THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES GIFT OF State Medics 1 Society AN INTERNATIONAL CONGRESS OF OPHTHALMOLOGY WASHINGTON, D. C. APRIL 25, 26, 27, 28, 1922 Held Under the cAuspices of THE AMERICAN OPHTHALMOLOGICAL SOCIETY THE SECTION ON OPHTHALMOLOGY OF THE AMERICAN MEDICAL ASSOCIATION THE AMERICAN ACADEMY OF OPHTHALMOLOGY AND OTO-LARYNGOLOGY WASHINGTON, D. C. 1922 EDITED BY THE COMMITTEE ON PUBLICATION DR. WILLIAM 2ENTMAYER, CHAIRMAN DR. WILLIAM M. SWEET DR. ARNOLD KNAPP DR. LUTHER C. PETER WM. F. FELL CO. PRINTERS PHILADELPHIA Library W3 CONTENTS PAGE Officers of the Congress 5 Official Government Representatives 6 Members of the Congress 7 Address of Welcome 31 Presentation of Credentials 32 Report of Committee on Nominations 36 Salutatory of President of Congress ' 37 Des Enseignements de la Guerre en Chirurgie Oculaire. Prof. F. de Lapersonne, Paris, France 39 Detachment of the Vitreous. Sir William Lister, London, England 50 On Diaphragm Lamps in Ophthalmology. Prof. Allvar Gullstrand, Sweden 69 Sintomas Oculares del Envenenamiento por el Piquete de Alacran. Dr. Jose de Jesus Gonzalez, De Leon, Gto., Mexico 81 Traitement du Trachome par les Injections sous Conjonctivales de Cyanure de Mercure. Dr. Gemblath, Paris, France 95 Hereditary Ocular Degenerations. "Ophthalmic Abiotrophies. " E. Treacher Collins, London, England 103 Bitemporal Contraction of Visual Fields in Pregnancy. Prof. C. E. Finlay, Havana, Cuba 144 Les Echanges d'Eau et d'lons a Travers la Cornee. Dr. V. Morax, Paris, France 157 Psyche-pathology in Ophthalmic Practice. Dr. Charles F. Harford, Cam- bridge, England 160 Nuevo Tratamiento Quirurgico del Estrabismo. Dr. B. Castresana, Madrid, Espana 171 A New Procedure in the Excision Method of Pterygium Operation. Dr. E. Campodonico, Lima, Peru 201 The Subconjunctival Excision of Pterygium. Dr. S. Lewis Ziegler, Phila- delphia 205 La Tuberculosis Ocular Infantil. Dr. Francisco Poyales, Madrid, Espana. . 214 Endophthalmitis Phacoanaphylactica. Drs. F. H. Verhoeff and A. N. Lemoine, Boston, Mass 234 Serum and Vaccine Treatment for the Prevention and Cure of Cataract. Dr. A. Edward Davis, New York City 284 Facoerisis. Prof. Ignacio Barraquer, Barcelona, Espana 313 Operation de Barraquer. Prof. Gallemaerts, Bruxelles 319 Troubles Oculaires Consecutifs a 1'Observation Directe de 1'Eclipse Solaire. Dr. Dragoutine Kostitch, Belgrade, Jugo-Slavia 340 Orbital Marsupialization and Superiority of Organic Grafts of Dead Tissue in Establishing a Mobile Stump. Dr. A. Magitot, Paris, France 359 La Peritomia en las Ulceras Cr6nicas Vasculares de la Cornea. Dr. Antonio F. Alonso, Mexico, D. F 371 Types of Pneumococcus Found in Corneal Ulcers. Dr. Robert Cartwright Cheney, Boston, Mass 378 L'Etat Vasculaire des Glaucomateux (Etude de 100 Malades de Glaucome Primitif). Dr. Carlos Charlin, Santiago, Chile 383 3 PAGE The Diagnosis of Glaucoma. Lt.-Col. R. H. Elliot, London, England 405 Blood-Pressure in the Vessels of the Eye. Dr. A. Magitot and Dr. P. Bailliart, Paris, France 435 Plastic Operations about the Eye. Dr. John M. Wheeler, New York City. . 443 Lagophtalmie Bilaterale Consecutive a la Perte Accidentelle de la Peau du Front, et du Cuir Chevelu. B16pharoplastie. Dr. J. N. Roy, Montreal. Canada 460 Light-Sense: The Practical Significance of its Variations: Simple Tests for Determining Them. Archibald Stanley Percival, M.A., M.B., B.C., Camb., Newcastle-upon-Tyne, England 468 Some Contributions to the Science and Practice of Ophthalmology. C. E. Ferree, Ph.D., and G. Rand, Ph.D., Bryn Mawr, Pa 479 Le Diagnostic et la Mesure des Vices de Refraction au Moyen de la Fente Ste"nopeique et du Cadran Horaire. Dr. Emile Junes, de Sfax, Tunisie . 520 Anomalies of Ocular Development and Pigmentation. J. Gray Clegg, M.D., B.S., F.R.C.S., Manchester, England 528 Los Mercuriales, el Salvarsan y sus Derivados en el Tratamiento de las Formas Graves de Conjuntivitis y Queratitis Eczematosas. Dr. Antonio Torres Estrada, Mexico, D. F 533 The Effects of Direct Instillation of Novarsenobillon in the Conjunctival Sac in Resistant Cases of Congenital Syphilitic Interstitial Keratitis. Dr. Arnold Renshaw, Manchester, England 548 Tratamientos de las Queratitis Infecciosas por las Vacunas. Dr. Rovirosa Virgili, Madrid, Espana 551 Carcinoma of the Choroid. Dr. Allen Greenwood, Boston, Mass 567 Metastatic Thyroid Tumor in the Orbit. Dr. Arnold Knapp, New York City. 573 Bilateral Lymphosarcoma of the Orbit with Intermittent Exophthalmos. Drs. Walter Scott Franklin and Frederick C. Cordes, San Francisco, Cali- fornia 579 Chloroma. Dr. Arthur J. Bedell, Albany, N. Y 588 PROPOSITIONS FOR CONGRESS ACTION The Value of Letters and Characters as Visual Tests. Dr. A. E. Ewing, St. Louis, Mo 604 Ophthalmologic Versus Anatomic Nomenclature. Dr. M. Uribe Troncoso, New York City 607 Standardization of Perimetric Technic. Dr. Luther C. Peter, Philadelphia. . . 615 ADDRESSES DELIVERED BEFORE THE CONGRESS Some Descriptive Errors in the Anatomy of the Orbit. Prof. S. E. Whitnall, Montreal, Canada 617 On the Clinical Anatomy of the Efferent Lacrimal Passageways. J. Parsons Schaeffer, Philadelphia, Pa 625 The Facts and Theories of Color Vision. Prof. Leonard Thompson Troland, Cambridge, Mass 652 The Production and Transmission of Certain Eye Defects. Prof. M. F. Guyer, University of Wisconsin 669 A New Technic for the Application of the Method of Cajal to Sections of the Retina. Dr. Felix Fernandez Balbuena, Gijon, Spain 690 Minutes of the Proceedings 692 Organization of the Congress 705 International Congress Committees 706 4 AN INTERNATIONAL CONGRESS OF OPHTHALMOLOGY OFFICERS OF THE CONGRESS PRESIDENT DR. G. E. DE SCHWEINITZ, OF PHILADELPHIA, PA. VICE-PRESIDENTS DR. FRANCISCO J. SORIANO, OF ARGENTINE PROF. EMILE GALLEMAERTS, OF BELGIUM DR. CESARIO DE ANDRADE, OF BRAZIL DR. PIMENTAL FRANCO, OF BRAZIL DR. T. M. Li, OF CHINA PROF. C. E. FINLAY, OF CUBA DR. WILLIAM Z. HONS, OF CZECHO-SLOVAKIA E.TREACHER COLLINS, F.R.C.S., OF ENGLAND PROF. F. DE LAPERSONNE, OF FRANCE PROF. G. F. ROCHAT, OF HOLLAND DR. SALVATORE FLORIA, OF ITALY DR. AURELIO BERAUN, OF PERU DR. GEORGE MACKAY, OF SCOTLAND PROF. IGNACIO BARRAQUER, OF SPAIN DR. D. FRANCISCO POYALES, OF SPAIN PROF. ALLVAR GULLSTRAND, OF SWEDEN DR. LUCIEN HOWE, OF UNITED STATES DR. EDWARD JACKSON, OF UNITED STATES DR. SANTOS DOMINICI, OF VENEZUELA SECRETARY -TREASURER DR. LUTHER C. PETER, OF PHILADELPHIA, PA. SECRETARIES DR. ALBERT LASALLE, MONTREAL, CANADA FRENCH DR. FRANCISCO M. FERNANDEZ, HAVANA, CUBA SPANISH DR. JESUS M. PENICHET, HAVANA, CUBA FRENCH AND SPANISH OFFICIAL GOVERNMENT REPRESENTATIVES CHINA DR. T. M. LI PEKING UNION MEDICAL COLLEGE CUBA PROF. C. E. FINLAY DR. J. M. PENICHET DR. F. M. FERNANDEZ HAVANA GREAT BRITAIN MR. EDWARD TREACHER COLLINS, F.R.C.S. DR. GEORGE MACKAY VICE-PRESIDENT. OF EDINBURGH. SCOTLAND. TO REPRESENT THE ROYAL COLLEGE OF SURGEONS OF EDINBURGH ITALY DR. SALVATORE FLORIA NETHERLANDS PROFESSOR G. F. ROCHAT PROFESSOR OF OPHTHALMOLOGY. UNIVERSITY OF GRONINGEN, PRESIDENT OF THE OPHTHALMOLOGICAL SOCIETY OF THE NETHERLANDS PERU DR. AURELIO BERAUN SPAIN DR. IGNACIO BARRAQUER PROFESSOR OF OPHTHALMOLOGY. UNIVERSITY OF BARCELONA DR. D. FRANCISCO POYALES CENTRAL UNIVERSITY, MADRID SWEDEN PROFESSOR ALLVAR GULLSTRAND. PH.D. UPSALA UNITED STATES ARMY MEDICAL CORPS LIEUTENANT-COLONEL F. H. GARRISON NAVY MEDICAL CORPS LIEUTENANT JAMES F. HOOKER PUBLIC HEALTH SERVICE SURGEON JOHN MCMULLEN REPRESENTATIVES FROM SOCIETIES AND UNIVERSITIES ACADEMIE DE MEDECINE DE PARIS FACULTE DE MEDECINE DE PARIS PROFESSOR F. DE LAPERSONNE ASOCIACION MEDICA ARGENTINA DR. FRANCISCO J. SORIANO FACULDADE DE MEDICINA DA BAHIA. BRAZIL SOCIEDADE MEDICA DOS HOSPITAN DA BAHIA. BRAZIL DR. CESARIO DE ANDRADE DR. PIMENTAL FRANCO PEKING UNION MEDICAL COLLEGE, CHINA DR. T. M. LI UNIVERSITE DE BRUXELLES SOCIETE BELGE D'OPHTALMOLOG IE PROFESSOR EMILE GALLEMAERTS MEMBERS OF AX INTERNATIONAL CONGRESS OF OPHTHALMOLOGY Members present are indicated by * FOREIGN MEMBERS ARGENTINE REPUBLIC Manes, Dr. Antonio J., Buenos Aires Noceti, Dr. Adolfo, Buenos Aires Oneto, Dr. Jose A., Buenos Aires Soriano, Dr. Francisco J., Buenos Aires AUSTRALIA *Spring, Dr. J. F., BELGIUM *Gallemaerts, Professor Emile, BRAZIL de Andrade, Dr. Cesario, Buriner, Dr. Jose P., Franco, Dr. Pimental, Gomes, Dr. Pereira, *Arrell, Dr. W., Badeaux, Dr. Georges, Bousquet, Dr. Paul E., *Byers, Dr. W. M. Gordon, "Campbell, Dr. Colin A., Chipman, Dr. L. D. V., *Courtney, Dr. J. D., Cunningham, Dr. Allan R., Doull, Dr. Arthur E., *Fales, Dr. A. C., *Fraser, Dr. W. G., *Kerry, Dr. Richard, *Lassalle, Dr. Albert, Laurent, Dr. E. E., *Lyon, Dr. Mortimer, MacCallum, Dr. James M., *McCulloch, Dr. R. J., *MacMillan, Dr. John A., *MacNeil, Dr. F. A., Mathers, Dr. R. Evatt, Mathewson, Dr. Geo. H., *McAuley, Dr. A. G., *MacDonald, Dr. Wm. A., CANADA Melbourne Brussels Bahia Campinas Sergipe S. Paulo Ontario Montreal Montreal Montreal Toronto New Brunswick Ottawa Halifax, N. S. Halifax, N. S. Middleton, N. S. Ottawa Montreal Montreal Montreal Toronto Toronto Toronto Montreal Winnipeg, Manitoba Halifax, N. S. Montreal Montreal Windsor 8 Members of An International Congress of Ophthalmology McKenty, Dr. Francis D., Winnipeg, Manitoba *Minnes, Dr. Robt. S., Ontario Morton, Dr. Jos. P., Ontario Panneton, Dr. Auguste, Quebec *Putnam, Dr. W. G., Nova Scotia *Rosenbaum, Dr. Jacob, Montreal *Roy, Dr. J. N., Montreal Sebert, Dr. Louis J., Toronto Smith, Dr. I. R., Toronto *Smith, Dr. W. Harvey, Winnipeg, Manitoba *Stirling, Dr. J. W., Montreal Thompson, Dr. Septimus, Ontario *Tooke, Dr. Fred. T., Montreal Trites, Dr. C. Bruce, Nova Scotia *Whitnall, Professor S. Ernest, Montreal *Wright, Dr. Walter W., Toronto CENTRAL AMERICA Guillen, Dr. Joaquin, El Salvador Luna, Dr. R. Pacheco, Guatemala CHILE Barranechea, Dr. M. J., Santiago Charlin, Dr. Carlos, Santiago CHINA *Li, Dr. T. M., Peking COSTA RICA Herdocia, Dr. Constantino, San Jose CUBA Altuna, Dr. Manuel, Cienfuegoa *Fernandez, Dr. Francisco M., Havana Fernandez, Dr. Juan Santos, Havana *Finlay, Prof. Carlos E., Havana Guiral, Dr. Rodolfo, Havana *Gutierrez, Dr. Gerardo, Havana *Penichet, Dr. Jesus M., Havana CZECHOSLOVAKIA *Hons, Dr. William Z. DOMINICAN REPUBLIC Grullon, Dr. A., Santiago ECUADOR Rubio, Dr. Juan F., Guayaquil EGYPT MacCallan, Dr. A. F., Cairo Members of An International Congress of Ophthalmology 9 ENGLAND *Clegg, Mr. John Gray, "Collins, Mr. Edward Treacher, *Elliot, Lt.-Col. R. H., Lauford, Mr. John B., Paton, Mr. Leslie, Percival, Mr. Archibald S., Manchester London London London London Newcastle-on-Tyne FRANCE Chaillous, Dr. J., *Gemblath, Dr. Said, Jeandelize, Prof. Paul C., Junes, Dr. Emile, Koenig, Dr. Chas. I., *de Lapersonne, Prof. F., *Magitot, Dr. A., Morax, Dr. Victor, Morgan, Dr. James A., HAWAII Paris Paris Nancy Tunisia Paris Paris Paris Paris Honolulu HOLLAND Marx, Dr. R., *Rochat, Prof. G. F-, *Roelofs, Dr. Otto, Van der Hoeve, Prof. J., Were, Dr. H. I. M., Zeeman, Prof. Dr. W. P. C., Leiden Groningen Amsterdam Leiden Rotterdam Amsterdam *Floria, Dr. Salvatore, ITALY MEXICO *Alonso, Dr. Antonio F., Avalos, Dr. Enrique, Estrada, Dr. Antonio Torres, Gonzalez, Dr. Jose de J., Gonzales, Dr. Leppoldo, Lopez, Dr. Fernando, Silva, Dr. Rafael, *Ulises de la Garza, Dr. J., Velez, Dr. Daniel M., *Beraun, Dr. Aurelio, Calderon, Dr. Juan Luiz, Campodonico, Dr. E., Dammert, Dr. Augusto, PERU Mexico Guadalajara Mexico Guanajuato Pueblo Mexico Mexico Saltillo Mexico Lima Lima Lima PORTO Rico Bernabe, Dr. Rafael, San Juan 10 Members of An International Congress of Ophthalmology SCOTLAND *Mackay, Dr. George, Pollock, Dr. W. B. Inglis, *Rowan, Dr. John, Sinclair, Dr. Arthur H. H., SPAIN Amiga, Dr. Hermenegildo, *Balbuena, Dr. Felix Fernandez, *Barraquer, Dr. Ignacio, Camison, Dr. Agustin A., Castresana, Dr. Baldomero, Marin-Amat, Dr. Manuel, Menacho, Dr. Manuel, *Ortin, Dr. Galo Leoz, Poyales, Dr. Francisco, Salterain, Dr., Virgili, Dr. Rovirosa, *Gullstrand, Prof. Allvar, *Xordenson, Dr. J. W., SWEDEN URUGUAY Tsola, Dr. Almerico, Arraiz, Dr. A. Jimenez, *Dominici, Dr. Santos, Espino, Dr. U. M., VENEZUELA Edinburgh Glasgow Glasgow Edinburgh Barcelona Gijon Barcelona Santander Madrid Almeria Barcelona Madrid Madrid Madrid Upsala Stockholm Montevideo Caracas Caracas Caracas UNITED STATES Abbott, W. J., *Abele, L. H., *Adams, Chas. F., Adams, Frederick, *Adams, W. Herbert, Alcorn, John B., *Alger, Ellice M., *Allen, Thos. D., * Ailing, Arthur N., Allport, Frank, Anderson, C. G., Andrews, Albert H., *Andrews, James H., Andrews, Jos. A., *Andrews, S. L., Arneberg, J. G., Arnold, Francis J., Ash, Arthur F., *Atkinson, Walter S., Aufmwasser, H. W., Austin, J. W., Cleveland, Ohio Chicago, 111. Trenton, N. J. Seattle, Wash. Jacksonville, Fla. Columbus, Ohio New York City Chicago, 111. New Haven, Conn. Chicago, 111. Carbondale, Pa. Chicago, 111. Brooklyn, N. Y. Santa Barbara, Calif. Lewiston, Me. Grand Forks, N. Dak. Burlington, Vt. Weehawken, N. J. Watertown, N. Y. Denver, Colo. High Point, N. C. Members of An International Congress of Ophthalmology 11 Austin, Thos. C., Austin, Wm. H., Aynsworth, Horace T., *Ayres, Wylie McL., Baer, B. F., Jr., Bahn, Chas., *Bailey, Fred D., Bailey, F. W., *Bailey, Harold, *Bailey, Wm. J., *Baker, Chas. H., *Baker, H. B., Balentine, P. L., *Ball, Dr. Jas. M., *Bane, Wm. C., *Banner, C. W., Barck, C., Barkan, Adolph, Barkan, Hans, *Barker, O. G. A., Barrows, F. L., Beach, Bennett S., *Beach, S. Judd, *Beattie, Robert, Beaudoux, Henry A., Beaumont, John F., Beatty, Hugh G., *Beck, A. J., *Bedell, Arthur J., Beem, lone F., Beeman, C. E., *Begle, H. L., *Bell, Geo. H., Bell, James H., Bell, M. H., *Benedict, W. L., *Benson, Geo. E., *Bentley, Frederick, *Bentley, Neil, *Benton, Lt. F. L., *Berens, Dr. Conrad, Jr. Binger, E. H., *Blaauw, Edmund E., Black, Howard, Black, Melville, Black, N. M., Blackburn, W. J., *Blackmar, F. B., *Blackwell, Enoch, *Blackwell, Karl S., Blackwood, Jas. M., *Blair, Wm. W., Pasadena, Calif. Griffin, Ga. Waco, Texas Cincinnati, Ohio Philadelphia, Pa. New Orleans, La. Brooklyn, N. Y. Cedar Rapids, Iowa Springfield, Mo. Connellsville, Pa. Bay City, Mich. Taunton, Mass. Philadelphia, Pa. St. Louis, Mo. Denver, Colo. Greensboro, N. C. St. Louis, Mo. San Francisco, Calif. San Francisco, Calif. Johnstown, Pa. Moscow, Idaho New York, N. Y. Portland, Me. Detroit, Mich. Minneapolis, Minn. Portland, Ore. Columbus, Ohio New Rochelle, N. Y. Albany, N. Y. Chicago, 111. Grand Rapids, Mich. Detroit, Mich. New York, N. Y. San Antonio, Texas Vicksburg, Miss. Rochester, Minn. Minneapolis, Minn. Seattle, Wash. Detroit, Mich. Washington, D. C. New York, N. Y. St. Paul, Minn. Buffalo, N. Y. Palo Alto, Calif. Denver, Colo. Milwaukee, Wis. Dayton, Ohio Columbus, Ga. Trenton, N. J. Richmond, Va. New Castle, Pa. Pittsburgh, Pa. 12 Members of An International Congress of Ophthalmology *Blake, Eugene M., Blake, Wm. F., *Bledsoe, R. W., *Blue, J. B. T Blum, H. N., *Boehringer, H. W., Boiler, W. F., *Bordley, James, Jr., Bouvy, Harry, *Branch, Frederick D., Brasefield, E. N., *Brawley, F. E., *Brawley, R. V., *Bribach, Eugene J., *Brickley, W., *Briggs, H. H, *Briggs, Wm. E., *Brinckerhoff, E. E., Broderick, Frank W., *Brose, L. D., *Broughton, Wm. R., Brown, E. T., *Brown, E. V. L., Brown, H. H., *Brown, J. C., *Brown, John E., Brown, Samuel H., *Brown, W. E., Brownell, Morton E., *Bruner, Wm. E., Bruns, H. Dickson, Bryant, D. C., *Buchanan, Mary, Buckman, E. V., Bullard, Robt. I., *Bulson, Albert E., *Burch, F. C., *Burdick, Austin F., *Burke, John W., *Butler, W. K., *Buvinger, Chas. W., Byrnes, Harry F., *Calhoun, F. Phinizy, Cameron, Howard McD., Camp, Walter E., Campbell, Chas. W., Campbell, Don M., "Campbell, W. K., *Capron, F. P., "Carleton, Ralph, Carlin, C. H., Carpenter, E. W., New Haven, Conn. San Francisco, Calif. Covington, Ky. Memphis, Tenn. New Orleans, La. Philadelphia, Pa. Iowa City, Iowa Baltimore, Md. La Grande, Ore. Binghamton, N. Y. Phjllipsburg, N. J. Chicago, 111. Salisbury, N. C. Atchison, Kans. Marion, Ohio Asheville, N. C. Sacramento, Calif. Oakland, Calif. Sterling, 111. Evansville, Ind. New York, N. Y. Burlington, Vt. Chicago, 111. Chicago, 111. Wichita, Kans. Columbus, Ohio Philadelphia, Pa. Pittsburgh, Pa. Oneonta, N. Y. Cleveland, Ohio New Orleans, La. Los Angeles, Calif. Philadelphia, Pa. Wilkes-Barre, Pa. Springfield, 111. Ft. Wayne, Ind. St. Paul, Minn. Lansing, Mich. Washington, D. C. Washington, D. C. East Orange, N. J. Springfield, Mass. Atlanta, Ga. Sacramento, Calif. Minneapolis, Minn. Columbus, Neb. Detroit, Mich. Long Branch, N. J. Providence, R. I. Springfield, Mass. Torrington, Conn. Greenville, S. C. Members of An International Congress of Ophthalmology 13 Carpenter, Forrest A., *Carpenter, John T., Carr, Andy M., Carroll, G. G., *Carroll, Jas. J., *Carson, W. E., *Carvill, Maud, Gary, Edward H., *Cattley, Stephen J., Cayce, E. B., *Chamberlain, W. P., *Chambers, Talbot R., *Chance, Burton, Chapman, V. A., Charles, Jose. W., Chattin, J. F., *Cheney, Robert C., *Childers, Robert J., Childs, Hal. A., *Christenbery, H. E., Churchman, V. F., Claiborne, John Herbert, *Clapp, Clyde A., Clark, C. F., Clark, J. Sheldon, Clark, J. Wendell, Clark, Lloyd H., *Clark, Newton T., Clayton, George R., Cleff, Oscar, Clement, Chas. C., Clement, L. O., Cline, B. McH., *Cobb, Edwin, Cochrane, Wayne A., *Cocklin, C. C., Cogan, J. E., *Cohen, Lee, *Cohen, Louis L., *Cohen, Martin, Collendar, Major E. R., Colliver, Samuel N., Colver, Benton N., *Compton, Robt. F., Connor, Ray, Constantine, K. W., Cook, F. S., Cook, W. Albert, Coover, D. H., Copeland, R. C., Cordes, F. C., *Corser, J. B., *Coulter, Chas. F., Statesville, N. C. Philadelphia, Pa. Minot, N. D. Rochester, N. Y. Baltimore, Md. Pittsburgh, Pa. Boston, Mass. Dallas, Texas Ogdensburg, N. Y. Nashville, Tenn. Cleveland, Ohio Jersey City, N. J. Philadelphia, Pa. Milwaukee, Wis. St. Louis, Mo. Newark, N. J. Boston, Mass. Plainfield, N. J. Creston, Iowa Knoxville, Tenn. Charleston, W. Va. New York, N. Y. Baltimore, Md. Columbus, Ohio Lexington, Ky. Chicago, 111. Rochester, N. Y. Spartanburg, S. C. Lima, Ohio Chicago, 111. Chicago, 111. Grants Pass, Ore. Milledgeville, Ga. Marshalltown, Iowa Jackson, Mich. Harrisburg, Pa. Cleveland, Ohio Baltimore, Md. Brooklyn, N. Y. New York, N. Y. Washington, D. C. Seattle, Wash. Battle Creek, Mich. Charlottesville, Va. Detroit, Mich. Birmingham, Ala. Eau Claire, Wis. Tulsa, Okla. Denver, Colo. New York, N. Y. San Francisco, Calif. Scranton, Pa. Great Falls, Mont. 14 Members of An International Congress of Ophthalmology *Covington, Maj. L. C. Cowin, Carl C., *Cowper, H. W., *Coyle, A. L., "Creighton, W. J., *Crigler, Lewis W., *Crisp, Wm. H., Crockett, R. L., Croman, Jos. M., Crook, Martin, *Croskey, John Welsh, Cross, A. E., *Cross, G. H., *Curdy, R. J., *Curran, E. J., *Curry, Glendon E., *Curtin, Thos. H., *Curtis, Elbert A.. Cutler, Colman W., *Dailey, R., Dancy, A. B., *Daugherty, L. E., Davidson, Morris, *Davis, A. Edward, *Davis, Frederick A., Davis, J. E., Davis, Ralph F., *Davis, W. T., Dayton, G. O., *Dyaton, W. L., Dean, F., Decker, John J., *Decker, P. H., Deery, Geo. E., Dempsey, W. H., Denig, R., *Dennis, D. N., *Derby, George S., *Dewey, J. H., Diaz, Jos. L., Dickson, John F., Diem, Oscar, Dilworth, W. D., *Dimitry, T. J., Dixon, W. E., *Dodd, C. S., *Dodd, Oscar, Dolan, Wm. E., Dolman, Percival, Donavan, J. A., Donnell, N. R., Donoher, W. D., West Point, N. Y. Jamestown, N. D. Buffalo, N. Y. Wheeling, W. Va. Philadelphia, Pa. New York, N. Y. Denver, Colo. Oneida, N. Y. Mt. Clemens, Mich. Spartanburg, S. C. Philadelphia, Pa. Worcester, Mass. Chester, Pa. Kansas City, Mo. Kansas City, Mo. Pittsburgh, Pa. New York, N. Y. Newark, N. J. New York, N. Y. Houston, Texas Jackson, Tenn. Cumberland, Md. New York, N. Y. New York, N. Y. Madison, Wis. McAlester, Okla. Portland, Ore. Washington, D. C. Butte, Mont. Lincoln, Neb. Council Bluffs, Iowa New York, N. Y. Philadelphia, Pa. Brooklyn, N. Y. Alton, 111. New York, N. Y. Erie, Pa. Boston, Mass. Philadelphia, Pa. Newark, N. J. Portland, Oregon New York, N. Y. Pasadena, Calif. New Orleans, La. Oklahoma City, Okla. Petersburg, Va. Evanston, 111. Worcester, Mass. San Francisco, Calif. Butte, Mont. St. Louis, Mo. Salt Lake City, Utah Members of An International Congress of Ophthalmology 15 Dorente, Dred R., Dorsey, J. G., Dow, Frank E., *Dowling, Jas. C., *Dowling, Jos. E., Dowling, J. Ivimey, *Downey, Jesse W., Jr., Drake, Chas. A., *Driver, W. E., *Duane, Alex., *Dunn, Ira J., *Dunn, Jas. W., Dunnington, John H., Duntley, G. S., *Dutrow, H. V., *Edgar, T. O., Edgerton, A. E., *Edmonds, J. P., Edwards, Frank A., Edwards, Slocum R., *Edwards, Walter, *Egan, B. W., *Ellegood, J. A., *EUett, E. C., *Ellingwood, William, Elliott, W. F., *Ellis, Bertha W., Ellis, John B., Emerson, Linn, Engle, H. P., Ericson, J. G., *Estabrook, Chas. T., Evensen, Harold O., *Ewing, Arthur E., Faith, Thomas, *Farnsler, H. Hershey, *Farrior, J. Brown, *Feingold, Marcus, *Felderman, Lem., Fenton, Ralph A., Fenton, Thomas H., Ferguson, E. I., *Ferguson, Robt. J., *Ferree, C. E., Findlay, E. K., *Finnoff, Wm. C., *Fisher, W. A., Fiske, David *Fiske, George F., Fitzgerald, F. J. C., *Fleck, H. K., Ft. Smith, Ark. Wichita, Kans. Northampton, Mass. Washington, D. C. Providence, R. I. Albany, N. Y. Baltimore, Md. New York, N. Y. Norfolk, Va. New York, N. Y. Erie, Pa. Cairo, 111. New York, N. Y. Bushnell, 111. Dayton, Ohio Dixon, 111. Taft, Calif. Middlesboro, Ky. Los Angeles, Calif. Fort Collins, Colo. Rochester, N. Y. Logansport, Ind. Wilmington, Del. Memphis, Tenn. Rockland, Maine Lincolnton, N. C. Lansing, Mich. Chicago, 111. Orange, N. J. Newton, Iowa Minneapolis, Minn. Worcester, Mass. Chicago, 111. St. Louis, Mo. Chicago, 111. Harrisburg, Pa. Tampa, Fla. New Orleans, La. Philadelphia, Pa. Portland, Oregon Philadelphia, Pa. Oklahoma City, Okla. New Haven, Conn. Bryn Mawr, Pa. Chicago, 111. Denver, Colo. Chicago, 111. Chicago, 111. Chicago, 111. New York, N. Y. Baltimore, Md. 16 Members of An International Congress of Ophthalmology Forchheimer, Walter, Forgrave, L. R., *Forster, A. E., Fowler, Earle B., Fox, Chas. H., *Fox, Frederick G., *Fox, L. Webster, Fox, Ralph D., Fox, Wra. H., Francis, Charles H., *Francis, Lee Masten, *Franklin, Walter S., *Fraser, R. C., *Frey, Clarence L., *Fridenwald, Harry, *Friesen, H. J., *Fringer, W. R., Frisch, Frederick, Frost, W. S., Fulkerson, C. B., Fullenwider, C. M., Fuller, Chas. G., Fuller, John A., Fuller, T. O., *Fulton, John F., Gamble, W. E., Gantt, L. Rosa H., *Gardiner, Edwin J., Garraghan, Edw. F., Garrison, Lt.-Col. F. H., Gavin, Edward F., George, Edgar J., *George, H. W., *Gibson, Robt. D., Gifford, Sanford R., *Gilbert, Frank Y., *Gilbert, Walter J., *Gill, George, *Gill, Jas. J., *Gillett, D. F., *Gillman, Robt. W., *Gillum, J. R., *Gittins, T. R., Glasser, Edw. F., Gleason, J. E., *Glover, S. P., *Goldbach, L. J., Goldenburg, Michael, *Golding, Jos. E., *Goldstein, Isadore, *Good, Wm. M., Goodenow, N. H., Cincinnati, Ohio St. Joseph, Mo. Philadelphia, Pa. Chicago, 111. Kearney, Neb. Chicago, 111. Philadelphia, Pa. Bloomington, 111. Washington, D. C. Chicago, 111. Buffalo, N. Y. San Francisco, Calif. Port Huron, Mich. Scranton, Pa. Baltimore, Md. Grand Forks, N. D. Rockford, 111. Atlantic City, N. J. Spokane, Wash. Kalamazoo, Mich. Muskogee, Okla. Chicago, 111. Reno, Nev. Texarkana, Ark. St. Paul, Minn. Chicago, 111. Spartanburg, S. C. Chicago, 111. Chicago, 111. Washington, D. C. Waukegan, 111. Chicago, 111. Middletown, Pa. Youngstown, Ohio Omaha, Neb. Portland, Me. Calais, Me. Elyria, Ohio Baltimore, Md. Syracuse, N. Y. Detroit, Mich. Terre Haute, Ind. Sioux City, Iowa San Francisco, Calif. Detroit, Mich. Altoona, Pa. Baltimore, Md. Chicago, 111. Brooklyn, N. Y. New York, N. Y. Waterbury, Conn. Sierra Madre, Calif. Members of An International Congress of Ophthalmology 17 *Goux, R. S., *Gradle, Harry S., Graham, R. Watson, Gratiot, Harvey B., Green, Aaron S., *Green, John, Jr., *Green, Louis D., *Green, Louis S., Greene, R. A., *Greenwood, Allen, Gregory, A. R., *Griesner, L. Lawrence, *Griffith, J. Beaty, *Griscom, J. Milton, Grosvenor, Lorenzo N., Grove, Benj. H., *Gullion, O. R., Gurley, Lycurgus M. ( Guthrie, J. M., *Guyer, Prof. M. F., Haas, Frederick J., *Haden, Henry, Haley, P. A., Hall, Alfred M., *Hall, Gaylord C., Hall, Wm. P., Hallett, Wayne, Hamlin, Francis A., *Hammett, Chas. M., Hampton, Robt. R., *Hancock, James C., Hansell, Howard F., Harbert, John P., Harbridge, D. F., "Harding, F. B., Hare, George R., *Hargitt, Chas. A., Harkness, Gordon F., *Harlan, Herbert, Harrington, A. F., Harris, C. M., *Harrower, David, Hartshorne, Isaac, Haskell, Alfred W., *Haskin, H. P., *Hauer, A. M., Haughey, Wilfrid, Hay den, Austin A., Hazen, E. H., Hearvy, John H., "Hebert, A. W., *Heckel, Edw. B., 2 Detroit, Mich. Chicago, 111. Los Angeles, Calif. Dubuque, Iowa San Francisco, Calif. St. Louis, Mo. San Francisco, Calif. Washington, D. C. Spokane, Wash. Boston, Mass. Jacksonville, 111. Roselle, N. J. Washington, D. C. Philadelphia, Pa. Huron, S. D. Buffalo, N. Y. Eugene, Ore. Johnstown, Pa. Meridian, Miss. Madison, Wis. Leavenworth, Kan. Houston, Texas Charleston, W. Va. Chicago, 111. Louisville, Ky. Utica, N. Y. New York, N. Y. Bakersfield, Calif. Washington, D. C. Salt Lake City, Utah Brooklyn, N. Y. Philadelphia, Pa. Bellefontaine, Ohio Phoenix, Ariz. Allentown, Pa. New York, N. Y. Brooklyn, N. Y. Davenport, Iowa Baltimore, Md. Muskegon, Mich. Johnstown, Pa. Worcester, Mass. New York, N. Y. Portland, Me. Williamsport, Pa. Columbus, Ohio Battle Creek, Mich. Chicago, 111. Oakland, Calif. Toledo, Ohio Philadelphia, Pa. Pittsburgh, Pa. 18 Members of An International Congress of Ophthalmology *Hedges, Halstead, Heeb, H. J., *Heed, Chas. R., *Heflebower, R. C., Heggie, N. H., Heitger, J. D., *Heitmuller, George H., *Henning, Carl, Henninger, L. L., *Henton, G. E., Hetrick, Llewellyn E., Hetzel, C. C., *Hicks, Vonnie M., *Hiers, Jas. L., Higbee, E. H., "Hilgartner, H. L., *Hill, Emory, *Hill, J. A., *Hillegas, Wm. M., Hitchcock, W. Alvan, Jr., *Hitzel, G. A., *Hoeffler, C. L., Hoffman, J. R., Hoffman, L. G., *Hoffman, Philip F., *Holloway, T. B.. Hollyday, W. H., Hoist, John, *Holt, E. E., *Holt, E. E., Jr., Holzapfel, Wm. H., *Holzer, Wm. F., Hood, T. C., *Hooker, Lt. James F., Hopkins, Guy H., *Hopper, W. L., Hosmer, C. M., *Hough, Perry B., *Howe, Lucien, *Howland, F. A., "Hubbard, H. V., Huber, L. H., *Hughes, F. W., Hughes, H. S., Hulen, Yard H., Humrichouse, J. W., *Hunt, Ella G., Hurley, Edward D., Ingram, Lawrence C., *Irwin, Frank N., *Isaacs, David, Israel, Jos. P., Charlottesville, Va. Milwaukee, Wis. Philadelphia, Pa. Cincinnati, Ohio Jacksonville, Fla. Louisville, Ky. Washington, D. C. Washington, D. C. Council Bluffs, Iowa Portland, Ore. New York, N. Y. Ogden, Utah Raleigh, N. C. Savannah, Ga. St. Louis, Mo. Austin, Texas Richmond, Va. Asbury Park, N. J. Philadelphia, Pa. Boston, Mass. Buffalo, N. Y. Everett, Wash. Chicago, 111. Chicago, 111. White Plains, N. Y. Philadelphia, Pa. 'Asheville, N. C. Omaha, Neb. Southern Pines, N. C. Portland, Maine New York, N. Y. Worcester, Mass. Indianapolis, Ind. Washington, D. C. Pueblo, Colo. Fort Scott, Kans. San Diego, Calif. New York, N. Y. Buffalo, N. Y. Adrian, Mich. Plainfield, N. J. Livingston, Mont. Indianapolis, Ind. St. Louis, Mo. San Francisco, Calif. Hagerstown, Md. Cincinnati, Ohio Boston, Mass. Orlando, Fla. New York, N. Y. Omaha, Neb. Houston, Texas Members of An International Congress of Ophthalmology . 19 Israel, N. E., Israel, Sidney, Mack, Edwin E., *Jackson, Edward, *Jacobi, Frank, Jacobs, M. W., Macoby, D. P. A., *Jameson, P. C., Jarvis, C. C., Mean, George W., Jenne, Byron H., Mennings, Chas. W., Mennings, J. Ellis, Jervey, J. W., Jessaman, L. W., Jobson, George B., Johnson, Walter B., Johnson, W. H., Mohnston, J. G., Johnston, Wilson, Jones, Arthur C., Jones, Chas. J., Mones, E. L., Mones, Elgin W., Jones, Fred W., Mones, L. Leroy, Jordon, George T., *Kahn, W. Randolph, *Keeler, Chas., *Keiper, George F., Kellog, Francis B., *Kemler, Jos., *Kennon, B. R., *Kershner, W. EL, *Key, Ben Witt, Kiehle, Frederick A., *Kincaid, J. H., *King, Clarence, *King, William Rufus, Kirk, Albert W., Kirkendale, John, Kirkpatrick, S., *Knapp, Arnold, Knapp, A. J., Knipe, J. C., *Knowlton, L. G., Koller, Carl *Kollock, Chas. W., Koonce, S. E., Kraft, Oscar, *Krebs, Adolph, Houston, Texas Houston, Texas Boston, Mass. Denver, Colo. Toledo, Ohio St. Ixniis, Mo. Newport, R. I. Brooklyn, N. Y. Clarksburg, W. Va. Santa Barbara, Calif. Detroit, Mich. Pittsburgh, Pa. St. Louis, Mo. Greenville, S. C. Framingham, Mass. Franklin, Pa. Paterson, N. J. Muscatine, Iowa Charlotte, N. C. Portland, Ore. Butte, Mont. Philadelphia, Pa. Cumberland, Md. Lynn, Mass. Alton, 111. Portsmouth, Va. Chicago, 111. Baltimore, Md. Darien, Conn. Lafayette, Ind. Los Angeles, Calif. Baltimore, Md. Norfolk, Va. Bath, Maine New York, N. Y. Portland, Ore. Knoxville, Tenn. Cincinnati, Ohio Washington, D. C. San Francisco, Calif. Ithaca, N. Y. Selma, Ala. New York, N. Y. Evansville, Ind. Philadelphia, Pa. Cleveland, Ohio New York, N. Y. Charleston, S. C. Wilmington, N. C. Chicago, 111. Pittsburgh, Pa. 20 Members of An International Congress of Ophthalmology Kress, George H., *Krieger, Wm. A., *Krimsky, S. Joseph, *Krug, Ernest F., "Kruskal, J. D., LaForce, E. F., Lakin, H. P., Lamb, Harvey D., *Lamb, Robert Scott, *Lambardo, M., *Lambert, W. E., Lamkin, Burt B., *LaMotte, W. O., *Lancaster, Walter B., Landa, Michael G., Landman, Otto, *Lane, Frances, "Lane, L. A., *Langdon, H. Maxwell, *Larkin, B. J., *Larsen, Carl E., Lauder, Clark H., *Lauterbach, W. F., Lederman, I. A., *Lee, Dorothea, Lee, John W., *LeFevre, S., Lefler, Anna B., *Lemere, H. B., *Lemoine, Albert N., *Lent, E. J., Lester, John C., *Levy, Louis, *Lewis, F. Park, Lewis, W. W., *Libby, Gecrge, *Lichtenberg, J. S., Lidikay, Chas. J., "Lilly, J. M., *Linn, Jay G., Lippincott, J. A., Lischkoff, Mozart, Lloyd, A. W., *Lloyd, Ralph I., *Loeb, Clarence, *Lokey, Hugh M., *Long, Jas. A., Loomis, E. A., *Looper, Edward A., *Loring, Francis B., Love, J. King, *Love, Louis F., Los Angeles, Calif. Poughkeepsie, N. Y. Brooklyn, N. Y. New York, N. Y. Brooklyn, N. Y. Burlington, Iowa Lansdale, Pa. St. Louis, Mo. Washington, D. C. Brooklyn, N. Y. New York, N. Y. Fresno, Calif. Wilmington, Del. Boston, Mass. New York, N. Y. Toledo, Ohio Chicago, 111. Minneapolis, Minn. Philadelphia, Pa. Indianapolis, Ind. St. Paul, Minn. Grinnell, Iowa Dayton, Ohio Ix)uisville, Ky. San Jos6, Calif. Minneapolis, Minn. Glens Falls, N. Y. Los Angeles, Calif. Omaha, Neb. Boston, Mass. South Bend, Ind. New York, N. Y. Memphis, Tenn. Buffalo, N. Y. St. Paul, Minn. Denver, Colo. Kansas City, Mo. Kansas City, Kans. Fayetteville, N. C. Pittsburgh, Pa. Pittsburgh, Pa. Pensacola, Fla. Hammond, Ind. Brooklyn, N. Y. Chicago, 111. Atlanta, Ga. Frederick, Md. Minneapolis, Minn. Baltimore, Md. Washington, D. C. Easton, Pa. Philadelphia, Pa. Members of An International Congress of Ophthalmology 21 Lowell, W. Holbrook, *Luedde, W. H., *Lukens, Chas., Lynch, J. F., Lyon, Martha M. Brewer, *McAllister, J. C., McBride, Wm. O., McCannell, Archibald D., *McCaw, John A., *McClelland, C. C., McConachie, A. D., *McConville, C. Adeline, McCool, Joseph L., McCoy, George W., McCubbin, J. B., *McDannald, Clyde E., McDonald, S. J., McDougall, Jas. C., *McDowell, George W., *McGuire, Hunter H., *McHenry, D. D., *McIntire, Frederic J., McKee, Albert M., *McKee, C. W., McKennan, Jas. W., *McKimmie, O. S., *McKinney, A. R., *McLean, Wm., *McMullen, Surgeon John, *McMurray, John B., McPherson, S. Dace, McQuade, M. A., *McReynolds, John O., McWilliams, J. M., Mackenzie, Alice V., *Mackenzie, George W., Macleish, A. C., Macleish, A. L., MacMillan, A. L., Jr., *Macnie, John S., *McKeon, E. E., Magruder, A. C., *Mahoney, Geo., Maire, Lewis E., Maloney, D. J., Mansur, Leon W., *Markel, J. Clyde, Markham, H. C., *Marlow, Frank W., *Marsh, Elias J., 'Marshall, J. W., *Martin, H. H., Boston, Mass. St. Louis, Mo. Toledo, Ohio Winona, Minn. South Bend, Ind. Ridgway, Pa. Fort Wayne, Ind. Minot, N. D. Denver, Colo. Detroit, Mich. Baltimore, Md. Brooklyn, N. Y. Portland, Ore. Los Angeles, Calif. Fulton, Mo. New York, N. Y. Boston, Mass. Atlanta, Ga. New York, N. Y. Winchester, Va. Oklahoma City, Okla. Lynn, Mass. San Francisco, Calif. Greensburg, Pa. Washington, Pa. Washington, D. C. Saginaw, Mich. New York, N. Y. Washington, D. C. Washington, Pa. Durham, S. C. Newburgh, N. Y. Dallas, Texas Fayetteville, Tenn. Philadelphia, Pa. Philadelphia, Pa. Los Angeles, Calif. Los Angeles, Calif. Concord, N. H. Minneapolis, Minn. Denver, Colo. Colorado Springs, Colo. Chicago, 111. Detroit, Mich. Waterbury, Conn. Los Angeles, Calif. Pittsburgh, Pa. Parsons, Kans. Syracuse, N. Y. Paterson, N. J. Leesburg, Va. Savannah, Ga. 22 Members of An International Congress of Ophthalmology *Matheny, R. C., Matison, E. A., Maxey, E. E., Maxson, Sands C., *May, C. H., May, Jas. V., Meadows, D. F., *Meanor, Wm. C., *Means, C. S., *Mehl, Wm., Meigs, R. J., *Mercer, Wm. F., *Merrill, H. G., Merritt, R. E., Mershon, Oliver F., Mertins, Paul S., *Metz, Roy B., *Metzger, Irvin D., Middleton, A. B., *Mikell, Pinkney V., *Miles, H. S., *Miller, Clifton M., *Miller, Edwin B., *Miller, Frank K., Miller, Frank W., Millett, Frank A., *Millette, John W., *Mills, Lloyd, *Minor, H. F., Minor, L. C., Mittendorf, A. D., *Monaghan, D. G., *Monson, S. H., *Moore, C. C., *Moore, G. A., Moore, G. H., *Moore, J. D., *Moore, T. J., Moore, T. W. *Morgan, A. D., *Morgan, Browne, Morgenroth, H. W., *Mori, S., 'Morrison, Edw. L., Morse, A. W., Morsman, L. W., Morton, Howard, Mott, John S., *Moulton, H. Moss, Robt. E., Mullen, Jos. A., *Muncaster, S. B., *Mundt, Henry, Galesburg, 111. Chicago, 111. Boise City, Idaho Utica, N. Y. New York, N. Y. Marinette, Wis. St. Louis, Mo. Pittsburgh, Pa. Columbus, Ohio Buffalo, N. Y. Lowell, Mass. Richmond, Va. Provo, Utah Los Angeles, Calif. Philadelphia, Pa. Montgomery, Ala. Cleveland, Ohio Pittsburgh, Pa. Pontiac, 111. Columbia, S. C. Bridgeport, Conn. Richmond, Va. Philadelphia, Pa. Philadelphia, Pa. Los Angeles, Calif. Greenfield, Mass. Dayton, Ohio Los Angeles, Calif. Memphis, Tenn. Springfield, Ohio New York, N. Y. Denver, Colo. Cleveland, Ohio Philadelphia, Pa. Palmer, Mass. Schuylkill Haven, Pa. Bloomfield, N. J. Akron, Ohio Huntington, W. Va. Norfolk, Va. Bloomfield, N. J. Oshkosh, Wis. Baltimore, Md. Washington, D. C. Butte, Mont. Hibbing, Minn. Minneapolis, Minn. Kansas City, Mo. Fort Smith, Ark. San Antonio, Texas Houston, Texas Washington, D. C. Chicago, 111. t Members of An International Congress of Ophthalmology 23 Murray, Alfred N., *Murray, Wm. R., *Myers, Dean, Myers, Harry L. ; Mytinger, Geo. S., *Nabers, Samuel F., Nance, Willis O., *Nardin, W. H., *Nebinger, Reid, *Neeper, Edw. R., *Neher, Edwin M., Nelson, Chas. F., Nelson, Louis, A. Newcomb, John R., *Newhart, Horace, *Newell, Wm. S., *Neulen, E. Nelson, North, Nelson L., *Norton, D. C., Noyes, Guy L., *Nutter, C. F., Nutting, R. J., *Oberdorfer, Archie L., *O'Brien, John I., O'Brien, Steve A., O'Brien, T. A., *O'Connor, Roderic, O'Donnell, Major G. A. *Oertel, T. E., "Offutt, W. N., *Ohly, John H., *Orcutt, D. C., *Overbay, F. A., *Owen, Arthur E., Owen, Frank S., *Paganelli, Terigi R., *Park, J. Walter, *Parker, Walter R., Pasternacki, B. W., Patterson, E. W. E., *Patterson, W. E., *Patton, Jas. M., *Payne, S. M., Peabody, H. C., Pearson, Geo. J., Pearson, W. W., Peery, Thos. E., Pelle, Harry L., *Pendexter, R. S., Perry, Richard W., Chicago, 111. Minneapolis, Minn. Ann Arbor, Mich. Norfolk, Va. Chillicothe, Ohio - Birmingham, Ala. Chicago, 111. Anderson, S. C. Danville, Pa. Colorado Springs, Colo. Salt Lake City, Utah Cleveland, Ohio St. Paul, Minn. Indianapolis, Ind. Minneapolis, Minn. Washington, D. C. Astoria, Ore. Brooklyn, N. Y. Manchester, N. H. Columbia, Mo. Nashua, N. H. Oakland, Calif. New York, N. Y. Schenectady, N. Y. Mason City, la. Philadelphia, Pa. San Francisco, Calif. Fort Sill, Okla. Augusta, Ga. Lexington, Ky. Brooklyn, N. Y. Chicago, 111. New Orleans, La. Lansing, Mich. Omaha, Neb. Hoboken, N. J. Harrisburg, Pa. Detroit, Mich. Detroit, Mich. Grand Rapids, Mich. Minneapolis, Minn. Omaha, Neb. New York, N. Y. \Vebster, S. D. Burlington, Iowa Des Moines, Iowa Bluefield, W. Va. Louisville, Ky. Washington, D. C. Seattle, Wash. 24 Members of An International Congress of Ophthalmology *Peter, Luther C., *Peterman, H. F., Pfingst, A. O., Phelj)s, Kenneth A., PhiUips, Frank A., Phillips, William H., 'Place, E. Clifford, *Pole, S. Boyce, Pontius, Nevin D., Pontius, Paul, Porter, Edwards H., Porter, L. B., *Posey, William Campbell, Post, Lawrence T., Post, M. H., Potter, W. W., *Pratt, Fred J., Presnell, C. W., *Price, N. W., *Prince, A. E., Procter, Percy C., Prout, J. S., *Pusey, Brown, *Pyle," Wallace, fPyle, Walter L., *Quackenboss, Alex., *Radcliffe, McCluney, Ralston, W. W., *Rand, Prof. Gertrude, Randolph, Wilson, Ravdin, M., Ray, Victor, Reaves, W. P., *Redding, Leonard C., *Reed, Charles L., Reed, J. Ross, Reeder, J. E., *Reese, Robert G., Reger, Harry S., Reynolds, H. G., *Rhode, Homer J., *Rice, John E., Rideout, Wm. J., Riker, John D., *Rindlaub, Martin P., Jr., *Ring, G. Oram, Ringle, C. A., Ringueberg, Eugene, Risley, J. N., Ritter, Howard M., t Deceased. Philadelphia, Pa. Baltimore, Md. Louisville, Ky. Minneapolis, Minn. Pasadena, Calif. Cleveland, Ohio Brooklyn, N. Y. Washington, D. C. Los Angeles, Calif. Philadelphia, Pa. Tiffin, Ohio Providence, R. I. Philadelphia, Pa. St. Louis, Mo. St. Louis, Mo. Knoxville, Tenn. Minneapolis, Minn. Trinidad, Colo. Niagara Falls, N. Y. Springfield, 111. Boston, Mass. Fishkill, N. Y. Chicago, 111. Jersey City, N. J. Philadelphia, Pa. Boston, Mass. Philadelphia, Pa. Houston, Texas Bryn Mawr, Pa. Detroit, Mich. Evansville, Ind. Cincinnati, Ohio Greensboro, N. C. Scranton, Pa. Pittsburgh, Pa. Pasadena, Calif. Sioux City, la. New York, N. Y. Jamestown, N. Y. Paducah, Ky. Reading, Pa. Worcester, Mass. Freeport, 111. Pontiac, Mich. Fargo, N. D. Philadelphia, Pa. Greeley, Colo. Lockport, N. Y. New Bedford, Mass. Williamsport, Pa. Members of An International Congress of Ophthalmology 25 Robbins, Elmer E., Jr., Robertson, Edwin M., *Robinson, H. T., Robinson, J. La Rue, *Robinson, R. E., *Roebuck, J. Paul, *Rogers, Robert H., Rogers, T. Avery, *Rood, L. C., Rosebrough, F. H., *Row, Geo. S., Rowland, John F., *Rowland, W. D., Ruby, Fred McK., Rudolphy, Jay Besson, Rust, E. G., *St. Clair, Chas. T., Saliba, Michel, Samuels, Bernard, Samuels, Maimon, Sanderson, Hermon H., *Sargent, A. Alonzo, Sartain, Paul J., Sattler, Robert, Sauer, W. W., *Savage, Moses M., Sawyer, W. W., Scarlett, Hunter W., *Schaeffer, Prof. J. Parsons, *Schipfer, L. A., *Schlichter, Chas. H., Schlindwein, G. Wm., *Schlivek, Kaufman, Schoch, Lester E., *Schoenberg, Mark J., *Schweinitz, George E. de, Schwenk, Peter N. K., Scott, Lewis M., *Sears, Wm. H., Sedwick, Wm. A., Seely, A. C., Seelye, Walter K., *Seiberling, Geo. F., *Seibert, E. G., *Sener, Walter J., *Sernoffsky, I., *Shackleton, W. E., Shahan, W. E., Shanklin, Eldridge M., *Shannon, C. E., *Shannon, John R., *Sharrett, G. O., Shastid, Thos. H., New Bedford, Mass. Concordia, Kans. Cumberland, Md. Reno, Nev. Waverly, Iowa Lancaster, Pa. Newark, N. J. Plattsburg, N. Y. Boston, Mass. Brownwood, Texas Indianapolis, Ind. Hot Springs, Ark. Boston, Mass. Union City, Ind. Philadelphia, Pa. Cleveland, Ohio Bluefield, W. Va. Wilson, N. C. New York, N. Y. Seattle, Wash. Detroit, Mich. Philadelphia, Pa. Philadelphia, Pa. Cincinnati, Ohio Marietta, Ohio Baltimore, Md. . Elizabeth City, N. C. Philadelphia, Pa. Philadelphia, Pa. Bismarck, N. D. Elizabeth, N. J. Erie, Pa. New York, N. Y. Shamokin, Pa. New York, N. Y. Philadelphia, Pa. Philadelphia, Pa. Jellico, Term. Huntingdon, Pa. Denver, Colo. Roseburg, Ore. Seattle, Wash. Allentown, Pa. Washington, D. C. Philadelphia, Pa. Buffalo, N. Y. Cleveland, Ohio St. Louis, Mo. Hammond, Ind. Philadelphia, Pa. New York, N. Y. Cumberland, Md. Superior, Wis. 26 Members of An International Congress of Ophthalmology *Sherman, Elbert S., Shields, Jas. M., Shine, Francis W.. *Shoemaker, J. F., Shoemaker, W. A., *Shoemaker, Wra. T., *Shreve, Owen M., *Shultz, Louis A., Shuman, G. H., *Shumway, E. A., *Shute, D. K., *Siegel, Francis X., *Simonds, Otis F., *Simpson, J. H., Simpson, W. Likely, Sims, W. S., *Singleton, E. M., *Skeel, H. Robertson, *Skirball, Jos. J., *Slataper, Felician J., *Sleight, R. D., *Sliteler, C. I., *Sloan, Henry L., *Slocum, Geo., *SmaU, Chas. P., *Smart, Frank P., Smith, Arthur E., Smith, Carroll, Smith, Chas. L., Smith, Dean S., *Smith, Borland, *Smith, E. Terry, *Smith, George, *Smith, George M., Smith, Harry A., Smith, Henry M., *Smith, H. Reginald, Smith, Josiah E., Smith, Owen A., Smith, S. S., *Smith, Victor C., *Smyth, P. Somers, Sneed, Carl M., *Snell, Albert C., *Snyder, Walter H., *Souter, W. N., Spalding, Fred M., Spalding, James, *Spencer, Frank R., *Spangler, John A., *Spiegelglass, A. B., Spratt, Chas. N., Stahlman, Fred C., Newark, N. J. Denver, Colo, New York, N. Y. St. Louis, Mo. St. Louis, Mo. Philadelphia, Pa. Erie, Pa. Rockford, 111. Pittsburgh, Pa. Philadelphia, Pa. Washington, D. C. Cincinnati, Ohio Cleveland, Ohio Louisville, Ky. Memphis, Tenn. Jackson, Miss. Marshalltown, Iowa New York, N. Y. Boston, Mass. Philadelphia, Pa. Battle Creek, Mich. Chester, Pa. Charlotte, N. C. Ann Arbor, Mich. Chicago, 111. Norfolk, Va. Minneapolis, Minn. Spokane, Wash. Independence, Kans. LaCrosse, Wis. Bridgeport, Conn. Hartford, Conn. Casper, Wyo. Rome, Ga. Delta, Colo. Brooklyn, N. Y. Chicago, 111. Charleston, S. C. Farmington, Mo. Pittsburgh, Pa. New Orleans, La. Boston, Mass. Columbia, Mo. Rochester, N. Y. Toledo, Ohio Portsmouth, N. H. Boston, Mass. Portland, Me. Boulder, Colo. Geneva, N. Y. Hackensack, N. J. Minneapolis, Minn. Charleroi, Pa. Members of An International Congress of Ophthalmology 27 Stanford, J. B., Standish, Myles, *Stark, H. H., *Stark, Jesse B., Starr, Elmer G., *Stauffer, J. Leaver, Steese, Edwin S., *Stegman, L. B., Steim, Jos. M., Steinfeld, A. C., Stephens, W. B., *Sternberg, Jos. E., Steuber, F. G., Stevenson, D. W., Stieren, Edw., Stillwell, Hiram R., Stockard, Cecil, *Stone, H. B., Stookey, W. M., Strader, Geo. L., *Strickler, David A., Strout, Eugene S., Stuart, Chas. C., *Stucky, J. A., Sturm, S. A., Suffa, G. A., Suker, George F., Sulzer, Gustavus A., *Sulzman, Frank M., Sutherland, Fred B., Sutphin, Theron Y., *Swab, Chas. M., *Swan, C. J., Sweet, Robert B., *Sweet, William M., Swift, Geo. W., *Tarun, William, Taylor, Joseph W., *Taylor, Lewis H., Tenner, A. S., Tenney, John A., *Theobald, Samuel, Thigpen, Chas. A., *Thomas, Frances W., Thomas, Jerome B., Thompson, P. H., Thomson, Edgar S., Thomson, John J., *Thorpe, Harvey E., *Tibbens, Clyde E., Tibbet, Albert, Tilderquist, D. L., Memphis, Tenn. Boston, Mass. El Paso, Tex. New York, N. Y. Buffalo, N. Y. Philadelphia, Pa. New York, N. Y. Battle Creek, Mich. New Kensington, Pa. Toledo, Ohio Alameda, Calif. ^ Boston, Mass. Lima, Ohio Akron, Ohio Pittsburgh, Pa. Denver, Colo. Atlanta, Ga. Roanoke, Va. Salt Lake City, Utah Cheyenne, Wyo. Denver, Colo. Minneapolis, Minn. Cleveland, Ohio Lexington, Ky. Pittsburgh, Pa. Boston, Mass. Chicago, 111. Columbus, Ohio Troy, N. Y. New York, N. Y. Newark, N. J. Philadelphia, Pa. Evanston, 111. Long Beach, Calif. Philadelphia, Pa. Seattle, Wash. Baltimore, Md. Tampa, Fla. Wilkes-Barre, Pa. New York, N. Y. Boston, Mass. Baltimore, Md. Montgomery, Ala. Columbus, Ohio Palo Alto, Calif. Boston, Mass. New York, N. Y. Mt. Vernon, N. Y. Pittsburgh, Pa. Washington, Pa. Washington, D. C. Duluth, Minn. 28 Members of An International Congress of Ophthalmology "Tingley, Louise P., "Tomassene, Raymond A., Torney, S. J., Townsend, C. E., Trimble, Clarence S., Tripp, Ira A., Troncoso, M. Uribe, "Tuckerman, W. C., *Tuckerman, W. H., *Turner, Hunter H., * r |pner, Oliver W., lydings, Oliver, "Tyson, Henry H., Upham, Helen F., *Urner, M. H., *Vail, Derrick T., *VanHorn, Alfred, VanKirk, V. E., Varick, Wm. R., *Veasey, Clarence A., "Verhoeff, F. H., *Virden, John E., Vinsonhaler, F., Voigt, C. B., VonColditz, G. Thomson, *Von der Heydt, Robert, Boston, Mass. Wheeling, W. Va. Bellingham, Wash. Akron, Ohio Emporia, Kans. Cleveland, Ohio New York, N. Y. Cleveland, Ohio Cleveland, Ohio Pittsburgh, Pa. Augusta, Me. Chicago, 111. New York, N. Y. Asbury Park, N. J. Cincinnati, Ohio Cincinnati, Ohio Plainfield, N. J. Pittsburgh, Pa. Manchester, N. H. Spokane, Wash. Boston, Mass. New York, N. Y. Little Rock, Ark. Mattoon, 111. Chicago, 111. Chicago, 111. *Wagner, Carl B., *Waldeck, George M., Walker, Arthur W., Walker, C. E., Walker, Herbert, Walter, Will, *Waltz, F. D., Wandless, Henry W., Walker, Clifford B., Wanamaker, A. T., Ward, G. Harold, Warner, Garden F., *Washburn, John S., *Watson, Henry D., *Watson, J. A., *Watson, R. S., Weaver, E. W., Weaver, T. W., *Webster, David H., *Weed, Harry M., *Weeks, John E., *Weeks, Webb W., *Weidler, W. B., Chicago, 111. Detroit, Mich. Riverside, Calif. Denver, Colo. Chicago, 111. Evanston, 111. Detroit, Mich. New York, N. Y. Springfield, Mass. Seattle, Wash. Englewood, N. J. Washington, D. C. Youngstown, Ohio Binghamton, N. Y. Minneapolis, Minn. Saginaw, Mich. Akron, Ohio Wichita, Kans. New York, N. Y. Buffalo, N. Y. New York, N. Y. New York, N. Y. New York, N. Y. Members of An International Congress of Ophthalmology 29 Weih, E. P., *Weill, N. J., *Weimer, E. S., Weiss, Louis, *Weisser, Edw. A., *Wells, David, Welsh, D. E., *Werts, C. M., *Wescott, C. D., Whaley, E. M., *Wheeler, J. M., *Wherry, W. P., *Whisnant, A. M., *Whitaker, Joel, White, Chas. P., *White, Jas. W., *White, Jos. A., *Whitman, Lloyd B., *Wible, Elmer E., *Wiener, Alfred, *Weiner, Meyer, Wilbur, Edw. P., *Wilder, W. H., *Wilkinson, Oscar, Williams, Kent E., *Wilmer, William H., Wilson, Alpheus K., *Wilson, Edgar A., *Wilson, Harold, *Wilson, N. L., Wilson, R. C., *Winter, Geo. E., Winter, John A., *Wise, Ralph C., Wolfe, Claude T., *Wolff , Julius, Wolfner, Henry L., Wood, Casey A., Wood, Douglas, *Wood, Hilliard, Wood, J. Scott, Woodruff, F. E., Woodruff, H. W. Woodruff, Thos. A., *Woods, Hiram, Woods, R. H., Woodson, J. M., *Worrell, J. P., Wright, C. L., Wright, John R., *Wright, J. W., 'Wright, R. H., Wiirdemann, Harry V., Clinton, Iowa Pittsburgh, Pa. Pittsburgh, Pa. Newark, N. J. Pittsburgh, Pa. Boston, Mass. Grand Rapids, Mich. Des Moines, Iowa Chicago, 111. Columbia, S. C. New York, N. Y. Omaha, Neb. Charlotte, N. C. Indianapolis, Ind. Wilmington, Del. New York, N. Y. Richmond, Va. Baltimore, Md. Pittsburgh, Pa. New York, N. Y. St. Louis, Mo. Kalamazoo, Mich. Chicago, 111. Washington, D. C. Rome, N. Y. Washington, D. C. Jacksonville, Fla. Meriden, Conn. Detroit, Mich. Elizabeth, N. J. Ithaca, N. Y. Jackson, Mich. Duluth, Minn. Mansfield, Ohio Louisville, Ky. New York, N. Y. St. Louis, Mo. Chicago, 111. Minneapolis, Minn. Nashville, Tenn. Brooklyn, N. Y. St. Louis, Mo. Joliet, 111. New London, Conn. Baltimore, Md. La Salle, 111. Temple, Texas Terre Haute, Ind. Minneapolis, Minn. Louisville, Ky. Columbus, Ohio Richmond, Va. Seattle, Wash. 30 Members of A n International Congress of Ophthalmology Wyatt, O. W., *Wylie, C. B., *Yost, Walter M., *Young, B. F., Young, H. B., Young, Thomas H., Yudkin, Arthur M., *Zehnder, A. Charles, *Zentmayer, William, *Ziegler, S. Lewis, *Ziporkes, Joseph, *Zvaifler, N., Manning, Iowa Morgantown, W. Va. Rochester, Pa. Knoxville, Tenn. Burlington, Iowa New Haven, Conn. New Haven, Conn. Newark, N. J. Philadelphia, Pa. Philadelphia, Pa. New York, N. Y. Newark, N. J. OPENING SESSION, APRIL 25, 1922 HALL OF THE DAUGHTERS OF THE AMERICAN REVOLUTION THE Congress was opened by the Chairman of the Committee on Arrangements, Dr. W. H. Wilmer, of Washington, D. C. The following address of welcome was then made by Hon. Cal- vin D. Coolidge, Vice-President of the United States: ADDRESS OF WELCOME Mr. Chairman, Members and Guests of the Congress: At the request of your Chariman I have the privilege of extending to you a word of greeting and of welcome. You are meeting in the capital of the United States of America, in a city that bears the name of a great world figure, dedicated to stability, to civilization, and to liberty. You are gathered this morning in the national headquarters of a society which for the past represents patriotism, and for the present represents the determination to support and maintain civil government. There are six governments officially represented here, several universities and scientific societies, many delegates from different countries, many delegates from different portions of our own nation. You are holding this conference for mutual instruction, mutual help, for the alleviation of human suffering, educating each other, for men do not educate themselves by exchange of ideas, by consultation, study and con- ference they educate each other in the arts and sciences and the humanities. You have come here on an errand of mercy, desiring to make your contribution to the alleviation of human suffering. You have come in the interests of good health, which is of great economic value as well as ministering to human comfort. As a national asset there is nothing of more value than sound public health. If you were to strike down all of those things which make up our civilization, our organizations, our institutions of learning, our arts and our sciences, the last thing with which humanity would part would be the asset of good health. With that remaining, it would be possible to reconstruct all else ; with 31 32 An International Congress of Ophthalmology that gone, everything else that men hold of value would of necessity perish. You have taken for your province the care and maintenance of the eye, one of the most wonderful and most delicate organs of the five human senses, one which makes the greatest contribution to human intelligence, for if the philosophers are right, that perfection of subject depends upon perfection of object, then the contribution that is made to the perfection of mankind through a clear and accurate eyesight is one of the greatest contributions made from any human source. The old Greeks understood the problem. In their language the perfect of "to see" is the present of "to know," for with them, as with us, to have seen means to know. " If therefore thine eye be single, thy whole body shall be full of light." I recall that during my grammar school days among the sentences in the old school-book given me to learn something of the importance and the use of language, there was this sentence, which has remained with me always a sentence full of meaning, full of inspiration, especially to those who follow your pro- fession "The eye is the window of the soul." But in addition to this you come with the broader, more extended purpose of scientific investigation. The world is turning to science as its refuge, as the source of its direction and as the means of its progress. You come as ministers to the truth, determined to follow it wherever it may lead, and it is under that principle that all the world, all nations and all men, are drawing together with a common purpose. You are uplifters of mankind, ministering to the general welfare of civilization. You follow the truth. In the words of my old preceptor, who never tired telling those who came under his direction and his instruction, "Truth and Freedom Truth coming from distinct sources, and Freedom knowing no bounds but those which Truth has set." That represents you, that represents civilization, that represents the standards of today and the hope the eternal hope of the morrow. Dr. E. C. Ellett, Dr. Cassius D. Wescott, and Dr. Clarence A. Veasey were appointed a Committee to Nominate Permanent Officers of the Congress. The Secretary called the roll of the official delegates in the alpha- betic order of their respective governments, with the request that each delegate present his credentials. CHINA: Dr. T. M. Li (Peking Union Medical College): It is indeed a great pleasure to me to be able to attend this Inter- national Congress that is being held in the capital city of this great country. I consider it a great pleasure and honor to be able to meet Address of Foreign Delegates 33 so many eminent ophthalmologists of this world who have devoted their lives to the conservation of vision. I come from a country in which the science of ophthalmology is still in its infancy. It is my hope that some day we shall be able to extend to you an invitation to hold your session like this in my country. I bring you greetings from China and wish you the success which I have no doubt you will have. CUBA: Prof. C. E. Finlay, Havana: I beg to extend greetings of the Republic of Cuba to her northern neighbor, the great Republic in whose beautiful capital we meet this morning, and to whom we are united by the bonds of lasting gratitude for the great moral and material support they extended to us during our war for independence; next, to the members of this Congress, meeting for the first time in fifteen years, and after the untimely inter- ruption in 1914. I wish to express the hope that this meeting may be a contribution, a material advance in the particular branch of medicine in which we are interested. FRANCE: Prof. F. de Lapersonne (Academic de Medecine de Paris; Faculte de Medecine de Paris) : Au nom de 1'Academie de Medecine de Paris, au nom de la Faculte 1 de Medecine et de Monsieur le Ministre de 1'Instruction Publique, j 'adresse mon respectueux hommage a Monsieur le President des Etats- Unis d'Amerique, et mon salut le plus cordial aux membres du Comite d'organisation du Congres d'ophtalmologie. J'apporte egalement les vifs regrets de beaucoup d'ophtalmologistes frangais, qui n'ont pu se rendre a Washington a cause de la distance et des difficultes materielles de 1'heure presente, mais qui sont de tout coeur avec vous. Us ont delegue aupres de vous un de leurs doyens d'age qui, a defaut d'autre merite, a celui d'etre profondement convaincu de 1'importance de la mission que vous accomplissez. Nos reunions periodiques, dont vous avez si heureusement renoue le cycle, marquent d'une pierre blanche les progres accomplis par notre science ophtal- mologique, mais elles ont aussi pour but de rapprocher des hommes dignes de se comprendre et par consequent de s'aimer. Salut et honneur au Congres International d'Ophtalmologie de Washington. GREAT BRITAIN: Mr. Edward Treacher Collins (Royal College of Surgeons; Royal College of Physicians): On behalf of the British ophthalmologists, and of the Royal College of Surgeons of England, and the Royal College of Physicians of Lon- 3 34 An International Congress of Ophthalmology don, I wish to express our indebtedness to the American Ophthal- mological Society, the Section on Ophthalmology of the American Medical Association, and the American Academy of Ophthalmology and Oto-Laryngology for having initiated this great Congress. I hope at a subsequent meeting to present an invitation that will help to pro- mote the continuity of such assemblies as this for the promotion of our special branch of the profession and for the consolidation and advance of the friendship of all ophthalmologists. HOLLAND: Prof. G. F. Rochat (Professor of Ophthalmology, Univer- sity of Groningen; President of the Ophthalmological Society of The Netherlands) : I have the honor to represent a country whose history has been closely connected with the earliest history of the United States, and we are very proud of the fact that a little trace of our blood runs in the veins of so many of your most prominent men. Therefore the Gov- ernment of Holland has been very glad to send their representative to this Congress. We are very eager to make scientific relations between our nations still more cordial than they have ever been, and as a repre- sentative of my country and of the Ophthalmological Society of Holland I wish to bring you their greetings. We wish to thank the committee of this Congress for their kind invitation and to express the hope that this Congress will serve the purpose of promoting ophthal- mology in particular, science in general, and better relations between the different nations in the future. ITALY: Dr. Salvatore Floria, of Washington, D. C.: I thank you for your kind invitation to be one of this illustrious scientific body. I bring to you the greetings of the Italian Govern- ment and best wishes for the success of this conference. PERU: Dr. Aurelio Beraun: I have the honor to be in this country to attend this great gathering of eminent ophthalmologists of the United States and of the countries of Europe, and it is a great honor to me. SPAIN: Dr. F. Poyales (Faculty of Medicine, Central University, Madrid) : Espana me envia a la gran nacion Americana, en representacion de todos los oculistas espanoles, las oculistas Norte-Americanos han invitado a un ilustre oftalmologo Espanol el Dr. Barraquer para mostrar sus procedimientos operatorios, he de unir al saludo en- tusiasta a todos los Congresistas del Internacional de Oftalmologia Address of Foreign Delegates 35 en Washington, nuestro proposito de colaboracion al progreso de la cicucia oftalmologica en favor de la humanidad. SWEDEN: Prof. Allvar Gullstrand, Upsala: The Swedish Government, by sending an official delegate to this Congress, has shown how it appreciates the high level of scientific re- search and of medical and ophthalmological work in this country. I came here with high expectations, but I must tell you that, having been here for a couple of weeks, I have learned and seen so much, I have found the level so high and all the colleagues so friendly, that I have gotten a mighty impression of this country. I want again to con- gratulate the United States on having such a staff of scientific oph- thalmologic men. BELGIUM: Prof. Emile Gallemaerts (University de Bruxelles; Societe Beige d'Ophtalmologie) : I shall take the opportunity offered by this occasion to say a few words of thanks for the welcome you have given us. Belgium had the honor of first proposing the organization of An International Congress of Ophthalmology, and I now have the honor of bringing the saluta- tion of the Belgians to your noble and generous country. The diffi- culties which you had to meet in the organization of this meeting did not discourage you; the number of subscribers, the list of announced communications, prove that success has resulted from your effort. This success shows the necessity of international meetings . After being side by side for the defense of justice, honor, and humanity, we shall meet each other hand to hand in science and work in the same way for the progress of our beloved specialty. Let us hope that this meeting, which will mark a new milestone in the history of ophthalmology, will be the starting-point of a long series of meetings which will never again be interrupted. SCOTLAND: Dr. George Mackay (Vice-President, representing Royal College of Surgeons, Edinburgh) : I have come a long way, but I do not propose to detain you for many minutes. I gladly take the opportunity you afford me, sir, to convey to you from the most ancient medical corporation of the British Isles, the Royal College of Surgeons of Edinburgh, founded in 1505, their hearty greetings and congratulations on your great effort to revive once more these important international meetings. Our warmest sympathies go out to you, and we feel confident that this will reorganize once more those friendly and helpful meetings which meant so much for the progress of ophthalmology. 36 An International Congress of Ophthalmology BRAZIL. Dr. Cesario de Andrade and Dr. Pimental Franco (Facul- dade de Medicina da Bahia, Sociedade Medica dos Hospitan da Bahia, Brazil). ARGENTINE: Dr. Francisco J. Soriano (Asociacion Medica Argen- tina) . Lt.-Col. F. H. Garrison, Army Medical Corps, United States; Lt. James F. Hooker, Navy Medical Corps, United States; Surgeon John McMullen, Public Health Service, United States. REPORT OF COMMITTEE ON NOMINATIONS The Committee on Nominations submitted the following names as permanent officers of the Congress: President : DR. GEORGE E. DE SCHWEINITZ, Philadelphia, Pa. Vice-Presidents : DR. FRANCISCO J. SORIANO, Argentine. PROF. EMILE GALLEMAERTS, Belgium. DR. CESARIO DE ANDRADE, Brazil. DR. PIMENTAL FRANCO, Brazil. DR. T. M. Li, China. PROF. C. E. FINLAY, Cuba. DR. WILLIAM Z. HONS, Czecho-Slovakia. MR. E. TREACHER COLLINS, England. PROF. F. DE LAPERSONNE, France. PROF. G. F. ROCHAT, Holland. DR. SALVATORE FLORIA, Italy. DR. AURELIO BERAUN, Peru. DR. GEORGE MACKAY, Scotland. PROF. IGNACIO BARRAQUER, Spain. DR. D. FRANCISCO POYALES, Spain. PROF. ALLVAR GULLSTRAND, Sweden. DR. LUCIEN HOWE, United States. DR. EDWARD JACKSON, United States. DR. SANTOS DOMINICI, Venezuela. Secretary-Treasurer : DR. LUTHER C. PETER, Philadelphia, Pa. Secretaries : DR. ALBERT LASALLE, Montreal, Canada French. DR. FRANCISCO M. FERNANDEZ, Havana, Cuba Spanish. DR. JESUS M. PENICHET, Havana, Cuba French and Spanish. Salutatory of President of the Congress 37 Upon motion of Dr. E. C. Ellett the report was adopted and the officers declared unanimously elected. The President of the Congress was then introduced by the Chair- man of the Committee on Arrangements. Ladies and Gentlemen of the Congress : In high appreciation of the honor conferred, and with a keen sense of the responsibilities involved, I beg, in representative capacity and personally, to extend a hearty welcome to all here assembled; and to convey to the Chairmen and members of the Committees heartfelt thanks, in which, I am sure, all now gathered together freely join, for their insistent, unselfish and admirable work, which has been translated into effective results of which we are the happy beneficiaries. If success shall be our portion, it will be due, not to any one man or group of men, but to the fine spirit of loyalty which has pervaded all men and all women, who, striving in perfect sympathy and uncontending equity, have made possible this Congress of ophthalmologists assembled for the purpose of interchange of scientific thought, and the presentation of the results of research and of clinical observation. For you, gentlemen, who have come from afar (I have it not in my heart to say from foreign countries, for by your very presence here you permit us to erase that word from our vocabulary) for you con- freres, colleagues and friends, I desire to sound a special note of wel- come, and to reveal to you our sense of deep obligation in that you are with us. From the clinics and laboratories of the countries of the old world we of this new world have drawn a rich income the support of our scientific existence. Our debt is large; we happily acknowledge it; we gladly owe it. We hope only that we have not been, and shall not be, either unworthy or unmindful of these benefits. We are glad because from the Far East, from the great Province on our north, from the countries to the south of us, and from our Island neighbor, representatives have come and joined with us in this enter- prise, and to them we extend our grateful welcome. Ladies and Gentlemen of the Congress, believing that I express our united hopes, I trust we may so respect our material that it shall leave our hands finished with the master's touch ; that as we proceed along the road of scientific effort our feet shall neither stumble nor hesitate ; and that great success shall attend us in all our endeavors. SCIENTIFIC PAPERS AND ADDRESSES DES ENSEIGNEMENTS DE LA GUERRE EN " CHIRURGIE OCULAIRE PROFESSEUR F. DE LAPERSONNE Paris, France La Guerre mondiale, en nous appelant a soigner un nombre con- siderable de blesses, nous a permis de mettre a Pepreuve et de juger sous un angle nouveau les methodes chirurgicales que nous avons employees jusqu'alors. Places le plus souvent dans des conditions tres defavorables, nous avons du nous adapter au milieu dans lequel nous soignions nos blesses. D'autre part le contact journalier avec les Chin irgiens nous a permis de comparer leurs methodes nouvelles et d'en faire une large application. Je voudrais presenter au Congres International d'Ophtalmoiogie quelques observations qui m'ont ete suggerees par la pratique de plus de qualre ans de guerre et qui resument plusieurs travaux publics avec nos Collegues Franc, ais. Je serais heureux si cette modeste contribution devenait le point de depart d'une discussion dans la- quelle les Ophtalmologistes eminents, reunis dans ce Congres, venaient nous apporter le fruit de leur pratique chirurgicale des blessures orbito-oculaires, et si nous pouvions ainsi etablir le bilan des progres accomplis. Un premier fait, qui domine la chirurgie oculaire de guerre, et que nous retrouverons dans les grands traumatismes du temps de paix, c'est que les effets de ces traumatismes sont rarement localises a Poeil ou a Porbite, qu'ils dejmssent beaucoup notre habituel domaine et qu'ils produisent de vastes delabrements cutanes, des fractures compliquees du crane et des cavite"s de la face avec corps Strangers plus ou moins volumineux. Toutes ces blessures imposent une decision prompte et des inter- ventions graves et dedicates dont Pophtalmologiste doit prendre la direction avec Passistance du chirurgien et de Potorhinologiste. Dans les services militaires que j 'ai diriges, comme dans les formations sanitaires de Pavant, j'ai toujours preconise ces collaborations qui nous ont ete precieuses. 39 40 F. DE LAPERSONNE La variete" des blessures orbito-oculaires est telle qu'elles se pretent mal a une classification. On peut cependant e"tablir quelques cate- gories ayant leurs indications distinctes. Ce sont d'abord les plaies craniofaciales avec vastes delabrements cutane"s des paupieres et des regions periorbitaires mettant a nu les os de la face et du crane avec fractures esquilleuses et enfoncement. Ou bien la peau est a peine dechire'e, mais on voit une tumefaction considerable de la region orbitaire et des parties voisines, une ex- ophtalmie tre"s marquee avec coloration noiratre des teguments due a de vastes he*matomes, le tout souille par du sang caille", de la terre ou des corps Strangers des plus divers. Derrie're ces teguments profondement contus, des fractures multi- ples interessent les parois orbitaires. Par ordre de frequence on rencontre: 1. Les fractures multiples de 1'os malaire, donnant une crepitation en sac de noix, avec irradiations vers 1'apophyse zygo- matique, le maxillaire superieur ou 1'apophyse orbitaire externe. 2. Les fractures du maxillaire superieur avec enfoncement du sinus maxillaire. 3. Les fractures du rebord supe"rieur de 1'orbite, ve"rita- bles fractures de la base du crane avec toutes leurs consequences. 4. Les fractures supero-internes interessant les sinus frontaux et eth- moidaux. Les corps Strangers orbitaires plus ou moins volumineux sont, en outre des balles, des Eclats d'obus ou de schrapnells, des fragments les plus vane's entrained par Pe'clatement du projectile. Parmi les plus curieux que j'ai observes je citerai le cas d'une bague en cuivre de detonateur, mesurant six centimetres de diametre, brise"e en deux demi anneaux, 1'un etait implante transversalement dans les deux orbites en arriere de la racine du nez, Fautre etait enfonce" verticalement dans 1'orbite gauche et le sinus maxillaire. On trouve e"galement des corps Strangers beaucoup plus petits, difficiles a repe"rer par la radio- graphie ou par 1'electro-aimant, dont la recherche dans 1'orbite est d'autant plus delicate. Au milieu de ces de*sordres, 1'oeil est plus ou moins atteint. Une violente contusion sans de*chirure de la coque oculaire peut produire de grosses he*morragies, des d4collements de la re" tine ou la luxation du cristallin. A cette cate"gorie de contusions semblaient appartenir ces petites hemorragies r^tiniennes, discretes, localise'es au pole pos- t^rieur et a la macula, produites par des contusions, avec ou sans fracture du rebord orbitaire supe*ro-externe, suivant un me'canisme dont M. Lagrange a bien d^gage" les lois. A peine visibles a 1'oph- Enseignements de la Guerre en Chirurgie Oculaire 41 talmoscope, elles ont cependant des consequences assez graves sur la vision. Parmi les plaies pene'trantes, tantot il s'agit d'un veritable eclate- ment du globe, dont il ne reste que des debris de membranes au milieu de caillots; tantot il y a une plaie penetrante plus ou moins irreguliere, sclero-corneenne ou poste"rieure, avec des de"sordres masques par 1 'epanchement sanguin presque total; tantot enfin la plaie est tres petite, a peine visible. Les corps etrangers penetrant dans la cavite oculaire a la faveur de ces plaies sont d'un volume tres variable. Mais une mention toute spe"ciale doit etre reservee aux petits eclats intra-oculaires sur les- quels j'ai attire 1'attention avec plusieurs de mes collegues. Fre- quemment observes pendant la guerre de tranchee et dans les com- bats a la grenade, ils penetrent par une plaie a peine visible et vite cicatrisee. Uniques ou multiples, magnetiques ou parcelles de bois, de pierre ou de verre, leur gravite est grande. En raison de la diffi- culte de leur reperage par la radiographie et des epreuves negatives par 1'electro-aimant, ils ne peuvent pas toujours etre extraits im- mediatement et ils entrainent des iridocyclites plastiques avec tout au moins perte fonctionnelle et atrophie du globe. C'est pour cette categoric de blessures que nous avons ete obliges de faire le plus d'enucleations secondaires, afin d'eviter 1'ophtalmie sympathique. Sans plaie penetrante, de petits eclats s'incrustent sur la surface corneo-conjonctivale, produisant une reaction violente, meme apres ablation methodique et soins antiseptiques. Peu de jours apres il peut survenir une iridocyclite tres douloureuse qui entraine la perte de 1'oeil. On pense a la penetration meconnue de quelques petits eclats, ou si 1'autre peil a etc* atteint, on conclut a une ophtalmie sympathique. Quelques faits suivis avec soin me permettent de dire qu'il n'en est rien. C'est particulierement dans les eclats d'obus ou de mines a courte distance, lorsque la face et les yeux sont cribles de poudre et de petits eclats, que Ton voit se produire ce phenomene. Deja il y a plus de 30 ans, etant a Lille, j'avais observe des faits analogues chez des mineurs a la suite de coup de grisou, et j'avais emis 1'hypothese que sous 1'influence de la commotion violente pro- duite par le deplacement d'air, il se faisait des hemorragies inter- stitielles du tractus uveal favorisant la production de 1'iridocyclite. Ce que nous savons aujourd 'hui des graves alterations cellulaires 42 F. DE LAPERSONNE dans le choc traumatique, nous permettent de mieux expliquer la production de ces iridocyclites fatales sans plaie penetrante. Dans ces diffe"rents traumatismes quelles sont les complications les plus fre"quentes que nous avons a craindre? Ce que je viens de dire des irradiations des fractures vers le crane, fait preVoir que les plus immediatement redoutables sont les menin- gites, et les meningo-encephalites traumatiques. Nous avons observe plusieurs cas dont Involution a ete tres differente. Tantot la menin- gite etait suraigiie avec elevation considerable de la temperature, delire, contractures et convulsions, bientot suivis de coma. La mort survenait au bout de deux ou trois jours; a 1'autopsie on trouvait une forte injection meningee, un aspect louche de la pie-mere a la base, mais pas de pus. Tantot la meningo-encephalite avait une allure plus insidieuse; apres un debut violent, les phenomenes paraissaient s'amender, mais il persistait de la cephalee avec raideur de la nuque et sou vent un ecoulement intermittent de liquide cephalo-rachidien ; la courbe thermometrique presentait de grandes oscillations avec periodes de torpeur, de somnolence faisant suite a 1'excitation, un amaigrissement rapide se produisait et la mort survenait au bout de trois ou quatre semaines, et meme plus tard. Tantot enfin des inter- ventions heureuses permettaient d'obtenir la guerison des blesses paraissant les plus gravement atteints mais ils conservaient pendant longtemps des troubles cerebraux, et ils se sont comportes depuis comme des trepanes. En opposition avec les grandes complications observees dans les blessures des membres et du tronc, le tetanos cephalique a ete tres rare grace a 1'emploi precoce et tres large du serum preventif anti- tetanique. Nous ne connaissons pas de cas de gangrene gazeuse dans les plaies craniofaciales. Les blessures orbito-oculaires sont rarement infectees primitive- ment par les corps etrangers, nous n 'avons suivi que trois blesses chez lesquels des fragments de vetements, d'etoffe ou de cuir, avaient ete entraines dans 1'orbite; il se produisait des cellullites orbitaires avec ecoulement tres fetide, e"tat general grave. Ils finirent cepen- dant par gue>ir avec des cicatrices irregulieres. L'inf ection de ces plaies est le plus sou vent secondaire ; elle est due au pneumocoque, ce qui n'est pas 6tonnant en raison des larges com- munications des plaies orbitaires avec les fosses nasales et les sinus. Elle est due egalement au staphylocoque et surtout au streptocoque. Enseignements de la Guerre en Chirurgie Oculaire 43 Chez les nombreux blesses qui nous ont ete envoye"s au debut de la guerre, plusieurs jours et meme plusieurs semaines apres le trauma- tisme, nous avons observe frequemment, apres la chute des escarres et dans la longue periode de suppuration, des erysipeles et des lymphan- gites. Malgre 1'apparente gravite de ces complications au debut, la terminaison a ete favorable, mais des recidives se sont produites, entrainant finalement des cicatrices etendues, rendant plus difficile une restauration prothetique. Contre ces complications le per- manganate de potasse, 1'eau oxygenee, les solutions hydrargyriques, employees tout d'abord, ne nous ont donne que de mediocres resultats, les differents serums polyvalents ont eu des fortunes diverses, c'est en somme les hypochlorites sous forme de liquide de Dakin ou de solution de chloramine, tres facilement toleres par la conjonctive et les tissus de la face, qui nous ont donne une plus grande satisfaction. La complication locale la plus redoutee des blessures oculaires devait etre I'ophtalmie sympathique. Ce que nous savions par les statistiques des guerres anterieures, aussi bien que par les accidents de travail du temps de paix, devait eveiller de grandes craintes et nous faire penser qu'elle serait frequente. II n'en fut rien, heureusement; 1'iridocy elite sympathique etaient rarement signalee dans les premieres annees de la guerre, si bien qu'on alia jusqu'a la considerer comme negligeable et ne justifiant pas des operations aussi mutilantes que 1'enucleation. Une statistique basee sur 39 cas, communiques par les chefs des centres militaires ophtalmologiques et publiee par M. Morax en 1917, vint remettre les choses au point; chacun de nous d'ailleurs ob- servait dans le meme temps des ophtalmies sympathiques dues a des plaies par accidents industriels. Les principales conclusions tirees de cette statistique etaient que le caractere des blessures, la presence ou 1' absence d'eclats intra-oculaires, ne paraissaient avoir aucune influence sur 1'evolution de I'ophtalmie sympathique, et que pour etre preventive, 1'enucleation devait etre pratiquee dans les quinze jours qui suivaient 1' infection du globe oculaire. Toutes les operations partielles devaient e"tre rejetees lorsqu'il yavait acraindre ces accidents. Une observation de M. Kalt montre qu'une e'visce'ra- tion, pratiquee quatre jours apres le traumatisme, n'avait pas empeche les accidents du cote oppose. L'ophtalmie sympathique etait d'ailleurs assez sou vent benigne et dans plusieurs observations on signalait une grande amelioration par 1'emploi du neoarse"nobenzol. Jusqu'a la fin de la Guerre les conclusions rassurantes de M. Morax 44 F. DE LAPERSONNE sont resides exactes dans leur ensemble, toutefois dans quelques cas isoles on a signale que 1'ophtalmie sympathique avait eclate quatre jours apres la blessure (Chaillous). Si 1'on compare Penorme frequence des blessures oculaires avec le petit nombre d'ophtalmies sympathiques constatees, on peut con- clure que cette redoutable complication a t6 reellement tres rare. Cette rarete" est due en partie aux enucleations parfois tres pre"coces et atypiques que des chirurgiens non spe"cialistes ont pratique"es aux ambulances du front, surtout au de"but de la campagne. Les soins plus judicieux donnas ensuite par des ophtalmologistes ont beaucoup contribue a eViter ce danger. Comme il y a lieu de le prevoir ce n'est pas dans les vastes eclatements du globe ou dans les panophtal- mies que 1'ophtalmie sympathique a ete constatee, elle a ete surtout observe'e dans les plaies penetrantes avec petits e"clats intra-oculaires. Le traitement des blessures orbito-oculaires a beneficie au cours de la Guerre de grandes ameliorations sur lesquelles je demande la per- mission d'insister maintenant. Au de*but la plupart des blesses arrivant trop tardivement dans les services d'ophtalmologie, nous avons du nous contenter de lutter centre 1'infection par les pansements antiseptiques, le drainage, Pextraction des corps Strangers, des fragments osseux, 1'enucleation retardee. Ce traitement aboutissait a des cicatrications vicieuses et necessitait plus tard des operations plastiques qui obviaient plus ou moins aux mutilations de la face. Des que les conditions d'installation dans les hopitaux de 1'avant, ou les evacuations plus rapides sur 1'Interieur Font rendu possible, nous avons applique dans la plus large mesure le traitement chirurgi- cal precoce des plaies orbito-oculaires. La methode des sutures primitives, preconisee par M. Gaudier, prenait dans le traitement des grands traumatismes de guerre, une place de plus en plus importante malgre quelques oppositions. Plus que dans toute autre region elle devait avoir son application dans la chirurgie craniofaciale, en raison de la rarete" des infections primitives et de la plus grande vitality des tissus; et de fait c'est cette methode qui nous a rendu le plus de services et a comple'tement transforme les resultats. Quelques publications francaises ont signale ces faits, je citerai ma communication a 1' Academic de Medecine en Decembre 1918 et Texcellent livre sur TOphtalmologie de guerre de mes col- laborateurs MM. Duverger et Velter, paru en 1919. Enseignements de la Guerre en Chirurgie Oculaire 45 Je crois devoir rappeler que le traitement precoce comprend: I. Une exploration methodique de la blessure permettant de se rendre compte non seulement des lesions superficielles mais surtout de 1'etendue des desordres profonds, interessant les cavites peri- orbitaires. C'est dire qu'on doit toujours avoir recours a un examen radiologique complet, radioscopique et radiographique, avec les pro- cedes les plus exacts de reperage des corps etrangers. Elle comprend egalement 1'emploi constant de Pelectro-aimant, la nature des corps etrangers ne p*ouvant etre prevue. II. L'anesthesie devra etre locale a de tres rares exceptions pres. Des instillations de cocaine a 4% (quatre pour cent) seront reservees pour les explorations superficielles de la conjonctive. II faut tou- jours avoir recours a 1'anesthesie par les injections de novocaiine a quatre pour cent, en y ajoutant deux ou trois gouttes d'adrenaline au millieme par centimetre cube. Les injections seront retro-oculaires ou profondes, passant en arriere du globe et venant inonder le tissu adipeux de 1'orbite dans la region du ganglion ciliaire; elles atteindront au sommet de 1'orbite les nerfs nasal, frontal et lacrymal; elles iront toucher le nerf maxil- laire superieur a sa sortie du trou sous-orbitaire; des injections sous conjonctivales et de veritables barrages sous cutanes completeront I'anesthe'sie totale de 1'orbite et des regions voisines qui sera obtenue apres dix ou quinze minutes. Je n'insiste pas sur la technique speciale qui a ete parfaitement decrite par le Prof. Duverger (de Strasbourg). Pour nous 1'anesthesie locale a presque completement remplace 1'anesthesie generale par le chloroforme, 1'^ther, le chlorure d'ethyle ou le protoxyde d'azote. Depuis la Guerre, dans un service de Clinique aussi actif que celui de 1'Hotel-Dieu de Paris, c'est a peine si nous avons recours deux ou trois fois par an a 1'anesthesie generale, tant pour les operations douloureuses de la chirurgie oculo-orbitaire que pour le traitement des blessures. La quantity de novocame employee, meme pour les anesthesies les plus difficiles, larges auto- plasties ou exenterations orbitaires pour grosses tumeurs, est tres inf erieure aux doses indiqu6es pour la chirurgie generale ; nous savons d'ailleurs que la toxicite de la novocame est faible. D'autre part il est a peine besoin de dire que cette anesthesie fait disparaitre toute crainte de shock pour des sujets plus ou moins deprimes ou atteints d'affections organiques. L'anesthesie a la novocai'ne est plus difficile a obtenir lorsque les 46 F. DE LAPERSONNE tissus sont enflamme's; il faut quelquefois attendre plus de vingt minutes avant de pouvoir intervenir et Poperation est souvent douloureuse; a plus forte raison lorsqu'il existe des fusees purulentes et des complications dont il est difficile de connaitre les limites. Pour le phlegmon de 1'orbite par exemple, il n'est guere possible de recourir a I'anesth^sie locale. Ceci est une nouvelle raison en faveur du traitement precoce des blessures orbito-oculaires. III. Les blessures interessant le globe devront 6tre abordees par la voie palpebro-conjonctivale et la conduite sera, 'bien entendu, differente suivant le cas. Je rappelerai seulement quelques principes: 1. La recherche et 1'extraction des plus petits corps Strangers intra- oculaires devront etre extremement precoces. Nous savons par les traumatismes industriels que les degres de reussite et de conservation de la vision est en raison inverse du temps ecoule depuis la blessure. On ne peut done indiquer aucune limite et la latitude de quarante huit heures, assignee pour certaines blessures, est ici beaucoup trop grande. La tolerance relative pour les corps etrangers est souvent trompeuse et nous avons cite plusieurs exemples de petits eclats intra- oculaires, permettant meme une bonne vision, qui ont donne lieu a des iridocyclites violentes apres dix huit mois ou deux ans. Une seule exception peut etre admise pour les corps Strangers intra- cristalliniens qu'il est preferable ou d'abandonner ou d'extraire avec la totalite de la cataracte. Malgre tout, nous avons conserve I'impression que les corps etrangers intra-oculaires, dus a des blessures de guerre, entrainent tou jours un pronostic beaucoup plus grave que ceux provenant de traumatismes industriels. Ceci se congoit facilement. 2. Si tout espoir de conserver tout ou partie de la fonction visuelle doit etre abandonne, on devra pratiquer Pablation du segment an- terieur, 1'evisceration ou meme Tenucleation s'il ne reste plus que des debris oculaires. Operant d'une fagon precoce, cette derniere sera plus rarement employee, ce qui est toujours preferable au point de vue prothe"tique. Mais le blesse sera e*troitement surveille" les jours suivants, en se souvenant que de violentes douleurs sont le meilleur signe d'une reaction inflammatoire et qu'il ne faudra pas he*siter a faire une enucleation secondaire seule preventive de 1'oph- talmie sympathique. 3. Ces operations devront etre complete"es par le manteau conjoncti- val qui pour etre efficace devra etre ample et bien cousu. La con- Enseignements de la Guerre en Chirurgie Oculaire 47 jonctive largement liberee devra e*tre reunie avec le plus grand soin d'un bout a 1'autre au moyen de sutures separe'es en U. 4. On terminera par la refection complete et methodique des paupieres, meme les plus contuses, en evitant les larges resections, en regularisant les bords des plus petits lambeaux,.particulierement au niveau de la fente palpebrale, en faisant meme des autoplasties par glissement ou par renversement du lambeau, avec pedicule, si la perte de substance est trop considerable. IV. Toutes les blessures orbitaires devront etre abordees par de larges orbitotomies, meme si le traumatisme a directement interesse le globe; apres avoir traite les plaies de 1'oeil comme il est dit plus haut, on fera une longue incision courbe suivant le rebord osseux. Elle permettra d'aller a la recherche des corps etrangers, des fragments osseux ou des volumineux hematomes. L'orbitotomie suivant les bords inferieur et externe donne la plus large voie d'acces meme sans resection de la paroi externe a la Kronlein. Mais le lieu de 1'incision sera souvent commande par les lesions osseuses. L'orbitotomie sera done superieure pour 1'exploration de la voute orbitaire, supero- interne pour les sinus frontaux et meme franchement interne pour aborder les sinus ethmoidaux. Elle nous a permis a plusieurs re- prises de rechercher des fracas osseux et des corps etrangers situes profondement dans la partie interne de 1'orbite et dans le massif ethmoidal. Apres le nettoyage soigne des parties profondes, 1'incision de 1'orbitotomie suturee se reunira toujours a premiere intention. Telles sont les considerations qu'il m'a paru de quelque interet de presenter au Congres International. Si nous nous reportons a la chirurgie orbito-oculaire de 1914, et surtout aux methodes employees au debut de la guerre, il nous semble juste de dire qu'un progres considerable a ete realise. Ces resultats favorables sont dus surtout au traitement chirurgical aussi precoce que possible, aide par 1'anesthesie locale a la novocame, avec recherche des lesions profondes de 1'orbite et sutures primitives de plaies cutanees et conjonctivales. Depuis la guerre nous avons continue* a appliquer rigoureusement ces methodes dans les traumatismes acci- dentels, elles nous ont donne la plus entiere satisfaction. 48 F. DE LAPERSONNE DISCUSSION DR. FREDERICK T. TOOKE (Montreal, Canada) : It affords me pleasure, as an old student of Professor de Lapersonne, to offer him my felicitations on his beautiful presentation. It would not be fitting on my part to raise any points in discussion ; but those of us who perhaps have had a little experience in war surgery, and those who have been able to follow him in his own language, notice Professor de Lapersonne's directness of thought, the same as in former years, and his beauty and simplicity of manner. Without bringing up any point of discussion I can simply assure Professor de Lapersonne and those who have heard him that "old friends are dearest and old tunes are sweetest." Many of his observations may perhaps be well known, and the application of some of the points he has brought out, more particularly in civilian life, may be interpreted by the latter part of the quota- tion. I am sure I can assure Professor de Lapersonne on your behalf, as I do most heartily on my own, that from now on the first part of the quotation as to old friends will apply very directly. DR. GEORGE S. DERBY (Boston, Mass.) : I feel it a privilege to testify to the great help which we medical men of the army serving in France obtained from our French colleagues. I had the opportunity to attend the meetings of the Socie'te' Franchise d'Ophtalmologie, and to visit the clinics of Prof, de Lapersonne, Dr. Morax, and Prof. Lagrange, and from each place I went away with information which certainly was of great benefit to me. Among the important observations of our French colleagues were the value of thorough exploration and cleaning of wounds; the employment of sutures early as an aid to better cosmetic results; the benefits to be obtained from collaboration with those engaged in other branches of surgical work; the effects and treatment of gas cases, especially mustard gas; and the effect of contusions, either as a result of direct injury to the eye or as secondary affec- tions the contusions which have been so beautifully described and pictured by Prof. Lagrange. Our experience with sympathetic disease was the same as others, and I think much was due to their teaching in regard to early exploration and treat- ment. It seems remarkable that the results in regard to sympathetic disease should have been so good, because in many cases the eyes were actually in pieces and it was with the greatest difficulty that the torn remnants were removed from the orbit. The value of local anesthesia, to which Prof, de Lapersonne devotes so much attention, and the early search for foreign bodies within the eye and their immediate removal if the sight of the eye was to be saved, in any con- siderable number of cases, were shown in the work of his clinic. We were also impressed with the results secured by Prof, de Lapersonne and his col- leagues in plastic operations, and the wonderful prosthetic appliances devised by them and which did so much to restore the good appearance of those who were mutilated in the war. DR. ALLEN GREENWOOD (Boston, Mass.) : I wish to draw attention to the fact that there probably may have been some difference between the French Enseignements de la Guerre en Chirurgie Oculaire 49 soldiers and our own, particularly in regard to infection with the Bacillus Welchii. I have personal records at this time of three cases of gas gangrene of the orbit. From the three cases the Bacillus Welchii was obtained in nearly pure culture, giving a positive diagnosis of gas gangrene of the orbit. One of these men died from infection, but the other two recovered after free drainage of the orbit. PROFESSOR G. F. ROCHAT (Groningen, Holland) : C'est vraiment remar- quable que sur tant de milliers de Hesse's de 1'oeil, il se trouvent si peu de cas d'ophtalmie-sympathique. D'abord on a meme cru que les cas d'ophtalmie- sympathique etaient d'une rarete exceptionnelle et il se trouvent dans la literature frangaise quelques communications dans lesquelles les auteurs doutent que 1'ophtalmie-sympathique se soit jamais montre'e. Mais, comme nous venons d'apprendre, le Docteur Morax a public une statistique sur 39 cas. Ce qui est encore tres peu. Ce re"sultat heureux est sans doute attri- buable a 1'habilite" de nos confreres frangais et aux soins judicieux que les malades recurent. Mais il me semble qu'en dehors d'une signification pure- ment pratique, ces re"sultats ont une importance au point de vue de la thiorie, car ils parlent fortement en faveur de la theorie que 1'ophtalmie-sympathique soit une infection et non pas une reaction anaphylactique due au pigment oculaire. Si 1'ophtalmie-sympathique fut due au pigment oculaire, on 1'aurait surement rencontre 1 tres souvent dans tant de milliers de blessures perforantes avec destruction de 1'epithelius pigmente. Et, d'autre part, 1'observation qu'a fait M. de Lapersonne, que 1'ophtalmie-sympathique s'est surtout montre 1 dans les cas de plaie pe'ne'trante, sans vastes eclatements, mais avec de petits corps Strangers intraoculaires, ce que s'explique facilement en admet- tant une infection, mais difficilement par la theorie anaphylactique. DR. E. E. BLAAUW (Buffalo, N. Y.) : Je viens justement d'arriver et n'ay pas eu le temps de me pr^parer. Veuillez Ms. de Lapersonne me prendre comme je suis. Permettez-moi de nous congratuler que vous nous avez donne" la possibility de renouveler la connaissance que nous avons fait au prece'dant congres de Naples. Comme marque de mon appreciation et de mon inte"ret pour 1'ophtal- mologie francaise, je vous demande de me donner votre opinion sur cette question: "Quand on voit, specialement apres un traumatisme que des vaisseaux viennent invader le parenchyme de la cornee et passent aussi pres de la Descemet, est-ce que vous conseillez I'e'nucle'ation immediate?" PROFESSOR DE LAPERSONNE (closing) : Je remercie bien mes collegues, qui ont fait des observations au sujet de ma communication. Ils ont approuve d'une fagon g6n6rale, ce que nous avons observe 1 en France. La question d'ophtalmie-sympathique n'a pas ete" discute"e au point de vue the"orique, mais il est eVident qu'elle est d'origine infectieuse plutot qu'anaphylactique. Ceci est plutot de la theorie. En ce qui concerne la question de l'e"nucleation qui doit etre faite dans les blessures re'centes, je crois, en effet, que toute infection ayant pour point de depart, 1'iris, le corps ciliaire avec vascularisation de la corne"e, est un signe tres important, et il est ne"cessaire de faire 1'enucle'ation le plus tot possible. 4 DETACHMENT OF THE VITREOUS SIR WILLIAM LISTER London, England I will begin my paper by briefly summarizing the information I have been able to gather with regard to the development and structure of the vitreous, and will then describe some of the changes which take place in it following hemorrhage or inflammatory infiltration, which are often associated with its contraction and detachment, and later proceed to my chief theme, namely, "Detachment of the Vitreous," and consider its frequency, its causation, its effects, and finally its in- fluence on certain pathologic changes in the posterior part of the eye. DEVELOPMENT From the beautiful work of Mawas and Magitot it seems possible that the old view we were taught, that the vitreous was derived from the mesoblast, which entered the secondary optic vesicle through the choroidal cleft, is incorrect and that the vitreous is mainly epiblastic in origin and that its development takes place in three stages : 1. There is a primordial vitreous, formed almost entirely from the retinal epithelial cells, especially from those of the pars ciliaris, and to a very slight extent from the cells of the lens. 2. This primordial vitreous is temporarily pushed aside by the in- vasion of the mesoblast, both that part which comes in through the choroidal cleft and that which enters the secondary optic vesicle anteriorly with the inclusion of the lens. This mesoblast forms what they call the transitory vitreous, viz., the vascular tissue which temporarily occupies the greater part of the so-called "vitreous chamber," and ensheathes the lens, but soon disappears, remaining only as the walls of the hyaloid canal. 3. Corresponding with the disappearance of the vascular transitory vitreous, the primordial vitreous tissue undergoes great development and becomes the main vitreous body, or definitive vitreous. Their view is, then, that the main vitreous body is epiblastic and 50 Detachment of the Vitreous 51 not mesoblastic in origin, and is derived chiefly from the retinal cells of the pars ciliaris. In this definitive vitreous fibers are found which are continuous with and closely united to the cells of the pars ciliaris. The firm adherence of the vitreous to the pars ciliaris found in post-natal life is thus associated with its origin; while to the rest of the retina the vitreous is merely applied, or if attached, only very slightly. One would expect, therefore, that on contraction detachment would take place at the posterior region from the retina proper, with a heaping-up of the vitreous into a mass situated behind the lens and the pars ciliaris. STRUCTURE OF VITREOUS BODY The vitreous in its fresh state is a pellucid, soft, gelatinous mass, apparently structureless except for the so-called "corpuscles" of the vitreous, of which some show ameboid movement and contain large vacuoles. That the rest of the vitreous is not entirely homogeneous is shown by the fact that, when thrown on a filter, a small portion always remains, although by far the larger part drains away and may be collected as clear watery fluid. When hardened and stained, a certain amount of structure can be made out. Definite fibers, already referred to, can be seen chiefly in the external part of the vitreous, and especially in the region opposite the ciliary body, to which the fibers are firmly attached. These fibers in the ciliary region are in series with the fibers of the suspensory liga- ment, which indeed are considered by many to be merely a highly developed group. "HYALOID MEMBRANE." Investing the whole of the vitreous, a "hyaloid membrane" has been described as a specialized, thin, glassy layer. Schafer describes the hyaloid as consisting of two layers in the ciliary region an inner one, which continues forward, the in- vesting coat of the vitreous, and an outer fibrous layer, which is closely adherent to the pars ciliaris, and anteriorly passes forward to fuse with the capsule of the lens and forms the suspensory ligament. Of the existence of the suspensory ligament there is, of course, no question, but certain observers have doubted the existence of these other vitreous structures. When fixed in chromic acid, more or less distinct lamellation of the vitreous can be seen, especially in the part next the retina, which, in the human eye, is of a firmer consistence than the central portion. In 52 WILLIAM LISTER addition to this indication of concentric lamellation a radial marking has also been observed in sections made transversely to the axis of the eyeball in similarly hardened specimens (Hanover). Some consider that the indications of concentric lamellation and radial striation and even the hyaloid membrane are artefacts due to hardening reagents, but I think when certain pathologic states of the vitreous are examined, they afford strong supporting evidence of some such structural formation. We may look upon hemorrhage or infiltration into the vitreous as most useful staining reagents of the vitreous in situ and in vita. Now it is well known that the vitreous may undergo various de- generations; it may liquefy and lose its gelatinous character, and when liquefied, it may either remain clear as is so often seen in cases of high myopia or it may become impregnated with products of degeneration, such as cholesterin, as in synchysis scintillans. It would be expected that in a vitreous which had become liquefied any structural characteristics, if they existed, would be lost, and if subse- quently it were infiltrated with round cells or blood, a comparatively even or general infiltration would take place; whereas if infiltration takes place in a previously healthy vitreous, some evidence of struc- ture, if such existed, might be expected .to be seen in the first stages before the whole vitreous became purulent; it is this evidence I hope to demonstrate. It is probably the anatomic structure of the vitreous which is the chief deciding factor that brings about the varied appear- ances of the vitreous seen on pathologic examination after effusion of blood or round cells into it. In septic infection of the vitreous a great variety in the distribu- tion of the round cells is seen (a) In some, the vitreous is evenly cloudy or evenly purulent. This may be due to the preexisting liquefied state of the vitreous, or to the suppuration having been so prolonged that any early uneven infiltra- tion had become lost, or to a special infection causing liquefaction of the vitreous pari passu with 'the infiltration. (b) In others the infiltration is far from homogeneous, thus : 1. Stilling's canal may be seen demarcated in pus. 2. In other cases we see pus extending backward from the ciliary region, after anterior infection, in streaks or Medusa-like locks, while in others there is very definite and beautiful lamination of the layers of pus. Such irregular distribution of the round-celled infiltration must be Detachment of the Vitreous 53 determined by some cause, and could be determined by lamellation of the vitreous or some remains of it. Thus cases with streaks or layers of pus in the vitreous appear to give strong support to the view that the vitreous body is not originally structureless, but lamellated. Though for years a specialized investing coat of the vitreous or hyaloid membrane has been described, others, Mawas and Magitot, for instance, state that no such structure exists. Pathologic conditions again throw light on the matter. When looking at specimens macroscopically, with infiltration of the vitreous associated with some degree of detachment, though in some the pos- terior boundary of the vitreous is shaggy and there is no definite edge, in others the vitreous has a perfectly defined margin. Such definition of the vitreous must have a determining cause. It seems impossible to avoid the view that there is some specialized layer limiting the vitreous which, provided it has not been previously degenerated, is capable of checking, to some extent, the progress of invading leuko- cytes; but if the vitreous were degenerated and liquefied, such limit- ing membrane would break up and disappear, and when infiltration takes place, no definite demarcation of the vitreous is visible, but its limits are shaggy. Another group of cases may throw some light on the structure of the vitreous, though this is doubtful, but they are interesting and afford scope for speculation. When a foreign body has passed through the vitreous, it is not uncommon to find straight thin planes of fibrous tissue traversing the vitreous in one or more places. These planes are very surprising; doubtless they are the result of hemorrhage, but one naturally wonders why the hemorrhage should be limited to a definite plane. One would expect to find a tuft of hemorrhage rather than a defined thin sheet. I think two suggestions can be put forward in explanation: (a) Either that the explosive force of the penetration split the vitreous just as a jelly (containing insufficient gelatin for artistic cooking) splits on a plate, or as a glacier, which we are told follows the same laws as semisolids, splits into seracs as it passes over a projecting portion of its underlying bed, or (b) That some radial structure of the vitreous has determined this peculiar distribution of the effused blood. Whatever may be the exact explanation of the latter group, the ex- amination of the pathologic specimens shown tends to confirm the 54 WILLIAM LISTER view that the vitreous has structure of a lamellated character and also that it possesses a definite and specialized limiting membrane. DETACHMENT OF THE VITREOUS Detachment of the vitreous is dismissed by Fuchs in his text-book very summarily as being much less common than was thought to be the case. He writes: "... Such detachment is much more rare than was formerly supposed, when observers were misled by the presence of artefacts produced by the hardening of the speci- mens," inferring that in most instances, when it is found on pathologic examination, it is due to the fixing reagent. That detachments are certainly not all due to fixing reagents is proved : 1. By the fact that in eyes fixed in formalin, for instance, detach- ment of the vitreous is not present in a large number of specimens. In some it is present; in others, the vitreous, clear or infiltrated, may fill the whole or practically the whole of the space normally allotted to it. If the formalin caused contraction, detachment would surely be present in every case examined, except where there was some morbid attachment of the vitreous to the retina. 2. By the presence of changes, shortly to be described, which, from their complicated structure, could not possibly be postmortem arte- facts, especially those found in the clear retrovitreous space un- attached in any way to the vitreous body. While it is well known that certain reagents, such as alcohol, cause extreme contraction, there seems no reason for thinking that formalin causes any alteration in the size of the vitreous. Detach- ment of the vitreous is without doubt commonly found in eyes fixed in formalin and examined pathologically, and there seems to be clear evidence that such separation of the vitreous from the retina proper has taken place during life, and is due either to actual contraction of the vitreous body or to its liquefaction, resulting, in either case, in the occurrence of a zone of nearly clear fluid between the retina and the vitreous, such as has been for long described in myopia. In cases of the more chronic infection of the eye, all stages of con- traction are met with. In the early and slighter cases, what little separation from the retina exists is only at the posterior pole, the vitreous still remaining attached to the optic disc. This is the last spot for detachment to occur in this posterior region, and it is the site at which greater adherence would be expected, since it is here that the hyaloid vessels passed from the disc into "Stilling's canal." Detachment of the Vitreous 55 Fig. 1. Embryonic vitreous, showing meshwork of fibers and nodes. Fig. 2. Punctate deposits on retina seen on flat, demonstrating that they have no special relation to the retinal vessels. Fig. 3. Pus extending backward from ciliary region. Fig. 4. Detachment of vitreous with sharply defined margins. 56 WILLIAM LISTER In the later stages of chronic inflammation the vitreous becomes con- tracted up into a firm mass behind the lens. Between these two extreme forms the slighter and the greater all intermediate varieties are found. An interesting and important variety is met with when the vitreous becomes adherent to the retina at one or more spots. Such adhesion may be the result either of inflammation in the retina due to a foreign body striking it within, a perforation of the ocular coats from with- out, or from some other cause, such as a hemorrhage from the retina bursting into the vitreous or a patch of retinochoroiditis. When contraction of the vitreous subsequently takes place, it remains, as it were, "pegged out" at certain parts, as we shall see later. Now, what the factor is, apart from traumatic loss of vitreous, which causes the diminution in its bulk and consequent separation or detachment from the retina to take place, it is difficult to say. We know that scar tissue tends to contract, and it is, therefore, to be ex- pected that when fibrous tissue has replaced the hemorrhage or inflammatory exudate, contraction of such a loosely attached body as the vitreous would ensue, but is it known why scar tissue contracts, apart from consolidation and loss of fluid? It is less easy to under- stand why in the early stages of suppuration of the less acute types contraction is so common. Still more is it difficult to see why, when there has been no hemorrhage or infiltration, the vitreous should shrink. I now pass on to show how detachment of the vitreous determines certain pathologic conditions. I. SUPPURATIVE INFLAMMATIONS. (i) When the head of the optic nerve has been irritated by toxins or organisms brought to it by the lymph-stream and pus pours out from the disc, we find quite different appearances in specimens where the vitreous is in situ from those where the vitreous has been detached. Thus in the former we have seen "Stilling's canal" injected with infiltrate, or others where a fountain of exudate jets out into the vitreous. Whereas in similar cases of irritation of the optic disc when the vitreous has become detached a beautiful, fan-like growth of pus may extrude out from the papilla into the zone of clear fluid behind the contracted vitreous. (ii) When the so-called "abscess of the vitreous" is formed around a retained foreign body lying somewhere in the retrolental area, the shrunken and infiltrated vitreous closely enwraps the bag of pus, while the rest of the vitreous chamber is filled with clear fluid. Detachment of the Vitreous 57 (iii) In other cases, as we have already seen, when the vitreous be- comes attached to the retina, we find it contracted forward but "pegged out" to the retina at certain spots. (iv) Again, in other cases of chronic infection with detachment of the vitreous, punctate deposits on the retina may occur as I described in a paper at the last Congress of the Ophthalmological Society of the United Kingdom. II. HEMORRHAGE. If a hemorrhage takes place into the vitreous from the retina or choroid, we know, from Parsons' work, the exact changes that occur. Either the blood elements may be completely absorbed, or if fibroblasts enter from the retina or choroid, a spindle or a fan of fibrous tissue may be formed, such as one sees in retinitis proliferans, whether of the "so-called" idiopathic or of the traumatic variety. I have a particularly beautiful specimen of a small hemorrhage which burst into the vitreous from the retina as a result of concussion, following which the vitreous began to detach, and a pointed tag of vitreous, with a hemorrhagic tip, was left attached to the retina. As the vitreous contracted the pointed tag dragged on the retina and caused this also to detach. That the retinal detachment was present during life and not the result of the fixative is clearly demonstrated by the fact that in the post-retinal space there is an albuminous coagulum which must have been there before excision. It seems to me one ought to lay great stress on these tags of fibrous tissue in the vitreous which are attached to the retina, for I believe they give rise to at least four separate and important phenomena. As is well known, by their traction they may cause folding of the retina, de- tachment of the retina, but I believe they may also give rise to holes in the retina and to the flashes which occur on movement in highly myopic eyes. Now, it is well known that hemorrhages, especially in myopic eyes, are all too common, and, in the specimens shown, it is seen that fibrous tags may develop as a result of hemorrhage. When once they are formed, then, by their traction, not only a detachment, but I think one variety of hole in the retina, may result. There are at least five varieties of holes in the retina : (i) The nearly circular holes which occur at the macula as the result of a blow, from a comparatively slowly moving, non-penetrating missile, on the front of the eye. (ii) Other circular lacunae at the macula, associated with retino- 58 WILLIAM LISTER Fig. 5. Even infiltration of vitreous with commencing detachment. Vitre- ous remains attached to optic disc. Fig. 6. Through and through wound. Vitreous attached to retina at site of exit. Fig. 7. Suppuration showing Still- ing's canal infiltrated with pus and other streaks of pus in the vitreous. Fig. 8. Fibrous fans in the vitreous following hemorrhage, formed before detachment of the vitreous has taken place. Detachment of the Vitreous 59 choroiditis, exactly resembling those following a blow, which are very probably due to bursting of cysts at the macula. In neither of these two groups is there, as a rule, much if any de- tachment. (iii) Then there are peripheral holes due to traumata with or without detachment. (iv) There are also holes associated with retinochoroiditis (else- where than at the macula) which has caused adhesion of the retina to the choroid. Subsequent detachment of the retina results in a rent in this membrane (Elschnig's theory). With this condition a hole may occur in two different ways according to whether the retina is pushed in by fluid in the post-retinal space or drawn in by an adherent and contracting vitreous. (a) When fluid collects between the retina and pigment epithelium and pushes the retina in, the retina may be torn at a point of attachment. Such a cause can produce only a single hole, for directly a breach takes place, the pressure on the two sides of the retina would be equalized. (b) When, however, the vitreous is attached to the retina and drags it inward, then any number of holes may occur cor- responding with the number of points of adhesion of the retina to the choroid. (v) Horseshoe-shaped Rents. It is these "horseshoe" rents which, I believe, are due to traction of vitreous tags, for in these we often notice that the central portion of the horseshoe is pulled inward by a tag of fibrous tissue. It would seem extremely probable that traction of such fibrous tissue attached at one end to the retina, and at the other to a contracting vitreous, would be sufficient to cause a rent. Such a pulling in of the center of the horseshoe probably many of us have seen both clinically and pathologically. Though it would seem possible that a steady pull might be sufficient to cause a rent, yet probably tearing could more easily be produced on sudden rotation of the eye. Thus, when a wineglass containing liquid is rotated, the glass turns before the liquid; similarly, in an eye with contracted and detached or partially liquefied vitreous, where a large part of the vitreous cavity is filled with limpid fluid, sudden rotation of the eye will cause the coats of the globe to move sooner than the fluid contents. If there is a fibrous tag attached, 60 WILLIAM LISTER on the one hand, to the retina, and, on the other, to the contracted vitreous, though in a state of rest it might cause little or no tension on the retina, yet on rotation a sudden tweak might be produced by it on the retina at the point of attachment sufficient to bring about a tear, and especially if the retina is weakened by cystic degeneration. Slighter pulls by such tags might be sufficiently forcible to stimulate the retina and cause flashes on movement of the eye. If, then, a vitreous hemorrhage may be followed by a fibrous tag, which in time may cause detachment of the retina, we have an obvi- ous practical indication to desist from all avoidable punctures of the vascular coats of the eye, and thus a strong reason for removing foreign bodies with the magnet by the "anterior route," through the avascular cornea, rather than by the "posterior route," through a new incision in the vascular sclerotic choroid and retina, from any of which structures a hemorrhage may pass into the vitreous. If a hemorrhage from the disc or the retina occurs after the vitreous has become detached, quite a different appearance is found from that when the vitreous is in situ. Just as we have seen that pus may ex- tend from the disc in fern-like fronds in the space behind the vitreous, so fibrous tissue fans may be developed in this space, which presumably are the result of a previous hemorrhage. I have an interesting specimen of a case of glaucoma with a shrunken vitreous in which a large hemorrhage from the disc was followed by a mass of fibrous tissue filling up the cup and extending into the vitreous chamber. In grossly degenerated eyes with retinochoroiditis we find the retina glued down to the choroid, and the vitreous contracted right up be- hind the lens. If fibrous tissue bands occur between the retina and contracted vitreous, though the retina cannot detach, these connecting bands may be drawn out into very delicate strands. They may be either in the form of small fans or of branching filaments. Some of these are partially pigmented and occasionally contain blood-vessels. The last section of my paper deals with what I propose to call "HOLES IN THE HYALOID." That such a membrane or differentiation of the outer layers of the vitreous exists is, to my mind, proved, as already stated, by the fact that though in some cases of contraction and detachment of the vitreous its edge is quite shaggy and uncertain, in others it is quite clearly defined. Its existence is supported by other evidence, both clinical and pathologic. 1. Thus in the case of an injury from a stone a hemorrhage Detachment of the Vitreous 61 Fig. 9. Hole in hyaloid. Opaque ring in vitreous, which on movement of eye appeared in three definite positions. Fig. 10. Horseshoe hole in retina. Fig. 11. a, Detached retina; b, Tag of fibrous tissue attached to the shrunken vitreous; c, hole to which inturned flap of retina, as seen with is attached shrunken vitreous, ophthalmoscope. 62 WILLIAM LISTER occurred at the macula which gave rise to a star figure of fibrous tissue from which radiated out multitudinous delicate rays imme- diately over the retina. These were much too fine to be foldings of the retina, such as one sees in cases of retinal edema, etc., and I have no doubt they were due to foldings of the hyaloid. 2. Again, we come across cases clinically in which, with the oph- thalmoscope, a fine membrane is seen in the vitreous chamber, 3 to 6 D. in front of the retina, in which there is a clear-cut hole. I have seen three such cases and in two of them there was a patch of old retinochoroidal atrophy, The obvious explanation seems to be that the inflammatory process in the retina caused adherence of the vitre- ous over the patch itself and some thickening of the vitreous envelop around the patch, and when contraction of the vitreous took place, a hole was torn in the membrane around the site of adhesion, leaving a visible thickened rim to the hole. Such holes in the vitreous might conceivably occur from tearing away of the hyaloid from either an adherent patch on the retina or from the disc itself. That the hyaloid may be torn from the disc so as to leave a hole is supported by a specimen with suppurative cyclitis which I examined pathologically, and found the vitreous contracted, and a definite round hole in its limiting envelop just opposite the disc. In the absence of any visible choroidoretinitis it is difficult to avoid the conclusion that this hole was torn from the margin of the disc, the site at which, as already noted, the vitreous is normally most adherent at the posterior pole of the eye. The only other explanation that has been offered, so far as I know, for these cases, is that a fibrous tissue plaque has for some reason or other formed in the vitreous, as in retinitis proliferans, and that a hole has developed in it, such as is seen in those curious fenestrated layers of fibrous tissue met with lying on the surface of a retina which has been severely concussed. Against such a view I urge: 1. That in none of my cases was there any other sign of retinitis proliferans of the ordinary types, and 2. It is very difficult to imagine how a hole could develop in such a membrane lying loose in the vitreous. To sum up my paper the specimens which I have shown suggest or corroborate the following conclusions: 1. The vitreous has some structure and is not homogeneous, and this structure is one of concentric lamellation, as described by Hanover. Detachment of the Vitreous 63 2. That there is a limiting membrane to the vitreous, i. e., the hyaloid is not a myth. 3. That under certain conditions degeneration of the vitreous may occur, and both the hyaloid and all other structures of the vitreous may disappear. 4. That clinical cases are seen which can only be explained by sup- posing that such a hyaloid membrane has been thrown into folds. 5. That thickening in the hyaloid may take place as the result of inflammatory processes occurring in the adjacent retina, which have caused adherence of the vitreous to the retina, so that if subsequent detachment of the vitreous occurs, this limiting membrane may tear around the edge of the adherent area, and a hole in the membrane may result which is visible with the ophthalmoscope. 6. That detachment of the vitreous is common during life, and its presence in pathologic specimens is not the result of the fixing reagent, at any rate when formalin has been used. 7. That if, from any cause, the vitreous has become adherent to the retina from injury, hemorrhage, or inflammation, then, on de- tachment, the vitreous becomes as it were '* pegged out" at certain spots, and traction is exerted on the retina which may cause flashes of light on movement of the eye, folding, detachment, or even holes in the retina. 8. That detachment of the vitreous is a necessary precursor to cer- tain pathologic conditions, e. g., punctate deposits on the retina, and the peculiar fan formations of pus or fibrous tissue which are some- times found extending from the optic disc. DISCUSSION DR. M. FEINGOLD (New Orleans, La.) : There is no question that the vitre- ous is one of the most puzzling organs in the human body. Those of us who are daily using the Gullstrand slit lamp can testify to the fact that the vitreous has some structure even in the normal eye. We see behind the lens a peculiar network, a lace-like structure, which in the normal eye has almost no move- ment, even with the microscope On the other hand, the arguments brought out by the paper certainly prove that the vitreous has a structure. Hemor- rhages into the vitreous and pus infiltration in a great number of cases tend to show a radial striated laminated arrangement, and I have seen some cases of injury where the radial arrangement of the hemorrhage into the vitreous was a diagnostic help, pointing to the site of the injury, showing the blood had been scattered in special directions and maintained in that position for weeks, proving that the vitreous really had some structure. As to the question of the structure of the vitreous derived from a histologic 64 WILLIAM LISTER specimen, that is an entirely different problem, because of the point raised by the essayist of the difficulties that the eyeball presents when it comes to fixa- tion. In a paper published some years ago from one of the German clinics the comparative value of the different fixing agents was described; there the fact was dwelt upon that the choroid in formalin fixation is greatly compressed, and the explanation given was that it was produced by swelling of the vitreous. This goes to show that we cannot at present, because of the lack of a multiplic- ity of fixing agents that give the same results, derive any conclusions as to the structure of the normal vitreous in vivo. As to the pathologic vitreous, there the changes are entirely different, and we can easily see with the Gull- strand apparatus distinct movement of the flakes floating in the vitreous. Whether detachment occurs in vivo is difficult to say, and we can only hope for help from this method ; but that detachment is occasionally found in the histologic specimen there is no doubt. I have in my own sections seen detach- ment of the vitreous in which, between the detached vitreous and the retina, a fluid was found exactly as described by the essayist. I hope that we shall in the future find new fixing agents by which we will be able to study the normal vitreous, and that we shall see results from the examination of the unfixed, unhardened vitreous with the Gullstrand lamp, as has already been started by Vogt. DR. T. B. HOLLO WAY (Philadelphia) : I believe that I am voicing the sen- timent of most of us preserft this morning when I say that we must feel very much indebted to Sir William Lister for bringing this subject to our attention. It has always impressed me that the vitreous is one of the particular portions of the eye that has been neglected at least neglected as far as positive find- ings are concerned. We know so little about it. It was that fact that made me presumptuous enough to volunteer, as did Dr. Feingold, to assist in open- ing the discussion of this subject. I question whether any of us today, as Sir William Lister has said, would doubt but what the vitreous has a very definite structure. We have all seen specimens that point very definitely toward a certain amount of lamination, particularly of the peripheral portion of the vitreous. In regard to the hyaloid, I am perfectly free to confess that I had always regarded the hyaloid membrane as definitely existing until I reviewed the splendid work of Mawas and Magitot, to which the essayist has referred, and then my faith became somewhat shaken, but I have never been able to recon- cile its absence with certain clinicopathologic findings. The essayist has seen fit to refer to certain degenerative changes of the retina and in doing so has touched upon a rather tender point in my own ob- servations. I am referring to the presence of cholesterin in the vitreous, to which he has referred. To my mind the presence of cholesterin crystals in the vitreous is an unusual manifestation of the degeneration of this structure. I think that in the majority of cases typical or atypical snowball vitreous opacities are observed. With reference to adhesions of the vitreous to the retina and the produc- tion of holes in the retina, as I understand Sir William Lister, he thinks that a tacking down of the vitreous may occur after a focal irritation. Under these Detachment of the Vitreous 65 circumstances the retina may be detached, or if a tear results, it may affect, in one instance, the retina, and in another, the hyaloid membrane, producing what he designates as a hole. Personally, I believe I have seen a tear of the first type in a case which presented itself in my service about three or four months ago, where there was a very definite lesion of this character of the horseshoe type, associated with a well-marked patch of retinochoroiditis. He also speaks of certain foldings of the hyaloid. On the records of a case that has been under my observation for some time, I have made clinical notes to the effect that the clinical picture might well be produced by a folding of the hyaloid membrane. The lesions were central and subsequently they proved to be proliferative. However, I can readily believe that such lesions may occur. PROFESSOR EMILE GALLEMAERTS (Brussels, Belgium): J'ai demande" la parole pour insister sur le point souleve par le Docteur Feingold. II n'est plus necessaire maintenant de faire 1'examen microscopique d'yeux enuclees pour etudier la structure du corps vitre a 1'etat normal ou pathologique. Si Ton examine 1'oeil vivant a 1'aide de la slit lamp de Gullstrand, on voit sur un fond noir, se detacher les fibrilles du corps vitre; 1'aspect de ces fibrilles varie, elles s'entr'croisent et demontrent la structure reticulaire du corps vitre. A 1'etat pathologique on peut observer les alterations si bien decrites microscopique- ment par Treacher Collins; on voit les fibrilles changer d'aspect, s'epaissir, se raccourcir, se condenser. II y a la un chapitre nouveau pour 1'etude du corps vitre\ DR. JOHN E. WEEKS (New York City): Much light may be thrown on the structure of the vitreous body by the careful study of. embryonal tissue. The embryonal vascular system of the vitreous bcpy and the vascular system of the retina develop from mesoblastic tissue and they both develop from the same process of mesoblast that enters the embry- onal retinal fissure. In the study of the embryo of the rabbit we will find that the outer surface of the vitreous is shaggy, due to minute proc- esses that extend from it into the nerve-fiber layer of the retina, as a result of the continuity of mesoblastic tissue. The distinctly shaggy condition of the outer surface of the vitreous body in the embryo is not present beyond the ora serrata, the anterior surface beyond this point being appar- ently limited by the network of capillaries of which the posterior part of the membrana vascularis lentis forms the greater part. This part of the vitreous body at this stage rests against tissue that is of epiblastic origin and is not incorporated with it. In the early stages of development of the vitreous body blood-vessels permeate all parts of it. These disappear as development pro- gresses, apparently having a very delicate framework. The capillaries are most numerous at the periphery of the vitreous body, particularly anteriorly, and here more than anywhere else the vitreous body presents a retaining structure which is apparently composed of any incomplete laminae, more closely associated near the surface of the vitreous body. This laminated membrane in the vitreous body is in effect a limiting membrane. It is not a membrane that can be seen with the microscope, as we see the limiting mem- brane of the lens. If we study the pathologic condition of the vitreous body, 5 66 WILLIAM LISTER we find that hemorrhages extending into the vitreous do so without regard to a uniform structure, and that the formation of fibrous bands do not follow any plan of structure of the vitreous. However, in certain pathologic conditions an infiltration may follow lines that indicate an irregular structure. The holes in the so-called limiting membrane of the vitreous, I think, are only the result of pathologic material in certain areas. DR. J. W. NORDENSON (Stockholm, Sweden) : I think we are much in- debted to Sir William Lister for calling our attention to the question of the detachment of the vitreous, and I only want to point out some details in his work where I think there might be some difference of opinion. There is, as you have heard, such a difference of opinion between him and the histologists who have worked on the structure of the vitreous. I wish, in this respect, to refer to the work published about thirty years ago by Gustav Retzius l who has shown that in his opinion the vitreous has no real membranes, but that it has a laminated structure. The laminae consist of densifications of its fibrillar tissue; and they are not concentric, but, as he has shown, are placed in a sagittal direction. These laminae, pointed out by him thirty years ago, have also been found by the investigators working with the Gullstrand slit lamp. If you take these laminae into consideration you will find an explanation not only of the clinical facts that Sir William Lister has described here, but they also seem to give a clue to the difference of opinion between him and the French investigators, Mawas and Magitot, who have worked with the vitreous. I am wondering whether what he calls a detachment of the vitreous might not be considered as a cleft or crevasse of the vitreous tissue, and what he calls the detached hyaloidea a densification of this tissue lying not in a sagittal but in a frontal plane ; also if the holes that he has observed are not places where this densification is absent. I think the whole question is a little difficult to grasp if you speak about detachment of the vitreous. Might we not speak of clefts, of the vitreous? Then I think the question of the hyaloid membrane would not cause any difference of opinion between histologists and clinicians. COLONEL R. H. ELLIOT (London, England) : My interest in the hyaloid was excited when I studied 750 consecutive cases of couching of the lens made by natives of India. Of these, I submitted 125 globes to anatomic examination, and in quite a considerable number a careful histologic examina- tion was made as well. In all these operations there was, first of all, often a perforating wound of the vitreous by the instrument used in couching; sec- ond, there was disturbance of the vitreous as a result of the lens being pushed bodily into it, and third, there was septic infection of the vitreous in a large number of cases. I want you to notice one point especially, viz., that in the specimens of my series (which are lodged in the museum of the Royal College of Surgeons of England) the infection is often localized, sometimes by spread along definite planes, sometimes by strict localization to a definite area of the vitreous. Now it seems incredible that this could happen in any but an organized structure. There is not time to take Sir William Lister's points one by one, but there ^iologische Untersuchungen, No. VI, Stockholm, 1896. Detachment of the Vitreous 67 are two or three I would especially like to give my support to. First, in a very definite manner my specimens indicated that the vitreous has a definite struc- ture. Then, again, I would like to say a word, not only from my examination of the eyes I have mentioned, but also from a clinical point of. view, of the existence of a definite anterior hyaloid membrane. You may speak of it as a membrane, or as a thickening of the anterior layers, but there is a definite hyaloid membrane, and that hyaloid membrane is a very definite protection (both mechanical and anti-infective) to the surgeon in a large number of operations, and especially in those for cataract. The question of the existence of clinical detachment of the vitreous is my next point. I sectioned a number of these couched eyes shortly after their removal, having first frozen them in ice and salt. Detachment of the vitre- ous, as Sir William Lister has detailed it to you, was common in those speci- mens. On that point I am emphatic. I speak of these matters particularly from the point of view of the clinician. It is important that we should have a clear view of the structure of the vitre- ous, and that we should recognize it as an organized structure with a definite limiting membrane. If we are not clear on this subject, our views will have a mischievous tendency in our surgery. PROFESSOR IGNACIO BARRAQUER (Barcelona, Spain): In my opinion the vitreous is a semisolid body, surrounded by a membrane or thickening of this structure, resistant enough to keep it isolated from the eye, and to pass it from hand to hand without losing its spheroidal form, but it can be liquefied by compressing it. Its structure is fibrillar, and with Gullstrand's lamp and the binocular microscope of Zeiss its fibers can be seen clearly contracted after an injury. The cicatricial retraction of those fibers is the cause of the detach- ment of the vitreous and sometimes of the retina. All detachments of the retina after cataract extraction have this origin. It is indispensable, therefore, to avoid compression of the eye during cataract operations, as well as the introduction of pointed instruments into its chambers. By doing this we shall see the disappearance of post-operative retinal detachments consecutive to wounds of the vitreous. One of the most dangerous operations is the cap- sulotomy, and also discission of the secondary cataract, as by them the vitre- ous is nearly always wounded. DR. F. PARK LEWIS (Buffalo, N. Y.) : There are two points I would like to add in supplement to Dr. Lister's observations. The manner in which the vitreous has been examined heretofore is the same as that which has been applied to other ocular structures. It has been placed in hardening fluid and sectioned and observations made. The vitreous is 90 per cent, fluid. When its contents are abstracted, the skeleton only remains and the rela- tionships of its parts are wholly changed by compression, giving a wholly inaccurate impression of its anatomy. Certain facts, however, can be de- duced from an examination even macroscopically of the vitreous when it is removed from the eyeball. The entire lenticular system comes out en masse. By placing this, consisting of the vitreous body and the crystalline lens, in slightly acidulated water it imbibes the fluid and its separate parts are more clearly brought into view. It will then be found that the vitreous is composed 68 WILLIAM LISTER of an outer exceedingly elastic membrane which balloons out to nearly one- third its normal size. But even when hardened and sectioned and placed under the microscope it will be found that the skeletonized remnant is com- posed of a number of fibers which curl upon themselves like shavings, showing that the internal structure of the vitreous is composed of elastic tissues. These two facts should be noted, as essential conclusions may be drawn from them. One other point must be mentioned. I have said that our methods of examining a fluid body by first extracting the fluid in it is essentially in- correct. A method which I have found of great value is to coagulate this body without extracting its substance. By placing it in a water-box with an optically perfect glass cover its structure may be definitely determined by the aid of the Gullstrand light and the corneal microscope. Such specimens I have here in demonstration, and I will also show a photograph in which can be definitely shown some of the tubules through which the nutrition of the vitreous is maintained. DR. F. H. VERHOEFF (Boston, Mass.) : I have frequently observed separa- tion of the vitreous on examination of pathologic specimens, and can confirm all the observations of the essayist except the finding of holes in the hyaloid. I have no doubt of their existence, but I have never observed them. I have not made a systematic study of the subject and, therefore, am not prepared to express an opinion as to its exact importance. One of the important things about the vitreous which we do not know is exactly how liquefaction may come about. If we could produce liquefaction of the vitreous at will, we would be doing an important thing in certain cases where we have vitreous opacities. I have tried, but have not succeeded. Separation of the hyaloid membrane may play a part in certain cases of sec- ondary glaucoma. In case of a very small sarcoma of the choroid I found the hyaloid membrane separated from the retina, allowing the vitreous and lens to be pushed forward, causing obliteration of the anterior chamber. After any method of fixation if you stain the vitreous deeply the hyaloid membrane is seen with sufficient distinctness, it seems to me, as to leave no doubt of its existence. If you fix the retina in Zenker's fluid and then stain it in Mallory's connective-tissue stain, the hyaloid membrane will show up as definitely as the lens capsule. It does not send projections into the retina, but is entirely distinct, and can easily be pulled off from the latter. One rea- son perhaps that there is this difference of opinion as to the existence of the hyaloid is that the vitreous does send very fine fibers into it, but that is no reason for not regarding it as membrane. The anterior part of the hyaloid membrane, that is, the part that leaves the retina and extends behind the lens, possibly may play a part in the causation of primary glaucoma. Thus, if its permeability should become altered so there was an increased osmotic pressure behind it, the anterior chamber would be shallowed. MR. E. TREACHER COLLINS (closing) : I do not wish to take upon myself to reply in behalf of Sir William Lister, but I would like to make a few remarks myself. I quite agree with Dr. Weeks that it is much easier to examine the structure On Diaphragm Lamps in Ophthalmology 69 of the vitreous in the fetal eye than in the fully developed eye. A good many years ago I examined fetal eyes hardened in Miiller's fluid and I came to the conclusion not only that the hyaloid membrane is as definite a structure as the capsule of the lens, but that the membrane in the fetal eye has cells in it scattered widely at definite distances. I think I will be able to demonstrate that to you with lantern slides made from my specimens. Further, the vitreous of the fetal eye is permeated throughout by a net- work of fibers with a lot of little fine, nodular points where they cross that take on the nuclear stain. We do not know what they are; they are smaller than any known nucleus of a cell. These nuclear staining bodies disappear in the adult, but I think sometimes a few persist and float about in the vitreous, and that the muscse volitantes are just remnants of this network of fibers. I have had sections of the fetal vitreous under the microscope, and at the same time have had float into my field of vision my own muscae, and have thus been able to compare the appearance of floating vitreous opacities with the net- work in the fetal eye. One of the most interesting points in Sir William Lister's paper is, I think, what he describes as "holes" in the hyaloid. In one of the cases in my own clinic the appearance seen seemed to me to be unexplainable on any other ground. One of these "holes " was somewhat anterior to the retina and moved about in movements of the eye. I took it that the place where the vitreous was normally attached to the optic disc had become detached and showed as a round hole. ON DIAPHRAGM LAMPS IN OPHTHALMOLOGY PROF. ALLVAR GULLSTRAND Upsala, Sweden The examination of the living eye for diagnostic purposes as well as for scientific investigations is highly facilitated by a suitable illumina- tion of the field, and the best results are obtained when the distribu- tion of light and shadow can be perfectly controlled. To obtain this effect it is necessary for a sharp optical image of a bright and uniform source of light to be projected on the most favorable place and other light to be shut out from the field. The latter condition requires not only a dark room, but also, in certain methods of examination, the shutting out of light that is reflected regularly by the refracting sur- faces of the eye or diffusely by the substance of the cornea and of the lens. Thus there are two conditions : the source of light must be uniform and sharply limited, with a high specific intensity, and a sharp optical image of this source of light must be procured. As is now well known, 70 ALLVAR GULLSTRAND the slit lamp and the aspheric lens (an aplanatic lens with a non- spheric surface of revolution) answer these conditions. But the slit lamp is not the only suitable lamp. What is wanted is a uniform source of light of high specific intensity adequately combined with a diaphragm through an appropriate optical system. The slit lamp is, therefore, only a special type of the diaphragm lamp. When the diaphragm has a circular aperture, another type results for which I suggest the name hole lamp. SLIT LAMPS That the first diaphragm lamp for ophthalmologic use was a slit lamp is due to practical reasons. Of the then available light sources, only the crater of the arc lamp and the glowing filament of the Nernst lamp had a sufficient luminosity combined with a sufficient area of uniformity. As the latter represented the simpler and more easily available means and proved practicable, I preferred it. As a rule, if the greatest effect is desirable, the shape of the diaphragm is de- termined by the shape of the source of light, and therefore with the Nernst lamp the diaphragm must be a slit. The Nernst slit lamp consists mainly of a tube which contains in one end the Nernst lamp, and which is closed at the other end by a plate carrying a slit of variable width. By means of a lens or a system of lenses an optical image of the glowing filament is procured which, by appropriate mechanical appliances, can be brought to coincide with the slit. At first I used this lamp for ophthalmometric investigations, and I have described it in the third edition of Helmholtz's handbook of physio- logic optics. Then, on my suggestion, the aspheric lens was calcu- lated by M. v. Rohr and brought on the market by Carl Zeiss in Jena. Using this lens for focal illumination with the slit lamp I immediately verified the superiority of the method, as I could see, for example, the structure of the normal vitreous body. During the war the fabrication of the Nernst lamp ceased and good Nernst filaments cannot be bought now. Therefore in the instru- ments of Zeiss the Nernst lamp has been replaced by a nitra lamp, which consists of a glowing narrow spiral of tungsten filament in a glass bulb filled with an inert gas. This lamp has several disad- vantages as compared with the Nernst lamp: the spiral is not a uniform source of light, and it is not always straight; the refraction in the glass of the bulb deteriorates the optical image projected in the slit; and the lamp demands a strong current with a low voltage, On Diaphragm Lamps in Ophthalmology 71 so that an encumbering resistance must be used in the circuit in con- nection with an ordinary supply of electricity. For certain methods, e. g., those of reflexless ophthalmoscopy, it is not essential that the source of light is uniform and the slit filled out by its optical image, so that the lamp can directly replace the Nernst lamp, but for focal illumination an optical image of a uniformly bright slit is of so high value that another device is preferable. If the lens is connected with the lamp by an -arm (a device of Henker), a narrow beam of light is sufficient and in this case it is not necessary that the optical image of the spiral coincides with the slit. It can be projected on the lens by pushing the lamp deeper in the tube, whereby the optical image of the slit becomes uniformly bright. For certain methods of reflexless ophthalmoscopy a small incan- descent lamp is a sufficient source of light. The filament must be straight, and an optical image of it is projected in a slit in the same way as with the Nernst lamp. HOLE LAMPS ^Nowadays there is another lamp with sufficient specific intensity on the market, namely, the pointolite lamp, which is a tungsten arc lamp, inclosed in a glass bulb containing an inert gas at low pressure. There are several types, but the smallest of them is sufficient for ophthalmologic purpose. The lamp is lighted by a strong ionization current of short duration, but demands only a current of less than 0.5 ampere when burning. Moreover, the voltage is higher than that of the nitra lamp, and as a consequence the necessary resistance is less encumbering. But the greatest advantage over the nitra lamp is the perfect uniformity of the light source, which is a ball of tungsten used as an anode. If an optical image of this ball is projected in a circular aperture, an ideal hole lamp can be obtained. The glass bulb is sealed up on the top, and when the lamp has been used some time, deposits from volatilized tungsten are seen here on the inside. It is consequently preferable to mount the lamp perpendicularly to the optical axis of the tube. In this position the optical image of the ball is not appreciably deteriorated by the refraction in the glass bulb, and the light is less weakened by the deposits. But for many pur- poses the lamp can also be mounted along the axis in the .same way as the Nernst lamp. It can, in these cases, replace the Nernst lamp in the ordinary slit lamp. Though the slit is then not filled out by the optical image of the ball, and though only a part of this image is 72 ALLVAR GULLSTRAND used, this combination answers well for many methods. Finally, with a special arrangement, the lamp can be used in a slit lamp for focal illumination when its optical image is projected on the lens. FOCAL ILLUMINATION The superiority of diaphragm lamps for focal illumination is so great that other lamps should never be used for this method of ex- amination. In every clinical case it can be expected that something more can be seen by using the aspheric lens in connection with these lamps than with ordinary lamps and lenses. For current clinical use it is not desirable to lose time by immobilizing the head of the patient on a support for the chin. If this is not done, a rather wide cone of light is necessary to allow for the motions of the patient's head. For this reason the optical image of the source of light has to be projected in the diaphragm, as in the original Nernst slit lamp, and the uni- formity of the source of light is a great advantage. The focal illumination with diaphragm lamp and aspheric lens de- mands a certain amount of skill, but is soon learned with a little practice. The lens is to be held with its most curved surface turned to the light at a distance of about 40 cm. from it, and perpendicularly to the ray that passes through its center, so that the diaphragm is situated on the optical axis of the lens. That this is really the case can be controlled by projecting an optical image of the diaphragm on the cornea. This position of the lens once found, the only diffi- culty consists in moving the lens parallel to itself, as the optical image is projected deeper in the eye. However insignificant this difficulty is, the device of Henker to fix the lens on an arm in connection with the lamp has probably con- tributed to render the method more accessible to oculists. With this device the immobilization of the patient's head by a support for the chin is desirable, but this complication offers an advantageous com- pensation in the possibility of using the microscope for examination. As a narrow beam of light is sufficient, the optical image of the source of light can, in the way already described, be projected on the lens, whereby the nitra lamp renders the optical image of the slit perfectly uniform. When the pointolite lamp is substituted for the nitra lamp in this apparatus, the optical image of the slit is not uniformly bright, the middle seeming darker than the ends. This inconvenience is caused by the spheric aberration of the lens system contained in the lamp On Diaphragm Lamps in Ophthalmology 73 tube in connection with the smallness of the glowing ball, and can be avoided by a special construction in which the distance between the lens system and the slit is reduced to a minimum. The slit lamp, with the device of Henker and the Nernst lamp, the nitra lamp, or, for certain investigations, an arc lamp as source of light, has enabled Koeppe and Vogt to create a whole new "branch of ophthalmology, the microscopy of the living eye. This is not the place to enter on the details of the results already obtained or to be expected by further investigations, but the modifications of the illuminating system ought to be mentioned. Vogt has insisted on the use of a very narrow beam of light for facilitating the localization in the third dimension. But as the slit grows smaller the chromatic aberration of the aspheric lens grows more disturbing. For this reason an achromatic combination of lenses was preferred to the aspheric lens. Such a substitution is possible because a small aperture is sufficient and, indeed, in some cases desirable for micro- scopic examination. Koeppe has completed the device of Henker with a tube which shuts off the light reflected in the interior of the lamp tube, with certain light filters, and with a mirror which facilitates the examination by giving the light that forms the optical image of the slit another direction than that of the optical axis of the instrument. Moreover, for the microscopic examination of the angle of the an- terior chamber Koeppe has devised both a hydrodiascopic chamber and a suitable contact lens. Another contact lens, which makes the eye highly hypermetropic, has enabled him to use the microscope for the examination of the deeper parts of the vitreous and of a certain area of the retina. Finally, with a third contact glass of annular shape and containing a conical reflecting surface, he obtains the necessary illumination for ultramicroscopy of the cornea with a dark field. He also uses polarized light for the microscopic examination of the living eye. SIMPLE CENTRIC OPHTHALMOSCOPY Under this name I have described a method of ophthalmoscopy of great value for current clinical work, and for which the hole lamp can be used as well as the slit lamp. In ordinary ophthalmoscopy by the direct method the corneal reflex makes it impossible to see the macula and neighboring parts of the fundus in the direction of the axis of the eye. Even though the pupil be dilated, a certain decentration of the hole of the mirror in respect to this axis is necessary to avoid the dis- 74 ALLVAR GULLSTRAND turbing corneal reflex, when this part of the fundus is examined, and this decentration is sufficient to deteriorate the optical image of the fundus, the refraction of the light being less regular in the excentric parts of the surfaces of the eye. But the diaphragm lamp affords a means of suppressing the corneal reflex and enabling the ophthalmo- scopic examination of the central parts of the fundus without any decentration of the hole of the mirror in respect to the axis of the ex- amined eye. In the light reflected by the mirror the hole acts as an opaque body and throws a shadow. If the source of light is suffi- ciently small, a full shadow of considerable extension can be obtained, and to suppress the corneal reflex it is sufficient that the center of curvature of the cornea (more exactly, its evolute) is situated within this full shadow. Thus, if a diaphragm lamp is used as source of light for ophthalmoscopy by the direct method, the corneal reflex can be extinguished by an adequate movement of the mirror. The observer sees a bright spot on the fundus and the corneal reflex. If care is taken that his own nose does not throw any shadow on the mirror, he needs only move the mirror so that the spot on the fundus is cen- tered on the corneal reflex to see the latter vanish. Looking through the central parts of the refracting surfaces of the eye he then sees more details in the macula and in its neighborhood than he can see with the ordinary method. He can also perform the examination without dilatation of the pupil in cases where nothing is seen of the macula with the ordinary method. To obtain a field of reasonable extension the mirror should be concave, with a rather short radius of curvature and a narrow hole. The small mirror of Morton's ophthalmoscope answers well. This method again demands a certain amount of skill which, how- ever, is easily acquired by a little practice. Its advantages induce me to give here some hints. An ophthalmoscopist who is able to give the mirror the correct position after he has approached the patient till the two fronts are in contact will meet with no difficulties if he tries the method the first time on a case with dilated pupil. But many oculists are accustomed not to approach the patient until they have seen the pupil red by throwing light in it at a distance of some 15 or 20 cm. If this is the case, the lamp must be placed so far off that the cone of light extends from the patient's eye to the point from which the examiner desires to see the pupil red. If the pupil is dilated, the extinguishing of the corneal reflex by appropriate movements of the mirror is soon learned. The illuminated part of the fundus shows On Diaphragm Lamps in Ophthalmology 75 a darker spot, which is situated in its center if no shadow from the nose of the observer is thrown upon the mirror, and as soon as this darker spot is centered on the corneal reflex, the latter vanishes. The spot is a half shadow from the hole of the mirror and can be avoided by bringing the lamp to a distance of 12 to 15 cm. and by using an angle of incidence of about 45 degrees on the mirror. In this way the method gives the best results, but also offers greater difficulties. The short distance diminishes the width of the cone of light at the place of the mirror, so that the observer must learn to find the correct position of the ophthalmoscope after having ap- proached the patient; and the great angle of incidence causes a shadow of his nose on the mirror and a consecutive diminution of the illuminated part of the fundus, if special care is not taken. As in ordinary ophthalmoscopic work a smaller angle of incidence is used, it may be necessary to change the habitual position of the ophthal- moscope in respect to one's own face. The new position is easily found out by using the large angle of incidence and a greater distance of the lamp. The shadow from one's nose on the mirror is then seen on the form of the illuminated part of the fundus. I have entered upon these details because the superiority of the method is so evident that nobody who has learned it will voluntarily use other lamps for ophthalmoscopy by the direct method. The slit lamp affords a somewhat greater field than the hole lamp. DIAPHRAGM LAMPS IN OTHER METHODS OF EXAMINATION WITH A MIRROR For the examination of the transparent media of the eye by transil- lumination diaphragm lamps are unrivaled. Fine dust-like opacities of the vitreous afford a striking example. It is well known that by the ordinary method such opacities can be seen with the plane mirror in cases where nothing is seen if a concave mirror is used. The usual explanation is that the light reflected by the concave mirror is too strong, but the real cause is that the plane mirror illuminates a smaller area of the fundus. Since this illuminated area serves as a source of light, and as shadows are the more conspicuous the smaller the source of light used, it is obvious a priori that the diaphragm lamp must give the best results. It is easy indeed to prove the sensibility of the method. If the lamp is placed at a distance of about 40 cm. and a plane perforated mirror with a narrow hole and with a convex glass of 10 or 12 diopters behind it is used, it is often possible to see 76 ALLVAR GULLSTRAND shadows which are caused by the distribution of the fluid moistening the cornea, and which change when the latter is wiped by the eyelid. Accordingly, opacities of the vitreous that, by the ordinary method, are seen only with the utmost difficulty as finest dust, appear as a sharply defined network. In skiascopy the most reliable results are obtained when a trans- parent unperf orated mirror is used. A hole in the mirror always causes a shadow which complicates the phenomena in the neighbor- hood of the point of reversal, and which makes it impossible to find the refraction in the central part of the pupil. Therefore a plate of glass with plane parallel faces is the best mirror, and the loss of re- flected light is supplied by the specific intensity of the diaphragm lamp. This method can be regarded as an evolution of the method of Jackson or that of Wolff accordingly as the hole lamp or the slit lamp is used. If a hole of small diameter is used as diaphragm and the mirror con- sists of a thin glass plate fixed in a position which allows the optical image of the hole to coincide with the observer's pupil, the sensibility of the method is highly increased and allows the examination of the aberration of the eye and of pathologic asymmetry. I have described this method under the name of objective stigmatoscopy in Helmholtz's handbook. With a diameter of only J/ mm. the dilatation of the pupil can be avoided in many cases. A diameter of 1 mm. gives excellent results if the pupil is dilated. TRANSILLUMINATION OF THE BULBUS My successor in the chair of ophthalmology in Upsala, Professor Lindahl, has described a new method of transillumination of the bul- bus with a Nernst hole lamp. He substituted a hole on the apex of a cone for the slit in a Nernst slit lamp, and used this lamp at first in the ordinary way, bringing the border of the hole in contact with the scleral conjunctiva in order to see whether the red light in the pupil was weakened by a tumor. But he found that the intensity of the light allows another method. If the cone of light is directed in the pupil, the illuminated part of the fundus constitutes a source of light sufficiently intense to show directly the shadow of a tumor and, moreover, the shadow of the ciliary body on the sclera, which appears brilliantly red. Thus Lindahl's method is an inversion of the old method for diagnosing tumors. As might be expected from the shape of the diaphragm, the pointolite lamp has proved superior to the On Diaphragm Lamps in Ophthalmology 77 Nernst lamp in Lindahl's instrument. A rather large area of the fundus being illuminated, the source of light for the transillumination is large, and shadows on the sclera can be expected only from opaque bodies situated near this membrane. But the ora serrata is dis- tinctly seen and, as a rule, the ciliary processes throw a visible shadow. CENTRIC REFLEXLESS OPHTHALMOSCOPY Before the construction of the slit lamp the reflexless ophthal- moscopy, developed principally by Thorner, was unable to give the best possible optical image of the fundus, inasmuch as the light that entered the eye of the observer had to be refracted in an excentric part of the optical system of the examined eye. For the same reason the maximum effect of stereoscopy could not be obtained. If the light that enters the observer's eye has to pass through the central part of the pupil of the examined eye, it can be shown that the light which illuminates the fundus must pass through a peripheral zone which, to avoid the light reflected diffusely in cornea and lens, must be the narrower, the greater the ophthalmoscopic field that is desired. This involves the use of a source of light with high specific intensity and necessitates the projection of an optical image of it in the plane of the pupil. It is not necessary that this optical image be small, as the superfluous part of it can be projected on the iris, but the optical image afforded by the slit lamp is sufficient, and therefore the Nernst slit lamp was used in my reflexless ophthalmoscopes. The large ophthalmoscope brought on the market by Carl Zeiss contains an aspheric lens not only in the examination system, but also in the illuminating system. The light of the latter is reflected into the examined eye by a transparent glass prism of small angle. A plate with parallel faces would give two different images, of which only one could be used if the plate were sufficiently solid. Therefore the prism is so calculated that both images coincide. In this instrument the Nernst lamp can be directly replaced by a nitra lamp or by a pointolite lamp. I have verified that the latter affords a sufficient illumination though the lamp be mounted along the axis of the illuminating system, and although only a part of the optical image of the glowing ball can be projected in a part of the slit. The same is the case with the large instrument for simplified re- flexless ophthalmoscopy. If two small reflexes caused by the surfaces of the aspheric lens are allowed, the construction of the instrument is 78 ALLVAR GULLSTRAND considerably simplified and only one aspheric lens is necessary. The light emerging from the slit is given the appropriate direction by means of a double reflection in a rectangular prism silvered on its hypotenuse face and combined with a decentrated lens. For this method of ophthalmoscopy I also have devised a hand ophthalmoscope, which is held in one hand, the aspheric lens being held in the other. The illuminating system is a slit lamp in which a small incandescent lamp is used as the source of light. Again this instrument demands a little skill, which must be acquired by practice. Ordinary ophthalmoscopy by the indirect method should be replaced by this method just as well as ordinary ophthalmoscopy by the direct method is to be replaced by simple centric ophthalmoscopy. CENTRIC PHOTOGRAPHY OF THE FUNDUS It is evident that the same principles that led to the centric reflex- less ophthalmoscopy are applicable theoretically to the photography of the fundus. In practice difficulties arise from the necessary in- tensity of light, and as long as perfectly aplanatic condensers of sufficient size and aperture are not available, the sun is the only practicable light source. But if an optical image of the sun is pro- jected in a hole, the method of the simplified reflexless ophthalmoscopy is applicable and has been elaborated by Dr. J. W. Nordenson, who has obtained excellent results with a rather compendious apparatus. Thus the light illuminating the fundus for photography is taken from what could be named a hole lamp with the sun as source of light. DISCUSSION DR. EDWARD JACKSON (Denver, Col.) : The name of Professor Gullstrand is universally known to us, but it will have a new significance after hearing the address he has given us this morning. We are especially happy in having in it a sort of summing up of the work he has been publishing for so many years, and that has made him so well known throughout the world. He has followed the normal method of instruction, starting with a concrete case with the slit lamp, and now bringing before us the general principles that were em- bodied in that, and which can be embodied in the use of light from other sources, the whole group to be called "diaphragm lamps." Vision depends upon getting from the object to be seen a sufficient light, as compared with the light received from sources in which we are not interested. We are just beginning to realize in our methods of examination that, if we want enough light from the structure that we desire to examine, we must exclude irrelevant light in so far as this is possible. That has been accom- plished best by the slit and other diaphragm lamps. The conditions of dis- On Diaphragm Lamps in Ophthalmology 79 tinct vision that have to be met that the light shall be bright enough (and external light is worse than useless) and that the field to be studied shall be uniformly illuminated. All of us have been misled for an instant by irregular illumination into thinking that we had some retinal or choroidal pathologic condition that was not present. That is accurately brought out by the use of the uniform illumination. But in order to get rid of the light that we do not want we must have sharp limits, we must not light up anything except the structures we are looking at. That is obtained with the diaphragm lamp, by the diaphragm primarily, and then by having it sharply focussed in the eye. That is what Professor Gull- strand has worked out. First, he gave us enough light with the Nernst slit lamp, and then he had a sharp image of the slit formed in the eye where the light would be limited to a certain field. Of course that can be done with the hole lamp, but I cannot help but feel that the slit offers certain advantages. As he has pointed out, we can still have the slit with the "hole lamp." This, I take it, is the idea running through the focussing apparatus that is worked out, and the result of utilizing the dif- ferent methods of illumination. I have been interested in one phase of illumi- nation, direct sunlight, and hope soon to call attention to the practical application of the principles that have been put before us by Professor Gull- strand in that direction. DR. HARRY S. GRADLE (Chicago, 111.) : It might be of interest to speak of some few things that we have been endeavoring to do in this country. The Pointolite lamp was developed in England in 1913, and has been used rather extensively by microscopists and metallurgists, and in this country in micro- photography with great success. For nearly a year it has been in our mind to employ the Pointolite with the apparatus for illumination of the eye for which we are indebted to Professor Gullstrand, the slit lamp, but owing to certain difficulties of material and manufacture it has been impossible until recently. Now we have a large tungsten arc in a low pressure gas chamber, giving as nearly a punctate source of light as possible. This may be used in the slit lamp, or it may be used when the slit is replaced by the diaphragm, resulting in a more nearly true focal illumination than the present slit. True it is that the slit has certain advantages for both direct and indirect focal illumination, but there are areas of aberration projected by the slit with the Nitra lamp on the cornea which increase as we narrow the slit down to a minimum, and which cannot be eliminated owing to certain mechanical difficulties. I believe if we could have a circular aperture with the Pointolite we would gain a great deal. The large ophthalmoscope of Professor Gullstrand, unfortunately, does not add any to the clinical examination of patients in any but the very excep- tional case, but to the ophthalmologist who takes pleasure in clean-cut, scientific work, it is a source of pleasure. The small hand ophthalmoscope of Gullstrand, which we have been using for eight or nine years, employs a slightly different principle, in which the lower portion of the cornea and of the pupil is illuminated and the rays returning from the fundus pass out through the upper portion of the cornea, which is without any illumination whatever 80 ALLVAR GULLSTRAND and consequently is reflex free. It makes indirect ophthalmoscopy much simpler and easier than by the older methods and allows us to study the macula without the corneal reflexes we are accustomed to. DR. E. E. BLAAUW (Buffalo, N. Y.) : On the question of the slit lamp I think the Congress stands where ophthalmology stood in 1851 when the ophthalmoscope was introduced. The lamp of Professor Gullstrand has given us a field of light so enormous that those who have not used the corneal micro- scope cannot appreciate what it means to us as ophthalmologists. But one should not say that its use is easy, for it takes hours and hours of study. We must be able to narrow the slit, because a slit that cannot be opened and closed is of no value. It is still difficult to interpret what we see with the slit lamp. Of enormous value is the appreciation of depth, for it enables us to see changes that have not been known before, and it shows us that we have no way of attacking the vitreous unless we do it in vivo. PROFESSOR G. F. ROCHAT (Groningen, Holland): I have no doubt that the new instrument that Professor Gullstrand has spoken of will be a much more beautiful instrument than his former one, but I think the slit lamp in its previous form has one special advantage over the new lamp he has described, and that is this: When we throw a beam of light into the cornea, its intersection with the cornea is a rectangular prism, of which the anterior surface coincides with the anterior surface of the cornea, while its lateral side shows a definite rectangular and plane section of the cornea, and in this luminous section you can observe and localize particles present as clearly as in microscopic section. I am afraid that in the new form, in which the intersection of the cornea and beam of light is not plane, but cylindrical, this advantage will have been lost. I shall be glad to have Professor Gull- strand's opinion on that. PROFESSOR ALLVAR GULLSTRAND (closing) : I am surprised that so many of my American colleagues have devoted so much time to the study of my meth- ods, and I want to thank those who have taken part in the discussion. Dr. Jackson has pointed out that you can get a good result with direct sunlight, and if I understood him aright he is operating with direct sunlight. I hope that the photographs that Dr. Nordenson will show tomorrow will prove that Dr. Jackson is right in trying sunlight. But I hope that the Pointolite lamp will be shown to be sufficient for most purposes. Dr. Gradle spoke of the scientific work that can be done with the slit lamp, and he as well as Dr. Blaauw questioned the necessity of having a slit for localization in opacities, or in pathologic signs, as to the dimensions. We now have a beam of light that is not too wide. I think the Pointolite is the best in practical work. SINTOMAS OCULARES DEL ENVENENAMIENTO FOR EL PIQUETE DE ALACRAN 1 DR. JOSE DE JESUS GONZALEZ De Leon, Gto., Mexico En la invitacion dirigida por la Comision General de Organizacion del Congreso Internacional de Oftalmologia, que se reunira en Wash- ington, indicase que "son apropiados a los fines del Congreso los trabajos que se refieran a enfermedades o fases de enfermedades, peculiares a los distintos paises o regiones." Esta indicacion me hace dar a conocer los sintomas oculares que he observado en personas que han sufrido el piquete del alacrdn, algunos de los cuales sintomas, por persistir cuando todo otro sintoma de envenenamiento ha desaparecido y aun revestir cierta gravedad, son interesantes de conocer por todo oculista que ejerza en las regiones infestadas por los escorpionideos. Ademas, desde el punto de vista puramente cientifico, algunos de los smtomas oculares son altamente interesantes, porque contribuyen a precisar la accion de la ponzoria del alacrdn. Para la mejor inteligencia del asunto, divide este pequeno estudio en tres partes : I. Algunos datos sobre los alacranes de Mexico. II. Sintomatologia general del envenenamiento por el piquete de alacrdn. III. Sfntomas y complicaciones oculares de dicho envenenamiento. I. ALGUNOS DATOS SOBRE LOS ALACRANES DE MEXICO Los alacranes o escorpiones son artropodos, pertenecientes a la clase de los ardcnidos y al orden de los escorpiones, orden que comprende de 350 a 400 especies diseminadas por todo el mundo. En la Republica Mexicana, segun la Biologia Centrali Americana, citada por el Sr. Moises Herrera, 2 unicamente viven dos especies de la 1 Estudio presentado al Congreso International de Oftalmologia que se reunird en Washington, E.U.A., en Abril de 1922. 2 Moises Herrera, Naturalista de la Direcci6n de estudios biolog. Los escor- piones de Mexico. Mem. de la Soc. Cientifica, "Antonio Alzate," Tomo39, Mexico, 1921. 6 81 82 JOSE DE JESUS GONZALEZ familia scorpionidae: el diplocentrus whitei (o diplocentrus mexicanus) y el diplocentrus keyserlingi, Karsch. Pero el distinguido Profesor Isaac Ochoterena 1 recuerda que en la magistral obra Das Tierreich (8. Lieferung. Arachnoidea. 1899) los escorpionideos se dividen en seis familias, la primera de las cuales, la de los Bothruridae, comprende las familias Centrurinae, con los ge"neros Centrums, Isometrus, Zabius y Tytius. Los alacranes del genero Centrums (Hemprich u. Ehrenberg) comprende 14 especies, de las cuales se encuentran en la Repiiblica Mexicana las siguientes: Centrurus infamatus, C. L. Koch, Centrurus gracilis, Latr., Centrurus margaritatus, Gerv., Centrurus infamatus, var. nigrovariegata, Poc., Centrurus nigrimanus, Centrurus fulvices, Poc., Centrurus flavopictus, Poc., Centrurus ochraceus, Poc., Centrurus nitidus, Thor. Uno de los alacranes mds venenosos del pais, el conocido con el nofnbre de alacrdn de Durango, (y que no es exclusive de esa ciudad, pues, segiin el Dr. Mariano Herrera, 2 existe en todo el Sur del pais, especialmente en las vertientes de la Sierra Madre) que ha sido bien estudiado por el Sr. Prof. I. Ochoterena, pertenece a la especie Cen- trurus exilicauda, descrito por Wood. En la ciudad de Leon, Gto., en donde ejerzo desde hace 25 afios, hay dos especies : una, poco venenosa, de color moreno obscuro (diplo- centrus mexicanus?), y otra muy venenosa, de color amarillento, que tiene gran semejanza con el Centrurus exilicauda, de Durango. He oido decir a medicos que tienen muchos afios de ejercer en la ciudad, que antes no observaban accidentes series con el piquete del alacran, lo que me hace suponer que tal vez ha sido importado el alacrdn venenoso de Durango, oculjto entre las pieles sin curtir que la industria peletera de la ciudad hace venir de las regiones del norte del pais, entre ellas de donde abunda el escorpionideo. Aunque suele encontrarse el alacran durante todo el ano, los meses en que mds abunda en esta ciudad, sin duda por ser su temperatura media mds favorable al ardcnido, son los de marzo, abril, mayo y junio, durante los cuales, ademds, parece ser mds activa la ponzona, pues los accidentes que he observado entonces son mds series. Igual 1 Prof. Isaac Ochoterena. El alacrdn de Durango (Centrurus exilicauda, Wood). Memorias y Revista de la Sociedad Cientifica "Antonio Alzate, " Tomo 37, nums. 4. 5 y 6, Mexico, 1920. 2 Dr. Mariano Herrera. Estudio sobre el piquete de alacran. Revista Medica, Tomo XIII, num. 1. Mexico, 1900. Sintomas Ocular es del Envenenamiento por el Piquete de A lacrdn 83 cosa pasa en Durango, segun el Dr. Mariano Herrera, quien textual- mente dice : " casi exclusivamente se observa a fines de abril, en mayo y en junio, terminando con los primeros aguaceros formales que se verifican en julio." Y agrega: "no porque no pueda haber acci- dentes en otras epocas del ano, como se ve en los cuadros de mor- talidad, sino porque tales accidentes tienen el caracter de excep- cionales." (Loco citato.) La temperatura media de esos meses escila entre 19 y 25. El aparato venenoso consta de dos gldndulas, colocadas a uno y otro lado del ultimo segmento del post-abdomen. Cada gldndula estd constituida por un tejido conjuntivo periglandular, muy delicado, una gruesa capa de tejido muscular, cuya contraccion expulsa el veneno, y el epitelio glandular con numerosas invaginaciones, capa propiamente secretante. De cada glandula parte un canal eferente que va a desembocar cerca de la extremidad del aguijon, que es curvo, muy duro, acerado y terminado por una punta roja. (Ochoterena.) El veneno es liquido, transparente, de reaction acida, propiedades que he observado personalmente. El Dr. Mariano Herrera cree que es de naturaleza oleoginosa, pues haciendo picar a un alacrdn sobre un papel delgado, se obtiene una pequena mancha translucida y persistente, analoga a la que deja un liquido aceitoso. El Prof. Ochoterena dice que se altera rdpidamente al contacto del aire, que, disuelto en agua, se vuelve opalescente con irisaciones azuladas y en parte precipita (globulinas), produciendo espuma si se agita. El alcohol, el yodo, el amoniaco, el tanino, el nitrato de plata, el acetato de plomo y el sulfato de amoniaco, lo precipitan de sus disoluciones y el producto de la evaporation en el vacio esta formado de laminillas de color amarillo obscuro. Parece que esta ponzona es una toxi-albumina especial (Calmette) . Su actividad es extraordinaria, pues la cantidad introducida por un piquete, es muy pequena: inmediatamente despues de producida en mi mismo una picadura en un dedo, he podido extraer, por expre- sion fuerte, una pequena gota de poco mds de un milimetro de did- metro. La manera de obrar la ponzona, nos la va a decir el cuadro sinto- mdtico desarrollado a consecuencia del piquete de alacrdn. 