War Surgery and Medicine
CHAPTER 25 — Ophthalmology
IN 2 NZEF the most striking feature of ophthalmology was its quantity, and it seemed that men tended to be more intolerant of small disabilities than they were in the First World War. Lieutenant-Colonel Barrett, writing of the work of 1 Australian General Hospital at Heliopolis during the Gallipoli campaign, a hospital of about 2700 beds, described its ophthalmic clinic as ‘enormous’. During the eight months of its existence 1142 cases were seen. In the eight months preceding the offensive at El Alamein, 2380 new ophthalmic cases were seen at 1 NZ General Hospital at Helwan.
There were four main reasons for the volume of work. Firstly, the medical boarding of recruits in New Zealand was uneven and a number of unfit men were sent abroad. Secondly, service glasses were not available in New Zealand until after the 4th Reinforcements had sailed, and the 5th, 6th, and 7th Reinforcements were equipped with them only in part. Thirdly, ophthalmic work was concentrated at the Helwan hospital, an area hospital serving not only New Zealand base but also many thousands of RAF and British troops. Lastly, owing to the discomfort from glare and the presence of so much ocular disease and blindness amongst the natives, many men were unreasonably apprehensive about their sight. Among the more imaginative soldiers, especially those with any reason to be aware of ocular weakness, the presence of so many partially blind and disfigured natives was attributed to the climatic conditions. From the beginning, therefore, and in spite of the pressure of work, a determined effort was made by explanation and reassurance to give the men some confidence. This time was undoubtedly well spent. Discomfort from glare in Egypt can be considerable, and this, together with prevalent mild conjunctivitis, tended to unmask errors of refraction previously tolerated and make men more dependent on glasses for carrying out their duties with comfort and efficiency.
The supply of spectacles in Egypt was inadequate until late in 1942. When Major Doctor arrived in November 1940 he began to refract for service frames all those of the first three echelons who were wearing spectacles. This laborious task was just completed when Major (later Lieutenant-Colonel) Coverdale succeeded page 429 him at Helwan, but the shortage at that time was so acute that only fifteen pair were being dispensed for the hospital by the army contractor each month. There was a long and rapidly increasing waiting list of about 270 New Zealand prescriptions, and men had to wait two to four months even when their need was urgent. It was not until 1943 that, owing to the work of the Opticians' Units in New Zealand, drafts arrived in the Middle East well investigated and equipped and with almost all optically unfit men withdrawn. This ultimate relief for the ophthalmologist abroad, however welcome, was achieved by a very high rejection rate in New Zealand, and there is no doubt that the whole question of standards would repay careful study.
In June 1944 the 14th Mobile Optician Unit, extremely well equipped and under the command of Lieutenant F. O. Davis, arrived in Italy. Its inception was attended by some misfortunes and it was not able to give a complete service until late in the year. Thereafter it proved to be a valuable acquisition.
Many hundreds of men complained of the light, but no corneal changes were visible with the loupe and it was probable that the great majority suffered, not from actinic burns, but from the intensity of the visible rays. The experience of three summers enabled Coverdale to classify most of these men into three groups: (1) those whose eyes were hypersensitive because of superficial inflammations of the lids or conjunctiva, often of a very mild sort; (2) those whose ocular muscles were in a state of irritable tension from uncorrected errors of refraction; (3) those whose nervous systems in general and eyes in particular were intolerant of stimuli because of functional instability.
Men were never discouraged from attending hospital as outpatients, and when subjective disability was out of all proportion to objective findings much time and energy had to be spent in clearing the miasma of minor psychoneurosis from discoverable fact; but Major Coverdale was satisfied that, if it occurred at all, wilful simulation of incapacity was exceedingly rare amongst New Zealand and British troops. Psychoneurosis was fairly common in 1941, much less so in 1942, and thereafter almost ceased to occur. This improvement was ascribed, at least in part, to better boarding in New Zealand. It was found that amongst 95 cases of hysterical amblyopia there were 44 with eyes defective at enlistment from squint, old injury, chronic disease or developmental defects, and 9 with histories of pre-enlistment head or eye injuries, but with no signs remaining. Most of the affected men paraded sick soon after arrival in Egypt, and very few indeed were sent back from forward units in the field. Apart from a few hysterics and some cases with pathological changes, night-blindness was not heard of in 2 NZEF.page 430
Medical Boarding Overseas
The general principle of regarding boarding as a medical assessment rather than a mechanical procedure was always adhered to, and every possible effort was made to keep men with their units in the field. The number of graded men that a Division can profitably employ is not large, and those relegated to Base and not fully engaged in useful work tended to deteriorate rapidly in morale. In spite of this conservative policy, about 200 men had to be boarded for defects present at enlistment. The visual acuity of some of these was, no doubt, Grade I in New Zealand, but other factors, especially temperamental instability, were not assessed or assessable, and the men proved to be of little use in the Middle East. One consequence of the lack of precise investigation at some centres in New Zealand was that many men were credited with much better visual acuity than they did in fact possess. Men, for instance, who had been blind in one eye for years or since birth had had their visual acuity recorded as 6/6 in each eye. Such examinations had their pensions complications. It is a matter of interest that, until late in 1940, men with squint could not be Grade I for service abroad. From experience in North Africa it was evident that, for psychological reasons, this regulation was wise.
