740

THE LANCET.

LONDON: SATURDAY, SEPTEMBER 3, 1910.

"606" " IN THE TREATMENT OF SYPHILIS.

" 6o6 " in the Treatment of Syphilis.THE position which mercury has held in the treatment of

syphilis almost from the first recognition of the disease inthe last decade of the fifteenth century has hardly ever been

seriously assailed until within the last few years, when an

attempt has been made to put forward arsenic as a rival, and

especially have organic compounds of arsenic been advocatedas suitable for the treatment of syphilis. Several of these

organic arsenical compounds have been introduced and theyhave been extensively employed. It is surprising in what

large doses they can be given, and for a time they wereconsidered to be comparatively harmless, and, in fact, thenames given to some of these compounds claimed that theywere non-poisonous, but a more extended experience hasshown that in a few cases serious results have followed, andthe most important of these is optic atrophy. Therefore,

although the efficacy of arsenic in the treatment of syphiliscannot be denied, there has been a very definite tendency oflate to restrict the employment of these organic arsenical

compounds to those comparatively rare cases of syphilis inwhich mercury cannot be given.

In the last few months, however, the whole position hasbeen altered. A new organic compound of arsenic has been

brought forward by EHRLICH which is believed to possess

marvellous therapeutic powers in syphilis, and yet to bein the doses employed of perfect innocuousness. Our foreigncorrespondents have already given some valuable informationon the matter. The substance is called from its constitution

dioxydiamidoarsenobenzol. but as this name is rather long,even for German use, the substance has been called 606

"

for short. Several observers have experimented with the

drug, and in the present issue of THE LANCET we publish a

paper by Dr. JAMES McINTOSH on its use, another byMr. J. E. R. McDoNAGH, and we also refer on another pageto a pamphlet on the same subject by Dr. JOHANNES

BRESLER of Lueben. The article contributed to the Deutsche

Medizinische Wochenschrift of August 11th by Dr. WECHSEL-MANN of Berlin, who has employed the substance in thetreatment of 503 cases, has, moreover, been read by this

time by many of our readers, who are now, therefore, in

possession of a good deal of practical knowledge on

the whole position. It is remarkable that in addition

to its action on the disease the drug exerts a beneficial

effect on the general condition, for the body-weightdefinitely increases after its use. There is a marked

feeling of well-being experienced by most of the patientson the very day of injection or on the following day;this fact is noted in several of Mr. MCDONAGH’S cases.

The patients feel much stronger and able to accomplishhings which they could not do before. The rapid

relief of chronic pain is one of the most striking effect:

of the drug. Soreness of the throat, which may have laste(for months or years, or pain in the mucous membrane of thi

mouth, may disappear almost magically the first night aftethe injection. It may, of course, be said that this relie

from pain is the effect of suggestion ; but the relief is ofteiso complete in cases where the pain has lasted for severayears that it is impossible to ascribe all or even th

greater part of the benefit to the action of suggestionOne of Dr. WECHSELMANN’s patients had for five year;suffered from swelling of the ulna with severe pain, buafter the injection he had a peaceful night, the first fo:

five years. Other cases are recorded by him, Mr. McDOnTAGHand other observers in which a rapid and complete cessatiorof pain occurred within 24 or 36 hours of the first injection.The action on the lesions of syphilis is surprising. Primary

sores of the mouth become completely healed within a

few days, and mucous plaques of the mouth will dis.

appear within 24 to 48 hours. The definite specificaction of the drug was shown in a case of a new-bon

child under Dr. WECHSELMANN who was attacked witl

a very severe form of bullous syphilide. One ala o:

the nose and the last joint of a finger were gangrenousand in addition there was oedema of the face and legsThe use of the drug was followed by a complete recover3of the skin manifestations in a few days, though th

child died ten days later from pulmonary complications,In Mr. MCDONAGH’S fifth case the same rapid clearingup of inflammatory conditions was observed. It is clear

then that this drug exerts a marvellous influence on

many syphilitic conditions, but all lesions produced bysyphilis are not equally easily affected. Thus, in one casewhile a primary sore of the tongue healed completely in twoor three days and the enlarged submaxillary glands also

diminished rapidly the papular syphilide which was alsc

present showed very little change three weeks later, so thata second injection was required. Dr. WECHSELMANN explain;this difference of action by suggesting that in those

lesions where an endarteritis has occurred and th(

vessels have become blocked thereby or by thrombosii

the drug cannot be carried into the tissues, because

the blood stream is cut off ; but if the vessels are stil:

pervious the results are rapid and complete. In a few cases

second injection seems to be required before much benefit iinoticeable, and it is early yet to speak definitely with regarcto the question of recurrences. It seems clear that the drug ha,a definite effect on the spirochoetes, which rapidly disappear,but it may well be that some of the germs may remain un.

