My Major Mistakes*

A M E R I C A N J O U R N A L OF O P H T H A L M O L O G Y VOLUME

N O V E M B E R , 1964

58

M Y

MAJOR

NUMBER

5

MISTAKES*

FREDERICK H . V E R H O E F F , M . D .

Marhlehead, Massachusetts With a discussion by DERRICK VAIL, M . D . , Chicago, Illinois

Because I have never seen or heard o f a similar

paper

a highly blurred

line must be due to the

I am almost sure that this

denser and probably less transparent nucleus

paper is unique in its title and subject. In

of the crystalline lens shutting off more rays

it I briefly describe the mistakes I believe

than the rest o f the refractive media o f the

to be the greatest I have made in my oph­

eye. In m y paper published the same year on

thalmologic career o f more than 65 years. I

the cause o f a special form o f monocular

do this in the hope that it will help other

diplopia," I pointed out this mistake

ophthalmologists avoid such mistakes. M i s ­

showed that the real cause o f the white line

takes, however, may be beneficial in that they

was

sometimes lead to discoveries that are more

aberration.

or less important. A s will be seen this was mistake

for

which

I

or

similar

monochromatic

In 1903, with R . G. Loring,^ I reported

true of several o f my mistakes. A

spherical

and

a case as a unique one o f epibulbar sarcoma myself

that had invaded the interior o f the eye. I

severely, I cannot describe in sufficient detail

blame

now feel sure that this was a mistake, that

because I cannot find the records of the case.

the case was really one o f diffuse malignant

I injured the optic nerve by diathermy when

melanoma o f the choroid and ciliary body

attempting to destroy a chorioretinal lesion

that had extended outside the eye. T h e de­

by this means.

ceptive feature o f this case was that there was m o r e tumor outside than inside the eye.

In my first t w o papers*-^ published 65 years ago, I proved beyond question that

Early in m y career I shared the common

cycloduction did not occur in m y experiments

mistake o f believing that ocular muscle sense

in which lines tilted laterally from the ver­

was important in the visual localization of

tical were used as stimuli. But my conclu­

objects. Various observations made by my­

sion

from

this,

that cycloduction did not

self and others soon convinced me that this

occur under any conditions, was a mistake.

was a mistake and that sense o f innervation

In

and

was the essential factor in such localization.

suitable

I explained m y views on this matter to S . R .

1934 I showed,' as had

Hofman

Bielschowsky* in 1900, that under

conditions cycloduction did occur, and that

Irvine and E . J. Ludvigh, then m y assistants,

the best stimuli for it were letters in rows

and requested them to make a thorough in­

gradually tilted from the horizontal.

vestigation of the subject. This they did, and

In m y paper o f 1900 on shadow images

brought

on the retinas,'' I made the mistake o f suggest­

out

convincing evidence that

the

views I had expressed to them were correct.*

ing that the white line seen in the middle o f

In a cataract operation I once made the mistake of irrigating the anterior

»Presented at the centennial meeting of the American Ophthalmological Society, Hot Springs, Virginia, May 28, 1964.

737

chamber

with a neutralized solution o f sodium aurate as a prophylactic against infection. B y in­ stillations into the conjunctival sacs o f rab-

738

FREDERICK Η. V E R H O E F F

bits and of my own eyes I thought I had

patient came to me with a large separation

proved this solution to be perfectly harmless

o f the retina in one eye. I made a sclero-

to tissues. But after the cataract extraction

choroidal puncture to let out the fluid, with

persistent bullous keratitis occurred, showing

the intention later to fasten down the retina

that the solution had seriously injured

with

at

least the corneal endothelium.

multiple

electrolytic punctures.

The

retina went back in place, but then revealed

Also early in m y career I made the mis­

behind it a dark mass which I assumed was

take o f accepting, on the subject of binocular

a malignant melanoma. Microscopic exami­

vision, too many o f the views held by con­

nation o f the eye showed the cause o f the

temporary supposed authorities. Recently I

dark mass to be a moderately large sub-

have pointed out h o w erroneous are some o f

choroidal hemorrhage due to the puncture.

these views I once accepted.'' So far as I can ascertain. Parsons in his

In 1931, I removed an eye because o f mis­ taking

for

a

malignant

melanoma,

blood

great textbook on pathology o f the eye, was

from a spontaneous hemorrhage beneath the

the first to use the term cytoid bodies for

pigment

the peculiar bodies now generally known by

Microscopic examination o f this eye led to

this name, which often occur in the retina.

m y discovery that disciform degeneration o f

epithelium

in

the

macular

area.

