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The Effect of Diet and Vitamins on Trachoma
EFFECT OF DIET AND VITAMINS ON TRACHOMA
735
Smith, Priestley. Statistics of the weight, volume and specific gravity of crystalline lenses at different times of life. Trans. Ophth. Soc, 1883, v. 3, p. 82. Thorington. Methods of refraction. P. Blakiston's Son & Co., 1931. Urbanek. Glaucoma juvenile inversum. Ztschr. f. Augenh., 1930, v. 77, p. 171. Wessely. Versuche am wachsenden Auge. Arch. f. Augenh., 1910, v. 65, p. 295. T H E EFFECT OF DIET A N D VITAMINS ON TRACHOMA SURGEON C. E. RICE, U.S.P.H.S. A. A. SURGEON ROBERT SORY, U.S.P.H.S. A. A. SURGEON J. E. S M I T H , U.S.P.H.S. A. A. SURGEON P. E. FAED, U.S.P.H.S. A. A. SURGEON A. A. DRAKE, U.S.P.H.S. ROLLA, MISSOURI
This contribution confirms the results obtained in animal experimentation; viz., that food does not affect the course of trachoma. With the incitant of trachoma still unknown or unestablished, it is perhaps natural that various opinions should ex ist regarding the etiological factor. While many investigators consider trachoma as due to a specific organ ism 1-7 or virus 8 , others 9 ' 1 0 are equally positive that constitution or defective diet is an important factor in its causa tion. With the facilities available at the Trachoma Hospital of Rolla, Missouri, and Richmond, Kentucky, an opportu nity was afforded for studying the pos sible relationship of trachoma to diet ary deficiency, by determining the ef fect of balanced diets and vitamins on the course of the disease, and on the speed of recovery. This study was be gun in the spring of 1931 and has been continued for 20 months. The patients selected for this study were representative of the three clinical forms of trachoma; namely, (a) lid trachoma, where the pathology is con fined largely to the lids, (b) corneal trachoma, and (c) a combination of lid and corneal trachoma. The patients' history was recorded on special charts. Local treatment was carried out in one eye only, called the control eye, and if operative interference was indicated, it was done on this control eye. The other eye, designated as the test eye, was not treated in any way (Group I excepted) for varying periods of time, depending upon the individual. Careful observa tions were then made for the progress or regress of the disease in the test eye. The selected patients were placed on
regular balanced diets with varying amounts of cod-liver oil. In some, codliver oil was administered by mouth, in others by mouth and by intramuscular injection. The latter group also received Brewer's yeast. Table 1 indicates the kind of food furnished the trachoma patients to gether with the amount served to each during a representative day of the four seasons of the year. The whole-milk ration of 720 c.c. was served to all un der 15 years of age and to those adults who seemed considerably undernour ished. Particular care was taken to see that these dietary-test patients ate the food placed before them. The food ac tually consumed by each individual was not weighed, however. The observations reported in this communication were made on the effect of balanced diet and certain additional vitamins on the progress of trachoma, measured by local clinical manifesta tions and vision in 30 patients. The in dividuals studied were divided into four groups depending upon the route of administration of the vitamins, the amount and kind of vitamin, and whether the test eye was molested in any way. While the number of patients included in the study is not large, nev ertheless it is felt that sufficient data have been obtained over a prolonged period so that certain conclusions can be made. Tables 2 and 3 summarize some of the factors concerning the individual cases, such as age, duration of the dis-
736
RICE, SORY, SMITH, FAED AND DRAKE
ease, duration of dietary test, weight of patient on entry to the hospital and at the end of test, and the total time hos pitalized. When it is considered that the average period of hospitalization is almost 30 days, it is seen that this pe riod has certainly not been shortened in the 30 patients undergoing this experi ment.
pluses (-1—r- + ) indicate in addition to last findings, photophobia, a watery dis charge from the eyes, and much -more thickening of the subconjunctival tis sue. The letter " S " indicates scar tis sue only, without any activity. Under pathology of the cornea ap pear symbols, P, + , U, and F. The " P " indicates varying degrees of pannus
Table 1 T A B L E SHOWING AMOUNTS OF FOOD SERVED TO INDIVIDUAL TRACHOMA PATIENTS UNDERGOING A DIETARY TEST DURING FOUR REPRESENTATIVE DAYS OF THE YEAR
Items Apricots Prunes Peaches Apples, raw Apple sauce Cereal cooked with whole milk Biscuits Bread, whole wheat Bread, corn Butter Milk, whole Coffee (Adults) Pork sausage Beef roast Veal roast Pork roast Gravy Potatoes Turnips Onions, raw Beans, fresh string Cabbage, raw Mustard, greens Rhubarb Corn, roasting Corn, pudding Salad, lettuce Salad, kidney bean Eggs, scrambled Brown Betty (a pudding of apples with bread and lemon juice) Tomatoes (fresh) Tomato juice
Spring
Summer
Autumn
90 gm.
93 gm. 217 gm. 150 gm. 93 gm. 139 gm. 30 gm. 720 c.c. 240 c.c. 87 gm. 50 gm. 181 gm.
138 gm. 78 gm.
93 217 150 93 140 30 720 240
gm. gm. gm. gm. gm. gm. c.c. c.c.
90 gm. 90 gm. 217 gm. 150 gm. 93 gm. 140 gm. 30 gm. 720 c.c. 240 c.c.
93 gm. 50 gm. 91 gm.
90 gm. 50 gm. 242 gm.
20 gm. 200 gm. 70 gm.
200 gm. 70 gm.
In tables 4 and 5 under pathology of the lids appear symbols + , + + , + + + and S. One plus ( + ) indicates a moder ate number of follicles or papillary areas involving only part of the palpebral and retrotarsal conjunctiva with some sub conjunctival thickening. Two pluses, ( + + ) indicate all or nearly all of the palpebral and retrotarsal conjunctiva showing either granular or papillary ac tivity or both together with considera ble subconjunctival thickening. Three
93 gm. 217gm. 150 gm. 93 gm. 140 gm. 30 gm. 720 c.c. 240 c.c. 140 gm.
60 230 130 20
gm. gm. gm. gm.
193 gm.
