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Treatment of phosphorus burns
P U B L I C H E A L T H , February, 1943 I n this i n t e r e s t i n g report it is a pity t h a t the c o l u m n m e t h o d of graphical r e p r e s e n t a t i o n is used i as the g r a p h s do n o t supply w h a t is n e e d e d - - a n easily grasped picture of the facts. S o m e of the conclusions r e a c h e d will n o t be generally accepted. T h e a u t h o r f o u n d t h a t the stillbirth rate a n d m o r t a l i t y d u r i n g the first m o n t h of life was h i g h e r a m o n g t h e f i r s t - b o r n t h a n a m o n g the s e c o n d - a n d t h i r d - b o r n , b u t b e t w e e n one m o n t h a n d five years of age the f i r s t - b o r n h a d the lowest d e a t h rate. Mrs. B u r n s concludes : " I t w o u l d seem t h a t the m o r e p r o b a b l e e x p l a n a t i o n of the p h e n o m e n o n is the greater w e e d i n g out of the weaklings by first b i r t h s . " T h i s m i g h t b e true if t h e c h i l d r e n were all exposed to the same risk of dying, b u t i n the case of infectious disease this is n o t so. Of the deaths u n d e r age 15 f r o m the four c o m m o n infectious diseases of c h i l d h o o d , a p p r o x i m a t e l y 7 0 % occur at ages 0-5. As the preschool child is i n f e c t e d by the school child, the l a t e r - b o r n child w i t h b r e t h r e n at school s t a n d s a larger risk of d y i n g f r o m infectious diseases t h a n the f i r s t - b o r n . T h a t this is a n i m p o r t a n t factor i n the d e a t h rate can b e s h o w n f r o m the deaths of 1921-30, w h e n the four c o m m o n infectious diseases a c c o u n t e d for 2 8 ~ of t h e total deaths at ages 1 to 5. S o m e of the s t a t e m e n t s m a d e in t h e r e p o r t are h o t e x a c t : e.g., the increase i n the d e a t h rate for b o t h boys a n d girls b e g i n s at age 12 a n d not, as suggested, a r o u n d age 15, u p o n e n t r a n c e into i n d u s t r y . A g a i n the a u t h o r s t a t e s : " A m o n g males . . . the accident rate r e m a i n s fairly c o n s t a n t f r o m 15 to 45 years." Actually the a c c i d e n t rate, i n w h i c h road accidents f o r m a n i m p o r t a n t part, rises to a p r o n 6 u n c e d peak i n the early twenties a n d t h e n declines. T h e bulge i n the curve in the p r o b a b i l i t y of d y i n g i n the E n g l i s h Life T a b l e No. 10 (1930-32), the qx at ages 22 to 24 was greater t h a n at ages 25 to 27, was due solely to the shape of the accident d e a t h rate
Treatment of Phosphorus Burns New instructions on the treatment of phosphorus burns have been substituted for those contained in E.M.S./Gen./336 (revised). It is now recommended that at the incident water should be applied immediately to the affected part to extinguish any burning phosphorus and to keep the area moist. T h e burn should then be covered with a clean mines dressing, or clean lint, or a clean cloth soaked in water. Whatever dressing is used it must be kept wet, as otherwise it may burst into flame. With the wet dressing in place, the casualty, if a sitting case or able to walk, should be conveyed or directed at once to the nearest First Aid Post or hospital for further treatment. Stretcher cases must be sent direct to a hospital with the least possible delay. T o ensure immediate attention at the hospital, these casualties must be labelled, and the label marked with a P. T h e attention of the ambulance attendant must be drawn to the case. At the First Aid Post or hospital the affected part should be immersed in water. If sufficient water is not available a mines dressing soaked in water should be applied. T h e dressing should be kept wet until the affected area can be thoroughly flooded and washed with bicarbonate of soda solution (roughly two tablespoonfuls of the powder to a pint of cold tap water). Any obvious particles of phosphorus, disclosed by examination in the dark (phosphorescence), can be picked off with forceps. The affected area is then swabbed with a 1% solution of copper sulphate, which will coat any remaining phosphorus particles with a dark deposit of copper phosphide. As much of this as is possible