CHICAGO OPHTHALMOLOGICAL SOCIETY

The regular monthly meeting of the Chicago Ophthalmological Society was held on Monday evening, February 17, 1919, with the president, Dr. William L. Noble, in the chair.

FUNDUS PATHOLOGY WITH THE RED-FREE
LIGHT OF VOGT

Part 1. A New Symptom of Retinal Atrophy.
Part 2. Macular and Foveal Changes.

Dr. Robert Von Der Heydt read a paper on this subject, in which he stated that in the normal fundus the red-free light gave the first absolute demonstration of the yellow coloring at the macula in the living eye. Owing to an increased contrast new details could be seen, especially of the fovea and macula. We could measure with it by comparison the yellow discoloration of the lens in old age. The increased visibility of the retinal fibers with the red-free light was of great importance.

With it pathologic changes in the retina could be studied and localized. In the various types of atrophy of the nerve there was a general or localized zone where the normal retinal striation was found to be absent. In its place was found a white moth-like mottling of the surface. In retrobulbar neuritis this change was found in the maculo-papillary bundle. This disappearance of the retinal striations must be added to the symptomatology of optic atrophy and was the only known visible sign of retinal atrophy.

The macular zone was practically absent in Albinos. Vogt and Affolter failed to find the yellow coloration at the macula in living Albinos. Its absence was in direct or indirect relation to the lack of pigment in general.

In normal eyes this yellow coloration of the macula was very beautiful in appearance; also the foveal reflex of Dimmer, which showed as a very luminous, glistening spot.

Vogt described certain honeycomb-like changes of the macula in the red-free light. This vacuoli formation was found in retinitis pigmentesa, embolism, as well as in bulbar trauma, and was presumed to produce in time the condition called "hole in the macula." In one case hyphemae were found in these systic spaces, which shifted on change of position of the patient.

Many new reflexes of the retinal surface were found with the red-free light; opacities of the media were increased in visibility.

It was not expected that this method would supersede the ordinary light for ophthalmoscopy. Certain conditions were seen in better contrast with the old light. There was no doubt, however, that with the red-free light there was added a most valuable and helpful method of diagnosis.

DISCUSSION

Dr. Michael Goldenburg said he became so interested in this lamp when Dr. Von der Heydt first called attention to it that he asked him to loan it to him and spent an entire afternoon looking at cases of various kinds. The lamp at present was not perfect, but he felt that Dr. Von der

Heydt should be given a great deal of credit for his work so far. The light offered wonderful avenues of approach which had never been available before. He had examined a number of cases and in one that he thought was an embolism of the central retinal artery with hemorrhages, the free blood looked black. The vascularization upon the disc of very fine vessels, which was not seen with the ordinary illumination, was visible as little black lines running across a white field. We were not sure about the nerve fibers but thought we could see them in one case; it required a good deal of practice to judge these things, and the three who had seen the case did not think they had sufficient experience to decide. In one case with an appar ently normal fundus he had never been able to see the so-called choroidal opacities before but saw numbers of them when using this light.

Probably the most fascinating part of the red-free light was the ability to see the macula, as bright canary yellow, just like a bright brilliant spot in the blue field. They examined one case that was going through a low-grade form of neuro-retinitis. The patient had had several attacks. He did not feel that he could see the yellow in the macula in that case and neither did Dr. Crossley, but they could see it in the others, of what significance, this he did not know.

In the patient he had presented to the Society, where there were little fine fibers out to the nasal side, one could see the white lines very thin but visible, and the hemor rhages were apparent, standing out as black spots. He could trace the fibers from the disc out for a way, but not to the macula, but this was probably because he was not familiar with the use of the instrument.

Unquestionably the red-free light would be of unlimited value in the early diagnosis of retinal and optic nerve conditions.

In the case of a colored woman examined, he thought his glass had black spots, for in looking at the fundus the ordinary tesselated picture appeared, as definite black and white strips-a very marked contrast. He had never seen a similar picture.

Dr. E. R. Crossley stated that he had had the pleasure of examining the cases with Dr. Goldenburg and the macula stood out very well. In one comparatively normal case one could see the nerve fibers coming out but could not trace them around the macula as was described. On more ex. perience with the light one might be able to do so. The blood vessels stood out plain and black and it gave a very good view of the macula.

