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FROST-BITE.
401
turpentine and lanoline applications; thorough cleansing and drying, followed by the swathing of the foot in boracic acid powder and wool; painting with tincture of iodine ; and I really think that, apart from the so forth. pain inflicted, there is no appreciable differ-
tried :
Correspondence. " Audi alteram
partem."
MILD SMALL-POX. To the Editor of THE LANCET.
in the results of these or other methods. time all cases were treated by local applications, over which was a covering of wool with a bandage. It is usual to hear the statement made that great pain is suffered by many, indeed by almost all, of the patients. The pain at times may be so severe as to call for morphine or opium for its relief. The pain, however, is due, not so much to the damage inflicted upon the parts, but to the fact that the feet are kept warm. During the last few weeks here the majority of the patients have had little or no dressing applied. The parts affected are smeared with some ointment, covered with a thin layer of gauze, and left without wool or bandage. The feet are often raised a few inches from the bed upon a hard pillow. The lower part of the legs and the feet are covered in bed only by a sheet. It has been our experience with few exceptions to find that the pain is very considerably lessened or abolished by keeping the parts cold. A patient whose feet have been well wrapped up and bandaged and who has nights of torture will experience relief in a few hours when the bandages are removed and the bedclothes are turned back. Pain, it may truthfully be said, is almost exactly proportioned to the degree of warmth of the foot. Seeing that, whatever the local treatment, the progress towards recovery in the foot appears to be equally rapid, it is the relief of pain during the time of healing that should be our chief consideraI am, Sir, yours faithfully, tion. BERKELEY MOYNIHAN, Feb. 13th, 1915. ence
At
one
’SIR,-In connexion with an annotation in ’THE LANCET of Feb. 13th, may I add a word on the ,subject, as I was unavoidably absent from the meeting of the Section of Epidemiology of the ’Royal Society of Medicine at which Dr. J. B. Cleland ,,and Dr. E. W. Ferguson reported on the outbreaks .,of small-pox in Australia ? Studying the disease during successive years, I ,came to the conclusion that it was not safe to .make any statement about it without consulting ’Sydenham, and students of these present mild outbreaks would have done well, as Dr. McPhail ,reminded them in the discussion, to look up the history of prevaccination outbreaks. The .extraordinary difference in their virulence was ,not only recognised by Sydenham, but by Van f3wieten, Mason Good, Jenner, and others. Mason Good mentions that in his own case (1770) he had not more than 20 scattered pustules, and Jenner ’describes an epidemic as mild and light as the inoculated variety. All the same, it is not a . pleasant experience, as happened in my wards, to have an outbreak arise and not reach a diagnosis until the seventh or eighth case proves to be one of confluent small-pox! One unvaccinated child had not more than half a dozen superficial pustules, and Welch and Schamberg report an instance with a single pox. Apart from the low virulence, an interesting feature of many of the recent American - outbreaks has been the high percentage of unvaccinated attacked-96 out of 97 cases in the out,break at Carbondale, Pennsylvania (1912). With this history one cannot agree with the conTHE POSITION OF THE FRENCH RED clusion of Dr. Cleland and Dr. Ferguson that in CROSS IN ENGLAND. Australia or elsewhere small-pox is unlikely to To the Editor of THE LANCET. recover again its general intense virulence. I am, Sir, yours faithfully, SIR,-The attention of our committee has been called to an appeal in your issue of Feb. 6th, p. 303, WILLIAM OSLER. Oxford, Feb. 13th, 1915. on behalf of the Wounded Allies Relief Committee for £100,000 for the purpose of establishing, or FROST-BITE. maintaining certain Anglo-French hospitals in To the Editor of THE LANCET. France. The admirable work done by THE LANCET SIR,-The paper by Mr. A. W. Mayo-Robson since the war began in aid of the wounded of all in THE LANCET nationalities makes one hesitate to offer anything on Frost-bite, which appears -,of Jan. 16th, is timely. The subject is certainly that may even savour of criticism. At the same of the most interesting, and is among time, in the best interests of at any rate the French - one the most novel of those which have come wounded, it seems well to call attention to certain under our consideration since the beginning facts. ’of this war. The severity of the cases which There is no doubt that in some of the distant of strife-Serbia, for instance-there is we have had in Rouen has varied within the fields widest limits. There are cases in which no ample scope for new societies and fresh individual - appreciable changes have taken place in the appear- effort. In the case of the French, however, these ance of the limbs, yet the whole of the skin, especonsiderations do not apply, and the advocacy of that on inner the side of the foot and on the new societies established through the enthusiasm cially dorsum of the toes, is acutely hypersensitive even of doubtless sincerely well-meaning people can to the lightest touch. There are, at the other result only in loss of coordination, overlapping, extreme, cases in which to all appearance the whole and not infrequently inevitable friction with foot is doomed to gangrene. thoroughly established and fully recognised organiI am not, however, at this moment so much con- sations. France has had for many years three cerned with the various grades of injury, with the excellent organisations for rendering assistance to means by which the condition is produced, nor with the injured in any public calamity. These are : La the absolute necessity in all cases of conservative Societe Francaise de Secours aux Blesses, 1’Union treatment. I wish more particularly to give a hint des Femmes de France, and 1’Association des with regard to the care of these patients. A great Dames Françaises. As regards the organisation of variety of methods of local treatment have been help from this country, the French Government,
suffered
turpentine and lanoline applications; thorough cleansing and drying, followed by the swathing of the foot in boracic acid powder and wool; painting with tincture of iodine ; and I really think that, apart from the so forth. pain inflicted, there is no appreciable differ-
tried :
Correspondence. " Audi alteram
partem."
