870 CHEMOTHERAPY 



that there is no single cause that will explain the varied reactive phe- 

 nomena following the administration of dioxydiamino-arsenobenzol. 

 Indeed, it is possible that the various groups of symptoms may be due 

 to different causes. 



It will perhaps lead to greater clarity if we classify the causes of 

 reaction under three heads: (1) Factors related to the patient; (2) 

 factors related to the technic of administration, and (3) factors related 

 to the chemical compound employed. 



1. Factors Related to the Patient. There can be no doubt that indi- 

 vidual susceptibility plays a part in reactions. Patients suffering from 

 syphilis vary greatly in their physical condition in the degree of func- 

 tional and organic integrity of the various organs. As a class, too, they 

 are prone to be neurasthenic, and the mental state at the time of injection 

 doubtless influences the incidence of some of the less reactive phenom- 

 ena. Patients may vary in their psychic response to the operation 

 per se y in the manner in which they react to errors of technic, and their 

 susceptibility to the drug itself. Two individuals may receive a solution 

 of the same drug prepared at the same time, and one may suffer reaction 

 and the other remain free. One of the writers had a striking example 

 of this in his practice. A physician and his patient each received half 

 of the quantity of an alkaline solution of salvarsan from the same mixing 

 cylinder. The physician shortly afterward developed pronounced 

 chills, elevation of temperature to 102 F., and severe pains in the legs; 

 the other patient, contrary to instructions, ate a hearty meal an hour 

 later and took a two hours' train ride to a neighboring city, but suffered 

 no reaction. There can be no doubt, therefore, that the personal element 

 may be a factor in causing or influencing reactive symptoms, but it is, 

 in our opinion, not the dominant factor. 



2. Factors Relating to the Technic. These factors have been given 

 much attention in literature, and different observers have attributed 

 great significance to one or another error of technic. The greatest 

 interest and controversy have attached to the " water error" or "Wasser 

 fehler" of Wechselmann. Wechselmann advanced the hypothesis that 

 water impurities, chiefly bacterial proteins, were largely responsible for 

 the febrile and gastro-intestinal reactions. This view was accepted 

 and indorsed by Ehrlich, Max Miiller, and many others. Yakimoff 

 and Yakimoff showed that the presence of bacteria in the salvarsan 

 solution increased the toxicity to a varying degree, depending upon the 

 type of organisms present. The colon bacillus increased the toxicity 

 most, the Bacillus pyocyaneus less, and other bacteria little or not at all. 



