1
213 reassured, and fear was therefore not important. It was easy to place back-splints or tin shoes on a patient in a Drinker apparatus, and in the latest type the arms could be abducted. He preferred light metal splints to plaster in the acute stages. He had found the Drinker apparatus invaluable in his hospital. A disadvantage of the Burstall negative-pressure respirator was that it had to be kept in different sizes. Patients in the Drinker respirator must be encouraged, and it was essential to have a sister who thoroughly understood the psychological diffi- culty and knew how to withdraw the patient. His nurses wore masks and gowns, but he thought that a virus that would pass the finest filter could not be kept out by a mask, and did not wear one himself. He did not consider that the tilting stretcher would be efficient in poliomyelitis, and its use by hand for prolonged periods would be impracticable. Dr. SYMONDS, also in reply, could not agree that the mask was inefficient : it would not stop a virus but it might stop droplets. Without seeing the results of a full histological examination of the two cases which had died from internal haemorrhage, he was inclined to question the diagnosis.-Sir HENRY GAUVAIN assured him that this examination had been made, and undertook to send him the material. MANCHESTER MEDICAL SOCIETY AT a meeting of the society on Dec. 7, Dr. A. R. SOMERFORD opened a discussion on Gold Therapy Some authorities may claim, he said, that they use gold salts in treatment without producing any untoward reactions, but this is not the experience of most observers. Some have noted reactions in as many as 45 per cent. of their cases, though they were often mild. Reactions may arise at three stages- within a few hours of the injection, including the so-called grippe aurique ; during the course of treatment, including urticarial, morbilliform, and scarlatiniform eruptions ; or after the cessation of treatment, possibly several weeks later, and at this stage it is not uncommon to find evidence of blood, hepatic, or renal damage in addition to skin eruptions. Reactions have been variously ascribed to hyper- sensitivity to gold, biotropism, the toxic effects of products resulting from the action of gold on the tissues, and faulty elimination by the kidneys due either to pre-existing deficiency or to renal damage produced by the gold. Whatever the cause, it is wisest to regard all reactions as signs of gold intolerance and to terminate treatment when even the mildest occur. In the prevention of reactions, Dr. Somerford went on, the type of gold salt used or its method of administration seems of little importance. Calcium gluconate, glucose, and whole-liver extract given simultaneously with the gold therapy have been found to reduce the incidence of toxic symptoms. Repeated examination of the urine for signs of renal damage is most important. It has been suggested that the gold acts as a catalyst and that equally good results may therefore be obtained with small as with larger doses. The results of gold treatment are encouraging but it must be remembered that serious symptoms and even death may result from injudicious dosage or lack of attention to mild symptoms of possibly toxic origin. Dr. NORMAN KLETZ briefly reviewed the history of gold as a therapeutic agent in pulmonary tuber- culosis and later in other conditions. It is interesting, he said, that its use in rheumatism was suggested by the analogy between the life-histories of tuber- culosis and arthritis. While our knowledge of the pharmacological action of gold is limited, many of its toxic effects are well known. These may be divided into (a) specific gold reactions, such as general malaise, pyrexia, and local response in the brain ; (b) local damage at the site of injection; and (c) effects on the digestive tract (anorexia, nausea, vomiting, diarrhcea, stomatitis), the skin (variable, localised, or general), the kidneys (albuminuria, some- times nephritis), the blood (action on the bone- marrow producing aplastic ansemia, agranulocytosis, or thrombocytopenic purpura), the liver (hepatitis), and the nervous system (peripheral neuritis, mental symptoms, or epileptiform attacks). Discussing the importance and non-assessability of idiosyncrasy, Dr. Kletz said that small dosage and short courses with a long interval between them minimised the dangers. When once toxic symptoms have developed, it is doubtful if any effective radical treatment is possible, and treatment can only be symptomatic. Gold therapy is likely to be effective, he said, in primary or secondary rheumatoid arthritis and spon- dylitis ankylopoietica. It is ineffective in fibrositis and also in osteo-arthritis except when there is a superimposed infective factor. In 103 cases that Dr. Kletz reviewed toxic reactions were rare and on the whole not severe. There was one death from thrombopenia and spontaneous haemorrhage, and one case of severe hepatitis which recovered. Assessment of results was difficult. In a considerable number of cases the improvement was almost miraculous, and in very few was there no material improvement. The general conclusion was that gold therapy is the most valuable weapon we have in the treatment of certain types of arthritis. It is, however, a dangerous weapon and only to be employed by those willing and able to control its use by adequate clinical and laboratory observations. In the discussion emphasis was laid upon the importance of care in dosage, a careful watch for signs of intolerance, efficient control of the treatment- preferably in hospital with regular blood investiga- tions-and the need for a full consideration of each patient’s condition before beginning gold therapy. THE LANCET 100 YEARS AGO January 26, 1839, p. 672. From a lecture by Michael Faraday at the Royal l Institution on electric fish. The electric power exhibited by these animals, Mr. Faraday said, was in the direct ratio of the nervous influence exerted by the animal. The electric action, like muscular action, was followed by exhaustion. It was after the exhaustion of the animal by repeated dis- charges that, in South America, the gymnotus was taken ... As the fatigue wore off they gradually recovered their electric strength. " It is thus evident," quoth the lecturer, " that nervous power may be converted into electric power, as clearly as that electricity may produce heat. Why may not the converse of the experiment be true, and nervous influence be generated from electricity, as electricity, after producing heat, may again be repro- duced from heat ? ... I have no doubt that this nervous power is as material as heat, light, or electricity, and is conducted along the nervous fibrils in the same manner as water, gas, or the electric fluid is carried through pipes or conducting wires."

