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TRAUMATIC ASPHYXIA
410 It is not suggested that the present scheme is perfect but it was evolved only after much thought and discussion. If Armv form I 1247 were sent backwards and forwards each time a man attended a civil clinic the chances of it surviving to reach the War Office, where it is reviewed, would be small. If Dr. Erskine will refer to my letter he will see I did not say there are a multiplicity of forms. it must be remembered that the commercial traveller, the actor and the merchant seaman Do they always go to a clinic only when they wish. attend regularly and do they never default ? The soldier is sent, often unwillingly. Jt is admitted that in some cases there are gaps in treatment ; this is bound to occur in those cases where there are adequate military A soldier suffering reasons why a man cannot attend. from V.D. has direct access to his M.O. ; he merely " informs a N.C.O. that he wishes to report sick." If M.O.’s in charge of civilian V.D. clinics will communicate with me direct in future, or with the Army specialist who treated the case in the first instance, we shall be only too pleased to cooperate to the best of our ability, and I feel sure this method will secure better results than ventilating the matter in the press and casting aspersions on Army methods. T. E. OSMOND, Adviser in Venereal Disease.
War Office.
FATAL STINGS
SiR,-In his interesting and important account of cases of sudden death following wasp-stings Dr. Dyke discusses the possible explanations of such tragedies. The one he favours is, I think, alone tenable-that the insect happens to puncture a vein in the dermis so that some of its venom enters the circulation directly instead of being fixed" " and destroyed by the skin. I remember many years ago discussing this question with Sir Patrick Laidlaw, to whom I never took a problem without receiving enlightenment or being shown a new angle from which to tackle it. He agreed with me that the above explanation was the only one that covered the facts. These rare cases afford another illustration of the importance of defensive reactions in the skin in disasters. Brocq in protecting the organism from major his " Cliniques Dermatologiques " describes some cases in which this function of the skin is strikingly apparent. Dr. Dyke refers to the experiments of Arthus in which rapid death in dogs was caused by injecting bee-venom intravenously. Injection of the venom intradermally, of course, merely provokes a local reaction in the skin. Another example of the disaster that may follow direct penetration of the skin-barrier is afforded by the rapid development of acute streptococcal septicsemia in surgeons or in those doing autopsies after puncturewounds as opposed to scratches. H. W. BARBER. London, W.1. HAMMER TOE
these there is great need of a safe simple cure for hammer toe which will permit the patient to return to duty with the minimal delay. I suggest that such a cure can be obtained from removal of the proximal phalanx. Wounding of the tendons must be avoided. The expanded extensor tendon soon retracts and the end-result is a slightly shortened toe SiR,-In times like
and
which retains bursa
some
movement.
Inflammation in the
the
bony prominence of the hammer toe subsides after a few days, and the corn which is always present can quickly be removed by using collodion salicylicum (20%) as a corn paint. No other method seems to me to need so short a time off duty and none gives so good a permanent result. over
Bradford.
NORBERT SCHICK. JOHANN PETER FRANK
SiB,—The significance of Frank’s pioneer work in the
development of medical clinics and of public health in general has hardly been overlooked in Germany as completely as you suggest (Lancet, Sept. 6, p. 296). Laudatory references to him are to be found in standard handbooks of medical history-e.g., Puschmann’s-and in historical introductions to hygiene manuals, apart from the scholarly monographs of Rohlfs (1880), Doll (1910), and K. E. F. Schmitz (Verdff. MedVerw. 1917, 6, 496). Frank was, moreover, honoured by medical
historians of other nationalities.
Thus Garrison writes : His great work on public hygiene, as covering the whole of man’s life from the womb to the tomb-sewerage, water-supply, even school hygiene, sexual hygiene, taxation of bachelors and suitable benches and meals for the children, as well as the ideal of a scientificmedical police,’ really left little for Pettenkofer and the moderns. In the preventive medicine of the future, the name of Frank will loom larger with meanings, for he was himself And quite recently Sigerist has true modern." a published (2?MH. Hist. Med. Jan. 1941) an oration by Frank, entitled The People’s Misery : Mother of Diseases, of which he says : " One hundred and fifty years have passed since Frank delivered his address. A great deal has changed since then, and yet his words still sound incredibly modern." S. H. S. H. DAUKES. DAUEBS. "
Wellcome Historical Medical Museum, N.W.1. N.W.I.
