673NON-OPERATIVE TREATMENT OF SQUINT.

- course, arise. Prof. Warthin, in his opening paper at- the Manchester meeting, stated that latent activelesions are found in the aorta of every male syphilitic- and in the majority of female syphilitics. Clinicallythe diagnosis is far less common than this statementwould suggest. The Wassermann reaction is not-always positive in aortic lesions, nor may the:signs and symptoms be at all distinctive. Prae-- cordial pain, not necessarily amounting to angina,discomfort or oppression over the sternum, a

.systolic murmur with a ringing aortic secondsound but without a raised blood pressure, andX ray evidence of aortic dilatation are our bestguides to diagnosis. In the presence of aortic regur-gitation or actual aneurysm the difficulties are

naturally less, and most clinicians would agree that- the presence of an aortic aneurysm is more certain- evidence of syphilitic infection than is a positiveW.R. in the blood.

Such high incidence of vascular lesions suggests aTeconsideration yet again of the curability of syphilis,.and the results of treatment as far as they are apparentto-day. There is general agreement that aortitisitself cannot be completely cured, and there is unfor-- tunately no evidence that arsenical preparations havein any way reduced its incidence or mortality. Warthinremarks that he has never seen at autopsy a case ofperfectly healed syphilis, and that search alwaysreveals active latent lesions in aorta, heart, or other- organ. Bergel concludes that syphilis is probablycurable only in the first or sero-negative stage, after-which true healing is unlikely ; and that even with ourpresent methods, though salvarsan is a most potentremedy, actual cure can never be established with anycertainty. Even if recovery does take place, Bergelbelieves that no lasting immunity is conferred andreinfection may thus occasionally occur. It is clearthat if this pessimistic attitude is accepted, our solehope of treatment must lie in early antisyphiliticmeasures, which must be instituted in the stage of the- disease in which the W.R. is still negative. Evenat this time, however, a satisfactory percentageof cures can hardly be expected unless at leasttwo full courses of combined arsenobenzol andmercury or bismuth treatment are administered. Suchabortive treatment in good hands gives, according to- different authors, complete success in between 76 and100 per cent. of cases, though to a given patient it isnever possible to make an absolutely certain reply tohis question " am I permanently cured ? " Dr.T. E. Osmond, who reviews in this issue the significanceof the W.R. at various stages of the disease, statesthat a case in which treatment is started at the early-primary stage will almost invariably continue to givea negative W.R. if the reaction has been negative fora period of one year. Patients beginning treatmentat a late primary or a secondary stage may relapseeven after giving a negative reaction for two years.It is clear that, as was emphasised by the openers ofthe discussion at Manchester, the true treatment of- cardiac syphilis must be preventive.

NON-OPERATIVE TREATMENT OF SQUINT.THE main object in the treatment of commencing

squint in young children is, of course, to preventamblyopia in the squinting eye. In the great majorityof children Nature provides a safeguard againstsquint by the development of the impulse to fuse theslightly different images on the two retinae so as toproduce binocular perception. In certain individuals,however, this power of fusion is weak or developsla,te, and it may even be altogether absent. Theseare the children who are likely to develop a squintif other factors in the causation of that condition,such as hypermetropia. are present; if the squint isconfined to one eye, and is constant, the tendency isfor the child to suppress the image formed by thesquinting eye. In young children the eye scon

becomes amblyopic in the absence of treatment ;when the onset of squint is deferred till the child isunder the degree of amblyopia is less pronounced,

but the longer it has persisted the more diffi-cult it is to overcome. C. A. Worth found 1 that of193 cases which were brought to him when the dura-tion of the squint was only one-eighth of the life ofthe patient he was successful in preventing any degreeof amblyopia in 165. In cases where the durationhad been more than one-eighth but less than one-half of the patient’s life, the corresponding cases ofcomplete prevention were 73 out of 188, and in thecases where the patient had squinted for more thanhalf his life the complete cures were only 14 out of604. Besides occlusion of the non-squinting eye thenon-operative treatment of squint consists in thetraining of binocular vision and of the fusion sense.Hitherto this has generally been attempted by meansof stereoscopic views and of the amblyoscope, bymeans of which the child is encouraged to combinethe two images presented separately to the two eyes.In practice, however, it is difficult to keep the child’sattention on the pictures, however childish thesemay be. It is to Dr. E. E. Maddox, the inventor ofthe " Maddox rod," that we owe a new principle inthis sort of treatment. By means of his " cheiro-scope

"2 the child’s hands, as well as his fellow eye,are made to assist in the development of binocularvision. He can trace the outline of a picture visibleto one eye only with a pencil visible to the other eyealone, or he can play a game of catching a butterflyvisible to one eye alone with a net held in the handof the other side and directed by the other eye.Such devices in the hands of properly trained guidesare without doubt a great advance on previousmethods. In certain cases they may even effect acomplete cure of incipient squint and forestall thenecessity of an operation. We understand that anew department at the Royal Westminster Oph-thalmic Hospital is about to be equipped with thenew apparatus, so that it will have every opportunityof an efficient trial.

