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The Modern Treatment of Syphilis
BOOK NOTICE
351
BOOK NOTICE
that it would be wise on the part of the eye physician to undertake the therapy himself even though he were entirely conversant with the necessary technique, which is unlikely, and had the needed equipment. The author comments on the persistent superstition that arsenical drugs are apt to cause damage to the syphilitic eye. According to the author, arsphenamine and its derivatives have no deleteri ous effect on any structure of the eye. True toxic reactions are confined to conjunctival hyperemia and, very rarely, a superficial keratitis or corneal ulcération in association with a postarsenical exfoliative dermatitis. He also observes that the diseased eye may be seriously affected by a Herxheimer reaction following the in itiation of arsenical therapy. Zimmerman considers this of importance only in pa tients with optic neuritis or primary optic atrophy. Concerning tryparsamide, its usefulness is in neurosyphilis alone, and there it may be used safely only when there is no involvement of the optic nerve or retina.
T H E MODERN T R E A T M E N T O F SYPHILIS. By Joseph Earle Moore, M.D. Second edition. Clothbound, 674 pages, numerous charts and illustra tions. Baltimore, Charles C. Thomas, publisher, 1941. Price $7.00. This second edition of a remarkably in formative and comprehensive treatise on the subject of syphilis is worthy of review in an ophthalmologic journal, if for no other reason, than because of the masterly chapter on treatment of ocular syphilis. This occupies 25 pages. Much of the ma terial is from the Johns Hopkins Clinic, where the author worked in collaboration with Dr. Alan Woods. The author first points out the necessity of the full cooperation of ophthalmologist and internist: The systemic treatment is so involved with the treatment of other manifestations of the disease in the body
In general, the treatment of ocular syphilis is no different from that of syphilis elsewhere in the body with cer tain exceptions which the author then describes. For the general treatment of early lues he prefers arsphenamine fol lowed by bismuth. Mapharsen may be substituted for the former, but thus far its virtues and its defects have not been so well determined. Uveitis, iritis, and kerato-iritis must be treated for at least a year after sérologie tests have become and remained negative. Much consideration is given to the treatment of optic atrophy. Malarial therapy is preferred, and next in prefer ence are subdural injections of arsphenamized serum to be followed by bismuth treatment. A prognosis of no further in volvement of the sight or improvement is given in 50 percent of cases if the treat-
ly, to allow the patient to "come out of it" without stimulation, although if neces sary metrazol can be used. According to the reports, repeated anesthesia can be given to the same patient without incur ring complications. For the patient the experience is relatively pleasant, far more so than after ether or chloroform anes thesia. The use of sodium pentothal as an anesthetic in war surgery will be of great importance. The drug can be easily trans ported, and its properties are not altered by change in temperature. It, therefore, can be used in places where the adminis tration of volatile ether would be out of the question. Its employment requires no elaborate apparatus beyond a hypodermic syringe, an air way, and a tourniquet. The ophthalmic surgeon is urged to investigate and become familiar with the use of this important new anesthetic. Derrick Vail.
352
CORRESPONDENCE
ment is begun at an early stage in the disease. Interstitial keratitis should be treated as other forms of the disease. The prog nosis, contrary to the opinion of the older writers, is definitely better with, than without, treatment. A final page deals with surgery in syphilitics. In acute cases surgery should be avoided if possible, but in old cases— such as in older people with cataracts, in whom the systemic infection is dis covered only by preoperative sérologie tests—there is no contraindication to surgery, although a limited amount of postoperative antiluetic therapy may be advisable. The chapter ends with the note that in certain nonspecific lesions anti luetic treatment seems occasionally to be beneficial. The entire book presents the subject of antisyphilitic therapy so simply, clear ly, and comprehensively that it can be ap preciated by any physician. Lawrence T. Post.
