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SURGICAL TREATMENT OF RETINAL DETACHMENT
822
by group of workers at the Mayo found that the incidence of a
Clinic,4 and they urinary infection was
the
when his doctor did not see must have committed the technical
previous Monday,
him, and many
greatly decreased. More than half their cases under- fault of issuing one. If the doctor is particularly prone to this failing the going gynaecological operations required postoperative catheterisation-a rather high figure. Of those who reason is not difficult to find. Familiarity has bred were catheterised and who received no sulphanilamide, . contempt, and, still worse, repeated doses have showed definite on from a pyuria 50% discharge produced hypersensitivity to the printed document, while of a similar so that the practitioner tends to face a certificate hospital, group receiving prophylactic treatment only 17-8% had pyuria. Unfor- proffered to him not only without interest but with the incidence of infection was irritation. The medical student is no respecter of tunately preoperative and full examination of the not determined cultural authority, and little attempt is made to teach him the urine was not always carried out, report being respect for the laws of certification. Early in his based on the amount of pus present; but the figures qualified career he is, as a house-officer, expected by suggest that many cases of urinary infection were tradition to sign certificates of incapacity handed him prevented. Sulphathiazole has been used prophy- in a heap by an outpatient or ward sister, and he signs lactically by YOUNGbefore and after urological them because he has full trust in her judgment and operations and in 12 cases, which included plastic knows them to be true in spirit though not necessarily operations, much better healing was obtained than in letter. This is the kind of compromise between was expected. Sulphathiazole, then, appears to convenience and exactitude that makes the working be the best of the sulphonamide drugs for the routine of a hospital possible, and it is not surprising if the treatment of urinary infections and has three main young doctor carries the principle with him into uses : to prevent infection in cases requiring cathepractice outside. There he is faced with a mass of terisation ; to cure a large proportion of uncomplicertificates, notifications, reports, and other dôcu"
cated infections ; and to control established and incurable infection. In the prevention and control of infection a far smaller dose than that used in treatment should prove effective, and in the presence of renal failure doses as low as 0-3-0-65 g. (gr. 5-10) a day may be adequately excreted and should control, if not cure, the infection.
LAX CERTIFICATION FRANCIS BACON was deposed from the highest judicial office in the land for the gravest judicial offence. In his admitted acceptance of bribes he did no worse perhaps than follow the custom of the age. Three centuries later the integrity of the bench is established beyond cavil. Similar progress, more speedy or more slow, can be claimed in other walks of life, and it is proof of this progress in our own profession that no-one even thinks of bribery when the General Medical Council issues a warning notice against lax certification, though, judged by some tests, a reckless want of care may be deemed as bad as fraud itself. Clergymen, barristers and others are authorised by the state to sign forms for various purposes. Are doctors more ready than these nonmedical men to put their names to printed statements which, if they had to write out the document in full, they would study and endorse with more scrupulous care ?1 Are they more ready to sign on the dotted line to save themselves trouble or to oblige an applicant ?1 That there is some laxity cannot be denied. Insurance committees complain that it is not unknown for the panel doctor to continue to certify advanced pregnancy after the insured mother has been delivered of her child. Then there was the doctor who lightheartedly continued to certify incapacity for work (" I hereby certify that I have examined you on the under-mentioned date ...") when the insured person was in prison ; the facts duly came out and penal action naturally followed. These are gross and inexcusable examples, but every insurance practitioner knows the long-incapacitated patient (or his relative) who comes on Friday for a certificate dated J. L. and Hammer, H. J. Ibid, 1940, 15, 801 ; Wilson, R. B. and Masson, J. C. Ibid, p. 806. Young, H. H., Hill, J. H. and Semans, J. H. J. Urol. 1940, 44, 714.
