a new treatment for hyperemesis gravidarum

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raised standards of examination for young people,admittedly desirable, are meanwhile to be providedfor. The advantage both to employers and thecertifying surgeons to be gained by an extension ofthe duties of the latter is undoubted, and associationof these surgeons with voluntary efforts such as

welfare schemes should certainly be encouraged.In order to give some guidance to employers andsurgeons on the remuneration that may fairly bedemanded for additional work, a scale correspondingto that paid by infant welfare centres (a guineaper hour’s work) is suggested as a minimum, and therecommendation is made that charges should bealways per week, month, or year, never per visit paid.It is not likely that in the present state of nationalfinance a comprehensive scheme of industrial medicinewill be introduced by any Government. The sugges-tions made by the Association are likely to be usefulin the interim, and indeed might well form the basison which an Industrial Medical Service could befounded. Of especial value would be the closerassociation of doctors with the welfare workers, andthe advice given to the latter on medical mattersconnected with their duties might with advantageinclude some talks on psychology. The factory handwho, when asked what troublesome factor in hisconditions of work he would most like removed,replied " the welfare worker," voiced the legitimateresentment of many of his kind at tactless interference.With the help of the factory surgeon, the efforts onthe part of the welfare worker to increase the comfortas well as the efficiency of the employee might beguided into directions which would be appreciatednot only in increased output, but in greater content.

THE COMPOSITION OF BAYER "205."

SINCE its introduction Bayer " 205 " has alwaysbeen surrounded by an air of mystery amountingalmost to romance. Its powers as a trypanocidewere at first said to be miraculous, whilst its toxicitywas, according to all accounts, incredibly small. Itscomposition and formula were rigidly guarded, butthe authorities of the Farbenfabrik Bayer statedthat the substance contained neither arsenic norantimony. The material was supplied only on thedistinct understanding that it was for clinical use,and the person to whom it was entrusted had to givehis word that no attempt would be made to determineits constitution. The clinical value of " 205 " cannotbe doubted, since many eminent authorities, includingP. H. Manson-Bahr’ and F. K. Klein e, have published.series of cases treated with the remedy. A full reviewand bibliography of the clinical side of Bayer " 205 "is given in a recent article in the Annales de l’InstitutPasteur.3 3 It would appear that the much vauntedlow toxicity is apparent rather than real. For instance,in practically all of the recorded cases there has beenalbuminuria, which is quite a rare symptom followingsalvarsan treatment. In many cases 1 g. of Bayer" 205 " is followed by albuminuria, whereas 0-9 g.of salvarsan (N.A.B.) can be given at weekly intervalswithout any such sign. The ratio of the curative tothe lethal dose may be very small, but the ratio to thedose causing toxic symptoms appears to be fairlyhigh. The medical, and at the same time the national,value of " 205 " can hardly be over-rated. Germanworkers have gone so far as to suggest that in

" 205 "

lies the key to Africa. It is thus not remarkable thatfor French and English authorities to obtain thissubstance was a very difficult matter, and it becameobvious that independent research into the constitu-tion, if successful, would be of the greatest possiblevalue. Fourneau, Trefouel, and Vallee started workwith this object in view, and in the article referred tohave put forward the formula of a substance whichthey state to be identical with the German Bayer" 205 " They were hampered at the outset by the

1 THE LANCET, 1922, ii., 1265. 2 Ibid., 1924, i., 384.3 Recherches de Chémiotherapie darts la Série du 205 Bayer.

Par E. Fourneau, Mme. Jacques Tréfouel et Jean Valeé. Annalesde l’Institut Pasteur, Fév., 1924. No. 2, p. 81.

difficulty of obtaining even a small quantity of theGerman substance. They were able, however, toovercome the rigid conditions laid down by theBayer Company, and by " une voie tres detournee,"they obtained a few centigrammes. Indications ofthe lines upon which to work were obtained bystudying a series of patents taken out by the BayerCompany on complex urea-like substances, obtainedby coupling the amides of amino naphthalenesulphonic acids. Starting with these compoundsand armed with a knowledge of the work done onsalvarsan, these investigators set out on what appearedto be an almost hopeless task. Chemi cally it is possibleto have an infinite number of compounds, and, atthe same time, it is all but impossible to be sure of theexact manner in which the acids are coupled in anygiven substance. The investigators must have beenimbued with wonderful hope and keenness. As theysay,