affected by the drug and may develop later. It is of interest

to note that in most cases WASSERMANN’s reaction becomes

negative within a few days of the injection, but later it

may again become positive. The drug has an effect, not onlyon syphilitic manifestation of the skin, mucous membranes,and bones, but also on the disease of the viscera. Syphili’of the brain seems to be amenable to the treatment and some

excellent results have been obtained. Those affections which

are called parasyphilitic also seem to be affected ; in somecases of tabes a rapid improvement in the condition of the

pupil was noticed, but only a few cases of tabes have beentreated. In one case, under Dr. WECHSELMANN’, in which

741VENTILATION AND THE MOSQUITO CURTAIN.

weakness of the sphincter of the bladder had caused in-

continence of urine for eight years, the condition dis-

appeared two days after the injection.The question naturally arises, " Does the drug ever do

any harm ?" " Dr. WECHSELMANN has seen none, and no

authenticated case has reached us. In one case an old

paralytic died in a typical fit a few days after the injection,but it is probable this had no connexion with the injection.No case of injury to the optic nerve has occurred, althoughin some of the cases the optic nerve was not perfectly healthybefore the injection. Local paralysis, constipation, vomiting,and rise of temperature have been noted, but the sym-

ptoms have been transient. Five of Dr. WECHSELMANN’S

patients were women near the end of pregnancy, but in

none of them was there any interference with the

pregnancy. It would seem then incontestable that dioxy-diamidoarsenobenzol has a very definite effect on manyforms of syphilis. It appears to have a direct action

on the micro-organism and it acts rapidly, but some

syphilitic manifestations are much more resistant than

others. No absolutely refractory case has yet been metwith, and it is far too early to make any verydefinite statement with regard to recurrence. So far,harmful effects are few, but it must not, at this earlystage of the inquiry, be accepted that no ill results can

occur. We consider, however, even on the small amount ofevidence yet available, that a new weapon of great valuehas been placed in our hands for the treatment of syphilis:its full power we do not yet know, and only with the

passage of time can we be fully assured of its capabilitiesand its limitations. The papers by Dr. MCINTOSH and Mr.

McDONAGH, which fully explain the dosage and methods ofillustration, will, we are sure, be read with much pleasure.

Ventilation and the MosquitoCurtain.

IN countries infested by biting flies that carry disease,like the mosquito, the net curtain becomes a necessity to all

persons except the few who are immune. This precaution,taken to ensure safety from fever, involves a sacrifice which,although rarely defined, is none the less real. In hot

countries a much more active circulation of air about the

human body is necessary than in cold countries, in order to

dispose of the surplus animal heat, and, although the nighttemperature is lower than that of the day, the increase ofrelative humidity and the absence of wind often render the

night period oppressive. The custom of sleeping on mattressesalso, which are well-known non-conductors, aggravatesthe situation, and when to this is added a mosquitonet, with all the resistance it offers to the passageof air, it is not surprising if the discomforts of the tropicalnight are regarded as the chief penalty of residence in hot

countries. The mosquito net is very heavy in proportion tothe mesh. The thread of the net occupies 39 per cent. ofthe total area, and in addition to this numerous cotton fibre

projecting into the openings offer a considerable friction

resistance to the passage of air. 39 per cent. is thus the

loss of area in a net that completely covers a bed. If

the bed is a camp cot with a calico roof to the curtain

the reduction of area due to the roof is 25 per cent. and to

the material of the net 39 per cent. on the sides of the

curtain. On a double bed the calico roof would representa loss of one-fifth of the total area, and as currents due

to small increases to temperature escape with difficultyin any but a vertical direction it is easy to understand

how the sleeper, under the conditions above stated, suffersfrom accumulation of animal heat. Men who smoke in

bed have an opportunity of observing the rate at which thesmoke disperses when the curtain is up or down. The

movement of the smoke represents exactly the movement ofthe air about a bed ; it makes clear how very slowly the

atmosphere is renewed within a curtain, and how greatlyventilation is interfered with.