4. Emmett, 5.
ments of
kindred character," to quote the Medical Register, many of which require much thought and skill in their completion and carry but a small fee, if any. Much of what he is expected to certify must necessarily be " to the best of his knowledge "-he has often only the patient’s word, for instance, that his name and address are as stated, and is not expected to verify these from the parish registers or a personal visit. Sometimes, when pressure of work is at its heaviest, he must choose between being a careless certifier and a careless doctor, and such is his training that he will choose the former every time. When officials and lawyers design new certificates ’ for doctors to sign they must remember, then, that they are to be completed by men and women with no legal training and a point of view which puts other considerations before legal ones ; who have neither time for nor patience with long-winded documents; and who may tend to give the benefit of a doubt to the patient whom they know rather than to an insurance company or other body which is but a name to them. Some existing certificates might well be revised to save abuse-for instance, the familiar N.H.I. certificate already quoted might read simply’ " So-and-so was incapable of work on ..." When this is said, however, it is up to the doctor and those responsible for training him to remember that these tiresome papers are legal documents and that anything they contain may later have to be justified on oath. The authority to certify in various statutory circumstances is one of the few privileges which distinguish the registered from the unregistered practitioner. It would be a pity if we showed ourselves unworthy to retain it. a
SURGICAL TREATMENT OF RETINAL DETACHMENT IT is 12 years since Prof. JuLES GONIN of Lausanne showed that a detached retina could be effectively replaced by sealing any tears in that membrane and producing an aseptic choroido-retinitis at the site of the lesions, thus uniting the sclera, choroid and retina by adhesion. This end has been achieved by various The first step is a thorough survey of the means.
823
detachment recurs. Good postoperative nursing is a large factor in success. As a rule the head should be placed so that the retinal tear and the adjacent serve as ophthalmoscopic landmarks during operation. diathermy perforations are in the most dependent Several such examinations each lasting about three- position possible. The retina and choroid thus remain quarters of an hour should be made, with the patientapposed, and any residual inter-retinal fluid drains in different positions, so that a retinal tear cannot away. Some however believe that posture is of no account provided the head is kept still. Technical escape detection or be obscured by a retinal fold. Full mydriasis is essential in cases suspected of small modifications will probably be made in both the holes in the region of the ora serrata, and gentle apparatus and the surgical technique, and thus instrumental compression of the sclera may be increase the scope of an operation which already necessary at the suspected site to make these visible allows us to restore vision in a disorder which not long through the ophthalmoscope. The position of the ago had a hopeless prognosis. retinal tear is assessed in terms of the meridian in which it lies, and its distance from the ora serrata is Annotations judged in optic disc diameters (1diameter =1-5 mm.). A RE-DRAFT OF THE DRUG BILL Surgical diathermy can be applied either to the surface of the sclera by a blunt applicator, 2-5 mm. in THE bill to repeal the medicine stamp duties as diameter, or more directly to the choroid and retina originally drafted has been amended in several important by a perforating needle of requisite length (1-2 mm. respects. It is understood that an entirely new clause or more). A combination of these two methods is has been inserted which will correct the anomaly, now generally favoured, the former being used to pointed out in THE LANCET of June 14 (p. 762), by which a grocer was to be allowed to sell recommended remedies an area of which shows produce thermocoagulation of unknown composition and not those whose composition white on examination and hence up ophthalmoscopic had been declared. The objection has been met by a helps to verify the site of the retinal tear and induce draft clause requiring disclosure of the composition of an aseptic choroido-retinitis around its edges. Per- medicines whether proprietary or non-proprietary. the of the interforating diathermy permits escape No person shall sell by retail any article consisting of or retinal fluid between the rods and cones and the comprising a substance recommended as a medicine unless retinal pigment epithelium. Two things are essential there is written so as to be clearly legible on the article or a to success : the production of an adequate local label affixed thereto, or, if the article is sold in any wrapper container, on the wrapper or container or a label affixed thermocoagulation of the retina and choroid around or either (a) a statement of the composition of the the site of a retinal tear, and the evacuation of the thereto, substance or of the active constituents thereof ; or (b) in the inter-retinal fluid so that the two membranes can case where the substance is described in any of the monocome together and adhere securely. graphs contained in the edition of the British Pharmacopoeia British Pharmaceutical Codex which was last published The initial evacuation of inter-retinal fluid by or before the date of the sale, either such a statement as aforeperforating diathermy and suction aspiration through said or the description, or an abbreviation or synonym of the the fine holes produced in the ocular tunics is still description set out at the head of that monograph." under discussion. Those in favour of this procedure This would not apply to medicines supplied by doctors claim that by removing the fluid both the retina and or dispensers on a