- Email: [email protected]
Congenital Anomalies
American Journal of Ophthalmology PUBLISHED MONTHLY BY T H E OPHTHALMIC
PUBLISHING
COMPANY
EDITORIAL STAFF EDWARD JACKSON, Editor, 217 Imperial Bldg., Denver, Colo. M. URIBE-TRONCOSO, 226 W. 70th St, New York City. MEYER WIENER, Carleton Bldg., St. Louis, Mo.
CLARENCE LOEB, Associate Editor, 25 E. Washington S t , Chicago, 111. LAWRENCE T. POST, Metropolitan Bldg, St. Louis Mo. HARRY V. WURDEMANN, Cobb Bldg, Seattle, Wash.
Original papers, correspondence, and other scientific communications should be addressed to the Editor. Books for review may be sent to any member of the editorial staff. Re ports of society proceedings should be sent to Dr. Lawrence T. Post, Metropolitan Bldg, St. Louis, Mo. Proof should be corrected, and returned within forty-eight hours to the printers. Reorints may be obtained from the printers, Tucker-Ken worthy Co, 501 S. La Salle St, Chicago, 111, if ordered at the time proofs are returned. But reprints to contain colored plates must be ordered when the article is accepted. Copy of advertisements must be sent to the Manager by the fifteenth of the month pre ceding its appearance. The annual subscription for the JOURNAL and the OPHTHALMIC YEAR BOOK is twelve dol
lars, in advance. Subscriptions, applications for single copies, communications with reference to advertising or other business, should be addressed to the Manager of Subscriptions and Advertising— J E A N MATTESON, ROOM 1209, 7 W e s t Madison Street, Chicago, 111.
CONGENITAL ANOMALIES. T h e first t h r e e p a p e r s in this issue give o p p o r t u n i t y to e m p h a s i z e t h e im portance of t h e careful s t u d y of such conditions, a n d t h e need for r e p o r t s of such cases. T h e basic service t h a t a n y physician can r e n d e r t o his p a t i e n t s is accurate, complete diagnosis of his case. O n such a diagnosis every val uable prognosis, a n d every t h e r a p e u t i c service—operative or n o n o p e r a t i v e — m u s t rest. T h e diagnosis m u s t be m a d e in every case, and in every case it is a real s e r v i c e ; even if it only fur nishes g r o u n d for p r o g n o s i s , or p r e vents t r e a t m e n t t h a t w o u l d be useless, expensive, or even harmful. T h e diag nosis of congenital a n o m a l i e s is val uable in itself, even if t h e y c a n n o t be t r e a t e d ; and exclusion of such condi tions is an e x t r e m e l y i m p o r t a n t step in the diagnosis of diseases, t h a t can be treated. L o r i n g , w h o s e c h a p t e r on t h e nor mal fundus contains an a c c o u n t of con genital anomalies, said, " F i v e s i x t h s of the a r t of o p h t h a l m o s c o p y are con tained in a k n o w l e d g e of the n o r m a l eye, t h e rest is a series of r e p r e s e n t a tions which can b e read a l m o s t at s i g h t . " I t is equally t r u e t h a t d i a g n o sis is five-sixths of t h e a r t of medicine. It should be an application of all t h e
p o w e r s of observation of t h e diagnos tician, a n d a focussing of all the re corded k n o w l e d g e of t h e medical p r o fession, on t h e q u e s t i o n s p r e s e n t e d in t h e individual c a s e ; c u l m i n a t i n g in j u d g m e n t t h a t is of value in p r o p o r tion to the b r e a d t h of individual expe rience a n d of t h e race experience, on which it is based. C o n g e n i t a l anomalies and individual peculiarities furnish a larger p r o p o r t i o n of t h e t h i n g s to be observed in a r r i v i n g at a diagnosis t h a n is a p p r e c i a t e d by a n y except t h o s e of w i d e s t professional experience. A y o u n g o p t o m e t r i s t g o t an oph t h a l m o s c o p e a n d learned t o u s e it, u n til he s a w t h i n g s . L o o k i n g into t h e eye of t h e wife of the p a s t o r of t h e c h u r c h h e h a d joined, he s a w red s t r e a k s a n d black p a t c h e s t n a t w e r e n e w to h i m . L o o k i n g into his m e a g r e k n o w l e d g e of ocular disease he s a w w o r d s like choroiditis, retinitis, a t r o p h y , etc. T h e w o m a n h u r r i e d t o an o c u l i s t ; w h o recognized a n d explained her choroid tigre, corrected t h e error of refraction t h a t had caused h e r t o seek relief in glasses, a n d so added to the p r e s t i g e of o p h t h a l m o l o g y , a s well as t o his o w n . T h e o p t o m e t r i s t soon s o u g h t a n e w field of activity. The s a m e m i s t a k e h a s been m a d e b y m e n with t h e medical degree w h o call t h e m 58
