ally 1943 patients died after such procedures in 1984 (West Midlands regional office of statistics, unpublished data). It seems possible that the extent of over the counter sales of trusses does not represent a real popularity but simply reflects the actions of hernia sufferers denied surgery by doctors but still seeking relief. In my prospective study 16 elderly patients with a symptomatic, reducible inguinal hernia had worn an elasticated truss for three months before surgery was performed. To date, 13 patients have had their hernia repaired and undergone postoperative assessment after three months. All symptoms were relieved by either a truss or surgery. Orthotists and doctors tended to overestimate the control exerted by a truss. Twelve of the 13 patients preferred surgery to wearing a truss, including three who had suffered postoperative complications (two with haematomas, one with urinary retention). The continuing interest in a virtually obsolete appliance seems to be a consequence of the unhealthy referral practices of doctors. In all but the most exceptional circumstances surgery should be the preferred option. For such a policy to provide maximum benefit to the patient, surgeons must also ensure a prompt surgical service. M GOLDMAN East Birmingham Hospital, Birmingham B9 5ST 1 Burns E, Whitley A. Trusses. BM7 1990;301:1319-20. (8 December.) 2 Kral JG. The use of trusses in cases of inguinal hernia in adults.
Lakartidningen 1972;69:5496-8. 3 Allen PIM, Zager M, Goldman M. Do we operate on enough hernias in elderlv people? BrJ Surg 1987;74:987.
Screening for people with mental handicap SIR, -I concur with the conclusions of Drs David N Wilson and Anne Haire concerning the hidden pathology found among mentally retarded adults.' I conducted a pilot project on behalf of Barnsley community health department on 33 clients of a local adult training centre, all of whom had attended schools for educationally subnormal children. I tested the clients' hearing by tympanometry and, if possible, pure tone audiometry and performed an ear, nose, and throat examination. I also measured refraction in the clients (using a cycloplegic in seven cases) and tested the visual acuity with a Snellen chart (letters or illiterate E) if possible, and examined the eyes. The accompanying staff from the adult training centre gave whatever history they could in terms of apparent auditory and visual functioning of the clients. Of the 33 clients, two had a known hearing problem and a further five had a previously undetected hearing problem (conductive hearing loss, including one large tympanic perforation). Eight were known to have visual problems (six had refractive errors, one had amblyopia, and one had retinitis pigmentosa), and seven had previously undiagnosed visual problems (four early cataracts, two refractive errors, and one keratoconus). The clients with the hearing problems were managed appropriately. Those with refractive errors were given prescriptions for new glasses (either a new prescription or a change of prescription for existing glasses if necessary). Those with early cataracts had good visual acuity and were to be reviewed; the client with keratoconus was very severely mentally handicapped and would have been totally uncooperative with any treatment so no referral was made. Mentally handicapped adults, like the "younger physically disabled," are a Cinderella group in terms of attracting medical and paramedical services. My study showed that over a third of the clients at an adult training centre had previously undiagnosed hearing or vision problems. As well as
BMJ
VOLUME
302
26 JANUARY 1991
the screening suggested by Drs Wilson and Haire, I would add a regular dental and chiropody check. The community health services are ideally placed to offer a regular "MOT" to the mentally and physically handicapped in the community. CHARLES ESSEX New Street Health Centre, Barnslev S70 ILP I Wilson DN, Haire A. Health care screening for people with mental handicap living in the community. BMJ 1990;301: 1379-81. (15 December.)
