit, with wards for public and private patients, laboratories, clinical and experimental, and out- patient department, which should prove a marked stimulus for research and advancement in the special subject to which it is dedicated." The records of the Johns Hopkins Bulletin, and the large amount of special articles sent out from the Brady Institute, show how well this aim is being fulfilled.
The building consists of seven storeys, with a basement. It is connected with the main corridor of the hospital, and is adjacent to the out-patient genito- urinary department. In the basement is housed what is perhaps one of the most interesting features of the institution—a machine and instrument shop, in charge of a skilled instrument maker. Here most of the experimental apparatus and specially devised surgical, as well as optical, instruments are made, and can be readily adapted to the case under consideration. The first floor is devoted to the clinical and laboratory study of the patients. Here are found waiting room, consulting rooms, and a series of examination rooms. In one of these a pre- liminary examination of the patient's case is made by a junior member of the staff, and the case record is dictated to a stenographer. The patient is then referred to one of the special examination rooms, where a senior member of the staff carries out the necessary investigation, details being again taken down by the stenographer. Of the five cystoscopy rooms, two are provided with X-ray equipment, so that radiography and pyelography, as well as high frequency treatment, can be carried out without moving the patient from the cystoscopy table. All material obtained from the patients is studied in the adjacent clinical laboratories on the same floor, which are completely equipped for chemical, bac- teriologic and histologic diagnosis. Forming a complement to these are the X-ray dark-room, viewing-room and library. A lecture-room and small museum complete this floor, which is connected on the same level with the out-patient clinic The second and third storeys contain public wards each for 20 patients, and the two floors above them provide a further 20 private beds, making 60 in all. The sixth floor is devoted to residents' quarters, and the seventh is occu- pied by laboratories for research. This department, thus separated from the clinical laboratories, is divided into branches for the study of those problems of
chemistry, physics, pathology and surgery (including animal experimentation) which have a bearing upon the science of urology. The wide scope of their work is shown by the range on the chemical side from the preparation and testinc ,
of various synthetic dyes for use as urinary antiseptics to the study of the efficiency of various renal function tests, while in the physics laboratory the study of radium and X-rays offers an equally extensive field for research.
One of the operating theatres of the general surgical block of the Johns Hopkins Hospital is used by the staff of the institute on two mornings each week.
This arrangement makes for close touch and co-ordination between the special department of urology and the general surgical work of the hospital. All patients' charts and records are kept in duplicate, one copy being preserved in the department and the other being filed in the general hospital records.
The staff of the Brady Institute is grouped in accord with the principles of itsfoundation into a clinical and a research division. Under the inspiring direction of Dr. Hugh Hampton Young, who is also Professor of Clinical Urology at the Johns Hopkins University, the work of the two divisions is wholly co-ordinated. Time-tables are so arranged that each of the clinical staff has three to four hours a day free in which to do laboratory research, and the men of the research staff have every facility to test out the results of their experiments on the clinical side. The visitor was much struck by the intimate accord between so many men working each at his own job, but fully conversant with all that the others were doing. This was well shown at lunch—a kind of family gathering—where the problems of the morning's work are discussed, as well as the latest news from other clinics with which a free exchange of visits is arranged. Dr. Young attaches great importance to this simple function, and it is an example of the spirit of fraternity and good fellowship that is found throughout American clinics, where a free interchange of views and opinions is greatly stressed, and fine team work is the order of the day. The journey to the Mayo Clinic at Rochester impresses upon the traveller one of the remark- able features of that famous organisation—its isolation. After a twelve-hour trip north-west from Chicago, through the flat wheat-fields of Wisconsin and Minnesota, one wonders at the personality of the men and the quality of their work, which attracts to what was a little out-back town an average population of 20,000 people, and brings to the clinic 57,000 patients a year, keeping 1600 beds constantly occupied in the six affiliated hospitals. Yet thirty-five years ago the brothers Mayo were operating in one small room above the chemist's shop of their home town.
At Rochester the urological work falls into line with the general arrange- ment—namely, that the clinic is concerned primarily with examination and diagnosis, while in-patient treatment is carried out at the various hospitals, which are financially independent, but receive their medical staffs from the central organisation. Charges are made for clinic services based upon a carefully worked out scale of costs of each procedure, and graduated according to the cir- cumstances of the patient. If hospital care is needed, payment for this is made by the patient direct to the institution.
