494 PROGRESSIVE GANGRENE ROUND OPERATION WOUNDS

treatment is skilled and prolonged, the prognosis inepilepsy beginning with convulsions in early child-hood must not be considered as hopelessly gloomy.In another group of 40 cases, in which the con-

vulsions had a psychogenic basis, the follow-upinquiries were unsatisfactory in that only 23 of thesechildren could be traced. By far the largest groupwas composed of the children whose convulsions weredue to some infectious disease. The follow-up studyshowed that 12 of these children had subsequentlydeveloped epilepsy, and 6 had shown themselves tobe mentally defective. A comparison of the childrenin the epileptic and the other groups suggested thatafter the age of 4 years the prognosis in convulsionsbecomes progressively worse. The frequency withwhich they occur has some prognostic significance,for while the convulsions with an epileptic basisare usually isolated and separated from each otherby fairly regular intervals, those due to other causes,such as an infectious disease, are apt to recur in

frequent bouts.

SCHISTOSOME AND MOLLUSC

IN a valuable article entitled "the carriage ofschistosomes from man to man, with special attentionto the molluscs which are their larval hosts in differentparts of the earth," Lieut.-Colonel Clayton Lane

I

reviews, with additions, the most important paperson the subject which have been epitomised in theTropical Diseases Bulletin. He begins by recallinghow Leiper and Atkinson in 1915 demonstrated thatSchistosoma japonicum develops from miracidiumto cercaria in a mollusc, thus confirming Miyairi’sprevious discovery. Owing to war conditions thesteps they took to identify the species of molluscresponsible were not perhaps the best possible;the molluscs were not of laboratory growth, and themethod used was based upon the differential degreeof attraction shown by various species for the

miracidia, and upon the examination of fully developedworms in animals infected with cercariae obtained

naturally from various species of snails. Nevertheless

Leiper and Atkinson were in no doubt that the

development of the worms was as they said, andwith this conclusion there has been full agreement.Clayton Lane suggests that the best chain of factswhich can be offered to support the view that a certainmollusc is the intermediate or larval host of a certainschistosome is that put forward by Gordon, Davey,and Peaston. The snails used by these workers wereof laboratory growth, so that unnoted naturalinfection was impossible; infection was given bymiracidia from eggs whose species was certain;and the cercariae coming from the molluscs gave theinfection to clean animals, as was clear when wormsof full development were seen in the veins. Followingup his earlier work Leiper in 1916 showed not onlythat two sorts of eggs came from worms which, whenof full growth, had a different structure, but alsothat the carriage of the two species from man toman took place in Egypt through molluscs whichzoological grouping had placed in different genera.

Clayton Lane next discusses the statement thatbesides the three blood flukes of which human beingsare the optimum host-viz., S. haematobium,S. japonicum, and S. mansoni-man is also theharbourer of others. This statement has sometimesbeen based upon the size and outline of the egg;while sometimes the morphology of cercariae whichhave come out of a snail has been used to put thatmollusc among the larval hosts of a schistosome of

1 Trop. Dis. Bull., January, 1936, p. 1.

man. He draws attention to several papers on thevariation in size of the eggs of a single species invarious circumstances, and examines critically manyothers dealing with differentiation based upondifferences in the appearances of eggs. Turning tothe morphology of cercariae he states that unhappilythere is no agreement about the anatomical details.of the cercariae of the schistosomes of man, and hethinks that attempts to say with our present know.ledge that cercariae coming from a mollusc are thoseof a certain species of schistosome, and that thatmollusc is the larval host of that species, are of novalue. He is forced, therefore, to the decision thatat present only S. homatobium, S. japonicum, andS. mansoni come into the picture of schistosomiasisin man. The rest of his article is a concise accountof the geographical distribution of the schistosomesof man and their larval hosts. Observations on theecology of the molluscs, with special reference totheir control, come in for discussion.

This review by Colonel Clayton Lane is of furtherinterest since, apart from words necessary for biology,.parasitology, and medical science, the paper is inbasic English, keeping to 850 words in the generallist and those in the special lists for science. Inthis way, the author believes, the informationcollected in the Tropical Diseases Bulletin can bemade more easily intelligible to those whose languageis not English.

