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.