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INFECTIONS OF THE HAND
848 several hospitals over the past few years, but in the last 20-30 cases treated in this way I have never failed to obtain this healed skin tube-not even in " complicated " " cases which had necessarily to be left open " for some days. (A proportion of the patients-as in Mr. Tumarkin’s series-had some eustachian discharge, but there are mucous glands in the tube, and if this remains patent some mucous discharge is to be expected. Many otologists have tried methods of assuring eustachian closure in the radical operation, but I have read of no claims of universal success.) To sum up, there is great need for an operation which will eliminate sepsis and preserve hearing in cases where the tympanic structures can still serve a useful soundconducting function, and it is to be hoped that other otologists will confirm that Mr. Tumarkin’s operation, in selected cases, is more successful than the many so-called " modified radical " operations that have been proposed in the past-and usually abandoned in the course of time. But in cases where the condition of the tympanic and/or mastoid structures makes a radical procedure necessary, I would urge otologists to try Mr. Sheridan’s operation with conservation of the cutaneous meatus. NORMAN A. PUNT. 31st British General Hospital, British Troops Austria. BELGIAN TRIAL OF STREPTOMYCIN
SiB,—Since the publication of the Medical Research Council report on streptomycin in tuberculous meningitis, I have received from Dr. Dubois, of Brussels, a report published in November, 1947, but which I had not seen previously, ’concerning the trials conducted by him and
-
Success is due to the fact that in this unit are all regarded as surgical cases of the
treatment.
infected fingers
first magnitude. There was- undoubtedly .
a
time when much havoc
wrought by inadequate surgery. Unfortunately the pendulum swung too far, and it may be as difficultto and other erase those mutilating " hockey stick
was
"
"
classical " incisions from the minds of modern surgeons it was to instil them into the surgeons of the past. ROBIN BURKITT. Ashford County Hospital,
as
Ashford, Middlesex.
SiR,-In the first eight months of last year 528 septic hands were treated in the hand clinic at this hospital, of which 80 were pulp-space infections. Of these, 62 were recorded fully enough for review. Of 18 treated by the orthodox incision or incisions within three days of onset, none developed osteitis of the phalanx. Of 44 first seen four or more days after onset, 13 had or developed osteitis, with delayed convalescence and (in some) permanent deformity.
I feel that Professor Pilcher pays too little tribute to the care and enthusiasm devoted by himself and his colleagues to the cases he describes. Septic hands, whether treated according to his principles or according to more orthodox " ones, will get well much more rapidly if they have the benefits of personal frequent attention from experienced surgeons, continuous supervision of dressing technique, plenty of time (as, for instance, for nerve-block anaesthesia), and the professorial authority which provides inpatient treatment when "
required.
Under the conditions at present obtaining in the his co-workers.1 The results reported from Brussels are of hospitals, however, I regard it as inadvisable majority superior to any published elsewhere (with the exceptiongenerally to adopt the conservative treatment of pulpof a small series by Lincoln in New York) and I hasten and, space infections, with or without penicillin; to bring them to your notice. indeed, until all those. who read Professor Pilcher’s Dubois reports on the condition, five months after article can avail themselves of his facilities, almost commencing treatment, of 24 patients with tuberculous dangerous to be aware of it. Most necrosed phalanges meningitis treated with streptomycin by both intra- are due to attempts at " conservative" (admittedly muscular and intrathecal routes ; 5 patients had died, inadequate) treatment on the part of the patient, his 2 were seriously ill, and 17 were making good clinical home doctor, or an overworked understaffed casualty progress and were without signs of meningitis apart from department. For some time to come, early incision, a Doses persistently abnormal cerebrospinal fluid. made, will confer the greatest good on the properly similar to those given in the M.R.C. trials were employed. greatest number. The main difference was in rhythm of treatment, particuT. G. LOWDEN. Royal Infirmary, Sunderland. larly in the long periods during which treatment was PRIMARY ATYPICAL PNEUMONIA suspended completely. The regimen was as follows : 45 days combined therapy (intrathecal daily) ; 20 days SiB,—I should like to suggest that the outbreak of rest; 20 days combined therapy (intrathecal daily) ; primary atypical pneumonia reported by Dr. J. W. 20 days complete rest; 30 days combined therapy Stephens in your issue of May 8 was caused not by a virus (intrathecal every 2 days). but by the Rickettsia burneti, the causative agent of Q It is stressed in the