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THE

A ustralian Medical 7ortrnal

OCTOBER 15, 1892.

.Ittertotonial RIOntal o.rngress of 1,u5tralasia.

The Third Session of the Intercolonial Medical Congress of Australasia is now a thing of the past. For one short week some hundreds of the profession thronged the halls of the Sydney University, read and discussed papers on every conceivable• topic of medical interest, and thoroughly enjoyed the varied forms of hospitality showered upon them by the Sydney residents. Now that it is all over, it seems impossible to summarise the proceed- ings—impossible, until the Transactions are published; for one individual even to know all that was done in the several Sections.

At eleven o'clock on the 26th of September, the magnificent Great Hall of the University was filled with a distinguished assembly, awaiting the formal opening of the Congress by His Excellency the Governor of New South Wales. After heartily welcoming members with the hope that the visitors would enjoy the charms of beautiful Sydney, His Excellency touched on the changes in medicine since the days of 1Esculapius and Galen, both as regards the modes of investigating disease and the payment received for medical services. The gratuitous work done by the profession in hospitals was gracefully alluded to, and a reference made to the subject of hospital construction, with a query as to the advisability of building all hospitals on a gigantic scale, and in a pretentious manner. Public health and the cholera received a passing word, and with a compliment to the Sydney Medical. School, and congratulations to the President, His Excellency declared the work of the Congress begun.

The report of the Executive Committee having been read and adopted, the Premier welcomed the visitors, and referred to some recent sanitary measures taken by the Government.

The President of the Congress (Dr. P. SYDNEY JONES) then delivered the following address :—

PRESIDENT'S ADDRESS.

YOUR EXCELLENCY, MEMBERS OF THE CONGRESS, LADIES AND GENTLEMEN,—My first duty is to thank the representatives of Her Majesty in this and the neighbouring colonies, for bestowing their

Vol,. XIV. No. 10. GG

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450

Australian Medical Journal OCT. 15, 1892

patronage on the Congress, and your Excellency in particular for corning here to-day to open this session ;Jny next is to explain how I came to occupy this chair. As is known to most of you, three years ago at our meeting in Melbourne, the Hon. Dr, Mac' Laurin, at that time medical adviser to the Government of this colony, was appointed President.of this Session. Last March, urgent private affairs called Dr. Maclaurin to England, and the Provisional Executive Committee did me the honour to ask me to fill the vacancy thus created. This, after mature deliberation and not without much misgiving as to my fitness for the office, I con- . sented to do, and my appointment was subsequently confirmed at a .meeting of the N.S.W. members of the Congress. I should not have accepted the position had I not felt confident of your generous sympathy and co-operation in the difficult task which lies before.

me. Lastly, it is my pleasing duty, in the name of the New South Wales members of the Congress, to tender a hearty welcome to this city to all of you who have come from Europe and the neighbouring colonies. We trust that your visit here will prove to be both profitable and pleasant, and that you will return to your respective spheres of labour refreshed in body and in mind, and with higher aspirations to advance the interests of the noble profession to which we have the honour to belong.

The meetings of this Congress afford opportunities, not only for

the fuller and wider discussion of questions of mutual interest,

but for the cultivation of those personal relations which aid so

powerfully in harmonising views, and in stimulating concerted

action for the advancement of our art. It has been a difficult

task to decide upon a subject on which to address you. My

predecessors in this chair have covered most of the ground which

one would naturally select. They have discoursed upon the

diseases which are of greater prevalence in this Southern land

than in more northern latitudes; upon the modifications of disease

brought about by our climate, and the wide field open to us in

elucidating its pathology ; as well as upon the possible therapeutic

properties of our vast flora and mineral springs. But they, with

perhaps commendable modesty, refrained from enlarging upon the

advances made in the prevention and treatment of disease

throughout the civilised world. It is seldom fitting, indeed, for

the disciples of any art to proclaim to the world the progress

Which- they have made. There are, however, occasions (and the

present, I think, is one of them) on which it is both useful and

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OoT. 15, 1892 Intercolonial Medical Congress.. 451 1)ecoming to ask ourselves the question, What advances have we made? There are sceptics within as well as without our ranks, and if the consideration of this question should serve to rescue one only of our number from the benumbing effect of doubt; and the paralysis of action which accompanies it, we shall not have spoken in vain. A sceptical mental attitude is fatal to the high ideal and hopeful aspiration which we must possess if we are to make any real progress. Moreover, as in the life of every thoughtful man, there are halting times in which, reviewing the past, and carefully considering his present condition, he deter- mines upon his future course of action ; so should there be in the life of the body corporate.occasions in which it should pause, and look back upon the way which it has travelled, note the tempting byways of progress which have been vainly followed, the mistakes into which it has fallen, and the victories which it has achieved.

And from all these considerations, deduce principles for its future guidance.

My subject then, is a very practical one, viz., " The progress of the healing art during the last forty years."

I have limited my view to this period of time, because it covers my personal experience, it being exactly forty years this month since my name was placed upon the roll of students at University College, London.

Some of my remarks will be autobiographical. My motive in introducing them will, I feel sure, not be misunderstood. They may help to give some slight interest to what, I fear, will other- wise prove to be a very dry address.

The progress of medicine is intimately affected by the progress of almost all the sciences, for it is one of the glories of our art that nearly all the sciences are tributary to it. In the eloquent and poetic language of James Hinton, at once philosopher and surgeon, "Not only chemistry, botany, zoology—these have been long its servants—but new domains of physics, molecular and other, of the science of electric currents, and of heat ; problems of the first dawnings of life—for the question of the dependence of putrefaction upon the presence of germs owes its interest and its passionate pursuit to medicine—are drawn into the widening vortex of our studies.. Further still, the structure of the earth is bidden to reveal what part it plays in the production of disease ; nor does the geologist touch a stratum too deep, or too remote, for the physician to have an interest in his researches. The explorers

GG 2

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452 Australian Medical Journal. OCT. 15, 1892 of the deepest sea bottom aid him in the study of respiration ; the student of storms for him discovers ozone ; and the spectroscope, we may be sure, will not have done its work till the study of the remotest star lays its offering at the feet of the healer of disease.

We

have—or, in the person of the physician of the future, shall have—an interest in the colours Sirius flashes back to the patient eye of the astronomer ; for they will teach us something more of the planet upon which we dwell. • Nay, the Milky Way itself becomes our servant, and holds up before us in its forms of beauty, winding in spiral clusters through infinitude, the very image of the living forms we question with half-hopeless curiosity beneath the powers of our microscopes." It would, however, be impossible, in the short space of time allotted . to this address, even to enumerate the advances made in the collateral sciences.

I

can only speak briefly on the progress of some of those which are more immediately connected with our art, and which are, indeed its foundation.

Here, perhaps, I shall be met with the objection that thera- peutic medicine has no scientific basis—that it is entirely empirical.

Now, we must all admit that our treatment of disease is not always as precise and rational as we could desire, but that empiricism, and what Professor Gairdner so aptly terms " the automatic method " which recognises only the disease and its assumed antidote, has given place very largely and rapidly to treatment founded on sound scientific principles, deduced from the study of chemical, physiological, and pathological processes, is indispu table.

