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STEREOSCOPIC RADIOGRAPHY.
822
mosquito control or research, and given by the staff to visitors to the museum, who have numbered 6551 in the past fiveand a half years. Photographs and lantern slides are also produced and lectures and demonstrations are given at scientific meetings. No detailed account of the work is attempted in the report, but certain items of interest are described. Among these may be mentioned the investigation of a number of females of Aedes cirzereus from the neighbourhood of Birmingham which were infested with larval hydrachnid mites, and a study of the habits of Culex pipiens by a zoology student of Cambridge University. An account is given of modifications and developments in the special apparatus originally designed by the Director in 1923 for ordinary and stereoscopic photography of insects, and a chart is reproduced which gives particulars of larvae collected on Hayling Island. short
courses
on
casual information
is steadily increasing. In an editorial published in the same issue the Journal of the American Medical Åssociat’ion doubts very seriously whether it is a sound trend in human life to postpone maturity more and more. The best conditions for reproduction exist before the age of 30, but no member of a profession nowadayshas an economic chance of marriage before that age. The editorial further points out that if the sum represented by the cost of a medical education were properly invested for a young man at the age of 20, he would, by the time he was 50, have an income which would maintain him in comfort for the rest of his life. It is a reasonable question whether the average income of the physician represents a proper economic return on the cost of his education. It is easier to point out the difficulties than to suggest their solution. The Jourital calls for more actual evidence, such as that offered by Dr. Leland, to take the place of arm-chair philosophy and unpractical ideals. ____
AMERICA. without,
COST OF MEDICAL EDUCATION IN IT is generally reckoned in this country that it costs round about S1000 to obtain a medical degree, of course, counting the money that the student might be earning during his fiveor six years’ education. The figure naturally varies with the amount of hard. ship which he is prepared to endure and with the fees and extras of the particular college which he selects. It is interesting to compare this rough popular estimate with a careful investigation of the costs of medical education in the United States which was published recently by Dr. R. G. Leland.1 He finds that the average annual sum spent by the student is$1100, this being an increase of$200 a year on the figure for 1920. At the lowest possible estimate, therefore, a medical education must cost at least$5000, and if all the factors, such as pre-medical education, expenses during post-graduate education and loss of potential income from other professions, are taken into consideration the actual cash cost may be more nearly$10,000. The information was obtained by giving expense-books to students and asking them to keep an account of their expenditure. As a result 1253 books were available, and this was reduced to 1161 when married students and students living at home were subtracted. The number is obviously insufficient for more than guarded conclusions. The fees in American universities differ very considerably - from$66 to$610 a year. The average amount expended for books, instruments, and journals also varied widely, from$67 to$189, and the expense for room and board varied from$272 at the University of Illinois to$569 at Harvard. The highest average total cost was$1716 per annum at Dartmouth Medical School, with Harvard a close second, while the lowest reported was$425 at the University of Wisconsin. Apparently at least half the students find time to There earn some money while they are working. seems to be a gradual increase in expense as the student years go by, except that freshmen pay more for their books and instruments. There also seems to have been a steady increase in expense during recent years; tuition and fees, books and instruments now cost over 50 per cent. more than in 1920. On the other hand, the cost of room, board, and clothing has only risen very slightly, and there is a decided decrease in expenses for recreation. A corresponding study in this country would be of interest. Medical students here suffer greatly from the lack of facilities for earning money in their spare time, and the length and expense of the curriculum 1 Jour. Amer. Med. Assoc., Feb. 28th, p. 682.
