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

Newcastle-on-Tyne, where I was house surgeon, differs so i

materially from those advocated that I have ventured to offera brief note as to the practice here.A paper on "The Diagnosis and Treatment of Abscess in

connexion with the Vermiform Appendix," by ProfessorRutherford Morison, published 11 years ago in THE LANCET(Feb. 23rd, 1901), has been overlooked by your contributors,and as a large experience has confirmed the truth of theviews he then expressed I should like to draw further atten-tion to them. At the end of this paper he draws thefollowing conclusions :—

The diagnosis (of abscess) is based upon the history of an acute attackof appendicitis and the presence of a definite tender lump. The positionof the appendix and the relations of the abscess may be foretold by acareful study of the tumour. (Every old house surgeon of Mr. Morisoncan fully bear this out, and the fact is insufficiently recognised, as it ismost helpful in prognosis and treatment.) ...... Early operation is theproper treatment, and with few exceptions the vermiform appendixshould be removed at the same time as the abscess is drained (pelviccases form the chief exceptions to this rule).

A warning as to this is offered in the same paper in thesewords :-

The operation should be done with the object of draining the abscessand removing the appendix, and, to do this safely, undoubtedlyrequires care and some practice. It also demands that the patientshould not be too seriously ill to tolerate a fairly long operation ; thatskilled assistance should be available ; and that the surroundings can beso 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 silkworm-gut and that the amount of gauze used for drainage purposeshas been diminished or altogether omitted. Later Mr.Morison 1 reports that he had operated on 110 consecutivecases on these lines without a death, and I recently collectedstatistics for him,2 showing that 157 abscess cases had beenoperated upon in the Royal Victoria Infirmary without adeath during the year 1910.

I am, Sir, yours faithfully,CHARLES F. M. SAINT.

KING EDWARD’S HOSPITAL FUND FORLONDON AND THE EVELINA

HOSPITAL.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 secre-taries of King Edward’s Hospital Fund, which you havepublished in your issue of to-day. Their communicationwill, I fear, give the impression that my committee havedeliberately departed from the uniform system of hospitalaccounts ; this is not the case. It must be remembered thatthe legacy in question was absolutely unconditional, and notspecified as being for the general purposes of the hospital.My committee, however, as a precaution sought legal advice,and ascertained that it would be a perfectly legitimate trans-action to allocate it to the Samaritan fund. This legacy wasthen dealt with in accordance with a regulation of the King’sFund (No. 7 on p. 12 of their red book), which exactlyapplies to the case. This course has been approved by thehospital auditor who signed the accounts.Paragraph 3 of the honorary secretaries’ letter states that

my committee have full power to apply the legacy to thegeneral purposes of the hospital. Granted; but, havingregard to the conditions just mentioned, they have also

equal power to allocate it to any other object which isfor the benefit of the hospital. If the committee of the

King’s Fund would be just in dealing with this matter, theymust admit that it is not merely a question of hospitalaccounts, but also the strict interpretation of the wording ofa will.The letter from the honorary secretaries cannot fail to

create the impression that my committee by their actionwish to conceal the purposes for which the income of theSamaritan Fund is used. To this I must give a completedenial, and would point out that the authorities of the King’sFund know full well that the accounts of all special fundsare published in our annual report, and are therefore open to

1 An address delivered at Halifax on Oct. 7th, 1903. See Northumber-land and Durham Medical Journal for 1904, p. 263.

2 Brit. Med. Jour., Oct. 28th, 1911 ; and THE LANCET, Dec, 16th, 1911,p. 1683.

the inspection and criticism, not only of the subscribers, butof anyone who may obtain a copy of the book.

In managing the affairs of this institution, which is the

only large hospital for children in the whole of South London,my committee’s only desire is to do, with the means at theirdisposal, the greatest amount of good for the sick poor, andby their straightforward policy hope to elicit the sympathyand support of the public.

Sincerely thanking you for your kindness and courtesy in

publishing my other letter,I am, Sir, yours faithfully,

Feb. 17th, 1912.D MALCOLM SCOTT,

Chairman of the Committee of Management.

THE BIRTHPLACE OF LORD LISTER.To the Editor of THE LANCET.

SIR,—I am writing in the room in which Lord Lister wasborn at Upton on April 5th, 1827. The house is, as you statein your obituary notice, now the Vicarage, and the Church ofSt. Peter is built upon a portion of the garden in which thegreat surgeon played as a boy. To the completion of thischurch Lord Lister himself contributed a few years ago, andwe who worship in it think that it is a fitting home for amemorial to him, and that the best form that the memorialcould take-of one who did more than any other man hasdone to alleviate suffering and to save human life-would bea 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 wishunaided. I therefore ask you of your courtesy to allow meto 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 hisbirth, the memory of one who has placed the whole worldunder an obligation. I am, Sir. yours faithfully,

__.

F. K. HODGKINSON, Vicar.

PUBLIC HEALTH IN GRAND CANARY.To the Editor of THE LANCET.

