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Russell on July 22nd, 1914, had this aim. He Ihimself explained at a Medico-Legal meeting on tJune 30th, 1914, that the patient would have no tchoice when sent in by a doctor; but the initial E

detention could not be continued against his will- Ii.e., in the event of his discovering that he had the right to leave. This would seem an anomalous E

arrangement. The writer in the British Medical ,

Journal sums up his remarks by a suggestion i

which, he says, commends itself for its simplicity-viz., to adopt the last clause of Section 13 of the aScotch Lunacy Act, 1866, by which any doctor can send anyone to an asylum for six months on his (

own sole authority. jThis measure, much as it may possibly commend i

itself to many doctors, will scarcely meet with the 1

same unqualified approval from the great majority of British subjects. The writer says that for years the organised body of English alienists and expert fopinion on lunacy has been calling for the incor- poration of this measure into English law. It ]remains to be seen whether the public will also call lfor it. It is maintained that with the march of : progress the question of disorder of the mind i

begins to be "regulated by scientific considera-tions." 1 This new consideration is, however,still in its extreme infancy. What we requireabove everything else is that all mental affec- tions should be genuinely taken into accountas a branch of medicine. Insanity is not andcannot be checked by the present methods of treatment. It is both unnatural and un-

scientific to regard mental treatment as a speciality, secluded from the light which might be thrownon it by every other branch of medicine. Mentaltreatment has often been of the crudest descrip-tion, and has failed signally in reducing the pre-valence of this worst of mortal ills. The reason ofthis is that its beginnings have been overlooked.The dread of the prison-bars of detention hasstood in the way of every early effort atsuccess. The only method by which the painfulsense of indignity and utter insecurity can beremoved, is to treat the earliest stages differently.We want places where early cases will not be afraidto come of their own accord for treatment-hospitals where prevention and common-sense willcome into action much earlier. We want not moredetention, but far less. We want free air andsunshine to penetrate into obscure recesses, and allthe skill of medical care, therapeutic resource,and the best all-round intelligence to be broughtto bear upon the treatment of derangement ofour highest faculties, and this at its very earlieststage. How this can best be facilitated I must

leave, with your kind permission, to a futureoccasion.-I am, Sir, yours faithfully,

S. E. WHITE, M.B. Lond.Upper Montagu-street, W., May 4th, 1915.

THE MANUFACTURE OF SALVARSANPRODUCTS IN ENGLAND AND FRANCE.

To the Editor of THE LANCET.

SIR,-I have read in your issue of last week Dr.David Watson’s criticisms on my letter of April 3rd,in which he suggests that my diagnosis of arsenicalpoisoning following an injection of novarsenobenzol"

Billon was incorrect, and that the symptomsmight have been " partly or entirely " due to " amercurial dermatitis." I can only say that it isunprecedented for a case of mercurial dermatitis to

1 See article in Times.

persist for nearly four months, and notwithstandingtreatment to still show symptoms of that condition;the patient referred to is still in hospital, and theskin over his whole trunk and lower limbs is at thepresent moment of a brick-red colour and is coveredwith branny desquamation. If this is Dr. Watson’sexperience of mercurial dermatitis I am happy to;ay that that condition is not met with in thisnetropolis.In his apologia for Burroughs and Wellcome’s

reparation kharsivan Dr. Watson states that hehas produced sufficient evidence to warrant theconclusion that a dose of 0’6 grm. of that substanceis inadvisable; but that firm, in one of their leafletswith which the medical profession is not altogetherunfamiliar, states that " kharsivan is to be used inprecisely the same manner and dosage as theGerman product." Dr. Watson further states "thatsalvarsan is not less toxic than kharsivan in similardosage is proved by our records," and therefore I

presume there is nothing more to be said, though Ihave given some thousands of injections ocsalvarsan without having met with any suchuntoward symptoms as those described in yourissues of April 3rd and May lst.

It is perhaps somewhat mal à propos thatimmediately preceding Dr. Watson’s letter inTHE LANCET last week there appears my com.

munication of two further cases of arsenicalpoisoning following injections of kharsivan, one

of which unhappily proved fatal. Possibly Dr.Watson will be able to explain this case to hisown satisfaction, but the position is this : a healthyyoung man contracts syphilis; he is given twointravenous injections of kharsivan; he developssymptoms of arsenical poisoning from which hedies one month later, and as to the diagnosis ofdeath there can, unfortunately, be no mistake.

