HALF A CENTURY
1
50 CONTACT LENSES AND THE WOULD-BE PILOT Petersen 17 describes a method for reconstructing a thumb from which a portion has been lost by means of a tube pedicle from the abdomen into which a bone-graft is subsequently inserted. Burns, whether in soldiers, airmen or civilians, tend to follow a common pattern with the maximum destruc- tion of skin on the dorsum. The early treatment may make or mar the final result, and the speed with which damaged skin can be replaced by grafting is of para- mount importance. Yet in the most ideal circumstances there is apt to be some contraction of the skin which may later have to be made good by grafting. In most cases good results are obtained by razor grafts or dermatome grafts ; an abdominal flap is rarely called for. After the more severe burns contractures of joints are common, the -most characteristic being loss of flexion at the metacarpophalangeal joints and loss of extension at the interphalangeal joints. Hyperextension at the meta- carpophalangeal joints is the worst deformity of all, and is liable to be accompanied by changes in the shape of the bone ends. Preservation of the position of func- tion throughout the period of healing is the greatest single measure in the prevention of these deformities. The wrist should be in slight dorsiflexion, says Boden- ham,18 the fingers in mid-flexion at all joints, the thumb in apposition with the tip of the index finger, and the long axis of the fingers pointing towards the lower end of the radius. Occasionally a plaster-of-paris cast may be permissible for one to two weeks only-in cases that cannot be controlled by other means-with suitable precautions to prevent syndactyly. Elevation of the hand allows the fingers to drop into a natural position. A splint intended to keep the hand flat on the bed is an abomination. A skin-graft alone will not restore many of these hands to a functional position, but carefully applied capsulotomy. may succeed dramatically. Arthro- plasties, though not invariably successful, also have a place. Manipulation is disappointing, and it is doubtful if it should ever be employed. It can rarely overcome stiffness in the small joints, but produces a violent fibrous-tissue reaction, with the last state often worse than the first. By the skilful application of a suitable graft, combined with capsulotomy, many otherwise useless hands can be given some useful function, and many men returned to duty. But prevention should be the aim; speakers at the RSM meeting agreed that the accepted principles of wound treatment are not yet being fully applied. An open type of dressing, rest and elevation in the early stages, active movements as soon as the acute phase is over, with the hand always in the position of function, and early skin-grafting, give the best possible results, and should greatly reduce the need for late reconstructive surgery. CONTACT LENSES AND THE WOULD-BE PILOT IF a refractive error was merely a problem in optics, lenses ground to fit directly on the eye-ball would offer the ideal means of correcting it. But the man behind the eye-ball likes good vision to be associated with comfort ; and contact lenses, like artificial teeth, harass the wearer until time and necessity have worked their usual conjuring trick, and he suddenly realises that he has ceased to be conscious of his appliance. The eye, however,.will put up with less than the mouth, so that the incentive needed to carry the patient through to well-earned indifference must be a strong one. Vanity -sometimes said to be the most powerful human motive -is not enough ; if ordinary spectacles give good vision the patient usually reverts to them. An eye recovered from a mustard gas burn will tolerate a lens readily because the cornea and conjunctiva have become anaesthetic, but generally speaking, to be worn success- 17. Petersen, N. S. S. Afr. med. J. 1943, 17, 137. 18. Bodenham, D. C. Lancet, 1943, i, 298. fully contact lenses must give good sight which cannot be obtained by other means. In a few cases this holds- notably in conical cornea and irregular astigmatism which cannot be corrected by spectacles. An important new incentive, recently operating, has just received its death blow. Contact lenses are used occasionally in the RAF by members of operational air crews of special skill and experience. Some hint of this in the lay press has led young men with high refractive errors and a powerful urge to fly to present themselves before medical boards wearing contact lenses, in the hope that they would be accepted. The Air Ministry, while sympathising with them, has made it clear that there has never been any. idea of accepting candidates with visual acuity below RAF standards ; and it is not in the country’s interest, unfortunately, that these resourceful patriots should escape detection by the medical boards. No doubt the ministry is right, but it is a pity this strong encourage- ment to wearers had to die so early a death. The technique of grinding and fitting these contact lenses has improved greatly during the last few years, and makers of them may well feel that the time has now come for patients to try a bit harder. HALF A CENTURY Sir John Ledingham, FRS, after 38 years’ service, left the Lister Institute on March 31, when Dr. Alan N. Drury, FRS, succeeded