104
Tetanus Successfully Treated with Antitoxin.
These cases I have exhibited at the Surgical Section of the Royal Academy of Medicine in Ireland, both looking the picture of health. ART. V I I I . - - O n Two Case, of Tetanus Sucee,sfully T~'eated with Antitoxin." By ROBERT GLASGOW PATTES0N, M.B. Univ. Dubi. ; Fellow and E x a m i n e r in Surgery, Royal College of Surgeons in I r e l a n d ; Surgeon to the Month Hospital and C o u n t y Dublin Infirmary. I~ introducing to y o u w h a t amounts to a discussion on the subject of the t r e a t m e n t of tetanus, it is not my intention to trespass a t a n y length on y o u r patience. T h e t r e a t m e n t of acut~ infective processes by means of serum injections is still so far in its infancy t h a t but little is definitely known as to the ultimate results obtainable, and therefore every contribution to the subject ha~ its merits enhanced b y the uncertainty t h a t surrounds the issue. T h e theory on which the t r e a t m e n t is based is familiar to y o u all; and as m y object in bringing these cases before y o u is to 'elicit information from the experience of others, and not tu ventilate a n y crude opinions of m y own, I shall deal with them as briefly as possible. CAs~.I . E N . C., aged fourteen, was admitted to the Meath Hospital on 13th August, 1896, having been sent i n b y Dr. Davy as a case of incipient tetanus. The following history was elicited ---About twelve days prevlousIy he had trodden on a thorn, which entered the web between the first and second toes of his right foot. The thorn was removed, and no pain or trouble was experienced until ~fter the expiration of a week~ when a small sinus opened between the two toes on the inner aspect of the second, and commenced to discharge a ~hin serous fluid. This spot was slightly tender. Four days later~that is, eleven days after the receipt of the injurymhe noticed his jaws beginning to stiffen~ and complained of vague pains in his back. On admission trismus was well markedmthe power of separating the teeth being limited to half an inch ; he could not eat~ but could take large quantities of liquid nourishment. The abdomen was hard, the neck muscles stiff~ so that he carried 9 Read before the Surgical Section of the Royal Academy of Medicine in Ireland on Fridsy, December 10, 1897. [For discussion on this paper, see page 155.]
By MR.
R. C~. PATTESON.
105
his head ~twkwardly. Temperature 98"8o; pulse normal. ,~o spasms had hitherto occurred. He was placed in a ward by himself, and a special nurse appointed~ He slept fairly well during the early part of the night, but at 6 a.m. the following morning a severe clonic spasm with intense pain developed. When I saw him later on the rigidity was well marked, the head retracted, the back arched, the abdomen tense as a board, while the recti stood out on either side like the muscles of a gladiator. Risus sardonicus was typically t~resent. Any et~ort to speak, caused spasm of the facial m~Sclesb and barely the tip of the tongue could be protruded between the teeth. Fifteen grains of dried serummthe only kind immediately available--were injected into the muscles of the back, but owing to its insolubility a large proportion of tlris failed to, pass through the syringe. A well-marked spasm occurred at the time, and the boy was evidently in great pain. Subsequently a supply of the liquid serum, prepared at the Pasteur Institute, was obtained through Messrs, Fannirb and this ~orm alone was afterwards employed ,i~ both cases. The serum is put up in flasks, each coutaiuing 10.c.cm., which is the dose for a single injection. The wound in the foot was carefully examined. Some of the serum was dried on cover-fflasses and stained for bacilli, but with negative results. After car~t~l and thorougl~ disinfection the wound healed slowly and without incident. Two further injections were given--one at 4 p.m., and one at 8 ~l~m. The evening temperature was normal. ]n addltio~ to the antitoxin, a drachm of ohloral anel a. drachm of potassium bromide, divided i~to four doses, were given during the night. ThiPteen spasms, varying in severity, occhrred during the same period~ the greater number between 11 p.m. and 2 a.m. I-Ie slept well in the intervals and perspired profusely. The next day, and indeed throughout the remainder of his illness, the pulse and temperature remained normal, nor was there much dyspnea duzing the spasms. Three injections of senu~ (30 c.cm. in all) were given during the day, and three doses of the bremide and chloral during the night. He had eight spasms, none of marked severity, and passed, on the, whole, a good night. The following day~ Sunday, 1 (ith~ three injections were also given and the bromide and chloral discontinued. He had six spasms before 2 a.m., the last of marked severity, the end of the tongue being almost bitten through. After 3 a.m. he stept well. Briefly summarised, the rest of the h~story is as follows : - 17th.--Threc injections as before ; fourteen spasms at intervals during the night.