84 JOSE DE JESUS GONZALEZ II. SlNTOMATOLOGIA GENERAL DEL ENVENENAMIENTO FOR EL PIQUETE DE ALACRAN Para que sirva de punto de comparacion a los observadores de otras regiones, voy a desarrollar el cuadro del envenenamiento por la ponzona de alacran, basado exclusivamente en lo que he observado personalmente. El piquete produce la sensacion de una delgada aguja que rdpida- mente se hundiera en la piel; pero esta dolorosa sensacion que he experimentado en mi mismo desaparece casi inmediatamente y por algunos minutos se cree que nada va a pasar. Y en efecto: si se exprime inmediatamente el punto picado, sale una pequena gota del liquido venenoso, y no se produce ningiin otro sintoma, ni local ni general. Para facilitar la expresion del veneno, es conveniente prac- ticar una pequena incision de la piel; desgraciadamente es raro que esta pequena operacion se haga oportunamente. Entonces se deja que el veneno se absorba, para lo cual sigue dos caminos: el de los capilares linfaticos y el de los capilares sanguineos. Pocos minutos despues comienza una sensacion de hormigueo en las partes cercanas al piquete y pronto esa penosa sensacion se generaliza, siendo uno de los sintomas que mas torturan al enfermo. Algunos de ellos me han comparado ese hormigueo al que se sufre cuando empieza a volver la sensibilidad a un pie que se ha adormicido por la compresion del ciatico. Otros dicen que son finas y repetidas cor- rientes electricas que circularan por todo el cuerpo, inclusive por las visceras abdominales: un enfermo permanecia inmovil, rogando que no se le tocara, porque una corriente electrica parecia atravesarle los intestines. En la cara, principalmente en los pdrpados y en las alas de la nariz, experimentase un cosquilleo insoportable, que origina penosos y frecuentes estornudos. Al lado de estas parestesias cutdneas, senalare uno de los sintomas mas frecuentes y mas precoces : la sensacion de una marana de cabellos en la lengua y en la garganta. Si se permite la extension del termino, dire* que es esta una parestesia mucosa, ya que parestesia es toda sensa- cion subjetiva anormal. Tambien existen perturbaciones objetivas de la sensibilida: la hiperestesia es intensa; cualquier contacto, el mas ligero frotamiento, causan al enfermo sensaciones dolorosas o de quemadura y aun despiertan intensos reflejos cutdneos o musculares. Sintomas Ocular es del Envenenamiento por el Piquete de A lacrdn 85 Creo que debe atribuirse a la hiperestesia de la mano y de los dedos una perturbation de la perception ester eognostica: los enfermos re- conocen bien todos los objetos por el tacto; pero les conceden dimen- siones mayores a las reales. Podrfa designarse esta perturbation con el neologismo de disestereognosia o, haciendo una contraction: dis- tereogosia. Simultaneamente con las perturbaciones sensitivas, desarrollanse otras secretoras y matrices. Entre las secretoras, la hipersecrecion saliver, de una saliva glutinosa y espesa, y de las mucosas nasal, faringea y bronquica, sonstituye uno de los sintomas mas precoces, que indica que la ponzona se ha generali- zado y van a empezar los fenomenos convulsivos de que luego hablare. El enfermo se ve obligado a estar continuamente escupiendo y ex- pectorando, sin conseguir amenguar la penosa sensation de cabellos que se le enredaran en la garganta. Senalare en este lugar, por tratarse de una perturbation secretora, aunque el sintoma se presente mas tarde, la hipersecrecion, de sudor que es abundantisma : toda la piel del enfermo esta constantemente bafiada en sudor. Tal parece que el organismo escoge por vias de elimination del veneno, el sudor, la saliva y las secreciones naso- f ar ingo-br onquicas . Son las perturbaciones matrices las mas penosas y las que ponen mas en peligro la vida del enfermo. Se presentan pocos minutos despues de que el hormigueo se ha generalizado y consisten en espasmos de los musculos lisos y convulsiones y contracturas de los voluntaries. Los espasmos empiezan por la faringe y el esofago: los enfermos, atormentados por la sed, se sorprenden de que no pueden pasar el agua o lo hacen con suma dificultad. Los espasmos del estomago producen vomitos, primero alimenticios y luego mucosos. Aunque raros, hay casos en que contrayendose el estomago en vacio, se pro- ducen homorragias y hematemesis de cierta gravedad. Los espasmos del intestino dan a los enfermos la penosasima sensation de que una corriente electrica atraviesa todos los organos abdominales. El espasmo del cuello vesical origina retention de orina, la que, por otra parte, es escasa, probablemente por la abundante sudacion. Los espasmos de los musculos bronquicos contribuyen sin duda a aumen- tar los fenomenos asfixicos de que pronto hablare. Las contracturas se presentan principalmente en los maseteros, originando un trismus que dificulta la ministration de medicamentos por ore. 86 JOSE DE JESUS GONZALEZ Las convulsiones pronto se generalizan y agitan contorcionan todo el cuerpo. Son de caracter tonico, a veces los miisculos se tetanizan y cuando el tetanismo invade los miisculos respiratorios, se presenta la asfixia, exagerada por la abundante hipersecrecion bronquica y los espasmos de los musculos lisos de la par red del arbol aereo. En los ninos estos accidentes son a menudo mortales: la respiration es estertorosa y superficial, los labios se cianosan, por la boca salen mucosidades espumosas, frecuentes accesos de tos convulsiva inter- rumpe y agrava el tetanismo de los musculos respiratorios, un sudor frio empapa los cabellos del nino y corre por el cuerpo, y el pequenuelo cae en un estado semicomatoso en el que a veces sucumbe. Pocas veces en el adulto llega la gravedad a tal extreme, aunque tambien hay casos mortales. En el niiio he observado convulsiones del diafragma y de otros musculos respiratorios que se traducen por un llanto espasmodico, tan caracteristico, que en dos ocasiones, con solo oir de lejos ese llanto en ninos que eran conducidos a mi consultorio, pude hacer el diag- nostico de piquete de alacrdn, luego confirmado por los padres del pequeno. En el adulto, en los mementos de mayor intensidad del envene- namiento, las convulsiones tonicas agitan y contorsionan los brazos y las piernas, las mucosidades excitan la laringe y producen accesos de tos y expectoration, el tialismo es abundante, un sudor copioso empapa todo el cuerpo, la temperatura se eleva hasta 40 y 41 tanto por el exceso de trabajo muscular, como por action de la pon- zona sobre los centres termogenos, pues a veces las convulsiones son poco intensas y sin embargo la temperatura asciende-, el enfermo siente un calor sofocante y, presa de grande inquietud, no encuentra sitio en su lecho para reposar un instante, y grita y gesticula y se retuerce. El pulso es frecuente. La cara estd congestionada y edematosa. La palabra es ininteligible : el trismus, las contracciones de los musculos de la lengua, la abundancia de saliva y de mucosidades, la horrible sensation de la marafia de cabelles, son todas circunstancias capaces de hacer la palabra tartajosa e ininteligible. Por regla general, la inteligencia se conserva, en medio de aquel cuadro intensamente dramatico: el enfermo entiende nuestras pre- guntas y contesta a ellas con acierto. Pero aun entonces el psiquismo no es enteramente normal: la atencion, prisionera del intense malestar, no puede fijarse en nada; las emociones exaltativas, sobre todo la Sintomas Oculares del Envenenamiento por el Piquete de Alacrdn 87 ira, contribuyen a aumentar la exaltacion del enfermo; la memoria es torpe. Pero no hay alucinaciones, ni ilusiones, ni delirio. Solo en los casos graves y fatales, el enfermo cae en un estado de estupor y de inconciencia, precursor de la muerte. Todo este periodo, que debe llamarse conjusticia, de excitation, es variable en intensidad y en duracion, segun diversas circunstancias : edad de la persona picada, sexo, epoca del ano, cantidad de ponzona inyectada; pues los ninos, los ancianos y las mujeres son mas sucep- tibles, los meses de marzo a junio, los de mayor actividad del aracnido, y las horas que siguen al crepiisculo las mds peligrosas, antes de que el alacrdn haya tenido tiempo de picar otres objetos insectos, etc. y, por lo mismo, antes de que haya vaciado en parte sus glandulas. El periodo de excitation dura de 12 a 24 horas y los smtomas se van poco a poco atenuando y disminuyendo la gravedad de la situacion. Pero al periodo primero sigue otro periodo de depresion: a las con- vulsiones, suceden la torpeza en los movimientos, los temblores, la ataxia y aun verdaderas paralisis, que suelen durar unos dias: he visto un enfermo que conserve por una semana cierta incoordinacion motriz, otro que sufrio una paraplejia, una pobre anciana que quedo con una paralisis de la vejiga que no llego a ceder, pues exigiendo el frecuente sondeo, acabo por infectarse la vejiga y producirse una cistitis mortal. A los hormigueos del principle, siguen sensaciones de adorme- cimiento, sobre todo en las extremidades ; es decir : a las parestesias de excitation suceden parestesias de depresion. Todavia dias despues, la deglucion se hace con dificultad, pero no ya por espasmo, sino por paresia faringea. Condensando en una dasificacion todos los smtomas observados, tenemos : Sintomas sensitivos: dolor, en el lugar de la inyeccion, parestesias (hormigueos, cosquilleos, sensacion de marana de cabellos), hiperes- tesias. Sintomas secretorios: hipersecrecion de las gldndulas salivares, mucosas de la nariz, faringe y broquios, glandulas sudoriparas. Sintomas vaso-motores: vaso-dilatacion de los vasos de la piel de la cara, de la mucosa nasal, de la conjuntiva; edema de la cara. Sintomas termicos: hipertermia en el periodo de excitacion; hipo- termia en los casos fatales. Sintomas motores: En el periodo de excitacion, espasmos de los miisculls lisos; contracturas y convulsiones de los rmisculos estriados. 88 JOSE DE JESUS GONZALEZ En el periodo de depresion : musculos lisos, paresias; musculos estria- dos, temblores, ataxia, pardlisis. Reflejos: periodo de excitacion, exagerados; periodo de depresion, normales. Se ha dicho que mientras el veneno de la serpiente es neurotoxico, el del alacran es miotoxico. El analisis cuidadoso de los sintomas que acabo de describir, nos inclinaran mas bien a considerar la ponzofia del alacran como neurotoxica, llevando su accion excitante sobre la medula (exageracion de los reflejios, fenomenos motores, fenomenos sensitives), sobre el simpatico (vaso-dilatacion, edema, espasmos de los musculos lisos, taquicardia, hipertermia, hipersecrecion) y aun sobre los cordones nerviosos mismos, como parecen demostrarlo algunas complicaciones oculares que luego describire. A proposito de la hipersecrecion salivar, debo recordar algunos datos recientes sobre la fisiologia del simpatico : las gldndulas submaxilares y sublingual, que son las directamente influenciadas con la excitacion del simpatico cervical, producen una saliva viscosa, es decir, exacta- mente igual a la que se produce en los emponzofiados con el piquete de alacrdn. Las parotidas, cuya saliva es espumosa y ms fluida, no son directamente influenciadas por la excitacion del simpatico. Estos datos hablan en favor de la accion excitante, sobre el simpatico, del veneno del alacran. El veneno del alacrdn es, pues, neurotoxico excitante; los fenomenos de depresion que se encuentran despues que cesaron los fenomenos tormentosos, pueden ser atribuidos a agotamiento de la celdilla ner- viosa, que ha hecho tan fuertes gastos de energia. No quiero terminar sin decir dos palabras sobre terapeutica. Mien- tras no poseamos un suero especifico como el anti-cobraico, como el anti-crotalico, nos veremos reducidos a dos medios curatives: uno, la eliminacion del veneno; otro, la medicacion sintomdtica. Para eliminar el veneno, tenemos que recurrir a las vias indicadas por la naturaleza: el sudor y la saliva. El medicamento indicado es la pilocarpina, en inyecciones hipodermicas, vigilando su empleo: en mis manos ha sido muy eficaz. La medicacion sintomdtica debe dirigirse principalmente contra el sintoma mds peligroso : los espasmos respiratorios. Las inhalaciones de cloroformo, hechas con la mayor prudencia, nos dardn tiempo para esperar la eliminacion del veneno, unico medio de salvar la vida del enfermo. Slntomas Oculares del Envenenamiento por el Piquete de A lacrdn 89 III. SlNTOMAS Y COMPLICACIONES OCULABES DEL ENVENENAMIENTO POR EL PIQUETE DE ALACRAN Durante el periodo de excitacion, en medio de la situacion tan dramatica y ante la gravedad del pronostico quoad vitam, los sintomas oculares ocupan.un segundo lugar ante la atencion del medico, aunque a veces molestan mucho a los enfermos; pero, pasados los mementos de peligro y de angustia, las manifestaciones oculares del envenena- miento empiezan a ocupar un lugar preponderante y, en ocasiones, llegan a constituir verdaderas complicaciones que, habiendo desapa- recido todo otro sintoma, son ellas la unica enfermedad. Salta a la vista la importancia que entonces alcanzan para el oftalmologista. En el primer periodo del envenenamiento periodo que he llamado de excitacion los sintomas que se presentan del lado de los ojos son de toda clase: sensitives, secretorios, vaso-motores, motores y sen- soriales. Los senalare en este orden. Perturbaciones sensitivas. Una de las regiones en que son mas intensas las parestesias que he senalado, es en la ocular : los parpados y la conjuntiva son el sitio de hormigueos y cosquilleos molestisimos, que obligan a los enfermos a frotarse continuamente los ojos, cuando menos al principio, antes de que las intensas convulsiones les impidan hacerlo. Perturbaciones secretoras. A la vez que las hipersecreciones nes de que he hablado, se establece un abundante lagrimeo. Precisa re- cordar que si la secrecion lacrimal es principalmente producida por la accion de las fibras organicas del sistema craneal (para-simpatico craneal), tambien la provoca la excitacion del simpatico cervical; la hipersecrecion salivar viscosa, como la que produce la excitacion del simpatico cervical, me hacen pensar que tambien el lagrimeo esta bajo la dependencia de la excitacion de esta parte del simpatico, aun- que no se limita a ella la accion de la ponzona, como lo indican sin- tomas tales como los espasmos intestinales y la contractura del esfinter del cuello vesical, que se deben a la excitacion de la cadena lateral lombar, para no citar otros. Perturbaciones vaso-motrices. Dos fenomenos de este orden pode- mos senalar : la hiperemia de la conjuntiva y el edema de los parpados. Es muy dificil explicar la vaso-dilatacion de los tegumentos de la cara y de las mucosas, que es un sintoma de interruption del simpatico cervical, al lado de otros sintomas de excitacion, como las hiper- secreciones lacrimal, salivar, sudoral. ^Se trata de accion directa de 90 JOSE DE JESUS GONZALEZ la ponzona del alacrdn sobre las fibras musculares de la pared vascu- lar? O bien la intensa actividad glandular en la piel y las mucosas, provocada por la excitacion del simpatico, tendrd, como consecuencia la produccion de metabolites segun la teoria de Gaskell que ten- drfan una accion vaso-dilatadora? No puedo hacer mas que emitir estas hip6tesis. Perturbaciones matrices. Producense tanto en los musculos ex- trfnsecos, como en los intrisecos del ojo. En el perfodo de excitacion que es el que describe en este momento he observado variados estrabismos, predominando el convergente, debidos a contracturas de los musculos oculo-motores. Del lado de la musculatura intriseca, el sintoma mas constante es la miosis. Habiendo otros sintomas de excitacion del simpatico, la miosis no podria ser atribuida a la paralisis de este sistema, tanto mds cuanto hay fenomenos de excitacion del motor ocular comun que acabo de senalar y que explican perfectamente la miosis por con- traccion del esfinter. Para precisar mejor esto, he recurrido, como medio de diagnostico, a las instilaciones de solucion de cocaina: re- cue"rdese que en la miosis por paralisis del simpdtico (paralisis de las fibras dilatadoras de la pupila) la instilacion de cocaina produce midriasis, mientras que queda sin efecto en la miosis por excitdcion del motor ocular comun (contraccion del esfinter pupilar). Esto ultimo pasa en la miosis de los emponzonados por el veneno del alacrdn. A la miosis acompanan espasmos de la acomodacion que, provo- cando miopia acentuada, son una de las causas de la perturbacion de la vista y tal vez de la micropsia de que se que j an algunos enfermos. Perturbaciones sensoriales. Quejanse los enfermos de que una niebla envuelve todos los objetos y de que las luces estdn rodeadas de circulos irisados; estos sintomas y la fotofobia, que casi nunca falta, podrfan ser atribufdos a la accion de la ponzona sobre la retina, direc- tamente, como parecen demostrarlo algunas observaciones, o a la congestion retiniana que probablemente se encuentra, ya que la vaso- dilatacion se extiende a todos los vases cutdneos y mucosos, pero que no he podido comprobar al oftalmoscopio, por impedirmelo la miosis y la agitacion motriz del enfermo. La diplopfa, causada por el estrabismo y la micropsia, seguramente consecutiva al espasmo de la acomodacion, son nuevos factores que contribuyen a la produccion de las perturbaciones visuales. Por regla general, todos estos smtomas van atenudndose a la vez Sintomas Oculares del Envenenamiento por el Piquete de A lacrdn 9 1 que los sintomas generales, y el enfermo, al recobrar la salud, no conserva ninguna perturbacion del lado de sus ojos. Pero no sucede siempre asf: a las contracturas de los miisculos extrinsecos o intrinsecos del periodo de excitacion, siguen paresias mds o menos acentuadas y hasta verdaderas pardlisis, y como estas suelen persistir no solamente dias, sino hasta semanas, puede pasar inadvertida para el oculista la verdadera causa que las produje, cuando el enfermo no da ensenanzas sobre el particular. Personas completamente sanas de sus ojos y que no se quejaban de ninguna perturbacion visual antes de sufrir el piquete del alacran, vienen al consultorio a contarnos que, desde que lo sufrieron, no pueden ver como antes, que los objetos lejanos les parecen borrosos o que les es imposible leer. El examen descubre, unas veces, pardlisis de los miisculos extrinsecos, en ocasiones tan leves, que no provocan desviacion de los ejes oculares y solo pueden ser descubiertas por el examen con los vidrios coloridos, que hacen aparecer. la diplopia; otras veces, lo linico que hallamos es la paralisis de la acomodacion que nos obliga a prescribir al enfermo mientras por otros medios la hacemos ceder el porte de cristales de + 1-50 D. a + 2 D., para los trabajos de cerca. Debo advertir que he tenido oportunidad de observar el cuadro dramdtico del envenenamiento, en personas perfectamente sanas de sus ojos, y en las que, despues, he encontrado las paralisis y las paresias de los musculos oculares que acabo de senalar, asi es que no abrigo duda sobre esta accion del veneno del alacran. Pero si estas complicaciones no carecen de importdncia, mucha mayor la tienen las que voy a describir en las observaciones siguientes, tanto porque en estos casos la ceguera absoluta persistio por algunos dias, como porque parecen demostrar que el veneno del alacran obra directamente sobre los cordones nerviosos, pues, en uno y otro caso, el oftalmoscopia permitio ver alteraciones en el nervio optico. Obs. I. Edema ligero del nervio optico, con amaurosis completa, consecutivo a piquete de alacran. Sra A. N., de 50 afios de edad, sin antecedentes morbosos. Sufre al piquete de alacrdn en una mano, estando en perfecta salud; en seguida se desarrollo todo el cuadro del envenenamiento que he descrito hormigueos, sialorrea, sudor abundante, convulsiones, espasmos, etc. revistiendo media inten- sidad. Desde el principio note la enferma que se nublaba su vista, pero esperaba que, al pasar los efectos de la ponzona, recobrarfa su buena vista habitual : no f ue asf, sino que la ceguera se acentu6 hasta llegar a ser completa. 92 JOSE DE JESUS GONZALEZ Al dia siguiente del piquete, el examen ocular me revelo la completa normalidad en el exterior de ambos ojos, asf como la integridad de todos los movimientos del globo. Ambas pupilas estaban dilatadas y no respondian al estfmulo luminoso, ni a la convergencia. Agudeza visual, nula. Por el examen oftalmoscopico encuentro los medios transparentes; pero las dos papilas estaban ligeramente edematosas: contornos borrosos, mayor didmetro que el habitual, venas mds gruesas que normalmente. Ningiin otro sintoma oftalmoscopico. Tension normal en los dos ojos. Ningiin dolor, ni espontdneo ni a la presi6n. Atribui el edema de los nervios opticos a la unica causa que me senalaban los antecedentes : la ponzona del alacrdn, y como la pobre enferma casi no habia tenido asistencia medica durante lo agudo de su envenenamiento, recurri a una inyeccion de cloruro de philocarpina, para eliminar las ultimas cantidades de ponzona; los resultados fueron favorables, pues la enferma empezo a ver. En los dias sigui- entes prescribi 1 gr. diario de yoduro de sodio, cuya accion sobre el exsudado papilar me parecio eficaz, pues en una semana el aspecto del fondo del ojo se volvio normal y la enferma recobro completa- mente la vista. Obs. II. Ceguera completa, con pocos sintomas oftalmoscopicos, consecutiva a piquete de alacrdn. Una jovencita de 17 afios, de buena constitution y en pleno estado de salud, sufre el 6 de diciembre de 1920, un piquete de alacrdn en una mano, seguido de todos los sin- tomas de envenenamiento y de ceguera completa que persistio 24 horas despues que habia desaparecido todo peligro. No la observe entonces. El 28 de diciembre del mismo ano, es decir, a penas tres semanas mas tarde, sufre neuvo piquete de alacrdn en el antebrazo izquierdo. En esta vez los fenomenos de envenenamiento fueron mucho mas intensos: trismus, espasmo faringeo, convulsiones tetaniformes, fe- nomenos asfixicos y perdida de conocimiento. La enferma estuvo luchando entre la vida y la muerte durante 24 horas. Al volver a la plena conciencia de si misma, noto que no vela absolutamento. No recurrio a mis cuidados sino hasta despues de ocho dias y cuando ella y sus padres habian ya perdido toda esperanza de que se recobrara la vista espontdnearnente. Entonces encontre lo siguiente: Ningiin sfntoma nervioso general. Movimientos normales de los globos oculares y de los pdrpados. Exterior de ambos ojos, normal. Tension, normal. Sintomas Ocular es del Envenenamiento por el Piquete de A lacrdn 93 Pupilas midriaticas cinco milimetros de diametro y sin reac- cionar a la luz. Agudeza visual, nula: la enferma no distiguia la luz de la oscuridad. Al oftalmoscopio encontre" los medios transparentes; en el fondo del ojo unicamente se veian ambas papilas muy rojas, pero el calibre de los vasos era normal y los contornos papilares bien limitados. La absoluta ceguera de la enferma, con tan pocas alteraciones oftalmoscopicas, me hizo pensar tanto en una neuritis retrobulbar por la hiperemia papilar tan evidente como en una accion estupe- faciente, sobre la retina, de la ponzona del alacrdn. La sudacion provocada por una sola inyeccion de pilocarpina, y una serie de inyecciones de estricnina como tonico retiniano, fueron poco a poco mejorando a la enferma, que recobro su vista en el breve espacio de doce dias. Este caso es interesante por haberse presentado dos veces la ceguera en la misma persona, y de mayor duracion en el segundo piquete. como si se hubiera producido anafilaxia. DISCUSSION DR. FRANCISCO M. FERNANDEZ (Havana, Cuba) : As Colonel Elliot has well said in his book on "Tropical Ophthalmology," which I have just had the pleasure of translating into Spanish, the ocular lesions caused by the arthro- pods in the different tropical countries chiefly depend upon what part of the tropics they are observed, but are all much the same all over. We have had no occasion of observing in Cuba the cases described by Dr. Gonzalez, perhaps because the scorpions we have there are not of the dan- gerous Durango variety identical to the Centrums exilicauda; and their bites do not give rise to serious toxic symptoms, either general or ocular, but only to local manifestations. The insectivorous life in Cuba is not abundant, and outside of the frequent cases of small flying insects that produce conjunctivitis, we can only remember now some cases of conjunctivitis of more serious nature produced by the toads that have been described by our teacher, Santes Fernandez, and that have presented a violent characteristic. These cases, however, have been pro- duced by the local access of the secretion in the conjunctival sac and have not given rise to any general toxic manifestations. DR. AURELIO BERAUN (Peru) : Ocular lesions caused by the bite of the scorpion are rare in Peru, The paper is important and the symptomatology is well described. I have had, however, no experience. COLONEL R. H. ELLIOT (London, England) : I would like to take this in- ternational opportunity to direct attention to the fact that work in the tropical branches of ophthalmology has been very scanty. Very little indeed has been done, for instance, on the stings of scorpions and insects of various kinds. 94 JOSE DE JESUS GONZALEZ May I start with the analogy of snake poisons? Some years ago I worked out the physiology of cobra venom. It was then generally assumed that if one had worked out one snake's venom, one had worked out the venom of all snakes; but I soon found that there was a difference between cobra venom and that of the other colubrine snakes (e. g., the karcut and the sea snakes), and a much wider difference still between the venom of colubrine snakes and that of vipers. I believe the same thing is true of the stings of scorpions in different parts of the world, and that they are each specific in their action. Indeed, the natives of India will tell you that the little white scorpion's bite is worse than that of the large black one in the same district. We have heard today that an ophthalmologist working in one area has found definite symp- toms after scorpion stings, while the rest of us have seen a large number of scorpion stings without any of these symptoms. I would suggest that it is a matter of the specificity of the poison in question. .After experimenting with snake poisons I worked a little with scorpion poi- son, and I was led to believe that the action of scorpion poison is closely allied to viper poison. Even here there are specific differences the intense pain of scorpion sting is an illustration of this. I believe that scorpion poison runs along much the same line as the viperine venom, and I want to make two suggestions to Dr. Goflzales: (1) One of the characteristics of viperine poison is the clotting that occurs in the small vessels all over the body with hemorrhages following. It would be interesting to know whether in any of these cases of severe scorpion poisoning you get such hemorrhages. (2) Running right through all the snake poisons I have worked with is the tendency to vasomotor constriction. To test for this I perfused the vessels of the frog with a weak solution of various venoms, and regularly found a marked tendency to vasomotor constriction. May it not be that the blindness spoken of by Dr. Gonzalez as a result of scorpion poison is due to a special con- striction of the retinal and choroidal circulation, an exaggeration of the gen- eral vasoconstriction which, as I have shown, runs through all snake poison- ing? I would like to persuade men who are working in the tropics to take up these questions of the eye symptoms of snake, scorpion and allied poisons. I believe they will get a harvest of material from it. DR. LLOYD MILLS (Los Angeles, Cal.) : I had some experience in this sub- ject in 1910. I was invited by the Southern Pacific Railroad Company of Mexico to investigate the reason why scorpions were holding up the construc- tion of their road. Their road passes through some old, ruined Aztec villages, and when the adobe walls were torn down scores of these scorpions would run out, and the men were stung on their feet and hands. Twenty or thirty workmen were seriously ill. Five small children and two old people died. At that time no particular attention was paid to eye conditions, as our object was the development of an anti-venom. We took six puppies of the same weight and injected them with a mixed venom from the same type of scorpion, using an increasing dose, from 1 to 6. All of these animals were examined after four hours and at two-hour intervals, and we found the main objective condition to be an increasing meningeal congestion with an increased quantity of fluid in the meninges, to the point that I was led to believe that many of the general symptoms were due to a serous meningitis, though the neurotoxic symptoms Traitement du Trachome 95 were the predominating ones. I would not be surprised if routine examination of the fundus in the graver cases would show various phases of a neuroretinal congestion with a distinct swelling of the disc in the more decided cases, the main source of these changes probably being found in the serous meningitis. TRAITEMENT DU TRACHOME PAR LES INJECTIONS SOUS CONJONCTIVALES DE CYANURE DE MERCURE DR. S. GEMBLATH Paris, France A defaut de substances reellement specifiques dans le traitement du trachome nous possedons une foule de moyens medicaux et chirurgi- caux pour arreter Fextension du processus morbide, sinon pour le faire disparaitre completement. Une des conditions essentielles pour que les methodes, d'ordre purement medical, soient efficaces c'est que leurs applications soient repetees pendant de longs mois et meme des annees. Les procedes chirurgicaux sont plus energiques, plus satis- faisants et reduisent la duree du traitement. Malheureusement leur action est temporaire et ils ne sont pas sans inconvenients. Tout le monde connait les cicatrices et les consequences facheuses des causti- ques violents et des scarifications trop etendues. De plus, employes seuls, ces precedes sont insuffisants a realiser une cure radicale. II fallait un precede energique, rapidement efficace et laissant le moins de sequelles possibles. Le probleme nous semble resolu par Pemploi des injections sous conjoncti vales de cyanure Hg, qui offre sur le jequirity un avantage pratique, c'est d'etre d'un dosage sur et d'un maniement facile. Bien que le virus ne soit pas encore connu, il est incontestable que cette affection est d'ordre infectieux; on a done cherche, depuis bien des annees, a exercer une action bactericide. Tous les antiseptiques y ont passe meme le cyanure. Mais si les lesions ont persiste, ou paru peu influencees, ce n'est point a cause d'une resistance par- ticuliere du virus, mais bien en raison du siege profond des lesions sous la mu.queuse siege qui parait les soustraire a 1'action des antiseptiques employes superficiellement. Deja les anciens s'etant rendu compte de ce fait avaient conseille" le massage, le raclage, le brossage ou les scarifications. De nos jours on preconise 1'electrolyse ou la galvano- caustie selon la methode d'Abadie. Ces methodes peuvent etre con- 96 S. GEMBLATH sideres comme satisfaisantes, mais nettement inferieures aux injec- tions de cyanure. Ce proce'de' n'est pas absolument nouveau. En Novembre 1920 deux Docteurs Roumains, MM. Lobel et Stiacovici en parlaient dans une communication publiee dans les Archives d'Ophtalmologie (de Paris) . Us le conseillaient dans les cas d'ulceres par suite de trachome. Leur technique differe un peu de la notre. De plus ce precede nous etait parfaitement inconnu lors de nos premiers essais. Travaillant a 1'Hotel-Dieu de Paris, dans le service de M. le pro- fesseur de Lapersonne, il nous a e'te donne de constater chez presque tous les malades a hypopion a qui nous faisions des injections sous conjonctivales de CyHg un epaississement de la conjonctive avec formation de tissu fibreux. Un genre de cicatrice se presentant sous la forme d'une plaque plus ou moins grande a 1'endroit ou avait eu lieu 1'injection; ce tissu etait plus ou moins transparent, blanc, jaunatre, adherent au tissu sous adjacent, parfois assez terne, conser- vant toujours cependant sa vitalite" et sa sensibilite. Nous nous sommes demandes quel pouvait etre 1'effet d'un pareil traitement dans les cas de pannus trachomateux. II nous a e'te permis de 1'essayer sur un trachomateux qui se trouvait alors dans le service, (observation 1). Notre maftre, qui suivait les malades, nous encouragea a continuer et nous guida darts notre etude par ses conseils bien- veillants. Aujourd'hui, bien que nos essais soient a leur debut, nous croyons utile de faire part a Nos Confreres Ophtalmologistes de ce precede centre ce veritable fleau qu'est le trachome. Nous esperons qu'ils contribueront au perfectionnement de ce nouveau precede the'ra- peutique qui nous parait devoir rendre service dans 1'avenir. TECHNIQUE La technique est tres simple: 1. Instillation de 4 gouttes de cocaine a 4% a 1 minute d'intervalle. L'anesthesie faite, le malade est couche: cette position n'est pas absolument necessaire, elle doit etre choisie dans le cas ou le malade est indocile ou pusillanime. 2. Si la fente palpebrale est retr^cie, par suite de processus in- flammatoire, ou lorsqu'il existe du blepharospasme, on place un blepharostat. Dans le cas contraire et lorsque le malade est facile, il suffit d'e"carter les paupieres avec le pouce et 1'index de la main gauche. On fixe la conjonctive avec une pince en prenant toute precaution utile pour ne pas la dechirer. On souleve alors l^gere- Traitement du Trachome 97 ment la conjonctive qui fait un pli on enfonce rapidement mais pru- demment 1'aiguille d'une seringue de 1 cm 3 . On injecte lentement la solution suivante: 1. Solution. Cyanure d'hydrargyre un milligr. Eau distillee un centimetre cube. 2. Solution. Novocaine deux centigr. Adrenaline au millieme deux gouttes. Eau distillee un centimetre cube. Prendre dans la seringue de 1 c 3 , une partie de la solution N 1 et une partie de la solution N 2. Une fois au courant de la technique des injections sous conjoncti- vales on fera mieux d'eviter 1'emploi de la pince a fixation. De plus pour diminuer les risques d'ecchymoses, nous conseillons 1'usage d'aiguilles tres fines. Ceci diminuera les chances d'issue du liquide injecte, car il a tendance & ressortir dans les cas ou il est, pour ainsi dire, sous pression par suite de Phyperemie conjonctivale et de I'oedeme inflammatoire, choses frequentes dans le trachome aigu. Si on procede lentement, le liquide se diffuse, soulevant la con- jonctive en une boule qui contourne la cornee, sans avoir a repiquer et sans faire avancer 1'aiguille. II nous semble qu'en agissant ainsi on diminue la frequence des ecchymoses en diminuant le nombre des vaisseaux lese"s ou coupes au passage. Un pansement suffisamment compressif est applique pendant 12 a 24 heures selon la tolerance du malade. S'il arrive que le malade se plaint de quelques douleurs on desserre un peu le pansement. Quelquefois la suppression complete et definitive de la bande est la seule chose qui assure un soulagement. Souvent il faut avoir recours a 1'aspirine. En presence de douleurs parfois intenses chez les jeunes sujets nous avons pu les prevenir completement, en administrant au malade O gr 50 d'aspirine une demi-heure avant, O gr 50 au moment meme de la piqure et gr 50 enfin deux heures apres. Le soir meme ou le lende- main on fait appliquer des compresses chaudes 3 fois par jour et des compresses froides les jours suivants. Cinq jours de repos et au sixieme une nouvelle injection au meme endroit ou du cote diametrale- ment oppose s'il y a lieu. Comme inconvenients, a part la douleur, nous n'en connaissons pas qui contredisent Femploi de cette methode. Et encore avec 1'usage d'aspirine arrive-t-on a prevenir toute douleur. D'ailleurs elles diminuent progressivement mais rapidement apres chaque piqure. 7 98 S. GEMBLATH Est-ce la un phenomene d'accoutumance de la conjonctive? Nous somraes plutot enclins a voir la cause dans 1'amelioration de l'e"tat ge'ne'ral du sujet et de 1'etat local de la conjonctive apres les premieres injections. Ce qui confirme cette idee c'est le peu de reaction chez les personnes dont les yeux sont peu enflammeX comme dans les cas regents de plaies pene'trantes du globe. Un autre moyen nous a paru tres efficace centre les douleurs; c'est les compresses chaudes qui, si elles sont appliquees quelques minutes apres 1'injection, re*duisent a rien la reaction et les douleurs. En suivant cette technique, on n'a pas d'hematome et d'ecchymose sous con joncti vale, peu esthetiques, et assez frequents dans les cas de pannus. Si on tient compte de la solution de cyanure: 1:2000 on eVite les eschares et les cicatrices qui en resultent. RESTJLTATS Au moment meme de 1'injection, si la solution est bien faite et la conjonctive bien anesthesiee, le malade ne sent absolument rien. Une demiheure apres apparait une gene, se traduisant par une lourdeur generate de la tete des battements dans les tempes, et une sensation de douleur dans la region oculaire dont Pintensite va en augmentant jusqu'a une heure et demie apres 1'injection, pour diminuer petit a petit et disparaitre completement 3 heures apres. Si on a eu soin de donner au malade O gr 50 d'aspirine au moment de 1'injection, les phenomenes subjectifs se reduisent a ce qu'un de nos malades a essayer de nous decrire "Je ne souffre pas mais mon oeil est tirailleV' Si on enleve alors le pansement et qu'on examine le malade, on constate un oedeme hyperemique des paupieres celles-ci deviennent souvent tres volumineuses et la tumefaction descend parfois jusqu'a la joue. Tous les tissus paraissent imbibes jusque dans leur profondeur. Le chemosis est considerable enveloppant pour ainsi dire une grande partie de la corne"e qui, a cette periode, ne parait pas etre changee. Le surlendemain tout rentre dans 1'ordre. Le 3 e jour un changement apparait sur la cornee qui devient plus nette le 4 e jour. La corner s'eclaircit, les vaisseaux qui la sillonnent diminuent de calibre et deviennent filiformes. Vers le 4 e ou 5 e jour apparait sur la conjonctive la formation du tissu fibreux de"ja decrite. Vers le 7 e ou 8 e jour les petits vaisseaux qu'on n'apercevait qu'a Pe'clairage oblique ne se voient plus. Vers cette e"poque, s'il existe (ce qui est fort probable) de 1'opacite corne"enne, on assiste a 1'eclair- cissement constamment progressif de la cornee. Vers le ll e ou 12 e Traitement du Trachome 99 jour, c'est a dire apres la 2 e injection, on constate un fait des plus curieux et des plus interessants, que nous avons constamment vu chez nos malades: les gros vaisseaux du pannus, qui sont devenus filiformes mais qui restent encore visibles a cette periode, pre"sentent sur le limbe comme un arret brusque, une zone exangiie de 1 a 1^ mm. A ce niveau leur trajet donne tout a fait 1'aspect d'une embolie, alors que les vaisseaux correspondants sur la conjonctive se con- tinuent avec un volume environ 2 fois plus grand. Ce n'est que du 15 e au 18 e jour, c'est a dire apres la 3 e injection, que les derniers restes des vaisseaux sanguins deviennent invisibles. De 1'opacite" corneenne totale, il ne reste qu'un leger nephelion central qui diminue d'etendue petit a petit pour disparaitre completement. Nous avons ete tres frappes durant le cours du traitement de notre premier malade Obs. I de voir 1'etat des conjonctives palpebrales, sur- tout au niveau des culs de sac, s'ameliorer d'une fagon tres rapide et tres marquee. (Trois a quatre jours apres 1'injection on constate 1'af- faissement des follicules et des granulations conjonctivales. Mais la conjonctive parfaitement lisse reste hyperemiee. A la place des grosses granulations on voit de petites tach.es plus ou moins transparentes jaune gelatineux, grosses comme des grains de semoule. Une semaine ou deux de nitrate d'argent rende a la conjonctive son aspect et sa coloration normale.) Nous avons d'abord pense que le cyanure avait agi sur les paupieres de la meme fagon qu'il avait agi sur la cornee, par reaction, ou par formation de tissu cicatriciel ou par action bactericide Mais devant 1'amelioration tres nette et tres rapide nous nous demandons si le cyanure n'aurait pas une action directe nous n'osons pas dire specifique sur le virus trachomateux. Le nombre limite de nos experiences ne nous permet pas de nous prononcer. II faudrait aussi pour cela des cas vierges traites ex- clusivement au cyanure. La date du Congres ne nous a pas permis de le faire. Mais dores et deja nous pouvons justifier de I'efficacite de la methode par ces resultats. La methode est applicable a tous les cas et tous en be"neficient = Restitutio ad integrum dans les cas legers de pannus (5 ou 8 jours apres 1'injection.) Meme resultat sur la conjonctive palpebrale dans tous les cas de la l e et 2 e periodes: toutes les granulations dis- paraissent en moins de 3 semaines, et la conjonctive re"cupere son aspect normal avec une ou deux semaines de nitrate d'argent ou de sulfate de cuivre Dans les cas plus marques de pannus, avec trouble considerable de la cornee, la guerison est moins rapide. On peut 100 S. GEMBLATH esperer la disparition totale et complete des ne'phe'lions pas trop anciens et du trouble diffus de la cornee. Le cyanure est sans action appreciable sur les leucomes e"tendues ainsi que sur 1'hypertrophie du tarse et de la conjonctive, avec formation de tissu scleYeux. Dans les cas graves et anciens, combines au nitrate d'argent ou au sulfate de cuivre, le cyanure diminue d'une facon considerable la dur6e du traitement. Dans tous les cas, le r6sultat fonctionnel est, comme on le voit, des plus encourageant. Nous posse 1 dons vingt observations suivies plusieurs mois. Les resultats obtenus sont a peu pres les memes dans tous les cas. Nous donnons seulement le resume de quatre observations les plus car- act6ristiques. OBSERVATION I. Trachome tres ancien non soigne 72 ans. ODG. S6cr6tion larmoiement. Blepharospasme, faux ptosis, e'paississement de la conjonctive et du tarse. Pannus crassus, cornees ternes et tres vascularisees empechant de voir 1'iris. OD. Mou et douloureux peut etre iridocy elite. La vision de cet oeil est r6duite a la perception lumineuse. VOG = compte les doigts a ^2 metre. Du 19 De"c. 1920 au 16 Janvier 1921 traite" sans resultat appreciable au sulfate de cuivre. 2 Janvier. Injection de cyanure a 1' O.D. Reaction assez mar- quee hematome sous conjonctival. Le 10 1'hematome est resorbe. Cornee moins terne et moins vascularise'e. Conjonctive moins rouge considerablement amelioree. L'oeil droit propre et bien ouvert. Sulfate de cuivre. Le 23 Janvier. Injection de cyanure a 1' O.G. Dix jours apres le malade se conduit seul. VOG. = T V Corne'e presque completement transparente, permet de voir une cataracte intumescente. OD. Infiltration 16gere et diffuse de toute la cornee cataracte en Evolution. Sort de 1'hopital appele chez lui d'urgence. Collyre au sulfate de cuivre. Admis a nouveau le 11 Mars pour etre opere de cataracte. 12 Mars: Iridectomie preparatoire. Un mois apres extraction. Suites normales. OBSERVATION II. L'interet de cette observation est dans la guerison tres rapide du pannus et des granulations par le cyanure; elle demontre bien la superiority de ce procede sur les moyens ordi- naires. M Jeune Grec, docteur en me'decine. Soigne" depuis 2 ans Traitement du Trachome 101 chez lui et a Paris pour trachome par du nitrate d' argent et du sulfate de cuivre. OD: Cornee normale. Quelques granulations ty piques dans le cul de sac conjonctivale sup. et sur le bord du tarse. OG: Photophobie et larmoiement intenses. La conjonctive palpe"brale tres hype'remiee est entierement couverte de granulations. Pannus typique du tiers supe"rieur. On devine, a travers le trouble de la cornee, la pupille en myosis. VOG = Voit passer la main. 10 Mars 1921. Injection de cyanure a 1' O.G. Reaction tres in- tense. Le 15, Vascularisation occupant les % sup. de la cornee. Le 18, les vaisseaux diminuent pour disparaitre completement le 22. Nitrate d'argent en application quotidienne. 10 Juin. Cornee transparente, conjonctive parfaitement lisse sans granulation ni cicatrice, de couleur et d'aspect normal. VOG = 1. OD: Soigne seulement par le nitrate d'argent presente une conjonc- tive legerement injectee mais beaucoup moins qu'avant avec quelques granulations vers Tangle externe. VOD = 1. OBSERVATION III AND IV. Ces cas ne sont pas moins interessants. II s'agit de deux jeunes Syriens, refuses a 2 reprises par les Medecins inspecteurs du port de New York entre Aout et Decembre 1920. Renvoyes a Paris pour la deuxieme fois ils consultent a 1'Hotel-Dieu et subissent deux injections de cyanure dans les deux yeux suivies de deux semaines de sulfate de cuivre. Au mois de Mars 1921 c'est a dire deux mois apres ils entrent a New York sans difficulte. DISCUSSION DR. J. M. PENICHET (Havana, Cuba) : I have no doubt that Dr. Gemblath has been successful in the treatment of trachoma and its complications with the subconjunctival injections of cyanid of mercury. We all have had cases of trachoma radically cured by one of the many methods employed to treat this affection and, vice versa, we all have employed almost every known method on some difficult case without any or with very little success. The point to consider is whether we are dealing with a simple case or with a complicated one. As a rule, trachomatous ulcers of the cornea and pannus do not yield to all forms of subconjunctival injections. That is why the results obtained by Dr. Gemblath should be taken into consideration. To prove my statement I will say that four years ago I tried the subcon- junctival auto vaccine treatment introduced by Dr. Demaria of the Argentine Republic, and with only a slight modification in the technic I used it in twenty cases of simple trachoma and five cases of ulcers and pannus. My results were not as satisfactory as those of Dr. Demaria, and I must explain that I fol- lowed every one of these cases to the end of the series. My impression is that the organisms of trachoma seem to lose their virulence in the presence of or- 102 S. GEMBLATH ganisms of ulcer and of pannus. In the five complicated cases better results were obtained. The main objections to the use of subconjunctival injections of cyanid of mercury are the pain, the chemosis, and the psychologic influence of a bad appearance upon the patient and the family. According to Dr. Gemblath, aspirin given before, during and after the injections takes away all possibility of pain, and the bandage does away with the chemosis and swelling. In my experience I have found, nevertheless, that a large number of these patients will look for a less painful and easier method. DR. JOSEPH KRIMSKY (Brooklyn, N. Y.) : In Palestine, where I had charge of a number of schools and thousands of children suffering from trachoma, I began to use cyanid of mercury by massage instead of the bichlorid, using a 1 : 500 solution with vigorous massage. I had such good results that I con- ceived the idea of using it by subconjunctival injection, and I can testify to what Dr. Gemblath has said, that, in cases where there is an unpleasant swelling of the eyelids and chemosis it is not painful, and will subside in a week. Those cases in which I used the subconjunctival injection recovered in less time than those in which I had not used it. Then I tried it in more complicated cases where there was a thickened pannus, but I had no benefi- cial results and had to resort to operative treatment. PROF. F. DE LAPERSONNE (Paris, France) : J'ai constate" a 1'Hotel-Dieu de Paris, les re"sultats obtenus par M. Gemblath dans le traitement du trachome par les injections sous-con jonctivales de cyanure Hg. Us sont extremement encourageants et ce traitement merite d'etre generalise. Avec la technique employee, ce traitement est peu douloureux, malgre la tume- faction considerable des paupieres. Je ne puis pas affirmer que dans ce cas le cyanure agise sp^cialement comme antiseptique; je crois plutot que c'est par la reaction inflammatoire violente qu'il produit et par. L'apport d'element fibrineux dans les tissus sous mu- queux. II agitait un peut a la maniere du jequirity, mais plus profonde"- ment. SURGEON JOHN MCMULLEN (U. S. Public Health Service) : I am interested in the paper of Dr. Gemblath in so far as it would seem to afford us a remedy or a means of curing trachoma without resort to operative measures. I have not used this particular method, although, like all of us, have covered the ground pretty well in medical treatment, using practically all the remedies that have been recommended. I shall carry out the treatment in the Govern-' ment Hospitals for the treatment of trachoma in the hope that we may relieve many of these cases. We have discarded medical treatment to a great ex- tent except in so far as it is post-operative. Our treatment of trachoma is now altogether surgical. DR. S. GEMBLATH (closing) : La remarque de M. Pe"nichet, est tres juste. La douleur causee par les injections nous a fait he"siter un moment, mais par 1'usage de 1'aspirine, nous avons pu la re"duire & une simple gene oculaire assez bien supported. Un mot pour r^pondre a Dr. Howe. Comme dans tous les cas traites nous Hereditary Ocular Degenerations 103 n'avons eu que des ameliorations, sans accidents, nous n'avons pas he'site' a employer le cyanure dans les cas meme tres lagers et sans lesions corneennes. Mais c'est surtout dans les cas de pannus et d'ulceres corne'ens que ce proce'de' donne les meilleurs r^sultats. Les injections de cyanure contrairement aux proce'de's chirurgicaux, sont applicables a tous les cas et par leur diffusion, leur action porte sur tous les points, atteints difficilement par les autres moyens. De plus, ils ne donnent pas naissance, comme le traitement chirurgical, a des cicatrices et a leurs con- sequences facheuses. HEREDITARY OCULAR DEGENERATIONS- " OPHTHALMIC ABIOTROPHIES " MR. E. TREACHER COLLINS London, England Most writers on hereditary affections of the eyes have omitted to draw any sharp line of differentiation between those in which the tissue involved has from the first been imperfectly developed, and those in which, after full development, degeneration sets in. As ex- amples of hereditary maldevelopments may be mentioned such obvious structural imperfections as microphthalmia, ectopia lentis, and con- genital cataract. Also conditions known to us best as functional dis- turbances, though doubtless having some anatomic basis, such as con- genital color-blindness and night-blindness. The hereditary ocular degenerations of which the fullest information has been collected in- clude the following affections: post-natal cataract; ocular palsies; retinitis pigmentosa; symmetric macular pigmentary degenerations; amaurotic family idiocy; Leber's optic atrophy; Doyne's "family choroiditis "; nodular and lattice-like degeneration of the cornea. Widely different as these affections may at first appear, they will be found to present similar characteristics, which allows of them being grouped together in a classification of eye diseases founded on a path- ologic basis. All these diseases are hereditary, in the sense that they may be met with in several siblings of the same generation, and all, with the exception of symmetric macular pigmentary degeneration and amaurotic family idiocy, in several different generations. The lesions in all these diseases are bilateral, and in none of them in which pathologic investigations have been made do the findings suggest the presence of inflammation, but are such as indicate degeneration in certain definite groups of cells cells which, having reached a full de- 104 E. TREACHER COLLINS gree of development and functional efficiency, have then undergone degeneration. The time of life at which the degeneration commences varies, as also does, what sometimes appears to be, the incidental ex- citing cause. The occurrence of the degenerations in several succes- sive generations of the same family renders it impossible to attribute them entirely to the absorption of any exogenous toxic substance, or to the absence of any exogenous essential nutrient material, such as a vitamin. So far as our knowledge at present goes there is no endogenous sub- stance, such as the secretion of one of the endocrine glands, upon which the structures involved in these diseases are dependent for their vital- ity ; nor do we as yet know of any toxic material developed endogen- ously, either by bacteria or as the outcome of some faulty metabolic process, capable of poisoning and slaying the cells picked out in these diseases. Even if such a toxin, or internal secretion, be discovered to account for the hereditary nature of the affections, it will still be necessary to assume some innate weakness in the cells attacked; or, in the case of some internal nutrient secretion, some innate tendency to a failure in its supply. Sir William Gowers accounted for the hereditary character of certain degenerative affections of the nervous system, muscles, and epidermal appendages, presenting similar characteristics to the eye affections dealt with in this paper, to want of vital force in the struc- tures involved, so that they are unable to maintain their nutrition be- yond full development and, therefore, gradually fail and degenerate. They fail, as he says, "from imperfect life, from abiosis, in what may be designated abiotic atrophy, or abiotrophy. " He points out that, "besides general life, the termination of which involves that of every part of the body, many of these parts have their own vitality. Some of them slowly die, while the life of all the rest goes on without impairment. They die from many causes some early, inevitably, from a very grave defect of vital endurance; some much later, the failure being but slightly premature; and some at various times, apparently from various causes. When the failure is early, it is often due purely to a defect in vitality, a defect which seems to be inherent, the tendency thereto inborn. We do not, indeed, apply the word ' death ' to this slow decay of the elements ; we speak of it as 'degeneration,' but the process is in many cases, perhaps in most, an essential failure of vitality, and I think it is instructive to consider the degeneration in this aspect. " Hereditary Ocular Degenerations 105 The term vital force, in the way in which it is here used, may be de- fined as "a force the possession of which differentiates living from dead matter. " Though we know little as to its real nature, it is con- venient to have a name to apply to it, just as in algebra we use a sym- bol to represent an unknown quantity. This vital force, as we know it, exists only in connection with cell protoplasm, and manifests it- self by what we term irritability. For its maintenance, the cells possessing it require the capacity of taking up certain substances from the fluid media surrounding them, and of discharging other waste products a process probably capable of a physicochemical explana- tion. In fission fungi and many unicellular protozoa the vital force may apparently be indefinitely prolonged, for these simply formed organ- isms multiply by division, so becoming transformed into two new in- dividuals without leaving any corpse behind. In a germ cell of multicellular organisms, as the result of fertiliza- tion, the vital force, instead of becoming gradually exhausted and leading to degeneration and death of the cell, regains fresh vigor, causing it to multiply, develop, and evolve into a new being. In the cells of multicellular organisms, which have become much differentiated from germ cells, and have acquired new and highly specialized functions, the vital force is always in a state of transition. These cells are always either in a state of evolution to maturity or in a state of involution to decay. At times the process is so slow that it might almost be thought that no change was taking place, but slow though it be, and minute the alterations that occur, it surely and steadily goes on. " For so we ripe and ripe and then we rot and rot. " The time required for the vital force to complete the cycle of changes which take place from birth to death varies considerably in different species of animals, in different individuals of the same species, and physiologically in the several tissues of which an animal is composed. Among mammals the vital force is of much longer duration in ele- phants and man than in horses and dogs. Among birds it is of much longer duration in parrots and geese than in fowls and thrushes. In the tortoise it is of longer duration than in any other vertebrata, one such animal is estimated to have lived for two hundred years. Among human beings longevity is frequently found to be a family characteristic. Here are three examples : Mrs. Amelia Spurgeon, the aunt of the great preacher, recently passed her one hundred and sec- ond birthday. Her mother lived to ninety, and her brother and two 106 E. TREACHER COLLINS sisters all passed the eighties. In a recent copy of a daily paper there was an account of an octogenarian, a Mr. Gibbins, who had eight brothers and sisters, not one of whom died before reaching the age of eighty. Thomas Parr, who was born in Shropshire in 1483, is reported to have reached the age of one hundred and fifty-two, and was buried in Westminster Abbey. The celebrated Harvey examined his body after death and was unable to discover any organic disease. Parr did not marry until the age of eighty-eight ; he had a son who lived until the age of one hundred and twenty-seven. Physiologically, in the human body, the vital force fails sooner in some tissues than in others, e. g., the thymus gland is highly developed during fetal life, reaches its maximum size during the third year of life, and shows signs of degeneration which rapidly progress after the age of ten. Other early physiologic failures of vital force, with which most of us are unfortunately only too familiar, are touchingly alluded to in the following verse from W. S. Gilbert's comic opera of "Pa- tience": Silvered is the raven hair, Spreading is the parting straight, Mottled the complexion fair, Halting is the youthful gait: Hollow is the laughter free, Spectacled the limpid eye, Little will be left of me, In the coming by-and by. As Sir James Paget 3 wrote in his famous Lectures on Pathology: "It is natural to become feeble and infirm, to wither and shrivel, to have dry, dusky, wrinkled skins, and greasy, brittle bones, to have weak, fatty hearts, blackened, inelastic lungs, and dusky thin stomachs, and to have every function of life discharged feebly, and as it were wearily; and then, with powers gradually decreasing, to come to a time when all the functions of bodily life ceasing to be discharged, death, without pain or distress, ensues." He goes on to say that such a death is rare, and that he has only seen two or three such cases. In other words, our bodies are not constructed like "The Deacon's Masterpiece; or the Wonderful One-Hoss Shay, " described by Oliver Wendell Holmes: "That was built in such a logical way, It ran a hundred years to a day. " Hereditary Ocular Degenerations 107 and then : "went to pieces all at once, All at once and nothing first, Just as the bubbles do when they burst. " To again quote Sir James Paget; he says : "The changes of natural degeneration in advanced life have a direct importance in all pathol- ogy, because they may guide us to the interpretation of many similar anomalies which, while they occur in earlier life, we are apt to call diseases, but which are only premature degenerations, and are to be considered, therefore, as methods of atrophy as defects, rather than as perversions, of the nutritive process or as diseases only in consid- eration of the time of their occurrence." This was written in 1853, and it is an interesting anticipation of Sir William Gowers ' theory of " Abiotrophy, " or degeneration of tissues due to defective vitality. Metchnikoff 4 would have us believe that the symptoms we speak of as senile degeneration are not a natural sequence of life, ushering in its close, but the outcome of auto-intoxication. In his writings, however, he frequently speaks of "the cycle of life" and of "natural death," which latter he defines as a "phenomenon that is intrinsic in the nature of an organism and not the mere result of an external acci- dent. " What apparently he does not recognize is that the cycle of life may be of variable duration in the different tissues of an individual, and the intrinsic phenomenon, "natural death," may take place sooner in some cells of the body than in others. Doubtless some tissues in which the cycle is drawing to a close are likely to succumb to some toxic influence earlier than they otherwise would, in which case the change produced might be attributed entirely to the toxin, the weakened resistance power of the tissue having been overlooked. It is as unreasonable to attribute all variations in the time of degen- eration of tissues to toxic influences as it would be.to account for all variations in the time of development of tissues to such influences. Just as we sometimes meet with precociousness in development, so sometimes we meet with precociousness in degeneration. It is with some of the precocious degenerations of the tissues of the eye that I now proceed to deal. HEREDITARY POST-NATAL CATARACT OR ABIOTIC CATARACT Under the heading of cutaneous abiotrophy Sir William Gowers 1 described the early baldness met with in the males of the family in 108 E. TREACHER COLLINS several successive generations, the essential cause of which is the failure of the life of the hair-follicles of the scalp. He also spoke of early grayness of the hair as a qualitative failure, an enduring defect of one function of the follicles. Another very common form of degeneration met with in a structure derived from cuticular epiblast is opacity of the lens of the eye, the outcome of a premature failure in the vitality of its fibers, a condition which may, I suggest, be aptly termed abiotic cataract. That these changes are due to defective vitality is shown by their inherent character. Nettleship 5 states that : " Post-natal or acquired cataract is often hereditary, and quite a number of pedigrees have been collected by many observers. " Such post-natal cataracts have been described according to age of onset as "senile," "presenile, " and "juvenile." But, as Nettleship says: "This subdivision is, no doubt, arbitrary, and does not corre- spond with any differences in the cause or character of the cataract, but is of some practical convenience." He collected and analyzed a large number of pedigrees of post-natal cataract, and, commenting on the age of onset, remarked: "In one and the same family hereditary cataract often begins at about the same, age in all who have it. But exceptions to this are very numer- ous for, as we have just seen, hereditary cataract often occurs at an earlier age in the children than in the parents, whilst in those of the same generation it frequently begins at about the same age in each." In 1917 I operated for cataract at the Moorfields Hospital on two members of a family of seven. The five other members of the family and their father had previously been operated on for cataract at the same hospital. These facts I was able to verify by reference to the in-patient notes. I was further told that my patient's two paternal uncles had been operated on for cataract, one at St. Thomas ' Hospital and the other at Cardiff. Of the family of seven two were males and five females. Their ages at the time they were-operated on were as follows: forty-two, fifty-six, forty-nine, sixty-three, fifty-six, fifty- eight. The age of their father at the time of operation was sixty. In a family such as this, in which so large a number of its members became affected with early senile cataract, it seems necessary to assume some inherent defect in the vitality of the lens-fibers which results in their degeneration. To speak of certain forms of post-natal cataract as abiotic does more than simply describe them as due to degeneration. I propose to show Hereditary Ocular Degenerations 109 that it enables us to understand their pathology more clearly than has previously been possible. In considering the degenerative processes which occur in the struc- ture of the lens it is first necessary to recognize that there is a physio- logic degeneration constantly taking place in its fibers which does not result in the formation of opacity, and which, in an anteroposterior section of an adult lens, can be seen in all its stages in passing from the periphery to the nucleus. Newly formed lens-fibers, such as are seen close to the capsule, form long flat bands with regular margins, rounded or hexagonal in trans- verse section, and containing rounded or elliptic well-staining nuclei. Older fibers, further from the capsule, become denser and flatter; their nuclei show at first an aggregation of chromatin toward the periph- ery, and later disappear altogether, clear oval spaces being left at the sites they occupied, which, in still older fibers, also disappear. The oldest fibers of all, those in the center of the lens, are harder and more condensed. They have crenated margins, the projections and in- dentations of which fit tightly into one another, and they are entirely devoid of any trace of nuclei. This gradual hardening of the lens- fibers is spoken of as sclerosis. In pathologic degeneration of the lens, such as is met with in senile cataracts, the first change observed is the formation of clefts between the fibers in its peripheral parts. In these clefts the interfibrillar fluid accumulates, and in hardened sections of the lens presents the appear- ance of irregularly shaped, coagulated masses, or of spheroidal bodies, the so-called Morgagnian globules. The formation of these clefts is usually attributed to an excess of the physiologic shrinking of the nu- cleus of the lens. In the adult lens, and to a larger extent in the senile lens, the nucleus is quite hard, due to the physiologic shrinking and de- generation which have taken place in its fibers.. It seems difficult to understand how there can be any increase in the physiologic shrinking of this already horny, sclerosed part of the lens. The region in which the clefts are formed and where the opacity begins is where the lens- fibers have not, in the normal state, undergone much shrinking or de- generation; and regarding the condition as due to abiotrophy, it would be natural to assume that the clefts are due to a premature shrinking and degeneration of what should be well-nourished fibers, rather than changes in a part of the lens where metabolic processes are practically at a standstill. Though the lens-fibers bounding the clefts at first show but little change beyond some condensation of their sub- 110 E. TREACHER COLLINS stance, such as is met in the physiologic degeneration process, later on their substance becomes granular, fatty globules may form in them, and they break down into the spaces formed between them by their shrinkage, and thus the cataractous process progresses. HEREDITARY OCULAR PALSIES. ABIOTROPHY OF THE MUSCLES OF THE EYELIDS AND EYEBALLS In discussing the various forms of hereditary paresis of the muscles of the eyes and eyelids it will be well first to quote some of Gowers' x remarks on muscular abiotrophy in general. In his first lecture on the subject he wrote as follows: "In the various forms of idiopathic muscular atrophy, in which there is a primary atrophy of the muscular fibers, we have examples of a true abiosis. To all these primary myopathies it has become custom- ary to apply the term 'muscular dystrophy,' and the custom is con- venient, if not quite accurate. The term thus includes both simple muscular atrophy and its well-known congener, pseudohy per trophic paralysis. In these the muscle-fibers, after full development, cease to maintain their nutrition. They slowly waste, and a large number most of them in many parts, all in some -perish. The connective tissue between them overgrows. Its increase may fail to maintain the normal bulk of the muscles, so that they waste conspicuously, some- times extremely. In other cases this tissue-weed, as we may regard it, presents a more luxuriant development, and produces fat-bearing cells which so much increase the bulk of the muscle as to cause the enlarge- ment of pseudohypertrophy. " In another lecture 2 on the same subject he wrote: "The nutrition of the muscle depends on that of the nerves through which its function is called forth. If the nerves slowly degenerate, so does the muscle; if .rapidly, from descending irritation, the muscles undergo speedy complete degeneration. Yet the muscle has a life which we may call organic, belonging to it as a structural entity, in consequence of which it may undergo morbid changes, apart from the nervous system, and may fail to live on, though the nerves preserve an unimpaired vitality. This failure is what I have called muscular abiotrophy failure of nutrition from defective vitality and for brevity we call it myopathy. " Among the muscular abiotrophies which he thus defines he includes the " f acio-scapulo-humeral type," also designated the "type of Landouzy-De'je'rine. " In this affection there is extreme wasting of Hereditary Ocular Degenerations 111 the muscles picked out, including the orbicularis palpebrarum. No matter how long the duration of the malady, it seems to remain purely muscular, the nervous system, even the motor nerves, remaining un- changed. It is a family and hereditary disease, and may be trans- mitted by either male or female parent; it affects both boys and girls alike. In 1915 I showed 6 a girl, aged seven, who had bilateral facial paralysis. At that time there was no affection of the muscles of the shoulder-girdle, though there was some paralysis of the extensor muscles of the leg, causing her to walk with a peculiar gait, her toes turning inward. She had the typical expressionless, so-called myo- pathic, face. She was unable to close her eyes from paralysis of the orbicularis muscles, and her lower lids fell a little away from the eye- balls, causing epiphora. There were no symptoms pointing to any involvement of the nervous system, and the case appeared to be one of purely muscular atrophy. Fuchs 7 in 1890 reported five cases in which bilateral ptosis was the only symptom of disease. In two of them, aged thirty and sixty re- spectively, the ptosis appeared early in life, was hereditary, and in course of time became complete. The other three, aged forty, sixty, and fifty-six years respectively, developed ptosis late in life; it slowly increased and became almost complete. There was no history of syphilis in these cases, and no evidence of brain disease. The upper eyelids were thinned to such an extent that the anterior parts of the eyeball showed plainly through them. There was also shrinking of the orbital fat in the immediate vicinity of the levator, as shown by falling in of the lid just below the orbital rim. Fuchs removed and examined a small portion, of the muscle in one of his cases, and found the fibers much thinner than those from a healthy muscle ; the nuclei were considerably increased in number, and there was marked pigmen- tary degeneration inside the sarcolemma but no fatty degeneration was found. In some parts the fibers themselves appeared normal in structure, the connective tissue between them being, however, in- creased in amount. Fuchs was of opinion that his cases were best ex- plained by a primary atrophy confined to the levator palpebrae muscles, an affection which, up to that time, had not been described. In 1909 I published the notes 8 of what I took to be a similar case to those described by Fuchs of bilateral ptosis, unaccompanied by paraly- sis of any other muscles. Like all Fuchs' cases, the patient was a female, and like some of his cases, there was a slight amount of ptosis, 112 E. TREACHER COLLINS dating either from birth or from early infancy. That the ptosis had steadily increased was well shown by the examination of a series of photographs she had had taken at different ages. At the time she came under my observation she was sixty-nine years old. She also had a very unusual circumferential encroachment by the limbus of the conjunctiva on to the cornea in the two eyes. I cut away a strip of the levator palpebrae muscle in each eye, as Fuchs did, and found it very atrophic ; unfortunately, I did not have it examined microscop- ically. In 1900 W. M. Beaumont published 9 the account of a family in which several members of four different generations suffered from ophthalmoplegia externa. The disease was never congenital, but al- ways appeared in adult life; it was slowly progressive, and never ap- pears to have had a fatal termination. The characteristics of the members of the family were to enjoy a long life and to have troops of children. The cases, most fully examined, showed complete paralysis of the levator palpebrae on each side, and very limited action of the recti muscles in any direction. In one case it was noted that the action of the orbicularis muscle was very feeble. In none of the cases were the intra-ocular muscles involved. McMullen and Hine, 10 in a recent paper on chronic progressive ophthalmoplegia externa, mention that: "Wilbrand and Saenger 11 grouped as a clinical entity certain cases of external ophthalmoplegia, which, in their opinion, had definite characteristics, which separated them not only from the congenital cases of this affection, but also from the cases definitely due to some toxic cause or to syphilis, or as- sociated with wider spread manifestations of nervous disease. " These cases, according to these authors, have the following characteristics: ''There is a gradual onset, generally in infancy or early childhood, more rarely in later life, of a bilateral, progressive paralysis of the ex- ternal eye muscles, not associated with other signs of disorder of the nervous system nor with fever. The disease may come to a standstill permanently, or for long periods, at any stage of its development, but generally ends in complete, or nearly complete, external ophthalmo- plegia. In most cases both sides are affected from the beginning, but sometimes it appears on one side long before the other; often the two sides are unequally affected in the early stages. Ptosis is generally the first sign, and may be for a long time the only one. When the muscles of the eyeball become affected, diplopia may be complained of, but this symptom is only rarely noted, principally because the paraly- Hereditary Ocular Degenerations 113 sis develops gradually, and often symmetrically, on both sides, and because it frequently comes on in childhood before the function of binocular vision is fully developed. The progress is often extremely slow, and thirty or forty years may elapse between the appearance of the first symptoms and the development of complete ophthalmoplegia. The general health is not affected, and there is a noteworthy absence of signs indicating disease in other parts of the nervous system. " Wilbrand and Saenger n collected records of 32 cases of this affection. McMullen and Hine, in their article, refer to two others described by Ayres 12 and Altland, 13 and give notes of three of their own. In Ayres ' case the maternal grandfather of the patient was said to have been similarly affected. The following case, evidently belonging to the same class, has recently come under my observation: Frederick R., aged forty-three, stated that his eyelids began to droop twenty-eight years previously, and that shortly afterward he was operated on for it by Mr. Lawford. His condition was improved, but the drooping had persisted. He came to me on account of some conjunctivitis in one of his eyes, and I then discovered that, in addition to bilateral ptosis of a very marked degree, he also had ophthalmoplegia externa. He had only very slight power of movement of either eye laterally or vertically, and practically no rotatory movement. His pupils were equal and active, and he had no more defect of accommodation than such as might be expected in a man of his age with a slight degree of hypermetropia. His occupation was a carman > he had never experienced any diplopia, or found any difficulty in driving about the crowded streets of London. He has six children none of them or, so far as he knows, any other member of his family has suffered from an affection of the eyes similar to his. He is a strong, healthy man, shows no sign of any affection of his nervous system. His Wassermann reaction was tested and found negative. In discussing these cases it is first necessary to draw a distinction be- tween them and cases of congenital defect in the movements of the eyeballs and eyelids, a class of cases dealt with very fully by G. Heuck 14 in 1879, and by Lawford 15 in 1888. The former found, by post- mortem examinations, that in these congenital cases the defect of movement was due either to absence of the muscle, its imperfect de- velopment, its insufficient length, or its faulty attachment to the eye- ball. In the class of cases here under consideration there has for a time been good movement of the eyelids and eyeballs, and then gradual and progressive failure has set in. In the one there is from 8 114 E. TREACHER COLLINS the first a defect of development, in the other degeneration sets in after full development. Most writers on these hereditary ocular palsies, and on the cases presenting similar symptoms which arise sporadically, regard them as due to lesions in the nuclei of the nerves supplying the affected muscles. It is, however, possible that the primary condition may be a degeneration of the muscle-fibers and that the nerves supplying them may be unaffected. Whichever be the true explanation, seeing that the affection is in some instances a hereditary one, and that it is not due to syphilis, it may appropriately be regarded as of an abiotic nature either an abiotrophy of the cells of the nerve nuclei, or an abiotrophy of the muscle-fibers. The assistance which might be obtained by examination of the electric reactions in these cases to determine the nature of the muscu- lar weakness is not available. The exact primary nature can cer- tainly be decided only by postmortem examination, but up to the present no such examinations have been carried out. The order in which the different series of paralytic affections of the muscles of the eyelids and eyeball are referred to above has been arranged with a purpose. The first-mentioned were cases of the facio- scapulo-humeral type, in which there was inability to close the eyes from paralysis of the orbicularis palpebrarum muscle; and then a case of bilateral facial paralysis without any affection of the muscles of the shoulder-girdle. These cases are undoubtedly of a myopathic nature. Next, Fuchs' cases of bilateral ptosis were quoted, some of which were hereditary; these he regarded as due to primary atrophy of the muscles, a view which received support from the appearance of a strip of one of the affected muscles examined microscopically. Following on these Beaumont 's family, with ophthalmoplegia in four different generations, was described. In one member of the family, in addition to the ophthalmoplegia, there was some paresis of the or- bicularis palpebrarum muscle. Finally came the group of cases sep- arated off as a clinical entity by Wilbrand and Saenger, in which there was chronic progressive bilateral paralysis of all the orbital striated muscles, the unstriated intra-ocular muscles invariably remaining un- affected. In this group the muscles affected are never confined to those supplied from one nerve nucleus, and the paresis of some of the muscles often remains for a long time incomplete. Many of the cases in this group have been watched for prolonged periods without de- veloping any symptoms due to disturbances of the nervous system. Hereditary Ocular Degenerations 115 These facts taken together offer, I suggest, strong circumstantial evidence in favor of the view that cases of bilateral ophthalmoplegia, like cases of bilateral facial paralysis and cases of bilateral ptosis, are due to a primary degeneration in the muscle-fibers. "RETINITIS PIGMENTOSA" OR ABIOTROPHY OF THE RETINAL NEURO- EPITHELIUM In a paper published in 1919 16 I collected together a considerable amount of evidence to show that the affection commonly known as retinitis pigmentosa should really be regarded as a primary degenera- tion, or abiotrophy, of the neuro-epithelium of the retina. It will be here only necessary to summarize the evidence set out in that paper. Nettleship, 17 in 1907, made a most comprehensive collection of all the data concerning retinitis pigmentosa then available, and described the disease as "the result of a tissue liability present, though seldom manifest, at birth, and known to be so often hereditary that we may be sure it is so also in many cases where the proof is wanting." Wagenmann 18 showed, by division of one of the posterior ciliary arteries in animal eyes, that the nutrition of the outer layers of the retina depend on the choroidal circulation. In the area supplied by the divided vessel both choroid and retina atrophied, the latter be- coming adherent to the former and also pigmented. Frequently after sclerosis of the choroidal vessels, due either to syphilis or to senility, pigmentation of the retina is observed. From this, and from Wagenmann 's experiments, it had been inferred that the pigmentation of the retina in retinitis pigmentosa is also due to sclerosis of the choroidal vessels. Pathologic examinations of eyes in cases of retinitis pigmentosa, at different stages of the disease, and made by different observers, have shown it may occur without any such thickening of the choroidal vessels being present. W. T. Lister, 19 in 1903, examined the eyes of a man who died at the age of sixty, who, at the age of thirty-eight, had been found by Nettle- ship to have advanced retinitis pigmentosa. Lister found that though the choriocapillaris was atrophied, the choroidal vessels seen in section showed no thickening of their walls. The layer of rods and cones was altogether absent, its place being taken by laminated fibrous tissue. Stock, 20 in 1908, examined microscopically an eye with typical retinitis pigmentosa, excised during life for an adjacent carcinoma, and fixed immediately in Zenker's fluid. He found a practically normal choroid. The primary changes appeared to be a degenera- 116 E TREACHER COLLINS tion of the bacillary layer of the retina, followed by degeneration of its nervous elements and disturbance of the pigment epithelium. Ginsberg, 21 in 1908, examined histologically the eyes of a man known to have had retinitis pigmentosa for ten years, who died of tu- berculosis at the age of thirty-five years. The vascular system of the choroids in these eyes showed no changes. The outer layers of the retinae were the parts most affected, the neuro-epithelium being almost entirely destroyed. He suggested that its degeneration was due to a congenital weakness in the standard of functional activity imparted to these cells, so that they had not grown in proportion to the de- mands made upon them and therefore gradually disintegrated; i. e., to abiotrophy. Suganama, 22 in 1912, examined microscopically the eye of a man, aged sixty-seven, with typical retinitis pigmentosa, removed on ac- count of a hypopyon ulcer. There was no sclerosis of the choroidal vessels and the choriocapillaris was normal, except in a few areas where it was absent or imperfect. There was complete absence of the rods and cones. The retinal nervous elements were atrophic, and the neuroglia had proliferated. The evidence afforded by these pathologic investigations seems conclusively to show that retinitis pigmentosa may arise and exist for many years unaccompanied by any thickening of the choroidal vessels. Further, that the disease starts in the retinal neuro-epithelium, which, having attained its full normal development, then degenerates. As it is a hereditary condition, this tendency to degenerate must be due to some inherent weakness in the affected cells. Atrophy of the percipient elements in a sensory organ is necessarily followed by atrophy of the nervous elements in connection with them, and a decrease in the vascular supply to the part. So in the retina in retinitis pigmentosa, following on the atrophy of the rods and cones, there is atrophy of the ganglion-cells and other nervous elements in the retina, together with a dwindling of the smaller blood-vessels of both the retinal and choroidal circulations. As often happens, when the highly specialized elements of a struc- ture degenerate, the less highly organized supporting framework of the tissue tends to increase. It will be well for me to quote here what Gowers l wrote of this matter in connection with neuronic abiotrophy of the central nervous system, because it applies so well to the retina in retinitis pigmentosa. He says: "Whenever the nerve elements waste there is always an overgrowth of the interstitial neuroglia, the Hereditary Ocular Degenerations 117 connecting and supporting tissue which lies between them. This overgrowth may be, indeed, on first inspection, the most conspicuous element, and its aspect has led the progress to be termed "sclerosis." I say "its aspect" because there is generally no increase of consistence in the part so changed. This is generally diminished; the interstitial tissue, which looks so fibrous and firm under the microscope, is really softer than the nerve elements that have perished. "The two elements, the neural and the neuroglial, seem to have a common but inverse vitality; it is in consequence of this that the in- terstitial tissue overgrows when the nerve elements decay. The over- growth seems to coincide with the very commencement of the decay, and may be at first the most conspicuous. "It is especially luxuriant where the connective tissue is naturally most abundant about the vessels and at the surface of the spinal cord beneath the pia mater." Having described the pathologic findings in this disease I will now show how well they help us to explain the sequence of the symptoms met with in connection with it. The first symptom a patient complains of in retinitis pigmentosa is night-blindness; this precedes the appearance of any pigmentation. As Nettleship 17 pointed out, the term "retinitis pigmentosa sine pig- mento" "usually signifies nothing more than the initial stage of the ordinary disease." The part of the retina first involved is the peri- macular zone; a ring scotoma is found to precede any contraction of the periphery of the field. Pigmentation of the retina when it makes its appearance is also first seen in an intermediate zone between the macula and the periphery. It is not until the later stages of the affection that the retinal blood-vessels become narrowed and the optic disc acquires its characteristic waxy appearance. In the dark-adapted eye the part of the retina which is most sensi- tive to light is that surrounding the macula. Experiments have shown that its sensibility increases centrifugally with each degree until 10 to 20 from the fovea, where the maximum is reached. On the other side of this maximum the sensibility decreases toward the periphery in approximately concentric circles. Degeneration of the percipient elements of the retina, in the part most acutely sensitive to light, accounts, therefore, for the early occurrence of the night-blind- ness. In a typical case of retinitis pigmentosa the inner border of the ring scotoma corresponds, as a rule, to about the 15 or 10 in perimeter 118 E. TREACHER COLLINS charts. That is to say, the part of the retina in which failure of function commences is that in which its neuro-epithelium first attains its full development. The macular area, together with the nerve- fibers proceeding from it, is both ontogenetically and phylogenetically of late development. Pigmentation of the retina is due to the migration of pigment epithe- lial cells into its substance. The reason why it is such a characteristic feature of the disease we term retinitis pigmentosa is that the disease commences in the rods and cones; the gaps left in the membrana limitans externa by their disappearance form tracks through which the pigment cells can make their way. We know that these pigment epithelial cells physiologically possess the power of ameboid move- ment. When stimulated by light, they throw out filamentous pro- cesses between the outer segments of the rods and cones, and on re- moval of the stimulus retract these processes into the body of the cell. They possess a capacity for positive phototactic movement which is kept in check only by their anatomic relations ; when these are altered by the atrophy of the rods and cones, together with the nerve elements of the retina, so that only a network of neuroglial tissue remains, then the pigment epithelial cells, attracted forward by the stimulus of light, are able to make their way into the innermost layers of the retina, where they accumulate in the lymph-spaces around the blood-vessels and give rise to the characteristic branching patches. The waxy appearance of the optic disc in retinitis pigmentosa, which is different from that met with in any other affection, is attributable to an overgrowth of its neuroglia. In rare cases hyaline bodies, some- times in grape-like clusters, are seen protruding from the surface of the disc. In microscopic appearance and in their reaction to chemical reagents these hyaline bodies are found to resemble those so commonly met with on the inner surface of the elastic lamina of the choroid. These latter are due to some perverted activity of the pigment cells i. e., cells which are derived from the outer layer of the secondary optic vesicle. Cells having a similar embryonic origin are found in connection with supporting neuroglia of the optic nerve. It would seem probable, therefore, that in retinitis pigmentosa, where there is an overgrowth of neuroglia in the optic nerve, the hyaline nodules met with on its surface are due to some perverted activity of the neu- roglia cells. Retinitis pigmentosa is not infrequently associated with other forms of hereditary degenerative conditions, the commonest of these Hereditary Ocular Degenerations 119 being deafness and idiocy. Nettleship 17 estimated that 33 per cent, of persons with retinitis pigmentosa may be deaf, and at least 4 per cent, of deaf-mutes may have retinitis pigmentosa. The deafness in these cases is always bilateral and is never recovered from. Even when accompanied by dumbness it may have been acquired, according to Politzer, as late as the age of seven years. The pathologic changes found in the labyrinth of deaf-mutes are comparable to those found in the retina in retinitis pigmentosa, and may be summarized as de- generation of the neuro-epithelium, atrophy of the nerve-fibers, and a new formation of fibrous tissue. 'It is then highly probable that, as in retinitis pigmentosa, the affection being primarily a degeneration of the neuro-epithelium, which is hereditary, it should be classed as an .abiotrophy. SYMMETRIC FAMILIAL PIGMENTARY MACULAR DEGENERATION. PRIMARY DEGENERATION, OR ABIOTROPHY, OF THE CONES AT THE MACULA De Wecker, in 1868, divided cases of retinitis pigmentosa in two groups: One which occurs in children, with comparatively rapid loss of central vision, and which is frequently associated with mental de- fects; the other, comprising the ordinary cases, beginning with night-blindness early in life, progressing very slowly, the central vision remaining unaffected until late in the disease, and in connection with which mental failure is but rarely met. Nettleship 17 also described atypical cases of retinitis pigmentosa with central changes. He pointed out that the pigmentation in them was in the form of scattered dots, instead of bone-corpuscle- shaped patches; and that the patients, instead of being night-blind, preferred a dull light. Several cases have been recorded of recent years of primary macular pigmentary degeneration, occurring in several members of the same family, often in association with cerebral degeneration, but sometimes without. These cases have been described under the following head- ings: " Family Cerebral Degeneration with Macular Changes" (Batten and Mayou); " Maculocerebral Degeneration (Familial)" (Oatman); "Progressive Familial Macular Degeneration" (Darier). None of these titles is satisfactory. From the two first it would be inferred that the cerebral changes were an essential part of the disease, and from the third that the disease tended to progress to complete loss of sight. I and others have recorded cases which have manifested 120 E. TREACHER COLLINS no mental symptoms, some of them having been kept under observation for several years. The disease, when it commences at the macula, gener- ally remains confined to that region and does not progress beyond it. The reason that the pigment patches in retinitis pigmentosa assume a bone-corpuscle shape is due to the pigment epithelial cells making their way into the lymphatic sheaths around the retinal blood-vessels ; as there are no blood-vessels in the retina at the macula, when the pigment epithelial cells migrate into the retinal tissue in that region they do not form branching patches, but rounded dots. The histologic changes in an eye of a typical case with symmetric pigmentary changes at the macula in each eye have been investigated by Mayou. 23 He found that the sclera and choroid were practically normal, the pathologic changes being confined to the retina. Briefly, they consisted of a complete disappearance of the cones and the neural elements of the retina, together with some increase of the supporting neuroglia and migration of pigment epithelial cells, to a slight extent, into the outermost layers of the retina. Mayou. in commenting on this case, inclined to the view that the primary change was in the ganglion-cells of the retina, and that the disappearance of the cones and the migration of pigment were secondary. Coats, 24 however, in commenting on this case in a later article, wrote very shrewdly as follows: "There is, I believe, no known instance of a disease which first attacks the inner retinal neural elements and then the outer, although instances of the opposite sequence of events might be cited ; nor does destruction of the inner layers from whatever cause produce any consecutive secondary change in the outer, however long the dur- ation of obstruction of the central artery or primary optic atrophy, in which the rods and cones and outer nuclear layer remain permanently intact. " When the general nervous system is affected in connection with this pigmentary degeneration, there is a progressive dementia and paralysis ending in death. After some years of normal development the mental degeneration sets in, accompanied sometimes by epileptic fits; before death the patients become noisy, dirty in habits, and de- velop a spastic condition of the limbs. In two cases examined post- mortem by Dr. F. E. Batten M diffuse degenerative changes were visi- ble microscopically, affecting the ganglion-cells in the cerebrum, cerebellum, and spinal cord. These changes, he says, were similar to those found in amaurotic family idiocy. From the account already given of retinitis pigmentosa, and from Hereditary Ocular Degenerations 121 that which follows of amaurotic family idiocy, it will be seen that this primary pigmentary macular degeneration presents some resem- blances to each of those affections, and also some striking differences. These resemblances and differences are set out in tabular form as follows : Retinitis Pigmentosa Macular Pigmentary Degeneration Amaurotic Family Idiocy Age and prog- ress Commences early in May commence at Onset at age of three life and progresses age of six or not to six months; slowly. until the second de- rapid failure of cade; rapid failure sight; death in two of sight and then years. stationary. Heredity More than one gen- Familial, no racial Familial ; only met eration affected; no proclivity. with in the Jewish racial proclivity. race. Visual defect Night-blindness fol- Central scotoma ; no Central loss of sight lowed by annular contraction of field; early, progressing scotoma; central no night-blindness. to complete blind- vision last affected. ness. Condition of retina Primary affection of Primary affection of Primary affection of bacillary layer at bacillary layer at ganglion-cells, caus- equator; later for- macula; later for- ing white opacity mation of branch- mation of dots of around macula. ing patches of pig- pigmentation. mentation. General ner- vous system Sometimes mental Sometimes demen- Always dementia. weakness, cause tia; ganglion-cells All ganglion-nerve unknown. affected as in am- cells in body in- aur ot i c family volved. idiocy. The eye symptoms in all three affections are due to some innate tendency to degeneration in the cells of the retina. The difference which they present in the three affections is due to the difference in the cells involved. Any one of them may be accompanied by a similar in- nate tendency to degeneration in ganglion-cells of the central nervous system. All three affections may, I suggest, be conveniently classified as varieties of abiotrophy. FAMILY AMAUROTIC IDIOCY (TAY-SACHS' DISEASE). ABIOTROPHY OF THE GANGLION-CELLS OF THE RETINA A considerable amount of evidence has accumulated of recent years as to the pathologic changes met with in the nervous system and retina in cases of family amaurotic idiocy. 122 E. TREACHER COLLINS All writers on the subject are agreed that there is no evidence of in- flammatory changes in the affected parts, and that the disease is due to a primary change in the cells themselves. Gordon Holmes showed that this change was not due to an arrest of their development or to any bacterial toxin. The essential histologic features of the disease are : a progressive loss of the Nissl substance in all the neurons of the body, and the increase of the neuroglia fibril substance to an abnormal degree. A chemical examination of the brain in two cases by Sidney A. Mann showed: (1) A decrease of nucleoproteid, which may be associated with the disappearance of the Nissl substance in the neur- ons; and (2) The increase of simple proteid, which may be correlated with the increase of glial fibrils. Both Gordon Holmes 25 and Sir Frederick Mott 26 attribute the cell changes to some faulty biochemical process in the protoplasm of the cells. The latter sums up his con- clusions on the matter as follows : " The fact that it affects the children of Jewish parents suggests that it owes its origin to some racial inborn tendency to neuronic decay, probably associated with some exciting or predisposing factor con- nected with an altered condition in the chemical composition of the blood, whereby the normal biochemical interaction of the nucleus on the cytoplasm and the environmental lymph on the neuron is interfered with. 'A cell nourishes itself and is not nourished' is as true for the highly complex and specially differentiated nerve cell, with its multiple processes and their arborizations, as for a simple unicellular organism. The nucleus is the trophic center of the nerve-cell, and possesses the specific inherent energy upon which the cell depends for its vital activities and durability. We may, therefore, suppose that this ex- traordinary neuronic regressive metamorphosis is brought about by a conspiracy of morbid factors, viz., an inherent racial lack of specific neuronic energy and some general alteration in the chemical composi- tion of the blood, either by the existence in it of a neurotoxin or the failure of some chemical substance in sufficient quantitj r for the build- ing up of the nucleoproteid substance of the nervous system." The cause of the opacity of the retina, seen around the macula, in these cases was for some time a matter of uncertainty, due to the difficulty in obtaining specimens free from postmortem changes and suitably fixed. Within two hours of death changes in the retina set in, causing it to swell, become rucked, and then present microscopically the appearances of edema or of a hole at the fovea. This edematous change was the most striking feature which I discovered in the first Hereditary Ocular Degenerations 123 specimen of the sort which was examined microscopically, and I at- tributed the opacity seen ophthalmoscopically to edema. Since then fresher material has been obtained, fixed in Zenker 's solution, sections of which have shown a complete absence of any edema, but well-marked changes in the ganglion-cell and nerve-fiber layers. There can now be no doubt that it is the altered condition of the ganglion-cells which give rise to the opacity. Where they are most numerous around the macula, there the opacity is densest. The changes in the ganglion- cells of the retina resemble those found in the ganglion-cells of the nervous system elsewhere. At first they appear somewhat swollen, then there is a gradual progressive loss of Nissl substance, followed by the formation of vacuoles in the cytoplasm, and finally shrinkage or disappearance of the cell. As Coats pointed out, the long continuance of the opacity of the retina around the macula may be correlated with the long time the degenerative change in the cells is going on before they finally disappear. Very different is this to the short duration of the opacity of the retina, similarly situated, in cases of embolism of the central artery of the retina, which is due to a coagulative necrosis of the ganglion-cells, after which they become rapidly ab- sorbed and disappear. Transverse sections of the optic nerve in advanced cases of amau- rotic idiocy show that the nerve-fibers have nearly all disappeared, the few remaining fibers being fine ones and irregular with varicosities. There is some difference of opinion as to the appropriateness of the use of the term abiotrophy as descriptive of the changes met with in family amblyopic idiocy. Sachs 27 says he gladly accepts it as indicat- ing the nature of the changes met with. Gordon Holmes, 25 on the other hand, writes: "The cell changes have not the characters of a simple atrophy; in fact, they seem to be due to an excessive growth of the protoplasm which later undergoes degenerative changes. This fact is not in favor of Sachs' hypothesis that the pathology of the dis- ease can be described by the term abiotrophy (a term suggested by Gowers to represent an inherent defective vitality of the cell), or of Schaff er 's suggestion that it may be explained by Edinger 's ' Ersatz- theorie, ' which assumes that the elements which are inherently feeble undergo degeneration when exposed to the strain of life to which they are not normally resistant." There can be no doubt that the change in the ganglion-cell is a form of hereditary ocular degeneration. The degeneration, as already mentioned, is of a different character to, and of slower progress than, 124 E. TREACHER COLLINS that which takes place when these cells are deprived suddenly of their nutrient supply by occlusion of the central retinal artery. If, as Mott suggests, the degeneration is in part due to the failure in the inherent specific trophic influence of the nucleus of a nerve-cell, upon which the vitality of the whole neuron depends, then the term abiotrophy is as appropriate as any that has been invented under which to classify the affection. Even though the first stage in the trophic disturbance presents the appearance of hypertrophy, the final stage in the process is invariably the premature death and atrophy of the affected cell. HEREDITARY OPTIC ATROPHY. " OPTIC ABIOTROPHY" The occurrence of what was termed "amaurosis" in several mem- bers of the same family was first described by Beer in 1817. Leber 28 published his classic paper on hereditary optic atrophy in 1871. Many cases of the same description have since been recorded, and much has been written on the subject, but, so far as I am aware, no pathologic examination has been made of these cases and we are, therefore, still ignorant as to the real nature of the disease. Gowers, 29 in 1904, described the affection under the heading of "Optic Abiotrophy," and spoke of it as follows: "Since some cases were discerned by Leber, much attention has been given to the form of optic atrophy which occurs in families, sometimes through more than one generation, soon after adult life is attained. Similar cases occur in sporadic form, isolated, as do other family maladies. The facts suggest that the inherent vital energy of these structures is inadequate to maintain their nutrition much be- yond full development, so that they gradually fail and degenerate. They fail from imperfect life, from abiosis, in what may be designated abiotic atrophy, or abiotrophy. The same atrophic failure is met with in other parts of the nervous system, as in Friedreich's disease, and conspicuously in the muscles in the varieties of muscular dys- trophy. " It is noteworthy that even vital failure is often associated with ex- traneous influences. Even in the cases in which the family disposition is most marked, the onset is often the immediate sequel of some ad- ventitious cause. It follows some acute specific disease, or, in males, excessive smoking, and this in cases in which the family tendency is so marked as to compel us to regard the excitant as merely such, an opinion which is confirmed by the slow progress of the atrophy after the cessation of the immediate influence. In such cases the interstitial Hereditary Ocular Degenerations 125 tissue undergoes overgrowth, in consequence of the solidarity of the vital tendency of the two structures, both of which arise from the same embryonal elements. When the vitality of the higher, neural elements fails, that of the residual, neuroglial elements becomes exuberant, and may even display an energy which carries it beyond the strict limits of the neural failure. Thus we are able to understand some features of this form which at first seem mysterious. It must be re- membered, also, that the defect in vital endurance varies in degree and in extent even within the range of the tissue which presents it. How grave it may be we cannot know until it is revealed by time, but the influence of a powerful excitant may at least afford ground for hope, and indicate room for treatment. It should be remembered also that, in such maladies, therapeutic measures, when most effective, may only prevent further failure. " In 1916 J. H. Fisher, 30 without taking into consideration Gowers' views on the nature of this affection, put forward a new hypothesis as to its causation; he wrote as follows: "It has occurred to me that if a disturbance of the pituitary body of temporary duration and moderate degree can be imagined, such a lesion might be adequate to explain the phenomena of Leber 's heredi- tary optic atrophy, in which case the inherited tendency would not lie in a special vulnerability of the macular fibers of the optic nerves, but in a liability of the pituitary body to such limited disorder as I suggest. A priori it is to me much easier to imagine an inherited tendency to disorder of the hypophysis than a family tendency on the part of the papillomacular fibers of the optic nerve to degenerative or inflammatory attacks." The points upon which Fisher based this hypothesis are: I. That cases of bilateral temporal hemianopsia, due to pressure on the chiasma, have been known to develop, in the first instance, a central scotoma. II. That individuals who develop hereditary optic atrophy are often of what Leber described as the neuropathic type. They are subject to frontal headache, vertigo, and epileptiform attacks; they also ex- perience subjective phenomena of light and color. Fisher suggests that these symptoms may be taken as suggestive of pathologic dis- turbance or excessive physiologic activity on the part of the pituitary gland. III. That the affection often coincides in its onset with puberty, or in women, the climacteric period, at which times, Fisher suggests, 126 E. TREACHER COLLINS variations in the size of the pituitary body are most likely to be met with. IV. That glycosuria is sometimes associated with a loss of central vision, similar in some respects to that met with in Leber's disease, and that disorders of the posterior lobe and pars intermedia of the pituitary body is frequently accompanied by glycosuria. V. That lesions of the optic chiasma due to pituitary body enlarge- ment or growth may, in the early stages of the affection, give rise to a very mild papillitis, and that this symptom has also been noticed in the early stages of Leber's disease. While in the later stages of both affections signs of optic atrophy present themselves in the optic disc. VI. That in some cases of the disease which have been examined with the x-rays an abnormal appearance has been observed in the vicinity of the sella turcica. Difficulties present themselves in the acceptance of either Gowers' or Fisher's theory as to the pathology of hereditary optic atrophy. If we regard the disease as a form of abiotrophy, it would be neces- sary to determine the structure in which the degeneration commences. As the failure of sight in the most typical cases is restricted to the central region, it would be most natural to locate it in the ganglion- cells from which the fibers start, which constitute the papillomacular bundle. In diseases in which the ganglion-cells of the retina are known to be affected with degenerative changes, such as embolism of the central artery of the retina, quinin amblyopia, and amaurotic family idiocy, for a time, varying induration in the different affections, an opacity of the retina is seen ophthalmoscopically. No such opacity has been observed in Leber's disease, though there is often, at first, a temporary appearance suggesting edema about the optic disc. That temporary opacity of the retina is not an essential preliminary phenom- enon in the onset of primary atrophy of the optic nerve we know, from its absence in connection with primary atrophy of tabes. In this latter affection we have no certain knowledge as to which part of the affected neuron is primarily involved. One of the most constant characteristics of diseases attributable to abiotrophy is their incurability; there is a degeneration due to loss of vitality, and once lost, it is not restored. There are cases of hereditary optic atrophy on record in which complete or partial recovery has taken place; thus Nettleship writes: "I find records of at least 25 affected persons (22 males, 3 females) Hereditary Ocular Degenerations 127 in 16 genealogies who recovered either perfect or quite useful central vision; minor degrees of improvement are probably rather common. " "In the same genealogy, and even in the same sibship, some may recover and others not. " "A very important feature in these cases is the length of time that may elapse before notable improvement of sight begins, often twelve or eighteen months, and in one case, if we can believe the history, as much as three years." Gowers would probably attribute recovery, or partial recovery, in such cases to variations of intensity in "the adventitious cause," which, he pointed out, in the quotation given above, is necessary, in addition to the family disposition, for the production of this disease. The most tangible factor for consideration in connection with Fisher's hypothesis is the appearances shown by x-ray examination. The table on p. 128 gives the result of examination of the sella tur- cica by x-rays in Fisher's, 30 - 31 Pollock's, 32 and Dr. James Taylor's 33 cases, together with three cases I have had under my own observa- tion, one hereditary and two sporadic. The results of x-ray examinations, which are given in the table, seem to show that there may be some association between the loss of central vision met with in Leber 's disease and changes in the vicinity of the sella turcica. Fisher naturally regards this as affording support to his hypothesis, that the affection is due to changes in the pituitary body. Indeed, it was with the idea of testing his hypothesis that he first undertook these x-ray examinations. So far no well-recognized case of hereditary optic atrophy has been known to develop bitemporal hemianopsia, and we do not know of any hereditary form of pituitary disease, whereas we are well acquainted with bilateral degenerative conditions affecting the nervous system, such as Friedreich's disease, due to atrophy of the motor neurons, a typical abiotrophy. It would seem well, therefore, to consider how Gowers' theory of abiotrophy, applied to Leber 's optic atrophy, might account for changes in the vicinity of the sella turcica, such as are revealed by x-ray examination. Gowers, as quoted above, speaks of overgrowth of neuroglia in the optic nerve in Leber 's disease; this is not the result of direct observation, as the optic nerves in this affection have not yet been examined pathologically. He must have inferred the presence of such overgrowth from the presence of similar over- growth in the nervous system in other forms of abiotrophy. There is, however, ophthalmoscopic evidence which affords support to the view that, associated with atrophy of the nerve elements in this disease, 128 E. TREACHER COLLINS Recorder Sex Age Duration of Affection Results of x-ray Examination Fisher Male 14 2 vrs. Sella turcica shows no departure Fisher Female ll\4 6 mos. from normal. Sella turcica not enlarged, out- Fisher ........ Male 22 3 mos. line not distorted, but the de- pression filled in with something which gives a cellular or honey- comb-like shadow. Sella turcica outline slightly in- Fisher Female \zy 2 5 mos. distinct posteriorly, but it is not enlarged or distorted. Pituitary fossa showed nothing Sporadic case Fisher Female 49 1 wk. abnormal. Seven months later fossa was found to be normal in size and outline, but there was a domed shadow which formed a roof over the sella turcica. Four months later still sella turcica again showed domed shadow roofing completely the fossa. Doubtful enlargement of the Sporadic case Pollock Female 11 6 mos. pituitary fossa and some want of distinction of the posterior clinoid processes. A second examination, made nine months later, showed more marked ap- proximation of the anterior and posterior clinoid processes. Situated a little below the center Pollock Male 8 1 mo. of the sella turcica, a shadow like a small bean, with the concavity downward. Same appearances as in the case James Taylor . . James Taylor . . Treacher Col- lins Male Male Male 52 60 42 A few months 10 yrs. 6 mos. last recorded, that of his sister. Sella turcica long and shallow; clinoid processes certainly not normal. Sella turcica shallow, and clinoid processes reduced in size. Sella turcica distinctly large. Treacher Col- lins Male 24 6 wks. and the opening into it ap- parently wider than usual. The floor of the pituitary fossa is Sporadic case Treacher Col- lins Female 33 14 mos. very shallow and flattened, also irregular. The anterior clinoid processes are unduly pro- nounced, and the posterior processes barely evident at all. No abnormal changes seen in the Sporadic case region of the sella turcia. Hereditary Ocular Degenerations 129 there takes place an excessive formation of neuroglia. After the dis- ease has been in existence for some time pallor of the outer half of the disc commences, and spreads over its whole surface. Leber himself described this pallor as due to increase of the connective-tissue ele- ments of the nerve. If, then, there is an overgrowth of neuroglia at the head of the nerve in this disease, we may be sure that there is also a similar overgrowth along the track of the papillomacular fibers else- where. The greatest thickening of this neuroglia would be expected to occur where the affected fibers in the two nerves came together, at the chiasma. A thickening of the chiasma, due to overgrowth of neuroglia, might press down the pituitary body, just as an enlarge- ment of the latter may press up the chiasma; or might also, in a skiagram of the sella turcica, give rise to the appearance of a roof-like covering to it, or of a bean-shaped body overlying it. All these speculations as to the real nature of hereditary optic atrophy might be cleared up by the pathologic examination of a typi- cal case. The best way to make known the urgent need of pathologic evidence of this description is, I think, to proclaim it to the members of a large congress such as this. DOYNE 's "FAMILY CHOROIDITIS, " OR ABIOTROPHY OF THE RETINAL PIGMENT EPITHELIUM R. W. Doyne 34 described a form of family choroiditis in 1899 and 1910. In his last communication concerning it he summarizes the condition as follows: "It first appears in early adult life, but much more commonly later. It may either affect the disc neighborhood or the macula neighborhood, or the disc macula area. It consists of circular patches of exudation ; these increase during middle age, and at least set up some irritation and pigmentary disturbance, for, though pigment is not always present, in some cases there is a good deal to be seen. During this stage the sight, though affected, is not grossly in- terfered with. In old age the condition passes into atrophy, with a corresponding degree of failure of sight. " He had met with the condition in two families, affecting several members of each, in the same and in different generations. A similar condition in the members of another family, a mother and two daugh- ters, was described by Major Mould 35 in 1910. At the conclusion of his communication in 1910 Doyne wrote: "I am keeping my attention carefully on some of the older cases, and 9 130 E. TREACHER COLLINS I hope, if I live long enough, I may be able to bring before the Society some microscopic sections." Doyne's health failed him in 1913, so that he had to retire from practice, but that year one of the elderly patients with this affection, whom he had been keeping under obser- vation, died, and he obtained the backs of his eyes, which he handed over to me for pathologic examination. In making the examination I had no preconceived notion or theory as to what the condition was and wrote the following description of the histologic appearances which the specimen presented. Mr. Doyne showed the specimen at the Ox- ford Ophthalmological Congress in 1913, and the description of it was published in that year. 36 "In sections through the posterior part of the eyeball in the region of the macula and optic disc are seen the following changes. Situated between the retina and choroid is a new formation of a hyaline sub- stance. It commences on each side of the optic disc close to its margin, and extends inward from it about a distance of two discs ' breadth, and outward a distance of six discs' breadth. Its external surface has a regular contour following natural curve of the choroid. Its inner, or retinal, surface presents several rounded nodular elevations with de- pressions between them. The thickness of the hyaline substance varies, therefore, considerably in different parts. It shows in places very definite lamination, and for the most part is entirely free from cells, although here and there a cell with a flattened nucleus is seen embedded in it. "The choroid external to the hyaline tissue shows marked thinning, and in places complete absence, of its internal capillary layer. The vessels of the outer layer appear, however, abnormally large, but their walls are not thickened. In the choroid, on the outer side of the optic disc, there is a small area of round-cell exudation, but apart from this there are no signs of inflammatory disturbance. Where the hyaline substance is present, the elastic lamina of the choroid or mem- brane of Bruch cannot be satisfactorily differentiated. At the periph- ery of the hyaline substance, on each side, the pigment epithelium can be seen extending for a short distance over its inner surface as a single layer of cells. Large parts of the inner surface of the hyaline substance are, however, devoid of any lining of pigment epithelium, while here and there irregular collections of pigment epithelial cells are met with. The outer surface of the retina has become much disorganized by the formation of the hyaline tissue. The rod-and- cone layer has become entirely destroyed where it is situated, also to Hereditary Ocular Degenerations 131 a very large extent the outer nuclear layer. In some localities the granular layers are thickened, the fibers crossing them being stretched out with spaces between them. The inner layers of the retina show but little change." To this description of the appearances of the sections, I, in 1913, added the following remarks : "The hyaline substance in these sections presents the same histo- logic appearances and staining reactions as the nodules of hyaline commonly met with in a similar situation in many degenerative condi- tions of the choroid. Such nodules are often termed 'Drusen. ' The hyaline continuous substance in this specimen is peculiar in forming such a long layer. In other conditions it is usually in the form of isolated nodules. The ophthalmoscopic changes, known as 'Tay's choroiditis, ' are generally regarded as being due to such nodules. Many different views have been put forward to account for the forma- tion of these hyaline nodules. They have the same characteristics as the elastic lamina of the choroid, and it seems probable that they are, like it, the product of the pigment epithelial cells. Some of the hya- line tissue in this specimen looks very like a number of superimposed layers of the elastic lamina. Further, it seems likely that the primary change was in the pigment epithelium, and that the changes in the choroid and retina around are secondary to the pressure caused by the formation of the hyaline substance." From the above description of pathologic appearances and remarks it will be seen that, in this family affection first described by Doyne, we have to do with a primary degeneration of the cells derived from the outer layer of the secondary optic vesicle, and not with an inflam- matory affection of the choroid. The white appearance seen in the fundus ophthalmoscopically is not due to an inflammatory exudation, but to the formation of hyaline substance by the cells involved, which is, on their part, a degenerative process. A degeneration of this nature handed down from one generation to another, and affecting several members of the same family, may, I suggest, be aptly included in the class of affections described by Gowers as "abiotrophies." The affection is, I think, one more commonly met with than the scant attention it so far has received in ophthalmic literature might lead one to expect. The slow progress of the affection, and the ab- sence of symptoms in its early stages, render its family nature likely to be overlooked. As pointed out by Gowers, though abiotrophies are usually hereditary conditions, sporadic cases of the same nature some- 132 E. TREACHER COLLINS times occur, so it is in this hyaline degeneration of the pigment epithe- lium of the retina. This year I have seen two cases in which the condition was well marked, though no history of failure of sight in other members of their families could be obtained. From what Doyne has said it is evident that the absence of a history of heredity is not suffi- cient evidence to exclude the presence of the disease, as it may be present in other members of the family though unsuspected for many years. HEREDITARY DEGENERATION OF THE CORNEA. ABIOTROPHY OF THE CORNEAL NERVES A bilateral affection of the cornea, starting usually about puberty, and manifesting itself by the formation of opaque nodules in the super- ficial layers, was first described by Groenouw 37 in 1898, under the name " knotchenf ormige Hornhaut-Triibungen. " His description of the appearances in his two cases remains substantially true for the many others which have since been recorded. He says: " The disease con- sists in the development of numerous small, rounded or irregular, gray, discrete opacities in the otherwise clear cornea. The larger opacities attain to a diameter of nearly a % mm., and between these lie much smaller, dust-like gray points; they, for the most part, are situated in the central region of the cornea, and rather avoid the marginal zone. The larger spots slightly raise the epithelium and thus give a certain minute irregularity to the surface. The opacities appear by degrees without any inflammatory reaction, and may re- main for years unchanged." The hereditary nature of the affection does not seem at first to have been noted. In 1902 Marcus Gunn 38 recorded four cases in a family of ten. Spicer, 39 in 1904, described a family in which three generations were affected. The following is the pedigree of a family, some of the members of which I have had under my own observation, in which four generations were affected. In none of the cases recorded has there been any evidence to show that the affection was of a syphilitic nature. Several observers have described the histologic appearances of small pieces of the cornea, either scraped off the surface or trephined. Paderstein had the op- portunity of examining the whole eye in a case, it having been removed after death from a patient who died from suppurative meningitis following an injury to the head. Hereditary Ocular Degenerations T 133 T" ~T >) 6" O III 9 6 IV 6 The changes found are situated in the basal cells of the epithelium, between the epithelium and Bowman's membrane, in Bowman's membrane itself, and in the superficial layers of the parenchymatous tissue of the cornea. Paderstein 40 said that, on first looking at the specimens, one gets the impression that the disease affects primarily Bowman's membrane; closer inspection, however, shows that the primary seat of the disease is in the basal epithelium. He considers that, through a degenerative process taking place in the epithelial cells, the nuc'eus is destroyed and the protoplasm changed into a hyaline substance. This hyaline substance tends to accumulate on the sur- face of Bowman 's membrane. Fuchs, 41 in his most recent article on the subject, states that: "The main points are that in this affection two primary changes are present, i. e., the deposition of a substance that is often in layers immediately under the epithelium, and gives an acidophile reaction, and a second basophile, granular substance in the cornea proper. " He is inclined to think that the acidophile is a later product than the basophile substance, since the latter has been found 134 E. TREACHER COLLINS in all the reported cases, while the former has not been always present. He describes as accessory changes the alteration in the epithelium, the thinning and destruction of Bowman's membrane, and the separation, swelling, or destruction of the corneal lamellae. Fuchs considers the affection to be of the nature of a dystrophy, and comparable to other similar processes found in old age, as the result of disturbance of general nutrition or, as a result of interference with the internal secretion of certain glands, as in myxedema. Besides the nodular opacities above described, hereditary degenera- tion of the cornea may take on the appearance of a trelliswork, or lattice-like opacity, confined, as in the nodular variety, to the central part of the cornea and to its anterior layers. The hereditary nature of the affection was first pointed out by Haab, 42 who met with it in a lad aged sixteen, and also in his maternal aunt and uncle. Dimmer re- corded three cases in two brothers and a sister. Freund 43 described 15 cases in two families seven in one and eight in the other, in four generations. That the two forms of hereditary degeneration of the cornea, the nodular and the lattice-like, are really only different manifestations of the same affection, was demonstrated by Doyne and Stephenson, 44 who wrote as follows: "The two diseases, then, agree- in several par- ticulars as, for example, that they begin at about the period of puberty; that they are accompanied by insignificant signs of inflam- mation; that they are slowly progressive; that they probably repre- sent not an inflammatory but a degenerative process. Then, lastly, there is the fact that the sensitiveness of the cornea, particularly as regards the central region, may be impaired; and, finally, that both conditions tend to run in families." They record seven cases of bi- lateral central degeneration of the cornea in three generations of a family ; in some of these cases the disease belonged to the lattice-like and in others to the nodular variety. It will be seen, then, that these degenerative, bilateral diseases of the cornea belong to the same class of ocular affections as those already de- scribed in this paper, and correspond with those degenerations met with in other parts of the body, attributed by Gowers to premature loss of vital force, or abiotrophy. The pathologic investigations which have been made, though enabling us to classify the disease as a degen- eration, do not supply us with sufficiently definite evidence to deter- mine in which structure in the cornea the degeneration primarily starts. Two points in the clinical history of these affections suggest Hereditary Ocular Degenerations 135 that possibly the nerves of the cornea might be the primary seat of the disease. Fuchs, in describing his nodular cases, spoke of the superfi- cial sensitiveness of the cornea being lessened. Jacqueau described a family in which eight cases of lattice-like variety were met with, and in whom the sensibility of the cornea to touch was diminished. It would seem most probable that an opacity occurring in a number of different cases in the form of a meshwork, the lines composing which, by focal illumination, look like glass thread (Haab), or birch- twig-like branches radiating from the periphery toward the center (Freund), must have some anatomic basis. It is clear, from the de- scription of the cases, that these lines do not represent tracks left by blood-vessels. In no stage of the disease does the cornea become vas- cularized, and its peripheral parts always remain clear and free from lines. Any tracks left by blood-vessels would necessarily extend out to the margin of the cornea, to join the vessels from which they were originally derived. The only other anatomic structure we know of in the cornea presenting the appearance of branching lines is its nerve- fibers. The most recent investigations into the arrangement of the nerve- fibers in the cornea are those of Dogiel, 45 who adopted a method of staining them with methylene-blue. According to him, two-thirds of the nerve-trunks which enter the cornea pass into the anterior lamellas, where they form what is termed the primary or fundamental plexus; the remaining third are distributed to the posterior layers. The nerves, from which the central portion of the fundamental plexus is derived, enter the cornea at a deeper level than those which consti- tute its peripheral parts. The fundamental plexus is composed of a network of fibers in the anterior layers of the stroma, where the fibers meet, forming nodal points at which nuclei are often to be seen; these are now regarded as belonging to the delicate investing sheaths of the nerves, and not, as formerly, to ganglion-cells. The spaces left be- tween the fibers are traversed by interlacing, delicate fibrils. From the fundamental plexus fibers pass forward, through channels in Bow- man 's membrane, and on its outer surface form the subepithelial plexus. From the subepithelial plexus fibrillse pass in between the epithelial cells, terminating either as round or pyriform end-bulbs or as terminal fibrillse. The fibrillse of the fundamental plexus, lying between the lamellae of the cornea, come into close relation with the corneal corpuscles, and it has been a matter of much discussion as to whether or not there is any direct continuity between the cells and the fibrillse. 136 E. TREACHER COLLINS A comparison of this description of the corneal nerves with the dis- tribution of the opacities in the cases of hereditary degeneration of the cornea suggests much similarity of arrangement. The nerve-fibers form a plexus in the anterior layers of the substantia propria, a sub- epithelial plexus, and terminate in end-organs situated among, the epithelial cells. In hereditary degeneration the pathologic changes are found in the same situations. The central part of the fundamental plexus and of the subepithelial plexus, which latter is constituted of fibers derived from the former, take origin from different nerve- trunks to those from which the peripheral parts of these plexuses pro- ceed. Hereditary degeneration of the cornea is confined to the central part, and there also anesthesia is noted to have been most marked, i. e., in a region which receives its nerve supply from one set of nerves. The fundamental plexus is composed of a network of fibers crossing and intersecting one another, similar in appearance to the arrangement of the lines of opacity met with in the lattice-like type of hereditary de- generation of the cornea. In hereditary degenerations of nervous structures in other parts of the body, associated with the atrophy of the nervous tissue, there are always changes in the surrounding supporting fibrous tissue. If, as I suggest, this hereditary degeneration of the cornea is a primary dystrophy of its nerve-fibers and nerve end-organs, then we should ex- pect to meet with thickening of the neuroglia tissue surrounding the nerves, some hyaline degeneration in it, and a formation of spaces filled with coagulum representing those previously filled by the nerve tissue. These changes resemble those which have been described as met with in cases of nodular degeneration of the cornea. It is possible that the different appearances in the arrangement of the opacity, which has been met with clinically in these diseases, may be accounted for by a difference in the part of the nervous system of the cornea which is primarily attacked. For instance, if it started in the fundamental plexus in the substantia propria, we should expect the opacity in the first instance to be of the lattice-like variety; whereas if it started in the end-organs in the epithelium, we should expect it to start in the form of opaque dots or nodules. For any final decision as to the primary seat of this disease, further research is necessary. I would suggest that the employment of Dogiel's method of methylene-blue staining to a fragment of an affected cornea, removed either by scraping or by trephining, might be of considerable assistance in clearing up the problem. Hereditary Ocular Degenerations 137 TREATMENT In dealing with the treatment of these various forms of hereditary ocular degeneration it is first well to point out that a medical man is called upon to certify that life is extinct, as well as to prescribe reme- dies for various ailments. Every medical student has to learn the signs of death in an individual, so it is well for an ophthalmic surgeon to learn to recognize the signs of death in a tissue of that organ of the body with which he specially deals. The recognition that these maladies are due to premature death of the tissues involved does not offer much hope for their alleviation by therapeutic measures. It may, however, save us from trying to revivify dead matter by iodid of potassium, vapor baths, or other measures of that description, which only raise illusive hopes in our patients, cause needless expenditure of money on their part, and are doomed to failure. Bichat defined life as "the sum of the forces which resist death," and though, like all other definitions of life which have been attempted, it leaves something to be desired, it is useful in connection with the subject now under consideration. One of the forces which resist death is inherent, and varies in its duration and degree. Though at some future date it may be accounted for by physicochemical changes, at present we know too little concerning it to attempt to control it. Other forces which resist death are connected with the environment of the organism or of its tissues. It is essential that it should have an adequate and suitable supply of nutrient material. If the vital force in a tissue is inherently weak, the adequate supply of suitable nutrient material may delay its final extinction; which, on the other hand, might be accelerated by the presence of toxic substances in the fluids in which the tissue is bathed. In these hereditary degenerations, to delay the failure of vital force by maintenance of nutrition, and to re- move any source of toxemia, is all we can hope to effect by medicinal measures. In some of the affections dealt with operative procedures may alleviate some of the inconvenience caused by them. Thus abiotic cataracts can be removed and the sight restored. In bilateral ptosis, the removal of a strip of the tarsal plate will do away with much of the discomfort which drooping of the eyelid gives rise to. In cases of retinitis pigmentosa trephining operations, by producing a state of hypotony, have caused dilatation of the retinal vessels, and tended to delay the atrophic process. In some cases of nodular opacity of the cornea its anterior layers have been scraped away or excised by a trephine, with some slight improvement of sight. 138 E. TREACHER COLLINS REFERENCES 1. Cowers, Sir William: The Lancet, April 12, 1902. 2. Cowers, Sir William: Brit. Med. Jour., July 12, 1902. 3. Paget, Sir James : Lectures on Surgical Pathology, 4th Ed., 1876, pp. 70 and 72. 4. Metchnikoff, E.: The Prolongation of Life. Eng. Trans., 1907. 5. Nettleship, E.: Bowman Lecture, Trans. Ophth. Soc. U. K., 1909, xxix. 6. Collins, E. Treacher: Trans. Ophth. Soc. U. K., 1915, xxxv, 371. 7. Fuchs, E. : Arch. f. Ophth., 1890, xxxvi, i, 234. 8. Collins, E. Treacher: Trans. Ophth. Soc. U. K., 1909, xxix, 225. 9. Beaumont, W. M.: Trans. Ophth. Soc. U. K., 1900, xx, 258. 10. McMullen and Hine: Brit. Jour. Ophth., 1921, v, 337. 11. Wilbrand and Saenger: Neurologic des Auges, 1900, i, 117. 12. Ayres: Amer. Jour. Ophth., 1896. 13. Altland: Arch. Ophth., 1909, 296. 14. Heuck: Klin. Monats. f. Augenh., 1879, xvii, 253. 15. Lawford, J. B.: Trans. Ophth. Soc. U. K., 1888, viii, 262. 16. Collins, E. Treacher: Trans. Ophth. Soc. U. K. 1919, xxxix, 165. 17. Nettleship, E.: Roy. Lond. Ophth. Hosp. Rep., 1907-8, xvii. 18. Wagenmann: Arch. f. Ophth., 1891, xxxvi, iv. 19. Lister, Sir William: Roy. Lond. Ophth. Hosp. Rep., xv, 258. 20. Stock, W.: Klin. Monats. f. Augenh., 1908, xlvi, 225. 21. Ginsberg: Klin. Monats. f. Augenh., 1908, xlvi, 1. 22. Suganama: Klin. Monats. f. Augenh., 1912, 1, 175. 23. Batten, Dr. F. E., and Mayou, M. S.: Proc. Roy. Soc. Med., Ophth. Sec., viii, 70. 24. Coats, G.: Proc. Roy. Soc. Med., Ophth. Sec., 1916, ix, 219. 25. Holmes, Dr. Gordon: Brain, 1906, xxix. 26. Mott, Sir Frederick: Arch. Neurol., 1907, iii, 219. 27. Sachs, B.: Jour. Nerv. and Ment. Dis., 1903, xxx, 1. 28. Leber: Arch. f. Ophth., 1871, xvii. 29. Gowers, Sir William: Medical Ophthalmoscopy, 4th Ed., 1904, 283. 30. Fisher, J. H.: Trans. Ophth. Soc. U. K., 1916, xxxvi, 298. 31. Fisher, J. H.: Trans. Ophth. Soc. U. K., 1917, xxxvii, 251. 32. Pollock, W. B.: Trans. Ophth. Soc. U. K., 1917, xxxvii, 247. 33. Taylor, Dr. James: Brit. Jour. Ophth., 1919, iii, 193. 34. Doyne, R. W.: Trans. Ophth. Soc. U. K., 1899, xix, 71; 1910, xxx, 274. 35. Mould, Major G. T.: Trans. Ophth. Soc. U. K., 1910, xxx, 189. 36. Collins, E. Treacher: Ophthalmoscope, 1913, ix, 537. 37. Groenouw: Arch. f. Ophth., 1898, xlvi, 85; Arch. Ophth., 1890, 245. 38. Gunn, Marcus: Trans. Ophth. Soc. U. K., 1902, xxii, 97. 39. Spicer, W. Holmes: Trans. Ophth. Soc. U. K., 1904, xxiv, 42. 40. Paderstein, R.: Klin. Monats. f. Augenh., 1909, xlvii, 159. 41. Fuchs, E.: Arch. f. Ophth., 1915, Ixxxix, ii. 42. Haab: Zeitschr. f. Augenh., 1890, 235. 43. Freund: Arch. f. Ophth., 1903, Ixxxvii, 377. 44. Doyne and Stephenson: The Ophthalmoscope, 1905, iii, 213. 45. Dogiel: Anatom. Anzeiger, 1890, v, No. 16. Hereditary Ocular Degenerations 139 DISCUSSION PROF. C. E. FINLAY (Havana, Cuba): In connection with Mr. Collins' interesting paper I want to state that in Cuba I have had opportunity of observing a good many of these cases. Congenital cataract is frequent; also retinitis pigmentosa, post-natal cataract, and the lattice-like degeneration. In most of these cases we have been able to see a certain amount of hereditary influence. That is especially marked in retinitis pigmentosa and post-natal cataract. We have a province in Cuba which before we had railroads was completely isolated, and there we have had a number of intermarriages in the same family, cousins marrying cousins, uncles marrying nieces, etc., so that the number of cases of congenital cataract is greater there than in the rest of the island. In one family cataract was observed in seven different mem- bers. In this same province a Chinaman married a white woman, and they had six children, five of whom had congenital cataract. As regards the lattice-like and nodular opacities, I have been able to observe them in the same family. I remember a mother, three daughters, and a niece, all of whom had the nodular variety or the lattice-like opacities. In all of these cases it was limited to the female members of the family. DR. F. H. VERHOEFF (Boston, Mass.): The term "abiotrophy," I take it, implies something inherent in the cell which causes it to die, irrespective of any external influence. It seems to me that the term has no advantage over the term with which we are more familiar, and that is "premature senility." The term "premature senility" would not necessarily mean immediate de- generation, and we know that senile changes do not always consist of death of the cells, but sometimes of hyperplasia. Mr. Collins' hypothesis is an attrac- tive one as regards senile cataract. In cataracts definitely known to be due to disturbance of nutrition the opacities are different from those in senile cataracts. They begin in the posterior cortex whereas those of senile cata- racts begin as peripheral strise. A typical senile lens, however, is a sclerosed lens, hence a senile cataract does not represent premature senility of the lens as a whole. We do, however, occasionally see sclerosed lenses in younger people. I recently saw a man of fifty who had a sclerosed lens such as you would expect in a man of seventy or eighty. In regard to Doyne's choroiditis, I understand Mr. Collins regards this as an exaggerated form of Tay's choroiditis. The changes in this are primarily proliferative in nature; they indicate not merely death of the cells, but that the pigment cells undergo proliferation. The hyaline material I think is produced by secretion of the cells, as Coats pointed out. So in this condition you see the term "premature senility" would be better than "abiotrophy." In regard to the treatment of some of these conditions I should like to suggest that it would be well to try the x-ray. We know that the latter in weak doses will stimulate resting cells, and in stronger doses will destroy pro- liferative cells. About a year ago I began to employ it in retinitis pigmentosa. A sufficient time has not elapsed to tell whether or not it has been of real benefit, but it certainly has done no harm. The difficulty has been to decide upon the dosage and frequency of exposure. 140 E. TREACHER COLLINS DR. E. E. BLAAUW (Buffalo, N.Y.): Since the previous Congress we have made certain advances in our -knowledge of the formation of cataract, and I think the term "abiotrophy " is an excellent one. The first lenticular changes appear at the age of twenty. If we dilate the pupils, we will find spots in 20 per cent, of eyes, which will increase in extent and intensity and progress to senile cataract. The changes appear in the cortex, at the place where outer and middle third of the radius meet (the coronary cataract of Vogt). With the slit lamp also can be demonstrated convincingly that these earlier cortical opacities do not appear directly below the capsule but always at a certain distance away from it. As a rule, senile cataract does not begin in the posterior cortex. I agree with Mr. Collins that in many of these cases we find heredity plays an important role. DR. GEORGE F. LIBBY (Denver, Col.) : We owe much to Edward Nettle- ship and his colleagues for putting the subject of ocular heredity on such a firm foundation; and I think it is a very happy circumstance that one of Nettleship's co-workers should bring before us this notable paper. Reading Mr. Collins' paper carefully in the presession volume I felt that at last we had a nomenclature that was satisfactory. I have not been fully satisfied with the rather hazy terms we have used in describing this condition. In reading the conclusions of the paper I felt that a little more hope was held out in the matter of hereditary degeneration perhaps more than the author has indicated in the summary of his paper just presented. At any rate, we get a definite idea as to what is actually hopeless, and what we may so represent to our patients. It seems to me that in the conditions which Mr. Collins has described we should look out particularly for the hygiene of such patients. I think they deserve a little more care, direction, counsel, and caution along hygienic lines than the majority of patients. DR. EDWARD JACKSON (Denver, Col.) : I feel that Mr. Collins has done us a real service in tracing the line of communication between the widely separ- ated individual conditions that he has grouped, such as ptosis, ophthalmo- plegia, Leber's disease, pigmentary degeneration of the retina, and others that we have thought of separately, not connected with each other. He certainly has given a new view with reference to these conditions, although the new view that we first get may be different from the final view. There are two or three points that I think are illustrated in the discussion. One of them has just been referred to, and that is the hopelessness. It has always been assumed that death of tissue is a hopeless condition. It is hope- less after it has occurred, but the family tendency in that direction need not by any means be hopeless, and, as I think Mr. Collins mentioned, and as the last speaker has indicated, it is rather an incentive to study more closely the conditions which hasten or retard the death of the tissue in premature senility, or abiotrophy. As to the connection between heredity and these affections, I can conceive that as the somatic death of the individual is hastened or retarded by certain influences, so the tendency to early death of the cell tissue, a degeneration that is not hereditary, may be so influenced. There may be a tendency to early Hereditary Ocular Degenerations 141 death of certain tissues of the eye, but that does not entirely remove retinitis pigmentosa from syphilitic disease. They are often confused, and the syphilis may have been the cause in one patient, of tendencies that are similar to the hereditary tendencies of another patient. In this connection I wish to refer to Leber's disease. It has been assumed very generally that it is a primary disease of the optic nerve in patients with a hereditary tendency. One case that I saw about thirty years ago (the only case I have ever seen in the beginning), and that I have heard from within a very few years, has gone through his life giving the ordinary history of hereditary optic atrophy. That patient entirely deceived me by lying about his family history, but one of my colleagues knew the family and quickly traced the history he knew the man's ancestors had been similarly affected, so that with the subsequent course of the case I was able to place it in that connection. That case illus- trated the fact that, even if we have not an enucleated eyeball to study with the microscope, we have the facilities to study the living eye with the ophthal- moscope. In that case the patient ran through a course of central retinitis with some small hemorrhages, not marked, confined entirely to the macula, and ending with an atrophy of the optic nerve corresponding to this central scotoma, with no visible change in the macula after the first few weeks or months. Now I can conceive, taking that for an illustration, that some temporary condition to which that family undoubtedly was extremely sensi- tive may have appeared in that young man to start a local process in the retina which gave the picture of Leber's atrophy. So, while we have connected these different conditions with tissue death, and that is right, yet I think treatment is valuable. It does not render them hopeless, and it gives to us not only a good ground for prognosis, but leaves us a wide field for study, with the hope that in the future the family perhaps may benefit from our labors. DE. MARY BUCHANAN (Philadelphia) : About 1904, a Hebrew woman who had retinitis pigmentosa, brought her infant with amaurotic family idiocy to the Polyclinic Hospital. The child died of pneumonia and the mother dis- appeared, so it was impossible to follow up the history. In another case, a child had been under treatment in the nervous clinic of the University Hospital for spastic diplegia due to hereditary lues. As there was no thought of an eye condition, the child was not referred to the eye clinic. The Wassermann was faintly positive for the baby and the father; the mother's was negative. The child was given mercury but did not im- prove. I saw the patient when two years five months old. The macular picture was lacking, and the vessels were almost normal in size, but the discs were white. The child was blind and idiotic. The spasticity of the lower limbs persisted, although the rest of the body was flaccid. A second child, then six months old, was healthy. DR. WILLIAM EVANS BRUNER (Cleveland, Ohio) : I desire to add merely a few words in regard to one point brought out by Mr. Collins x-ray exami- nation in hereditary optic atrophy. The essayist refers to the work of Mr. Fisher along this line. His results were first published in 1916. In 1912, or four years earlier, I read a paper before the American Ophthalmological 142 E. TREACHER COLLINS Society upon "Hereditary Optic Atrophy, with X-ray Findings." 1 The paper pretends to give no new theorj', but does show some points of interest and especially one the x-ray findings which suggest the advisability of future study along this line in other cases of the same and allied diseases. The patient, a man aged thirty-six, was seen by Dr. de Schweinitz, who con- curred in the diagnosis and wrote: "I do not recall that I have before x-rayed a patient with this type of optic nerve atrophy, but certainly the stereoscopic x-ray plates show marked thickening either in the sphenoid region or in the neighborhood of the sella, and it occurs to me that this lesion, whatever it may be, has something to do with the optic nerve disease." Dr. Spiller, of Philadelphia, made a neurologic examination, confirmed the diagnosis and adds: "The x-rays show a projection upward of the floor of the sella turcica and suggest that the pituitary body may have its function impaired in this way. I do not know in how many cases of family optic atrophy x-ray plates have been made." X-ray plates were made of a sister who had the disease and of a nephew who from the history also probably had it. By way of comparison, plates were made also of his mother and a sister who did not have the disease, and their plates showed nothing abnormal. Later he saw Dr. Harvey Gushing, who also agreed with the diagnosis, though the subsequent history would indicate that it was an atypical case. I closed the paper with the "hope that other patients presenting similar symptoms may be subjected to like x-ray examinations." I have not had the opportunity of seeing another case of this disease since that time and have naturally been much interested in the results of such examinations by other observers. MR. E. TREACHER COLLINS (closing) : First of all I would like to congratu- late Prof. Finlay on having such a fine field for pathologic investigation of hereditary diseases as Cuba. I hope we may soon hear from him of a case of hereditary optic atrophy on which he has been able to perform a pathologic examination. I am also interested in his cases of degeneration of the cornea in which some members had the nodular and others the lattice-like type. That helps to confirm the theory that the two are but different manifestations of the same affection. Dr. Verhoeff takes exception to the term "abiotrophy" he prefers "pre- mature senility." Premature senility seems to me to imply something to do with old age, while some of the cases I brought before you began quite early in life, for instance, the amaurotic family idiocy. It does not seem correct to speak of senility, even premature senility, in connection with a disease beginning early in life. Again, the term "abiotrophy" goes farther and gives more the idea that Sir William Gowers had in mind in using it that is, a loss of some vital energy. Dr. Verhoeff also takes exception to the hyaline sub- stance met with on the inner surface of the choroid being regarded as a degen- eration. He regards it as due to proliferation. The condition is most cer- tainly a degeneration in function even if the cells do not absolutely perish. 1 Trans. American Ophthalmological Society, 1912; and Archives of Ophthal- mology. 1912, vol. xl, p. 435. Hereditary Ocular Degenerations 143 Dr. Blaauw, I am glad to hear, agrees with me in liking the term "abio- trophy." He also agrees that the senile cataract begins in the cortex. Dr. Libby says the recognition of these cases helps us in our statements to patients. I quite agree with that. Since I came to regard these cases from my present point of view it had given me much confidence in speaking to patients as to prognosis and of those precautionary measures they should take in regard to nutrition, etc. I feel I can speak with more confidence. Dr. Jackson compared retinitis pigmentosa with a syphilitic choroido- retinitis. They are often very similar ophthalmoscopically. We know that in syphilitic choroiditis the primary change is vascular; it is a change in the capillary layers producing secondary degeneration of the rods and cones, not a primary degeneration of those structures. I congratulate Dr. Jackson on his optimistic outlook in treatment of these conditions. I think Dr. Buchanan's case must have been one of amaurotic family idiocy from the account she gives of it. Dr. Bruner spoke of z-ray findings in a case of hereditary optic atrophy. I quote a number of cases in my paper, and have learned from Dr. Zentmayer that he also reported a case, some of them with slight changes, and others without. In cases of abiotrophy we should expect overgrowth of fibrous tissue. The changes seen in the x-ray picture might be due to a thickening of the chiasma pressing down on the pituitary body instead of the pituitary body pressing up on the chiasma. BITEMPORAL CONTRACTION OF VISUAL FIELDS IN PREGNANCY PROF. C. E. FINLAY Havana, Cuba On February 15, 1919, a case was sent to me in consultation which gave rise to the investigations which form the subject of this paper. Its clinical history was as follows: L. E. Fig. L E. P. M., February 15, 1919. Mrs. E. P. M., aged twenty-four years, a leading society lady, in the eighth month of pregnancy, had suffered a month previously a severe attack of influenza. After recovery she had developed a series of seizures of a cataleptic nature, during which she could not move, though perfectly con- scious of what was going on around her. My examination of her eyes re- sulted as follows: Corneae and conjunctivse normal. Media clear. Pupillary reactions normal. Fundi: Slight contraction of retinal arteries and dilatation of retinal veins. Visual acuity (each), 20/20. Visual fields: Temporal contraction (more pronounced on right side) for white, with marked concentric contraction for colors, the red field being larger than that for blue, there being also a crossing of the limits of the color fields on the left side (Fig. 1). 144 Bitemporal Contraction of Visual Fields in Pregnancy 145 I concluded that there exists a hypophyseal compression of the chiasm, but was at a loss as to whether this was due to a hypophyseal tumor or to an enlargement of the hypophysis in connection with preg- nancy, and as to whether the cataleptic seizures were due to the en- largement of the hypophysis or of a hysteric nature. The further history of this case has no particular bearing on this paper. The seizures continued after confinement, and some of the experts who later saw the patient thought there was some endocrinic disturbance with hysteric manifestations. But the study of the case made me seek to determine whether the normal hypertrophy of the pituitary body which takes place in connection with pregnancy was of such a R.E. Fig. 2. Case I. E. E., July 10, 1920. degree as to determine changes in the visual fields. Through the courtesy of Professor Bustamante, in charge of the Maternity Clinic of the General Calixto Garcia Hospital, I proceeded to examine the visual fields of a number of women awaiting confinement, selecting only cases that presented no general complications, with normal eye- grounds and perfect visual acuity. The following are the reports of the 31 cases examined: CASE I. E. E., white, aged twenty, Cuban. Pregnancy, eight months. Urine normal. Fundi normal. Visual acuity, 2Q /20. Visual fields: Marked contraction more marked in temporal half; more pronounced on left side (Fig. 2). 10 146 C. E. FlNLAY CASE III. J. F., Cuban, mulatto, aged thirty-six. Nine months pregnant. Urine: No albumin; specific gravity 1000. Visual acuity (each), 20/20. Visual fields: Marked bitemporal contraction (Fig. 3). This patient had a normal labor on August 16, 1920, and a second examination ten days later showed a slight reduction in the bitemporal defects. L. JB. 12 R.E. Fig. 3. Case III. J. F., July 10, 1920. CASE IV. L. A., Cuban, negress, aged sixteen. Nine months pregnant. Urine: No albumin; specific gravity 1011. Fundi normal. Visual acuity (each), 20/20. Visual fields: Marked bitemporal contraction (Fig. 4). R.E Fig. 4. Case IV. L. A., July 13, 1920. Bitemporal Contraction of Visual Fields in Pregnancy 147 CASE VII. C. C., Cuban, mulatto, aged twenty-nine. Eight months pregnant. Urine: Trace albumin; specific gravity 1020. Fundi normal. Visual acuity (each), 20/20. Visual fields: Very pronounced concentric contraction, greater in temporal half (Fig. 5). L. &. Fig. 5. Case VII. C. C., July 19, 1920. CASE VIII. C. V., Cuban, mulatto, aged thirty-seven. Nine months pregnant. Urine: No albumin; specific gravity 1031. Fundi normal. Visual acuity (each), 20/20. Visual fields: Marked bi temporal contraction (Fig. 6). fLK Fig. 6. Case VIII. C. V., July 15, 1921. 148 C. E. FlNLAY CASE X M. C., white, aged thirty-eight. Eight months pregnant. Urine: No albumin; specific gravity 1024. Fundi normal. Visual acuity (each), 20/20. Visual fields: Marked bitemporal contraction (Fig. 7). L. S. 120 ft.". Fig. 7. Case X. M. C., July 17, 1921. CASE XI. C. G., Cuban, mulatto, aged twenty-eight. Eight months pregnant. Urine: No albumin; specific gravity 1016. Fundi normal. Visual acuity, 20/20. Visual fields: Moderate bitemporal contraction (Fig. 8). L.S. j, R.K Fig. 8. Case XI. C. G., July 17, 1921. Bitemporal Contraction of Visual Fields in Pregnancy 149 CASE XIII. M. C., Cuban, white, aged eighteen. Nine months pregnant. Urine: Trace albumin; specific gravity 1012. Fundi normal. Visual acuity (each), 20/30. Visual fields: Marked bitemporal contraction (Fig. 9). L. & R.K Fig. 9. Case XIII. M. C., July 22, 1921. CASE XIV. A. L, Cuban, negress, aged seventeen. Eight months preg- nant. Urine: No albumin; specific gravity 1012. Fundi normal. Visual acuity (each), 20/20. Visual fields: Moderate bitemporal contraction (Fig. 10). L. ff. R.E. 210' 370" Fig. 10. Case XIV. A. L, August 21, 1921. 150 C. E. FlNLAY CASE II. J. G., white, Spanish, aged twenty-two. Nine months pregnant. Urine: No albumin; specific gravity 1020. Fundi normal. Visual acuity (each), 20/20. Visual fields: Practically normal. CASE V. A. G., Cuban, negress, aged sixteen. Seven months pregnant. Urine: Trace albumin; specific gravity 1015. Fundi normal. Visual acuity (each), 20/20. Visual fields: Bitemporal contraction. CASE VI. R. G., Cuban, white, aged twenty-one. Nine months pregnant. Urine: Trace albumin; specific gravity 1023. Fundi normal. Visual acuity, 20/20. Visual fields: Very slight contraction (R); slight contraction (L). CASE IX. G. S., Cuban, negress, aged thirty-seven. Nine months preg- nant. Urine: No albumin; specific gravity 1018. Fundi normal. Visual acuity (each), 20/20. Visual fields: Moderate bitemporal contraction. CASE XII. M. S., Cuban, white, aged fourteen. Five months pregnant. Urine: Trace albumin; specific gravity 1016. Fundi normal. Visual acuity (each), 20/20. Visual fields: Slight temporal contraction (R); moderate temporal contraction (L). CASE XV. F. A., white, aged twenty-three. Nine months pregnant. Urine: Trace albumin; specific gravity 1030. Fundi normal. Visual acuity, 20/20. Visual fields: Practically normal. CASE XVI. S. A., white, aged twenty-five. Nine months pregnant. Urine: No albumin; specific gravity 1022. Fundi normal. Visual acuity, 20/20. Visual fields: Slight bitemporal contraction. CASE XVII. V. A., Cuban, negress, aged eighteen. Nine months preg- nant. Urine: No albumin; specific gravity 1005. Fundi normal. Visual acuity, 20/20. Visual fields: Slight bitemporal contraction. Bitemporal Contraction of Visual Fields in Pregnancy 151 CASE XVIII. Cuban, mulatto, aged thirty-one. Nine months pregnant. Urine: No albumin; specific gravity 1030. Fundi normal. Visual acuity. 20 /20. Visual fields: Practically normal. CASE XIX. C. H., Cuban, negress, aged twenty-eight. Nine months pregnant. Urine: No albumin; specific gravity 1012. Fundi normal. Visual acuity, 20 /20. Visual fields normal. CASE XX. G. G., Cuban, negress, aged thirty-one. Nine months preg- nant. Urine normal. Fundi normal. Visual acuity, 20/20. Visual fields: Slight bitemporal contraction. CASE XXI. J. B., Cuban, mulatto, aged thirty-nine. Nine months pregnant. Fundi normal. Visual acuity, 20/20. Visual fields: Moderate bitemporal contraction. CASE XXII. F. I., Spanish, aged twenty-five. Nine months pregnant. Urine: No albumin; specific gravity 1012. Fundi normal. Visual acuity, 20/20. Visual fields: Slight bitemporal contraction. CASE XXIII. C. F., Cuban, negress, aged sixteen. Nine months preg- nant. Urine: No albumin; specific gravity 1010. Visual acuity, 20/20. Visual fields: Slight temporal contraction (R). CASE XXIV. P. R., Spanish, aged thirty-six. Eight months pregnant. Urine: Trace albumin; specific gravity 1023. Fundi normal. Visual acuity, 20 /20. Visual fields: Slight temporal contraction (L). CASE XXV. B. P., Cuban, mulatto, aged eighteen. Eight months preg- nant. Urine: No albumin; specific gravity 1012. Fundi normal. Visual acuity, 20/20. Visual fields: Slight bitemporal contraction. 152 C. E. FlNLAY CASE XXVI. M. 0., Spanish, white, aged twenty-two. Eight months pregnant. Urine: Trace of albumin; specific gravity 1020. Fundi normal. Visual acuity, 20/20. Visual fields: Slight bi temporal contraction. CASE XXVII. A. A., Spanish, white, aged thirty-four. Nine months pregnant. Urine: No albumin; specific gravity 1020. Fundi normal. Visual acuity, 20/20. Visual fields normal. CASE XXVIII. V. S., Cuban, negress, aged twenty-two. Nine months pregnant. Urine: Trace albumin; specific gravity 1018. Fundi normal. Visual acuity, 20/20. Visual fields normal. CASE XXIX. C. L. V., Cuban, white, aged seventeen. Eight months pregnant. Urine: No albumin; specific gravity 1025. Fundi normal. Visual acuity, 20/20. Visual fields practically normal. CASE XXX. A. P., Cuban mulatto, aged nineteen. Nine months preg- nant. Urine: No albumin; specific gravity 1016. Fundi normal. Visual acuity, 20/20. Visual fields normal. CASE XXXI. F. P., white, aged twenty-eight. Eight months pregnant. Urine: Trace albumin; specific gravity 1031. Fundi normal. Visual acuity, 20/20. Visual fields normal. From an examination of these visual fields we find that out 'of the 31 cases examined only 9 could be considered approximately normal, the remainder showing changes in the nature of a temporal contrac- tion; of these, 8 were slight, 9 moderate, and 5 pronounced. These surprising results led me to a thorough study of the literature at hand in connection with the anatomic and other data requisite for a complete explanation. For a long time I was under the impression Bitemporal Contraction of Visual Fields in Pregnancy 153 that my observations were the only ones made in this connection, but I eventually discovered that changes in the visual fields of a similar nature to those which I have recorded have been published first by Bellinzona and Tridonani, 1 and later confirmed by Forti, 2 which they all attributed to dynamic or vasomotor disturbances similar to those occurring in hysteria. This more or less forced explanation seems to me unnecessary, as the changes described can be perfectly explained by the mechanical pressure brought to bear on the chiasm by the enlarged pituitary gland resulting from the normal hypertrophy of this organ which occurs in pregnancy. The gland increases two to three times its weight and volume during this state, 3 this being due to an increase in number of oxyphil cells (Schwangerschaftzellen) in the "pars an- terior," 4 a good many of the disturbances occurring in connection with pregnancy being probably due to the corresponding hyper- function. The chiasm, which is situated over the center of the "sella turcica," and not in contact with its anterior border, from which it may be pressed upon by a reflexion of the dura mater (cisterna chiasmatis) from behind and below by an enlarged hypophysis, if this attains at least a volume of 0.5 cm. The differences in the degree of the changes in the visual fields de- pend on the degree of hypertrophy and on anatomic peculiarities which may favor or hinder the above-mentioned compression. In conclusion I consider I can establish: That during pregnancy there often occurs, as a result of the normal hypertrophy of the pituitary gland in connection with this state, a compression of the chiasm which manifests itself by changes in the visual fields in the nature of a bitemporal contraction which varies in degree according to the amount of compression suffered, this depending on the cor- responding amount of hypertrophy and on the anatomic peculiarities of the case which may favor or hinder this compression. DISCUSSION DR. W. B. LANCASTER (Boston, Mass.) : Professor Finlay's proposition has a great deal of theoretical interest. In order to establish his thesis two points have to be proved: first, that bitemporal contraction of the visual field is fairly constant in the normal pregnant woman; second, that enlargement of 1 Bellinzona and Tridonani: Boll. d. Soc. med.-chir. di Pavia, 1903. 2 Forti: Arch, di ottal., February, 1910. 3 Shafer: Endocrine Glands, London, 1916, p. 115. 4 Erdheim and Stumme and Emory Hill: Amer. Encyc. Ophth., xiii, 10232. 154 C. E. FlNLAY the pituitary is also a fairly constant phenomenon in the normal pregnant woman. As to the latter point, various men long ago surmised that the pituitary was enlarged in pregnancy, notably Le Conte in 1898, and Launois and Mulon in 1903. In 1908 Erdheim and Stumme demonstrated the in- cidence of this enlargement by the examination of 150 subjects, and they showed that in women who had never been pregnant the average weight of the hypophysis was 61.8, the maximum, 75; in primiparae the average was 84.7, the maximum, 110; in multiparse the average was 106, the maximum, 165. This shows beyond reasonable doubt that there is a normal enlargement of the pituitary in the pregnant woman. As to the second point, I happened to be so situated as to have material well suited to add to the data. It is just a question of collecting a sufficient number of fields from a sufficient number of independent sources to establish or disprove the thesis. I was unable personally to make these tests, but I was fortunate in enlisting the services of Dr. Maud Carvill, who is my associate on the staff of the New England Hospital for Women and Children. They have a large obstetrical clinic well suited to this sort of test. One always wishes that he could himself examine the fields when a doubtful point comes up, but I think if you will examine these charts, and several hundred have been taken, you will see that they bear in themselves the marks of genuine, accurate, competent work. If you, therefore, can establish the thesis that the pituitary is enlarged in normal cases, and that the visual fields are bitemporally contracted, the con- clusion is irresistible that one is the cause of the other, just as various other phenomena of pregnancy can be attributed to this enlargement of the hypophysis, which is not always free from pathologic consequences. DR. MAUD CARVILL (Boston, Mass.) : Through the courtesy of the staff of the Maternity Department of the New England Hospital for Women and Children of Boston we are making a study of a group of women in the later weeks of normal pregnancies to learn to what extent the hypertrophy of the hypophysis occurring in pregnancy affects the visual fields. Up to the present time we have examined the visual fields of sixty-seven gravid women, the progress of whose pregnancies was otherwise normal, i. e., there were no complications. Their blood pressures, urines and general con- ditions were considered normal by the internist. Their fundi were normal, and their vision was of normal acuity. These women were of good intelli- gence, many of them former students in our high schools and some graduates therefrom. Their central fixation was steady and their peripheral tests very accurate. The definiteness of the delineation of the fields has impressed us. In many cases the variation of a degree in the position of the test object was a definite question of seeing it or not seeing it. The fields were taken by day- , light by a northerly exposure, with a perimeter with a radius of 28 cm., using a 5 mm. opaque white test object. Six of these sixty-seven cases we are not including, as their last examination was taken more than one month before parturition and at that time their fields were normal. Of the remaining sixty-one cases, only seven, or 11 per cent., could be considered normal; the remaining fifty-four cases, or 89 per Bitemporal Contraction of Visual Fields in Pregnancy 155 cent., showed bitemporal contraction of greater or less extent; sixteen cases, or 28 per cent., showed a marked contraction (20 or more) ; twelve cases, or 20 per cent., showed moderate contraction (10 to 20); twenty-six cases, or 42 per cent., showed slight contraction (less than 10). Five degrees was the minimum regarded as a definite contraction. The cases we have noted in the literature refer to the multiparous gravid state. Professor Finlay has not stated the number of pregnancies in his cases. About 57 per cent, of our cases were primiparae. TABLE SHOWING THE VARYING DEGREE OF CONTRACTION ARRANGED BY GRAVID STATE Contraction Pregnancies I II III IV V VI VII VIII IX 16-28% marked 11 4 15 5 1 6 2 1 '4 2 2 1 i 2 1 1 1 1 12-20% moderate 26-42% slight 7-11% normal Total 35 10 4 4 2 3 1 2 TABLE SHOWING VARYING DEGREES OF CONTRACTION OF FIELDS ARRANGED BY AGE OF PATIENT Age 18 19 20 21 22 23 24 25 26 27 28 29 30 35-40 40-44 Marked 1 1 3 3 1 2 1 1 2 Moderate .... 1 1 5 2 2 5 3 6 1 Slight . 1 1 1 1 1 1 1 2 1 Normal 1 1 1 1 1 1 1 1 1 TABLE SHOWING FIELDS IN WEEKS PRECEDING PARTURITION Period Contracted Marked Moderate Slight Normal One week before 53 14 17 22 13 Two weeks before 35 8 10 17 8 Three weeks before 24 7 8 9 7 Four weeks before ... . 15 4 6 5 6 Five weeks before 10 2 5 3 5 Six or more weeks before. . . . 