" Bien des fois meme, découragés, nous avons eule desir d’interrompre la poursuite d’un but quisemblait fuir devant nous." Their courage andpatience seem to have been rewarded, since in theircompound " 309 " they appear to have produced asubstance identical with Bayer " 205 " Theyreproduce the formula and state that its chemo-therapeutic ratio-i.e., ratio of curative to toxicdose-is equal to that of the original German com-pound. Owing to the small quantity of " 205 " atthe authors’ disposal, it was impossible to provebeyond doubt that the two compounds were the same,but in all the reactions that they were able to tryboth substances behaved in an identical manner.The therapeutic tests were carried out on mice, andthe final clinical test has yet to be performed. Theauthors are making trials of " 309 " in Africa,and it is hoped that good results will be obtained.If these are satisfactory, as one is justified in hoping,the discovery of " 309 " will form a landmark inchemo-therapeutics ; but whatever the outcome ofthe clinical tests may be, the zeal and patience of theauthors deserve the utmost commendation.

A NEW TREATMENT FOR HYPEREMESISGRAVIDARUM.

AMONG the various morbid manifestations whichmay happen to a pregnant woman that of vomiting,which may become uncontrollable and constitute adanger to life, is undoubtedly the most important, andits treatment has for a long time been a problem amongobstetricians. It is unnecessary here to enumerate thevarious therapeutic and operative measures whichhave been employed to combat this disease, but wemay call attention to a new method which Dr. PietroCastagna has recently put forward. He claims tohave obtained excellent results from the intravenousinjection of a concentrated solution, 35 per cent., ofchloride of calcium given in doses of 2 c.cm., a curehaving resulted after the third or second or even afterthe first injection. His technique in order to avoidinjury to the perivascular tissue is as follows. Beforeinserting the needle into the vein in the elbow, care istaken by aspiration that it does not contain anytrace of the fluid, and the injection having been madea little blood is aspirated several times and re-injectedinto the vein so that the walls of the needle are wellwashed out, as to ensure that after it is withdrawn fromthe vein not the least trace of the caustic fluid is leftin its track. By this method any sloughing actionupon the paravascular tissues can be avoided, theslight erythema produced being easily remedied bywet applications. Details of five cases are given, fourof which were primiparee and in whom the vomitingwas of an uncontrollable character. Treatment bymorphine, adrenalin, orexin, oxalate of cerium hadfailed to relieve the violence of the vomiting, so thatin one case rectal feeding had to be resorted to. Allthe cases responded promptly to the injections ofchloride of calcium and the pregnancies went on tofull term. These reports seem encouraging enough to

1 Il Policlinico, Practical Section, xxxi., Feb. 25th, 1924.

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justify a further trial of this method of treatment Ibefore having recourse to artificial interruption ofpregnancy in the more severe cases.

PLANTS AND MEN.

ALTHOUGH Sir Frederick Keeble made no directmention of medicine in his delightful address lastweek at the Royal Institution on the Plant Common-wealth and Its Government, yet there was much inwhat he said which appealed particularly to thetrained medical mind. The lecture was largely con-cerned with the transmission of messages in plants.Sir Frederick Keeble depicted the vegetable organismas being constantly assailed by impulses to which itreacts. He showed how the plant cell is more con-stantly subjected to stimulus than are the cells of ourown body and how mistakenly we employ the termto lead a " vegetable existence." Moreover, thesensitiveness of the plant is so acute that it can reactto the stimulus of a weight so minute that it would beimperceptible to the most sensitive human skin. Thetransmission of impulses is carried out in the lecturer’sopinion by hormones. The plant commonwealth isVictorian-it has but one means of transmission, theold post office-as opposed to the neo-Georgiananimal mechanism, with its telephones and wireless,its nerves and arteries, veins and lymphatics.Experiments in which the growing tip of a leaf orof a root is removed and then stuck on again with alayer of gelatine through which hormones can passwere related to prove the route by which plantstransmit messages in their commonwealth. Theactivity of plant cells in response to trauma, and thedamage done to the wounded surface by over-washingwere illustrated by diagrams, and were of extraordinaryinterest to the medical man when compared with thelatest teaching of aseptic an d antiseptic surgery. Therecan be no doubt that advances in human physiologyand therapeutics might well follow on experimentsdevised on the lines described by Sir Frederick Keeble.

THE L.C.C. SCHOOL MEDICAL STAFF.

