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OPHTHALMOLOGY IN THE FIELD
OPHTHALMOLOGY 1 THE FIELD.-THE, VOLUNTARY HOSPITALS .
472
the
pronounced element of nodular hyperplasia, especially in younger subjects. The same agent acting over a longer period may produce a slightly different picture, such as that typical of of fibrosis with
foreign body, and reason all fragments removed through the
a
sclera by the posterior route. There seems to be no disadvantage to this operation, and PHILPS 10 has shown that useful eyes result from it, but it requires good theatre conditions, such as would certainly not be available at a casualty clearing station. Out of 105 eyes containing a foreign body STALLARD found that in 39 it was magnet-positive, though removal often failed at the first attempt, and in 3 others it was possible to remove the fragment with forceps. In 63 cases the foreign body was nonmagnetic and had to be left in the eye, but some of these eyes remain quiet for years, sometimes with good vision. In his opinion no harm resulted from leaving the fragment in the eye until the man reached a base hospital, but its ultimate extraction is undoubtedly made more difficult by a delay of four or
alcoholic " cirrhosis," which it is estimatedtakes 5-15 years to develop. These differences are, however, believed to be differences of degree and not fundamental. To what extent can liver disease in man be attributed to dietary deficiency ? While pointing out that " No certain evidence of the occurrence of massive hepatic necrosis due to a deficient diet has yet been produced " in man, HIMSWORTH and his colleaguedraw attention to the suggestion the that high incidence of cirrhosis of the liver among poor natives in the Punjab and Rand may be of this nature, a suggestion which GILLMAN7 has supported by producing hepatic cirrhosis in rats by feeding them on the ordinary diet of natives in the mines of South Africa.
OPHTHALMOLOGY IN THE FIELD
North African campaign the first specialised wounding was dispensed by a mobile ophthalmic unit. This unit, though fully equipped and able to work on its own, usually attached itself to a casualty clearing station at the first bottleneck of casualties. It has sometimes been possible to group together at the CCS a mobile eye unit, neurosurgical unit and faciomaxillary unit, and where this has been done there has been great saving of time with consequent benefit to the patient, for all wounds IN the
eye treatment after
above the chin can then be referred to these teams. This must be the ideal arrangement to be aimed at in the future. Owing to the appalling nature of the desert tracks in North Africa, 36 hours usually elapsed before the wounded man reached the eye unit, and during that time the only treatment that could be given was a shell dressing to the eye and sulphonamides by mouth. ])ANSEY -BROWNING 8 records his experiences in treating 514 battle casualties at a mobile eye unit in Libya. Operative procedures were reduced to a minimum, for his patients could not be retained at the CCS more than one or two days, and it was found better to evacuate as many as possible to a base hospital for operation there. Even so, 200 major operations were performed in his unit-chiefly removal of hopelessly disorganised eyes and covering perforating wounds with a conjunctival flap. However, wars are not won by eye operations, and the main military value of his unit was in preventing men with minor injuries and errors of refraction from being evacuated to a base hospital. All such cases could be dealt with at once and returned to the line. Half of all casualties The shell seen were concussion changes in the eye. is still of the commonest cause perforating splinter wounds, with land-mines a good second, but the bullet is locally the most destructive. The intraocular foreign body of modern warfare presents a difficult problem, and as with most war surgery of the eye the operative results are often disappointing. Even so, some eyes can be saved by skilful surgery. Owing to considerations of weight, less iron and more alloy is used in bomb and shell casings these days, with the result that an intraocular fragment gives a poor response to the electromagnet. The magnet must be brought as close as possible to 7.
8.
Gillman, J. Brit. med. J. 1944, i, 149.
Dansey-Browning, G. C. Brit. J. Ophthal. 1944, 28, 87.
STALLARD 9 found that for this behind the lens were better
five days. It is the task of the
ophthalmic surgeon in the field wounds and remove prolapsed perforating uveal tissue. When this is done the man is better evacuated to the base, and the surgeon in the forward area does not have to consider which eyes should be removed for fear of sympathetic ophthalmia. No case of sympathetic ophthalmia was reported from STALLARD’s area, which is in accord with what we have come to expect. This complication does not arise for-at least a fortnight after wouring, and usually much later than this. It is now a very rare disease, and it maybe recalled that the only 4 cases of blindness from this cause to pass through St. Dunstan’s in the last war arose not from war missiles at all but from civilian " accidents to. soldiers.’-I to
cover
"
THE VOLUNTARY HOSPITALS WE publish this week reviews of the white-paper by the house-governor of a voluntary hospital and doctor directing a municipal hospital service. The former thinks the proposals threaten the autonomy of voluntary hospitals and the latter supports his pessimism by foreseeing that they will eventually lose their supporters and the special status now accorded them. We agree that this may well prove the fate of some of the smaller institutions which have As we said on never set a particularly high standard. March 4, however, we believe that many voluntary hospitals, including those with teaching schools, should be able tojustify their autonomous existence by the special contributions they can make to the public service. They have long traditions ; they inspire loyalty ; they are at present the chief home of research ; and they are efficient going concerns. There is in fact, good reason why the Government should sincerely wish them to continue the work they are doing in the way they are doing it. In our view, the Government intends to offer them financial terms that will enable them to perform their valuable functions. It is true that the white-paper argues that if they wish to manage their own affairs they cannot expect to receive from ublic funds the full cost of treating their patients, but the gap between receipts of public money and expenditure on public patients might be made very small-a mere token.
.
by a
9. Stallard, H. B. Ibid, p. 105. 10. Philps, A. S. Trans. ophthal. Soc. U.K. 1942, 62, 169. 11. Lawson, A. War Blindness at St. Dunstan’s, London,
p. 59.