him as director. It is now fifty years since the institute began its work, and in war as in peace its record of investigation remains impressive. The report 1 presented by Sir Henry Dale, FRS, to the annual general meeting on June 24 contains little that has not been published, but it draws together much diverse work done-because of the war-in many differ- ent places. On the long’view, and sometimes on the short view, it is an encouraging report. The first fifty years arouse expectations for the second. ANÆSTHETIC RECORD CARDS FIGURES, they say, can be made to prove anything- but only a statistician can do it. Certainly the collector of statistical data on clinical subjects must step warily and methodically if he is to extract anything more than im- pressions from them, and where no proper records are kept even honest impressions can be astonishingly unreliable. Nosworthy2 describes an ingenious indexing card which. should help considerably in the systematic recording of the anaesthetists case-notes and their subsequent analysis. Each essential item in the story has its heading on the card and a hole punched near the edge. In recording, for example, that Pentothal ’ was the anaesthetic used, a note is made under the appropriate heading and the corresponding hole is converted into a notch. When the cards are filed all that need be done to produce, say, those on the pentothal cases is to pass a knitting needle through the pentothal hole and shake the pack, when. the desired cards will fall out. To keep even such simple record cards as these will probably require more help than is now provided in the average hospital, and much of their value will be lqst unless they are filled up for every case. The system, too, cannot tabulate such imponderables as the dexterity of the surgeon, the competence of the anaesthetist, or the quality of the post-operative nursing, but where these factors can be taken as reasonably constant it should enable the anaesthetist to assess the value of the different anaesthetic agents in his own hands. Above all, it will instil into the anaesthetist a habit of careful and unbiased observa- tion, and make it easy for him to keep an eye on his results. 1. From the Lister Institute of Preventive Medicine, Chelsea Bridge Road, London, SW1. 2. Nosworthy, M. D. Brit. J. Ancesthes. July, 1943. The cards measure 5 in. by 8 in. and can be obtained from A. Charles King, Ltd., 27, Devonshire street, W.1.
Transcript of HALF A CENTURY
50 CONTACT LENSES AND THE WOULD-BE PILOT
Petersen 17 describes a method for reconstructing a thumbfrom which a portion has been lost by means of a tubepedicle from the abdomen into which a bone-graft is
subsequently inserted.Burns, whether in soldiers, airmen or civilians, tend
to follow a common pattern with the maximum destruc-tion of skin on the dorsum. The early treatment maymake or mar the final result, and the speed with whichdamaged skin can be replaced by grafting is of para-mount importance. Yet in the most ideal circumstancesthere is apt to be some contraction of the skin which maylater have to be made good by grafting. In most cases
good results are obtained by razor grafts or dermatomegrafts ; an abdominal flap is rarely called for. Afterthe more severe burns contractures of joints are common,the -most characteristic being loss of flexion at the
metacarpophalangeal joints and loss of extension at theinterphalangeal joints. Hyperextension at the meta-
carpophalangeal joints is the worst deformity of all,and is liable to be accompanied by changes in the shapeof the bone ends. Preservation of the position of func-tion throughout the period of healing is the greatestsingle measure in the prevention of these deformities.The wrist should be in slight dorsiflexion, says Boden-ham,18 the fingers in mid-flexion at all joints, the thumbin apposition with the tip of the index finger, and thelong axis of the fingers pointing towards the lower endof the radius. Occasionally a plaster-of-paris cast maybe permissible for one to two weeks only-in cases thatcannot be controlled by other means-with suitableprecautions to prevent syndactyly. Elevation of thehand allows the fingers to drop into a natural position.A splint intended to keep the hand flat on the bed is anabomination. A skin-graft alone will not restore manyof these hands to a functional position, but carefullyapplied capsulotomy. may succeed dramatically. Arthro-plasties, though not invariably successful, also have aplace. Manipulation is disappointing, and it is doubtfulif it should ever be employed. It can rarely overcomestiffness in the small joints, but produces a violentfibrous-tissue reaction, with the last state often worsethan the first. By the skilful application of a suitablegraft, combined with capsulotomy, many otherwiseuseless hands can be given some useful function, andmany men returned to duty. But prevention should bethe aim; speakers at the RSM meeting agreed that theaccepted principles of wound treatment are not yet beingfully applied. An open type of dressing, rest and elevationin the early stages, active movements as soon as theacute phase is over, with the hand always in the positionof function, and early skin-grafting, give the best
possible results, and should greatly reduce the need forlate reconstructive surgery.