In 1922, I found apparently the same kind

the macula is usually due to the organization

o f bodies in gliomas o f the optic nerve and

o f such an extravásate."

brain.'" Their abundance in portions o f the

In 1926, I made a mistake that led to my

optic nerve tumors that could never have

devising what is n o w known as the sliding

contained either ganglion cell or nerve fibers

method o f cataract extraction. A t the time,

proved conclusively that they did not arise

I was using for removing a cataract with its

from either o f these elements. F r o m their

capsule,'* a method I had devised

staining reactions and morphology, I judged

that has since been commonly used but sel­

in 1914,

that they resulted from a deposit o f neurog-

dom attributed to me. In attempting to carry

lialike substance in the neuroglial syncytium

out this method, I grasped by mistake the

of the glioma or retina. Later, for a time, I

lens capsule with m y forceps at a place I

abandoned this view because I found these

then thought was too high. T h e cataract with

bodies so often associated with hemorrhage

its capsule intact, came out so easily without

that I was led to believe that they always

tumbling that I at once devised the sliding

consisted of altered blood. This I am n o w

technique." This ever since has been m y

sure was a mistake, for it is n o w known that

routine method f o r extraction o f cataracts.

cytoid bodies can appear and even disappear

Simple as it is in execution, it is difficult ade­

without ever being associated with hemor­

quately to describe.

rhage. I have, therefore, returned to m y orig­

Although Grüter as long ago as 1912 dem­

inal view as to the nature and origin o f

onstrated that herpes simplex o f the cornea

these bodies. Altered metabolism due to lo­

was produced by a virus, I did not accept this

cally impaired nutrition might explain the

fact as true until 1923 when Jonas Frieden­

formation o f the assumed neuroglialike sub­

wald"' under m y direction and in my labora­

stance. Those who still believe that the cytoid

tory investigated this virus. Before then I

bodies o f the retina are derived from nerve

had developed a theory that a lesion o f the

fibers must believe that those o f gliomas are

Gasserian or ciliary ganglion could produce

not so derived since they occur where nerve

lesions in the eye b y its irritation causing an­

fibers have never existed.

tidromic impulses to travel back to the eye.'*

M o r e than 40 years ago I removed an eye

O n this basis I explained what I called neuro­

because of mistaking blood from a choroidal

pathic keratitis, '^ including herpes zoster ke­

hemorrhage for a malignant melanoma. T h e

ratitis, herpes

simplex keratitis, disciform

739

M Y MAJOR MISTAKES

keratitis, Fuchs' superficial punctate kerati­

sections showed that the

tis," keratitis profunda and rosacea keratitis.

thought because o f the retinal necrosis were

T h e repeated demonstration o f the virus in

characteristic only o f tuberculosis, were in

changes,

I

had

the corneal lesions o f herpes simplex proved

fact characteristic only o f toxoplasmic cho­

that, for these lesions, m y theory o f anti­

rioretinitis. T h e evidence was conclusive that

dromic impulses was not true. I

therefore

in the eye I had examined microscopically,

abandoned this theory as a major explanation

the chorioretinitis was caused by toxoplas­

o f any ocular lesions except those o f trau­

mosis. Since o n macroscopic examination,

matic

the fundus picture in this eye was essentially

remain

relapsing good

keratitis. H o w e v e r , there

reasons

to

continue

calling

the same as the ophthalmoscopic picture o f

neuropathic the conditions mentioned, f o r in

the localized chorioretinitis I had described,

these the nerves are certainly involved, but

and since there is no evidence that it can

how and to what extent are unknown.

be produced b y any other cause, it is safe

In 1928, from m y findings in an enucleated eye, I made the mistake o f assuming that I had discovered the nature and cause o f angioid

steaks.'^

In

this case I

found

the

streaks were corrugations o f the inner sur­

to assume that toxoplasmosis is the only cause o f this fundus picture. In m y opinion, the ophthalmoscopic pic­ ture o f

toxoplasmic chorioretinitis

is

so

characteristic that this disease can be diag­

face o f the choroid due to cicatricial con­

nosed b y it even after the lesions have healed.

traction o f the deeper layers. Later, when

Obviously, this will be a highly

eyes in true cases o f angioid streaks were e x ­

fact if and when an effective treatment f o r

amined histologically, one by m e , " it became

the disease is discovered.

important

evident that m y case with corrugation o f the

I f in m y paper,'* which is entitled " H i s ­

choroid was not a true case o f the affection.

tological observations in a case o f localized

Evidently it was a unique case the like o f

chorioretinitis," m y mistakes

which has never been recorded before or

tuberculosis

since.

are

corrected, as

in regard they

to

easily

can be, and the term tuberculous changed to

A l s o in 1928, I made a mistake that I n o w

toxoplasmic, I believe this paper then gives

think was m y greatest. It prevented me from

the best description ever published of toxo­

being recognized as the first to be able to

plasmic chorioretinitis in adults. Following

diagnose with the ophthalmoscope the chorio­

are

retinitis o f toxoplasmosis. In that year

about this condition: M o s t attacks and re­

described

a

condition

I

termed

I

localized

some additional

facts

currences are mild and

I have

learned

subside in a few

chorioretinitis.'' This I believed to be due to

weeks. O f course even a mild attack is dis­

tuberculosis because o f m y histologic findings

astrous if it involves the macula. Severe cases

in one case. In this case another surgeon had

may not subside for a year or m o r e in spite

removed one eye because o f an

o f treatment. M y impression is that, in gen­

erroneous had

eral, the cases are either mild o r severe, that

sent it to me f o r histologic examination.

