MARCH FRACTURE-PIED FORCE Developed Reactions to These Test Products and to Witte Peptone at Least As Severe As Those Shown by Our by Anaphylactic Case
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FEB. 24, 1940 ANAPHYLAXIS AFTER TETANUS TOXOID MERCALTSORHL 95 erythema than similar dilutions of the extracts, and that within a few minutes of injection many persons MARCH FRACTURE-PIED FORCE developed reactions to these test products and to Witte peptone at least as severe as those shown by our BY anaphylactic case. Further investigations are in progress which it is hoped will be the subject of another paper. F. A. R. STAMMERS, Ch.M., F.R.C.S. Our observations throw considerable doubt on the value Major R.A.M.C., Surgical Specialist of scratch and intradermal tests as usually interpreted on the basis of early readings. Nevertheless, our patient Army medical officers everywhere have been asked to see was the only subject who developed mild anaphylactic all sorts of foot troubles precipitated by military training. symptoms-itching of the nose and tongue, slight swelling More often than not these are due to pre-existing con- of the lower lip, smarting of the eyes, and flushing of the ditions such as hallux rigidus, hallux valgus, hammer-toe, face-soon after 1 in 1,000 dilutions of Witte peptone and or pes planus, which, though formerly symptomless, break two other beef fibrin digests had been injected intra- down under the strain of route-marching, physical train- dermally; and she alone showed areas of redness, 50 to ing, and the general extra footwork the soldier- is called 60 mm. in diameter, swelling, and induration (" like upon to do in heavy army boots. Even a seemingly those occurring after staphylococcus toxoid ") about two normal foot may develop trouble under such circum- hours later at the sites of injection of these products. stances, and none is more dramatic in onset or crippling in These " late " reactions were at their maximum about effect than the so-called march fracture. This short paper this time and faded completely during the next three records three cases admitted within the first two months hours. of the war to what was probably the first Territorial general hospital to function. So little is said of the con- We feel, therefore, that Witte peptone may be the dition in the textbooks, and so puzzling may it prove at substance in tetanus toxoid to which the patient had the beginning, that no apology is necessary for reporting become sensitive. Some degree of sensitivity to Witte these cases. peptone may be more common than is generally sup- posed: Parish (1936) and Bousfield (1936) reported cases Case I in this country and referred to others in America in which allergic reactions had followed the use of Schick A medical officer, aged 41, while walking along a corridor test fluids, which at that time were stabilized by Witte at about 10 a.m. one day, felt discomfort in the outer part of the forefoot. Within half an hour this amounted to frank peptone. pain, and by lunch time he was forced to walk with a The patient in the present inquiry had received two marked limp; yet he is satisfied that there was no trauma, courses of staphylococcus toxoid-in May, 1937, and sudden strain, or unaccustomed activity, at any rate within January, 1938. In view of the high content of Witte several hours previously. On examination there was tender- peptone in the medium in which the staphylococcus toxin ness on deep pressure on the dorsum of the fourth inter- was prepared it was thought that sensitization to the osseous space just behind the heads of the metatarsal bones, been and weight-bearing, especially on the outer border of the peptone might have acquired by the repeated foot, was very painful, though all discomfort ceased with injections of staphylococcus toxoid. The patient, how- rest. Next day the situation was much the same, but a slight ever, had tolerated the first injection of tetanus toxoid puffiness appeared in the fourth interosseous space at the site in July, 1939, which led to the suggestion that it was this of the tender point, and the enforced gait of walking on the injection that had caused the sensitization. We have inner border of the externally rotated foot produced the heard of other allergic reactions after second injections added discomfort of peroneal strain. By the third day of tetanus toxoid. These manifestations appear to be oedema of the dorsum was sufficient to hide the extensor rare and readily controlled by the injection of adrena- tendons of the toes, and weight-bearing was so painful that line. It would seem advisable to keep all persons injected had he not been able to do his work at his own pace he under observation would have been forced to "go sick." The