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OPHTHALMOLOGICAL CONGRESSES IN LONDON
987
by a right paramedian incision and was found to be nearly filled by a dark plum-coloured loop of bowel. This proved to be tightly twisted on itself several times. After undoing the volvulus the affected bowel was recognised as a Meckel’s diverticulum with a blind The small intestine proximal and free distal end. to the point of origin of the diverticulum was much distended while beyond this it was represented by only a thin fibrous cord. The diverticulum was
excised and the divided end of the small intestine implanted into the abdominal wall as an
was
enterostomy. The child stood the immediate effects of the operation well but died about 24 hours later. On post-mortem examination the body was that of a normally formed infant except for the terminal portion of the ileum, which was represented by a thin fibrous cord joining the site of origin of the large Meckel’s diverticulum to the caecum (see figure). The appendix and large intestine were normally formed but small and contracted.
The results of the treatment of intestinal atresias have hitherto been extremely discouraging. According to Morley’s (1921) survey ofthe literature there were no recorded cases of an infant surviving operation for this condition for more than a few days. Nevertheless, two considerations seem to justify an exploratory laparotomy in all cases of intestinal obstruction in the newborn where the general condition of the infant permits it. First, the inevitably fatal outcome of intestinal atresia in the absence of
surgical intervention, and secondly, the impossibility of making an exact preoperative diagnosis of the precise cause of the obstruction, with the consequent possibility of finding a condition more easily amenable to surgical treatment. I
am
indebted to Dr.
J. N. Deacon, medical
superintendent of Redhill County Hospital, for permission to publish this case, and to Dr. Hamilton Patterson for his careful post-mortem examination. REFERENCES
LONDON OPHTHALMOLOGISTS assembled in London for 3 congresses last week, all held at the house of the Royal Society of Medicine at 1, Wimpole Street, W.l. The annual congress of the Ophthalmological Society of the United Kingdom The president, (Birmingham), gave an address on the anterior capsule. He showed that clearly defined zones can be recognised and that the zonular lamella, which is probably of different origin from that of the hyaline capsule, has characteristic lesions of its own. The epithelial cells were probably the oldest part of the lens and have a purely nutritional function. The address was profusely illustrated with drawings from clinical cases.
April 20,
21 and 22.
Mr. T. HARRISON BUTLER
SOME COMMUNICATIONS
Dr. W. J. B. RIDDELL (Glasgow), speaking
multiple factors
in
hereditary
eye
diseases, pointed
SURGEON
PARKER, M.B. Manc.
LIEUTENANT, ROYAL NAVY
THE usual treatment of scabies by means of sulphur ointment and baths has other disadvantages besides that of inconvenience, especially when a number of In March cases have to be treated simultaneously. of last year 8 cases of scabies were detected in a naval mess where spread of infection was inevitable under the conditions of close contact found in a small warship.’ The patients were isolated and their kit" fumigated and it was decided to try the " Hypo-HCl method of treatment. According to Fitch (1938) this method was employed in at least one British field ambulance during the late war, but it was later rediscovered in Germany and is being used satisfactorily by Huber (1938) in Budapest. It consists of painting the whole of the patient’s skin with a 25 per cent. aqueous solution of sodium "
thiosulphate (the photographer’s hypo "), allowing this to dry and then painting with 5 per cent. hydrochloric acid. This is repeated, so that a single treatment consists of two alternate applications of hypo and acid. The result is a very fine deposit of sulphur on the skin without a tedious and somewhat unpleasant inunction. A full course consists of two treatments All the cases on each of three successive days. cleared up on one course without incident. One further case occurred some months later and responded to the same treatment. This method does not seem to be so widely known as it deserves. It is entirely free from discomfort or it can be carried out anywhere and requires risk; no special skill; its cost is low ; and finally it is particularly convenient in cases where bath facilities are conspicuous by their absence. Huber, A.
OPHTHALMOLOGICAL CONGRESSES IN
on
BY W. S.
Fitch, W.
MEDICAL
place
HYPO-HC1 " TREATMENT OF SCABIES
REFERENCES
Bland-Sutton, J. (1891) Brit. med. J. 1, 343. Carwardine, T. (1897) Ibid, 2, 1637. Morley, J. (1921-22) Brit. J. Surg. 9, 103.
took
"
on
out
that the association otherwise than accidental of two inherited conditions gaye identifiable syndromes and opened the theoretical possibility of constructing
K. (1938)
Lancet, 1, 347. (1938) see Ibid, p. 285.
SOCIETIES human chromosome maps. He discussed in detail the association of colour-blindness and haemophilia and described a pedigree containing colour-blindness, blue sclerotics, deafness and fragilitas ossium. In a paper by Dr. M. KLEIN (Budapest), read in his absence by Mr. F. RIDLEY (London), a survey of different methods of wound closure after cataract extraction was given on the basis of 600 cases. Conjunctival flaps, Kuhnt’s conjunctival apron and the Liegard corneal suture were employed. Mr. F. A. JULER (London), in a paper on hypotony after solero-corneal trephining, suggested a readjustment of the conjunctiva for the hole or a fresh flap rotated from the temporal side as suitable measures for this unpleasant complication which showed itself by choroidal detachment, pupillary exudate and lens I
opacity. Prof. H. LAUBER
(Warsaw), discussing pall01" of
the
disk, observed that three different factors may be involved : anaemia, lipaemia and ischsemia, the latter
being the most important and the most often met. The disappearance of nerve-fibres and their substitution by glial tissue, as also the disappearance of capillaries, were not insignificant. In tabes pallor was largely due to ischaemia and the normal pink colour of the disk might be restored when the disproportion between the normal intra-ocular tension and the diminished arterial pressure in the vessels is
988 overcome. It was, therefore, important to recognise that pallor of the disk is not synonymous with atrophy of nerve-fibres. Prof. Lauber also contributed a paper on combined operations for glaucoma, saying that in refractory cases cyclodialysis combined with iridectomy had definite advantages, the cyclodialysis being done from the iridectomy incision or independently. Posterior sclerotomy was also a useful procedure in some cases
prior
to
iridectomy.
