of tl|e
THE ALSXANDER MACDONALD
FOUNDATION
HANDBOUND
AT THE
UNIVERSITY OF
TORONTO PRESS
n
29
I oi
hJ
OPHTHALMOLOGICAL TRANSACTIONS.
VOL. IV.
TRANSACTIONS
OF THE
OPHTHALMOLOGICAL SOCIETY
OF THE
UNITED KINGDOM.
VOL. IV.
SESSION 1883-84.
WITH
LIST OF OFFICERS, MEMBERS, ETC.
LONDON:
J. & A. CHURCHILL, NEW BURLINGTON STREET.
1884.
CO* J/
'^SlTY OF TO^O^V^
S92H9
PEINTFD BY J. E. ADLAED, BABTHOLOMEW CLOSE.
IN EXCHANGE.
ArcTiives d'Ophtalinologie, Panas, Landolt and Grayet.
Centralblatt fiir praktische Augenheilkunde, J. Hirschberg.
Klinische Monatsblatter, Augenheilkunde, W. Zehender.
Recueil d'Ophtalraologie, Galezowski and Cuignet.
Eevue generale d'Ophtalmologie, Dor and E. Meyer.
Transactions of the American Ophthalmological Society.
Eevue des Sciences Medicales, Hayem.
NOTICE.
The present volume comprises the proceedings
of the Ophthalmological Society of the United
Kingdom, during its fourth Session, October, 1883,
to July, 1884.
The Society does not hold itself responsible for
the statements, reasonings, or opinions expressed
in the communications which the Council has
deemed suitable for publication.
TABLE OF CONTENTS
OF VOLUME IV.
PAGE
Officees and Council . . . . ix
List of Members . . . . xi
eules ...... xxv
List of Communications made dueinq the Session
1883-84 .... .XXII
List of Plates .... xxxix
List of Woodcuts . . . . xl
Inteoductoet Addeess . . . .1
Diseases of Etelids ai^d Conjunctiya . . 15
Diseases and Tumoues of the Oebit . . 36
Intea-oculae Tumoues . . . .49
Diseases of the Zeis . . . .57
Injueies and Sympathetic Ophthalmitis . . 62
Panophthalmitis . . . .90
GrLAUCOMA . . . . .93
Diseases of the Lens and Capsule . . 116
Diseases of Eetina and Choeoid ... . 132
Diseases of Optic Neeye . . . 172
Functional Diseases .... 292
Affections of Musculae and Neeyous Systems . 300
Congenital Defects .... 332
New Insteuments .... 352
Eepoet of the Council . . . . 363
Appendix ..... 306
OFFICERS AND COUNCIL
OF THE
#plj%lmological Sotietn of t^t ^nittb liingbom,
ELECTED AT
THE ANNUAL GENERAL MEETING, JULY 4tit, 1884.
JONATHAN HUTCHINSON, F.R.S.
ilPicje-^rcsibeirts.
Sir WILLIAM BOWMAN, Bart., F.R.S.
C. E. FITZGERALD, M.D. (Dublin).
HENRY POWER.
THOMAS REID, M.D. (Glasgow).
T. SHADFORD WALKER (Liverpool).
J. C. WORDSWORTH.
J. F. STREATFEILD.
Coutuil.
GEORGE COWELL.
G. A. CRITCHETT.
R. MARCUS GUNN.
E. NETTLESHIP.
PRIESTLET SMITH (Bir
minscliiini).
GEORGE JOHNSON, M.D., | SIMEON SNELL (Sheffield).
F.R.S. T. SYMPSON (Lincoln).
STEPHEN MACKENZIE,M.D.
CHARLES MACNAMARA.
JOHN TWEEDY.
W. SPENCER WATSON.
JOHN ABERCROMBIE, M.D.
W. A. BRAILEY, M.D.
*#* Members are requested to communicate with the Secretaries when correc-
tions are necessary.
LIST OF MEMBERS OF THE SOCIETY.
JBonorarg lEembers.
Peofessor Dondees, Utrecht.
Peofessoe Helmholtz, Berlin.
Peofessoe Stokes, Cambridge.
E. Williams, M.D., Cincinnati, United States.
EXPLANATION OF ABBREVIATIONS.
O.M. — Original Member. V.-P. — Vice-President.
Fres. — President. S. — Secretary.
T. — Treasurer. C— Member of Council.
*. — Denotes Resident Life Members who have paid the Com-
position Fee.
f. — Denotes Non-Resident Life Members who have paid the
Composition Fee.
•GENERAL LIST OF MEMBERS.
ELECTED
O.M. *Abeeceombie, John, M.D. (S.), Assistant Physician to
the Charing Cross Hospital, and to the Hospital for
Sick Children, Great Ormond Street; 39, Welbeck
Street, W.
O.M. Adams, James E., care of F. Gordon Brown, Esq., 17,
Finsbury Circus, E.C. (C. 1880-3.)
O.M. Adams, M. A., Surgeon to the Kent County Ophthalmic
Hospital, Ashford Boad, Maidstone.
XII
ELECTED
1884 fALLisoN, H., M.D., care of Messrs. Binny and Co.,
Madras, India.
1884 Andekson, James, M.D., Assistant Physician to the
Victoria Park Hospital for Diseases of the Chest ;
84, "Wimpole Street, W.
O.M. Andrew, Edwtk, M.D., Surgeon to the Shropshire
Eye and Ear Hospital ; Hardwick House, St. John's
Hill, Shrewsbury. (C. 1881-4.)
1883 Andeews, a. Gt., London Hospital, Whitechapel Eoad, E.
O.M. Appletaed, John, M.B., Assistant Surgeon to the
Bradford Eye and Ear Hospital ; 1, Clifton Villas,
Manningham, Bradford, Yorkshire.
O.M. Aechee, T. Beittin, Senior Surgeon to the Central
London and Western Ophthalmic Hospitals ; 64,
South Molton Street, Brook Street, W.
O.M. Bankaet, James, M.B., Surgeon to the Devon and
Exeter Hospital, and to the West of England Eye
Infirmary ; 19, Southernhay, Exeter.
O.M. Baelow, Thomas, M.D., Assistant Physician to, and
Assistant Teacher of Clinical Medicine at, Univer-
sity College Hospital ; 10, Montague Street, Eussell
Square, W.C. (C. 1880-81.)
1883 Baeton, J. Kingston, 2, Courtfield Road, Gloucester
Road, S.W.
O.M. Baxtee, E. Buchanan, M.D., Assistant Physician to
King's College Hospital ; Professor of Materia
Medica and Therapeutics, King's College ; 28, Wey-
mouth Street, Portland Place, W.
O.M. Beeyoe, C. E.,M.B., Assistant Physician to the National
Hospital for the Paralysed and Epileptic ; 33,
Harley Street, W.
O.M. Benson, A. H., M.B., Assistant Surgeon to St. Mark's
Ophthalmic Hospital, Ophthalmic Surgeon to the City
of Dublin Hospital, and Examiner in Ophthalmic
Surgery to the Royal College of Surgeons of Ireland ;
42, Eitzwilliam Square, Dublin.
XIII
ELECTED
O.M. Beeet, Gr. A., M.D., Assistant Ophthalmic Surgeon,
Royal Infirmary, and Lecturer on Ophthalmology,
Eoyal College of Surgeons, Edinburgh ; 23, Eutland
Street, Edinburgh.
1881 BicKEETON, T, H., 1, St. James Road, Liverpool.
1884 Bond, Cdaeles J., The Infirmary, Leicester.
O.M. Boon, Alfeed, St. Kitts, West Indies.
O.M. Bowman, Sir W.,Bart.,LL.D., E.R.S. (V.P.), Consulting
Surgeon to the Royal London Ophthalmic Hospital,
Moorfields; 5, Clifford Street, Bond Street, W.
(Fres. 1880-3.)
O.M. Beailet, W. a., M.D. (S.), Ophthalmic Assistant Sur-
geon to Guy's Hospital ; Ophthalmic Surgeon to
the Evelina Hospital for Children ; 16, Orchard
Street, Portman Square, W. (C. 1880-3.)
O.M. Beoadbent, W. H., M.D., Physician to, and Lecturer
on Medicine at, St. Mary's Hospital ; 34, Seymour
Street, Portman Square, W. (V.-P. 1882-3.)
1881 fBEOCKMAN, E. E., Professor of Physiology and Diseases
of the Eye at the Medical College, Madras ; Eye In-
firmary, Madras.
O.M. Beonnee, Edwaed, M.D., Surgeon to the Bradford Eye
and Ear Hospital ; 33, Manor Row, Bradford.
1882 Beown, Geoege A., Tredegar, Monmouthshire.
O.M. Beowne, Edgae A., Surgeon to the Liverpool Eye and
Ear Infirmary ; 86, Bedford Street, Abercromby
Square, Liverpool.
1882 Beowne, John Walton, M.D., 10, College Square
North, Belfast.
O.M. Beuce, S. N., 43, Kensington Gardens Square, W.
O.M. BuBB, J., Surgeon to the Cheltenham and Gloucester
Ophthalmic Infirmary ; 6, Royal Crescent, Chelten-
ham.
1883 tBuLLEE, Feank, M.D., 1351, St. Catherine Street,
Montreal, Canada.
O.M. tBuENHAM, G. H., M.B., 157, Simcoe Street, Toronto,
Canada.
XIV
ELECTED
O.M. BuzzAED, Thomas, M.D., Physician to the National
Hospital for the Paralysed and Epileptic ; 56, Grosve-
nor Street, W. (C. 1881-2.)
1882 Cant, W. J., 13, Silver Street, Lincoln.
O.M. Caeteb, H. Bktjdenell, Ophthalmic Surgeon to, and
Lecturer on Ophthalmic Surgery at, St. George's
Hospital ; 27, Queen Anne Street, W. (C. 1880-3.)
O.M. Chaenley, "William, M.D., Surgeon to the Western
Ophthalmic Hospital ; 14, Old Burlington Street,
W.
O.M. Chesshiee, Edwiis", Senior Surgeon, Birmingham and
Midland Eye Hospital ; 58, Newhall Street, Bir-
mingham.
1881 Cholmelet, William, M.D., Physician to the Great
Northern Central Hospital ; 63, Grosvenor Street, W.
O.M. CooPEE, William White, Consulting Ophthalmic Sur-
geon to St. Mary's Hospital; 19, Berkeley Square, W.
1884 Cotjltee, William, M.D., 50 Chelsham Boad, Clapham,
S.W.
O.M. Coupee, John, Surgeon to the London Hospital, and to
the Boyal London Ophthalmic Hospital, Moorfields ;
80, Grosvenor Street, W. (C. 1881-2.)
O.M. CouPLAND, Sidney, M.D,, Physician to, and Lecturer on
Pathological Anatomy at, the Middlesex Hospital;
14, Weymouth Street, Portland Place, W.
O.M. CowELL, Geoege (C), Senior Surgeon, Lecturer on Sur-
gery and Ophthalmic Surgeon to the Westminster
Hospital ; Surgeon to the Eoyal Westminster Oph-
thalmic Hospital ; 3, Cavendish Place, Cavendish
Square, W.
O.M. Ceitchett, G. Andeeson (C), Ophthalmic Surgeon to
St. Mary's Hospital ; 21, Harley Street, W.
1881 Ceoss, F. B., Honorary Ophthalmic Surgeon to the
Bristol Dispensary ; Surgeon to the Bristol Boyal
Infirmary ; 5, The Mall, Clifton, Bristol.
O.M. Davidson, A. Deas, Ophthalmic Surgeon to Swansea
Eye Hospital ; 5, Picton Place, Swansea.
XV
ELECTED
O.M. Davidson, Alex. Dtce, Lecturer on Ophthalmic Sur-
gery, University o£ Aberdeen ; Ophthalmic Surgeon
to the Eoyal Infirmary, Aberdeen j 224, Union Street,
Aberdeen.
1882 Deane, Andrew, M.D., Bengal Army, Naini Tal, N.W.P.
India.
O.M. Denbt, S. C, Assistant Surgeon to the Bradford Eye
and Ear Hospital ; 1, Camden Terrace, Bradford,
Yorkshire.
O.M. Dent, Clinton Thomas, Assistant Surgeon to St.
G-eorge's Hospital ; 19, Savile Eow, W.
1883 Dew, Henet, Berkeley Square, Bristol.
1881 Dixon, W. E., 21, New Cavendish Street, W.
1882 Dodge, Stephen, M.D., Halifax, Nova Scotia.
O.M. DuNCANsoN, J. J. KiEK, M.D., Assistant Surgeon, Eye
Infirmary, Edinburgh ; 22, Drumsheugh Gardens,
Edinburgh.
O.M, Eales, Henet, Surgeon to the Birmingham and Mid-
land Eye Hospital ; 7, Newhall Street, Birmingham.
O.M. Edmunds, Waltee, M.D., Medical Officer, St. Thomas's
Home ; 79, Lambeth Palace Eoad, Albert Embank-
ment, S.E.
1883 Emets-Jones, A., M.D., Surgeon to the Eoyal Eye
Hospital ; 10, St. John Street, Manchester.
1881 Eaeeant, Samuel, Surgeon to the Taunton and Somerset
Hospital, and to the Taunton Eye Infirmary ; North
Street House, Taunton.
O.M. fFEEGusoN, H. L., Dunedin, New Zealand.
O.M. Fitzgeeald, C. E., M.D. (V.-P.), Ophthalmic Surgeon
to the Eichmond Hospital ; Lecturer on Ophthalmic
Surgery Carmichael School of Medicine ; 27, Upper
Merrion Street, Dublin. (C. 1880-1.)
O.M. Eitz-Geeald, W. A., M.D., 9, Ely Place, Dublin.
1882 Fox, Aethue E. W., M.B., 16, Gay Street, Bath.
O.M. Feost, W. a.. Assistant Ophthalmic Surgeon to St.
George's Hospital ; 77, Wimpole Street, W.
1883 fD-A- Gama, Jeeminio Accacio, Khoja Moola, Bombay.
XVI
ELECTED
1883 GiBEONs, E. A., M.D., Physician to the Grrosvenor Hos-
pital for Women and Children • 32, Cadogan Place,
S.W.
O.M. Q-LASCOTT, C. E., M.D., Surgeon to the Manchester Eoyal
Eye Hospital; 11, St. John Street, Manchester.
1882 fGrOSSE, Chaeles, M.D,, North Terrace, Adelaide, South
Australia.
O.M. GowEES, W. E., M.D., Assistant Professor of Clinical
Medicine at, and Assistant Physician to. University
College Hospital ; 50, Queen Anne Street, W. (C.
1880-3.)
O.M. Geeeneield, "W. S., M.D., Professor of Pathology Uni-
versity of Edinburgh ; Heriot Eow, Edinburgh.
O.M. Geossman, K. a., Ophthalmic Surgeon Stanley Hos-
pital, Liverpool ; 70, Eodney Street, Liverpool.
1881 GuLLiYEE, Geoeoe, M.B,, Assistant Physician to St.
Thomas's Hospital, and to the London Fever Hos-
pital ; 75, Lambeth Palace Eoad, S.E.
O.M. GuNN, E. Maecus (C), Assistant Surgeon to the Eoyal
London Ophthalmic Hospital, Moorfields, Ophthal-
mic Surgeon to the Hospital for Sick Children, Great
Ormond Street ; 108, Park Street, Grosvenor Square,
W.
1882 *Haeteidge, Gustayus, Consulting Ophthalmic Surgeon
to St. Bartholomew's Hospital, Chatham, and Assis-
tant Surgeon to the Eoyal Westminster Ophthalmic
Hospital ; 47, Kensington Park Gardens, W.
1882 tHENDEESON, W. H., M.D., Kingston, Ontario, Canada.
1883 Hewetson, H. B., Ophthalmic and Aural Surgeon Leeds
General Infirmary ; 11, Hanover Square, Leeds.
O.M. Higgens, Chaeles, Ophthalmic Surgeon to, and Lec-
turer on Ophthalmology at, Guy's Hospital ; 38,
Brook Street, W. (C. 1880-3.J
O.M. Hodges, Eeank H., Ophthalmic Surgeon to the Leicester
Infirmary ; 17, Horse Fair Street, Leicester.
O.M. HoEEOCKS, Petee, M.D., Assistant Obstetric Physician
to, and Demonstrator of Practical Obstetrics at,
Guy's Hospital j 9, St. Thomas's Street, S.E.
XVII
ELECTED
1884 Hudson, Eenest, Eoyal London Ophthalmic Hospital,
Moorfields, E.G.
O.M. Hflke, J. "W., E.E.S., Surgeon to, and Lecturer on
Surgery at, the Middlesex Hospital ; Surgeon to
the Eoyal London Ophthalmic Hospital, Moorfields ;
10, Old Burlington Street, W. (V.-P. 1881-2. C.
1880-1.)
O.M. Hutchinson, Jonathan, E.E.S. (Pres.)^ Consulting
Surgeon to the London Hospital, and to the Eoyal
London Ophthalmic Hospital ; 15, Cavendish Square,
W. (Y.-P. 1880-1.)
O.M. Iewin, H. E., Surgeon to the Darlington Eye and Ear
Hospital ; Coniscliffe Eoad, Darlington.
1883 Jackson, James, M.D., Collins Street, East, Melbourne,
Australia.
O.M. Jackson, J. Hughlings, M.D., F.E.S., Physician to the
London Hospital, and to the National Hospital for
the Paralysed and Epileptic ; 3, Manchester Square,
W. (V.-P. 1880 2.)
O.M. Jeaffeeson, C. S., Surgeon to the Newcastle-on-Tyne
Eye Infirmary ; 1, Savile Eow, and 2, Fernwood
Eoad, Newcastle-on-Tyne.
1883 tJENKiNS, E. J., M.B., Nepean Towers, Douglass Park,
Sydney, N.S.W., Australia.
1883 Jessop, W. H. H., Senior Assistant Surgeon to the Cen-
tral London Ophthalmic Hospital ; Ophthalmic
Surgeon to the Paddington Green Children's Hos-
pital ; 73, Harley Street, W.
1881 Johnson, Geoege, M.D., E.E.S. (C), Physician to King's
College Hospital ; Professor of Clinical Medicine at
King's College ; 11, Savile Eow, W.
1882 Johnson, G. L., M.B., Fern Lea, Highfield Hill, Upper
Norwood, S.E.
O.M. Jones, Evan, Ty-mawr, Aberdare, Glamorganshire.
O.M. Jones, H. Macnatjghton, M.D., 141, Harley Street, TV.
O.M. Julee, H. E., Assistant Ophthalmic Surgeon to St.
Mary's Hospital ; Senior Assistant Surgeon, Eoyal
Westminster Ophthalmic Hospital ; 77, Wimpole
Street, W.
vol. IV. h
XVIII
ELECTED
1882 Keall, W. p., Surgeon to the Bristol General Hospital,
and to the Eye Department ; Lecturer on Operative
Surgery at the Bristol Medical School ; Nelson
Lodge, Bristol.
1884 Kemp, J. E., 101, Jermyn Street, S.W.
1881 fKNAGGS, S. T., M.D., 16, College Street, Hyde Park,
Sydney, New South Wales.
O.M. Lang, William, Ophthalmic Surgeon to the Middlesex
Hospital ; 26, LTpper Wimpole Street, W.
1881 Lais-gdon, J. WiNKLEY, Ophthalmic Surgeon to Preston
and County of Lancaster Royal Infirmary ; Winkley
Square, Preston.
O.M. Lawford, J. B., M.D., Curator and Librarian to the
Boyal London Ophthalmic Hospital, Moorfields ;
E-oyal London Ophthalmic Hospital, Moorfields, E.C.
O.M. Lawsoi^", George, Surgeon to the Royal London Oph-
thalmic and to the Middlesex Hospitals ; 12, Harley
Street, Cavendish Square, W. (C. 1882-4.)
O.M. Lediard, H. a., M.D., Surgeon to the Cumberland In-
firmary ; 43, Lowther Street, Carlisle.
O.M. LiDDOT^, W., Surgeon to the Taunton and Somerset
Hospital, Taunton.
O.M. Little, David, Surgeon to the Royal Eye Hospital,
Manchester; Ophthalmic Surgeon, Royal Infirmary ;
Lecturer on Ophthalmology, Owens College, Man-
chester; 21, St. John Street, Mauchester. (C.
1880-1.)
1883 Ltjnn, J. R., Resident Medical Officer, Marylebone
Infirmary, Notting Hill, W.
1884 MacGregor, Alexander, M.B., 256, Union Street,
Aberdeen.
O.M. Mackenzie, E. M., 10, Hans Place, S.W.
O.M. Mackenzie, Stephen, M.D. (C), Physician to, and
Lecturer on Medicine at, the London Hospital ;
Physician to the Royal London Ophthalmic Hos-
pital, Moorfields; 26, Einsbury Square, E.C. (S.
1880-2.)
XIX
ELECTED
O.M. Mackinlat, J. Ot.f Ophthalmic Surgeon to the Eoyal
Eree Hospital, and Assistant Surgeon to the South
London Ophthalmic Hospital; 15, Stratford Place, W.
O.M. Macnamaea, Chaeles (C), Surgeon to the Westminster
Hospital, and to the Royal Westminster Ophthalmic
Hospital ; 13, Grosvenor Street, W.
1881 tMACONACHiE, G-. A., M.D., Grant Medical College, Bom-
bay.
1883 Mahee, W. O., M.D., 20, College Street, Hyde Park,
Sydney, N.S.W.
1883 Mahomed, F. A., M.D., Assistant Physician to Guy's
Hospital ; 24, Manchester Square, W.
1883 Maelow, Feank William.
O.M. Masou^, Feedeeick, Surgeon to the Bath Eye Infirmary ;
20, Belmont, Bath. (Y.-P. 1881-4.)
1884 Maxwell, Patetck William, M.B., 10, Lower Mount
Street, Dublin.
O.M. McHaedt, M. M., Ophthalmic Surgeon to King's College
Hospital ; Professor of Ophthalmology, King's Col-
lege ; 5, Savile Eow, W.
1884 McKeown^, Dayid, M.D., 25, St. John Street, Man-
chester.
1884 McKeown, W. A., M.D., 20, College Square East,
Belfast.
O.M. Meighan, T. S., M.D., Surgeon to the Glasgow Eye
Infirmary ; 219, Gallowgate Street, Glasgow.
[. 1881 Milles, W. Jennikgs.
1883 Monet, Ax gel, M.D., Assistant Physician to the Vic-
toria Park Hospital for Diseases of the Chest ; 14,
Langham Place, W.
: O.M. MoETON, A. Staneoed, Senior Assistant Surgeon to the
Eoyal South London Ophthalmic Hospital ; 57,
Welbeck Street, W.
[ O.M. Mules, P. H., M.D., Surgeon to the Eoyal Eye Hospital,
Manchester ; 20, St. John Street, Manchester.
O.M. Nelson, Joseph, 2, Glengall Place, Belfast.
XX
ELECTED
O.M. *]S"ettleship, Edwaed (C), Ophthalmic Surgeon to, and
Lecturer on Ophthalmic Surgery at, St. Thomas's
Hospital ; Assistant Surgeon to the Eoyal London
Ophthalmic Hospital, Moorfields ; 5, "Wimpole Street,
W. (S. 1880-3.)
1881 Nicholson, A., Honorary Surgeon to the Sussex and
Brighton Infirmary for Diseases of the Eye ; 98,
Montpellier Eoad, Brighton.
1881 Oeam, a. M., M.D., Liverpool Street, Sydney, Australia.
O.M. Oed, "W. M., M.D., Physician to, and Lecturer on Medi-
cine at, St. Thomas's Hospital ; 7, Brook Street, "W.
1881 Oemeeod, J. A., M.D., Assistant Physician to the
National Hospital for the Paralysed and Epileptic ;
25, Upper Wimpole Street, W.
O.M. Owen, D. C. Lloyd, Surgeon to the Birmingham and
Midland Eye Hospital ; 51, Newhall Street, Birming-
ham.
O.M. Page, Heebeet W., Surgeon to St. Mary's Hospital ;
146, Harley Street, W.
O.M. Peneold, Henet, Senior Surgeon to the Sussex and
Brighton Infirmary for Diseases of the Eye ; 7,
Brunswick Place, Brighton.
O.M. PowEE, Henet (Y.-P.), Senior Ophthalmic Surgeon to,
and Lecturer on Ophthalmic Surgery at, St. Bartho-
lomew's Hospital ; Surgeon to the Westminster
Ophthalmic Hospital ; 37a, G-reat Cumberland Place,
W. (C. 1880-2.)
1882 Peichaed Aethue William, 31, Victoria Place, Clifton.
O.M. Peichaed, Atjqtjstin, Consulting Surgeon to the Bristol
Eoyal Infirmary and Eye Dispensary ; 4, Chesterfield
Place, Clifton. (Y.-P. 1881-4.)
1882 Peingle, J. J., M.B., Assistant Physician to the Eoyal
Hospital for Diseases of the Chest, City Eoad ; 35,
Bruton Street, W.
O.M. PuEYEs, W. Laidlaw, Aural Surgeon to G-uy's Hospital ;
Ophthalmic and Aural Surgeon to the Hospital for
Paralysis and Epilepsy ; 20, Stratford Place, Oxford
Street, W.
XXI
ELECTED
O.M. Pte, Walteb, Surgeon to St. Mary's Hospital, and to
the Victoria Hospital for Children j 4, Sackville
Street, Piccadilly, "W.
O.M. Pye-Smith, E. J., Surgeon to the Sheffield Public Hos-
pital and Dispensary, 6, Surrey Street, Sheffield.
O.M. Eedmond, D. D., Ophthalmic Surgeon to St. Vincent's
Hospital, Dublin ; 14, Harcourt Street, Dublin.
1881 tE-EEYE, E. H., M.D., Surgeon to the Toronto General
Hospital, and to the Mercer Eye and Ear Infirmary ;
22, Shuter Street, Toronto, Canada.
O.M. Eeid, Thomas, M.D. (V.-P.), Surgeon to the Glasgow
Eje Infirmary, and Lecturer on Ophthalmic Medi-
cine, University of Glasgow ; 11, Elmbank Street,
Glasgow.
O.M. EoBEETsoN, D. Aegtll, M.D., Ophthalmic Surgeon to
the Edinburgh Eoyal Infirmary ; 18, Charlotte Square,
Edinburgh. (V.-P. 1881-2.)
O.M. EocKLiEEE, W. C, 9, Charlotte Street, Hull.
O.M. EoGEES, G. H., 3, Clifford Street, W.
1884 EoGEEs, HiLDTAED, 43, Uxbridge Eoad, "W.
1882 fEoTH, Eeijtee E., 61, Botany Street, Sydney, New
South "Wales.
1881 1 EuDALL, J. T., 121, Collins Street, East, Melbourne,
Australia.
O.M. Eyeeson, G. S., M.D., Lecturer on Ophthalmic and Aural
Surgery at Trinity Medical School, and Ophthalmic
and Aural Surgeon to the General and Sick Children's
Hospitals, Toronto ; 317, Church Street, Toronto.
O.M. Samelson, a., M.D., 15, St. John Street, Manchester.
1884 Sandfoed, Aethue V., M.D., St. Patrick's Place, Cork.
1881 Sansom, a. E., M.D., Assistant Physician to the London
Hospital ; Physician to the North-Eastern Hospital
for Children ; 84, Harley Street, "W.
O.M. Savage, G. H., M.D., Lecturer on Mental Diseases at
Guy's Hospital ; Medical Superintendent and Eesi-
dent Physician, Bethlem Eoyal Hospital, S.E.
XXII
ELECTED
O.M. Sharkey, S. J., M.B., Assistant Physician to, and Joint
Lecturer on Physiology and Demonstrator of Morbid
Anatomy at, St. Thomas's Hospital; 77, Lambeth
Palace Eoad, S.E.
1883 Sheaes, Chaeles, Eye and Ear Infirmary, Myrtle Street,
Liverpool.
1883 SiLcocK, A. Q., M.D., 5, Graham Eoad, Dalston, E.
1883 Skinnee, D. S., M.D., 1, Bedford Gardens, Campden
Hill, W.
1883 Smith, E. Peect, M.D., St. Thomas's Hospital, S.E.
O.M. Smith, Peiestley (C), Ophthalmic Surgeon to the
Queen's Hospital, Birmingham ; 21, Broad Street,
Birmingham.
1881 Smith, T. Gilbaet, M.D., Assistant Physician to the
London Hospital ; 68, Harley Street, W.
O.M. Snell, SiMEOif (C), Ophthalmic Surgeon to the Sheffield
General Infirmary ; 17, Eyre Street, Sheffield.
O.M. Solomon, J. Yose, Surgeon to the Birmingham Eye
Hospital ; Professor of Ophthalmic Surgery, Queen's
College, Birmingham ; 22, Newhall Street, Birming-
ham. (C. 1880-3.)
O.M. Sqijaee, W., Surgeon to the Plymouth Eoyal Eye In-
firmary ; 14, Portland Square, Plymoutli.
O.M. Stoey, J. B., Surgeon and Clinical Lecturer on Ophthal-
mic and Aural Surgery at St. Mark's Ophthalmic
Hospital; 24, Lower Baggot Street, Dublin.
O.M. Steeateeild, J. F. (T.), Senior Surgeon to the Eoyal
London Ophthalmic Hospital, Moorfields ; Ophthal-
mic Surgeon to University College Hospital ; and
Professor of Clinical Ophthalmic Surgery at Uni-
versity College, London ; 15, Upper Brook Street,
W.
O.M. fSTUEGE, W. A., M.D., 15, Eue Longchamp, Nice, Les
Alpes Maritimes.
1883 Sutton, S. W., M.D., St. Thomas's Hospital, S.E.
XXIII
ELECTED
O.M. SwANZT, H. E., Surgeon to the National Eye and Ear
Infirmary, Dublin ; Professor of Ophthalmic and
Aural Surgery to the Eoyal College of Surgeons,
Dublin; 23, Merrion Square, Dublin. (V.-P.
1880-1.)
1883 fSYMONs, Mark Johnston, M.D.
O.M. Stmpson, Thomas (C), Surgeon to the Lincoln County
Hospital ; 2 and 3, James Street, Lincoln.
O.M. Tay, "Waeen, Surgeon and Ophthalmic Surgeon to the
London Hospital ; Surgeon to the Koyal London
Ophthalmic Hospital, Moorfields ; 4, Finsbury
Square, E.C. (C. 1880-2.)
1882 Tatloe, C. B., M.D., Surgeon to the Nottingham Eye
Infirmary ; 9, Park Eow, Nottingham.
O.M. Teale, T. Peidgin, Surgeon to the Leeds G-eneral In-
firmary; 38, Cookridge Street, Leeds. (Y.-P. 1880-1).
O.M. Thomas, Jabez, Surgeon to the Swansea Hospital and
Eye Infirmary ; Ty-Cerrig, Swansea.
O.M. TiBBiTS, Heebeet, M.D., Senior Physician to the "West
End Hospital for Diseases o£ the Nervous System ;
68, Wimpole Street, W.
1883 fToBiN, "William, 31, Hollis Street, Halifax, Nova Scotia,
Canada.
1883 Tooth, Howaed H., M.B., Assistant Physician to the
Metropolitan Free Hospital ; 34, Harley Street, "W.
O.M. TosswiLL, L. H., Surgeon to the West of England Eye
Infirmary, 49, Magdalen Street, Exeter.
O.M. Tweedy, John (C), Assistant Ophthalmic Surgeon to,
and Professor ot Ophthalmic Medicine and Surgery at.
University College Hospital ; Surgeon to the Eoyal
London Ophthalmic Hospital, Moorfields ; 24, Harley
Street, ^Y.
1883 Uhthofe, J. C, M.D., Surgeon to the Sussex and
Brighton Eye Infirmary ; 46, Western Eoad, Hove,
Brighton.
O.M. Veenon, Bowatee, J., Ophthalmic Surgeon to St. Bar-
tholomew's Hospital, and to the West London
Hospital ; 14, Clarges Street, Mayfair, W.
XXIV
ELECTED
O.M. Walkee, G. E., Surgeon to St. Paul's Eye and Ear
Hospital, Liyerpool ; 43, Eodney Street, Liverpool.
O.M. "Walkee, T. Shadfoed (V.-P.), Lecturer on Ophthalmic
Medicine and Surgery at the Liverpool E-oyal Infir-
mary ; Senior Surgeon to the Liverpool Eye and Ear
Infirmary ; 88, Eodney Street, Liverpool. (C. 1881-4.)
O.M. Walkee, W., Consulting Surgeon to the Eye Dispensary
and Eye Wards, Edinburgh ; 47, Northumberland
Street, Edinburgh. (V.-P. 1880-1).
O.M. Walton, Hatnes, Consulting Surgeon to the Central
London Ophthalmic Hospital, and Senior Surgeon
to St. Mary's Hospital ; 1, Brook Street, W.
O.M. Watson, W. Spencee (C), Surgeon to the Great
Northern Central Hospital and Eoyal South London
Ophthalmic Hospital ; 7, Henrietta Street, Cavendish
Square, W.
O.M. West, S. H., M.D., Medical Tutor and Eegistrar of St.
Bartholomew's Hospital ; 15, Wimpole Street, W.
O.M. Wheeet, G. E., M.B., Surgeon to Addenbrooke's Hos-
pital ; 53, Trumpington Street, Cambridge.
1882 Wilkinson, T. M., Surgeon to the Lincoln County Hos-
pital ; Lindum Eoad, Lincoln.
O.M. Williams, E., Surgeon to the Liverpool Eye and Ear
Infirmary ; 82, Eodney Street, Liverpool.
O.M. WooDHEAD, G. Sims, M.D., 6, Marchhall Crescent,
Edinburgh.
O.M. WoEDSwoETH, J. C. (V.-P.), Consulting Surgeon to the
Eoyal London Ophthalmic Hospital, Moorfields j
20, Harley Street, W. [Ee-elected 1883.]
EULES.
1. The object of the Society is the cultivation and promotion of
Ophthalmology in the United Kingdom, India, and the Colonies.
2. The Society shall consist of Ordinary and Honorary members.
All legally qualified medical practitioners shall be eligible as ordinary
members.
3. The ofl&cers of this Society shall consist of a President, four or
more Yice-Presidents, a Treasurer, two Secretaries, and twelve other
members, who together shall form the Council and manage the
Society's affairs.
4. Election of Members. — Candidates shall be proposed on a form
provided for the purpose and signed by three members from personal
knowledge. The proposal paper shall be read at one Ordinary
Meeting, and the Ballot shall be taken at the following Meeting.
No election shall take place unless ten members vote, and no person
shall be elected who does not obtain four fifths of the votes given.
If any candidate, who is legally qualified to practise in India or the
Colonies, be not personally acquainted with three members of the
Society, the signatures, from personal knowledge, of teachers in the
Medical School at which he was educated shall be accepted instead
of the signatures of the same number of members of the Society.
5. Form of Admission by the Chairman. — Members shall be admitted
personally by the following form, after signing their names in the
Admission Book, and paying their first Annual Subscription. Form,
of admission. — " By the authority and in the name of the Ophthal-
mological Society of the United Kingdom, I admit you a member
thereof."
6. Honorary Members. — The Council shall have the power of pro-
posing men of distinguished eminence in Ophthalmology, or in the
sciences bearing upon it, not exceeding ten in number, for election
as Honorary members. They shall be elected in the same manner
as Ordinary members.
\
XXVI
7. Expulsion of Members. — A member can be expelled only at a
General Meeting specially called for tbat purpose, and of which a
written notice shall have been sent to every member at least four-
teen days previously. At least ten votes must be recorded, and four
fifths shall carry the expulsion.
8. Subscriptions. — The Annual Subscription shall be One Guinea,
payable in advance at the date of the Annual General Meeting.
Each member on election shall pay an Entrance Fee of One Guinea
in addition to the Subscription, but in the case of a member elected
at a meeting of the Session subsequent to Easter he shall not be
required to pay a Subscription during the next Session, Any mem-
ber whose Subscription is six months in arrear shall be reminded of
the same by one of the Secretaries, and if it be not paid within the
current year he shall -cease to be a member. Any member may, at any
time, pay a Composition Fee of Fifteen Guineas and be thereby ex-
empted from paying any further Subscriptions, such member enjoying
all the same rights and privileges as if he were a Subscribing member.
Any member resident out of the United Kingdom may pay a Com-
position Fee of Five Guineas instead of the Annual Subscription,
and will then be entitled to receive, post free, a copy of the Society's
* Transactions-' each year, and to have his name printed in the list of
members; but if at any time he subsequently become a Resident
member of the Society, the question of further payment by him
shall be decided by the Council. N.B. — The Composition Fee in
either instance will include the Entrance Fee.
9. The Officers of the Society shall be elected yearly by Ballot at
the Annual Meeting, to which all the Ordinary members shall be
summoned one week before. No gentleman shall hold the same
office for more than three consecutive years. Balloting lists of the
names recommended by the Council for election shall be sent to each
Ordinary member, together with the notice of the Annual Meeting.
10. Two Scrutineers appointed by the Chairman at the commence-
ment of the Annual Meeting shall receive the lists during the first
hour, and report the result to the Chairman. In the event of equality
of suffrage the Chairman shall determine.
11. The President and Vice-Presidents. — The President shall regu-
late all the proceedings of the Soc^'ety and Council, state and put
questions, interpret the application of the Laws, and decide any
doubtful points. He shall check irregularities and enforce the
observance of the Laws. He shall sign the minutes of General and
Council Meetings. In the absence of the President one of the Yice-
Presidents, the Treasurer, or some other member chosen by the
Meeting, shall perform his duties.
XXVII
12. The Secretaries sliall manage all correspondence, shall attend
every meeting of the Society and Council, and take minutes, which
shall be read at the following meeting. They shall notify to new
Members their election. They shall arrange with the President the
order of proceedings at all the meetings. They shall have charge of,
and keep a register of, all papers communicated, and shall be the
Editors of the ' Transactions.'
13. The Treasurer shall receive all moneys due to the Society, and
make all payments ordered by the Council, keeping an account of
all such receipts and payments. He shall keep a printed receipt
book for the subscriptions, and every receipt shall be signed by
himself and countersigned by one of the Secretaries. He shall
present to the Annual Meeting a written Report of the financial
state of the Society, signed by himself and by two members of the
Audit Committee.
14. Audit Committee. — The President, one of the Secretaries, and
two Members of the Society nominated by the President at some
meeting of the Society previous to the Annual Meeting, shall form a
Committee to audit the Treasurer's accounts.
15. The Council shall meet half an hour before the meeting in
October, January and May, and half an hour before the Annual
General Meeting, and at such other times as they may be specially
convened. Three shall form a quorum. The Council shall deter-
mine questions by show of hands (or by Ballot if demanded), the
President having in both cases a casting vote in addition to his
ordinary vote. They shall have the power of filling up any vacancies
which may occur in any of the offices of the Society between one
Annual Meeting and another. They shall decide upon all questions
relating to the reception of communications and to their publication
in the Society's ' Transactions.'
16. ' Transactions.' — A copy of the ' Transactions ' shall be sent to
each Member of the Society.
17. The Ordinary Meetings shall be held from 8.30 to 10 p.m. on
the second Thursday in October, December, January, March, and
May, and on the first Thursday in June, and the Annual General
Meeting on the Friday after the first Thursday in July.
18. Visitors. — Each Member may introduce two visitors on writing
their names in the attendance book.
19. The business at Ordinarij Meetings shall consist in the reading
and discussion of papers, which may be illustrated by specimens,
drawings, &c. When patients are to be shown they should attend
half an hour before the meeting.
20. Communications shall be taken in the order in which they
XXVIIl
have been sent in to the Secretaries, subject to the discretion of the
President. If an author be not present when the time arrives for
his communication to be read, it shall be dealt with as the President
may direct.
21. All papers, except those relating to living specimens, must be
sent to the Secretaries at least one week before the meeting, together
with an abstract suitable for immediate publication in the journals.
22. Nothing relating to the Laws or management of the Society
shall be considered at Ordinary Meetings.
23. At the Annual General Meeting proposed alterations of Rules
shall be considered and decided upon, notice of such alterations having
been given in the summons convening the meeting. Ten shall form
a quorum at this meeting, and for the adoption of any alteration of
the Laws four fifths of the votes given must be in its favour.
24. A special General Meeting may be called at any time, on one
week's notice, by the President or any three members of the Council,
the nature of the business being specified in the summons sent to
each Member of the Society, and no other business being considered.
I
LIBKARY RULES.
1. The Library shall be open at the same hours as that of the
Medical Society, viz. from 1 p.m. to 6 p.m. daily, except on Saturdays,
when it will be closed at 3 p.m.
2. Members will be entitled to read the books belonging to the
Society at 11, Chandos Street, between those hours, or to take them
out on signing a form provided for that purpose. But any books of
extraordinary value may be placed by the Council on a separate list,
such books not being allowed to be removed from the Library.
3. A large number of the current periodicals will be accessible to
Members in the Library. These will not be allowed to be taken out
of the Library.
4. A book must be returned at the expiration of a fortnight if
wanted by any other Member. The Librarian will in such a case
write to the Member in whose name the book was taken out.
5. If the book be not returned within four days of such notice,
a fine of 6d. will be charged for each day that the book is retained
beyond such days of grace.
XXIX
6. Instruments and drawings cannot be taken out of the Library
except with the express permission of the Council.
7. A Member taking out a book will be held responsible for its
being returned in good condition.
THE BOWMAN LECTURE.
Resolution of Council, Sejptember 18th, 1883.
"That in recognition of Mr. Bowman's distinguished scientific
position in ophthalmology and other branches of Medicine, and in
commemoration of his valuable services to the Ophthalmological
Society, of which he was the fi.rst President, the Council shall each
year, or periodically, nominate some person to deliver a lecture before
the Society to be called ' The Bowman Lecture,' which shall consist
of a critical resume of recent advances in ophthalmology or in such
subject or subjects as the Council shall select, or upon any original
investigation, and shall be delivered at a special Meeting of the
Society held for the purpose, at which no other business shall be
transacted."
LIST OF COMMUNICATIONS
BROUGHT BEFORE THE SOCIETY DURING THE SESSION 1883-4
I. DISEASES OF EYELIDS AND CONJUNCTIVA.
PAGE
1. Two cases of extreme ectropion of the lower lids ;
different operations. By J. E. Streatfeild ' 15
2. Jequirity and its value as a therapeutic agent.
By Arthur H. Benson 19
3. On the relation of bacilli to jequirity ophthalmia.
By W. A. Brailet, M.D., and H. W. Pigeon 28
4. A case of severe conjunctivitis with formation of mem-
brane on the cornese, caused by whisky thrown into
the eyes. By Gr. A. Brown 29
5. Peculiar conjunctival affection.
By Anderson Critchett and Henry Julee 30
6. Papilloma of the conjunctiva.
By Anderson Critchett and Henry Julee 31
7. Bony tumour of conjunctiva (microscopical section).
By Simeon Snell 31
Report of the Committee on the prevention of blind-
ness from ophthalmia neonatorum. 32
II. DISEASES AND TUMOUES OE THE CEBIT.
Case of proptosis, first of one and then of the other
eye, in association with enlargement of various
glands. By Jonathan Hutchinson, F.E.S. 36
XXXII
PAGE
2. Orbital tumour (sarcoma?).
By A. Emets-Jones, M.D. 45
3. Nsevus, ? lymphatic, affecting the brow, orbit, and
exterior of the eyeball, with lamellar cataract. No
cataract in the other eye. (With Plate I, fig. 1.)
By E. Nettleship 47
III. INTEA-OCDLAE TUMOURS.
1. Two cases of retinal glioma, in one of which shrinking
of the eyeball occurred without perforation.
By Simeon Snell 49
2. Sarcoma of choroid.
By Geoege Cowell and Henet Julee 55
IV. DISEASES OF THE lEIS.
1. Case of serous cyst of iris. By "W. J. Cant 57
2. Serous cyst of iris. By "W. Adams Feost 58
3. Granular-looking body on iris. By E. H. Hodges 59
4. Growth on iris (? tubercular). By "W. Lang 60
V. INJURIES AND SYMPATHETIC OPHTHALMITIS.
1. On the various forms of sympathetic disease of the eye
and their bearing on the theories of its transmission.
By W. A. Beailet, M.D. 62
2. Muco-purulent conjunctivitis of sympathetic origin.
By W. A. Beailey, M.D. 73
XXXIII
yi. PANOPHTHALMITIS.
VII. GLAUCOMA.
PAGE
3. Sympathetic ophthalmitis not appearing till after
enucleation of exciting eye. By W. Adams Frost 80
4. Note on the treatment of sympathetic ophthalmitis.
By Geoege E. Walkee 82
5. A case of sympathetic ophthalmitis with whitening of
the eyelashes. By E. Nettleship 83
6. Enucleation within forty-eight hours of severe contused
wounds of eyeball and orbit. Severe subacute iritis
of remaining eye setting in several weeks later,
probably sympathetic. Eecovery of good sight.
By E. Nettleship 85
7. Sympathetic neuritis without other visible structural
change. By W. A. Brailet, M.D. 87
8. Specimen showing traumatic detachment of retina and
choroid. By W. Adams Eeost 89
9. Total detachment of retina ; globe filled with organised
blood-clot. By W. Adams Eeost 89
1. Case of pseudo-glioma. (Communicated by Bowatee
J. Veenon.) By H. Lewis Joi^^es 90
1. Clinical observations which appear to indicate a means
of reducing the danger from malignant glaucoma
while increasing the efficacy of iridectomy in the
treatment of primary chronic glaucoma.
By M. M. McHaedt 93
VOL. IV. />
XXXIV
PAGE
2. Acute glaucoma of four weeks' duration, treated by
cyclotomy ; recovery of good vision.
By Geoege E. "Walkee 100
3. Examination of a glaucomatous eye in which retinal
haemorrhages were present, and were distributed in a
manner suggestive of obstruction to the descending
branches of the central vessels. (With Plate I, fig.
2.) By E. Nettleship 108
4. Grlaucoma with retinal haemorrhages, thickening of
retinal veins, and obliteration of arteries. (AVith
Pate II, fig. 1.) By E. Nettleship 111
5. Chronic glaucoma with a new connective tissue growth
in the right vitreous springing from the glauco-
matous cup. (Under Mr. Adams' care.)
By W. Lang 113
6. Case of glaucoma following a blow in a boy, set. 14,
the symptoms of which were relieved by eserine.
By W. A. Beailet, M.D. 113
YIII. DISEASES OP THE LENS AND CAPSULE.
1. On 200 operations for extraction of cataract.
By Chaeles Higgens 116
2. On a preliminary precaution to be taken in cases of
cataract extraction, when there is, or has been, any
lacrimal obstruction or catarrh.
By J. P. Steeateeild 118
3. The treatment of cystoid cicatrix after cataract extrac-
tion. By John B. Stoet 126
XXXV
IX. DISEASES OF KETINA AND CHOROID.
PAGE
1. On ansBmia as a cause of retinal hsBmorrhage.
By Stephen Mackenzie, M.D. 132
2. Haemorrhage in region of macula. (With Plate III,
fig. 1.) By A. Stanfoed Moeton, M.B. 148
S. Syphilitic retinitis with retinal haemorrhages and
growth of new blood-vessels from the disc into the
vitreous humour. (With Plate TV, figs. 1, 2.)
By E. Nettleship 150
4. On tortuosity of retinal vessels in association with
hypermetropia. (With Plate V, figs. 1, 2 ; YI, fig.
1.) By Stephen Mackenzie, M.D. 152
5. Direct arterio-venous communication on the retina.
(With Plate YI, fig. 2.) By R. Maecus Ounn 156
6. A third instance in the same family of symmetrical
changes in the region of the yellow spot in each eye
of an infant, closely resembling those of embolism.
By Waeen Tat 158
7. Tubercle of choroid. (With Plate YII, fig. 1.)
By P. H. Mules, M.D. 159
8. Disseminated choroiditis. (With Plate III, fig. 2.)
By Andeeson Ceitchett and Henet Julee 161
9. Central senile guttate choroiditis (without defect of
sight). By E. Nettleship 162
10. Central guttate choroiditis without defect of sight ;
premature presbyopia. (With Plate II, fig. 2.)
By E. Nettleship 164
11. Central senile areolar choroidal atrophy. (With Plate
YIII, fig. 1.) By E. Nettleship 165
12. Peculiar lines in the choroid in a case of post-papillitic
atrophy. (With Plate YIII, fig. 2.)
By E. Nettleship 167
13. Naevus of the right temporal and orbital region ; naevus
of the choroid and detachment of the retina in the
right eye. By W. Jennings Milles 168
14. Ossification of choroid, causing repeated attacks of
sympathetic irritation. By W. Adams Eeost 171
XXXVI
X. DISEASES OF OPTIC NEEVE.
PAGE
1. An analysis of cases of intracranial tumour with respect
to the existence of optic neuritis.
By "Walter Edmunds and J. B. Lawfoed 172
2. On cases of retro-ocular neuritis. By E. Nettleship 186
3. A case of central amblyopia and concentric contraction
of fields of vision ; recovery of normal acuteness of
sight. By J. B. Laweobd 226
4. On a case of acute optic neuritis associated with acute
myelitis.
By Seymour J. Sharkey, M.B., and J. B. Lawford 232
5. On cases of recovery from amaurosis in young children.
By E. Nettleship 243
5. Injury to the head ; immediate and permanent blind-
ness of the left eye and deafness of the right ear ;
subsequent atrophy of the left optic disc.
By Waeen Tay 266
6. A case of severe concussion of the brain followed by
temporary blindness with papillitis and anosmia.
By W. Spencer Watson 269
7. Cerebral haemorrhage with passage of blood into both
optic nerves. (With Plate IX, fig. 1.)
By Priestley Smith 271
8. Case of haemorrhage into the sheaths of both optic
nerves after a fracture of the skull.
By A. Quarry Silcock, M.D. 274
9. A case of homonymous hemianopia probably due to a
cortical lesion. By Seymour J. Sharkey^ M.B. 276
10. Failure of left eye (to blindness) passing into atrophy
of the disc ; later, paralysis of left third nerve and
loss of right half of right visual field with evidence
of atrophy of disc ; discharge of bloody mucus from
left nostril, and late appearance of tumour behind
left angle of jaw. Death seven years after onset of
symptoms ; large tumour compressing left optic
nerve, chiasma, and tract, and left third nerve.
By E. Nettleship 285
XXXVIl
PAGE
11. Fundus oculi from case of cerebral tumour ; appear-
ances like those of retinitis albuminuria. (With
Plate VII, fig. 2.) By Walter Edmunds 291
XI. FUNCTIONAL DISEASES.
1. A case of nerve disease with ocular symptoms, including
alleged uniocular diplopia.
By E. Marcus Gunn and James Anderson, M.D. 292
2. Case of paralysis of external rectus and mydriasis with
a recent history of uniocular diplopia.
By W. A. Beailey, M.D. 298
XII. AFFECTIONS OF MUSCULAE AND NEEYOUS
SYSTEMS.
1. Case of complete paralysis of accommodation and con-
vergence, persisting for ten months, in a girl aged
thirteen years, who presented no other evidence of
disease. By Henry Eales 300
2. On certain forms of spasm of the ocular muscles.
By W. E. GowERS, M.D. 306
3. A case of paresis of upward movement of eyes.
By J. A. Ormerod, M.D. 310
4. Acute spasm of the accommodation.
By C. E. Fitzgerald, M.D. 311
5. Observations on miners' nystagmus and its cause.
(With Plate X, figs. 2, 3.) Simeon Snell 315
G. Concomitant squint following severe scalp wound, com-
plicated by slight paralysis of the right external
rectus.
By Anderson Ceitchett and Henry Juler 332
XXXVIII
XIII. CONGENITAL DEFECTS.
PAGE
1. Congenital cysts in the lower eyelids in one case with
(apparent) anophthalmos, and in the other with
microphthalmos ; a case also of coloboma of optic
nerve sheath, with other cases of congenital defects.
(With Plate X, fig. 1.) By Simeon Snell 333
2. Congenital unilateral absence of lacrimation.
By A. Stanfoed Moeton 350
3. A case of uniocular coloboma of the choroid, iris, and
lens, with a bridge of iris tissue over the coloboma.
(With Plate IX, fig. 2.) Arthue Benson 351
4. Persistent hyaloid vessel and choroido -retinal changes.
By M. M. McHaedy 352
XIV. NEW INSTRUMENTS.
1. Model illustrating conjugate movements of the eyes.
(With Plate IX, fig. 3.) By Peiestley Smith 353
2. A large apparatus for demonstrating some of the
principal operations on the eye.
By. J. E. Steeatfeild 355
3. An improved microtome (made by Katsch, of Munich),
and a new method of mounting eyes in celloidin.
By W. Jennings Milles 360
Eepoet of the Council . . . 363
Appendix ..... 365
XXXIX
LIST OF PLATES.
FACING
PAGE
I. Fig. 1. Lymphatic nsevus of eyeball.
E. Nettleship 47
Fig. 2. Grlaucoma with retinal haemorrhages.
E. Nettleship 108
II. Fig. 1. „ „ with thickened veins.
E. Nettleship 112
Fig. 2. Central guttate choroiditis. E. Nettleship 164
III. Fig. 1. Haemorrhage in the region of the macula.
A. Stanpobd Moeton 149
Fig. 2. Disseminated choroiditis.
A. Ceitchett and H. Juler 161
IV. Blood-vessels in the vitreous humour during an
attack of syphilitic retinitis. E. Nettleship 151
V. Tortuosity of retinal vessels in connection with
hypermetropia. Stephen Mackenzie 153
VI. Fig. I. Tortuosity of retinal vessels with hyper-
metropia. Stephen Mackenzie 154
Fig. 2. Arterio-venous communication on the
retina. Marcus GtUnn 156
VII. Fig. 1. Tubercle of choroid. P. H. Mules 160
Fig. 2. Papillo-retinitis from a case of cerebral
tumour. Walter Edmunhs 291
Vin. Fig. 1. Central senile areolar atrophy of choroid.
E. Nettleship 166
Fig. 2. Peculiar lines on the choroid after papillitis.
E. Nettleship 167
IX. Fig. 1. Haemorrhage into the optic nerve-sheath.
Priestley Smith 278
Fig. 2. Coioboma of the choroid, iris, and lens.