The section of urology is part of the system of Group Medicine upon which the work at Rochester has been built up. Thus, all patients arriving at the clinic are first examined by general diagnosticians. After a full general examination, each case is sent on to one or more of the consulting specialists, as is indicated by the symptoms. Consultations and the referring of cases between the sections
THE SPECULUM. 113' are freely made use of, and the urologist recognises the great importance of hav- ing the close association of other specialists, such as the radiologist, gynaecologist, neurologist, who likewise find themselves often dependent upon him for the solving of many diagnostic problems. The whole organisation demonstrates the value of professional combination as compared with the methods of professional competition. The interest and vision of every specialist are necessarily broadened, and the advantages to the patient are equally great in a more complete diagnosis, and in economy of time and expense.
In the department of urology, which is generally admitted to be one of the most complete and brilliantly successful of those at the clinic, many aids to exact and efficient work were noted. Radiography and pyelography were done with a portable X-ray machine, which was wheeled into any of the series of cystoscopic rooms. Sterile water for irrigation and electric current were laid on by pipes to each cystoscopy table.
The staff consists of Dr. W. F. Braasch, the chief, three permanent assistants, and a varying number of Fellows, with a full complement of lay assistants. The post-graduate training received by the Fellows during a course of three years at Rochester receives recognition from the University of Minnesota in the grant- ing of a Diploma of Urology. This has followed the incorporation of the Mayo Clinic as a post-graduate training school of the University. A feature of the work is the daily staff conference, which the visitor is privileged to attend. At 3.45 each afternoon the whole staff of the department meet under the chairman- ship of Dr. Braasch, when all the findings of the cases examined during the day are reviewed and discussed, and a diagnosis made to be sent to the central bureau of the clinic as the united opinion of the section. It is interesting to note that of 60,000 patients admitted to the clinic in the year 1920, cystoscopic examinations were made on 5860, approximately one in ten, and of 20,000 patients submitted to operation, 5 per cent. were operated on for lesions of the urinary tract. In New York attention was 'concentrated mainly at the urological department of the New York Hospital, where an institute, which also owes its foundation to Mr. Brady, is under the direction of Dr. 0. S. Lowsley. This unit is more a special clinical department of a general hospital than a complete institute, such as its larger namesake at Baltimore, where so much space and time are given to experimental work. In the adaptation of existing buildings to the needs of a urologic department many ingenious devices were seen, and it was noted that all the X-ray work was done in the department by a radiographer attached to the staff. The wards accommodate thirty patients, an important arrangement being that of six rooms with single beds. They are in charge of a Sister specially trained in the nursing of urinary cases. Here, and also at the urological depart- ment of the Bellevue Hospital, the monthly staff conference was interesting and instructive, as all cases dealt with during the month,- with full pathological data and X-ray findings, were brought forward, discussed and reviewed.
From the experience of the writer a warm welcome awaits any Australian visitor to the clinics of America, and he will be given every facility to see all their work. Discussion is keen, and conducted on very give-and-take lines, and upon two other subjects they are particularly anxious to be informed—the quality of the next Davis Cup team, and how long it takes to get to Australia from America! As rapidity of travel increases we shall have many visitors from the States, much to our benefit, and, we hope, somewhat to theirs as well.
Woes of a 'Woman %tubent.
I wonder if all Meds. feel the same depressing sense of their own inferiority which I do on meeting my fellow-students' admiring friends and relatives in the outside world ! My colleagues are all so extraordinarily brilliant --according to their friends !
"How is work progressing, and where are you now ?" asks an elderly friend of one's aunt.
"Oh, quite well, thank you. I am at the Melbourne Hospital."
"Dear me ! You do surprise me ! I thought you'd be practising now, and making your fortune !"
One explains somewhat coldly that one is not allowed to complete the course under five years. The aunt's friend thinks this over, and says soothingly :
"Yes, yes, but you must not mind that ! I am sure it is better to do it thoroughly, and not hurry through."
One thinks of the mad rushes from hospital to Uni., from "bugs" to the Pharmacy College, from 8.30 lectures at M.H. to "Kids'," from O.P. to Fairfield, Royal Park and Kew—and one agrees fervently that to hurry would be indeed a mistake.
"And have you seen Percy lately ?" asks the aunt's friend archly.
This is a shock. One has had one's indiscretions—what would life be with- out them ?—but one's past holds no Percys. Who has been spreading these rumours?
"Pup-pup-Percy ?"
"Why, yes. I told you all about Percy the last time I met you. Percy Pinkhead ! He's doing your year. Such a lovely boy ! So brainy ! So clever ! So brilliant ! So—!" The aunt's friend runs out of adjectives, and gives several moans, which would seem to indicate that Percy is something very superior. "His mother is one of my dearest and oldest friends—a sweet woman, and so clever ! She does the most beautiful tatting—and Percy takes after her.
