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bly originate from a concretion of blue granules (mulberry

In sections in which no color differentiation occurs between
red and blue granules, the inclusion presents quite a different

The development of the inclusion proceeds in the following
manner. At first round, sharply circumscribed, blue forma-
tions the size of a coccus are seen in the protoplasm of the
epithelial cell, sometimes double bodies or in masses collected
in a hollow of the protoplasm. The individual granules, how-
ever, are always sharply defined, and like Gram f)ositive cocci
appear in strong contrast to the red background. (Contrast
Stain Lindner.) These granules, which he designates initial
formations, multiply (division forms) and subsequently ex-
hibit a central bluish clearing, "n which very fine granules
originate. Diu-ing the further jrrowth of the inclusion the
marginal initial formation gradually clears, the bluish central
area progressively increases in size and the granules within
proportionately become more numerous. Ultimately the mar-
ginal initial formations disappear entirely.

Wolfrum remarked this difference in size in section prepa-
rations, attributing the same to better nutrition of the marginal

Still in strip preparations, the trachoma granules in the
same inclusion are always of the same size, viz., very small;
never do they reach the size of the initial formations. On the
other hand, it is undoubtedly true that the late marginal forms
are identical with the initial formations, which again corre-
spond to the blue granules (the so-called plastin) in strip
preparations. Inasmuch as in the beginning only blue gran-
ules are dis.cernible, which ordinarily are entirely unable to
conceal the red color of the trachoma bodies, they must be
considered mother cells, if we regard the red granules of
parasitic origin.

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Moreover, in the discharge formations are found in the free
state exactly like the initial formations — pale blue round or
oval formations, the size of a coccus or larger, with distinct
polar staining, on superficial examination liable to be mistaken
for a diplococcus. Rarely do division forms occur. The
smallest specimens are hardly larger than trachoma granules
and generally exhibit a pale center.

Such formations are at times found not only in the inclu-
sions of section preparations (alcohol-sublimate, fixing with
contrast or Weidenhein-Eisenham stain), but also, though
rarely so well demonstrable, in the inclusions of strip prepa-
rations. They are found in all preparations obtained from
acute trachoma, in so-called inclusion blenorrhoea (acute
trachoma of infants), and in monkeys inoculated with inclu-
sion blenorrhoea or directly from the maternal vagina.

He thus considers the so-called plastin a stage in the life
history of the causative agent. If the initial formations mul-
tiply in the protoplasm a considerable length of time before
granules appear, an inclusion rich in plastin results; if the
initial formations without multiplying to any extent imme-
diately go over to the second stage, an inclusion with little
plastin results.

In sections the inclusions are found in larger numbers;
the epithelium is usually lacerated and disarranged, a sign of
the marked desquamation.

The author considers it impossible with the staining meth-
ods in use at the present time to diagnosticate free trachoma
bodies in sections (they are hardly well seen in the inclu-
sions) or even free initial formations, because of their resem-
blance to other granules. Mast cells, etc.

Trachomatous Patmus, No inclusions are found in the cor-
neal epithelium resembling those seen in the conjunctiva : the
trachoma bodies lie scattered throughout the cell protoplasm
and massed forms are exceedingly scarce. So-called plastin
is never present. Double forms occur frequently. The bodies
vary in size from visibility to the size of a coccus. In two
cases of acute pannus he found the most seriously infected
epithelial cells in that uneven corneal zone in advance of the
vascularized pannus. Most of the scrapings from the pannus
epithelium show spindle-shaped bodies of a pale blue color,
or contain granules staining red. The formations may be
either intra- or extracellular.

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Lindner also finds the trachoma bodies in red blood cells,
confirming Leber's observations. He finds them generally in
pairs or arranged in a row and always in association with
spindle-shaped bodies.