In reboarding for defects of vision it was found to be impossible to adhere strictly to the standards of vision laid down for recruits. A man, for example, with two dioptres of myopia can seldom see 6/60 without glasses unless he peers, and yet a trained soldier with normal corrected vision, eager to serve and brought to the Middle East at great expense, cannot lightly be discarded. Major Coverdale decided, therefore, to regrade only those with high degrees of myopia of six or more dioptres, or those with degenerative changes. The number of myopes investigated who were not technically Grade I was, by August 1941, over 300, but for the whole of the North African campaign only about 20 were regraded. Nothing occurred to cause the wisdom of this decision to be questioned.
A small minority of men gave valuable service for long periods in spite of great visual handicaps. A private of 21 Battalion, for example, who made no complaint was sent to the out-patients department because he drove dangerously. One eye was blind and the other, although having 6/9 vision, had been damaged five years previously and showed an irido-dialysis, some posterior cortical cataract, and a rupture of the choroid. A private in the Maori Battalion fought through all the Middle East campaigns with one eye blind and the vision in the other reduced to 6/18 from old trachomatous keratitis. Another man, a lance-corporal page 431 in 23 Battalion, had one blind eye and the vision in the other with a - 4D cylinder reduced to 6/60 on looking to the front. He had a considerable degree of nystagmus and could see 6/18 if he looked across his nose. He served in Greece, Crete, Libya, and at El Alamein up to August 1942.
Standards of Vision
It was found that men with old abnormalities had such a tendency to hysteria or minor psychoneurosis that, even if the vision should be Grade I, they should not be sent abroad. The following are examples of such abnormalities compatible with Grade I vision:
Old perforating injury.
Conditions in the Middle East were admittedly unfavourable for men with ocular defects of this type.
Men with high degrees of refractive error or with amblyopia were found to be unsuitable in the infantry, and this raised the question of what might be called unit grading. It was undesirable to have more Grade II men than Base could profitably use, and, in an effort to avoid grading down borderline cases in the infantry, some attempts were made in 1941 to have them transferred to other units. These attempts did not meet with any substantial success as it was ruled, quite correctly, that if a man is not Grade I for one unit he cannot be Grade I for any other unit. Yet an infantryman requires better vision than a man in the Field Ambulances or the Engineers.
Another type of differential grading which received some consideration overseas was known as category classification. Immediately after the campaign in Greece, and as a result of the reported reluctance of the Germans to engage at night, some unit commanders were asked if they thought anything would be gained by selecting men with exceptional night vision. It was pointed out that normal men vary considerably in this respect, but that it might not be prudent to make them conscious of the fact. The unit commanders replied that they must be able to use any of their men for any purpose at any time.
This question of dividing up Grade I men for special tasks within units was later discussed in New Zealand, though not in connection with night vision. It was evident that, while differential grading between units might have some value, category classification was undesirable.page 432
During the North African campaign 306 men, excluding battle casualties, were graded down in the ophthalmic department at Helwan, and it can be said that about 200 of these were regraded for conditions present at enlistment. It is worth while summarising the reasons for so many time-consuming medical boards.
|To NZ||To Base||Total|
|Chronic or recurring superficial infections, including keratitis||41||9||50|
|(1) Without ocular pathology||14||1|
|(2) With old pathological complications||18||7|
|(3) With amblyopia ex anopsia||9||1||50|
|Amblyopia ex anopsia||2||39||41|
|Errors of refraction||15||12||27|
|Old perforation of the globe||12||7||19|
|Detachment of retina||6||6|
It has been noted that conditions in North Africa were trying for men with visual defects and led to a high attendance rate at the ophthalmic department. Yet, in spite of this and of the somewhat haphazard testing in New Zealand, the analysis of medical boards at Helwan discloses that only 27 men were regraded for errors of refraction and none for errors of muscle balance. Nothing occurred to suggest that by the use of various refinements in testing a more efficient army could have been selected.
As time went on there was a tendency to elaborate the visual testing of recruits, due possibly to some dissatisfaction with the results obtained up to 1943. But the early defects were not so much due to weaknesses in the prescribed standards as to excessive decentralisation of the work, and it is probable that the grading of men from a purely medical point of view showed at least an equivalent margin of error. The problem was one of administration, not of visual standards or clinical competence.
