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INTRAOCULAR FOREIGN BODIES
214 is next brought over the transverse colon and laid of the fistulous tract in such a way that there is no kinking or traction of the intestine. The selected portion of jejunum is lifted up with four pairs of Allis forceps, and at a chosen point exactly opposite the antimesenteric border a purse-string suture of fine silk is inserted, and in the centre of this a small hole is made with mosquito forceps. As the Allis forceps exert upward traction and steady the gut, the forceps are thrust through the wall of the intestine and the blades are separated to make the opening of sufficient size to accommodate the fistulous tract. Two silk sutures, threaded on intestinal needles, are passed near the end of the fistulous tract. These help to guide or lead the tract into the jejunum, and when it is ascertained that the tract and the rubber tube are lying comfortably in the lumen of the intestine, the pursestring suture is drawn taut and tied, while the guide sutures The tightening of the purse-string are immediately removed. suture cannot occlude the lumen of the,fistulous tract owing to the presence of the retained rubber tube. The jejunum is then anchored to the base of the fistulous tract above and below and to the tissues around on either side, not only to fix it into position and to prevent it from being drawn away from the fistulous tract but also to avoid any angulation of the intestine where it is sutured. Portions of the adjacent omentum are drawn over the operative site and the abdomen is closed in the usual manner, pains being taken to guard against dehiscence of the wound. After a variable time the rubber tube in the fistulous tract works loose and is passed per anum.
jejunum
by the side
I maintain that the technique here described is preferable to that outlined by Mr. Edwards, in which a portion of the skin of the abdominal wall is anastomosed to the mucous membrane of the stomach The skin must become digested and in this process leakage may possibly occur at the line of anastomosis. Again, there are many disadvantages in the partial loss of pancreatic ferments which result from the interaction of gastric secretion and the pancreatic juices. RODNEY MAINGOT. Wimpole Street, W.1. INTRAOCULAR FOREIGN BODIES SIR,—The extraction of magnetic foreign bodies from the vitreous chamber of the eye by the scleral route-a procedure condemned by your reviewer of Spaeth’s book -is a satisfactory operation and one likely to cause less damage to the eye than if such fragments are pulled out through the suspensory ligament of the lens and through the anterior chamber. This was the conclusion of William Sweet of Philadelphia, who reported on over 700 cases of intraorbital foreign body, many of them treated by himself, and most of them patients of the Wells Hospital, Philadelphia, where he X rayed the eyes. He undertook a careful follow-up of the patients and so his opinion is founded on a wide knowledge of the subject. His conclusion is certainly borne out by the results in those patients on whom I have used the method. I realise that there is antagonism in some quarters to the scleral operation, and I have in the past tried to find out on what grounds it is disliked. I found that the objections-three in number-were for the most part theoretical and often voiced by those who had not tried the method. First, they said, it increases the liability to retinal detachment ; but this statement has no foundation in fact, and was disproved by Sweet’s careful follow-up. Detached retina does not follow sclerotomy for glaucoma, so why should one expect it after sclerotomy for foreign-body extraction ? If the surgeon persists in regarding it-against all the facts-as a drawback, he can apply the diathermy to the sclera before making the section ; but I have never done this myself as I consider it unnecessary and it adds further injury to a severely damaged eye. Secondly, they said, there is the likelihood of vitreous loss during the operation. I can only’reply that if the operative procedure is correct vitreous does not escape and does not appear likely to do The third objection was that a weak scar would be left so. in the sclera. There may be more point to this objection, but if the incision is placed beneath the reflected external rectus, and if the scleral wounds are closed by sutures which have been inserted before the section is made, then I do not think there is any danger of a weak scar. The scleral approach is especially suitable to the vitreous foreign body of war-time, which often contains a very small amount of iron and is therefore only slightly
By this method the magnet can be brought to the fragment and there is thus more likelihood of it being extracted. The end-result in these patients is determined by factors largely outside the surgeon’s control-the extent of the damage already done to the eye, and the length of time the foreign body has been present. The surgeon’s aim must be to extract the particle with as little additional damage as possible, and I believe that this condition is fulfilled bv the scleral operation. SEYMOUR PHILPS. Harley Street, W.1.
magnetic.
