1879

Re-examined on Nov. 26th, four weeks after the injection, ithe patient’s condition was as follows. Speech was more easily

I

dicited, but was quite imbecile in character. Articulationwas like that of a cleft-palate case. The pupils were unequal,the left reacting feebly to light under strong electric illumina-tion, the right inactive. Reaction to accommodation couldnot be satisfactorily ascertained. The superficial reflexeswere still exaggerated. Elbow-jerk, wrist-jerk, knee-jerk,and ankle-clonus well-marked and easily elicited. The

bodily condition showed continued wasting since the injec-tion. There was no difference in the fundus. Loss ofcontrol of bladder and rectum was present, and the patientwas unable to stand or sit up.

It will thus be seen that there was practically no improve-ment, and this is in keeping with the vast majority ofclinical reports recorded in the adult type and in tabes. Atthe outset Ehrlich cautioned against the use of " 606 " indegenerative changes, and in a recent communication toSachs stated that there had been 12 deaths in advancedcerebral and spinal disease after its use (35). In cerebralsyphilis, however, Neisser states that paralysis and

pains disappear like magic, and advises that it may betried in early tabes and general paralysis, questioning,however, if it is safe when optic atrophy is present.From experiments on animals it has been found that " 606 "

is not injurious to the normal eye, but in the human subjectit is stated that transitory blindness may occur. Speithoffand Michaelis had a tabetic who 50 hours after an injectionof O. 6 gramme was seized with temporary blindness forseveral minutes, and another who, eight weeks after an injec-tion of 0-45 gramme, developed sudden ptosis of one lidand blindness lasting ten minutes. Nothing was foundophthalmologically (36). Gluck treated two cases of paresisand one of optic atrophy without result (37). Fordyce 5treated nine tabetics with little result, and one case ofcerebral syphilis with wonderful success. Dr. Ivy Mackenziereports that of 16 general paralytics four were undoubtedlybenefited (38). Michaelis in one of his general paralytics hada remission lasting two months. In 12 paralytics treated byMeyer there was no lasting result. The Wassermannreaction after treatment in these cases of Meyer wasvery interesting ; four gave a negative reaction, four Ia diminution, and four were uninfluenced (39). In thisconnexion it is interesting to note the extreme diffi-

culty of influencing the Wassermann reaction by treat-ment in congenital syphilis. In the London Lock Hospitalfor Women and Children we found that even after two years’in-patient treatment by inunction children still gave an

active Wassermann reaction; and McDonagh states that

congenital syphilis, irrespectively of treatment, tends to

give a positive Wassermann reaction throughout life (40).This statement, though there are strong reasons for believingthat it is in the main correct, is probably not absolutelywithout exception, as the term "congenital syphilis " is atpresent loosely used to include cases both of infection beforebirth, in which the child is born dead, or if alive comes intothe world with well-marked signs of syphilis, and cases ofinfection from the placental blood, occurring during theperiod of delivery, and manifesting themselves some three orfour weeks after birth.

Reverting again to the main subject, it will be seen fromthe cases quoted above that in syphilitic and parasyphiliticaffections of the nervous system hopes of success may beentertained in cerebral syphilis, and that amelioration of

symptoms in some tabetics and remissions in some generalparalytics may follow the use of the drug. To anyone, how-ever, acquainted with the frequent remissions, and even some-times complete cessation of ataxic and mental symptoms,for a time in tabetics and general paralytics withouttreatment, the evidence that such improvement is due, inthe cases quoted above, to the use of "606" " is not con-vincing, and the necessity of early and systematic treatmentto prevent these late manifestations becomes increasinglyurgent. In Wassermann’s reaction we apparently have ameans of discovering latent congenital syphilis in thechildren of known syphilitics, and these are the cases thatseem particularly liable to develop juvenile general paralysis.Considering, then, the apparent hopelessness of checking themalady by even the latest form of treatment, and the knownfact that mercury has been proved time and again to beequally useless, it is imperative that such children should be

5 Loc. cit., supra.

given the very best possible chance at the earliest possibleopportunity; and the mere fact that treatment has a verydubious effect on the character of the Wassermann reaction,instead of suggesting to us the impossibility of curing con-genital syphilis, should stimulate us, on the contrary, tocontinue treatment, possibly for years, instead of, as is sofrequently the case, stopping treatment as soon as the earlymanifestations during the first year of life subside.

