142 RETINAL DETACHMENT.-HOSPITALS AND MOTORING ACCIDENTS.

system is informative and accurate, except forsome curious slips, such as the statement that thedoctors’ fees are distributed through the regionalmedical offices. The important part taken by thedoctors in the administration of the scheme is

pointed out, and the general conclusion is thatnational health insurance in this country has beenadvantageous both to the medical professionand the public. It is interesting to note that theresults of this impartial survey, based as it is oncareful inquiries made on the spot, are on the wholefavourable to the system, whether regarded from thepoint of view of the doctors, the patients, or thepublic.

RETINAL DETACHMENT.Dr. GoNiN’s treatment of detachment of the

retina, which is referred to by Miss IDA MANN inanother part of this issue, formed the subject ofdiscussion, opened by Dr. GONIN himself, at a

crowded session of the Oxford OphthalmologicalCongress last week. Dr. GoNlN’s main thesis isthat in every case of spontaneous detachment ofthe retina-i.e., cases apart from trauma, tumour,and albuminuric exudation from the choroid, it ispossible to discover a hole in the retina if only wetake enough trouble to look for it. The detectionof this hole may be a matter of some difficulty,since it often lies far forward in the region of theora serrata. The theory presupposes a partiallyliquefied vitreous, also the existence of vitreous tagsadherent to the retina and thus capable ofpulling on it, so that when a hole is made bytraction there is free communication between thevitreous chamber and the inter-retinal space.Consequently, the only possible means of curingthese detachments is to close the hole. This entailsa most careful search, for the hole may be coveredby a fold or may be too far forward to be easilyvisible. Typically it is of horse-shoe shape with theconcave face directed outwards, but it may beround. If the lips of the hole can be sealed bymeans of the cautery the communication betweenvitreous chamber and inter-retinal space is perma-nently closed. Earlier operators who have employedthe cautery have directed it towards the deepestpart of the detachment, which is generally in thelower part ; GoNiN’s new principle is to direct italways to the hole, which is often in the upper part.The success of his technique, then, depends first onthe ophthalmoscopic detection and then on theaccurate localisation of the hole. The fact thatthere have been undoubted cures following GONIN’Sprocedure-the proportion of successes in recentcases is reported by him to be 60 per cent.-encourages the hope that a real advance in thetreatment of this condition has been made. At thesame time it would be wrong to encourage unjus-tified expectations of an infallible cure. In the first

place, the method is only applicable to cases inwhich a hole can be discovered, and if the firstattempt to close it is unsuccessful the operationmay have to be repeated. In the second place,the holes may be multiple and a separate operationmay be necessary for the closure of each. In the

tmro. place, even 11 tne noie or notes nave oeen

successfully sealed, the condition which originallycaused them-a diseased vitreous, or the stretchingdue to high myopia, or both-will still persist.Further, the operation itself is not free from risk;a haemorrhage into the vitreous may occur whichmay make vision worse instead of better. At theOxford Congress Mr. CHARLES GouLnErr reportedthat out of 11 cases in which he had performedthe operation he had had nine successes but twohad been failures from this cause. In this connexionthe suggestion of Sir WiLLiAM LISTER is valuable,that instead of allowing the cautery to penetrateas far as the detached retina itself, it would bebetter to stop it at the choroid, trusting to theadhesive inflammation set up opposite to the holeto close it.

In considering the prognosis of these cases itmust not be forgotten that after having beendetached for a period the retina loses its function.How long this period may be in any special case isunknown, but it is obvious that from the point ofview of restoration of vision any operation is lesshopeful the longer the detachment has been present..Also, it is a fact that, although the majority of casesof double detached retina at present inevitably endin blindness, there are cases in which a certainamount of useful vision is retained for years, even

though the detachment persists. The possibilityof making the vision not better but worse byoperation must therefore never be overlooked.The discussion at Oxford will long be remembered

by those who were present and may mark thebeginning of a new epoch so far as the treatment ofdetachments is concerned. So far only a fewoperators in this country have had practicalexperience of the method, but the results reportedat Oxford were on the whole encouraging, and it islikely that others will familiarise themselves witha complex technique. Unfortunately, the operatorcannot be guided by direct vision in directing thecautery. He has to find the hole with the ophthal-moscope, localise its position on the outside of theeye by minute and exact measurements, and then,after reflecting the conjunctiva, insert a Paquelincautery at a place which his calculations have ledhim to believe is the right one. Ample warning wasgiven at the Congress of the dangers of the procedureeven in skilled hands, and it is unnecessary to

emphasise here that the operation should only beattempted by those who have completely masteredthe technique.