PROGRESSIVE GANGRENE ROUND OPERATION

WOUNDS

A RARE complication of operations on the serouscavities is the spread of gangrene of the skin on oneor both sides of the scar. The course of the gan-grenous process is rather slow, and healing by scartissue follows gradually in the wake of the ulceration,but the advance of the process is quite relentless,until the trunk may be encircled by the ulcer, anddeath follows unless drastic treatment is undertaken.During the past six years 5 cases have been reportedin this country ; of these, 2 have died and 3 haverecovered. The usual history is that of the fruitless.trial of all types of local application, the onwardspread of the gangrene being quite unchecked bythese or by antivirus, antitoxin, vaccines, or ultra-violet light. The heroic measure, a wide excision ofthe edges of the wound, was necessary to ensure

complete arrest of the disease and the promotion ofhealing. This was the treatment adopted in the3 cases which recovered ; it is the recognised treat-ment in America where the condition has been the

subject of much discussion. Excision may be eitherby the scalpel or by the diathermy cautery. A trenchcut an inch or so outside the growing edge of theulcer will effectually stop its advance, and the

sloughing edge can be excisod at a future operation.The infective process is in the skin, and it will notadvance across scar tissue; it never affects the scarof the operation wound, so that the secret of itsarrest seems to be the formation, well outside thearea of affected skin, of a line of scar tissue. In themost recent case, reported by H. T. COX,l the natureof the condition was recognised 26 days after thefirst operation, and the treatment by excision success-fully carried out, with complete epithelialisationthree months later. The primary operation in thiscase was for repair of a perforated duodenal ulcer,as it was also in the cases reported by R. Owen-Jonesand L. M. Hawksley in 1931,2 and by H. J. Nightingale

1 Brit. Jour. Surg., 1936, xxiii., 576.2 Brit. Med. Jour.. 1931, i., 537.

495TREATMENT OF BACTERIAL MENINGITIS

and E. C. Bowden in 1934.3 F. H. Scotson’s case,reported in THE LANCET in 1933,4 followed operationfor an appendix abscess ; and A. M. Stewart-Wallacein 1935 5 reported a case following drainage of an-empyema. The gangrenous process may start aroundthe edge of a sinus at the site of drainage, or aroundone or more punctures made by deep tension sutures.The sinus itself always heals, and there is an immuneisland of tissue around the scar. Outside this is thedenuded base of the ulcer, possibly with granulationscovering it; then a slough of varying extent; theblackish gangrenous edge ; and, at the periphery, ared, usually very tender, serpiginous margin, raisedand oedematous, and largely undermined.The cause of the gangrene has given rise to much

speculation. One difficulty is that secondary infec-tion may render impossible culture of the originalorganisms. In Owen-Jones and Hawksley’s case

long-chained streptococci were found invading thetissue, but the peculiar nature of the microscopicalappearances led to them being reported as " corre-sponding with the appearances of granulomafungoides." The most usual finding is of a com-bination of a non-haemolytic streptococcus with a non-specific staphylococcus. Stewart-Wallace gives it ashis opinion that the streptococcal infection comesfrom the serous cavity, and that the particularstreptococcus at fault is capable of adaptation toaerobic and non-aerobic conditions. The symbiosisof this organism with a non-specific staphylococcusintroduced from without produces the peculiar typeof skin reaction. He suggests that cutaneous hyper-sensitivity may play an important part, and thisseems likely from the rarity of the complication.

THE DETECTION OF STRYCHNINE

IT is a remarkable fact that no sensitive qualitativetest, based on the formation of a well-definedderivative, is available for strychnine. The laboriouswork of Dr. Douw G. Steyn,l veterinary researchofficer at Onderstepoort, South Africa, on the detec-tion of this alkaloid in carcasses and corpses is,therefore, of considerable interest. Authorities on