Dr. HARALD GJESSING (Oslo) in iridencleisis antiglaucomatosa gave
Holth’s of the results of 198 operations followed up from 6 to 280 months. In 72 per cent. the intra-ocular tension was normalised without pilocarpine and in a further 18 per cent. with pilocarpine. Central vision had not declined in 80 per cent. of the cases and the field had not been reduced in 86 per cent. He held that if after 36 months no deterioration had occurred a permanent cure could be assumed. Technically it was essential to combine the operation with meridional iridotomy. In a paper on bipolar electrolysis in the treatment of detachment of the retina, Dr. W. J. W. FERGUSON (Sheffield) described the method elaborated by von Szily. Ease of access, absence of adhesions, accurate estimation of dosage, relative absence of postoperative reaction and pain and mildness of scarring were some of the features which recommended this procedure. The treatment of increased ocular tension with diathermy in glaucoma was the subject of a paper by Mr. J. P. F. Lloyd (Cheltenham), who pointed out that this treatment was not new, but was none the less most effective. In cases of acute and subacute glaucoma it was often successful as the sole measure and at least made it possible to defer operation till a more quiescent stage had been reached. Dr. T. J. PHILLIPS (London) stressed the value of short-wave diathermy in ophthalmology and indicated a series of conditions in which it could be used. Mr. J. MINTON (London), in a paper on the one-eyed worked in industry, pointed out that those who had had amblyopic eyes from childhood were sometimes but little handicapped and those who lost an eye in adult life often adjusted themselves and obtained The standards reasonable perception of depth. factories required too high a adopted by many binocular visual acuity and standards on the vocational need of good vision were desirable. Mr. G. T. W. CASHELL (Reading) and Dr. S. K. KON, in a paper describing studies in lactose and galactose cataracts in rats, drew attention to the work of Mitchell, who had obtained nutritional cataract in the rat by high concentrations of lactose and galactose in the diet. In extending these experiments they found that when the lactose and galactose were administered in different vehicles the results were rather different. Diets containing less protein were more toxic. Fresh liquid skim milk was more toxic than the dried product, and a greater liquid intake with a dried milk powder was also more toxic. Regression of the cataract occurred with the discontinuation of the toxic agent and high proportions of protein tended to act
as a
a
paper
an
on
analysis
protective. (London) discussed some aspects of of the optic nerve and retina. He papillo-macular bundle is relatively
Mr. E. WOLFF the blood-supply showed that the
poorly supplied with blood.
The arteria centralis
itself until its bifurcation had probably nothing to do with the nutrition of the nerve. Mr. LINDSAY REA (London), speaking on the further uses of the curved retrobulbar needle, described the technique of injecting analgesic agents into
capsule, and thus obtaining a direct effect ciliary nerves. The anaesthesia was complete and therefore general anaesthesia could be avoided Tenon’s
on
often than when other methods were used. Mr. J. ADAMSON and Mr. E. F. FINCHAM (London),
more
in describing the effect of lenses and convergence upon the state of accommodation of the eye, showed that by the use of transparent plane mirror and the " coinci. dence optometer " it could be determined that accommodatipn remained unaltered within certain limits, with the maintenance of the best vision, whilst the vergence of the light entering the eye was modified by positive and negative lenses. Changes in converg. ence also influenced the state of accommodation; the accommodation in binocular vision differed from the monocular state by amounts dependent on the presence and magnitude of horizontal muscle imbalance. Mr. W. 0. GIBSON TAYLOR (Glasgow), speaking on the effect of enucleation of one eye on the growth of the face, gave an analysis of 50 cases investigated at intervals of from two to ten years following removal of an eye in childhood. External measurements, confirmed by X-ray examination, showed that enucleation before the age of 7 years resulted in an aberration of development in both size and shape of the orbit. This abnormal development affected in some part the surrounding air sinuses. Mr. L. P. JAMESON EvANS (Birmingham), in a paper on tobacco amblyopia, reviewed the clinical aspects and pathology of the affection and discussed the significance of the water content of the different types of tobacco in relation to their toxicity, and the rôle of the liver in the elimination of the toxic agent. Stressing the importance of vasoconstriction in this affection he brought forward evidence of the value of the use of antispasmodics. The Bowman lecture was delivered by Prof. H. WEVE (Utrecht) on DIATHERMY IN OPHTHALMIC PRACTICE
After indicating the historical and physical basis of the use of diathermy he stressed its value in facilitating accurate dosage and strict localisation of effects. It had the further advantages of leaving soft and flexible scars, stopping haemorrhage, having an antiseptic action, and, above all, enabling an approach to the interior of the eye to be made without opening the globe. He illustrated clinical applications of in ophthalmology by case reports with diathermy the effect of diathermy in a wide showing drawings range of affections including epibulbar sarcomata and
carcinomata, contracted sockets, conjunctivitis, glaucoma and intra-ocular tumours, including hseman-
giomata. Another field where it found application was the letting-out of fluid in cases of vitreous opacities in chronic inflammation and intra-ocular haemorrhages; in intra-ocular tuberculosis too it had found its uses. The greatest success was, however, the treatment of detachment of the retina ; in 1938 he obtained 81 per cent. of successful results in 141 cases. The technique employed at Utrecht was illustrated by a colour film. The main discussion of the congress was devoted to the PROBLEMS OF REFRACTION
Mr. C. B. GOULDEN (London) opened with a restatement of general principles, emphasising that the taking of visual acuity involves the determination of the light sense, the form sense for grating, contour and letters, and the colour sense. In the discussion on the criteria necessary- for distant types and near types he recalled the principles underlying Snellen’s
989 test types, which were a direct development of Hooke’s observations in 1645 of the minimum angle of visual acuity. In speaking of retinoscopy he pointed out the advantages of the diaphragm lamp of Gullstrand on the slit-lamp plan and of a plane transparent mirror. Other aspects discussed were the use of test lenses, trial frames, the measurement of the near point and of muscle balance.
