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COLLEGB OF PHYSICIANS OF PHILADELPHIA



see, to observe the treatment instituted
by the representative of the United
States Public Health Service, Dr. Mc-
MuUin, and make a report, to be used
in the treatment of cases of trachoma
in the army. I was also requested to
make suggestions to the Quartermaster
General's Office as to accepting infected
individuals in the draft. The observa-
tions that I made, conclusively proved
that trachoma, under the treatment in-
stituted by the Public Health Service,
could be cured ; and in a time sufficiently
limited to permit of the man's being avail-
able for service. Recommendations were
made that a trachoma concentration camp
be formed, to which should be sent men
from the various camps for observation,
treatment and training. The general
staff, however, did not see fit to accept
these recommendations; so the trachoma
concentration camp never developed.
However, the next article's reference to
acceptance to the draft included trachoma
as a remediable disease. Later, that was
thrown out ; and all trachoma cases were
to be rejected. Still later on, they were
to be received for treatment in the base
hospital, and if not cured in a certain
length of time, were to be discharged.

As to the question of the transference
of contagion in our armies, I think that
the training that the men received in
personal hygiene and the establishment
of an Ophthalmological Section in the
Medical Department of the Army, made
the possibility of infecting the army ab-
solutely nil. The men took care of their
eyes. If they had eye trouble, they went
to the regimental surgeon, who sent them
to the field hospital ; and from there, they
were sent to the base hospital, where, if
they had trachoma, it was taken care of.
So if a man had trachoma, even in a stage
in which infection was evident, there
would be no chance to infect the army
at large, because of the precautions due
to personal hygiene and the establishment
of an ophthalmologic department in the
army.

(To be continued.)



COLLEGE OF PHYSICIANS

OF PHILADELPHIA

SECTION ON OPHTHALMOLOGY

April 17, 1919
Dr. William T. Shoemaker,
Chairman
Bilateral Congenital Entropion.

Dr. Wm. Zentmayer presented an
infant upon whose eyes he had per-
formed an operation for congenital en-
tropion of both lower lids. The re-
moval of a crescent of skin with a few
of the underlying fibers of the orbi-
cularis had been sufficient to cure the
condition. Mayou states that these con-
ditions are never true entropion but a
malposition of the cilia. In this case
the margin of the lid was rolled in also,
so that the cilia were turned down into
the cul-de-sac. It may, therefore, be
properly termed congenital entropion.
Congenital Pigmentation of the Scle-
rotics.

Dr. Zentmayer showed R. C, aged
eighteen years, a Russian Jewess.
Each eye presents a broad interrupted
zone of pigmented sclera reaching from
within a few millimeters of the cornea
almost to the equator of the globe.
The pigment is blotchy and varies
from light to dark slaty gray and in
places brownish, probably due to the
presence of capillaries, as the instilla-
tion of adrenalin causes it to lose the
brownish color. The skin of the lids
is dusky and the veins dilated and
dark. The skin of the face shows
linear pigment stripes. There are
disseminated areas of "port-wine"
nevus over the entire body with the
exception of the right arm and foot.
The ocular fundus has a dark steel-
gray hue. The patient is the oldest of
five children. None is similarly af-
fected. She had good teeth and has
broken no bones. The condition is a
pigmented nevus of the sclcrotics.
Uveitis with Disciform Opacities.

Dr. Zentmayer since sending in the
title had become convinced that his
case was not really one of asteroid hy-
alitis as he had thought possible at first.
The appearance being similar to a dot-



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196



ted veil. There is a patch of exuative
retinochoroiditis in the same eye.

Discussion. — Dr. Halloway stated
that he agreed with Dr. Zentmayer
that the present opacities were those
sometimes seen in cases of severe uvei-
tis. Since the publication of his pre-
vious report he has seen three cases
of these snowball vitreous opacities,
the details of which will be published
later.

Congenital Ptosis. Motais Operation.
The case was reported to emphasize
the value of the Shoemaker modifica-
tion of Motais's operation. The child
was aged five years, and the superior
rectus so frail that the difficulties of
the procedure would have been unsur-
mountable had not the open method
been used. The result is not perfect
but is very good.

Use of Ethylhydrocuprein.

