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Choice of Operation for Retinal Detachment
EDITORIALS
better understanding of optics would remedy this condition, and ophthal mologists can easily get such an under standing. A long course in algebra and calcu lus may be necessary to read some famous books on optics, but it is not needed to understand the truths of op tics, that have a practical bearing on the diagnosis and correction of errors of refraction. Geometric figures give a clear idea of the reflection and refrac tion of light, and elementary trigo nometry, as taught in high schools, will give a practical mastery of aber rations, coflexures and transposition of lenses. These with such simple experi ments as can be performed with a boyscout flashlight, and the ordinary trial set, will put the eye physician beyond the reach of the salesman for copy righted glasses. It will not be long before we have good books on ophthalmology that do not start with trying to lead the stu dent off into the mathematical wilder ness ; because there lies the path blazed out by the most famous writers on op tics and physics in the past. Meanwhile eye physicians, who are young and am bitious enough really to master the ophthalmology of today and the future, will find efficient help for self-instruc tion. Such a student can begin by study ing, or reviewing, plane geometry. Solid geometry, too, will give him a better mastery of space perception, and is not hard for one who has done the proper amount of reading for an undergradu ate medical course. Then inquire about books on elementary trigonometry and obtain a book recommended for high school students. With that help, study plane trigonometry. Spherical "trig" also is good for any one who likes mathematics, but is not essential. With such preparation one can read Tscherning's Optique Physiologique, or the good English translation of it by Carl Weilànd, Donder's or Landolt's Refrac tion of the Eye, or the parts of Helmholtz Physiological Optics, which were written by the great master himself. The mathematical wanderings of Gullstrand need not be taken too seriously. Edward Jackson.
447
CHOICE OF OPERATION FOR RETINAL DETACHMENT It is neither surprising nor inap propriate that the space devoted during the last few years to discussion of retinal detachment has been out of pro portion to the incidence of this malady in ophthalmic statistics. Gonin revived in modified form earlier suggestions for the treatment of the condition, and at the same time put forward a very strongly supported opinion that retinal detachment was secondary to retinal laceration. While his theory is still much disputed, the value of his operative pro cedure has been rather generally ad mitted ; but there has also been a great variety of effort to discover more con venient or more effective means of cure. Since it is not likely that any method for treatment of retinal detachment will ever prove infallible, and since the ef ficacy of any given method will vary according to the enthusiasm and skill of the individual operator, the debate on this question is certain to be a pro tracted one. -Several well known sur geons, with abundant clinical facilities for fair trial, have made comparison be tween Gonin's thermocauterization and its twin electrocauterization, Guist's and Lindner's chemical cautery, and the diathermy method of Larsson and Weve. Some have favored one, some an other line of treatment, while a few workers find it difficult to select one method as superior to the others. Praiseworthy are the attempts to try out the value of the different procedures upon animals, especially rabbits, in whom retinal tears have been produced experimentally; although, alike as to primary condition and as to the results of treatment, the comparability of arti ficial lesions in lower animals with more or less spontaneous lesions in the human subject will always be open to question. Arruga of Barcelona has enriched the literature with a number of essays in which particularly he has discussed and beautifully illustrated the retinal tear, has reported many operative cases, and has suggested important modifications in technique of localization and opera tion. Before the Fiftieth Anniversary meeting of the Société Française
448
EDITORIALS
d'Ophtalmologie, July, 1932 (published in the Bulletins et Mémoires of the So ciety, and also in the Italian Annali di Ottalmologia, volume 60, page 473), Arruga described the production of "ex perimental adhesive choroiditis" in rab bits, and also in a young woman whose eye was to be removed three days later on account of choroidal sarcoma. In cases treated by trephining of the sclera followed by chemical irritation of the choroid, or in diathermal applica tions, Arruga regards it as probable that adhesive choroiditis is the principal fac tor in recovery. In cauterization with the thermocautery other factors play a more important part. The mode of action of the thermo cautery (whether Paquelin or electric) was shown to vary according to whether the application was short or long. Whether the cautery point was white or red hot did not seem to matter much as regards