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INFECTIONS OF FINGERS AND HAND
1010
CORRESPONDENCE CHLOROFORM
To the Editor
of THE
LANCET
SIR,-The restrained letter from Dr. J. E. C. Rouse in your issue of Oct. 10th on the subject of chloroform is most timely. It is the fashion in England to decry chloroform. During my service in India, as a civil surgeon, I estimate that I had chloroform administered for me at least 13,000 times with only two deaths. Further comment seems unnecessary. I am, Sir, yours faithfully, T. HUNTER, Lieut.-Colonel, I.M.S. (ret.) ; late Civil Surgeon, Lucknow.
FIXED DENTAL APPLIANCES
To the Editor
of THE
LANCET
interested to read Dr. Bardswell’s supports my claim that, in favourable circumstances, fixed dental appliances can be free from the vices they have been so often accused of. In his case I understand that the teeth supporting the work were devitalised, and, this being so, it "’ appears that even the much execrated " dead tooth, with a little expert encouragement, can be usefully employed on occasion. It is my experience, however, that when compared with other and vital teeth in the same mouth the devitalised members may have shorter periods of existence, and I try to avoid interfering with the vitality of pulps for this
SIR,-I
was
letter which
reason. as it is not a necessary part of the procedure that teeth in the incisor region and elsewhere should be devitalised and excised in order to support " bridges," even the doubtful ones can feel satisfied that no new cause of apical infection can be introduced when this work is attached. This kind of restoration in most cases can be made so quickly, and with so little interference with the structure of the teeth which act as its supports, that there is small excuse for wearing a removable appliance which is apt to damage the structures it is in I am, Sir, yours faithfully, contact with. J. H. OLVER. 16th. Oct. Park-crescent, W.,
But,
now
NEPHRITIS AND THE SERUM FEVER REACTION
To the Editor
of
THE LANCET
SiR,-Sir William Willcox in his address
on clinical of which appeared in THE LANCET last week, states that " If a patient is allergic, or has any disease associated with hypersensitiveness, such as exophthalmic goitre or nephritis, dangerous symptoms may be associated with the serum fever reaction." I agree with him to the extent that there are certain forms of hypersensitiveness the subjects of which are not suitable for serum treatment. But is nephritis one of these ? Your readers will remember that when the serum treatment of diphtheria was introduced 42 years ago, it was accused of being the cause of certain morbid states of the kidneys. But in my experience that was so far from being the case that I published in your columns (1896, ii., 1450) three instances of patients, the subjects of the nephritis which follows scarlet fever, who were treated with serum without ill effects. I published subsequently the notes of two similar cases (Rep. of the Clinical Society’s
immunity,
an
abridgement
Committee on the Antitoxin of Diphtheria, 1898, p. 36). After that date I observed several cases of the same sort; so far as post-scarlatinal nephritis is concerned there is no harm, in my experience, in administering horse serum. I remember also one case of chronic nephritis, not due to scarlet fever, in which the patient who contracted diphtheria was treated with serum without any ill effect. I am, Sir, yours faithfully, E. W. GOODALL. Hemingford Abbots, Hunts, Oct. 18th.
INFECTIONS OF FINGERS AND HAND
To the Editor
of THE
LANCET
SIR,-I have read Mr. Handfield-Jones’s article and Sir David Wilkie’s comments on it with great interest. There are but few engaged in the practice of surgery over a number of years who have escaped the tragic experience of the loss of a colleague or friend from streptococcal lymphangitis following a trivial injury. Whether the infection arises in the lip, or following the extraction of a tooth, or the prick of a finger, the outlook is the same. Look. ing back I realise that mortality was often the result of too active surgical treatment. There is no place for the knife in cases of acute lymphangitis. A minor lesion followed by red lines, rigors, and high temperature calls for conservatism. Operative surgery is contra-indicated. Handfield-Jones and Wilkie have emphasised this point. Patience and delay are the watchwords. Active measures must be left to Nature’s powerful efforts at defence ; conservatism on the part of the surgeon assists this activity to become effective. By conservatism we mean, as pointed out by Wilkie, the injection of concentrated antistreptococcal serum, the light application of a Bier’s bandage for three days above the infected area and heat to the limb. The injection of Prontosil as advocated by Handfield-Jones is full of promise. Personally I avoid stupes. Their application causes constant disturbance, the skin becomes soppy and a nidus for infection, the heat is transitory. Rest is essential. The limb should be splinted over copious layers of cotton-wool or encircled by an electrically heated pad. Many acute cases resolve under such manage. ment, but there are some which cause daily anxiety for many weeks. In the latter group the appearance of localised pus in the axilla or elsewhere is the first ray of hope. When localisation is manifest further delay is indicated; we should wait until the process of walling-off is complete. If the abscess opens spontaneously all will be well, if we hasten the process it should be by the mere prick of a sharp knife. No forceps should be introduced to enlarge the opening, no squeezing or milking of the abscess should be attempted. Fulminating cases seldom survive, death terminates the infection within two or three days. I have however seen many desperate cases recover when only the most conservative methods of treat. ment were employed and when abscess formation was patiently awaited. It goes without saying that playing for time in anxious cases taxes the power of restraint. Time may be well employed by the giving of blood transfusions, the instalment of the glucose drip, and the employment of sunshine, artificial or real. I am,
Sir, yours faithfully,
Harley-street, W., Oct.
19th.
