TETANUS—Prophylaxis and Treatment of the Disease

Cleansing and debridement is paramount in dealing with tetanus-prone wounds (severe crushing injuries, piercing wounds, blisters and burns are outstanding examples, particularly if contaminated with dirt, grass or other debris).Prophylaxis then is relatively easy in persons who have been actively immunized by toxoid injections. For them, a “booster” injection is indicated.Use of antitoxin, however, is hazardous, whether for prophylaxis or for treatment of the disease. Since it may in itself cause severe disease, including anaphylactic reaction and serum sickness, decision to use it must be weighed against the possibility of the development of tetanus in each case.To prepare for use of it, careful history should be taken, with particular reference to sensitivity to horse dander. Dermal tests, and perhaps ophthalmic tests, for sensitivity to the serum should be carried out. Even the tests may be hazardous and precautions should be taken accordingly.If it is decided that the use of antitoxin is necessary even though the patient is sensitive to the material, desensitization must be carried out promptly, with adequate preparation for severe reaction.There is experimental evidence that antibiotics of the tetracycline group, given soon after injury, may have prophylactic effect against tetanus.     

Parkinsonism—Evaluation and Treatment of Movement Disorders

Patients with movement disorders from parkinsonism were treated with thalamotomy performed by stereotactic surgical procedure. In order to determine with any degree of objectivity the results of these lesions, an accelerometer was used to record hand tremor and various mechanical tests were carried out that included self-care activities to evaluate impairment of function. On the basis of these tests, patients were selected for surgical operation, their condition before and after operation was evaluated, and a program for their rehabilitation was drafted.     

RELATION OF A STREPTOCOCCUS TO EPIDEMIC POLIOMYELITIS—Studies in Etiology,Diagnosis and Specific Treatment

The production in 1915 of herpes zoster or “posterior” poliomyelitis in animals with a streptococcus led to further research on the etiologic importance of streptococci in “anterior” poliomyelitis.A specific streptococcus was demonstrated consistently in persons with poliomyelitis and in well persons having contact with them or merely inhabiting an area in which poliomyelitis was epidemic. That the organism was not present in areas remote from contact with the disease was likewise demonstrated.The streptococcus has been isolated from filtrates of poliomyelitis virus and from the tissues and exudates which harbor the virus. It appears in the spinal fluid in the preparalytic stage of poliomyelitis and disappears from the spinal fluid during the severe stage of the disease.Antibody and antigen prepared from the streptococcus were used to determine the presence of antigen and antibody indicative of streptococcal infection in many patients with poliomyelitis and in well persons. The intensity of reaction indicating specific streptococcal antigen was directly proportional to the degree of paralysis in patients; the reaction was greater in persons whose age, sex and previous isolation from the disease would normally indicate greater susceptibility. The test for antibody gave opposite results.Specific agglutinins for the streptococcus and neutralizing antibody for the virus were present consistently in the serum of persons and monkeys during recovery from poliomyelitis.Virus produced in vitro from the associated streptococcus caused all the clinical and pathologic features of poliomyelitis in monkeys inoculated with it, and the animals that recovered from the disease thus induced were proved to be immune thereafter to the natural virus.Antistreptococcic serum prepared in horses was used to treat poliomyelitis. In a group of monkeys inoculated with the virus of the disease, 6 per cent of those receiving the serum before inoculation died of the disease; of the control group, 82 per cent. In a series of poliomyelitis patients treated with the serum the mortality rate was 8 per cent; in a control series, 21 per cent. In a series treated in all stages of the disease by the author, 10 per cent died; of those who did not receive the serum, 25 per cent.An antibody has been prepared from the streptococcus which appears to prevent paralysis and otherwise mitigate poliomyelitis and to provide immunization from the disease.The conclusion is reached that the virus of poliomyelitis is a form of the specific streptococcus, which is the agent in primary infections and in the development of the immunizing antibody.     

INTESTINAL ADHESIONS—Present Status of Prevention and Treatment

Although many treatments have been proposed for the prevention of intestinal adhesions, none has been completely effective. For bowel obstruction due to adhesions the initial approach should be conservative. If operation becomes necessary, the best results depend on avoidance of trauma and infection, division of adhesions with cautery, use of mesothelial grafts, instillation of intraperitoneal hyaluronidase and stimulation of early postoperative peristalsis. In the event of massive adhesions or failure of other treatment, intestinal plication is the treatment of choice.     

CRUSHING INJURY OF THE HAND—Prevention of Ischemic Contracture

Crushing injury of the hand usually causes “explosive” damage. Subsequent swelling of the palmar structures further impairs venous outflow, and hemorrhage into structural spaces increases the pressure. The arterial system and the large dorsal veins, however, are seldom obstructed and provide adequate circulation unless hampered by improper bandaging. A bandage that compresses the dorsal veins causes back-pressure, which increases the swelling further and brings about ischemia. Swelling and pain cause the patient to restrict exercise of the injured hand, which permits contractures to develop.The author has averted this sequence in more than 100 cases by preserving integrity of veins during debridement, arresting hemorrhage, bandaging the hand with compression dressings in functional flexion, and reducing swelling with hyaluronidase. In these cases, on removal of bandages in 24 hours, swelling was reduced and continued to diminish. All patients exercised the hand at this time without discomfort and only a few required aspirin for pain.