Arthur Benson 352
Fig. 3. Model to illustrate the conjugate move-
ments of the eye. Priestley Smith 353
X. Fig. 1. Congenital cyst of the (left) lower eyelid.
Simeon Snell 334
Figs. 2 and 3. Miners' nystagmus. Simeon Snell 325
XL
LIST OF WOODCUTS.
PAGE
Extreme ectropion of the lower lids (Mr. Streatfeild's
case) . . . . .17
Iridectomy in primary chronic glaucoma (Mr. McHaedt's
paper) . . . . .99
Charts of fields of vision in retro-ocular neuritis (Mr.
Nettleship's cases) . 198, 203, 204, 206, 212
Ditto (Mr. Laweord's case) . . .229
Ditto (Dr. Shaexet's case) . . . 278
Diagram to explain the occurrence of hemianopia from
cortical lesions (Dr. Sharkey's case) . 282
Chart of field of vision in hemianopia and cerebral tumour
(Mr. Nettleship's ca&e) . 287
INTRODUCTORY ADDRESS
AT THE
Opening Meeting op the Session 1883-4^
October llth, 1883o
By Jonathan Hutchinson, F.R.S., Presidento
Gentlemen, — We begin to-day tlie fourth session of the
Ophthalmological Society of Grreat Britain. In the first
place I must thank you heartily for the honour you
have done me in electing me your second President.
Appreciating this honour most highly, I yet accept it with
much misgiving, more especially when I remember who
has been my predecessor.
In Mr. Bowman you have enjoyed the services of a
President of unequalled fitness and ability — of one, indeed,
who had already conferred inestimable benefits on oph-
thalmic science. His acceptance of the ofiice of President
at once secured the success of our infant Society, and in
his recent resignation of it we have sustained a heavy
loss — one which, I am well assured, it will be quite out of
my power, in any degree, to make you forget. The chief
satisfaction which I have, in venturing to accept your
invitation to succeed him, is the knowledge that he still
takes the warmest interest in our affairs, and that I shall
always have the advantage of his advice and help.
It will be my duty to mention to you directly, facts
which will prove that, although Mr. Bowman has resigned
the nominal presidency, he still occupies in relation to us
an almost paternal position. Long may he live to do so 1
We meet this evening, as you will have observed, in
VOL. IV. 1
2 INTRODUCTORY ADDRESS.
rooms whicli tave been made much more commodious
since our last session^ and in connection with this subject
I have to give you some important items of information.
The first is, that the Medical Society of London, whose
tenants we are, on entering upon their greatly improved
prsmises, felt themselves obliged very materially to
increase our rent. There was nothing in the least un-
reasonable in this j indeed, our landlords have throughout
acted towards us in a liberal spirit. The proposed
increase was, however, in respect to our finances, a very
heavy one, and as the Council was desirous to collect a
library, and to form a museum of instruments and appli-
ances— ^both objects demanding outlay, — we found our-
selves for a time in a position of great difficulty. It is
almost certain that the Society could not have afforded to
continue in these rooms and develop itself in the proposed
directions had it not been helped by an act of scientific
beneficence not often surpassed.
Having acquainted himself with the facts, and noting
our position, our ex-President made an offer to the
Council to himself undertake the cost of purchase of all
fittings necessary for the museum and library, and further,
to make a gift to the Society annually, for twenty years,
of the sum of £50, in order to defray the expenses of rent
of rooms. Need I say that the Council on your behalf
thankfully accepted Mr. Bowman's munificent offer, and I
have now the pleasure of informing you that we are, in all
probability, rent-free for twenty years, and shall be able
to devote the whole of our income from subscriptions to
the publication of our annual volume. I am sure that
you will receive this most liberal gift of your past Presi-
dent as one in the highest degree worthy not only of
praise in the present, but of imitation in the future. The
pecuniary advantages which it confers upon us are solid,
extensive, and durable ; but, warmly as we appreciate
them, I believe I may say that those who have been most
closely associated with the early years of our Societv
derive }et greater pleasure from the fact, that one so
INTRODUCTORY ADDRESS. 3
competent to judge, should in so emphatic a manner have
crowned their efforts with his approbation.
I have next to allude to a remarkable coincidence.
Mr. Bowman's offer was made only about a month ago,
and quite unexpectedly to us all, whereas for at least
three months before this, and wholly unknown to him, the
Council had had under consideration a proposal to recog-
nise his pre-eminent position in respect to ophthalmology
in Britain, and the invaluable services which he had
already rendered to our Society. It was from Dr.
Gowers that the suggestion had first come that we should
found a lectureship to be known as the Bowman Lecture,
but it was no sooner mentioned than it was received with
unanimous approbation.
I am anxious, for reasons that will be self-evident, to
make it clear that the Council's endeavour in this slight
manner to do honour to Mr. Bowman, and his liberal
endowment of the Society, had no connection one with
the other, although the two projects ripened about the
same time. Dr. Gowers' proposal has been several times
discussed in our Council meetings, and should it meet
with your approbation, as I feel sure that it will, the
lecture in question will be founded forthwith. Without
wishing unduly to bind the executive in future years, the
present proposal is that a Bowman Lecturer shall be
appointed each year, and invited to prepare for us a
critical summary of the best extant information upon some
special subject to be selected by the Council, or, if not
selected, approved by it.
This lecture will probably be an annual one, and will
be delivered at a meeting specially appointed for that
purpose. We hope in it not only to permanently asso-
ciate with our Society the name of a great man, but also
to contribute each year something real towards that
" advancement of knowledge for the good of man's
estate," which has been Mr. Bowman's lifelong aim.
With this statement I end, gentlemen, the announce-
ments which it has been my most pleasing duty to make
4 (KTRODUCTORY ADDRESS o
to joUy but I purpose before sitting down to trespass upon
your attention with a few further remarks on our
general position and the possible scope of our future worko
I thmk that we may now fairly congratulate ourselves
that the organisation of our Society^ if we regard it
simply as providing means for the furtherance of research
in ophthalmology _, is well-nigh perfect. We shall have
regular meetings in commodious and central rooms, at
which any subject which is brought forward will be
certain to receive the attentive criticism of an audience,
than which none exists better qualified for the task. We
invite in the freest possible manner the production of all
new facts, opinions, and suggestions, whether relating to
extended series of observations or isolated cases. All
that concerns the eye, whether in health or disease, con-
cerns us, and we shall be thankful alike for the single case
and the elaborate paper. Nor is there, I am happy to
say, any spirit of exclusiveness as regards membership
with us. We shall willingly accept the help of all whc
take an interest in our pursuits. Those who had the
largest share in the formation of this Society were careful
that it should have a wide basis, and, tha,nks to their fore-
sight, it has now the good fortune to include amongst its
members many, physicians, surgeons, and others engaged
in general practice, who are not, and never have been, in
any sense, specialists.
To say nothing of the original contributions which we
have had from some of these, their help in our debates
and their services on our committees have been, and will
be in the future, simply invaluable. • It is true that we
have not yet a library of reference, or a museum. But
the first of these desiderata will, I doubt not, soon be
supplied, and the other will be put in course of formation
to such extent as may suitably come within our lines of
work. We shall probably never attempt the formation of
a pathological collection, since we have no convenience
for its preparation or its display, and there exists, besides,
at other institutions, ample provision in this direction.
INTEODUCTORY ADDRESS. &
We do, however, contemplate the formation of a collec-
tion of instruments and appliances, and to this object Mr.
Bowman^s endowment will, as I have said, be in part
devoted. Probably also we shall make gradually a collec-
tion of drawings and other forms of graphic illustration.
These can be easily classified and stored for reference in
the drawers of our library. Should it occur to any of our
more wealthy friends to emulate Mr. Bowman's noble
example, I cannot, for my own part, think of any object
to which a second endowment could be more usefully
devoted than to the formation of such a collection.
Morbid conditions of the eye, whether external or
revealed by the ophthalmoscope, lend themselves with
peculiar facility to the artist's skill „ If we had the funds
I would suggest that, under the auspices of a committee,
we should copy, collect, and classify, from all available
sources, private and public, published or otherwise, all
such illustrations of eye disease as are passably good in
execution, and duly authenticated and described. With
but few exceptions I would leave aside all in which the
history of the individual case is omitted. If this schema
were completed we should find, if I am not mistaken, that
we were in possession of a sort of clinical museum wbich
would prove of very great use alike to students and to all
engaged in original research. I certainly count this
object as chief among the desiderata for which adequate
provision has not yet been made.
Hitherto I have been speaking of our arrangements and
organisation as a Society for the improvement of know-
ledge in our special branch. To those who, with me,
believe that it would be difficult, in any material
degree, to alter these arrangements for the better, it is, I
may repeat, a source of great satisfaction to know that
they have received the emphatic imprimatur of our first
President, than wbom there is no man living so well
qualified to judge.
The improvement of ophthalmic knowledge is unques-
tionably our first, and by far our principal duty. I
6 INTRODUCTORY ADDRESS.
canHot but think, however, that it is possible that in tbe
future such societies as ours may find another kind of
work open to them, which is only second in importance.
I allude to the systematic and strenuous endeavour to
diffuse rapidly amongst the profession at large, for the
prompt benefit of our patients universally, all items of
new knowledge which may have been obtained.
There are many directions in which thoughtful help
might be given towards this end. We may, in the first
place, endeavour to induce as many as possible to join us,
and attend our demonstrations and discussions and receive
our volumes. We shall not, however, in this way reach
many excepting London residents.
It is perhaps possible that something might be done to
make some of our meetings, and the reports of them which
appear in the journals, more valuable to the bulk of the
profession, by becoming less definitely special than they
now are. We might, for instance, bring forward for dis-
cussion, occasionally, the commoner forms of eye disease
— such as are scarcely likely to be often made the themes
of original communications. Not only would this help
others, but it is very desirable for our own good that we
should occasionally make recapitulation in public of our
knowledge of common things, and thus ascertain how far
our opinions have advanced towards unanimity*
There is another branch of the same topic on which I
incline, if you will permit me, to enter into a little more
detail, since it offers possibly a sphere for much useful
work in the future on the part of societies like ours. It
is one, indeed, to which perhaps this Society in particular
is more specially called than any other. I refer to the
promotion of what may be named every-day therapeutics.
It is obviously quite possible that the knowledge of
diseases of the eye might be cultivated by a few up to a
point of very high excellence, and with great finish of
detail, and yet remain a possession of the specialist, and
benefit but little the family practitioner, and the public
his patients. In some degree this state of things is un-
INTBODUCTOEY ADDRESS. 7
avoidable, and in some departments of our practice we
cannot hope to ever escape it. Still, however, it will be
admitted by all to be a matter of regret. So far as we
can do it, it is our duty to make such knowledge popular
— to diffuse it over an area the widest that we can obtain.
A practical knowledge of astigmatism is not to be
expected from a general practitioner ; possibly not even
from all who are engaged in the treatment of eye diseases
as a specialty. The attempt to use the ophthalmoscope
for purposes of diagnosis, although quite possible to a
large section of the younger part of the profession, enjoy-
ing constant opportunities and fresh from hospital train-
ing, would probably, to by far the greater part, prove to
be a source of error rather than a help.
Skill in the diagnosis and, as a necessary consequence,
in the treatment of a not inconsiderable group of rare dis-
eases of the eye, must always, despite any development of
education which it is reasonable to hope for, and any arti-
ficial aid which can possibly be given, remain the
possession of the specialist only. But it is otherwise in
respect to a majority. Almost all the examples of the
commoner forms of eye disease come under the care, in
the first instance and often throughout, of those who are
not specialists, and have perhaps never even had any
training in an ophthalmic hospital. Circumstances over
which no one has any control render this inevitable.
Whether or not the surgeons concerned desire it, they
must perforce take charge of ^^ eye cases '' as well as of
others. It is in reference to practitioners so placed that
I would suggest that our Society has possibly a duty to
perform. If I trouble you with a few examples, I shall
probably be best able to convey my meaning.
Concerning the treatment of sj^philitic iritis, there is
probably but little hesitation or difference of opinion
amongst specialists, and perhaps I could hardly mention
another disease respecting which the opinions of specialists
are more widely known and accepted. That atropine
should be used from the first, frequently, freely, and in
8 INfRODUCTORY ADDRESS.
strong solution, and that mercury and iodide of potassium
are very useful and ought always to be given, but in no
degree compare in importance with mydriatics, I take to
be the acknowledged canon. It would be easy to prepare
an explicit schema for the treatment of this disease, giving
the exact strength of the atropine, the frequency of its
application, the precise dose of the mercurial, and suggest-
ing a few of the more important means which help success,
such as a purgative, leeches to the temples, and low diet.
This might be done in ten lines, and so printed in a
visiting-list or pocket-book that it should be readily
accessible to all. It would be better that such a schema
should be propounded under the auspices of a Society than
that it should come from an individual. In many parallel
instances, the discussion and examination which such
schemata of treatment would receive at the hands of our
Society would, no doubt, be of great use in perfecting
them, as well as in adding to their authority.
I do not doubt that there are, at the present moment,
whilst I am speaking to you, in the homes, the schools,
the workhouses, and the hospitals of England, some thou-
sands of children who are suffering from ulcerations on
the cornea, attended with intolerance of light, causing the
patient great distress and annoyance through many
months, and destined often to leave disfiguring and in-
capacitating scars. If my own experience may be trusted,
I believe that three fourths of these would be almost well
in the course of a fortnight under the use of a very weak
yellow oxide ointment. Many of them, no doubt, are
getting it, but a considerable majority probably are not ;
for this plan of treatment is not yet universally acknow-
ledged among specialists, and certainly not very widely
known in the profession.
If this Society could, after an examination of the sub-
ject, determine upon the recommendation of an explicit
formula which would be likely to result in the prompt
cure of these very troublesome cases, it would confer an
immense boon upon the public. Such a formula, so
INTRODUCTORY ADDRESS. 9
recommended, would "be copied into every n^edical journal
and into every manual. It would be reprinted over and
over again, and would become the property of the whole
profession.
Is it not somewhat humiliating to reflect that if a quack
were to bring out a very weak Pagenstecher's ointment,
give it a telling name, and push it into notice as a specific
for chronic inflammations of the eye, he would be a public
benefactor? No doubt it would often be used in error,
but it would even then do little or no harm, and I have
not the least doubt that the balance of gain would enor-
mously preponderatOc My own experience has been, that
since I knew the virtues of this ointment I have been able
to abandon almost entirely the use of blisters, setons, and
like painful measures, and to effect the cure in a tenth of
the time. I have reason to think that a large majority of
ophthalmic specialists have had a like experience. Yet
we hesitate to come boldly before the general profession
and announce loudly an important item of progress. We
fear to boast, we dread to impair the scientific spirit by
the formation prematurely of general rules ; and, seeking
to quiet our consciences by reminding ourselves that after
all the thing is no secret, we do nothing further in the
matter. Our reticence is a loss to the nation, it is an
injury to hundreds and to thousands whom the benefits of
modern ophthalmological science might reach if we would
only consent to throw away our fastidiousness. Is it not a
frequent failing among the more scientific part of our profes-
sion to become superfine? We dread the spirit of the
charlatan and the self-seeker so much, that we come, like
David when in presence of the sinner, to '^ hold our peace
even from good,'' In the individual, scrupulous care in
these respects is most meritorious ; nothing is less to be
desired than that those who believe themselves to have
made therapeutic discoveries should deem it their duty to
proclaim them ostentatiously. Let them be brought for-
ward in the first instance quietly, and under the cogni-
sance only of those skilled to judge of them.
10 INTEODUCTORT ADDRESS.
But the fact that it is meritorious in individuals to
abstain from pushing their favorite remedies, only throws
the duty, to which I have been alluding, the more defi-
nitely upon public bodies like ourselves. No one could
impugn our motives or doubt our sincerity, and our
verdicts would be received not cerfcainly as final, but as
entitled, at any rate, to a temporary acceptance.
Let no one suspect me of wishing to stereotype know-
ledge or to damp the ardour of any skilled person in the
endeavour yet further to improve our therapeutic resources.
There is no fear in that direction ; and what I am con-
cerned to assert is this, that nine out of ten of the prac-
tising part of the profession would most thankfully receive
from this Society detailed schemata for the treatment of
various typical forms of eye disease. Let me further add
— without, I hope, hurting anyone^s feeling — that I am sure
that the use of them would tend immensely to the benefit
of their patients as compared with the extemporised pre-
scriptions now employed. It is not in the power even of
the most laborious of those engaged in family practice, to
keep their minds well stored with details respecting the
management of diseases which, although very common
with us, are rarities to them.
I might easily mention a number of special types and
forms of eye disease — purulent ophthalmia, rheumatic
iritis, episcleritis, catarrhal ophthalmia, glaucoma, and the
like — for which definite schemes of treatment could easily
be laid down. It will, I have no doubt, be objected, that,
after all, successful treatment depends upon the correct-
ness of the diagnosis. This statement is almost as obvious
as was the famous injunction to "first catch your hare.^'
It is no reason that because diagnosis is difl&cult, thera-
peutics should be left in a muddle also.
I might urge further that I believe, working on the
same lines, this Society might do much to put the dia-
gnosis of eye diseases more easily within the reach of
British practitioners in general.
There is no one present who has not been pained over
INTRODUCTORY ADDRESS. 11
and over again by having to treat cases of glaucoma
which were brought to him too late. In spite of all that
has been done by specialists, and in spite of the fame
which iridectomy cures have obtained, it is still the fact
that a large proportion of cases of acute glaucoma are un-
recognised during the first fortnight by those under
whose observation the patients come. Practitioners of
the most scrupulous care, of wide general information, and
the most conscientious regard for their patient's good, are
yet very commonly misled by the acute congestion and
severe constitutional symptoms which often attend the
early stages of this disease.
It was my fortune, some years ago, to operate upon
three cases of this kind in one week, in all of which the
proper time for interference had been allowed to pass by,
on account of the patients' severe general illness.
In one instance I became acquainted with the facts of
a case in which a benevolent country surgeon, aided by
two or three friends, was himself maintaining a lady who
had lost her sight, and consequently her occupation, from
double acute glaucoma. He had himself attended her
from the beginning, and when I gently hinted at the
possibility — to me, a practical certainty — that iridectomy
at the proper time would have saved the lady's sight for
the rest of her life, he promptly replied ^^ that the eyes
were so much inflamed in the first instance, and the
patient so ill, that he was quite sure I should never have
thought of operating." I said no more, for it would have
been cruel to tell him that these were the very symptoms
which denoted the necessity for an operation.
Some years ago, in the early days of the keratome, I
felt so strongly on this subject that I had some thoughts
of engaging a full page in the ' Lancet ' for a big red-
lettered anonymous advertisement, so staring that all must
read it, stating in a dozen words the symptoms and in-
evitable result of glaucoma, together with the certainty of
its cure by operation.
And now, looking back upon such impulses of enthu-
12 INTEODUCTORY ADDRESS.
siasm, I do deliberately declare my conviction that a
Society like our own would have been more than justified
in taking such a step. At that time acute glaucoma pro-
bably had^ on British soil alone, its daily victim, whom it
left in irrevocable blindness. In the present day the
number has been greatly diminished, but it is still, no
doubt, very considerable. Our confidence in the remedy
which we then hailed has remained unshaken ; and it is
most certainly a very melancholy thought, that there are
thousands now living without sight who might have saved
it very easily had there existed any efficient means for the
rapid diffusion of the new knowledge,
I must not trespass further upon your patience in this
matter. Briefly, what I desire to urge is this, that we
ought not to be content with doing our utmost to make
knowledge perfect, and to secure its application in our
own immediate spheres of action, but that it is well worth
a thought whether Societies like our own have not duties
to perform in respect to its diffusion. I will not for a
moment doubt that a subject so important will receive
from you such attention as your judgments may deem it
entitled to.
Is it too much to hope that something of the nature of
a compendium of ophthalmic therapeutics may sometime
be prepared, which shall bear the authority of a Society's
consensus ? Such a code should of course be destined to
modification from time to time, but it would probably from
the first be a great advance upon the statements of any
individual, both in explicitness, in brevity, and in the
amount of practical experience which it would sum-
marise.
Should the Society see its way in the future to any
action in this matter, much collateral advantage might be
expected by the more detailed attention to therapeutics
which would be given by the committees appointed to
report o
Had time permitted, I might have ventured to bring
before you a few other suggestions as to work which the
INTEODUCTORY ADDRESS. 13
Society miglit undertake collectively — such, for instance,
as a systematic examination of symptoms with the object
of defining and describing them more accurately j of pre-
paring detailed lists of the more rare types and forms of
disease, and giving to each its concise description ; and
possibly, after this were done, of preparing nosological
lists which might assist the labours of hospital registrars »
I have occupied, however, already much more time than
I had intended, and must not detain you any longer from
the proper work of our meeting.
REPORTS.
I. DISEASES OF EYELIDS AND CONJUNC-
TIYA.
1 . Tivo cases of extreme ectropion of the lower lids ; different
operations.
By J. F. Steeatfeild.
Or these two cases, one of the patients is here this
evening so that his present state can be seen,, and his
former condition is represented in the drawing I have now
the honour to present. In this case the ectropion was
treated by transplantation of a large piece of skin without
pedicle. Thomas M — , set. 22, came to University College
Hospital about a year ago, for the results of very extensive
disease of the bones of the face ; the nose, and roof of the
mouth being destroyed. The disease began when he was
fourteen years old, and is I believe a result of inherited
syphilis. He came under my care because he was chiefly
inconvenienced, and perhaps most disfigured by the abso-
lute eversion of the left lower lid. The palpebral conjunc-
tiva was exposed to the extent of seven mm. measured
vertically. The cornea had not suffered, but the ocular
conjunctiva was very much congested, there was much
lacrimation with other consequent inconveniences. On the
13th of March, last year, the patient being under anaes-
thetic influence, and carbolic acid solution being used for
16 DISEASES 01? EYELIDS AND CONJUNCTIVA.
all the instruments, and to bathe the parts concerned in
the operation, I made an incision just below the margin of
the everted lower lid, extending from the outer to the
inner canthus, and dissected the skin from the lid and its
orbicularis muscle, so as easily, without dragging, to bring
up the lower lid into contact with the upper one. Then,
both being made raw by removing a narrow strip of mucous
membrane from the inner margin of the edges of the two
lids, they were sewn together with three stitches. In the
next place, I measured the size of the raw space, thus left
exposed, 1^ by ^ inch, and then I outlined, by cutting just
through the cuticle, a piece of skin on the inner aspect of
the patient's left arm, midway between the axilla and the
elbow ; it was of the shape of half an oval divided verti-
cally, and measured If by f inches; then having introduced
four fine black silk sutures through the edges of this half
oval piece of skin, and holding the sutures up together, in
my left hand and with equal traction, I dissected the
skin piece off from the arm, without any fat, or areolar
subcutaneous tissue, and without touching the piece of
skin with my hands. Then, at once it was put in the
vacant space over the lower lid, the straight side, of course
upwards. It shrank very much, and looked opaque yel-
lowish white. Then the four suture needles, two above
and two below, were carried through the edges of the
skin of the gap in the eyelid, and tied. Two pads of
boracic lint and wool, dipped in a saturated solution of
warm boracic acid, were put close together, one over each
of the united eyelids, and then two turns of a light bandage
round the head, over this a large layer of wool, then a piece
of thin india-rubber sheeting, and another loose bandage,
which with the outer wool, and everything down to the
inner bandage, was to be taken off once in every half-hour
or hour, so as to keep the parts beneath the inner bandage
and pads, wet with the warm boracic acid solution.
On the 14th, the next day, the transplanted skin looked
as it did the day before. On the 16th, it looked a little
bluish, rather dusky, and slightly swollen. The same
EXTREME ECTROPION OF THE LOWER LID.
17
treatment was continued. On the 20th, the slightly bluish
tinge of the graft was not more decided, in the greater
part of its extent, but all along its lower border it was
,...^<p4^^?^^^S^^5:^:: = .
^-^'^\
^^f^^
.■:,1:ri:-:,:r'X'-'^.
Fm. 1.
p>V<^^- ■■""""• ■■■■ ■■•-,.■>
:^V.
r-fe^
l-i''
''yii^i' ■■■■■'
FiCr. 2.
much darker, almost black. The epidermis was becoming
detached in one piece from the piece of skin transplanted.
Dressing continued, as before. On the 24th the trans-
VOL. IV. 2
18 DISEASES OF EYELIDS AND CONJUNCTIVA.
planted skin seemed to have separated itself into two
nearly equal parts horizontally, the upper next the margin
of the lid living, and the lower, hanging almost loose,
nearly all dead, dark coloured. On the 27th the whole of
thip lower half of the graft was now lost and separated,
the rest of it was pink and altogether healthy-looking.
On the 30th the living half of the transplanted skin was
quite safe, and the raw surface below it was healing
rapidly. On the 10th of April the gap was filled in and
quite healed except at the inner end, where the tears over-
flow. On the 13th he was discharged.
He returned to the hospital after nine months at the
beginning of the present year. The edges of the eyelids
were then separated, and made free with a knife, on a
director. The left eye has now been again exposed for
about six weeks. The patient says the eye is no longer
^^ sore,^' that he sees better with it, and that it seldom
^^ waters ^^ now. The ocular conjunctiva is now in a nor-
mal condition, not red at all.
The deformity is very much less than it was, and the
eye is fairly protected now. I suppose the loiver half of
the skin graft died because of the unhealthy cicatricial
condition of the skin of the cheek with which it was in
contiguity. If it had not died I suppose the cure would
have been perfect in every respect.
The other patient is not here this evening. The eyelids
in this case have been sewn together, and not yet separated.
The patient is a young woman whose lower eyelid was as
completely everted as in the first case, the result of a burn.
I did the V Y operation six months ago with very incom-
plete success, so that I have since done another operation
by making and dissecting up tiuo flaps, pointed downwards
as a W (the two middle strokes of the W bisecting the
two strokes of the scar of the former Y) and then the
inner sides of the two flaps of the W, have been brought
up and sewn together. But even this second operation
will be but an incomplete success, so that I begin to wish
that I had adopted the plan of the large graft, from some
JEQUIRITY AS A THERAPECJTIC AGENT. 19
other part where the skin is naturally soft, thin, and
pliable.
(March V6th, 1884.)
2. Jequirity and its value as a therapeutic agent.
By Arthur H. Benson (Dublin).
Since Wecker published his first experiences of jequirity
in the 'Annales d'Oculistique ' for July, August, 1882,
and Sattler in the ^Klinische Monatsblatter ' for May, 1883,
recorded the results of his investigations regarding the
intimate nature of the ophthalmia produced by it, oculists
and physiologists in all quarters of the civilised world have
devoted a large share of their attention to this drug. For
us who practise ophthalmic surgery in Ireland, any im-
provement in the mode of treating granular ophthalmia
possesses a more lively interest than can be expected to
exist amongst those living in communities where this form
of conjunctivitis and its consequences are comparatively
infrequent.
It is unnecessary for me to occupy the time of this
Society by referring to the botanical characters of the
plant or to the story of its introduction into Europe as a
therapeutic agent. Nor need I trouble you with a des-
cription of the results obtained by others. The recent
ophthalmic literature is full of such accounts, which are no
doubt familiar to all present. What I purpose doing is
very briefly to record the mode of preparing and using the
infusion, which I have found useful, and to state the
results, and then to make a few remarks on the nature
of the ophthalmia and the theory of its origin from
bacilli.
For the last eleven months I have been using joqui-
20 DISEASES OP EYELIDS AND CONJUNCTIVA.
rity pretty constantly at St. Mark's Ophthalmic Hospital,
and more lately at the City of Dublin Hospital. In all
I have employed it in about sixty cases, with almost
uniformly satisfactory results.
Pre^paration. — The mode of preparing the infusion differs
in some respects from that adopted elsewhere. The fresh
dry seeds, without being decorticated or macerated are
ground fine in a hand coffee-mill. Twenty-five grains of
the powder are then mixed with one ounce of water and
shaken up at intervals for half an hour, when the liquid is
ready for use. It is not strained or filtered, but the
coarser particles having settled the supernatant fluid is
decanted when required for use. In some cases the liquid
is not decanted at all. In others it is decanted after
having been in contact with the seeds for several days or
weeks.
Application. — The mode of application has been pretty
uniform. The lids being everted the solution is brushed
on abundantly with a hair pencil, the conjunctival cuU
de-sac being at the same time filled with the liquid. This
is repeated from one to ten times in the day, and continued
from one to fourteen days according to the result required
in each case. In some instances the liquid was dropped
into the eye. Both methods produced the same results.
Effect. — The effect of a single application has been, in
most cases, the production within six hours of a sharp
attack of conjunctivitis, which in another six hours had
produced a very definite membrane on the conjunctiva,
both of the lids and of the globe, with the occurrence of
much pain, swelling, and redness of the lids, photophobia,
lacrimation and muco-purulent discharge in abundance.
I have never seen the pus fall drop by drop from the lids
when the patient bent his head, as Wecker described.
Within twenty -four hours the maximum effect had been
reached, the membrane could be lifted off the conjunctiva
without causing it to bleed, and usually without causing
pain. For the next twelve hours or so the inflammation
remained at its height. From this time the stage of re-
JEQUIRlTY AS A THEEAPEUTIC AGENT. 21
trogression began, and within twenty-four or forty-eight
hours more the membrane had generally wholly disappeared
leaving the conjunctiva pale, opaque, and somewhat milky-
looking for a day or so longer.
Result. — The result has been in most cases an immediate
diminution of the granular ophthalmia and of the pannus
when such was present. In most cases the application
had to be repeated often and for long periods of time before
the granulations were destroyed. In some cases the solu-
tion has been applied as often as ninety times within a
few weeks. In other cases three or four applications
seemed to effect a cure. In one case in particular the most
perfect cure has been obtained, but it took three months
to get it. The boy had been under treatment in the hos-
pital for five months previous to the use of jequirity, and
was treated with sulphate of copper, &c., assiduously
all that time, but with hardly any benefit. After three
months of jequirity treatment, his conjunctiva was wholly
free from granulations, his cornea was clear from the
pannus, and the boy looked as though he had never suffered.
I have noticed a very great difference in the rapidity with
which, under the same treatment, cases will recover ; and
I am of opinion that jequirity will be found to do com-
paratively little good where the palpebral conjunctiva is
in a thick, soft, congested state, with deep furrows between
the granulation masses, and where there is but little
pannus, and no tendency to contraction of the tarsus ;
whilst it will act like a charm on the more definitely
trachomatous cases where the conjunctiva is hard and
the so-called granulations are prominent and bloodless,
and where there is a distinct tendency to entropium and
much pannus especially in old-standing cases. I have
never found jequirity do permanent harm, even where the
cornea was ulcerated. In most cases of chronic ulceration
it seems to act beneficially on the cornea, although in
some cases the cornea in the neighbourhood of the ulcer
became infiltrated. This, however, soon cleared off. In
one case an attack of iritis occurred each time the infusion
22 DISEASES OF EYELIDS AND CONJUNCTIVA.
was applied, but this too passed off in a few days without
leaving any permanent traces. This patient had four or
five transient attacks of iritis while under treatment for
his ophthalmia.
In some forms of strumous keratitis, where with dense
pannus the palpebral conjunctiva was almost normal,
jequirity destroyed the pannus which other treatment had
failed to do, and this without apparently injuring the con-
junctiva. It is true that in the hands of some oculists the
most untoward results are stated to have occurred,
Galezowski, Parisotti, and others cease not to write of the
"insuccess of jequirity'' and its lamentable results.
The constitutional disturbances caused by the occur-
rence of jequirity ophthalmia are often very severe ; the
temperature increases steadily until the membrane is fully
formed ; it may rise several degrees above the normal.
There is headache, furred tongue, restlessness, loss of
appetite, and in some cases severe vomiting. The sus-
ceptibility of the conjunctiva to jequirity seems to dimi-
nish with each attack, until finally it becomes impervious
to its influence. A period of rest again partially restores
its susceptibility.* To obtain the maximum result in the
shortest time, the solution should be applied to the con-
junctiva several times at short intervals before the mem-
brane forms. To keep up the effect the conjunctiva
should be brushed with the solution three or four times a
day for as long as it is desired to keep up the membrane.
The stronger the infusion the more intense is the oph-
thalmia, but it is not proportionate to the strength. It
is probably better not to filter the solution, but to leave it
in contact with the seeds, decanting the supernatant
liquid as required. The process of decortication aud
* In this connection it may be noted that the boiled seeds of jequirity are
said to be used as an article of diet in Egypt. In India cattle are maliciously
poisoned by shooting them with arrows whose points consist of a cone of
hardened jequirity paste. The owners of the cattle, however, protect them by
previous inoculation with small quantities of jequirity, which gives them
immunity from the effects of subsequent larger doses. Cornil and Berlioz
found the same thing true of rabbits.
JEQtJIRITY AS A THERAPEUTIC AGENT. 23
maceration is unnecessary. The perfectly fresh solution
within half an hour of its manufacture will produce the
ophthalmia. The dry freshly powdered jequirity will also
produce the ophthalmia with great intensity.
In jequirity we possess a safe, comparatively speedy,
and efficacious method of treating granular ophthalmia.
To what does jequirity owe its remarkable properties ?
Since Sattler published the results of his experiments it
seems to have been generally agreed that the question was
a settled one. That there existed in jequirity infusion a
bacillus, and that this bacillus produced the ophthalmia,
and that without the presence of this bacillus or its spores
no result followed the application of jequirity. Many
physiologists, notably Cornil and Berlioz,* experimented
on rabbits, guinea-pigs, and frogs, and their experiments
still further confirmed Sattler^s views. I was anxious to
make out for myself something of the life -history of this
ophthalmia. To find at what period of the inflammation
bacilli could be discovered in the secretions from the eye
and in the membrane, and thus to connect their develop-
ment with that of the ophthalmia.
For that purpose in January last I admitted into St.
Mark's Hospital three boys sujffering from well-marked
granular ophthalmia. One application of freshly prepared
jequirity infusion was made to each eye. Six hours after,
when the irritation began to show itself, microscopical pre-
parations were made of the secretion from each eye. Six
hours later slides were again prepared of the secretion and
of the membrane, which by this time had formed. Twelve
hours later similar slides were taken, and so on every twelve
hours till the membrane disappeared, which it did on the
third day. These preparations were stained with gentian
violet and mounted in Canada balsam. I have here to
thank Dr. Keane, the house surgeon at St. Marks, for the
care he took in obtaining the specimens, and for the help
he gave me in preparing the material for this paper.
* * Archives de Physiologie,' Nov. 15th, 1883.
24 DISEASES OF EYELIDS AND CONJUNCTIVA.
My own examination of these preparations of the
discharge and of the membrane failed to discover the
presence of a single one of the typical bacilli. Fearing
that some error of preparation or of observation prevented
my seeing the bacilli that I had so confidently expected
to find, I brought three other boys, all well-marked cases
of jequirity ophthalmia, to the physiological laboratory of
Trinity College, and asked my friend. Professor Purser, to
examine the secretion and membrane for me, which he
kindly did. I subsequently brought down slides from
three others, and had their secretion examined, but in all
these cases also not a single jequirity bacillus could Pro-
fessor Purser find. We therefore came to the conclusion
that they did not exist in the secretions at all or in the
membrane.
An examination of the jequirity infusion itself showed
that when freshly made (as above described) it was free
from bacilli, and remained free for a varying time. I
prepared two specimens of unstrained infusion, in, as I
believe, an exactly similar way, kept them both un-
stoppered in my consulting room at a fairly uniform tem-
perature of 60° F. to 65° F. and examined each night and
morning. In both the characteristic freely moving bacillus
of jequirity appeared only after three days. Some time
later I noted that one of the solutions had not changed
colour, whilst the other had assumed the usual dirty-green
hue which has so often been described. At the end of a
week from the first appearance of bacilli, and ten days
after the manufacture of this infusion, I noted that the
bacilli were entirely motionless, there was a deposit at
the bottom of the bottle, which on being examined was
found to consist almost entirely of motionless, probably
dead bacilli, having all the appearances of those seen in
active motion before. The other infusion still swarmed
with bacilli in most active motion* I kept these infusions
side by side in my room, examining them every now and
again, and invariably the one was green and showed innu-
merable bacilli, in every kind of motion, whilst the other was
JEQUlRlTY AS A THERAPEUTIC AGENT. 25
clear or only slightly opalescent, without a shade of green,
and showed only motionless or dead bacilli lying at the
bottom. After six weeks these two fluids still retained their
respective characters ; the green fluid had, however,
become considerably thickened by evaporation, and rapid
decomposition seemed to be going on in it, as evinced by
a very copious discharge of gas which kept bubbling up
through it constantly. Moreover, it had become inhabited
by a very great variety of micro-organisms.
Pathology. — Wishing to test the efficacy of these two
solutions, each six weeks old, I applied some of the green
infusion to one eye, and some of the clear infusion to the
other eye, of a boy who came for the first time to my
clinique that day. The application was made only once
to each eye. When the boy returned next day the con-
junctiva of each eye was covered with a membrane of
unusual thickness and extent. It occupied the whole of
the conjunctiva, both ocular and palpebral, and could be
lifted off as a whole. The smaller specimen which I
show is from the lower lid of this boy. Microscopical
preparations were made of the membrane from each eye,
but in these too no bacilli could be found. No further
application was made in his case, but the next day he
returned with another membrane formed just as thick
as the first ; this which I show is the membrane raised
off his lower eyelid and the ocular conjunctiva. It will
be seen that it forms a complete cast of the inferior
cul'de-sac, and is unbroken except at the extremities.
A third membrane formed as thick as the previous ; this
I show.
I repeated the experiments with these solutions on the
eyes of a girl, with exactly similar results ; the membranes
formed were, however, not so dense as in the case of the
boy.
The discharge and membrane are non-infedious. — To try
whether jequirity ophthalmia was capable of being con-
veyed by the discharge from one eye to another, I took
a child suffering from a very mild attack of granular
26 DISEASES QF EYELIDS AND CONJUNCTIVA.
opHthalmia^ who had never had jequirity used, and into
her eye I transferred the large fresh membrane that was
formed on the boy^s eye after the first application. I
had the two sitting side by side, so that it was trans-
ferred without a second's delay, hot from his eye, which
was swollen and intensely inflamed, into her eye. Having
placed the transported membrane under her upper lid
I bandaged her eye, covering it with wool to kept the
mass well in contact with the conjunctiva. Next day
I examined her eye, and found absolutely no sign of any
inflammation whatever having been set up by the mem-
brane.
I then again inserted into her eye a large piece of the
second membrane found in the boy's eye, the children
here also being placed side by side, and the transfer being
effected without delay. On this occasion the eye was not
bandaged. The result of this second inoculation was
likewise entirely negative. These experiments seem sufla-
ciently conclusive, and, taken in conjunction with, those
performed elsewhere, show that jequirity cases may with
safety be treated in the same ward with other patients.
Jequirity freshly powdered and sprinkled on the con-
junctiva will produce a well-marked membrane in the
same time as the solution. I ground some jequirity and
put it into a muslin bag which I shook over the conjunc-
tiva of the everted eyelids so as to allow the finest dust of
the jequirity to fall on it. The eye was then bandaged,
and the result was a very thick typical membrane and
well-marked jequirity ophthalmia.
In the ^ British Medical Journal ' of March 1 0th, in a
note on the subject it stated that the active principle of
jequirity was a '^ something which does not exist in the
infusion for a certain time after it is made.'' My experi-
ment disproves this.
Whilst endeavouring to make my observations tally with
those of Sattler, and finding it most difficult, I came
across Dr. Klein's paper in the ' Centralblatt fiir die
medicinischen Wissenschaften ' of February 23rd, in which
JEQUIRITY AS A THERAPEUTIC AGENT. 27
he combated Battler's views regarding the part played by
micro-organisms in jequirity ophthalmia^ and 1 was very
pleased to find that his results were entirely confirmatory
of mine. He found that fresh jequirity infusion without
a trace of micro-organisms (as proved by cultivation
experiments) produced characteristic ophthalmia ; that
the conjunctival discharges contained no bacilli ; that
they possessed absolutely no infective characters, and cul-
tivation experiments with them failed to obtain a crop of
bacilli. He found, further, that the infusion if boiled for
a certain time lost its power of producing ophthalmia, but
did not fail to produce a crop of bacilli, but that these
were incapable of producing ophthalmia. From these he
concluded that the ophthalmia was produced by a non-
organised ferment, something like the pepsin ferments,
which was destroyed by boiling, but that the bacilli were
merely accidental impurities in the infusion.
It seems then that jequirity ophthalmia can be pro-
duced—
1. By the dry jequirity freshly powdered.
2. By the perfectly fresh infusion in which no micro-
organisms exist.
3. By an infusion in which active, recently-produced
bacilli exist.
4. By an infusion in which the bacilli, having been
active, have ceased to move and are presumably dead.
5. By very old (six weeks) infusions, in which an
immense variety of different kinds of micro-organisms
exist.
Sattler states that corrosive sublimate (1 in 10,000) in
a solution of jequirity prevents the formation of bacilli,
but permits a very intense ophthalmia. In other words,
it matters not whether the bacilli or their spores are
present or absent, whether the bacilli if present are alive
and in motion or not, the ophthalmia is the same.
On the other hand, no ophthalmia is produced by —
1. Boiled jequirity solution (although the bacilli can
be grown in it) .
28 DISEASES OP EYELIDS AND CONJUNCTIVA.
2. By the discharge from the eye or the membrane
formed on the conjunctiva.
It would seem^ therefore^ that Sattler's views regarding
the nature of the active principle of jequirity require
modification.
{March I3th, 1884.)
3. On the relation of bacilli to jequirity ophthalmia.
By W. A. Beailey, M.D., and H. W. Pigeon.
The authors showed a series of preparations showing
the development of the bacilli in the infusions of jequirity.
The bacilli began to appear directly the infusion was
made, and went on increasing in number for two days.
They continued abundant till the fifteenth day.
The discharges from the ophthalmia produced by inocu-
lation with recent jequirity infusion were found to contain
bacilli immediately after the inoculation, but the number
of these gradually decreased for four hours, subsequent to
which time no bacilli were to be found without re-inocu-
lation.
The authors concluded that the bacilli found in the dis-
charge were simply those introduced by the inoculation,
and that the bacilli do not grow in the conjunctival sac,
and are not essential to the inflammation produced by
jequirity.
{December Uth, 1883.)
MEMBRANOUS CONJUNCTIVITIS. 29
4. A case of severe conjunctivitis with formation of mem-
hrane on the cornese, caused hy whisky thrown into the
eyes.
By G. A. Brown (Tredegar).
On the 18th of September last (1883) I was called to
see a man, aet. 50, by trade a whitesmith. I found both
his eyes closed, the lids greatly swollen, and a yellowish,
sanious, semi-purulent discharge was escaping from
between them. I had some difficulty in opening the
lids sufficiently to expose the globe, when the corneas
appeared covered in their lower half by a diphtheritic -
looking membrane, which peeled off at its edges, leaving
the surface of the cornea clear, but was firmly adherent
at its central parts. The upper half of the cornea was
clear. The conjunctiva3 were deeply injected but were
nob chemosed, in several places there were slight ecchy-
moses. The man complained of constant and severe
circumorbital pain and great intolerance of light, and
there was considerable constitutional disturbance. I
could get no history beyond a statement that the man
had been drinking heavily, and that the attack had com-
menced suddenly two days before.
I ordered the eyes to be gently syringed every two or
three hours with a tepid solution of boracic acid, and
belladonna fomentations to be constantly applied, and I
prescribed a grain of opium every sixth hour and a brisk
saline purgative in the morning.
The following day the man was much easier, the dis-
charge had diminished, the swelling of the lids was less,
and the membrane was still further loosening at the
edges. By the third day of my attendance the cornea)
had become clear, but the injection of the conjunctivae
and the ecchymoses were present for a few days longer,
together with some photophobia. At the end of a fort-
night, however, the man had completely recovered.
30 DISEASES OP EYELIDS AND CONJUNCTIVA.
He subsequently confided to me that his wife, irritated
by his continual intemperance, had thrown a glass of neat
whisky, which he was about to drink, into his eyes, and
had thus caused the state of things above described.
(March ISth, 1884.)
5. Peculiar conjunctival affection.
By Anderson Critchett and Henry Juler.
Hannah H — , aet. 50, married ; health good. Nine
months ago she had an attack of ^' cold in the eyes "
accompanied by gritty sensation, muco-purulent discharge,
and redness of the conjunctiva. Since then the eyes have
never been quite well, but during the last six weeks the
right eye has steadily become worse.
Present condition. — Bight eye : the whole fornix con-
junctivae is greatly thickened so that both the upper and
lower cul-de-sac are almost obliterated, and the upper lid
cannot be everted. The ocular and palpebral conjunctivae
are also thickened and congested. The central three
fourths of the cornea are clear and unaffected, but at the
circumference the conjunctival layer is seen to be thickened
and opaque. Y. = ■^. Left eye : the cornea is unaffected.
The ocular and palpebral conjunctivae are slightly con-
gested, but that of the upper cul-de-sac is becoming
similarly thickened to that of the right eye. V. = ^.
{December I3th, 1883.)
BONY TUMOUR OP CONJUNCTIVA. 31
6. Papilloma of the conjunctiva.
By Andeeson Critchett and Henry Juler.
The patient is a healthy girl, aet. 14. Vision normal.
For some five years a small reddish mass has been noticed
near the inner canthus of the right eye. This has steadily
increased to its present dimensions. It has never given
rise to any pain, and now only causes occasional discom-
fort. The growth consists of a fleshy-looking mass,
similar in colour to the caruncle. It is about 2 cm. wide
and 4 cm. thick. It occupies the inner half of the palpe-
bral sac, being situated between the lower lid and the
globe. The greater portion of its surface is free and
moveable, whilst its base is firmly adherent to the lower
cul-de-sac. When the eyelids are closed the free edge of
the growth just protrudes through the inner portion of the
palpebral fissure.
{December ISth, 1883.)
7. Bony tumour of conjunctiva {microscopical section).
By Simeon Snell (Shefiield).
Florence W — , aet. 13, was admitted into the SheflBeld
General Infirmary on September 30th, 1882. Her mother
informed me that since earliest infancy she had observed
in the right eye ^^ a piece of skin,'^ which protruded when
the child turned the eyes to the left. There had been no
complaint of pain, and no notice was taken of the con-
dition mentioned, until a few weeks previous to coming
under my care, since which time it has appeared to have
increased in size and has become more inconvenient.
Examination disclosed a tumour situated beneath the con-
32 DISEASES OP EYELIDS AND CONJUNCTIVA.
junctiva, between tlie cornea and the external canthus,
and somewhat under cover of the upper eyelid. It was
more distinct when the eye was turned inwards. It was
about the size of an almond or less, and felt hard at the
centre. On October 2nd the conjunctiva was divided and
the growth readily removed ; the wound was closed by
sutures. On the 6th she left the infirmary.
The growth consisted of adipose and fibrous tissues,
with a central hard nucleus about the size of a large pea ;
it was surrounded by a fibrous covering (periosteum).
Dr. J. B. Story, of Dublin, kindly made for me the
beautiful section of the hard nucleus which I show this
evening. It is an excellent example of true bone. It
presents Haversian canals, lacunae, and canaliculi of
typical character.
The presence of a tumour containing true bone in the
situation of the case related must be very rare. Mr.
Anderson Critchett, in the ^ Transactions,' vol. ii, relates
a similar case, which he deemed unique. Mine closely
resembles his in its situation, and in probably being
congenital.
{July 4th, 1884.)
The prevention of blindness from ophthalmia neonatorum.
At the March meeting of the Society, in consequence of
a communication by Dr. David McKeown, of Belfast, a
committee was appointed consisting of the President, Mr.
Frederick Mason, Dr. C. E. Fitzgerald, Dr. Argyll
Eobertson, Mr. Brudenell Carter, Mr. Priestley Smith,
Mr. Tweedy, Mr. R. Marcus Gunn, Dr. David McKeown,
and the Secretaries, to investigate as far as possible the
relative frequency of blindness from ophthalmia neona-
torum in this country. At the June meeting the Committee
presented the following report which Avas duly adopted.
It should be added that the resolutions are substantiallv
PREVENTION OF BLINDNESS FROM OPHTHALMIA NEONATORUM. 33
the same as the ones originally proposed by Dr. D.
McKeown.
In answer to a very large number of inquiries from
private persons^ opbthalmic and lying-in hospitals, and
from institutions for the blind, we have received twenty-
three statistical replies, all of them from institutions for
the blind.
Four of these, viz. those of the Belfast Deaf, Dumb,
and Blind Institution, the London Society for Teaching
the Blind to Read, the Blind School at York, and the
Blind Institution at Hull are decidedly superior, being
tolerably explicit. Moreover, the answers appear to us
from other evidence to be trustworthy. In the first
(Belfast), 30 per cent, of the persons concerned owe their
blindness to ophthalmia neonatorum. In the second (the
London Society, &c.), 20 per cent, are certainly blind from
this disease, but from the extremely frequent occurrence
of " congenital cataract ^^ and " cause unknown ^^ in cases
of blindness from birth, we are of opinion that at least
another 10 per cent, should be added, thus making again
30 per cent. In the third (the Yorkshire School), 41 per
cent, are blind from this cause. And in the fourth, that
at Hull, five cases out of fourteen personally examined by
Dr. Rockliffe, 35 per cent., are with certainty attributable
to the same disease.
The statistics of the other institutions are so inexplicit
as to be of little direct value, but their figures, so far as
they go, point to about the same results. It will be
observed that these numbers agree substantially with those
of foreign investigators, notably those of Reinhard, who, on
investigation of twenty-two German blind asylums, found
658 blind from this disease among a total of 2 165 = 30 J
per cent.
The Committee also recommend the adoption by the
Ophthalmological Society of the following resolutions,
which they have slightly modified from those originally
suggested by Dr. David McKeown.
VOL. IV. 3
34 DISEASES OF THE EYELIDS AND CONJUNCTIVA.
(1) That the purulent ophthalmia of newborn infants
being the cause of a vast amount of blindness, mainly
because of the ignorance of the public regarding its dan-
gerous character and the consequent neglect to apply for
timely medical aid, it is desirable to instruct those in
charge of newborn children by a card, in substance as
follows :
Instructions regarding newborn infants. — If the child^s
eyelids become red and swollen, or begin to run with
matter, within a few days after birth, it is to be taken
without a day's delay to a doctor. The disease is
very dangerous, and, if not at once treated, may destroy
the sight of both eyes.
This to be distributed through the medium of the Poor-
law and Birth Registration organisations of the United
Kingdom. In England the Relieving Officer, and in Scot-
land the Inspector of the Poor should, in every case of
labour under the Poor-law system, read to and leave with
the person obtaining the order for medical aid, or the
persons in charge of the patient, a copy of the card. In
Ireland the card should be attached to the order for
medical aid in such cases, and the person who gives the
order and card should, before doing so, read the card to
the applicant. The Registrar of Births should read and
hand to each person registering a birth a copy of the card.
(2) That the advocacy and aid of the medical press be
solicited in drawing general attention, and especially that
of the authors of text-books on midwifery, of the lecturers
on the same subject for students and midwives, and of the
various institutions which train, and charitable institutions
which employ midwives, to this important subject.
(3) That a copy of the first resolution be forwarded to
the respective Presidents of the Local Government Boards
of England and Ireland, and of the Board of Supervision
in Scotland, and such other persons, if any, as may be
necessary, and that a deputation be appointed to wait upon
the said Presidents and other persons, if necessary, and
urge upon them the official adoption of the views therein
PREVENTION OP BLINDNESS FROM OPHTHALMIA NEONATORUM. 35
expresed, and to take sucli other steps as they consider
necessary.
Signed, Fredk. Mason,
Chairman of the Committee,
This report having been adopted, the following
members of the Society were appointed to take charge of
the report, in accordance with Resolution 3, viz.. Sir
William Bowman, Bart., F.R.S. ; Mr. Jonathan Hutchin-
son, F.R.S. ; Mr. Brudenell Carter, Mr. Tweedy, Dr.
David McKeown, and the Secretaries.
On the motion of the President, a vote of thanks was
accorded by acclamation to the Committee who had drawn
up this report, and to the representatives of the Obstetrical
Society who had given valuable aid to that Committee.
36
II. DISEASES AND TUMOURS OF THE ORBIT.
1. Case of pro ptosis, first of one and then of the other eye, in
association with enlargement of various glands.
By Jonathan Hutchinson, F.R.S.
Mr. S — , a Hindoo barrister, came over to England in
September, 1882. I saw him in consultation with his
brother, who was a surgeon, on the day after he landed.
His right eye had been lost by inflammation after an
operation for the removal of an orbital tumour, and his
left eye was now in a condition of extreme proptosis.
The lower lid was everted, and the whole of its mucous
membrane exposed. The prominence of the eyeball and
the e version of the lid were very much greater than they
are shown in the photographs, as these were not taken until
about two months after the commencement of treatment.
Mr. S — believed that the condition of his left eye was
now almost exactly similar to that of the right at the
time the operation was performed. It is to be noticed
that the proptosis was decidedly downwards. The move-
ments of the eye were not much interfered with, but there
was much conjunctival congestion and chemosis. The
edge of the lacrimal gland, greatly enlarged and very
firm, could easily be detected on a level with the upper
margin of the orbit. On careful examination I could not
feel certain of the existence of any definite tumour-growth
in other parts of the orbit.
The upper eyelid hung rather loosely, but it was of
course quite impossible to close the lids. There was a
general puffiness of the whole of the face, especially in the
parotid region and under the jaw. The subcutaneous
PRO PTOSIS WITH ENLARGEMENT OF GLANDS. 37
cellular tissue and fat being abundant definite examination
was rendered difficult.
Mr. S — brought with him an excellent narrative of his
case^ written out by Mr. Cayley, of Calcutta, who had
attended him there, and by whom the operation had been
performed. It appeared that Mr. S — had always had
full eyes, and that about three years ago it was for the
first time noticed that his right eye was rather more pro-
minent than the other. There was, however, nothing
that was inconvenient or unsightly until about two years
later, when the prominence had very greatly increased,
and a firm tumour could distinctly be felt in the region of
the lacrimal gland. Subsequently another growth was
recognised in the lower part of the orbit. There was
little or no pain, and Mr. S — was in his usual health.
By degrees the eyeball was so much pushed out that the
lids would not cover it. Mr. Cayley's notes state that
the cornea had begun to look steamy, and the sight was
somewhat affected. In April, 1882, an operation was
performed, and the external can thus having been freely
divided, the lids were dissected up and down, and first
the lacrimal gland removed and next a firm lobulated
mass, which occupied the outer and lower part of the orbit
and adhered firmly to the periosteum. As far as could
be ascertained, the whole mass was got away, and without
injuring the eye or its muscles.
