MAIRCHMWRC119, 1907..19079]9, ANTITETANIC SERUM IN TETANUS. LTuICul,KUIA JBaItTBam 55555 the operation described, whether in its technique or in its bromide mixture was given thrice daily. Spasms were still absent, nor, with the exception of one spasm at 2.30.a.m. on scope, bears no resemblance whatever to that which bears August 31st, did they recur. The tongue cleaned gradually, my name. but was not free from ulceration till September 10th. His con- Dr. Fuller published the description of his operation valescence was chequered by a rise of temperature to 1020 and with 6 cases in June, 1895, but his teachings seem to 1030 on September 3rd and 18th, and 21st, along with an urti- have fallen on deaf ears. No one ever seems to have carial and erythematous rasb. On September 14th he was thought it worth while to point out the resemblance it allowed up. On October 10th he was sent to a convalescent bore to McGill's operation, which had then fallen into dis- home. He is now at school, and is perfectly well. favour. So far as I am aware, his name was never referred The interesting points about this case are: First, the *to on this side of the Atlantic for more than six years absence of any apparent inlet, except the foul mouth, for after-till it was unearthed from the dusty archives of the the germ; secondly, the slow development, and this bears Medico-Chirurgical Society by Mr. Mayo Robson during on the happy issue of the case; thirdly, the loss of weight the controversy that ensued on the publication of my first (3 lb. 14 oz.) while the spasms continued, and the steady lecture on my operation in July, 1901, and then only after gain after they ceased; fourthly, the almost normal tem- the attempt by Mr. Robson to father my operation on him- perature while the convulsions were at their worst, and self had been .exposed and refuted. I am not aware that the high temperatures occurring later with antitoxin in his own country it fared much better. Contrast with rashes; fifthly, the treatment. Here it is noteworthy that, this the profound interest elicited by the publication of though the chloral and bromide made him sleep, they had my first 4 cases of my operation; the extraordinary no apparent action on the spasms; while diminution in rapidity with which it has been adopted by surgeons all number and intensity and length of spasm was evident at the world over; the irresistible conviction carried to the once after the use of antitetanic serum. The dose of profession and public by the details of the severdl series, serum given is also noteworthy. In all, 120 c.cm. were gradually increasing in number, since published. given; this required twelve separate punctures, and cost £2 8s. The authorities recommend 400 c.cm. in all, which would mean forty punctures, and a cost of £8; but surely few patients could stand this. It seems desirable that CASES OF both the cost and the bulk of the remedy should be TETANUS TREATED WITH ANTITETANIC somehow lessened. Yet my conclusion is that in a case of tetanus, whatever the pain and whatever the cost, SERUM: RECOVERY. antitetanic serum should be fairly tried, and with as little 1. By W. WINSLOW HALL, M.D., M.R.C.S., delay as possible. LONDON. II.-By EUSTACE (G. CARTER, M.R.C.S.ENO., THE following case affords an example of the value of antitetanic serum: CHAPEL-ALLERTON, LEEDS. A. B., aged 8 years, previously healthy, of a family prone to PROFESSOR SIMS WOODHEAD, in AllMutt's System ofMedicine, rheumatism and otitis media, was brought to me on August states: " Of those cases where the incubation period is 15th, 1906. It was said that his breath was offensive, and that under ten days not more than 3 to 4.5 per cent. recover; he screamed at nights. The tongue, and the mouth generally, were swollen and sore. when the incubation period is still longer, about half the On August 18th I saw him at his own home. He had stiff- patients attacked throw off the disease." In the case ness about the neck, and a slight risus sardonicus ; but his described below the incubation period was seven to eight father maintained that this painful smile was his natural days, and belongs, therefore, to the more serious group. expression; the pule was good, and the temperature was I think, therefore, to the antitetanus serum must be given normal. I could find no physical signs of disease other than the credit for-the favourable termination of the case. the foul mouth. The bowels were cleared out with calomel, and potassium bromide gr. 5 was given every four hours. On On the evening of July 24tb, 1906, 1 was sent for to a young August 19th the condition was unchanged. On August 20th farmer aged 22, who had fallen fromawallastride a dahlia stick, the risus