STEREOSCOPIC RADIOGRAPHY. MEDICAL opinion in this country is divided on the value of stereoscopy in the diagnosis of chest diseases. The tuberculosis experts who made a tour last summer of institutions in Canada and the United States were struck by the reliance there placed upon stereoscopic radiography, and on their initiative the subject came up for full discussion at the Oxford meeting of the Tuberculosis Association reported elsewhere in Dr. J. B. Christopherson indicated our columns. at the outset that the ordinary radiogram of the thorax is a shadowgraph-a picture of a flat area, having two dimensions-and that in order to unravel questions of orientation and of relative depth of structures, or to discover the relative position of different parts of the same structure in the chest, resort must be had to screening or to the study of films taken from different angles. The aim of stereoscopic radiography is to introduce the additional factor of solidity or depth. Binocular vision is stereoscopic vision, and stereoscopic vision might be defined as the direct perception of the relative distances of objects. Until, however, two films can be taken simultaneously the success of a stereoscopic picture of the chest will largely depend on the exact maintenance of immobility during exposure, a period of 31/5 seconds with the apparatus in use at Victoria He had found radiostereoscopy of Park Hospital. the chest of special value in four conditions : (1) in artificial pneumothorax, for orientating adhesions; (2) in cases where lipiodol is used for investigation; (3) for locating foreign bodies ; and (4) for locating cavities in tuberculous lungs. Unsatisfactory stereoscopic effects in chest cases were due as a rule, he thought, to failure in equipment, which more collaboration between clinician, radiologists, and engineer might be expected to eliminate. Dr. Peter Edwards (Cheshire) admitted that stereoscopy had given him a new interpretation of the value of X ray films in his daily work. His routine was to screen every chest, and then to decide whether to take a flat or a stereo film. Eight types he selected for the stereo were : (1) one that revealed very little wrong on the screen ; (2) one that revealed a foreign body; (3) one that revealed a hydatid ; (4) the doubtful silicotic ; (5) the artificial pneumothorax case with adhesions, to decide as to thoracoscopy ; (6) cases after injection with lipiodol; (7) cases in which there was encysted fluid ; (8) cases in which it was essential to localise the lobe in which there was an abscess, or bronchiectasis. Moreover, in the stereo one often found early indication of the development of disease.
823 which could only be seen in the flat film months later. With good screening and stereos he thought there would be less need for the thoracoscope. With the apparatus he used both exposures could be taken in 9/20 second. Dr. L. B. Stott (Papworth) enumerated various possible sources of error in shadow stereography, such as the fact that minute lateral displacements will produce considerable anteroposterior distortion, and the increase or decrease of the stereoscopic effect according to the different degrees of tissue translucency to X rays. The clinician, he thought, was on safer ground in depending upon conscious deduction from anteroposterior and lateral views rather than running the risk of stereoscopic illusion. Many speakers formed a bridge between these extreme views. It was suggested that the conflict might be due, at least in part, to stereoscopic blindness, unsuspected by those who suffered from it. ____
an electric cautery. R. Rubbrecht, of makes an incision 4 or 5 mm. long and passes the cautery rapidly along its whole length in order to make more sure of hitting upon the hole.l Sir William Lister2 points out that the cautery, when once in the subretinal fluid, can no longer retain its heat, and considers it safer not to pierce the choroid but to use the cautery to cause an inflammatory focus in it at the spot opposite the hole, in the hope that the margin of the tear may become adherent to it. Instead of puncturing the sclerotic with a Graefe knife he prefers to make a hole gradually by burning with the galvano-cautery which will block up any vessels which may be divided. Mr. G. W. Black 3 describes the procedure as now carried out at
I cedure,usuallywith Bruges,
Moorfields Hospital. The sclera may be first pierced by a knife, and the interretinal fluid allowed to escape, or the passage through it may be effected by the cautery. The electric cautery with a point of 1 mm. diameter, is used white-hot, and after piercing the sclera it is withdrawn to allow it to recover its heat and then plunged rapidly in and out again to produce scarring of the retina.