Vitamin A and measles in Third World children SIR,-Dr Michael Chan advocates vitamin A supplements as a simple measure to reduce the morbidity and mortality from measles in Third World children. I We agree that this would seem to be a great potential benefit but would like to point out an aspect of vitamin A metabolism that is important in west Africa but was not mentioned in Dr Chan's editorial. In west Africa the main dietary source of vitamin A is the carotene in red palm oil. Striking hypercarotenaemia is common in Ghana,2 leading to yellow colouration of the palms and soles and even the eyes. With colleagues from west Africa we have been investigating various aspects of hypercarotenaemia including its possible role in the reaction to experimental murine malaria.3 It is interesting, too, that Yoruba mothers give a teaspoonful of red palm oil to babies with fever (T A Laniyan, personal communication). We therefore suggest that any attempt to ameliorate the course of measles with vitamin A should also test the potential value of palm oil, a cheap and readily available local alternative. Finally, enteritis of bacterial, viral, or parasitic origin would have to be considered, both as a factor predisposing to malabsorption of carotene and its conversion to vitamin A and as a potential interference with absorption of vitamin A supplements. HEATHER M DICK H B GOODALL D B WALSH Dundee General Hospitals Unit, Ninewells Hospital and Medical School, Dundee DDI 9SY I Chan M. Vitamin A and measles in Third World children. BMJ 1990;301:1230-1. (I December.) 2 Dagadu M, Gillman J. Hvpercarotenaemia in Ghanaians. Lancet 1963;i:531-2. 3 Laniyan TA, Goodall HB, Dick HM. The effects of dietary oils on murine malaria. Trans R Soc Trap Aed Hvg 1989;83:863.
Guidelines on management of hyperlipidaemia SIR,-Does sufficient consensus exist among lipid clinicians to enable clear guidelines on the management of hyperlipidaemia to be sent to all doctors?' The answer is yes, as exemplified by a booklet sent to over 35 000 general practitioners last summer.2 Detection and Management of Blood Lipid Disorders represents the views of the British Hyperlipidaemia Association and was published and distributed at its own expense. Copies may be obtained by sending a cheque for £2.50 to Current Science Ltd, 34-42 Cleveland Street, London WlP 5FB. GILBERT R THOMPSON
MRC Lipoprotein Team, Hammersmith Hospital, London W12 OHS 1 Anonymous. Audit in practice: news and information. BMJ 1990;301:1377. (15 December.) 2 British Hyperlipidaemia Association. Detection and management of blood lipid disorders. London: Current Science, 1990.
Injuries due to chemical weapons SIR,-The timely editorial by Drs V S G Murray and G N Volans on the management of injuries due to chemical weapons offers comprehensive advice about the agents used and the management of the damage they may cause,' but the advice concerning the treatment of eye injuries requires clarification. Primary treatment of any chemical eye injury should include copious irrigation with normal saline but there is no place for daily irrigation. Mucoid discharge is often copious but should be removed by simple bathing of the lids with sterile cotton wool and saline. Repeated irrigation with large volumes of fluid can only increase the conjunctival irritation and risk of infection. Mydriatics, topical antibiotics, topical steroids, and dark glasses all help to relieve symptoms. Local anaesthetic drops are useful only for relieving discomfort of the initial examination and irrigation of the eye. Their long term use is absolutely contraindicated because of the toxic effect on replicating corneal epithelium. Any patient with a corneal epithelial defect persisting beyond one week or with limbal ischaemia requires intensive topical treatment with sodium citrate 10% and potassium ascorbate 10% drops in addition. These have been shown to prevent late corneal melting, which can otherwise be a disastrous complication, and also permit steroid drops to be continued without risk of worsening the corneal changes.2 Advice on the management of eye injuries following exposure to war gases has been sent to all fellows and members of the College of Ophthalmologists, and additional copies may be obtained from the college office. Ascorbate and citrate drops are not commercially available but may be obtained from the Pharmacy, Moorfields Eye Hospital, City Road, London EC1V 2PD. PETER WRIGHT
College of Ophthalmologists, London W14 9PQ 1 Murray VSG, Volans GN. Management of injuries due to chemical weapons. BMJ7 1991;302:129-30. (19 January.) 2 Pfister RR, Haddox JL, Yuille-Barr D. There is an additive effect of combined citrate/ascorbate treatment in decreasing corneal ulceration and perforation of alkali injured eyes. Invest Ophthalmol Vis Sci 1990;31:487.
