INTRAVENOUS MEDICATION IN

SYPHILIS

The discovery of salvarsan, some years ago, constitutes an important advance in the treatment of syphilis and other protozoal diseases, not so much through providing a definite or new remedy, but, rather, because it inaugurated the intensive administration of drugs known to be of service in these diseases by the intravenous

route.

As a means of producing a complete sterilization of the organism, as to protozoa, salvarsan soon was found to be ineffective. It proved, however, to be of superior value for the purpose of introducing into the circulation a large amount of an arsenical compound; and, under methods combining mercury and iodine with the salvarsan treatment, truly splendid clinical results were obtained.

In an article contributed to The Practioner for October, Mr. R. L. Spittel asserts that a comparison between salvarsan and mercury and the iodides has not been a fair one hitherto for the reason that the older drugs have not been administered in the same massive doses and by the intravenous route as was the case with arsphenamine. Keeping this in mind and being conscious of the remarkable powers of iodides in causing the absorption of syphilitic growths, as also of the curative action of mercury upon indurations of chancres and lymphatic glands, Mr. Spittel devoted his attention to these two drugs when, soon after the outbreak of the war, it became evident that supplies of arsphenamine would be increasingly difficult to procure.

Experience had show that all syphilitic lesions react better to a combination of mercury and iodide than to one or the other alone, and the author soon was convinced that the drugs contained in Donovan's solution lent themselves to a form of treatment by which these remedies were pushed to the point of tolerance under ad

The solution is made up in the following way: It has to be rendered slightly alkaline, and this is best done by first adding to it 20 minims (1 mil) of a 0.5-percent solution of phenolphthalein, and then neutralizing by carefully adding drops of a 25 percent solution of sodium hydrate (about 2 drachms are required). When alkalinity is reached, the solution begins to assume a pink color owing to the presence of phenolpthalein which, thus, serves both as an index of correct alkalinity and as a coloring agent. Once the neutral point is reached, the alkali is cautiously added drop by drop until a distinct pink color is obtained. If thought necessary, glazed litmus paper may be used as a control of alkalinity, but, phenolphthalein is by far the more delicate index. It is important that the solution should be only slightly alkaline; if too alkaline, a precipitate results either immediately or after some hours or days, and the efficiency of the solution is impaired. Should the color fade on keeping, it means that it has become too acid (due probably to the presence of hydriodic acid); in which case dilute alkalis should be added until the original pink color returns. The solution keeps well for several weeks, and, if stored in a glass-stoppered bottle under aseptic precautions, it may be drawn upon for injection without subsequent resterilization.

As to dosage and mode of administration, 8 to 15 mils is the dose for an adult. The dose should be small to begin with and gradually increased according to tolerance. Four to six injections at intervals of four days to a week constitute a course. Several such courses should be given with intervals of a month or six weeks between them.

The injection is administered with a 20or 30-mil glass syringe, into which the required quantity of solution is drawn; the syringe is then filled up to its full capacity with sterile water. This further dilution is necessary to obviate the slight phlebitis that otherwise is apt to ensue, rendering future injections into the same vein somewhat difficult. The solution is introduced into the vein after the usual manner of intravenous injection; should any of it escape into the tissues outside the vein, pain, tenderness and induration are caused.

Results. There is no lesion of syphilis that is not markedly and rapidly benefited by the injection. One dose is often sufficient to cause the disappearance of recent lesions. The primary sore heals rapidly, leaving little induration behind. The lesions of secondary syphilis quickly disappear as well as such symptoms as headache, osteocopic pain, and others. Cutaneous syphilides of all kinds, mucous papules, snail-track ulcers, et cetera, get well after one or two injections. Tertiary lesions such as gummata, ulcers, nodes, improve with remarkable rapidity; so do joint-pains, headaches, bone-pains, and recent eye affections such as irido-cyclitis and keratitis. A constant feature of these injections is, the inflammatory reaction (Herxheimer) that follows them. Any lesion, whether it be the primary sore, the cutaneous syphilide, the node, or the inflammation of the eye, becomes more painful and inflamed some hours after the injection before becoming painless and subsiding.