Dr. Von der Heydt, in closing, said that Vogt and Affolter had been using the light since 1913 and had a vast amount of literature on the subject. Last fall he had the filters made and showed them to the Society.

With ordinary light it was comparatively simple to use the ophthalmoscope. One could pick up the light anywhere. With the red-free light, however, one had to seek the center of the cone of light. If one got into the periphery one ran into chromatic aberration.

His instrument was so tilted that it threw the cone of light in an upward incline. This enabled him to seat the patient at varying distances, according to his height. He guided himself by the bluish disc, thrown on the window shade, watched the image of the patient's head in it and led his ophthalmoscopic mirror into the center of the cone of light.

The colored person, rich in pigment, was comparatively a poor subject for the red-free light.

In the embolism case, seen with Dr. Goldenburg, he could not expect to see much more with the red-free light than with ordinary light, because the case was a very recent one. There was still present an edema of the retina and it was too early to expect to see the atrophic zones which would later be visible in the fiber layer of the retina.

ORBITAL ABSCESSES

Dr. Robert H. Good read a paper on this subject in which he considered orbital abscesses caused by

infections of the adjacent anatomical structures to the orbit, with special reference to the early manifestations of infracranial complications, so that by early operative procedure many cases might be arrested fom meningitis and brain abscess.

These abscesses were found either subperiosteal, between periosteum and orbital bony wall, or between the extrinsic muscles with their membranous connections, and the periosteum; or between the extrinsic muscles and the optic nerve in the orbital fat.

Etiology.-1. Subperiosteal abscesses in the orbit were by far the most frequent and were caused by acute and chronic inflammations of the ethmoids, frontal sinus, maxillary sinus and splenoid sinus. A good stereo x-ray would show whether the orbital wall was necrosed or not. Fractures of the orbit might cause a subperiosteal hemorrhage, which, if it became infected, formed an abscess. Extradural abscesses might find their way from the anterior fossa of the skull through the optic foramen external to the orbital periosteum. However, it was more frequent to have the pus go in the other direction, causing an extradural abscess from the orbital abscess. Tumors in the nose, such as polypi, fibroma and sarcoma, were often the cause of this form of orbital abscess. Tuberculosis and syphilis of the orbital bony wall were common.

2. Abscess between the periosteum and the extrinsic muscles of the eye, with their membranous connective sheath, were caused by an extraperiosteal abscess breaking through the periosteum into this space. Trauma, such as blows, causing hemorrhages in the subcutaneous areolar tissue, would form an abscess in this space if the blood clot became infected. Penetrating wounds and foreign bodies along the margin of the orbit, external to the extrinsic muscles of the eye and internal to the periosteum, would cause the abscess to form in this space. In dacryocystitis the sac might rupture into this region. Infection from subconjunctival injections of the eye would form an abscess in this space. Abscess of the lachrymal might rupture into this space.

3. Abscess internal to the extrinsic muscles were in the orbital fat around the optic nerve. As the membranous connective tissue sheath between the extrinsic muscles was very thin, it did not form a great barrier to the abscess external to the extrinsic muscles from breaking into this region. Ulcers of the cornea, panophthalmitis and penetrating wounds of the sclera had caused abscesses in this area of orbital fat. Penetrating wounds and foreign bodies posterior to the bulb and through the extrinsic muscles, or surgical procedures which entered this space, followed by infection, were sometimes etiological factors. The sphencidal sinus was more frequently responsible for an abscess in the orbital fat than of the other sinuses. The serious complications were extradural abscess, optic neuritis, optic atrophy, meningitis, brain abscess and thrombosis of the cavernous sinus.

The extradural space was continuous with the sub

periosteal space of the orbit and communicated with each other through the optic foramen, so that a subperiosteal orbital abscess might drain into the extradural space and form an extradural abscess. The optic nerve had the same coverings as the brain, namely, from without in, the inner layer of the dura, arachnoid and the pia. The subdural lymph space in the skull extended all along the optic nerve to the eyeball and the subarachnoid space, which contained the cerebrospinal fluid, and communicated with the subarachnoid space of the optic nerve.