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TONSILLECTOMY AND PULMONARY ABSCESS.

To’-NTS]ILLECTO14Y is so common an operation thatserious complications, even if they occur only in asmall proportion of cases, may be responsible for alarge amount of’ serious ill-health. Perhaps themost usual complication is some form of pulmonaryinflammation, and the way in which this is producedhas often been studied and discussed. Of two mainschools of thought one maintains that infectedmaterial is inhaled at the time of operation, and theother that the pulmonary lesions are caused by thelodgment of emboli from the site of operation in thepulmonary vessels. The former theory is the morewidely accepted, and finds further support in aninvestigation published in America by Harkavy.3He begins by pointing out that one of the reasonscited in favour of the embolic theory is that it ishard to produce inflammation in the lungs of experi-mental animals by introducing septic material intothe bronchial tree, and then he goes on to describehis own experiments in this direction. Using dogsin which the recurrent laryngeal nerves had first beendivided and which were anaesthetised by intraperi-toneal injection, he introduced, through a cannulapassed down a bronchoscope into the terminal branchesof the bronchi, 0-5 c.cm of mixed cultures of bacteriaalong with fresh sputum, both derived from patientssuffering from pulmonary abscess following tonsillec-tomy. Five out of 27 dogs so treated developedpulmonary suppuration. The fact that a patientsuffers from chronic tonsillitis indicates that he hasa low resistance to the particular organism present,and therefore one would expect his lungs to beabnormally vulnerable to infection by such organismsby whatever route they were introduced. Thedogs had no such chronic focus of infection fromwhich organisms might be introduced into their

1 Squint, its Causes, Pathology, and Treatment, 5th edition,1921.

2 Made by C. W. Dixey and Son, 19, Old Bond-street,London. W. 1.

3 Harkavy, J.: Arch. Int. Med., 1929, xliii., 767.

674 THE LATE PROF. W. H. PERKIN.

lungs, and their resistance might consequently beexpected to be higher. This factor may accountfor the relatively small incidence of suppurationwhich followed the experiments. Harkavy hascertainly shown that it is possible to produce suppura-tion in the lungs of dogs by direct inoculation withseptic material, but it is hard to see how this knowledgewill reduce the incidence of pulmonary complicationsfollowing tonsillectomy. As it is, every possibleprecaution is taken by surgeons to prevent theinhalation of septic material during these operations,because they are confident, without the reassuranceof experiment, that it is a real source of danger.

HOUSING IN THE IRISH FREE STATE.

A CENSUS was taken in the Irish Free State in 1926,and that section of the report which deals with therelation of population to housing was published lastweek. Accepting as the standard of overcrowdingthe fact of more than two people living in one room,it appears that in the whole country 781,000 persons,or 27-2 per cent. of the population, live in over-crowded conditions. The comparative percentagesfor Northern Ireland, Scotland, England, and Walesare respectively 18-1, 43-3, 9-8, and 7-2. The IrishFree State is thus shown to be in a better positionthan Scotland in this respect, but compares unfavour-ably with Northern Ireland, England, and Wales.The overcrowding in Ireland is worse in the ruralareas than in the smaller towns, and among ruralareas the worst are those along the western coast,particularly the counties of Donegal, Mayo, and Kerry.It is noteworthy, however, that this overcrowding inthe rural areas does not express itself in a higherdeath-rate. Mayo, for example, with 41-7 per cent.overcrowding has a lower death-rate than the com-bined 24 best-housed urban districts with an over-crowding of 15-2 per cent. In urban areas there areother influences deleterious to health which morethan counterbalance any advantage that may arisefrom better housing.

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EMBOLECTOMY.

