- Email: [email protected]
THE ADMINISTRATION OF EMETINE.
258 method is used by the same observer, and if the serum dilutions are not too widely separated (which applies to any method) a curve can be plotted out equally well in both cases. The important matter is to use the same technique and the same emulsion of known sensitiveness in each case. There is no difficulty about this if a good strain of organism is kept properly subcultured and a fresh batch of emulsion made about every two months, such fresh emulsion being tested at intervals against a known high-titre serum. I am, Sir, yours faithfully, ARTHUR H. PRIESTLEY, Aldershot, August 8th, 1917. Captain, R.A.M.C.
was
subsequently confirmed by Isle of Wight, ’’ 40 years
the late
Dr.
Wilks, of
For the years she has been under the care of my partner, Dr. W. H. Fawcett, who has observed the condition of the heart on many occasions, and who is thus able to confirm the diagnosis of aortic regurgitation, a condition which has led to only a very moderate degree of hypertrophy and dilatation of the left ventricle, and which has given rise to no symptoms other than occasional attacks of giddiness and faintness. I might add that the only other illness from which the patient has suffered was an attack of diphtheria at the age of 22, but, as Sir William Osler remarks, 11 Simple endocarditis in diphtheria is rare," whilst in rheumatic fever it is exceedingly common. She probably owes the immunity which she has enjoyed hitherto to the fact that she has remained single, and has never been obliged to undertake any hard physical exertion. Needless to say, I look upon this case as the exception which proves the rule, and the rule is too well known to need reiteration. i am, Sir, yours faithfully, J. STANLEY AVERY. Bournemouth, August 8th, 1917.
Ryde,
or
more
ago."
last 10
THE ADMINISTRATION OF EMETINE. To the Editor of THE LANCET.
SIR,-Emetine is being utilised
so largely in treatment that it may be worth while to draw attention to a better method of administering it than that generally employed at present. Since emetine was first advocated by Sir Leonard Rogers in the treatment of amoebic dysentery, it has always been given hypodermically. Dixon (’’A Manual of Pharmacology,’’ fourth edition) states :If ipacacuanha is injected subcutaneously, pain and inflammation, followed by suppuration and the formation of an abscess, are produced at the seat of inoculation....... The action of cephaeline and emetine is the same as that of ipecacuanha. In actual practice, the subcutaneous injection of emetine and its allied alkaloids does not produce abscesses at the sites of inoculation except in a small percentage of cases. There is always, however, great pain, with redness, swelling, and induration, which is often so deep-seated that muscular movement becomes an agony. Local tenderness is often very acute, and I have had several cases where the patient refused further emetine injections after the first one or two because of the pain, and I sympathised with them, It has also to be remembered that dysentery is sometimes followed by neurasthenia, and the patient is not disinclined in these cases to put the blame for his woes on the emetine. The method of administration that I have adopted and find most satisfactory is intra-muscular injection. The best sites are on the upper arm over the deltoid and in the gluteal region. A prolonged course of treatment can be given in this way without causing any inconvenience to the patient. There is no pain and sometimes only a little tenderness at the site of injection 24 hours afterwards. Injections can be given on alternate arms day by day. Summarised briefly, the advantages of the intra-muscular method are as follows : 1. Pain during inoculation is limited to theprick of the needle. 2. After-pain is generally absent, and when present disappears within 24 to 48 hours. 3. There is no tenderness, swelling, induration or discolouration of the skin, and scarring is minimal or absent. 4. The efficacy of the drug may be increased, as there is probably less precipitation through more rapid absorption. 5. The same site of inoculation may be used repeatedly at intervals of 48 hours. I am; Sir, yours faithfully, P. FIGDOR, M.B., Ch.B. Glasg., Temporary Captain, R.A.M.C.; Late Temporary Physician to Out-patients, City of London Hospital for Diseases of the Chest, and Assistant Medical Officer, North-Eastern Lucknow, India, July 24th. Hospital.