Our calling has long ceased to. be open to the charge brought against it by Voltaire, when he cynically remarked, that "the, art of medicine consists in putting a number of drugs, of which one knows little, into a body of which one knows less."

Moreover, successful methods of treatment, formerly regarded as of a purely empirical character, have been shown by fresh advances in biological science to be perfectly rational. For instance, the success of the old practice of drawing a stick of lunar caustic around and a little beyond the edge of a patch of erysipelatous inflammation, with a view to check its spread, is now explained by the increased quantity of blood, and therefore of leucocytes brought to the part so cauterised, the white cells concentrating their forces like a defensive army devour the erysipelatous streptococci, and thus stay their onward and destructive progress.

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OCT. 15, 1892 Intercolonial Medical Congress 453 To some degree, indeed, the healing art must always remain part- ially empirical, or, at any rate, until psychology has become an exact science, for there is a factor in every case of disease which the most complete knowledge of the structure and functions of the body and of the action of medicines cannot explain. I mean the ego—the individual. As Arniel so well observes, " Every illness is a factor, simple or complex, which is multiplied by a second factor invariably complex—the individual, that is to say, who is suffering from it, so that the result is a special problem demand- ing a special solution, the more so the greater the remoteness of the patient from childhood or from country life."

The influence of the mind over the body, of the mental and spiritual over the physical nature, cannot be weighed in scales or reduced to its elements in a crucible;' but it is a potent influence, nevertheless, and the wise physician takes it into account in the treatment of his patient.

But to turn now to my retrospect.

The teaching of general anatomy was, probably, as perfect in my student days as it is now, and under the able guidance of such accomplished anatomists as Ellis and Holden, it was our own fault if we did not acquire a very thorough knowledge of the coarse anatomy of the human frame. Is was far otherwise, however, with microscopic anatomy, which was then only in its infancy.

Owing in great part to the improvements effected in the manu- facture' of lenses, in the making of sections, in staining and mounting specimens, our knowledge of ,histology has made marvellous strides. An entirely new world has been opened up to the student who has the diligence to investigate it.

The same may be said of physiology. Our knowledge of the functions of the organs and tissues of the body is now far wider and more precise. In proof of this, need I do more than remind you how largely the functions of the nervous system have been elucidated by the experiments of Ferrier, Horsley, and others ; and the accurate clinical observations of such men as Hughlings Jackson, and Gowers, to mention only British observers.

Forty years ago, we knew comparatively nothing of the nervous centres regulating the movements and functions of different parts of the body, and, consequently, were quite unable to localise, with anything like accuracy, lesions of the brain and spinal cord. To- clay we can—in many cases with absolute certainty—point out

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tr

454 Australian Medical Journal. OCT. 15, 189`

the exact seat of a growth, an abscess, or other morbid process, and perform the appropriate operation for its removal.

Quite recently, the researches of Arthus and Pages, of Woo- ridge and Wright, have shown that the coagulation of the blood outside the body may be arrested by precipitating its lime salts in the form of insoluble oxalates, and may be reinstated by the addition of calcium salts. The important bearing which this observation has upon the operation of transfusion is manifest.

The control of the process of coagulation also within the body which this discovery holds out a hope of securing will, should it be realised, enable us,to deal effectually with such morbid conditions as internal haemorrhage, aneurism, and haemophilia.

Chemical science, likewise, has contributed largely to our means of combating disease. A more complete knowledge of the chemistry of the organic and inorganic world has furnished us with remedies which were unknown in my student days, and has enabled the pharmacist to give us both old and new remedies in a small compass and in an attractive form Contrast the boluses and nauseous potions of our fathers with the compressed tabloids, the liquid extracts, and the concentrated tinctures of to-day. The ingenuity of our time displayed in contriving means for conceal- ing the disagreeable taste of medicineS, and for preventing the decomposition' of incompatible drugs is Indeed marvellous. The capsules, the cachets, the palatinoides and hi•palatinoides, are all inventions of recent times.

Simply to enumerate the discoveries which have been made in pathological science during the last forty years would exhaust your patience. Their practical importance cannot be over-estimated, correct diagnosis being dependent upOn sound pathological views, and successful 'treatment upon correct diagnosis. Since Obermier in 1868 discovered the bacillus of relapsing fever, bacteriological science has made unprecedented progress.. The specific bacilli of tuberculosis, of typhoid fever, of diphtheria, of leprosy, of tetanns, of malignant pustule, have been isolated and described, and quite recently the bacillus of influenza has been discovered.

It is true 'that in only a, few cases have these diseases been

clearly proved to depend upon the presence of a specific microbe,

and that in some of the specific fevers, typhus, small-pox, and

measles for instance, none have been discovered ; nevertheless,

the presence of a particular parasite, and the invariable repro-

duction of a disease by inoculation with its virus, makes it.higbly

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OCT. 15, 1892 IntercoloRial Medical Congress, 455 probable that the 'bacillus and the disease stand in the relation of cause and effect. We are not yet able to battle with tuberculosis, with tetanus, and the other bacillary diseases in the way so successfully done with anthrax and hydrophobia. But there are not wanting indications that these diseases will yet be overcome by methods founded on a knowledge of the life history of these minute but numerous and powerful enemies of our species.

Bacteriology has before it a great future in its application to preventive .as well as to curative medicine, and I am proud of the fact that one of our wealthy citizens, and a Fellow of the Senate of our University, recently deceased, left .a large share of .his fortune to this University for the teaching and prosecution of this branch of science.

One of the most interesting problems engaging the attention of pathologists at the present time is the manner in which the system resists the attacks of bacilli. That the white cells of the blood do offer battle to the invading bacilli is a recognised fact, since they have been seen to devour them, but whether that is the manner in which they are destroyed, as maintained by the phagocytists, or whether the plasma of the blood is the active agent in their destruction, as asserted by the humoralists, is as yet undecided.

The light thrown upon the pathology of myxcedenia, of actinci- mycosis, of ulcerative endocarditis, of multiple neuritis, the differentiation of sarcoma and carcinoma, the recognition of lupus as a tubercular disease—these, and many other discoveries in pathological science, are the result of researches prosecuted within the last quarter of a century.

Having thus rapidly glanced at some of the advances made in the knowledge of the sciences directly related to our art, let us now see if we are better able to cope with the ailments to which the human frame is subject.

There is little doubt that the most important surgical advances of the last half century are the result—(1) Of a wider recognition of the importance of the principle of mechanical and physiological rest, 'a recognition which we owe chiefly to that philosophic surgeon, the late John Hilton; and ,(2) To the introduction of the antiseptic method, for which we are indebted to the genius of Lister. The amount of pain .prevented, and the number of lives saved by the observance of these two principles in our surgical

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- 456 Australian Medical Journal. OCT. 15, 1892

procedures is incalculable. Contrast the issues, the setons, the nioxas, the hot irons which were employed by our fathers in the treatment of say, tuberculous disease of joints, with the present methods of dealing- with those painful affections, and the truth of the above affirmation will be evident.