General practice fundholding SIR,-Like the great majority of the medical profession and the BMA membership I have been steadfastly opposed to the concept of fundholding for general practitioners in the form enshrined in the NHS and Community Care Act 1990. I have little doubt that as predicted it will be divisive for both doctors and patients and heralds the acceptance of cash limitation of clinical services in primary care by those who undertake it. It prepares the way for our political masters not only to transfer to the profession the unpleasant choices associated with the rationing of services but also to distance themselves from the consequences of such rationing. It is with dismay therefore that I witness the inability of the leaders of the BMA to stand by all the resolutions of the council, the representative body, the conference of local medical committees, and the General Medical Services Committee by trying both to abhor the concept and to woo the potential fundholders. The action of the chairman of the GMSC in taking the problems of fundholders to the department may well be unconstitutional. The article of association No 141 states: "All Committees whether carrying delegated powers or not shall take all reasonable steps to implement Policy decisions of the Association."
239
Lakartidningen 1972;69:5496-8. 3 Allen PIM, Zager M, Goldman M. Do we operate on enough hernias in elderlv people? BrJ Surg 1987;74:987.
Screening for people with mental handicap SIR, -I concur with the conclusions of Drs David N Wilson and Anne Haire concerning the hidden pathology found among mentally retarded adults.' I conducted a pilot project on behalf of Barnsley community health department on 33 clients of a local adult training centre, all of whom had attended schools for educationally subnormal children. I tested the clients' hearing by tympanometry and, if possible, pure tone audiometry and performed an ear, nose, and throat examination. I also measured refraction in the clients (using a cycloplegic in seven cases) and tested the visual acuity with a Snellen chart (letters or illiterate E) if possible, and examined the eyes. The accompanying staff from the adult training centre gave whatever history they could in terms of apparent auditory and visual functioning of the clients. Of the 33 clients, two had a known hearing problem and a further five had a previously undetected hearing problem (conductive hearing loss, including one large tympanic perforation). Eight were known to have visual problems (six had refractive errors, one had amblyopia, and one had retinitis pigmentosa), and seven had previously undiagnosed visual problems (four early cataracts, two refractive errors, and one keratoconus). The clients with the hearing problems were managed appropriately. Those with refractive errors were given prescriptions for new glasses (either a new prescription or a change of prescription for existing glasses if necessary). Those with early cataracts had good visual acuity and were to be reviewed; the client with keratoconus was very severely mentally handicapped and would have been totally uncooperative with any treatment so no referral was made. Mentally handicapped adults, like the "younger physically disabled," are a Cinderella group in terms of attracting medical and paramedical services. My study showed that over a third of the clients at an adult training centre had previously undiagnosed hearing or vision problems. As well as
BMJ
VOLUME
302
26 JANUARY 1991
the screening suggested by Drs Wilson and Haire, I would add a regular dental and chiropody check. The community health services are ideally placed to offer a regular "MOT" to the mentally and physically handicapped in the community. CHARLES ESSEX New Street Health Centre, Barnslev S70 ILP I Wilson DN, Haire A. Health care screening for people with mental handicap living in the community. BMJ 1990;301: 1379-81. (15 December.)
Vitamin A and measles in Third World children SIR,-Dr Michael Chan advocates vitamin A supplements as a simple measure to reduce the morbidity and mortality from measles in Third World children. I We agree that this would seem to be a great potential benefit but would like to point out an aspect of vitamin A metabolism that is important in west Africa but was not mentioned in Dr Chan's editorial. In west Africa the main dietary source of vitamin A is the carotene in red palm oil. Striking hypercarotenaemia is common in Ghana,2 leading to yellow colouration of the palms and soles and even the eyes. With colleagues from west Africa we have been investigating various aspects of hypercarotenaemia including its possible role in the reaction to experimental murine malaria.3 It is interesting, too, that Yoruba mothers give a teaspoonful of red palm oil to babies with fever (T A Laniyan, personal communication). We therefore suggest that any attempt to ameliorate the course of measles with vitamin A should also test the potential value of palm oil, a cheap and readily available local alternative. Finally, enteritis of bacterial, viral, or parasitic origin would have to be considered, both as a factor predisposing to malabsorption of carotene and its conversion to vitamin A and as a potential interference with absorption of vitamin A supplements. HEATHER M DICK H B GOODALL D B WALSH Dundee General Hospitals Unit, Ninewells Hospital and Medical School, Dundee DDI 9SY I Chan M. Vitamin A and measles in Third World children. BMJ 1990;301:1230-1. (I December.) 2 Dagadu M, Gillman J. Hvpercarotenaemia in Ghanaians. Lancet 1963;i:531-2. 3 Laniyan TA, Goodall HB, Dick HM. The effects of dietary oils on murine malaria. Trans R Soc Trap Aed Hvg 1989;83:863.