CLOSING THE HOLE IN CASES OF DETACHED RETINA. Gonin’s procedure, however, is apparently unchanged. THE treatment of detached retina by cauterising He lays stress on the importance of the after-treatment. the hole has been practised by several ophthalmic The patient is put to bed for a week with his head surgeons in England during the past year. According in such a position that the weight of the vitreous to its originator, J. Gonin, of Lausanne, nearly all tends to keep the hole closed. If the hole is in the idiopathic detachments-i.e., those not due to disease, lower part of the fundus the patient may be allowed trauma, or tumour-are caused by adhesions between to sit in an arm-chair a few days after operation. vitreous and retina at the site of old patches of An ophthalmoscopic examination should not be choroiditis, usually in the periphery, not far from the made before the expiration of five days. If not When the vitreous contracts it is liable successful the first time the operation may have to be ora serrata. to pull on the retina at these points and the result repeated in about a fortnight. Gonin has made as may be a tear, through which the fluid in the vitreous many as six thermo-punctures on the same eye chamber enters the subretinal space and causes before obtaining a cure, but as a rule one or two the detachment. If the tear can be located with suffice. A case was recently shown at the Royal sufficient accuracy and can be sealed, the channel Society of Medicine by Mr. Humphrey Neame where through which fluid flows is closed, any remaining three unsuccessful attempts to close the hole were fluid is absorbed, and the condition is cured. Gonin followed by a fourth successful one with restoration is convinced that a hole is formed in every case of of vision. Gonin claims to have obtained definite cures in spontaneous detachment though it may be very difficult to find, and in some cases impossible owing about 60 per cent. of his recent cases, this percentage to opacities in the media. If, however, it can be diminishing with the age of the detachment. found, and the detachment is recent, he claims Although it is undesirable to encourage hopes doomed that his operation gives a very good chance of cure, to disappointment in the case of old detachments though in view of the uncertainty of exact location the experience already gained may justify the belief and the frequent presence of multiple holes it may that this operation, or some modification of it, marks have to be repeated several times. In cases of long a distinct advance in the treatment of this distressstanding the retina may have lost its function and ing disease. This belief might be considerably the prognosis for vision is, of course, much worse. strengthened if it were possible to publish details The first essential in preparation for operation of the condition of patients who had been operated is to localise the hole and this is a very laborious on not less than a year ago. We note that Mr. C. and difficult task. After finding it with the Shapland will read to the Oxford Congress of Ophthalophthalmoscope the exact spot on the sclera which is mological Societies later on this month an analysis over it has to be defined. For this there are two of 100 cases treated by cautery puncture. indispensable data-first the exact meridian of the globe in which it is situated, and secondly, the exact DIPHTHERIA IMMUNISATION. distance of the spot on this meridian from the corneal OuR control over diphtheria proceeds margin. To define the meridian indian ink marks I apace ; potential our actual control will presumably follow in are made just outside the corneal margin in the line due course. Schick-testing and deliberate immunisawhich is continuous with that joining the hole with with toxin opened up the possibility of a population the’macula. The distance from the corneal margin tion made artificially resistant. The use of toxin is found by estimating the distance from the hole led to some inconvenience and a few disasters, itself to the ora serrata in disc diameters, one disc diameter and the that it could be made non-poisonous being reckoned at 1-5 mm. Add to this 8 mm. for without discovery its immunising power by treatment losing the distance from ora serrata to corneal margin, and if your estimations are accurate you have localised with dilute formalin was a step of first-rate hygienic importance; this " toxoid " or " anatoxin " is now your hole. This is all done before the operation. in general use. Further improvements have lately4 Now, having reflected the conjunctiva at this spot been introduced by A. T. Glenny and his colleagues and made a 2 mm. incision with a Graefe knife through 1 sclera and choroid, Gonin introduces a Paquelin Brit. Jour. Ophthal., 1930, xiv., 359. 2 Trans. Ophthalmol. Soc., 1930, 1., 545. heated to white in order to seal the heat cautery lips 3 Middlesex Hospital Journal, March, 1931. 4 of the hole. Others have practised a modified proJour. Path. and Bact., 1931, xxxiv., 131 and 267.
