Morning Call: pick of the papers

The ten must-read comment pieces from this morning's papers.

1. Economic crisis isn't over yet. This may not even be the beginning of the end (Guardian)

Statistically, the UK is out of recession – but it took an Olympian effort to achieve even this fragile upturn, writes Larry Elliott.

2. Gordon Brown’s secret army could defeat the coalition’s welfare and education reforms (Daily Telegraph)

Britain’s charities and quangos are now stuffed to the gunwales with Labour placemen, says Fraser Nelson.

3. There is no ‘unishambles’ in education (Independent)

The government's university reforms are putting a new focus on the student experience, promoting opportunity and helping reduce the public deficit, argues David Willetts.

4. Look out, wolves. The little pigs’ time is here (Times) (£)

Whether you’re Man Utd manager, Chief Whip or BBC boss, don’t expect deference any more, writes Gaby Hinsliff.

5. This withering assault on farm workers' wages is a race to the bottom (Guardian)

Farming is the last sector where pay rates have some level of protection, and now that is under threat, writes Polly Toynbee. Labour, take note.

6. Turkey stumbles on the road to Damascus (Financial Times)

Ankara has come to realise that it has been overtaken by events, writes Philip Stephens.

7. Good news for the economy at last... now can we cut taxes? (Daily Mail)

Osborne must recognise that high taxes are the enemy of enterprise and growth, says Alex Brummer.

8. Whether it’s the Hutton Report or Jimmy Savile, the BBC is hopeless in a crisis (Daily Telegraph)

Peter Rippon of Newsnight has been hung out to dry as his BBC bosses play the blame game, writes Andrew Gilligan.

9. The threat to local government's heroic, civilising role (Guardian)

Brutal cuts and the demands of core provision put services such as museums, parks and community halls at huge risk, says Tristram Hunt.

10. If the City of London loses the trust of the people it serves, whether home or abroad, it's finished (Independent)

Customers are not to be thought of as sales targets but as people with whom the institution aims to have a mutually profitable relationship, writes Andreas Whittam Smith.

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The surprising truth about ingrowing toenails (and other medical myths)

Medicine is littered with myths. For years we doled out antibiotics for minor infections, thinking we were speeding recovery.

From time to time, I remove patients’ ingrowing toenails. This is done to help – the condition can be intractably painful – but it would be barbaric were it not for anaesthesia. A toe or finger can be rendered completely numb by a ring block – local anaesthetic injected either side of the base of the digit, knocking out the nerves that supply sensation.

The local anaesthetic I use for most surgical procedures is ready-mixed with adrenalin, which constricts the arteries and thereby reduces bleeding in the surgical field, but ever since medical school I’ve had it drummed into me that using adrenalin is a complete no-no when it comes to ring blocks. The adrenalin cuts off the blood supply to the end of the digit (so the story goes), resulting in tissue death and gangrene.

So, before performing any ring block, my practice nurse and I go through an elaborate double-check procedure to ensure that the injection I’m about to use is “plain” local anaesthetic with no adrenalin. This same ritual is observed in hospitals and doctors’ surgeries around the world.

So, imagine my surprise to learn recently that this is a myth. The idea dates back at least a century, to when doctors frequently found digits turning gangrenous after ring blocks. The obvious conclusion – that artery-constricting adrenalin was responsible – dictates practice to this day. In recent years, however, the dogma has been questioned. The effect of adrenalin is partial and short-lived; could it really be causing such catastrophic outcomes?

Retrospective studies of digital gangrene after ring block identified that adrenalin was actually used in less than half of the cases. Rather, other factors, including the drastic measures employed to try to prevent infection in the pre-antibiotic era, seem likely to have been the culprits. Emboldened by these findings, surgeons in America undertook cautious trials to investigate using adrenalin in ring blocks. They found that it caused no tissue damage, and made surgery technically easier.

Those trials date back 15 years yet they’ve only just filtered through, which illustrates how long it takes for new thinking to become disseminated. So far, a few doctors, mainly those in the field of plastic surgery, have changed their practice, but most of us continue to eschew adrenalin.

Medicine is littered with such myths. For years we doled out antibiotics for minor infections, thinking we were speeding recovery. Until the mid-1970s, breast cancer was routinely treated with radical mastectomy, a disfiguring operation that removed huge quantities of tissue, in the belief that this produced the greatest chance of cure. These days, we know that conservative surgery is at least as effective, and causes far less psychological trauma. Seizures can happen in young children with feverish illnesses, so for decades we placed great emphasis on keeping the patient’s temperature down. We now know that controlling fever makes no difference: the fits are caused by other chemicals released during an infection.

Myths arise when something appears to make sense according to the best understanding we have at the time. In all cases, practice has run far ahead of objective, repeatable science. It is only years after a myth has taken hold that scientific evaluation shows us to have charged off down a blind alley.

Myths are powerful and hard to uproot, even once the science is established. I operated on a toenail just the other week and still baulked at using adrenalin – partly my own superstition, and partly to save my practice nurse from a heart attack. What would it have been like as a pioneering surgeon in the 1970s, treating breast cancer with a simple lumpectomy while most of your colleagues believed you were being reckless with your patients’ future health? Decades of dire warnings create a hefty weight to overturn.

Only once a good proportion of the medical herd has changed course do most of us feel confident to follow suit. 

This article first appeared in the 20 April 2017 issue of the New Statesman, May's gamble

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