To enable my younger surgical brethren to realise how largely these 'principles' were neglected, and how wide is the difference between the conduct of a surgical operation at the present day and the procedure followed even thirty years ago, I shall briefly refer to two of my earliest operations. The first case which' I shall mention was one of compound comminuted fracture of the leg, and amputation of the thigh was necessary. The limb was washed, but no special precautions were taken to make it surgically clean ; my hands and those of my assistants were not thoroughly disinfected ; the coats which we wore were left-off frock or overcoats, which had seen much service, and were much bespattered. The nurses were uneducated and untrained, some of them being of the "Sairey Gamp " type. They wore stuff dresses, which, perchance, had been in contact with the bodies of patients suffering from contagious diseases. The instruments were fairly clean, but no antiseptic fluid or sterilised water was at hand in which to immerse them. In short, we were ignorant of the existence of septic germs, and -therefore used no means to exclude or destroy them. Kceberle's or Spencer Well's pressure forceps had not been invented, and we had, therefore, no rapid means of arresting haemorrhage as the steps of the operation were completed.

The sponges had done service on many similar occasions, and no measures beyond ordinary washing had been used to purify them.

We had no catgut or other absorbable ligatures, and I was, therefore, compelled to leave the silk ligatures hanging out at one angle of the wound, offering thereby an obstacle to primary union, favouring the formation of a suppurating track, and seriously increasing the risks of septic absorption. Water dressings were applied, thus further adding to the chances of pywinia. The necessity of frequently changing these dressings involved constant disturbance of the stump, gave the patient pain, and - retarded the healing—another illustration of the manner in which the principle of rest to an injured part was violated. Contrast this picture with that with which we-are all familiar at the present day—the thorough Cleansing of the skin rendering it absolutely aseptic ; the prepatation of the hands of the surgeon and his assistants;

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OCT. 15, 1892 Intereolonial Medical Congress 457 their spotless white linen coats ; the perfect antiseptic precautions in every particular ; the intelligent nurses, in their washing dresses, white caps and aprons ; the instruments immersed in some antiseptic fluid, or, at any rate, in sterilised water ; the pressure forceps ; the absorbent wool sponges ; the drainage tubes ; the absorbable ligatures ; the dry absorbent dressings, needing to be changed but rarely, and thus securing the utmost degree of mechanical rest to the stump. The second case was one of ovariotomy, and was performed at a date when our knowledge of the operation in this colony was derived solely from books.

Surgeons were by no means agreed as to the best methods of dealing with the pedicle, and the battle raged between those who advocated the use of the clamp and those who pronounced in favour of the ligature ; these last, again, being divided in opinion as to whether the ends of the ligature should be cut off short and dropped into the peritoneal cavity, or left long and brought outside the body. The encapsulation of silk ligatures was then a matter of doubt, Listerism was unborn, the value of the drainage tube was not known, and the necessity for absolute cleanliness was not fully recognised. At the present day all these questions have been settled, definite rules for our guidance are laid down in the best books, and the steps of the operation are performed with almost undeviating uniformity.• Time would fail• me to par- ticularise other advances in surgery which the past four decades have witnessed. I can only enumerate some of the more important :--Aspiration for diagnostic -and curative purposes, incision and drainage of hydatid cysts and suppurating cavities, removal of tumours from the brain and spinal cord, gastrostomy, and the various forms of enterostomy ; cholecystotomy, nephrec- tomy, hysterectomy, Bigelow's method of performing lithotrity, many of these operations being designed with the object of giving a diseased organ, or part, mechanical and physiological rest ; osteotomy, osteoplastic operation, skin-grafting, nerve-stretching, and suture of divided nerves. Many, indeed most, of these operations would not have been attempted but for the introduction of Listerism into surgical practice. The wide range of subjects, and the extensive knowledge required of each, has rendered necessary - that division of labour which we call specialism. We have now our gyn

ae

cologists, our ophthalmologists, our laryngolo- gists, our otologists, our rhinologists, our dermatologists, our medical electricians, and some others.

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158 Australtan

Medical Journal.

Ocr. 15, 1892 I am

aware

that much has been said and written of the danger in which the specialist stands of looking at his subject from one point of view only. BUt

I

have no fear of specialism in that direction, so long as it is founded upon a sound generaliam. It is dangerous only when it forgets that it is special.

I must, however, leave this subject, and hasten on to show that

in

the domain of therapeutics we have made substantial progress, and I shall again narrate my own experience in the use of a drug that is now universally recognised as of the greatest value in some forms of disease of the heart. in my student days we were taught that digitalis was a depressant of the heart's action, and should be administered only in cases of hypertrophy of that organ, and that its employment was most dangerous in cases of weak and dilated heart. In the year 1866, a near relative of my own presented all the signs and symptoms of dilated left ventricle—

rapid, irregular action, feeble impulse, laboured breathing, drop- sical extremities, sleepless nights—in short, the whole class of symptoms with which we are all so painfully familiar. Ammonia, ether, and alcohol were prescribed to support the failing heart, opium was given to induce sleep ; these remedies at that day being recommended by all authorities. The most experienced and distinguished practitioners in this city gave me their aid and advice, but all to no purpose; my patient gradually grew worse, -until it was evident to all that, having been able to procure no more sleep than a fitful doze in his chair for more than a week, the dropsy having invaded the abdominal cavity, and the bases of the lungs having become oedematous, the end could not be far off.

relatives and friends bade him goodbye, as they believed, for the last time. In this desperate condition, called to mind a .paper

I had

seen a short time before, in which the author endeavoured to show that the orthodox view of the action of digitalis was erroneous, and that the reverse was the truth ; that in fact digitalis was, as we now know that it is, a powerful heart tonic. After most anxious deliberation, I determined

to

administer the drug to my literally dying relative. I gave the first dose in fear and trembling, watching anxiously its effects.

The breathing seemed to .become a little easier, and the pulse a little less irregular, and after the second doss the patient sank into a deep slumber, such as he had not enjoyed for many weeks.

in forty-eight hours the dropsy had almost entirely disappeared, and he was able to take nourishment freely. In a week -he was

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OM Is, 1892 Intercolonial Medical 0)919.Iva 459 out of all immediate danger, taking his digitalis mixture: every few weeks. He lived for eight years, and 'died in his 81st year;

Until within a few 'Months of his death, he was able to get about and enjoyed a fair measure of comfort.

This is a familiar-experience to the practitioner of to-day, but at the time of which I write the recovery of my patient was regarded as well-nigh a resurrection.

Many other heart remedies have been introduced into practice within the last quarter of a century, and some of them are of great value, such as caffeine, strophanthus, and convalaria. The remarkable relief afforded by ,nitrite of amyl and nitro-glycerine in angina pectoris is known to all. Opium still holds its ground as the most powerful of all anodynes, but a new class of analgesic and hypnotic remedies enable us to relieve the less severe forms of pain and sleeplessness with less unpleasant after-effects than was formerly possible. The important class of anti-pyretic drugs is also of quite recent introduction. Formerly, our means of reduc- ing dangerously high temperatures were confined to such feeble agents as suclorifics, purgatives, and cold locally applied. ,Here I must utter a word of caution against the unadvised use which is so largely made of these powerful neurotic remedies. Already a number of nervous and digestive ailments are traceable to the indiscriminate use of these remedies, especially by women, and unless the tide is stemmed, they are more likely to prove a curse than a blessing.