’
mosquito control or research, and given by the staff to visitors to the museum, who have numbered 6551 in the past fiveand a half years. Photographs and lantern slides are also produced and lectures and demonstrations are given at scientific meetings. No detailed account of the work is attempted in the report, but certain items of interest are described. Among these may be mentioned the investigation of a number of females of Aedes cirzereus from the neighbourhood of Birmingham which were infested with larval hydrachnid mites, and a study of the habits of Culex pipiens by a zoology student of Cambridge University. An account is given of modifications and developments in the special apparatus originally designed by the Director in 1923 for ordinary and stereoscopic photography of insects, and a chart is reproduced which gives particulars of larvae collected on Hayling Island. short
courses
on
casual information
is steadily increasing. In an editorial published in the same issue the Journal of the American Medical Åssociat’ion doubts very seriously whether it is a sound trend in human life to postpone maturity more and more. The best conditions for reproduction exist before the age of 30, but no member of a profession nowadayshas an economic chance of marriage before that age. The editorial further points out that if the sum represented by the cost of a medical education were properly invested for a young man at the age of 20, he would, by the time he was 50, have an income which would maintain him in comfort for the rest of his life. It is a reasonable question whether the average income of the physician represents a proper economic return on the cost of his education. It is easier to point out the difficulties than to suggest their solution. The Jourital calls for more actual evidence, such as that offered by Dr. Leland, to take the place of arm-chair philosophy and unpractical ideals. ____
AMERICA. without,
COST OF MEDICAL EDUCATION IN IT is generally reckoned in this country that it costs round about S1000 to obtain a medical degree, of course, counting the money that the student might be earning during his fiveor six years’ education. The figure naturally varies with the amount of hard. ship which he is prepared to endure and with the fees and extras of the particular college which he selects. It is interesting to compare this rough popular estimate with a careful investigation of the costs of medical education in the United States which was published recently by Dr. R. G. Leland.1 He finds that the average annual sum spent by the student is$1100, this being an increase of$200 a year on the figure for 1920. At the lowest possible estimate, therefore, a medical education must cost at least$5000, and if all the factors, such as pre-medical education, expenses during post-graduate education and loss of potential income from other professions, are taken into consideration the actual cash cost may be more nearly$10,000. The information was obtained by giving expense-books to students and asking them to keep an account of their expenditure. As a result 1253 books were available, and this was reduced to 1161 when married students and students living at home were subtracted. The number is obviously insufficient for more than guarded conclusions. The fees in American universities differ very considerably - from$66 to$610 a year. The average amount expended for books, instruments, and journals also varied widely, from$67 to$189, and the expense for room and board varied from$272 at the University of Illinois to$569 at Harvard. The highest average total cost was$1716 per annum at Dartmouth Medical School, with Harvard a close second, while the lowest reported was$425 at the University of Wisconsin. Apparently at least half the students find time to There earn some money while they are working. seems to be a gradual increase in expense as the student years go by, except that freshmen pay more for their books and instruments. There also seems to have been a steady increase in expense during recent years; tuition and fees, books and instruments now cost over 50 per cent. more than in 1920. On the other hand, the cost of room, board, and clothing has only risen very slightly, and there is a decided decrease in expenses for recreation. A corresponding study in this country would be of interest. Medical students here suffer greatly from the lack of facilities for earning money in their spare time, and the length and expense of the curriculum 1 Jour. Amer. Med. Assoc., Feb. 28th, p. 682.
