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. massage again, and this no longer caused pain. Still having Honiorary Physician, Royal Victoria and West Hatnts in mind the first case, a third radiograph was taken, and this Hospital, Boiirnemoutlh revealed a tiny crack of the neck of the third metatarsal bone The habit of swallowing atmospheric air by gulping so as surrounded by a collar of callus. The patient was allowed to distend the stomach becomes noticeably commoner in to walk about the building at the end of five weeks, and nervous individual in times of personal anxiety or of returned to his unit at the end of seven. The general oedema the of the dorsum had disappeared, and the last evidence of the national stress like the present, particularly in women lesion was slight thickening corresponding to the callus. during the climacteric-and sometimes, though seldom, in men about the same period of life-and can excite much discomfort, even pain, with more or less constant Case Ill complaint of ailing. The condition occurs in those This patient was also a healthy infantryman 22 years old. given to worry and anxiety of an imaginary or trifling His story was that towards the end of a session of physical kind, being an actual gastric neurosis. Such persons training he felt discomfort in the anterior part of the right readily suffer from nausea, the sialorrhoea thereby forefoot which rapidly developed into real pain on any provoked causing the frequently repeated act of attempt to walk. He reported to the medical officer and swallowing saliva with atmospheric air into an empty was taken off duty, but as no improvement ensued he was sent stomach so as to distend it. In its turn this distension to this hospital. On examination there was tenderness in the however, fourth interosseous space and over the third interosseous bone. forbids the taking of food. As a rule, such Pulling the third toe away from the tarsus caused pain. patients are never anorexic but well nourished and stout. There was slight oedema of the dorsum of the right foot as Once the habit is established air-gulping is often compared with the left, but this was not so marked as in the practised almost paroxysmally for half an hour or so first and second cases. A radiograph showed an oblique at a time, or until the patient tires of the physical fracture of the shaft of the third metatarsal bone with no efforts at swallowing and produces a comforting sensa- displacement. The foot was put in plaster-of-Paris with a tion of gastric repletion akin to that of a full meal, Bohler iron for one month, and after massage for a further this feeling becoming one of discomfort only when the fortniglt the patient returned to full duty. distension of the stomach is excessive. Complaints of " wind " or flatulence seem to be more Comments often than not due to this habit. To diagnose the If march-foot is defined as a spontaneous fracture of condition, apart from the usual physical signs of an over- a metatarsal bone during prolonged marching two of these distended stomach with occasional borborygmi to be heard cases would have been missed, for it was not until the as air rattles on through the pylorus, all one need do is second x-ray pictures were taken three weeks after the to ask the patient: " Let me hear the wind." The first that the tell-tale callus declared the true diagnosis of process can then be observed. What the patient does is to a condition that up till then had been most puzzling; and crane the neck; then she proceeds to gulp air, at the it is almost certain that these second radiographs would same time complaining of tightness and pain across the never have been taken had not I myself been Case I, epigastrium. She then straightens the neck and eructates and been stimulated constantly by the annoyance of the noisily, so obtaining relief. A similar phenomenon can disability to believe that no stretching of ligaments could be witnessed in the mentally deficient child given to the possibly account for all the symptoms. From the radio- practice of "rumination," or in the ruminating cow that graphic appearances in Cases I and II at the third week "chews the cud." But not all women who practise the lesion seems to be a subperiosteal transverse crack aerophagy suffer from that neurosis alone. Some few of the neck of a metatarsal bone. The site of tenderness are reflexly dyspeptic: they may suffer from chronic in the interosseous space rather than over the bone in cholecystitis or gall-stones, this constituting the under- these two cases is difficult to explain, unless it be that lying disposing cause of the habit. tearing of a periosteal nerve is referred back to the The treatment of air-gulping is simple: to stop or interosseous nerve, which it joins. prevent the actual process of gulping, a small rubber