For a few days after the operation sight remained good,
but eventually suppurative inflammation of the orbit
ensued, the eyeball was again pushed out, and the cornea
sloughed. After this the remains of the eyeball col-
lapsed and receded, no fresh growth in the orbit taking
place. The tumours removed were examined by Dr.
MacConnell, the pathologist of the Calcutta Medical Col-
lege, who described the one as glandular and developed
from the lacrimal gland, the other as composed of fibro-
adipose tissue, the fibrous elements preponderating ;
("delicate, nucleated, fibro-elastic filaments ^^).
Such was the history of the eye which had been first
38 DISEASES AND TUMOURS OP THE ORBIT.
affected and which was now lost. It is to be especially
noted, as bearing upon the nature of the new growth, that
there had been no recurrence, the condition of the parts
in the orbit being much as is usual after suppuration of
the eyeball from any other cause. At the time that the
operation was performed there was no reason to suspect
anything amiss with the left eye, but within a week
Mr. S — was alarmed by finding that it was taking on
exactly the conditions which had been observed in the
first stages of the right. It became prominent for a time
and then receded, and then became prominent again.
He now determined to come over to England for advice,
and left Calcutta on July 22nd. During the voyage the
proptosis very greatly increased.
The condition of things at the time that he landed I
have already described. It was sufficiently alarming, and
Mr. S — was in great distress, regarding the loss of his
remaining eye as almost inevitable. On the most careful
examination I could detect nothing in his general health
nor elicit any facts in his personal or family history which
threw any light on the na,ture of the disease. He had
worked hard in his profession, but had always enjoyed
fairly good health. The proptosis, although attended by
some difl&culty in breathing, had not been associated with
headache, nor as yet with any material diminution of
sight.
As the result of the operation in the other orbit had
not been encouraging, I decided to try, for a time at any
rate, other measures. Mr. S — was admitted into Fitzroy
House, a hospital home, and was treated by the sedulous
application of ice over the forehead, the eye itself, and to
the back of the neck. He also took six grain doses of
iodide of potassium. Within a week a very considerable
improvement had taken place ; the eyeball was less pro-
minent, the swelling of the conjunctiva less, and the
lacrimal gland not so easily felt. The same measures
of treatment were persevered with for about a month,
when the recession of the eyeball was such that he could
PROPTOSIS WITH ENLARGEMENT OP GLANDS. 39
close the lids. It was at this stage that the photograph
was taken.
There was stilly however, a roll of everted mucous
membrane visible below. At this time Mr. S — was
allowed to go out, and the use of the ice was much inter-
rupted ; for a week also he omitted the iodide. A relapse
took place, and the border of the lacrimal gland again
came prominently forward. I now suggessed a consulta-
tion with Mr. Bowman and Mr. Nettleship, and this took
place in the early part of November. It resulted in an
increase of the dose of the iodide and the addition of
small doses of mercury.
It should have been stated that before this I had dis-
covered that the edges of the parotid gland on each side
could be distinctly felt, projecting as a firm lobulated
mass forwards on the masseter. The edge of these glands,
although not quite so hard, was to the touch remarkably
like that of the lacrimal gland. There was also some
enlargement of the lymphatic glands on both sides of the
neck. The result of the more vigorous treatment was as
satisfactory as it had been in the first instance, and my
note on December 6th states that the eye had receded so
that he could again quite close the lids, that the lacrimal
gland could be discovered only by deep pressure, and that
both the parotid and the lymphatic glands were very much
reduced in size. Mr. S — at this time appeared quite
well and was accustomed to take much exercise.
A month later he returned to Calcutta. The eyeball at
this time had receded almost to its natural position, but
there was still a narrow rim of everted mucous mem-
brane visible between it and the lower lid. He was to
continue the iodide and increase the dose if threatened
with relapse.
In attempting to investigate the nature of this remark-
able case, we must remember that amongst the conditions
which were demonstrable was the enlargement of glands of
three different functions, a salivary gland (the parotid),
the lacrimal gland, and the lymphatics of the neck. In
40 DISEASES AND TUMOURS OP THE ORBIT.
each instance tlie enlargement was firm and fleshy, quite
painless, and without tendency to inflammation. The
increase in size of the lacrimal gland, although coincident
with the proptosis, certainly did not cause it. The gland
ovei^hung the eyeball and was moveable on it. We are
driven therefore to the belief that there must have been
some swelling of the fibrous or fatty contents of the
orbit which caused the prominence of the globe. What-
ever it was it appeared to be capable of spontaneous dimi-
nution and prone to relapse, and to be, as well as the
enlargement of the several gland structures, definitely
under the influence of the iodide of potassium.
Remembering the degree of recovery which took place
and the fact that there has been no fresh growth in the
right orbit, it is not possible to entertain the suspicion of
malignant disease. My impression is that the case should
be placed in the same group with certain rare examples
of the symmetrical formation of ill- defined but more or
less lobulated masses of fibro-fatty tissue in the region of
the neck. This affection was, I believe, first well described
by Brodie. I have seen several examples of it, and Mr.
Morrant Baker has reported a series of cases in the ^ Trans-
actions of the Clinical Society,^ and has very carefully
investigated its nature. In several cases portions of these
tumours have been excised and demonstrated to consist
of fibrous and fatty tissue. But in at least one case
under my own care there appeared reason to suspect that
the case was complicated by adenoma, death ensuing
with symptoms of intra-thoracic disease. I have never
as yet in any of these cases observed the symptom of
proptosis, nor witnessed enlargement of the lacrimal
gland, but in a case which was sent to me recently by
Mr. G-eorge White, of Hackney, the parotids were enlarged
in exactly the same way as has just been described in the
case of Mr. S — .
In this instance, the patient, a man aet. 40, had huge
symmetrical masses on the back of his neck and under
his jaw, whilst in each forearm near the elbow there were
PEOPTOSIS W[TH ENLARGEMENT OP GLANDS. 41
several of the common subcutaneous fibro-fatty tumours .
I show a photograph of this patient.
I excised a portion of one tumour and proved that it
consisted of fat. It is to be clearly recognised that in
these cases the condition is one not of new growth, but of
hypertrophic development. The fatty masses are con-
tinuous with the subcutaneous fat. They are, however,
remarkably local and are not coincident with any marked
tendency to general obesity. In the case first mentioned
they were associated with isolated fatty tumours in the
forearms.
It seems probable that we ought to widen our views of
this group of affections and not too much restrict concep-
tion of its features to the typical and more common cases
described by Brodie and Mr. Morrant Baker. In these
the patients are almost always men, and the fatty out-
growths occur at the back of the neck. In women, if I
mistake not, there is a parallel affection in which the fat
accumulates not at the nape, but deep in the root of the
neck. The cases which I have cited prove that in some
instances there is with the tendency to local fat hyper-
trophy a liability to increase in size of glands. Perhaps
on closer examination we may find that this conjunction is
the rule instead of the exception. Very probably the
apparent increase in the size of the glands is due rather
to overgrowth of interlobular fat and cellular tissue than
to increase of gland elements. This would explain why
we find glands of very different functions simultaneously
affected. There may be cases — and I think I have seen
some — in which general hypertrophy of glands of the same
nature occurred without any form of fatty outgrowth ; for
example, symmetrical hypertrophy of the parotids. The
physical cause of the proptosis in Graves' disease is not
well understood, and in many cases it appears to be in
part at least hypertrophy of fat. This singular malady
may possibly be a member of the same family group.
It is to be noted that some of the cases of the Morrant
Baker type are accompanied by very marked disturbance
42 DISEASES AND TUMOURS OF THE ORBIT.
of nerve functions. The man whose case I have men-
tioned was excitable to the verge of insanity. It is to be
noted further that these fatty outgrowths are liable to
remarkable alterations in size in connection with the state
of health and mode of life of the patient. Mr. Baker
has observed that they usually happen to be heavy beer
drinkers and are benefited by abstinence. I can corrobo-
rate this observation, and may add that I have known
definite reduction of size from change of air from London
to the country.
I fear it may be thought that I have entered upon a
disquisition which is surgical rather than ophthalmic.
It must be remembered, however, that my aim has been
to discover the nature and probable cure of a malady
which is special so far that it leads to destruction of the
eyes, but which probably in all its relationships outsteps
the domain of the ophthalmologist.
{July 3rd, 1884.)
Dr. Stephen Mackenzie remarked that he was very much
interested to hear towards the close of Mr. Hutchinson's
paper some remarks on Graves' disease in which he
appeared to trace some relationship between his case and
that disease. He would like to ask Mr. Hutchinson
whether any change was found in the thyroid body or any
pulsation of the vessels of the neck, or whether palpitation
or evidence of disturbance of the heart's action or rhythm
had been observed. Of course, it would not be con-
tended by anyone that Mr. Hutchinson's case was a
characteristic example of Graves' disease, but it seemed to
have certain alliances with that disease. It was a point
on which there was now a general agreement that the
immediate cause of the proptosis in Graves' disease, or
the anatomical condition that was associated with it, was
an overgrowth of the orbital fatty and connective tissue.
But this was not the primary cause that led to the prop-
tosis, there being an antecedent vascular disturbance
which led to this overgrowth by over- supply. Now, the
PROPTOSIS WITH ENLARGEMENT OF GLANDS. 43
application of ice to the neck was known to have a
remarkable influence not only on the swelling and vascular
excitement at that part in Graves' disease^ but in dimi-
nishing also the proptosis. It was therefore a point of
much interest in Mr. Hutchinson's case that the proptosis
subsided in a great measure in the first instance on the local
application of ice. It was true that iodide of potassium
was at the same time administered in small doses. The
impression conveyed to his mind was that Mr. Hutchin-
son believed at the time that the ice was the active agent
in reducing the swelling. It was therefore important to
ascertain from Mr. Hutchinson what was the small dose of
iodide of potassium administered in the first instance, and
to what extent this was augmented. Mr. Hutchinson had
drawn attention to the fact that several glands with quite
different functions underwent enlargement in his case.
In Graves' disease, whether it was regarded as a disease
of the central nervous system, the brain or spinal cord, or
of the cervical sympathetic nervous system, there was, in
any case, a widely- spread vascular disturbance, and it was
readily conceivable that in Mr. Hutchinson's case a widely-
spread vascular disturbance of nervous origin was the
cause of a simultaneous enlargement of glands functionally
disassociated.
Mr. Eales (Birmingham) was much interested in the
case described by Mr. Hutchinson, as he had a case,
which appeared to be precisely similar, under his care at
the present time, and which he had thought almost if not
quite unique. It was that of a man, aged about 45 years,
who had for many years worked as a puddler at a glass
furnace, who came to the Eye Hospital some weeks ago
in consequence of a rapid protrusion of both eyes, accom-
panied by headache. On admission there was consider-
able exophthalmos of both eyes, most marked on the left
side, much conjunctivitis, and considerable chemosis —
moreover, the lacrimal glands were found remarkably
swollen, and protruded forwards under the cartilage of the
upper eyelid. The left side of the face, which was most
44 DISEASES AND TUMOUES OP THE OEBIT.
exposed to tlie fire, presented tlie results of chronic
scorching. Both optic discs were of a rosy pink hue and
the retinal vessels were larger and more numerous than
is usual, but there was no effusion on the papilla. He
(Mr. Eales) considered the condition of the fundus oculi
rather as the result, the man being constantly before the
fire, than a new condition associated with the proptosis ;
as this appearance was often found in puddlers and
remained unaltered for several weeks. In the present
case, though all the other symptoms had considerably sub-
sided under treatment by iodide of potassium, vision was
unimpaired.
Prof. Beockman (Madras) inquired what nationality Mr.
Hutchinson's patient belonged to. Elephantiasis, he said,
was common amongst the Eurasians, and not infrequently
was accompanied by proptosis. In these cases mercury
and iodide of potassium were useful. Possibly Mr,
Hutchinson's was a case of this nature.
Mr. Hutchinson, in reply, said that his patient was of
the Indo-European stock, that is, a Hindoo. He did not
believe, however, that either race or locality afforded any
explanation of the disease, for it had appeared quite as
exceptional to the distinguished surgeons who had seen him
in Calcutta as it had to himself. He had carefully ques-
tioned the patient on this point, and he stated that he had
never heard of any Hindoo who had suffered in a similar
manner. It was not desirable to connect the case too
closely either with Graves' disease or with the symmetrical
fatty outgrowths which were associated with Mr. Morrant
Baker's name ; whilst it had features of resemblance
to both it differed from them both in some important
particulars.
Thus, the patient had never suffered from palpitations,
nor displayed any nervousness or irritability of temper, as is
usual in the former, nor had he any enlargement whatever
of the thyroid. From the fatty outgrowth type the case
differed in that there were no fatty growths on the nape of
the neck, whilst proptosis was a symptom which had, ho
ORBITAL TUMOUR. 45
believed, not yet been observed in any case of this
class.
In spite, however, of these important differences, it
was, he thought, of much interest to place these several
maladies together as individual members of the same
family group. There were certain cases in women, usually
in those a little past middle age, which, were characterised
by the development of ill-defined fatty lumps symme-
trically placed deep in the neck. These were, he believed,
almost always attended by nervousness and irritability,
and were liable to remarkable variations in connection with
change of air and varying states of health. Cases of the
Morrant Baker type almost invariably occurred to men.
It might be suggested that something of the nature of
vaso- motor disturbance favouring local hypertrophies was
the bond of connection between the different members of
a family group which, he had tried to constitute. This,
however, was conjecture, the important practical point
being that the local use of cold seemed to be of great
value in controlling them. It was his knowledge of the
value of cold in G-raves' disease which had in part induced
him to use it in the present instance.
In reply to those who had asked whether he thought
that the cold or the iodide of potassium had been the chief
agent in tbe cure, he must say that it was impossible to
speak with confidence. He felt no doubt that both had
helped. The dose of iodide had never exceeded fifteen
grains every four hours.
2. Orhital tumour {sarcoma?).
By A. Emrys- Jones, M.D. (Manchester).
Mary C — , aet. 50, was admitted to the Manchester
Eye Hospital on June 2nd, 1883. Sbe received a blow
46 DISEASES AND TUMOURS OP THE ORBIT.
over the right eye twelve years ago. For the last two and a
half years the eye has '^ watered occasionally and has been
puffed up from time to time.'' She noticed at this period
that the right eye was at a lower level than the left. Her
general health has been excellent and her family history
good.
Eight eye pushed down ; no exophthalmos ; ciliary
border of right eyelid a quarter of an inch lower in level
than left. On digital examination of upper lid, an elastic
lobulated tumour can be felt below the upper border of the
orbit, extending deep into the orbit.
Motion upwards diminished. Vision |-. Media of eye
normal. Left eye normal. A longitudinal incision about
an inch and a half long was made over the tumour and
the tissues were carefully dissected and as much of the
growth removed piecemeal as possible, numerous adhesions
to the bone being found. The wound healed by first
intention and movements upwards became more free.
On August 11th, nodular growth distinctly felt in same
position. A similar incision was made and growth again
removed ; wound healed satisfactorily.
She complained of severe pain over the right eye and
some hard glands could be felt in front of lobe of right
ear, and at present (December 13th) some small hard
glands can be felt in front of sterno-mastoid muscle in
the neck, and patient looks yellow and cachectic. The
tumour has not grown much lately.
My friend. Professor Drescbfeld, reports that, microsco-
pically it is composed entirely of small round cells with
large granular nuclei, some fine embryonic blood-vessels
filled with blood-corpuscles. He thinks it must be a
sarcoma, and he says if it had occurred in the retina he
would call it a glioma on account of the close resemblance
of the cells to glioma cells. No glandular structures can
be detected, although from its position it is probably
connected with the lacrimal gland. In some respects it
resembles Mr. Power's case described in page 253 of the
second volume of the Society's * Transactions,' but it seems
Trans. Oplith. Soc.Vol.iy.Pl. 1-
Fxq. 2.
^-^// ^-
/:/'i;ni ''■''■'''
Fxa. 1.
West Newman *G° chr iuh
DESCRIPTION OF PLATE I.
Fig. 1 illustrates Mr. Nettleship's case of Lymphatic Nsevus
of Orbit, &c. (p. 47).
The figure shows, moderately well, the tortuous, beaded vessels, filled by
clear yellow fluid, which were present on the outer and upper part of the
eyeball. From a drawing by Miss Boole.
Fig. 2 illustrates Mr. Nettleship's case of Glaucoma with
Retinal Haemorrhages (p. 108).
The haemorrhages are confined to the lower half of the retina, and the
corresponding retinal vessels are so small as to be for the most part invisible.
The specimen had been placed in strong alcohol immediately after enuclea-
tion. The drawing (enlarged about twice) was made by Miss Boole.
N^VUS, WITH LAMELLAR CATARACT. 47
to be of a decidedly more malignant type from its greater
proneness to recur.
{Living sjpecimen, December l^th, 1883.)
P.S. — July 29tli, 1884. — I saw the patient again to-
day. There has been no recurrence of the growth, and
» her general health has improved.
3. NxviiSj ? lymijJiaticy affecting the brow, orbit, and exterior
of the eyebally with lamellar cataract. No cataract in
the other eye.
By E. Nettleship.
(With Plate I, fig. 1.)
Michael D — , aet. 15, presents a large, partly degene-
rated, subcutaneous naevus, affecting the temporal part of
the right brow and the cavity of the orbit ; the eye is
considerably protruded, but its movements are free ; the
cornea is obviously smaller than that of the other eye.
In the upper-outer part of the ocular conjunctiva a
number of tortuous, beaded vessels of large size and filled
with clear, yellowish fluid, were visible when he first
applied for advice at the Moorfields Hospital (January,
1884). These vessels (tolerably well shown in Plate I,
fig. 1) are, for the most part, situated at some distance
from the cornea, and are probably dilated lymphatics.
The lower part of the ocular conjunctiva (not shown in
the drawing) was, on admission, in a state of translucent,
semi-solid, yellowish oedema, but showed no distinct
vessels.
It seems probable that the mass of the nasvus is com-
posed, partly at least, of dilated lymphatics like those seen
on the eyeball ; but that it also contains blood-vessels with
48 DISEASES AND TUMOURS OF THE ORBIT.
thin walls is proved by the fact that on one occasion
the swelling became a good deal ecchymosed after it had
been handled.
The pupil of the corresponding eye is considerably
smaller than that of the left ; it becomes larger when
shaded, but does not dilate to the normal extent under
atropine. A well-marked lamellar opacity of moderate
size is seen in the lens. So far as can be made out the
fundus shows nothing unnatural ; but there is marked
enlargement and tortuosity of the anterior ciliary vessels
over the insertion of the internal rectus. Vision =
fingers at 18''.
There is a large pigmented patch of skin (mole) on the
lower part of the neck on the same side behind the
clavicle.
The left eye is normal in all respects ; its lens clear ;
V. = It, H. m., ID.
March ISth, 1884. — The network of lymphatics is now
seen to extend all round the globe at a distance from the
cornea ; probably it was in the same condition before^ but
the oedema of the lower part, which has now disappeared,
obscured the then state.
{Living specimen. March ISth, 1884.)
49
III. INTRA-OCULAR TUMOURS.
1. Two cases of retinal glioma^ in one of which shrinMng
of the eyeball occurred without perforation.
By Simeon Snell (Slieffield).
Case 1. — R. H. T— , a little boy aged about 18 montlis,
was brought to me at the Sheffield General Infirmary on
April 13th^ 1877. The mother stated that when nine
months old the child had a " fit " and was ill for a fort-
night ; again, at twelve months, he had an attack of
" congestion of the brain/' and he was subsequently ill in
the same way. After the first illness he was noticed to
be losing his sight, but his parents observed nothing
wrong in the appearance of the eyes ; later on, the left
eye had become enlarged.
At the time of his coming under my notice there was
a yellowish-white deposit situated in the interior of each
globe at its posterior part. This appearance was much
more marked in the left than in the right eye, which
was also somewhat increased in size. The diagnosis
formed at this time was that the case was an instance of
strumous deposit in the eye (pseudo-glioma). The
immediate development of the case appeared to support
this view. It was decided for the present to watch its
progress.
During the next three months the left eye increased
.much in size, the globe became filled with the deposit,
the iris was infiltrated, and exudation appeared in the
anterior chamber. The eyeball next began to soften and
shrink, but at this time (September 14th, 1877) it was
noticed that the right eye, which had remained almost
VOL. IV. 4
50 INTEA-OCULAR TUMOURS.
I
quiescent^ its condition having altered but little since
first observed^ now commenced to go through apparently
the same stages as the fellow organ. Instead^ however,
of beginning to soften and shrink like the left, after having
reached a similar point, its course was very different.
On February 13th, 1878, it is stated that the right globe
was enlarged, there was exudation in the anterior chamber,
and the pupil was opaque looking. Again, on April 8th
— and the patient had not been brought to me between
these dates — the eyeball had so increased in size as almost
to fill the orbit, the cornea was destroyed in part, and
there was a tendency to fungoid protrusion. Removal of
the globe was advised and the eyeball was excised at the
date just given. Section of the eye showed it to be com-
pletely filled with a growth which, examined microscopi-
cally, left no doubt as to its gliomatous nature. ■
In a few weeks the disease had returned in the orbit,
and after filling this cavity appeared on the cheek, forming
a tumour as big as a large orange. The patient died
from exhaustion on August 28th, 1878.
A post-mortem examination was made the next day.
It was limited to the head. The left orbit contained the
merest stump of the globe. The tumour was traced into
the right orbit and found to be continuous with the optic
nerve. There was considerable emaciation of body.
Case 2. — Early in 1877, a little baby, Sarah D — , aged
about 8 months, was brought to me on account of a
peculiar appearance the parents had noticed in her eyes.
The child had had no " fits.^^ Since she was three months
old attention had been directed to her eyes, but the father
recently in playing with her had particularly noticed a
" shining '' in the right eye. When brought to me, in
the interior of the right eye at its posterior part was a
whitish-looking growth (?) and vessels were distinctly
traced over its surface. A similar appearance, though
very much less developed, was noticed in the left eye.
The diagnosis made was glioma in both eyes, and in this
RETINAL GLIOMA. 61
opinion my esteemed friend, Mr. Gillott, who saw the
case, concurred. The right eye was blind, but in the
left a measure of sight remained. The patient was
admitted into the Sheffield General Infirmary, and on
February 25th, 1877, the right eyeball was excised.
My friend. Dr. Dyson, was good enough to examine
with me the growth in the interior of the excised globe
with the microscope. As the result of the examination
we were lead to hope it was not gliomatous but rather
caseous tubercular matter with calcareous concretion.
The child remained under observation for some time and
then the mother ceased attending at the Infirmary with
her. Three years later, however (April, 1880), she was
again brought to me in consequence of the altered con-
dition of the remaining eye. After the excision of the
right globe, the child had been able to see big objects,
and up to about two years of age could play with her
toys. For the last three months especially the eye had
been getting worse, and quite recently its progress had
been rapid. Now the interior of the globe was filled
with the growth. On April 19th the left eyeball was
enucleated.
Dr. Dyson also in this instance kindly gave me his
valuable assistance in the microscopic examination of the
contents of the removed eyeball. The gliomatous nature
of the disease was readily recognised.
After a short time the patient ceased to attend,
and it was not until the succeeding March (1881) that
I again saw her. My attention was directed to a promi-
nence on the forehead a little above the left eyebrow.
It was not larger than a walnut and it had been noticed
only for a few weeks. The parents had observed it first
when no bigger than a pea. There had been no return of
disease in the left orbit, and the right remained, exactly
as it had done since the enucleation of the globe four years
and a half previously, perfectly healthy. The tumour on
the forehead rapidly increased in size, and by the early
part of May was larger than an orange.
52 INTRA-OCULAR TUMOURS.
On July 15tli it measured nine inches across and seven
inches from above downwards. Its limits on the right
were more defined, but on the left it extended gradually
into the temple as far as and above the ear ; the left
upper lid was drawn out and somewhat involved, and the
growth reached well down the nose. Large veins coursed
over its mottled and distended surface.
On September 2nd the measurements of the tumour
were fifteen inches across by thirteen vertical, and there
had been some bleeding from one of the veins over the
left orbit ; this recurred at different times, and the surface
towards the inner side* became more or less ulcerated.
The patient died on September 28th.
Permission to remove the tumour for preservation was
granted. It was found firmly attached to the bone, which
was honeycombed and sent numerous bony spiculse into
the substance of the growth. The frontal bone was
densely thickened at some parts and very much thinned
at others. During a change of house surgeons the specimen
became lost.
It must be mentioned that the parents stated that
the child received a blow on the forehead before the
formation of the tumour in that situation.
The cases I have related are not as complete in some
particulars as one would have liked, but I believe they
are of interest and worth placing on record.
The first one would appear to be rare ; at least I cannot
find a precisely similar one recorded. When the patient
was first seen the diagnosis was by no means easy, but after
short observation the appearances seemed more in accord
with those one is accustomed to associate with strumous
deposit, pseudo-glioma. The subsequent shrinking of the
left eye, and that without perforation, apparently confirmed
the diagnosis. The development, however, in the right
eye ultimately of unquestioned glioma with the return of
ths disease, naturally calls in question the accuracy of
the opiition formed in the first instance. It will be
admitted that the left eye underwent the changes expecteil
RETINAL GLIOMA. 53
of it, if the disease were one of the varieties described
under the term pseudo-glioma, and it may be added that
up to a certain point the processes in the two eyes were
identical. It may be regarded as possible that, in the right
eye, the glioma was engrafted on such a condition as the
diagnosis would indicate. Sarcomata, it is well known,
are in a similar manner met with in eyes damaged by
injury or disease, as well as in other regions.
On che other hand, it is possible, looking at the case
with the after-history before us, to regard it from the
outset as glioma with an unusual course. I have never
seen a glioma present the appearances this case did at the
commencement of the attendance. Temporary shrinking
has sometimes been reported in glioma.
Dr. Brailey tells me of a case of his in which a semi-
shrunken globe was filled with degenerated glioma. Such
an amount of shrinkage, ultimately to a mere button, has
not, I fancy, been previously reported in a gliomatous
eye. It is to be regretted that at the time the remains
of the left globe were not examined microscopically.
Atrophy of malignant growths, it is well known, is met
with in other regions. I extract the following quotation
from ' Bryant's Surgery ' : '^ In rarer cases, the cancer
withers ^ atrophic cancer,' the disease slowly progres-
sing to a point and then disappearing by a gradual process.
In this way cancerous tubercles will appear and disappear,
cancerous nodules will form and fall oJff by the contraction
of their own fibres. In this way cancer may become
cured or so stationary as not to interfere with life.''
It appears to me that opinions may well differ on these
hypotheses. Perhaps the latter will be more readily
accepted, and I may add that Dr. Brailey takes such a
view of the case. My thanks are due both to him and
Mr. Nettleship for kindly looking through my notes and
giving me their opinions.
The second case is also of interest, though it cannot be
viewed in the same light as the first. The microscopical
examination of the eye first removed led Dr. Dyson and
54 INTRA-OCULAR TUMOURS.
myself to hope that the condition was non-gliomatous.
It is, however, probable that it was in reality glioma ;
indeed, the subsequent history points to its having been
of this nature.
There can be little doubt that the disease was con-
genital in both eyes. The other points of interest are :
(a.) The non-return of the disease in the right orbit up
to the death of the child, a period of four years and a half.
(6.) The quiescent state of the disease in the left eye
for two years or more.
(c.) The non-return of the disease in either orbit, but
on the forehead^ and that, it is stated, following a blow.
{March 13th, 1884.)
Dr. Brailey had observed at Moorfields in 1876 a
case reminding him of that of Mr. Snell, of which the
following account had been written at the time :
" Laura S — , set. 9 months, had her left eye excised
by Mr. Hutchinson on July 17th, 1876. It was painful
and evidently shrinking. Its tension was somewhat dimi-
nished and its cornea small, very prominent, hazy, and vas-
cular. The anterior chamber was filled with blood.
''After excision the globe was found to be somewhat
squared, the retina was detached into an umbrella shape,
only adhering at the optic disc and ora serrata, and at a
point to the outer side of the disc. The substance occu-
pying the vastly reduced cavity of the detached retina is
tough and fibrous and bluish white in colour. It is
evidently inflammatory and by its contraction the cornea is
drawn into its present very convex shape. The detached
retina is much thicker than normal, and its external layers
contain much black pigment mixed with a pinkish- white
basis substance which appears to be inflammatory in its
origin. The pigment granules are mostly in cells which
are rather elongated in shape. The microscope shows
nothing that can be taken as indicating the existence of
a glioma. The anterior surface of the iris is covered with
a pinkish layer which also blocks the pupil.
SARCOMA OF CHOROID. 55
'^ The right eye has an appearance exactly like that of
intra-ocular glioma. There is a whitish reflex from
behind the lens with blood-vessels upon it. Its tension is
normal. It appears to have perception of light from the
nasal side. This eye was excised some years later, and
was found to contain a true retinal glioma.
'' The parents stated that the child had never had any
illness. When it was three months old they noticed a
white reflection with blood-vessels on it coming apparently
from the back of the left eye. When the child was six
months old the eye became red and was apparently
strongly inflamed. The other appearances did not alter
materially up to the time of excision.
'^ Nothing was thought to be the matter with the right
eye till four days before excision. Then they noticed in
certain lights a white appearance from the back of it,
exactly like the other except that they did not see any
vessels on it. There was never any inflammation.
''The parents have been married three years, and have
good general health. The eldest child is two and a half
years old and the patient is nine months old. There have
been no other children and no miscarriages. The father
is a butcher living in the country.'^
2. Sarcoma of choroid.
By George Cowell and Henry Juler.
Ann M — , aet. 37, married. Family history good, no
cancer, no syphilis. Patient is a healthy-looking woman.
Vision was always good till two years ago, when she
noticed floating specks in front of the right eye. This
was followed by dimness in reading. She first came under
our notice in January of the present year (1884) and was
shown to the Society at the March meeting. At that
Kil
5b INTRA-OCDLAR TUMOURS.
time the patient could only count fingers witli difficulty in
the lower and inner portion of the right visual field. The
vision of the left eye was normal (|- and Sn. 0'5). With
the ophthalmoscope the retina was seen to be pushed for-
wards over the upper and outer quadrant of the fundus
where it was of a light greyish colour. The surface of
the projecting portion appeared to be slightly striated as
if from superficial vessels. The remaining two thirds of
the fundus presented a good red choroidal reflex, but the
details of the fundus as to the optic disc and retinal
vessels were obscure. The tension of the globe was in-
creased to T + 1. The abdominal vessels of the globe
were tortuous and distended. There was no pain.
After the March meeting the vision of the affected eye
became much worse, the retina became totally detached,
and perception of light was abolished. The eye was ex-
cised in April.
The globe was then hardened in Miiller's fluid and bi-
sected in a frozen state, when it was found to be occupied
over the upper and outer third by a pigmented, lobulated
tumour; this, as shown in the jelly preparation, extends
inwards to the centre of the globe and forwards nearly to
the lens. The retina is situated immediately in front of
the tumour. Over the rest of the fundus the retina is
seen to be separated from the choroid ; the sub-retinal
space was here occupied by serum.
Microscopic sections of the tumour have been made and
are upon the table ; they show the tumour to be of the
nature of a pigmented sarcoma, and to have commenced
in the choroid.
The optic nerve, the sclerotic, and surrounding tissues
are apparently free from the disease. It is now over a
month since the eye was excised, and we hope that there
will be no recurrence of the affection.
(Living specimen. March 13th and June hth, 1884.)
7
lY. DISEASES OF THE IRIS.
1 . Case of serous cyst of iris.
By W. J. Cant (Lincoln).
The case I wish to bring before the Society is that of
a man_, set. 40, who was first seen by me in February,
1884. He stated that when a boy his right eye was
injured by a piece of steel, and although the injury
caused severe inflammation at the time, as far as he knew,
it completely recovered, so that he was unable to detect
any alteration, either in vision or appearance. About
three years ago he noticed that " the coloured part of his
eye was a little puckered at the upper part,^^ but it caused
him no pain, and he took no more notice of it till about
twelve months ago when he found his sight failing, which
gradually increased so that he became quite unable to
follow his occupation, his left eye being already useless
from opacity of the cornea. He occasionally had aching
in and around the eyeball.
On examination I observed a tumour about the size of
a small pea, of a skim-milk whiteness, growing from the
periphery of the upper segment of the iris, but intimately
connected with it as far as the margin. The iris was
very much drawn towards the tumour, atrophied and
altered in colour, on the right side of the tumour it being
of a light yellow colour, and on the left almost black,
with a peculiar reddish thread skimming the edge of the
iris on the nasal side. The tumour appeared to be in
contact with the cornea and lens. The pupil, when not
under the influence of atropine, was as nearly as possible
filled up by the tumour. Fundus-reflex could be obtained
68 DISEASES OP THE lEIS.
through the tumour. The eyeball tension was increased
(T + 1 or 2) . Vision equalled -^^^ but his sight was very
*^ misty/' and he could only read 16 J., and that with
difficulty.
Taking into consideration the increasing growth of the
tumour and of the tension I decided to attempt its removal.
On February 28rd, chloroform having been given, a
corneo-sclerotic section was made in the upper segment,
the tumour seized with a pair of iridectomy forceps and
removed with a piece of iris. There was free bleeding
into anterior chamber. The wound healed without a bad
symptom. The iris being drawn upwards towards the
line of incision, a downward iridectomy was made.
The vision has greatly improved, V. = -^ clearly, and
he reads 2 J. easily. There is no trace of inflammation,
and the tension is normal. He is able to do his work
without any difficulty.
{July Uh, 1884.)
2. Serous cyst of iris.
By W. Adams Frost.
History. — William M — , aet. 28, under care of Mr.
Waren Tay at Royal London Ophthalmic Hospital. Left
eye wounded by a fork at age of four, no operation at
the time. At age of eighteen years an operation (iridec-
tomy ?) performed by Mr. Bubb, of Cheltenham. Patient
thinks that appearance of eye was then much as now, but
that the cyst did not extend so far over the pupil. He
thinks that the growth increases very slowly, and that
the sight of this eye has been gradually deteriorating for
many years. There have never, within his recollection,
been any Inflammatory symptoms.
Present condition. — Left eye, just external to the vertical
SEROUS CYST OP IRIS. 59
meridian of cornea and 2*5 mm. from its upper margin, is
a transverse cicatrix, 1*5 mm. long. Occupying the upper
and inner quadrant of anterior chamber is an opalescent,
semitransparent, rounded swelling ; anteriorly it appears
to touch the cornea by .its most prominent part, and
posteriorly to rest on the lens. It extends quite to the
periphery of the chamber, while its pupillary edge pro-
jects about half way across the pupil. The posterior sur-
face, as far as it can be seen, is lined by a layer of uveal
pigment, and this is continued round its lower border.
The swelling terminates below in a regular rounded
extremity, which is separated by a very narrow chink —
through which there is a good fundus-reflex — from the
lower edge of the artificial pupil made by the former
iridectomy. The cyst as well as the iris seems to be adhe-
rent to the corneal cicatrix above, and it is difficult to
define its exact limit.
Examined by oblique illumination the cyst is of a milky
colour and is semitransparent.
With the ophthalmoscope a fundus-reflex can be
obtained through several parts of the cyst.
The free portion of the pupil is as active as is usual
after an iridectomy. Fundus slightly blurred, owing
apparently to haze of the lens ; nothing abnormal seen.
V. -^Q. Eight eye normal.
[June bth, 1884.)
8. Granular 'loolcing body on iris.
By F. H. Hodges (Leicester).
Lizzie H — , aet. 17, Stoke Allway, Leicestershire.
Patient noticed right eye to be " red ^'* first week of
December, 1883 ; it became slightly painful, and she
came to me on December 18th. Granular-looking body
60 DISEASES OF THE lEIS.
size of millet-seed on outer rim of right iris, close to
sclera ; slight ciliary injection. Pupil dilated freely
under atropine except at point of granular body. On
December 28tli iritis with adhesions ; A. 0. half full of
pus. Pus evacuated by incision with keratome. Pas
reaccumulated, but on January 7th, 1884, was completely
absorbed. Granular body slowly and painlessly increased;
perforated sclera, and appeared outside. Specks like in-
flammatory deposits formed in deeper layers of cornea.
Tension has never increased, now = —1. V. = -^q.
No family history of tubercle or cancer.
{Living specimen. March IZth, 1884.)
4. Growth on iris {? tubercular).
By W. Lang.
Henrietta M — , set. 5, a well-grown child, pale and
flabby, with good features and sound teeth. The mother
says the child was always healthy, with a ruddy complexion,
prior to last winter, when she caught a cold. Since then
she has always been ailing with a series of colds. Came
to the hospital on May 31st. The mother had noticed
the eye to be bloodshot about a fortnight before, and
about four days before she had noticed a yellow spot in
the eye.
On admission the cornea was hazy, with two spots seen
on its posterior surface, and numerous growths on the iris,
the larger being on the lower part of the iris. The growths
were yellowish in colour, with blood-vessels plainly seen
on the surface. The iris was bound down by numerous
adhesions, and the lower part of the A. C. contained
fluid pus. The gi'owths have gradually increased in size
in spite of mercury and 01. Morrh., coalescing, and now
GROWTH ON IRIS. 61
nearly fill the lower part of the A. C, the growths on
the posterior surface of the cornea remaining the same.
The family history is good. The patient is the eldest of
four children, all healthy; no miscarriages.
No changes in lungs. Left eye healthy.
[Living sjyecimen. July 4th, 1884.)
P.S. — August 5th. — The growths on the iris have all
coalesced, and now fill the lower part of the anterior
chamber, and cover the iris almost entirely up to the
level of the upper part of the pupil. The cornea is still
hazy, and the deposits on its posterior surface remain the
same. The child's general health is fairly good.
62 INJURIES AND SYMPATHETIC OPHTHALMITIS.
V. INJURIES AND SYMPATHETIC
OPHTHALMITIS.
1. On the uarioics forms of sympathetic disease of the eye
and their hearing on the theories of its transmission.
By W. A. Beailey, M.D.
Some two years and a half ago I had the opportunity of
bringing before the International Medical Congress the
results of my microscopical examination of many cases of
sympathetic disease.
I then dealt only with the one best recognised form, the
sympathetic inflammation of the uveal tract, and I indi-
cated a microscopical similarity between the different cases
I examined.
In each one there were cells either in small isolated
clusters or in a continuous layer on the lower part of the
posterior surface of the cornea and also round the blood-
vessels of the papilla, extending thence along the central
vessels of the optic nerve.
The iris showed, if it were but slightly affected, clusters
of cells in its middle layers. Or, if the iritis were severe,
the whole iris was densely packed with, similar cells and
cells were also found making a stratum of adhesive inflam-
matory exudation on its posterior surface. Its blood-
vessels had their walls thickened and their lumen occupied
by a proliferation of their endothelial layer.
If cyclitis accompanied the iritis the inflammatory cells
were mostly in the connective tissue layer of tbe ciliary
body internal to tbe muscular fibres, where they were dis-
tributed either in clusters or in a dense stratum occupying
its whole thickness. The exudation cells were on the
TRANSMISSION OF SYMPATHETIC DISEASE. 63
internal aspect of the ciliary body and overlying pars
ciliaris retinge.
If tlie choroid were also implicated the cells occupied
similarly its middle layer, but there were no exudations on
either of its surfaces.
To these characters of sympathetic inflammation, that
is to say, of the inflammation in the second eye, I still
rigidly adhere.
But there are many eyes which we have no opportunity
of observing except in their clinical aspects, which fail to
coincide entirely with this description. Thus, though I
have found deposit on the posterior corneal surface in each
of the four cases I have examined pathologically, I have
recorded such in only about one third of the cases that I
have been able to observe in their clinical aspect alone.
I am sure, however, that this number is understated, for I
have but of late years become aware of the care that may be
required to find them. Moreover, I have observed at least
one instance where they were present only in the earlier
stages and, conversely, one where they were not found
when the patient was first seen, but became clearly apparent
in the course of some weeks.
There are, moreover, many cases which can only be
observed clinically (those in which there are punctate
deposits on the back of the cornea, with the iris dull and
sluggish and the anterior chamber deep), in which it is
difficult to suppose that the implication of the uveal tract
is more than of a slight nature. Such cases are connected
by transitional forms of gradually increasing severity with
the more severe typical forms above described. I think
that future observation will show the existence of dots on
the cornea in every case at some period of its course.
Since then I have observed many more cases of sym-
pathetic disease both in their clinical and pathological
aspects, and I have been surprised to find in how large a
proportion of them some structure other than the uveal
tract is implicated, either conjointly with this or to all
appearance alone.
64 INJURIES AND SYMPATHKTIC OPHTHALMITIS.
For example^ out of fifty-three undoubted cases of
sympathetic inflammation of the uveal tract leading to
excision, which are comprised in 763 cases of enucleation
in 5 J years at Moorfields, I have noted thirty cases of pure
uveitis, the iris being always implicated, and, as far as
could be judged from the clinical appearances, the ciliary
body often, and the choroid, in addition, sometimes. But
dobs were observed on the cornea in fourteen of them, and
a more marked implication of the cornea, making a dis-
tinct kerato-iritis, was found in ten. Probably the kera-
titis punctata should form a larger proportion, especially
at the expense of the kerato-iritis, for some of the reasons
given above.
But on looking over the hospital books for the same period,
I find, after carefully excluding the numerous cases where
there was the* slightest evidence that the keratitis might
be due to some general constitutional condition, fifteen
cases where, under circumstances such that sympathetic
inflammation might reasonably be expected to arise, i.e.
perforating wounds or ulcers, recent or old, the cornea oE
the other eye has become inflamed once or several times.
It is difficult to refuse to such the name of sympathetic
keratitis. They are in reality far more common than my
figures, derived from the statistics of enucleation, would
show, for they, unlike sympathetic uveitis in this country,
have comparatively rarely been the cause of the enucleation
of the first eye.
I have at least two such cases under my care at Guy's
Hospital at this moment, and I can recall to mind many
others of recent occurrence. Also, I find, in the same way,
thirty -one cases where at the time of excision of the first
eye there was in the other some ophthalmoscopic evidence of
neuritis such as a redness and slight haziness of the disc. It
will be said with justice that such appearances are difficult
to be sure about. This I grant, especially with regard
to variations in the colour of the disc. But the same
reason would render them liable to be overlooked, and
indeed, I think they are far more common than I have
TRANSMISSION OF SYMPATHETIC DISEASE. 65
represented, partly for this reason and partly because the
patient often is unable, on account of the associated sym-
ptoms of sympathetic irritation, to bear the light of an
ophthalmoscopic examination.
Closely allied to and probably consequent on these mor-
bid conditions are atrophies of the disc, of which I have
observed one apparently due to sympathy, and since that
observation one other (see page 87), and haze of vitreous,
of which I have seen four instances, two being uncompli-
cated, one associated with choroiditis, and one with detach-
ment of the retina.
I have also occasionally observed cases where the affec-
tion of the sympathising eye is a conjunctivitis with a
greater or less amount of muco-purulent discharge (for a
case subsequently recorded see page 73) . In the same
way most of the cases of so-called sympathetic irritation
present some conjunctival or ciliary injection. It is im-
possible to draw the line between this condition and the
conjunctivitis with muco-purulent discharge just referred
to, and again between that and the graver and more un-
doubted lesions of sympathetic inflammation.
With regard to other phenomena of sympathetic oph-
thalmitis, I have been much struck by three cases in which
the affection of the sympathising eye, a comparatively mild
iritis, was ushered in by swelling of the lids so marked as
to be out of all proportion to the severity of the iritis
according to our usual experience of such inflammations.
I have also noted two cases where, the first eye having
been for long free from pain and tenderness, the outbreak
of sympathetic iritis was accompanied by severe neuralgic
pain affecting various branches of the fifth nerve of that
side and extending from the vertex and the post-aural
region to the teeth of the lower jaw, whereas the pain in
the eye itself was comparatively slight.
With regard to the disease in the first or exciting eye,
I have had to modify my previous views very considerably.
Formerly I supposed that the disease in the first eye was
always a severe adhesive inflammation and that this must
VOL. IV. 5
Q6 INJUEIES AND SYMPATHETIC OPHTHALMITIS.
be, to some extent at least, in activity at the time of the
outbreak of sympathetic disease.
But I have since then seen many cases of undoubted
sympathetic ophthalmitis, where the first eye, perhaps a
mere stump at the time of the outbreak, was neither tender
nor painful, having been quiet for long, even for years,
and several where such, when examined microscopically,
presented at the most but very doubtful signs of present
inflammation.
And the history of several cases has distinctly impressed
upon me the truth of the observations of others, that
eyes shrunken and perfectly quiet after panophthalmitis
may excite ^' genuine sympathetic iritis.'^
I have even recorded a case where an eye, shrinking
from a small intra-ocular sarcoma, was the cause of a
typical sympathetic iritis with keratitis punctata, and of
another where a sarcoma in the first eye was followed by
numerous vitreous opacities in the second.
Thus the condition of the exciting eye may vary
extremely, and these various conditions may be the results
of very different causes, from the most common, perfo-
rating wounds (45 cases out of 58), through spontaneous
inflammations (10 cases out of 58), and blows with blunt
instruments (2 cases), to the rarest, the choroidal sarcoma
(1 case above mentioned).
Moreover, the parts affected do not correspond in the
two eyes. True it seems necessary that in the first eye
the uveal tract should be inflamed, but this is in all pro-
bability simply because no inflammation, whether traumatic
or otherwise, could be of considerable severity without
implicating this adjacent very vascular tissue, I may
here note that the choroidal sarcoma was accompanied, as
is usual, by uveitis.
Thus iritis or kerato-iritis in the first eye may give rise
sympathetically either to a pure iritis, occasionally with
hypopyon, a kerato.iritis, an iritis with keratitis punctata,
or to an affection of the conjunctiva, optic disc, or even
vitreous body.
TRANSMISSION OF SYMPATHETIC DISEASE. 67
It appears to me that these facts, if admitted, arc
strongly opposed to the theory of direct transmission of
the inflammation from one eye to the other by whatever
route, whether by inflammatory cells in the blood or by a
continuous actual neuritis, either of the ciliary or optic
nerves, or by an inflammation of the fibres of the inter-
♦ sheath space of this last, not that it needs any particular
display of evidence to contradict w^hat after all is solely
or principally a theory.
I have said, and I venture to say again, that there is
j no pathological evidence before us of the least value to
show an actual travelling neuritis of any nerve as the
cause of sympathetic ophthalmitis. True the optic disc of
the first eye is usually somewhat swollen, and the fibres
of the subdural space bear some excess of nuclei. But
these changes are far more pronounced in any ordinary
[ case of purulent iritis than in the vast majority of the eyes
! exciting sympathetic disease.
Inflammatory changes extending along the central
vessels of the nerve are also markedly well seen in iritis
serosa, but, though deposits on the posterior corneal sur-
face occur so commonly in the sympathising eye, I have
only once seen, and then somewhat doubtfully, an iritis
serosa give rise to sympathetic disease.
I The clinical case observed by Snellen, where a menin-
gitis* leading to deafness accompanied a sympathetic oph-
thalmitis, is of decided importance, but its precise bearing
upon the transmission of sympathetic inflammation remains
undemonstrated .
With regard to the ciliary nerves I can speak more
confidently. I have examined the long ciliaries in many
cases, sometimes in the second, but more often in the first
eye, but I have never seen any proof that an inflammation
travelling along them is the cause of the transmission of
the disease. There may be in some cases an excess of
inflammatory cells surrounding them before their exit
from the eye, but that is only when the adjacent choroidal,
* ' Trans. International Medical Congress, 1881.'
68 INJURIES AND SYMPATHETIC OPHTHALMITIS.
scleral and episcleral tissues participate markedly in the
inflammation. Sucli cells do not appear to be out of pro-
portion to or to extend beyond tlie inflammatory changes
in adjacent structures.
But tlie cases where sympatlietic disease occurs after
excision of the exciting eye have a strong bearing on this M
question. The industry and keen observation of Nettle-
ship have recorded two such cases and called attention to
seven more in the practice of others. I have observed at
least five at Moorfields, one of which occurred ten months,
one three months, one two months, one five weeks, and one
two weeks after excision. In all of them marked sym-
ptoms of sympathetic irritation preceded the enuclea-
tion.
One of Nettleship's cases occurred twenty-two days,
and the other twenty-three days after excision. That of
Cowell, which Nettleship also records, broke out twenty-
five days after the removal of the exciting eye. One, re-
ported by Snell in the ' Transactions ^ of this Society for
1882, was of thirty-two days, and one, by Frost, of twenty-
two days' duration from excision.
Lawson has recorded in the ^' Moorfields Hospital
Reports,' vol. x, a case in which sympathetic inflamma-
tion came on after the lapse of nine years. Whether this
last case was, as the history given appears to indicate,
considered simply as a relapse, or whether it was a pri-
mary outbreak of sympathetic disease, is much the same
with regard to its bearing on the theory of direct trans-
mission. If the disease is communicated only by direct |
transmission why should relapses occur, as they do fre-
quently even within the sphere of my personal observation,
without any apparent corresponding difference in the con-
dition of the first eye ?
But what other theory can we accept conformabl}^ with
the above observations ?
The symptoms of irritation produced in the second eye,
v\^hether such be pain, lacrimation, photophobia, obscura-
tions, failure of accommodation, or perhaps even vascular
TRANSMISSION OF SYMPATHETIC DISKASK. G9
congestions, can bo satisfactorily explained by the trans-
mission of the irritation from the first eye to a nerve-centre
and tlien back througli the corresponding nerve of the
opposite side.
The nerves concerned are generally admitted to be the
fifth pair with their centres, to which we must add, on
account of the obscurations that sometimes occur, the optic
nerves themselves.
Out of twenty-nine cases of sympathetic irritation taken
at hazard from those observed and recorded by myself,
sixteen were relieved, seven were unaffected, and six ren-
dered worse by excision of the other eye. In the first
cases the change must be merely a functional one, but in
the others some permanent affection of the second eye must
have resulted from the irritation of the other.
Some similar cases have been explained by the entangle-
ment of the ciliary nerves in the cicatrix of excision. And
others are clearly due to the irritation of the socket by an
artificial eye. The first explanation is rather hypothetical,
and the entanglement has rarely been demonstrated, but
the second is of tolerably frequent occurrence. In my
cases referred to above there was no evidence of any such
cause.
The permanent change in the second eye may reside in
the nerves, in their centre, or in the tissues of the eye
itself. In the absence of any evidence of structural change
we may presume that the nutrition of the second eye is
lowered more or less permanently by the influences trans-
mitted from the fellow eye.
I am satisfied that a single eye is more prone than ono
of a pair to disease ; for example, to cataract, especially of
the nuclear form, to iritis, and to corneal ulcers. And I
ascribe this liability to an alteration in its nutrition
depending on the previous occurrence of disease in the
first eye or even to the operation of enucleation itself.
I admit the difficulty of establishing such a proposition,
since out-patient rooms do not furnish a fair sample of
one-eyed patients. Naturally persons having but one eye
70 INJURIES AND SYMPATHETIC OPHTHALMITIS.
would, more readily than others, apply for treatment of
slight affections of it.
There is no doubt but that a defective eye is more liable
to disease than a sound one. This is markedly shown in
spontaneous suppurations of such eyes and even in the
occurrence of sarcoma in them.
I observe also that eyes, the subjects of recent severe
operations, for cataract, for example, are more liable than
others to the occurrence of small corneal infiltrations and
iritis. Such phenomena appear to me precisely similar in
their causation to those of sympathetic disease, except that
the evidences of lowered nutrition are restricted to the one
eye.
1 have also become impressed with the fact that an injury
or operation affecting an unsound eye is unduly likely to
excite sympathetic disease, especially if the fellow eye is
also defective. It is in this way that I account for the
comparatively large number of cases, amounting to 1*3 per
cent, of the total number of eyes excised at Moorfields
during my curatorship of eight years, where the needling
of so-called opaque membranes has started sympathetic
disease.
If then sympathetic irritation is transmitted from one
eye to the other through a functional nerve condition, and
if the irritation, with or without an increased liability to
morbid processes, persists after the removal of the other
eye, we can only (in the absence of any cause of irritation
in the empty socket) ascribe it to an altered nutritive con-
dition of the second eye, and it is immaterial to our pur-
pose whether this lowering of vitality has its seat only
in the tissues of the second eye, or depends on an altered
condition of a nervous centre.
Why should not the same explanation be applied to the
phenomena of sympathetic inflammation ? Against it
would be proofs of direct transmission and also points of
dissimilarity between the two conditions of inflammation
and irritation. Forms of disease intermediate between
the two conditions would be in favour of it.
TRANSMISSION OF SYMPATHETIC DISEASE. 71
The evidences of direct transmission, that is to say hy
continuity of inflammation, are extremely slight. I have
previously stated (page 67) why I hold the optic, and
more decidedly still, the ciliary nerves, faultless in this re-
spect. And it is clear that the more various the phenomena
of sympathetic disease are shown to be, the more difficult
it will be to establish direct transmission. The undoubted
fact that the anterior region of the second eye, viz., the
iris or cornea^ is the first and frequently the only part
affected, is opposed to the arrival of the disease by the optic
and ciliary nerves.
The early and great swelling of the lids (page 65) and
the whitening of the eyelashes recorded in certain cases by
Hutchinson and Nettleship are not without weight in this
direction.
In the same way^ how can direct transmission explain
the occurrence of sympathetic disease weeks, months, and
perhaps even years after the removal of the first eye and
certainly very long after the subsidence of active inflam-
mation in the first eye ?
All these things will^ however, be reasonably explained
by the supposition of such an altered nutritive state of the
second eye as would be induced by the morbid functional
nerve influence derived from an inflammation, atrophy^ or
even absence of the first. This would render it liable far
beyond other eyes to inflammations clearly dependent on
constitutional conditions, e.g. syphilis and rheumatism^ and
also to inflammations which in the absence of such evidence
we are used to call spontaneous.
Such inflammations would be comraotly severe ; they
would be liable to recur j they would attack the parts
usually most liable to inflammatory disturbances.
Sympathetic inflammations are marked by their severity
and intractability^ and I have lately had abundant evidence
of their liability to relapses.
