taught this form of intervention be aware of this and use it by offering additional positive suggestions, where appropriate (e.g., that voiding will be easy), for the relief of pre- and postoperative discomfort. Simple instruction in the principles of suggestion will greatly enhance the effectiveness of nurses, whether or not they use systematic desensitization. All effective physicians and nurses use suggestion and hypnosis, often unconsciously. It is a big component, as Raginsky1 noted, in the art of medicine. Formal trance states are simply a special case. Those interested in this field may learn much from references 2 and 3 given below. F.W. HANLEY, MD 913 Fairmont Medical Building 750 West Broadway Vancouver, BC References 1. RJAGINSKY BB: in Hypnosis in Modern Medicine, 3rd ed, SCItNECK JM (ed), CC Thomas, Springfield, Ill, 1953, p 29 2. KROGER WS, FEZLER WD: Hypnosis and Behavior Modification: Imagery Conditioning, Lippincott, Philadelphia, 1976 3. DENGROVE E (ed): Hypnosis and Behavior Therapy, CC Thomas, Springfield, Ill, 1976

To the editor: In view of the relatively few papers on psychiatry and the even fewer papers on behaviour modification that appear in the Journal, the publication of the article by Dr. Marshall is both surprising and disturbing. Although this paper addresses an important topic, and one that may well be of interest to many readers, it surely could not have received expert opinion. First, the title notwithstanding, the article has almost nothing to do with behaviour modification in the technical sense. Although there is not universal agreement on a definition of the term behaviour modification, it is generally used to refer to a group of treatment methods that owe their existence and theoretical justification to modern learning theory. Leaving aside for the moment the more subtle distinctions that are

states: "The basic premise underlying these techniques is that there is a high positive correlation between muscle tension and subjective anxiety." What he may be referring to is the principle of reciprocal inhibition on which systematic desensitization was initially based, which states that: "If a response antagonistic to anxiety can be made to occur in the presence of anxiety-evoking stimuli so that it is accompanied by a complete or partial suppression of the anxiety responses, the bond between these stimuli and the anxiety responses will be weakened."1 There are important theoretical and practical differences between these statements. The remainder of the article offers a hodge-podge of statements from a variety of often incompatible theories, and it contains numerous other inaccuracies. After an equally unsatisfactory review of the literature concerning psychologic interventions intended to alter patient response to hospitalization and surgery, Dr. Marshall concludes that he has presented evidence that "points clearly to the value of a psychologic support system for [such] patients . ." He has, of course, done nothing of the sort. That this paper was published raises serious questions about the Journal's editorial standards in reviewing manuscripts on behavioural problems and interventions. PAUL LATIMER, MD, FRcP[c]

Assistant professor McMaster University Medical Centre

Hamilton, Ont.

Reference 1. WOLPE J: Psychotherapy by Reciprocal inhibition, Stanford U Pr, Palo Alto, Calif, 1958

[Dr. Marshall's paper was reviewed by two medical authorities with recognized expertise in the field of behaviour modification and recommended for publication in the Journal as a brief communication. The author has chosen not to comment on the points raised by Dr. Latimer. - Ed.]

Bilateral retinoblastoma

sometimes made between the terms To the editor: Not long ago a 21behaviour modification and behav- year-old Chinese woman noted that iour therapy, the only behavioural her 3-month-old daughter had a technique discussed in this paper is white reflex behind the pupil and systematic desensitization. Dr. Mar- divergent strabismus of the right eye. shall is completely in error when he Fixation was very poor in the right 126 CMA JOURNAL/JANUARY 20, 1979/VOL. 120

eye, but good in the left. A large white mass emanating from the entire retina of the right eye nearly filled the vitreous cavity. In the left eye three large, white masses projected like fingers from the retina into the vitreous; the macula was spared. A diagnosis of bilateral retinoblastoma was made. The right eye was removed and the three lesions in the left eye were treated with irradiation. Histopathologic examination confirmed the clinical diagnosis of retinoblastoma. The woman had had her right eye removed at 3 months of age while living in Hong Kong. She and her parents were never told the diagnosis and reason for enucleation. When she immigrated to Canada 6 years ago she was examined by a number of physicians, who did not enquire whether she had undergone eye surgery. She told the physicians several times that she had an artificial eye, but no one seemed to pay attention. A large, circumscribed, grey-white, atrophic scar was noted in the inferior retina of the left eye. The uncorrected visual acuity was 6/6. An enucleation performed very early in life and a large, circumscribed, atrophic retinal scar in the other eye were compatible with only one diagnosis - bilateral retinoblastoma. The eye with advanced retinoblastoma had been removed and the single lesion in the left eye had presumably been treated with irradiation or chemotherapy or both, or it may have regressed spontaneously, although this rarely happens. Physicians should be alert to the fact that a person who has had an eye removed early in life, even when the reason for removal is obscure, should always be considered to have had retinoblastoma. If the woman was referred as a child to an ophthalmologist a diagnosis of bilateral retinoblastoma would easily have been made on the basis of the clinical findings, for there is no other condition in children with similar clinical features. Almost all the enucleations performed in children under 2 years of age at the Montreal Children's Hospital are for retinoblastoma. Rarely is enucleation performed for other reasons, such as trauma or glaucoma. Perhaps personal grief would have been averted in this case if the mother had known the diagnosis and been aware of the risk