Two most valuable local anesthetics have been introduced into practice—cocaine and chloride of ethyl. I must not omit to mention, among the new :methods of treatment, the Weir-Mitchell plan of isolation and. 'feeding, by which many otherwise hopeless invalids have been restored to health. I cannot conclude this part of my subject without a reference to the hopes that were raised two years ago, that in tuberculin we had an agent des- tructive to the bacillus of tubercle, and a cure, therefore, for the greateSt scourge of our time. Those :hopes have been blighted but there is still room for the belief that on, the lines of this method of treating tubercular disease, we shall yet find a germi- cide that will destroy the bacillus without endangering the life of its host.

For the present, in ,consumption we must rely on measures which owe their efficacy to the exclusion of 'the specific bacilli

from

the air 'which we breathe, and to the fortification of the

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460 Andralidn Medical Journal: Om. lb, 1892 system so that it shall be better able to resist their attacks, or, in other words, to render the soil so barren that the parasite will not grow in it. Happily for us in these southern lands, we possess, on the mountains and inland plains, climatic conditions which fulfil both the purposes above mentioned, and which, therefore, are highly favourable to the arrest of this disease.

Forty years ago the cure of tubereular peritonitis was considered to be quite hopeless, but to-day we have records of recovery from this and other forms of tubercular disease.

In the sphere of preventive medicine, the progress that has been Made is as great, or perhaps greater, than in any other department of our art, and from its nature is more open to public cognisance..

For the maintenance of the body in a healthy state, many things are useful, but three things are essential—p e air, pure water, and wholesome food—in one word, absolute cleanliness in its widest sense.

Much has been done during the past forty years to secure to our citizens a purer atmosphere; public parks and recreation grounds—

the very lungs of our cities—have been provided, sewers and mines have been ventilated, house and street sanitation has been greatly improved, smoke consumption has, to some extent, been made compulsory, and overcrowding has been rendered illegal. It is no .exaggeration to say that tens of tho,usanas of have been saved, and hundreds of thousands of cases of illness have been prevented by the Sanitary Acts, all of which have been brought into operation within my lifetime. The day is perhaps not far distant when, by the substitution of electricity for gas for the purposes of illumination, and gas for coal for heating purposes, by the compulsory consumption of smoke, and the destruction of refuse and noxious vapours by fire, as well as by extensive tree- planting in our streets, the air we breathe will be rendered still purer.

It is to he hoped, also, that cremation of the dead will soon be universally practised, for although it must be admitted that the return of the body to the earth is the natural mode of the dis- posal of the dead, yet in the artificial 'circumstances under which we live, crowded together in cities and towns, cremation is the only method by which we can secure pure air and uncontaminated water, There are few towns of any magnitude which do not now possess an abundant supply of pure water, Nit forty years ago there were many places, not only in the Australian colonies, but

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Om. 15, 1892 Intercolonial Medical Congress. 461 in Europe and America, which derived their water supply from an uncertain rainfall, collected from the roofs of houses, or, still worse, from wells which in too many instances were in dangerous proximity to cesspits or other possible sources of contamination.

Lead poisoning, also, arising from the use of leaden pipes and cisterns, was quite common, but owing to the substitution of iron and earthenware cisterns and pipes for those made of lead, and to more perfect filtration, plumbism is now rarely seen.

I

may here

express the hope, that in these colonies the adoption of filter beds, as used by the great water companies of England, will soon become general. The large amount of organic vegetable matter which many of our water supplies contain, and the animal matter which is accidentally introduced would thus be largely removed, and the risk of communication of zymotic and parasitic disease greatly diminished.

It was in my student days that attention was first seriously directed to the adulteration of foods. The late Dr. Letheby, then.

Medical Officer of the City of London, and Dr. A. H. Hassall did good service in exposing the practices of dishonest tradesmen.

Such necessary articles of food as flour, bread, milk, sugar, tea and coffee were found to be largely adulterated with noxious or innocuous substances. The appointment, by the vestries and sani- tary authorities of England, of medical officers of health and public analysts, together with the passing of the Food and Drugs Act, had a marked effect in reducing the frequency of these frauds. The inspection of dairies and the .seizure of diseased meat exposed for sale are preventive measures of quite recent date. The communication of typhoid fever by drinking milk contaminated with sewage water, was first clearly traced nearly forty years ago by my friend and tutor, Dr. E. Ballard, late of the Local Government Board. Since that time, it has been one of the well recognised ways in which that great scourge of our civili- sation spreads. Outbreaks of diphtheria have also been traced to the same cause. It has also been pretty clearly proved, that scarlatina has been caused in the human subject by drinking the milk of cows affected by a specific disease. Moreover, there is a strong probability that not only the flesh of tuberculous cattle may communicate tuberculosis to man, but that the milk of tuberculous cows is capable of imparting that disease to children and young persons. If this be true, skilled supervision of our dairies and abattoirs is a matter of vital importance.

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462 Australian. Medical. Journal. OCT. 15, 18.92

In recent •times, "notification of disease, disinfection, isolation, and segregation have done much to preVent the spread of specific infectious diseases. Ever-increasing efforts are being made to prevent the widespread diffusion of the germs of disease. And we can foresee the time when deeper biological and chemical research, and a wider acquaintance With natural phenomena, and the laws which regulate them, will have conquered the whole range of the zymotic and exanthematous diseases.

There are other commodities of unhappily too large consump- tion, the purity of which needs, to be jealously watched, if it be true,. as I believe 'it is, that intemperance in the use of beers, wines, and spirits, is fostered by their adulteration. The very large proportion of disease generated by excess both in eating and drinking; is one of the alarming features of our social life. I am disposed to agree in the main with Dr. Pye Smith that the malady of the century is not so much a disorder of the nerves as of the stomach, and that more of our ailments are due to errors and excesses in food and drink than to the "terrible pace " at which we live.

More or less successful efforts have been made during the past four decades, to protect the workmen employed in lead and arsenic manufactories from the injurious effects of these metals. Phos- phorus necrosis of the jaw is also much less common than it was, owing to the greater attention bestowed upon the teeth of the lucifer match manufacturers, and to the stronger insistance upon the observance of personal cleanliness.

Without detracting from the merits of others, it is only just to say that in all the movements which have been made, and which I have but touched upon for the bettering of the physical environment of the race, the members of our profession have, with a self-abnegation which is rarely found in other callings, taken, a leading part. •

I cannot close these remarks upon preventive medicine without mentioning a subject which is closely connected with it. I refer to the anthropometrical system, in which a careful estimate and record of the physical qualities of man is made, a system which has been practised in some countries on a small scale, but which it would be well, in my opinion, to carry out in all lands on a very extensive one, and perhaps to enforce by legislation. The physical advance or degeneration of the race would in the course of a few decades be clearly demonstrated, and not be, as it now is, a matter of opinion or surmise. We should then possess

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OCT. 15, 1892 Intereolonial M•idieal Congress.

