1249

placed entirely on latrine control and the use of saltwhich thus appears effectively to prevent transmis-sion to the European miners.

Dr. Orenstein’s staff consists of 13 full-time medicalofficers, 1 research medical officer, 81 subordinateEuropean personnel, 79 female native nurses, and262 other native personnel, apart from sanitarysupervision and ambulance officers employed bythe individual mines who come under the indirect

supervision of his department. That no pains arespared in enlisting the intelligent cooperation of

compound officials is clear from the Notes on Elemen-tary Hygiene, by Dr. Orenstein in collaboration withMr. A. Gordon, chief health inspector, issued in bookform for their use, of which a second edition has

just reached us. Introductory remarks on the humanbody and its requirements and the theory of healthand disease are followed by admirable chapters onhousing, the disposal of wastes, disinfection and clean-liness, food, kitchen methods, the rat-proofing ofbuildings, compound inspection, recreation, and

finally an elementary account of the common diseasesand injuries which includes notes on pneumonia,tuberculosis, enteric, typhus, plague, chicken-pox,hookworm, injuries, and sepsis. Very clear diagram-matic illustrations of buildings and equipmentcomplete a manual which merits more than a localcirculation.

THE DISADVANTAGES OF TANNIC ACID

IN MILD BURNS

THE application of tannic acid is rapidly becomingthe stereotyped treatment for burns. In severe

burns it has given results in the saving of life and inthe prevention of pain and disfigurement far superiorto those following any other form of treatment. Itis sometimes forgotten, however, that the tanningeffects of the solution are not confined to the deadtissues. Dr. Frederic Taylor 1 is concerned about thegrowing tendency to use tannic acid as a universalapplication for burns of all degrees of severity.In the second degree burn he thinks that the damageto the delicate layer of the epithelium is a seriousconsideration. Intact skin is protected by thecornified layer of the epithelium, but when that

layer is once destroyed the growing cells responsiblefor the regeneration of the surface epithelium are atthe mercy of the tannic acid and may easily be killedby it. The effect of tannic acid on the skin of rabbitsillustrates this point. The rabbit’s skin containsno protective cornified layer ; tanning extends

throughout the surface epithelium and even alongthe epithelium of the hair follicles. Dr. Taylor’sadvice is to withhold coagulating applications exceptin burns of such severity that they are needed tosave the life of the patient. Of the coagulatingsolutions he prefers gentian-violet as being leastharmful to the generating epithelium. In all milderburns he advises bland applications such as sodiumhypochlorite and ointments, as he regards rapidity ofepithelial regeneration as of first importance. Thestupidity of causing deep injury to tissues, by drastictreatment carried out to promote healing of a

comparatively superficial lesion, is self-evident. Theremay well be many burns in which the old-fashionedmethods yield satisfactory results ; but in the rathercommon type of burn of moderate severity it seemsto us that the increased incidence of pain and suppura-tion, which Dr. Taylor admits to be a disadvantageof treatment by ointments and such like, is a big

1 Jour. Amer. Med. Assoc., April 4th, 1936, p. 1144.

price to pay for rapidity of healing. May it not bethat the enthusiasm of some surgeons for the tannicacid treatment has carried them too far, and thatthey are using the solutions too strong and applyingthem unnecessarily often ? After all, if deep destruc-tion of the epithelium results, scarring will follow,and that is one of the sequelse the treatment is

particularly designed to avoid.

EARLY AMPUTATION FOR SEVERE INJURY

A FEW months ago we published a paper fromCairo recommending very early amputation forsevere crushing injuries of the limbs. An impressiveseries of cases led Abdelsamie to conclude thatthese seriously injured patients stand operationquite well, and that the risk of death increases asamputation is delayed. Benajas on the other hand,is not convinced of the necessity for speedy operationin every case. Its advantages, he considers, are thatit anticipates the development of infection and pos-sibly of septicaemia, and so may save life or theunnecessarily extensive sacrifice of tissue ; that it

prevents shock by removing the source of toxins ;and that in cases where the great vessels are destroyedthe patient is spared the sufferings and dangersassociated with gangrene. Objections, however, arethat it is likely to increase traumatic (as contrastedwith toxic) shock, and that it carries a risk of removingeither too little or too much tissue, whereas withdelayed operation a line of demarcation has hadtime to form and shock and haemorrhage have beentreated. Benajas believes in immediate amputation(1) where infection has already set in and thepatient’s general condition is bad, (2) where thegreat vessels are injured and operation is requiredto check haemorrhage, and (3) where the principalnerves (especially in the upper limb) are destroyed.He admits that if a patient is seen within thefirst three hours, before shock has developed,it is best to operate at once, but he main-tains that if shock has already set in the

operation should be delayed while anti-shocktreatment is carried out. This is in direct oppositionto the conclusions of Abdelsamie, who has watchedtwo patients die during the interval and wouldtherefore avoid a minute’s unnecessary delay. In

practice the decision is often made harder becauseother injuries are present which make one hesitateto attempt operative treatment of any kind. Sur-geons will always be divided into two camps, the boldand the cautious, but it seems highly desirable thatboth types should have a background of informationderived from further observations on the " imme-diate " method.

NITROUS OXIDE AND ASPHYXIA NEONATORUM

CONTINUING his valuable studies on the chemistryof the blood of the new-born baby, N. J. Eastman 1has tried to ascertain whether anaesthetics playa part in the causation of asphyxia neonatorum.Blood samples were obtained from the umbilical

artery and vein in a special segment of cord removedimmediately after birth, before the delivery of theplacenta, and before the onset of respiration. Maternalblood specimens were also taken from the arm veinand radial artery. The blood of forty babiesdelivered from mothers under anaesthesia was

examined in this way. In four cases the anaestheticwas chloroform, in eight ether, and in twenty-eight

1 Abdelsamie, L. : THE LANCET, Jan. 25th, 1936, p. 187.2 Benajas, P. C. : Medicina Latima, 1936, ix., 183.1 Amer. Jour. Obst. and Gyn., April, 1936, p. 563.