The dura of the optic nerve was only the inner layer of the dura, and was thin compared with the dura of the skull, and it was very vascular with many blood vessels entering it, so that toxins would penetrate it much more readily than the dura of the skull. The dura of the optic nerve differed from the skull dura in that it did not have the properties of forming bone, and, therefore, was much less dense in structure.

When toxins entered the subdural space of the nerve, they might cause cerebral symptoms, and if they entered the subarachnoid space of the nerve they resulted in cerebrospinal meningitis because this space was in direct communication with the cerebrospinal fluid. An abscess pressing on the nerve with accompanying edema, as well as absorption of toxins, resulted in optic neuritis and atrophy. An abscess around the optic nerve in the orbital fat pushed the eye straight forward and generally ended in blindness or in meningitis. Involvement of the central vein of the retina or the ophthalmic vein resulted in thrombosis which might extend to the cavernous sinus and produce the same symptoms as lateral sinus thrombosis.

The most frequent location of the abscess was at the inner anterior aspect of the orbit in the region of the lamina papyracea of the ethmoid cells which cause the eye to be pushed outward and somewhat downward.

The next frequent location was in the upper and inner angle of the orbit where the frontal sinus wall was the thinnest and pushed the eye downward and outward. Either of these, if untreated, might break and leave a fistula above the inner canthus of the eye. When due to maxillary sinus infection, the abscess was in the floor of the orbit and pushed the eye up and outward. Orbital abscess from posterior ethmoids and sphenoidal sinus were rare, but when they did occur the eye was pushed forward and the pain was severe even in chronic cases.

The symptoms varied greatly, depending upon whether it was acute or chronic, the part and extent of the orbit involved, as well as the nature of the infection. In chronic cases the symptoms were usually mild, a slight pain with tenderness on pressure. There was slight swelling of the lids and conjunctiva. On palpation a firm mass could be felt. The febrile symptoms were usually negative. In acute cases we had a different picture, especially if the abscess were between the periosteum and the extrinsic muscles or in the adipose tissue. There was marked exophthalmos

and great swelling of the lids and conjustivs with inability to close the eye. The pain was severe in the orbit, radiating to the temple. The temperature was usually high, from 100 to 103 with a corresponding rapid pulse. The eye ball was almost immovable and the power of accommodation was lost.

When the abscess burrowed along the periosteum or along the dura of the optic nerve, it entered the extradural space of the skull by way of the optic foramen and produced an extra dural abscess which cause an absolute change in symptoms and could easily be diagnosed. The tenderness in the eye might be the same or lessened, but when the skull was firmly compressed over the painful areas, the pain was much more marked. The temperature dropped to 96 or 97, no matter if the temperature had been 104. The temperature lingered around subnormal to 99. The pulse dropped at times as low as 50. In addition, the patient complained of dizziness, especially on stooping. The projectile or cerebral vomiting was always present and the mental symptoms varied from indifference and slow cerebration to coma. The blood pressure was increased.

In these cases, in addition to opening the abscess one must expose the dura by removing the posterior wall of the frontal sinus and the patient would make an uneventful rapid recovery.

When the toxins entered into the subdural space, the symptoms were those of mild cerebral irritation, whereas, if they entered into the subarachnoid space of the optic nerve, it caused a cerebro spinal meningitis; both of which should be treated with Flexners or Lederly's anti-meningitis serum intra spinally.

As to treatment, an incision was made through the skin over the most prominent portion of the abscess, not necessarily into the abscess, then a small curved blunt artery forceps was inserted into the abscess and withdrawn by opening the forceps. Care should be taken to direct the forceps towards the orbital wall, instead of the optic nerve region, so as not to penetrate the extrinsic muscles or their membranous sheath, as most abscesses were external to these. When the abscess was very large and surrounded the bulb, it was wise to drain it in more than one place.

The great majority of orbital abscesses were due to sinus infections, and in these cases the sinuses should be thoroughly drained in addition to the above. Where the abscess was outside of the orbital periosteum and the sinus wall was broken down, an intranasal operation on any of the sinuses was sufficient to relieve the orbital abscess. Ten years ago the speaker was of the opinion that the frontal sinus or ethmoids had to be opened from the outside, but his rather extensive experience in intranasal sinus surgery had proved to him that these cases recovered faster with less tendency to recurrence with the intranasal than with the external operations.