I am, Sir, yours faithfully,J. ERNEST LANE,

Surgeon to the London Lock Hospital.Queen Anne-street, W., May 2nd, 1915.

CLINICAL RESULTS OF KHARSIVAN, BILLON, AND

NEOKHARSIVAN.

To t7te Editor of THE LANCET.

SIR,-The following results of the injection ofthese drugs may be of interest at the presentmoment.

Kharsivan.

No. of cases. gead-I Vomit- Temperature. Other ill-effects.

-

ache. Ing. ---’ ---

78 (25 with no 107 % 5 % 12’5; maximum Nil, except 1 caseprevious arsenical 100.8° F. No of bronchial

treatment) : temperature in pain lastingPrimary 2, 7 cases with our 2 days.

secondary bO, late own re-distilled secondary 24, water.tertiary 2.

Kharsivan is an arsenical preparation made byMessrs. Burroughs, Wellcome, and Co., havinga formula exactly similar to salvarsan (" 606 ")-C12H12O2N2AS2(HCl)22H2O. It is a yellow acid powderdissolving with some difficulty in water and ratherdarker than " 606." To prepare the drug for intra-venous injection 250 c.c. of 0’5 per cent. salinesolution made with doubly distilled water and a15 per cent. solution of caustic sodium hydroxideare required.According to directions 30 c.c. of doubly distilled

water were put in a narrow graduated stopperedflask, to this the powder was added, and the whole

991

shaken vigorously until the powder dissolved

(latterly saline was used and the powder dissolvedin it equally well). Caustic sodium hydroxide solu-tion 15 per cent. was then added, until the precipitatefirst found cleared. Sterile saline solution was nextadded up to 250 c.c.; the solution often becamecloudy on adding the saline, and then causticsodium hydroxide was added drop by drop until aftervigorous shaking the solution remained clear. The

quantity of 15 per cent. solution needed varied con-siderably, 14 minims being the least used, 34 minimsthe most, for a 0’4 gramme dose. In all cases thesolution was tested with litmus paper, and nevergave more than a faintly alkaline reaction. Thesolution was always given cold and intravenously,and in no case was a vein cut down upon.In every case saline or distilled water was run in

before and after the kharsivan. The addition ofsaline to run in after the injection caused the lastpart of the solution to become cloudy. Distilledwater had not this effect to the same extent. Inseven cases our own doubly distilled water was usedwith no after-effects at all. The dosage given neverexceeded 0’45 gramme. In a large majority thedose was 0’4 gramme. All the patients were

females.Billon.

This drug was first prepared by one of us withunsatisfactory distilled water, in that the still wasold and useless, and it was found that the waterwas seldom doubly distilled.

Billon ?cith Uizsati,3factoi,y Water.

In the three patients who suffered from rigorsthese occurred ½ hour, 1½ hours, and 5 hours afterinjection. In two of the cases too large a dose wasgiven-viz., 0’6 gramme to children of 15 years.

Dillon with Satisfactory Water.

Of the 26 cases given at the Lock Hospital (18secondary and 8 late secondary), 10 had had noprevious arsenical treatment.Novarsenobenzol "Billon" is the dioxydiamido-

arsenobenzol (monomethylene) sulfoxylate de soude- viz., "914." It is of French preparation, the manu-facturers being Poulenc Freres. It consists of ayellow powder, darker and more yellow than theoriginal " 914," very soluble in water, forming aperfectly clear yellow solution. To prepare thepowder for use it was dissolved in 20 to 30 c.c. ofdoubly distilled water and given intravenously, asmall quantity of the water being introduced beforeand after the drug. The dosage given was from0’45 gramme to 0’6 gramme, the patients being bothmale and female. One of us gave 24 injections of"Billon" to private cases, mostly male patients,who received 0’6 gramme, but one female patientwith the same dose vomited and suffered fromheadache; she had no temperature. She wassuffering from two alveolar abscesses at the time.

The others had no after-symptoms whatever. Allhad had no previous arsenical treatment.

Neokharsivan.