463- precise data from which to draw conclusions as to the beneficial or deleterious influences of our habits, customs, systems of education, occupation, climate, and so forth, and we should further be aided by such data in reaching a solution of that interesting question, viz., the effect of the higher education upon the physical condition of women.

Finally, Your Excellency, Ladies and Gentlemen, the bearing of all these sanitary improvements upon the mental and moral health of the people, it is not difficult to see. We cannot expect to find the

mens sana

except in the

corpore sano.

The world is better than it was, in great part, because better physically—because it is cleaner, a healthier mental attitude, and a higher moral tone prevail to-day ; and while thankfully and freely acknowledging the large share in that improvement which is due to the school, the University, and the Church, I do not hesitate to affirm that a very considerable portion most be credited to brighter and more sanitary surroundings—so much is man affected by his physical environment. There is meaning as well as wit in the saying

All that's good and great in men Has its source in oxygen.

In conclusion, let me say that, although I have tried to

,

show that our art has advanced both on its scientific and practical sides, and although I am proud of what has been done during my own lifetime, I am deeply conscious of how much we have yet to learn, and how often we stand helpless at the bedside of the suffering.

We have but touched the brink of this great sea of knowledge.

" The great art of healing is not brief, but hard and long." If what I have said, inadequate though it be to so large a survey, does but stimulate one of our number to strive to add even one little fact to the sum of knowledge, it will not have been said in vain. Of this I feel confident, that, if we are faithful to the inductive method, and constantly correct the premiss by more , precise observation and experiment, being ever ready to relinquish the most cherished theory when the smallest fact renders it untenable, we shall pursue our art with ever-increasing satisfac- tion to ourselves and advantage to our patients.

There are large victories still in store for us to reward our utmost labour--victories which will bring incalculable blessing to the suffering, to whom it is our high vocation to minister ; so,.

labouring in the profoundest reverence for truth, we shall be

working in the spirit of Him whom we are accustomed to call

the Great Physician.

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464 Australian Medical Journal. OCT. 15. 1892

On the motion of Dr. GARDNER (Melbourne), seconded by D1'.

MORIER (Nairne, S.A.), a vote of thanks was passed to the President for his address, and was duly acknowledged.

On the motion of Professor ALLEN (Melbourne), seconded by Dr. POULTON (Adelaide), a vote of thanks was accorded to the Governor.

Lord JERSEY, in responding, said that he was in the happy position of being able to make an announcement which be felt care would be well received. The Premier had asked him to say that the Government would be very happy

,

to do anything by way

of

undertaking the printing of the record of the business which took place at the Congress.

The evening of the opening day was devoted to (we had almost said wasted in) the discussion of a motion proposed by the Hon.

Dr. TARRANT, " That the question of the nomination of members of the Executive Committee of the next session of Congress be referred to the following committee for report :—Drs. Vero), Sydney Jones, Balls-Headley, Bright, Milford, Creed, Gibson, Hankins, M'Carthy, and the mover ; and that the report of such committee be considered on the last day of the present Session, or at such other period of the sitting of the Session as the President shall determine." The motion was rejected, and the less said about the discussion, and the proceedings that gave rise to it, the better.

On Tuesday the Sectional work began, and we propose to con- sider the work of each Section separately, devoting nearly the whole of the present, and a large part of the next, number of the Journal to this purpose. The account will not, perhaps, be as accurate and complete as it might be, as we regret that the Congress authorities did not see fit to afford the representatives of the medical press more facilities for acquiring information.

The Session was concluded on Saturday, October 1, when a telegram from the Otago Branch of the New Zealand Medical Association was read, inviting the Congress to hold its next • Session in New Zealand ; and an invitation was extended through Dr. Lockhart Gibson, a Member of the Congress, to the Congress to hold its next Session in Brisbane.

Dr. VERCO (Adelaide) moved, and Dr. F. NORTON MANNING (Sydney) seconded a motion--" That the next meeting be held in Brisbane."

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OCT. 15, 1892

Intercolonicil Medical Congress.

The Hon. Dr. MACKELLAR (Sydney) moved, and Dr. FIASCH1 (Sydney) seconded an amendment—"That the next Session of

,

the Congress be held about three years hence in New Zealand."

The amendment was carried by a large majority.

On the motion of Professor Anderson Stuart, seconded by Dr. Scot Skirving (Sydney), and supported by Dr. Verco (Adelaide), the President (Dr. Sydney Jones), and others, Dr. BATCHELOR was unanimously elected President of the next Session.

The following resolutions were carried :-

I. Moved by Dr. STRUTHERS-" (1) That this Congress is of opinion that there is a real and yearly growing possibility of the introduction of small-pox into Australia ; that, in spite of the admirable precautions adopted by the various Boards of Health, there is danger of its becoming epidemic ; and that owing to the large number of unvaccinated persons in Australia, an epidemic, of small-pox would be attended with very great loss of life.

(2) That this Congress desires emphatically to express its belief, that efficiently performed vaccination is a valuable protection from small-pox ; that when it does not prevent an attack, vaccination deprives the disease of most of its horrors in the great majority of instances ; that there need be no apprehension that vaccination, when performed under proper precautions, will injure health or communicate disease ; and that vaccination should not be deferred until the actual appearance of small- pox."

II. Moved by Dr. NORTON MANNING-" That in view of the fact that the present recognised legal test for insanity is false in theory and unsatisfactory in practice, and that legal authorities have expressed a desire to obtain an expression of medical opinion upon the subject, the Congress approves of the following resolutions :—(1) That it is impossible to frame any one test for insanity in criminal cases which is capable of general application. (2) That for criminal cases it would be in accord with present medical opinion to define insanity as a disease of the brain affecting the intellect (and also the emotions and will), and not immediately induced by the default of the individual,' leaving the following questions for the jury

:—(a)

Had the accused at the time of committing the act such disease of the brain ? (6) If so, did such disease prevent, in relation to the alleged

HH

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466

Australian Medical Journal.

OCT. 15, 1892.

crime : (1) A knowledge of the nature and quality of the act he was doing ; (2) Knowledge that the act was wrong (illegal) ; (3) A free determination of his will ?"

III. Moved by Dr. LOCKHART GIBSON-" The members of the subsection for diseases of the throat, nose, and ear, are unanimously of opinion that—(1) The form of nasal obstruction produced by post-nasal growths is very prevalent in the Australian colonies. (2) It is the chief cause of ear disease, and produces other physical disturbances. (3) The widest publicity should be given to the fact that habitual mouth breathers are in a serious condition. (4) That with early recognition and appropriate treatment, the number of cases -of deafness and deformity, with arrest of development, will be greatly reduced."

IV. Moved by Dr. BICKLE-" That it was desirable that an Australasian Medical Journal should be published."

V. Moved by Professor A. STUART-" That Dr. Martin be requested to carry out a series of investigations relative to strychnine as an antidote to snake-poison."

The social side of the Congress was very successful in affording members opportunity of friendly meeting. On the afternoon of the opening day, the Mayor and Mayoress held a reception in the Town Hall, and an excellent programme was rendered on the grand organ by Mr. Wiegand.

