VOL. III.

No. 7

EDITORIAL COMMENT

WORKING OF THE STATE

BOARD.

In spite of many adverse criticisms the State Board of Medical Examiners is still attending to its duties in carrying out the provisions of the Medical Act to the best of its ability. In a recent conversation. had with the attorney for the board we learned of many cases of prosecution, which have been published, that certainly do credit to any body of men appointed to enforce the law. The annual report will show a year's good work well performed.

The part of the work which was the subject of most criticism was the board's ruling as to the standard of qualification which candidates were required to conform to.

This matter was freely discussed during last winter, and much of the discussion pro and con was published in COLORADO MEDICINE, and much more withheld for the reason that in many instances argument was replaced by sarcasm which could accomplish no good.

Thinking to settle the controversy the Denver County Medical Society appointed a committee of investigation. The report of this committee was full and elab

practice of medicine in Colorado is one of the best that has been adopted by any state in the Union.

"That the present State Board of Medical Examiners is administering it honestly, intelligently, and efficiently; and on that account deserves the confidence and support of the profession and the people of the state.

"That in proportion as this support becomes assured it will be possible to make the law and its administration still more effective and satisfactory.

"EDWARD JACKSON,
"F. E. WAXHAM,
"HOWELL T. PERSHING,
"Committee."

RESOLUTION.

At the Boston session of the American Medical Association the following resolution was introduced by Dr. E. Eliot Harris of New York, and on motion of Dr. C. E. Cantrell, of Texas, was unanimously adopted:

"Resolved, That the Committee on Publication of the journals of medicine published by the State Medical Associations affiliated with this body, be asked to assist the Board of Trustees in their efforts to suppress the advertisements of medical nostrums and to co-operate in the work of

ordered published in COLORADO MEDICINE, but instead was given to the Colorado Medical Journal.

By request we quote from above Journal the closing paragraphs of that report: "The conclusions reached by your committee are:

the United States."

A RARE TREAT.

The Committee on "Scientific Program" of the State Society report their success in securing the attendance of Dr. Richard C. Cabot of Boston at our next

Dr. Cabot, although younger in years than some of the others, is one of the leaders in the group of energetic young men who have placed Boston once more in the position it has long deserved but not held, in the forefront of medical matters in America. For a generation preceding the opening of this century medical Boston did not know officially that any medical work worthy of the name was being done elsewhere certainly not west of the Alleghenies. Her practical withdrawal from the American Medical Association in 1865 left her in isolated contentment.

Meanwhile equally as good work in teaching medicine was being done in several other American cities, as judged by those at a distance. The post-graduate schools of New York, Philadelphia, Baltimore and Chicago set their candles in high places and won a predominating influence over the great mass of the profession.

But a few years ago the younger generation in Boston came to the front and discovered that, excellent as was the work done there, it was not known elsewhere. With facilities for the highest class of post-graduate instruction, little was being given. The publication of Cabot's work. on the blood was one of the first signs of the awakening of Boston to her long-neglected opportunities. Through his subsequent volumes, his addresses and many excellent short articles, he has become known more widely than perhaps any of the group of younger American clinicians. The subject of Dr. Cabot's main address will be announced shortly. He will also give a clinic illustrating "Case Teaching in Medicine" at the City and County Hospital or at the Denver and Gross College of Medicine. Our society has never entertained a guest better able to bring us at once instruction and encouragement, or to lend us some of that enthusiasm without which medicine is but a dull trade.

J. N. H.

ORIGINAL PAPERS

RETINAL HEMORRHAGES IN APPARENTLY HEALTHY EYES.

E. W. STEVENS, Denver.

A special consideration of retinal hemorrhages from any cause is of great importance from a clinical viewpoint to both the ophthalmologist and the physician; to the former because they may destroy sight; to the latter because they are often of great value in determining the general condition of the patient.

Setting aside at once retinal hemorrhages due to optic neuritis, renal diseases, retinitis, choroiditis, etc., I confine this paper to hemorrhages occurring in eyes otherwise free from disease.

Primary retinal hemorrhages may occur from the following general conditions:

I. Blood changes:-Purpura, pyæmia, septicæmia, scrofula, pernicious anæmia, and parasitic blood affections. Cardiac disease.

2.

3.

4.

Embolic processes and thrombosis. Disturbances of menstruation. Accidental, including retinal hemorrhages at birth.

5.

6. High arterial tension.

Co

Retinal hemorrhages at birth are, according to Coburn, of frequent occurrence. He examined the eyes of 37 infants stillborn or dying before the age of 22 days, and found hemorrhages in 17 cases. burn has also collected nearly 700 cases of children who survived and were examined with the ophthalmoscope a few days after birth. Among these the percentage showing retinal hemorrhages averaged about 20 per cent. about 20 per cent. He points out that the physical conditions of birth strongly favor hemorrhages, especially after the head has been born and the body is subjected to the powerful compression of the uterus. Coburn thinks that such birth

hemorrhages may account for cases of congenital amblyopia, and also anamolies of the fundus as pallor of disc, peculiar pigmentation, etc.

