Patients with organic disease do not tolerate intensive treatment of any kind, and syphilitic therapy must be administered with great caution.

ANTENATAL SYPHILIS.

In the treatment of syphilis during pregnancy great care must be exercised in the administration of our specific drugs. The ideal place to treat pregnant syphilitic patients would be in the hospital where all precautions could be carefully carried out. If the patient is treated in the office or clinic and permitted to go home she should be instructed to lie down on reaching home and remain in the recumbent position for at least four to six hours. Every precaution should be taken to prevent a reaction, for severe vomiting may stimulate uterine contractions and result in miscarriage. Weekly examinations of the urine should be made to determine the kidney function.

The treatment is given in courses of 6 neoarsphenamine and 10 bichloridol injections, using the continuous method—that is, first the neoarsphenamine and then the mercury; after four to six weeks' rest repetition. In this way the patient is not overtaxed by the drugs. Two courses of each are usually sufficient during the period of gestation and result in the birth of a healthy baby.

CONGENITAL SYPHILIS.

The treatment of infants and young children consists of intramuscular injections of neoarsphenamine (neutral) and mercuric chloride (bichloridol).

Here again emphasis is laid on two factors: First, the earlier the treatment is begun the more rapid the serological cure, and, secondly, treatment must be carried out in a routine manner in courses as follows:

As in acquired syphilis the treatment must be individualized and the intervals lengthened or the dosage changed as indications arise. The urine should be examined at frequent intervals, as occasionally a trace of abumin is found. This quickly subsides when medication is discontinued.

A course consists of 8 intramuscular injections of neoarsphenamine and 10 to 12 intramuscular injections of bichloridol not given together as in the case of adults, but one drug followed by the other. Two full courses, each with proper rest intervals regardless of a negative reaction, and possibly a third course of mercury are usually given. In very feeble infants, and in the presence of active syphilitic manifestations, it is advisable to begin with mercury, giving at least 4 to 8 injections before the administration of neoarsphenamine.

SPECIAL REMARKS.

First. Before receiving arsphenamine patients should be properly instructed regarding a cathartic the night before treatment, abstinence from food before and after the injection, and rest.

Second. Careful examination must be made of the heart, lungs, kidney function, etc., to gauge the amount of treatment that may be tolerated with safety, and the possible toxic effects of the drugs. Third. Careful routine eye examination should be carried out early in the disease and repeated during the time of treatment.

Fourth. A lumbar puncture should be made to determine the presence or absence of cerebrospinal involvement.

Fifth. A patient should never be discharged as cured until the Wassermann test has been negative for at least two years after repeated testing. It is customary to give a provocative arsphenamine injection as a final measure. This consists of the ordinary intravenous injection of average dose with tests taken at intervals of 24, 48, 72 hours, 1 week, and 1 month. If these are negative and the spinal fluid is negative, the patient may be discharged as cured.

Sixth. A patient with positive findings in the cerebrospinal fluid should not be discharged even if the blood is negative.

Seventh. Care must be exercised in the future treatment of patients who have complications following arsphenamine, such as cutaneous and nitritoid reactions and jaundice. In some a change in the preparation may be tolerated; in others the same reactions occur. We must, therefore, rely on mercury and iodides.

CONTRAINDICATIONS TO ARSPHENAMINE THERAPY.

1. Marked organic disease of the heart and aorta, kidneys, and other viscera.

2. Degenerative changes of the blood vessels, arteriosclerosis, etc. 3. Extreme malnutrition and cachexia where other diseases are as

sociated with the syphilitic infection.

4. Severe nitritoid reactions and cutaneous manifestations following the administration of the arsenicals.

5. Arsenical neuritis. While this condition is a rare one patients complaining of pain or dysaesthesias in the extremities should be investigated for a possible neuritis.

6. Jaundice the result of an arsenical intoxication. Pains in the joints developing during treatment are suggestive of a beginning jaundice.

JAUNDICE OCCURRING AS A COMPLICATION DURING THE TREATMENT OF SYPHILIS.