LEVY (London) followed with an of methods of estimation-refinements exposition additional to the minimum laid down by Mr. Goulden. He spoke of the principles underlying the use of the keratometer for the measurement of the refractive power of the anterior surface of the cornea, of retractionometers’ for the estimation of the total refraction of the eye, of the duochrome test and astigmatic fans. The clinical aspects were discussed by Mr. R. ÅFFLECK GREEVES (London), who indicated various pitfalls, stressing in particular the difficulties in the correction of presbyopia. The general discussion was opened by the PRESIDENT who laid stress on the problem of spasm of accommodation. Mr. W. H. MCMULLEN (London) emphasised the importance of precise fitting of lenses. Dr. R. ONFRAY (Paris), speaking for Prof. Terrien and himself, strongly commended the use of the diploscope as a routine procedure, whilst Dr. VICTOR PURVIS (London) and Mr. J. P. F. LLOYD (Cheltenham) spoke of the value of crossed cylinders. Wing-Commander P. C. LIVINGSTON (London) drew attention to the importance of leaving alone high errors of muscle balance when the patients did not experience any discomfort and discussed the difficulties and advantages of correcting troublesome lower errors. He showed a test type adapted for determining visual acuity in children. Dr. BASIL GRAVES (London) deprecated excessive activity in correcting errors of refraction, particularly of the low variety. Mr. THOMSON HENDERSON (Nottingham), in supporting this view, emphasised the constitutional factor in discomfort which is generally ascribed to refractive errors. During the congress Dr. A. J. BEDELL (Albany, N.Y.) demonstrated colour photographs of fundus lesions, dealing in particular with the fundus in diabetes, and Mr. H. B. STALLARD (London) showed a cinematograph film of ophthalmic operations. Mr. A.
H.
International Association for Prevention of Blindness This association met on April 19, the session being devoted to a discussion on OPHTHALMIA NEONATORUM
With the president, Dr. P. BAILLIART (Paris), in the chair, Dr. A. H. H. SINCLAIR (Edinburgh) spoke of The incidence per the disease in Great Britain. thousand live births in Scotland ranged between 15-5 per cent. and 19.2 per cent. in the years 1933 to 1937, while in England and Wales the incidence was between 7-0 per cent. and 8-3 per cent. He described the administrative measures for its prevention in different parts of Scotland and held that 1 per cent. silver nitrate was still the most effective prophylactic, though much might be hoped in the future from sulphanilamide and its derivatives. Prof. A. VON SZILY (Munster) discussed the position in Germany, emphasising the great changes that had taken place since Credé first introduced his prophylactic method. The Crede method was, however, not an absolute guarantee of safety, which could only be obtained by eliminating the source of infection. The treatment of maternal gonorrhoea was, therefore, the first line of defence, the second line being insistence that
midwives carried out the Crede method scrupulously. Compulsory notification of gonococcal ophthalmia was essential to ensure early treatment. Dr. R. P. WILSON (Cairo) discussed the puzzling rarity of ophthalmia neonatorum in Egypt, where gonorrhoea was not uncommon. Dr. C. BERENS (New York) on the of the affection in the United decline reported States since the introduction of the Crede method and gave an account of the present administrative procedures. He stressed the need for a prophylactic agent other than silver nitrate. Prof. F. TERRIEN (Paris) spoke of cleanliness as the first line of defence and reported that in France few obstetricians used 2 per cent. silver nitrate, the concentration commonly used being 1 per cent. or 0’75 per cent. The omission of any prophylactic method he regarded as a breach of duty as serious as abstention from aseptic measure before operation. Mr. J. D. M. CARDELL (London) emphasised the importance of a freshly made solution of silver nitrate, as evaporation and decomposition by light were dangerous factors. Silver acetate (1per cent.) had the advantage that it could not become more concentrated owing to the insolubility of the salt ; should it decompose the acetic acid set free was less irritating than nitric acid. Prof. L. MAGGIORE (Genoa), in relating Italian experiences, reported the use of Protargol and Argyrol as a substitute for silver nitrate; it was important to have standard solutions. Where prophylactic remedies are given out to midwives the agent should be prepared and distributed under state control. Prof. A. VASQUEZ-BARRiBRE (Montevideo). in giving the experiences of Argentine, reported that in South American republics ophthalmia neonatorum constitutes between 25 per cent. and 48 per cent. of all causes of blindness. Active administrative measures were now being legally enforced to overcome this
great toll
on
sight.
