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Saint Louis Ophthalmic Society
466
SOCIETY PROCEEDINGS TABLE S SUPRANUCLEAR
LESIONS
AFFECTING
THE
THIRD NERVE
I. Cortical lesions : paralytic, irritative II. Pontine : paralysis of lateral gaze with preservation of convergence III. Midbrain (a) Paralysis of upward movements ( P a rinaud's) (b) Paralysis of downward movements (c) Paralysis of convergence (d) Vertical nystagmus TABLE 6 THIRD-NERVE
AFFECTIONS—MISCELLANEOUS TYPES
I. Pupillary abnormalities (a) The unilateral fixed dilated pupil in expanding cerebral lesions (b) Argyll Robertson pupil—lues, alcohol, encephalitis, tumors in or about the midbrain, diabetes, multiple sclerosis, and trauma (c) Adie's syndrome ( d ) Other pupillary changes II. Neuritis : Diphtheritic and other systemic infections ; "rheumatic," serum treatment III. Arteriosclerosis and diabetes IV. Migrainous ophthalmoplegia V. Periodic oculomotor paralysis. Familial types
Discussion. Dr. Robert A. Groff said Dr. Yaskin's presentation was so com plete as to have seemingly exhausted the subject. He thought it very interesting and particularly as a presentation from the anatomic point of view. From the sur gical standpoint, he had been interested in the third nerve in connection with sphenoid-ridge meningiomas. He had seen about four cases in association with the lesser-wing sphenoid-ridge meningiomas, and, in each instance, there was complete paralysis of the third nerve. In the case mentioned by Dr. Adler, the diagnosis was apparently made very early, upon which he is to be congratulated. In the cases in which there was a complete palsy, even though the tumor was completely removed, there was no recovery from the third-nerve palsy. We have also seen cases of pontine gliomas and pinealomas caus ing paralysis of upper or lateral gaze,
which is the result of third-nerve im pairment. Dr. Groff said he had been interested in the occurrence of dilated pupil in association with subdural hematoma. In a series of over SO cases, we have seen 12 cases in which the pupil was dilated; in 6 of these cases it occurred on the same side as the hematoma, and in 6 on the opposite; this particular sign apparently has not much value for locali zation. In each instance, following the operation, the dilation of the pupil dis appears. Warren S. Reese, Clerk. SAINT LOUIS OPHTHALMIC SOCIETY November 22, 1940 DR.
J. F.
HARDESTY,
president
S U L F O N A M I D E T R E A T M E N T OF TRACHOMA.
AN
EXPERIMENTAL
STUDY
WITH
RE
VIEW OF THE LITERATURE DR. J. E. S M I T H and
DR. L. A.
JULIA-
NELLE presented a paper on the above subject, which has been published in this Journal (1941, v. 24, p. 174). Discussion. Dr. R. E. Mason asked Dr. Julianelle to comment more in de tail upon what the reservation doctors were diagnosing as nutritional disease that simulated trachoma. Dr. B. Y. Alvis said that the cases he had observed, though not numerous, were very materially benefited by sulfanilamide. Cases in which there were ulcers that had resisted treatment and caused much concern for weeks, recovered in a few days, the ulcers healing under sulfanilamide therapy. He wondered how sulfanilamide, which had proved disap pointing to the speakers, could have gained such popularity with other clini cians. Dr. L. T. Post asked Dr. Julianelle to
SOCIETY PROCEEDINGS
make some comment on the different types of virulence in different parts of the world and in different races. Dr. Julianelle, in conclusion, said there were certain observers who considered trachoma as a nutritional disease, in the sense that a dietary deficiency initiated trachoma. That, however, was not the point he had in mind. What he intended to show was that, according to certain ophthalmologists, the failure of sulfanda mide to check a condition previously ac cepted as trachoma implied that the con dition under treatment was not trachoma but rather a nutritional disorder. He said that he did not intend to classify trachoma as a dietary disease. In many instances it becomes a matter of personal judgment as to the diagnosis of trachoma, and as such the diagnosis may, of course, be open to question. Such general criteria as history, clinical ap pearance, presence of inclusion bodies, infectivity, and so forth, are all helpful, but there are frequent cases lacking one or another of these factors. In any case, he was sure that certain patients at the time of the one examination were bound to have presented a doubtful picture of trachoma, and the diagnosis must be ac cepted or refused depending upon one's confidence in the diagnostician. Dr. Julianelle was quite sure that dif ferent strains of virus vary in virulence. Also it seemed to him that trachoma, as occurring among the Navajos, is much milder than that seen among the whites of the Ozark mountains. This might be due to a difference in racial resistance to the particular virus. In reply to Dr. Alvis's question, Dr. Julianelle said there was unquestionably much enthusiasm on the effect of sul fandamide, though this enthusiasm was difficult to explain. Judging by recorded observations it seemed to him that if sulfanilamide is curative it cannot be
467
