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Wills Eye Hospital Fourth Annual Clinical Conference
726
EDITORIALS
tinuing their present graduate training and programs, the cry of "unfair competition" would probably die a natural death. More serious would be the apparent conflict with the recently adopted Hess Committee report and the "Revised principles of ethics" of the A.M.A. It should, however, be noted that the pertinent clause contains the words "for the financial profit of the agency concerned." If any f ee-f or-service collected by the hos pitals were segregated in a special fund for medical research, or a fund for the further ance of graduate medical training, or to pro vide adequate remuneration for the now underpaid resident staffs, and thus did not accumulate for the financial profit of the hos pitals, such an arrangement might meet both the letter and spirit of the "Revised princi ples." This might well be a matter for deci sion by the Judicial Council of the A.M.A. The cry against hospitals going directly into the business of the practice of medicine is after all something of a red herring. One has only to glance at the charges made against patients for the services of hospitalemployed anesthesiologists and radiologists, all of which usually are collected and retained by the hospitals. One has only to realize that fees collected for professional services ren dered by a university full-time staff are as a rule used for the support of the department earning such fees. To a somewhat limited extent the hospitals and many university clinical departments are already in business. The question is simply one of degree. If this proposal should not prove feasible, then perhaps some more palatable substitute might be worked out. The essential thing is to realize that all insurance programs for medical care, be they voluntary or compul sory, together with changing economic condi tions, contain a threat to the integrity of our residency training programs. This threat is real and not fancied. In many parts of the country the attendance in the out-patient departments is on the wane. There are no longer long waiting lists for admittance to the public wards, and in many of our ophthalmic hospitals our public wards
are only partially filled. At the same time the demand for semiprivate accommodations is growing by leaps and bounds. The semipri vate beds are all filled and there is a long waiting list for admittance. The chiefs of clinics in ophthalmology are already scouring the high-roads and the hedges, the outlying private hospitals, and city- and state-supported institutions, for operative and clinical material for the train ing of their resident staffs. If the present trend continues, and there is every indication that it will continue, unless some frontal and direct measures are taken, the integrity of our graduate residency training systems will be damaged and possibly destroyed. Alan C. Woods.
W I L L S EYE H O S P I T A L F O U R T H ANNUAL CLINICAL CONFERENCE Approximately 350 ophthalmologists at tended the fourth annual clinical conference of the staff and ex-residents held at the Wills Eye Hospital, Philadelphia, on March 21 and 22, 1952. Dr. L. Pellman Glover presented a paper on 'Theochromocytomas: Emphasis on eye symptoms, especially in children." He de scribed a case which was cured after removal of the tumor of the adrenal. An improved model of his muscle tucker was presented by Dr. William J. Harrison. Dr. Edmund B. Spaeth spoke on "The surgical aspects of defective abduction." He recommended tendon transplant in the ac quired type for functional improvement of the paralyzed muscle. Based on a survey of 150 cases, Dr. James S. Shipman, Dr. James H. Delaney, and Dr. R. H. Seely emphasized the anterior route for extraction of intraocular foreign bodies less than three mm. in size. Dr. Shipman stated that he relied more on the Sweet geo metric method of localizing intraocular for-
EDITORIALS eign bodies. The Berman locator had proved of little assistance to him. A symposium on "Wound closure" in cluded a review by Dr. Howard F. Hill of types of incisions and sutures in cataract sur gery. Dr. Wilfred E. Fry advocated the use of "track" sutures for a more secure closure to minimize complications, preferring silk to catgut sutures. Dr. I. S. Tassman described the use of plasma, thrombin, and hyaluronic acid as added safety factors for corneal wound closure and healing. Dr. Perce DeLong presented evidence and results in mi croscopic sections of animal eyes, showing that fibroblastic proliferation occurs within 48 hours. He also showed that in all treated eyes there was positive evidence that healing and repair of corneal wounds was stimulated and accelerated. Dr. Irving H. Leopold and Dr. Thomas G. Dickinson gave an interesting discussion on "Antihyaluronidase antistreptolysin titres in uveitis." A search, they feel, for the anti bodies developed by the body against sub stances produced by the streptococcus organ ism may help in the diagnosis of the basic cause of uveitis. A report of studies made with some of the newer drugs in the hospital's research lab oratory by Dr. Leopold and his associates revealed: 1. Autonomic ganglion blocking agents, when administered parenterally—that is, by intramuscular or intravenous injection—will produce a lowering of intraocular pressure in normal eyes. This suggests, they feel, that these agents may be of value in the treatment of glaucoma. In their studies they have also shown that agents which are frequently used for the relief of patients with peptic ulcers may produce elevations of intraocular pres sure, that is, these agents may precipitate glaucomatous attacks. It is possible they point out, by virtue of these studies, that several of these agents may be superior to ones which are presently available for refraction of the human eye. 2. Dilute di-isopropyl fluorophosphate ( D F P ) seems to fulfill some of the require
