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The Clinical Interpretation ofAids to Diagnosis.

A Series of Special Articles contributed by Invitation.

LXII.—INTERPRETATION OF REPORTS ON

LESIONS OF THE EYE.

PART II.*

IN the first part of this article I dealt with definiteorganisms. When questions arise on the inter-

pretation of the results of tests, such as theWassermann reaction or Pirquet’s test, the answersare less easy. The modern tendency to relymore and more on laboratory tests and less and lesson clinical experience and knowledge imposes a

responsibility on the bacteriologist which is unfairboth to him and to the patient. It must be reiteratedthat. laboratory tests, no matter how reliable, formonly part of the data essential for correct diagnosis.

The Wassermann Reaction.It often happens that a patient is sent to a laboratory

for a Wassermann reaction. The result is positive-.and without any further consideration the patient ispassed on to a V.D. department, the eye conditionbeing labelled " syphilitic." Further considerationmay prove that the eye condition is due to septicteeth and the positive Wassermann to a congenitaltaint which requires no treatment. It is the clinician’sjob to elucidate these facts, not that of the personmaking the test. I am not suggesting that it is wrongto treat a patient with a positive reaction as a

- syphilitic, but only that it is wrong to label an eyedisease as syphilitic on a positive Wassermann reactionalone.

Reports on Patients with Iritis. The interpretation’ of the reports on investigations

designed to elucidate the cause of iritis is clifficult.The causes are so many and varied that it is oftenimpossible to say with certainty what variationfrom the normal is responsible for the iritis. Itmay be accepted that iritis and iridocyclitis are, as arule, the result of toxic irritation due to some distantseptic focus. It is, indeed, rare to examine a patientwithout finding some septic focus, a suspicious tooth,infected sinus or antrum, a collection of pus behinda deflected septum or septic tonsils ; any of them maybe the cause (and equally may not be the cause) ofthe iritis. There is one cause of iritis in men whichshould always be inquired into-viz., gonorrhoea.In women gonorrhoea] iritis is extremely rare. I have Inever seen a case. The history of gonorrhoea, how-ever, is not enough, and in my V.D. department allthe other causes of iritis are gone into before thepatient is examined for evidence of an old gonorrhoealinfection. Gonorrhoeal iritis seldom occurs duringthe acute urethritis stage of the disease, and theaverage time after the acute attack of gonorrhoeaart which the iritis appeared worked out at 9 yearsin one series of 250 cases, and 14 years in anotherseries.

Significance of Pus and Gonococci-Having assessed - the importance of any other

’septic foci the next step is to examine the patientfor evidence of a residual gonorrhcea. Urethritis andgleet are rare at this stage of the disease, and it isonly when we come to the examination of the materialexpressed by prostatic and vesicular massage thatevidence of the original infection appears. It isquite usual to find pus in considerable quantities, but

Iis quite unusual to find the gonococcus, and although-at one time I was finding the gonococcus in 9 percent. of the cases of rheumatic iritis sent to my depart-

*Part I. appeared last week.

ment for examination, my last figures worked out at3 per cent., due to a more critical definition as

to what was a gonococcus in the slides examined.Perhaps even this is too high a percentage. Thedifficulty of detecting the gonococcus amongst thedebris of pus cells, spermatozoa, and organisms inthe smear is so great that a definite statement israrely possible. However, when pus has beenfound in the prostate or vesicles, treatment has tobe carried out in spite of inability to find the gono-coccus in the discharge, and the condition is labelledgonorrhoeal iritis. The report made on a prostaticmassage will often record the finding of all sortsof other organisms, streptococci, staphylococci,pneumococci, colon bacilli, and diphtheroids. Theseare probably the results of secondary infections andmust be taken into consideration when arranginga course of treatment. This should consist of (1)the symptomatic treatment ordered by the ophthalmicsurgeon, such as atropin, leeches, hot bathing, &c., t(2) specific treatment, such as vaccines, prostaticand vesicular massage, irrigation, &c. ; and (3) treat-ment to clear up other septic foci.

-and of Rheumatic Pains.Rheumatic was at one time frequently applied

to what we now know is often gonorrhoeal iritis.Rheumatism is almost always present in the historyof patients who come with gonorrhceal iritis. Con-sidering the small percentage of cases in which thegonococcus is found it is naturally open to debate as towhether these cases should or should not be diagnosedas gonorrhceal iritis. I myself use this classification,because the cases of iritis in which I find pus in thematerial from the prostatic massage are the caseswhich react to gonococcal vaccine. The reactionmay be one of exacerbation of the existing iritis, orone of rapij cure of the condition. I believe thatgonorrhceal iritis is a toxic condition and that thegonococcus is not present in the eye. Dr. E ric Riddle,when he was working with me at Moorfields, made theobservation that it was quite rare to find gonorrhoealiritis in patients who had clean mouths, or perhapsit would be better put that people with septic teethwere more likely to get gonorrhceal iritis than thosewith clean mouths. This may account for thecomparative rarity of the condition in private practiceand certainly one of the first things to do in treatingthese cases is to have the mouth attended to.

Tuberculin Tests.The tests for tuberculosis of the eye are few, and of

little real value as proof tests. The only one of anyreal value is the subcutaneous injection of tuberculin,with resulting focal, local, and general reaction, butthis test is practically debarred from use in eye work,since it is inadvisable to risk stirring up a tuberculouseye lay a focal reaction. The graduated Pirquet test,using human and bovine tuberculin, is of some valueif the results are used with discrimination, althoughthe test cannot give definite information like thesubcutaneous test.

i If the result of the test is taken into considerationwith the clinical evidence it is of help in youngpatients, and in adults may be a useful guide as to thetype of tuberculin to use in treatment. The presenceof a positive Pirquet test does not mean that the eyecondition is a tuberculous one.

S. H. BROWNING, M.R.C.S. Eng.,Bacteriologist to and Lecturer on Bacteriology and Medical

Officer i/c V.D. Dept. to the Royal LondonOphthalmic Hospital.

HOSPITAL COOPERATION.—As the result of a

Conference of representatives of the voluntary hospitals in theCounty of Durham a committee of ten was appointed tojoin with a similar number of members of the medical staffsof those institutions to meet the Durham County Council todiscuss questions of hospital service arising out of the pro-visions of the Local Government Act.