proved by many of the reports which say so, because in many instances the usual local treatment was continued during the sulfonamide therapy. His own belief was that sulfanilamide induced a definite im provement in trachoma, only rarely cur ing it. Consequently, his advice was by all means to use sulfanilamide in order to obtain the rapid and definite benefit usually effected by the drug, but that when the improvement had become more or less static, the treatment had better be supplemented. Personally, he had always found it difficult to explain the widely different results reported in studies of this kind. H l S T O G E N E S I S A N D PATHOLOGY OF GLIOMA RETINAE
DR. JULE T. ELZ presented a com munication on this subject. Discussion. Dr. J. F. Hardesty reported a case in which the second eye had been given intensive X-ray treatment, and he did not find rosettes to be present. Would that be an indication or would it not, that X-ray therapy had been helpful? The patient had a widely dilated pupil and had been given as much X-ray treat ment as the roentgenologist would per mit. The patient got no benefit at all from the treatment. Dr. L. T. Post asked for the age of the patient and what the state of his health had been. Dr. H. R. Hildreth said that there were reports of apparent improvement if not cures of tumors in the eyes among chil dren with bilateral disease. He had seen no later reports, so did not know the final outcome. Treatment had been by means of radon seeds. He wished to know which method of treatment was considered to be the better. Dr. W. H. Luedde said the second eye showed the greater signs of malignancy. Did the X-ray contribute to these find-
468
SOCIETY PROCEEDINGS
ings? The second tumor was there the longer and therefore the more dangerous. Dr. J. T. Elz said that in the first eye there was a large amount of necrosis. Duke-Elder does not consider irradiation the best means to a cure, but he does think there are cases in which it should be tried. Many patients have been bene fited by the use of the X ray and radon seeds. Martin and Reese published a pa per on the X-ray treatment of tumors. There are, however, as many cases of spontaneous cure as of cures with ir radiation. T H E CASE OF JOE (MALINGERING) DR. W. E. SHAHAN gave a case re port on a patient named Joe. Discussion. Dr. W. H. Luedde, in dis cussing Dr. Shahan's report, mentioned a case he had seen some years ago. The
patient had had a foreign body in one eye, following the removal of which he claimed that he could not see. The first examiner had reported to the Commis sion for the Blind that this patient was unable to see. Dr. Luedde was able to prove definitely that the man was able to see with the eye. In spite of this, the com pensation board gave the malingerer com pensation for half the loss of an eye. The same patient had been seen by an other doctor who became so angry in the course of the examination, since he was sure that there was no loss of vision, that he swore most vigorously at the man and frightened him into reading his entire chart. Dr. Luedde believed this technique to be of definite value in cer tain instances. Adolph C. Lange, Editor.
SOCIETY PROCEEDINGS TABLE S SUPRANUCLEAR
LESIONS
AFFECTING
THE
THIRD NERVE
I. Cortical lesions : paralytic, irritative II. Pontine : paralysis of lateral gaze with preservation of convergence III. Midbrain (a) Paralysis of upward movements ( P a rinaud's) (b) Paralysis of downward movements (c) Paralysis of convergence (d) Vertical nystagmus TABLE 6 THIRD-NERVE
AFFECTIONS—MISCELLANEOUS TYPES
I. Pupillary abnormalities (a) The unilateral fixed dilated pupil in expanding cerebral lesions (b) Argyll Robertson pupil—lues, alcohol, encephalitis, tumors in or about the midbrain, diabetes, multiple sclerosis, and trauma (c) Adie's syndrome ( d ) Other pupillary changes II. Neuritis : Diphtheritic and other systemic infections ; "rheumatic," serum treatment III. Arteriosclerosis and diabetes IV. Migrainous ophthalmoplegia V. Periodic oculomotor paralysis. Familial types
Discussion. Dr. Robert A. Groff said Dr. Yaskin's presentation was so com plete as to have seemingly exhausted the subject. He thought it very interesting and particularly as a presentation from the anatomic point of view. From the sur gical standpoint, he had been interested in the third nerve in connection with sphenoid-ridge meningiomas. He had seen about four cases in association with the lesser-wing sphenoid-ridge meningiomas, and, in each instance, there was complete paralysis of the third nerve. In the case mentioned by Dr. Adler, the diagnosis was apparently made very early, upon which he is to be congratulated. In the cases in which there was a complete palsy, even though the tumor was completely removed, there was no recovery from the third-nerve palsy. We have also seen cases of pontine gliomas and pinealomas caus ing paralysis of upper or lateral gaze,
which is the result of third-nerve im pairment. Dr. Groff said he had been interested in the occurrence of dilated pupil in association with subdural hematoma. In a series of over SO cases, we have seen 12 cases in which the pupil was dilated; in 6 of these cases it occurred on the same side as the hematoma, and in 6 on the opposite; this particular sign apparently has not much value for locali zation. In each instance, following the operation, the dilation of the pupil dis appears. Warren S. Reese, Clerk. SAINT LOUIS OPHTHALMIC SOCIETY November 22, 1940 DR.
J. F.
HARDESTY,
president
S U L F O N A M I D E T R E A T M E N T OF TRACHOMA.