One of the chief attractions of Indian hill stations is the

ability, in the absence of mosquitoes, to sleep without anet; a greater sense of refreshment is felt in the morning,due to the free circulation of air. The resistance of a

mosquito net to a light horizontal current of air is nearly60 per cent. ; the use of a net, therefore, is sufficient in hotweather to destroy the comfort of the sleeper. The net

is made strong in order to resist the brutal treatment

of the laundry, for as soon as holes begin to appearthe mosquito gets through. Cotton is plainly not strongenough for the purpose of giving safety from the attackof flies, as it will not resist the washing process. Among the

possible fibres that might be used rhea seems to stand out

conspicuously for its strength, fineness, and durability. It is

already used for many purposes requiring these qualities, forit is made into racing sails for yachts, and thread for

lace-making, and is employed in harness work, and as

fishing lines. A mosquito net of rhea, having at least

three times the strength of cotton, might be of much

finer thread, offering less surface to the air, and the

meshes, owing to the resemblance of rhea to linen,would not be encumbered with straggling fibres. In

places where the sand-fly is common the net ceases to

be a protection, and nothing coarser than muslin can be

used, whose resistance to circulation must be at least twicethat of mosquito net. Muslin is much used by the natives of

India, and especially by women when sleeping on balconiesor verandahs on account of the privacy it affords. Some-

times the roof is made of net, but in any case the ventilationis greatly impeded. The loss of current due to the curtain

may be restored by means of the punkha, but the attendantcoolie is a grave nuisance. )When, a few years ago, a

self-acting portable fan was put on the market in

India, it was welcomed by the public and sold in

thousands. It consists of a small hot air engine of well-known pattern, geared with, or driving direct, a revolvingfan, in shape like the electric fan. The engine is heated bymeans of a spirit or a kerosene lamp, and the whole packsconveniently in a case for transport. The saving in cost, as

compared with the punkha walla, not to speak of its

trustworthiness and handiness, has gained for it consider-

able popularity, but a serious fault has been observed bymedical men in the arrangement of the machine. All the

products of combustion and so much of the heat as is notconverted into work are carried into the fan current, so that

the air blown by the machine is both raised in temperature

742 SURGERY AND ANAESTHETICS IN MEDICAL DISEASES.

and reduced in purity. This is inevitable under the best

conditions, but as the lamp is generally managed by aservant it is very often badly trimmed, and fouling of

the air may occur easily if the wick is turned too high,when smoke escapes, or too low, when partially burnt gases,escape. In cases of extreme carelessness or stupiditymosquito nets have been blackened in a single night.In the large cities like Calcutta, Madras, and Bombayelectric current is available for all who wish to use it, but

elsewhere, except in the palaces of native princes or in largemanufactories, punkhas must continue to be driven by othersources of power. The small portable machine has, there-

fore, a good future before it. At present it offars a very

interesting, and by no means easy, problem to the inventor :that of separating all the products of combustion from theair current produced by the fan. It is also possible that tha

efficiency of the fan itself may be increased by a better

design, for in common with the majority of electricallydriven fans the propelling angle of the blades has no

variation from tip to root. It thus produces currents

of varying velocity, that interfere with each other and

affect prejudically the efficiency of the machine. Even in

the angle at the tip air propellers vary enormously, the

range being at the least from 90 or 10°, with the plane ofrotation, to 18°.

We have entered into these details at considerable lengthbecause it cannot be too often insisted that the chief art of

living healthily in the tropics consists in the means of

procuring sound rest at night, so as to arise refreshed in Ithe morning. This is accomplished principally by reducingthe usual amount of bedding and by ensuring an adequateair current to carry away the surplus animal heat. If the

ordinary mattress is used heat will accumulate beneath thesleeper, and a stronger current will be required to

keep him cool. He is thus exposed to irregular cooling,which is more than likely to cause a chill. If the

bedding is reduced until the body appears to cool

at an equal rate below and above a very moderate air

current will suffice to produce the desired comfort. To

write of tropical heat in such weather as we have experiencedthis summer may seem uncalled for, but nowadays all theworld travels, and many of our readers are asked for advice

upon these points.

Surgery and Anaesthetics in MedicalDiseases.

