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EDITORIALS
in the late stages of retinitis pigmentosa. In the early stages of the disease, on the other hand, its development is usualy very slow, and yet the visual condition fluctuates appreciably from time to time. Young patients who still possess fairly good vision, and who are honestly advised as to the extreme uncertainty of beneficial results and also as to the unpleasant disturbances which commonly follow sympathectomy, are hardly likely to show enthusiasm for the experiment. Conscientious surgeons, too, may properly feel a good deal of reluctance to expose patients to these inconveniences in the earlier stages. It seems at least possible that some of the favorable results reported have depended partly upon an excess of credulity in the patient or even in the surgeon, and partly upon natural fluctuations in the patient's condition. It is a suggestive fact that after unilateral sympathectomy improvement has been reported as to both eyes. One patient showed no increase in visual field or acuity, but "believed" her night blindness had improved. Walsh and Sloan (Archives of Ophthalmology, 1935, volume 14, page 699) conclude that the merit of the operation is not yet proved, although they would not discard the procedure until further cases have been thoroughly studied. Karsch's review satisfies him that, in view of the unpleasant disturbances produced, the method has not been sufficiently successful to encourage its continuance or further development. As a general principle, it would be unscientific to argue that failure of previous experiments condemned trial of new measures. To what extent the hazards associated with further experimentation are justifiable is a problem for the surgical conscience. In the presence of substantial risks, it may be questioned whether operations should be urged for the mere purpose of adding to the sur-
313
geon's statistical material, especially when the evidence previously accumulated affords no significant prospect of success. W. H. Crisp.
GRADUATE STUDY The need for a physician to continue to study so long as he continues in practice, is being more widely recognized every year. The Research Study Club of Los Angeles met for its Sixth Annual Mid-Winter Course on Ophthalmology and Otolaryngology, January 18th to 29th; and the American Board of Ophthalmology held an examination in the Los Angeles County Hospital, on Saturday, January 23d. The registration for the Course was over two hundred, and about thirty took the examination for the Certificate of the Board. This year the foreign guest-teacher was Felix R. Nager, Professor of Otolaryngology in the Medical School of the University of Zurich, Switzerland. He proved to be a good teacher, with a broad view of his subject, of general pathology, and of the public responsibility of a medical man, whatever branch of medicine he may practice. In ophthalmology the principal course was given by Dr. Meyer Wiener, of St. Louis. He gave about twenty lectures on "The surgery of the eye." Beginning with the preparation of the patient, he discussed the details of operations, from those for cataract to those on the lids and lacrimal passages. He amply sustained his reputation as a skillful teacher. These courses were well iIIustrated, largely by lantern slides and drawings on an illuminated background. There were also valuable lectures by Dr. Frederick C. Cordes, Professor of Ophthalmology in the Medical School of the University of California, San Francisco, on the "Histopathology of the eye"
314
EDITORIALS
and "Recent phases of ocular therapeutics," and by the writer on "Applied physiologic optics." In addition to these instruction courses were given each day to groups of the class. Those on ophthalmology were on "Immunology of the ocular tissues," by H. F. Whalman; "Pathology of the eye," by 11. N. Beigelman; "Problems of refraction," by F. C. Cordes; "The eye muscles," by J. P. Lordan; "Sliplamp microscopy," by J. G. Kinney. "Anatomical studies, with specimens," by P. S. McKibben and W. J. Mellinger, were of interest to both groups. The discussion luncheons, devoted to answering questions from members of the class, were held each day and were found both interesting and instructive. The lectures were listed as didactic but were generally illustrated by outlines of clinical cases and lantern slides, showing pictures of patients, histopathology of cases, instruments, methods of treatment, and results attained. Even in general surgery it has been learned that "dry clinics" can be made more broadly instructive than clinic operations. In ophthalmology it has always been true that only a few could see the exact clinical conditions and operative technique. These mid-winter courses have always been well attended, by those who were practicing in the Pacific Coast States; but there have been some from all parts of the Rocky Mountain region. This year there were men from Canada, Pennsylvania, Ohio, Michigan, Minnesota, Indiana, Illinois, and one from India. The demand for such courses has now led to their establishment in all parts of the country. Often they are given in medical schools; but everywhere they rest on the support of the members of the medical profession who recognize that the rapid spread of scientific knowledge demands that they continue to be students. Edward Jackson.