THE LANCET 100 YEARS AGO

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213

reassured, and fear was therefore not important. Itwas easy to place back-splints or tin shoes on a patientin a Drinker apparatus, and in the latest type thearms could be abducted. He preferred light metalsplints to plaster in the acute stages. He had foundthe Drinker apparatus invaluable in his hospital.A disadvantage of the Burstall negative-pressurerespirator was that it had to be kept in differentsizes. Patients in the Drinker respirator must beencouraged, and it was essential to have a sisterwho thoroughly understood the psychological diffi-

culty and knew how to withdraw the patient. Hisnurses wore masks and gowns, but he thought thata virus that would pass the finest filter could not bekept out by a mask, and did not wear one himself.He did not consider that the tilting stretcher wouldbe efficient in poliomyelitis, and its use by hand forprolonged periods would be impracticable.

Dr. SYMONDS, also in reply, could not agree thatthe mask was inefficient : it would not stop a virusbut it might stop droplets. Without seeing the resultsof a full histological examination of the two caseswhich had died from internal haemorrhage, he wasinclined to question the diagnosis.-Sir HENRY GAUVAINassured him that this examination had been made,and undertook to send him the material.

MANCHESTER MEDICAL SOCIETY

AT a meeting of the society on Dec. 7, Dr. A. R.SOMERFORD opened a discussion on

Gold TherapySome authorities may claim, he said, that they usegold salts in treatment without producing anyuntoward reactions, but this is not the experience ofmost observers. Some have noted reactions in as

many as 45 per cent. of their cases, though they wereoften mild. Reactions may arise at three stages-within a few hours of the injection, including theso-called grippe aurique ; during the course of

treatment, including urticarial, morbilliform, andscarlatiniform eruptions ; or after the cessation oftreatment, possibly several weeks later, and at thisstage it is not uncommon to find evidence of blood,hepatic, or renal damage in addition to skin eruptions.Reactions have been variously ascribed to hyper-sensitivity to gold, biotropism, the toxic effects of

products resulting from the action of gold on thetissues, and faulty elimination by the kidneys dueeither to pre-existing deficiency or to renal damageproduced by the gold. Whatever the cause, it is wisestto regard all reactions as signs of gold intoleranceand to terminate treatment when even the mildestoccur.