The author concludes that, although the claim is not made that these injections should replace salvarsan and its derivatives but, rather, reinforce them, still, when the latter are difficult to procure, or

can not be afforded by the patient, the injections here advocated are sufficient of themselves to bring about a cure.

IPECAC IN THE TREATMENT OF AURICULAR DISEASES

There is hardly any drug more frequently prescribed than ipecacuanha, although physicians are not really conscious of how often they do use it. Thus, it constitutes an essential ingredient of the rhubarb, ipecac, and soda combination that is the standard remedy for all undefined functional stomach disorders presenting themselves in the clinics of New York City. It is used in the form of Dover's powder, because physicians know that this is a remedy that gives relief under varying circumstances.

So, in the treatment of cardiac conditions, ipecac has, naturally, been employed in this way as an adjunct, while it also has been given by many as an emetic, with the idea of terminating attacks of palpitation of the heart. Of course, the belief has been that the effect upon the auricular functional disorders was purely reflex.

In The Medical Record for August 31, Dr. Louis Faugeres Bishop, records the observation that, in disorders of the auricle, which he believes are very often of toxic origin, ipecac seems to be a valuable adjunct to digitalis. In people that are suffering from fibrillation of the auricle, severe attacks of cardiac distress may осcur, in which treatment must be pushed to a degree that it is to be considered as bold. Doctor Bishop often has felt obliged in such cases to order digitalis given until vomiting has been produced. However, on one occasion, when he was afraid that when the vomiting by digitalis came on it might do harm, he combined some ipecac with the digitalis, in order to increase the nauseating effect of the latter. This was indicated, especially since digitalis-nausea may be postponed too long to be of value. On this particular occasion, the response to the treatment was unusually favorable, so that Doctor Bishop has been led to repeat the combination of ipecac with digitalis. Although it does not always hasten nausea, yet, he is under the impression that the effect of the digitalis seems to be improved.

We desire to add to the foregoing that it is owing to the rather slow action of

digitalis and to the necessity of securing quick results in certain heart crises that remedies have long been demanded, the action of which might be secured more rapidly than is the case with the galenical digitalis preparations and also with the more modern products. It is for this reason that the chemically pure digitalin and certain other digitalis products (for instance, the one known as digipoten) are being injected intravenously by many clinicians, and with most remarkable and pleasing results. In this mode of procedure, it manifestly is impossible to add ipecac to the digitalis, while the addition of emetine hydrochloride is entirely feasible, even for intravenous injection. In any event, the desired action of ipecac can be secured much more promptly and energetically from the alkaloid, and it is somewhat of a matter of surprise that so many physicians do not see fit to employ the alkaloid in place of the crude drug.

INTRAMUSCULAR INJECTION OF CINCHONINE SALTS IN MALARIA

Sir Leonard Rogers, who is one of the greatest authorities in the world on tropical diseases, contributes to the October 26 number of The British Medical Journal a very interesting article, in which he suggests the use, intramuscularly, of cinchonine salts, instead of the quinine salts. Introduced intravenously in large doses, quinine is not free from danger. Cinchonine, on the other hand, is less toxic, while it has the very decided advantage that it can be administered intramuscularly and subcutaneously without causing notable pain. Moreover, it is much more readily absorbed when injected intramuscularly than are the quinine salts. Cinchonism is produced by cinchonine in 15-grain doses in one or two hours, and the alkaloid soon appears in the urine in the form of quinine. This, Rogers has demonstrated by experiments with rabbits.

Comparative experiments with quinine bihydrochloride and cinchonine bihydrochloride injected into the muscle showed that, when the former was employed, 80 milligrams remained in the muscle unabsorbed after twelve hours, while 30 milligrams were absorbed and found in the vital organs the brain, kidneys, liver, spleen, and adrenals. When cinchonine hydro

The clinical effect upon the animals was even more striking; for, while the animals injected with quinine salts appeared to suffer from no definite symptoms of poisoning, the cinchonined animals became violently convulsed within half an hour after the injection.

A series of experiments tried out with cinchonine, as compared with quinine injections, in malarial patients suffering from the disease in more or less severe form showed up equally favorably.