EPIDEMIC KERATOCONJUNCTIVITIS DIVERSIFORMIS H. G. Merrill reported a series of cases of follicular conjunctivitis in the American Journal of Ophthalmology for November, 1936, page 137, under the title of "Epidemic keratoconjunctivitis diversiforrnis." He believed this condition to be similar to an epidemic described by Colonel Wright as occurring in India between 1928 and 1934. In Colonel Wright's clinic more than 1200 cases were seen. Dr. Merrill stated that he was seeing from one to eight cases daily, the numbers being slightly on the increase. Patients had consulted him especially from Idaho, Utah, California, and Nevada. Because of the lack of serious consequences, little attention has been paid to the disease and few comments have been received relative to the report. Major C. E. Rice, Surgeon, U.S.P.H.S., sent the editor a report from Dr. Louis A. Packard of Bakersfield, California, which was enclosed with an abstract of Dr. Merrill's paper. Dr. Packard submitted records from a study made in Bakersfield during the summer of 1930. In the spring of that year he had found a rapidly increasing number of cases such as those described by Wright and Merrill. Some of these quickly became severe, resembling mild trachoma. The absence of symptoms was noteworthy. A check of 5000 grammarschool children in Bakersfield during the summer of 1930 revealed that more than 70 percent of these children were estimated to be affected and 3544 of them attended a clinic established for their treatment. Dr. Packard saw from 10 to 20 cases each day in his office. In September of the same year, 1437 cases of the milder form were noted at the time of the opening of school. Few ophthalmologists apparently have observed the condition, although similar epidemics were noted in Imperial and
BOOK NOTICES
Kern counties. The condition has persisted in Bakersfield, but much lessened in degree. Well-nourished children are affected as frequently as the malnourished. Major Rice in commenting on these two reports in the Health Officer for January states that from descriptions the disease apparently resembles inclusionbody conjunctivitis, and an attempt to differentiate the two diseases should be made. The possibility that they are really the same disease is one that should be carefully considered, especially as Dr. Merrill has mentioned the presence of some sort of inclusion body. Although the disease is apparently a mild one, the reports cited indicate that it is very wide spread and extremely prevalent in the affected regions. It certainly would be well for ophthalmologists to be on the lookout for it in order that the necessary steps may be taken for combating its spread. The general acceptance in the last few years of the idea that a virus is the cause of trachoma and of inclusion-body conjunctivitis has awakened interest in the possibility that a virus may cause other ophthalmological inflammations. Much further work is necessary to determine the exact nature of these viruses and their relationships one to another. The small amount of virus material available from trachoma and inclusion-body conjunctivitis has handicapped their study very greatly. It is possible that this epidemic of follicular conjunctivitis might offer possibilities of more prolific investigations along these lines. Lawrence T. Post. BOOK NOTICES WILLS HOSPITAL EYE l\IANUAL FOR NURSES. By Gladys Elaine Cole, R.N. Cloth binding, 202 pages, 97 illustrations, price $1.75. Philadel-
315
phia and London, W. B. Saunders Company. This short book is a brief abstract of ophthalmic material, exceedingly well adapted to the purpose for which it is intended. The information, especially applicable for nurses, is good and important. The abstract of the general subject of ophthalmology is well chosen and adequate for the nurse. The book should be available in every nurses' training school and should be owned by any nurse who handles ophthalmic cases. The illustrations are numerous and well selected. The criticisms are minor ones: M.ore complete discussion as to the care of droppers; e.g., the impropriety of merely boiling used droppers without first cleaning them might be elaborated, as mere boiling will not eliminate the possible effects of such drugs as atropine. Also some discussion as to the desirable type of droppers and medicine bottles might be included. Suggestions as to the method of application of drops intended for intraocular absorption might be given. There is a question of the accuracy of the statement that cocaine and euphthalmine do not cause some loss of accommodation, and the failure to mention strong solutions of adrenalin in the group producing mydriasis without cycloplegic effect is worth noting. It seems to the reviewer that directions for the use of scopolamine hydrobromide should be qualified by some instruction as to its particular toxic action. In the paragraph on homatropine hydrobromide for refraction the frequency of its application is mentioned and the strength of the solution but not the number of instillations. Only one method of turning the upper eyelid is given and this method does not permit the holding of the dropper at the same time. Inasmuch as the application of drops is an important part of the nurse's duty it would seem that she should be instructed in several methods.
