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Tartar-Emetic Trachoma Therapy
EDITORIALS
whether any individual is suitable for holding a scholarship or for becoming a teacher in England no longer depends upon hard and fast rules, but upon the mature judgment of an eye specialist. Butler believes there is "no proof or even probability" that near work in itself has anything to do with the progress of myopia. He instances cases in which one eye is highly myopic and the other normal, and asks how close work could affect one eye and not the other. He has also seen malignant cases of myopia in Bedouin Arabs who had never done any near work. He regards heredity as the chief factor, aided by poor nutrition. In the words of Sorsby, who presented one of the opening papers on the subject at the Oxford Congress. "The changed outlook on myopia ... gives a theoretical justification for what most of us have learned clinically-that most myopia is not pathological. The bio-mathematical approach is teaching us to appreciate low and medium myopia as a non-pathological and non-pathogenic variation.... In freeing itself from its mechanistic strangleholds the problem of myopia has emerged as a problem in biology." W. H. Crisp. TARTAR-EMETIC TRACHOMA THERAPY Any new therapy for as widespread and devastating a disease as trachoma at once becomes a matter of great interest to the ophthalmic profession. Coming down through the years since the beginning of its history, a tremendous number of drugs and procedures have been advocated for this disease; for, the nature of the etiologic agent having been unknown until recently, therapy was necessarily empirical. Within the past few years, however, it has been conclusively established that the disease is due to a virus, and the use of
683
agents having a particular value in destroying viruses is therefore a reasonable approach to the problem. In determining the effect of various substances on the virus of trachoma, Dr. Louis Julianelle found that tartar emetic had a marked virucidal action on this agent in vitro. His past experience in the use of this drug in the treatment of granuloma inguinale, possibly another virus disease, encouraged him to test its efficacy in trachoma therapy. A few experiments were first undertaken at Dr. Julianelle's suggestion about two years ago, but systematic study was begun only this winter. In this issue of the Journal (page 651) Dr. J ulianelle has published a preliminary report on about 40 cases. The results have been extremely interesting. The most outstanding change has been an improvement in the corneal condition in cases presenting an acute inflammation. Almost without exception these have become quiet in a remarkably short period of time. One other gratifying aspect has been the manner in which follicular cases have recovered from scrapings, almost without reaction, when tartar-emetic injections had been administered. A corollary to this statement is rather obvious; namely, that follicular types have shown little if any change from tartar-emetic treatment alone. The scars of chronically inflamed corneae and conjunctivae, as would be expected, have not responded. The administration of this drug is not difficult, although any intravenous treatment may present some inconvenience to the ophthalmologist who has become accustomed to delegating such procedures. Tartar emetic is dispensed as a liquid in 5-c.c. ampules, each ampule containing one-twentieth gram. Treatment must be given daily for at least a week in order that the patient may become saturated with the drug. Great care must be exercised to make certain that the needle is
BOOK NOTICES
684
within the vein, for painful swelling will be occasioned if the preparation escapes directly into the subcutaneous or perivascular tissues. Patients may leave the office shortly after administration of the drug. With excessive use, they may occasionally experience nausea, even, more rarely, coughing. One of the important reasons for publishing this paper as a preliminary report is in order that this treatment may be tried by those who see large numbers of cases. The only other mention of tartar-emetic therapy for trachoma in the literature thus far is that of Derkac (Klinische Monatsblatter fur Augenheilkunde, 1937, volume 99, page 311), who reported favorable results in the treatment of 50 cases. Details of the method of administration are not given. Having followed Dr. ]ulianelle's work carefully, I believe that there is good reason to hope that this treatment may prove a valuable adjunct in the care of trachoma. Lawrence T. Post.