1922,
472
the
pronounced element of nodular hyperplasia, especially in younger subjects. The same agent acting over a longer period may produce a slightly different picture, such as that typical of of fibrosis with
foreign body, and reason all fragments removed through the
a
sclera by the posterior route. There seems to be no disadvantage to this operation, and PHILPS 10 has shown that useful eyes result from it, but it requires good theatre conditions, such as would certainly not be available at a casualty clearing station. Out of 105 eyes containing a foreign body STALLARD found that in 39 it was magnet-positive, though removal often failed at the first attempt, and in 3 others it was possible to remove the fragment with forceps. In 63 cases the foreign body was nonmagnetic and had to be left in the eye, but some of these eyes remain quiet for years, sometimes with good vision. In his opinion no harm resulted from leaving the fragment in the eye until the man reached a base hospital, but its ultimate extraction is undoubtedly made more difficult by a delay of four or
alcoholic " cirrhosis," which it is estimatedtakes 5-15 years to develop. These differences are, however, believed to be differences of degree and not fundamental. To what extent can liver disease in man be attributed to dietary deficiency ? While pointing out that " No certain evidence of the occurrence of massive hepatic necrosis due to a deficient diet has yet been produced " in man, HIMSWORTH and his colleaguedraw attention to the suggestion the that high incidence of cirrhosis of the liver among poor natives in the Punjab and Rand may be of this nature, a suggestion which GILLMAN7 has supported by producing hepatic cirrhosis in rats by feeding them on the ordinary diet of natives in the mines of South Africa.
OPHTHALMOLOGY IN THE FIELD
North African campaign the first specialised wounding was dispensed by a mobile ophthalmic unit. This unit, though fully equipped and able to work on its own, usually attached itself to a casualty clearing station at the first bottleneck of casualties. It has sometimes been possible to group together at the CCS a mobile eye unit, neurosurgical unit and faciomaxillary unit, and where this has been done there has been great saving of time with consequent benefit to the patient, for all wounds IN the
eye treatment after
above the chin can then be referred to these teams. This must be the ideal arrangement to be aimed at in the future. Owing to the appalling nature of the desert tracks in North Africa, 36 hours usually elapsed before the wounded man reached the eye unit, and during that time the only treatment that could be given was a shell dressing to the eye and sulphonamides by mouth. ])ANSEY -BROWNING 8 records his experiences in treating 514 battle casualties at a mobile eye unit in Libya. Operative procedures were reduced to a minimum, for his patients could not be retained at the CCS more than one or two days, and it was found better to evacuate as many as possible to a base hospital for operation there. Even so, 200 major operations were performed in his unit-chiefly removal of hopelessly disorganised eyes and covering perforating wounds with a conjunctival flap. However, wars are not won by eye operations, and the main military value of his unit was in preventing men with minor injuries and errors of refraction from being evacuated to a base hospital. All such cases could be dealt with at once and returned to the line. Half of all casualties The shell seen were concussion changes in the eye. is still of the commonest cause perforating splinter wounds, with land-mines a good second, but the bullet is locally the most destructive. The intraocular foreign body of modern warfare presents a difficult problem, and as with most war surgery of the eye the operative results are often disappointing. Even so, some eyes can be saved by skilful surgery. Owing to considerations of weight, less iron and more alloy is used in bomb and shell casings these days, with the result that an intraocular fragment gives a poor response to the electromagnet. The magnet must be brought as close as possible to 7.
8.
Gillman, J. Brit. med. J. 1944, i, 149.
Dansey-Browning, G. C. Brit. J. Ophthal. 1944, 28, 87.
STALLARD 9 found that for this behind the lens were better
five days. It is the task of the
ophthalmic surgeon in the field wounds and remove prolapsed perforating uveal tissue. When this is done the man is better evacuated to the base, and the surgeon in the forward area does not have to consider which eyes should be removed for fear of sympathetic ophthalmia. No case of sympathetic ophthalmia was reported from STALLARD’s area, which is in accord with what we have come to expect. This complication does not arise for-at least a fortnight after wouring, and usually much later than this. It is now a very rare disease, and it maybe recalled that the only 4 cases of blindness from this cause to pass through St. Dunstan’s in the last war arose not from war missiles at all but from civilian " accidents to. soldiers.’-I to
cover
"
THE VOLUNTARY HOSPITALS WE publish this week reviews of the white-paper by the house-governor of a voluntary hospital and doctor directing a municipal hospital service. The former thinks the proposals threaten the autonomy of voluntary hospitals and the latter supports his pessimism by foreseeing that they will eventually lose their supporters and the special status now accorded them. We agree that this may well prove the fate of some of the smaller institutions which have As we said on never set a particularly high standard. March 4, however, we believe that many voluntary hospitals, including those with teaching schools, should be able tojustify their autonomous existence by the special contributions they can make to the public service. They have long traditions ; they inspire loyalty ; they are at present the chief home of research ; and they are efficient going concerns. There is in fact, good reason why the Government should sincerely wish them to continue the work they are doing in the way they are doing it. In our view, the Government intends to offer them financial terms that will enable them to perform their valuable functions. It is true that the white-paper argues that if they wish to manage their own affairs they cannot expect to receive from ublic funds the full cost of treating their patients, but the gap between receipts of public money and expenditure on public patients might be made very small-a mere token.
.
by a
9. Stallard, H. B. Ibid, p. 105. 10. Philps, A. S. Trans. ophthal. Soc. U.K. 1942, 62, 169. 11. Lawson, A. War Blindness at St. Dunstan’s, London,
p. 59.
1922,