689

RAPID DEATH FOLLOWING INJECTION OF

ANTITETANIC SERUM

ERIC GARDNERM.B. Camb.

CONSULTANT PATHOLOGIST, WEYBRIDGE HOSPITAL

ON Nov. 19, 1945, a strong healthy well-built boy,aged 15, a pupil at an agricultural training-school,crushed the last joint of his left index finger in a plough.He received immediate first-aid and was driven to thelocal hospital. A doctor was summoned by telephoneand attended, but ordered 3000 units of antitetanicserum to be given at once before his arrival. This was

injected into the pectoral muscle just below the rightclavicle. A small quantity was injected at first ; andthen, :as there appeared to be no reaction, the rest of thedose was given without removing the needle.Almost immediately the boy complained of feeling ill.

in ten minutes he was vomiting, and very soon collapsed.He had increasing respiratory difficulty, with cyanosis,and this deepened till his death, which took place an hourafter the onset of symptoms. On the initial collapse aninjection of ’ Coramine ’ was given, followed by 10 minimsof adrenaline intramuscularly. Artificial respiration wasmaintained with oxygen, and when the heart stopped,10 minims of adrenaline was injected into the heart. Laterthe abdomen was opened and the heart massaged, after afurther 10 minims of adrenaline had been injected into it.

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Necropsy Findings.—Organs healthy. Face, upper chest,and arms eyanosed ; and deep and widespread postmortem

staining, rising high on each flank. Scalp oedematous ;skull dark red from deep cyanotic congestion of diploe.Large surface veins of brain full, and small vessels in piamater and on section of brain congested. Cortex a palemulberry colour. On mediastinum, surface of pericardium, surface of heart,

costal pleura, and thymus were innumerable haemorrhages,from mere pin-points to 5 mm. across. Lungs (15 oz. each)aerated, not very deeply congested or oedematous, butposteriorly lower lobes and much of upper lobes covered withalmost continuous sheet of subpleural hæmorrhage. Intenseeyanotic congestion and oedema of pharynx and glottis,which must have materially contributed to death from

asphyxia. ,

Great veins of neck and right chambers of heart distendedwith dark fluid blood, and large subendocardial haemorrhageson septum.Mucosa of stomach and intestines only slightly congested

and pale pink, but mucosa of duodenum more deeply con-gested, with some submucous haemorrhages. ,

Liver (44 oz.) and kidneys not deeply congested; spleen(4 oz.) pale.

I failed to find the site of the injection till the doctorpointed to an almost imperceptible mark below the rightclavicle. There was no urticaria round this minute

puncture and no oedema along the track of the needle,which had been directed upwards, nor was any seen inthe muscle at the presumed end of the track. From theseobservations and the rapid onset of symptoms it isprobable that the point of the needle had entered avein, into which the injection was made.My thanks are due to Mr. Wills Taylor, H.M. coroner for

West Surrey, for permission to publish this case. -

Medical Societies

TUBERCULOSIS ASSOCIATION

AT a meeting in London on March 15, with Dr. NORMANTATTERSALL, the president, in the chair, a discussionon the

Changing Chest Clinic ,

was opened by Dr. PHILIP ELLMAN. The hospitalsurveys, he said, had revealed glaring deficiencies in thetuberculosis service in some parts of the country, andthese could best be remedied by a wider conception ofthe service’s functions and by greater integration withQther branches of medicine, especially diseases of thechest. Recent figures showed that only 18 % of thepatients attending his clinic were tuberculous ; theterm " chest clinic " was more apt than " tuberculosisdispensary." Preferably the clinic should be a generalhospital department while remaining the pivot of thetuberculosis service ; it should in fact be the outpatientdepartment of the whole chest service, of which the chestunit and the sanatorium constituted the inpatientdepartments. Such an arrangement would ensure

suitable disposal for patients with non-tuberculous chestdisease, and would facilitate special treatment fortuberculous subjects with superadded lesions, such asdiabetes. A section of beds in the chest unit and sana-torium would be allocated to thoracic surgery. Massradiography would be closely linked to the clinics.The social service department, responsible for thefunctions of almoner and health visitor, would be thelink between the service and the patient’s home, andwould have preventive- and restorative duties. Thephysician in charge of the department would have tobe fundamentally a general physician, but with morespecialist training than was now demanded by theMinistry of Health, and with interest in social andpreventive medicine.

Dr. F. PIDEHALGH recalled that the late R. C. Wingfield,himself a sanatorium physician, always emphasisedthat only the tuberculosis officer saw the whole pictureof the tuberculosis problem. To the medical officer ofhealth the disease was a study in epidemiology ; the con-sulting physician concentrated on the clinical problem ;but the tuberculosis officer, though conversant with theepidemiological and clinical aspects, was above all

interested in his patients. Tuberculosis had’two out-standing characteristics. First, it constituted a- viciouscircle-the disease produced poverty, and poverty pre-disposed to the disease. Secondly, the treatment was" not medicine but a mode of life." Thus the everydayproblems of the tuberculous family became the everydayproblems of the tuberculosis officer, and the uniquedoctor-patient relationship thus evolved was the cementbetween the bricks of a good service. The tuberculosisofficer could give the lie direct to those who argued that,under State control, medicine must lose its soul.. Hewas clinician, administrator, epidemiologist, and econo-mist. It seemed logical that he, with his broad outlook,should command the battle against tuberculosis. Todo this he must preserve his perspective and his identity.He was, or should be, a chest diagnostician of the firstorder ; the argument that he should treat non-tuberculouschest conditions was attractive, but there was real

danger that by concentrating on clinical aspects hemight lose his perspective and neglect his main dutywhich was the eradication of all forms of tuberculosis. Heshould emphatically not become simply the head of achest clinic ; the constant help of other specialists wouldalways be needed, and the tuberculosis officer shouldcontinue to handle all forms of the disease. The assimila-tion of tuberculosis into the general hospital, thoughit had obvious advantages, also carried the risk that theservice might lose its autonomy, which should at allcosts be retained. -

Dr. BRIAN THOMPSON drew attention to the lack ofcontinuity in treatment; when the patient was admittedto a sanatorium, neither the physician there nor thetuberculosis officer followed the condition throughoutits course.

Dr. E. K. PRITCHARD considered that the serviceenvisaged by Dr. Ellman was too comprehensive ; non-pulmonary tuberculosis was usually seen by tuberculosisofficers only after it had been diagnosed.

Dr. C. K. CULLEN said that the tuberculosis serviceinterlocked with all the other health services of thecountry, Further association with hospitals would easediagnosis, but would not help in the epidemiological field.

Dr. A. F. BLAGG left £105,169, the-residue of which, subjectto a life interest, is to pass to University College HospitalMedical School.