The incidence of hysteria in eye cases was not marked. Lieutenant-Colonel Coverdale, through whose hands went all these cases in 2 NZEF, reported only 95 cases seen during the three-year period page 433 from March 1941. The total New Zealand troops during that time was 59,000. It was found that the cases were limited to susceptible individuals with an incapacitating loss of function. The incidence was highest during periods of stress, though the large majority of cases arose at Base shortly after arrival in the Middle East. After Greece and Crete there were 32 cases, 24 arising at the Base. At the second Libyan campaign period there were 17 cases, and after Minqar Qaim 13 cases. On the other hand, at the time of the advance from Alamein to Tunis only 6 cases were seen—only 1 of them from the Division, but 3 from recent arrivals in Egypt.
A high percentage of the cases had had some pre-existing ocular defect dating generally from childhood, many such cases being missed at the medical examinations of recruits in the early period of the war before the institution in New Zealand of mobile optician units. The main symptoms complained of in the series were:
|Main Symptoms||Severe Cases (50)||Mild Cases (45)|
|Pain in or behind eye||9||8|
|Contracted fields of vision||43||39|
|Defects of accommodation||2||2|
|Conjunctivitis (presumed self-inflicted)||3|
Of the 50 severe cases, 42 were invalided to New Zealand and 8 were graded for Base. The 45 mild cases were retained in their units. Of the 53 cases retained in the Middle East, 20 were subsequently sent back to New Zealand and 7 were graded for Base, while 3 were killed in action and 1 died of disease. At the end of the period 15 were still in the Middle East, while 12 had returned to New Zealand on furlough or for non-medical reasons.
Forty-two men judged to be hopeless cases of hysterical amblyopia were sent back to New Zealand, as their influence would have been unfavourable at all times and their presence even at Base a source of weakness and disquiet. It can be said that few of these were even Grade II at enlistment, but, in regrading them, it was anticipated that some would be able to give useful service at home. Post-war investigations have shown, however, that this view was optimistic. In March 1949 the medical files of 41 of these 42 page 434 men were examined and it was found that 37 had been pensioned for varying periods, 11, it seemed, permanently. Only 3 had had pensions refused and only 1 had made no application.
The problem of hysteria, therefore, was not a serious one, and with the elimination of susceptible men in New Zealand in the later years of the war few cases were seen.
Every grade of intensity of functional disorder, from trivial asthenopia to total uniocular blindness, was met with. The chief difficulty was in deciding what degree of incapacity was necessary to justify the serious yet only permissible diagnosis of hysteria.
This clinical embarrassment was appreciated by the DMS, who called a conference of some senior medical officers to contrive a solution, though it cannot be said that the problem was solved. The fact that when hysteria was diagnosed the man could not thereafter be convicted of malingering is sufficient to indicate that the difficulty was not mere pedantry.
The letters NYD (Not Yet Diagnosed) were allowed in our hospitals, but they often had the obvious disadvantage of being untrue. After having brought a long and exhausting investigation to a successful conclusion, to write NYD seemed unreasonable and destroyed the usefulness of the designation for cases where it was really required.
Of 8772 ophthalmic cases seen by Coverdale by the end of 1943, 2521 required treatment for infection of some kind. There were many isolated cases of acute muco-purulent conjunctivitis with hazy corneae, but no vision was lost in these from ulceration. There was never any suggestion of an epidemic in a unit or of contagion in the ward. No case of gonococcal ophthalmia was diagnosed. Whilst trachoma was prevalent amongst the Egyptians and troops of certain Allied nations, it was found in New Zealanders only in the Maori Battalion. Eleven Maoris were repatriated on this account, and of these it may be said that no more than two or three contracted the disease in Egypt.
The older men seemed less resistant to infection for it was found that, in 35 consecutive cases of pyogenic ulceration of the cornea, the average age was 32, probably well above the average age in 2 NZEF.
Blepharitis was troublesome in Egypt and, to make frequent attendance at the RAP unnecessary, men were provided with yellow oxide ointment in tube form purchased with Red Cross funds. In Italy superficial inflammations of this type were very much less common. Chronic conjunctivitis was frequently seen, and it was page 435 difficult to determine whether glare and dust were causative or merely aggravating factors.
In all lesions of the cornea repair was slow, especially in dendritic ulcers. Recurrent ulcers were common and it was necessary to keep the eyes covered for two weeks after healing.
Intra-ocular inflammation, apart from wounds and injuries, was not very common. About 60 cases were seen of active uveitis of one kind or another, about 10 of these being due to relapsing fever.
In some cases of intra-ocular infection from wounds in Northern Italy remarkable results were obtained by instilling penicillin drops every minute or two for periods of about an hour at a time.