its effect on adjacent tissues. But if the cautery was applied very rap idly the heat was not transmitted to these tissues and the effect was that of simple incision with very little inflam matory reaction ; whereas if the appli cation was slow the heat had time to be transmitted so as to produce the ef fect of a burn. Secondary contraction thus occasioned may explain the reduc tion of myopia after extensive cauteri zations. Adhesion of retina to choroid only began to appear solid after four to six days. Although Guist has offered his ex periments on rabbits in support of the contention that potash is the most suit able caustic for provoking adhesive choroiditis, Arruga's findings did not suggest any difference between results obtained with caustic potash and those from caustic soda. Experimental cases treated by trephining followed by ap plication of five percent solution of caus tic soda showed adequate choroidal adhesion, with the advantage that no im portant neighborhood changes were produced in the retina. Satisfactory ad hesions were also obtained experi mentally with tincture of iodine or with a five percent solution of zinc chloride, immediately followed (as were all the
milder chemical applications) by lavage with physiological salt solution. Interesting effects were demonstrated after the use of diathermy according to Weve's technique; that is, applying the current through the round electrode long enough to produce "parchmentizing" of the sclera, a peculiar greenishgray discoloration of the area of contact. (See also editorial, American Jour nal of Ophthalmology, 1932, volume 15, page 858). The inflammatory exudate developed in the subretinal space was fibrinous, and the choroid was greatly congested and was swollen to five or six times its normal thickness. More pro longed applications were quickly and definitely destructive. Both externally and ophthalmoscopically the changes visible after such applications were sharply delimited. Multiple diathermal electropuncture produced the same ef fects as superficial application of diathermy. Arruga draws a sharp distinction be tween the mode of action of scierai tre phining and of ignipuncture as regards closure of tears. After trephining and application of caustics, adhesion of retina to choroid is entirely due to ad hesive choroiditis from chemical irrita tion. In thermopuncture, especially if rapid, almost no choroiditis is provoked, but vitreous hernia favors speedy ad hesion of the retina to the edges of the scierai opening, and not elsewhere. It is for this reason that thermopuncture is followed by the most rapid healing, whereas those procedures which pro voke choroiditis demand a more pro longed period of rest. On the other hand, the latter modes of treatment seem to be less subject to relapse of the detach ment. W. H. Crisp. OPTIC ATROPHY AND F L U I D DROPPING FROM T H E NOSTRIL Nettleship, in 1882, reported a case of optic neuritis followed by dropping of fluid from the nostril. Before she was first seen, this patient had obscure cerebral symptoms, and for two months there had been profuse running of clear
better understanding of optics would remedy this condition, and ophthal mologists can easily get such an under standing. A long course in algebra and calcu lus may be necessary to read some famous books on optics, but it is not needed to understand the truths of op tics, that have a practical bearing on the diagnosis and correction of errors of refraction. Geometric figures give a clear idea of the reflection and refrac tion of light, and elementary trigo nometry, as taught in high schools, will give a practical mastery of aber rations, coflexures and transposition of lenses. These with such simple experi ments as can be performed with a boyscout flashlight, and the ordinary trial set, will put the eye physician beyond the reach of the salesman for copy righted glasses. It will not be long before we have good books on ophthalmology that do not start with trying to lead the stu dent off into the mathematical wilder ness ; because there lies the path blazed out by the most famous writers on op tics and physics in the past. Meanwhile eye physicians, who are young and am bitious enough really to master the ophthalmology of today and the future, will find efficient help for self-instruc tion. Such a student can begin by study ing, or reviewing, plane geometry. Solid geometry, too, will give him a better mastery of space perception, and is not hard for one who has done the proper amount of reading for an undergradu ate medical course. Then inquire about books on elementary trigonometry and obtain a book recommended for high school students. With that help, study plane trigonometry. Spherical "trig" also is good for any one who likes mathematics, but is not essential. With such preparation one can read Tscherning's Optique Physiologique, or the good English translation of it by Carl Weilànd, Donder's or Landolt's Refrac tion of the Eye, or the parts of Helmholtz Physiological Optics, which were written by the great master himself. The mathematical wanderings of Gullstrand need not be taken too seriously. Edward Jackson.