EDITORIALS
selves oculists; and with no benefit to themselves or their patients. The writer has seen congenital ab sence or displacement of the puncta, which was the unrecognised cause of epiphora; and congenital anomaly of the hyaloid canal or artery, which was taken for cysticercus in the vitreous. A patient came with vision 0.3 in one eve and 1.3 in the other. In the first eye the fundus appeared normal; in the other the whole macular region was disfigured with pigment blotches. The first eye had a congenital amblyopia, the other only a congenital anomaly of pigmentation. An applicant for a blind benefit claimed to have onl" light pereption; and an experienced and care ful examiner found such striking changes in his fundus, that the state ment was accepted. Later, with the same fundus appearances present, the eye was proved to have not less than 0.8 vision. In two patients, the writer has seen congenital anomalies of the physiologic cupping of the optic disc, which exact ly resembled glaucoma cups. Entire absence of other symptoms of glaucoca, until these patients died several years later, proved that these cups were not produced by excessive intra ocular pressure. The anomaly of a pro truding opaque optic nervehead will be met by every observer of large ex perience in ophthalmoscopy. Every one of them should be examined re peatedly and with great care; not only to determine that it is not a case of op tic neuritis; but also, that the observer may become so familiar with the ap pearances of pseudooptic neuritis, that this condition will not be misleading when encountered in a case of head ache, injury to the skull, or acute dis ease, where true optic neuritis might be looked for. Going back to the anomalies re ported in this issue: Persistent pupil lary membrane, in an inflamed eye, may easily be taken as evidence of iritis. Congenital deficiencies of ab duction and other ocular movements have repeatedly led to muscle opera tions; that were of no benefit to either patient or surgeon, except such as
59
comes by learning through our mis takes. The anomalies mentioned on page 1 are very rare. But for a knowl edge of very rare conditions, we have to rely on the experience of the profes sion, as recorded in the literature, rath er than on our own. All such records should receive careful study and con sideration.
E. J.
THE EYE AND INTERNAL SECRETION.
In analysing the effects of the secre tion of the ductless glands on the eye, one must consider the results obtained by experimental investigation, as well as those from clinical observation. The former are limited, on account of the restrictions necessarily imposed in ex periments on animals; while the ad mitted check, or stimulating influence of the secretions of one set of glands over another, or combination of glands, complicates conclusions one might be inclined to draw from a more simple scheme of things. No one questions the relation between exophthalmos and hyperactivity of the thyroid. Also the accompanying widening of the palpebral fissure and weakness of conver gence. Removal of the parathyroids in rats is followed by ossification of the lenses. Several observers have noticed the as sociation of zonular cataract in chil dren, with bad teeth from a deficiency in enamel, and suffering from rickets and convulsions. Changes in the brows and lashes have been reported as due to disturbance of the gonad function. There is a strong probability that coni cal cornea is the result of an edocrin disturbance, its appearance about the age of puberty being strongly sugges tive. Bearing these facts in mind, it would seem that our attention should be fo cused more on the influence that the endocrin system might have on the function and diseases of the eye. Per haps we are omitting something in our routine investigation into the cause of certain diseases. Again, there may be disturbances of eye function which will
PUBLISHING
COMPANY
EDITORIAL STAFF EDWARD JACKSON, Editor, 217 Imperial Bldg., Denver, Colo. M. URIBE-TRONCOSO, 226 W. 70th St, New York City. MEYER WIENER, Carleton Bldg., St. Louis, Mo.