in the late stages of retinitis pigmentosa. In the early stages of the disease, on the other hand, its development is usualy very slow, and yet the visual condition fluctuates appreciably from time to time. Young patients who still possess fairly good vision, and who are honestly advised as to the extreme uncertainty of beneficial results and also as to the unpleasant disturbances which commonly follow sympathectomy, are hardly likely to show enthusiasm for the experiment. Conscientious surgeons, too, may properly feel a good deal of reluctance to expose patients to these inconveniences in the earlier stages. It seems at least possible that some of the favorable results reported have depended partly upon an excess of credulity in the patient or even in the surgeon, and partly upon natural fluctuations in the patient's condition. It is a suggestive fact that after unilateral sympathectomy improvement has been reported as to both eyes. One patient showed no increase in visual field or acuity, but "believed" her night blindness had improved. Walsh and Sloan (Archives of Ophthalmology, 1935, volume 14, page 699) conclude that the merit of the operation is not yet proved, although they would not discard the procedure until further cases have been thoroughly studied. Karsch's review satisfies him that, in view of the unpleasant disturbances produced, the method has not been sufficiently successful to encourage its continuance or further development. As a general principle, it would be unscientific to argue that failure of previous experiments condemned trial of new measures. To what extent the hazards associated with further experimentation are justifiable is a problem for the surgical conscience. In the presence of substantial risks, it may be questioned whether operations should be urged for the mere purpose of adding to the sur-
313
geon's statistical material, especially when the evidence previously accumulated affords no significant prospect of success. W. H. Crisp.
GRADUATE STUDY The need for a physician to continue to study so long as he continues in practice, is being more widely recognized every year. The Research Study Club of Los Angeles met for its Sixth Annual Mid-Winter Course on Ophthalmology and Otolaryngology, January 18th to 29th; and the American Board of Ophthalmology held an examination in the Los Angeles County Hospital, on Saturday, January 23d. The registration for the Course was over two hundred, and about thirty took the examination for the Certificate of the Board. This year the foreign guest-teacher was Felix R. Nager, Professor of Otolaryngology in the Medical School of the University of Zurich, Switzerland. He proved to be a good teacher, with a broad view of his subject, of general pathology, and of the public responsibility of a medical man, whatever branch of medicine he may practice. In ophthalmology the principal course was given by Dr. Meyer Wiener, of St. Louis. He gave about twenty lectures on "The surgery of the eye." Beginning with the preparation of the patient, he discussed the details of operations, from those for cataract to those on the lids and lacrimal passages. He amply sustained his reputation as a skillful teacher. These courses were well iIIustrated, largely by lantern slides and drawings on an illuminated background. There were also valuable lectures by Dr. Frederick C. Cordes, Professor of Ophthalmology in the Medical School of the University of California, San Francisco, on the "Histopathology of the eye"
314
EDITORIALS
and "Recent phases of ocular therapeutics," and by the writer on "Applied physiologic optics." In addition to these instruction courses were given each day to groups of the class. Those on ophthalmology were on "Immunology of the ocular tissues," by H. F. Whalman; "Pathology of the eye," by 11. N. Beigelman; "Problems of refraction," by F. C. Cordes; "The eye muscles," by J. P. Lordan; "Sliplamp microscopy," by J. G. Kinney. "Anatomical studies, with specimens," by P. S. McKibben and W. J. Mellinger, were of interest to both groups. The discussion luncheons, devoted to answering questions from members of the class, were held each day and were found both interesting and instructive. The lectures were listed as didactic but were generally illustrated by outlines of clinical cases and lantern slides, showing pictures of patients, histopathology of cases, instruments, methods of treatment, and results attained. Even in general surgery it has been learned that "dry clinics" can be made more broadly instructive than clinic operations. In ophthalmology it has always been true that only a few could see the exact clinical conditions and operative technique. These mid-winter courses have always been well attended, by those who were practicing in the Pacific Coast States; but there have been some from all parts of the Rocky Mountain region. This year there were men from Canada, Pennsylvania, Ohio, Michigan, Minnesota, Indiana, Illinois, and one from India. The demand for such courses has now led to their establishment in all parts of the country. Often they are given in medical schools; but everywhere they rest on the support of the members of the medical profession who recognize that the rapid spread of scientific knowledge demands that they continue to be students. Edward Jackson.