IMPETIGO CONTAGIOSA AND NEPHRITIS
SIR,-Dr. Hope Simpson (Lancet, Sept. 13, p. 328) a point about nephritis following impetigo contagiosa which deserves comment. Nephritis as a specific complication of impetigo must, he says, be very rare, raises
whereas albuminuria and anasarca due to sensitivity to ammoniated mercury ointment is not uncommon. Nephritis may at present be a rare complication of of scarlet fever impetigo just as it is now a rare sequela but there are numerous records of " impetigo-nephritis " in the literature (see the recent reviews of Silvers, S. H. N.Y. St. J. Med. 1939, 39, 1093 ; Futcher, P. H. Arch. intern. Med. 1940, 65, 1192). For example, R. Southby and B. L. Stanton (Med. J. Aust. 1926, 1, 127), in an inquiry about antecedent infection in 103 children with acute nephritis, found that 17 had had impetigo two to six weeks prior to admission to hospital. On the other hand, sensitivity or idiosyncrasy to ammoniated mercury is, according to P. Harper (J. Pediat. 1934, 5, 794), mercurial nephritis following its uncommon, and inunction must, if it occurs at all, be extremely rare, for this mercury compound, being very insoluble, is poorly absorbed. ROBERT CRUICKSHANK. London, N.W.3. TRAUMATIC ASPHYXIA
SIR,-Mr. Grant Bonnin writing of traumatic asphyxia (Sept. 20, p. 333) states that no case has been reported
showing petechiae only. I cannot believe that such cases are rare and suggest that they have not been reported as they are thought to be of little interest. I have seen one air-raid casualty witli petechiae of the distribution characteristic of traumatic asphyxia. This is the only case of which I have notes but I have seen the phenomenon in civil injuries. The patient was a boy of 14, who was buried by debris in a shelter as a result of a bomb explosion. I saw him 7 hours after injury. He did not appear to be shocked or seriously hurt ; he had petechial haemorrhages of the eyelids, brow, neck and upper part of chest. None were found in the retinae. X-ray of his chest showed no abnormality, although for 2 days there were signs suggesting consolidation at the right base. He did not spit blood. His petechiae faded rapidly and were gone in a week. The exact nature of the injury was not determined. The boy had not lost consciousness and said that he was rescued quickly. ROBIN PILCHER. Hospital. article Mr. Grant Bonnin recalls an SiR,-The by interesting case of traumatic asphyxia which I saw 5 weeks ago. A young woman had an epileptic attack and came under my care the same day. She had subconjunctival haemorrhages, " total " on the right side, but incomplete on the left. Her face and neck were a vivid cyanotic hue. She was wearing collar and tie at the time of the attack, and the discoloration stopped abruptly at the level of a constriction mark caused by the collar. There was no discoloration below this level. I was able to observe her for 3 days, during which time the high colour definitely faded, and also became rather more red than blue. It is suggested that the epileptic spasm caused venous congestion with swelling of the neck, and that the tight collar then caused further congestion sufficient to produce the appearance described above the constricting band. E. E. T. TAYLOR. Lowestoft. Leavesden
War Office.
FATAL STINGS
SiR,-In his interesting and important account of cases of sudden death following wasp-stings Dr. Dyke discusses the possible explanations of such tragedies. The one he favours is, I think, alone tenable-that the insect happens to puncture a vein in the dermis so that some of its venom enters the circulation directly instead of being fixed" " and destroyed by the skin. I remember many years ago discussing this question with Sir Patrick Laidlaw, to whom I never took a problem without receiving enlightenment or being shown a new angle from which to tackle it. He agreed with me that the above explanation was the only one that covered the facts. These rare cases afford another illustration of the importance of defensive reactions in the skin in disasters. Brocq in protecting the organism from major his " Cliniques Dermatologiques " describes some cases in which this function of the skin is strikingly apparent. Dr. Dyke refers to the experiments of Arthus in which rapid death in dogs was caused by injecting bee-venom intravenously. Injection of the venom intradermally, of course, merely provokes a local reaction in the skin. Another example of the disaster that may follow direct penetration of the skin-barrier is afforded by the rapid development of acute streptococcal septicsemia in surgeons or in those doing autopsies after puncturewounds as opposed to scratches. H. W. BARBER. London, W.1. HAMMER TOE
these there is great need of a safe simple cure for hammer toe which will permit the patient to return to duty with the minimal delay. I suggest that such a cure can be obtained from removal of the proximal phalanx. Wounding of the tendons must be avoided. The expanded extensor tendon soon retracts and the end-result is a slightly shortened toe SiR,-In times like
and
which retains bursa
some
movement.
Inflammation in the
the
bony prominence of the hammer toe subsides after a few days, and the corn which is always present can quickly be removed by using collodion salicylicum (20%) as a corn paint. No other method seems to me to need so short a time off duty and none gives so good a permanent result. over
Bradford.