SIR,—Some report having appeared in the press regardingthe prevalence of epidemic disease, I should be greatlyobliged if you will give publicity to the fact that this islandis, and has been, particularly free from infectious disease ofany kind, the report being therefore quite without founda-tion. Visitors and invalids can enjoy the advantages of thisdelightful climate under as healthy conditions as exist any-where. I am, Sir, yours faithfully,

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

FATALITIES FOLLOWING THE INTRA-VENOUS INJECTION OF SALVARSAN.

To the Editor of THE LANCET.

SIR,-A correct appreciation of the value of salvarsan insyphilis, its efficacy in treatment, and the risks incurred, canonly be attained by a careful consideration of all the aspectsof the case. In THE LANCET of Jan. 20th (p. 152) youpublished an article by Mr. Willmott Evans in favour ofsalvarsan when employed with due care, and in your issue ofFeb. 3rd (p. 283) you printed a valuable paper by Mr. ArthurFoerster, who has employed the drug widely, and who, witha recognition of its value, is also very certain that its use isby no means free from danger. In your issue of Jan. 20th(p. 153) Dr. J. H. Sequeira laid stress on the use of redistilledwater in the preparation of the salvarsan for intravenousinjection. It is certain that many precautions are needed toobtain the best results. You have referred 1 to fatal cases inwhich epileptiform convulsions and death occurred in youngand strong patients after the intravenous injection of an

ordinary dose of salvarsan. In those in which a necropsywas made haemorrhagic encephalitis was found.At the Académie de M6decine of Paris Professor Gaucher,

who has succeeded Fournier as the leader of the French.

school of syphilography, referred recently to two fatalcases at the Saint-Louis Hospital. In one, a strong

1 THE LANCET, Dec. 23rd, 1911, p. 1785.

537THE MEDICAL PROFESSION AND THE NATIONAL INSURANCE ACT.

country youth, in excellent health, contracted syphilis ’,a month after going to Paris. A month later he came under the care of M. de Beurmann with an induratedchancre and double inguinal adenopathy. Examination ofhis organs revealed nothing abnormal and the urine did notcontain albumin. On Sept. 18th an intravenous injectionof 60 centigrammes of salvarsan was given with the usualaseptic precautions. There were no immediate symptoms,but after 15 minutes he was seized with vertigo and a feelingof heat. During the day he vomited abundantly, and in theevening his temperature was 100.7° F. On the followingday he was quite well. On the 21st the injection wasrepeated under the same conditions as before. The samesolution was used for the injection of another patient, whoexperienced no ill effects. At first the injection seemed tobe well borne, but in the afternoon the patient was seizedwith vertigo, headache, and vomiting. The evening tem-perature was 101’ 50. During the night he vomited againand complained of pain in the epigastrium. On the 23rd,while asleep, he uttered a cry like the bark of a dog andwas seized with epileptiform convulsions, first tonic, thenclonic. He bit his tongue and foamed at the mouth. At4 P.M. he was comatose and made incoordinate movements.

BThe pupils were dilated and immobile, and the face waspale and covered with sweat. The respiration was

stertorous, the pulse 110, and the temperature 99.1°.At 4 AM. on the 24th he died. At the necropsythe heart, great vessels, and lungs were found normal.So were the abdominal organs, except the kidneys, whichwere much enlarged, hard, congested, and of the colour ofwine lees. The capsules were not adherent. Microscopicexamination showed acute nephritis with epithelial degenera-tion and destruction of the tubules. The brain and meningeswere normal to the naked eye. Professor Gaucher concludedthat the patient died from uraemia, the result of arsenicalpoisoning. He considered salvarsan a dangerous drug, whichshould be used with the greatest care and reserved forcases in which mercury is badly borne or is withouteffect.At a meeting of the Académie on Nov. 21st Professor

Gaucher reported two more cases in which salvarsanhad proved fatal. In one, communicated to him byProfessor Oltramare, of Geneva, a robust man, aged48 years, who had contracted syphilis 15 years before,desired an injection of salvarsan, although he had no

symptoms. A complete examination revealed no signof cardiac, renal, or nervous disease. On August 17thhe was given an alkaline intravenous injection of 60 centi-grammes of salvarsan. When seen again on the 19thhe declared that he bad well borne the injection andwas quite well. On the 20th he complained of slight head-ache, and on the 21st he was found lying on the floor of hisroom. A medical man was summoned and found him un-conscious, with convulsive movements, elevated temperature,and violaceous face. He remained in this state on thefollowing day, and had several attacks of convulsions. Hewas covered with sweat and cyanosed. The pulse andrespiration were rapid, the pupils were first dilated, thencontracted, the temperature rose to 104 9°, and he died atmidnight. The necropsy showed lepto-meningitis, scars onthe ascending aorta, fatty degeneration of the heart, chronicbronchitis, and broncho-pneumonia of the lower lobes.

