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Optic Atrophy and Fluid Dropping from the Nostril
448
EDITORIALS
d'Ophtalmologie, July, 1932 (published in the Bulletins et Mémoires of the So ciety, and also in the Italian Annali di Ottalmologia, volume 60, page 473), Arruga described the production of "ex perimental adhesive choroiditis" in rab bits, and also in a young woman whose eye was to be removed three days later on account of choroidal sarcoma. In cases treated by trephining of the sclera followed by chemical irritation of the choroid, or in diathermal applica tions, Arruga regards it as probable that adhesive choroiditis is the principal fac tor in recovery. In cauterization with the thermocautery other factors play a more important part. The mode of action of the thermo cautery (whether Paquelin or electric) was shown to vary according to whether the application was short or long. Whether the cautery point was white or red hot did not seem to matter much as regards its effect on adjacent tissues. But if the cautery was applied very rap idly the heat was not transmitted to these tissues and the effect was that of simple incision with very little inflam matory reaction ; whereas if the appli cation was slow the heat had time to be transmitted so as to produce the ef fect of a burn. Secondary contraction thus occasioned may explain the reduc tion of myopia after extensive cauteri zations. Adhesion of retina to choroid only began to appear solid after four to six days. Although Guist has offered his ex periments on rabbits in support of the contention that potash is the most suit able caustic for provoking adhesive choroiditis, Arruga's findings did not suggest any difference between results obtained with caustic potash and those from caustic soda. Experimental cases treated by trephining followed by ap plication of five percent solution of caus tic soda showed adequate choroidal adhesion, with the advantage that no im portant neighborhood changes were produced in the retina. Satisfactory ad hesions were also obtained experi mentally with tincture of iodine or with a five percent solution of zinc chloride, immediately followed (as were all the
milder chemical applications) by lavage with physiological salt solution. Interesting effects were demonstrated after the use of diathermy according to Weve's technique; that is, applying the current through the round electrode long enough to produce "parchmentizing" of the sclera, a peculiar greenishgray discoloration of the area of contact. (See also editorial, American Jour nal of Ophthalmology, 1932, volume 15, page 858). The inflammatory exudate developed in the subretinal space was fibrinous, and the choroid was greatly congested and was swollen to five or six times its normal thickness. More pro longed applications were quickly and definitely destructive. Both externally and ophthalmoscopically the changes visible after such applications were sharply delimited. Multiple diathermal electropuncture produced the same ef fects as superficial application of diathermy. Arruga draws a sharp distinction be tween the mode of action of scierai tre phining and of ignipuncture as regards closure of tears. After trephining and application of caustics, adhesion of retina to choroid is entirely due to ad hesive choroiditis from chemical irrita tion. In thermopuncture, especially if rapid, almost no choroiditis is provoked, but vitreous hernia favors speedy ad hesion of the retina to the edges of the scierai opening, and not elsewhere. It is for this reason that thermopuncture is followed by the most rapid healing, whereas those procedures which pro voke choroiditis demand a more pro longed period of rest. On the other hand, the latter modes of treatment seem to be less subject to relapse of the detach ment. W. H. Crisp. OPTIC ATROPHY AND F L U I D DROPPING FROM T H E NOSTRIL Nettleship, in 1882, reported a case of optic neuritis followed by dropping of fluid from the nostril. Before she was first seen, this patient had obscure cerebral symptoms, and for two months there had been profuse running of clear
EDITORIALS water from the nose. Her optic discs showed post-papillitic atrophy, which was unchanged during the year she had been under observation. Nettleship noted two cases previously reported, one by Sir James Paget and one by Dr. Baxter. In the same number of the Ophthal mic Review (January 1883) Priestley Smith reported two cases of the kind, that he had seen. In one the dropping continued for over two years. In the other the dropping of fluid from the right nostril had continued for six months, and amounted to 18 fluid ounces in the 24 hours. It was thought, possibly to come from the frontal sinuses. In the other case brain symp toms had been noticed six years before, and two years and one half after that, when he was recovering power in his legs, the dropping of fluid began. The same year, Leber reported a case of the kind (Graefe's Archiv) starting with hydrocephalus, He also reviewed the previously reported cases. In his case the fluid contained a substance that reacted as sugar, to the Fehling test, and he concluded that the fluid was derived from the cerebrospinal fluid. In some other cases there was no evidence of a reducing substance allied to sugar, but this might be due to dilution by nasal