93 gm.
240 c.c.
93 gm.
300 gm. 109 gm.
87 gm.
139 gm.
Winter
190 gm.
240 c.c.
240 c.c.
which may be extended only a few mil limeters or may involve the whole corneal surface. The plus ( + ) refers to cellular infiltration of the corneal tissue which is only slight in amount. Two pluses ( + + ) indicate infiltration in volving much of the cornea, and three pluses ( + + + ) that the whole cornea is involved. The " U " indicates ulcers or staining areas of the corneal surface and the " F " indicates follicles or petechial hemorrhages in the corneal tissue.
737
E F F E C T O F D I E T AND VITAMINS ON TRACHOMA In evaluating any changes in the clinical condition as compiled in tables 4 and 5, it must be pointed out that the change in disciplinary and hygienic habits in the hospital, as contrasted with those of the primitive homes from
slight in all but four* cases and two of these received irrigations in the test eye. In six b cases the condition became notably worse. In all cases but one 0 which started with considerable in volvement of the lids, it was necessary
Table 2 GROUP I
Patient
Age
Duration Disease
Duration Test
1. G.H. 2. E.H. 3. I.S. 4. R.T. 5. O.M.
F9 24 11 17 29
Few weeks 1 month 4 years Unknown Unknown
46 days 41 days 28 days 26 days 25 days
Weight—lbs. Before After
Total Time Hospital ized
Final Dis position Test Eye
63 185 80 144 135
104 days 145 78 31 27
Diathermy Grattage Grattage No operation No operation
58 182 73 139 129
This group was the first to be placed under dietary test. The patients were on a blanced diet together with cod-liver oil by mouth. All the test eyes in this group received local treatment in the form of irrigations of boric acid in normal saline. Each patient received a minimum of 12,000 units of vitamin A (U.S.P.) and 900 units vitamin D (Steenbock) daily in the cod-liver oil in addition to a balanced diet. GROUP II
1. H.L. 2. M.E. 3. M.E. 4. C.E. 5. B.V. 6. C.S.
20 12 8 10 14 17
15 years 11 years 1 year 9 years Sev. mo. 2 years
19 days 40 days 40 days 40 days 35 days 57 days
127 73 64 73 65 140
128 78 70 80 70 150
39 71 71 71 39 117
Grattage* Grattage Grattage Grattage Grattage Diathermy
The patients in this group received a balanced diet and cod-liver oil by mouth. The test eyes were not molested in any way during the experimental period. Each patient received a minimum of 12,000 units vitamin A (U.S.P.) and 900 units vitamin D. (Steenbock) daily in the cod-liver oil used. * Patient discharged against medical advice before reaching maximum improvement. GROUP
1. J.H. 2. J.M. 3. D.R. 4. K.R. 5. B.M. 6. W.N. 7. D.L.
13 11 10 7 7 10 18
3 years 10 years 2 years 18 mos. 5 years 8 years 15 years
33 days 45 days 34 days 34 days 37 days 37 days 51 days
III
78 65 53 42 50 61 136
83 70 55 45 50 65 132
103 110 78 78 92 92 82
Grattage Grattage Grattage Grattage Grattage Grattage Grattage
The test eyes in this group were not molested in any way. Each patient received 4,300 units of vitamin A (U.S.P.) and 270 units vitamin D (Steenbock) daily in the cod-liver oil in addition to a balanced diet. which the patients usually came, fre quently causes per se some improve ment in trachoma, usually of a subjec tive nature. Accessibility of hot and cold water, and soap, as well as regu lated sleep are important therapeutic agents in trachoma. Improvement was absent or very
to proceed with grattage or to use diathermy on the lids at the end of the diet experiment. As stated before, the "Cases 4 and 5, Group I; cases 1 and 4, Group IV. * Cases 1, 2, and 4, Group I I ; case 1, Group I I I ; cases 6 and 12, Group IV. ° Case 4, Group IV.
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RICE, SORY, SMITH, FAED AND DRAKE
period of hospitalization was not short ened, and scar-tissue formation was not stimulated. In table 5 are compiled the findings as regards vision and pathology in the control eye at the beginning and end of the test period. These eyes received local treatment during this period. The results are much more striking than in the test eyes. The disease in many of the lids is shown to have become ar rested and corneal improvement is more marked. Nine corneae of these control eyes reached maximum improvement during the experimental period.
maximum improvement. However, only four corneae 1 in the test eyes reached maximum improvement during the ex perimental period, as shown by lessened engorgement of pannus vessels, absence of infiltration of corneal tissue, and smoothing of corneal surface. On the whole, when improvement did take place it was more noticeable in the cor neal pathology than in the lid condition. The notes on two of the cases are as follows: Case three (c), Group I—this was a very destructive granular type of trachoma with marked corneal in volvement of both eyes. Pannus was
Table 3 GROUP IV
Patient 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
E.T. O.J. H.S. C.R. G.W. J.H. W.C. C.H. J.W. H.W. C.W. E.C.
Age
Duration Disease
Duration Test
22 28 7 17 13 12 30 17 9 10 43 24
3 mos. 2 years 2 years 3 mos. 3 years 5 weeks 3 mos. 4 years 1 year 1 year 2 years 6 years
76 days 32 days 70 days 81 days 45 days 44 days 31 days 46 days 41 days 41 days 27 days 14 days
Weight Weight Total Time in pounds in pounds Hospital Final Disposi tion Test Eye After Before ized 139 136 46 127 72 89 144 135 53 58 122 121
160 142 51 136 79 99 160 143 65 69 129 127
120 days 160 180 93 45 84 91 118 45 45 71 19
Diathermy Grattage Grattage No operation Grattage* Diathermy Diathermy Grattage Grattage Grattage Diathermy Grattage*
The test eyes in this group were not molested in any way. Each patient received cod-liver oil by mouth and six received the oil intramuscularly also. All received Brewer's yeast (12 gm. daily) in addition to a balanced diet. Each patient received daily a minimum of 32,000 units of vitamin A (U.S.P.) and 2400 units vitamin D (Steenbock) and 130 units vitamin B (Sherman) in the cod-liver oil and yeast. * Patient discharged against medical advice before reaching maximum improvement.