Even before the discovery of the initial formations Lindner
was convinced that those bodies were specific for trachoma
and represented organized formations. The subsequent find-
ing of initial formations, he thinks, proves positively the para-
sitic nature of Prowazek's inclusions

After alluding to articles by Heymann, Stargart, Schmeich-
ler, Hialberstadter and Prowazck relative to inclusions in cases
of ophthalmia neonatorum, Lindner cites his own experiences.
Up to the present time he has examined 31 cases of blenor-
rhoea neonatorum, a term which he applies to all purulent in-
flammations of the conjunctiva in the newborn. Excluding
three chronic cases, negative in every respect, there were
found amongst the remaining 28, 13 gono-blenorrhoeas. In 12
of these, also in 6 acute and 2 more chronic cases of adult
gonorrhoeal ophthalmia, no Prowazek's inclusions could be

In one blenorrhoea with gonococci and in the other 15 cases
free from gonococci (9 unilateral cases) epithelial inclusions
were found which could not be distinguished from those oc-
curring in trachoma, the number of inclusions being propor-
tional to the severity of the disease. Initial formations were
numerous, also granules, some of which were free, others
contained in pus cells. Excepting the one case of mixed infec-
tion, most of the remaining cases were of less severity.

Inclusions could be demonstrated even after two weeks'
treatment. The disease set in between the sixth and seven-
teenth days.

From these findings Lindner concludes that there are some
cases of ophthalmia neonatorum (usually the less severe
forms) which have no connection with the gonococcus, but
in which are found inclusions exactly resembling the inclu-
sions found in acute trachoma of adults.

The findings and clinical similarities between gonorrhoeal
ophthalmia and acute trachoma make it seem reasonable to
suppose that such cases of ophthalmia nonatorum are really
cases of acute conjunctival trachoma. A trachoma of the
genital tract must, therefore, also be assumed. Experimental
inoculations at least have demonstrated that in the vagina a

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virus may exist which in the newborn causes an inclusion
blenorrhoea; in monkeys, however, a disease of the conjunc-
tiva clinically and pathologically the same as true trachoma.

Contrast Stain. The cover slips (epithelial scrapings) are
dried in the air, fixed in absolute alcohol, and floated (smear
surface downwards) for one hour or longer in the following
solution :

5 gtts Giemsa (orig. Griibler).
10 cc distilled water.
1 gtt 1% acetic acid.
Then dried, and mounted in cedar oil. The inclusions stain
blue, cell nucleus and protC4)lasm a rose color.

(Sections remain in the above solution 8-12 hours; then im-
mersed in absolute alcohol, xylol and cedar oil.)

Having found inclusions and noted the position of the same
(on the movable object carrier), the slips are passed through
xylol, absolute alcohol, water into the
Permanent Stain,

(More beautiful preparation)
5 gtts. Giemsa, 2 gtts. Giemsa,

10 cc. Aqua destill., 10-15 cc. Aqua destill.,

1 hour. About 12 hours.

Thereupon rinsed in absolute alcohol as long as blue color
is given off, dried and mounted in acid-free cedar oil. For
sections only the contrast stain can be employed. A. C. S.

OcHitributlon to the Question of the Etiologic Factor of Trachoma.

Werner, Ernst, Marburg (Zeitschrift f. Augenheilkunde,
October, 1909, Band XXII, Heft 4).

Werner made a number of microscopic examinations in cases
of fresh non-treated trachoma, treated trachoma and in tra-
choma with scar tissue, using as a control 25 cases of non-
trachomatous conjunctivae. In this latter class were cases with
normal conjunctiva, conjunctivae affected with acute and
chronic catarrh, also follicular and spring catarrh, eczema and
tuberculosis. AH of the preparations were stained with a
modified Giesma stain, as suggested by Greeff. The trachoma
bodies were found solely in the trachomatous cases, and were
much more numerous in the acute cases and those that had
not been previously treated.

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The trachoma bodies were of various shapes and were
usually in contact with the nucleus in the shape of a close-fit-
ting cap. In old, scarred trachoma cases and conjuctiva not
affected with trachoma these bodies were never found.

A description of the differential diagnosis between these
trachoma bodies or chlamydozoen, as Prowazek calls them, is
hardly possible, but the author believes that any one who has
once seen and followed the various stages of the trachoma
bodies will never mistake them for anything else. F. K.

Experimental Transference of Ophthalmic Neonatonun (Free

From Gonococci, but with Epith^ial Invasions)

to Monkeys.

Lindner, K. (Wiener klin, Wochenschrift, 1909, No. 45).
At the International Congress in Budapest, 1909, Heymann
showed preparations of gonoblenorrhcea of the newborn with
epithelial cell inclusions which could not be differentiated from
trachoma inclusions. Prowazek and the writer, however,
could find these inclusions only in those cases of ophthalmia
neonatorum in which no gonococci could be demonstrated. To
prove that these cases were allied to trachoma, he selected two
cases of ophthalmia neonatorum free from gonococci, but with
epithelial cell inclusions, and inoculated three macaque apes
and one pavian. •

In one macaque ape a mild conjunctivitis was observed at
the end of six days, and in the scrapings were found several
Prowazek bodies. In the other two monkeys no reaction en-
sued and no inclusions could be demonstrated.