doctor’s prescription, but it would the choroid are assured of effective local thermo- apply to medicines supplied by way of counter-prescribby a pharmacist. While it has become a fairly coagulation around the site of the retinal hole. Its ing common practice among owners of proprietary medicines disadvantages are that it renders the eye soft and to some indication of the composition of their give distorted so that the application of diathermy, the practice is by no means universal and is products, at the surface, may be difficult whether perforating or not enforceable by law. The insertion of this clause in and sometimes inaccurate. Moreover, leakage of a bill which was intended to appear before Parliament inter-retinal fluid moistens the sclera and thus lessens as a measure agreed upon by the parties interested in the the effect of surface diathermy. Probably the best manufacture and distribution of proprietary medicines method at present lies in a compromise. Surface would probably come as a surprise to the trade, and diathermy is used initially for localisation, and efforts although the majority of owners of proprietary articles, faced by Hobson’s choice, may decide that it would be useare made to produce the desired response in both retina and choroid. Later the sclera and choroid are less to oppose it, it is doubtful if they are pleased about it. They will find some consolation in the fact that the bitter punctured by the perforating diathermy needle, inter- pill is gilded by the proposal to allow their medicines to retinal fluid is removed by gentle suction, and a few be distributed through all the usual channels free of tax. more perforations are made so that the needle point The bill as redrafted contains other provisions which operates in the retina around the site of the hole. can hardly have been expected by the parties concerned. This work must be done with just the amount of Thus the sale of recommended non-proprietary medicines diathermy current necessary to induce the degree of would not be restricted solely to pharmacists, but would thermocoagulation judged capable of forming secure be allowed in the case of " a person who has served a choroido-retinal adhesions. The strength of current regular apprenticeship to a registered pharmacist, or to necessary to achieve this varies in different subjects, a body corporate authorised to sell poisons by virtue because their bodily electrical resistance varies. In of section 9 of the Pharmacy and Poisons Act 1933." The sale of such medicines would also be allowed in the some, 70-80 mA for 7 seconds is sufficient, while case of a person who is at present carrying on business others need 120 mA for the same time. Too heavy on his own account " which consists of or includes the an application of diathermy may cause exudate and of drugs." There is no provision for the transferselling cellular infiltration into the vitreous, damaging it ence of this privilege to the purchaser of a business. A considerably ; too little may produce a choroido- mild form of concession is made to herbalists by a proretinal adhesion which will not hold, so that retinal vision which allows the sale of a recommended medicine fundus oculi, careful drawings being made of lesions and of the vascular pattern, particularly in the neighbourhood of any retinal tears, so that these may
"
-
by group of workers at the Mayo found that the incidence of a
Clinic,4 and they urinary infection was
the
when his doctor did not see must have committed the technical
previous Monday,
him, and many
greatly decreased. More than half their cases under- fault of issuing one. If the doctor is particularly prone to this failing the going gynaecological operations required postoperative catheterisation-a rather high figure. Of those who reason is not difficult to find. Familiarity has bred were catheterised and who received no sulphanilamide, . contempt, and, still worse, repeated doses have showed definite on from a pyuria 50% discharge produced hypersensitivity to the printed document, while of a similar so that the practitioner tends to face a certificate hospital, group receiving prophylactic treatment only 17-8% had pyuria. Unfor- proffered to him not only without interest but with the incidence of infection was irritation. The medical student is no respecter of tunately preoperative and full examination of the not determined cultural authority, and little attempt is made to teach him the urine was not always carried out, report being respect for the laws of certification. Early in his based on the amount of pus present; but the figures qualified career he is, as a house-officer, expected by suggest that many cases of urinary infection were tradition to sign certificates of incapacity handed him prevented. Sulphathiazole has been used prophy- in a heap by an outpatient or ward sister, and he signs lactically by YOUNGbefore and after urological them because he has full trust in her judgment and operations and in 12 cases, which included plastic knows them to be true in spirit though not necessarily operations, much better healing was obtained than in letter. This is the kind of compromise between was expected. Sulphathiazole, then, appears to convenience and exactitude that makes the working be the best of the sulphonamide drugs for the routine of a hospital possible, and it is not surprising if the treatment of urinary infections and has three main young doctor carries the principle with him into uses : to prevent infection in cases requiring cathepractice outside. There he is faced with a mass of terisation ; to cure a large proportion of uncomplicertificates, notifications, reports, and other dôcu"
cated infections ; and to control established and incurable infection. In the prevention and control of infection a far smaller dose than that used in treatment should prove effective, and in the presence of renal failure doses as low as 0-3-0-65 g. (gr. 5-10) a day may be adequately excreted and should control, if not cure, the infection.