All the doctors at the hospital think the world of him. They say he has a mar- vellous future !"
Apparently Percy goes around the hospital trailing clouds of glory, and followed by an admiring throng of students and Collins Street specialists. That is not a usual sight, and it is strange that one has not noticed it.
At last one places Percy. Why, of course ! He was in Dr. —'s clinic—a mild, inoffensive little youth, who looked as if he wanted a prolonged course of iron, and six months' running about on a farm. One does not remember his doing anything particularly noteworthy.
At this stage one's aunt joins in. "Oh, was Hilda telling you about failing in her surgical anatomy exam.? It was a pity, of course, but I always say I don't see why she wants to do medicine. She doesn't have to. There was such a nice young fellow at Queenscliff who seemed so taken with her. He was in a bank, and was getting thirty shillings a week, and, of course—"
The friend interrupts. "Percy has never failed in an exam. yet—he just flies through—but then, of course, he has such brains ! Everyone said he should have got the exhibition in—I forget what it was, but an extremely difficult subject ! But the father of the man who got it was a friend of the examiner ; so, of course, the examiner gave it to him, but everyone said that Percy won it really."
[HE SPECULUM. 115 Someone else wants to know how work is progressing. . . . "Of course you must find it very difficult ! I suppose you don't know George McMinim- old family friends of ours, the McMinims ! He's nearly through, so you wouldn't see much of him, but, of course, you've heard of him !"
"We are in the same clinics."
The McMinims' family friend obviously does not believe this. She gives a long eulogy upon George, who, it appears, is almost as brilliant as Percy, and excites a like amount of admiration from the honoraries. They are not usually given to lavishing compliments upon students. They dwell on our mistakes with brilliant sarcasm, and rub our noses in the mud hard and frequently for our souls' good; and we are humbly grateful and admire them tremendously. When they predict future fame for anyone, it usually means that he has made a horrible faux pas.
"George is so brilliant ! He never fails in an exam. They say he is the coming surgeon! He just lives for his work !"
"I've heard of the wonders he can do with a full hand," one murmurs gently.
"And how he'll wait all day long on the chance of one coming his way."
"A full hand? I suppose that would be dropsy, would it?"
"No. Poker," one says briefly.
One is most cheered when sitting for anatomy again at the Supps. to see Percy at the next table and George quite near, both giving piteous groans, and convulsively biting pieces off the property pen supplied by the management, and one looks forward with some glee to telling one's aunt's friends that George—
or Percy—has failed in an exam. at last--if not sooner. Is either friend daunted? She is not! She laughs indulgently and says :
"Oh, that wasn't Percy ! It was someone else of the same name. Percy never fails in anything!"
cd
111:11:Constipation.
The most common example of the misuse and abuse of drugs is the taking of aperients for "constipation." Misconception as to the meaning of this term, and in regard to the ills that are supposed to result therefrom, together with the belief that a remedy is to be found in the taking of aperients, is the cause of much morbid introspection, unhappiness, and ill-health. Constipation means the passage with difficulty, and usually delay, of motions which are too firm in con- sistence. It is true that it is apt to occur when the bowels act less frequently than once a day, but infrequency and irregularity of bowel action does not con- stitute constipation. Infrequency and irregularity may be of no consequence so long as the motions are normal and easy when passed, as may occur where the diet consists of foodstuffs which after digestion leave little residue. I have seen a baby on the breast perfectly healthy, happy and contented, whose bowels only acted once in 5-7 days, the motion being the soft yellow stool of perfect health. Presumably it digested an unusual percentage of its food.
It must be recognised, then, that, whilst regularity of bowel action is wise, the missing of a day or so occasionally is of no importance so long as the bowel action is normal when it recurs ; also one must appreciate the fact that constipa- tion is not curable, but only more permanently established, by the taking of drugs ; whilst bowel irregularity and constipation, not due to organic lesions, such as bands and kinks, etc., are curable by measures dietetic and hygienic, which aim at producing a normal and regular stimulus to bowel action by-
(i.) No regular accumulation in the lower bowel of a sufficient mass of undigested food to produce a stimulus.
(ii.) Increase of the nerve and muscle tone of the bowel, and consequently of its response to the stimulus.
To this end we have the following measures, which will rarely fail- if honestly tried :—
A.—Hygiene, Etc.
1. The cultivation of a regular habit of expecting a bowel action, not only every day, but at the same hour on each day--e.g., on rising in the morning, after breakfast, etc.
2. Exercise: General, as in a brisk walk, outdoor games, etc., and local, such as exercises for the abdominal muscles (lying on the back and raising the legs to overhead position several times, etc.).
