SALVARSAN IN THE TREATMENT OF SYPHILIS 283 



second injection, and if threatening symptoms exist it may even 

 be better to begin with a course of calomel and to follow this up with 

 a very small dose of salvarsan. Our final aim, however, should be 

 the injection of full doses. 



Should by any chance symptoms denoting grave danger develop 

 notwithstanding this mode of procedure, lumbar puncture is to be 

 performed without delay, and if no meningeal involvement then 

 manifests itself (as evidenced by the presence of a small amount of 

 fluid only), this is to be followed by trephining. Above all there 

 should be no delay in carrying out such treatment. 



A month after the last injection the Wassermann test is made. If 

 this still shows a positive reaction the salvarsan treatment should 

 be repeated, and may advantageously be followed by a brisk course 

 of mercury. If the latter is used, a month should then elapse during 

 which no medication whatever is employed, before the next test is 

 made, and so on, until a negative reaction is reached. From this 

 point off the Wassermann is repeated at more and more distant 

 intervals for from two to three years (see Wassermann Reaction). 



Centra-indications to the Use of Salvarsan. At the very beginning 

 of its use Ehrlich emphasized the importance of excluding all those 

 cases from the salvarsan treatment in which there was reason to 

 assume the existence of advanced disease of the heart or of the 

 central nervous system; particularly cases of angina pectoris, aneur- 

 ysm (notably of the cerebral vessels), advanced paresis, and cases 

 of atrophy of the optic nerve, while in other syphilitic diseases of 

 the eyes as w r ell as in advanced syphilis of the abdominal viscera 

 the remedy may be advantageously employed. If any doubt exists 

 in an individual case, whether the remedy should be used or not, 

 and the condition of the patient so far as the syphilitic process in 

 itself is concerned makes this desirable, a careful attempt may be 

 made with a very small dose (0.1 gram), which, if no disturbing 

 symptoms develop, may then be followed up with one of equal size 

 or even a little larger (see above, Dosage). 



After all we must remember that the number of deaths which 

 can be attributed to the salvarsan itself, or to its effect upon the 

 syphilitic process, and not to harmful technique, is ridiculously 

 small in comparison with the enormous number of cases where no 

 harmful result has followed its use, and where, on the contrary, the 

 greatest amount of good has been accomplished. As Ehrlich has 