In the pavian, after an inoculation period of four days, a
rather severe purulent conjunctivitis set in, and on the seventh
day numerous Prowazek inclu.-^ions were found.

These experiments show that it is possible to transfer to
monkeys the virus obtained from a case of ophthalmia neona-
torum free from gonococci, but containing cell inclusions. In-
asmuch as the clinical course of a positive inoculation resem-
bled a trachoma inoculation, the idea suggests itself that such
cases of ophthalmia neonatorum are cases of conjunctival
trachoma of the newborn. A. C. S.

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On the Care of Trachomatous Pannus by InoealationB With
Gonorrhoea! Secretion.

GoLDZiEHER, W., Budapest (Wiener klin,Woch,, December
30, 1909). Goldzieher details the histories of three patients with
trachomatous pannus (pannus crassus, carnosus), in which
he resorted to inoculations with g^onorrhoeal secretion. Follow-
ing an inoculation period varying from 3-4 days a violent pur-
ulent conjunctivitis usually set in, after the subsidence of
v/hich vision was found in every case to be greatly improved.

He thinks the treatment, however, only indicative where
the pannus appears as a dense, vascular network, almost en-
tirely concealing the iris, ofttimes distorting the corneal curva-
ture and reducing vision to hand movements. In cases in
which it is possible to make out the individual parent stems
at the limbus, galvano cauterization is always the operation of

In unilateral cases the question of inoculation must receive
more careful consideration and the patient fully informed as
to the possible consequences. Still the writer has never ob-
served an infection to follow in the unaffected eye. He pro-
tects the eye by covering it with a modified Buller's shield.

The less virulent gonorrhceal secretion should be employed,
the secretion obtained from a case of ophthalmia neonatorum
being the most suitable. Such inoculations often result in a
complete return to normal anatomical conditions without the
formation of any scar tissue.

Goldzieher believes the inflammatory reaction causes a de-
struction of the young, unstable cells of the infiltration tissue.
He emphasizes that the method is only to be considered in cases
in which vision is practically lost and other remedial agents
have failed. The vascular, succulent porous tissue, containing
in its vessels protective bodies, is much more resistant than the
transparent cornea.

He considers jequiritol in mild cases unreliable and not free
from danger, and in extreme cases usually ineffectual.

A. C. S.

Burn of the Cornea Caused by Blue dtone. Snit for Malpractice.

ZvRM, E., Olmiitz (Wiener klin, Woch,, December 16,
1909). The patient, a 34-year-old man, afflicted with chronic
trachoma, had been under Zirm's care in the hospital for about

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ten weeks, during which time daily applications of crystallin
copper sulphate were made. He was then discharged, and
subsequently entrusted with a stick of copper sulphate. He
had treated himself for about eight months, when one day,
according to the patient's statement, while using the copper
stick a piece broke off and remained in his eye, all attempts to
remove the same proving ineffectual. No physician, however,
was consulted until Zirm saw the patient on the following day,
and found an extensive eschar of the upper tarsal and bulbar
conjunctiva, including the upper portion of the cornea. The
case proved very obstinate to treatment, the final result being
a dense corneal opacity, with symblepharon between the upper
inner corneal quadrant and the upper lid. Fingers could not be

The patient then brought suit against Zirm. A letter con-
taining the following questions was sent by Zirm to leading
ophthalmologists, Fuchs, Uhthoff, Hirschberg, Kuhnt, etc.:

1. Do you permit patients to treat themselves with the cop-
per stick?

2. Have you ever encountered a case of burn of the cornea ?

3. Do you consider the possibility of such an accident an
event easily foreseen?

No one had ever met with such a complication. Fuchs
thought the breaking off of chips during the application a
most unusual occurrence, never observed by him, and some-
thing that could not be foreseen. Elsching olten observed a
crumbling of the stick during vigorous application, but never
a case of burn resulting therefrom.

Various answers were received to question No. 1, the
answers for the most part depending upon the location of the
respective ophthalmologists. Zirm thinks clinicians in large
cities seldom find it necessary to prescribe copper sulphate in
crystal, whereas in the provinces such method of treatment
often becomes necessary and in trachomatous families a great

The case was finally settled out of court. A. C. S.

