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GAS INJURIES TO THE EYES
756
GAS INJURIES TO THE EYES
part to the contraction of the fibrous tissue round the joint. At this stage sclerosis of the bone is likely to develop, with formation of osteophytes, provided that some degree of movement has been retained to provide
’
the stimulus. Gouty arthritis.-The effect of local anaemia in causing sclerosis of bone and a more proliferative type of arthritis explains the frequency with which these changes are found in elderly and in arteriosclerotic patients. The products of disordered metabolism, such as are formed in gouty arthritis, damage the joints, and in some cases this is the primary cause of the subsequent osteo-arthritis. This form of arthritis also consists of two components : (1) the primary metabolic disorder with its local effects on the joint, and (2) the resulting mechanical arthritis. To these may be added a third factornamely, ansemia of the tissues from the often associated arteriosclerosis. This factor tends to accelerate the deterioration of the joint and may increase the sclerosis of the ends of the bones. Nutritional disturbances.-In many cases, especially in elderly subjects, no definite primary cause can be found for the osteo-arthritis. In such cases deterioration of the cartilage, which becomes soft and fibrillated, is usually the first change, and I suggest that this is probably due to deficient nutrition. In this sense such changes may reasonably be described as " trophic " and are probably a direct result of the often associated arteriosclerosis. Once such changes have taken place in the articular cartilage, the eventual onset of generalised osteo-arthritis becomes inevitable. (To be concluded)
GAS INJURIES TO THE EYES THE damage to the eyes that may arise from high explosives and incendiary bombs will not differ essentially from that met with in peace-time practice, and its treatment can be based on established but injuries due to gas are largely an unknown quantity. Though the value of gas as a measure of offence in comparison with high explosives is open to doubt, and therefore the extent to which it will be used in this war remains to be seen, the possibility that it will later be employed to produce panic and disorganisation among civilians must be prepared for. The experience gained in the last war, however, may not be applicable to this, not so much because new unknown gases may be used but because the methods of distribution of gases are now more effective. Almost all gases used in chemical warfare cause some ocular discomfort and lacrimation, but the groups known as lacrimators and vesicants are of special significance. The lacrimators produce severe subjective symptoms, which are mainly ocular but also include burning sensations in the throat and pain and discomfort in the chest when patients are exposed to relatively high concentrations. The eye symptoms are outstanding-they consist of a stinging in the eyes, immediate and profuse lacrimation, and spasm of the eyelids, sometimes so severe that the victim is unable to open his eyes at all. These symptoms, though alarming, are transient, and within a few hours the whole condition subsides, leaving no permanent after-effects.
principles,
As against these dramatic and obvious effects of the lacrimators, the action of the vesicants is insidious. This group comprises mustard gas and the allied Lewisite ; the latter, though first prepared in 1917, has not as yet been used in war. When the eye is exposed to mustard gas there is a latent period whose duration depends on the concentration of the gas. In the last war it was, as a rule, six to eight hours, though sometimes it was as short as two hours, and it is absent when gas in its liquid form splashes directly into the eyes. After the latent period pain and a feeling of grittiness under the lids develop, followed by photophobia, blepharospasm and profuse lacrimation. The lids become oedematous and glued together. The conjunctiva, particularly in the interpalpebral area, is intensely engorged and swollen. Where the cornea is involved, the photophobia and blepharospasm are more severe, and the patient may think himself blind because he cannot open his eyes. There is no purulent discharge unless secondary infection takes place. In cases of corneal involvement the part of the cornea that is covered by the upper lid is usually unaffected. The exposed inter. palpebral area loses its lustre ; a turbid horizontal band is thus seen stretching across the clear cornea to become confluent with the affected interpalpebral conjunctiva. The pupil is contracted. Abrasion, ulceration and secondary infection may all occur, rendering the immediate prognosis more grave. Where there has been a direct splash with liquid gas intense lacrimation sets in within a few minutes; within half an hour there is great injection of the conjunctiva and within an hour progressive chemosis. Infiltrating ulceration involving the cornea, conjunctiva and lids develops. The corneal lesion is similar to that of any severe caustic burn, but the
slowly progressive damage and delayed healing more resemble an X-ray burn. During the last war only about 10 per cent. of gassed men developed corneal lesions-mostly transient-and it is said that only about 15 men in all were blinded by gas. This figure is almost certainly an underestimate, if the cases of late keratitis, not recognised till several years after the war, are included. None the less, the figures do help us to place the risks of mustard gas to the eyes in their proper perspective, for protective measures against gas have developed considerably in the last twenty years. TREATMENT
Fundamental difficulties arise in treatment. Experimental works by Warthin and Welleron various animals suggests that the action of gas is instantaneous. If drops of liquid mustard gas are put on both corneas of an animal, and one eye is at once thoroughly irrigated, the lesions in the two eyes on the following day are identical. Histologically all the layers of the cornea are involved, and in severe cases the whole of the cornea is necrosed, exposing Bowman’s membrane. If these findings are applicable to man, the end-result will be determined almost entirely by the concentration of the gas reaching the eye, and treatment can only be directed to relieving symptoms and combating the cumulative action of the gas. This lamentable view, which is generally accepted, is contested by Bonnefon,2 who points out that horses were more affected than men by gas during the last war, and records the severe Warthin, A. S., and Weller, C. V., Medical Aspects of Mustard Gas Poisoning, St. Louis, 1919. 2. Bonnefon, Gaz. scien. méd. Bordeaux, March 12, 1939, and Siècle méd. Sept. 1, 1939. 1.