was more marked, and the parents volunteered an causing a lacerated wound of the scrotum, and exposing both account of opisthotonos occurring during the night ;'the pulse testicles, which were otherwise UDiDjured. As is frequently was 72, the temperature 99.6.0 I took the boy into St. Monica's the case in those that work on the land, the skin in the neigh- Home Hospital; there the mouth was carefully treated with bourhood of the'wound was extremely dirty, and it took a con- boric acid, and afterwards with hydrogen peroxide. He was siderable time to cleanse it even comparatively the wound given chloral hydrate gr. 5, and potassium bromide -gr. 7i, itself was freely douched with a mercury biniodide solution, every two hours. and the edges drawn together with catgut sutures. The wound On August 21st it was reported that he had slept, but that suppurated, and at least a square inch of the scrotum spasms had occurred every ten minutes during the night. sloughed, but there was no elevation of temperature or any Risus sardonicus was unmistakable, as a spasm occurred in other symptom of constitutional disturbance till the morning my presence, opisthotonos was equally unmistakable. He of August 1st, eight days after the accident, when he com- could swallow slowly, but with pain. Grey, pultaceous ulcers plained of stiffness about the angles of the jaws and difficulty were visible over the tongue and cheeks, but full examination in openiDg his mouth. Within four hours I injected 10 c.cm. of the mouth was impossible, owing to rigidity of the jaws. of antitetanus serum, prepared by the Lister Institute, under The pupils were small and equal, and the eyeballs rotated the skin of the abdomen. The general condition of the down. There was no otorrhoea, but the right membrana tym- patient was good, temperature normal, pulse 72, respira- pani was thickened and opaque. The skin reflexes in tions 16. the abdomen and the lower extremities continued unduly When I saw him on the following morning he had passed a brisk. restless night, the rigidity of the jaws was more marked, and At 3 p.m. 60 c.cm. of antitetanic serum were injected in the accompanied by stiffness in the muscles of the abdominal wall iliac regions. The chloral and bromide mixture was given and lower extremities. I injected 10 c.cm. of serum, and four-hourly. ordered 20-gr. doses of chloral hydrate and potassium On August 22nd the boy's condition had improved. There bromide every four hours, to be discontinued if the patient had been only 23 spasms in twenty-four hours, against some 96 became too somnolent; the same evening 10 c.cm. of serum in the preceding day and night. The temperature was 98.60; were injected as before. the pulse remained strong, and was 100 to 108; the respira- On the morning of August 3rd the nurse reported that the tions were 22 to 28. The tongue was cleaner. Nourishment patient had passed a restless night, and that he had had was taken better. Reflexes were less brisk. At 11 a.m. 30 c.cm. several tetanic spasms. I found the general rigidity of the of antitetanic serum were injected. The chloral and bromide muscles of the jaws, abdomen, and thighs more marked, so I mixture was given two-hourly again. injected 20 c.cm. of serum, which as I inserted the needle pro- On August 23rd improvement continued. There had been duced a violent spasm, the patient being thrown into a condi- twenty-two spasms in twenty-four hours. The temperature was tion of pronounced opisthotonos. There being no change for normal the pulse and respiration the same as on the preced- the better in the condition of the patient, I again injected ing day. The tongue was rather cleaner; the mind clear; the 20 c.cm. of serum twelve hours subsequently. On August 4th cremasteric and abdominal reflexes absent, the patellar and the nurse reported that for two or three hours after each plantar reflexes were only moderate. An injection of 30 c.cm. injection of the serum the patient had fewer attacks of spasm, was given again. On August 24th the patient looked brighter; otherwise he remained much the same. This I found to be only eight spasms had occurred in twenty-four hours; the the case after every subsequent injection. tongue was still cleaner, and he had swallowed two pints of It is not necessary to give a detailed account of the progress milk since the preceding morning. On August 25th only seven of the case from day to day;* the patient was now in the midst spasms had occurred. On the morning of August 26th there of an attack of acute tetanus, which lasted for twenty-eight had been no spasms for over twenty-four hours. The sloughs days * that is to say, the last spasmodic seizure occurred on the were cleaning off the tongue. On August 27th the reflexes had twenty-eighth day after the onset of. the trismus. For some reappeared up to the level of the epigastrium. The chloral and da,ys longer, howcver, there remai'led some stiffness about the 556 -I- BoUT=I THE STAINING OF 'ANIMAL PARASITES. LMARCH 9, 1907.