NORBERT SCHICK. JOHANN PETER FRANK
SiB,—The significance of Frank’s pioneer work in the
development of medical clinics and of public health in general has hardly been overlooked in Germany as completely as you suggest (Lancet, Sept. 6, p. 296). Laudatory references to him are to be found in standard handbooks of medical history-e.g., Puschmann’s-and in historical introductions to hygiene manuals, apart from the scholarly monographs of Rohlfs (1880), Doll (1910), and K. E. F. Schmitz (Verdff. MedVerw. 1917, 6, 496). Frank was, moreover, honoured by medical
historians of other nationalities.
Thus Garrison writes : His great work on public hygiene, as covering the whole of man’s life from the womb to the tomb-sewerage, water-supply, even school hygiene, sexual hygiene, taxation of bachelors and suitable benches and meals for the children, as well as the ideal of a scientificmedical police,’ really left little for Pettenkofer and the moderns. In the preventive medicine of the future, the name of Frank will loom larger with meanings, for he was himself And quite recently Sigerist has true modern." a published (2?MH. Hist. Med. Jan. 1941) an oration by Frank, entitled The People’s Misery : Mother of Diseases, of which he says : " One hundred and fifty years have passed since Frank delivered his address. A great deal has changed since then, and yet his words still sound incredibly modern." S. H. S. H. DAUKES. DAUEBS. "
Wellcome Historical Medical Museum, N.W.1. N.W.I.
IMPETIGO CONTAGIOSA AND NEPHRITIS
SIR,-Dr. Hope Simpson (Lancet, Sept. 13, p. 328) a point about nephritis following impetigo contagiosa which deserves comment. Nephritis as a specific complication of impetigo must, he says, be very rare, raises
whereas albuminuria and anasarca due to sensitivity to ammoniated mercury ointment is not uncommon. Nephritis may at present be a rare complication of of scarlet fever impetigo just as it is now a rare sequela but there are numerous records of " impetigo-nephritis " in the literature (see the recent reviews of Silvers, S. H. N.Y. St. J. Med. 1939, 39, 1093 ; Futcher, P. H. Arch. intern. Med. 1940, 65, 1192). For example, R. Southby and B. L. Stanton (Med. J. Aust. 1926, 1, 127), in an inquiry about antecedent infection in 103 children with acute nephritis, found that 17 had had impetigo two to six weeks prior to admission to hospital. On the other hand, sensitivity or idiosyncrasy to ammoniated mercury is, according to P. Harper (J. Pediat. 1934, 5, 794), mercurial nephritis following its uncommon, and inunction must, if it occurs at all, be extremely rare, for this mercury compound, being very insoluble, is poorly absorbed. ROBERT CRUICKSHANK. London, N.W.3. TRAUMATIC ASPHYXIA
SIR,-Mr. Grant Bonnin writing of traumatic asphyxia (Sept. 20, p. 333) states that no case has been reported
showing petechiae only. I cannot believe that such cases are rare and suggest that they have not been reported as they are thought to be of little interest. I have seen one air-raid casualty witli petechiae of the distribution characteristic of traumatic asphyxia. This is the only case of which I have notes but I have seen the phenomenon in civil injuries. The patient was a boy of 14, who was buried by debris in a shelter as a result of a bomb explosion. I saw him 7 hours after injury. He did not appear to be shocked or seriously hurt ; he had petechial haemorrhages of the eyelids, brow, neck and upper part of chest. None were found in the retinae. X-ray of his chest showed no abnormality, although for 2 days there were signs suggesting consolidation at the right base. He did not spit blood. His petechiae faded rapidly and were gone in a week. The exact nature of the injury was not determined. The boy had not lost consciousness and said that he was rescued quickly. ROBIN PILCHER. Hospital. article Mr. Grant Bonnin recalls an SiR,-The by interesting case of traumatic asphyxia which I saw 5 weeks ago. A young woman had an epileptic attack and came under my care the same day. She had subconjunctival haemorrhages, " total " on the right side, but incomplete on the left. Her face and neck were a vivid cyanotic hue. She was wearing collar and tie at the time of the attack, and the discoloration stopped abruptly at the level of a constriction mark caused by the collar. There was no discoloration below this level. I was able to observe her for 3 days, during which time the high colour definitely faded, and also became rather more red than blue. It is suggested that the epileptic spasm caused venous congestion with swelling of the neck, and that the tight collar then caused further congestion sufficient to produce the appearance described above the constricting band. E. E. T. TAYLOR. Lowestoft. Leavesden