757
MOVEMENT OF THE MEDICAL SCHOOLS
GENERAL POST : course
of eye lesions in animals as the result öf the absence of lacrimal secretion with its defensive mechanism. As against the classical treatmentirrigation with some bland lotion such as sodium bicarbonate solution, instillation of castor oil or liquid paraffin, and atropine drops where necessaryBonnefon advocates measures to increase the flow of tears and induce drainage from the conjunctiva and cornea by osmosis. He regards oily drops as harmful because they absorb the gas and thus keep it pent up in the eye; ointments he condemns for the same reason and also because they impede the flow of tears by glueing the lids together. He suggests irrigation for 10 minutes, two or three times a day, with a hypertonic lotion such as saturated solution of sodium sulphate 800 grammes, solution of glucose 200 g. One other method of treating severe corneal lesions may perhaps be found applicable. Of late years Denig has proposed immediate mucous grafting of the cornea in severe caustic burns, the graft being taken from the mucosa of the lower lip. The results are said to be gratifying, and this method may be worth trying out in exceptional cases. In all degrees of eye lesions from mustard gas two
The system will offer certain great advantages. The amount of clinical material and the opportunities for practical experience will be enormously increased, and this should more than compensate for the dispersal of clinical teachers. Many students will for the first time realise that municipal hospitals are not to be despised, and that there are many whole-time doctors in municipal service who can hold their own at the bedside with their voluntary-hospital colleagues. In some of the smaller hospitals, generalpractitioner members of the staff are already doing their share of teaching, and the students are learning at first-hand that general practice is not the occupation of the second-rate doctor. The position of the clinical students will be reviewed by the deans of the London hospitals towards the end of the year. The arrangements for the London medical schools will be reviewed by their deans towards the end of the year ; at present they are as follows :St. Bartholomew’s.-The preclinical anatomy and physiology will be carried on at Cambridge, while clinical studies will go on at St. Bartholomew’s casualty clearing station and the other hospitals in sector 3. Teaching in first year subjects has yet to be arranged.
symptoms require special attention, as was urged by Sorsby at the Aberdeen meeting of the British Medical Association. The blepharospasm induces a fear of blindness with a severe anxiety state. By gently separating the lids the patient can be convinced of the groundlessness of fears. The pain that patients experience has led to the suggestion that cocaine drops should be instilled, but most authorities agree that cocaine should be avoided owing to its devitalising effect on the corneal epithelium. Sub-
Charing Cross.-Preclinical students for Charing Cross Hospital normally attend King’s College. They will follow King’s College to Glasgow University. Clinical students will be distributed throughout the hospitals of sector 4. Teams of surgical dressers and blood-transfusion groups have been arranged. Clinical beginners are likely to be posted to the base hospital and an interchange of students between the hospitals to vary clinical experience will probably be organised. The address of the secretary of the Medical School is 81, St. Margaret’s Road, Twickenham, Middlesex.
stitutes such as Pantocaine and Larocaine have also been recommended,3 and Dor4 advocates 2 per cent. dionin drops. Where pain is severe, atropine is generally indicated because of the associated corneal lesion, and this should usually suffice. ,
GENERAL POST MOVEMENT OF THE MEDICAL SCHOOLS
DETAILS of the arrangements for the future ’of medical education in London and the provinces have In now been worked out by most medical schools. general, it may be -said that preclinical teaching in London is to stop, the London students being transferred to various provincial universities. The clinical teaching of the London schools, on the other hand, is to continue in the hospitals of the sector of each teaching hospital. The provincial schools are staying where they are, though many of them will have to make changes in organisation to cope with the London evacuees. In most cases, these newcomers are bringtheir own teachers with them, and the students ing will continue to take London examinations. The arrangements for clinical teaching in hospital sectors vary as yet in completeness. The most usual plan appears to be to dispatch those needing elementary clinical instruction to the base hospital, while the other students are divided into small groups that will move from hospital to hospital. At certain hospitals, usually those accommodating the sector pathological laboratories, arrangements will be made for teaching practical pathology, and as a rule one or two hospitals in each sector have adequate facilities for midwifery. Groups of students will be on duty at casualty
clearing stations for short spells. 3. Stallard, H. B., Lancet, Sept. 2, 1939, p. 576. 4. Dor, quoted in Pr. méd. July 5, 1939, p. 1066.