Primary or independent retinal hemorrhages in the adult are comparatively uncommon. I have collected from my practice the following cases, whose histories I have very briefly summarized. While in most of these cases the retina was unchanged, in a few there were slight changes, such as localized swellings and exudations secondary to the hemorrhages. Case 1. Mr. L., Aet. 64, vision poor in the left eye for the past two days. On examination vision O. D. 4/4 O. S. fingers I metre. Small hemorrhage at macula and several larger hemorrhages scattered over retina. Retinal vessels tortuous. No albumen or sugar in urine. Has occipital headaches, but health is excellent. No sclerosis. Arterial tension measured by Riva Rocci with 5 centimetre armlet 216 to 276 mm. Hemorrhages increased and burst into vitreous. Glaucoma developed, T plus 2. Patient is alive 20 mos. later. Vision normal in right eye. Left eye quiet for past six mos. with 1. p.

Case 2. Dr. W., Aet. 31. Two weeks ago, while on a hunting trip, suddenly lost sight in right eye. On examination, vision O. D. fingers 1 metre, O. S. 4/4. Large hemorrhages into vitreous. Urine normal. Patient regained in two months normal vision, two small vitreous opacities remaining. Two years later the fundus in each eye is normal with normal vision.

Case 3. Mr. B., Aet. 44. Found vision poor in O. S. on getting up that morning. On examination vision O. D. 4/5 O. S. 4/60. Large retinal hemorrhage between disc and macula. Several small hemorrhages above and below nerve. Retinal vessels tortuous. Urine normal. Patient large, fine looking man, does not use alcohol, but is a very heavy eater

eats four big meals a day. Pulse rigid. No sclerosis of vessels. Died suddenly from cerebral hemorrhage within a year from onset of retinal hemorrhage.

Case 4. Mr. W. Aet. 50. Mr. W. Aet. 50. Four days ago first noticed vision was bad in O. S. On examination, O. D. 4/5, O. S. 4/30. Large hemorrhage just below disc with spots of hemorrhage above and below macula. Urine normal. In three months vision normal or 4/5 and no lesion could be discovered with the ophthalmoscope. Three months later a large hemorrhage burst into vitreous of the left eye and vision lost. Four years later the patient is alive and well, with normal vision in right eye, the left having light perception.

Case 5. Mrs. B. Aet. 60. Two days ago suddenly lost sight in left eye. Had just learned of sudden death of daughter the evening before and passed a restless night. On examination, vision O. D. 4/6 O. S. fingers 1 metre. Numerous flameshaped hemorrhages in retina left eye. Urine normal. Strong, healthy Irish woman. Pulse tense. Patient had hemipligia within six mos. of the retinal hemorrhage and three mos. later died from cerebral hemorrhage.

Case 6. Mr. Byrd Aet. 23. Two days ago first noticed poor sight in left eye. On examination vision right eye 4/4, left eye 4/30. Numerous hemorrhages scattered over retina of the left eye. Urine normal. Hemorrhages cleared up quite rapidly, vision became normal. In two weeks a fresh hemorrhage occurred. This again cleared up and recovery seemed to have taken place. Another hemorrhage into the vitreous followed and the vision of the eye was lost permanently.

Four years later this patient had hemorrhages in his remaining good eye. Vision 4/30. The urine was normal. Blood pressure 100 with Riva Rocci. Heart and blood vessels normal. The patient was encouraged by Dr. Hill and myself in his wish to seek a lower altitude, and two

months ago went to Los Angeles. A recent letter informs me that the hemorrhages are clearing up and relapsing as before.

Case 7. C. O'N. Aet. 10. Noticed sight was bad in the right eye this morning. This lad had been under my observation during the preceding week on account of extensive hemorrhages into his conjunctiva and lids, due to a severe attack of whooping cough. On examination a large subhyaloid hemorrhage extended from about one-third of the temporal side of the disc nearly to the macula. Vision Vision 4/40. In about eight weeks' time the hemorrhage had entirely absorbed and vision was normal.

Case 8. Mrs. K. Aet. 55. Vision foggy in the right eye for the past week. On examination R. E. 2/60 L. E. 4/8. Spots of hemorrhages surrounding macula and above and below disc. Retinal arteries in both eyes tortuous. Urine normal. Arterial tension 197 with Riva Rocci.

These eight cases of retinal hemorrhages may be classified as follows:

Retinal hemorrhages ....
Hemorrhages in vitreous
Subhyaloid hemorrhage ...

·3

4

8

Now let us examine these cases in reference to cause, prognosis and other points. Three eyes in which the hemorrhage burst into the vitreous became blind, and one recovered normal sight with two or three floating opacities in the vitreous.

The large subhyaloid hemorrhage due to whooping cough recovered normal sight, and exemplifies, as far as one case can, that the prognosis as regards sight is usually good in this form of hemorrhage. This case, as before mentioned, was under my care for extensive, and to the parents, alarming hemorrhages into his conjunctiva and eyelids when the retinal hemor

rhage occurred. Retinal hemorrhages from whooping cough must be very uncommon, though severe coughing might readily, I think, produce them.

