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Evaluation of Clinical and Laboratory Findings
162
EDITORIALS
tending from the southern Allegheny Mountains to Kansas and Oklahoma, and to the Indian tribes. The negroes seem quite immune to trachoma. It is also common among the Indians of western Canada. Trachoma is a very serious cause of blindness in China, Indo-China, and the Dutch East In dies. In Java, the trachoma index is 5 percent among the Europeans, and 16.5 percent among natives. Racial immu nity, or tendency to it, must be con sidered, but habits of living are very important. The efforts to prevent trachoma have been greatly handicapped by ignorance as to its specific cause. In spite of our knowing that it is spread by contagion, the particular germ or virus causing it has remained uncertain. The observa tions recently reported in this Journal (1935, v. 18, p. 811) seem to throw im portant light upon the subject. But smallpox was eradicated by vaccina tion before there was the knowledge or the discovery of a germ for it, or of the nature of its specific virus. We know about trachoma that under regu lar, effective treatment it ceases to be contagious; and that by segregation and treatment, its spread can be con trolled. Its tendency to cause blindness, either by corneal involvement or by distortion of the lids and consequent injury to the cornea, makes persistent treatment of it by well-known local remedies very important; and not only for the prevention of blindness, but for the comfort of the patient as well. Edward Jackson. EVALUATION OF CLINICAL AND LABORATORY FINDINGS The correct evaluation of a method of treatment is often exceedingly diffi cult, even when both clinical and labo ratory tests can be made. If the evi dence derived from these two methods is in agreement, the case is apt to be proved, although both are open to er rors. In those cases, however, in which clinical and laboratory findings sug gest opposite conclusions, the physi cian is left in doubt. Usually, the clini
cian is the enthusiast; the laboratory worker the restrainer. As to the for mer, he can observe the action on the patient, and this is, after all, the point under consideration. But so many fac tors other than those in question can be influential in producing the effect in an individual subject, that it is not always possible to be certain that the therapy involved produced the result noted. In the laboratory, known materials can be used and exact experiments per formed. The test-tube outcome can be predicted and the laboratory possibili ties of the new treatment can be de termined. But man is no test tube, and in his enormously complicated mecha nism are multitudinous unknown fac tors that may vitally modify the labo ratory experiment. It is best, therefore, to keep an open mind, to weigh most carefully labora tory evidence against clinical evidence, and if these differ to be slow in arriv ing at a conclusion. In such a state is aniseikonia today. Thus far, no one who has used the new instrument for determining size-image differences and has prescribed the lenses indicated in the examination of many patients is known to have been unimpressed by the number of patients made comfortable by size-image cor rections ; and if ever there was a diffi cult group of patients with which to deal, this is it, for the unfortunates who compose it have been from pillar to post seeking without avail relief from the intolerable eyestrain of which they complain and which has usually inca pacitated them for close work. In the St. Louis eikonic clinic, which has been conducted for a year and four months, about sixty percent of those for whom eikonic corrections were ordered have been clinically helped— some of them amazingly. Every effort has been made to conduct the test critically and skeptically. The work has been done by an ophthalmologist whose only interest has been to determine, if possible clinically, whether there is real merit in this test. The importance of the psychic effect is never for one mo ment overlooked, and although every
BOOK NOTICES effort has been made to eliminate this, its possible weight as a factor in the good results is so seriously considered that no clinical conclusion can yet be given. On the other hand, though clinical evidence may seem very suggestive, laboratory tests indicate that the ele ment of unequal size of retinal images in amounts found with the eikonometer cannot be of very great importance, since they are equalled or surpassed frequently in many of the activities of a routine day. An excellent article on this subject will appear in an early is sue of the Journal. This and other theo retical papers previously published are so suggestive as to force the careful reconsideration of the cases clinically aided by eikonic lenses. It is difficult to explain as psychical many of the cases that we have seen personally, such as that of a thirty-year-old sur geon who said, when told that theo retically the help he was experiencing could not derive from his eikonic lenses, "Let me give my own evidence. I have tried the glasses out in every way for the past six months, and whereas I was about to give up surgery because of my ocular discomfort, I can now, when using the correct eikonic lens, carry on with perfect comfort." This patient