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INTESTINAL PROTOZOA IN SALONIKA WAR AREA.
297 of acetic acid has proved very efficient in it.8 The streptococcus group showed a slight decrease with the bicarbonate dressings. No effect appears to have been produced upon the incidence of the organism by the other dressing solutions, with the exception of cresol and the
use
eliminating
INTESTINAL PROTOZOA IN SALONIKA WAR AREA. LIEUTENANT
BY
W.
ROCHE, R.A.M.C.,
PROTOZOOLOGIST, SALONIKA WAR AREA.
IV.-Percentage Incidence of B. pyocyanens, Streptococci, Staphylococci, and B. aerogenes capsulatus (Welch) in Wounds under Various Dressing Solutions compared ivith the Average Incidence of each Organism.
TABLE
(Report
to Medical Research
Committee.)
DURING the months of August, September, and October, I had the opportunity of examining the stools of 893 cases of diarrhoea and dysentery among the troops of the Salonika war area. Some of these cases had their stools examined two or three times weekly, but the great majority of them not more than once. This work was all part of the routine laboratory examination of stools of patients suffering from diarrhoea or dysentery in three of the general hospitals in this area. Troops of the Salonika zone of the Eastern Mediterranean have suffered severely from diarrhcea and dysentery. These infections started about the month of May, 1916. They have continued, with slight variations, up to the present. These variations, I think, are mainly due to climatic changes. The great spreaders of diairhcea and dysenteries are flies. Heat and moisture are necessary for these pests to thrive. In the very hot spells, when everything was dried up, flies became less numerous. On the contrary, during a cold spell, their numbers were markedly diminished, and in these periods there was decidedly less diarrhoea and dysentery. Bacillary dysentery was the predominant type, but there were quite a number of acute amoebic cases. It is a remarkable thing there were not more, inasmuch as many of the troops, particularly those which had come from Gallipoli and Egypt, were carriers of Entamaeba hixtolytiaca. Microscopical examinations of the stools of these troops in Egypt, Malta, and Salonika continually showed evidence of this.
1916,
and
hypotonic saline, where there seems to have been a slight increase in the percentage. Staphylococcus showed a slight decrease among the cases
dressed with Dakin’s solution or cresol. It seems to have been little affectea by the other dressings. In the case of the gas bacillus no effect seems to have been produced by any of the dressing solutions with the exception of quinine, where the early disappearance of the organism was strikingly apparent. This resale is consistent with earlier experience with this alkaloid, both in vitro and in clinical application. With this organism there appeared to be a higher incidence among the cases on dry dressings than among those on any of the dressing solutions. In spite of the fact, therefore, that our methods of applying antiseptics are still very inadequate and their efficiency as dressing solutions greatly hampered, definite effects on the bacterial flora of the wounds were obtained. Furthermore, these effects were evidenced in no case upon the bacterial flora in toto but upon one or more specaes of bacteria, at a timethose for which the dressing was most specific. The failure to produce a greater effect upon the streptococci and staphylococci may have been due to a deeper distribution of these organisms in the tissues, or, the other factors being equal, to the failure to use an antiseptic having an exceptional bactericidal value for those particular groups. Possibly a wider choice of dressing solutions would have shown antiseptics with this property.
Summary. It has been suggested that the specific method of treatment is applicable to wound infection as well as to systemic infection. Some instances of the variation of antiseptics in their activity against different bacteria in vitro have been offered in support of the principle. A large number of bacteriological examinations of wounds under treatment with different solutions has been recorded and instances of the specific action of certain dressing solutions demonstrated. It is believed that further analytical study of antiseptics will result in the discovery of dressings specific for one or more groups of bacteria. By a successive application of these dressings the organisms present in the wound may be reduced in number or eliminated one variety at a time, and true sterilisation of a suppurating wound accomplished. But first the concept of the "general antiseptic" must go by the board and the search for a cure-all be recognised as
Number of cases
Table of Findings. examined, 893; number of examinations, 1425.
By E.F. (free amoebae),
we mean amœbse found in fresh of stools in a resting or precystic stage. This group includes cases in which there was no time for staining, nor was further examination possible for a more complete
specimens diagnosis.
