ETIOLOGIC SIGNIFICANCE OF T H E ELEMENTARY BODY IN TRACHOMA PHILLIPS THYGESON, M.D.

IOWA CITY

FRANCIS I. PROCTOR, M.D.

SANTA FE

AND POLK RICHARDS, M.D.

ALBUQUERQUE

Epithelial scrapings from the trachomatous eyes of Indian children were found to contain Prowazek-Halberstaedter bodies. A preparation made from them was filtered through a collodion membrane. Part of the nitrate was cultured, part centrifuged, and part instilled into the conjunctival sac of a normal human eye. The culture media yielded no growth; the sediment after centrifugalization contained elementary bodies; and the eye of the human volunteer after five days' incubation developed an acute inflammation which after six weeks was diagnosed as trachoma, the cornea showing characteristic changes. Elementary bodies were recovered from the conjunctival smears. From the Department of Ophthalmology, College of Medicine, State University of Iowa. Aided by a grant from the Committee on Scientific Research, American Medical Association.

The active agent of trachoma has in general been retained by ordinary bac­terial filters1. The experiments of Nicol-le, Cuenod, and Blaizot2* (1912, con­firmed by those of Thygeson and Proc­tor5 (1935), indicate, however, that ac­tive bacteria-free filtrates are obtainable with filters designed so as to reduce ad­sorption losses. Nicolle and his co-workers used a filter of small filtra­tion area made by cementing a button of Berkefeld V substance into a glass tube. Thygeson and Proctor used graded collodion membranes (Elford6) with average pore diameter of 0.75 microns. In four experiments on ba­boons they confirmed the original ob­servations of Nicolle, Cuenod, and Blaizot as to the virus nature of the etiologic agent of trachoma.

The failure usually to obtain active filtrates with kieselguhr or porcelain filters suggests that the particle size of trachoma virus may be within the range of microscopic vision. In 1907 Halber-staedter and Prowazek7 reported the presence in trachoma of minute coccus­like bodies, the elementary bodies, both free in the secretion and massed togeth-

* Bertarelli, E., and Cechetto, E.,* and Marongiu, L.* reported positive nitrations prior to those of Nicolle, Cuenod, and Blai­zot, but their experiments appear to have been insufficiently controlled.

er in the cytoplasm of conjunctival epi­thelial cells to form the so-called Hal-berstaedter-Prowazek inclusion bodies. The size of the elementary bodies (0.25 micron when stained with Giemsa) is consistent with filterability. They re­semble closely the elementary bodies of inclusion conjunctivitis and psittacosis in size and staining reactions^ but stain more readily with Giemsa and other dyes than do the elementary bodies of vaccinia-variola,, fowl-pox, and mollus-cum contagiosum, which they resemble in other respects. They have been found in trachoma throughout the world and are the only formed elements** demon­strable in a sufficient proportion of cases to indicate etiologic significance. The claims of Halberstaedter and Prowazek have been accepted by Axen-feld8, Lindner9, Taborisky10, Howard11, and others, although no conclusive ex­perimental evidence has been offered in their support.

In an effort to test the identity of the elementary body and trachoma virus, the following experiment was per­formed :

Material. On April 2, 1935, epithelial scrapings were taken from both eyes

** The significance of the Rickettsialike bodies found by Busaccau has not yet been determined. Thejr may be identical with the elementary and initial bodies (Lindner) of trachoma.

811

812 P. THYGESON, F. I. PROCTOR, AMD P. RICHARDS

of ten Indian children * * * with tracho­ma I la-III . The material was shown by microscopic examination to con­tain Halberstaedter-Prowazek inclusion bodies and to have no gross bacterial contamination.

Preparation. The removed material was suspended in 5 c.c. of sterile nutri­ent broth (pH 7.3), ground thoroughly in a mortar for five minutes, and passed through hard filter paper to remove cellular debris.

Filter. An Elford graded collodion membrane, 0.14 mm. thick with 0.6 micron average pore diameter, was mounted in a Jenkins filter, modified for collodion discs. The filtration area was 0.64 sq. cm.

Filter test. Discs from the same mem­brane sheet passed elementary bodies of molluscum contagiosum but retained Bacterium granulosis (FD4 and T13 strains) and H. influenzae.

Filtration. The filter was sterilized by steaming for one hour. Filtration time was less than five minutes, with negative pressure of less than 30 cm.

The filtrate was divided into three equal parts.

Filtrate culture. One third of the fil­trate was used for inoculation of blood-agar slants and semisolid leptospira medium. There was no growth.

Filtrate sediment. One third of the filtrate was centrif uged. Moderate num­bers of elementary bodies were seen in the sediment.

Subject. C. B., male, aged 50 years. Normal right eye and conjunctiva. Left eyelids and eye had been lost from epidermoid carcinoma.

*** The experiment was performed at Fort Apache, Arizona. The trachoma cases were from Fort Apache Indian School. We are in­debted to the Indian Service and to the em­ployees of the White River Agency for their cooperation in this study.

Inoculation. One third of the filtrate, approximately 1.6 c.c, was instilled into the conjunctival sac of the right eye af­ter preliminary light scarification with a platinum spatula. The conjunctiva was rubbed lightly with a cotton ap­plicator.