is only one of several who feel equally strongly and have been equally critical, but, obviously, this is not conclusive evidence. Other factors may be present that have in fluenced these persons favorably. Fur thermore, some patients who apparent ly should be helped are not. The pos sibility that the correcting of aniseikonia may act favorably on heterophoria has been pointed out by more than one writer on the subject, and this factor must be considered. More instruments will soon be in use. It is most important that clinical reports be published by those who have only a scientific interest in the matter, so that the truth can be determined as early as possible. This is the desire of the originators of the instrument. They have a strong belief that the subject is of great clinical importance. From the standpoint of the individual who is
163
helped, it is unimportant whether his improvement is of mental or optical origin, but it is of great importance to the physician, for these are very elabo rate and expensive tests to be done solely for their psychic effect. Lawrence T. Post. BOOK NOTICES Pacific Coast Oto-Ophthalmological Society, 1935. 180 pages, 2 plates, 15 illustrations in the text. Pub lished by the Society, Dr. Fred erick C. Cordes, Secretary. This twenty-third annual meeting of the Society was held in Portland, Ore gon. The Society, with its 351 members, its 41 Honorary and Associate mem bers, the latter scattered from Vienna and London to Victoria and San Diego, is devoted to both ophthalmology and oto-laryngology. The subjects of par ticular interest to ophthalmologists were: Surgical correction of pure con vergence insufficiency; Hyaline bodies (Drusen) of the optic nerve and retina; Tuberculosis of the uveal tract; Spheno-palatine ganglion neuralgia, Iris bombe, The Genesis of glaucoma; A clamp for holding lid sutures in cataract operations; Unusual bilateral retinal detachment; and moving pic tures of the Safar operation for de tachment of the retina. At this meeting the Society inaugu rated an Instruction Course, of which no account is given in the Transac tions. But for the course a synopsis was furnished of each subject; and, generally, with references to the pe riodical literature and books bearing upon it. The subjects of interest to ophthalmologists were: Uses of the cross cylinder; Injuries of the eye and their treatment; Practical application of slitlamp observations; Management of foreign bodies in the eyeball; Man agement of problems of cataract surgery; and Diagnosis and treatment of diseases of the cornea. The interest manifested in such in struction has led to the policy of in cluding it in connection with each an nual meeting. Edward Jackson.
EDITORIALS
tending from the southern Allegheny Mountains to Kansas and Oklahoma, and to the Indian tribes. The negroes seem quite immune to trachoma. It is also common among the Indians of western Canada. Trachoma is a very serious cause of blindness in China, Indo-China, and the Dutch East In dies. In Java, the trachoma index is 5 percent among the Europeans, and 16.5 percent among natives. Racial immu nity, or tendency to it, must be con sidered, but habits of living are very important. The efforts to prevent trachoma have been greatly handicapped by ignorance as to its specific cause. In spite of our knowing that it is spread by contagion, the particular germ or virus causing it has remained uncertain. The observa tions recently reported in this Journal (1935, v. 18, p. 811) seem to throw im portant light upon the subject. But smallpox was eradicated by vaccina tion before there was the knowledge or the discovery of a germ for it, or of the nature of its specific virus. We know about trachoma that under regu lar, effective treatment it ceases to be contagious; and that by segregation and treatment, its spread can be con trolled. Its tendency to cause blindness, either by corneal involvement or by distortion of the lids and consequent injury to the cornea, makes persistent treatment of it by well-known local remedies very important; and not only for the prevention of blindness, but for the comfort of the patient as well. Edward Jackson. EVALUATION OF CLINICAL AND LABORATORY FINDINGS The correct evaluation of a method of treatment is often exceedingly diffi cult, even when both clinical and labo ratory tests can be made. If the evi dence derived from these two methods is in agreement, the case is apt to be proved, although both are open to er rors. In those cases, however, in which clinical and laboratory findings sug gest opposite conclusions, the physi cian is left in doubt. Usually, the clini