Amœbic Dysentery. the above table, Ent. histolytica was present in 37 cases. In two of these it was found post mortem. In one the patient died two hours after admittance to hospital. There were six perforations in the large gut and typical lesions of acute amoebic dysentery, from which different scrapings showed large numbers of Ent. histolytiea. This patient had never been in Egypt or Gallipoli or other inft-eted area, and he did not belong to a division that had been in one, nor was he in camp with any troops known to be infected. The second case died from sepsis, the result of a severe gunshot wound of the thigh. In the routine post-mortem examination of the organs the gut showed signs of acute amoebic dysentery, and scrapings from it showed Ent. histozytica. This patient had also never been in any unprofitable. It is a pleasure to express my acknowledgments to Dr. infected area. In cases where Ent. minuta was found a history of Joseph A. Blake for his advice and criticism, and to Miss recurrent diarrhaea was usually given. The stools were H. for Buxton their share in Mary Davies and Dr. B. large faecal with mucus, but seldom was there blood. These the technical part of this work. patients, one generally found, had been in Gallipoli or in As well as the Ent. minitta, but included in the 3 Treatment of Bacillus Pyocyaneus Infection, Journal of the Egypt. American Medical Association, Nov. 25th, 1916, vol. lxvii., p. 1598. table under that category, I found in a few cases a specially 4 Use of Quinine in the Treatment of Experimental Gas Gangrene, THE LANCET, Sept. 4th, 1915, p. 538. Use of Quinine Hydrochloride small form of amoeba with its cyst, a type which had been Solution as a Dressing for Infected Wounds, Brit. Med. Jour., Dec. 25th, demonstrated to me in Egypt by Lieutenant-Colonel Wenyon, 1915. R.A.M.C., and which has been described by him. Cases As is
seen
in
298 where any type of Ent. histolytioa was found in the stools iis the best prognosis permissible from the nature of the iinjury. Such cases often last many months, entailing intense were treated in the ordinary way with emetine (1 gr. hypo,suffering. Unless the limb is fixed without mobility a bad dermically daily for 12 days). War-time exigencies did not allow of all patients being alignment results from muscular action, when the ligaments retained in hospital after their course of treatment was con- of the joint are softened by long-continued suppuration. I cluded, so that further examination for cysts was impossible.have seen such dislocations outwards and backwards, and Seven patients, however, in whose stools Ent. histolytica cysts the only possible treatment was to amputate at the thigh. were found to persist after their emetine course were further The only other splints that would occur to any surgeon treated with Dale’s double iodide of emetine and bismuth. in this class of !case are : The Wallace-Maybury; this is These cases were discussed in THE LANCET of Jan 6th, p. 17. bad, since it tends to separate the opposing bony surfaces ’Eight of the Ent. leistnlytiecc patients had also a bacillary of the joint, and it allows the knee to sag down at each infection. In all but one it was of the Flexner type. dressing. The same remarks apply to the Thomas. Of Amœbae coli, considering how commonly they are found in course, the use of the Balkan splint with this splint is the gut, may be said to have been present only in a small obviously the best treatment in conjunction with this fixing percentage of cases. apparatus. The materials required are :Flagellate Protozoa. 1. For covering the leg : two cotton bandages, one flannel In almost all cases where any of the flagellate protozoa roller, and four strips of mackintosh 7 in. wide and of were found there was mucus mixed with fascal matter ; in a sufficient length to encircle the limb, with 2 in. overlap at -very few cases there was blood and mucus only. Tetramitus each of the four edges of the plaster splint. inesnili was the flagellate most commonly present, more often 2. Eight plaster bandages and some 2 or 3 lb. of loose in its than in its cystic stage. This was due, I plaster, three bowls, a wooden stirrer, and some warm think, to the fact that the patient’s stool was examined soon water. 3. A piece of charcoal or charred stick for marking the leg -after the diarrhoea commenced and before the slowly-forming the plaster, &c. cysts had time to develop. Repeated examinations of the and 4. The iron-hoop arches made with flanges for fixing are of :stools were not possible, but in patients who remained in the following gauge and dimensions : Breadth, 13- in. ; length, hospital for some time, and in whom further search could be the arch span, i.e., the distance of 2 in. above and below the made, tetramitus cysts were found. extreme wound, included. The flanges 3 in., and turned Lamblia intestinalis was a common infection, the cystic slightly upwards at their extreme end. The arch is to be 4 in. form being more often present than the flagellate form. high, and the sides of the arch drop vertically to the flange. This is due, I think, to this fact, that lamblias attaching The gauge should be 1/20 in., and if made of malleable iron themselves by their suckers to the mucous membrane of the can be easily bent and adapted by the fingers. 