4 1 2 1 3 156 C. E. FlNLAY The conclusive studies of Erdheim and Stumme prove the question of func- tional hypertrophy beyond the stage of conjecture. These authors have demonstrated by actual measurement an increase in size and weight of the structure of the pituitary gland. After parturition there occurs a subsidence, the involution being complete at the termination of lactation. With a suc- ceeding pregnancy a further augmentation takes place. Bandler states in his book on "Endocrinology," published in 1921, that "the gland never goes back to its former ante-pregnant stage." In the 42 cases which we have examined postpartum, all but four have had normal fields. We think later examinations would have found these normal. PROFESSOR F. DE LAPERSONNE (Paris, France) : J'ai e'te' extremement in- teresse" par la communication de M. le Professeur Finlay. Si ses recherches sont confirmees dans un tres grand nombre de cas, c'est un nouveau chapitre qui s'ouvre pour la physiologic pathologique de 1'hypophyse. Dans les champs visuels qui nous sont pre"sentes, tous n'ont pas les dispositions caracteristiques de rhe"mianopsie bitemporale. A cote" de ces troubles passagers, disparaissant apres la grossesse, il en est peut-etre qui persistent. J'ai observe" une dame de 35 ans qui, au cours de sa troisieme grossesse, eut des ce'phale'es, de la polyurie, sans glycosurie, et dif- ferents troubles endocriniens. L'ayant examinee huit mois apres la grossesse, je constatai une hemianopsie bitemporale avec atrophie partielle de la papille; 1'autre oeil etait atrophi^ depuis longtemps. Le Wassermann e"tait ne"gatif et la selle turcique 16gerement augmente'e. Si la grossesse n'a pas (He" la cause primaire de cette Idsion hypophysaire, elle paratt 1'avoir nettement aggrav6e. PROFESSOR C. E. FINLAY (closing) : In regard to Dr. Lancaster, I am glad he is able to confirm both the enlargement of the gland, as well as the bi- temporal contraction. I am interested in seeing the cases of Dr. Carvill and how the visual fields compare with mine, especially as Dr. Lancaster men- tions that some of these cases are quite typical in their characteristics. Owing to the length of time of pregnancy the bony body where the hypophysis lies is hardly formed, and one would not expect it except where there is some com- pression against a bony wall. I have had a similar case to that mentioned by Professor de Lapersonne of the appearance of these symptoms after pregnancy. Most of the cases which I followed afterward showed that the bitemporal contraction disappeared comparatively rapidly after pregnancy, but lately I saw a woman who, two years after pregnancy, was suffering from headaches and blurring of vision, and in whom I found a slight optic neuritis and a bitemporal contraction. I cannot state whether this was the hypertrophy of pregnancy which had not disappeared, or whether the pregnancy provoked this in a patient already pre- disposed, or whether it was simply an independent hypophyseal tumor. But examination showed a marked enlargement of the sella turcica. LES ECHANGES D'EAU ET D'lONS A TRAVERS LA CORNEE DR. V. MORAX Paris, France La question des echanges a travers la cornee est une de celle qui doit interesser le plus Pophtalmologiste puisque la part la plus im- portante de sa therapeutique locale repose sur les phenomenes d'ab- sorption et d'absorption qui se produisent a travers la coque oculaire. Lorsque par une instillation d'atrophine ou de pilocarpine, nous pro- voquons la dilatation ou le retrecissement de la pupille, nous faisons passer dans la chambre anterieure une certaine quantite de substance active, celle-ci etant a son tour absorbee par le tissu irien. Si cet effet physiologique du passage des substances medicamen- teuses est bien connu, le mecanisme de sa production est par centre tres ignore. Ce n'est certes pas que la question n'ait pas ete etudiee de divers cotes mais elle 1'a ete surtout jusqu'ici au point de vue pure- ment chimique. Or ; 1'analyse chimico-physique a transforme 1'etude des echanges a travers les membranes. De nouvelles conceptions sur la tension osmotiques des solutions, sur la constitution ionique, des sels se sont developpees et il nous a paru necessaire d'aborder la question des echanges a travers la cornee a la faveur de tous les progres realises dans 1'etude des phenomenes chimico-physiques. Les recherches dont je voudrais donner ici un court resume ont etc" faites en collaboration avec M. Girard ou avec M. Girard et Mestrezat. Bien qu'elles soient encore loin d'etre achevees, certains re'sultats peuvent des maintenant interesser Pocu- liste et le physiologiste. II s'attache en effet un grand interet pratique a 1'etude des moyens qui permettent de modifier le "milieu interieur de 1'ceil qui est 1'hu- meur aqueuse. Ces modifications peuvent etre envisagees a deux points de vue; au point de vue du volume liquide dont depend un facteur physiologique essentiel qui est la tension oculaire et au point de la constitution chimique et notamment de la constitution ionique de 1'humeur aqueuse. Ce dernier probleme qui touche egalement a 157 158 V. MORAX la therapeutique, est en somme celui de la permeabilite de la cornee aux substances dissoutes dans les solutions qui en baignent Pepi- thelium externe. Nos recherches ont d'abord trait a un moyen pratique nouveau de faire yarier le volume de 1'humeur aqueuse dans la chambre anteri- eure et de modifier par consequent la tension oculaire en elevant ou en abaissant considerablement la valeur. Ce moyen, c'est 1'osmose electrique (endosmose ou exosmose) . Nous ne voulons pas developper ici la theorie du phenomene et la representation qu'on peut se faire de son mecanisme ; nous ne 1'encisagerons que comme moyen pratique. Disons d'abord que ces osmoses electriques, nous les avons pratiques sur 1'ceil vivant et en place de 1'animal vivant. Essentiellement, elles consistent dans le glissement sous 1'action d'un champ elec- trique, de veines liquides dans les interstices cellulaires d'un tissu vivant, la cornee en 1'espece. L'un des poles de la sourcee electrique qu'on utilise, etant relie a un point quelconque du corps de 1'animal par une large electrode, une electrode en platine reliee a Fautre pole plonge dans la solution d'electrolyte dont est baigrie 'par le moyen d'un bain d'ceil en verre 1'epithelium externe de la cornee. La theorie du phenomene fait prevoir que pour une valeur et une orientation fixees du champ difference de potentiel entre la cornee et la solution qui en baigne 1'epithelium externe ce sera de la consti- tution ionique de cette solution que dependra le sens du glissement des veines liquides dans les interstices cellulaires: endosmose ou exosmose. Pour une connection polaire telle que la cathode etant au corps de 1'animal 1'anode plonge dans le liquide du bain d'ceil, on obtient lorsque celui-ci est constitue par des solutions de sulfate de magnetic des endosmoses qui font monter la tension intraoculaire, au bout de 30 minutes environ de 25 a 70 ou 50 millimetres de Hg. Au con- traire, toujours pour la meme connection polaire, lorsque ce liquide est constitue" par une solution de nitrate de calcium, cette tension oculaire s'abaisse dans le meme temps du fait de 1'exosmose de 1'hu- meur aqueuse qui filtre a travers la cornee hors de 1'organisme a 8 ou 10 millimetres de Hg. A la fin de 1'experience, lorsque les precautions necessaires ont ete prises (concentrations moleculaires convenable de la solution, debit electrique ne depassant pas 2 milliamperes et surtout absence d'elec- trolyse), on ne constate aucune lesion de la cornee, non plus qu'aucune trace d'oedeme. Les Echanges d'Eau et d'lons a Travers la Cornee 159 Ajoutons que sur les yeux dont la circulation est normale et sur lesquels aucun blocage vasculaire n'a dte pratique, ces desequilibres de tension se re"parent au bout d'une heure environ et I'humeur aqueuse dite de nouvelle formation differe alors de 1'humeur aqueuse normale. Mais ce n'est pas seulement le volume de 1'HA., c'est aussi la con- stitution ionique qu'il est possible de modifier momentanement tout au moins. L'utilisation d'un champ electrique pourra etre, en vue de cette fin tres avantageuse; mais elle n'est pas indispensable et au cours de nos experiences sur les echanges d'ions a travers la cornee, nous avons utilise tres souvent la diffusion pure et simple sans source electrique exterieure. Le fait essentiel que nous avons trouve en collaboration pour cette partie avec M. Mestrezat peut se resumer ainsi: lorsqu'une solution d'un sel determine, dissocie en ses ions, baigne la cornee dans 1'HA., ce n'est pas le sel qui diffuse a travers le cornee dans I'humeur aqueuse, ou plus exactement les deux ions de ce sel, ainsi dissocie ne diffusent jamais en proportions chimiquement equivalentes. Si, par exemple, la solution est constitute par du sulfate de magnesie, il ne diffusera pas dans 1'humeur aqueuse, un nombre egal d'anions et de cations (comme cela se passerait si c'etait du sulfate de magnesie qui diffusait dans la chambre anterieure, mais il diffusera beaucoup plus d'ions magnesium que d'ions sulfate en sorte que ce ne sera plus du sulfate de magnesie qui aura diffuse dans 1'hiimeur aqueuse. Mais d'autre part, comme 1'exces de magnesium a diffuse sous forme d'ions porteurs de charges electriques positives, et que I'humeur aqueuse reste cependant electri- quement neutre aucune charge non compensee n'y apparassant le principe de Pequilibre electrique exige qu'au passage dans un sens d'un exces d'ions, corresponde le passage en sens inverse c'est a dire vers la solution baignant 1'ceil d'un nomber electriquement et chimiquement equivalent d'ions (metalliques) de meme signe. Ce serait, par exemple, les ions sodium de 1'humeur aqueuse. Ensorte que le contact de 1'epithelium externe de la cornee avec une solution de sulfate de magnesie nous prenons ce sel a titre d'exemple n'a pas du tout, comme consequence comme il eut e"te naturel de le penser, 1'enrichissement de I'humeur aqueuse en sulfate de magnesie; I'humeur aqueuse s'enrichit relativement beaucoup en magnesium, tres peu en ions SCX Pour certains sels, comme les sels d'ammonium, la discrimination est tellement accusee que pratique- 160 CHARLES F. HARFORD ment un seul ion passe et elle s'apauvrit en un metal qui sera par exemple du sodium en une proportion electriquement et chimique- ment equivalente a celle en laquelle elle s'est enrichie en magne'sie. II en re"sulte dans la composition ionique de 1'humeur aqueuse de tres importantes modifications. Pour certains sels comme les sels monocalents d'ammonium ce sont au contraire les anions (radicaux acides) qui diffusent en exces, exces si grand parfois qu'on peut ici parler d'une veritable hemipermeabilite ionique. D'ailleurs il est possible en faisant varier la reaction du milieu (legere alcalinite ou le"gere acidite") de modifier ou meme d'inverser le sens de ces r6sultats. La re'elle difficulte dans ces experiences a e"te de pratiquer sur des quantites tres petites (chaque ponction d'humeur aqueuse ne donnant guere que 2 a 3/10 de cent.) le dosage des 2 ions de chaque sels. Seules les niethodes microchimiques permirent de la surmonter. De 1'en- quete syste"matique que nous comptons poursuivre relativement a cette perme'abilite elective de la cornee vis a vis lesions, sortiront peut- etre d'interessantes conclusions chimio-therapeutique. PSYCHOPATHOLOGY IN OPHTHALMIC PRACTICE CHARLES F. HARFORD, M.A., M.D. Cambridge, M.R.C.S. Eng., L.R.C.P. London Ophthalmology occupies, in many ways, a central position among the various departments of medical and surgical practice. This was well shown in a paper by Dr. F. Park Lewis at the meeting of the American Medical Association at Atlantic City, N. J., in June, 1919. The author took as an illustration the close connection between den- tal caries and many forms of ophthalmic disease. He might have greatly extended the scope of his paper and traced the intimate con- nection of ophthalmology with all the general infections, especially those which are of a chronic character. There is, however, a new field of medical research which is rightly claiming close attention at the present time which is destined to in- fluence every branch of medical study, and that is the rapidly de- veloping science of psychopathology. No department is more likely to be affected by this than that of ophthalmology. It is not only that ophthalmic conditions often form an exciting factor in the on- set of the psychoneuroses, but that there are psychic elements com- Psychopathology in Ophthalmic Practice 161 plicating most ophthalmic diseases. Thus again we find the central place of ophthalmology and the necessity of recognizing the psycho- logic aspects of ophthalmic work, and, where necessary > of full cooper- ation with those who practise psychotherapy. I have been led to realize the urgency of this problem by certain cir- cumstances which it may be of some interest to record. During the war, when acting as an ophthalmologist in connection with a British division composed very largely of miners, I was for the first time brought in contact with the ailment most unfortunately named miners ' nystagmus. Recognizing the seriousness of the malady, and believing that it would be of some value to record observations on these cases when removed from underground work, I prepared a paper on this subject. The paper was published in the British Medical Journal on March 4, 1916, with the title, "Visual Neuroses of Miners in Their Relation to Military Service." I pointed out that nystag- mus was only one of a series of symptoms in the disease, and drew at- tention to the great importance of the mental factor and the possibil- ity that these cases might be treated by suggestion. At that time I was not interested in psychology as I have been during the past two years, but the study of these cases gave me a special interest in the re- lation between the mind and vision. At the Ophthalmological Congress in London in May, 1921, I took part in a discussion on the Psychology of Vision in Health and Dis- ease, and expressed in that my strong conviction as to the importance of knowledge of modern psychologic teaching in ophthalmic work. I had for the previous eighteen months been engaged in special study on these lines, with the result that I had benefited in my own powers of work and found great scope for the exercise of the knowledge gained in my own practice. After six months ' further study I decided to formulate more clearly the conceptions which had helped me, and on November 11, 1921, I contributed a paper to the Ophthalmological Section of the Royal Society of Medicine of London on "The New Psychology in its Rela- tion to Problems of Vision. " This has been published in the Medical Press and Circular on November 30 and December 7, 1921. The pres- ent paper is intended to be a sequel, and it will be necessary to refer very briefly to the line adopted in that contribution, seeing that a proper appreciation of the general lines of normal psychology is essen- tial before proceeding to deal with psychopathology. This is the more necessary in view of the great diversity of opinion which prevails on 11 162 CHARLES F. HARFORD these subjects. A chart was used to represent the working of the psyche, and this is reproduced here in order to make clear the stand- point of the author. The chart includes the following parts: 1. A circle X representing, as if it were a gramophone, the mechan- ism of the psyche divided into its three sections of a cognition, by which an image or impression, visual or otherwise, is recognized; an CHART OF ACTION OF PSYCHE ve RESULTS OF CASUAL OBSERVATION THE AMNESIA OF COMMON LIFE PATHOLOGICAL REPRESSION INSTINCTIVE AND HEREDITARY INFANTILE STORE -CHAMBERS OF PSYCHE BELOW CENTRAL LINE = THE UNCONSCIOUS affection, which stands for the emotional result of cognition, which in its turn leads to a conation or action. 2. A second disc, Y, as if it were a gramophone record, stood for the field of consciousness, which would present to the psyche the visual and other images or impressions received from external objects or from the memory or from both combined. Psychopathology in Ophthalmic Practice 163 3. The store-chambers of the psyche or of the memory were de- scribed as divided into six compartments, referred to as (a) results of careful observation ; (6) results of casual observation ; (c) amnesia of common life; (d) pathologic repression; (e) infantile impressions; (/) instinctive and hereditary factors. These signified the author's idea of what is usually termed the unconscious, and the circles within them indicated the mental concepts stored in the memory which were spoken of as psychograms. The salient features in this scheme may be explained as follows: 1 . The part of the circle X marked with shading or black was taken to represent the emotional part of the psyche, which was also regarded as the center of force or energy in the working of the mind. This, in the author's view, was comparable to the "elan vital" of Bergson, the " libido " of Freud or Jung, or " the urge " of English-speaking psychol- ogists, whatever their special conception might be as to the nature of this all-pervading force. The marking in a similar manner of the psychograms stored up in the unconscious indicated that each mental concept is activated by this emotional force, with its conflicting character. This might be illustrated by ideas of attraction or repulsion, of light or darkness, of harmony or discord, of rest or pain, of hope or fear, or any other antag- onistic forces. This is laid stress upon seeing that the conflict graphic- ally described by Freud, which is an essential element in psycho-an- alysis, may be regarded as a prominent symptom in all kinds of dis- ease. Some aspect of distress is a constant factor in every ailment, whether it is a malignant tumor, toothache, or an error of refraction, and it is this which we, whose duty it is to combat human ills, are called upon to alleviate. 2. The second point of importance to which attention is directed is to the medium, as shown by the disc Y, whereby diverse impressions or images, whether of the past or present, are harmonized and pre- sented to the main mechanism of the psyche. It was this harmonizing or reconciliation between new images and past memories, or in psychologic terms of apperception, which was the main point of the paper which demonstrated, by various instances, that visual memory is an essential feature in every visual concept. The instances given were the following: infantile vision; individuals blind from birth; the recognition of strange objects; the use of optical apparatus; the artistic eye; the athletic eye. The meaning of the disc Y was also regarded as an illustration of 164 CHARLES F. HARFORD even wider significance. Though it is marked in the chart with the words " field of consciousness," yet it is suggested that there may be modifications of this idea which might represent the dream state or the hypnotic state, and might be labeled Yl or Y2. Thus, on falling to sleep the change from Yl to Y2 would occur, this dream state being one in which access appears to be attained to chambers of the psyche which are inaccessible to the normal conscious state. These different states are instances of the process of dissociation which is responsible for most of the abnormalities of mental life, and is represented by cases of so-called multiple personality, forms of drug intoxication, or actual insanity. This may also explain the visual irregularity spoken of as " deja vu," or false recognition, which has been the subject of many hypotheses. Bergson has devoted much attention to it, and it has been dealt with recently by Kinnier Wilson at the last Ophthalmological Congress in London in 1921, when he gave instances of this phenomenon in relation to epilepsy. Of these epileptic cases I have no personal knowledge, but I have recently conversed with a number of people who claim to have had this experience in ordinary life. In these cases I am strongly of opinion that the condition is due to a momentary day dream. Let me give an illustration of this. A soldier in the recent war came to the top of Cassel Hill in France, near to the Flanders frontier. When he saw the view of the plain stretched before him he at once felt that he had been there before, and had seen precisely the same picture, though he knew that this was impossible. A similar story is told by others, most of whom would re- ject with scorn the idea that they were remembering a similar situa- tion or had only seen a picture of the view. They are certain that the picture is identical. This I believe is due to a day-dream. For the moment when they are brought face to face with the new condition, some alternative Y disc must be in operation which receives the im- pression and is immediately replaced by the normal conscious disc, and the whole impression has thereupon been relegated to the store- chambers of the memory without appreciation of space or time. This is the explanation which satisfies me and has satisfied those with whom I have spoken who have themselves experienced the phenomenon which is infinitely more important. 3. The third essential feature of the chart, the store-chambers of the memory, represents not only the accumulation of ideas, but the storehouse of energy. Starting from instinctive and hereditary be- Psychopathology in Ophthalmic Practice 165 ginnings with the psychic momentum, which has been acquired throughout life, it forms the wonderful conception of the mind which is being unfolded to us in what may be called the story of the un- conscious. Here is the inexhaustible mine from which we may ob- tain the solution of many of life's riddles; this is the great dynamic force which is elusive to the impetuous promptings of the will, but can be influenced by suggestion or auto-suggestion ; yet all of these are under the control directly or indirectly of the personality of the normal man, and for them he is responsible. Thus we have endeavored to picture the working of the human mind, not as an isolated problem, but in its relation to vision. No at- tempt has been made to correlate in any exact manner the functions of the psyche and the soma, or yet the higher realms of the pneuma, but it is the author 's firm belief that each of the domains of spirit soul and body must be explored in their relation to one another. Only thus can we satisfactorily treat the whole man the patient who seeks our aid. For the moment it is the psyche and soma which are under special consideration because of the new light which is being thrown upon the working of the psyche. So far as these are concerned we must regard the psyche as the directing force, and as the nearest approach to the essential ego that we have yet reached. This then is the new stand- point from which we must view our ophthalmic practice. We must be no less scrupulous in our methods of examining organic defects, or in the identification of cerebral or nervous lesions, but above all we must include in our reckoning the psychologic factor. The application of the new psychology to ophthalmic practice will only gradually be realized, but it is hoped that the suggestions which have been made as to the methods of mind-working may help many to interpret some of the difficulties occurring in their own practice. We will now endeavor to describe some of the cases in which psycho- pathology and ophthalmology meet. Most of these will include some measure of dissociation in which repression with amnesia will have a part, and in which often, in proportion to the amnesia, there will be some emotional distress. In all of these it is probable that an un- conscious motive can be detected, and the demonstration of this may lead to the resolving of the conflict, the restoration of harmony, and relief from the distress. We shall proceed to consider these cases in three main classes: 166 CHARLES F. HARFORD I. THE PSYCHOPATHOLOGY OF EvERY-DAY LlFE This admirable phrase, used by Freud as the title of a volume, will form a good introduction to our subject. It is a mistake to regard all psychic disturbances as conditions which can be dealt with only by specialists in psychotherapy. The truth is that there is a psychic ele- ment in every malady, and that whether we know it or not we must deal with it if we are to help our patients. Every practical physician or surgeon recognizes this, though perhaps unconsciously, and an older generation with its stress on temperament, anticipated much that is being taught in a new way to-day. The manner of the older practitioner was studied more closely perhaps than at the present time, and the confident assurance of success in treatment can be re- garded only as a method of suggestion. To-day we approach these problems with new light. In our ophthalmic clinics public or private patients come to us not so much because they know of any distinct dis- ability, but because they are anxious about themselves. Mysterious pains in the eye or head, floating bodies or clouds before the eyes, unusual appearances about the eyes or lids, are often re- garded as threatening disaster, perhaps blindness. In many cases the anticipation of evil is more serious than any actual disease, and may even produce illness, and in some this foreboding is the only trouble with which we may have to deal. Obviously, our duty is to eliminate any organic disease or cause for trouble, including particularly the correction of refractive errors. We must further seek to convince our patient by our methods and manner that we are genuinely concerned in delivering him from his fears, whether real or, as we may style them, imaginary. Only thus can we obtain that true "rapport" which must exist between doctor and patient if success is to be insured. This gained, we may, by simple persuasion, be able to clear away the fear and suffering which may still exist, not because the patient is intentionally exaggerating his symptoms, but because of some unconscious prejudice or habit which is responsible for the trouble. It is useless to treat these cases by stern rebukes or ridicule, however veiled. Action of this kind will only develop resistances which may result in troublesome repression with an intensification of the malady. Freud points out that the ordinary forgetfulness of every-day life, the slips of tongue and pen and other trivial blunders, are frequently due to an unconscious cause which may be discovered. Let us take an example from the common experience of a refraction- Psychopathology in Ophthalmic Practice 167 ist. The prejudice against glasses is often very great. In the poorer districts of London, and no doubt elsewhere, those who wear glasses are called goggle-eyed or some similar nickname is given to them. During the war soldiers were greatly prejudiced against glasses, be- cause the army glasses were round instead of oval, as is most commonly supplied in England. Many girls prefer to endure any amount of suffering rather than wear any form of glasses which may not be regarded as becoming. The result of this is the development of an unconscious motive, which shows itself in an unwillingness to give a correct history, in mistakes in reading test types, and later on in difficulty with the glasses. These patients have come to us for some real complaint and a desire for relief from their troubles, but when they are brought face to face with the remedy, they shirk the issue. They may be said to regress, to prefer phantasy to reality in a word, they act like children. Any one with observation on these lines could multiply instances in- definitely where similar prejudices complicate our practice. II. PSYCHIC DISORDERS OF A MORE PRONOUNCED FORM ASSOCIATED WITH VISUAL DISTURBANCES We now come to a second class of cases of a definite psychopathic character, which may vary from the persistent headache to the more pronounced forms of psychic troubles. The nomenclature of these conditions, which includes such terms as hysteria and neurasthenia, is liable to be misleading, so we will not here attempt any definite classification. It will be sufficient to mention some of the symptoms common to many of these conditions. Headache, minor obsessions or delusions, often visual, tremors of various kinds, disorders of the circulatory, respiratory, or the many glandular systems of the body, may all be met with. Fatigue, inability to concentrate on mental work, varieties of amnesia, insomnia, and phobias of a distressing type may all occur. Ophthalmologists have for long been aware of the importance of correcting errors of refraction in cases of this kind, but with new knowledge much better results may be anticipated. These are un- doubtedly cases which call for comprehensive treatment, and should be dealt with by a psychotherapist, but many of them will first consult an ophthalmologist, owing to the prominence of symptoms referable to the eye and the importance of being able to diagnose the condition is evident. 168 CHARLES F. HARFORD To take an instance from my own practice: A patient consulted me on account of symptoms which had shown themselves a few weeks previously on the occasion of the last eclipse of the sun. He had looked at the sun without proper safeguards, and he believed that his eyes had been injured thereby. He had some conjunctivitis and some slight astigmatism, and both of these conditions were dealt with. There was no sign of any retinal lesion and no scotoma or interference with his color perception. It seemed clear that his main trouble was psychic, and this was confirmed later when, as the result of some slight exposure to glare, he was affected in the same way in spite of wearing Crookes ' glasses, and was obliged to give up his work. His medical attendant, a writer on psycho- logic subjects, formed the same view, and psychotherapy was ad- vised. This is a common incident in ophthalmic practice, and it is impor- tant that it should be recognized, so that it may be appropriately treated. Any attempt to deal with such cases by simply assuring them that there is nothing the matter with them, without recognizing the psychologic aspect, may even intensify the mischief. Here again we see that ophthalmology occupies a central position, with the added responsibility which arises in consequence. III. PRONOUNCED CASES OF MENTAL DISEASES In the class of cases which would be certifiable by British law the ophthalmologist is not likely to be concerned except to deal with in- cidental defects which call for attention. Seeing, however, that the major psychic diseases are usually a development from the minor, it may be possible to prevent the graver forms of disorder by a careful recognition of the premonitory symptoms. Seeing that visual obsessions are a common element in these cases, it may be of value to inquire into their possible origin. I was recently asked to see a patient who was in a state of marked dissociation, with visual delusions. She stated that she could see moving objects in the dark corners of the room taking certain definite shapes. The purpose for which I was consulted was on account of defective vision and the possibility of prescribing more suitable glasses. I found that she was developing opacities in the lens which were mainly in the form of minute dots scattered throughout the lens. I am of opinion that these early disturbances of vision due to incipient cataract are quite sufficient to form imperfect images which may grad- Psychopathology in Ophthalmic Practice 169 ually materialize into a concept of defined objects, human or other- wise. Possibilities of the development of serious psychic conditions in connection with cataract, and indeed in other cases of opacities in the media, should be carefully considered, and the experience of ophthal- mologists as to the relation between cataract and psychic disorders might be a valuable contribution to psychologic medicine. In a case of cataract which was under my care and operated upon by a colleague of mine the following points may be noted! Previous to the onset of cataract there were some psychic difficulties, with prejudices and suspicions which were evidently morbid. These were accentuated by other physical infirmities, including deafness, and with the onset of cataract these were much increased. In spite of this mental condition, and indeed with the hope of relieving in some measure these symptoms, and in any case bringing some relief to a condition of pitiable discomfort, it was decided to operate. The change in a monotonous life of removal to a nursing home, with devoted nursing, had a great effect upon the patient. The operation was most successful, and though, as the result of starting up in the night two days after the operation, a prolapse of iris occurred, recovery was satisfactory. During the after-treat- ment her whole outlook to life seemed to change and the improvement was most gratifying. Glaucoma again is a disease in which the severity of the pain and the rapid interference with sight are likely to lead to serious forms of phobia. It is worthy of inquiry in these cases as to the possibility of the psychic attitude complicating the physical malady. These are matters which should engage our serious attention. As ophthalmologists we are brought in contact with disease in all its forms. As we have already stated, ophthalmology occupies a central position in medicine. Let us prove ourselves worthy of the charge committed to us. It may be that we may be able to give substantial assistance to our colleagues who are grappling with the obscure disorders which afflict the mind, but at the same time we may look for help from them in many of the mysterious ailments which we must deal with in our own sphere. DISCUSSION DR. GEORGE F. KEIPER (Lafayette, Ind.) : This is an extremely interesting paper because it calls to our attention things which every ophthalmologist ought to know from the standpoint of the new psychology, which starts with 170 CHARLES F. HARFOBD the anatomy and physiology of the central nervous system. We are dealing not with chambers of the mind, but with nerve cells. In the cortex of the brain there are from three billion to eight billion nerve cells, so the physiolo- gists have estimated. These cells are the repositories of impressions, and when they are properly connected up we have that which is called knowledge, and when we take this and go out into the everyday affairs of life and attempt to apply it we get the substance which we call wisdom, and that varies, of course, in different individuals, according to capacity and capability. Of course, we know what some of these nerve cells are for we have been able to work out what we call localization of function, as along the fissure of Rolando and in the occipital lobes which localize vision, or in the left temporal sphenoidal lobe, where several years ago Dr. Jack, of Boston, and I, simul- taneously and independently, pathologically located it by operating for abscess of that lobe, our diagnoses being based upon the symptoms of aphasia which these patients manifested after mastoid operation. There has been no better definition of memory than that given by Dr. Max Nordau, in his work on "Degeneration," a number of years ago, when he said that memory is nothing more nor less than the product of stored-up nerve-cell action. In the retina of each eye we have the same kind of nerve cells as in the cortices of our brains, and, after all, vision is nothing more nor less than the product of stored-up nerve-cell action. The eye is but a pro- longation of the brain in order that the brain may come in contact with that form of motion which we call light and the phenomena produced by it as it comes in contact with all nature. We have in our offices the same kind of apparatus that the physiologist uses in his laboratory, and we have an exceedingly wide and interesting field for study of psychologic states in relation to these special senses, for, after all, it is through the medium of these seven or eight special senses that we get all our knowledge. MR. J. GRAY CLEGG (closing) : Undoubtedly there are many cases in which we have difficulty in satisfying our patients, the patients who will not take cylinder lenses, who get comfort only when the cylinders are removed. It seems to me some of these are cases where the psychic influence is one of the main factors. Then one occasionally comes across patients who have two sets of glasses from the same prescription they are perfectly comfortable with one and absolutely uncomfortable with the other, and nothing will persuade them that the two are alike, although the optician and oculist are unable to see the difference. There again we have the psychic element. In the case of muscce volitantes many patients are seriously perturbed in their mind until they are advised not to look at floating spots, and that by suppressing them in their consciousness they will have a return to a state of psychic comfort and rest. I have had two patients, each of whom complained of seeing his nose constantly. The only remedy was either to suppress that consciousness or to have a radical operation undertaken. Undoubtedly in all our work' physicians and surgeons are constantly exercising the factor of suggestion to the mind of the patient. Some patients are satisfied with advice in Europe; others come to America to secure their contentment. I am also pleased to be able to say that the reverse holds good. NIJEVO TRATAMIENTO QUIRURGICO DEL ESTRABISMO DR. B. CASTRESANA Madrid, Espana El problema del estrabismo en Espana es uno de los capitulos de nuestra especialidad que menos ha progresado en la ultima decada del siglo que corremos. La falta de cultura en las masas populares creyendo de buena fe incurable su enfermedad, la resistencia constante para dejarse intervenir quirurgicamente, el escaso perfeccionamiento de la tecnica operatoria y el no poder asegurar al enfermo el exito seguro y definitive despues de la intervencion, son los factores que mas poderosamente han contribuido al escaso desarrollo y poca in- tensidad, que tiene el estudio de la correccion estrdbica en nuestra patria. En Espana existen multitud de enfermos estrabicos; pero solo se pre- sentan en nuestras cllnicas escaso numero de ellos, con la pretension de que centremos bien sus ojos y les demos vista en el ojo que desvian, sin practicarles operacion alguna. Las intervenciones quirurgicas en los enfermos estrdbicos eran esca- sisimas hace diez anos, aun en clinicas numerosas, como la mia. Al- gunos colegas que me honraban presenciando mis operaciones, al manifestarme deseo de ver operar un estrabismo, tenfa que decirles: Los enfermos estrabicos no se dejan operar en Espana, no por pre- juicio religioso, como opinaba un ilustre colega extranjero, sino por- que creen que su enfermedad no tiene remedio. En cierta ocasion aconsejaba a una muchacha de diez y ocho se dejase operar un estrabismo interno pronunciadisimo que padecia. Despues de exponerle varios razonamientos de indole estetica y fun- cional, cuando crei haberla convencido, me contesto que el bizquear los ojos era una gracia especial que no estaba dispuesta a corregir. Como se ve", la incultura en el publico resistiendose sistemdticamente al tratamiento operatorio ha sido, es y serd en el porvenir, la causa precisamente primordial de que no se haya hecho en nuestra nacion un estudio acabado y perfecto de un punto tan importante como es de las desviaciones oculares. 171 172 B. CASTRESANA Hay que confesar, sin embargo, que la reaccion ha sido tan favorable para nosotros, por el e"xito alcanzado con el procedimiento quirurgico que practicamos en la actualidad, que en estos ultimos afios el ma- terial clinico humano ha sido mds abundante, dilatandose mucho el campo de nuestra experifnentacion. Los mismos operados de estrabismo, al ver corregida su desviacion oculaque no solamente les afeaba, sino que tambien era en mil circun- stancias motive de burlay de molestia en las distintas manifesta- ciones de su vida social, han sidojlos ms entusiastas propagandistas, aconsejando a otros individuos que padecian igual defecto se dejen intervenir quirurgicamente. La desviacion manifiesta de la linea visual en uno de los ojos, o la falta de paralelismo de los ejes visuales, es el defecto ocular que recibe el nombre de estrabismo. Este puede ser paralitico o con- comitante, siendo considerado el ultimo como el verdadero estrabismo, porque sin haber paralisis de ningun miisculo, no coinciden las dos lineas visuales en el mismo objeto. De otra parte, en esta variedad estrdbica, las desviaciones primarias y secundarias con iguales, y no existe la diplopia, porque generalmente la vision imperfecta que el enfermo tiene en uno de sus ojos constantemente, hace que se acos- tumbre a eliminar -la imagen borrosa del ojo estrabico. El estrabismo concomitante, que a simple vista parece monocular, porque se manifiesta aparentemente por la desviacion de uno de los ojos, que es precisamente el que tiene menor agudeza visual, es, sin embargo, bilateral siempre, y el ojo desviado represente, segun la opinion de Terrien, la suma de la desviacion de ambos ojos. El estrabismo alternante y la igualdad de la desviacion primaria y secundaria, nos prueba la existencia de la bilateralidad de la afeccion, y a la vez nos demuestra que los dos globos oculares estan afectados igualmente, sin que exista pardlisis muscular de ningun genero. Al comentar este punto del estrabismo el doctor Ribas Valero, uno de nuestros ilustres colegas que mas trabajos ha publicado sobre las desviaciones estrabicas, emite la opinion de Parinaud y dice; "La causa unica, tanto del estrabismo convergente como del divergente, es una lesion de convergencia, conservdndose Integra la funcion de direccion, es decir, una alteracion del aparato de la vision binocular, tanto de su parte sensitiva como de su parte motora, y de consig- uiente de las conexiones nerviosas que las unen, por donde normal- mente se transmiten los reflejos. A estas alteraciones primitivas se agregan posteriormente otras secundarias que las modifican y alteran, Nuevo Tratamiento Quirurgico del Estrabismo 173 y cambiando su naturaleza producen retracciones fibrotendinosas." De donde se deduce que para el citado autor frances, el estrabismo consiste en un vicio de desarrollo del aparato de la vision binocular, que afectara a la parte sensitiva y motora a la vez, y que ha de im- pedir se realice la convergencia de los dos ojos sobre el objeto que miramos. No debe admitirse, por lo tanto, un trastorno muscular organico, por que la conservacion de los movimientos asociados de direction, la existencia del estrabismo alternante, la normalidad del campo de mirada cuando se inicia la afeccion, prueban todo lo con- trario. Fig. 1. Debilitacion al musculo antagonista. El consignar la -bilateralidad del estrabismo nos es indispensable si hemos de razonar el tratamiento que empleamos para su curacion y nos justifica tambien nuestra intervention quiriirgica a la vez en los dos ojos, estando en este punto compenetrados con los grandes clinicos Panas y Landolt, que consejaban corregir siempre bilateral- mente el estrabismo, puesto que el desequilibrio ocular afecta a los dos ojos. El estrabismo tiene tambien su tratamiento medico, habiendo sido Javal uno de sus ma's fervientes partidarios, pero la oclusion de un ojo por largo tiempo, el uso de la atropina, de los vidrios correctores del defecto de refraction, y los ejercicios ortopticos que ocupan un 174 B. CASTRESANA lugar muy importante con relation al tratamiento quirurgico en los primeros aiios de iniciarse el estrabismo, deben sustituirse por la intervention operatoria si no produce su aplicacion el efecto apetecido. Esto no quiere decir que el tratamiento quirurgico pueda curar por si solo un estrdbico, porque lo unico que hace es corregirle su estra- bismo aparente, sin intervenir en las funciones de asociacion visual, susceptibles de modificar por los medics opticos que indicabamos anteriormente. Claro estd que no todos los estrabismos son curables, entendiendo por estos aquellos a quienes se pueda devolver la vision binocular, pero Fig. 2. Reseci6n de un trozo de la conjuntiva que deja al descubierto la inserci6n muscular en la escler6tica. todos se puede 'decir que son corregibles, es decir, que mediante la intervention quirurgica podemos suprimirles el estrabismo aparente, y el enfermo queda muy satisfecho desde el momento que le hemos hecho una buena correction estetica, que haga desaparecer su defecto, aun cuando no consiga la vision binocular que nunca tuvo. Nosotros hemos de procurar la curacion verdadera del estrabismo mediante el tratamiento quirurgico y 6ptico consecutivo; pero si fuera imposible conseguir la vision binocular, nos conformaremos con haber mejorado la estetica facial del enfermo, que tiene capital im- portancia, sobre todo cuando se trata del sexo femenino. Nuevo Tratamiento Quirurgico del Estrabismo 175 En el siglo XVIII es cuando parece germino la idea de poner re- medio quirurgico a la desviacion estrdbica, relatando Eschenbach, que un ingles llamado Taylor curaba el estrabismo, plegando la con- juntiva con unos hilos de seda, pero mo esta probado que seccionase el musculo, como opinan algunos autores. La primitiva idea de cura- cion del estrabismo partio de Taylor, pero indudablemente el trata- miento que aplico fue muy incomplete. Es preciso que transcurra casi un siglo, hasta el afio 1838, para que se hable de nuevo de la operacion del estrabismo por Stromeyer, quien hizo una description detallada de la tecnica operatoria, seccionando el Fig. 3. Cogida del musculo con la f^nra de Prince, a una distancia de su inserci6n tendinosa, proportional al grado de estrabismo. musculo. Pero Stromeyer realize sus experiencias en el cadaver, siendo Paulin en 1839 el primero que practice la operacion en el ser viviente. Casi al mismo tiempo Dieffenbach seccionaba el musculo en su portion posterior, realizando, por lo tanto, una miotomia, hasta que Guerin en 1840 hizo la tenotomia, que vino a sustituir, aquella, gracias a los trabajos de Bonet de Lion. Los resultados obtenidos con la miotomia y la tenotomia desani- maron a los operadores. La primera producia un estrabismo para- litico, y la segunda a la larga el estrabismo en sentido contrario. Diez anos mas tarde, Jules Guerin ideo el avance muscular para con- 176 B. CASTRESANA trarrestar los estrabismos producidos por la miotomia y tenotomia, mal reglada por aquel entonces. En los anos 1860 al 62 es cuando Graefe, Critchett, Agnew, Cunier, Lucien, Boyer y Bachm, se ocuparon de estudiar con detalle el avanza- miento muscular, perfeccionaron la tcnica operatoria, y sustituyeron el avance simple por el avance con reseccion parcial del tendon. Mas tarde, el afio 1883, Wecker ide6 el plegado del musculo y prac- tice el avance capsular, metodo que aun en la actualidad es seguido por ilustres colegas espafioles y extranjeros. En 1890 Parinaud Fig. 4. El musculo sujeto por la pinza, se secciona por delante de ella quedan- dose un trozo suelto mayor o menor segiin la desviaci6u estrabica unido a la esclerotica por su insercion anterior. sustituye la tenotomia por los desbridamientos capsulares amplios, y Lagleyze propone dos anos mds tarde el acortamiento muscular. Por ultimo Landolt en 1894 dice que el avance muscular aumenta la energia del musculo y aconseja se practique el avance bilateral. En realidad, los distintos procedimientos quinirgicos propuestos para corregir el estrabismo se pueden reunir en dos grandes grupos: En el primero, pueden congregarse los metodos que tienen por objeto disminuir la traccion ejercida por el recto interne, externo, o su cdp- sula, segun que el estrabismo sea convergente o divergente. Entre estos consignaremos la tenotomia y los desbridamientos de Parinaud. Nuevo Tratamiento Quirurgico del Estrabismo 111 En el segundo, incluiremos aquellas intervenciones quiriirgicas que tienden a aumentar la traccion ejercida por el recto externo y su capsula, cuahdo se trata del estrabismo interne, o viceversa, si la desviacion estrabica es externa. Este resultado se pretende con- seguir mediante el acortamiento y los avanzamientos musculares y capsulares. Al estudiar cada una de las operaciones propuestas en los dos grupos precedentes, no hemos de exponer su tecnica operatoria, descrita en las obras y monografias de nuestra especialidad que tratan Fig. 5. Sutura romboidal compuesto de tres puntos, uno central y dos laterales desviados hacia el ecuador del globo ocular y que pueden oblicuarse, si el estra- bismo es algo superior o inferior. del estrabismo : me voy a limitar solamente a exponer sus resultados y consecuencias fisiologicas, despues de haber pasado algun tiempo de la intervencion. Modificada y reglada por Bonet de Lion la tecnica de la tenotomla, que practice primero Stromeyer y despues Dieffenbach, se puede decir que ha sido la operacion que mas frecuentemente se ha practicado contra el estrabismo, a pesar de tener, a mi juicio, mds inconvenientes que ventajas. Es indudable que la tenotomia produce, inmediatamente despues de practicada, un enderezamiento del globo ocular desviado, pero en 12 178 B. CASTRESANA general el enderezamiento no persiste en los dias sucesivos, pudiendo algunas veces desaparecer por complete. Solo en casos muy espe- ciales y en tenotomias muy amplias se ha conseguido alguna vez una correccion de 10 a 12. Si no hemos suturado la membrana con- juntival, la caruncula lagrimal se hunde, debido a que la conjuntiva del dngulo interne adherida a los tejidos profundos, es arrastrada por el musculo retractado. Se presenta tambien una exoftalmia posto- peratoria que si es bastante acentuada produce una deformidad muy desagradable, que si bien podemos corregir con una cantoplastia del ojo del lado opuesto, no deja de ser una complication digna de tenerse en cuenta. Fig. 6. Sitio de uni6n de los puntoos de sutura despues de verificar el avance indirecto, fijando los extrenos de los puntos de seda con un esparandvayso en la parte externa o interna, segun el estrabismo que se opere. Los inconvenientes lejanos de la tenotomia son todavia mds graves. Lo ma's frecuente es que la vision binocular no se restableza despues de la operation, y que sobrevenga el relajamiento espontaneo de la conyergencia, dando lugar a un estrabismo externo de un efecto ma's desagradable que la desviacion ocular interna que tenia el enfermo, afectado de estrabismo convergente. Por otra parte, la tenotomia del recto interne produce un retroceso en la insertion del tendon muscular, que dard origen a una insufi- ciencia del musculo, y, por consiguiente, de la misma convergencia. No obstante, la tenotomfa prudente practicada en el nino que tenga buena agudeza visual del ojo desviado puede en algun caso muy raro determinar el enderezamiento del globo ocular, establecer la vision Nuevo Tratamiento Quirurgico del Estrabismo 179 binocular y conseguir la verdadera cura del estrabismo; pero estos casos son excepcionales. Lo que ocurre generalmente es que, si bien al principio el endereza- miento es bastante aceptable, a medida que el nifto crece sin que se restablezca la vision binocular, de una parte el relajamiento espon- tdneo de la convergencia y de otra efecto de la tenotomia, hace que se presente un estrabismo secundario externo que anula por complete la correccion estetica que conseguimos en la nifiez. El campo de mirada de los operados de tenotomia se observara que se encuentra disminuido en la abduccion del globo ocular, y, en cambio, no se encuentra aumentado en la abduccion. Es verdad que el ojo operado presenta un enderezamiento en los movimientos correspondientes a la esfera de accion del musculo tenotomizado, pero es un enderezamiento aparente, realmente debil, al querer seguir a su congenere, no tardando en presentarse la falsa proyeccion y la desar- monia entre las excursiones del globo ocular. La vision binocular no se puede, por lo tanto, restablecer, puesto que falta la armonia indispensable en los movimientos de lateralidad y convergencia de los dos ojos. Si la doble imagen generalmente no aparece, es porque existe una ambliopia en el ojo tenotomizado, con neutralizacion de la imagen percibida. Aunque hayamos conseguido mejorar la agudeza visual del ojo operado, y goce de una vision sufi- ciente, veremos que no es posible se realice la vision binocular, porque entonces aparecera una diplopia cruzada en el campo de accion del musculo tenotomizado, y como la amplitud de la convergencia se dis- minuye por haber debilitado el recto interne, la diplopia se presentard en cuanto el enfermo quiera hacer uso de la vision proxima. Por eso dice Landolt que el efecto de la tenotomia separando el musculo recto interne del globo ocular es el mismo que el de una paresia, puesto que da lugar a una insuficiencia de convergencia, "y, sin embargo, el nombre sol de convergencia decia que no era preciso tomar, sino anadir; no debilitar, sino mds bien reforzar." El efecto de la tenotomia en el estra6ismo divergente, se traduce tambien por un enderezamiento del ojo desviado; pero como en el estrabismo divergente las desviaciones son muy pronunciadas, el enderezamiento que se consigue tenotomizando es generalmente muy insuficiente. Como persiste la divergencia, cuando el enfermo quiere hacer uso de su vision proxima, se presenta la diplopia cruzada, que sera homonima si mira el operado de lejos, parecie"ndonos entonces que su bizqueza se interna. 180 B. CASTRESANA Se comprende que asi suceda; porque si el estrabismo divergente resulta de la debilidad de inervacion del recto interne, y hemos teno- tomizado el recto externo paresiandole, no podrd contraerse lo sufi- ciente en la vision lejana para relajar la convergencia y tendrd nece- sariamente que presentarse un estrabismo convergente con diplopia homonima, como deciamos anteriormente. Charles Giraud sintetiza su opinion diciendo: "Para tener derecho a tenotomizar el musculo recto externo de un ojo cuya vision es suficiente, haria falta que este ojo presentase un gran exceso de divergencia activa." Onfray se expresa en estos te'rminos: "La tenotomia es una operacion peligrosa, cuyo resultado no puede ser absolutamente previsto, y la tenotomia del recto externo es una operacion casi siempre intitil y frecuentemente perjudicial." For ultimo, Parinaud emite su parecer en esta especie de corolario: "A medida que se adquiere experiencia, a medida sobre todo que se persigue en el tratamiento del estrabismo, no solamente el enderezamiento de los ojos, sino el restablecimiento de la vision binocular, tropieza uno con mas y mas inconvenientes del recula- miento muscular." Cuenta Paul Charles Giraud, que habiendose encontrado un dia su maestro Rochon Duvigneaud con el celebre anatomico Farabouf le dijo este en tono sarcastico: "Se cortan todavia los musculos en Oftalmologia." En los Archives de Oftalmologia Hispano-Americanos del mes de Junio pasado, el profesor Landolt, al hablar de los efectos de la teno- tomia, dice que produce la desviacion del ojo en direccion opuesta, la limitacion de la excursion y la falsa proyeccion en direccion de la acci6n del musculo. Al tenotomizar los rectos internos en el estra- bismo convergente concomitante, se crea una insuficiencia de con- vergencia que se opone al restablecimiento de la vision binocular, ademas del efecto antiestetico resultante de la retraccion de la ca- runcula. Si por el contrario tenotomizamos los rectos externos en el estrabismo divergente, producira por igual causa los mismos efectos perjudiciales. Estos hechos, dice Landolt, son la condenacion de la tenotomfa. Esta intervenci6n resultaria todavia mas perturbadora, a mi juicio, practicandola como intervencion unica en el ojo que no se desvia, segiin aconseja Battremieux, el cual corrige indirectamente todo el estrabismo operando sobre el ojo sano, en lugar de limitarse a corregir en este ojo la mitad o poco mas, y el resto en el ojo desviado. Este procedimiento produce en un estrabismo convergente, que es la Nuevo Tratamiento Quirurgico del Estrabismo 181 variedad donde emplea su me'todo, una abduccion del ojo fijador igual a la abduccion o convergencia estrabica. De este modo, cuando fije en primera posici6n con el ojo operado, tendrd que efectuar un movimiento igual al grado de desviacion corregida, y en virtud de la inervacion recuperada por el ojo fijador, para trasladarse desde el sitio donde fue llevado por la tenotomia, hasta colocarse en primera posicion, el ojo desviado que permanecia indiferente en su posicion anormal, se enderezard, por sinergia hasta que alcance la primera posicion. Este procedimiento no ha sido practicado mas que por su autor. De otra parte, el efecto corrector de la tenotomia no se interpreta de igual modo por los diversos autores que se han ocupado de esta cuestion. Las dos hipotesis que mds partidarios han tenido, son la de Parinaud y la de Motais. Para el primero, la tenotomia remedia un trastorno de inervacion y obra debilitando el rmisculo que retrocede de su insercion. Esta debilidad, esta insuficiencia muscular, se podria explicar por la disminucion de extension, a consecuencia del enroscamiento del musculo. En cambio, el segundo fundamente su opinion en el papel importantisimo que juegan las aletas ligamentosas de la cdpsula Tenon, que se prolongan hasta el borde orbitrario cor- respondiente donde tienen su insercion. Estas aletas, supone el profesor Motais, que limitan la contraccion de los musculos, porque son susceptibles de alargarse en cierta medida cuando practicamos la tenotomia. En virtud de este alargamiento, la aleta dispondrd, por consiguiente, de una porcion menor susceptible a ceder en la contraccion muscular. El musculo tendra que luchar desde el principio de su contraccion, con una tension mayor de la aleta ligamentosa, facilmente comprensible, por haber retrocedido el tendon, al separarse de la membrana esclerotical. Esto,nos explicaria la disminucion en la excursion del ojo, y la debilidad o insuficiencia del musculo tenotomizado. El Dr. Lagleyze no acepta la hipotesis de Motais, porque funda- menta sus experiencias en diseccion de animates muertos, es decir, en las peores condiciones para resolver un problema de dindmica muscu- lar, y ademds, porque dice que el dibujo presentado por Motais para sus explicaciones no coincide con los casos, porque la figura deberfa representar en iguales condiciones estdticas de sus musculos, la posi- cion del estrabismo y la de su correccion, para observar el estado del musculo y de su aleta ligamentosa, antes y despue*s de la operation. No hemos nosotros de seguir las disposiciones cientificas que hace 182 B. CASTRESANA tan sabio profesor con respecto a la interpretacion de los esquemas indicados, puesto que no es de nuestra incumbencia en este momento ; solo daremos a conocer sinteticamente su opinion, que al fin y al cabo, es una hipotesis mas en el campo de la ciencia. En la tenotomia dice : " Lo primero que se produce es un endereza- miento del ojo. El musculo antagonista libre de la contractura del musculo tenotomizado, disminuye su longitud, por su propia conici- dad. Abierta la capsula de Tenon al practicar la intervencion, per- mite que la elasticidad propia de la hoja periorbitaria de esta capsula, se retracte sobre el borde orbitario cbrrespondiente al lado operado, y el globo del ojo, una vez disminuidas las adherencias que le detenian en el sitio del tendon cortado, se dirige hacia adelante, volviendo al mismo tiempo hacia el lado opuesto." El resultado, por lo tanto, despues de la tenotomia, sera que el musculo conserva sus dimensiones anteriores, obedece como antes al mismo influjo nervioso, no esta debilitado, y tiene la misma contractilidad, o mayor que antes de la operacion. En la tenotomia de un musculo el que se acorta es el antagonista, en una cantidad proporcional correspondiente a la cor- reccion del estrabismo, quedando el musculo tenotomizado con la misma longitud que antes de la intervencion. En vista de los inconvenientes que tiene le tenotomia, se le ha querido sustituir por otros procedimientos quirurgicos, que respetando la insercion anterior del musculo no la debilite. Empecemos por los desbridamientos capsulares de Parinaud. En el afto 1890, Parinaud ideo su operacion de los desbridamientos, que vino practicando hasta su muerte, como verdadero sustituto de la tenotomia. El ilustre oculista fundamentaba su intervencion quirur- gica, en que la extensibilidad del musculo esta sujeta por sus co- nexiones con la cdpsula, cuyas suspensiones fibrosas podrfan en los estrabismos antiguos presentar adherencias patologicas, que es precise liberar para el enderezamiento del globo ocular. El desbridamiento capsular de un musculo ha de ir acompanado siempre del avance del antagonista resultando la operacion combinada, puesto que se interviene en los demds musculos a la vez. Segiin el Dr. Parinaud, la operacion combinada producira un en- derezamiento inmediato de 25 a 30 que yo no he podido compro- bar. Es precise tengamos una asepsia rigurosa y no traumaticemos mucho en la operaci6n, porque nos puede venir una retraccion in- flamatoria secundaria, que neutralice por complete el efecto, que en un principio se consiguio con el acto quirurgico. Este procedimiento Nuevo Tratamiento Quirurgico del Estrabismo 183 tiene la ventaja de que no modifica la movilidad del globo ocular hacia su parte interim, y por lo tanto, no se opone al restablecimiento de la vision binocular, porque no hace mas que librar al musculo de sus adherencias respetando su insercion anterior. Solo a titulo de curiosidad merece consignarse el alargamiento muscular de Landolt, puesto en vigor el ano 1905. En este pro- cedimiento como lo indica su nombre, el objeto es alargar el musculo encogido, o mejor dicho acortarle, respetando su insercion anterior. En ocasiones, en vez de alargar el musculo se le secciona, y entonces nos encontramos con los graves inconvenientes de la miotorma de Dieffenbach, y asi lo comprendio el mismo Landolt al limitar mucho sus indicaciones. Julio G. Guerin, en 1849, dio a conocer el nuevo procedimiento quirurgico del avance muscular, con el que pretendia corregir el estra- bismo secundario consecutive a tenotomias desgraciadas. En 1872 Critchett modifico su tecnica empleandole como tratamiento de las desviaciones oculares primitivas, y Wecker en 1883, en vez de separar el musculo de su insercion tendinosa, lo plegaba sencillamente, practi- cando un avanzamiento cdpsulomuscular, asociado casi siempre a la tenotomia del musculo antagonista, que fue suprimida mas tarde por Landolt. Este colega, partidario entusiasta de los avanzamientos, desecha las tenotomias y no se contenta solo con el aislamiento del tendon, sino que reseca la parte anterior del musculo, para llevarle mas cerca del limbo esclerocorneal, constituyendo la operacion del avanzamiento con reseccion muscular. El procedimiento de Wecker se caracteriza por la plegadura del musculo y de su capsula, respetando la insercion tendinosa de los rectos. El efecto corrective que conseguimos eon esta operacion varia segun la mayor o menor extension del plegamiento y segun la combinemos o no con la tenotomia. Si practicamos el procedimiento cldsico de Wecker, avanzamiento con tenotomia del antagonista, la desviacion estrabica se corregira de 15 a 20, porque el avance cap- sular aumenta la accion correctora de la separacion muscular, pero en cambio disminuye la abduccion y la amplitud de la convergencia, factores que mas tarde vendran a perturbar la vision binocular. Si hacemos caso omiso de la tenotomia, e intentamos corregir el estrabismo empleando el avance capsular bilateral, observaremos que no corrige mas de 10 a 12, pero no perturba la convergencia, y puede producir la curacion verdadera de estrabismos muy poco pronunci- 184 B. CASTBESANA ados. La correccion que produce el avance capsular bilateral es, por lo tanto, muy limitada y se disminuye, porque al quitar los puntos de sutura desaparece la plegadura del musculo. La cdpsula tenoniana no queda avanzada segiin parecen demostrar las operaciones hechas por Halt en los animales. Es posible, dice Parinaud, que los hilos de sutura determinen en el musculo y la cdpsula una ligera retraction cicatricial. En suma, el inconveniente del avance cdpsulomuscular es que no corrige mds que las desviaciones estrabicas muy d^biles. En mi humilde opinion, de iguales defectos adolece el acortamiento muscular de Lagleyze aun asociado a la tenotomia. Solo corrige las desvdciones estrdbicas pequenas, si no se practican amplias tenoto- mias con todas sus consecuencias. Los estrabismos pronunciados aunque parecen corregirse despues de la intervention, vuelven a reaparecer de nuevo con igual intensidad al cabo de cierto tiempo. La verdadera intervention quirurgica que merece el nombre de avanzamiento muscular, se realiza cuando separamos el musculo de su insertion y lo trasplantamos mas cerca del limbo esclerocorneal. Las modificaciones que se ban hecho en la tecnica cldsica del avanza- miento por Jocqs, no resecando la conjuntiva; el avanzamiento en A de Valude; el avanzamiento y sus cdpsulas en sutura por Rochon Duvigneaud, y la sustitucion de" los hilos de seda por tendones de renguifo, para suturar la esclerotica y no tener que quitar los puntos de sutura, empleados por Terson, han dado casi los mismos resultados. El procedimiento del avance musculocapsular con sutura especial de Jocqs, presentado en el Congreso de 1903, y los distintos trabajos de este ilustre publicista, dados a conocer los afios 1904 y 1909 en La Clinique Ophtalmologique, hicieron que se emplease su tecnica opera- toria por algunos oculistas con resultados halaguenos en los estrabis- mos d^biles. En los pronunciados, aconseja Jocqs que se practique una pequena tenotomia del musculo antagonista, por resultar poco energico su procedimiento. En el avance muscular admite Motais el aumento de la fuerza y la extension del musculo avanzado, funddndose en la hipotesis de que la aleta ligamentosa del musculo que se avanza, se relaja. Para demostrar su opinion presenta unos dibujos artificiosos que segun Lagleyze tienen el mismo error senalado en los esquemas de la teno- tomia. La aleta ligamentosa antes y despue's del avance muscular, ocupa el mismo sitio en el espacio orbitario, dice Lagleyze, y, por consiguiente, las eletas no pueden influir aumentando la action del musculo. Este no avanza en el espacio orbitario como parece des- Nuevo Tratamiento Quirurgico del Estrabismo 185 prenderse de las figuras de Motais, porque seria precise para ello que el globo ocular se mantuviso fijo y no estuviera suspendido en la cavidad orbitaria, como una especie de articulacion del ge"nero de las enartrosis. Para el profesor de la Universidad de Buenos Aires el musculo no aumentara la fuerza, por crearse un nuevo obstdculo en el aumento del antagonista, que ha de neutralizar, empleando parte de su energia, lo que no ocurria antes de la intervencion, puesto que el antagonista en posicion estrdbica tenfa un estado de menor tension. Si nosotros no aumentamos la fuerza de un musculo debilitado, con el avanza- miento del mismo, creo que podemos por lo menos aumentar la eficacia de su contraction, como afirma Landolt en su reciente trabajo, publicado en los Archivos de Oftalmologla Hispano- Americanos en el mes de Junio del afio anterior. Al avanzar el musculo, aumentamos la extension de contacto sobre el globo ocular, lo que producira un efecto suficiente, a pesar de su fuerza escasa. El avance muscular origina por si solo un enderezamiento del globo ocular, sin producir exoftalmia ni deformation de la hendidura palpebral. No disminuye la abduction, y la amplitud de la abduc- tion se ha conservado. El estrabismo secundario no se presenta en el transcurso del tiempo, y con ejercicios constantes de vision binocular, pueden algunos casos de estrabismo muy poco pronunciado llegar a la verdadera curacion. El inconveniente de este procedimiento es que no produce mas que un enderezamiento insuficiente, no sirviendo para los estrabismos de un grado elevado. Para las desviaciones estrabicas muy pronunciadas Landolt reco- mienda las resecciones parciales combinadas con el avanzamiento, me'todo en realidad que se diferencia muy poco en su te"cnica del avanzamiento muscular sencillo. El enderezamiento que se consigue es, sin embargo, mejor, y aumenta tanto ma's cuanto mayor sea la resection muscular que practiquemos, sin que se observe estrabismo secundario. La cor- recci6n es mds acentuada, y, con el empleo de los medios opticos y ortopticos, se consigue en algunos casos la verdadera curacion. Esta se comprende, si tenemos en cuenta que el miisculo, despues de la intervencion quirurgica, no solo queda arrollado sobre el globo ocular, sino acortado, lo que acrecienta su action, sin perjudicar el funcion- amiento del antagonista, para que pueda realizarse la vision binocular. Desgraciadamente, la correction no suele ser duradera en la mayor parte de los casos, cuando el avance con reseccion ha sido monocular, 186 B. CASTRESANA piles bien pronto vuelve a presentar de nuevo el desequilibrio muscu- lar, cuando nuestra intervention se limita solo a un ojo. Es verdad que aparentemente, siendo solo uno el ojo desviado, parecer natural que la operation no debe realizarse mas que sobre el globo ocular que se desvia; pero la observation demuestra que la unilateralidad del estrabismo no existe mas que de una manera aparente, y que la bilateralidad, cuando no es espontanea podemos provocarla mandando al enfermo cubrir el ojo que habitualmente fija, lo que dara origen a la alternativa de la desviacion igual para los dos ojos. El estrabismo al parecer monocular, dice Onfray, "se debe a que uno de los ojos esta forzosamente dirigido hacia el objeto que el individuo quiere ver; pero en realidad se trata de un espasmo de la convergencia, funcion eminentemente binocular por su misma de- finition. Es, pues, logico repartir el efecto operatorio sobre los dos ojos, y los resultados ban demostrado que este metodo, no rompiendo el equilibrio normal binocular en los movimientos asociados, facilita la verdadera cura." Algunos ilustres colegas sostienen nuestra misma opinion, y creen que siendo una afeccion binocular se la debe aplicar un tratamiento quinirgico bilateral. Consecuente con este principio, Pannas prac- ticaba la doble tenotomia de los rectos internes y externos, segiin fuera el estrabismo convergente o divergente, y Landolt, el doble avanzamiento de los rectos externos o internos, segun se trate de una desviacion estrdbica interna o esterna. Si echamos una rdpida ojeada sobre las opiniones emitidas por diversos autores, veremos que casi todos hablan de la tenotomia, del avance capsulomuscular, de avance muscular unilateral con resec- tion, de la tenotomia combinada con el avance; pero ninguno men- ciona el avance bilateral indicado por Landolt. Es mas, asiin despues de haber sido preconizado por tan eminente colega, apenas si lo han practicado aquellos oculistas que mds estrabismos han tratado quirurgicamente. En efecto; si recorremos el capitulo del estrabismo en algunas publicaciones modernas, no encontramos en ellas la recomendacion del doble avance muscular puro y simple, hecha por Landolt. En el trabajo de Guedel (1875) sobre la patogenia y tratamiento del estrabismo despues de emitir la idea de que el verdadero trata- miento del estrabismo es el quiriirgico, dice que debemos practicar la tenotomia sola o combinada con el avance del musculo antagonista, verdadera panacea de la correction estrabica. Nuevo Tratamiento Quirurgico del Estrabismo 187 Testut, en 1881, al publicar el avanzamiento del tendon en el tratamiento del estrabismo, manifiesta que hace falta repartir entre los dos ojos la correction de la desviacion, pero asociada siempre a la tenotomia del recto interne. En la publication de Bonnemaison el afio 1882 acerca de los difer- entes procedimientos quinirgicos para el estrabismo monolateral excesivo, tambien indica que debe practicarse a la vez el avanzamiento del recto externo y la tenotomia. El mismo consejo de Lagrave en 1893 en su trabajo de contribution al estudio del tratamiento qui- rurgico del estrabismo, afirmando que la base del tratamiento radica precisamente en la tenotomia. Mas tarde, tres afios despues, en 1896, Langle en nada modifica las opiniones anteriores, hasta que en 1906 Alberto Delbarne en su "Estudio clinico sobre el tratamiento operatorio del estrabismo con- comitante interne," indica que en los casos de gran desviacion debe intervenirse en los dos ojos, practicando el doble avance, pero asociado siempre a la tenotomia, como venian preconizando los demas autores. Wecker discute sobre las tenotomias simples, o las tenotomias con avanzamiento, y Fuchs y Kavel no hablan del doble avance, el primero en su Tratado, y el segundo en su Manual de estrabismo. Lo mismo le sucede a Bielchowsky en el Tratado reciente de Axenfeld del aiio 1914. Lagleyze en su Tratado del estrabismo, ano 1913, aconseja su acortamiento muscular especial, sin separar el miisculo de la inserci6n, con o sin tenotomia del antagonista. En el Congreso de la Sociedad Francesa de Oftalmologia de 1893, Parinaud, que era el penente para el tratamiento del estrabismo, ni siquiera menciona el doble avanzamiento muscular. Morax y Terrien se limitan en sus modernos Tratados, a citar sencillamente la operation. Solamente Landolt vuelve a insistir, despues de haber emitido la idea del doble avance, en la necesidad de que la operation se generalice, siendo Benet Onfray el que mas la ha dado a conocer en su magnifico trabajo sobre el estrabismo, publicado en 1907. Antes de esta epoca, en 1905, Rochon Duvigneaud habia empezado a tratar a los estrabicos por doble avanzamiento de los rectos externos con resultado positive. Los exitos que consiguio, le hicieron aplicar este metodo a la mayoria de los estrabicos que opero en los Hospitales de Laennec y de la fundacion Rothschild. Su discipulo predilecto, Giraud, en su notable trabajo sobre el doble avanzamiento muscular, al hablar de su maestro, dice : " El no cree que toda la desviacion pueda ser corregida por el doble avance mas considerable posible, es decir, 188 B. CASTRESANA con reseccion importante del tendon muscular," pero le considera un procedimiento excelente. El Dr. Giraud, consecuente con la doctrina de su maestro, cree que no se puede desterrar la tenotomfa actualmente en el tratamiento del estrabismo si bien ha de reservarse solo para ciertos casos, a causa de los inconvenientes que tiene para que se realice la convergencia, debiendo procurar obtener la mayor ventaja con el doble avanza- miento muscular. En cambio, hay otros oculistas como Parinaud, que solamente cuando el resultado obtenido por la intervencion unilateral resulta incompleto, es cuando interviene en el ojo fijador, Lapersonne en las desviaciones debiles tampoco interviene mas que en un ojo, y es precise que la desviacion pase de mds de 10 para que practique la intervenci6n quirurgica bilateralmente. Por mi parte, de conformi- dad con la opinion de Wecker, creo que la intervenci6n unilateral podrfa aplicarse en alguno de los casos de estrabismo que el llama incorrigibles, en los que no podemos esperar mas que una correccion de su deformidad, pero nunca en los curables, que son susceptibles de recuperar la vision. En estos, la intervencion a mi juicio debe ser siempre bilateral, respetando al sinergia binocular. La opinion de Rochon Duvigneaud, cuando dice: "En aquellos casos en que los musculos rectos externos muy debiles se oponen a los rectos internes muy fuertes, el doble avanzamiento muscular por extenso que sea resulta insuficiente, es cierto;" para que el avance de resultado, tendremos que debilitar los internes. Como realizaremos esta debilitacion? Para Rochon Duvigneaud, por un procedimiento ignorado aun, porque la tenotomia es una operacion brutal, excesiva e imposible de dosificar. En efecto, esta operacion que todavia la practican algunos oculistas y que en algunos casos muy excepcionales puede llenar alguna indi- cacion, podrfa tener su apogeo antiguamente, cuando se admitia la teoria muscular del estrabismo, pero en la actualidad no debe prac- ticarse largo, manu, como se hace, porque al debilitarse el musculo, no solo se disminuye la abduccion y la amplitud de convergencia, que son fact-ores indispensables para restablecer la vision binocular, sino que produce alguna vez el estrabismo secundario. iSe debe abandonar en absolute la tenotomia? Creo que la tenotomia bilateral no debe practicarse nunca; unicamente la de un solo lado puedo estar justificada, cuando se trata de un estrabismo con ambliopia acentuada, cuando la contractura muy marcada del mus- Nuevo Tratamiento Quirurgico del Estrabismo 189 culo se acompaiio de cambios de estructura con peidida de su elas- ticidad, y cuando el enfermo es de edad avanzado, y no dispone del tiempo necesario para someterse despues de la operation a los ejer- cicios ortopticos que le pudieran reintegrar a la vision binocular. Aun reuniendose todas estas circunstancias, se debe hacer la teno- tomfa con gran prudencia y solo en las desviaciones estrabicas muy debiles, puesto que hemos indicado que la tenotomia produce una paresia incurable, que dificulta convergencia. Si la asociamos al avanzamiento, constituye la operation com- binada, que produce un enderezamiento del globo ocular mucho mas acentuado. Este hecho no se puede negar, porque la clinica nos lo confirma algunas veces; pero .de admitirla, a creer, como dicen los partidarios de la tenotomia combinada, que son menos marcados sus inconvenientes, porque la debilitation del musculo es limitada por el obstaculo que opone el avance del antagonista a la exoftalmia, hay una gran diferencia. El resultado que se obtiene con algunas tenotomias combinadas, depende, como dice Onfray, del musculo que hemos avanzado en modo alguno del que hayamos tenotomizado. No puedo tampoco admitir la opinion de Worth, al suponer que en los grades considerables el estrabismo, no se puede enderezar el globo ocular con los avances sin producir una enoftalmia, porque tengo operados de estrabismos muy fuertes con el doble avanzamiento indirecto, sin que se haya presentado el fantasma enoftalmico. Debo confesar que en estos enfermos no se practice el doble avance sencillo, lo asociamos a la debilitation del musculo antagonista, en la forma que indicare al hablar de la tecnica operatoria que ejecuto general- mente, cuando opero estrabismos pronunciados. Los inconvenientes de la tenotomia no se evitan ni disminuyen en lo que se relaciona con la convergencia asociandola al avanzamiento, y solo debera practicarse en algunos casos muy especiales como indicaba anteriormente. La operation que no tiene ninguno de los inconvenientes de la tenotomfa es el avance muscular, que yo llamo indirecto, que no solamente nos corregira el estrabismo, sino que muchas veces de- volvera al enfermo estrabico la vision binocular perdida. La ob- jecci6n que se ha hecho a los avances diciendo que tiene unos efectos correctores limitados, puede tener algiin valor, cuando se trate el avance capsular, o muscular unilateral, que es insuficiente, pero la citada objection no puede hacerse cuando se practique el avance bilateral, con resection muscular que duplica el efecto de la operation. En el caso de una desviacion muy debil, en la que no podamos ob- 190 B. CASTRESANA tener la curacion verdadera, por alteraciones irremediables en el aparato dioptrico, el avance muscular unilateral puede ser algunas veces suficiente ; pero si queremos baucar la vision binocular, la cor- reccion debe ser repartida entre los dos ojos. La aplicacion de distintos avances para cada variedad de desviacion no la podemos ad- mi tir en la actualidad. Es inadmisible establecer, que para un estra- bismo inferior a 10, se practique un avance capsular, para uno de 15 a 20 muscular, y si pasa de 25, se refuerce con la reseccion del musculo. Al radicar la desviacion estrabica, al parecer, sobre un ojo solo, lo natural es que la operacion recayese solamente sobre el ojo desviado pero la unilateralidad del estrabismo, repito que es aparente, la desviacion estrabica es alterante, lo que se comprueba mandando tapar al enfermo el ojo que fija, como dejo indicado; pues entonces veremos que hay desviaciones iguales en los dos ojos. Si la desvia- cion, por lo tanto, es bilateral, el efecto operatorio debera repartirse entre los dos ojos, puesto que ambos se hallan afectados. El doble avance muscular indirecto, por acortamiento de los musculos, lo practicaremos en el estrabismo convergente, avanzando los dos rectos externos indirectamente, como describira despues, y en el divergente los rectos internes. Este avance no disminuye el campo de adduccion, aumenta el de abduccion y respeta la conver- gencia. Debe practicarse siempre bilateralmente, si perseguimos conseguir la vision binocular del enfermo. Con el avanzamiento muscular doble indirecto por reseccion del tendon, que le injertaremos despues de acortado en su primitive punto de insercion, aumentamos de una manera considerable la potencia de enderezamiento del avance muscular, y conservaremos siempre la convergencia. Las excursiones nasales no pierden nada, las tenporales se normalizan, y los ojos se mueven correctamente. Muchas veces se obtiene la vision binocular, y una amplitud de convergencia normal. Al ocuparse el Dr. Rochon Duvigneaud del doble avanzamiento, no pretende corregir todas las desviaciones por ,esta operacion. Cuando los rectos internes son muy fuertes en el estrabismo conver- gente, y los rectos externos muy debiles, dice que sera precise ademas de los avances, disminuir la energia potencial de los musculos rectos internos, por algiin medio especial, que quizas pudiere ser seccionado alguna fibra muscular en todo el ancho del musculo, porque la teno- tomia es una operacion que no se puede dosificar. En el estrabismo divergente lo mismo que el convergente, la accion Nuevo Tratamiento Quirurgico del Estrabismo 191 correctora del doble avance indirecto es buena y podemos aumentarla resecando una portion mayor o menor del musculo, segun nos con- venga. La abduction no disminuye con la operation y en cambio conse- guimos que aumente notablemente la adduction. En este variedad de estrabismo el campo de adducci6n est limitado en los dos ojos y mejora con el avance bilateral. A los rectos internes les proporciona una contraction suficiente y paralena para poder realizar la vision binocular, sobre todo en aquellos estrabicos que tienen la facultad de fusion muy desarrollada. Con los avances, por lo tanto, conseguiremos una correction estetica y funcional a la vez, que es precisamente nuestro bello ideal. Claro esta que no se pueden corregir los estrabismos muy pro- nunciados con solo el avance bilateral indirecto, pero si lo asociamos a la debilitation del musculo antagonista, en la forma que indicare, el problema de la correction del estrabismo queda resuelto para todos los casos que se nos puedan presentar. La tecnica operatoria que practicamos en el avance bilateral in- directo con debilitation del musculo antagonista, se diferencia de la que emplean otros eminentes colegas, en detalles, tan importantes, que la podemos considerar como nueva, aunque se nos diga parodiando a Salomon jque nibil novum sub sole. Es cierto que nada puede con- siderarse como nuevo, pero si a un procedimiento operatorio se le modifica en su principio fundamental, y ademds se le anade un acto quirurgico que viene a complementarle, y corregir las deficiencias que tiene, creo nos podemos considerar autorizados para calificarle como nuevo. iComo se debe realizar el procedimiento operatorio ideal del estra- bismo pronunciado? En la forma que vamos a describir: Se hace anestesia local mediante inyecciones subconjunti vales y musculares con solution en suero fisiologico de novocaina y adrenalina que es suficiente, o anestesia general con cloroformo que es la que prefieren casi todos los enfermos para evitar el dolor por complete. Anestesiado el paciente en cualquiera de las dos formas, se desinfecta el campo operatorio, por medio de repetidos lavados con la solution acuosa al 4 por 100 de dcido borico, y se empieza la operation de- bilitando los musculos rectos internos en el estrabismo convergente, para despues practicar el doble avanzamiento indirecto, o viceversa, se debilitan los externos y se avanzan los internos cuando se trata de un estrabismo divergente. 192 B. CASTRESANA Para debilitar el musculo que es el punto mas original e impor- tante de mi intervention, se empieza por aislar su tendon en la forma que lo hacemos cuando se desea separar lo del globo ocular. Colocado el separador palpebral, se coje con la pinza la conjuntiva a unos cuantos milimetros del limbo esclerocorneal. El pliegue que hemos levantado de la membrana conjuntival se escinde de un tijeretazo, y nos queda de este modo abierto en ojal en la conjuntiva, de unos cinco o seis milimetros de extension aproximadamente. Despue"s, con ayuda de las tijeras disecamos los labios del ojal, levantando la conjuntiva en todas direcciones hasta poner al des- cubierto la inserccion tendinosa del musculo, que estard cubierta por la capsula. Cogemos a esta con la pinza al nivel del borde superior del tendon, y con la punta de la tijera la incindimos pro- duciendo una pequena abertura por donde se introduce el gancho de estrabismo. La punta de este instrumento dirigida hacia atrds rasando sobre la esclerotica pada por debajo del musculo, y se pre- senta cubierta por la capsula al nivel del borde inferior del tendon muscular. Se da un corte con la tijera en la capsula y queda libre la punta del gancho. Se introduce otro por la abertura practicada, que sustituye al primero y que camina en sentido opuesto, con el fin de coger el tendon en su totalidad, y una vez conseguido, se levanta con fuerza sujetandolo con la mano izquierda. Colocado el tendon en esta forma, con la tijera o un bisturi, se dan dos cortes en direction vertical, a unos dos o tres milimetros por detras de la inserccion que tiene el musculo con la esclerotica y eri una extension variable, segun quera- mos debilitar mas o menos la potencia muscular. Los citados cortes seran practicados en las partes intermedias, sin cortar nunca las fibras correspondientes a los bordes musculares, superior e inferior, ni tampoco las correspondientes a la parte central, con el fin de que no se modifique el centre del rotation del globo ocular. Cortada en esta forma la cantidad del musculo que nos convenga, se saca el gancho que lo sujetaba y se reunen los bordes cruentos de la con- juntiva, mediante un punto de sutura, pasando inmediatamente despues a practicar el avance bilateral indirecto de los miisculos debilitados. Se coloca el blefarostato y se desinfecta el ojo en igual forma que lo hicimos para la debilitation del musculo. Despues un ayudante por medio de una pinza para fijar, colocada cerca del limbo, sostiene por dentro del globo ocular, mientras que el operador coge con la Nuevo Tratamiento Quirurgico del Estrabismo 193 pinza un pliegue de la conjunctiva, a unos cuatro milimetros del limbo esclerocorneal y de un tijeretazo lo escinde, resecando una pequena porcion de conjuntiva en forma de media luna de concavidad corneal, que deja al descubierto la insercion muscular en la esclerotica. Descubierta la insercion del tendon, se coge la capsula en el borde su- perior del musculo, y con la punta de la tijera se practica en ella una pequena abertura, por la que se introduce un gancho fino de estra- bismo, que llevandolo al ras de la esclerotica por debajo del musculo, viene a levantar en su borde inferior la capsula que se desprende de un tijeretazo. Cogido el tendon muscular en toda su extension con el gancho, se diseca el musculo con tijeras curvas de punta roma, aislandole de la conjuntiva de la capsula y de tejido episcleral. Separado completa- mente, se levanta con la ayuda del gancho de estrabismo, para su- jetarle con la pinza de Prince, a una distancia de su insercion tendi- nosa proporcional al grado de estrabismo. Colocado el musculo en esta situacion, se secciona al ras de la pinza, por delante de ella, quedandonos un trozo suelto de musculo mayor o menor unido a la escler6tica por su insercion anterior, que serd el que resequemos despues de colocar la sutura en rombo que describiremos mds tarde. El trozo de musculo que resecamos, es mas o menos extenso, segun sea mayor o menor la desviacion estrabica, calculando su extension con bastante exactitud en la actualidad, a consecuencia de los estudios comparatives que hemos hecho en la clinica al ver los efectos que producen las distintas cantidades de musculo resecado. Desde luego podemos decir que no se pueden dar dosis de resecci6n con exactitud matematica, por cada grado de desviacion, pero pode- mos asegurar, que no se deben tener las amplias resecciones, y menos si se aplica este calificativo a la reseccion de 4 6 5 milimetros como quiere Landolt. En los estrabismos muy pronunciados he llegado yo a resecar hasta 12 y 15 milimetros con une resultado muy satisfactorio. El Dr. Jenaro Gonzalez, uno de los oculistas espanoles que ha estudiado con mds entusiasmo el problema quinirgico del estrabismo, en su comunicacion a la Academia Quirurgica el afio 1915, acerca de modificaciones quirurgicas al procedimiento operatorio de reseccion tendinosa Schweigger, establece un cdlculo matematico para precisar con exactitud la cantidad de tendon que hemos de resecar, conforme el angulo de desviacion estrabica. Segiin sus calculos matematicos, la cantidad de tendon que podemos resecar es de 2 milimetros por cada 10 de desviacion. En la clinica esta cantidad resulta algo 13 194 B. CASTRESANA insuficiente, y el resultado de su modificaci6n al procedimiento Schweigger no lo cree muy seguro cuando dice: "En algunos casos puede completarse la operacion alongando el miisculo antagonista, segiin el metodo de Verhoeff." Es dificil responder a esta cuestion con una cifra exacta, dice La- gleyze, al hablar del acortamiento muscular, porque la solucion de- pende de causas desconocidas que pueden cambiar segiin las cir- cunstancias. Entre ellas las resistencias de los diversos tejidos, que varian de un sujeto a otro, en virtud de la edad, de la antigiiedad del estrabismo, de las diferencias de la estructura de los miisculos, o en las adherencias anormales que han podido realizarse en el transcurso del tiempo, del conocimiento exacto de la resultante de fuerzas, que acentuan sobre el ojo en distinta direccion, al ejecutar sus movi- mientos, y de causas funcionales o anatomicas imposibles de resolver. De este modo, puede explicarse como en dos estrabismos de un grado igual de desviacion, una misma cantidad de miisculo resecado puede dar un resultado diferente. No obstante, creo se puede calcular aproximadamente una reseccion muscular de dos y medio milimetros por cada diez grados, por lo que he podido observar en la clfnica. El mismo Dr. Gonzalez expresa, que la solucion matemdtica apli- cable a los tejidos tiene su limite, porque en ellos inter vienen ciertos factores que no es posible solucionar con niimeros. Los rmisculos, dice Onfray, no son cintas inertes, sino tejidos que tienen una con- tractilidad propia, sometida a la accion mas o menos intensa de la energia nerviosa, y aunque pudieramos calcular con exactitud mate- mdtica la mudanza de insercion del miisculo resecado, aiin en este caso, nos serla imposible precisar exactamente la cantidad de tendon que debemos resecar, porque la prdctica clinica demuestra que tal precision es imposible. El trozo de tendon libre, separado de la pinza de Prince al ser cortado el musculo que permanece unido a la esclerotica en su parte anterior, nos sirve de punto de apoyo para sujetar con la pinza el globo ocular, al colocar la sutura en rombo, que es otro de los puntos diferenciales importantes de este procedimiento. La sutura en rombo la componen tres puntos, uno central y dos laterales. El primero sigue el didmetro horizontal. Comienza penetrando desde cerca de la cornea por debajo de la conjuntiva y de algunas fibras escleroticales, pasa por debajo de la inserci6n del tendon por donde sale, penetra de nuevo en el espesor de las fibras de la esclerotica por donde camina en una extension de unos dos mili- Nuevo Tratamiento Quirurgico del Estrabismo 195 metres, y finalmente, pasando de dentro a fuera por detras de la pinza de Prince, el miisculo, la cdpusla y la conjuntiva, viene a salir cerca del angulo palpebral externo. Los otros dos puntos laterales de la sutura superior e inferior, em- piezan a unos dos milimetros del central y atraviezan los mismos tejidos. Al salir por debajo de la insercion tendinosa del trozo de miisculo que hemos cortado se desvian hacia el ecuador del globo ocular, para atravesar en este punto algunas fibras escleroticales. Despues de haberlas atravesado convergen en direction al central a pasando por la parte interna del miisculo, capsula y conjuntiva, viene a terminar en la misma region del punto central. Estos puntos de sutura pueden oblicuarse mas o menos, hacia arriba o hacia abajo, si el estrabismo es algo superior o inferior. Constituida la sutura en esta forma limita una superficie romboidal con un diametro anteroposterior mayor que el vertical. Actiian en ella tres fuerzas sobre la linea que une los tres puntos de intersection del miisculo con la esclerotica, produciendose asi una composition de fuerzas cuya resultante dependera del valor de cada una de ellas, o sea de la potencia de cada una de estas cuerdas. Su colocacion especial da lugar a fuertes adherencias escleroticas, que impiden con el tiempo vuelva a presentarse de nuevo la desviacion ocular, como ocurre con las suturas que se practican en otros procedimientos, proque no debemos olvidar que la colocacion de los puntos es uno de los factores principales de la operation. Colocados en la forma indicada los puntos de sutura, se suelta la pinza de Prince, y teniendo los hilos de seda algo tensos un ayudante, se secciona la porci6n resecada del miisculo al ras de su insercion tendinosa. Despues, aproximando el ayudante con las pinzas los bordes de la incision de la conjuntiva, se hace el anudamiento de los puntos, comenzando por el del centre. Al colocar estos, se trae el borde cruento del miisculo resecado a injertarle en el punto de la esclerotica, donde se insertaba el tendon, provocando, por lo tanto, un avanzamiento indirecto del musculo, puesto que una parte mas posterior del mismo viene a colocarse en una region mds anterior de la esclerotica, pero sin traspasar los limites de la primitiva insercion tendinosa, con el fin no se rompa el equilibrio muscular. Si el estra- bismo es directo, se aprietan igual todos los puntos, pero si es ligera- mente oblicuo, pondremos un poco mds tenso el lateral correspon- diente. Hecho esto, se fijan los extremes de la seda con un esparadrapo a la 196 B. CASTRESANA parte externa, se instilan en ambos ojos unas got as de atropina con el fin de paralizar la acomodacion, y se coloca un vendaje binocular. Los grabados que publicamos hacen que se comprendan facilmente los distintos tiempos de la nueva tecnica operatoria que empleamos para corregir el estrabismo. Si hemos seguido todas las reglas de la asepsia, no hay temos a la infeccion, y, por lo tanto, no es necesario levantar el vendaje hasta pasadas las cuarenta y ocho opras despue"s de la operacion. Al levantar el vendaje lavaremos bien ambos ojos con la solucion borica e instilaremos nuevamente atropina. Estas curas se repetiran cada dos dias, y al octavo se podran quitar los puntos de sutura, dejando un vendaje monocular en el ojo que no se desviaba, y en el estrabico una pantalla colocada mas hacia el lado que tuvo el estrabismo, para que el enfermo mire por el lado contrario. Se sigue instilando atropina hasta que desaparezca por complete todo fenomeno de reaccion operatoria, y llegado este momento se suprime el midriasico para que vuelvan a contraerse las pupilas, conseguido lo cual se hace la direccion del defecto de refraccion que hubiere en los ojos y se da comienzo a la gimnasia de convergencia y acomodacion, que ejecutara el enfermo por espacio de mucho tiempo, empleando los medios ortopticos, con el fin de conseguir la vision binocular, que es la ver- dadera curacion del estrabismo. Desde el afto 1915, que empece a practicar esta tecnica operatoria, hasta la epoca presente, la he modificado en algunos detalles para corregir pequenas deficiencias que pude observar tenia en mis primeras intervenciones. En la description que dejo expuesta, se incluyen hasta los datos m&s insignificantes de las modificaciones hechas en el procedimiento operatorio hasta el momento actual. Creo se puede decir que he llegado a su perfeccionamiento complete, si tenemos en cuenta los resultados altamente satisfactorios que obtengo con su empleo. El numero de enfermos que he sometido a esta intervencion qui- rurgica desde el afto 1915 al 1919 pasan de 100. iComo podria evitarse la intervention quirurgica en el estrabismo? En muchos casos preViniendo el desarrollo de la enfermedad, para lo que es necesario tratarlo convenientemente cuando se inicia, porque hemos de advertir que el tratamiento quirurgico no produce siempre la curacion verdadera del estrabismo. Es, por lo tanto, de un valor terape"utico inferior a los medios 6pticos y ortopticos. Los primeros corrigen los vicios de refraccion del aparato dioptrico, Nuevo Tratamiento Quirurgico del Estrabismo 197 o lo que es lo mismo, evitan las causas que predisponen al estrabismo, y los segundos educando la vision binocular contribuyen poderosa- mente a remediar el defecto de la facultad de fusion, de donde resulta, en realidad, que el enderezamiento ocular mediante la intervencion quirurgica, no es mas que un auxiliar de los medios funcionales cuando buscaraos la curacion verdadera del estrabismo. Si el estrabismo es un vicio de desarrollo de la vision binocular, que se favorece por causas locales, se comprende facilmente que el empleo de los llamados medios funcionales debe establecerse desde el momento que se inicia el estrabismo en la nifiez. Es precise educar a los padres para que salgan de su indiferencia in justifiable, esperando una curacion expontanea que nunca llega, y es necesario convencer a las madres de que es imprescindible hacer cuanto sea posible para que los ninos lleven cristales correctores de su vicio de refraccion, aun cuando sean antiesteticos. Si los padres abandonan a sus hijos en la nifiez, las modificaciones que se realizan en el aparato de la vision binocular son cada vez mas profundas, y cuando son ya crecidos, la correccion optica y el tratamiento ortoptico daran un resultado poco satisfactorio, teniendo necesidad de asociarlo al tratamiento quiriirgico. La intervencion operatoria no esta justificada en los ninos pequenos de dos a siete anos. En esta edad limitaremos nuestro tratamiento a una correccion optica bien hecha, a la atropinacion del empleo de los ejercicios ortopticos desde el momento que lo permita la inteli- gencia del nifio, con lo que se consigue muchas veces desarrollar la facultad de la fusion, manteniendo el equilibrio monocular. Estos ejercicios los hara el niiio lo antes posible con el amblioscopio Worth, instrumento el mas aproposito para el nifio porque le divierte, al mismo tiempo que le hace desarrollar el sentido de al fusion. Cuando los padres han abandonado al enfermito, en los primero tiempos de presentarse la enfermedad, y el estrabismo se ha hecho permanente con marcada ambliopia del ojo desviado, es precise mejorar la agudeza visual de este, corrigiendo la anatropia atro- pinizando el ojo fijador. Desde el momento que el ojo ambliope trabaja diariamente, mejora su agudeza de una manera rdpida, y en poco tiempo nos encontramos en condiciones de practicar con fruto ejercicios de vision simultdnea y binocular, con el amblioscopo y el esteroscopo. El mismo adolescente, que sabe leer, debe someterse a los medios funcionales que dejo indicados y ademds hard diariamente sesiones 198 B. CASTRESANA de vision binocular ayudado del diploscopo de Remy, alternando los ejercicios eteroscopicos con cartones divertidos. El uso del estero- scopo, dice Onfray, es muy util, despues de hacer uso del diploscopo "para relajar activamente la convergencia, fortificar el sentido de la fusion y producir la sensacion de relieve"; los ejercicios ortopticos deberdn terminarse con sesiones de vision binocular sin instrumento, mediante la lectura comprobada. El estrabico debe trabajar con- stantemente por extender su campo de vision binocular, y forti- ficar sin descanso la aptitud adquirida de fusionar la doble imagen, para lo que es precise que ejerzamos sobre el una especie de sugestion y no abandone el tratamiento. Aiin cuando no llegamos al enderezamiento del globo ocular, la aptitud a la fusion de las imagenes que hayamos conseguido por medio de los ejercicios funcionales, contribuird poderosamente a la curacion verdadera del estrabismo cuando tengamos necesidad de intervenir quinirgicamente. Si a pesar de haber empleado todos los medios llamados funcionales, el nino llega a los doce o catorce afios sin haber conseguido la vision mas que en ciertas posiciones de la mirada y sin haber corregido mas que de una manera incompleta su desviacion, debemos aconsejarle la intervencion quirurgica, que aplicaremos sobre los dos ojos, con el fin de obtener su curacion verdadera. La tecnica quirurgica que apliquemos ha de variar necesariamente segun el grado de desviacion estrabica que tenga el enfermo. Si esta es debil, inferior a 14, es suficiente el doble avance muscular indirecto con pequena reseccion tendinosa y la sutura en rombo, para que podamos conseguir facilmente la correction del estrabismo. Cuando el dngulo de desviacion alcanza de 18 a 20, serd precise ademds del avance, la reseccion muscular mas extensa en la forma indicada anteriormente, y por ultimo, para las desviaciones mas elevadas hasta cuarenta y tantos grados, asociaremos al avance y reseccion, la debilitation de los musculos antagonistas, rectos, internes o externos, segun sea el estrabismo convergente o divergente, practicando en todos los casos la sutura romboidal. No olvidaremos en la tecnica operatoria un detalle que, a mi juicio, tiene mucha importancia; me refiero a que no debemos quietar los hilos de sutura mientras no pasen ocho dias despue's de la intervencion para que las adherencias de los tejidos puestos en contacto durante el acto operatorio se consoliden completamente antes de separar los hilos. Es necesario tambien recordar el beneficio que reporta la Nuevo Tratamiento Quirurgico del Estrabismo 199 atropinizacion de los dos ojos para relajar la convergencia, el empleo inmediato de los ejercicios ortopticos, mediante el diploscopo, el esteroscopo y los ejercicios de vision binocular sin instrumentos, en el ultimo perfodo. Mediante estos recursos, podemos en muchos casos, si el enfermo dispone de tiempo y paciencia, llegar a la ver- dadera curacion del estrabisrno. Decimos al hablar de la intervencion quiriirgica, que debe aplicarse sobre los dos ojos, y asi debe ser en efecto, cuando buscamos la cura- cion verdadera; pero en aquellos casos en los que el enfermo no desee recobrar su vision binocular, o se trate de una muchacha joven, que bajo ningun concepto ha de llevar puestos sus vidrios correctores, para no afear su belleza, estamos autorizados a practicar una inter- vencion monocular y hasta la tenotomia prudente, operacion que hemos de rechazar en la mayoria de los casos, por las razones que hemos consignado al hablar de la te"cnica quimrgica del estrabismo. De cuanto llevo expuesto se deducen los siguientes corolarios : El estudio de la tecnica operatoria del estrabismo, es uno de los capitulos de nuestra especialidad que menos ha progresado en Espana, hasta la epoca actual, lo que se debe a la escasez de material clinico humane para iritervenir quinirgicamente, y no al prejuicio religiose, como opina algiin ilustre colega extranjero. Las intervenciones quirurgicas del estrabismo son diversas, segun dejamos consignado. La mayor parte de los autores emplean una tecnica que se diferencia de la general, en detalles mas o menos im- portantes, sin que tengamos hasta la fecha una que sea aceptada como procedimiento ideal por todos los operadores. La tenotomia, el acortamiento muscular, el avanzamiento muscu- lar, el avance capsular, capsulomuscular, el muscular simple, o con reseccion de mayor o menor parte del rmisculo, y la miectomia, son los distintos procedimientos que aisladamente, o combinados con la tenotomia del musculo antagonista, se vienen aconsejando indistinta- mente segun la variedad y mayor o menor grado de desviacion que tenga el enfermo estrabico, lo que demuestra la falta de un procedi- miento quiriirgico que pueda aplicarse con las variantes consiguientes, en todos los casos de estrabismo que se nos presenten. La tenotomia, operacion indosificable, de efectos variables, in- seguros y perniciosos siempre para la convergencia, debe abandonarse casi por complete, practicandose solamente en algun caso muy ex- cepcional, porque puede producir a la larga fecha la retraccion del 200 B. CASTRESANA pliegue semilunar de la caruncula, desviaciones secundarias, paresia muscular y dificultades en la vision binocular. El avanzamiento muscular, o el acortamiento del miisculo, que aconsejan practicar algunos autores unilateralmente, es insunciente en la mayorfa de los estrdbicos, si no se combina con la tenotomfa, en cuyo caso la intervention adolece de los defectos de esta operacion. Lo mismo ocurre con los desbridamientos capsulares, el avanza- miento muscular sencillo monocular asociado con la reseccion del mtisculo. Son procedimientos operatorios insuficientes por si solos para corregir los diversos grades de una desviacion estrabica pronunciada. El doble avanzamiento muscular sencillo indirecto o con resecci6n de cierta cantidad de miisculo, siempre asociado a la sutura romboidal y combinado con la debilitation de los musculos antagonistas cuando la desviacion estrdbica es pronunciada, me parece el tratamiento quirurgico ideal del estrabismo en la actualidad. Las desviaciones estrabicas de poca intensidad se corrigen con el doble avanzamiento sencillo indirecto, pequena reseccion tendinosa y la sutura en forma romboidal. En los grades fuertes de estrabismo es preciso afiadin ademas, la reseccion muscular en mayor o menor extension, y la debilitation de los musculos antagonistas. Con este tratamiento quirurgico, la correccion estetica, conseguida desde el primer momento, persiste y mejora en el porvenir al restable- cerse el equilibrio muscular, lo que no ocurre generalmente con otros procedimientos. Es la operacion mas racional para que se normalicen paulatinamente las excursiones del globo ocular y para que la vision binocular se restablezca en todos aquellos casos que lo permita su agudeza visual. Los operados deben someterse a la correccion 6ptica y al trata- miento ort6ptico consecutive, como en los demds procedimientos operatorios. El doble avance muscular indirecto, la sutura romboidal y la de- bilitacion del rmisculo antagonista, son los tres factores importan- tisimos que nos autorizan a considerar como nuevo el procedimiento quirurgico que practicamos nosotros, para corregir el estrabismo. A NEW PROCEDURE IN THE EXCISION METHOD OF PTERYGIUM OPERATION DR. E. CAMPODONICO Lima, Peru It is a well-known fact that pterygium is of frequent occurrence in the tropics as compared with its relative rarity in the temperate regions. In the coastal zone of Peru it is especially prevalent, owing to the dusty condition of the air consequent on the dryness of the soil and the lack of rainfall. In my one-year-long visit to the clinics of the United States I have seen very few operations for pterygium, whereas here in Peru it is an operation of almost daily occurrence. My experience in the Euro- pean clinics points to the same infrequency. With such an ample field and variety of cases as are forthcoming in the Peruvian ophthalmic clinics I had the opportunity of lavishly trying all the known methods, gauging their advantages and disad- vantages as well. Indeed, our outdoor patients' consulting depart- ment of the Italian hospital in Lima has an average daily number of 150 ophthalmic cases. In the following exposition I beg to outline a procedure which has given me the best results for a period of over twenty years. The needed instruments are: lid-speculum, small fixation forceps, preferably one-toothed, angular keratome, straight or curved fine scissors, fine silk suture, and occasionally a needle-holder. The operation is performed in three steps: (1) Dissection of the pterygium 's head out of the cornea and adjacent sclera by means of the angular keratome; (2) excision of the pterygium's head and body by means of small scissors; (3) suturing of the flaps. I have nothing to say about the first and second steps, as the per- ormance thereof is a matter of routine practice. The only thing I should insist upon is the use of the anesthetic by instillation, not by subconj unctival injection, as the areolar infiltration resulting from the injection is detrimental to the accurate subsequent coaptation of the flaps. 201 202 E. CAMPODONICO The third step, i. e., suturing, is the one wherewith I shall deal with some detail on account of the decisive influence on the outcome and ultimate issue of the whole operation. The placing of the conjunctival suture and cicatrix in a position favorable for recurrence is the paramount disadvantage of most of the methods in vogue for the extirpation of pterygium. The safest plan is to remove such conjunctival union from exposure in the Fig. 1. Conjunctival defect after excision. palpebral fissure, as by so doing, in the excision operation, we actually lessen the proclivity to recurrence. Fig. 1 shows the conjunctival defect after excision of the pterygium. Our method consists in suturing the conjunctiva to the point a with the episcleral tissue and conjunctiva of the point b, as is shown in Fig. 2. Next the points c and d of conjunctiva are united by another suture, as shown in Fig. 3. As is easy to understand, the essential feature of this method is the insertion of a suture which is passed through the conjunctiva of one flap at a point a (Fig. 1), and through the episcleral tissue and con- New Procedure in the Excision Method of Pterygium Operation 203 Fig. 2. Conjunctiva sutured in place. Fig. 3. Second conjunctival suture. 204 . E. CAMPODONICO junctiva of the point b. The points a and b (Fig. 1) are equidistant from y. Thus, when a comes to b, the tract a y overlaps the portion of limbus b y. The point a is perfectly movable, because it takes the conjunctiva only, whereas the point b is quite steady and immovable by reason of comprising the limbus conjunctivas and episclera as well. Occasionally, and especially in cases when the pterygium's head is large, it is advisable to undermine a little the flap a in order to avoid the stretch on this flap when a is anchored to 6. On drawing the flap a to b an actual overlapping of a portion of the cornea may result; this, however, is quite uneventful, and on taking off the bandage in a couple of days' time everything will be found in a perfect coaptation. Instead of making the lower flap movable and the upper one fixed, we may just as well do the reverse and anchor a loose point of the upper flap to the episcleral tissue and limbus conjunctivas of the lower. This we have done several times, namely, in cases in which it is easier to loosen and slide the upper flap than the lower. We prefer, how- ever, the first way, because the conjunctival seam is thus more effi- ciently protected by the agency of the upper lid from exposure. At the end of the operation it will be found also that fibers which had before a horizontal direction, now have a vertical one; their natural trend of growing is consequently thwarted. A still further advantage in removing the conjunctival apposition line from the horizontal meridian is the fact that by so doing we eliminate in the horizontal line the presence of sutures which un- doubtedly act as a stimulus for reproduction of connective and fibrous cicatricial tissue, just exactly in a place where it is least desirable. The eye is bandaged for seven or eight days, after which the sutures are removed. The bandage is changed every other day. Whenever possible, it is a good plan to keep both eyes bandaged at least for a couple of days. As previously stated, in a place like Lima, where pterygia are espe- cially plentiful, I have operated many hundreds of cases by the procedure just described and have eagerly and abundantly tried every new method that reached my acquaintance, with the result that I always gave it up to return to the simple course I have outlined above. SUMMARY The most salient disadvantage in the ordinary excision method of pterygium operation is the placing of the conjunctival suture and The Subconjunctival Excision of Pterygium 205 cicatrix in the horizontal meridian, i. e., in a position especially favor- able for recurrence. The author's procedure consists in removing the suture and cicatrix as much as possible from the palpebral fissure by simply anchoring a movable and nearly middle point of the lower conjunctival flap to a fixed and steady point of the upper flap, namely, to the episcleral tissue and limbus conjunctives of the upper flap. Thus the limbus corneae, from which the pterygium's fibers have been extirpated, is covered by a sound stretch of conjunctiva and the horizontal trend of the fibers is thwarted vertically. THE SUBCONJUNCTIVAL EXCISION OF PTERYGIUM DR. S. LEWIS ZIEGLER Philadelphia That pterygium is a vascularized, fleshy growth of conjunctiva invading the cornea, and composed chiefly of hypertrophied subcon- junctival tissue, is a pathologic fact which is highly significant in its relation to both treatment and prognosis. The ancients regarded pterygium as malignant in origin, and, like other neoplasms, they removed it by total ablation. Scarpa 1 was the first to deny this origin, but classified it as a varicosity resulting from chronic con- junctivitis. Alt 2 hypothetically ascribed the origin of pterygium to a marginal corneal ulcer, although he could not demonstrate this in his prepara- tions. Goldzieher 3 found considerable disturbance of the corneal epithelium around the head, while beneath it Bowman's membrane was detached and the fibers of the corneal stroma were thickened. At the margins he described small cavities dotted with epithelium and other signs of mucous degeneration. He also noted episcleral thickening, and believed that corneal ulceration was the origin. Horner 1 first promulgated the view that pinguecula and pterygium were two stages of a similar pathologic process. Poncet, 5 in a recent specimen, found no evidence of- corneal ulceration, although Bow- man's membrane was slightly eroded and the vessels somewhat dis- torted; but there was no sign of inflammatory proliferation. Al- though neoformation of tissue was absent, he did observe that the elements of a cicatrix were present. In a few preparations he found 206 S. LEWIS ZIEGLER vibrios and spores which he thought might be responsible for the focal point of the affection in these individual cases. Fuchs, 6 in an extensive study of several hundred specimens, both in vivo and postmortem, eliminated ulceration and supported the view that pinguecula was the origin. He had never found the vibrios noted by Poncet, nor were other microorganisms observed. He occasionally found yellowish spots with hyaline aggregation, and in six cases he noted small cystic cavities filled with a clear liquid. De Schweinitz, 7 Strachow, 8 and others have confirmed this observation by reporting similar cases of cystic formation within the body of the pterygium. Panas, 9 in reviewing the pathology of pterygium, called attention to its macroscopic resemblance to cicatricial tissue. He further de- clared that the theory of corneal ulceration is founded neither on clinical observation nor on histologic examination. He concluded that the primary lesion was an involutive dystrophy of the cornea with secondary hyperemia, hypertrophy, and retraction of the con- junctiva; that there was a predisposing cause in the individual, to which were added exciting causes due to prolonged exposure to irritants, such as dust, sand, heat, wind, or lacrimal disturbances. Pterygium should always be removed (a) When it is progressive; (6) when it interferes with vision; (c) when it limits ocular motility; (d) when a capital operation on the globe is planned; or (e) when it is cosmetically disfiguring. The requisites necessary to success in the operative treatment of pterygium are: (1) Thorough removal of the head, leaving clear corneal tissue; (2) careful excision of the subconjunctival tissue, especially about the limbus; (3) complete closure of the conjunctival wound, with close approximation to the limbus; (4) the avoidance of conjunctival tearing and tension; (5) rapid primary union, with as thin a conjunctival flap as it is possible to secure. The earliest methods resorted to for the removal of pterygium de- pended upon excision, more or less complete. The resulting wound was universally left open, to be healed by granulation. This neglect was responsible for many cases of recurrence. The necessity for a complete covering of the scleral defect cannot be too strongly empha- sized as a precautionary measure to obviate such a danger. It is better to insert a suture close up to the limbus, and if necessary, to include the scleral and episcleral tissue, in order to fix it there evenly and thus promote firm, smooth healing. Neglect of this simple The Subconjunctival Excision of Pterygium 207 technic will often permit the formation of cicatricial tissue, which will not only interfere with the motility of the subjacent rectus muscle, but may encourage recurrent or pterygoid growth. Another defect in many of the older operations arose from the neglect to remove the head of the growth, which, if progressive, con- tinued to encroach upon the cornea. Many methods have been devised for the successful accomplishment of this simple essential, and a variety of instruments have been suggested. A narrow von Graefe cataract knife is the knife of choice adopted by the majority of operators. As a rule, this is entered flatwise beneath the con- stricted neck, with the edge turned forward and the head cleanly shaved off from the cornea. Others select Beer's knife for the same purpose, because its angular point makes it easier to insert, and be- cause the wider blade yields a clean, broad incision that is safer to make and freer from post-operative tags of tissue. Personally, I prefer to use Beer's knife as a dull dissector, first making firm traction on the neck with forceps and then applying the back of the blade near its point to the stretched-out marginal fibers. These will gradually yield, just as a lichen is pulled off from a tree, and a clean corneal surface is secured. If, by chance, a small shred of tissue is left behind, the knife should be reversed and the blade applied as a razor to cleanly shave the corneal surface. The ordinary broad- pointed scalpel is often used in a similar manner. Some choose the blunt-pointed knife of Desmarres. Others prefer to use the angular keratome or Taylor's broad needle to accomplish a like purpose, the value of the latter having been strongly urged by Black. 10 A bent, double-edged, short von Graefe knife has been adopted by McRey- nolds, 11 but this again is practically identical with the angular broad needle of Taylor. McReynolds insists that shaving the cornea is far more effective in his climate than divulsion. Removal of the head by blunt dissection has been warmly advocated by many. Prince 12 has particularly recommended divulsion with a strabismus hook applied successively to small sections on each side of the growth, which is torn loose by short, jerky movements from the neck toward the apex, until all the filaments are severed and the cornea stripped clear. The strabismus hook "divulsor" has also been made up with a beveled edge or with a knife edge, and also with a sharp point. Special hooked scissors, such as Chadwick's, have been devised for this purpose, but many simply use the closed blades of the tenotomy scissors as a blunt dissector. .The multi- 20S S. LEWIS ZIEGLER plicity of instruments shows that there is no really important advan- tage to be gained from the use of one over the other; all of which emphasizes the fact that the choice of an instrument is a mere matter of detail in the technic of each individual operator. Curetment of the corneal surface should be gently made if any apical fibers remain adherent. The Gallardo corneal curet, the small toothed curets of Skeel or Ziegler, and the hoe-shaped corneal spud have all been employed for this purpose. Both the knives of Beer and of von Graefe have been used to shave the surface of the cornea. The galvanocautery, as suggested by Panas, may be lightly applied to the rough corneal surface if other measures should fail to clear it. This is of particular advantage where the growth is so adherent as to require morcellation. The eschar must be promptly removed with the curet and ^ per cent, formalin carefully applied to prevent leukomatous scarring. Accepting the theory that subconjunctival hypertrophy is more or less cicatricial in character and possesses, therefore, a persistent tendency to undergo contraction, and that it is this, tissue which invades the cornea and causes recurrence, I conceived the idea that the thorough removal of this subconjunctival tissue would not only encourage smooth healing, but would also eliminate the danger of recurrence. It is likewise my belief that the same principle holds good in the surgery of symblepharon or other growth of a cicatricial character. Acting on this theory, I began, in 1890, to practise the following simplified method of subconjunctival excision, which in my hands has proved to be not only a cosmetic success, but has been absolutely free from recurrence. Cocain is sufficient as an anesthetic, and adrenalin may be instilled as a hemostatic. If desired, a stronger solution of cocain (20 per cent.) can be applied directly to the growth with an applicator while the lids are held open to avoid contact with the cornea. Some pre- fer to inject novocain, 1 per cent., beneath the field of operation, but the consequent edema may distort the outlines of the growth. AUTHOR'S METHOD OF SUBCONJUNCTIVAL EXCISION First Stage. The neck of the pterygium is grasped firmly with rat-tooth fixation forceps, drawn tense, and the marginal fibers of the head freely divided with the back and point of a Beer's knife, used as a dull dissector. If the apex is unusually adherent, the knife may be passed beneath the neck and the head shaved off (Fig. 1). The Subconjunctival Excision of Pterygium 209 Second Stage. Still grasping the apex and holding it tense, both sides of the pterygium are cut loose with the conjunctival scissors, the body undermined, and the flap lifted up (Fig. 2). Third Stage. The forceps which grasp the apex are now handed to Fig. 1. First Stage: Head removed with Beer's knife as dull dissector. Fig. 2. Second Stage: Detaching body from sclera with scissors. an assistant, who continues to hold the flap taut, while the subcon- junctival tissue beneath the flap is grasped by a second pair of forceps and carefully dissected off from the conjunctiva by delicate snips of the sharp-pointed conjunctival scissors (Fig. 3). When the con- junctival flap is freed from the underlying tissue its apex is excised and 14 210 S. LEWIS ZlEGLER the remaining flap of pure conjunctiva dropped back toward the canthus. Fourth Stage. According to the size of the scleral defect to be covered I resort to one of three different procedures (a), (6), or (c): Fig. 3. Third Stage: Hypertrophied subconjunctival tissue being carefully dissected from conjunctiva with scissors. Fig. 4. Fourth Stage: Sutures inserted. Juxtacorneal one anchored in sclera. Roll of conjunctiva snipped to relieve tension and smooth it out. (a) // the pterygium is small, the conjunct! val wound is closed by two sutures, the Juxtacorneal one being anchored in the sclera. This may cause overlapping of the corneal margin, which is corrected by clipping the cuff -like roll of conjunctiva in several places with scissors The Subconjunctival Excision of Pterygium 211 and pushing it back. As the conjunctiva again smooths out these "pie-cuts" open into small, diamond-shaped perforations which relieve all tension and heal smoothly (Fig. 4). (6) // the wound is larger and the conjunctival tension is great, two short paracorneal incisions (5 mm.) are made, above and below, the conjunctival edges undermined, and the wound united by two sutures, the juxtacorneal one being anchored in the sclera. (c) // the denuded area is extremely large, two sets of liberating incisions are made, the paracorneal incisions above and below being supplemented by incisions made parallel to the first (5 to 10 mm.), and placed at the canthal extremity of the wound. The quadrilateral flaps thus formed are closed with three sutures, the juxtacorneal one being anchored in the sclera, and a mattress anchor suture placed at the canthal intersection, as in Knapp's double transplantation. AFTER-TREATMENT. As a rule, the simple technic of the first pro- cedure (a) is wholly adequate to close the wound . Healing is smooth and prompt, owing to the avoidance of extensive dissection and the freedom from tension. A monocular dressing is applied for three or four days. The Liebreich patch may be worn a day or two longer. The stitches can be removed on the third or fourth day. Boric acid irrigation is used once daily until the pad is discarded, then three times a day. The eye usually remains red for one or two weeks. If there is lacrimal disturbance, the tear-duct should be dilated at least ten days before the pterygium operation is attempted. The principle of Subconjunctival excision of the hypertrophied adventitious tissue can be applied as well to any other of the well- known pterygium procedures. I have tried it in McReynolds' modi- fication of the technic of Desmarres, Sr., and found it successful in producing a much thinner flap, which made the procedure a greater success. To recapitulate briefly the advantages of Subconjunctival excision of pterygium, I should say that the four factors most worthy of con- sideration are (1) Reduction of a thickened flap; (2) avoidance of extensive dissection; (3) freedom from conjunctival tension, and (4) prevention of recurrence. REFERENCES 1. Scarpa: TraitS des Malad. des Yeux, 1821, i, 261. 2. Alt: Anat. des Auges, 1880, 52. 3. Goldzieher: Centralb. f. prakt. Augenh., 1878. 4. Homer: Corresp. f. Schweiz. Aerzte, 1875, 554. 212 E. CAMPODONICO AND S. LEWIS ZIEGLER 5. Poncet: Arch. d'Ophtal., 1881, i, 31. 6. Fuchs: Graefe's Arch. f. Ophth., 1891, iii, 143; 1892, ii, 1. 7. de Schweinitz: Trans. Coll. Phys. Phila., 1908, 319. 8. Strachow: Klin. Monatsbl. f. Augenheilk., 1908, 563. 9. Panas: Traite des Malad. des Yeux, 1894, T. ii, 262. 10. Black: Ophthal. Rec., December, 1897, 650. 11. McReynolds: Jour. Am. Med. Assn., 1932, 296. Ophthal. Rec., November, 1909, 526. Ophthalmoscope, March, 1914. 12. Prince: Arch. Ophthal., January, 1885, 16. DISCUSSION OF PAPERS OF DRS. CAMPODONICO AND ZIEGLER DR. JOHN 0. MCREYNOLDS (Dallas, Texas) : In discussing the papers of Drs. Ziegler and Campodonico three distinct observations are relevant: 1. For small and medium size pterygia in localities that do not strongly predispose to the development or recurrence of the growth many different surgical measures may yield excellent results. The crucial test is made, however, in the large vascular types associated with atmospheric conditions favorable for the production of this condition. 2. The second observation relates to the removal of the head of the ptery- gium from the cornea. In my experience the essential thing is an absolutely complete and smooth removal of every vestige of the head, leaving only smooth clear corneal tissue beneath. This eliminates all forms of divulsion, curetting and cauterization, and requires a dependable cutting instrument. For ordinary cases a Graefe knife is sufficient, but for exceedingly large pterygia, covering practically y 9 ^ of the cornea, the most effective instrument is a very sharp angular keratome not broader than 2 mm. at its base. This permits the surgeon to apply the cutting edge in such a way to- the spherical surface of the cornea that it can shave off every particle of the growth without going too deep into the corneal stroma. 3. The third observation relates to the removal and disposition of the body of the growth with the necessary covering of the denuded area of the sclera. Each of the papers emphasizes a feature of value. The paper of Dr. Ziegler dwells upon the importance of removing the redundant subcon- junctival tissue. The paper of Dr. Campodonico dwells upon the importance of eliminating all sutures in the palpebral opening. Both of these objects are worthy of every consideration and both can be accomplished by means of a single suture which fixes the growth in the lower cul-de-sac, utilizing the attenuated conjunctival element of the pterygium in covering the scleral defect, taking care that there shall be no break along the superior border of the growth which would allow the wound to gape and necessitate the intro- duction of sutures in the palpebral opening. DR. A. E. PRINCE (Springfield, 111.): The subconjunctival removal of pterygium is a practice which I have followed for many years in cases where there is a large amount of hypertrophied tissue, and this I have done by simply excising the fleshy portion after laying back the superficial conjunctiva. I wish particularly to speak of a method of treating pterygium in another class of cases; those which are attenuated, spread over considerable area, or The Excision of Pterygium 213 are very minute, and have no flesh under them. They hardly justify a sur- gical operation if it can be avoided. In those cases I have found that by taking some carbon dioxid ice, having previously cocainized the cornea, and applying the ice at intervals of about a week, the pterygium will disappear. I think what takes place is a destruction of the blood globules in the minute capillaries and subsequent atrophy of the tissue. In an old lady, where three-fourths of the cornea was covered and vision reduced to 1 /200, four treatments brought vision to 20 /200. The application should be one second. Carbon dioxid is simple to handle. You can get a tank of the gas in almost every city where there is a soda fountain. Suspend it on the wall with the portion at which the faucets are attached at an angle of about twenty degrees, so that all of the impurities will be at the top and the liquid come to the bot- tom. Have a plumber make a little reducer, the fine end of which will fit an ear speculum. The ear speculum is then put into this reducer, and a nap- kin, folded about eight thicknesses, is held securely over the ear speculum. Upon opening the faucet at the end of the tank the liquid carbon dioxid fills the ear speculum and the portion which escapes in gaseous form through the folded napkin freezes that which remains in the ear speculum and is a solid cast of carbon dioxid ice. This can be made to take any shape desired by cutting it with a knife or scissors. This use of carbon dioxid ice for pterygia was described in Archives of Ophthalmology in the year 1916, under the cap- tion, "Carbon Dioxide Ice in the Treatment of Trachoma, Vernal Catarrh, and Pterygiums." I wish to add a previous report of a case which proved intractable after six attempts at excision, and was entirely cured by eight weekly applications of the carbon dioxid ice. DR. S. LEWIS ZIEGLER (closing) : I have not had an opportunity of trying the carbon dioxid snow, recommended by Dr. Prince, but it is a good sug- gestion for the attenuated cases ; in the fleshy cases I have sometimes resorted to galvano-cautery puncture similar to the operation I once suggested for ectropion, except, of course, that you pass your needle, which must be a fine one, parallel with the surface of the globe instead of passing the tip into the tissue vertically, because you must not cauterize the sclera, since Knapp has shown there is danger of disturbance of the aqueous and ultimate cataract. You can also resort to electrolysis. Another method is high frequency desiccation, as practised by Dr. Clark, of Philadelphia. In some cases of keloid that has been of value. The manner of removing the head of the pterygium is an individual ques- tion. I happen to prefer Beer's knife; Dr. McReynolds uses the broad needle, and Dr. Prince practises divulsion one selects that which is most effective in his own hands. Where there is morcellation following removal of the growth it may be necessary to cauterize the small particles left. If you do and wish to avoid leucoma of the cornea, it would be wise to remove the eschar by curetting and applying weak formalin, one-half of one per cent. Slicing off the cornea has been advocated by some and criticized by others. Dr. McReynolds thinks in his climate it is most successful. In the literature are cases in which severe ulceration has followed, so that again is a matter of individual choice. The French school generally favors the galvano-cautery. 214 FRANCISCO POYALES They cauterize only the area of the cornea where the head has been removed. In regard to cases where there is considerable ulceration of the cornea after operation, I think the suggestion of Dr. Pontius, of Philadelphia, 1 in regard to the use of full strength adrenalin for regeneration of the cornea, is an ex- cellent one. It has proved most successful in my hands. LA TUBERCULOSIS OCULAR INFANTIL DR. FRANCISCO POYALES Madrid, Espana En la patologia ocular del nino, el capitulo de la tuberculosis aparece estudiado de un modo incomplete, sobre todo en lo que se refiere a la comprobacion anatoma-patologica de las lesiones. De nuestro material clinico hemos utilizado tres casos, en los que fue necesario practicar la enucleacion por lesiones graves y como medio profildctico y terapeutico. El estudio histologico de estos globes oculares es el material uti- lizado para esta conferencia, pues en ellos hemos podido determinar procesos tuberculosos como etiologicos de los graves transtornos que presentaban a nuestra observacion clinica. Los procesos tuberculosos primaries del globo ocular ofrece para el diagnostico clinico gran dificultad, pueden confundirse con lesiones inflamatorias de tipo cronico, y no presentan estigmas precisos para su diagnostico diferencial, esto unido a que pueden no existir mani- festaciones en ninguna otra parte del organismo, ausencia de ante- cedentes familiares reaction de Pirquet negativa, ningiin antecedente morboso ocular. Las manifestaciones secundarias corresponden con frecuencia a enfermos de tuberculosis intestinal y pulmonar, existe antecedentes familiares, reacci6n de pirquet positiva, terreno abonado a la infeccion, ataques repetidos de conjuntivitis pustulosa o flictenular, en esta forma el diagnostico clfnico es mas sencillo. No haremos ahora la description de sintomas clinicos tan variados como ofrece la tuberculosis ocular. En el ojo humano constituido por tres capas de naturaleza tan distinta como cornea, esclerotica, iris, ciliar coroides, retina y optico es posible observar formas sim- ples de infeccion de estas membranas o combinaciones. Siempre que es un proceso cronico o agudo, no obtengamos mejoria por los medios terapeuticos corrientes y la investigation de otro tipo 1 N. Y. Med. Jour., 1912, p. 637. La Tuberculosis Ocular Infantil 215 de infeccion resulte negativa debemos pensar en una lesion tuber- culosa. Cuando el globo ocular es atacado de tuberculosis se destruye antes de generalizarse la infeccion, en un raismo globo es posible encontrar desde la zona inflamatoria o productiva, hasta la zona gaseosa; zonas de propagation, lesiones mas avanzadas o intensas en relacion a la resistencia de la membrana. No podemos excluir la posibilidad de la generalization si tenemos en cuenta la emigration bacilar por vias sangineas, solo favorece a la localization ocular la capilaridad de los vasos en los plexos arteriales y venosos, los bacilos que resisten al ataque de los leucocitos poli- nucleares, quedan detenidos en los vasos por un trombus fibrinosos. Nuestro estudio va a quedar limitado al globo ocular propiamente dicho prescindiendo de los anejos, y se las manifestaciones tuber culosa de la conjuntiva. El problema terapeutico de la tuberculosis ocular queda reducido a las manifestaciones primarias, debe intentarse un tratamiento general apropiado a estos casos, el local en relacion a la sintomatologia, si nada se consigue, asi el proceso avanza y la funcion visual estd, completamente abolida, se impone la enucleacion como medio pro- filactico. HISTORIAS CLINICAS CASO 1. Nino de nueve anos. Diagnostico. Esclero queratitis con irido ciclitis cronica, 0. I. Sin antecedentes familiares Wassermann negative) Arneth a la izquierda Pirquet negativo Dolores en el ojo Hipotension ocular Vision cero No presenta sintomatologia tuberculosa en ninguna parte del organismo Desnutricion. No mejora con un tratamiento apropiado. Etiologia probable Tuberculosis. Enucleacion y prescription de tonicos generales. Estudio histologico del globo ocular. Inclusion en celuidina Coloraci6n de los cortes por el metodo Van Gieson Hematoxilina y eosina. Escler6tica (Fig. 1). Nodulos situados casi en el limite exterithat is, they seemed to prevent further develop- 1 Zinsser: Loc. cit., p. 171. 308 A. EDWARD DAVIS ment of the cataracts. This was obtained particularly in case No. 7. We know, however, that incipient cataracts may remain stationary for years, so a larger number of cases must be treated and a more extended time allowed to ascertain if the serum actually arrests development of immature cataracts. The one case of sclerosing black cataract was not affected in the least by the treatment. Perhaps a possible explanation of the more marked effect on mature senile cata- racts is that the fibers are more or less disintegrated, and the broken down fibers, for that reason, can be more easily liquefied. Perhaps more rapid and satisfactory effects could be obtained if the patients received more intensive treatment, that is, to give the injections every other day for two weeks, then rest a week, and again repeat the injections for two weeks. However, this remains for the future. 7. It may be asked by some, why should these insane patients blinded by cataracts be subjected to more or less risky treatment? For two reasons : first, many of the patients cannot be operated upon for the cataract because of their disturbed condition, the patient destroying the eye at the time of the operation, or subsequently, be- fore the wound is healed, by his violent actions. No such risk to the eye is incurred when vaccines and immunized sera are given; second, when these anti-lens sera and lens vaccines are given subcutaneously or deep into the tissue, no more risk is incurred to the patient's general condition than is now taken daily by injecting the various bacterial vaccines and sera, for instance, diphtheria antitoxin. The general condition of these insane patients is often greatly improved by the removal of cataracts; therefore, if we can devise a safe means for the absorption of their cataracts, even in the most disturbed cases, we will have accomplished a great advance in their treatment. Furthermore, the full consent of relatives or friends was obtained before these experi- ments were started. 8. Twelve of these patients were bled on December 24, 1921, and precipitin tests on their sera were made, which proved rather incon- clusive, as serum in Case No. 2 was negative in all the dilutions of the serum. On the other hand, in Case No. 3 the test was positive in dilution 1 : 10; in Case No. 9 + in dilution, 1 : 100, and in Case No. 11, + in dilution 1 : 100. It will be noted in case reports that the lenses in Cases 3 and 9 were not affected by the treatment, while in Case 11 only slight effect was produced on the lens. Treatment for the Prevention and Cure of Cataract 309 PRECIPITIN TESTS ON SERA OF PATIENTS TREATED WITH LENS ANTIGEN No. of Case Dilution of Lens Antigen Dilution of Serum 1 1:10 1:10 1:100 1:200 2 3 + 4 5 6 7 9 + 10 11 + 12 13 CONCLUSION No definite conclusions can be drawn from so few cases (13) as here reported. The partial results so far obtained would seem to indicate : First, that mature senile cataracts (at least the cortical layers) may be absorbed or liquefied ; second, a possibility that immature cataracts may be retarded or entirely checked in their progress. The present paper is to be considered simply as a preliminary report, to be followed by further and more extended experiments. I cannot close the paper without expressing my deep appreciation of the assistance given me by Dr. Russell L. Cecil, who prepared the sera and vaccines and gave valuable suggestions in the method of ad- ministration, and my thanks are due to Dr. George A. Smith, Super- intendent of the State Hospital at Central Islip, N. Y., and to the staff of this institution. I am particularly indebted to Dr. Ralph G. Reed, Dr. Charles Vaux and Dr. McNeill, who helped conduct the treatment and who gave many of the injections. Without their assistance the treatment could not have been carried on. The pathologist of the in- stitution, Dr. King, made the differential blood counts and hemo- globin tests. DISCUSSION DR. LUCIEN HOWE (Buffalo, N. Y.) : In dealing with this question, it seems essential to remember that the lens is a complex substance. The chemists tell us it contains at least five different proteins. What the action of one may be as compared with another as yet we know not. It is quite sure, however, that in one way the lens does act as a lysin. That 310 A. EDWARD DAVIS is shown by the experiments of Guyer. But this action may prove to be a two-edged sword. Although we may sometimes obtain action on the lens which we wish, we may also get a severe anaphylactic action otherwise, and destroy other parts of the eye. This is a new subject, one that gives us hope for the future. But at present the only patients who will consent to be treated in that way, according to the doctor's report, are those who are al- ready in an insane hospital. All that can be said is that for the present the curtain is drawn aside and we get a glimpse of the great field for investiga- tion that lies beyond. PROF. M. F. GUYER (Madison, Wis.) : I know nothing about the clinical or the pathologic aspects of this problem. I am a mere biologist, but I have been interested in Dr. Davis' report, particularly in connection with his use of vaccines. In our own case, as he has said, we observed no direct effect on the eyes of the injected mother rabbits. But, as a matter of fact, we judged largely by obvious defects. We have not tried to go into the refine- ments of the question; we have gone largely by conspicuous marks like a cataractous lens. In our experience defects were produced first in the uterine young. We timed our injections so as to get them into the pregnant mother about the time the lens was forming at its best in the young, which means about the tenth to the fourteenth day. It is surrounded then by a network of blood- vessels, and anything we got through the placenta could easily reach the lens by means of the circulating blood. Lens-defects established in this way apparently became hereditary. The thing that has interested me most in Dr. Davis' account is that he gets direct effect on the mother. And the paper of Drs. Verhoeff and LeMoine also speaks of the fact that where you have an injured lens you are likely to get sensitization. This suggests that a lytic substance may have been pro- duced in the blood stream; and may not such lytic substances operate on the cells of the young in pregnant females so as to form the beginning of congenital defects? Certainly in the eyes of some of our fetal rabbits we secured such an effect. This occurred not only after the injection of fowl-serum immunized against rabbit lens, but also when we injected rabbit-lens directly into preg- nant rabbits. It is difficult to get the defect in the latter way. One female so treated, however, has three defective-eyed young. This opens up the whole field of congenital defects in the first place. If an animal can build up antibodies against its own tissues when these become injured or diseased, and if such antibodies can also affect the fetus or the gonads, you see where the facts lead. Our work with rabbits tends to make us believe that there is some thread of chemical identity between substances in the germ-plasm and the finished organ in the adult. And if you get a lytic effect in one may you not get a like action in the other? DR. HENRY H. TYSON (New York City) : Clinically, the subject of Dr. Davis' paper is one of interest not only to ophthalmologists but to those who may be afflicted with cataracts, for individuals if given their choice between medical and surgical treatment, with anticipated equal results, will in a vast majority of cases select the former procedure. This being so, it can be Treatment for the Prevention and Cure of Cataract 311 readily seen how important these preliminary researches may be, providing the future should fulfil Dr. Davis' fondest hopes. Unfortunately, in my opinion, the results so far obtained and reported are too few and of too short duration to enable us to form reliable conclusions. All of us have seen quite similar results in cases, some with no treatment and others under what might be termed ordinary routine tonic treatment. Guyer and Smith, in their researches in animal experimentation, demon- strated the fact that while lens serum did not apparently affect the eyes of the adult animal injected, it did produce anatomic changes in the eyes of the offspring. Dr. Davis, however, with his method thinks he finds that the cortex of the cataractous lenses of human adults is acted upon with similar serums and vaccines. Assuming this to be a fact, much progress still remains to be made in finding a solvent for the nucleus of the lens before it could assume a definite, practical therapeutic value. That spontaneous absorption of cataractous lenses may occur I can testify from a recent personal observation of an unrecorded case in a physician aged forty years, with soft cataract and an uveitis anterior, who, while under treat- ment with thyroid extract and tuberculin therapy for the latter condition, had his cataractous lens absorbed, leaving only the capsule remaining. There was no history nor evidence of traumatism while under observation. If Dr. Davis' future researches should prove that he can at will aid or induce nature to produce results similar to the foregoing case with his method of vaccine and serum therapy, he will then have added a very important and valuable chapter to the history of "bloodless surgery of the eye." DR. FREDERICK A. DAVIS (Madison, Wisconsin) : What I have to say has only an indirect bearing on the subject, as it deals exclusively with rabbits in which hereditary blindness has been produced by the injection of fowl serum immunized against rabbit lens, or by direct injection of lens into the pregnant mother, after the method of Dr. Guyer. Recently I have undertaken, with my associate, Dr. Neff , the study of all the defective-eyed stock in Dr. Guyer's laboratory. To date we have studied about 20 pairs of eyes. The work is not yet finished, and therefore only an incomplete report can be given at this time. Of the rabbits studied so far which showed some abnormality, six had one normal eye. The right eye was more frequently affected than the left. The most striking and more typical changes are as follows : The globes varied in size and shape from an almost total absence to a size somewhat larger than normal, the atrophic and microphthalmic globes pre- dominating. The tension to -palpation was usually subnormal. The conjunctivas frequently were watery and injected. The sclera often showed marked thinning between the muscle attachments, with a staphyloma in the posterior and inferior portion of the globe. This was so great at times that the cornea became displaced behind the lids, the large staphylomatous mass protruding between them. The cornese were at times clear, though frequently a keratitis was present, especially characterized by an invasion of the conjunctiva at the limbus, or an appearance resembling sclerosing keratitis. The central portion of the 312 A. EDWARD DAVIS cornea often showed a deep opacity. The anterior chamber varied in depth, some being deep, some shallow. They were usually deep where the globe was not atrophic. The iris, with one exception, showed a large coloboma below. They appeared atrophic and usually did not react to light. Abnormal vasculariza- tion was present in some instances. The lens usually showed some form of opacity, varying from discrete cortical spots to a general diffuse cloudiness, and at times an appearance of calcareous degeneration. One post-polar cataract was observed. The lenses appeared to be dislocated below and backward in the colobomatous area. No liquefaction or absorption of the lens has yet been found in this series. The vitreous was usually apparently clear in the upper portions of the globe, but in the lower half it was filled with masses of vascularized tissue or exudate, especially in the region of the coloboma. Numerous blood-vessels could be seen in these masses, and they often appeared to run forward in an anteroposterior direction. The choroid practically always showed a broad coloboma below, spreading from the nerve-head through the ciliary body. The normal arrangement of the choroidal vessels could be made out above the disc with the ophthal- moscope. The margins of the coloboma were often clear-cut and sharply defined, but a clear view of the entire colobomatous area was obscured by the vascularized masses of tissue anterior to it. The optic nerve head and retina in the normal eyes showed the character- istic arrangement of the medullated nerve-fibers, with an unusually deep cupping of the entire disc, varying in depth from 4 D. to 9 D. In the diseased eyes only the upper margins of the disc could be made out, the lower portions merging with the coloboma of the choroid below. We have not yet deter- mined whether or not there is a coloboma of the retina and optic nerve. There was a rather striking absence of hemorrhages except in one baby rabbit. The retinae were apparently normal in the upper part of the eye. It is interesting to note that these more or less typical changes were already present in the eyes of a baby rabbit of two months, a specimen of which I have with me. DR. A. E. DAVIS (closing) : I realize the two-edged sword that Dr. Howe spoke of. Some years ago I consulted with Dr. Flexner, of the Rockefeller Institute, and he also mentioned the same point. In fact, that is one of the reasons I gave up the experiments in the early part of them. However, after I had seen the results of Guyer and Smith I did not hesitate to go on. As Dr. Howe has said, the most of them were on insane patients. I may say, however, that I have now five private patients who have come and asked to be treated. It is a rare thing when a patient comes in with cataract and wants to be operated. Like the old colored gentleman down South, they usually ask if you cannot "scatter" it. We hope to make the operation for cataract obsolete. FACOERISIS PROF. IGNACIO BARRAQUER Barcelona, Espana Daviel, al idear la extraccion de la catarata, se proponia hacer la extraccion total, pero dificultades tecnicas le impidieron llevar a cabo su deseo, quedando instituido desde entonces el me'todo clasico por quistitomia, que se ha practicado con muchas modificaciones en su tecnica, todas ellas encaminadas a extraer la mayor cantidad posible de restos blandos y capsula del cristalino, con el minimum de manio- bras. Prueba evidente del profundo convencimiento, que en el animo de todos los oftalmologos existe de que la mayor parte de accidentes operatorios son debidos a las multiples maniobras, que re- quiere una evacuaci6n completa de masas (presiones, lavados, iridec- tomia, etc.), y de que los accidentes post-operatorios reconocen por origen las flogosis determinadas por dichos restos y los enclavamientos de los mismos. A pesar de todas las modificaciones llevadas a cabo en la quistitomia y de las operaciones complementarias ideadas (iridectomia prepara- toria, discision, etc.), para obtener los resultados de una operacion perfecta, nunca con dicho metodo se puede lograr este ideal, toda vez que s'empre dentro del ojo quedan restos de la lesion que nos pro- ponemos extirpar. La extraccion simple total es el unico metodo racional que existe para operar la catarata. Esta se ha practicado por muchos procedi- mientos que, si bien libraban al ojo de los accidentes post-operatorios, por dejarle libre de restos de catarata, le predisponian a accidentes operatorios, por complicar las maniobras del acto quirurgico. Convencido de que unicamente debfamos practicar la extraccion total, ensaye la mayor parte de los metodos existentes durante varies anos, cerciorandome de que los menos expuestos eran los que, cogiendo el cristalino por su cara anterior, lo extraian fuera del ojo, envuelto en su cdpsula, si bien los instrumentos para ello ideados rasgaban la cdpsula cristaliniana, convirtiendo en la mayoria de casos la tan deseada extraccion total en una simple quistiectomia ; era pues pre- 313 314 IGNACIO BARRAQUER ciso construir una pinza que no rompiera la cdpsula del cristalino. Esta fue mi idea primordial del procedimiento que denomine Faco- erisis, del griego Faco, lente y Erios, arrancar. Una pequena ventosa adaptada a la cara anterior del cristalino debia hacer presa fuerte- mente en el y permitir arrancarlo, rompiendo las debiles fibras de la zonula que le mantienen en su sitio. Muchas fueron las tentativas y pruebas, que lleve d cabo variando la forma y dimensiones de la ventosa y la intensidad del vacio; antes de lograr, coger y sacar enteras las cataratas con un minimum aceptable de rupturas de su cdpsula pero sin embargo las tracciones que sobre la insercion peri- f erica de las fibras zonulares se practicaban, predisponian al ojo a complicaciones por parte de la region ciliar. Mi metodo, distaba mucho de la perfeccion, si bien obtenia con el resultados superiores d los de la quistitomia. Mi primer Erisifaco era una pinza pneumatica, mientras que el actual es pinza pneumdtica y zonulotomo toda vez que al coger el cristalino y deformarle, reduciendo su didmetro mdximo, lo hace por pequenas y frecuentes sacudidas, con las que se le imprime un movi- miento vibratorio rapidisimo, y de suficiente altura de onda, para que al ser transmitido d las fibras zonulares ocasionen su ruptura cerca del cristalino, sin que la fuerza tenga tiempo de transmitirse d su insercion periferica, y sin que la intensidad de vacio empleada sea capaz de romper la elasticidad de la capsula, rompiendola. Claro esta que dicha intensidad de vacio (altura de la vibracion) y el numero de interrupciones por minuto (amplitud de la vibracion) son condi- ciones mecanicas del enrarecimiento del aire en la ventosa, que deben guardar relacion con las condiciones ffsicas de cada uno de los ojos d operar, y que el operador debe regular de antemano en su Erisifaco, con arreglo a la mayor o menor dureza del cristalino y esclerosis de la zonula. Las alturas de onda (intensidad de vacio), que empleamos, estan en razon directa de la mayor dureza del cristalino, y la amplitud de las vibraciones (numero de las mismas) en raz6n inversa de la mayor esclerosis de las fibras, de modo que en una catarata incompleta, blanda, deformable, con una zonula eldstica poco esclerodada, debemos emplear un vacio debil y un numero de vibraciones grandes, mientras que en los sujetos viejos con cataratas completas y zonulas friables, hace falta mayor intensidad de vacio para deformar el cristalino y siendo menos elastica su zonula, necesita menor numero de vibraciones para romperse. Facoerisis 315 A pesar de haber logrado la extraccion sin tracciones en la insercion periferica de la zonula, se veian mis estadisticas afeadas por alguna iridociclitis tardia, iridociclitis debida al enclavamiento en los labios de la herida de las fibras zonulares o de los angulos del coloboma quirurgico. Complicacion que raramente se presentaba en los casos operados sin iridectomia, por lo que, salvo en casos escepcionales, hago la extraccion simple con una pequena brecha periferica en el iris para evitar la hernia. Las maniobras operatorias en una Facoerisis simple, quedan re- ducidas a la mas minima espresi6n, pues que una vez tallado el colgajo, basta introducir en la camara anterior un solo instrumento, el Erisifaco, que aplicado sobre la cara anterior del cristalino adhiere a ella y lo libra de sus naturales adherencias, sin que el ojo se deforme, sin la menor violencia, y con solo retirar el instrumento de la camara anterior, con suavidad pasmosa se ve salir el cristalino envuelto en su capsula, adherido d su extremidad quedando la pupila de un negro purisimo, central y redonda. Las reacciones post-inflamatorias debidas en la quistitomia: 1 d las repetidas maniobras del acto quirurgico, 2 a los restos de sub- stancias degeneradas del cristalino y su capsula, y 3 d los enclava- mientos de restos de la capsula entre los labios de la herida, no existen, toda vez que con una sola maniobra extirpamos de una vez toda la lesion, sin dejar dentro del ojo el menor resto de ella. La presencia de restos cristalinianos en el humor acuoso y la flogosis que ellos originan, convierten & la camara anterior en un terreno abonado a los germenes infectivos, condiciones que no existen en la extraccion total, por lo que las infecciones en esta clase de operacion son rarisimas. La tecnica de la operacion es f acil, pero requiere una serie de pequenos detalles indispensables para el buen resultado. Los enfermos son examinados detenidamente, con la pupila dilatada, al microscopic binocular y lampara de hendidura, a fin de conocer las earacterfsticas del cristalino, su cdpsula, y la zonula, que nos han de permitir graduar la intensidad del vacio y el mimero de vibraciones por minuto, con que debe llevarse a cabo la inter vencion, asi como tambien el tiempo necesario para obtener la dilatacion pupilar deseada y asesorarnos de que el ojo reune las condiciones de asepsia necesarias para sufrir una intervencion. Previa dilatacion pupilar por un midri&tico de acci6n fugaz (euftal- mina), tallamos con el cuchillo de Graeffe un colgajo de los f de la 316 IGNACIO BARRAQUER circunferencia de la cornea, emplazando en ella sus dos tercios estro- mos y el tercio medio en la esclerotica, acabdndolo con una larga lengueta conjuntival, en la que, si lo creemos indicado, emplazamos un punto de sutura que anudaremos despue"s de terminada la opera- cion. Si esta debe ser simple, introducimos en la cdmara anterior, rozando la cara posterior de la cornea, sin tocar el iris, la pequena ventosa del Erisifaco, previamente regulado con arreglo a las con- diciones fisicas del ojo d operar, y al nivel del centre de la pupila se aplica sobre la cristaloides sin ejercer la menor presion, y la hacemos resbalar hacia abajo hasta que su estremo inferior se oculta debajo del iris, en la cdmara posterior; entonces es cuando abriendo paso al vacio, se produce el enrarecimiento del aire en la ventosa d la que se adhiere el cristalino, rompiendose instantaneamente las fibras de la zonula. Con suma lentitud y sin hacer nunca la menor presion sobre el vitreo. hacemos que el cristalino gire sobre un eje transversal hasta que su borde inferior, rozando la cara posterior del iris primero y la de la cornea despues, se convierta en superior en cuyo momento, con solo retirar el instrumento del ojo acabamos la extraccion, quedando la toilette reducida a la aplicacion de la pomada de eserina para que el miosis producido prive el enclavamiento de las fibras zonulares. Si la talla del colgajo y la maniobra de extraccion han sido efec- tuadas con suavidad y sin hacer la menor presion sobre el globo ocular, nunca tendremos perdidas de vitreo, ni accidentes operatorios, a no ser que el paciente contraiga el orbicular de los parpados o haga movimientos intempestivos. Para evitar con toda seguridad los movimientos que por la indocilidad del paciente pudieran sobrevenir, provocamos como Van Lint y Villard la paralisis temporal del orbicu- lar. Aunque soy partidario entusiasta de la extraccion simple, practice en casi todos mis enfermos un pequeno agujero en la periferia del iris, que sin privarnos de las ventajas de aquella, nos da las garantias de la iridectomia en cuanto a la hernia del iris. Regulando apropiadamente la intensidad de vacio y mimero de vibraciones, pueden extirparse sin temor d accidente alguno, toda clase de cataratas (maduras, incipientes, Morganianas, etc.) en su- jetos mayores de 40 anos de edad, y en sujetos mas jovenes todas las completas y aun algunas variedades de las incompletas en que la zonula se presenta muy esclerosada. Las cataratas polares posteri- ores sintomdticas de la miopia, se extraen con facilidad ya que la zonula en ellas es muy fr&gil. Facoerisis 317 Llevo practicadas mds de 2800 Facoerisis y los unices accidentes operatorios que en estos ultimos tiempos registran mis estadisticas son los siguientes: 1. Dificultad de practicar la iridectomia peri- ferica que se convierte en total, por exceso de dilatacion pupilar, resultando que hemos practicado involuntariamente una extraccion combinada. Rarisimo, si los enfermos estan bien preparados. 2. Despues de tallado elcolgajo, algunas veces la pupila se contrae de- masiado, dificultando el emplazamiento de la ventosa, lo que sin em- bargo se logra con un poco de habilidad. Caso de coger el iris entre la ventosa y el cristalino basta, despues de haber dado la vuelta al cristalino dentro de la camara anterior, interrumpir el paso del vacio, permitiendo la entrada en la ventosa de la presion atmosferica para que suelte la catarata, y cogerla nuevamente. 3. Rotura de la capsula. (a) Esta puede ser instantanea al coger la catarata, lo que significa que nos hemos equivocado empleando un vacio demasiado intense. Ocurre raramente. (b) En aquellos sujetos jovenes con zonula muy resistente, puede abrirse el saco capsular por su borde inferior, y si bien es extraida la capsula entera, su micleo y gran cantidad de masas, quedan en las camaras del ojo pequefios restos de substancia blanda. (c) Al acabarse la extraccion, los labios del colgajo, pellizcando la catarata, pueden romper la capsula; en este caso el contenido del saco capsular se derrama fuera de las camaras del ojo, en los fondos de saco conjunti vales. Como se comprende, la rotura de la capsula no tiene otro inconveniente que el convertir la extraccion total en una quistiectomia. Es muy poco frecuente cuando se tiene practica en el procedimiento. 4. Perdida de vitreo; unicamente se presenta cuando el operador hace una presion indebida sobre el globo, o si el paciente contrae los musculos orbitarios. Rarfs- ima, con la paralisis temporal del orbicular. Las complicaciones post-operatorias, si la operacion ha sido sin accidentes, y el enfermos no comete ninguna imprudencia durante los tres primeros dias, no existen, salvo en rarisimas escepciones. Si hemos practicado la extraccion combinada, es posible un enclava- miento en los labios de la herida de las fibras zonulares o de los angulos del coloboma, ocasionandose retrasos en la cicatriz, iridociclitis plas- tica y glaucoma secundario. En los casos de extracci6n laboriosa, en los que se ha pellizcado el iris, puede sobrevenir ligera iritis. Si durante el transcurso de la operacion se ha roto la capsula, las com- plicaciones son analogas a las que se producen operando por quisti- tomia. En los casos de hernia vitrea, si logramos seccionarla y 318 IGNACIO BARRAQUER coaptar los labios de la herida con la sutura, queda la pupila negra, central redonda, y como unica consecuencia ligeras opacidades del vitreo que desaparecen lentamente. En los enfermos indociles, que se mueven, tienen tos, propensos al vomito o que reciben algun traumatismo, si la operacion ha sido practicada con brecha periferica y sutura del colgajo, la complicacion se limita, las mas de las veces, d una ligera reabertura subconjuntival de la herida y una gota de hifema. Complicacion que desaparece con 24 horas de reposo sin ulteriores consecuencias. Del estudio atento de las historias clinicas de mis operados se deduce que todos los accidentes operatorios y post-operatorios re- conocen por origen una imprevision, una falta de tecnica, 6 una indo- cilidad por parte del enfermo, y que el maximum de garantias consiste en la extraccion simple con brecha periferica, sutura conjuntival previa y paralisis temporal del orbicular. La falta de sintomas reaccionales debidos a la simplicidad de la maniobra quinirgica, y d la ausencia de restos cristalinianos en las camaras del ojo, acortan la duracion de la convalescencia y aseguran una agudeza visual normal. OPERATION DE BARRAQUER PROFESSEUR EMILE GALLEMAERTS Bruxelles L'extraction du cristallin dans sa capsule a ete a differentes epoques mise en pratique; ses avantages et ses inconvenients ont ete sou vent mis en discussion; mais en raison des difficultes inherentes a son execution sans que 1'oeil ait a en souffrir, elle a ete abandonnee et remise en honneur tour a tour. L'operation de Smith et celle de Barraquer viennent a nouveau de poser le probleme de 1'extraction totale. J'ai public la relation de 24 cas operes par la methode de Barraquer; de ces 24 cas, j 'en avais opere 6 avec succes sous la direction de Barra- quer; il est inutile d' insister sur la surete que Ton possede quand on peut a chaque instant recourir aux conseils d'un maitre. Lorsque on est livre a ses propres moyens on se trouve a tout moment devant une serie de difficultes qu'il faut resoudre sur le champ. Cette communication a surtout pour but d'exposer les accidents qui me sont survenus au cours de 46 operations que j ' ai pratiquees ; leur description permettra a ceux qui voudraient essayer la methode nouvelle de les eviter et de diminuer le nombre de leurs insucces. . ERISIPHAQUE L'operateur doit porter une grande attention a la marche reguliere de 1'appareil. Lorsque on prend livraison de 1'appareil, il est prudent de nettoyer d'abord le moteur, en y faisant passer un courant de petrole; sinon la premiere partie d'huile qu'on y introduit revient chargee d'impurete's; on peut clarifier cette huile, en la nltrant sur du noir animal. II est bon d'enlever 1'huile apres chaque seance d'opera- tion, et de nettoyer ensuite le moteur au petrole. L'appareil porte-ventouse doit etre d'une proprete extreme. , On le nettoie a Faide d'un petit baton dont le bout taille" en pointe est recouvert de gaze. II faudra passer un mandrin dans les divers trous et trajets, bouches souvent par du sang ou des debris organiques en- traines par 1'aspiration; il faudra nettoyer de meme la ventouse. 319 320 EMILE GALLEMAERTS Au debut, pour m'assurer du fonctiormement, j'approchai la ven- touse de Foreille pour entendre le clapotement produit par la succion. Actuellement j'ai etabli un systeme de controle qui me renseigne sur le champ sur le fonctionnement regulier de Fappareil. J'ai intercale sur la trajet du tube d'aspiration un petit vacuometre, a 1'aide d'un tube en T. Lorsqu'on met le moteur en marche, on voit rapidement, au bout de 4 a 5 secondes, le vide atteindre 55 a 60 centimetres; puis je place la ventouse sur la peau du bras ou sur la levre, et j'etablis la com- munication en pressant sur le bouton de 1'appareil porte-ventouse; on voit d'abord une chute brusque du vide a '45 centimetres, puis une remonte rapide; on a a peine le temps de compter j usque 4 et deja le vacuometre est revenu a 60. L'appareil est alors en ordre; pour I'emploi il suffit de steriliser la ventouse dans la flamme d'une lampe a alcool. Je considere I'emploi du vacuometre non seulement comme utile, mais comme indispensable; il permet de se rendre compte, a chaque instant, avant et pendant 1'operation, de la marche reguliere de 1'aspirateur. PREPARATION DE L'OPERE Barraquer prepare le malade en vue de 1'operation pendant plusieurs jours; apres 1 'avoir couche il lui fait faire des mouvements des yeux. J'ai trouve* cette pratique inutile, je dirai meme nuisible. J'ai con- state que les operes que Ton traitait de cette fac.on pendant plusieurs jours, arrivaient a 1'operation bien plus agites et anxieux que ceux que 1'on se contentait simplement de coucher sur la table apres leur avoir recommande de se tenir tranquilles et de ne pas faire de mouvements brusques avec les yeux. Tous les ope"res sont examines preablement a la lampe a fente; on se rend ainsi compte beaucoup mieux de la forme de la cataracte; en meme temps j 'examine 1'etat de 1'iris. C'est ainsi que sur 45 cas, j'ai trouve 19 fois de la degenerescence hyaline du bord pupillaire avec disparition plus ou moins etendue de la collerette; deux fois, il y avait en meme temps de 1'atrophie du feuillet posterieur de 1'iris. La veille de 1'operation, on lave abondamment les yeux, au se"rum sterilise; on s'assure de la permeabilite des voies lacrymales; on savonne le bord des paupieres et on le badigeonne avec une solution de nitrate d'argent a 3%. Une heure avant 1'operation, on instille toutes les dix minutes un collyre a 1'euphtalmine, a 4% contenant quelques gouttes de cocaine a 5%, de maniere a obtenir une dilatation pupillaire maxima qui est absolument indispensable. Puis on met de la cocaine 5% dix minutes Operation de Barraquer 321 avant 1'operation. Je ne fais I'injection & la tempe pour la paralysie partielle des paupieres que lorsque je me trouve en presence de malades indociles. Au moment d'operer, un aide retourne la paupiere superi- eure, et la saisit entre les mors d'une pince, de maniere a etaler large- ment le cul de sac conjonctival; 1'aide ecarte en meme temps la pau- piere inferieure; une infirmiere arrose alors abondamment 1'oeil de maniere a entrainer toutes les mucosites. TECHNIQUE DE L'OPERATION Le moteur est place sur un plateau rond et cale a 1'aide d'une vis; ce plateau est adapte a une bague mobile sur une tige verticale portee par un pied en fonte ; la bague porte le vacuometre et en meme temps un petit plateau pour les instruments. L'appareil est place a droite de 1'operateur. Avant de commencer, il est prudent de controler une derniere fois la marehe de Fappareil; j'insiste sur le fait, par ce qu'il m'est arrive de devoir, apres 1'incision de la cornee, attendre pendant quelques minutes pour deboucher la ventouse. Pour ecarter les pau- pieres je me suis servi au debut d'un ecarteur de Desmares; actuelle- ment j 'emploie avec avantage un crochet a strabisme que Ton place et retire plus facilement. L'aide ecarte la paupiere superieure a 1'aide du crochet a strabisme tenu d'une main; 1'autre main ecarte la paupiere inferieure 1'opera- teur fait son incision corneenne comme il a 1'habitude de la faire; seulement le lambeau doit etre plus grand, il doit occuper les 2/5 de la cornee. L'incision est faite a Funion de la cornee et de la sclerotique, et terminee par un lambeau conjonctival. L'incision faite, 1'on retire le crochet a strabisme, et je pratique alors une petite iridectomie soit totale soit peripherique a la maniere de Hess. Je maintiens moi-meme la paupiere superieure en la pressant centre le rebord orbitaire a 1'aide du petit doigt de la main gauche qui manie la pince ou le crochet de Tyrrel. S'il y a du sang dans la chambre anterieure, je lave abondamment avec du serum sterilise. Ensuite je replace moi-meme le crochet a strabisme de la main gauche et je releve la paupiere tout en la tirant en haut. Je ne commande pas au malade de regarder, en bas je lui demande de se tenir tranquille. A ce moment le moteur est mis en marehe ; quand le vide atteint le degre voulu de 55 a 65 centimetres, j'introduis lateralement la ventouse, en dehors pour 1'oeil droit, en dedans pour 1'oeil gauche. La ventouse passe sous le bord pupillaire. Apres 1'avoir delicatement pose*e sur le cristallin, on presse le bouton 21 322 EMILE GALLEMAERTS pour e"tablir la communication entre la ventouse et 1'aspirateur. A ce moment, le vacuometre descend vers 45c. pour remonter immediate- ment a son point de depart. Alors on peut retirer la ventouse en faisant glisser le cristallin sur la fossette patellaire, tout en faisant basculer le manche de 1'instrument en avant. Ou bien on fait exe- cuter au cristallin un cumulet de maniere a ramener sa face posterieure en avant; il faut pour cela faire basculer le manche en arriere. Le cristallin sorti, on instille de 1'eserine huileuse; on attend quelques minutes avant de faire la reduction de Piris; j'emploie pour cette manoeuvre une spatule coudee a angle droit. Comme pansement, je place le binocle avec une bande, ou bien, comme Barraquer, je maintiens les bourdonnets d'ouate a 1'aide de bandelettes croisees. Si Popere" ne se plaint pas, j'enleve le pansement de 1'oeil non opere le 4ieme jour, celui de 1'oeil opere au bout de 7 a 8 jours. Le pansement reste done en place plus longtemps que dans 1'operation ordinaire. J'ai vu une hernie du vitre se produire chez une malade privee de pansement le 6ieme jour. Telle est la marche d'une operation normalement conduite. ACCIDENTS OPERATOIRES Une plaie trop petite empeche 1'introduction facile de la ventouse, et surtout arrete la sortie du cristallin. On doit agrandir la plaie, en sectionnant un des angles avec des ciseaux droits a branches courtes et fortes. Si le lambeau conjonctival commence trop bas, il empeche 1'intro- duction de la ventouse; cet accident m'est arrive deux fois. Pour eviter cet inconvenient, il faut changer le point d'introduction, ou meme faire sou lever le lambeau conjonctival a 1'aide d'une pince. Le pincement de 1'iris provoque de la douleur, et aussi de 1'hem- orrhagie; on peut meme en retirant la ventouse, produire un decol- lement de 1'iris. En cas de pincement, il faut lacher le bouton de pres- sion et r&ntroduire la ventouse. L'hemorrhagie dans la chambre ante"rieure disparait tou jours facile- ment par lavage; dans un cas cependant, il s'etait forme un grand caillot, que je ne parvins pas a enlever. Je me suis decide a trans- former 1'operation de Barraquer, en une operation de Smith; en pressant sur la partie inferieure de la cornee a 1'aide d'un crochet a strabisme, j'ai pu faire sortir le cristallin sans perte de vitre; la vision de cet opere' fut de 0.1 avec +11 dioptrics. L'accident le plus frequent est celui qui provient d'un defaut dans Operation de Barraquer 323 Padherence du cristallin a la ventouse; la ventouse lache le cristallin, soit ail moment ou on veut faire 1'extraction, soit lorsque le cristallin est deja mis en mouvement, soit lorsqu'il se presente de"ja dans la plaie: un bruit de friture annonce 1'accident. II faut alors retirer rapidement la ventouse. Dans un cas, le cristallin s'est engage dans le trou d'une iridectomie periphe'rique ; avant de reintroduire la ven- touse, j'ai sectionne le bord pupillaire qui avait ete conserve. Si les circonstances restent favorables, on peut reintroduire la ventouse plusieurs fois; il m'est arrive de reussir a Ia4ieme reprise; mais il faut naturellement dans les tentatives repetees, veiller a ne pas aspirer le vitre. Le cas suivant extraordinaire, merite d'etre rapporte. Je faisais une troisieme tentative d'aspiration chez un de mes operes, quand tout d'un coup j'entends un bruit de succion, je vois 1'oeil s'affaisser completement; malgre 1'enorme perte de vitre je me decide sur le champ a faire 1'extraction du cristallin a Taide de 1'anse de Snellen; la manoeuvre reussit mais Foeil est tout ratatine; la cornee deborde la levre scleroticale, en outre il s'est forme dans la sclerotique un pli que je m'efforce de require. Je m'attendais naturellement a un desastre. Les jours suivants le malade ne se plaint pas; j'enleve le pansement le 7ieme jour. A mon plus grand etonnement, I'oeil s'est reconstitute completement; la plaie est fermee; le malade voit. Actuellement la vision est de 0.6 avec 13 dipotries. De toutes les operations que j'ai faites, .c'est la plus extraordinaire. Un autre accident consiste dans la rupture deja capsule, trop faible pour resister a la traction exercee par le vide; on se trouve alors en presence d'une extraction avec discission que Ton termine suivant les regies ordinaires. La luxation du cristallin constitue Paccident le plus grave. Parfois le cristallin est luxe directement en haut; on peut le faire glisser en bas a 1'aide d'une spatule et puis tenter de nouveau 1'aspiration. Ou bien il bascule en arriere, le vitre venant se placer au devant ; dans ce cas il ne reste que la seule ressource de recourir a 1'extraction a 1'aide de 1'anse de Snellen ou de Taylor. On 1'introduit rapidement derriere le cristallin, puis on reporte le manche en arriere ; au lieu de retirer le cristallin en 1'appliquant contre la cornee, on le fait glisser sur 1'anse a 1'aide d'un crochet a strabisme applique exterieurement sur la cornee. Cette manoeuvre est moins brutale et expose a moins de perte de vitre. L'ecoulement de vitre avant 1'introduction de la ventouse ne m'est pas arrive. Apres. la premiere introduction, le corps vitro" peut se 324 EMILE GALLEMAERTS placer au devant du cristallin, sans qu'il y ait luxation; dans ce cas il faut faire 1'extraction par discission. A deux reprises, il m'est arrive" le singulier accident suivant : Apres une premiere tentative inutile, 1'iris prend la forme d'entonnoir au fond duquel se trouve le cristallin. La corne'e bombe'e, rigide au lieu d'etre affaissee, est se'pare'e du cristallin par un grand espace; quand on introduit une spatule, la cornee s'affaisse. L'ecoulement du vitro" peut se produire apres la sortie du cristallin. Parfois apres la sortie, le vitre se prsente un moment dans la plaie, puis rentre aussitot. Parfois au lieu de s'ecouler, il vient former une boule entre les levres de la plaie : il vaut mieux dans ce cas exciser la hernie du vitro" avec les pince-ciseaux. Si au bout de quelques jours la hernie persiste, je n'hesite pas a la recouvrir & 1'aide d'un lambeau con- jonctival; dans deux cas trace's de la sorte, j'ai obtenu une bonne et rapide fermeture de la plaie. SUITES DE L'OPERATION II y a souvent de la keratite stride qui disparait assez rapidement sans laisser de traces. Dans un cas de keratite stride, le corps vitro etait venu s'accoler a la face posterieure de la corne'e et y determiner une forte opacite". L'enclavement de 1'iris dans Tun des angles de la plaie s'est produit dans une demi douzaine de cas. Dans 7 cas il y a eu une deformation de la pupille deViee ve.rs le haut. Cette complication est moins grave que dans 1'extraction avec discission. Dans un cas j'ai eu apres une extraction normale, une hernie du vitre constatee le 6 ieme jour. II est interessant d'examiner au bout de quelque temps les ope"re"s a la lampe a fente. On constate dans le champ pupillaire que le vi- tro" tombe en avant; dans un cas opere sans iridectomie, j'ai trouve le vitro" sous forme de champignon pedicule, faisant saillie a travers 1'ouverture pupillaire. J'ai obtenu un decollement de la re"tine, con- secutif a 1'operation. Barraquer a e"crit qu'il ne pouvait se former d'adhe"rence entre 1'iris et le vitr6 ; j'ai vu un cas ou il s'etait produit une adherence tres nette entre le vitro" et le bord pupillaire; 1'extraction s'etait faite normale- ment. Dans deux cas ou j'ai du employer 1'anse, il s'est forme aux depens de masses cristallines, un amas de substance blanche, masquant com- pletement la pupille ; dans un cas la resorption est presque complete ; dans le second la resorption est en train de se faire. Operation de Barraquer 325 Si je resume les cas voici les visions obtenues: Vision dans deux cas d'insucces complet. un cas de choroiidite maculaire. (Resultat operatoire par- fait.) 2 cas de chorioretinite specifique ancienne (idem). 1 cas de decollement de la retine anterieur (idem). Vision 0.1 6 cas. 0.2 7 cas. 0.3 6 cas. 0.4 5 cas. 0.5 1 cas. 0.6 4 cas. 0.7 4 cas. Vision 0.1 a 3 metres 1 cas. 0.2 a 2 metres 1 cas. 0.1 a 1 metre 1 cas. Le point le plus delicat de 1'operation de Barraquer, celui dont depend le succes, est le moment de la pression sur le bouton de 1'ap- pareil porte-ventouse ; il suffit d'un instant d'inattention, lorsqu'on fait la traction pour la manoeuvre de sortie, pour que le vide diminue, et que le cristallin retombe. C'est pour moi le defaut de 1'appareil; le vide ne devrait pas dependre d'un mouvement involontaire; il devrait rester permanent et ne pourrait disparaitre que par une manoeuvre volontaire. C'est pour remedier a cet inconvenient que nous avons essaye de rendre le systeme d'occlusion independant de la ventouse. A cet effet, la ventouse est place'e a 1'extremit^ d'un manche long de 7 centimetres et de 7 mill, de diametre ; Pappareil porte-ventouse con- tenant les soupapes est intercale dans le trajet du tuyau en caou- tchouc entre le vacuo metre et la ventouse. La disposition est repre- sente dans la photographic ci-contre (Fig. 1). La ventouse semanie comme le manche d'un instrument ordinaire. Un aide presse sur le bouton au commandement de Poperateur, quand la ventouse est en place; 1'aide signale le moment ou le vide a de nouveau atteint le de"gre" voulu; la manoeuvre d 'extraction commence alors avec plus de surete et de chance de succes que lorsqu'on se sert du dispositif de Barraquer. II faudrait probablement modifier la ventouse aussi, de maniere a rendre plus intime 1'adherence du cristallin. Quand cette derniere condition sera realised, je crois que les chances d'insucces seront re"- duites au minimum. 325 EMILE GALLEMAERTS Y A-T-IL UN VlDE VlBRATOIRE? L'existence du vide vibratoire produit par 1'erisiphaque a ete mise en doute; nous avons le docteur Kleefeld, et moi, essaye de le mettre clairement en evidence et meme de 1'inscrire. Kleefeld a d'abord note des vibrations en introduisant le tuyau aspirateur de 1'erisiphaque dans 1'entonnoir d'un appareil de physique appele flamme sensible. Ensuite nous avans eu recours a un dispositif imagine par le pro- Fig. 1 fesseur de physique Henriot. Le dispositif employe consiste en une capsule manometrique, formee d'une boite cylindrique dont une des bases est plus depressible que 1'autre. Deux pertuis y sont menage's, Tun pour faire 1'aspiration, 1'autre pour etre mis en rapport avec 1'ap- pareil porte-ventouse. Le controle du vide se fait a Paide du vacuo- metre. Un fil metallique est tendu a la face exterieure de la capsule, et rattache aux deux extremites du diametre vertical; ce fil soutient Operation de Barraquer 327 une lamelle m^tallique qui s'appuie sur la surface de la capsule, il porte un petit miroir concave. En face de la capsule on place comme source lum- ineuse une ampoule electrique, type monowatt. L'image de cette lampe est concentree sur une regie graduee en cel- luloi'de ; on peut ainsi suivre le mouve- ment de la mouche lumineuse le long de la graduation. Au moment ou le vide s'etablit, on voit la mouche se deplacer rapidement sur Pechelle, en meme temps le filament devient flou. ; il en est de meme lorsque on fait manoeuvrer les soupapes de 1'appareil porte-ven- touse. Si on remet le filament au point par interposition d'une lentille conver- gentie entre le miroir et Fechelle, on constate la nettete absolue du filament quaiid le vide maximum a ete atteint. Get kppareil experimental tout en reu- nissant certaines conditions de sensi- bilit6 ne nous a pas permis d'inscrire des vibrations. La deformation de la paroi de la capsule sous Faction de la pression atmospherique diminue les possibilites d'une transmission de vi- brations existant a Finterieur du sys- tems d'aspiration. Pour arriver a se rendre compte des mouvements de Fair dans le tuyau d'aspiration, Kleefeld a imagine le dis- positif suivant : dans un tube de verre d'un calibre a peine superieur a la section interieure de la tuyauterie de caoutchouc, on suspend une feuille d'or. La minceur, Fextreme mallea- bilite, Fabsence de vibrations propres, le poids negligeable, font de la feuille d'or un indicateur precieux des moin- 328 EMILE GALLEMAEBTS dres vibrations d'un systeme gazeux. On interpose cet indicateur entre l'6risiphaque et le porte-ventouse. On place le systeme dans line lanterne a projection. L'ombre de la feuille d'or est recueillie sur un 6cran, ou bien inscrite sur une plaque photographique. Quand on met I'erisiphaque en marche, on voit sur 1'ecran, la feuille d'or animee d'un mouvement de vibration tres intense, tandis qu'elle se souleve assez rapidement dans la direction de Inspiration. Au bout d'un cer- tain temps cette vibration parait cesser et la feuille d'or ne presente plus que quelques soubresauts; elle conserve cependant Finclinaison qu'elle avait acquise au d6but de 1'aspiration. Pour inscrire les vibrations, nous remplagons l'e*cran par un chassis 55 cm. Hg 60cm. Fig. 3 65 cm. dans lequel on fait glisser une plaque photographique ; la plaque passe en un mouvement re"gulier et continu, devant une fente horizontale. Nous avons ainsi obtenu les traces ci-joints (Figs. 2 et 3), qui montrent nettement les oscillations. Nous avons ainsi la preuve que l'6risipha- que de Barraquer produit un vide oscillant ou vibratoire. Si on peut affirmer que ce vide vibratoire existe, il est plus difficile de dire quelle est sa part d'intervention dans le mecanisme de 1'extrac- tion. A-t-il une action preponderante? 