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Wills Eye Hospital
863
EDITORIALS
the importance of the fundus lesions in'the evaluation of general diseases bear emphasis. In the discussion of medical ophthalmology the ophthalmology of pediatrics should not be neglected. The student should also be told of the legal responsibility he assumes when he treats an eye. This discussion should include such items as the legal responsibility of X-ray ex amination in cases of trauma of an eye where metal has struck metal. It would appear that there is no place in the curriculum for teaching ophthalmic surgery aside from a simple explanation of what is done in the surgery of congenital and senile cataracts, glaucoma, and muscle surgery. In discussing muscle anomalies, only the very basic conditions need be mentioned without going into the intricate details of these anomalies. In refraction, only the sim ple definitions of the various types of re fractive errors together with the symptoms they produce need be considered, entirely avoiding the confusion caused by the neces sarily inadequate discussion of optics. It was most interesting in reviewing Adler's new edition of Gifford's textbook re cently to find that he has similar convictions and that he has omitted the details of surgery, muscle anomalies, and the more technical phases of ophthalmology and has placed greater emphasis on the broader scope of our specialty. It has been the changed medical student of today who has called to our attention the necessity for revision of the undergraduate teaching of ophthalmology. We have the grave responsibility of teaching the medical student the ophthalmology that is needed to meet the present-day requirements of the general practitioner. It is equally important that he also be taught his limitations. It is only by doing this that we can hope to reduce to a minimum the unnecessary loss of vision. That teachers of ophthalmology are aware of this is evidenced by the teachers' section of the American Academy of Ophthalmology
and Otolaryngology where the entire prob lem is receiving serious consideration. Frederick C. Cordes.
WILLS EYE H O S P I T A L F I F T H ANNUAL CLINICAL CONFERENCE
The fifth annual clinical conference of the staff and ex-residents of the Wills Eye Hos pital, Philadelphia, was held at the hospital on March 20 and 21, 1953. Registration ap proximated 350. The meeting was opened by Dr. Ivan J. Koenig with a clinicopathologic case report of a malignant melanoma of the iris in a one-eyed patient, observed for 20 years. Dr. Clyde H. Jacobs presented a movie showing several cataract extractions under intravenous pentothal-sodium anesthesia. The hospital's research staff, under the di rection of Dr. Irving H. Leopold, made the following reports on five of their current projects: Dr. Virginia L. Weimer, Dr. Harry Green, and Dr. Irving H. Leopold described a method for determining steroid concentra tion in the intraocular fluids which has en able them to establish the presence of cer tain steroids in these fluids of the experi mental animal eye. Dr. J. Eisenberg, Dr. Irving H. Leopold, and Dr. J. W. Hallett presented evidence showing that the radioactive isotope P 32 could be helpful in the differential diagnosis of in traocular tumors. The ability of the normal eye to concentrate P 32 was determined and the percent variation of over 50 normal eyes was used for this determination. More than 40 eyes suspected of having intraocular neo plasms were then subjected to this test. Wherever the probe could reach the sus pected area, positive readings were obtained in histologically confirmed cases of intra ocular neoplasms. Those neoplasms, which were in the extreme posterior segment of the globe where it was difficult for the probe
864
EDITORIALS
to reach, occasionally produced negative re sults. All cases of serous detachment gave negative results. Five inflammatory condi tions gave positive uptake values. The auth ors tentatively concluded that this is a valu able method to help in the differential diag nosis. They offered it simply as an adjunct and not to be used to supplant any technique already available. Dr. William F. Kratka and Dr. Irving H. Leopold arrived at the following tentative conclusions from their studies with isonicotinic acid hydrazides in experimental and clinical ocular tuberculosis: Isonicotinic hydrazides will control experi mental and clinical ocular tuberculosis when therapy is maintained for a long period of time. In the experimental animal, improve ment was not noted until after 50 days of therapy, when treatment was instituted nine days after inoculation into the anterior cham ber or cornea. If therapy was stopped too soon, even though there was obvious clinical improve ment, recurrences developed. The best results were obtained in those in whom therapy was continued for six months. Evidence of clini cal quiescence of the lesion often belies the true picture, in that histologic preparations of the same eyes show definite activity which may account for the numerous recurrences with too short a period of therapy. Therapy of experimental lesions com pared favorably with streptomycin, paraaminosalicylic acid. In some instances, supe rior results were obtained with the combina tion of the three drugs than with strepto mycin and para-aminosalicylic acid alone. In some, isonicotinic acid was superior in the results in the experimental eye to that ob tained by streptomycin and para-aminosali cylic acid. Penetration studies were also done follow ing the subconjunctival intramuscular topical administration of isonicotinic hydrazides. By all forms of administration, adequate pen etration into the intraocular tissues and fluids could be obtained.