727
ments of the ideal miotic agent in that it re quires fewer instillations than the commonly employed drugs and produces less variation and less fluctuation in the daily pressure curves. They have found urecholine to be a potent miotic agent. It appears to be equally as effective in the control of mild chronic simple glaucoma as other agents available to date. 3. There was no significant difference be tween compound F and cortisone as an antiinflammatory agent when tested experi mentally. However, their clinical studies have shown that compound F may be more effective than cortisone in some types of ocular inflammations, particularly in severe vernal conjunctivitis, in cases of uveitis, and in other ocular inflammations such as episcleritis and phlyctenular disease. Staff doctors who assisted in these studies were: A. H. Keeney, C. R. Mullen, B. Gettes, C. Steinmetz, A. Cleveland, F. Frisch, J. Deichler, P. R. McDonald, R. Mulberger, and A. Vogel. Dr. Derrick Vail delivered the Arthur J. Bedell Lecture. His subject was "Zonule membrane and cataract expression." His thorough covering of the subject from the embryologic and anatomic standpoint made the practical approach to his remarks on cata ract expression most interesting and enlight ening. Another important feature of the confer ence was the presentation of eye surgery in color television, through the courtesy of Smith, Kline, and French Laboratories. In cluded among the nine operations which were viewed with great interest by those in attend ance was a Ridley plastic lens implant in a case of cataract extraction. Two interesting clinical pathologic pres entations were made by Dr. William H. Annesley, Jr., and Dr. James H. Parker. The meeting was not without its social aspects. A cocktail party and informal recep tion for the doctors and their wives were held at the Barclay Hotel, Friday evening, followed by a delicious dinner. Kenneth L. Roper.
EDITORIALS
tinuing their present graduate training and programs, the cry of "unfair competition" would probably die a natural death. More serious would be the apparent conflict with the recently adopted Hess Committee report and the "Revised principles of ethics" of the A.M.A. It should, however, be noted that the pertinent clause contains the words "for the financial profit of the agency concerned." If any f ee-f or-service collected by the hos pitals were segregated in a special fund for medical research, or a fund for the further ance of graduate medical training, or to pro vide adequate remuneration for the now underpaid resident staffs, and thus did not accumulate for the financial profit of the hos pitals, such an arrangement might meet both the letter and spirit of the "Revised princi ples." This might well be a matter for deci sion by the Judicial Council of the A.M.A. The cry against hospitals going directly into the business of the practice of medicine is after all something of a red herring. One has only to glance at the charges made against patients for the services of hospitalemployed anesthesiologists and radiologists, all of which usually are collected and retained by the hospitals. One has only to realize that fees collected for professional services ren dered by a university full-time staff are as a rule used for the support of the department earning such fees. To a somewhat limited extent the hospitals and many university clinical departments are already in business. The question is simply one of degree. If this proposal should not prove feasible, then perhaps some more palatable substitute might be worked out. The essential thing is to realize that all insurance programs for medical care, be they voluntary or compul sory, together with changing economic condi tions, contain a threat to the integrity of our residency training programs. This threat is real and not fancied. In many parts of the country the attendance in the out-patient departments is on the wane. There are no longer long waiting lists for admittance to the public wards, and in many of our ophthalmic hospitals our public wards
are only partially filled. At the same time the demand for semiprivate accommodations is growing by leaps and bounds. The semipri vate beds are all filled and there is a long waiting list for admittance. The chiefs of clinics in ophthalmology are already scouring the high-roads and the hedges, the outlying private hospitals, and city- and state-supported institutions, for operative and clinical material for the train ing of their resident staffs. If the present trend continues, and there is every indication that it will continue, unless some frontal and direct measures are taken, the integrity of our graduate residency training systems will be damaged and possibly destroyed. Alan C. Woods.