Some of the test eyes reached the maximum improvement in vision by the end of the test period. Vision as a cri terion of improvement or lack of im provement in the corneal pathology of trachoma is not very satisfactory, as nine of the test eyes showed normal or nearly normal vision at the beginning of the experiment. Other corneae were so badly damaged by formation of scar tissue that little improvement in vision could be hoped for. Infiltration and roughening of the cornea over the pupil lary area might change for the better and still the remaining portion of the cornea be far from having reached
generalized in each cornea. Numerous pin-point staining areas appeared in each cornea. A large follicle in the left cornea near the upper limbus, under higher magnification of the corneal microscope, appeared to be full of fine pin-point reddish particles. The epi thelium over this follicle was pushed up above the rest of the corneal surface. Grattage was applied to the left eye on entrance while the right, as the test eye, was untreated for a period of 28 days except for irrigations. The Kahn test * Case 4, Group I; cases 1, 4, and 10, Group IV.
EFFECT OF DIET AND VITAMINS ON TRACHOMA was negative: Mantoux test was also3 negative to 1 mg. of O.T. Case two, Group II, was one of ai granular trachoma with no scar tissuet visible even though disease had lastedI from infancy. There were 2 mm. of pannus in each cornea and much infiltra
739
the cornea of the test eye the pannus had increased slightly and two areas of petechial hemorrhage had developed. This eye was finally subjected to grattage. It does not seem possible to us that sufficient balanced food elements had
Table 4 S U M M A R I Z I N G A L L T H E test ( U N T R E A T E D ) E Y E S S H O W I N G V I S I O N A T B E G I N N I N G A N D E N D O F E X P E R I
M E N T A L PERIOD TOGETHER WITH PATHOLOGY PRESENT AT BEGINNING OF THE PERIOD AND THE CHANGE IN PATHOLOGY AT THE END OF THE PERIOD.
Case
Vision in Pathology in Test Eye at Vision in Test Eye at Test Eye at - Beginning of Experiment End of Start of Lids Cornea Experiment Experiment
Pathology in Test Eye at End of Experiment Lids
Cornea No path. P+ P+ + + P P+
1. 2. 3. 4. 5.
G.H. E.H. I.S. R.T. O.M.
20/20 20/50 20/100 20/60 5/200
20/20 20/30 20/100 20/15 20/40
++ +++ +++ +
No path. P++F P-r-f-rP + +U P + + +U
++ +++ +++
1. 2. 3. 4. 5. 6.
H.L. M.E. M.E. C.E. B.V. C.S.
10/200 20/40 20/30 20/20 20/15 20/70
? 20/40 20/20 20/20 20/15 20/30
+++ +++ ++ +++ ++ +++
P+ + P + -IP+ P P+ +
+
+++ +++ ++ +++ ++ ++
P+F P P+
1. 2. 3. 4. 5. 6. 7.
J.H. J.M. D.R. K.R. B.M. W.N. D.L.
14/200 20/200 20/70 20/70 20/100 20/40 20/30
8/200 20/200 20/70 20/50 20/100 20/30 20/30
+++ +++ ++ ++ +++ ++ +++
P+ + P+ + P+-IP+ + P+ + + P+ + P+ +
+++ +++ ++ ++ +++ ++ ++
P+ P+ P+ P+ P+ P+ P+
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
E.T. O.J. H.S. C.R. G.W. J.H. W.C. C.H. J.W. H.W. C.W. E.C.
20/70 1/200 20/40 20/30 2/200 20/30 20/50 20/30 20/30 20/30 20/100 1/200
20/30+2 2/200 20/30 20/20 3/200 20/20 20/20 20/30 20/30 20/30 20/70 ?
+++ +++ +++ +++ +++ +++ +++ +++ +++ +++ +++ +++
P+ + P+ + + P-f-rP+ + P+ + +
++ ++ +++ + ++ ++ ++ ++ + + ++ +++ +++
S
tion of the upper cornea. Kahn and Mantoux tests were negative. Grattage was applied to the left eye on entrance and the right eye left unmolested as the test eye for a period of 40 days. At the end of this period the pathology in the lids of the test eye was unchanged. In
P
P+ +
P P P+
P+ + + P+ +
S
s
P+ + + P+ + F
+
+ + + + + +
P
P+ + +
P+ P
P+ +
P+ P+ P P P
P++1 P+ + +
any direct influence on the course of trachoma, even when reinforced by codliver oil and Brewer's yeast. It is interesting in this connection to recall the experiments of Kendall and Gifford" and of Tilden and Miller 12 . These authors showed that a granular
740
RICE, SORY, SMITH, FAED AND DRAKE Table 5
SUMMARIZING ALL THE control (TREATED LOCALLY) EYES SHOWING VISION AT BEGINNING AND END OF EXPERIMENTAL PERIOD TOGETHER WITH PATHOLOGY PRESENT AT BEGINNING OF THE PERIOD AND THE CHANGE IN PATHOLOGY AT THE END OF THE PERIOD, ALL THESE EYES RECEIVED LOCAL TREATMENT AND THE MAJORITY, GRATTAGE.
Case
Vision in Vision in Control Eye Control Eye at End of at Start of Experiment Experiment
Pathology in Con Pathology in Control Eye Changein trol Eye at End of Experi at Beginning of Test ment Lids
Cornea
Lids
Cornea
S
No path. P
S S
P
+ + +S
P+
1. 2. 3. 4. 5.
G.H. E.H. I.S. R.T. O.M.
20/20 20/40 20/100 20/70 10/200
20/20 20/15 20/100 20/15 20/40
++ +++ +++ +
No path. P++UF P++F + P + +U P + +U +
1. 2. 3. 4. 5. 6.
H.L. M.E. M.E. C.E. B.V. C.S.
1/200 20/40 20/20 20/20 20/15 20/70
20/200 20/40 20/20 20/20 20/15 20/15
+++ +++ ++ +++ ++ +++
P+ + P+ +
1. 2. 3. 4. 5. 6. 7.
J.H. J.M. D.R. K.R. B.M. W.N. D.L.