106
Tetanus Suocesafully Treated with Antitoxin,
18th.--Two in~eetions duvlng the day; some slight spasms ;: twelve spasms during the nig~.t. 19th,~Two in~cotions; trismus less pronotmeed ; can protrude the tongue a little ; three spasms during the day and nine during the night. ~0th,--Two injections given, W a s able t o d a y to eat a little bread and butter. Three slight spasms during the day, and one severe spasm during the night ; slept well. 21st.--Two injections. All the symptoms show improCement; the rigidity is much less, and the spasms less frequent aud less severe--only throe during the twenty-fottr hours, 22nd.~TWo injections ;. had a good~ day~ but had nine slight spasms during the night. 23rd.~No injection gLveu; six sligh~ spasms dating the night. 2~th.--Throe injections given, as the spasms had been increasing in frequency ; one very slight spasm during the night. After this date no more injections of serum wer~ given. In all twenty-three had been administered. The following night he had two very slight spasms. On the night os ~he 26th---the second night after stopping the inactions--the spasms recurrod~ seven in number~ and potassium bromide was again resorted to. Two nights later one very slight spasm occurred, but after that convalescence was uninterrupted and rapid. He was allowed up on the 30th of August, seventeen days after admission. For a couple of days afterwards any sudden shock or noise would bring on a slight spasm, lasting only a few seconds. A few days later he was sent home perfectly well. CASE II.---J. K., aged nineteen, a gardener, was admitted to the Meath Hospital on the 11th of August, 1897. He gave the following history :--About a fortnight previously he got a fall off a cart, injuring his right ,knee. ~he skin was br and it did not heal up, although he was not prevented from following his usual occup/ttion. A few days ago he noticed the muscles of his neck becoming stiffi and found that he could not masticate freely, and as these symptoms were gradually increasing he sought relief at the hospital. On admission he presented well-marked rigidity of the spinal muscles, cervical and dorsal The back was arched, the head thrown back, the abdominal muscles rigid and prominent, the risns sardonicus was pronounced, and only the tip of the tongue could be protruded between the teeth. His temperature was 101"8 ~ ; pulse 80. Spasms were tolerably frequent bat not severe. The patient
By MR. R. G. PAT'r~OS.
107
was isolated, and an in~ection of 10 c.em. of ~erum wM given at noon, and again at 5 p.m. He was able to take fair quantities of beef-tea and milk, and slept well during the night. The s morning the temperature had f d e n to 99 ~ the pulse was~tuieterm 64rebut the spasms had been frequent and trismus was more marked. Three injections were given during the day. The arching of the back and the abdominal rigidity were more marked. The evening temperature was 100"6 ~ ; pulse 64. The spasms were less marked in intensity during the night, and ~e slept at intervals. In the morning the temperature was normal. The wound on ~he knee, which had ~previously been carefully cleansed, wa~ now thoroughly cauterised with puwe carbolic acid, the eeehar involving a considerable area of the healthy tissues around. There was no discharge from the wound. On the l ~ t h ~ t h e third day after admission--only two injections were given, as the supply had run out. He continued to t ~ e large quantities of nourishment, as, although the teeth were tightly clenched, he was able to swallow fluids freely througlt some existing g,ps. During the twenty-four hours he took 2~ pints of milk, 2 pints of beef-tea, and an egg beaten up. On the following d a y - the 14th--three injections were given, and his condition in every way showed signs of improvement. The tl,ismus was less marked, the spasms were diminishing in s and in intenaity, and he was altogether brighter and more cheerful. On the 15th only one injection was given. On the 16th--the sixth day after admission~his temperature rose to 101"6 ~. Serum was administered, and the whole surface of the body was sponged. The temperature rapidly fell to 100 ~ A. second injection was given in the afternoon, and another in the evening~11 30 p . m . u a t which hour his temperature was normal. He passed a good night, and ,the following morning showed signs of decided improvement: the rigidity was much less, the s@asms slighter~ and occurring only at rare intervMs, and the tongue could be protruded for about half an inch between the teeth. From Zhls date his condition ~laity improved, and no further injections were given. He had gee in all thirteen injections~ which, as in the previous case, were administered deeply into the muscles of the back and the gluteal: region, and in no instance gave rise Zo any local or constitutional reaeti~n. On the 23rdutwelve days after admission--he was sent to the Convalescent Home, and ahcr a fortnight spent there was able to resume his employment in perfect health,
108
A Case'of Syphilitic EncephaloTathy.
Such, in' brief outline, is the essential history of these two cases. I am quite aware that they are open to the obvious criticism that they belong to the type of tetanus which would recover if Ieft to the vls me,cat,ix IVatura~ ~lone. I can only auswer---I ]nave seen cases o f tetanus with no more pronounced symptoms rapidly run t o n fatal t'erminat~0n; and one is not justified in~ standing/idly b y while a remedy full of promise lies ready at hand. W?nether the future will justify our hopes can, only be estimated b y the conscientious record of every case, and it is in the desire to help this end that I lay these before you. At any rate, in this direction of serum therapeutics lies at present all our hope of combating some of the most terrible infeoti,ve ills that humanity c a r ever suffer from,
ART. I X . - - A Case of Syp~ititlc ]ffncephalopathy.w B'y W. R. DAWSO1%M.s Assistant Medical Superintendent, Farnham House Private Asylum, &c. THE delimitation of the area occupied b y the disease or group of diseases commonly designated General Paralysis of the Insane is a problem which is receiving an increasing amount of attentiom b Its difficulty lies in the fac~ that neither clinically nor anatomically is the boundary line between this and ~ ~umber of ~)ther diseases i~ a n y w a y distinct. Especially is this true of the clinical aspect, for, however characteristic a typiual case may appear, there can be no question that the percentage of such cases is now relative']y small, at least as regards the earlier stages of the disease,, and that in the majority of instances t h e d~agnosis presents varying degrees of difficulty in consequence of the more or less atypical nature o f the symptoms. O a t h e other hand, there i s a well-reeognised class o f cases, mostly of a toxic character, which may exhibit a group of symptoms almost, i f not %uite, indistinsuishable from those of the graver malady, from which they c a n 9 Read before the Medical Section of bhe Royal Aca~lemy of Medicine in Ireland, December 1,7, 1897. Cf. Discussion opened by Binswanger at the Twelfth International Congress, Moscow.