cian is the enthusiast; the laboratory worker the restrainer. As to the for mer, he can observe the action on the patient, and this is, after all, the point under consideration. But so many fac tors other than those in question can be influential in producing the effect in an individual subject, that it is not always possible to be certain that the therapy involved produced the result noted. In the laboratory, known materials can be used and exact experiments per formed. The test-tube outcome can be predicted and the laboratory possibili ties of the new treatment can be de termined. But man is no test tube, and in his enormously complicated mecha nism are multitudinous unknown fac tors that may vitally modify the labo ratory experiment. It is best, therefore, to keep an open mind, to weigh most carefully labora tory evidence against clinical evidence, and if these differ to be slow in arriv ing at a conclusion. In such a state is aniseikonia today. Thus far, no one who has used the new instrument for determining size-image differences and has prescribed the lenses indicated in the examination of many patients is known to have been unimpressed by the number of patients made comfortable by size-image cor rections ; and if ever there was a diffi cult group of patients with which to deal, this is it, for the unfortunates who compose it have been from pillar to post seeking without avail relief from the intolerable eyestrain of which they complain and which has usually inca pacitated them for close work. In the St. Louis eikonic clinic, which has been conducted for a year and four months, about sixty percent of those for whom eikonic corrections were ordered have been clinically helped— some of them amazingly. Every effort has been made to conduct the test critically and skeptically. The work has been done by an ophthalmologist whose only interest has been to determine, if possible clinically, whether there is real merit in this test. The importance of the psychic effect is never for one mo ment overlooked, and although every
BOOK NOTICES effort has been made to eliminate this, its possible weight as a factor in the good results is so seriously considered that no clinical conclusion can yet be given. On the other hand, though clinical evidence may seem very suggestive, laboratory tests indicate that the ele ment of unequal size of retinal images in amounts found with the eikonometer cannot be of very great importance, since they are equalled or surpassed frequently in many of the activities of a routine day. An excellent article on this subject will appear in an early is sue of the Journal. This and other theo retical papers previously published are so suggestive as to force the careful reconsideration of the cases clinically aided by eikonic lenses. It is difficult to explain as psychical many of the cases that we have seen personally, such as that of a thirty-year-old sur geon who said, when told that theo retically the help he was experiencing could not derive from his eikonic lenses, "Let me give my own evidence. I have tried the glasses out in every way for the past six months, and whereas I was about to give up surgery because of my ocular discomfort, I can now, when using the correct eikonic lens, carry on with perfect comfort." This patient is only one of several who feel equally strongly and have been equally critical, but, obviously, this is not conclusive evidence. Other factors may be present that have in fluenced these persons favorably. Fur thermore, some patients who apparent ly should be helped are not. The pos sibility that the correcting of aniseikonia may act favorably on heterophoria has been pointed out by more than one writer on the subject, and this factor must be considered. More instruments will soon be in use. It is most important that clinical reports be published by those who have only a scientific interest in the matter, so that the truth can be determined as early as possible. This is the desire of the originators of the instrument. They have a strong belief that the subject is of great clinical importance. From the standpoint of the individual who is
163
helped, it is unimportant whether his improvement is of mental or optical origin, but it is of great importance to the physician, for these are very elabo rate and expensive tests to be done solely for their psychic effect. Lawrence T. Post. BOOK NOTICES Pacific Coast Oto-Ophthalmological Society, 1935. 180 pages, 2 plates, 15 illustrations in the text. Pub lished by the Society, Dr. Fred erick C. Cordes, Secretary. This twenty-third annual meeting of the Society was held in Portland, Ore gon. The Society, with its 351 members, its 41 Honorary and Associate mem bers, the latter scattered from Vienna and London to Victoria and San Diego, is devoted to both ophthalmology and oto-laryngology. The subjects of par ticular interest to ophthalmologists were: Surgical correction of pure con vergence insufficiency; Hyaline bodies (Drusen) of the optic nerve and retina; Tuberculosis of the uveal tract; Spheno-palatine ganglion neuralgia, Iris bombe, The Genesis of glaucoma; A clamp for holding lid sutures in cataract operations; Unusual bilateral retinal detachment; and moving pic tures of the Safar operation for de tachment of the retina. At this meeting the Society inaugu rated an Instruction Course, of which no account is given in the Transac tions. But for the course a synopsis was furnished of each subject; and, generally, with references to the pe riodical literature and books bearing upon it. The subjects of interest to ophthalmologists were: Uses of the cross cylinder; Injuries of the eye and their treatment; Practical application of slitlamp observations; Management of foreign bodies in the eyeball; Man agement of problems of cataract surgery; and Diagnosis and treatment of diseases of the cornea. The interest manifested in such in struction has led to the policy of in cluding it in connection with each an nual meeting. Edward Jackson.