3. Abdominal massage, including the rolling of a tennis ball under the palm of the hand around the abdomen in the course of the large bowel.
B.—Dietetic.
The only objective here is to increase the fluid intake, and recommend food- stuffs which leave a bulky and more or less irritating residue. Of course, it must be remembered a sufficient amount of food must also be taken before a daily action of the bowels should be looked for.
1. Water.—It is necessary to ascertain what kind of water the patient is in the habit of drinking. Most water from springs and some of the service waters in country towns are hard and decidedly constipating. Where the water is not soft then it must be boiled. Four drinks might be taken a day. The first on rising in the morning, in which is stirred a spoonful of coarse oatmeal. This will be a drink before breakfast. Then a glass of water should precede the midday and evening meals. The meals should then be eaten without further drinking till the end of the meal, when I allow tea, etc. The last drink in the day is at bedtime—a glass of hot water sipped slowly whilst eating a few dates, prunes, raisins or figs.
2. Porridge.—A coarse meal, more efficacious if under-cooked, though not so palatable. The addition of cream and treacle is useful.
3. Brown Bread.—A home-made loaf made from bran is a good substitute :
—One cup of bran, one cup of self-raising flour, and one tablespoonful of treacle.
Mix with milk and bake in a tin. Toast should be avoided, as also should boiled milk.
4. Fruit.—Fresh fruit for choice, but stewed prunes are a good substitute, and readily provided.
THE SPECULUM. 117 5. Vegetables.—The best are green vegetables, young carrot, cauliflower.
6. Fats.—Butter, cream, bacon fat, olive oil.
7. Such articles of food as marmalade, jams with seeds, honey, treacle, golden syrup, and gingerbread.
As to drugs, paraffin oil, which may be regarded as lubricant and not as an aperient, is decidedly useful in obstinate cases, at any rate in the early stages of treatment, and it is easily taken in fruit juice. As to aperients, they may be necessary in bad cases for a time, to produce the required daily stimulus. They should only be administered in such a form that the dosage may be gradually diminished as a regular habit is established. A liquid preparation such as cascara is perhaps the best, and the much-advertised pill quite unsuitable.
L,,con,;
zump.
To the feminine mind a lump on the human body is as enthralling as someone else's wedding or a new hat.
We have perused since infancy a multitude of prose and verse about such abstract amusements as Beauty, Truth and Love. From the time when the Persian singer scratched amorous phrases on his draw sheet with the only sur- viving leaden nob of his cradle, till the time of Ella Wheeler Wilcox and Eleanor Glynn, love has been the "tour de force" of every poor poet aspiring to leave some trifle to live after him. Poor wights, they write in ignorance and with an addled brain.
But lumps. We see their terrific appeal in clinics. "What a beautiful lump !" and the feminine soul turns a complete somersault with joy, and crowds around to see the gladsome sight.
We seek a reason, and it would seem that the answer lies in the mystery that surrounds all lumps on the human body, a mystery that becomes all-powering even as the lump's position becomes the more abnormal and remote. Moreover, large lumps have an interest far greater than their puny prototypes.
What vast potentialities lie in the as yet undiagnosed lump—with what awe will its observers gaze at it, silent in wonderment, even as stout Cortez, yet ever and anon babbling of its possibilities. Once diagnosed, once a reputable clinician has openly given away the secret of its birth and nature, all mystery goes, and its observers turn again with many a sigh to other spheres.
The sight of a gory scalp wound might conjure up, as Wilfred Trotter so inimitably has it, the vision of an erring spouse among the more strenuous classes using a frying pan as a weapon of domestic correction; but there is no great interest in this—the picture palls when one has seen a score of erring husbands on whom such corrective measures have fallen.
Pain, again, is intangible, possibly a mere figment of the patient's imagina- tion. There is little mystery in this.
But a lump—here is something that we can see, touch, feel, sometimes hear ; here is something that may in a few months wipe off the face of the earth a man who has expected a lifetime before him. Yet another lump, to the casual observer similar, will stay harmless and unaltered for a century.
Tender lumps are a nuisance, rightly resented by those who, seeking to feel them; are met with remonstrance and turned away ; for to feel a lump, and to feel it longingly and lingeringly, not cursorily as is the wont of some, is to its apostles the acme of joy.
Men come to love lumps on their persons, and those lumps that have been blessed with an uninterrupted existence for scores of years are loved beyond the love of friend or brother. It is no fear of the scalpel's edge, nor the deathly sleep of the anaesthetic that prevents the so-called sufferer from sanctioning removal, but an honest liking for something he has that is his only, and that his fellows have not. Maybe it disfigures—that is little matter.