Result. After an incubation period of exactly 5 days, an acute inflammation developed. Smears and cultures re­vealed only C. xerosis. Halberstaedter-Prowazek inclusion bodies and free ele­mentary bodies were present in large numbers. The diagnosis of trachoma was established at six weeks by the presence of the infiltrative and vascular changes in the cornea which are typical of trachomatous pannus. The conjunc­tival changes and clinical course**** have been characteristic of trachoma. There has been no secondary bacterial infection.

The experiment confirms the virus nature of the etiologic agent of tracho­ma, and offers evidence to support the view that trachoma virus and the tra­choma elementary body (Halberstaed­ter-Prowazek) are identical. This evi­dence may be summarized as follows: (1) Elementary bodies were demon­strated in the infective material; (2) elementary bodies were seen in the cen­trif uged filtrate; (3) elementary bodies were present in large numbers in the experimentally produced disease; and (4) no other formed elements of pos­sible etiologic significance were culti­vated from, or demonstrated micro­scopically in, the induced disease.

We wish to express our sincere ap­preciation to Mr. Clarence Brown of Iowa City who volunteered for the ex­periment and, although in poor health, made the journey to Fort Apache.

****Drs. C. S. O'Brien and P. J. Lein-felder confirmed our diagnosis.

References 1 For a review of the literature on filtration experiments in trachoma, see Stewart, F. H.

Eighth Annual Report Giza Memorial Ophthalmic Laboratory, Cairo, 1934, p. 152. Also Julianelle, L. A., and Harrison, R. W. Amer. Jour. Ophth., 1935, v. 18, p. 133.

' Nicolle, C, Cuenod, A., and Blaizot, L. Compt. rend. Acad. Sci., 1912, v. 152, p. 1504; Arch. Inst. Pasteur Tunis, 1913, v. 3-4, p. 157.

"Bertarelli, E., and Cechetto, E. Centralbl. Bakt., 1908, v. 47, p. 432. 4 Marongiu, L. Le Policlinico, 1908, v. 15, p. 805. Cited from Julianelle and Harrison1.

TENDON TRANSPLANTATION 813

" Tbygeson, P., and Proctor, F. I. Arch, of Ophth., To be published. 'Elford, W. J. Jour. Path, and Bact., 1933, v. 36, p. 49; Proc. Roy. Soc, London, s.B.,

1933, v. 112, p. 384. ' Halberstaedter, L. and von Prowazek, S. Deutsche med. Wchnschr., 1907, v. 33, p.

1285; Arch. f. Protistenk., 1907, v. 10, p. 335; Arb. a.d.k. Gsndhtsamte, 1907, v. 16, p. 1.

* Axenfeld, Th. Die Aetiologie des Trachoms. Jena, Gustav Fischer, 1914. ' Lindner, K. Zeitschr. f. Augenh, 1926, v. 57, p. 508. "Taborisky, J. Arch. f. Ophth., 1930, v. 123, p. 140. 11 Howard, H. J. Amer. Jour. Ophth. 1924, v. 7, p. 1909. " Busacca, A. Arch. f. Ophth., 1934, v. 133, p. 41.

TENDON TRANSPLANTATION IN OCULAR-MUSCLE PARALYSIS

RODERIC O'CONNOR, M.D. SAN FRANCISCO

This paper emphasizes the need to have cases of ocular-muscle paralyses under the observation, from their onset, of an ophthalmologist who is able to handle them sur­gically, in_ order that operation may be done as soon as it becomes certain that the paralysis is permanent and before contractures have developed in the opponents. It also disproves the contention of some authorities (B.ielschowsky) that transplantations are not worth while because of a mistaken idea that binocular action is never secured. Binocular vision is secured, at least in positions near the primary, in all cases that have come to operation before contractures have occurred. It summarizes the author's personal experience with the four types of transplantation methods, three of which are original. Read before the Western Ophthalmological Society, at Butte, Montana, July 19, 1934.

The statements to be made in this paper are based on an experience of about thirty operations; consequently, they are not mere theoretic opinions.

The first question is "Who should decide when to operate?" The answer, of course, is self-evident and yet, in a recent meeting, a neurologic surgeon stated that he never referred such pa­tients to an ophthalmologist until a year had elapsed from the onset of the palsy. Of course, he thought he was giving his patients every chance to get well witheut operation but overlooked the fact that he is virtually deciding the conduct of a condition entirely out of his line and is reducing the prospect of a good result. This fact will be made even more plain when we come to con­sider the subject of contractures.

The internist, as well as the general and neurologic surgeon, should be in­terested in this subject because paraly­sis of ocular muscles is due to some general disease or head injury and is first seen by one or the other. The pediatrician also sees these cases as congenital defects. The oto-laryngolo-gist sees abducens palsy as part of the Gradenigo syndrome and palsy of other

muscles as complications of orbital in­fections. This means that practically all doctors should be informed that relief is possible in spite of statements to the contrary still to be found in some text­books—even those on ophthalmology.

Therefore cases of ocular-muscle palsy should not be dismissed as incur­able but should be referred at once to an ophthalmologist who is able to handle them surgically, for continued observation, in order that operation may be done as soon as it is certain that the paralysis is permanent.

Operation should be done before contractures start in the opponents be­cause it may then be possible to avoid extensive tenotomies and so obtain a better functional as well as cosmetic result.

Usually a paralysis, when it is go­ing to recover, shows early improve­ment and a fairly rapid progress to­ward its final position. If it is complete at the end of three months, in spite of proper treatment, the prospect of cure is too slight to warrant much more de-lay. In cases of partial paralysis opera­tion should be delayed till it is certain that progress toward cure has ceased.