FATALITIES FOLLOWING THE INTRAVENOUS INJECTION OF SALVARSAN.

536

KING EDWARD’S HOSPITAL FUND FOR LONDON & EVELINA HOSPITAL.

i Newcastle-on-Tyne, where I was house surgeon, differs so the inspection and criticism, not only of the subscribers, but materially from those advocated that I have ventured to offer of anyone who may obtain a copy of the book. In managing the affairs of this institution, which is the a brief note as to the practice here. A paper on "The Diagnosis and Treatment of Abscess in only large hospital for children in the whole of South London, connexion with the Vermiform Appendix," by Professor my committee’s only desire is to do, with the means at their Rutherford Morison, published 11 years ago in THE LANCET disposal, the greatest amount of good for the sick poor, and (Feb. 23rd, 1901), has been overlooked by your contributors, by their straightforward policy hope to elicit the sympathy and as a large experience has confirmed the truth of the and support of the public. views he then expressed I should like to draw further attenSincerely thanking you for your kindness and courtesy in

tion to them. At the end of this paper he draws the following conclusions :— The diagnosis (of abscess) is based upon the history of an acute attack of appendicitis and the presence of a definite tender lump. The position of the appendix and the relations of the abscess may be foretold by a careful study of the tumour. (Every old house surgeon of Mr. Morison can fully bear this out, and the fact is insufficiently recognised, as it is most helpful in prognosis and treatment.) Early operation is the proper treatment, and with few exceptions the vermiform appendix should be removed at the same time as the abscess is drained (pelvic cases form the chief exceptions to this rule). A warning as to this is offered in the same paper in these words :-

publishing

my other letter, I am, Sir, yours faithfully, D MALCOLM

Feb. 17th, 1912.

SCOTT,

Chairman of the Committee of

Management.

THE BIRTHPLACE OF LORD LISTER.

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To the Editor of THE LANCET. SIR,—I writing in the room in which Lord Lister was born Upton on April 5th, 1827. The house is, as you state in your obituary notice, now the Vicarage, and the Church of St. Peter is built upon a portion of the garden in which the great surgeon played as a boy. To the completion of this church Lord Lister himself contributed a few years ago, and we who worship in it think that it is a fitting home for a memorial to him, and that the best form that the memorial could take-of one who did more than any other man has done to alleviate suffering and to save human life-would be a rood screen with the figure of the Saviour of the World, and. to this the character of the church is peculiarly adapted. We are all poor people here and cannot carry out our wish unaided. I therefore ask you of your courtesy to allow me to appeal through your columns for donations for this purpose -they could be given as a thankoffering in many cases for benefit received, as well as to perpetuate, on the scene of his birth, the memory of one who has placed the whole world an obligation. I am, Sir. yours faithfully, F. K. HODGKINSON, Vicar.

at

The operation should be done with the object of draining the abscess and removing the appendix, and, to do this safely, undoubtedly requires care and some practice. It also demands that the patient should not be too seriously ill to tolerate a fairly long operation ; that skilled assistance should be available ; and that the surroundings can be so adapted as to approach a hospital standard.

No detail of the operation then described has been altered, except that the catgut sutures are reinforced with silkwormgut and that the amount of gauze used for drainage purposes

has been diminished or altogether omitted. Later Mr. Morison1 reports that he had operated on 110 consecutive cases on these lines without a death, and I recently collected statistics for him,2 showing that 157 abscess cases had been operated upon in the Royal Victoria Infirmary without a death during the year 1910. I am, Sir, yours faithfully, CHARLES F. M. SAINT. .

under

KING EDWARD’S HOSPITAL FUND FOR LONDON AND THE EVELINA

To the Editor of THE LANCET.

SIR,—Some report having appeared in the press regarding the

prevalence of epidemic disease, I should be greatly obliged if you will give publicity to the fact that this island is, and has been, particularly free from infectious disease of any kind, the report being therefore quite without foundation. Visitors and invalids can enjoy the advantages of this delightful climate under as healthy conditions as exist anyI am, Sir, yours faithfully, where.

To the Editor

of THE LANCET. SIR,-In justice to my committee I trust you will find space for this reply to the letter from the honorary secretaries of King Edward’s Hospital Fund, which you have published in your issue of to-day. Their communication will, I fear, give the impression that my committee have deliberately departed from the uniform system of hospital accounts ; this is not the case. It must be remembered that the legacy in question was absolutely unconditional, and not specified as being for the general purposes of the hospital. committee, however,

as a

__.

PUBLIC HEALTH IN GRAND CANARY.

HOSPITAL.