without damaging the tissues must be removed with forceps or gauze. T h e affected area should be immersed in the bicarbonate of soda solution for a prolonged period. T h e duration of this soaking depends upon the size and depth of the burn--i.e., small b u m s { hour, large burns I to 2 hours. If immersion is impossible, the sterile dressing should be kept repeatedly wetted with the bicarbonate solutiori. Finally, the burn must be re-examined in the dark for phosphorescence. If this is not present the burn can be dressed in the ordinary way. If there is still any doubt about the presence of phosphorus the burn should be dressed four-hourly with lint soaked in sodium bicarbonate solution (2 tablespoonfuls to the pint of water). No oils or greasy dressings and no tannic acid, triple dye or brilliant green must be used in the treatment of phosphorus burns so long as any trace of phosphorus remains in the tissues. Oils and greases are solvents of phosphorus and their use while it is present will cause risk of poisoning from absorption. To help the Ministry of Health in its campaign against venereal diseases. the Central Council for Health Education has recently issued three attractively printed leaflets, pocket'size, entitled " Women in Wartime," "' Facts on Sex for Men," and " What are the Venereal Diseases?" In all cases the subject is handled in a tactful but frank way. Emphasis is placed upon the risks of casual sexual intercourse.
53 TUBERCULOSIS
IN
YOUNG
CHILDREN*
By JEAN MACKINTOSH, M.B., Ch,B. (OLASG.), D.P.H., Regional M . O . f o r M . ~ C . W . , City @Aberdeen. M y remarks in this p a p e r are m a d e as a child-welfare officer w i t h no p r e t e n t i o n s to any specialist knowledge of tuberculosis, a n d while I shall a t t e m p t to s u r v e y the subject as a whole f r o m t h e child-welfare p o i n t of view, yet m y remarks, so far as statistics at least are concerned, m u s t necessarily t e n d to be confined m o r e to S c o t l a n d a n d m y o w n region i n the n o r t h - e a s t of t h a t c o u n t r y , w h i c h e m b r a c e s t h e City a n d C o u n t y of A b e r d e e n a n d the C o u n t y of K i n c a r d i n e . T h e region has a total p o p u l a t i o n of 353,815, a n d a l t h o u g h there are three local authorities, yet for p u b l i c h e a l t h purposes t h e r e is o n e M . P . H . w h o co-ordinates the work of his staff t h r o u g h o u t the region. He also co-ordinates the work of the hospitals. I t will be c o n v e n i e n t at t i m e s in this p a p e r to c o m p a r e the City a n d C o u n t y of A b e r d e e n , w h i c h have e s t i m a t e d populations of 179,628 a n d 146,414 respectively. T h e b u l k of the A b e r d e e n shire p o p u l a t i o n live i n the rural area a n d only a b o u t 40,000 live i n t h e t e n small b u r g h s scattered t h r o u g h o u t the county. A b e r d e e n City is a neutral area a n d A b e r d e e n s h i r e a n d K i n c a r dineshire are receiving areas. T h e outlook o n t u b e r c u l o u s infection in y o u n g c h i l d r e n has changed since I was a medical s t u d e n t . A f t e r V o n P i r q u e t ' s f i n d i n g t h a t 8 0 % of c h i l d r e n reacted positively to the t u b e r c u l i n test, it was c o n s i d e r e d inevitable t h a t before r e a c h i n g a d u l t life the majority of persons w o n l d be infected w i t h tuberculosis to a greater or less degree, a n d t h a t there was n o t m u c h to be done a b o u t it. A p a r t f r o m collaborating w i t h t h e tuberculosis officer i n the removal of c h i l d r e n f r o m the v i c i n i t y of o p e n cases of tuberculosis a n d a t t e m p t i n g to i m p r o v e the c o n d i t i o n of maln o u r i s h e d children, m a n y M . & C.W. d e p a r t m e n t s took very little active p a r t i n the anti-tuberculosis campaign. C e r t a i n l y n o t h i n g has b e e n done comparable with, for example, the p r e s e n t drive for d i p h t h e r i a p r e v e n t i o n . I shall try to deal w i t h some of the a d m i n i s t r a t i v e p r o b l e m s of tuberculosis in y o u n g c h i l d r e n a n d to assess w h a t influence the war has h a d o n these p r o b l e m s .
