TRANSACTIONS. NORTHERN TRI-STATE MEDICAL ASSOCIATION. STATED MEETING, JANUARY 12, 1909, AT ANN ARBOR. READING OF PAPERS. DOCTOR WILLARD H. HUTCHINGS, of Detroit, read a paper entitled, "The Treatment of Tetanus." (See page 253.) DISCUSSION. DOCTOR REUBEN PETERSON: It is very well to discuss dispassionately in a meeting of this kind tetanus in its various phases, its etiology and especially its treatment. It is entirely a different matter to meet with a case in your surgical practice, in a patient who has undergone a perfectly simple operation for the cure of dysmenorrheal symptoms. For this patient when she consulted me was in no danger of death and would have refused the operation if it had entailed much risk. Yet in a comparatively short time after the operation, she was in serious danger, her life being threatened by one of the most serious complications of abdominal surgery. Like all surgeons I have had my poor results and have had sorrowful moments, when I wished I had adopted a different treatment. We are human and prone to error, but we try to profit by our mistakes and after awhile our courage returns. This accident was the most terrible calamity which has ever befallen me in an operative experience of twenty years and my only consolation is that the patient recovered. In a general way I knew from my reading that tetanus sometimes follows clean operative cases, but like many things one reads, it did not leave much of an impression upon my mind and I was totally unprepared for such a diagnosis. Since this experience I have worked up the literature carefully and find some one hundred and fifty similar cases recorded, where tetanus followed clean gynecologic operations. Only relatively few patients recovered, irrespective of the kind of treatment instituted. Some of these cases followed where catgut was employed, in others different suture material was used. Hence the subject under discussion must necessarily be interesting to every surgeon, for he will never know but that he may furnish the next case from his own practice. I do not know the origin of the infection although I am inclined to believe it originated from the catgut. I have employed the latter suture material for the past twenty years, always endeavoring to make use of the best methods of sterilizing the catgut or using a commercial gut that has given satisfaction in the hands of others. For some years past I have employed the Van Horn catgut with complete satisfaction. For certain reasons it seemed best to have the gut prepared in the laboratory of my NORTHERN TRI-STATE MEDICAL ASSOCIATION. 261 private hospital, according to a modified Claudius method. But before using the catgut, I had it tested in the bacteriologic laboratory where it was pronounced sterile. Yet tetanus developed in my patient shortly after we began to use this kind of catgut in the hospital and since there had been no other change in the hospital technique it is to be presumed that the infection came from this source. As regards the treatment of tetanus by chloretone, I can only say that as far as its antispasmodic action in this case was concerned, it was simply perfect. Just before the administration of the chloretone clonic convulsions were aroused by the mere turning on of the electric light. The jaws were firmly locked so that liquid food could be taken only with the greatest difficulty. Fifteen minutes after the administration of the chloretone, there was relaxation of the jaws and she was able to open her mouth. There were no more convulsive movements and she soon went to sleep. After a repetition of the chloretone the next morning the clonic convulsions ceased and the patient made a good recovery although it was some time before she could open her mouth to its full extent. When I reported this case before the Chicago Gynecological Society, one speaker claimed the case to be one of grave hysteria, and that no absolute diagnosis of tetanus could be made, unless the tetanus bacillus be isolated. Of course it depends upon chance whether one finds the bacillus or not. In only a comparatively few cases of tetanus has it been isolated. Still it is not a very difficult task to make a diagnosis between this affection and hysteria. An hysterical patient does not awaken at night from having bitten her tongue as this patient did. At first when she complained of soreness about the jaws I thought of parotitis, which occasionally is a complication of gynecologic operations, but the absence of swelling and temperature precluded this diagnosis. Hysteria was considered as a possibility, but was dimissed after the development of