On Tuesday, members were entertained by His Excellency and Lady Jersey at a Garden Party at Government House, the perfect weather and charming situation making the afternoon most enjoyable. On Wednesday, the President of the Congress gave a dinner in the Town. Hall. Several harbour excursions were made—to the Quarantine Station, where members were entertained by the Government, and to the Little Bay Hospital, Walker Convalescent Home, Lunatic Asylums, &c. On Friday evening, a Conversazione was held at the University, which proved a deserved success, and the festivities closed with a picnic to Fern Bay. Numerous private dinner parties were also given, which were among the most enjoyable events of the meeting.

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Our. 15, 1892

hatorcolonitil •edicql •Congress. 467 SECTION I.—MEDICINE.

'PRESIDENT'S ADDRESS.

By JAMES ROBERTSON, M.A.. M.D.

Consulting Physician, Melbourne Hospiial; formerly Leda er in Medicine in the University of Melbourne.

In occupying this chair, permit me . in the first place to acknow- ledge the high honour done me by the Executive Committee of the Intercolonial Medical Congress,. in electing me to the position

of President

of the Section of Medicine; and in the second place,

to

bespeak your generous sympathy and kind consideration, in my endeavour to fulfil the duties devolving on me. The choice of a subject for my address : has proved rather embarrassing. It occurred to me that a resume of the progress of Medicine since last meeting of Congress, would, afford appropriate matter for an address. But, as Pathology, at first included in the Section of Medicine, was afterwards allotted to another Section, I felt • that Medicine would indeed be crippled without the support rendered

by

Pathology, its essential ally and sure guide, from which it cannot be legitimately divorced.

The most recent,

and important advances in Medicine have originated from the study of Bacteri- ology. By its revelations, the -natural history of infective diseases has been elucidated, and their

pathology, embracing a

-

:tiology,

diagnosis, general course, and termination, has been unfolded.

The hope is

now

excited that the treatment of contagious diseases, by active or prophylactic measures, may be ultimately discovered.

On ruminating over the subjects that have occupied most attention in the medical periodicals, I found that discussions on the administration of chloroform, on Koch's treatment of tuberculosis, 411d on the spread-of influenza, had been the stirring events of the period. •

The existence of Koch's treatment iota been transitory ; its extinction is only delayed by the effete efforts of the credulous.

It was prematurely introduced into practice with great confidence in its efficacy, was at

once extensively

adopted, and used in the various stages of tuberculosis, by many with doubtful success, and by some with eminently successful results, if reports may be credited ; it was claimed for this agent that it

was

prophylactic, :diagnostic, and _therapeutic. It

has

failed to fulfil the high hopes and expectations entertained, and is

now apparently passing into Dbliy

HH 2

(20)

468 Australian Medical Journal, OCT. 15, 1892 Influenza has always been a Mysterious visitor at more or less prolonged intervals, its origin and source being veiled in obscurity.

Generally, it originates in the Northern regions, _breaks out suddenly, spreads rapidly, extending westwards, and soon becomes epidemic, and even pandemic, affecting all nations and races, apparently independently of heat, or cold, or climate, or any meteorological condition. It certainly differs from all other acute specific fevers, in assuming a pandemic character. It is, however, very variable in its progress—sometimes slow, sometimes very rapid, attacking many countries almost simultaneously.- Observa , tions made during the latest epidemic have tended to strengthen the opinion that it is a specific contagious disease, and that it -is communicated directly from the sick to the healthy. The disease runs its course speedily in healthy subjects to a favourable termi.

nation. It is dangerous to the young and aged from the general prostration that accompanies it, and from the liability to the supervention of bronchitis, or broncho-pneumonia, more especially in the case of those having a tendency to lung affections. It is said to still linger in the colonies, but the so-called sporadic cases now occurring may be due to febrile catarrh, so prevalent in the winter months, or at the change of seasons:.

Cholera appears to be 'following in the wake of Influenza, as it has done on some former occasions, but it is more particularly confined to the lines of human inter-communication. Its extension is not so rapid as that of influenza; the medium of its transmission is terrestrial, while that of influenza is rather aerial. Cholera is more a filth disease. It attacks insanitary places, finds its nidus in filth, and is especially liable to be propagated through the medium of polluted water.

I am now about to introduce to your notice the special subject of my address—a subject with which you are all familiar, and on which, doubtless, many of you have already formed decided opinions—

THE ADMINISTRATION OF CHLOROFORM, AND ITS DANGERS. . In doing so, I feel that I owe some apology. The vital impor- tance of the subject, the frequent occurrence of fatalities, and the conclusions arrived at by the Hyderabad Chloroform Commission, which I regard as fraught with danger if acted on, have induced me to select this subject. The administration of chloroform—the most potent and valuable of anmsthetics—is to be regarded as

one

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OcT. 15, 1892 Intercolonial Medical Congress. 469 of

the most responsible duties devolving on a medical man, seeing that the life of a human being is at stake, and its sudden termination is dependent, in a great measure, on his care and vigilant circumspection.

Since the introduction of Chloroform into practice in 1847, our advanced knoWledge of medicine has not contributed to greater safety in its administration, and it .cannot be regarded otherwise than as an

opprobrium Medicince,

that deaths from the exhibition of that anwsthetic have not diiiiinished, but have of late years rather increased in frequency. We are by no means agreed in regard to experiments, and the lesSonsthey convey as to the lethal effects of Chloroform inhalation. Indeed, the danger~ liable

to

result from the careless exhibition of chloroform have been seriously urged as reasons for abandoning its use altogether, and Substituting ether, or some other anaesthetic. 1 n estimating the dangers of chloroform, it should not be -forgotten that, in the pre- anaesthetic period, sudden deaths on the operating table were not unknown. Some patients were found to succumb .on the first incision through the skin, some on sawing through the. bone.

Fear or fright, and also pain and shock, were adduced as the causes, the more immediate cause being syncope ; and even now some are reported to have died from fear while beginning to inhale chloroform. Doubtless lives are now saved by the use of chloroform which would have been otherwise lost, and possibly the deaths prevented are quite as numerous as those attributed to its effects. The mission and effort of the physician is to alleviate suffering and prolong life by every means in his power ; conse- quently, the use of chloroform should not be withheld in severe and painful operations, especially if tedious or long continued, involving the brain or

,

abdominal organs ; but the utmost pre- caution should be taken to guard against the dangers liable to supervene.

Professor Simpson regarded its administration as unattended with danger. Professor Syme stated that " used with moderate care, it -is perfectly safe." Dr. Snow was of opinion that

"chloroform may be given with safety and advantage in -every case, if in - a condition , to undergo a surgical operation." Dr.

Anstie concurred with Dr Snow's opinion. Surgeon-Major

Lawrie concludes " that chloroform , may be given in any case

requiring an operation with perfect ease and absolute safety, so as

to do good without the risk of evil.'! I might quote other opinions

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470 ugralian Medical Journal Ocr. 15, 1891 alike favourable, and might refer to statistics equally so, but as 1 find statistics to differ very widely, I will not trouble you with an array of figures.

Noth withstanding the-numerous .attestations in favour of chlo- rofoiln, many in doubt and distrust are adopting the use of ether.