DISCUSSION

Dr. Oliver Tydings complimented Dr. Good on the work and illustrations he had presented. He said he had a case under his care at present who was operated upon by a

some

man who was an expert, but the patient was blind in one eye. The history was unique. The patient had intense pain which the speaker attributed to an eye trouble, an infective condition. She never had any pus but had sinus pain and the sinus was opened on the left side and following that was a mastoiditis, blindness due to orbital pressure. That was operated upon and from what the patient said there must have been a meningitis which lasted for some days, during which time she claimed to have been unconscious. The patient finally recovered from that but still had a suppurating condition. He did a radical mastoid but had not yet finished the nasal work. The operations described by Dr. Good were apparently safe in his hands but, unfortunately, were not always safe in the hands of some others.

In the treatment of these cases he had followed practically the line laid down by Dr. Good, except in infants. An orbital abscess due to a sinus condition he thought would not be very safe. He had treated most of these cases and he felt that the fact that he knew so much about nose work might account somewhat for the success he had in treating them. He would make both an external and internal incision, starting down through the projecting portion and making an incision through the orbital plate of the ethmoid and down through the nose, a single incision, usually breaking the abscess down with the knife, being careful not to cut any muscular tissues. He had operated quite a large number of cases in that way in children perhaps less than two years old, with very good results. He felt that free drainage was worth a great deal in these

cases.

Dr. M. H. Lebensohn thought that an orbital abscess was just like one any place else. It made no difference originally where the infection came from as to what sort of an infection it was. About four years ago a man of seventy developed a large orbital abscess following probing of a stenosis of the lachrymal duct. Within twenty-four hours after the probing he developed an orbital abscess and they found a pure streptococcus culture. It was opened several times, no pus was found, but it finally got to the eye. The same night he had another case and that was a staphylococcus infection. It was opened and drained and within a week or ten days the patient got well. In a patient who had recently been discharged, a boy of eighteen, he could not make a diagnosis as to the etiology. It looked like an ethmoid infection with an almost pure pneumococci culture. He drained the abscess and when it was opened he got between three and four drams of pus. He kept on ethyl hydrochlorate with little strips of gauze and it cleared up remarkably well. He thought it was not so much the opening, but advised opening them as soon as possible. He thought the prognosis would depend upon what the infection was. The staphylococci infections have a good prognosis, the pneumococci and stretpococci bad. Dr. R. H. Good, in closing, agreed with Dr. Tydings that establishing a perfect drainage was the best treatment. In cases of suspected ethmoid infection, instead of spending so much time in finding out the nature of the infection bacteriologically, it was a better plan to take a stereoroentgenorgram and find out the nature of the condition

at once.

Dr. Michael Goldenburg exhibited a case of embolism of the central retinal artery as a complication of influenza during the fall epidemic of 1918.

Mrs. E., age 22, married, one child. Had always been in good health.

On November 20th, 1918, during the virulent epidemic of influenza, she developed this disease, passing through the usual stages, a very sick individual. On about the eighth day, when her temperature was at its highest point, she suddenly felt something had happened to her right eye; then noted that she was blind in that eye; further states that the eye felt stiff and

was wild looking and later eye deviated outward. I should judge from her description that the pupil was widely dilated.

On February 12, 1919, she presented herself to our clinic at "The Illinois Charitable Eye and Ear Infirmary."

Examination: Lids, conjuctiva, cornea and anterior chamber negative.

Pupils equal and react to light.

Vision, Right: Fingers at two feet and then only in the upper temporal field.

Left: 20/20-3.

Fundus, Right: Disc-primary optic atrophy, cloudy. grayish pink area about two disc diameters noted from disc temporalward beyond macular region. All arteries markedly diminished in caliber, except upper temporal branch which is about half normal in diameter. Branches running nasalward very thin and end in white lines. Many small hemorrhages in region of macula and on nasal side, both superficial and deep. Directly over bifurcation of artery a small grayish dot is noted that I was inclined to think was in the vessel, but could not be positive, other observers would make no definite statement upon that fact.