Dr. J. O'Rourke and Dr. Irving H. Leo pold reported the inability of the enzymes, streptodornase and streptokinase, to lyse rab bit blood, and further demonstrated the nec essity of a human serum factor, namely, plasminogen for the lysis of human and experi mental animal blood by these enzymes. Their studies indicated a safe dosage of these en zyme preparations for intradermal injection. It was shown that many of the toxic features of the commercially available enzyme, strep tokinase, are due to the contained hyaluronidase. The action of these fibrolytic enzymes is greatly influenced by temperature changes, more so than by concentration. The length of time that the enzyme re mains in the anterior chamber is of practi cal importance. In trials against standard experimentally induced anterior-chamber hemorrhages, the combination of the injec tion of the enzymes plus paracentesis and flushing of the anterior chamber gave the most satisfactory results. In low concentra tions, these enzymes lose their anticoagulant properties. Apparently this property may be due to impurities. These enzymes were found to have the ability of provoking antibiotic re sponse. Dr. Adolph W. Vogel and Dr. Irving H. Leopold described a method for producing experimental posterior-segment lesions. They demonstrated the production of localized in flammatory and neoplastic lesions in the choroid with their technique. Dr. Warren S. Reese and Dr. Turgut Hamdi reported their experiences with the Ridley implant in cataract surgery. Dr. Reese has performed 14 of these operations at the hospital during the past year, with favorable results in 12 of them. Dr. P. Robb McDonald spoke on the in dications for scleral resection in retinal sep aration as a primary procedure rather than as a "last resort" procedure in cases which have a poor prognosis. Dr. Wilfred E. Fry, Dr. Max Kasser, and Dr. Samuel DeLong advocated excising a partial thickness of the sclera as a valuable
865
OBITUARY addition to the surgical treatment in retinal detachment. Their conclusions were based on experimental work on rabbits' eyes. Dr. Robert E. Shoemaker discussed the ocular complications of erythema multiforme exudativum. He described an unusual case of an eight-year-old boy who presented symptoms of an eruptive fever, stomatitis, endophthalmitis with vision reduced to light perception, and arthritis with effusion. This, he considered a probable variant of erythema multiforme. With the use of systemic cortone all symptoms disappeared within a week with the exception of those of the eyes. Vi sion eventually recovered to 20/30 three months following the onset. Dr. Raynold N. Berke accompanied his splendid movie on resection of the levator palpebrse muscle for blepharoptosis with many practical and instructive comments. In general terms and based on more than 800 cases over a three-year period, Dr. Ed mund B. Spaeth gave the indications and basic principles for surgery of the vertically acting muscles in strabismus. The Arthur J. Bedell Lecture was given by Dr. Ellen F. Regan in the absence of Dr. John H. Dunnington. The paper was en titled: "Absorbable sutures in cataract sur gery," and was of joint authorship by Dr. Dunnington and Dr. Regan. Their conclusions were based on experi mental studies and clinical observations. They found that the initial response with catgut sutures was a polymorphonuclear re action which with the plain type was rapid and marked, leading to an early disintegra tion of the suture. When mildly chromicized material was used, this polymorphonuclear response was less pronounced and the suture remained intact for about seven days. Fibroblastic proliferation became evident on about the fifth day, as did increased vasculariza tion of the wound. During the second week, the healing pro cess progressed and, at the end of 14 days, the wounds appeared well healed but some what broader and more vascularized than
comparable ones closed with silk. The in creased vascularization of these wounds is an undesirable feature but this is counter balanced by the relative absence of tissue necrosis and of epithelial invasion that the authors have found in the presence of silk sutures. In view of these findings and their pres ent clinical experience, the authors felt that mildly chromicized catgut is a satisfactory material for closing cataract incisions. An important "repeat" feature of the con ference was the color television program presented by the members of the surgical staff of the hospital, through the courtesy of Smith, Kline, and French Laboratories. These surgeons are becoming expert T-V operators as well as commentators. Fourteen commercial exhibitors were also on hand with splendid displays. As in former years, the meeting was not without its social side. The first evening, there was an informal reception for the doc tors and their wives at the Barclay Hotel, followed by a delicious dinner. The Wills Eye Hospital Society held its annual dinner at the Union League Club on Saturday eve ning. Kenneth L. Roper.