CONTACT LENSES AND THE WOULD-BE PILOT
IF a refractive error was merely a problem in optics,lenses ground to fit directly on the eye-ball would offerthe ideal means of correcting it. But the man behindthe eye-ball likes good vision to be associated withcomfort ; and contact lenses, like artificial teeth, harassthe wearer until time and necessity have worked theirusual conjuring trick, and he suddenly realises that hehas ceased to be conscious of his appliance. The eye,however,.will put up with less than the mouth, so thatthe incentive needed to carry the patient through towell-earned indifference must be a strong one. Vanity-sometimes said to be the most powerful human motive-is not enough ; if ordinary spectacles give good visionthe patient usually reverts to them. An eye recoveredfrom a mustard gas burn will tolerate a lens readilybecause the cornea and conjunctiva have becomeanaesthetic, but generally speaking, to be worn success-
17. Petersen, N. S. S. Afr. med. J. 1943, 17, 137.18. Bodenham, D. C. Lancet, 1943, i, 298.
fully contact lenses must give good sight which cannotbe obtained by other means. In a few cases this holds-notably in conical cornea and irregular astigmatismwhich cannot be corrected by spectacles. An importantnew incentive, recently operating, has just received itsdeath blow. Contact lenses are used occasionally in theRAF by members of operational air crews of special skilland experience. Some hint of this in the lay press hasled young men with high refractive errors and a powerfulurge to fly to present themselves before medical boardswearing contact lenses, in the hope that they would beaccepted. The Air Ministry, while sympathising withthem, has made it clear that there has never been any.idea of accepting candidates with visual acuity belowRAF standards ; and it is not in the country’s interest,unfortunately, that these resourceful patriots should
escape detection by the medical boards. No doubt theministry is right, but it is a pity this strong encourage-ment to wearers had to die so early a death. The
technique of grinding and fitting these contact lenses hasimproved greatly during the last few years, and makers ofthem may well feel that the time has now come forpatients to try a bit harder.
HALF A CENTURY
Sir John Ledingham, FRS, after 38 years’ service,left the Lister Institute on March 31, when Dr. Alan N.
Drury, FRS, succeeded him as director. It is now fiftyyears since the institute began its work, and in war as inpeace its record of investigation remains impressive.The report 1 presented by Sir Henry Dale, FRS, to theannual general meeting on June 24 contains little thathas not been published, but it draws together muchdiverse work done-because of the war-in many differ-ent places. On the long’view, and sometimes on theshort view, it is an encouraging report. The first fiftyyears arouse expectations for the second.
ANÆSTHETIC RECORD CARDS
FIGURES, they say, can be made to prove anything-but only a statistician can do it. Certainly the collectorof statistical data on clinical subjects must step warily andmethodically if he is to extract anything more than im-pressions from them, and where no proper records are kepteven honest impressions can be astonishingly unreliable.Nosworthy2 describes an ingenious indexing card which.should help considerably in the systematic recording ofthe anaesthetists case-notes and their subsequentanalysis. Each essential item in the story has its
heading on the card and a hole punched near the edge.In recording, for example, that Pentothal ’ was theanaesthetic used, a note is made under the appropriateheading and the corresponding hole is converted into anotch. When the cards are filed all that need be done toproduce, say, those on the pentothal cases is to pass aknitting needle through the pentothal hole and shakethe pack, when. the desired cards will fall out. To keepeven such simple record cards as these will probablyrequire more help than is now provided in the averagehospital, and much of their value will be lqst unless theyare filled up for every case. The system, too, cannottabulate such imponderables as the dexterity of thesurgeon, the competence of the anaesthetist, or the qualityof the post-operative nursing, but where these factorscan be taken as reasonably constant it should enable theanaesthetist to assess the value of the different anaestheticagents in his own hands. Above all, it will instil intothe anaesthetist a habit of careful and unbiased observa-tion, and make it easy for him to keep an eye on hisresults.
1. From the Lister Institute of Preventive Medicine, Chelsea BridgeRoad, London, SW1.
2. Nosworthy, M. D. Brit. J. Ancesthes. July, 1943. The cardsmeasure 5 in. by 8 in. and can be obtained from A. Charles King,Ltd., 27, Devonshire street, W.1.