1 On pourrait peut-etre aug- menter 1 effet des vibrations en imprimant a un moment donne, des 1 Peut Stre 1 'aspiration agit-elle en (informant la surface du sac cristallinien. La capsule du cristallin est attire"e dans la ventouse; en m6me temps elle exerce une traction sur les fibres de la zonule qui se tendent et fmissent par se rompre. L'action des oscillations scrait ainsi renforcee. Operation de Barraquer 329 oscillations directement a la ventouse et favoriser les chances de rupture de la zonule. Quoiqu'il en soit 1'erisiphaque de Barraquer est un instrument qui est venu donner a 1'extraction totale de la cataracte, une vogue nou- velle ; il supprime la pression sur le corps vitre qui est si brutale dans 1'operation de Smith; sous ce rapport, reparation de Barraquer sur celle de Smith; Si on a des deboires dans un certain nombre de cas, de"boires inevitables dans les premiers essais, du moins dans ceux qui se terminent avec succes, le resultat donne de grandes satisfactions; pas d'irritation, une pupille noire, une vision excellente, et surtout pas de cataracte secondaire a redouter. Ce sont des avantages dont il ne faut pas meconnaitre le prix. Avant de pouvoir se prononcer sur la valeur definitive du procede, il faudra que la me"thode soit largement raise en pratique. II en a e"te" de meme de 1'extraction avec discission. Que 1'on relise le nombre incalculable de travaux publics sur ce su jet, les discussions dans les congres, on verra qu'il a f allu des annees pour e"tablir les regies qui nous ont amenes a la precision obteniie par le procede operatoirs de la dis- cission. II en sera de meme pour 1'extraction totale par 1'erisiphaque ou pour toute autre methode semblable. II faut que chacun aborde cette 6tude sans parti pris; en y apportant le sincerite" que Ton doit exiger dans toute recherche scientifique. Pour moi, malgre les insuc- ces que j'ai signales, je reste convaincu que 1'operation de Barraquer est appelee & un grand avenir et qu'elle ne tardera pas a entrer dans la pratique courante. DISCUSSION OF PAPERS OF PROFESSORS BARRAQUER AND GALLEMAERTS DR. LUCIEN HOWE (Buffalo, N. Y.): Although I have not seen this opera- tion, the principle described is not new. As I understand it, some suction must in reality be made, otherwise there would be no need of what is prac- tically a suction pump. Many years ago, when Knapp reported a series of extractions, he said, in substance, that while the "vis a tergo" principle served our purpose, it would be much better if we could have some way of drawing out the lens by a "vis a fronte." It then occurred naturally to me, as probably to many others, to employ some arrangement by which suction could be made. I tried, but failed at first, because the suction sucked out lens arid vitreous also. Therefore I simply attached a small rubber bulb to a short tube with a minute elliptical opening, as shown in the accompanying illustration. That serves the purpose admirably. But not being one of ardent advocates of extraction in the capsule, this suction bulb is used only in exceptional cases. When, however, we reach the embarrassing point where 330 IGNACIO BARRAQUER AND EMILE GALLEMAERTS the lens appears and we cannot make it come out properly, it is of real ad- vantage to employ slight suction, applying the tube to the edge of the lens in such a way that it can be tipped from side to side. I think the older men are rather inclined to follow the advice of one of our American poets, who was also a physician, and say with Holmes : "Be not the first by whom the new is tried Nor yet the last to lay the old aside." DR. JOHN WESTLEY WRIGHT (Columbus, Ohio): My conception of the intracapsular operation for cataract was the result of fortui- tous circumstances in my early experience in the flap and combined methods prevalent at that time, which because of an extensive in- cision of one-half of the corneal circumference and an equally extensive flap, resulted too frequently in imperfect coaptation, a prolapse of the iris, a drawn-up or obliterated pupil, and more or less corneal opacity. To avoid such discouraging conditions I conceived an incision much smaller, less liable to gap, and of such dimensions as to permit the ready delivery of the lens. Briefly, the incision is made entirely within the cornea, the puncture and counterpuncture being one-third down the corneal circumference, at the sclerocorneal junction, and completed at a point 2 mm. within its upper border. With this incision I discovered that pressure upon its upper segment, in addition to making the opening for the delivery of the lens much larger than in the usual methods, caused a detachment of the lens from the annular ligament at its upper portion, when with careful pressure it is stripped out from the surrounding attachments and its delivery in capsule was readily affected. Pressure thus made causes a displacement of the vitreous in such manner that there is a tendency for it to seek a point of least resistance, thus forcing the lens toward the open gap caused by the incision. After considerable experience with the technique and realizing its impor- tance, a description of the operation was published in the Columbus Medical Journal, October, 1884. Since its conception I have practised this technique with general satisfaction during my professional career. The pupil, as a rule, dilates widely under the effects of a mydriatic and no injury to the iris results. For this reason I rarely find it necessary to make an iridectomy. The lens, therefore, with gentle pressure, will pass through the pupillary space without bruising or lacerating the pupillary border. I have knowledge of cases of dislocated lens where, without any effort whatever on the part of the patient, it passed readily from the posterior chamber to that of the anterior, and back again in the absence of the effects of a mydriatic. Operation de Barraquer 331 I have the history of a case where the transition was readily effected at the pleasure of the patient by certain movements of his head. If the pupil does not dilate well, it is useless to attempt to force the lens through. This applies whether within its capsule or in capsulotomy. Then I make a small iridectomy, or otherwise an iridotomy, by slitting the iris slightly from the center of its superior border toward its periphery. My experience is that a small iridectomy or an iridotomy, as indicated, will facilitate the passage of the lens as efficiently as a large one. The posterior surface of the lens lying as it does against the vitreous, it is not unusual for adhesions to occur between their supporting membranes; this, often at the hyaloid fossa, although they may occur at other points, when the attempted removal of the lens in capsule is liable to rupture the hyaloid membrane, with more or less loss of vitreous, or, on the other hand, should a rupture of the lens-capsule occur, fragments of it will remain adherent to the hyaloid membrane, and interfere with vision to a greater or less ex- tent. In such cases capsulotomy has no advantage over the intracapsular, inasmuch as the remaining capsule interferes with the visual acuity in either method. These are conditions that cannot be determined prior to operation. There are cases where the lens cannot be delivered within its capsule without the risk of serious injury or loss of the eye, generally for the reason that it is so firmly attached to its supports. This condition cannot be defi- nitely diagnosed before an attempt to dislocate has been made. My experience has taught me about how much pressure should be made with safety, and I do not usually go beyond that point. If the lens does not readily become detached from its moorings, then I do capsulotomy, because in this event I consider it the safer operation. I have succeeded in dislocating the lens in some instances without difficulty where there had been considerable iritic adhesions. The point upon which pressure is made is an important matter. It should be made upon the center of the upper segment of the cornea, near the incision, and the counterpressure, simply enough to steady the eye, on the opposite side of the cornea. When applied near its center, it causes contraction of the opening and impedes the delivery of the lens. Besides, it frequently causes buckling or kinking and occasionally leaves slight opaque streaks in the cornea. This is entirely avoided with the pressure above the incision. DR. JOHN 0. MCREYNOLDS (Dallas, Texas) : I am fully conscious of my inability to present a comprehensive analysis of the paper of Prof. Barraquer, and I can only hope to offer a few conclusions from my observation of his work in Barcelona, in New York, Boston, Philadelphia and Richmond, together with some personal experience with his method during the past year. The immediate results and the impressions produced upon the profession have varied exceedingly in different cities. In Barcelona, and indeed through- out Spain, the procedure has met with a most enthusiastic endorsement. In New York and Boston the results were not up to the standard, while in Philadelphia and Richmond the operations were performed with practically uniform success. In Richmond, 14 operations were made in one day, and in only one case was there any rupture of the capsule with a tiny bead of vitreous 332 IGNACIO BARRAQUER AND EMILE GALLEMAERTS lost. In Philadelphia there were 9 extractions, with no vitreous lost, in the Wills Hospital, the Jefferson Hospital, and the Polyclinic Hospital. In Boston there were 5 operations made at the Massachusetts Eye Infirm- ary on the first day, with 3 cases of ruptured capsule, in two of which there was also some loss of vitreous. The rupture of the capsules in these cases was evidently due in large measure to the fact that the current was much too strong. This difficulty was remedied on the second day, when 2 extractions were made without accident of any kind. In New York, 2 extractions were made at the Knapp Memorial Hospital, without accident; 1 at the Manhattan Eye Hospital, without accident; 3 at McLean's Hospital, 2 of which were correct, and one had expulsive hemorrhage immediately following the incision before any effort at extraction was made. Seven operations were made at the New York Eye & Ear Infirmary, with 3 capsules ruptured, including 2 cases of vitreous loss. In the four American cities there were 43 extractions with 5 cases of slight vitreous loss and 6 cases of ruptured capsule, while in the last 23 cases there was only one case of a tiny bead of vitreous loss. In the last series of 23 cases Prof. Barraquer had the same assistant, Dr. Poyales, of Madrid, who employed regularly lid retraction instead of the speculum, and the result was approximately 4 per cent, of vitreous loss. Conclusions. 1. In the hands of an experienced and skilful operator the method can be developed to a point where vitreous loss will become an unimportant factor. 2. An uncomplicated rupture of the capsule reduces the operation essen- tially to a capsulotomy operation. 3. There is no increase in the hazard of choroidal hemorrhage. 4. With a peripheral buttonhole iridectomy, which is regularly employed when possible, there should remain a permanently mobile pupil without any incarceration of the iris. 5. With a conjunctival flap adequately held in position with sutures, according to Prof. Barraquer's method, the healing process should be suffi- ciently complete after one week to permit the patient to leave the hospital, provided reasonable supervision is maintained. 6. The danger of infection and postoperative inflammation of all kinds should be reduced to the minimum. 7. Much can be accomplished by a critical study of the intimate structure of each lens to be operated, so that the form of operation may be modified to meet the requirements of each individual case. 8. The method should not be undertaken without previous abundant experience with the older and more established measures of dealing with all forms of cataract, because it is more difficult of execution and developments may occur which only experienced hands can safely control. 9. It has a definite place in ophthalmic surgery as the ideal to be attained through unremitting diligence, experience and care. DR. LODIS D. GREEN (San Francisco, Cal.) : Dr. Barraquer deserves great credit for reviving the suction operation by putting it on a firm basis, thereby placing the intracapsular operation many steps forward. Ophthalmologists Operation de Barraquer 333 who have mastered the intracapsular operation and performed it consistently by one of the two or three methods over a period of years, commend it highly. But even for the most skilful, there was much that was left to be desired. By the forceps method, too many capsules were ruptured so that one suc- ceeded in doing the intracapsular operation in only a small proportion of cases. The Smith-Indian method requires a high degree of skill, only acquired after a great deal of practice on a large number of cases. The Bar- raquer method requires highly developed apparatus and skill in its use, and even then the considerable traction necessary in certain cases with tough suspensory ligaments may result in a detachment of the choroid or retina; or if the capsule breaks, vitreous is liable to be drawn into the tube. It is only natural that every surgeon should prefer to use the instruments with which he obtains the best results, and in the hands of Dr. Barraquer his apparatus undoubtedly does all that one could desire. In our hands, however, we find it has certain mechanical inconveniences that interfere somewhat with the delicacy of manipulation. We have accordingly modified it so that the valve is controlled by the foot, permitting the use of a very light cannula that is held in the hand, as delicately as a cataract knife, thus relieving the fingers of any cramped position. According to the manner in which cataracts are removed, operations may be classified as extractions or expressions. The classical capsulotomy and the Smith-Indian operation are expression operations. The Hulen or Barraquer vacuum and Stanculeanu or Knapp forceps methods are extraction operations. We have gradually evolved a technique which is a combination of expression and extraction, and from an experience of over 100 cases that we have operated by this procedure, we believe it minimizes, to a great extent, the dangers in either the Smith-Indian operation or the vacuum operation as advocated by Dr. Barraquer. This we have described elsewhere. Briefly, the method consists of making a full half section of the cornea with a conjunctival flap. The flap is grasped and cornea raised with a special delivery forceps which also act as a delivery hook, and are held in the left hand, and the cannula held in the right hand is introduced and lightly placed upon the cataract. The foot valve is now engaged and a few seconds allowed for the spoon to become firmly attached to the anterior capsule and lens; the cannula is gently raised so that the upper border of the cataract is tilted forward into the wound, at the same time drawing the cataract out of the eye. At the moment when rotation for the delivery of the lens starts, the left hand releases the conjunctiva and the forceps which held it are shifted to the lower part of the eye near the limbus, and by gentle pressure assists in delivering the lens. We thus attain an expression-extraction with a division of the forces in each and with less trauma to the eye than would occur if either procedure were used alone. COL. R. H. ELLIOT (London, England) : I had not wished to speak to-day, but several of my American friends have asked me to do so on the strength of my having had some cataract practice in the East. I am conscious on this and similar occasions of the warning uttered by Gamaliel before the San- 334 IGNACIO BARRAQUER AND EMILE GALLEMAERTS hedrin, if I may change one word, "Lest by any means we may be found to fight against the truth." I want first of all to differ with Dr. Barraquer most respectfully in the analogy he has more than once used between the capsule laceration operation and the removal of cysts from the abdomen. I respectfully submit, that there is no such analogy. The irritating contents of such cysts and the nature of their walls, and the fact that they will fill or grow again if not com- pletely removed, put them in an entirely different class from the lens inside its capsule. I emphasize this because many of us with large experience in cataract and the capsule laceration operation can confidently rely upon get- ting from 90 per cent, to 96 per cent, of good results from that operation. But the side of the question that I want to bring before you today please understand that I am not fighting against this operation, but I do want you to think squarely about it is related to what is often called the "diaphragm of the eye," that is, the ciliary body with the suspensory ligaments and capsule. This diaphragm is a great protection to the eye, both from the mechanical escape of vitreous, and also from infection. It powerfully strengthens the anterior hyaloid membrane. That is a matter on which any man with large cataract experience can have no question in his mind. I look upon and always will look upon the integrity of the vitreous at the close of a cataract operation as a very great asset. It is not merely that in these cases you are apt to get an escape of vitreous, but that both in the Smith operation and I believe also in Dr. Barraquer's operation, there is a tendency to a damage of the upper part of the hyaloid body leading to a definite tendency to herniation of that part. That was observed by Col. Kirkpatrick working with the Smith operation in Madras. It has been observed by Dr. Wright working with the Barraquer operation. Within the last few days an exponent of the Barraquer operation with whom I raised the question was good enough to tell me that he had observed such a tendency to herniation with the Gullstrand slit lamp. I do not think you can look upon any operation that weakens the upper part of the hyaloid and tends to herniation, and to impaction of that body in your wound, without some apprehension. I hold that the sound thing for the younger operators to do is to first of all select a safe operation. Then when they have acquired manipulation facility, when they have learned all that the old operation has to teach, they can make up their minds for themselves whether they ought or ought not to undertake such a procedure as this. I can only say, that if in the course of years I have a cataract to be removed, I shall go to a surgeon who will do a preliminary iridectomy, who will lacerate the capsule, and who will subse- quently do a discission. I admit you can get very beautiful results with the Barraquer operation, but if today you were having the two the old and the new procedures presented to you for the first time, with all that can be said for and against both of them, I think you would pause before you took up the intracapsular operation. Judge the method logically, look at it in the large, and make up your mind. If you are going to do it, watch your records very carefully and do not forget to look for impaction of the hyaloid and for disturbance of the transparency of the hyaloid body. Operation de Barraquer 335 PROF. F. DE LAPERSONNE (Paris, France) : En attendant que le traitement medical, que les scrums et vaccins nous permettent de preVenir ou de gue>ir la cataracte, l'ide"al ope"ratoire est de faire 1'extraction dans la capsule. Le proce'de' de M. Barraquer marque un grand progres, mais ce n'est pas une operation de tout repos. Les perfectionnements successifs et les si justes observations de mon ami le Professeur Gallemaerts, en sont les meilleures preuves. Trois facteurs principaux interviennent (1) l'ope"rateur; tout le monde n'a pas la grande habilite" de M. Barraquer pour cette operation: je ne conseillerais jamais a un jeune oculiste de faire sa premiere cataracte par ce proce'de: meme pour un oculiste exerc.e', il faut un stage, qui se fait aux depens du malade; en plus le diagnostic des indications ope"ratoires, le calcul exact, fait a 1'avance, de la resistance de la zonule me paraissent tres difficiles. (2) il faut avoir un aide tres sur pour eViter toute pression (3) il faut enfin que I'instrument soit encore perfectionne'. DR. LLOYD MILLS (Los Angeles, Cal.) : When Prof. Barraquer published his first paper in the Siglo Medico, I read his work with the conviction that it promised to be an improvement upon the Smith intracapsular operation which I was then using in selected cases with normally variable success. My attempts to get in touch with Prof. Barraquer failed, and, without knowing the detail of his instrumentarium, I took up the problem by attempting the vacuum extraction of kittens' lenses, using an aluminum-bodied erisphake with an air vent in the side. This vent was so much larger than the tube which carried air to the suction cup, that the cup could be applied to the lens with the suction already active and yet without engagement between cup and lens, until the side vent was closed by my finger, when the lens was drawn at once into the cup. As a source of negative pressure I used succes- sively water suction, the electric vacuum apparatus used for ridding the throat of blood in tonsil work, and finally connected our operating room directly with the great steam vacuum exhaust of the engine-room, capable of developing a vacuum of 18 inches, which, of course, was far in excess of any practical needs. The first lesson learned was that the lens slipped away from the cup with too little vacuum; the second was that too sharp suction ruptured the capsule; the third was that with strong suction applied directly to the central part of the lens and using a pull straightforward the lens could be extracted in capsule, but practically always with the entire vitreous body attached. Only by rocking the lens with some vigor, not radially, as in turning a wheel, but in the anteroposterior plane, could an uncomplicated delivery of a lens in its capsule be obtained. A study of this method led me to believe that the delivery of lens, with vitreous attached, came from the lack of entrance of aqueous or air into the patellar fossa, for, when this was accomplished by the simple gentle insertion of a narrow grooved spatula behind the lens with- out rupturing the hyaloid, and with atmospheric pressure behind the lens equal to that in front of it, normal intracapsular extraction became the rule and not the rarity. May I suggest that possibly the entrance of fluid or air 336 IGNACIO BARRAQUER AND EMILE GALLEMAERTS into this situation is an additional and important accomplishment of vibra- tion? In the light of our constant experiences with the rise and fall of surgical innovations in general I feel that any criticism, and especially that any exaggerated approval of Barraquer's method, should be withheld until it has been tested analytically by competent men and along the exact lines which the master himself has so painstakingly worked out over so many years. It seems to me to be the height of presumption, and our medical editors are partly responsible for this, that men should be permitted to rush into print after a few performances of a surgical novelty and then advise extreme modifications of a method whose exacting details as a rule they have never fundamentally acquired. We saw the evils of this on the Pacific coast in the propaganda for another form of cataract operation now quietly sinking to its natural surgical level, when the entire profession of that coast, and indirectly many of our patients, were so circularized as to the easy adapta- bility of this method to all kinds and conditions of cataract that those who did not acquire this technique were at times stigmatized as laggards, if not actually considered to be to some extent incompetent. The constancy with which any surgical method gives success to the average qualified operator is its real measure of merit, and it is sincerely to be hoped that the develop- ment of Prof. Barraquer's brilliant operation in America, if it is to develop here, will be done in that orderly and decent fashion which the scientific attitude of mind properly demands. DR. Jos. A. WHITE (Richmond, Va.) : In a rather long professional career I have had some little experience with cataract, extraction, and have become wedded to a capsulotomy operation with an iridectomy, preferably pre- liminary, if I can get my patient's consent. This has been reasonably suc- cessful with me in not a large series of cataract extractions, but something over 1500, which is enough to judge of results, and I believe that it offers more chances of restoring sight than any of the more recently suggested operations. There is no question as to the fact that the intracapsular method has come to stay, but I have been loath to attempt it. The first time that I saw the Smith-Indian operation there were two cases. The pressure applied was so great that expression of the lens was followed by considerable loss of vitreous, which is not to be regarded lightly. This operation, however, is reported as very successful in the hands of those who have had a large experience with it. Many modifications of the intracapsular operation have been suggested to diminish pressure and lessen traumatism, and as they come more to what I consider the safety line it is possible that I may undertake the procedure. Recently I saw Prof. Barraquer do his operation under favorable circum- stances. I was fortunate, with the help of my colleagues, to offer him 18 cases of cataract. Owing to a little secretion in the eye of two cases, a slight dislocation of the lens in one, and not sufficient light projection in the field of another, Prof. Barraquer rejected four and operated on the balance. Of these operations he had two ruptured capsules, but he removed the capsule ap- parently completely. There was only one case where a little vitreous pre- sented at the end of the operation. Later I returned to the hospital, and none Operation de Barraquer 337 of the patients had the slightest discomfort from the time of the operation, except one, and all seemed to be doing well. Notwithstanding the brilliant operations that I saw done by the intracapsular methods, if I had a cataract I would have a preliminary iridectomy done, the lens extracted after capsulot- omy, and take the chance of capsular or after-cataract. I am satisfied that the old operation will hold its own among us for the reason that the intra- capsular method is not suited to certain forms and to certain ages. MR. J. GRAY CLEGG (Manchester, England): I have never done the operation, but I have seen friends of mine do it in London. When all is well, undoubtedly it is an ideal operation. What I am particularly interested in is the after-results, and I wish therefore to ask Prof. Barraquer as to the length of time of recovery and what post-operative complications occur; whether he often finds detachment of the choroid and other intra-ocular conditions which detract from the final results. These, it appears to me, are points of great interest, quite apart from the question of the operation itself. DR. S. GEMBLATH (Paris, France): Dans une operation de cataracte, le but primordial, est 1' amelioration de la vue du malade. Monsieur Barraquer ne nous donne aucun detail sur le resultat fonctionnel de 1'oeil op6re. A cause de la manoeuvre op6ratoire assez traumatisante, on peut craindre des iridocyclites traumatiques plus ou moins tardives. D'autre part, la large incision corne'enne ne"cessaire pour permettre la sortie a la fois du cristallin et de la canule, doit n6cessairement, il me semble, donner lieu a un astigmatisme plus fort que celui des m6thodes usuelles. DR. W. A. FISHER (Chicago, 111.) : The first paragraph of Prof. Barraquer's paper states that the simple total extraction is the only rational method of operating for cataract, and his conclusions state among other things that loss of vitreous is rare with paralysis of the orbicular, and that it occurs only when the operator uses undue pressure on the globe or the patient contracts his orbital muscle. If his conclusion is well founded, and I believe it is, then the first paragraph of his paper must be true that the simple total extraction is the only rational method of operating for cataract. I believe Prof. Barraquer has given us a method of removing senile cataracts that has come to stay. In his hands it appears to be perfect, but I do not believe experienced operators will encounter more difficulties by this method than by other methods. Prof. Barraquer's personal skill makes his operation appear quite simple, but such is not the case, and the same can be said of all methods. Recently I had the pleasure of seeing Prof. Barraquer operate upon nine cases in Philadelphia, and fourteen in Richmond, Virginia. There was not a trace of vitreous loss in Philadelphia, and in only one case was there a loss of vitreous in Richmond, and in that one only a drop. But I do not believe his operation will supplant all other methods. Twenty-three opera- tions performed among strange surroundings by any method with only one vitreous loss and that one only a drop, with a prospect of little if any post- operative inflammation, no after-cataracts and good vision in all of them, with the pupils all round and looking normal, is more than most operators 22 338 IGNACIO BARRAQUER AND EMILE GALLEMAERTS expect. Prof. Barraquer has achieved the above results in twentj'-four consecutive operations, and I feel, as I believe most of you do, that he should be congratulated and encouraged, and I am sure the profession will be bene- fited by his coming. PROP. IGNACIO BARRAQUER (closing) : Yo doy las gracias a los distinguidos oftalmologos que me han permitido verificar tan gran numero de operaciones en sus clinicas y a los que han tornado parte en esta discusion, aunque siento no tener tiempo para ser tan extenso como desearia y solo me limitare a esclarecer algunos conceptos sobre mi operacion : 1. No debe llamarse operacion de la catarata por succion toda vez que la ventosa no aspira nada del ojo; unicamente coje el cristalino por su cara anterior. 2. No hay posibilidad de perdida de vitreo si no se practican presiones, aun las mas pequenas, sobre el ojo; toda perdida de vitreo es un defecto de tecnica o de preparacion. 3. No se producen desprendimientos ni de la coroides ni de la retina ya que el vacio vibratorio rompe las fibras de la zonula junto al cristalino, sin que experimenten ninguna traccion en su insercion perif erica. 4. Regulando convenientemente la intensidad del vacio, solamente se rompen las capsulas en un minimum despreciable de casos. 5. El Erisifaco es un instrumento delicado y debe cuidarse y probarse cada vez, como hacemos para con el cuchillo de Graeffe. 6. La tecnica de la operacion no es dificil tal como yo la practico ; cualquier operador que sepa tallar correctamente un colgajo puede hacerlo, pues considero mas dificil la talla de colgajos correctos que la maniobra de extrac- cion con el Erisifaco. 7. Es de suma importancia el estudio previo, seleccion y preparacion minuciosa de los pacientes. Siendo las principales complicaciones en la oppracion clasica de la catarata debidas unas a traumatismos del iris y del vitreo por falta de tecnica y otras a la persistencia dentro del ojo de la capsula y restos cristalinianos, es inneg- able que la extraccion total simple, por un procedimiento que no traumatice ni el iris, ni el vitreo ni ningun otro organo intra-ocular mas que la lesion, ni exija la practi ca de presiones sobre el ojo, sera el mas aproximado a lo ideal. Con el Erisifaco en nuestra clinica los accidentes operatorios han quedado reducidos a una minima espresion y el tanto por ciento de enfermos con agudeza visual normal ha aumentado considerablemente. No quiero acabar sin antes invitar a todos mis companeros a asistir a mis sesiones operatorias en Barcelona. Apres avoir remercie' les ophtalmologues distingue's qui m'ont permis d'op6rer un si grand nombre de malades dans leurs cliniques, et ceux qui ont pris part a cette discussion, je tacherai de faire remarquer certains points, les plus importants, sur mon operation : 1. On ne doit jamais appeler reparation "aspiration de la cataracte" toute fois que la ventouse adhere au cristallin mais sans rien aspirer de rinte"rieur de 1'oeil. 2. La perte de vitr6 n'est pas possible si on eVite la moindre pression. Operation de Barraquer 339 Chaque fois qu'elle survient c'est a cause d'un de"faut de tecnique ou de preparation du malade. 3. Avec le vide vibratoire qui casse les fibres zonulaires pre"s du cristallin, les tractions de 1'Erisiphaque n'arrivent pas a 1'insertion ciliaire de la zonule. 4. Pour ne pas casser la capsule il faut re"gler la quantite" de vide selon les conditions physiques de la cataracte a operer. 5. L'Erisiphaque est un instrument de precision qui doit e"tre soigne" minutieusement et essaye" chaque fois comme nous fai sons avec nos couteaux de Graeffe. 6. La tecnique de Pope"ration, telle que je la practique n'est pas tres dificile. L'oprateur qui peut tailler correctement les lambeaux doit 1'ap- prendre facilement; je conside"re plus dificile la taille du lambeau que la manoeuvre extraction. 7. J'attache la plus grande importance a 1'^tude, selection et preparation des patients. Les principales complications de 1'ope'ration classique reconnaissent deux origines: deTauts de tecnique dans 1'acte operatoire et la persistance dans 1'oeil de re"sidus cristallinniens et de la capsule. Certainement 1'extraction totale simple, correctement 6x6cut4e par un proce'de' ne traumatisant pas 1'iris ni le vitre, serait le plus rapproch6 de.l'ideal. Dans notre clinique nous avons reduit au minimum les accidents et releve" le pourcentage d'opere"s avec acuite vasuelle normale depuis que nous pra- tiquons la Phacoe'risis. J'invite mes confreres americains a assiter a mes seances operatoires a Bar- celona. PROF. EMILE GALLEMAERTS (closing): L'ope"ration de Barraquer per- mettra de realiser la maximum de resultata. C'est un immense progres sur tout ce qui a e"te" fait jusqu'ici. Pourra-t-elle etre execut^e avec toute la s6curit6 qu'exige reparation de la cataracte, 1'avenir nous le dira. Nous pourrons au prochain Congr^s apporter le resultat des experiences faites dans nos diff brents pays alors que nous pourrons discuter cette operation au point de vue pratique aussi bien qu'au point de vue the"orique. TROUBLES OCULAIRES CONSECUTIFS A L'OBSERVATION DIRECTS DE L'ECLIPSE SOLAIRE DR. DRAGOUTINE KOSTITCH Belgrade, Jugo-Slavia HlSTORIQUE Les effets nocifs des rayons directs du soleil sur les yeux sont connus depuis longtemps. On savait deja depuis la plus haute antiquite que Denys, tyran de Syracuse, les coupables condamnes a perdre la vue, apres leur avoir prealablement enleve les paupieres, les exposait aux rayons directs du soleil jusqu 'au moment ou leur vision soit completement abolie. On sait aussi que les Carthaginois employaient le meme procede pour aveugler Attilus Regulus. Plus tard Galien a observe "des curieux perdre la vue pour avoir examine avec trop d'attention les taches du soleil." D 'apres Beauvais, Galien, Lucretius et Aristote savaient aussi que les ellipses du soleil provoquent les troubles de la vision. A une periode plus rapprochee le celebre occuliste du XVIII. siecle, signale nettement les effets nocifs du soleil. Apres Maitre-Jean (1717) Saint- Yves dans son "Nouveau Traite des maladies des yeux" de 1722 dit: "Plusieurs personnes ont perdu leur vue a moitie pour avoir regarde trop longtemps les eclipses du soleil." A la meme 6poque d'apres Boyer, le celebre naturaliste, Buffon, apres avoir regarde longtemps le soleil, fut atteint de mouche volante, et ce trouble de la vue devint insupportable quand ce grand savant examinait les objets tres e" Claire's. Le cas interessant de Reid dont 1'observation a e'te' reproduite par Mackenzie fut atteint de troubles visuels graves et permanents en 1761 qui sont survenus a la suite de la fixation imprudente du soleil au moment du passage de Venus sur le disque solaire. Parmi les Auteurs Allemands c'est Plenck en 1783 qui cite aussi quelques cas. Au XlXeme siecle les observations sont plus nombreuses et ont e'te publie"es dans differents ouvrages. Ces accidents sont cites par Wenzel en 1808 apres lui par Demours en 1820 qui a observe "plus de vingt observations d'amauroses in- 340 Troubles Oculaires Consecutifs a V Observation de I'ficlipse 341 completes survenues peu apres 1'eclipse du soleil du 7 octobre 1820." C'est a cet auteur qu'appartient le me*rite d'avoir trouve" le premier dans ce genre de malade le scotome central, car il cite "mouche fixe par rapport a 1'axe optique." Nous avons apres les observations cities par Larrey "qu'il relate un cas tres grave chez un soldat," par Weller, puis par Sichel (1837) "qui a donne ses soins a cinq personnes qui furent atteintes d'amblyopie de nature torpide chez les unes, irritatifs, chez les autres apres avoir trop longtemps fixe le soleil lors de Pe'clipse qui a eu lieu en 1886," par Carron de Villard (1836), par Rognetta, par Jaeger (1851) qui a trouve les troubles oculaires chez quatorze personnes a la suite de 1'eclipse solaire, par Van Roosbroeck (1853), par Mackenzie (1857) pour lequel Sulzer affirme que cet auteur a fait le premier la classification de ce genre de troubles oculaires, par Desmarres (1858). Plus tard ces troubles oculaires sont e'tudie's dans les memoires speciaux en 1879 et 1882 par Dufour, en 1882 par Emmert, Deutsch- mann, Leber, Haab, Pannee suivante par Reich (un cas), Sulzer (4 cas), Swanzy (2 cas). L'e"clipse du soleil du 16 au 17 mars 1887 a donne le memoire de Haab, Marc Dufour, Sulzer, Emmert et Deutschmann. En 1890 nous avons trois cas de Bock et le cas de Siegfried de Zurich, en 1895 de Duane et Barret et en 1896 de Collins. A cette e*poque Magavly le premier en 1887 de"crit les lesions du fond d'oeil. A la fin du XIX. siecle nous avons aussi une eclipse du soleil le 28 mai 1900 qui a donne lieu a de nombreuses publications comme celle de Menacho (14 cas), Marquez (2 cas), Aubaret (12), Batten, Sime'on Snelle, Lescarret, etc. Plus tard en 1905 on trouve les observations de Delord et en 1907 celles de Casali (14 observations). Au XX. siecle a la suite de 1'eclipse du 4 avril, 1912, on rencontre les publications suivantes: celles de Blessig(20 cas),Strahoff (112 cas), Jess (33 cas), Katz (6 cas), Hirsch (6 cas), Lasarew (40 cas dont 3 avec retinite perforente), Bahtin (1 cas), Joffrio (13 cas), Viguodsky (22 cas), Guermann (4 cas), Koubli (8 cas),Tche'molossow;(4 cas), Szafinski (11 cas), Cords (32 cas), Hoppe, Uhthoff, Birch-Hirschfeld, etc. ETIOLOGIE La fixation plus ou moins prolongee du soleil en general, comme la fixation de T^clipse de cette grande planete peut provoquer des troubles oculaires. 342 DRAGOUTINE KOSTITCH Pendant 1'examen des taches qui apparaissent a la surface du soleil (Galien cite par Demours) et pendant la fixation un peu prolongee du "Passage de Venus devant le disque solaire" (cas de Reid cite par Mackenzie, cas de Swanzy et cas de Diiane) peuvent donner les acci- dents oculaires ce qui confirme nos premiere ide'es. Dans les circonstances quand les rayons solaires entrent en abon- dance dans 1'oeil (comme par exemple dans le voyage a travers le champ couvert de neige et le voyage a travers les montagnes glacees) peuvent provoquer ce qu'on appelle " Snow Blindness " remarque pour la premiere fois deja dans la plus haute antiquite par Xenophon cite par Funari. Plus tard les cas avec les accidents pareils sont cites par Maitre-Jean et Saint- Yves, Demours, Weller, et Mackenzie. Reich dans son memoire interessant de 1880 dans lequel il decrit une veritable epidemic de 73 ouvriers atteints de "Snow Blindness" a la suite du nettoyage de la chaussee transcaucasienne couverte de neige qui passe a travers les plus grandes hauteurs du Caucase. Nous avons encore 15 cas semblables a Samara en Russie et decrits par le Dr. Klykoff en 1904. A part ces troubles oculaires ci-dessus decrits on trouve souvent des accidents oculaires chez les personnes qui sont obligees de voyager a travers les deserts (Sahara), ou les rayons du soleil sont en abon- dance. Avec le deVeloppement de 1'e'lectricite nous rencontrons les publica- tions dans de differents ouvrages, les lesions retiniennes survenues a la suite d'un usage du courant electrique. La retine peut etre lesee par les rayons X, substances radio-actives, acetylene, gaz oxyhydrique, les metaux et les verres en fusion, etc. Malgre qu'on trouve les accident oculaires pendant la fixation a 1'oeil nu de 1'eclipse solaire, on rencontre aussi ces troubles oculaires chez les personnes qui " Ensuivant les diverges phases de 1'eclipse dans un baquet plein d'eau qui reflechissait 1'image du soleil" (Demours), fixation de 1'image du soleil dans un miroir ou dans 1'eau (Casali), quand on regarde 1'eclipse a travers les doigts (Betten) ; La fixation de 1'eclipse avec les mains en cornet, ou a travers le verre non suffisam- ment noirci (Villard et Kostitch), a travers le verre irregulierement noirci (Demours et Larrey) en fixant a travers le verre colore" par une couleur mal choisie (Berret, James et Snell) a travers une carte a jouer trouee au milieu {Strakhoff), fixation par un telescope imprudem- ment manie (Lawrance, Regretta, Snell) et enfin a travers un trou pratique dans un verre fume (Strakhoff). Troubles Oculaires Consecutifs a VObservation de V Eclipse 343 La duree de 1'observation de 1'eclipse solaire est differente dans differents cas. Dans le cas de Barret la duree de fixation etait de 15 minutes, dans celui de Colins de 5 a 10 minutes, dans le cas personnel de 3 a 30 minutes et dans un cas d'un auteur Russe la dur6e a & de 40 minutes.. Lazareff croit comme la loupe ramasse les rayons du soleil quand on veut a 1'aide de celle-ci allumer la cigarette ou un morceau de papier, le cristallin a le meme role dans le cas de lesion retinienne survenue pendant 1'observation a 1'oeil nu de 1'eclipse solaire par rapport a la macula laquelle doit etre brulee sous 1' influence des rayons directs du soleil ramasses par le cristallin et concentres sur la retine. SYMPTOMATOLOGIE Ordinairement ces "accidents oculaires" qui arrivent comme con- sequence de 1'examen direct de 1'eclipse apparaissent immediate- ment apres la fixation de ce corps celeste. Mais les victimes de ce phenomene, ordinairement au commencement ne font pas attention a ces "accidents oculaires," en croyant que c'est "la simple prolonga- tion de 1'eblouissement habituellement observe quand on regarde trop longtemps ou de trop pres un corps incandescent et tres lumi- neux." Beaucoup de ces malades immediatement apres la fixation de 1'eclipse solaire a 1'oeil nu se plaignent de voir se promener devant les yeux une tache verte (obs. No. 7) tache sombre comme la poussiere (Obs. No. 11) tache jaune (Obs. No. 12) tache jaune verdatre (Obs. No. 13), une tache qui au debut etait rouge claire puis violace"e et enfin est devenue jaunatre (Obs. No. 14) et enfin une tache noire (Obs. No. 16). Un malade de Lazareff se plaignait de voir un "cheval vert." II y a certains malades qui ne voyaient pas les mots entiers pendant la lecture, d'autres perdaient certaines lettres et en cherchant a les voir pendant la lecture ils, arrivaient finalement mais perdaient les lettres voisines. D'autres malades se plaignaient que certaines lettres leur parais- saient etre couvertes par une espece de tache d'encre. Une de nos malades se plaignait qu'elle voyait son mari mais n'apercevait pas " le milieu de la tete." Un autre de nos malades (Obs. No. 4 or 13) qui depuis 1'eclipse d'avril de cette annee se plaint que la vision de son oeil gauche est troublee, mais il accuse d'avoir pendant la lecture un point noir, qui 344 DRAGOUTINE KOSTITCH 1'empechait de voir deux ou trois lettres de chaque mot qu'il lisait et au lieu de ces lettres il voyait une tache bleu verdatre dont le vert e*tait tres fence* qui ressemblait a une tache d'encre. L'Etat du Fond D'Oeil. A 1'ophtalmoscope on de*cele des lesions du fond d'oeil provoque*es par la fixation a 1'oeil nu plus ou moins long- temps de l'e*clipse solaire. Ces lesions pourtant, surtout immediate- ment apres la fixation sont souvent malgre les troubles de la vision introuvables par 1'ophtalmoscope et le fond d'oeil parait tout-a-fait normal comme dans les cas de Emmert, Swanzy, Bocca, Duane, Snell, Lawward, Aubaret, Menacho et observations personnelles. Comme nous venons de le dire plus haut quand la lesion du fond de 1'oeil existe, on voit a 1'ophtalmoscope quelque fois la coloration plus intense de la tache jaune (Reich, Schirmer) d'autres fois on remarque une pigmentation plus intense de cette region (Sulzer et Dufour) ou 1'oedeme de macula. Mais de tous ces changements du fond d'oeil on voit le plus souvent au niveau de la macula des taches rouges noires ou de la couleur des framboises, ce qui prouve qu'il y a une congestion plus ou moins intense dans cette region (Swanzy, Bocca, Aubaret, Menacho. Delord, Vigodsky, Joffrio, Bourzeff). Les lesions vues a 1'ophtalmoscope peuvent etre quelquefois plus intenses que celles que nous venons de citer plus haut. Lazareff a trouve chez trois malades apres une fixation longue a 1 (oeil nu de l'e*clipse solaire, la perforation de la retine au niveau de la macula. PATHOGENIE Nombreux sont les auteurs qui ont fait differentes experiences par les rayons solaires sur les yeux de differents animaux pour ex- pliquer les lesions de 1'oeil, que 1'on trouve chez 1'homme que dans les troubles provoque's par 1'eclipse solaire. Parmi ces auteurs c'est Czerny (1867) a le premier commence par les experiences pareilles sur les animaux, apres lui c'est Deutschmann (1882), Widmark (1890), Aubaret et Lescaret (1907) et Birch Hirsch- feldt (1912). Czerny et Deutschmann apres avoir prealablement dilate* la pupille d'une grenouille et d'un lapin concentraient a 1'aide d'un miroir con- cave ou d'une lentille convexe des rayons du soleil sur la re*tine des animaux en experience. Apres 1'effet de dix a quinze minutes de ces rayons ils observaient sur la retine a 1'aide de 1'ophtalmoscope une tache claire entouree par une Troubles Oculaires Consecutifs d I 1 Observation de I'ficlipse 345 aureole jaunatre ou grisatre et un peii plus tard la couleur d'aure'ole devenait d'abord rougeatre puis brune et enfin presque noire. Pendant trois semaines le processus de cette lesion evoluait, les couleurs changeaient et finalement.il se formait au centre du foyer retinien une tache durable. Au bout d'un certain temps on enucie"ait les yeux en experience et apres un examen histologique on constatait que ce sont les couche des fibres nerveuses, des cones et batonnets, et la couche des granula- tions internes qui subissent le plus de degats. Dans ces couches ci-dessus citee"s, il se forme une degenerescense granulaire avec un developpement hypertropique des cellules fibrineuses. II est difficile d'adapter Foeil experimente pour que les rayons solaires tombent juste sur les fovea, sur la macula. Puisque la macula est composee surtout de cones et batonnets et couches granu- leuses externes, il est comprehensible que les lesions sur ce lieu soient d'un caractere severe (Lazareff). Strahoff, croit que les cones et batonnets paraissent etre plus leses a cause d'une couche pigmentaire qui se trouve derriere et qui attire beaucoup les rayons lumineux. Birch-Hirschfeld a expose les yeux de lapins aux rayons solaires dans les conditions qui se r'approchent le plus aux conditions de 1'eclipse solaire. Par les recherches microscopiques deja experimentees il a trouv6 une hyperemie choroidale, 1'oedeme de la couche pigmentaire et la degenerescence de la partie externe de 'la retine. Dans ces experiences de 1'exposition des yeux de lapins aux rayons ultra-violets Birch-Hirschfeld est arrive aux resultats contraires de ses premieres experiences, il a trouve que la partie externe de la retine etait intacte mais la couche des cellules ganglionaires et la couche granu- leuse interne etaient lesees. Les rayons ultra-violets sont absorbes par la couche interne de la retine, mais les rayons lumineux traversent cette couche et ne sont absorbes que par la couche pigmentaire, par consequent les degats de la retine qui dependent de 1'influence des rayons solaires pendant 1'eclipse se resument par une necrose coagul- lente provenant le 1'epithelium de la vision et par exudation de la choroide. De ces experiences on voit que les rayons calorifiques ne sont pas nuisibles comme les rayons lumineux. Aubaret et Lescaret ont fait quatre experiences sur des lapins, en 346 DRAGOUTINE KOSTITCH exposant durant 20 a 40 minutes les yeux de ces animaux aux rayons calorifiques, 1'autre aux rayons chimiques et les yeux des deux derniers aux rayons solaires. Ces auteurs sont loin des re"sultats de leurs devanciers. Apres 1'examen ophtalmoscopique immediat et les jours suivants ils n'arri- vent pas a deceler les lesions apparentes. A 1'examen microscopique apres e"nucleation de 1'oeil experimente ils n'ont pas pu trouver la partie e"blouie de la retine. Aubaret dans son travail public dans les archives d'ophtalmologie du fevrier 1907 se borne a critiquer le precede de 1'experimentation de ses devanciers en abolissant leurs theories que la radiation calorifique et chimique peuvent produire photo-trauma. Pour lui la radiation lumineuse seule produit le photo-trauma. SCOTOME CENTRAL C'est Emmert qui a donne le nom de scotome helie'clipticum et le nom de scotome helioplegicum est donn6 par Szafinsky. Dans les incidents oculaires provoques par Peclipse on trouve pres- que toujours un scotome qu'on nomme ordinairement scotome he'lieclipticum ou scotome helioplegicum. Quelquefois on ne trouve pas de scotome ou meme s'ils existent ils sont si petits qu'on ne peut pas les definire par le perimetre ordinaire et ces scotomes peuvent etre psychiquement annules par les malades. Le scotome est le plus souvent central et les cas de scotome para central sont plus rares. Dans certaines observations publiees on trouve les scotomes "posi- tifs" comme une tache eblouissante et dans 1'autre le scotome "nega- tif " c'est a dire le scotome qui se manifeste par un petit deficit dans le champ visuel. Quand a la forme de ce scotome c'est la forme circu- laire "Ring scotome" qui est la plus habituelle. Par les examens scotometriques (Jess) on est arrive a conclure que la forme du scotome correspond au optograme du soleil est rare (Birch-Hirschfeld). La forme de ce scotome central est quelquefois ovale. Dans un cas curieux de Duane relatif a 1'observation du passage de Venus devant le soleil, ce scotome avait une forme circulaire avec un e"chancrure a la partie supe"rieure et reproduisait exactement la forme du disque solaire au moment de 1'observation. Le scotome d'apres Aubaret consiste dans un edeme locale de la ratine et d'apres Villard correspond a une he"morragie locale de la re" tine. L'influence de V eclipse solaire sur I'acuite visuelle. L'acuite* visuelle Troubles Oculaires Consecutifs a ^Observation de I'fidipse 347 chez les malades qui ont des accidents oculaires survenue a la suite de fixation a 1'oeil nu de 1'eclipse solaire, peut etre de 0.8-0.9, ou Pacuite" peut etre normale. Mais il y a des cas dans lesquels 1'acuite" visuelle est de 0; la 0.2. Les cas ou la vision est presque normale s'expliquent par le fait que la lesion de la retine n'occupe pas toute la fovea centrale de la macula. Dans certains cas le malade peut ameliorer sa vision par une fixa- tion excentrique c'est a dire par une deviation de 1'oeil pendant le regard, et par ce fait 1'objet n'est pas fixe par le centre de macula, mais il est fixe par les autres parties de macula qui ne sont pas si lesees que la fovea centrale. Par cela on peut conclure en dehors de centre de la macula que les autres parties de celle-ci restent intactes (Strahoff). LE RAPPORT ENTRE LES TROUBLES ET LA REFRACTION Theoriquement les yeux des emmetropes sont plus exposes aux lesions pendant la fixation que ceux des hypermetropes et myopes. Dr. Tchemolossoff de Petrograd a public un cas qui correspond a 1'hypothese ci-dessus. Une jeune femme bien portante a fixe avec les deux yeux nus 1'eclipse solaire; elles n'a eu les troubles oculaires qu'a un seul oeil qui etait emmetrope. L'autre oeil dont la refraction etait myopique est reste sans aucun accident. Nous avons aussi comme chez notre malade obs. No. 18 1'oeil Emmetrope etait lese et 1'autre oeil hypermetrope resta intact. COMPLICATION Marquez a public un cas dans lequel aussitot apres la fixation a 1'oeil nu de 1'eclipse solaire, il a trouve ophtalmoscopiquement une grande congestion des papilles et neuroretinite dans les deux yeux. Les atrophies des nerfs optiques arrivent ordinairement comme complica- tion tar dive. Comme nous 1'avons deja remarque Lazareff a trouve trois cas dans lesquels il a constate, bientot apres la fixation, la perforation de la retine au niveau de la region maculaire. Batten a trouve un cas de trombose d'une artere re"tinienne et un autre cas d'hemorragie de la retine. Menacho a eu 1'occasion de voir 14 malades qui ont pre'sente' dif- fe*rentes complications de 1'oeil survenues a la suite de l'e"clipse solaire. De ces 14 observations un malade presentait une papillite centrale, 2 malades presentaient de 1' hyalite, 1 cas d'apoplexie maculaire, un autre 348 DRAGOUTINE KOSTITCH une nevrite re"tro-bulbaire ; une f ois il a trouve" chez un malade de la lym- phangite anterieure avec glaucome et enfin deux fois des nevrites optiques. Sulzer a trouve" aussi un cas de neuro-re'tinite. Ste"phenson a constate" un cas de nevrite legere. Katz de ces 6 observations a trouve* un cas de conjonctivite avec ke"ratite du limbe. (2e) cataracte polaire poste"rieure; (3e) paralysie du sphincter pupillaire. Marenholtz a trouve un cas de nevrite optique. Hirsch de 6 cas il a remarque chez trois malades de conjonctivite. Jssakowitz a observe un cas de l'e"blouissement du cristallin. Nous avons trouve" aussi un cas de conjonctivite (obs. No. 19). Aubaret et Villard pensent que les complications graves survenues a la suite le la fixation de l'e"clipse sont rares et arrivent & 1'hypothese, a part des rayons solaires qu'il y a d'autres causes qui provoquent ces troubles oculaires. Ainsi Aubaret pense que la complication d'hyalite chez des malades cite"e par Menacho n'est pas survenue a la suite de fixation de 1'eclipse, mais qu'elle est survenue a cause de la myopie forte, qui existait chez ces malades deja avant 1'eclipse. Villard a public une observation d'un malade fortement myope chez lequel il a trouve un de'collement de la retine a la suite de fixation de l'e"clipse. Get auteur croit que cette complication n'est pas arrivee comme consequence de Faction des rayons directs du soleil. Fromaget a constate" chez un malade a la suite de 1'eclipse une choroidite se"reuse, mais ce malade souffrait pendant 6 ans avant l'e"clipse de sinusite maxillaire du meme cote. PRONOSTIC Dans cette maladie le pronostic doit etre toujours reserve*. II y a des cas qui guerissent assez rapidement, dans lesquels 1'acuite visuelle devient presque normale ou tout a fait normale. Le petit scotome qu'on rencontre chez ces malades disparait aussi assez rapide- ment. Dans d'autres cas 1'acuite" visuelle s'ame'liore seulement au bout de 4 a 6 mois et elle n'aboutit que jusqu'a 0.5 a 0.6. Le scotome ne disparait pas chez ces malades, a cause de la disparition des cones et des batonnets au ni veau du centre de la macula qui sont ' ' brules "par les rayons directs du soleil. Malheureusement comme ces elements ne se re"generent pas, ces malades sont condamne's a supporter ce scotome eternellement. Troubles Oculaires Consecutifs d I 'Observation de 1'eclipse 349 Dans certains cas le pronostic est encore plus grave. "Maitre Jean fait allusion: toutes ces choses disparaissent quand les fibres de la retine se remettent dans leur etat normal; mais quand le vice que ces fibres ont contractee est considerable il continue quelquefois a paraitre tout le reste de la vie." Saint- Yves signaler "Des personnes qui ont perdu la vue a moitie pour avoir regarde trop longtemps des eclipses du soleil." Rognetta cite un cas qui resta completement aveugle. De Wecker croit que I'abaissement de 1'acuite visuelle et le scotome peuvent rester e'ternellement. Reich a constate" un cas ou 1'acuite" visuelle est reste a 0.3 pour tou- jours avec scotome central persistant pour les couleurs. Dans le cas de Winsellmann 1'acuite visuelle a ete presque nulle pendant 3 ans a partir du commencement des accidents oculaires. Dans 1'observation de Collins: "Les troubles de 1'oeil le plus atteint n'avaient pas sensiblement diminues 9 ans plus tard." Duane cite un cas dans lequel le scotome existait pendant 12 ans apres le debut des accidents, avec la complication d'attaque d'hemi- anopsie. Aubaret a constate* chez un malade apres 45 ans de 1'eclipse solaire un scotome helieclipticum, avec une diminution de 1'acuite visuelle de 2/3 et dans un autre cas il trouva un scotome apres 28 ans de 1'eclipse solaire. TRAITEMENT La plupart des auteurs conseillent au point de vue prophylactique de ne regarder le soleil qu'a travers des verres fortement teintes, qui atte"nuent beaucoup 1'intensite des rayons qu-il emet. Les verres employes doivent etre suffisamment teinte's en noir. Autrement, comme on 1'a deja constate, si Ton fixe 1'eclipse solaire a travers le verre insuffisamment teinte; dans ce cas les troubles oculaires peuvent se produire, aussi bien dans le cas de fixation a 1'oeil nu. Certains auteurs comme Holden ont conseille de superposer trois verres, un rouge, un vert et un bleu. II parait que ces verres colores bien choisis "ne changeraient en rien la couleur du soleil, tout en affaiblissant suffisamment son intensite lumineuse pour en rendre 1'observation directe inoffensive pour 1'oeil." Quand le malade s'adresse au me"decin imme'diatement apres les accidents, il faut mettre les yeux du malade au repos complet. Le malade ne doit pas quitter la chambre; laquelle doit etre peu eclaire"; on ordonnera un purgatif que Ton renouvellera plusieurs fois; on 350 DRAGOUTINE KOSTITCH prescrira des saign6es locales (vantouses scarifiers de Heurteloup), on peut conseiller aussi 1'injection de strychnine; enfin plus tard on donnera de 1'iodure de potassium. A part ce traitement nous avons conseille 1 a nos malades qui etaient presque tous des Sieves du Lycee, de quitter l'6cole provisoirement et de passer leurs vacances a la campagne dans la verdure. Le plus part de nos malades ont acceptes notre conseil, d'autant plus que 1'eclipse solaire du 9 avril est tomb6 juste avant la fin de 1'annee scolaire. LES OBSERVATIONS 06s. No. 1. Zagarka Popovitch, age* de 23 ans. Bonne. Le 9 avril elle a fixe* avec les deux yeux Peclipse solaire a 10 heures du matin. Apres une courte fixation des deux yeux elle a continue" a fixer pen- dant une demi-heure avec 1'oeil droit seulement. Tout de suite apres la fixation elle a perdu la vision momentanement, mais aussitot la vision est revenue surtout a 1'peil gauche, et la vision s'est amelire difficilement, mais comme nous verrons plus tard Pacuite* visuelle surtout de Poeil droit est reste" en defaut. 13 avril 10 D. Devant cet oeil elle a une tache qui lui a trouble cet oeil. La couleur de cette tache au debut etait jaune puis verte et enfin est devenue rouge. La malade a declare* qu'avec 1'oeil droit elle voyait son mari mais elle ne lui voyait pas le milieu de la figure. Son acuite visuelle a etc* le 13 avril de 0.7. Done chez cet oeil existe le scotome central. A Pexamen ophtalmoscopique on voyait que P aureole de la macula etait e*bloui, et dans le centre de la macula on voyait un petit cercle de couleur foncee et vers la peripheiie de ce centre il existait une petite tache jaune. 0. G. Pas de scotome. F. 0. normale V. = 0.9. A la sciascopie les deux yeux Etaient emmetropes. 19 avril O. D. Sans changement. 0. G. V. = 1. 06s. No. 2. A. D. eleve du Lycee. II a fixe" Peclipse du 9 avril 2 fois avec 1'oeil droit nu en fermant 1'oeil gauche. Le lendemain il a remarque que sa vision n'etait pas si bonne qu'avant, et surtout une tache grisatre persistante devant cet oeil le genait. Le 12 avril. 0. D. V.: 0.5. En lisant il ne voit que chaque troisieme lettre du mot F. 0. macula avec un aureole clair, dans le centre de la macula une petite tache rouge fonce*e. Petit scotome central. O. G. normal. A la Sciascopie les deux yeux sont &nm6tropes. 4 octobre, meme annee. O. D. V.: 1. Disparition de la tache. F. 0. La petite tache de la macula est diminuee. Pas de scotome. 06s. No. 3. F. F. Age* de 14 ans, eleve du Lycee a fixe" le 9 avril, 1921, avec 1'oeil gauche nu Peclipse solaire pendant 4 a 5 minutes. Aussitot il a remar- Troubles Oculaires Consecutifs a V Observation de I'ficlipse 351 quo* que la vision.de cet oeil e"tait trouble et en meme temps une petite tache persistante se promenait devant cet oeil , pendant la lecture il ne voyait pas certaines lettres du meme mot. 14 avril. 0. D. normal. 0, G. F. 0. Toute la region de la macula e"tait couverte on dirait par une se"rosite" qui empechait de voir les de" tails de cette region. Scotome central tres grand. V. : 0.3. 20 septembre. 0. G. F. 0. Au niveau du centre de la macula une tache gris fonce". Scotome existe encore. V.: 0.6. 0. D. normal. 06s. No. 4- M. V. e"leve du Lycee, age de 17 ans, a fixe" le 9 avril au de"but avec les deux yeux a travers le verre fume" l'e"clipse solaire. Au bout d'un certain temps il a continue" a, fixer avec 1'oeil gauche nu a peu pres pendant 20 minutes. Son oeil droit pendant la fixation e"tait ferine". Aussitot il a re- marque" un e"blouissement et la fatigue des deux yeux. Cet e"blouissement n'est pas e"te" de longue dure"e, mais devant son oeil gauche, persistait une tache 1'empechant de voir deux ou trois lettre de chaque mots. A la place de ces lettres il voyait une tache de la couleur bleu verdatre-fonce*. 11 avril. O. D. normal. O. G, V.: 0.4. F. 0. Dans le centre de ma- cula on trouve une tache en forme de demi cercle de couleur rouge fonc6. Scotome central positif. 20 avril. 0. D. normal. 0. G. V.: 0.7. Le reste sans changement. 1 octobre. O. D. normal. 0. G. Scotome central positif V.: 0.7. F. 0. Petite tache blanche dans la region maculaire. 06s. No. 5. Le nomine" M. V. 416 ve du Lycee age* de 16 ans a fixe" avec 1'oeil gauche nu Eclipse solaire du 9 avril 1921. Aussitot il a remarque" une tache devant cet oeil qui lui cachait une partie de petits objets. Cette tache a duree pendant 2 jours. Nous ne 1'avons vu que 7 jours apres 1'accident. II n'avait pas de scotome. 0. D. normal. O. G. le contour du macula n'etait pas tres net. L'acuite" e"tait normale aux deux yeux. 2 septembre. Les deux yeux e"taient normaux. 06s. No. 6. Le nomine" M. Man, age" de 11 ans e"leve du Re*al gymnase. Ce malade a fixe" Pe"clipse solaire du 9 avril deux fois avec les deux yeux nus. Chaque fois la dure"e de fixation e"tait de 10 a 15 minutes. Apres la fixation il est rentre" en classe pour travailler, mais quand il a commence" a lire toutes les lettres lui semblait etre couvertes par des points noirs ou plutot comme il disait couvertes de "taches d'encre." En meme temps les lignes imprime*es lui semblaient etre interrompues par places. Nous 1'avons vu le lendemain de la fixation c'est-a dire le 10 avril, 1921. 0. G. F. 0. Tout le centre de macula e"tait couvert par une tache rouge fortement fonce"e. A la partie infe"rieure de cette tache on voyait un petit point jaune comme une tete d'epingle. L'aure"ole de la macula e"tait forte- ment hyp6re"mie"e. V. : 0.2. 0. D. F. 0. Tout Paure"ole de la macula e*tait oedemacie"e et la partie in- 352 DRAGOUTINE KOSTITCH fe>ieure e"tait presque bleu&tre. Au centre de macula existait une tache fortement rouge. V.: 0.3. Le soleil le gene beaucoup. Le scotome central des deux yeux e"tait positif. 10 octobre, meme anne"e. Le scotome positif des deux yeux 0. G. V.: 0.2. F. O. aureole maculaire pas nette. Au centre de la macula on voit un petit cercle rouge avec un point blanc au centre. 0. D. V.: 0.3. F. 0. aureole maculaire pas nette. Le malade lit un peu plus facilement mais encore assez difficilement de telle sorte qu'il e"tait oblige" de repasser ses examens a la session de novembre. 06s. No. 7. R. B. e"leve du Lyc6e age" de 10 ans. II a fixe" pendant 2-3 minutes avec les deux yeux 1'e'clipse solaire. Le meme jour il avait devant les deux yeux une tache verdatre. Au bout de quelques jours cette tache avait disparue. Nous 1'avons vu le 12 avril. Pas de scotome. Les taches persistent. F. 0. Aux deux yeux normaux ainsi que 1'acuite 1 visuelle. 06s. No. 8. M. S. eleve du Lyce"e, age" de 13 ans. Le malade a fixe" avec 1'oeil droit pendant 3-4 minutes, 1'e'clipse solaire du 9 avril, 1921. II y a eu une tache devant cet oeil aussitdt mais elle a disparue le lendemain. Les lignes et les lettres lui semblaient etre courbe's. Nous 1'avons vu le 11 avril, 1921. O. D. V.: 1 F. O. normal. 06s. No. 9. B. M. eleve du Lyce"e, age" de 12 ans. A fixe" plusieurs fois dans la matinee du 9 avril 1'e'clipse solaire avec 1'oeil droit tantot nu, tantot & travers le verre fume". Le meme jour il avait une tache bleu-verdatre de- vant cet oeil. En lisant il ne voyait pas certaines lettres de chaque mot. Nous 1'avons vu le 12 avril. Ce malade pre"sentait & 1'oeil gauche un petit scotome. V. : 0.9. F. 0. hype're'mie le"gere de la macula. 10 aout. 0. D. V.: 1. Pas de scotome. F. 0. normal. 06s. No. 10. J. C. Eleve du Lyce"e, age" de 13 ans, a fixe" avec les deux yeux 1'e'clipse solaire du 9 avril, plusieurs fois pendant 2-3 minutes. Dans la meme journe"e il a remarque" devant son oeil guache une tache; pourtant devant 1'oeil droit qui est strabique n'a rien remarque". II est venu chez nous le 10 avril 1921. 0. D. V.: 0.1 Pas de scotome. Strabisme convergent. F. 0. normal. Pas de tache subjective. 0. G. V.: entre 0.9 et 1. Pendant la lecture les lignes sont troubles. La tache persiste. Petit scotome central. 06s. No. 11. A. A. age" de 14 ans, a fixe" le 9 avril avec 1'oeil droit 3 fois 1'e'clipse solaire. Le meme jour il a remarqu^ une tache devant cet oeil qui 1'empeche de lire. Cette tache lui semble comme une petite poussiere. Le 1 1 avril il est venu chez nous. O. D. V.: 0.6. F. O. A 1'ophtalmoscopique on ne voyait pas bien l'aure"ole. Au centre de macula il existait un petit point rouge sous la forme d'un petit cone de'coupe'. Le scotome central existe. 0. G. normal. Troubles Oculaires Consecutifs a ^Observation de I'ficlipse 353 06s. No. 12. S. R. A fixe* avec 1'oeil droit et il a ferine* son oeil droit strabique. II a fixe en deux fois pendant 4-5 minutes. Apres la seconde fixation il a remarque* une tache jaune devant son oeil droit. Le 15 avril a la date ou nous Favons vu pour la premiere fois son oeil droit pre"sentait 1'acuite* visuelle de 0.7. La tache jaune persiste. F. 0. normal. Petit scotome. 0. S. Strabisme convergent. V.: 0.5. Pas de tache. 20 aout, 1921. O. D. Pas de scotome. Pas de tache. V.: IF. 0. normal. 06s. No. 13. S. Y. age" de 12 ans. A fixe" le 9 avril l'e"clipse solaire pendant 15 minutes avec 1'oeil gauche tantot nu tant6t a travers le verre fume". Le lendemain apres la fixation il a remarque" devant son oeil gauche une tache jaune-verdatre. Pendant la lecture il ne voyait pas certaines lettres et sur- tout le soir quand il lisait a l'e"clairage e'lectrique. 13 avril. II est venu pour la premiere fois a la consultation chez nous. 0. G. V.: 0.4. Scotome existe. La tache persiste. F. 0. Au centre de macula une tache presque noire, avec deux petits points jaunatres au centre. 0. D. normal. 06s. No. 14- T. P. age" de 20 ans. A fixe" le 9 avril avec 0. D. pendant une heure avec interruption tantot a 1'oeil nu tantot a travers le verre fume". Aussitot il a remarque devant son oeil droit une tache rouge, le lendemain cette tache est devenue violace*e et le 13 avril le jour ou il est venu chez nous pour la premiere fois cette tache e"tait de couleur jaune. 0. D. V.: 0.7-0.8. F. 0. aurdole de la macula tres pale. Au centre de la macula une tache en forme de bague avec un petit point jaune au centre. Scotome existait. Pendant la lecture le malade ne voyait pas les mots entiers. 1 Sept. Sans changement. 06s. No. 15. B. M. e"leve au Lycee, age* de 18 ans, a fixe" le 9 avril a travers le verre fume", puis avec 1'oeil droit nu pendant 10 minutes. Le meme jour il a remarque" devant son oeil droit une tache jaune pale. En lisant il ne voyait pas certaines lettres. Le 19 avril nous 1'avons vu. 0. D. F. 0. Au centre de la macula une petite tache rouge sous le point jaune au centre. Scotome paracentral. La tache qui a persiste" devant cet oeil est moins forte. V.: 0.8. 0. G. normal. 06s. No. 16. M. S. e"leve du Lyce"e, age" de 13 ans, a fixe" le 9 avril 1921 l'e"clipse solaire pendant 15 minutes avec 1'oeil droit nu. Le meme jour il a remarque* une tache noire devant cet oeil ; et pendant la lecture il ne voyait pas certaines lettres du mot. 19 avril. Le jour ou nous 1'avons vu il pre"sentait les symptomes suivants: 0. D. Scotome existe. F. 0. Au centre de la macula on voyait un petit point rouge. Au niveau de la partie supe"rieure de l'aure"ole existait un point rouge fence" et entre ce point et celui du centre il y avait deux points blancs. V.: 0.5. 0. G. normal. 23 354 DRAGOUTINE KOSTITCH 4 Octobre. 0. D. Scotome persiste. V.: 0.6. F. 0. Au centre de la macula un point blanc au dessous duquel on voyait une tache rouge en arc. La lecture est possible. O. G. normal. 06s. No. 17. S. V. e"leve du Lyce*e, age" de 13 ans. A fixe" le 9 avril avec les deux yeux nus pendant 3 minutes. Le lendemain il a remarque" une tache noire devant chaque oeil ce qui 1'a fait venir le 11 avril a la consultation chez nous. 0. D. Pas de scotome. V. : IF. 0. On n'a remarque" rien d'anor- mal a 1'ophtalmoscopie. O. G. La meme chose que 1'autre. 25 avril. Les scotomes subjectifs ont disparus. 06s. No. 18. B. K. 61eve du Lyce*e age de 12 ans a fixe" le 9 avril avec les deus yeux nus pendant une demi heure. Le meme jour il a remarqu6 devant Poeil gauche une tache verdatre. Le 14 avril jour ou nous 1'avons vu pour la premiere fois. O. G. A la sciascopie 2 D. Scotome central existait. V.: 0.1. Avec la correction de +2 D. 1'acuite" e"tait de 0.4. La tache e"tait si grande qu'elle 1'empechait de voir plusieurs lettres du mot. F. O. Dans un petite veine qui passe en dessus de la macula a 1 'image ren verse" on remar- quait un petit noeud. Toute la region maculaire oedemacie*. A la partie supe"rieure du centre de la macula il existait une petite tache de la couleur framboise. 0. D. e'mme'trope. V.: 1. F. 0. normal. II n'est plus revenu a la con- sultation. 06s. No. 19. P. K. e"l(;ve du Lyce"e age" de 14 ans a fixe" avec I'oeil droit pendant plus d'une demi heure. Nous 1'avons vu le lendemain de 1'^clipse. II se plaignait que cet oeil avait des larmoiements et en meme temps d'avoir du sable sous les paupieres et en parti culier sous les paupieres superieures. O. D. Conjonctivite sub aigue. Cette conjonctivite 1'empechait de remar- quer la tache noire habituelle chez ce genre de malades, mais apreis la gue"rison de la conjonctivite, la tache noire est apparue. V.: 0.9. F. O. la region maculaire un peu rougeatre. Pas de scotome. 0. G. normal. II n'est plus revenu a la consultation. 06s. No. 20. J. K. e"leve du Lyce"e, age" de 11 ans, a fixe" avec I'oeil droit nu pendant 5 a 6 minutes. Une heure et demi apres la fixation il a remarqu6 une esp6ce de brouillard jaunatre. Ce brouillard comme une toile d'ar- raigne"e 1'empechait de lire. Le lendemain de la consultation il est revenu de nouveau chez nous. Nous 1'avons constate" a la sciascopie une myopie de 5.0 aux deux yeux 0. D. V. : apres la correction 0.6. F. 0. Dans la region maculaire oedemacie". Scotome central. Le brouillard persiste. 0. G. myopie de 5.0. V.: apres la correction: 1. F. 0. normal. 25 avril. Aucun changement. Troubles Oculaires Consecutifs d I 'Observation de I'Bclipse 355 CONCLUSIONS 1. L'observation de 1'eclipse solaire du 9 avril 1921 a Belgrade a provoque chez les curieux qui ont fixe 1'eclipse avec les yeux nus des troubles oculaires, forts chez les uns, plus faibles chez les autres. 2. II est caracteristique que, de nos 20 malades, 19 sont des e"lves des Lycees de Belgrade. Avant 1'eclipse, les ryceens de Belgrade etaient prevenus du danger que courent leurs yeux s'ils ne prenaient pas les precautions neces- saires, qui ont ete explique"es par nous et par leurs professeurs. 3. Nous croyons que les eleives, empeches de lire par des eblouisse- ments provoques par scotome, sont venus immediatement consulter le me'decin, tandis que les autres malades qui, surtout chez les paysans, croyaient que ce n'etaient que des troubles passagers, ne sont pas venu consulter le medecin. 4. Les lesions oculaires provoquees par la fixation de l'6clipse solaire peuvent etre faibles ou tres fortes. 5. Le symptome le plus habituel chez ces malades est le scotome helioplegicum ou helieclipticum. 6. II semble que les rayons lumineux directs du soleil sont les plus nuisibles. 7. Les yeux emmetropes sont plus exposes aux accidents pendant la fixation que les yeux myopes ou hypermetropes. BIBLIOGRAPHIE 1. Holden: Verres pour observer le Soleil, Academic de medecine de New York, 1900. 2. Dr. Klykoff: Keratitis Solaris exfoliativa, Wiestnik Ophtalmologyi, 1904, xxi. 3. Zirm: Ein Fall von bleibenden ausgedehnten Veranderungen der beiden Macu- lae durch direktes Sonnenlicht, Graefe's Arch., 1905, Ix, 3. 4. Sgrosso: Su d una diversita di Tinzione che osservasi nelle retine di rane tenuta alia oscurita e alia luce e trattate col triacido di Ehrlich, Archivio di ottal- mologia, 1906, 5-6. 5. Cohen: tlber den Einfluss des Lebensalters auf die Adaption, Klinische Mo~ natsblatter fiir Augenheilkunde, Februar-Marz, 1906. 6. Marc Dufour et J. Gonin: Eblouissement de la retine, Encyclopedic fr. d. opht., 1906, vi. 7. Bossalino: Ancora una parolla, sulla visibilita dei raggi, Annali di ottalmol., 1907, Fasc. 5. 8. Coats: The Pathology of Macular Holes, Royal London Ophth. Hosp. Re- ports, 1907, xvii. 356 DRAGOUTINE KOSTITCH 9. Cords: tlber die Verschmelzungsfrequenz bei periodischer Netzhautreizung durch Licht oder elektrische Strohme, Graefe's Archiv, 1907, Ixvii, 1. 10. H. Villards: Troubles oculaires conse"cutifs a 1' observation directe des eclipses du Soleil, Annales d'Oculistique, Aout, 1907, cxxxvi. 11. Aubaret: Sur les scotomes par eclipse solaire. Scotoma helieclipticum, Arch. d'ophtal., Fevrier, 1907. 12. Casali: Ambliopia consecutiva e fissazione del sol, Annali di ottalmol., 1907, Fasc. 3-4. 13. Lazareff : Trois cas de retinite dans la region de la macula suvernus a la suite des e"ffets des rayons directs du soleil pendant la fixation a 1'oeil nu de 1 'eclipse solaire etun cas de m^me maladie d 'origine traumatique, Wiestnik Ophtal. mologyi, 1912, xxix, No. 7-8. 14. Vostrotine: Un cas de retinite consecutif a la fixation de 1'eclipse solaire, Roussky Vratch, 1912, No. 19. 15. Cords: Sonnenblendung, Zeitschr. f. Augenheilk., Juni, 1912. 16. Hoppe: Augenscheidigung durch die Sonnenfinsternis am 17. April, 1912. Munch, med. Wochenschr., 1912, No. 45. 17. Uhthoff: Zu zentraler Blendungs-Retinitis bei Beobachtung der Sonnenfin- sternis am 17. April, 1912, Klin. Monatsbl. f. Augenheilk., September, 1912. 18. Kaz: Schadigungs-Veranderungen des Bulbusabschnittes durch Beobachtung der Sonnenfinsternis, Wochensch. f. Therapie und Hygiene des Auges, 1912, No. 10. 19. Birch-Hirschfeld: Zum Kapitel der Sonnenblendung des Auges, Zeitschr. f. Augenheilk., Oktober, 1912. 20. Strachoff: Les troubles oculaires survenus d la suite de 1' Eclipse solaire de 4 Avril, 1912. V.O., 1913, xxx, iv, No. 3. 21. Blessigue: A propos des troubles oculaires survenus a la suite de la fixation de 1'eclipse solaire le 4 Avril, 1912. V. O., 1913, xxx, iv, 1. 22. Szafinski: Scotoma helioplegi um Postep okylistyczny, Giepec, Sierpien, 1913. DISCUSSION COL. R. H. ELLIOT (London, England) : I saw a good deal of eclipse blindness in India, and would like to mention some additional causes which are not mentioned in the paper. One is the reflection of light from water when a boat is being steered in the sun's eye on a tropical sea or river; another is taking observations by the sextant at sea; a third is a religious rite of the Brahmins : Every orthodox Brahmin has to cross his hands and look through them at the sun at certain times of day. I understand a number of them do not trouble to look at the sun, but look through a wall on which the sun shines; but a number do really look at the sun, and Col. Kirkpatrick has described eclipse blindness as a result of this rite. The practice of observing an eclipse through a pail of water is common in the Tropics, and is extremely dangerous. It may lead to very definite eclipse blindness. Some little time ago I saw an officer of the Indian Government who had ridden a long distance besides rice fields in the early morning. The sun came obliquely through the rice fields to his eyes, and when he came to me after- ward he had a well-marked eclipse scotoma. Troubles Oculaires Consecutifs a V Observation de I' Eclipse 357 An interesting point in Dr. Kostitch's paper is the youth of the subjects, because the opinion hitherto held by ophthalmologists is that it is rare to find eclipse scotoma in young people. A point I do not find referred to is the association of eclipse scotoma with a ring scotoma lying between 35 degrees to 50 degrees in the field. This has been noticed both in aviators and in those who have had to do with anti- aircraft guns. Another extraordinary thing in this paper is the number of people in whom both eyes are affected, because past experience would seem to indicate that most of the patients had involvement of only one eye. There is a practical point I would like to call attention to in the differential diagnosis from hysteria. Scotoma due to sun-blindness is small; at twenty feet away it just covers the face. I recently saw a girl who had looked at the sun, and believed she had central scotoma, but her scotoma covered the whole subject standing a few feet away. That was obviously not a central scotoma, as the subsequent history proved. Another point in hysterical cases is that the scotoma does not necessarily appear immediately after the exposure to the sun, whereas in the real cases the patients give a history of a scotoma coming on at once. A point about prophylaxis. The best way to look at a sun eclipse is first to use a negative which has been suitably exposed to light and fully developed so as to get a uniform dark plate; and second, to avoid looking at the sun for any prolonged period. It is the prolonged looking at the sun that does the mischief. Another point is to do what certain countries Sweden, for instance have done, and to start a press campaign before each eclipse warn- ing people of the dangers involved in looking at the sun, telling them how they may safely and comfortably view the eclipse. DR. GEORGE MACKAY (Edinburgh, Scotland) : The subject under discus- sion attracted my attention many years ago. The writer of today's paper has limited his survey of the literature to the period of 1900 to 1912, which makes me feel somewhat antediluvian, because my paper was written in 1894, and has not received Dr. Kostitch's attention. However, I am somewhat to blame because the title of my paper did not indicate that it had reference to eclipse blindness, it being entitled "Blinding of the Retina by Direct Sun- light." It so happens that a majority of cases of retinal damage from solar rays do arise after gazing at an eclipse, but I venture to think that my title is more correct, since this damage may happen at any time if an observer directs his gaze to the sun's face. My paper contained a complete survey of the literature so far as I knew up to 1894. I was about to make a fresh survey of the whole literature of the subject about 1912, as I thought a sufficient interval had elapsed, but just then there appeared a paper written by a German, a monograph presented I think as a thesis at one of the German universities, and it so completely covered the ground that I set to work to translate that rather than prepare a new paper. I have already pointed one moral, namely, that if you want to attract the public eye you must be careful what title you employ, for my paper has been frequently overlooked. 358 DRAGOUTINE KOSTITCH Another point I would like to make is this: I would most respectfully sug- gest to the organizers of meetings such as this that before they put out a pre-session volume they should endeavor to anticipate that by a still earlier pre-session list of the titles of the papers which will be discussed. That could be sent out before the full contents of the papers are set up in print. Those who have come from a distance are at a great disadvantage in being unin- formed before leaving home as to the subjects to be discussed. I must make apology, therefore, which is not altogether my own fault, that I cannot remember the name of the writer of that important paper, but it will un- doubtedly be found in the Index Medicus about the years 1912 or 1913. It is a most admirable monograph, bringing the literature up to that date. There are one or two points to which reference has not been made by Dr. Kostitch, and on which I should like to have had his opinion had he been here. One symptom to which he does not refer, but which many have observed, is a quivering movement complained of by the patient. What is that due to? It passes away in many cases, but it is often persistent. In fact, in one case, that of a medical colleague, it is the only thing he still feels, although the accident happened a quarter of a century ago. I suggest that whereas the normal stimulus of moderate light only excites molecular or atomic vibrations in retinal cones and rods, the more violent assault of fo- cussed sunlight loosens the attachment of some of the cells to one another so that a whole cell vibrates separately or in groups. Another question is as to whether the injury is produced by the concentra- tion of the light rays or from the heat rays. One is inclined to think that it is more probably the light rays than the heat rays. That is a point upon which I should be glad to have had some information. Another point upon which I especially endeavored to start inquiry in my communication of 1894 has reference to the prognosis. Recently a book was sent me for review, "Medical Ophthalmology," by Dr. Foster Moore, and I am gratified that he has reproduced the tentative conclusions which I put forward in 1894. It appeared to me that here we had an illustration of the most exact injury to the human tissues which it was possible to produce by purely physical methods; an injury to a part which is beyond external con- tamination by septic influence. Moreover, the injured part can give expres- sion to the extent and intensity of the damage received, and continued observations afford a very exact method of indicating the prognosis, depend- ent upon the nature and extent of the primary injury and the time elapsing since it was received. The basis for deduction is broadened if there is any record of the vision prior to the sun blinding. Therefore what I endeavored to lay down was this, based upon the results up to 1894. I defined the term "practical recovery" as meaning the "cessation of obtrusive defect" which leaves the patient unconscious of having received damage. I was able to classify the cases into four groups. Taking direct acuteness of one-third of Snellen's type as the starting point, the patient with one-third vision in the first week has a good chance for practical recovery in one month; the patient with one-third vision in the second week has a good chance for practical recovery in three or four months; the patient with one-third vision in the third week has good chance for practical recovery in five or six months, but Orbital Marsupialization 359 if the vision at any time is less than one-third of the normal there is a very poor chance of ever recovering six-sixths. I venture to hope that these suggestions may be pursued and confirmed or corrected. DR. F. M. FERNANDEZ (Havana, Cuba) : With each new eclipse the number of cases of retinal lesions becomes less and less. This is due in Cuba to the extensive warnings that are published in the daily papers. Some few cases of solar retinitis have been observed in Cuba in the past fourteen years. Symptoms have been moderate in the majority of the cases central and para-central scotoma, diminution of visual acuity, and so forth. There have been observed two cases of retinal detachment after prolonged observation of the eclipse, one of them in a myopic eye. This detachment has also been observed, without any eclipse, by prolonged exposure to the sun's rays. This last case was observed by Dr. Santos Fernandez and myself in a gentleman who was a spectator at the Willard-Johnson fight in Havana years ago, and who, after being three or four hours exposed to the direct solar rays, had a total detachment of the retina in one eye. MR. J. GRAY CLEGG (Manchester, England) : I would like to emphasize the wisdom of what Dr. Mackay suggests about a list of subjects to be dis- cussed. I was personally unaware until I arrived here just what was coming up. I shall only mention a case which is referred to in a letter that I received two days ago.. A little boy got some glass in one eye and as a result had sympathetic disease. He had recovered from the sympathetic disease with perfect acuity, but had another attack of iridocyclitis six months ago. During my absence, a fortnight ago, he looked at an eclipse of the sun, and a rather severe recrudescence has resulted. ORBITAL MARSUPIALIZATION AND SUPERIORITY OF ORGANIC GRAFTS OF DEAD TISSUE IN ESTABLISHING A MOBILE STUMP DR. A. MAGITOT Paris, France Since the year 1885, in which Mules proposed enclosing a glass sphere in the sclerotic in order to create a mobile stump, numerous authors have repeated the operation. The question was also dis- cussed in many scientific meetings, and particularly in 1900 at the International Congress of Paris. It would seem that it might be treated anew in order to determine the results obtained by clinical practice. Moreover, during the last few years experimental re- searches on grafts of dead tissue have brought fresh data by which ophthalmologists should profit in their choice of the substance to be inserted in the funnel of the ocular muscles. 360 A. MAGITOT Though making no pretension to writing the history of the ques- tion, we think that it is necessary to recall the successive stages fol- lowed by the different operators. Mules, in 1884, had at the same time as v. Graefe, proposed the amputation of the anterior segment and the evisceration of the eyeball in all cases in which total extirpa- tion could be avoided. In 1885 he proposed enclosing in the sclerotic a glass ball; in the following years, Brudnell Carter, A. Frost, Grims- dale, Lang, Kroll and Cross, Bickerton, Swanzy in England, L. W. Fox and Orax, Reeve, de Schweinitz, and Buller in America, experi- mented with the new process. The enclosure of a glass sphere in the Tenon capsule was also tried ; later on numerous substances were proposed rubber (Pick), celluloid (Lang), paraffin wax (Hepburn), asbestos (Claiborne), the pith of the elder tree (Elschnig), etc. But the preference of the authors was for precious metals. Kuhnt (1887) had enclosed silver spheres in the sclerotic, but two years later Wagen- mann had occasion to study some of his stumps and came to the con- clusion that dangerous inflammatory reactions might be produced. Operators then returned to spheres in platinum and particularly in gold. We know that many American ophthalmologists have made use of this substance and that certain of their patients have preserved a mobile stump for many years. Today, twenty-six years after Mules's communication, we are able to measure the ground covered. To judge *by the results obtained and the opinions published, it seems that many ophthalmologists are agreed to attempt to make a mobile stump in all cases where there is no orbital infection. Some are in favor of evisceration with inclusion of a glass or gold ball; others, fearing sympathetic ophthal- mia, prefer extirpation and planting a sphere in the Tenon capsule. These two methods constitute, in fact, a part of the foundations on which rests the problem to be solved. The other part is constituted by the choice of the substance to be enclosed. If we are to judge by the number of ill-assorted substances which have been employed, this second part of the problem is not the least important. Many substances have not given satisfaction, others are heavy, others are rare and costly. Those which have been employed most often are glass and gold, as being the ones producing the mini- mum of painful or inflammatory reactions. As a corollary, it is patients operated in this way who have most frequently been pre- sented in scientific societies. However, for an operation not to have come into universal use, in Orbital Marsupialization 361 spite of the examples of wearers of gold or glass spheres who had been operated ten or fifteen years previously, it must have aroused some hesitation and distrust. Many hold that we have not yet emerged from the experimental stage and leaving to others the onus of experi- menting, reserve their opinion until they shall be convinced of the excellence and innocuousness of a method. Indeed, in spite of a few cases remarkable for their duration and the esthetic effect obtained, it must be confessed that the inclusion of a gold or glass sphere does not always succeed. Precocious or tardy expulsion may take place, when the operation has succeeded and after a lapse of several weeks ; it is therefore impossible to assert that the mobile stump will be permanent. ORGANIC AND INORGANIC SUBSTANCES The expulsion of a gold or glass sphere may take place shortly after the operation, when the asepsis has not been perfect or when an accident occurs, such as a hematoma which distends the tissues and brings about rupture of the sutures. But this expulsion can also take place several years later as if there had been a sort of wearing out of. the conjunctiva which covers the sphere. This tissue gradually becomes thinner, a small orifice appears which grows progressively and one day the sphere escapes from the cavity without there having been properly speaking any suppuration. Such an accident may supervene just as well with other inorganic substances such as ebonite, galite, celluloid, asbestos, agar-agar, etc. As for paraffin wax, injected under pressure or fashioned into a ball (Brockart, Camann, M. Ramsay, Spratt), it likewise has caused many disappointments. Generally speaking, its point of fusion is too low. When it is 75 C. (like that used by Hertel), its superiority over ebonite lies only in the facility with which the operation can give it the desired shape. It was certainly for the purpose of obtaining a permanent stump that recourse was had no longer to an inorganic substance but to living tissue. Baraquez, Velez, Bartels, Marx, Lauber, recom- mended the use of fatty tissue, usually taken from the abdomen of the patient and enclosed either in the sclerotic or in the Tenon cap- sule. This method has been repeated sufficiently often these last few years for it to be possible to judge of its value. The results of recent operations are good, those of long standing are disappointing. As Marx has noted in his histologic examinations, the graft is re- 362 A. MAGITOT absorbed and the stump becomes of insignificant volume. In 1912 Sattler, in 1914 Carlotti and Bailleul tried successfully on man the graft of living costal cartilage, but the long-standing results of their transplantations have remained unknown. In 1915, I in my turn tried this method on men wounded in the war, and I was able to con- vince myself that it offered many serious inconveniences. First of all must be placed the extreme sensitiveness of this tissue to infection and in consequence of this frequent premature eliminations. Sec- ondly, living cartilaginous tissue, like fatty tissue, is absorbed in a few months. This disappearance is the more rapid as the thin and flat human costal fragment is far from being sufficiently voluminous to constitute (even in the beginning) a good stump. We shall merely make a passing mention of the living heteroplastic grafts of dog's or cat's eyes (Lagrange, Rohmer, Boiadjeff) whose atrophic evolution is similar and we shall now speak of a very inter- esting category of substances: we refer to dead organic transplan- tations. Belt, shortly after Mules's communication, had the idea of im- planting in the Tenon capsule a piece of sponge, following in this a study of Hamilton's which appeared in 1881. Hamilton had re- peated experiments already made by Strieker (of Vienna) consisting in keeping under supervision the evolution of aseptic sponges intro- duced into the peritoneum of laboratory animals. He had noted that the framework of the sponge served as guides for the vessels to fresh connective tissue and that at the end of a certain time the organism completely incorporated this exogenous tissue. Belt's experiment was renewed by Trousseau and by Valude, these opera- tions were not successful: elimination took place in the first few days. Much more favorable were the attempts of Schmidt (1910) who made use of globes of bone sterilized by steam. There was no elimina- tion and the stump kept its primitive dimensions. De Wecker and Kuhnt also obtained favorable results with sterilized bone; and if this method has not become more universal, it is probably due to the difficulty of finding spheres cut to the necessary dimensions (fifteen to twenty millimeters in diameter) and ready for use. In 1915, having had disappointments in attempting to graft living costal cartilage in the Tenon cavity, I had the idea of practising on wounded soldiers inclusions of calf cartilage fixed in formalin of 20% for a week, and then carefully washed. My intention was to proceed by two stages. First to make an inclusion of dead cartilage, pre- Orbital Marsupialization 363 liminary operation, whose object was to avoid elimination of the living cartilage which is so sensitive to infection. I desired in this way to get over the dangerous period and three months later to remove the temporary inclusion and graft in its place costal cartilage, which according to my idea, was to form a permanent stump. The insertions of formalinized cartilage were successful, but my astonishment was great on finding that after several trials the living transplant rapidly diminished in volume whereas the first had not varied. I therefore modified my mode of operation and systematic- ally employed in all cases of extirpation inclusions of formalinized cartilage. In 1917 I presented to the Paris Ophthalmological So- ciety a number of patients operated since twelve months. In 1918 I presented some more, but I published no monograph on the subject, wishing to submit the process to the proof of time. Today after six years' practice, and an experience of sixty cases, I can speak with a full knowledge of the subject. In the meanwhile researches on grafts have made clear certain obscure points. They have brought to light certain biologic conditions which it is indispensable to know. TRANSPLANTS OF DEAD TISSUE For a very long time it was believed that only living tissue could be grafted, that is to say once transplanted they were accepted by their host's organism, and that they continued to live on their own account. All that was known was that the chances of success were slight, and that even under the most favorable conditions (autoplasty) there were for grafts without pedicle about 40% of failures. In the years following the great war, a considerable number of prosthetic opera- tions were attempted on the limbs, radiographic examinations were multiplied, experimental studies were carried out and it was dis- covered that the vascular, osseous, tendinous or nervous grafts which appeared to be really living, in reality died a short time after their transplantation. But, and it is of capital importance, it was re- marked that simultaneously their carcass served as a framework for a young tissue, the newly formed cells of which took the place of those of the transplant. This phenomenon occurs on condition that there be contact between the graft and the tissue of similar nature of the organism of the host. Here is therefore a new conception of living grafts which revolu- tionizes our old ideas and explains the bad results obtained by trans- plantation into the orbit of living cartilage. It is a sort of biologic 364 A. MAGITOT law to which the only exceptions appear to be the cutaneous epi- thelium and the corneal epithelium. But if all living tissue (nerve, bone, cartilage, tendon) dies, it must be remembered that its presence suffices to provoke the appearance of young cells of the same nature, and it comes to mind immediately that a transplantation of dead tissue ought to provoke the same phenomenon. Experiments have shown that this is so, and that nerves, tendon or bone killed by alcohol or formalin, fulfilled quite as well and even better their role as framework for the new tissue. These facts explain Hamilton's remark, which we have previously mentioned, and enable us to understand how an aseptic sponge can be invaded by connective tissue. For the same reason we can no longer feel astonished at the good results obtained by Schmidt and by Kuhnt, in making use of bone to execute Mules's operation. Professor Nageotte (Paris) has likewise shown (1920) how the tissues of the host act differently with an inorganic transplant, such as glass, gold, ebonite, etc., and with a transplant of organic tissue killed by histologic fixation. A disk of glass, silver or of rubber, inserted under the skin of a rabbit's ear, causes no reaction of the tissue: it encysts and the membrane of this cyst is itself insignificant. If the pocket be opened, the foreign body will be found there in a state of liberty. The result is quite different if we insert, in the same place, a disk of bone or cartilage previously fixed in alcohol or formalin, that is to say, a disk of substance organized but deprived of life. Union almost immedi- ately takes place by continuity of substance between the inserted piece and the connective tissue of the host. In the case of cartilage this adherence takes place through the perichondrium. In the case of dead bone an analogous phenomenon occurs. The natural surfaces adhere to connective substance of the host, but neither in the case of cartilage nor of bone do the surfaces of section join with it. Independently of this union between dead and living tissue, a phenomenon which already differentiates entirely the inclusions of organic or inorganic substances, there appears later a new factor of great interest. When the transplants are osseous or cartilaginous, there appear at the points of contact of the dead tissue osseous nodules or again cartilaginous nuclei produced by the connective tissue of the host. It follows that, at the end of a certain period a fresh skeleton piece is formed which envelops the transplant. The latter enveloped Orbital Marsupialization 365 in a living sheath will persist unless young living tissue substitute itself for it progressively. From these facts, we now know that when introduced into the organism organized substances, even when they are deprived of cells and unable to be re-inhabited, take up once more a role in the life of the tissues. We have at the same time the explanation, not only of the perfect toleration of dead cartilaginous or osseous fragments transplanted into the orbit, but also of their persistence without diminution in volume. CARTILAGE FIXED IN FORMALIN I chose cartilage in preference to bone because it can be cut as easily as a potato. The sternal piece of large-sized calves is, however, the sole material voluminous enough to allow the cutting out of fragments of twenty to twenty-five millimeters in thickness and of the length required. One should be very careful not to remove the perichondrium, as this membrane will be the point of union between the transplant and the tissues of the host. This fresh cartilage is fixed during eight to ten days in a solution of formalin, 20%. The formalin is then decanted and replaced by sterilized water. This substance is ready for use two weeks later when it has had time to disgorge the fixing product. This formalin will permeate the water and in this weak antiseptic solution, the fragments will keep inde- finitely, forming a reserve on which one can draw according to re- quirements. The mode of operation I followed is very simple. After extirpa- tion, the fragment is inserted into the muscular funnel. It is neces- saryjthat hemostasis should be complete. The edges of the muscular plane are seized with small clips the vertical traction of which keeps the pocket open. The fragment, which should be as large as possible, is then pushed into the bottom, and the pocket is very carefully sutured with catgut. Over this muscular layer the conjunctiva must be closed with U-shaped stitches so as to make sure that the edges must meet perfectly. I terminate the operation by a temporary blepharorrhaphia which I suppress on the third day. This sealing of the eyelids is a precautionary measure in case of secondary hemor- rhage which would distend the pocket. Its effect is to prevent the chemosis which often results from the rubbing of the eyelashes on the conjunctiva. 366 A. MAGITOT The patient is then furnished with a binocular dressing for three days in order to immobilize the ocular muscles. Since 1917 I have always followed this same technic after having assured myself of its perfect efficacy. I consider as essential: 1. The suturing of the muscles and of the conjunctiva in two planes with separate stitches. 2. Complete hemostasis. 3. The inclusion of a voluminous cartilage from which the perichon- drium must not have been scraped off. 4. A binocular dressing for three days. All those who may try the implantation of formalinized cartilage by this method, will perceive the ease with which the organism ac- cepts this dead tissue. Except in the case of panophthalmia or of orbital infection, recourse may be had to it and I have had numerous successes after extirpation for laceration of the eyeball by projectiles of war. Elimination in the first days will only take place if there is infection, serious hematoma and if the cartilage has been deprived of all its perichondrium. But if there is no elimination in the first fort- night, the transplant may be considered as permanent, for in my cases I have never had a tardy elimination. Dead cartilage offers over living cartilage the great advantage of being able to furnish voluminous fragments. Whatever its origin may be, it is nevertheless always made up of pieces rather long and thick. The cross section is at the two extremities whereas the other faces are covered with the perichondrium. When inserting the transplant into the cavity, I proceed so that the sides covered with this connective sheath may be in contact with the rectus internus and externus muscles, so that the adherence may take place princi- pally with the muscles which control the horizontal movements. MARSUPIALIZATION AND TRANSPLANTATION I have just spoken of the transplantation of formalinized cartilages at the moment of extirpation. This operation is, however, still pos- sible in cases of long-standing extirpation where the patients are not satisfied with their immovable stump. The only conditions required are: a clean conjunctival cavity and behind a small mobile cluster formed of retracted muscles. Briefly, extirpation must have been practised in a proper manner. The problem consists in creating in the midst of the fibromuscular Orbital Marsupialization 367 mass at the bottom of the orbit a pocket (marsupialization), in the middle of which will be inserted the fragment of cartilage. This result is obtained by incising and then freeing the conjunctiva from its deep attachments. The fibromuscular mass is then seized by its center, an opening is made in it, and this is enlarged by means of a forceps. The edges are drawn forward and the cartilaginous transplant is pushed in. The muscles are then sutured with catgut, the conjunctiva with silk and we terminate by a blepharorrhaphia as in an ordinary opera- tion. In December, 1921, I presented to the Ophthalmological Society of Paris an officer who had been obliged to undergo the operation of extirpation during the war. Two years later, immediately after the armistice, he came to see me, complained of his immovable stump, and asked me to remedy it. He was operated in February, 1919. The consequences of the operation were very simple, and for three years he has been wearing a movable stump which has not diminished in volume. The transplant, which is very large, raises the eyelid well, and avoids that ugly fold which cannot be prevented in ordinary enucleation. CONCLUSION The superiority of inclusions of dead organic tissues to living tissues is established by clinical practice. When the inclusions are assimilated by the organism, they do not diminish in volume. The fundamental difference between inclusions of inert, unorganized tissues, such as glass or gold, and dead organic tissues, such as bone or cartilage, lies in the fact that the former are foreign bodies tolerated and encysted, whereas the latter are adopted and young osseous cells are seen to appear in them. The former may be expelled one day, whereas the latter, once admitted, are permanent. These inclusions may be made at the same time as the extirpation, but they can also be effected on extirpations of long standing, provided that this extirpation has been properly made. It is in this case necessary to create a pocket in the middle of what remains of the muscles, but the results obtained are often excellent and comparable to the best stumps consecutive to amputation of the anterior segment. 368 A. MAGITOT REFERENCES Ahlstrom: Cent. f. prat. Augenh., August 17. Bartels: Arch. f. Augenh., 1910. Boiadjeff: These, Nancy, 1899. Bickerton: Brit. Med. Assoc., 1896. Baraquez: Jahresb. f. Opht., 1901. Claiborne: Brit. Med. Jour., 1887. Greenwood: Arch. Ophth., 1914. Green: Ophth. Rec., 364. Hertel: v. Graefe's Arch. f. Ophth., 1903 Hepburn: Jour. Amer. Med. Assoc., 1902. Kuhnt: Arch. f. Augenheilk., Ixxi, and Korrespondenzblatt d. allg. art. Verein, Tubingen, 1887. Lagrange: Soc. Med. et Chir. de Bordeaux, 1900. Lang: Brit. Med. Jour., 1887. Lauber: Zeits. f. Augenh., 1910. Mules: Brit. Med. Jour., 1885. Maitland Ramsay: Clin. Ophth., 1905. Marx: Arch. f. Augenh., 1910. Pflueger: Cong., Paris, 1900. Posey: Ophth. Rec., 81. Sattler: Heidelberg Soc., 1912. Schmidt: Klin. Mon. f. Augenh., 1896. Suker: Ophth. Rec., 1901. Tschirkowski : Arch. Ophth., 1912. Velez: Ann. Ophth., 1908. Verry: Soc. Franc.. d'Ophtal., 1898. Walstein: Klin. Monats. f. Augenh., 1909. Weeks and Greenwood, A.: Surg. a. Gyn. Soc., 1920. Trousseau: Ann. d'Oculistique, 1897. de Schweinitz: Cong., Paris, 1900. Swanzy: Cong., Paris, 1900. Valude: Cong., Paris, 1900. DISCUSSION DR. J. N. ROY (Montreal, Canada): J'ai e"te" fort heureux d'entendre la tres inte'ressante communication de monsieur le Docteur Magitot et d'apres ce qu'il nous a dit, je viens a la conclusion que les greffes adipeuses et cartila- gineuses agissent diffe'remment en autant qir'elles sont places dans la cavite" oculaire ou dans un endroit quelconque de la face ou du crane. En effet, j'ai eu 1'occasion pendant et apres la guerre de pratiquer un nombre consid- e"rable de greffes adipeuses, cartilagineuses et osseuses pour reparer des lesions de la figure, des maxillaires et du crane, et c'est le re"sultat de mon experience personnelle, compare" a ce que vient de nous exposer le conferencier, que je desire vous soumettre tres rapidement. D'apres M. Magitot, la graisse plac.6e dans la cavite" oculaire ne rendrait Orbital Marsupialization 369 aucun service, puisqu'elle se re"sorbe en totalitS dans un espace de temps relativement court. Je serais curieux de savior si, apres 1'avoir experiments, il a constate cette transformation partielle du tissu adipeux en liquide huileux que Ton observe quelquefois, et qui s'Scoule ensuite de 1'endroit ou le greffon a StS plase". Mise dans la figure ou le cou, pour rSparer esthStiquement une depression locale, la graisse donne d'excellents rSsultats, .surtout si on a eu la precaution d'en mettre une quantity plus considerable que la cavite" a combler, et apres I'ope'ration, d'appliquer un bandage compressif pour la faire durcir, tout en diminuant son volume a volonte". Ce greffon s'adapte tres bien aux tissus environnants qui ont la meme consistance que lui, et si dans ce cas, il se rSsorbe tres peu, comparativement a ce que 1'on rencontre dans 1'oeil ou la graisse disparait totalement, ce ph^nomene est probablement du au fait que placed dans la cavite" fibreuse de la coque oculaire, cette graisse, d'SlSments diffSrents avec ceux qui 1'entourent, perd sa vitalite" et se rSsorbe plus ou moins rapidement. J'ai eu aussi 1'occasion de me servir de morceaux d'Sponge st^rilisSe pour remplir des depressions a la figure. Je dois dire que dans tous les cas je n'ai eu que des insucces. Ce corps Stranger, en contact avec le tissu adipeux, a pour propriete d'user les cellules, de les ramolir, et de les transformer en une substance huileuse aseptique controlSe par le microscope, et ce liquide s'echappe a 1'extSrieur jusqu'a ce que le morgeau d'Sponge soit a son tour SlimmSe. Monsieur Magitot nous a dit que la greffe cartilagineuse humaine, plac^e dans la coque oculaire, se rSsorbe toujours, tandis que les zoogreffes un morceau de cartilage de veau par exemple, garde pendant une dizaine de jours dans une solution de formaline ne se resorbe pas. Ce fait est encore excessivement intSressant, puisqu'il est reconnu que les greffons de cartilage animal employe's pour rSparer une ISsion du crane, du sinus frontal, de la paroi orbitaire, de 1'os malaire, du nez et du maxillaire infSrieur se rSsorbent toujours, tandis que les greffons pris sur un etre humain ne disparaissent jamais, en autant que 1'operation est faite aseptiquement. D'ailleurs les remarquables travaux de Morestin sur ce sujet sont connus de vous tous, j'en suis sur, et ce tres habile chirurgien greffait meme des morceaux de cartilage pris sur une autre personne. Les examens microscopiques ont prouve" que la greffe animale sevant a rSparer un traumatisme du crane ou de la face, se transforme en un tissu fibreux, et qu'elle se rSsorbe ensuite dans un espace de temps plus ou moins long. Aussi Stant donne" la maniere tout-a-fait diffSrente dont se comportent les greffons de cartilage humain et animal, je suis portS a croire que le fait de garder pendant quelques jours ces morceaux de zoogreffes dans une solution de formaline, a pour propriStS de leur donner plus de stabilitS, et de les empecher ensuite de se rSsorber; et en terminant, je serais tres heureux de connaitre 1'opinion du confSrencier sur cette hypoth&se. DR. A. MAGITOT (closing): La question que me pose le Dr. J. N. Roy concerne deux points: la greffe vivante, la greffe morte. En matiere de greffe vivante il faut faire trois parts: Phe'teroplastie c'est a dire lorsque la greffe est pre'levee' sur un individu d'espece differente, Thomo- 24 370 A. MAGITOT plastie lorsquelle est prise sur un individu de memeespece et 1'autoplastie sur 1'individu lui meme. Depuis longtemps il est bien connu que Fhe'teroplastie vivante est de"cevante et je prie mon aimable interlocuteur de bien vouloir a ce propos se reporter a mon premier memoire sur les greffes corne"ennes qui a paru en 1911 dans les Annales d'Oculistique. En ce qui concerne 1'homoplastie, ses chances de succes ont paru meilleures. En realite", les faits cliniquesetexperimentaux sont assez nombreux pour qu'on puisse juger de leur valeur, et je conseille au Dr. J. N. Roy qui evoque le souvenir de Morestin de bien vouloir lire les discussions qui ont en lieu a la Socie"te" de Chirurgie de Paris a propos des greffes osseuses. De meme je lui recommande la lecture des bulletins de la Socie'te' de Biologie et les notes si interessantes du Prof. Nageotte. De tout cela, il ressort que si j'avance que les greffes vivantes meurent au bout de peu de temps et se re"sorbent, ce n'est pas seulement une vue personnelle, mais le r6sultat auxquels sont parvenus d'eminents experimentateurs. II faut du reste bien remarquer que cette greffe qui ne survit pas est tres utile par sa presence puisqu'elle sert de trame a un tissu nouveau. Le resultat cherche" est done souvent atteint. Je passe main tenant a la greffe de tissu adipeux. De nombreux confreres y ont eu recours pour Porbite. Les re"sultats imme'diats sout excellents les re"sultats e'loigne's sout de"testables. Les cellules adipeuses qui a 1'etat vivant sont semi-liquides, laissent e"chapper leur contenu huileux et ne sont pas penetre'e par un tissu nouveau. La charpente est insuffisante pour exciter la production d'une masse conjonctive jeune et Marx (cite" par moi) a parfaite- ment mis cette question au point. La greffe de tissu organique mort ne peut etre considere*e comme homo-ou he" te"roplastique. II s'agit la d'une masse impersonnelle, osseuse ou cartilagineuse qui par la presence du tissu conjonctif qui la recouvre excite la production de cellules mesodermiques qui finissent par prendre le type osseux. Voila pourquoi des transplantations de tissu fixe histologiquement reussissent. Peu importe que ce soit du cartilage ou de 1'os de veau. C'est le tissu con- jonctif qui importe. Ou aurait sans doute un resultat comparable avec une grosse masse tendineuse. Si le Dr. J. N. Roy vent bien essayer pour les reparations faciales le car- tilage formole", ou fixe dans 1'alcool, il est probable qu'il aura debonsresultats. Je 1' ai fait souvent pendant la guerre lorsque je dirigeais le service ophtal- mologique du groupe des armies de 1'Est; je 1'ai fait depuis. Mais pour re"ussir, il faut plus encore que pour 1'orbite, que la plaie faciale soit parfaitement aseptique, et que 1'on ait attendu pour intervenir suffisamment de temps apres la cicatrisation afin de ne pas reveiller un processusinflammatoire encore recent. J'ai ainsi refait des arcades sourcillieres, des pommettes, des rebords orbitaires infe"rieurs. Nul doute qu'on puisse utiliser le meme materiel pour le nez. LA PERITOMIA EN LAS ULCERAS CRONICAS VASCULARES DE LA CORNEA DR. ANTONIO F. ALONSO Mexico, D. F. En Tratados cldsicos y Enciclopedias oftalmologicos se habla generalmente solo de la Peritomia al tratar del panus de la cornea. Los autores se refieren por lo comiin d esta intervencion quirurgica al estudiar el tratamiento de las Keratitis vasculares consecutivas d las oftalmias escrofulosas 6 al Tracoma. Las primeras producirian con mas frecuencia el panus superficial 6 panus tenuis; el segundo el panus crasus llamado tambien, tracomatoso 6 sarcomatoso, en cuya genesis toma parte con frecuencia la triquiasis el entropion y el ectropion. En el excelente tratado del Prof, de Schweinitz se recomienda en la Keratitis panosa tocar con el galvano cauterio el lado convexo del creciente vascular 6 hacer una libre peritomfa. En la ultima edicion inglesa de la obra del Prof. Fuchs el Prof. Duane traductor, hace la anotacion interesante que la peritomfa se prdctica para curar un grueso panus y algunas veces en otras con- diciones como la episcleritis, herpes, acne rosacea. Verhoeff dice Darier en sus Tratados de Terapeutica ocular que considerando la acnea corneal de naturaleza neuro-trofica, prdctica en esta enfermedad una peritomia despegando la conjutiva y cu- briendo con ella las lesiones corneales. En la Enciclopedia Francesa de Oftalmologfa el Dr. Valude habla solamente de la Peritomia al referirse al panus corneal. En el bello libro de cirujia del Dr. Terson se afirma que la peritomfa es un medio precioso en muchos casos para los panus de toda na- turaleza y para las manchas vascularizadas de la cornea. Se agrega : "aciertas ulceras pueden tambien beneficiar." En el reciente tratado de cirujia ocular del Dr. Terien, asi como en la obra tan completa de oftalmologfa del Prof. Axenfeld, no se habla de la peritomia sino para combatir el panus tracomatoso. Como se v4 por lo anteriormente expuesto, para no citar sino 371 372 ANTONIO F. ALONSO algunas solamente de las obras mds importantes, no se ha hecho un estudio metodico, especial, te'cnico, de las indicaciones de la peritomia en las lilceras cronicas vasculares de la cornea, cual creemos nosotros, lo merecerfa por su importancia. Nuestra diaria experiencia nos ha ensenado todo lo frecuente que es encontrar enfermos portadores no de panus crasus 6 tenuis; no de esas corneas enrojecidas y carnosas consecutivas d la oftalmia tracomatosa 6 escrofulosa, en que el diagn6stico se impone con la necesidad de una evidencia ffsica; ni siquiera se trata de un pequeno grupo de ulceras localizadas en algiin sector corneal vascularizadas mds 6 menos intensamente, no. Se trata de una, dos, 6 tres ulceras pequenas, de origen variable, trasparentes, u opacas, solas 6 acorn- panadas de algunas manchas cicatrizales; ulceras que son el punto de terminaci6n de algunos vasos, bien visibles muchas veces s61o con la ayuda de la lente, insignificante al parecer, cronicas y rebeldes d todos, los tratamientos habituales. Muchos de estos pacientes han recorrido clinicas y gabinetes oftalmologicos donde han sido tratados durante muchos meses por toda la gama de excitantes: calomel oxide amarillo de Hg, dionina, fomentos calientes, masajes electricos, etc., etc., sin obtener mejorfa alguna. Una peritomfa ignea ha terminado en 8 6 15 dfas en una completa curacion de los pacientes. Estas ulceras no producen generalmente grandes molestias; algo de lacrimoso, algunos pequenos dolores, y son casi compatibles con la vida ordinaria. Los enfermos, sobre todo cuando las ulceras estdri acompanadas de opacidades de la cornea, preocupados ma's que por otra causa por la disminucion de la agudeza visual, consultan fre- cuentemente en este sentido al oculista. No siempre estas ulceras son resultado de oftalmias tracematosas 6 impetiginosas, se observan como consecuencias de herpes corneales, keratitis tuberculosas, como el caso que relatamos despue"s. iCual deberd ser en estos casos el criterio del oftalmologo? Es principie de Patologia Oral, que los vasos son los principales encar- gados de llevar los materiales de reparacion a los tejidos, y parecerfa paradojico interrumpir los elementos vasculares para la cicatrisation de una ulcera corneal. Que elementos informardn entonces el juicio del especialista para saber el momento en que los vasos, en lugar de conducir elementos litiles d la reparacion de una ulcera en la cornea, llevan las celdillas emigratrices de la opacificacion y de la esclerosis, que profundizando la membrana de Bowman hardn indeleble la Iesi6n, como lo han demostrado los bellos estudios de Iwanoff? La Peritomia en las Ulceras Cronicas Vasculares de la Cornea 373 Varies elementos deberdn d nuestro juicio ilustrar el criterio clinico del oftalmologista. Desde luego la antiguedad de la lesion. Ulceras cronicas rebeldes d todo tratamiento, deberian hacer pensar iempre en la posibilidad de ulceras mantenidas por vasos anormales de la cornea. Nunca el oculista deberd despreciar en estos casos examinar d la lente de una manera cuidadosa la membrana trasparente. El factor causal se presenta bajo la forma de vasos superficiales, tortuosos, varicosos, poco sensibles & la accion de la adrenalina. Son estas lilceras corneales a las que se refiere Darier sin duda en su Tratado de Terapeutica, con el caracter de no tenirse con la florescina. El tratamiento en estos casos por medio de todos los excitantes y aun el recubrimiento conjuntival, es intitil. La peritomia es la terapeutica heroica que salvard ojos destinados, de otra suerte, d la perdida de la vision por opacidad y esclerosis corneal. La peritomia es una de las operaciones mds antiguas de la oftal- mologia. Aunque se atribuye a Furnari como el inventor a mediados del pasado siglo, es mucho ma's antigua, pues segiin Terson se en- cuentra ya en Guy de Chauliac, quien la tomo de los drabes. La operacion estd constituida por la desinsercion conjuntival al derredor de la cornea. Si en lugar de una simple incision se reseca una lengueta de tejido conjuntival, se llama periectomia 6 sindec- tomia. Algunos autores como Panas conceptuan suficiente la simple peritomia y dividen los vasos muchas veces por medio de la punta fina del termo 6 galvano-cauterio, lo que se ha llamado la peritomia ignea. Nuestra experiencia nos ha ensenado que la peritomia ignea no s61o tiene ventajas por la rapidez de su ejecucion, sino que nos parece de especial efecto, para evitar reincidencias, debido a la esclerosis consecutiva d la cauterisation. Esta intervention quirurgica no solo produce excelentes resultados para la cicatrisacion de las ulceras cronicas vasculares de la cornea, sino la mejoria de la opacidades que los acompafian, imposible de obtener con las inyecciones subconjuti vales y dema's medios tera- p^uticos conocidos. Siendo prolija la descripcion de los multiples casos que en rela- cion con este estudio hemos observado en nuestra prdctica, y fuera del proposito de estas lineas, recordaremos muy brevemente los tres ultimos, de grande interes clinico. 374 ANTONIO F. ALONSO Obs. 1 H. M. Mujer de 30 anos escrofulosa. Padece desde su infancia de los ojos. El ojo isquierdo tiene una serie de pequenas manchas cicatrizales en la cornea, huellas de antiguas erupciones flictenulares, obstruyendo en parte la pupila y habiendo producido un estigmatismo iregular que compromete algun tanto la vision. OIV =1/3. El ojo derecho tiene varias manchas que obstruyen completamente la pupila, dejando libre un sector infero interne de la cornea, y 2 ulcera- ci6nes centrales d donde van d terminar algunos vasos delgados, tortuosos, poco visibles, viniendo de la de parte superior del globo. La agudeza visual de la enferma se reducia d contar los dedos d 2 metres de distancia, teniendo este ojo lacrimoso y adolorido. Ten- sion normal. Cuando 1 vimos a esta enferma tenfa 9 meses de tratamiento casi continue con oculistas en varias partes de la Republica, bajo la accion de la pomada amarilla de hg., calomel, dionina, atropina, inyecciones subconjunti vales, tonicos, yodurados, inyecciones intramusculares de hg., etc., sin obtener alivio alguno. El 10 de Enero de 1920 practicamos una peritomia ignea superior con el galvano-cauterio fino, haciendo la seccion profunda de los vasos corneales. Oclusion del ojo que se cura diariamente. A los 15 dlas no solo estaban las ulceras cicatrizadas, sino las manchas acom- panantes se redujeron y esclarecieron notablemente. Una iridectomia infero-interna practicada d la enferma despues, le hizo ascender su agudeza visual d 1/3. Obs. 2 V. T. Nino de 12 anos de edad linfdtico, ha padecido desde hace varies anos ataques de Kerato conjuntivitis impetiginosa en ambos ojos. El tiltimo, que data de siete meses, ha dejado un pequeno grupo de ulceraciones en el sector infero interne de la cornea, vascu- larizadas y rebeldes d todo tratamiento. Consulta con varios espe- cialistas de la frontera norte de Mexico y de San Antonio, Texas, que lo tratan per medio de tonicos, fiero, arsenicales, y localmente con fomentaciones calientes, pomada amarilla, dionina, etc., sin resultado. El 10 de Mayo de 1920 le practicamos una peritomia en todo la parte inferior 6 interna del globo, con infiltracion conjiintival a la novocaina adrenalina. El resultado fu6 verdaderamente sorprendente, pues d los 10 dias se encontraban las ulceras absolutamente cicatrizadas sin haber dejado opacificacion alguna. La Peritomia en las Ulceras Cronicas Vasculares de la Cornea 375 Obs. 3 M. C. Senora de 50 afios de edad. El afio de 1918 le atendimos un lupus de la nariz que habia invadido la conjuntiva y borde corneal del ojo izquierdo. Le tratamos por inyecciones de tuberculina con excelentes resultados habiendo desaparecido por complete la lesion. Vuelve a enfermarse su ojo izquierdo d principios de 1920 poniendose el organo rojo, doloroso y disminuyendo notablemente la vision. Consulta con varios oculistas de la capital, ausente nosotros de ella, d la sazon, que le tratan por medio de fomentos calientes, dionina, argirol pomadas varias, masaje electrico, etc., sin resultado favorable. Volvemos aver la enferma en Agosto de 1921, ynos encontramos una ulcera central de la cornea de forma redonda y de 2 mils de ex ension, invadida por dos 6 tres vasos delgados, tortuosos, desprendidos de la parte superior del globo y acompanada por una corona de man- chas cicatrizados que ocupaban gran parte de la cornea. La ulcera no se teiiia por la florescina. El ojo lacrimoso, sensible d la luz y doloroso, y con la vision perdida. La tension del organo era normal. No se habia reproducido el antijuo lupus nasal. Ante la rebeldia de 1 afio y medio d todos los tratamientos de aquella lesion ocular, practicamos a la enforma desde luego el 15 de agosto de 1921 una peritomia ignea superior dividiendo d la lente binocular todos los vasos que penetraban en la cornea. Desde el tercer dia se comenzo d ver una mejorfa notable en el estado local de la enferma y d los 20 dfas se encontraba la ulcera absolutamente ci- catrizada. Las manchas corneales se ban esclarecida de tal modo despues de la intervencion, que la paciente ha alcanzado una agudeza visual de 1/10 y rehusado a una iridectomia optica que le habfamos propuesto. Esta breve comunicacion podrfamos sintetizarla en algunas con- clusiones. la. El unico tratamiento eficiente, y con frecuencia her6ico, de las ulceras cronicas y vascularizadas de la cornea es la Peritomia. 2a. En toda ulcera corneal cronica rebelde a los tratamientos varios usuales, el oculista debera sistematicamente examinar la cornea d la lente, para definir si no existen vasos mantenedores de la lesion. 3a. La frecuencia de estas ulceraciones, su rebeldia a la Terapeutica ordinariamente, empleada, y las consecuencias funestas que tienen para la funcion visual, meritan que los tratadistas los consagren una atencion mds amplia y un sitio mds importante en la nosografia, oftalmologica. 376 ANTONIO F. ALONSO DISCUSSION DR. L. WEBSTER Fox (Philadelphia): Considerable credit is to be given to this author for bringing to the attention of the ophthalmic world the value of this therapeutic measure. Many times in the past have prominent surgeons noted the value of this operation but have failed to impress it sufficiently upon their students and followers, so that it has just so often been allowed to fall into the discard, to be revived from time to time by some progressive surgeon who has had to discover for himself the great benefit to be derived from its employment. Dr. Alonso adds a note to the indications for its use when he advises the operation in chronic vascular ulcers of the cornea. His comment that it has been referred to mostly in connection with pannus secondary to scrofulous and trachomatous inflammation is accurate, and it is rather unfortunate that the authorities he quotes should be averse to admitting of its larger possi- bilities, and indeed rather reluctant to acknowledge even its usefulness in that obstinate condition, pannus. The French have given it a much higher status than the Americans, as Dr. Alonso has shown. His personal experi- ence with intractable ulcers is of great interest and shows close attention to minute clinical detail. It is most certainly necessary, as he implies, to bring about resolution in these cases in order to avoid the scarring of the cornea and the consequent disturbance of vision. Ifc-is agreeable to note that Dr. Alonso stresses the importance of good ophthalmic judgment in deciding when the vessels leading to one of these ulcers has ceased to conduct useful elements for the reparation of the ulcer ated site, and instead carry migratory cells of opacification and sclerosis He regards with good cause the age of the ulcer as an index of its patholog c condition. The chronic rebellious ulcer is maintained by normal blood- vessels. It is in this phrase of Dr. Alonso's that the whole story of rebellious ulcers is told. The vessels are abnormal. At no time are blood-vessels normal to the cornea, and these fine red lines which we see in these cases, while .they carry blood are not blood-vessels in the histologic sense but are the' same capillary loops that we see in all forms of exuberant granulation. These ulcers are in fact exuberant granulations. In any other situation the surgeon would entertain no other treatment than complete eradication. Dr. Alonso prefers what he terms "igneous peritomy," which consists of division of the vessels many times by means of the fine point of the galvano-cautery. The scarring produced by this cauterization is believed to prevent recur- rences. There must be a great merit to this method as his experience coincides with my own. My own preference has been for a clean excision of the con- junctiva surrounding the cornea, and an experience of over a thousand cases in the last twenty years since I first used this method convinces me that my selection of this technic is the correct one. The operation is a modification of that of Furnari and is known in many circles as "peridectomy." The tachnic consists first of anesthetization of the conjunctiva with a five per cent, solution of cocain, and the additional installation of a drop or two of adrenalin solution to control slight hemorrhage. A strip of bulbar La Peritomia en las Ulceras Cronicas Vasculares de la Cornea 377 conjunctiva from 5 mm. to 15 mm. immediately surrounding the cornea is then excised with sharp scissors. The vessels on the cornea at the limbus are then scarified by means of a sharp curved knife devised by myself but no cauterant is used. Special emphasis must be laid upon the necessity of a clean cut incision of the conjunctiva. Chewing of the conjunctiva with dull or imperfectly set scissors will induce an unnecessary inflammation. When Furnari brought forth his operation in 1842, trachoma was present in a most virulent type in the French Army and in the French Colonial possessions, and his enormous experience with this disease in Algiers prompted him to the development of a radical technic in the expectation of checking the ravages of the disease. His operation consisted in first making an incision at the outer canthus, after which a broad ring of bulbar conjunctiva was excised extending from the margin of the cornea to within 3 mm. of the line where the conjunctiva is reflected from the globe to the inner surface of the lid. A flap of conjunctiva at the margin of the cornea was allowed to remain to the last in order to fix and rotate the globe at the will of the surgeon during the opera- tion. The conjunctival tissue was then carefully dissected away so as to expose the sclera to view. The vessels of the cornea were then scarified, after which the sclera and ulcerated portions of the cornea were touched with silver nitrate. The success attending Furnari's cases led other surgeons to practise this operation but with innumerable modifications. One of the early and prob- ably the best, was to discard the cauterizing feature. This is mentioned here in order to call attention to the fact that attractive as the cauterizing may appear, it has always been discarded after any prolonged experience with it. However, it may be that the use of the galvano-cautery may be a little more elegant and give a much better result than the cauteries used in bygone days. In closing the discussion I wish to call the author's attention to my article in the American Annals of Ophthalmology, October, 1903. DR. S. LEWIS ZIEGLER (Philadelphia): I want to endorse what Dr. Fox has said in regard to the advantages of peridectomy over peritomy, or peri- dotomy as it should be designated. The operation of Furnari is successful in cutting off the vascular supply in these cases. I recall, however, that in addition to this Dr. Fox, about thirty-five years ago, used Burow's operation to release the tension of the lid. The two points in these cases of vascular ulcer are (1) the maceration and (2) the lid tension. I have used galvano-cautery peridectomy extensively, but after 1890 I abandoned it, for the reason that I found I could gain the same result without conjunctival destruction by resorting to rapid dilatation of the tear duct to relieve the maceration and cantholysis to release the lid tension. There is destruction, as a rule, in peridectomy, because if you take off a strip of conjunctiva when it is already atrophic you shorten it and cause xerosis. By stretching the tear duct you relieve the corneal maceration and by the operation of cantholysis you release the tension of the lid, and thereby gain freedom from friction of the cornea. I advocated these measures in a paper on "The Surgery of Trachoma," presented before the American Medical Association in 1898. 378 ROBERT CARTWRIGHT CHENEY There is only one thing that must be observed in this operation. Canthot- omy or cantholysis, as Agnew preferred to call it, means the division of the external (superior) canthal ligament. In performing the operation you make a small incision at the external canthus with sharp-pointed scissors, then with forceps you grasp the border of the superior lid at the point of incision, pass in your scissors and feel for the canthal ligament just as you would feel for the optic nerve when you enucleate. As soon as you feel the ligament, open your scissors and divide it, and the corner of the lid will jump up about a centimeter. If you do not get that freedom of the upper lid you have not divided the ligament. DR. ALONSO (closing) : To estimo en alto grado que los Senores profesores que han hecho uso de la palabra prop6sito de mi trabajo esten en el fondo de acuerdo commigo; muy especialmente celebro y estimo las f rases del Dr. Fox, que le ha merecido elogias mi actuaci6n en esta asamblea al traer d su seno la question del tratamiento de las ulceras cr6nicas y vasculariza das de la cornea. El asunto esencial es que no hay que con fundio el tratamiento quirurgico del Panus corneal en el cual la peritomia esta recommendada fur les autores con las tridicaciones de esta operacion en las ulceraciones que hacen el objeto de un comunicacion. Como lo indico ampliamente en mi trabajo estas ulceraciones son muchas veces discretas y mantenidas por vasos quisibles solamente con ayuda de la lente. Todes los tratamientos excitantes conocidos como la dioni na las fomentaciones calientes el exido amarillo de hyla canterisaciones la electrici- dad, el recubrimiento conjuntival mismo, no producen resultado. Nelo con la peritomia se obtienen resultados excelentes y definitives, ha gran cuestion es hacer el diagnostico ele sus indicaciones acerca de las cuales insisto ampliamente en mi trabajo. Ulceraciones cronicas vascularizadas, rebeldes a les tratamientos ordinarios, no colorandose por la florescina, etc. TYPES OF PNEUMOCOCCUS FOUND IN CORNEAL ULCERS ROBERT CARTWRIGHT CHENEY, M.D. Boston, Mass. (From the Massachusetts Charitable Eye and Ear Infirmary) In 1902 Romer, 1 realizing the inadequacy of the treatment of pneumococcus ulcer of the cornea and the disastrous end result as far as useful vision was concerned, attempted serum treatment in these cases. Using small doses of immunized animal serum, he had promis- ing results in rabbits. In men, however, the results were by no means 1 Romer, P.: Experimentelle Grundlagen fur klinische Versuche einer Serum- therapie des Ulcus cornea serpens nach Untersuchungen liber Pneumokokkenim- munitat, Arch. Ophth., 1902, liv, 99. Types of Pneumococcus Found in Corneal Ulcers 379 as striking, and in the five cases treated only three were apparently successful. A significant fact is that these three cases were only forty -three, thirty-one, and sixteen years of age, and hence had a much better chance of recovery under any treatment. Indeed the serum treatment has never proved of any clinical value and has never sur- planted cauterization or other previously recognized forms of therapy. In recent years the value of serum treatment in cases of lobar pneumonia has apparently been proved and a very satisfactory sum- mary is given in a monograph from the Rockefeller Institute by Avery, Chickering, Cole, and Dochez. 1 It was found that pneumococci might be divided into four types on the basis of their specific immunity reactions. To quote directly, "pneumococci of types of I, II, and III, which compose about 80 per cent, of all strains encountered in disease, and which represent three apparently fixed types of highly parasitic organisms, each possessing common immunologic characters." Type III is the pneumococcus mucosus. Type IV pneumococcus is a hetero- geneous group and is mostly made up of individual strains which are not interrelated and do not have a common agglutination reaction with any single immune serum. In short, it is possible to obtain three stock sera, types I, II, and III, which have specific agglutination reac- tions for the corresponding types of pneumococci, but as is evident from the preceding statement, there is no type IV serum, and a pneumococcus which does not agglutinate any of the three sera is relegated to the type IV group. In the actual clinical application of these sera, the type I serum in large intravenous doses is seemingly highly effective in lobar pneumonia caused by a type I organism, but of no use in a case caused by a pneumococcus of another type. Type II and III sera as yet have not been proved to be of clinical value. In view of the above facts it seemed important to ascertain the types of pneumococcus found in corneal ulcers, with the hope of find- ing an ulcer caused by a type I organism which might advantageously be treated with serum. Some difficulty was encountered at first in obtaining a satisfactory culture medium as naturally comparatively little material for inocula- tion is obtainable from a corneal ulcer. Intraperitoneal injection in white mice was not satisfactory, but Avery medium proved to be just what was needed, and I never failed to get a growth from a pneumo- 1 Monograph of The Rockefeller Institute for Medical Research. No. 7. Acute Lobar Pneumonia, Prevention and Serum Treatment, by Oswald T. Avery, M.D., H. T. Chickering, M.D., Rufus Cole, M.D., and A. R. Dochez, M.D. 380 ROBERT CARTWRIGHT CHENEY coccus ulcer when this medium was employed. It was described by Avery in 1918 l and is a meat infusion broth three-tenths to five- tenths acid to phenolphthalein. To each 100 c.c. of broth is added 5 c.c. of 20 per cent, sterile glucose solution and 5 c.c. sterile defibrinated blood. The following was the method of procedure : the eye was carefully cocainized, a speculum inserted, and as much material as possible ob- tained by curetting the advancing infiltrated edge of the ulcer, which was found to be the only place where pneumococci were plentiful enough to give a satisfactory culture. Great care should be taken not to traumatize the normal corneal tissue, and the ulcer should be cauterized immediately after curetting, as curetting alone tends to make the process somewhat worse. Next, a tube of Avery medium was inoculated with the material so obtained and, after careful shaking, was placed in the incubator for six to ten hours at the end of which time the blood corpuscles had settled at the bottom of the test tube. The supernatant fluid was almost always found to contain a pure growth of pneumococci and from this the type was ascertained by direct microscopic agglutination with the sera obtained from the New York State Board of Health and the solubility of the organisms in bile determined (pneumococci soluble in bile, streptococci not). Romer called attention to the usual occurrence of a pure growth in pneumococ- cus ulcer of the cornea, obtaining 18 pure cultures in 20 cases. Thus no centrifuging was necessary, and the culture was directly grouped, the reaction being a combination of agglutination and precipitation. Care should be taken, however, not to allow cultures to go over 10 to 12 hours as the organisms in Avery medium form acid which soon kills them. * During a period of over a year at the Massachusetts Charitable Eye and Ear Infirmary cultures were obtained from 12 cases of pneumococcus ulcer of the cornea. These were pure cultures with but one exception, where there was a slight growth of staphylococcus. In eight of these cases the organism was type IV pneumococcus, while in the other four cases it was type III pneumococcus. No type I or type II organisms were found, the percentage being 66.6 per cent, type IV, and 33.3 per cent, type III. From the standpoint of any serum treatment the results were very disappointing, but nevertheless 1 Avery, O. T. : Determination of Types of Pneumococcus in Lobar Pneumonia. A Rapid Cultural Method. Jour. Amer. Med. Assn., January, 1918, Ixx, 17. Types of Pneumococcus Found in Corneal Ulcers 381 interesting when compared with the following statistics taken from Monograph 7 of the Rockefeller Institute: 1. Occurrence of the various types of pneumococci in lobar pneu- monia and the mortality. Occurrence Mortality Type 1 33.3% Type 1 25% Type II 29.3% Type II 32% Type II (Atypical) 4.2% Type III 45% Type III 13.0% Type IV 16% Type IV :.. 20.3% 2. Types of pneumococci found in mouths of normal persons (297) . Present 116 cases. Absent 181. Type I 0.9% Type II 0.0% Type II (A) 0.8% Type II (B) 5.8% Type II (X) 11.6% Type III 28.1% Type IV 52.9% 3. Types of pneumococcus recovered from dust in rooms in which lobar pneumonia had not occurred. Type I 5.5% Type II 0.0% Type II (A) 0.0% Type II (B) 22.0% Type II (X) 16.6% Type III 11.0% Type IV 44.4% The preceding statistics show that of the types of pneumococci found in the mouths of normal people 28.1 per cent, are type III and 52.9 per cent, are type IV which compare fairly closely with 33.3 per cent, and 66.6 per cent, respectively as found in corneal ulcers. Thus it is to be wondered if the conjunctiva or the tear sac in clinically nor- mal persons does not also contain type III and IV organisms as well as the mouth. Of the 12 corneal ulcers studied by me 11 were clinically typical serpent ulcers, but one case needs special description : a boy 13 years old with a severe membranous conjunctivitis and a very superficial corneal ulceration which was secondary to the conjunctivitis. Type III pneumococcus was isolated from the conjunctiva. This eye re- covered quickly with no impairment of vision. In lobar pneumonia, type III pneumococcus is by far the most virulent, carrying a 45 per cent, mortality, so naturally there arises the question of prognosis in eye infections as determined by the type of 382 ROBERT CARTWRIGHT CHENEY pneumococcus. In this extremely small series with various methods of treatment, etc., no definite evidence is obtainable, but it does seem significant that, in the 11 cases of ulcus serpens, the only two eyes that required enucleation during the patient's stay in the hospital were infected with a type III organism. Summary: Of the ulcers studied, 66 per cent, were caused by a type IV organism and 33 per cent, by a type III organism. The failure of serum in pneumococcus ulcers of the cornea is ade- quately explained by the fact that none of the organisms are of type I. The present pneumococcus sera obtainable have little, if any, specific action on organisms in the cornea and absolutely no benefit is to be expected from their use. That the type IV pneumococci found in the cornea belong to one definite sub-group for which there may be a specific serum, is possible but not probable. In conclusion, I wish to thank Dr. G. S. Derby and Dr. F. H. Verhoeff for their kindness in giving me valuable suggestions and in allowing me to report their cases. DISCUSSION DR. GEORGE S. DERBY (Boston, Mass.) : This is an important bit of re- search, because, according to my knowledge, it is the first time pneumococci found in the eye and corneal ulcer have been typed. It was necessary that this should be done. It explains the failure of sera to work. To those who think there is some virtue in making bacteriologic examina- tion of secretions in the conjunctival sac, especially before cataract operation, the use of Avery media is certainly to be recommended. It is a compara- tively simple medium to make up, and it will grow pneumococci nearly every time. Moreover, it grows pneumococci in from six to ten hours, so that you can have your patient come to the hospital the night before, have a culture taken, and have your bacteriologic report early next morning before you are ready to operate. DR. R. C. CHENEY (closing): I do not think that serum treatment in pneumococcus ulcers of the cornea will ever be of value, even if type I organ- isms are found. When you consider the avascular character of the cornea, it is hard to conceive how you could influence the process to any great degree by injection of serum into the blood-stream which is conspicuous by its absence at the site of the lesion. L'ETAT VASCULAIRE DES GLAUCOMATEUX (ETUDE DE 100 MALADES DE GLAUCOME PRIMITIF) DOCTEUR CARLOS CHARLIN Charge de cours a 1'Universite de Santiago du Chile. Professeur extraordinaire d'Ophtalmologie, Santiago, Chile Au mois d'octobre de cette annee, nous avons envoye d la Societe d'Ophtalmologie de Paris un memoire sur 1'etat vasculaire des glaucomateux, me'moire fait en collaboration avec notre e'le've, le Docteur Cristobal Espildora. Nous avions reuni au hasard de leur arrivee d notre consultation 75 observations de glaucomes primitifs ou les malades etaient etudies au point de vue general, surtout au point de vue cardio-vasculaire. Depuis lors, nous avons poursuivi notre etude et ce sont les 25 nouvelles observations reunies, que nous presentons au Congres International d'Ophtalmologie de Washington de 1922. Ce nouveau materiel clinique accumule a confirme dans les grandes lignes les conclusions de notre premier me'moire. Nous faisons prece"der ces 25 observations d'un resume, de 1'exposi- tion de la matiere contenue dans cette premiere communication faite d la Societe francaise d'Ophtalmologie de Paris. Dans les 25 dernieres observations nous avons e"tudie plus min- utieusement nos malades : (a) Nous avons insiste davantage sur 1'examen des urines. (b) Nous avons mesure a plusieurs reprises, en diffe'rentes seances, la pression arte>ielle quand la normalite de celle-ci se pretait a des doutes. (c) Nous avons fait la Reactivation de la Reaction de Wasser- mann (methode de Millian) quand celle-ci etait negative, malgre des antecedents suspects. 1 (d) Nous avons complete notre examen clinique par une amnese generale, aussi souvent que cela a e^e* possible. 1 Nous faisons la Reactivation en injectant % eg. de cyanure de mercure intraveineux tous les 2 jours; apres la Seme injection, nous refaisons le jour suivant la Reaction de Wassermann. 383 384 CARLOS CHARLIN I. LES ALTERATIONS VASCULAIRES CHEZ LES GLAUCOMATEUX Qu'avons-nous trouve sur les 100 premiers malades examines: 90 malades avec des alte"rati6ns cardio-vasculaires; 3 id. sans alterations cardio-vasculaires perceptibles, mais avec Reaction de Wassermann positive; 7 id. avec examen cardio-vasculaire et serologique negatif. Nous nous empressons de dire que tons les cas ne se pre"sentaient pas sous un type clinique de"fini, de constatation et de diagnostic faciles ainsi, chez quelques-uns, 1'affection vasculaire aurait passe inapergue sans la manometrie, la radioscopie, la sphygmographie et 1'examen des urines. Chez la grande majorite", au contraire, la lesion aortique, 1'hyper- tension arterielle ne pouvaient rester meconnues, meme a un examen superficiel. La localisation clinique predominante a e"te 1'aortite et 1'hyperten- sion arte*rielle. L'aorte est malade 59 fois sur 100 cas, 15 fois 1'aortite chronique etait accompagne"e d'insuffisance valvulaire, 5 fois de re"- tre"cissement aortique pur et 1 fois de retrecissement et d'insuffisance simultane'e. (obs. 18.) L'aortite s'est souvent presentee silencieuse sans symptomes sub- jectifs. L'hypertension arte"rielle est encore plus frequente (62 fois sur 100 malades). Le compromis du rein constatable par un examen d'urine anormal (faible densite et indices d'albumine) n'est pas tres frequent. Mais si nous devons interpreter 1' augmentation de la pression systolique comme un signe de sclerose renale, nous devons admettre que le rein a du etre touche bien plus souvent et qu'une etude plus approfondie de la fonction de la glande nous aurait permis de constater, chez beaucoup de malades, la nephrite chronique ebauche'e. En effet, au commencement de notre e"tude, la grande majorite" des examens d'urine ont e^e" tre"s superficiels et absolument insuffi- sants. La discordance entre Pexamen re"nal et I'examen vasculaire de nos 65 premieres observations nous a surpris et un peu de*routes. Dans les observations posterieures, 1'etude de 1'e'limination urinaire a etc" plus complete et nous avons trouve ce qui nous faisait supposer l'tat vasculaire anormal: le compromis frequent du rein. La L'Etat Vasculaire des Glaucomateux 385 nephrite chronique fruste se pre'sente Ire's souvent chez le glauco- mateux. En tout cas, ces 62 malades, ce 62% d'hypertension systolique parle de la grande frequence de la sclerose vasculaire peripherique chez les glaucomateux. La pression diastolique ou minima 6tait augmentee chez quelques malades d'une facon manifeste. La myocardite a e"te constatee 5 fois. A noter 5 malades avec lesion mitrale. Le diabete s'est present^ 3 fois et accompagne d'aortite et d'hyper- tension arte"rielle. L'emphyseme et la sclerose pulmonaire n'ont pas ete rares. La tuberculose pulmonaire n'a ete observed en periode d'activite 1 qu'une seule fois. (obs. 91.) Les ganglions bronchiaux ont ete deceles frequemment a I'examen radioscopique. II. ETIOLOGIE DE L' ALTERATION VASCULAIRE GENERALE CHEZ LES GLAUCOMATEUX Nous avons dit que sur nos 100 malades, 90 presentaient des al- terations de 1'appareil vasculaire. De ces 90, 59 avaient 1'aorte anormale et 62 de 1'hypertension arterielle. Les auteurs indiquent comme cause des lesions vasculaires chroni- ques et specialement des aortites, les infections et intoxications, par exemple la syphilis, Palcoolisme, la senilite, la goutte et le paludisme. De ces facteurs, nous pouvons eliminer la goutte et le paludisme, maladies exceptionnelles au Chili, veYitables trouvailles cliniques (nous n'en avons rencontre aucun cas parmi nos glaucomateux). La syphilis et 1'alcoolisme sont au contraire d'une extreme frequence, surtout la premiere de ces affections. II ne serait pas tr6s aventure de supposer qu'une grande part de 1'action de 1'intoxi cation etylique soit due a la syphilis, que 1'on trouve souvent chez les antecedents d'un alcoolique. La senilit^ a une influence, semble-t-il, plus secondaire que la syphilis, puisque entre nos 100 glaucomateux, 41 seulement sont entres dans 1'age se'nile, ayant depasse 1 les 60 ans, et entre ces 41, 11 e"taient surement et 3 probablement syphilitiques. Le Glaucome s'est present^: 25 386 CARLOS CHARLIN De moins de 30 ans 1 f ois De 31 a 40 ans 2 De 41 a 50 ans 26 De51 60 ans 30 De61 a 70 ans 31 De 71 a 80 ans 9 De 81 a 90 ans 1 100 malades: 35 hommes, 65 femmes. En tenant compte des deux grands facteurs e"tiologiques de 1'affec- tion de 1'appareil vasculaire, la syphilis et la senilite, de beaucoup les plus importants, nous sommes arrives a se*parer nos malades en 4 groupes : 1. Glaucomateux avec arteriopathies syphilitiques que nous de- signerons sous 1'expression ' ' glaucomateux syphilitiques. ' ' (Page 11.) 2. Glaucomateux non syphilitiques avec lesions arteriosclereuses, que nous de*signerons sous Texpression "glaucomateux arte'rioscler- eux." (Page 28.) 3. Glaucomateux avec affections cardio-vasculaires d'etiologie diverse. (Page 37.) 4. Glaucomateux d examen general negatif. (Page 39.) TABLEAU GENERAL. GLAUCOMATEUX Total Syphili- tiques Arterio- sclereux ? N6gatifs De moins de 30 ans 1 1 De 31 a 40 ans 2 1 1 De 41 & 50 ans 26 22 4 De 51 60 ans 30 20 8 2 De 61 a 70 ans 31 9 18 4 De 71 80 ans 9 4 5 De 81 90 ans 1 1 100 57 32 4 7 III. GLAUCOMATEUX SYPHILITIQUES (57 Gas) Des 100 glaucomateux etudie*s, 46 e"taient surement syphilitiques et 11 tre"s suspects, ce qui donne un haut pourcentage de pres de 60%. Le Glaucome s'est pre'sente' chez des syphilitiques: De moins de 30 ans 1 fois De 31 a 40 ans 1 De41 d 50 ans 22 De 51 a 60 ans 20 De 61 a 70 ans.. , 9 De plus de 70 ans _4_ Total . . . . 57~ L'Etat Vasculaire des Glaucomateux 387 Sur le total des 100 glaucomateux, 29 n'avaient pas de'passe' la cinquantaine et de ces 29, 24 etaient syphilitiques et 5 seulement apparemment etaient libres de 1'affection venerienne. Nous croyons que .cette constatation doit etre soulignee parce qu'elle a une certaine portee pratique. Notre petite statistique dit : le glaucomateux de moins de 50 ans, le glaucomateux jeune, est presque tou jours syphilitique. II nous semble que ce resultat statistique n'est pas un simple effet du hasard, mais naturellement cette affirmation a besoin, pour ac- querir sa veritable valeur, qu'une observation etendue a un plus vaste materiel clinique, la confirme. Des 57 glaucomateux, consideres par nous comme syphilitiques ou tres suspects de syphilis, 32 avaient une Reaction de Wassermann positive, 1 etait heredosyphilitique, 13 avaient des antecedents specifiques non discutables, 11 seulement sur ces 57 sont des cas pro- bables, tres probables, mais non prouves. Entre les 32 malades avec Reaction de Wassermann positive : 3 ne presentaient aucun symptome cardio-vasculaire, 4 seulement une image radioscopique anormale, 2 une insuffisance mitrale (obs. 12 et 84) et 23 de 1'hypertension arterielle ou de 1'aortite, etc. Le compromis du myocarde a e"te observe 5 fois chez les syphiliti- ques. Des 18 glaucomateux, consideres comme syphilitiques, mais avec Reaction de Wassermann negative, 9 avaient de 1'aortite chronique, compliquee d'insuffisance valvulaire sygmoidienne, aortite du type syphilitique; 5 de 1'aortite et de 1'hypertension arterielle avec des antecedents specifiques non discutables, 1 avait de 1'aortite et pre- sentait simultanement de la nevrite optique syphilitique a 1'oeil de tension normale (obs. 46), 1 de 1'aortite et un retrecissement aortique (obs. 79) 1 de 1'aortite et de la nephrite (obs. 81) et 1 de 1'hyperten- sion arterielle (obs. 78). Le diabete a etc" observe 2 fois. (Obs. 91 et 96.) Sur le total de 57 malades 1'aortite a ete signalee 42 fois, avec lesion valvulaire 18 cas; 1'hypertension arterielle 37 fois. Entre ces 57 observations, nous avons rencontre 5 fois le glaucome aigu. f 1. Glaucomateux syphilitiques avec Reaction de Wasser- mann positive. 2. Glaucomateux syphilitiques avec Reaction de Wassermann GLAUCOMATEUX SYPHILITIQUES negative. 3. Glaucomateux suspects de syphilis. 388 CARLOS CHARLIN 1. GLAUCOMATEUX AVEC REACTION DE WASSERMANN PosiTiVE. 1 Les observations contenues dans ce Me"moire apparaissent soulignees. (a) Sans manifestations vasculaires ge'ne'rales perceptibles; obs. 11, 16, 82. (b) Avec image radioscopique cardio-aortique anormale; obs. 6, 9,51. (c) Avec symptomes vasculaires ge'ne'raux frustes (legere hyper- tension arterielle) ; obs. 8, 25, 93. (d) Avec insuffisance mitrale et dilatation du coeur; obs. 12. (d') Avec insuffisance mitrale et hypertension arterielle; obs. 84 (e) Avec aortite et sphygmogramme avec plateau; obs. 32, 45, 71. (f) Avec aortite et hypertension arterielle; obs. 39, 54, 92, 98, 100. (f ) Avec aortite, hypertension arterielle et diabete; obs. 96. (g) Avec aortite et myocardite; obs. 41, 95. (g') Avec myocardite; obs. 99. (h) Avec aortite, re'trecissement aortique, hypertension arterielle et insuffisance mytrale; obs. 66, 53. (k) Avec aortite, insuffisance aortique et hypertension arterielle; obs. 22, 26. (1) Avec aortite, insuffisance aortique, hypertension arterielle et myocardite; obs. 23. (m) Avec aortite, arteriosclerose et hypertension arterielle; obs. 13, 37, 21, 28. 2. GLAUCOMATEUX SYPHILITIQUES AVEC REACTION DE WASSER- MANN NEGATIVE. (a) Avec aortite du type syphilitique complique'e d 'insuffisance valvulaire sygmoidienne : (I) Sans hypertension arterielle; obs. 50; (II) Avec hypertension arterielle, obs. 20, 30, 34, 52, 57, 86, 87. {b) Avec aortite du type syphilitique avec insuffisance et re'tre'cis- sement aortique et hypertension arterielle; obs. 18. (c) Avec aortite, sans lesions valvulaires, avec hypertension ar- terielle et antecedents cliniques de syphilis; obs. 19, 31, 40, 63. (d) Avec symptomes aortiques et avec une lesion syphilitique en pleine Evolution; obs. 46. 3. GLAUCOMATEUX AVEC SYMPT6MES VASCULAIRES ET SUSPECTS DE SYPHILIS. (a) Avec symptomes d'arterioscierose pe"ripherique apparus pre- cocement; hypertension arterielle; obs. 14. 1 Les observations de 1 d 75 forment partie du M6moire present^ a la Socit d'Ophtalmologie de Paris. L'Etat Vasculaire des Glaucomateux 389 (b) Avec hypertension arte"rielle; obs. 78. (c) Avec symptomes cardio-aortiques et ancienne Irite; obs. 3. (d) Avec aortite et nephrite chronique; obs. 87. (e) Avec aortite et hypertension arte"rielle d 50 ans; obs. 4. (f) Avec aortite, hypertension arterielle et diabete; obs. 91. (g) Avec aortite et retrecissement aortique; obs. 79. (h) Avec aortite et insuffisance aortique; obs. 42. (i) Avec aortite, insuffisance aortique, hypertension arterielle et myocardite; obs. 48. (k) Avec aortite, insuffisance aortique, hypertension arterielle; obs. 56. (1) Avec hypertension arterielle, nephrite chronique et symptomes aortiques a 44 ans; obs. 55. I. OBSERVATIONS DE GLAUCOMATEUX SYPHILITIQUES 1. AVEC REACTION DE WASSERMANN POSITIVE. (a) Sans Symp- tdmes Cardiovasculaires Perceptibles. Obs. 82 (No. 5661) (No. d'ordre de la clinique). Rosa A., femme, 55 ans. Diagn. ophtalm. : 0. D., glaucome absolu; 0. G., glaucome chronique. Diagn. clinique: Syphilis. Examen oculaire (Juillet, 1921) ; O. D., corne"e opacifie"e dans son % inferieur ; chambre ant&ieure aplatie; pupille mydriatique immobile; iris atrophique; opacite" totale du cristallin. Vision = 0. Tension + 2. 0. G., chambre ante>ieure aplatie; pupille mydriatique moyenne, sans reactions; excavation glaucomateuse profonde, mais rose"e. Vision, perception lumineuse. Tension + 2. Examen clinique: Pointe du coeur au 5e"me espace intercostal, ligne mamil- laire; 26me bruit aortique renforce'. Pression arterielle (Pachon): MX. 15; Mn. 7. Radioscopie: Coeur Ie"g6rement augment^ de volume Aorte normale. Urine: Densite" 1016: indices d'albumine; peu d'indican et traces d'urobiline. Ur^e 7.80 %; chlorures 9.0%; au microscope: peu de globules blancs, de cellules e'pithe'liales polygonales et rondes. Sang: Ur6e 0.20%. Reaction de Wassermann positive. (6) Avec Symptdmes Cardiovasculaires Frustes. Obs. 93 (No. 5754). Fidelisa J., 48 ans, femme. Diagn. ophtalm.: 0. D., glaucome aigu; 0. G., idem. Diagn. clinique: Syphilis. Examen oculaire (Aout, 1921): 0. D., injection bulbaire, corne"e trans- parente, normale, pupille en mydriase moyenne, immobile; fond pas ex- aminable. Vision, 0. D., compte les doigts d 40 cm. Tension, Schiotz 1/10 = 70 mm. 0. G., injection bulbaire, corne"e de surface chagrine'e; 390 CARLOS CHARLIN pupille mydriatique, immobile, fond pas examinable. Vision, mouvements de la main a m. 50. Tension, Schiotz 1 /10 = 70 mm. 8 Aout: Iridectomie antiglaucomateuse O. D. en bonnes conditions sous anesthe"sie locale. 18 Aout: Vision, O. D. 5/30. Tension = 1 ou 1. Iridectomie anti- glaucomateuse O. G. sans incidents, sous anesthe"sie locale (Duverger). 8 Sept.: Vision, O. D. 5/15; O. G. 5/40. Tension, 0. D. 8/7.5 = 16 mm. (Schiotz); O. G. 12/7.5 = 9 mm. 22 Sept.: Vision, 0. D. 5/10; 0. G. 5/30. Tension, Schiotz, O.D. 8/7.5 = 18 mm.; 0. G. 6/7.5 = 23 mm. Examen clinique: Renforcement du 2e"me bruit aortique. Pression arte- rielle (5 Aout) Pachon, MX. 16.5 Mn. 8; pression arte'rielle (6 Sept.) Pachon, MX. 16.5 Mn. 10.5; pression arte'rielle (22 Sept.) Pachon, MX. 17 mm. Mn. 11 mm. Radioscopie thoracique negative. Reaction de Wassermann: positive. Urine: examen ne"gatif. (Densite" 1016 Ure"e 9.10%; chlorures 9.8%; pas d'albumine, pas d'e'le'ments figures. Liquide ce"phalo-rachidien : examen ne"gatif. Antecedents: 3 avortements, 6 enfants de terme, 1 mortus nato dans une grossesse ge"mellaire 2 fils sont morts. (c) Avec insuffisance Mitrale et Hypertension Arterielle. Obs. 84 (No. 5658). Pedro H., 65 ans, homme. Diagn. ophtalm. : O. D. G., glaucome chronique. Diagn. clinique (Dr. J. Rodriguez) : Insuffisance mitrale, hypertension arte'- rielle, arythmie extrasystolique Syphilis. Examen oculaire (Juillet, 1921) : Est malade des yeux depuis deux ans. 0. D., pterigion chambre anterieure le"gerement aplatie; pupille immobile en mydriase moyenne; opacite diffuse du cristallin, empeche examen ophtalmo- scopique. Vision = 0. Tension + 2. 0. G., le'ge're opacite corne"enne quadrant inf. -interne; pupille immobile mydriatique Profonde excavation papillaire glaucomateuse atrophique. Vision, perception lumineuse. Ten- sion + 2. Examen clinique: Arytmie extrasystolique Le'ge're insuffisance mytrale. Pression arte'rielle: MX. 21; Mn. 11. Radioscopie: Coeur augmente de volume. Reaction de Wassermann negative. Apres 3 injections intra- veineuses de cyanure (en 6 jours) elle devient positive. Examen d'urine: Densite" 1022, indices d'albumine et d'urobiline, ure"e 19.51%; chlorures 11.4%; quelques globules blancs et rouges, quelques cellules e'pithe'liales polygonales et rondes. (d) Avec Aortite, Hypertension Arterielle. Obs. 92 (No. 5724). Rosario R. 60 ans, femme. Diagn. ophtalm.: 0. D., anophtalmie ope"ra- toire; O. G., glaucome inflammatoire chronique. Diagn. clinique (Dr. Borquez) : Syphilis Hypertension arte'rielle, aortite Nephrite chronique. L'Btat Vasculaire des Glaucomateux 391 Examen oculaire (Juillet, 1921): 0. G., injection pericorn^ale; corn^e de surface chagrine"e; chambre anterieure aplatie; pupille mydriatique immo- bile; fond pas examinable. Vision, perception lumineuse. Tension + 2. Examen clinique: Battements arteriels suprasternaux et supraclaviculaires choc de la pointe du coeur violent au 5e"me espace intercostal (e*re*thisme cardiaque). Pression arterielle (Potain): MX. 26; au autre jour (Pachon): MX. 22; Mn. 12. Radioscopie: Crosse aortique dilatee. Reaction de Wassermann negative; reactivation positive. Urine: Densite 1016; al- bumine 0.10. Ur^e 9.10; chlorures 8.8; quelques globules rouges, cellules epitheliales polygonales et rondes. Sang: Uree 0.25%. Antecedents: Souffre fre"quemment de cephaiees, douleurs rheumatoides, troubles gastriques pas de grossesses. Obs. 98 (No. 5850) Louisa S., 74 ans, femme. Diagn. ophtalm.: 0. D. G., glaucome absolu. Diagn. clinique: Aortite Hypertension arterielle Nephrite chronique Syphilis. Examen oculaire: 0. D., pupille mydriatique immobile, cristallin opacifie. Vision = 0. Tension + 1; Schiotz 3/7. 5 = 36 mm. 0. G., pupille mydria- tique immobile; excavation papillaire glaucomateuse atrophique, halo pe*ri- papillaire. Vision = 0. Tension + 1 ; Schiotz 4 /7.5 = 31 mm. Examen clinique: Aorte haute et elargie; renforcement du 2eme bruit aortique Pouls 108. Pression arterielle (Pachon) : MX. 27; Mn. 16. Radio- scopie: Aorte ascendante et descendante augmentee uniformement. La crosse de"passe la clavicule. Grande hypertrophie du ventricule gauche. Reaction de Wassermann positive. Urine: Densite 1017; indices d' albumine. Ur6e 11.53%; chlorures 9.0%; assez de globules blancs, quelques globules rouges et cellules epitheliales polygonales. Sang: Uree 0.60%. Sphygmo- gramme: tendance au plateau. Antecedents : Personnels : sans importance. Obs. 100 (No. 5896) Maria FL, 50 ans, femme. Diagn. ophtalm.: 0. D., atrophie bulbaire; O. G., glaucome absolu. Diagn. clinique (Dr. Borquez) : Aortite, Nephrite chronique, Hypertension arterielle Syphilis. Examen oculaire: O. D., bulbe oculaire atrophique. 0. G., vaisseaux ciliaires anterieurs dilates; -chambre anterieure aplatie; pupille en mydriase moyenne, immobile; fond pas examinable. Vision = 0. Tension + 3; Schiotz 0/7.5 = 60 mm. Examen clinique: Bruit aortique exagere et systole un peu obscur Battements suprasternaux et supraclaviculaires. On sent 1'aorte derriere la fourchette sternale. Pression arterielle (Pachon): MX. 22; Mn. 11; pouls 78; respiration 18 par minute. Radioscopie: Aorte tres haute et obscure, 392 CARLOS CHARLIN legerement plus grosse Hypertrophie du ventricule gauche Scle"rose peribronchiale. Reaction de Wassermann negative; reactivation (apres 3 in- jections de mercure) positive. Urine: Densite" 1014; albumine 0.20. Ur6e 8.96%; chlorure 7.0%. Antecedents: Mari mort 1'annee pass^e a 1'age de 40 ans avec une hemi- piegie gauche. 1 avortement, 3 enfants vivants. (e) Avec Aortite, Hypertension Arterielle et Diabete. Obs. 96 (de la clientele privet). Calixto P., 72 ans, homme. Diagn. ophtalm.: 0. D., aphaquie operatoire, glaucome absolu. Diagn. clinique: Diabete Hypertension arterielle Aortite chronique Syphilis. Examen oculaire (Dec., 1920): O. D., colobome de 1'iris operatoire; chambre anterieure profonde; aphakie; excavation papillaire glaucoma- teuse avec halo peri papillaire. Vision = 0. Tension + 2. 0. G., opacite diffuse nucieaire initiale du cristallin, papille normale; pupille et reaction pupillaire normales. Vision 5/50. Tension = 1. (Novembre, 1921): 0. D., idem examen anterieur. Vision = 0. Tension + 1; Schiotz 5 /7. 5 = 26 mm. O. G., opacite du cristallin partielle. Vision 1/50. Tension = 1; Schiotz 7/7.5 = 18 mm. Examen clinique (Novembre, 1921): On touche 1'aorte derriere la four- chette sternale. Pression arterielle: (7 Nov.) Pachon: MX. 21; Mn. 9; pouls 72. (16 Nov.) Pachon: MX. 23; Mn. 8. Radioscopie (Dr. Ducci): Aorte augmentee dans ses trois dimensions gros coeur. Reaction de Wasser- mann positive. Urine: Glucose 8.54%. Antecedents: A ete op6re de cataracte 0. D. en 1914, mais apres 1'opera- tion, la vue ne s'etait guere ameiioree. Souffre d'otite moyenne et salpingite catarrhale bilaterale. (Dr. J. Castro.) (/) Avec Myocardite. Obs. 99 (No. 5880). Elias M., 45 ans, homme. Diagn. ophtalm.: 0. G., panophtalmite second- aire a une ancienne iridectomie antiglaucomateuse; 0. D., glaucome absolu. Diagn. clinique (Dr. Rodriguez) : Myocardite chronique Syphilis. Examen oculaire: II y a quelques annees a ete opere des deux yeux pour glaucome. 0. D., colobome operatoire de 1'iris; excavation papillaire glaucomateuse atrophique. Vision = 0. Tension +1. 0. G., oedeme palpebral; injection bulbaire et quemosis conjonctivale; la conjonctive aux environs de XII montre une tumeur jaunatre; reflet vert jaunatre de la pupille; Fond pas examinable. Vision = 0. Tension + 2; Schiotz 0/7.5 > 60 mm. 31 Aout: 0. D., exenteration oculaire avec anesthesie locale, injection 2 cc 3 de novocaine 3%, retro-oculaire abces du vitre. L'fitat Vasculaire des Glaucomateux 393 Examen clinique: Aorte normale; Tachy cardie (pouls 120); Arythmie, respiration 17 par minute; temperature 362. Pression arterielle : MX. 14.5; Mn. 1 1 (Pachon) : Sphygmogramme athe>omateux (plateau) . Pouls apr6s quelques jours de digitale : tachy cardie et arythmie. Reaction de Wassermann negative; reactivation (apres 3 injections mercurielles) positive. Urine: indices d'albumine. Sang: Ure"e 0.35 %. Antecedents: La femme a eu 4 avortements, 3 enfants morts dans la premiere enfance, 5 enfants vivants, sains. (g) Avec Myocardite et Aortite. Obs. 95 (No. 5817). Anastasie T. 59 ans, femme. Diagn. ophtalm.: 0. D., glaucomechronique; 0. G., glaucome absolu. Diagn. clinique (Dr. J. Rodriguez): Myocardite chronique Aortite chronique Nephrite chronique hydrurique Emphyseme et scierose pul- monaire Syphilis. Examen oculaire (Aout, 1921): O. D., cornee de surface chagrinee; cham- bre anterieure aplatie; pupille mydriatique ; immobile; fond pas examinable. Vision, perception lumineuse. Tension + 2; Schiotz 2 /7. 5 = 60 mm. 0. G., injection pericorneale; cornee chagrinee ; chambre anterieure effacee ; pupille mydriatique immobile; opacite totale du cristallin. Vision = 0. Tension + 2; Schiotz 1/7.5 = 70 mm. Examen clinique: Aorte legerement elevee, eiargie, pouls frequent 96 p. avec intermittences. Pression arterielle (Pachon): MX. 15; Mn. 8.5. 28 Aout: 2eme medition: MX. 17.5; Mn. 10.5. 6 Sept.: MX. 15; Mn. 9; pouls 120, respiration 29, tachycardie et arythmie. 15 Sept.: Apres 3 jours de digitale et de theobromine. Pression arterielle: MX. 16; Mn. 9, pouls 100 arythmie. 20 Sept.: Apr6s 1 gramme de digitale: MX. 12; Mn. 6.5; pouls 112, arythmie. Radioscopie negative; reaction de Wassermann negative; reactivation (avec 3 injections de cyanure de Hg en 6 jours) positive. Urine: quantite 2050 en 24 heurs; densite 1012; indices d'albumine; uree 7.08, chlorures 6.6%; quelques rares globules blancs et cellules epitheiiales poly- gonales. Sang: UreeO.15%. Li quide cephalorachidien normal. Antecedents: personnels: pas d'avortements; 11 enfants desquels, 8 morts dans la premiere enfance. 2. GLAUCOMATEUX SYPHILITIQUES. Avec Reaction de Wassermann Negative. Anciens syphilitiques traites. (a) Aortite, insuffisance Aortique, Hypertension Arterielle. Obs. 86 (No. 5690). Carlota N., 55 ans, femme. Diagn. ophtalm.: 0. G., glaucome incipient. Diagn. clinique (Dr. Garavagno) : Diabete, aortite avec insuffiance aortique Hypertension arterielle Nephrite chronique Ancienne syphilitique. 394 CARLOS CHARLIN Examen oculaire (Juillet, 1921) : Depuis 3 mois irritation intermittente de O. G. O. D. G., examen n^gatif. (A 1'oeil droit, pres de la papille, il y a une tache blanche rose, tres suspecte . . . Retinite?) Vision, O. D., 0. G. 5/10. Tension, Schiotz: 0. D. 7/7.5 = 18 mm. 0. G. 4/7.5 = 31 mm. Examen cardiovasculaire: Coeur augment^ de volume, on touche 1'aorte derrie're la fourchette sternale souffle diastolique au 2^me espace intercostal droit. Pression arterielle (Pachon): MX. 26; Mn. 11. Radioscopie: Aorte haute et grosse Hypertrophie du ventricule gauche. Reaction de Wasser- mann negative (apres des injections de Mercure). Examen d'urine: Densite* 1033; albumineO.20%; glucose 76.44% ; acetonaO.09; ur^e 28.62; chlorures l6.2 ; indices d'urobiline; au microscope: rien de pathologique. Antecedents: En differentes occasions a fait quelques series de piqures de mercure. Obs. 87 (No. 5818) Jose" M. 57 ans, homme. Diagn. ophtalm.: 0. G., glaucome de'gene'ratif; O. D.: glaucome incipient. Diagn. clinique (Dr. Mardones): Syphilis Insuffisance aortique Hypertension arterielle Paralysie faciale droite d'origine centrale. Examen oculaire (Juillet, 1921) : 0. D., chambre anteYieure un peu aplatie; pupille et fond n^gatifs. Vision, 0. D. 5 /5. Tension, Schiotz 5 /7.5 = 26 mm. Depuis trois semaines seulement se plaint de douleurs intermittentes a I'O. D. avec irradiations aux dents de ce cote". O. G., corne*e en partie opaci- fiee; chambre anterieure aplatie, pupille en myose pilocarpinique; fond pas examinable. Vision = 0. Tension, Schiotz 0/7.5 = 62 mm. Examen clinique: Coeur augmente* de volume, bruits un peu etouffe*s On touche 1'aorte derrie're le sternum; souffle diastolique aortique pouls76. Pression arterielle (Pachon) : MX. 23; Mn. 12. Radioscopie: Coeur grand et globuleux; aorte assez grosse et obscure, elle touche la ligne articulaire sterno claviculaire Clavicules immobiles Hiles pulmonaires infiltre"s. Reaction de Wassermann negative (a requ des injections mercurielles) . Examen d'urine : Densite 1020; albuminel%; chlorures 13%; pas d'urobiline; au microscope : rien de particulier. Antecedents: A Page de 22 ans, chancre unique avec ganglions non supures d 1'aine, un mois apr6s laryngite. Quelques mois plus tard, gonorrhee com- pliquee de cystite, prostatite et orchite. Est arrive dans 1'annee dans un ser- vice de medecine interne avec dyspn6e d'effort, oedeme des extremites, dou- leurs retrosternales tres failbles, palpitations cardiaques. S'est alors ameiiore avec regime dietatique et traitement iodo mercuriel. Se plaint de frequentes amnesics et de vertiges. 3. GLAUCOMATEUX SUSPECTS DE SYPHILIS. (a) Hypertension Ar- terielle. Obs. 78 (No. 5449). Franchise E., 60 ans, femme. Diagn. ophtalm.: 0. D., glaucome absolu; L'fitat Vasculaire des Glaucomateux 395 0. G., glaucome incipient. Diagn. clinique (Dr. Borquez): Hypertension arterielle, nephrite chronique. Examen ophtalm. (Juin, 1921): Vision, 0. D. = 0; 0. G. 5/10. Tension, 0. D. > 62 mm.; 0. G., 23 mm. (Schiotz); 0. D., corne'e de surface chag- rine'e; chambre anterieure aplatie; pupille deformee, mydriatique, immobile; fond pas examinable. O. G., chambre anterieure aplatie; pupille et fond normaux. 