EPIDEMIC KERATOCONJUNCTIVITIS DIVERSIFORMIS H. G. Merrill reported a series of cases of follicular conjunctivitis in the American Journal of Ophthalmology for November, 1936, page 137, under the title of "Epidemic keratoconjunctivitis diversiforrnis." He believed this condition to be similar to an epidemic described by Colonel Wright as occurring in India between 1928 and 1934. In Colonel Wright's clinic more than 1200 cases were seen. Dr. Merrill stated that he was seeing from one to eight cases daily, the numbers being slightly on the increase. Patients had consulted him especially from Idaho, Utah, California, and Nevada. Because of the lack of serious consequences, little attention has been paid to the disease and few comments have been received relative to the report. Major C. E. Rice, Surgeon, U.S.P.H.S., sent the editor a report from Dr. Louis A. Packard of Bakersfield, California, which was enclosed with an abstract of Dr. Merrill's paper. Dr. Packard submitted records from a study made in Bakersfield during the summer of 1930. In the spring of that year he had found a rapidly increasing number of cases such as those described by Wright and Merrill. Some of these quickly became severe, resembling mild trachoma. The absence of symptoms was noteworthy. A check of 5000 grammarschool children in Bakersfield during the summer of 1930 revealed that more than 70 percent of these children were estimated to be affected and 3544 of them attended a clinic established for their treatment. Dr. Packard saw from 10 to 20 cases each day in his office. In September of the same year, 1437 cases of the milder form were noted at the time of the opening of school. Few ophthalmologists apparently have observed the condition, although similar epidemics were noted in Imperial and
BOOK NOTICES
Kern counties. The condition has persisted in Bakersfield, but much lessened in degree. Well-nourished children are affected as frequently as the malnourished. Major Rice in commenting on these two reports in the Health Officer for January states that from descriptions the disease apparently resembles inclusionbody conjunctivitis, and an attempt to differentiate the two diseases should be made. The possibility that they are really the same disease is one that should be carefully considered, especially as Dr. Merrill has mentioned the presence of some sort of inclusion body. Although the disease is apparently a mild one, the reports cited indicate that it is very wide spread and extremely prevalent in the affected regions. It certainly would be well for ophthalmologists to be on the lookout for it in order that the necessary steps may be taken for combating its spread. The general acceptance in the last few years of the idea that a virus is the cause of trachoma and of inclusion-body conjunctivitis has awakened interest in the possibility that a virus may cause other ophthalmological inflammations. Much further work is necessary to determine the exact nature of these viruses and their relationships one to another. The small amount of virus material available from trachoma and inclusion-body conjunctivitis has handicapped their study very greatly. It is possible that this epidemic of follicular conjunctivitis might offer possibilities of more prolific investigations along these lines. Lawrence T. Post. BOOK NOTICES WILLS HOSPITAL EYE l\IANUAL FOR NURSES. By Gladys Elaine Cole, R.N. Cloth binding, 202 pages, 97 illustrations, price $1.75. Philadel-
315
phia and London, W. B. Saunders Company. This short book is a brief abstract of ophthalmic material, exceedingly well adapted to the purpose for which it is intended. The information, especially applicable for nurses, is good and important. The abstract of the general subject of ophthalmology is well chosen and adequate for the nurse. The book should be available in every nurses' training school and should be owned by any nurse who handles ophthalmic cases. The illustrations are numerous and well selected. The criticisms are minor ones: M.ore complete discussion as to the care of droppers; e.g., the impropriety of merely boiling used droppers without first cleaning them might be elaborated, as mere boiling will not eliminate the possible effects of such drugs as atropine. Also some discussion as to the desirable type of droppers and medicine bottles might be included. Suggestions as to the method of application of drops intended for intraocular absorption might be given. There is a question of the accuracy of the statement that cocaine and euphthalmine do not cause some loss of accommodation, and the failure to mention strong solutions of adrenalin in the group producing mydriasis without cycloplegic effect is worth noting. It seems to the reviewer that directions for the use of scopolamine hydrobromide should be qualified by some instruction as to its particular toxic action. In the paragraph on homatropine hydrobromide for refraction the frequency of its application is mentioned and the strength of the solution but not the number of instillations. Only one method of turning the upper eyelid is given and this method does not permit the holding of the dropper at the same time. Inasmuch as the application of drops is an important part of the nurse's duty it would seem that she should be instructed in several methods.