As regards the resemblance of so-called sympathetic
irritation to sympathetic inflammation, I have stated that
a very considerable percentage of the cases of irritation
72 INJURIES AND SYMPATHETIC OPHTHALMITIS.
are not relieved by excision and that some cases are even
rendered worse.
Sympathetic inflammation is usually not relieved by
excision, but I have observed sufficient cases to satisfy my
mind that the disease is sometimes favourably influenced by
the excision of the exciting eye.
Sympathetic irritation may arise directly, whereas
sympathetic inflammation takes at least a certain time, say
two weeks. But such a chauge of nutrition as could
produce obvious structural disease could not be induced
directly. The occurrence of sympathetic inflammation
weeks, months, or years after the removal of the other eye
is perfectly in accord with the theory of diminished resist-
ance to disease.
Cases occur of sympathetic inflammation without previous
irritation, and more frequently of irritation followed by
inflammation. Those where irritation is the sole sym-
ptom are of course by far the most common of all. But
the fifth nerve contams other fibres than sensory ones. I
mean that irritation of the second eye may indirectly cause
a lowering of its nutrition, but that other nerve-fibres, the
so-called trophic fibres, will induce this condition directly.
I do not admit that a sharp line can be drawn between
sympathetic irritation and inflammation. An iritis may
appear to be very different from photophobia, but if the
latter condition is accompanied by a vascular congestion
the two conditions then become drawn together. For I
can see no line of demarcation between a vascular
congestion and an inflammation with microscopic evidence
of an increased cell exudation. And if it be admitted, as
I firmly believe to be the case, that vascular congestion,
conjunctival or ciliary, or conjunctivitis with muco-puruleut
discharge, is an occasional symptom of sympathetic irrita-
tion, I repeat that I can see no limit between this and sym-
pathetic inflammation.
It has been recorded that dental neuralgia is sometimes
followed or accompanied by conjunctival injection and even
iritis of the same side. But such cases, though they may
MUCO-PURDLENT CONJUNCTIVITIS. 73
bear upon and support the views that I maintain, may yet
be explained by supposing that there is a general affection
of the fifth nerve of that side, or of certain parts of it.
The outbreak of glaucoma in the second eye imme-
diately after operative interference with the first, bears a
more direct relation to the points in question.
If it were asked why should the eye alone, of all organs
in the body, be liable to sympathetic disease, I should
reply, first it has not been shown that certain other organs,
the lungs, for example, do not suffer in the same way ; and
second that no two organs of sense stand to each other in
anything like the same relation as the eyes.
These cover the same ground and see better together
than separately, whereas, so far as my rough obser-
vations go, sounds coming from the side are heard better
when the opposite ear is blocked up than with the two
together.
And the immunity or comparative immunity of the
lower animals may be accounted for by the comparative
independence of the two eyes in them. For example, there
are few animals in which the fields of vision cover the
same ground as they do in man.
(December ISth, 1883.)
2. Mxico -purulent conjunctivitis of sympathetic origin.
By W. A. Brailey, M.D.
Abraham J — , aet. 6Q, had a blow on his right eye
by a piece of wood fifteen months ago, in consequence of
which the cornea is now shrunken and opaque and adhe-
rent to the iris. It is probable that a sloughing ulcer
was the immediate result of the injury. Two weeks after
the injury the left eye began to discharge, having been
74 INJURIES AND SYMPATHETIC OPHTHALMITIS.
previously perfectly healthy, and the discharge has con-
tinued up till the 29th November,, 1883, when the right
eye was excised. For some weeks previous to the exci-
sion the conjunctivitis had been treated with various drugs,
but showed no material improvement. The treatment was
continued for six weeks after excision, but the condition
remained much the same. Vision with + 9 D. amounted
to -j^g" ii^tier atropine. He had never worn glasses for
distance till about two weeks after the excision.
{Living Specimen, January 10th, 1884.)
Mr. Spencer Watson said that Dr. Brailey had stated
that in a certain percentage of eyes affected with sympa-
thetic ophthalmitis he found '' dots ^^ on the cornea, and
the inference seemed to be that this peculiar condition
(punctiform keratitis) was characteristic of sympathetic
ophthalmitis. Mr. Watson, however, had seen this kind
of keratitis under varying conditions, such as those of
syphilitic and rheumatic iritis and in cases in which no
peculiar constitutional disease was present, but he had not
observed it in cases of traumatic origin. He thought
therefore that the occurrence of these punctiform de-
posits was by no means a characteristic lesion in sym-
pathetic ophthalmitis. There seemed to be some vagueness
as to the kind of affection intended to be described as
sympathetic ophthalmitis in Dr. Brailey's paper, and it
would therefore be desirable to have the affection more
strictly defined. If we were to accept the occurrence of
conjunctivitis in the uninjured eye as evidence of sympa-
thetic disease due to an injury of the fellow eye it would
be difficult to arrive at any satisfactory definition. As to
the theory that the removal of an injured eye actually ex-
cited sympathetic ophthalmitis it was hard to reconcile
it with the old axiom that having removed the cause the
effect was also removed. The mere sequence in point of
time could not be taken as evidence that the two events
were related as cause and effect/ and hence it was open to
question whether the operations performed for glaucoma
SYMPATHETIC OPHTHALMITIS. 75
were always the cause of glaucomatous attacks in the second
eye. It was more probable that the second eye was affected
by a cause common to its own and the previous attack^ or
possibly in other cases to some underlying constitutional
cause. The interval that had elapsed between the two
attacks might only indicate that the disease in the last
affected eye had been longer in coming to maturity than
hat to which attention had been first called. The same
reasoning would apply to all other instances in which the
two eyes were affected by a similar disease, but with
an interval between the periods at which they were
attacked.
Mr. Story (Dublin) referring to the patient exhibited
by Dr. Brailey, thought that it was rather stretching the
use of the term to attribute the conjunctivitis to sympa-
thetic inflammation. He did not see in its occurrence
anything more than a mere coincidence. He was of
opinion that it was very desirable that our list of sympa-
thetic inflammations should not be lengthened. In refer-
ence to the paper, and the theory as to the origin of sym-
pathetic inflammation therein propounded, he felt that he
could not allow such a theory to pass unchallenged. No
one had as yet produced inflammation by reflex irritation
of a nerve. Sympathetic ophthalmitis, he pointed out,
possessed certain peculiarities. Thus irido-choroiditis, if
produced by sympathetic inflammation, was peculiar in its
course. If caused by simple reflex action, then removal
of the other eye ought to have a much greater effect than
it had. If caused by direct transmission, then the removal
of the cause would not have much influence. All diseases
had at one time or another been attributed to disturbance
of the sympathetic system. Congestion from nerve irri-
tation did not run on to inflammation, nor did the con-
gestion of one eye from a foreign body in the other lead
to sympathetic ophthalmitis. His own experience did not
permit him to say whether keratitis punctata was constant
or not.
76 INJURIES AND SYMPATHETIC OPHTHALMITIS.
Mr. W. Adams Frost asked whether the conjunctivitis
showed any unusual obstinacy in yielding to treatment,
and whether it differed in any other respects from an
ordinary case of conjunctivitis ? As the case stood, there
seemed to be no evidence whatever of its being of sympa-
thetic origin. He was surprised that Dr. Brailey con-
sidered that the fact of the conjunctivitis not being
improved by enucleation of the injured eye was in favour
of its being of sympathetic origin. It seemed to him,
on the contrary, that if such improvement had imme-
diately followed the operation that circumstance would
have been evidence in favour of its being of that
nature. He also took exception to one of the premisses
on which Dr. Brailey rested his theory, — namely, that
there was no line of demarcation between conjunctival
injection such as was met with in the so-called sympa-
thetic " irritation ^^ and a muco-purulent conjunctivitis
such as was present in Dr. Brailey's case. It appeared to
him, on the contrary, that there was this distinction, that in
the one case there was merely dilatation of existing vessels,
and if any excessive secretion only that of normal character,
whilst in the other there was emigration of leucocytes
leading to the formation of morbid secretion. Dr. Brailey
claimed that the cases in which sympathetic mischief did
not make its appearance until after the enucleation of the
exciting eye were not more difficult to explain on the reflex,
irritation than on the direct transmission theory ; it was,
however, surely difficult to conceive how a reflex irritation
could occur months after the removal of the exciting cause.
If, on the other hand, we assumed that there was a process
gradually extending from the one eye to the other by
continuity of tissue there was nothing very surprising in the
morbid process appearing in the second eye if it was well
on its journey before the starting-point was removed.
Mr. Nettleship said : I agree with Mr. Story that
Dr. Brailey has given us but little evidence that the
conjunctivitis in the patient shown this evening is sympa-
SYMPATDETIC OPHTHALMITIS. 77
thetic. The patient is predisposed by his age to chronic
muco-purulent ophthalmitis, and it is highly probable that
the conditions and treatment immediately followiog his
accident, such as bandaging, especially with wet applica-
tions, and the use of atropine, would set up the state of
things we see. Before adding conjunctivitis to the group
of sympathetic diseases, we may fairly ask Dr. Brailey to
give us the detailed particulars of the cases which he
thinks are of this nature, and which seem to be tolerably
common in his experience.
Passing to the very important paper which Dr. Brailey
read at the last meeting, I would make the same request as
to the several forms of disease which, in addition to the
common form. Dr. Brailey asks us to recognise as sympa-
thetic. I find it very difficult, in the absence of detailed
cases, to accept Dr. Brailey^s belief that mere diffuse
keratitis or mere papillitis are ever sympathetic in the
sense of being produced by a wound of the opposite eye.
Papillitis of course occurs, and sometimes quite early, in
cases of sympathetic ophthalmitis, but in the present state
of our knowledge it may, I think, always be attributed
with greater probability to extension from the adjoining
cboroid than to a primary optic-neural inflammation ; such
early and acute choroiditis would not necessarily produce
any marked ophthalmoscopic changes. The same criticism
applies in general terms to the assertion of uncomplicated
optic atrophy as a sympathetic disease ; let us have the
cases in detail.
In respect to the mode of transmission of sympathetic
inflammation from one eye to the other, it seems to me
that if those who incline to believe in a travelling of
neuritis along the ciliary nerves hold their belief on
slender anatomical evidence, the position of such as are
disposed to deny this mode of transit is at least as diffi-
cult. Dr. Brailey knows, even better than I, how, recently,
descending inflammation has been shown, largely by
Gowers, Stephen Mackenzie, Edmunds and himself, to
furnish the true explanation of almost if not quite all
78 INJUEIES AND SYMPATHETIC OPHTHALMITIS.
cases of papillitis from intracranial disease. Yet the optic
nerve is easy to examine in comparison with the ciliary
nerves, for these besides being numerous and very small,
are available only in such small bits as may chance to be
removed with the enucleated globe. The mere failure to
find in every case histological signs of inflammation in such
fragments of nerve-tissue, under the ordinary conditions
of examination, does not, of itself, go far to disprove the
hypothesis of a travelling neuritis.
Mr. McHardy said : After paying every attention to Dr.
Brailey^s case of so-called '' sympathetic conjunctivitis '^ I
fail to recognise any sort of evidence that the reported
conjunctivitis had any such causation as clinical ophthal-
mologists understand by the prefix ^' sympathetic.^' After
the foregoing avowal, I would mention that in only one
instance have I seen an unquestionable sympathetic oph-
thalmitis ushered in by conjunctivitis.
In that instance, however, the rebellious nature of the
conjunctivitis occurring in a man at the prime of life, and
its sequel in general uveitis and turbidity of the vitreous
humour, served to establish the true nature of the case,*
an ample report of which I furnished for Mr. Nettleship's
instructive communicationf on '' Sympathetic Ophthal-
mitis setting in after Excision of the Other Eye."
Should not some concurrent or imm-cdiately associated
inflammation of structures other than the conjunctiva be
observable, in addition to the ordinary symptoms of con-
junctivitis before an example of this most ordinary affec-
tion of senile eyes is ascribed to such an exceptional cause
as sympathetic influence, and this too on the sole ground
that the fellow eye is judged to be one capable of exciting
sympathetic mischief ?
I have not yet learned that the deposits upon Descemet's
membrane characteristic of serous iritis (keratitis punc-
tata or aquo-capsulitis) are present, though not invariably
* ' St. Georpe's Hosp. Reports,' vol. ix, pp. 496, 505, 508 (1878).
t 'Trans. Cliiiical Soc.,' Case ix, p. 216, vol. xiii, 1880.
SYMPATHETIC OPHTHALMITIS. 79
observed, at one stage or another of every example of sym-
pathetic ophthalmitis.
Nevertheless, I am convinced of the very great frequency
with which such serous iritis does occur in the course of
sympathetic ophthalmitis. We are therefore debarred
from pronouncing the persistent absence of these deposits
from Descemet^s membrane as decisively negativing the
sympathetic character of an ophthalmitis. So again, their
presence is not enough to establish the sympathetic causa-
tion of an ophthalmitis. T am most familiar with these
characteristics of serous iritis in a class of cases unassoci-
ated with a previous traumatism, or syphilis, or rheuma-
tism, or gout, but usually coincident with some neurosis,
often contemporary with uterine functional disorders,
commonest about the establishment and cessation of men-
struation, sometimes subject to very notable periodic
exacerbations, unduly prevalent in the victims of malaria,
exceedingly tedious and obstinate under treatment, very
prone to relapse into a low form of uveitis, usually attack-
ing the second eye several weeks or as much as six months
later than its fellow, and so much commoner in females
than in males, that I have seen at least ten examples in
the former to one in the latter. I venture to suggest,
therefore, the importance of especially noting the sex in
particular, as well as the age, also the sexual and constitu-
tional condition of all patients who present this symptom
in connection with a so-called sympathetic ophthalmitis.
Might not our views of the causation of such serous iritis
be materially modified, according to the sex, age, and
general condition of the patient ?
80 INJURIES AND SYMPATHETIC OPHTHALMITIS.
3. Si/mjJathetic ophthalmitis not appearing till after
enucleation of exciting eye.
By W. Adams Feost.
Henry T — _, set. 25, admitted into St. George's Hospital
November 9tli, 1883. He stated that there was nothing
amiss with his eyes until a month previous to admission,
when in clipping a horse some hair flew into his right eye.
The eye became much inflamed and continued so up to the
time of his admission. There was no history of syphilis or
rheumatism.
On admission. — Right eye, general conjunctival injec-
tion most marked in circum-corneal zone, on inner side a
few vessels encroaching on the cornea. Lower half of the
cornea thickly dotted with punctate opacities. Pupil
irregular and fixed, presenting numerous synechias. T. n.
Left eye normal in all respects.
November 14th. — Slight prominence noticed of ciliary
region above.
17th. — An iridectomy was performed upwards.
December 1st. — Conjunctival injection slight. Ciliary
staphyloma as before operation. He was now discharged
at his own request, but returned and was readmitted a
few days later.
6th. — Bye very painful; ciliary staphyloma increased in
size ; anterior chamber very shallow.
15th. — An iridectomy downwards was attempted, but
owing to the rottenness of the iris and its firm adhesions
none could be removed. Ten days later he again left the
hospital.
January 28th. — Readmitted. Eye very painful, and
had been so for several days. Ciliary staphyloma larger.
Vision = p. 1., with good projection. Left eye normal.
February 2nd. — The right eye was enucleated.
7th. — Very slight conjunctival injection noticed in left
SYMPATHETIC OPHTHALMITIS. 81
eye. Numerous punctate opacities on lower half of
cornea and three fine adhesions of iris below. On dilating
the pupil with atropine a ring of uveal pigment could be
seen on tbe lens capsule. No pain or tenderness. Fundus
slightly blurred, no distinct evidence of neuritis. Vision
not noted. The eye was covered with a black bandage,
atropine used three times a day, and from February 18th
to March 22nd pilocarpine injections were given, beginning
with gr. -/g and increasing to gr. J.
23rd. — Cornea clearer. Adhesions as before. Vision
— 6.
— 9-
March 19th. — Only one adhesion remaining. No opaci-
ties on cornea. Vision = -|-.
April 2nd. — Discharged. Vision normal. One adhe-
sion remaining. To continue atropine for a few weeks.
Examination of the enucleated eye. — One half mounted
in glycerine jelly (specimen shown). Mr. Jennings Milles
kindly examined the other half (section shown) and reported
as follows : ^^ There is an upward circumscribed staphy-
loma of the ciliary region, the sclerotic is here much
thinned. Beneath the staphyloma is a nodule originating
in the posterior part of the ciliary region ; this has pushed
the sclerotic outwards, and the ciliary body inwards and
forwards, destroying the uveal pigment and the pars ciliaris
retinge covering its inner surface. The nodule consists of
small round cells of inflammatory origin closely packed
together — a localised purulent cyclitis. Spreading inwards
from the nodule between the iris and lens is a layer of
connective tissue. There is well-marked plastic iritis,
the whole iris being firmly adherent to the capsule at the
pupillary margin ; its parenchyma is filled with small round
cells, frequently in groups.
'^ Lens normal.
'' The vitreous contains a large number of cells in the
neighbourhood of the nodule, apparently chiefly migration
cells.
^' Retina normal, with the exception of a slight increase
of cells round the blood-vessels.
VOL. IV. 6
I
82 INJUEIES AND SIMPATHETIO OPHTHALMITIS.
^' The choroid is thickened in its whole extent^ especially
in the region of the papilla. Anteriorly there are groups
of cells ; posteriorly these groups seem to have merged
together/^
(July 3rd, 1884.)
4. Note on the treatment of symjpathetic ophthalmitis.
By George E. Walker (Liverpool).
As it was confidently declared, by more than one
member of the Ophthalmological Section at the last
Association meeting, to be impossible for one eye which
had undergone the complete sympathetic process to
recover useful sight, I think I am justified in bringing
before you the case of the young woman whom I now
present to you. She was brought to me in March, 1877,
by her mother, who stated that four and a half years before
her right eye was cut across by a piece of mug, and
enucleation, or rather abscission was performed on account
of the second eye having shown signs of inflammation.
In spite of the operation the disease progressed, and when
she was brought to me the pupil was quite closed, the iris
bulged forwards, and the sclerotic thinned and blue as you
see it now. Of course there was mere perception of light.
I was very unwilling to interfere, seeing that all authority
was on the side of leaving such eyes alone. But her mother
urged me to operate, saying that I could make her no worse
and I might make her better. This I thought unanswer-
able, and operated. Like others, I had attempted these
cases before and had failed by the methods which have been
advocated, such as incising the membrane, or cutting out
with scissors a triangular piece. This time I grasped tho
centre of the false membrane with iris forceps, and using
considerable force, tore out the false membrane together
SYMPATHETIC OPHTHALMITIS. 83
with some iris. The vitreous beiug fluid escaped, and
the eye collapsed, but it soon plumped out and healed as
you now see it. Some seventeen weeks after, she read
Sn. 44. Now her vision for distance is ^^ and she reads
1 J. When she is at her best Y = -|§. I ought to have
mentioned that two months after the operation, I used mer-
curial inunction freely, and I have no doubt this greatly
influenced the recovery. Since then, I have operated on
four similar cases with benefit in each case, very slight in
one, more in another, in which I think, were I permitted,
I could restore sight ; and in two very good results indeed ;
in these latter I removed nearly the whole of the iris as
well as the false membrane.
{March IWi, 1884.)
5. A case of sympathetic ophthahnitis ivith whitening
of the eyelashes.
By E. Nettleship.
Jessie S — , aet. 23, is an undergrown and very stupid
woman. Her left eye is in a late stage of severe sympa-
thetic inflammation ; the globe somewhat shrunken,
squared, and very soft (T. — 2 or 3), the pupil blocked,
the iris buff-coloured and showing several large vessels,
the cornea clear ; there is still fair perception of light. All
the eyelashes of both eyelids on this side are quite white,
and are said to have got so since the eye became bad ;
the hairs of the eyebrow are not altered, and there is no
perceptible change in the skin of the lids or brow. The
lashes on the other (right) side are of their natural black
colour.
On the August Bank Holiday of 1882, she fell down-
stairs and injured the right eye ; she had no sight in it
84 INJURIES AND SYMPATHETIC OPHTHALMITIS.
afterwards, and was subsequently told it had been
*' ruptured/^ She seems to have had no advice for about
two months, when she went to the Westminster Oph-
thalmic Hospital, where not long afterwards (about three
months from the injury) the eye was excised.
Her account of the failure of the sympathising (left)
eye was far from clear. On the whole it seems probable
that this did not begin until some weeks after the removal
of the exciting eye ; but I should not like to record
the case as certainly one of post-operative sympathetic
disease. The attack was evidently of the sub-acute type
with some neuralgia at times, but no severe pain and no
great congestion ; the failure of sight, '^ like a mist,^' was
the first symptom that attracted her attention.
This case resembles, in the bleaching of the eyelashes,
a case which I saw under Mr. Hutchinson's care at Moor-
helds some years ago, and which I think was described in
his lectures at the College of Surgeons. In that case, if I
remember rightly, the eyes were lost, one after the other,
with severe plastic inflammation of the uveal tract, exactly
like that seen in ordinary sympathetic ophthalmitis, but of
spontaneous, i.e. not traumatic origin. Cases of spon-
taneous destructive irido- choroiditis in both eyes are of
course not so excessively rare, and the occasional occur-
rence of this peculiar change in the eyelashes, both in them
and in ordinary sympathetic inflammation, strengthens the
probability that the pathological processes are essentially
the same in the two groups of cases. There has of late
been a tendency to go back from the doctrine that sym-
pathetic inflammation is transmitted by the fifth or at least
by the ciliary nerves. Cases such as the one now narrated
seem distinctly to favour that belief.
{Living Specimen, Decemher 13 f/?, 1883.)
INJURIES AND SYMPATHETIC OPnTHALMITIS. 8o
6. Enucleation loitJiin forty -eight hours of severe contused
wounds of eyeball and orbit. Severe subacute iritis of
remaining eye setting in several luecks later, probably
sympathetic. Recovery of good sight.
By E. Nettleship.
Thomas D — , set. 41 ^ a railway engine driver, had
his right eye injured in a railway accident in August, 1882.
The other eye was not injured. The damaged eye was
excised by Dr. C. W. Philpot, of Croydon, within forty-
eight hours of the occurrence. Dr. Philpot tells me that
the eye was '^ very badly smashed and the muscles bruised
and pulped. The optic nerve was cleanly divided at the
operation by one cut of the scissors, but judging from the
state of the muscles it may have been previously injured
beyond the point of division. It seems likely that in the
accident the man was thrown against some small projec-
ting knob or angle which smashed into the orbital cavity.
The orbital tissues did not heal kindly, an unusual amount
of suppuration following the operation.^'
Six months after the accident, Feb. 14th, 1883, the man
applied at St. Thomas's Hospital with iritis of the remain-
ing (left) eye. The eye was moderately congested, the
iris fleshy-looking, the pupil small, irregular from nume-
rous adhesions and blocked by membrane ; T. n. ; vision
so bad that he could hardly see his way about and could
not make out 20 J.
He stated that the eye had become affected about a
month or six weeks after the accident above detailed ; it
was painful, irritable, watery, and slightly bloodshot, and
the sight got very dim. The inflammation lasted about a
month, then the eye became quiet and the sight improved
a little until a few days before admission, when the eye
again became inflamed. The man did not come again for
five weeks (March 20th). At that date the eye had im-
86 INJUEIES AND SYMPATHETIC OPHTHALMITIS.
proved very mucli in appearance and in power of sight.
The iris was almost natural in texture, but the adhesions
and membrane in the pupil were unchanged and atropine
had very little effect ; T. n. ; anterior chamber natural ;
vision -|^ imperfectly and words of 4 J. (there was a
minute clear hole in the pupillary false membrane). I have
not seen him again ; at the last visit he had just got his
award from the company, and was going away to live in
a distant part of the country.
Of course the question in this case is whether the iritis
was sympathetic or due to some other cause ? In its
chronic course and the formation of tough adhesions and
membranes it resembles a sympathetic case more than any
other. But if it were sympathetic the attack was doubly
peculiar ; peculiar because it did not begin until long after
removal of the exciting eye, and because the exciting
organ was removed so soon after the injury that inflamma-
tory changes could have only just commenced in it. We
may ask whether the sympathetic inflammation may not
have been excited by some of the bruised orbital tissues
which inflamed after the operation ? And this explanation
seems on the whole not unlikely.
Against the sympathetic hypothesis is the apparently
permanent recovery with good sight, and the fact that,
though there was no evidence that the man was syphilitic,
four years previously he had been laid up for two months
by rheumatism in the hip, knee and elbow, on the same
side (left) as the iritis ; but there had been no inflamma-
tion of the eye then.
{Dec. 13th, 1883).
SYMPATHETIC NEURITIS. 87
7. Sympathetic neuritis without other visible structural
change.
By W. A. Brailey, M.D.
Mary Ann R — , aefc. 27, was admitted to Guy's Hos-
pital under my care on Marcli 31st, 1884.
On Marcli 6tli the left eye was cut with a piece of
broken crockery, the wound extending transversely through,
the entire cornea and ciliary region of the inner side.
After the accident she had no vision in the eye. It was
red, but little painful. She kept it tied up, but had no
medical treatment. Two weeks later there was some little
pain in the right eye and she noticed that its sight began
to fail. She therefore came to the hospital.
On admission. — The wound of the left was united, but
the iris was adherent to it very closely and extensively.
Some opaque lens substance was visible. She had percep-
tion of light. There was some ciliary injection.
The right eye looked perfectly normal. It was not
tender. Slight pain was mentioned, but it did not seem
to be or to have been more than trifling and of doubtful
position. The iris looked normal and dilated fully to atro-
pine. Vision = -^Qj barely. Field complete. Colour
vision normal.
Ophthalmoscojpically . — The media were clear. The disc
was slightly swollen and whiter than normal, its margins
were blurred; the vessels from it were smaller than normal;
some of them had faint white streaks edging them in the
immediate neighbourhood of the disc. Some small tor-
tuous vessels were visible in the neighbourhood of the
yellow spot.
Both the eyes were tied up. Atropine drops were
used, and -j^ grain of perchloride of mercury was admi-
nistered thrice daily. Two days later (April 2nd) there
was no pain in either eye.
April 16th. — Right eye. The disc appears more swollen
88 INJURIES AND SYMPATHETIC! OPHTHALMITIS.
and rather more white. The vessels beyond the margin
of the disc are tortuous and in places obscured.
She thinks the vision is slightly improved, but for the
last three days she has had severe pain on the internal
side of both orbits.
23rd. — The pain has ceased for some days and she
leaves the hospital to attend as out-patient.
29th. — Vision slightly better. A blister ordered to the
temple for four nights.
May 13th. — Vision = •^- (1 letter). Left sees hand
moving at five feet.
20t}i.— Right Vision = 3%.
27th.' — A little pain over brow for the last two days and
vision = -^Q only. She is still taking mercury, and both
eyes are still tied up.
The sight gradually improved till July 4th (the day of
the meeting) when right vision = -^. The optic disc is
less swollen and decidedly more white. No fine vessels
are visible on it. Its margins are still blurred. The
arteries from it are smallish and slightly bordered with
white near the disc ; the veins are of fair size and some-
what tortuous, especially those running upwards.
Remarlis. — The sympathetic nature of the affection of
the right eye is inferred from the fact that it began two
weeks after the injury to the other, tbis injury being of
a very grave nature. A careful inquiry into the history
of the case failed to reveal any other cause of the neuritis.
[July Uh, 1884.)
Mr. W. Adams Feost mentioned a case of sympathetic
ophthalmitis which was under the care of Mr. Tay,* in
which the changes in the anterior part of the uveal tract
were comparatively slight, and in which perfect recovery
of vision took place, but in which optic neuritis was
present, the swelling of the disc persisting long after all
other symptoms had disappeared.
* This case has not been published.
COMPLETE DETACHMENT OF EETINA. 89
8. Specimen sJwiving traumatic detachment of retina and
choroid.
By W. Adams Frost.
Edward A — , ast. 27, admitted into St. George's Hos-
pital under the care of Mr. Brudenell Carter (by whose
permission I publish the case), February 8th, 1884. Left
eye wounded by a splinter of wood eight days before
admission.
On admission. — A jagged wound in lower half of
cornea extending just beyond its margin. Anterior
chamber full of blood.
February 16th. — Globe enucleated. Bisected and
mounted in glycerine jelly.
Retina completely detached and forced out to centre of
globe. The choroid was similarly detached, except for
about 3 mm. round optic nerve entrance, and formed a
complete sheath round the detached retina-globe, filled
with coagulated and fluid blood. Blood in optic nerve-
sheath.
{Card specimen. May 8th, 1884.)
9. Total detachment of retina ; globe filled with organised
blood-clot.
By W. Adams Frost.
Harriet B — , aet. 19, admitted into St. George's
Hospital under Mr. Frost, February 21st, 1884. At age
of three right eye injured in a fall ; no vision in that eye
since. Globe enucleated, bisected, and mounted in glyce-
rine jelly. Globe small. Cicatrix in cornea near centre to
which iris adheres. Lens reduced to a dense white mem-
brane 1 mm. thick. Retina totally detached. Cavity of
globe completely filled by a firm solid mass of dark
colour ; organised blood-clot.
{Card specimen. May 8th , 1884.)
90 PANOPHTHALMITIS.
VI. PANOPHTHALMITIS.
1. A case of pseudo- glioma.
By H. Lewis Jones.
(Communicated by Bowater J. Yernon).
Emily S — _, eet. 1 year and 9 months, was admitted
into St. Bartholomew's Hospital under the care of Dr.
Gee, to whom I am indebted for permission to bring the
case before you.
On October 4th, 1883. — The patient fell down twelve
steps and braised her forehead, but did not seem to be
much hurt. Next day (Oct. 5th) she screamed^ became
insensible, squinted and had a fit.
On Oct. 6th the mother brought her to the hospital.
She had a fit in the surgery.
On admission. — She is a well-nourished child ; her face
is flushed, her head retracted ; she has a bilateral internal
squint, is very restless, and vomits frequently, pulse rapid
and irregular. Temp. 102°, resp. 35.
Family history. — Mother has been subject to cough for
nine years and spits blood at times. She was born with
imperforate anus and has an internal squint of left eye.
Father undersized and has delicate health. Has external
squint of right eye. No syphilis.
7th. — Eesp. 40, pulse 140. Head strongly retracted.
8th. — Partially unconscious ; at 8 p.m. her temperature
rose to 107*4° and there was a slight general convulsion;
after tepid sponging and an ice cap to the head the tem-
perature fell to 1 02° at midnight ; pulse then 1 76.
PSEUDO-GLIOMA. 91
9th. — On the 9th there was some coryza, and injection
of conjunctiva.
10th.. — Head still retracted, knees drawn up, some red
blotches on chest and limbs, best marked on legs and feet
(not like measles in the opinion of Dr. Gee).
11th. — Since admission five days ago, the child has
become shrunken, pale, tremulous, and fretful, and lies in
an unconscious state. There is to-day acute iritis with
hypopyon in the right eye.
12th. — Retraction of head less, otherwise as on 11th.
14th. — The iritis is much improved, the pupil well
dilated by atropine, the hypopyon absorbed ; a white flake
of lymph lies in the pupillary aperture. Mr. Vernon saw
the patient and found well-marked optic neuritis in the
other eye (the left). The child is less fretful and less
unconscious.
From ]4th to 26th there was slow improvement in the
symptoms. On 26th the temperature fell below the normal
for the first time. Some urine also was obtained and
found to be slightly albuminous. Only a slight film now
in pupil of right eye. The patella tendon reflex on both
sides is exaggerated.
November 5th. — Left optic disc and retinal vessels well
defined. Right pupil clear, slight ptosis of right eyelid.
There is no fever ; the child is cheerful and intelligent.
16th. — She was transferred to another bed facing the
light, and it was noticed that there was a whitish reflex
from within the eyeball of right eye.
Mr. Vernon saw the patient on Nov. 21st and gave the
following report.
jB. — Detachment of retina by a yellowish translucent
mass behind. Pupil. — Fixed, dilated. Iris. — Atrophied,
bulging forward, and, owing to the extreme shallowness of
the anterior chamber, in contact with the cornea. Cornea.
— Slightly nebulous. Tension of eyeball much diminished.
L. — Optic disc rather discoloured and indistinct as if
from past neuritis. Choroid. — Deficient in pigment, pro-
bably congenital.
92 PANOPTHALMITIS.
28tli. — Urine still slightly albuminous.
The child remained in the hospital until December
18th. No change occurredj but she grew more plump
and rosy.
At the date of the meeting there was no change in the
condition of the right eye.
{Living specimen. January lOth, 1884.)
IRIDECTOMY IN PRIMARY CHRONIC GLAUCOMA. 93
VII. GLAUCOMA.
1. Clinical observations ivhich appear to indicate a means
of reducing the danger from malignant glaucoma while
increasing the efficacy of iridectomy in the treatment of
primary chronic glaucoma.
By M. M. McHardy.
The usually trifling value of isolated examples of any
but the most rare disorders would prevent my recording
the facts of the two following cases, did I not recognise in
them such exceptional circumstances as appear to warrant
my soliciting your patient attention thereto. Moreover,
I am unwilling to longer delay affixing such small link as
my own experience may furnish, to that almost irresistible
chain of evidence which, laboriously constructed from
widely-scattered fragments, goes so far towards estab-
lishing that rational pathology of glaucoma and its treat-
ment, which Priestley Smith has given to the world in his
Jacksonian prize essay, and by his subsequent work.
Some preface to the curtailed notes of the cases will
promote both brevity and clearness.
In common with the majority of the most experienced
ophthalmic operators, I have long believed, and taught,
that the treatment par excellence for primaiy chronic
glaucoma is by iridectomy, performed through an extensive
initial incision, the whole length of which should be, as
nearly as practicable, in the plane of the external angle
of the anterior chamber ; a large portion of iris being
excised, quite up to its ciliary attachment, along the
whole length of the primary incision. It has been my
habit to supplement such iridectomies by interdicting the
9 A GLAUCOMA.
wearing of any compress over tlie eye after completion of
tlie operation, the primary incision for whicli it is desirable
should heal by a wide and porous, or elastic cicatrix, rather
than by one which is close and resisting.
Uuided by the above conviction regarding the desiderata
of an iridectomy for the treatment of primary chronic
glaucoma, one naturally considered what was the largest
initial incision warranted by the special circumstances,
and justified by the behaviour of large, similarly placed,
incisions through the ocular envelope. This brought one
to reflect upon the initial incision for the extraction of
full-sized hard cataracts by either the modified linear
section or by De Wecker^s peripheric flap section. It
was then obvious that it should be very exceptional for an
average adult eye to succumb from a well-placed, well-
executed, corneo-scleral incision, having an external chord
of at least 10 millimetres. For the extraction of a
cataract a primary incision of such dimensions is usually
dictated by the average bulk and diameter of the body to
be removed through it.
The following questions then suggested themselves and
could only be answered by the results of actual experience :
Could a larger, somewhat similarly placed incision be
safely practised when it was not intended to remove the
lens ? This question is answered in the affirmative by
my own experience in upwards of twenty-five cases of
primary chronic glaucoma treated and cured by iridec-
tomies j the primary incisions for which have had an
external chord with a minimum length of 10 mm.
To what, if any, greater extent could the incision be
advantageously carried, and why ? The occurrence of
primary glaucoma should, cdsteris paribus, lead us to
suspect the presence of an exceptionally large lens.
Priestley Smith's admirable paper, in the last volume of
our ^ Transactions,' indicated that cataractic lenses were
probably smaller than transparent lenses of like ages. This
led one to anticipate that in elderly non-cataractic adults
wo should encounter lenses larger than those which usually
lEIDECTOMY IN PEIMARY CHRONIC GLAUCOMA. 95
present in tlie extraction of senile cataracts. Hence, that
for its easy delivery a transparent lens would require a
larger ocular wound than would a cataractic lens of equal
age. Furthermore, the conditions of the anterior chamber
in glaucoma are prohibitory to any such approximation of
the length of the internal to the external chord of the
incision, as is practicable in operating for extraction ;
when the point of the linear knife, in puncturing, may be
safely directed some 70° below the chord of the projected
initial incision.
Those who accept Priestley Smith's theory of primary
glaucoma must recognise that in a safe removal of the lens,
in its capsule, we should find the most radical cure for the
most sight-destroying of eye affections. The conditions
of the lens, however, in ordinary primary glaucoma would
forbid its removal save in the capsule. Before attempting
to practise the removal, in their capsules, of such trans-
parent lenses, the surgeon would have to feel the ground
very carefully and to advance his efforts very cautiously.
At a loss for any trustworthy evidence upon the facility
or reverse with which such lenses could be extracted, I
judged that the first essential to deciding the point was to
practise an initial incision of such ample size that a
minimum obstacle would be offered to the exit of any encap-
suled lens which might present. However, the risk of
unduly favouring the development of malignant glaucoma
can never be banished from the mind of an operator medi-
tating upon these cases. Too many have experienced
a larger percentage of such disaster than the 2 per cent,
which fell to the lot of Yon Graefe. But — Is not
malignant glaucoma after iridectomy due to an advance
of the lens against the cornea ? Is not its almost invariable
consequence destruction of the sig'ht of the eye ? Advance
of the lens would be hardly less favoured by a restricted
post-corneal incision than by one which was both larger
and more extensively post-corneal than that which is
daily practised for extraction. The latter incision would,
however, almost certainly allow any lens which became
96 GLAUCOMA.
displaced forwards to escape,, and would thus prove the first
step towards favouring the much-desired removal of the
lens^ and would furnish, as suggested by Pagenstecher, a
very ready means of release from the horrors and dangers
which attend malignant glaucoma, developing in an eye
from which the lens cannot get away.
By such arguments I was led to design the following as
my ideal initial incision, which I make by transfixion
with a narrow stiff linear knife, in cases of primary chronic
glaucoma ; viz., tlie external chord of the incision has a
length equal to the diameter of the co^^nea [viz., about
12 mm.) and externally the entire incision lies parallel
with hut one millimetre posterior to the margin of the cornea.
When the particular features of any eye forbid my making
quite such an incision, I am not content with one less than
would suffice for an ordinary extraction, and my belief
that such an extensive incision is not usually practised
leads me to trouble you with my experience of its applica-
tion, and to solicit your valuable criticism upon its merits
or demerits ; while, moreover, I see some hints that it may
prove to be a pioneer of the practical treatment by removal
of the lens of certain unpromising cases of glaucoma.
I instituted this section with a full appreciation of the
gravity of extracting such lenses, as has been well said by
Priestley Smith in a footnote on page 230 of his Jack-
sonian essay. I now have notes of upwards of thirty cases
of chronic glaucoma in which I have practised the section
already described. In no instance have I been able to
associate any unfavourable sequel with the exceptionally
large section. One eye was totally lost through haemor-
rhage which occurred some few minutes after completion
of the operation, and speedily expelled, first the lens, and
then the bulk of the vitreous humour.
In every case the following course, which has given me
the greatest satisfaction, was adopted from the moment of
completing the operation.
Dressings. — Over the closed eyelids a double layer of
lint is laid, and kept moistened with cold boracic lotiou.
IRIDECTOMY IN PRIMARY CHRONIC GLAUCOMA. 97
The case lias the constant attention of a nurse, who ia
provided with a pad of cotton wool, with which she ia
instructed to afford the eye temporary support should the
patient strain, through vomiting, sneezing, coughing, or
ejecting excreta.
The case of Eliza G — , aet. 53 (exhibited January 10,
1884), furnished my only example of malignant glaucoma,
after iridectomy by the above section. She was the
subject of chronic glaucoma, of from five to eight months'
standing, with occasional exacerbations in her symptoms.
She applied with right T. + 2, left T. + 1 and other typical
symptoms. The right pupil was dilated, and did not
contract, neither did the tension diminish in response to
eserine. On the afternoon of November 14th, I performed
an upward iridectomy, with a rather larger section than is
usual for extraction, but owing to the extreme shallow-
ness of the anterior chamber, found it impossible to remove
as much iris as I could desire, and left the case in the
hands of experienced persons. Five hours later the eye
was hard and painful ; the next morning it was chemosed
and presented a typical example of malignant glaucoma.
Twenty- two hours after the operation the lens in its
capsule escaped spontaneously. I then examined the
wound, from which no vitreous humour was protruding,
but in which there was a considerable prolapse of those
portions of iris which I had failed to withdraw on the
previous day. Judging that any interference at the wound
would then be meddlesome and mischievous, a firm compress
was applied, as after any senile cataract extraction, and the
eye has since continued to make an uninterrupted recovery,
the bulging of the cystoid cicatrix gradually diminishing
and the sight improving to what we usually consider to
forebode a good result, after cataract extraction, viz.
counting fingers at 65 cm. without any lens. It has not
been deemed prudent to make a more exhaustive exami-
nation of the acuity of vision.
The left eye was treated on December 5th by a similar
iridectomy, at which a larger segment of iris was more
VOL. IV. 7
98 GLAUCOMA.
thoroughly removed than was possible in the right. The
second eye made a satisfactory recovery. It is noteworthy
that the left eye has never ceased to be full hard since the
operation wound closed^ and has occasionally exhibited an
almost morbidly high tension ; while the right, now
aphakialf eye has shown no glaucomatous symptoms since
the lens escaped.
John T — J set. 49, applied May 9th with sympathetic
ophthalmitis of the left eye, which was tender, photophobic,
injected, and weeping. The right globe was shrunken
and painless ; it had been blinded fourteen years previously
by '' a blow from a 2| in. cut clasp nail.'^
The exciting stump was immediately enucleated. The
sympathising eye was, as far as possible, kept in total
darkness, and atropine drops were used to break down
some posterior synechioe which were found to have formed.
May 17th. — Iritic symptoms almost disappeared; there
is a single posterior synechia at lowest part of pupil, which
is widely dilated elsewhere. Eye feeling uneasy and full.
T. + 2.
Three days later. — The excess of tension has subsided
under the occasional use of eserine, and an absolute
interdiction of the atropine drops.
June 20th. — Recurrence of definite glaucomatous
symptoms ; T. + 2, not relieved by eserine, but which
subsided after an immense upward iridectomy, from which
the eye recovered very satisfactorily.
During September the glaucomatous symptoms recurred
and persisted in spite of everything short of operative
treatment, until V. was reduced to perception of light. I
then again explained the gravely critical bearing of the
case to the patient, and on October 4th he submitted his
sole eye, with T. + 2, Y. = perception of light, pupil
irregularly wide but attached by one fine posterior synechia
at lowest part, to operative treatment. I made a section
such as described, only downwards ; the iris did not
prolapse, I introduced forceps to seize the iris near the
posterior synechia, withdrew a considerable segment of iris,
IRIDECTOMY IN PRIMARY CHRONIC GLAUCOMA.
99
was detaching its ciliary border^ when I discovered the
edge of the lens presenting ; then, rapidly completing
my excision of iris, I removed the speculum, steadied the
globe by two finger-pulps applied over the upper lid, and
had the infinite satisfaction of seeing the entire lens, in
its capsule, escape on to the lower lid, unfollowed by any
vitreous humour. The eye was then treated as after an
ordinary cataract extraction, and made a steady recovery.
Its tension never rose above normal, and its vision quickly
improved to counting, without a lens, fingers at 50 cm.
DiAGEAM TO Scale* (enlaeged 2 diameters).
Each subdivision represents a square millimetre. The cornea is
represented as 12 mm., and the linear knife as 2 mm. in width. The
interrupted line shows the extent and position of the section now
advocated. This diagram demonstrates that with the puncture and
counter-puncture placed exactly 1 mm. posterior to the corneal
margin, and using a knife just 2 mm. wide, the chord of the incision
is given precisely the dimensions recommended, if only a vestige
less than ^ mm. of iris be left visible above the edge of the knife
during the transfixion.
and with suitable lenses the eye now exhibited can read
1 J. fluently, and has distant Vision = j^ Snellen.
Another case (exhibited January lOth, 1884), James
* This is reduced 20 diameters from the exhibited diagram and model
knife, which with others of similar construction greatly facilitate class
demonstrations of ocular sections.
100 GLAUCOMA.
T — J aet. 47. A case of chronic glaucoma wliich was treated
by two sucli iridectomies performed on the right and left
eyes respectively on April 18th and May 9th last year.
They show how close a union may occur without any
compress being worn after the iridectomy, and that after
the close union of even such extensive sections the tension
may remain threateningly high. With its ametropia cor-
rected the left or better eye now has Y. :=. -^.
After judging the desirable size for the incision, I
decided upon the above-named descrijption of its maximum
limits, for the practical reason that it rendered the operator
independent of any measurements other than his eye could
at once gauge upon an inspection of the patient's cornea.
Furthermore, with one exception, I have never practised
this section upon a patient who was not fully anaesthetised
by the inhalation of ether ; and, though I have notes of
some vomiting shortly after eleven of the operations, it
did mischief in not more than one case, — that one in which
haemorrhage worked destruction.
[March nth, 1884.)
2. Acute glaucoma of four weeks^ duration, treated by
cyclotomy ; recovery of good vision.
By Geokge E. Walker (Liverpool).
The case which I bring before you to-night is one which
I showed to the Ophthalmological Section of the British
Medical Association, at the meeting held last autumn in
Liverpool.
It was then in an incomplete state, and as the tension
of the eye was still in excess, there could be no possibility
of dispute as to its having been glaucomatous.
William A — , a master cabinet maker, aet. 55, came to
me on the 7th of July, 1883. I found his right eye
ACUTE GLAUCOMA TREATED BY CYCLOTOMY. 101
suffering from an intense attack of acute glaucoma ; the
tension stone-like, pupil dilated, vision reduced to tlie
barest perception of ligtt, and tlie pain proportionately
great. He gave tke following history : up to the year
1881 he had always enjoyed good sight, and had no ocular
trouble ; but at this time he began to suffer from severe
headache, which was accompanied by acute pain in the
eyes and followed by drowsiness and languor ; also on
going into the open air the eyes would fill with water.
These were the usual symptoms until the early part of
June, 1883, when the right eye began to be painful and
inflamed, so that on or about June 14th he sought medical
advice. The symptoms increased, and he came to me on
the 7th of July. It appears, therefore, that we have a
history of an attack of acute glaucoma lasting at least a
month.
The case seemed to me so bad that I despaired of doing
much more than relieving pain, and, as the sequel will
show, the eye was in such a profound state of disease
that had I made any large incision in all probability I
should have destroyed it at once.
I began by instilling freely a four-grain solution of
eserine which gave him no relief but which put the circular
ciliary fibres on full stretch. I asked him afterwards
whether it had increased his pain, as I have observed it
do so in similar cases, but he said the pain was so bad
before that he thought it impossible for it to become worse.
I waited long enough for the drug to act fully, and then
operated after the manner I have described, viz. keeping
open the lids with a wire speculum I seized the lower
part of the conjunctiva with toothed forceps, thrust
a very narrow knife well within transparent tissue
through the lowest part of the cornea, through the iris,
and then depressing the point of the knife withdrew it,
cutting through all of the ciliary body up to the sclerotic,
but without enlarging the corneal wound. The eserine
had done its work well, seeing that the circular fibres
snapped like a fiddle- string. The characteristic pain
102 GLAUCOMA.
ceased instantly and the smart of the operation in a very
few minutes afterwards. Scarcely any aqueous was lost, so
that the tension appeared not perceptibly affected, and
next morning it was about the same. I therefore ventured
on using a quarter-grain solution of eserine once daily for
a week, then twice daily. The tension slowly went down,
but I think the eserine had little or no effect, the solution
being too weak to have an appreciable influence on the
diseased muscle. Later on I shall mention how, under
different circumstances, a strong solution produced different
effects.
Twenty-five days after the operation I showed him to
the Section at Liverpool. The tension then was so far in
excess, not only in this eye but also in the other, that one
gentleman advised me to perform iridectomy or sclerotomy
at once on both.
But vision had improved so much that two days before
this advice was given, that is twenty-three days after the
operation, he could read with 10-inch glasses, which he
had used six or seven years before the attack, No. 6 of
Wecker's type, and a fortnight after this, vision for distance
was ■^■§-. He improved further up to ■^, and then his
health began to give way and his sight to retrograde,
what with the long strain of the glaucoma and the cares
of business which were now superadded. Generally it
was manifested in debility and loss of appetite.
To recruit his health he went to visit a friend, a flower-
gardener, in the vale of Gresford, where he injudiciously
worked in gathering flowers. The heat of the weather
and the bright colours of the flowers had a very bad effect
on his eye, and he came back to me on October 22nd,
when I found he had an attack of keratitis beginning at
the cyclotomy wound and spreading upwards. For this I
prescribed a one-grain solution of eserine and some tinc-
ture of quinine, and sent him to Alnwick, in Northumber-
land, his native place, where he stayed three weeks and
came back another man.* His vision so improved that
* He told me, however, that he was soon obliged to give up the use of the
ACUTE GLAUCOMA TREATED BY CYCLOTOMY. 103
on November 25th it was ^^ and 1 J., on December
16th ^^, and on February 15th, 1884, some of j|-.
I have not mentioned so far his glasses for distance.
When his acuteness became sufficient to profit by glasses
I found + 1 gave him most help, then after a few-
weeks 36 inch, then 32, 28, and now for the four weeks
ending February 15th, a 26 in. + gives him most help.
On February 25th, 30 + suits him better; he has been
using his eyes much lately.
Of course, after four or five weeks of acute glaucoma
considerable limitation of the field was inevitable. Hori-
zontally the limitation is not nearly so great as one might
expect, but vertically it is great. The vertical field of
vision, however, has considerably enlarged of late.
In the disc one can see how nearly total extinction of
sight was imminent. A physiological cup has been greatly
deepened, but still it is very distinguishable from a fully
developed glaucomatous excavation.
The iris shows several points of adhesion to the lens,
but I have never dared to use a mydriatic in order to
gratify curiosity as to the real extent of them.*
A striking illustration of the efficacy of hyposcleral
cyclotomy is afforded by the following case :
Wm. H — , set. 57, a master of a Dock Board Flat,
was sent to me last summer on account of pain in the
right eye. I found a scar at the lower and inner part of
the sclero-corneal junction and a cyst of the iris attached
to the scar. He had also cataract and some posterior
synechia3. I cut through the anterior synechia, cyst and all,
and sent him home. He had great pain all night and
next morning, but a single instillation of eserine stopped
one-grain solution of eserine, as, although it did him good at first, it afterwards
caused his eye to flush up and become painful. On trying this myself I
found his statement to be quite correct. I think that the posterior synechiae
were caused at this time, but the cloudiness of the cornea prevented recog-
nition of the iritis.
* Since the reading of this paper I have dilated the pupil with duboisine,
without producing any unfavourable symptoms.
104 GLAUCOMA.
it, and the eye soon recovered. As he had good perception
of light I thought I might make an attempt to improve it,
but knowing from the effects of the former operation how
easily the eye could be provoked to inflammation I passed
a cataract needle through the cornea and made an experi-
mental minute cross-cut in the anterior capsule. I could
not detect any change in the capsule with a pair of 5 in.
glasses, so minute was the cut, but it was enough. Before
he reached his home the eye was violently painful and the
lids much swollen. He was most eloquent afterwards
about the pain he suffered all through the night, and when
1 saw him next day he was quite stupid, did not know me
until I spoke loudly to him, and then answered in a con-
fused manner. The eye was stony hard, so at once I instilled
a four-grain solution of eserine freely, and, after giving it
time to act, operated after the plan above described.
At once his long, deep-drawn sighs of relief showed
what a load of pain had been lifted.
He told me afterwards that he had been quite out of his
mind, and I believed him.
The eye gave no further trouble, and I suggested that
lie might have the cataract removed in a short time. But
I fear he is too loth to run the risk of a recurrence of such
suffering as he experienced after the first, and still more
after the second operation, for I have never seen him
since my hint about further operative treatment.
I propose now to make a few brief remarks on the
causation and cure of glaucoma. In 1879 I published an
essay on the subject, in which, reasoning from the relief
of glaucoma by section of the ciliary body, I made these
propositions :
1. That all glaucoma is inflammatory, whether acute or
chronic.
2. That it is produced by inflammation of the ciliary
body, the immediate cause of the increase of tension being
the blockage of the trabeculas of the ligamentum pecti-
natum.
ACUTE GLAUCOMA TREATED BY CYCLOTOMY. 105
3. That the modus curandi, whether by iridectomy,
sclerotomy, or by cyclotomy, is through the rest of^ and
relief of tension in, the inflamed ciliary body, brought
about by the operation, thereby allowing the inflammatory
products to be absorbed from the ligamentum pectinatum
especially, and so bringing about the normal efflux from
the eye.
4. That the ultimate cause of glaucoma is the excessive
action of the ciliary muscle, chiefly of its circular fibres in
hypermetropic eyes, in which group the vast majority of
glaucomatous attacks occur ; and that, therefore, by cor-
recting defects of refraction by means of suitable glasses,
we may guard against and prevent such attacks.
In myopic eyes, also, there is often ove^^-action of the
circular fibres of the ciliary muscle.
The first and second of these propositions now appear
to most ophthalmic surgeons to be truisms ; few think
otherwise than that all glaucoma is inflammatory, and that
it is chiefly through blockage of the ligamentum pecti-
natum that the rise of tension occurs. Of course much
has been discovered since I drew these inferences from the
action of cyclotomy. The adhesion of the periphery of
the iris to the cornea is an anatomical fact which could
not be inferred, and there are other minutiae, which need
scarcely be named in this short review. But the blockage
of the trabeculae is the main factor, and probably in recent
cases the only necessary one, the others being mere
subsidiaries.
But about the third and fourth propositions there is no
such agreement. I am not sure whether I do not stand
alone in maintaining them.
The third, that the three operations iridectomy, sclero-
tomy, and cyclotomy — m acute glaucoma be it always
understood — cure by the ordinary method of relief of
inflammatory tension as in furuncle, anthrax, phlegmonous
erysipelas, &c., I think few would doubt, had they, as I
have done repeatedly, felt a tense ciliary muscle snap like
a fiddle-string at the touch of the knife in the operation
106 GLAUCOMA.
of cyclotomy. Iridectomy and sclerotomy acting in a more
roundabout way do not convey that ready instruction to
the mind afforded by the simple and direct operation of
cyclotomy.
The instant relief afforded by the last-named operation,
even before the withdrawal of the knife from the eye, and
therefore before the very slight escape of aqueous can
have complicated matters, shows that the essential thing
is the relief of inflammatory tension in the ciliary body,
and not the mere temporary lessening of the hydraulic
tension of the globe.