The case presented had been one of
severe pneumococcic traumatic ulcer,
7 mm. in diameter, with hypopion.
Vision — L. P. The treatment con-
sisted in the use of ethylhydrocuprein,
ice compresses and atropin. The re-
sult was a corneal scar not as large
as the original ulcer and vision «=
3/60. Dr. Zentmayer's faith in ethyl-
hydrocuprein strengthens with his ex-
perience. Any bactericidal agent to
be effective must be, as far as practical,
constantly in contact with the organ-
isms. His method of using optochin is
to have a 1 per cent solution dropped
into the conjunctival cul-de-sac every two
hours during the day and every three
hours during the night, and to have
the ulcer touched with 2 per cent twice
daily. A local anesthetic should be
used before each application.

Buphthalmos: Results of Posterior
Sclerotomies and Optical Iridec-
tomy.

Dr. Luther C. Peter exhibited P.
v., aged seventeen months, who was
shown at the section about a year ago.
Briefly the history at that time was as
follows :

The child had a condition of buph-
thalmos at birth. The comeae were
both very large, blue and the centers



of the corna were occupied by marked
white opacities and granulations. It was
pebbly in appearance, with marked
juvenile arcus. The anterior chambers
were very deep and the iris indistinctly
visible thru the cloudy cornea;
pupils dilated to about 4j4 mm.; ten-
sion of the eyeballs about 35 mm. The
scleras are bluish white in color.

Family History. — ^The parents are
Italians, second cousins; one other
child, an older brother, is suffering
from the same disease and is totally
blind, enucleation having been per-
formed on one eye. There are five
other healthy children.

Myotics were used the first six
months without any apparent improve-
ment. At this time posterior sclerot-
omy was performed on the right eye
without any untoward symptoms and
was followed by a marked clearing of
the cornea. Subsequently at intervals
of two months repeated posterior scle-
rotomies were performed, four on each
eye, followed in each instance by
marked clearing of the cornea, which,
however, had a tendency to relapse.
By this series of tapping the posterior
chamber the tension of the eyes has
been kept at about 25 mm. of mercury.
Because of the cloudy media the child
was developing lateral nystagmus.
Optical iridectomies were therefore de-
cided upon and a small section of the
iris was removed at the outer limbus in
the right eye and the inner limbus in the
left eye as the areas in the cornea offer-
ing the best visual results. Very lit-
tle reaction followed these operations,
and the child now is able to see objects
fairly small, and the nystagmus has
practically disappeared.

The results obtained from this
method of treating the patient are satis-
factory up to the present time. (1)
The corneal opacities were decidedly
lessened after each posterior scle-
rotomy ; (2) the tension of the eyeballs
was held at about 25 mm. of mercury ;
(3) thc^ optical iridectomies have de-
cidedly improved central visual acuity
and have practically removed the
nystagmus which was rapidly develop-
ing. The child is kept under observa-
tion, and should the tension be in-



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AMERICAN OPHTHALMOLOGICAL SOCIETY



creased further, posterior sclerotomies
will be performed. One cannot say
what the ultimate prognosis will be in
this case as the results of the surgical
procedures, but the visual results and
the general improvement at this time
are very satisfactory.

Dr. Zentmayer thought that Dr.
Peter was fortunate in the result ob-
tained. From the opinion expressed
by many of the ophthalmic surgeons
of America it is evident that any opera-
tive procedure to be of value must be
done early. He recalled that Dr. de
Schweinitz had reported successes with
posterior sclerotomy, and Dr. Zent-
mayer believed that, except in the very
earliest stage of the disease, this was
the only justifiable procedure.

Dr. Holloway stated that in examin-
ing this child he had noted that there
occurred some reflex sneezing. In his
experience this very frequently occur-
red, and he referred to two children at
the Overbrook School for the Blind
where this was present to a persistent
and excessive degree upon the slight-
est attempts of the patients to open
their eyes. There was intense photo-
phobia in each case. He thought it
worth while to comment upon this, not
because he regarded it as peculiar to
this particular affection, but simply be-
cause it is frequently associated with
it.

Dr. de Schweinitz stated that his at-
tention had been directed by Haab's
recommendation to the value of re-
peated sclerotomies in the treatment of
buphthalmos. He briefly referred to
two cases treated by corneoscleral
trephining, the operations having been
performed not by himself. Certainly
in these two cases apparently there was
temporary benefit, but he was unable
to relate the ultimate outcome of the
operations.