CLARENCE LOEB, Associate Editor, 25 E. Washington S t , Chicago, 111. LAWRENCE T. POST, Metropolitan Bldg, St. Louis Mo. HARRY V. WURDEMANN, Cobb Bldg, Seattle, Wash.
Original papers, correspondence, and other scientific communications should be addressed to the Editor. Books for review may be sent to any member of the editorial staff. Re ports of society proceedings should be sent to Dr. Lawrence T. Post, Metropolitan Bldg, St. Louis, Mo. Proof should be corrected, and returned within forty-eight hours to the printers. Reorints may be obtained from the printers, Tucker-Ken worthy Co, 501 S. La Salle St, Chicago, 111, if ordered at the time proofs are returned. But reprints to contain colored plates must be ordered when the article is accepted. Copy of advertisements must be sent to the Manager by the fifteenth of the month pre ceding its appearance. The annual subscription for the JOURNAL and the OPHTHALMIC YEAR BOOK is twelve dol
lars, in advance. Subscriptions, applications for single copies, communications with reference to advertising or other business, should be addressed to the Manager of Subscriptions and Advertising— J E A N MATTESON, ROOM 1209, 7 W e s t Madison Street, Chicago, 111.
CONGENITAL ANOMALIES. T h e first t h r e e p a p e r s in this issue give o p p o r t u n i t y to e m p h a s i z e t h e im portance of t h e careful s t u d y of such conditions, a n d t h e need for r e p o r t s of such cases. T h e basic service t h a t a n y physician can r e n d e r t o his p a t i e n t s is accurate, complete diagnosis of his case. O n such a diagnosis every val uable prognosis, a n d every t h e r a p e u t i c service—operative or n o n o p e r a t i v e — m u s t rest. T h e diagnosis m u s t be m a d e in every case, and in every case it is a real s e r v i c e ; even if it only fur nishes g r o u n d for p r o g n o s i s , or p r e vents t r e a t m e n t t h a t w o u l d be useless, expensive, or even harmful. T h e diag nosis of congenital a n o m a l i e s is val uable in itself, even if t h e y c a n n o t be t r e a t e d ; and exclusion of such condi tions is an e x t r e m e l y i m p o r t a n t step in the diagnosis of diseases, t h a t can be treated. L o r i n g , w h o s e c h a p t e r on t h e nor mal fundus contains an a c c o u n t of con genital anomalies, said, " F i v e s i x t h s of the a r t of o p h t h a l m o s c o p y are con tained in a k n o w l e d g e of the n o r m a l eye, t h e rest is a series of r e p r e s e n t a tions which can b e read a l m o s t at s i g h t . " I t is equally t r u e t h a t d i a g n o sis is five-sixths of t h e a r t of medicine. It should be an application of all t h e
p o w e r s of observation of t h e diagnos tician, a n d a focussing of all the re corded k n o w l e d g e of t h e medical p r o fession, on t h e q u e s t i o n s p r e s e n t e d in t h e individual c a s e ; c u l m i n a t i n g in j u d g m e n t t h a t is of value in p r o p o r tion to the b r e a d t h of individual expe rience a n d of t h e race experience, on which it is based. C o n g e n i t a l anomalies and individual peculiarities furnish a larger p r o p o r t i o n of t h e t h i n g s to be observed in a r r i v i n g at a diagnosis t h a n is a p p r e c i a t e d by a n y except t h o s e of w i d e s t professional experience. A y o u n g o p t o m e t r i s t g o t an oph t h a l m o s c o p e a n d learned t o u s e it, u n til he s a w t h i n g s . L o o k i n g into t h e eye of t h e wife of the p a s t o r of t h e c h u r c h h e h a d joined, he s a w red s t r e a k s a n d black p a t c h e s t n a t w e r e n e w to h i m . L o o k i n g into his m e a g r e k n o w l e d g e of ocular disease he s a w w o r d s like choroiditis, retinitis, a t r o p h y , etc. T h e w o m a n h u r r i e d t o an o c u l i s t ; w h o recognized a n d explained her choroid tigre, corrected t h e error of refraction t h a t had caused h e r t o seek relief in glasses, a n d so added to the p r e s t i g e of o p h t h a l m o l o g y , a s well as t o his o w n . T h e o p t o m e t r i s t soon s o u g h t a n e w field of activity. The s a m e m i s t a k e h a s been m a d e b y m e n with t h e medical degree w h o call t h e m 58