To those who cherish the belief that medicalpractice is international, at any rate on the surgicalside, it must come as a surprise to discover that certainoperations are frequently practised in some countrieswhile they remain almost unknown in others. Theoperation of embolectomy illustrates this point.Were it an exceedingly technical and dim cult opera-tion, or were there grave reasons for regarding it asundeserving the serious attention of the practitioner,it would be easy to understand why its employmentis geographically so patchy. More than 20 years agoMr. Sampson Handley attempted the removal of anembolus lodged at the bifurcation of the abdominalaorta, and restored for a time the blood current inthe femoral artery. He placed the case on record 1as

" one of those pioneer failures on which ultimate

success so often rests." His report led Sir BerkeleyMoynihan to mention 2 a case under his care at theLeeds Infirmary four years previously, in which anembolus was removed from the popliteal artery andthe artery sutured; the patient, who had mitraldisease and granular kidneys, died with extensiveinfarcts five days later. But this work does notseem to have been followed up, and for the mostpart it has been Scandinavian surgeons at home orin the United States who have taken the lead in thisfield of surgery. The names of Haggstrom, Key,Lundberg, and Michaelsson appear in the literatureof the subject, and in the public hospitals of Scan-dinavia this operation has been increasingly per-formed during the last ten years, the general practi-tioners in these countries being sufficiently cognisant ofthe indications for, and prospects of, embolectomyto send their patients to hospital as soon as the correct

1 Brit. Med. Jour., 1907, ii., 712.2 Ibid., p. 826.

diagnosis has been made. In Minnesota Medicinefor May, 1929, the Norwegian surgeon, F. H. Wiese,.publishes a case of embolism of the right brachialartery in a woman, aged 64, suffering from heartdisease. She awoke one morning with severe painin the right arm, which was pale, cold, and paralysed.But she was not medically examined till between-6 and 7 P.M., nor was the operation, under localanaesthesia, started until 10.40 P.M., at least 14 hoursafter the onset of symptoms. Yet the operation wassuccessful, relieving her of severe pain, restoring-movement to the arm, and saving her from the-gangrene which would eventually have developed,.had the operation not been undertaken. Her deathseven weeks after the operation from embolism else-where in the body, complicated by a three-day-attack of pneumonia, emphasises the fairly commonobservation that this operation is in a certain sense-only a palliative. But even then the operation maybe justified, as it relieves pain, saves the patient fromthe much more serious operation of amputation for-gangrene, and restores the use of the limb. Dr.Wiese’s paper includes a useful summary of the-literature.

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THE LATE PROF. W. H. PERKIN.

To many doctors the name of Perkin--especiallyin association with Kipping-will recall little more-than a text-book on organic chemistry, which, in theirstudent days, they were compelled, more or lessunwillingly, to study. At that early stage of his;

career the medical student has little time, inclination,or knowledge to grasp the true significance of organicchemistry, and the important bearing which its methodshave upon medicine. As the result of the introductionof the term biochemistry there is a tendency tooverlook the fact that, without the preparatory workof the pure organic chemist, many of the outstandingachievements of biochemistry would still be in therealm of unsolved problems. The ability to establishthe constitution of a complex carbon compound.depends upon the skilful application of the methods oforganic chemistry, and no sooner has the constitutionof a physiologically important natural product beendetermined-be it hormone or alkaloid or what not-than attempts are made to synthesise it by those samemethods. It is in this field of synthetic organicchemistry that the work of Prof. W. H. Perkin, whodied last week, has been of such outstanding value.The son of Sir William Perkin, whose discovery of thefirst aniline dye from coal tar led to the foundation ofthe modern dye industry, Prof. Perkin was giftedwith great technical skill and an amazing facilityin overcoming experimental difficulties. He devotedmost of his life to elucidating the constitutionof some of the most complicated natural productsand accomplished synthesis of many of them.At the beginning of his research career he sethimself the problem of synthesising compounds con-taining three, four, or five membered carbon rings-

the possible existence of which was, at that time,scouted by such great organic chemists as AdolfvonBayer-his teacher ,Victor Meyer, and Emil Fischer.In spite of this discouragement, which wouldhave been sufficient to make other people hesitate,he persisted, and succeeded in producing such com-pounds. It would be impossible in small space togive an adequate account of Perkin’s contributionsto organic chemistry, but a few of his outstandingresearches may be recalled, while he originallystudied the synthesis of closed carbon chains for itsown sake, the methods thus initiated came to be

. developed and applied to the synthesis of naturalproducts ; amongst these, the colourless precursors.

.

of the logwood dyes brazilin and haematoxylin claimed’ his attention, and resulted in his assigning to these-

substances their probable constitution. It is in thegroup of alkaloids, however, that in recent years he