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INTERNATIONAL CANCER CONVENTION.
765 to employ an open or closed method of drainage is not of such moment to the patient as the choice of the most favourable time to perform the operation. Whether the patient is to be left with a large cavity which will not heal without further surgical help, whether, in fact, he is to become a chronic invalid, depends scarcely at all upon whether an open or closed method of drainage has been used, but upon the presence or absence of adhesions round the periphery of the empyema which are strong enough to prevent the lung from collapsing when the cavity is opened. Aspiration should be employed until the surgeon is reasonably sure that this state of affairs exists. The removal of thick pus with a needle is usually a sign that it is safe to open the cavity. When only turbid fluid is withdrawn operation had better be postponed. In this stage also the sudden collapse of the lung which the operation would bring about has other dangers for the patient beyond that of leaving him with a chronic empyema cavity ; it may suddenly flood the circulation with a dose of toxin with which he is unable to deal. Early operation in empyema is immediately risky and may be the cause of serious later trouble. Many surgeons will agree with Farr and Levine that the method of drainage has very little significance upon prognosis. The various closed methods of drainage have all been devised with the idea of making this discharge of pus easy while the ingress of air into the chest during inspiration should be hindered. As a rule, there is scarcely any advantage to be gained by using them ; sometimes indeed they impede, to some extent, the exit of pus. A simple moderately sized drainage-tube cut almost level with the skin round which the tissues are snugly sutured and covered with a thick dressing is very satisfactory. With coughing and other expiratory efforts pus can be freely expelled, but during expiration the dressing is sucked tightly against the open end of the tube, thereby occluding it. Particularly when the gauze is soaked with discharged pus does this valvular mechanism come into play. The simplest method seems here the best. Whether for drainage an intercostal incision should be made or a piece of rib removed does not seem to be very material; it should be remembered, however, that when aspiration has shown pneumococci alone to be present, it will sometimes be possible to avoid any operation whatsover. Repeated aspiration may suffice to bring the case to a successful conclusion.
Annotations. 11 Ne quid nimis."
THE CAUSATION OF GLAUCOMA. GLAUCOMA is essentially an increase in the intrafluid pressure, greater than the inextensible outer coat of the eyeball is able to sustain without involving serious injury to the visual mechanism which it encloses. The fluid content of the eyeball’ is in either constant or intermittent flux, the ingress. depending either, as Treacher Collins first taught, on the secretory activity of the ciliary body, as W. E. Duke-Elder maintains, on the or, osmotic interchange of fluid through the capillary walls, whilst the egress depends, apart from this sameosmotic interchange, on the efficiency of the drainage system. In normal eyes this is so perfect that anyextra influx of fluid into the eyeball is at once com-pensated for by an extra outflow of an equivalent amount. It was at one time supposed that the cause of glaucomatous rise of tension is to be found in an increased influx of fluid, and recently this idea has been revived by E. P. Fortin.2 On the other hand, the view till lately almost universally held is that the cause of high tension is an interference with thedrainage system by the partial or complete closureof the angle of the anterior chamber, rendering it difficult for the aqueous to have access to Schlemm’s canal. Nevertheless, Duke-Elder, in the work already referred to, inclines to the opinion that obstruction to the exit of fluid is a secondary or adjuvant factor in the aetiology of the disease. In chronic glaucoma adhesions of the periphery of the iris to the back of the cornea have been demonstrated and it is generally believed that such adhesions are facilitated by a large crystalline lens, a relatively small cornea, a swollen ciliary body, and, generally speaking, by anything which increases the pressure from behind the iris, causing the anterior chamber to be shallow. It is in these cases that the trephining operation is most likely to be successful. In glaucoma secondary to iritis or to some other primary causes the matter is not so simple. We must attack theprimary condition. There are yet other cases which may show a glaucomatous cupping of the disc and a progressive contraction of the visual field without a shallow chamber and without any demonstrable rise tension. Long ago Schnabel called these cases of INTERNATIONAL CANCER CONVENTION. Others " cavernous atrophy of the optic nerve." it is WE announced some weeks ago that the British have observed similar cases of late years, and to a trephining operation difficult how understand Empire Cancer Campaign was to hold an international could do them any good. But borderland cases alsÚ" convention in London in July, and we are now able of raised tension may be few to give a provisional account of the programme. occur in which periods far but do occur. We shall have tÛ’ between and On Monday, July 16th, the delegates will be received " recognise that the term glaucoma is a wide oneby the President, Sir John Bland-Sutton ; the following covering cases of varying pathology and possibly day will be given up to general discussions on the requiring varying treatment. Meantime, with regard relative value of surgery and radiation in the treat- to of cases, the weight of opinion the majority great ment of cancer of the cervix, rectum, buccal cavity in this country will and breast, and on the aetiology of cancer ; whilst among ophthalmic surgeons with the views put forward by Mr. Leighton coincide Wednesday, the 18th, will be devoted to sectional Davis in the article which appeared in our columnsr, discussions and a reception by the Duke of York. last week. It is well to remember, however, that The subjects to be considered by the various sections the trephining operation is an excellent one though include the biological effects of radium and X rays ; it can scarcely be deemed perfect. No operation in relations the between clinical occupational cancer ; which the failures amount to as as 9 per centmalignancy, histological characters and response can be considered as such, and nomany ophthalmic surgeon to treatment; diagnostic methods ; the geographical can undertake an operation for glaucoma without a and racial prevalence of cancer; and the public In action that should be taken to control the disease. certain amount of anxietv as to the result. The section of surgery will have a session on cancer these circumstances, and in view of the number of of the stomach, and there will be a general discussion cases in which any operative treatment is for one of chemotherapeutic methods, with special reference reason and another impracticable, we do not think to lead, by the Convention as a whole. Those who that the importance of treatment by eserine should be wish to contribute to the discussions should com- minimised. In some cases it is capable of preventing municate with Mr. Cecil Rowntree, chairman of the the vision from deteriorating for years; though executive subcommittee, at 9, Upper Brook-street, this may be exceptional, and though the practice of London, W. 1. It is hoped to arrange for operations 1 Recent Advances in Ophthalmology (see THE LANCET, and demonstrations at various centres every afternoon 1927, ii., 922). 2 during the meeting. Semana Medical, 1927, ii., 663.