In two cases the retinal hemorrhages were followed by the deaths of the patients within the year from cerebral hemorrhages. In both of these cases the arterial pressure was recorded as high, but from tactile impression alone.

Cases I and 8 registered high arterial pressure with the Riva Rocci, and I feel sure had I been earlier and better acquainted with this instrument I should have more to say under this head.

Arteriosclerosis combined with increased arterial pressure was probably the cause of the retinal hemorrhages in one case. The senile form of arteriosclerosis is not, in my experience, a cause of retinal hemorrhages. In this form of arteriosclerosis the heart is not necessarily hypertrophied or the arterial tension increased. During the past year I have carefully examined with the ophthalmoscope, with special reference to retinal hemorrhages, eyes of 54 cases, whose ages ranged from 60 to 90 years. These cases were examined at the Denver County Hospital, St. Anthony's Hospital and in private practice. No cases of retinal hemorrhages were found, though many of the patients. were typical pictures of senile sclerosis.

I should like to hear from other members of the society in reference to this mat

ter.

Probably retinal hemorrhages occur more frequently in the diffuse arteriosclerosis of Councilman, which generally occurs in the prime of life, most of the subjects being strongly built, well nourished. muscular individuals, and where hypertrophy of the heart is always present. I know of no observations on this point.

In conclusion, the unfortunate case of Mr. Byrd, case 6, seems to me to merit a few further observations.

Young men, and, more uncommonly,

young women, between the ages of 15 and 30 years appear to be exposed to attacks of relapsing retinal hemorrhages. While in good physical condition, these hemorrhages come on suddenly. The hemorrhage is absorbed somewhat rapidly, and there may be no trace of it left. New hemorrhages soon follow, and in unfavorable cases the vitreous becomes hazy with the formation of connective tissues as a sequel to the hemorrhages, resulting in blindness from degeneration of the vitreous body and retinal detachment.

Prognosis of these cases is always doubtful, and treatment, on the whole, seems of very little value.

Discussion.

Dr. Black: I am very much interested in Dr. Stevens' report, particularly from the blood tension side. The measurement of the blood tension throws a great deal of light upon the subject. I think there was a time, and only a very short while ago, too, when we were very much in doubt as to the cause of a great many of these retinal hemorrhages. Within the last year and a half I have been having in all this class of cases, the urine examined and the blood pressure carefully estimated. Dr. Hill has taken care of quite a number of these cases for me, and I feel that he probably can throw some more light upon this subject for us. In every one of the cases that I have had during this time the blood tension has been excessive, running from 175 to 280, and sometimes higher. The after treatment in these conditions has been productive of a great deal of value. The liability of death ensuing from cerebral hemorrhage can oftentimes be prevented by appropriate diet and after treatment. These retinal hemorrhages serve oftentimes as a warning to the patient and to his physician. They come very frequently under the direct observation of the oculist, but it is very rare that they continue under our care; but they serve as a good lesson in so far as the patient's after diet and care is concerned.

are some cases in which recurring hemorrhages have been noted for many years without the eye being seriously damaged. I remember, about two and a half years ago, seeing a woman of about 70 years with a history of recurring retinal hemorrhages, extending over the last thirty years. She had been under the care of Dr. Sutphen of Newark, N. J., a thoroughly competent observer and diagnostician. While in Colorado for two or three weeks a hemorrhage occurred, which I watched largely clear up during that time. She had had retinal hemorrhages repeatedly during thirty years, and yet had very fair vision and no severe damage to the eyes. The prognosis in a case of retinal hemorrhage should be

guarded, although for most of patients it is unfavorable, both as regards the recovery of the eye and also for the prospect of prolonged life.

Dr. Edson: Dr. Stevens has called our attention to a subject of great interest, and of importance not only to the ophthalmologist, but to the general practitioner. While the chief interest and care of these cases is the former's, it is the general practitioner who is apt first to see the case, and who should draw from the accident a suggestion which is of clinical interest to himself and may be of the utmost value to the patient. As. Dr. Stevens has said, his paper deals with cases of hemorrhage occurring spontaneously into the eye of an otherwise apparently healthy person. I say apparently healthy person, for I believe in the majority of such cases a reason for the rupture of the blood vessel will be found in some disproportion between wall strength and arterial pressure. It has been only within the last very few years that anything like an accurate clinical study of blood pressure has been possible, and this new study has already taught us at least one important fact: that high blood pressure is one thing, and arterial sclerosis, organic changes in the vessel walls are very different matters, and have no constant or even necessary relation to each other.

Blood pressure is a physiologic phenomenon; arterial change, calcification, selerosis, is a pathologic state. Now the thickening in the walls of the arteries, whether it be cellular, as it is at first, in the sub-internal layer, or due to deposit of lime, salts, render the wall more rigid, less tortuous, hard, incompressible, and pipestemery. These conditions you all recognize, but if you will recall your cases I think you will find that they are associated