5. Half-pint of boiled linseed-oil "driers,"pint of spirit duodenum and jejunum are difficult to detach therefrom by and two brushes to apply these. the action of drugs. On the other hand, their cysts, which varnish, 6. Some strapping to fix the endings of bandages, &c. are free and mixed up with the intestinal contents, are readily washed down by aperients. Five of the cases of lamblia infection I was able to examine weekly during three months, and despite all treatment they continue to discharge lamblia cysts up to the present time. Trichomonas was found in comparatively few cases. This is peculiar, as this parasite is so often present in the stools of people living in tropical and subtropical climates. In trichomonas and cercomonas one case where I found -flagellates in the stools of a patient who subsequently died from pyæmia these flagellates were found post mortem, both in scrapings from the large bowel and in the fæecal contents. Cociclia, were found in 18 stools. In this infection mucus As a rule, these parasites was always present in the stools. disappeared within a few days, but in one patient they were found in daily examinations for three weeks. The lamblia and tetramitus infections were the most difficult to get rid of. Calomel, bismuth, thymol, salol, turpentine, emetine, and Dale’s double emetine were amongst the drugs tried without any result. Rectal irriga- FIG. 1.-Inner side of leg and thigb, showing splint applied and coattions with quinine, turpentine, eusol did not lessen the sleeve mackintosh and rings of wire to affix to Balkan. infection. of FIG. 2.-Section leg seen from below with plaster and iron arches. 1. Arches of hoop-iron. 2. Flanges in thickness of plaster. 3. Plaster of Paris. 4. Flannel roller. 5. Section of upper part of leg. METHOD OF PLASTER SPLINTING FOR FIG. 3.-The hoop-iron arches.
flagellate
________________
THE TREATMENT OF KNEE-LESIONS. BY GEORGE
DAVIS, M.D., B.S. DURH., M.R.C.S., &c.,
CAPTAIN, R.A.M.C., SURGICAL SPECIALIST TO HOSPITAL, EASTBOURNE.
THE MILITARY
ESSENTIALLY this method is a thigh plaster and leg plaster conjoined by three equidistant arches of hoop-iron. The points of the method are :-1. That the interrupting supports radiate from a point in the centre of the limb and resist mobility equally in all planes. 2. The iron-hoops being covered with plaster become one with the splint, are much strengthened and much smoother, and less awkward. 3. There is quite free room for dressings, however bulky. The splint can be made much more serviceable by having an extension of plaster around the pelvis-a spica. The technique is the outcome of my own attempts. The splint is especially suitable for all cases of long-continued suppuration of the knee and for cases of resection of the knee-joint. Also where the tibia is fractured into the knee or where infection has reached the joint from a wound in the tibia. It will be most useful where fibrous ankylosis
The detailed
technique is
as
follows
(Figs. 1-3) :-
1. Ansesthetise the patient. 2. Mark the limits to be reached by the plaster. Dress the wound and bandage firmly. Pass a cotton roller over the area to be covered by the plaster, at the same time fixing the mackintosh strips, and protecting any old healed wounds, that willbe covered by the plaster, with gauze squares. Over this put a layer of flannel roller, fastening off with a piece of
strapping.
3. Plaster bandages are applied to the thigh and leg, above and below the marks, and made of three thicknesses of bandage. This mustset"before proceeding. 4. Sling the limb to the Balkan splint and have two capable persons to hold the limb both as to lateral form and axial alignment, under the continued supervision of the surgeon. 5. The irons are covered with a layer of cotton bandage and marked 1, 2, and 3 at their upper flanges. Take them in order, and having marked with charcoal three equidistant lines cn the newly set plasters, fit each iron to its proper place by slight bending and axial twisting. When they ride truly make a complete outline of the site of each on the plaster, numbering each place. 6. The irons are now fixed, first all at one end and then at the other, by means of plaster bandages; further bandages are added until a thickness giving the required stability is
use
eliminating
INTESTINAL PROTOZOA IN SALONIKA WAR AREA. LIEUTENANT
BY
W.
