preserved meats, canned vegetables or fruits, or foodstuffs kept in brine, together with a symptom complex including typical symptoms noted above, botulinus poisoning is strongly suggested. When the subjective data is supported by the eye signs, including especially ptosis, frequently almost a masklike or Parkinsonian facial expression, together with certain other typical signs of bulbar paresis, the tentative diagnosis may be made with some assurance, to be confirmed by laboratory examination of suspected food materials, and by animal experimentation.

Certain clinical aspects of these cases may be, and have been, confused in certain instances with some of the forms of encephalitis lethargica, which disease has been more or less prevalent throughout the country in recent months. Careful analysis of clinical symptoms and signs, however, with reference to history and course, should distinguish clearly for us in the great majority of cases. It may be said in this connection that as a rule no two encephalitis cases are exactly alike, while cases of botulinus intoxication are often "groove" cases in presenting very similar symptoms and signs throughout the group. From our own experience it would seem that the average clinician should recognize fairly clearly in these cases a toxic paresis rather than a clearcut infection. In further differential diagnosis, brain tumor, brain abscess, and meningitis in various forms, present occasional points in common. In cases of brain tumor, examination of the eye grounds, fairly definite localization of the lesion, with frequent indications of the increase of

intracranial pressure, including lowering of blood pressure, nausea and vomiting, etc., should distinguish. In brain abscess, the signs of infection, the usually increased leukocyte count, and the signs of intracranial pressure, should be sufficient. In the various forms of meningitis, examination of the spinal fluid, together with the characteristic evidences of meningeal irritation, differentiates fairly clearly as a rule.

TREATMENT

The treatment of botulism until recent months has been a most discouraging field of therapeutics. At the time of this outbreak we were confronted with a problem with which we had had no previous experience, and possibly the average practitioner anywhere would have been in much the same position. We are indebted to Dr. G. W. McCaskey of Fort Wayne, Indiana, for the suggestion contained in the report of cases from Decatur, Indiana, published in the American Journal of Medical Sciences for July, 1919. Recalling that article, and acting on data mentioned there, we communicated promptly with Dr. Robert Graham at the University of Illinois and obtained from him a supply of polyvalent anti-toxic serum, and later, the type A serum which was indicated by the type determination in our cases.

Rest in bed and liquid diet were used from the onset, together with strychnin in doses of of a grain hypodermatically every four hours as indicated by the apparent bulbar paresis. Difficulty in swallowing in certain cases made it necessary for us to introduce medication and various

forms of liquid nourishment into the stomach per Ewald tube for a varying period-in 1 case for four days. In many cases castor oil and enemas were apparently of little avail in securing bowel activity, but, as noted above, pituitrin hypodermatically, accomplished satisfactory results in each case. in which it was used. We made use to some extent of rectal feeding by means of Murphy drip, and for one day fed one very seriously ill patient through a duodenal tube.

Through courtesy of Dr. Graham, who dispatched polyvalent serum to us by special messenger, the antitoxin was available within thirty-six hours of the admission to the hospital of the first case. Two fatalities had occurred before the serum reached us. A third case, which we considered in extremis, extremis, was was given the usual densitizing dose of 3 minims hypodermatically, and one-half hour later was given 3 cc. intravenously and 10 cc. intramuscularly. Similar doses were repeated at intervals of about six hours, and one intraspinal injection of 10 cc. was made. Rather prompt and definite improvement was noted, and the patient whom we had considered practically moribund lived for about twenty-four hours. In other cases from 5 to 15 cc. intravenously at intervals of six to twenty-four hours were used. As soon as the type determination was completed, the type A serum was substituted for the polyvalent variety. The dosage was more or less experimental, and somewhat different from that employed by Dr. McCaskey. In one very seriously ill patient, 115 cc. of botulinus antitoxic serum was given over a period of four and one

half days-45 cc. of which were of the polyvalent variety and 70 cc. the type A the type A serum. Ninety-seven cubic centimeters were given intravenously and 18 cc., subcutaneously. In this case definite improvement in swallowing, in speech, and in general appearance, followed the administration of serum from the third day, and at times temporary relief of the sense of constriction in the throat and of occasional difficulty in breathing was mentioned by the patient about an hour after the serum injection. As we look over this program of treatment, we have felt that possibly even larger doses might have been given to better advantage.

We recognize that gradual improvement might have been noted in a certain percentage of this group without any specific treatment, but in the several seriously ill cases, in which the largest doses of serum were given, improvement was so evident that we feel justified in stating that the antitoxic serum was of definite and proven value. We have also felt that the use of it was, in considerable measure, responsible for the low mortality of 10.3 per cent in this group of 29 cases of which we lost 3.

Signs of serum sickness appeared in a majority of cases between the fourth and eighth days, usually with urticaria and headache, and occasionally with nausea. This was relieved symptomatically as a rule by the routine administration of 8 to 10 minims of solution of adrenalin 1/1000 hypodermatically.

Complications in these cases were not numerous. In one instance associated, we felt, with definite persistent paresis of muscles of the soft palate

and

other pharyngeal structures, an abscess of the left submaxillary gland developed and required surgical drainage.

Sequelae have comprised chiefly persistence in the milder cases of blurring of vision over a period of days or even weeks, and especially, long continued muscle weakness in the two most seriously ill of the recovered cases. Weakness of the muscles of the legs in one instance, and of the muscles of the neck and back in the other, persisted for more than six months. In all cases care of the eyes has been directed by an ophthalmologist through the early period of disturbed vision, and for the muscle weakness and associated conditions, regular massage, hydro-therapy, and well regulated exercise, have been employed. On year after the occurrence of this outbreak, one patient presents marked muscular weakness. of the legs, especially affecting the quadriceps groups of the thigh, and also a residual extreme paresis of the left vocal cord.

SUMMARY AND CONCLUSIONS

1. There is reported here, an outbreak of 29 cases of botulinus intoxication among persons who had eaten canned spinach in which type A botulinus toxin was present.

2. Brief historical account of the occurrence of symptoms, and rather detailed report of the onset and duration of principal symptoms is made, including systematic neurological examinations which, to the knowledge of the authors, have not so far been made in previously reported outbreaks.

3. A contribution to knowledge of the pathology of botulism in man is

made in the report of the pathological findings in the brains of the 3 fatal

cases.

4. The use of polyvalent botulinus anti-toxic serum and also of the type A serum is described, with the conclusion of the authors that this specific agent is of definite value in the treatment of such cases.

5. The use of pituitrin hypodermatically is reported as a valuable adjunct in the treatment of the severe constipation occurring in many of these cases, which is seemingly not relieved by castor oil and other usual procedures. 6. The mortality in this group of cases was 10.3 per cent.

In making the foregoing report the writers wish it understood that they have acted as spokesmen for the entire medical staff of Blodgett Memorial Hospital, to many of whom they are greatly indebted for detailed clinical data and for personal help in care of the cases.

We are most appreciative of the interest shown and grateful for assistance rendered by: Surgeon General Cummings, Dr. G. W. McCoy and the associates of the U. S. Public Health Service; Dr. Robert Graham of the University of Illinois; Drs. K. F. Meyer and J. C. Geiger, San Francisco, California; Dr. H. W. Emerson of the University of Michigan; Dr. A. S. Warthin of the University of Michigan; Dr. C. D. Camp of the University of Michigan.

We wish to acknowledge the cooperation offered by local and state health authorities and representatives of the Bureau of Chemistry of the United States Government, and also the untiring assistance of the nursing service, interne-staff, and all other personnel of Blodgett Memorial Hospital.

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