(Tel. : Popesgrove 1226.) St. George’s.-Preclinical students who normally study at King’s College will be transferred with that college. Clinical students are dispersed throughout sector 7. About 25 are at Isleworth, 15 at Staines, 10 at Slough, and smaller numbers at various L.C.C. hospitals. Guy’s.-The preclinical students at Guy’s will not go to Oxford as previously announced but to Sherwood Park, near Tunbridge Wells. Students will be lodged in private houses converted into hostels. Clinical students are distributed to the hospitals throughout sector 10.
King’s College Hospital.-The preclinical students at King’s College will go to Glasgow University. The clinical students have been distributed through the hospitals in sector 9. The London.-Preclinical students
are
to go to
Cambridge. They are being provided with board and lodging at St. Catherine’s College, but their teaching arrangements are in the hands of their own professors and not the university staff. Clinical students are distributed throughout the hospitals of sectors 1 and 2. Subject to the approval of the county borough
councils concerned, teaching will be carried on in the municipal hospitals at Romford, Rochford, and Whipps Cross, and in many voluntary hospitals including Southend General, Queen Mary’s at Stratford, and the King George V Hospital at Ilford. In sector 2 there are 12 large L.C.C. hospitals and also two important Middlesex county council hospitals. A service of dressers at casualty hospitals in dangerous
will be maintained and students will take turns for short spells on duty at these casualty hospitals. Facilities for teaching obstetrics will probably be available at the Hackney and Mile End Hospitals of the L.C.C., at f)ldchurch County Hospital, Romford, and at Brockett Hall which is being opened as an obstetric hospital for the county of Hertfordshire. Courses in pathology will be organised at Billericay Hospital under Professor Bedson, pathologist to
areas
GAS INJURIES TO THE EYES
part to the contraction of the fibrous tissue round the joint. At this stage sclerosis of the bone is likely to develop, with formation of osteophytes, provided that some degree of movement has been retained to provide
’
the stimulus. Gouty arthritis.-The effect of local anaemia in causing sclerosis of bone and a more proliferative type of arthritis explains the frequency with which these changes are found in elderly and in arteriosclerotic patients. The products of disordered metabolism, such as are formed in gouty arthritis, damage the joints, and in some cases this is the primary cause of the subsequent osteo-arthritis. This form of arthritis also consists of two components : (1) the primary metabolic disorder with its local effects on the joint, and (2) the resulting mechanical arthritis. To these may be added a third factornamely, ansemia of the tissues from the often associated arteriosclerosis. This factor tends to accelerate the deterioration of the joint and may increase the sclerosis of the ends of the bones. Nutritional disturbances.-In many cases, especially in elderly subjects, no definite primary cause can be found for the osteo-arthritis. In such cases deterioration of the cartilage, which becomes soft and fibrillated, is usually the first change, and I suggest that this is probably due to deficient nutrition. In this sense such changes may reasonably be described as " trophic " and are probably a direct result of the often associated arteriosclerosis. Once such changes have taken place in the articular cartilage, the eventual onset of generalised osteo-arthritis becomes inevitable. (To be concluded)
GAS INJURIES TO THE EYES THE damage to the eyes that may arise from high explosives and incendiary bombs will not differ essentially from that met with in peace-time practice, and its treatment can be based on established but injuries due to gas are largely an unknown quantity. Though the value of gas as a measure of offence in comparison with high explosives is open to doubt, and therefore the extent to which it will be used in this war remains to be seen, the possibility that it will later be employed to produce panic and disorganisation among civilians must be prepared for. The experience gained in the last war, however, may not be applicable to this, not so much because new unknown gases may be used but because the methods of distribution of gases are now more effective. Almost all gases used in chemical warfare cause some ocular discomfort and lacrimation, but the groups known as lacrimators and vesicants are of special significance. The lacrimators produce severe subjective symptoms, which are mainly ocular but also include burning sensations in the throat and pain and discomfort in the chest when patients are exposed to relatively high concentrations. The eye symptoms are outstanding-they consist of a stinging in the eyes, immediate and profuse lacrimation, and spasm of the eyelids, sometimes so severe that the victim is unable to open his eyes at all. These symptoms, though alarming, are transient, and within a few hours the whole condition subsides, leaving no permanent after-effects.
