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THE TONIC PUPIL

THE Argyll Robertson phenomenon, in whichboth pupils are either totally inactive or verynearly so to light, but react briskly on stimulationto convergence, is a familiar sign of tabes, and isonly found in syphilitic patients. There are,

however, other pupillary conditions more or lesssimulating the Argyll Robertson pupil to which Dr. W. J. ADIim draws attention in an enlighteningcontribution to our knowledge of the tonic pupilreaction.! It is important to distinguish theseconditions, since they appear to have no connexionwith syphilis nor any grave significance. Theyhave been described by various observers duringrecent years under the names of tonic pupillaryreaction, myotonic reaction, tonic convergencereaction of pupils apparently inactive to light,non-luetic Argyll Robertson pupil, or pseudo-Argyll Robertson pupil. Confusion is the more

apt to occur since this reaction also may beassociated with absence or diminution of one ormore of the tendon reflexes. The essential featureof the true tonic pupil, according to Dr. ADIE, is itsbehaviour during and after convergence.

" While the patient gazes at a near object the pupil,often after some delay, contracts slowly and with increasingslowness through a range sometimes greatly in excess ofthe normal, often down to pinhead size ; having beenlarger, it almost always becomes much smaller than itsnormal fellow. After the effort to converge is relaxed oneof several things may happen: the pupil continues tocontract (rare), or remains fixed for several or many seconds(the rule), or begins to dilate at once (common); dilatationonce begun proceeds at a rate even slower than that of thepreceding contraction, and many seconds, or even minutes,elapse before it regains its usual resting size."

The reaction to light appears to be absent oncasual testing, but after a long sojourn in a darkroom the tonic pupil can usually be made tocontract through a normal range. It is almost

always larger than its normal fellow. This contrastswith the behaviour of the Argyll Robertson pupil.Where the contraction of the pupil to convergenceand its return to its usual state are rapid, otherpoints of difference are that the tonic reaction isunilateral in about 80 per cent. of the cases,whereas in the Argyll Robertson it is unilateralonly in about 5 per cent. The tonic pupil is hardlyever small, and dilates to its full size with

mydriatics ; the Argyll Robertson pupil is small,the diameter being less than 3 mm. in 80 per cent.of cases, and dilates with difficulty to mydriatics.A large proportion of the patients with tonic pupilsare healthy young females. There is no evidenceof any but an accidental connexion with eithersyphilitic or any other disease of the nervous

system. When the tonic pupil is associated withdiminution or absence of one or more reflexes,loss of one ankle-jerk is the most common abnor-mality. Asymmetry is indeed not unusual; eitherknee- or ankle-jerk may be absent on one sideonly. The symptomatology of the condition appearsto be extremely variable. Difficulty of accommoda-tion is the only symptom likely to cause incon-venience to the patient, and it does not alwaysoccur. In Dr. ADIE’S view many cases of so-called

1 Brit. Jour. Ophth., August, 1932, p. 449.

" ophthalmoplegia interna " or

" iridoplegia,"whose origin is obscure, are of the same natureas the disorder known as tonic pupil. In the pastthere may have been too great a tendency to

suspect a syphilitic taint in such conditions.Dr. ADIE believes that the disorder of which theyare signs is one in the production of which no knownhereditary or acquired morbid factor plays a part.It runs a benign course without the incidence offurther symptoms, and is compatible with longlife.

HOSPITAL SWEEPSTAKESTHE voluntary hospitals do not wish their

needs to be made a pretext for the legalisationof lotteries, but on the other hand they are notopposed to legislation, and would be willing toaccept money derived from properly legalisedsources. This, in brief, is the message conveyedby Sir ARTHUR STANLEY in his evidence before theRoyal Commission on Betting and Lotteries onSept. 16th. Only a statistician would complainthat the importance of this pronouncement islessened by the fact that he actually submittedhis statement of evidence to only a small numberof hospitals (72, of which 52 replied, 40 agreeingwith his views). Sir ARTHUR is president ofthe British Hospitals Association, and his longand intimate connexion with the work of the

voluntary hospitals gives him a title to be theirspokesman. His evidence may, therefore, beconsidered as authoritative. He holds thatlotteries could best be managed and safeguardedfrom fraud by the appointment of a statutorybody on the lines of the British BroadcastingCorporation. A percentage of the proceeds of

public lotteries and sweepstakes would be setaside as a general fund, out of which grants wouldbe made to national organisations for charity;grants to voluntary hospitals, for example, wouldbe made through the British Hospitals Association.He believes that if large sums were given out ofthe proceeds of lotteries to individual hospitalsthere would be a tendency for charitable contribu-tions, which now amount to £8,000,000 a year,to diminish seriously. A considerable part ofthat sum is given by people who oppose lotterieson principle, and who would withdraw their

support, while many others would feel that theircontributions were no longer needed.

Although Sir ARTHUR believes that the funds formaintenance of hospitals will continue to becontributed by the charitable public, the declinein large fortunes makes it inevitable, in his view,that large sums for capital purposes will be increas-ingly difficult to obtain. It is this need which he

contemplates being met out of a lottery fundwithout danger of alienating subscribers ; and the

large sums of money which are at present goingto Ireland would be kept in this country andspent on deserving objects at home. Sir ARTHUR’Sevidence shows an interesting modification of theviews he expressed in our columns in May of lastyear. In a letter written at that time he was

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sceptical of the value of sweepstakes, pointingout that if 1,000,000 were available for charity.as the result of a sweepstake, nearly 1000 hospitals.and unnumbered charities would be clamouring.for a share, thus taking most of the gilt off the,gingerbread. At that time he advocated the

- legalisation of lotteries in which all the prizeswere to be in kind and presented by donors, thewhole of the cash proceeds going to the hospitalrconcerned. He still considers that any statutorybody appointed to deal with sweepstakes should.have authority to licence lotteries on such lines.