Unusual Case of Perivasculitis.

Dr. Luther C. Peter showed Mrs.
A. J., colored, aged sixty-one years,
housekeeper, who complained that her
sight began to fail about three years
ago. Her present ocular condition is
as follows :

Vision in the right eye is 20/200 and



in the left 20/30. Arcus senilis is
marked in both eyes; pupils 3 mm.
equal in diameter; react to light and
accommodation. Eye-grounds: Right
eye pupil is oval, long axis, 90 degrees.
There are a few fine lenticular opaci-
ties and a few floating masses in the vit-
reous. The disc is 16x18 mm.; long
axis, 90 degrees, well defined, except-
ing at the upper and outer border;
edges somewhat obscured. The veins
are overfilled and tortuous; arteries are
tortuous and light streaks are for the
most part absent. The superior tem-
poral branch of the central artery
shows a marked perivasculitis. It
consists of a broad ribbon-like perivas-
cular tissue thru which a narrow col-
umn of blood is visible here and there.
About 3 d. d. from the disk the vessel
and its branches disappear in a retinal
haze, but appear beyond in bifurca-
tions, which are surrounded by narrow
borders of white. The terminal
branches are exceedingly narrow and
tortuous and the macula branch, which
is derived from the superior temporal
artery, is also a solid mass of white
tissue and is lost in a hazy macula area.
This temporal vessel, including the
macular twig, is at least twice the size
of the other branches of the central
artery in the neighborhood of the disc.
Surrounding the macula is a beginning
stellate figure which, is regarded as di-
agnostic of the so-called "albuminuric
retinitis." Beneath the macula are a
few minute round hemorrhages. Other
parts of the fundus show moderate ret-
inal haze and edema and evidences of
arteriosclerosis. There are no hemor-
rhages. The perivasculitis is dis-
tinctly confined to the superior tem-
poral branch.

The left fundus is similar in appear-
ance to that of the nasal half of the
right retina, characteristic of the fun-
dus usually found in chronic intersti-
tial nephritis.

The fields in each eye show the char-
acteristic contraction for form and
color. In addition to this concentric
contraction there is a quadrant area of
blindness down and in. This quadrant is
almost lost for form and totally lost for
red, and in a small area to the nasal



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697



side 6i the field the green test object
is recognized as white.

The patient shows a generalized ar-
teriosclerosis. The urine is of low
specific gravity and contains an occa-
sional cast and albumin. The blood
Wassermann is negative. The clinical
medical diagnosis is that of chronic in-
terstitial nephritis, with marked car-
diovascular changes.

The case is of unusual interest both
because of the imitation of the peri-
vasculitis, the superior temporal
branch of the right eye, and also be-
cause of its very pronounced appear-
ance and the abundance of the perivas-
cular tissue. As to the immediate etio-
logic factor, embolic or thrombotic
processes can be safely eliminated.
The condition undoubtedly is a peri-
vascular change, arteriosclerotic in ori-
gin and associated with chronic inter-
stitial nephritis.

Dr. de Schweinitz agreed with Dr.
Peter that the vascular changes in his
patient were not the result of an em-
bolic process, and thought they repre-
sented lesions in association with ar-
teriosclerosis and nephritis. He as-
sumed that the influence of syphilis
had been eliminated. He described a
case of extensive retinal vasculitis and
perivasculitis in a colored man which
he had reported, and which was almost
certainly due to syphilis, and referred
to the fact that it had seemed to him
that such vascular changes were apt to
be more pronounced in the colored
than in the white race.

Sudden Loss of Vision from Acute
Sphenoiditis, Recovery.

Dr. H. Maxwell Langdon presented
the history of this case because of the
three cases reported by Dr. D. T. Vail
in the American Journal of Oph-
thalmology for February, under the
title, "Monocular Retrobulbar Optic
Neuritis from Hyperplasia of the Eth-
moid Bone." Dr. Langdon's case was
very similar to them except that the
sphenoidal sinus was involved instead
of the ethmoid. Mrs. M. B. W. was
first seen on January 23, 1917, with
the following history: She had had
grip, with much pain around the right



eye and brow for the preceding ten
days. O. D. vision blurred the past
two days.