19 Juillet: Tension, Schiotz 0. G. 5/7.5 = 26 mm.; pupille en mydriase moyenne, avec bonnes reactions; fond ne"gatif. Examen clinique (Drs. Espildora et Borquez): 26me bruit aortique ren- force 1 ; sousclavie'redroitee'levee; lagers battements suprasternaux. Pression arterielle (Pachon): MX. 22; Mn. 15. Radioscopie: Aorte oblique obscure; hypertrophie du ventricule gauche; pointe rejete en dehors. Condensation peribronchiale; scle>ose pulmonaire peu etendue. Reaction de Wassermann egative; apres reactivation negative. Urine: Quantity 1700 cc 3 en 24 heures; densit^ 1017; indices d'albumine, peu d'indican, traces d'urobiline. Ure'e 10.40%; chlorures 9.8%; au microscope: globules blancs et cellules e'pithe'- liales rares. Sang: Ure'e 0.48%. Antecedents: 3 avortements, 7 fils morts dans les premieres annees de la vie. (6) Aortite, Retrecissement Aortique. Obs. 79 (No. 5592). Isabelle C., 60 ans, femme. Diagn. ophtalm. : 0. D. G., glaucome chronique. Diagn. clinique: Syphilis, aortite. Examen ophtalm. : O. D., cornee de surface chagrinee; pupille mydriatique, immobile, deformee; chambre anterieure aplatie; papille vue d travers un nuage, est blanchatre, excave"e. Vision 4/50. Tension, Schiotz 1/7.5 = 51 mm. 0. G., pupille deformee, en mydriase moyenne avec reaction paresseuse la lumiere, papille rosee, excavee. Vision 5/30. Tension, Schiotz 5/7.5 = 26 mm. 3 Aout: Sciero-iridectomie de Lagrange O. D. 13 Aout: Tension, O. D. 2/7.5 = 44 mm.: 0. G. 4/7.5 = 31 mm. 27 Aout: Tension, 0. D. 1 /7.5 = 51 mm.; 0. G. 5/7.5 = 26 mm. Examen clinique: Souffle systolique doux d 1'aorte. Pression arterielle (Juillet) Pachon, MX. 14; Mn. 9.5; pression arterielle (1 Aout) Pachon, MX. 18; Mn. 10.5; pression arterielle (27 Aout) Pachon, MX. 18; Mn. 10.5. Radio- scopie: Aorte haute, coeur augmente de volume (pointe rejetee de sa situa- tion normale en dehors). Leger degre de scierose pulmonaire. Reaction de Wassermann : negative ; reactivation de la reaction : negative. Urine : Densite 1026; albumine 0.20; beaucoup d'indican traces d'urobiline; uree 26.02%; chlorures 10.6%; au microscope: globules de pus sepals et en plaques nombreux; peu de globules rouges et de cellules epitheiiales renales; rares cellules vesicales; pas de cylindres. Sang: Ur6e 0.22%. Antecedents: Positifs de syphilis. Veuve, n'a pas eu de famille, n'a jamais 396 CARLOS CHARLIN etc" enceinte. Le mari est mort & 35 ans, d'une affection, parait il, he"patique ; avait la syphilis et 1'avait communique'e d sa femme. Celle-ci, au commence- ment de son mariage, a souffert de maladies ve'ne'riennes. (c) Avec Aortite, Nephrite Chronique. Obs. 81 (No. 5630) The're'se H., femme, 49 ans. Diagn. ophtalm.: 0. D., glaucome initial; O. G., glaucome chronique. Diagn. clinique (Dr. J.Rodriguez): Aortite, nephrite chronique, syphilis. Examen oculaire (Juillet, 1921) : 0. D., chambre ante"rieure un peu aplatie; pupille en myose pilocarpinique; papille normale. Vision 5/20. Tension, Schiotz 5/7.5 = 26 mm. 0. G., chambre ante"rieure aplatie; pupille en mydriase moyenne sans reactions, de"form6e; papille atrophique avec pro- fonde excavation glaucomateuse. Vision, compte les doigts a 20 cm. Tension, Schiotz 1 J7.5 = 52 mm. Examen clinique: Aorte haute, on la palpe, battements suprasternaux. Pression arte'rielle (Pachon) : MX. 17; Mn. 8. Radioscopie: Aorte d'e"paisseur normale, crossee'leve'e. Hiles pulmonaires fibreux. Reaction deWassermann; negative. Urine: Densite 1 ; albumine 1.10%; ure"e 18.21; chlorures 11.6; au microscope: de nombreux globules rouges, peu de globules blancs, peu de cellules e'pithe'liales polygonales ; pas de cylindres. Sang: Ur^e 0.57%. Antecedents: Syphilitiques positifs. Mari syphilitique mort a 50 ans. (d) Avec Aortite, Hypertension Arterielle, Diabete. Obs. 91 (clien- t61e particuliere). Juan F., 52 ans, homme. Diagn. ophtalm.: 0. D., glaucome chronique ancien; O. G., glaucome chronique initial. Diagn. clinique (Dr. J. Rodriguez) : Ancien diabe"tique, grande hypertension arte'rielle, aortite, syphilis ou tuber- culose pulmonaire? Examen oculaire: A e^e" ope>e, il y a peu de mois de 0. D.; depuis quelques semaines gene a 0. G. 0. D., pupille de'forme'e, pyriforme, sans iridectomie pe'riphe'rique visible; petit kyste conjonctival d XII en face de scle'rectomie ; papille blanchatre avec excavation profonde centrale. Vision 5 /10. Tension = 1, Schiotz 9/7.5 = 14 mm. 0. G., examen ne"gatif. Vision 5/5. Tension + 1, Schiotz 3/7.5 = 36 mm. Examen clinique: Hypertrophie du coeur Dilatation de 1'aorte (aortite chronique), renforcement du 26me bruit aortique; bruit de timbre m^tallique; infiltration portion moyenne du poumon gauche; tuberculose ou syphilis pulmonaire? Pression arte'rielle (Pachon): MX. > 35 mm.; Mn. 9; pouls 110. Radioscopie: Aorte grosse et haute-Hypertrophie du coeur. Urine: Densite" 1019; quantity 2800 gr. en 24 heures. Indices d'albumine, indices de mucine, glucose 25.10; ur6e 17.40; acide urique 0.42; phosphates 1.06; chlorures 5.60; un peu d'exce's de leucocytes et quel ques cellules rondes. Reaction de Wassermann plusieurs fois negative en diff^rentes occasions. L'Etat Vasculaire des Glaucomateux 397 Antecedents: 1 avortement, 4 fils sains. II y a un an forte attaque de grippe, depuis lors, il dit avoir le poumon faible. L'etiologie de 1'affection pulmonaire est encore en etude. IV. GLAUCOMATEUX ARTERIOSCLEREUX (32 Gas) Nous avons estime que 1'affection vasculaire de nos malades de pres de 60 ans pouvait e"tre consideree comme obeissant au proces de sclerose senile, s'il n'existait pas une autre etiologie capable d'ex- pliquer P alteration des vaisseaux. Le Glaucomateux arteriosclereux, non syphilitique, a ete observe 32 fois sur 100 malades. Des 100 glaucomateux etudies, 41 avaient plus de 60 ans et de ceux-ci 24 etaient arteriosclereux et 13 syphilitiques. Tout en donnant une valeur relative d notre petite statistique, on pourrait dire que: Si avant 50 ans le glaucomateux est presque toujours syphilitique, apres les 60, on trouve chez lui plus sbuvent I'arteriosclerose que la syphilis. Comme chez les syphilitiques, 1'hypertension arterielle et la lesion aortique est d'une grande frequence: Hypertension 25 fois sur 32 cas; lesion de 1'aorte 17 fois. Le retre"cissement aortique a ete trouve 2 fois. Le compromis du rein n'est pas rare, mais nous repetons ici la meme advertance que precedemment, 1'examen renal a ete par trop super- ficiel dans presque toutes nos 65 premieres observations. Une fois, la nephrite etait accompagnee de diabete (obs. 15). GLAUCOMATEUX ARTERIOSCLEREUX. 1 (32 cas.) (Les observa- tions contenues dans ce Memoire apparaissent soulignees.) (a) Avec signes vasculaires peripheriques legers; obs. 2, 17. (b) Avec symptomes cardio-vasculaires frustes; obs. 68, 72, 74, 94' (c) Avec hypertension arterielle; obs. 1, 24, 64, 60, 77, 97. (d) Avec hypertension arterielle et nephrite chronique; obs. 67. (e) Avec hypertension arterielle et image radioscopique anormale; obs. 10. (f) Avec hypertension arterielle, image radioscopique anormale et legere nephrite chronique; obs. 68. 1 Les observations de 1 a 75 forment partie du Memoire presente la Socie'te' d'Ophtalmologie de Paris. 398 CARLOS CHARLIN (g) Avec hypertension arterielle et atherome aortique; obs. 5, 7, 27, 29, 33, 35, 38, 43, 70, 85, 88. (h) Avec hypertension arterielle et mitro-aortisme; obs. 83. (1) Avec athe'rome et re'tre'cissement aortique; obs. 59. (m) Avec athe'rome aortique, hypertension arte*rielle et nephrite chronique; obs. 15, 58, 73. (n) Avec athe'rome et retrecissement aortique, hypertension arte- rielle, nephrite chronique; obs. 61. II. OBSERVATIONS DE GLAUCOMATEUX ARTERIOSCLEREUX Contenues dans ce memoire (a) Avec hypertension arte*rielle; obs. 60, 77, 97. (b) Avec hypertension arte*rielle et mitro-aortisme; obs. 83. (c) Avec hypertension arterielle, atherome aortique, arythmie; obs. 85, 88. (d) Avec symptomes vasculaires frustes; obs. 94. (a) Avec Hypertension Arterielle. Obs. 60 (No. 5849). Cas conside*re" comme negatif dans notre communication a la So- ciete" d'Ophtalmologie de Paris. La malade e*tant revenue se pre- senter a notre clinique au mois d'Aout 1921, nous avons pu constater alors un franc compromis du systeme vasculaire Aurora D., 63 ans. Diagn. ophtalm. : 0. D. G., glaucome chronique. Diagn. clinique: Cas negatif, Sept. 1920: hypertension arterielle, nephrite chroni- que hypertensive. (Aout, 1921.) Examen oculaire (Sept., 1920): 0. D., pupille mydriatique avec bonnes reactions, milieux transparents normaux; papille avec excavation glaucoma- teuse rose clair, halo pe'ripapillaire. Vision 5/7.5. Tension +1. O. G. Chambre ante"rieure trouble; pupille mydriatique immobile; papille atrophi- que avec excavation glaucomateuse ; halo pe'ripapillaire. Vision, perception lumineuse. Tension + 2. Examen clinique (Sept., 1920): Aorte et coeur normaux. Radioscopie negative. Reaction de Wassermann negative. Urine: Ex. ne"gatif? (douteux). Examen oculaire (Aout, 1921): Diagn. ophtalm.: O. D. G., glaucome absolu. O. D. G., profonde excavation glaucomateuse atrophique, entoure"e d'un halo pe'ripapillaire; pupilles immobiles, de'forme'es en mydriase moyenne. Vision, 0. D. G. = 0. Tension. Schiotz: 0. D. = 71 mm.; 0. G. = 60 mm. Examen clinique (Aout, 1921), (Dr. Borquez): 2e"me bruit aortique ren- force". Pression arterielle (Potain): 22 au lieu de 15 d 18; 2e"me examen (Pachon): MX. 20; Mn. 11 (Dr. Prado); athe'rome aortique. Urine: Densite" L'Etat Vasculaire des Glaucomateux 399 1017; indices d'urobiline; albumine 0.20: chlorures 7.8; Ur^e 16.35%; globules de pus scare's et en plaques nombreux; quelques globules rouges; quelques cellules epitheiiales polygonales et rondes. Obs. 77 (No. 5498) Marguerite C., 65 ans, femme. Diagn. ophtalm.: 0. D. G., glaucome chronique. Diagn. clinique (Dr. Gonzalez Cortes) : Hypertension arterielle. Examen ophtalm. (Juin, 1921) : Diminution de la vue survenue brusque- ment il y a plus d'un mois accompagne"e de grandes douleurs frontales. 0. D. G., injection pe'rike'ratique, anesthe"sie corn^enne; pupilles mydriati- ques, deformees, immobiles; fond pas examinable (d TO. D. on distingue sans details la papille). Vision, 0. D. = 0; 0. G., mouvements de la main a m. 50. Tension, 0. D., 0. G. + 2. 24 Juin: Operation 0. D. sclero-iridectomie sans incidents. 13 Septembre: Tension, Schiotz 0. D. 8/10 23 mm.; 0. G. 5/10 37 mm. Examen clinique: Coeur et aorte ne"gatifs. Pression arterielle (Pachon): MX. 20; Mn. 13. Sphygmogramme : Tendance au plateau. Radioscopie: negative. Reaction de Wassermann negative. Urine: Quantite" 2000 gr. en 24 heures. Densite" 1014; indices d'albumine, peu d' indican, traces d'urobi- line; ure"e6.50%; chlorures 10.6%; au microscope; quelques globules rouges; des globules blancs et des cellules epitheiiales polygonales rares; pas de cylindres. Sang: Ure"e 0.45%. 28 Septembre: Pression arterielle (Pachon) : MX. 18; Mn. 10.5. Antecedents : Familiaux et personnels sans importance. Obs. 97 (No. 5772) Gracia F., 70 ans, femme. Diagn. ophtalm. : 0. D., glaucome inflammatoure chronique; 0. G., glaucome absolu. Diagn. clinique (Dr. Rodriguez): Atherome aortique Hypertension arterielle. Examen clinique: On touche 1'aorte derri^re la fourchette sternale. Pres- sion arterielle (Aout) Pachon, MX. 17; Mn. 12; pression arterielle (13 Sept.) Pachon, MX. 19; Mn. 12.5; pression arterielle (28 Sept.) Pachon, MX. 16; Mn. 9.5. Radioscopie: Aorte haute, obscure, de grosseur normale. Condensation peribronchiale. Sphygmogramme atheromateux (plateau). Reaction de Wassermann negative; reactivation negative. Urine: Densite" 1015; indices d'albumine; ur^e 13.01; chlorures 6.2% ; quelques globules blancs et cellules e'pithe'liales polygonales. Sang: Ure"e 0.25%. Antecedents personnels Sans importance. Examen oculaire: 0. D., injection bulbaire, chambre anterieure aplatie; pupille en mydriase moyenne, deformee, sans reactions, fond pas examinable. Vision, perception lumineuse. Tension + 2, Schiotz > 60 mm. 0. G., opacite corneenne legere, pupille mydriatique immobile; chambre anterieure aplatie; fond pas examinable. Vision = 0. Tension + 3 Schiotz > 60mm. 400 CARLOS CHARLIN (6) Avec Hypertension Arterielle et Mitro-aortisme. Obs. 83 (No. 5678). Rosario A., 64 ans, femme. Diagn. ophtalm.: O. D., glaucome inflamma- toire absolu. Diagn. clinique (Dr. Borquez) : Mitro-aortisme, hypertension arte'rielle. Examen oculaire (Juillet, 1921) : Depuis un mois douleurs oculaires droites violentes et neVralgies faciales. 0. D., injection bulbaire intense; pupille mj'driatique sans reactions; iris d^colore 1 ; corned chagrined avec sensibilite" tre"s diminu6e; excavation papillaire glaucomateuse. Vision = 0. Tension + 2, Schiotz 1 /7.5 = 57 mm. 0. G. chambre ante"rieure aplatie; papille avec excavation physiologique. Vision 5/30. Tension = 1, Schiotz 9/7.5 = 14 mm. Examen clinique: Battements suprasternaux et sous claviers visibles; coeur augment^ de volume, pointe en dehors de la ligne mamellaire Souffle systolique mitral et souffle marque", un peu rude systolique au foyer aortique. Pression arte'rielle (Pachon): MX. 21.5; Mn. 9; un autre jour (Potain): MX. 20; pouls 88. Radioscopie: AdheVences costodiaphragmatiques droites Examen aorte et coeur n^gatif. Examen d'urine: indices d'albumine. Sang: Uree 0.30%. Reaction de Wassermann negative. Antecedents syphilitiques: Ne*gatifs (c) Avec Hypertension Arterielle, Atherome Aortique, Arythmie. Obs. 85 (No. 5451). Manuel G., 80 ans, homme. Diagn. ophtalm.: 0. D. G., glaucome chroni- que; dacryocystite gauche. Diagn. clinique (Dr. Rodriguez): Atherome aortique, Arythmie, Hypertension arte'rielle. Examen oculaire (Mai, 1921): 0. D. G., en mydriase moyenne avec fac- tions pupillaires paresseuses a la lumiere, bonne a la convergence; papilles blanches atrophiques avec excavation pas profonde; champ visuel un peu re"tr 1 /7.5 > 52 mm. Examen clinique: Tachycardie (100 p.) aorte le'ge'rement dilated trans- versalement; palpation doutoureuse des caro tides. Pression arterielle (Pachon): MX. 23; Mn. 14, d la radiale gauche; pression arterielle (Pachon) : MX. 21; Mn. 14, droite. Radioscopie: Aorte haute et grosse; hyper- trophie du ventricule gauche. Reaction de Wassermann negative; r^activa- tion negative. Examen d'urine: Density 1024; albumine 0.20%; ure"e 15.27%; chlorures 12.4%; traces d'urobiline; au microscope; globules de pus se'pare's et en plaques rares; globules rouges tre"s rares; peu de cellules epitheiiales polygonales et rondes. Antecedents: 2 fils sains, pas d'avortements ni de mortus nato. (d) Avec Symptdmes Vasculaires Frustes. Obs. 94 (No. 5707). Toribio P., 68 ans, homme. Diagn. ophtalm.: O. D. G., glaucome absolu. Diagn. clinique: Arterioscierose. Examen oculaire: 0. D. G., chambres anterieures un peu efface"es; pupilles deformees, mydriatiques, immobiles; excavation glaucomateuse atrophique. Vision, 0. D. G. = 0. Tension, Schiotz, O. D. G. 1 /7.5 = 51 mm. Examen clinique: Bruits valvulaires de ton me"tallique. Pression arterielle (Pachon): MX. 14.5; Mn. 7. Radioscopie: Aorte dilated uniformement Hypertrophie du ventricule gauche. Sphygmogramme athe"romateux. Reac- tion de Wassermann negative. Urine: Densite 1014; indices d'albumine; uree 8.96; chlorures 7.8; rares globules blancs et cellules epitheiiales poly- gonales. V. GLAUCOMATEUX AVEC SYMPTOMES CARDIOVASCULAIRES D'ETIOLOGIES DIVERSES Rhumatisme Obs. 75 Obesite Obs. 69 Douteuse Obs. 36, 89 Obs. 89 (No. 5696) Augustin R., 45 ans, homme. Diagn. ophtalm. : 0. D., glaucome absolu. Diagn. clinique: Nephrite chronique incipiente? (Dr. Garces.) Examen oculaire: 0. D., pupille deformee, sans reaction lumineuse, papille atrophique avec excavation glaucomateuse. Vision = 0. Tension, Schiotz 2/7.5 = 43 mm. 0. G., negatif. Vision 5/10. Tension 7/7.5 = 19 mm. 26 402 CARLOS CHARLIN Examen clinique: Coeur et aorte ne'gatif s, cependant bruits du coeur e'touffe's, systole apre. Pression arte"rielle (Pachon) : MX. 13; Mn. 7. Sphyg- mogramme athe'romateux (plateau). Radioscopie negative. Examen d'urine ne'gatif. Sang: Ure'e 0.35%. Reaction de Wassermann negative; re*activa- tion negative. Constante d'Ambard positive (Dr. Garce"s). Ure'e dans le sang (ur) 0.59. Urine produite en 60 minutes 61 c.c. ; urine en 24 heures (selon calcul) 1464. Ure'e dans Purine %; (C) 17.93; ure'e dans 1'urine en 24 heur; (D) 26, 25 . Poids du malade; (P) 66. 0.59 V70 / 17 01 26.25 X ^ X V i ^ = 1.09 DO \ ZO (Normal 0.042 a 0.074.) VI. GLAUCOMATEUX A EXAMEN CARDIOVASCULAIRE NEGATIF Ante'ce'dent clinique: grippe Obs. 44 senilite Obs. 47, 65, 76, 80 aucun Obs. 49 de syphilis Obs. 90 Obs. 76 (No. 5478) Manuel C., 61 ans, homme. Diagn. ophtalm.: 0. D., glaucome chronique inflammatoire, cataracte; 0. G., glaucome absolu. Diagn. clinique: Arte'rio- scle'rose se'nile incipiente? Examen ophtalm. (28 Mai, 1921): II y a huit ans qu'il ne voit pas avec 0. G. Depuis quatre ans sa vue de 0. D. a baisse" progressivement. 0. D., injection pe'rike'ratique; chambre ant&ieure effacee; pupille de'forme'e, mydriatique, immobile; opacit<3 du cristallin. Vision, perception lumineuse. Tension, Schiotz 1 /10, 70 mm. 0. G., injection pe'rike'ratique le'ge're; cham- bre ant^rieure aplatie; pupille mydriatique immobile; excavation glaucoma- teuse atrophique profonde. Vision = 0. Tension, Schiotz 3/10, 52 mm. Examen clinique : Pouls 76, radiale situation anormale, inspection et palpa- tion negative, renforcement du 2e"me bruit aortique. Coeur examen ne'gatif. Pression arte"rielle (Pachon) : MX. 18; Mn. 9. Sphygmogramme (humeral) trace" suspect d'hypertension. Radioscopie: Sommets pulmonaires obscurs; infiltration fibreuse des poumons; aorte et coeur normaux. Reaction de Wass- ermann negative. Examen d'urine: Densite" 1017; indices d'albumine; un peu d'indican; traces d'urobiline; ure'e 7.80%; chlorures 8.6%; au micro- scope: globules blancs et cellules e'pithe'liales polygonales rares. Obs. 80 (No. 5587) Romualdo A., 62 ans, homme. Diagn. ophtalm.: 0. D. G., glaucome chronique. Diagn. clinique: Le'ger degre" d'emphyse'me pulmonaire Pasde lesions vasculaires perceptibles. L'fitat Vasculaire des Glaucomateux 403 Examen ophtalm.: 0. D. G., chambre ante"rieure aplatie; iris normal; pupille sans reaction lumineuse, l^g^rement mydriatique; papille blanchatre, excave"e. Vision, 0. D., perception lumineuse; 0. G., compte les doigts. Tension, Schiotz 0. D. 2/7.5 = 43 mm.; O. G. 3.5/7.5 = 33 mm. Examen clinique: Aorte haute et e"largie? coeur normal. Pression arte"rielle (Pachon) MX. 17.5, Mn. 7.5 (on n'a pas fait de nouvelles me'ditionsl . Reaction de Wassermann negative ; (on n'a pas fait de reactivation) . Radio- scopie : Aorte et coeur normaux. Scle"rose pulmonaire, le"ger degre d'emphy- se"me. Urine: Densite" 1025; indices d'albumine; beau coup d'indican, traces d'urobiline. Ure"e 16.91%; chlorures 15.2%; au microscope globules blancs et rouges rares; peu de cellules e'pithe'liales polygonales; pas de cylindres; de rares cristaux de phosphate amonio-magne'sien. Obs. 90 (No. 4507) Macario A.,homme, 62 ans. Diagn. ophtalm.: 0. D. G., glaucome chroni- que, avec atrophie papillaire. Diagn. clinique: Cas ne"gatif, syphilis douteuse? Examen oculaire (Novembre, 1919): 0. D. G., pupilles en mydriase moyenne avec bonnes reactions ; profonde excavation glaucomateuse atrophi- que; champ visuel retre"ci en dedans. O. D. > 0. G. Vision, O. D. 5/30; 0. G. 5/10. Tension, 0. D. = 1; 0. G. + 2. 2e"me Examen (Juillet, 1921). 0. D. G., pupilles mydriatiques avec reactions pupillaires toe's paresseuses; atrophie papillaire avec excavation glaucomateuse profonde. Vision, O. D. mainaO.m.30; 0. G. 5/20. Tension, Schiotz : 0. D. 31mm.; 0. G., 37mm. Examen clinique : Cardiovasculaire ne"gatif . Pression art&ielle (Pachon) : MX. 18; Mn. 7. Radioscopie negative. Sphygmogramme : Normal. Rac- tion de Wassermann negative; reactivation negative. Examen d'urine: Ne*gatif (ure"e 24.34, chlorures 15.2%). Constante d'Ambard: Normale 0.056 (Dr. Garcs). Reaction de Wassermann chez la femme negative. Antecedents cliniques de syphilis positifs. Marie 2 fois Du premier lit 8 enfants, 6 vivants, 1 avortement, 1 mortus-nato Du 2me lit, le premier et le 3e"me enfants mortus nato, 5 vivants. VII. CONSIDERATIONS PATHOGENIQUES CONCLUSIONS CLINIQUES Nous venons de constater que sur 100 malades de glaucome primitif examines au point de vue general, 90 presentaient des symptomes vasculaires. On accepte d'autre part aujourd'hui que dans le glaucome la lesion anatomo-pathologique primordiale, et peut-etre initiale, serait la lesion du vaisseau oculaire. Si on relationne ces deux faits, on voit aussitot qu'il doit exister une parente tres proche entre eux. La clinique en nous devoilant 1'hypertension arterielle, Faortite, la 404 CARLOS CHARLON myocardite, etc., . . . sur le glaucomateux, nous oblige d'abord d accepter au moins une parent^ anatomique entre I'affection oculaire et I'affection ge'ne'rale, puisque dans les deux affections c'est toujours 1'arbre vasculaire qui est malade, que ce soit dans le tronc ou dans ses branches. La Biologic, de son c6te", nous dit qu'une lesion vasculaire de*ter- min6e est un proems toujours le me* me, absolument identique, soit qu'il se de"roule sur le vaso-vasorum de 1'aorte, de Parte're radiale ou sur les capillaires de Poeil. II existerait done aussi entre le proems vasculaire oculaire et general une parente pathologique. L'hypothe'se qui fait dependre, en premier lieu, P hypertension oculaire de la lesion du vaisseau, n'est qu'une hypothese, mais la frequence extreme du compromis du systeme vasculaire general chez le glaucomateux, donne un puissant appui d cette theorie patho- ge"nique. Si cette theorie etait dans le vrai, Petiologie du glaucome, proble"me si obscur, s'e"clairerait d'une fac.on inattendue. En effet, il serait logique alors d'admettre qu'une seule cause a du toucher la paroi vasculaire, ici et Id, le vaso-vasorum de Paorte et le re"seau ophtalmique, malades simultanement. L'examen clinique, Pe*tude des antecedents, la Reaction de Wasser- mann, etc., . . . donnent Petiologie de Phypertension arte"rielle, de la myocardite, de Paortite on arriverait dans le glaucome, par un chemin identique, a la solution du probleme. En d'autres termes, le glaucome aurait la mSme signature etiologi- que que la cardiopathie qui Paccompagne. Mais refusons toute valeur a ces considerations pathogeniques, comme e"tant de simples vues de Pesprit non demontrees. " Le Glaucomateux n'est pas seulement un malade des des yeux, puisque dans un 90% des cas il souffre en me'me temps d'une autre affection." Le me'decin a le devoir de chercher d de"pister cette autre maladie par une investigation clinique minutieuse; Pexamen oculaire doit done se computer par Pexamen general. Et ceci fait, le traitement local hypotensif doit aussi se computer par la therapeutique gene"rale propre a chaque cas. Santiago, l er Decembre, 1921. THE DIAGNOSIS OF GLAUCOMA COL. R. H. ELLIOT London, England To present a paper on the diagnosis of glaucoma before an Inter- national Congress is a task entirely different from that of writing on the same subject for the purposes of a text-book, since a mass of detail required by the student is better omitted, attention being directed to the less well-known or more debatable departments of the subject. Another point to be borne in mind is that diagnosis helps us in two somewhat different directions: (1) To ascertain whether glaucoma is present or not and (2) to enable us to decide whether to adopt thera- peutic or operative measures in the treatment of individual cases. There are few problems confronting the ophthalmic surgeon which are more difficult than that of the diagnosis of a pathologic rise of tension in certain cases; and yet the writer would desire to anticipate what is yet to come by the very emphatic statement of his belief that a surgeon, who will take the trouble to avail himself to the full of the modern methods of diagnosis, need never be long in doubt as to the presence or absence of glaucoma. It is true that a correct diagnosis can sometimes only be made by waiting ; but if the surgeon is alive to the condition present, and loses no time in collecting the necessary data, it may be questioned whether the delay involved need ever lead to serious consequences. The same remarks are true of the measures and observations necessary to enable us to come to a sure conclusion as to whether a condition of glaucoma is progressive or stationary. Few systems are more evil than that of the collective consultation, in which a number of surgeons meet, conduct a superficial examination, and assure the patient that he should, or should not, be operated upon. Such a method appeals powerfully to the patient and his friends. It is popular, dramatic, and worthless. The diagnosis of a difficult case of glaucoma, whether the point at issue be the presence of increased ten- sion or the question of the progress of the disease, can only be estab- lished by the work of an individual surgeon, who conducts a routine and careful examination, to which he is willing to devote unlimited 405 406 R. H. ELLIOT time. When all his data are available, he may perhaps with profit lay them before one or more colleagues and get the latter to check doubt- ful points which his work has revealed. This is not the method of the sensational novelist or the equally sensational newspaper paragraph writer, or, only too often, of the friends who prefer the consultation of a number of surgeons; but it is the one which best subserves the inter- ests of the patient. With this introduction, we shall now take up a number of points in turn. THE CONJUNCTIVA AND SCLERA It is well known that circumcorneal congestion, which may be of a very pronounced type, is a constant accompaniment of acute and sub- acute glaucoma, while enlargement of the episcleral vessels, and espe- cially of those which perforate the tunic of the eye, is the rule in chronic cases. It has been suggested that these vessels are arteries. The writer has no hesitation in asserting that they are veins : (1) They have the appearance and color of veins ; (2) when cut across in the course of an operation, their bleeding is typically venous; (3) when the lumen of one of these vessels is closed at each of its ends as far apart as possible, it not only fills up from either end indifferently when the pressure is released, but it actually fills from lateral feeder vessels even while the two ends are still blocked ; (4) under high magnifica- tion with a corneal microscope and Gullstrand slit-lamp, no pulsation whatever can be observed in any of these trunks. THE CORNEA The steaminess of this membrane in acute cases and the secondary changes in late cases are too familiar to need more than a mention. There are, however, two symptoms due to the steaminess of the cornea which deserve notice, viz., mists and halos. The great importance of these lies, not merely in the fact that they attract the patient's atten- tion very markedly, but still more in that they serve as a very delicate test of the recurrence and duration of exacerbations of the disease. Those who are suffering from simple glaucoma, even with mild con- gestive intervals, may never be conscious either of mists or of halos, but the victims of acute and subacute attacks need never be in any doubt as to the recurrence of their trouble, once they have been trained to employ this test. It is important to distinguish two quite different sets of conditions under which mists and halos are observed, viz., (1) in the early morn- The Diagnosis of Glaucoma 407 ing, and (2) at those times of the day or night when fatigue is most pronounced. The early morning symptoms are due to the failure dur- ing the sleeping hours of the pump action, described by Professor Thomson, and exerted on Schlemm's canal through the action of the ciliary and iris muscles. Those which come on late in the day, as the result of fatigue, are to be attributed to vascular congestion and are frequently relieved by food or rest. They, in fact, constitute the in- cursion into the case of the vascular factor, as an outcome of dis- turbances of the vasomotor equilibrium. MISTS OF VISION. It is important to remember that, though these are undoubtedly due in part to edema of the corneal epithelium and of the superficial layers of the cornea (and possibly also of the endothe- lium lining 1 Descemet's membrane), a similar condition of the retina almost certainly plays an important part in the production of the symptom. Such a condition is predisposed to by the cutting off in some measure of the arterial blood supply, and by the obstruction to venous return, both being factors which interfere with the due nutri- tion of the retina. HALOS. These are best seen when looking at bright lights in the dark. When they are present, the ordinary patient can see them ex- cellently around a match or candle flame held at arm's length. In the dark-room the glow of a self -lit ophthalmoscope bulb especially when not too bright gives very vivid halos. It is most important that our patients should understand what we mean by halos, since so many conditions may easily be confused with the true colored rings seen by the glaucomatous subject. For this purpose a glass plate dusted with lycopodium should be kept handy; once a patient has looked through this, he knows for all time exactly what we mean when we ask him whether he has seen colored rings. The following conditions are from time to time mistaken for halos : (1) The golden haze made up of radiating luminous beams which a normal eye may see surrounding a light in the dark, and which is often dissipated by rubbing or drying the eye. (2) Imaginary halos seen by nervous people who have heard glaucoma discussed. (3) The scintil- lating scotoma of migraine. (4) The rapidly closing in rings of color seen by nervous or overtired people when they shut their eyes in the dark. (5) The halos due to damage to the corneal epithelium pro- duced by caustic and other medicinal applications. (6) The transient halos complained of by those who suffer from conjunctivitis. These are associated with mucous discharge, and they at once disappear on 408 R. H. ELLIOT washing the eye; they are probably due to the inclusion in the sticky mucus of masses of leukocytes imprisoned in the conjunctival exudate. (7) The halos seen when looking at a bright light far back in a big room through a steamy plate-glass window from the dark outside; these are the same as those seen through breathed on or steamy spec- tacle glasses. (8) The halos seen by some patients in the early stage of cataract; these are said to disappear if looked at through a pin- point diaphragm. (9) Trie physiologic halos which any normal eye can see if carefully looked for. These are said to be brighter and more prominent in the old. (10) The physiologic halos seen by many normal eyes when the pupils are dilated. The majority of these conditions can be easily differentiated from the glaucomatous halos by any surgeon who is acquainted with the fact that they may possibly be seen by non-glaucomatous people. A few inquiries will soon show their true nature. There are, however, some points which may here be profitably emphasized. The real glaucoma halo is much brighter than its imitators; the patient can very easily recognize at least three colors, a central blue, a middle yellow, and an outer orange red, or orange. In addition a band of green can often be detected between the blue and yellow. The diam- eter of the glaucomatous halo varies considerably in different patients, and even in the same patient at different times. I have never found it less than 6.50 or more than 11.54. The physiologic halos, on the other hand, are stated by authorities to measure constantly about 7 in diameter. It has already been mentioned that the colored rings are very feeble, requiring close attention for their recognition. The fact that a patient sees a colored halo after the use of a mydriatic may easily lead to the suggestion that the surgeon has been guilty of negligence in the use of the drug. The danger is all the greater since many members of the public are better informed on the subject of glaucoma halos than the majority of the medical profession. It is therefore essential that in every such case we should take note of the diameter of the halos, of their brilliance, of the colors recognized, and of the tension of the eye at the time. By doing so we may save a colleague much undeserved discredit. So important did this subject appear to the writer, that he sought the assistance of Mr. H. H. Emsley, of the Northampton Polytech- nique Institute, Clerkenwell. This gentleman has most kindly spent a great deal of time and trouble over the matter. He points out that Druault's test, as suggested by Morax, is not quite accurate. If a true The Diagnosis of Glaucoma 409 glaucoma halo, or any other halo, due to interference with the corneal tissues is observed, and at the same time a straight-edged screen (a stenopeic slit held vertically, does excellently) is moved across the area of vision close to the eye, the ring of the halo is obliterated just in proportion as the eye is covered by the slit. If, on the contrary, we observe a physiologic halo and this is much easier with a dilated pupil and if we now move our straight-edged screen across the area of the field of vision, an entirely different phenomenon is seen, due to the fact that the halo is here produced by the grid-like criss-crossing of the lens fibers. As the screen comes across the eye, instead of seeing the complete halo, we now only see two rather narrow spectral bands, one at each end of a diameter of the halo ; with the movement of the screen, these swing round like the spokes of a cart-wheel, traveling clockwise or counter-clockwise alternately, according as the screen is moved in one or the other direction. This beautiful little experiment of Mr. Emsley's enables us to tell at once whether the halos whether seen spontaneously by the old, or as a result of mydriasis in younger people are produced by the lens fibers, or are truly corneal. In the former case they have no connection with the intraocular pressure; in the latter, they may or may not have such a connection. A last word as to the measurements of halos: With the light 10 feet from the observing eye, the diameters of the halos will be approxi- mately as follows: For 4, 8.5 inches; for 5, 10.5 inches; for 6, 12.5 inches; for 7, 14.75 inches; for 8, 17 inches; for 9, 19 inches; for 10, 21 inches; for 11, 23.33 inches; for 12, 25.35 inches. THE ANTERIOR CHAMBER SHALLOWING OF THE ANTERIOR CHAMBER. This well-known sign may occur under two quite different conditions: (1) It may be the result of an overdistention of the vitreous body, of congestion of the ciliary body, or of both ; or (2) it may result from the sealing down of the angle of the chamber, due to the adhesion of the iris base to the corneal periphery. In either case, and especially in the latter, it may be important to be able to measure the depth of the chamber. Much information may thus, possibly, be obtained as to the progress a case is making on the downward road, and as to the prospect of an operation proving a success. With regard to the latter point, the writer holds strongly that an iridectomy is useless once the angle is sealed down, unless it accidentally gives rise to a filtering scar. If this be accepted, it is 410 R. H. ELLIOT obvious that we should aim at performing a filtering operation to start with, and should not leave our main object to be the sport of chance. Again, if we desire to trephine, it is of importance to know beforehand how far forward the obliteration of the angle has pro- gressed, and, if we have reason to believe that it is very far forward, we should get all the corneal splitting we safely can. Messrs. Zeiss have fitted to their corneal microscope a device known as "the Ulbrich drum." With the aid of this, and by a simple cal- culation, the depth of the chamber can easily be measured. Even apart from any calculation, the relative depths of the same chamber can be estimated from time to time; this is probably the most impor- tant element in the case. These considerations have been put forward because it seems prob- able that important advances can be made if such lines of work are followed up; and America is far more likely to do the work than most parts of Europe, for the present at least. CLOUDINESS OF THE ANTERIOR CHAMBER, OR THE PRESENCE OF DEPOSITS ON THE ANTERIOR SURFACE OF THE IRIS, OR ON THE POS- TERIOR SURFACE OF THE CORNEA. These are, in reality, signs of an iridocyclitis; their observation is most important, as the diagnosis of the cause of the glaucoma, and the main indication for the exhibition of mydriatic drugs hang on their recognition. This point was well brought out in the valuable discussion before the American Ophthal- mological Society, at their Fifty-fifth Annual Meeting in Atlantic City in 1919. KOEPPE'S SIGN. Koeppe has claimed that glaucoma can be rec- ognized, even in what he terms "the pre-glaucomatous stage," by the aid of the Gullstrand slit-lamp and this months or even a year be- fore any other sign of the disease has appeared. He states that as. a result of the morbid changes, which are taking place, pigment granules are set free, and that these wander out in the form of a fine dust, and are to be seen on the surface of the iris stroma. The observation has been both supported and contradicted. The writer has certainly seen such granules in glaucoma cases, but, he has also seen unquestioned cases of established glaucoma, in which no trace of them can be de- tected. The matter is one of great interest, and as some American ophthalmologists have devoted their attention to the subject, it is to be sincerely hoped that some further light will be shed on it at the Congress. If we could, by this or by any other means, anticipate a certain diagnosis of progressive glaucoma, it would be of incalculable The Diagnosis of Glaucoma 411 benefit to us, for we could then undertake a well-planned operation at a date when everything is in favor of success, instead of being forced to resort to surgery at a dangerous time, as is now only too often the case. THE CILIARY BODY The impairment of accommodation which accompanies glaucoma is too well known to require more than a passing mention. The ap- pearance of a manifest hyperopia is less widely recognized as a sign of the disease, although it is far from being uncommon. Its genesis is easily explained: The original condition in such cases was one of latent hyperopia; under the paralyzing influence of the increase of pressure, acting upon the third nerves and on their terminals in the ciliary muscles, the hyperopia has become manifest. THE LENS Much has been written recently on the subject of cataract com- plicating glaucoma. It is necessary to distinguish sharply between 3 conditions which are too often confused with each other: (1) The form of cataract secondary to glaucoma is characterized by a want of definition in its appearance. It looks like a smoky, greenish or bluish haze, and does not present the definite features with which we are all familiar in an ordinary primary cataract. (2) Glaucoma Secondary to Cataract. The appearance of the lens in the majority of these cases is characteristic of the intumescent variety, the history is unmistakable, and the presence of a primary and hith- erto uncomplicated cataract in the opposite eye clinches the diagnosis. (3) Cataract occurring as an accidental complication of glaucoma is by no means uncommonly met with by any surgeon in large practice. The so-called "green reflex of glaucoma" is not characteristic of the disease; it can be often seen in old eyes; the conditions that favor its appearance are a dilatation of the pupil combined with some want of perfect transparence of the aqueous humor, lens, and cornea, or of all three combined. THE OPTIC Disc AND RETINA CUPPING OF THE OPTIC Disc. The typical cupping of the optic disc, on which so much reliance is placed, is a feature of established glaucoma, and is often absent in early cases. The sign may, therefore, fail us in the very class of case in which the greatest difficulty in diagnosis occurs. 412 R. H. ELLIOT The method of formation of the cup in the great majority of cases is typical and unmistakable: (1) If a case is watched from the first, a slight and subtle change is observed at the very margin of the disc; this, either around a large area or throughout the whole circumference, shows a slight depression, not sufficient to be estimated by the aid of the ophthalmoscope but quite enough to be recognized by any trained observer. (2) At a slightly later stage a faint bend can be observed in the course of the vessels as they pass over this depressed margin; by this time the whole circumference of the disc tends to be involved. (3) As time goes on, the depression in the floor of the disc increases so that it can be estimated ophthalmoscopically, and the kinking of the emerging vessels becomes increasingly accentuated. The aberrant types of cupping are comparatively rarely met with. This is all the stronger reason for the surgeon to be on his guard and prepared to recognize them early. They are of two types: (1) The circular, central, physiologic cup, which gradually widens out toward the circumference on the papilla, and (2) the steadily enlarging physio- logic cup. It is necessary to repeat that these are rare forms of cup- ping, and that the diagnosis of glaucoma in such cases must rest on a comprehensive survey of all the evidence that the case can afford. PULSATION OF THE RETINAL VESSELS. We must take the veins and arteries separately: THE RETINAL VEINS. It is commonly believed that retinal venous pulsation is a sign of glaucoma. This view has recently been chal- lenged, and the writer has therefore studied the subject very closely. There can be no question that venous pulsation and even strong venous pulsation may be met with in eyes in which the tension is normal, and, again, that a complete absence of pulsation may be found in high tension eyes. There are, however, certain items of evidence which we must consider: (1) The exertion of a moderate amount of digital pressure on the globe will in many cases provoke a marked venous pulsation or exaggerate a pulsation already present. (2) The instillation of mydriatic drugs into the eye will, in a certain number of cases, have a precisely similar effect. (3) In a number of cases of glaucoma a very marked venous pulsation will be found present, and in not a few of these this pulsation will disappear or greatly lessen in character after the performance of a successful decompression opera- tion. The writer's view is that when the other features of a case point toward glaucoma, the presence of a marked venous pulsation in the retina is a suggestive piece of contributory evidence. Further, the The Diagnosis of Glaucoma 413 presence of such a marked venous pulsation, whenever it is detected, should raise in the observer's mind the possibility of a threatening of glaucoma. The circulation within the eye has a marvelous power of adapting itself to altered conditions, but in the transition stage from one condition to another, the vascular system may give such evidence as we have been discussing of the strain which is being put upon it. THE RETINAL ARTERIES. Spontaneous pulsation of the retinal arteries is spoken of in the text-books as though it were a common, if not an invariable, accompaniment of glaucoma, whereas the truth is that it is a sign which is very rarely seen indeed, and then only in the course of congestive attacks of the disease, passing away as soon as the exacerbation is got under control. The writer can never recall a single instance in which he has detected it in an eye suffering from sim- ple glaucoma or in a congestive case in the interval between two at- tacks. In many of our cases of acute glaucoma and by this we mean acute exacerbations of a glaucomatous condition the media are too hazy to allow us to see pulsation of the retinal vessels. In others we can see the vessels and note the absence of pulsation, while in yet others and these very few in number a distinct, and sometimes a very marked, arterial pulsation may be clearly discerned. We know that arterial pulsation means an intermittence of the even flow of blood through the arteries, as a result of the intraocular pressure hav- ing risen to such a height that it is greater than the retinal arterial pressure during the diastolic phase of the latter. In other words, it is clear evidence that the retinal circulation has become intermittent instead of continuous. Very different grades of this condition can be recognized: (1) The arterial pulse is nothing more than a flicker which affects, however, the whole course of every branch of the retinal artery on the disc and even beyond it; it can be counted against, and confirmed by the radial pulse. Here we obviously have to do with the slightest possible interference with the retinal arterial circulation; it is only at the lowest phase of diastole that the even flow of the current is interrupted. (2) The arterial pulse becomes more and more marked; the phase of blanching of the artery may be so prolonged as to equal or exceed that of its greatest fulness with blood; here the interruption of the retinal circulation is obviously becoming very serious. (3) In extreme cases the intraocular pressure has become so excessive that circulation can only be maintained at the height of systolic pressure ; the phases of blanching of the vessels exceed those in which they are filled, giving almost the appearance of an aortic pulse, and justifying 414 R. H. ELLIOT the simile, used by a French writer, that the blood seems to spill in jets over the edge of the disc. It will require but little consideration to show any thoughtful mind that the watching of this phenomenon will provide valuable clinical data to the observant ophthalmologist. So far we have been dis- cussing the spontaneous arterial retinal pulse. We shall now turn to consider a phenomenon which can be observed not only in glaucoma- tous, but also in healthy eyes, and yet one which has a very definite clinical significance. The Induced Pulsation of the Retinal Arteries. It is well known that by the exertion of digital pressure on the globe of the eye we can produce a pulse in the retinal arteries. This pulse follows closely the char- acters described in dealing with the spontaneous arterial pulse : With mild pressure the phase of interruption is extremely short. As the pressure is increased it lengthens until it exceeds the period of onward flow. Finally, if the pressure is made still greater and it is question- able whether we have a right to employ such a means the whole circulation through the eye is stopped, and the current through the retinal arteries definitely ceases. The real value of these observations lies in the fact that, as the intra- ocular pressure rises, the amount of digital pressure necessary to pro- duce a retinal arterial pulse tends to become less and less; conse- quently, when we can evoke an arterial pulse by light pressure upon the eye we are led to the conclusion that the intraocular pressure has risen until it is nearly equal to the diastolic arterial pressure. The word "tends" has been advisedly and deliberately used, and for the following reason: There are cases of undoubted glaucoma in which quite considerable pressure is required before the arterial pulse can be elicited, and there are cases in which no rise whatever of intraocular pressure has taken place, in which the diastolic pulse can be very easily produced by light pressure; this latter occurrence is most often met with in young eyes. It is obvious that in the former class of cases, the arterial pressure has risen part passu with the rise in intraocular pressure one more instance of the compensatory mechanism which is to be found in the eye, and whose working we understand so little. In the latter class we appear to have to do with a condition in which the normal diastolic arterial pressure is unusually low. PALLOR OF THE Disc. This pallor may be found under two quite different conditions : (1) It is seen in some cases of glaucoma at a very early stage, and is then presumably due to a constriction of the The Diagnosis of Glaucoma 415 vascular supply as a result of increased ocular pressure. That this should be so will surprise no one who is familiar with the very marked blanching of the disc which is produced by digital pressure. It has been claimed that it may be a very early and very suggestive sign, in the absence of other evidence, of an increase in intraocular pressure. This is certainly a point which should be kept carefully in mind, for in no disease is it truer that every shred of evidence helps. (2) It is met with as a marked, and often as an unmistakable, feature of estab- lished glaucoma. Its interest here lies not so much in establishing the diagnosis of the disease which by this time has usually already been made without difficulty but in furnishing a criterion as to the prob- able prognosis for vision, if and after a successful decompression opera- tion has been performed. A similar relative pallor of the retina may sometimes be observed. This is, however, very difficult to appreciate, and a more significant sign is therefore to be found in a slight relative decrease of the diameters of the arteries, as compared with those of the veins. A dragging over of the retinal vessels in a bundle toward the nasal side of the fundus is a not uncommon phenomenon in late cases of glaucoma, and the appearance presented is very striking. Even when there are considerable opacities in the media of the eye, the bundle of red lines running inward and the contrasting dead whiteness of the disc in every other direction furnish a picture which is unmistakable. This dragging over of the vessels is probably always associated with some measure of posterior staphyloma. THE SIZE OF THE GLOBE According to Priestley Smith, the average horizontal diameter of the cornea is 11.1 mm. in the glaucoma tous as against 11.6 mm. in healthy eyes. The importance of this fact lies in the help it gives us, when patients with a glaucomatous family history consult us as to the condition of their own eyes, being made nervous by the fear that they may have inherited the disease. Should we find that they have a low corneal diameter we would be justified in recommending them to keep themselves under periodic observation, and to report the ap- pearance of any suspicious symptoms of the disease. On the other hand, the observation of a large corneal diameter would be a distinct factor in enabling us to give a good prognosis. The writer has been extremely dissatisfied with the devices employed for making these measurements; they seem to him far too rough and ready for their 416 R. H. ELLIOT purpose. If it is important to have the information, that information should be as exact as it is possible to make it. This is the principle on which all our examinations of the glaucoma patient should be con- ducted if the opinions we give are to be really reliable. The requisites for a perfect instrument of the kind are: (1) A head-rest must be provided, so that the patient may be absolutely steady. (2) The instrument itself must be rigidly fixed on a firm stand. (3) The observed eye must have a definite point of fixation, so that it may not make the least move during the examination. (4) The scale and the eye must be sufficiently magnified to enable the observer to measure accurately in tenths and preferably in twentieths of a milli- meter. Messrs. Zeiss are constructing such an instrument especially for the writer, which will give a magnification of eight diameters. This can be substituted for their corneal microscope on the standard adjust- ment stand of that instrument, and will be focused by a rack and pinion movement. SUBJECTIVE PHENOMENA PAIN. Speaking broadly, pain is here, as elsewhere, a measure of the congestion present. A simple glaucoma may run its whole course without one moment of pain in the eye. Again, the early slight at- tacks of subacute glaucoma may be attended only by mild feelings of discmofort or of ocular pressure. On the other hand, the acute dis- ease is marked by great suffering. Our principal interest in the subject lies in the fact that the trouble is not always referred to the eye ; the patient and even his medical adviser may make the mistake of think- ing that the cause of the trouble is in the teeth, the ears, or the nose, since the 'neuralgia" complained of appears to start from one of those organs. Again, as we well know, the headache, vomiting, and pyrexia may lead to the erroneous and mischievous diagnosis of that refuge of incompetence, " the bilious headache." The taking of a meal or the obtaining of sleep may greatly alleviate the symptoms; such drugs as phenacetin and antipyrin are useless, while the bold instilla- tion of miotics acts like a charm. All these are points that help the careful surgeon to a right appreciation of the cause of a patient's suffering. LACRIMATION. According to Morax, various reflex troubles may suggest the commencement of glaucoma; the most suspicious of these is intermittent lacrimation, unconnected with wind or other pro- vocative agency. The Diagnosis of Glaucoma 417 NAUSEA AND VOMITING. Morax states that, even if the glaucoma is untreated, the actual vomiting subsides within twenty-four or at most forty-eight hours, while the sensation of nausea may persist for several weeks. He has met with patients suffering from subacute attacks, in whom the feeling of nausea was the only warning sign of a fresh rise in intraocular pressure. PHOTOPSI^E are not unknown in the early stages of congestive glaucoma. They may occur as flashes of light, as the impression of a ball of fire which rolls across the field of vision, as sudden, sharp, flash-like spots of light, or as a continuous luminous glow, lasting from seconds to minutes or even longer. The patient is most apt to suffer from these photopsise when he is tired and when he first gets into bed at night. It must be remembered that like symptoms may be observed under any conditions in which the retina is irritated, dragged upon, or otherwise interfered with. Nor must we forget that similar phenomena, but of central origin, are met with in neurasthenic pa- tients suffering from errors of refraction, from migraine, and from other nervous troubles. Rest tends to relieve photopsise of retinal origin, while those due to cerebral trouble are often worst at night. RAINBOWS ROUND LIGHTS. These have already been discussed. A DIMINUTION OF VISUAL ACUITY is a frequent, if not a constant, sign of glaucoma; its causes may be classified into (1) medial and (2) neuroretinal. The former include (a) interference with the refractile power of the cornea, owing to overstretching of that membrane; (b) corneal edema; (c) deposits on the back of the cornea; (d) degenera- tive and other permanent changes in the cornea; (e) turbidity of the aqueous; (f) opacities in the lens; (g) deposits of various kinds on the surface of the lens capsule; and (h) vitreous opacities. (2) Neuro- retinal causes include pressure on, and overstretching of, the bundles of the optic nerve and of the layers of the retina and (b) starvation of the nerve and retina due to interference with the blood supply as a result of intraocular pressure. The lesion may be manifested by a diminution of central vision or by an interference with the visual field. The former is practically always an evidence that a congestive element has entered into the case; otherwise good central vision is retained almost to the last. Defects in the field, on the other hand, are to be attributed to injury to the nerve fibers at the edge of the disc, rein- forced by starvation of the retinal blood supply. The distinction is obviously important. 27 418 R. H. ELLIOT THE VISUAL FIELD The subject of the changes in the visual field in glaucoma is so vast that it will be possible only to touch on a few of the main points of interest. The examination of a suspected glaucoma patient is very incomplete unless the fields have been carefully taken. Nor does one measurement suffice for each eye. The whole field should first be charted on a short radius (33 cm.) instrument, care being taken that the moving object is sufficiently small (not above 3 mm. in diameter for a daylight instrument) ; next, the central portion of the field, lying within 26 of the center, should be examined at a distance of 1 m. with a 1 mm. object. The results obtained by the two procedures are best kept on separate charts. PERIMETRY OF THE WHOLE FIELD. From this method we obtain certain very important indications: (1) There is a tendency for the nasal portion of the field to be affected before the temporal, and also for it to be more affected than the temporal, as the disease runs its course. Though this is not an invariable rule, it is so frequent an occurrence that it deserves to be kept carefully in mind. (2) As the disease progresses, the whole field tends to shrink from the periphery toward the center. (3) The blind spot shows distinct signs of enlarge- ment, even on examination by the small perimeter, if the fields are carefully taken from time to time as the disease progresses. (4) Roenne's step appears on the charts (Fig. 1). This has been de- liberately left till the last, not because it is the least important but because the writer desires to draw special attention to it. This sign is far too little known and appreciated. It is an evidence of the lesion of the optic nerve bundles at the edge of the disc (Fig, 2), and it therefore clearly points to the essential pathologic process which is responsible for the harm done to the optic nerve as a result of in- creased pressure within the eye. This does not mean that it is necessarily pathognomonic of glaucoma, for we know that other mor- bid conditions may damage the nerve fibers as the latter flow over the edge of the disc. Nor, again, does it imply any doubt as to the influ- ence of the vascular factor in the damage inflicted on the optic nerve and retina. It is obvious that the nerve fibers and retinal elements, which are starved of arterial blood and engorged with venous blood, as a result of increased pressure within the eye, must be thereby placed in a condition unfavorable to the resistance of trauma. In this we see the contributory element furnished by interference with the The Diagnosis of Glaucoma 419 Fig. 1. Chart from R. E. with chronic glaucoma. Bjerrum's sign is well shown. So also is Roenne's sign. The most severe lesions to the bundles of optic nerve- fibers lie at the upper temporal edge of the disc; compare with diagram in Fig. 2. Over the dotted area vision is indistinct. POR.M- Fig. 2. The diagram shows roughly the defects in the nerve bundles of the retina, which would correspond with the visual field defects shown in Fig. 1. The illustration is diagrammatic and only approximate. 420 R. H. ELLIOT retinal and choroidal vascular blood supply; but it cannot be too strongly emphasized that for the essential lesions of glaucoma, and for the evidence whereby we diagnose them by means of perimetry we must look to the edge of the disc and to the damage done to the nerve fibers at that area. This being so, the importance of Roenne's sign stands out large against the background of other perimetric ob- servations. Why has it been so little appreciated, and why is it so seldom observed? The answer is : Because so much of the perimetric work in consulting rooms and other places is done against time, and sufficient leisure and trouble is not devoted to it. Moreover, as has so often been pointed out, this sign is best observed when the circular method of perimetry is adopted, for the simple reason that the fibers, whose damage we are studying, run in arc-like curves around the cen- ter of vision, and any lesions they sustain are more easily studied when the observed object travels along the length of the fibers instead of across them. To take eight radial measurements of a field, and then to fill in a chart by drawing lines between them is not perimetry; on the contrary, it is bad work, and is most unfair to the patient. It will not reveal the presence of a Roenne's step, nor will it give a true, or even an approximately true, idea of the state of the visual field. One point more deserves to be remembered: The glaucomatous patient is sensitive to changes in light, and it is therefore important that periodical examinations of his field should be made as nearly as possible under the same conditions of illumination. It is difficult to obtain these by daylight in northern latitudes, and for this reason, self -lit instruments or those illuminated by artificial light are unques- tionably preferable to daylight apparatus. At the same time, it is very important to know the limitations of the instrument we use; these can be learned only by constant practice. Under no circumstances must either the fixation or the traveling object be too bright. If it is so, the patient will soon become fatigued, while before this happens, the limits of his field will be exaggerated. SCOTOMETRY OR CENTRAL PERIMETRY. Bjerrum was the first to point out that in glaucoma we commonly meet with arc-like sco- tomata, which are connected with the blind spot, and which curve round the center of the field of vision to end on the horizontal raphe. Such scotomata may be met with above the horizontal raphe", or below it, or in both situations simultaneously. In the last case we get ring scotomata. He maintained that these scotomata were the expression of lesions of nerve-fiber bundles at the edge of the disc. The Diagnosis of Glaucoma 421 Roenne, working on Bjerrum's hypothesis, looked for and found the sign, which is called by his name, and which we have already spoken of in connection with perimetry of the whole field of vision. Seidel went a step farther, and showed that very early in glaucoma, before any other sign of the disease could be certainly recognized, an enlargement of the blind spot, either upward, or downward, or both, could be detected with certainty in a number of cases. These enlarge- ments were always described as ending in single pointed or rounded ends. From the first, it appeared to the writer that this clinical feature was inconsistent with the accepted pathology of the condition, for, if it were a question of a lesion of a number of bundles of nerve fibers selected, as it were, out of the whole mass of the nerve, it would only be reasonable to expect that the lesions they would sustain would vary widely amongst themselves, and that therefore the scotoma pro- duced would not end in a point but in a number of points. Experi- ments with Bjerrum's screen and with other apparatus of a similar nature failed to confirm this suggestion, until the writer devised the scotometer which bears his name. Then the scotoma with jagged points was at once found, and has since proved to be so consistent a manifestation as to make the appearance of this phenomenon of high diagnostic value. Three principles are involved in the make-up of this apparatus: (1) That of the circular, instead of the radial, method of examination of the field of vision, as advocated by Priestley Smith ; (2) that of the magnification of the scale on which the phenomena are observed, so making the results easier to obtain and more striking to the examined eye, as advocated by Bjerrum; and (3) that of the examination of the field at intervals of 1 instead of at those of 5 or 10 as is so often done. This last was a device which suggested itself to the writer's mind as likely to bring out the jagged nature of the scotoma; if this could by any means be accomplished. It has been pointed out by some that the writer's sign is not ob- tained by other forms of scotometric apparatus, and it has conse- quently been suggested that it is an artefact. That this argument is not a very strong one is clear from the fact that the sign in question has been obtained in glaucoma cases by a number of reliable observers, who have abundantly confirmed the writer's findings with this instru- ment. A little consideration will show that when dealing with glau- coma cases it would be only natural to expect more accurate results from the Elliot instrument than from an ordinary scotometer, and this 422 R. H. ELLIOT for the following reasons: (1) As has already been shown, the circular method has special advantages in dealing with scotomata which are the result of lesions to nerve fibers at the edge of the optic disc; for these fibers sweep in curves around the central area of vision to reach the horizontal raphe; and it is always much easier, both for the surgeon and for the patient if, in mapping a scotoma, we pass through its longest and not through its shortest axis. Moreover, in the author's experience, a scotoma will always be carried further, and therefore shown to the greatest advantage, if we pass from the blind in to the seeing area, instead of in the opposite direction. (2) One can explore the whole field out to the 26 circle at 1 intervals by means of 26 circles easily, accurately, and mechanically traced for us by a rotating disc; whereas to do this at the same intervals, working radially from the center would demand 360 observations and would hopelessly tire our patient. Moreover, the closely set radial lines would for the first ten or fifteen degrees be practically impossible to dissociate from one another. (3) Whatever may be the verdict of other surgeons, nothing can shake the writer's conviction that the magnification of scotomata, whether these be. physiologic or pathologic, makes the patient's task enormously easier, and the surgeon's results much more accurate. THE NORMAL BLIND SPOT, as mapped out by the new instrument, does not differ materially from the records of other instruments em- ployed for the same purpose. This is all the more important since the field changes which it reveals in glaucoma are so very distinctive. We shall now consider these: 1. THE JAGGED ENLARGEMENT OF THE BLIND SPOT (FiG. 3). This is so marked a feature in many cases that it cannot easily be missed by any one who works with reasonable care. Even in quite early cases the pointed enlargement of the normal physiologic scotoma may be highly suggestive of the presence of intraocular pressure. On the other hand, if, under this test, we find the blind spot of absolutely normal size in a suspected eye, we must regard this negative evidence as of great value in suggesting that there is no rise of intra- ocular pressure present, or at least that any such rise that may be, or may have been, present has probably up to date done no harm. 2. DETACHED PARACENTRAL SCOTOMATA. A certain amount, though not a great deal, has been written about scotomata in glau- comatous eyes which are found at some little distance from the blind spot. Such defects are not infrequently met with when using the author's scotometer. If such a case is followed for some < ime, these The Diagnosis of Glaucoma 423 defects can often be traced until they join up with the enlarged blind spot. They are obviously due to lesions of those nerve-fibers which are distributed to parts further away from the disc. Consider for a moment a bundle emerging from the optic nerve at the disc edge. It would naturally be expected that the fibers which would be earliest and most damaged would be those on the periphery of the nerve; such a lesion would be evidenced by an enlargement of the blind spot. If, however, those fibers which are distributed to the area of the Fig. 4. Defect in the same case as Fig. 3, ten days after relief of tension by a successful trephining. The pointed peculiarity can still be traced in this scotoma. Fig. 3. Defect mapped out by author's scotometer in an early case of glaucoma a few days before operation. Note the irregularity of the endings of the upward and downward extensions of the scotoma; these show a number of points, which presumably represent lesions of small bundles of fibers. The test-object in both examinations was a 2 mm. disc of white blotting paper. Each circle represents 5. P. S. A third test was made six weeks after the operation, and the blind spot was then found to be practically normal, having undergone a considerable further contraction. retina, represented by that portion of the field close to the horizontal raphe, happen to be earliest damaged, we get one of these detached paracentral scotomata close to the horizontal meridian. Again, if some of the intermediate fibers are damaged, we get a scotoma in a corresponding position somewhere along the curved arc of the course of the bundle. In explanation of these vagaries in the scotometric phenomena, the following considerations may be suggested: (a) The bundles at the periphery of the nerve are most liable to be damaged by the sharp 424 R. H. ELLIOT edge of the scleral ring over which they curve to reach the retinal sur- face, (b) The central bundles, destined for the more peripheral parts, are more likely to be injured by the overstretching to which they are subjected when the nerve is pushed back under pressure, (c) Varia- tions in the anatomic arrangements of the nerve-fiber bundles them- selves may possibly explain some of the discrepancies in the phe- nomena observed, (d) There are considerable anatomic variations in the supporting framework of the optic nerve-head, and it is highly probable that consequently the nerve-head yields differently in dif- ferent eyes, and unevenly in the same eye. We are therefore justified in expecting that the injury inflicted will vary from case to case, and so will materially influence the signs of disease presented by the perimetric picture. 3. INVASIONS OF THE CENTRAL AREA OF THE FIELD. The surgeon who employs the writer's scotometer as a routine step in the examina- tion of his glaucoma cases, will be surprised to find how often the cen- tral area of the field is affected in eyes in which, under an ordinary superficial examination, he would not have suspected any such defect. This is a matter of great interest and importance. The writer has seen patients whose medical men believe that they were holding their own, and whose fields, taken on an ordinary small radius perimeter, supported such a view, and yet they themselves were firmly con- vinced that they were losing ground, as indeed they were; careful scotometry at once showed that they had good reason for their com- plaints. The value of the writer's instrument in explaining such cases, in following doubtful eyes before coming to a decision as to operation, and in gauging the effect of operative or other treatment must be experienced to be appreciated. The invasions of this area of the field tend to move steadily onward toward the obliteration of the upper, or of the lower, central field, or of both. Two clinical types are thus evolved: (1) When the scotoma is confined to either the upper or the lower field, the condition may amount to a nearly complete central hemianopia, before the patient is aware of the serious defect in his vision. This can only be the case when the opposite eye is comparatively normal. For obvious reasons the hemianopia is always superior or inferior and never lateral. (2) When the invasion of the central field takes place simultaneously above and below the horizontal meridian, the patient is more likely to detect it at an early date. The progress of the formation of a ring scotoma can be watched in such cases throughout its stages. The Diagnosis of Glaucoma 425 The diversity met with in different glaucoma fields has already been commented on, and some indication of its various causes has been furnished. We must now shortly discuss the influence of the incursion of the vascular factor on the broad features of these fields. As has already been pointed out, the field changes which are due to the mechanical effects of intraocular pressure, owe their variations to anatomic differences in the supporting framework of the nerve-head, and in the arrangement of the fibers of the nerve. If the congestive element could be excluded entirely from a case, we should get very different, but always clear-cut, perimetric pictures, and from these we would be able to speak with very little hesitation as to the nature and extent of the damage which has been inflicted on the optic nerve. This, however, is far from being the case. The element of congestion has to be reckoned with in most instances. (1) In some it dominates the whole picture, blurring all details like a fog lying across a land- scape; (2) in others it modifies our findings to a considerable extent, and yet we may be quite unable to apportion the just amount of blame to the two great factors, (a) the mechanical, modified by anatomic circumstances, and (b) the congestive ; (3) in yet others the vascular factor is so weak that it is with the utmost difficulty we can trace its influence. This, however, we may say truly, that, while simple glaucoma tends to produce definite and uneven curtailments of the field, the entry of the vascular factor blots out, or tends to blot out, the sensitiveness of the whole retinal area. TONOMETRY There are comparatively few ophthalmic surgeons and probably none in America who do not make abundant use of one or another form of tonometer. Even the student of to-day is trained to employ this instrument just as naturally as he does the thermometer or the binaural stethoscope. The ophthalmologist who does not do so fails in his duty to his patients and is an anachronism. Some of us use the Schiotz, some the Gradle, and some the McLean. It matters com- paratively little which model we adopt so long as we keep to one and learn to understand its indications. Nor is it a matter of any great importance from the clinical point of view that the translated reading in mm. Hg may not accurately represent the intraocular pressure in the eyes measured. We cannot fix for any tonometer a point below which the recorded pressure is certainly normal, or a corresponding point above which it is supernormal, for we know that the pressure 426 R. H. ELLIOT may vary considerably in different normal eyes; what may be low for one may be normal for another, and what may be normal for a third may be high for a fourth. It is to take an altogether perverted view of the use of a tonometer to regard its readings as if they were of the nature of a scientific laboratory experiment. They are nothing of the sort, and it may be a long time before they ever become as accurate as this. On the other hand, the indications they do give us are of the greatest possible value: (1) In a very large number of cases they tell us most definitely whether the intraocular pressure is dis- tinctly high or normal. (2) When the pressure is different in the two eyes, and especially if there are other indications of glaucoma in the higher tension eye, we are confronted with a very strong suggestion that a pathologic rise in pressure is present. (3) Variations in the pressure of an individual eye, occurring from time to time, afford us a most valuable criterion of the progress favorable or otherwise that the case is making, and of the value of the medicinal, operative, or other means that we are employing in the treatment of the case. In this connection Butler's tonometer charts deserve a mention, as they enable the surgeon to follow up his cases at a glance. It must be made quite clear that nothing which has been written above is meant as a criticism of the effort which have been made to standardize the Schiotz tonometer. Such an aim is altogether desira- ble, and I would like to pay here a tribute of admiration to the splen- did work done in this field by American surgeons and especially by McLean. THE LIGHT-SENSE There can be no question that the light-sense is profoundly affected in glaucoma. We know this well from the bitter complaints of our patients. They frequently tell us of their difficulties when they pass from light into darkness or vice versa. Moreover, bright days dazzle them, while in dull, cloudly weather they have difficulty in finding their way about. An examination of the light-sense ought, therefore, to be productive of valuable data. It has been claimed by reliable British writers that in the earlier stages of glaucoma there is a rapid reduction in light minimum sense, but only a very slight reduction in the light difference sense, while in incipient atrophy, the reverse is the case. On the other hand, French writers have obtained diametrically opposite results, finding the light difference sense the first to be at- tacked, and the light minimum sense to be diminished only in the The Diagnosis of Glaucoma 427 presence of optic atrophy. The writer has been very much troubled over this question: He has met with well-established cases of glau- coma in which the light-sense, tested by various instruments, does not appear to be inferior to the normal, either in minimum or in difference, and yet the patients undoubtedly suffer when their light is reduced. He suggests as a possible explanation that the central light-sense, like the central visual acuity, may long remain practically normal, while the peripheral light-sense may share the deterioration with which we are so familiar at the boundaries of the visual field. The writer would emphasize that he in no way wishes to set up his own opinions on the subject against those whose findings differ from his, and that the remarks he has now made on the subject are merely a call to other workers to persist in unravelling a tangled skein. Nor is the interest of the subject purely academic; on the contrary, the most valuable results from the point of view of the early diagnosis of the disease may well spring from such work as is now suggested. It could not fail to be of interest if members of the Congress would give their views on the best pattern of photometer for use in the examination of glaucoma patients, and if they would, at the same time, indicate the means they employ for differentiating central and peripheral acuity of vision for light. CONCLUSION This paper has endeavored to take up and deal with a few of the less well understood aspects of the diagnosis of glaucoma. The sub- ject is far too vast to be treated at length and the writer is deeply conscious of the many deficiencies of his contribution. There are cer- tain points that he would like to insist upon with the utmost emphasis : 1. In order to decide whether glaucoma is present or not, the patient should be exhaustively examined. This is a long, painstaking, and fatiguing business, and cannot be accomplished at one sitting, or the subject will become overtired, and the data collected will be un- trustworthy. Given time, patience, and suitable equipment, any sur- geon should be able to make up his mind definitely either (a) that a patient has glaucoma and requires treatment, or (b) that he has not got glaucoma, or (c) that, in the absence of definite and distinct signs of the disease, the case should be followed and watched until an un- hesitating opinion is arrived at. No means should be neglected to make the diagnosis as precise as possible; the history should be taken; a routine inspection of the eye should be made in a good light without 428 R. H. ELLIOT any form of apparatus, and later an examination by oblique illumina- tion with the aid of a corneal loupe; the refraction should be carefully estimated ; the corneal diameter and the depth of the chamber should be measured; further details should be sought for with the corneal microscope, the field being illuminated by a Gullstrand lamp; the pos- sibilities of ophthalmoscopy, perimetry, scotometry, tonometry, and photometry should be exploited to the full; halos, if present, should be measured. Then, if the surgeon, having thus made the most of the means at his disposal, is still in doubt, he has little, if anything, to lose by watchful waiting. 2. The second point is the complement of the first : A diagnosis of glaucoma should never be made on any one sign or symptom, no mat- ter how suggestive that may be. Such a course can never be necessary, and is not justifiable. 3. Once glaucoma has been definitely diagnosed, the patient should be very carefully watched, and if he is going downhill, in spite of gen- eral and therapeutic treatment, an early operation should be under- taken to reduce the intraocular pressure. The recurrence of congestive attacks is a strong indication for a decompression operation. One of the most delicate tests of such recurrences is the observation by the patient of halos around lights. If the congestive attacks are well marked, the diagnosis is obvious; it is only in the very mild subacute exacerbations of glaucoma that we need to rely on such a test. In those cases where all evidence of congestion is absent, we must look for our indications to scotometry, perimetry, tonometry, oph- thalmoscopy, the testing of central visual acuity, etc. The order is deliberate, and indicates the writer's views as to the relative impor- tance of the methods. Much has been said and written about an exaggerated tendency to resort to operation for glaucoma. What has impressed the author more than anything else in connection with this disease during the eight years that he has practised in Europe, has been the inclination, even of very able surgeons, to postpone a glaucoma operation if it is possible to do so. He believes that where one operation is undertaken too early, very many are put off till far too late. From the days of von Graefe and de Wecker onward, it has been a guiding surgical principle that the earlier an operation is undertaken for the relief of glaucoma the better is the prospect of success. It is the operations performed at a late stage which give us the worst results, and the later the stage the worse the prognosis. The Diagnosis of Glaucoma 429 DISCUSSION DR. JOHN E. WEEKS (New York City) : I would like to emphasize one or two points. One is in regard to the cupping of the disc. In the very early stage of glaucoma we may have a cupping beginning at one margin of the disc, that is, the bending of the vessels will be evident perhaps only at the lower margin, or perhaps at the upper margin of the disc. I have recently read a statement by a German authority claiming that all bending of the vessels at the margin of the disc indicates glaucoma, and I am inclined to agree with him in that respect. Another point is the repeated examination with the tonometer of the tension of the eyeball in all suspected cases. DR. LUTHER C. PETER (Philadelphia): The cornerstone of Col. Elliot's carefully constructed diagnostic symptom-complex of glaucoma is found in the first clause of his summary namely, an exhaustive examination. Two of the important signs in this disease are field studies and tonometry. They are most important because they not only are "high spots" in establishing a diagnosis, but are the factors upon which we largely determine the general management of a case. , His statement as to what should be our practice in tonometry is timely and logical. It matters little what instrument is employed in measuring approxi- mately intra-ocular tension, provided, as he says, "we keep to one and learn to understand its indication." Imperfect though it may be, it serves to relatively determine whether the intra-ocular tension is too high for safety as compared with the other eye. When used with routine care and the skill acquired by frequent measurements, any of the instruments mentioned, and others as well, will serve a useful purpose, until an instrument of greater accuracy and better adapted for routine clinical work will be available. In the matter of field studies, peripheral changes and central disturbances are important. Peripheral changes, especially in the nasal quadrant, are early phenomena, but, as Col. Elliot has pointed out, we are not so careful to search for these errors as we might be. This, however, is due largely to the inadequacy of the instruments at our disposal a phase of our work which we hope the Ferree perimeter will remedy. More vital even than the early peripheral changes are those found in the paracentral field, because their presence means that the process has advanced to dangerous limits, and that surgical intervention can no longer be side- stepped either by patient or surgeon. The slightest evidence of a begin- ning Bjerrum sign, whether it appears first at the margin of the blind spot, or above or below the point of fixation, speaks for surgical in- terference. The development of this sign is most interesting. In not a few cases it has its origin at the upper or lower temporal margin of the blind spot the so-called Seidel sign, but really only a variation in the beginning of a typical Bjerrum scotoma. More frequently, in the speak- er's experience, it has its beginning above or below the point of fixation between the 10th and 20th meridians. The earliest evidence of its presence may be detected by a half-degree test object for green or red, either at close range or at a meter's distance. When found in this location, it enlarges 430 R. H. ELLIOT toward the blind spot and toward the periphery at times toward the raphe", where it may meet a similar scotoma from the opposite half of the field and from a ring scotoma. At times the blind spot may show an enlargement and at the same time the area above or below the fixation point may undergo relative or absolute changes simultaneously, with healthy retina intervening. If increased intra-ocular tension is not checked, the two areas will finally unite and the typical Bjerrum sign will appear. This sign may be present without alarming changes in the peripheral field. If not sought for assiduously, the false assurance that all is well because the peripheral field is of good size may lead to error. It is the sign which the author searches for with the most delicate test available, and it is the recovery from this sign in its relative or absolute stage that determines the efficacy of the surgical measure practised. When the scotoma is fully developed and extends to the periphery, the border lines of the destroyed nerve bundles may be watched with equal interest to determine whether the surgical measures practised are holding. Its exten- sion is the most delicate indication for further surgical interference. As to the best method of determining even slight enlargements of the blind spot, there is much room for argument. There can be no doubt that the methodical method of approach as practised by Col. Elliot will uncover a blind area if present not only because he determines the outline by a circular motion but because his method is painstaking and methodical. The same area can be plotted by the more flexible hand method, which, if practised in the same methodical and accurate manner, must yield even more accurate results than those of a mechanically operated instrument. It is a matter of common knowledge that the points on the scleral edge of the disc where the retinal fibers are most apt to suffer compression are not necessarily at the extreme upper and lower boundaries but on the temporal side, involving the upper and lower quadrants. Using the blind spot, therefore, as a center of study a radial movement of the stimulus is apt to uncover the total de- fect quite as well as a meridional movement. Equally good results, how- ever, can be obtained by not limiting oneself to either a meridional or radial movement, but by practising a freehand movement in all directions which will bring out the defect as it exists. MR. E. TREACHER COLLINS (London, England) : I should like to emphasize some of the points made by Col. Elliot and the last two speakers. First, with regard to the halos in glaucoma. As Col. Elliot has pointed out, they may be due to change in the lens, and I think that is an important point to remember. Fine changes of the nucleus of the lens, sometimes spoken of as sclerosis, may produce persistent colored halos around lights. I have seen a patient who had had both eyes operated on because of halos due to this condition of the lens, and as the halos persisted after the operations one eye was operated on a second time; there was no cupping of the disc, no constric- tion of the field, no other symptom of glaucoma. I have several patients with this condition whom I have watched for a long time, but no symptoms of glaucoma have developed. Then it is necessary to make our patients clearly understand what we mean by "halos." I had a patient come to me some years ago and ask me to tell The Diagnosis of Glaucoma 431 him if he had glaucoma. I examined his eyes very carefully with the perim- eter, looked into them with the ophthalmoscope, but found no signs of glaucoma. He then said that two years previously an ophthalmic surgeon examined him as I did and then asked him if he had ever seen "rainbows." He said yes, he had, and this surgeon then said, "Well, you have glaucoma." He was a very intelligent man and he went home and got a medical dictionary and looked up all he could find about glaucoma, frightening his whole family and himself, and for two years he had lived in trepidation. Then he came to me and I told him he had no glaucoma. Several years have now elapsed and no symptoms have occurred. As Col. Elliot says, there may be a physiologic appearance of colored rings when the pupil dilates. I know a member of our own fraternity who fre- quently sees these rainbow rings, especially in the evening. I have watched him for a long time he was very anxious about himself but he has never developed any signs of glaucoma. With regard to Koepp's sign, there is much to be learned. It is not present only in glaucoma. It can be seen readily with a Gullstrand slit lamp or by contact illumination. With regard to the optic disc, I think an early symptom of glaucoma is the displacement of the retinal vessels laterally toward the nasal side. In eyes where there is definite glaucoma in one eye and in the other perhaps no marked symptoms one may see this lateral displacement of vessels towards the nasal side. One word in regard to scotometry, and that is as to the diagnosis of whether the glaucomatous process has been checked by operative procedure. As previous speakers have said, the field may show no increased contraction, the acuity of vision may remain the same as before operation, and you are inclined to say the operation is satisfactory; but the patient says his eyesight is not so good as before. If you try scotometry you will find the scotomatous area has extended around the fixation spot. Another symptom which these patients sometimes complain of is that they get no pleasure from reading. They may have 6/6 vision, but they do not care to read, and I think the reason is that the scotoma is spreading around the fixation spot, and that patients, although they see the word they look at, do not see the next word, so the pleasure of reading for them is gone. DR. E. E. BLAAUW (Buffalo, N. Y.) : Col. Elliot said it is a simple thing to measure the depth of the anterior chamber, but I think it is difficult to know where the limits are. The iris margin is very different; the pigment of the margin has a different size and extent; the cornea is not of the same thick- ness and curvature in all eyes; where are we going to take the measurement, in the periphery or the center? I do not know. The change of the cornea, which has appeared to me in many instances the beginning of high tension, may be considered the symptom which Stahli called "betauung." It is only seen when the epithelial cells form small blebs, best seen in reflected light. In my very limited experience I have thought that it is not a pathognomonic sign. 432 R. H. ELLIOT I am a little surprised that Col. Elliot did not speak of gonioscopy. This gives us a new method of attacking the anterior angle. I agree that Koeppe's sign does not include deposits on the posterior layer of the cornea. In elderly eyes frequently pigment moves away from the pupillary iris border. Koeppe values, therefore, fine pigment deposits in the crypts. DR. J. W. NORDENSON (Stockholm, Sweden) : The discussion having also treated of the methods of examining eyes in reference to symptoms of glaucoma and Col. Elliot having requested in his paper members of the Congress to tell their ways of testing the light sense, I venture to call your attention to some methods of investigation that are practised in our clinics. In testing the light sense two different things are to be examined : the sense for light- differences and the sense of light-perception. The testing of the sense for light-difference will be dealt with later in a paper by Dr. Percival, so that solely the testing of light-perception comes in question here. The testing of this function, which nowadays is of greatest importance in examining aviators and motor drivers, is done in our clinics with an instrument, originally devised by Gullstrand and further elaborated and described by S. Lindquist of Sodertalge. 1 The instrument consists of a box containing a light source of constant intensity and shut at one end by a milk-glass plate covered by a sieve with 900 holes. With the aid of two slides any number of these holes can be opened and shut according to wish. In making the test all the patients are assembled in a totally dark room where they are left for about half an hour in order to get adapted to dark. The instrument is then put up in front of a square piece of white paper of certain dimensions and the holes are opened one after another until the examined patient affirms that he can see the paper. The intensity of light coming from the paper when lighted by one hole, having once been tested, the examination gives you the amount of light re- quired to give the patient perception of light. Simulation is avoided by re- peating the test several times and by comparing the number of holes required each time. The method, which is a modification of the apparatus of Foerster, has the advantage that the examiner himself need not be adapted for dark. If it were possible to devise a method to control the fixation of the patient, it would be possible to use the instrument also for testing the sense of light-perception in different parts of the retina. For the use of the slit lamp to measure the depth of the anterior chamber of which Dr. Blaauw spoke, an instrument has been constructed by Lind- steadt of Stockholm. 2 The principle of it is that the pencil coming from the slit is made astigmatic by an optic system, whereby one of the focal lines is placed on the anterior surface of the cornea, the other on the anterior surf ace of the crystalline. With knowledge of the power of the astigmatic system that is required to so adjust the focal lines, the depth of the anterior cham- ber can be determined very exactly. MR. J. GRAY CLEGG (Manchester, England): Several points I wish to 1 Upsala Lakareforenings forhandlingar, 1906. 2 Arch. f. Augenheilkunde, vol. 80. The Diagnosis of Glaucoma 433 mention, and one is that in making a diagnosis we cannot rely on any absolute line as to the height of pressure when determining the presence of glaucoma in the particular eye under examination. One finds a considerable variation, and perhaps this is well illustrated by a case that I have had recently, an iridocyclitis with high tension, but where there was perfect peripheral vision, no scotoma, no enlargement of the blind spot, but the tension was high over 40 mm. It was only after some months of treatment, the tension remaining high, that slight enlargement of the blind spot was found and operation was resorted to. Other cases show the signs of chronic glaucoma, although the tension is never found above normal. In the old days my predecessor, Dr. David Little, used to be afraid of the iridectomy operation when there was a blind area near the fixation point, for fear the surgical interference might, as it were, tip the eye over the precipice; but we find that with the trephining operation we need not hold back, even though the blind area extends within two or three degrees of the central point. Another important point is that we must not overlook the general health of the patient. DR. GEORGE F. KEIPER (Lafayette, Ind.) : I want to add the history of a patient with chronic glaucoma, who before I first saw him had lost one eye, and I have been afraid to operate on the other eye, and have been controlling him with miotics. When I drew the curtains down in the dark room he said he could see the test letters better when the room was brightly illuminated. I tried that with him a number of times, and found it to be true. I now make this test with all persons over the age of forty, and if I find they can see the letters in the dark room better with the curtains up rather than in a shaded room, my suspicions are immediately aroused, and I am inclined to think of the advice Dr. Ellett gave years ago, to use tonic drops of eserin in order to be on the guard against cases of glaucoma that may manifest themselves by any other symptoms. DR. ARNOLD KNAPP (New York City) : While we may not all agree on the form of operation, we are all united on the fact that the value of any treat- ment of glaucoma rests in the early diagnosis, and the most important factor in this is the examination of the paracentral area by the scotometer. Al- though it is many years old, the profession in general owes Col. Elliot a debt for so instructively drawing our attention to this method. The other point I wish to mention is that among the early signs there is a curious susceptibility of the glaucomatous eye to adrenalin. In some in- vestigations made and reported to the American Ophthalmological Society last year, I drew attention to the fact that adrenalin causes a dilatation of the pupil in glaucoma in nearly all cases. In some cases the tension was reduced, in some it remained the same, and in a few it was increased. When adrenalin was instilled into the other eye which has had no symptoms of glaucoma, a dilatation of the pupil was observed. DR. GEORGE W. JEAN (Santa Barbara, Cal.) : With regard to the loss of blood-vessels at the disc edge, which Dr. Weeks said he had recently seen mentioned in a foreign text-book, I would like to call attention to the fact 28 434 R. H. ELLIOT that I spoke of this sign in my text-book published in 1915. Men working under Lauber in Vienna a dozen years ago will well remember how he insisted that this sign, if present, was an absolutely pathognomonic sign of glaucoma. There are two exceptions : in congenital colobomas of the nerve head and also in those peculiar cases with a congenital hole in the disc that often goes several millimeters deep. Lauber has reported several cases of the latter, and I have seen one such case with lost vessels at the disc edge. Of course, the sign is not always there, but with the exceptions mentioned "the short bend of a single vessel immediately at the disc edge is sufficient in every case for the diagnosis of glaucoma." COL. R. H. ELLIOT (closing) : With regard to Dr. Weeks' remarks, I have observed, as he says, over and over again, that cupping occurs first at one portion of the disc, and I think that is explained by Fuchs' recent work on the difference in the way in which the disc yields unevenly, according to the state of the distribution of the fibrous tissues in the lamina cribrosa. I am not prepared to go as far as some of the speakers who feel that a single vessel out of place means glaucoma, because I have seen cases where vessels at one part of a disc were suspicious, but when the cases were followed for a long time I could not satisfy myself that there was glaucoma present. At the same time, though, the sign always makes one suspicious. I would like to press home what Dr. Peter said about the tonometer. The tonometer is the only accurate method of measuring the tension of the eye, and to do anything else is equivalent to putting your hand on a patient's skin and saying he has a temperature of 102. I also agree with him that when paracentral scotoma is present a dangerous stage has been reached, and the patient should be watched; also that detached paracentral scotoma is extremely common in glaucoma. All I claim for my instrument is that you can make a reliable clinical examina- tion in a remarkably short time by its use. I have never put it forward as an instrument for scientific research, but it is an instrument of great delicacy and can be used rapidly. Mr. Collins spoke of the gentleman who saw rainbows. I would like to pass this lycopodium slide around. I keep it in my dark room and say to my patient, "Have you ever seen halos?" He does not know. Then I say, "Look at the bright light through this." He looks and knows at once what we mean by a halo. Dr. Blaauw took me up on the question of the depth of the chamber. When I wrote that I had no idea I was being so dogmatic. That was written months ago, and I would have been less assertive if I had written it now, after more experience with the Ulbrich drum. All the same, I believe it can be made a useful adjunct to diagnosis. With regard to contact glasses, I have not had the courage yet to use con- tact glasses, but I am in hope of being put in the way of using them. I admit it is an important matter. Dr. Nordenson spoke of a light-sense apparatus. I have had constructed for me by Zeiss an apparatus which I am using in my dark room and which will, I think, prove useful. Blood-Pressure in the Vessels of the Eye 435 Mr. Clegg raised the important point of the general treatment of the patient. Of course the glaucomatous individual has a sick eye in a sick body, and you must examine the whole patient. With regard to Dr. Keiper's point, the thing that strikes me more than anything else is the way in which every glaucomatous patient has deficient light sense, and yet there is difficulty in getting him to show it by any ordinary sort of apparatus. The explanation that I offer I have already given you elsewhere. I think Dr. Knapp's test is one that we should follow very carefully. BLOOD-PRESSURE IN THE VESSELS OF THE EYE DR. A. MAGITOT AND DR. P. BAILLIART Paris, France It has long been known that a slight compression of the eyeball causes arterial pulsation in the retina. Physiology enables us easily to understand that this arterial pulsation appears when the tension of the ocular media reaches the diastolic pressure of the central artery of the retina. Similarly, we knew, that the pulsation will cease when the pressure exercised through the ocular media is greater than the systolic pressure of the central artery. It was soon discovered that, in the case of patients suffering from arterial hypertension, it was necessary to exercise on the eyeball a strong pressure to bring about the disappearance of the retinal pulsation; Bailliart (1909), then Melville Black (1911), and-Deyl (1912), had drawn attention to this method of recognizing the 'existence of arterial hypertension. In order to measure the arterial pressure in the central artery of the retina, it remained therefore only necessary to know the amount of force it was necessary to apply to the eyeball, to bring about the appearance and disappearance of the pulsation. Henderson had, for this purpose, constructed, as early as 1914, an apparatus which calculated in millimeters of mercury the pressure which, exerted on the exterior surface of the eyeball, was sufficient to bring about the appearance of the diastolic pulsation. Henderson thought, which is not altogether incorrect, that by adding the ocular tension to the figure given by his apparatus, he would get the diastolic pressure of the central artery. Bailliart, in 1917, suggested a method for determining the figures of the diastolic and systolic pressures of the central artery. By 436 A. MAGITOT AND P. BAILLIART means of a special dynamometer, graduated in grams of water so that it might be easily verified on any scales, a pressure is exerted on the eye in the region of the insertion of the rectus externus, until the operator notes the appearance and then the disappearance of the retinal pulsation. Two successive readings will thus give the amount of force which it is necessary to exert to balance the diastolic and then the systolic pressure of the central artery. But the thing that it is then important to know is, how the primitive ocular tension has been modified by these dynamometric pressures, for, finally, it is by its intermediary that we act on the vessels of the eye. Henderson has had the idea of measuring in millimeters Hg the pressure exerted on the eyeball and of adding to it the ocular ten- sion determined by means of Schiotz's tonometer; but in this method there is a double cause of error, first, from a physical point of view, two successive pressures do not add up together, and on the other hand, the pressure transmitted by a liquid is proportional to the surface compressed. Here is, however, another method: In a dark room, the patient being placed in a recumbent position, the operator causes the appearance and disappearance of the pulsation and notes the weight in grams necessary to obtain these two results. Then Schiotz's tonometer is applied to the eye while at the same time by means of the dynamometer a pressure is exerted equal to that which was found necessary a few moments before to produce the ap- pearance and disappearance of the pulsation. The tonometer weighted with its heaviest weight . will indicate approximately in millimeters Hg the pressure exerted on the vessels of the retina. It is evident that the greater the pressure exerted on the eyeball the greater will be the ocular tension. But this method complicates the operation and is only possible with exceptionally docile subjects. It is for this reason that we undertook to study experimentally, on an animal, the modifications of the intraocular tension under different pressures and to draw up a chart. But to be of use clinically the knowledge of these modifica- tions of the ophthalmotonus caused by pressure exerted on a healthy or diseased eye, must apply not only to a particular case, but to a whole series of figures of initial tensions. The method would indeed be singularly restricted, if we only knew the tensions produced by a pressure of 10, 20, 40 or 80 grams on an eyeball the initial ophthal- motonus of which would be uniformly 20 mm. Hg. It is indispensable to acquire a knowledge of the effect produced on different initial Blood-Pressure in the Vessels of the Eye 437 ophthalmotonus, for we must evidently suppose that the same pres- sure of 20 grams will produce a different tension in an eye of which the primitive ophthalmotonus was 15 mm. Hg and in another of which the ophthalmotonus would be 30 mm. Hg. The drawing up of such a chart was possible only by experiment. We carried out researches on cats anesthetized with chloralose, this product being easier to manipulate than curare and causing only a slight modification in the general blood-pressure, on condition that the animal is not allowed to get cold. We have also made use of a mercury manometer invented by one of us and of which the manipu- lation appears to us to be easier than of Wessely's or of other instru- ments derived from Schulten's. The ocular tension of the cat oscillates between 15 and 25 mm. Hg according to conditions. It was, therefore, relatively easy to establish the figures of ophthalmotonus starting from these initial tensions. But it was necessary to obtain greater tensions and others still weaker. We were able to produce higher starting figures by practising sub- conjunctival injections of NaCl. We were thus able to obtain quite easily tensions of 40 or 45 mm. Hg, rarely more. In order to operate on lower ocular tensions than 15 mm. Hg we had recourse to a deeper narcosis in order to act upon the general blood-pressure. But we were unable to obtain less than 10 mm. Hg which in the cat, as in man, is the immediate postmortem tension. We chose the cat in preference to the rabbit (which is, however, an easier animal to handle) on account of its ocular nervous system, which is very similar to that of man. Yet both of them possess a much larger anterior chamber and we do not know whether the general elasticity and resistance are identical with those of the human eye. We have avoided producing modifications of the tonus by injection or aspiration of the intraocular liquid as these means give erroneous figures for the two following reasons : 1. On account of the resorption. 2. On account of the intraocular vasodilatation which, very probably, takes place after a few seconds. As to the pressures, they are made by means of Bailliart's dynamometer, which is either held in the hand or immovably fixed in a ratchet-support. The chart on next page will avoid any useless descriptions. It gives us the figures for pressures applied horizontally (as on a patient sitting or reclining) on eyeballs of which the initial tensions vary from 10 438 A. MAGITOT AND P. BAILLIART mm. to 50 mm. Hg. It will be noted that the different lines starting from different initial tensions are remarkable for their parallelism and also for being nearly straight. It results from this that the chart can be completed for all the initial pressures and for all pres- sures applied. It will be seen that with this chart the determination of diastolic or systolic arterial pressure in the branches of the central artery be- comes easy. We first measure with Schiotz's tonometer the initial ocular tension, then we seek what dynamometric pressure will bring about the ap- Blood-Pressure in the Vessels of the Eye 439 pearance and later the disappearance of the arterial pulse. We then refer to the chart and we find in millimeters Hg the required figures. In an eye of normal tension in a eubject whose arterial pressure is normal, the arterial retinal pressure is about 35 mm. for the diastolic and 70 mm. for the systolic. If the retinal circulation has a primordial importance since it insures the visual function, the choroidal circulation also plays a considerable part; the part it takes in the modifications of the oph- thalmotonus is well known. It is moreover possible by studying the effects produced by compression of the eye to obtain on the uveal circulation notes similar to those obtained on the retinal circulation. Sometimes, particularly in extreme myopia, it is possible to per- ceive through the retina the choroidal vessels; but we can but ill distinguish the arteries from the veins and on the other hand these vessels never show, except in certain exceptional cases, either spon- taneous or forced pulsations. When considerable pressure is applied, it is even difficult to tell at what precise moment they are emptied, and, even if we did know it, this would have little value since we can- not distinguish the small arteries from the small veins. Consequently, the direct examination and measuring of the arterial pressure in the choroidal vessels is not yet possible. In a recent work G. Leplat has shown that it was possible under certain favorable conditions to study "de visu" the blood-pressure in the arteries of the dog's iris by making use of the process we have described. The importance of this fact is truly considerable; this process enables us to acquire for the first time some ideas on the circulation of the uvea of which the iris is the sole portion which is clearly visible. In man, unfortunately, the iris circulation, like the choroidal cir- culation, does not lend itself to these investigations, and, however great was our desire, we were unable (even with the magnification of Czapskc's loupe) to observe any iris pulsation. It may be that we should see in this fact a confirmation of Thomson Henderson's opinion that the arterial circle of the iris in man is in reality a venous circle. The dog, which G. Leplat used for his researches, possesses in the periphery of the iris, particularly on the side toward the nose, verit- able arterial trunks of which the beatings can be seen with a magni- fying glass of low power or even under good conditions of lighting, with the naked eye. The observation of the pulsatile arterial reac- 440 A. MAGITOT AND P. BAILLIART tions is thus very easy and enables us to study, as our Belgian col- league has done so well, the pressure in the vessels of the iris. On our side we have undertaken a series of researches for the purpose of studying comparatively the iris circulation and the retinal circulation ; and we have made use of the cat. The dog, which is a good subject for the vessels of the iris, appeared to us to be of no service for the study of the vessels of the retina; for its central vessels when they reach the disc are already divided into fine branches surrounded by neuroglia tissue. This disposition does not allow the beating to attain the amplitude desirable. The retinal vessels of the cat, apart from their being disposed on the periphery and not in the center of the disc, and their ciliary origin, resemble on the contrary fairly exactly the vessels of the human retina. At the limit of the dark gray disc we see three or four arteries each with a vein running by its side. The artificial beats which we provoke must always be sought for in the immediate circumference of the disc. They are, moreover, very easy to observe ; when the appropriate pressure is applied to the eyeball, three or four small arteries can be seen beating simultaneously. The vessels of the iris are per contra rather less easy to observe than those of the dog. In order to see them well, it is necessary to make use of Czapskc's magnifying glass, and to examine the nasal extremity of the horizontal meridian; a voluminous vein (particularly if one looks very closely at the root of the iris, before its bifurcation) will be seen lifting up the trabecular tissue ; at this spot we recognize the existence of spontaneous arterial movements which pressure on the eyeball exaggerates and transforms into veritable pulsations and finally suppresses completely. If the retinal pulsations of the cat are always easy to see, it must be added that the pulsations of the vessels of the iris are sometimes less so. The comparative study of these two pulsatile phenomena has enabled us to remark that in the eye of the cat the pressure in the arteries of the iris and of the retina is practically the same; if in the average case it has been necessary to apply somewhat stronger pres- sures to study the pulsation in the iris than in the retina, this is due, no doubt, on the one hand to the greater difficulty of observation in the iris. We can give as an average in the cat for the arteries of the iris and the retina 45 to 100 mm. Hg, which figures are slightly higher than those in man. Blood-Pressure in the Vessels of the Eye 441 These experiments on animals have led us to recognize (which we consider to be quite probable) that the systems of blood-vessels of the retina and the uvea, so similar to each other in many ways, have in their normal state an identical working pressure. We have since had fresh confirmation of this in a work of Vossius. This author had occasion to examine with the corneal microscope a filament of an iris in a persistent pupillary membrane. On applying dynamometric pressure to the eyeball he noted that circulation was arrested when the ocular tension reached 70 mm. Hg. This figure (70 mm. Hg) is also that which we found for the normal systolic pressure. The study of the effects of graduated and known pressures on the eyeball has also led us to other results. We have been able to ob- serve a constant phenomenon which can be formulated as follows : 1. From an initial tension of 15 mm. there exists always a lowering of the ocular tension after each application of the tonometer, how- ever correctly the application be made. Example: take an eyeball of which the tension is 20 mm. Hg; submit it for a duration of three seconds to a pressure of 30 gram. We shall find immediately after that the ophthalmotonus is no longer 20 mm. Hg, but only 15 mm. 2. This phenomenon no longer exists when the same pressures are applied to eyeballs possessing only a tonus of 10 to 12 mm. Hg. 3. This phenomenon is exaggerated when the pressure is applied to eyeballs in which the tension has been raised artificially (in our experiments by means of subconjunctival injections of hypertonic serum). , These modifications of the ocular tonus under the influence of slight pressures applied to the eyeball had already been noted in tonometric experimentation. This observation had already been made clinically in 1911 by Polak Van Gelder. Using Schiotz's tonometer, he remarked that in normal individuals the repeated applications of this instru- ment at intervals of 3 or 5 seconds always furnished figures lower than the first ones. If we translate into grams the pressure exerted on the eyeball by the tonometer loaded with these weights of 5 or of 7 grams, we see that it varies from 21 to 25 grams. In Polak Van Gelder's tables we note that the difference between the ocular tensions before and after this tonometric pressure is about 10 mm. Hg. This fact is also quite clear when dynamometric pressures are applied to the eyeball in order to measure the arterial retinal pressure. 442 A. MAGITOT AND P. BAILLIART If, when by means of a given pressure we have managed to efface the last arterial pulsation, this pressure is maintained for a few seconds, it will be seen that the arterial pulsation reappears very rapidly; to suppress it, greater pressure must be applied; if this pressure is main- tained the pulsations reappear. Thus the ocular tension diminishes immediately and constantly under the influence of dynamometric pressure. This fact must be noted as it explains why beginners, who proceed by feeling their way, always find very high figures in their attempts to determine the arterial retinal pressure. This lowering of tension under the influence of pressure is, more- over, very transitory : to the depression there succeeds even a slight ulterior elevation which lasts a very short time. How can we explain this diminution of the ocular tension under the influence of ocular pressure? Evidently by the issuing of a part of its liquid contents. The supporters of the continuous stream of the aqueous humor explain it by a more active filtration of this liquid which is driven out of the eyeball by the mechanical effect of the compression. For our part, we believe that the question is not so simple. Remembering the modifications of the ocular tonus under all the influences which can act upon the circulatory system of the choroid, the fall of the ophthalmotonus after ligature of the ciliary arteries or of the carotid, after stimulation of the "sympa- thetic," its rise which follows inhalation of amylis nitris, after division of the sympathetic, we remain convinced that the compression of the eyeball acts by emptying the choroidal system, and that this mechani- cal expansion of the external coat of the eye brings about the fall of the ocular tonus, which rises again when little by little the blood fills once more the exceedingly rich vascular system of the uvea. PLASTIC OPERATIONS ABOUT THE EYE SUGGESTIONS FOR SEVERAL IMPORTANT CONDITIONS DR. JOHN M. WHEELER New York City In considering the subject of plastic surgery of the structures about the eye, I shall limit myself to some of the more important features of operations which have been developed in my experience, while attempting to determine the best methods of correcting deformities in the eye region. In my opinion surgery of the eyelids, eyebrows and orbital region should be performed by ophthalmologists, and not by those who have no special knowledge of surgery of the eye region. General surgeons are uninformed on the peculiar features and require- ments here, and they are not trained in the refinements essential to success in plastic eye surgery. Plastic eye work enriches the field of ophthalmic surgery and broadens the scope of the ophthalmologist without interfering with the special skill which he must develop in order to perform successfully the important operations on the eyeball proper; and certainly nothing should be allowed to detract from the high importance of the skill and refinement and judgment called for in handling such conditions as cataract and glaucoma. In studying and applying methods for handling cases of deformity about the eyes I have always had in mind these two things. First, to avoid adding new deformities through my surgery. Second, to develop procedures which are as simple as possible and which are appropriate for general adoption by trained eye surgeons. In order to make satisfactory comparisons of the relative merits of different sorts of grafts in corrective, surface work of the eyelids and thereabouts, I have used different types of grafts and different meth- ods on the same patient. For instance, one patient who needed more than one correction received a true skin flap from the inner aspect of the arm, a free graft of true skin from one temple, and a pedunculated flap from the other temple. Another received epidermic grafts from the thigh, and true skin from an upper lid. Another, a pedunculated 443 444 JOHN M. WHEELER flap from the temple, a free graft from the arm and a free graft from the upper eyelid, and so on. Thus, by making different sorts of com- binations, it was possible to study results in an unprejudiced and con- vincing way. ClCATRICIAL ECTROPION SIMPLE CICATRICIAL ECTROPION. This is the ordinary variety that we have to deal with most commonly, in which the lower eyelid, or more rarely the upper, is pulled away from the globe by scar tissue, but in which the lids otherwise have suffered little. In most cases of traumatism resulting in ectropion, only a single eyelid is involved, and the lower lid suffers more frequently than the upper. For simple ectropion, by far the most satisfactory correction can be obtained by means of an inlay of true skin from one of the upper lids. It is sur- prising how seldom one or the other upper lid will fail to provide ample skin for grafting. So for most cases of cicatricial ectropion I employ detached upper lid dermis. A match in appearance is assured without the creation of an additional deformity. There need be no fear for the upper lid on account of removal of the skin. A fusiform flap of true skin 50 mm. long and 25 mm. wide can be taken safely from most any normal upper eyelid, and some could furnish much greater width. In one young adult I have taken, at intervals of a few months, three separate grafts from the left upper eyelid without lagophthalmos or appreciable deformity. The stretching of this skin tissue and readjustment to the normal appearance is remarkable. A description of this operation was published in 1921. : Technic of Operation. The primary incision should be parallel to the distorted lid margin. Cicatricial tissue should be so thoroughly and painstakingly removed that there will be no tendency of the lid to evert, and scarcely more than normal resistance to upward traction at the lid margin (Fig. 1). In making the preparatory dissection, the tissues should not be handled roughly. Artery clamps should not be used unnecessarily and no ligatures should be used on bleeding vessels. Either two or three firm adhesions between the upper and lower lids are made by dissecting off epithelium at corresponding positions on the upper and lower lid margins, and carrying mattress sutures through the little raw surfaces. They are passed through small plates of rubber (cut from sterile rubber tubing) overlying the skin of both upper and lower lids near their margins (Fig. 2). These sutures are 1 Jour. Amer. Med. Assn., July 19. Plastic Operations About the Eye 445 tied snugly to insure firm apposition of the opposing raw surfaces. Union of these raw surfaces causes the formation of adhesions for the support of the lower lid. Later, these adhesions stretch somewhat and are covered with a growth of epithelium. This stretching allows of very slight separation of the lids, so that the patient can see through the palpebral fissure, a thing to be encouraged, as elevation of the upper lid stretches the lower. With this in view, it is well to avoid making an adhesion directly in front of the pupil. Removal of the True Skin Graft from the Upper Lid. This is very Fig. 1. Simple cicatricial ectropion of left lower eyelid. Dissection in lower lid completed and graft outlined in upper lid. Fig. 2. True skin graft from upper lid sutured in position in lower lid. simple as compared with the dissection of a dermic flap from the arm, thigh or elsewhere. Almost no allowance need be made for contrac- tion. In fact, a graft exactly the dimensions of the raw surface to be covered will answer. This graft can be taken from either upper lid, but ordinarily would be taken from the ipsolateral lid. In removing the graft, I do not use a grasping forceps of any kind for fear of bruis- ing the tissue cells. Outlining incisions are made through the dermis of the upper lid. A fusiform or semilunar shaped design is convenient to take. A cataract knife is slid under the skin from the lower incision 446 JOHN M. WHEELER to the upper. The knife is carried by careful sliding motions nearly to one end of the graft. Then it is turned about and carried to the other end, freeing it. The piece of skin is picked up with the fingers and set free. By placing the graft, epithelial surface downward, on a pad wet with warm (body temperature) normal salt solution, any fragments of subcutaneous tissue can be quickly snipped off with the scissors. This is not a tiresome process as it is in the case of an arm graft. Fine silk sutures (No. 1 twisted) impregnated with paraffin are used to stitch the graft in position. The ends should be secured first, and then the margins should have as many sutures as may be needed to hold them in place. No undermining is necessary in order to bring the wound edges together on the upper lid. The raw surface is easily closed over by fine silk sutures, and there need be no fear of subsequent opening of this wound. Dressing. The graft should be covered with rubber tissue, having the slightest smear of sterile petrolatum. I prefer to put the tissue on in two layers with the grains running at right angles, to guard against the possibility of perforations through separation of the tissue fibers. The rubber tissue will prevent the skin graft from getting dry. If a covering other than rubber tissue is chosen, it should be of smooth sur- face, pliable and without perforations. Over the tissue, gauze fluff is packed and secured firmly by adhesive plaster, and then by pressure bandage, which in turn should be secured by adhesive plaster. It is well to put a separate dressing over the other eye, to be left for two or three days, and then to be cut down without disturbing the main dressing and bandage. This should be left for six days, at the end of which time it is removed with the utmost care, and the graft pains- takingly cleansed with damp (not wet) boric acid sponges, and all sutures taken out. At the first dressing the grafted skin will appear pink, not anemic like a graft from the arm. The outlines of the beautiful inlay are hardly seen even at the first dressing. Rubber tissue, gauze dressing and bandage, changed every two days, are con- tinued for another week ; then dressing is no longer necessary, and the graft is kept smeared with a little sterile petrolatum. About three weeks after operation it is well to start massage with petrolatum. This is kept up daily for several weeks. The adhesions between the lids should remain for at least three months. They should be left until all tendency to malposition of the lid has passed. They are then cut with the scissors and no deformity results from them. Plastic Operations About the Eye 447 SEVERE ECTROPION DUE TO BURNS. Occasionally we have to deal with extreme ectropion of all the lids associated with facial burns, and large loss of the cilia and brows. Usually the outer canthus is pulled well down out of position and there may be epicanthal folds. In such cases it may not be feasible to implant true skin grafts, and it is con- venient to resort to epidermis. Fortunately, in these bad burn cases epidermis matches the scarred tissue of the face about as well as true skin from a distant part, and it is possible to cover as large areas as necessary. Operation. Usually general anesthesia is called for in the severe Fig. 3. Operation for severe cicatricial ectropion. Dissection for replace- ment of eyelids completed. Upper lid held by forceps to show areas denuded in margin for intermarginal adhesions. cases. After the preparatory dissection of the eyelids, there is a large exposure for the reception of the epidermic graft. Both upper and lower eyelids are repaired at the same sitting. Fig. 3 shows at the lid margins the little areas which have been denuded of epithelium in prep- aration for the adhesions to hold the lid margins together. These adhesions are important in the correction of all ectropion cases, but especially so in the severe cases where large denuded areas have to be covered. After passing the sutures to secure apposition of the raw areas of the margins, a single large piece of epidermis from the outer 448 JOHN M. WHEELER aspect of the thigh is placed over the lids, overlapping the margins of the denuded areas all around. For this purpose a graft with an area of 9 to 12 square inches may be needed. (It is taken as for restoration of the socket.) No sutures are used but the pressure of a secure dressing and bandage are relied on to hold the graft firmly in place. After placing the skin in position a slit should be made in it just in front of the palpebral fissure to provide for drainage of conjunctival secretion. A slit is also made in the rubber tissue which is placed over the graft (Fig. 4). Dressing and after-care are the same as described for the Fig. 4. Eyelids in position for reception of epidermic graft. Sutures have been passed through denuded areas in lid margins and tied over little plates of rubber. A single epidermic graft has been placed over denuded areas in lids. Slit in graft in front of palpebral fissure. dermic graft. In cases with bad facial scars, especially if there is a tendency to keloid formation, it may be wise to leave the interpalpe- bral adhesions for as long as a year, and it may be necessary to graft a second time if late contraction of facial scar tissue pulls the palpebral fissure out of place. When the work is completed the external canthus should be on a level with the internal. Let me suggest an important precaution in regard to the preparatory dissection of the lids. It is permissible for the denuded areas of the upper and lower lids to com- municate at the temporal side of the palpebral fissure, but it is a mis- Plastic Operations About the Eye 449 take for the surgeon to establish a communication at the nasal side, as a fold will form during the healing process and make a cicatricial epicanthus. This gives a cosmetic blemish for which we have no sat- isfactory operation. If the brows have not been destroyed, it may be worth while to graft from them for cilia lines, before the interpalpebral adhesions are severed. Otherwise artificial lashes may be resorted to. An important question which is apt to confront us in connection with the severe burn cases, is whether to operate early, before the facial burns are healed, or to wait until cicatricial contraction has progressed. I should operate as soon as the physical condition of the patient will allow, even if it means operating again later on. This judgment is based on the importance of protection for the cornea by the lids, which will be held by the adhesions between their margins. In ectropion I now find use for pedunculated flaps only in those cases where there has been loss of bony tissue with a consequent depression to be filled in. Here thickness is called for. A flap can be turned down from the temple or forehead by the well-known methods of procedure, and the thickness can be gauged to suit the needs of the case; that is, where the depression is greatest the flap can be made thickest. RESTORATION OF BROW Dislike for making new deformities and desire for simplicity have kept me from turning pedicled flaps from the hairy scalp or elsewhere in attempts to bring about the formation of new brows. I have used only free grafts. Loss of the brow is usually not complete, and rather satisfactory patch work can be done in some cases by taking from one part of the brow to fill out another, or by taking from one brow to help out its fellow. If one brow is intact and the other partially or wholly destroyed, the intact brow can be divided longitudinally and the lower part trans- planted as a detached graft to the other side. In order to have the hairs of the transplanted graft slant toward the temple, it must be turned upside down. This splitting procedure is not altogether sat- isfactory, as the resulting brows are usually noticeably narrow, and the direction of the hairs in the graft is not ideal. Moreover, some of the follicles are liable to be destroyed in the process. The reason for selecting the lower part of the brow for transplantation is that the skin tissue is much thinner below than elsewhere in the brow and the hair- follicles are shorter. This is true to such an extent that a graft includ- 29 450 JOHN M. WHEELER ing the hairs of the lower part of the brow is wedge-shaped on cross- section, with the apex of the wedge downward. Possibly the most satisfactory way of grafting for an entire brow or a large part of one is to remove a flap of scalp from the occipital region of the desired size and shape and place it in position. The hair-follicles are usually closely placed in the middle of the occipital region, and they are well slanted. Moreover, no visible scar results. One objec- tion to the scalp graft is that the color of the hair may not accurately match the color of the fellow brow. Another objection is that a part of the graft may be lost. The reason for this is that the scalp tissue is thick, and the graft cannot be made thin without injuring the hair- follicles, which are long enough to go entirely through the scalp skin. One cannot transplant thick detached grafts with confidence, as is possible with thin skin grafts. A few suggestions as to the technic of implanting the scalp graft may be offered. Novocain infiltration anesthesia is satisfactory. In preparing the bed for the reception of the graft, a curved incision through the thick supraorbital skin is made in the proper position and of the proper length. Usually the skin is on the stretch on account of the presence of scar tissue and the wound gaps in admirable fashion, so that it may not be necessary to remove any skin in order to get a good exposure of the subcutaneous tissue. The thick scalp graft will not set into the depression made by the skin incision, but will project and its life will be endangered. So a longitudinal incision should be carried along the middle of the exposed area down to the periosteum or near it. Usually it is possible to avoid the supraorbital nerve and vessels. Regeneration of the nerve can be expected, however, if it is cut. In preparation for removal of the graft the scalp area should be shaved, cleansed with alcohol and ether, and painted with iodin. The graft needed is usually rather long and pointed. The curved in- cisions for its removal should slant toward each other, so that a cross section of the graft is like a truncated wedge with base at the surface. This will fit deeply into the depressed exposed area in the brow region, as the sides of this depression will be "banked." In taking a scalp flap there is inevitable destruction of some of the hair-follicles, but with a complete take or nearly that a good mat of hair should result. The graft should be sutured in place and firm pressure applied. The resistance offered by the skull is a valuable help to the pressure dress- ing in getting firm contact between raw surfaces. "Tulle Gras," as Plastic Operations About the Eye 451 recommended by Morax and others, is suitable to lay over the graft before putting on the gauze dressing and pressure bandage. A few layers of vaselin gauze will answer equally well as a covering for the graft. RESTORATION OF THE CILIA LINE There are several types of cases calling for restoration of the eye- lash line. I should like to give four suggestive ideas: 1. In cases such as were mentioned under the head of severe ectropion, usually extensive loss of eyelashes results. Occasionally in Fig. 5. Loss of eyelash line. Eye- lids held together by adhesions. Eye- ball intact. Bed prepared for graft at margin of upper lid. Hairy graft from brow about to be turned and placed at lid margin. Fig. 6. Hairy graft from brow su- tured in position at lid margin. Brow wound closed by sutures. extreme ectropion the upper lid margin is found in the brow, and it is possible to make the releasing incision in the lower part of the brow instead of below it, and so carry down a hair line at the time of the dissection made in preparation for the epidermic graft. This idea is decidedly worth bearing in mind. 2. Let us suppose a case of severe ectropion in which the lid margin is not actually in the brow and so the scheme just mentioned is not feasible, and let us suppose epidermic grafts have covered both upper and lower lids, and the lids are held together by adhesions in front of 452 JOHN M. WHEELER the eyeball. Figs. 5 and 6 indicate the scheme to be recommended. The hairs should be taken as largely as possible from the nasal end of the inferior border, as here they are more numerous than at the temporal end and stand out in better direction. The idea in turning the graft upside down is to bring the hair line as near the lid border as Vv \ Fig. 7. Loss of part of upper lid margin and eyelashes. Eyeball has been removed. Sutures introduced to unroll skin at injured lid margin and attach it to orbital contents. Fig. 8. Graft shown both before complete detachment from brow and after suturing in position at lid margin. possible. A few weeks after the interpalpebral adhesions have been cut the lid margin should be trimmed off evenly close to the new cilia line. 3. In another type the eye may have been lost and a part of the lid margin with the cilia may have been destroyed. In such a case a Plastic Operations About the Eye 453 curved incision may be made near the injured margin and the skin below it dissected up. Then this skin is rolled back and tied down to the fundus of the socket with silk sutures, as shown in Fig. 7. Then a graft from the nasal end of the lower margin of the brow is placed so that the hairs will line up with the remaining cilia as accurately as possible (Fig. 8). It will be seen that the hairs of the graft really over- lie the unrolled skin and so fall in line with the cilia. A little trimming of the margin of the lid may have to be done later. 4. Another possibility should be borne in mind. When skin of the upper eyelid is used for an ectropion of a fellow upper lid or a lower lid, it is feasible to carry the upper graft incision into the lower part of the brow and so carry with the graft a line of hairs to be placed for cilia. The graft below the cilia line may be made as large as desired. If this idea is used, in order to bring the hair line to the lid margin, the graft is carried directly to the denuded area, without turning, for the lower lid; but for ectropion of the upper lid the detached graft has to be turned upside down. It would be absurd for one to expect a perfect line of eyelashes to result from any attempt at substitution, but patients are delighted with the imperfect results which can be obtained by the schemes suggested. NOTCH AT LID MARGIN A condition which we have to deal with occasionally is a deformity associated with laceration of the tarsus, manifesting itself in angulation of the lid margin and in destruction and distortion of cilia at the site of injury. This may be associated with ectropion or other deformity, but should be recognized as an entity. In a paper entitled "War Injuries of the Eyelids," 1 I referred to a method of handling this con- dition and called the little procedure the " Halving Operation." The illustration (Fig. 9) gives the appearance of the deformity and the scheme of correction. Operation. The little mass of scar formation around the laceration of the tarsus is excised, and the tarsal flaps are cut cleanly across to give accurate apposition. Assuming that the deformity is in the upper eyelid, care should be taken to excise fully as much tarsus at the upper margin as at the lower in each flap of the tarsus. This is important, and even a slight overcorrection of the notch can be obtained, at the surgeon's discretion, by diverging the tarsal incisions from the lid mar- 1 Trans. Amer. Ophth. Soc., 1919. 454 JOHN M. WHEELER gin, so as to make the tarsal flaps slightly shorter above than below. The skin and orbicularis are cut so as to make a flap on one side, and a rectangular area of tarsus is exposed on the other. If necessary, to prevent tension on the wound, especially if the eyeball has not been removed, a canthotomy should be performed, and the branch of the external canthal ligament should be severed to release the tarsus. The little tongue of skin is trimmed enough for adjustment and a small triangular piece of skin may be removed above to avoid puckering. The conjunctiva and tarsal flaps are first sutured. A mattress suture is carried through the flaps, and tied after passing through a small rubber plate cut from sterile tubing. Sutures are introduced to give good apposition of the skin flaps. The mattress suture should be Fig. 9. Scheme for correction of notch of eyelid. removed in two or three days, and the others about five days after operation. An important point is that tarsal wound and skin wounds should never be in the same position, but should be placed in such a way that there is overlapping. Thus, what is known in carpentry as halving is accomplished, and union is assured, even if there is a little sloughing of the skin. Furthermore, recurrence of the notch formation is pre- vented. After healing there is no break in the continuity of the lid margin or in the row of eyelashes. In handling notch cases different short-cut procedures have been tried, but the " halving" method has been the only satisfactory one in my hands. In notch cases sometimes it is necessary to dissect out bands of scar tissue which lead from the tarsal laceration to the margin of the orbit. Plastic Operations About the Eye 455 There should be complete release, so that the lid margins will fall ea'sily and completely together. TRAUMATIC COLOBOMA OF LOWER EYELID NEAR INNER CANTHUS A rather common injury is that of laceration of the lower eyelid through the canaliculus, extending downward and outward more or less accurately along the lower orbital margin. Improper primary healing of such a wound results in a coloboma near the inner canthus and ectropion of the lid near the coloboma. Complete correction of this deformity can be obtained by a simple manceuver. Fig. 10 is Fig. 10. Operation for correction of coloboma of lower lid near inner canthus. To show sutures ready to tie at apex of flap. from an unpublished series of drawings and is an attempt to show the way the dissection is made and the way the sutures are placed to make the correction. Scar tissue at and near the coloboma is dis- sected away. An incision is carried from the coloboma downward and outward. The attachment of the lower lid to the external canthal ligament is severed, and if necessary, another incision is carried out- ward and slightly upward from the outer canthus. The flap is under- mined as much as necessary so that its apex can easily be carried to the inner canthus. The amount of dissection necessary will depend upon the amount of tissue loss at the coloboma. Sutures are placed 456 JOHN M. WHEELER diagonally along the incisions in such a way as to advance the whole flap and have as little pull as possible for the sutures at the apex of the flap during the healing process. Of greatest importance is the adjust- ment of the tissues at the apex of the flap. The small amount of skin just external to the inner canthus is carefully and completely under- mined. The skin and orbicularis are stripped from the anterior sur- face of the tarsus so as to expose 4 or 5 mm. of the tarsus. A suture is carried through the exposed tarsus, and then it is carried well into the internal lateral ligament or into the deep fascial tissue behind it so as to get a firm hold. A mattress suture mounted with two needles is carried through the exposed tarsus, then through the flap of skin which has been dissected up near the inner canthus (Fig. 10). When the sutures are snugly tied the apposition will be secure and the lid will lie well back against the globe and well up to the proper level, or even high enough to be in a position of overcorrection. Without this careful adjustment and definite overlapping of raw surfaces one can- not be sure of complete obliteration of the deformity. RESTORATION OF OBLITERATED SOCKET Many suggestions have been made for making new sockets after obliteration, and many disappointments have resulted from various sorts of procedures. Without entering into a discussion of the relative merits of the different operations designed for socket restoration, let me speak briefly of the method which I have adopted, and which I can recommend with confidence. Epidermis has been chosen as the most satisfactory tissue for lining the cavity, as it will give a thin, pliable lining, free from hairs and an excess of oily secretion. The lateral aspect of the thigh is usually the most convenient place from which to take it. No elaborate prepara- tion is necessary. The part from which the epidermis is to be taken is shaved and cleansed with alcohol and ether. Then with a long- bladed knife or razor with a keen edge, a large piece of epidermis is taken. For taking the graft I am now using the Stille (Norwegian) graft knife, and an interested barber gives it an exquisitely sharp edge, without which it is impossible to get a large graft free from per- forations and free from true skin. This knife has a long blade, and is like a large table knife. The method adopted has been previously described in detail. 1 If the lid margins are adherent, they are separated by an incision. 1 Amer. Jour. Ophth., July, 1921. Plastic Operations About the Eye 457 The dissection is then carried out in such a way as to separate the lids from the orbital contents. The following points should be borne in mind: 1. The dissection must be kept superficial so that in front of the dis- secting knife or scissors there is only lid tissue, i. e., only skin, orbic- ularis, the thin fascia of the lid, and the tarsus. It is not necessary to save the tarso-orbital fascia with the lid. Carrying the dissection back into the orbital tissue is probably one of the most common causes of failure. 2. Not only the superficial plane of the dissection, but the extent and limitation of the dissection are of importance. Temporally and below, the dissection should be carried well to the orbital margin or even 1 mm. or 2 mm. beyond it, as the graft must adhere to the periosteum of the anterior aspect of the orbital margin. On the nasal side the dissection should be extended to the anterior crest of the lacrimal groove and to the orbital margin above it. In dissecting at the inner canthus the caruncle should be saved if it has not been destroyed. The graft will adhere to the posterior surface of the car- uncle and give it a permanent lining. In the division of the tissues above, the dissection should be carried behind the orbital rim but not necessarily to the roof of the orbit. In some cases the levator pal- pebrae superior is can be saved. 3. In preparing the bed for the graft all cicatricial and granulation tissue should be removed. Excision of granulation tissue is especially important as the contraction of such tissue may result in contraction of the socket. Reduction in size of the newly made socket is due to contraction of the underlying tissue rather than to contraction of the skin itself. 4. A common fault which manifests itself after restoration of the socket is that of too great thickness of the lid margin. This deformity can be obviated by cutting away tarsus. If the skin graft must ex- tend completely to the margin of the eyelid, the tarsus may be split and thinned. If the graft is to extend nearly to the margin, sufficient tarsal plate may be cut away so that the graft will set in as an inlay In any case, enough tarsus should be left to support the cilia, but not necessarily any more. A form should then be molded to fit the cavity. Dental impression compound is ideal for this purpose. Ordinarily for full restoration of the socket, the dimensions are approximately as follows: length 40 mm. to 45 mm., width 30 mm., thickness 5 mm. The ideal graft for socket restoration is one without perforations 458 JOHN M. WHEELER which is made up of epidermis only, free from layers of true skin, and large enough to be wrapped around the form of impression compound with generous overlapping. This means a graft 3}/ to 4 inches long and about 3 inches wide. Fig. 11. Restoration of obliterated socket. Eyelids retracted to show dis- sected cavity for socket. Orbital margins indicated by curved dotted line above. Anterior view and cross-section of form of dental impression compound covered with a single epidermic graft for lining of new socket. The graft of epidermis is immediately wrapped about the form of impression compound, raw surface outward, and overlapped on the surface which is to be anterior. The form, completely covered with epidermis, is forced into the socket cavity (Fig. 11). It is not nec- essary to remove small blood-clots before placing it as they will not Plastic Operations About the Eye 459 prevent a take. The overlapping portion of the graft is placed for- ward so that if the edges are disturbed by manipulation they can be carefully replaced through the palpebral fissure so that every part of the form will be covered. No sutures are used. A pressure bandage is applied, and over this adhesive strips. Very firm pressure is of importance to secure accu- rate contact at all points and to keep the cavity absolutely obliterated. This first dressing is left in place for a week. The form is left in place and is not touched for about three weeks. It is then removed and left out permanently. The artificial eye may be introduced at any time. If the surgeon has been successful in carrying out the technic, the result will be a permanent socket, extending well beyond the canthi and of sufficient dimensions all around. The lids will be normally thin and pliable, and the thin-walled socket will not prohibit motility of the stump and artificial eye although the movements of the eye will be somewhat less than those following ordinary enucleation. An interesting development is that usually lacrimal secretion will find its way into the new socket and maintain a comfortable moisture. As far as I know, trouble never results from activity of the lacrimal gland. DISCUSSION DR. W. E. LAMBERT (New York City) : It has been my privilege to witness many of the operations which Dr. Wheeler has performed, and to follow up the end results, and I simply wish to express my admiration for the skill which he has displayed. He is rather modest in saying that the restoration of the lid margin adheres not particularly well. I recall one case which showed me that it was wonderful. Not only does it require a great deal of skill and painstaking, but I think one who does this kind of surgery must have a certain temperament. DR. JOHN E. WEEKS (New York City) : In former years, before asepsis was thoroughly understood, the great question involved in all of these plastic operations was how best to get the flap to take what sort of a flap would be most liable to give the results desired. Reverdin, as we know, first taught the use of flaps without a pedicle by using minute particles of skin. Then Wolf followed with large skin flaps, and when these flaps were put in position with- out infection they usually took well, flaps with pedicles being safer than those without pedicles. The recent opportunity for great experience in plastic operations about the face, with our knowledge of asepsis, has served to revolutionize our ideas regarding plastic surgery about the eye and face, and our idea that flaps with pedicles must be used has changed entirely; our idea that no skin must be used has changed. With a knowledge of what has preceded the modern ophthalmologist bases his operation on the evidence that has been accumulated. Dr. Wheeler has not been hampered by previous 460 J. N. ROY knowledge. He has overstepped the boundaries laid by men who have preceded him, and has produced results far superior to those previously obtained. The principle of operating soon after the injury has occurred is one that he has changed entirely. Previously we had the impression that it was better to wait until the cicatrix was fully formed before we attempted to do plastic surgery. Dr. Wheeler has demonstrated that we may operate early and get most excellent results. DR. J. M. WHEELER (closing) : I have been asked many times how a large epidermic graft such as I have described can be taken. It requires some training and some patience to get the sort of graft that is necessary to cover a large area. I have found that the instrument makers will not give a keen enough edge to a razor or knife to take the proper kind of graft. The edge must be extremely keen and evenly keen. If there is any place that is not sharp, you are sure to have trouble. An interested barber can get a keen edge on a grafting knife if you explain to him what you want, and he will take special care because he will feel that it is the most important work he has ever done. LAGOPHTALMIE BILATfiRALE CONSECUTIVE A LA PERTE ACCIDENTELLE DE LA PEAU DU FRONT, ET DU CUIR CHEVELU. BLfiPHAROPLASTIE DOCTEUR J. N. ROY Professeur agrege a 1'Universite de Montreal, Medecin de l'H6tel-Dieu Montreal, Canada OBSERVATION Le 28 octobre 1920, la soeur M. J. agee de 37 ans, vient nous con- suiter pour une lagophtalmie double, remontant a pres d'un quart de siecle. Elle raconte qu'a 12 ans, un jour qu'elle travaillait dans une buanderie me*canique, sa chevelure fut prise dans une courroie qui la souleva jusqu'au plafond. Sa tete etant venue en contact avec un soliveau, elle fut instantane'ment scalpe"e, et retomba sur le plancher, sans avoir perdu connaissance, et sans avoir a de"plorer de fractures. La plaie frontale se limitait aux sourcils qui etaient arrach^s, celle de la region temporale faisait une encoche a la partie superieure du pavilion des oreilles, surtout a droite, et a part un peu de cheveux qui restaient a la nuque, toute la peau du crane e"tait disparue. Les paupires supe*rieures, n'e"tant plus attire*es en haut, se retournrent et recouvrirent les fentes palp6brales. La douleur fut naturellement tr&s vive, et Phe'morragie considerable. Des linges humides froids Lagophtalmie Bilaterale Blepharoplastie 461 furent immediatement appliques en attendant le medecin. A son arrivee, celui-ci fit un pansement antiseptique a 1'acide phenique. Durant les quatre semaines qui suivirent 1'accident, des hemorragies assez frequentes se produisirent. Le perioste etait partout intact, et les pansements humides a 1'acide phenique furent continues pen- dant trois mois. Apres cette periode, ils ne furent faits que la nuit, et le jour on appliquait de 1'acide borique en poudre, tout en laissant le crane a decouvert. Peu de temps apres ce nouveau genre de panse- ment alternatif, un eresipele se declara, et faillit emporter la malade. Environ six mois aprs le traumatisme, la plaie commenga a s'ame- liorer et les paupieres, grace aux pansements compressifs appropries, se replacement petit a petit; toutefois les cantus externes eurent des le debut une tendance a etre attires en haut. Cette traction s'aug- mentant toujours par 1'epidermisation de la peau du front et de la tempe, fit qu'a la fin de la premiere annee, la malade ne pouvait plus fermer les yeux. Huit ans apres 1'accident, une keratite double par lagophtalmie se declara, surtout localisee a 1'oeil gauche. L'oculiste consulte prescrivit le traitement ordinaire, sans oublier naturellement le bandeau que la malade ne cessa jamais de porter la nuit depuis cette epoque, et la guerison fut complete au bout de deux mois. La region fronto-temporale fut tres lente a guerir, puisqu'elle prit cinq ans a se cicatriser. Pendant cette periode, la lagophtalmie augmenta toujours, et les paupieres superieures devinrent presque immobiles. Les oreilles furent attirees en haut. La region occipitale s'epidermisa assez rapidement. Quant au vertex, il fut particulierement rebel a la guerison, bien que les pansements humides a 1'acide phenique fussent repris et toujours continues depuis son infection eresipelateuse. Dix-huit ans apres 1'accident, un eczema envahit la region fronto- temporale, et prit une anne"e avant de disparaitre. Comme a ce moment la plaie du crane semblait vouloir s'eterniser, un chirurgien pratiqua la greffe de Thiersch. II fit aussi une incision dans la region du cantus externe de 1'oeil gauche, des tractions et des pansements appropries, dans le but d'abaisser la paupiere superieure correspon- dante. Malheureusement ces deux interventions ne donnerent aucun resultat, car une seconde infection se declara, et les greffes furent elimine'es. Un mois apres cette premiere tentative, le chirur- gien essaya sur le vertex la greffe dermo-epidermique en flots, qui cette fois fut tole're'e. Pendant les six annees qui suivirent, 1'ame'liora- tion progressa tres lentement, sans toutefois donner un resultat complet. A plusieurs endroits, la cicatrisation ne voulait pas se faire, 462 J. N. ROY des croutes se formaient pour tomber ensuite, et malgre les panse- ments humides, il y avait toujours de la suppuration. A 1'examen des yeux, nous constatons deux petites taies des cornees. La vision est cependant excellente apres correction d'un l^ger astig- matisme hypermtropique. Quant aux paupieres, il existe une lagophtalmie mecanique des plus considerables. Les cantus externes, dcolles de la conjonctive oculaire, sont tres fortement attires en haut, et la traction est encore Fig. 1 plus prononcee a droite qu'a gauche. L'aspect de la malade rappelle, d'une maniere exageree, le type caracteristique de la race mongolique. Lorsqu'elle fait un effort pour fermer les yeux, les paupieres bougent a peine. II n'y a pas d'ectropion. Les sourcils sont entierement disparus. La peau du front et des tempes est tres mince, sans tissu adipeux sous-jacent, et parcourue par un grand nombre de petits vaisseaux sanguins superficiels. Lagophtalmie Bilaterale Blepharoplastie 463 L'oreille gauche est remontee de quinze millimetres environ, et la droite de deux centimetres. II y a sur le vertex, encore incompletement cicatrise, une dizaine de petits endroits remplis de bourgeons, ou recouverts de croutes. La region occipitale est parfaitement guerie, et il existe huit centi- metres de cuir chevelu a la partie infer ieure de la nuque. Apres nous avoir fait part des ennuis resultant de la lagophtalmie, la malade nous explique jusqu'a quel point est desagreable la sensa- tion de traction continuelle de ses cantus extern'es. Aussi est-ce avec une certaine anxie"te qu'elle nous demande si nous pouvons la guerir. Sur notre reponse affirmative, et apres 1' avoir mise au courant de ce qui devait etre fait dans son cas, elle accepte immediate- ment Foperation qui, pour des raisons personnelles, est fixe"e au 4 decembre. A cette epoque, 1'apparence de la patiente est celle indi- quee par la photographic No. 1. OPERATION Apres avoir decide de commencer par le cote gauche, toute la partie sur laquelle nous devions intervenir etant parfaitement sterilisee, nous faisons a la region fronto-temporale et sur la joue, une serie d'injections de novocaine-adrenaline. Une incision de cinq centi- metres environ est ensuite pratiquee, se terminant un peu en bas et a onze millimetres du cantus externe. Cette incision est tres legere- ment concavo-convexe, a direction inferieure, et se trouve a traverser 1'emplacement du tiers externe du sourcil arrache. Apres avoir largement disseque toute la region environnant le cantus, nous reus- sissons a abaisser sumsamment les paupieres pour leur donner une posi- tion tout a fait horizontale. Ann de combler cette plaie entr'ouverte, nous prelevons sur la joue un lam beau de sept centimetres environ de longueur sur quinze millimetres de largeur dans son plus grand diametre qui, une fois detache, est mis en place. Dans le but d'im- mobiliser le cantus, et d'empecher qu'il remonte de nouveau pendant la cicatrisation post-operatoire, nous Fattirons en bas au moyen d'un catgut passe dans le perioste de la region malaire. Le lambeau fronto-temporal est soigneusement sutture a la soie, et apres avoir decolle la peau adjacente a 1'incision jugale, les levres de la plaie sont facilement coaptees et maintenues en place au moyen de crins de florence. Finalement nous appliquons un pansement legerement serre, et le plagons de telle sorte que la compression se fasse de haut en bas. Les suites operatoires sont des plus simples, et la plaie guerit par premiere intention. 464 J. N. ROY Comme la malade est tres de"sireuse d'etre retablie le plus tot pos- sible, nous intervenons a droite dix jours apres la premiere operation. La technique suivie e"tant tout a fait semblable pour les deux cotes, nous ne croyons pas devoir la de"crire de nouveau. Cependant comme le cantus externe e"tait un peu plus releve a droite qu'a gauche, sa dissection fut plus laborieuse pour parvenir a un abaissement com- plet. Encore cette fois, les suites ope"ratoires eVoluent sans incident et nous obtenons une reunion par premiere intention. Un soin par- Fig. 2 ticulier est apporte" aux pansements, et grace a la plus ou moins forte compression pratique"e de haut en bas, nous augmentons 1'effet de notre operation, et re*ussissons a avoir deux fentes palpebrales par- faitement symetriques et horizontales. La malade pent maintenant fermer les yeux sans effort, et comme le releveur des paupi^res su- pe"rieures n'avait pas e"te l^se lors de 1'accident, elle peut aussi les ouvrir normalement. La conjonctive palp6brale des cantus externes est en contact avec la conjonctive oculaire, et il n'existe aucune trac- Lagophtalmie Bilaterale Blepharoplastie 465 tion disgracieuse de cette partie. A la fin de decembre la patiente est assez bien pour retourner dans sa communaute. Naturellement nous avions profile de son sejour a 1'hopital pour trailer ses petites plaies craniennes au moyen de pansements humides, de curettages des bourgeons et d 'applications de teinture d'iode. Ce traitement, continue dans la suite, amena une forte amelioration Fig. 3 sans toutefois donner une guerison complete. Pour atteindre ce but, il faudrait, croyons-nous, pratiquer encore quelquesgreffes dermo- epidermiques, vu la tres mauvaise nutrition de tout le tissu cicatriciel cranien. Le 26 fevrier et le 8 mars 1921, nous faisons sous anesthetic locale, une petite autoplastie des pedicules de nos lambeaux indiens. Comme ceux-ci avaient ete tailles avec assez de precision, et qu'il n'existait pas de bourrelets cutanes a la region sourciliere, nous ne sommes pas obliges d'y faire de retouches. 30 466 J. N. ROY Apres gue"rison complete de ces deux plaies, nous proposons a la malade de tenter la greffe des sourcils que nous aurions prelevee sur ce qui restait de cuir chevelu a la partie inferieure de la nuque. Etant donne" que son lambeau frontal, porte dans sa communaute", en mas- que 1'absence, et qu'elle est enchante*e du resultat operatoire obtenu, elle refuse cette derniere intervention. Les paupieres, sur un plan bien horizontal, se ferment avec la plus grande facilite, et les yeux s'ouvrent sans effort ,d'ailleurs comme il peut 6tre constate sur les photographies 2 et 3, prises le 7 avril. L'operee, revue en de"cembre 1921, est toujours dans le meme etat, et a peine existe-t-il quelques traces de ses incisions cutanees. En publiant cette observation, nous n'avons pas la prevention de preconiser une me*thode nouvelle de blepharoplastie. Nous nous sommes simplement inspire de 1'experience personnellement acquise pendant la re*cente guerre, en fait de chirurgie de la face et des pau- pieres, en choisissant 1'unique precede rationnel dans le cas present. En effet, avec la greffe dermo-e'pidermique, nous aurions probable- ment couru vers un echec, car, meme si elle avait ete pratiquee d'une maniere impeccable au point de vue de Pasepsie et de la taille d'un lambeau suffisamment grand, il ne faut pas oublier que notre intervention portait sur un tissu tres mince et mal nourri. Ann de sauvegarder Pesthetique de la face, nous aurions pu nous servir du precede de Snydacker de Chicago, en prenant un lambeau pedicule sur le cou. Toutefois ce precede aurait produit un trau- matisme operatoire beaucoup plus considerable que celui employe chez notre patiente, et n'aurait pas eu sa raison d'etre dans le seul but d'eviter une cicatrice jugale maintenant a peine perceptible. Comme il etait nullement question dans notre cas de recourir a la methode italienne, il nous restait done, pour combler 1'espace pro- duit par 1'incision et 1'abaissement du cantus externe, qu'a prendre sur la joue, au voisinage immediat de la plaie, un lambeau approprie, ce qui revenait a choisir la me'thode indienne. D'ailleurs les differents precedes de blepharoplastie sont maintenant bien connus, surtout depuis les remarquables travaux de Morax de Paris, qui est certaine- ment Poculiste possedant la plus grande experience en chirurgie pal- pebrale. Nous-memes avons eu Poccasion de publier un certain nombre de memoires sur les greffes osseuses et cartilagineuses, que dans la pre*sente communication, nous passerons sous silence et sur les autoplasties de la face en general, dans lesquels nous avons expose" les meilleures me'thodes & pre'fe'rer dans chaque cas particulier. Lagophtalmie Bilaterale Blepharoplastie 467 Pour celui-ci, nous attirons 1'attention sur le fait de nous etre servi de deux catguts passes dans les cantus et attaches au perioste malaire, ce qui a grandement contribue a les stabiliser. Le pansement, corn- prime de haut en bas, a egalement augmente 1'effet de notre interven- tion. Si la malade en avait manifesto le desir, nous aurions volontiers essaye de lui greffer des sourcils, sans toutefois etre certain du succes, etant donne la mauvaise qualite de la peau et des tissus sous-jacents, qui auraient eu le role de nourrir ces greffes. Aussi, en presence du resultat obtenu, nous avons lieu d'etre satisfait du precede chojsi. BIBLIOGRAPHIE J. P. de Carvalho: Autoplastie palpebro-faciale a lambeau p&iicule" cervical (pro- cede de Snydacker) avec ou sans utilisation du pedicule (technique modifie par Morax), These de Paris, 1918. - Traitement de certaines mutilations palpebrales de guerre par le precede autoplastique de Snydacker-Morax, Annales d'Oculistique, octobre, 1919. M. Kalt: Restauration d'une paupiere totalement detruite par le moyen d'un lambeau a double face, Annales d'Oculistique, septembre, 1919. V. Morax: L' Autoplastie palpebrale ou faciale a 1'aide de lambeaux pedicules empruntes a la region cervicale (precede de Snydacker) et 1'autoplastie en deux temps avec utilisation du pedicule, Annales d'Oculistique, Janvier, 1908. Plastic operations on the orbital region including restoration of the eye- brows, eyelids and orbital cavity. The Bowman lecture, Transactions of the Ophthalmological Society, xxxix, 1919. V. Morax et R. Beal: Nsevus pigmentaire du front et du sourcil avec dermoi'de conjonctival. Autoplastie fronto-sourciliere en deux temps a lambeau pedicule emprunte a la region cervicale, Annales d'Oculistique, Janvier, 1908. G. DuPont et J. N. Roy: Cancer des paupieres et de 1'orbite. Autoplastie, Le Journal de Medecine et de Chirurgie, Mars, 1910. J. N. Roy: Autoplastie de la face pour un epithelioma des paupieres, Le Journal de M6decine et de Chirurgie, Mars, 1908. Quelques cas de labioplastie (chirurgie de guerre), L'Union Medicale du Canada, avril, 1919. Perforating Gunshot Wound of the Face with Extensive Destruction of the Superior Maxillae (War Surgery), The Laryngoscope, February, 1920. La autoplastia adiposa facial (cirurgia de la guerra), Cr6nica medico- quinirgica de la Habana, Julio, 1921. Plaie penetrante du nez. Autoplastie avec lambeau indien (chirurgie de guerre), L'Uni6n medicale du Canada, aout, 1921. E. F. Snydacker: A Plastic Operation of the Eyelids by Means of Skin Flaps Taken From the Neck, Archives of Ophthalmology, January, 1906. Lidplastik mit gestieltem Lappen vom Halse, Monatsblatter fur Augen- heilkunde, Januar, 1907. LIGHT-SENSE: THE PRACTICAL SIGNIFICANCE OF ITS VARIATIONS: SIMPLE TESTS FOR DETERMINING THEM ARCHIBALD STANLEY PERCIVAL, M.A., M.B., B.C. Camb. Senior Surgeon to the Newcastle-on-Tyne Eye Infirmary Newcastle-on-Tyne, England I deeply regret that I have been unable to attend this International Congress and that I have missed this opportunity of learning so much from ophthalmologists of world-wide reputation. I would now express my thanks to the Committee for allowing me to present this paper for your criticism in my absence. Light-sense is the faculty of recognizing different luminous intensi- ties. Too little attention has been paid to the sensibility of the eye to variations in the light stimulus, although this may be of extreme im- portance in certain services. We are asked for a report on a candi- date's sight, and we send a report of his visual acuity; i. e., of his macular form-sense (without and with correcting glasses, should he require any) . A man may have a visual acuity of 6/6 and yet unless we examine his light-sense we may miss the fact that he is night- blind. Of what use is such a man, when on watch at sea, in detecting an object, whether a derelict or an iceberg, in the ship's course at night? You will all have noticed at nightfall, when there is no moon, that as the light begins to fail that red colors become much darker, and presently a red geranium will appear quite black and the grass grayish, although yellow and blue flowers can still be seen ; for a time the blue flowers appear extraordinarily brilliant, as all other colors are unrec- ognizable, and then finally, as the darkness deepens, blue disappears, and one becomes totally color blind. This successive disappearance of colors is called Purkinje's phenomenon. When this stage of dark-adaptation, or scotopia as it is called, is reached, one can still dimly see objects by their differing depths of grayness, but it will be found that one sees best by looking a little to one side of them. Arago first called the attention of astronomers to 468 Light-sense: Simple Tests for Determining 469 this point, telling them that they could best get a glimpse of a very faint star by looking a few degrees away from it. It will be found that in complete scotopia the fovea is a blind spot; i. e., there is a central scotoma in the rod-free area of the retina. Normally with full illumination the visual acuity or form-sense diminishes very rapidly from the fovea toward the periphery. With a foveal acuity of 6/6, at 5 distance the acuity is 6/24, at 10 4/60 and so on. In a very dim illumination light sense is absent at the fovea, and is at a maximum about 10 from the fovea. Fovea 5 10 15 Form-sense 6/6 6/24 4/60 2/60 Full illumination Light-sense Good Max. Good Dim illumination Now the fovea subtends an angle of about 1 and the rod-free area an angle of about 3 at the second nodal point of the eye; beyond this area rods appear in increasing numbers and cones become less and less as one proceeds towards the periphery. One is, therefore, led to think that rods, or something associated with rods, must be the percipient elements for light-sense. Comparative anatomy supports this view. With one exception all nocturnal animals possess an excessive number of rods which are espe- cially long, and a very ill-developed fovea, whereas all diurnal animals have a well-developed fovea and a far greater number of cones. A very striking example of this peculiarity is found in the family of Saurians. All the diurnal lizards (e. g., the chameleon) possess only cones, while the nocturnal lizards or geckos have only rods. The exception mentioned above is the nocturnal tortoise which has only cones; but the tortoise is peculiar, it moves so slowly that it can neither escape from its enemy nor pursue its prey, and it is quite possible that it may be guided to the insects and plants it eats by scent alone. When we pass from bright sunlight to a very dimly lighted room we can see nothing until our eyes have become scotopic or adapted to the dark. In order to obtain full dark -adaptation it is necessary to remain in an absolutely dark room for three-quarters of an hour or so, and then some very curious phenomena are found. In scotopia the light- sense is about twice as great with both eyes as with only one, again if 470 ARCHIBALD STANLEY PERCIVAL an object be illuminated by a dim composite white light the retinal sensibility is proportional to the square root of the area stimulated. In light-adapted eyes there is no such binocular summation of stimuli, nor, if the retinal area stimulated exceeds I', is there any increase of brightness from stimulating a larger area. Prof. E. M. Barnard some years ago caused great consternation among the pundits of ophthalmology owing to their ignorance of this fact. He found that he could detect a wire at such a distance that its diameter only subtended an angle of 0'.44". Most people jumped to the conclusion that his minimum visual angle was less than half a second and that it was his form-sense that was being tested. The minimum visual angle for form-sense is 53", and for convenience is usually assumed to be 1', so many discredited his observation. This was absurd for Prof. Barnard is known throughout the world for his reliable and accurate observations at the Yerkes Observatory. We can see that it has nothing to do with his form-sense, it was only a proof of his great sensibility to light difference. If you try, as I have done, putting up a fine wire 16 feet long horizontally against the sky, you will see it quite easily at a considerable distance, but if you block out from your view all but a foot of it, you will not see it at all, as its effect on your retinal sensibility is only one-fourth of what it was, thus showing that as it obeys the square root area law it must be a light- sense, not a form-sense, test. The subject is a very difficult one, as most of our so-called form- sense tests are really composite tests of our light-sense also; as, for instance, especially the common dot tests and even Landolt's excellent broken ring tests. Now visual purple or rhodopsin occurs according to Kiihne in the rods only, and there is good evidence to show that rhodopsin plays a very important part in the physiology of light-sense. When a spec- trum of very low intensity is viewed in the dark by a scotopic eye, it appears as a colorless gray streak, the brightest part of which is in the green ( X = 5300 A. U.) and not about X = 5800 A. U. in the neighbor- hood of the D line, as is the case in the normal photopic eye. The luminosity curve seems to be bodily shifted toward the violet end of the spectrum as the red end is shortened, it is in fact exactly similar to the luminosity curves of the totally color blind. Then again the bleaching effect of light on a frog's rhodopsin is greatest when it is of wave length 5300 A. U. (in the green). For these and further details I would refer every earnest inquirer to Parsons' excellent "Color Light-sense: Simple Tests for Determining 471 Vision" (published at the University Press, Cambridge), to which much of this paper is due. You will, however, be wearied with all this academic stuff, and be anxious to know what practical bearing it has on diagnosis, so I turn now to this aspect of the subject. Light-sense is tested in two different ways : (1) The discovery of the smallest quantity of light that can be recognized on a black back- ground; this is called the light minimum test, and is always referred to as L. M.; and (2) the smallest difference of illumination that can be appreciated between two sources of nearly equal luminosity. This is called the light difference test and is always denoted by L. D. Now the important practical point is that the sense for L. M. is always most affected if the receptive part of the retina is most impli- cated; i. e., in affections of the bacillary layer, the visual purple, and the choroid on which the efficiency of the visual purple depends; whereas the sense for L. D. fails if the conductive part of the visual function is primarily at fault. For instance, in optic neuritis and in retrobulbar neuritis L. D. is at fault. An easy memoria technica is to associate L. D. with o. d., the optic disc, but I wish to emphasize the point that L. D. fails also when the nerve fibrils in the retina are chiefly affected. This I have only recently found out. In all previous publications that I have seen on the subject it has been stated that defective light difference was diagnostic of a lesion in the optic nerve. This hasty assumption was no doubt due to the very troublesome apparatus that was used for testing light-sense. With my simple little rotating disc the whole examination need not take longer than three minutes, and so more experience of the diagnostic value of light-sense phenomena can be gained in a week's hospital practice than could be formerly attained in a year, unless one's whole time were devoted to the subject. I long ago found that toxic amblyopia was always associated with a L. D. defect, and yet we most of us suspect the lesion to be in the ganglionic layer of the retina. It was Dr. Traquair, to whom I pointed out my difficulty, who suggested the association of L. D. defects with lesions of the conducting apparatus instead of simply confining them to those of the optic nerve. I have verified this suggestion by finding L. D. defects in several cases of retinitis. I now think that if the super- ficial layers of the retina are affected a L. D. defect will be found, but if the deeper layer (of the rods and cones) or if the choroid be at fault there will be a L. M. defect. 