1/200 20/70 20/200 20/70 20/100 20/50 20/50
10/200 20/70 20/200 20/40 ' 20/100 20/30 20/30
+++ +++ ++ ++ +++ ++ +++
P + + -T-
P+ + P+ + + P+ + P+ + + P+ + P+ +
+ + s s s s
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
E.T. O.J. H.S. C.R. G.W. J.H. W.C. C.H. J.W. H.W. C.W. E.C.
Shad. 2' 6/200 20/40 20/40 8/200 20/40 20/70 20/30 20/30 20/30 20/70 20/20
20/30 18/200 20/30 20/20 18/200 20/20 20/20 20/30 20/30 20/20 20/30 20/20
+++ +++ +++ +++ +++ +++ +++ +++ +++ +++ +S + +
P + + +U P+ + + P+ + P++U P+ + + P+ P+ + P P+ P+ P+ +
s + + + s s + + s s + s
S
condition of t h e p a l p e b r a l conjunctiva of m o n k e y s following injections of Bact. g r a n u l o s i s w a s n o t affected b y v i t a m i n - A deficiency. Similar experi m e n t s b y D r . R. A. H e t l e r of St. L o u i s indicate t h a t a folliculosis of m o n k e y s ' conjunctivae, induced b y direct t r a n s f e r of t r a c h o m a , m a t e r i a l , is likewise n o t influenced b y v i t a m i n - A deficiency o r by v a r i o u s d e g r e e s of general m a l n u t r i tion. Conclusions 1. T h i r t y p a t i e n t s w i t h t r a c h o m a were studied for v a r y i n g periods to de
+
P P
P+ +
P
+ +
P+++
P+ P++
+
S
s
p p p
S
P++
P-f-r-
P+ + P+ P+
P+ P+
P
P+ p+ p p+ p p p p p
p+ p
t e r m i n e t h e effect of diet a n d v i t a m i n s on the course of t h e disease. 2. T h e r e is n o evidence t h a t a bal anced diet s u p p l e m e n t e d w i t h cod-liver oil b y m o u t h affected t h e course of t r a c h o m a in t h e u n t r e a t e d eyes of e i g h t e e n p a t i e n t s k e p t u n d e r observa tion for v a r y i n g p e r i o d s of t i m e . N e i t h e r is t h e r e evidence t h a t a b a l a n c e d diet s u p p l e m e n t e d b y cod-liver oil, b o t h b y mouth and intramuscularly, and Brew er's y e a s t affected t h e c o u r s e of t h e dis ease in t w e l v e t r a c h o m a t o u s p a t i e n t s during the time they were kept under observation.
THE VASOMOTOR SYSTEM IN RETINAL LESIONS
741
References •Koch, R. Wien. med. Wchnschr., 1883, v. 33, p. 1550. •Weeks, J. E. N.Y. Med. Rec, 1887, v. 31, p. 571. '4 Miiller, L. Wien. klin. Wchnschr., 1897, v. 10, p. 920. Sattler, H. Ber. Versamml. Ophth. Ges., 1881, v. 13, p. 18. 5 Rohlmann, E. Beit. z. Augenh., 1905, v. 7, p. 35. ■Williams, A. W. Studies Bureau Lab. New York City Dept. Health, 1912-13, v. 7, p. 159. * Noguchi, H. Jour. Exp. Med., 1928, v. 48, Suppl. No. 2. "Nicolle, C, Cuenod, A., and Blaizot, L. Arch. d. l'lnst. Past, de Tunis, 1911, v. 3, p. 185. "Roger, B. F. Jour. Amer. Med. Assoc, 1926, v. 87, p. 482. M Stucky, J. A. Trans. Acad. Ophth. and Otol., 1930, pp. 217-224. 11 Kendall, A. I., and Gifford, S. R. Arch, of Ophth., 1930, v. 4, p. 322. 12 Tilden, E. B., and Miller, E. G., Jr. Nutri., 1930, v. 3, p. 121.
T H E VASOMOTOR SYSTEM IN RETINAL AND CEREBRAL VASCULAR LESIONS DANIEL KRAVITZ, M.D. BROOKLYN, N.Y.
Because the growth of pathology has contributed so largely towards the rapid progress medicine has made, many have come to think of loss of function only in relation to an underlying pathology. However, extensive pathology and even death may be secondary to a primary disturbance in function. A brief resume of the anatomy and physiology of the vasomotor system and its relation to the functional integrity of the brain and retina is given, and cases are recited in which such disturbances have resulted in accidents rivaling those caused by severe organic lesions.