Headache and Heterophoria
Headache was one of the commonest complaints for which men were referred to the ophthalmologist. Refractions were almost always done with the assistance of a retinoscopy under a mydriatic and the state of muscle balance was always investigated. From his experience with orthoptics Major Bruce Hamilton of the AIF contended with some reason that heterophoria could cause headache in the prevailing glare, but our very complete records made it possible to doubt the validity of this in all but a few instances. In a series of 2432 refractions it was found that the relative degrees of imbalance in 636 men complaining of headaches were almost the same as in 1796 who made no such complaint.
One effect of glare was to interfere to some extent with the suppression of an amblyopic eye and to cause transient confusion.
In North Africa men with ocular wounds were sent back as soon as possible to base hospital in Egypt, where they remained under continuity of observation and treatment until all inflammation had subsided and any risk of sympathetic inflammation had passed.
This ideal was not always practicable in Italy, where we had hospitals as it were in series from Naples to Helwan. It may be imperative for the forward one to move patients back quickly to keep beds empty for further convoys. Ophthalmic casualties could pass through several hospitals while their wounds were still in a dangerous state, and we learned from experience that a convoy by train or road or sea could be directed or diverted to a hospital where there was no ophthalmologist. There can be little doubt that once an ophthalmic casualty reaches a hospital where an equipped ophthalmologist is available it is better that he should not be transferred while any danger remains.
To give an idea of the relative proportions of different types of wounds the following analysis has been prepared of a series of 239 page 436 major battle casualties seen at 1 NZ General Hospital up to January 1945. The cases are of serious wounding and do not include functional or blast disturbances, subcutaneous foreign bodies, or head injuries not involving the orbit. In this connection it should be mentioned that, unless the precise type is stated, figures for ocular wounds can be misleading. Amongst the casualties admitted to hospital, Lieutenant-Colonel Coverdale's estimate of the proportion with ocular wounds is about 3 per cent with serious and 3 per cent with minor wounds, a fairly high percentage for the ophthalmologist when it is remembered that he is also called to see many men with subjective difficulties, but with no signs of injury.
The wounds were mostly due to shell, mortar, or mine fragments, and were often multiple and dirty with lacerations of the skin, lids, or conjunctiva.
|Right eye wounded||75||39||114|
|Left eye wounded||57||28||85|
|Both eyes wounded||22||18||40|
|Men with other wounds elsewhere, 120.|
|(1) Penetrating or perforating wounds of the globe of one or both eyes||67||30||97|
|(2) Penetrating or lacerating wounds of the lids or orbit—|
|(a) With contusion of the globe and intra-ocular injury||44||19||63|
|(b) Without injury to globe||8||3||11|
|(3) Contusion of the globe without injury to the lids or orbit||11||6||17|
|(4) Superficial penetrating or lacerating wounds of the globe of one or both eyes||23||27||50|
|(5) Burns of the globe||1||1|
|Both eyes lost or blinded||7||0||7|
|One eye lost or blinded and the other seriously injured||5||2||7|
|Both eyes seriously injured||0||1||1|
|One eye lost or blinded||68||21||89|
|One eye seriously injured||20||21||41|
|Men with one or both eyes removed||49||16||65|
|Men presumed on clinical grounds to have small retained intra-ocular foreign bodies after disposal||9||6||15|
These figures cover patients treated at 1 General Hospital in Egypt and Italy up to and including January 1945, and are not complete for 2 NZEF although they probably include the great majority of cases.
Of 67 men with penetrating or perforating wounds of the globe in Egypt, 51 (76 per cent) eyes were removed—usually farther forward than the base hospital. Of 29 such cases in Italy, 16 (55 per cent) eyes were removed. The number of cases with one eye seriously injured (but not removed) was therefore proportionately higher in Italy. This may have been due, at least in part, to evacuation difficulties in the desert, but it is also evidence of the value of penicillin and albucid soluble which were not available to ophthalmologists before about April 1944. All those with contracted sockets after enucleation or evisceration in forward areas (10 in all) arrived at Helwan with fibrosis already established. The condition of the sockets was a salutary reminder that in ophthalmology there is no substitute for the day-to-day watchfulness and care of the ophthalmic surgeon. Many of these men were in transit for two weeks and the consequences could not have been avoided. A feature of interest present in about 30 per cent of wounds was the severity of the retinal and vitreous haemorrhages from foreign bodies which were either disproportionately small in size and extra-ocular, or which caused tangential or penetrating wounds of the brow or cheek not directly involving the orbit. This was commented on in the First World War, and was due, no doubt, to the velocity of the fragments.
Intra-ocular foreign bodies so frequently consisted of non-magnetic alloys, stone, or bakelite that the giant magnet was not often of value. Many eyes had retained foreign bodies of very small size, and these will need to be watched over long periods. In some situations, stone and bakelite may remain stable and cause no reaction. Time alone will show. (Six years after the war Coverdale had seen no late harmful effects.) The element of uncertainty was increased by the fact that no radiological method of exact localisation was available in the Middle East.