In another case, communicated by Dr. Caraven, of theMedical School of Amiens, a strong man, aged 21 yeara, whohad just passed for the military service, came to hospital witha chancre. There were no signs of visceral disease and theurine did not contain albumin. On Oct. llth an intravenous

injection of 60 centigrammes of salvarsan was given and waswell borne. On the 18th the injectirn was repeated and wasequally well borne. But on the 20th the patient complainedof headache, which was worse on tre 21st. On the 22ndthere were symptoms of meningitis—delirium, carphology,rigidity of the neck and upper limbs, and Kernig’s sign. Therespiration was stertorous and the pulse was 112. The

pupils were slightly dilated, the eyes half open, and the con-junctivæ much congested. The face and nails were cyanosedand the patient was comatose. Lumbar puncture yieldedcloudy, amber-coloured fluid. The urine contained 2 3grammes of albumin per litre. In the afternoon he sweated

profusely and there was Cheyne-Stokes respiration; the

temperature rose to 104 - 20. In the evening he died. The

necropsy showed intense congestion of the brain and lungs.

The kidneys were red and soft. The stomach presented adiffuse haemorrhage.

It is now I think impossible to explain away all thefatalities by attributing them to errors of technique or use ofthis drug in unsuitable oases, as has been attempted byEhrlich and his followers. To me it seems that there isincontrovertible evidence that the remedy is dangerous andmay prove fatal to young strong patients. It is too soon, Iconsider, to estimate the position which will finally be givento salvarsan, but not too soon for emphasising its dangers,especially as they may present themselves to the generalpractitioner. I am, Sir, yours faithfully,

THE MEDICAL LIBRARY ASSOCIATION OFAMERICA.

To the -Editor of THE LANCET.

SIR,—I have just read with interest the annotation on theMedical Library Association in THE LANCET of Jan. 13th. Ifyou will permit me to correct an error, I believe conditions inthis country are the same as in England-that is, we havesome few large libraries and a number of small ones. In thelarge libraries it is "all give and no take," as the smallerlibraries have nothing, or next to nothing, to contribute,while the larger libraries have hundreds of duplicates.We have been endeavouring to develop an altruistic spirit

in the medical libraries in this country, and, judging from thework in our Exchange, I think we are succeeding. I want tothank you for your kind words concerning our associationand the Bqtlletin. I am, Sir, yours faithfully,

JOHN RUHRÄH,Treasurer.

THE MEDICAL PROFESSION AND THENATIONAL INSURANCE ACT.

To the Editor ot THE LANCET.

SIR,-In the National Insurance Act, published byauthority, at p. 135, Fourth Schedule, Part II., AdditionalBenefits, para. 1 runs as follows :—"Medical treatment andattendance for any persons dependent upon the labour of amember." This evidently includes wives and children whoare not themselves workers. Does it apply only to relativesof members of approved societies ? And what is the scale ofremuneration for such medical treatment and attendance ? Is it left for the Insurance Commissioners to arrange ? Canany of your readers explain ?

I am. Sir. vours faithfnllv.W. J LE GRAND, M.D. R.U.I.

To the Editor of THE LANCET.

SIR.—May I be allowed to refer to a section of the NationalInsurance Act to which nobody seems to have given muchattention, but which is of very great importance to allmedical men practising in seaport towns ? The section has,I think, never been referred to in the correspondence in yourcolumns ; it does not seem to have been brought up before theCouncil of the British Medical Association, for it is nowherereferred to in their recently issued 6 Report" ; it has

apparently escaped the notice of the eminent counsel con-

sulted by the Prccotitioner; it is not noticed in the" ReformCommittee’s" " proposal for an amended Act," and in the" tabulated list of clauses published by you in your numberof Feb. 10th the number of the section is divorced from itscontents, yet it is the only section of the Act which gives adirect negative to one of the " six cardinal points."The section referred to is Section 48, 11 special provisions

for the mercantile marine," and the especially interestingsubsections are :-

(4) The Board of Trade shall ...... cause a society to be formed, t becalled the Seamen’s National Insurance Society, of which any masters,seamen, and apprentices to the sea service and the sea fishing servicewho are employed within the meaning of this ...... Act shall be entitledto become members.

(5) The affairs of the S.N.I.S. shall be managed by a committee ......comprising representatives of the Board of Trade, of shipowners, and ofmembers of the society in equal proportions, and the society shall, not-withstanding anything in this ...... Act, become an approved society.

(12) Members of the S.N.I S. shall be deemed to reside in England, andthe medical benefit of such members shall be administered by the