report that the results given were fever and of " Balkan grippe," a similar respiratory those observed at the end of five months, and that these infection occurring in Greece and Southern Europe. As results were modified in patients observed for a longer Dr. Stephens says, Q fever was later found to have been period, by a number of late relapses. The course of the the cause of several outbreaks of acute upper respiratory disease in a second five-month period is to be reported infection in Italy during the winter of 1944-45, though in a later paper. this fact was not recognised by him at the time. MARC DANIELS. London, W.C.I. The cases which he describes are similar in many to those reported as primary atypical pneumonia respects THE INFECTIONS OF HAND Turnerand by Adams et awl.2 Several similar outby SIR,-I have read with great interest the article of breaks, including one in a British parachute regiment May 22 by Professor Pilcher and others. I have waited that had recently been transferred from Athens, were -for a long time to hear authoritative doubt cast on the investigated at the same time by a team of American mechanical theory of terminal phalangeal necrosis. It workers (Robbins and Rustigan 3). The diagnosis of Q is also refreshing to hear the conservative treatment of fever was confirmed by the isolation of R. burneti from infected hands preached from so distinguished a pulpit. the blood and by serological tests. It was also shown. At this hospital we are fortunate in being able to admit that approximately 75% of cases of "atypical pneuall but the most trivial cases of infected hands. Their monia " occurring in Italy were, in fact, cases of Q treatment stands on a firm tripod of rest, elevation, fever. The cases reported by Dr. Stephens occurred in and systemic penicillin. Resolution is the rule, but if March, 1946, a year later, at about the same season the abscess points, the pus is evacuated through a minimal (January-March) and in the same-area (Naples-Caserta). incision. As your contributors point out, the " classical " Furthermore it was shown bv the American workers incisions advocated by Kanavel and others have no that quite a high proportion of the civilian population in place whatever in modern treatment. During 21/2 years this area showed a high level of antibodv to Q fever, here as registrar and then chief assistant to a busy surgical suggesting that the infection was endemic (Commission unit, I can recollect only one case in which necrosis of the 4). In view on Acute Respiratory Diseases, Fort Bragg terminal phalanx resulted from a pulp-space infection, of these findings Caughey and Dudgeon5 re-examined and only one patient who was left with stiffness of her 1. Turner, R. W. D. Lancet, 1945, i, 493. terminal interphalangeal joint. As we seldom have less 2. Adams, A. B., Staveley, J. M., Rolleston, G. L., Henley, W. E., than half a dozen " septic fingers " in our wards, such Caughey, J. E. Brit. med. J. 1946, i, 227. the results prove fairly conclusively value of conservative 3. Bobbins, F. C., Rustigan R. Amer. J. Hyg. 1946. 44, 72. on Acute Respiratory Diseases, Fort Bragg. Ibid, 1944, 44, 103. 5. Caughey, J. E., Dudgeon, J. A. Brit. med. J. 1947, ii, 684.
4. Commission
1.
Dubois, R., Linz, R., Leschanowski, H., Schlesser, R., Wattiez, R. Acta pædiat. belg. 1947, 4, 193.
SiB,—Since the publication of the Medical Research Council report on streptomycin in tuberculous meningitis, I have received from Dr. Dubois, of Brussels, a report published in November, 1947, but which I had not seen previously, ’concerning the trials conducted by him and
-
Success is due to the fact that in this unit are all regarded as surgical cases of the
treatment.
infected fingers
first magnitude. There was- undoubtedly .
a
time when much havoc
wrought by inadequate surgery. Unfortunately the pendulum swung too far, and it may be as difficultto and other erase those mutilating " hockey stick
was
"
"
classical " incisions from the minds of modern surgeons it was to instil them into the surgeons of the past. ROBIN BURKITT. Ashford County Hospital,
as
Ashford, Middlesex.
SiR,-In the first eight months of last year 528 septic hands were treated in the hand clinic at this hospital, of which 80 were pulp-space infections. Of these, 62 were recorded fully enough for review. Of 18 treated by the orthodox incision or incisions within three days of onset, none developed osteitis of the phalanx. Of 44 first seen four or more days after onset, 13 had or developed osteitis, with delayed convalescence and (in some) permanent deformity.
I feel that Professor Pilcher pays too little tribute to the care and enthusiasm devoted by himself and his colleagues to the cases he describes. Septic hands, whether treated according to his principles or according to more orthodox " ones, will get well much more rapidly if they have the benefits of personal frequent attention from experienced surgeons, continuous supervision of dressing technique, plenty of time (as, for instance, for nerve-block anaesthesia), and the professorial authority which provides inpatient treatment when "
required.