BOOK NOTICES OPHTHALMIC HOSPIT ALSEGYPT. Annual Report of 1936. Paper, 44 pages, Illustrated. Cairo, Government Press, 1937. This annual report is of exceptional value for the reproduced photographs it contains of 58 hospitals, ophthalmic units, and the Giza Memorial Ophthalmic Laboratory. Both traveling and permanent hospitals are represented, and with each picture is printed the year of its establishment. There is also an outline map of Egypt, showing where each hospital is located. In no other country, and for no other branch of medical practice, has state medicine been so well organized and efficiently applied. In Egypt it was not initiated by the Government but by the gift of £40,000 by Sir Ernest Cassel, and
by the sending to Egypt, in 1903, of a young man from Moorfields Hospital, A. F. MacCallan, to organize and start this system of hospitals. Egypt has now 73 of these hospitals, 59 permanent and 14 traveling hospitals. The annual report of their work is the most important statistical report of eye diseases and ophthalmic operations published anywhere in the world. The numbers reported for the year range from 76,646 patients and 18,838 operations at Rod elFarag (Cairo) to 148 patients and 35 operations at Biba, in a hospital established during the year. There are five hospitals which each report over 10,000 operations for the year. The general total of operations was 344,661. Of these 2,818 were cataract operations: 1,463 extractions of senile cataract with iridectomy, 263 after preliminary iridectomy, the rest for soft cataract and division of membranes. Of glaucoma there were 6,059 cases, of which 4,049 were already absolute. Among the operations performed were 1,182 of sclerocorneal trephining with iridectomy, and 79 of trephining alone. Iridectomies alone for glaucoma numbered 1,666. The total number of cases of blindness of both eyes was 11,430; and of blindness of one eye, 51,707. Tests of vision of 10,757 pupils in the schools showed that 61.14 percent had vision of 6/6 to 6/9; 19.85 precent had vision of 6/6 to 6/18; and 19.01 percent had "bad vision," less than 6/18. There are also graphs showing the correspondence of average temperatures, and the number of new patients admitted each month; the two showing a close correspondence. Graphs showing the increasing number of patients treated from 1904 to 1935, and the decreasing percentage of cases of blindness during the same period are also given. In race, social conditions, customs, and climate there are
whether any individual is suitable for holding a scholarship or for becoming a teacher in England no longer depends upon hard and fast rules, but upon the mature judgment of an eye specialist. Butler believes there is "no proof or even probability" that near work in itself has anything to do with the progress of myopia. He instances cases in which one eye is highly myopic and the other normal, and asks how close work could affect one eye and not the other. He has also seen malignant cases of myopia in Bedouin Arabs who had never done any near work. He regards heredity as the chief factor, aided by poor nutrition. In the words of Sorsby, who presented one of the opening papers on the subject at the Oxford Congress. "The changed outlook on myopia ... gives a theoretical justification for what most of us have learned clinically-that most myopia is not pathological. The bio-mathematical approach is teaching us to appreciate low and medium myopia as a non-pathological and non-pathogenic variation.... In freeing itself from its mechanistic strangleholds the problem of myopia has emerged as a problem in biology." W. H. Crisp. TARTAR-EMETIC TRACHOMA THERAPY Any new therapy for as widespread and devastating a disease as trachoma at once becomes a matter of great interest to the ophthalmic profession. Coming down through the years since the beginning of its history, a tremendous number of drugs and procedures have been advocated for this disease; for, the nature of the etiologic agent having been unknown until recently, therapy was necessarily empirical. Within the past few years, however, it has been conclusively established that the disease is due to a virus, and the use of
683
