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The position of the patient is preferably flat on his face, and a precaution never to be forgotten is that one finger of the operator must be on the gluteus about to receive the injection, determining whether the patient hardens the same or not. If the muscle is held rigid the injection must cease momentarily until the patient relaxes it. Injection into the rigid nniscle is extrejnely painful and moreover forces the injection within the muscle into the fat and in part even 'ujion the skin. Just after the injection, gentle massage for about twenty minutes should Buy Cheap Viagra With Mastercard be given the part by the ilurse. The patient should then lie in bed for an hour or two. The balance of the aftercare will be discussed later. I use a No. iBuy Cheap Viagra With Mastercard the injection treatment of syph- ilis. The penetration secured with this needle de- 514 FEDEKSEX: THERAPEUTICS OF SYFHILIS. pends on the size of the individual, the amount of fat, etc., all of which are matters of common sen=e. The range, variation, and repetition of dose are not yet determined. The consensus of opinion, however, is that the safe rule to follow is 0.6 gramme for adult male and 0.4 gramme for women. Factors in this decision are obviously activity of the disease, general health of the patient, previously known susceptibility to other drugs. The reported limits of dose are 0.3 gramme, and i.o gramme in a few cases. Repetition of dose, according to Schreiber, may be safely 0.5 gramme. A case re- ferred to me through courtesy of Dr. Noguchi re- ceived 0.6 gramme on the 2nd and 26th of October by Dr. Xoguchi, and the same dose by me Decem- ber 13, 1910. Further notes on this case are Liter given in this paper. A most important detail is that it is better to err on the side of a full dose than of a deficiency, the theory being that the spirochsts become Buy Cheap Viagra With Mastercard arsenofast unless the dose is sufficient to destroy them at once. This is with reference to arsenic, a dictimi which I hold to be the fact with regard to mercury in the internal treatment of syph- ilis, namely, the amount of mercury absorbed dur- ing the first few weeks of the disease is so little that the Treponema pallidum becomes more or less in- dififerent to the mercury and the disease goes on. The best region for the injection is undoubtedly the buttocks, although the Buy Cheap Viagra With Mastercard back below the scapula has been used and the abdomen when the subcutaneous method was in vogue. The intravenous method is very active, but seems to have had less favor with Ehrlich and most authorities than the intramus- cular, chiefly because the absorption and the Buy Cheap Viagra With Mastercard elimi- nation of the arsenic are so rapid. The first five of mv cases received the intravenous method large- ly from the fact that Dr. Krug, of Magdeburg, Germany, agreed with Neisser's dictum in prefer- ring this method. Dr. Krug was presented to me through one of my former associates and had only a few Jays on shore before returning. Since then I have given the medicine subcutaneously once and intramuscularly twenty times. (c) Reactions to the injection are ^both immediate and remote. The latter come on after a few da.ys. In their order of onset, the reactions are pain, swelling, fever, digestive disturbances, nervous ir- ritation, and cutaneous eruptions. The ])ain may be unbearable and require mor- phine. The more slowly the injection the warmer the [ireparation up to body heat, the more accurate- Iv neutral the solution, and the greater the softness of the gluteus, the less will be the pain, as a rule. One element in the pain, concerning which I have written Professor Ehrlich, is whether or not the use of a normal salt solution in distilled water is not preferable to plain distilled water. No chemical reaction can occur, as the salt is already the dichlor- dioxydiamidoarsenobenzol. As pointed out in my palmer on the injection method of treating syph- ilis, gentleness and deliberation in the injection of the material will greatly decrease the pain. Radi- ating pains, which are occasionally observed down the backs of the legs, may possibly be due to the proximity of the injection to the sacrosciatic nerves. After the first few hours oi active pnin it is re- placed by a dull distress: thus the wh-^Ie process simulates the pain of a severe bruise. In fact, that is what it is, with certain chemical reactions added. The swelling is of two classes, superficial and deep. If the injection has been properly landed within the muscle, only the deep swelling appears, feeling Buy Cheap Viagra With Mastercard much like a hasmatoma just after the blood is clotted and before it breaks down within the muscle. If the injection has been subcutaneous or, what means the same thing. fi)rced by a ri.gid mus- cle into the subcutaneous re.gion, a severe inflam- matory reaction may occur, greatly resembling a phlegmon in its early stages. The tissues about the points of injection may Buy Cheap Viagra With Mastercard become swollen, boggy, and tender over a very large region, as described in one case. These subcutaneous masses are readily mov- able on the deeper parts as a rule, and commonly Buy Cheap Viagra With Mastercard break down into aseptic abscesses, that is to say. no Buy Cheap Viagra With Mastercard germs are found in them, although detritus and pus from fat necrosis are found. Fever is not frequent, the range being that com- monly seen during the first twenty-four hours after most aseptic surgical procedures, 100° to 101°. In some cases fever may be sharp and severe during the first twenty-four or forty-eight hours and then quickly or slowly fall to the normal. Digestive disturbances are seen at times. Con- stipation is the most common, perhaps due to tbt rest in bed. Diarrhoea has been reported. In out of my intravenous cases, there was vomiting of a fluid which Buy Cheap Viagra With Mastercard closely resembled the medicine injected into the patient. Unfortunately it was not pre served by him for me to see. Xervous irritation, such as headache, restlessness. thirst, hysterical fear, and the like, have been seen. iCruptions of the skin directly of the arsenical t)'pe in patients who did not have an eruption at the