LAX CERTIFICATION FRANCIS BACON was deposed from the highest judicial office in the land for the gravest judicial offence. In his admitted acceptance of bribes he did no worse perhaps than follow the custom of the age. Three centuries later the integrity of the bench is established beyond cavil. Similar progress, more speedy or more slow, can be claimed in other walks of life, and it is proof of this progress in our own profession that no-one even thinks of bribery when the General Medical Council issues a warning notice against lax certification, though, judged by some tests, a reckless want of care may be deemed as bad as fraud itself. Clergymen, barristers and others are authorised by the state to sign forms for various purposes. Are doctors more ready than these nonmedical men to put their names to printed statements which, if they had to write out the document in full, they would study and endorse with more scrupulous care ?1 Are they more ready to sign on the dotted line to save themselves trouble or to oblige an applicant ?1 That there is some laxity cannot be denied. Insurance committees complain that it is not unknown for the panel doctor to continue to certify advanced pregnancy after the insured mother has been delivered of her child. Then there was the doctor who lightheartedly continued to certify incapacity for work (" I hereby certify that I have examined you on the under-mentioned date ...") when the insured person was in prison ; the facts duly came out and penal action naturally followed. These are gross and inexcusable examples, but every insurance practitioner knows the long-incapacitated patient (or his relative) who comes on Friday for a certificate dated J. L. and Hammer, H. J. Ibid, 1940, 15, 801 ; Wilson, R. B. and Masson, J. C. Ibid, p. 806. Young, H. H., Hill, J. H. and Semans, J. H. J. Urol. 1940, 44, 714.
4. Emmett, 5.
ments of
kindred character," to quote the Medical Register, many of which require much thought and skill in their completion and carry but a small fee, if any. Much of what he is expected to certify must necessarily be " to the best of his knowledge "-he has often only the patient’s word, for instance, that his name and address are as stated, and is not expected to verify these from the parish registers or a personal visit. Sometimes, when pressure of work is at its heaviest, he must choose between being a careless certifier and a careless doctor, and such is his training that he will choose the former every time. When officials and lawyers design new certificates ’ for doctors to sign they must remember, then, that they are to be completed by men and women with no legal training and a point of view which puts other considerations before legal ones ; who have neither time for nor patience with long-winded documents; and who may tend to give the benefit of a doubt to the patient whom they know rather than to an insurance company or other body which is but a name to them. Some existing certificates might well be revised to save abuse-for instance, the familiar N.H.I. certificate already quoted might read simply’ " So-and-so was incapable of work on ..." When this is said, however, it is up to the doctor and those responsible for training him to remember that these tiresome papers are legal documents and that anything they contain may later have to be justified on oath. The authority to certify in various statutory circumstances is one of the few privileges which distinguish the registered from the unregistered practitioner. It would be a pity if we showed ourselves unworthy to retain it. a
SURGICAL TREATMENT OF RETINAL DETACHMENT IT is 12 years since Prof. JuLES GONIN of Lausanne showed that a detached retina could be effectively replaced by sealing any tears in that membrane and producing an aseptic choroido-retinitis at the site of the lesions, thus uniting the sclera, choroid and retina by adhesion. This end has been achieved by various The first step is a thorough survey of the means.