In the one case of rigor, pyrexia, and vomiting,the rise in temperature occurred about four hoursafter injection. The patient was perfectly well 24hours later. There was no reaction with a

previous and a later dose of kharsivan.Neokharsivan is prepared by Burroughs, Well-

come, and Co., and is declared to be identical inessential particulars with " 914." It is a yellowpowder, a little darker than " 914," very easilysoluble in water, yielding a clear solution. Forintravenous injection the powder was dissolved infrom 30 to 60 c.c. of doubly distilled water, doublydistilled water being introduced before and afterthe drug. The dose given ranged from 0’45 to0’6 gramme.

General remarks.-The intervals between the

injections varied in different cases from one to fiveweeks, there being two routine treatments used:(a) at intervals of seven to ten days, (b) at intervalsof one month, all patients receiving full doses ofmercury.

i The hospital patients had the following prepara-tion :-Pil col. cum hyosc., 4 grs., at 6 P.M. ; mist.alb. at 2 A.M. ; en. sap. at 5 A.M.; glass of hot milk at10 A.M., and nothing more for four hours beforeinjection. These patients remained in bed until theafternoon of the following day and took no solidfood for about 24 hours after injection. The pre-parations were always given cold and as soon aftermixing as possible, the bottle being kept wellstoppered and tightly corked until the drug wasused. Ether was rubbed over the vein before theinsertion of the needle.An aperient was administered to private patients

on the preceding day, no breakfast, but a cup of teaand a piece of toast at 8 A.M., the injection beinggiven at 10 A.M.; this was followed immediately byan ordinary breakfast, after which the patientremained in bed from two to six hours only.Results.-The results of these three drugs were

entirely satisfactory when we were using doubly-distilled water of assured purity. All the patients(164) were improved in health and increased inweight. The disappearance of symptoms seemedto be much the same as in Ehrlich’s last pre-parations. Some cases which had failed to

respond to mercury responded readily to arsenic.This was very noticeable in three cases of iritis.Four of the patients were suckling and the babiessuffered no ill-effects. No local disturbance wasnoticed in the vein of the arm. All were

perfectly well 48 hours after the injections and tothe present date. The Wassermann results in

private cases were negative. The urine was freefrom albumin except in one case-slight for twodays only.Headache is the only symptom which is more

marked in these drugs than in Ehrlich’s prepara-tions, notably in female patients; in the malepatients it very seldom occurred. The severity of

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the preparation and the starvation after the injec-tions may be the causes of this headache in thehospital (female) cases.Vomiting and temperature are at a minimum

with pure water ; only one rigor occurred in all theinjections with pure water. We are convinced thatthe high percentage of temperatures in kharsivaninjections is due entirely to the use of unsatis-factorily distilled water.Dosage.-The general dosage used was 0’4 gramme

kharsivan and 0’45 to 0’6 gramme of billon andneokharsivan. It will be understood that thismoderate dosage was employed because we weredealing with new and untried drugs.In conclusion, it must be noted that these results,

although satisfactory, would have been even betterif. all the water used had been of assured purity.Granted that the distilled water is satisfactory, witha good technique and appropriate dosage we arepersuaded that the British and French chemistshave overcome the main difficulties and have pro-duced drugs of equal utility to those of our more"

cultured enemy., We are, Sir, yours faithfully,

CHARLES GIBBS, F.R.C.S. Eng.,Surgeon to London Lock Hospital

and to Charing Cross Hospital.MORNA RAWLINS,

House Surgeon to London LockMay lst, 1915. Hospital.

CHARLES GIBBS, F.R.C.S. Eng.,Surgeon to London Lock Hospital

and to Charing Cross Hospital.MORNA RAWLINS,

House Surgeon to London LockHospital.

ENTERIC FEVER DUE TO A URINARYCARRIER OF LONG STANDING.

To the Editor of THE LANCET.