Under the conditions at present obtaining in the his co-workers.1 The results reported from Brussels are of hospitals, however, I regard it as inadvisable majority superior to any published elsewhere (with the exceptiongenerally to adopt the conservative treatment of pulpof a small series by Lincoln in New York) and I hasten and, space infections, with or without penicillin; to bring them to your notice. indeed, until all those. who read Professor Pilcher’s Dubois reports on the condition, five months after article can avail themselves of his facilities, almost commencing treatment, of 24 patients with tuberculous dangerous to be aware of it. Most necrosed phalanges meningitis treated with streptomycin by both intra- are due to attempts at " conservative" (admittedly muscular and intrathecal routes ; 5 patients had died, inadequate) treatment on the part of the patient, his 2 were seriously ill, and 17 were making good clinical home doctor, or an overworked understaffed casualty progress and were without signs of meningitis apart from department. For some time to come, early incision, a Doses persistently abnormal cerebrospinal fluid. made, will confer the greatest good on the properly similar to those given in the M.R.C. trials were employed. greatest number. The main difference was in rhythm of treatment, particuT. G. LOWDEN. Royal Infirmary, Sunderland. larly in the long periods during which treatment was PRIMARY ATYPICAL PNEUMONIA suspended completely. The regimen was as follows : 45 days combined therapy (intrathecal daily) ; 20 days SiB,—I should like to suggest that the outbreak of rest; 20 days combined therapy (intrathecal daily) ; primary atypical pneumonia reported by Dr. J. W. 20 days complete rest; 30 days combined therapy Stephens in your issue of May 8 was caused not by a virus (intrathecal every 2 days). but by the Rickettsia burneti, the causative agent of Q It is stressed in the report that the results given were fever and of " Balkan grippe," a similar respiratory those observed at the end of five months, and that these infection occurring in Greece and Southern Europe. As results were modified in patients observed for a longer Dr. Stephens says, Q fever was later found to have been period, by a number of late relapses. The course of the the cause of several outbreaks of acute upper respiratory disease in a second five-month period is to be reported infection in Italy during the winter of 1944-45, though in a later paper. this fact was not recognised by him at the time. MARC DANIELS. London, W.C.I. The cases which he describes are similar in many to those reported as primary atypical pneumonia respects THE INFECTIONS OF HAND Turnerand by Adams et awl.2 Several similar outby SIR,-I have read with great interest the article of breaks, including one in a British parachute regiment May 22 by Professor Pilcher and others. I have waited that had recently been transferred from Athens, were -for a long time to hear authoritative doubt cast on the investigated at the same time by a team of American mechanical theory of terminal phalangeal necrosis. It workers (Robbins and Rustigan 3). The diagnosis of Q is also refreshing to hear the conservative treatment of fever was confirmed by the isolation of R. burneti from infected hands preached from so distinguished a pulpit. the blood and by serological tests. It was also shown. At this hospital we are fortunate in being able to admit that approximately 75% of cases of "atypical pneuall but the most trivial cases of infected hands. Their monia " occurring in Italy were, in fact, cases of Q treatment stands on a firm tripod of rest, elevation, fever. The cases reported by Dr. Stephens occurred in and systemic penicillin. Resolution is the rule, but if March, 1946, a year later, at about the same season the abscess points, the pus is evacuated through a minimal (January-March) and in the same-area (Naples-Caserta). incision. As your contributors point out, the " classical " Furthermore it was shown bv the American workers incisions advocated by Kanavel and others have no that quite a high proportion of the civilian population in place whatever in modern treatment. During 21/2 years this area showed a high level of antibodv to Q fever, here as registrar and then chief assistant to a busy surgical suggesting that the infection was endemic (Commission unit, I can recollect only one case in which necrosis of the 4). In view on Acute Respiratory Diseases, Fort Bragg terminal phalanx resulted from a pulp-space infection, of these findings Caughey and Dudgeon5 re-examined and only one patient who was left with stiffness of her 1. Turner, R. W. D. Lancet, 1945, i, 493. terminal interphalangeal joint. As we seldom have less 2. Adams, A. B., Staveley, J. M., Rolleston, G. L., Henley, W. E., than half a dozen " septic fingers " in our wards, such Caughey, J. E. Brit. med. J. 1946, i, 227. the results prove fairly conclusively value of conservative 3. Bobbins, F. C., Rustigan R. Amer. J. Hyg. 1946. 44, 72. on Acute Respiratory Diseases, Fort Bragg. Ibid, 1944, 44, 103. 5. Caughey, J. E., Dudgeon, J. A. Brit. med. J. 1947, ii, 684.
4. Commission
1.
Dubois, R., Linz, R., Leschanowski, H., Schlesser, R., Wattiez, R. Acta pædiat. belg. 1947, 4, 193.