472 ARCHIBALD STANLEY PERCIVAL In all the cases of early glaucoma that I have examined in this way, I have always found a L. M. defect as the earliest symptom, and that it was afterwards followed by a L. D. defect. I suggest as an explana- tion of this that the bacillary layer is more sensitive to slight pressure than the* nerve-fibers. My observations need most careful confirma- tion, and I would be exceedingly grateful to any of you if you can confirm or refute them. It is most important to obtain a really re- liable indication of the first onset of chronic glaucoma, and I believe that the light-sense test will be found to be far more trustworthy than any single tonometric reading. I think that too much reliance is now placed upon the tonometer; we all know that there are fairly wide physiologic variations from what is regarded as the standard reading. On physical grounds the reading must depend upon the stiffness of the cornea, on the size of the eyeball, etc., as well as upon the tension of its contents, so that although a series of tonometric readings taken every week on the same case has a very great value, undue weight should not be given to one isolated observation. In cases of early cataract or hazy media when no details of the fun- dus can be seen with the ophthalmoscope, it is often of extreme im- portance to obtain some indication of the condition of the structures at the back of the eye. An examination of the light-sense of the patient helps us out of the difficulty. If you view these rotating discs through dark-tinted glasses, you will find that both your L. M. and your L. D. perception is as good as without the dark glasses. This is no doubt due to the partial scotopia induced by the dark glasses. If the obscuration is very great, the L. M. and the L. D. perception will fail almost equally. Two months ago I was consulted by a new patient for cataract who told me that now she was quite sure that her right eye was ready for operation. With the ophthalmoscope I could only see a very dim red reflex, but on testing her light-sense I found that both L. M. and L. D. perceptions were very defective but especially her L. M. sense (L. M. less than 12.5, L. D. = 50, according to my nomenclature where the standard is L. M. = 200, L. D. = 100). I concluded that there was probably a macular hemorrhage present, as projection was good, or fairly good. Needless to say I did not recommend an opera- tion on that eye, and it was the light-sense test that saved me from a disastrous operation. We know that, unlike form-sense, light-sense is fairly good even to Light-sense: Simple Tests for Determining 473 the periphery of the field, and this peripheral or rod vision is of far more importance than most people think. All must have noticed how very readily one notices a movement of any object in the peripheral field, and so the eyes are turned in that direction to see clearly with the maculae what it is. Indeed, as the projection from the periphery is so good it is often unnecessary to turn one's eyes toward the object. In a town one avoids bumping up against passers-by not by macular vision but by peripheral or rod vision, i. e., by light-sense not by form- sense. Without good light-sense one will not see what to look at. The British Board of Trade ordains that seamen should pass a very high standard of tests for macular visual acuity, but pays little regard to light-sense. Quickness of sight to see an iceberg in twilight, for in- stance is what is wanted, not ability to determine details about its shape that subtend angles of one minute. Light-sense is the most primitive of the visual functions and is, therefore, the last to be lost in ordinary cases of amblyopia. At any rate in children with an amblyopic squinting eye in which the form- sense may be diminished to 6/36 or even less, its light-sense will usually, if not always, be found very good, often better than in the normal eye; however, in later life this extraordinary light perception seems to be lost. There are some curious points about night-blindness that I have not the time here to discuss, for these and other matters I would refer you to a paper of mine on Light-sense published in the Transactions of the Ophthalmological Society of the United Kingdom, vol. xl, 1920. PERCIVAL'S LIGHT-SENSE TESTS The test can be made in ordinary daylight by rotating these cellu- loid discs on any convenient rotor or by spinning them on an ordi- nary dissecting needle. L. M. Discs. There are two black discs, on each of which are three white sectors of different sizes, when one of these discs is rotated three lighter rings are seen of which the inner is the lightest. On the disc with the large sectors, the inner ring denotes a L. M. of 1/12.5, the intermediate ring 1/25, the outer 1/50, which it is more convenient to denote by 12.5, 25 and 50 as ability to see the outer ring denotes a better light minimum sense than that which can only see the inner ring. Similarly the disc with the smaller sectors denotes L. M. of values 50, 100 and 200. 474 ARCHIBALD STANLEY PERCIVAL L. D. Discs. These are white discs with black sectors of corre- spondingly different sizes, and when rotated indicate the light dif- ference sense for values of 12.5, 25, 50 and 50, 100 and 200. It will be noticed that a light-sense of either kind, of value 50, is given twice ; this is often useful in forming an opinion of the reliability of the statements of the patient. It will be found that few can distinguish the faint gray ring that corresponds to L. D. = 200, and so I assume that the standard for L. D. is 100, while that for L. M. is 200. It might be hastily assumed that the size of the black sector denot- ing L. D. = 100 should be of angular aperture f f$ or 3 36", but as Abney has shown us that 5 per cent, of the incident light is reflected from lampblack, we must add 1/19 to the angle, so that this sector must be of 3 47' 22"; similar additions have been given to the other sectors. DISCUSSION DR. C. E. FERREE (Bryn Mawr, Pa.) : Mr. Percival expresses the hope that his conclusions with regard to the light difference and light minimum will receive a wider confirmation than he has given them. It may be of interest in this connection to note that we are just beginning a long study of the appli- cation of functional testing to the diagnosis of eye diseases at the Polyclinic Hospital of the Graduate Medical College of the University of Pennsylvania. This study will include, among others, determinations of the light minimum and light difference, also the color minimum and color difference, with appa- ratus which permits of finely graded changes of intensity and the exact speci- fication of the amounts of light used in every case. In Mr. Percival's test for the light minimum the task set for the patient is the discrimination of the gray just noticeably lighter than black (coefficient of reflection, 4-6 per cent.) with the eye adapted or sensitized to high or day- light intensities of illumination. The light difference is determined under the same conditions of adaptation. This can scarcely be said to test the eye for scotopic or twilight vision. Of course these two determinations can be made with the eye in any state of adaptation and it may be of great diagnostic value to make them with the eye in a photopic state of adaptation as is done in Mr. Percival's tests; however, since a disturbance of the process of dark- adaptation is believed by many to be characteristic of certain types of disease, it seems to me to be important to make the test also with the eye dark adapted. This does not seem to be possible with the discs described by Mr. Percival. Mr. Percival's tests also should be made with a constant intensity of light on the discs. The Fechner fraction or the ratio expressing the value of the light difference is independent of the intensity of illumination only over com- paratively small ranges of change. The type of disc used by Mr. Percival was first described by Masson in 1845. It was much used by the earlier psychophysicists: Fechner, Aubert, Light-sense: Simple Tests for Determining 475 Delboeuf, Helmholtz, Miiller, Kraepelin, Schirmer, and others, for the de- termination of the light difference. Its advantages for this purpose in clinic work are its very great simplicity and the speed with which it can be used. Some of its disadvantages are its inflexibility of gradation and the fact that it cannot be used for dark adaptation, or over wide ranges of illumination, without the provision of many gradations, or rings of gray representing the needed differences in brightness from the background. It is also fit only for the determination of the light difference. The light minimum cannot be determined by this type of device. The determination of the light mini- mum should be made in the dark room, and in the strict sense of the term requires a fully dark-adapted eye. I would suggest as tests for the use of the British Board of Trade acuity at low illumination and speed of discrimination both of the acuity object and of the light difference at low illumination. We have devised and used apparatus for making these determinations and have found them to be of great value for selecting eyes as to fitness for vocations requiring speed and accuracy of seeing at low illuminations. Eyes having the same acuity at high illuminations will by no means always be rated as equal at the low illu- minations and the scatter is very much greater still when speed is added to the requirement at low illumination. Speed and power to sustain are aspects which have been very much neglected in the testing of acuity and other ocular functions. When added to the test they not only greatly increase its sensitivity, but take account of functions which are of the greatest impor- tance to the working eye. Errors in refraction, for example, which cannot be detected by the conventional method of testing acuity, show plainly in acuity at low illumination, and in speed and power to sustain at any illu- mination, more particularly at low illumination. While these extraordinary tests may not at this time be considered feasible for office and clinic work, the results of investigations in which they have been used should teach us not to be too well satisfied with our present standards of accomplishment in the detection and correction of defects. DR. OTTO ROELOFS (Amsterdam, Holland) : I was surprised at hearing that in dark-adaptation and binocular vision there is a summation of stimuli which would fail by light-adaptation. This conception, first defended by Piper, is not right. Several investigations, principally made at the Univer- sity of Amsterdam, showed that this summation does not exist, neither by light-adaptation nor in dark-adaptation. The phenomena found by Piper are the results of a fault in his examination. If we take care that the adapta- tion of both eyes is perfectly equal it is impossible to find any summation of stimuli. For all that it is true that the threshold for light-perception (the light minimum) is lower by binocular vision than by monocular vision; this fact wants another explanation, which I cannot discuss now because it would take too much time. I only wish to mention that this difference between binocular and monocular vision can be found as well by light- adaptation as by dark-adaptation. These results are confirmed by the investigations of Lehmann. 476 ARCHIBALD STANLEY PERCIVAL I want to ask the attention to the connection between apparent distur- bances in the sense of light and disturbances in the field of vision, and I should like to consider the possibility that a disturbance in the center of the field of vision will give in the first place a disturbance of the light difference, because there it is examined by more light-adaptation, and that a disturbance in the periphery of the field of vision will give a disturbance of the light mini- mum because it is examined by more ctarfc-adaptation. I must say that the method of examination does not satisfy me. We always must have the same dark- or light-adaptation as a starting point for our examination of the sense of light. If we are not sure that at the beginning of every examination the dark- or light-adaptation is perfectly the same, our results cannot be of any significance. Especially I am surprised that a cataract operation can be refused on the result of such an examination. This method of examination requires not only a certain degree of sense of light, but also a certain degree of visual acuity; we have to discern the several bands on the rotating disc. An opaque lens is not the same as a dark-tinted glass. COL. R. H. ELLIOT (London, England) : I want to express my dissatis- faction with the present state of our knowledge of light-sense, and of our tests for light-sense. I think we need much more spade-work before we can be satisfied. Both the central and peripheral fields require to be tested. We see cases of glaucoma obviously suffering from a deficient light-sense in the peripheral field, and yet having excellent central appreciation both of light minimum and of light difference. It is this divergence, or apparent diver- gence, of my experience from that of Mr. Percival and others that has led me to speak. I suggest that the appreciation of light by the glaucomatous eye follows the variations in the visual field, whether central, paracentral or peripheral, and that just as we may find a patient with good central vision, but with damage to his paracentral or peripheral visual fields or both, so his light-sense over the same areas may be affected. Chronic glaucoma may be expected to strike first at the paracentral area, and next at the periphery of the field. Congestive glaucoma will attack the whole field from center to periphery in light-sense, just as it does in the other functions of the eye. My preference is for a light-sense apparatus working with an actual light, and Zeiss has made one such for me, which I think will prove satisfactory for a clinical test both of light minimum and light difference. Are we safe in neglecting all dark-adaptation of our patient in advance? It seems doubtful, and I think we need expert guidance on this subject. DR. ALEXANDER DUANE (New York City): Mr. Percival in his paper reviews some elementary principles in the physiology of the light-sense, calling attention especially to the following facts: 1. The rods are particularly associated with this function. 2. Hence, the rod-free portion of the retina, i. e., the fovea, is undersensitive to differences in illumination, and therefore when the illumination is consider- ably reduced ceases to function, so that a central scotoma develops. Light-sense: Simple Tests for Determining 477 3. In the peripheral portions of the retina, on the other hand, in which the form-sense is so weak, the light-sense is strong. It reaches its maximum in a zone some 10 degrees out from the fovea, but is good on either side of this zone. It is hence especially important in determining the capacity for peripheral vision. 4. The light-sense is the most primitive of the retinal functions and is hence found well developed in conditions in which the form-sense is very deficient; for example, in strabismic amblyopia. Moreover, in normal sub- jects it is well retained even when the illumination is so considerably reduced that the form-sense is notably impaired. 5. Some of our so-called form-sense tests, in other words, tests of visual acuity, are really in part tests of the light-sense. This applies to the ordinary letter tests. Failure to recognize this fact has led to some erroneous conclu- sions. Thus because Prof. Barnard could recognize a wire against the sky at a distance which made the wire subtend an angle of 0.44 second, it was argued that this represented his minimum visual angle, which would mean that his visual acuity was 125 times that usually regarded as normal. As a matter of fact, however, the test was a test of light-sense only and no more represented a test of visual acuity than is the ability to distinguish a fixed star which, practically speaking, subtends no angle at all. Turning from these theoretical considerations to practical points, we may make the following statements : 1. The tests of the light-sense are important clinically in two regards: (a) The light-sense being concerned especially with peripheral vision and with the discrimination of objects affording but a faint contrast with their surroundings it is important that it should be systematically examined as a routine matter in those who in their avocations have to discriminate objects situated in the periphery of the field and but faintly visible. It is important, that is, to test it in sailors, particularly in lookouts and signalmen, railroad men, chauf- feurs, aviators, etc. Of its great significance for the Army and Navy service I can personally testify. (6) The test is important in determining the pres- ence of diseases of the sensory apparatus of the eye and in discriminating between different affections of this apparatus. In this regard we must note that mere opacities of the media, unless very dense, do not greatly diminish the light-sense. 2. In making tests of the light-sense we must distinguish between the light minimum (LM) and the light difference (LD). The former is meas- ured by the smallest amount of light that can be distinguished in contrast with darkness; the latter by the smallest difference that can be appreciated between two contrasting light stimuli. 3. The light difference is particularly affected in diseases of the conducting apparatus, that is, the optic nerve and, according to Percival, the pro- longations of the latter in the retina. Lowered light difference, therefore, is found in optic neuritis and atrophy, retrobulbar neuritis, and toxic amblyopia ; probably also generally in affections involving specifically the superficial layers of the retina. The light minimum, on the other hand, is lessened in choroidal affections and in the deeper forms of retinal disease. Percival finds it affected quite early in glaucoma, the light difference not failing until later. 478 ARCHIBALD STANLEY PERCIVAL 4. In affections of the media so dense as to affect the light-sense, both light difference and light minimum fail and fail equally. Here a marked dispro- portion between the two in the case, for example, of a cataract, indicates a disease either of the light-perceiving or light-conducting apparatus retina or optic nerve. Percival cites an interesting case of cataract in which he declined to operate because the presence of such a disproportion made him infer, correctly, the existence of a macular hemorrhage. 5. The appliances that he uses for testing the two are exceedingly simple. They have the great advantage that they do not require a long preliminary period of dark-adaptation, and hence can be used by daylight. Moreover, the examination can be completed in one or two minutes. 6. The tests themselves are simply the well-known rotating discs, of which the Maxwell disc is a type. Their special significance consists in the way they are graduated so as to indicate the normal, or definite fractional propor- tions of the normal. The test for the light minimum consists of a black disc which has on each side three white sectors. The innermost sector on the back surface occupies 1 /12.5, the next 1 /25, the outermost 1 /50 of the ring in which it is contained. On the front surface the sectors represent similarly white areas of 1 /50, 1 /100 and 1 /200 of the corresponding black portion. The light difference tests are precisely similar, but the sectors here are black on white instead of white on black. A small ratchet rotatoV worked by thumb pressure is used for spinning the discs around. 7. When the light minimum disc is rotated the sectors appear as grayish rings on a black ground. The normal eye should distinguish all three rings on the front surface, even the outermost. The light minimum then equals 1 /200 or, as Percival more conveniently expresses it, 200. If a man can distinguish only the innermost ring, his LM is 50; if he can distinguish no ring on the front surface and only two on the back, his LM is 25. 8. A similar notation obtains for the LD disc, only here it is found that very few people can recognize more than two rings on the front surface of the disc, so that the normal LD may be stated as 100. SOME CONTRIBUTIONS TO THE SCIENCE AND PRACTICE OF OPHTHALMOLOGY C. E. FERREE, PH.D., AND G. RAND, PH.D. Bryn Mawr College, Bryn Mawr, Pa. I. AN ILLUMINATED PERIMETER WITH CAMPIMETER FEATURES 1 This apparatus was devised in response to a request from a com- mittee appointed by the American Ophthalmological Society to work out a better standardization of the illumination of perimeters and test charts. The request was for a feasible means of illuminating the perimeter arm with light of a good intensity and quality, so that every point on the arm in any meridian in which it may be placed shall receive equal intensities of light. Intensity and quality of illumina- tion, however, are only two of the factors which influence the results of the perimetric determination. In devising the instrument described in this paper it has been our purpose to provide a control also of other factors which are of importance to the work of the office and clinic. The perimeter to be described in this paper has been adopted by the committee as the standard instrument for office and clinic work. The variable factors which influence the apparent limits of color sensitivity are, so far as we have been able to discover, the wave- length and purity of the stimulus, the intensity of the stimulus and the visual angle, length of exposure of the eye, the method of exposure (moving or stationary stimulus), accuracy and steadiness of fixation, the intensity of the general illumination of the retina and its state of adaptation, breadth of pupil, and the brightness of the pre-exposure and of the background or surrounding field. The most important of these from the standpoint of the office or clinic are perhaps the in- tensity of the stimulus, the brightness of the pre-exposure and the surrounding field, the intensity of the general illumination, and the accuracy and steadiness of fixation. Perhaps errors in refraction should be included in the above list of factors. They differ from those factors, however, in that they are a source only, or mainly at least, of differences in breadth of field between 1 A description of the earliest model of this apparatus appeared in Trans. Amer. Ophthal. Soc., 1920, 172. 479 480 C. E. FERREE AND G. RAND observers, not for the same observer at different times. They are not, therefore, a serious source of trouble in the use of perimetry to check up the advance or recession of a given pathologic condition, but they are confusing in diagnosis. We have no certain means of telling, for example, how much of the results in any given case of high myopia is due to the refractive condition and how much if any is pathologic. To add to our knowledge on this point we are now conducting an in- vestigation to determine the effect of various amounts and kinds of refractive errors on the results of field taking. We can not help but feel, as is stated and discussed later in the paper, that a provision should be made in our practice of field taking to include one set of results under correcting glasses, even though it means either working under conditions which give a narrow field or being content with results which do not include the wider portions of the temporal field. 1. INTENSITY OF STIMULUS. By a sufficiently wide variation of this factor alone, the zones of color sensitivity may be made to have almost any breadth within the limits of the field of vision, to differ radically in shape, and even to change or reverse their order of ranking as to breadth, changes of a type and magnitude to which the clinician might ascribe a grave and important pathologic signifi- cance. Without great precision in the control of intensity, it is obvious that reproducibility or result can not be obtained and little diagnostic significance can be attached to extent or shape of field, to order of ranking as to breadth of field, or to any variations from time to time or from person to person in these important features. When pigment surfaces are used as stimuli, the illumination of the perimeter arm de- termines the intensity of the stimulus light. Two methods are pro- posed for securing an even illumination of the stimulus at every point on the perimeter arm and of reproducing this illumination froni time to time. Method 1. When the source of light is inlaid in the surface of the arm or its continuation, the illumination on this surface will be equal for approximately 180 on either side of the source. The value of this illumination at every point will be equal to the normal flux of light from the luminous surface divided by four times the square of the radius of curvature of the perimeter arm, or four times the square of the distance of the eye from the perimeter arm. 1 In a later publica- 1 For a discussion of the principle by which an even illumination of the per- imeter arm is secured by this method, the reader is referred to the Trans. Amer. Ophthal. Soc., 1920, 165-167. Contributions to the Science and Practice of Ophthalmology 481 tion the method will be elaborated and a perimeter constructed on this principle of illumination will be described. This type of device is open to the objections of being difficult of construction and wasteful of light. Method 2. When the source of light lies in the perpendicular to the plane of the perimeter arm at its center of curvature, it will be equi- Fig. 1 distant from every point on the arm ; also the angles of emission and incidence of the beam of light will be equal for every point on the arm. A perimeter (Figs. 1 and 2) has been constructed embodying this principle of" illumination. Two arcs of the same radius of curvature were constructed at right angles to each other, one a 180 arc, the perimeter arm ; the other a 90 arc, the lamp arm, at the end of which is 31 482 C. E. FERREE AND G. RAND placed the source of light. In order that the source of light shall sus- tain a fixed relation to the perimeter arm for all positions of that arm, the two arms are fastened together at the center of rotation. About the source is a housing which is designed in such a way as to shield the eye of both patient and physician without interfering with the dis- Fig. 2 tribution of the light which radiates freely from the filament to every point on the perimeter arm. The lamp house is well ventilated and the lower part is hinged to provide for the removal of the lamp. Pro- visions are further made in the construction of the lamp house for filtering the light to daylight quality. A well-seasoned type C 2 Mazda lamp operated by ammeter and rheostat control is used as the source Contributions to the Science and Practice of Ophthalmology 483 of light. The instrument is designed to run on any 110- volt circuit. This perimeter is not difficult to construct nor to operate. It provides for a uniform illumination of the perimeter arm in all meridians with light of a good intensity and quality; and with it a precision of con- trol is possible which is comparable with the work of the physical lab- oratory. Of the two instruments we have constructed, it is without doubt much the more feasible and it is also very probably the more correct in actual practice. Both instruments are correct in theory. 2. THE BRIGHTNESS OF THE PRE-EXPOSURE AND THE SURROUNDING FIELD. The brightness of the surface to which the eye is pre-exposed may change the apparent limits in certain meridians as much as 17 to 20. A pre-exposure lighter than the color gives a dark, and one darker than the color a light, after-image. These after-images change profoundly the saturation of the color sensation, also its hue. A back- ground or surrounding field lighter or darker than the color produces a similar effect on the limits, but not so great. In this case, the dis- turbing achromatic effect is due to physiologic induction or con- trast. The variable effect of brightness of pre-exposure and surround- ing field can be eliminated only by making both a gray of the same brightness as the stimulus color. Here again a precise control of the intensity of the illumination for all points on the perimeter arm be- comes important. That is, the shade of gray which is needed to match the color in brightness changes with change of illumination; there- fore, the selection of a gray which will match the color in brightness for all points of work presupposes constancy and uniformity of il- lumination. A further advantage is gained by making the background of the same brightness as the color. That is, when color and back- ground are of the same brightness the stimulus disappears completely when the limit of sensitivity to that color is reached, instead of turning into a gray concerning the colorlessness of which the patient is apt to be in doubt. This gives the effect of the disappearance type of photom- eter and like it adds greatly to the ease and certainty of making the judgment. For the control of brightness of pre-exposure and surrounding field cards are provided covered on one side respectively by grays of trie brightness of the colors to be used as seen in the peripheral retina. At the center of each of these cards is pasted a disc of the appropriate color subtending a visual angle of 1. To provide for the control of the pre-exposure for the stationary method of giving the stimulation, cards identical with the background cards are provided, covered also 484 C. E. FERREE AND G. RAND on one side with a gray of the brightness of the color. The stimulation by this method is given as follows : The stimulus is placed at the point to be tested and covered with the pre-exposure card. The observer is told to take his fixation. At a given signal the stimulus is uncovered for one second and recovered. In case the moving stimulus method is used, the surrounding field serves as the pre-exposure. 3. THE ACCURACY AND STEADINESS OF FIXATION. All are familiar with the disturbing effect of inaccuracy and unsteadiness of fixation. If correct and reproducible results are to be obtained, the eye must be accurately placed at the center of the sphere in the surface of which lies the perimeter arm, and the line of sight must not shift from the fixation point while the color observation is being made. As an aid to the correct placement of the eye and a check on its steadiness of fixation, two devices have been provided : 1 . A small circular mirror is used as a fixation object in which the ob- server sees the image of his own eye. 1 When the eye is correctly placed with the line of sight normal to the surface of the mirror at its central point, the fact is indicated to the observer by the position of the image of his pupil and iris as seen in the mirror. Not only is this simple device of service in determining the correct position of the eye. but it aids the observer greatly in holding a steady fixation by giving him an immediate indication of deviations in the line of regard. We scarcely need to point out that the ordinary fixation object does not afford an accurate control of fixation. Exact checking methods show that the observer is not always fixing the object when he thinks he is. The only guide to monocular fixation is clearness of seeing and this is a criterion that presents considerable latitude. However, with a mirror the observer has an objective check on the position of his eye. One of the objections to the use of a mirror as a means of controlling fixation is the liability of glare from its surface, probably due to a com- bined specular and diffuse reflection rendering unnecessarily difficult the clear seeing of the eye by the observer. This objection has been obviated in our instrument by cutting off from the mirror the direct radiations from the lamp by a narrow shield which can be turned back out of the way when not in use. With the shield in position the eye receives from the mirror only the light which is first reflected from the eye to the mirror and then back to the eye. The elimination of the troublesome glare from the surface of the mirror is rendered particu- 1 For a cut of the perimeter furnished with this fixation device, see Trans. Amer. Ophthal. Soc., 1920, 167. Contributions to the Science and Practice of Ophthalmology 485 larly simple and easy in case of our instrument because of the plan of illumination employed, i. e., the light all comes from a fixed source above and directly in front of the mirror. 2. The second device for the control of fixation is similar in principle to a peep-sight and may be called a parallax or peep-sight device. A small disc placed at the center of rotation of the perimeter arm is viewed through a circular opening in a small metal plate. The plane of both disc and opening is normal to the line of sight when the eye has the correct position and fixation. When the eye has this position and fixation the relation of size of disc and opening is such that the disc is seen not quite to fill the opening. The disc is painted black, also the edge of the opening, thus when the eye has the proper position and fixation, the edge of the opening is seen concentric to the disc with a narrow ring of the gray of the perimeter arm between. The control afforded by this device is very sensitive. A very slight deviation of the position or fixation of the eye results in the complete or partial extinction of this gray ring at a point in the direction of the deviation. In order to locate the eye at the correct distance from the fixation object a light measuring rod 33 cm. in length is provided, to one end of which is fastened a small metal disc. In making the adjustment for distance one end of the rod is placed against the fixation object at its center and the distance of the perimeter from the observer's eye is changed by means of a coarse screw adjustment until the closed lid is just in contact with the metal disc. A final important feature in the correct adjustment of the eye is to insure a constancy of relation of the meridians of the retina to the meridians of the field of vision as laid off by the perimeter arm; in other words, to guard against a slight tilting of the head to one side or the other. For this purpose we have designed a very small and unob- jectionable mouth bit of light wood (Fig. 1) to be changed for each observer, so shaped that it can not be bitten too far forward or back, and thus the distance of the eye from the mirror be changed, or too far to one side or the other. There seems, however, to be an insuper- able prejudice against the use of a mouth bit by both the physician and the patient. We have therefore designed a head rest (Fig. 2) which follows approximately the outlines of the forehead, side of the head and face, furnished with a suitably cupped chin rest the height of which is adjustable. To provide for individual differences in shape and breadth of forehead, an adjustable forehead piece or band of thin spring steel extending well around to the side of the head is screwed at 486 C. E. FERREE AND G. RAND its central point to the forehead piece of the head rest. This forehead band is adjusted to fit foreheads of different shape and breadth by means of a set screw on either side near the two ends of the band. When the chin rest is adjusted to its proper height and the forehead band is made to fit the forehead, the patient's head is held com- fortably in position and sufficiently rigid, it is believed, to satisfy the needs of office and clinic work. At least the probability of tilting the head to one side or the other, thus causing a disagreement of the meridians of the field of vision as indicated by the perimeter readings with the meridians of the retina is very greatly lessened, if not en- tirely obviated. In order to quickly and conveniently locate the patient's eye at the center of the perimeter system three adjustments are provided: a rack and pinion to raise and lower the head, a second rack and pinion to shift the head to right or left, and a coarse screw adjustment to change the distance of the perimeter arm from the eye. A very great practical need in a clinic perimeter is a method of controlling fixation for patients who have a central scotoma or patho- logic blind area. With the eye properly adjusted for taking the fields these patients are not able to see a central fixation object. We have constructed a device for this purpose which can be inserted into the hollow axle of the perimeter in place of the mirror or the peep sight. This device consists of four light arms at right angles to each other curved to follow the arc of the perimeter arm, and of sufficient breadth to provide for all probable breadths of scotoma. Each of these arms carries a small stimulus, the distance of which from the center of the field is adjustable. In adjusting the patient's eye the physician looks through a small telescope contained in the hollow axle and lines up the pupil of the patient's eye with the cross hair in the field of the telescope. If desired the patient's eye can be made more visible by reflecting light from the lamp directly on it. This is pro- vided for (Fig. 1) by placing a small oblong mirror of specular metal on the lamp arm at such a position and angle that the light received from the lamp will be reflected on the iris. This mirror is hinged to the lamp arm and can be turned back against it when not in use. When the eye is observed to be in position, the four stimuli are adjusted so that they can just be seen by the patient at the edges of the scotoma. These stimuli serve as the control of the patient's fixation, his instruc- tions being so to direct the eye that all are visible. This fixation device can be made serviceable for mapping the sco- Contributions to the Science and Practice of Ophthalmology 487 toma itself by adding 12 or more graduated arms equally spaced, pro- vided with stimuli similar to those already described (Fig. 1). Then when the fixation is obtained by the adjustment of the four stimuli designed for that purpose, the further mapping of the scotoma is accomplished by moving the remaining 12 until they are on the edges of the scotoma. Or if preferred the physician may watch the patient's eye through the telescope directing the fixation by means of the cross hairs, while all of the stimuli are moved into position on the edges of the blind area. This objective control of the fixation by the physician may be used, if desired, both in mapping the scotoma or in taking the fields when a central scotoma is present. Another important need in a clinic perimeter is a method of giving the correct location and fixation to eyes suffering with high myopia. Eyes with myopias ranging from 8 to 20 diopters would have great difficulty in seeing a fixation object at a distance of 33 cm. Because of the grave pathologic changes which take place in the retina and choroid of eyes suffering from high myopia, particularly in the region of the macula and nerve head, it is of great importance to be able to use both the perimeter and tangent screen in the examination of eyes in the more advanced stages of myopia. Three provisions have been made for this: (1) The mirror may be mounted on a rod sufficiently long to permit of its location at any point in the line of sight between the perimeter arm and the eye. This rod may be inserted into the tubular axle on which the perimeter arm rotates. (2) A peep-sight device is provided similar in principle to the one already described and so constructed that it may suffice as a fixation control for values of myopia ranging between 8 and 20 diopters. And (3) the perimeter arm may be illuminated with two intensities of light, one carrying the fields well toward the periphery of the retina; the other giving limits narrow enough to fall within the corrected field of the glasses which are worn or may be worn by the patient. This feature provides also for the correction of high astigmatisms the presence of which make field taking annoying and uncertain as a diagnostic procedure. There are other advantages of providing for the taking of fields at more than one intensity of illumination : (a) Because of the concentric arrangement of the fibers in the nerve trunk and their order of distri- bution in the retina, it may be of importance as a point of diagnosis to sample the response of the retina at different degrees of eccentricity. And (b) the low illumination fields are in general more sensitive to the influence of the pathologic factors which cause the fields to have dif- 488 C. E. FERREE AND G. RAND ferent breadths. This is in part due to the fact that low illumination fields are narrow fields. That is, sensitivity falls off gradually near the center of the retina, therefore, smaller changes of sensitivity are re- quired near the center of the retina to expand or contract the field. It is probably also due in part to the change produced in the state of the retina's sensitivity at the low illumination. The control of fixation for the presbyopic eye also presents a prob- lem to the perimetrist. The eye with a high degree of presbyopia would have considerable difficulty in seeing with the necessary clear- ness a fixation object at a distance of 33 cm. By the use of the mirror as fixation control this distance is extended to 66 cm. ; but the satis- factory use of the mirror requires that the image of the eye be seen fairly clearly. An eye without power of accommodation, even if there is no hyperopia for far seeing, is approximately 1.50 diopters out of focus for an object at a distance of 66 cm. When 1.50 diopters out of focus the eye can not see its image in the mirror with a satisfactory degree of clearness. However, the mirror can be used with a fail- degree of satisfaction for lesser degrees of presbyopia. We have three proposals to make for the control of fixation for the presbyopic eye: (1) The use of the mrror, if desired, for the lesser degrees of presbyopia. (2) The use of an illumination sufficiently low to bring the color fields within the field of the correcting glasses. And (3) the use of a peep-sight or parallax fixation device similar in principle to the one already described, with the target at a distance great enough to be seen by the eye without power of accommodation. 1 Sixty-six cm. has been chosen for this distance because (a) the target can be seen at 66 cm. with sufficient clearness to determine whether or not it is at the center of the viewing opening, formed by the hollow axle and tube, even though the eye is as much as 1.50 diopters out of focus; and (b) a greater distance presents difficulty as to feasibility of construction. The device is provided also with a lens the distance of which from the target can be varied from its focal length to that which is needed to render the target clearly visible at 66 cm. This lens is mounted in the end of a short tube which telescopes to the desired depth into the main tube at the end facing the target. By suitably changing the distance of the lens from the target the apparent distance of the target can be made to have any value between 6 m. and 66 cm. 1 As already stated, the device for control of fixation in high degrees of myopia is also shown in Fig. 2 in position for use. When using either, the other should, of course, be removed. Contributions to the Science and Practice of Ophthalmology 489 By means of this optical device, therefore, a clear image of the target can be formed on the retina of patients having all possible degrees of presbyopia. However, as we have already stated, it is quite possible to secure a good control of fixation for any degree of presbyopia with- out the use of the optical attachment. The steadiness of fixation is greatly influenced by the method of giving the stimulation. One of the serious objections to a moving stimulus is the difficulty of holding a steady fixation while the object to be observed is moving. The alternative procedure is the use of a stationary stimulus. That is, the stimulus is placed at the desired point on the perimeter arm and covered with the pre-exposure card. The observer takes his fixation and at a given signal the stimulus is exposed and recovered. By this method of giving the stimulation more time is consumed but a much greater precision of result is pos- sible. A compromise procedure is recommended. That is, the ap- proximate location of the limit is determined with the moving stimulus and the exact location with the stationary stimulus. By this com- promise but very little more time is required and there is no sacrifice of precision. In order to provide for the mapping of the normal blind spot and for the quick detection and mapping of central and paracentral scoto- mata, it has been deemed advisable to add to the perimeter a tangent screen, subtending a visual angle of 60 or more degrees. Provision is made so that this screen can be quickly and conveniently attached to the stimulus carriage and moved into position. The stimulus carriage and the tangent screen have at their exact center a circular opening equal in size to the cross-section of the tubular aperture about which the perimeter arm rotates. Thus when the tangent screen is in posi- tion, i. e., with its central point in the axis of rotation of the perimeter arm, the tubular opening in the perimeter is continued through to the front surface of the tangent screen. This provides both for the exact adjustment of the tangent screen and permits of the convenient use with it of all of the fixation controls which we have described. Cards of white or black, as may be desired, with the fields laid off on the tan- gent scale are provided for the mapping of the area deficient in the light sense, and of grays of the brightness of the colors for mapping the color deficiencies. In our own work we have found it convenient to use this large screen for a quick survey of the field for scotomata and a smaller screen similar to the one used to carry the colored stimulus in the field taking 490 C. E. FERREE AND G. RAND for the actual detailed mapping of the scotomata and the normal blind spot. This screen was made considerably larger than the screens which serve as backgrounds for the colored stimulus in field taking in order that it might serve for the mapping of large scotomata and pathologically enlarged blind spots. It is mounted in a carriage of its own and is shaped to take the curvature of the perimeter arm. This screen is intended not as a substitute for the larger screen but as a supplement in cases in which such a supplement is found to be con- venient and desirable. This device has the following advantages over the large central tangent screen for the actual mapping of the blind areas : (1) It can be moved to any part of the field from the center out to 90 in any meridian and its center located at the center of the area to be mapped. When the screen is properly centered the mapping can be done as it is on any tangent screen. (2) Upon each screen are drawn sixteen meridians radially from the center of the screen. These meridians are finely graduated so that the limits of sensitivity in any meridian can be read off for the permanent record and transferred to properly planned maps at the convenience of the experimeter. (3) Blind areas are most easily and precisely mapped when the stimulus is made to follow lines radiating from the center of the area. Unless there are such guiding lines it is difficult to pass from within out or from without in consistently when determining the limits of the blind area or when checking up the location of a limit by a second or third determination. On a large fixed screen these lines would have to be drawn specially for each scotoma. (4) All of the evidence points toward the importance of mapping the blind areas with colored stimuli particularly the Mariotte spot. It is highly important that the determinations for the different colors be made on backgrounds of the same brightness as the colors, as will be shown by blind spot studies to be published later. It is much more feasible to arrange for this in case of the smaller movable fields than in case of a large fixed field. When the background for the smaller field is laid off in grad- uated radial lines it can serve for the mapping of many blind spots and scotomata before it need be replaced. In case of a large fixed screen, this superior adaptability and long service would not be possible. (5) With the movable smaller field it is more nearly possible to map all blind areas under the conditions of equal illumination which ob- tains in the perimetry of the color fields than it is in the use of the large fixed screen. In the latter case the illumination at which the mapping is done in one part of the field may be quite appreciably dif- Contributions to the Science and Practice of Ophthalmology 491 ferent from that at which it is done in another part of the field. The control of illumination, while not so important for mapping the blind areas to the light sense stimuli, is very important in the mapping of the blind areas to color. With the controls provided in the perimeter recommended, a care- ful worker can without difficulty reproduce the limits of sensitivity within 1 or 2 degrees. II. VARIABLE FACTORS WHICH INFLUENCE THE DETERMINATION OF THE COLOR FIELDS We have already given a list of the variable factors which influence the apparent limits of color sensitivity and have stated that the most important of these factors from the standpoint of the work of the office and clinic are perhaps the intensity of the stimulus and the precision of its control, the brightness of the surrounding field and of the pre-exposure, the intensity of the general illumination, and the accu- racy and steadiness of fixation. Space can be taken here for the dis- cussion of the effect of intensity alone. Reference will, however, be given to discussions and data bearing on the other factors. 1 INTENSITY OF STIMULUS. By a sufficiently wide variation of this factor alone the fields of color sensitivity may be made to have almost any breadth within the field of vision, to differ radically in shape, and even to change or reverse their order of ranking with regard to breadth. For example, with very high intensities the limits of red, yellow and blue are coincident with the limits of white light vision. Green can not be made to have so wide an extent;. With stimuli of medium intensity and of the relative energies found in the prismatic spectrum of a Nernst filament the limits are concentric and in the order from widest to narrowest of red, yellow, blue and green. With stimuli of medium intensities of equal energy the limits of red, yellow and blue interlace or crisscross. The limits for green again are nar- rower. The limits for pigment stimuli may be either interlacing, or concentric in the order of widest to narrowest of red, blue and green ; 1 The Factors that Influence the Sensitivity of the Retina to Color. A Quanti- tative Study and Methods of Standardizing, Psych. Rev. Monog., 1913, xv (1), 178; Factors Which Influence the Color Sensitivity of the Peripheral Retina, Trans. Amer. Ophthal. Soc., 1920; The Extent and Shape of the Zones of Color Sensitivity in Relation to the Intensity of the Stimulus Light, Amer. Jour. Physiol. Optics, 1920, i, 185-213; The Limits of Color Sensitivity: Effect of Brightness of Pre-exposure and Surrounding Field, Psych. Rev., 1920, xxvii, 377-398. 492 C. E. FERREE AND G. RAND or of blue, red and green depending upon the pigments used and the intensity of light falling on the perimeter arm. It seems only fair to conclude, therefore, that the conventional clinic rating of the limits from widest to narrowest in the order of blue, red and green is a func- tion of the relative and absolute intensity of the stimuli employed as well as of the actual distribution of sensitivities. A change in the intensity of the stimulus not only changes the limits but, because of the irregular distribution of sensitivities in the different meridians, causes a marked change in the shape of the fields; and because of changes in the ratio of sensitivity to the different colors in the same meridians, a change in their ranking as to breadth. Without great precision in the control of intensity, it is obvious thatreproducibility of result can not be obtained and little significance can be attached to extent or shape of field, to order of ranking as to breadth of field, or to any variations from time to time or from person to person in these important features. The effect of changes in the intensity of the stimulus both on the extent and shape of the color fields varies with the order of magnitude of intensity employed. For medium and low intensities the effect of a given amount of change is very much greater than for high intensities. This is an obvious corollary of the type of distribution of sensitivities found in the peripheral retina. That is, in passing from the center toward the periphery of the retina the decrease in sensitivity is com- paratively slow and gradual in the paracentral retina; it is much faster and more abrupt in the mid periphery; and very abrupt in the far periphery. It requires, therefore, comparatively large changes in stimuli of high intensity which carry the limits of sensitivity into the far periphery, to produce a significant change in the fields; not so great a change in stimuli of medium intensity; and a still smaller change in stimuli of low intensity. This effect varies greatly, however, for the same color in the different meridians and for different colors in the same meridian. For stimuli of the medium and low intensities used in the office and clinic, the effect of change of intensity is very marked indeed both on the extent and shape of the fields of sensitivity. We have stated that the order in which the fields may be found to occur ranked with regard to breadth depends both upon the actual distribution of sensitivities, and upon the relative and absolute in- tensities of the stimuli employed. That it depends upon the relative intensities of the stimuli employed should be more or less obvious, provided, of course, that the relative differences of intensity are great Contributions to the Science and Practice of Ophthalmology 493 enough to overcome or reverse actual differences in sensitivity. In support of the statement that it depends also on the absolute intensity, maps will be shown in which for the same eye and a constant ratio of intensity of stimuli, the limits for red and blue in some cases interlace or crisscross; in others they are concentric or nearly so, the limits for blue lying outside of the limits for red or conversely the limits for red lying outside of the limits for blue, the difference in result depending solely upon the absolute intensities of the stimuli employed. The 1090 fl flei Green l# Jttffl HIM ia 2IOM I1HO nut HIM 1054) 8151 7000 13' 10" JO' -W f U' Tf W 13" Fig. 3. Chromatic thresholds for the Fig. 4. Chromatic thresholds for the four colors, temporal meridian. four colors, nasal meridian. determinations were made with the Hering standard pigments pre- sented to the eye by means of the perimeter just described, with the pre-exposure and surrounding field of the brightness of the color, the only variable being the intensity of illumination of the perimeter arm. The effect of such factors as intensity on the extent and shape of the color fields and their order of ranking as to breadth can be better understood when a thorough knowledge is had of the actual distribu- tion of sensitivities from point to point from center to periphery of 494 C. E. FERREE AND G. RAND the retina. In order to show this distribution of sensitivity from cen- ter to periphery of the retina we have made determinations of the threshold of sensation (the amount of light required just to arouse the color sensation) with spectrum lights and under proper conditions of control for the different colors at near lying points in the different meridians. A graphic representation of the results of these determi- nations for two meridians, the temporal and nasal, is given in Figs. Fig. 5. Chromatic thresholds (en- larged scale) for the four colors, tem- poral meridian. Fig. 6. Chromatic thresholds (en- larged scale) for the four colors, nasal meridian. 3 to 6. In these curves the degree of eccentricity is plotted along the horizontal co-ordinate and the energy or intensity values of the threshold in watts (10 7 ergs per second) are plotted along the vertical co-ordinate. Maps have been made also showing the effect of varying the intensity of the stimulus on the breadth, shape, and order of rank- ing of the color fields as to breadth in sixteen meridians. Two sets of conditions have been used: high intensities, the fields having been taken with our rotary campimeter and spectrum lights; and medium Contributions to the Science and Practice of Ophthalmology 495 and low intensities, the fields having been taken with the perimeter described in the preceding section and pigment stimuli. Space will be taken here for a representation only of the results obtained under the second set of conditions. 1 In this second series of determinations five intensities of light reflected from pigment stimuli were used: the Hering standard pig- ments under 51, 17, 7, 3 and 0.03 foot-candles of light. In order to show how these illuminations compared with the day-light illumina- tion falling on the perimeter arm in an ordinary room, measurements were made of the daylight at the level of the perimeter in a room with a window, southern exposure, the lower sill of which was somewhat higher than the level of the perimeter arm placed in the horizontal. These measurements were made on a bright day, January 14, 1921. It was found that our highest intensity of illumination, 51 foot-candles, was the same as that falling on the perimeter arm at the fixation point when facing the window at 1 p. M. ; our second highest illumination, 17 f . c., was the same as that falling at the fixation point at 2.30 P. M. ; the third highest illumination, 7 f. c., the same as that falling on the fixation point at 3.45 p. M. ; and the fourth, 3 f. c., the same as that falling on the fixation point at 4.15 P. M. Measurements were also made with the perimeter placed parallel to the window. Our second illumination, 17 f. c., was the same as that falling on the fixation point at 11 A. M.; the 7 f. c. illumination, at 1.30 P. M.; and the 3 f. c. illumination, at 2.30 P. M. The decrease of illumination from 51 to 3 foot-candles narrowed the limits for red by an amount ranging from 11 to 37 degrees; blue, 13 to 37 degrees; and green 10 to 19 degrees, a result, it will be remembered, which was produced by a change of illumination equal to that which occurred from 1 to 4.15 P. M. in a well-lighted room on a bright winter day. The decrease of illumination from 51 to 0.03 foot-candles nar- rowed the limits for red by an amount varying from 27 to 72 degrees ; blue, 29 to 61 degrees; and green, 22 to 45 degrees (Figs. 7 to 13). Since this perimeter, with its pigment stimuli different from those now in use in office and clinic work, and its standardization and con- trol of factors, introduces a new situation in perimetry, it becomes 1 For the results for the first set of conditions, the reader is referred to The Extent and Shape of the Zones of Color Sensitivity in Relation to the Intensity of the Stimulus Light, Amer. Jour. Physiol. Optics, 1920, i, 185-213; Factors Which Influence the Color Sensitivity of the Peripheral Retina, Trans. Amer. Ophthal. Soc., 1920; The Absolute Limits of Color Sensitivity and the Effect of Intensity of Light on the Apparent Limits, Psych. Rev., 1920, xxvii, 1-23. 496 C. E. FERREE AND G. RAND necessary to determine a norm for the color fields under the new con- ditions to serve as a standard or basis for comparisons. This work is in Fig. 7. Fields taken under 51 foot- candles of light, an illumination equal to the daylight falling on the perimeter at the fixation point when facing a window on a bright day, 1 P. M. Fig. 8. Fields taken under 17 foot- candles of light, an illumination equal to the daylight at the fixation point, perimeter facing a window on a bright day, 2.30 P. M., or at 11 A. M., perim- eter parallel to window. Fig. 9. Fields taken under 7 foot- candles of light, and illumination equal to the daylight at the fixation point, perimeter facing a window on a bright day, at 3.45 P. M., or at 1.30 p. M., perimeter parallel to window. Fig. 10. Fields taken under 3 foot- candles of light, an illumination equal to the daylight at the fixation point, Serimeter facing a window on a bright ay at 4.15 p. M., or at 2.30 p. M., perimeter parallel to window. progress but has not yet been finished. Average fields for blue, red, and green have been determined for 35 normal observers just as the Contributions to the Science and Practice of Ophthalmology 497 perimeter stands, i. e., with 17 foot-candles of light on the test object and with the controls described (Fig. 11). As fast as possible studies will be made also of typical pathologic cases, also of normal and Average color fields Fig. 11. Fields for blue, red, and green, for 35 normal observers. Fields for blue Fig. 12. Showing variations in both the extent and the shape of the color fields when taken under 51, 17, 7, 3, and 0.03 foot-candles of light. Fields for red Fields for green Fig. 13. Showing variations in both the extent and the shape of the color fields when taken under 51, 17, 7, 3, and 0.03 foot-candles of light pathologic cases at a suitably selected lower illumination. An other feature of the advance work will be to ascertain how far if at all the determination of central sensitivity can be substituted for field taking 32 498 C. E. FERREE AND G. RAND in the diagnosis of pathologic conditions; and how valuable as a supplement such determinations are in a diagnostic program. The quickness and the superior ease and precision with which the determi- nation of central sensitivity can be made are strong points in favor of its use in practical work. A further advantage is that the determi- nation can be readily made with the eye corrected for defects in refraction. III. THE ACUITY LANTERN This apparatus was devised in response to a request by the Eye Division of the U. S. Naval Hospital for a means of making a quick and accurate test of acuity at low illumination. Experience has shown, roughly speaking, that only 25 to 30 per cent, of the men on the battle- ships have a sufficiently keen acuity at low illuminations to qualify for all branches of the lookout and signal service work. The apparatus provides for a wide range of illumination in just noticeably different steps (beginning at 0.07 meter-candle or lower) with no change in the color value of the light and with a specification at each step of the intensity of light falling on the test-object. For use in laboratory and clinic work the original apparatus has been elaborated to serve the following purposes : (a) for testing acuity with a means of varying, controlling and specifying the amounts of light used over a wide range of intensity of illumination; (b) for de- termining the exact amount and location of an astigmatism with great delicacy and precision and for using at will either the visual angle or the illumination scale for the detection of errors in refraction or in their correction; (c) for testing the light and color sense in terms of the amount of light required just to arouse the light and color sensations; and (d) for varying independently the saturation and brightness of a color and for color mixing. Among the requirements for an apparatus for determining acuity at low illuminations or the effect of change of illumination, the following points may be mentioned: (1) A means of changing the illumination by small amounts over a wide range, beginning at or below the thres- hold for the test-object employed, without changing the color value of the light. If in making this change the color value of the light is altered it is obvious that another factor affecting the results is intro- duced. (2) A means of keeping constant for an indefinite length of time any desired intensity of illumination and of reproducing this intensity at will. (3) A means of specifying accurately at any point in Contributions to the Science and Practice of Ophthalmology 499 the scale the intensity of light falling on the test-object; and (4) it is desirable that the apparatus employed for controlling the illumi- nation can be used with the test-objects already accepted in clinic practice. The most difficult problem one has to face in constructing an appa- ratus for determining the minimum amount of light that permits of the discrimination of a given test-object, more particularly if that object consists of a line of test letters, is to secure a uniform illumina- tion of the line. We were able satisfactorily to meet this difficulty in only one way, namely, by selecting an aperture sufficiently small to permit of its uniform illumination and projecting a magnified image of this aperture on the test card. That is, an aperture was selected of such a size and shape that when magnified five-fold it gave a band of light which just blocked off one line of the test letters. It is obvious that this aperture could be made of different sizes and shapes depend- ing upon what is wanted in the projected image. For example, two or three lines of test letters could be blocked off if desired, or the whole card or any part of it could be illuminated, etc. There is no reason, moreover, why the aperture could not be made adjustable in size to suit the needs and preferences of the individual operator. In one model of the apparatus these apertures were cut in a series of slides which could be inserted in the projection tube just outside the lamp house in grooves in a light-tight boxing. A convenient means was thus provided for changing the aperture, if desired, during a series of tests without having to open the lamp house. The source of light is a well-seasoned Mazda C lamp of the round bulb or stereopticon type of 100, 250 or 500 watts, depending upon the range of illumination that is desired. The lamp is installed vertically in the roof of the lamp house at such a height that its filament is well above the aperture which is to be illuminated. In order to secure a uniform and diffuse illumination of the aperture the lamp house is lined with opal glass ground on one side. The aperture, 6x1 cm., is cut at the center of the cap covering the inner end of the projection tube. Further to aid in the even illumination of the aperture it is covered with a slide of ground glass. The changes in the intensity of light are produced by means of an iris diaphragm. When such a diaphragm is placed either at the front or back surface of the focusing lens, changes in the flux of light can be produced without any alteration in the size or the shape of the image produced by the lens, just as happens, for example, in the action of the iris of the eye. At a suitable point in the circum- 500 C. E. FERREE AND G. RAND ference of the diaphragm is fastened a pointer which, as the diaphragm is opened and closed, moves over a translucent millimeter scale. This scale is mounted over a slot in the projection tube and receives its illumination from the light inside of the tube. The inside of the tube is painted a mat black. At the further end of the projection tube, 18.1 em. from the illuminated aperture, in a brass ring and collar is mounted the focusing lens. This lens is 7.5 cm. in diameter and has a focal length of 14.8 cm. On the platform supporting the lamp house Fig. 14 are mounted a small Weston ammeter and a small rheostat to guard against fluctuations in the current and consequent fluctuations in light intensities. In order that any line of the chart may be illumi- nated at will, the lamp house is mounted on the end of a rod which is raised and lowered by means of a rack and pinion. The test card is mounted at a distance of 81 cm. from the focusing lens. A photo- graph of the apparatus is shown in Fig. 14. In order that the intensity of light used at any time may be known, a calibration chart is provided in which are given the readings on the millimeter scale and the equivalent meter-candle values at the test Contributions to the Science and Practice of Ophthalmology 501 card. This calibration was accomplished as follows : The lamp house was removed and mounted on a photometer bar at a distance from the photometer head equal to its original distance from the test card. The scale was then gone over point by point and the meter-candle value of the light at the photometer head was measured. These values were corrected to conform- at the center of the card to the cosine law. 1 For our own use in the laboratory we have preferred to substitute for the Snellen chart a single test character, the broken circle (the international test-object), which can be turned in different directions and the judgment of its direction rather than the recognition of the character be required of the observer as a test of discrimination. Our reasons for this preference are as follows: (1) A test letter may be recognized when it is not seen at all clearly. Recognition is too de- pendent on extraocular functions to be used with precision as a measure of ocular capacity. (2) The different letters of the Snellen chart set an unequal task for the resolving power of the eye. (3) An objective check is had on the judgment. This is especially helpful in case of children and the unintelligent, untrained, or subjective type of adult. (4) By the use of the same test character turned in different directions at will all possibility of learning the test series is eliminated. Also the test-object becomes more valuable for the detection of astigmatisms. And (5) at low illuminations the eye fatigues very rapidly. Thus if the task is the reading of the whole line of letters the results obtained measure not only acuity, but the power to sustain acuity which may or may not be compatible with the purpose of the test. 1. THE USE OF THE ILLUMINATION SCALE FOR THE DETECTION OF SMALL ERRORS IN REFRACTION AND IN THEIR CORRECTION. There are doubtless many ways in which sensitivity can be added to the acuity test for the detection of small errors in refraction and in their correc- tion. In connection with the problems which we have undertaken during the past ten years involving modifications and refinements in functional testing, three principles have come to light which can be used very effectively to this end : (1) An undue lag or slowness of dis- crimination and of making the adjustments needed for clear seeing. (2) A marked loss in power to sustain clear seeing. And (3) an in- crease in the amount of light required just to discriminate details in the standard acuity object. The devising of test methods based on 1 For the calibration chart and the calibration curve in which the divisions of the millimeter scale are plotted against meter-candle values at the test card, see Amer. Jour. Ophthal., May, 1920, iii. 502 C. E. FERREE AND G. RAND the first two of these principles has been treated of in former papers. The third alone will be considered here. The relation of the illumination scale to the detection of small errors in refraction and in their correction may be stated briefly as follows : Insofar as the test-object is concerned, clearness of seeing depends both upon the value of the visual angle subtended and the intensity of the illumination. It follows from this that either the illumination scale or the visual angle scale may be used for the detection of errors in refraction, i. e., in the diagnostic procedure either the illumination may be held constant and the visual angle varied, or the converse. Since the visual angle scale sustains by convention a 1 : 1 relation to acuity while acuity changes slowly with change of illumination for all but very low illuminations, the illumination scale possesses the greater sensitivity for the detection of small errors in refraction also the greater feasibility of contrivance and manipulation. Used in this way the illumination scale becomes in effect an amplifying scale some- what analogous to the use of the tangent scale in detecting small deflections in the magnet system of a galvanometer and has an ad- vantage in sensitivity in proportion to the amplification. In clinic practice it has been shown to be of particular value in determining the exact amount and placement of the correction of astigmatisms. That is, if the eye has equal resolving power in all meridians, the amount of light required just to discriminate the test-object in all meridians will be the same ; if the resolving power is not equal, the amount of light required will be different in the different meridians and different in proportion to the amplification represented by the illumination scale. This gain in sensitivity over the clinic methods is needed in particular to determine the exact amount of the correction in case of high astig- matisms and both the amount and exact placement of the correction in case of low astigmatisms. The checking up of a number of cases shows that the corrections by the clinic methods may be and fre- quently are off from 0.12 to 0.25 diopter in the strength of the cylinder and, in case of low astigmatisms, from 5 to 20 degrees in the placement of the cylinder axis. While errors of this magnitude may or may not be troublesome in the ordinary uses of the eye sometimes they are very troublesome indeed and perhaps always tend in time to increase the amount of the defect they do constitute a much more serious handicap, in fact an actual disqualification, for work or vocations re- quiring special ocular proficiencies, e.g., keen acuity, particularly keen acuity at low illuminations; speed in the use of the eye, especially Contributions to the Science and Practice of Ophthalmology 503 speed of discrimination and of making the adjustments needed for clear seeing; etc. Moreover a considerably greater amount of light is required as a comfortable and efficient working minimum by the poorly than by the well corrected eye. Indeed our experience with the tricornered relation of intensity of light, resolving power, and the retinal sensitivity to acuity has impressed us with the relative impor- tance of resolving power in explaining the difference in the amount of light that is required by different people as a working minimum. The relation of the intensity of illumination to acuity may be ills- trated by the curve shown in Fig. 15. This curve represents the average results for four observers, tested by Koenig. 1 In this curve acuity is plotted along the ordinate and intensity of illumination along the abscissa. It will be noted, for example, that a change of from 1 to t\ttcr- cattcl/es Fig. 15. Showing the effect of increase in intensity of light on acuity (four observers), acuity plotted against meter-candles of light normal to the surface of test-object. 9 meter-candles, an increase of 800 per cent, in the intensity of illumi- nation, produced an increase of only 74 per cent, in acuity; and a change from 9 to 100 meter-candles, an increase of 1011 per cent, in illumination, produced an increase of only 28 per cent, in acuity. The amplification within the latter range of illumination is doubtless too great for feasibility of application. That is, too wide a range of illumination would have to be used to compensate for the difference between the resolving power in the poorest and best meridians in the ordinary run of astigmatisms. The range from 1 to 9 meter-candles is, however, quite feasible and the relation between the two scales gives abundant sensitivity. These values fall within the range given by the apparatus described in the preceding chapter, 0.07 to 9.5 meter- candles. The testing of a large number of astigmatisms with this 1 Ueber die Beziehung zwischen der Sehscharfe und der Beleuchtungsintensitat. Verhandl. der Physikal. Ges. in Berlin, 1885, xvi, 79-83. 501 C. E. FERREE AND G. RAND apparatus showed that in the majority of cases the minimum amount of light required for the discrimination of the opening in the broken circle (visual angle, 1 min.) in the most favorable meridian was of the order of 1 to 3 meter-candles ; in the least favorable meridian, of the order of 6 to 9.5 meter-candles or more. A very convenient apparatus for using the illumination scale for detecting low astigmatisms and small errors in the amount and place- ment of their correction has been described in the chapter immediately pfcceding. For this purpose the lantern was used to give the varia- tions in illumination needed and the broken circle served as the test- object. The broken circle was fastened at the center of a graduated dial the opening of which (visual angle, 1 min.) could be turned into any meridian that was desired. The angle of turning could be read in terms of the divisions of the dial which was graduated to correspond to the readings on the trial frames used in office and clinic work. Doubtless the apparatus can be used for the detection of astigma- tisms in different ways depending upon the experience and preference of the operator. The quickest and most feasible method is first to make an approximate determination of the amount and placement of the correction by the clinic methods and employ the illumination method only for a more precise determination. In using this method as a refinement in the clinic methods, the procedure we ordinarily employ is as follows : The patient's eye is fitted with a cylinder of the strength and placement indicated by the clinic tests and the minimum amount of light required to discriminate the opening in the circle is determined in four positions, two in the meridian of the cylinder-axis and two in the meridian at right angles to this. If the minima are not equal in these four positions, the cylinder-axis is shifted and the determinations are made again, the four positions of the opening of the circle always being in the meridian of the cylinder-axis and the meridian at 90 degrees from it. If no placement of the cylinder is found which gives equal minima for the four positions, the strength of the cylinder is changed. The strength and placement of cylinder which requires both equal and the smallest amounts of light for the four positions of the test-object is accepted as the final correction. In the testing and demonstration of the sensitivity and service- ability of the illumination method for determining the exact amount and placement of the correction of an astigmatism the following types of material have been selected: (1) Artificial astigmatisms made with 'cylinders of low diopter value. In choosing to include artificial astig- Contributions to the Science and Practice of Ophthalmology 505 matisms in this work it should be understood that we did not consider the artificial astigmatism the precise functional equivalent of the natural astigmatism. We are too strongly impressed with the possi- bility that the astigmatic eye may progressively acquire power to compensate in part for its defect to be of this opinion. They were selected because we wished to have in one set of cases an exact knowledge of the amount and location of the defect as a check on the determinations made by the test. (2) Natural astigmatisms without a cycloplegic. (3) Office and clinic cases with a cycloplegic. The dif- ference in result between the most and least favorable meridians or between a true and false correction have thus far been of a consider- ably greater order of magnitude with than without a cycloplegic either in case of a natural or an artificial astigmatism. (4) Office and clinic cases in which the apparatus has been used merely to check up correc- tions already made by the clinic methods, objective and subjective. Among these cases it was comparatively rare to find one in which the minimum amount of light required to discriminate the test-object in the corrected meridian was equal or nearly equal to that required in the other meridians. Indeed in some cases the difference between the most and least favorable meridian exceeded the range of variation obtainable with the apparatus when provided with the 100-watt lamp. And (5) irregular astigmatisms. 1 In our own work we have found that the apparatus would be very helpful if it were used only to check up the corrections made by the clinic methods and were not employed further as an aid in finding out the exact amount and placement of the correction. For example, but very few minutes are required to determine with it whether any given correction equalizes or levels up the resolving power of the eye in the different meridians. The advantage of a checking method which is definite and at the same time feasible can readily be appre- ciated by any one who has tried to decide by the clinic methods in any wide range of cases just what should be the exact amount and place- ment of the correction of an astigmatism. The method has its chief value perhaps in those cases in which it is particularly difficult to make a decision by the clinic methods, that is, in determining the exact amount of the correction in case of high astigmatisms and both the 1 For data showing the sensitivity of the method, see Visual Acuity at Low Illumination and the Use of the Illumination Scale for the Detection of Small Errors in Refraction, Amer. Jour. Ophthal., June, 1920, iii; Sensitivity of Illumi- nation Scale for Determining Exact Amount and Placement of Correction of Astigmatism, ibid., January, 1921, iv. 503 C. E. FERREE AND G. RAND amount and placement of correction in case of low astigmatisms. The simple character of the judgment, namely, the mere indication of the direction in which the opening of the circle points instead of the more difficult task of deciding under the comparatively rough conditions of the office and clinic test whether this or that placement or strength of cylinder gives the clearer vision, together with the objective check on the correctness of each judgment, also contribute to make the method especially valuable in case of children, and the subjective, unintelli- gent or untrained type of adult. A further advantage of the method as worked out in connection with the present apparatus is its great sensitivity for the detection of irregular astigmatisms. The lack of satisfactory tests for this troublesome defect is generally conceded. 2. AN ATTACHMENT FOR TESTING THE LIGHT AND COLOR SENSE. A consideration of the foundation principles of the acuity apparatus reveals at a glance that they lend themselves readily to light and color sense testing for clinic purposes. In order to convert the appara- tus in the form described in this paper into a light sense tester three features are needed: (a) the choice of an aperture such that when magnified fivefold a stimulus is obtained of a size and shape suitable for a sensitive judgment of the threshold of sensation; (b) the pro- vision of a suitable surface on which to project the magnified image of the aperture; and (c) means of reducing the intensity of light from the acuity threshold to the light sense threshold, i. e., from the amount needed just to discriminate the standard acuity object to the amount needed just to arouse the light sensation. The iris diaphragm used in the present form of apparatus, range of pupil 5 to 65 mm., does not provide for this range of intensity without changing the source of light. It is obvious that an attachment for the further reduction of the light which does not interfere in any way with the use of the apparatus for the acuity work, would afford a more convenient means of securing the lower intensities than the changing of the source of light. Provision has been made for this in two ways: (a) by neutral absorption screens or filters; (b) by a Nicol prism (polarizer and analyzer) ; and (c) by a metal plate which may be made to move by minute amounts across the aperture of the iris diaphragm by a screw adjustment. The advantage of the two latter devices over the perish- able filter is their very greatly superior constancy and permanency. The advantage of the moving plate over the Nicol prism is its extreme simplicity. The optical principle on which the use of the moving plate is based is that the image receives light equally from all parts of the Contributions to the Science and Practice of Ophthalmology 507 lens, therefore the transmission of light through any segment of the lens, whatever the size or shape of that segment, gives an equal distri- bution of light in the image. The attachment is made so that it will hold any of these reducing agencies, leaving the operator an option as to which shall -be used. It is fastened to a narrow collar which slips over the end of the projection tube of the lantern and is held in place by a set-screw. The testing of the color sense is provided for by inserting color filters in the beam of light. These filters are inserted in the attach- ment just described immediately in front of the lens and the intensity of light is cut down to threshold value by means of the iris diaphragm. Color sense apparatus for clinic purposes seems at present, so far as the central field is concerned, to be limited to the testing of such gross deficiencies as are classed as color blindness. They are of little use for detecting the smaller changes which mark the advance and recession of many pathologic conditions. The present apparatus is designed for detecting and measuring the degree of deficiency in terms of the amount of light of a given range of wave-lengths which is required just to arouse the color sensation. It can be used, however, for testing color blindness in the conventional way by throwing the full strength of color on the test surface, or if a still higher intensity of light is wanted, by turning the lantern around to face the observer, instead of the test surface, and using the full strength of the beam. If desired, a ground glass plate can be inserted in the filter holder to diffuse the light and eliminate glare, or any strength of neutral filter to cut down the intensity. Also by means of the iris diaphragm the area of the colored surface may be varied from 5 to 65 mm. 3. AN ATTACHMENT FOR VARYING INDEPENDENTLY THE SATURA- TION AND BRIGHTNESS OF A COLOR AND FOR COLOR MIXING. The attachment just described can be made into the form of a simple filter holder, or it can be made to serve the purposes noted above. We have constructed both types of attachment. The simple filter holder is made from three grooved metal strips 8 cm. long and of appropriate width and thickness, built into a three-sided rectangular figure open at the top. It is fastened to a narrow collar which slips over the end of the projection tube of the acuity lantern and is held in place by a set- screw. The more elaborate holder which can be made readily to serve the purposes of both attachments is constructed as follows : A frame holding one filter is made to travel from below in a groove across the aperture in the iris diaphragm by means of a screw motion. A second 508 C. E. FERREE AND G. RAND frame holding a filter or opaque plate as may be desired, also operated by a screw, is made to travel from above in the same groove across the aperture in the iris diaphragm in the opposite direction. Each screw is furnished with a large head with a finely graduated beveled edge. As the screw is turned this head travels along a vertical mm. scale. Thus the position and movement of the filter can at any time be determined with great exactness and the scale be subjected to calibra- tion in terms of amounts of colored and colorless light. The optical principle upon which this attachment is based is that the image re- ceives equally light from every part of the lens. That is, when the colored filter covers a given segment of the lens aperture, the light transmitted is distributed uniformly through the image formed by the lens ; or when an opaque plate covers a segment of the lens the light from the remaining segment is distributed equally in the image. Thus with the possibility of using one colored filter alone, one colored filter and an opaque plate to vary the amount of white or unfiltered light which mixes with the colored light, or two color filters, quite a wide range of variation can be produced in the composition and intensity of the light of which the image is formed. For example, (a) by use of one filter the color may be mixed with any amount of the available white light, i. e., all the tints of the color may be produced from full satura- tion to white; (b) by the use of one filter and the opaque plate all degrees of saturation of the color at a constant brightness may be produced over a wide range of brightnesses and all the shades of the color from full saturation to black; and (c) by the use of two filters mixed colors can be produced with any proportion of the two com- ponents and of any brightness from full saturation to white. IV. THE EFFECT OF VARYING THE INTENSITY AND COMPOSITION OF LIGHT ON ACUITY, SPEED OF DISCRIMINATION, SPEED OF ACCOM- MODATION, AND OTHER IMPORTANT OCULAR FUNCTIONS Space will be taken at this point only for an abstract of two articles bearing on the above topics. 1 One of our reasons for conducting studies of this type and for bringing them to the attention of the ophthalmologists is that we may enlarge our knowledge of the princi- ples and possibilities of functional testing in relation to diagnosis and 1 The Effect of Variations in Intensity of Illumination on Functions of Impor- tance to the Working Eye, Trans, of the Illuminating Engineering Society, 1920, xv, 769^801; The Effect of Variation of Visual Angle, and Intensity and Composition of Light on Important Ocular Functions, Trans. Illuminating Engineering Soc., Feb., 1922, xvii. Contributions to the Science and Practice of Ophthalmology 509 other important applications, and broaden our understanding of clear seeing and the factors upon which it depends. In these articles the effect of increase of intensity of light is shown on the following functions : acuity, power to sustain acuity, speed of discrimination, and speed of adjustment of the eye for clear seeing at different distances. Wide ranges in change of illumination were used. The effect was found to be very much greater on the latter three than on the first of these functions. It was measured both on normal eyes and eyes with slight errors in refraction of a type and amount of frequent occurrence even in the corrected eye. The benefit of the increase was found to be considerably greater in case of these slight defects than for the normal eye. A comparison was made of the effect of increase of intensity of illumination and increase of size of visual angle. The importance of testing the neglected aspects of acuity: speed and power to sustain, in relation to diagnosis, vocational selection and hygiene or welfare work on the eye was demonstrated, and a comparison was made of their sensitivity and that of acuity and speed of adjustment, as test features for picking up small differences in the functional powers of the eye. The investigation was also extended to include the effect of varia- tions in the composition of light on acuity, power to sustain acuity and speed of discrimination. Two intensities of light at seven points in the spectrum were used, all made photometrically equal at each intensity. The highest acuity, speed of discrimination and power to sustain acuity were found in the mid-region of the spectrum (maxi- mum in the yellow) even though, as is well known, lenses have their highest resolving power for the short wave-lengths. Again speed of discrimination and power to sustain acuity were much more affected by the change in the illumination condition (change of wave-length) than acuity. The relative importance of resolving power of the re- fracting media and resolving power of the retina is discussed in rela- tion to the effect of changes in composition of light on acuity, speed of discrimination and power to sustain acuity. Two comments are added: (1) All of the functions referred to above are aspects of acuity. They are aspects, however, which are not brought out by the conventional method of testing acuity. The conventional test of acuity takes little account of either speed or power to sustain, two aspects which are not only of great importance to the working efficiency of the eye, but are extremely sensitive indicators of differences in functional power, whether' due to fatigue, 510 C. E. FERREE AND G. RAND bad conditions of seeing, or refractive and pathologic disturbances. Add either of these aspects to the method of testing acuity and the effect is very similar, so far as sensitivity is concerned, to that ob- tained when an amplifier is added to a physical recording instrument. For example, changes of intensity of light which produce compara- tively small differences in acuity, as ordinarily tested, cause very large changes in the speed of discrimination and the power to sustain acuity. The conventional acuity test is, comparatively speaking, not only insensitive, but it is not sufficiently comprehensive in the range of aspects covered to bring out differentially some of the most important functional powers of the eye. (2) Considered with reference to the eye there are three factors in acuity or the power of the eye to see clearly the resolving power of the refracting media, the space discrimination of the retina, and its sensitivity to light. To put it another way, there are the resolving power of the refracting media, or the power to form clear images on the retina; and the resolving power of the retina, or the power to discriminate detail in the physical image formed. Considered with reference to the stimulus light, six factors may be mentioned which are effective in acuity the physical factors: intensity, wave-length, and purity of light; and their three subjective aspects: hue, satura- tion and brightness. Of these the wave-length and purity alone affect the resolving power of the refracting media or the power to form clear images. Intensity, hue, saturation and brightness affect the power to discriminate detail in these images, or what we have called the resolving power of the retina. For example, the benefit of the increase of intensity of illumination, cited above, came through the effect on the resolving power of the retina, not of the refracting media. Again the wave-lengths in the middle of the spectrum gave the highest acuity, speed of discrimination and power to sustain acuity although the resolving power of the refracting media is greater for the shorter wave-lengths. Here the effect. of the more favorable hue and saturation of these colors (yellow, etc.) on the retina's power of discrimination more than compensated "for the effect of wave- length on the resolving power of the refracting media. A third point is, the acuity and speed of the eye is greater for green light than for red; but the converse is true for the power to sustain. Doubtless the explanation here is that the refracting system has a higher re- solving power for green than for red; but the retina sustains its re- solving power better for the red than for the green, probably due in Contributions to the Science and Practice of Ophthalmology 511 part to the greater activity of the "streaming phenomenon" under the shorter wave-lengths, which is readily observed in the experi- ments on the power to sustain. A final striking example of the interplay of these two types of resolving power is the difference in the effect of wave-length on acuity in the microscopic field and in the visual field. In the microscopic field the shorter wave-lengths bring out detail more clearly, while in the visual field the longer yellow waves give the higher acuity. In the latter case the eye views its image directly; in the former, an image of the object formed by an accessory refracting system. That is, in the former case the relative importance of the refractive resolving power is greatly exaggerated. A discrepancy should be expected, therefore, between the effect of wave-length of light on acuity as represented in the natural eye and in the eye whose refracting powers are amplified by means of a micro- scope. In one case the resolving power of the retina is dominant; in the other the resolving power of the refracting system. Both in administering to the welfare and comfort of the eye and in testing its powers analytically for diagnosis and other purposes, it seems important to know what factors influence the resolving power of the refracting media; what the resolving power of the retina; and, roughly speaking, in what proportions they combine to influence the total result in clear seeing. V. THE ILLUMINATION OF TEST CHARTS The question frequently comes before standardizing committees: At what intensity of illumination should acuity be tested? Our answer would be, It depends for what purpose the test is to be made. There are three obvious applications of acuity testing: vocational selection, diagnosis, and hygiene or welfare of the eye. In the rating of eyes as to fitness for vocations, the test should be made as nearly as possible at the illumination usually employed in the vocation in question. The study of even a small number of cases shows that the eye can not be given the same relative rating as to acuity at different intensities of illumination. For example, ex- perience has shown in the navy that only 25 to 30 per cent, of the men accepted for the service on the basis of the conventional acuity test at the higher illuminations are able to qualify for the lookout work at night on the bridge of the battleships. Further in a test of 61 ob- servers made by us, all under 28 years of age and rating 6/4 acuity by the conventional test with 5 foot-candles of light on the test chart, 13 per cent, rated below 6/6 at 0.55 foot-candle of light and 33 per 512 C. E. FERREE AND G. RAND cent, below 6/6 at 02 foot-candle. The acuity of the remainder was 6/6 or better at these illuminations. If speed in the use of the eye at low illuminations be added to the requirement, the scatter is very much greater still. The amount of time required just to discriminate 3 4 f & 7 . $ al et s'ap- plique aussi bien a I'astigmatisme qu'aux vices de refraction du type sph^rique. 522 EMILE JUNES Ces deux images possedent des caracteres parfaitement tranche's et sont facilement opposables Tune a 1'autre; leur difference est assez manifesto pour qu'elle ne puisse echapper meme aux sujets les plus bornes. En outre, le second aspect du cadran, par exemple, qui se produit tant que 1'image de ce cadran ne se fait pas exactement sur la ratine, est remplace par le premier d'une maniere immediate, brusquement pour ainsi dire (tout au moins en pratique), au moment ou 1'ame'tropie du meridien se trouve completement corrigee. Ajou- tons que ce phenomene optique se presente avec nettete meme avec une acuite visuelle notablement reduite, pourvu cependant que celle- ci ne descende pas au dessous d'une certaine limite et que 1'oeil puisse distinguer tout au moins la disposition generale des lignes du cadran. L'application de ces donnees permet d'effectuer tres simplement le diagnostic et la mesure d'un vice de refraction quelconque, a la condition cependant qu'une distinction soit etablie entre les ametro- pies du type spherique et 1'astigmatisme. Dans le premier cas, 1'ex- amen d'un seul meridien, pris au hasard, permet de determiner la refraction generale de 1'oeil. Dans le second cas (il ne sera question ici que d'astigmatisme re*gulier), Pexamen devra porter exclusive- ment sur les deux meridiens a refraction extreme (meridiens princi- paux) : ce qui ne peut se faire que si leur orientation est deja connue. II y aura done lieu, chez les astigmates, de considerer un temps suple- mentaire dans lequel on recherchera prealablement cette orientation. TECHNIQUE DE LA METHODE Cette technique exige essentiellement le materiel suivant: (1) Un cadran horaire dont les lignes aient une certaine epaisseur (type du cadran de Green) ; (2) une monture d'essai double et dont la gradua- tion soit identique a celle du cadran; (3) un disque noir perce* d'une fente stenopeique et pouvant s 'adapter sur la monture prece'dente; 1 (4) les series convexe et concave des verres spheriques. 2 1 Nous conseillons de recourir aux lunettes d'essai et de rejeter, malgre tons leurs perfectionnements, les disques stenopeiques mobiles a manche ou a pied. II est indispensable, en effet, si le sujet est astigmate, que, pendant tout le cours de 1'examen, la fente soit maintenue dans une direction rigoureusement parallele a celle du meridien qu'elle delimite. C'est pour la mme raison que nous con- seillons de toujours placer le disque dans la rainure posterieure de la lunette; outre que la fente, grace a son rapprochement de 1'oeil, encadre plus etroitement le me'ridien examind, on 6vite mieux ainsi son d6placement lore de 1'emploi ulterieur des verres. 2 On pourrait avoir recours a un optometre du type Badal, muni d'une fente stenopeique et dont la photographie representant l'6chelle visuelle serait remplacee par celle d'un cadran horaire. Mais, pour la raison exposee dans la note pre- cedente, son emploi dans 1'astigmatisme pourrait donner lieu a des erreurs. Le Diagnostic et la Mesure des Vices de Refraction 523 On examine chaque oeil separement. Le sujet etant place a 5 metres du cadran horaire, on 1'invite a definir 1'aspect de ce cadran vu a 1'oeil nu. Trois cas se presentent, selon que 1'oeil examine": (1) Ou bien distingue nettement toutes les lignes du cadran; (2) ou bien ne distingue nettement qu'une seule de ces lignes ou un petit groupe de lignes immediatement voisines (pour la commodite* de la description, nous designerons cet aspect du cadran sous la denomina- tion de "phenomene de la ligne noire"); (3) ou bien ne distingue nettement aucune des lignes du cadran. La technique se modifie legerement suivant le cas considere. Nous 1'etudierons, en supposant, une fois pour toutes: (1) Que 1'oeil ex- amine presente une integrite absolue de ses milieux transparents es de ses elements sensoriels; (2) que le muscle ciliaire possede toute son activite fonctionnelle. PREMIER CAS LE SUJET DISTINGUE NETTEMENT TOUTES LES LIGNES DU CADRAN. L'oeil examine n'est pas astigmate. II peut etre emmetrope, myope de tres faible degre ou hypermetrope ac- comodant pour Finfini. Nous envisagerons successivement : (1) L'encadrement de cet oeil par la f ente stenopeique ; (2) le diagnostic de son etat de refraction; (3) la mesure, s'il y a lieu, de son degre d'ametropie. 1. Mise en Place de la Fente Stenopeique. L'oeil est muni de la monture d'essai, sur la rainure posterieure de laquelle on adapte le disque stenopeique. La fente peut etre disposee suivant une orienta- tion quelconque; tous les meridiens possedant le meme pouvoir re- fringent, Ton n'a, en effet, a examiner ici qu'un seul meridien, pris au hasard. 2. Diagnostic de I'Etat de Refraction. II resulte de 1'aspect que prend le cadran apres 1'application du disque stenopeique. Ou bien son aspect ne change pas, c'est a dire que toutes les lignes du cadran continuent a etre pergues avec la meme nettete. Dans ce cas, 1'oeil est emmetrope ou hypermetrope. Plagons devant la fente (dans la rainure anterieure de la lunette), un verre convexe de faible puissance. Si 1'aspect du cadran reste le meme, c'est que 1'oeil est hypermetrope; dans le cas contraire, si le phenomene de la ligne noire se manifesto, 1'oeil est emmetrope. Ou bien 1'aspect du cadran se modifie: le phenomene de la ligne noire apparait. Dans ce cas, 1'oeil est myope. 3. Mesure du Degre d'Ametropie. L'oeil est myope L'applica- tion de la fente a fait apparaitre le phe'nomene la ligne noire. 524 MILE JUNES Flagons, devant la fente, des verres concaves de degre croissant. Le verre le plus faible qui provoque la disparition du phe'nomene, en rendant e"galement nettes toutes les lignes du cadran, mesure le degre de la myopie. L'oeil est hyperine" trope. L'application du disque n'a pas modifie 1'aspect du cadran vu a 1'oeil nu. Faisons passer, devant la fente, des verres convexes de degre croissant. L'un de ces verres provoque 1'apparition de la ligne noire; celui qui le precede imme*diatement mesure le degre" de 1'hypermetropie. DEUXIEME CAS LE SUJET DISTINGUE NETTEMENT UNE SEULE LIGNE DU CADRAN ou UN GROUPE DE LIGNES IMMEDIATEMENT VOISINES. L'oeil est astigmate. Son diagnostic devra se faire ex- clusivement suivant les deux meridiens a refraction extreme. Ces deux meridiens seront examines successivement et, pour chacun d'eux, on determinera: (1) Son orientation; (2) son isolement au moyen de la fente stenopelque; (3) son e"tat de refraction; (4) s'il y a lieu, le degre" de son ametropie. L'exainen du premier meridien servira de type a notre description. 1. Orientation du Meridien. L'astigmate, place en face du cadran, ne pergoit nettement qu'une seule des lignes qui le composent, par- fois un groupe de lignes immediatement voisines (phenomene de la ligne noire). Or, la direction de cette ligne se trouve etre precise- ment celle d'un meridien principal. On la releve, en lisant, sur le cadran, le degre qui lui correspond. 2. Isolement du Meridien. L'oeil e"tant muni de la monture d'essai, on dispose le disque dans sa rainure posterieure, de telle fagon que la fente soit exactement orientee suivant le degre indique; 1 des lors, on veillera, pendant toute la dure"e de 1'examen, a ce que cette direction soit rigoureusement maintenue. 3. fitat de Refraction du Meridien. Le meridien, ainsi isole, peut etre emmetrope, myope ou hypermetrope accommodant pour 1'infini. Deux cas se presentent. Ou bien, 1'aspect du cadran, vu a travers la fente ste'nope'ique, ne change pas, c'est a dire que le phenomene de la ligne noire persiste; le me*ridien est myope. Ou bien, cet aspect change; le phenomene de la ligne noire dis- parait et toutes les lignes du cadran sont vues avec la meme nettete : 1 Si 1'on ayait affaire a un groupe de deux lignes noires, la fente serait orientee suivant la bissectrice de Tangle forme' par ces deux lignes; si ce groupe com- prenait trois lignes, son orientation serait celle de la ligne intermediate. Le Diagnostic et la Mesure des Vices de Refraction 525 le me'ridien est emmetrope ou hyperme'trope. Disposons, devant le disque, un verre convexe de faible puissance. Si le phe'nomene de la ligne noire reapparait, on a affaire a un me'ridien emme'trope; sinon, si toutes les lignes persistent avec une egale nettete, le meridien est hyperme'trope. 4- Degre d'Ametropie du Meridien. Considerons successivement le cas d'un meridien myope et celui d'un me'ridien hyperme'trope: Gas d'un meridien myope La fente ste'nopeique a laisse" persister le phe'nomene de la ligne noire apparu a 1'oeil nu. Faisons passer, devant elle, des verres concaves de degre croissant. Le verre le plus faible qui provoque la disparition du phenomene et rend toutes les lignes du cadran egalement distinctes, mesure le degre" de myopie du me'ridien. Cas d'un me'ridien hypermetrope. La fente ste'nope'ique a fait disparaitre le phe'nomene de la ligne noire. Flagons, devant cette fente, des verres convexes de degre croissant. L'un d'eux provoque la reapparition du phenomene. Celui qui le precede imme'diatement mesure le degre d'hypermetropie du me'ridien. Nous serons plus bref en ce qui concerne 1'examen du second meridien. La fente sera disposee suivant une direction exactement perpendiculaire a celle qu'elle occupait precedemment (les deux meridiens principaux e"tant, comme on le sait, perpendiculaires entre eux). L'aspect du cadran, Examine a travers la fente ainsi oriente"e, nous permettra, grace aux notions qui viennent d'etre exposees, de diagnostiquer 1'etat de refraction du second me'ridien et de mesurer, s'il y a lieu, son degre" d'ame'tropie. Comme on le voit, Pemploi de la fente ste'nope'ique et du cadran horaire nous donne le moyen de mettre en evidence 1'un des elements indispensables au diagnostic de Fastigmatisme : la puissance diop- trique des deux meridiens principaux. Des lors, connaissant la direc- tion de ces meridiens, on peut etablir la formule ne"cessaire a la pre- scription des verres correcteurs. TROISIEME CAS LE SUJET NE DISTINGUE NETTEMENT AUCUNE DES LIGNES DU CADRAN. II s'agit, dans ce cas, soit de myopie, soit d'hypermetropie accompagnee d'un deficit plus ou moins marque" de raccomodation pour 1'infini. 1'une ou 1'autre pouvant etre simple ou compliquee d'astigmatisme. Nous aurons a diagnostiquer: (1) La nature de 1'ame'tropie ; (2) son degre*. 1. Nature de I'Ametropie. On la determine avec le seul secours du cadran horaire. Flagons, devant 1'oeil examine", tout d'abord les 526 EMILE premiers verres de la serie concave. Si les lignes du cadran de- viennent toutes e"galement plus distinctes, on a affaire a .de la myopie simple; si 1'une seulement de ces lignes devient plus nette, c'est qu'il s'agit d'astigmatisme compose myopique (meridiens principaux tous deux myopes); 1'on note soigneusement alors la direction de cette ligne. Les verres concaves n'ameliorent-ils pas la vision, Ton pro- cedera de la meme maniere avec les verres de la serie convexe ; ceux- ci nous feront savoir s'il s'agit d'hypermetropie simple ou d'astig- matisme compose hyperme'tropique (meridiens principaux tous deux hypermetropes) . II est preferable de commencer par les verres concaves, car les formes myopiques sont les plus frequentes. 2. Degre de V Ametropie. Sa determination necessite 1'interven- tion du disque stenopeique. La mise en place de la fente differe selon que Ton est en presence d'une ametropie du type spherique ou d'astigmatisme. Dans le premier cas, la fente encadrera un meridien quelconque, pris au hasard; dans le second cas, il faudra la disposer successivement suivant les deux meridiens principaux. Le meridien ainsi encadre est, nous venons de le voir, myope ou hypermetrope avec accommodation deficiente pour Pinfini. Quelle que soit la nature de son ametropie, la simple application du disque au devant de la cornee determine 1'apparition du phenomene de la ligne noire. 1 Le changement que subit cet aspect du cadran sous 1'influence de verres spheriques surajoutes permet de mesurer le degre d'ame*tropie du meridien. Cas d'un meridien myope. Ici encore, le degre de myopie est determine par le verre concave le plus faible qui fait disparaitre le phenomene de la ligne noire en rendant toutes les lignes egalement nettes. Cas d'un meridien hypermetrope. Faisons passer, devant la fente stenopeique, des verres convexes de degre croissant. A un moment donne, par suite d'une correction partielle de 1'hypermetropie, 1'ac- comodation produit son plein effet: Le phenomene de la ligne noire disparait et toutes les lignes sont pergues avec la meme nettete. Continuons a interposer des verres de degre de plus en plus eleve; 1'un d'eux fera reapparaitre le phenomene; le verre qui le precede donnera le degre d'hypermetropie cherche*. 1 L'apparition de cette ligne est immediate si le degre d'ame'tropie n'est pas trop eleve et permet d'entrevoir tout au moins la disposition gne"rale des lignes du cadran; dans le cas contraire, le phe'nomene n'apparait qu'apres interposition d'un verre corrigeant partieilement cette am6tropie. Le Diagnostic et la Mesure des Vices de Refraction 527 AVANTAGES DE LA METHODE Cette methode comporte plusieurs avantages: 1. Elle n'exige aucun outillage nouveau. Bien plus, elle simplifie 1'outillage existant, grace a la suppression des verres cylindriques et parce que le cadran horaire est susceptible d'un usage universel, convenant aussi bien aux lettres qu'aux illettres et a ceux dont 1'ecriture ne correspond pas au type courant (Arabes, Russes . . .). 2. En raison de la simplicite et de la nettete du phenomene optique qui la caracterise, elle permet un examen rapide et precis des ame- tropies, quels que soient 1'etat de la refraction et Intelligence du sujet a examiner. 1 3. Sa superiority eclate specialement a propos de Fastigmatisme. A 1'encontre de la methode des verres cylindriques, nous avons affaire ici a une methode permettant de determiner, avec facilite et de prime abord, ce vice de refraction. 2 4. Pour conclure, nous dirons que cette methode, en ce qui con- cerne le diagnostic et la mesure des ametropies, est plus precise et moins malaisee a appliquer que la methode de Bonders. 3 Nous n'hesitons pas, en outre, a affirmer que, sauf pour certains cas tres particuliers (simulation, enfants trop jeunes, diminution trop con- siderable de 1'acuite visuelle . . .), cette methode peut soutenir la comparaison avec la plupart des methodes objectives. C'est ainsi qu'elle peut rendre les plus grands services a tous ceux qui ne sont pas familiarises avec les difficultes de la skiascopie ou qui, momentane- ment, ne peuvent disposer d'une installation appropriee a ce dernier mode d' investigation (armees en campagne, tournees ophtalmolo- giques dans le bled). 1 L'existence d'une contraction accomodative, frequente chez les jeunes sujets, peut e"tre une cause d'erreur a laquelle on remediera, ici aussi, par des instillations d'atrophine. 2 Ce qui rend si compliquee la determination de 1'astigmatisme par la seule methode des verres cylindriques, c'est que, les differents meridiens de la cornee laissant simultanement passer les rayons lumineux, 1'oeil, au cours du meme examen, peut accomoder tantot pour Tun, tantot pour 1'autre des meridiens principaux. Ici, par contre, du seul fait que les rayons ne traversent a la fois qu'un seul meridien, cette intervention d6sordonnee de 1' accommodation se trouve supprimee. * Elle ne saurait toutefois pas la remplacer completement. A la methode de Bonders est reserve", en effet, un role fort important et qui lui est propre. Com- plement obligatoire des autres m6thodes, elle intervient & titre de contr61e des que Ton aura effectue, a 1'aide de ces dernieres, le diagnostic et la mesure du vice de refraction. Elle nous renseigne alors sur 1'acuite visuelle de 1'oeil exactement corrige et nous fait connaitre le verre le mieux tolere et le plus utile. Elle permet ainsi une prescription plus appropri6e a l'6tat physiologique du sujet. ANOMALIES OF OCULAR DEVELOPMENT AND PIGMENTATION J. GRAY CLEGG, M.D., B.S., F.R.C.S. Manchester, England BILATERAL SYMMETRIC CONGENITAL CORECTOPIA WITH IRIDODONESIS AND MlCROCORIA ; MlCROLENTIS AND COLOBOMA LENTIS William S., male, aged fifty-eight. History. Always poor sight. Worked as stoker and engine tender. Could not see enough to gain much at school. One half -brother- and two half-sisters, all by one mother. All have good sight except the brother, who is short-sighted and wears glasses. No other member of family had eye trouble except one with squint. Patient has five daughters -and one son. All have normal eyes. Patient is of impression that when a child he was brought to the Manchester Royal Eye Hospital and was told sight was wrong way up. Sight got better as grew older until forty-six or so, but since then worse. Could just read newspaper with the left eye by holding near face and screwing eyelids up. Could only see headings of newspaper with the right. Never could obtain glasses to help. Came under my care about June, 1921, because he frequently ran against people in street. Condition on Admission, September 27, 1921 : Extrinsic muscles act well. Lids, conjunctivas, and lacrimal passages normal. Cornea clear, but a trifle smaller than normal. Diameter, 10 mm. vertically by 11 mm. horizontally. Anterior chambers rather deep. Irides and pupils as in sketch. Plane of irides flat and coronal. The tissue of the iris thin but thickened in immediate neighborhood of the pupils. Pupils reacted definitely to light. Drugs had no marked effect on the pupils, except that atropin alone brought about some dilatation, increasing the pupillary area to double its ordinary size. It was impossible to see through the pupils with the ophthalmoscope, but they lighted up well by transillumination, showing as small, irregular sided slits, the pupillary margins of the iris roughly dovetailing their prominence and fissures when contracting. With a strong loupe the stretched iris tissue appears as irregular alternating bands of blue and brown, but the tissue surrounding the pupil is finely radi- ally furrowed, and of a light brown tint. V.R.E. = fingers; V.L.E. + 2 sph. = J. 20. 528 Anomalies of Development and Pigmentation 529 October 13th: V.R.E. + 3 D. sph.= J. 20; V.L.E., 6/60; with + 3 D. sph. = J. 20. October 26th: Iridectomy inner side (Fig. 1). October 29th : Lids swollen, good hole in iris, somewhat square in shape. November 2d: Lens appeared in anterior chamber completely opaque. Calcareous, with small coloboma below. November 3d: Lens slipped back into vitreous cavity; could not be seen by the ophthalmoscope. November 4th: Lens again in anterior chamber. Patient kept on right side. Lens 5 mm. in diameter with coloboma below. Under a local anes- 7**#l$fF Fig. 1. Bilateral symmetric congenital corectopia after operation on right eye. thetic a section of the cornea was made up and out, Lens spooned out. In the process the capsule was ruptured partially. Whole drawn out by forceps; atropin instilled. November 10th: Some swelling of lids, slight injection, and chemosis of the conjunctiva. Keratitis striata. Fair anterior chamber. Coloboma larger than before extraction of lens. December 3d: Right palpebral fissure smaller than left. Slight redness of skin of lids. Merest trace of limbal injection. Wound perfectly healed. Cornea bright. Fair anterior chamber. The new pupil is absolutely black. The original pupil is almost closed by sphincter and shows as black, irregular 34 530 J. GRAY CLEGG Appearance of iris like fine Palate brown velvet, with two patches of brown jelly ly- ing on surface. Fig. 2. Melanosis of right eye, scalp, cheek, and palate. Anomalies of Development and Pigmentation 531 line only. V.R.E.+ 9 D. sph. O + 2 D. cyl. ax. 15= 6/36; + 16 D. sph.O + 2 D. cyl. ax. 15 = J. 8. Vitreous clear. Disc is somewhat blurred at margin. Staphyloma pos- terior disc % diameter in width. Superior temporal retinal veins tortuous. No other fundal lesion. The left field shows slight contraction, but the right is normal. There is no scotoma. Tension normal. MELANOSTS OF THE EYE, SKIN OF RIGHT SIDE OF HEAD, AND RIGHT PALATE Ethel Mary R., female, aged twelve. History. One sister aged ten; one sister aged seven, all healthy. One half brother, seven months, quite well. No history of any abnormal pigmentation in two maternal uncles, eight maternal aunts, three paternal uncles, two paternal aunts. Has numerous cousins, all well. Patient had slight scarlet fever and varicella. There is an extensive patch of pigmentation of the skin of the right side of the head, affecting the upper part of the cheek, the temple, and the skin of the scalp, reaching nearly to the vertex. The density of the pigmentation is not uniform, and it resembles the color of a blue-black ink-splash. The edges of the area are irregular and not sharply defined. The skin is not swollen and does not fade on pressure. There is no nevoid condition. A similar pigmentation is found on the right palate, with indistinct margins, and a less deeply pigmented area is seen in the mucous membrane of the right cheek. The patch on side of cheek and temple fades a little when weather is fine, and goes darker when wet. The pigmentation was present at birth and has not changed. No other abnormal pigmentation is discernible. The right globe presents the most striking feature of the case. It is some- what enlarged and divergent to the extent of some 15 degrees. The palpe- bral fissure is a trifle wider than the left, exposing the sclera below for about 1 mm. The conjunctiva itself is not affected. The ocular portion is free from any abnormal adhesion to the episcleral tissue. The latter presents extensive areas of brown-black pigmentation. Two of the better defined areas are distinctly swollen to the extent of 1 mm., viz., the large one below the cornea and a smaller one above. The cornea shows in a small central area fine superficial pitting, but it is otherwise clear. The anterior chamber is rather shallow. The surface of the iris is a stippled dark brown, as seen in the brown eyes of dark races. There are two areas of brownish, gelatinous material, apparently lying on it, both of which extend slightly over the pupillary margin. The anterior capsule and cortex are clear. Some bluey opacity in the nucleus of the lens is easily seen. No red reflection is ob- tained by the ophthalmoscope. V. R. E.: No 1. p. No lighting of pupil by transillumination. T + 1. 532 J. GRAY CLEGG The left eye is normal in every respect and its field good. The thyroid is large; some thrill felt on pressure on gland. Impairment of resonance with some collapse of the lung at the right apex, but no evidence of active disease. There is a deep-seated mass in the right hypochondrium, which is moder- ately tender on pressure (glands?). Vascular and nervous systems normal. DISCUSSION MR. E. TREACHER COLLINS (London, England) : I have been much inter- ested in the subject of melanosis of the eye and the appearance of the iris in such cases. Some years ago the late Dr. George Coates showed a case of this description in which on high magnification of the surface of the iris there was a very peculiar appearance. It presented a number of little nodular elevations very much like the elevations on a golf ball. At the same meeting I was able to show a case of melanosis in which the surface of the iris presented a shaggy appearance which might be compared to that of an India rubber sponge. Then about two years ago Dr. Sterling, of Atlanta, Ga., had a case of melanosis of the iris in which he had occasion to remove a portion of it, and he kindly sent me the fragment of iris to examine microscopically'. It showed that on the anterior surface there was a marked hyperplasia of the endothelium of the iris, and this accounted for the irregularity of pigmentation of the surface. I would like to ask Mr. Clegg whether he had examined the surface of the iris in his case under high magnification, and if so whether he found any such appearance. DR. E. E. BLAAUW (Buffalo, N. Y.) : Mr. Clegg has mentioned that the extracted lens in the one eye had a 5-millimeter dimension. This points to Vogt's conception of "embryonal nucleus" being a definite stage in the lens development, a stage which can be followed through man's complete life. DR. EDWARD JACKSON (Denver, Col.): The anomaly of pigmentation, apparently general and not strictly local, certainly on one side, leads us back to the thought of the radical relation which pigmentation seems to have with the vital processes of development, the general biologic processes. It sug- gested to my mind, on reading Mr. Clegg's case, that probably in that eye would be found some other radical departures which would account for the complete blindness. The suggestion made that possibly it is going on to tumor development, sarcoma of the eye that is a possibility from the doubt- ful rise of tension gives an obvious explanation; but even such a development may be associated with the radical connection between pigmentation and the development of organs that normally contain pigment. MR. J. GRAY CLEGG (closing) : In reply to Mr. Collins, I would say that the iris under strong magnification presented the appearance of very fine dark brown velvet, and lying on the iris near the pupillary margins were two gelati- nous, flattened, irregular membranes, extending on to the pupil itself. LOS MERCURIALES, EL SALVARSAN Y SUS DERI- VADOS EN EL TRATAMIENTO DE LAS FORMAS GRAVES DE CONJUNTIVITIS Y QUERATITIS ECZEMATOSAS DR. ANTONIO TORRES ESTRADA Ex-Jefe de Clinica Oftalmologica en Escuela National de Altos Estudios, Medico del Hospital Oftalmologico de Nuestra Sar. de la Luz. Oculista de la Casa de Nifios Exp6sitos y del Dispensario del Servicio Higienico Escolar, en la Ciudad de Mexico, D. P., Rep. Mexicana La conjuntivitis eczematosa, conocida tambien con los nombres de flictenular, impetiginosa, estrumosa, vascular, oftalmia linfatica, y recientemente con el nombre de conjuntivitis tuber culosa, es sin duda una de las enfermedades que se presentan con mds frecuencia al oftalmologo. La gran mayorfa de los casos corresponden a formas benignas, que ceden con relativa facilidad al tratamiento clasico; pero tambien, con bastante frecuencia, se presentan formas graves cuya evolucion cronica, su tenaz reincidencia y la rebeldia a todo tratamiento, constituyen un verdadero problema para el me'dico tra- tante. En cuanto a las consecuencias de estas formas graves son dignas de tomarse en consideration y de temerse por los dafios, a veces irreparables, que producen en la cornea, consistentes en panus, nefelios, infiltraciones> esclerosis y leucomas, con o sin enclavamiento del iris. En efecto, la participation de la cornea en las formas graves es constante y de aqui que los sintomas sean tan molestos y tan alarmantes y las consecuencias tan severas. Esta enfermedad, peculiar a los nifios de 3 d 15 afios, encierra hasta la fecha el misterio mas complete sobre su etiologia. En verdad pocos puntos hay en Medicina tan obscuros como el presente, en el que la tenacidad y laboriosidad de los investigadores ha fracasada. La literatura sobre el tema es enorme, y por lo tanto solo me limitare" a hacer una breve exposition de las ideas y de los hechos mas cul- minantes, asi como de las opiniones mas autorizadas. Las causas hasta ahora senaladas pueden clasisncarse de la siguiente manera: A. Causas Constitucionales; B. Causas toxicas; C. Causas microbianas; D. Causas parasitarias, y E. Causas neurotroficas. 533 534 ANTONIO TORRES ESTRADA (A) Desde hace muchos anos se ha atribuido al terreno un papel preponderante en esta enfermedad, de aqui los nombres de conjun- tivitis escrofulosa, estrumosa, oftalmia linfatica, que ha recibido desde antano; en efecto, desde entonces se habfa visto que los por- tadores de ella eran en su mayorfa individuos escrofulosos, cuya cir- cunstancia hizo que se llegara a considerar la presencia de esta con- juntivitis como el signo mas eficaz y constante del temperament o linfatico. La alimentacion deficiente, las malas condiciones higienicas, la dentition y la convalecencia de las enfermedades infecciosas agudas, han sido otras tantas causas invocadas, cuya accion se refleja directa- mente sobre el terreno. (B) Burns, Colombo, etc., han senalado entre las causas de este grupo la autointoxication por retention de materias ester corales. 1 Turner, en un estudio sobre la etiologia de esta enfermedad, ha senalado como causa la toxemia, debida principalmente a trastornos depen- dientes del aparato respiratorio : adenoides, hipertrofias amigdalinas y de los cornetes nasales; asi como infecciones de la nariz y de los senos anexos, cu-yos trastornos, a su vez, los subordina a la autoin- toxicacion gastro intestinal. 2 (C) Contra la opinion casi unanime de los oftalmologos, Leber y Sattler, Gifford y otros investigadores, han atribuido esta enfermedad al estafilococo, que han logrado aislar de la secretion conjuntival de algunos enfermos; mas seme j antes ideas no han sido admitidas y la interpretation general que se ha dado a dichos hallazgos, es considerar la presencia de tales germenes como ocasional y no como causal. En efecto, contra la posibilidad de una causa microbiana, estan las experi- encias de Terrien, quien ha inyectado en la camara anterior de monos, conejos y cuyos, diversos productos obtenidos de las flictenas, sin haber logrado ninguna inoculation. 3 Por otra parte, Saemisch, quien designo la enfermedad con el nombre de conjuntivitis flictenular, llego tambien, por una serie de investigaciones, a la conclusion de su no inoculabilidad. Los trabajos en este sentido han sido numerosos y todos convergen hacia la misma conclusion. Axenfeld, Dor, Weckers y algunos otros oftalmologos, atribuyen la enfermedad a la accion debilitada de las toxinas tuberculosas, cuyo origen seria habitualmente algun foco tuberculoso distante del ojo, pulmonar, oseo, ganglionar, etc., Wolff ha lanzado la teorla de que las flictenas no serian sino una manifestation anafildctica de la conjuntiva, consistente en una hipersensibilidad de ella a las toxinas tuberculosas El Tratamiento de las Formas Graves de Conjuntivitis 535 atenuadas, procedentes habitualmente de algun foco ganglionar del cuello y supone, que el ojo mismo, haya sufrido con anterioridad algun padecimiento bacilar, del cual ha sanado por los procesos naturales. 4 Gibson en 92 casos de conjuntivitis flictenular haencontrado 90 con von Pirquet positive y ha logrado producir flictenas en conejos tuber- culosos mediante la instilacion de tuberculina en los fondos de saco conjuntivales. 5 Weckers en 55 casos encontro 51 con reaccion positiva a, la misma prueba." Wesseley sefiala un 95 por %. 7 Kollner ha estu- diado 140 casos de la enfermedad con relacion a diversas manifesta- ciones tuberculosas de que eran portadores los enfermos, y encontro una relacion entre la evolucion de estas y la enfermedad ocular. 8 En Mexico Fernandez MacGregor sefiala un 98% de von Pirquet posi- tive. 9 Pero en contra de estos datos positives hay que senalar otros diametralmente opuestos. Asi, el Dr. Pacheco Luna de Guatemala ha declarado que, tanto los examenes radiologicos como las pruebas de von Pirquet, han sido constantemente negativas. 10 Burnett ha encon- trado una proporcion muy inferior a las senaladas, y niega que haya una relacion de causa a efecto entre la enfermedad y la tuberculosis. 11 Igualmente opina Morax a este respecto. 12 Por mi parte puedo anadir que en compania del Dr. Daniel M. Velez he practicado la prueba de Calmette en varios ninos de la Casa de Expositos de Mexico y pude observar, contra lo que me espera, que aquellos que habian padecido poco antes de conjuntivitis flicte- nular, dieron constantemente una reaccion negativa. 13 (D) Chevalereau, Axenfeld, Pacheco Luna, y algunos mas, han indi- ado la coincidencia de esta enfermedad con la existencia de otiriasis en los ninos portadores de la enfermedad, y atribuyen la causa a la accion toxica de la saliva del parasito que es introducida en el mo- mento de la picadura. 14 Ademas de los piojos han sido considerados como causa de esta con- juntivitis, los oxiuros, entre otros autores por el Dr. Andrade de Brasil, quien ha logrado producir experimentalmente la enfermedad en el cachorro, por instilacion en la conjuntiva, del liquido perienterico de los expresados vermes. 15 (E) Se ha pensado que esta enfermedad tiene alguna analogia con el herpes zona, lo que ha recibido confirmacion por el hecho real de que las partes preferentemente afectadas en la cornea, corresponden frecuentemente a las terminaciones nerviosas, lo que justifica en ierto modo la sintomatalogia tan aparatosa de algunos casos. De lo anteriormente expresado se deduce que hasta la fecha no hay 536 ANTONIO TORRES ESTRADA en definitiva una causa a que atribuir la enfermedad, cuya etiologfa queda aun por establecerse ; pero pueden asentarse tres hechos per- fectamente probados y generalmente admitidos: 1. La enfermedad se encuentra habitualmente en ninos estrumosos; aunque puede presentarse en algunos de constitucion aparentemente sana. 2. Tiene marcada relacion con las lesiones impetiginosas de la nariz, de la cara y aun de otras regiones del cuerpo; por lo que le viene los nombres de eczematosa, impetiginosa y pustulosa. 3. Que es amicrobiana y por lo tanto no inoculable. Por mi parte puedo senalar un hecho mas que hasta la fecha no ha merecido reparo, o bien que ha sido negado y es su frecuencia en ninos heredo sifiliticos comprobados. En efecto, no alcanzo a comprender, como siendo relativamente grande el niimero de ninos afectados de esta enfermedad, que pre- sentan al mismo tiempo signos o estigmas evidentes y aun culminantes de dicha infeccion, no hay a llamado la atencion de los investigadores. Sus pesquizas no se han orientado en este sentido y, en cambio, si han sido de preferencia sobre la tuberculosis, siendo esta infeccion mas discreta y mas dificil de comprobar por tener que valerse, casi de una manera exclusiva, de medios de laboratorio. No solo esta enfermedad es freciiente en los ninos heredo sifiliticos, sino que la mayor parte de las veces que la he visto en los adultos, se trataba de sujetos portadores de sifilis. Por otra parte, no es extrano observar formas asociadas de esta enfermedad con alguna otra mani- festacion netamente espedfica, como la de una queratitis intersticial, una escleritis profunda, una iridociclitis, etc., dates sobre los cuales tampoco se ha hecho la mencion debida y apenas si Wecker y Landolt, mencionan en su obra, la asociacion de la conjuntivitis eczematosa con las epiescleritis. 16 Esto no quiere decir que senale de una manera categorica a la sifilis como causa de la conjuntivitis eczematosa; pues carezco hasta estos mementos de las pruebas y los fundamentos necesarios; pero como quiera que he sido uno de los primeros en mencionar esta causa volvere a tratar del asunto al final de este trabajo. TRATAMIENTO POR LOS MERCURIALES Todos los autores estan conformes en que los mercuriales en forma de colirios son especfficos contra esta enfermedad, y desde hace mucho tiempo se vienen prescribiendo. El calomel y el 6xido amarillo El Tratamiento de las Formas Graves de Conjuntivitis 537 de mercuric recientemente precipitado, han sido los dos medica- mentos mas puestos en boga; tambien el bicloruro de mercuric, el cinabrio y el oxide rojo, han sido usados, aunque menos extensamente que los anteriores. Con relacion a la manera como obran estas substancias, nada se sabe; algunos creen que es debido a la descomposicion lenta que sufren en presencia de las Mgrimas, y otros les han atribuido una action puramente mecanica, que experiencias posteriores han vehido a des- mentir. Algunos autores han usado las sales de plata, como el argirol y el protargol, pero su accion es indudablemente inferior a la de los mer- curiales. El Dr. Menacho recomienda el uso de colirios con tanino; pero per- sonalmente me he convencido de su inferioridad con el calomel. Por ultimo Colleman, Wolff, etc., aplican los rayos X asegurando buenos resultados. Este ultimo autor no solo ha logrado mejoria en las lesiones oculares, sino que aun en las de los ganglios del cuello, y usa para la aplicacion ocular 4 unidades H. 17 Por mi parte puedo decir que uso un colirio de calomel a 10 % en suspension en vaselina liquida, del que estoy muy satisfecho. Como tratamiento general los cldsicos aconsejan el aseo, la buena alimentacion, buena ventilaci6n y toda clase de preceptos higienicos encaminados a mejorar la salud del paciente. Ademas indican alguna medicacion tonica o antiescrofulosa, como los glicerofosfatos, el aceite de higado de bacalao, el iodo, etc. Hasta la fecha no se ha mencionado un tratamiento general, que obre de una manera energica y eficaz sobre la evolucion del padecimiento ocular, de que me vengo ocupando, como obraria el tratamiento espe- cifico en una iritis o en una coroiditis de origen sifilitico. En las querato conjuntivitis flictenulares de forma grave, tanto el trata- miento local como el general hasta ahora aconsejados, son ineficaces, pues hay casos en que la enfermedad se prolonga indennidamente y que si curan, es expontaneamente, cuando los medios naturales tienden a hacerlos regresar. El resultado de esta evolucion tiene sobre la corena las fatales consecuencias que antes he senalado, y no siendo aun bastante, queda el enfermo constantemente propenso a recaer en su enfermedad. Desde hace seis anos pude accidentalmente darme cuenta de que el mercuric introducido al interior del organismo se mostraba eficaz 538 ANTONIO TORRES ESTRADA contra la enfermedad, determinando una accion decididamente favora- ble sobre la evolucion de los casos mas severos. Hasta ahora el tratamiento general por el mercurio en este padeci- miento no ha sido men.cionado, con excepcion de Bruns, quien reciente- mente e independientemente de mi, lo ha manifest ado. 18 Posteriormente, como se verd en el curso de este trabajo, he usado con e"xito aun mayor los derivados del salvarsan, a cuya circunstancias debo el honor de trazar estas lineas. Me creo en la obligacion de decir como llegue al conocimiento de estos hechos, y por lo tanto transcribe la siguiente nota clinica que f ue para mi de grandes ensenanzas : El ano de 1915, atendia de queratitis parenquimatosa a un nifio, en quien la sifilis estaba fuera de toda duda, a juzgar'por los estigmas de que era portado. Al mismo tiempo una hermanita, cuatro afios mayor que el, habia sido internada en un sanatorio de esta ciudad, para ser tratada de multiples y enormes ganglios infartados del cuello. Se le practice la extirpacion de los ganglios estrumosos; pero la opera- cion f ue seguida del f racaso mas complete : algunos ganglios sanos que quedaron, a su vez se infarataron; el cuello en general estaba invadido de una enorme empastamiento y presentaba una rubicundez violacea ; las heridas operatorias se habian retrasado en cicatrizar y secretaban una serosidad espesa que se secaba f ormando costras ; la deglucion era muy dificil; los movimientos del cuello eran casi imposibles y la en- fermita apenas si dormitaba reclinada entre almohadones. La desnu- tricion cada dia se acentuaba y el caso llego a ser tan alarmante que se abrigaron los temores de un desenlace fatal. En los dias en que se iniciaba esta gravedad aprecieron en un ojo varias flictenas, le hice una visita a la paciente y recete un colirio con calomel ; pero la enfermedad ocular se empeoraba al mismo tiempo que el estado general. Por ultimo la enfermita fue trasladada a su domici- lio con la idea de que fuera a morir en el seno de su familia. Le prac- tique una segunda visita y entonces, en un momento de dolor en que abrio demesuradamente su boca, pude observar que presentaba unos dientes de Hutchinson enteramente tipicos y una vobeda paltina ojival, cuyos datos, unidos a la queratitis intersticial del nino, y algunos otros que pude recoger por el interrogatorio, me hicieron recordar la expresion inmortal de Fournier: "La escrofula es un escrofulato de verole." En el acto concebf la esperanza de que un tratamiento espe- cifico mejoraria a aquella nina tan gravemente enferma, y ese mismo dia le aplique" una inyeccion intravenosa de cianur de mercurio de El Tratamiento de las Formas Graves de Conjuntivitis 539 0.01. Despues de ocho inyecciones, el resultado era verdaderamente milagroso: Las heridas operatorias habian cicatrizado; el empasta- Ano de 1921 Casa de Ninos Exp6sitos. Datos relatives al ntimero de ninos enfermos de conj. flictenular y a la existencia mensual miento del cuello habia desaparecido ; la enferma dormia y comf a, con lo que recobraba visiblemente fuerzas y animo. En cuanto a la Iesi6n ocular, que se habfa declarado tan revelde al tratamiento local, 540 ANTONIO TORRES ESTRADA evoluciono de una manera tanto o mds admirable que el estado general de la enferma. 1 / Ano de 1920 Casa de Ninos Exp6sitos. Datos relatives al niimero de ninos enfermos de conj. flictenular y a la existencia mensual Poco tiempo despues se me presento otro caso de conjuntivitis flictenular de mediana intensidad, en una niiia con datos negatives de heredo sffilis, pero muy revelde al tratamiento local, y vivas como El Tratamiento de las Formas Graves de Conjuntivitis 541 tenia las ensenanzas del caso anterior, no vacile" en inyectar en la region glutea una solucion de 0.01 de cianuro de mercuric. Al dfa Ano de 1919 Casa de Ninos Exp6sitos. Datos relatives al niimero de nifios enfermos de conj. flictenular y a la existencia mensual siguiente habfa una notable mejoria, obteniendose una curacion com- pleta mediante dos inyecciones mds. Desde entonces comence a usar el mercurio como tratamiento 542 ANTONIO TORRES ESTRADA general en los casos de conjuntivitis eczematosas, obteniendo cada vez resultados altamente satisfactorios. Pero como en la mayor parte de los casos se trata de ninos, repugna hacerlos sufrir por las inyecciones intramusculares de sales hidrargiricas, o bien por que se dificulta sobre manera la inyecci6n intravenosa, me he decidido por las fricciones de unguento mercurial, con no menos buenos resultados. Este tratamiento es el que uso en la clientela de hospital, en el dispensario del Servicio Higie"nico Escolar y en la Casa de Ninos Expositos. Acompano tres grdficas con datos tornados de la Casa de Ninos Expositos, en las que estdn expresos la existencia total de ninos en cada mes y el numero de enfermos de conjuntivitis eczematosa. La primera, que corresponde al ano de 1919, indica un numero muy alto de enfermos, coincidiendo con la ausencia del tratamiento mercurial. La del ano de 1920, epoca en que me hice cargo del Servicio, arroja ya una disminucion apreciable del numero de casos, debido a que los pacientes comenzaron a ser tratados por las fricciones mercuriales. La grdfica del presente ano, comparada con las anteriores, sefiala una desproporcion enorme, aun teniendo en cuenta que el numero de ninos ha sido menor que en los afios anteriores. El resultado del tratamiento mercurial sobre el padecimiento de que me vengo ocupando, no puede ser mds ostencible. La disminucion gradual que se ha conseguido, la atribuyo a que la mayor parte de estos ninos tienen frecuentemente padecimientos nasales impetiginosos, que tambien mejoran rdpidamente con el tratamiento mercurial, y algunos son francamente heredo especificos, lo que me ha hecho insistir con relativa frecuencia en el ; y no solo se ha logrado la reduccion senalada en el numero de casos, sino que cuando estos se han llegado a presentar, es de una manera esporddica y han sido de una benignidad notable. Como confirmacion a este dato puedo manifestar que en el curso del presente ano, los casos graves no han excedido de dos. TRATAMIENTO POR EL ARSENOBENZOL Y Sus DERIVADOS La accion terape't'ca energica del mercuric en el tratamiento de los casos graves, asi como la frecuencia de algunos estigmas, o por lo menos indicios de sffilis en los pacientes, me hicieron probar otros agentes antisifilfticos y no vacile" en inyectar dosis de los derivados del arsenobenzol, siendo el resultado el mds alhagador y sorprendente que se pudiera esperar, pues su accion supera notablemente a la ya grande abtenida por los mercuriales. El Tratamiento de las Formas Graves de Conjuntivitis 543 Los casos clinicos que a continuacion relate, dardn una idea clara de esta terapeutica. A. G. de L. Nina de seis afios. Constitucion debil y muy delicada. Su padre murio hace cuatro anos de tuberculosis pulmonar. No hay mas ante- cedentes de tuberculosis en la familia. A la edad de cuatro anos, la pequena tuvo un padecimiento gastro-intestinal muy revelde. No presenta estigmas ni antecedentes de heredo sifilis. No presenta ganglios infartados, ni cicatrices en el cuello. Hace un ano cuatro meses viene padeciendo de una querato con- juntivitis eczematosa en ambos ojos, con pequenas mtermitencias y mas acentuada en el ojo derecho. El examen revelo en este ojo multiples flictenas en el limbo y algunas en la cornea y e"sta cubierta de panus. La fotofobia era intensa y los parpados presentaban escoriaciones en el dngulo externo. El ojo izquierdo presentaba algunas pequenas flictenas en el limbo y algunos nefelios, que testificaban ataques anteriores de la enfermedad y la participa- cion de la cornea en ellos. La prueba de von Pirquet fu6 negativa. Trata- miento: colirio de calomel y aplicacion de una dosis de 0.10 de Muscbarsenol Corbiere, logrdndose dias despu^s una mejoria muy apreciable. Seis dlas mds tarde aplique una dosis de 0.15 y el alivio se acentuo mds. Al cabo de tres dfas de la tercera inyeccion, que tambien fue de 0.15, ya no se veian las flictenas; el panus habia desaparecido a la simple vista y s61o la lente revelaba toda via algunos vasos; lo unico que aun persistfa, pero muy mejoradas, eran las escoriaciones de los parpados. Fueron aplicadas dos inyecciones mds de la misma dosis y se obtuvo una curacion completa, mejorando al mismo tiempo el estado general de la nina. C. N. de 15 anos. Constitucion debil. Presenta antecedentes hereditarios que suponen la sifilis. Nulos respecto a la tuberculosis y el von Pirquet nega- tive. No presenta infartos ganglionares del cuello. No hay estigmas de heredo sifilis, pero la reaction de Wassermann es dos veces ms. Desde su infancia viene padeciendo ataques de conjuntivitis eczematosa en ambos ojos y de una manera mds insistente en el ojo izquierdo, en los dos ultimos anos. El examen revelo numerosas flictenas conjuntivales y corneales en ese ojo; una ulcera en el limbo, como a las 9 h/; panus y algunas infiltraciones en la cornea. La fotofobia era muy intensa. La vision estaba muy disminuida, al grado de no ver si no el bulto de la mano. Tratamiento: colirio de calomel, atropina y vendaje. Previo reconoci- miento de orina, se le aplico una dosis de 0.15 de neosalvarsan por la via endo- venosa, desapareciendo dias ma's tarde, la fotofobia y pudie'ndose dejar el ojo al descubierto por haber cicatrizado la ulcera. El medicamento se fu6 inyec- tando en serie cada seis dias hasta llegar a la dosis de 0.45, y se obtuvo despue's de cuatro inyecciones un alivio tan complete, que la agudeza visual llego; a 0.3. En la cornea persistian, sin embargo, nefelios y algunas in- filtraciones gruesas, muy blancas y vascularizadas. J. S. Sexo femenino de 19 anos. Constituci6n muy debil y delicada. Ha 544 ANTONIO TORRES ESTRADA tenido quince hermanos, de los cuales ocho han muerto, tres antes de dos meses de nacidos y los cinco restantes, de pocos afios. Uno de los que viven es loco. Otro es marcadamente escrofuloso. La madre padece de epilepsia. El padre vive y es aparentemente sano. La paciente no presenta infartos ganglionares del cuello ni estigmas de heredo sifilis y la reacci6n de Wasser- mann fu6 negativa. Desde pequefia tuvo varies ataques de conjuntivitis eczematosa, permaneciendo algunos afios libre de ellos; pero desde hace seis afios ha vuelto a tener brotes de ella. Hace seis meses se queja de tos. Se ha acentuado su enflaquecimiento y a veces por las tardes, tiene elevaciones de temperatura y sudores profusos. El padecimiento que la ha traido a consulta data de tres meses, encontrdndose al examen del ojo izquierdo una con- juntivitis flictenular de forma grave, con panus, flictenas en la cornea y dos ulceras pequefias de hordes netos y redondos, como hechas con sacabocado y con insignificante infiltration de ellos y del fondo. La fotofobia era tan in- tensa, que la enferma ocultaba su cabeza entre el colch6n y las almohadas, y habia ademas una intensa cefalea. El ojo derecho acusaba en la cornea huellas de varios ataques del padecimiento. El examen general de la enferma hizo presumir una tuberculosis pulmonar incipiente. El von Pirquet fu6" debilmente positivo. No obstante los datos anteriores se comenzo a inyectar neosalvarsan por la via endovenosa, obtenie"ndose una curacion tan r^pida que a los tres dias de la segunda inyecci6n, las ulceras estaban espejeantes, el panus muy adelgazado y la fotofobia y la cefalea habian desaparecido. Despue"s de la tercera inyec- ci6n fue" necesario suspender el tratamiento, en vista de la dificultad para puncionar las venas a la paciente y este descanso determine la reaparici6n de algunas flictenas y un pequefio engrosamiento del panus. En vista de lo cual le fu4 aplicada una dosis de 0.30 en la yugular, haci&idose sentir mas tarde los efectos bene'ficos. La enferma euro despue's de un tratamiento de seis inyec- ciones. El estado general mejor6 notablemente y desaparecieron muchos de los sfntomas que hacfan presumir la tuberculosis pulmonar. DISCUSION Es innegable que la mayor parte de las conclusiones relativas a la etiologfa de este padecimiento, convergen hacia la hipotesis de su origen tuberculoso, y digo hipotesis porque hasta la fecha no se ha senalado la presencia del bacilo de Koch en las flictenas, ni tampoco de una manera constante en el organismo de los enfermos. Esta uni- formidad de criterio contrasta desde luego con la accion casi nula de toda terape"utica antituberculosa, incluyendo las tuberculinas y con los dos hechos fundamentales que antes he senalado: su frecuencia en pacientes sifiliticos y su curacion pronta por los mercuriales adminis- trados ocal y generalmente, asi como por los derivados del salvarsan. El Tratamiento de las Formas Graves de Conjuntivitis 545 El problema adquiere una complicacion mayor por el hecho fre- cuentemente observado y citado por algunos autores alemanes, entre ellos Zehener, quienes han senalado la excesiva coincidencia de la sifils con la tuberculosis, y se suponen que la primera de estas en- fermedades prepara favorablemente el terreno debilitandolo, para que pueda desarrollarse con mas facilidad la segunda. Ademas han logrado tratar y curar por un tratamiento antisifilitico algunos trastor- nos que indudablemente no eran de origen tuberculoso. 19 De los datos que dejo consignados, asi como de otros muchos que no hubiera sido posible relatar, se desprende que tanto la sifilis como la tuberculosis pueden estar presentes en el enf ermo, solos o en concurso ; pero de todas maneras el problema acerca de la etiologia del padeci- miento queda en pie, pues como lo he indicado, las valiosas pesquizas de aptos y respetables investigadores, no han llegado a demostrar en el la naturaleza tuberculosa, ni menos por los datos que llevo con- signados debe deducirse un origen sifilitico. Sin embargo, la hipotesis de que en un gran mimero de casos pueda atribuirse a la sifilis el padecimiento, no es tan despreciable. En efecto, desde Iwanoff quien fue el primero en estudiar la anatemia patalogica de las flictenas, se ha comprobado que estas lesiones corre- sponden a inflamaciones del tipo nodular en su face inicial, lo que ha hecho mirar a los partidarios del origen tuberculoso un pequeno tube"rculo en la flictena; pero precisamente esto seria lo que daria algun fundamento al origen sifilitico de la lesion. Realmente, el micro- scopic dificilmente podria decir si una granulacion pequena y reciente, supongamos de las meninges, seria sifilitica o tuberculosa, pues ambas tiene exactamente la misma forma de infiltracion linfocitaria, forma- cion de celdillas gigantes, etc., y solo la distincion es posible cuando el examen se lleva sobre lesiones mas avanzadas, en las que ya es posible observar las zonas necroticas, disminucion de la irrigacion sanguinea, etc., en el tuberculo; o bien el tejido de neoformaci6n, esclerosis y demas caracteres, que identifican las lesiones sifiliticas. Bien pudiera decirse que esta hipotesis va tomando forma, pues en los casos de conjuntivitis flictenular de duracion muy prolongada y en la queratitis fascicular, algunos autores, entre ellos Gruber, Hertel, Augstein, Yamaguchi, Baas, etc., han senalado en la capa de Bowman y aun debajo de ella, invadiendo el tejido propio de la cornea, algunas esclerosis y producciones de tejido de nueva formaci6n. De estos autores el ultimo mencionado, no solo ha demostrado estas lesiones, 35 546 ANTONIO TORRES ESTRADA sino que eran frecuentes en pacientes sifiliticos y pudo ademas de- mostrar en los ojos exminados, algunas lesiones de coroiditis sifilitica. 20 Estos datos, unidos a la no inoculabilidad del padecimiento ; a la ausencia de microrganismos patogenos en las lesiones, por mas empefio que ha habido en descubiertos, y a la accion curativa que tienen los agentes antisifiliticos, robustecen la hipotesis del origen sifilitico de la conjuntivitis flictenular, si no en todos los casos, por lo menos en una gran parte. Carezco por completo de la autoridad y de los fundamentos nece- sarios para asentar categoricamente esta aseveracion; pero quedaria altamente honrado y satisfecho si con lo que he dicho hasta ahora abriera nuevas vias de investigacion, fueran o no coronadas por el e"xito. De todas maneras estdn patentes las conclusiones que hacen pre- sumir el origen tuberculoso de la enfermedad y no creo que sea tan facil destruirlas. En cuanto a la accion curativa de los mercuriales, no se realmente a que atribuirla, sobre todo en ausencia de sifilis en el enfermo. Queda la posibilidad de considerarles propiedades terapeuticas distintas de las senladas. Mucho se ha dicho de su accion resolutiva; pero esta cada dfa pierde terreno por encerrar una idea vaga, muy poco satisfactoria, si no es que muchas veces erronea. 21 En cuanto a los derivados del salvarsan hay una gran tendencia a emplearlos en diversidad de padecimientos que no son sifiliticos ni hematoparasitarios, tales como la piorrea, el reumatismo, la oftalmia simpatica (Morax 22 ), la gangrena pulmonar (Svolin y Sjoblom 23 ),etc. Pero la mayoria de los autores que emplean dichos derivados arseni- cales en los padecimientos no sifiliticos, no indican la manera como obran. Tratdndose de enfermos sifiliticos tampoco es facil darse cuenta exacta de la manera como obran los agentes terapeuticos, mercurio y salvarsan, pues no habiendose demostrado la naturaleza sifilitica del padecimiento, no se puede atribuir a esta circunstancia su curacion. En los casos en que la sifilis y la tuberculosis concurren en el paciente, la explication se hace mas incomprensible y se podria sentar la hipotesis de que estos casos serian mas favorecidos que aquellos en que solo existe la tuberculosis, debido a que los agentes especificos obrarf an de una manera ma's segura, robusteciendo al organismo ; lo cual se podria lograr por un camino indirecto, o sea estimulando al El Tratamiento de las Formas Graves de Conjuntivitis 547 organismo por una medication tonica, mejorando la alimentation y las condiciones higienicas. CONCLUSIONES 1. Los casos graves de conjuntivitis eczematosa constituyen aun un problema muy serio para el oftalmologo y una amenaza para la vista de los ninos quienes son los que habitualmente padecen esta en- fermedad. 2. La etiologia del padecimiento por ahora es completamente desconocida. Generalmente se atribuye a las toxinas tuberculosas ; pero no es esta la linica causa. 3. La sifilis es frecuente en los ninos afectados de la enfermedad, hecho que casi no ha sido mencionado; pero no hay fundamentos suficientes para atribuir el padecimiento ocular a dicha enfermedad. 4. El mercurio y los derivados del salvarsan, tienen una action marcadamente especifica contra el padecimiento. BIBLIOGRAFIA 1. Colombo: Klin. Monatsbl. f. Augen., 1, p. 2, p. 610, 1912; citado por the American Encyclopedia of Ophthalmology, ix, 6801. 2. H. H. Turner: Etiology of Phlyctenular Ophthalmia, American Journarof Ophthalmology, ii, No. 2, 1919, 115. 3. Terrien: Cit. por la Revista Cubana de Oftalmologia, ii, No. 3, 1920, 604. 4. Wolff, C. K. : Relapsing Phlyctenular Keratitis in Children, Lancet, mayo de 1920, 509. Cit. por The Ophthalmic Literature, xvii, No. 1, 98. 5. Gibson: Revista Cubana de Oftalmologia, No. 3, 1919, 377. 6. Weckers: The American Encyclopedia of Ophthalmology, ix, 6802. 7. Wesseley: Munch, med. Woch., 1920, cit. por The Ophthalmic Literature, xvii, 87, mayo de 1921. 8. Kollner: Ocular Eczema and Skin Tuberculosis (Munch, med. Woch.,lxvi, 1919, 1109), cit. Por The Ophthalmic Literature, xvii, 88. 9. J. C. Fernandez MacGregor: La querato conjuntivitis eczematosa, tesis professional, p. 10. 10. Pacheco Luna: Revista Cubana de Oftalmologia, ii, 226. 11. Burnett: American Encyclopedia of Ophthalmology, ix, 6801. 12. V. Morax: Precis d'Ophtalmologie, deuxieme edition, p. 196. 13. Daniel M. Velez: Acci6n de la tuberculina en los ojos sanos y enfermos, Anales de la Sociedad Mexicana de Oftalmologia y Otorinolaringologia, ii, No. 12, 240. 14. Pacheco Luna: Revista Cubana de Oftalmologia, ii, 225. 15. Andrade: Revista Cubana de Oftalmologia, iii, 231. 16. L. D. Wecker y Landolt: Trite Complet d'Ophtalmologie, i, 345. 17. Wolff: Revista Cubana de Oftalmologia, i, No. 4, 1919. 18. Bruns: The American Encyclopedia of Ophthalmology, ix, 6803. 548 ARNOLD RENSHAW 19. K. Zehner: Schweizerische medizinische Wochenschrift, 1920, No. 30,651. Cit. por The American Journal of Syphilis, v, No. 1, 151. 20. Baas: Pathology of the Eyes. Parsons, cit. por The American Encyclopedia of Ophthalmology, ix, 6799. 21. Torres Estrada: La Sifilis como factor en algunas complicaciones del tifo y de la influenza, Anales de la Sociedad de Oftalmologia y Otorinolaringologia, ii, 2, epoca, No. 10, 227. 22. Morax: Cit. por el Dr. Arruga. Tratamiento de la Of talmia simpatica por el salvarsan y sus derivados, Espafia Oftalmol6gica, Ano v, No. 3. 23. M. Svolin y J. C. Sjoblom: La neoarsfenamina en el tratamiento de la gang- rena pulmonar, Del Finska Lakaresallskapets Handlingar, Helsingfors, Julio de 1921. Cit. por the Journal American Medical Association, E. E., vi, No. 10, 717. THE EFFECTS OF DIRECT INSTILLATION OF NOV- ARSENOBILLON IN THE CONJUNCTIVAL SAC IN RESISTANT CASES OF CONGENITAL SYPHILITIC INTERSTITIAL KERATITIS ARNOLD RENSHAW, M.D., B.S. (Lond.), D.P.H. (Mane, and Cantab.) Hon. Pathologist, Ancoats Hospital, and Bacteriologist, Royal Eye Hospital, Manchester Manchester, England In any extensive series of cases of interstitial keratitis of syphilitic origin one comes across a number which are very resistant to ordi- nary mecurial treatment. At the Royal Eye Hospital in Manchester these cases, and in fact most of the ordinary type, are submitted to treatment by means of salvarsan or its derivatives, novarsenobillon, neosalvarsan, or neokharsivan. Of these I have been able to dis- tinguish three types: 1. The type which rapidly improves under combined mercurial and arsenical treatment. 2. The type which rapidly improves but subsequently relapses under this treatment. 3. The type which, even after prolonged administration of mercury, iodids and salvarsan derivatives fails to improve in so far as the in- filtration of the cornea is concerned. Having noted that a definite ground-glass or hazy appearance of the cornea persisted even after twelve to fifteen injections of novarsenobillon or neokharsivan, it Novarsenobillon in Congenital Syphilitic Interstitial Keratitis 549 occurred to me that the direct instillation of concentrated solutions of the novarsenobillon might be of use. In view, however, of the irritant action of this drug on the subcutaneous tissues, I discussed the matter with Dr. J. Gray Clegg, of the Manchester Royal Eye Hospital, and we decided that it was advisable to ascertain the effects on the eyes of animals before using it clinically on human beings. A 1% solution of N. A. B. in distilled water was prepared and instilled into the conjunctival sacs of the eyes of rabbits. The results were examined by Dr. Clegg and myself, and he decided that there appeared to be nothing to contraindicate its use in children. Accordingly a number of patients were submitted to me by him for this method of local treatment. Subsequently other members of the honorary staff of the Man- chester Royal Eye Hospital sent cases for similar applications. All the above-mentioned types have been dealt with; namely, the early type, the relapsing type, and the resistant type. In the two former types general anti-syphilitic treatment was in its earlier stage and it is difficult to appraise in a scientific manner the exact value of the local treatment with regard to the improvement found. Its effect was more to be noticed, therefore, in the resistant type which had been treated so thoroughly with mercury, iodids, and salvarsan derivatives that one became almost hopeless of any further good resulting. Instillations have been continued over a period of months from the cessation of general treatment by salvarsan deriva- tives. METHOD. A few drops of a 1% solution of novarsenobillon deriva- tives in distilled water were dropped into the eyes usually at intervals of seven days, but in the later stage the interval has been fourteen days. The total number of cases treated was 20. The immediate effect of instillation is a slight hyperemia at the corneal limbus. The patients usually complain only of slight irrita- tion, but the lacrimal secretion is increased temporarily. The patient is recumbent during the application, and is told to roll the eyeball about so as to get a uniform concentration of the drug, and the drops are added slowly, preferably until the dilatation of the circumcorneal vessels is well marked. The effects consist chiefly of some slight alleviation of the photophobia in the earlier cases, manifest after two or three weeks. Secondly, in the more resistant cases, in which intravenous injections have been abandoned, the corneal haze 550 ARNOLD RENSHAW gradually disappears and the substantia propria becomes compara- tively clear. The cornea resumes its transparency first at the periph- ery, and usually the upper part of the cornea clears before the lower part. The disappearance of the corneal infiltration is, of course, associated with much improved vision, and one patient under this form of treatment can now thread with ease a very fine needle whereas previously she could scarcely detect hand movements. The effect in all cases has been to reduce the degree of corneal infiltration; and in relapsing cases to subdue the local inflammation. ILL EFFECTS. So far as can be ascertained no ill effects are pro- duced. In one case only, a very difficult one, which had resisted all forms of treatment, a slight corneal ulcer formed and perforation occurred, but this might have happened quite apart from this form of treatment, and the patient made a good recovery, the cornea eventu- ally clearing very well except for a small scar of the ulcer at the per- foration site. CONCLUSION. This method is, I believe, a very valuable adjunct to the usual treatment ; further, this method can be continued when further intravenous injections become dangerous. It should, however, be used only as an adjunct to general systematic treatment of the disease. It is interesting to speculate as to whether Spirochsetse are actually present in the cornea, and if so whether their persistence is due to the lack of blood supply to this tissue. I wish to express my indebtedness to the courtesy of Dr. Clegg, who has specially assisted in this investigation and to the other members of the honorary staff who have also submitted their cases for this treatment. TRATAMIENTOS DE LAS QUERATITIS INFECCIOSAS FOR LAS VACUNAS DOCTOR ROVIROSA VIRGILI Madrid, Espana LA BACTERIOTERAPIA EN OFTALMOLOGIA Voy a tratar de un asunto completamente nueva en el terreno de la oftalmologia, y de tal importancia, que creo, andando el tiempo, ha de constituir un verdadero tesoro para dicha especialidad. El progreso que realiza la vacuna estafilococica, y alcanza de dla en dia en el campo medico quinirgico, no podia por menos de llamarme la atencion y por ende ensayar un agente terapeutico que nos podia reportar ya como curative, ya como coadyuvante, inmensos bene- ficios en la practica de la oftalmologia. Todos sabemos los medios para combatir localmente los estragos causados por el estafilococo piogeno en el organo de la vision; pero todos tampoco desconocemos la insuficiencia de estos medios en multiples y determinados casos, como en panoftalmias, queratitis ulcerosas, dacriocistitis, blefaritis ulcerosas, etc., que 6 bien se hace en unos casos necesaria la extirpacion del organo, y en otros, a pesar de los mejores medios empleados y la mayor constancia, se retarda la curacion de un modo indefinido. Sabemos que la experimentacion clinica no ha demostrado todavfa en las afecciones oculares la eficacia curativa de los sueros estafilo- cocico y estreptococico (inmunizacion pasiva). Por lo tanto un agente como la vacuna estafilococica polivalente (inmunizacion activa), es decir, que obra excitando al organismo a la produccion de anticuerpos en la totalidad del individuo, y al mismo tiempo que libran al organismo de lo que por la puncion artificialmente le hemos introducido, llegan al proceso estafilococico ocular y contri- buyen a su curacion, ha de ser, andando el tiempo y cuanto mds se hay a estudiado, jalon inestimable para la especialidad oftalmologica. Los primeros vacunados fueron dos enfermos de panoftalmia, y como por su historia clinica se vera, en los dos se ha podido evitar la enucleacion; mas en la mujer la reparacion tomo tal incremento, que 551 552 ROVIROSA VIRGILI fu6 aclardndose la cornea de tal manera, que ha llegado a distinguir visi6n de bultos; venfa propuesta para enucleacion de otra clfnica, presentando fenomenos tan alarmantes, que yo tambien de no haber podido disponer de la vacuna, me hubiera visto precisado a recurrir al extreme antes dicho a fin de evitar la oftalmfa simpatica. El tercer -caso tratado con vacuna es un niiio, a quien solo incindi el saco lagrimal, raspando profundamente sus paredes, pero conser- vando el organo, habiendo antes hecho una siembra en agar, y de la que se obtuvo una auto-vacuna. A la cuarta inyecci6n habia des- aparecido el pus completamente, cicatrrzando a los pocos dfas. El examen bacteriologico llevado a cabo por el Dr. Mayoral dio un bacilo del grupo del dipte"rico, y que ha encontrado muchas veces en inflamaciones cronicas diversas, y sobre todo, en otitis y rinitis. Los otros dos casos de raspados que corresponden al 16 y 18, en los que se emplean la auto-vacuna y vacuna estafilococica, respectiva- mente, ambos cicatrizan rapidamente a los veintiuno y diez y nueve dfas de la aplicacion de la vacuna. En los demds casos ha sido la vacuna un poderoso coadyuvante, pues vemos se ha modificado muy satisfactoriamente la supuracion, y en algunos casos por completo hasta el presente. Por la rapidez con que se ha presentado la cicatrizacion en los tres casos de intervencion, creo sera un medio terape*utico no despreciable en las afecciones de las vias lagrimales, estando el beneficioso papel encomendado y digno de estudiarse a las auto-vacunas. Cuarto caso. La enferma presenta dos ulceras, una que ocupa toda la parte supero-externa de la cornea, y otra la infero-externa de la misma, habiendo entre sus bordes una distancia minima de dos mfli- metros por la parte central. La flogosis conjuntival es intensa, los dolores agudos y glerosis de la conjuntiva; a todo esto, como la enferma habia perdido hace afios el ojo conge*nere, por ulceras seme- j antes a las presentes, el estado de abatimiento es enorme. Hecha la siembra en agar, encuentra el Dr. Mayoral el estafilococo pi6geno. Despues de la primera inyeccion, al dfa siguiente, hay un pequeno aumento de la flogosis y pus, por lo que la Ifnea demarcativa de las ulceraciones avanza algo ; avanzamiento muy compensado al otro dfa por la remision, no s61o de los bordes ulcerados, sino de los trastornos subsiguientes a esta clase de queratitis, cesando tambie'n el estado de aplanamiento en que se hallaba la enferma, y se le prdctica, con dos dfas de intervale, una segunda inyeccion estafilococica polivalente. Solo se ha podido apreciar dos de"cimas de aumento en la temperatura, Tratamientos de las Queratitis Infecciosas por las Vacunas 553 y las queratitis marchan francamente en la curacion. Solo se emplean en dias sucesivos dos inyecciones mas hasta la curacion defmitiva. Como huellas del proceso antes dicho, se aprecian en la cornea dos cicatrices sumamente tenues, y como se ha podido evitar la fusion de sus bordes por la parte central, la enferma queda con la vision perfecta. Los casos 16 y 18 corresponden a una queratitis ulcerosa con hernia y a una queratitis perforante con hipopion, respectivamente ; en ambos enfermos se ha inyectado la vacuna estafilococica poli- valente, y ambos han seguido identicas fases que el caso primero expuesto, quedando la hernia reducida en el primero y cicatrizada la fistula corneal en el segundo. Los tres casos de queratitis ulcerosa que he citado, como ven los lectores, son de lo m&s grave; y si bien se han tratado, como ya se supone, localmente, tambien he de advertir que estos medios fra- casaron hasta que se aplico la vacuna estafilococica. El ultimo caso de lilcera serpiginosa de la cornea con hipopion, que ocupaba la tercera parte de la cdmara anterior, rasando con la exca- vacion ulcerosa, ha sido tratado por la vacuna pneumococica del Laboratorio Municipal de Madrid. Al dia siguiente de la primera inyecci6n acusa el enfermo haber sufrido durante la noche un fuerte dolor, como un latigazo. A la inspecci6n macrosc6pica se observa una gran remision del hipopion, el iris un poco sanguinolento y cierto rezumamiento de pus que, despue"s de limpiado, deja ver una fistula en el centre de la lilcera, es decir que se trata de una paracentesis espontanea de la camara an- terior. Al tercer dia el hipopion, muy reducido, apenas se distingue en la parte inferior del angulo corneal; al cuarto dia, nueva inyeccion de vacuna pneumoc6cica; al quinto dia ha desaparecido por complete el hipopion y la ulcera ha entrado en vias de franca cicatrizacion. De no haberse verificado la paracentesis espontdnea, claro estd que toda la gloria recaeria en la vacuna pneumococica; pero como es bastante frecuente la termination favorable de estos procesos por hechos an&logos, ya de paracentesis natural 6 provocada con el cuchillete lanceolar 6 con un simple midridtico, este hecho puedo restar algo de certidumbre, aunque la marcha ulterior, regresion rdpida de todos los sintomas, la coloration del iris que recupera pronto su bril- lantez y la transparencia pupilar que se observa a los pocos dias, hacen pensar que la vacuna no ha sido un factor despreciable en el presente caso. 554 ROVIROSA VIRGILI Los cinco casos de blefaritis ciliar que a continuation expongo todos datan de muchos anos de duration, y en algunos se remonta su eo- mienzo a la edad infantil. En todos se ha comprobado los bene- ficiosos resultados de la vacuna estafilococica desde las primeras inyecciones, y hasta el caso 8, el mds rebelde, y de smtomas mas alarmantes, en cuya siembra se hallo el streptococo, cedio a la auto- vacuna. CASOS 1. Rafael Lopez, veintisiete anos, natural de Mostoles. Carretera de Getafe. Ingreso el 8 de Enero de 1915. Diagnostico: Ulcera infiltrada de toda la cornea ojo izquierdo, con smto- mas de panoftalmia. Terapeutica: Se le aplica la vacuna estafiloc6cica en los dias 11, 14, 17 y 20, y se le da de alta el 31 del mismo mes. Observaciones : A travel del leu coma se percibe la coloration del iris; la temperatura no se ha elevado mds que 3 decimas a la primera inyeccion. 2. Catalina Roncero Diaz, cuarenta y nueve anos, natural de Toledo. Sombrereria, 5. Ingreso el 14 de Enero de 1915. Diagnostico: Panoftalmia ojo izquierdo, propuesta ya para enucleacion en otra clinica. La primera vacuna se efectua el dia de su entrada; el 17 se le aplica la segunda, y dos mas en los dias 20 y 23. Observaciones: Desde la segunda vacuna cesan los dolores y se despeja la cornea por su parte superior; al terminar la cuarta, solo presenta leucoma la mitad inferior corneal. 3. Jos6 Maria Vegas Perez, doce anos, natural de Madrid. Pez, 1 prin- cipal. Diagnostico: Dacrio-cistitis ojo izquierdo; raspado prof undo del saco lagrimal; a pesar de ello, hay alguna supuracion, que desaparece a la tercera inyeccion de vacuna autogena, cicatrizando completamente despues de la cuarta inyecci6n. 4. Ana Maria Pizarro, sesenta anos, natural de Puertollano. Ingreso el 17 de Febrero de 1915. Diagnostico: Queratitis ulcerosas ojo derecho. Se le aplica la vacuna estafilococica en los dias 21, 24 y 28 de Febrero y 4 y 8 de Marzo, dandosele el alta el 25 del mismo mes. 5. Priscila Perez, diez anos, natural de Villanueva del Campillo. Ingresa el 20 de Febrero de 1915. Diagnostico: Blefaro-conjuntivitis cronica de muchos anos, a pesar de los tratamientos corrientes en esos casos, no se nota mejorfa hasta la a plication de la primera vacuna estafilococica, el 12 de Marzo, aplicandola sucesivamente los dias 16, 20, 25 y 31 del mismo mes. Observaciones: En lugar de los hordes ciliares, rojos y desprovistos de Tratamientos de las Queratitis Infecciosas por las Vacunas 555 pestana que presentaba la enferma a su ingreso en mi clinica, presentan en la actualidad su coloration normal, empezando a contarse algunas pestanas. 6. Benigno Galan, treinta y ocho aftos, natural de Madrid. Miraelsol, no. 4. Entr6 el 8 de Marzo de 1915. Diagnostico: Blefaro-conjuntivitis antigua, desde que era nifto. Se le aplica la vacuna estafilococica en los dias 12, 16, 20, 26 y 31 de marzo y 8 de Abril, habiendo mejorado notablemente. 7. Hermenegilda die Barrio, treinta y siete aiios, natural de Segovia. San Vicente, 38. Entro el 20 de Diciembre de 1914. Diagnostico: Dacrio-cistitis ojo izquierdo; se la trata con sondas e" irri- gaciones desinfectantes, a pesar de lo cual no cesa del todo la supuracioH. Se le inyecta la primera vacuna estafilococica el 12 de Marzo de 1915, y se le vuelve aplicar en los dias 16, 24 y 31 del mismo. En la actualidad ha cesado la supuraci6n; solo hay excretion del liquido mucoso. 8. Mercedes Iglesias Taboada, treinta y un aftos, natural de Toledo Divino Pastor, 1. Diagnostico: Blefaro-conjuntivitis cronica de muchos afios, pe"rdida abso- luta de las pestanas y escoriaciones que, naciendo del borde ciliar se extienden por la epidermis palpebral. Se le aplica la vacuna estafilococica en los dias 13, 17, 20, 24 y 31 de Marzo, habiendose modificado bastante, pero no lo debido, por lo cual se le hace una vacuna autogena en la que se halla el estrep- tococo, y con cuya aplicacion se logra el resultado apetecido. 9. Francisca Recio Guerra, veinticuatro anos, natural de Santa Cruz del Retamar. Corredera Baja, 5. Diagnostico: Blefaro-conjuntivitis ulcerosa, habiendo sido ya operada con exito de triquiasis; los bordes escoriados y sin pestanas; se le aplica la vacuna estafilococica en los dias 13, 16, 20 y 31 de Marzo, y 3 y 6 de Abril; en el pre- sente se observa una coloraci6n normal en los bordes ciliares, y acusa la en- ferma una comodidad nunca sentida. 10. Amalio Quiroga, 18 anos, natural de Villanueva de la Torre. Luisa Fernanda, 14. Diagnostico: Blefaro-conjuntivitis eczematosa, presentando un eczema muy extenso en las cejas y la f rente, que ha resistido a cuantos tratamientos se han ensayado en el. Se le aplica la vacuna estafilococica en los dias 13, 16, 20, 24, y 31 de Marzo, habiendo desaparecido, no s6lo el eczema ciliar, sino tambin el frontal. 11. Jose Zamora Mendez, natural de Madrid, Buenavista, 35. Diagnostico: Dacri-cistitis doble: a pesar de haberse empleado las sondas de mayor calibre e irrigaciones desinfectantes, no cesa la supuraci6n. Se le aplica la vacuna estafilococica en los dias 13, 16, 23 y 31 de Marzo, y 3 de Abril, habiendo desaparecido completamente el pus del ojo derecho y siendo necesario el empleo de una auto-vacuna para conseguir la extincion del pus del ojo izquierdo. 556 ROVIROSA VIRGILI 12. Benita Gonzalez, treinta y siete anos, natural de Fuencarral. Ingreso el 24 de Febrero de 1915. Diagn6stico: Dacrio-cistitis doble; tratamiento: sondas e" irrigaciones antise"pticas; a pesar de ello, el pus no desaparece. Se le aplica la vacuna estafiloc6cica en los dias 14, 18, 22 y 26 de Marzo, habiendo desaparecido el pus hasta el presente. 13. Ram6n Herranz, cincuenta y cinco anos, natural de Moralejo. (Sego- via). San J6se", 2. Diagn6stico: Dacrio-cistitis ojo derecho; a pesar de sondarsele mucho tiempo, no desaparece el pus. Se le aplica la vacuna estafiloc6cica poli- valente en los dias 14, 20, 25 y 30 de Marzo; en le presente ha cesado la supuraci6n. 14. Hip6lita Vidal, treinta y dos anos, natural de Recas (Toledo). Plaza de Salmeron, 4. Diagnostico: Dacrio-cistitis doble; la enferma se niega tan to a las sondas como a la operaci6n. Se le aplica la vacuna estafilococica en los dias 15, 18, 24 y 30 de Marzo y 8 de Abril, habiendo cesado la supuracion pero conser- vando cierta rubicundez y mucosidad que, dada la naturaleza de la enfer- medad y el poco tiempo de tratamiento, no permiten emitir un juicio satis- factorio y definitive. 15. Rosalia Pastrana Torre, veintid6s anos, natural de Madriedejos. Diagn6stico: Ulcera perforante de la cornea, con enturbiamiento de toda ella, glerosis conjuntival y fuertes dolores; en vista del incremento que iba tomando la supuracion, a pesar de los multiples lavados antise"pticos, se le aplica la vacuna estafilococica polivalente en los dias 22, 25, y 30 de Marzo, y 3 y 9 de Abril. La enferma es dada de alta el 14 de Abril, con una cicatriz apenas perceptible y una buena vision. 16. Agapita Palafox, treinta y dos anos. Guadalajara. Diagn6stico: Dacrio-cistitis, ojo izquierdo, en el que se le prdctica un pro- fundo raspado; y como continua la supuracion, se hace una siembra en la que se halla el estafilococo, del que se obtiene una autovacuna que se le aplica el 27 y 31 de Marzo y 4 y 11 de Abril, habiendose extinguido por complete la supuracion, con conservation del organo y de su funcion. 17. Nominando Lopez Villar, cincuenta y tres anos, natural de Juncos (Toledo). Diagn6stico: Ulcera herniada con hipopion. Se le aplica la vacuna esta- filococica el 31 de Marzo y 3 y 6 de Abril; se ha podido reducir la hernia, y habiendo cicatrizado completamente ha recuperado una buena vision. 18. Gins Monllor Domenech, treinta y nueve anos, natural de Madrid. Plaza del Rastro, 9. Diagn6stico: Dacrio-cistitis ojo izquierdo; raspado del saco lagrimal. Como hay supuraci6n, se le aplica la vacuna estafilococica en los dias 5, 10, Tratamientos de las Queratitis Infecciosas por las Vacunas 557 13, y 16 de Abril. A los pocos dias de la primera inyecci6n desapareci6 el pus y la cicatrizaci6n se presenta franca. 19. Cirilo de la Torre, cincuenta anos, natural de Valdearenas. (Gua- dalajara.) Diagn6stico: Ulcera serpiginosa, con grande hipopi6n, en el ojo derecho; se le aplica la vacuna pneumococica en los dias 9, 12, y 15 de Abril. Al dfa siguiente, a la primera inyeccion, sobreviene una paracentesis espontdnea; iris sanguinolento y cesaci6n de dolores; en las inyecciones siguientes desa- parece por completo el hipopi6n; la pupila se presenta completamente negra y redonde; hay una excelente visi6n. MARCHA En las enfermedades cronicas, como dacrio-cistitis, eczemas pal- pebral blefaritis ciliar, etc., puede empezarse con dosis de 0.50, 1.00 y 1.50 de vacuna estafilococica polivalente, siendo en las autovacunas la mitad de las dosis antedichas, siempre teniendo en cuenta el peso del individuo y en las afecciones agud-as, oftalmias y queratitis ulcerosas, a pesar de que hay que tener en cuenta la fase negativa, nosotros hemos empleado las mismas dosis elevadas, sin que la pequena agravacion de trastornos locales que se nota en esta haya sido de gran duracion; en los presentes casos nunca ha llegado a las treinta horas; y en ciianto a los fenomenos generales, solo hemos podido apreciar unas decimas de elevacion de la temperatura. Si esta fase negativa resulta algo intensa, hay que retardar algo ma's la segunda puncion y no aumentar ma's la dosis anterior. RESUMEN Cinco blefaritis ciliares de las mas rebeldes y antiguas, curadas. Se ha empleado la vacuna estafilococica y streptococica autogena. Tres casos de raspado de saco lagrimal con conservation de organo y funcion. En los demas tratados por el sondaje se ha extinguido el pus hasta el presente. Se ha empleado la vacuna estafilococica y auto-vacunas de ge*rmenes di versos. Dos panoftalmias, en las que se ha podido evitar la enucleaci6n y conservaci6n, y alguna agudeza visual en una. Pero donde las vacunas, como se ve por los casos anteriormente citados, han alcanzado un importante y brillantisimo papel, ha sido en las afecciones corneales, precisamente las ma's temidas. 