OBITUARY EDWARD VAIL LAPHAM BROWN (1876-1953) Another major contributor to the credit side of modern American Ophthalmology is gone: Edward Vail Lapham Brown, or "E. V. L." as most of his colleagues spoke of him, was called from this world, from his family, and from a still very active profes sional life on March 1, 1953. As successful organizer of systematic, carefully graduated postgraduate education in ophthalmology, Dr. Brown was known personally to a good section of today's prac ticing ophthalmologists. To his many direct and indirect pupils the loss of their oph-
EDITORIALS
the importance of the fundus lesions in'the evaluation of general diseases bear emphasis. In the discussion of medical ophthalmology the ophthalmology of pediatrics should not be neglected. The student should also be told of the legal responsibility he assumes when he treats an eye. This discussion should include such items as the legal responsibility of X-ray ex amination in cases of trauma of an eye where metal has struck metal. It would appear that there is no place in the curriculum for teaching ophthalmic surgery aside from a simple explanation of what is done in the surgery of congenital and senile cataracts, glaucoma, and muscle surgery. In discussing muscle anomalies, only the very basic conditions need be mentioned without going into the intricate details of these anomalies. In refraction, only the sim ple definitions of the various types of re fractive errors together with the symptoms they produce need be considered, entirely avoiding the confusion caused by the neces sarily inadequate discussion of optics. It was most interesting in reviewing Adler's new edition of Gifford's textbook re cently to find that he has similar convictions and that he has omitted the details of surgery, muscle anomalies, and the more technical phases of ophthalmology and has placed greater emphasis on the broader scope of our specialty. It has been the changed medical student of today who has called to our attention the necessity for revision of the undergraduate teaching of ophthalmology. We have the grave responsibility of teaching the medical student the ophthalmology that is needed to meet the present-day requirements of the general practitioner. It is equally important that he also be taught his limitations. It is only by doing this that we can hope to reduce to a minimum the unnecessary loss of vision. That teachers of ophthalmology are aware of this is evidenced by the teachers' section of the American Academy of Ophthalmology
and Otolaryngology where the entire prob lem is receiving serious consideration. Frederick C. Cordes.
WILLS EYE H O S P I T A L F I F T H ANNUAL CLINICAL CONFERENCE
The fifth annual clinical conference of the staff and ex-residents of the Wills Eye Hos pital, Philadelphia, was held at the hospital on March 20 and 21, 1953. Registration ap proximated 350. The meeting was opened by Dr. Ivan J. Koenig with a clinicopathologic case report of a malignant melanoma of the iris in a one-eyed patient, observed for 20 years. Dr. Clyde H. Jacobs presented a movie showing several cataract extractions under intravenous pentothal-sodium anesthesia. The hospital's research staff, under the di rection of Dr. Irving H. Leopold, made the following reports on five of their current projects: Dr. Virginia L. Weimer, Dr. Harry Green, and Dr. Irving H. Leopold described a method for determining steroid concentra tion in the intraocular fluids which has en able them to establish the presence of cer tain steroids in these fluids of the experi mental animal eye. Dr. J. Eisenberg, Dr. Irving H. Leopold, and Dr. J. W. Hallett presented evidence showing that the radioactive isotope P 32 could be helpful in the differential diagnosis of in traocular tumors. The ability of the normal eye to concentrate P 32 was determined and the percent variation of over 50 normal eyes was used for this determination. More than 40 eyes suspected of having intraocular neo plasms were then subjected to this test. Wherever the probe could reach the sus pected area, positive readings were obtained in histologically confirmed cases of intra ocular neoplasms. Those neoplasms, which were in the extreme posterior segment of the globe where it was difficult for the probe
864
EDITORIALS
to reach, occasionally produced negative re sults. All cases of serous detachment gave negative results. Five inflammatory condi tions gave positive uptake values. The auth ors tentatively concluded that this is a valu able method to help in the differential diag nosis. They offered it simply as an adjunct and not to be used to supplant any technique already available. Dr. William F. Kratka and Dr. Irving H. Leopold arrived at the following tentative conclusions from their studies with isonicotinic acid hydrazides in experimental and clinical ocular tuberculosis: Isonicotinic hydrazides will control experi mental and clinical ocular tuberculosis when therapy is maintained for a long period of time. In the experimental animal, improve ment was not noted until after 50 days of therapy, when treatment was instituted nine days after inoculation into the anterior cham ber or cornea. If therapy was stopped too soon, even though there was obvious clinical improve ment, recurrences developed. The best results were obtained in those in whom therapy was continued for six months. Evidence of clini cal quiescence of the lesion often belies the true picture, in that histologic preparations of the same eyes show definite activity which may account for the numerous recurrences with too short a period of therapy. Therapy of experimental lesions com pared favorably with streptomycin, paraaminosalicylic acid. In some instances, supe rior results were obtained with the combina tion of the three drugs than with strepto mycin and para-aminosalicylic acid alone. In some, isonicotinic acid was superior in the results in the experimental eye to that ob tained by streptomycin and para-aminosali cylic acid. Penetration studies were also done follow ing the subconjunctival intramuscular topical administration of isonicotinic hydrazides. By all forms of administration, adequate pen etration into the intraocular tissues and fluids could be obtained.