agents having a particular value in destroying viruses is therefore a reasonable approach to the problem. In determining the effect of various substances on the virus of trachoma, Dr. Louis Julianelle found that tartar emetic had a marked virucidal action on this agent in vitro. His past experience in the use of this drug in the treatment of granuloma inguinale, possibly another virus disease, encouraged him to test its efficacy in trachoma therapy. A few experiments were first undertaken at Dr. Julianelle's suggestion about two years ago, but systematic study was begun only this winter. In this issue of the Journal (page 651) Dr. J ulianelle has published a preliminary report on about 40 cases. The results have been extremely interesting. The most outstanding change has been an improvement in the corneal condition in cases presenting an acute inflammation. Almost without exception these have become quiet in a remarkably short period of time. One other gratifying aspect has been the manner in which follicular cases have recovered from scrapings, almost without reaction, when tartar-emetic injections had been administered. A corollary to this statement is rather obvious; namely, that follicular types have shown little if any change from tartar-emetic treatment alone. The scars of chronically inflamed corneae and conjunctivae, as would be expected, have not responded. The administration of this drug is not difficult, although any intravenous treatment may present some inconvenience to the ophthalmologist who has become accustomed to delegating such procedures. Tartar emetic is dispensed as a liquid in 5-c.c. ampules, each ampule containing one-twentieth gram. Treatment must be given daily for at least a week in order that the patient may become saturated with the drug. Great care must be exercised to make certain that the needle is
BOOK NOTICES
684
within the vein, for painful swelling will be occasioned if the preparation escapes directly into the subcutaneous or perivascular tissues. Patients may leave the office shortly after administration of the drug. With excessive use, they may occasionally experience nausea, even, more rarely, coughing. One of the important reasons for publishing this paper as a preliminary report is in order that this treatment may be tried by those who see large numbers of cases. The only other mention of tartar-emetic therapy for trachoma in the literature thus far is that of Derkac (Klinische Monatsblatter fur Augenheilkunde, 1937, volume 99, page 311), who reported favorable results in the treatment of 50 cases. Details of the method of administration are not given. Having followed Dr. ]ulianelle's work carefully, I believe that there is good reason to hope that this treatment may prove a valuable adjunct in the care of trachoma. Lawrence T. Post.
BOOK NOTICES OPHTHALMIC HOSPIT ALSEGYPT. Annual Report of 1936. Paper, 44 pages, Illustrated. Cairo, Government Press, 1937. This annual report is of exceptional value for the reproduced photographs it contains of 58 hospitals, ophthalmic units, and the Giza Memorial Ophthalmic Laboratory. Both traveling and permanent hospitals are represented, and with each picture is printed the year of its establishment. There is also an outline map of Egypt, showing where each hospital is located. In no other country, and for no other branch of medical practice, has state medicine been so well organized and efficiently applied. In Egypt it was not initiated by the Government but by the gift of £40,000 by Sir Ernest Cassel, and
by the sending to Egypt, in 1903, of a young man from Moorfields Hospital, A. F. MacCallan, to organize and start this system of hospitals. Egypt has now 73 of these hospitals, 59 permanent and 14 traveling hospitals. The annual report of their work is the most important statistical report of eye diseases and ophthalmic operations published anywhere in the world. The numbers reported for the year range from 76,646 patients and 18,838 operations at Rod elFarag (Cairo) to 148 patients and 35 operations at Biba, in a hospital established during the year. There are five hospitals which each report over 10,000 operations for the year. The general total of operations was 344,661. Of these 2,818 were cataract operations: 1,463 extractions of senile cataract with iridectomy, 263 after preliminary iridectomy, the rest for soft cataract and division of membranes. Of glaucoma there were 6,059 cases, of which 4,049 were already absolute. Among the operations performed were 1,182 of sclerocorneal trephining with iridectomy, and 79 of trephining alone. Iridectomies alone for glaucoma numbered 1,666. The total number of cases of blindness of both eyes was 11,430; and of blindness of one eye, 51,707. Tests of vision of 10,757 pupils in the schools showed that 61.14 percent had vision of 6/6 to 6/9; 19.85 precent had vision of 6/6 to 6/18; and 19.01 percent had "bad vision," less than 6/18. There are also graphs showing the correspondence of average temperatures, and the number of new patients admitted each month; the two showing a close correspondence. Graphs showing the increasing number of patients treated from 1904 to 1935, and the decreasing percentage of cases of blindness during the same period are also given. In race, social conditions, customs, and climate there are