558 ROVIROSA VIRGILI La rapidez de la cicatrization que hemos podido observar, la falta de huellas cicatrizales y la conservation funcional, ponen a las vacu- nas, en primer lugar, en el tratamiento de las queratitis ulcerosas. Se ha empleado la vacuna estafilococica y pneumococica. For lo tanto se han ensayado en esta experiencia las vacunas estafilococica polivalente, la pneumococica, y las auto-vacunas strep- tococica, estafilococica y una del grupo difterico. En oftalmologla, como en las demas ramas de la Medicina, se im- pone hoy el diagnostic bacteriologico de los procesos infectivos y, sobre todo, los localizados 6 cronicos, pues la bacterioterapia ha ensanchado enormemente el campo de los tratamientos especificos ; el tratamiento bacterioterapico es compatible con los demas, locales 6 generales, que la experiencia ha demostrado ser los mejores, y los ayuda haciendo colaborar a la totalidad del organismo en el proceso de curacion local. Las vacunas polivalentes se emplearan con preferencia, por ser de mas comoda preparation y, por lo tanto, mds economicas; pero cuando el proceso es poli-microbiano; cuando estd, causado, por germenes contra los que no hay preparada vacuna polivalente 6 de dep6sito, y cuando ha fracasado la vacuna polivalente, deberd re- currirse a las auto-vacunas. TRECE CASOS DE ULCERA SUPURATIVA DE LA CORNEA TRATADOS CON VACUNA EsTAFiLoc6ciCA Las queratitis no supurativas, tanto superficiales como profundas, ceden por lo general la mayoria de las veces con un tratamiento apropiado, pero no pasan las cosas en la misma forma cuando se trata de queratitis supurativas, que dividiremos en tres grupos: ulceras, accesos, y queratitis por desnutricion. Solo voy a tratar aqui de las primeras. De entre estas descontaremos las queratitis secundarias debidas al gonococo, difteria y tracoma, que responden a una terapeutica ya estudiada. Nos restan cuatro especies de queratitis supurativas que son en el orden de f recuencia las siguientes : (1) Ulceras debidas al estafilococo piogeno, mas raramente al estreptococo; (2) ulceras serpiginosas, tfpica o atipica, pneumococica; (3) queratomicosis aspergilar; (4) ulceras liquidante, diplobacilo, de Petit de Rouen, de la que solo se han reunido contadas observaciones. Tanto la queratitis liquidante como la queratomicosis aspergilar, Tratamientos de las Queratitis Infecciosas por las Vacunas 559 debida al "aspergillus fumigatus," su paso por las clinicas es por extremo raro, tanto que pueden pasar anos sin que el especialista observe un solo caso. La queratomicosis aspergilar cede por lo general a un concienzudo raspado coadyuvado por los medios desinfectantes ordinaries y la queratitis liquidante es de esperar que ceda a la autovacuna. Nos quedan, pues, como las mas frecuentes, las queratitis estafilo- cocica, estreptococica, y pneumococica; pero estas dos ultimas en una proporcion por demas inferior. De este analisis se deduce que la lilcera estafilococica es la mas fre- cuente de todas; es la que tenemos cotidianamente entre manos, y como su gravedad es extrema, de aqui la importancia de un trata- miento como el que tengo el honor de exponer, con el cual he alcanzado siempre hasta el presente resultados satisfactorios. La queratitis estafilococica queda bien deslindada por sus caracteres clinicos de la ulcera pneumococica, a lo menos en sus comienzos; pero no asi de la queratitis estreptococica, si bien esta es sumamente rara. Por esto se impone el examen bacteriologico, pues puede darse tambien el caso de asociarse ambas bacterias en el mismo proceso. Esto, no obstante, siempre que sospechemos por los cardcteres clinicos un caso de ulcera estafilococica, a mas de obtener varias siembras en caldo aerobic y anaerobic en agar y suero debe practicarse desde luego la inyeccion de vacuna estafilococica por ser esta inofensiva, y que casi siempre el examen bacteriologico comprobara el aserto, en cuyo caso habremos ganado un tiempo inapreciable, y en el caso de hallarse otros germenes, puede continuarse e' tratamiento con las auto- vacunas elaboradas con dichas bacterias. Los trece casos que a continuacion expongo de queratitis supura- tivas en todos la ulceracion alcanzo grandes dimensiones, presentando abundante hipopion, habiendo por lo tanto llegado a mi clinica en un estado de suma gravedad, y en los cuales se habian empleado los medios ordinarios sin resultados. En dichos casos hay que anotar las siguientes observaciones : El caso septimo, recomendado por el Dr. Rey Becerra, corresponde a un enfermo que adem&s de presentar una extensa ulceracion corneal, con hipopion, estd afecto de dacrio- cistitis con abundante supuracion, y al que practique en el acto la extirpacion del saco lagrimal; no obstante la ulceracion y el hipopion siguen progresando, a pesar de una rigurosa antisepsia, siendo ne- cesario aplicar la vacuna al segundo dia de operado; la mejorfa se 560 ROVIROSA VIRGILI observa rapidamente, y el enfermo ve hoy regularmente gracias a una iridectomfa. El caso undecimo, muy parecido al anterior, pues presenta tambien la enferma ulcera con hipopion y dacriocistitis; pero en este caso se ha podido conservar la visi6n sin necesidad de recurrir a la iridectomfa, pues se le aplico la vac una desde el primer momento antes de operar el saco, y tanto el proceso corneal como lagrimal cicatrizaron en breve tiempo. El caso noveno, el mas grave de todos, lo recomienda el Dr. Bajo; la lilcera se extiende casi hasta los Ifmites corneales y el hipopion tapa completamente el iris; despus de la aplicacion de la vacuna cede tanto la ulceracion como el hipopion hasta la desaparici6n de e"sta; queda un leucoma adherente, pero deja sitio para una iridectomia bastante extensa. El caso duodecimo recomendado por el doctor Santacana, que a pesar de presentar una ulceracion central y extensisima con hipopion enorme, apenas ha dejado huella cicatrizal, tanto que la enferma ve regularmente no obstante el leucoma central, por ser este muy diafano. CASOS 1. Socorro Pat6n, de cuarenta y dos afios, natural de Valdepefias, ingresa el 31 de Mayo del corriente afio, afecta de ulcera supurativa con hipopi6n. Se le aplicaron tres inyecciones de vacuna estafilococica polivalente del Laboratorio Municipal; leucoma reducido en la parte inferior de la c6rnea, bastante transparente. 2. Rufina Garcia, de treinta afios, de Casatejada (Cdceres), ingres6 el 2 de Junio con ulcera supurativa con hipopi6n del ojo izquierdo. Se le aplico tres veces la vacuna estafilococica polivalente. Leucoma muy didfano. 3. Pablo Berlanga, de cincuenta y siete afios, de Vallecas, ingresa el 2 de Junio, presentando en su ojo derecho una extensfsima ulcera con abundante hipopion; se le aplicaron cinco inyecciones de vacuna estafiloc6cica poli- valente. Leucoma adherente. Iridectomfa 6ptica. Regular visi6n. 4. Pedro Sanz, de sesenta y seis afios, de Cedillo de la Torre (Segovia), ingresa el 16 de Julio con ulcera traumdtica con hipopi6n. 5. Juana Vifiuelo, de cincuenta y seis afios, de Puebla de Velena (Gua- dalajara), ingresa el 29 de Julio presentando una ulcera con hipopi6n ojo izquierdo; se le aplic6 la vacuna estafilococica en los dfas 24, 26 y 29 de Julio y 2 y 5 de Agosto. Leucomo algo extenso pero muy transparente. 6. Ram6n Peral de cincuenta afios de edad, de Navas del Rey (Madrid), ingresa el 27 de Julio afecto de ulcera supurativa con hipopi6n en su ojo izquierdo; se le aplica la vacuna estafiloc6cica en los dias 28 de Julio, 1, 3, y 6 de Agosto. El leucoma ocupa el cuarto externo de la c6rnea. Tratamientos de las Queratitis Infecciosas por las Vacunas 561 7. Gervaso Sanchez de cuarentay ocho afios de Espinosa del Rey (Toledo), ingresa el 30 de Julio afecto de dacriocistitis y ulcera con hipopi6n en su ojo izquierdo; se le aplica la vacuna estafiloc6cica en los dias 31 de Julio, y 2, 4, 7, 11, y 16 de Agosto. Leucoma adherente: Iridectomfa. 8. Esteban Uceda, de cincuenta y seis afios, de Brunete (Madrid), ingresa el 11 de Agosto con una ulcera central con hipopi6n en su ojo izquierdo; se le aplic6 la vacuna estafiloc6cica en los dias 12, 16, 18 y 21 del mismo mes: Leucoma muy transparente. 9. Narciso Luengo, de cuarenta y nueve anos, de Calzada de Orepesa (Toledo), ingresa el 18 de Agosto presentando en su ojo izquierdo una ulcera extensisima con abundante hipopi6n; se le aplican cinco inyecciones de va- cuna estafilococica: Leucoma tercio inferior corneal. 10. Rosario Arellano de veintocho afios, de Fuensalida (Toledo), ingresa el 31 de Agosto presentando una ulcera con hipopi6n en su ojo izquierdo; se le aplic6 tres veces la vacuna estafilococica: Leucoma transparente. 11. Alejandra Duefias, de cincuenta afios, de Ye"benes (Toledo), ingresa el 4 de Septiembre afecta de dacriocistitis y ulcera supurativa con hipopi6n de su ojo izquierdo; se le aplic6 la vacuna en los dias 6, 8, 10, 13, y 15 del mismo: Leucoma inferior y transparente. 12. Adela de la Pefia, cuarenta y ocho afios, de Zarzalejo (Madrid), in- gres6 el 10 de Septiembre afecta en su ojo derecho de ulcera central con hipopi6n; se le aplic6 tres veces la vacuna estafiloc6cica polivalente: Leucoma muy didfano. 13. Juliana Serrano, veintiocho afios, de Palencia, ingres6 el 11 de Sep- tiembre presentando en su ojo izquierdo una ulcera supurativa con hipopi6n; se le aplica tres veces la vacuna estafilococica polivalente: Leucoma muy transparente. RESUMEN Del estudio de los precedentes cases he podido deducir las conclu- siones siguientes: 1. La bondad del procedimiento ; pues en los trece casos de ulcera corneal supurativa a cual mds graves que he presentado, en todos se ha podido conservar la vision; y si a estos trece casos unimos los cuatro que expuse en mi anterior articulo sobre la bacterioterapfa en oftalmologfa, suman diez y siete observaciones de queratitis supurativa en las que ha triumfado el tratamiento por la vacuna, cuando ya habfan fracasado los denies medios hasta aquf conocidos. 2. Que a pesar de las dimensiones exorbitantes de la ulceracion que han presentado la mayoria de los citados casos, la extension del leucoma no es proporcional a dichas dimensiones, pues es mds pe- queno y mds transparente que los leucomas que quedan en las ulceras tratadas por los medios ordinaries. 36 562 ROVIROSA VIRGILI 3. Que si bien en la mayoria de los casos se nota la mejoria desde el dia siguiente de la primera inyeccion, hay algunos en que esta mejoria es mas tardia, sobre todo cuando se trata de procesos de extrema gravedad, habiendo podido observar en dichos casos la re- gresion de los smtomas cuando mas inminente parecia el peligro; regresion que se fue acentuando hasta quedar el ojo con una regular vision, por lo que recomiendo perserverar, a pesar de los fenomenos alarmantes que presente el proceso hasta la quinta o la sexta in- yecci6n. Una rigurosa antisepsia local completara el tratamiento. Por lo tanto estamos en presencia de un agente terapeutico, el mas eficaz en el tratamiento de las queratitis supurativas. El mejor, por la diafanidad de las huellas cicatrizales que se alcanza con su empleo, y que es ademas completamente inofensivo. APLICACIONES PRACTICAS DE LA INMUNIDAD EN OFTALMOLOGIA No es nuestro objeto hacer un estudio complete de la inmunidad en Oftalmologia, pero si creemos conveniente exponer los principios que han guiado nuestros estudios de bacterioterapia oftalmica y las reglas que seguimos en la aplicacion de las vacunas, nuevo recurso terapeutico que necesita manejar bien el oculista. La lectura del admirable trabajo del Dr. Juan Campos Fillol, Profesor auxiliar de la Facultad de Medicina de Valencia, titulado " Investigaciones acerca de la cantidad de anticuerpos en el suero de la sangre y en los humores del ojo" demuestra cuanta atencion deben dedicar al estudio de la sueroterapia y bacterioterapia especial oftal- mologica los que practican esta especialidad me"dica, y aun los medicos generates . El Dr. Juan Campos ha demostrado con sus importantes trabajos: (1) Que los anticuerpos se encuentran en el humor acuoso y vitreo en cantidad muy inferior a la del suero sanguineo, proximamente en la relation de 1 por 100; (2) que las inyecciones subconjunti vales y otros estimulos externos del globo ocular acrecientan la cantidad de anticuerpos contenidos en los humores del ojo; (3) la paracentesis corneal eleva la proportion de anticuerpos del humor acuoso entre cuatro y cincuenta veces. En consecuencia con estos datos, aconseja la aplicacion directa de los sueros antit6xicos y bacteriolisicos, cuando necesiten emplearse para combatir infecciones oculares, y espera que "la sueroterapia especifica y paraespecifica, la autosueroterapia y la aplicaci6n de vacunas, lo mismo profilacticas que curativas, enri- Tratamientos de las Queratitis Infecciosas por las Vacunas 563 quezcan el arsenal terapeutico de la Oftalmologfa, proporcionando brilliantes exitos." Suscribimos en absolute la idea del Dr. Campos, referente a la aplicacion directa de los sueros terapeuticos al ojo, por ser el mejor medio de llevar al foco del mal en maxima concentration las sub- stancias defensivas que los sueros contienen. La instalacion fre- cuente de suero en la conjuntiva cuando se trate de procesos super- ficiales de la cornea; la inyeccion subconjuntival y hasta la intro- duction directa en la camara anterior del ojo, son los medios que nos permiten obtener el fin deseado. Cuando en vez de suero se emplean vacunas; cuando no se inyectan substancias defensivas, sino, por el contrario, toxicas, que obligan a reaccionar al organismo, haciendo que el prepare los anticuerpos que necesita para destruir los germenes que le atacan y neutralizar sus toxinas, entonces hay que inyectarlas lo mas lejos posible del foco, en el tejido celular subcutaneo 6 en las venas. La inyeccion de vacunas obliga a la totalidad del organismo a colaborar en la defensa que realizan los elementos atacados del ojo y los que aporta la sangre, y se fuerza la production de substancias defensivas que permiten yugular el proceso local. La inyeccion metodica de vacunas provoca la aparicion de anti- cuerpos en el suero de la sangre, principalmente, por reaction de los elementos del tejido conjuntivo: sangre, ganglios linfaticos, bazo y medula 6sea, excitados por las substancias microbianas que las vacunas contienen, y que no se realiza, o, de verificarse, es mucho menos intensa cuando el individuo que tiene una infeccion ocular no se somete a este tratamiento. Segiin el Dr. Campos, la cantidad de anticuerpos elaborados por la totalidad del organismo que pasan del plasma hematico a los humores del ojo, es muy inferior a la que este contiene, e* indica que artificios podemos litilizar para aumentar dicho paso; pero hay que tener en cuenta que nuestro companero ha experimentado en ojos normales. Ha visto que los estimulos que sobre el globo ocular se realizan elevan la proportion de anticuerpos de los humores oculares ; teniendo en cuenta estos datos y las observaciones clinicas que hemos publicado sobre bacterioterapia de las queratitis supuradas, creemos que el estimulo que realiza la infeccion ocular es suficiente para atraer al ojo los anticuerpos hematicos en cantidad suficiente para neutralizar la action de los germenes. La paracentesis de la camara anterior es, segiin el doctor Campos, 564 ROVIROSA VIRGILI el mas poderoso recurso de que disponemos para enriquecer en anti- cuerpos hemdticos el humor acuoso. Nosotros hemos podido evitar la paracentesis con la bacterioterapia en casos en que parecia indicada ; no obstante, la reputamos como un excelente recurso cuando se acumula gran cantidad de pus en la cdmara anterior, pues con ello se libra al ojo de las substancias toxicas microbianas, y de la tripsina leucocitaria que queda libre al destruirse los polinucleares, y cuya accion sobre los tejidos oculares es nefasta. Ademds, la paracentesis obra aportando anticuerpos y elevando el poder antitripsico del humor acuoso. Quizd se presente algiin caso en el que la relativa dificultad que seiiala el Dr. Campos para el paso de los anticuerpos de la sangre a los medios del ojo, dificulte obtener el maximum de beneficios que puede reportar el empleo de las vacunas; es decir, que a pesar de la intensa production de substancias defensivas por el organismo, pro- vocada por la inyeccion de vacuna, pasen en escasa cantidad al foco ocular, en el que han de cumplir su accion anti-infecciosa. En estos casos, estarfa plenamente indicada la autosueroterapfa de que habla el Dr. Campos; diez o doce horas despues de extraer al enfermo por punci6n venosa algunos c.c. de sangre, se podria inyectar su suero, y con el los anticuerpos debajo de la conjuntiva 6 en la camara an- terior del ojo, sin miedo a ocasionar reacciones sericas, ya que precede del propio individuo. De lo expuesto se deduce que la inmunizacion activa terapeutica que realizan las vacunas es perfectamente compatible con los medios de accion local, cuya eficacia ha comprobado la experiencia y las molestias que ocasiona al enfermo, infinitamente menores que las ventajas que sobre la enfermedad se obtienen. El empleo de las vacunas en Oftalmologia se rige por las reglas generates de bacterioterapia; ante todo, es necesario establecer el diagnostic etiologico de la infection ocular. Unas veces, este diag- nostico se hard por los medios de que dispone la bacteriologia; pero en otras, los caracteres clinicos permitiran suponer de que germenes se trata. Por lo que se refiere a las infecciones supuradas de la c6rnea, que son los procesos oculares en que hemos estudiado prdcticamente la bacterioterapfa, diremos que la gonococica comienza por una infiltra- tion grisdcea y limitada de la cornea, que abandonada a si misma, se extiende rdpidamente a la totalidad de la membrana; como caranteres Tratamientos de las Queratitis Infecciosas por las Vacunas 565 diferenciales, seiialaremos lo enorme del gle>osis conjuntival y lo abundante de la supuracion tfpica de este proceso. En la queratitis tracomatosa la ulceraci6n es casi siempre mul- tiple y mas o menos profunda, segun la mayor o menor destruccion de la c6rnea por la lesion tracomatosa, siendo los sfntomas diferen- ciales el pannus, las granulaciones 6 las cicatrices granulosas. En las queratitis difterica, la ulceracion se extiende rapidamente y va acorn panada de iritis e hipopion. Estos caracteres clinicos, unidos a los antecedentes, nos permitiran casi siempre suponer la etiologfa de esta clase de queratitis. De las restantes queratitis supurativas, la mas frecuente es la causada por el estafilococo piogeno, siguiendo en orden de frecuencia la queratitis neumococica, estreptococica, diplobacilar, aspergilar y licuante. Por orden de frecuencia, las queratitis debidas al estafilococo y al pneumococo son las mas importantes, siendo muy distinto el sfndrome de unas y otras. La lilcera serpiginosa, semilunar, de base infiltrada, 6 sea la pneu- moc6cica, se presenta con el caracteristico borde en forma sigmoidea; este esta elevado y socavado en fondo de saco, limpiandose y ali- sandose los bordes situados en el lado opuesto que se recubre de epitelio sin formacion de vasos. La queratitis estafilococica se asemeja, por su aspecto, a las ulce- raciones simples no septicas, de las que la diferencian lo rapido del crecimiento y las tumultuosas manifestaciones que la acompanan. La infiltracion ocupa toda la perdida de substancia, al contrario de la pneumococica (ulcus serpens), que avanza solo por su borde sig- moideo. El hipopion, inyeccion ciliar, dolor, etc., sintomas que acompanan a esta clase de queratitis, no lo sefialo, para no distraer los caracteres verdareramente diferenciales. En la queratitis debida al estreptococo, los sintomas son muy parecidos a la producida por el estafilococo, de la que solo difiere por su marcada propension a la perforacion, pues la infiltracion invade desde los primeros momentos las capas corneales profundas. En la queratitis debida al diplobacilo de Morax, la infiltracion es marginal y grisacea, cede pronto al sulfato de zinc al 3 por 100. La bacilar de Weekes puede ser central, es superficial, y grisacea, hay secrecion y cede a los preparados arge"nticos. La queratomicosis, debida al arpergillus fumigatus, presenta una 566 ROVIROSA VIRGILI infiltracion corneal reducida al principio, andloga a una flictena, rodeado de bordes limpios y cortantes. La queratitis licuante, debida al diplobacilo de Petit (Rouen), es muy parecida a la ulcera serpiginosa superficial o sea la tipica, pero se diferencia de esta por la caracte- ristica de ser completamente indolora. Conocido el germen causante de la lesion que necesitamos combatir, podemos emplear una autovacuna, o sea una vacuna hecha con los propios germenes aislados en el enfermo, o vacunas ya preparadas, polivalentes 6 de deposito. Las auto vacunas son mas eficaces que las de deposito 6 comerciales, pero su preparacion no es posible en todos los casos, y siempre es mas costosa. Las vacunas comerciales son suficientes en la inmensa mayoria de los casos, como hemos tenido ocasion de demostrar en nuestros trabajos, pues casi todas las observa- ciones son casos tratados con vacuna polivalente. Las inyecciones de vacuna provocan reacciones que es necesario observar atentamente, pues ellas son los dates que nos sirven para dirigir el tratamiento; estas reacciones son: local, general y focal. Reaccion local es la que se observa en el sitio en que la vacuna se inyecta, siempre de naturaleza inflamatoria, mds 6 menos intensa, segun la dosis de vacuna inyectada y las condiciones individuales. La reaccion general consiste en malestar, inapetencia, insomnio, frecuencia de pulso, y sobre todo, elevacion de temperatura, que habra que observar con ayuda del termometro. La reaccion focal nos interesa muy especialmente, pues dada la delicadeza del organo en que la lesion asienta, una reaccion excesiva en ella puede ser per judicial. Nosotros hemos tenido la fortuna de no observar reacciones focales perjudiciales, pues hemos procedido con cautela en la elevacion progresiva de la dosis, sobre todo en la primera inyeccion que sirve para tantear la susceptibilidad del sujeto; en la primera inyeccion hemos utilizado siempre dosis pequenas, inferiores a las que aconseja el preparador de la vacuna en las in- strucciones que la acompaiian. Cuando la inyecci6n produce reaccion local o general muy fuerte, y con mayor motivo si se observa reaccion local, la dosis empleada es grande, y en la inyeccion siguiente no se aumentara la dosis; se repetird la que resulte fuerte hasta que el enfermo la tolere bien. Procediendo como queda dicho, hemos obtenido los brillantes resultados publicados en los trabajos precedentes, y que demuestran que no es hoy especialista completo quien no sepa servirse de la bacterioterapfa, y muy especialmente para combatir la queratitis Carcinoma of the Choroid 567 supurada, afecciones oculares que con mayor frecuencia conducen a la perdida de la visi6n. En fecha 1 de Junio de 1915, registramos 31 casos de queratitis supurada, todos ellos graves, en los que habian fracasado los medios terapeuticos habituales, y que la bacterioterapia nos permitio curar rapidamente; a pesar de las enormes dimensiones de la ulceracion que presentaban la mayoria de los citados casos, la extension del leucoma, que se produjo al curar no es proporcional a dichas dimen- siones: es mas pequeno y transparente que los producidos despue"s de ulceras tratadas con los medios ordinaries. Hoy, en el dia de la fecha, la estadistica se remonta a 472 casos tratados por las vacunas y en los que se ha comprobado los resultados satisfactorios precitados. CARCINOMA OF THE CHOROID DR. ALLEN GREENWOOD Boston, Mass. Metastatic carcinoma of the choroid is such an infrequent mani- festation of a general carcinosis that the chance to see and follow more than one case but rarely falls to the lot of an ophthalmologist. The opportunity which has come to the author to follow four cases makes it seem worth while to publish them. The first case, that of a man, W. G. C., was published fully in the Boston Medical and Surgical Journal by Greenwood and Southard 1 in 1903, including the results of a postmortem examination and an ex- haustive microscopic examination of all metastatic growths. At that time 29 cases of metastatic carcinoma of the choroid had been reported. Later, Oatman, 2 Parsons, 3 and Krukenberg 4 brought the number of cases up to 41 and in 1908 Suker and Grosvenor 5 brought the number up to 64. Since then a number have been reported. On reference to the author's report of his first case, it will be seen that the patient came to the hospital on account of acute glaucoma 1 Greenwood and Southard: Boston Med. and Surg. Jour., 1903. 2 Oatman: Am. Jour. Med. Sci., March, 1903. 3 Parsons: Royal London Ophth. Hosp. Report, xv, 3. 4 Krukenberg: Manz-Sattler Festschr., Klin. Monatsbl. f. Augenh., 1903, xli 145. 5 Suker and Grosvenor: Trans. Am. Acad. Ophth. and Oto-Laryn., August, 1908. 568 ALLEN GREENWOOD in the left eye. The fundus, after the glaucoma had been relieved by miotics, showed a separation of the retina in the upper temporal quadrant, covering a flat, grayish-white mass. A diagnosis was made of sarcoma of the choroid, but the eye was not removed as it was suspected that other organs were involved, particularly the liver. The ocular pain was easily controlled by cocain and miotics. The general examination of this patient had shown no evidence of any tumors in other parts of the body, except the probability of an in- volvement of the liver, which was enlarged. Prior to his death the patient became mentally incompetent, suggesting an involvement of the brain. The autopsy findings would indicate the prostate as the original source of the general carcinosis. The organs particularly involved in the general disease were the lungs, pleura, peribronchial lymph-glands, the liver, the brain, and the eye. In this case, as in one other, the eye condition was the first to call attention to the possibility of disease in other parts of the body. CASE II. Miss J. D., aged forty-eight, cook. Came under observation April 12, 1908, with the history that the sight in the left eye had been dim for several months and lately had grown very much worse. Right eye normal. Vision = 20 /20 and fundus normal. Left eye had a vision of hand motions only in outer field. Fundus showed a retinal separation in the outer part extending up to the disc, and including most of the upper and lower part as well. Through the separated retina 3 d. d. temporally from the disc could be seen a white mass elevated centrally about 3 d. d., which gradually flattened out in all directions. The tumor was quite white in the most elevated por- tion, giving the appearance as though a disc of some substance like cheese had been inserted under the retina. Immediately the similarity of the fundus picture to that seen in Case I came to mind and questioning the patient brought out the history that for a year there had been a hard lump in the left breast and she had become very short of breath. She had seen no physician so was sent to one who reported cancer of left breast, involving left lung and the axillary glands; therefore, unoperable. Seen again August 4, 1908, complaining that the right eye had a spot of dimness. Right eye examination showed up and out from the disc awhitish, flatmass about2 d. d. in size with retina over it elevated 1 D. This tumor beneath the retina corresponded in all but size to the one seen in the left eye in April. The left eye showed at this time complete retinal separation and opaque striae in lens. Tension was normal in both eyes. I next saw the patient in consultation at the Waltham Hospital in October, 1908, she having been taken there on account of her weakened general and mental condition. I found her semi- conscious and incoherent. The tumor mass in the right eye had increased Carcinoma of the Choroid 569 to more than double its former size and was elevated at its highest point 4 d. d. and extended to the disc. The left eye showed a retinal separation up against a cloudy lens. The patient died several weeks later from cerebral involvement. CASE III. Mrs. J. S., aged sixty. Seen September 12, 1912, at her home as she was too feeble to come to the office. Patient gave a history of vision failing for several months beginning first in the left eye and shortly after in the right. Two years before had been through an amputation of the right breast and dissection of the axilla for carcinoma. Had been losing strength and had a harsh, dry cough with much shortness of breath. Examination showed right eye fundus with a flat retinal separation out and down. Retina elevated 3 d.d. about 4 d.d. down and out from disc with the elevation growing less as one looked toward the disc, or peripherally. A white discoid tumor mass could be seen through the overlying retina, but no independent vessels were to be seen and no inflammatory reaction was present. Left eye fundus showed extensive separation of the retina from the disc outward and extending somewhat to the nasal side above and below the disc. The lower part of the separation was billowed forward by exudate. Up and out there could be seen, through the overlying retina, a grayish-white mass, somewhat uneven, the highest elevation being about 4 D. This mass extended from the tem- poral side of the disc, where it was very thin, outward beyond the equator. There was no independent vessel formation on the mass. The pupils were fairly large but tension not above normal. The daily use of pilocarpin was advised with the hope of preventing hypertension and pain. The patient died three months later with evidences of cerebral involvement and prac- tically blind, but without the eyes becoming painful. CASE IV. Mrs. A. E. H., aged thirty-six. Seen November 7, 1921, com- plaining that "something seems to come frequently before the right eye so that print blurs and there is a constant tendency to rub something from the right eye." Vision 0. U. = 20/30. Patient is slightly myopic. Examina- tion of fundus, right eye, revealed a very flat discoid subretinal mass located down and out from the macula. It was round and 3 d. d. in size and the upper inner edge reached to lower border of the macula. It was quite white, with the center whiter than toward the periphery. No independent vessel forma- tion was seen and no measurable elevation of the retina. No evidence of inflammatory reaction to its presence. The visual field showed a partial scotoma up and in. A more extensive examination of the field was not attempted at this time on account of the patient's poor physical condition. From these appearances, which were similar to those in Cases I, II, and III, a diagnosis of carcinoma of the choroid was made and then the history was obtained of operations for mammary carcinoma April 2, 1920, and October 4, 1920, at the Massachusetts General Hospital. A few days later an x-ray examination at the hospital showed extensive involvement of the left lung. Efforts were made to have additional examinations but this has not been 570 ALLEN GREENWOOD possible owing to the patient's mental and physical condition, which has grown rapidly worse. (Seen in consultation with Dr. Wm. E. Fay.) A study of these cases discloses several facts worthy of mention. In all four cases either an autopsy, an x-ray or physical signs showed involvement of the lungs. With the lungs involved, it is easy to understand how cancer emboli can be taken up by the pulmonary vein, carried to the heart and thence through the arteries to the . meninges, choroid and other parts of the uveal tract. The lungs be- come involved either by direct extension, as from a mammary car- cinoma, or through the lymphatics and the pulmonary arteries. The presence of cancer emboli in the arterial circulation is well illustrated by the case of Ishihara, 1 who described a primary mammary car- cinoma with multiple carcinomatous emboli in the choroidal capil- laries. There were three isolated tumor nodules in the choroid and eleven distinct capillary emboli composed of carcinoma cells. In one of Weeks' 2 cases an eye with a choroidal tumor was removed and the growth found to be carcinomatous with the primary source in the lungs only discovered at autopsy. A great many of the cases so thoroughly tabulated by Suker and Grosvenor showed an involve- ment of lungs when the records indicated a thorough general post- mortem examination. The author queries as to how often, if ever, a choroidal carcinoma occurs until after some involvement of the lungs. The discovery, therefore, of a whitish discoid subretinal tumor with moderate or little elevation of the retina, no independent vascular system and no surrounding inflammatory reaction of the retina, should lead to a careful examination of the lungs, especially by the use of the x-ray. In the author's first case, the tumor was diagnosed as a sarcoma. This has frequently been the case and, if the patient is first seen after the onset of pain and hypertension, is to be expected. Hypertension is not the rule, as in sarcoma, even when the eye is extensively in- volved. In my last three cases, including five eyes, hypertension was not present. How much the daily use of a miotic may have to do with preventing this painful complication can only be conjectured. In Case I pain and hypertension after arising were made to disappear by the use of cocain and miotics sufficiently to prevent any necessity of enucleation. Pain and hypertension are the only complications which, if unrelieved by treatment, call for an enucleation of the eye, 1 Ishihara: Klin. Monats. f. Augenh., liii, 127. 2 Weeks: Am. Ophth. Soc., 1915, xiv, 326. Arch. Ophth., xliv, 554. Carcinoma of the Choroid 571 unless one is in doubt as to the differential diagnosis between meta- static carcinoma and sarcoma and, in such a case, the removal should only be advised after an exhaustive physical and x-ray examination has proved negative as to carcinoma. It is possible that the more extensive pushing forward of the vitreous due to the greater projec- tion of sarcomata tends to increase the liability to hypertension while the flat carcinoma masses, even when extensive, do not encroach so much or so rapidly on the vitreous space and thus lessen the liability. DIFFERENTIAL DIAGNOSIS Situation. Shape. . . Color Projection. Growth. . New vessel formation Retina. . Vision . Tension . Metastatic Carcinoma . Posteriorly, usually temporally and not far from the macula. .Flat discoid with thin edges rarely elevated more than 2 or 3 mm. . Gray or white, without pigment. .Very little if any projection into the vitreous. . Spreads rapidly in all directions and ultimately surrounds the disc but always flat. . Not present. .Very slightly projected at first by the tumor growth and with little subretinal fluid separa- tion of the retina around the tu- mor comes quickly and spreads rapidly as the tumor grows and soon becomes complete. .Early disturbed and soon lost owing to rapid growth under or toward the macula. .Not usually increased in early stage and usually amenable to miotics. Enucleation .... Almost never necessary and of no value to the patient unless for otherwise unrelieved pain does not prevent metastases. Occurrence Always metastatic and primary focus or other metastases can usually be found often bi- lateral. Treatment Palliative. Prognosis Inevitably bad. Sarcoma Usually equatorially, or far- ther forward, rarely near disc. Rounded, nodulated. Usually dark gray or showing much pigment and mottled. Projecting far into the vitre- ous early. As size increases slowly pro- jects more and more into vitreous. Usually present. Projected into the vitreous early by the tumor and separation of the retina around the tumor comes slowly and does not become complete until much later. Vision centrally not early dis- turbed and not quickly lost unless glaucoma appears eyes with sarcoma often enucleated with vision nor- mal. Usually raised early and acute glaucoma almost inevitable if eye not enucleated early enough not affected favor- ably by miotics. Always necessary as early as possible and of great value to the patient in preventing metastases. Always primary seldom, if ever bilateral and causes metastases later. Early enucleatiqn. Usually good, if seen early, though metastases of the liver may occur years later. 572 ALLEN GREENWOOD It is not possible to arouse much interest in such an absolutely hopeless condition, but one should be on the lookout for these cases, particularly as they seem to be on the increase. Finding an eye, therefore, that presents a discoid white, or grayish-white, subretinal mass located temporally not far from the macula, with the overlying retina only elevated 2 or 3 D. at the most and no evidence of inflam- matory reaction, or independent vascular system, particularly in women, would be suspicious of metastatic carcinoma, remembering that such tumors rarely need enucleation. In spite of an attempted differential diagnosis cases will occur later where an eye will be enucleated for sarcoma when the tumor is a metastatic carcinoma. In the author's first case this would have oc- curred but for the evidences of an enlargement of the liver. It is doubtful if the reverse is ever found, viz., that a tumor having, after careful study, been diagnosed as carcinoma, later turns out to have been sarcoma. This fact should be borne in mind when making a differential diagnosis. Therefore, when a tumor having all the char- acteristics described above as being indicative of carcinoma is so diagnosed and later the patient succumbs to what is very evidently a general carcinosis, especially if with evident lung and brain involve- ment, it may be safely considered that the correctness of a diagnosis of metastatic carcinoma of the choroid has been established, even if a microscopic study of the eye or a general postmortem be not made. DISCUSSION DR. GEORGE E. DESCHWEINITZ (Philadelphia): At Dr. Greenwood's request I exhibit a specimen of metastatic carcinoma of the choroid, the eyeball having been enucleated twenty-five years ago. The patient, a single woman, had carcinoma of the left breast, which was thoroughly removed. Six months later vision of the left eye became indistinct and examination re- vealed a flat carcinoma of the choroid. The patient died three months later, metastasis to the brain and lower end of the spine having occurred. The tumor was composed of epithelial cells, rather spheroidal in shape, with large nuclei, collections (here and there) of small cells representing necrotic foci, pigment granules and a moderate amount of stroma. In some portions the carcinoma cells were arranged in long tubules, separated by faint stromal tissue, which contained pigment granules. A similar appearance has been described by Lagrange. In the region of the choriocapillaris, remnants of original choroidal structure were visible, also vessels plugged with cancer cells. The optic nerve and retina were normal; there was no change in the filtration angle. A second case examined at about the same time concerned a married woman, aged forty-three, whose left breast was removed for carcinoma; re- Metastatic Thyroid Tumor in the Orbit 573 currence in loco, in the other breast and in the axilla occurred. The recurrent growths were excised; ten months later dimness of vision of the left eye was noted, and the typical appearances of metastatic carcinoma were found. The patient also had carcinoma nodules above the left clavicle. The patient was seen only once, and her subsequent history is unknown. METASTATIC THYROID TUMOR IN THE ORBIT DR. ARNOLD KNAPP New York City Cohnheim was the first to recognize that a struma may cause metastases, and called them metastatic benign strumas. These metas- tases occur in the bones and in the lungs. Why they seem to select the bones is unsettled; A. Miiller believes that the medulla of the bone furnishes a favorable site for their growth because of its retarded circulation. Thyroid gland cells are unusual in that they may, after entering the circulation, remain viable, and in certain places prolife- rate and form tumors. Trauma plays here a definite r61e. Striking is the destructive power of these metastases, which is particularly evident in the bones. This destructive tendency, the formation of metastases, and recurrences, cause some authors to regard them as essentially malignant. The thyroid in some of these cases seemed per- fectly normal. The tumor may, of course, be overlooked in the thy- roid gland. Schmidt (Zur Kasuistik und Statistik der Knochentumoren mit Schilddriisenbau, Inaug. Diss., Rostock, 1906) has collected 49 cases of struma metastases. In the metastasis, careful search reveals a car- cinomatous part in the normal thyroid gland tissue. The site of these metastatic thyroid gland tumors is in various bones, particularly the cranial bones. Twenty-nine metastases occurred in the skull, princi- pally in the frontal and parietal bones; in the vertebrae, 16; in the ribs and shoulders, 4; in the pelvis, 11; in the femur, 7; in the humerus, 6. The size varies from that of a fist to an egg. The age of the patient is between 30 and 60. It affects women more frequently than men. Trauma was elicited in 11. From the standpoint of the histology of the tumor and the clinical course, the struma metastases were malignant in 39 ; uncertain in 5; possibly benign in 5. 574 ARNOLD KNAPP The following is an instance of this form of tumor: Case Report. E. R. B., aged 66; Dec. 18, 1917: Has always been in good health until recently. Has complained of vertigo and comes on account of dis- comfort in reading. Vision with glasses, 20 /20. Both eyes seem unduly promi- nent. The right upper lid droops and the right eye is distinctly more prominent Fig. 1. Metastatic thyroid tumor in the orbit. than the left. Exophthalmometer R. 32, L. 28. The motility of the right eye upward is restricted, particularly in abduction (superior rectus) . Distinct ver- tical diplopia, increasing upward and to the right. This diplopia patient was observed for one week. On palpating the right upper orbital margin there is a resistance to be felt, especially in the region of the pulley, which consists of a soft mass within the upper margin of orbit, occupying a round defect in the bone, where pulsation can be felt. The pulley is displaced. Optic nerve nor- Metastatic Thyroid Tumor in the Orbit 575 mal. Field normal. The blood count is normal; hemoglobin, 9(J per cent. The Wassermann test is negative. The Roentgen examination shows an area of increased radiability on the right side, indicating an area of softening. It involves the orbital plate of the frontal bone and extends above the superciliary ridge. It is about three- quarters of an inch in its widest diameter. It extends about one inch above the supra-orbital ridge and along the orbital plate to the sphenoid fissure. There seems to be no involvement of the frontal sinus, but there is a supra-orbital extension of the ethmoid cells which seems to be very near indeed to this area of softening. With the exception mentioned, we find no indication of disease of any of the accessory nasal sinuses. The skull is unusually thick, especially the outer table of the frontal bone (H. M. Imboden). Increasing doses of potassium iodid are prescribed for six weeks without any change in the tumor. An operation is advised. Feb. 19, 1918, operation. Curved incision below the eyebrow down to the periosteum, which was found continuous downward with a mass. Incision also through the periosteum and the attempt made to elevate it. It was so firmly adherent to the underlying structure that this failed. The center of the mass seemed to be soft. The incision through the periosteum was then enlarged and immediately a dark, hemorrhagic-like mass resembling granulation tissue presented. The area was fully exposed, some of the perios- teum removed and the above-described material was scooped out. The cavity was found in the bone extending back, upward anteriorly and laterally. Profuse bleeding made it difficult to see, and one had to be guided by a sense of touch. After cleaning out all this soft material and some of the rough bone along the margins, a rather well-defined cavity was exposed. The constant oozing was somewhat controlled by packing; it could then be seen that in two small places in the upper wall the dura was exposed without being directly involved. The edges of the bony cavity were trimmed off and the entire cavity packed with iodoform gauze. The external wound was left open. Length of operation, one hour. In brief, this seemed to be a tumor arising in the medulla of the bone, particularly in the anterior part of the frontal, where it forms the upper wall of the orbit. The cavity was filled with soft, dark-red material. This in the lower part was directly adherent to the periosteum. A striking feature was the extensive bleeding, which seemed to be general. The bony walls of the cavity were smooth. No reaction followed the operation. At the first dressing some of the pack- ing was removed; considerable oozing. The specimen removed at operation was sent to Professor James Ewing, who reported as follows: "The tumor (Fig. 1) of the bone in the case of E. R. B. proves to be an adenoma of aberrant thyroid tissue. It is rather orderly in structure and not 576 ARNOLD KNAPP very malignant, although in some spots the alveoli are small and numerous. It reproduces thyroid structure to the smallest detail, many alveoli containing soft acidophile colloid surrounded by flat thyroid cells. Many small alveoli are exactly similar to the usual thyroid adenoma. The stroma is scanty and not vascular. "This tumor may arise from a portion of thyroid tissue originally present at that point in the embryo, or it may represent a metastasis of an adenoma in the thyroid. The thyroid gland should be examined for the presence of any small tumor at any point. I am inclined to prefer the former hypothesis, especially if there is no tumor found in the thyroid. "The prognosis of these cases is not entirely favorable. Although they have been called 'benign metastasizing struma' they are not always benign. They recur locally, and the only other case in the skull which I have seen (Jeffries' case, in parietal bone) recurred locally and eventually produced metastases elsewhere. The thyroid was normal. Hence I recommend that radium be inserted in the wound, as the alveoli penetrate the bone spaces and are hard to reach by the knife. I know of no cases treated by radium, but would expect this structure to respond well (J. Ewing)." February 24th : All of the packing is removed and a radium tube 27 me. protected by a lead plate is introduced for four hours. The thyroid gland seems normal. March 1st: No reaction, slight secretion superficially; wound is allowed to close. April 1, 1918: The wound healed. A swelling remained at the upper mar- gin of the orbit continuous with a bony mass externally just above the ex- ternal canthus. Some exophthalmos remains, measuring R. 30, L. 28. Vision is normal. Eyeground normal. November 26, 1918: General condition good; no change in orbit. April 8, 1919: Has lost about 30 pounds in weight; complains of band over head and obscure abdominal symptoms. July 1st: R. 31.5, L. 28. Diffuse swelling in orbit. Vision and eyeground normal. October 8th: Drawing sensation in right half of head. R. 32, L. 28. December 19th: The orbital condition is unchanged. Diplopia to the right. Distinct soft pulsating mass in orbit. A swelling had been noted over right scapula for some months and patient complains of neuralgia in right groin. December 29, 1919: The patient is referred to Professor James Ewing, who reports as follows: "There is a tumor mass behind the eye which causes distinct exophthalmos and protrusion of the supraorbital tissues of about 1 cm. The body of the right scapula is largely replaced by a tumor mass about 5 cm. in diameter, as shown by the x-ray. This tumor is of recent discovery and evidently growing actively. The left lower portion of the thyroid gland is the seat of a well- Metastatic Thyroid Tumor in the Orbit 577 circumscribed, rather firm tumor mass about 4 cm. in diameter. There is pain in the use of the right thigh muscles, which was not investigated, but will receive attention later. The x-ray of the right lung shows several suspicious isolated nodules, which I suspect are tumor nodules, but which cannot be positively identified as such. Further x-ray photos of the lungs and bones will be taken. The patient has lost weight, is anemic and rather feeble, and is therefore distinctly cachectic. I feel that the prognosis is unfavorable, but that some help may come from x-ray and radium treatment. "I would recommend that the tumor of the scapula be treated by x-ray that the orbital growth be treated at first by a radium pack, and that the thy- roid tumor be treated by the insertion of radium needles. This latter tumor is probably the source of the others. The scapular growth was treated this afternoon. We propose to go after the others slowly, but steadily, avoiding undue disturbance of the patient (J. Ewing)." The shoulder tumor was given eleven x-ray treatments from December 29, 1919, to May 18, 1920. A radiograph on January 7, 1920, showed a destruc- tive process in the eighth rib posteriorly and an area of bone destruction in pubis to right of symphysis. On January 20, 1920, a small area of destruction was found in the sixth rib posteriorly. The right groin was treated by x-ray four times from January 6 to May 4, 1920. Radiograph on January 7, 1920, showed dense shadow above manubrium and to the left of about the size of a small orange, indicating the presence of a calcified mass in the thy- roid gland; pushing the trachea over to the right. The orbit was treated with radium three times from January 19, 1921, to April 27, 1921. The patient, according to Dr. R. W. Lowe, Ridgefield, Conn., then grad- ually lost weight, suffered from hallucinations and delusions, and was at times mildly maniacal. There was flatness over anterior and posterior chest (left) ; pleuritic pain, loss of motion over chest, dyspnea, slight cough. Lym- phatic enlargement in neck (left side). Edema of lower extremities, increasing during last two weeks. Died July 21, 1921, apparently from cerebral hem- orrhage. In this patient a tumor in the roof of the orbit was the first symp- tom of a malignant process. At operation destruction of bone by a brownish, granulating, tissue-like mass was found present and unusu- ally free hemorrhage occurred. The histology of the tumor showed it to be composed of thyroid gland tissue. No tumor could be detected in the thyroid gland on palpation. Symptoms of other metastases appeared one and a half years later and were confirmed by the x-ray examination in the scapula, in the sixth and eighth ribs, in the lungs and in the pubis, and at that time a distinct tumor was discovered in 37 578 ARNOLD KNAPP the thyroid gland, and the x-ray showed that it extended behind the sternum. The localization of these thyroid gland tumors in the walls of the orbit is unusual. In the literature there is a report of a case by von Eiselsberg (Langenbeck's Archiv, vol. xlvi, p. 440) of a woman thirty- seven years old, who showed externally a bulging nodule in the sub- stance of the parietal bone, projecting inward and adherent to dura. Another nodule was situated in the right upper orbital wall extending through into the skull. The sixth rib right and the left humerus were also involved ; struma present (adenocarcinoma) ; autopsy report. Jaboulay's patient (Bull. soc. de chirurgie de Lyon, 1903), a female, sixty-five years old, presented a tumor in the supero-internal angle of the left orbit, pulsating; old swelling of the thyroid gland. At opera- tion the bone was found perforated, exposing the meninges. In the discussion of von Eiselsberg's report (Verh. d. d. G. f. Chir., 1893, p. 88, i) Kraske said that he had observed a case where a tumor occurred in the frontal bone, the patient also having a struma. The association at first was not clear. At operation an unusual hemor- rhage occurred, which is characteristic for this tumor. The tumor was adherent to the dura, necessitating excision of a part of this structure. The struma has remained stationary and no other metastases ap- peared. Microscopically the tumor resembled thyroid gland tissue and was regarded as an adenoma. According to von Eiselsberg (ibid., p. 255, ii), though the histologic structure of the tumor suggested adenoma, the clinical picture is that of an adenocarcinoma, because whenever a tumor metastasizes, it becomes malignant. The metastases of the adenocarcinoma of the thyroid may show normal thyroid adenomatous tissue. The metastases grow slowly, while the primary tumor in the thyroid is small and escapes detection. The bone metastases should be operated upon, von Eiselsberg believes, though it is a general rule in surgery not to operate on bone metastases. The primary tumor in the thyroid is often not found until the char- acter of the metastases is made known. BILATERAL LYMPHOSARCOMA OF THE ORBIT WITH INTERMITTENT EXOPHTHALMOS WALTER SCOTT FRANKLIN, M.D. Clinical Professor of Ophthalmology, University of California Medical School AND FREDERICK C. CORDES, A.B., M.D. Instructor of Ophthalmology, University of California Medical School San Francisco, California The subject of orbital tumors is an ever-increasing one which com- prises a large field. The case at hand has several unusual features which warrant its presentation. Mrs. M. B , aged thirty-three, was first seen in 1908. Her symptoms were those of a refractive error, namely, hyperopia. The eyes were prominent without any apparent etiology. There was no thyroid disease and all other physical findings were negative. August, 1917 (eight years later), patient returned, complaining of a slight drooping of the left upper lid. She was also under the care of Dr. A. W. Hewlett, Professor of Medicine at Stanford Medical School, who was treating her for an acquired lues. The eye findings were as follows: Slight ptosis of left upper lid. No apparent paralysis. Lid could be voluntarily elevated. Right globe somewhat more prominent than left. (At this time we did not possess an exophthalmometer.) Movements of eyeballs normal. Tension of left eye 32 mm., right 24 mm. No pupillary changes. Fundi negative. Perim- eter fields, stereoscopic vision, and color sense all normal. The following is an excerpt of the salient points in Dr. Hewlett's report: "The general physical examination in October, 1916, showed the presence of numerous crackling and musical rales in the left back and axilla. Wassermann reaction was 3+. Sputum negative for tubercle bacilli. On March 3, 1917, the white blood-corpuscle count was 7,400, with 83% polymorphonu- clear cells, 6% lymphocytes, and 11% large mononu clears. From March, 1917, to September, 1917, the patient was receiving anti-luetic treatment." By October of the same year the ptosis of the left eye had increased, with a beginning exophthalmos of 3 mm. The patient continued under most vigorous anti-luetic treatment. November 21, 1917, the left eyeball became prominent. There was a marked swelling of the lids with chemosis. The 579 580 WALTER SCOTT FRANKLIN AND FREDERICK C. CORDES examination for leukemia was negative, the white-cell count being 7,500, with 81% polymorphonuclears, 6% lymphocytes, and 11% large mononuclears. December 20, 1917, the right eye was beginning to show exophthalmos, while the left eye was at its height and with its upward motion limited. Eight days later the left was receding, and by January 15, 1918, both eyes were somewhat improved. January 20 the left eye was beginning to show recurrent exophthalmos, while the right continued receding, and on February 20 the left was at its acme for the second time, with the right normal. On March 1, 1918, the right was again markedly exophthalmic, with the left stationary, and by March 10 the left receded, leaving the right still somewhat swollen. When the patient reported on April 5, 1918, the exophthalmos of the left eye was beginning to recur for the third time and the right was normal. On May 10 the left eye protruded markedly and the right was beginning to be prominent for the third time. As there was no improvement by July 6, 1918, the patient was put to bed, and by October 2, 1918, both eyes had receded ; the therapy was limited to hot compresses and rest in bed. The left fundus now for the time showed a beginning optic neuritis. A month later a circumscribed nodular swelling was observed in the bulbar conjunctiva at the nasal side of the left eye. There being a definite left-sided optic neuritis, the patient was sent to the University Hospital. A small vesicle developed which was punctured and showed a pure culture of staphylo- cocci, the bacteriologic diagnosis being made by Dr. Karl Meyer. The family history was negative. Father died at 81 (old age and asthma). Mother living and well. No Tb, malignancy, or other familial diseases. Past history negative except for the usual exanthemata of childhood. On January 20, 1919, the right eye was still normal, but the left showed for the fourth time a marked exophthalmos, and the patient was again sent to the hospital for further detailed examination. Physical examination at this time was entirely negative. The blood count showed hemoglobin 75% ; white blood cells 9,200; polymorphonuclears 70% ; lymphocytes 26%; large mononuclears 4%; urine examination negative; stereoscopic x-ray examination of the skull negative; examination of nose: no evidence of sinus involvement; no involvement of preauricular or cervical glands. EXAMINATION OF EYES. Right eye normal. Left eye, marked edema of both upper and lower lids, with chemotic conjunctiva bulging through pal- pebral aperture. The globe protruded markedly, the exophthalmos being 10 mm. Entire conjunctiva injected and chemotic; at the inner canthus was a rounded nodule about the size of a pea, which appeared less edematous than the remainder of the swelling. The lower lid was overlapped by the growth while the upper lid was enlarged, covering the superior third of the mass, as shown in the illustration (Fig. 1). The eye was amaurotic and showed a secondary atrophy of the nerve-head. Under cocain anesthesia a small por- tion of the nodule was excised for microscopic examination. Bilateral Lymphosarcoma of the Orbit 581 The pathologic report of Dr. G. Y. Rusk, University of California patholo- gist, follows: Specimen consists of a small, irregular mass of tumor removed from the subconjunctival tissue overlying the left eyeball. Microscopic examination shows the tissue to be composed of a fairly uni- form small cell, approaching a lymphocyte in size, but slightly larger and showing less condensation of the chromatic material. A slight rim of proto- plasm can be made out in many of the cells. Mitotic division is observed with fair frequency, averaging about one to a high power field. Thin-walled ves- sels occur and also some with fairly well-developed walls. Extending from the vessels, fibers appear to run for a short distance between the cells. This ap- RS. Fig. 1. Extent of exophthalmos on lateral view. pearance, seen in the hematoxylin and eosin stained tissue, was confirmed by the use of the anilin-blue connective-tissue method. Away from the vessels no fine interstitial reticulum is demonstrable. In different areas the density of the cells varies, there being apparently some edema in places. DIAGNOSIS. Sarcoma of small round-cell type, possibly lymphosarcoma. Later a diagnosis of lymphosarcoma was made' and confirmed by Drs. Whipple and Meyer, of the University Staff, and by Dr. Ophiils, of the Leland Stanford, Jr., University, Department of Pathology. January 20, 1919, the left eye was enucleated. It was debated whether to eviscerate the orbit or do a simple enucleation. We decided to remove as much tissue as seemed feasible, depending upon our operative findings. A circular incision was made just outside the limbus through the conjunctiva, 582 WALTER SCOTT FRANKLIN AND FREDERICK C. CORDES which was decidedly indurated. The ocular conjunctiva was dissected back, and the eyeball freed to the apex of the orbit. Muscles and nerve were then severed. The internal rectus muscle was obscured by a soft cellular tumor mass which involved it throughout its length. Digital palpation of the orbit showed the tumor mass to extend to the apex of the orbit and impinge upon the superior orbital fissure. There was no apparent bony involvement at the superior nasal border of the orbit. Due to the extensiveness of the growth and the likelihood of involvement of the other eye, as indicated by the tumor, and the practical impossibility of radical excision, evisceration of the orbit was decided as contraindicated. All available parts of the tumor were removed and the wound packed. Fig. 2. Anterior view with nodule at inner canthus. The pathologic report follows: The eyeball and tumor in the case already reported (S. 19.9) was received in formalin. The tumor mass was loosely adherent to the ball except at the edge of the cornea, where it apparently merged with a circular opaque ring, completely encircling the cornea. The tumor measures 3J^ x 2 x 2 cm. The eyeball and tumor were cut in the horizontal plane just above the optic nerve posteriorly and slightly above the center of the cornea anteriorly. From the larger portion of the bulb and tumor a block of tissue through the whole mass is taken and prepared for microscopic examination. The details of the tumor correspond to those already described in report S. 19.9. One, however, gets relationships in a much more satisfactory man- ner. Anteriorly the tumor starts from the edge of the cornea and is covered Bilateral Lymphosarcoma of the Orbit 583 for some distance by conjunctival epithelium. It shows apparently little tendency to infiltrate the sclera, and in this region there is some edema of the pre-existing tissues. The tumor as a whole is somewhat lobulated, and while the main mass tends to grow away from the bulb, yet between the main mass and the bulb there is considerable tumor infiltration into the loose cellular tissue present. Toward the posterior end of the tumor extensive infiltration of muscle is observed. Connective-tissue septa of some size are observed in the posterior portion of the tumor, probably representing pre-existing struc- Fig. 3. Gross specimen. Fig. 4. Cross-section showing involvement of internal rectus muscle. tures, and these show varying degrees of infiltration. At the angle of the cornea and sclera on the side opposite to the growth there is some edema, but the growth has not encircled the cornea, as was suggested by the gross appear- ance. As to the eyeball proper, the retina appears normal, the pigment tissues in both the retina and sclera are normal, and there is no evidence of tumor having originated within the orbit. The optic nerve contains a suspicious number of clustered cells in places, small and round, which morphologically appear something like the tumor cells. Adjacent to the nerve, however, in 584 WALTER SCOTT FRANKLIN AND FREDERICK C. CORDES the angle which it makes with the sclera and on the side opposite the main tumor growth is considerable invasion of areolar connective tissue with loosely scattered masses of small cells, simulating strongly the tumor type. DIAGNOSIS. Lymphosarcoma. On January 25, 1919, the patient received 350 milligram hours of radium to the left orbit (screened by }/% mm. of silver and 1 mm. of brass) and an addi- tional 300 milligram hours on February 3, 1919. Healing took place without signs of recurrence, although there was considerable skin reaction from the radium. April 2, 1919, the right eye was negative to inspection and to all tests. The Fig. 5. A. (X 581.) Area with connective-tissue septum, showing lymphoid character of cells. B. (X 1000.) Proportionate same area under high magnification. Illustrations show one-tenth reduction of original drawing. left orbit showed a small palpebral aperture, slight symblepharon; no visible signs of recurrence. The patient was apparently well physically. Up to and including April 26, 1921, the patient reported every few months for observation, and during that time there was no sign of recurrence on the left side, and the right eye was normal. The examination on April 26, 1921, showed V. R. E. 1/2. There was no exophthalmos, the exophthalmometer reading being 24 mm. The fundus was negative and the perimetric field for white and colors was normal. In July, 1921, we were informed that the patient had died, death being caused by an acute cardiac decompensation. There was an enlarged spleen, extending down to the pelvis, accompanied by a marked ascites. Several months previous patient had complained of a chronic cough, and on one x-ray examination a diagnosis of sarcoma of the lung was made. On a "retake" the diagnosis was altered to that of pulmon- Bilateral Lymphosarcoma of the Orbit 585 ary lues. Unfortunately, because of the religious creed of the family, it was impossible to obtain a postmortem examination. Clinically the entire picture was rather suspicious of a sarcomatosis. COMMENT The right eye of the case under discussion was presumably also effected by lymphosarcoma as its actions were identical to the left, with the exception of the appearance of the nodular mass. The case can justifiably be considered one of bilateral lymphosarcoma. Several unusual points are to be noted. First, the bilateral occurrence of lymphosarcoma, with marked exophthalmos. The occurrence of lymphosarcoma of the orbit is rather infrequent. Chauvel 1 reports a single-sided lymphosarcoma, as does Wurdemann, 2 while Meller 3 describes a bilateral lympho- sarcoma. Retrogression followed by progression was not noted in any of the above orbital tumors. Because of the infrequency of lym- phosarcoma in the orbit, we had the pathologic diagnosis confirmed by several independent pathologists. Bilateral exophthalmos due to retrobulbar conditions is compara- tively rare. It generally occurs accompanying exophthalmic goiter and orbital varices. Syphilis had to be considered in this case, due to the triple plus Wassermann. In Forster's 4 case of symmetric tumors with exophthalmos the condition subsided under KI. Bail- Hart 5 reports bilateral symmetric gummata of the orbit. Anti-luetic treatment had no effect on our case. Among the other causes of bilateral exophthalmos may be men- tioned serous tenonitis (Tersen, A., and Tersen, J. 6 ) and adenoids (Posey 7 )- Infrequent conditions to be considered are the various orbital tumors. Bilateral lymphomata are comparatively frequent. Becker and Arnold 8 reported a case of bilateral lymphomata with exophthal- mos and orbital glands which healed through extirpation. Gerl- lach's 9 case, a four-and-a-half -year-old boy, showed lymphomata of the neck, liver, breasts, and conjunctiva. There were double- sided tumors of the orbital glands. Autopsy showed a generalized lymphatic involvement. There was symmetric exophthalmos of two years' duration, which extirpation showed to be due to lymphoma, in a case recorded by Bernheimer. 10 Guaita's 11 patients showed diffuse lymphomata of the conjunctiva, as did Boerma's. 12 Arnold believes these to be due to hypertrophy of small lymphatic groups of 586 WALTER SCOTT FRANKLIN AND FREDERICK C. CORDES tissue that occur in the orbit. Goldzieher 14 thinks they are due to follicular tissue from the conjunctiva that has grown into the orbit while Axenfeld 15 considers them as misplaced fetal lymphatic tissue. A large number of these tumors are found in cases of leukemia and pseudoleukemia. Leber 16 reports such a case of double-sided retinal hemorrhage, together with numerous orbital tumors in a case of leukemia. Similar cases are also reported by E. Treacher Collins, 17 Ostenwald, 1 * Deleus, 19 Gayet, M., 20 Reymond, 21 and others. Ahl- strom 22 goes so far as to claim that double-sided orbital tumors are always due to leukemia or pseudoleukemia. In his case of pseudo- leukemia the orbital tumors were the first sign of the disease. We considered the possibility of lymphomata, but all examinations for leukemia or pseudoleukemia were negative. Among bilateral orbital tumors is a case reported by Henry Juler 23 of bilateral, round, and spindle-cell sarcoma, while Major Kirk- patrick's 24 patient had bilateral endothelioma of the sarcomatous type. In Silcock's 25 case, a girl of nine, the bilateral orbital tumors were round, all sarcomata. Exophthalmos of the intermittent type due to circulatory changes in the orbit such as telangiectases, cavernomas, angiomata, and orbital varices, have been reported by Birch-Hirschfeld and Ro- meick, 26 Saint-Martin, 27 Hegner, 28 Enroth, 29 Alger, 30 Dupuy-Dutemps and Marvas, 31 Posey, 32 Mathus and Cerise, 33 and others. In none of the cases of intermittent exophthalmos was it due to an orbital tumor, although Birch-Hirschfeld 34 describes an intermittent increase of exophthalmos due to propagation of tumor cells in the orbital veins. Another interesting feature in our case was the continued observa- tion, post-operatively for a period of almost two and a half years, with no signs of recurrence on the operated side or the unoperated eye. It has been observed a number of times that removal of a tumor on one side has been followed by improvement of the unoperated eye. Among the more recent reports, Wilder 35 and also Lustig 36 made the same observation. The question arises as to the effect on the un- operated eye of the massive doses of radium and whether or not the effect was sufficient to check the tumor's progression. We have been unable to find in the. literature a case of bilateral lymphosarcoma with intermittent exophthalmos of the type described. Bilateral Lymphosarcoma of the Orbit 587 BIBLIOGRAPHY 1. Chauvel: Gazette hebdomadaire, No. xxiii, 1877. 2. Wiirdemann: Am. Jour. Oph., iii, 210. 3. Meller: Trans. Ophth. Gesell. in Wien, October, 1909. 4. Forster: Zehender's Monatshefte, 1866. 5. Bailliart: Clin. Ophth., xx, p. 531. 6. Tersen, A., and Tersen, J.: Ann. d'oculist, December, 1908. 7. Posey: Oph. Rec., xxi, p. 296. 8. Becker and Arnold: Arch. f. Ophth., xviii, ab. 2, p. 56. 9. F. Gerllach: Jahrbuch f. Kinderh., 1895. 10. Bernheimer: Report of 20th Oph. Congress, Heidelberg. 11. Guaita: Trans, of 12th Italian Ophth. Congress, Pisa. 12. Boerma: Arch. f. Oph., xviii, 2. 14. Goldzieher: Wiener med. Wochensch., 1893. 15. Axenfeld: Arch. f. Oph., xxxvii, 4, 102. 16. Leber: Arch. f. Oph., xxiv, ab. 1, 295. 17. E. Treacher Collins: Oph. Hosp. Reports, xiii, 248. 18. Ostenwald: Arch. f. Oph., xxvii, ab. 3, 203. 19. Deleus: Arch. d'Opht., March, 1866. 20. Gayet: Arch. d'Opht., vi, 15. 21. Reymond: Annali di Ottalmol., xii, 337. 22. Ahlstrom: Monatsch. f. Augenh., 1904, ii, 276. 23. Juler, H.: Trans, of Oph. Soc. Unit. Kingdom, xii, 44. 24. Kirkpatrick: Brit. Jour. Oph., i, 364. 25. Silcock: Trans. Oph. Soc., viii, 53. 26. Birch-Hirschfeld and Romeick: Klin. M. f. Augenh., April, 1912, 411. 27. Saint-Martin: Ann. d'Oculist, xii, p. 353. 28. Hegner: Arch, of Oph., xlv, 385. 29. Enroth: Jour. Am. Med. Ass., Ixvi, 1066. 30. Alger: N. Y. Med. Jour., January 27, 1907. 31. Dupuy-Dutemps and Marvas: Soc. d'Oph. de Paris, October, 1913. 32. Posey: Jour. Am. Med. Assoc., February 18, 1906. 33. Mathus and Cerise: Soc. d'Oph. de Paris, April, 1908. 34. Birch-Hirschfeld: Arch. f. Oph., xc, 299. 35. Wilder: Ophth. Rec., xiv, 195 and 327. 36. Lustig: Zeitsch. f. Augen., October, 1908, 388. CHLOROMA ARTHUR J. BEDELL, M.D. Albany, N. Y. About one hundred years ago the first description of chloroma ap- peared in literature. Since that time cases have been reported from England, France, Russia, Germany, Austria, Italy, Japan, and the United States. Therefore it seems fitting that we should devote a few minutes to a disease that is even yet subject to discussion, not only from its etiologic standpoint, but especially in relation to earlier diagnosis and subsequent treatment, of which we know so little. Four cases are here summarized, two of which have never been pub- lished : CASE 1. J. L., a boy eight years old, of foreign birth, entered the Albany Hospital December 3, 1906. The patient, semi-comatose, was extremely emaciated, and his skin was yellowish. The right eye was proptosed 11 mm., with a growth in the upper part of the orbit. The lower orbital region was outlined, but a freely movable mass, 12 mm. wide, extended from the outer to the inner canthus. This mass was not attached to either skin or periosteum, and its posterior margin was not palpable. There were two subconjunctival hemorrhages. Complete ophthalmoplegia externa. The cornea was clear. There was a marked optic neuritis, with complete obliteration of disc outline, with areas of white exudate along the larger vessels. Vision equal to fingers at six feet. The left eye was extremely prominent, extending 20 mm. beyond the orbital ridge, with complete ophthalmoplegia externa. The veins surrounding the lids were enormously distended and tortuous. Projecting beyond the superior orbital margin was a firm, freely movable, not adherent growth, which ex- tended deeply into the orbit and was palpable from the supra-orbital foramen outward. The conjunctiva was markedly chemotic, with numerous ecchy- moses. The upper part of the cornea was clear, but the lower half showed a superficial necrosis and was covered with a dry exudate. Pupil 5.5 mm., not reacting to light or accommodation. There was a deep yellowish-gray reflex from the fundus. No detail; no light perception. The right ear showed swelling of the posterior superior canal wall with tender mastoid. The left was almost the same. The lymphatic glands of the neck were palpable with difficulty on the right side, but on the left they were 588 Chloroma 589 visible as large as peas. Marked systolic thrill in the vessels of the neck. No abnormalities of the lungs. Heart dulness began at the third rib and extended on the right side to the midsternal line. Apex-beat in the fifth intercostal space, 4 mm. inside nipple line. Loud systolic murmur over pulmonic area; second aortic sound accentuated. Apical sound clear and distinct. Pulse 120; tension good. Fig. 1. The larger type lymphoid cell in connective tissue. Case 1. Moderate pressure on the sternum caused pain. Liver dulness extended from the sixth rib to the free costal margin. Spleen not palpable. Dulness from ninth to eleventh ribs. Abdomen negative except sligh: distention. Inguinal glands about the size of small peas. Umbilical, costal, and plantar reflexes normal. No knee-jerks. Urine clear, amber, acid, s. g., 1020; no sugar, but a trace of albumin without casts. 590 ARTHUR J. BEDELL Blood examination made by Dr. A. T. Laird showed : Red cell count, 1,410,- 000; white cell count, 79,600; hemoglobin, 30 per cent.; and a differential count of 6,000 leukocytes showed polynuclears, 16.2 per cent. ; large mononu- clears, 5.3 per cent.; large lymphocytes, 15.3 per cent.; transitionals, 0.8 per cent.; eosinophiles, 0.7 per cent.; small lymphocytes, 33 per cent.; neutro- phile myelocytes, 28.2 per cent.; eosinophile myelocytes, 0.5 per cent. Five nucleated red cells were noted: three were normoblasts, two were * larger than normoblasts and were classed as megaloblasts. A number of degenerated leukocytes were seen, but no record of them was made. The patient was given chloroform, and a 3 cm. incision was made over the outer half of the superior orbital ridge. The entire orbit was found filled with a greenish mass of almost cartilaginous consistence, in part encapsulated, no- where palpably adherent to the periosteum. We could outline the optic nerve, but could not distinguish any of the ocular muscles. Palpation to the apex of the orbit proved that the entire contents consisted of a pale green tumor which was diagnosed as probably chloroma. The tissue removed was sent to Dr. R. M. Pearce, of the Bender Labora- tory, who reported as follows: Tissue from left orbit: Material consists of three small pieces of tissue, the largest about 0.5 cm. in diameter. These are irregular in shape; in part firm and of light greenish color, and in part soft and pink in color. On section they show a uniform, smooth surface, firm in the green but soft in the pink portions. Histology. The centers of the nodules are composed of closely arranged cells of the type of the larger lymphoid cell. These have a deeply but slightly irregular staining nucleus and a small ring of eosin-staining protoplasm. As a rule, they are round or slightly oval in shape, but occasionally are irregular, resembling in a general way the plasma cell. No multinucleated cells are seen. Toward the periphery are single fat spaces which have resisted the general infiltration. These spaces are more abundant at the extreme periph- ery, but the tissue between is extensively invaded by the new cells. Only here and there are small areas of uninvolved fat tissue seen. Here also are areas, apparently at point of periosteal attachment, with considerable fibrous tissue infiltrated with lymphoid cells and more or less hyaline in character. In the center of the nodules there is but a faint reticulum of indefinite arrange- ment. Few blood-vessels are seen; polymorphonuclear leukocytes are not present in appreciable numbers. Histologic Diagnosis. Chloroma. Dr. James F. Rooney saw the patient November 26, 1906, when the blood showed: reds, 1,596,000; whites, 41,200; hemoglobin, 30 per cent. ; color in- dex, 1 +. Differential count of 400 whites: polymorphonuclears, 37.9 per cent.; large mononuclears, 11 per cent.; small mononuclears, 12 per cent.; eosinophiles, 3.1 per cent.; myelocytes, neutrophilic, 32.8 per cent. ; myelo- cytes, eosinophilic, 7.2 percent.; 5 nucleated reds, all normoblasts; poikilo- cytosis, many microcytes and macrocytes; many degenerated whites. Chloroma 591 The patient's condition grew progressively worse from the date of admis- sion. Emaciation was extreme. Proptosis of both eyes more marked. On the right side the tumor mass increased 2 mm. in width and the eyelid became darkly congested, with tortuous, prominent vessels. Vision almost totally lost. Pupil 6 mm., not reacting. No increase in the retinal changes. The lower half of the cornea of the left eye was infiltrated, and the outer layers eroded. No fundus visible; no decrease in the chemosis; veins more enlarged. No drainage from the wound. The glands of the neck were greatly enlarged, on the left side being as large as pigeon-eggs. Veins of the neck showed no signs of thrombosis. On December 10th the child had a convulsion, which started with general muscular tremor of the right side, followed by marked contraction with turn- l. Case 1. The extreme exophthal- Case 2. Bilateral exophthalmos. mos of the left eye with a marked en- gorgement and discoloration of the eyelids. ing toward the left. The left side was entirely paralyzed; respirations ster- torous; patient unconscious. He rallied, and from time to time seemed to comprehend things. He was removed from the hospital and died that day. Autopsy was not permitted. CASE 2. Mrs. N. G., aged eighteen, married, a Russian by birth, was ad- mitted to the Albany Hospital April 7, 1909. Family and personal history negative. Patient menstruated from thirteen years of age until one week after marriage, July, 1908. One month prior to admission she first noticed many small, hard, insensitive lumps in each breast, which she believed had not increased in size. March 8, 1909, she had "pink eye," from which she seemingly recovered; on March 27th her eyes began to bulge, causing pain and attacks of blindness. The patient was an undersized, delicately built, poorly nourished woman. 592 ARTHUR J. BEDELL The skin had a peculiar satiny texture and was of grayish-yellow color. Sev- eral nodules, about 2 cm. in diameter, which were attached to muscle and bone, were palpable in each breast and along the sternum. The axillary and inguinal glands were enlarged. The woman was eight months pregnant; a systolic murmur, audible over the whole precordium, was not transmitted. Fig. 2. Closely packed large round or oval cells of the lymphatic series; cytoplasm variable in amount, also many cells having fine and coarse granules resembling myelocytes. Case 2. The section of Case 3 was practically the same, except that eosinophiles were found throughout. These were the only departures from an otherwise negative physical examina- tion, except for the ocular lesions and blood changes. April 8th the right eye prop tosed 20 mm.; immobile. The upper lid showed great dilatation of the blood-vessels, and although it covered one-third of the cornea, it could be retracted, while the lower lid was covered with chemotic conjunctiva. A definite tumor mass, 20 by 12 by 8 mm., was outlined over the lacrimal gland, entirely in the lid, with no deep attachment. The superior Chloroma 593 two-thirds of the cornea was clear, but the lower third showed a dense inter- stitial and superficial haze. Pupil 1.5 mm. Vision = fingers at 3 feet. Left eye proptosed 18 mm. ; small nodule in the upper lid at the outer side; cornea hazy below; pupil 4.5 mm., stationary. Vision = fingers at 3 feet. A large mass of grayish appearance pressed the retina forward, and except for an occasional vessel, obscured fundus detail. . Blood examination made by Dr. James F. Rooney, April 8th showed : reds, 3,150,000; whites, 36,500; hemoglobin, 55.0 per cent. Differential count of 300 white cells: polynuclears, 15.8 per cent.; lymphoblasts, 37.2 per cent.; small mononuclears, 37.0 per cent.; large mononuclears, transitionals, 9.0 per cent.; eosinophiles, 0.8 per cent.; mast cells, 0.2 per cent. Five normoblasts seen in counting 300 leukocytes. Four days later, April 12th, the condition was as shown in the illustration. The right eye bulged forward 25 mm., with intense engorgement of the veins of the lids and temporal regions. The tumor was now 25 by 12.5 mm., axis 60 degrees, not adherent to the skin or periosteum, although extending deeply into the orbit. The outer part of the lower lid was filled by an oval, unat- tached growth, 18 by 9 mm., axis 120 degrees. The lower half of the eyeball, including the entire cornea, was exposed. The conjunctiva was chemotic, with many small ecchymoses, and a small hypopyon in the anterior chamber. Pupil 2 mm., stationary, tension normal; extremely limited motion of the globe ; vision = light perception. Left eye proptosed 22 mm., with many irregular nodular masses in the upper outer two-thirds of the orbit, close to the superior wall, but not adherent to it. The upper half of the cornea was covered by a vein-filled upper lid; the lower half was rough and infiltrated. The bulbar conjunctiva was decidedly con- gested and the eyeball stationary. The interior of the eye was as before. Pupil, 4.5 mm.; faint reaction to light; tension normal. Dr. Rooney 's blood examination, April 12th, showed: reds, 2,200,000; whites, 52,000. Differential count of 300 whites; lymphoblasts, 42.5 per cent.; polynuclears, 10.6 per cent.; small mononuclears, 19. 2 per cent.; large mononuclears and transitionals, 8.0 per cent.; eosinophiles, 3.0 per cent.; myelocytes, 0.7 per cent.; degenerated, 1.0 per cent.; six normoblasts, one megaloblast. The disease was diagnosed chloroma by the examination of breast tissue. This was done before the patient died, on April 16th, after premature delivery of a dead child. As in many cases, persistent, uncontrollable nasal hemorrhage was present for several days before death. The following is the autopsy report of Dr. Wolbach, held April 16, 1909: 38 594 ARTHUR J. BEDELL Autopsy limited to chest and abdomen, so that the orbits were not investi- gated. Body is that of a short-statured, slightly built white woman. There is ex- treme double exophthalmos, and both eyeballs are reddened and covered with pruriform material and crusts. Breasts are large and nodular. The areolae are deeply pigmented. Midline of the abdomen is deeply pigmented. Rigor mortis is complete. Marked postmortem lividity of dependent parts. No edema. Peritoneal cavity: Peritoneum is smooth, moist, glistening. Appendix normal. Mesenteric lymph-nodes not enlarged. Chest: Under surface of the sternum is covered with many green tumor nodules, which are situated on the surface and beneath the periosteum. The intercostal muscles on both sides for a distance of several centimeters are invaded and replaced by tumor tissue which completely surrounds the costal cartilages of the upper five or six ribs. Pleural and pericardial cavities negative. Heart: Normal in size. Myocardium is of good consistence. Valves and endocardium are normal. There are three tumor nodules in the auricles of the heart, situated as follows: one in the posterior wall of the left auricle, near the interauricular septum. This nodule is olive green in color and measures 2 by 1.5 cm. In the interauricular septum, just above the mitral valve, and close to the posterior border, is a nodule 0.5 cm. in diameter, which is pale green in color. In the wall of the right auricle, in the posterior side, close to the interauricular septum, is a similar nodule, 1 cm. in diameter. Lungs: Both are negative, except for edema and congestion. At the root of the left lung, presumably in the mesenteric nodes, are two pale green tumor nodules about 1.5 cm. in diameter. Spleen: Normal in color and consistence. Liver: Pale, reddish brown in color, normal in size and consistence. No tumor nodule found on close inspection. Pancreas: There is a mass of large, green glands at the head of the pancreas. On section, these vary in color from a pale green to an olive green. Embedded in the tail of the pancreas are two similarly colored nodules, about 1 cm. in diameter. Gastro-intestinal Tract: Not opened. Kidneys: Both kidneys are normal in size, pale in color, and each contain many nodules, varying in size from 2 mm. to 1.5 cm. The largest are situated beneath the capsule, and are flattened and soft in consistence. Smaller ones are distributed throughout from cortex to pyramids, and are firmer in con- sistence. These nodules are of rather pale color, but of a decided green tint. The larger ones show small red areas presumably hemorrhages. Adrenals: Both are normal. Prevertebral lymph-nodes are markedly enlarged. On the left side, just Chloroma 595 above the bifurcation of the aorta, is a large mass of pea-green tumor tissue which is firmly attached to the periosteum covering the vertebrae. This mass is roughly hemispheric in shape, with a base 5 cm. in diameter and a depth of 3 to 4 cm. Consistence is very firm. Genitalia: Uterus large and has the partially contracted appearance of a recent delivery. Ovaries and tubes normal. Owing to the lack of time, genitalia were not more closely inspected. Fresh microscopic examination of the tumor shows it to be made up of small round cells, a few of which contain many refractive granules. The fluid obtained by teasing and expressing glands contains many refractive globules, which on exposure to fumes of osmic acid turn dark brown. Breasts: Both breasts and surrounding fat tissue are largely replaced by green tumor tissue. The growth consists of spheric and ovoid masses, from a size just visible to nodules 3 cm. in diameter. These nodules are of quite firm consistence. The color varies from a pale green to an olive green. Anatomic diagnosis: Chloroma with metastases to sternum, heart, bron- chial nodes, kidney, pancreas, and lymph-nodes. CASE 3. B. R., aged five years, entered the Albany Hospital April 23, 1913, and was discharged May 16, 1913. The dominant symptom was a firm, ovoid growth occupying the upper one-half of the right orbit, producing the effect, as shown in the illustration, of a mass anterior to the eyeball. The skin was freely movable over it, but the tumor extended deeply into the orbit. The right eye was movable in all directions, without fundus lesion. The left eye and orbit were uninvolved. The patient had a peculiar sallow appear- ance. He had several slight hemorrhages from nose. The blood count showed: White blood cells, 7,700; red blood cells, 1,930,- 000; hemoglobin, 55 per cent. (Tallquist); differential white count, 250 cells; poly morphonu dear neutrophiles, 25.6 per cent.; small lymphocytes, 65.6 per cent.; large lymphocytes, 5.6 per cent.; large mononuclears, 1.6 per cent.; eosinophiles, 0.4 per cent.; transitionals, 1.2 per cent.; irregularity in size and shape of red cells; no nucleated red seen. The day of his discharge showed: White cell count, 6,200; red cell count, 1,510,000; hemoglobin, 50 per cent. (Tallquist); differential count, 250; poly morphonu clear neutrophiles, 12.8 per cent.; small lymphocytes, 70.4 per cent.; large lymphocytes, 2.4 per cent.; large mononuclears, 14.4 per cent.; the red cells are somewhat irregular in shape and size. The increase in mononuclears is noteworthy. The temperature ranged from 99 to 102 F. Wassermann reaction was negative. Before the child was taken home, where he died June 5, 1913, the right eye became very prominent, with practically no motion. Definite masses, similar to that in the upper lid, also appeared in the lower, filling the orbit. A firm, lobulated tumor deep in the left orbit produced marked exoph- thalmos. The temporal region became infiltrated. The hearing was greatly 596 ARTHUR J. BEDELL reduced. There was no marked glandular enlargement. The patient died with meningitic symptoms. On April 26, 1913, the patient was given an anesthetic and a curvilinear incision was made close to the superior orbital margin. The entire orbit was filled with a firm green mass. Part was excised for histologic study, and the diagnosis of chloroma confirmed. During the time of the patient's stay in the hospital he was given benzol without improvement. Despite strenuous efforts, autopsy was not permitted. CASE 4. J. N., a girl seven years old, of foreign extraction, entered school a year ago, and seemed to be normal in every way. After being in school a few weeks she began to complain of headache and would cry for hours. On July 4, 1921, the child's right arm was severely burned and she was sick for three weeks. On October 27, 1921, Dr. LaSalle Archambault sent her to my Case 3. Ovoid mass in the right upper Case 4. Marked bilateral exoph- lid which extended far into the orbit. thalmos greater on the right side with temporal fullness. office. The right eye bulged forward 11 mm., with limitation of motion ver- tically but not horizontally. There were several large, rounded masses freely movable beneath the skin, but extending into the orbit and seemingly ad- herent to the superior orbital ridge. There were also masses in the lower por- tion of the orbit, with the same characteristics. The pupil was 6 mm. sta- tionary, media clear,, with an intense neuroretinitis, many areas of whitish exudate and several flame-shaped hemorrhages. The left eye protruded 8 mm., with the same type masses extending deep in the orbit. There was definite swelling of the optic nerve, with retinal exudate. In both temporal regions there was a firm swelling and the patient was totally deaf. I sent her to the Albany Hospital with a diagnosis of chloroma. This was verified by the blood examination, which showed: Red blood cells, 3,100,000; white blood cells, 20,800; hemoglobin, 67 per cent.; polymorphonuclears, 19 Chloroma 597 per cent.; large and small lymphocytes, 81 per cent.; large mononuclears, 68 per cent. ; small mononuclears, 32 per cent. ; benzidene reaction shows the lymphocytes to be of the myeloblastic series. The second count, October 30, 1921, showed: Polymorphonuclears, 21 per cent.; large lymphocytes, 6 per cent.; small lymphocytes, 12 percent.; large mononuclears with granular cytoplasm (myelocytes and myeloblasts), 54 percent.; transitionals, 7 per Fig. 3. Blood smear from Case 4. Wright's stain, showing the usual red blood- cells, polymorphonuclears, lymphocytes, and myelocytes. cent. Oxydase stain showed granular forms in the ratio of 9 to 1 non- granular. Urinalysis: Color, amber; cloudy; reaction acid; sp. gr. 1017; albumin positive; sugar negative; microscopic loaded with amorphous urates, mucus. Tempera.ture, which was on admission 100.3, dropped to 98 the next morning, but then rose above 103. The parents took the child from the 598 ARTHUR J. BEDELL hospital when they were told that the outcome would be fatal. The child died at home November 9, 1921, and it was impossible to get an autopsy. In the complete review of the literature we find that 90 cases have been reported 25 females, 5 sex not stated, and the remainder males. The age varied from one year nine months to fifty-five years, by far Fig. 4. Oxydase reaction of the blood of Case 4, showing polymorphonuclears, myelocytes, myeloblasts, and nuclei of small lymphocytes. the greater number being in children and young adults. The duration of the disease was so uncertain that even the statement that many died within one month, some even within four days after the primary visit, helps little in the diagnosis. The greatest number of cases were only properly understood at autopsy. The reported white counts varied from 6,200 to 519,600. In only six cases, however, was it 100,000 or more. The commonest count is Chloroma 599 less than 40,000, and, as will be noted in our own cases, one count was 6,200. On the other hand, the differential count gave information of the greatest value, for in all cases we find a marked decrease in the polymorphonuclears, with a considerable increase of the myelocytes. The diagnosis of this condition can be made early. Every case of exophthalmos in a child should have an immediate complete blood examination, for, as has been proved by many and corroborated by our cases, the first symptom is in the blood change. The treatment has ranged from benzol to x-ray to radium. The lack of curing power when late, at least, is evidenced by the fatal out- come of all cases. To summarize: Chloroma, a disease of the blood-making organs, lends itself to early diagnosis by its characteristic blood picture. The common eye symptoms are lid and orbital tumors, exophthalmos, sub- conjunctival hemorrhages, retinal hemorrhages and exudate, neuro- retinitis, and blindness, although frequently unilateral, most often the changes become bilateral and, finally, investigation will doubtless prove an infection the origin of the disease, and that such infection will be diagnosed and cured. It is with this hope that this clinical communication is presented. It is with great pleasure that I acknowledge my indebtedness to Dr. C. S. Merrill, who so kindly made it possible for me to diagnose and treat Cases 1 and 3; to Dr. G. Emory Lochner, for giving me the control of Case 2; to Dr. Charles E. Allen for his assistance in Case 4, and to Mr. J. A. Glenn for the microphotographs of tumors and blood, and to my able and conscientious assistant, Dr. Anton S. Schneider. REFERENCES Alt: A Case of Chloroma, Am. Jour. Ophth., March, 1897, xiv, 78. Aran: Note sur une forme particuliere et encore peu connue de cancer de la Dure mere et des os du Crane (Cancer vert, chloroma), Arch. gen. de med., 1854, 385. Arnold and Becker: Doppelseitiges symmetrisch-gelegenes Lymphadenom der Orbita, Arch. f. Ophth., 1872, 56. Axenfeld: Zur Lymphombildung in der Orbita, Arch. f. Ophth., 1891, xxxvii, 102. Ayers: A Case of Chloroma, Jour. A. M. A., 1896, xxvii, 986. Balfour: Case of Peculiar Disease of the Skull and Dura Mater, read December 3, 1834, Edinburgh Med. and Surg. Jour., 1835, 319. Bedell: Another Case of Chloroma, Annals Ophth., July, 1912, xxi, 452. Behring and Wicherkiewiez : Ein Fall von metastasirendem Chlorosarkom, Berl. klin. Wochen., 1882, No. 33, 509. Benjamin and Sluka: Das Chlorom, Jahrb. f. Kinderh., etc., 1907, Ixxiii, 87. 600 ARTHUR J. BEDELL Berl : Pseudo-leuksemische Erkrankung der Bindehaut u. des orbitalen Gewebes, Beitrag z. Augenheilk., 1899, iv, 32. Bergmeister: Ein Chlorom der Orbita, Zeitschr. f. Augenh., 1909, xxii, 544. Bierring: Chloroma, Jour. A. M. A., 1912, 1434. Birk: Ein interessantes Fall von Leukamie, St. Petersburg, med. Wochen., 1833, viii, 377. Bock: Lymphoma orbitse sinistrae, Wien. med. Wochen., 1898, No. 32, 1559. Boots: Chloroma with Report of a Cage, Jour. Lab. and Clin. Med., 1917, 622. Bramwell: Notes on a Case of Chloroma and of Three Cases of Lymphatic Leukemia, Scot. Med. and Su'rg. Jour., 1902, x, 219; Lancet, London, 1902, 520; Brit. Med. Jour., 1902, ii, 453. Bruce: Chloroma of the Jaws, Ann. Surg., January, 1910, 52. Burgess: Chloroma, Jour. Med. Research, 1912, xxvii, 133; Boston City Hosp. Med. and Surg. Reports, 1913. Burns: Observation on the Surgical Anat. of the Head and Neck, Baltimore, 1823, 386. Buschke : Ueber ein Fall von symmetrischen sarkomatosen Tumoren der Schlaf- enregiones und der Wangen, Chlorom, Berl. klin. Wochen., 1905, xlii, 1001. Butler: A Case of Chloroma, Brit. Med. Jour., April 20, 1907, 929. Calderaro and Cirincione: Chloroma bilaterale dell orbita, Clin. Oculistica, 1903, 1417. Catalino: Archives Espanolas de pediatria, May, 1918. Chiari: Zur Kenntnis des Chloroms, Prag. Zeitschr. f. Heilk., 1883, iv, 177. Collins: On a Case with a Tumor in Each Orbit, Death Necropsy, Royal Lon- don Ophthalmic Hospital Report, December, 1891, 248. Coppez : Tumeur Orbitaire avec envahiessement secondaire de la sclerotique et de la cornee, Arch. d'Ophtalmologie, 1895, xv, 544. DeGraag: Lymphatische Leukamie und Chlorom, Geneeskundige Bladen u. Klin., 1904; Ergebn. d. allg. Path. u. path. Anat., 760. Delens: Observations des tumeurs lymphadeniques des deux orbits, Arch, d'opht., 1886, vi, 154. Di Cristina: Contributo clinico ed anatomico. Pathologico allo studio del chlo- roma, Pediatria, October, 1914, 721. Dittrich: Vierteljahr. f. d. prakt. Heilk., 1846, 104. Dock: Chloroma and its Relation to Leukemia, Amer. Jour. Med. Sc.. July, 1893, 152. Dock and Warthin: A New Case of Chloroma with Leukemia, Trans. Assn. Am. Phys., 1904, 64; Medical News, 1904, 971. Dreschfeld: Ein Beitrag zur Lehre von den Lymphosarkomen, Deutsch. med. Wochen., 1891, 1175. Dressier: Ein Fall von sogenanntem Chlorom, Virchow's Arch. f. path. Anat., 1866, 605. Drozda: Akutes Leukamie mit eigenartigen an Chlorom erinnerenden Obduc- tionsbefund, Gesellsch. f. inn. Med., October 23, 1902; Wien. klin. Wochen., 1902, 1236. Dunlop: A Case of Chloroma with Pathologic Report and Some Notes Descriptive of the Disease, Brit. Med. Jour., 1902, 1072. Chloroma 601 Dunn: Leukemia with Rare Lymphoid Growths of Orbit and Parotid Glands, from Trans. College Phys., Philadelphia, 1893, 103; Ophth. Rev., 1894, No. 151, 167. Durand and Fardel: Bull, de la Societe" anatomique, March 1, 1836, xi, 195. Eichhorst: Uber eigentlimliche Knochenmarks-Befunde bei Chloro-leuksemie, Deut. Arch. f. klin. Med., 1921, cxxxv, 129. Emden and Rothschild: Uber das Chlorom und seine Beziehung zur Myelo- blastenleukamie, Deutsch. Arch. f. klin. Med., 1914, 304. Esser: Myeloblastenchlorom, Deutsch. med. Wochen., 1912, xxxviii, 783; Myelo- blastic Chloroma, Sitzungsb. b. d. naturh. Ver. d. preuss. Rheinl. u. West- phal, Bonn, January 22, 1912, 5. Fabian: Uber lymphatische und myeloidische Chloroleukamie, Beitrage zur path. Anat. u. z. allg. Path., 1908, xliii, 172. Firth and Ledingham: Atypical Chloroma, Roy. Soc. Med., Proceedings, 1910, 60. Flohr: Ein Beitrag zur Kenntnis der Chloromerkrankung, Bonn, 1912. Fowler: On the Occurrence of a Form of Leukemia, etc., International Clinics, 1903, 217. Fukushi: Chlorom, Deutsch. med. Woch., 1909, xxxv, part 11, 1816. Gade: Bidrag til kundskaben om klorom, Nord. Med. Arkv., 1884, xvi, No. 19, 1. Gallemaerts: Personal Communication, 1922. Gould and Lewald: Chloroma, A Report of Two Cases, Together with Rontgeno- logical Findings, Amer. Jour. Obstet., 1916, 1159; Arch. Fed., 1916, 417; Medical Record, 1916, 757. Gulland and Goodhall: The Pathology of Lymphatic Leukemia and Chloroma, Jour. Path, and Bacteriol., June, 1906, 332. Gumbel: Ueber das Chlorom und seine Beziehung zur Leukamie, Virchow's Arch. f. path. Anat., 1903, clxxi, 504. Hall, Hebb and Bernstein: Chloroma, Proceedings Medical Section, Royal So- ciety of Medicine, February 23, 1909, 157. Hall and Hebb: Chloroma, Brit. Med. Jour., March 6, 1909, 601. Harris and Moore: Preparation from Case of Chloroma, Lancet, London, 1902, 525. Hepburn: Chloroma, Canada. Med. Assoc. Jour., 1914, xliii, s. 2; iv, 616-619. Herz: Zur Frage der gemischten Leukamie, Wien. klin. Wochen., 1909, 1030. Heyden: Das Chlorom, 1904, Inaug. Diss., Rostock. Hillier: Recurrent Tumor of the Orbit Followed by Similar Growths on the Other Side of the Head, on the Dura Mater and Under Costal Pleura, Trans. Path. Soc., London, 1855, 337. Hird: Chloroma, Birmingham Med. Review, 1917, 49. Kitchens: Some Remarks on a Case of Chloroma, Brit. Med. Jour., December 26, 1903, 1632. Hochhaus: Anatomischen Praparate eines Falles von Chlorom, Munch, med. Woch., 1911, Iviii, 1271. Hochheim: Ein Beitrag zur Kenntnis der symmetrischen Lid und orbital Tu- moren, Graefe's Arch. Ophth., 1900, 347. Horing: Ein Beitrag zur Kenntnis des Chloroma, Inaug. Diss., Tubingen, 1891; also Arb. a. d. Path. Anat. Inst. za Tubingen, 1891, part 1, 180. Huber: Studien liber das sogenannte Chlorom, Arch. d. Heilk., 1878, 129. 602 ARTHUR J. BEDELL Hudson: A Case of Chloroma, Royal London Ophth. Hospital Report, 1910, 181. Jacobaeus: Beitrage zur Kenntnis der myeloiden Chloro-leukamien, Deutsch. Arch. f. klin. Med., 1909, 7. Kelsch and Vaillard: Tumeurs lymphadeniques multiples avec leucemie, Annales de I'lnst. Pasteur, iv, 276. King: A Case of Chloroma, Jour. Med. Sc., Edinburgh, August, 1853, xvii, 97. Klein and Steinhaus: Ueber das Chlorom, Centralbl. f. allg. path. Anat., 1904, 49. Koerner: Ein Fall von Chlorqm beider Sdilafenbeine, etc., Zeitschr. f. Ohrenh. 1896, xxix, 92; also Arch. Otol., 1897, xxvi, 289. Kramer and Birnberg: A Report of a Case of Chloroma, Jour. Amer. Med. Assoc., June 23, 1917, 1900. Lang: Monographic du chloroma, Arch. ge"n. de. med., November, 1893, 555; and January, February, and March, 1894, 63, 186, 313; De quelques cas recents de chloroma ou cancer vert., ibid., July, August, and September, 1898, 98, 207, 317. Lehman: Ein Fall von Chlorom, St. Petersburg, med. Wochen., September 7, 1906, 411. Lehndorff: Zur Kenntnis des Chloroms (Chloroleukamie, Chloroleukosarkoma- tose), Jahrb. f. Kinderh.. July 1, 1910, 53. Leighton: Note on the Demonstration of Eosinophile Granulation in the Cells of Chloromata, Jour. Path, and Bacteriol., 1908, xii, 111. Lewis: A Case of Chloroma Simulating Mastoid Disease, Lancet, 1919, 831. Libman: Discussion Bierring's Case, J. A. M. A., 1912, 1436. Lubarsch: Koerner's Case, Zeitschr. f. Ohrenh., xxxii, 129, and Arch. Otol., 1898, xxvii, 450. Mackenzie: A Practical Treatise on Diseases of the Eye, Philadelphia, 1855, 128. Meizner: Zur Kenntnis des myeloiden Chloroms, Wien. klin. Wochen., May 16, 1907, xx, 593. Meller: Die lymphomatosen Geschwulstbildungen in der Orbita und im Auge. Arch. f. Ophth., 1905, 130. Merrill and Bedell: Chloroma, with Special Reference to the Ocular Symptoms, New York State Jour. Med., October, 1907, 393. Mieremet: Ein Klinik unter dem Bilde eines malignen Tumors verlaufender Fall von myeloidschen Chlorom, Virchow's Arch. f. path. Anat. u. Physiol., 1914, 353. Paltauf : Lymphosarcom, etc., Ergeb. d. allge. Path., 1896, 679. Pappenheim : Die Stellung der Chlorome und Myelome unter den Tumarerkrank- ungen des hamatopoetischen Apparats, Folio hsematol., 1909, vii, 439. Paulicek and Wutscher: Zur Kenntnis des myeloidschen Chloroms, Deutsch. med. Wochen., 1911, xxxvii, part 1, 155. Pearson: Chloroma with Special Reference to Ear, Nose, and Throat (Bierring's cases), Annals Oto., Rhin. and Laryn., September, 1920, 807 Pfieffer: Ueber das Chlorom des Schadels ein typisches Krankheitsbild, Munch. med. Wochen., 1906, 1909. Pinkus: Chloroma, Nothnagel's Encyclopedia of Practical Medicine, Am. Ed., 1905, ix, 576. Pissavy and Richet Fils: Etude clinique, hematologique et anatomique d'un cas de chlorome atypique, Arch, des Maladies de Coeur, 1912, v, 248. Chloroma 603 Pope and Reynolds: A Case of Chloroma, Lancet, London, May 18, 1907, 1351. Port and Schutz: Zur Kenntnis des Chloroms, Deutsch. Arch. f. klin. Med., October 23, 1907, 588. Risel: Zur Kenntnis des Chloroms based on one of Rosenblath's cases, Deutsch. Arch. f. klin. Med., 1901, 31. Rocca villa: Chloroma leucemico Pathologica, 1911, iii, 229. Rosenblath: Ueber Chlorom und Leukamie, Deutsch. Arch. f. klin. Med., 1901, 1. Sakaguchi: Ueber myeloisches Chlorom, Mitt. a. d. kaiserlichen Univ. zu Tokyo, 1914-1915, xiii, 197. Sattler: A Case of Chloroma, Arch. Ophth., 1912, 452; Amer. Oph. Soc. Trans., 1912, 214. Sauer: Ein Beitrag zur Kenntnis des Chloroms, Virchow's Arch. f. path. Anat. u. Physiol., 1914, 341. Schlaugenhaufer: Ein Fall von Chloroleukamie mit griinem Uterus, Arch. f. Gynakologie, 1911-12, xcv, 1. Schmidt: Ueber einen Fall von Chlorom, Inaug.-Dissert., Gottingen, 1895. Simmonds and Romer: Chlorom, Deutsch. med. Woch., 1914, 260. Simon: Myeloidische Chloroleukamie (Chlorom) unter dem Bilde eines malignen mamma Tumors, Berlin, klin. Wochen., 1912, xlix, 893. St. Bernheimer: Ueber Lymphadenome der Orbita, Beilage bericht. Ophth. Gesellschaft, Heidelberg, 1889, 199. Sternberg: Ueber lymphatische Leukamie, Verhandl. d. Deutsch. path. Gesellsch., 1903, 30; also Discussion Wien. klin. Wochen., 1903, 462; Munch, med. Wochen., 1902, 126; Wien. klin. Woch., 1902, 55. Sternberg: Zur Kenntnis des Chloroms, Chloromyelosarkom, Beitr. z. path. Anat. u. z. allg. Path., 1905, 437. Sutherland: A Case of Chloroma, Scot. Med. and Surg. Jour., 1902, 137. Treadgold: Chloroma and Acute Lymphatic Leukemia with an Account of Four Cases and a Discussion of the Pathology of the Disease, Quart. Jour. Med., April, 1908, 239. Tresilian: A Case of Chloroma, Brit. Jour. Children's Diseases, 1910, 536. Trevithick: A Case of Chloroma, etc., Lancet, July 18, 1903, 158, a note; ibid., 530. Turk: Discussion Wien. klin. Wochen., 1903, 462; Gesellsch. f. inn. Med., December 12, 1901. Von Recklinghausen : Uber Chlorome, Tageblatt der 58. Versammlung deut- scher Naturforscher und Arzte, Strasburg, 1885, 421. Waldstein: Ein Fall von progressiver Anamie u. darauf folgender Leukocythamie mit Knochenmarkerkrankung und einen sogenannten Chlorom, Virchow's Arch., 1883, xci, 12. Walls and Goldsmith: Chloroma with a Report of a Case of the Myeloid Variety, Amer. Jour. Med. Sci., 1914, 836. Weinberger: Lymphoides Chlorom mit allgemeiner lymphoid Hyperplasie, etc , Zeitschr. f. Heilk., 1907, 44; Wien. klin. Wochen., 1903, xvi, 461. PROPOSITIONS FOR CONGRESS ACTION THE VALUE OF LETTERS AND CHARACTERS AS VISUAL TESTS A. E. EWING, M.D. St. Louis, Mo. Since the fixing of the visual angle by Hooke (1674) and its practical adaptation by Snellen to test letters (1862), there have been efforts on the part of various investigators to find an object or objects of universal recognition that could be made use of to represent this angle for the accurate testing of vision. The ideal has not yet been at- tained. The nearest approach to its attainment has been the employ- ment of letters from the alphabets of various languages. For the Anglo-Saxon, the Latin and the Teutonic peoples the block letter was suggested by Snellen, was used by him in his charts and has become the almost universal standard in these countries. Snellen realized that these letters offered only an approximately correct representa- tion of the relative visual acuity, even though certain openings in the lines constructing the letters indicated the one-minute angle, as the opening in the letter E and in the letter C, the two representative letters among those used for measuring the vision, the one being round and the other square. The realization that letters were variable and faulty in the attain- ment of uniform visual results led to the suggestion of the so-called one-minute tests, as the Landolt "broken ring," the "interrupted square" of Jackson, the central dot of Wolff berg and the broken line test. The difference in the values of various letters as visual tests was pointed out by Green in 1872, Dennett in 1885, Randall in 1894, and later by Jackson. When Snellen first adopted the "block" or "Egyptian paragon" letters he recognized these differences and for this reason he selected letters which would approach as nearly as possible to his three line, one and five minute standard square. 604 The Value of Letters and Characters as Visual Tests 605 In order to get at this subject more definitely, at the suggestion of Dr. Jackson a committee was appointed by the Ophthalmic Section of the American Medical Association in 1914 on "Standardizing Test Cards." At the further suggestion of Dr. Jackson, the members of this Committee selected all the appropriate square and round letters in the alphabet, both in the " Egyptian paragon " or " block " form and in the "Gothic" or "antique" form, the two forms in general use, and working separately with various patients of all types, each committee- man gave his conclusions as to the visual value of each of the letters as compared with the Landolt "broken ring." The average per- centage visual value of these results is shown in the accompanying table. Gothic Block L 0.62 F .0.81 L 0.71 P 0.81 A 0.71 C 0.85 T 0.74 D 0.82 T 0.72 K 0.88 V ...0.78 Z 0.84 V 0.74 0.88 U 0.79 N 0.85 H 0.74 D 0.88 C 0.79 E 0.85 Z 0.76 X 0.91 O 0.80 R 0.88 E 0.77 R 0.93 . Y 0.80 S 0.89 N 0.79 S 1.05 F 0.81 C 0.92 P 0.79 B 1.16 H 0.92 B 1.00 These results revealed that few of the letters could be depended on to give so-called normal visual acuity as compared with the "broken ring" of Landolt. They further confirm Snellen's observation that the "block" letter was superior to the "Gothic" letter for the con- struction of visual test-types. Also they standardized so far as was possible the relative visual value of each letter. In this table it is shown that the letter L is the most readily seen of any of the letters at a given distance, but it is well known to all ophthalmologists that persons who are able to recognize the' L have sufficiently good vision to pursue any of the ordinary vocations neces- sary to the earning of a living. In this lies the reason why test letters are almost universally employed as visual tests. In other words, the Committee has demonstrated that persons with 0.62 per cent, of so- called standard or normal vision, see well enough for all ordinary purposes. "In all times letters and numbers have been preferentially em- ployed by ophthalmologists in the investigation of the power of vision," observed Donders in his work on refraction in 1864. After the lapse of another half century, during which period workers in 606 A. E. EWING ophthalmology have increased by thousands, it may be safely claimed that this observation is now an axiom, with letters still in the ascen- dant. The investigations of the Committee above mentioned have given each letter a definite visual value in comparison with an accepted visual standard. Experience has proved that a visual acuity of 75 per cent, of this visual standard indicates sufficiently good vision for even the highest grades of occupations in securing a living. The army accepted 50 per cent, as sufficient for ordinary occupations, and practically 75 per cent, for the finest rifle work, as the vision of the riflemen was taken as a rule with Snellen type, and the work of the Committee has shown that the visibility of this type ranges all the way from 66 to 100. Another circumstance that has been confirmed by experience is, that ophthalmologists as a rule consider the so-called "one-minute" tests as nuisances and time consumers, and will not bother to employ them when letters and characters serve the purpose. When great accuracy is required, or an exact comparison is necessary, it is well to have some one of these tests at hand. With the above data at our command the rational method of dis- posing of this vexed question of visual acuity would be to accept, as the standard or normal vision, the vision measured by any of the block letters from T to H in the report of the Committee, when these letters are drawn to the one- and five-minute scale of Snellen. The same rule should apply to characters when they are drawn practically within these limits. This would mean a variation in the visibility of 18 points, but experience has further demonstrated that this counts for little after the 75 point limit has been passed. The reading of any one of these letters should be considered as the 100 mark, instead of the reading of the broken ring of Landolt, and visual acuity above this standard 100 mark should be indicated as normal plus. Such an arrangement would satisfy every visual requirement. M. URIBE TRONCOSO, M.D. New York City It is a rule in anatomic descriptions to consider the subject stand- ing in front of the observer, who, when speaking of the right side, for instance, always refers to the subject's right, which is in front of the observer's left hand. This is a basic rule and all anatomic treat- ises in the medical literature of all countries conform to it. The same rule holds good in physiology, in surgery (when not otherwise specified), in clinical methods of examination, etc. The description of one operation is easily understood when the author conforms to the anatomic nomenclature and the reader can visualize the different stages of the interference with the organs as they really are in front of him. In this way the necessary repetition of "pa- tient's right or left side" or "surgeon's right or left" is avoided, and medical descriptions will gain in accuracy, clearness, and conciseness. In ophthalmology, unfortunately, the official anatomic nomencla- ture is not followed up altogether, with the resultant misunderstand- ing, confusion, and unnecessary mental strain. Diseases of the anterior segment of the eye are studied in the text- books and treatises generally according to the anatomic standard be- cause this is unavoidable, the illustrations necessarily showing the patient's eye facing the observer; but the confusion begins when the pathologic sections are represented inverted, the eye in the same posi- tion in space as the physician's eye. Passing from the description of the changes to the study of the sections, an effort of imagination is necessary to replace the organs and lesions in the proper position. In this way two different standards are set up and the relation of the parts and structures to each other changed, without sufficient reason or practical benefit. In the description of the normal and pathologic iris, for instance, the membrane is represented outstretched in front of the observer, whereas the microscopic sections show the posterior or pigmentary 607 608 M. URIBE TRONCOSO layer, forward. When the ophthalmologist is accustomed to remem- ber the angle of the anterior chamber, in the non-anatomic position, it is very difficult for him to transpose it to the proper place if the new method of examination with the contact glass and the ophthalmoscope (ophthalmogonioscopy) is used. Many competent observers fail to grasp the relations of the ciliary body with the anterior chamber, its continuity with the sclera, the position of the sclerocorneal trabecu- lum and Schlemm canal in relation with the cornea, etc. The different systems of blood-vessels in the anterior part of the eye, easily understood in the old schematic figures, become difficult to represent in their true position with the patient's eye in front, particu- larly the relations of the perforating ciliary vessels with the intra- scleral network and the iris and ciliary vessels. In glaucoma, when there is an adhesion of the root of the iris to the cornea, it is easier to visualize the formation of the new iridocorneal angle and correlate it with the diminution in depth of the anterior chamber, the enlargement of the pupil and its irregular shape due to partial adhesion, if the mental picture of the structures has been made in the anatomic position. The confusion and misunderstanding grow worse in the study of the optic nerve, optic tracts, decussation in the chiasm and the relations of the bundles of the nerve-fibers and tract forming a forked sensorial organ, with the two lateral halves of the retina and the visual field. The well-known schematic figures of the optic pathway are always printed considering the observer standing at the back of the patient. This was probably made in order to facilitate the understanding of the visual fields which, as recorded by the campimeter and perimeter, are also inverted and shown in the non-anatomic position, as we will consider later. The transfer and reversal of the visual field found in hemianopsia and the location of the homonymous halves of the retina to the proper side of the patient have been the cause of the great obscurity, mis- understanding, and mental effort which generally confronts the stu- dent in this particular subject. Homonymous is taken generally as meaning the two halves of the same name in the retina, for instance, both nasal or temporal halves, while in reality they refer to the patient's right or left side. Any one who will study this subject according to the anatomic sta'hdard will readily realize the numerous advantages derived, and the facility to memorize the lesions. Ophthalmologic Versus Anatomic Nomenclature 609 It is, however, in the diagnosis of the troubles of motility of the eye where the principal difficulties arise for the student; an earnest effort and great mental strain are required to transpose the mental images from one position to the other. The anatomy of the ocular muscles is taught in reference to the observer's eye and he needs to memorize the insertion and action of the six extrinsic muscles in this position. Afterward in clinical examinations, with the patient in front of him, either watching the limitation of movements of the eyeball in case of paralysis of the muscles, or when moving the candle from one side to the other in the subjective examination for diplopia, he will con- stantly need to reverse his mental images or go back and place himself behind the patient to be able to arrive at a diagnosis. The excellent Fuchs text-book, fifth English edition, page 713, shows, in Fig. 301, the place and insertion of the ocular muscles in the inverted position, and side by side the next figure represents the eye in the anatomic way. The four frozen sections of the orbit and the schematic plan of the action of the muscles after Marquez are seen from before, as are also the lines of insertion of the four recti, but a few pages later, in the chapter on paralysis, the inversion reappears, and although the student must detect the primary and secondary deviations facing the patient and visualize the angle of deflection and the limitation of movement in the affected areas, still he must revert his findings to the common position for comprehending them. A strange contradiction is found in the use of Duane's tangent plane for plotting the double images. Although the observer is in front of the patient carrying the light and thrusting pins in the curtain, and although the graduation of the latter is turned toward the observer and the marks made in it show through, still he must consider the right and left side according to his own and not to the patient's sides. In the detection, measurement, and correction of heterophorias the same thing happens. The tests must be conducted from before the patient, but the estimation of the defect and the thinking is done from behind. For men who are accustomed to use the anatomic nomenclature the reading in the text-books of the chapters on paralysis of the ocular muscles, and the transfer and memorizing of symptoms in the proper position, require a long, painful, and strained mental process, which will be made unnecessary if one standard position both for objective and subjective examination be used (Fig. 1). This does not mean that the observations and tests upon our own * 39 610 M. URIBE TRONCOSO eye should be entirely discarded, but only that they shall constitute the exception and not the rule as they are to-day. Of course, many ophthalmologists already trained in this school of double positions, and who have attained the habit of the mental processes required to make the inversion quickly and without effort, will find it entirely unnecessary or even inadvisable to depart from their habits, but for the beginner in ophthalmology to be taught in the orthodox way shall mean much time saved and much effort spared. Fig. 1. Homonymous diplopia. The deviation of the left eye inward makes the image of the candle fall at the inner side of the macula, M, and is projected outward, where a false image is seen at the left. THE INVERSION OF THE VISUAL FIELD The ordinary way of recording the visual fields is to consider the findings as seen from an observer at the back of the patient. This was probably made necessary in the beginning by the use of the black- board or campimeter, in which the limits were drawn up as if made by the patient's hand. In this position the visual field of the left eye faces the left side of the patient and has the normal notch correspond- ing to the nose downward and inward, opposite to the corresponding part of the right side (Fig. 2). With the advent of the perimeter, however, the interpretation of the findings became more difficult, because the observer, standing in Ophthalmologic Versus Anatomic Nomenclature 611 front of the patient and watching his eye for a correct central fixation, needs to transfer his findings from the arc to a chart and use a mental operation to determine on which side the marking ought to be done. To facilitate the recording and make it a mechanical operation the self -registering perimeter was devised. In this instrument the findings are marked on the opposite side of the art, upon a graduated scale, which has the same color of the figures on the arc. The violation of the anatomic standard which this recording of the field entailed made imperative for the understanding of the subject proper orientation of the oculist to extend this same faulty position J;o Uftf Fig. 2. The fields of vision as recorded at present. the anatomy, physiology, and neurology of the eye, setting two dif- ferent standards for the description of the organs, lesions, and func- tions. The result of this great departure is an added mental strain in order to transpose the mental images from the patient in front of the observer to the field, and determine, for instance, to which part of the retina one scotoma, a sector-like defect, etc., corresponds. In case of a thrombosis of the superior temporal artery of the right retina, where will the sector-like defect of the field correspond? Undoubtedly to the inferior nasal quadrant. The student visualizing the ophthal- moscopic lesion and wishing to represent to himself the defect on the 612 M. URIBE TRONCOSO field needs to transfer the lesion first to his own eye and then find the normal inversion in the field and locate the defect. The understanding of certain complicated lesions in the brain and the impairment of the functions they produce are more difficult to visualize with the present standard. As we have pointed out* before, in case of hemianopsia the correla- Fig. 3. Schematic representation of the optic pathway s, fields of vision on both sides as projected in the space in front of the observer, and records of the fields in the anatomic position. tion of the blind sides of the retinae with the visual fields and the patient's right or left is very difficult. If a lesion is present in the left optic tract, the text-book tells the student that the left halves of both retinse shall be wanting; the patient will see only the left halves of all objects. In the clinic the patient is facing us and explaining which side of the objects he sees; Ophthalmologic Versus Anatomic Nomenclature 613 by the perimetric examination we shall determine that the temporal field in the right eye of the patient and the nasal field of the left are wanting, still we must record the defect referring all these symptoms to our own eye and make the diagnosis by ascertaining which side of the objects our hemianopic eye would see, then we will call the hemi- anopsia right or left sided. Would it not be easier to follow the anatomic rules and record the fields as projected into the space in front of the subject, the right field in front of his right eye and the left before his left? (Fig. 3.) We would look at them as we see the fundus, as we really found them when moving the test object upon the arc of the perimeter. In this way the transfer to our own eye will be useless and no mental operations shall be necessary to visualize the field as located in space. This new method has many advantages: In the first place, the un- derstanding of the normal retinal projection with the field mapped out in space, in the opposite side of the retina, and the difference between the size of the temporal and nasal sides of the field, is made much easier. The extension farther forward of the sensitive portion of the retina on the nasal side, and the crossing of the limiting rays in the nodal point of the eye, can be demonstrated more clearly. The localization of the blind spot and paracentral scotomas in rela- tion with the visual axis is much easier to understand, as we are more accustomed to visualize the relations of the disc and the macula in the fundus with the ophthalmoscope. The reference of the ophthalmoscopic and neurologic lesions to the sides and places in the fields are greatly simplified by one physiologic inversion only instead of the two now in use. There are no technical difficulties in the change from the old to the new anatomic standard. The ordinary campimeter can be made of cloth instead of board, and with a graduation in the back which will allow, by thrusting pins, .the reading of the extent of the field in front of the patient. The Bjerrum screen, as now made, will be more easily used, no transfer of the readings in the back to the present unanatomic standard being necessary; this transfer and also recording from the campimeter being a real difficulty for the beginner. With the perimeter the only changes will be first to print the same schema now in use not exactly inverted but as seen by translucency ; the temporal side in front of the temporal side of the patient's orbit in each side, and the nasal side before the nasal side of the orbits (Fig. 4). 614 M. URIBE TRONCOSO The positions of the test-carrier in the arc shall be marked on the same side of the recording scale, the temporal findings in the temporal side of the scale, and so on. In order to avoid the confusion which in the beginning falls to the lot of any change, the charts will be left as they are now, only printing on the back another schema, with the graduation and limits as seen by translucency. A short direction printed in them will direct the operator to pencil the markings in the same side of the graduated scale ; temporal side of arc on outer part of the scale, nasal on inner side. -Ki&tEy 17 tftr -tXAt^cavriii- on The 1 fide, of Fig. 4. The fields of vision as recorded in the-anatomic position. The above reasons and the numerous advantages to be derived from a change in the present position and in the field of vision afford us the opportunity and honor of submitting to the International Congress of Ophthalmology of Washington, D. C., the following proposition : The International Congress of Ophthalmology, held in Washington, U. S. A., recommends to the authors and editors of books and essays dealing with ophthalmology to adhere faithfully to the anatomic nomenclature, and always consider the subject standing or lying down in front of the observer, his right side facing the left hand of the latter. This rule to be applied both to objective and subjective examina- tions of the eye and also to the visual field. STANDARDIZATION OF PERIMETRIC TECHNIC LUTHER C. PETER, M.D. Philadelphia The variable elements in field taking can be included in two groups : First, those which are correctable and due to a lack of care on the part of the operator, on the part of the patient, or to inadequacy of the necessary equipment; and, second, those which tend to yield variable results from day to day because of organic or functional changes in the visual pathway. By perimetric study we endeavor to uncover the latter group for correlation with other symptoms. In order, however, to be of de- pendable value, the errors of the first group must be eliminated. To this end efforts have been made from time to time to develop a technic which can be made uniform, or approximately so, through- out the world, or wherever perimetry is practised. Notwithstanding these efforts the frequent mention in literature of the need of stan- dards in our methods, and of urgent appeals by individuals for uni- formity, the first group of variable factors continues to rob field studies of their real value, although these errors can, for the most part, be eliminated. In order, therefore, to approach this subject from an international standpoint, and to secure the co-operation of ophthalmologists from the countries here represented, the following resolution is respectfully submitted : Resolved, That a Committee be appointed by the President of this Congress of Ophthalmology now assembled, to consider and to recom- mend to this Congress, before its close, a standard in technic which may be applicable in any part of the civilized world. First: With reference to the designation of the test objects or stimuli in degrees, minutes, or seconds. Second: The designation of the pigments, or papers, to be em- ployed as colored stimuli in definite and understandable language, by which they can be reproduced by the manufacturers of perimetric instruments. 615 616 LUTHER C. PETER Third: Uniformity in charts. Fourth : A standard method of illumination. Fifth : A method by which pre-exposure and surrounding field may be applied to perimetric studies. Sixth : The use of instruments in field studies with special reference to the needs of the case. Seventh: Other recommendations which, in the judgment of the Committee, may seem advisable at this time. PROF. S. E. WHITNALL McGill University, Montreal The points briefly described in the address were illustrated by lantern slides of figures from various text-books compared with photographs of actual dissec- tions. It is not feasible to reproduce them here, but the figures are referred to in the text, and the photographs will be found in the writer's recent work on the anatomy of this region. A comparison of the figures and descriptions of certain features in the eyelids, lacrimal apparatus, and orbital muscles, as given in the current anatomic text-books and copied thence into special ophthal- mologic works, with what may easily be shown by dissection to be the actual formations, shows that some revision of the subject is called for. In addition, a general acceptance of one term instead of the vicarious application of several names to the same structure may well be urged. The following points in particular seem worthy of notice ; they are put forward in no hostile criticism of our text-books, but as the writer's experience in dissection of a considerable number of orbits. (1) The ligaments by means of which the conjoint extremities of the tarsal plates of the eyelids are attached to the orbital margin are referred to in the texts by various names, and are not accurately described. They should properly be called TARSAL LIGAMENTS, medial and lateral, since the term "palpebral" in connection with such composite structures as the eyelids is somewhat indefinite; the expression "palpebral ligament," moreover, has been applied by some authors to the septum orbitale. The MEDIAL TARSAL LIGAMENT (the ligamentum palpebrale mediale of the B.N.A. terminology, also known as the tendo oculi internus, orbicular tendon, internal palpebral or tarsal ligament) is always illustrated as a band with well-defined upper and lower mar- gins, crossing over the middle of a bulging lacrimal sac on its way to gain attachment to the anterior lacrimal crest and frontal process of 617 618 S. E. WHITNALL the maxilla, as in Gray, Fig. 938; Fuchs, Fig. 285; Cunningham's Text-book, Fig. 699, and Practical Manual, vol. iii, Fig. 7; Piersol, Fig. 1199; Sappey, vol. iii, Fig. 665; Merkel, Fig. 38; Spalteholz Atlas, Fig. 929; Sobotta-McMurrich Atlas, Fig. 763; and Testut, vol. iii, Fig. 494, which is reproduced in many books. Actually, the medial tarsal ligament forms a complete anterior cov- ering to the whole of the upper half of the lacrimal sac. Superiorly it is thin and spreads out to blend with the periosteum of the bone, so that any definition of an upper margin appears to the writer quite artificial; this fact can easily be verified by removal of the skin over the medial commissure of the eyelids, and then dissecting away the fibers of the orbicularis oculi muscle which arise from the face of the ligament. Inferiorly, however, the ligament does present a con- spicuously free and thick lower margin; this edge lies on a more an- terior plane than the rest of the somewhat obliquely disposed liga- ment, and is denude of muscle fibers, facts which account for its prominence beneath the skin in the living, and its accentuation by lateral traction of the eyelids. Satisfactory definition of a posterior or reflected portion of this ligament, passing behind the lacrimal sac (as figured by Testut, vol. i, Fig. 697; Poirier, Fig. 685; Sobotta, Fig. 763), is difficult; it is very thin and appears of quite secondary importance, being merely the fascia clothing the front of the pars lacrimalis muscle. Sometimes it is apparently confused with the lacrimal fascia (vide infra). . [ The terms LATERAL TARSAL or PALPEBRAL LIGAMENT (tendo oculi externus, ligamentum canthi externum) and RAPHE PALPEBEALIS LATERALIS (B.N.A.) are variously and confusedly applied, both in text and illustration, to two entirely different and separate structures, of which only the one or the other is recognized, whereas both are actually demonstrable. Extending between the lateral canthus of the eyelids and the orbital margin there is an actual RAPHE, formed by the interlacing fibers of the palpebral portion of the orbicularis oculi muscle and strengthened upon its deeper aspect by the fascial septum orbitale, but it passes superficial to the orbital margin and is only adherent to the bone by connective tissue. On cutting through this raphe, the tarsal plates, though more movable, will be found still attached to bone by a deeper lying, much stronger and more definite band of connective-tissue fibers, which is the true lateral tarsal LIGA- MENT. It is separated from the superficially lying raphe by a narrow but usually definite cleft, in which there may be present a few lobules Some Descriptive Errors in Anatomy of Orbit 619 prolonged downward from the lacrimal gland ; and its actual attach- ment is just within the orbital margin, onto the orbital tubercle of the zygomatic bone. Some books figure the muscular raphe correctly in one place, but misapply the name to what is evidently the ligament in another; they also show the ligament as passing, like the raphe, superficial to the orbital margin instead of within or posterior to it (compare Figs. 340 and 929 in Spalteholz). Both structures are illus- trated in Piersol, Figs. 500 and 1199, but the text denies the existence Of the ligament on p. 484. Cunningham misapplies the terms in the text-book, Fig. 699, and practical manual, vol. iii, Fig. 7; as does also Sobotta, Fig. 763. Fuchs alone describes both correctly (p. 650). With further reference to the TARSAL PLATES, it may be noted as an example of the longevity of anatomic descriptive errors that the term "tarsal cartilage" still occasionally persists (Young's Handbook, fifth edition, p. 373; Howe, vol. i, pp. 15 and 16); though C. Krause pointed out as long ago as 1842 that no cartilage cells are present. In spite of the firm consistency of these plates, the most striking feature seen in microscopic sections is the relatively enormous size of the con- tained tarsal or meibomian glands ; indeed, there appears more gland- ular formation present than supporting connective-tissue framework. As further terminologic inexactitudes it may be noted that the "glandulae mucosse Krausei" of the B.N.A. are not mucous glands, but are accessory lacrimal glands of the conjunctiva. Also that Zeis, who apparently first described in 1835 the sebaceous glands of the eye- lid margins known by his name, spelled the latter as above, and not, as generally given, Zeiss. (2) The LACRIMAL FASCIA (fascia lacrimalis) is an extension of the periosteal (periorbital) lining of the medial wall of the orbit which passes from the posterior to the anterior lacrimal crest, bridging over com- pletely the lacrimal fossa or groove with its contained lacrimal sac. Its presence must surely be well recognized by and be of interest to the practising ophthalmologist, yet the writer has found no figure and but rare mention of it in the books, and even then it is referred to by such misleading terms as the "deep" or even "palpebral" fascia (e. g., Schaeffer, p. 249) ; sometimes it appears to be confused with the deep or reflected lamella of the medial tarsal ligament (Toldt, Fig. 1393; Morris, p. 1106; Fuchs, Fig. 284). It is a strong definite layer of fibrous tissue, and forms the immediate lateral and complete covering of the lacrimal sac; it is pierced by the lacrimal canaliculi and blood- vessels. Occasionally the fascia is adherent to the sac, but it can 620 S. E. WHITNALL usually be incised separately in gaining entrance to the lumen of the latter; failure to realize this point in passing a probe commonly leads the student in the dissecting room to force the instrument downward between the incised fascial covering and the unopened sac, and nat- urally a difficulty is experienced in reaching the nasal cavity. The extent and attachments of the fascia and the manner in which it com- pletely roofs over the fossa can best be demonstrated by dissecting out the entire nasolacrimal duct and lacrimal sac from the nasal side; that is, by cutting away the medial bony walls of these passages by appropriate working from the inside of the lateral wall of the nasal cavity in a sectioned head (as illustrated by Schaeffer, Fig. 175). After severing the lacrimal canaliculi and freeing the fundus of the sac, the entire tube formed by the sac and duct can be lifted out from the excavation in one piece; and removal of the whole contents of the orbit with detachment of the eyelids on the opposite or orbital side of the preparation will leave the lacrimal fascia as a complete entity, exposed on both sides. (3) The PARS LACEIMALIS MUSCLE (the muscle of Horner, 1824, but chronologically more correctly designated as that of Duverney, who previously described it in 1749, and well named it the tensor tarsi; it is also known as the posterior lacrimal muscle). The books nearly all follow the account given by Horner, who described the muscle as passing from its origin on the lacrimal bone forward and out- ward to divide and terminate near the puncta lacrymalia of the eye- lids (e. g., Morris, p. 391; Testut, vol. i, p. 732; Howe, vol. i, p. 51, calls it a "supernumerary" muscle, and gives an insertion into the conjunctiva). The customary method of displaying it is from behind, by dissecting both eyelids away from the front of the eyeball and turning them nasalward, as depicted in Gray, Fig. 520; Piersol, Fig. 500; Sobotta, Fig. 261, and in Homer's original figure; so viewed, the pars lacrimalis fibers of the orbicularis oculi certainly appear to end as described near the lacrimal puncta. If, however, the tarsal plates be now dissected away (as shown, for example, in Spalteholz, Fig. 340), it will be realized that whilst some of the muscle fibers are short and do end on the canaliculi and tarsal plates, yet the bulk of them are continued on across the front face of the plates as far laterally as the lateral raphe. In other words, the pars lacrimalis or Horner's muscle appears to the writer to denote merely the conjoint ends of two con- tinuous long muscle bands (the pretarsal part of the pars palpebralis of the orbicularis oculi) which sweep across the eyelids from one side Some Descriptive Errors in Anatomy of Orbit '621 to the other, lying in front of and closely applied to the tarsal plates. They can thus serve far better to keep the latter curved and approxi- mated in their whole length to the eyeball under all its movements, than if they were merely inserted into the medial ends of the plates. The continuity of the fibers and their passage at the medial end behind the lacrimal sac would explain why removal of the medial tarsal ligament in ablation of the lacrimal sac does not necessarily entail ectropion of the lower lid, as suggested by the writer in a paper in "The Ophthalmoscope," April, 1913. It may be noted that the liga- ment passes across the front of the upper half of the lacrimal sac, whilst the pars lacrimalis muscle passes behind its upper half, so that the two form a complete hood over the fundus of the sac. The lower half of the sac is related to the orbital fat behind, and is merely cov- ered in front by septum orbitale, orbicularis oculi muscle, and skin. (4) The shape of the normal LACRIMAL SAC appears, according to the writer's findings, wrongly represented in every instance. In all the figures enumerated in reference to the medial tarsal ligament in the first part of this article, the sac is drawn as seen from the front in the form of the bulging or dilated upper end of the nasolacrimal duct. Possibly this is due to the exigences of pictorial representation, though it is also so described in some texts (e. g., Quain, Schaeffer, Sobotta). Actually the sac conforms in shape to the bony fossa or groove in which it lies, and tapers off above, though its anteroposterior diameter in its middle may exceed that of the duct below. The shape of the whole tube, lacrimal sac and nasolacrimal duct together, may be likened to the end of a quill-pen seen sideways, a configuration that the writer has always found, especially in formalin hardened dissec- tions prepared as described above with reference to the lacrimal fascia, and as is shown by Aubaret's series of isolated lacrimal sacs, and in the casts made by Zabel. Toldt's Fig. 1393 shows well the narrow transverse lumen of the sac in section, and will enable one to realize that any action which the fibers of the orbicularis oculi muscle may have upon it in the act of winking must be transmitted through the agency of the covering lacrimal fascia, and will tend to dilate the sac, which is possible from its collapsed condition (and, as indeed Scimemi proved experimentally) rather than to compress it, which does not appear possible either from its position or its condition. (5) The LEVATOR PALPEBR^D SUPERIORIS MUSCLE is oftentimes described as having a threefold insertion into the upper eyelid, namely to the skin, the tarsal plate and the conjunctiva, but it is 622 S. E. WHITNALL misleading to depict all three insertions as being of equal importance (e. g., Cunningham's Practical Manual, Fig. 8 and p. 26). The primary and essential attachment is to the skin, through the agency of the splayed out anterior margin of the expanded aponeurosis in which the muscle belly ends. The tarsal attachment is effected by the agency of the involuntary superior tarsal or palpebral muscle of Miiller, which, though in close contact with the under surface of the aponeurosis and springing like it from the fore end of the belly of the muscle, does not "largely form part of it" (Piersol, p. 502); it is an extremely interesting little muscle, from a clinical standpoint as well as from a morphologic one, since its tone may be strikingly responsive to the state of the sympathetic nervous system by means of which it is supplied; and it may indicate by a slight drooping of the eyelid a condition of malaise (as is well seen in children) or of mental fatigue beyond the power of the will to counteract. The third so-called inser- tion of the levator is merely the attachment of its fascial sheath, fused with that of the subjacent superior rectus muscle and void of striated muscle fibers, to the superior conjunctival fornix. Its action is to pull this conjunctival fold upwards in harmony with movement of the cornea in the corresponding direction, and it might more fittingly be described as an additional "insertion" of the superior rectus, comparable to the similar fascial slips derived from the sheaths of the other recti muscles which pass to the conjunctival fornix below, lateral, and medial to the eyeball. Most of the illustrations give a complicated and indefinite view of these insertions; Spalteholz, Fig. 923, is the clearest. Lastly, in descriptions of the levator, the osseous attachments of the lateral extremities or horns of the aponeurosis surely deserve more notice than they generally receive; the especial strength of the lateral horn, its enfolding by the lacrimal gland, and its strong fixation to the orbital tubercle of the zygomatic bone might well be mentioned. (6) The LACRIMAL GLAND is described as being enclosed in a definite capsule (e. g., Poirier, vol. iii, p. 1122; Morris, pp. 1106 and 1113), but the writer has never been able to satisfy himself as to the existence of such a structure. The lobules of the gland are bound together by a connective tissue stroma which is certainly continuous behind with the interlobular fascia of the orbital fat; it is slightly more abundant upon the surface of the gland, where a delicate tissue can be picked off piecemeal, but such formation can hardly be considered as a " capsule " in the usual acceptance of the term. Nor can " suspensory ligaments " Some Descriptive Errors in Anatomy of Orbit 623 be satisfactorily demonstrated. The gland is kept in place by the eye- ball below and medially, by the orbital fat behind, but chiefly by the fact, usually not mentioned, that it is cut deeply into and so partly subdivided into its two lobes (orbital and palpebral portions) by the lateral horn of the aponeurosis of the levator palpebrae superioris muscle; it is, as it were, folded round the lateral part of the aponeuro- sis, and may possibly participate to some extent in its movements. (7) The LATERAL RECTUS MUSCLE of the eyeball is commonly de- scribed as arising by "two heads" from the annulus communis of Zinn at the apex of the orbit, and certain nerves are described as entering the orbit between them. The statement conveys an exag- gerated idea of the muscle origin, reflected in the figures where two definite and separate heads are depicted (e. g., Gray, Fig. 933; Cun- ningham's Practical Manual, vol. iii, Fig. 96). The muscle certainly arises from that part of the annulus which crosses the superior orbital fissure, but, as D wight points out (p. 96), there is no break in the continuity of the annular origin of the muscle fibers, such as the expression "two heads" denotes. The term is probably a subversion of Merkel's description of one head arising from the annulus and another from the spina recti lateralis of the sphenoidal apex of the lateral orbital wall; he shows these two origins clearly (Fig. 28), as does Spalteholz (Fig. 916), but they do not span the superior orbital fissure, no structures enter the orbit through them, and they are not the same "heads" as described in later works. Merkel described the nerves which here enter the orbit as traversing an "oculomotor foramen," which is a definite fibrous ring formed between the annular origin of the lateral rectus muscle and the optic nerve. The position of the nerves (the oculomotor in two divisions, the nasociliary and the abducent) relative to one another at this point receives unwarrantable stress in the text-books (e. g., Buchanan, p. 1149), since they are all crowded together and compactly fill a space not more than three milli- meters in diameter. It would appear better to describe these nerves as entering the orbit through either the oculomotor foramen, or be- tween the lateral rectus muscle and the optic nerve (as does Sobotta), or within the cone of recti muscles which arise from the annulus, since the practical point is that the trochlear, frontal, and lacrimal nerves enter outside the cone of muscles. (8) The FASCIA BTJLBI (Tenon's capsule) will lose much of its descriptive complexity if simply regarded as the primary socket of the eyeball, fused with the f ascial sheaths of the muscles where they pierce 624 S. E. WHITNALL it. The elaborate description of Motais (followed by Maddox and Howe, and formerly included, but now replaced, in Poirier's Anatomy) forces one to agree with D wight that the " complications of this mem- brane are limited only by the perverted ingenuity of those who de- scribe it." The thickening of the capsule below to form Lockwood's ligament, and the peripheral expansions of the muscle sheaths to form "check ligaments" are easily demonstrable, but the formation of "pulley-bars" at the points of junction of the muscle sheaths with the capsule to prevent compression of the eyeball in contraction of the recti (Fisher, Fig. 14; Morris, p. 1107; Cunningham's Practical Manual, vol. iii, p. 260) is surely uncalled for if one considers the ab- sence of angle or even curve in the run of a muscle at such point, together with the extreme mobility of the eyeball. The writer cannot find evidence that the capsule is continuous behind with any pro- longation around the optic nerve, or that the interfascial space of Tenon, which separates the capsule from the eyeball, is continuous with the so-called supravaginal space along the nerve, as depicted in Piersol, Fig. 800, and elsewhere described. The eyeball cannot move freely within the capsule, as it is sometimes stated to do (Morris, p. 1107; Cunningham's Practical Manual, vol. iii, p. 259; Buchanan, p. 1151); there can be only limited movement between them, and both work together on the bed of orbital fat, as is agreed by Dwight, Fisher, and, indeed, by Motais. The point might be illustrated by comparing the capsule to a closely fitting woolen shirt, tightly but- toned round the neck (the sclero-corneal junction) and at the ends of the sleeves (the muscle sheaths), and so allowing no really free move- ment of the body ensheathed by it. BIBLIOGRAPHY Aubaret: Bibliographic Anatomique, 1910, xx, i, p. 97. Buchanan: Manual of Anatomy, Third Edition, Macmillan, Toronto, 1916. Cunningham: Textbook of Anatomy, Fourth Edition, Frowde, 1913; and Manual of Practical Anatomy, Seventh Edition, 1920. Dwight: Article in Norris and Oliver's System of Diseases of the Eye, Lippincott, 1900. Fisher: Ophthalmological Anatomy, London, 1904. Fuchs: Textbook of Ophthalmology, Duane's Fifth Edition, Lippincott, 1917. Gray: Anatomy, Twenty-first Edition, Longmans Green, 1920. Heisler: Practical Anatomy, Second Edition, Lippincott, 1920. Howe: The Muscles of the Eye, Putnam, New York, 1907. Maddox: Tests and Studies of the Ocular Muscles, Second Edition, Philadelphia, 1907. Clinical Anatomy of the Efferent Lacrimal Passageways 625 Merkel: Article on Makroskopische Anatomie des Auges in Graefe-Saemisch Handbuch, 1901. Morris: Human Anatomy, Sixth Edition, Blakiston, 1921. Motais: L'appareil moteur de 1'oeil, Paris, 1887. Piersol: Human Anatomy, Seventh Edition, Lippincott, 1919. Poirier: Charpy's Abrege d' Anatomie, Masson, Paris, 1909. Quain: Elements of Anatomy, Eleventh Edition, Longmans Green, 1909. Sappey: Traite d' Anatomie, Paris, 1888. Schaeffer: The Nose and Olfactory Organ, Blakiston, 1920. Spalteholz: Hand Atlas of Human Anatomy, Barker's translation, Third English Edition, Lippincott. Sobotta-McMurrich: Atlas and Textbook of Human Anatomy, Saunders, 1907. Testut: Traite d' Anatomie Humaine, Seventh Edition, Doin, Paris, 1922. Toldt: Anatomischer Atlas, Vienna, 1914. Whitnall: Anatomy of the Human Orbit, Oxford Medical Publications, Frowde, London, 1921. Young: Handbook of Anatomy, Fifth Edition, Davis Co., 1919. Zabel: Anatomische Hefte, 1900, xv, p. 153. ON THE CLINICAL ANATOMY OF THE EFFERENT LACRIMAL PASSAGEWAYS J. PARSONS SCHAEFFER, M.D., PH.D. Professor of Anatomy and Director of the Daniel Baugh Institute of Anatomy of the Jefferson Medical College, Philadelphia I take it as axiomatic that of first importance is a knowledge of the basic plan of the anatomy of the human body and that, in the diag- nosis, treatment and prognosis of diseased states, the regions and organs of the body must needs be approached from the viewpoint of an average anatomy. It is fortunate that there is such a constancy in what may be considered basic, and the wonder is not that there are departures in anatomic conformations but that nature so regularly reproduces that which is fundamental. Despite the general truth of the foregoing an ideal or unvarying anatomy of many parts is uncom- mon. There are variations in essential details and the adherence to an arbitrary and so-called fixed normal is fraught with considerable danger, since with variations come altered size, shape and topo- graphic relations; moreover, interiors and exteriors of parts are pro- foundly influenced by developmental potentialities. Anatomic varia- tions of an organ and apparatus and of their relational field must have an important bearing in diagnosis, pathology, clinical medicine, and 40 626 J. PARSONS SCHAEFFER surgery, and the attention given to this fact may be the narrow mar- gin between success and failure. It is this thesis that I venture to support and develop in my address on the efferent lacrimal passage- ways this evening rather than enter into a detailed account of the conventional anatomy of the parts concerned. GENESIS AND DEVELOPMENT It would be futile to attempt a discussion of this problem without a brief presentation of the embryology of the efferent lacrimal appar- atus. The genetic and developmental anatomy not only point the way to a clearer understanding of the ground plan of the anatomy, but of the anatomic types and anomalies as well. In the early embryo, extending from the medial angle of the eye to the olfactory pit, is the naso-optic (nasolacrimal) groove or fissure, bounded above by the lateral nasal process and below by the maxillary process. These embryologic, mesenchymal and epithelial covered processes unite by coalescing from the depth toward the periphery, thus obliterating or outfolding the intervening groove or fissure. In 12 mm. human embryos, aged approximately five weeks, a ridge-like thickening of the deep layer of the epithelial lining of the now rudi- mentary naso-optic groove takes place. This epithelial ridge grows and pushes into the underlying mesenchyme and becomes entirely separated from its surface connections and wholly surrounded by mesenchymal tissue (embryos aged from thirty-six to forty days). The detached solid strand or cord of epithelial cells is the rudiment or anlage of the nasolacrimal passageways, and while it corresponds to the line of the previous naso-optic groove, it must be understood that the system of efferent lacrimal ducts does not represent a cut-off portion of the obliterated groove brought about by the coalescence of the lateral nasal and maxillary processes. The rudiment of the nasolacrimal passageways is a solid cord of epithelial cells, detached from its genetic area and for a brief period entirely surrounded by mesenchyme and without a lumen. From the parent cord of cells sprout the upper and lower lacrimal ducts, the upper part of the lacrimal sac and the nasal end of the nasolacrimal duct, thereby establishing secondary connections with the epithelium of the free border of the eyelids and the nasal fossa. The lumen of the several segments of the nasolacrimal passageways is irregularly and variously formed. This is accomplished by an apparent necro- biosis and resorption of some central cells and a rearrangement of Clinical Anatomy of the Efferent Lacrimal Passageways 627 others. Canalization begins early at the ocular end of the stem rudi- ment, progresses rapidly toward the nasal end and is well advanced in embryos aged one hundred days. At times it would appear that the upper (eye) and lower (nasal) ends of the stem rudiment were the first and the mid-section the last to gain a lumen. The horizontal -no/ Fig. 1 Fig. 2 Fig. 3 Fig. 4 Figs. 1, 2, 3, 4. Photomicrographs of frontal sections of the heads of human embryos showing several stages in the development of the nasolacrimal passage- ways: Fig. 1, aged thirty-three days; Fig. 2, aged thirtv-nve days; Fig. 3, aged thirty-six days; Fig. 4, aged forty-three days. X 7. (Schaeffer: The Nose and Olfactory Organ.) nof, Remains of naso-optic furrow; /, nasal fossa; e, eye; d, different stages of the rudiment or anlage of the nasolacrimal passageways. portions of the lacrimal ducts become canalized before the vertical portions. In embryos aged one hundred and twenty days the vertical segments not infrequently are solid cords of epithelial cells, while the horizontal segments already possess a lumen. The canalization of the points of union between the free border of the eyelids and the 628 J. PARSONS SCHAEFFER lacrimal ducts is often deferred for a later period. The point of coal- escence between the nasal end of the sprouting parent cord and the inferior nasal meatus is the last to become patent the attenuated lacrimonasal membrane "rupturing" approximately at birth or later. As stated elsewhere, the rudiment of the nasolacrimal passageways grows into the subjacent mesenchyme and becomes encompassed by it. The lacrimal ducts and the ocular and nasal ends of the nasolac- rimal duct are secondary outgrowths and soon establish their defini- tive connections. Subsequently (third or fourth month) a stumpy cartilaginous process (processus paranasalis) arises from the lateral wall of the cartilaginous nasal capsule and surrounds a part of the developing nasolacrimal duct segment. The surrounding mesen- chyme ossifies in the formation of the maxilla, the lacrimal bone and the inferior nasal conchal bone; the related cartilage usually disap- pears and the greater portion of the nasolacrimal duct ultimately becomes encased in bone, the canalis nasolacrimalis. The lacrimal sac comes to rest in an oblong, rounded osseous depression, the fossa sacci lacrimalis, while the lacrimal ducts occupy the soft tissues of the eyelids and a lower non-osseous portion of the nasolacrimal duct not infrequently courses in the mucosa of the lateral wall of the inferior nasal meatus. 1 ATYPICAL DEVELOPMENT The foregoing recounts the origin and early development of what may be termed an ideal or so-called typical efferent lacrimal duct system. However, there is early evidence of variations from the ideal. From the genetic point of view the variations in the anatomy of the nasolacrimal passageways appear to fall into three important and more or less clearly defined groups : First, those that have their basis in rudiment potentials; second, those due to early arrests in the development of parts which should proceed from the stem rudiment, and third, those due to division of previously continuous ducts into discontinuous segments. The complete dissociation of the efferent lacrimal ducts, owing to marked monster formations, might be con- sidered an unimportant fourth group, and deserving of no further mention in this connection. ^or a more detailed account of the embryology see J. Parsons Schaeffer, "The Genesis and Development of the Nasolacrimal Passageways in Man," Amer. Jour. Anat., vol. xiii, 1912. Clinical Anatomy of the Efferent Lacrimal Passageways 629 RUDIMENT POTENTIALS Rudiment potentials are encountered which explain such varia- tions and abnormalities as supernumerary lacrimal ducts for one or both eyelids; duplication, triplication, et cetera, of the lacrimal punctum; the slit and furrow lacrimal punctum; mucosal ledges and so-called valves within the nasolacrimal passageways; irregularities of contour; diverticula; variations in the anatomy of the lacrimal aperture in the inferior nasal meatus; osseous and membranous seg- ments of the nasolacrimal duct, etc. As a rule, but two sprouts proceed from the upper end of the parent or stem rudiment, one becoming the upper lacrimal duct and the other the lower lacrimal duct or canaliculus. However, occasionally one encounters multiple buds or sprouts, some of which develop sufficiently to establish definitive connections with the free border of the eyelids and become supernumerary lacrimal ducts. Others fail to establish connection with the eyelids and end blindly. The majority of these additional buds are resorbed or become small, blindly ending divertic- ula. Complete supernumerary lacrimal ducts also lead to multiple lacrimal puncta. However, at times in the normal number of lacrimal ducts, multiple puncta are encountered for one or both lids. These are readily accounted for by the fact that the lacrimal duct in coalescing with the free border of the eyelid may do so over a relatively extehsive area. The canalization of this wide area of contact- the lacrimo- conjunctival membrane may be slit-like, oval or fenestrated, the latter giving rise to multiple puncta. Indeed, the greater portion of the lacrimal duct or canaliculus may be represented by a furrow along the free border of the eyelid. The canalization of the solid nasolacrimal rudiment occurs very irregularly and there is all evidence at an early time of mucosal ledges and valves and shallow diverticula. Secondary buds from the stem rudiment account for the larger diverticula, and the belief that these are acquired in adult life and the result of disease is not justified. The variation in the topography and type of the nasolacrimal ostium or aperture in the inferior nasal meatus is cleared up by the embryology of the lacrimonasal membrane, formed by the fusion of the epithelium of the nasolacrimal duct with the mucous membrane of the nasal fossa. When the developing nasolacrimal duct comes in contact with the nasal mucosa at the roof and highest point of the inferior nasal meatus, the resulting ostium nasolacrimale is single, 630 J. PARSONS SCHAEFFER large, unguarded by a mucosal valve, and, since it becomes surrounded by an osseous ring, stands permanently open. On the other hand, when the developing nasolacrimal duct establishes contact and fusion with the lateral wall of the inferior nasal meatus, the area may be a considerable one. In the latter, the ostium nasolacrimale generally is slit-like and has a mucosal flap or valve. This valve may or may not be efficient physiologically in preventing regurgitation. The aperture may be single or multiple and located variously on the lateral wall of the inferior nasal meatus, from the attached border of the inferior nasal concha to the floor of the nose. Varieties of these two basic types of nasolacrimal ostia or apertures are very frequently encountered, but a discussion of them is not vital in this connection. The posterior lacrimal crista is very prominent in the newborn, rendering the lacrimal fossa relatively deep. The hamular process of the lacrimal bone at times undergoes conspicuous development, resulting in division of the lacrimal sac. DEVELOPMENTAL ARRESTS Patients are encountered with one or both lacrimal ducts wanting in whole or in part; or if complete, the point of coalescence with the eyelids may be imperforate, or atresias over greater segments may be encountered. The connection with the inferior nasal meatus may be defective or absolutely imperforate. Atresias of portions of the naso- lacrimal passageways are not uncommon in the newborn. The stem rudiment may not become detached wholly from its original surface connections, thereby leading to lacrimal fistulse or false adult connections. This is especially prone to occur in the region of the lacrimal sac. The nasal end of the stem rudiment may fail to sprout or may establish connections with the middle nasal meatus by means of a side bud. Connections may be made with the lip, and the lower orifice of the nasolacrimal duct established there. The cause for the failure of normal development is not clear. So far as the lacrimal ducts are concerned, there appears to be a critical period for them shortly after the detachment of the solid epithelial rudiment of the nasolacrimal passageways from its surface connection. If the lacrimal ducts which normally grow as secondary sprouts from the stem rudiment fail to show beginning growth shortly after this stage, there appears to be a great likelihood that they will not develop subsequently. Since the rudiments are solid epithelial cords, want of canalization will lead to atresias of various degrees and levels later. Clinical Anatomy of the Efferent Lacrimal Passageways 631 These are most common at the distal or nasal end of the nasolacrimal duct in the newborn and child. It would appear that many of the latter atresias become perforate during the first weeks or months of extrauterine life. Atresias of the lacrimal ducts or canaliculi also are encountered. There also is some evidence of obliteration of a previously established lumen by a secondary proliferation of the epithelial lining of the ducts, especially the nasolacrimal duct. OTHER ANOMALOUS CONDITIONS There are a few anomalous conditions in the anatomy of the nasolacrimal passageways that appear to have no basis in the rudi- ment potentials nor in arrested development. For example, divided lacrimal ducts are encountered, the lacrimal sac may be detached from the main nasolacrimal duct, the nasolacrimal duct proper may be found as two discontinuous segments, etc. It appears certain that the division of a lacrimal duct or of the nasolacrimal duct proper occurs secondarily; that is, after the definitive connections are fully formed. These conditions often occur in monsters or in children with secondary facial fissures. Ask and van der Hoeve 1 suggest amniotic bands and ingeniously use secondary facial furrows and the develop- ment of the lacrimal caruncle in attempting to establish their thesis. Ask's previous conclusions on the development of the lacrimal caruncle are generally accepted as correct. 2 It is my belief, for example, that the lacrimal ducts wholly grow from the ocular end of the stem rudi- ment of the nasolacrimal passageways and not, as some argue, one part from the free border of the eyelid and the other from the stem rudiment. Therefore, when one encounters a lacrimal duct with normal definitive connections, divided into two discontinuous seg- ments, there is no other explanation but that the duct suffered divi- sion secondarily. The same applies elsewhere. Amniotic bands are suggestive in this connection and are deserving of further study. The discussion, however, cannot be extended here. 1 Fritz Ask und J. van der Hoeve: Beitrage zur Kenntnis der Entwicklung der Tranenrohrchen unter normalen und abnormen Verbal tnissen, letzteres an Fallen von offener schrager Gesichtsspalte, von Graefe's Archiv fur Ophthalmologie, cv, 1921. 2 Ask, Fritz : Uber die Entwicklung der Caruncula lacrimalis beim Menschen, nebst Bemerkungen iiber die Entwicklung der Tranenrorchen und der Meibom- schen Driisen, Anatom. Anz., xxx, 1907. 632T J. PARSONS SCHAEFFER EARLY POSTUTERINE DEVELOPMENT The nasolacrimal duct at birth has very irregular walls. The ragged mucosal surface gradually changes to a more even contour. However, some of the recesses remain and others become extended into goodly sized diverticula. Some of the mucosal fringes undergo definite organization and form permanent mucosal ledges and valves within the ducts. Not infrequently the nasal end of the nasolacri- mal duct is imperf orate at birth. Many of these go unrecognized, becoming perforate in the early weeks of extrauterine life and showing Fig. 5. a, Photograph of a section through the nasal end of the nasolacrimal duct, showing a lacrimonasal membrane of considerable thickness and imper- forate. Fetus aged seven months, b, Note lacrimonasal membrane thinned out but imperforate. Newborn child, c, Section of the entire nasolacrimal duct, showing great irregularity of lumen. The communication with the inferior nasal meatus is established. Child aged one month. that developmental processes are carried on after birth. However, some remain imperforate for a longer period and give definite symp- toms. They may become perforate spontaneously, even after the first year. While an expectant treatment should be adopted, opera- tive procedures may be required. The nasolacrimal duct at birth averages less than 2 mm. .in diame- ter, at the third year 3 mm., with extremes of 1.5 mm. to 6 mm., the latter being rare. The osseous nasolacrimal canal is somewhat larger. The subepithelial tissue stratum harbors a plexus of veins and lymphoid tissue. Clinical Anatomy of the Efferent Lacrimal Passageways 633 The outlet into the inferior nasal meatus is extremely variable at an early time and is subject to the same influences that obtain in the adult. Since these will be discussed at length subsequently, they need not detain us here. The plane of direction, in the infant, of the lacrimal fossa and the nasolacrimal canal, with the contained lacrimal sac and the naso- lacrimal duct, is more direct and more nearly vertical. As age ad- vances the plane of projection of the canal and duct must conform to the type of face, size of the inferior meatus, width of the pyriform aperture and the width of the bridge of the nose, which take definition and become more and more positive as puberty is neared. MACROSCOPIC ANATOMY The Lacrimal Fossa and the Nasolacrimal Canal. The osseous fossa which lodges the membranous lacrimal sac (fossa sacci lacri- malis) is an oblong, rounded depression located on the ventro-medial aspect of the orbit, the frontal process of the maxilla and the lacri- mal bone participating more or less equally in its formation. The fossa is limited dorsally by the posterior lacrimal crista and ventrally by the anterior lacrimal crista, the former a prominent crest on the lacrimal bone (especially conspicuous in the newborn) and the latter a crest on the frontal process of the maxilla. Above, the lacrimal fossa becomes shallower and shallower, ultimately losing its identity at the fronto-lacrimo-maxillary suture line, while below it is directly confluent with the osseous nasolacrimal canal. The latter terminates immediately below the attached border of the inferior nasal concha at the cupola of the inferior nasal meatus. The osseous canal is formed by the maxilla, the lacrimal bone and the inferior nasal concha, the maxilla by its frontal process and body contributing the greater portion. Variations occur. The length of the osseous nasolacrimal canal does not necessarily conform to the enclosed membranous nasolacrimal duct, which is frequently longer (see elsewhere). The osseous canal proper varies in length from 10 to 20 mm., and the lacrimal fossa from 10 to 14 mm., making the total length of the osseous channels from 20 to 34 mm. The diameter of the osseous canal is seldom uniform throughout, measuring on an average 5 mm. at its narrowest part and 8 mm. at its widest. Extremely narrow (2 mm.) segments are occasionally encountered. At times the widest point is apove and the narrow point at its inferior outlet. Again, the reverse may be true, or the nar- 634 J. PARSONS SCHAEFFER row part be in the mid-section. These congenitally constricted seg- ments simulate a stricture in passing the lacrimal probe. The plane of direction of the osseous nasolacrimal canal obviously conforms to the type of the facial skeleton. The breadth of the bridge of the nose, the width of the inferior nasal meatus, and the degree of expansion of the pyriform aperture also influence the course or direction of the nasolacrimal canal. Generally speaking, one may say that the osseous nasolacrimal canal is projected caudal ward, lateral ward and dorsalward . Its surface mark is an oblique line erected from the lacrimal fossa to a variable point on the medial aspect of the alveolar process of the maxilla, corresponding to the interval between the second premolar and the first molar, the first and second molars or even as far dorsal as the second and third molar teeth. The almost vertical plane frequently shown in text-books is erroneous. The Lacrimal Ducts. The lacrimal ducts or canaliculi begin nor- mally by minute openings, the lacrimal puncta, which either surmount or are placed on the sides of the conical lacrimal papillae, located on the free border of the eyelids, the upper about 6 mm. and the lower about 8 mm. from the medial palpebral commissure (internal can thus). The puncta normally are directed against the eyeball, and should there be a malposition (congenital or acquired) of the puncta there is usually an overflow of tears. The same results if the lumen is obstructed. The lacrimal ducts consist of vertical and horizontal portions, with dilatations or ampullae at the knees. They average from 8 to 10 mm. in their total length; 0.1 to 0.2 mm. in diameter at the puncta, 1 mm. at the knees and 0.5 to 0.8 mm. in the horizontal portion. The inferior lacrimal duct almost invariably is longer than the superior duct. Irregularities and sacculations of the lumen are not infrequent. The horizontal portions of the lacrimal ducts communicate with the lacrimal sac (a) by the ducts uniting into a short, narrow common duct, (b) by each duct emptying separately into a diverticulum of the lacrimal sac and (c) by the ducts emptying separately directly into the lacrimal sac. The first/ is the most frequent. The Lacrimal Sac and the Nasolacrimal Duct. The membranous lacrimal sac occupies the lacrimal fossa and extends for some dis- tance into the upper end of the nasolacrimal canal. It is bridged over by the palpebral fascia, which extends from the anterior to the pos- terior lacrimal crests; the medial palpebral ligament; fibers of the orbicularis palpebrarum and skin and subcutaneous tela. The Clinical Anatomy of the Efferent Lacrimal Passageways 635 orifice (or orifices) of the lacrimal ducts usually is located from 2 to 5 mm. from the extreme top or fornix of the lacrimal sac. The lacrimal sac at times merges imperceptibly with the naso- lacrimal duct. Again, there may be a slight or marked constriction or isthmus, or the lacrimal sac and the nasolacrimal duct may not be in alignment, but joined side by side. It will be recalled that the osseous nasolacrimal canal terminates at the highest point of the in- ferior nasal meatus. The contained membranous nasolacrimal duct may or may not conform to this termination. At times the nasolacrimal duct is continued for a considerable distance within the mucous membrane of the lateral wall of the inferior nasal meatus, beyond the nasal end of the osseous nasolacrimal canal. This accounts for the discrepancy in length between the membranous nasolacrimal duct and the osseous nasolacrimal canal; moreover, leading to an osseous-supported segment of the duct and a purely membranous segment. The latter has an important clinical sig- nificance (see elsewhere). Since the ostium of the nasolacrimal duct varies in its location, the nasolacrimal duct has a range in length from 10 to 28 mm. The diameter of the nasolacrimal duct is not uniform. At times the isthmus is much constricted, 3 mm., the remaining portion of the duct averaging approximately 5 mm. However, this is much re- duced at times by encroachment of the osseous canal or by an unusual development of the subepithelial strata. The nasolacrimal duct may be wide above and narrow below, narrow above and wide below, or hour-glass in character, i. e., constricted midway. Diverticula and Valves. A large number of nasolacrimal ducts have fairly regular and uniform walls. However, not infrequently there is a retention of developmental structures leading to the formation of valve-like folds and diverticula, with great irregularity of the lumen of the duct. Krause and Beraud long ago described a valve at the junction of the lacrimal sac and the lacrimal duct. Frequently this is merely an elevation of mucosa. Again, it may be sufficiently reduplicated to form a true valve. Bochdalek and the writer have found that the opening of the lacrimal ducts may be placed in the center of a mucous membrane diaphragm. Additional valves and mucosal ledges are not infrequently encountered in the mid-portion of the nasolacrimal duct. Lateral evaginations of the mucosa result in minor depression and fossae. However, at times these extensions are of considerable pro- 636 J. PARSONS SCHAEFFER . portions, leading to the formation of variously sized, blindly ending diverticula. These diverticula have a lining not unlike that of the nasolacrimal duct proper, with which they always communicate. The genesis of these diverticula seems established, and from the evidence at hand one must conclude that they are congenital rather than acquired. The anomalies of the efferent passageways were briefly discussed in connection with the development, therefore, no further mention of them need be made here. MICROSCOPIC ANATOMY The lacrimal ducts have a lining of stratified squamous epithelium superimposed upon a sparse tunica propria rich in elastica. Fibers of the orbicularis oculi muscle lend strength and support, paralleling the horizontal segment of the ducts and encircling the vertical seg- ment. The circular fibers are in essence a true sphincter and are so arranged that from the physiological point of view the lumen of the ducts is readily occluded. This may be brought about reflexly follow- ing excitation in the immediate neighborhood or at a remote and unsus- pected point. There may, therefore, be an overflowing of tears from a physiologic obstruction of the very beginning of the efferent lacrimal passageways. The lacrimal sac has a lining of columnar epithelial cells, usually arranged in a double layer. Here and there the surface cells are provided with cilia. Beneath the epithelium is a relatively thick fibro-elastic tunica propria with an abundance of lymphoid tissue, some of which is arranged in definite masses not unlike the aggregated nodules of the small intestine. Small tubular glands are always present; in some specimens in great abundance, in others but few are found. Not infrequently numerous elements of epithelium exhibit stages of conversion into mucus-containing goblet cells. These may be found over considerable stretches of epithelium. Here and there the epithelium becomes depressed and gland-like, goblet-cells lining the depressions. The tubular glands not infrequently contain goblet- cells. Another important anatomic feature is the loose tissue which connects the tunica propria with the periosteum. This tissue every- where is occupied by a rich plexus of veins which partakes of the nature of a modified erectile tissue. The tissue spaces are large. This stratum is subject to very rapid engorgement and depletion, and Clinical A natomy of the Efferent Lacrimal Passageways 637 under reflex and pathologic conditions may increase in thickness many fold. There is every reason that this stratum can be influenced reflexly owing to the excessive venous plexus. Complete physio- logic obstruction of the lumen of the lacrimal sac may ensue from its engorgement. The nasolacrimal duct also is lined with a columnar epithelium. Small tubular glands are encountered most of the mucous type, others appear mucoserous in character. Between the epithelium and the a b Fig. 6. a, A section of the mucous membrane of the lacrimal sac, considerably magnified. Note, e, the epithelium with glands and goblet cells; /, lymphoid tissue, nodular-like in character; and, v, the large venous spaces, b, Same as a, at a lower magnification; showing a larger field and the great venous plexus in the tunica propria. The blood-spaces are all engorged. periosteum is a stratum of very loose areolar tissue with an abundant venous plexus. The lower part of the duct is not unlike the erectile mucosa of the inferior nasal concha and the related meatus. One cannot but be impressed with the abundant venous plexus of the lacrimal sac and the nasolacrimal duct. Its real significance has not been determined. At times and in places it is suggestive of an erectile tissue. One wonders whether this stratum of the lacrimal sac and the nasolacrimal duct is subject to the same influences as are the erectile tissues of the nose. The clinical potentialities here appear 638 J. PARSONS SCHAEFFER great. Reflex neuroses may be a factor. However, in obscure cases careful search should be made for a disease focus which invokes a reflex turgescence and a possible physiologic occlusion of the naso- lacrimal duct. It also is remotely possible that over-sexual activity may have a bearing as it does in nasal conditions. Of course, primary and secondary infection also markedly thickens the mucosa; especially is the venous plexus engorged and the lymph oid tissue multiplied. Another striking anatomic feature is the glands and the many mucus-containing goblet-cells. The anatomy is such that should the nasal outlet be interfered with a mucocele of the nasolacrimal duct and the lacrimal sac could readily follow. In view of the foregoing one wonders whether the lacrimal sac and the nasolacrimal duct are merely conveyors of fluid (tears) or whether an additional function should be ascribed. THE EXTRAMURAL RELATIONS The etiological connection between affections of the nasolacrimal passageways, the nasal fossae and the paranasal sinuses is established beyond perad venture. This does not minimize the important ana- tomic and clinical connections between the efferent lacrimal passage- way sand the conjunctival culdesac. de Schweinitz says: "Although it might seem natural that conjunctivitis, and especially purulent conjunctivitis, should cause lacrimal disease, this is by no means frequently the case." 1 Kuhnt placed the nasal and paranasal origin of disease of the nasolacrimal passageways as high as 93.7 per cent. Others consider this too high. All, however, agree that the nasal cavity and its ancillary structures are fruitful fields from which disease spreads to the nasolacrimal passageways. Therefore, a brief consideration of the underlying anatomy is in order. A. THE PARANASAL SINUSES The Newborn and Child. At birth the nasolacrimal duct lies approx- imately 2 mm. directly in front of and from 1}^ to 2 mm. medial to the ventral end of the maxillary sinus. By the eighteenth month the distance intervening between the maxillary sinus and the nasolac- rimal duct is reduced for a limited segment of the duct to an intimacy not unlike that in the adult. Later, when the infraorbital recess as- sumes larger proportions, the nasolacrimal duct and the maxillary sinus come into intimate relationship for a considerable distance. Of 1 George E. de Schweinitz, Diseases of the Eye, 8th edition, page 569, 1916. Clinical Anatomy of the Efferent Lacrimal Passageways 639 the ethmoidal cells, those developing from the frontal recess are nearest the lacrimal sac at birth. Topographic relationship is, how- ever, not intimate at this time. Even at two years as much as 5 mm. intervenes between the lacrimal sac and the nearest ethmoidal cell, save in precocious development, when intimate relationships are established very early. In the sixth year the upper segment of the nasolacrimal duct and the maxillary sinus are intimately related, and the anterior ethmoidal cells (frontal and infundibular) have pneu- matized the region formerly existing between the lacrimal sac and the frontal recess. Even the rudimentary frontal sinus may have close relationships at an early time. After the eighth year the anatomic relationships between the paranasal sinuses and the nasolacrimal passageways are in essence those of the adult. The Adult. The frontal and maxillary sinuses and the anterior group of ethmoidal cells need to be mentioned in this connection, and of these the latter are of special importance. Even the posterior ethmoidal cells when they pneumatize extensively forward into the middle nasal concha (conchal cells) may have a bearing in this con- nection. Very commonly two or more ethmoidal cells which develop from the frontal recess and the ethmoidal infundibulum come into very intimate relationship with the dorsal and medial aspects of the lacri- mal sac. Indeed, at times the entire lacrimal fossa and the upper part of the nasolacrimal canal are pneumatized by ethmoidal cells, variously related to the lacrimal sac and the upper part of the nasolacrimal duct. These ethmoidal cells for the most part arise from the ethmoidal infundibulum and the frontal recess and extend into the agger nasi, the uncinate process, the frontal process of the maxilla, and the lacrimal bone. While ethmoidal cells most frequently are located medial and dorsal to the lacrimal sac and the upper part of the naso- lacrimal duct, they also are found cap-like over the cupola of the lacrimal sac and occasionally develop lateroventrally covering the lacrimal sac at the medial palpebral commissure. The expansion of the ethmoidal cells (anterior or posterior) into the middle nasal concha also is a factor. These readily become the seat of a mucocele, pyocele, etc. The almost constant extension of ethmoidal cells from the frontal recess and the ethmoidal infundibulum on the nasal side of the lacrimal sac are of practical importance since dacryocystorhinostomy is prac- tised in this location. Of course, when the nasolacrimal duct is 640 J. PARSONS SCHAEFFER operated on in its lower third, the ethmoidal cells in question are avoided. The osseous party walls between the lacrimal sac and the upper segment of the nasolacrimal duct and the ethmoidal cells are at best reduced to extremely thin and delicate lamellae. Not infrequently the osseous partitions are partly or wholly defective whereby the mucoperiosteal layers of the related parts become contiguous. The nasolacrimal duct courses in the osseous nasolacrimal canal, Dvctas nasofrontalis I ltifiLti4tib.af frontal sums/ lnfuidAulu.il gtfiHteielalt Aaoer nasi cell.... ...