there are few if any cases with severity be­

Macroscopically, the eye showed the typical

tween these extremes. Recurrences seldom

picture o f the localized chorioretinitis

happen in elderly patients but, when they do,

diagnosis o f sympathetic

uveitis, and

de­

scribed by me. Microscopically, I made the

they are apt to be severe.

diagnosis o f tuberculosis because I mistook

O n c e and only once did I make the mistake

for caseation the retinal necrosis I found. I

of employing in a cataract operation, a knife

discovered that this diagnosis was a great

that was so thin it was too flexible. A s a re­

mistake when I read M r s . W i l d e r ' s paper in

sult, when in this case I attempted to make

which

m y usual corneoscleral incision, the

she

described

finding

the

micro­

organisms o f toxoplasmosis in sections. H e r

knife

did not enter the anterior chamber but kept

740

F R E D E R I C K Η. V E R H O E F F

within the corneal stroma almost entirely across the cornea. N o t realizing until too late what was happening, I continued the incision to within about three mm. o f the upper corneal limbus. Then I withdrew the knife without completing the incision. I then made a small ab externo incision and en­ larged it with scissors. I removed the lens with its capsule without difficulty and closed the wound with two corneoscleral sutures. Healing was about as rapid as usual, but the vision obtained was poor because o f corneal opacities and irregularities. Until it happened it never occurred to me that this catastrophe was possible. Probably, after I was aware of this possibility, I could have made a good incision with this same knife, but I never tried to do so. The story o f retrolental fibroplasia is a long one involving many investigators but it begins with an excusable mistake made b y me. In the cases o f two premature infants

seen b y me as a consultant within two days in 1941, I made, on ophthalmoscopic evi­ dence, the diagnosis, n o w known to have been erroneous, o f persistent tunica vasculosa lentis. Since I had never seen this supposed condition in a premature infant and had never known it to b e bilateral, I suggested to Dr. Terry, whose patient one of the in­ fants was, that he investigate the matter. This he promptly proceeded to do. H e never doubted m y diagnosis and introduced the term retrolental fibroplasia only because he thought it a more accurate one for the sup­ posed condition. D r . T e r r y died before it be­ came known that the condition he was calling b y this new name was entirely different in origin from persistent vasculosa lentis, the condition he supposed it to be. A s a matter of fact, even n o w the two conditions in their later stages often cannot be distinguished b y means of the ophthalmoscope. 252 Pleasant Street.

REFERENCES 1. Verhoeff, F. H . : A new instalment for measuring heterophoria and the combining power of the eyes. Bull. Johns Hopkins Hosp., 10 :87, 1899. 2. : A description of the reflecting phorometer, and a discussion of the possibiHties concerning torsion of the eyes. Tr. Am. Ophth. Soc, 8 ;490, 1899. 3. : Cycloduction. Tr. Am. Ophth. Soc, 32:208, 1934. 4. Hofman, F. Β., and Bielschowsky, Α . : Ueber die der Wilkür entzogenen Fusionsbewegungen der Augen. Arch. f. d. ges Physiol., 80 :1, 1900. 5. Verhoeff, F. H . : Shadow images on the retina. Psychological Rev., 7 :18, 1900. 6. : The cause of a special form of monocular diplopia. Arch. Ophth., 29:S6,S, 1900. 7. Verhoeff, F. H., and Loring, R. G.: A case of primary epibulbar sarcoma, with secondary growths in limbus and sclera, and invasion of the choroid, ciliary body and iris, Arch. Ophth., 32:97, 1903. 8. Irvine, S. R., and Ludvigh, E. I.: Is ocular proprioceptive sense concerned in vision? Arch, ophth., 15:1037,1936. 9. Verhoeff, P. H . : Panum's areas and some other prevailing misconceptions concerning binocular vision. Tr. Am. Ophth. Soc, 57:37, 1959. 10. : Primary intraneural tumors (gliomata) of the optic nerve. Arch. Ophth., 51:239, 1922. 11. Verhoeff, F. H., and Grossman, H. P.: Pathogenesis of disciform degeneration of the macula. Arch. Ophth,, 18:561, 1937. 12. Fridenwald, J. S.: Studies in the virus of herpes simplex. Arch. Ophth., 52:105, 1923. 13. Verhoeff, F. H . : Neuropathic keratitis and some allied conditions, with special reference to treat­ ment. J.A.M.A., 53:191, 1909. 14. : The pathology of superficial punctate keratitis, with remarks on neuropathic keratitis in general, and on a hitherto undescribed lesion of the iris. Arch. Ophth., 40:486, 1911. 15. : The nature and pathogenesis of angioid streaks in the ocular fundus. Tr. Sect. Ophth., A M A , 1928, p. 243. 16. : Histological findings in a case of angioid streaks. Brit. J. Ophth., Sept. 1948. 17. : A new operation for removing cataracts.with their capsules. Tr. Am. Ophth. Soc, 25:54, 1927. 18. : Improved capsule forceps for intracapsular cataract extraction. Tr. Am. Ophth., Soc, 1915. 19. : Histologic observations in a case of localized tuberculous chorioretinitis. Arch Ophth 1:53, 1929.