W. I.
DE C. WHEELER.
CORRESPONDENCE CHLOROFORM
To the Editor
of THE
LANCET
SIR,-The restrained letter from Dr. J. E. C. Rouse in your issue of Oct. 10th on the subject of chloroform is most timely. It is the fashion in England to decry chloroform. During my service in India, as a civil surgeon, I estimate that I had chloroform administered for me at least 13,000 times with only two deaths. Further comment seems unnecessary. I am, Sir, yours faithfully, T. HUNTER, Lieut.-Colonel, I.M.S. (ret.) ; late Civil Surgeon, Lucknow.
FIXED DENTAL APPLIANCES
To the Editor
of THE
LANCET
interested to read Dr. Bardswell’s supports my claim that, in favourable circumstances, fixed dental appliances can be free from the vices they have been so often accused of. In his case I understand that the teeth supporting the work were devitalised, and, this being so, it "’ appears that even the much execrated " dead tooth, with a little expert encouragement, can be usefully employed on occasion. It is my experience, however, that when compared with other and vital teeth in the same mouth the devitalised members may have shorter periods of existence, and I try to avoid interfering with the vitality of pulps for this
SIR,-I
was
letter which
reason. as it is not a necessary part of the procedure that teeth in the incisor region and elsewhere should be devitalised and excised in order to support " bridges," even the doubtful ones can feel satisfied that no new cause of apical infection can be introduced when this work is attached. This kind of restoration in most cases can be made so quickly, and with so little interference with the structure of the teeth which act as its supports, that there is small excuse for wearing a removable appliance which is apt to damage the structures it is in I am, Sir, yours faithfully, contact with. J. H. OLVER. 16th. Oct. Park-crescent, W.,
But,
now
NEPHRITIS AND THE SERUM FEVER REACTION
To the Editor
of
THE LANCET
SiR,-Sir William Willcox in his address
on clinical of which appeared in THE LANCET last week, states that " If a patient is allergic, or has any disease associated with hypersensitiveness, such as exophthalmic goitre or nephritis, dangerous symptoms may be associated with the serum fever reaction." I agree with him to the extent that there are certain forms of hypersensitiveness the subjects of which are not suitable for serum treatment. But is nephritis one of these ? Your readers will remember that when the serum treatment of diphtheria was introduced 42 years ago, it was accused of being the cause of certain morbid states of the kidneys. But in my experience that was so far from being the case that I published in your columns (1896, ii., 1450) three instances of patients, the subjects of the nephritis which follows scarlet fever, who were treated with serum without ill effects. I published subsequently the notes of two similar cases (Rep. of the Clinical Society’s
immunity,
an
abridgement
Committee on the Antitoxin of Diphtheria, 1898, p. 36). After that date I observed several cases of the same sort; so far as post-scarlatinal nephritis is concerned there is no harm, in my experience, in administering horse serum. I remember also one case of chronic nephritis, not due to scarlet fever, in which the patient who contracted diphtheria was treated with serum without any ill effect. I am, Sir, yours faithfully, E. W. GOODALL. Hemingford Abbots, Hunts, Oct. 18th.
INFECTIONS OF FINGERS AND HAND
To the Editor
of THE
LANCET
SIR,-I have read Mr. Handfield-Jones’s article and Sir David Wilkie’s comments on it with great interest. There are but few engaged in the practice of surgery over a number of years who have escaped the tragic experience of the loss of a colleague or friend from streptococcal lymphangitis following a trivial injury. Whether the infection arises in the lip, or following the extraction of a tooth, or the prick of a finger, the outlook is the same. Look. ing back I realise that mortality was often the result of too active surgical treatment. There is no place for the knife in cases of acute lymphangitis. A minor lesion followed by red lines, rigors, and high temperature calls for conservatism. Operative surgery is contra-indicated. Handfield-Jones and Wilkie have emphasised this point. Patience and delay are the watchwords. Active measures must be left to Nature’s powerful efforts at defence ; conservatism on the part of the surgeon assists this activity to become effective. By conservatism we mean, as pointed out by Wilkie, the injection of concentrated antistreptococcal serum, the light application of a Bier’s bandage for three days above the infected area and heat to the limb. The injection of Prontosil as advocated by Handfield-Jones is full of promise. Personally I avoid stupes. Their application causes constant disturbance, the skin becomes soppy and a nidus for infection, the heat is transitory. Rest is essential. The limb should be splinted over copious layers of cotton-wool or encircled by an electrically heated pad. Many acute cases resolve under such manage. ment, but there are some which cause daily anxiety for many weeks. In the latter group the appearance of localised pus in the axilla or elsewhere is the first ray of hope. When localisation is manifest further delay is indicated; we should wait until the process of walling-off is complete. If the abscess opens spontaneously all will be well, if we hasten the process it should be by the mere prick of a sharp knife. No forceps should be introduced to enlarge the opening, no squeezing or milking of the abscess should be attempted. Fulminating cases seldom survive, death terminates the infection within two or three days. I have however seen many desperate cases recover when only the most conservative methods of treat. ment were employed and when abscess formation was patiently awaited. It goes without saying that playing for time in anxious cases taxes the power of restraint. Time may be well employed by the giving of blood transfusions, the instalment of the glucose drip, and the employment of sunshine, artificial or real. I am,
Sir, yours faithfully,
Harley-street, W., Oct.
19th.
W. I.
DE C. WHEELER.