A film on industrial eye accidents by Mr. J. MINTON (London).
was
demonstrated
Organisation against Trachoma This congress met in the evening of April 21. In his presidential address, Mr. A. F. MACCALLAN (London) dealt, among other matters, with the current views on the virus origin of trachoma. He International
doubted the role of the louse as a carrier and was sceptical of the value of sulphanilamide in the treatment of the affection. He emphasised the persistence of foci of infection in the tarsus in apparently healed A symposium on the incidence and clinical cases. type of trachoma met with in Europe and North and South America-that is, in countries which are commonly considered to be non-trachomatous-was opened by Dr. F. J. LAVERY (Dublin), who reported that in Ireland though the disease was not widespread it was endemic and still constituted a major problem. In six orphanages that he had visited 66 out of 319 children were affected, 41 coming from one institution. In 913 school-children he had found 5 affected. He estimated trachoma as being responsible for about 12 per cent. of the total blindness in Ireland. Dr. HARRY GRADLE (Chicago) estimated the number of affected persons in the United States at 33,000. Trachoma was mainly seen in the indigenous Indian
population, amongst illegal emigrants coming from Asia and Mexico, and previously also in RussianPolish immigrants. It was endemic along the river banks, but sporadic cases were seen throughout the country. Prof. W. ROHRSCHNEIDER (Konigsberg) reported that in Germany trachoma was chiefly confined to the eastern frontier, but sporadic cases,
990
mainly
in
the non-native
population,
were
seen
elsewhere. In his experience there was no evidence for the view that the louse was the carrier of the virus ; trachoma and the louse were the common factors of a low standard of hygiene. Mr. ARNOLD SORSBY (London), reporting on the direct information available from Glasgow and the indirect information from London, as also on the evidence from blind certifica-
tion, showed that trachoma was a progressively diminishing problem in Great Britain. Contrasting the administrative measures taken in Glasgow and in London, he recalled successess obtained by other measures elsewhere and emphasised the ease with which trachoma is overcome by systematic effort of almost any kind. He could not support the current view that trachoma in this country always runs a mild course. A discussion on the treatment of trachoma by sulphanilamide and its congeners, opened by Dr. HARRY GRADLE, who spoke highly of this mode of treatment, concluded the meeting,
MEDICAL SOCIETY OF INDIVIDUAL PSYCHOLOGY AT a meeting of this society held in London on April 13, with Dr. H. C. SQUIRES in the chair, a
paper
on
Into Activities In animals, he said, was read by Dr. A. SANDISON. activity is primarily concerned with the necessities of self and race preservation, supplemented by the exercise necessary for health, and beyond these needs the animal does not indulge in excess of activity. In man the natural causes of activity are fundamentally the same but extend into wider spheres of self-fulfilment and mental creation. In so far as man’s activity can be related to such objects it is normal; otherwise it needs further explanation. It is, however, difficult to define a normal range for man’s activities since individuals vary widely in their capacity and circumstances. A quantitative standard is perhaps a better guide than a qualitative one. When activity becomes activities, when " Doing is activity ; he will still be doing," common sense begins to criticise and inquire. The proper spacing of rest periods is a function of life and when activities are pursued in a way that hinders adequate rest and repose we can suspect abnormal circumstances. The causes of activity are stimuli ; successful living
Escape
UU11618LIB 111
60ELifig
UUL
however, that activity is itself
a biological method of and combat both involve strenuous exertion, and the sudden transition from paralysing fear to violent anger is an attempt to escape by an increase in activity. May it not be that this association in animals between escape and increased activities has extended itself in man to the mental spheres7 When the stresses from which escape is sought increase in number or intensity we may react by multiplication of activity into activities. The process may be conscious and deliberate, but the seeking refuge in an accumulation of miscellaneous activities is probably more often subconscious, and
escape.
Flight
not readily or willingly understood. In judging the therapeutic valudof such activities
Dr. Sandison
suggested restlessness as a criterion, as ill-directed uncoordinated activity; it defining a confusion resulting from inability to deal effi. ciently with stimuli. When, by increasing activities, the excess of stimuli is absorbed and correlated, the restlessness may diminish or disappear and the escape into activities has been a therapeutic success. But when, despite increase of activities, restlessness increases and becomes restiveness, the cure is not working and the therapy needed may be a giving of insight into the escape motive. Dr. Sandison concluded, therefore, that escape by activity is a normal physical and psychological phenomenon and that its quantitative increase into activities may be a reasonable form of self-therapy. Its therapeutic value and normality can be judged by the extent to which it controls the restlessness it seeks to remedy.
NEW INVENTIONS DIRECTOR FOR THE INSERTION OF SMITH-PETERSEN NAILS IN inserting Smith-Petersen’s nails I have sometimes found that the guide-wire is bent by the cortex of the femur. In the original description of his guide-wire Watson Jones advocated the use of a Morse drill for perforating the cortex, but his advice
(jilt) 6ulLUU11 auu
dealing with them according to their importance. When this selection of stimuli becomes uncoordinated we lose balance, and our engine is apt to race or stall. Excess of activities may often be a reasonable response to temporary emergencies, and in war, for example, there may be no limit but capacity as the correct The semi-educated, fussy, person lacks response. proper training in response to stimuli, but his futile activities do not necessarily need deep psychological explanation. It is when the ordinarily well-controlled person breaks out into a profusion of activities that another explanation is required. The condition may be pathological or physiological, but is not infrequently psychological. Can it ever be a manifestation of a desire to escape from real or imagined fears or discomfort ? The escape motive, although a good working hypothesis, has become rather too fashionable and needs critical study. It is noteworthy,
has not been followed because it is not possible to drill with Hey Groves’s director. The modification illustrated here, which can be carried out
use a
inexpensively on any existing instrument, overcomes this difficulty. When the guide is in position the inner sleeve is removed and a 3/16 in. hole is drilled in the cortex. The inner sleeve is then replaced and the guide-wire is in no danger of deflexion. The modified director has been made for me by Messrs. Down Bros. of St. Thomas’s Street, S.E.I. CHARLES E. KINDERSLEY, F.R.C.S. Surgeon, Royal United Hospital, Bath.
by a right paramedian incision and was found to be nearly filled by a dark plum-coloured loop of bowel. This proved to be tightly twisted on itself several times. After undoing the volvulus the affected bowel was recognised as a Meckel’s diverticulum with a blind The small intestine proximal and free distal end. to the point of origin of the diverticulum was much distended while beyond this it was represented by only a thin fibrous cord. The diverticulum was
excised and the divided end of the small intestine implanted into the abdominal wall as an
was
enterostomy. The child stood the immediate effects of the operation well but died about 24 hours later. On post-mortem examination the body was that of a normally formed infant except for the terminal portion of the ileum, which was represented by a thin fibrous cord joining the site of origin of the large Meckel’s diverticulum to the caecum (see figure). The appendix and large intestine were normally formed but small and contracted.