CORRESPONDENCE ANISEIKONIA AND ORTHOPTICS
December 2, 1941 Editor, American Journal of Ophthalmology : The writer of the editorial "Iseikonic enthusiasm" takes a broad view of the subject and aims to deal with it in a judi cial spirit. The writer points out that there is a well-recognized tendency toward "thera peutic optimism" and would group to gether the use of prisms, ocular exercises, and orthoptics with aniseikonia as ex amples of "several ophthalmic causes which have had their too passionate ad vocates." I submit that the writer has gone too far in his condemnation of or thoptics, probably because he has not had the excellent results that are enjoyed by
those favored ophthalmologists who have expert orthoptic technicians of the mod ern approved type available for their orthoptic cases, and also that he has gone too far in his condemnation of the use of prisms and ocular exercise, although I happen to know that he wears prisms him self and frequently orders them. These are clues or hints which make the reader prepared for misjudgments concerning aniseikonia later in the article. These are clearly not due to any intoler ant, conceited, or unfriendly verdict, as is the case with some critics, but solely to a quite understandable lack of knowl edge of the facts involved. For example, the editor says : "Since the difference in size of images is presumed to reside in the brain and can hardly therefore make important demands upon the nerve or blood supply of the eye or its external adnexa, . . . ." This is quite erroneous. The commonest cause of a difference in the size of the perceptual images derived from the two eyes is a well-marked physi cal, anatomical difference between the two eyes as shown by a difference in the re fraction (anisometropia). Moreover, there is good reason to attribute many cases of aniseikonia not associated with anisometropia to other anatomic differ ences between the eyes, differences having their seat in the dioptric image-forming apparatus or in the retinal mosaic of the two eyes. It is not possible with our pres ent lack of knowledge to do more than theorize, when it comes to the part played by the cerebral cortex (compare article in same issue of the American Journal of Ophthalmology by Talbot and Mar shall). Whatever the anatomic seat of the disease aniseikonia* the important facts are that the patient has a considerable * It is classified in the "Standard classified nomenclature of disease" under xlO: "struc tures concerned in vision, generally and un specified."
351
BOOK NOTICE
that it would be wise on the part of the eye physician to undertake the therapy himself even though he were entirely conversant with the necessary technique, which is unlikely, and had the needed equipment. The author comments on the persistent superstition that arsenical drugs are apt to cause damage to the syphilitic eye. According to the author, arsphenamine and its derivatives have no deleteri ous effect on any structure of the eye. True toxic reactions are confined to conjunctival hyperemia and, very rarely, a superficial keratitis or corneal ulcération in association with a postarsenical exfoliative dermatitis. He also observes that the diseased eye may be seriously affected by a Herxheimer reaction following the in itiation of arsenical therapy. Zimmerman considers this of importance only in pa tients with optic neuritis or primary optic atrophy. Concerning tryparsamide, its usefulness is in neurosyphilis alone, and there it may be used safely only when there is no involvement of the optic nerve or retina.
T H E MODERN T R E A T M E N T O F SYPHILIS. By Joseph Earle Moore, M.D. Second edition. Clothbound, 674 pages, numerous charts and illustra tions. Baltimore, Charles C. Thomas, publisher, 1941. Price $7.00. This second edition of a remarkably in formative and comprehensive treatise on the subject of syphilis is worthy of review in an ophthalmologic journal, if for no other reason, than because of the masterly chapter on treatment of ocular syphilis. This occupies 25 pages. Much of the ma terial is from the Johns Hopkins Clinic, where the author worked in collaboration with Dr. Alan Woods. The author first points out the necessity of the full cooperation of ophthalmologist and internist: The systemic treatment is so involved with the treatment of other manifestations of the disease in the body
In general, the treatment of ocular syphilis is no different from that of syphilis elsewhere in the body with cer tain exceptions which the author then describes. For the general treatment of early lues he prefers arsphenamine fol lowed by bismuth. Mapharsen may be substituted for the former, but thus far its virtues and its defects have not been so well determined. Uveitis, iritis, and kerato-iritis must be treated for at least a year after sérologie tests have become and remained negative. Much consideration is given to the treatment of optic atrophy. Malarial therapy is preferred, and next in prefer ence are subdural injections of arsphenamized serum to be followed by bismuth treatment. A prognosis of no further in volvement of the sight or improvement is given in 50 percent of cases if the treat-
ly, to allow the patient to "come out of it" without stimulation, although if neces sary metrazol can be used. According to the reports, repeated anesthesia can be given to the same patient without incur ring complications. For the patient the experience is relatively pleasant, far more so than after ether or chloroform anes thesia. The use of sodium pentothal as an anesthetic in war surgery will be of great importance. The drug can be easily trans ported, and its properties are not altered by change in temperature. It, therefore, can be used in places where the adminis tration of volatile ether would be out of the question. Its employment requires no elaborate apparatus beyond a hypodermic syringe, an air way, and a tourniquet. The ophthalmic surgeon is urged to investigate and become familiar with the use of this important new anesthetic. Derrick Vail.