In the prevention of reactions, Dr. Somerford wenton, the type of gold salt used or its method ofadministration seems of little importance. Calcium

gluconate, glucose, and whole-liver extract givensimultaneously with the gold therapy have beenfound to reduce the incidence of toxic symptoms.Repeated examination of the urine for signs of renaldamage is most important. It has been suggestedthat the gold acts as a catalyst and that equally goodresults may therefore be obtained with small as withlarger doses. The results of gold treatment are

encouraging but it must be remembered that serioussymptoms and even death may result from injudiciousdosage or lack of attention to mild symptoms ofpossibly toxic origin.

Dr. NORMAN KLETZ briefly reviewed the historyof gold as a therapeutic agent in pulmonary tuber-

culosis and later in other conditions. It is interesting,he said, that its use in rheumatism was suggestedby the analogy between the life-histories of tuber-culosis and arthritis. While our knowledge of thepharmacological action of gold is limited, many ofits toxic effects are well known. These may bedivided into (a) specific gold reactions, such as generalmalaise, pyrexia, and local response in the brain ;(b) local damage at the site of injection; and

(c) effects on the digestive tract (anorexia, nausea,vomiting, diarrhcea, stomatitis), the skin (variable,localised, or general), the kidneys (albuminuria, some-times nephritis), the blood (action on the bone-marrow producing aplastic ansemia, agranulocytosis,or thrombocytopenic purpura), the liver (hepatitis),and the nervous system (peripheral neuritis, mentalsymptoms, or epileptiform attacks).

Discussing the importance and non-assessabilityof idiosyncrasy, Dr. Kletz said that small dosageand short courses with a long interval between themminimised the dangers. When once toxic symptomshave developed, it is doubtful if any effective radicaltreatment is possible, and treatment can only besymptomatic.

Gold therapy is likely to be effective, he said,in primary or secondary rheumatoid arthritis and spon-dylitis ankylopoietica. It is ineffective in fibrositisand also in osteo-arthritis except when there is a

superimposed infective factor. In 103 cases thatDr. Kletz reviewed toxic reactions were rare and onthe whole not severe. There was one death from

thrombopenia and spontaneous haemorrhage, and onecase of severe hepatitis which recovered. Assessmentof results was difficult. In a considerable number ofcases the improvement was almost miraculous, andin very few was there no material improvement. Thegeneral conclusion was that gold therapy is the mostvaluable weapon we have in the treatment of certaintypes of arthritis. It is, however, a dangerous weaponand only to be employed by those willing and ableto control its use by adequate clinical and laboratoryobservations.

In the discussion emphasis was laid upon the

importance of care in dosage, a careful watch for signsof intolerance, efficient control of the treatment-preferably in hospital with regular blood investiga-tions-and the need for a full consideration of eachpatient’s condition before beginning gold therapy.

THE LANCET 100 YEARS AGO

January 26, 1839, p. 672.

From a lecture by Michael Faraday at the Royal lInstitution on electric fish.The electric power exhibited by these animals, Mr.

Faraday said, was in the direct ratio of the nervousinfluence exerted by the animal. The electric action,like muscular action, was followed by exhaustion. Itwas after the exhaustion of the animal by repeated dis-charges that, in South America, the gymnotus was taken ...As the fatigue wore off they gradually recovered theirelectric strength. " It is thus evident," quoth the

lecturer, " that nervous power may be converted intoelectric power, as clearly as that electricity may produceheat. Why may not the converse of the experimentbe true, and nervous influence be generated from electricity,as electricity, after producing heat, may again be repro-duced from heat ? ... I have no doubt that this nervouspower is as material as heat, light, or electricity, and isconducted along the nervous fibrils in the same manneras water, gas, or the electric fluid is carried throughpipes or conducting wires."