The results of the treatment of intestinal atresias have hitherto been extremely discouraging. According to Morley’s (1921) survey ofthe literature there were no recorded cases of an infant surviving operation for this condition for more than a few days. Nevertheless, two considerations seem to justify an exploratory laparotomy in all cases of intestinal obstruction in the newborn where the general condition of the infant permits it. First, the inevitably fatal outcome of intestinal atresia in the absence of
surgical intervention, and secondly, the impossibility of making an exact preoperative diagnosis of the precise cause of the obstruction, with the consequent possibility of finding a condition more easily amenable to surgical treatment. I
am
indebted to Dr.
J. N. Deacon, medical
superintendent of Redhill County Hospital, for permission to publish this case, and to Dr. Hamilton Patterson for his careful post-mortem examination. REFERENCES
LONDON OPHTHALMOLOGISTS assembled in London for 3 congresses last week, all held at the house of the Royal Society of Medicine at 1, Wimpole Street, W.l. The annual congress of the Ophthalmological Society of the United Kingdom The president, (Birmingham), gave an address on the anterior capsule. He showed that clearly defined zones can be recognised and that the zonular lamella, which is probably of different origin from that of the hyaline capsule, has characteristic lesions of its own. The epithelial cells were probably the oldest part of the lens and have a purely nutritional function. The address was profusely illustrated with drawings from clinical cases.
April 20,
21 and 22.
Mr. T. HARRISON BUTLER
SOME COMMUNICATIONS
Dr. W. J. B. RIDDELL (Glasgow), speaking
multiple factors
in
hereditary
eye
diseases, pointed
SURGEON
PARKER, M.B. Manc.
LIEUTENANT, ROYAL NAVY
THE usual treatment of scabies by means of sulphur ointment and baths has other disadvantages besides that of inconvenience, especially when a number of In March cases have to be treated simultaneously. of last year 8 cases of scabies were detected in a naval mess where spread of infection was inevitable under the conditions of close contact found in a small warship.’ The patients were isolated and their kit" fumigated and it was decided to try the " Hypo-HCl method of treatment. According to Fitch (1938) this method was employed in at least one British field ambulance during the late war, but it was later rediscovered in Germany and is being used satisfactorily by Huber (1938) in Budapest. It consists of painting the whole of the patient’s skin with a 25 per cent. aqueous solution of sodium "
thiosulphate (the photographer’s hypo "), allowing this to dry and then painting with 5 per cent. hydrochloric acid. This is repeated, so that a single treatment consists of two alternate applications of hypo and acid. The result is a very fine deposit of sulphur on the skin without a tedious and somewhat unpleasant inunction. A full course consists of two treatments All the cases on each of three successive days. cleared up on one course without incident. One further case occurred some months later and responded to the same treatment. This method does not seem to be so widely known as it deserves. It is entirely free from discomfort or it can be carried out anywhere and requires risk; no special skill; its cost is low ; and finally it is particularly convenient in cases where bath facilities are conspicuous by their absence. Huber, A.
OPHTHALMOLOGICAL CONGRESSES IN
on
BY W. S.
Fitch, W.
MEDICAL
place
HYPO-HC1 " TREATMENT OF SCABIES
REFERENCES
Bland-Sutton, J. (1891) Brit. med. J. 1, 343. Carwardine, T. (1897) Ibid, 2, 1637. Morley, J. (1921-22) Brit. J. Surg. 9, 103.
took
"
on
out
that the association otherwise than accidental of two inherited conditions gaye identifiable syndromes and opened the theoretical possibility of constructing
K. (1938)
Lancet, 1, 347. (1938) see Ibid, p. 285.
SOCIETIES human chromosome maps. He discussed in detail the association of colour-blindness and haemophilia and described a pedigree containing colour-blindness, blue sclerotics, deafness and fragilitas ossium. In a paper by Dr. M. KLEIN (Budapest), read in his absence by Mr. F. RIDLEY (London), a survey of different methods of wound closure after cataract extraction was given on the basis of 600 cases. Conjunctival flaps, Kuhnt’s conjunctival apron and the Liegard corneal suture were employed. Mr. F. A. JULER (London), in a paper on hypotony after solero-corneal trephining, suggested a readjustment of the conjunctiva for the hole or a fresh flap rotated from the temporal side as suitable measures for this unpleasant complication which showed itself by choroidal detachment, pupillary exudate and lens I
opacity. Prof. H. LAUBER
(Warsaw), discussing pall01" of
the
disk, observed that three different factors may be involved : anaemia, lipaemia and ischsemia, the latter
being the most important and the most often met. The disappearance of nerve-fibres and their substitution by glial tissue, as also the disappearance of capillaries, were not insignificant. In tabes pallor was largely due to ischaemia and the normal pink colour of the disk might be restored when the disproportion between the normal intra-ocular tension and the diminished arterial pressure in the vessels is
988 overcome. It was, therefore, important to recognise that pallor of the disk is not synonymous with atrophy of nerve-fibres. Prof. Lauber also contributed a paper on combined operations for glaucoma, saying that in refractory cases cyclodialysis combined with iridectomy had definite advantages, the cyclodialysis being done from the iridectomy incision or independently. Posterior sclerotomy was also a useful procedure in some cases
prior
to
iridectomy.