principles,
As against these dramatic and obvious effects of the lacrimators, the action of the vesicants is insidious. This group comprises mustard gas and the allied Lewisite ; the latter, though first prepared in 1917, has not as yet been used in war. When the eye is exposed to mustard gas there is a latent period whose duration depends on the concentration of the gas. In the last war it was, as a rule, six to eight hours, though sometimes it was as short as two hours, and it is absent when gas in its liquid form splashes directly into the eyes. After the latent period pain and a feeling of grittiness under the lids develop, followed by photophobia, blepharospasm and profuse lacrimation. The lids become oedematous and glued together. The conjunctiva, particularly in the interpalpebral area, is intensely engorged and swollen. Where the cornea is involved, the photophobia and blepharospasm are more severe, and the patient may think himself blind because he cannot open his eyes. There is no purulent discharge unless secondary infection takes place. In cases of corneal involvement the part of the cornea that is covered by the upper lid is usually unaffected. The exposed inter. palpebral area loses its lustre ; a turbid horizontal band is thus seen stretching across the clear cornea to become confluent with the affected interpalpebral conjunctiva. The pupil is contracted. Abrasion, ulceration and secondary infection may all occur, rendering the immediate prognosis more grave. Where there has been a direct splash with liquid gas intense lacrimation sets in within a few minutes; within half an hour there is great injection of the conjunctiva and within an hour progressive chemosis. Infiltrating ulceration involving the cornea, conjunctiva and lids develops. The corneal lesion is similar to that of any severe caustic burn, but the
slowly progressive damage and delayed healing more resemble an X-ray burn. During the last war only about 10 per cent. of gassed men developed corneal lesions-mostly transient-and it is said that only about 15 men in all were blinded by gas. This figure is almost certainly an underestimate, if the cases of late keratitis, not recognised till several years after the war, are included. None the less, the figures do help us to place the risks of mustard gas to the eyes in their proper perspective, for protective measures against gas have developed considerably in the last twenty years. TREATMENT
Fundamental difficulties arise in treatment. Experimental works by Warthin and Welleron various animals suggests that the action of gas is instantaneous. If drops of liquid mustard gas are put on both corneas of an animal, and one eye is at once thoroughly irrigated, the lesions in the two eyes on the following day are identical. Histologically all the layers of the cornea are involved, and in severe cases the whole of the cornea is necrosed, exposing Bowman’s membrane. If these findings are applicable to man, the end-result will be determined almost entirely by the concentration of the gas reaching the eye, and treatment can only be directed to relieving symptoms and combating the cumulative action of the gas. This lamentable view, which is generally accepted, is contested by Bonnefon,2 who points out that horses were more affected than men by gas during the last war, and records the severe Warthin, A. S., and Weller, C. V., Medical Aspects of Mustard Gas Poisoning, St. Louis, 1919. 2. Bonnefon, Gaz. scien. méd. Bordeaux, March 12, 1939, and Siècle méd. Sept. 1, 1939. 1.
757
MOVEMENT OF THE MEDICAL SCHOOLS
GENERAL POST : course
of eye lesions in animals as the result öf the absence of lacrimal secretion with its defensive mechanism. As against the classical treatmentirrigation with some bland lotion such as sodium bicarbonate solution, instillation of castor oil or liquid paraffin, and atropine drops where necessaryBonnefon advocates measures to increase the flow of tears and induce drainage from the conjunctiva and cornea by osmosis. He regards oily drops as harmful because they absorb the gas and thus keep it pent up in the eye; ointments he condemns for the same reason and also because they impede the flow of tears by glueing the lids together. He suggests irrigation for 10 minutes, two or three times a day, with a hypertonic lotion such as saturated solution of sodium sulphate 800 grammes, solution of glucose 200 g. One other method of treating severe corneal lesions may perhaps be found applicable. Of late years Denig has proposed immediate mucous grafting of the cornea in severe caustic burns, the graft being taken from the mucosa of the lower lip. The results are said to be gratifying, and this method may be worth trying out in exceptional cases. In all degrees of eye lesions from mustard gas two
The system will offer certain great advantages. The amount of clinical material and the opportunities for practical experience will be enormously increased, and this should more than compensate for the dispersal of clinical teachers. Many students will for the first time realise that municipal hospitals are not to be despised, and that there are many whole-time doctors in municipal service who can hold their own at the bedside with their voluntary-hospital colleagues. In some of the smaller hospitals, generalpractitioner members of the staff are already doing their share of teaching, and the students are learning at first-hand that general practice is not the occupation of the second-rate doctor. The position of the clinical students will be reviewed by the deans of the London hospitals towards the end of the year. The arrangements for the London medical schools will be reviewed by their deans towards the end of the year ; at present they are as follows :St. Bartholomew’s.-The preclinical anatomy and physiology will be carried on at Cambridge, while clinical studies will go on at St. Bartholomew’s casualty clearing station and the other hospitals in sector 3. Teaching in first year subjects has yet to be arranged.