nearer
GINGIVITIS
IN
THE
FORCES
SIR,—In their ietter 01Jan. 31(p. 153) Dr. Stuhl and
Mr. Coventry state that the gingivitis occurring in the Midlands is due largely to lack of vitamin C. They suggest that " the initially swollen and bleeding gum " (presumably a manifestation of active scurvy) became infected " where treatment was delayed," and give the impression that the septic gingivitis was due to organisms already present in the patient’s mouth. During the past three months, in a hospital not far from their own, I, too, have seen a number of patients with gingivitis, 57 of them soldiers. From the description of the disease given by Dr. Stuhl and Mr. Coventry it appears that the cases I have watched are of the same nature, but my conclusions are different. I do not doubt the prevalence of vitamin-C deficiency, for, though I have been unable to carry out blood or urine estimations on my patients, the observation has been confirmed by other workers in the district and the patients’ descriptions of their diets were certainly suggestive. I agree entirely that such dietetic inadequacy should be remedied but I doubt whether it is the factor primarily responsible for the present outbreak. If it is, the condition should be rapidly cured by ascorbic acid, even without local treatment, but this has not been my experience. Possibly I gave inadequate amounts of the vitamin, but. surely if deficiency is responsible a few patients should show haemorrhage into the hair follicles, or some other manifestation of scurvy. Neither they nor I have yet met such cases. For the following reasons I believe that infection is the essential cause of the epidemic : 4 1. The disease has not been sporadic, as might be expected with scurvy, but contact with other cases has been the rule. 2. There have been two examples of a man on leave infecting his wife and at least one instance of spread in a ward, the -
affected having been in hospital and on an excellent diet for many weeks. 3. A few of the patients, especially those working as cooks, have had plenty of fruit.
patient
In curious contrast to the experience of Dr. Stuhl and Mr. Coventry, Vincent’s organisms, which I had assumed to be responsible for the foetor, have been present in profusion in almost every case. It would be unwise to say that they cause the disease, for the weight of evidence suggests that they are only secondarily pathogenic. I have previously stated my belief that the primary cause of the condition is a virus (or thrush in infants) which prepares the ground for invasion by Vincent’s organisms (Arch. Dis. Childh. 1940, 15, 43). It is possible that vitamin-C deficiency may similarly lower resistance to the infecting virus. Roughly a quarter of the patients I have seen developed labial herpes in the course of the disease, and at the onset some had an herpetiform eruption on the oral mucous membrane. I do not consider that this in itself is evidence that the herpes virus is responsible for the condition, for all the men who developed labial eruptions were subject to recurrent herpes, usually associated with upper respiratory infections, and in no case did herpes develop de novo during the course of the gingivitis. There is, however, experimental evidence to support the view that it is the herpetic virus which is the essential cause of this kind of gingivitis (Dodd, K., Johnston, L. M. and Buddingh, G. J., J. Pediat. 1938, 12, 95 ; Amer. J. Dis. Child. 1939, 58, 907). I hope that Dr. Stuhl and Mr. Coventry will be able to report the comparative results of treatment: (a) with ascorbic acid alone ; (b) with local treatment only ; and (c) with a combination of both. My own feeling is that the excellent results they have obtained are due to the very efficient local treatment which they prescribe,
°
jejunum
by the side
I maintain that the technique here described is preferable to that outlined by Mr. Edwards, in which a portion of the skin of the abdominal wall is anastomosed to the mucous membrane of the stomach The skin must become digested and in this process leakage may possibly occur at the line of anastomosis. Again, there are many disadvantages in the partial loss of pancreatic ferments which result from the interaction of gastric secretion and the pancreatic juices. RODNEY MAINGOT. Wimpole Street, W.1. INTRAOCULAR FOREIGN BODIES SIR,—The extraction of magnetic foreign bodies from the vitreous chamber of the eye by the scleral route-a procedure condemned by your reviewer of Spaeth’s book -is a satisfactory operation and one likely to cause less damage to the eye than if such fragments are pulled out through the suspensory ligament of the lens and through the anterior chamber. This was the conclusion of William Sweet of Philadelphia, who reported on over 700 cases of intraorbital foreign body, many of them treated by himself, and most of them patients of the Wells Hospital, Philadelphia, where he X rayed the eyes. He undertook a careful follow-up of the patients and so his opinion is founded on a wide knowledge of the subject. His conclusion is certainly borne out by the results in those patients on whom I have used the method. I realise that there is antagonism in some quarters to the scleral operation, and I have in the past tried to find out on what grounds it is disliked. I found that the objections-three in number-were for the most part theoretical and often voiced by those who had not tried the method. First, they said, it increases the liability to retinal detachment ; but this statement has no foundation in fact, and was disproved by Sweet’s careful follow-up. Detached retina does not follow sclerotomy for glaucoma, so why should one expect it after sclerotomy for foreign-body extraction ? If the surgeon persists in regarding it-against all the facts-as a drawback, he can apply the diathermy to the sclera before making the section ; but I have never done this myself as I consider it unnecessary and it adds further injury to a severely damaged eye. Secondly, they said, there is the likelihood of vitreous loss during the operation. I can only’reply that if the operative procedure is correct vitreous does not escape and does not appear likely to do The third objection was that a weak scar would be left so. in the sclera. There may be more point to this objection, but if the incision is placed beneath the reflected external rectus, and if the scleral wounds are closed by sutures which have been inserted before the section is made, then I do not think there is any danger of a weak scar. The scleral approach is especially suitable to the vitreous foreign body of war-time, which often contains a very small amount of iron and is therefore only slightly
By this method the magnet can be brought to the fragment and there is thus more likelihood of it being extracted. The end-result in these patients is determined by factors largely outside the surgeon’s control-the extent of the damage already done to the eye, and the length of time the foreign body has been present. The surgeon’s aim must be to extract the particle with as little additional damage as possible, and I believe that this condition is fulfilled bv the scleral operation. SEYMOUR PHILPS. Harley Street, W.1.