AN
EXPERIMENTAL
STUDY
WITH
RE
VIEW OF THE LITERATURE DR. J. E. S M I T H and
DR. L. A.
JULIA-
NELLE presented a paper on the above subject, which has been published in this Journal (1941, v. 24, p. 174). Discussion. Dr. R. E. Mason asked Dr. Julianelle to comment more in de tail upon what the reservation doctors were diagnosing as nutritional disease that simulated trachoma. Dr. B. Y. Alvis said that the cases he had observed, though not numerous, were very materially benefited by sulfanilamide. Cases in which there were ulcers that had resisted treatment and caused much concern for weeks, recovered in a few days, the ulcers healing under sulfanilamide therapy. He wondered how sulfanilamide, which had proved disap pointing to the speakers, could have gained such popularity with other clini cians. Dr. L. T. Post asked Dr. Julianelle to
SOCIETY PROCEEDINGS
make some comment on the different types of virulence in different parts of the world and in different races. Dr. Julianelle, in conclusion, said there were certain observers who considered trachoma as a nutritional disease, in the sense that a dietary deficiency initiated trachoma. That, however, was not the point he had in mind. What he intended to show was that, according to certain ophthalmologists, the failure of sulfanda mide to check a condition previously ac cepted as trachoma implied that the con dition under treatment was not trachoma but rather a nutritional disorder. He said that he did not intend to classify trachoma as a dietary disease. In many instances it becomes a matter of personal judgment as to the diagnosis of trachoma, and as such the diagnosis may, of course, be open to question. Such general criteria as history, clinical ap pearance, presence of inclusion bodies, infectivity, and so forth, are all helpful, but there are frequent cases lacking one or another of these factors. In any case, he was sure that certain patients at the time of the one examination were bound to have presented a doubtful picture of trachoma, and the diagnosis must be ac cepted or refused depending upon one's confidence in the diagnostician. Dr. Julianelle was quite sure that dif ferent strains of virus vary in virulence. Also it seemed to him that trachoma, as occurring among the Navajos, is much milder than that seen among the whites of the Ozark mountains. This might be due to a difference in racial resistance to the particular virus. In reply to Dr. Alvis's question, Dr. Julianelle said there was unquestionably much enthusiasm on the effect of sul fandamide, though this enthusiasm was difficult to explain. Judging by recorded observations it seemed to him that if sulfanilamide is curative it cannot be
467
proved by many of the reports which say so, because in many instances the usual local treatment was continued during the sulfonamide therapy. His own belief was that sulfanilamide induced a definite im provement in trachoma, only rarely cur ing it. Consequently, his advice was by all means to use sulfanilamide in order to obtain the rapid and definite benefit usually effected by the drug, but that when the improvement had become more or less static, the treatment had better be supplemented. Personally, he had always found it difficult to explain the widely different results reported in studies of this kind. H l S T O G E N E S I S A N D PATHOLOGY OF GLIOMA RETINAE
DR. JULE T. ELZ presented a com munication on this subject. Discussion. Dr. J. F. Hardesty reported a case in which the second eye had been given intensive X-ray treatment, and he did not find rosettes to be present. Would that be an indication or would it not, that X-ray therapy had been helpful? The patient had a widely dilated pupil and had been given as much X-ray treat ment as the roentgenologist would per mit. The patient got no benefit at all from the treatment. Dr. L. T. Post asked for the age of the patient and what the state of his health had been. Dr. H. R. Hildreth said that there were reports of apparent improvement if not cures of tumors in the eyes among chil dren with bilateral disease. He had seen no later reports, so did not know the final outcome. Treatment had been by means of radon seeds. He wished to know which method of treatment was considered to be the better. Dr. W. H. Luedde said the second eye showed the greater signs of malignancy. Did the X-ray contribute to these find-
468
SOCIETY PROCEEDINGS
ings? The second tumor was there the longer and therefore the more dangerous. Dr. J. T. Elz said that in the first eye there was a large amount of necrosis. Duke-Elder does not consider irradiation the best means to a cure, but he does think there are cases in which it should be tried. Many patients have been bene fited by the use of the X ray and radon seeds. Martin and Reese published a pa per on the X-ray treatment of tumors. There are, however, as many cases of spontaneous cure as of cures with ir radiation. T H E CASE OF JOE (MALINGERING) DR. W. E. SHAHAN gave a case re port on a patient named Joe. Discussion. Dr. W. H. Luedde, in dis cussing Dr. Shahan's report, mentioned a case he had seen some years ago. The
patient had had a foreign body in one eye, following the removal of which he claimed that he could not see. The first examiner had reported to the Commis sion for the Blind that this patient was unable to see. Dr. Luedde was able to prove definitely that the man was able to see with the eye. In spite of this, the com pensation board gave the malingerer com pensation for half the loss of an eye. The same patient had been seen by an other doctor who became so angry in the course of the examination, since he was sure that there was no loss of vision, that he swore most vigorously at the man and frightened him into reading his entire chart. Dr. Luedde believed this technique to be of definite value in cer tain instances. Adolph C. Lange, Editor.