diagnosis of with tetanus toxoid for at least half march-foot was considered, even though there had been an hour. no question of long marching and in spite of the fact that the Summary only sign mentioned by textbooks as characteristic--namely, pain on pulling on the toe of the affected metatarsal-was A case of anaphylaxis after the injection of tetanus toxoid absent; moreover, an x-ray picture failed to reveal any bony is described. abnormality. Two other signs, however, developed-pain on Allergic phenomena, though alarming, appear to be rare, and pushing the third toe axially backwards on to the metatarsus, are due to some constituent of the medium in which tetanus and tenderness on pressing the plantar surface of the head of toxoid is the Witte peptone. the third metatarsal; the dorsal tenderness in the fourth prepared, possibly interosseous space was still present. The condition remained Adrenaline I in 1,000 should always be readily available as much the same until a fortnight after the onset, and then a precautionary measure when tetanus toxoid is injected. walking became less painful provided it did not exceed fifty yards. By the end of a month about a mile could be REFERFNCES covered without pain, after which severe aching in the fourth Bousfield, G. (1936). Med. 0#., 56, 193. interosseous space ensued and an occasional click was sensed Parish. H. J. (1936). Lancet, 2, 310. in this region. A second x-ray picture, taken at this stage, showed callus round a transverse crack in the neck of the third metatarsal bone. About a week later the oedema in the dorsum began to subside, and a more localized swelling, Male Vagrants in Sweden.-An examination of eighty-one corresponding to the callus, remained. It was seven weeks tramps showed that over half were to some degree mentally before full activity was completely painless, and ten before defective, one-fifth certifiably so. One-tenth suffered from the extensor tendons were unmasked by residual thickening schizophrenia, two-thirds showed constitutional psychological of the soft tissues. abnormalities. The incidence of insanity in their near relatives was also very high.-Psychiatric Examinations of Certain Male The second and third cases were admitted on the same Vagrants and Alcoholists in Sweden in the Year 1938 (Eng.). day, about a month after the first, and each had developed G. Adell.-Acta psychiat. Kb/i., 1938, 1J3, Fasc. 4, 447. symptoms a few days bgefore admission. 296 FEB. 24, 1940 MARCH FRACTURE MEDICALJOURNB L Case II Conclusion A healthy Class A infantryman, 22 years old, stated that The case showing an oblique fracture at the first x-ray a week previously he had developed discomfort in the outer examination offers no problem. Where the history is that part of the front of his left foot, and that within two hours of spontaneous discomfort in the forepart of the the pain caused by walking was so great that he had to report foot, sick. Though his training included route-marching he had developing within an hour or so into frank pain with any done none, nor any other violent exercise, within thirty-six attempt at weight-bearing; local tenderness in the inter- hours of the onset of the trouble. There was nothing to see osseous space, followed within a day or so by puffiness of at the time, but the medical officer discovered a tender point the space which spreads to involve the whole dorsum, so in the dorsal part of the fourth interosseous space and burying the extensor tendons; and complete freedom from ordered him to rest. In spite of this the pain continued on pain on resting the foot-these signs and symptoms, even any attempt at walking, and he was therefore sent to this in the absence of immediate x-ray evidence, should make hospital. On examination tenderness was found on deep one very suspicious of a subperiosteal crack of one of the pressure on the dorsal aspect of the fourth interosseous space, metatarsal bones, and the radiograph should be repeated tenderness on the plantar aspect of the third metatarsal bone, pain on pushing the third toe backwards on to the tarsus in three weeks. In the meantime complete rest in bed is but none on- pulling it away from the tarsus, and moderate the quickest method of restoring the patient to normal. oedema of the dorsum of the foot hiding the extensor tendons of the toes. The patient was kept in bed and given massage treatment, but as the latter caused pain it was with- held for a fortnight and then restarted. The case was so AEROPHAGY exactly parallel with the first one that a second radiograph was taken at the end of two weeks from the onset, but still BY no unmistakable lesion was shown. Progress continued to be satisfactory, and by the end of three weeks he was put on S. WATSON SMITH, M.D., F.R.C.P.