Hypopyon Keratitis With Unusual Bacterial JRindings.

RosENHAUCH, Cracau (Klin. Monatsblf.,Augenheilk., Sep-
tember, 1909). In ten of Rosenhauch's cases the pathogenic
organism was Petit's bacillus (Diplobacillus liquefaciens

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Petit) ; six occurred in women and four in men. With but
two exceptions they occurred at about the fiftieth year. In all
cases iritis was present; the exudate in the anterior chamber
varied in amount, but in all was gray in color, with here and
there a yellowish hue. In the majority of the cases the
ulcer was extensive and occupied the fissural portion of the
cornea. In two cases the ulcer was of the serpens tyi>e. In
five cases trauma had occurred. In two dacryocystitis was
present. In four cases the infiltration destroyed the tissues
down to Descemet's membrane. He concludes that from the
clinical appearances it is impossible to decide with certainty
as to the etiology of an ulcer. In one case, in which the cause
was the staphylococcus aureus sarciniformis, panophthalmitis
developed. In one case the organism was an unidentified
Gramme-negative bacillus. Morphologically it resembled the
Friedlander pneumococcus, the bacillus pyocyaneus and the
ooli bacillus. It diflFered from the first in that it gave a marked
indol reaction, formed colonies in bullion, liquefied gelatin and
evolved no gas in sugar agar. From the second it diflFered in
beii^ thicker and in producing no stain ; it did not coagulate
milk and evolved no gas on sugar agar. From the third it dif-
fered in not coagulating milk, decomposing sugar a^far and
liquefying gelatin. W. Z.

Fathological Anatomy of Phlyctenular and Phlyctenular-LIke


Sayasha> Tokio (Klin. MonatsbL /. Augcnheilk,, November,
1909). has made a histological study of preparations from
cases of marginal phlyctenular conjunctivitis where there was
also a peripheral triangular infiltrate in the corneal tissue. The
conjunctival stroma, just beneath the epithelium, showed
marked infiltration with lymphocytes and in places polynuclear
leucocytes, with here and there greatly congested blood vessels
and dilated lymphatics. In the deeper layers there were cir-
cumscribed nodular foci with pale staining center, partly
homogeneous and partly granular, with nuclear debris. Sur-
rounding this was a zone of granulation tissue, made up prin-
cipally of lymphoid and a few spindle cells, resembling epi-
thelioid cells; also giant cells. In other words, the picture of
a tubercular node, with incipient caseation. Still deeper simi-
lar changes were found. The overlying conjunctiva was scant-

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ily infiltrated with leucocytes. No microorganisms were dis-
covered. The author attributes these changes to the action of
tubercle toxines. W. Z.

Nodular Keratitis.

Wehrli, Frauenfeld (Klin. MonatsbL f. Augenheilk., Sep-
tember, 1909), reports a third case of nodular keratitis. The
patient, a gardener, aged 28 years, had had good vision until
two years previously, when sight began to fail without inflam-
matory symptoms. He had been treated at Moorfields, where
the Calamette test had been made, with a positive reaction.
The clinical picture was typical, differing from the author's
former cases in that the opacities lay deeper, and, consequently,
caused less elevation of the epithelium, and in that they were
less irregular and more oval in form. Physical examination
gave evidence of "latent active tubercular lung and glandular
affection." In several preparations of the subepithelial foci,
granular tubercle bacilli were demonstrable by employing the
Much stain. The points of interest in the case, confirming
the author's previous observations, are that the affection occurs
principally between the second and third decades ; that it is not
congenital, that histologically it consists of a focal, entirely
superficial parenchymatous inflammation and is in every way
analogous to the changes induced in Schleik's experiments by
inoculating the cornea with tubercle bacilli of attenuated viru-
lence. W. Z.
Keratitis Oonorrhoica Metastatlca.

AsHER, W., Leipsic (Zeitschrift f. Augenheilkunde, Novem-
ber, 1909. Band XXII, Heft 5). The patient, a 19-year-old
male, had gonorrheal rheumatism of the knees, associated with
metastatic conjunctivitis, followed later by inflammation of
the interstitial corneal layers.

Under atropin and heat, the keratitis cleared up. A second
attack of gonorrheal metastatic conjunctivitis occurred, the
purulent secretion of which wis sterile. F. K.