secretion, or to defective tests. In one case the thickening of the nasal mucous membrane, on the side of the dropping fluid, was taken as evidence that it was the source of the discharge. But it might have been that the thick ening was due to the maceration, with fluid from another source. In the cases that have been examined post mortem, no one has discovered any channel for the fluid from the cerebral ventricles to the nose, and the essential nature of such cases has remained in doubt. In the Archives of Oto-Laryngology (v. 14, p. 611) Carroll Smith and L. Walter report a case in which roentgenograms showed evidence of pitui tary disease. Frontal operation dis closed a cystic growth of the pituitary body. Puncture and fulguration were followed by recovery; which appeared complete seven months later. The exact
449
fistulous tract was not traced ; but bone absorption suggested an opening into the sphenoid, from which the fluid drained from normal channels. Other cases have been reported in the literature of oto-laryngology ; but their pathogenesis remains obscure. They are rare, but worthy of most care ful study, and a better understanding of them may throw light on other ob scure conditions of cerebral pathology. Some light may be expected from the different methods of examination with the Roentgen rays. Edward Jackson. COMPARISON OF METHODS OF INTRACAPSULAR CATARACT EXTRACTION Since the introduction of linear ex traction of cataract, undoubtedly the most important contribution to the method of operating for this condition, excluding asepsis, has been the develop ment of intracapsular extraction. The beautiful clear pupils in the suc cessful cases certainly surpass any thing that can be accomplished by operations in which the capsule is rup tured. W i t h the standardizing of an im proved technic, increasing numbers of ophthalmologists are adopting this op eration. There are two methods which have found most favor ; one being that in which the capsule is seized with for ceps and the lens, loosened from the zonule by various rotations, tractions and counterpressures is delivered through the incision and the other in which the lens is sucked into a vacuum cup, lifted from its bed and out of the eye. For the former method it may be said that it requires only one small instru ment, the capsule forceps, in addition to the usual equipment for cataract ex traction and that if the capsule ruptures the extraction may be carried out in the usual manner. Rupture of the capsule does take place fairly frequently even in the hands of the most skilled. The procedures involved do not differ radically from those employed in the extracapsular method so present noth ing very unusual for the surgeon.
EDITORIALS
d'Ophtalmologie, July, 1932 (published in the Bulletins et Mémoires of the So ciety, and also in the Italian Annali di Ottalmologia, volume 60, page 473), Arruga described the production of "ex perimental adhesive choroiditis" in rab bits, and also in a young woman whose eye was to be removed three days later on account of choroidal sarcoma. In cases treated by trephining of the sclera followed by chemical irritation of the choroid, or in diathermal applica tions, Arruga regards it as probable that adhesive choroiditis is the principal fac tor in recovery. In cauterization with the thermocautery other factors play a more important part. The mode of action of the thermo cautery (whether Paquelin or electric) was shown to vary according to whether the application was short or long. Whether the cautery point was white or red hot did not seem to matter much as regards its effect on adjacent tissues. But if the cautery was applied very rap idly the heat was not transmitted to these tissues and the effect was that of simple incision with very little inflam matory reaction ; whereas if the appli cation was slow the heat had time to be transmitted so as to produce the ef fect of a burn. Secondary contraction thus occasioned may explain the reduc tion of myopia after extensive cauteri zations. Adhesion of retina to choroid only began to appear solid after four to six days. Although Guist has offered his ex periments on rabbits in support of the contention that potash is the most suit able caustic for provoking adhesive choroiditis, Arruga's findings did not suggest any difference between results obtained with caustic potash and those from caustic soda. Experimental cases treated by trephining followed by ap plication of five percent solution of caus tic soda showed adequate choroidal adhesion, with the advantage that no im portant neighborhood changes were produced in the retina. Satisfactory ad hesions were also obtained experi mentally with tincture of iodine or with a five percent solution of zinc chloride, immediately followed (as were all the
