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NEUROSURGICAL SERVICE
539
composed of water, this means that there will be a correspondingly greater absorption of energy by the tissues. The local heat produced in the body by this kind of energy brings about an increase of venous return and a vasodilatation through local reflex mechanisms
for medical and surgical neurological cases adopted the practice of admitting all closed head injuries to the The virtue of this arrangement was medical wards. twofold : it saved surgical beds ; and from the start of treatment these cases were in the hands of the physicians, whose interests perhaps qualified them better to take charge up to and including convalescence. The occasional intervention by the surgeon-for example, to make a burr-hole-which is cited as a reason for surgical control, was seen as an incident in a disorder which was essentially medical ; and, since the committee visualises medical and surgical units working side by side in a single specialised department, there seems to be no practical reason why this view should not prevail in the future. The further contention that few physicians have displayed much interest in head injuries should make neurologists look to their laurels.
The heart-rate may be and direct metabolic effects. increased by speeding up the generation and propagation of impulses through the sino-auricular node. On the basis of the experimental tests, the Mayo Clinic have been carrying out clinical studies with microwaves for the past year. NEUROSURGICAL SERVICE IN their new organisation by regions, the British hospital services form a clear pattern, in which each segment gathers strength from, or gives support to, its neighbours. Even so, there are still dangerous gaps, particularly in the services which are least often called for or most difficult to supply ; and perhaps the most
WAR RESEARCHES ON THE CORNEA
SOME of the work undertaken for
notable of these is neurosurgery. The Society of British Neurological Surgeons, like the Society of Thoracic Surgeons, has produced its own design for the future 2 ; and this shows how pitifully deficient are the present resources. The expansion of neurosurgical work, like that of chest surgery, has been swift; and this means that there are neither enough hospital beds nor enough trained surgeons. The late increase in the number of beds specialty ; but even now large areas have no neurosurgical centre whatever. The report suggests that the aim should be to supply for every million people a centre having 50-60 beds (though some hold that 80-100 are needed). The regions named as specially needy are South Wales, the eastern counties, Scotland, Northern Ireland, and London ; and in addition area centres, with some 25 beds each, are proposed for the East Midlands, the East Riding of Yorkshire, north Lancashire, and the south-west. New centres, says the report, should be placed on land shared with a teaching, or at least a general, hospital. For full use of resources, convalescent beds should, if possible, be in the same hospital ; but, if this advantage can be won only by the exclusion of the whole unit from the general hospital, then it should be foregone. The committee, insisting that surgical neurology is a proper subject for the undergraduate’s clinical training, holds that units of not less than 25 beds should be installed ’in teaching hospitals. Considerable thought has been given to the training of future neurosurgeons. This, in the, committee’s view, should be in two stages. The first is that of general training in which the young graduate spends a year in junior resident appointments, a second year in wholetime study of the basic sciences, and a third as senior house-surgeon or R.S.O. After taking the F.R.c.s. he will, the report points out, become a better recruit by doing another year in general surgery. " We say this from the knowledge that the best and most telling experience in general surgery is not usually to be had until this diploma has been acquired." The second stage-that of special apprenticeship-would take at least a further four and a half years, the trainee spending a year each in work as senior house-surgeon in neurosurgery ; in or an alternative subject (including six months in medical neurology) ; in neurosurgery as a registrar ; and finally as a registrar with work outside the hospital as a domiciliary consultant. Not all neurologists, and perhaps not every neurosurgeon, will agree with the committee in maintaining that head injuries should necessarily be treated in the surgical unit. In the late war the largest Service hospital war
brought
set aside for
a
great
this
neurophysiology
-
1. See
Lancet, 1948, i, 801. 2. Society of British Neurosurgeons, Planning Committee 1945-47 : Notes on the Neurosurgical Needs of the Population and the Training of the Neurosurgeon.
