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DIAGNOSTIC AND THERAPEUTIC ERRORS IN OPHTHALMOLOGY.
924
regarded
established facts,
yet practically
can only be diagnosed by exact methods in the hands of an expert, while to leave the diagnosis until it is so unmistakable that a tyro can make it may often mean to make an avoidable blindness inevitable. One of the most essential things for a general practitioner to THE LOW TEMPERATURE RESEARCH STATION know is the way to distinguish an acute glaucoma from an acute iritis, and the dangers of a wrong AT CAMBRIDGE. diagnosis. He will find the main points stated, but THE Food Investigation Board, in presenting their again we think it is a mistake that he should be report for 1921 to the Committee of the Privy Council advised to employ the tonometer. It is certainly for Scientific and Industrial Research, include in the much easier to gauge the tension in any marked case introduction to the report a short description of the by the fingers than by an intrument which, in hands newly-built low temperature station for research in unaccustomed to its use, may very likely prove biochemistry and biophysics at Cambridge. The fallacious. There are parts of ophthalmology which station is a roughly cubical building of three storeys, every general practitioner ought to know, but when of which two floors are divided into insulated chambers, it comes to niceties of diagnosis he will do well, unless with laboratory accommodation on one side. The circumstances have given him special aptitude, to call ground floor contains 11chambers, each separately in some recognised authority. supplied with brine to allow the maintenance of different temperatures in every chamber ; the refrigINTRACARDIAC SURGERY. erating arrangements on this floor are planned to give temperatures between freezing-point and —10°F. OxE by one the less accessible portions of the human The first floor, planned chiefly for work on fruit and are becoming amenable to surgical interference, body vegetables, contains eight chambers, some intended but up to the present time very little has been done for work above freezing-point, others for work at or within the chambers of the heart. Bullets have been below it. Electric thermostats have been installed in removed from various situations in the heart, but no some of these chambers, and the expected range on has been made to bring the treatment of mitral attempt this floor will be 28-80’ F. On both floors the air- stenosis into line with that of strictures in other parts supply is so arranged that no exhaust from any chamber of the body. Recent experiments carried out upon to goes any other chamber ; thus there is no risk of dogs by D. S. Allen and E. A. Grahamat Washington contamination of material in one chamber by vapour University have now indicated the lines upon which from another. The top floor is not insulated as a this problem may be attacked. These observers have whole, being reserved for future extensions, but in one applied to the heart the principle of an operating part of it insulated tanks have been put down for cardioscope. the auriculo-ventricular valve beingZ) freezing by direct immersion in brine ; a small chamber approached through the wall of the auricle. It was will also be erected on this floor for prolonged tests of found that making an incision in most parts of the insulating materials under cold storage conditions- heart wall, whether auricle or ventricle. for passage of tests complementary to those carried out by the the instrument usually resulted in serious haemorrhage Engineering Committee of the National Physical or interference with the heart’s action, and that the Laboratory at Teddington. A striking additional necessary suturing was also unsatisfactory. They feature of the station is a small greenhouse on the roof, have accordingly introduced their cardioscope through designed for the study of the effect of low temperature the tip of the auricular appendage. This is usually upon plants exposed to full solar radiation-having long enough on the left side to be occluded while the insulated walls and floors and a roof of plain glass and instrument is introduced through an incision, and being fitted with refrigerating pipes. A bed of earth leakage of blood during the operation is prevented by has also been laid on the roof, traversed by refrigerat- a simple ligature round the instrument and appendage. ing pipes to admit of cooling of the roots of plants The same ligature is tied after the removal of the otherwise subjected to ordinary air temperatures. instrument and it seems that the end of the appendage These additions, it is hoped, will be of value in the can be sacrificed without detriment to the heart’s analysis of factors controlling the rate of growth of action. In this way the use of sutures in the heartwall crops. The engineering side of the equipment of the is avoided. When the cardioscope has entered the station proved a very complex problem ; the tempera- auricle it is pushed on until a lens at its extremity is ture obtainable in each chamber was required to be in contact with the valves that are the object actually not only of wide range, but also independent of that of