No anaesthetic can be said to be absolutely free from danger, but with judicious care and caution the risk may be reduced to a minimum. Chloroform has been well described by Dr. Lauder Brunton, as being "like a sharp knife in the hands of the surgeon, as, compared with a blunt one. It is more efficient for good, if properly handled ; it is more powerful for evil, if misused."

Ether, it must be alloWed, is less dangerous than chloroform, in not causing so much depression of the heart's action, but it is unpleasant, irritating to the air-passages, cannot be used under certain circumstances, or in every case. 'Besides, it requires special apparatus for its administration.

Chloroform maintains supremacy as the most "pleasant, speedy, • and efficient" anTsthetic, requiring no special apparatus, suitable in every case fit for operation, and safe when given with judicious care. . Its advantages are such, that it has been generally adopted in preference to all other anaesthetics, and is still regarded with Most favour.

In 1888, and again in 1889, Commissions were appointed by His Highness the Nizam of Hyderabad, at the request of Surgeon-Major Lawrie, to investigate the action of chloroform:

The philanthropy of His Highness, in liberally supplying funds for the experiments, and the expenses of an expert sent from England, cannot he too highly appreciated, the laudable object of the Commision being, in the words of the Nizam, " to 8ave peoples' lives." The Commission, after the sacrifice of heca' tombs of dogs and monkeys, arrived at the conclusions, that, "in every case where chloroform was pushed, the respiration stopped before the heart," and that "the administrator should be guided as to the effect entirely by the respiration." The numerous experiments and their record manifest careful and laboriouS investigation, and merit the thanks of the profession, but the conclusions arrived at cannot he accepted as applicable to the Human subject. The result of the experiments has been to direct attention to a subject Of vast importiince, and to arouse inquiry;

which cannot be otherwise than beneficial.

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Om 15, 1.892 Intercolonial Medical Congress.

47 My experience of the administration of chloroform extends from the year of its introduction by Professor Simpson, 1847, the year in which I myself commenced practice. For nearly forty-five years I have exhibited that anaesthetic in many thousand cases, often in prolonged operations, and never with fatal consequences.

I refrain from reducing the number to figures, as I cannot even give a close approximation to it. , In not a few instances, alarming and even dangerous symptoms have presented themselves, and have strongly impressed me with the risk of trusting alone to respiration as the index of danger. I have watched both pulse and respiration, and ultimately came to regard the state of the pulse as the first signal of danger. I have no new experiments to lay before you, but I shall endeavour to demonstrate, from the experiments of othei.s, and from clinical observation and experience, that the state of the pulse is not of less importance than the state of respiration, as an indiciition of danger in the administration of chloroform ; that it is, indeed, the earliest and most significant danger signal.

I shall notice briefly the physiological effects of chloroform on the human subject, and its action on animals as compared with man. The vapour of chloroform inhaled through the pulmonary mucous membrane enters the circulation, and is first carried to the left side of the heart. With the next cardiac contraction it circulates throughout the system, and in the coronary blood-vessels.

The first

,

effect appears to be slight stimulation of the heart, and of the cerebro-spinal centres. The action of the heart is quickened, but this may be due .partly to nervousness. The cerebral functions are stimulated, as evinced by mental excitement, by talking, sometimes singing, laughing, and, not infrequently, by active movements of the extremities. The stage. of excitement is often absent, or of short duration. It speedily merges into one of depression, the pulse becoming weaker and slower, and loss of consciousness, and voluntary, motion supervening.

Reflex irritability is the list function to disappear ; so that 'the

abolition of, the conjunctival reflex, and Wining up of the eyes are

regarded as evidence of complete anaesthesia. The respiratory

movement continues automatically when all other reflex move-

ments are aboliShed. Different individuals are differently affected

by chloroform inhalation, and this may be accounted for by coniti-

tuitional peculiarities. Some inhale quietly, and are speedily brought

under its influence ; some becoMe excited, and toss their extremities

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472 Australian Medical Journal. OCT. -15, 1892 about ; while others resist and struggle violently. This, however, may be due to the mode of administration, and is a source of danger I shall presently notice.

It is very generally urged, that the pulse should not be taken as any guide in the administration of chloroform ; that the 'respiration alone demands attention. This contention seems to be strengthened by the Report of the Hyderabad Commission, to the effect that, in animals, respiration always stopped before the heart, and that all danger can be averted by attending to the respiration alone. Although I do not decry the results of experiments on the lower animals, inasmuch as they afford most valuable indications, I object to hard and fast lines being drawn, and hesitate to accept the dictum, " that the effects of chloroform are identical in the lower animals and in the human subject."

It

is well known that the effects of various drugs differ much, more especially of narcotics, when administered to the lower animals and to man. The lower animals are-not capable of being influenced by the same feelings and emotions as man, and, according to the testimony of the Hyderabad Chloroform

Commission,

operations liable to produce shock and syncope in man, were singularly devoid of effect in dogs. The effects of chloroform are not uniform in different human individuals, even when administered in the same way, and in certain definite proportions, or even in the same individuals at different times. According to the experiments of the Hyderabad Chloroform Commission, respiration always fails before the circulation, and there is no such thing as chloroform syncope. Experiments on animals reported by other Commis- sions, "the Royal Medico-Chirurgical Society's Committee of

Inquiry," and "the British Medical Association's Committee on Anaesthetics," negativ8 to some extent the conclusions of the Hyderabad Chloroform Commission, showing that, while in most Cases the respiration stopped before the heart, sometimes both respiration and the heart's action failed simultaneously, and sometimes the heart failed before respiration. The testimony of other observers is not less adverse. Dr. Snow, forty years ago, showed that, in animals killed by chloroform inhalation, when the Air contained' not more than 5 per cent. of vapour, the heart continued to pulsate when respiration had ceased. When the air contained 10 per cent. and upwards, death took place more speedily, respiration and circulation ceasing at the same time, there being sufficient vapour in the lungs at the moment the breathing stopped

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Oct. 15, 1892

Intercolonial Medical Congre' ss.

47

to paralyse the heart, as soon as it was absorbed and added to that already in the blood. This, he terms its cumulative property, when the effects of chloroform increase after discontinuance of

inhalation.

It appears that the more immediate effect of chloroform on the heart, or on the respiration, was influenced by the more or less 'concentrated state in which it was administered. But, even were it proved that chloroform invariably causes death in animals by paralysing the respiration, we have the most positive evidence that failure of the heart's action is the most frequent cause of death in man. An overwhelming. amount of evidence has accumulated, and still continues to accumulate, since the first recorded death from chloroform in 1848, to the effect that the occurrence of death in the human subject is almost invariably due to primary failure of the heart, or syncope. Such is, indeed, the principal source of danger, and it is a remarkable circumstance that a diversity of opinion should exist in regard to a question capable of definite Solution. Dr. Sibson was the first (according to .Dr. Snow) to Toint out, in commenting on the first four deaths recorded from chloroform, that death was caused by its paralysing the heart, "that in man;• death is usually instantaneous, and dub to paralysis of the heart ; in animals, death is usually due to paralysis of the muscles of respiration." An analysis of the first fifty fatal cases from inhalation of chloroform by Dr. Snow, shows that in forty (40) of these cases death took place by cardiac syncope, or arrest of the action of the heart ; " that in only four the breathing appeared to be embarrassed and arrested by the effect of the chloroform on the brain and medulla oblongata, at the time when the action of the heart was arrested by it ; and only in one of these cases that the breathing was distinctly arrested by the effect of the chloroform, a few seconds before that agent also arrested the action of the heart."