Besides, as has been seen by several now present, in the
case shown here to-night, the tension after cyclotomy takes
many days to reach the normal standard, the only expla-
nation of which is, that until the inflammatory tension of
the ciliary body is relieved, and the inflammatory products
absorbed, the organ cannot accomplish its duty.
In iridectomy and sclerotomy an artificial drainage goes
on for some time, unless the wound heal at once, when
the tension rises. Hence the frequent observation that
an imperfect iridectomy, one in which a tag of iris has
prolapsed and kept the wound open, often succeeds
better than one in which the wound heals up soundly and
at once.
Dr. Brailey suggests that sclerotomy and cyclotomy
cure by opening up a new channel into Schlemm's canal.
This may be so, but, as far as iridectomy is concerned,
I cannot see how it is possible for this operation to do
otherwise than absolutely close and destroy all access to
Schlemm^s canal so far as the incision extends. Surely
when the iris is torn from its connection with the ciliary
body the raw surface must heal up with cicatricial tissue,
and therefore be less likely to allow absorption to take
place than the normal tissue, even though inflamed.
So much for the modus curandi of acute glaucoma.
For chronic glaucoma, if the disease be far advanced, I
submit that all operations when they give relief, do so by
forming a subconjunctival fistula. The scleral wound
ACUTE GLAUCOMA TREATED BY CYCLOTOMY. 107
does not form a cicatrix of filtration because scar tissue is
just as impermeable to fluid as healthy tissue. As I have
shown, it will stand a pressure three times the normal
pressure of the eye, and probably three times three more.
Unless the wound heal up before the intra-ocular
pressure has time to reassert itself, it cannot heal, but
leaves a fistula over which the conjunctiva heals and so
forms a cystoid cicatrix. I have seen this occur several
times after cyclotomy for chronic glaucoma, being able to
watch the process with great ease.
But the most important of all the propositions which I
have made is, that glaucoma depends on overtaxed accom-
modation. If this theory be correct then we can, by early
correction of deficiency of refraction, prevent glaucoma
as easily as smallpox can be prevented by vaccination.
I will adduce very shortly a few proofs. Some years
ago I operated on a lady who had lost one eye completely
by glaucoma. A year afterwards she came saying that
the other eye presented exactly the same symptoms as
those which preceded the destruction of the first. She
wore a suitable glass and came back a few weeks after
having lost the symptoms altogether. The patient I have
shown to-night had in the left eye almost T. + 2 when I
operated on the right. He has been treated only by
glasses, yet the tension is now normal.
But there are certain anatomical conditions elucidated by
Dr. Brail ey which seem to prove my case up to the hilt.
He finds in cases of glaucoma dependent on adhesions of
the iris to the cornea, that the sclerosis and atrophy of the
ciliary region is most intense and complete at that part
which is most dragged upon by the adhesion. Now, if
this be the case, viz. that an anterior synechia of, may be,
a few months' standing, shall cause sclerosis and atrophy
of the ciliary body opposite to it, why should not a drag
all round the ciliary region by a constantly contracted
circular muscle going on perhaps from the time of learning
letters to middle age, produce a similar effect ? It would
be impertinent for me to dwell long on this.
108 GLAUCOMA.
The phrase whicli I used more than five years ago
to denote this, viz. " ciliary spasm/' is now current
technical language, and everyone has seen patients
requirirg, say, — 1*5 D. for distance and yet, after the
spasm has been released, showing a hypermetropia of
+ 1'5 D. That is, there has been a ciliary spasm of 3 D.,
which is as if a patient were reading small print constantly
for three or four years. This is a very mild instance. I
have seen many greater, and so, no doubt, have most
of us.
Then the fact brought out by Dr. Brailey, that in the
early stages of simple glaucoma the sclerosis, &c., is
more marked at some points than others, can be accounted
for. Most of such eyes are astigmatic, and therefore the
lens has to be more acted upon in the meridian corresponding
to the meridian of lesser curvature of the cornea. Hence
that part of the ciliary muscle which has to accomplish
this must be more overworked than the opposite, and
therefore more likely to be first inflamed.
(Living specimen. March 'iSthj 1884.)
3. Examination of a glaucomatous eye in which retinal
haemorrhages were present, and were distributed in a
manner suggestive of obstruction to the descending
tranches of the central vessels.
By E. Nettleship.
(With Plate I, fig. 2.)
Amelia W — , set. 58, a laundry-woman, who had never
worn spectacles, began to notice "rainbows '^ and mist
with her left eye about six months before admission ; two
or three months later the right also began to fail. She
had no pain and the sight did not vary much from day to
day, though generally rather better in the evening.
HJIMOERHAGTC GLAUCOMA. 109
She was admitted on June Btli, 1883, into St. Thomas's
Hospital. With the L. she had only perception of light ;
p. about 6 mm. when shaded, acting somewhat to light ;
O.D. very pale and deeply cupped ; numerous haemor-
rhages seen in the retina, but their distribution not noted.
T. + 1. R. counts fingers, F. extremely contracted
(varying from 10° to 5° from fixation point) ; p. rather
smaller than left, and fairly active to light (from 5 to 4
mm.) ; T. ? + . State of anterior chambers not noted, but
had they been very shallow I should certainly not have
performed sclerotomy. Urine 1015, no albumen, no sugar.
On June 8th sclerotomy was performed upwards in eacli
eye under ether ; eserine had been used, but the ps. would
not contract well. All went well in the R., and six weeks
later sight had improved to seeing the test-board at 20',
choosing +4 D. for this distance, and reading letters of
16 J. with +9 D. No prolapse occurred, and the wounds,
separated by a narrow scleral bridge, remained flat.
In the L. (the worse eye), though a similar scleral
bridge was left, the iris prolapsed freely into the first (or
puncture) wound, on the table ; and although it was per-
fectly replaced with a small vulcanite spatula, the prolapse
recurred next day, and the eye became very painful. An
anaesthetic was again given and the iris removed, but not
successfully, and a little vitreous escaped. Temporary
relief followed, but pain and irritability returned and the
lens began to get hazy ; the eye was therefore excised on
July 10th.
On opening the globe, equatorially, whilst quite fresh,
the lower half of the retina was found to be studded with
very numerous blood patches of various sizes ; it was at
once placed in strong alcohol, and the accompanying draw-
ing was afterwards made (Plate I, fig. 2). All the
haemorrhages are situated below a line running horizon-
tally through the disc and yellow-spot ; they show a ten-
dency to radial grouping, they extend far forwards, and
it is to be noted that all the vessels of the affected half of
the retina are extremely small, only one artery and two
110 GLAUCOMA.
veins being visible, and these witb difficulty. The vessels
distributed to the other half, though no doubt smaller J
than during life, are all easily visible. As these appear-
ances suggested that the bleeding had been caused by
an obstruction to tbe return of venous blood from the
lower half of tbe retina I boped to be able to find
evidence of venous thrombosis. Arterial occlusion might
also probably account for the appearances.
Although the case is not an example of typical retinitis
hemorrhagica such as is believed with much probability
to be often due to venous thrombosis, the arrangement
and distribution of the extravasations are very similar, and
considerable interest would therefore attach to the deter-
mination, in the present specimen, of the local cause of
the bsemorrhages. I have, however, not succeeded in
positively proving the existence of occlusion in any of the
vessels. In many of the veins on the disc and in the
retina, the blood-corpuscles are represented by bodies of
various sizes, some larger, others smaller than natural, as
if some breaking up and amalgamation of corpuscles had
taken place ; and these appearances are not found in the
choroidal veins, nor in sections of the trunk of the central
retinal vein in the optic nerve. They certainly suggest
a condition of stagnation in the veins referred to. Most
of the arteries were extremely thickened, alike in the
retina, choroid, and optic nerve ; but none were seen to
be occluded.
{July 4th, 1884.)
GLAUCOMA WITH THICKENED VESSELS. Ill
4. Glaucoma ivith retinal haemorrhages, thickening of
retinal veins, and obliteration of arteries.
By E. Nettleship.
(With Plate II, fig. 1.)
Martha B — _, 45, married 23 years, has had nine
children. Admitted at St. Thomas's Hospital in Febru-
ary, 1883, with double absolute glaucoma. Sight had
been failing in the left, and probably in the right, for
about two years, when nine or ten weeks before admission
a severe acute attack with headache, vomiting, and deli-
rium (?) came on, and she went blind.* The eyes had
now become quiet, but T. was -|- and the anterior cham-
bers shallow. The ophthalmoscopic appearances in the
left were not particularly noteworthy ; the disc moderately
cupped and not very pale, very marked spontaneous arte-
rial pulsation on the disc, no vascular changes and no
haemorrhages.
But in the right, the appearances shown in Plate II, fig.
1, were seen : — The disc is deeply cupped, extremely pale,
and shows only a small number of the central vessels, and
these much shrunken, on its area. The retinal arteries
(except the ascending main division) either become invisible
shortly after leaving the disc, or are traceable further on
only as white lines ; the ascending division, though very
small, is pervious for a long distance, but one of its
chief branches is obliterated and white. The veins at
some distance from the disc are represented by thick white
bands ; as they approach the disc a blood-column of
greater or less width appears in all, though the upper
main vein (corresponding to the pervious artery) is the
only one carrying anything like a natural quantity of blood.
This vein is extremely tortuous and is obscured, close to
* From the appearances it is probable that the right eye had been blind
for a much longer time.
112 GLAUCOMA.
the disc, by some mottled extravasations. Another vein,
the descending temporal, is also very tortuous, but only at
a long distance from the disc, and near this tortuosity also
are a number of haemorrhages ; a few are also seen in
other parts. The white cords representing obliterated
veins are seen to be broader than the normal veins would
be at corresponding distances from the disc.
The patient looked in good health, but was weak in
body, and her memory and articulation were defective. A
double bruit was heard over the base of the heart, and the
pulse was collapsing (water-hammer) ; urine 1030, free
from albumen ; lungs and abdomen normal. For some
time (two years) her manner had been '^ odd,^^ and she
had been subject to " numby fits '^ in the right arm with
'' loss of speech, and pins and needles.'^ During the
acute glaucoma she was " quite out of her mind,'^ but had
been '^ sensible again ^' for a fortnight before admission.
She was taken in (under Dr. Bristowe's care) for a
short time, and during her stay had several attacks, begin-
in g with emotional excitement and going on to noisy
delirium with delusions that she was going to be killed.
After one attack she had a distinct '^ lisp '^ in her speech
for a short time. Temperature normal throughout. She
has lost one child from ^^ heart disease,^' and has a sister
who has had numbness and loss of power in one leg.
The coincidence of aortic insufficiency with increase of
tension in the eye is probably enough to account for the
obliteration of the retinal arteries, though we must assume
the existence of some other factor to account for this
occurring in the right eye alone. The cause of the venous
thickening, also confined to the right eye, is not clear.
{Card specimen. March 13th, 1884.)
DESCEIPTION OF PLATE II.
Fig. 1 shows the ophthalmoscopic appearances in Mr. Nettle-
ship's case of Glaucoma with Thickening of Retinal Veins and
Obliteration of Arteries (p. 112).
Right eye ; erect image. From a drawing by Miss Boole.
Fig. 2 shows the ophthalmoscopic appearances in Mr. Nettle-
ship's case of Central Guttate Choroiditis (p. 164).
Left eye ; erect image. From a drawing by Miss Boole.
Figl
Trans. Ophth. 6'oc Vol JV^, PI U
M. Boole, del.
Lebor. ^Co.
GLAUCOMA FOLLOWING A BLOW. 113
5. Chronic glaucoma ivlth a neiv connective tissue growth
in the right vitreous springing from the glaucomatous
cup.
By W. Lang.
(Under Mr. Adams' care.)
James W — , aet. 48, labourer. Right and left both
'^ operated on/^ Right ten years ago at Manchester.
Left sixteen months ago at St. Bartholomew's Hospital.
Right, no p. 1. Pupil very wide, scarcely any iris visible ;
edge of lens shows. Disc cupped, but filled by a new
growth which spreads forwards into vitreous nearly as
far as ciliary processes, principally on the outer half of
globe. Vessels are seen springing from the retinal vessels
and then coursing in the growth, which, is white in colour
and of a fibrous appearance.*
Left field much contracted, forming a narrow horizontal
slit stretching outwards. Vision ■^, Hm. 2*5 D. ^, 1 J.
with 5 D. ; deep glaucomatous cup. No other change.
(Living specimen. May 8th j 1884.)
6. Gase of glaucoma following a blow in a hoy, set. 14, the
symptoms of luhich were relieved by eserine.
By W. A. Brailey, M.D.
Henry H — , aet. 14, was brought by Dr. Matcham to
Guy's Hospital on September 21st, with the pupil of the
right eye fully dilated and fixed, and the tension increased
to 2. The vision was -^ and 16 J. at 10" ; the fundus
reflex was more dull than in the other eye ; the disc, though
* A painting by Mr. Morton showed the course of the vessels perfectly,
and Mr. Milles showed a similar condition under the microscope.
VOL. IV. 8
114 GLAUCOMA.
sufficiently visible, appeared a little misty. In all other
respects the eye appeared normal, inclusive of the ante-
rior chamber. The left eyehad Y=|- and 1 J. at 10". It
was quite unaffected.
The history taken by Mr. Pigeon showed that eight days
before at 10.30 p.m. he received a blow on the right eye
from the cork of a ginger-beer bottle. The eye, though
not painful, was kept closed as a precaution till morning,
when the vision appeared about as defective as on admis-
sion.
Within an hour of the time of his being first seen the
tension was reduced by means of one instillation of a four-
grain solution of eserine sulphate from T. 2 to T. n.
(slightly full). The vision had improved from -^ and 16
J. at 10'' to -^ and 4 J. at 1", The pupil was contracted
fully, though not to the typical pin^s point. Next day,
September 22nd, at 10.30 a.m., the vision had again fallen.
Y=^ and 16 J. at 10'', and the tension was +1.
Eserine was then ordered thrice daily, and the vision
and tension again improved as before ; afterwards showing
still further slow improvement.
On September 28th the drops were omitted with a
resulting increase of the tension, &c., as before, nor did a
hypodermic injection of ith grain of hydrochlorate of
morphia cause any improvement. This^ however^ was
not sufficient to contract the pupil.
September 29th. — The eserine was resumed.
October 2nd.— ¥ = ^2, 2 J. at 7", T. full (one hour
after eserine).
4th (one hour after eserine). — Y-=-^, very slight im-
provement with — *75 D.^ ] J. at 6'' hesitatingly. T. full.
Field complete.
9th (no eserine to-day). — T. full, pupil medium
sized, slightly excentric upwards, reaction to light
extremely slight. V=i% ^^^ ^ J* ^^ ^" * -^^ pain.
One instillation of hydrobromate of homatropine now
made ; T. n. (full) . Pupil dilates and is circular. Optic
disc slightly hazy, apparently from haze in the vitreous,
GLAUCOMA FOLLOWING A BLOW. 115
"but its details are sufficiently visible for me to be able to
say tliat it is about normal. Fundus reflex not so bright
as in the other eye. ^=-^ ^^^J) H. = 2 D._, Y = -^^
perfectly. No pain or inconvenience noted.
11th (day of meeting). — No eserine to-day. P. medium
sized. 0. D. as before. Says Y. not quite so good since
the homatropine. Slight opacities in lens near its ante-
rior surface, markings in the form of slight stellate difficult
to recognise, except by oblique illumination. T. still a
little fuller than in the other eye.
There is no obvious change in this case to account for
tlie tension, except perhaps the condition of the pupil.
Certainly the tension falls when this is contracted. Is
this due to the tension on the iris at the periphery of the
anterior chamber causing a stretching of the fibres
between the spaces of Fontana, and thus opening out
these and causing a more ready access of the fluids of the
anterior chamber to the canal of Schlemm ?
If this explanation of the fall of tension be allowed we
must admit that the ways of outflow when thus opened out
are more than equal to the passage of the fluids of the
normal eye. And as the tension remains full even under
the use of eserine we are driven to admit an increased in-
flow into the eyeball upon which the tension may be
reasonably considered to depend. In this connection the
haze of vitreous may be noted. The author has pointed
out the invariable increase in the cell elements of the
vitreous in glaucoma.
(Living specimen, October 1 \thj 1883.)
116 DISEASES OF THE LENS AND CAPSULE.
YIII. DISEASES OF THE LENS AND CAPSULE.
1. On 200 operations for extraction of cataract.
By Charles Higgens.
In March, 1879, I read before the Eoyal Medical and
Chirurgical Society, a paper ^^ On One Hundred and Fifty
Operations for Extraction of Cataract,^^ which is published
in the Society's *^ Transactions ' for that year (vol. Ixii).
The cases on which the present paper is based occurred
between May, 1878, and February, 1883.
The 200 operations were performed on 175 patients, of
whom 93 were males and 82 females. Both eyes were
operated upon in 25 patients. 181 of the cataracts were
nuclear, 19 were cortical.
The results are collected under three heads : successful,
partially successful, and failures. Under the first head
are placed all eyes which, aided by a suitable convex lens,
could read types from Snellen '5 to Snellen 4, or 1 J. to
16 J. at a distance of about 20 cm. to 50 cm., and had
vision for distance = ^ to -^q, could tell the time on a
watch a fortnight or three weeks after the operation ; or
in patients, unable to read, could see the stitches in a shirt
wristband or thread a large sewing needle. One case,
counted successful, could only read 19 J., but the patient
suffered from retinitis pigmentosa, which was the cause of
the want of sight. The number of successful cases is 175
(87'5 per cent.)
Under the second head are placed eyes which could see
to count fingers, tell one from the other, and whether the
back or front of the hand was looked at. The number of
partially successful cases is 9 (4'5 per cent.).
Under the third head are placed all eyes that saw no
OPERATIONS FOR EXTRACTION OF CATARACT. 117
better, or worse than before tbe operation. The number
of failures is 16 (8 per cent.) ; of these, however, two
might be brought under the second head by further
treatment. Anaesthetics were given in all but twelve of
the operations.
Loss of vitreous occurred eight times. A traction in-
strument, sharp hoop or scoop, was used in fourteen in-
stances.
Secondary operations — needling opaque capsule, iridec-
tomy and cutting through opaque membranes with scissors
— were required in 38 cases (19 per cent.).
Two methods of extraction were employed. A small
flap section either upwards or downwards, associated with
iridectomy performed at the time of extraction or some
weeks or months previously, and an oblique corneal section
(Bader's or Leibreich's extraction).
By the first method 176 cataracts were removed, 121
by upper sections, 55 by lower. The second method, in
all instances with downward section, was employed in 24
cases, in 7 of which a small piece of iris was removed.
My experience since the publication of the first table
has led me to almost entirely discard every other method
of operating in favour of the small flap section, with iri-
dectomy performed at the time of extraction in cases of
mature cataract, and as a preliminary, not less than a fort-
night before the extraction, in cases of immature cataract.
In the majority of cases I make the section upwards, but
when operating without anaesthesia or in cases where I
expect any difiiculty I make it downwards.
The section is made with a Graefe's knife ; it should lie
entirely in the sclero- corneal junction and form a flap con-
sisting of about one third of the cornea. The iridectomy
should be narrow, but extend through the whole breadth
of the iris. I do not aim at making a conjunctival flap,
but if the conjunctiva stretches over the knife, as is often
the case, and is cut at a distance from the incision in the
sclero-corneal junction I have no objection to it.
(May 8th, 1884.)
118 DISEASES OF THE LENS AND CAPSULE.
2. On a preliminary precaution to he tahen in cases of
cataract extraction, when there is, or has been, any
lacrimal obstruction or catarrh.
By J. F. Streatfeild.
I may take it for granted that tlie proportionate
number of successful as compared vrith. the unsuccessful
results of cataract extraction is very much, greater than it
was a quarter of a century ago, and also that one of the
most worthy objects of the ambition of any eye surgeon
is that he might be able to reduce the present very small
percentage of failures as a consequence of this very
common and most important operation. With this object
in view I venture to claim your attention for a short time
to a matter which you will admit to be of very great
practical importance, speaking generally, and if I add to
this that I have now in my mind particularly, some cases
of cataract requiring extraction, in which an unsuccessful
result means absolute failure, and total loss of the eye, the
subject must appear to be of the greatest importance.
The cases in question are those which are complicated
with lacrimal obstruction, or catarrh (not in itself a very
important matter, and happily not a very common com-
plication of cataract, for there is no connexion between
them but in the fact of their occasional coincidence), but
when it happens that there is a cataract requiring extraction,
and a lacrimal obstruction, or catarrh, of the same eye, it
is a very serious matter indeed ; for without any special
and extraordinary preliminary precautions, such as I am
about to propose, the operation in such cases (as I have
said) involves a probable, if I may not say a certain, failure
of the worst kind, and as the cause of failure in these
cases has been overlooked or misunderstood, this cata-
strophe seems to me to have been almost inevitable ; the
eye was lost absolutely— even a partial success was, I
believe, well-nigh impossible with the imperfect precautions
CATARACT EXTRACTION. 119
which hitherto only may or may not have been taken in
such cases. If, for these exceptional cases, I can point
to a certain preliminary precaution which will give an
average and ordinary chance of success to the subsequent
extraction operation, that is to say (considering the
favourable statistics of average cases of cataract to be
operated on, and eliminating beforehand, as I propose, the
unfavourable prognostic complication of these exceptional
cases) a chance which is almost a certainty, I venture to
think that my suggestion will be adopted, or at least that
ycu will try it, in the cases to which it is applicable. As
I have said I am not now concerned with the cases of
partial failure of cataract extraction, with those, for
instance, which are the result of early or late iritis sub-
sequent to the operation, but only with some of those in
which the eye is quite spoilt, as a consequence of the
cataract extraction ; a secondary operation is therefore
in these cases out of the question, and no imperfect
vision is to be obtained in any way, — the eye in fact is
absolutely lost. If the result in these complicated cases
is not always as fatal to vision as I have suggested, I feel
sure that I am not much exceeding the truth. To return
to the particular point of my argument, the unfortunate
cases to which I am alluding are those in which suppui^-
tion follows purulent infiltration of the corneal wound,
when it occurs as the direct and immediate consequence of
the extraction operation, — the common, almost invariable,
beginning of the suppuration of the whole eye. These cases
are of course not common, because the absolute loss of an
eye after cataract extraction operation from any cause is
happily a rare event, and the suppuration cases are only
some of these absolute losses. (In my experience I may say
that most of the absolute losses have been the result of
suppuration : of the last six absolute losses after extraction
at Moorfields three were the result of suppuration.) Now,
as I have been so unfortunate as to have two such cases
within the past year, one in private practice, and the other
at Moorfields, and as both were in every respect alike (but
120 DISEASES OF THE LENS AND CAPSULE.
that, in the former case, I used greater antiseptic pre-
cautions)— my attention has been more particularly drawn
to this way by which eyes are lost sometimes after
extraction. I will relate the case of the hospital patient,
the last case I have had, and the last case I hope I shall
have, and, at least as regards the cause from which these
two losses have resulted, I have some reason for the hope
I have expressed, as I shall endeavour to induce you to
believe. The reason why the eye is thus lost by suppura-
tion after cataract extraction is generally said to be
obscure, I may say unknown. It is not at all satisfactorily
accounted for, surmises are indulged in, but I am now
inclined to think it is generally due to some lacrimal
obstruction and secretion of purulent matter from the
outlets of the tears, in connexion with the eye operated
on. But, you will say, who would ever think of operating
for extraction when there is any lacrimal catarrh, or at
least when there is any purulent regurgitation from the
lacrimal sac, or indeed any pus of any kind or from any
part of the mucous surfaces within the palpebral aperture ?
I am willing to admit that no operator would do this, and
to assume that there is no eye surgeon who would not be
careful to ascertain in a general way, and in the usual
manner, before operating for cataract extraction, that there
was no slight, chronic and persistent secretion from the
lacrimal or conjunctival mucous membranes. Of these
two, the latter may be seen for the most part, and some
part of the conjunctiva at least is always seen, but the
state of the lacrimal mucous membrane is much less easily
investigated, and, as it is not so obvious, if it is not
ostensibly diseased, it is so ranch the more likely to be
considered to be in a healthy state when it is not so,
no suspicion of its abnormal condition having been
aroused. A purulent discharge from either mucous tract
is liable to recurrence, and such a discharge from the
lacrimal mucous membrane is, I think, even more likely to
recur than the conjunctival discharge at any time,
especially if an operation on the eye has been done, — it
CATARACT EXTRACTION. 121
is more hidden and obscure when it does recur, so that
altogether there is great risk, in such cases, even if no
discharge, purulent or otherwise, can be found at the time,
when any one of the more considerable operations on the
eye is to be performed. We must try, by deep pressure
made over the lacrimal sac, if any accumulated fluids can be
expressed and made to regurgitate, but the lacrimal sac
is a cavity imperfectly compressible ; perhaps it is lax and
dilated by former distension, perhaps its lower outlet, the
nasal duct, is perfectly patent, and then, although nothing
can be squeezed from the sac, so as to appear on the con-
junctival surface, it may be nevertheless secreting pus in
small quantity, and an inconspicuous quantity of pus will
be sufficient to infect the corneal section, to poison the
wound, and so to ruin the eye, which otherwise, as regards
the operation, promised to do perfectly well. We must
therefore not be contented to look at the conjunctiva, and
to try, before extracting cataract, if there is any regur-
gitation from the lacrimal sac on pressure with the point
of the forefinger ; we must also inquire if the eye has been
any way inflamed and particularly if it has been, at any
time, habitually, a watery eye. For, although there is no
present or recent lacrimation from obstruction, and no
catarrh of the lacrimal mucous membrane, we know how
small a cause, perhaps affecting primarily the conjunctiva,
will generally induce a recurrence of the inflammation of
the lacrimal mucous membrane, whether it is propagated
from below or from above. In this way, as it is con-
tinuous with the conjunctiva, and as, when the operation
of cataract extraction is done in the ordinary way, the
conjunctiva is exposed for some time, compressed by
the speculum, torn slightly by the fixation forceps, and
probably cut with the knife, I am in no doubt of the
reason why, when a cataract is extracted, when there has
been also, at a former time, inflammation of the lacrimal
mucous membrane, and probably obstruction of the nasal
duct, this inflammation is then at once set up afresh,
pus soon follows, and reaches the corneal wound, before
122 DISEASES OF THE LENS AND CAPSULE.
it is healed. In this way it is, I think, that, generally at
least, eyes are lost by suppuration ; there may be no trace
of lacrimal or any other discharge, purulent or otherwise,
but for the reason I have given it comes to much the
same thing, practically, if there is the latent proclivity.
And, for my part, I will do no more cataract extractions
if I know of, or even if I have reason to suspect this latent
proclivity, till I am assured that this risk, however remote
it may be in any case, is completely obviated and no
longer existing. It is now my object to show that this
can be done. The particular case I have to relate for
this purpose, as an illustration, is the following :
John L — , set. 68, a thin and healthy countryman,
was admitted at the Moorfields Eye Hospital on the 4th of
July last year, with cataracts which, in both eyes, were
mature, and in this and in every other way were fit
for operation and promised well ; but both the lower
lacrimal puncta were somewhat everted, and consequently
there was an overflow of the tears in either eye. The
lower canaliculi were consequently slit. Pus was found
in the lacrimal sac on either side. After this the nasal
ducts were probed every day, or nearly every day, for ten
days. This was very successful; the cure seemed to be
complete, there was no more purulent or any other
discharge from the lacrimal sacs. And therefore, on the
16th of the same month, I extracted, without any diffi-
culty or mishap, the left cataract. On the 1 7th, the day
after the extraction, suppuration had begun, with the
usual signs and symptoms, as a purulent infiltration of the
wound at tbe upper part of the cornea. It spread rapidly
from thence, the eye was very soon lost for all practical
purposes, and on the 23rd it was excised. The patient
left the hospital on the 2nd of August. On the 24th of
November he was readmitted. I had now to do with the
right eye and its surroundings ; there was some lacri-
mation, but no evidence of any pus in the discharge from
the sac at this time. The lower canaliculus, which had
been slit, was patent. The eye was in all respects
CATARACT EXTRACTION. 123
healthy, the cornea, anterior chamber, and iris, all the
parts in front of the opaque lens, were normal. The right
nasal duct was probed occasionally. On the 9th of
December the eye was still in much the same condition ;
the tears still collecting, in small quantity, at the inner
canthus, and, at times, with very little excitement, running
over the margin of the lower lid. As before, there was
no appearance of pus or muco-purulent matter, in this
fluid ; no regurgitation from the sac on pressure. The
patient thought the eye was much less '^ watery ^' than it
was when he was last admitted. Now, this was a very
unsatisfactory state of things ; there was no difficulty in
passing the large probes ; the case was better, not well.
There was, or there seemed to be, no pus in the discharge,
but there might be again, as I knew by past experience,
at any time. I dared not operate for extraction on this
eye when he had but this eye to depend upon, and it was
in much the same condition as that of the other eye which
he had lost. The patient had absolute confidence in me,
which I did not feel in myself, and the result of my
deliberations was that I determined, in his case, to resus-
citate the old operation for the total obliteration of the
lacrimal sac, the canaliculi, and all the lacrimal mucous
surface, which was so troublesome, and, in such a case as
this, so threatening and dangerous. This operation used to
be done occasionally, twenty years ago, not as I now propose
it, for the purpose of securing- an eye, before cataract
extraction, from purulent infection, but for chronic obsti-
nate discharge from, and distension of, the lacrimal sac
from obstruction of the nasal duct. (This was before the
time of the very large and much more efficient probes for
the nasal duct which are now in use.) The treatment
may be considered heroic, but I could think of nothing
else to be done, and I could not help thinking that, by
thus destroying the abnormally secreting mucous surface,
I should make sure of a good result, for there was no
other point in which the prognosis was unfavourable. I
did not therefore hesitate, or make any further delay.
124 DISEASES OF THE LENS AND CAPSULE.
Oq the lOth of December he was anaestlietised, tlie upper
canaliculus of tlie right eye was slit, from tlie punctum to
the lacrimal sac (the lower canaliculus of this eye liad
been slit, as I have said, and was patent). When the
bleeding had stopped the eyelids were held widely apart,
the eye itself being covered and protected, and the pointed
end of Paquelin's thermo-cautere was passed rapidly in the
direction of first one and then the other canaliculus, along
them, and quite into the sac. I then made a skin incision
over the lacrimal sac, rather longer than the whole of its
extent, downwards and a little outwards, between the root
of the nose and the lower eyelid ; this was then continued
more deeply and quite into the mucous cavity itself, and,
when the bleeding was arrested, the two edges of the deep
incision were held widely apart for me with retractors,
and I applied the broader end of the cautery very freely
and repeatedly to all parts of the exposed mucous surface,
from the top to the bottom of the sac, for it is very diffi-
cult to be sure of the destruction of mucous membrane.
The cavity was stuffed with carbolic-oiled lint. On the
22nd the hollow space was filling up slowly. The mucous
membrane seemed to have been completely destroyed.
On the 1st of January this year, the wound had healed.
The sac and the canaliculi were apparently obliterated.
There was slight lacrimation, but there was no pus or
any muco-purulent matter in the eye. On the 6th of this
month the patient left the hospital. On the 23rd of
April he was again admitted. There was then a depressed
scar in the place of the lacrimal sac, and a small hole
leading down in that direction. There was also an indica-
tion of a part of the lower canaliculus ; there was no dis-
charge, but the eye was a little watery, with tears only.
The following day I used the cautery again to the fistulous
orifice and to the remains of the lower canaliculus. On
the 8th of May I used the cautery a third time, to satisfy
my scruples and suspicions. On the 20th there seemed
to be no trace of the canaliculi remaining, and no indica-
tion left of a lacrimal sac ; both seemed to have been
CATARACT EXTRACTION. 125
completely destroyed at last. There was now no discharge
upon the conjunctival surface at any time, the flow of tears
was not much, and it was no longer troublesome. On the
2nd of June I extracted the cataract of the right eye ;
there was no mishap at the time of the operation. The
eyelids were washed with a (1 in 40) solution of carbolic
acid before the operation, and boracic acid ointment (gr. x
to 3j of vaseline) was smeared on the dressing. A weak
solution of boracic acid was used subsequently every day
to bathe the eye, and the same ointment was reapplied
with the after-dressings. On the 9th, that is to say after
a week, the eye was examined. It looked well ; there was
very slight congestion ; the pupil well dilated (with
atropine, which was used once daily). He had had no
untoward symptoms. On the 16th he had a little pain,
slight ciliary congestion, and photophobia, but the pupil
continued to be well and widely dilated ; a blister was
applied to the temple. On the next day the pain was less,
but there was considerable spasm of the orbicularis,
together with the intolerance of light. From this time to
the 23rd all these symptoms decreased, and at that time
the ciliary congestion, pain, photophobia, and muscular
spasm were gone, the conjunctival redness had almost
disappeared ; the eye was a little watery, with tears.
There had not been at any time, since the extraction
operation, any conjunctival discharge, and the pupil
continued to be large and black. There was a small portion
of the remains of the lens capsule to be seen in it. The
wound is now well healed, and I suppose he cannot fail to
have good vision when the time comes for this to be
tested.
I need only remark that, in this case, I have succeeded
according to my intention, and I do not see how, in
another such case, I can fail in excluding the risk which
is incurred by extracting cataract when there is a suspi-
cion or a probability of purulent infection of the corneal
wound, from the common source of this infection. For
if, as I believe, the pus which is the source of this pecu-
126 DISEASES OF THE LENS AND CAPSULE.
liar danger, conies from the lacrimal, not from tlie
conjunctival mucous tract, and if tlie lacrimal mucous
membrane is destroyed, or shut out from its connexion
with the surface of the eyeball, it caunot poison the wound
in the cornea, and the loss of an eye, after extraction, by
purulent infection will become a very much less common
event than it has been hitherto. Allow me to reiterate
that the danger is almost as great in extracting cataract,
that is to say, in making a large section of the cornea,
when there has been lacrimal obstruction or catarrh, as
there is, or would be, in doing the operation at the time
when pus is obviously present ; because, in the former
case, there is such a strong probability that a discharge
from the lacrimal sac will reappear after the operation,
and pus reappear in it, before the wound in the cornea is
healed. I need not detain you by trying to set aside the
objections, which are not practically very strong objections,
to the obliteration of the lacrimal sac. At least in these
cases, in which I am now advocating a revival of this
obsolete practice, it seems to me to be absolutely neces-
sary in order to succeed in operating for cataract subse-
quently.
{July 4th, 1884.)
3. The treatment of cystoid cicatrix after cataract
extraction.
By John B. Story (Dublin).
The subject which I have the honour to bring before
the Ophthalmological Society is of considerable interest,
and does not seem to have hitherto received the attention
its importance deserves. Since the peripheral linear
extraction of Yon Graefe has been in vogue few oculists
in large practice have failed to see occasionally the good
results obtained by a cataract extraction rendered nuga-
CYSTOID CICATRIX IN CATARACT EXTRACTION. 127
tory by the occurrence of a cystoid cicatrix, and what is
worse, in some cases an actual suppuration of the whole
globe brought about directly or indirectly by means of this
curious affection. And yet the text-books are silent upon
the treatment of this condition, and a careful search
through ophthalmic literature throws such little light
upon the subject that the history of the following case
cannot, I think, be without its value in the dearth of more
authoritative statements than we at present possess.
Mrs. P — , an extremely corpulent old lady of between
60 and 60 years of age, consulted me first in May, 1881,
with commencing cataracts in both eyes, the right lens
being the more opaque of the two, but neither cataract
being ripe enough for operation. With the left eye,
which had hitherto been her worse eye owing to a corneal
nebula, she had Y = -2^. The disc in this eye was
healthy ; that in the right could not be seen. The
opacities in both lenses were more marked at the posterior
poles and at the equators than elsewhere ; projection and
reaction of the pupils were normal, and the tension was
perhaps slightly on the high rather than on the low side
of normal.
January 31st, 1882, I extracted the cataract from the
right eye by a 3 mm. peripheral flap upwards, making a
small iridectomy, and meeting with no difficulty in deliver-
ing the nucleus. However, the patient was extremely
unruly, and, after the easy delivery of the nucleus, in her
struggles a quantity of perfectly fluid vitreous escaped,
rendering it necessary to bandage up the eye without
removing all the cortex. I should mention that according
to my usual custom, on this occasion strengthened by the
request of the patient herself, the operation was performed
without anaesthetics. As I have stated, everything con-
nected with the eyeball was normal, except that its ten-
sion was perhaps a little higher than I liked (it was far
from being anything so high as T+1), and if the patient
had consented I would have preferred to operate with a
preliminary iridectomy. However^ Mrs. P — absolutely
128 DISEASES OF THE LENS AND CAPSULE.
refused to submit to two operations when one miglit
suffice, and I saw no sufficient reason to prevent me
from operating in the ordinary manner.
Seven days after the operation the wound was closed
by a greyish gelatinous-looking matter uniting its edges,
but the latter were some distance apart. The anterior
chamber was pretty deep, and there was a good deal of
cortex in the pupillary area. Atropine was used, probably
on the second day and subsequently to guard against
iritis, but I have no note of the first application of the
mydriatic. Three weeks later the eye was healthy,
except for the existence of an iritic hernia at the inner
corner of the wound, and there was still some cortex in
the pupillary area. It was not for another five months
that I noticed the presence of a cystoid cicatrix at the
inner corner of the wound, but the cyst was not, as has
been asserted by some writers, a simple extension of the
hernia iridis, the transparency of the wall being produced
by absorption of the pigment ; it occurred to the outer
side of the hernia in the greyish gelatinous-looking cica-
tricial tissue.
I treated the hernia of the iris successfully enough by
bandaging, although the patient's skin and disposition
were both so irritable that it was difficult to apply a pres-
sure bandage with proper regularity and firmness, but the
cystoid cicatrix did not yield to this treatment at all,
though after some weeks it became stationary and did not
increase in size. Every now and then as far as I could
ascertain the fluid escaped through its apex, and after-
wards slowly re-collected inside. Some time before the
appearance of the cyst I did a secondary needle operation,
leaving a perfectly clear black pupil, which to my great
regret became again closed over by a delicate membrane
some weeks later. The cortex had by that time absorbed
completely, and I had only the posterior capsule to divide.
In October, nine months after the extraction, Y. was greater
than -^, and the patient read 14 J., and was able to see
her way about with the operated eye, the other being use-
CYSTOID CICATRIX IN CATARACT EXTRACTION. 129
less. Ffteen months after the operation she could read
Wecker 6, the cicatrix remaining nearly unaltered during
all this time, and the tension of the eye being generally,,
when I examined it^ either normal or subnormal. I noted
it often as — 1 or — ?
In July, 1883, I performed a successful cataract extrac-
tion upon the left eye, with which, in spite of the corneal
nebula, she now sees well both walking in the streets and
reading. In September the cystoid cicatrix in the right
eye began again to enlarge, the tension being rather below
than above normal at all my examinations. I noted it as
T — ? The patient complained of photophobia, and stated
that the left eye was getting uncomfortable owing to the
state of the right one. The base of the cyst was broad,
extending over both cornea and sclerotic, and having a
diameter of 6 mm. Its height might have been about 3 mm.
I was not able to find any authoritative statements in
ophthalmic literature upon the treatment of such cysts
except that of Yon Graefe published in his ' Archives '
in 1862, in the article which is still the locus classiciis for
the subject.
This treatment, as will be seen later on, would not have
effected a cure in my case, and as at the time I thought it
i would not be sufficient for the purpose, I had to initiate a
method of treatment for myself, which can hardly be
i regarded as original, as Yon Graefe warns us against the
use of such measures in the paper quoted above.
On October 16th I divided the cyst horizontally with a
Graefe^ s knife, and six hours later I touched the wound
with solid nitrate of silver with the object of producing
sufficient inflammatory reaction to close the fistulous open-
ing beneath. This cauterisation I repeated on the four
following days, the result being an ulcer nearly 2 mm. in
diameter just at the corneo-sclerotic junction, to the outer
side of the place where the old hernia of the iris had been,
the position of which was still marked by some black pig-
ment in the inner side of the ulcer, the pupil too being
|L' slightly drawn up towards that side.
VOL. IV.
i
130 DISEASES OP THE LENS AND CAPSULE.
For ten days I ceased to cauterise, and merely applied
the continuous bandage,, but then finding no improve-
ment I had recourse to the nitrate of silver again, using
it very freely five or six times in the course of the
succeeding ten days. During all this time fluid freely
escaped from the ulcer, moistening a piece of filtering
paper continuously as long as I kept it in contact with the
orifice, which I used to do on every occasion as long as
the patient permitted it — and I should mention that during
all this time I could detect no perceptible difference in
the size and depth of the anterior chamber, neither after
the first operation, nor during the process of soaking up
the fluid with filtering paper. I used latterly very fine
pointed pieces of caustic, and inserted them well into the
ulcer. I found the best method of preventing the effects
of the caustic from spreading was dabbing a little bit of
vaseline on the place as I removed the nitrate of silver.
On November 17th, one month after the incision, I found
for the first time no fluid escaping from the cicatrix, which
looked firm and flat, although it still had a darker hue
than the neighbouring tissues. I kept on the bandage
for another fortnight after this, and the cure remaining
permanent I then allowed the patient to dispense with it.l
The eye is now no trouble to her, and the cicatrix perfectb
flat and firm ; Tn. The opacity in the pupillary are?
interferes extensively with vision, but affords a fair prog-
nosis if the patient submits to another needle operation.
I do not know exactly how often I cauterised the little
fistulous opening. I have notes of eleven cauterisations,
but I probably did half as many more. It is hardly
necessary to state that I proceeded most tentatively in my
first cauterisations, and did not use the caustic freely until
emboldened by the perfectly harmless result. I hesitated
for a long time before using it at all, and at one time
intended to use the actual cautery in place of it. Indeed,
it is not improbable that the actual cautery would have
produced equally good results.
In conclusion I would formulate the following pro-
CYSTOID CICATRIX IN CATARACT EXTRACTION. 131
positions : Cystoid cicatrices as sequelae to operations upon
the eye occur, so far as is known, oiily i^ the sclerotic, not
in the cornea. Their development is favoured as Schmidt
asserts by the presence of an iritic hernia, but they are
not merely the final stages of such hernias, as has been
supposed by some. The communication between the cyst
and the anterior chamber is certainly small, as was ascer-
tained by Yon Graefe in the first published work upon the
subject in the ' Ophthalmic Archives ' in 1862. Whether
cases occur in which no such communication exists at all I
cannot undertake to say. The affection may in some
cases be merely a cystoid degeneration of cicatricial tissue,
and not in any wise a distension of the cicatrix from
intraocular pressure. The intraocular tension is commonly
subnormal. This corresponds with the experience of that
acute observer Yon Graefe in the paper already quoted,
and is in conflict with the experience of Becker given in
Graefe und Saemisch Handbuch, vol. v. In severe forms
of the affection the treatment proposed by Yon Graefe,
that of excising the anterior wall of the cyst and applying
a pressure bandage, is insufficient to effect a cure. Good
results may be obtained by combining this treatment with
the free use of nitrate of silver. If discreetly used, this
caustic produces no evil consequences when applied to
this susceptible region in the neighbourhood of the much-
dreaded ciliary body.
(January lOth, 1884.)
132
DISEASES OF RETINA AND CHOEOID.
IX. DISEASES OF RETINA AND CHOROID.
1. On ansemia as a cause of retinal hemorrhage .
By Stephen Mackenzie, M.D.
Retinal haemorrliage is a condition sometimes met witlij
in connection with ansemia, and from tlie fact that it is
especially met with in the severe and fatal cases of idio-
pathic ana3mia, or progressive pernicious anaemia, there isj
a growing tendency to look upon retinal haemorrhage as a]
diagnostic sign of this particular and dangerous form o\
anaemia. I propose on the present occasion to bring undei
notice a series of cases of secondary anaemia, some oi
which recovered and one of which died, and then to discuss]
the significance of retinal haemorrhage in relation to]
anaemia. The series includes three cases of hasmatemesisj
from ulcer of the stomach, two cases of cancer with great]
anaemia^ and one case of scurvy.
Case 1. Ulcer of stomach ; repeated prof use hsematemesis i
recovery. — Hannah S — , aet. 29, machinist. Admitted into]
London Hospital, March 9th, 1881.
Family history. — Rheumatism in family. Brothers and]
sisters died of some brain affection. One sister has con-J
sumption.
Past history. — Has been a machinist since eleven yeai
of age. Has had long hours, and worked in a dark room]
lighted by gas. Was married seven years ago and has
had three children j one living. Last three or foui
months has been subject to headache and '^ swimming inj
the head.^^ but apart from this she has had pretty goodj
health. Appetite generally good ; no indigestion ; bowels
regular.
ANJ-MIA AS A CAUSE OF RETINAL HEMORRHAGE. 133
Present illness. — Dates from February lOth^ four weeks
before admission. Hurrying to her work in the morning
brought on palpitation and great dyspnoea. When she
arrived at the workshop she fainted. On recovery she
vomited " about a pint ^^ of blood, bright red and unmixed
with food (had taken very little breakfast this morning).
Some brandy was given her and she again fainted. On
again coming to she felt a craving for fresh air and
soon vomited again (about half a pint), the blood this time
being mixed with the brandy she had just taken. Then
she fainted a third time, but did not vomit again. Was
taken home, but did not go to bed at once, for if she lay
down a stifled feeling came over her. The same evening
she fainted and vomited '^ pure blood ''' twice (quantity
stated to be Oij and Oss) .
Felt very weak the next day, had giddiness and pain
between the eyes.
During the next ten days she twice vomited dark-
coloured blood (diet had been milk and beef tea). She
had no pain with the vomiting, or at any time, except
after eating a chop for dinner a fortnight before admis-
sion.
The last fortnight she has vomited three times, but no
blood.
The last week only had slight epistaxis, which relieved
the pain between eyes. Has remained weak and giddy,
having singing in the ears and specks before the eyes.
Motions have been very dark-coloured.
On admission. — Patient is fair complexioned and fairly
well nourished. Pallor of lips, palpebrae, conjunctiva, and
face is very striking. She had nearly fainted in walking
across waiting hall of out-patient department. Slight
headache. Slight oedema of legs.
Digestive system. — No pain with food or at other times.
Often has a bad taste in mouth. Appetite fair ; bowels
costive. Liver and spleen appear normal. Pain over
region of right ovary and tenderness on pressure.
Vascular system. — Heart-sounds at apex clear though
134 DISEASES OF RETINA AND CHOROID.
feeble. Over aortic cart, a soft first-sound murmur.
Pulse soft, full, and regular.
Respiratory system. — Physical signs healthy. Shortness
of breath on exertion.
Blood. — Corpuscular richness 42*9 per cent., 1 colourless
to 420 coloured.
Urine. — Contained a trace of albumen.
Fundi. — Pale. Retinal haemorrhages in each eye. In
the right fundus above and to the outside of the disc is a
small punctate haemorrhage, and a mucb larger extrava-
sation in the lower segment. In th.e left fundus above
and to the inner side of the disc are several flame-shaped
haemorrhages.
March 19th. — Corpuscular richness 52 8 per cent., 1
colourless to 352 coloured. Milk and arrowroot make
her feel sick.
21st. — Feels stronger; smarting in epigastrium un-
changed by food. Occasional headache, vertigo and pal-
pitation. Some tenderness over seat of pain.
25th. — Corpuscular richness 72*9 per cent. Still marked
anaemia. No oedema.
April 12th. — To get up one hour. To have milk
puddings.
17th. — To have fish and bread.
May 3rd. — Haemorrhages disappeared from right eye :
traces only in left retina.
5th. — Retinal haemorrhages disappeared in both eyes.
Corpuscular richness 73 per cent.
20th. — An attack of nausea and pain in epigastrium and
between shoulders came on after a meal, accompanied by
a feeling of suffocation and faintness and by palpitation.
To go back to milk and beef tea again.
24th. — Still some pain in epigastrium.
June 3rd. — Much better. Fundi normal.
12th. — Gets up half a day now. Feels much stronger
and less Ipnguid ; colour has much improved. Lips almost
normal. No giddiness lately. No pain anywhere. No
tenderness on firm pressure over abdomen. Appetite
ANAEMIA AS A CAUSE OF RETINAL HEMORRHAGE. 135
good. Has moat again to-day. No pain after food.
Lungs and heart normal. Corpuscular richness 89*7 per
cent., 1 colourless to 286 coloured.
Temperature usually about normal, occasionally 100 at
night. Albumen disappeared from urine six days after
admission. Had seven attacks of haematemesis during
first ten days.
Blood.
Corpuscular richness. Proportion colourless to coloured cells.
March 9 42'9 per cent 1—420
„ 19 52-8 „ 1-352
„ 25 72-9 „ —
May 5 73- „ —
June 12 89-7 „ 1—286
Case 2. Ulcer of stomach ; severe hsematemesis. — Char-
lotte G — , ^t. 36, was admitted under my care on April
29th, 1882, complaining of pain in the prsecordial region,
slight swelling of the feet, loss of flesh, and that she
vomited blood three weeks ago.
Family history. — Is good. Patient was born and had
always lived in London ; she married at the age of 1 9, had
nine children, five of which are living and quite well, the
other four died when young of measles and scarlatina.
Her husband died eighteen months ago. She had always
been a healthy woman, never having during her recollec-
tion been laid up before her present illness. She has had
to work very hard, and has been exposed to vicissitudes
of weather. Her occupation has been that of a herring-
curer, and since her husband^s death she has often been
out hawking. There is no history whatever of intempe-
rance, though she may have had one or two glasses of ale
daily.
Present illness. — Patient was quite well until a few days
before Easter Monday (about three weeks ago). About
this time she noticed that she was losing flesh, becom-
ing pale in the face, experiencing a sense of weight and
occasional pain in the chest, and gradually feeling weaker.
Her appetite, which previously had always been good^ began
186 DISEASES OF RETINA AND CHOROID.
to fail her, and she would have considerable discomfort
and flatulence after taking food. Notwithstanding that she
felt ill, and that she was having a good deal of trouble
about her children, she was married to a second husband
on Easter Monday. On her way home from the church
she felt very faint, had severe pain in '' the pit " of the
stomach, and vomited a large quantity of blood. (She
feels sure that she vomited the blood, and has never had
any cough). The blood was dark, almost black in colour,
very clotted, and she thinks was slightly mixed with food.
As soon as she got home she brought up some more blood,
making, it is said, about a quart in all. She was then
brought to the hospital, but as she refused to remain in
she was sent home with some medicine. She has never
been able to leave her bed since, and her mother-in-law
says that she was ^' out of her senses '^ for a week after
this. She has had no convulsive seizure of any kind.
There is no history of hemophilia in the family.
When admitted, — Patient appeared very absent-minded
and frequently contradicted her own statements. Her
face had a pasty, anaemic, somewhat oedematous look, and
the feet, and legs also, pitted slightly on pressure. Her
conjunctivae and all her mucous membranes were extremely
anaemic, there was no headache and no ascites. She only
complained of slight pain over the heart, and would lie in
bed in any position. Temp. 101,° respirations 32, and her
pulse, which was small and somewhat thready, 116. Her
tongue was large, flabby, pale, and slightly coated ; teeth
were well-formed and regular, and there has been no sick-
ness since that described above. Her bowels are regular,
and her motions quite normal. No pain or distension in
the abdomen, the liver dulness extends from the sixth rib
to the costal margin, no tenderness and no jaundice.
Heart. — Apex beat is in the nipple line, somewhat
heaving in character, heart's dulness extends from mid-
sternum to the left nipple line. There is a blowing sys-
tolic murmur heard at the apex, conducted slightly into
the axilla, there is also a double roughish sound heard
AN.EMIA A8 A CAUSE OF RETINAL HEMORRHAGE. 137
over the mid-sternum, which is localised to a small area
aud suggestive of pericarditis. There is no prascordial
pain, and there is no dyspnoea. The respirations quite
easy, 32 in the minute. Beyond a few scattered rales
here and there in the chest there are no adventitious
sounds in the lungs.
^yes. — Patient reads No. 2 Nettleship with either eye.
Ophthalmoscopic examination ; Right. — The disc is nor-
mal but very pale, the veins are dark, somewhat tortuous,
and very disproportionate in size from the arteries, which
are excessively small, and in places indistinct. There are
several whitish patches in the outer half of the retina, and
scattered here and there amongst them are some small
linear and flame-shaped haemorrhages. These as well as
the white patches are mostly to be observed in the outer
and lower quadrant of the retina. The white patches do
not appear to invade the yellow spot region, but there is
a large, opaquish white patch diffused a little below and to
the outer side of it.
Left eye. — The changes here are similar in nature to
those just described, but both hgemorrhages and white
patches are much fewer and smaller than those observed
in the other eye. The disc is not swollen, there is a trifle
of myopia in both eyes.
Patient has passed 40 oz. of urine in the last twenty-
four hours, which is clear straw in colour, acid in reaction,
has a specific gravity of 1008, and contains neither albu-
men, sugar, nor casts.
The red corpuscular richness is 45 per cent, and there
are 5 per cent, of white corpuscles.
May 5th. — Patient has been improving since admission ;
she is a better colour, has not been sick, complains of no
pain, and insists that she is quite well. There is still a
systolic murmur heard at the apex, but the friction sounds
have altogether disappeared. Her urine has been ex-
amined daily, but although it is still of low specific gravity
it contains no albumen.
There are fewer haemorrhages in the retina ; at the lower
138 DISEASES OF RETINA AND CHOROID.
part of the right fundus there are patches of diffused^ dull
whiteness, with small central haemorrhages.
May 6th. — Blood : Red corpuscular richness 44 per
cent.; white corpuscular richness 1*5 per cent.
11th. — Red corpuscular richness 50 per cent. ; white
corpuscular richness 1*4 per cent. Patient is improving
rapidly.
16th. — Changes in the fundi are clearing up ; there are
only one or two scattered haemorrhages now to be seen,
and very few white patches. Patient has greatly improved
in appearance, colour has come back into lips, cheeks, and
fingers. There is now neither bruit nor pericardial friction.
22nd. — Patient refuses to stay in the hospital any
longer, but she is looking much better and says she feels
quite well. There are two small haemorrhages in the left
eye at the upper part of the fundus. The red corpuscular
richness is now 68 per cent. ; the white corpuscular
richness, 1'2 per cent. She is taking her food well, there
are no dyspeptic symptoms.