MILD SMALL-POX. To the Editor of THE LANCET.
in the results of these or other methods. time all cases were treated by local applications, over which was a covering of wool with a bandage. It is usual to hear the statement made that great pain is suffered by many, indeed by almost all, of the patients. The pain at times may be so severe as to call for morphine or opium for its relief. The pain, however, is due, not so much to the damage inflicted upon the parts, but to the fact that the feet are kept warm. During the last few weeks here the majority of the patients have had little or no dressing applied. The parts affected are smeared with some ointment, covered with a thin layer of gauze, and left without wool or bandage. The feet are often raised a few inches from the bed upon a hard pillow. The lower part of the legs and the feet are covered in bed only by a sheet. It has been our experience with few exceptions to find that the pain is very considerably lessened or abolished by keeping the parts cold. A patient whose feet have been well wrapped up and bandaged and who has nights of torture will experience relief in a few hours when the bandages are removed and the bedclothes are turned back. Pain, it may truthfully be said, is almost exactly proportioned to the degree of warmth of the foot. Seeing that, whatever the local treatment, the progress towards recovery in the foot appears to be equally rapid, it is the relief of pain during the time of healing that should be our chief consideraI am, Sir, yours faithfully, tion. BERKELEY MOYNIHAN, Feb. 13th, 1915. ence
At
one
’SIR,-In connexion with an annotation in ’THE LANCET of Feb. 13th, may I add a word on the ,subject, as I was unavoidably absent from the meeting of the Section of Epidemiology of the ’Royal Society of Medicine at which Dr. J. B. Cleland ,,and Dr. E. W. Ferguson reported on the outbreaks .,of small-pox in Australia ? Studying the disease during successive years, I ,came to the conclusion that it was not safe to .make any statement about it without consulting ’Sydenham, and students of these present mild outbreaks would have done well, as Dr. McPhail ,reminded them in the discussion, to look up the history of prevaccination outbreaks. The .extraordinary difference in their virulence was ,not only recognised by Sydenham, but by Van f3wieten, Mason Good, Jenner, and others. Mason Good mentions that in his own case (1770) he had not more than 20 scattered pustules, and Jenner ’describes an epidemic as mild and light as the inoculated variety. All the same, it is not a . pleasant experience, as happened in my wards, to have an outbreak arise and not reach a diagnosis until the seventh or eighth case proves to be one of confluent small-pox! One unvaccinated child had not more than half a dozen superficial pustules, and Welch and Schamberg report an instance with a single pox. Apart from the low virulence, an interesting feature of many of the recent American - outbreaks has been the high percentage of unvaccinated attacked-96 out of 97 cases in the out,break at Carbondale, Pennsylvania (1912). With this history one cannot agree with the conTHE POSITION OF THE FRENCH RED clusion of Dr. Cleland and Dr. Ferguson that in CROSS IN ENGLAND. Australia or elsewhere small-pox is unlikely to To the Editor of THE LANCET. recover again its general intense virulence. I am, Sir, yours faithfully, SIR,-The attention of our committee has been called to an appeal in your issue of Feb. 6th, p. 303, WILLIAM OSLER. Oxford, Feb. 13th, 1915. on behalf of the Wounded Allies Relief Committee for £100,000 for the purpose of establishing, or FROST-BITE. maintaining certain Anglo-French hospitals in To the Editor of THE LANCET. France. The admirable work done by THE LANCET SIR,-The paper by Mr. A. W. Mayo-Robson since the war began in aid of the wounded of all in THE LANCET nationalities makes one hesitate to offer anything on Frost-bite, which appears -,of Jan. 16th, is timely. The subject is certainly that may even savour of criticism. At the same of the most interesting, and is among time, in the best interests of at any rate the French - one the most novel of those which have come wounded, it seems well to call attention to certain under our consideration since the beginning facts. ’of this war. The severity of the cases which There is no doubt that in some of the distant of strife-Serbia, for instance-there is we have had in Rouen has varied within the fields widest limits. There are cases in which no ample scope for new societies and fresh individual - appreciable changes have taken place in the appear- effort. In the case of the French, however, these ance of the limbs, yet the whole of the skin, especonsiderations do not apply, and the advocacy of that on inner the side of the foot and on the new societies established through the enthusiasm cially dorsum of the toes, is acutely hypersensitive even of doubtless sincerely well-meaning people can to the lightest touch. There are, at the other result only in loss of coordination, overlapping, extreme, cases in which to all appearance the whole and not infrequently inevitable friction with foot is doomed to gangrene. thoroughly established and fully recognised organiI am not, however, at this moment so much con- sations. France has had for many years three cerned with the various grades of injury, with the excellent organisations for rendering assistance to means by which the condition is produced, nor with the injured in any public calamity. These are : La the absolute necessity in all cases of conservative Societe Francaise de Secours aux Blesses, 1’Union treatment. I wish more particularly to give a hint des Femmes de France, and 1’Association des with regard to the care of these patients. A great Dames Françaises. As regards the organisation of variety of methods of local treatment have been help from this country, the French Government,
suffered