magnetic.
nearer
GINGIVITIS
IN
THE
FORCES
SIR,—In their ietter 01Jan. 31(p. 153) Dr. Stuhl and
Mr. Coventry state that the gingivitis occurring in the Midlands is due largely to lack of vitamin C. They suggest that " the initially swollen and bleeding gum " (presumably a manifestation of active scurvy) became infected " where treatment was delayed," and give the impression that the septic gingivitis was due to organisms already present in the patient’s mouth. During the past three months, in a hospital not far from their own, I, too, have seen a number of patients with gingivitis, 57 of them soldiers. From the description of the disease given by Dr. Stuhl and Mr. Coventry it appears that the cases I have watched are of the same nature, but my conclusions are different. I do not doubt the prevalence of vitamin-C deficiency, for, though I have been unable to carry out blood or urine estimations on my patients, the observation has been confirmed by other workers in the district and the patients’ descriptions of their diets were certainly suggestive. I agree entirely that such dietetic inadequacy should be remedied but I doubt whether it is the factor primarily responsible for the present outbreak. If it is, the condition should be rapidly cured by ascorbic acid, even without local treatment, but this has not been my experience. Possibly I gave inadequate amounts of the vitamin, but. surely if deficiency is responsible a few patients should show haemorrhage into the hair follicles, or some other manifestation of scurvy. Neither they nor I have yet met such cases. For the following reasons I believe that infection is the essential cause of the epidemic : 4 1. The disease has not been sporadic, as might be expected with scurvy, but contact with other cases has been the rule. 2. There have been two examples of a man on leave infecting his wife and at least one instance of spread in a ward, the -
affected having been in hospital and on an excellent diet for many weeks. 3. A few of the patients, especially those working as cooks, have had plenty of fruit.
patient
In curious contrast to the experience of Dr. Stuhl and Mr. Coventry, Vincent’s organisms, which I had assumed to be responsible for the foetor, have been present in profusion in almost every case. It would be unwise to say that they cause the disease, for the weight of evidence suggests that they are only secondarily pathogenic. I have previously stated my belief that the primary cause of the condition is a virus (or thrush in infants) which prepares the ground for invasion by Vincent’s organisms (Arch. Dis. Childh. 1940, 15, 43). It is possible that vitamin-C deficiency may similarly lower resistance to the infecting virus. Roughly a quarter of the patients I have seen developed labial herpes in the course of the disease, and at the onset some had an herpetiform eruption on the oral mucous membrane. I do not consider that this in itself is evidence that the herpes virus is responsible for the condition, for all the men who developed labial eruptions were subject to recurrent herpes, usually associated with upper respiratory infections, and in no case did herpes develop de novo during the course of the gingivitis. There is, however, experimental evidence to support the view that it is the herpetic virus which is the essential cause of this kind of gingivitis (Dodd, K., Johnston, L. M. and Buddingh, G. J., J. Pediat. 1938, 12, 95 ; Amer. J. Dis. Child. 1939, 58, 907). I hope that Dr. Stuhl and Mr. Coventry will be able to report the comparative results of treatment: (a) with ascorbic acid alone ; (b) with local treatment only ; and (c) with a combination of both. My own feeling is that the excellent results they have obtained are due to the very efficient local treatment which they prescribe,
°