burns of the eyelids
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in lime produced by the addition of calcium to whiteflour is very much less than that used by Kletzien andTompsett in their experiments. There was an old viewthat excessive consumption of milk leads to anaemia,and if milk is taken to the exclusion of other foods thismay well be true, not because of the high calciumcontent of milk but because of its very meagre contentof iron. The same may apply to the abnormal diets forcedon us in war-time. It will be wise, therefore, for the familydoctor to make increasing use of his haemoglobinometerjust now, especially with expectant mothers and children,in whom the chances of iron deficiency are greatest.
AUTOPSIES IN RURAL PRACTICEHIMSELF a country practitioner, Dr. W. F. Putnam 1
pleads for the routine performance of post-mortemexaminations in country practice and has contrived toget permission for, and to carry out, autopsies on 34 ofthe 64 of his patients who died in the years 1936-39. Inmost cases his clinical and pathological findings talliedtolerably well, though a clinical diagnosis of " stillbirth "is not greatly amplified by a pathological diagnosis of" stillbirth " ; autopsies ought to take us further thanthis. It is easy to be wise afterwards but it may bewondered why some at least of the conditions firstdiscovered at autopsy were not suspected before death.It seems incredible, for example, that peritonitis due toa ruptured gall-bladder should have been completelysilent. Nor should a thrombophlebitis have beenmissed, whereas a thoracic aneurysm might surely havebeen suspected and subsequently confirmed radio-
logically. In so far as he wants us to perform autopsiesto attain greater knowledge and accuracy Putnam carriesus all with him. It is only when he argues that, withoutthe salutary cold douche of post-mortem evidence,country doctors are apt to become complacent andunconscious of their errors and limitations that some willwant to join issue with him. In this country the standardof country practice is at least as high as, if not higherthan, that of towns and few if any rural patients dieundiagnosed for lack of necessary special investigation.One of the reasons why Putnam wants country doctorsto carry out autopsies is to improve the standard of ruralpractice and so
" eliminate the bogy of state medicine."It is difficult to follow his reasoning here. A superstitionwidely held among those practising in towns is that
country doctors enjoy a life of arcadian leisure whereasin fact one of the many difficulties of autopsy in countrypractice is to find the time and the place and the cadaverall together. Post-mortem examinations conducted on atrestle-table in a freezing outhouse with a bucket of coldwater as the sole amenity and the local Dogberry asassistant are toughening experiences which, thoughbetter than nothing, are not conducive to good andaccurate work; where a post-mortem room, with askilled pathologist hovering in the background is at
hand, it is another pair of shoes. Might not Putnam’sdreaded bogy provide us with these 7
BURNS OF THE EYELIDSHow far coagulants must be held responsible for
contractions following burns of the face or hands, is stillundecided,,but the burns team of the M.R.C. war-wounds committee have left no doubt of their own
opinion, by their recommendation that no coagulantof any kind should be used on the face, hands and wrist,or feet.2 The voice of eye surgeons has been littleheard in the discussions on this question, but certainlysome of them maintain that eyes have been lost withtannic acid which might have been saved with othertreatment. In their view coagulants applied to thelids render them rigid, immobile and contracted, theirprotective function to the eye is lost, the cornea dries
1. New Engl. J. Med. Feb. 20, 1941, p. 324.2. See Lancet, March 29, 1941, p. 426.
and ulcerates from exposure, and perforation andpanophthalmitis will ultimately destroy the eye.Whatever his personal opinions, no surgeon is likely tofeel certain enough of them to ignore this warning,so that for the rest of the war coagulants are likely to bediscarded in the treatment of burns involving the eye-lids. Careful diagnosis of the depth and extent of suchburns is essential. First-degree burns merely requirecleansing with saline or sodium bicarbonate, the appli-cation of saline packs and observation. Those ofsecond degree should be treated in the same way, withcareful excision of all tags of dead epithelium andvesicles. During observation it may become evidentthat some areas are in fact third degree. In most burnsof the eyelids the lid margins remain intact. This is of
great advantage in that it’allows tarsorrhaphy to beperformed, a procedure of vital importance for the
protection of the cornea and the prevention of ectropionduring healing or after the application of a Thierschgraft. In third-degree burns cleansing, excision of alldevitalised tissue and tarsorrhaphy are followed by theapplication of a Thiersch or Wolfe graft, held securelyin place by suturing the edges of the graft to adjacentskin and covering this with tulle gras and a piece of stentmoulded to shape and held in position by sutures.
ANÆSTHESIA FOR CHEST SURGERYTHE development of anaesthetic methods and technique
to meet the full needs of the surgeon carrying out severechest operations was discussed on April 4 by Dr. M. D.Nosworthy at the section of anaesthetics of the RoyalSociety of Medicine. He warmly advocated " controlledrespiration," that system by which natural respiratorymovement is suspended and the respiratory exchange iseffected by rhythmic pressure on the breathing bag.The advantage to the surgeon working within the chestof having the cavity free from movement needs noemphasis ; and a safe technique to provide this may beacquired by experience. Controlled respiration isobtained either by lowering the carbon-dioxide tensionor by heavy depression of the respiratory centre by drugs;to obtain it Dr. Nosworthy uses cyclopropane at a
percentage strength much above that considered safe inordinary surgery. He does not consider the use ofAvertin or paraldehyde permissible to repress respirationbecause they abolish the cough reflex for too long.For empyema and lung abscess local anaesthesia wasrecommended. Cough must be prevented, because itdisseminates infection; for this purpose either theinfected zone of the lung must be shut off from the
healthy parts or else suction must be used effectively.Dr. Nosworthy believes that the surgeon is well advisedto forgo the advantage he might sometimes gain from theuse of diathermy for the sake of using an anaestheticwhose inflammability must not be forgotten. In civillife the subjects of severe chest surgery have generallysuffered long-standing illness, often complicated byamyloid disease, and every possible step has to betaken to maintain circulatory and respiratory efficiencyat the best possible level during operation. In militarychest surgery the position is different, the patient being,apart from his chest injury, a first-class subject. Dr. C.Langton Hewer considered the post-operative fall inblood-pressure after - cyclopropane to be due to thedisturbance of metabolism produced by a sudden returnfrom an atmosphere containing excessive oxygen.
Sir CoMYNS BERKELEY has been re-elected chairmanof the Central Midwives Board for the year endingMarch 31, 1942.
In a circular (No. 2323) addressed to local authorities andhospital boards the Minister of Health recognises the seriouseffect on private practice of the recruitment of practitionersof military age and suggests ways of allocating medicalman-power between the civilian and military services.