milder chemical applications) by lavage with physiological salt solution. Interesting effects were demonstrated after the use of diathermy according to Weve's technique; that is, applying the current through the round electrode long enough to produce "parchmentizing" of the sclera, a peculiar greenishgray discoloration of the area of contact. (See also editorial, American Jour nal of Ophthalmology, 1932, volume 15, page 858). The inflammatory exudate developed in the subretinal space was fibrinous, and the choroid was greatly congested and was swollen to five or six times its normal thickness. More pro longed applications were quickly and definitely destructive. Both externally and ophthalmoscopically the changes visible after such applications were sharply delimited. Multiple diathermal electropuncture produced the same ef fects as superficial application of diathermy. Arruga draws a sharp distinction be tween the mode of action of scierai tre phining and of ignipuncture as regards closure of tears. After trephining and application of caustics, adhesion of retina to choroid is entirely due to ad hesive choroiditis from chemical irrita tion. In thermopuncture, especially if rapid, almost no choroiditis is provoked, but vitreous hernia favors speedy ad hesion of the retina to the edges of the scierai opening, and not elsewhere. It is for this reason that thermopuncture is followed by the most rapid healing, whereas those procedures which pro voke choroiditis demand a more pro longed period of rest. On the other hand, the latter modes of treatment seem to be less subject to relapse of the detach ment. W. H. Crisp. OPTIC ATROPHY AND F L U I D DROPPING FROM T H E NOSTRIL Nettleship, in 1882, reported a case of optic neuritis followed by dropping of fluid from the nostril. Before she was first seen, this patient had obscure cerebral symptoms, and for two months there had been profuse running of clear
EDITORIALS water from the nose. Her optic discs showed post-papillitic atrophy, which was unchanged during the year she had been under observation. Nettleship noted two cases previously reported, one by Sir James Paget and one by Dr. Baxter. In the same number of the Ophthal mic Review (January 1883) Priestley Smith reported two cases of the kind, that he had seen. In one the dropping continued for over two years. In the other the dropping of fluid from the right nostril had continued for six months, and amounted to 18 fluid ounces in the 24 hours. It was thought, possibly to come from the frontal sinuses. In the other case brain symp toms had been noticed six years before, and two years and one half after that, when he was recovering power in his legs, the dropping of fluid began. The same year, Leber reported a case of the kind (Graefe's Archiv) starting with hydrocephalus, He also reviewed the previously reported cases. In his case the fluid contained a substance that reacted as sugar, to the Fehling test, and he concluded that the fluid was derived from the cerebrospinal fluid. In some other cases there was no evidence of a reducing substance allied to sugar, but this might be due to dilution by nasal secretion, or to defective tests. In one case the thickening of the nasal mucous membrane, on the side of the dropping fluid, was taken as evidence that it was the source of the discharge. But it might have been that the thick ening was due to the maceration, with fluid from another source. In the cases that have been examined post mortem, no one has discovered any channel for the fluid from the cerebral ventricles to the nose, and the essential nature of such cases has remained in doubt. In the Archives of Oto-Laryngology (v. 14, p. 611) Carroll Smith and L. Walter report a case in which roentgenograms showed evidence of pitui tary disease. Frontal operation dis closed a cystic growth of the pituitary body. Puncture and fulguration were followed by recovery; which appeared complete seven months later. The exact
449
fistulous tract was not traced ; but bone absorption suggested an opening into the sphenoid, from which the fluid drained from normal channels. Other cases have been reported in the literature of oto-laryngology ; but their pathogenesis remains obscure. They are rare, but worthy of most care ful study, and a better understanding of them may throw light on other ob scure conditions of cerebral pathology. Some light may be expected from the different methods of examination with the Roentgen rays. Edward Jackson. COMPARISON OF METHODS OF INTRACAPSULAR CATARACT EXTRACTION Since the introduction of linear ex traction of cataract, undoubtedly the most important contribution to the method of operating for this condition, excluding asepsis, has been the develop ment of intracapsular extraction. The beautiful clear pupils in the suc cessful cases certainly surpass any thing that can be accomplished by operations in which the capsule is rup tured. W i t h the standardizing of an im proved technic, increasing numbers of ophthalmologists are adopting this op eration. There are two methods which have found most favor ; one being that in which the capsule is seized with for ceps and the lens, loosened from the zonule by various rotations, tractions and counterpressures is delivered through the incision and the other in which the lens is sucked into a vacuum cup, lifted from its bed and out of the eye. For the former method it may be said that it requires only one small instru ment, the capsule forceps, in addition to the usual equipment for cataract ex traction and that if the capsule ruptures the extraction may be carried out in the usual manner. Rupture of the capsule does take place fairly frequently even in the hands of the most skilled. The procedures involved do not differ radically from those employed in the extracapsular method so present noth ing very unusual for the surgeon.