Dr. HARALD GJESSING (Oslo) in iridencleisis antiglaucomatosa gave
Holth’s of the results of 198 operations followed up from 6 to 280 months. In 72 per cent. the intra-ocular tension was normalised without pilocarpine and in a further 18 per cent. with pilocarpine. Central vision had not declined in 80 per cent. of the cases and the field had not been reduced in 86 per cent. He held that if after 36 months no deterioration had occurred a permanent cure could be assumed. Technically it was essential to combine the operation with meridional iridotomy. In a paper on bipolar electrolysis in the treatment of detachment of the retina, Dr. W. J. W. FERGUSON (Sheffield) described the method elaborated by von Szily. Ease of access, absence of adhesions, accurate estimation of dosage, relative absence of postoperative reaction and pain and mildness of scarring were some of the features which recommended this procedure. The treatment of increased ocular tension with diathermy in glaucoma was the subject of a paper by Mr. J. P. F. Lloyd (Cheltenham), who pointed out that this treatment was not new, but was none the less most effective. In cases of acute and subacute glaucoma it was often successful as the sole measure and at least made it possible to defer operation till a more quiescent stage had been reached. Dr. T. J. PHILLIPS (London) stressed the value of short-wave diathermy in ophthalmology and indicated a series of conditions in which it could be used. Mr. J. MINTON (London), in a paper on the one-eyed worked in industry, pointed out that those who had had amblyopic eyes from childhood were sometimes but little handicapped and those who lost an eye in adult life often adjusted themselves and obtained The standards reasonable perception of depth. factories required too high a adopted by many binocular visual acuity and standards on the vocational need of good vision were desirable. Mr. G. T. W. CASHELL (Reading) and Dr. S. K. KON, in a paper describing studies in lactose and galactose cataracts in rats, drew attention to the work of Mitchell, who had obtained nutritional cataract in the rat by high concentrations of lactose and galactose in the diet. In extending these experiments they found that when the lactose and galactose were administered in different vehicles the results were rather different. Diets containing less protein were more toxic. Fresh liquid skim milk was more toxic than the dried product, and a greater liquid intake with a dried milk powder was also more toxic. Regression of the cataract occurred with the discontinuation of the toxic agent and high proportions of protein tended to act
as a
a
paper
an
on
analysis
protective. (London) discussed some aspects of of the optic nerve and retina. He papillo-macular bundle is relatively
Mr. E. WOLFF the blood-supply showed that the
poorly supplied with blood.
The arteria centralis
itself until its bifurcation had probably nothing to do with the nutrition of the nerve. Mr. LINDSAY REA (London), speaking on the further uses of the curved retrobulbar needle, described the technique of injecting analgesic agents into
capsule, and thus obtaining a direct effect ciliary nerves. The anaesthesia was complete and therefore general anaesthesia could be avoided Tenon’s
on
often than when other methods were used. Mr. J. ADAMSON and Mr. E. F. FINCHAM (London),
more
in describing the effect of lenses and convergence upon the state of accommodation of the eye, showed that by the use of transparent plane mirror and the " coinci. dence optometer " it could be determined that accommodatipn remained unaltered within certain limits, with the maintenance of the best vision, whilst the vergence of the light entering the eye was modified by positive and negative lenses. Changes in converg. ence also influenced the state of accommodation; the accommodation in binocular vision differed from the monocular state by amounts dependent on the presence and magnitude of horizontal muscle imbalance. Mr. W. 0. GIBSON TAYLOR (Glasgow), speaking on the effect of enucleation of one eye on the growth of the face, gave an analysis of 50 cases investigated at intervals of from two to ten years following removal of an eye in childhood. External measurements, confirmed by X-ray examination, showed that enucleation before the age of 7 years resulted in an aberration of development in both size and shape of the orbit. This abnormal development affected in some part the surrounding air sinuses. Mr. L. P. JAMESON EvANS (Birmingham), in a paper on tobacco amblyopia, reviewed the clinical aspects and pathology of the affection and discussed the significance of the water content of the different types of tobacco in relation to their toxicity, and the rôle of the liver in the elimination of the toxic agent. Stressing the importance of vasoconstriction in this affection he brought forward evidence of the value of the use of antispasmodics. The Bowman lecture was delivered by Prof. H. WEVE (Utrecht) on DIATHERMY IN OPHTHALMIC PRACTICE
After indicating the historical and physical basis of the use of diathermy he stressed its value in facilitating accurate dosage and strict localisation of effects. It had the further advantages of leaving soft and flexible scars, stopping haemorrhage, having an antiseptic action, and, above all, enabling an approach to the interior of the eye to be made without opening the globe. He illustrated clinical applications of in ophthalmology by case reports with diathermy the effect of diathermy in a wide showing drawings range of affections including epibulbar sarcomata and
carcinomata, contracted sockets, conjunctivitis, glaucoma and intra-ocular tumours, including hseman-
giomata. Another field where it found application was the letting-out of fluid in cases of vitreous opacities in chronic inflammation and intra-ocular haemorrhages; in intra-ocular tuberculosis too it had found its uses. The greatest success was, however, the treatment of detachment of the retina ; in 1938 he obtained 81 per cent. of successful results in 141 cases. The technique employed at Utrecht was illustrated by a colour film. The main discussion of the congress was devoted to the PROBLEMS OF REFRACTION
Mr. C. B. GOULDEN (London) opened with a restatement of general principles, emphasising that the taking of visual acuity involves the determination of the light sense, the form sense for grating, contour and letters, and the colour sense. In the discussion on the criteria necessary- for distant types and near types he recalled the principles underlying Snellen’s
989 test types, which were a direct development of Hooke’s observations in 1645 of the minimum angle of visual acuity. In speaking of retinoscopy he pointed out the advantages of the diaphragm lamp of Gullstrand on the slit-lamp plan and of a plane transparent mirror. Other aspects discussed were the use of test lenses, trial frames, the measurement of the near point and of muscle balance.