URBAN VITAL STATISTICS. (Week ended August 4th, 1917.) English and Welsh Towns.-In the 96 English and Welsh towns, with an aggregate civil population estimated at nearly 17,000,000 persons,
the annual rate of mortality was 10’3 per 1000, which is 0’9 per 1000 less than that recorded in the previous week. In London, with a population exceeding 4,000,000 persons, the death-rate was 10’3, or 0’1 per 1000 below that in the previous week ; among the remaining towns. the death-rates ranged from 3 9 in Ilford, 4’4 in Enfield and in Great Yarmouth, and 5’2 in Grimsby to 15’7 in Blackpool, 16’8 in Carlisle, 17’3 in Rotherham. and 17’5 in Southampton. The principal epidemic diseases caused 287 deaths, which corresponded to an annual rate of 0’9 per 1000, and included 107 from infantile diarrhoea, 95 from measles, 39 from diphtheria, 37 from whooping-cough, 4 from scarlet fever, and 5 from enteric fever. The deaths from diarrhoea were12 above the number in the previous week, and included 28 in London, 13 in Liverpool, 11 in Manchester, and 10 in Birmingham. Measles caused the highest death-rates of 2’4 in Northampton and 2-7 in York. The 625 cases of scarlet fever under treatment in the Metropolitan Asylums Hospitals and the London Fever Hospital were 2& fewer than the number in the previous week; the 1111 cases of diphtheria showed an increase of 30. Of the 3357 deaths from all causes in the 96 towns 133 resulted from violence. The causes of 29 deaths were uncertified, of which 7 were registered in Birmingham, 6 in Liverpool, and 2 each in Warrington, Barrow-in-Furness, and Gateshead. Scotch Towns.-In the 16 largest Scotch towns, with an aggregate population estimated at nearly 2,500,000 persons, the annual deathrate was 10’8. against 12’5 and 12’9 per 1000 in the two preceding weeks. The 240, deaths in Glasgow corresponded to an annual rate of 11’2 per 1000, and included 14 from whooping-cough, 8 from infantile diarrhoea, and 6 from measles. The 73 deaths in Edinburgh were equal to a rate of 11’5, and included 2 from measles and 1 each from whooping-cough, diphtheria, and infantile diarrhoea. Irish Towns.-The 113 deaths in Dublin corresponded to an annual rate of 14’8, or the same as the rate in the previous week, and included 14 from infantile diarrhoea, 2 from whooping-cough, and 1 from enteric fever. The 84 deaths in Belfast were equal to a rate of 11’1 per 1000, and included 2 from infantile diarrhoea, and 1 each measles and whooping-cough.
(Week ended August llth, 1917.) and Welsh Towns -In the 96 English and Welsh, towns, with an aggregate civil population estimated at nearly 17,000,000’ persons, the annual rate of mortality was 10-4 per 1000, and was 0’1 more than that in the previous week. In London, with a population exceeding 4,000,000 persons, the death-rate was 10’3, and coincided with that recorded in the previous week; among the remaining townsthe death-rates ranged from 4’1 in Walthamstow, 4’4 in Barrowto 161 in in-Furness, 4-9 in Willesden, and 6’5 in Dewsbury, 16’7 in Dudley, 17’6 in Oxford, and 17’7 in Hastings. The principal epidemic diseases caused 328 deaths, which corresponded to an annual rate of l0 per 1000, and included 180 from infantile diarrhoea, 78 from measles, 31 from whooping-cough, 29 from diphtheria, 6 from scarlet fever, and 4 from enteric fever. The deaths from diarrhoea were 221 in excess of the number in the previous week, and included 67 in London, 16 in Liverpool, 10 in Manchester, 9 in Birmingham, and 8 in West Ham. Measles caused the highest rates of 2-7 in Stockton-on-Tees and 3’6 in Northampton. The 633 cases of scarlet fever under treatment in the Metropolitan Asylums Hospitals and the London Fever Hospital were 8 above the number remaining at the end of the previous week ; the 1071 cases of diphtheria showed a decrease of 40. Of the 3394 deaths from all causes in the 96 towns 111 resulted from violence. The causes of 29 of the deaths were uncertified, of which 6 were registered in Birmingham. 4 in Liverpool, 3 in St. Helens, and 2 each in Leicester and Manchester. Scotch Towns.-In the 16 largest Scotch towns, with an aggregate population. estimated at nearly 2,500,000 persons, the annual rate was 11’2, against 129 and 10’8 per lOCO in the twopreceding weeks. The 242 deaths in Glasgow corresponded to an annual rate of 11’3 per 1000, and included 17 lrom infantile diarrhoea, 9 from whooping-cougb, and 7 from meaeles. The 71 deaths in Edinburgh were equal to a rate of 11’2 per lOCO, and included 1 each from whooping-cough and infantile
English
W.kefield,
THE EXPECTATION OF LIFE IN AORTIC
REGURGITATION.