Tuberculosis Mortality in Scotland I n S c o t l a n d the d e a t h rate f r o m tuberculosis has s h o w n a t e n d e n c y to rise since t h e o u t b r e a k of war, a n d this is true of b o t h the p u l m o n a r y d e a t h rate a n d the n o n - p u l m o n a r y d e a t h rate ( T a b l e I). T h e City of A b e r d e e n over the past n u m b e r of years has s h o w n a tuberculosis d e a t h rate c o n s i s t e n t l y lower t h a n t h e o t h e r cities in Scotland, the lowest rate ever r e c o r d e d b e i n g t h a t of 1939 w i t h 47 p e r 100,000 of the p o p u l a t i o n , w h i c h c o m p a r e s v e r y favourably w i t h E n g l i s h count3" b o r o u g h s . A b e r d e e n s h i r e , too, has a low d e a t h rate f r o m tuberculosis, the lowest i n r e c e n t years b e i n g 37 p e r 100,000 in 1938, followed closely b y 38 i n 1939. I n b o t h areas, however, the d e a t h rate, as in t h e rest of Scotland, s h o w e d a t e n d e n c y to rise in 1940, rather m o r e so i n the City t h a n the C o u n t y : in the City f r o m 47 to 61 a n d i n the Count)" f r o m 38 to 46 ( T a b l e I). I n the City of A b e r d e e n the rise is practically c o n f i n e d to the g r o u p of deaths f r o m p u l m o n a r y tuberculosis ; in the C o u n t y the rise is almost e n t i r e l y c o n f i n e d to the g r o u p of deaths f r o m n o n p u l m o n a r y tuberculosis. I n n e i t h e r the City n o r ' t h e C o u n t y does this rise seem likely to c o n t i n u e i n 1941, a l t h o u g h it seems unlikely t h a t the d e a t h rates will r e t u r n to the 1939 level. I n this respect t h e r e is a difference b e t w e e n the p r e s e n t w a r a n d the war of 1914-1918, w h e n the tuberculosis d e a t h rate in S c o t l a n d actually fell slightly d u r i n g these years, i n c o n t r a s t to E n g l a n d a n d Wales, w h e r e t h e tuberculosis d e a t h rate rose. Collis 1, i n a r e c e n t s t u d y of the rise of the tuberculosis d e a t h rate in various c o u n t r i e s in t h e 1914-18 war, stated his belief t h a t it was due in great m e a s u r e to t h e increasing m a l n u t r i t i o n a m o n g t h e p o p u l a t i o n . T h i s view is s u p p o r t e d b y figures g i v e n of the d e a t h rates f r o m respiratory tuberculosis a m o n g various grades of-society i n t h e R e g i s t r a r - G e n e r a l ' s s u p p l e m e n t for E n g l a n d a n d Wales for 1938: the d e a t h rate i n the lowest social grade was s h o w n to be twice t h a t in the highest social grade. O n the o t h e r h a n d , C o b b e t t * t h o u g h t t h a t m o s t of t h e • Paper read before a meeting of the Maternity and Child Welfare Group of the Society in February, 194,2.