LEVY (London) followed with an of methods of estimation-refinements exposition additional to the minimum laid down by Mr. Goulden. He spoke of the principles underlying the use of the keratometer for the measurement of the refractive power of the anterior surface of the cornea, of retractionometers’ for the estimation of the total refraction of the eye, of the duochrome test and astigmatic fans. The clinical aspects were discussed by Mr. R. ÅFFLECK GREEVES (London), who indicated various pitfalls, stressing in particular the difficulties in the correction of presbyopia. The general discussion was opened by the PRESIDENT who laid stress on the problem of spasm of accommodation. Mr. W. H. MCMULLEN (London) emphasised the importance of precise fitting of lenses. Dr. R. ONFRAY (Paris), speaking for Prof. Terrien and himself, strongly commended the use of the diploscope as a routine procedure, whilst Dr. VICTOR PURVIS (London) and Mr. J. P. F. LLOYD (Cheltenham) spoke of the value of crossed cylinders. Wing-Commander P. C. LIVINGSTON (London) drew attention to the importance of leaving alone high errors of muscle balance when the patients did not experience any discomfort and discussed the difficulties and advantages of correcting troublesome lower errors. He showed a test type adapted for determining visual acuity in children. Dr. BASIL GRAVES (London) deprecated excessive activity in correcting errors of refraction, particularly of the low variety. Mr. THOMSON HENDERSON (Nottingham), in supporting this view, emphasised the constitutional factor in discomfort which is generally ascribed to refractive errors. During the congress Dr. A. J. BEDELL (Albany, N.Y.) demonstrated colour photographs of fundus lesions, dealing in particular with the fundus in diabetes, and Mr. H. B. STALLARD (London) showed a cinematograph film of ophthalmic operations. Mr. A.
H.
International Association for Prevention of Blindness This association met on April 19, the session being devoted to a discussion on OPHTHALMIA NEONATORUM
With the president, Dr. P. BAILLIART (Paris), in the chair, Dr. A. H. H. SINCLAIR (Edinburgh) spoke of The incidence per the disease in Great Britain. thousand live births in Scotland ranged between 15-5 per cent. and 19.2 per cent. in the years 1933 to 1937, while in England and Wales the incidence was between 7-0 per cent. and 8-3 per cent. He described the administrative measures for its prevention in different parts of Scotland and held that 1 per cent. silver nitrate was still the most effective prophylactic, though much might be hoped in the future from sulphanilamide and its derivatives. Prof. A. VON SZILY (Munster) discussed the position in Germany, emphasising the great changes that had taken place since Credé first introduced his prophylactic method. The Crede method was, however, not an absolute guarantee of safety, which could only be obtained by eliminating the source of infection. The treatment of maternal gonorrhoea was, therefore, the first line of defence, the second line being insistence that
midwives carried out the Crede method scrupulously. Compulsory notification of gonococcal ophthalmia was essential to ensure early treatment. Dr. R. P. WILSON (Cairo) discussed the puzzling rarity of ophthalmia neonatorum in Egypt, where gonorrhoea was not uncommon. Dr. C. BERENS (New York) on the of the affection in the United decline reported States since the introduction of the Crede method and gave an account of the present administrative procedures. He stressed the need for a prophylactic agent other than silver nitrate. Prof. F. TERRIEN (Paris) spoke of cleanliness as the first line of defence and reported that in France few obstetricians used 2 per cent. silver nitrate, the concentration commonly used being 1 per cent. or 0’75 per cent. The omission of any prophylactic method he regarded as a breach of duty as serious as abstention from aseptic measure before operation. Mr. J. D. M. CARDELL (London) emphasised the importance of a freshly made solution of silver nitrate, as evaporation and decomposition by light were dangerous factors. Silver acetate (1per cent.) had the advantage that it could not become more concentrated owing to the insolubility of the salt ; should it decompose the acetic acid set free was less irritating than nitric acid. Prof. L. MAGGIORE (Genoa), in relating Italian experiences, reported the use of Protargol and Argyrol as a substitute for silver nitrate; it was important to have standard solutions. Where prophylactic remedies are given out to midwives the agent should be prepared and distributed under state control. Prof. A. VASQUEZ-BARRiBRE (Montevideo). in giving the experiences of Argentine, reported that in South American republics ophthalmia neonatorum constitutes between 25 per cent. and 48 per cent. of all causes of blindness. Active administrative measures were now being legally enforced to overcome this
great toll
on
sight.