Problems of special importance were the penetrating injuries of the eye and the injuries to the cornea produced by small particles following mine explosions, and to a lesser extent explosions of shells and mortars. Ophthalmological specialists were attached to the CCS after the Alamein period and electro-magnets were available then, but not of sufficient power to be efficient in the majority of cases.
Minimal treatment was recommended in the forward areas before cases were seen by an ophthalmologist. Excision of the eye was page 438 restricted to completely disorganised eyes, the removal of which was necessitated by the general treatment of a face wound. A simple pad and bandage was then applied, no packing being inserted. In wounds of the globe, atropine was instilled, and if a penetrating wound was present a pad and bandage was applied, the lids being stitched together if damaged and the case evacuated lying.
At a forward ophthalmic unit the only treatment advised was that urgently necessary for the conservation of vision. Excision was carried out only for extensive rupture of one blind eye, this being done within ten days of injury. Excision of any prolapsed uvea or lens capsule was done, wounds of the sclera sutured, and wounds of the cornea covered by conjunctival flaps. Foreign bodies were removed only if easily extracted when the magnet was applied to an existing wound of the sclera, or when they could be brought forward from the anterior chamber for anterior extraction. Foreign bodies spattering the cornea were difficult to remove and were generally left alone unless causing irritation. General sulphonamide or penicillin treatment was instituted early in all perforating wounds of the eye and orbit. Corneal exposure was prevented, when necessary, by suturing the lids together. Moderate delay in the removal of foreign bodies did not prove harmful, so that patients could be evacuated to base for major operative procedure. At the Base useless eyes were removed when any danger of sympathetic ophthalmia arose. Foreign bodies were removed by the anterior or posterior route with the use of the magnet if possible. Forty per cent were magnetisable.
Sympathetic ophthalmia proved very uncommon, only one case being reported in the Middle East Forces in three years. No case of sympathetic ophthalmia was recorded in 2 NZEF. There were periods of anxiety, however, when cases with penetrating wounds of the globe were evacuated to the Base and any delay meant encroachment on the danger period. This was accentuated by the shortage of ophthalmologists in 2 NZEF. No ophthalmologist was attached to a New Zealand general hospital in Italy until 1 General Hospital went there five months after the force had landed. Cases during this period were referred back to Egypt, causing some danger of delay in treatment.
The equipment of our hospital departments was left to the RAMC, which had drawn up a scale to be regarded as the irreducible minimum required. For an ophthalmic department this page 439 did not include a magnet, corneal microscope, or diathermy, but it was adequate provided that these larger instruments were available at some other hospital within easy reach.
As the Helwan hospital was one of the first to be established in Egypt, it was fortunate in obtaining an almost complete set of the standard ophthalmic equipment. Supplies soon became exhausted, and Captain Simpson's department at 2 NZ General Hospital on the Suez Canal and later at 3 NZ General Hospital at Bari, in Italy, was never equipped. It was not until Captain Trevor-Roper joined us at 2 NZ General Hospital at Caserta, near Naples, that we had two fully functioning ophthalmic departments.
As time went on and it became possible to buy instruments in England with Red Cross funds, a diathermy was obtained and later, in Italy, a corneal microscope and a supply of sodium sulphacetamide. Essential drugs such as atropine, homatropine, and argyrol were unobtainable only on rare occasions, and any shortage did not affect us as Coverdale had purchased in New Zealand and taken overseas a considerable quantity of atropine, homatropine, cocaine, and mercurochrome in crystal form. Penicillin became available for ophthalmic use in May 1944.
The supply of electricity is an essential supplement to ophthalmic equipment, and although we often lacked batteries for the torch and ophthalmoscope we were fortunate at Helwan in having an adequate supply of 220 volt alternating current. In Northern Italy, where enemy demolitions made us dependent on our own resources, the G1098 scale provided only one small engine of 3 or 4 kilowatts. We gradually accumulated several of these, which sufficed for lighting on a limited scale, and at the end of 1944 obtained a 16 kilowatt engine supplying 220 volt current.
The ophthalmic surgeon was on General Hospital establishment and was entitled to special nursing and clerical assistance only by courtesy of the Commanding Officer and Matron. The appointment of a trained ophthalmic nursing sister to look after cases in the ophthalmic ward was conceded when 1 NZ General Hospital replaced 2 NZ General Hospital at Helwan in August 1941, and then, no doubt, only with some sacrifice of administrative felicity. New Zealand hospitals were peculiar in that the establishment for nursing sisters made no provision and did not recognise the necessity for any specialisation. An excellent clerk was provided for the out-patient department at Helwan, but when No. 1 Hospital settled down among the sandhills of the Northern Adriatic, page 440 it was soon crowded beyond its establishment of beds and the ophthalmologist had to forgo this assistance.