Left: Fundus and media negative.

General physical examination, made by a competent internist disclosed the following: Heart negative. Aortic second sound slightly accentuated, which speaks against a valvular lesion.

Lungs not quite healed. In right upper part of lung still some consolidation that could be tubercular, but most likely unresolved area.

Blood pressure-120.

Urine-Negative.

CHICAGO LARYNGOLOGICAL AND OTOLOGICAL SOCIETY

The regular monthly meeting of the Chicago Laryngological and Otological Society was held in the room of the Chicago Political Equality League, Tuesday evening, February 18, 1919.

The president, Dr. Elmer L. Kenyon, in the chair. Dr. Walter B. Swift, of Boston, addressed the Society on "Problems Involving the Nasality of the Human Voice."

Dr. Swift appreciated the fact that he had been requested to address the Society and thought this pointed to the fact that men were becoming interested in some of the more complex things that were inside the specialty. Speech defects had been left to the end of our study because the subject was considered absolutely too complex and hard to analyze, but in the last few years that attitude had largely changed and medical men were having their eyes opened to the simplicity of the things that looked so complex before. He considered speech a function of this specialty and thought that by understanding and trying to build up the capacities of the function they would not only become finer and more thorough throat and ear men, but that it would be of value financially and in research. The subject of speech de

fects was much like the nervous system in medicine. The nervous system was left unstudied and unknown for many years, but twenty or twenty-five years ago people went into it, and things that formerly could not be recognized were now easy to understand, so much so that there was now a recognized system of diagnosis of nervous disorders. This complex field was opened out, and its parts separated and divided so that the parts could be seen and analyzed and one could make scientific judgment upon it.

The same thing had occurred in speech until now it was fairly easy to diagnose defects and build up functions. He hoped that the members of the Society would become interested in the relationship of this work to public school work. He was devoting his entire time to speech disorders, for it seemed to him he saw a large field unplowed. There was no field in medicine that was so interesting as this field of speech. There was a National Organization composed of about two hundred and fifty members that had been in existence for about four years and up to date four hundred and thirty papers had been read in that organization.

In Chicago public schools, they are endeavoring to build up a plan similar to the one in operation in Cleveland, where they had a large and successful speech department in the public schools. There they had three thousand cases with fifteen teachers who were trained to do the work. Here in Chicago the cases were not taken care of until they were in the higher grades, and that was largely without diagnosis. In Cleveland they had diagnosis and also a movement for prevention, which was a new idea in speech correction. They began by training speech cases in the kindergarten and expect in that way to prevent from one-third to three-fourths of the cases of speech disorder higher up. This was very interesting and valuable and they hoped to be able to amplify and perhaps improve on it in Chicago. There ought to be a good deal of expert diagnosis in these cases because speech correction could not be established without portraying the causes behind it. The diagnosis of paralysis, of Mongolian idiocy and all other diseases was of great value and no program of speech correction in the public school was reliable or what it should be without the diagnosis in the background. They wanted to have Chicago an example to the world and with such an able representative as Doctor Kenyon in the field this could be accomplished here. There were enough men interested to accomplish these things if they worked in collaboration.

Dr. Swift described in some detail the various different forms of speech defects. He believed that speech correction was now being taken up in a more scientific way than ever before. At the present time Cleveland stood as a model for speech correction for America, but they hoped to have even a better department in Chicago. At present no city had the movement for speech defect prevention that they had in Cleveland, no other city had speech correction taught ir. two normal schools as they had there, and no other city had speech correction inserted into the regular

school grades as there. It was not merely a mouth treatment; but when done in the modern way was largely mental up-building. It built up the visual perceptions and a more acute ear than was ever the case before, especially in the teachers who studied the subject. In the Cleveland schools they had "part time" teachers who did this work part of the time in the afternoons, but he considered this better than having special teachers for speech correction. After careful analysis they had come to the conclusion that this was the most efficient way to attack this problem.

There were four fields or faults to be dealt with in the nasality of the human voice-"Obstruction Nasality," "Destruction Nasality," "Misdirection Nasality," and "Misplacement Nasality," and all must be treated in different ways.