ROCHE, R.A.M.C.,
PROTOZOOLOGIST, SALONIKA WAR AREA.
IV.-Percentage Incidence of B. pyocyanens, Streptococci, Staphylococci, and B. aerogenes capsulatus (Welch) in Wounds under Various Dressing Solutions compared ivith the Average Incidence of each Organism.
TABLE
(Report
to Medical Research
Committee.)
DURING the months of August, September, and October, I had the opportunity of examining the stools of 893 cases of diarrhoea and dysentery among the troops of the Salonika war area. Some of these cases had their stools examined two or three times weekly, but the great majority of them not more than once. This work was all part of the routine laboratory examination of stools of patients suffering from diarrhoea or dysentery in three of the general hospitals in this area. Troops of the Salonika zone of the Eastern Mediterranean have suffered severely from diarrhcea and dysentery. These infections started about the month of May, 1916. They have continued, with slight variations, up to the present. These variations, I think, are mainly due to climatic changes. The great spreaders of diairhcea and dysenteries are flies. Heat and moisture are necessary for these pests to thrive. In the very hot spells, when everything was dried up, flies became less numerous. On the contrary, during a cold spell, their numbers were markedly diminished, and in these periods there was decidedly less diarrhoea and dysentery. Bacillary dysentery was the predominant type, but there were quite a number of acute amoebic cases. It is a remarkable thing there were not more, inasmuch as many of the troops, particularly those which had come from Gallipoli and Egypt, were carriers of Entamaeba hixtolytiaca. Microscopical examinations of the stools of these troops in Egypt, Malta, and Salonika continually showed evidence of this.
1916,
and
hypotonic saline, where there seems to have been a slight increase in the percentage. Staphylococcus showed a slight decrease among the cases
dressed with Dakin’s solution or cresol. It seems to have been little affectea by the other dressings. In the case of the gas bacillus no effect seems to have been produced by any of the dressing solutions with the exception of quinine, where the early disappearance of the organism was strikingly apparent. This resale is consistent with earlier experience with this alkaloid, both in vitro and in clinical application. With this organism there appeared to be a higher incidence among the cases on dry dressings than among those on any of the dressing solutions. In spite of the fact, therefore, that our methods of applying antiseptics are still very inadequate and their efficiency as dressing solutions greatly hampered, definite effects on the bacterial flora of the wounds were obtained. Furthermore, these effects were evidenced in no case upon the bacterial flora in toto but upon one or more specaes of bacteria, at a timethose for which the dressing was most specific. The failure to produce a greater effect upon the streptococci and staphylococci may have been due to a deeper distribution of these organisms in the tissues, or, the other factors being equal, to the failure to use an antiseptic having an exceptional bactericidal value for those particular groups. Possibly a wider choice of dressing solutions would have shown antiseptics with this property.
Summary. It has been suggested that the specific method of treatment is applicable to wound infection as well as to systemic infection. Some instances of the variation of antiseptics in their activity against different bacteria in vitro have been offered in support of the principle. A large number of bacteriological examinations of wounds under treatment with different solutions has been recorded and instances of the specific action of certain dressing solutions demonstrated. It is believed that further analytical study of antiseptics will result in the discovery of dressings specific for one or more groups of bacteria. By a successive application of these dressings the organisms present in the wound may be reduced in number or eliminated one variety at a time, and true sterilisation of a suppurating wound accomplished. But first the concept of the "general antiseptic" must go by the board and the search for a cure-all be recognised as
Number of cases
Table of Findings. examined, 893; number of examinations, 1425.
By E.F. (free amoebae),
we mean amœbse found in fresh of stools in a resting or precystic stage. This group includes cases in which there was no time for staining, nor was further examination possible for a more complete
specimens diagnosis.