Treatment of Phosphorus Burns New instructions on the treatment of phosphorus burns have been substituted for those contained in E.M.S./Gen./336 (revised). It is now recommended that at the incident water should be applied immediately to the affected part to extinguish any burning phosphorus and to keep the area moist. T h e burn should then be covered with a clean mines dressing, or clean lint, or a clean cloth soaked in water. Whatever dressing is used it must be kept wet, as otherwise it may burst into flame. With the wet dressing in place, the casualty, if a sitting case or able to walk, should be conveyed or directed at once to the nearest First Aid Post or hospital for further treatment. Stretcher cases must be sent direct to a hospital with the least possible delay. T o ensure immediate attention at the hospital, these casualties must be labelled, and the label marked with a P. T h e attention of the ambulance attendant must be drawn to the case. At the First Aid Post or hospital the affected part should be immersed in water. If sufficient water is not available a mines dressing soaked in water should be applied. T h e dressing should be kept wet until the affected area can be thoroughly flooded and washed with bicarbonate of soda solution (roughly two tablespoonfuls of the powder to a pint of cold tap water). Any obvious particles of phosphorus, disclosed by examination in the dark (phosphorescence), can be picked off with forceps. The affected area is then swabbed with a 1% solution of copper sulphate, which will coat any remaining phosphorus particles with a dark deposit of copper phosphide. As much of this as is possible without damaging the tissues must be removed with forceps or gauze. T h e affected area should be immersed in the bicarbonate of soda solution for a prolonged period. T h e duration of this soaking depends upon the size and depth of the burn--i.e., small b u m s { hour, large burns I to 2 hours. If immersion is impossible, the sterile dressing should be kept repeatedly wetted with the bicarbonate solutiori. Finally, the burn must be re-examined in the dark for phosphorescence. If this is not present the burn can be dressed in the ordinary way. If there is still any doubt about the presence of phosphorus the burn should be dressed four-hourly with lint soaked in sodium bicarbonate solution (2 tablespoonfuls to the pint of water). No oils or greasy dressings and no tannic acid, triple dye or brilliant green must be used in the treatment of phosphorus burns so long as any trace of phosphorus remains in the tissues. Oils and greases are solvents of phosphorus and their use while it is present will cause risk of poisoning from absorption. To help the Ministry of Health in its campaign against venereal diseases. the Central Council for Health Education has recently issued three attractively printed leaflets, pocket'size, entitled " Women in Wartime," "' Facts on Sex for Men," and " What are the Venereal Diseases?" In all cases the subject is handled in a tactful but frank way. Emphasis is placed upon the risks of casual sexual intercourse.
53 TUBERCULOSIS
IN
YOUNG
CHILDREN*
By JEAN MACKINTOSH, M.B., Ch,B. (OLASG.), D.P.H., Regional M . O . f o r M . ~ C . W . , City @Aberdeen. M y remarks in this p a p e r are m a d e as a child-welfare officer w i t h no p r e t e n t i o n s to any specialist knowledge of tuberculosis, a n d while I shall a t t e m p t to s u r v e y the subject as a whole f r o m t h e child-welfare p o i n t of view, yet m y remarks, so far as statistics at least are concerned, m u s t necessarily t e n d to be confined m o r e to S c o t l a n d a n d m y o w n region i n the n o r t h - e a s t of t h a t c o u n t r y , w h i c h e m b r a c e s t h e City a n d C o u n t y of A b e r d e e n a n d the C o u n t y of K i n c a r d i n e . T h e region has a total p o p u l a t i o n of 353,815, a n d a l t h o u g h there are three local authorities, yet for p u b l i c h e a l t h purposes t h e r e is o n e M . P . H . w h o co-ordinates the work of his staff t h r o u g h o u t the region. He also co-ordinates the work of the hospitals. I t will be c o n v e n i e n t at t i m e s in this p a p e r to c o m p a r e the City a n d C o u n t y of A b e r d e e n , w h i c h have e s t i m a t e d populations of 179,628 a n d 146,414 respectively. T h e b u l k of the A b e r d e e n shire p o p u l a t i o n live i n the rural area a n d only a b o u t 40,000 live i n t h e t e n small b u r g h s scattered t h r o u g h o u t the county. A b e r d e e n City is a neutral area a n d A b e r d e e n s h i r e a n d K i n c a r dineshire are receiving areas. T h e outlook o n t u b e r c u l o u s infection in y o u n g c h i l d r e n has changed since I was a medical s t u d e n t . A f t e r V o n P i r q u e t ' s f i n d i n g t h a t 8 0 % of c h i l d r e n reacted positively to the t u b e r c u l i n test, it was c o n s i d e r e d inevitable t h a t before r e a c h i n g a d u l t life the majority of persons w o n l d be infected w i t h tuberculosis to a greater or less degree, a n d t h a t there was n o t m u c h to be done a b o u t it. A p a r t f r o m collaborating w i t h t h e tuberculosis officer i n the removal of c h i l d r e n f r o m the v i c i n i t y of o p e n cases of tuberculosis a n d a t t e m p t i n g to i m p r o v e the c o n d i t i o n of maln o u r i s h e d children, m a n y M . & C.W. d e p a r t m e n t s took very little active p a r t i n the anti-tuberculosis campaign. C e r t a i n l y n o t h i n g has b e e n done comparable with, for example, the p r e s e n t drive for d i p h t h e r i a p r e v e n t i o n . I shall try to deal w i t h some of the a d m i n i s t r a t i v e p r o b l e m s of tuberculosis in y o u n g c h i l d r e n a n d to assess w h a t influence the war has h a d o n these p r o b l e m s .