These staffing difficulties were due to the inflexibility of a hospital's establishment, that useful refuge behind which administration could recoil in safety from an exasperated suppliant. If an ophthalmic unit with adequate trained personnel were attached to a hospital, it could move easily from one to another as need might arise and the nursing sister could do dressings in general surgical wards as well as in her own. It is noteworthy in this regard that over half the men with major ocular wounds had other wounds elsewhere, and they could not all, therefore, be segregated in one ward.
At the beginning of 1945 three nursing sisters were sent to Rome to take a special course in ophthalmic nursing organised by Lieutenant-Colonel B. W. Rycroft, RAMC.
While administration worked smoothly throughout the war, the need was felt in Egypt for a relieving ophthalmologist. The quantity of work was exhausting and so unremitting that it was seldom possible for the ophthalmologist to take any leave of absence.
Summary of Cases
Figures for Italy are not available, but some idea of the work done is provided in the following summary which includes cases seen at Helwan up to the end of December 1943. Although outpatient investigations were relatively fewer in Italy, the total for the hospital for both theatres of war would be well over 10,000.
It will be noted that nearly a third of the cases were from British or Allied units. Helwan was an Area Hospital and served the RAF Middle East Transit Camp and Signals School and the Base Depot of the Royal Corps of Signals, through all of which passed an ever-changing and unceasing stream of men. It was a pleasure to be able to reciprocate in this way:
|numbers of cases up to 31 december1943—|
|RAF, BTE, and others||1,972|
|numbers of men for whom spectacles were ordered—|
|RAF, BTE, and others||922|
|Superficial infections of lids, conjunctiva, and cornea||2,521|
|Major battle casualties and accidental injuries||618|
For the purposes of this summary the varying and sometimes difficult distinction between a battle casualty and an accidental injury has been evaded.
In Fiji in 1941 and 1942 ophthalmic work was carried out under difficulties. Little suitable equipment was available, and there was at the time no civilian ophthalmologist practising in Suva, so that there was no one attached to the Memorial Hospital to whom cases might have been referred. The hospital did, however, lend Major L. S. Talbot a box of ophthalmic lenses and did all it could to help. It was fortunate that the period of occupation by the New Zealand forces did not include combat conditions, as it would have been difficult to give efficient ocular operative treatment for lack of surgical instruments. When the Tamavua military hospital was built in the middle of 1941 an adequate Eye and ENT examination room was provided in it, enabling refractions to be done quickly and conveniently, and the department was kept very busy as a number of civilians attended as out-patients.
Tropical eye conditions were very uncommon, as also proved to be the case in New Caledonia and the Solomon Islands. There was little trouble from heterophoria or from functional asthenopia. An idea that ‘glare’ in a tropical country would need to be counteracted by the wearing of tinted glasses was at first widespread among the troops. As a matter of fact glare was no more a problem in Fiji than in New Zealand. The country, at least on the Suva side, is green and the sky often cloudy, as would be expected with an annual rainfall of from 75 to 150 inches. The idea died out with persuasion and explanation. (In the Air Force special conditions are met with in which such lenses are necessary.) Little conjunctival infection occurred, and it responded well to the treatments available in the pre-penicillin era.
Though trachoma is endemic in Fiji among both Indians and Fijians, no cases of trachoma were found in New Zealand troops. It appeared that the good standard of personal cleanliness which obtained among the troops rendered infection unlikely, even when New Zealand and Fijian soldiers were training in fairly close contact.
Trachoma Scare in Fiji
In January 1945 an alarming message was received by the Director-General of Medical Services to the effect that 40 per cent of the New Zealanders serving with the Fiji Defence Force were suffering from an eye disease diagnosed as early trachoma by medical officers and the local ophthalmologist. Lieutenant-Colonel W. J. Hope-Robertson page 442 and Major L. S. Talbot, two ophthalmologists, were immediately sent to Fiji to investigate. Trachoma is thought to be a virus disease which can be spread where there is dirt, either personal or environmental. It is difficult to diagnose in its early stages. The ophthalmologists examined 102 New Zealanders and 13 other white servicemen, most of whom had previously been diagnosed as trachoma cases, but in no case did they find a trachomatous condition. A papillary hypertrophic condition only was seen in some. Of 30 Fijian servicemen examined there were only four with a slitlamp appearance of the cornea that suggested the existence of a previous pannus. There was no evidence of present or previous trachoma in 30 white residents of long standing.