Ehlers of Copenhagen reports a death five days after theinjection of 0 - 5 gramme of "606" " in a general paralytic. 6The patient was a man, aged 40 years, who had developedsyphilis 11 years previously and had been insufficientlytreated. In April, 1908, he had an apoplectiform seizure.In August of the same year he first began to show signs ofgeneral paralysis (dementia paralytica). In July, 1910, hehad a second seizure. On August 25th he was injected inthe interscapular region subcutaneously with a neutralsuspension after the manner of Wechselmann. His symptomswere those of poisoning ; there was tremor, shivering,sweating, and progressive loss of strength. His temperaturerose to 103 - 60 F. (39 - 80 C.). He died from paralysis of theheart. A post-mortem examination showed all the organsto be healthy except the heart, in which there was acute

parenchymatous degeneration. Details of the microscopicexamination of the nervous system have not yet been

published.I beg to acknowledge my indebtedness to Dr. F. R. P.

Taylor for permission to record the case, to Dr. C. H. Fennellfor much help in valuable details, to Mr. H. W. Bayly ofthe Lock Hospital for the Wassermann results, and to Dr.Otto Grunbaum for the use of the 606."

Bibliogralty.-1. Clouston : Journal of Mental Science. October,1877, p. 419. 2. Turnbull: Ibid., October, 1881, p. 391. 3. Nolan : Ibid.,April, 1883; Wiglesworth, Ibid., 1883, p. 391. 4. Regis : L’Encephale,1883. 5. Alzheimer: Allgemeine Zeitschrift fur Psychiatrie, Band Iii.,f. 3, 1895. 6. Thiry: De la Paralysie Générale Progressive dans le JeuneAge. 7. Mott: Archives of Neurology, vol. i., p. 250. 8.Mott:Practi-tioner, January, 1908. 9. Mott : System of Syphilis, vol. iv. 10.Fennell: Practitioner, 1907, p. 518. 11. Mott: Tabes in AsylumPractice, Archives of Neurology. vol. ii. 12. Fournier: Les AffectionsParasyphilitiques, Paris, 1894. 13. Krafft-Ebing : Neurol. Cent., 1897,quoted from the discussion on General Paralysis at the InternationalCongress, Moscow, 1897. 14. Rosenfeld: Allgemeine Zeitschrift fiirPsychiatrie, Band lxv., H. 3. 15. Stertz: Ibid., Band lxv., H. 4. 16.Williamson: Journal of Mental Science, October, 1909. 17. Gilmour :THE LANCET, Nov. 19th, p. 1492. 18. Ford-Robertson: Journal of MentalScience, October, 1906, and January, 1909; THE LANCET, Nov. 14th, 1908,p. 1438. 19. O’Brien: American Journal of Insanity, 1908. 20. Marie:Revue de Psychiatrie, October, 1908. 21. Mott: Svstem of Syphilis,vol. iv., p. 203. 22. Thomson: Journal of Mental Science, July, 1909.23. Williamson : Ibid.. The Bacillus Paralyticans, October, 1909, p. 650.24. Mott: Archives of Neurology, vol. i., p. 254. 25. Collin: BulletinSociete Clin. Med. Ment., July, 1908. 26. Mott: Practitioner, 1908.27. McDowall : Journal of Mental Science, January, 1908. 28. Burzio:Quoted from the Journal of Mental Science, January, 1906. 29. Mott :System of Syphilis, vol. iv., p. 233. 30. Watson: Archives of Neuro-logy, vol. ii., p. 628. 31. Nonne: Deutsche Zeitsehrift fiir Nerven,Band xxxviii., p. 291, February, 1910. 32. Nonne and Holzmann:Ibid., Band xxxvii., p. 195, September, 1909. 33. Remond andChevalier-Levaure: Un Cas de Paralysie Générale Juvenile, ProgresMedical. March 8th, 1909. 34. Kleineberger : Allgemeine Zeitschriftfiir Psychiatrie, Band lxv., Heft 3. 35. Fordyce: New York MedicalJournal, Nov. 5th, 1910, p. 900. 36. Ibid., Quoted by Fordyce.37. Gluck : Miinchener Medicinische Wochenschritt. August 2nd, 1910,p. 1639. 38. THE LANCET, Nov. 19th, 1910, p. 1492. 39. Quoted byFordyce. 40. McDonagh : THE LANCET, Nov. l9th, p. 1490.Queen’s-road, W.