My

am

W. M. M. JACKSON, M.D., D.P.H.

precaution sought legal advice,

and ascertained that it would be a perfectly legitimate transaction to allocate it to the Samaritan fund. This legacy was then dealt with in accordance with a regulation of the King’s Fund (No. 7 on p. 12 of their red book), which exactly applies to the case. This course has been approved by the hospital auditor who signed the accounts. Paragraph 3 of the honorary secretaries’ letter states that my committee have full power to apply the legacy to the general purposes of the hospital. Granted; but, having regard to the conditions just mentioned, they have also equal power to allocate it to any other object which is for the benefit of the hospital. If the committee of the King’s Fund would be just in dealing with this matter, they must admit that it is not merely a question of hospital accounts, but also the strict interpretation of the wording of a will. The letter from the honorary secretaries cannot fail to create the impression that my committee by their action wish to conceal the purposes for which the income of the Samaritan Fund is used. To this I must give a complete denial, and would point out that the authorities of the King’s Fund know full well that the accounts of all special funds are published in our annual report, and are therefore open to

FATALITIES FOLLOWING THE INTRAVENOUS INJECTION OF SALVARSAN. To the Editor of THE LANCET. SIR,-A correct appreciation of the value of salvarsan in syphilis, its efficacy in treatment, and the risks incurred, can

be attained by a careful consideration of all the aspects of the case. In THE LANCET of Jan. 20th (p. 152) you published an article by Mr. Willmott Evans in favour of salvarsan when employed with due care, and in your issue of Feb. 3rd (p. 283) you printed a valuable paper by Mr. Arthur Foerster, who has employed the drug widely, and who, with a recognition of its value, is also very certain that its use is by no means free from danger. In your issue of Jan. 20th (p. 153) Dr. J. H. Sequeira laid stress on the use of redistilled water in the preparation of the salvarsan for intravenous injection. It is certain that many precautions are needed to obtain the best results. You have referred1 to fatal cases in which epileptiform convulsions and death occurred in young and strong patients after the intravenous injection of an ordinary dose of salvarsan. In those in which a necropsy was made haemorrhagic encephalitis was found. At the Académie de M6decine of Paris Professor Gaucher, who has succeeded Fournier as the leader of the French 1 An address delivered at Halifax on Oct. 7th, 1903. See Northumber- school of syphilography, referred recently to two fatal cases at the Saint-Louis land and Durham Medical Journal for 1904, p. 263. Hospital. In one, a strong 2 Brit. Med. Jour., Oct. 28th, 1911 ; and THE LANCET, Dec, 16th, 1911, 1 THE LANCET, Dec. 23rd, 1911, p. 1785. p. 1683. .

only

537

THE MEDICAL PROFESSION AND THE NATIONAL INSURANCE ACT.