jaws and much general muscular rigidity, and the patient was symptom, which subsided as soon as the bowels were well not fully convalescent till September 28th, two months and opened. After this the patient took nourishment very four days from the date of the accident. well, the total aimount being sometimes as much as eight, During the course of the illness the most prominent milk milk coffee, symptoms were rigidity of the muscles of the jaws, back, pints of various liquids, such as tea, abdomen, and upper part of the thighs, accompanied by milk cocoa, Benger's food, broths, etc., in twenty-four frequent clonic spasms at irregular intervals ; the muscles of hours. the upper extremities were but little affected. Swallowing The patient began to sit up during the first week in was accomplished with great difficulty, but fortunately the act January, and since then has made steady progress. of deglutition never failed completely. Tenacious mucus The notable points in this case appear to be: accumulated in the pharynx, causing much trouble and dis- with recovery. tress. The bowels were constipated; urine passed without 1. The short incubation period, combined difficulty. Temperature varied-between 1010 and 1020, and on 2. The beneficial effect of the antitoxic serum given one occasion reached 1030. Pulse became very rapid, some- subcutaneously. This was obtained through Messrs. times almost uncountable, and even when convalescence was Burroughs and Wellcome. fully established remained well over 80. From the third day and for seventeen subsequent days 20 c.cm. antitetanus serum were injected every twelve hours, till on August 20th the patient was able to open his mouth a THE STAINING OF ANIMAL PARASITES. little way, the spasms being also less frequent, so the dose of By I. WALKER HALL, M.D., serum was reduced to 10 c.cm. twice in twenty-four hours; the PROFESSOR OF PATHOLOGY, UNIVERSITY COLLEGE, BRISTOL; improvement being maintained, the dose of serum was PATHOLOGIST TO THE BRISTOL ROYAI, INFIRMARY. recuced still further, to 10 c. cm. once in twenty-four hours for the next five days; on the twenty-seventh day the serum was WHILE many of the higher parasites do not require any omitted altogether for twenty-four hours; the rigidity of the in to demonstrate their anatomical muscles was much less marked, and there was only one spas- special staining order modic seizure, which proved to be last, on the twenty-eighth structure, their ova and embryos may sometimes escape day ; as a precaution 10 c.cm. of serum was administered for detection when unstained, especially if they are present in the last time. Though the patient had the large number of 83 small numbers. This is particularly the case when it is injections under the skin of the abdomen and flank, not one necessary to examine secretions such as the urine or caused more than the temporary discomfort due to the inser- faeces, or the contents of parasitic cysts. Staining is also tion of the needle, Ten days from the commencement of the in embryos, ova, or sections serum treatment the patient was covered with a profuse scar- an advantage demonstrating latinoid rash, which caused him a good deal of discomfort, and of the entire animal, either by the aid of the microscope or which was followed by general desquamation. The bromide by the lantern microscope. and chloral mixture was given as occstsion required. As it was These facts were brought home to the writer while impossible to clear out the tenacious mucus that accumulated endeavouring to project preparations of filaria on to a in the pharnyx the patient was frequently turned on to his screen, and while examining specimens of faeces in which side with his shoulders projecting over the edge of the bed, the ova were difficult to find. and his head hanging down, supported sometimes for an hour was or more by his mother or the nurse ; this position was assumed Under such circumstances the following device by the patient of his own accord, as in this way the mucus employed, and as in its entirety the procedure does not escaped out of his mouth and cleared his throat. appear in the available literature, it is here described in A turpentine enema was administered every third day, pro- the hope that it may obtain further application. ducing evacuation of the bowels. The wound caused no anxiety; it was treated with boric acid fomentations, and METHOD. eventually granulated