to 10 parasites per 100 erythrocytes. An immediate enquiry revealed that he and his parents had returned 2 weeks before from a 1-month tour of Liberia and the Ivory Coast. They had taken chioroquine as prophylaxis once or twice. The boy was lethargic on his return home, and had sores on the lower legs, the site of previous mosquito bites. Two weeks later he became acutely ill with fever and vomiting, and after 5 days he was brought to our hospital. He was severely ill and dehydrated, and had a temperature of 39.40C. A urine sample was yellow and clear; the specific gravity was 1.012, the pH was 6.0, and a trace of albumin, 0 to 2 leukocytes per high-power field and rare, finely granular casts were evident. The urine output was low. Hematologic examination revealed a leukocyte count of 5.3 x 109/L (31 % bands, 37% neutrophils, 25% lymphocytes and 7% eosinophils, with 1 nucleated erythrocyte per 100 leukocytes), a platelet count of 80 x 109/L, an erythrocyte count of 3.06 x 1 0"/L, a hemoglobin concentration of 8.6 g/dL, a hematocrit of 25%, a mean corpuscular volume of 82 fL and a mean corpuscular hemoDepartment of ophthalmology globin concentration of 34 g/L. Montreal Children's Hospital There was occasional polychromatoMcGill University philia and basophilic stippling of Montreal, PQ the erythrocytes, with moderate hypochromia and slight anisocytosis and References poikilocytosis. Serum concentrations 1. ELLswoRm RM: The practical manwere as follows: total bilirubin 1.4 agement of retinoblastoma. Trans Am mg/dL, sodium 136 mmol/L, potasOphthalmol Soc 67: 462, 1969 2. WARBURG M: Retinoblastoma, in Gen- sium 4.5 mmol/L, chloride 102 etic and Metabolic Eye Disease, GOLD- mmol/L and bicarbonate 18 mmol/L. BERG MF (ed), Little, Boston, 1974 Chloroquine was given orally and further treatment was undertaken at Severe falciparum malaria during the Children's Hospital Medical Cena blizzard ter in Boston, where the child fully To the editor: In these days of rapid recovered. The boy's father had a air travel, malaria and other "exotic" mild infection with P. falciparum and tropical infections can occur any- is now well. He was born in Liberia where, irrespective of apparently in- and moved to the United States in appropriate climatic conditions.1'2 We 1970. The child had not been abroad report a case of falciparum malaria before. Immunity acquired during that occurred in Massachusetts dur- the father's childhood in Liberia would have lessened the effects of ing a blizzard. his infection, and possibly he took Case report more chloroquine during the recent The day after a blizzard in Massa- trip abroad. chusetts a 2½-year-old boy was brought to our emergency room with Comments a high fever. Malaria ring forms The advice of the United States noted in a thin blood smear were Public Health authorities that a phyidentified as Plasmodium falciparum sician should be notified if a person by standard criteria;3 there were 6 becomes ill within 6 weeks of entry

of transmitting bilateral retinoblastoma. Retinoblastoma is the most common intraocular malignant disorder in childhood. Its frequency varies from 1 per 17000 to 1 per 34000 infants. The average age at the time of diagnosis is 18 months. The presenting sign in 56% of cases is a white reflex or a "cat's eye reflex", and in 20% it is strabismus.' Of all cases of retinoblastoma the tumour is bilateral in 25% to 30% and unilateral in 70% to 75%. There are two types of retinoblastoma :1 one is inherited as an autosomal dominant trait with a rate of penetrance of 80%, and the other arises as a somatic mutation. Bilateral retinoblastomas are considered to be germinal mutations, and the risk of persons with bilateral retinoblastomas transmitting the trait is 40%. While most unilateral tumours are the result of a somatic mutation and are considered to occur sporadically, an estimated 15% to 20% are the result of a germinal mutation that gives rise to an autosomal dominant trait. Genetic counselling is therefore an essential part of the management of retinoblastoma. R.C. POLOMENO, MD

130 CMA JOURNAL/JANUARY 20, 1979/VOL. 120

into the United States should not be taken lightly. In 1975 there were 430 cases of malaria in the United States alone, and between 1970 and 1975, 12 American travellers died of malaria after returning home.4 Yet malaria is curable and preventable. The first and most important step in making the correct diagnosis is to ask a person with a high fever whether he or she has been outside the United States or Canada. If not, and it is the tick season, babesiosis should be considered..7 The diagnosis of falciparum malaria in our case was confirmed by the parasitology division of the Center for Disease Control in Atlanta, Georgia. The importance of prompt, accurate diagnosis is paramount in cases of malaria. In contrast to other plasmodial infections, falciparum malaria is a killer and should be considered a medical emergency. Deaths from babesiosis have been described, but, as with forms of malaria other than falciparum, parasitemia in humans is rarely of high degree.6 Therefore, a high parasite count in a thin blood film is most likely to indicate P. falciparum infection. It is usually timeconsuming to search a thin blood smear for P. vivax or P. malariae. A mixed infection (with P. vivax, P. malariae or P. ovale as well as P. falciparum) was possible in our case. Fortunately all African strains remain sensitive to chloroquine, in contrast to strains of P. falciparum in South-East Asia and in Central and South America, which are largely resistant.8 Even in a blizzard a case of malaria can surface. There must be no delay in the diagnosis of this disease because it is eminently treatable. All health workers should be aware of the hazards of rapid present-day travel, and travellers should know of the necessity of malaria chemoprophylaxis.4 CHARLES R. RoBINsoN,* MB, FRCP[C], CERT BACT, CERT PATH DIANE WILSON, MT (AScP) ERIC P. KAPLAN, MD

Lowell General Hospital Lowell, Massachusetts *Present address: P0 Box 105, Harvard, Mass.

References 1. SCHULTZ MG: Current concepts in parasitology. Parasitic diseases. N Engi J Med 297: 1259, 1977

Bilateral retinoblastoma.

taught this form of intervention be aware of this and use it by offering additional positive suggestions, where appropriate (e.g., that voiding will b...
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