To the Editor of THE LANCET. SIR,-In his letter to THE LANCET of August 4th Sir Clifford Allbutt, referring to a statement by Sir James Mackenzie that a man with aortic regurgitation may reach his " normal span," exhibits his scepticism of the accuracy of that statement by remarking that were Sir James Mackenzie a writer of less authority he would boldly answer "Never." It seems that the case of longest duration of life from the establishment of an aortic regurgitation which he (Sir Clifford Allbutt) has witnessed was 23 years, and that the patient died quite suddenly at the age of 55. It may therefore be of interest to your readers to know that I am now in attendance on a lady who is 72 years of age, and has in all probability had aortic regurgitation for the last 50 or 60 years. She had a mild attack of rheumatic fever at diarrhoea. the age of 14, and a second, which she describes as a bad Irish Towns.-The 115 deaths in Dublin corresponded to an annual per 1000, and included 18 from infantile diarrhcea, 2 from attack, at the age of 18. She was then under the care of the: rate of 15’0 and 1 each from measles and whooping cough. The 8& late Dr. Robinson, of Newbury, who informed her of the diphtheria, deaths in Belfast were equal to a rate of 11’7 per 1000, and included a weak heart," a statement, which 1 each from measles, whooping-cough, and infantile diarrhoea. fact that she had .
a
was
subsequently confirmed by Isle of Wight, ’’ 40 years
the late
Dr.
Wilks, of
For the years she has been under the care of my partner, Dr. W. H. Fawcett, who has observed the condition of the heart on many occasions, and who is thus able to confirm the diagnosis of aortic regurgitation, a condition which has led to only a very moderate degree of hypertrophy and dilatation of the left ventricle, and which has given rise to no symptoms other than occasional attacks of giddiness and faintness. I might add that the only other illness from which the patient has suffered was an attack of diphtheria at the age of 22, but, as Sir William Osler remarks, 11 Simple endocarditis in diphtheria is rare," whilst in rheumatic fever it is exceedingly common. She probably owes the immunity which she has enjoyed hitherto to the fact that she has remained single, and has never been obliged to undertake any hard physical exertion. Needless to say, I look upon this case as the exception which proves the rule, and the rule is too well known to need reiteration. i am, Sir, yours faithfully, J. STANLEY AVERY. Bournemouth, August 8th, 1917.
Ryde,
or
more
ago."
last 10
THE ADMINISTRATION OF EMETINE. To the Editor of THE LANCET.