Tuberculosis Mortality in Scotland I n S c o t l a n d the d e a t h rate f r o m tuberculosis has s h o w n a t e n d e n c y to rise since t h e o u t b r e a k of war, a n d this is true of b o t h the p u l m o n a r y d e a t h rate a n d the n o n - p u l m o n a r y d e a t h rate ( T a b l e I). T h e City of A b e r d e e n over the past n u m b e r of years has s h o w n a tuberculosis d e a t h rate c o n s i s t e n t l y lower t h a n t h e o t h e r cities in Scotland, the lowest rate ever r e c o r d e d b e i n g t h a t of 1939 w i t h 47 p e r 100,000 of the p o p u l a t i o n , w h i c h c o m p a r e s v e r y favourably w i t h E n g l i s h count3" b o r o u g h s . A b e r d e e n s h i r e , too, has a low d e a t h rate f r o m tuberculosis, the lowest i n r e c e n t years b e i n g 37 p e r 100,000 in 1938, followed closely b y 38 i n 1939. I n b o t h areas, however, the d e a t h rate, as in t h e rest of Scotland, s h o w e d a t e n d e n c y to rise in 1940, rather m o r e so i n the City t h a n the C o u n t y : in the City f r o m 47 to 61 a n d i n the Count)" f r o m 38 to 46 ( T a b l e I). I n the City of A b e r d e e n the rise is practically c o n f i n e d to the g r o u p of deaths f r o m p u l m o n a r y tuberculosis ; in the C o u n t y the rise is almost e n t i r e l y c o n f i n e d to the g r o u p of deaths f r o m n o n p u l m o n a r y tuberculosis. I n n e i t h e r the City n o r ' t h e C o u n t y does this rise seem likely to c o n t i n u e i n 1941, a l t h o u g h it seems unlikely t h a t the d e a t h rates will r e t u r n to the 1939 level. I n this respect t h e r e is a difference b e t w e e n the p r e s e n t w a r a n d the war of 1914-1918, w h e n the tuberculosis d e a t h rate in S c o t l a n d actually fell slightly d u r i n g these years, i n c o n t r a s t to E n g l a n d a n d Wales, w h e r e t h e tuberculosis d e a t h rate rose. Collis 1, i n a r e c e n t s t u d y of the rise of the tuberculosis d e a t h rate in various c o u n t r i e s in t h e 1914-18 war, stated his belief t h a t it was due in great m e a s u r e to t h e increasing m a l n u t r i t i o n a m o n g t h e p o p u l a t i o n . T h i s view is s u p p o r t e d b y figures g i v e n of the d e a t h rates f r o m respiratory tuberculosis a m o n g various grades of-society i n t h e R e g i s t r a r - G e n e r a l ' s s u p p l e m e n t for E n g l a n d a n d Wales for 1938: the d e a t h rate i n the lowest social grade was s h o w n to be twice t h a t in the highest social grade. O n the o t h e r h a n d , C o b b e t t * t h o u g h t t h a t m o s t of t h e • Paper read before a meeting of the Maternity and Child Welfare Group of the Society in February, 194,2.