Closure of the central retinal artery or of a cerebral blood vessel is not a rare condition. Sometimes it occurs in vascular disease; at other times there is no obvious pathology to account for the lesion. Lately, the importance of vas cular spasms as a cause of many syn dromes affecting the eye and brain has assumed increasing proportions. The question- of whether the cerebral and retinal blood vessels are under the control of the sympathetic system is still under dispute. The older physiolo gists are mainly responsible for the opinion, prevalent until recently, that the blood vessels of the brain and eye have no vasomotor nerves. Because of the difficulty in performing experiments on the blood vessels of the eye, we can, draw analogies from experiments on those of the brain. This is possible be cause the blood vessels of the retina, as well as the retina, are off-shoots of the brain and its vascular supply. Following a series of experiments, Bayliss 1 concluded that "there is no evidence that the cerebral blood vessels have any vasomotor control; the im portance of the brain is such that its
circulation is regulated by the whole of the rest of the body." With this concept, Hill 2 was in complete agreement. Cushing 3 observed that by exerting pressure on the brain, and increasing this pressure progressively, a local venous stasis was produced which later extended to remote parts of the brain. This venous stasis was first seen in the retinal vessels on the same side as that in which the pressure was produced. When the intracranial pressure equaled the capillary pressure, blanching of the brain resulted; if the pressure was raised to such an extent that the medul lary centers became anemic, the blood pressure rose and the brain resumed its rosy color. The blood pressure could thus be considerably raised in stages. If, however, the vagi were cut to re move their inhibitory effects, the blood pressure could be made to rise more readily. If, in addition, the cord was cocainized or cut at a level above the point of departure of the great splanch nic nerves, the intracranial pressure did not rise. Cushing therefore concluded that the mechanism controlling the rise of intracranial pressure was largely due
735
Smith, Priestley. Statistics of the weight, volume and specific gravity of crystalline lenses at different times of life. Trans. Ophth. Soc, 1883, v. 3, p. 82. Thorington. Methods of refraction. P. Blakiston's Son & Co., 1931. Urbanek. Glaucoma juvenile inversum. Ztschr. f. Augenh., 1930, v. 77, p. 171. Wessely. Versuche am wachsenden Auge. Arch. f. Augenh., 1910, v. 65, p. 295. T H E EFFECT OF DIET A N D VITAMINS ON TRACHOMA SURGEON C. E. RICE, U.S.P.H.S. A. A. SURGEON ROBERT SORY, U.S.P.H.S. A. A. SURGEON J. E. S M I T H , U.S.P.H.S. A. A. SURGEON P. E. FAED, U.S.P.H.S. A. A. SURGEON A. A. DRAKE, U.S.P.H.S. ROLLA, MISSOURI
This contribution confirms the results obtained in animal experimentation; viz., that food does not affect the course of trachoma. With the incitant of trachoma still unknown or unestablished, it is perhaps natural that various opinions should ex ist regarding the etiological factor. While many investigators consider trachoma as due to a specific organ ism 1-7 or virus 8 , others 9 ' 1 0 are equally positive that constitution or defective diet is an important factor in its causa tion. With the facilities available at the Trachoma Hospital of Rolla, Missouri, and Richmond, Kentucky, an opportu nity was afforded for studying the pos sible relationship of trachoma to diet ary deficiency, by determining the ef fect of balanced diets and vitamins on the course of the disease, and on the speed of recovery. This study was be gun in the spring of 1931 and has been continued for 20 months. The patients selected for this study were representative of the three clinical forms of trachoma; namely, (a) lid trachoma, where the pathology is con fined largely to the lids, (b) corneal trachoma, and (c) a combination of lid and corneal trachoma. The patients' history was recorded on special charts. Local treatment was carried out in one eye only, called the control eye, and if operative interference was indicated, it was done on this control eye. The other eye, designated as the test eye, was not treated in any way (Group I excepted) for varying periods of time, depending upon the individual. Careful observa tions were then made for the progress or regress of the disease in the test eye. The selected patients were placed on
regular balanced diets with varying amounts of cod-liver oil. In some, codliver oil was administered by mouth, in others by mouth and by intramuscular injection. The latter group also received Brewer's yeast. Table 1 indicates the kind of food furnished the trachoma patients to gether with the amount served to each during a representative day of the four seasons of the year. The whole-milk ration of 720 c.c. was served to all un der 15 years of age and to those adults who seemed considerably undernour ished. Particular care was taken to see that these dietary-test patients ate the food placed before them. The food ac tually consumed by each individual was not weighed, however. The observations reported in this communication were made on the effect of balanced diet and certain additional vitamins on the progress of trachoma, measured by local clinical manifesta tions and vision in 30 patients. The in dividuals studied were divided into four groups depending upon the route of administration of the vitamins, the amount and kind of vitamin, and whether the test eye was molested in any way. While the number of patients included in the study is not large, nev ertheless it is felt that sufficient data have been obtained over a prolonged period so that certain conclusions can be made. Tables 2 and 3 summarize some of the factors concerning the individual cases, such as age, duration of the dis-
736
RICE, SORY, SMITH, FAED AND DRAKE
ease, duration of dietary test, weight of patient on entry to the hospital and at the end of test, and the total time hos pitalized. When it is considered that the average period of hospitalization is almost 30 days, it is seen that this pe riod has certainly not been shortened in the 30 patients undergoing this experi ment.
pluses (-1—r- + ) indicate in addition to last findings, photophobia, a watery dis charge from the eyes, and much -more thickening of the subconjunctival tis sue. The letter " S " indicates scar tis sue only, without any activity. Under pathology of the cornea ap pear symbols, P, + , U, and F. The " P " indicates varying degrees of pannus
Table 1 T A B L E SHOWING AMOUNTS OF FOOD SERVED TO INDIVIDUAL TRACHOMA PATIENTS UNDERGOING A DIETARY TEST DURING FOUR REPRESENTATIVE DAYS OF THE YEAR
Items Apricots Prunes Peaches Apples, raw Apple sauce Cereal cooked with whole milk Biscuits Bread, whole wheat Bread, corn Butter Milk, whole Coffee (Adults) Pork sausage Beef roast Veal roast Pork roast Gravy Potatoes Turnips Onions, raw Beans, fresh string Cabbage, raw Mustard, greens Rhubarb Corn, roasting Corn, pudding Salad, lettuce Salad, kidney bean Eggs, scrambled Brown Betty (a pudding of apples with bread and lemon juice) Tomatoes (fresh) Tomato juice
Spring
Summer
Autumn
90 gm.
93 gm. 217 gm. 150 gm. 93 gm. 139 gm. 30 gm. 720 c.c. 240 c.c. 87 gm. 50 gm. 181 gm.
138 gm. 78 gm.
93 217 150 93 140 30 720 240
gm. gm. gm. gm. gm. gm. c.c. c.c.
90 gm. 90 gm. 217 gm. 150 gm. 93 gm. 140 gm. 30 gm. 720 c.c. 240 c.c.
93 gm. 50 gm. 91 gm.
90 gm. 50 gm. 242 gm.
20 gm. 200 gm. 70 gm.
200 gm. 70 gm.
In tables 4 and 5 under pathology of the lids appear symbols + , + + , + + + and S. One plus ( + ) indicates a moder ate number of follicles or papillary areas involving only part of the palpebral and retrotarsal conjunctiva with some sub conjunctival thickening. Two pluses, ( + + ) indicate all or nearly all of the palpebral and retrotarsal conjunctiva showing either granular or papillary ac tivity or both together with considera ble subconjunctival thickening. Three
93 gm. 217gm. 150 gm. 93 gm. 140 gm. 30 gm. 720 c.c. 240 c.c. 140 gm.
60 230 130 20
gm. gm. gm. gm.
193 gm.
93 gm.
240 c.c.
93 gm.