attack. Direct vision is thus obtained in spite of of any other chamber. Carbonic acid gas, it may be the of the blood. A special knife introduced opacity noted, was chosen as the cooling substance in preference alongside the cardioscope is then brought into play, and to ammonia on account of the probable toxic action the valves may be slit with accuracy. The instrument of small quantities of ammonia on fruit or other living is then withdrawn and the auricular appendage ligasubstances. tured as already described. Post-operative mortality following this procedure has been high, but the cause DIAGNOSTIC AND THERAPEUTIC ERRORS IN of death has usually been empyema, presumably owing to some failure in asepsis. Several animals have, OPHTHALMOLOGY. of slitting the mitral survived the however, operation A SYSTEMATIC work on diagnostic and therapeutic and all these have developed a loud systolic errors and their avoidance is being published in valves, murmur as evidence that the objective had been Germany in separate volumes. Oneof these, the second in the series having to do with ophthalmology, reached. Developments in the surgery of the heart is intended as a guide to the general practitioner. For on these lines are to be expected. a practical guide it appears in some respects too full and in others too meagre. Two or three times every AGGLUTINATION AND COLLOID CHEMISTRY, year, says the author, cases of chronic glaucoma come THE paper by Dr. Takuji Shionoya, which we to his clinic which have been diagnosed by the general practitioner as ordinary senile cataract. To the man publish in our present issue, is a useful illustration of who could make such a mistake it is surely useless to the ever-widening influence of colloid chemistry on talk about measuring the tension of the eye with a biological investigation. The author starts from the tonometer, or examining the fundus to determine well-known facts first, that an agglutinin-bacteria whether or not there is cupping of the disc. It is adsorption complex is obtainable, and secondly, that positively dangerous to instruct such a man to measure the presence of salts is necessary for the agglutinathe field roughly by his hand because early glaucoma tion of this complex. By the use of solutions of the salts of various cations he shows that the as
are as
a
closed book to the practitioner and to the medical student. The position is one which cannot continue.
____
1 Erkrankungen der Iris, der Linse und des Glaskörpers. By Prof. Dr. U. Stock, Director of the Eye Clinic in the University of Tübingen. Leipzig : Georg Thieme. 1922. Pp. 32. 1s.
1 Jour. Amer. Med. Assoc., vol. lxxix., p. 1028, Sept. 23rd, 1922.
regarded
established facts,
yet practically
can only be diagnosed by exact methods in the hands of an expert, while to leave the diagnosis until it is so unmistakable that a tyro can make it may often mean to make an avoidable blindness inevitable. One of the most essential things for a general practitioner to THE LOW TEMPERATURE RESEARCH STATION know is the way to distinguish an acute glaucoma from an acute iritis, and the dangers of a wrong AT CAMBRIDGE. diagnosis. He will find the main points stated, but THE Food Investigation Board, in presenting their again we think it is a mistake that he should be report for 1921 to the Committee of the Privy Council advised to employ the tonometer. It is certainly for Scientific and Industrial Research, include in the much easier to gauge the tension in any marked case introduction to the report a short description of the by the fingers than by an intrument which, in hands newly-built low temperature station for research in unaccustomed to its use, may very likely prove biochemistry and biophysics at Cambridge. The fallacious. There are parts of ophthalmology which station is a roughly cubical building of three storeys, every general practitioner ought to know, but when of which two floors are divided into insulated chambers, it comes to niceties of diagnosis he will do well, unless with laboratory accommodation on one side. The circumstances have given him special aptitude, to call ground floor contains 11chambers, each separately in some recognised authority. supplied with brine to allow the maintenance of different temperatures in every chamber ; the refrigINTRACARDIAC SURGERY. erating arrangements on this floor are planned to give temperatures between freezing-point and —10°F. OxE by one the less accessible portions of the human The first floor, planned chiefly for work on fruit and are becoming amenable to surgical interference, body vegetables, contains eight chambers, some intended but up to the present time very little has been done for work above freezing-point, others for work at or within the chambers of the heart. Bullets have been below it. Electric thermostats have been installed in removed from various situations in the heart, but no some of these chambers, and the expected range on has been made to bring the treatment of mitral attempt this floor will be 28-80’ F. On both floors the air- stenosis into line with that of strictures in other parts supply is so arranged that no exhaust from any chamber of the body. Recent experiments carried out upon to goes any other chamber ; thus there is no risk of dogs by D. S. Allen and E. A. Grahamat Washington contamination of material in one chamber by vapour University have now indicated the lines upon which from another. The top floor is not insulated as a this problem may be attacked. These observers have whole, being reserved for future extensions, but in one applied to the heart the principle of an operating part of it insulated tanks have been put down for cardioscope. the auriculo-ventricular valve beingZ) freezing by direct immersion in brine ; a small chamber approached through the wall of the auricle. It was will also be erected on this floor for prolonged tests of found that making an incision in most parts of the insulating materials under cold storage conditions- heart wall, whether auricle or ventricle. for passage of tests complementary to those carried out by the the instrument usually resulted in serious haemorrhage Engineering Committee of the National Physical or interference with the heart’s action, and that the Laboratory at Teddington. A striking additional necessary suturing was also unsatisfactory. They feature of the station is a small greenhouse on the roof, have accordingly introduced their cardioscope through designed for the study of the effect of low temperature the tip of the auricular appendage. This is usually upon plants exposed to full solar radiation-having long enough on the left side to be occluded while the insulated walls and floors and a roof of plain glass and instrument is introduced through an incision, and being fitted with refrigerating pipes. A bed of earth leakage of blood during the operation is prevented by has also been laid on the roof, traversed by refrigerat- a simple ligature round the instrument and appendage. ing pipes to admit of cooling of the roots of plants The same ligature is tied after the removal of the otherwise subjected to ordinary air temperatures. instrument and it seems that the end of the appendage These additions, it is hoped, will be of value in the can be sacrificed without detriment to the heart’s analysis of factors controlling the rate of growth of action. In this way the use of sutures in the heartwall crops. The engineering side of the equipment of the is avoided. When the cardioscope has entered the station proved a very complex problem ; the tempera- auricle it is pushed on until a lens at its extremity is ture obtainable in each chamber was required to be in contact with the valves that are the object actually not only of wide range, but also independent of that of attack. Direct vision is thus obtained in spite of of any other chamber. Carbonic acid gas, it may be the of the blood. A special knife introduced opacity noted, was chosen as the cooling substance in preference alongside the cardioscope is then brought into play, and to ammonia on account of the probable toxic action the valves may be slit with accuracy. The instrument of small quantities of ammonia on fruit or other living is then withdrawn and the auricular appendage ligasubstances. tured as already described. Post-operative mortality following this procedure has been high, but the cause DIAGNOSTIC AND THERAPEUTIC ERRORS IN of death has usually been empyema, presumably owing to some failure in asepsis. Several animals have, OPHTHALMOLOGY. of slitting the mitral survived the however, operation A SYSTEMATIC work on diagnostic and therapeutic and all these have developed a loud systolic errors and their avoidance is being published in valves, murmur as evidence that the objective had been Germany in separate volumes. Oneof these, the second in the series having to do with ophthalmology, reached. Developments in the surgery of the heart is intended as a guide to the general practitioner. For on these lines are to be expected. a practical guide it appears in some respects too full and in others too meagre. Two or three times every AGGLUTINATION AND COLLOID CHEMISTRY, year, says the author, cases of chronic glaucoma come THE paper by Dr. Takuji Shionoya, which we to his clinic which have been diagnosed by the general practitioner as ordinary senile cataract. To the man publish in our present issue, is a useful illustration of who could make such a mistake it is surely useless to the ever-widening influence of colloid chemistry on talk about measuring the tension of the eye with a biological investigation. The author starts from the tonometer, or examining the fundus to determine well-known facts first, that an agglutinin-bacteria whether or not there is cupping of the disc. It is adsorption complex is obtainable, and secondly, that positively dangerous to instruct such a man to measure the presence of salts is necessary for the agglutinathe field roughly by his hand because early glaucoma tion of this complex. By the use of solutions of the salts of various cations he shows that the as
are as
a
closed book to the practitioner and to the medical student. The position is one which cannot continue.
____
1 Erkrankungen der Iris, der Linse und des Glaskörpers. By Prof. Dr. U. Stock, Director of the Eye Clinic in the University of Tübingen. Leipzig : Georg Thieme. 1922. Pp. 32. 1s.
1 Jour. Amer. Med. Assoc., vol. lxxix., p. 1028, Sept. 23rd, 1922.