The SiRniflcanre of the Wassermann Reaction and Old Tuberculin
Injection in the Etiology of Parenchymatous Keratitis.

KummKll, Erlangen (Klin, MonatM, /. Augenheilk., De-
cember, 1909). The results of Kunimeirs studies were that in
11 cases of parenchyinatous keratitis, in which syhilis was
either the likely or the sure cause, and three in which tuber-

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culosis was suspected on the grounds of the history and the
physical examination, the Wassermann reaction was positive
in every case. The same was true in nine cases which gave
a positive reaction to old tuberculin injections. Which of the
reactions is to be given the preference is debatable, but ap-
parently the Wassermann reaction is of the greater impor*
tance. W. Z.

Contribatioii to the P»tholo|^eal Anatomy of Scteritls.

KoMOTO^ Tokio (Klin, MonatsbL f. Augenheilk,, December,
1909), gives a histological study of an eye, the seat of a scle-
ritis, which had to be removed because of intense pain. The
patient was a woman, 47 years of age. In the upper-inner
quadrant of the globe the conjunctiva was congested and
swollen. Cornea clear. Iritis with pupillary membrane. De-
spite treatment, the injection spread around the cornea and
the swelling towards the equator, and a palpable tumor
formed behind the equator, pushing the eye forwards and up-
wards. Cornea now hazy.

Microscopic study showed the tumor to be composed of
round and oval mononuclear cells, occupying the fissures in
the very vascular scleral tissue. The outer layers were most
involved. In the most involved portions the scleral fibres
could scarcely be traced throuiafh the infiltrate. The conjunc-
tiva and orbital fat contained disseminated infiltrate. Vessels
were not numerous, no necrotic areas were detected, but in
some places the cells stained lightly and weie endothelial-like,
but there were no giant cells. Posterior to the growth the
infiltrate was slight, but could be traced in places to the s-heath
of the optic nerve. Between the limbus of the cornea and the
growth the infiltrate was more diflFuse. The conjunctival infil-
trate was very marked and dense. The blood vessels and
lymph spaces were very numerous, giving the appearance of
cavernous angioma. Nodes, resembling trachoma follicles,
were found, made up of pale endothelial cells. Ther^'were no
phagocytes or giant cells. In the corneal layers the infiltrate
reached quite a distance into the parenchyma. Descemet's
membrane was destroyed only in the vicinity of Schlemm's
canal. W. Z.

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Donoeming the Employment of Wright*s Opsonic Technic in
Ophthalmology with Special Reference to Tuherculous

* Stock, Freiburg (Klin, Monatsbl. f. Augenhcilk,, November,
1909), concerned himself in his painstaking investigations
with the questions : Is it necessary in the therapeutic employ-
ment of tuberculin to determine the opsonic index? Are bet-
ter results thus obtained than by purely clinical observations?
Can a conclusion be drawn as to whether a disease of the eye
is or is not tuberculous by estimating the opsonic index ? From
a careful study of eight cases he concludes: That if the op-
sonic index is estimated during a tuberculin treatment an in-
crease in that index may be noted in many cases under small
^d few injections. This increase does not prove that the
case has been favorably influenced clinically by the tuberculin
employed. It was proven that while with these small doses
the cure made no progress, larger doses favorably influenced
the disease. He is of the same opinion with many other writ-
ers that high opsonic index is not significant of cure. It is
unnecessary as a control to the emplo\Tnent of tuberculin
therapeutically. He injects as high a dose of tuberculin as
the patient will bear without manifesting any reaction (pain
at the point of injection, rise in temperature or indisposition).
He made use of the fact that the opsonic index is influenced
by irritation of a tuberculous focus, for diagnostic purpose.
He irritated the diseased eye with dionin and found that the
index for tuberculosis fluctuated markedly, v/hereas if the
ocular inflammation had another cause it was not materially
changed. This observation is clinically interesting and impor-
tant, as it proves that through irritation of a diseased eye ma-
terial is disseminated into the body. It is possible that dionin
and subconjunctival injections of salt bring about the forma-
tion in the body of antibodies. W. Z.

Concerning the Beginning of Senile Cataract in the Inferior Half

of the Lens.

Online Librarysciences et arts de la Dordogne Société d'agricultureThe Annals of ophthalmology → online text (page 32 of 82)