A film on industrial eye accidents by Mr. J. MINTON (London).
was
demonstrated
Organisation against Trachoma This congress met in the evening of April 21. In his presidential address, Mr. A. F. MACCALLAN (London) dealt, among other matters, with the current views on the virus origin of trachoma. He International
doubted the role of the louse as a carrier and was sceptical of the value of sulphanilamide in the treatment of the affection. He emphasised the persistence of foci of infection in the tarsus in apparently healed A symposium on the incidence and clinical cases. type of trachoma met with in Europe and North and South America-that is, in countries which are commonly considered to be non-trachomatous-was opened by Dr. F. J. LAVERY (Dublin), who reported that in Ireland though the disease was not widespread it was endemic and still constituted a major problem. In six orphanages that he had visited 66 out of 319 children were affected, 41 coming from one institution. In 913 school-children he had found 5 affected. He estimated trachoma as being responsible for about 12 per cent. of the total blindness in Ireland. Dr. HARRY GRADLE (Chicago) estimated the number of affected persons in the United States at 33,000. Trachoma was mainly seen in the indigenous Indian
population, amongst illegal emigrants coming from Asia and Mexico, and previously also in RussianPolish immigrants. It was endemic along the river banks, but sporadic cases were seen throughout the country. Prof. W. ROHRSCHNEIDER (Konigsberg) reported that in Germany trachoma was chiefly confined to the eastern frontier, but sporadic cases,
990
mainly
in
the non-native
population,
were
seen
elsewhere. In his experience there was no evidence for the view that the louse was the carrier of the virus ; trachoma and the louse were the common factors of a low standard of hygiene. Mr. ARNOLD SORSBY (London), reporting on the direct information available from Glasgow and the indirect information from London, as also on the evidence from blind certifica-
tion, showed that trachoma was a progressively diminishing problem in Great Britain. Contrasting the administrative measures taken in Glasgow and in London, he recalled successess obtained by other measures elsewhere and emphasised the ease with which trachoma is overcome by systematic effort of almost any kind. He could not support the current view that trachoma in this country always runs a mild course. A discussion on the treatment of trachoma by sulphanilamide and its congeners, opened by Dr. HARRY GRADLE, who spoke highly of this mode of treatment, concluded the meeting,
MEDICAL SOCIETY OF INDIVIDUAL PSYCHOLOGY AT a meeting of this society held in London on April 13, with Dr. H. C. SQUIRES in the chair, a
paper
on
Into Activities In animals, he said, was read by Dr. A. SANDISON. activity is primarily concerned with the necessities of self and race preservation, supplemented by the exercise necessary for health, and beyond these needs the animal does not indulge in excess of activity. In man the natural causes of activity are fundamentally the same but extend into wider spheres of self-fulfilment and mental creation. In so far as man’s activity can be related to such objects it is normal; otherwise it needs further explanation. It is, however, difficult to define a normal range for man’s activities since individuals vary widely in their capacity and circumstances. A quantitative standard is perhaps a better guide than a qualitative one. When activity becomes activities, when " Doing is activity ; he will still be doing," common sense begins to criticise and inquire. The proper spacing of rest periods is a function of life and when activities are pursued in a way that hinders adequate rest and repose we can suspect abnormal circumstances. The causes of activity are stimuli ; successful living
Escape
UU11618LIB 111
60ELifig
UUL
however, that activity is itself
a biological method of and combat both involve strenuous exertion, and the sudden transition from paralysing fear to violent anger is an attempt to escape by an increase in activity. May it not be that this association in animals between escape and increased activities has extended itself in man to the mental spheres7 When the stresses from which escape is sought increase in number or intensity we may react by multiplication of activity into activities. The process may be conscious and deliberate, but the seeking refuge in an accumulation of miscellaneous activities is probably more often subconscious, and
escape.
Flight
not readily or willingly understood. In judging the therapeutic valudof such activities
Dr. Sandison
suggested restlessness as a criterion, as ill-directed uncoordinated activity; it defining a confusion resulting from inability to deal effi. ciently with stimuli. When, by increasing activities, the excess of stimuli is absorbed and correlated, the restlessness may diminish or disappear and the escape into activities has been a therapeutic success. But when, despite increase of activities, restlessness increases and becomes restiveness, the cure is not working and the therapy needed may be a giving of insight into the escape motive. Dr. Sandison concluded, therefore, that escape by activity is a normal physical and psychological phenomenon and that its quantitative increase into activities may be a reasonable form of self-therapy. Its therapeutic value and normality can be judged by the extent to which it controls the restlessness it seeks to remedy.
NEW INVENTIONS DIRECTOR FOR THE INSERTION OF SMITH-PETERSEN NAILS IN inserting Smith-Petersen’s nails I have sometimes found that the guide-wire is bent by the cortex of the femur. In the original description of his guide-wire Watson Jones advocated the use of a Morse drill for perforating the cortex, but his advice
(jilt) 6ulLUU11 auu
dealing with them according to their importance. When this selection of stimuli becomes uncoordinated we lose balance, and our engine is apt to race or stall. Excess of activities may often be a reasonable response to temporary emergencies, and in war, for example, there may be no limit but capacity as the correct The semi-educated, fussy, person lacks response. proper training in response to stimuli, but his futile activities do not necessarily need deep psychological explanation. It is when the ordinarily well-controlled person breaks out into a profusion of activities that another explanation is required. The condition may be pathological or physiological, but is not infrequently psychological. Can it ever be a manifestation of a desire to escape from real or imagined fears or discomfort ? The escape motive, although a good working hypothesis, has become rather too fashionable and needs critical study. It is noteworthy,
has not been followed because it is not possible to drill with Hey Groves’s director. The modification illustrated here, which can be carried out
use a
inexpensively on any existing instrument, overcomes this difficulty. When the guide is in position the inner sleeve is removed and a 3/16 in. hole is drilled in the cortex. The inner sleeve is then replaced and the guide-wire is in no danger of deflexion. The modified director has been made for me by Messrs. Down Bros. of St. Thomas’s Street, S.E.I. CHARLES E. KINDERSLEY, F.R.C.S. Surgeon, Royal United Hospital, Bath.