urgent
reasons
during the war is only now being published. Two monographs appearing within the last few months describe investigations, by teams in the United States and in England, on the mode of action of war gases on the eye.’- Both reflect the high academic standard of research favoured by the Allied policy of employing civilian scientists to study Service problems. Though largely concerned with the effects of substances unlikely in ordinary circumstances to come in contact with the eye, the thirteen authors have done much to set knowledge of the biochemistry and histopathology of the The Americans directed cornea on a sounder basis. their attention mainly to biochemistry, and the English mostly to cellular reactions ; but both groups start with fundamentals applicable to the study of any chemical injury to the cornea. They point out that the action is determined not only by the toxicity of the material, but also by its physical power of penetration. They emphasise the importance of SH groupings in reaction with proteins, and by bringing the problem of injury into the realm of enzyme inhibitions and activations they have advanced ophthalmic pathology far beyond its previous boundaries. The metabolism of the cornea has been studied in great detail. The functions of its various layers have been separated. Attention has been drawn to such phenomena as the inability of the stroma to take up oxygen or to utilise lactate or pyruvate, the great capabilities of the epithelium, and the existence of a hydrogen transport system from stroma to epithelium. The epithelium-stroma boundary, probably a proteinlipoid multilayer, is the seat of many important activities, and the circumstances in which the epithelium becomes loosened have been carefully examined. Oxygen is essential for this loosening, which does not occur anaerobically even after poisoning of enzyme systems with various toxins. The effects of chemical and physical agents (e.g., mustard gas, colchicine, ultraviolet light, and X rays) on the mitosis and on nuclear fragmentation have also been worked out, and so have the effects on the stroma and epithelium of a large number of chemicals not related to war, The English team, who began work nearly iibree years before the Americans, gave its attention largely to the clinical appearances of chemical injuries and to the histology of various types of healing. The problem of avascular healing of the corneal stroma and of the epithelium has puzzled ophthalmologists for many decades and the experiments described in the British 1. Studies on the Physiology, Biochemistry, and Cytopathology of the Cornea in relation to Injury by Mustard Gas and Allied Toxic Agents. Bull. Johns Hopk. Hosp. 1948, 82, no. 2. An Experimental and Clinical Study of the Reaction of the Anterior Segment of the Eye to Chemical Injury with special reference to Chemical Warfare Agents. Brit. J. Ophthal.
monograph, 1948.
composed of water, this means that there will be a correspondingly greater absorption of energy by the tissues. The local heat produced in the body by this kind of energy brings about an increase of venous return and a vasodilatation through local reflex mechanisms
for medical and surgical neurological cases adopted the practice of admitting all closed head injuries to the The virtue of this arrangement was medical wards. twofold : it saved surgical beds ; and from the start of treatment these cases were in the hands of the physicians, whose interests perhaps qualified them better to take charge up to and including convalescence. The occasional intervention by the surgeon-for example, to make a burr-hole-which is cited as a reason for surgical control, was seen as an incident in a disorder which was essentially medical ; and, since the committee visualises medical and surgical units working side by side in a single specialised department, there seems to be no practical reason why this view should not prevail in the future. The further contention that few physicians have displayed much interest in head injuries should make neurologists look to their laurels.
