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52 Annotations NEW PROBLEMS IN MENINGITIS IT is not very long since we first incredulously heard of cures of pneumococcal meningitis, but we may have been slow to realise that new remedies have introduced new problems. With penicillin and sulphonamides most patients with purulent meningitis will now recover, but we must set a fresh standard and not be content until the proportion of recoveries is the highest - possible. For example, in cases of pneumococcal meningitis which relapse repeatedly after sulphonamide and intrathecal penicillin by the lumbar route it may be desirable to give penicillin repeatedly into the ventricles of the brain. Elsewhere in this issue Shalom shows that circulation of cerebrospinal fluid may be blocked at the foramen mag- num to such an extent that lumbar intrathecal penicillin, though it cures the spinal meningitis, cannot reach the base of the brain. Of special importance is his observa- tion that in such a case reduction of intracranial pressure by ventricular tap leads to a flow of purulent fluid into the spinal theca and prompt relief of the other signs of foraminal impaction. He maintains that, when peni- cillin is given by lumbar puncture, artificial reduction of intracranial pressure will release the block at the foramen magnum and allow the penicillin to reach the meninges at the base of the brain. His application of this idea was to give 20% dextrose intramuscularly with penicillin every 3 hours, one of the injections to follow closely the daily intrathecal dose of penicillin. This routine may or may not be sound, but the principle of artificially reducing intracranial pressure immediately after giving intrathecal penicillin certainly deserves further trial. Most neurologists will probably prefer to attempt this in the first place either by ventricular tap or by a single intravenous injection of hypertonic dex- trose. The efficacy of the method chosen can readily be tested in the ways Shalom describes. THE SKIN AS A WATERPROOF IT is now a commonplace that one of the most serious consequences pf burns is dehydration, but it has always seemed a little surprising that the loss of fluid can be so extensive from the local lesion. A recent investigation of the water-retaining properties of the skin, carried out by Burch and Winsor of New Orleans, enables us to visualise the magnitude of loss to be expected. They have collected the moisture which seeps through the skin of the abdomen by sealing on to it a capsule, from the interior of which the moisture is continuously re- moved by a stream of dry oxygen. Conditions under which sweating occurs were avoided, and it was shown that when the interior of the capsule became saturated with water vapour through stopping the ventilation no further accumulation of moisture took place—i.e., the process being measured was the passive one of diffusion which automatically stopped as soon as there was no wet-to-dry gradient from the inside to the outside of the skin. The rate of water loss from the surface was about 0-1 mg. per sq. cm. per min., and was practically the same as that from pieces of skin removed immediately after death and freely exposed to water. It was also the same as the rate of diffusion through the outer surface of a blister raised by cantharides and big enough to take the capsule. Cutting away the blister with the capsule attached made no difference to the transfer of water through the skin cut away, even after it had been kept for 24 hours. The surprising uniformity of all these findings throws into ctntrast the rate of water loss from the exposed floor of the blister, which was nearly 10 times as great. Thoroughly controlled experiments show beyond doubt that the waterproof layer is the stratum corneum of the skin. Dissolving out fatty 1. Burch, G. E., Winsor, T. Arch. intern. Med. 1945, 74, 428, 437. materials from the surface layer with fat-solvents made no difference to the diffusion rate, and neither did the ’ production of an erythema. Sandpapering, on the other hand, by actually removing the cornified layer caused a rapid increase in water loss. j . The same workers 2 have investigated the loss of water by diffusion from the skin of the whole body by two good methods ’at a temperature of 75° F and a relative humidity of 50%. It averaged 1.63 g. per sq. metre in 10 minutes and represents about 1/5th of the loss which would be estimated on the basis of the capsule experiments. The difference is presumably due to the skin being exposed in the one case to a moving stream of dry oxygen and in the other to relatively still air half saturated with moisture. In more familiar figures the actual loss would represent about 400 g. a day, whereas calculated on the basis of the capsule experiments, which must represent the maximum possible, it would be 2000 g. a day. If we assume that denuded skin can lose water at ten times the rate of normal skin, then these quantities should also apply to 1/l0th of the body surface over which the stratum corneum had been destroyed. The loss of fluid from the blood into the swelling of an extensive local injury is regarded as important, but it now appears that from a burn or abrasion covering this area water can be lost at a rate equivalent to that of its natural evaporation from the whole’ of the rest of the body, and that in conditions favouring evaporation or removal of the exudate by other means the loss might attain very high values indeed. THE MEMORY OF LAWSON TAIT DEFINITIONS ot genius cannot be adequate. The recipe is not known for a power in which the ingredients range, at different times and in different people, from an infinite capacity for taking pains to a painless and joyful facility. In medicine, however, and perhaps especially in surgery, genius is often associated with an abundant and thirsty energy--an ability to do twice as much as anybody else in half-the time. This inspired hypomania certainly distinguished Lawson Tait, whose centenary was celebrated on June 30 at Birmingham, his adopted city. Members of the Midland Medical Society, the University of Birmingham, and the Birmingham Women’s Hospital met at Nuffield House, in Queen Elizabeth Hospital, to honour him ; and as part of the ceremony the honorary degree of doctor of laws was conferred on Major-General P. R. Hawley, chief surgeon to the American Forces in the European theatre of war, and Mr. Eardley Holland, PRCOG. Prof. Leonard Gamgee, in an oration on Tait, des- cribed him as " clear-thinking, courageous, original, inventive, bound by no precedent." He was born at Edinburgh in 1845, qualified there, and at the age of 22 became a house-surgeon at Wakefield. In 1870, having become FRCSE and FRCS, he bought a practice at Birm- ingham, but found his energy and surgical ability lacked scope ; and at 26, without a hospital appointment, and with only his self-reliance to justify him, he gave up general practice to be a consulting surgeon. He pros- pered and, helped by Arthur Chamberlain, he was soon responsible for founding the Birmingham -Women’s Hospital, housed at first in a converted farmhouse. As a member of its staff he became an increasingly brilliant operator, and achieved the sequence of advances in abdominal surgery which have made him famous. Pro- fessor Gamgee recalled that he brought down the mortal- ity-rate from ovariotomy from nearly 30% to less than 4’5%, a remarkably low figure for his day. By a para- dox, Tait, who was a strong opponent of Lister and did not understand the principles directing him, yet by his own scrupulous attention to cleanliness improved on Lister’s methods and became the first exponent of 2. Amer. J. med. Sci. 1945, 209, 226.