352
CORRESPONDENCE
ment is begun at an early stage in the disease. Interstitial keratitis should be treated as other forms of the disease. The prog nosis, contrary to the opinion of the older writers, is definitely better with, than without, treatment. A final page deals with surgery in syphilitics. In acute cases surgery should be avoided if possible, but in old cases— such as in older people with cataracts, in whom the systemic infection is dis covered only by preoperative sérologie tests—there is no contraindication to surgery, although a limited amount of postoperative antiluetic therapy may be advisable. The chapter ends with the note that in certain nonspecific lesions anti luetic treatment seems occasionally to be beneficial. The entire book presents the subject of antisyphilitic therapy so simply, clear ly, and comprehensively that it can be ap preciated by any physician. Lawrence T. Post.
CORRESPONDENCE ANISEIKONIA AND ORTHOPTICS
December 2, 1941 Editor, American Journal of Ophthalmology : The writer of the editorial "Iseikonic enthusiasm" takes a broad view of the subject and aims to deal with it in a judi cial spirit. The writer points out that there is a well-recognized tendency toward "thera peutic optimism" and would group to gether the use of prisms, ocular exercises, and orthoptics with aniseikonia as ex amples of "several ophthalmic causes which have had their too passionate ad vocates." I submit that the writer has gone too far in his condemnation of or thoptics, probably because he has not had the excellent results that are enjoyed by
those favored ophthalmologists who have expert orthoptic technicians of the mod ern approved type available for their orthoptic cases, and also that he has gone too far in his condemnation of the use of prisms and ocular exercise, although I happen to know that he wears prisms him self and frequently orders them. These are clues or hints which make the reader prepared for misjudgments concerning aniseikonia later in the article. These are clearly not due to any intoler ant, conceited, or unfriendly verdict, as is the case with some critics, but solely to a quite understandable lack of knowl edge of the facts involved. For example, the editor says : "Since the difference in size of images is presumed to reside in the brain and can hardly therefore make important demands upon the nerve or blood supply of the eye or its external adnexa, . . . ." This is quite erroneous. The commonest cause of a difference in the size of the perceptual images derived from the two eyes is a well-marked physi cal, anatomical difference between the two eyes as shown by a difference in the re fraction (anisometropia). Moreover, there is good reason to attribute many cases of aniseikonia not associated with anisometropia to other anatomic differ ences between the eyes, differences having their seat in the dioptric image-forming apparatus or in the retinal mosaic of the two eyes. It is not possible with our pres ent lack of knowledge to do more than theorize, when it comes to the part played by the cerebral cortex (compare article in same issue of the American Journal of Ophthalmology by Talbot and Mar shall). Whatever the anatomic seat of the disease aniseikonia* the important facts are that the patient has a considerable * It is classified in the "Standard classified nomenclature of disease" under xlO: "struc tures concerned in vision, generally and un specified."