the clonic convulsions. It is not claimed that the chloretone is anything more than an antispasmodic, but unless the convulsive movements be controlled the patient may die by respiratory spasm. Hence some such agent must be employed until the poison can be eliminated. Chloretone is a safe drug to administer. It will control the convulsive movements just as well as the reports would indicate is accomplished by the use of spinal injections of magnesium sulphate, and the latter method is dangerous since it acts badly upon the respiratory centers. I think every practitioner should give this drug a trial, if he be so unfortunate as to have a case of tetanus. Certainly we are under obligations to Doctor Hutchings for his experimental and practical work and for his presentation of the subject this evening. DOCTOR DE NANCREDE: I saw one of these cases that Doctor Hutchings has reported, and certainly it looked like a serious case. The paper ought to be carefully discussed, and I have sent a request to the committee on arrangements of the American Surgical Association to give Doctor Hutch ings a place on the program next May that the Fellows may hear and profit by what he has demonstrated. If he only saves a few patients he will do a great deal more than most of us. DOCTOR VICTOR C. VAUGHAN: I think that the report made by Doctor Hutchings is exceedingly gratifying. It is certainly unusual to have so many recoveries of severe cases. I have had several cases of tetanus, and the antitetanic serum does not appear to do very much good after the development of symptoms, though as a prophylactic measure it is of great value. I can only say that I am very much interested, and await with a great deal of interest the further development of this treatment. DOCTOR V. C. Vaughan, JR.: I would like to lay stress on just one point. I was fortunate enough to see two of these cases, and I must say I am impressed with the fact that three essentials equally demand attention. First, consider the poison; second, consider the spasm; and third, remove the laboratory in which the poison is formed. I would have the physician clean out the wound, and then if fresh signs of poisoning become manifest, only one reason can account therefor, that is, the laboratory is still forming poison, and the rest of the product must be removed before the patient can recover. DOCTOR : I would like to mention three cases that happened when I was house physician. The physician in charge has not yet reported them. It was over three years ago. The first case was severe, a lesion in the palm of the hand, and the case came into the hospital after tetanus had developed. The wound was thoroughly opened, cauterized, and then carbolic acid and glycerine employed, ninety per cent carbolic acid, and also antitetanic serum. The second case was that of a boy eleven years of age. He was kicked by a mule, and had a severe gash in the supraorbital region which had healed by first intention. Eight days after the accident he was brought to the hospital with symptoms of tetanus. The wound was opened and a small pocket of pus found. The wound was thoroughly cauterized with carbolic acid. He was given eighteen minims of carbolic in all, three doses of six minims with an equal amount of glycerine. Besides this he had antitetanic serum. The third case was that of a small girl who caught her foot in the fork of a railroad track, and as a result amputation of two toes was necessary. Eighteen days after the injury she developed tetanus. The wound was not interfered with after tetanus manifested, but treatment was given. All three cases made good recoveries. DOCTOR DE NANCREDE: If the association will permit the Chair to make a few remarks, I would like to say that I have seen tetanus patients in every stage of the disease, have seen every kind of treatment employed, and this is undoubtedly the best treatment with which I am personally acquainted. We used to kill patients with the calabar bean or its active principle. Then we kept them under chloroform twelve or fifteen hours continuously. Remember that any and every kind of treatment has been followed by recovery, but that in all cases the laboratory must be removed. I think that is one of the most important things. Roth has reported some fifty cases where recovery took place with amputation. Therefore, I think Doctor Vaughan, Jr., in bringing up this matter of cleaning the laboratory has adverted to an important piece of work. But do not expect every case to get well and do not be disappointed. ORIGINAL ABSTRACTS. MEDICINE. ALBION WALTER HEWLETT, B. S., M. D. PROFESSOR OF MEDICINE IN