SIR,-The following small outbreak of entericfever, due to a carrier, appears to me to be ofsufficient interest to place on record. It occurredlast autumn at the Alexandra Palace while thatbuilding was being used for the reception of

Belgian refugees. Between the commencement ofOctober and the end of November five members ofthe staff developed this disease. The first to fall illwas a clerk working in the trustees’ office, thesecond was a waiter in the staff dining-room, thethird waited on the better-class refugees, the fourthon the general body of refugees, while the fifth andlast was the night nurse on duty in the hospitalward where there had been no case of entericfever for six weeks. These five individuals,consequently, were all working in different parts ofthe building. They had only one thing in common,and that was the preparation of their food by thecook who was in charge of the staff kitchen. On

being questioned this man stated that he hadsuffered from enteric fever 18 years ago, and wasin St. Mary’s Hospital for six months. I obtainedspecimens of his excreta, which were bacteriologi-cally examined for me by Dr. G. E. Cartwright Wood,who reported that the bacillus typhosus was presentin the urine but was not found in the faeces. Inanswer to my inquiries, the man informed me thathe had never at any time suffered from pain ordiscomfort in the region of the bladder, nor fromfrequency of micturition; nor had he ever noticedanything unusual in the appearance of his urine.I was not able to make any inquiries of previousemployers of this man because for the last 16 yearshe has had no fixed employment, but has movedabout the country acting as temporary cook at racemeetings, during manoeuvres, and at hotels.The points of interest in this case are : (1) The

long duration of infection in a urinary carrier; (2)the complete absence of bladder symptoms. After

the cook’s departure no further case of entericoccurred among the staff. I might add that therewere only six cases of this disease among the 32,000refugees who passed through the Alexandra Palace.

I am, Sir, yours faithfully,HERBERT E. CUFF,

Principal Medical Officer of the MetropolitanApril 30th, 1915. Asylums Board.

HERBERT E. CUFF,Principal Medical Officer of the Metropolitan

Asylums Board.

THE SCOTOMA OF MIGRAINE.To the Editor of THE LANCET.

SIR,-Mr. Charles Higgens’s observations in THELANCET of May lst are of great importance. A

simple experiment which proves conclusively thatthe photo-chemical stimulus is external to the conesmay be made as follows. On arising in the morningarrange a mirror so that the sun is reflected fromits surface, then whilst one eye is closed and coveredwith the hand the othex eye is opened and closed sothat the image of the sun is visible for a fraction ofa, second; both eyes being now closed and coveredwith the. hands a clear-cut after-image of the sunis seen on a dark background. It will be noticedthat there is nothing else visible in the field ofvision. If the head be now moved rather sharply toone side the after-image will be drawn out into along sausage-shaped form with irregular knobson it. If the head be sharply jerked we can

obtain several after-images, plainly showing thatthe photo-chemical stimulus is movable in theretina and therefore cannot be situated in the cones.I find these experiments succeed best in the morn-ing immediately after sleep, probably because theprocesses of the pigment cells are retracted. If

any reader find that he cannot see any of the

subjective phenomena described by me I wouldsuggest that he select one of the most accurateobservers of his acquaintance and ask him to

repeat the experiment without giving him theleast clue as to what he is to see. If he describethe phenomenon as I have described it, it is obviousthat we have obtained important confirmatoryevidence. I find that whilst many older men failto see various subjective phenomena they are

rarely missed by the young.I am, Sir, yours faithfully,

London, May 1st, 1915. F. W. EDRIDGE-GREEN.F. W. EDRIDGE-GREEN.

THE BACTERIAL INFECTIONS OF PRO-JECTILE WOUNDS.

To tAe Editor of THE LANCET.

SIR,-In the leading article under the above title-in your issue of April 24th, as well as in the illumi-nating address of Sir Almroth Wright and the" Memorandum on the Treatment of the BacterialInfections of Projectile Wounds " in the same issue,stress is laid on the importance of free drainage ofthese wounds and of the necessity of securing "a freeoutflow of lymph "-and Sir Almroth Wright andthe other writers mention the various means

adopted to secure these ends. But I see that there-is no mention of the use of "Bier’s method" ofevacuating abscesses and sinuses by means ofcupping glasses and other forms of aspiration.Are there not cases where this method would be

useful-especially when two or three days haveelapsed after the injury ? By suction or aspirationpent-up matter is evacuated and " a free flow oflymph " and an

"

active hypereemia " are induced.I am, Sir, yours faithfully,

Llandrindod Wells, April 29th, 1915 R. ACKERLEY.R. ACKERLEY,