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TREATMENT OF BLTRN S
IN his Honyman Gillespie lecture in Edinburgh on thecauses and treatment of the lethal factors in burnsProf. W. C. Wilson said that burns were among the mostcommon injuries met with in the Services just now. Inthe Navy they are frequent among the men workingbetween decks, the exposed parts of their skin beingburnt by the blasts of extremely hot air caused by shellexplosions. These burns are mostly superficial. Burnson active service often go septic because there is as arule a delay of some days before the patient reaches abase hospital. In the Air Force ’injuries are caused byburning petrol and again it is the face and hands whichare especially exposed to danger. Many such burns aredeep and scarring is sometimes severe. Scarring of thefingers may end the career of a pilot while facial scarshave an undesirable effect on his companions. Plasticsurgeons in Britain and America claim that the bestlocal results are obtained with saline packs and salinebaths but Professor Wilson believes that coagulation isequally good. It is impossible, however, to save life bythe local treatment of severe burns. They are accom-panied by many complex and obscure general systemicdisturbances whose nature can only be determined byclinical investigations in man.Apart from early death due to damage to the brain,
to asphyxia, or to carbon-monoxide poisoning the firstlethal factor is initial shock. This is very rare and inmost cases the blood-pressure is normal a few minutesafter the injury. Secondary shock, which develops 15-30minutes after the burn, is much more important. It isassociated with a progressive diminution in the pulse-pressure, a rise in the pulse-rate, and a fall in the rectaltemperature. This very serious condition is accom-
panied by a grossly deficient blood-supply to the tissuesgenerally and certain recognisable changes. The bloodbecomes concentrated owing to a loss of plasma. The
haemoglobin may rise to 130 or 150%, equivalent to adrop in the plasma volume to 75 or 55% of the normal.Professor Wilson disapproves of the treatment originallysuggested by Underhill-the administration of largequantities of saline-because it is likely to lead to waterintoxication. There is a fall in both the total quantityand the concentration of the plasma proteins. The dropmay be very great if an excessive quantity of non-protein fluids are given intravenously. At the sametime the blood sodium falls and the blood potassiumrises. These changes are not themselves the cause ofthe circulatory failure and their degree is no index of theseverity of that failure ; they can be corrected by theadministration of desoxycorticosterone acetate, whichalso tends to correct the hsemoconcentration, but thiscompound has only a minor effect on the circulatoryfailure. Natural adrenal cortical hormone has not beenavailable in large enough quantities for a thorough trial.In the treatment of secondary shock the restoration ofthe plasma volume is of first importance. This can becarried out by the intravenous injection of normal humanplasma, but dried serum is very useful because it can begiven in any desired concentration. Local treatmentshould aim at limiting the amount of exudation from theburnt surface. The more rapid the coagulation thebetter, and Professor Wilson advises the application of10 % silver nitrate. Doca has given excellent results incombination with other treatment. The second lethalfactor is acute toxaemia, which is not very commonnowadays but occurs irregularly and bears no relationto the extent of the injury. Its cause is not fully under-stood ; it is not due to haemoconcentration or to a changein the chemistry of the blood. On the assumption thatit is due to early bacterial infection gentian violet andother dyes have been used which exert a powerful actionon organisms in vitro with a more doubtful action invivo, but they have not reduced the incidence of acutetoxaemia. The evidence of the presence of severe
bacterial infection is often small. It is also doubtfulwhether protein autolysis of injured tissue is responsible.Pathologically the main lesion is an intense necrosis ofliver cells and a severe disturbance of liver function.The third lethal factor is late bacterial infection, whichis almost inevitable when the softened sloughs are
separating. Such infection with septicaemia and pyaemiais frequent in deep burns but sulphanilamide has greatlyreduced its dangers.
In Professor Wilson’s opinion the coagulation methodof treatment is not ideal ; a better local treatment isneeded which will allow of earlier separation of the sloughsand earlier grafting. It is imperative to avoid brutalmethods of cleaning the burned area-for example, witha nail brush and strong antiseptic-for these are highlydamaging and lead to deeper injury and worse infection.
DR. ROBERT STIRLING
Dr. Stirling died in Perth last month at the age of 81.He was a graduate of St. Andrews University in 1885and was house-surgeon at Edinburgh Royal Infirmaryto Joseph Bell. He studied in Vienna and London andsettled in Perth in 1887, taking his F.R.C.S.E. in 1890.He served in South Africa during the Boer War when hewas attached to the Scottish Red Cross hospital inKronstadt, and again in France during the last war whenhe was in command of the 51st Division (Highland)Clearing Station and retired with the rank of lieutenant-colonel. He served as surgeon to the Perth RoyalInfirmary and was closely associated with the supervisionof the Hillside Homes which had been founded by hisfather. He took a prominent part in public affairs inPerthshire and was a member of the county educa-tion authority and convener of the medical inspectionand general welfare committee.
MEDICINE AND THE LAW
Dangerous MachineryIN Lewis u. Denye the House of Lords came close to
the problem whether dangerous machinery must besecurely fenced even if the machine will thereby becommercially useless. Lewis was employed to work apower-driven circular saw. His hand was caught by theblade and severely injured. When he sued for damages,Mr. Justice Tucker held that the employer had notfenced the saw securely as was his statutory duty undersection 10 of the Factory and Workshop Act of 1901(now superseded by the recent Factories Act) ; neverthe-less he dismissed the claim on the ground that theplaintiff’s own negligence was the real and effectivecause of the accident. The Court of Appeal and Houseof Lords have upheld his decision.Lord Simon’s judgment does not quite settle for
employers the question whether they are to be expectedto comply with the duty to fence a dangerous machineeven to the extent that the machine will be industriallyunworkable. In 1919 Mr. Justice Salter remarked (inDavies v. Thomas Owen & Co.) that, if a machine can-not be securely fenced while remaining commerciallypracticable or mechanically useful, the Factory Act ineffect prohibits its use. Lord Simon was not preparedto endorse this view. He left this part of the problemunsolved, being reluctant to make any final pronounce-ment on a matter so important to British industry inpeace and in war. It will be recalled that under regula-tion 59 of the Defence (General) Regulations the Ministerof Labour and National Service (to whom the power ofthe Home Secretary under factories enactments havelately been temporarily transferred) has authority byorder to exempt any premises or operations from statu-tory obligations, if exemption is desirable in the publicinterest for facilitating war work.
One small point in the course of the appeal may be ofinterest to expert witnesses. A model of the saw hadbeen prepared for use at the trial, to illustrate therespective possibilities of precaution and danger. LordSimon observed, when following the shorthand note ofthe evidence given at the trial, that professional witnessesare apt to forget that, if the case should go to a highercourt on appeal, their references to " this " and " that "and " here " and " there " do not help the judges of theappeal tribunal. The expert who demonstrates a modelby pointing the finger at this or that part may be entirelyilluminating to those who see and listen in the trialcourt; but his exposition is so much the less simple whenit is reduced to the dull pages of a shorthand note. Thepoint is a practical one for counsel as well as for witnesses.