symptoms require special attention, as was urged by Sorsby at the Aberdeen meeting of the British Medical Association. The blepharospasm induces a fear of blindness with a severe anxiety state. By gently separating the lids the patient can be convinced of the groundlessness of fears. The pain that patients experience has led to the suggestion that cocaine drops should be instilled, but most authorities agree that cocaine should be avoided owing to its devitalising effect on the corneal epithelium. Sub-
Charing Cross.-Preclinical students for Charing Cross Hospital normally attend King’s College. They will follow King’s College to Glasgow University. Clinical students will be distributed throughout the hospitals of sector 4. Teams of surgical dressers and blood-transfusion groups have been arranged. Clinical beginners are likely to be posted to the base hospital and an interchange of students between the hospitals to vary clinical experience will probably be organised. The address of the secretary of the Medical School is 81, St. Margaret’s Road, Twickenham, Middlesex.
stitutes such as Pantocaine and Larocaine have also been recommended,3 and Dor4 advocates 2 per cent. dionin drops. Where pain is severe, atropine is generally indicated because of the associated corneal lesion, and this should usually suffice. ,
GENERAL POST MOVEMENT OF THE MEDICAL SCHOOLS
DETAILS of the arrangements for the future ’of medical education in London and the provinces have In now been worked out by most medical schools. general, it may be -said that preclinical teaching in London is to stop, the London students being transferred to various provincial universities. The clinical teaching of the London schools, on the other hand, is to continue in the hospitals of the sector of each teaching hospital. The provincial schools are staying where they are, though many of them will have to make changes in organisation to cope with the London evacuees. In most cases, these newcomers are bringtheir own teachers with them, and the students ing will continue to take London examinations. The arrangements for clinical teaching in hospital sectors vary as yet in completeness. The most usual plan appears to be to dispatch those needing elementary clinical instruction to the base hospital, while the other students are divided into small groups that will move from hospital to hospital. At certain hospitals, usually those accommodating the sector pathological laboratories, arrangements will be made for teaching practical pathology, and as a rule one or two hospitals in each sector have adequate facilities for midwifery. Groups of students will be on duty at casualty
clearing stations for short spells. 3. Stallard, H. B., Lancet, Sept. 2, 1939, p. 576. 4. Dor, quoted in Pr. méd. July 5, 1939, p. 1066.
(Tel. : Popesgrove 1226.) St. George’s.-Preclinical students who normally study at King’s College will be transferred with that college. Clinical students are dispersed throughout sector 7. About 25 are at Isleworth, 15 at Staines, 10 at Slough, and smaller numbers at various L.C.C. hospitals. Guy’s.-The preclinical students at Guy’s will not go to Oxford as previously announced but to Sherwood Park, near Tunbridge Wells. Students will be lodged in private houses converted into hostels. Clinical students are distributed to the hospitals throughout sector 10.
King’s College Hospital.-The preclinical students at King’s College will go to Glasgow University. The clinical students have been distributed through the hospitals in sector 9. The London.-Preclinical students
are
to go to
Cambridge. They are being provided with board and lodging at St. Catherine’s College, but their teaching arrangements are in the hands of their own professors and not the university staff. Clinical students are distributed throughout the hospitals of sectors 1 and 2. Subject to the approval of the county borough
councils concerned, teaching will be carried on in the municipal hospitals at Romford, Rochford, and Whipps Cross, and in many voluntary hospitals including Southend General, Queen Mary’s at Stratford, and the King George V Hospital at Ilford. In sector 2 there are 12 large L.C.C. hospitals and also two important Middlesex county council hospitals. A service of dressers at casualty hospitals in dangerous
will be maintained and students will take turns for short spells on duty at these casualty hospitals. Facilities for teaching obstetrics will probably be available at the Hackney and Mile End Hospitals of the L.C.C., at f)ldchurch County Hospital, Romford, and at Brockett Hall which is being opened as an obstetric hospital for the county of Hertfordshire. Courses in pathology will be organised at Billericay Hospital under Professor Bedson, pathologist to
areas