\ ff *Hr*Mi^,.l.-- ~-.*r\ (Sinua prclariialis, '1 (ktuan dacha n Jtfcesses .-'' Fig. 7. A dissection of the lateral nasal wall with especial reference to the nasolacrimal duct, the lacrimal sac (indicated by dotted outline, in white), the agger nasi cell, and the prelacrimal recess of the sinus maxillaris. (Schaeffer: The Nose and Olfactory Organ.) located in the nasal wall of the maxillary sinus. Almost constantly this wall of the maxillary sinus is pushed into a bold, mound-like relief by the nasolacrimal canal and its contained duct. Another very important relationship of the maxillary sinus is the forward and cephalic expansion of the sinus in the formation of the prelacrimal or infraorbital recess. This recess is often of conspicuous size and hol- lows out the osseous boundary on the dorsal and nasal side of the lacrimal sac and more frequently of the nasolacrimal duct. Unless Clinical Anatomy of the Efferent Lacrimal Passageways 641 one bears this expansion of the maxillary sinus in mind in surgical endonasal procedures, the sinus is readily opened into instead of the osseous nasolacrimal canal and the membranous duct. Where the recess is very extensive, opening into it may be unavoidable. As elsewhere, the osseous party walls, not infrequently, are extremely thin, even to the point of dehiscences. The frontal sinus usually does not bear an intimate relationship to the lacrimal sac and the nasolacrimal duct. However, when the pneumatization extends into the nasal bone, the frontal process of the maxilla and the lacrimal bone, beyond the confines of the suture line separating these bones from the frontal, the frontal sinus bears a direct and at times a very intimate relationship to the lacrimal sac and the fossa which lodges it. That is, the frontal sinus extends into the walls of the lacrimal fossa. The osseous partition between the frontal sinus and the lacrimal sac is, as a rule, of considerable thickness. However, it may be reduced to a papery delicacy or be defective. The paranasal sinuses, especially the anterior ethmoidal (frontal and infundibular), may develop to such an extent and in such direc- tion as to encroach upon the lacrimal sac and the upper segment of the nasolacrimal duct and mechanically affect their lumen. If, how- ever, the enlargement of the ethmoidal cells is wholly on the dorsal and medial aspects of the lacrimal sac the latter is crowded merely ventrally and laterally, since there is no bone to prevent bulging in this direction. The nasolacrimal duct may be profoundly influenced by the ethmoidal cells, the maxillary sinus and the conchal cells, since it is imprisoned in an osseous canal and is readily pinched by pressure or by cells pneumatizing its walls. Again, the lacrimal sac and the nasolacrimal duct may be encroached upon by the paranasal sinuses actually invading the walls of the lacrimal fossa and the nasolacrimal canal. The degree of this encroachment is variable and depends upon the number of cells differentiated, the direction of growth and the size attained. While the intimate topographic relations of the paranasal sinuses and the nasolacrimal passageways usually are of importance only in diseased states, the fact remains that occasionally in healthy cells and sinuses the encroachment on the lacrimal sac and the ocular end of the nasolacrimal duct is such as to mechanically obstruct to a greater or less degree the lumen of the passageways. The incidence of nasal and paranasal disease is greater than that of the efferent lacrimal passageways. However, the direct or indirect transference of chronic disease from the paranasal sinuses to the tear 41 642 J. PARSONS SCHAEFFER passageways is well established clinically. Apart from the intimate topographic relationships already referred to there are other contrib- uting factors. The bony party walls frequently are extremely thin or web-like. Again, they may be fenestrated, or single, large con- genital dehiscences may be encountered. The venous plexuses of the mucosa of the nasal fossa, the paranasal sinuses and the lacrimal sac and the nasolacrimal duct freely communicate. The lymphatic net- works of the parts also connect up, and where the osseous party wall is fenestrated or defective, the abundant tissue spaces are in direct relation. The venous plexuses of the nasolacrimal passageways con- nect with the facial, infraorbital and ophthalmic veins and Zucker- kandl has described a lacrimonasal vein which perforates the lacrimal bone and connects with a goodly sized vessel emerging from the sub- mucosal venous plexus of the anterior ethmoidal cells. These ana- tomic features explain the spread of infection from the nasal fossa and the paranasal sinuses to the nasolacrimal passageways and vice versa. Contiguous tissue spaces and planes of tissue may be involved in diseased states. The blood and lymph vascular systems also are factors. Thin, bony party walls may be perforated and pus foci established between the ethmoidal cells and the lacrimal sac, between the lacrimal sac and the lacrimal fossa, and between the lacrimal sac and the skin, the latter frequently resulting in the formation of fistulas. Again, the party walls may break down entirely and an empyema of ethmoidal cells directly transferred to the lacrimal sac and duct. The opposite also occurs, whereby ethmoidal cell and maxillary sinus suppuration is secondary to diseased states of the efferent lacrimal passageways. B. THE NASOLACRIMAL OSTIUM AND THE INFERIOR NASAL MEATUS The nasolacrimal ostium or aperture in the inferior nasal meatus may, from the clinical viewpoint, be divided into five types: (1) those that fail of canalization, that is, the lacrimonasal membrane remains intact; (2) those of microscopic size, therefore wholly inadequate for the function intended; (3) those located at the highest point of the inferior nasal meatus and unguarded by a valve-like fold of mucous membrane and because of complete osseous walls are wide-mouthed and stand permanently open; (4) those located in the mucous mem- brane of the lateral wall of the inferior nasal meatus some distance below the attached border of the inferior nasal concha and guarded by a valve of mucous membrane which is both anatomically and Clinical Anatomy of the Efferent Lacrimal Passageways 643 physiologically adequate and (5) those located as above in the mucous membrane of the lateral wall of the inferior nasal meatus and have a valve of mucous membrane, but which from the viewpoint of physiol- ogy is inadequate. It is certain that many children are born with atresia of the nasal end of the nasolacrimal duct, owing to an intact or imperforate lacri- monasal membrane. It also is equally certain that a goodly number a b Fig. 8. a, Type of nasolacrimal ostium located in the mucous membrane of the lateral wall of the inferior nasal meatus considerably below the highest point of the latter. Apertures in this position and of this nature are readily influenced by intranasal conditions. Note the valve-like folds guarding the slit-like orifice. Adult, b, Type of nasolacrimal ostium located at the highest point of the inferior nasal meatus, supported by an osseous ring and standing permanently open, unguarded by a mucosal valve. Adult. of these persistent lacrimonasal membranes become attenuated and rupture spontaneously during the early weeks or months of infantile life. Indeed, at times it occurs much later. Of course, where the lacrimonasal membrane as such never formed; that is, where a goodly amount of connective tissue (of mesenchymal origin) persists between the epithelium of the nasolacrimal duct and the mucous membrane of the inferior nasal meatus, the barrier may be too thick for spon- 644 J. PARSONS SCHAEFFER taneous rupture and surgical procedures often are necessary. This also is true in some instances of typical lacrimonasal membranes which are relatively thin, but for some reason or other do not "give way." 1 Again, epithelial debris may act as an occluding plug. Moreover, there is some ground for believing that previously established lacrimo- nasal communications occasionally become occluded secondarily by epithelial proliferation. Analogous processes occur elsewhere in the body; e.g., the duodenum and the nares. The nasolacrimal ostium when of microscopic size usually requires surgical attention. The small aperture may be the result of inade- quate canalization or undue encroachment of the surrounding bone as it ossifies around the early nasolacrimal duct in the formation of the nasolacrimal canal. Not infrequently these small nasolacrimal ostia are located at the highest point of the inferior nasal meatus. Again, they may be located at a lower level in the mucosa of the lateral wall of the meatus. There can be no doubt that the connection of the nasolacrimal duct with the inferior nasal meatus serves as a means whereby infection of the nasal fossa can extend into the nasolacrimal apparatus. Obvi- ously the type of nasolacrimal ostium influences the incidence of occurrence of such extension and when once established the prognosis of speedy or delayed cure. When the nasolacrimal ostium is located high and supported by an osseous ring, causing it to stand widely and permanently open and unguarded by a valve of mucous membrane, it is possible for infectious air and fluids to pass into the naso- lacrimal duct and from there into the lacrimal sac. Blowing of the nose in these cases readily drives particles of foreign material through the open and unguarded ostium into the duct and the sac beyond. Tobacco snuff has been known to ascend to the lacrimal puncta and cigar and cigarette smoke to make its escape from these apertures on the free border of the eyelids. The writer observed in a patient with a depressed fracture of the ventral or facial wall of the maxilla, hemor- rhage from both lacrimal puncta. The nasolacrimal canal and the contained duct in the medial or nasal wall of the maxilla must have been injured. Fein reports a case of air escaping from the lacrimal puncta in which the nasolacrimal duct was injured in perforating the 1 For an interesting and valuable clinical paper see William Zentmayer, Im- perf oration of the Lacrimonasal Duct in the Newborn and its Clinical Manifesta- tions, Jour. Amer, Med. Assoc., vol. li, 1908. Clinical Anatomy of the Efferent Lacrimal Passageways 645 maxillary sinus. It also has been observed in some cases of nose bleeding that blood escapes from the lacrimal puncta. The same regurgitation of air and fluids from the inferior nasal meatus into the nasolacrimal duct may be argued when the ostium lacrimale is located in the mucosa of the lateral wall of the inferior meatus and has an anatomic valve but which is physiologically inade- quate or insufficient. There is, however, a basic difference, since ostia in this position are not supported by osseous boundaries ; more- over, the nasal end of the nasolacrimal duct courses for some distance in the nasal mucosa. Increased intranasal pressure would tend to Fig. 9. A section through the nasolacrimal ostium. Particularly note the cavernous or erectile character of the mucous membrane forming it and that it is not unlike the erectile tissue of the inferior concha adjacent to it. collapse not only the nasolacrimal aperture, but the nasal end of the membranous duct as well, while the cases in which the nasolacrimal aperture is supported by bone and no membranous segment of the duct exists, would not be similarly influenced. In such cases where the fold of mucous membrane at the outlet of the nasolacrimal duct is redundant, it not only may serve as an ana- tomic valve, but from the physiologic point of view be sufficient to prevent the regurgitation or passage of air and fluid from the nose into the nasolacrimal duct. It also may, to some degree, serve as a barrier to the extension of diseased processes from the nose to the nasolacrimal 646 J. PARSONS SCHAEFFER apparatus. However, disease processes affecting the mucosa of the nose may extend into the nasolacrimal duct and sac despite the type of ostium, owing to the continuity of the mucous membranes, tissue spaces, etc. It is but necessary to recall the location of the nasolacrimal ostium to comprehend why the aperture may be occluded by definite me- chanical and pathologic states of the nose. Here again the type of ostium plays a conspicuous role. Hypertrophy of the inferior nasal concha may wholly or partially occlude the opening; the type sup- ported by an osseous ring being less influenced than the one located in the mucous membrane of the lateral nasal wall and without bony support. Periostitis would affect the open-mouthed type of ostium and the duct in the neighborhood, but would not influence the actual ostium if located in the mucous membrane of the lateral wall some distance below the attached border of the inferior concha. Tumors, polypi, dental cysts, synechia?, rhinoscleroma, etc., etc., readily influ- ence the efficiency of the nasal outlet of the nasolacrimal duct. It also is important to recall that the mucous membrane of the inferior nasal concha and the related lateral nasal wall and the ostium of the nasolacrimal duct frequently is of an erectile character. A mucosa of this sort is readily influenced reflexly and directly by dis- eased states. DISCUSSION The origin and development of the efferent lacrimal passageways point the way to a better understanding of the congenital variations and defects. A knowledge of the developmental history and poten- tialities is a distinct aid in deciding upon the course of the treatment in the several types of congenitally atypical ducts. Fortunately the development of the efferent lacrimal or naso- lacrimal passageways (lacrimal ducts, lacrimal sac, nasolacrimal duct) usually proceeds along methodical rather than fortuitous lines. Despite the general truth of the foregoing it does not necessarily mean a constant and unvarying anatomy in the adult; variations in essen- tial details are not uncommon. The more important variations are subject to grouping into normal anatomic types and it is the thought of anatomic types arid anomalies rather than the idea of an unvarying typical anatomy and anomalies that should be kept in mind when considering the applied or clinical anatomy of the efferent tear ducts. There can be no doubt that the important anatomic types or de- partures from the so-called typical have a bearing in disease, prog- Clinical Anatomy of the Efferent Lacrimal Passageways 647 nosis and treatment. Once infected arxd other factors being equal, it would appear established from an anatomic point of view that the lacrimal sac and the nasolacrimal duct free of mucosal ledges, valve- a b Fig. 10. a, A nasolacrimal duct (adult) with an unusually large, blindly ending diverticulum; b, a transaction of an adult nasolacrimal duct in the region of a goodly sized diverticulum. like formations and blindly ending diverticula; moreover, with a large open-mouthed and unobstructed connection with the inferior nasal meatus would give rise to less severe symptoms and yield more 648 J. PARSONS SCHAEFFER readily and promptly to treatment; while the passageways with irregular walls, mucosal ledges and valves, diverticula of various degrees and an inadequate nasal communication would give rise to maximum symptoms, resist treatment, enter the stage of chronicity and, in all likelihood, require surgical interference. Granting the same type of infection and degree of involvement, the prognosis for a speedy and permanent cure in the two types of the efferent lacrimal apparatus is not the same. Not all of the anatomic factors mentioned neces- sarily need apply in one patient. The prognosis may rest entirely in the adequacy or inadequacy of the nasolacrimal ostium in the inferior nasal meatus as a drainage aperture. Again, diverticula alone may be the factor or the junction of the lacrimal sac with the nasolacrimal duct may be congenitally of extremely small size, et cetera. The extension of disease processes from the nasal fossa and the paranasal sinuses to the efferent lacrimal passageways is of common occurrence and generally recognized. This is in keeping with the intimate relational anatomy. The incidence of nasal and paranasal disease, however, is greater than secondary disease of the efferent lacrimal apparatus. The extension doubtless is dependent upon the nature, severity and duration of the pathologic processes within the nose and paranasal sinuses, and the degree of intimacy of the topo- graphic interrelations of the several parts (see the nasolacrimal ostium and the paranasal sinuses, etc., referred to before). Of course, minor involvement of the efferent lacrimal channels, secondary to patho- logic states within the nasal fossa and the related sinuses may go unrecognized. For example, epiphora may be caused by a mild infection of some portion of the mucosa of the efferent lacrimal channels resulting in congestion of the venous plexus of the lacrimal sac and the nasolacrimal duct and a marked lessening of the lumen. It is difficult to decide in some cases whether the overflow of tears is due to an overproduction or to an inadequate removal. Probably both are factors, since the nasal state may reflexly stimulate the lacrimal gland to greater activity and affect the lumen of the efferent system of ducts by bringing about hyperactivity of the sphincter muscle about the vertical segment of the lacrimal ducts and a reflex engorgement of the venous plexus in the mucosa of the sac and main duct. However, it is well to remember that epiphora is frequently caused reflexly by diseased foci elsewhere and by conditions other than obstruction of the efferent lacrimal channels. Operative pro- Clinical Anatomy of the Efferent Lacrimal Passageways 649 Fig. 11. Reconstruction of the naso- lacrimal passageways of an adult, aged sixty years. Note the regularity of the nasolacrimal duct and the gradual mergence of the lacrimal sac into the nasolacrimal duct at the constriction of the isthmus. X 3.2. Abbrevia- tions as in Fig. 12. (Schaeffer: The Nose and Olfactory Organ.) Fig. 12. Reconstruction of the nasolacrimal passageways of an adult, aged sixty-five years. Especially note the irregularity and diverticula of the nasolacrimal duct. The inset shows the details of the side-to-side union of the lacrimal sac and the nasolacrimal duct; moreover, illustrates the large bud-like divertic- ulum from the nasolacrimal duct. X 3.2. SI, Saccus lacrimalis; Dlv, ductus lacrimalis verticalis; Dlh, ductus lacri- malis horizon talis; Die, ductus lacri- malis communis; Dnl, ductus naso- lacrimalis; Mni, meatus nasi inferior; Div'lm, diverticulum of the nasolacri- mal duct; Jc, junction channel be- tween the lacrimal sac and the naso- lacrimal duct. 650 J. PARSONS SCHAEFFEK cedures should be held in abeyance until the case is studied from every angle. Congenital and acquired strictures, imperforations and other con- ditions are encountered and the use of the lacrimal probe may be indicated. 1 The lacrimal puncta may need adjustment or enlarge- ment. An endonasal operation upon the nasolacrimal duct or the lacrimal sac may be deemed advisable, the type of operation being dependent upon the kind and position of the obstruction. The only alternative may be the extirpation of the lacrimal sac or even the lacrimal gland. However, the majority of cases of diseased efferent lacrimal passageways require less severe treatment, frequently medical rather than surgical. In directing treatment of the efferent lacrimal apparatus one should always recall a few salient points in the applied anatomy : The mucosa of the lacrimal sac and the naso- lacrimal duct between the tunica propria and the periosteum is richly supplied with a venous plexus not unlike an erectile tissue. This stratum is readily engorged directly or indirectly and the resulting swelling of the mucosa is at the expense of the lumen of the sac and duct, especially the latter, since it is encased in a bony canal. The passageways may be of the regular or irregular type. There is no actual stricture or absolute anatomic obliteration of the lumen. The use of stilettes and cannulas in these cases would appear to stimulate reflexly further engorgement, and the good to be derived to be but momentary. The anatomy and physiology are such that the treatment must be directed at the agent which stimulates the receptor neuron in the reflex arc, whether located in the mucosa of the lacrimal passageways, the related nose and paranasal sinuses, or at more remote points. Again, not infrequently the lumen of the lacrimal sac and the nasolacrimal duct is encroached upon and made irregular by mucosal ledges and partial or complete valves and diverticula. In infection, the swelling and engorgement of the mucosa in these cases result even in a greater obstruction to the flow of tears. As before there is no actual stricture or absolute anatomic obstruction of the lumen. 1 See S. Lewis Ziegler for valuable contributions to this subject. The Radical Treatment of Lacrimonasal Disease by Rapid Dilatation and Allied Measures, Jour. A. M. A., Vol. 54, 1910. Since submitting copy of this address the writer had the privilege of reading another communication by Dr. Ziegler, "A Further Note on Rapid Dilatation in the Radical Treatment of Lacrimonasal Disease," published in the volume of papers to be presented before the Section on Ophthal- mology of the American Medical Association, St. Louis, 1922. Clinical Anatomy of the Efferent Lacrimal Passageways 651 However, the obstruction may be absolute from the physiologic point of view. The advancing lacrimal probe or stilette, doubtless, would lacerate the mucosal ledges and valves and scrape the mucous mem- brane, which would aggravate conditions. One sees that an im- permeable stricture might result from this procedure, and in cases where the primary condition merely was a reduction of the lumen to a potential canal by a swollen and engorged mucosa; that is, a physiologic, but not an anatomic, occlusion. The majority of specimens show that the lacrimal sac and the nasolacrimal duct are in direct alignment and meet each other by a constriction or isthmus or imperceptibly passing one into the other. A probe is readily passed from the sac into the duct in these cases, unless the isthmus is unduly small. Occasionally the lacrimal sac and the lacrimal duct are not in alignment and are joined side by side, the lower end of the lacrimal sac extending below the highest point reached by the nasolacrimal duct. In such cases it would be utterly impossible to pass the lacri- mal probe from the sac into the duct and if undue force were used the instrument would be pushed through the lower blind end of the lacrimal sac and advance between the nasolacrimal duct and the osseous canal, again to be pushed back into the membranous pathway or to proceed by making a false ostium into the inferior nasal meatus. It appears certain that the lower aperture of the nasolacrimal duct is a factor in disease and treatment and that it should receive more attention clinically. It may invite infection of the efferent lacrimal apparatus. Again, in a diseased lacrimal duct and sac, the naso- lacrimal ostium may be wholly inadequate as a drainage apparatus. Frequently the anatomy is such that a simple operation would result in adequate drainage of the efferent tear ducts. Even troublesome and unexplained epiphora may be caused by a congenitally inade- quate type of ostium or aperture. Heretofore the surgeon did not know what anatomic conformation of the efferent lacrimal passageways confronted him in a specific case. Now that roentgenographic study has been extended to in- clude the efferent lacrimal passageways in the living body, it appears certain that the future treatment and surgery of these structures will be advanced. I now return to my original thesis the anatomic type and the variations in the relational anatomy have an important bearing in disease, treatment and prognosis. THE FACTS AND THEORIES OF COLOR VISION PROF. LEONARD THOMPSON TROLAND Harvard University Cambridge, Mass. I. INTRODUCTION Guessing at nature's secrets has always been a favorite amusement of the human mind, but in no department of thought has this form of diversion been so wantonly pursued as in the theory of color vision. Only in the domain of metaphysics have the guesses been more wild or untamed by the facts. I cannot hope in the brief time which has been allotted to me to review the multitudinous speculations which have appeared regarding the basis of color vision, and it would be impossible also to discuss in detail the relations existing between even one of these speculations and all of the facts in the case. I shall, therefore, confine myself to a more general theme, mentioning particu- lar theories or facts merely by way of illustration. This theme will be to outline the requirements which must be satisfied by a really accept- able hypothesis, one which will not be merely a wild, unbridled specu- lation, but which will seem at home in the company of all of the facts. The study of color vision leads one immediately into three seemingly separate domains of scientific thought, those of physics, physiology and psychology. Color itself, apart from its stimulus, is now generally conceded by physicists, as well as by philosophers, to be psychologic in character. It is a reality of immediate experience or of the indi- vidual consciousness merely. In and for itself color must be studied by the methods of mental science since it proves impossible to identify color either with the wave-lengths of radiant energy or with physio- logic activities in the nervous system. However, it is very evident that the knowledge of color vision cannot stop where introspective psychology stops. Color would be color if we knew nothing of phy- siology or of physics, but it would not be vision. We must not only recognize the nature and relationships of our visual sensations in and among themselves, but we must understand how they are related psychophysically to the processes of the living nervous system and via 652 The Facts and Theories of Color Vision 653 these with the factors of the physical environment which surrounds the organism. Thus we are brought face to face with problems not only in psychology but in physiology and physics. The vast multitude of extant color theories have been propounded by thinkers within all three of the just mentioned domains of science as well as by others whose domains have not been scientific at all. Nearly every available psychologic, physiologic, or physical idea has been utilized. To explain the selectivity of the retinal response, recourse has been had to every known property of radiant energy. The mechanism of the retina itself has been conceived mechanically, chemically, and electrically. Neurologic conceptions of all sorts have been applied or invented. The optic nerve currents have been sub- divided or combined, in the course of conduction or at the brain, in a kaleidoscopic variety of hypothetic patterns. Within conscious- ness itself colors have been classified in many different ways. Nearly a hundred major attempts at an explanation of the phenomena of color vision have appeared in the nineteenth and twentieth centuries. Out of such a host of trials we might expect to find something besides errors. Our hopes, however, are so poorly fulfilled that it seems pertinent to consider briefly what Mrs. Ladd-Franklin has aptly called the theory of color theories. II. THE GENERAL FACTS OF COLOR VISION It will be generally conceded that the task of science is restricted to giving an account of what exists or what may reasonably be supposed to exist. If, therefore, we should assert that the function of a color theory is to explain the facts of color vision, we would be obliged to interpret this as meaning that the theory supplements the facts in the direction of a more complete account of the system which is under consideration. An hypothesis concerning the mechanism of color vision cannot legitimately be regarded as being merely a pedagogic or mnemonic device. However much it may assist us in teaching or in remembering the facts of our science, if we are to consider it seri- ously we must look upon it as a representation of some kind of reality. A scientific hypothesis is an attempt, so to speak, to project the facts beyond themselves, to reach out into the as yet undiscovered domain, to prophesy the facts of the future. In so far as an hypothesis is valid, in so far is it liable to become in time a fact and not a fancy. When we say that an hypothesis or a theory should explain the known facts, we merely mean that it should combine with these facts 654 LEONARD THOMPSON TROLAND in such a way as to produce a logically coherent account of things. The reason why we need to advance hypotheses lies exactly in the truth that in nearly every department of science the facts which we possess do not in themselves form a coherent logical system. How- ever, the more facts we have in any science the more coherent the science becomes, and consequently we believe that a complete under- standing of any reality will always yield such a logically satisfactory account. This is why we are justified in using our imaginations to fill in the gaps between the facts, even when these gaps are so large as to leave relatively little indication of the real underlying order which is involved. Our actual data in such a field of investigation as that of color vision are like scraps of a chopped-up picture puzzle, most of the pieces of which have been lost. However, enough may be given so that we have some chance of reconstructing the whole in imagina- tion. It must be realized, however, that the fewer the parts or the facts at hand, the lower is the probability that our reconstruction will be correct. These considerations should indicate to us clearly both the nature of our problem and the method which we must employ in its at- tempted solution. A theory of color vision is a picture of reality which must be set harmoniously in the frame of facts. In order to evaluate any such theory we must view it within this frame, and since the frame of facts is a definite thing and the possible pictures many and shifting, we shall do well to study briefly the former before we con- sider the latter in any detail. In outlining the facts which any theory of color vision must satisfy I shall divide them into two classes, as the general and the special facts respectively. The general facts comprise the established principles of physics, physiology, psychology and psychophysiology which inevitably bear upon the problem. The special facts consist of the more or less scattered data which have thus far been gathered in the immediate study of color vision itself. Let us first consider some of the more important of the general principles which are involved in the situation. These principles can be divided systematically into the physical, the psychologic and the psychophysical respectively. Under the first will be included not only the conceptions of physical optics but also those of physiology, since physiology can be classed as a special physical science dealing with the properties of particularly complex material structures called living organisms. The psychologic principles relate to experience or con- sciousness in itself, without reference to any supposed physiologic or The Facts and Theories of Color Vision 655 other physical foundations or correlatives which it may possess. The psychophysical principles, in turn, involve the relation between con- sciousness and the physical system. If we look first at the physical side of the problem we find that we have to deal in vision with a mechanism which in its general outlines is capable of being very specifically defined. This mechanism we may designate as that of visual response, while recognizing that the meaning which we shall assign to the term response in this connection is somewhat broader than that which is usually given to it. Visual response is one example of a general type of physical process known as propagation. Other examples of propagation are to be found in sound, in the conduction of electricity through a wire, or of water through pipes, etc. In each of these processes there is involved a chain of events depending one upon another in serial order, corresponding events, or events ultimately traceable to the same initial cause, being displaced successively both in space and in time. In the case of visual response the initial event may be conceived to lie in the emis- sion or the reflection of visible radiant energy from a physical object, while the final result may be laid in some adaptive adjustment of the organism to its environment, such as a movement of the eyes or of some other member of the body. Between such initial and final events, and binding them together causally, there lie a considerable number of intermediate stages. A schematic analysis of the response from beginning to end would reveal the following successive stages : (1) the object, (2) the visual stimulus, (3) the visual sense-organ process, (4) the retinal or visual-receptor process, (5) the optic nerve stimulation, (6) the optic nerve, or afferent nerve conduction, (7) the central or adjuster process, (8) the efferent nerve conduction, (9) the end-plate process, (10) the effector process, (11) the effect. All of these component processes are linked together as cause to effect, although at the same time each one possesses its own charac- teristics which make its description different from those of either its cause or its own effects. Thus, the retinal reaction is governed by the exact manner in which the radiation is incident upon the retina in forming the retinal image, and yet must be conceived to differ radically from the radiation itself. At the same time we must recognize that those links in the response chain which lie within the organism are ultimately just as physical as are those which lie outside of it, the entire system forming a continuous physical mechanism all of which is ultimately reducible to terms of such fundamental units 656 LEONARD THOMPSON TROLAND as electricity and energy. Nowhere within this complex physical apparatus'do we find, nor do we need to assume, the existence of such a thing as sensation, and hence as color. Let us consider briefly some of the known specific characteristics of these several stages in the visual response. The first stage, the visible object, consists of any congeries of electrons and protons constituting a physical body, some of the elec- trical particles in the surface of which are vibrating at frequencies lying between about 715 and 440 trillion oscillations per second. Such oscillations set up electromagnetic waves of lengths lying be- tween approximately 420 and 680 millimicrons which travel radially away from their sources at the rate of 186,000 miles a second. Before the advent of Einstein we used to believe that these waves were undula- tions in a medium called the ether, but now we are content to say simply that they are electromagnetic in character, which does not prevent them from being waves although they are seemingly deprived of anything in which to undulate. When such waves impinge upon the cornea they are refracted from their normally rectilinear path so that, after suffering further convergence in passing through the crys- talline lens, they come to a focus upon the retina to form a pattern roughly similar to that which they possessed at the object. Thus far we are carried very securely by our knowledge of physical optics and the anatomy of the eye, but here our knowledge comes abruptly to a chasm. The fourth stage, the retinal receptor process, is known to exist as a fact but its specific nature is as a fact unknown. Consequently this stage becomes a subject of hypothesis and speculation. Similar statements apply to the fifth stage, or the process by which the retinal excitation is transformed into a nerve impulse. When we come to the sixth stage, however, the conduction along the optic nerve fibers, we are in a somewhat better position. We can detect and accurately measure these nerve currents in animals by means of a galvanometer, and modern studies upon nerve processes in general lead us to very definite conceptions as to the physical nature of such processes. There is no reason to suppose that the human optic nerve currents form exceptions to these generally established principles. The nerve current, as we now conceive it, consists of a series of so-called "all-or- none" pulses, each of which involves a local alteration of the electric polarization and chemic permeability of the membrane surrounding the nerve cell. The Facts and Theories of Color Vision 657 We find that the seventh or central stage in the response propaga- tion has many representatives in the case of vision, since the transfer of visual nerve currents from sensory to motor channels may take place at a number of different brain levels, and a succession of synapses is involved in the transmission of the nerve impulses to the very highest centers in the cerebral cortex. Although we have very little first-hand information concerning the physical nature of the central processes, fairly safe inferences can be made regarding them from a combination of our knowledge of plain nerve trunk conduction, and conduction through entire reflex arcs. The differences between these two types of neural transfer have been properly assigned by Sher- rington to the synapse. The four efferent or motor stages in visual response are also quite diverse in separate instances. We must recognize in this connection, not only the motor adjustments of the eyes themselves, highly specific and delicate as these truly are, but also all adaptive movements of any part of the organism which are regulated through vision. So much for the general frame of physical or physiologic concep- tions into which our pictorial hypotheses of the color mechanism must fit. We must now consider briefly another aspect of the frame, the psychologic decorations with which it is embellished, and the manner in which they are associated psychophysically with its more material aspects. The subject-matter of modern psychology is consciousness and its relations to the physical world, and consciousness for the modern psychologist is not some sort of subtle relation between a subject and an object, but consists simply in the concrete experiences of human individuals, taken and described exactly as they are found without amplification by the methods of speculative inference and hypothesis which characterize physical thought. Our immediate visual experi- ences, objective-seeming though they are, comprise the best possible exemplification of what modern psychology means by consciousness. Color, whether chromatic or achromatic, is a psychical element and a psychical element only. It cannot be identified in any respect with its stimulus, radiant energy. The stimulus, according to the phy- sicist, is endowed with wave-length, amplitude and spectral com- plexity, and it has no color, but the color itself is self-evidently neither long nor wavy, has no amplitude, and is perfectly simple. Having thus identified color as an essential component of the visual consciousness, we must next consider the manner in which this con- sciousness is related to visual response. There are two apparent 42 658 LEONARD THOMPSON TROLAND ways in which we may conceive these two separately denned systems to be associated. One of these ways involves the question as to the place of consciousness in the universe at large, as to the manner in which the physical and the psychologic facts fit together to form a single huge mosaic. This is clearly a philosophic and metaphysical question. The other way is simply that of association through mathe- matic or logically formal laws. Such laws would tell us how to predict the visual consciousness from a knowledge of the visual response, or vice versa, since they would exhibit one of these systems as a function of the other, but they would in themselves offer no explanation of the indicated interdependencies. The metaphysical account, indeed, is really an attempt to explain the psychophysical laws which are established by the empirical methods of laboratory psychology. Psychophysiology has only begun its task of determining the laws which link the visual consciousness with the mechanism of visual response. However, enough progress has been made to indicate in a skeletal way the principal facts which probably enter into the rela- tionship. It seems quite evident in the first place that although our visual experiences seem to represent the first, or object, stage in the response, their direct determination lies exclusively with the highest central stage or the cerebrocortical activities. Only via the depen- dency of the central stages upon prior and more afferent stages is any relationship established between visual experience and the object or stimulus which initiates the response. If we could reproduce the central activities by artificial means and could then eliminate the entire afferent system, consciousness would remain exactly as before just as vivid and exactly as objective-seeming. Ultimate visual psychophysics, then, would involve nothing but consciousness and the brain process, the remainder of the system being purely physiologic or physical. Unfortunately, however, we are still very far from achieving such an ultimate knowledge and we are, therefore, forced to study, in the laboratory or clinic, the relations between the subject's consciousness and stages of the response which are, as a rule, more peripheral than the central activity. In all such cases we are clearly considering indirect or mediate psychophysical linkages, and we must realize that all such linkages are subject to physiologic disturbances. It is very probable that visual conscious- ness actually depends upon activities occurring in some of the very highest association areas of the cerebral cortex, so that even the estab- lishment of correlations between consciousness and the visual pro- The Facts and Theories of Color Vision 659 jection area processes does not provide us with direct psychophysical knowledge. The most extensively cultivated department of visual psychophysiology is that of visual sensation, which may be denned in terms of the relation of dependency obtaining between the visual consciousness and the first four stages in the response, terminating in the receptor process, but including the environmental forces which govern this process in part. Although it seems practically certain that the general facts of the psychophysical relationship are as we have described them above, we are nevertheless sadly lacking in exact information concerning the detailed nature of the psychophysical correlations. Consciousness itself is wide open for our examination, and introspective psychology is doing its best to give us a description of its contents. Because of the fact, however, that up to the present time our psychophysical investigations have been largely confined to indirect relationships between consciousness and the response activity, we are not in a position to formulate on empirical grounds the equations which con- nect mind directly with body. Hence the psychophysical connection is another free and fertile field in which to sow the seeds of scientific hypothesis. It is clear that the rational guesses which comprise a theory of color vision must be consistent with the general principles which we have just considered if they are to be regarded seriously. Any such theory must recognize the extreme complexity of the visual response system and must be prepared to specify the relationships supposed to exist between the elements in the theory and the known subdivisions of the response. Any theory of color vision must deal ^ separately with the data of consciousness and must specify a scheme by which the psy- chologic color elements are associated with definite factors in the response. Unless the color theorist thus envisages the actual system to which his speculations refer, he has small chance of producing a valid or even a useful sketch. III. THE SPECIAL FACTS OF COLOR VISION It appears that a theory or hypothesis of color vision may be regarded as an attempt to fill up the gaps which exist in our general knowledge of the psychophysical response mechanisms ; and in such a way as to explain or to harmonize with our special knowledge of visual psychophysiology. Having briefly reviewed the general facts, 660 LEONARD THOMPSON TROLAND we must now consider succinctly the special visual data, mostly relating to color sensation, which any theory must satisfy. The first set of special facts which we must recognize are concerned with the nature of color itself. The Colorimetry Committee of the Optical Society of America, in its forthcoming report, will recommend that the term color be used to designate not only visual sensations which manifest hue, such as red, green, blue, etc., but also the achro- matic sensations or grays which form a series between black and white. Colors in this sense comprise all possible visual experiences with the exception of the depth factor. Although each discrimin- able color is in itself perfectly simple, we find it possible to describe any color in terms of three attributes, technically known as hue, saturation, and brilliance. The achromatic colors, however, possess no hue and no saturation and are differentiated solely by their differ- ences in brilliance. The facts regarding visual sensation can be formulated in terms of relations between these three attributes of color and various factors of the response mechanism on the afferent side. We find that char- acteristic laws connect each of the three attributes with practically every variable which is involved in the response. Ordinarily we associate brilliance or apparent brightness with the intensity of the stimulus. We look upon hue as an index of wave-length and regard saturation as an indication of the purity or homogeneity of the radiant energy forming the stimulus. However, careful studies show that brilliance depends even more fundamentally upon wave-length than upon intensity, the so-called visibility curve expressing the nature of this dependence for daylight vision. It appears, moreover, that there are two visibility curves, one hold- ing for day vision and the other for night vision, and that these curves represent the responses of two different sets of retinal receptors, the cones and the rods, respectively. The facts which are summarized in the so-called duplicity or rod-cone theory, and which underlie such phenomena as that of Purkinje, must be accepted by any hypothesis of color vision. The relations between brilliance and the spectral constitution of the stimulus are explicable in terms of the two visi- bility functions and the simple principle of the additive combination of luminosities. Fechner's law, with its upper and lower deviations, provides us with a very accurate expression of the manner in which brilliance, regarded as a psychologic variable, depends upon the The Facts and Theories of Color Vision 661 intensity of the stimulus, this law representing not a simple linear, but a quasi-logarithmic relationship. The brilliance of a color, however, depends not merely upon the three fundamental characteristics of the stimulus, but upon the exact mode of incidence of the stimulus upon the retina, including also the condition of the retina and of the remainder of the visual mechanism at the given moment. Thus the brilliance resulting from a stimulus of fixed inherent character varies with its position in the retinal field, with its form, with its time of application and with the nature of other stimuli which are simultaneously active in outlying portions of the retinal area. Many of these relationships have been worked out quantitatively, but others are only known in a vague way and remain to be investigated in the future. All of them must be ex- plained by a completely satisfactory theory of color vision. When we pass from the consideration of brilliance or the achromatic factor in vision to the study of hue and saturation we encounter an even more complex system of relationships. The dependency of hue upon the wave-length of the stimulus, in case the latter is mono- chromatic or homogeneous, has been very definitely determined, but follows a mathematically complex law. Although hue is mainly an index of wave-length constitution, it is also a function of intensity, since at very high intensities all stimuli (of whatever constitution) tend to arouse only yellows or blues, these being of low saturation and passing over at extremely high intensities into a white. The depen- dency of hue as well as of saturation upon the composition of stimulus mixtures has been very thoroughly studied and the results are repre-? sented by the well-known color-mixture triangle. The fundamental fact that in normal vision all of the hues can be reproduced by appro- priately proportioned mixtures of three simple homogeneous spectral stimuli must be explained by any color theory which is to merit serious consideration. As part of this set of data we must recognize the importance of the complementary relationship between two or more stimuli, by virtue of which they combine in the production of a white. There appear to be an indefinitely large number of pairs of single wave-lengths in the physical spectrum which are capable of combining in the proper intensity ratios to yield this result, but it is of great interest that in the mid-region of the spectrum there is a range of stimuli which have no single complementaries but require the addition of at least two other wave-lengths to yield an achromatic sensation. 662 LEONARD THOMPSON TROLAND Although saturation is ordinarily regarded as an index of the purity or homogeneity of the stimulus, careful measurements show that it varies for different wave-lengths even when they are unadulterated; the mid-region of the spectrum, including the yellow and the yellow green, being much less saturated than the end regions, the blue and the red. As we have already seen, saturation also depends upon intensity, being reduced for all stimuli at extremely high intensities and for certain stimuli which act upon the retinal rods at very low intensities. Both hue and saturation depend, like brilliance, upon the mode of incidence of the stimulus upon the retina and upon the condi- tion of the latter. The dependency of the hue upon the position of the stimulus in the retinal field is summarized in our doctrine of color zones in the visual field which is of much importance in diagnostic technique. Saturation also varies in a parallel manner. The phenom- ena of color contrast are well known, although they have been studied quantitatively much less than could be desired. The time of action of a stimulus, with the correlated effects of retinal fatigue, influences in a very radical manner both the hue and the saturation which are evoked. In addition to dependencies in normal persons, illustrated by what we have just said, every theory of color vision must necessarily con- sider the astonishing way in which color experiences for given stimuli may differ in different individuals. We recognize now that color blindness is only a radical form of a variability which is always to some degree manifest. Not only do hue and saturation vary for given stimulus conditions, but the brilliance which, in our everyday attitudes, we regard as an infallible index of the stimulus intensity also shows radical discrepancies between different observers as indi- cated by departures of their visibility curves from one another. Clearly, it would be quite impossible for me to enumerate in this brief address all of the special facts of color vision. My purpose is merely to suggest to you as vividly as I can the extremely involved relationships which are resident in these facts, and thus to show you what a very difficult task it is to construct a really satisfactory hy- pothesis which will harmonize at once with these special facts and with the more general requirements laid down by physiology and by psychophysics. The Facts and Theories of Color Vision 663 IV. THE OLDER THEORIES OF COLOR VISION In the discussion of color theories all ideas appear to root back ultimately to the hypotheses of Young and of Hering. Both of these theories postulate the existence in the retinal receptors, or somewhere in the afferent section of the response, of three distinct sensitive sub- stances. However, one of these theories is a physicist's doctrine while the other is essentially a psychologist's creation. The Young- Helmholtz hypothesis starts with the stimulus and stops before it reaches consciousness. The Hering scheme, on the other hand, begins with an introspective analysis but becomes vague and unsatis- factory by the time it has been carried back to the stimulus. Physical thinkers are seemingly satisfied with the Young-Helmholtz scheme because they are sensation-blind. Psychologists, for their part, adhere faithfully to the Hering conception because they are stimulus- blind. Needless to say, theories which rest upon a defective recogni- tion of facts, either on the physical or the physiologic side, can scarcely lead to comprehensive explanations. The Ladd-Franklin hypothesis meets this situation by a well-bal- anced consideration of both the psychologic and the physical facts in the case. In Mrs. Franklin's theory the three substances become one substance with three specific reactivities. The resulting scheme not only lays due emphasis upon the facts of color-mixture which sub- stantiate the Young-Helmholtz hypothesis, and on the other hand upon the psychologic interrelations of the colors which provide the basis for the Hering theory, but fits better with each of the two sets of facts than did the original doctrines. Mrs. Franklin very cleverly crams two imposing arrays of facts into a single molecule, and thus seems to reduce the data of her science to an ideal logical explanation. As a pedagogic device nothing better than this could be desired, but it may legitimately be questioned whether this very simplicity of the Ladd- Franklin hypothesis does not constitute the principal argument against it, if we are seeking, as we have previously avowed, an actual portrayal of the missing links in the psychophysical mechanism of visual response. We have seen in our preliminary analysis of the general structure of visual response that the latter mechanism involves a plurality of superposed operations upon the uppermost of which only does color directly depend. All three of the best known color theories, those of Young and Helmholtz, of Hering, and of Ladd-Franklin, are con- 664 LEONARD THOMPSON TROLAND cerned primarily with the mechanisms of a single stage in the response, namely, those of the retinal receptors. Hering, it is true, endeavors to expand the scope of his theory by using the term Netzhaut to desig- nate the entire response mechanism from the retina to the brain, but this device does not liberate his theory from the difficulties which go with the simplicity of its assumptions. When we look at the problem in a realistic attitude we see that a theory which deals with only a single stage in the response has very little chance of explaining all of the facts of color vision, and moreover is not consistent with the general demands of the case. Although by far the greater number of the extant theories of color vision have dealt exclusively with the retinal process there have been in the past an appreciable number of attempts to subdivide the visual apparatus, and to hypothecate different mechanisms for the several stages. Theories of this type are known as zone theories because they break up the visual mechanism into separate zones. In the most primitive doctrines of this sort only two zones are considered, those corresponding with the retinal and the cerebro-cortical activities, respectively. A plausible suggestion for such a two-zone doctrine would obviously be to assign the mechanism of the Hering theory exclusively to the cortex and to reserve the Young-Helmholtz appara- tus for the retina, since, as we have seen, Hering starts with conscious- ness (which is directly correlated with the central stage) whereas the Young-Helmholtz scheme has been developed mainly with reference to stimuli. A view of this general character has been advocated by von Kries. Hering, it will be remembered, divides the psychologically primary colors into three pairs of antagonists : black versus white, red versus green, and yellow versus blue. These antagonistic pairs he associates psychophysically with similarly antagonistic processes of catabolism and anabolism in his three visual substances, respectively. He ex- plains a large number of special visual phenomena by means of these antagonistic interactions of the specified color mechanisms. The rela- tionships of complementaries, for example, are said to depend upon the balanced excitation of such mutually neutralizing processes, as do also the processes of simultaneous and successive contrast. If we take the cue from von Kries and place Hering's three substances, or their neurologic equivalents in the brain, we shall naturally look for the. explanation of these special particular facts in the central zone of visual response. It seems more probable that antagonistic rela- The Facts and Theories of Color Vision 665 tionships of this sort should exist in the nerve centers than that they should be found in the receptors, since the latter are essentially excitatory in their responses whereas in the centers we as often find inhibition as excitation. In other departments of sensation, for example in temperature sensibility, the facts demonstrate immedi- ately the central locus of the antagonistic interactions between simul- taneously operative processes. On the other hand, the three sub- stances of the Young-Helmholtz theory seem ideally fitted to operate within the receptor cells of the retina, since their reactions are con- ceived wholly in terms of excitation and may easily be regarded as instances of a purely physical process of molecular resonance. Although this dual zone hypothesis excludes any specific con- sideration of the conduction mechanism which links the retina with the cortex it nevertheless necessitates a set of intermediate assump- tions which state exactly how the Young-Helmholtz apparatus in the retina is linked up with the Hering mechanism in the brain. Naturally, we like to conceive of such relations as being of the simplest possible point to point character, but there seems to be no a priori reason why we should insist upon such forms of connection. If instead of supposing that the red sensitive substance in the retina is linked exclusively with the red producing elements of the cortex we associate the former with the yellow and white generating brain mechanisms, as well as with the red, we shall obtain a system which has a considerably enhanced capacity for dealing with the special facts of color vision. We shall be able to explain, for example, why it is that a pure spectral red stimulus degenerates into an almost perfect yellow as a result of continued fixation, or adaptation, and we shall be able to account for the differences in luminosity curves which exist between the two common forms of partial color blindness. Thus a combination of the Young-Helmholtz and Hering systems into a two zone hypothesis with a well-considered set of linkages between the two mechanisms should provide us with a theory having a very respectable explanatory power. Von Kries is by no means the only one among the earlier writers on color vision to suggest a zonal treatment of the visual mechanisms. The very interesting but little known theory of Bonders is explicitly of the zonal type. Bonders agrees that the retinal mechanism is as described by Young and Helmholtz, but he supposes that in the brain quite a different apparatus is functioning. This cerebral system consists of a single chemical substance which is capable of being split 666 LEONARD THOMPSON TROLAND along four different diametrical lines of cleavage, corresponding with the four psychologically primary hues, red, yellow, green and blue. Simultaneous cleavage along all possible lines yields the sensation of white or gray, while various mixed modes of cleavage result in colors of intermediate hues or saturation. The theory of Schenck, with its distinction between stimulus-receptors and sensation-stimulators, is also at least implicitly a zone doctrine. G. E. Miiller's edition of the Hering theory is an attempt to put the latter scheme into zonal form with a minimum of logical change, while McDougall's discussion of the Young-Helmholtz theory performs a similar service for the latter hypothesis. All of these views are subject to. the objection that they are more complex, involving more logically independent assumptions than their parent single zone hypotheses. However, the failure of the latter to satisfy all of the facts in the case indicates that an increased complexity of assumptions is essential in order to provide us with a really satisfactory conception of the mechanisms which are actually involved. V. SOME NEWER THEORIES OF COLOR VISION When we see clearly how manifold are the factors which our general knowledge of the visual mechanism inevitably imposes upon our consideration, we must realize definitely how futile must be the search for a simple but all comprehensive explanation of visual phenomena. In the domain of physics it has often proved possible to explain a highly complex array of facts by means of a single simple assumption. General considerations, however, make it highly probable that this possibility is limited to the inorganic realm. While we are committed to the view that organic or vital activities are essentially reducible to the concepts of physics or chemistry this very fact makes it inevit- able that living organisms should possess a most elaborate physical structure. Vitality is in essence nothing but intricacy and instability, and we should not be surprised if in biology true explanations should sometimes turn out to be more complicated than are the apparent facts. If we pursue this line of thought, we shall not only permit our visual theorists to distinguish definitely between the mechanisms which are operative in the retina and those which function in the brain but we shall sanction an even more detailed analysis of the hypothetical mechanisms into zones or stages of the response. On general grounds there appears to be no reason for supposing that the conduction The Facts and Theories of Color Vision 667 processes transpiring in the optic nerve fibers are identical, or cor- related point to point, with either the retinal excitations or the cere- bral processes. Accordingly we might take the further step of intro- ducing a conductional or intermediate zone in our theories, lying between the retina and the brain. This step has actually been taken in a recent very promising hypothesis which is due to the Norwegian psychologist, Harald K. Schjelderup, whose views are worthy of a somewhat detailed presentation. Schjelderup accepts the classification of colors made by Hering into six primaries, red, yellow, green and blue, black and white, and complies with the usual psychophysical principle in correlating these unit for unit with six corresponding physiologic elements in the brain. These six components in the central zone or stage, however, are con- ceived to be independently functional mechanisms, not associated to- gether into antagonistic pairs, as in Bering's formula, so that it is possible as in certain cases of color-blindness for any one of the cerebral components to drop out without involving others. The admitted antagonism between certain of the colors is laid to the dis- tinctive mechanism of another and more peripheral stage in the re- sponse mechanism which Schjelderup calls the Zwischenprozesse or " be- tween-process, " and which we may conceive to represent the nerve conduction between the retina and the brain. In this zone, Schjel- derup hypothecates the existence of paired processes corresponding exactly with the Hering scheme, so that any dropping out of factors here will involve at the least two unitary colors. The indi- vidual single color processes of this intermediate zone are conceived to be connected in a simple point to point manner with the cor- responding individual processes of the central zone. Tracing the process backward to the retina, Schjelderup assumes the existence in the receptor zone, of three photochemic substances possessing reactivities to light similar in a general way to those of the Hering hypothesis. One of these substances responds by undergoing oxidation to practically all of the visible wave-lengths of the spectrum. The other two substances, however, are oxidized by the longer waves but are reduced chemically by the shorter ones, the maxima of re- sponse either by oxidation or reduction for the two substances lying at different points in the spectrum, so that one reacts mainly to physical red and green whereas the other responds principally to the physical yellow and blue. The linkage between these retinal activities and those of the conduction zone is not, like that between 668 LEONARD THOMPSON TROLAND the latter and the cortical process, a simple point to point corres- pondence except in the case of the substance which responds to all of the wave-lengths of the spectrum. This latter substance is linked solely with the intermediate process, which is associated indirectly with the sensation of white. The long-wave oxidation process, however, is linked not only with the red sensation processes of higher zones, but also with those of white and yellow, while the corresponding reduction reaction is associated not merely with the green sensation but likewise with blue and black. The mid-spectral oxidation process, in turn, is connected with both green and yellow sensation processes, while the corresponding reduction activity evokes, through the intermediate mechanism, both red and blue. Although this system seems intricate, it is by no means difficult to apply to the facts and it is probably no more complex than they actually demand. Schjelderup demonstrates that the eight best known forms of color blindness can all be explained in terms of his hypothesis as conse- quences of the dropping out of one or more of the component activities in his three zone mechanism. If time permitted I would review for you certain other of the more modern theories of color vision. I would outline for you the recent elaborate speculations of John Joly, in which the modern quantum conception of radiation is brought to bear upon the theory of retinal reaction. I might also summarize the very suggestive speculations of R. A. Houstoun, which take the form of a zone theory. I might refer to the ideas of Barton and Browning, as well as to those of H. E. Ives, bearing upon the physics of retinal response. I might tell you something of Hecht's very suggestive researches regarding the chemistry of visual reactions. I might even refer to the fantastic imaginings of Edridge-Green. I must content myself, however, with the foregoing general comments, which I hope will not leave you altogether without some inkling as to what good a color theory may be, and how good some of the current theories probably are. THE PRODUCTION AND TRANSMISSION OF CERTAIN EYE DEFECTS 1 PROF. M. F. GUYER University of Wisconsin By way of introduction to the discussion of eye defects, I wish to review briefly some points in the embryologic development of the eye. Although it will prove to be an old story to ophthalmologists, I feel, nevertheless, that by so doing I can get before you most effec- tively the materials I have to present. Cleavage of the fertilized ovum, formation of the three fundamental germinal layers, and general embryogeny in the rabbit do not differ in any important ways from these same processes in other mammalian forms. Through the successive divisions which begin shortly after penetration of the ovum by the spermatozoon, a mulberry-like mass of cells enclosed by the zona radiata is built up. Some of the cells divide more rapidly than others, so that the resulting spherical mass comes to consist of a central group of larger, more granular cells surrounded by a superficial layer of smaller, clearer elements. Soon fluid appears between the central cells and the peripheral layer except at one side. As the liquid accumulates the entire mass becomes transformed into a fluid-filled vesicle consisting of a single layer of small transparent cells with the original central mass projecting from one side into the cavity. The outer layer, termed the trophoblast, is concerned only with the establishment of relations between the developing organism and the uterine mucosa. The inner mass is the part out of which the embryo is formed. At this stage the developing ovum is commonly termed the blastodermic vesicle or blastocyst. Seen from without, the germinal area appears as a circular disc at the upper pole of the blastocyst. Within this disc the cells are rapidly shaping up into the two primitive germinal layers ectoderm and entoderm. By unequal growth the disc soon becomes oval, then more or less pear-shaped. At its smaller end a median denser streak, formed by a keel-like thickening of the ectoderm, appears. This is 1 Illustrated by lantern-slides and living animals. 669 670 M. F. GUYER the so-called primitive streak. From each side of the primitive streak cells are budded off between ectoderm and entoderm to form the third germinal layer, the mesoderm. The mesoderm grows rapidly until it finally spreads around the entire wall of the blastocyst on the inside. Only that part confined to the germinal area, however, takes part in the formation of the embryo. Ultimately the mesoderm splits into two layers, one of which adheres to the ectoderm and, within the germinal disc, helps to form the body wall; the other adheres to the entoderm, and together, inside the embryo, they form the alimentary tract and its outgrowths. As the embryo takes form, a shallow median groove, the neural groove, appears on its surface in front of the primitive streak. This is the first indication of the central nervous system. The groove is formed by the upgrowth of ectodermal folds, the neural folds; by con- tinuation of the upgrowth it is converted into a deep furrow. Ulti- mately the neural folds fuse above in the mid-axial line and thus form a closed canal, the neural canal, which is the forerunner of the cerebro- spinal nervous system. The surface ectoderm soon overgrows the neural tube and becomes separated from it. The anterior end of the neural canal enlarges further to form the three primary brain-vesicles, the fore-brain, mid-brain, and hind-brain. Since it is from the fore-brain that the eyes originate, we shall con- fine our attention to this region only. It should be understood at the outset that there is a sharp distinction embryologically between the sensory part of the eye and the accessory parts. The sensory part of any sense-organ is always the first to arise in the embryo. The beginnings of the optic vesicles appear very early as lateral expansions of the fore-brain, even before the latter is closed dorsally. They are well established in the rabbit embryo by the ninth day. The cavities of the optic vesicles are widely confluent at first with the main cavity of the fore-brain, but as development proceeds this broad communica- tion is rapidly reduced by the downward growth of a ridge of tissue which soon distinctly marks off the optic vesicles from the fore-brain proper by narrowing the original communication to a tubular stalk, the optic stalk. Through this stalk, which is attached to the ventral portion of the fore-brain, the cavity of the latter is still continuous with the cavities of the optic vesicles. The optic vesicles extend laterally until they come in contact with the primitive epidermis or, at least, until separated from it by only a thin layer of connective tissue. Each optic vesicle then becomes The Production and Transmission of Certain Eye Defects 671 converted into a two-walled optic cup by a process of invagination which occurs at two places, the outer and the ventral surfaces. With the first, the formation of the crystalline lens is associated ; the second constitutes the so-called choroidal fissure. The inner wall of the optic cup, destined to become the sensory part of the retina, is much thicker than the outer wall, which will eventually become the pigment layer of the retina. These infoldings of the walls of the optic vesicles to form the optic cups commence on the tenth day in the rabbit and are completed by the fourteenth day. The crystalline lens is making its appearance simultaneously with these changes. In the formation of the choroidal fissure the infolding extends a certain distance along the optic stalk toward the brain, so that, near the eye, the optic stalk is a tube deeply grooved along the under sur- face by an infolding of its thick lower wall. It is along this groove, through the choroidal fissure, that the central artery of the retina gains admittance to the eye. This artery supplies the retina through- out life, but during the development of the eye it also supplies the vitreous body and the capsule of the growing lens. At first rather wide, the choroid fissure becomes more and more narrow until under normal conditions it closes altogether soon after the entrance of the arterial blood-vessel, but, as you well know, this fissure may remain unclosed, producing the not uncommon malformation known as coloboma. I stress this condition, at this point, because of its bearing upon some of the eye-anomalies I shall describe later. The lens first appears before the invagination of the primary optic vesicle, at the place where the epidermis passes over the surface of the latter. At first a slightly thickened disc, it soon invaginates to form a small pit, which by approximation of the edges becomes converted into the lens-vesicle. In the cavity of the lens of the rabbit and of man epithelial cells occur; but their significance is unknown. They ulti- mately degenerate and disappear. The lens-vesicle finally becomes constricted off from the surface-epidermis. As the optic cup invaginates it and the lens draw apart somewhat although they remain connected by protoplasmic strands. The inner wall of the lens- vesicle very early increases in thickness and encroaches on the lens-cavity but the outer wall remains thin. This thin anterior layer persists throughout life as a simple layer of cubical cells, the so-called lens-epithelium; but the cells of the pos- terior layer grow forward into the cavity as the lens-fibers. The central fibers are straight and long; the peripheral fibers, somewhat 672 M. F. GUYER curved, become shorter and shorter toward the surface of the lens, where they merge into columnar cells which are continuous with the anterior lens-epithelium. The cavity is gradually obliterated and the developing lens thus becomes a solid body. The part formed so far, however, constitutes only the core of the adult lens. Around this core (beneath the lens epithelium of the front surface of the organ) successive coats of lens-fibers arise, lying in layers one over another like the coats of an onion. These secondary fibers arise at the equator of the lens, and, increasing rapidly in length, spread over the ends of the first-formed fibers. In discussing the formation of the optic cup it has already been pointed out that the deeper parts of this structure become the retina. There is a thinner outer rim, however, marked off from the retinal region by the so-called or a serrata. This thinner portion, together with invading mesenchymatous tissue, is concerned in the formation of the iris and the ciliary body. The cornea and its associated structures are formed mainly by a layer of invading mesenchymatous tissue which surrounds the lens and separates it by a thin sheet from the epidermis. This sheet thickens by immigration of adjacent cells; then it separates into two layers, one of which, the pupillary membrane, remains thin and becomes very vascular, while the other becomes the early cornea; covered, however, by a corneal epithelium of ectodermal origin. Between the two layers the anterior chamber of the eye appears as a narrow fissure which becomes filled with fluid, the aqueous humor, and gradually increases in size with the appearance of the iris. In mammals, the pupil is closed at first by a thin vascular connective-tissue membrane (pupillary membrane) which also forms the anterior part of the tunica vasculosa lentis. The blood-vessels of this anterior part are continu- ous with those of the connective tissue at the margins of the optic cup. It will be noted from this that during its main period of develop- ment the lens of the fetal rabbit is surrounded by a membrane, the posterior part of which is supplied by the hyaloid artery, the anterior surface, by branches of the anterior ciliary arteries. Thus, by the thirteenth day, the lens is relatively large and is inclosed in a mem- brane richly supplied with blood-vessels. Before birth the blood- vessels of this membrane disappear and the membrane becomes (or merges with?) the lens-capsule. During its earlier formation the cavity of the optic cup is practically filled with the newly forming lens, but as development proceeds the The Production and Transmission of Certain Eye Defects 673 retinal layer of the cup draws away from the lens and thus forms the vitreous chamber. However, nuclear-free protoplasmic threads still connect the lens and the future retinal epithelium, and it is this net- work which apparently constitutes the formed elements of the vitreous body and the zonule of Zinn. There is also some invasion by mesen- chymatous tissue. The vitreous matrix rapidly increases in amount and becomes more and more watery. Later it is surrounded by a structureless membrane, the membrana hyaloidea. As noted earlier, the hyaloid artery, a branch of the retinal artery, extends across the vitreous chamber from the entrance of the optic stalk and not only supplies the tunica vasculosa of the lens but gives off branches to the vitreous body itself. Along with the hyaloid artery these disappear before birth, leaving the vitreous body of the adult destitute of blood- vessels. The old path of the hyaloid artery persists, however, as a canal filled with fluid, the canalis hyaloideus, or canal of Stilling. The optic nerves arise in connection with the original optic stalks. The interior of each stalk becomes converted into a glial network through which nerve-fibers having their origin from ganglion cells in the retina grow inward to the brain. The sclerotic and choroid coats respectively arise as two layers differentiated from the mass of mesenchyme which surrounds the optic cup. In front, the cornea is continuous with the sclerotic. The two are at first identical in structure ; it is only later that the cornea becomes transparent. In the rabbit the sclerotic coat becomes glistening white. It contains no cartilage. As we have seen, the retinal part of the eye has a very different origin embryologically from the outer and middle coats. It never becomes closely fused with them and may thus easily be detached. This is a condition which has direct bearing upon certain of the eye- anomalies we have found, characterized by detachment of the retina. A number of interesting facts about the developmental mechanics of the eye have come to light through the efforts of experimental embryologists. It will not be time misspent, therefore, if we digress a bit to review some of the more significant of these, which have bear- ings on our problems of eye-anomalies. For example, there has been much discussion regarding the way in which cyclopean defects occur. The condition, as you recall, ranges all the way from an aborted or a full-sized single, median eye, through eyes showing varying degrees of doubleness to two separate eyes that are merely unusually close together. While cyclopia has long been known to medical men as a 43 674 M. F. GUYER rather rare teratological phenomenon, experimental embryologists, and notably among them Stockard (1909), have developed chemical means by which, in certain species of fish, at least, cyclopia can be induced almost at will. Stockard has found that when the developing eggs of Fundulus heteroclitus, for instance, are subjected to the action of various magnesium salts dissolved in sea water, a large percentage of them as many as sixty in one hundred individuals develop a single median eye instead of the ordinary pair. He and others have also secured cyclopean monsters through the use of alcohol, ether, and certain other reagents. Stockard believes such results are due to an early developmental arrest, and he raises the question as to the original location of the optical elements in the embryonal central nervous system. Visibly, the eye-antecedents first appear as paired outgrowths from the primary fore-brain, but what is their earlier condition in the medullary tissues? Stockard (1913), partly as an inference from the way his cyclopean monsters are formed, but also from the outcome of certain operations he performed on embryos of one of the salamanders (Amblystoma punctatum), has come to the conclusion that the original material of the optic outgrowths is median and single, and that later it separates into two growth-regions which, developing in lateral directions, give rise to the primitive optic vesicles. He regards cyclopia as due to an arrest in eye-formation while the optic-elements are still in the median axis of the developing nervous system. This is contrary to the older view which located the antecedents of the eyes in lateral positions along the margins of the medullary plate, and held that the cyclopean defect was due to a coming-together and fusion of the incipient optic vesicles in the median plane. Stockard submitted the problem to experimental test by excising various parts of the medullary plate. He found that in the very young embryo, operations which removed the tissue of the median line prevented the development of eyes, while operations in which the removed tissue was confined to a lateral position though still involving the lateral fold, in nine of the eleven embryos employed, did not pre- vent the development of a perfect eye on the operated side as well as on the other side. His inference is, of course, that the material for both eyes was medially located at the time of operation. Lateral operations upon somewhat older embryos indicated that the eye- antecedents, in these later stages, were coming to occupy more lateral regions. Apparently the different degrees and kinds of cyclopean The Production and Transmission of Certain Eye Defects 675 defect depend in large measure upon the stage in development at which the arrest occurs. If cyclopia is complete, according to Stock- ard's theory, obviously the arrest must come before the median tissue has separated into two lateral components. Stockard's comparative study of cyclopean individuals in which the single eye grades all the way down from an eye of normal size to one of extremely minute dimensions confirms him in the belief that the earliest eye material occupies a median position. Differences of size are due to different degrees of completeness of the arrest. The "hour-glass" eye, or incom- plete cyclopia, he regards as due to a later or a less complete arrest. To secure cyclopia in Fundulus the embryo must be subjected to appropriate stimuli not later than the fifteen-hour stage of develop- ment. Since the optic vesicles do not appear under normal conditions until about thirty hours of development, it is apparent that important steps in their formation are in progress long before the two vesicles themselves become visible. Under the same experimental condition which causes cyclopia an entirely different type of eye-anomaly is common, in which one normal eye occurs in the usual lateral position while the eye of the opposite side may be wholly lacking or may show various degrees of imperfec- tion. Such an anomaly is termed monophthalmia asymmetrica, to distinguish it from the cyclopean type. Stockard is inclined to believe that in such cases some inhibitive influence becomes operative on the one center of growth after the future eye centers have begun to be localized in more or less lateral positions. He found some notable examples of this in chick embryos from eggs which had been exposed to alcohol fumes, as well as among his fish embryos. Under such methods of treatment not infrequently, also, both eyes would remain small and defective. Inasmuch as the same types of defect may be produced by any one of a number of different chemical or physical means, it is clear that the response in such cases is not specific with respect to a given agent. The widely differing agents apparently merely act similarly on the embryonic organism or on certain of its parts at critical stages in their development. Stockard's explanation of such defects as developmental arrests of particular structures at such critical periods is the most acceptable that has been offered. Child (1915, 1921) has shown in numerous studies extending over a period of twenty years or more, on a wide range of animals, that the developing embryo of bilaterally symmetric forms has a marked polarity along an antero-posterior axis, with different rates of metab- 676 M. F. GUYER olism at different points along the axis. In the early embryo the developing head-end always shows the highest rate of activity, the activity gradually diminishing toward the posterior end. Child has also shown that the more active a region is, the more susceptible it is to adverse chemical or physical influences. Since the rate of oxida- tion gradually diminishes along the gradient from the region of highest activity, he holds that differences in oxygen supply probably play a very important part in the local metabolic differences. In a recent experimental study on twins, double monsters and other deformities, and on interactions among embryonic organs, Stockard (1921) likewise attributes much importance to reduction of oxygen supply at critical stages of embryonal or organal development in causing arrests which result in the production of abnormalities. He shows that by temporarily lowering the temperature and thereby reducing the rate of oxidation, or by directly cutting off the supply of oxygen, the normal, continuous course of development of the embryo or of some embryonic part may be interrupted, with the result that characteristic suppressions or distortions may occur. Interruption of development during late cleavage, for example, results in the produc- tion of a considerable number of twins and double individuals. During the past twenty years or so experimental embryologists have also furnished us with various interesting and significant facts concerning the origin and development of the early crystalline lens. There has grown up through their efforts, in fact, a distinct "lens- problem." As we have already seen, under normal conditions the lens develops in very close association with the optic cup. The ques- tion arose, therefore, as to whether the lens, like the optic cup, was in a sense a self-differentiating structure, or whether it owed its occur- rence to a contact-stimulus exerted by the optic vesicle upon the over- lying ectoderm. The belief that the ectoderm was unable to give rise to a lens without the optic vesicle stimulus was experimentally sup- ported by the early work of Spemann (1901, 1903) and Herbst (1901). Spemann, for instance, showed that injury to the medullary plate of the frog (Rana fusca) might inhibit development of the optic cup, or, if the cup developed, might keep it from coming into contact with the ectoderm. In either event no lens formed. If, however, in spite of the injury, the cup or even a part of it reaches the epidermis, a lens forms at the point of contact. Lewis (1904, 1907a, 1907b) also, from a series of studies on other species of frog and on the salamander (Amblystoma) , concluded that lens would not arise from the normal The Production and Transmission of Certain Eye Defects 677 lens-forming region of the ectoderm without the contact-stimulus of the optic vesicle on the inner layer of the ectoderm. He showed, moreover, that a piece of ectoderm taken from another part of the body and grafted over the optic cup would form a lens, and also that the optic cup experimentally removed and engrafted under the epi- dermis of another region of the head would stimulate the development of a lens at any point of the surface-ectoderm with which it came in contact. Lewis found, furthermore, that the optic cup of one species of larval amphibian can probably even stimulate the formation of lens from the ectoderm of another species. Thus, optic vesicles of the frog, Rana sylvatica, were transplanted beneath the head-ectoderm of salamander embryos (Amblystoma). Lenses were later found associated with several of the transplanted eyes. He was not abso- lutely sure of the source of these lenses, but as the amblystoma embryos had normal lenses in their own eyes, uninfluenced by these secondary lenses, the inference was that formation of the latter had been initiated by the transplanted alien optic vesicles. Spemann reports having secured lens-formation in the ventro-abdominal ectoderm of Bom- binator, by transplanting it over the bared optic vesicle of Rana. From the various experiments just related it is obvious that epi- dermis that does not normally give rise to lens will differentiate into a lens if brought into contact with the optic vesicle. It would seem that there are no special cells predetermined to form lens. In his later papers, however, Spemann (1908, 1912) modifies his opinion somewhat on the basis of other experiments, concluding that while in some species of frogs lens cannot develop if the optic vesicle fails to make contact with the overlying epidermis, in at least one species the epidermis is capable of engendering lenses without such contact. King (1905) and Stockard (1910), furthermore, maintain on the basis of their experimental work that there can be independent origin and development of the crystalline lens. In his studies of the problem, Stockard (1910) substituted chemical means of experimentation for the mechanical operations employed by other investigators. The developing eggs of the minnow, Fundulus heteroclitus, were subjected for a time to the action of magnesium salts, alcohol or ether. Such treatment frequently prevented the outgrowth of the optic vesicles. In this way he secured embryos with the optic outgrowths as entirely lacking as in specimens with these parts cut out. This method has the advantage of avoiding the injury to the ectoderm which results from mechanical operation. In many of the 678 M. F. GUYER fish embryos with optic outgrowths thus suppressed by chemical means, he found developing crystalline lenses. He concluded, there- fore, that typical lenses may originate and develop from ectoderm without any direct stimulus from optic vesicle or cup. The possi- bility that optic vesicles may have arisen, stimulated the formation of lens and then degenerated, he believed, judging from the hundreds of Fundulus embryos he has studied, is entirely out of the question. Stockard (1910b) takes the ground, therefore, that while unques- tionably an optic vesicle or cup possesses power to induce lens-forma- tion from various regions of the ectoderm with which it may come in contact, there can also be independent formation of the lens. He believes that independent lens-forming power is present over the entire head, but that it diminishes from before backward until trunk- ectoderm is reached, which no longer possesses this capacity. He maintains that when, in eyeless larvae, free lenses occur, they usually arise near the anterior tip of the head. Posterior lenses as large as anterior ones may appear, but they occur less frequently. He thinks that the ectoderm of the head has a distinct tendency to form lens but that it exercises this capacity much more certainly and effectively when stimulated by optic vesicle or optic cup. In a later critique of the whole lens problem Werber (1918) argues that the original interpretation which regarded actual contact of optic outgrowth with the ectoderm as essential to lens formation is the correct one. In experiments based on extirpation of the optic vesicles or optic cups, for example, he maintains, from evidence he finds in his own studies (1916c), that fragmentation of the optic vesicle has occurred, so that bits of it sufficient to stimulate lens- formation have been left behind and he thinks that the same thing has probably happened in the operations of others. In teratological material, likewise, he points out, there is frequently much dissociation and shifting of tissues. He cites a case in his own experience in which the optic cup became profoundly dissociated and scattered so that fragments of it came into contact with the ectoderm of the head in many places, with, the result that lentoid bodies were formed in great numbers. In the face of the amount of evidence brought forward by Stockard, however, Werber's arguments against independent lens-formation are not very convincing, at least, as regards the cases of chemically induced monstrosities in Fundulus. The conclusion that ordinarily the lens arises only in response to a stimulus from the optic vesicle, The Production and Transmission of Certain Eye Defects 679 but that under certain conditions it can arise independently seems to be the most justifiable one in the present state of the evidence. Experiments have shown that lens-formation may also be initiated in or by later derivatives of the optic cup. Thus the epithelium of the iris can apparently undergo lens-formation, as can also the retinal cells. For example, when the lens is removed in certain amphibia, a new lens may be generated from the margin of the iris. Wachs (1914) found, moreover, that when he implanted a fragment of iris in the vitreous chamber of an eye deprived of its lens, the implanted fragment and the animal's own iris each formed a new lens. It has also been shown experimentally that retinal cells can both furnish the stimulus for lens-formation and respond to it, since retinal lentoids can be induced to form by experimental injury of the retina. It is an interesting fact that the mechanical effect of contact may play an important part in lens "regeneration." Fischel (1902), for example, removed the lens of a salamander and replaced it by a small spherical bit of potato. When this was large enough to fit the pupil, new lens-formation did not take place, but if the diameter of the foreign body was smaller than that of the pupil, an attempt toward new lens- formation occurred. More recently Fischel (1916) found, in larvae of the salamander (Salamandramaculosa),when the extirpated lens was transplanted under the skin of various parts of the head or trunk, that while the lens degenerated more or less and tended to be resorbed, the overlying skin underwent changes which eventually led to its becom- ing transparent and very similar to a cornea. Wachs (1914) had earlier obtained much the same result with a transplanted fragment of the optic cup containing both iris and retina. Such an effect, how- ever, is probably mechanical and not adaptive, as would appear at first sight, since Cole (1922) has shown that although tail-skin grafts over the eyes of frog-tadpoles become absorbed in such a manner as to tend to expose the eyes and restore vision, absorption also occurs in tail-skin grafts over small hemispheres of glass or celloidin. Cole regards such absorption, therefore, not as functional regulation, but as entirely a mechanical reaction to the tension caused by the curva- ture of the underlying object. As work in the field of immunology has progressed during the past quarter of 'a century it has become increasingly evident that the serologic reactions all have their broader biologic aspects. They must in last analysis be but special manifestations of the general processes which underlie all life phenomena. Unquestionably the 680 M. F. GUYER serologist has put important tools and ideas into the possession of the experimental biologist which may be utilized in new attacks upon certain fundamental biological problems. The hemolysins, for example, discovered by Bordet in 1895, are now known to be special members of a general class of substances termed cytotoxins or cytolysins. For just as alien red blood-cells lead to the production of specific hemolysins, so various other materials, as leukocytes, nervous tissues, spermatozoa and crystalline lens any foreign protein, in fact when injected into the blood-stream of an unrelated species, will cause the formation of lytic substances more or less specific for the antigen used in the immunizing process. All cytolytic sera so far studied have been found to be more or less hemo- lytic, and it is probable that none acts exclusively upon its own antigen. While a particular cytolytic serum may affect some other tissues, it attacks the special tissue used as antigen much more vigorously. Although presumably distinct from one another, the various classes of the so-called antibodies precipitins, agglutinins, bacteriolysins, cytolysins or cytotoxins, etc. seem to have many points of similarity, as, for instance, their method of origin, their reaction to heat, and, in some cases, their mode of operation. Chemically their natures are still unknown. Considerable evidence of their close association in some way with the euglobulin constituent of the blood is appearing in various recent researches. To the biologist viewing this fascinating field, many questions arise. If, for example, it is possible to originate in living organisms anti- bodies which will destroy particular tissue-elements, is it not possible to secure similar selective action on certain parts of the developing embryo? May not serologic methods enable us to make a new attack upon the long-standing problem of the inheritance of somatic modifications, or that of provoking specific modifications in the germ through direct operation of external agents? If a special serum can be developed which will single out and destroy a certain element of the adult, is it not possible that there is sufficient constitutional identity between the mature substance of such a part and one or the other of its material antecedents in the germ, that the latter may also be influenced specifically by the serum in question? If external influ- ences can be transmitted to the germ-cell, it is clear that in higher animals the one obvious means of conveyance is the blood. In an attempt to find answers to certain questions of this kind I and my research associate, Dr. E. A. Smith, began various experi- The Production and Transmission of Certain Eye Defects 681 ments some six years ago which we are still continuing. Among other things we undertook, by means of cytolysins, to produce antenatal effects in fetuses. Our main work in this direction has been on rabbits with fowl-serum immunized against rabbit-lens, although we have also experimented somewhat with mice and with guinea-pigs. I shall confine my discussion largely to certain eye-abnormalities we secured in fetal rabbits, and to the inheritance of such defects. In our first experiments 1 the lenses of newly killed young rabbits were pulped thoroughly in a mortar and diluted with normal salt solution. About four cubic centimeters of this emulsion was then injected intravenously or intraperitoneally into each of several fowls. Four or five weekly treatments with such lens-emulsions were given. A week or ten days after the last injection the blood-serum of the fowls was ready for use. The rabbits had been so bred as to have their young advanced to about the tenth day of pregnancy, since from the tenth to the thirteenth day seems to be a particularly impor- tant period in the development of the lens. As we saw in reviewing the embryology of the eye, the lens is then growing rapidly and is surrounded by a rich vascular network that later disappears. From four to seven cubic centimeters of the immunized fowl-serum were injected intravenously into the pregnant rabbits at intervals of two or three days for from ten days to two weeks. A number of the rabbits died from the treatment and many young were killed in utero. Of sixty-one surviving young from mothers thus treated, four had one or both eyes conspicuously defective and five others had eyes that were clearly abnormal. It is possible that still others were more or less affected, as we judged only by conditions easily visible. In some of the descendants of this stock, indeed, ophthalmologists who have examined the eyes more thoroughly have pointed out defects which we had overlooked, and occasionally rabbits, that in their earlier months passed for normal, have later manifested defects in the lens or in other parts of the eye. The commonest abnormality seen in both the original subjects and in their numerous descendants was partial or complete opacity of the lens (Plate I, Fig. 4), usually accompanied by reduction in size of the eye (Plate I, Fig. 2). In a few of our later strains in a different experi- ment, however, we have had several cases of enlargement of the eye, or buphthalmia (Plate I, Fig. 3) . Among the rabbits I brought with me for demonstration there is one of this type which I shall be glad 1 Guyer and Smith, 1918, 1920. 682 M. F. GUYER to have you examine. Other common defects which have appeared are cleft-iris, displacement of the lens, persistent hyaloid artery, bluish or silvery color instead of the characteristic pink of the albino eye, microphthalmia, and even almost complete disappearance of the eyeball. The cases of cleft-iris, or coloboma, range all the way from a narrow slit in the lower edge of the iris to a broad wedge- or U-shaped opening which amounts practically to the absence of the entire lower part of the iris. The cleft may be confined to the iris or it may extend back deeper into the eye. When one takes into account the early embryology of the eye, it is easy to see how such clefts result from failure of the choroidal fissure to close as it should do normally. The bluish or silvery color, I am told by ophthalmologists who have examined the rabbits, is due mainly to detachment of the retina. Here again, when one recalls the loose embryologic connection between the retinal layers of the eye and the outer coats, even in the normal eye, it is easy to see how almost any distortion of the eyeball, unevenness of growth, or accumulation of fluid might bring about such detachment. Many of the eyes take abnormal postures (Plate I, Fig. 3). This is particularly true in some of our later strains. One or both eyes are likely to be strongly rotated downward or backward. The backward- rotation is carried to such an extreme in some cases that the cornea is visible only when the eyelids are drawn back at the outer corner (Plate I, Fig. 3), or occasionally when the animal attempts to roll its eyeball forward. In such eyes the exposed sclera in front usually bulges (staphyloma) and becomes transparent, simulating a cornea. When we first came across this anomaly, in fact, we thought that we had a rabbit with a double eye on each side. I have brought one such individual with me for demonstration. Taking into account the method of embryologic development the relations of lens, optic cup and choroidal fissure the defects, except those of the muscular attachment, are practically all such as might reasonably be attributed to arrests of development based upon early lens-defect. It is possible, to be sure, that we have developed antibodies against other eye-tissues as well as against the lens, since undoubtedly more or less of the aqueous humor and the vitreous body adhered to the lenses when we removed and pulped them for the original injections. Moreover, if proteins from other parts of the eye are ever in solution in the humors, they too may have been present in the antigen. Each individual protein, of course, has the capacity The Production and Transmission of Certain Eye Defects 683 PLATE I Fig. 1 Fig. 2 Fig. 1. Showing appearance of normal eye. Fig. 2. Microphthalmic eye with cleft iris and opaque lens; eyeball rotated downward somewhat. Fig. 3 g Fig. 4 Fig. 3. Buphthalmic eye with staphylomatous sclera. The eyeball is so rotated backward that the edge of the cornea is just visible at the upper outer angle of the lids; the lenses in both eyes are opaque. Fig. 4. Showing opaque lens and coloboma of the iris. 684 M. F. GUYER for engendering antibodies specific for itself. Even the lens is composed of at least four proteins: albuminoid (constituting the lens-fibers), alpha-crystallin, beta-crystallin and albumin. According to Jess and Reiss (Jess, 1920), in their study of the chemical changes which take place in cataract, alpha- and beta-crystallin, both soluble in water, make up the greater part of the lens of the young animal. These gradually decrease in quantity with age, accompanied by sclero- sis a process even more in evidence in cataractous lenses. In some of our animals we find that an eye defective at birth, par- ticularly if microphthalmic, may undergo further degeneration, characterized by collapse of the eyeball and resorption, so that the eyeball may eventually disappear entirely. The eyes of the mothers originally injected have always remained apparently unaffected. This is probably due to the fact that the lens-tissue of the adult is largely a vascular, and that, therefore, the injected antibodies did not come into contact with it. That the changes in the eyes of the fetuses resulted from the specific action of lens-antibodies is indicated by the fact that in the original experiment, in not one of the forty-eight controls obtained from mothers which had been treated with pure fowl-serum or with fowl- serum immunized to rabbit-tissues other than lens, was there any evidence of eye-defects. I may add that since then, among over five hundred young obtained from mothers which are being experimented upon for other purposes with various types of sera or protein-extracts, or with typhoid bacilli, just before or during pregnancy, not a single case of eye-defect has appeared. To one familiar with the results obtained by the experimental embryologist, which show how suscep- tible the eye is in early embryogeny to any kind of harmful influence, the natural inclination is to regard such abnormalities as due merely to a general poisonous or inhibitive effect, rather than to specific anti- bodies in the blood-serum. That lens-defects may be produced by general chemical or physical means is undeniable. I know of no case yet, however, where they have become inheritable. Bagg (1922), for example, has recently found that as a result of exposure of rats to radium emanation (gamma-ray radiation) during late pregnancy, some of the young, after birth, developed eye-defects. In his paper he gives photographs of an adult in which both lenses have become opaque and the left eyelids nearly closed. As a rule, such fetally irradiated young showed other marked defects, particularly of the nervous system, and were usually sterile. The Production and Transmission of Certain Eye Defects 685 Regarding our own rabbits I can only repeat that we have never obtained the defects in question except with serum carrying specific antibodies. In any event, should the effect have originally been a general rather than a specific one, it is obvious that, germinally con- sidered, it must sooner or later have become specific, since the anoma- lous eye-condition appears generation after generation without any recognizable accompanying malformations of other parts of the body. Before passing on to the question of inheritance, I may say that by way of control, for genetical studies, in addition to what we have termed our 3A1 line, we developed another line from wholly unrelated stock, our so-called 16A1 line. Moreover, we have established still a third strain, the 84 line, which was started, not by means of fowl- serum immunized to rabbit-lens, but by the use of pulped rabbit -lens intravenously injected directly into rabbits just before or during their pregnancy. In this last case the rabbit must herself have developed antibodies against the invading lens-material. Out of eleven different females so treated, in twenty-three matings, only one individual gave us young with abnormal eyes. These defects are of the same general nature as those secured by means of fowl-serum immunized to rabbit- lens, and they behave similarly in inheritance. As already indicated, once the defect is secured, it may be trans- mitted to subsequent generations through breeding (Fig. 1). So far, in the 3A1 line, we have succeeded in passing it down through nine generations. There is no reason apparent why it will not go on indefi- nitely, since the imperfections tend to become worse in successive generations, and also to occur in a proportionately greater number of young. The same genetical conditions hold for the other lines, although because of their more recent origin, we have manifestly not been able to carry them through so many generations. The transmission is not infrequently of an irregular unilateral type (Fig. 1), sometimes only the right, at others only the left, eyeshowing the defect. In this respect it resembles genetically such anomalies as brachydactyly or polydactyly in man. In later generations there has been an increasing number of young with both eyes affected. Though not analyzed completely as to its exact mode of inheritance, the abnormal condition has in general the characteristics of a Mende- lian recessive. When either defective-eyed males or females are bred to normal-eyed individuals from other strains, for instance, only normal-eyed progeny result in the first generation, but the abnormal condition may be made to reappear in subsequent generations if 688 M. F. GUYER appropriate matings are made. If we were dealing with a pair of simple Mendelian characters, the young from two individuals with si'tif i *i5 ZtUHiili O S^ ' &P '" ^ -S'S Oj'oQ ^^>J, ' the same recessive trait should all show this trait. Two of our defective-eyed rabbits, however, when bred together, are likely to The Production and Transmission of Certain Eye Defects 687 produce some normal-eyed young. If, therefore, this inheritance is to be interpreted in terms of Mendelism, there is probably more than one pair of unit-factors involved. To meet the objection that we are not getting instances of true inheritance but merely placental transmissions of antibodies or related substances from the blood-stream of the mother in each successive generation, we have established the descent through the male line in Line Extractions n I 26AZ/Z6/I7 Z6A6 2.8A4 Fig. 2. Inheritance of the defects through the male line. It is plain that indi- viduals of the 32B, 46A and 61A series could have derived their defects only from male ancestry originally, since female 17 was of normal and unrelated stock. Symbols same as in Fig. 1. a number of cases, one of which is represented in Fig. 2. To do this, females from strains of rabbits unrelated to our treated stock were mated to defective-eyed males. The first generation produced in this way was invariably normal-eyed ; that is, the defective condition was recessive to normal condition. When, however, females of this generation were mateS to defective-eyed males, or to normal-eyed males of similar derivation to themselves, the defects reappeared in 688 M. F. GUYER some of the progeny, somewhat after the manner of an extracted Mendelian recessive. It is obvious that the normal condition could have been introduced into these new strains only through the germ- cells of the males, and that its transmission is, therefore, an example of true inheritance. I feel that in establishing and developing from unrelated stock three different strains of defective-eyed rabbits two (3A1 line and 16 A 1 line) by the use of fowl-serum immunized to rabbit-lens, the other (84 line) by direct injection of rabbit-lens into a pregnant rabbit we have placed our results beyond the bounds of coincidence or chance. We can also cite further the production recently of similar lens-defect in the young of the guinea-pig, if need be, although we are not yet ready to report on this latter series of experiments. To the biologist, perhaps the most interesting fact brought to light in these researches is the possibility of directly or indirectly inducing germinal changes by means of antibodies developed in an animal's own body against tissues taken from individuals of the same species. Such a result together with another I have obtained in inducing the male rabbit to develop spermatotoxins against its own spermatozoa (Guyer, 1922a), lend support to the idea that an animal can build antibodies against its own tissues when these are misplaced, altered or injured, and that such antibodies may so affect the germ-cells as to induce germinal changes. Since I have discussed this point rather fully in recent papers (Guyer, 1921, 1922b, 1922c), I need not enter into it here. LITERATURE CITED Child, C. M. Individuality in Organisms. University of Chicago Press, 1915. The Origin and Development of the Nervous System. University of Chicago Press, 1921. Cole, W. H. The Transplantation of Skin in Frog Tadpoles, with Special Reference to the Adjustment of Grafts over Eyes and to Local Specificity of Integument. Jour. Exp. Zool., v. 35, no. 4, May, 1922. Fischel, A. Weitere Mitteilungen iiber die Regeneration der Linse. Arch. f. Entw.-Mech., v. 15, 1902. Uber riicklaufige Entwicklung, Arch. f. Entw.- Mech., v. 42, 1916. Guyer, M. F. Immune Sera and Certain Biological Problems. Am. Nat., v. 55, Mar.-Apr., 1921. Studies on Cytolysins: Experiments with Sperma- totoxins. Jour. Exp. Zool., v. 35, No. 2, Feb., 1922. Serological Reac- tions as a Probable Cause of Variation. Am. Nat., v. 56, Jan.-Feb., 1922. Orthogenesis and Serological Phenomena. Am. Nat., v. 56, Mar.-Apr., 1922. The Production and Transmission of Certain Eye Defects 689 Guyer, M. F., and Smith, E. A. Studies on Cytolysins: Some Prenatal Effects of Lens Antibodies. Jour. Exp. Zool., v. 26, No. 1, May, 1918. Studies on Cytolysins: Transmission of Induced Eye Defects. -Jour. Exp. Zool., v. 31, No. 2, Aug., 1920. Herbst, C. Formative Reize in der tierischen Ontogenese, 1901. Jess, A. Die Monoaminosauren der Linsenproteine. Ztschr. f. physiol. Chem., 110, 266, 1920. King, H. D. Experimental Studies on the Eye of the Frog Embryo. Arch. f. Entw.-Mech., v. 19, 1905. Lewis, W. H. Experimental Studies on the Development of the Eye in Amphibia. Am. Jour. Anat., v. 3, 1904. Experimental Studies, etc. . . . On the Origin and Differentiation of the Lens. Am. Jour. Anat., v. 6, 1907. Lens Formation from Strange Ectoderm in R. Sylvatica. Am. Jour. Anat., v. 7, 1907. Speman, H. tJber Correlationen in der Entwickelung des Auges. Verh. Anat. Ges., Anat. Anz., v. 19, Erganzungsbd., 1901. Uber Linsenbildung bei defekter Augenblase. Anat. Anz., v. 23, 1903. Neue Versuche zur Ent- wicklung des Wirbeltierauges. Verh. d. deutsch. Zool. Ges. (Stuttgart), 1908. Zur Entwicklung des Wirbeltierauges. Zool. Jahrb., Abt. f. allg. Zool. u. Physiol., v. 32, 1912. Stockard, C. R. The Development of Artificially Produced Cyclopean Fish. Jour. Exp. Zool., v. 6, 1909. The Independent Origin and Development of the Crystalline Lens. Am. Jour. Anat., v. 10, 1910. An Experimental Study of the Optic Anlage in Amblystoma punctatum, with a Discussion of Certain Eye Defects. Am. Jour. Anat., v. 15, 1913. The Artificial Production of Structural Arrests and Racial Degeneration. Proc. N. Y, Path. Soc., N.S., v. 13, 1914. Developmental Rate and Structural Ex- pression: an Experimental Study of Twins, Double Monsters and Single Deformities, etc. Am. Jour. Anat., v. 28, 1921. Wachs, H. Neue Versuche zur Wolff'schen Linsenregeneration. Arch. f. Entw.- Mech., v. 39, 1914. Werber, E. I. Critical Notes on the Present Status of the Lens Problem. Biol. Bull., v. 34, No. 4, April, 1918. 44 A NEW TECHNIC FOR THE APPLICATION OF THE METHOD OF CAJAL TO SECTIONS OF THE RETINA 1 DR. FELIX FERNANDEZ BALBUENA Gijon, Spain 1. Rolling up the Retina Around the Optic Disc. If the animals are small, we leave the retinal block resulting from the rolling up adher- ing by means of the optic nerve to a round segment of the eyeball. In the large retinae of the bull or sheep we make several blocks, in order to facilitate the penetration of the fixation fluid. 2. Fixation of the retinal blocks in absolute alcohol (50 c.c.) with pyridin (5 to 10 c.c.), according to formula 2 a B of Cajal. We also use the absolute alcohol alone, and ammoniacal alcohol, as in the classic method. The retinal blocks remain in the fixation fluid twelve, twenty-four, or forty-eight hours, according to the thickness of the specimens. 3. When the specimens are once fixed, they are enclosed in celloidin and mounted on corks. They are then immersed in 70 per cent, alcohol and the sensibilization of the specimens is ascertained. The blocks mounted on cork should remain in 70 per cent, alcohol from a few days to two or three months. The best results are usually obtained within the first month. This third operation is usually decisive. We call it provisionally sensibili- zation of the retinal block, since it appears that, without a more or less prolonged impregnation of the blocks in 70 per cent, alcohol, the succeeding steps of nitration, developing, and fixing of the sections will be failures. 4. Impregnation of the Sections in a Nitrate of Silver Solution. After the retinal blocks have undergone the impregnation process described, sections are made which are grasped with a paint-brush and deposited on the bottom of a porcelain or glass vessel still moistened with the alcohol which we have used for lubricating the blade of the micro- tome; then 5 c.c. or more of a 1 : 2000 silver nitrate solution to which 1 Special demonstration at the Army Medical Museum. 690 A New Technicfor the Application of the Method of Cajal 691 a few drops of pyridin (5 or 10 drops 20 c.c.) have been added, are poured over the sections. When the sections are saturated, we slowly heat the solution until a slight steam rises, whereupon we let the solution cool off. Sometimes it happens that the section does not assume a yellow color, as is the case when the conditions are favorable to impregna- tion. In such cases the solution is heated several times until the yellow color appears. Generally three to ten minutes of embedding in the nitrate of silver bath are sufficient. 5. Preparation of the Colloid Medium and Developing of the Sections. Three or four drops of tincture of yellow amber added to the nitrate of silver bath impart to the solution a colloid consistence. Afterward two or three drops of a 1 per cent, hydroquinone solution are added, at the same time shaking the vessel to render the mixture homo- geneous. When the reaction is favorable, a gradual deepening of the color of the sections and a clear differentiation of the various regions are noticed. The time in which the sections remain in the developing fluid varies from four to ten minutes. By watching the effects we find when we have to terminate the process. By some calculation we easily arrive in each case at the desired results. In some cases it is necessary to assist the reaction by slow heating on the alcohol lamp. 6. Fixation. When the sections are developed, they are washed in the same vessel with distilled water. Then we pour on them a 1 per cent, borax solution and three or four drops of a 1 per cent, yellow chlorid of gold solution. We finish the process by fixation in a 5 per cent, hyposulphite solution. AN INTERNATIONAL CONGRESS OF OPHTHALMOLOGY MINUTES OF THE PROCEEDINGS The first session was called to order in Colonial Hall of the Daugh- ters of the American Revolution, by the Chairman of the Committee on Arrangements, Dr. W. H. Wilmer, Washington, D. C., and an address of welcome was made by Hon. Calvin D. Coolidge, Vice- President of the United States. After roll call of delegates to the Congress the committee appointed to nominate permanent officers of the Congress made its report, which was unanimously adopted, and the officers named were de- clared elected (page 5). The Committee of Arrangements made the following report: Owing to the fire at the Hotel Willard it has been necessary to make ex- tensive changes in the plans for the Congress. The scientific sessions and the evening addresses will be held in Colonial Hall, Daughters of the American Revolution. On Tuesday afternoon there will be an official trip to Mount Vernon by trolley. A wreath will be placed upon the tomb of Washington. On Tuesday evening, at the Corcoran Gallery of Art, the President and the Officers of the Congress will hold a reception in honor of the members of the Congress and ladies. On Wednesday afternoon the President of the United States will receive the members of the Congress and ladies at the White House. Members may also visit the Pan American Union Building, the Army Medical Museum, Library of Congress, and other places of interest. On Thursday afternoon there will be an official visit to the Bureau of Standards, and demonstrations will be given at the Army Medical Museum. On Friday evening a banquet will be held at the Hotel Willard. The Report of Committee on Scientific Business was as follows: The Report of the Committee on Scientific Business consists of the pre- session volume, which most of you have received, and the program of over one hundred pages. This was possible only through the co-operation of another committee, the Committee on Publication, who have most nobly 692 Minutes of the Proceedings 693 carried on our work. The third part of our work is the Daily Bulletin, which will be ready for distribution each morning. The work of securing a scientific program has been arduous, but it has been a most grateful task, one which has brought us into communication with some of the great men in ophthalmology of our age, and we hope to share with all the members of the Congress an even more intimate communication in the three days that are to come. THE PKESIDENT: We will now proceed with the scientific discussions. The first paper is entitled "Des Enseignements de la Guerre en Chirurgie Ocu- laire" (Teachings of the War in Ocular Surgery), by Prof. F. de Lapersonne, of Paris. The paper of Prof, de Lapersonne was discussed by Drs. Frederick T. Tooke, George S. Derby, Allen Greenwood, G. F. Rochat, Edmond E. Blaauw, and Prof. F. de Lapersonne. The paper of Sir William Lister, on "Detachment of the Vitreous," was read by Mr. E. Treacher Collins, who said: I first of all have to express to you Sir William Lister's sincere regret that he is unable to be present. The state of his health prevented his undertaking the journey. When he asked me to read an abstract of his paper I undertook to do so with a light heart because I felt sure that any deficiency which there might be on my part would be fully compensated for by the beautiful lantern slides which he had given me .to show. The paper of Sir William Lister was discussed by Drs. Marcus Feingold, Thomas B. Holloway, John E. Weeks, J. W. Nordenson, Ignacio Barraquer, F. Park Lewis, F. H. Verhoeff, Col. R. H. Elliot, Mr. E. Treacher Collins and Prof. E. Gallemaerts. The next paper was read by Prof. Allvar Gullstrand, of Upsala, Sweden, on "On Diaphragm Lamps in Ophthalmology." The paper of Prof. Gullstrand was discussed by Drs. Edward Jackson, Harry S. Gradle, E. E. Blaauw, G. F. Rochat and Prof. Allvar Gullstrand. The paper by Dr. Jose" de Jesus Gonzalez, of Mexico, on "Sintomas Ocu- lares del Envenenamiento por el Piquete de Alacran " (Ocular Symptoms of Poisoning by the Sting of a Scorpion), was read by Dr. J. M. Penichet. The paper of Dr. Gonzalez was discussed by Drs. Francisco M. Fernandez, Aurelio Beraun, Lloyd Mills, and Col. R. H. Elliot. At the conclusion of the paper of Dr. Gonzalez the Congress adjourned. WEDNESDAY MORNING, APRIL 26, 1922 The Congress was called to order by the President, Dr. George E. de Schweinitz. Dr. S. Gemblath, of Paris, read a paper on "Traitement du Trachome par les Injections sous Conjonctivales de Cyanure de Mercure" (Treatment of Trachoma by Subconjunctival Injections of Mercury Cyanid). 694 Minutes of the Proceedings The paper of Dr. Gemblath was discussed by Drs. Jesus M. Penichet, Joseph Krimsky, John McMullen, Lucien Howe, Prof. F. de Lapersonne, and Dr. Said Gemblath. The President announced the following members on the committees to take in charge the consideration of propositions which were brought before the Congress for action, with the understanding that they should divide their energies between the three problems: The Value of Letters and Characters as Visual Tests: Dr. Edward Jackson, Denver, Colorado. Dr. A. E. Ewing, St. Louis, Mo. Dr. G. F. Rochat, Groningen, Holland. Ophthalmic versus Anatomic Nomenclature : Dr. M. Uribe Troncoso, New York City. Dr. M. Feingold, New Orleans. Dr. J. W. Nordenson, Stockholm, Sweden. Standards for Field Taking: Col. Robert H. Elliot, London, England. Dr. Luther C. Peter, Philadelphia, Pa. Dr. A. Magitot, Paris, France. Prof. C. E. Ferree, Bryn Mawr, Pa. THE PRESIDENT: It is the Chair's understanding that these three com- mittees are combined in one, each section having its special duty. A report will be made which shall be regarded as a preliminary one. A more ex- tended study will be reported at a future Congress. The Chair suggests that the Secretary of the Congress, himself the author of one of the propo- sitions, shall be requested to communicate with the various members as to their meetings. The Chair has the honor to ask the senior Vice-President of the Congress, Dr. Lucien Howe, to take the chair. DR. LUCIEN HOWE: The next paper on "Anomalies of Ocular Develop- ment and Pigmentation: 1. Bilateral Symmetric Congenital Corectopia with Iridodonesis and Microcoria; Microlentis and Coloboma Lentis. 2. Melan- osis of the Eye, Skin of Right Side of Head, and Right Palate," will be presented by Mr. J. Gray Clegg, of Manchester, England. The paper of Dr. Clegg was discussed by Mr. E. Treacher Collins and Drs. E. E. Blaauw, Edward Jackson, and J. Gray Clegg. DR. LUCIEN HOWE: The next paper, "Bitemporal Contraction of Visual Fields in Pregnancy," will be presented by Prof. C. E. Finlay, of Havana, Cuba. The paper of Prof. Finlay was discussed by Drs. Walter B. Lancaster, Maud Carvill, and Profs, de Lapersonne and Finlay. The President, Dr. de Schweinitz, then took the Chair, and announced that the next paper on the scientific program was "Les Echanges d'Eau et d'lons a Travers la Corne"e," by Dr. V. Morax, of Paris. Dr. Weeks stated Minutes of the Proceedings 695 that Dr. Morax was unable to attend on account of illness in his family, but that he wished to convey his greetings to the members of the Congress and to express his regrets and his apologies for his inability to be here. The next paper was by Dr. Francisco Poyales, of Madrid, entitled "La Tuberculosis Ocular InfantiP' ("Infantile Ocular Tuberculosis"). The paper of Dr. Poyales was discussed by Drs. W. C. Finnoff, J. Gray Clegg, Ignacio Barraquer, H. H. Stark, John E. Weeks, E. Treacher Collins, Richard Kerry, F. H. Verhoeff, and Francisco Poyales. Prof. F. de Lapersonne, of Paris, at the request of the President, took the Chair and announced the paper of Dr. C. F. Harford, of Cambridge, on " Psychopathology in Ophthalmic Practice," which was read by Mr. J. Gray Clegg. The paper of Dr. Harford was discussed by Drs. George F. Keiper and J. Gray Clegg. Dr. B. Castresana, of Madrid, was not present to read his paper entitled "Nuevo Tratamiento Quirurgico del Estrabismo" ("Treatment of Stra- bismus by a New Surgical Procedure"). Dr. E. Campodonico, Lima, Peru, was not present to read his paper en- titled "A New Procedure in the Excision Method of Pterygium Operation." Dr. S. Lewis Ziegler, Philadelphia, read a paper entitled "The Subcon- junctival Excision of Pterygium." The papers of Drs. Campodonico and Ziegler were discussed by Drs. John 0. McReynolds, A. E. Prince, and S. Lewis Ziegler. WEDNESDAY AFTERNOON, APRIL 26, 1922 By the permission and courtesy of Brig.-Gen. Robert E. Noble the following demonstrations were given at the Army Medical Museum, the arrangements being in charge of Mayor G. R. Callender. APPARATUS AND METHODS OF EXAMINATIONS MR. E. TKEACHER COLLINS, London, England: Lantern Slide Demonstra- tion. PROF. ALLVAR GULLSTRAND, Upsala, Sweden: Diaphragm Illumination. DR. J. W. NORDENSON, Stockholm, Sweden: Centric Photography of the Fundus Oculi. PROF. I. BARRAQUER, Barcelona, Spain: Moving Pictures of the Operation of Extraction of Cataract in the Capsule. COL. ROBERT H. ELLIOT, M.D., London, England: The Elliot Sign of Glau- coma. DR. GEORGE MACKAY, Edinburgh, Scotland: Clockwork and Cable Tre- phines. DR. JOHN A. McCAW, Denver, Col.: A Rotating Campimeter for Mapping Paracentral Scotomas. LUTHER C. PETER, M.D., Philadelphia, Pa.: Perimetry. 696 Minutes of the Proceedings DR. J. ELLIS JENNINGS, St. Louis, Mo. : Improved Test for Color-Blindness. DR. W. H. CRISP, Denver, Col. : Photographic Demonstration of Crossed Cyl- inder Test for Astigmatism. PATHOLOGIC SPECIMENS AND MICROSCOPIC SLIDES Exhibit from the Museum of the American Academy of Ophthalmology and Oto-Laryngology. MR. J. GRAY CLEGG, Manchester, England : Miscellaneous Specimens for Self and Colleagues. PROF. W. GORDON M. BYERS, Montreal, Canada: Acute Tubercular Uveo- keratitis. PROF. M. F. GUYER, Madison, Wis.: Experimental and Transmitted Eye Defects. DR. LUCIEN HOWE, Buffalo, N. Y. : Eyes of Rabbits in Which Hereditary Blindness Has Been Produced. PROF. ALBERTS DEL MONTE, Naples, Italy: Protozoan Bodies Discovered and Demonstrated in Chalazion. DR. FELIX F. BALBUENA, Gijon, Spain: A New Technic for the Application of the Method of Cajal to Sections of the Retina. DR. F. H. VERHOEFF, Boston, Mass. : a. Characteristic Lesions and Organisms (Leptothrices) of Parinaud's Conjunctivitis; b. Microscopic Specimen of Coralliform Cataract Showing Protein Crystals in the Lens; c. Micro- scopic Specimen of Asteroid Hyalitis. DR. E. V. L. BROWN, Chicago, 111.: Massive Band of Connective Tissue Surrounding the Choroidea in a Traumatized Shrunken Eye. DR. W. C. FINNOFF, Denver, Col.: Tuberculosis as It Appears in the Eye. DR. CASEY A. WOOD and LIEUT.-COL. F. H. GARRISON: An exhibit of books of historic interest to ophthalmologists arranged in the Library of the Surgeon-General's Office. DR. A. MAGITOT demonstrated in the auditorium of the Corcoran Art Gallery a series of Lantern Slides Showing Development of the Human Eye. WEDNESDAY EVENING, APRIL 26, 1922 The Congress met at the Colonial Hall, and the following addresses were delivered: PROF. S. E. WHITNALL, McGill University, Montreal, "Some Descriptive Errors in the Anatomy of the Orbit." PROF. J. PARSONS SCHAEFFER, Jefferson Medical College, Philadelphia, "On the Clinical Anatomy of the Efferent Lacrimal Passageways." THURSDAY MORNING, APRIL 27, 1922 The Congress was called to order by the President, Dr. George E. de Schweinitz. The Chair announced that the Chairman of the Section on Oph- Minutes of the Proceedings 697 thalmology of the American Medical Association wished to extend to the foreign guests an invitation to attend that meeting in St. Louis, May 24 to 26, inclusive. A similar invitation was extended by the President of the American Ophthalmological Society to attend the meeting of the Society in Washington, D. C., May 2-4 inclusive. Drs. F. H. Verhoeff and A. N. Lemoine, of Boston, read a paper on " Endophthalmitis Phacoanaphylactica." The paper of Drs. Verhoeff and Lemoine was discussed by Drs. Lucien Howe, G. F. Rochat, James M. Patton, L. C. Rood, Arnold Knapp, George S. Derby, Albert N. Lemoine, and F. H. Verhoeff. Prof. Emile Gallemaerts, of Brussels, Belgium, at the request of the Presi- dent, took the Chair. PROF. GALLEMAERTS: The next paper is by Dr. A. E. Davis, of New York City, on "Serum and Vaccine Treatment for the Prevention and Cure of Cataract." The paper of Dr. Davis was discussed by Drs. Lucien Howe, M. F. Guyer, Henry H. Tyson, F. A. Davis, and A. E. Davis. PROF. G. F. ROCHAT, Gronigen, Holland, at the request of the President, took the Chair, and announced that the papers of Prof. Barraquer and Prof. Gallemaerts would be discussed together. Prof. Barraquer's paper is entitled "Facoerisis" ("Phacoerisis"), and Prof. Gallemaerts' paper is on "Operation de Barraquer" ("Operation of Barraquer"). The papers of Professors Barraquer and Gallemaerts were discussed by Drs. Lucien Howe, John Westley Wright, John 0. McReynolds, L. D. Green, Col. R. H. Elliot, Prof. F. de Lapersonne, Drs. Lloyd Mills, Joseph A. White, J. Gray Clegg, S. Gemblath, Francisco Poyales, W. A. Fisher, and Professors Barraquer and Gallemaerts. PROF. G. F. ROCHAT: The paper of Dr. D. Kostitch, Belgrade, Serbia, entitled "Troubles Oculaires Consecutifs a l'Obs6rvation Directe de PEclipse Solaire" ("Ocular Troubles Following Direct Observation of the Solar Eclipse"), will be read by the Secretary. The paper of Dr. D. Kostitch was discussed by Col. R. H. Elliot, Drs. George MacKay, J. Gray Clegg, and Francisco M. Fernandez. PROF. G. F. ROCHAT: The next paper on "Orbital Marsupialization and Superiority of Organic Grafts of Dead Tissue in Establishing a Mobile Stump," will be read by Dr. A. Magitot, of Paris. The paper of Dr. Magitot was discussed by Drs. J. N. Roy and A. Magitot. DR. EDWARD JACKSON, Denver, Col., at the request of the President, took the Chair. DR. EDWARD JACKSON announced the next paper by Dr. A. F. Alonso, of Mexico, entitled "La Peritomia en las Ulceras Cr6nicas Vasculares de la Cornea" ("Chronic Vascular Ulcers of the Cornea"). The paper of Dr. Alonso was discussed by Drs. L. Webster Fox, S. Lewis Ziegler, and A. F. Alonso. 698 Minutes of the Proceedings DR. EDWARD JACKSON: The last paper on the program is by Dr. R. C. Cheney, of Boston, on "Types of Pneumococcus Found in Corneal Ulcers." The paper of Dr. Cheney was discussed by Drs. George S. Derby and R. C. Cheney. '. THURSDAY EVENING, APRIL 27, 1922 The Congress met in Colonial Hall, and the following addresses were delivered: PROF. LEONARD T. TROLAND (Harvard University): "The Facts and Theories of Color Vision." PROF. M. G. GUYER (University of Wisconsin): "The Production and Transmission of Certain Eye Defects." FRIDAY MORNING, APRIL 28, 1922 The session was called to order by the President, Dr. George E. de Schweinitz. COL. R. H. ELLIOT, London, England, read a paper on "The Diagnosis of Glaucoma." The paper of Col. Elliot was discussed by Drs. John E. Weeks, Luther C. Peter, Mr. E. Treacher Collins, Drs. E. E. Blaauw, J. W. Nordenson, J. Gray Clegg, George F. Keiper, Arnold Knapp, Col. R. H. Elliot, and Dr. George W. Jean. Prof. C. Charlin, Santiago, Chile, was not present to read his paper, "L'fitat Vasculaire des Glaucomateux " ("fitude de 100 Malades de Glau- come Primitif") ("Vascular Condition of Glaucomatous Patients"). MR. E. TREACHER COLLINS took the Chair at the request of the Presi dent, and announced that the paper, " Blood- Pressure in the Vessels of the Eye," by Drs. A. Magitot and P. Bailliart, of Paris, would be read by Dr. Magi tot. MR. E. TREACHER COLLINS: The next paper is by Dr. J. M. Wheeler, of New York City, on "Plastic Operations About the Eye." The paper of Dr. Wheeler was discussed by Drs. W. E. Lambert, John E. Weeks, and John M. Wheeler. MR. E. TREACHER COLLINS: Prof. J. N. Roy, of Montreal, Canada, will read his paper on " Lagophtalmie Bilate'rale Consecutive a la Perte Acci- dentelle de la Peau du Front, et du Cuir Chevelu. Btepharoplastie " ("Bilat- eral Lagophthalmos Following Accidental Loss of the Scalp. Blepharo- plasty"). THE PRESIDENT, DR. DE SCHWEINITZ, in the Chair. The next paper, by Mr. A. S. Percival, of Newcastle-on-Tyne, entitled "Light Sense: The Practical Minutes of the Proceedings 699 Significance of Its Variations: Simple Tests for Determining Them," will be read by Dr. Alexander Duane, of New York City, in the absence of Mr. Percival. The paper of Mr. Percival was discussed by Drs. C. E. Ferree, Otto Roelofs, Col. R. H. Elliot, and Dr. Alexander Duane. PROF. C. E. FINLAY, Havana, Cuba, took the Chair at the request of the President, and announced the next paper by Drs. C. E. Ferree and G. Rand, of Bryn Mawr, Pa., "Some Contributions to the Science and Practice of Ophthalmology." The paper of Drs. Ferree and Rand was discussed by Drs. Alexander Duane, Luther C. Peter, William L. Benedict, William Zentmayer, J. Gray Clegg, and C. E. Ferree. PROF. C. E. FINLAY: As Dr. E. Junes, of Sfax, Tunis, is not present, the next paper is on "Carcinoma of the Choroid," by Dr. Allen Greenwood, of Boston. The paper of Dr. A. J. Bedell, of Albany, N. Y., on "Chloroma," will follow, and these papers will be discussed together. The papers of Drs. Greenwood and Bedell were discussed by Dr. George E. de Schweinitz. FRIDAY AFTERNOON, APRIL 28, 1922 BUSINESS SESSION The meeting was held at the building of the Medical Society of the District of Columbia. THE PRESIDENT: The first order of business is a resolution which Dr. Lucien Howe wishes to present: WHEREAS, Arrangements for any International Congress necessitate much time and careful attention; and, WHEREAS, The destruction by fire of the hall and part of the hotel agreed upon for the meeting involved many and important changes, just as the Congress began; and, WHEREAS, That emergency was met so promptly and efficiently by the local committee as not to disturb our delightful sojourn in Washington; therefore be it Resolved, That we express our hearty thanks to the chairman and members of the Committee on Arrangements for making these meetings, from first to last, so eminently satisfactory, and, Resolved, That our thanks be extended also to each of the chairmen and mem- bers of the various committees whose united efforts have proved so efficient in causing this to be long remembered as the largest and one of the best organized of any International Congress of Ophthalmology. MR. E. TREACHER COLLINS (London, England): On behalf of my col- leagues, the British representatives to this meeting, I wish to express our most emphatic appreciation of this resolution and to cordially support it. We are very grateful to the officers for the care and attention which they have given 700 Minutes of the Proceedings to the carrying out of this meeting, and we wish to express our special indebt- edness to them. The motion was unanimously carried. The Secretary was directed to spread the resolution upon the minutes of the Congress, and to send a copy to the chairman of each special committee. MR. E. TREACHER COLLINS: I wish to read a letter from the President of the Ophthalmological Society of the United Kingdom, Mr. J. Herbert Fisher. 11 Chandos Street Cavendish Square, W. 1. 17th March, 1922 Dear Mr. Collins: International Congress of Ophthalmology. The Council of this Society strongly approves of the proposed suggestion to hold the next International Congress in London in 1925. It has been in communication with the following ophthalmic bodies, which have all given their approval and promised their assistance toward ensuring success to such a meeting, namely: Ophthalmic Section, Royal Society of Medicine. Oxford Ophthalmological Congress. Midland Ophthalmological Society. North of England Ophthalmological Society. Irish Ophthalmological Society. Scottish Ophthalmological Club. Such a consensus of opinion may be taken to represent the views of British ophthalmic surgeons, and the Council of this Society has instructed me to ask you to convey an invitation (enclosed herewith) to the International Congress of Ophthalmology at Washington. A similar congress has not been held in Great Britain for many years, and, if the proposal is agreed to, it would be esteemed a high honour to British ophthal- mology. Yours sincerely, (Signed) J. HERBERT FISHER, President. I will hand to the President a letter addressed to him. THE .PRESIDENT: This letter reads as follows: 11 Chandos Street, Cavendish Square, W. 1. 17th March, 1922 Dr. G. E. de Schweinitz, Chairman of the General Committee, International Congress of Ophthalmology, Washington. Dear Sir: Ophthalmologists in this country are very desirous that the next International Congress should be held in Great Britain in 1925; and we shall esteem it a high honour if the Congress at Washington will accept this invitation, which our col- league, Mr. E. Treacher Collins, has been asked to convey. Minutes of the Proceedings 701 This proposal has met with unanimous approval not only by the Council of this Society, but also by the Councils of the following: (1) Ophthalmic Section, Royal Society of Medicine, London. (2) Oxford Ophthalmological Congress. (3) Midland Ophthalmological Society. (4) North of England Ophthalmological Society. (5) Irish Ophthalmological Society. (6) Scottish Ophthalmological Club. We beg to remain, dear Sir, Yours obediently, (Signed) J. HERBERT FISHER, President. J. F. CUNNINGHAM, FRANK JULER, Secretaries. PROF. EMILE GALLEMAERTS (Brussels, Belgium): The Ophthalmological Society of Belgium asked me to bring before you the same invitation as that of Mr. E. Treacher Collins, but in the face of so great an invitation from Mr. Collins I can only present the hope that in the course of time such invitation will be received with the applause accorded the invitation of Mr. Collins. THE PRESIDENT: The Chair feels sure the time will never come when an invitation from Belgium will not be warmly applauded. The Chair permits himself to suggest that, before proceeding with this matter, someone shall move a vote of thanks to Professor Gallemaerts, which he in turn may convey to his colleagues in Belgium. The motion was made by Prof. Allvar Gullstrand, seconded, and unani- mously carried. PROF. ALLVAR GULLSTRAND (Upsala, Sweden): We have received an invitation from our colleagues of England, and I should like to point out a few hints at this opportunity. I am the official delegate of the Government of a country that was strictly neutral during the War, and I can prove that I was strictly neutral, for I have received, during the War, honorary member- ships from both sides one from Great Britain and one from Austria, and that would not have happened if I had not been neutral. Now we neutrals stand at a corner on the one side we see Germany, who thinks you are boycotting her science and her language; and on the other side we see yourselves, and we know you are not. I move in the first place that this Congress shall accept the kind invitation that we have received from the Ophthalmological Society of the United King- dom; and in the second place that this Congress shall express its wish that the next Congress is to be strictly international, and that the German lan- guage shall be an official language among others. DR. LUCIEN HOWE (Buffalo, N. Y.) : In rising to second this motion made by Professor Gullstrand I desire to do so in words which will tend to clear up an evident misunderstanding concerning the languages to be used at this Congress. We all know that when the first steps were taken toward its or- ganization, over two years ago, an invitation was transmitted through the 702 Minutes of the Proceedings Department of State to each of the countries with which we were then in diplomatic relations, requesting that a representative be assigned to the Con- gress, and therefore such an invitation could not go to those countries with which such diplomatic relations did not exist at that time. This probably led to the impression, unfortunately widespread and often repeated, that we Americans had "boycotted"' the German language. The fallacy of this, however, was shown by the fact that in one of the earliest circulars issued by our Central Committee it was distinctly stated that any language could be used which the speaker preferred, provided it be translated into one of the three official languages of the Congress. Also, it seemed probable then that very few colleagues would come just now from Germany or Austria, and the printing of notices and of transactions in four languages would involve a deficit even greater than the one of several thousand dollars which we are now obliged to supply for the publication in only three languages. Therefore it seems proper for some one to prove that this is an Inter- national Congress, not only in name, but that it is catholic in its scope and hospitable to ideas, no matter whence they come. In other words, the German language should purposely be used by some one who was born and bred in America and without a trace of German predilection. We need that as a proof of consistency. Speaking in German, Dr. Howe continued: Deshalb, Herr President, mochte ich meiner Meinung dahin Ausdruck geben, dass solange wir gewillt sind die Arbeiten der Forscher anzuerkennen, und unsere Kenntnisse dadurch zu bereichern, so miissten wir doch deutlich zeigen dass wir nicht ihre Sprache verbannen. Es ist zwar moglich, dass diese Konsequenz, auf die ich hinweise, von den Anwesenden missverstanden werden, ebenso wie wir seinerzeit von den Deutschen misverstanden wurden, ich bin aber bereit irgend welchen Beschuldigungen entgegen zu treten. Ich behaare also auf das Recht, wenn ich es wunsche, die deutsche, oder irgend eine andere fremde Sprache zu gebrauchen. Indem ich meine Zustimmung fur die Annahme der Einladung nach Lon- don abgebe, hoffe ich, gemeinsam mit Prof. Gullstrand und will es auch ev. fur die meisten der englischen Kollegen hoffen, dass beim nachsten interjia- tionalen Ophthalmologen Kongress Deutsch als eine der offiziellen Sprachen gelten wird. DR. GEORGE MACKAY (Edinburgh, Scotland): I rise to support the pro- position put before you by Mr. E. Treacher Collins, speaking in behalf of all the ophthalmologic colleagues in Great Britain, and I trust I may say of Ireland, inviting you most cordially to accept this invitation to make your next meeting place the capital of the British Empire. The last name in the list read is that of the Scottish Ophthalmological Club. It is a small body, but I venture to say it is a very select body. It represents a country which has ever stood for liberty, for progress, for freedom. I take it, gentlemen, that that is a sentiment, an aspiration, which appeals to you all. I beg, then, to assure you that in visiting the British Isles you come not only to receive a hearty welcome from London and from England, but from bonnie Scotland, to which you will find time to extend your visit. Minutes of the Proceedings 703 DR. JOHN ROWAN (Glasgow, Scotland) : I wish to second Mr. E. Treacher Collins' invitation, which I hope the Congress will accept, and which I wish to back up from the point of view of the Scotch colleagues. We hope that while you are there, either going or coming, you will take the northern route. There are plenty of trains, three or four lines, and it is only about an eight-hour trip. We assure you the clinics will be open to you and we will do our best to show you all our different methods. I am afraid, however, by the time you have attended the meetings in London the wives and daughters will have taken command and that you will be taken to the north of Scotland for sight- seeing. We will do our best in that way, too. If you will let us know what you want, we will be pleased to do it. We will try to live up to the standards that have been set at this Congress, although that will be difficult. The work has been extremely good, the organization has been good, and the discipline has been good. There has been no time wasted. MR. J. GRAY CLEGG (Manchester, England) : There is no delicate question in the north of England as regards nationality, and as representing my col- leagues of the North of England Ophthalmological Society I wish to add our strong invitation and to express the hope that this Congress will accept it. The stimulus of this visit to America will certainly set the north of England ball rolling at a great pace, and I expect we will be able to have something to show you in spite of the fact that perhaps we have not been quite up to the mark in times gone by. I have pleasure, therefore, in expressing the hope of the North of England Ophthalmological Society that you will accept the invitation. COL. R. H. ELLIOT (London, England) : Nothing has been said about Wales and very little about Ireland, but I am both Welsh and Irish and I am sure both will be as glad to see you come as any of us. THE PRESIDENT: The invitation conveyed by Mr. E. Treacher Collins, which bears the endorsement of the various societies enumerated, is now be- fore you. Does the Congress understand that it includes the wish expressed in Professor Gullstrand's motion? An affirmative answer having been recorded, the Congress by vote accepted the invitation to hold the next meeting in England in 1925. THE PRESIDENT: Mr. Collins, will you please convey to your confreres and the societies enumerated the acceptance by this Congress of Great Britain's invitation? Is there any other business before the Congress? DR. C. D. WESCOTT (Chicago) : As a member of the Hospitality Committee of Chicago I wish to extend an invitation to all our guests and to any mem- bers of the Congress to come to Chicago. We will be glad to do anything we can to assist you in seeing anything we have to show you. SCIENTIFIC SESSION THE PRESIDENT: The first number in our scientific program this afternoon is a paper on "Metastatic Thyroid Tumor in the Orbit," by Dr. Arnold Knapp, of New York City. 704 Minutes of the Proceedings The next paper was by Mr. E. Treacher Collins, of London, "Hereditary Ocular Degenerations 'Ophthalmic Abiotrophies.' " The paper of Mr. Collins was discussed by Drs. C. E. Finlay, F. H. Verhoeff, George F. Libby, Mary Buchanan, William E. Bruner, Mr. E. Treacher Collins, Edward Jackson, and E. E. Blaauw. Drs. Walter Scott Franklin and Frederick C. Cordes presented a paper on " Bilateral Lymphosarcoma of the Orbit with Intermittent Exoph- thalmos." DR. A. TORRES ESTRADA, of Mexico City, was not present to read his paper, "Mercurials and Salvarsan and its Derivatives in the Treatment of Grave Eczematous Conjunctivitis and Keratitis." The next paper, "The Effects of Direct Instillation of Novarsenobillon in the Conjunctival Sac in Resistant Cases of Congenital Syphilitic Inter- stitial Keratitis," by Dr. A. Renshaw, of Manchester, England, was read by Mr. J. Gray Clegg. DR. EDWARD JACKSON made the following report: The Committee appointed to report on Suggestions for Congress Action con- cluded it was quite impossible to give either of the three questions referred to it any adequate consideration during the time of this Congress, and recommend that it be authorized to continue its consideration and to report either to a sub- sequent Congress or through the journals. After the action taken today probably the report should be made when the Congress meets in London. That is the only report the committee has to make. The final paper on the scientific program was "Treatment of Infectious Keratitis by Vaccine," by Dr. Rovirosa Virgili, of Madrid, Spain. Dr. Virgili was not present to. read the paper. DR. ALLEN GREENWOOD (Boston) : I wish to move a rising vote of thanks to the President for the very able manner in which he has conducted the sessions of this Congress. And I would like to give the same vote of thanks to our Secretary. The motion seconded by Mr. J. Gray Clegg, and unanimously carried. THE PRESIDENT: Ladies and Gentlemen of the Congress : This concludes the scientific program. I beg on behalf of my colleagues to express our best thanks for your courtesy and your kindness and to reiterate our high appreciation of your sympathetic interest and your notable scientific con- tributions which have brought success to the Congress of Ophthalmology. ADJOURNMENT. ORGANIZATION OF THE CONGRESS In 1919, the American Ophthalmological Society, the Section on Ophthalmology of the American Medical Association, and the American Academy of Ophthalmology and Oto-Laryngology each ap- pointed a committee of three members, with instructions to formu- late plans for the organization of an International Congress of Oph- thalmology to meet in the United States. The membership of these committees was as follows: American Ophthalmological Society, Drs. G. E. de Schweinitz, W. H. Wilmer, and Frederick T. Tooke. Section on Ophthalmology of the American Medical Association, Drs. W. H. Wilder, Lucien Howe, and Francisco Fernandez. American Academy of Ophthalmology and Oto-Laryngology, Drs. Edward Jackson, W. B. Lancaster, and Luther C. Peter. At a meeting in New York, on October 21, 1919, an organization of the combined committees was effected with the election of the follow- ing: Dr. G. E. de Schweinitz, Chairman; Dr. Edward Jackson, Vice- Chairman, and Dr. Luther C. Peter, Secretary. A temporary Sub- committee on Time and Place was appointed, which at a subsequent meeting recommended that the place of meeting should be Washing- ton, D. C., April 18, 1922.* This recommendation was adopted at a later meeting of the general committees of the Congress. Numerous other sub-committees were appointed by the Chairman, selected to represent all sections of the United States, as well as Canada, Cuba, Mexico, and Central and South America. The several committees in charge of the organization of the Congress, as finally appointed, consisted of a General Committee, a Committee on Organization, a Committee on Scientific Business, a Committee on Arrangements, a Committee on Membership and Credentials, a Committee on Finance, a Committee on Publication, and a Committee on Entertainment for each of several leading cities throughout the country. * The final date selected was April 25-28, 1922. 45 705 706 Organization of the Congress INTERNATIONAL CONGRESS COMMITTEES GENERAL COMMITTEE DR. GEORGE E. DE SCHWEINITZ, CHAIRMAN DR. EDWARD JACKSON. VICE-CHAIRMAN DR. LUTHER C. PETER. SECRETARY-TREASURER DR. FRANCISCO M. FERNANDEZ DR. FREDERICK T. TOOKE DR. LUCIEN HOWE DR. WILLIAM H. WILDER DR. WALTER B. LANCASTER DR. WILLIAM H. WlLMER SPECIAL COMMITTEES COMMITTEE ON ORGANIZATION DR. EDWARD C. ELLETT. CHAIRMAN DR. HENRY D. BRUNS PROF. R. PACHECO LUNA DR. WM. GORDON M. BYERS DR. ARCHIBALD L. MACLEISH DR. ENRIQUE B. DEMAR1A DR. WALTER R. PARKER DR. ALEXANDER DUANE DR. DANIEL M. VELEZ DR. A. E. EWING DR. CASEY WOOD DR. HIRAM WOODS COMMITTEE ON SCIENTIFIC BUSINESS DR. EDWARD JACKSON, CHAIRMAN DR. GEORGE s. DERBY DR. THOMAS B. HOLLOWAY DR. ALEXANDER DUANE DR. WALTER B. LANCASTER DR. MARCUS FEINGOLD DR. URIBE TRONCOSO COMMITTEE ON ARRANGEMENTS DR. WILLIAM H. WlLMER. CHAIRMAN JOHN W. BURKE DR. EDWARD L. MORRISON MAJ. G. R. CALLENDAR DR. STEWART B. MUNCASTER DR. WILLIAM T .DAVIS DR. EDWARD G. SEIBERT DR. LOUIS S. GREENE DR. DANIEL K. SHUTE DR. CARL HENNING DR. WILLIAM M. SWEET DR. ROBERT S. LAMB DR. SAMUEL THEOBALD DR. WALTER E. LAMBERT DR. CASSIUS D. WESCOTT DR. OSCAR A. MCK1MMIE DR. JOSEPH A. WHITE COMMITTEE ON MEMBERSHIP AND CREDENTIALS DR. WALTER R. PARKER, CHAIRMAN DR. JAMES BORDLEY. JR. DR. WILLIAM R. MURRAY DR. ALBERT E. BULSON, JR. DR. JAMES M. PATTON DR. F. PHINIZY CALHOUN DR. WILLIAM H. ROBERTS DR. A. E. EWING DR. FREDERICK T. TOOKE DR. ALLEN GREENWOOD DR. CLARENCE A. VEASEY DR. JOHN O. MCREYNOLDS DR. JOHN E. WEEKS DR. WILLIAM H. WILDER Organization of the Congress 707 COMMITTEE ON FINANCE DR. LEE M. FRANCIS, CHAIRMAN DR. WILLIAM L. BENEDICT DR. EMORY HILL DR. CONRAD BERENS, JR. DR. CLARENCE KING DR. w. GORDON M. BYERS DR. JOHN R. NEWCOMB DR. EDWARD H. GARY DR. LUTHER C. PETER DR. RALPH A. FENTON DR. VICTOR C. SMITH DR. WILLIAM C. F1NNOFF DR. WILLIAM P. WHERRY DR. HARRY S. CRADLE DR. HILLIARD WOOD COMMITTEE ON PUBLICATION DR. WILLIAM ZENTMAYER. CHAIRMAN DR. ARNOLD KNAPP DR. LUTHER C. PETER, EX-OFFICIO DR. WILLIAM M. SWEET LOCAL COMMITTEES ON ENTERTAINMENT ANN ARBOR, MICH. DR. WALTER R. PARKER, CHAIRMAN ATLANTA, GA. DR. F. PHIN1ZY CALHOUN, CHAIRMAN ATLANTIC CITY. N. J. DR. H. L. HARLEY, CHAIRMAN BALTIMORE, MD. DR. JAMES BORDLEY, JR., CHAIRMAN BOSTON, MASS. DR. F. H. VERHOEFF, CHAIRMAN BUFFALO, N. Y. DR. E. G. STARR, CHAIRMAN CHICAGO, ILL. DR. CASSIUS D. WESCOTT. CHAIRMAN CINCINNATI, OHIO DR. ROBERT SATTLER, CHAIRMAN CLEVELAND, OHIO DR. WILLIAM EVANS BRUNER, CHAIR- MAN DENVER, COLO. DR. MELVILLE BLACK, CHAIRMAN DETROIT, MICH. DR. GEORGE E. FROTHINGHAM. CHAIRMAN KANSAS CITY, MO. DR. J. L. MYERS, CHAIRMAN LOUISVILLE. KY. DR. ADOLPH O. PF1NGST, CHAIRMAN LOS ANGELES. CAL. DR. ARCHIBALD L. MACLE1SH, CHAIR- MAN NEW ORLEANS, LA. DR. CHARLES A. BAHN, CHAIRMAN NEW YORK, N. Y. ' DR. WALTER E. LAMBERT. CHAIRMAN OMAHA, NEB. DR. HAROLD GIFFORD, CHAIRMAN PHILADELPHIA, PA. DR. G. ORAM RING, CHAIRMAN PITTSBURGH, PA. PITTSBURGH OPHTHALMOLOGICAL SOCIETY DR. GEORGE H. SHUMAN, SECRETARY PORTLAND, ORE. DR. JOSEPH L. MCCOOL, CHAIRMAN RICHMOND, VA. DR. JOSEPH A. WHITE, CHAIRMAN ROCHESTER, MINN. DR. WILLIAM L. BENEDICT, CHAIRMAN SAN FRANCISCO, CAL. DR. A. S. GREEN. CHAIRMAN SPOKANE, WASH. DR. CLARENCE A. VEASEY. CHAIRMAN ST. LOUIS, MO. DR. JOHN GREEN. JR., CHAIRMAN ST. PAUL AND MINNEAPOLIS, MINN. DR. FRANK E. BURCH. CHAIRMAN 708 Organization of the Congress The report of the Committees on Organization as presented to each of the three component societies, was as follows: It has been resolved, if the report of the Committees is accepted, to issue invitations as speedily as possible to join this Congress to physicians (oph- . thalmologists and others interested in ophthalmology) in good standing in the American Medical Association or other recognized scientific and medical societies of the United States and Canada, and to physicians (ophthal- mologists) in good standing in Cuba, Mexico, Central and South America, and also to physicians through their constituted ophthalmologic societies in those foreign countries with whom we are (March 6, 1920) in diplomatic relation- ship. It was further resolved that the official languages of the Congress shall be English, French, and Spanish, and that the membership fee shall be ten (10) dollars in United States money. The report of the Committee was received and accepted by each of the three societies, and the following invitation was transmitted by the Department of State through the various embassies and lega- tions abroad: The American Ophthalmological Society, The Section on Ophthalmology of The American Medical Association, and The American Academy of Oph- thalmology and Oto-Laryngology have the honor to invite, through his Excellency, the Minister of Foreign Affairs, the Government of - , to participate in An International Congress of Ophthalmology, by sending an official delegate. The Congress will be held under the auspices of these Societies in the City of Washington, United States of America, April 25th to April 28th, 1922. GENERAL COMMITTEE Dr. George E. de Schweinitz, Chairman Dr. Edward Jackson, Vice-Chairman Dr. Luther C. Peter, Secretary-Treasurer Dr. William H. Wilder Dr. William H. Wilmer Dr. Lucien Howe Dr. Frederick T. Tooke Dr. Francisco M. Fernandez Dr. Walter B. Lancaster SPECIAL COMMITTEES Dr. Edward C. Ellett, Chairman of Committee on Organization Dr. Walter R. Parker, Chairman of Committee on Membership and Credentials Dr. William H. Wilmer, Chairman of Committee on Arrangements Dr. Edward Jackson, Chairman of Committee on Scientific Program Dr. Lee M. Francis, Chairman of Committee on Finance Office of the Secretary, 1529 Spruce Street, Philadelphia, Pennsylvania, U. S. A. June the first, nineteen hundred and twenty-one Organization of the Congress 709 This invitation was sent to the following countries: Argentina, Belgium, Bolivia, Brazil, Bulgaria, Chile, China, Colombia, Costa Rica, Cuba, Czecho-Slovakia, Denmark, Ecuador, Finland, France, England, Egypt, Greece, Guatamala, Honduras, Italy, Japan, Morocco, Netherlands, Nicaragua, Norway, Panama, Paraguay, Persia, Peru, Poland, Portugal, Roumania, Salvador, Kingdom of Serbs, Croats and Slovenes, Siam, Spain, Sweden, Switzerland, Turkey, Uraguay, Venezuela. The Committee on Membership sent invitations to the leading members of the profession interested in ophthalmology and to the various ophthalmological societies in these countries, and in Canada, Mexico, and the United States, asking that they make application for membership in the Congress. The members of the Congress and the societies represented are printed in the volume. INDEX ADDRESS of Welcome, 31 Alonso, Antonio F., 371, 378 Andrade, Cesario, 56 Anomalies of Ocular Development and Pigmentation, 528 Bailliart, P., 435 Balbuena, Felix Fernandez, 690, 696 Barraquer, Ignacio, 67, 230, 313, 338, 695 Barraquer, Operation de, 319 Bedell, Arthur J., 588 Benedict, Wm. L., Beraun, Aurelio, 5, 6, 93 Blaauw, E. E., 49, 80, 140, 431, 532 Blindness, Hereditary, in Rabbits, 696 Blood-pressure in the Vessels of the Eve, 435 Books, Historic, 696 Brown, E. V. L., 696 Bruner, Wm. E., 141 Buchanan, Mary, 141 Byers, W. Gordon M., 696 Cajal Method, New Technic, 696 Callender, G. R., 695 Campimeter, Rotating, 695 Campodonico, E., 201 Carvil, Maud, 154 Castresana, B., 171 Cataract, Coralliform, Protein Crystals, 696 Moving Pictures Showing In- tracapsular Operation, 695 Serum and Vaccine Treatment for the Prevention and Cure of, 284 Chalazia, Protozoan Bodies in, 696 Charlin, Carlos, 383 Cheney, Robert Cartwright, 378, 382 Chirurgie oculaire, Des Enseignements de la Guerre en, 39 Chloroma, 588 Choroid, Carcinoma of, 567 Clegg, J. Gray, 170, 229, 337,359,432, 517, 528, 532, 696, 703 Collins, E. Treacher, 5, 6, 68, 103, 142, 231, 430, 532, 695, 699, 700 Color-blindness, Improved Test, 696 Color Vision, The Facts and Theories of, 652 Committee Report on Suggestion for Congress Action, 704 Committees of An International Con- gress, 706 Organization, 706 Organization of An Inter- national Congress, 705 Resolution of Thanks to Various, 699 Congress, International, Invitation, from British Ophthalmo- logical Societies, 699 Members of, 7 Minutes of Proceedings, 692 Officers of, 5 Organization of, 705 Contents, 3 Coolidge. Hon. Calvin D., 31 Cordes, Fred C., 579 Corneal Ulcers, Types of Pneumococcus Found in, 378 Credentials, Presentation, 32 Crisp, W. H., 696 Davis, A. Edward, 284, 312 Davis, Frederick A., 311 Del Monte, Alberts, 696 Derby, George S., 48, 282, 382 Development of Human Eye, 696 Diaphragm Lamps in Ophthalmology, 69 Dominici, Santos, 5 Duane, Alexander, 476, 514 Echanges d'Eau et d'lons a Travers la ^Cqrnee, Les, 157 1'Eclipse Solaire, Troubles Oculaires Consecutifs a 1'Observation Directe de, 340 Elliot, R. H., 66, 93, 333, 356, 405, 434, 476, 695, 703 Endophthalmitis Phacoanaphylactica, 234 Estrabismo, Nuevo Tratamiento Qui- rurgico, 171 Estrada, Antonio Torres, 533, 704 Ewing, A. E., 604 Exhibit for Museum, A. A. O. and O. L., 696 Eye Defects, The Production and Trans- mission of Certain, 669 Transmitted, 696 711 712 Index Facoeresis, 313 Feingold, M., 63 Fernandez, Francisco M., 5, 6, 93, 359 Ferree, C. E., 474, 479, 518 Finlay, C. E., 5, 6, 139, 144, 156 Finnoff, William C., 229, 696 Fisher, W. A., 337 Floria, Salvatore, 5, 6 Fox, L. Webster, 376 Franco, Pimental, 5, 6 Franklin, Walter Scott, 579 Gallemaerts, Emile, 5, 6, 319, 339, 701 Garrison, F. H., 6 Gemblath, S., 95, 102, 337 Glaucoma, The Diagnosis of, 405 Elliot Sign, 695 Glaucomateux, L 'Etat Vasculaire des, 383 Gonzalez, Jos6 de Jesus, 81 Cradle, Harry S., 79 Green, Louis D., 332 Greenwood, Allen, 48, 567, 704 Gullstrand, Allvar, 5, 6, 69, 80, 695 Guyer, M. F., 310, 669, 696, 698 Harford, Chas. F., 160 Holloway, T. B., 64 Hons, William Z., 5 Hooker, Jas. F., 6 Howe, Lucien, 5, 281, 309, 329, 696, 699, 701 Hyalitis, Asteroid, 696 Jackson, Edward, 5, 78, 140, 532, 704 Jean, Geo. W., 433 Jennings, J. Ellis, 696 Junes, Emile, 520 Keratitis, Congenital Syphilitic Inter- stitial, The Effect of Direct Instilla- tion of Novarsenobillon in the Conjunctival Sac in Resistant Cases, 548 Keiper, George F., 169, 433 Kerry, Richard, 233 Knapp, Arnold, 282, 433, 573 Kostitch, Dragoutine, 340 Krimsky, Joseph, 102 Lacrimal Passageways, On the Clin- ical Anatomy of the Efferent, 625 Lagophtalmie Bilatrale Consecutive a la Perte Accidentelle de la Peau du Front, et du Cuir Chevelu. B16ph- aroplastie, 460 Lambert, W. E., 459 Lancaster, Walter B., 153 Lapersonne, F. de, 5, 6, 39, 49, 102, 156, 335 Lasalle, Albert, 5 Lempine, A. N., 234, 282 Lewis, F. Park, 67 Li, T. M., 5, 6 Libby, Geo. F., 140 Light-Sense : The Practical Significance of its Variations: Simple Tests for Determining Them, 468 Lister, Sir William, 50 Mackay, George, 5, 6, 357, 695, 702 Magitot, A., 359, 369, 435, 696 Magitot, A., and Bailliart, P., 435 McCaw, John A., 695 McMullen, John, 6, 102 McReynolds, John O., 212, 331, 377 Mills, Lloyd, 94, 335 Morax, V., 157 Noble, Robert E., 695 Nomenclature, Ophthalmologic versus Anatomic, 607 Nordenson, J. W., 66, 432, 695 Ocular Degenerations, Hereditary, "Ophthalmic Abiotrophies," 103 Operations (Plastic) About the Eve, 443 Orbit, Bilateral Lymphosarcoma with Intermittent Exophthalmos, 579 Metastatic Thyroid Tumor in the, 573 Some Descriptive Errors in the Anatomy of, 617 Orbital Marsupialization and Superior- ity of Organic Grafts of Dead Tissue in Establishing a Mobile Stump, 359 Parinaud's Conjunctivitis, Lesions and Organisms, 696 Patton, Jas. M., 281 Penichet, Jesus W., 5, 6, 101 Percival, Archibald Stanley, 468 Perimetric Technic, Standardization of, 615 Perimetry, 695 Peritomia en las Ulceras Cronicas Vasculares de la Cornea, 371 Peter, Luther C., 5, 429, 515, 615, 695 Photography, Centric, of Fundus, 695 Poyales, Dr. Francisco, 5, 214, 233 Pregnancy, Bitemporal Contraction of Visual Fields in, 144 Prince, A. E., 212 Proceedings, Minutes of, 692 Propositions for Congress Action, 604 Psychopathology in Ophthalmic Prac- tice, 160 Index 713 Pterygium, A New Procedure in the Excision Method of, 201 The Subconjunctival Ex- cision of, 205 Queratitis Infecciosas, Tratamientos, por las Vacunas, 551 Rand, G., 479 Refraction, Le Diagnostic et la Mesure des Vices, au Moyen de la Fente St6nopeique el- du Cadran Horaire, 520 Renshaw, Arnold, 548 Representatives, Official Government, 5 Retina, A New Technic for the Appli- cation of the Method of Cajal to Sec- tions of the, 690 Rochat, G. F., 5, 6, 49, 80 Roelofs, Otto, 475 Rood, L. C., 281 Rowan, John, 703 Roy, J. N., 368, 460 Salutatory of President, 37 Schaeffer, J. Parsons, 625, 696 Schweinitz, G. E. de, 5, 37, 572, 704 Science and Practice of Ophthalmology, Some Contributions to, 479 Scientific Papers and Addresses, 39 Shrunken Eye, Changes in, 696 Smtomas Oculares del Envenenamiento por el Piquete de Alacran, 81 Soriano, Francisco J., 5, 6 Stark, H. H., 230 Tooke, Fred. T., 48 Trachoma, Traitement du, par les Injections sous Conjonctivales de Cyanure de Mercure, 95 Tratamiento de las Formas Graves de Conjuntivitis y Queratitis Eczema- tosas, 533 Trephines, Clockwork and Cable, 695 Troland, Leonard Thompson, 652, 698 Troncoso, M. Uribe, 607 Tuberculosis, la Ocular Infantile, 214 Ocular, 696 Tyson, Henry H., 310 Uveokeratitis, Acute Tuberculous, 696 Verhoeff, F. H., 68, 139, 232, 234, 283, 696 Verhoeff, F. H., and Lemoine, A. N., 234 Virgili, Rovirosa, 551 Visual Tests. The Value of Letters and Characters as, 604 Vitreous, Detachment of, 50 Weeks, John E., 65, 230, 429, 459 Wescott, C. D., 703 Wheeler, John M., 443 White, Jos. A., 336 Whitnall, S. E., 617, 696 Wood, Casey A., 696 Wright, John Westley, 330 Zentmayer, William, 517 Ziegler, S. Lewis, 205, 213 UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. NOV Form L9-107n-3,'48 ( A7920 ) 444 LC 000937698 9