THE increasing tendency towards specialisation in the

practice of medicine, using this term in its widest sense to

include all applications of what has been tritely called the

healing art, is a condition which demands careful considera-tion in the best interests of the public and of the professionalike. The advances made by the application of surgicalmethods to medical diseases, more especially in those whichGerman writers not inaptly describe as the boundary zone,have led to an invasion by the surgeon of the territory ofthe physician from all sides. The pioneer in all phases ofhuman activity is particularly prone to be a zealot and a

propagandist. A calm and dispassionate analysis of the

results and after-results of new forms of treatment and of

new adaptations of surgical procedures is theretore a

necessity, if these are to be applied intelligently and with

judgment. This can but rarely be achieved by one

individual, and hence the value of congresses, where men

of different zones of practice, and, still more important,men with various points of view, may foregather, expresstheir opinions publicly, and thus afford the general practi.tioner and the consultant physician and surgeon, upon whomin the majority of cases rests the responsibility of the ohoiceof treatment, an opportunity for estimating the value of

their work. We cannot but feel after some of the dis-

cussions before the recent annual meeting of the British

Medical Association that the time is ripe for a review of thevalue of the surgical invasion of medicine with the object of

securing a more careful selection of the cases to which

surgery should be applied so as to afford the best chance of

relief with the least risk. The age of therapeutic nihilismwhich followed the studies of the morbid anatomists of the

middle of the last century gave place to an age of poly-pharmacy with special symptomatic treatments largely as

a consequence of the labours of the physiologist, the

pharmacologist, and the synthetic chemist. This phaseseems to be giving place to a surgical period, when practi-tioners and public both demand the drastic and dramaticmethods of surgery. Surgical technique has now advancedto such a degree that there are but few operationswhich the mind of man can devise that cannot be success-fully carried through by the practised special surgeon. The

time has, however, arrived for something more than a con-sideration of mortality statistics as a criterion of the value

of surgical treatment. The percentage mortality of a givenoperation is for the most part the measure of the technical

skill of the operating surgeon, and, to a less degree, of his

ability in the selection of cases. It is this second factor

which requires further development, and for this purposewe need much more information regarding the aEGer-

histories of the patients operated upon, information whichthe surgeon is not always able to afford owing necessarily tothe conditions of his practice. It sometimes happens that the

triumphs of surgery in certain fields are less apparent to the

patient and the family practitioner, who are concerned withthe after-results, than to the surgeon, whose responsibilityoften ceases when the patient has recovered from the imme-diate effects of the operation. In the past the surgeon hashad to deal with gross and for the most part tangibleconditions, and has therefore been but little concerned withthose vague but none the less real factors in disease-

personality, temperament, and constitution-which loom so

large upon the horizon of the family practitioner antl the

physician. Now that the surgeon is also concerned in

matters formerly in the field of what the Germans and the

Americans term internal medicine, it is important that he

should also extend his point of view to these factors, other-wise the somewhat selected nature of the cases he encounters

is liable to give him entirely erroneous conceptions of the

symptomatology of medical diseases, and to lead him to

appraise them at other than their real value.An interesting illustration of this position is afforded by the

discussion before the Surgical Section of the British MedicalAssociation of the operative treatment of exophthalmic

743THE METROPOLITAN WATER-SUPPLY.

goitre, so ably opened by Professor THEODORE KOCHER of 01

Berne, of which a report appears in our issue of August 13th ai

(p. 471). Professor KocnER discussed the pathology of the fa

disease, its symptomatology, and, most important of all from c(

the practical point of view, the principles of selection of m

cases for operation. He gave statistics of his own operations ir

for this disease, amounting to 619 operations in 469 cases,

many of the cases requiring more than one operation ; they tl

showed a decreasing mortality from 5 per cent. at first to 1’ 3 t(

in his latest series of 72 cases. It is tempting to draw the ir

conclusion that this decreased mortality is in the main due to q

improved selection of cases, the more so when we are told zi

that the only fatal case in the 72 last mentioned was in a c;young woman with nephritis in whom the operation was only c

performed at the special request of the patient and her

friends, and the case was admittedly one which should not a

have been operated upon. Mr. H. A. BRUCE of Toronto t,

quoted collected statistics of 1055 cases with a direct s

operative mortality of 4 per cent , and complete cure in n

16 per cent., as many as 85 per cent. being able to resume o

their ordinary occupations. Dr. HECTOR MACKENZIE stated f,

that under medical treatment 36 per cent. of hospital patients il

recovered completely, and not more than 20 per cent. ended o

fatally. He gave some statistics of operation so unfavourable i

as to suggest that Professor KocHER’s cases were of a I

different type from those seen in London. The case for in- t

discriminate treatment of the condition by surgical methods f

can hardly be said to be established as a result of the f

discussion, and we are still in need of more detailed and exact. analysis of the after-history as regards symptoms, c

