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925 MEDICAL SOCIETY FOR THE STUDY OF VENEREAL DISEASES. mixed infection with B. coli and B. proteus. Alkaline treatment encouraged the B. proteus while acids encouraged B. coli. If the patient happened to get an unconnected tonsil or throat infection the kidney condition became much worse at once, though the reason for this was not known. MEDICAL SOCIETY FOR THE STUDY OF VENEREAL DISEASES. A MEETING of this Society was held in the rooms of the Medical Society of London on April 24th, Colonel L. W. HARRISON, the President, being in the chair. TOXIC EFFECTS OF ARSENOBENZOL TREATMENT. Mr. DAVID LEES opened a discussion on the toxic effects of arsenobenzol treatment and their prevention. He said that these toxic effects, both after intravenous and intramuscular injection, were produced in many ways, and many factors entered into consideration. The chief determining factors were the health of the patient prior to administration, the preparation of the patient, the drug used, the method of preparing it in solution, and the technique of administration. Physical exertion on the part of the patient, especially just before or after administration, might play a part in some of the reactions that were observed. The daily regulation of the bowels, again, was essential. With regard to the drugs, the " 606 " group were more toxic in general than the " 914," and in the case of " 606 " it was very necessary to be careful and slow in administration. Indeed, in all the drugs given for the treatment of syphilis this slowness in administra- tion was an important factor. He was a strong believer in dilute solutions, and he believed also in filtration. There was no doubt that any undissolved particles would open the way to accidents, which might be avoided by using completely soluble preparations. In a great many patients psychic reactions occurred at the first administration ; they could be overcome usually by careful technique and by having the patient in the lying posture. The fact that the beginning of the injection caused pain to the patient might set up fainting and other minor reactions. Some patients, no matter what precautions were taken, would react adversely to either intravenous or intramuscular injections of arsenic. He discussed the various reactions, first those which occurred immediately on or after administration or within the first 24 hours, and then those which occurred later, up to a period of months. In the immediate reactions were included headache, vomiting, and diarrhoea. It was probable that more than one cause was present in the acute reactions which occurred after treatment with I arsenobenzol. In his own experience, with care in the I preparation of the drug, and especially in the dissolving of the drug, its filtration before use, and its slowness in administration, the incidence of the immediate reactions, both minor and major, was exceedingly small. Occasionally a sensitive patient was encountered and it was necessary to consider what steps should be taken to safeguard him. Mr. Lees found that with atropine desensitisation there was less likelihood of the patient having cardiovascular upset than with adrenalin. Of the reactions which occurred within 24 hours, skin eruptions, such as herpes and urticaria, were of little importance except as danger-signals. Special care should be taken to watch the kidneys of such patients. He spoke of vasomotor disturbances and gave particulars of cases. With regard to later reactions, albuminuria often presented considerable difficulty. Was the albuminuria due to drug therapy or to syphilis ? Only by waiting and watching could one possibly decide. One of the most interesting reactions was a gross exfoliating dermatitis. There were certain individuals who had a special idiosyncrasy of the skin to therapeutic irritants, and these showed undoubtedly a greater tendency to such a condition. From the experience of the past ten years he could not agree with the observation that the joint exhibition of arsenical and mercurial therapy predisposed to the onset of dermatitis. There was no actual proof that the dermatitis was due to over-excitation of the tissues by metallic arsenic, as suggested by McDonagh, and one was left to assume that it was due to hyper- sensibility to arsenic on the part of the patient. Patients made a slow and uninterrupted recovery unless complications set in. Of the complications the most dangerous was broncho-pneumonia, while others were peripheral neuritis and jaundice. If these com- plications could be avoided the prognosis was good. The drug most useful in the treatment of this condition was one of the sulphur compounds. In arsenical dermatitis the Wassermann test frequently became negative and might remain negative for a considerable time. Some workers had stated that such a patient never again showed any manifestation of syphilis, but this he believed to be very dangerous teaching. With regard to jaundice, many considered that this was due to the toxic action of arsenobenzol on the liver tissues. The predisposing factors were constipation and intestinal toxaemia. A very considerable number of the mild cases of jaundice one met with were not due to the salvarsan, although that might be a con- tributory factor, irritating, as it did, the mucous surface of the intestinal canal. It was a small matter for the inflammation to extend from the bowel through the biliary tract and set up a liver condition. In other words, salvarsan was more likely to injure the liver in a person infected with syphilis who, in addition, had an intestinal toxaemia and a possible predisposition to catarrhal jaundice. For treatment, rest in body evacuation of the bowels, and careful dieting were necessary, also the administration of alkalies in association with salicylate of soda, glucose given intravenously, and - a diet rich in glucose. As a routine procedure he had recently been giving 50 c.cm. of glucose by the mouth to every patient half an hour before treatment with arsenic. This fortified the liver against the arsenic action, and he had had very few cases of catarrhal jaundice. In conclusion, he emphasised the great necessity of careful preparation of the patient for administration and careful examination, especially of the urine, prior to administration. Next he emphasised care in dosage and in the technique of administration. Alcohol must be avoided throughout the whole course of the treat- ment. As to the amount and frequency of the drug, moderate doses should be given with a safe interval (one week), the average course of injections extending over eight weeks and the intervals of rest eight to ten weeks. Except in the early stage of the disease, heroic therapy by massive doses was not of so much value as moderate, safe, and prolonged dosage. Intra- muscular administration was to be preferred to intra- venous, especially in the later stages. Dr. J. C. BUCKLEY said that in his clinic for the first two years, while the novarsenobenzol was of the old " Rochester Row pattern" not a single case of jaundice occurred, but during the last five years he had seen about 120 cases of jaundice, all of them very mild, except one, which proved fatal, the patient dying four and a half months after the administration of the drug. Of these 120 cases about 20 occurred among patients who had been put down as provisionally cured, having had a negative Wassermann for two years, and coming up every six months or so for a provocative dose or a test. As to dermatitis, the worst case he ever saw was long before " 606 " was introduced. Dr. T. ANWYL DAVIES thought the most important lesson to be gathered was that the prophylactic against arsenical intoxication was intramuscular administration. In addition this had greater thera- peutic value, and undoubtedly brought about a negative Wassermann sooner than did any other form of administration. Dr. FONVLER WARD said that he had had formerly a good many cases of stomatitis, but now he made a