toxicology differ greatly as to the limiting dilutionat which the characteristic bitter taste of strychninecan be detected, some placing it as low as 1 in 700,000and others as high as 1 in 67,000. In this connexion,Dr. Steyn points out, an hour or more should beallowed to elapse between each test since the tastenerves very soon become exhausted. Even with thisprecaution he himself was unable to detect strychninein a solution of 1 in 200,000 when only one dropwas placed on the tongue, but he could appreciatethe bitter taste of 1 c.cm. of the same solution. Themost delicate precipitating agent for strychnine seemsto be Wagner’s reagent No. 1 (prepared by dissolving2 g. iodine and 6 g. potassium iodide in 100 ml. ofwater), which, he found, will give a macroscopicrecognisable precipitate with one drop of a 1/20,000solution of the alkaloid, whilst the next sensitivereagent is .l4Tayer’s solution, of which the limit is1/8000. Steyn appears to consider the well-knownOtto test, with bichromate or other oxidising agentand sulphuric acid, to be the most delicate colourtest for strychnine, but it is not, in his experience,specific, as he obtained from a decomposed liverwhich was known not to contain strychnine a positivesulphuric-bichromate test and the solution was

3 Brit. Jour. Surg., 1934, xii., 392.4 THE LANCET, 1933, i., 80.

5 Brit. Jour. Surg., 1935, xxii., 642.6 Onderstepoort Journal of Veterinary Science and Animal

Industry, 1935, v.

bitter to the taste. In order to express a definiteopinion as to the presence or absence of strychninein purified extracts of specimens of organs, it is

essential, in Steyn’s view, to conduct the followingtests : (a) taste test, (b) colour test, and (c) a biologicaltest. For this latter he prefers immature white mice(about 14 days old) to frogs, on grounds that miceare always obtainable and behave uniformly, whilstthe sensitivity of various species of frogs differs andsome are not obtainable at all seasons of the year. Thestability of strychnine in the bodies of animals whichhave been killed by this alkaloid is still a matter ofdiscussion. Steyn, using Glaister’s method of extrac-tion, which he finds the best, was able to detect it inthree carcasses of dogs exhumed 10 weeks afterdeath, but in only one of four dogs exhumed 18 weeksafter death, and in only four out of eight which hadbeen buried for 11 months.’

TREATMENT OF BACTERIAL MENINGITIS

THE wireless appeal on Feb. 24th to any doctorwith a patient recently recovered from infection withPfeiffer’s bacillus met with immediate response. It

suggested a confidence that the life of a child suffer-ing from meningitis might be saved by some form ofserum therapy or immuno-transfusion which maynot be generally shared ; but the discovery, usuallyafter repeated examinations of the cerebro-spinalfluid, of the infecting organism in bacterial meningitisnaturally brings with it the impulse to try specifictherapy. A recent analysis by C. J. Tripoli 1 of allthe cases of bacterial meningitis admitted to theState Charity Hospital of Louisiana during the pastten years, many of them being under his personalobservation, gives little encouragement to the useof serum in meningitis other than the cerebro-spinalform. The total was 468, and among them meningo-coccal meningitis heads the list with 221 cases (47 percent. of the total) and 144 deaths, a case-mortalityrate of 65 per cent. There were 111 examples of pneu-mococcal meningitis (24 per cent.), 90 being untyped,and all save one of these proved fatal. From tuber-culous meningitis (51 cases, 11 per cent.) there wereno recoveries. The remaining 86 cases includedstreptococcal and staphylococcal infections of varyingstrains, mixed infections, and purulent meningitisof unknown causation.

In the treatment of meningococcal meningitis(cerebro-spinal fever) six different methods were

employed; serum administration was the basis offive. Simple lumbar drainage was used for 14 patients,all of whom died ; but since most of them were mori-bund on admission, the results are not a true indexof the value of the method. Many of the patients(130) suffering from cerebro-spinal fever were treatedby repeated intravenous, intramuscular, and intra-spinal injections of antimeningococcal serum afterwithdrawal of " as much spinal fluid as possible."Of this group 87 died (a case-mortality of 67 per cent.).Tripoli points out that with the foregoing methodsno attempt is made to maintain the normal spinalfluid pressure, and further it is difficult for the serumto reach the ventricles and particularly the moreimportant subarachnoid spaces. Serum injectedintravenously does, it is true, ultimately reach thecerebral ventricles but in a very much diluted form.Therefore, in 54 patients, the intracisternal routewas utilised alternately with the intraspinal. Ofthese patients 26 died (case-mortality 48 per cent.).Tripoli describes a modification of the Lyon 2

1 Jour. Amer. Med. Assoc., Jan. 18th, 1936, p. 171.2 Lyon, G. M. : Amer. Jour. Dis. Child., 1932, xliii., 572.