ORGANOTHERAPY AND HORMONOTHERAPY 141 



hour after the injection. In cases intolerant of salvarsan, he gives 1 mg. 

 A.M. and P.M. by mouth for 4 days, and 5 minutes before the salvarsan is 

 given he injects 1 mg. subcutaneously and 0.5 mg. intramuscularly. Bee- 

 son reports that 1 or 2 (!) 44 mg. given intramuscularly ten minutes before 

 administration of the salvarsan proved beneficial in warding off unfavor- 

 able reactions. 



Undesirable Results and Contraindications. Mention has previously 

 been made of some of the uncomfortable and at times alarming systemic 

 reactions which follow the subcutaneous administration of ordinary doses 

 of epinephrin. While very often in patients who have received ordinary- 

 sized doses neither subjective nor objective phenomena are noted, it is 

 by no means unusual for the following effects to occur: The patient 

 experiences a feeling of general distress and anxiety, becomes pale and 

 suffers from a sensation of precordial discomfort and pain, and shivers 

 more or less violently. He may be conscious of an increase in the rate 

 and force of the heart action, which may also become decidedly irregular 

 and rarely he may suffer a more or less typical anginal attack. Occa- 

 sionally the rise in blood-pressure may be very pronounced. 45 Vertigo, 

 nausea, and vomiting, paresthesias, and heartburn are other symptoms 

 which occasionally occur. 46 As a rule these exaggerated and more or 

 less alarming effects last only a very few minutes and have no serious 

 results. However, such pronounced effects on the blood pressure and 

 heart action may well prove harmful in cases of hypertension, arterio- 

 sclerosis, apoplexy, aneurism, or feeble dilated heart. The sympathetico- 

 mimetic action on the heart may in cases with premature (ectopic) con- 

 tractions temporarily aggravate this condition, but Bayer's fear that it 

 may be harmful in such cases seems justified only in connection 

 with its use in chloroform narcosis. Arnstein and Schlesinger report 

 that in elderly patients injections of ordinary doses are occasionally 

 followed by a sharp rise followed by a sharp fall in the blood-pressure and 

 by a tachycardia lasting several hours. They also state that in patients 

 with coronary disease such injections may cause anginal attacks. 



The local effects at the site of injection may also at times contribute 

 to undesirable results. There is a growing belief among those frequently 



"The intramuscular injection of 2 mg. of epinephrin may, in a susceptible indi- 

 vidual, be followed by a very disagreeable systemic reaction. So large a dose should, 

 in my opinion, never be given intramuscularly unless previous trial has shown that 

 the patient is not sympathicotonic. 



45 1 have seen a rise from 110 to over 22 mm. of Hg following an intramuscular 

 injection of 1.5 cm. of adrenalin chlorid 1-1,000 solution (see p. 129). 



46 Such uncomfortable reactions ordinarily result only from unusually large doses 

 or from the dose being accidentally introduced into a vein. Experience, however, has 

 shown that they are especially likely to occur in cases of hyperthyroidism and other 

 conditions associated with increased sympathetic tone (sympatheticotony) . In cases 

 where there is ground for suspecting such conditions epinephrin should be given in 

 small doses (5 to 7 minims (0.3 to 0.5 c.cm.) of the 1-1,000 solution). My own prac- 

 tice is never to give more than 10 minims as the initial dose. 