HOSPITALS AND MOTORING ACCIDENTS.A YEAR ago we said in these columns, when

drawing attention to the ominous prevalence ofmotoring accidents and the burden which this

implied upon the hospitals and the medical pro-fession, that, if the situation continued, legislationto relieve somehow and in some degree a scandalousstate of affairs would be required. Last weekan interesting debate ensued upon the point, anda certain degree of legislative remedy appearsprobable. Under the Road Traffic Bill the ownerof a motor-car is required to take out an insurance

143BATHING IN THE SERPENTINE.

policy covering him against third party risks,while a subsection provides that, such a policybeing existent and benefiting a third party,hospital expenses should be paid by the authorisedinsured in respect of the victims of motor casualtiesup to an amount not exceeding £ 2 for each persontreated. In the course of the debate discussionwas confined to consideration of the hard positionof the voluntary hospitals, where beds are occupiedby cases for which hospitality had never beencontemplated, the claims for attention by individualpractitioners not, apparently, being recognised inthe Bill-at least in so many words.The debate arose out of an amendment by Major

HILLS to delete the subsection in question, and itmust be admitted that he made a series of objectionsto the intended legislation which were logical.He pointed out that it would be a new departurein insurance law to call upon a motorist to pay,through the medium of a policy to an outsideperson, money which he was under no legalliability to pay at present; the provisions to bringthis about would, he said, be exceedingly difficultto work. Further, he criticised the omission toextend the liability to vehicles owned by localauthorities, and to drivers and their passengers.He was supported in his amendment by Mr.MORRISON, the Minister of Transport, who saidthat the matter was one upon which the Membersof the House would be left free to express their

opinion by their votes, a line of conduct which metwith general approval. But the Minister thenmade a vigorous plea for State-run hospitals,finding in the position revealed by the debate onemore argument for the taking over of the hospitalsfrom their voluntary control. Mr. MORRISONsaw in the inability of the voluntary institutionsto meet the new and growing charge upon theiraccommodation and resources a vision that theState sooner or later would have to shoulder theburden, and, while he felt that those who voted tothe detriment of the hospital finances might incurodium, he none the less found the challengedsubsection a retrograde step. But although theproposer of the amendment and his supportersin the House, were able to criticise the terms of theclause effectively, no constructive proposals wereforthcoming by which the immediate and growingevils could be met. The real effect of the passingof the amendment would have been that nothingcould be done until the day arrived, if ever,when the establishment of State hospitals, overand above the present provision of this sort, wasfound by the country to be necessary. On thisattitude two things call for obvious remark :first, there is no consensus of opinion that thevoluntary principle has broken down, but on thecontrary it has derived considerable strengthfrom recent developments ; and secondly, theadmitted abuse of charities, often in pecuniarydifficulty, must not remain indefinitely unrelieved.

Legislation is necessary, however illogical in itsplanning or difficult in its working, because therisk to life and limb is growing, and the number ofpersons who are trading upon the generosity ofhospitals and individual practitioners seems to be i

growing also. The circumstances may often beunfavourable to the normal methods of charge andpayment ; the seriously injured person cannot

arrange for the remuneration for his treatment, norcan this be expected from Samaritans who help himto hospital or surgery. We are happy to believe thatthe class of motorists that leaves its victims by theside of the road uncared for is quite a small one,and in this case if the offender makes good hisescape it is clear that there is nothing to be done.But where elementary decency, aided sometimesby the fear of detection, leads the driver of the carwhich causes the accident to accompany the injuredperson to the place where medical succour can begiven, he will yet hesitate to make himself respon-sible for the cost of treatment, and this not throughmeanness, but because any disbursement maypresent the appearance of admitting guilt, whereasit may be the intention strongly to contest thatpoint. Much money to meet the heavy expenditureby hospitals upon motoring casualties may not beforthcoming through the insurance scheme, but,whatever it may turn out to be, it will be welcome.

BATHING IN THE SERPENTINE.THE suggestion is made by Civil Engineering

that a part of the Serpentine, containing some

3,000,000 gallons, should be enclosed by concreteand provided with a complete water purification plant.This brings up the large question whether peopleshould ever bathe in large numbers in small openlakes. The Serpentine must, of course, be regarded as alarge piece of water; it is nearly a mile long, and arough estimate shows that its content is somewherefrom 70 to 100 million gallons. Moreover, it isnot altogether stagnant, for it was formed bydamming the West Bourne, and this river still runsthrough the lake. In London we are not withoutexperience of similar waters devoted to bathing;the Hampstead and Highgate ponds have been soused for years, and are not known to have spreaddisease. It is clear, however, that each bather mustbring into the water a contribution of oxidisableorganic matter and of bacteria. In water freelyexposed to air, and containing a naturally balancedcommunity of animal and vegetable life, the disturb-ance of equilibrium caused by a reasonable numberof bathers would be small. In the Serpentine,assuming that there are a million bathers a year, thedisturbance would be of the same order as the soilingof a large domestic bath by one bather, but thismakes no allowance for the distribution of the millionbathers over several months, and this provides thedifference. On general aesthetic grounds the nearerthe approach to natural surroundings the more

pleasant things are for bathers and onlookers. It

might, however, be wise of the Office of Works tohave periodical analyses, chemical and bacteriological,of the water entering the Serpentine at the KensingtonGardens end, before it flows under the road bridge,and as it leaves the lake to flow over the fall at theeastern end. It is a great benefit to London that thefinest sheet of water in the metropolis should be madeavailable for a sport which has been too much

neglected, but the two fatal accidents raise a doubtwhether such a large, deep, and opaque mass of watershould be used without restriction. Swimming bathsare the only places where poor swimmers can bathe inperfect safety, and a good deal of protection andsupervision may be required for young people.