Medical Societies.ROYAL SOCIETY OF MEDICINE.

BALNEOLOGICAL AND CLIMATOLOGICAL SECTION.

British Health Resorts tbr Foreign Invalids.A MEETING of this section was held on Dec. l4th, Dr. T. F.

GARDNER, the President, being in the chair.Dr. NEVILLE T. WOOD read a paper on British Health

Resorts for Foreign Invalids. He said;- Whereas a largepercentage of the patients at the better known continentalspas hail from Great Britain, the number of foreign invalidssent to British health resorts is quite insignificant. Thereason for this state of things is that the policy of Britishmunicipalities exhausts itself in the endeavour to keepBritons from foreign countries rather than to bring theforeigner to ours, and in addition to that no serious

6 Ein Todesfall nach Ehrlich-Hata: "606," Munchener MedicinischeWochenschrift, Oct. 18th, p. 2183.

1880

attempt has been made by the profession in Englandto inform their foreign colleagues that there existin our island spas and climatic stations of the highestrank. Continental spas should not be regarded as competingwith British spas, nor British with continental, the indica-tions for the two groups differing so widely that they arecomplementary to each other. Speaking generally, the

categories of foreign invalids for which our spas are typicallysuitable include those who thrive in a relatively cool climateand are able to walk well, those who in association withcomplete change derive benefit from baths which are

neither very hot nor taken in close succession, and thosewhose maladies are held to be tributary to the waterswe possess-that is to say, the muriated, sulphuretted,iron indifferent, earthy, and alkaline sulphated. A com-

prehensive view of British spas from an international

standpoint is that, whereas for Britons they are mineralwater stations with climatic advantages, for foreigners theyare climatic stations with the advantage of mineral waters.It has been objected that our spas are intolerably dull, butthere are very many on the continent visited annually bythousands of invalids which are not in any way more

lively. Excessive rainfall has been urged against all ofour resorts, but on the European mainland, too, it isnot uncommon for a whole season to be spoilt by per-sistent downpour of rain; and, as a matter of fact, insummer less rain falls in the eastern division of Eng-land than at some of the stations of Western Europe.Our seaside resorts possess for foreigners advantages which,if not so well defined, are even wider in range. Foreignersare accustomed to and demand higher temperatures insummer than are agreeable to English people. This difficultymay be met by sending continental patients to the warmerof our coast stations. We have, in addition, inlandclimatic stations where the air, though bracing, is not devoidof sedative qualities. Among such stations may be mentionedHindhead, Church Stretton, Crowborough, Okehampton, andBen Rhydding. When the inhabitants of Central Europebecome as well aware of the advantages of British healthresorts as we are of the indications for theirs, there will bea free interchange of invalids instead of as now a movementin only one direction-and that away from our shores. Inorder to accomplish this purpose a book is now under con-sideration with descriptive monographs written and the wholecollated by whatever chapters may appear to be necessary.The PRESIDENT, Mr. E. SOLLY, Dr. F. BAGSHAWE, Dr.

R. FORTESCUE Fox, Dr. A. MANTLE, Dr. F. H. HUMPHRIS,and Dr. J. LIDDELL took part in the discussion whichfollowed, and Dr. WOOD replied.

EDINBURGH OBSTETRICAL SOCIETY.

The Modern Treatment of Contracted Pewas.-LccnternDemonstration.

A MEETING of this society was held on Dec. 14th, Dr.F. W. N. HAULTAIN, the President, being in the chair.

Sir JOHN HALLIDAY OROOM read a paper on Modern Treat-ment of Contracted Pelvis. At the outset he referred tothe diminution of sepsis in hospital practice, which per-mitted many interferences now which were impossible inthe olden days, and he further referred to the fact that

sepsis still continued in private practice. He thought itwas useless to discuss the methods of dealing with thenarrow pelvis until practitioners recognised the fact that acareful and accurate measurement of the pelvis in everyprimiparous woman, and in every multiparous womanwith a bad obstetrical history, must be carried out.He referred to the fact that in midwifery, as well as in

general medicine, preventive treatment was more important,instancing the successful prophylaxis of obstetric com-

plications in the Pre-Maternity Home in Edinburgh. Hedivided narrow pelvis, for all practical purposes, into threecategories. First, those below 3 inches ; second, those above3 ; and third, those between 3 and 3-. With the first

variety there was no difficulty in dealing, because in themthe only treatment, when diagnosed before labour, was