SIR,-Emetine is being utilised
so largely in treatment that it may be worth while to draw attention to a better method of administering it than that generally employed at present. Since emetine was first advocated by Sir Leonard Rogers in the treatment of amoebic dysentery, it has always been given hypodermically. Dixon (’’A Manual of Pharmacology,’’ fourth edition) states :If ipacacuanha is injected subcutaneously, pain and inflammation, followed by suppuration and the formation of an abscess, are produced at the seat of inoculation....... The action of cephaeline and emetine is the same as that of ipecacuanha. In actual practice, the subcutaneous injection of emetine and its allied alkaloids does not produce abscesses at the sites of inoculation except in a small percentage of cases. There is always, however, great pain, with redness, swelling, and induration, which is often so deep-seated that muscular movement becomes an agony. Local tenderness is often very acute, and I have had several cases where the patient refused further emetine injections after the first one or two because of the pain, and I sympathised with them, It has also to be remembered that dysentery is sometimes followed by neurasthenia, and the patient is not disinclined in these cases to put the blame for his woes on the emetine. The method of administration that I have adopted and find most satisfactory is intra-muscular injection. The best sites are on the upper arm over the deltoid and in the gluteal region. A prolonged course of treatment can be given in this way without causing any inconvenience to the patient. There is no pain and sometimes only a little tenderness at the site of injection 24 hours afterwards. Injections can be given on alternate arms day by day. Summarised briefly, the advantages of the intra-muscular method are as follows : 1. Pain during inoculation is limited to theprick of the needle. 2. After-pain is generally absent, and when present disappears within 24 to 48 hours. 3. There is no tenderness, swelling, induration or discolouration of the skin, and scarring is minimal or absent. 4. The efficacy of the drug may be increased, as there is probably less precipitation through more rapid absorption. 5. The same site of inoculation may be used repeatedly at intervals of 48 hours. I am; Sir, yours faithfully, P. FIGDOR, M.B., Ch.B. Glasg., Temporary Captain, R.A.M.C.; Late Temporary Physician to Out-patients, City of London Hospital for Diseases of the Chest, and Assistant Medical Officer, North-Eastern Lucknow, India, July 24th. Hospital.
URBAN VITAL STATISTICS. (Week ended August 4th, 1917.) English and Welsh Towns.-In the 96 English and Welsh towns, with an aggregate civil population estimated at nearly 17,000,000 persons,
the annual rate of mortality was 10’3 per 1000, which is 0’9 per 1000 less than that recorded in the previous week. In London, with a population exceeding 4,000,000 persons, the death-rate was 10’3, or 0’1 per 1000 below that in the previous week ; among the remaining towns. the death-rates ranged from 3 9 in Ilford, 4’4 in Enfield and in Great Yarmouth, and 5’2 in Grimsby to 15’7 in Blackpool, 16’8 in Carlisle, 17’3 in Rotherham. and 17’5 in Southampton. The principal epidemic diseases caused 287 deaths, which corresponded to an annual rate of 0’9 per 1000, and included 107 from infantile diarrhoea, 95 from measles, 39 from diphtheria, 37 from whooping-cough, 4 from scarlet fever, and 5 from enteric fever. The deaths from diarrhoea were12 above the number in the previous week, and included 28 in London, 13 in Liverpool, 11 in Manchester, and 10 in Birmingham. Measles caused the highest death-rates of 2’4 in Northampton and 2-7 in York. The 625 cases of scarlet fever under treatment in the Metropolitan Asylums Hospitals and the London Fever Hospital were 2& fewer than the number in the previous week; the 1111 cases of diphtheria showed an increase of 30. Of the 3357 deaths from all causes in the 96 towns 133 resulted from violence. The causes of 29 deaths were uncertified, of which 7 were registered in Birmingham, 6 in Liverpool, and 2 each in Warrington, Barrow-in-Furness, and Gateshead. Scotch Towns.-In the 16 largest Scotch towns, with an aggregate population estimated at nearly 2,500,000 persons, the annual deathrate was 10’8. against 12’5 and 12’9 per 1000 in the two preceding weeks. The 240, deaths in Glasgow corresponded to an annual rate of 11’2 per 1000, and included 14 from whooping-cough, 8 from infantile diarrhoea, and 6 from measles. The 73 deaths in Edinburgh were equal to a rate of 11’5, and included 2 from measles and 1 each from whooping-cough, diphtheria, and infantile diarrhoea. Irish Towns.-The 113 deaths in Dublin corresponded to an annual rate of 14’8, or the same as the rate in the previous week, and included 14 from infantile diarrhoea, 2 from whooping-cough, and 1 from enteric fever. The 84 deaths in Belfast were equal to a rate of 11’1 per 1000, and included 2 from infantile diarrhoea, and 1 each measles and whooping-cough.