The ophthalmologists were of the opinion that trachoma did exist among the native population of Fiji, but that white troops could continue to serve there without danger to their eyes if reasonable precautions against infection were taken. They recommended that an eye specialist be provided where troops were quartered in areas where there was endemic eye disease of a contagious or infectious nature. They made further recommendations regarding quartering and messing of white troops in these areas— facilities for personal cleanliness in the way of hot and cold water showers; cleanliness of clothing, with towels and handkerchiefs washed in boiling water; cooking of food for Europeans by Europeans; native servants to be employed as sparingly as practicable, and only after a careful medical examination; and the desirability of white and native troops not messing together, unless for military reasons it could not be avoided.
Recommendations for the Future
For a regular army in peacetime standards are usually raised, but for any scheme of national service or for mobilisation in war about 90 per cent of eligible men will be obviously Grade I on visual standards, about 10 per cent will need to be referred for specialist opinion, about 5 per cent will need glasses, and there will be a very small number visually unfit for any service. These rejects will amount to one or two per cent of the whole. If, however, recruits are tested for, say, colour vision and those with a defect are downgraded, some thousands of men in New Zealand will be needlessly wasted. If the results are not used to grade the men it is better that the tests should not be made. It should also be realised that to order spectacles for a man is tantamount to excluding him from service with the infantry or armoured regiments, and must not be done without very good reason.
In order to make the best use of available manpower a recruit who is not obviously Grade I should be seen by an ophthalmic page 443 surgeon for a medical estimation of his capacity. It is always unwise to grade a man only to have to grade him up again should manpower conditions change.
The minimum requirements for a division overseas are two ophthalmic surgeons, one for the ophthalmic wing at the base hospital and equipped with such heavy instruments as a giant magnet, corneal microscope and diathermy, and the other with lighter equipment for attachment to the CCS when required. In addition, there should be a mobile opticians' unit. It is important that the ophthalmic surgeons should be constitutionally fit as they are not dispensable. At the base hospital the ophthalmic surgeon requires the assistance of a trained ophthalmic nursing sister and a clerk of lance-corporal rank. For the more mobile surgeon an orderly is sufficient. These officers and other ranks should not be on a hospital's establishment. If the Force should be widely dispersed an extra ophthalmologist with assistants would be required.
The necessary equipment, which must include a generous supply of essential drugs and engines capable of generating electricity of voltage suitable for the instruments, should be accumulated in peacetime so that the units may sail prepared to function efficiently and at once wherever they may be sent.
|Admissions to Hospital, July 1941-December 1945||Invalided to New Zealand, 1940–45|
|Other||232||69 (Includes some injuries)|
VISUAL GRADING IN NEW ZEALAND
A statistical survey of visual gradings and eye conditions was made by the Institute of Opticians in August 1941, and it covered 2579 recruits from the group of single men aged 21 to 40 years who were examined at six North Island centres. The visual grading were found to be: Grade I, 2324 (90.11 per cent); Grade II, 161 (6.24 per cent); Grade III, 81; page 444 Grade IV, 1, and referred cases, 12; a total of 94 (3.65 per cent) lower than Grade II.
Of those in Grade I 220, or 9.47 per cent, were referred for further examination in camp for the possible supply of glasses. It was estimated that 6–7 per cent of this Grade I group would require glasses to be visually efficient. In Grade II 119, or 73.9 per cent, required glasses, having high visual and refractive errors.
The reasons for Grade III grouping were: Myopia (—2.50 to —16.00 dioptres), 66 cases; high hyperopia, astigmatism, amblyopia, 9 cases; myopia with strabismus, 2; cataract, 2; recent eye operation, 1; optic atrophy, 1. The Grade IV case had congenital subluxation of the crystalline lenses. The referred cases had suspected active pathology.
Colour vision statistics were: Normal, 2366 (91.74 per cent); defective but safe, 91 (3.53 per cent); defective unsafe, 122 (4.73 per cent).
The opticians observed that relatively few more men would be obtained by lowering the standard of Grade I men. They pointed out that no attention was given to the loss of vision being in the right eye. They also stressed the danger of accepting as Grade III one-eyed men or high myopes because of the possibility of complete or serious loss of vision in these cases. They recommended only slight modification in the standards with regard especially to the elimination of the one-eye cases and high myopes. They suggested the subdivision into three categories.
It is noted that 66 of 81 cases graded III were myopes with a range of —2.50 to —16.00 dioptres. In the opinion of some ophthalmologists the majority of these cases are fit to serve overseas. Brigadier Sir William Duke-Elder, British Army Consultant, stated that myopes up to 6 and 7 dioptres were accepted by the British Army for service overseas. Lieutenant-Colonel Hope-Robertson, ophthalmic consultant to the forces in New Zealand, considered that a large number of physically fit myopes were unnecessarily debarred from overseas service.