Lord LuEE, chairman of the British CharitiesAssociation, who also gave evidence before the

. ,Commission, described the efforts of the association

to raise money by prize competitions ; they hadcome to the conclusion that the public did notsubscribe primarily because of the charitable aspectof appeals, but because of the attractiveness ofthe prizes and their confidence in the association.There was a public demand for prize competitionscombining an. element of chance with an elementof skill. The question whether lotteries should orshould not be’ authorised was one that should beconsidered on its own merits and not confused with

the needs of the hospitals. If the Commissionshould reach the conclusion that lotteries were

desirable, they had better, he said, be run by theState as a method of voluntary taxation for thebenefit of the national revenue.

ANNOTATIONS

ARSENIC POISONING FROM A WINE RATION

.

EPIDEMICS of arsenical poisoning in any countryserve as a reminder of the dangers inseparable from,the use of arsenic in any form. Manufacturers and I.fruit growers who use arsenic as a chemical or para--siticidal agent must not be allowed to forget thatowing to the solubility of nearly all arsenical salts’contamination is easy and usually insidious, for the-accident is rarely discovered until a number ofserious and sometimes fatal cases of poisoning haveoccurred. Fifteen persons died in an epidemic of500 cases due to contaminated wine at Hyeres andToulon in 1888, and in 1901 no less than 6000

- cases, with a mortality of 70, due to contaminatedbeer were reported from Liverpool. A recent occur-rence of " mass poisoning " by arsenic is the subjectof an interesting communication by Caspar Tropp.and Gustav Rauch.1 The epidemic they describe- concerned a French ship’s crew-a small communityunder ideal conditions for control and scientificobservation. The wine ration of the crew was 1 litreper day per man ; -it was proved to contain up to12 mg. of arsenic per litre, and the characteristic.symptoms of arsenical poisoning began to maketheir appearance about a month after the first issueof the ration. The whole crew of 32 men were

- affected, although only 6 of them were consideredill -enough for in-patient treatment at Hamburg.. When these came under the observation of Tropp.and Rauch they had been drinking the wine for aperiod of three months, so that most of the symptomswere of chronic cutaneous type. The first case, asailor aged 30, developed a rash on the chest, axillae,,internatal folds, thighs, and popliteal spaces, abouta month after signing on. There was severe irrita-tion and some peeling of the affected areas. Pig-mentation followed subsidence of the eruption, and’on the palms and soles there developed markedhyperkeratosis, with anaesthesia of the toes and pain-on pressure, so that walking was impeded. At alater date gastric pain and vomiting, lacrymation,.and difficulty of visual fixation developed, with lossof weight and debility. The eczematous symptomsyielded in three weeks to intravenous injections of.calcium, combined with boracic compresses, and a.sulphur salicylic ointment as local treatment. Ablood count revealed secondary ansemia. In another.member of the crew, aged 38, the symptoms were.almost identical. Pain, especially of the lower- extremities, was so acute that he could not tolerate

1 Derm. Woch., July, 1932, p. 1023.

the pressure of the bedclothes, and lacrymation wasalso a marked feature. This patient also presenteda reduction both in the haemoglobin percentage andin the red cells (3,250,000). A third patient admittedtaking large quantities of wine ; in his case the erup-tion became bullous with a strong tendency to deposi-tion of dark pigment in the affected areas. Gastricand intestinal symptoms were also marked, and thered cells had fallen to 2t millions. Pain inthe extremities and ocular symptoms were a

further feature. Three intravenous calciuminjections, followed by thiosulphate of soda, from0-6 to 1 g. (9-1 g. in all) intravenously, and calciumby the mouth controlled the symptoms after onerelapse in a little more than a month. ’The otherthree cases were rather less violent in their mani-festations, and displayed less hyperkeratoses on

hands and feet. The intravenous calcium therapyseemed to allay the intense itching and subjectivesensations in all six cases, and probably assistedelimination to a considerable extent, since arsenicaleruptions and the characteristic hyperkeratoses notinfrequently persist and continue to recur for weeks andmonths after ingestion of the poison, even under treat-ment with thiosulphate of soda. The possible sourcesof accidental arsenical poisoning are many. The chiefhere recorded are wine and beer (from the sulphuricacid used to invert the sugar necessary for fermenta-tion), medicine (from the administration of salvarsanand its derivatives), and fresh fruit which has beentreated for the destruction of parasites. Certaincases from the last-named cause occurred in SouthAfrica in the autumn of last year, the victims havingeaten peaches sprayed with a solution of arsenic.

THE NATURE OF CONDITIONED REFLEXES

THE great contributions to neurophysiology, madewithin the last few years by the schools of Sherringtonand Pavlov, have been achieved respectively throughthe study of the decerebrate and of the normal animal.The Oxford workers have analysed the mechanismof the various reflexes to be obtained from decerebrateanimals ; both excitation and inhibition have beenshown to be active processes. In Russia, Pavlovhas investigated the reactions of an intact animal tovarious stimuli and the linkage of such stimuli tocertain responses with such success that even in laycircles the phenomenon of conditioned reflexes isnow accepted. A critical analysis of the mechanismof conditioned reflexes by a member of the Sherringtonschool is especially welcome, not only because it