Cassarean section, which, of all abdominal operations, was byfar the most satisfactory. He then dealt with the question ofsuch cases being seen late in labour, and with the field ofcraniotomy, which he pointed out as getting more and morecircumscribed every day. He recommended a more general

use of maternity homes and nursing homes for the treatmentof all obstetric operations. Sir John Halliday Croom pointedout that with the disappearance, in hospitals at least, of

puerperal septicaemia, confidence in the forces of nature hadreturned, and labour in a narrow pelvis was allowednow to complete itself spontaneously in a great pro-portion of cases. This method of treatment was strikinglysuccessful both for the mother and child. He believedthat spontaneous delivery might be looked for in caseswith a conjugate of slightly under 32 inches in flat

pelves and 3 inches in generally contracted pelves. TheWalcher position should never be omitted in these cases asan aid to the fixation of the head. The duration of thesecond stage of labour was to be limited only by the con-dition of the mother and child. The great difficulty centredround the quarter of an inch between 3 and 3 inches. In thatsmall area there was a choice of treatment. If the conditionwere recognised early, there was the option of inducing pre-mature labour ; if not seen until term, there was the choiceof attempting to deliver by forceps or by some operation forenlarging the pelvis. The position of the operation of theinduction of premature labour was that it was perfectly safefor the mother, but unfortunately was accompanied by a veryconsiderable infantile mortality. In regard to high forcepsoperations in narrow pelvis, the mortality and morbidity tothe mother were unquestionable. This was absolutely provedby statistics. The fcetal mortality in these cases ran between20 and 40 per cent. He then referred to the developmentof the operations for the enlargement of the pelvis. These.

operations were not uniformly safe for the children, andwere not unassociated with considerable risk to the mother.The cases in which these operations were useful were thoseof moderate contractions in which, after ample time hadbeen given for the head to enter the brim, it still remained,unengaged. There pubiotomy might be expected to befollowed by spontaneous delivery, but if necessary, and

particularly if the child’s life were endangered, might bejustifiably supplemented by forceps delivery. He thoughtthat no high forceps operation should be seriously undertakenunless the operator was prepared to perform one of thesecutting operations if necessary.

Dr. J. M. MuNRO KERR (Glasgow) alluded to the tendencyin recent years to leave difficult cases to nature. Yet heremembered how Dr. Milne Murray extolled highly the useof axis-traction in high forceps cases and how he couldaccomplish delivery in pelves with a conjugate of 281 inches.But in high forceps difficult cases the foetal mortality wasabout 50 per cent. If these cases were given plenty of time,from 50 to 60 per cent. were delivered spontaneously. Insuch cases one should estimate the size of the head and

pelvis, and give plenty of time for nature to mould the head;-if that failed forceps should be applied. If fair traction wasnot sufficient one should never resort to brute force to pullthe head through, but then perform pubiotomy. In obstetricscare should be taken not to be led by fashions. Even now

pubiotomy was being decried by previous supporters.Dr. J. W. BALLANTYNE advocated the education of public

opinion as to the necessity for careful examination of thepregnant woman to ascertain the presence of such conditionsas albuminuria and pelvic deformity. Obstetrical homeswere much needed, and also an obstetrical bed readilyadaptable to the Walcher position and for the performanceof operations.

Dr. J. HAIG FERGUSON alluded to the complete change intheir views as regards the application of the high forceps,considering it unjustifiable to apply them if the head wasfree above the brim. It was better to give plenty of time formoulding of the head to take place, at least in slighter degree,before applying the forceps. In private practice the fcetalmortality was not nearly so great as in hospital practice.

Dr. W. FORDYCE thought they were losing sight of thevalue of the old operation of turning; it gave the advantageof engaging the narrow wedge of the head in the conjugate,and this could be assisted greatly by the pressure of the handdirectly on the head through the abdominal walls. SirHalliday Croom had given exact measurements of the con-j ugate in his paper, but he (the speaker) had found it ex-

ceedingly difficult exactly to estimate the true conjugate.The diagonal conjugate was a help, and consideration mustalso be given to the position of the head.The PRESIDENT said he thought the maternal mortality

given by Sir Halliday Croom was impossible in experienced