300 gm. 109 gm.
87 gm.
139 gm.
Winter
190 gm.
240 c.c.
240 c.c.
which may be extended only a few mil limeters or may involve the whole corneal surface. The plus ( + ) refers to cellular infiltration of the corneal tissue which is only slight in amount. Two pluses ( + + ) indicate infiltration in volving much of the cornea, and three pluses ( + + + ) that the whole cornea is involved. The " U " indicates ulcers or staining areas of the corneal surface and the " F " indicates follicles or petechial hemorrhages in the corneal tissue.
737
E F F E C T O F D I E T AND VITAMINS ON TRACHOMA In evaluating any changes in the clinical condition as compiled in tables 4 and 5, it must be pointed out that the change in disciplinary and hygienic habits in the hospital, as contrasted with those of the primitive homes from
slight in all but four* cases and two of these received irrigations in the test eye. In six b cases the condition became notably worse. In all cases but one 0 which started with considerable in volvement of the lids, it was necessary
Table 2 GROUP I
Patient
Age
Duration Disease
Duration Test
1. G.H. 2. E.H. 3. I.S. 4. R.T. 5. O.M.
F9 24 11 17 29
Few weeks 1 month 4 years Unknown Unknown
46 days 41 days 28 days 26 days 25 days
Weight—lbs. Before After
Total Time Hospital ized
Final Dis position Test Eye
63 185 80 144 135
104 days 145 78 31 27
Diathermy Grattage Grattage No operation No operation
58 182 73 139 129
This group was the first to be placed under dietary test. The patients were on a blanced diet together with cod-liver oil by mouth. All the test eyes in this group received local treatment in the form of irrigations of boric acid in normal saline. Each patient received a minimum of 12,000 units of vitamin A (U.S.P.) and 900 units vitamin D (Steenbock) daily in the cod-liver oil in addition to a balanced diet. GROUP II
1. H.L. 2. M.E. 3. M.E. 4. C.E. 5. B.V. 6. C.S.
20 12 8 10 14 17
15 years 11 years 1 year 9 years Sev. mo. 2 years
19 days 40 days 40 days 40 days 35 days 57 days
127 73 64 73 65 140
128 78 70 80 70 150
39 71 71 71 39 117
Grattage* Grattage Grattage Grattage Grattage Diathermy
The patients in this group received a balanced diet and cod-liver oil by mouth. The test eyes were not molested in any way during the experimental period. Each patient received a minimum of 12,000 units vitamin A (U.S.P.) and 900 units vitamin D. (Steenbock) daily in the cod-liver oil used. * Patient discharged against medical advice before reaching maximum improvement. GROUP
1. J.H. 2. J.M. 3. D.R. 4. K.R. 5. B.M. 6. W.N. 7. D.L.
13 11 10 7 7 10 18
3 years 10 years 2 years 18 mos. 5 years 8 years 15 years
33 days 45 days 34 days 34 days 37 days 37 days 51 days
III
78 65 53 42 50 61 136
83 70 55 45 50 65 132
103 110 78 78 92 92 82
Grattage Grattage Grattage Grattage Grattage Grattage Grattage
The test eyes in this group were not molested in any way. Each patient received 4,300 units of vitamin A (U.S.P.) and 270 units vitamin D (Steenbock) daily in the cod-liver oil in addition to a balanced diet. which the patients usually came, fre quently causes per se some improve ment in trachoma, usually of a subjec tive nature. Accessibility of hot and cold water, and soap, as well as regu lated sleep are important therapeutic agents in trachoma. Improvement was absent or very
to proceed with grattage or to use diathermy on the lids at the end of the diet experiment. As stated before, the "Cases 4 and 5, Group I; cases 1 and 4, Group IV. * Cases 1, 2, and 4, Group I I ; case 1, Group I I I ; cases 6 and 12, Group IV. ° Case 4, Group IV.
738
RICE, SORY, SMITH, FAED AND DRAKE
period of hospitalization was not short ened, and scar-tissue formation was not stimulated. In table 5 are compiled the findings as regards vision and pathology in the control eye at the beginning and end of the test period. These eyes received local treatment during this period. The results are much more striking than in the test eyes. The disease in many of the lids is shown to have become ar rested and corneal improvement is more marked. Nine corneae of these control eyes reached maximum improvement during the experimental period.
maximum improvement. However, only four corneae 1 in the test eyes reached maximum improvement during the ex perimental period, as shown by lessened engorgement of pannus vessels, absence of infiltration of corneal tissue, and smoothing of corneal surface. On the whole, when improvement did take place it was more noticeable in the cor neal pathology than in the lid condition. The notes on two of the cases are as follows: Case three (c), Group I—this was a very destructive granular type of trachoma with marked corneal in volvement of both eyes. Pannus was
Table 3 GROUP IV
Patient 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
E.T. O.J. H.S. C.R. G.W. J.H. W.C. C.H. J.W. H.W. C.W. E.C.
Age
Duration Disease
Duration Test
22 28 7 17 13 12 30 17 9 10 43 24
3 mos. 2 years 2 years 3 mos. 3 years 5 weeks 3 mos. 4 years 1 year 1 year 2 years 6 years
76 days 32 days 70 days 81 days 45 days 44 days 31 days 46 days 41 days 41 days 27 days 14 days
Weight Weight Total Time in pounds in pounds Hospital Final Disposi tion Test Eye After Before ized 139 136 46 127 72 89 144 135 53 58 122 121
160 142 51 136 79 99 160 143 65 69 129 127
120 days 160 180 93 45 84 91 118 45 45 71 19
Diathermy Grattage Grattage No operation Grattage* Diathermy Diathermy Grattage Grattage Grattage Diathermy Grattage*
The test eyes in this group were not molested in any way. Each patient received cod-liver oil by mouth and six received the oil intramuscularly also. All received Brewer's yeast (12 gm. daily) in addition to a balanced diet. Each patient received daily a minimum of 32,000 units of vitamin A (U.S.P.) and 2400 units vitamin D (Steenbock) and 130 units vitamin B (Sherman) in the cod-liver oil and yeast. * Patient discharged against medical advice before reaching maximum improvement.