Clinical experience goes to prove that death from failure of the heart is the usual source of danger in the human subject, and is especially liable to occur when the vapour of chloroform is inhaled in a concentrated form, or insufficiently diluted with air. The records of the numerous fatal cases reported in the various medical periodicals conclusively attest that death by syncope is the most common termination in man. For not only have the deaths been attributed to failure of the heart, but in cases where

post-mortem

examinations were made, such lesions have been described , as

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474

Australian Medical Journal; .00T. 15, 1.8

" fatty heart," " flabby heart," " heart dilated," &et, &c. It is well known, however, that in many, if not in most, cases, where death has supervened, no lesion of heart, or of any other organ, has been discovered—that, in fact, the syncope was due to chloroform poisoning.

Although the Hyderabad Chloroform 'Commission arrived at the opinion, that failure of the respiration is the alone source of danger in chloroform administration, the results of their experiments decidedly show that a gradual fall in the mean blood pressure took place, and continued until respiration gradually ceased, and lastly that the heart stopped beating. A few quota- tions from the Report will indicate more clearly the tendency to heart failure. " If chloroform is pushed, there comes a time, not easy to define, when the blood-pressure and respiration will no longer he restored spontaneously, although the heart continues to beat after. inhalation is stopped." "As a rule, if the respira- tion has stopped, or even becomes slow and feeble, at the time

lien the inhalation is discontinued, and artificial respiration is not resorted to, the fall of blood-pressure will continue until death ensues." "Artificial respiration was nearly always successful if commenced within 30 seconds after the respiration ceased, very seldom successful if commenced between 30 and 60 seconds after, and always unsuccessful if not begun till after 60 seconds." Seeing the heart continued to act from two to six minutes, or on an average for upwards of three minutes, after cessation of the respi- ration ; it might have been reasonably expected that artificial respiration would in every instance have proved successful, even after the lapse of a minute. According to Dr. Lander Brunton,

"the time of grace is only half a minute, and if the administrator's attention should be so distracted as to allow this half-minute to elapse after the respiration has ceased, the patient will probably die."

It, must be allowed that , ft marked. fall of blood-pressure and slowing of the pulse precede the stoppage of respiration ; evidence that the action of the heart is feeble, and the circulation retarded.

The only two points left open to discussion by the Hyderabad Chloroform Commission are thus stated by Surgeon-Major Lawrie

—What is the harmless fall of blood-pressure due to'? and what happens to the heart after the respiration failed? These questions`

have been answered by the results of experiments of various physiologists. The experiments of Drs. Sibson and Snow, at

an

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OCT, 15, 1892 Intercolonial Medical. Congress.

4Th

early stage in the history of - chloroforin, proved that its action was local,' affecting 'file muscular structure of the heart (more immediately), as well as through . the medium of its nervous supply. The effect on the heart was More pronounced when the vapour was inspired in a concentrated forM, when the air Con- tained more than 10 per cent. of vapour. The action of the heart was alsO paralysed by injecting chloroform into the jugular vein; and by exposing the heart to its Vapour. it seems asLif the labours of those men, in investigating the mode of action, and sources of danger of chloroform, had been forgotten. Dr. Snow's work, .‘ On Anvesthetics," still maintains its position as a standard Work, and a reliable guide in the administration of chloroform, the conclusions arrived at being supported by more recent investigations.

The recent experimenta of the Chloroform Committee of the British. Medical Association, of Professors Schiff, Golt, Drs. Wood and Hare, Dr.' Ctishny, Professor McWilliam, and of many others, support the view that paralysis of the heart is brought about by the action of chloroform on the muscular tissue of the heart, or on its nervous ganglia, or through the influence of the vaso-motor nerves on the blood-vessels being abolished. Goltz found that, when the vaso-motor nerves were paralysed, both arteries and veins became dilated, so that little blood reached the heart, hence the weakness of the pitIse. Dr. T. G. Hake, from experiments performed in Professor Schiff's laboratory at Florence, concludes that the force of the circulation becomes so enfeebled by the paralysing action of chloroform on the nerves of the heart and blood-vessels, that the blood is not brought into contact with the air in the lungs sufficiently often for its renewal. The blood- vessels become dilated and congested from paralysis of the vaso- motor nerves, and the circulation is thus retarded. Professor McWilliam, of Aberdeen, has shed a light by his recent experi- ments in regard to the action of chloroform on the heart.

He

found that a fall of blood-pressure, and a change of left auricle and ventricle took place, even before the conjunctival reflex was obliterated, the auricle and ventricle becoming dilated ; and that death did occur from failure of , the circulation in some cases, all the chambers of the heart being dilated. - Among the general conclusions he arrived at,

I

wish particularly to notice the follow.

ing :—" The dilatation affected all parts of the heart more or less When the heart becomes greatly dilated, it fails as an efficient

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476 Australian Medical Journal.

OCT. 15, 1892 force in keeping up the circulation ; its rhythmic movement goes on for a time unchanged in rate, but so feeble as to he ineffective.

The failure of artificial respiration to bring about recovery in some cases when collapse has occurred from chloroform poisoning, and when artificial respiration has been begun directly the natural respiration ceased, is in all probability, due mainly to 'the distended and enfeebled state of the heart, which is unable

to maintain the circulation. The fall ' of blood pressure under chloroform is in the earlier stages usually due to the depressing influence of the drug upon the vaso-motor. centre., The later stages of a great fall of blood-pressure, are commonly associated with a failing condition of the heart, as well as of the vaso-motor centre." The rhythmical movements of the heart after the cessation of respiration, observed and tested by the movements of a needle, inserted through the chest wall into the heart, doubtless led the members of the Hyderabad Chloroform Commission to suppose that the action of the heart continued in its normal condition.

The absence of pulse in the femoral artery, while the movements of the heart continued, proved that the heart was inefficient to propel the blood to the extremities.

From experiments made in the physiological laboratory of Bern University, Dr. Cushny found " that the

1

eart needle was not an accurate index of the heart beat, as in some cases, it continued to vibrate after paralysis of the ventricles had taken place, owing to the continued pulsation of the auricles communicating a motion to the ventricles, through which the needle passed." He also states that " the chances of recovery after paralysis of the respiration, depend entirely on the conditionof the heart, and therefore on the concentration in which the drug has been used. If, as in the case -of rabbits, the heart is very much weakened by very concentrated 'administration, it is impossible to restore the respiration. In dogs, the heart is comparatively unaffected, the animal can always be revived, provided the- necessary measures are taken within a reasonable time. The essential point is, that the drug be given in sufficient dilution, to avoid its action on the heart." Abundant evidence from experiments on animals has now been adduced to prove that the heart is directly affected by chloroform inhalation, and that it speedily, becomes paralysed, when chloroform is exhibited in a concentrated form. Clinical observation and experience in regard to the effect of chloroform on the human subject, are strictly in 4ccord with those conclusions.

References

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