The patient at this date, at her own request, left the
hospital, but reported herself as an out-patient for some
months. The haemorrhages and white patches entirely
disappeared from the retina and the general condition
greatly improved. The heart remained very excited for
many weeks, but the murmur disappeared.
Blood. — April 2nd. — Coloured corpuscles 45 per cent.,
colourless 51 per cent. May 6th. — Coloured corpuscles
44 per cent., colourless 1'5 per cent. 11th. — Coloured
corpuscles 50 per cent., colourless 1*4 per cent. 23rd. —
Coloured corpuscles 68 per cent., colourless 1*2 per cent.
Case 3. Ulcer of stomach. Severe hcematemesis. —
Sarah H — , set. 29, dressmaker. — The patient applied for
treatment at the London Hospital on September 12th,
1883. Whilst in the waiting room she fainted, and on
regaining consciousness vomited a quantity of altered
blood (amount not estimated). She was admitted to the
ward.
ANEMIA AS A CAUSE OF RETINAL HiEMORKHAOE. 139
She had been engaged in dressmaking since the age of
ten, has worked under favorable hygienic conditions, and
walked about three miles a day. Is a total abstainer.
About a fortnight before admission she felt a good deal
of discomfort from pain in the chest, behind the sternum.
She attributed it to the smell of paint to which she was
exposed. On September 8th she was walking upstairs at
the workshop and suddenly felt so faint that she had to
lean against the wall to support herself. She recovered
and continued her work until the evening, when, feeling
worse, she was assisted home and stayed in bed on the
following day. She then resumed her work, feeling better
until the day when she applied for treatment, but it sub-
sequently transpired that her motions had been somewhat
black for the few preceding days.
On admission, September 12th, she was slightly anaemic
in lips and face, and her complexion rather dull. Her
pulse was 100, respirations 25, the temperature 98*5°.
She complained of throbbing in the head. There were no
noticeable signs of disease in the fundi. The apex beat
of the heart was an inch below and an inch and a quarter
to the inner side of the nipple line. There was a slight
systolic bruit. Tongue slightly furred, bowels confined.
September 14th. — An enema was given, which brought
away a good deal of faeces mixed with altered blood-clots.
15th. — About 4 p.m. on this day she vomited about
sixteen ounces of blood, previous to which she had singing
in her ears, and her vision became blurred. She became
very anaemic.
16th. — She vomited a small quantity of blood,
17th. — Has had no more vomiting. She looked washy
white, and her lips were bloodless. Temperature in
morning 98'8°, in evening 101°,
18th. — During the night she felt chilly, and her tempe-
rature was found to have risen to 103°. Her pulse this
morning was 120 and bounding.
Her blood was examined, and it was found that the
140 DISEASES OF RETINA AND CHOROID.
coloured corpuscles were 34*6 per cent., haemoglobin 24 per
cent.
Her condition now was very striking. She appeared
exsanguine. The whole surface of the body was of a
uniform pallor, the lips and gums and palpebral conjunc-
tiva appearing almost white. She gazed vacantly into the
air, and paid no heed to what was passing around her.
Her sense of hearing was a little impaired. When her
attention was aroused she answered questions in a slow
deliberate manner, but lapsed into the same indifferent
condition. Her manner and marble-like whiteness, were
statuesque. The right pupil was fully dilated by atropine.
The retinal arteries and veins were pale and unusually trans-
lucent. The papilla and retina appeared normal. Temp.
103°.
On September 19th. — The retinal veins were noticed to
be a little tortuous, but pale. There was an appearance
suspicious of a small haemorrhage in the superficial layer
of the retina below the left disc. Temperature 101°,
pulse 132.
20th. — No more vomiting. Pulse 140, temp. 1005°.
She had the same waxy appearance and abstracted look.
No haemorrhages whatever are to be seen in the retinae
in the afternoon. Coloured corpuscles 30*2 per cent.,
haemoglobin 23.
In the evening a small haemorrhage was noticed in the
left retina, on a branch of the ascending artery, some
little distance from the papilla. It was about one-fifth the
diameter of the disc and had a white centre. It occupied
the nerve-fibre layer. It was the only unequivocal
haemorrhage. The margin of the papilla is distinct, the
veins large, and both veins and arteries pale. Had the
same vacant look and waxy appearance.
22nd. — The haemorrhage observed on the 19th still
present, but fading. Just below it and close to another
vessel was another fresh haemorrhage of about the same
size. She had up to this time been fed by nutrient
ANiEMIA AS A CAUSE OP RETINAL HAEMORRHAGE. 141
enemata, but was now able to take milk by stomach. Her
temperature was 100*5° in the morning, 100° in the
evening.
23rd. — Coloured corpuscles 34*8 per cent., haemoglobin
20 per cent.
24th. — The two first haemorhages still noticeable, but
fading. A fresh one, of small size, is seen below and to
the inner side of the left papilla. When seen in the after-
noon it had no white centre, but when seen in the evening
it had a distinct white centre. Patient, though still very
pallid, was improving. Temp. 99°.
25th. — Coloured corpuscles 41*4 per cent., haGmoglobin
27'0 per cent. The vacant look was not so marked, and
general appearance better. Still extremely pallid.
26th. — No more haemorrhages in fundi, and that first
noticed had quite disappeared. General condition much
improved. Takes fiuid nourishment. Ice bag that had
been applied to epigastrium now discontinued. Temp.
98*8 morning, 99'5° evening. Coloured corpuscles 38
per cent., haemoglobin 27 per cent.
29th. — Looked better, but still very pallid. There was
very little trace of the retinal haemorrhages.
October 2nd. — Coloured corpuscles 36*8 per cent.,
haemoglobin 23 per cent.
3rd. — Left eye : The remains of the older haemorrhages
had quite disappeared. There was, however, another
haemorrhage larger than any of the others some distance
above and to the inner margin of the disc, not situated
near to any vessel.
Right eye : Some distance below and to the inner side
of the papilla was a small white speck, possibly the
remains of a haemorrhage, the eyes not having been
examined for two days.
5th. — The haemorrhage that was noticed on the 3rd
fading.
8th. — Coloured corpuscles 35'6 per cent., haemoglobin
29 per cent.
The temperature up to this date had been remittent ;
142 DISEASES OF RETINA AND CHOROID.
the morning temperature being about normal, whilst the
evening temperature averaged about 100^. The pulse
remained about 120. She took milk and bread and
pudding. Was free from pain. Her manner had become
quite natural, and she was cheerful, but great pallor
remained.
Since this date her condition has been one of continued
progress ; nothing illustrates this better than the blood
chart.
Red corpuscles. Hgemoglobin.
Sept. 18 346 per cent 24 per cent.
20 30-2 „ 23 „
23 34-8 „ 20 „
25 41-4 „ 27 „
26 38 „ 27 „
Oct. 2 36-8 „ 23 „
8 35-6 „ 29 „
11 42-8 „ 30 „
12 35-8 „ 28 „
15 48-2 „ 35 „
16 59 „ 40 „
19 63 „ 46 „
23 67-4 „ 53 „
25 77-6 „ 58 „
28 80 „ 61 „
31 84 „ 66 „
Nov. 5 85 „ 66 „
10 90 „ 68 „
16 88 „ 70 „
23 92 „ 80 „
30 90 „ 78 „
With the exception of some pain and vomiting after
taking solid food at the end of October, patient had no
further symptoms. She was sent to Brighton on December
1st, when she looked and felt quite well, and was able to
eat minced meat, and bread and butter and eggs.
Case 4. Cancer of pyloric end of stomach ; great
ans&mia. — Arthur B — , set. 35, admitted into the London
Hospital under my care July 13th, 1881.
The patient bad an epigastric tumour, pulsatile and
ANEMIA AS A CAUSE OF RETINAL HAEMORRHAGE. 143
expanding, over which and along aorta a bruit was heard.
These symptoms suggested the presence of aneurysm,
which was disproved by the necropsy.
Ansemia, which was present on admission, was progres-
sive and became extreme. On August 25 I noted :
^' The ansemia now is really extreme, approaching that
seen in idiopathic anasmia, the pink colour having disap-
peared from the matrix of the nails. His temperature
has been high for the last few nights, but there is no
discoverable cause for its elevation. There is no general
distension of the abdomen, nor is it anywhere tender ;
there are no changes in the lungs. There is no indication
save the anasmia to indicate internal haemorrhage. It is
possible that the ansemia is the cause of the elevation of
temperature.
" Ophthalmoscopic examination. — At some distance from
the right disc on the temporal side, just below a horizontal
vessel there is a narrow red streak like a small superficial
haemorrhage. Some distance higher in the upper and
outer quadrant are two irregular white patches very small
in size.^^ On the following day it was noted : ^' Above
the right disc and just to the inner side of the middle line
two small haemorrhages can be seen.^^
August 29th. — A V-shaped haemorrhage seen below the
right disc this morning.
September 5th. — The haemorrhages above the right disc
have almost disappeared, but there remain several below.
The white patches are slightly enlarged and run together.
There are several small haemorrhages in the left fundus ;
one in the upper and outer quadrant, small and with a
white centre. There is a white patch in lower and inner
quadrant.
9th. — There are two or three new haemorrhages in the
left eye ; one on a level with the disc on the temporal
side, one on each side of a white patch. The right disc
appears to be oedematous, and so does the retina in its
vicinity. Some of the vessels, especially the main veins,
are partially concealed in the oedematous retina. There
144 DISEASES OP RETINA AND CHOROID.
is a fresh white patch above the yellow spot, and another
white patch higher up, just below a large vein. There
are no fresh haemorrhages. The left eye presents similar
appearances. The white patches are more numerous ; no
albumen in urine.
The conditions persisted ; the patient became progres-
sively weaker and more anaemic and died October 1st.
At the necropsy, cancer of stomach at pyloric end was
found. No disease of kidneys.
Case 5. Abdominal cancer; great ansemia. — Emma L — ,
aet. 61, admitted on August 15th, complains of a dragging-
down pain on the left side and increasing weakness.
Family history, — Unimportant, no history of cancer.
Personal history. — Never had any illness until thirty-
two, when she had inflammation of the kidneys after con-
finement j she has had pain in the left side of the abdomen
for years, but the pain has never been severe enough to
prevent her from working. Last October (1882) had a
severe attack of diarrhoea, and after this she was left in a
very weak condition and began to lose flesh, strength, and
colour, and this dragging-down pain in the left side
began.
On admission. — She is a weakly, anaemic-looking woman
with a faint yellowish tinge in face and conjunctiva ; the
pain in the left side is almost constant and is relieved by
lying on that side.
Physical examination. — Heart : A systolic murmur at
apex and base. Lungs clear. The liver is enlarged, extend-
ing nearly to umbilicus. The left side of abdomen is occu-
pied by a more or less rounded somewhat nodular growth,
extending from just below ribs to the iliac fossa ; it is
uninfluenced by change of posture, but affected by the
respiratory movements ; the tips of the fingers can be
passed between it and the costal cartilages. The tumour
pulsates distinctly (up and down), but there is no audible
bruit. The cervix is high in vault of the vagina, and is
short but freely moveable.
ANEMIA AS A CAUSE OF RETINAL HEMORRHAGE. 145
August 25tli. — A few small haemorrliages in fundi.
Haemoglobin 30 per cent. Coloured corpuscles 46*5 per
cent.
Sept. 11th. — The pain is more severe ; she is much
weaker and does not take any solid food, but has nutrient
enemata three times a day. Haemoglobin 23 per cent.
Red corpuscles 50" 6 per cent.
26th. — Greneral condition much the same. The tumour
remains about the same in size and shape. Haemoglobin
20 per cent. Red corpuscles 46*4 per cent.
October 9th. — Haemoglobin 22 per cent. Red corpuscles
40'5 per cent.
26th. — The shape and condition of tumour about the
same. Patient is much weaker and is kept alive by
nutrient enemata ; the pain is more severe and has to be
moderated by morphia. Haemoglobin 26 per cent. Red
corpuscles 32'2 per cent.
Case 6. Scurvy with dilatation of the heart and retinal
hemorrhages. — This case was brought before the Royal
Medical and Chirurgical Society by Dr. Hale White,
March 3rd, 1883, with the following abstract :
The patient was admitted into the Seamen^s Hospital
on November 13th, 1882. He had left Calcutta four and a
half months previously, and whilst there had had dysentery.
On admission he was very sallow, and evidently the case was
a severe one ; there was swelling of the gums and the usual
bruise-like swellings about the body. The apex beat was
in the fifth space one inch outside the nipple line, the area
of cardiac dulness was increased, there was in the third
left intercostal space a loud systolic murmur, the first
sound at the apex was muffled, and arterial murmurs were
present in the neck. Pulse was weak and almost thready.
In the right eye were two large haemorrhages, one above
and one below the disc ; they were striated at the margin,
white in the centre. The blood showed only 40*5 per
cent, of the normal number of white corpuscles and only
20 per cent, of the normal quantity of haemoglobin. The
VOL. IV. 10
146 DISEASES OF EETINA AND CHOROID.
patient remamed in the hospital a fortnight, and was
treated with lime-juice and put on full diet. He steadily
improved ; the retinal haemorrhages became less distinct.
The red corpuscles increased to 63 per cent., and
the haemoglobin to 35 per cent. The basic systolic
murmur disappeared, but the apex beat remained in the
same position. It was pointed out that this case presented
the following points of interest : firstly, the influence of
the previous dysentery in making the attack of scurvy
severe, which severity was evidenced by th.e marked blood
changes ; secondly, the presence of retinal baemorrhages,
a very unusual occurrence as compared with other
anaemic diseases, and to be explained by the fact that
scurvy as seen nowadays was not severe enough to pro-
duce retinal haemorrhages ; and thirdly, the dilatation of
the heart. It was shown that this is the only recorded
example of this condition in scurvy, and that, considering
the close alliance of this disease to other anaemic diseases
in which it was known that the heart was fatty, it was pre-
sumed that here also this was the cause of the dilatation.
Various writers (Quincke, Litten, Saundby, Mules, and
others) have stated that retinal haemorrhage occurs in con-
nection with the anaemia of cancer, haematemesis, uterine
haemorrhage, &c., but as far as I know observations on
this point have not been recorded which show the exact
degree of anaemia with which such haemorrhage is asso-
ciated. It is as a contribution to information on this
point that these cases seem to me to be of value.
It will be seen that in all these cases the corpuscidar
richness was below oO per cent, of the normal, the haemo-
globin being, in some of the cases, reduced to an equal or
greater degree. From a consideration of these cases the
conclusion may be drawn that when the corpuscular rich-
ness falls below 50 per cent, or below half the normal
quantitv the tendency to haemorrhage becomes developed.
This induction leaves out of consideration the estimation
of the haemoglobin. The quantity of the latter exercises
a qualifying influence, according as it is greater, equal to.
ANEMIA A3 A CA[J3B OF RETINAL H-EMOBRHAGE. 1^7
or less than the corpuscular deficiency. Retinal haemor-
rhage is certainly rare, as a consequence of anaemia alone,
when the corpuscular richness exceeds 50 per cent. The
lower the degree below 50 per cent, to which the blood-
corpuscles fall, the greater is the tendency to retinal
haemorrhage ; and thus ib is that in the cases of that
extreme degree of anaemia to which some would restrict
the terms ^' idiopathic " or " progressive pernicious,"
retinal haemorrhage is very common, and all but constant.
In such cases the corpuscular richness falls to as low as
20, 15, or even 10 per cent. Retinal haemorrhage does
not always occur when the corpuscular richness sinks to
50 per cent., or even much lower, and it may be that
other factors contribute to its occurrence. But at 50 per
cent, the liability to haemorrhage occurs, whatever has
produced the corpuscular defi.ciency, and in cases of
anaemia in which improvement takes place, when this point
is passed the liability to haemorrhage is lessened or ceases.
For these reasons I regard 50 per cent., or the half of
the 100 per cent, in '000022 cubic millimetres of blood, as
a critical point below which the corpuscles cannot sink
without grave danger to the patient. It is of practical
importance to have a ready means by which, in the
absence of the haemocyto meter, we can gauge whether the
corpuscular richness is above or below this point. 1
believe the following will be found serviceable. As long
as any pink colour can be seen through the finger-nails,
in the nail-bed, it will be found that the patient has above
50 per cent, of red blood-corpuscles, and when all colour
has disappeared from beneath the nails it may be assumed
that the corpuscular richness is below 50 per cent. Of
course this is a rough test, but I have often tried it
against the haemocytometer, and so far have always found
it correct. This takes no cognisance of the haemoglobin
richness, an important element in aniemia, but I have not
been able to determine how far we can estimate in this
manner the degree of deficiency of blood-colouring matter.
The accuracy of the test was well shown in Case 3.
148 DISEASES OF EETINA AND CHOROID.
When the corpuscular deficiency was below 50 per cent.,
all colour had. disappeared from the matrix of the finger-
nails. When the hsemic chart showed the corpuscular
richness at 60 per cent., I remarked, before looking, — we
ought to find the colour returning to the nails ; and such
we found to be the case.
In an interesting article on a case of " progressive per-
nicious anaemia,'^ Drs. Kansome and Mules* point out,
from a consideration of some recorded cases, " that retinal
haemorrhages commence when the corpuscles have dropped
to 32 per cent, or thereabouts.^' The above series of cases
make it clear, however, that the corpuscular richness
cannot sink below 50 per cent, without the liability to
retinal haemorrhage.
{December IWi, 1883.)
2. Haemorrhage in region of macula.
By A. Stanford Morton, M.B.
(With Plate III, fig. 1.)
Henry C — , aet. 35, came to Moorfields on the 4th of
Feb., 1884, under the care of Mr. Tay, to whom I am in-
debted for permission to bring forward the case. For a
month he had experienced aching pain over the right brow,
and a fortnight previous to his visit he discovered acci-
dentally on covering the other eye that the sight in the
right was very defective. The vision in this eye was 20 J.,
and on examining him with the ophthalmoscope I found
the appearances which I have represented in Plate III,
fig. 1. On taking his field of vision some days later I
found an absolute scotoma corresponding in shape and
position to the haemorrhage.
Since his first visit there have been very considerable
* ' Brit. Med. Journ.,' 1883, vol. i, p. 1112.
DESCEIPTION OF PLATE III.
Fig. 2 illustrates Messrs. Critchett and Juler's case of Dis-
seminated Choroiditis (p. 161).
Right eye; erect image. From a drawing by Lebon and Co.
Fig. 1 illustrates Mr. Stanford Morton's case o£ Haemorrhage
in the Eegion of the Macula (p. 149).
Right eye; erect image. From a drawing by the author.
I'lcf 2
Tran.s. Ophth Soc Vol IV PL J
M.HLapiclge lith.
licr. J .
Hanhart imp.
HJ5M0RRHAGE IN REGION OF MACULA. 149
changes in the appearances. The large semicircular
hsemorrhage, as well as the smaller ones on the upper half
of the circular area, underwent gradual absorption, and the
retina was thrown into folds over the site of the haemor-
rhage. When examined on March 31st, though there had
been a little fresh haemorrhage, the patient's vision in the
right eye was 1 J. and -|§ partly. There is not any his-
tory of a blow, and the patient's health has been generally
good, with the exception of what he calls '^ rheumatic gout."
The first attack of this was in the large joint of the great
toe, and most of bis larger joints have been affected, but
not any smaller than the wrist and great toe. The
patient's father was gouty, and his eldest brother has
"rheumatic gout." The urine is normal, the heart sounds
are normal, but the radial pulse feels very firm on pres-
sure. The patient states that for the last two years he
has had epistaxis from the right nostril once or twice a
week ; that these attacks ceased from the time he found
his sight defective until two days before his vision was
found to be I J. and |^§. Vision in the left eye is normal,
but there are a few changes near the disc and a minute
circular haemorrhage towards the periphery. It appears
as if there had been a large circular haemorrhage subsiding
by gravitation till it became semicircular with the convexity
downwards. It seems also probable that it is of gouty
origin.
{May 8th, 1884.)
P.S. (July 1st.) — When seen a few weeks since the ab-
sorption was still proceeding, the retina was regaining its
normal appearance, and the vision remained as when last
tested.
Mr. Nettleship said that a single very large and dense
retinal haemorrhage of semicircular, or possibly in the first
instance, as Mr. Frost had just suggested, circular outline,
was not very uncommon at the yellow-spot region, though
not, he believed, in other parts. It seemed probable that
150 DISEASES OP RETINA AND CHOROID.
this remarkable regularity of outline was due to some pecu-
liarity in the anatomical arrangement of the retinal
structures at the yellow-spot region. Such colossal soli-
tary extravasations probably depended on rupture of a
single, rather large, artery whose coats were diseased,
and not upon any general disease, or retinal venous ob-
struction.
3. Syphilitic retinitis with retinal hemorrhages and growths
of new blood-vessels from the disc into the vitreous
humour.
By E. Nettleship.
(With Plate IV, figs. 1,2.)
John K — , aet. 50, commissionaire, an Irishman, was
admitted at St. Thomas's Hospital on August 23rd, 1883.
Sight had been failing for seven months or more, the left
being the first to begin and the worst. He had had a
chancre a year previously, followed by a full attack of
secondary symptoms.
The condition of the eyes was as follows :
Right sees ^^^ and 16 J. ; a posterior synechia at lower
edge of pupil ; numerous webs in the vitreous ; a good
many rounded haemorrhages of rather small size at the
fundus, chiefly at the upper part of the periphery, also
several dark ones, apparently in front of the retina, near
the y. s.
Leftj opacities in the vitreous ; extensive deep detach-
ment of the retina ; slight congestion.
The subsequent course of the right was as follows :
September 6th. — There is a close mesh work of very
small, tortuous vessels on the outer side of the disc, and
another small patch of vessels on the inner side ; no
evidence of obliteration of any of the central vessels ; disc
pale and hazy.
I
Figl
Trans. Ophik.Soc lol. IV H. JV
V ! 0- ic
M Boole, del
Lebon $
DESCEIPTION or PLATE lY.
Illustrating the ophthalmoscopic appearances in Mr. Nettle-
ship's case of Blood-vessels in the Yitreous Humour during an
Attack of Syphilitic Eetinitis (p. 151).
Fig. 1 was taken in September, 1883. Right eye ; erect image.
Fig. 2 shows the appearances in the same eye in March, 1884,
From drawings by Miss Boole.
SYPHILITIC RETINITIP. 151
October 9tli. — Vitreous much clearer ; still many haemor-
rhages at y. s. and at upper periphery.
23rd. — There is now a flat, transparent, vascular mem-
brane attached to the outer border of 0. D. and projecting
straight forwards into the vitreous ; its vessels are looped
and very numerous, one larger one forming its anterior
free border. The top of the membrane is seen with
+ 4 D. (The drawing represented in Plate lY, fig. 1, was
taken at about this date.)
December 6th. — Condition unaltered, except that the
haemorrhages have disappeared ; still some fine webs in
vitreous. Vision not -^^q ; 14 J., barely with + 4*5 D.
January 14th, 1884. — The vascular veil has now bent
over towards nasal side of disc.
February 21st. — Two fresh growths of vessels are now
seen in the form of long, narrow leashes, one passing up
and out, the other inwards, from the upper part of the
disc. The original vascular membrane has bent over still
more towards the nasal side of the disc.
March 8th and 10th. — Drawing represented in Plate IV,
fig. 2, made. The vitreous has cleared and the retinal
haemorrhages have been absorbed.
Course of the left eye. — Towards the end of August
this eye became inflamed and painful ; it inflamed again
in September and about the middle of November, by which
date there was a circular posterior synechia with bulging of
the iris and T. + 1.
On November 16th a satisfactory iridectomy was done,
much fluid escaping from behind the iris. The eye con-
tinued inflamed and liable to severe attacks of pain,
though T. was u. and the iris flat.
On the 29th the right had become irritable ; the left
having no p. 1. and being still painful was excised. Retina
totally detached ; some small spots of choroiditis.
Mercury has been given at intervals for a considerable
portion of the time since his first admission and he is easily
affected by it (diarrhoea and salivation) .
There is nothing of special interest in the previous
152 DISEASES OF RETINA AND CHOROID.
history : lie was in the army from 1860 till 1881, but
never went abroad, and had scarcely any illness except an
attack of chronic rheumatism. Urine free from albumen
and sugar. Has not had ague or scurvy. When a boy
used to bleed from the nose, but does not bleed severely
when cut.
{Livmg specimen. March 13th, 1884.)
P.S. (Aug. 21st.) — R. has improved V. i^ ; with
+ 2*5 D. reads 14 J. fairly. Fundus much as at last
note, but there is now a good deal of white opacity (con-
nective tissue) about the bases of some of the vascular
growths ; the veil-like growth at the disc has turned so
that its plane is now nearly horizontal instead of vertical
as before. He has had no medicine for many months.
4. On tortuosity of retinal vessels in association with
hypermetropia.
By Stephen Mackenzie, M.D.
(With Plate V, figs. 1, 2 ; VI, fig. 1.)
For the opportunity of seeing this case and bringing it
before the Society I am indebted to Mr. Streatfeild, under
whose care the patient came at Moorfields.
M. W — , aged 20, Hereford, was always delicate.
When eleven years old her sight was much affected, she
had '* inflammation of the eyes,'' and was under the care
of an ophthalmic surgeon for two years. She was suited
with spectacles, and advised to use them regularly, but she
does not appear to have done so. For two years after
this she suffered from hysteria, and at the end of this
DESCEIPTION OF PLATE V.
Illustrating Dr. Stephen Mackenzie's case of Tortuosity of
Retinal Vessels in Connection with Hypermetropia (p. 153).
Fig, 1 shows the ophthalmoscopic appearances in the left eye.
Fig. 2 the same in the right eye (nearly normal).
Erect image.
From drawings by Miss Boole.
TORTUOSITY OF RETINAL VESi^KLS. 153
period her sight was better. She then, being sixteen, went
to school, when her sight again failed, especially with the
left eye. She got some glasses from an optician which
she used for twelve months, but during this time her
vision steadily deteriorated. She tried stronger glasses,
but these only suited her for a short time.
During the last eighteen months, and especially in the
last twelve months, her vision has still further diminished
and she has had much pain in the head, along the temples,
especially on the left side. She never quite loses the
pain, but it is worse in the evening with artificial light.
The headache, she says, is not like an ordinary one ; it is a
throbbing, shooting sensation and the head feels heavy.
She suffers a good deal from constipation. The catamenia
have been scanty, lasting for only part of a day, during
the last year.
She has two brothers whose sight is good. Her father
and mother are free from any ocular defect, nor does she
know of any in the family.
Without spectacles she cannot see to read or sew.
With + 2*5 D. her vision is a little improved, but she
cannot then see to read.
In the left eye (Plate V, fig. 1) the retinal veins are
extremely tortuous. The main trunks are slightly dilated
and twisted, and coiled round in places in a corkscrew-like
manner. The branches of the veins share in the tortuosity,
but are not dilated. Most of the arteries are natural,
but a few of the smallest are a little tortuous. Disc
oval, congested. In the right eye (Plate Y, fig. 2) the
veins are scarcely at all tortuous, presenting a marked
contrast with the opposite eye. The following are Mr.
Streatfeild's notes as to refraction :
-p r Vertical meridian + 2 5 D. over corrects.
* (^ Horizontal „ + 8 D. over corrects.
J ( Vertical „ + 3*5 D. over corrects.
(^ Horizontal „ + 8 D. over corrects.
But the vision was not improved by cylindrical glasses.
Strabismus convergens, right occasional.
154 DISEASES OF RETINA AND CHOROID.
Heurteloup tried and relieved headache slightly. Bro-
mide of potassium made throat dry.
When she left off attendance there was no improvement.
y. with both eyes together = ^^, with + 2-25 D. =
20
~2 0 o"-
In the case of a girl aet. 12, I showed on Dec. 13th,
1883, with extreme tortuosity of the veins of left retina
(Plate VI, fig. 1), slightly of veins of right, there was
hypermetropia, but I had not attached any significance to
the fact. Mr. Nettleship, however, suggested to me its
importance, and the advisability of having the refraction
carefully tested.
This has been kindly done by my colleague, Mr. James
Adams, with the following result :
f R. "I^ Hm. less than 0*5 D., no improvement with
Y. < sph. lenses.
( L. f§ Hm. 1 D. Each reads 1 J., at 12".
/^R. vertical meridian M. 0*5.
Under j horizontal „ H. 2 '5.
atropine, j with + 3 D. axis vertical V. = ^ imperfectly .
U- H. 2-5 D., V. = |§.
I have at the present time under care at the London
Hospital, a girl set. 17, suffering from rather severe
anaemia.
The retinal veins in both eyes are distinctly tortuous,
though not to anything like the same degree as in the two
others. Her vision is as follows :
E. M Hm. 0-5 D. : 1 J. at 12".
y |- 20
L. I* Hm. 0-5 D. : 1 J. at 12^
Under \ E. ^^f, H. 1-75 D., Y. = ^.
atropine. J L. ^o". H. 2 D., Y. = |§.
In the case of tortuosity of the retinal veins in a patient
the subject of vesicular emphysema I reported last session,
an illustration of which appears in ' Transactions ' vol.
iii (Plate III, Bis), I have unfortunately no note as to the
refraction, but I believe had there been any peculiarity it
would have been recorded.
In Mr. Benson's case there was hypermetropia, but
TORTUOSITY OP RETINAL VESSELS. 155
whilst this was in R. =3 D. and in L. = 1*75 D., the
tortuosity of tlie vessels, both, arteries and veins, '^ existed
nearly to the same degree in each eye '^ (' Trans./ vol. ii, p.
56, Plate III, fig. 1). Of Mr. Nettleship's two recorded
cases,* in Case 1 there was asthenopia caused by a con-
siderable degree of hypermetropic astigmatism. The tor-
tuosity was confined to tbe veins, in every part of the
fundus of each eye. The refraction of the two eyes is
not separately stated. In Case 2 the tortuosity was con-
fined to the veins, and the patient was emmetropic.
It is evident, therefore, that in most of the cases in
which the condition was so marked as to merit placing on
record, the tortuosity of retinal vessels, whether of veins
only or of veins and arteries, has been associated with
hypermetropia simple or astigmatic. In some of the
cases the tortuosity has been greatest in the eye in which
the hypermetropia predominates. In other cases, however,
the tortuosity has been equal in two eyes with very
different degrees of hypermetropia, and has been present
in an emmetropic person. Some of the patients have
complained of headache, which has predominated on the
side where the greatest tortuosity of vessels and hyperme-
tropia prevailed, but this has not been relieved by the
correction of the hypermetropia.
The subject is evidently one inviting further contribu-
tion and elucidation, and I hope members will state their
experience on the association of tortuosity of retinal vessels
(slight or severe) with hypermetropia.
{May 8th, 1884.)
* 'Trans./ vol. ii, p. 57, Plate III, fig. 2.
156 DISEASES OP RETINA AND CHOROID.
5. Direct arterio -venous communication on the retina.
By R. Marcus Gunn.
(With Plate YI, fig. 2.)
Lily W — , aet. 11^, came under observation at tlie
Hospital for Sick Children, Great Ormond Street, in
January, 1884. She had previously been under the care
of Dr. E-. Lee, at that hospital, on account of severe
headaches.
History. — As a baby she was delicate ; when a month
old had convulsions. She grew stronger when about niue
months old, and continued in fairly good health, with the
exception of an attack of bronchitis, until the age of four
years. At this date she had inflammation of the brain
and was laid up for six weeks. During this illness her
head was drawn backwards and she was unconscious.
When nearly recovered she had an eruption of small bullae
over the cheek, arm, and leg of the left side ; slight scars
remain. Two years later she was again mentally deranged
for two or three days, when suffering from an abscess
in connection with a bad tooth. She has always, her
mother says, been highly excitable and very quick intel-
lectually. For the last four years or more she has been
subject to severe headaches ; at first they occurred two or
three times daily, each attack lasting from fifteen minutes
to one or two hours. She used to feel sick at the time,
and once she vomited and retched considerably just after
the headache had passed off. Lately they have been less
frequent and seeminglj^ less violent than formerly. The
pain is chiefly in the vertex and occiput. During the
attack her face looks grey and pinched, and her mother
says that the white of her eyes looks red when the pain is
very severe. The headache seems to be brought on by
any excitement, as when she is at play or working hard at
school. No history of injury.
DESCEIPTION OF PLATE YI.
Fig. 1 shows the ophthalmoscopic appearances in Dr. Stephen
Mackenzie's case of Tortuosity of E-etinal Vessels with Hjper-
metropia (p. 154).
Left eye ; erect image. From a drawing by Miss Boole.
Fig. 2 shows the ophthalmoscopic appearances in Mr. Marcus
Grunn's case of Arterio-venous Communication on the E-etina
(p. 156).
Left eye ; erect image. From a drawing by Miss Boole.
TEANSACTIONS OF THE OPHTHALMOLOGICAL
SOCIETY OF THE UNITED KINGDOM,
Vol. IV.
In Plate VI, fig. 2, tlie place of junction of the principal
descending vein with the large vessel that establishes the
arterio-venous communication has been accidentally omitted.
The omission is supplied in the accompanying figure.
'f^-'-
f
\
'-' ^
ARTERIO-VENOUS COMMUNICATION ON THE RETINA. 157
Present condition. — The patient is a quick^ intelligent,
highly nervous girl, with fair hair and light blue irides.
Her face is pale and rather puffy; her pupils are wide, active
to light and with convergence, but decidedly oscillatory.
Urine (morning), sp. gr. 1010, acid, no albumen, no sugar.
On ophthalmoscopic examination of the left eye the atten-
tion is at once attracted by the presence of a large vessel
running vertically immediately to the inner side of the
yellow spot. On tracing this vessel downwards it is found
to be a branch of the inferior temporal vein. Following
it upwards we find that soon after passing the level of
the y. s. it bifurcates ; one of the terminal branches con-
tinues upwards in the line of the vessel, while the other
passes upwards and inwards for a short distance and then
opens directly into an artery, viz. the superior temporal of
the retina. In addition, there are other minor peculiari-
ties in vascular distribution to be found in this fundus.
Several of the retinal veins appear to commence abruptly,
doubtless having their origin in the choroid and piercing
the retina vertically. In one place a vein begins in this
abrupt manner and soon attains a large size and dark
colour, while further on it becomes much smaller again,
and lighter in hue before it ultimately joins the inferior
nasal vein of the retina. The relief of the dilated portion
of this vessel is probably due to another communication
with the choroidal circulation, concealed by the vessel
itself.
In the right eye there are two cilio-retinal arteries at
the outer side of the disc.
Under atropine H. = 1*75 D. Vision = -|§.
Her father and his family generally are very nervous ;
one or two of them have had peculiar mental symptoms.
Family history otherwise is unimportant.
(Livirig specimen, March 13/7/, 1884.)
A*
158 DISEASES OF RETINA AND CHOROID.
6. A third instance in the same family of symmetrical
changes in the region of the yellow spot in each eye of
an infant, closely resembling those of embolism.
By Waren Tay.
A MALE cMld, aet. 6 months, shown with changes in the
region of the yellow spot in each eye, precisely resembling
those shown in PL III, vol. i, of the ' Transactions.^ In
this child, however, there is also atrophy of the optic
nerves. When a few weeks old the baby simply showed
marked evidences of optic neuritis. When first seen no
defect oE general nutrition or spinal feebleness could be
detected. He seems now, however, to be beginning to
fail as the first child did.
This is the third instance in the same family. The
history of the first child is given in the first volume of the
' Transactions,' p. 55. He died at the age of one year
and eight months. The second child, a boy also, was
seen within a few months of birth with very similar con-
ditions as to the eyes. There was nothing noticeably
wrong with his muscular or nervous system generally.
After the age of six months he began to get ^^ weak all
over '^ like the first child, and gradually became quite
helpless. When eighteen months old (on June 2nd, 1883)
he was admitted into the London Hospital. He was then
precisely in the condition of the eldest born when first
seen. He had slight convulsive seizures not noticed in
the elder child ; he turned '^ black in the face and became
quite stiff for a minute or two.'' Subsequently he had a
definite epileptiform convulsion one morning. The right
side of the body was perfectly rigid, and the eyes deviated
to the right ; there was also twitching and drawing up of
the right angle of the mouth. The optic discs were in a
state of atrophy and the yellow-spot region in each eye
TUBERCLE OF CHOROID. 159
precisely resembled the drawing. The patient brought
up about half an ounce of blood on June the 22nd.
He had a fit which lasted about an hour on the evening
of the 23rd, and another on the 24th. The child had
no further fit, but gradually sank. He died on June 26th.
The temperature was normal till June 10th ; then it
varied from 100*5° to 103*5°. Post-mortem examination
refused.
(Living specimen. January 10th, 1884.)
July, 1884. — The mother promised to attend with the
baby from time to time. She did not do so more than
once or twice. She cannot be found (on personal inquiry)
at the address which I obtained from her myself.
7. Tubercle of choroid.
By P. H. Mules, M.D. (Manchester).
(With Plate VII, fig. 1 .)
The drawing which I bring before the Society this
evening appeared to me sufiiciently rare to warrant more
than a passing notice. The detection of miliary tubercles
in the choroid during life has not been so often reported
as to have lost its interest, nor am I aware that there
exists a coloured representation similar to the one I
show this evening, which I believed to be a typical
example of miliary tubercles of the choroid. This has been
since substantiated by post-mortem examination.*
In my own experience and that of my colleagues,
extending in the aggregate over a large number of cases,
we have here the one solitary example of tubercles
* Microscopical sections of the tubercles were exhibited at the meetiug.
160 DISEASES OF RETINA AND CHOROID.
of the choroid seen by us during life, an experience
participated in by Dr. Ashby, physician to the Children's
Hospital at Pendlebury, near Manchester, to whom I am
indebted for these preparations, and who has placed his
notes of this case at my disposal. The specimens were
found in a girl, a3t. 10, the victim of acute miliary tuber-
culosis attacking all the viscera and further developing in
the meninges. The course of the case was exceedingly
rapid, the child dying within fourteen days from the
apparent commencement of her illness.*
Of the appearances seen at both fundi whilst the child
lay in a semi-comatose condition two days before her
death, the drawing gives a faithful representation.
Some eight to ten nodules were observed, surrounding
the disc at varying distances, yellowish white at the centre,
shading towards the base to the colour of normal choroid,
and in three instances underlying the retinal vessels, the
little masses being circular and much smaller than the
disc, whilst there was also evidence of double optic neuritis.
No more faithful description can be given than that found
in Dr. Gowers' work on ^ Medical Ophthalmoscopy. 'f At
the post-mortem examination the lungs were found loaded
with miliary tubercle; the kidneys, liver, and spleen were
studded throughout their substance with similar deposits,
and fine tubercle was found on vessels in the Sylvian
fissures. The eyes were removed with the hope of detect-
ing bacilli in the choroidal tubercles ; the staining and,
subsequent examination was carried out by Dr. Maguire
in the Pathological Laboratory of Owens College, and,
although exceptional care was taken, no rods could be
found. I confess I was not disappointed, because in a
case of tuberculosis confined to the eyeball, which I had
the honour of bringing before the Society, every known
staining was tried without avail to detect bacilli. Whether
they exist as a spore which will not stain, or whether,
* A full report of the case will be found in the 'Medical Times' for ISS-i,
vol. ii, p. 80.
t p. 198.
DESCRIPTION OE PLATE YII.
Eig. 1 shows the ophthalmoscopic appearances in Mr. Mules's
case of Tubercle of Choroid (p. 160).
Right eye ; erect image. From a drawing by the author.
Eig. 2 shows the ophthalmoscopic appearances in Dr. Walter
Edmunds's case of Papillo-Retinitis from a case of Cerebral
Tumour, but with appearances closely resembling those usually
seen in Albuminuric Retinitis (p. 291).
Right eye ; erect image. From a drawing by Miss Boole.
Trans. OpktJi. Snr.VoITV.Pl. 7.
Fig.
1.
/
H
iK
Fi
^•t^
"West.Nowmaji & C? chromo.litk.
DISSEMINATED CHOROIDITIS. 161
having originated a fresh development in the shape of
these masses of lymphoid cells, the bacillus is superseded,
leaving these new organisms to finish the work it has
commenced, we know not ; it is sufficient, so far as this
paper is concerned, to say that in the above-named cases,
specially in that of primary tuberculosis of the eyeball,
tubercle existed, but no bacillus. The microscopical
appearances seen in logwood-stained sections in no way
differ from those that have been recorded before — th.e
giant-cells fairly numerous, and patches of retrograde
tubercle to be easily detected.
I would only further add that tlie ophthalmoscopic
appearances taken alone are hardly diagnostic of tubercle
as apart from other choroidal affections, notably the very
early stage of choroiditis disseminata, but taken in con-
junction with other symptoms they appear to perfect the
chain of evidence should there be a link found wanting.
{June bth 1884.)
8. Disseminated choroiditis.
By Anderson Critchett and Henry Juler.
(With Plate III, fig. 2.)
Sarah D — , aet. 46. There is a distinct history of
acquired syphilis five years ago (syphilitic sore followed
by rash, sorethroat, &c.) .
The left eye became first affected tbree years ago, when
she gradually lost the sigbt over the inner half of the left
visual field. A year ago this eye became greatly inflamed
and the vision disappeared entirely. The right eye has
also been slightly red from time to time, but its vision has
not been particularly defective ; in fact, the patient was
unaware of the diseased condition of this eye until she
VOL. IV. 11
162 DISEASES OF EETINA AND CHOEOID.
came under our treatment at St. Mary's Hospital in Marcli
last. The state of tlie fundus of the right eye is one
which we have thought would be interesting to the
Society, for although the vision is equal to |- of the dis-
tant and 0'5 of the reading types of Snellen, yet we find
innumerable whitish-yellow circular patches scattered over
the fundus ; these, as represented in PI. Ill, fig. 2, occupy
not only the greater part of the periphery, but also the
yellow-spot region of the fundus.
The case has been treated as one of secondary syphilis.
Mercury has been given in the form of inunction by the
axilla, just short of salivation, during the last six weeks.
Since this treatment was commenced the white spots
on the choroid of the right eye appear to have receded
and become less numerous.
The visual acuteness is still normal and the visual field
presents no marked scotomata.
In the left eye there appears also to be much improve-
ment, for when we first saw her, there was bare p. 1. in
this eye, whilst at the present time she can count fingers
in the outer part of the visual field.
{Living specimen. June bth, 1884.)
9. Central senile guttate choroiditis [without defect of
sight) .
By E. Nettleship.
Daniel L — , set. 61, slipper maker, an Irishman, admitted
at the Moorfields Hospital in July, 1883, stated that his
left eye had been failing nine months and the right four
months ; as, however, he was hypermetropic but little
reliance could be placed on his account. He had been
subject to winter cough for many years, but had otherwise
had good health. No history of syphilis could be obtained;
CENTRAL SENILE GUTTATE CHOROIDITIS. 163
married ten years, wife had never been pregnant. Urine
free from albumen and sugar, sp. gr. 1015. Notwith-
standing the position and abundance of the choroidal
disease, visual acuteness was but little impaired.
R. -^^^, Hm. 3-5 r). = f§ j with^ Tension and field
^ J +6 D. = l J. C ^^ vision nor-
L. "2^^; Hm. 3* D. = f^; with C mal in each
+ 6D. = 4J. ) eye.
The drawing (shown at the meeting") is from the erect
image of the right eye ; exactly similar changes were
present in the left eye. At the region of the yellow
spot in each eye are numerous dots of choroidal disease.
They are very small, uniformly scattered, yellowish-white,
and free from pigment accumulation. The smallest of
all are round, but the larger ones are often rather
irregular as if formed by the confluence of two minute
ones. The dots look as if caused by deposit rather than
atrophy, the boundary of each dot being rather softened,
not sharply defined. The disc and retinal vessels show
no marked change.
This case and the next are good examples of an early
stage of the disease described by Tay and Hutchinson
in the ' Ophthalmic Hospital Reports ' for 1875, vol. viii,
p. 231, and are presented for comparison and contrast with
the case of central choroidal atrophy also exhibited* {vide
p. 165).
(Living sjpecimen. March \othy 1884.)
* They may also be compared with a case published by Mr. Adams {vide
' Trans. Ophth. Soc.,' vol. iii, p. 113) j the appearances, however, are not the
same.
164 DISEASES OF RETINA AND CHOROID.
10. Central guttate choroiditis without defect of sight ;
premature presbyopia.
By E. Nettleship.
(With Plate II, fig. 2.)
The drawing (PI. II, fig. 2) sliows the appearances of the
erect image in the left eye. A number of small, perfectly
circular_, pale greyish-yellow spots are thickly congregated
at the yellow-spot region, and more thinly scattered all
around that part, reaching on the nasal side as far as the
disc ; in these outlying parts the spots are usually grouped
in small patches, or in linear series as if following the course
of some large vessel or nerve in the choroid. Some of
the spots are more defined than others, but none are
sharply cut ; the most defined ones are surrounded by a
shaded grey ring such as might be produced if the pig-
ment epithelium were pushed aside by a slightly promi-
nent nodule ; there is nothing suggesting proliferation of
the pigment epithelium. The small retinal trunks which
feed the lower half of the yellow-spot region are larger
and more tortuous than usual, and it is just in this part
that the spots of disease are thickest ; indeed, the upper
half of the yellow spot is nearly free, and its retinal
vessels are so small that the artist has not shown them.
Discs perhaps rather pale ; retinal vessels normal. No
choroidal disease elsewhere.
The other eye showed changes exactly similar in kind
and very nearly as abundant.
The patient, Sarah C — , aet. 41, married, came to St.
Thomas's Hospital for spectacles early in the present
year.
r E. f § Hm. -5 D.
^ • I L. |§ Hm. -5 D.
Although only forty-one, she required + 4'5 D. for
reading at 22 cm., i.e. she had no accommodation what-
CENTRAL SENILE AREOLAR CHOROIDAL ATROPHY. 165
ever. I have unfortuately no note of the pupils, but
they were certainly not dilated. Her sight had been
" weak ■'' since a severe illness following parturition fifteen
years before j no other history obtainable.
{Living specimen. May Sth, 1884.)
11. Central senile areolar choroidal atrophy.
By E. Nettleship.
(With Plate VIII, fig. 1.)
Caroline M — , aet. 60, married, admitted at the Moor-
fields Hospital in October, 1883, only able to see letters
of 20 J. with each eye. Eefraction slightly H. Sight
has been fading for twelve years (perhaps only from Pr.),
but has got decidedly worse only four months. Has had
eighteen children ; health has been good except for some
chronic rheumatism ; urine contains neither albumen nor
sugar. Father was blind for six years before he died,
but no details are known. Patient attended at hospital
a few times, but no change occurred in the sight or
ophthalmoscopic appearances.
In each eye a large area of atrophied choroid occupies
the central region of the fundus ; in the left it is almost
perfectly circular, in the right it is rather larger and not
quite so regular in outline.
The drawing (PI. YIII, fig. 1) is from the erect image of
the left eye. The disc is situated on the nasal border of the
diseased area. Over the nasal portion of the area the
atrophy is complete, only a few white lines seen against the
slightly grey background remaining to indicate obliterated
blood-vessels. Towards the temporal side the atrophy
becomes gradually less marked, and on this part very
conspicuous thickening of the coats of the large vessels is
166 DISEASES OF RETINA AND CHOROID.
noticed, a cliarige wliicli no doubt passes on to their com-
plete obliteration. The diseased area is sharply defined
everywhere except at the extreme outer part. The
choroid bounding its lower border is darkened_, possibly
by capillary congestion, but with this exception there is
no evidence of inflammation preceding the atrophy ; nor
is there any accumulation of pigment. The first change
seems to be the disappearance of the chorio-capillaris ; this
is well seen at the right hand lower part of the drawing,
where, although the large vessels show as yet but little
change, the limit of the disease is marked by the sudden
cessation of the ^^ stippled " appearance produced by the
epithelial and capillary layers. The disc shows no marked
change and the retinal vessels are normal.
The case illustrates one variety, well marked and not
very rare, of senile disease of the choroid. A similar
case is given in the ' Hand Atlas ^ of Wecker and Jaeger,
fig. 97 ; the patient was a woman set. 60 ; only the right
eye was affected, and the disease had begun about two
years previously with the appearance of large muscae and
a grey cloud before the sight ; the affected eye was
emmetropic, the other hypermetropic.
The disease here illustrated does not seem, so far as
we yet know, to have anything in common, anatomically,
with the central guttate choroiditis of Tay and Hutchinson
{vide p. 163) ; but the similarity in the age of the patients
and in the region affected suggests some similarity of
cause.
The thickening (? atheroma, ? sclerosis) of the large
choroidal vessels (chiefly veins) seen in this case is not
uncommon in other varieties of choroidal atrophy near
the disc, especially in elderly persons.
{Living specimen. March ISthj 1884.)
DESCEIPTION OF PLATE VIII.
Fig. 1 shows the ophthalmoscopic appearances iu Mr. Nettle-
ship's case of Central Senile Areolar Atrophy of Choroid
(p. 166).
Left eye ; erect image. From a drawing by Miss Boole.
Fig. 2 shows the ophthalmoscopic appearances in Mr. Nettle-
ship's case of Peculiar Lines on the Choroid after Papillitis
(p. 167).
Right eye ; erect image. From a drawing by Miss Boole.
Trans. Ophth. Soc.Voi.IV.Pl. 8
//J
SI
\
t
,v
V.V-at .J^ewmaii j& C? chroiao .iith
PECULIAR LINES IN THK CHOROID. ]67
12. Peculiar lines in the choroid in a case of loost-
papillitic atrophy.
By E. Nettleship.
(Witli Plate VIII, fig. 2.)
The drawing (PI. YIII, fig. 2) shows tlie erect image of
the right fundus. The disc is pale, its margin in parts
slightly hazy, the retinal veins still tortuous and rather
turgid, the retinal arteries somewhat shrunken. Vision
is almost abolished (hand moving only) . About eighteen
months before the drawing was made the eye had passed
through an attack of papillitis, but beyond the fact that
this was well marked, no particulars have been kept.
The peculiarity is the presence of a number of straight
lines in or upon the choroid running parallel with one
another nearly in the horizontal direction. These lines
are longest and broadest at the yellow-spot region ; they
are equally numerous, though finer, to the nasal side of the
disc, and a few are seen above ; they are all horizontal,
not radiating from the disc. Below the disc there is dis-
turbance of the superficial (epithelial) pigment, but no
straight lines are seen. Each line shows a dark and a
light border ; these change to some extent when the
direction of the light is altered, as if the dark were at
least partly caused by a shadow ; it is, however, certainly
in part due to pigment. The lines look as if due to a
number of delicate ridges or plaits, such as might pos-
sibly have been left by the subsidence of an oedema of
the choroid. (Edema of choroid is often seen in micro-
scopical specimens of cases of papillitis from brain
disease.
The other eye is in the same state, but vision not quite
so bad {-^fpQ and 10 J.) .
The patient is a man (Arthur H — ), now aet. 36, who was
in the Queen Square Hospital for the Paralysed and
Epileptic, under Dr. Hughlings Jackson and Dr. Ferrier
168 DISEASES OF RETINA AND CHOROID.
in the summer of 1882 for fits affecting the right side more
than the left, with numbness of the right side at times,
and other cerebral symptoms. The papillitis and defective
sight were present in August, 1882, when I saw him (by the
kindness of Dr. Coxwell, then house physician), but made
no note of the ophthalmoscopic condition. He is now
under the care of Dr. Beevor, who tells me that the sym-
ptoms point to a cortical tumour of the left hemisphere,
about the ascending and third frontal convolutions. He
had syphilis when about thirty, and the brain disease is
undoubtedly due to that cause.
I am indebted to Dr. Beevor for the opportunity of
seeing the man again and for permission to have the draw-
ing made.
{Living specimen. May 8thj 1884.)
Dr. Stephen Mackenzie remarked that he had two cases
under observation at the present time, in which a white
streak or scar passed from the papilla in the direction of
the yellow spot. In each case there had been papillitis
from brain disease. He had not been able to satisfy
himself as to the nature of the condition, which was very
closely alike in the two cases.
13. Nsevus of the right temporal and orbital region ; nsevus
of the choroid and detachment of the retina in the
right eye.
By W. Jennings Milles.
William M — , aet. 15, was brought to the hospital by
his mother because he was blind in his right eye. The
history as stated by the mother was that the boy was
born with a large birthmark involving the eyelids on the
right side ; that this birthmark had never been markedly
NJiVUS OF THE RIGHT TEMPORAL AND ORBITAL REGION. 169
discoloured, but varied considerably in size ; that the right
eye had apparently been a good one till the boy was six
years old, when it was found to be blind, and that there
had never been any complaint of pain in this eye. The
birthmark had somewhat diminished in size during the
last few years.
His condition on examination was as follows. There
was some deformity on the right side of his face, pro-
duced by a puffy swelling, involving the orbital and tem-
poral regions and reaching outwards to the hairy scalp.
It had all the appearance of a naevus, but scarcely affected
the skin at all. The lids were distinctly puffy. There
were no dilated vessels in the conjunctiva. The cornea
was clear, the anterior chamber rather shallow, the pupil
was dilated and inactive to light, the lens was clear, and
the retina was completely detached and closely in contact
with the posterior surface of the lens. T. n., V. = bare
The left eye was myopic with some asthenopia when
used.
The right eye was excised and the following patho-
logical changes were found. The retina is detached in
an umbrella form (as seen in the specimen mounted in
glycerine). A roughly circular area of the choroid
measuring about 20 mm. in diameter, and occupying the
posterior and outer part of the globe, consists of a soft
spongy porous structure ; it is thickest in the centre,
where a cross section measures 2 J mm. ; on its inner
surface the pigment is irregularly heaped up with a tag
projecting towards the detached retina. The porous
structure is very distinct to the naked eye.
Microscopically it is a simple angioma consisting of
dilated veins and capillaries ; there are at places large
dilated spaces filled with blood, in fact a cavernous
angioma. The pigmentary layer of the retina is remain-
ing with choroid greatly altered, and converted into a
connective tissue layer.
(May 8tk, 1884.)
170 DISEASES OF RETINA AND CHOROID.
Dr. Brailey said : If this is a genuine case of naevus it
appears to me somewhat remarkable that there should be
found associated with the affected part of the choroid
some of what are usually reckoned inflammatory products,
e.g. a fibrous layer on the inner surface of the lamina
vitrea of the choroid, and in the inner layers of the affected
choroid itself, very near to the lamina vitrea, a small hard
plate exactly resembling an earlier stage in the formation
of bone.