Dr. Calvin S. Case presented a paper entitled "The Efficiency of the Modern Velum Obturator."

The essayist stated that anything which was capable of restoring the possibilities of perfect speech to cleft palate patients must be capable of imitating the action and function of the normal voice.

The first and most indispensable part of the involuntary function of the normal velum was the act of completely closing the oro-nasal passage in order that the air blasts of speech might be wholly directed and forcibly thrown into and through the oral cavity to be formed into the articulate sounds of speech.

The second important part of its function was its light, sensitive rapidity of movement.

The third important part of its function pertained to normal voice tone quality and resonance.

In the complete closure of the oro-nasal passage, the natural velum performed two important functions: First, it enabled forcibly pressing the air which was the medium of speech, into and through the oral cavity for the distinct articulation of all the breath sounds of the consonant oral elements, which would not be possible to that perfect extent if any portion of the air were allowed to escape into the nose. Second, this closure was quite as necessary for the requisite resonating quality of the vowel elements as it is in the performance of its office for the consonants, but for the distinct articulation of the vowels it was not so necessary that it be completely closed. For this reason nearly all patients with open clefts would quite distinctly articulate all the oral elements of the vowels, but always with a decided nasal tone and with no true resonating quality. The only times when it was admissable in perfect speech for the oro-nasal passage to be open was in the utterance of the nasal oral elements, m, n. and ng, which were similar to vocalized humming tones that were sounded before, after and between the true vowel and consonant oral elements which demand a complete closure of the oronasal passage.

Relative to treatment-if a surgical operation could be performed that would restore the requisite normal mobility of velum with its full functioning power to completely close the oro-nasal passage, perfect acquirement of speech was then possible. If a complete

surgical closure of the cleft was accomplished during infancy in such a manner as to leave a minimum amount of cicatricial tissue in the velum, there was a chance that the soft palatal tissues would grow and develop in proportion to the normal development of the maxilla and adjoining bones, at least up to the time of beginning its speaking function. With patients who have had no operation the bifurcated palatal tissues were usually found quite lacking in normal growth development, somewhat in proportion to age. Operations at any time after five years of age were not very successful and while the skillful surgical method would often be found to greatly improve or fully correct the articulation, rendering the patient's speech readily understood even by strangers, the predominating character of his speech would always be of a nasal cleft palate quality.

These same imperfect results must also obtain with all artificial palates and obturators which were incapable of imitating the functions of the velum palati. The modern velum obturator which had developed within the past fifteen years was instrument which came very close to all the scientific requirements of perfect speech, and one which could be depended upon to enable all patients under twenty-five years of age, with typical clefts to speak with not only perfect articulation, but with normal voice tone quality and resonance, providing the operation was followed by the proper kind of training in phonology and orthoepy.

The principal reason for its successful activity in the requirements of speech was the fact that it was almost as light as a feather, and that it was not attached to any dial or dental fixture, and therefore was able to freely and quickly respond to the slightest movement of the palatal muscles. It rests evenly and freely upon the floor of the nares and along the upper surface of the palatal tissues, completely closing the cleft. Its velum-like pharyngeal portion was as thin as a wafer, except at the borders which receive the firm pressure of the pharyngeal muscles in the active state, in completely closing the passage to the nose; while in the relaxed state of the muscles there was sufficient space for healthy nasal breathing, etc.

While it necessarily extends far back in the throat. being unattached it moves freely with the muscles, is worn with perfect unconsciousness of its presence during all waking and sleeping hours and there is no possibility of its falling into the throat, although it is easily removed for cleansing purposes. The obturator must be seen in action to be fully appreciated.

DISCUSSION

Dr. Elmer L. Kenyon vouched for the remarkable efficiency from a voice standpoint of Dr. Case's obturator. It not only effectively fills in the cleft, but it in no way interferes with the movements of the palate. Nearly all patients operated for cleft palate after the development of speech had begun require speech training. This is because of the wrongness of education under the impaired physiologic con. ditions of the voice apparatus of the sensory and motor word centers. He reported a case in illustration of the importance of discrimination in operating for adenoids and tonsils on a person having an open nasal voice. Such a patient is apt to have a short palate and this operation is