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J. Edward Tether, M.D.
JAMA. 1948;137(12):1078. doi:10.1001/jama.1948.02890460074020.
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To the Editor:—  In "Clinical Notes," page 362 of The Journal, May 22, 1948, an article entitled "Neostigmine Toxicity" by Dr. George G. Merrill reports the first fatality presumably due to neostigmine to be found in the literature. As author of an article entitled "Intravenous Neostigmine in Diagnosis of Myasthenia Gravis," accepted for publication in the Annals of Internal Medicine, I feel obligated to comment on this report.The standard test for myasthenia gravis proposed by Viets and Schwab, and referred to but not described by Dr. Merrill, consists of the intramuscular injection of 1.5 mg. of neostigmine methylsulfate in combination with 0.6 mg. (gr. Moo) of atropine in a single ampule. In spite of over twelve years of intensive experience with this test by these authors at Massachusetts General Hospital, as well as its use in other institutions throughout the country during this time, no fatalities or extremely severe


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