LAST week the London County Council came toa decision which will result in a reorganisation of itsmedical department. Following the example of theMinistry of Health, a new grade of officer has beencreated, designated ‘ senior medical officer," withstipend appropriate to the position. By effectingcertain economies, the cost of the department underthe new scheme will be less than formerly, with theresult that it has been possible to increase the salariesof the assistant medical officers. Perhaps the mostinteresting part of the scheme is the declaration thatin the future greater use will be made of part-timeofficers than has heretofore been the case. Diverseviews are still held as to the advisability of thepublic medical services being composed entirely ofwhole-time officers or largely of part-time officers, andit is noteworthy that the London County Councilshould after considerable experience of either courseresolve that " as large a proportion as possible,compatible with efficiency, of the subordinate medicalstaff should be engaged on a part-time basis." Apartfrom the senior officers there are at present 30 full-time permanent assistant medical officers in the

department, and these posts will be reduced to 23 asand when opportunity arises. Eight assistant medicalofficers, who are engaged on a yearly basis; are to bereplaced by part-time officers. This is the extent ofthe contemplated change in the immediate future.

NOBLESSE OBLIGE.

WE understand that Lord Banbury has in the IHouse of Lords, as previously on two occasions in theHouse of Commons, stated that he had the authorityof THE LANCET for an assertion that dogs were notnecessary for experiment. Such a statement isuntrue, and Lord Banbury has already been informedthat it is misleading.

Modern Technique in Treatment.A Series of Special Articles, contributed byinvitation, on the Treatment of Medical

and Surgical Conditions.

LXIV.THE TREATMENT OF CERVICAL ADENITIS.A CONSIDERABLE amount of discussion has taken

place in recent years concerning the nature of enlargedglands in the neck. Formerly, it was the customto regard chronic cervical adenitis as practicallysynonymous with tuberculous adenitis, but there wasno real evidence for this view. The assumption thatthe persistence of a chronic enlargement of a gland isdue to the tubercle bacillus is valueless. Investigationof the glands, after removal, in cases clinically identicaloften fails to show any tuberculous lesion, whilstbacteriological examination of the glands often onlyshows the presence of a streptothrix, streptococci, orstaphylococci, and these, in many cases, apparentlyof a low degree of virulence. Consequently, it is nowincreasingly realised that a large number of cases ofchronic adenitis are, at any rate in their earlier stages,of a simple nature and dependent on some chronicirritative lesion. The subject of local irritation inrespect to the development of tuberculous glands is anexceedingly important one, and it has, I think, beenproved satisfactorily that in a large majority of casesthe incidence of a tuberculous proeess in a glandulargroup has been preceded by injurious irritation insome part of the region drained by the lymphaticsafferent to the group.

Causes other than Tuberculosis.In the region of the neck there are so many sources

of possible irritation that the most thorough investiga-tion must be undertaken before any drastic treatmentof the actual glandular enlargement is embarked on.The scalp must be examined for impetigo, seborrhoeiceczema, pediculi, and other lesions. The possibilityof oral sepsis must be investigated, and carious teeth,alveolar periostitis, unhealthy tonsils, or ulcerativelesions of the fauces, tongue, and floor of mouth lookedfor. The ears must be examined for any evidence ofdischarge, whether due to infections of the external

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auditory meatus or to chronic suppurative otitis media,whilst adenoids must be looked for in the nasopharynx.It is not easy to say by which route the infectiveprocess more commonly enters, but it is probable thatin the majority of cases in children, unhealthy tonsilsand adenoids and carious teeth are responsible. It isquite remarkable, at any rate in the south of England,how the number of cases of extensive cervical adenitishas diminished since the teeth and tonsils have beenproperly attended to, so that it is quite unusual to seepatients with large masses of glands in the neck, thoughthis was quite a common sight 20 years ago.That the tonsil is a portal of entry has been, I think,

satisfactorily proved, and recently published investiga-tions by Dr. S. R. Gloyne and myself over a series of300 cases of unhealthy tonsils associated with cervicaladenitis showed that the infecting organisms weremainly streptococci (heemolytic and non-hsemolytic)and pneumococci, whilst the tubercle bacillus was onlyfound in the tonsil in 5 per cent. of the cases. If, as isprobable, tuberculosis is a late and superadded infec-tion, the most important factor in the treatment ofchronic glandular enlargement, with a view to theavoidance of extensive operative interference, is thecomplete elimination of all primary foci of infection.If this is effected it will be found that in a large numberof cases the glands subside and eventually disappear.Complete resolution should not, however, be expectedalways to take place immediately, and occasionally ayear or more may elapse before the glands finallydisappear. In slow cases especially, though it appliesto all, good fresh air, preferably in the country or atthe seaside (the latter usually better for adults)

1 THE LANCET, 1923, i., 1202.