Extract from analysis of Causes of Rejection in 42,022 men rejected from 105,311 men aged 18 to 45 years, who were examined for military service during 1942 and 1943. (Prepared by National Service Department, 14 December 1943.)
|Central Age of Group||Number in Group Examined||Percentage other than Grade I||Defective Vision||Blindness One or Both Eyes||Other Eye Disorders||Total Eye Disorders|
|19 yrs (single)||10,855||22.1||3.98||0.28||0.25||4.51|
|28 yrs (married)||22,585||28.3||3.43||0.39||0.25||4.07|
|33 yrs (married)||28,239||35.2||3.41||0.42||0.32||4.15|
|42 yrs (married)||43,632||53.4||4.35||0.50||0.34||5.19|
|Diseases of the eyes||1061|
|Errors of refraction only||957|
|Enucleation both eyes||1|
|Penetration of eye||22|
|Penetration of eye with blindness||10|
|Penetration of eye retained FB||9|
|Penetration of both eyes||6|
|Penetration of both eyes with blindness||3|
|Perforation both eyes||2|
|Injury cornea both eyes||6|
|Injury cornea and contusion||2|
|Contusion with blindness||4|
|Contusion with retained FB||1|
|Contusion with haemorrhage||2|
|Contusion with perforation||5|
|Burns both cornea||1|
|Injury cornea and cataract||1|
|FB cornea and partial loss sight||1|
|Penetration and cataract||2|
|Penetration and loss vision||2|
|Penetration and retained FB||1|
|Blind eye (PW)||1|
|H. V. Coverdale||Hysteria in Ophthalmology, British Journal of Ophthalmology 29, pp. 120–4, March 1945.|
|Ophthalmic Experiences at Helwan, Egypt, New Zealand Medical Journal, Vol. XLIII 234, pp. 53–7, April 1944.|
|Headache and Heterophoria Amongst Soldiers, Aust and NZ Journal of Surgery, Vol. XIV, 4 April 1945.|
|Ophthalmology in 2 NZEF, New Zealand Medical Journal Ophthalmology Supp., 1949.|
|G. Dansey-Browning||The Value of Ophthalmic Treatment in the Field, British Journal of Ophthalmology 28, pp. 87–97, February 1944.|
|Ophthalmic Treatment in the Field, 1943, British Journal of Ophthalmology 30, pp. 26–35, January 1946.|
|Visual Defects in Army Recruits, British Journal of Ophthalmology, August 1947.|
|W. J. L. Duncan||Occular Injuries of Soldiers in the Middle East, Aust and NZ Journal of Surgery 12, pp. 235–9, April 1943.|
|J. B. Hamilton||Occular Complications in Relapsing Fever, British Journal of Ophthalmology 27, pp. 60–80, February 1943.|
|Orthoptics in the Field, Aust and NZ Journal of Surgery, 13, pp. 107–10, October 1943.|
|The Incidence of Eye Disease in the AIF Middle East, British Journal of Ophthalmology 28, pp. 383–93, August 1944.page 446|
|I. C. Michaelson||War Injuries of the Eye, British Journal of Ophthalmology 27, pp. 449–61, October 1943.|
|Defective Night Vision Among Soldiers, Dark Adaptation Results and their Use in Diagnosis, British Journal of Ophthalmology 28, pp. 140–7, March 1944.|
|Epidemic Kerato-conjunctivitis in the Middle East, British Journal of Ophthalmology 29, pp. 389–406, August 1945.|
|Ocular Manifestations of Neurosis Commonly Found Among Soldiers, British Journal of Ophthalmology 2, pp. 536–41, October 1943.|
|B. W. Rycroft||Ophthalmology in the BNA and CM Forces, British Journal of Ophthalmology 29, pp. 113–20, March 1945.|
|G. I. Scott and I. C. Michaelson||An Analysis and Follow-up of 301 cases of Battle Casualty Injury to the Eyes, British Journal of Ophthalmology 30, pp. 42–5, January 1945.|
|H. B. Stallard||War Surgery of the Eye, British Journal of Ophthalmology 28, pp. 105–35, March 1944.|
|The Eye Department in a Middle East General Hospital. British Journal of Ophthalmology 28, pp. 261–75, June 1944.|
|War Surgery of the Eye, British Medical Journal 2, pp. 629–31, November 1942.|
|Retinal Detachment; a series of 78 cases in the Middle East Force, British Medical Journal 2, pp. 329–33, September 1944.|
|H. H. Skeoch||Penetrating War Wounds of the Eye and Orbit. British Journal of Ophthalmology 29, pp. 113–20, March 1945.|
|P. D. Trevor-Roper||The Late Results of Removal of Intra-ocular Foreign Bodies with Magnet, British Journal of Ophthalmology 28, pp. 361–5, June 1944.|
|E. C. Zohrab [sic]||War Surgery of the Eye in Forward Areas, British Journal of Ophthalmology 29, pp. 579–93, November 1945.|