Externally the right pupil was 4
mm. ; no reaction to direct light, but a
good consensual response. The left
pupil was 2.5 mm.; good direct reac-
tion; no consensual reaction. Each
acted well to accommodation. The oc-
ular rotations were full in all direc-
tions. O. D. vision. Fingers at one
foot. O. S. vision 6/10. The media
were clear; the right disc somewhat
hyperemic with blurred nasal margins ;
the left disc was normal; there were
no other fundus changes. The right
field was gone except for an irregular
light field, and the left field was normal
except for a slight contraction for col-
ors.

Dr. G. B. Wood examined the nose
and found no evidence of sinus in-
volvement except some slight conges-
tion of the right middle turbinate; an
X-ray investigation made by Dr. H. K.
Pancoast was negative except for some
clouding of the left antrum.

Later, Dr. Wood again examined the
nose, and after applying cocain to the
right ostium sphenoidale there was a
sudden improvement in vision, the pa-
tient seeing the pattern on the floor
covering. Dr. Wood then removed the
posterior end of the right middle tur-
binate and drilled a small hole thru the
front wall of the sphenoidal sinus with-
out finding any pathologic secretion.
The vision improved with washing oi
the sphenoid, until on the tenth day
after the first operation the vision was
6/15, and with no treatment other than
nasal. The disc hyperemia disappeared
and there were no further complica-
tions, corrected vision being 6/5.

That this was an involvement of the
optic nerve from a sphenoidal sinuitis
seems beyond all doubt, and yet there
was no pathologic secretion on tap-
ping the sinus and no shadow on an
X-ray plate from a cloudy content of
the sinus. It seems there must be a
form of involvement which gives a
clear secretion, at least in the early
stages, for this case was attacked as
soon as the vision was disturbed. It
opens up an interesting point as to



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COLLEGE OF PHYSICIANS OF PHILADELPHIA



whether Dr. Vail did not have some-
thing of the kind involving the
sphenoid rather than hyperplasia of
the ethmoid bone.

Dr. de Schweinitz briefly discussed
a case of . acute retrobulbar neuritis
^'''' which had been examined and de-
'^m^ scribed by Dr. W. R. Parker, where
there had been sudden improvement
in vision after the free use of adrenalin
in the nasal chambers, which had ap-
parently started drainage and thus re-
lieved pressure on the optic nerve. He
questioned whether negative X-ray ex-
aminations and investigation of the
nasal chamber in the sense of failure
to find purulent secretion were suffi-
cient to exclude the presence of some
types of ethmoiditis which might be
the cause of optic nerve changes. He
referred to the fact that unilateral in-
traocular as well as retrobulbar neu-
ritis were strongly suggestive of sphe-
noidal or ethmoidal infection.

H5rpopyon Ulcer of Cornea Treated by
Chauffage.
Dr. H. Maxwell Langdon related the
case of W. M., who was first seen Feb-
ruary 2, 1919, with the history that on
February 22, while digging a street ex-
cavation, a piece of asphalt struck him
in the right eye, since which time the
eye had been sore. The eye was
slightly injected, and there was a cor-
neal ulcer, about 3 mm. in diameter,
slightly to the upper, outer side of the
pupil. The ulcer was touched with
carbolic and a bandage was applied,
the pupil dilating readily with atropin.
The ulcer spread slightly, but was
checked by further carbolization, tho
the center would not heal and there
was steady increase of the hypopyon
until the lower half of the anterior
chamber was filled, and it was deter-
mined to try the effect of radiant heat.
A galvanic cautery was heated until a
thermometer held over it registered
145° F., and when held below the cau-
tery registered 125° ; as the eye was
below the instrument, this is the tem-



perature applied, the eye having been
thoroly cocainized. It was held as
close to the eye as possible, avoiding
contact, for a minute, then away for
three minutes, during which time the
eye was irrigated with salt solution;
the application was repeated twice -^t
the same sitting. In twenty-four hours
the hypopyon was beginning to ab-
sorb, the iris at the lower outer por-
tion of the anterior chamber becoming
visible. The improvement was unin -
terrupted until the hypopyon is now
entirely absorbed and nothing remains
but a moderately dense scar near the
center of the cornea, due probably as
much to the repeated use of carbolic
acid as to the heat. Had the heat be^n
used sooner it seems most likely tKat
the scar would have been much less.