up. 1. Prepare a film of the blood, faeces, or sediment of the The diet consisted of two to four pints of milk every twenty- secretion. Fix by heat, or, less preferably, by formalin four hours, the patient preferring this to any other form of vapour. liquid food. .Treat the film with the following solution,uin i to2muesto 2 minutes: Watery methylene blue, 1 per cent., 100 c.cm. ; glacial acetic In reviewing the case I think I ought to have injected acid, 5 c cm. (Neisser's methylene blue solution may be a larger dose of antitetanus serum on the first occasion, equally well used if at hand. Methyl violet, Nile blue, etc., but my want of knowledge of the treatment made "I are not so good.) dare not, wait upon I would! " If in the future I should 3. Wash in water. have another case of acute tetanus I should begin by 4. Cover the film with saturated alcoholic eosin solution. at least 20 c.cm., and preferably Allow to stain for 5 to 10 minutes, or (following Muir's excel- injecting by the intra- lent method described in the Journal of Pathology, 1906) venous method. heat over the flame, blowing out the alcohol each time it catches fire, until the film is almost dry. 5. Wash in water. III.-By C. R. HOWARD, M.B., B.C.CANTAB., 6. Fix in potash alum solution. i to 2 minutes. WOOLSTON, HANTS. 7. Decolourize in 90 per cent. alcohol until a uniformly pink colour obtains. ON November 26th, 1906, J. E. grazed his hand when work- 8. Wash in water; allow to dry; mount In Canada balsam. ing on a troopship. Two days later he began to complain It is the treatment with acetic acid which affects the of aching and stiffness in the jaws, and on the fourth day outer coverings of the ova, embryos, and parasites, and had marked risus sardonicus. On the fifth day after the allows the stain to permeate the entire structure. injury spasms appeared and treatment was commenced; it consisted in keeping the patient quiet by means of APPLICATION. silence, darkness, and drugs, feeding him, excising the Faeces -Spread a film of the faeces on a large slide. A and quarter photographic plate from which the film has been wound, injecting antitetanic serum. Of the latter removed may be utilized. The acid solution decolourizes the 110 c.cm. in all were administered on the following dates faecal material and softens the membranes of the ova. After -December lst, 5th, 9th, 11th, 12th. The injections were stage 6, the decolourization is continued until the ground stain given subcutaneously in the back, and seem to have is a light pink. Using a Zeiss A lens the ova are then seen exercised a most beneficial influence, but they apparently as small deep-red spherules or ovoids. Their detailed structure caused an intensely irritative erythematous rash to is well defined under the high power. develop. Sediments from Secretions and Cyst Contents.-By these means the protein constituents are stained a uniform light The rigidity of the body decreased about December 9th, eosin shade. Hooklets and ova are stained red, and stand out but the spasms continued till December 11th. They were sharply against the pink background. severe on several occasions, and had to be controlled by Filaria.-For the demonstration of these and other chloroform, chloral and bromide, or morphine, of which organisms infesting the blood stream, Leishman's method during December 3rd and 4th about gr. iij were given. gives results far suDerior to those obtained by using Jenner's The dye, eosin and methylene blue, haematoxylin and eosin, iron bowels were at first very confined, and croton oil alum haematoxylin, fuchsin, or resorcin-fuchsin. It stains had to be given on two occasions, but subsequently they the sheath a delicate pink, the granular material a desp blue, were regulated by means of magnesium sulphate 3 iij and both "spots," as well as the muscular cutaneous layers, every four hours. The motions were most offensive, are well defined. An advantage possessed by this acid-eosin greatly increasing the labour and discomfort of nursing. method over that of Leishman is that the sheath stands out This was overcome by 5-gr. doses of salol given occasion- sharply in light red, the body is a bright, deep red, and the ally. During the first day or two of granular material purple, and a better lantern picture can be the illness much obtained. With Leishman's stain the red corpuscles are terra anxiety was caused by persistent vomiting, but a mixture cotta and the white corpuscles present the usual colouring of containing bismuth, compound tincture of cardamoms, the granules. With this staining method the red corpuscles chloroform, morphine, and hydrocyanic acid, relieved this are only outlined, but the coarsely eosinophilous granules