447
CHOICE OF OPERATION FOR RETINAL DETACHMENT It is neither surprising nor inap propriate that the space devoted during the last few years to discussion of retinal detachment has been out of pro portion to the incidence of this malady in ophthalmic statistics. Gonin revived in modified form earlier suggestions for the treatment of the condition, and at the same time put forward a very strongly supported opinion that retinal detachment was secondary to retinal laceration. While his theory is still much disputed, the value of his operative pro cedure has been rather generally ad mitted ; but there has also been a great variety of effort to discover more con venient or more effective means of cure. Since it is not likely that any method for treatment of retinal detachment will ever prove infallible, and since the ef ficacy of any given method will vary according to the enthusiasm and skill of the individual operator, the debate on this question is certain to be a pro tracted one. -Several well known sur geons, with abundant clinical facilities for fair trial, have made comparison be tween Gonin's thermocauterization and its twin electrocauterization, Guist's and Lindner's chemical cautery, and the diathermy method of Larsson and Weve. Some have favored one, some an other line of treatment, while a few workers find it difficult to select one method as superior to the others. Praiseworthy are the attempts to try out the value of the different procedures upon animals, especially rabbits, in whom retinal tears have been produced experimentally; although, alike as to primary condition and as to the results of treatment, the comparability of arti ficial lesions in lower animals with more or less spontaneous lesions in the human subject will always be open to question. Arruga of Barcelona has enriched the literature with a number of essays in which particularly he has discussed and beautifully illustrated the retinal tear, has reported many operative cases, and has suggested important modifications in technique of localization and opera tion. Before the Fiftieth Anniversary meeting of the Société Française
448
EDITORIALS
d'Ophtalmologie, July, 1932 (published in the Bulletins et Mémoires of the So ciety, and also in the Italian Annali di Ottalmologia, volume 60, page 473), Arruga described the production of "ex perimental adhesive choroiditis" in rab bits, and also in a young woman whose eye was to be removed three days later on account of choroidal sarcoma. In cases treated by trephining of the sclera followed by chemical irritation of the choroid, or in diathermal applica tions, Arruga regards it as probable that adhesive choroiditis is the principal fac tor in recovery. In cauterization with the thermocautery other factors play a more important part. The mode of action of the thermo cautery (whether Paquelin or electric) was shown to vary according to whether the application was short or long. Whether the cautery point was white or red hot did not seem to matter much as regards its effect on adjacent tissues. But if the cautery was applied very rap idly the heat was not transmitted to these tissues and the effect was that of simple incision with very little inflam matory reaction ; whereas if the appli cation was slow the heat had time to be transmitted so as to produce the ef fect of a burn. Secondary contraction thus occasioned may explain the reduc tion of myopia after extensive cauteri zations. Adhesion of retina to choroid only began to appear solid after four to six days. Although Guist has offered his ex periments on rabbits in support of the contention that potash is the most suit able caustic for provoking adhesive choroiditis, Arruga's findings did not suggest any difference between results obtained with caustic potash and those from caustic soda. Experimental cases treated by trephining followed by ap plication of five percent solution of caus tic soda showed adequate choroidal adhesion, with the advantage that no im portant neighborhood changes were produced in the retina. Satisfactory ad hesions were also obtained experi mentally with tincture of iodine or with a five percent solution of zinc chloride, immediately followed (as were all the
milder chemical applications) by lavage with physiological salt solution. Interesting effects were demonstrated after the use of diathermy according to Weve's technique; that is, applying the current through the round electrode long enough to produce "parchmentizing" of the sclera, a peculiar greenishgray discoloration of the area of contact. (See also editorial, American Jour nal of Ophthalmology, 1932, volume 15, page 858). The inflammatory exudate developed in the subretinal space was fibrinous, and the choroid was greatly congested and was swollen to five or six times its normal thickness. More pro longed applications were quickly and definitely destructive. Both externally and ophthalmoscopically the changes visible after such applications were sharply delimited. Multiple diathermal electropuncture produced the same ef fects as superficial application of diathermy. Arruga draws a sharp distinction be tween the mode of action of scierai tre phining and of ignipuncture as regards closure of tears. After trephining and application of caustics, adhesion of retina to choroid is entirely due to ad hesive choroiditis from chemical irrita tion. In thermopuncture, especially if rapid, almost no choroiditis is provoked, but vitreous hernia favors speedy ad hesion of the retina to the edges of the scierai opening, and not elsewhere. It is for this reason that thermopuncture is followed by the most rapid healing, whereas those procedures which pro voke choroiditis demand a more pro longed period of rest. On the other hand, the latter modes of treatment seem to be less subject to relapse of the detach ment. W. H. Crisp. OPTIC ATROPHY AND F L U I D DROPPING FROM T H E NOSTRIL Nettleship, in 1882, reported a case of optic neuritis followed by dropping of fluid from the nostril. Before she was first seen, this patient had obscure cerebral symptoms, and for two months there had been profuse running of clear