STEREOSCOPIC RADIOGRAPHY. MEDICAL opinion in this country is divided on the value of stereoscopy in the diagnosis of chest diseases. The tuberculosis experts who made a tour last summer of institutions in Canada and the United States were struck by the reliance there placed upon stereoscopic radiography, and on their initiative the subject came up for full discussion at the Oxford meeting of the Tuberculosis Association reported elsewhere in Dr. J. B. Christopherson indicated our columns. at the outset that the ordinary radiogram of the thorax is a shadowgraph-a picture of a flat area, having two dimensions-and that in order to unravel questions of orientation and of relative depth of structures, or to discover the relative position of different parts of the same structure in the chest, resort must be had to screening or to the study of films taken from different angles. The aim of stereoscopic radiography is to introduce the additional factor of solidity or depth. Binocular vision is stereoscopic vision, and stereoscopic vision might be defined as the direct perception of the relative distances of objects. Until, however, two films can be taken simultaneously the success of a stereoscopic picture of the chest will largely depend on the exact maintenance of immobility during exposure, a period of 31/5 seconds with the apparatus in use at Victoria He had found radiostereoscopy of Park Hospital. the chest of special value in four conditions : (1) in artificial pneumothorax, for orientating adhesions; (2) in cases where lipiodol is used for investigation; (3) for locating foreign bodies ; and (4) for locating cavities in tuberculous lungs. Unsatisfactory stereoscopic effects in chest cases were due as a rule, he thought, to failure in equipment, which more collaboration between clinician, radiologists, and engineer might be expected to eliminate. Dr. Peter Edwards (Cheshire) admitted that stereoscopy had given him a new interpretation of the value of X ray films in his daily work. His routine was to screen every chest, and then to decide whether to take a flat or a stereo film. Eight types he selected for the stereo were : (1) one that revealed very little wrong on the screen ; (2) one that revealed a foreign body; (3) one that revealed a hydatid ; (4) the doubtful silicotic ; (5) the artificial pneumothorax case with adhesions, to decide as to thoracoscopy ; (6) cases after injection with lipiodol; (7) cases in which there was encysted fluid ; (8) cases in which it was essential to localise the lobe in which there was an abscess, or bronchiectasis. Moreover, in the stereo one often found early indication of the development of disease.
823 which could only be seen in the flat film months later. With good screening and stereos he thought there would be less need for the thoracoscope. With the apparatus he used both exposures could be taken in 9/20 second. Dr. L. B. Stott (Papworth) enumerated various possible sources of error in shadow stereography, such as the fact that minute lateral displacements will produce considerable anteroposterior distortion, and the increase or decrease of the stereoscopic effect according to the different degrees of tissue translucency to X rays. The clinician, he thought, was on safer ground in depending upon conscious deduction from anteroposterior and lateral views rather than running the risk of stereoscopic illusion. Many speakers formed a bridge between these extreme views. It was suggested that the conflict might be due, at least in part, to stereoscopic blindness, unsuspected by those who suffered from it. ____
an electric cautery. R. Rubbrecht, of makes an incision 4 or 5 mm. long and passes the cautery rapidly along its whole length in order to make more sure of hitting upon the hole.l Sir William Lister2 points out that the cautery, when once in the subretinal fluid, can no longer retain its heat, and considers it safer not to pierce the choroid but to use the cautery to cause an inflammatory focus in it at the spot opposite the hole, in the hope that the margin of the tear may become adherent to it. Instead of puncturing the sclerotic with a Graefe knife he prefers to make a hole gradually by burning with the galvano-cautery which will block up any vessels which may be divided. Mr. G. W. Black 3 describes the procedure as now carried out at
I cedure,usuallywith Bruges,
Moorfields Hospital. The sclera may be first pierced by a knife, and the interretinal fluid allowed to escape, or the passage through it may be effected by the cautery. The electric cautery with a point of 1 mm. diameter, is used white-hot, and after piercing the sclera it is withdrawn to allow it to recover its heat and then plunged rapidly in and out again to produce scarring of the retina.