823
detachment recurs. Good postoperative nursing is a large factor in success. As a rule the head should be placed so that the retinal tear and the adjacent serve as ophthalmoscopic landmarks during operation. diathermy perforations are in the most dependent Several such examinations each lasting about three- position possible. The retina and choroid thus remain quarters of an hour should be made, with the patientapposed, and any residual inter-retinal fluid drains in different positions, so that a retinal tear cannot away. Some however believe that posture is of no account provided the head is kept still. Technical escape detection or be obscured by a retinal fold. Full mydriasis is essential in cases suspected of small modifications will probably be made in both the holes in the region of the ora serrata, and gentle apparatus and the surgical technique, and thus instrumental compression of the sclera may be increase the scope of an operation which already necessary at the suspected site to make these visible allows us to restore vision in a disorder which not long through the ophthalmoscope. The position of the ago had a hopeless prognosis. retinal tear is assessed in terms of the meridian in which it lies, and its distance from the ora serrata is Annotations judged in optic disc diameters (1diameter =1-5 mm.). A RE-DRAFT OF THE DRUG BILL Surgical diathermy can be applied either to the surface of the sclera by a blunt applicator, 2-5 mm. in THE bill to repeal the medicine stamp duties as diameter, or more directly to the choroid and retina originally drafted has been amended in several important by a perforating needle of requisite length (1-2 mm. respects. It is understood that an entirely new clause or more). A combination of these two methods is has been inserted which will correct the anomaly, now generally favoured, the former being used to pointed out in THE LANCET of June 14 (p. 762), by which a grocer was to be allowed to sell recommended remedies an area of which shows produce thermocoagulation of unknown composition and not those whose composition white on examination and hence up ophthalmoscopic had been declared. The objection has been met by a helps to verify the site of the retinal tear and induce draft clause requiring disclosure of the composition of an aseptic choroido-retinitis around its edges. Per- medicines whether proprietary or non-proprietary. the of the interforating diathermy permits escape No person shall sell by retail any article consisting of or retinal fluid between the rods and cones and the comprising a substance recommended as a medicine unless retinal pigment epithelium. Two things are essential there is written so as to be clearly legible on the article or a to success : the production of an adequate local label affixed thereto, or, if the article is sold in any wrapper container, on the wrapper or container or a label affixed thermocoagulation of the retina and choroid around or either (a) a statement of the composition of the the site of a retinal tear, and the evacuation of the thereto, substance or of the active constituents thereof ; or (b) in the inter-retinal fluid so that the two membranes can case where the substance is described in any of the monocome together and adhere securely. graphs contained in the edition of the British Pharmacopoeia British Pharmaceutical Codex which was last published The initial evacuation of inter-retinal fluid by or before the date of the sale, either such a statement as aforeperforating diathermy and suction aspiration through said or the description, or an abbreviation or synonym of the the fine holes produced in the ocular tunics is still description set out at the head of that monograph." under discussion. Those in favour of this procedure This would not apply to medicines supplied by doctors claim that by removing the fluid both the retina and or dispensers on a doctor’s prescription, but it would the choroid are assured of effective local thermo- apply to medicines supplied by way of counter-prescribby a pharmacist. While it has become a fairly coagulation around the site of the retinal hole. Its ing common practice among owners of proprietary medicines disadvantages are that it renders the eye soft and to some indication of the composition of their give distorted so that the application of diathermy, the practice is by no means universal and is products, at the surface, may be difficult whether perforating or not enforceable by law. The insertion of this clause in and sometimes inaccurate. Moreover, leakage of a bill which was intended to appear before Parliament inter-retinal fluid moistens the sclera and thus lessens as a measure agreed upon by the parties interested in the the effect of surface diathermy. Probably the best manufacture and distribution of proprietary medicines method at present lies in a compromise. Surface would probably come as a surprise to the trade, and diathermy is used initially for localisation, and efforts although the majority of owners of proprietary articles, faced by Hobson’s choice, may decide that it would be useare made to produce the desired response in both retina and choroid. Later the sclera and choroid are less to oppose it, it is doubtful if they are pleased about it. They will find some consolation in the fact that the bitter punctured by the perforating diathermy needle, inter- pill is gilded by the proposal to allow their medicines to retinal fluid is removed by gentle suction, and a few be distributed through all the usual channels free of tax. more perforations are made so that the needle point The bill as redrafted contains other provisions which operates in the retina around the site of the hole. can hardly have been expected by the parties concerned. This work must be done with just the amount of Thus the sale of recommended non-proprietary medicines diathermy current necessary to induce the degree of would not be restricted solely to pharmacists, but would thermocoagulation judged capable of forming secure be allowed in the case of " a person who has served a choroido-retinal adhesions. The strength of current regular apprenticeship to a registered pharmacist, or to necessary to achieve this varies in different subjects, a body corporate authorised to sell poisons by virtue because their bodily electrical resistance varies. In of section 9 of the Pharmacy and Poisons Act 1933." The sale of such medicines would also be allowed in the some, 70-80 mA for 7 seconds is sufficient, while case of a person who is at present carrying on business others need 120 mA for the same time. Too heavy on his own account " which consists of or includes the an application of diathermy may cause exudate and of drugs." There is no provision for the transferselling cellular infiltration into the vitreous, damaging it ence of this privilege to the purchaser of a business. A considerably ; too little may produce a choroido- mild form of concession is made to herbalists by a proretinal adhesion which will not hold, so that retinal vision which allows the sale of a recommended medicine fundus oculi, careful drawings being made of lesions and of the vascular pattern, particularly in the neighbourhood of any retinal tears, so that these may
"
-