THE REAL THINGS IN MEDICINE
Journal of the American Medical Association
Under certain pathologie conditions, this equilibrium is more easily disturbed. I shall only refer to the increased possibility "of producing reactions in case of diminished functioning of the excretory organs. It is a common practice to test kidney function before and during a course of arsphenamin or its substitutes, for obvious reasons. In special cases, previous treatment with a drug which produces a cumulative effect has also to be taken into account. In a case of malignant malaria which
... ant malaria which is treated intensively with quinin by mouth, it is decidedly dangerous to give the intravenous dose of quinin ordi¬ narily recommended for this purpose without first allowing the patient to dispose of the drug previously given ; and this is equally true of the arsenical treatment of syphilis, and of the intravenous use of strophanthin in cases which are under treatment with digitalis by mouth. Having seen that intravenous medication is not nec¬ essarily superior therapeutically to other modes of drug administration, and having pointed out the numerous possibilities of injury to the patient inherent in this method, we should strive to simplify the technic of the administration of drugs wherever possible, in order to avoid the necessity of the injection of the medicament directly into the circulation. The subcutaneous injec¬ tion of morphin and similar drugs is an exceedingly simple procedure, which very often is left to the attend¬ ing nurse. Would it not be a great step forward if such drugs as arsphenamin or its substitutes could be given subcutaneously ? During the last year, in collaboration with Miss Dyer, Dr. Johnson and Mr. Thompson, I have studied such a preparation experimentally, and so far it meets all the essential requirements. It is prepared from arsphenamin, formaldehyd and sodium bisulphite ; its aqueous solutions are very stable and do not increase in toxicity on standing for twenty-four hours or on vigor¬ ous shaking. Its parasiticidal effect is extremely con¬ stant, and it does not cause any local reactions if injected hypodermically. The chemotherapeutic index or, in other words, the ratio between the curative and the maximum tolerated dose is as good as in the case of arsphenamin. The drug is now being tested clinically, and, should our hopes be fulfilled, I believe that it will have a considerable effect on the practical problem of the control of syphilis ; for it stands to reason that such a preparation would make it possible for physicians who have not the required experience with intravenous arsphenamin treatment to give the treatment in this simple manner, if necessary under the general supervision of an experienced syphilologist, as advocated recently by Stokes. DISEASE CONTROL AND PREVENTION I believe that it should be emphasized in this connec¬ tion that intravenous medication, of necessity, places decided restrictions on the treatment as well as on the prevention of certain diseases, on account of the more or less difficult technic inherent in this method. Take, for instance, the problem of the control and eradication of syphilis; it surely stands to reason that a simple technic of treatment, such as the subcutaneous injec¬ tion, would make it possible to put a larger number of syphilitics under the controlling influence of the arsen¬ icale; and this would unquestionably help in checking the spread of this disease, and it might also assist in its eradication. Again, the practicability of the prevention of malaria by means of the oral administration of quinin rests exclusively on the fact that it is possible to produce a prophylactic effect by taking quinin tablets by mouth ; and I doubt whether anybody would claim that the pre¬ vention of this disease could be made a feasible propo¬ sition if quinin had to be injected intravenously for this purpose. Therefore, every effort should be made to render the administration of such drugs as simple and safe as possible, without, however, sacrificing their therapeutic efficiency. Intravenous medication, to my mind, will never serve this purpose, and will always have a more or less restricted field of usefulness.