This heat was applied, of course,
after the method described by Week-
ers, and not in the way Shahan advises,
one of his thermophors not being
available.

Dr. de Schweinitz, altho he had had
no personal experience with Dr. Sha-
han's thermophor in ophthalmic prac-
tice, referred to reports he had received
of its value in the treatment of in-
fected corneal ulcers in the service of
U. S. General Army Hospital No. 14,
at the time of the report in charge of
Dr. Meyer Wiener.

Dr. Holloway stated that he regarded
Dr. Langdon's result with chauffage as
excellent, but he felt that it was worth
while emphasizing the important work
which had been done in this country by
Shahan in placing the application of heat
to the eye upon a somewhat more scien-
tific basis. Unfortunately, Shahan's in-
strument was not available at the present
time, and until this could be secured it
would be necessary to use some of the
other methods, which while they doubt-
less give satisfactory results are by no
means as accurate in determining the
actual degree of heat applied.

J. Milton Griscom, M. D., .
Qerk.



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American Journal of Ophthalmology

Series 3, Vol. 2, No. 9 September, 1919

PUBLISHED MONTHLY BY THE OPHTHALMIC PUBLISHING COMPANY

EDITORIAL STAFF



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THE BELGIAN SOCIETY OF
OPHTHALMOLOGY.

After more than five years intermis-
sion necessitated by enemy occupation,
the Belgian Society of Ophthalmology
held its reopening meeting on the 29th
of June. 1919. with Professor J. Coppez
as president.

In his address of welcome Professor
Van Duyse, the general secretary, paid
tribute to the members of the society,
who on the one hand, devoted them-
selves to the cause of law and justice
in the army, and on the other, rendered
signal services in the occupied terri-
tory.

The following resolutions of the offi-
cers of the society were adopted :

"The bureau of the Belgian Society
of Ophthalmology, reunited in the
meeting of June, 1919, at Brussels,
takes cognizance of the facts disclosed
by a letter of the Academy of Science
of Belgfum, of the 20th of January,
1919, and by various documents, which
give evidence that the German scien-
tific and university world approved the



deeds of the Central Powers, against
us and against our allies. These deeds,
contrary to all civilized usage, became
familiar to the population of .occupied
territory during the world war, and.
they remain an ineffaceable stain . upon
conquered Germany.

Therefore the bureau of the Belgian
Society of Ophthalmology engages
that its members:

1. Withdraw from German and Aus-
trian scientific societies and give up all
collaboration with Germans and Aus-
trians.

2. Exchange no publications and
have no intercourse with the Central
Powers.

3. Renew scientific intercourse with
the enemy only when they prove by
public declaration that they condemn
the mentality of those who signed the
manifesto of October, 1914."

Correlative to this order of the day,
the assembly announced the removal
of the names of German and Austrian
honorary members and correspondents
from its lists.

Professor Coppez received congratu-



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EDITORIALS



lations upon the completion of fifty
years of professional service. The sec-
retary recalled to the society that Pro-
fessor Coppez was the founder of the
science of ophthalmology and its teach-
ing in Belgium. Moved by the dem-
onstration, Professor Coppez replied
that it was to the French masters of
the science, past and present, that such
recognition was due.

M. Danis.



THE ETIOLOGY OF MYOPIA.

The relation of the sclera to the skel-
eton, which is mentioned in the paper
by Ochi is suggestive of thought, and
a subject for investigation that may
have very practical results in improv-
ing the management of myopia. The
bony skeleton is, of course, but a part
of the general connective tissue frame
work, which supports all parts of the
body. The peculiarities of structure
and the deposit of lime salts that char-
acterize bone, easily arise in parts of
this connective tissue framework that
usually remain soft, as in anomalous
sesamoid bones, or the "pully*' of the
superior oblique muscle.

The congenital anomaly manifest in
"blue scleras and brittle bones," which
association has occupied an important
place in the recent literature of oph-
thalmology, seems to be an illustration
of the close relation between the sclera
and the bony skeleton as to essential
conditions of nutrition. Other evi-
dence of such a relation is worth look-
ing for, and is likely to prove equally



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