THE UNIVERSITY OF MICHIGAN. DAVID MURRAY COWIE, M. D. CLINICAL PROFESSOR OF PEDIATRICS IN THE UNIVERSITY OF MICHIGAN. PAROXYSMAL HEMOGLOBINURIA. THE paroxysms of this disease are characterized by the passage of urine containing hemoglobin and are associated with certain other symptoms, especially chill, fever, lassitude, hepatic and splenic enlargements. The paroxysms are caused by a rapid intravascular destruction of the red blood corpuscles. The exciting cause of the paroxysms in most instances is exposure to cold and it is usually possible to induce them artificially by having the patient thrust his arm into cold water. The recent studies of Meyer and Emmerick (Deutsche Archiv für klinische Medicin, 1909, XCVI, 287), of Macalister (Quarterly Journal of Medicine, 1909, II, 368) and of Moro, Noda, and Benjamin (Münchener medicinische Wochenschrift, 1909, LVI, 545) confirm the theory advanced by Eason and by Donath and Landsteiner that the blood of these patients contains an abnormal hemolytic substance. This latter belongs to Ehrlich's class of amboceptors. It is not destroyed by heating to 56° centigrade, and it does not hemolyse the red blood corpuscles unless activated by complement. The activating complement may be derived. either from the patient's own serum or from that of normal individuals. The amboceptor unites with the red blood corpuscles only at low temperatures and if the complement is not added this union may be broken up by washing the corpuscles in warm water. If complement be added and the mixture be placed in a thermostat hemolysis takes place rapidly. Variations occur in the hemolytic properties of the blood serum of patients with paroxysmal hemoglobinuria, due mainly to variations in the amount of complement present. The complement is often absent after a paroxysm, apparently because it has been exhausted during the destruction of the erythrocytes. The blood pressure rises at the onset of a paroxysm, remains high during the chill, and falls at the height of the fever. During the paroxysm the mononuclear cells are relatively diminished and the polynuclears increased. The serum develops opsonic properties which favor the ingestion of red blood corpuscles by large mononuclear cells. These changes are analogous to those occurring in acute infectious processes. The most important predisposing cause of this disease is syphilis. Even when no history of lues is obtained, the Wassermann reaction may be strongly positive. This was the case in two of the six patients whose histories are here reviewed; in three others a positive history of syphilis could be obtained; while in only one were both history and Wassermann reaction negative. PEDIATRICS. ARTHUR DAVID HOLMES, M. D., C. M. A. W. H. MODERN LABORATORY FEEDING AND THE WIDE RANGE OF RESOURCES WHICH IT PROVIDES. ROTCH (Archives of Pediatrics, September, 1908) has published a paper the object of which is to show the profession how unnecessary it is to use any of the patent or proprietary foods, because knowing what each food contains of value, this constituent can be added in the milk prescrip tion at the laboratory. The writer describes in a practical way all the important points in infant diet. He claims the successful use of fats depends on the knowledge by the physician of the requirements of the individual case and he discusses fully the different carbohydrates, lactose, dextose, succrose and maltose. Starch is used for rendering the precipitated casin finer by mechanical means and for the purpose of nutrition. He approves of the principle of dividing the proteids into whey and casinogen, and of the use of sodium citrate because it gives a flocculent curd. He suggests a new prescription card for use by the laboratory. OPHTHALMOLOGY. WALTER ROBERT PARKER, B. S., M. D. PROFESSOR OF OPHTHALMOLOGY IN THE UNIVERSITY OF MICHIGAN. . A CASE OF HYSTERICAL HEMIANOPSIA AND AMBLYOPIA IN A BOY OF TWELVE YEARS. STEPHENSON (The Ophthalmoscope, Volume VII, Number V), after speaking of the controversy of the various authorities regarding hysterical hemianopsia, and giving a brief résumé of the previously recorded cases, reports a case of binasal hemianopsia and amblyopia of four months duration, in which the diagnosis of hysteria was clearly demonstrated. Contrary to the stand taken by many writers that purely hysterical other of homonomous hemianopsia of both eyes, which followed a unilateral hemianopsia does not exist, authentic cases have been reported by such men as Lees, Mitchell, de Schweinitz, Dejerine and Violet, Pierce, Janet, Lamois and Tournier, and Wilfred Harris. Lees reported a case of double |