Some of the test eyes reached the maximum improvement in vision by the end of the test period. Vision as a cri terion of improvement or lack of im provement in the corneal pathology of trachoma is not very satisfactory, as nine of the test eyes showed normal or nearly normal vision at the beginning of the experiment. Other corneae were so badly damaged by formation of scar tissue that little improvement in vision could be hoped for. Infiltration and roughening of the cornea over the pupil lary area might change for the better and still the remaining portion of the cornea be far from having reached
generalized in each cornea. Numerous pin-point staining areas appeared in each cornea. A large follicle in the left cornea near the upper limbus, under higher magnification of the corneal microscope, appeared to be full of fine pin-point reddish particles. The epi thelium over this follicle was pushed up above the rest of the corneal surface. Grattage was applied to the left eye on entrance while the right, as the test eye, was untreated for a period of 28 days except for irrigations. The Kahn test * Case 4, Group I; cases 1, 4, and 10, Group IV.
EFFECT OF DIET AND VITAMINS ON TRACHOMA was negative: Mantoux test was also3 negative to 1 mg. of O.T. Case two, Group II, was one of ai granular trachoma with no scar tissuet visible even though disease had lastedI from infancy. There were 2 mm. of pannus in each cornea and much infiltra
739
the cornea of the test eye the pannus had increased slightly and two areas of petechial hemorrhage had developed. This eye was finally subjected to grattage. It does not seem possible to us that sufficient balanced food elements had
Table 4 S U M M A R I Z I N G A L L T H E test ( U N T R E A T E D ) E Y E S S H O W I N G V I S I O N A T B E G I N N I N G A N D E N D O F E X P E R I
M E N T A L PERIOD TOGETHER WITH PATHOLOGY PRESENT AT BEGINNING OF THE PERIOD AND THE CHANGE IN PATHOLOGY AT THE END OF THE PERIOD.
Case
Vision in Pathology in Test Eye at Vision in Test Eye at Test Eye at - Beginning of Experiment End of Start of Lids Cornea Experiment Experiment
Pathology in Test Eye at End of Experiment Lids
Cornea No path. P+ P+ + + P P+
1. 2. 3. 4. 5.
G.H. E.H. I.S. R.T. O.M.
20/20 20/50 20/100 20/60 5/200
20/20 20/30 20/100 20/15 20/40
++ +++ +++ +
No path. P++F P-r-f-rP + +U P + + +U
++ +++ +++
1. 2. 3. 4. 5. 6.
H.L. M.E. M.E. C.E. B.V. C.S.
10/200 20/40 20/30 20/20 20/15 20/70
? 20/40 20/20 20/20 20/15 20/30
+++ +++ ++ +++ ++ +++
P+ + P + -IP+ P P+ +
+
+++ +++ ++ +++ ++ ++
P+F P P+
1. 2. 3. 4. 5. 6. 7.
J.H. J.M. D.R. K.R. B.M. W.N. D.L.
14/200 20/200 20/70 20/70 20/100 20/40 20/30
8/200 20/200 20/70 20/50 20/100 20/30 20/30
+++ +++ ++ ++ +++ ++ +++
P+ + P+ + P+-IP+ + P+ + + P+ + P+ +
+++ +++ ++ ++ +++ ++ ++
P+ P+ P+ P+ P+ P+ P+
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
E.T. O.J. H.S. C.R. G.W. J.H. W.C. C.H. J.W. H.W. C.W. E.C.
20/70 1/200 20/40 20/30 2/200 20/30 20/50 20/30 20/30 20/30 20/100 1/200
20/30+2 2/200 20/30 20/20 3/200 20/20 20/20 20/30 20/30 20/30 20/70 ?
+++ +++ +++ +++ +++ +++ +++ +++ +++ +++ +++ +++
P+ + P+ + + P-f-rP+ + P+ + +
++ ++ +++ + ++ ++ ++ ++ + + ++ +++ +++
S
tion of the upper cornea. Kahn and Mantoux tests were negative. Grattage was applied to the left eye on entrance and the right eye left unmolested as the test eye for a period of 40 days. At the end of this period the pathology in the lids of the test eye was unchanged. In
P
P+ +
P P P+
P+ + + P+ +
S
s
P+ + + P+ + F
+
+ + + + + +
P
P+ + +
P+ P
P+ +
P+ P+ P P P
P++1 P+ + +
any direct influence on the course of trachoma, even when reinforced by codliver oil and Brewer's yeast. It is interesting in this connection to recall the experiments of Kendall and Gifford" and of Tilden and Miller 12 . These authors showed that a granular
740
RICE, SORY, SMITH, FAED AND DRAKE Table 5
SUMMARIZING ALL THE control (TREATED LOCALLY) EYES SHOWING VISION AT BEGINNING AND END OF EXPERIMENTAL PERIOD TOGETHER WITH PATHOLOGY PRESENT AT BEGINNING OF THE PERIOD AND THE CHANGE IN PATHOLOGY AT THE END OF THE PERIOD, ALL THESE EYES RECEIVED LOCAL TREATMENT AND THE MAJORITY, GRATTAGE.
Case
Vision in Vision in Control Eye Control Eye at End of at Start of Experiment Experiment
Pathology in Con Pathology in Control Eye Changein trol Eye at End of Experi at Beginning of Test ment Lids
Cornea
Lids
Cornea
S
No path. P
S S
P
+ + +S
P+
1. 2. 3. 4. 5.
G.H. E.H. I.S. R.T. O.M.
20/20 20/40 20/100 20/70 10/200
20/20 20/15 20/100 20/15 20/40
++ +++ +++ +
No path. P++UF P++F + P + +U P + +U +
1. 2. 3. 4. 5. 6.
H.L. M.E. M.E. C.E. B.V. C.S.
1/200 20/40 20/20 20/20 20/15 20/70
20/200 20/40 20/20 20/20 20/15 20/15
+++ +++ ++ +++ ++ +++
P+ + P+ +
1. 2. 3. 4. 5. 6. 7.
J.H. J.M. D.R. K.R. B.M. W.N. D.L.