signs, and duration of life in these patients. It is of some c

interest to note that many of the deaths from operation in this condition usually occur during, or shortly after, anaes-

thesia, and that in this disease, which in its manifestations a

offers the very anatomy and physiology of terror, and in

which the patients are obviously over-sensitive to emotional

influences, one of the improvements in the technique ofanaesthesia recommended should be in the direction of lessening the psychical shock of this procedure after themanner suggested by Professor G. W. CRILE. This con-

sists in giving the patient brief and, in a sense, fictitious

inhalations on several days as a preparation, and then

on a settled day giving morphia and going on to completeanæsthesia. Professor CRILE contributed a highly suggestivepaper to the section. The special interest of his work in con-nexion with the subject we are now discussing was his state-ment that fear alone in animals was capable of causing wide-

spread histological changes in the brain cells, especially inthose of the carebellar cortex. These changes, like thoseinduced by other factors-such as trauma, anaemia, and infec-tion—were capable of being demonstrated by the well-knownXissl’s method of investigating the minute structure of nervecells. Fear and these other factors influenced the immediate

surgical risks and decreased the margin of safety in

operative procedures upon patients with any grave handicapfrom disease or other conditions. Professor CRILE em-

phasised the existence of hypersensibility to fear and to

trauma in exophthalmic goitre, and claimed that the adop-tion of the principles he described had totally altered the Iimmediate results of operation. He lessened the influence l,

F the factor of fear by judicious management of the patientfter the manner already referred to, and he excluded the

Lctor of surgical trauma by interrupting the physiologicalnnexion between the brain and the field of operation byeans of local anaesthesia. His arguments are certainly veryigenious.These experiments and the recommendations deduced fromlem serve to illustrate what a number of details may have

) be taken into consideration in the applications of surgicaliethods to grave medical diseases, even apart from the

uestion of the selection of the cases. In this boundaryone, where physician, surgeon, and anaesthetist meet, eachan bring special experience in regard to certain matters

oncerned, but equal coöperation is a necessity if the bestesults are to be obtained, and if surgical methods

re to be prevented from falling into disrepute owingo over-zeal on the part of some of its exponents. The

urgeon must be more than an operator, he must be a

ledical practitioner as well and must look at a’l sides

f the problem. In this connexion we cannot but

eel that some surgeons have something to learn

n regard to what was aptly called the æsthetics

f Anaesthetics by Dr. F. W. HBWITT, in an interest-

ng lecture published in THE LANCET of March 5th, p. 623.lis recommendations in regard to the anæsthetist gaininghe confidence of the patient and sparing him all unnecessaryear and apprehension acquire further support from Pro-

assor CRILE’S experiments, and it would be as well that the

)atient should be spared the sight of the fear-inspiring garb)f the modern aseptic surgeon and his assistants before

>peration, and also that instruments should be covered if a

separate room for anaesthesia is impracticable. We do not

wish in any sense to belittle the advantages which have

accrued to medicine from the application of surgery, but

simply to register a plea for more scientific application of

surgical methods, and for careful analysis of records of resultswith a view to the formulation of the rules which should

guide us in the selection of cases for operation.

Annotations.

THE METROPOLITAN WATER-SUPPLY.

" Ne quid nimis."

Dr. A. C. Houston, the director of water examinations for theMetropolitan Board, presented on July 15th his fourth annualreport on the Results of the Chemical and BacteriologicalExaminations of the London Waters for the 12 months endedMarch 31st, 1910. Dr. Houston also presented with this hisfifth report on Research Work in Connexion with the Metro-politan Water. The reports contain most interesting andimportant records of careful, painstaking, and accurate labour,and f)r. Houston is to be congratulated on the valuable workwhich has been done under his direction during the perioddealt with in his writings. The purity of the metropolitanwater is of vital importance to the health of some

millions of consumers, and a very great responsibility rests onthose to whom is entrusted the task of rendering the rawLondon waters fit for drinking purposes. It would be dangerousto trust to merely empirical methods of purification, and itis essential that the engineers of the Metropolitan WaterCompany, who have immediate control over the working of