21

H.—l9b

The quantity of serum given by the method varied considerably according to the severity of the case, as much as 120 cc. having been injected at one time. In the 27 military cases which recovered in which the treatment was carried out the average amount of serum injected was 146 cc, the quantities varying from 50 cc to 319 cc. (i of the eases receiving over 200 cc In the severe cases the object aimed at was to inject as large a quantity of serum as was considered safe in the first twenty-four hours. For example, in a case which was one of the worst, L.P. was done at 2.30 p.m. on the day of admission, and 25 cc of serum injected intrathecally ami 100 cc. intravenously. At 9 a.m. next day 95 cc serum was injected subcutaneously, anil at 2 p.m. L.P. was repeated and 25 cc. serum injected intrathecally and 75 cc intravenously, so that in twenty-four hours 50 cc. was injected' intrathecally and 1.75 cc intravenously and 95 cc subcutaneously, a total of 245 cc This boy was in a desperate condition on admission, being quite unconscious, extremely pale instead of the usual dusky appearance, and his pulse was very feeble. He began to recover consciousness the following day, and. though very confused mentally for two or three days, made a complete recovery, convalescence, however,' being delayed somewhat by a synovitis of the right knee-joint. In addition to the intravenous method, which, as will be mentioned later, has certain drawbacks, serum was injected subcutaneously in large quantities. The first injection of serum, however, in nearly all cases was given intravenously to secure greater rapidity of action. In the case of the baby treated at Featherston only one L.P. was done with injection of serum intrathecally, but the serum was administered subcutaneously, and the baby made an excellent recovery. The injection was usually followed in seven or eight days, occasionally in six, by a, serum rash. ■ The severity of the rash did not seem to bear any relation to the amount of serum administered. The appearance of this rash was regarded as a contra-indication to more serum. The intravenous injections were usually well borne on the first two or three occasions. Subsequent injections were on several occasions followed by a condition of extreme collapse which was very alarming. This condition was quite distinct from the condition of the man who died from anaphylactic shock. In that case the vaso-motor and respiratory centres appeared to be paralysed, and the man became extremely cyanosed. The heart was beating strongly when respiration ceased, and continued to beat for ten minutes afterwards. In the condition of collapse following intravenous injection the symptoms are those of heart-failure : the patient is cold and often sweating, the pulse becomes imperceptible at the wrist, and the respiration is somewhat sighing in character. These symptoms come on rapidly within three or four minutes of the injection. It is curious that the most severe of these cases occurred when no general anesthetic was administered. It was very seldom that any collapse followed the injection when the patient was under chloroform. It was found that the administration of pituitrin, | cc, repeated in fifteen minutes, was followed by quick recovery, and in less than an hour the condition of the patient was normal. Later on the practice of giving J cc. of pituitrin prior to the injection was adopted, with apparently a greater freedom from collapse. Although, as stated above, the early injections were generally free from symptoms of collapse, it is curious that the worst cases of this kind followed the first injection. Thus in the 34th case there was a severe blood-infection with hemorrhagic spots, many as large as a shilling, all over the body, but most numerous on legs and arms. He had headache, vomiting, and slight stiffness of neck, but was quite clear mentally. At 12 noon on the day of admission L.P. was done under a local anesthetic An injection of pituitrin was given and the injection of serum commenced. He was in excellent condition at this time, but before 50 cc was injected he became very pale and rapidly lost consciousness. The pupils dilated and became fixed, and the conjunctive were insensitive. The injection was immediately stopped and more pituitrin was given, and the foot of the bed was raised. The pulse was imperceptible at the wrist. The respiration became very faint and sighing, and he became somewhat cyanosed. Artificial respiration was commenced, ether was injected subcutaneously, and hot, application was made to the cardiac region. In about ten minutes he improved somewhat and he became conscious, but the pulse did not improve. During the afternoon he was very restless, and early in the evening he became unconscious again. He remained in this condition throughout the night, no pulse being perceptible at the wrist. During the following day, however, he improved, and in two or three days he was doing well, and he made a complete recovery. No more serum was given intravenously, but he received three injections subcutaneously, amounting to 130 cc, without any ill effects. Owing in all probability to the prolonged circulatory depression the superficial portion of the skin, where the hemorrhagic spots were present, separated in the form of sloughs during the second week. This was the only case in which sloughing of the skin was observed. In no other case, however, which recovered wore the hemorrhagic spots so large. Inquiry was made as to whether he had had any injection of serum before, but he stated that he had never had any serum administered previously. The cause of this condition of collapse is not obvious. In case 34 referred to it was possibly an idiosyncrasy. In the others it cannot be due to this cause, for the previous injections had generally been well borne. The greatest care was taken to avoid injecting air into the vein. The injections were given from a funnel attached to the needle by a short rubber tube with a glass inspection-piece, and tube and needle were both, filled before the needle was inserted into the vein. The serum was allowed to run in slowly by gravity. In one case the collapse followed the last three injections. Although occasionally air might find its way into the vein it is improbable that it would do so in three consecutive injections into the same patient. The local anesthetic used for the L.P. can be excluded as a cause of the symptoms, for, although it was used very frequently when L.P. alone was done, no symptoms of collapse were ever noticed.