As a result of these experiments, Sir Leonard concludes that cinchonine bihydrochloride in a 1 : 2 solution carefully sterilized is so rapidly absorbed when given intramuscularly that he considers it nearly as effective in its action in severe malarias as quinine intravenously, while it has the advantage of being much safer and capable of administration practically without pain.

In severe cases of malaria, as well as in patients who vomit when quinine is administered by the mouth, he suggests a trial of intramuscular injections of from 7 1-2 to 15 grains of cinchonine bihydrochloride during the first few days of the attack, for the purpose of controlling the fever and infection, following with full doses of quinine by mouth, to prevent relapses.

IN THE FIELD HOSPITAL

Elizabeth Fraser gives, in The Saturday Evening Post, a striking picture of the doctor's work in an evacuation-hospital.

An evacuation-hospital, says the writer, is dramatic, picturesque, full of potentialities and surprises, with tragedy, comedy, and broad farce competing for first place every hour in the day.

Here, during a big offensive, when Allied and enemy wounded are pouring in in a continuous stream, surgeons, nurses, and personnel work like fiends under a tremendous pressure, twelve, twenty-four, even forty-eight hours at a stretch. Here, there can be witnessed in the operatingroom running fights with death as tense and thrilling as anything upon the battlefield. Sometimes the wounded man is exactly upon the great divide, hovering between life and death, an extra hair's weight capable of sending him to either side; sharpnel in his chest, his lungs full of blood, breathing like a trumpeter, suffering from shock, exhaustion, lack of foodand still able to smile up into the surgeon's eyes and say faintly: "I'm all right, sir. Take that other poor guy. He's worse off than me."

In cases, like these, three minutes more or less in the duration of the operation spells all the difference between time and eternity. The surgical team works with the perfect union of a football eleven. In their white apron, caps, and masks, they look like priests performing a rite. The sweat stands out on their foreheads. Their expert fingers move like lightning, yet, precise, unhurried, sure.

In an operation of this kind, with life and death in the saddle and both riding hard, I have seen the assistant hold a watch on the operating team, as if it were a horserace, and call aloud the minutes, thus: "Three! Five! Seven! Ten!" Two minutes too long, and the patient may expire on the table or die of pneumonia from the added strain of ether on the lungs. Here, margins are short and time is more precious than the weight of iron in rubies.

STROPHANTHUS IN PNEUMONIA

Maj. D. Elliott Dickson reports, in the October 19 number of The British Medical Journal, a series of 67 cases of pneumonia, with only 2 deaths. These cases were treated in the general military hospital in France to which Major Dickson was attached. The mortality in the hospital area for the same period, including his own cases, was 12.25, in comparison with which the mortality of 3 percent in his cases is remarkably favorable.

The treatment employed consisted in keeping the patient absolutely at rest. He was not, under any circumstances, allowed to sit up, while the examinations of the chest were limited in number to the irreducible minimum. The novel feature of the treatment consists in the use of strophanthus from the moment the diagnosis has been made, given in doses sufficient to keep the pulse as satisfactory as possible. It is given in the very beginning of the

illness and is used as a prophylactic rather than as a curative remedy; the idea being to get the drug into the system to antidote the pneumotoxin.

Major Dickson begins with 5 minims of the tincture of the new British Pharmacopeia, repeated every four hours. (The tincture of strophanthus, B. P., edition 1914, is of the same strength as the official U. S. P. tincture; but, is four times as strong as the corresponding preparation of the British Pharmacopeia of 1898.) If the frequency of the pulse increases to 120 per minute or more, he gives the same dose every two hours, or even hourly, if necessary. Two minims of tincture of capsicum is given with each dose, to guard against any digestive disturbance. Small doses of heroin were prescribed, to control cough, while cold sponging was resorted to whenever the temperature rose above 104 degrees.

PROPHYLACTIC VALUE OF QUI

NINE

In an article published in the October 26 number of The British Medical Journal, serious doubt is thrown upon the value of the internal use of quinine, for preventing malaria, by G. Waugh Scott, a physician employed on a rubber-plantation in the Malay States.

The laborers on this plantation were divided into two groups, the first group consisting of tappers-strong men who do comparatively easy work-the other group being weeders, who have longer hours and do more work. Those of the first group were daily given 10 grains of quinine at a single dose, as a prophylactic. In spite of this, there actually was a lower percentage of malaria-cases among the weeders, who had received no quinine whatever. This, even though they worked longer and were physically of a lower type.