W I L L S EYE H O S P I T A L F O U R T H ANNUAL CLINICAL CONFERENCE Approximately 350 ophthalmologists at tended the fourth annual clinical conference of the staff and ex-residents held at the Wills Eye Hospital, Philadelphia, on March 21 and 22, 1952. Dr. L. Pellman Glover presented a paper on 'Theochromocytomas: Emphasis on eye symptoms, especially in children." He de scribed a case which was cured after removal of the tumor of the adrenal. An improved model of his muscle tucker was presented by Dr. William J. Harrison. Dr. Edmund B. Spaeth spoke on "The surgical aspects of defective abduction." He recommended tendon transplant in the ac quired type for functional improvement of the paralyzed muscle. Based on a survey of 150 cases, Dr. James S. Shipman, Dr. James H. Delaney, and Dr. R. H. Seely emphasized the anterior route for extraction of intraocular foreign bodies less than three mm. in size. Dr. Shipman stated that he relied more on the Sweet geo metric method of localizing intraocular for-
EDITORIALS eign bodies. The Berman locator had proved of little assistance to him. A symposium on "Wound closure" in cluded a review by Dr. Howard F. Hill of types of incisions and sutures in cataract sur gery. Dr. Wilfred E. Fry advocated the use of "track" sutures for a more secure closure to minimize complications, preferring silk to catgut sutures. Dr. I. S. Tassman described the use of plasma, thrombin, and hyaluronic acid as added safety factors for corneal wound closure and healing. Dr. Perce DeLong presented evidence and results in mi croscopic sections of animal eyes, showing that fibroblastic proliferation occurs within 48 hours. He also showed that in all treated eyes there was positive evidence that healing and repair of corneal wounds was stimulated and accelerated. Dr. Irving H. Leopold and Dr. Thomas G. Dickinson gave an interesting discussion on "Antihyaluronidase antistreptolysin titres in uveitis." A search, they feel, for the anti bodies developed by the body against sub stances produced by the streptococcus organ ism may help in the diagnosis of the basic cause of uveitis. A report of studies made with some of the newer drugs in the hospital's research lab oratory by Dr. Leopold and his associates revealed: 1. Autonomic ganglion blocking agents, when administered parenterally—that is, by intramuscular or intravenous injection—will produce a lowering of intraocular pressure in normal eyes. This suggests, they feel, that these agents may be of value in the treatment of glaucoma. In their studies they have also shown that agents which are frequently used for the relief of patients with peptic ulcers may produce elevations of intraocular pres sure, that is, these agents may precipitate glaucomatous attacks. It is possible they point out, by virtue of these studies, that several of these agents may be superior to ones which are presently available for refraction of the human eye. 2. Dilute di-isopropyl fluorophosphate ( D F P ) seems to fulfill some of the require
727
ments of the ideal miotic agent in that it re quires fewer instillations than the commonly employed drugs and produces less variation and less fluctuation in the daily pressure curves. They have found urecholine to be a potent miotic agent. It appears to be equally as effective in the control of mild chronic simple glaucoma as other agents available to date. 3. There was no significant difference be tween compound F and cortisone as an antiinflammatory agent when tested experi mentally. However, their clinical studies have shown that compound F may be more effective than cortisone in some types of ocular inflammations, particularly in severe vernal conjunctivitis, in cases of uveitis, and in other ocular inflammations such as episcleritis and phlyctenular disease. Staff doctors who assisted in these studies were: A. H. Keeney, C. R. Mullen, B. Gettes, C. Steinmetz, A. Cleveland, F. Frisch, J. Deichler, P. R. McDonald, R. Mulberger, and A. Vogel. Dr. Derrick Vail delivered the Arthur J. Bedell Lecture. His subject was "Zonule membrane and cataract expression." His thorough covering of the subject from the embryologic and anatomic standpoint made the practical approach to his remarks on cata ract expression most interesting and enlight ening. Another important feature of the confer ence was the presentation of eye surgery in color television, through the courtesy of Smith, Kline, and French Laboratories. In cluded among the nine operations which were viewed with great interest by those in attend ance was a Ridley plastic lens implant in a case of cataract extraction. Two interesting clinical pathologic pres entations were made by Dr. William H. Annesley, Jr., and Dr. James H. Parker. The meeting was not without its social aspects. A cocktail party and informal recep tion for the doctors and their wives were held at the Barclay Hotel, Friday evening, followed by a delicious dinner. Kenneth L. Roper.