I ocular
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Annotations. 11 Ne quid nimis."
THE CAUSATION OF GLAUCOMA. GLAUCOMA is essentially an increase in the intrafluid pressure, greater than the inextensible outer coat of the eyeball is able to sustain without involving serious injury to the visual mechanism which it encloses. The fluid content of the eyeball’ is in either constant or intermittent flux, the ingress. depending either, as Treacher Collins first taught, on the secretory activity of the ciliary body, as W. E. Duke-Elder maintains, on the or, osmotic interchange of fluid through the capillary walls, whilst the egress depends, apart from this sameosmotic interchange, on the efficiency of the drainage system. In normal eyes this is so perfect that anyextra influx of fluid into the eyeball is at once com-pensated for by an extra outflow of an equivalent amount. It was at one time supposed that the cause of glaucomatous rise of tension is to be found in an increased influx of fluid, and recently this idea has been revived by E. P. Fortin.2 On the other hand, the view till lately almost universally held is that the cause of high tension is an interference with thedrainage system by the partial or complete closureof the angle of the anterior chamber, rendering it difficult for the aqueous to have access to Schlemm’s canal. Nevertheless, Duke-Elder, in the work already referred to, inclines to the opinion that obstruction to the exit of fluid is a secondary or adjuvant factor in the aetiology of the disease. In chronic glaucoma adhesions of the periphery of the iris to the back of the cornea have been demonstrated and it is generally believed that such adhesions are facilitated by a large crystalline lens, a relatively small cornea, a swollen ciliary body, and, generally speaking, by anything which increases the pressure from behind the iris, causing the anterior chamber to be shallow. It is in these cases that the trephining operation is most likely to be successful. In glaucoma secondary to iritis or to some other primary causes the matter is not so simple. We must attack theprimary condition. There are yet other cases which may show a glaucomatous cupping of the disc and a progressive contraction of the visual field without a shallow chamber and without any demonstrable rise tension. Long ago Schnabel called these cases of INTERNATIONAL CANCER CONVENTION. Others " cavernous atrophy of the optic nerve." it is WE announced some weeks ago that the British have observed similar cases of late years, and to a trephining operation difficult how understand Empire Cancer Campaign was to hold an international could do them any good. But borderland cases alsÚ" convention in London in July, and we are now able of raised tension may be few to give a provisional account of the programme. occur in which periods far but do occur. We shall have tÛ’ between and On Monday, July 16th, the delegates will be received " recognise that the term glaucoma is a wide oneby the President, Sir John Bland-Sutton ; the following covering cases of varying pathology and possibly day will be given up to general discussions on the requiring varying treatment. Meantime, with regard relative value of surgery and radiation in the treat- to of cases, the weight of opinion the majority great ment of cancer of the cervix, rectum, buccal cavity in this country will and breast, and on the aetiology of cancer ; whilst among ophthalmic surgeons with the views put forward by Mr. Leighton coincide Wednesday, the 18th, will be devoted to sectional Davis in the article which appeared in our columnsr, discussions and a reception by the Duke of York. last week. It is well to remember, however, that The subjects to be considered by the various sections the trephining operation is an excellent one though include the biological effects of radium and X rays ; it can scarcely be deemed perfect. No operation in relations the between clinical occupational cancer ; which the failures amount to as as 9 per centmalignancy, histological characters and response can be considered as such, and nomany ophthalmic surgeon to treatment; diagnostic methods ; the geographical can undertake an operation for glaucoma without a and racial prevalence of cancer; and the public In action that should be taken to control the disease. certain amount of anxietv as to the result. The section of surgery will have a session on cancer these circumstances, and in view of the number of of the stomach, and there will be a general discussion cases in which any operative treatment is for one of chemotherapeutic methods, with special reference reason and another impracticable, we do not think to lead, by the Convention as a whole. Those who that the importance of treatment by eserine should be wish to contribute to the discussions should com- minimised. In some cases it is capable of preventing municate with Mr. Cecil Rowntree, chairman of the the vision from deteriorating for years; though executive subcommittee, at 9, Upper Brook-street, this may be exceptional, and though the practice of London, W. 1. It is hoped to arrange for operations 1 Recent Advances in Ophthalmology (see THE LANCET, and demonstrations at various centres every afternoon 1927, ii., 922). 2 during the meeting. Semana Medical, 1927, ii., 663.
I ocular
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