Guidelines on management of hyperlipidaemia SIR,-Does sufficient consensus exist among lipid clinicians to enable clear guidelines on the management of hyperlipidaemia to be sent to all doctors?' The answer is yes, as exemplified by a booklet sent to over 35 000 general practitioners last summer.2 Detection and Management of Blood Lipid Disorders represents the views of the British Hyperlipidaemia Association and was published and distributed at its own expense. Copies may be obtained by sending a cheque for £2.50 to Current Science Ltd, 34-42 Cleveland Street, London WlP 5FB. GILBERT R THOMPSON
MRC Lipoprotein Team, Hammersmith Hospital, London W12 OHS 1 Anonymous. Audit in practice: news and information. BMJ 1990;301:1377. (15 December.) 2 British Hyperlipidaemia Association. Detection and management of blood lipid disorders. London: Current Science, 1990.
Injuries due to chemical weapons SIR,-The timely editorial by Drs V S G Murray and G N Volans on the management of injuries due to chemical weapons offers comprehensive advice about the agents used and the management of the damage they may cause,' but the advice concerning the treatment of eye injuries requires clarification. Primary treatment of any chemical eye injury should include copious irrigation with normal saline but there is no place for daily irrigation. Mucoid discharge is often copious but should be removed by simple bathing of the lids with sterile cotton wool and saline. Repeated irrigation with large volumes of fluid can only increase the conjunctival irritation and risk of infection. Mydriatics, topical antibiotics, topical steroids, and dark glasses all help to relieve symptoms. Local anaesthetic drops are useful only for relieving discomfort of the initial examination and irrigation of the eye. Their long term use is absolutely contraindicated because of the toxic effect on replicating corneal epithelium. Any patient with a corneal epithelial defect persisting beyond one week or with limbal ischaemia requires intensive topical treatment with sodium citrate 10% and potassium ascorbate 10% drops in addition. These have been shown to prevent late corneal melting, which can otherwise be a disastrous complication, and also permit steroid drops to be continued without risk of worsening the corneal changes.2 Advice on the management of eye injuries following exposure to war gases has been sent to all fellows and members of the College of Ophthalmologists, and additional copies may be obtained from the college office. Ascorbate and citrate drops are not commercially available but may be obtained from the Pharmacy, Moorfields Eye Hospital, City Road, London EC1V 2PD. PETER WRIGHT
College of Ophthalmologists, London W14 9PQ 1 Murray VSG, Volans GN. Management of injuries due to chemical weapons. BMJ7 1991;302:129-30. (19 January.) 2 Pfister RR, Haddox JL, Yuille-Barr D. There is an additive effect of combined citrate/ascorbate treatment in decreasing corneal ulceration and perforation of alkali injured eyes. Invest Ophthalmol Vis Sci 1990;31:487.
General practice fundholding SIR,-Like the great majority of the medical profession and the BMA membership I have been steadfastly opposed to the concept of fundholding for general practitioners in the form enshrined in the NHS and Community Care Act 1990. I have little doubt that as predicted it will be divisive for both doctors and patients and heralds the acceptance of cash limitation of clinical services in primary care by those who undertake it. It prepares the way for our political masters not only to transfer to the profession the unpleasant choices associated with the rationing of services but also to distance themselves from the consequences of such rationing. It is with dismay therefore that I witness the inability of the leaders of the BMA to stand by all the resolutions of the council, the representative body, the conference of local medical committees, and the General Medical Services Committee by trying both to abhor the concept and to woo the potential fundholders. The action of the chairman of the GMSC in taking the problems of fundholders to the department may well be unconstitutional. The article of association No 141 states: "All Committees whether carrying delegated powers or not shall take all reasonable steps to implement Policy decisions of the Association."
239