CLOSING THE HOLE IN CASES OF DETACHED RETINA. Gonin’s procedure, however, is apparently unchanged. THE treatment of detached retina by cauterising He lays stress on the importance of the after-treatment. the hole has been practised by several ophthalmic The patient is put to bed for a week with his head surgeons in England during the past year. According in such a position that the weight of the vitreous to its originator, J. Gonin, of Lausanne, nearly all tends to keep the hole closed. If the hole is in the idiopathic detachments-i.e., those not due to disease, lower part of the fundus the patient may be allowed trauma, or tumour-are caused by adhesions between to sit in an arm-chair a few days after operation. vitreous and retina at the site of old patches of An ophthalmoscopic examination should not be choroiditis, usually in the periphery, not far from the made before the expiration of five days. If not When the vitreous contracts it is liable successful the first time the operation may have to be ora serrata. to pull on the retina at these points and the result repeated in about a fortnight. Gonin has made as may be a tear, through which the fluid in the vitreous many as six thermo-punctures on the same eye chamber enters the subretinal space and causes before obtaining a cure, but as a rule one or two the detachment. If the tear can be located with suffice. A case was recently shown at the Royal sufficient accuracy and can be sealed, the channel Society of Medicine by Mr. Humphrey Neame where through which fluid flows is closed, any remaining three unsuccessful attempts to close the hole were fluid is absorbed, and the condition is cured. Gonin followed by a fourth successful one with restoration is convinced that a hole is formed in every case of of vision. Gonin claims to have obtained definite cures in spontaneous detachment though it may be very difficult to find, and in some cases impossible owing about 60 per cent. of his recent cases, this percentage to opacities in the media. If, however, it can be diminishing with the age of the detachment. found, and the detachment is recent, he claims Although it is undesirable to encourage hopes doomed that his operation gives a very good chance of cure, to disappointment in the case of old detachments though in view of the uncertainty of exact location the experience already gained may justify the belief and the frequent presence of multiple holes it may that this operation, or some modification of it, marks have to be repeated several times. In cases of long a distinct advance in the treatment of this distressstanding the retina may have lost its function and ing disease. This belief might be considerably the prognosis for vision is, of course, much worse. strengthened if it were possible to publish details The first essential in preparation for operation of the condition of patients who had been operated is to localise the hole and this is a very laborious on not less than a year ago. We note that Mr. C. and difficult task. After finding it with the Shapland will read to the Oxford Congress of Ophthalophthalmoscope the exact spot on the sclera which is mological Societies later on this month an analysis over it has to be defined. For this there are two of 100 cases treated by cautery puncture. indispensable data-first the exact meridian of the globe in which it is situated, and secondly, the exact DIPHTHERIA IMMUNISATION. distance of the spot on this meridian from the corneal OuR control over diphtheria proceeds margin. To define the meridian indian ink marks I apace ; potential our actual control will presumably follow in are made just outside the corneal margin in the line due course. Schick-testing and deliberate immunisawhich is continuous with that joining the hole with with toxin opened up the possibility of a population the’macula. The distance from the corneal margin tion made artificially resistant. The use of toxin is found by estimating the distance from the hole led to some inconvenience and a few disasters, itself to the ora serrata in disc diameters, one disc diameter and the that it could be made non-poisonous being reckoned at 1-5 mm. Add to this 8 mm. for without discovery its immunising power by treatment losing the distance from ora serrata to corneal margin, and if your estimations are accurate you have localised with dilute formalin was a step of first-rate hygienic importance; this " toxoid " or " anatoxin " is now your hole. This is all done before the operation. in general use. Further improvements have lately4 Now, having reflected the conjunctiva at this spot been introduced by A. T. Glenny and his colleagues and made a 2 mm. incision with a Graefe knife through 1 sclera and choroid, Gonin introduces a Paquelin Brit. Jour. Ophthal., 1930, xiv., 359. 2 Trans. Ophthalmol. Soc., 1930, 1., 545. heated to white in order to seal the heat cautery lips 3 Middlesex Hospital Journal, March, 1931. 4 of the hole. Others have practised a modified proJour. Path. and Bact., 1931, xxxiv., 131 and 267.
’