This complication is probably due to the direct action of arsenic on the liver, causing acute inflammatory changes in the liver cells and biliary passages, resulting in a blocking of the free flow of bile into the intestines.

The treatment consists of discontinuance of all arsenicals, free and forced elimination through the kidneys and intestines, and a fatfree and low-protein diet. Plenty of water, lemonade, sodium phosphate and cholagogue cathartics (such as Veracolate and Taurocol tablets with pancreatin and pepsin) should be taken.

It usually takes several weeks for the jaundice to develop, during which time the patient complains of digestive disturbances, lassitude, and pains of varying grade in the joints and extremities. Patients with jaundice should not be given the arsenicals for at least six to nine months after the attack, and then they should be administered very cautiously in small doses.

INDICATIONS FOR INTRASPINAL TREATMENT.

1. Rapidly advancing optic atrophy due to a basilar meningitis where intravenous medication has failed to control the progress of the disease. The indications for or against intraspinal treatment are determined by the spinal fluid formula.

2. Cerebrospinal syphilis where thorough intravenous and intramuscular medication has failed to bring about the desired clinical and serological results.

3. Cerebrospinal syphilis where patients do not tolerate arsphenamine intravenously.

(Cerebrospinal syphilis includes syphilitic meningitis, meningo encephalitis, meningo-myelitis, vasculitis, tabes, tabo-paresis, and paresis.)

METHOD EMPLOYED FOR INTRASPINAL TREATMENT.

The patient receives his regular intravenous treatment; 30 minutes later 50 cubic centimeters of blood are withdrawn in a sterile tube and placed on ice until the following day, when he is to be treated. The blood is centrifugalized, the serum pipetted into a

sterile tube, centrifugalized again to make certain that all the red cells have been thrown down, and pipetted into another sterile tube. The serum is then placed in an incubator at 56° C. for 40 minutes, after which it is ready for use.

The patient should be kept in bed at least 24 hours after each intraspinal treatment, instructed to lie flat without a pillow, drink water freely, and not leave his bed for any reason until the next day.

Intraspinal injections are given every two to four weeks, depending upon the reaction of the patient, for six to eight treatments. A rest period of two to three months follows, and then a similar course is given. The spinal fluid should be examined after each

treatment.

The serological improvement is determined by the decrease in the lymphocytes, globulin, Wassermann reaction, and the character of the gold sol reaction.

BOOK NOTICES.

Publishers submitting books for review are requested to address them as follows:

The Editor,

U. S. Naval Medical Bulletin,

Bureau of Medicine and Surgery, Navy Department,

Washington, D. C.

For review.

'Books received for review will be returned in the absence of directions to the contrary.

A MONOGRAPH ON GONORRHEA, by A. Reith Fraser, M. D. (Aberd.), lecturer in venereal diseases, University of Cape Town; honorary visiting venereologist, New Somerset Hospital, Cape Town. Henry Kimpton, London, 1923.

The field of the venereologist has never been defined. This is unfortunate, for in no other special branch of medicine do the diseases with which he deals overlap and encroach on the domains of so many other special branches. This excellent account of gonococcal disease has been written from the viewpoint of the venereologist, and it is noted that complications which concern the gynecologist, the ophthalmologist, the neurologist, or the internist have been but' briefly considered.

The work is a plea for the conservative treatment of gonococcal urethritis and for the management of gonorrhea as a general systemic disease instead of as a local specialized catarrh. As the author informs us in the preface, the production of his contribution has been impelled by a desire to throw over altogether stereotyped and oft-reiterated teaching which conflicts with clinical experience and to submit an account of gonococcal disease which will enable the student to make an efficient disposition of data-accepted, speculative, controversial, and experimental.

The author is to be congratulated upon his effort, for he has produced not only a very readable book but one which is intensely practical.

The work bears the earmarks of the author's originality. In its pages he unhesitatingly condemns accepted treatment and methods. which do not produce the results expected.

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