The heart-rate may be and direct metabolic effects. increased by speeding up the generation and propagation of impulses through the sino-auricular node. On the basis of the experimental tests, the Mayo Clinic have been carrying out clinical studies with microwaves for the past year. NEUROSURGICAL SERVICE IN their new organisation by regions, the British hospital services form a clear pattern, in which each segment gathers strength from, or gives support to, its neighbours. Even so, there are still dangerous gaps, particularly in the services which are least often called for or most difficult to supply ; and perhaps the most
WAR RESEARCHES ON THE CORNEA
SOME of the work undertaken for
notable of these is neurosurgery. The Society of British Neurological Surgeons, like the Society of Thoracic Surgeons, has produced its own design for the future 2 ; and this shows how pitifully deficient are the present resources. The expansion of neurosurgical work, like that of chest surgery, has been swift; and this means that there are neither enough hospital beds nor enough trained surgeons. The late increase in the number of beds specialty ; but even now large areas have no neurosurgical centre whatever. The report suggests that the aim should be to supply for every million people a centre having 50-60 beds (though some hold that 80-100 are needed). The regions named as specially needy are South Wales, the eastern counties, Scotland, Northern Ireland, and London ; and in addition area centres, with some 25 beds each, are proposed for the East Midlands, the East Riding of Yorkshire, north Lancashire, and the south-west. New centres, says the report, should be placed on land shared with a teaching, or at least a general, hospital. For full use of resources, convalescent beds should, if possible, be in the same hospital ; but, if this advantage can be won only by the exclusion of the whole unit from the general hospital, then it should be foregone. The committee, insisting that surgical neurology is a proper subject for the undergraduate’s clinical training, holds that units of not less than 25 beds should be installed ’in teaching hospitals. Considerable thought has been given to the training of future neurosurgeons. This, in the, committee’s view, should be in two stages. The first is that of general training in which the young graduate spends a year in junior resident appointments, a second year in wholetime study of the basic sciences, and a third as senior house-surgeon or R.S.O. After taking the F.R.c.s. he will, the report points out, become a better recruit by doing another year in general surgery. " We say this from the knowledge that the best and most telling experience in general surgery is not usually to be had until this diploma has been acquired." The second stage-that of special apprenticeship-would take at least a further four and a half years, the trainee spending a year each in work as senior house-surgeon in neurosurgery ; in or an alternative subject (including six months in medical neurology) ; in neurosurgery as a registrar ; and finally as a registrar with work outside the hospital as a domiciliary consultant. Not all neurologists, and perhaps not every neurosurgeon, will agree with the committee in maintaining that head injuries should necessarily be treated in the surgical unit. In the late war the largest Service hospital war
brought
set aside for
a
great
this
neurophysiology
-
1. See
Lancet, 1948, i, 801. 2. Society of British Neurosurgeons, Planning Committee 1945-47 : Notes on the Neurosurgical Needs of the Population and the Training of the Neurosurgeon.
urgent
reasons
during the war is only now being published. Two monographs appearing within the last few months describe investigations, by teams in the United States and in England, on the mode of action of war gases on the eye.’- Both reflect the high academic standard of research favoured by the Allied policy of employing civilian scientists to study Service problems. Though largely concerned with the effects of substances unlikely in ordinary circumstances to come in contact with the eye, the thirteen authors have done much to set knowledge of the biochemistry and histopathology of the The Americans directed cornea on a sounder basis. their attention mainly to biochemistry, and the English mostly to cellular reactions ; but both groups start with fundamentals applicable to the study of any chemical injury to the cornea. They point out that the action is determined not only by the toxicity of the material, but also by its physical power of penetration. They emphasise the importance of SH groupings in reaction with proteins, and by bringing the problem of injury into the realm of enzyme inhibitions and activations they have advanced ophthalmic pathology far beyond its previous boundaries. The metabolism of the cornea has been studied in great detail. The functions of its various layers have been separated. Attention has been drawn to such phenomena as the inability of the stroma to take up oxygen or to utilise lactate or pyruvate, the great capabilities of the epithelium, and the existence of a hydrogen transport system from stroma to epithelium. The epithelium-stroma boundary, probably a proteinlipoid multilayer, is the seat of many important activities, and the circumstances in which the epithelium becomes loosened have been carefully examined. Oxygen is essential for this loosening, which does not occur anaerobically even after poisoning of enzyme systems with various toxins. The effects of chemical and physical agents (e.g., mustard gas, colchicine, ultraviolet light, and X rays) on the mitosis and on nuclear fragmentation have also been worked out, and so have the effects on the stroma and epithelium of a large number of chemicals not related to war, The English team, who began work nearly iibree years before the Americans, gave its attention largely to the clinical appearances of chemical injuries and to the histology of various types of healing. The problem of avascular healing of the corneal stroma and of the epithelium has puzzled ophthalmologists for many decades and the experiments described in the British 1. Studies on the Physiology, Biochemistry, and Cytopathology of the Cornea in relation to Injury by Mustard Gas and Allied Toxic Agents. Bull. Johns Hopk. Hosp. 1948, 82, no. 2. An Experimental and Clinical Study of the Reaction of the Anterior Segment of the Eye to Chemical Injury with special reference to Chemical Warfare Agents. Brit. J. Ophthal.
monograph, 1948.