(Week ended August llth, 1917.) and Welsh Towns -In the 96 English and Welsh, towns, with an aggregate civil population estimated at nearly 17,000,000’ persons, the annual rate of mortality was 10-4 per 1000, and was 0’1 more than that in the previous week. In London, with a population exceeding 4,000,000 persons, the death-rate was 10’3, and coincided with that recorded in the previous week; among the remaining townsthe death-rates ranged from 4’1 in Walthamstow, 4’4 in Barrowto 161 in in-Furness, 4-9 in Willesden, and 6’5 in Dewsbury, 16’7 in Dudley, 17’6 in Oxford, and 17’7 in Hastings. The principal epidemic diseases caused 328 deaths, which corresponded to an annual rate of l0 per 1000, and included 180 from infantile diarrhoea, 78 from measles, 31 from whooping-cough, 29 from diphtheria, 6 from scarlet fever, and 4 from enteric fever. The deaths from diarrhoea were 221 in excess of the number in the previous week, and included 67 in London, 16 in Liverpool, 10 in Manchester, 9 in Birmingham, and 8 in West Ham. Measles caused the highest rates of 2-7 in Stockton-on-Tees and 3’6 in Northampton. The 633 cases of scarlet fever under treatment in the Metropolitan Asylums Hospitals and the London Fever Hospital were 8 above the number remaining at the end of the previous week ; the 1071 cases of diphtheria showed a decrease of 40. Of the 3394 deaths from all causes in the 96 towns 111 resulted from violence. The causes of 29 of the deaths were uncertified, of which 6 were registered in Birmingham. 4 in Liverpool, 3 in St. Helens, and 2 each in Leicester and Manchester. Scotch Towns.-In the 16 largest Scotch towns, with an aggregate population. estimated at nearly 2,500,000 persons, the annual rate was 11’2, against 129 and 10’8 per lOCO in the twopreceding weeks. The 242 deaths in Glasgow corresponded to an annual rate of 11’3 per 1000, and included 17 lrom infantile diarrhoea, 9 from whooping-cougb, and 7 from meaeles. The 71 deaths in Edinburgh were equal to a rate of 11’2 per lOCO, and included 1 each from whooping-cough and infantile
English
W.kefield,
THE EXPECTATION OF LIFE IN AORTIC
REGURGITATION.
To the Editor of THE LANCET. SIR,-In his letter to THE LANCET of August 4th Sir Clifford Allbutt, referring to a statement by Sir James Mackenzie that a man with aortic regurgitation may reach his " normal span," exhibits his scepticism of the accuracy of that statement by remarking that were Sir James Mackenzie a writer of less authority he would boldly answer "Never." It seems that the case of longest duration of life from the establishment of an aortic regurgitation which he (Sir Clifford Allbutt) has witnessed was 23 years, and that the patient died quite suddenly at the age of 55. It may therefore be of interest to your readers to know that I am now in attendance on a lady who is 72 years of age, and has in all probability had aortic regurgitation for the last 50 or 60 years. She had a mild attack of rheumatic fever at diarrhoea. the age of 14, and a second, which she describes as a bad Irish Towns.-The 115 deaths in Dublin corresponded to an annual per 1000, and included 18 from infantile diarrhcea, 2 from attack, at the age of 18. She was then under the care of the: rate of 15’0 and 1 each from measles and whooping cough. The 8& late Dr. Robinson, of Newbury, who informed her of the diphtheria, deaths in Belfast were equal to a rate of 11’7 per 1000, and included a weak heart," a statement, which 1 each from measles, whooping-cough, and infantile diarrhoea. fact that she had .
a