Dr. J. O'Rourke and Dr. Irving H. Leo pold reported the inability of the enzymes, streptodornase and streptokinase, to lyse rab bit blood, and further demonstrated the nec essity of a human serum factor, namely, plasminogen for the lysis of human and experi mental animal blood by these enzymes. Their studies indicated a safe dosage of these en zyme preparations for intradermal injection. It was shown that many of the toxic features of the commercially available enzyme, strep tokinase, are due to the contained hyaluronidase. The action of these fibrolytic enzymes is greatly influenced by temperature changes, more so than by concentration. The length of time that the enzyme re mains in the anterior chamber is of practi cal importance. In trials against standard experimentally induced anterior-chamber hemorrhages, the combination of the injec tion of the enzymes plus paracentesis and flushing of the anterior chamber gave the most satisfactory results. In low concentra tions, these enzymes lose their anticoagulant properties. Apparently this property may be due to impurities. These enzymes were found to have the ability of provoking antibiotic re sponse. Dr. Adolph W. Vogel and Dr. Irving H. Leopold described a method for producing experimental posterior-segment lesions. They demonstrated the production of localized in flammatory and neoplastic lesions in the choroid with their technique. Dr. Warren S. Reese and Dr. Turgut Hamdi reported their experiences with the Ridley implant in cataract surgery. Dr. Reese has performed 14 of these operations at the hospital during the past year, with favorable results in 12 of them. Dr. P. Robb McDonald spoke on the in dications for scleral resection in retinal sep aration as a primary procedure rather than as a "last resort" procedure in cases which have a poor prognosis. Dr. Wilfred E. Fry, Dr. Max Kasser, and Dr. Samuel DeLong advocated excising a partial thickness of the sclera as a valuable
865
OBITUARY addition to the surgical treatment in retinal detachment. Their conclusions were based on experimental work on rabbits' eyes. Dr. Robert E. Shoemaker discussed the ocular complications of erythema multiforme exudativum. He described an unusual case of an eight-year-old boy who presented symptoms of an eruptive fever, stomatitis, endophthalmitis with vision reduced to light perception, and arthritis with effusion. This, he considered a probable variant of erythema multiforme. With the use of systemic cortone all symptoms disappeared within a week with the exception of those of the eyes. Vi sion eventually recovered to 20/30 three months following the onset. Dr. Raynold N. Berke accompanied his splendid movie on resection of the levator palpebrse muscle for blepharoptosis with many practical and instructive comments. In general terms and based on more than 800 cases over a three-year period, Dr. Ed mund B. Spaeth gave the indications and basic principles for surgery of the vertically acting muscles in strabismus. The Arthur J. Bedell Lecture was given by Dr. Ellen F. Regan in the absence of Dr. John H. Dunnington. The paper was en titled: "Absorbable sutures in cataract sur gery," and was of joint authorship by Dr. Dunnington and Dr. Regan. Their conclusions were based on experi mental studies and clinical observations. They found that the initial response with catgut sutures was a polymorphonuclear re action which with the plain type was rapid and marked, leading to an early disintegra tion of the suture. When mildly chromicized material was used, this polymorphonuclear response was less pronounced and the suture remained intact for about seven days. Fibroblastic proliferation became evident on about the fifth day, as did increased vasculariza tion of the wound. During the second week, the healing pro cess progressed and, at the end of 14 days, the wounds appeared well healed but some what broader and more vascularized than
comparable ones closed with silk. The in creased vascularization of these wounds is an undesirable feature but this is counter balanced by the relative absence of tissue necrosis and of epithelial invasion that the authors have found in the presence of silk sutures. In view of these findings and their pres ent clinical experience, the authors felt that mildly chromicized catgut is a satisfactory material for closing cataract incisions. An important "repeat" feature of the con ference was the color television program presented by the members of the surgical staff of the hospital, through the courtesy of Smith, Kline, and French Laboratories. These surgeons are becoming expert T-V operators as well as commentators. Fourteen commercial exhibitors were also on hand with splendid displays. As in former years, the meeting was not without its social side. The first evening, there was an informal reception for the doc tors and their wives at the Barclay Hotel, followed by a delicious dinner. The Wills Eye Hospital Society held its annual dinner at the Union League Club on Saturday eve ning. Kenneth L. Roper.
OBITUARY EDWARD VAIL LAPHAM BROWN (1876-1953) Another major contributor to the credit side of modern American Ophthalmology is gone: Edward Vail Lapham Brown, or "E. V. L." as most of his colleagues spoke of him, was called from this world, from his family, and from a still very active profes sional life on March 1, 1953. As successful organizer of systematic, carefully graduated postgraduate education in ophthalmology, Dr. Brown was known personally to a good section of today's prac ticing ophthalmologists. To his many direct and indirect pupils the loss of their oph-