Dr. Stephen Mackenzie thought that very great interest
attached to Mr. Milles's specimen. Dr. Allen Sturge had
described a case at the Clinical Society some years ago
(• Clin. Soc. Trans. ,^ vol. xii, 1879, p. 162), in which there
had been a congenital port-wine mark on one side of the
face, with tortuous retinal vessels ^nd changes in the
choroid on the same side. The patient had suffered from
epileptiform seizures of the side of the body opposite to
the port-wine markings, and Dr. Allen Sturge was inclined
to attribute the partial epileptic seizures to a naevoid con-
dition of the vessels of the brain similar to that which
existed in the face and eye. Mr. Nettleship had made a
careful ophthalmoscopic examination in this case. Dr.
Horrocks had recently brought before this Society
(' Trans.,^ vol. iii, p. 106) a case in which there was a
naevoid condition of the face and eye, with clonic con-
vulsions on the opposite side of the body. The anato-
mical evidences afforded by the beautiful microscopical
preparations exhibited by Mr. Milles were therefore very
important in establishing that a nsevoid condition existed
in the choroid. This, whilst it did not prove that a
naevoid condition of the vessels existed on the same side
of the brain, lent a certain support to the view that such
a state might be present in cases in which, with naevoid
conditions of the skin of the face and tunics of the eye,
unilateral nervous symptoms were present on the opposite
side of the body.
Mr. Nettleship said that in Dr. Allen Sturge's case
referred to by Dr. Stephen Mackenzie there was distinct
OSSIFICATION OP CHOROID. 171
evidence that the affected eye was larger than the other, the
cornea being wider and the refraction being considerably
myopic (the other eye being hypermetropic) ; the choroid,
moreover, was seen to be darker than in the other eye.
In a case of na3vus of the orbit, which he had shown at a
previous meeting, the eye on the affected side appeared
smaller than its fellow, and its lens showed lamellar
cataract.
14. Ossification of choroid, causing repeated attacks of
sympathetic irritation.
By W. Adams Frost.
George S — , set. 43, admitted into St. George's Hospital
April 3rd, 1884, under Mr. Frost. When thirteen years
old the right eye was injured by a kick from a horse ;
vision in that eye was destroyed at once, and permanently.
Since then he has had several attacks of conjunctival
injection and tenderness in the injured eye, lasting usually
about a fortnight ; during each of these attacks there has
been conjunctival injection with overflow of tears and
great intolerance of light in the other eye. The last
attack was five years ago, the present commenced five
weeks ago.
When admitted. — R: conjunctival injection, large opaque
scar on cornea, T. — 3, no p. 1.
L : No conjunctival injection, but free lacrimation,
y ^ 6
V . — g.
Right eye enucleated, globe bisected and mounted in
glycerine jelly (Priestley Smith's method). Lens almost
entirely absorbed. Total detachment of retina. Greater
part of choroid converted into bone, which in one situation
formed a rounded nodule projecting 4 mm. into the
vitreous chamber.
{Card specimen. May 8th, 1884.)
172 DISEASES OF OPTIC NEltVE.
X. DISEASES OF OPTIC NERVE.
1 . An analysis of cases of intracranial tumour with respect
to the existence of optic neuritis.
By Walter Edmunds and J. B. Lawford.
In a communication to the Society last session we ex-
pressed the opinion^ based chiefly on microscopical obser-
vations, that the optic neuritis which occurs in intracranial
disease is due to the presence of a secondary meningitis.
If this be so it is to be expected that tumours about the
base of the brain would be more likely to cause optic
neuritis than those situated towards its convexity.
To ascertain if such be the case we bave collected from
various sources notes of 107 fatal cases of cerebral tumour,
and have analysed them with special reference to the
presence or absence of optic neuritis at the time
when they were first examined ophthalmoscopically ; and
it is to be understood that in the table the statement '^ no
optic neuritis '^ means only that there was no optic
neuritis at a stage of the case when the other symptoms
were well developed, and does not necessarily imply that
optic neuritis did not supervene before the close of the
case.
The cases are divided into ten groups, and the result of
the analysis is as follows :
(1.) Tumours in the frontal lobes, anterior to the
cortical motor regions. Ten cases. Optic neuritis was
present in eight of the cases and absent in two.
(2.) Tumours in cortical motor area. Twelve cases.
None of these had optic neuritis when first examined, in
only three is it noted that it subsequently came on, and in
CASES OF INTRACRANIAL TUMOUR.
173
two other cases it is expressly stated that it was absent
throughout.
(3.) Tumours of occipital lobes. Nine cases. In five
cases there was optic neuritis^ and in four there was
not.
(4.) Other tumours in hemispheres (not more precisely
localised). Ten cases. Optic neuritis present in six,
absent in four.
(5.) Tumours of the ganglia at or about the base of the
brain. Twenty cases. Optic neuritis present in seven-
teen, absent in three cases.
(6.) Tumours of temporo-sphenoidal lobes. Three
cases. Optic neuritis present in one, absent in two cases.
(7.) Tumours of cerebellum. Twenty-three cases.
Optic neuritis present in twenty cases, absent in three.
Of the twenty cases who had optic neuritis, seven were
actually blind on admission to hospital, and two others
became blind before death.
(8.) Tumours of medulla and pons. Nine cases. In
three there was optic neuritis, and in six there was not.
(9. Tumours springing from meninges, involving cor-
tical motor areas of hemispheres. Five cases. Four had
and one had not optic neuritis.
(10.) Meningeal growths in other situations. Six
cases. Four had and two had not optic neuritis.
Group I. — Tumours of Frontal Lobes.
No.
Sex.
Age.
Optic disc.
Tumour.
Reference.
1
2
P.
F.
32
32
Double optic neu-
ritis passing into
atrophy
Epileptoid attacks ;
double optic neu-
ritis, worse in
right; later left
hemiplegia
Gummatous tumour of ante-
rior part of left frontal
lobe
Glioma in right frontal lobe ;
dura muter adherent
Knapp,
in Knapp's
Arch., vol. iv.
Gowers,
B. M. J.,
1879, vol. i.
174
DISEASES OF OPTIC NERVE.
No.
Sex.
Age.
Optic disc.
Tumour.
Reference.
3
M.
60
Right hemianop-
Glio-sarcoma in left frontal
A.rchiv f.
sia; no optic neu-
lobe of cerebrum ; chiasma
Path, und
ritis
normal; left optic tract
small
Physiol.,
1875.
4
F.
32
Double optic neu-
Ill-defined tumour in right
Gowers,
ritis
frontal lobe; "optic nerves
appear to be invaded by in-
flammation from meninges"
Medical Oph-
thalmoscopy.
5
F.
34
Optic neuritis
Tumour in left frontal lobe ;
membranes adherent; chi-
asma compressed
Habershon,
Guy's Hosp.
Reports, 1879.
6
F.
39
Blind; atrophy of
Tumour in right anterior
St. Thomas's
optic nerves
lobe of cerebrum, extend-
ing backwards into middle
fossa ; optic nerves com-
pressed and atrophied
Hosp. Rep.,
1880.
7
M.
25
No optic neuritis
Gumma in anterior lobe of
right hemisphere; ventri-
cles not involved
St. Thomas's
Hosp. Rep.,
1880.
8
M.
41
Late neuritis in
Tumour in both anterior
St. Thomas's
right eye ; left
lobes of brain
Hosp. Rep.,
normal
1882.
9
M.
36
Double optic neu-
Endothelioma occupying
Philipson,
ritis (fortnight
whole of right frontal lobe ;
Med. T. & G.,
before death)
dura mater adherent
1882, vol. ii.
10
M.
53
Double optic neu-
Tumour, size of Tangerine
Russell,
ritis six weeks be-
orange, in right frontal
B, M. J.,
fore death
lobe ; similar tumour in left
frontal lobe; a third tumour
in right occipital lobe
1881, vol. ii.
Group II. — Cortical Lesions.
11
M.
49
No optic neuritis
Tumour in ascending frontal
convolution
Hughes
Bennett,
Brain, vol. v.
12
M.
44
Never optic neu-
Tumour at base of superior
Ferrier,
ritis ; right hemi-
frontal and corresponding
Brain, vol. vi.
plegia
part of ascending frontal
convolution
13
M.
52
For months no op-
Several small tumours ;
Gowers,
tic neuritis ; later
largest in upper part of
Medical
optic neuritis,
left parietal lobe. (He had
Ophthalmo-
which subsided
right-sided convulsions and
scopy.
and reappeared
right hemiplegia)
CASES OF INTRACRANIAL TUMOUR.
175
.\o.
14
15
16
17
Sex.
M.
F.
M.
M.
Age.
40
38
18
M.
37
19
M.
29
20
21
F.
M.
a.
52
22
M.
22
Optic disc.
Tumour.
No optic neuritis ;
craral monoplegia
Left-sided convul-
sions and paraly-
sis of left leg ; no
optic neuritis
No optic neuritis
Never optic neu-
ritis; convulsions,
beginning in right
foot ; right hemi-
plegia
Convulsions, begin-
ning in right leg ;
no optic neuritis,
but came on six
weeks before death
No optic neuritis;
unilateral epilep-
sy, followed by
temporary hemi-
plegia
Caseous tubercular degene-
ration at upper extremity
of fissure of Rolando
mass in upper Sharkey,
of two central Lancet, 1883,
Tubercular
extremity
convolutions of right hemi-
sphere
Tumour, li diam., involving St. Thomas's
Reference.
Ferrier,
Brain, vol. iii.
vol.
11.
white matter, subjacent to
ascending frontal and ase-
parietal convolutions
Glioma, involving superior
and ascending frontal con-
volutions, on left side
Tumour in upper and hinder
portion of left frontal lobe ;
ventricles distended with
fluid
Tumour, involving second
and third frontal convolu
tion, on right side
Convulsions
right arm ;
optic neuritis
of
Glioma involving posterior H. Jacks(
part of superior frontal and M. T. & (
adjacent part of ascending 1875, vol,
■frnnffil fnnvnlnf.inna
Right-sided fits,
chiefly limited to
right arm ; for
some time no optic
neuritis; later op-
tic neuritis came
on
No optic neuritis
? signs of previous
neuritis; epilepti-
form seizures be-
ginning in left
thumb
Hosp. Rep.,
1884.
Hughlings
Jackson,
Lancet,
1882, vol. i.
H. Jackson,
M. T. & G.,
1875, vol. ii.
Russell,
M. T. & G.,
1874, vol. i.
H. Jackson,
" T. &G.,
i.
Tumour upper part left H. Jackson,
parietal lobe j three smaller M. T. & G.,
tumours on surfoce 1875, vol. i.
Tubercular tumour, size of H. Jackson,
hazel nut, in third right M. T. & G.,
frontal convolution ; micro- 1872, vol. ii.
scopical examination of op-
tic nerves — normal (Pa-
genstecker)
176
DISEASES OF OPTIC NERVE.
Group III. — Tumours of Occipital Lobe.
No.
Sex.
Age.
23
F.
36
24
F.
61
25
F.
8
26
M.
55
27
F.
21
28
M.
56
29
M.
—
30
M.
30
31
F.
59
Optic disc.
Double optic neuri
tis ; vision almost
lost in both
No optic neuritis
observed at any
time
Double optic neu
ritis appeared 14
days after first
observation
Choked disc in left
eye only
Double optic neu
ritis; hemiopia
Optic neuritis m
left only ; no later
ophthalmoscopic
examination
Right hemianopsia
aphasia ; right
hemiparesis ;
optic neuritis
Epileptoid attacks;
visual amaurosis;
no optic neuritis
early in case, later
stage not known
Double optic neu-
ritis
Tumour.
Tumour, size of billiard ball,
in left occipital lobe
On median surface at apex
of right occipital lobe a
cyst surrounded by soften-
ing, which was limited to
the cortex
Reference.
Hamilton,
Brain, vol. vii
Haab, in Klin.
Monatsbl. fiir
Augenheilk.,
1882, p. 146.
Tubercular tumour on me- Haab, in Klin,
dian surface of apex of Monatsbl. fiir
right occipital lobe ; another Augenheilk.,
in second right frontal 1882, p. 146.
convolution
Gumma in left occipital
lobe
Glio-sarcoma in left occi
pital lobe adherent to
membranes
Tumour li in. diameter in
left posterior lobe, closely
adherent to dura and pia
mater
Myxosarcoma in occipital
lobe ; optic tracts chiasma
and optic nerves normal
Sarcoma in right occipital,
extending into posterior
part of right parietal lobe
Tumour size of goose's egg
in posterior half of left
hemisphere ; did not ex-
tend to base of brain
Pooley, in
Knapp's
Arch, fiir
Augenheilk.,
vol. vi.
Ludwig Jany,
in Knapp's
Arch., vol. xii.
Pooley, in
Knapp's
Archives,
vol. V.
Jasbrowitz,
Centralblat f.
Pract.
Augenheilk.,
1877.
Gowers,
B. M. J.,
1879, vol. i.
Burney Yeo,
Brain,
vol. i.
CASES OP INTEACEANIAL TUMOUR.
177
Group TV, — Tumour of hemisphere not otherwise specified.
No.
Sex.
Age.
Optic disc.
Tumour.
Reference.
32
M.
40
Double optic neu-
ritis J defect of
sight
Glioma at posterior extre-
mity of centrum ovale on
right side
Jamieson,
M. T. and G.,
1882, vol. ii.
33
M.
60
Right hemiplegia
and aphasia ; no
optic neuritis
Tumour in left cerebral
hemisphere
St. Thomas's
Hosp. Rep.,
1883.
34
F.
19
Commencing optic
neuritis
Tumour in upper part of
right cerebral hemisphere
J. E. Shaw,
Brain,
vol. V.
35
M.
26
No optic neuritis;
later optic neu-
ritis only in eye
on side opposite
to tumour
Tumour size of pigeon's
egg on surface of right
hemisphere
Field,
Brain,
vol. iv.
36
P.
36
Never optic neu-
ritis
Large cystic new growth in
left centrum ovale
Habershon,
Guy's Hosp.
Reps., 1879.
37
F.
16
No optic neuritis ;
hysterical sym-
ptoms; blindness
Tumour in medullary sub-
stance of middle lobe
superior to lateral ventricle
Hughes
Bennett,
Brain,
vol. i.
38
M.
46
Double optic neu-
ritis
Tumour in corpus callosum
extending laterally into
white substance; no menin-
gitis
St. Thomas's
Hosp. Rep.,
1880.
39
M.
25
Double optic neu-
ritis
Fibro-sarcoma of right
hemisphere
Nieden,
Archiv. f.
Augenheilk.,
1881.
40
M.
18
Double optic neu-
ritis
Tubercular tumour size of
pigeon's egg in right
ventricle ; basal menin-
gitis
Bouvin,
KUn.
Mouatsbl. f.
Augenheilk.,
1884.
41
Double optic neu-
ritis; subsequent
atrophy
Glioma, size of an apple, in
cortex of right hemisphere
Stiimpfell, in
Archi\' f iir die
Med. Wiss.
Dec, 1882.
VOL. IV.
12
178
DISEASES OP OPTIC NERVE.
Geoup V. — Tumours involving ganglia at base of brain.
"No.
Sex.
Age.
42
M.
25
43
F.
25
44
M.
42
45
M.
7
46
M.
4
47
F.
13
48
F.
43
49
M.
24
60
M.
14
Optic disc.
Double optic neu-
ritis
Nearly blind,
double optic neu
ritis
At first double
optic neuritis ;
later white
atrophy
No optic neuritis
on admission j
slight neuritis 4
days before death
" Commencing
optic neuritis'
Double optic neu
ritis; left eye sees
well, right eye
only counts
fingers j later
optic atrophy and
blindness
Optic neuritis
Double optic neu-
ritis
Double optic neu-
ritis
Tumour.
Tumour in corpora quadri
gemina, causing absorption
of right optic thalamus
Tumour springing from
surface of right corpus
striatum and optic thalamus
Tumour (glioma) in right
corpus striatum and right
prefrontal lobes
Tubercular tumour in cor-
pora quadrigema ; tuber
cular meningitis
Tubercular mass in 3rd
ventricle, involving both
thalami ; meningitis
Tumour in third ventricle ;
optic commissure stretched
and softened
Tumour in lenticular nucleus
of the corpus striatum,
optic part softened, but
not invaded
Tumour in front of and in
volving corpora quadri
gemina
Tumour in right optic tha
lamus and right side of
corpora quadrigemina
Reference.
Duffin
(Clinical
Society),
M. T. and G.,
1876, vol. ii.
St. Thomas's
Hosp. Rep.,
1883.
Fox and
Field,
Brain,
vol. iii.
Bristowe,
Brain,
vol. vi.
See also Oph.
Soc. Trans.,
iii, p. 151.
Bristowe,
Brain,
vol. vi.
Gowers,
Medical
Ophthal-
moscopy.
Gowers,
Medical
Ophthal-
moscopy.
Gowers,
Medical
Ophthal-
moscopy.
Ferrier,
Brain,
vol. V.
CASES OP INTRACRANIAL TUMOUR.
179
No.
51
Sex.
M.
Asje.
24
52
53
54
M.
M.
M.
21
44
55
M.
23
56
M.
57
58
59
M.
M.
21
41
Optic disc.
Headache, weak-
ness of limbs ;
moderate optic
neuritis
Double optic neu-
ritis
Left hemianopsia j
double optic neu-
ritis, later atrophy
Left homonymous
hemiopia; left
eye neuritis, right
consecutive
atrophy
" Temporal hemi
opia '" no optic
neuritis; not ex
amined at close
of case
Double optic neu
ritis
Optic neuritis
(only had one
eye)
Slight optic neu-
ritis
Vision affected ;
double neuritis,
worse in left
Tumour.
Sarcoma between posterior
parts of optic thalami, in-
vading corpora quadri-
gemina ; very slight
meningitis contiguous to
the nerves, which were
found microscopically to
be inflamed
Tumour of pituitary gland,
pressing on and causing
aneurysm of carotid artery
of one side
Syphilitic tumour in front
of and below left optic
thalamus; two cysts at
base of brain
Tubercles in right half
chiasma; tubercular men in
gitis
Tumour in front of chiasma
between optic neuritis ;
second tumour beneath
pons Varolii ; acute menin-
gitis
Syphilitic tumour in neigh-
bourhood of corpora quad-
rigemina
Tumour size of walnut
fiUinpr third ventricle and
pressing downwards
Cyst in region of right
gyrus hippocampi reaching
forward to tuber cinereum
Tumour on right side of
interpeduncular space
pressing on right optic
nerve and tract
Reference.
Gowers,
B. M. J.,
1879,
vol. i.
E. L. Holmes,
in Knapp's
Arch., vol. iv.
Mohr,
Graefe's
Archiv.,
1879.
Hjort,
Zehender's
K. M. f.
Augenh.,
1867.
Saemisch,
Klin.
Monatsbl. f.
Angenheilk.,
1865.
Landsberg,
Centr. fiir
Pract.
Angenheilk.,
1878.
Dehio,
Centr. fiir
Med.
Wissench.,
1882.
Marchaud,
Graefe's
Archiv.,
18, ii, p. 64.
St. Thomas's
Hosp. Rep.,
1879.
180
DISEASES OP OPTIC NERVE.
No.
Sex.
Age.
Optic disc.
Tumour.
Reference.
60
F.
4
N^o optic neuritis
at first J day
before death left
disc blurred, right
not seen
Tumour in right crus; tuber-
cular meningitis later
Warner,
M. T. & G.,
1880, vol. i.
61
M.
51
Optic neuritis in
left eye only ; left
hemiplegia
Tumour on right side, out-
side corpus striatum and
optic thalamus
H. Jackson,
M. T. & G.,
1874, i.
GrROUP YI. — Tumours of temporo-sphenoidal lobes.
62
F.
45
No optic neuritis j
case simulated
hysteria
Tumour in left temporo-
sphenoidal lobe
Bruce,
Brain,
vol. vi.
63
M.
52
No optic neuritis
Tumour of large size in left
temporo-sphenoidal lobe
St. Thomas's
Hosp. Rep.,
1880.
64
F.
59
Slight optic neu-
ritis ; frequent
examinations
Large glioma in right tem-
poro-sphenoidal lobe; small
tumour in right hippo-
campus major ; tumour
appearing at base
H. Jackson,
Royal Ophth.
Hosp. Rep.,
vol. viii.
Group YII. — Cerebellar tumours.
65
M.
9
Double optic neu-
ritis
Tubercular tumour, size of
billiard ball, in middle lobe
of cerebellum; distension
of ventricles
H. Jackson,
B. M. J.,
1872, vol. ii.
66
F.
52
Double optic neu-
ritis; blind
Tumour in right posterior
cerebellar fossa, inserted
between two flaps of right
cerebellar lobe
H. Jackson,
B. J. M.,
1872, vol. ii.
67
F.
20
Sight affected
early ; blindness
and double optic
neuritis, with
much swelling, on
admission
Tumour starting from valve
of Viessens, involving
cerebellum and corpora
quadrigemina
Bristowe,
Brain, vol. vi.
68
M.
4
Blind ; optic neuri-
tis; "woolly discs"
passing into atro-
Tubercular mass in left lobe
of cerebellum; eftusion of
fluid into ventricles
Bristowe,
Brain, vol. vi.
CASES OF lilTRACRANIAL TUMOUR.
181
No.
Sex.
Age.
69
M.
4
70
M.
43
71
F.
45
72
F.
9
73
M.
25
74
M.
2
75
F.
2
76
?
?
77
M.
11
78
M.
28
79
M.
34
Optic disc.
Double optic neu-
ritis ; quite blind
Blind on admis-
sion ; double optic
neuritis passing
into atrophy
Optic neuritis in
right eye; optic
atrophy in left
eye ; blind for two
months before ad-
mission
Blind on admission
from double optic
neuritis
No optic neuritis on
admission j later
it came on
No neuritis; discs
pale
No optic neuritis
Double optic neu-
ritis
Intense double op-
tic neuritis
Optic neuritis
Double optic neu-
ritis
Tumour.
Reference.
Spherical tumour on under St. Thomases
Hosp. Rep.,
1883.
surface of middle of cere
bellum
Myxo-sarcoma ; tumour at
base involving right side of
cerebellum
Glioma attached to anterior
border of left lobe of cere
bellum
Tumour (glioma) in middle
lobe of cerebellum
Tubercular tumour, size of
pigeon's egg, situated in
and appearing on surface
of left lobe of cerebellum ;
no meningitis
In cerebellum and pons large
tubercular masses; slight
meningitis at base
Tubercular mass, size of pea,
in inferior vermiform pro-
cess of cerebellum
Cyst in right lobe of cere-
bellum
Tumour in middle lobe of
cerebellum ; tumour sprang
from under surface of dura
mater
Tumour, size of a walnut,
on under surface of left
cerebellar hemisphere
Syphilitic tumour in poste-
rior and inferior part of
middle lobe of cerebellum
Leber,
Ziemssen's
Cyclopaedia,
vol. xii.
Long Fox,
Lancet,
1877, vol. i.
H. Jackson,
M. T. & G.,
1875, vol. i.
St. Thomas's
Hosp. Rep.,
1880.
St. Thomas's
Hosp. Rep.,
1881.
St. Thomas's
Hosp. Rep.,
1883.
B. M. J.,
1871, vol. ii.
Beevor,
Brain, vol. iv.
Caton,
Lancet,
1875, vol. ii.
H. Jackson,
M. T. & G.,
1874, vol. ii.
182
DISEASES OP OPTIC NERtEl.
No.
80
81
82
83
84
85
86
87
Sex.
Age.
F.
20
M.
10
M.
5
M.
11
M.
14
M.
16
M.
18
M.
23
Optic disc.
Double optic neu-
ritis
Double optic neuri-
tis; later atrophy
and blindness
Double optic neuri-
tis; subsequently
blind
Optic neuritis; left
eye blind; right
eye counts fingers
Double optic neu-
ritis; almost blind
in left eye
Double optic neu-
ritis ; some defect
of vision
Double optic neu-
ritis
Double optic neu-
ritis
Tumour.
Reference.
Tumour and cyst of cere-
bellum
Two tubercular nodules in
cerebellum
Tubercular tumour, size of
billiard ball, in middle lobe
of cerebellum ; ventricles
distended
Tubercular tumour in cere-
bellum, and a second in
medulla ; tubercular me-
ningitis
Tumour in cerebellum ex-
tending to corpora quadri-
gemina
A large tumour in central
lobe of cerebellum
Degenerated cyst (or cystic
degeneration) of right
cerebellum
Tumour, 3 x 2'6cm.,on under
surface of cerebellum, ex-
tending forwards on the
pons
H. Jackson,
M. T. & G.,
1872, vol. ii.
St. Thomas's
Hosp. Rep.,
1883.
H. Jackson,
B. M. J.,
1871, vol. ii.
Gowers,
Medical
Ophthalmo-
scopy.
Ross,
Brain, vol. ii.
St. Thomas's
Hosp. Rep.,
1883.
Nieden, Arch.
f'iir Augen-
heilk., 1881.
Swan, in
Knapp'sArch.
ofOphthalmo-
logy, vol. vi.
Geoup YIII. — Tumours in msdulla and jpons.
88
89
90
M.
M.
M.
26 Double optic neu-
ritis (" slight ")
No optic neuritis
16
When first seen no
optic neuritis, al-
though great im-
pairment of sight ;
later neuro-reti-
nitis
Glio-sarcoma of right side
of pons and medulla
Tumour in medulla and
pons
Tumour in right side of
pons
Nieden, Arch,
fiir Augen-
heilk., 1881.
Hobson,
Brain, vol. iv.
King,
Brain, vol. v.
CASES OF INTRACRANIAL TUMOUR.
183
No.
Sex.
91 M.
92
93
94
95
96
M.
M.
M.
M.
Age.
35
24
12
33
46
Optic disc.
Optic atrophy when
first came under
observation
Commencing optic
neuritis
Defect of sight ;
later,blindness for
19 days ; later,
hemiopia of outer
halves of fields of
vision; no optic
neuritis
On admission no
optic neuritis; 5
days before death
optic neuritis
No optic neuritis
No optic neuritis
Tumour.
Reference.
Tumour, probably syphilitic,
in pia mater, over pons
Tumour of medulla oblon-
gata
Two tumours, sarcoma ; one
between optic nerves in
front of chiasm a ; a second
tumour beneath pons
Medullary glioma in pons;
membranes of base red and
congested
Tubercular tumour in pons
Two small tumours, one in
pons, one in medulla
Mills,
Brain, vol. ii,
Immermann,
in Ziemssen's
Cyclop.,
vol. xii.
Saemisch,
in
Ziemssen's
Cyclopaedia,
vol. xii.
H. Jackson,
M. T. & G.,
1874, vol. i.
H. Jackson,
M. T. & G.,
1874, vol. i.
Broadbent,
M. T. & G.,
1872, vol. i.
Group IX. — Meningeal growths involving motor regions.
97
98
99
P. I 45 Convulsions begin-
ning in left great
toe ; no optic neu-
ritis
F.
M.
22
35
Epileptiform seiz-
ures beginning in
right little finger;
right hemiplegia;
optic atrophy , pro-
bably post-neuri-
tic
Epileptiform seiz-
ures beginning
right hand ; optic
neuritis
Tumour 1^ x 1 inch, grow- H. Jackson,
ing from dura mater, pro- M. T. & G.,
jecting into right anterior 1873, vol. ii.
ascending parietal convolu-
tion ; other lesser changes ;!
syphilis I
Dura mater mater adherent H. Jackson,
to brain and bone; mass M. T. & G.,
size of three walnuts grow- 1873, vol. i.
ing from dura mater into
brain, softening several
convolutions (syphilitic)
Left hemisphere ; dura H. Jackson,
mater much adherent;, M. T. & G.,
right hemisphere ; tumour 1872, vol. ii.
(? syphilitic) behind fissure]
of Rolando
184
DISEASES OF OPTIC NERVE.
No.
I
Sex. Age.
100 M. 16
101
F.
40
Optic disc.
Convulsions begin
ning in left hand;
double optic neu
ritis
Epileptiform seiz-
ures beginning in
the left hand ;
double optic neu-
ritis
Tumour.
Syphilitic tumour growing
from dura mater, invading
right ascending parietal,
ascending frontal, supra
marginal, and angular con-
volutions
Right side j dura mater ad-
herent 2i X 2| inches ; tu-
mour size of bean in supe-
rior frontal convolation ;
left side; dura mater adhe-
rent 1x1 inch above fis-
sure of Sylvius ; syphilis
Reference.
H. Jackson,
M. T. & G.,
1876, vol. i.
H. Jackson,
M. T. & G.,
1873, vol. i.
Group X. — Other meningeal growths.
102
P.
22
103
—
—
104
M.
30
105
M.
20
106
F.
50
107
F.
47
No optic neuritis
when examined
Double optic neu-
ritis
Double optic neu-
ritis
Double optic neu-
ritis three and a
half years after
first head sym-
ptoms
Never optic neu-
ritis
Double optic neu-
ritis ; gradual
hemiplegia
Tumour of sella turcica;
bone carious; chiasma soft-
ened
Sarcoma of dura mater at
base of cranium pressing
on chiasma, &c.
Gumma upper surface ; left
petrosal bone; basal menin-
gitis
Tumour at base lying on
sphenoid and adjacent tem-
poral bones
Tumour 1^ x 1 inch, at
tached by peduncle to
cerebrum, lying in olfac-
tory groove
Tumour growing from dura
mater over hemisphere,
compressing brain
E. Miiller,
Archiv. fiir
Ophthalmol.,
vol. viii, 1861.
Landsberg,
Centr. fiir
Pract., Augen-
heilk., 1878.
Hulke,
R. L. O. H.
Rep., vol. vi.
Spalding, in
Knapp's
Arch., vol. ix.
Wood,
Philad. Med.
Times, 1874.
H. Jackson,
M. T. & G.,
1874, vol. i.
These figures may be tabulated tlius :
CASES OF INTRACRANIAL TUMOUR.
185
Locality of tumour.
(1) Anterior frontal convolutions
(2) Motor convolutions
(3) Occipital lobes
(4) In hemispheres
(5) Ganglia at base
(6) Teraporo-sphenoidal lobes
(7) Cerebellum
(8) Medulla and pons
(9) Meningeal growths at motor convolutions
(10) Meningeal growths elsewhere
Total
Optic
No optic
Total
neuritis.
neuritis.
8
2
10
~.
12
12
5
4
9
6
4
10
17
3
20
1
2
3
20
3
23
3
6
9
4
1
5
4
2
6
68
39
107
The two most noteworthy points of this analysis are :
(1.) The immunity from optic neuritis of the cases of
tumour in the cortical motor area ; cases in which para-
lysis of one limb occurred or convulsions starting in one
part. In none of the twelve cases was there optic
neuritis when first looked for. If it be thought fairer to
add to these cases the five cases of Group IX in which the
same area was affected secondarily by growths starting in
the meninges we still have thirteen cases without optic
neuritis against four with.
(2.) The severity with which optic neuritis occurred
in the cerebellar tumours : out of twenty-three cases,
twenty had optic neuritis when first examined, and in nine
of the cases it progressed to blindness. This is even worse
than the cases of tumours of the basal ganglia, Group V, for
although out of twenty cases of this latter group seventeen
had optic neuritis, in only five is it probable that there
was blindness. The explanation of this may possibly be
that cerebellar tumours are not so rapidly fatal as basal
tumours, and thus allow time for the neuritis to pass on to
atrophy and blindness.
If all the cases towards the convexity of the brain, that
is to say the cases in Groups I, II, III, IV, and IX be added
together we find that out of forty- six cases, twenty-three
had optic neuritis when first examined, i,e, 50 per cent.
If on the other hand the cases towards the base, that
186 DISEASES OP OPTIC NEEVE.
is to say, the cases in Groups V, VI, VII, VIII, and X he,
added together, we find that out of sixty-one cases forty-
five had neuritis, i.e, 74 per cent.
Thus, the figures are not discordant with the view that
the neuritis is due to basal meningitis.
There were only six cases of hemiopia ; in three of these
there was, and in three there was not optic neuritis. From
this it seems that the occurrence of neuritis is not
specially connected with the affection of the paths for the
transmission of visual impressions, or with the visual
centres themselves.
{July 4th, 1884.)
2. On cases of retro-ocular neuritis.
By E. Nettleship.
Under this rather vague title I wish to refer to certain
not very common cases in which acute inflammation seems
to take place in some small part of the course of the
optic nerve. These cases have been described before
by more than one writer and under more than one
title.* They are characterised by failure of sight
* Leber, * Graefe u. Saemisch's Handbuch,' v, 829. Leber includes, how-
ever, under his title of " chronic retro-bulbar neuritis," the common sym-
metrical form due to tobacco. The morbid anatomy of the cases described in
the present paper is probably often the same as that of tobacco amblyopia,
but from the clinical point of view the two groups are very distinct.
Hutchinson, ' Ophth. Hosp. Reports,' vol. ix, p. 316, " Groups of Cases of
Amaurosis," Group XI ; I had the advantage of seeing several of these cases
and assisting in the compilation of the notes. Ibid., vol. iv, p. 123 (Case 3).
Ibid., vol. iv, p. 381, " Cases illustrating the occasional connection between
Neuralgia of the Dental Nerves and Amaurosis ;" only the third of these cases
seems to bear on my present subject, and it was possibly double embolism or
thrombosis.
Hock (Vienna), " Neuritis retrobulbaris peripherica (acuta et subacuta),"
* Hirschberg's Centralblatt,' April, 1884, p. 107. In this interesting paper.
CASES OP RETRO-OCULAR NEURITIS. 187
limited to one eye, often accompanied by neuralgic pain
about tbe temple and orbit and by pain in moving the
eye ; many recover, but permanent damage and even
total blindness may ensue; there is at first little^ some-
times no_, opbtbalmoscopic change, but the disc often
becomes more or less atrophic in a few weeks, and occa-
sionally there are slight retinal changes. There are no
other symptoms ; for I should, provisionally at least,
exclude from the group all cases showing simultaneous
paralysis of other nerves in the same orbit. In a few
instances, however, paralysis of some other single
nerve, usually a cranial nerve, has occurred previously,
and in one case (Case 1) the patient had suffered from
sciatica, probably neuritic.
In more detail the following features can generally be
made out :
The failure of sight is noticed quickly and often gets
to its height in two or three days, though in the worst
cases it may take longer ; when recovery ensues it
is usually complete in a month or six weeks from the
onset. The pain, which is a variable symptom, is usually
circum-orbital, but often also shoots back to the occiput ;
there is often definite pain and uneasiness, or a feeling of
" stiffness,^^ when the eye is quickly and strongly moved,
and sometimes pressing the eye back into the orbit,
through the closed lids, causes pain. The pain commonly
begins with, or a little before, the defect of sight, and
seldom lasts many days ; but in several of the cases which
ended in blindness or caused great temporary damage to
sight, it was very severe and lasted much longer (Cases
16 to 24).
which I had not read at the time my own was written, Hock, after men-
tioning as characteristic symptoms, spontaneous pain about the orbit, pain in
movements of the eye, and on pressing the eye backwards, goes so far as to
say that the part of the field of vision which is damaged, and, therefore, the
position of the affected bundles of the optic nerve, can be inferred by noticing
the direction in which the eye has to be moved in order to cause pain j he
assumes this pain to be due to stretching of the inflamed pai-t of the optic
nerve'sheath.
188 DISEASES or OPTIC NERVE.
The defect of vision is often described at first as a
" gauze '^ or a " yellow mist/' or a " dark patch '^ or
'^ spot '^ which covers the object looked at and gives it
an unnatural colour, the hand looking^ for example, as if
covered by a brownish glove (Case 17).
The state of the visual field corresponds in many cases
with the above symptoms, for in at least eleven of the six-
teen cases where the field was examined, a definite central
defect was found, either absolute or relative (Cases 1, 2, 3,
4, 6, 7, 8, 9, 11, 13, 17). In some of these cases (2, 8,
11) there was marked contraction of the field also, whilst
in the other eight the field was peripherally of full ex-
tent. In one (Case 14) the field was invaded in other
ways. In Cases 5, 10, 19, 20, 22, the field was not
examined ; and in Cases 18, 20, 21, 23, 24, 28 the eye
had no perception of light.
As to the ophthalmoscopic changes : — In several of the
worse cases, with severe localised pain and ending in
blindness (Nos. 17, 18, 19) the disc looked quite healthy
for nearly a month; whilst in some of the milder ones
(Cases 1, 6, 7, 8, 10, 11, 15) there were decided, if slight,
changes much earlier, and in two (Cases 7, 8) haze of the
retina near the yellow spot.
These variations in the state of the field and of the
fundus show that the morbid process does not always
begin at the same distance from the eyeball and does not
always affect the same strands of nerve-fibres.
The cases we are considering differ clinically from
embolism of the retinal artery and allied conditions, and
from progressive atrophy affecting one eye before the
other, in the quick, though not sudden onset, the slight-
ness of the early ophthalmoscopic changes and often in
the characters of the visual field. From uniocular neu-
ritis due to disease of the corresponding anterior lobe of
the brain, of which I have seen two cases, they are separ-
ated by the absence of vomiting, convulsions, and other
cerebral symptoms.
It is not so easy to draw a good distinction, save
CASES OF RETRO-OCULAR NEURITIS. 189
oplitlialmoscopieally, between the cases now specially
referred to and those much more rarely seen, in which
single, violent papillitis occurs, with severe localised pain
and sometimes paralysis of other nerves in the same
orbit. In these the morbid process is no doubt more
widely spread and probably situated not far from the eye-
ball, besides very probably attacking different structures.
Cases 25, 26, and 27 illustrate this form of disease.
It must be confessed, however, that a few cases (such as
Nos, 12, 22, and 28) occur which seem intermediate
between the two groups, so far as the ophthalmoscopic
changes are concerned.
Returning to our proper subject : perhaps a very
limited periostitis in the optic canal may account for such
cases as Nos. 15 to 19, in which the pain was severe, the
damage to vision great, and the ophthalmoscopic changes
delayed. Where, however, as in certain of the milder
cases, the disc shows changes, although slight ones, at
an early period we cannot suppose the mischief to be
seated so far back. In some we seem, for the present,
driven to assume a rheumatic origin for the attack, as in
certain cases of sciatica, of facial palsy, and of single oculo-
motor paralysis.
The following short statement as to previous history,
age, sex, and result is based on twenty -five cases (Cases
1—24 and 28). (Cases 25, 26, and 27 being a different
form of disease are not counted in this total).
Of the whole number fourteen cases were in men, eleven
in women ; the average age was about 35, the youngest
being 18, the oldest 60 when the attack occurred ; nineteen
of the patients were between the ages of 25 and 40. The
right and left eye were not attacked with quite equal fre-
quency (right fourteen times, left ten times).
At least five of the patients (Cases 12, 13, 14, 15, 16)
had had syphilis ; in one (Case 15) the interval was two
years, in one (Case 16) Gyo years, in the others from
twelve to twenty years. There was much probability of
syphilis in several others (Cases 5, 8, 18, 19).
190 DISEASES OF OPTIC NERVE.
A history of severe sciatica was obtained in one
(Case 1), and of fever (either malarial or typhoid), in
three (Cases 7, 8, and 14). (Fever had also occurred as
well as syphilis in Case 26.)
Sleeping in a draught or in a damp room was blamed
by three of the patients (Cases 1, 2, 21). Severe pro-
tracted toothache had occurred in Cases 20 and 22.
Result.— In six (Cases 18, 20, 21, 23, 24, 28) the sight
of the affected eye was completely and permanently lost.
In fourteen (Cases 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 15, 16,
22) complete or almost complete recovery of vision took
place. In the remaining five more or less permanent
damage to sight persisted. In those which got quite
well the amblyopia seldom reached a higher grade than
|-§ (Y. = -g^), but in Cases 11 and 15 it was much worse
for a few days.
I have said that the disease was always uniocular, but
in one remarkable case (11) the patient, a young man,
became almost blind, first in one eye, then in the other,
complete recovery ensuing in both, and the whole attack
covering scarcely three weeks.
The particulars of all the cases, including this one, are
appended.
Case 1. Failure of right eye {chiefly central amhlyopia)
with pain in and around eyeball. Recovery with pale disc.
Previous sciatica. Gout and arthritis in several relations.
— Miss B — , a3t. 34, a district visitor, working hard and
going out in all weathers, was sent by Sir William
MacCormac, because she had some defect of the right eye,
on June 20th, 1882. She gave the following history :
A month ago she began to suffer from pain, referred at
first to the right eyeball, then passing to the parts around,
and finally spreading to the temples and all over the head,
although always felt most on the right side. She described
the pain as '^ neuralgic.'' Besides this spontaneous pain she
described what she called '' stiffness '' in moving the right
eye, and said that the act of moving the eye was painful.
CASES OF RETRO-OCULAR NEURITIS. 191
The right eyelid felt '^ heavy," i.e. as she explained, she felt
easier when it was closed, but there was no loss of power
to raise it. There was no '^ inflammation " of the eye or
lids. For the last few days the pains and discomfort have
been decidedly less, but quick movements of the right eye
towards her right still cause a little pain. The sight of the
right eye became dim at the time when the pain began;
the defect did not reach a high degree, and was described
as a "mist.''
I saw her first on June 20th, 1882.
Right eye : V. |-§^, slowly and badly, Hm. 0*5 D. ; reads
1 J., but it looks " misty,^' and she describes a ^^ dark
mark '^ near the centre of the visual field.
Left eye : Y. |-^, well, Hm. 0*5 D. ; reads 1 J. well.
Accommodation equal and of full extent in each eye.
Pupils equal and act to light, but the direct action of
the right perhaps not so brisk and full as the left.
The right disc showed a uniform, yellowish, misty pallor
over its whole surface, the branches of the arteria cen-
tralis were decidedly diminished in size, the veins normal,
or if anything also diminished. There was no blocking
of the artery, for the branches pulsated well when the
globe was pressed upon by the finger. There were no
changes in other parts of the fundus.
The left disc was healthy and very different in appear-
ance from the right.
On taking the field of vision of the right it was found
of full size for white, but the field for red was very much
contracted, and even at the centre, where the colour was
best seen, it appeared much duller than in the same part
of the field in the other eye ; the red spot (of 10 mm.)
indeed looked " yellow '' till very near the centre. I did
not make out any scotoma in the field.
In the other eye the red field was of full size. She was
not tested with coloured wools.
I did not think, at this examination, of trying whether
pain was caused by pressing the eye back into the orbit.
The treatment consisted in the use of repeated small
192 DISEASES OP OPTIC NERVE.
blisters about the temple, &c., dark glasses, and the
administration of iodide of potassium.
A week later (June 27th) V. was exactly the same, but
the disc decidedly clearer. Pressure into the orbit and
over the supra-orbital notch caused no pain.
Next week (July 4th) V. |-§- well, and some letters of
1^^. There is now no pain on movements of the eye as
on admission. She has once or twice had a little
neuralgic pain, once in the right ear, once in the left
temple.
July 11th. — No change, except that she now does not
notice the " black mark,'^ of which she at first complained,
in the visual field. Last night she was sick and slept
badly.
20th. — Right can now pick out all the letters of |-§-,
though slowly. The disc is now quite clear, and its entire
surface is very pale with a dirty yellowish tinge ; the veins
slightly tortuous, but both they and the arteries are now
noted of normal size.
The fields were taken again for red, green, blue, and
white at this date. In the R. the red had enlarged, but
was still much smaller than in the other eye ; the green
field was also small, and perception of green was nowhere
so good as in the other eye ; the blue field was as large,
and the colour appeared as bright, as in the other eye.
The blind spot was enlarged. She was to report herself
later on, but has not done so.
During the previous winter (1881-2) this lady had an
attack of '^ sciatica ^' in the right lower limb. The pain
went all down the back of the limb from the hip to the
heel ; it got better in about a fortnight, but for weeks
afterwards the heel was '^ numbed ^^ and she would at
times have what she called a " fluttering ^^ in the muscles,
and she remained more or less lame for a couple of
months, more from weakness than pain. The attack as a
whole was not severe enough to prevent her from keeping
at her work. She is liable to chronic pain across the
loins worse on movement (? lumbago).
CASES OF RETR0*0CULAR NEURITIS. 193
Miss B — ^s paternal grandfather had gout, and one of
her nieces, aged seventeen, is said to have had gout in a
thumb. One of Miss B — 's sisters has swollen knuckles
after ^' nearly having rheumatic fever,'^ and another, twin
sister to the patient, has had rheumatism in one knee and
lumbago.
These facts in the personal and family history seem of
importance in relation to the eye attack, for the only cir-
cumstance suggestive of a cause was that, for some nights
before the attack began, she had been sleeping with her
bedroom window open, having just then moved into a
badly-ventilated room without a fireplace ; she did not,
however, feel the cold.
Case 2. Acute central amblyopia of one eye without other
definite symptoms ; no changes ; recovery. — Mrs. X — , aet.
29 (P. 8, 6), rather delicate, very nervous. February 8th,
1883. — Ten days ago noticed a '' gauze like mottled soap ''
over sight of right eye. Vision has remained about the
same, things she looks at appearing broken or ^^ gapped. ''
No pain, but a " numb feeling '^ over outer rim of orbit
" as if something had been pressed against it for a little
while. '^
R. V. -|§ partly, F. much contracted in outer half,
being in fact rudely circular and extending 40° to 50° in
each direction from fixation point ; not tried for scotoma ;
oph., normal. T. n. Colour vision slightly defective
(Bull's test). Left eye normal. To take small doses of
iodide of potassium and mercury.
15th. — R. |~§ slowly but well; the ''gaps'' in things
are less evident. F. same.
22nd.—R. V. |§ slowly, fg well ; reads 1 J. slowly.
March 8th.— R. V. f§.
July 26th.— R. V. f^. L. V. |^, each rather better
with + 0*5 D. cyl. axis vertical. The eye throughout
showed no definite ophthalmoscopic change.
For some time before failure of right had slept near to
a draughty window. Formerly had much toothache.
VOL. IV. 13
194 • DISEASES OP OPTIC NERVH.
Never rheumatism or sciatica. I was not able to make
any inquiries as to syphilis.
Case 3. Slight central amblyopia in one eye set-
ting in quickly with pain on movements of eyeball. No
changes ; recovery. — Miss C — _, 89t. about thirty-five (P.
6, 113) was sent to me by Mr. Noble Smith on March 18th,
1882, for a defect of the right eye. She said that on the 13th
she began to notice shooting and aching pain at the back of
the right eye and in the temple, and something amiss with
sight ; on closing the left, the right eye was found to be
'^dim," but the defect had not increased. A day or two
later the pain was in the top of the head on the same side,
and in the same side of the neck, as well as behind the eye,
and became associated chiefly with movements of the head
and eye, especially sudden lateral movements. Does not
play lawn -tennis (this in reference to painful stiffness of eye-
muscles from violent use) . Had been unable to sing owing
to '' a suppressed cold in the head '^ for some days before
the pain and dimness of sight came on. Remembers that
on 3rd inst. she struck the right (affected) eye (or brow ?)
against a gas-jet ; the blow was, however, very slight, and
the symptoms did not begin till ten days later.
March 18th.— R. V. |§ badly and 1 J. p.p. 6"; the
paper is *^ darker ^' and the print not so clear as with L.,
especially upper part of page. F. (hand test) of full size ;
a slight but decided relative scotoma (detected by red
spot) just above centre of F. (very carefully and repeatedly
tried). Oph., normal, P. normal and dilates well when
covered. Has an uncomfortable feeling, sometimes actual
pain, in moving eye to either side. Left eye normal in all
respects ; looks larger than right. Mother' and a sister of
patient very rheumatic ; no history of gout. Patient formerly
had bilious headaches, sometimes with dimness of sight,
but these attacks have now ceased ; they were not uni-
lateral. When not feeling well she often notices that
right eyelid droops a little.
I only saw this lady once more and have little doubt
that she recovered perfectly.
CASES OF RETRO-OCULAR NEURITIS. 196
Case 4. Slight central amblyopia with pain in moving
eye and pain on same side of head ; recovery ; had health ;
hysteria ; pelvic troubles. — Miss B — , aet. 35, was sent to
me by Mr. G. H. Makins in November, 1882 (P. 7, 125),
for asthenopia. She kept a girls^ school, and had been
overworked from time to time for some years, and her
eyes had occasionally been troublesome. She was nervous
about her eyes because an aunt had gone blind from
glaucoma, and I thought her somewhat hysterical. Her
eyes, which were emmetropic, became much better under
the use of glasses, changed two or three times at rather
short intervals, and a long course of iron.
On April 17th, 1884, she came again, complaining that
for the last fortnight there had been a " spot '' before the
right eye ; it was most apparent when looking at coloured
objects. Everything looked '^ peculiar,^' and white paper
did not look so white as to the other eye. Thinking that
she was perhaps fanciful, I simply asked, " Have you been
quite well lately V She replied that before the " spot '^
came, and until three days ago, she had had a good deal
of ^' neuralgia '^ about the head ; the pain soon settled in
the right eye and was made worse by moving the eye,
especially by looking strongly upwards to her right.
This account was given without my putting anything like
a leading question. She said the defect came on in
about one day and had not got worse. She did not seem
to have had neuralgia before, but had for some time
past been out of health, and was under the care of a
gynaecologist for pains in the back and weakness of
legs.
On examining the affected eye (the right), vision was
full, "l^ and 1 J. with her + 25 D., but the print not so
black as with the left, and a large patch of " mist '' seemed
to lie over what she looked at. F. of full size (perimeter
, test), but F. for red shows considerable relative defect
in some parts ; the worst part is rather above and to
inner side of centre, and beyond this the colour is again
I well seen. Oph. showed doubtful congestion of o. d.
196 DISEASES OF OPTIC NERVE.
The F. for red in left eye quite perfect. Ordered
iodide of potassium and mustard leaves to the temple.
April 80th. — Almost well ; colours now look quite alike
to the two eyes and there is only the slightest possible
difference in the clearness of print as seen by each eye.
The slightness of the symptoms and the neurotic state
and antecedents of the patient almost led me to overlook
the real nature of the attack in this case.
Case 5.* — William G — , set. 33, wheelwright, tall, pale,
strong. Under Dr. Greenfield's care at St. Thomas's
Hospital for right facial paralysis attributed to sleeping
in keen draught ; recovered under galvanism. About a
year later (September 26th, 1878), complained to Dr.
Greenfield of ^^ flashes '' in left eye followed by pain
passing to back of head. On 29th found defect of sight
coming on in left eye ; pain continued, especially on
sudden movements of head or eye.
When Dr. Greenfield sent him to me on October 10th,
I found left could only count fingers, and best at upper
and lower parts of F., direct light-reflex of pupil
defective ; movements of eye perfect, but eyelids rather
puffy ; no congestion of eye ; no pain on pressing eyeball
backwards ; oph., normal, or optic disc doubtfully
redder than right. Right eye, vision and oph., normal.
No symptoms of vaso-motor paralysis. Not liable to
rheumatism or neuralgia, but occasional slight stiff neck.
Gonorrhoea six years ago ; no proof of syphilis.
On 20th vision of left began to improve.
On 31st left, vision ^ and 4 J. Oph., as before.
On November 7th left, vision |-§- and 1 J., right -|§.
On January 2nd, 1879, still could not see quite so well
with left as with right, the print of 1 J. looking " brighter ''
to the right than to the left. Field and colour vision never
carefully tested.
Case 6.* — James G — , aet. 27, a very intelligent man of
half Irish parentage, with old granular lids, had attended
* These cases were published in full in the * Lancet,' 1880, vol. i, p. 766.
CASES OP RETRO-OCULAR NEURITIS. 197
Mr. Liebreich from time to time at St. Thomas's Hospital
to have his lids touched.
In April, 1878, Mr. Liebreich noted right H. As. -^=f^,
left defective from old convergent squint, sees black board
and 20 J. with difficulty.
On May 14th I examined again with same result.
On September 5th right began to fail, and on 9th
'' could not see anything.''
On 10th y. = 18 J. badly, and optic disc was very hazy.
On 17th vision much better, |-§ and 8 J. ; optic disc
still hazy and congested, and retinal veins somewhat
engorged, pupil active. Left optic disc healthy.
On 26th and again on October 3rd, right, vision ^^ and
1 J. ; oph., about as at last note. F. not taken, but his
description of his symptoms pointed to central scotoma.
Evening before failure began had been staring at long
line of gas jets. For several days before had had pain,
chiefly ^' dull " but sometimes " shooting " in side of
head, behind ear, and down back of neck, all on right
side ; at same time eye was reddened and hurt him '^ as
if strained " in looking up and to his left. Noticed that
he was sweating very freely in head about the same time,
but not more on one side than the other. Treated with
iodide of potassium.
Married eight years. No history of paralysis of any
other nerve. Not subject to stiff neck. Father for
twenty years in asylum for " recurrent mania from fall on
head."
Case 7. Rajpid onset of amblyopia in one eye with dense,
nearly central, scotoma ; some pain behind eye j localised
retinal haze; '' fever '^ four years and a half previously ;
liability to headaches and temporary dimness of sight
{megrim) ; recovery. — Mr. C. A. L — , aet. 37, watchmaker
(P. 8, 10). On January 31st, 1883, a dimness came over
right and has remained. Some days later some pain at
back of same eye and slight pain in moving it.
First seen February 9th. Right, vision |§ and 1 J.
198
DISEASES OF OPTIC NERVE.
slowly and rather eccentrically, best to inner side of fixa-
tion point, T. and p. n. ; oph. shows central, diffuse
haze of retina around yellow spot, *' in distribution and
appearance like embolism, but less intense than usual '^
and scarcely noticeable at optic disc ; central arteries and
veins normal in size and pulsating on pressure ; no haomor-
rhages ; F. of full size, not tested for scotoma. Left
eye normal. Ordered iodide of potassium and mercury
in small doses.
Pig. 2. Fig. 1.
Fields of vision (left eye).— Case 7. Fig. 1, Feb. 16th ; Fig. 2, May 18th.
16th. — Right, vision and oph., same ; retinal haze
greatest below yellow spot. F. now tested for sco-
toma and shows a considerable, absolutely blind, gap
above fixation point (Fig. 1). Urine normal, 1023. Heart-
sonnds normal.
March 9th. — Right, vision |-§ and 1 J. well ; still
cannot see the line above the one he is looking at on the
test-board.