Women, on the other hand, dislike lumps on their persons, and of ten are anxious for their removal, may be a dislike born of an ingrained fear of car- cinoma of the breasts.
Let it be lumps, not tumours or swellings—such words are for the unread tomes, and may our judges forgive those who, loving a mystery unsolved, can give a lump no other name. A small-celled sarcoma has no more interest to one so minded than a tubercular meningitis or a surgical catastrophe. Death will follow them all, fate has set its mark on the doorpost of another victim, "ce ne fait rien," there is nothing more to it. But a lump, so long as it shall have no other name, is as an untapped barrel in Hades.
Ehe 'phenomenon of " abstinence %vmptoms" in narcotic 3Drug Lbbiction.
It has long been known that narcotic drug habitues, when suddenly and completely cut off from the drug, exhibit characteristic "abstinence symptoms,"
the most prominent features of which are feebleness of the heart's action, tremors, vomiting, purging, mental and physical pain, and even actual collapse.
The explanation of these clinical phenomena has not yet been satisfactorily settled ; indeed, investigators in general seem to have attached but little im- portance to'them. A recent paper* by J. A. Gunn, of Oxford, throws some light on the subject.
For the sake of brevity morphine addiction only will be dealt with, morphine being the commonest of the narcotic addiction drugs. The fact that an extraor- dinary tolerance to morphine can be acquired is indubitable ; cases of habitues taking 90 grains daily have been reported, although the M.L.D. for an unaccus- tomed person is, according to Gunn, 3-6 gr. Price and McIver found the average daily dose in a group of habitues to be 15 gr.
The way in which this tolerance is established is a subject of dispute, but the general consensus of opinion, supported by a majority of the conflicting results, is that it is due to two factors—firstly, to an increased destruction of the drug, and, secondly, to a diminished susceptibility of the tissues to the action of the drug.
*Cellular immunity : congenital and acquired tolerance to non-protein substances.
THE SPECULUM. 119 In regard to the first factor, the majority of results indicates that the drug is oxidised by the aid of an enzyme in the tissues, particularly in the brain and liver, and that the increased production of this ferment is one of the causes of the tolerance.
The evidence in favour of a ferment action is that in in vitro experiments with liver or brain emulsions, heating above 60° C. entirely inhibits the destruc- tion of the drug. An interesting point in this connection is that Tamura considers that the action of morphine on the C.N.S. is due, not to the drug itself, but to its oxidation products.
The large number of results which show this destruction to take place, and the close parallelism most observers have found between this increased destruc- tion and acquired tolerance to the drug, point very strongly to its being a factor in morphine tolerance ; but against this must be recorded the investigations of Van Edmond and Van Dongen, who separately found that in dogs accustomed respectively to 200 times a dose which originally produced vomiting, narcosis, etc., and to 1800 times the smallest active dose, "the vagus centre showed no increased tolerance, the pulse rate slowing from 120 to 82 for 5-1 hours, just as previously."
We will now consider the question of "abstinence symptoms." The best explanation probably is afforded by the theory that they are due to an excess of the enzyme. The main points which favour this theory may be briefly tabulated as follows :-
(1) "Abstinence symptoms" are very characteristic.
(2) They are immediately relieved by a dose of the drug.
(3) This dose can be mathematically worked out. Thus in a given case a minimum amount of morphine can be determined, which will for a certain number of hours prevent the development of the symptoms.
(4) "Hirschlaff claimed that the serum of rabbits alleged to be immunised to morphine contained an anti-morphine, and that this serum, if previously injected into control animals, would protect them from lethal doses of morphine."
These results have, however, been contradicted by subsequent observers up to more recently Pellini and Greenfield.
(5) Valenti claims that the serum of "abstinent dogs" (i.e., dogs immunised to morphine and then cut off from the drug) can produce circulatory disturbances in normal dogs. This result, if correct, is extremely strong positive evidence in support of the theory.
(6) Biberfeld temporarily broke the tolerance of dogs to morphine by (a) withdrawal of blood, (b) subcutaneous injection of proteins (milk). The second result might be explained by absorption of the enzyme, while the first result is probably due to direct withdrawal of the enzyme.
(7) The balance between drug and ferment in the body is analogous to that between insulin and the acetone bodies. Insulin is Nature's method of reducing the toxic acetone bodies in the blood, but, should the insulin be in excess, as when a diabetic patient takes an overdose, convulsions and collapse follow.
(8) This balance affords an explanation of the difficulty, indeed usually impossibility of curing advanced morphinism. We have here a physical explana- tion of the drug "craving"--it is a calling of the body for the re-establishment of the normal balance, which is accomplished by another dose of the drug, and