1/200 20/70 20/200 20/70 20/100 20/50 20/50
10/200 20/70 20/200 20/40 ' 20/100 20/30 20/30
+++ +++ ++ ++ +++ ++ +++
P + + -T-
P+ + P+ + + P+ + P+ + + P+ + P+ +
+ + s s s s
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
E.T. O.J. H.S. C.R. G.W. J.H. W.C. C.H. J.W. H.W. C.W. E.C.
Shad. 2' 6/200 20/40 20/40 8/200 20/40 20/70 20/30 20/30 20/30 20/70 20/20
20/30 18/200 20/30 20/20 18/200 20/20 20/20 20/30 20/30 20/20 20/30 20/20
+++ +++ +++ +++ +++ +++ +++ +++ +++ +++ +S + +
P + + +U P+ + + P+ + P++U P+ + + P+ P+ + P P+ P+ P+ +
s + + + s s + + s s + s
S
condition of t h e p a l p e b r a l conjunctiva of m o n k e y s following injections of Bact. g r a n u l o s i s w a s n o t affected b y v i t a m i n - A deficiency. Similar experi m e n t s b y D r . R. A. H e t l e r of St. L o u i s indicate t h a t a folliculosis of m o n k e y s ' conjunctivae, induced b y direct t r a n s f e r of t r a c h o m a , m a t e r i a l , is likewise n o t influenced b y v i t a m i n - A deficiency o r by v a r i o u s d e g r e e s of general m a l n u t r i tion. Conclusions 1. T h i r t y p a t i e n t s w i t h t r a c h o m a were studied for v a r y i n g periods to de
+
P P
P+ +
P
+ +
P+++
P+ P++
+
S
s
p p p
S
P++
P-f-r-
P+ + P+ P+
P+ P+
P
P+ p+ p p+ p p p p p
p+ p
t e r m i n e t h e effect of diet a n d v i t a m i n s on the course of t h e disease. 2. T h e r e is n o evidence t h a t a bal anced diet s u p p l e m e n t e d w i t h cod-liver oil b y m o u t h affected t h e course of t r a c h o m a in t h e u n t r e a t e d eyes of e i g h t e e n p a t i e n t s k e p t u n d e r observa tion for v a r y i n g p e r i o d s of t i m e . N e i t h e r is t h e r e evidence t h a t a b a l a n c e d diet s u p p l e m e n t e d b y cod-liver oil, b o t h b y mouth and intramuscularly, and Brew er's y e a s t affected t h e c o u r s e of t h e dis ease in t w e l v e t r a c h o m a t o u s p a t i e n t s during the time they were kept under observation.
THE VASOMOTOR SYSTEM IN RETINAL LESIONS
741
References •Koch, R. Wien. med. Wchnschr., 1883, v. 33, p. 1550. •Weeks, J. E. N.Y. Med. Rec, 1887, v. 31, p. 571. '4 Miiller, L. Wien. klin. Wchnschr., 1897, v. 10, p. 920. Sattler, H. Ber. Versamml. Ophth. Ges., 1881, v. 13, p. 18. 5 Rohlmann, E. Beit. z. Augenh., 1905, v. 7, p. 35. ■Williams, A. W. Studies Bureau Lab. New York City Dept. Health, 1912-13, v. 7, p. 159. * Noguchi, H. Jour. Exp. Med., 1928, v. 48, Suppl. No. 2. "Nicolle, C, Cuenod, A., and Blaizot, L. Arch. d. l'lnst. Past, de Tunis, 1911, v. 3, p. 185. "Roger, B. F. Jour. Amer. Med. Assoc, 1926, v. 87, p. 482. M Stucky, J. A. Trans. Acad. Ophth. and Otol., 1930, pp. 217-224. 11 Kendall, A. I., and Gifford, S. R. Arch, of Ophth., 1930, v. 4, p. 322. 12 Tilden, E. B., and Miller, E. G., Jr. Nutri., 1930, v. 3, p. 121.
T H E VASOMOTOR SYSTEM IN RETINAL AND CEREBRAL VASCULAR LESIONS DANIEL KRAVITZ, M.D. BROOKLYN, N.Y.
Because the growth of pathology has contributed so largely towards the rapid progress medicine has made, many have come to think of loss of function only in relation to an underlying pathology. However, extensive pathology and even death may be secondary to a primary disturbance in function. A brief resume of the anatomy and physiology of the vasomotor system and its relation to the functional integrity of the brain and retina is given, and cases are recited in which such disturbances have resulted in accidents rivaling those caused by severe organic lesions.
Closure of the central retinal artery or of a cerebral blood vessel is not a rare condition. Sometimes it occurs in vascular disease; at other times there is no obvious pathology to account for the lesion. Lately, the importance of vas cular spasms as a cause of many syn dromes affecting the eye and brain has assumed increasing proportions. The question- of whether the cerebral and retinal blood vessels are under the control of the sympathetic system is still under dispute. The older physiolo gists are mainly responsible for the opinion, prevalent until recently, that the blood vessels of the brain and eye have no vasomotor nerves. Because of the difficulty in performing experiments on the blood vessels of the eye, we can, draw analogies from experiments on those of the brain. This is possible be cause the blood vessels of the retina, as well as the retina, are off-shoots of the brain and its vascular supply. Following a series of experiments, Bayliss 1 concluded that "there is no evidence that the cerebral blood vessels have any vasomotor control; the im portance of the brain is such that its
circulation is regulated by the whole of the rest of the body." With this concept, Hill 2 was in complete agreement. Cushing 3 observed that by exerting pressure on the brain, and increasing this pressure progressively, a local venous stasis was produced which later extended to remote parts of the brain. This venous stasis was first seen in the retinal vessels on the same side as that in which the pressure was produced. When the intracranial pressure equaled the capillary pressure, blanching of the brain resulted; if the pressure was raised to such an extent that the medul lary centers became anemic, the blood pressure rose and the brain resumed its rosy color. The blood pressure could thus be considerably raised in stages. If, however, the vagi were cut to re move their inhibitory effects, the blood pressure could be made to rise more readily. If, in addition, the cord was cocainized or cut at a level above the point of departure of the great splanch nic nerves, the intracranial pressure did not rise. Cushing therefore concluded that the mechanism controlling the rise of intracranial pressure was largely due