Amœbic Dysentery. the above table, Ent. histolytica was present in 37 cases. In two of these it was found post mortem. In one the patient died two hours after admittance to hospital. There were six perforations in the large gut and typical lesions of acute amoebic dysentery, from which different scrapings showed large numbers of Ent. histolytiea. This patient had never been in Egypt or Gallipoli or other inft-eted area, and he did not belong to a division that had been in one, nor was he in camp with any troops known to be infected. The second case died from sepsis, the result of a severe gunshot wound of the thigh. In the routine post-mortem examination of the organs the gut showed signs of acute amoebic dysentery, and scrapings from it showed Ent. histozytica. This patient had also never been in any unprofitable. It is a pleasure to express my acknowledgments to Dr. infected area. In cases where Ent. minuta was found a history of Joseph A. Blake for his advice and criticism, and to Miss recurrent diarrhaea was usually given. The stools were H. for Buxton their share in Mary Davies and Dr. B. large faecal with mucus, but seldom was there blood. These the technical part of this work. patients, one generally found, had been in Gallipoli or in As well as the Ent. minitta, but included in the 3 Treatment of Bacillus Pyocyaneus Infection, Journal of the Egypt. American Medical Association, Nov. 25th, 1916, vol. lxvii., p. 1598. table under that category, I found in a few cases a specially 4 Use of Quinine in the Treatment of Experimental Gas Gangrene, THE LANCET, Sept. 4th, 1915, p. 538. Use of Quinine Hydrochloride small form of amoeba with its cyst, a type which had been Solution as a Dressing for Infected Wounds, Brit. Med. Jour., Dec. 25th, demonstrated to me in Egypt by Lieutenant-Colonel Wenyon, 1915. R.A.M.C., and which has been described by him. Cases As is
seen
in
298 where any type of Ent. histolytioa was found in the stools iis the best prognosis permissible from the nature of the iinjury. Such cases often last many months, entailing intense were treated in the ordinary way with emetine (1 gr. hypo,suffering. Unless the limb is fixed without mobility a bad dermically daily for 12 days). War-time exigencies did not allow of all patients being alignment results from muscular action, when the ligaments retained in hospital after their course of treatment was con- of the joint are softened by long-continued suppuration. I cluded, so that further examination for cysts was impossible.have seen such dislocations outwards and backwards, and Seven patients, however, in whose stools Ent. histolytica cysts the only possible treatment was to amputate at the thigh. were found to persist after their emetine course were further The only other splints that would occur to any surgeon treated with Dale’s double iodide of emetine and bismuth. in this class of !case are : The Wallace-Maybury; this is These cases were discussed in THE LANCET of Jan 6th, p. 17. bad, since it tends to separate the opposing bony surfaces ’Eight of the Ent. leistnlytiecc patients had also a bacillary of the joint, and it allows the knee to sag down at each infection. In all but one it was of the Flexner type. dressing. The same remarks apply to the Thomas. Of Amœbae coli, considering how commonly they are found in course, the use of the Balkan splint with this splint is the gut, may be said to have been present only in a small obviously the best treatment in conjunction with this fixing percentage of cases. apparatus. The materials required are :Flagellate Protozoa. 1. For covering the leg : two cotton bandages, one flannel In almost all cases where any of the flagellate protozoa roller, and four strips of mackintosh 7 in. wide and of were found there was mucus mixed with fascal matter ; in a sufficient length to encircle the limb, with 2 in. overlap at -very few cases there was blood and mucus only. Tetramitus each of the four edges of the plaster splint. inesnili was the flagellate most commonly present, more often 2. Eight plaster bandages and some 2 or 3 lb. of loose in its than in its cystic stage. This was due, I plaster, three bowls, a wooden stirrer, and some warm think, to the fact that the patient’s stool was examined soon water. 3. A piece of charcoal or charred stick for marking the leg -after the diarrhoea commenced and before the slowly-forming the plaster, &c. cysts had time to develop. Repeated examinations of the and 4. The iron-hoop arches made with flanges for fixing are of :stools were not possible, but in patients who remained in the following gauge and dimensions : Breadth, 13- in. ; length, hospital for some time, and in whom further search could be the arch span, i.e., the distance of 2 in. above and below the made, tetramitus cysts were found. extreme wound, included. The flanges 3 in., and turned Lamblia intestinalis was a common infection, the cystic slightly upwards at their extreme end. The arch is to be 4 in. form being more often present than the flagellate form. high, and the sides of the arch drop vertically to the flange. This is due, I think, to this fact, that lamblias attaching The gauge should be 1/20 in., and if made of malleable iron themselves by their suckers to the mucous membrane of the can be easily bent and adapted by the fingers. 