The stomach presented a were red and soft. month after going to Paris. A month later he came diffuse haemorrhage. It is now I think impossible to explain away all the under the care of M. de Beurmann with an indurated chancre and double inguinal adenopathy. Examination offatalities by attributing them to errors of technique or use of his organs revealed nothing abnormal and the urine did not this drug in unsuitable oases, as has been attempted by contain albumin. On Sept. 18th an intravenous injection Ehrlich and his followers. To me it seems that there is of 60 centigrammes of salvarsan was given with the usual incontrovertible evidence that the remedy is dangerous and aseptic precautions. There were no immediate symptoms, may prove fatal to young strong patients. It is too soon, I but after 15 minutes he was seized with vertigo and a feeling consider, to estimate the position which will finally be given of heat. During the day he vomited abundantly, and in the to salvarsan, but not too soon for emphasising its dangers, evening his temperature was 100.7°F. On the following especially as they may present themselves to the general I am, Sir, yours faithfully, day he was quite well. On the 21st the injection was practitioner. repeated under the same conditions as before. The same solution was used for the injection of another patient, who experienced no ill effects. At first the injection seemed to THE MEDICAL LIBRARY ASSOCIATION OF be well borne, but in the afternoon the patient was seized AMERICA. with vertigo, headache, and vomiting. The evening temperature was 101’ 50. During the night he vomited again To the -Editor of THE LANCET. and complained of pain in the epigastrium. On the 23rd, SIR,—I have just read with interest the annotation on the while asleep, he uttered a cry like the bark of a dog and Medical Library Association in THE LANCET of Jan. 13th. If was seized with epileptiform convulsions, first tonic, then clonic. He bit his tongue and foamed at the mouth. At you will permit me to correct an error, I believe conditions in 4 P.M. he was comatose and made incoordinate movements. this country are the same as in England-that is, we have In the some few large libraries and a number of small ones. The pupils were dilated and immobile, and the face libraries it "all and no take," as the smaller is large give pale and covered with sweat. The respiration was libraries have nothing, or next to nothing, to contribute, stertorous, the pulse 110, and the temperature 99.1°. while the libraries have hundreds of duplicates. larger AM. on the he At 4 24th died. At the necropsy We have been endeavouring to develop an altruistic spirit the heart, great vessels, and lungs were found normal. So were the abdominal organs, except the kidneys, which in the medical libraries in this country, and, judging from the work in our Exchange, I think we are succeeding. I want to were much enlarged, hard, congested, and of the colour of wine lees. The capsules were not adherent. Microscopic thank you for your kind words concerning our association I am, Sir, yours faithfully, examination showed acute nephritis with epithelial degenera- and the Bqtlletin. JOHN RUHRÄH, tion and destruction of the tubules. The brain and meninges Treasurer. Professor Gaucher concluded were normal to the naked eye. that the patient died from uraemia, the result of arsenical poisoning. He considered salvarsan a dangerous drug, which THE MEDICAL PROFESSION AND THE should be used with the greatest care and reserved for NATIONAL INSURANCE ACT. cases in which mercury is badly borne or is without effect. To the Editor ot THE LANCET. At a meeting of the Académie on Nov. 21st Professor the National Insurance Act, published by SIR,-In Gaucher reported two more cases in which salvarsan at p. 135, Fourth Schedule, Part II., Additional authority, In one, communicated to him by had proved fatal. 1 runs as follows :—"Medical treatment and Professor Oltramare, of Geneva, a robust man, aged Benefits, para. attendance for any persons dependent upon the labour of a 48 years, who had contracted syphilis 15 years before, member." This evidently includes wives and children who desired an injection of salvarsan, although he had no Does it apply only to relatives are not themselves workers. symptoms. A complete examination revealed no sign of members of approved societies ? And what is the scale of of cardiac, renal, or nervous disease. On August 17th remuneration for such medical treatment and attendance ? he was given an alkaline intravenous injection of 60 centiIs it left for the Insurance Commissioners to arrange ? Can When seen again on the 19th grammes of salvarsan. of your readers explain ? he declared that he bad well borne the injection and any I am. Sir. vours faithfnllv. was quite well. On the 20th he complained of slight headW. J LE GRAND, M.D. R.U.I. and the 21st was found the floor of his on he on ache, lying room. A medical man was summoned and found him unconscious, with convulsive movements, elevated temperature, and violaceous face. He remained in this state on To the Editor of THE LANCET. following day, and had several attacks of convulsions. He I be allowed to refer to a section of the National SIR.—May was covered with sweat and cyanosed. The pulse and Insurance Act to which nobody seems to have given much respiration were rapid, the pupils were first dilated, then attention, but which is of very great importance to all contracted, the temperature rose to 104 9°, and he died at medical men practising in seaport towns ? The section has, midnight. The necropsy showed lepto-meningitis, scars on I think, never been referred to in the correspondence in your the ascending aorta, fatty degeneration of the heart, chronic columns ; it does not seem to have been brought up before the bronchitis, and broncho-pneumonia of the lower lobes. Council of the British Medical Association, for it is nowhere In another case, communicated by Dr. Caraven, of the referred to in their recently issued 6Report" ; it has Medical School of Amiens, a strong man, aged 21 yeara, who the notice of the eminent counsel conapparently escaped had just passed for the military service, came to hospital with sulted the Prccotitioner; it is not noticed in the" Reform by a chancre. There were no signs of visceral disease and the Committee’s"" proposal for an amended Act," and in the urine did not contain albumin. On Oct. llth an intravenous " tabulated list of clausespublished by you in your number injection of 60 centigrammes of salvarsan was given and was of Feb. 10th the number of the section is divorced from its well borne. On the 18th the injectirn was repeated and was contents, yet it is the only section of the Act which gives a equally well borne. But on the 20th the patient complained direct negative to one of the six cardinal points." of headache, which was worse on tre 21st. On the 22nd The section referred to is Section 48, 11 special provisions there were symptoms of meningitis—delirium, carphology, for the mercantile marine," and the especially interesting rigidity of the neck and upper limbs, and Kernig’s sign. The subsections are :respiration was stertorous and the pulse was 112. The cause a society to be formed, t be (4) The Board of Trade shall pupils were slightly dilated, the eyes half open, and the con- called the Seamen’s National Insurance Society, of which any masters, junctivæ much congested. The face and nails were cyanosed seamen, and apprentices to the sea service and the sea fishing service Act shall be entitled and the patient was comatose. Lumbar puncture yielded who are employed within the meaning of this become members. cloudy, amber-coloured fluid. The urine contained 2 3 to (5) The affairs of the S.N.I.S. shall be managed by a committee grammes of albumin per litre. In the afternoon he sweated comprising representatives of the Board of Trade, of shipowners, and of of the society in equal proportions, and the society shall, notprofusely and there was Cheyne-Stokes respiration; the members Act, become an approved society. anything in this temperature rose to 104 - 20. In the evening he died. The withstanding (12) Members of the S.N.I S. shall be deemed to reside in England, and showed the brain and shall be administered by the intense of of such members the medical congestion lungs. benefit necropsy ’, kidneys country youth, in excellent health, contracted syphilisThe a

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