THE WOUNDED "YANK"

In Elizabeth Fraser's article, published in The Saturday Evening Post, we are given a moving picture of what happens to the soldier from the time he is wounded until he is lifted from the operating-table in the evacuation-hospital-and here it is:

"A soldier is wounded on the field, in the trenches, in a wood. If alone, he applies his own first aid. If he has given it away to a comrade, he uses his belt for a tourniquet, his bootlaces anything. If he can not get at his wound or if he is knocked unconscious, he lies until he is picked up by a friend or foe. If he is not picked up, he 'goes west,' joining the great host of immortal comrades, and all is well. That is the first step, where each individual attends to himself, is attended to by others or is lost.

"The second step consists in getting him to a dressing-station, usually in some abri, where he is bandaged, given a hot drink and an injection of antitetanus serum, and an iodine cross is marked on his forehead to indicate that he has received the same. If he is suffering acutely, he is, in addition, given a morphine tablet. After this, he is transported by ambulance to the divisional field hospital, where, if he is in good condition, he is not even unloaded, but, sent straight on to the evacuationhospital a few miles farther back.

"Thus, he receives personal, regimental, and divisional first aid before ever he strikes the evacuation-hospital. All of which, if he is lucky, he may get inside of two or three hours and be safely tucked away in his cot, coming out from under the ether, raving, not of home and mother, but, of going 'over the top', shouting in stentorian accents: 'Shoot 'em to hell, boys! The dirty skunks! Shoot 'em to hell!' To the infinite delight of his comrades in the tent ward, who cheer him on: 'That's the stuff, buddy! Atta-boy! Eat 'em alive!'

"Finally, after much batting of wobbly eyelids, he opens his eyes feebly upon the white-capped nurse at the foot of the bed and murmurs in weak, flat tones of pleasure: 'Well, hello, chicken! How'd you ever git here? Gosh! That's a foul taste in my mouth. Say, can a guy spit in this place?' And if he thus far has come through alive, the chances are that he will stick. He is the stuff that survives."

PSYCHOLOGICAL HANDLING OF

TUBERCULOSIS

Charles L. Minor, of Asheville, North Carolina, discusses the psychological handling of the tuberculous patient in the American Review of Tuberculosis for October. In no disease is the relation between mind and body so close and so important as in pulmonary tuberculosis.

This fact must be recognized as an important factor both for prognosis and treatment, and the complete confidence of the patient obtained. A proper personal atmosphere is important for the welfare of the patient and is often better obtained in an institution than in the home, especially in a cottage sanatorium where a group of patients, socially and financially compatible, are all educated to a proper attitude toward each other and toward themselves. It is essential that the patient be seen for proper psychic treatment as well as supervision. At first, twice a week, and after thorough acquaintance is established, once a week, should be enough. When office visits become feasible a fifteen minute interview twice a week and an hour for physical examination once a month is sufficient. The study of the mental side of the case will become so fascinating that the handling of the case becomes a pleasure rather than a task.

The tuberculous are by no means always or even often abnormal, as has been implied by some writers, though there is a good deal of neurasthenia and hysteria among them and they are apt to have a rather labile temperament. When one considers the terrifying effect, for a person, ignorant of the real nature of tuberculosis, of first learning that he is suffering from this disease, it is no great wonder that it causes a fearful upset of his mental poise and easily produces in any but the most phlegmatic or the most self-controlled a temporary neurasthenia. There is no such school of character as tuberculosis bravely met and rightly faced. No doctor could want a more splendid work than to have a part in teaching these patients to master the bitter sorrow of sickness. He must be hopeful in order to inculcate hope. While there are many that cannot be saved, there also are many who can be restored to working efficiency for long periods or for good, and even in the long drawnout chronic cases life can be made useful and filled with interests and happiness if the patients are but taught to face it aright. A foolish optimism which refuses to see the truth is a miserable thing, that only doubles the sorrow of the patient when he comes to a realization of the facts. But, a wise optimism can yet give him hope and a power to fight whose value cannot be overestimated in its effects on the success of our physical efforts. Finally, the