5. Half-pint of boiled linseed-oil "driers,"pint of spirit duodenum and jejunum are difficult to detach therefrom by and two brushes to apply these. the action of drugs. On the other hand, their cysts, which varnish, 6. Some strapping to fix the endings of bandages, &c. are free and mixed up with the intestinal contents, are readily washed down by aperients. Five of the cases of lamblia infection I was able to examine weekly during three months, and despite all treatment they continue to discharge lamblia cysts up to the present time. Trichomonas was found in comparatively few cases. This is peculiar, as this parasite is so often present in the stools of people living in tropical and subtropical climates. In trichomonas and cercomonas one case where I found -flagellates in the stools of a patient who subsequently died from pyæmia these flagellates were found post mortem, both in scrapings from the large bowel and in the fæecal contents. Cociclia, were found in 18 stools. In this infection mucus As a rule, these parasites was always present in the stools. disappeared within a few days, but in one patient they were found in daily examinations for three weeks. The lamblia and tetramitus infections were the most difficult to get rid of. Calomel, bismuth, thymol, salol, turpentine, emetine, and Dale’s double emetine were amongst the drugs tried without any result. Rectal irriga- FIG. 1.-Inner side of leg and thigb, showing splint applied and coattions with quinine, turpentine, eusol did not lessen the sleeve mackintosh and rings of wire to affix to Balkan. infection. of FIG. 2.-Section leg seen from below with plaster and iron arches. 1. Arches of hoop-iron. 2. Flanges in thickness of plaster. 3. Plaster of Paris. 4. Flannel roller. 5. Section of upper part of leg. METHOD OF PLASTER SPLINTING FOR FIG. 3.-The hoop-iron arches.
flagellate
________________
THE TREATMENT OF KNEE-LESIONS. BY GEORGE
DAVIS, M.D., B.S. DURH., M.R.C.S., &c.,
CAPTAIN, R.A.M.C., SURGICAL SPECIALIST TO HOSPITAL, EASTBOURNE.
THE MILITARY
ESSENTIALLY this method is a thigh plaster and leg plaster conjoined by three equidistant arches of hoop-iron. The points of the method are :-1. That the interrupting supports radiate from a point in the centre of the limb and resist mobility equally in all planes. 2. The iron-hoops being covered with plaster become one with the splint, are much strengthened and much smoother, and less awkward. 3. There is quite free room for dressings, however bulky. The splint can be made much more serviceable by having an extension of plaster around the pelvis-a spica. The technique is the outcome of my own attempts. The splint is especially suitable for all cases of long-continued suppuration of the knee and for cases of resection of the knee-joint. Also where the tibia is fractured into the knee or where infection has reached the joint from a wound in the tibia. It will be most useful where fibrous ankylosis
The detailed
technique is
as
follows
(Figs. 1-3) :-
1. Ansesthetise the patient. 2. Mark the limits to be reached by the plaster. Dress the wound and bandage firmly. Pass a cotton roller over the area to be covered by the plaster, at the same time fixing the mackintosh strips, and protecting any old healed wounds, that willbe covered by the plaster, with gauze squares. Over this put a layer of flannel roller, fastening off with a piece of
strapping.
3. Plaster bandages are applied to the thigh and leg, above and below the marks, and made of three thicknesses of bandage. This mustset"before proceeding. 4. Sling the limb to the Balkan splint and have two capable persons to hold the limb both as to lateral form and axial alignment, under the continued supervision of the surgeon. 5. The irons are covered with a layer of cotton bandage and marked 1, 2, and 3 at their upper flanges. Take them in order, and having marked with charcoal three equidistant lines cn the newly set plasters, fit each iron to its proper place by slight bending and axial twisting. When they ride truly make a complete outline of the site of each on the plaster, numbering each place. 6. The irons are now fixed, first all at one end and then at the other, by means of plaster bandages; further bandages are added until a thickness giving the required stability is