EDITORIALS
selves oculists; and with no benefit to themselves or their patients. The writer has seen congenital ab sence or displacement of the puncta, which was the unrecognised cause of epiphora; and congenital anomaly of the hyaloid canal or artery, which was taken for cysticercus in the vitreous. A patient came with vision 0.3 in one eve and 1.3 in the other. In the first eye the fundus appeared normal; in the other the whole macular region was disfigured with pigment blotches. The first eye had a congenital amblyopia, the other only a congenital anomaly of pigmentation. An applicant for a blind benefit claimed to have onl" light pereption; and an experienced and care ful examiner found such striking changes in his fundus, that the state ment was accepted. Later, with the same fundus appearances present, the eye was proved to have not less than 0.8 vision. In two patients, the writer has seen congenital anomalies of the physiologic cupping of the optic disc, which exact ly resembled glaucoma cups. Entire absence of other symptoms of glaucoca, until these patients died several years later, proved that these cups were not produced by excessive intra ocular pressure. The anomaly of a pro truding opaque optic nervehead will be met by every observer of large ex perience in ophthalmoscopy. Every one of them should be examined re peatedly and with great care; not only to determine that it is not a case of op tic neuritis; but also, that the observer may become so familiar with the ap pearances of pseudooptic neuritis, that this condition will not be misleading when encountered in a case of head ache, injury to the skull, or acute dis ease, where true optic neuritis might be looked for. Going back to the anomalies re ported in this issue: Persistent pupil lary membrane, in an inflamed eye, may easily be taken as evidence of iritis. Congenital deficiencies of ab duction and other ocular movements have repeatedly led to muscle opera tions; that were of no benefit to either patient or surgeon, except such as
59
comes by learning through our mis takes. The anomalies mentioned on page 1 are very rare. But for a knowl edge of very rare conditions, we have to rely on the experience of the profes sion, as recorded in the literature, rath er than on our own. All such records should receive careful study and con sideration.
E. J.
THE EYE AND INTERNAL SECRETION.
In analysing the effects of the secre tion of the ductless glands on the eye, one must consider the results obtained by experimental investigation, as well as those from clinical observation. The former are limited, on account of the restrictions necessarily imposed in ex periments on animals; while the ad mitted check, or stimulating influence of the secretions of one set of glands over another, or combination of glands, complicates conclusions one might be inclined to draw from a more simple scheme of things. No one questions the relation between exophthalmos and hyperactivity of the thyroid. Also the accompanying widening of the palpebral fissure and weakness of conver gence. Removal of the parathyroids in rats is followed by ossification of the lenses. Several observers have noticed the as sociation of zonular cataract in chil dren, with bad teeth from a deficiency in enamel, and suffering from rickets and convulsions. Changes in the brows and lashes have been reported as due to disturbance of the gonad function. There is a strong probability that coni cal cornea is the result of an edocrin disturbance, its appearance about the age of puberty being strongly sugges tive. Bearing these facts in mind, it would seem that our attention should be fo cused more on the influence that the endocrin system might have on the function and diseases of the eye. Per haps we are omitting something in our routine investigation into the cause of certain diseases. Again, there may be disturbances of eye function which will