April 6th. — Right, still some dimness, but it is now
several lines above the line he looks at ; describes occa-
sional micropsia with this eye.
May 18th. — Right fundus still shows a scotoma but
much smaller (Fig. 2). Vision -|§ and 1 J. well ; oph.,
optic disc decidedly pale and hazy as compared with left ;
retinal haze has quite gone.
Mr. L — , had always been liable to attacks of '^ bilious-
ness '^ with temporary loss of sight, followed after one to
two hours by '' return of vision from the lower side ; '*
CASES OP RETRO-OCULAR NEURITIS. 199
no flickering or colours^ but " plain dimness/^ though
sometimes '' it separates and holes come in the dimness •/'
these ocular symptoms had been followed by nausea and
severe frontal headache. Has always located the dimness
in right eye, and thought attack described above was of
same kind till he found it did not^ as usual, clear off.
Four years and a half ago had malarious (? typhoid) fever
with pains in joints, but no swelling. Not rheumatic. No
history of venereal disease obtainable. Had not been
exposed to cold or to specially bright light before the
failure of vision.
Whilst under treatment, when eye had nearly recovered,
had an attack of the old temporary dimness described
this time as ^' golden light,^' and asserted that the appear-
ance was removed by shutting right eye (?).
This case is possibly allied more with cases of repeated
temporary interference with retinal blood- supply owing to
some cardiac or vaso-motor disturbance than with the
proper subject of this paper. There is, however, some
doubt, and I have therefore retained it. I could not
decide from the patient's account whether the attacks of
temporary dimness or spectra were really, as he asserted,
limited to the right eye and noticeable only when the eye
was open, or binocular and subjective in the sense of being
visible when both eyes were closed, as in ordinary cases of
megrim.
Case 8. Rajpid onset of central amblyopia in one eye
with some pain behind eyeball ; haze of disc and retina ;
recovery ; typhoid fever six months before. — Mr. R — , aet.
40 (P. 6, 128), house-painter, sent by Dr. Verdon.
Several weeks ago a little pricking pain in right eye, and
a ^' heavy feeling at back of eye as if eyeball were too
large ; ■" then rapid failure of sight in the eye so that in
about one day it got to its present state.
April 25th, 1882. — Right, vision -|-§ ; " sees a haze over
centre of objects,^ ^ not improved by glasses ; (partly under
atropine) ; F. (hand test) shows a defect in centre and
200 DISEASES OF OPTIC NERVE.
extending more downwards than in other directions.
" The haze looks yellow ^' when he looks at things out
of doors. Tried with coloured spots, and all colours
lock "duir' or ''pale/' in centre of F. Oph.,
streaky haze of optic disc with some haze at region of
yellow spot, and white lines along some of the central
vessels, especially along one vein going inwards. Left
eye, vision -f^ and 1 J. well.
May 2nd. — Eight, vision f^.
August 5th. — Right, vision -|-^ partly and 1 J. fairly.
Oph., much as before ; optic disc not pale. F. shows
slight contraction above and an enlargement of blind
spot, the blind area passing gradually into the seeing
part ; no central defect. Pupils act fairly to light and
accommodation. Patellar tendon reflex, now tested for
first time, quite absent on both sides.
Dr. Yerdon told me that the patient had typhoid fever,
and got quite well, about six months before eye failed.
No gout j no lead-poisoning ; no injury. Five years before
had gleet lasting three months ; no history of syphilis.
Married two years and has one child alive and well.
The treatment was iodide of potassium and mercury
for between two or three months and a few blisters.
Case 9. Rapid failure of one eye with slight pain ; large
central loss of field ; atrophy of disc ; question of emho-
lism. — Miss K — , eet. 53 (P. 9, 130), was sent to me by
Mr. Alfred Ford on May 1st, 1884, about six weeks after
failure of her right eye. She told me that about seven
weeks ago there had been a little pain in the eye and
something like " a thin crape " had come over the sight ;
when this had lasted a few days the sight one day very
rapidly got much worse and had remained unaltered
since. On the day of this occurrence she saw a well-
known oculist, who told her he thought the loss of sight
was caused by plugging of a vessel.
I found a band of complete blindness stretching hori-
zontally across the right field of vision, a large oval central
CASES OP RETRO-OCULAR NEURITIS. 201
scotoma in fact. The disc was pale all over and rather
hazy, and the retinal arteries considerably diminished and
their coats thickened ; no changes at yellow spot or else-
where. Left eye had 1 D. of My. As, vision ^.
Miss K — is a thin, ascetic, very nervous person, of
active habits ; she has not had rheumatic fever and knows
of no arthritic complaints in her family.
Admitting that the interpretation of this case is doubt-
ful, I think that the history of slight mistiness for a few
days before the severe failure of sight, and the character
of the visual field, point more to an acute partial neuritis
than to embolism or arterial thrombosis ; in embolism of
one or more divisions of the retinal artery the loss of field
is usually sector-like, not insular or band-like as in axial
neuritis.
Case 10. Bepeated, sudden, brief attacks of failure of one
eye during about four months in a healthy young man ;
no proof of heart disease ; slight inflammatory changes at
disc. — Benjamin C — , aet. 28, single, carpenter. Three
months before admission, while at work one afternoon,
left eye became suddenly misty. No giddiness and no
pain. The mist entirely disappeared in half an hour.
During the next three months he had nearly twenty
similar attacks, never lasting half an hour, and always in
the same eye. They are all characterised by suddenness
of onset without flickering or scintillation ; and there is
never either giddiness, headache, or vomiting. He is
not '' bilious.'^ When the attack is at its height, if he
closes the other eye, everything looks like white mist or
ground glass to the affected eye.
Admitted at St. Thomas's Hospital November 27th,
1878 (T. 2, 99), and attended for a month. Vision with
each eye -|§ and 1 J., accommodation and pupils natural.
Refraction Em. to ophthalmoscope andglasses(no atropine).
Colour perception normal. T. and F. not noted.
The disc in the affected eye (left) was in comparison
with the other unmistakably, though slightly, hazy and of
202 DISEASES OF OPTIC NERVE.
redder colour, the haze was in the form of a delicate
veiling over some of the vessels at the inner side close to
the disc, and was visible by both methods of examination ;
no other changes.
No tenderness of orbit or supra-orbital notch. Lately
some shooting pains in the eye and history of its being
congested the first thing in the morning. No syphilis.
Once during attendance, whilst reading hymn-book in
chapel, the mist came over the other eye, its first attack ;
had no headache ; it recovered as was usual in the case
of the left eye in about half an hour.
Mr. Battle, at that time house physician, examined
him and found no evidence of heart disease. The urine,
repeatedly examined, contained excess of lithates but no
sugar or albumen.
He was seen again two years later (October, 1880) ;
he had had no more attacks of dimness since the end
of December, 1878. The haze over the vessels to inner
side of left disc was still present and exactly as before.
I should not have put this case in the present group
had there not been unmistakable changes in the disc of the
affected eye.
Case 11. Acute, double, post-ocular neuritis with a
week's interval between right and left ; recovery of each in
a fortnight ; early but slight changes at discs ; no cause
found, — Mr. John H — , aet. 23, pale, lean, very nervous,
unmarried, in charge of a provincial free library, was
brought to me by Mr. Frederick Mackenzie on May 1 7th,
1883, for recent defect of the right eye. He gave the
following account :
Three months ago had three attacks of " mist '^ in
right eye ; each occurred before breakfast and passed off
completely in about ten minutes. On 10th inst. (May),
began to have pain of an aching and shooting character
over right eyebrow, and presently pain in moving the eye.
On 13th (a Sunday), sight of right was found to be dim
on waking and did not, as heretofore, clear off ; defect has
CASES OP RETRO-OCULAR NEURITIS.
203
continued without getting better or worse. For the last
two days has also felt pain in the right upper jaw. Has
lost almost all the molars of both jaws, and incisors also
in upper jaw, and has often had neuralgia in the stumps.
No rheumatism or sciatica. Scarlet fever mildly some
years ago. Mr. Mackenzie reports that there is a loud
mitral bruit, and that the urine is free from albumen and
sugar. Has had no venereal disease and is quite con-
tinent. Has never smoked. Ten years ago crushed right
index finger, and nail has several times since been grooved;
had a short attack of painful cramp in this finger some
months ago. No neurotic family history, except that a
maternal aunt has gone blind of " disease of optic nerves
from worry '' (? glaucoma) .
May 17th. — Right eye (under atropine) sees only 16 or
18 J. badly and best in nasal part of F. ; cannot see 2^%.
Oph., optic disc rather pale especially on outer side, arteries
decidedly too small and veins too large by comparison
with other eye ; arteries pulsate easily on pressure. F.
1 Right eye. 2
Field of vision (right eye).— Case ll.|Fig. 1, May 17th; Fig. 2, May 26th j
Fig. 3, June 8th.
204
DISEASES OP OPTIC NEEVE.
Left eye.
Field of vision (left eye).— Case 11. Fig. 4, May 26tli; Fig. 5, May 30th;
Fig. 6, June 8th.
somewhat contracted at inner side and showing a very-
large scotoma of somewhat sector- shape, extending from
fixation point downwards and outwards (Fig. 1).
He has pain in moving the eye, especially inwards^ and
quite flinches in doing so ; there is also marked tenderness
on pressing the eye back into the orbit ; there is, how-
ever, not the slightest tenderness over the supra-orbital
notch nor over any part of the wall of the orbit within
reach. Left, vision |-§ ; oph., normal.
19th. — Eight has begun to improve, but to-day left
began to fail with some pain over the eye and on moving
it.
25th and 26th. — Eight, vision f§ and 12 J. words.
0. d. as before, but arteries and veins now of normal
size ; F. of same extent, but now no definite scotoma can
be found (Fig. 2). Left, vision yoo" ^^^ letters of 20 J.;
Oph., o. d. decidedly pale and filled in all over, arterial
coats thickened and white, veins somewhat distended ; F.
highly contracted and very irregular, centre blotted out
(Fig. 4).
CASES OP RETRO-OCULAR NEURITIS. 205
30th.— Left, vision f§ ; F. much larger (Fig. 5).
June 2nd and 8th. — Now sees -|§ easily, and -|-^ by-
looking rather eccentrically with each eye separately ;
Hm. 0*5 D. Still has occasional shooting pains behind left
ear. F. now of full extent in each (Figs. 3 and 6), but
there must still be some slight lowering of visual acute-
ness close to fixation point in each. Both discs remain
somewhat pale. No other symptoms have developed.
The treatment consisted of small doses of iodide of potas-
sium and mercury, with blisters.
August, 1884. — Has once or twice had dimness lasting
a few minutes, perhaps only due to varying accommo-
dation.
Case 12. Rapid failure of one eye with defect of field
and diplopia (?) ; slight papillitis ; probably due to syphi-
litic periostitis ; recovery. — Mr. W — , aet. 44, a clerk, was
seen at the South London Ophthalmic Hospital on June
12th, 1875. Ten days previously left eye had failed in
sight ; for a short time he saw double when looking down,
but this passed off.
On admission. — Left, vision y§ and 16 J. ; with + ^o
reads 6 J. badly ; F. much contracted in nasal and upper
half (hand test) ; pupil rather larger than right, both
pupils are sluggish ; no visible defect of movement of
eye ; oph., slight and doubtful haze of o. d., arteries on
o. d. pulsate normally on pressure ; no other changes.
Right, normal in every respect.
Had gonorrhoea twenty years ago. Gives no history
of syphilitic symptoms, but has had foetid discharge from
nose for two or three years and now has sinus in floor
of left nostril and another in hard palate leading to dead
bone. Ordered iodide of potassium.
July 10th. — Left has recovered ^^ perfectly ; '' vision
^ and 2 J. unaided by lens ; F. (to hand test) perfect.
Iodide continued.
September 8th. — Left, vision ^o ^^^ 2 J. p. p, 15''.
Right, V. ^ and 1 J. p. p. 15''. Dead bone in floor of
206 DISEASES OP OPTIC NERVE.
nose quite loose and a small bit removed, but he would
not submit to further treatment.
In this case we may infer with much likelihood that
optic neuritis was caused by very limited syphilitic peri-
ostitis at the apex of the orbit, possibly implicating in a
slight degree one of the motor nerves or the attachment
of a muscle.
Case 13. Failure of sight in one eye with absolute central
scotoma ; no other local symptoms ; changes at disc ; syphilis
twelve years previously, — Mr. John R — , aet. 55 (P. 7, 140),
was seen on December 2nd, 1882. He had lived much
in India, China, and Japan, and had just come from the
last-named country where, three months previously, he had
found the sight of the left eye to be very defective. He
had had no pain or discomfort about the head or eye, and
the sight had, he thought, got rather better. I found that
with the left eye he could only count fingers, and this best
above the centre of the field ; field of full size, but a large
scotoma of oval shape extending horizontally from about
10° within, to about 35° degrees external to, fixation point ;
the greater part of this area was well defined, and a
white spot of 10 mm. square was quite invisible on it,
but at the temporal side the boundary between blind and
Field ©f vision (left eye). — Case 13.
seeing part was not abrupt {vide Fig.). Oph., o. d. pale
with a yellowish tinge, physiological pit filled in, arterial
coats thickened, no other changes. Right, vision ^,
Hm. 0*75 D. = f§ slowly; uses + 2*5 D. for reading;
o. d. natural.
CASDS OP RETRO-OCULAR NEURITIS. 207
A tall, thin Scotchman^ sallow and extremely dyspeptic.
Has not had ague, dysentery, rheumatism, or gout ; no
injury to head, but some years ago had a slight '^ sun-
stroke/' Twelve years ago had syphilis, and has lately
had some ulceration of tongue, the scars of which are
visible, but has had no other manifestations. Dr.
Buchanan Baxter, who examined him at my request,
found no positive signs of organic disease, but suspected
incipient cirrhosis of the liver ; urine normal.
Though he smoked but little, and his eye failure was
not likely to have been caused by tobacco, I advised him
to leave it off, and he did so. When seen two months
later he thought the defective eye had improved a little,
butt I could not satisfy myself that this was the case.
He was returning to Japan, and I had no further oppor-
tunity of watching him.
No active treatment was adopted. Although the disease
of optic nerve was very probably syphilitic, it seemed to
have become stationary before he came to me, and the state
of his health made vigorous treatment undesirable.
Case 14. Rapid failure of one eye with loss of field,
coming on soon after malarious fever in a man who had
had syphilis many years before ; atrophy of disc. — Mr. John
P — , set. 38 (P. 6, a), six weeks ago when in Spain engaged
as a mining engineer had an attack of fever of an irregu-
larly intermittent type ; was not laid up by it, but lost
fourteen pounds in weight. A few days after the onset
of the fever he found the sight of the left eye as now ;
there was a little pain about the eye, and especially he
noticed that it was painful and stiff when he moved it.
Had syphilis twenty years ago.
October 4th, 1881. — Left, vision -^^ badly ; loss of nearly
the entire lower half of field, the boundary between seeing
and blind part not being sharply defined ; the field is not
like that in any of the other cases. Oph., optic disc pale
and clear, central vessels rather smaller than in right.
Right has a high degree of H. As., but is healthy. He
208 DISEASES OE OtTIC NERVE.
took mercury in small doses for several months, but
when I saw him again in February, 1883, the eye was in
just the same state.
Case 15. Severe pain in temple for one day with rapid
failure of same eye ; very slight changes ; complete recovery ;
syphilis two years and a half before ; subsequently symtoms
of cerebral disease. — Henry E — , set. 28, an attendant in
an asylum, was sent by Mr. Lawford to St. Thomas's
Hospital on September 26th, 1883, with the following
notes :
On the 21st inst. he had severe pain in left brow and
temple and the sight of the eye became dim ; the pain
was very bad and kept him awake that night, but ceased
altogether the next day ; the sight, however, got worse.
No cerebral symptoms. Oph. (on 22nd), showed only doubt-
ful enlargement of the retinal veins. Had a slight 'blow
on the eye from a patient ten or fourteen days previously.
Had a chancre two years and a half ago, followed in six
months by full secondary symptoms, and has had relapses
several times. Took iodide and mercury last spring
(1883) for return of eruption, and again began same
treatment in August and was under it when the above
attack occurred.
25th. — Left, vision only 19 J. badly ; pupil rather larger
than other. Right, vision 1 J. well. I saw him later, on
the same day, and noted by ophthalmoscope the veins rather
larger, the arteries smaller and showing thicker coats, than
in other eye.
27th. — Taken into the hospital. Left sees only 20 J.
and best in temporal part of F. ; oph., as on 25th ;
pupil has very little direct light -reflex. Inunction of
weak mercurial ointment every night, to be washed off
next morning.
29th. — Mr. Marlow notes : " Some of the retinal veins
are three times as large as the corresponding arteries.'^
October 1st. — No effect from inunction ; ointment to be
left on after each inunction.
CASES OF EETRO-OCULAR NEURITIS. 209
4th. — No salivation ; inunction twice a day, and to
take ten grains of iodide thrice daily. Sight already
better; can spell 16 J.
8th. — Left pupil now acts well to direct stimulation.
Oph., as before.
9th. — Left reads letters of 1 J.
11th. — Commencing salivation. Bowels confined unless
he takes house medicine. Stop inunction.
19th. — Left, vision ^% partly and 1 J. at 8." Oph.,
arteries relatively larger ; optic disc not so transparent as
in right eye ; F. and colour perception normal. Dis-
charged from ward; to continue iodide.
January 10th, 1884. — Mr. Marlow notes : '' Vision of
left now precisely the same as of right. Oph., arteries in
left still somewhat small in comparison with veins of same
eye and compared with arteries of right eye.'^
August 30th. — Has been under Dr. Bristowe's care,
since the above date, for partial right hemiplegia with
mental dulness ; no aphasia. Symptoms came on gradu-
ally. The eye remains good, and there are no further
oph. changes.
Case 16. — Failure of sight and paralysis of sixth nerve
on one side with severe pain in temple and forehead on the
same side ; late pallor of disc ; recovery of sight; syphilis
five years before. — Mary C — , a^t. 30, married, sent by Dr.
F. W. Parsons to St. Thomases Hospital (T. 3, 114). For
the last three weeks severe pain in right temple and fore-
head. About a week ago noticed failure of sight of right
eye and squinting. There was double vision for a short
time. She said that the right eye had occasionally been
'' misty '' for two months past.
On admission, October 5th, 1880, there was still pain
in right temple and forehead. Eight external rectus
paralysed ; convergent squint which sometimes alternates
to left eye ; vision very bad, can only count fingers ; oph.,
normal ; no remains of iritis. Left eye ■!§, H.m. 1*5 ;
VOL. IV. 14
210 DISEASES OF OPTIC NERVE.
with + 2 D. reads 1 J., old posterior synechias, no disease
of fundus. Pupils equal and active.
Five years ago had inflammation of both eyes, sore-
throat, falling of hair, and a scaly eruption on legs and
forehead. No history of rheumatism or gout in patient
or her parents. Ordered ten grains of iodide of potassium
and one sixteenth of a grain of bichloride of mercury three
times a day.
December 7th (two months after admission). — Right,
vision ^, H.m. 1*5 D. = f g, + 2 D., reads 2 J., F.
normal ; Oph., o. d. decidedly pale all over and not
perfectly clear ; no other changes ; movements of eyeball
of full extent, but sometimes sees double in sudden move-
ments. Left, vision f§, Hm. 1*75 = f^ partly ; + 2 D.
reads 1 J. ; Oph., o. d. normal. Ps. act equally, but right
rather larger than left (as 4 to 3) .
January 11th, 1881. — Vision as at last note in each.
Right p. still larger than left. Sometimes has a stab of
pain " like a knife '' in right eyeball.
February 8th. — No diplopia for many weeks, but now
occasional drooping of right upper lid ; no limitation
of movements of eye in any direction. Vision of each
eye, when corrected, is ^^ ; ace. about normal and equal
in the two eyes. Ps., right still larger than left ; asso-
ciated action and direct light-reflex action good and equal
in each eye.
April 19th and May 24th. — Still some pain at times
over right brow and occasional drooping of eyelid. Dis-
charged.
Case 17. Failure of one eye, with central dense scotoma,
going to complete blindness, and followed by severe pain in
corresponding temple and behind eye ; late atrophy of disc ;
recovery of a little sight. Paresis of inferior rectus of same
eye som^ months before failure of sight ; no cause found. — Mr.
D — , aet. 50 (P. 6, 27), a pale dyspeptic man retired from
business, of studious habits and fond of reading late into
the night, was sent to me by Dr. Gandy on November
CASES OF RETEO-OCULAR NEURITIS. 2 1 1
18th, 1881, for diplopia. His symptoms had begun just
ten days before, on the 8th, with an indistinctness of sight,
noticed when walking about ; before long he found that
he saw double, particularly when looking down as in going
upstairs. He had a little dull pain ^^ in the eyes," worse
in the right, when the symptoms began, but no ^^ head-
ache.'^
On examination there was no visible squint or defect of
ocular movements, but he had marked diplopia in the
lower half of the field of fixation, the false image belonging
to the right eye and appearing to him to be below and to
the left of the true one. This diplopia would be accounted
for by paresis of the right inferior rectus. That the
affection was of the right, not of the left eye (left superior
rectus, e.g.), was also shown by his liking to shut the right
eye (not the left) when crossing the street, or otherwise
especially desiring to get rid of the double vision ; and by
the presence of slight, though definite, giddiness when he
was made to walk with the left closed {i.e. when compelled
to guide himself with the right eye) .
The vision, accommodation, pupils, and ophthalmoscopic
appearances were perfectly normal in each eye. He had
been taking some iodide, and this I advised should be
continued, also that he should rest and avoid stooping and
straining.
He had been married many years, his wife was living,
and he entirely denied ever in his life running the risk of
syphilis. There had been no brain symptoms. He was
not gouty and had only once, a year ago, had trifling
rheumatism (in the left arm). He had formerly been
very subject to bilious headache. His mother died of
apoplexy.
I saw no more of him till May 9th, 1882. He said he
had lost the diplopia long ago, but as he said he had
continued to like occasionally to shut the right eye, I
doubt whether the muscle had perfectly recovered. Lately
he had had some aching and tenderness in the same eye, and
the day before (8th) he had accidentally found out that the
212 DISEASES OF OPTIC NERVE.
sight of the eye was defective. Everything looked
^' dark ^' or *"' brown '' to this eye ; the naked hand of a
passenger opposite to him in the railway carriage looked,
to this eye, as if gloved.
The pupil of the defective (right) eye acted to light
directly and was not enlarged ; vision ^, slowly (the
left being -|§) ; visual fields roughly tested, seems normal ;
no actual colour-blindness, all colours look dull, but he
does not confuse any complementary ones. No ophthal-
moscopic changes. Urine tested next day, no albumen;
not tested for sugar.
May 15th.— Vision of right much worse, cannot see
-^^ or 20 J. ; seems to see best at periphery of field.
A careful perimetric examination of the field by Dr.
Gowers at this date showed a large scotoma extending
from the fixation point outwards and rather downwards
and including the natural blind spot [vide Fig.) ; its posi-
tion and size were just such as is common in tobacco cases,
but it was more intense, for on this area even a white spot
was not seen at all. No peripheral contraction of field.
Field of vision.— Case 17 (left eye), May ISth.
Since last visit has had much pain, really severe, at the
back of the bad eye and in the top of the head ; no pain
in the temple and none during movements of the eye. No
pain or tenderness about the jaw. The pain has aroused
him ou two or three occasions early in the morning. No
vomiting. Ophthalmoscopic appearances still quite natural;
retinal arteries pulsate easily on pressure.
I sent him to Dr. Gowers in order to exclude authori-
CASES OP RETRO-OCULAR NEURITIS. 213
tatively central nervous disease. He found no evidence
of intracranial mischief, and agreed that the symptoms
were probably caused by neuritis of the trunk of the optic
nerve in some part of its course.
On May 31st I saw Mr, D — again. There was now
no perception of light whatever_, and he thought the eye
had been as blind for some days. The pupil, previously
acting directly to light, now acted only indirectly, but it
was not larger than the other. The pain at the back of
the eye and about the temple had become much worse
and was disturbing his sleep a good deal.
He was from the first very sceptical as to treatment,
and would not take medicine of any kind for more than a
day or two ; iodide, he said, always upset him. He applied
a blister or two to the temple after much persuasion.
At this last visit the disc was, I thought, beginning to
get pale, but there were no other changes.
November 28th, 1882. — Mr. D — came in reply to
my inquiry. The eye remained quite blind for a few
weeks and then he began to see a little with it and
gradually improved for a time ; but it has not bettered
lately. He sees best in the outer part of the field, but
can only see the hand moving. There is slight direct
action of the pupil to light. The disc is now very pale,
almost paper white, cupped in a shelving (atrophic)
manner, and the lamina cribrosa exposed ; arteries normal,
veins normal or rather large ; refraction at disc is myopic,
1 D.
The pain in the head continued very badly for a long
time (some weeks), but has now quite ceased.
Case 18. Failure of one eye to complete hlindness after
ideeks of pain in corresponding temple ; late atrophy of
disc ; paresis of fifth nerve on same side; syphilis probable ;
neurotic family and personal history. — Anne F — , aet. 28,
married. South London Ophthalmic Hospital, August,
1876. Is intemperate. Two years ago swelling of forehead
and sides of face, said to be erysipelas ; since then has
214 DISEASES OP OPTIC NERVE.
been quite unable to smell. For last six weeks much
pain in right temple and eyeball, and for about same time
has occasionally had a ^' film ^' over sight of right eye.
Decided failure of this eye began a few days before
admission.
August 28th, 1876. — Right can only see shadows ; no
direct light-reflex action of pupil, but indirect action
good j oph., no changes whatever ; refraction H. Left
eye good, but sight not noted. There was frequent
twitching and doubtful weakness of right facial muscles
and partial anaesthesia of right face, but no affection of
fifth nerve muscles.
September 19th. — Right has no perception of light;
optic disc has now become considerably paler than in
left eye, where it is normal, but central vessels are not
diminished. Condition of fifth and facial nerves as
before. Difiiculty in shutting mouth after opening widely,
from a feeling of a lump in region of digastric. There
is apparently slight weakness of grasp of right hand, but
no dragging of foot.
The previous history was complicated and not all trust-
worthy, but is sufficiently important to be given in full.
Has had four pregnancies ; one miscarriage, three chil-
dren born alive but died at or under six months. Syphilis,
therefore, is very probable. Is said to have had a fit
when eleven years old, followed by drawing of face and
weakness of right arm and leg ; another fit after second
confinement, evidenced by face being drawn to one side
on waking one morning. Doubtful history of a third fit
during third pregnancy. Since last confinement subject
to '^ cramps " of right face, arm, and leg. Patient is
youngest of eight : Nos. 1, 2, and 3 died in middle age,
details wanting ; No. 4 (f.), set. 40, is very subject to
fits, in which left arm and leg work about, married, and
has four* children ; No. 6 (f.), set. 37, and No. 6 (m.), set.
34, healthy ; No. 7 (f.), set. 31, often has fits, married, and
has had seven children, all are living ; No. 8, the patient.
Her father died, set. 69, of " abscess of brain,^' having been
CASES OF RETRO-OCULAR NEURITIS. 215
'^ silly ^' for years before ; his sight was very defective
for four years before death ; one of his brothers (patient^s
uncle) had fits and was blind.
Case 19. Failure of one eye ending incomplete blindness
after two lueehs of severe pain in corresponding temple ; late
atrophy of disc with return of a little sight ; patient binder
observation five years. — John W — ^ a hale, muscular lighter-
man, ast. 43, was sent to St. Thomases Hospital by Dr.
Oswald on account of his left eye on May 12th, 1879.
About three weeks previously he had begun to suffer from
severe pain in the left temple ; he called it ^^ excruciating.'^
It came on in attacks lasting about a couple of hours, be-
ginning in the temple and passing back over the head ; he
said the eye watered when the pain was going to begin ;
the scalp did not become tender from the pain, though he
said at one time there was a tender spot just above the
corresponding ear. He said also that he was liable to
attacks of giddiness lasting a quarter of an hour, during
which he felt and walked as if drunk ; this giddiness was
not related to the pain. There were no other symptoms.
When the pain had gone on about a fortnight, the sight
of the eye on the same (left) side began to get misty ;
this was on May 4th. The defect increased, and by
Friday, 9th, the eye was quite blind. He came to the
hospital on the 12th with the following condition : — Right
■|§ and 1 J., accommodation and refi'action normal. Left,
no perception of light ; pupil acts to light indirectly
but not directly j no ophthalmoscopic changes. Had a
chancre about fifteen years ago and says he was '' saliva-
ted '' for it ; no history of syphilitic symptoms then or
since. He says he has been liable to headaches for many
years, but evidently they have been quite different in
character and intensity from the recent pain in the left
head.
Ordered blisters, iodide in fifteen-grain doses, and blue
pill in two-grain doses each thrice daily.
May 14th. — Pain rather better. — Movements of eye
216 DISEASES OP OPTIC NERViJ.
normal ; pressure on the eye through the lid causes acute
pain deep in the orbit ; on pressing over the supra- orbital
notch on each side there is very marked comparative
tenderness of the left.
23rd. — Pain worse again. No salivation. Blue pill
increased to 5 gr. Now complains of defect in the lower
part of the visual field of the other eye and says it was
so on admission ; it is not obvious on trial by finger-test.
(It may be stated here that nothing more was heard of
this.) Ophthalmoscope, both eyes quite normal.
27th. — No ophthalmoscopic changes.
30th. — No salivation. Ordered inunction. Bromide
added to the iodide.
June 2nd. — Pain better last night than for a long time.
5th. — Salivation beginning. Free from pain.
16th. — Left optic disc now paler than right. There is
some diffuse swelling over left temple.
20th. — Since yesterday has had some perception of
light with the left ; to-day it is quite distinct. Salivation
not increased.
The treatment was continued nearly as above until
July 11th, when drachm doses of Liquor Hydrargyri
Perchloridi were ordered instead.
July 18th. — Left optic disc pale and arteries dimi-
nished.
August 14th. — Vision no better than on June 20th.
Still some pain in head, but not nearly so bad ; it is now
" dull/^ not '' sharp. ^' Left disc now of a dirty yellowish
pale colour with considerable diminution of the arteries ;
they all pulsate on pressure.
October 13th. — Left, vision still only shadows. Pupil
acts a little directly, well indirectly ; it is usually smaller
than the other.
November, 1882. — Comes on account of muscae in the
right ; no changes in it except commencing presbyopia.
Left, as before, except that the direct action of the pupil
to light is apparently better than it was; its comparative
size was not noted. Disc in much the same state, a dirty
CASES OP RETRO-OCULA.R NEURITIS. 217
yellowisli colour ; some connective tissue about the vessels
at their point of emergence.
July, 1884. — Left, as before; fancies he can see fingers
in lower part of fundus rather better.
Case 20. Blindness of one eye with atrophy of disc
during pain on same side of head. — Louisa M — , aet. 30,
single, tall, pale, nervous, but not hysterical.
Six years ago had neuralgia in one temple, does not
remember which ; had a good many teeth drawn to cure
it. Had no recurrence of pain till about three months
ago, when, two or three days after bathing in the sea and
staying in the water half an hour, she began to have pain
at back of head. After a time it became much worse and
was localised to left temple and occiput. The sight of
the left eye failed during the early part of the attack and
the eye became ^^ blind '^ ten weeks ago. The eye used
to water and could not bear the light, but was not red.
Admitted to St. Thomas's Hospital, October 4th, 1880
(T. 3, 112). — Left eye has no perception of light; indirect
light-reflex of p. good, and p. slightly larger than right
when both are open (as 4*5 to 4) ; oph., o. d. moderately
pale all over, no evidence of previous papillitis, central
vessels normal size, and arteries pulsate easily on pressure.
No note as to syphilis. Patient only seen once.
Case 21. Rapid and permanent hlindness of one eye
during severe neuralgia of same side of face ; attach pro-
bably due to cold J condition fifteen years later. — Colonel
H — , aet. 41 (P. 3, 28), was sent to me by Dr. Ord, in
November, 1878, for conjunctivitis apparently excited by
excessive office-work in Barbadoes about two months
previously. It affected only the right eye. Vision of
right eye y|, and 1 J. p.p. 9''. Left, absolutely blind ;
o. d. atrophied ; border rather irregular ; central vessels
somewhat diminished in size, but arteries pulsate readily
on pressure ; p. slightly smaller than right, its indirect
reflex action good.
218 DISEASES OF OPTIC NERVH.
History of left eye. — Fifteen years ago sailed from West
Indies, in the hot season, for Scotland, where he arrived in
May, and was housed in bad barracks ; almost immediately
had very bad neuralgia in left face, and left eye became
blind and has remained so ever since. Had skilled advice
soon after the eye had become blind. Never had similar
neuralgia before or since. No note as to syphilis.
Case 22. Post-papillitic pallor of one disc with history of
neuralgia confined to same side of head some months before. —
Louisa Y — , a3t. 18, came for asthenopia (St. Thomas's
Hospital, 2, 171) in July, 1879. During previous winter
two attacks of neuralgia of right face and head, with
slight swelling of face, attributed to bad teeth ; the pain
did not run down back of neck. Does not know whether
sight of right eye failed. Health good.
On admission :
Eight |§ and 2 J., + 0*75 D. sph. ") ^^
Y.
— 1 D., cyl. axis !> ^^t , -r
,.'*;, V and 1 J.
horizontal.
Left |§ and 1 J., H.m. 1 D. fg.
On ophthalmoscopic examination, however, right o. d.
pale all over, edge not quite clear, arteries decidedly
diminished. " There has evidently been neuritis."
Left o. d. normal but rather congested.
Case 23. Blindness of one eye ivith post-neuritic atrophy ;
no history ; other eye healthy. — Mrs. S — , aet. 63 (P. 7, 39).
Two years ago, whilst at Brighton recruiting her health
after having been overworked, she accidentally found right
eye blind or very nearly so ; cannot assign any cause or
give any further history.
September 14th, 1882. — Right has no perception of
light ; indirect reflex action of p. normal ; oph., o. d. very
pale (yellowish tint) and hazy, but not at all swollen ;
veins about normal, arteries rather small and showing
thickened sheath on o. d., their calibre rapidly diminishing
beyond o. d. ^' Disc much more hazy than in atrophy after
CASES OP RETRO-OCULAR NEURITIS. 219
embolism/' Left H.m. 2 D, vision = |g, + 5 D. = 1 J.
at 12''.
Case 24. Blindness of one eye with simple atrophy of
disc ; no history ; other eye healthy. — Mr. E — , aet. 32,
a healthy farmer, was sent to me for opinion by Dr.
Parsons, of Dover, in June, 1883 (P. 8, 197). Five years
previously, in trying to shoot, for experiment, from the
left shoulder, he found the sight of the left eye defective.
History entirely negative. He had skilled advice soon
after making the above discovery. Left eye diverges ;
no perception of light ; indirect reflex action of pupil
normal ; oph., advanced, yellowish-white atrophy of optic
disc with atrophic cupping and exposure of lamina crihosa,
arteries considerably diminished. Right eye, vision and
oph. normal.
Case 25. — Severe acute papillitis of one eye ivith blind-
ness ; pain about eye and side of head ; partial recovery of
sight with pale disc ; no cause. — Eliza C — , set. 22, a
healthy, fair, freckled woman, suckling her first baby six
months old, was admitted at St. Thomas's Hospital on
August 2nd, 1881, scarcely able to count fingers with the
right eye. The pupil acted both directly and indirectly,
and was not larger than the other ; there was well-marked
papillitis, the veins large and tortuous, and the arteries
partly obscured ; there were no hsemorrhages ; the swel-
ling was almost limited to the area of the disc ; other
cranial nerves normal. Left eye normal, but slight H.
She said that three days ago, on waking in the morn-
ing, she had found the eye almost blind ; it had been
'^ weak and watery '' over-night. For some days previously
she had had pain over the eye and eyelid and at the top
and back of the head, worse at night ; it was still present
on admission. A short time before the sight failed her
husband told her she a " blue mark '' on the upper lid.
A month ago she had felt rather ill from the sun's heat, but
had not been sick. No injury. No history of syphilis
(direct questions). Ordered iodide and mercury.
220 DISEASES OP OPTIC NERVti.
August 6tli. — There is now slight fulness of the skin
and enlargement of a vein of the upper lid (doubtless the
^^ blue mark ^' mentioned above). Less headache. No
pain or tenderness on pressing eye back into orbit. Sight
of R. is now entirely abolished, no perception to light ; the
venous engorgement and swelling of the disc are very
intense, but the opacity not great {i.e. chiefly oedema).
The eye already diverges, but there is no paralysis. No
direct action of pupil. Iodide and mercury increased.
Other eye normal.
8th. — R. now has good perception of light.
10th. — Same. Ophthalmoscopic appearances the same ;
no haemorrhages.
12th. — Vision not better, but disc not so swollen. No
pain for several days past. Breath getting mercurial.
22nd. — Counts fingers at 2' for the first time. Not
salivated.
29th.— Reads 20 J. at 12''. Outer border of disc
clearly defined, but still some swelling of its inner side.
No salivation.
September 21st.'— Reads -^^ and 19 J. Disc now
quite clear and rather pale, no trace of haze ; veins still
large and more tortuous than in left ; some white lines ;
direct action of right pupil to light, slow and imperfect.
Left eye normal. Omit mercury.
October 13th. — Right, reads words of 16 J.
27th.— 2^ and 14 J. words.
December 20th. — Still only words of 14 J. and veins
still enlarged.
February 3rd, 1882. — Words of 10 J. by moving the book
about. Disc shows a uniform greyish pallor and its tissue
is opaque and filled up, but arteries of normal size ; veins
still much larger than in the other eye. There is evidence
of collateral circulation on the disc. The visual field is of
normal extent, but was not examined for scotoma. Slight
defect for green (she tends to confuse greens and greys
unless she compares them carefully), but she does not
confuse reds and greens even in the more delicate test of
CASES OF EETRO-OCULAR NEURITIS. 221
Ole Bull. Tested again in May and found to give the
same answers. Unfortunately acuteness of vision was not
noted at this, her last, visit, but I believe it was about the
same as in February.
Case 26. Severe acute papillitis of one eye with hlindness ;
pain on same side of head for a few days ; recovery of
sight ; syphilis six years before ; typhoid fever {?) eighteen
months before. — H. Wm. C — , set. 27, a very tall, rather
thin man, a bricklayer, was sent by Dr. F. W. Parsons, of
Wimbledon, on March 18th, 1881, for recent blindness of
the left eye ; Dr. Parsons had already diagnosed optic
neuritis.
On admission the left eye has only bad p. 1. ; pupil
not larger than right, acting well indirectly, but not at all
directly ; gross papillitis or papillo -retinitis with a high
degree of steep swelling, but comparatively little opacity,
so that the margin of the disc can still be made out ; the
swelling passes about a discos breadth into the retina;
movements of eye normal ; one or two small haemor-
rhages ; slight tenderness on pressing the eye back into
the orbit (none on the other side) ; no affection of other
nerves. Other eye natural in all respects, but o. d. shows
an unusually deep physiological cup.
Eight days before I saw him the affected eye had become
suddenly dim, accompanied by aching pain over the corre-
sponding temple and the back of the head. The pain
was bad enough to make him keep his bed for two days,
and he vomited once. In five days {i.e. three days before
I saw him) the eye had become quite '^ blind. ^^ The pain
subsided as the sight failed, and he was quite free from
pain when I saw him on March 18th.
Had a chancre followed by eruption six years ago ; has
had no symptoms since ; married a year later ; wife has
had two miscarriages and one child, now aged four months,
but living sickly. Patient has had no injury to the head
and no fits.
Eighteen months ago he had an illness after working
222 DISEASES OP OPTIC NERVE.
in the sewers, thought by Dr. Parsons to be typhoid, and
has not been really well since. A few months ago his
left leg became ulcerated and he now shows a large area
of superficial ulceration with dusky eczema and varicose
veins. Ordered iodide of potassium and perchloride of
mercury.
March 31st. — Dose increased. Left can now see fingers,
but not -2^ or 20 J.
April 7th. — Reads words of 20 J. badly, not 19 J.
Taken in, and mercury given by mouth and skin with the
intention of getting slight salivation. It caused diarrhoea,
but only slightly touched the gums. Mercury was resumed
in small doses on 13th, and continued with iodide, till the
end of May.
April 16th. — Reads some letters of 18 J.
20th. — Field now taken, no contraction, but not tried
for scotoma. Words of 16 J.
May 4th.— Left 3-0% and 14 J. at 8''. The disc is now
pale all over and its tissue looks opaque, but the vessels
are neither obscured nor diminished in size, and the
physiological pit is not filled up, though there are white
lines along one (descending) artery.
May 13th. — Some words of 12 J. Discharged from
ward.
27th. — Vision y-^ and words of 8 J.
He did not come again till September 22nd, though I
believe he had been going on with iodide from Dr.
Parsons for at least part of the time. With left he
now sees |-§^and 2 J. slowly, no H.m. The veins are still
too large and tortuous, and the disc whiter than the other ;
still white lines along the descending artery.
November 2nd, 1881. — Left -|§ and words of 1 J.
November 6th, 1882 — Left ^ partly and 1 J. slowly.
" Disc nearly as good a colour as the other, and edge
clearly definod, but lamina cribrosa not quite so distinct.
Very marked white lines along the artery running down-
wards ^' (Mr. Lawford^s note).
It should be mentioned that he was tried for colours
CASES OF RETRO-OCULAR NEURITIS. 223
when vision liad just begun to return (April 12tli, 1881),
and a considerable degree of red-green blindness was
found.
Case 27. — FosUpajpillitic atrophy of one disc with hlincl-
ness and ^permanent paresis of third and fifth nerves on
same side ; history of severe, prolonged headache on same side
with double ptosis for a time. — Wm. C — , shoemaker^ from
Leicester, set. 41, single. Syphilis possible but not
proved. Comes for ulcer of left cornea.
At set. 384 (t^o years and a half ago, January, 1874),
very severe right headache, lasting weeks and worst when
lying down. Never before or since. Had no fits.
During this attack, right eye turned in and lid dropped ;
saw double for a long time, and eye was '' quite fixed. ^^
Then left lid also dropped for some weeks, then it went
up, and more than a year later (March, 1875) right lid
also rose. Vision of right began to fail some weeks after
pain had quite ceased, and was months in fading quite
away.
Admitted at South London Ophthalmic Hospital Sep-
tember, 1876, ast. 41. Right no perception of light ; glis-
tening, white, tendinous atrophy with streaked retina (old
severe papillo-retinitis) ; vessels much diminished, lamina
cribosa exposed. Paresis of all third nerve muscles of
same side, and of first and second divisions of fifth ; other
cranial nerves normal.
Probably this was a case of large node on the body of
the sphenoid chiefly on the right side, but passing over
when at its height to the left of the middle line.
Case 28. — Blindness of one eye luith jpost-papillitic
atrophy of disc ; previous temporary failure of same eye ;
attacks of neuralgia on same side of head; history of rheu-
matic fever J formerly subject to megrim with ocular sym-
ptoms.— Mrs. G — , set. 35 (P. 3, 134), was sent to me in
August, 1879, for opinion by Mr. Story, of Dublin.
With the right she had no perception of light ; optic disc
224 DISEASES OF OPTIC NERVE.
moderately pale and showing evident traces of some pre-
vious inflammation ; arteries extremely small, veins only
slightly diminished ; pulsation easily produced in arteries
by pressure j ^' very like the result in many cases of
embolism/^ Pupil same size as left and acting well to
indirect stimulus of light. Left, vision and oph. normal,
but liable to intolerance of light, aching, and attacks of
'' white mist '' over nasal part of field ^ hyperaesthesia
retinae ^') . This mist is quite different from the flicker-
ing she used to have with her sick headaches ; ^' that was
horrid, like looking through running water ; this is quite
different."
Formerly much sick headache with flickering before
sight as above mentioned ; has lately had no such head-
aches. Rheumatic fever ten years, and again two years,
ago. Heart reported to be normal. During last two
years has had three attacks of severe neuralgia of right
side of head and face, independent as she believes of
decayed teeth and of cold. The failure of right eye was
in some relation to these attacks, and her account was as
follows: — In February, 1878, had the ^^ neuralgia" for
ten days ; in the summer again had it for ^' several
weeks ; " in November she suddenly found one morning
that she could not see the outlines of things with her
right eye ; she believes the sight returned perfectly in a
week, but does not supply convincing evidence of this,
and it is also doubtful whether there was any neuralgia at
this date, her statements on this point being confused. In
March, 1879, she again had the neuralgia, and during the
attack the eye again failed. On arising one Thursday
she " could not see much " with it, and by the Sunday
following it had become, as now, totally blind.
(July Uh, 1884.)
Dr. Stephen Mackenzie supposed that, owing to the
defect of vision caused by the lesion, these cases only
came under the notice of the ophthalmic surgeon. They
did not, in his experience, occur in medical practice. He
CASES OP RETRO-OCtJLAR NEURITIS. 225
would like to ask Mr. Nettleship whether an examination
of the blood had been made in any of his cases. His
reason for asking was that, in leuco-cythaemia, papillitis and
a diffuse inflammation of the retina occurred, and that the
latter had been ascribed to thrombosis of the orbital veins.
It might be that thrombosis explained some of Mr.
Nettleship^s cases. Next, he would ask Mr. Nettleship
as to the time that elapsed between the fever some of
the patients were stated to have suffered from, and the
occurrence of the ocular symptoms, as this was a point of
some importance. It was known that in some fevers,
especially typhoid, thrombosis was apt to occur during or
immediately after the attack. He could not recognise any
community of type amongst the cases described by Mr.
Nettleship such as entitled them to the relationship of a
natural group. Arthritic diseases were so common that
it required very close evidence, in his opinion, before we
could refer a diseased condition to the convenient category
of an arthritic diathesis. He made these criticisms with
deference, as he had no knowledge of the class of cases,
and his observations were only founded on Mr. Nettle-
ship's careful description.
Mr. Nettleship said, in reply to Dr. Stephen Mackenzie :
The blood was not examined in any of my cases ; none of
the patients, however, were conspicuously anaemic, and
most of them seemed in good health. I do not, at present,
attach much importance to the occurrence of typhoid, or
other, fever before the eye failure. Of the four patients in
whom this was noted at least two had certainly had
syphilis : the interval between the fever and the eye attack,
moreover, varied greatly ; thus, in Case 7 typhoid fever
occurred 4^ years previously, no syphilis ; in Case 8,
typhoid 6 months before, syphilis very probably 5 years ;
Case 14, intermittent fever just before the failure of the
^J^} syphilis 20 years ; Case 26, typhoid 18 months,
syphilis 6 years. It must be freely admitted, for the
whole series, that we can at present do little more than
VOL. IV. 15
226 DISEASES OP OPTIC NERVE.
guess at the seat and nature of the changes, and that these
almost certainly differ in different cases. In the cases with
severe pain, great damage to sight, and late changes at
the disc, periostitis of the orbital canal seems very pro-
bable ; but in the milder forms, with or without slight early
ophthalmoscopic changes, the seat of disease probably
lies further forward, and we may conjecture that a small
gumma in or upon the optic nerve may account for some
of these, as it does for some cases of paralysis of oculo-
motor nerves. The presence of a well-defined central
scotoma in many of the cases must, in the present state of
our knowledge, be taken as evidence of disease limited to
those bundles of nerve-fibres which lie at some distance
from the eye in the centre of the optic nerve, but reach
the surface of the nerve, close to the globe at the temporal
side.
3. A case of central amblyopia and concentric contraction
of fields of visioji ; recovery of normal acuteness of sight.
By J. B. Lawford.
Sidney P — , aet. 18, a printer for three years, became
an out-patient at the Royal London Ophthalmic Hospital
on November 17th, 1883, under the care of Mr. Hulke,
to whom I am indebted for permission to bring the case
before you.
Family history. — Parents living. Father suffers from
gout. Five years ago he had a sudden attack of blind-
ness, from which he recovered in a short time. No
further history of this attack obtainable. Mother healthy.
No phthisis, no insanity or other neurosis known.
Personal history. — Patient is the only child. Two
years ago was laid up for two months with " gastric
fever.^' With this exception has had no illness since early
childhood. A discharge from right ear following measles
CENTRAL AMBLYOPIA. 227
when a child ceased some years ago. Has not had
gonorrhoea or chancre. Denies masturbation. No
evidence of hereditary or acquired syphilis. Does not
smoke.
The history he gave of his present illness was as
follows : — About the last week of June, 1883, he struck
the back of his head against some machinery in the shop ;
was '^ almost stunned.'^ The next day when walking in
the street he noticed a '' numbness ^' of the right leg,
which seems to have passed off in a short time. On
July 14th he slipped and fell on the pavement, on to his
left side. He did not fall heavily and thinks he did not
strike his head. He slept well the following night, but
the next morning on rising he was giddy and kept falling
to his right side, though he was able to use his right
leg. Was violently sick for three days. Noticed that
his right leg felt '^ numbed. ^^ About a month or five
weeks later his vision began to fail ; headache, chiefly in
the morning, came on ; it was unilateral, right sided,
*' beginning behind right ear and extending to the eye.'^
The arms became affected, he thinks, as he was unable to
raise a cup to his lips without spilling the contents.
Bowels were constipated.
On August 25th he was admitted into Guy's Hospital
under Dr. Moxon's care. I am indebted to Dr. Carring-
ton. Medical Registrar at Guy's, for kindly supplying me
with a copy of the notes of the case when in that hos-
pital. The history the patient gave of the beginning of
the illness was identical with that which I have just read.
The following notes are copied almost verbatim from
those taken at Guy's Hospital :
'^ On admission. — Well developed. No wasting. Mus-
cles firm. Expression apathetic. Skin cool and dry.
Appetite good. Slight thirst. No vomiting or nausea.
Submaxillary glands slightly enlarged. Pupils wide, act
well to light, Respiratory and circulatory systems normal.
Slight pain on micturition. Urine free from albumen and
sugar.
228 DISEASES OF OPTIC NERVE.
'^ Nervous system. — Memory is said to have been im-
paired since commencement of illness ; otherwise mental
faculties appear good. No hesitation or slowness of
speech. Movements of upper extremities not impaired.
Grasping power as good on right as left side. Dorsum
of right hand not so sensitive to various stimuli as that
of left. Sensation almost lost all down left leg ; in left
foot the loss is absolute. There is inability to move the
toes of left foot and the movements of that foot are
imperfect. There is also some loss of power in the left
leg. Ankle-clonus well marked on right, absent on left
side. Knee-jerks equal and good. Sight of left eye
better than that of right ; both defective.
^' Ophthalmoscopic examination, — Both discs healthy.
Ordered —
5b Liq. Hyd. Perchlor., n\lxxx ;
Pot. lod., gr. V ;
Aq. ad 5j. T. d. s.
" September 3rd. — Eyes slightly improved. Less head-
ache. Numbness extending up right arm, but sensation
is not abolished. Considerable loss of power in the arm.
Left foot devoid of sensation, which is much impaired in
the leg also, especially on the outer side, and to a slight
extent on outer side of thigh. No vomiting. Urine
sometimes passed involuntarily, sp. gr. 1021, alkaline in
reaction, deposit of mucus and phosphatic crystals.
'^ 6th. — Sensation much improved in right hand, being
almost perfect. There is a small spot behind right ear
where sensation is greatly impaired. Sensation, though
still impaired, is better in left leg and foot. Patient
complains of a feeling of numbness in right foot, but
sensation is perfect when tested. There is a central area
of darkness in each eye, larger in the right eye, this one
being almost blind.
^' 10th. —Power in right arm much increased, almost
equal to left. Patient tried to stand, but failed, saying
" he could not feel the ground. '^ Sight is better. Ec-
centric fixation.
CENTRAL AMBLYOPIA.
229
^' 15th. — In centre of field of vision cannot see the light
of an ophthalmoscopic mirror.
'^ 17th. — Convulsive fit lasting three minutes ; all
limbs convulsed. No twitching of face. Eyes deviated
to the left. Pupils contracted. Conjunctivae insensitive.
Tongue bitten. Ten minutes later patient was quite
sensible^ with no knowledge of the attack.
^' 25th.— Right arm very shaky ^ but grasp is good.
Soles of feet feel numb and cold.
'' October 1st. — Patient very tremulous to-day, nearly
the whole body jerking about with any attempt at
movement.
'^ 3rd. — Much less tremor _, only the right arm shakes
when raised. Patient can only recognise a watch at three
feet. Fields of vision taken by Dr. Brailey. Right con-
Left.
Right.
Fields of vision of Sidney P.
tracted concentrically ; the limits being 50° upwards and
outwards, 45° downwards and inwards. There is also in
this field a large central scotoma, for form, approximately
circular, extending from fixation point, 15° upwards and
outwards, 20° downwards and inwards. Left F. of full
extent downwards and inwards, but only reaches 40° up-
wards and 65° outwards. There is a small central scotoma
extending from fixation point 5° downwards and outwards,
10° upwards and inwards. Acuity of vision not noted ;
ophth., no changes.
'' 8th. — Temperature rose to 1 02°. Vertigo, vomiting,
tremulousness of right arm and impairment of power.
280 DISEASES OF OPTIC NERVE.
Sight much worse, and there is little power of discriminat-
ing colours.
^^ 9th. — No pyrexia. Movements of right leg jerky.
•' 22nd. — Right arm steady.
'^ 29th. — Can read a little and walks steadily.
'^ November 1st. — Discharged at his own request."
No definite diagnosis was made. Dr. Carrington tells
me it was thought to be probably a case of cerebral new
growth. When he presented himself at Moorfields
(November 17th) his condition was as follows :
Grasp of left hand stronger than that of right (is right-
handed) ; this was not tried by dynamometer. Patient is
aware of this weakness of right hand. Knee-jerks very
marked, equal on both sides. No paralysis of sensation.
No headache or tenderness over any part of cranium.
No squint. Memory, as far as ascertainable, good. Ap-
petite good. Sleep disturbed. Urine 1025, no albumen
or sugar.
^j ( K. ^ and 1 J. ") Refraction H. (low degree). No
(L. fgand 6 J.) H.m.
Pupils equal, 3 J mm., active to light and accommodation.
Visual fields considerably contracted. The limits of
R. F. are 30° upwards, 55° downwards, 60° outwards,
40° inwards ; those of L. F. are 20° upwards, 35° down-
wards, 35 outwards, 30° inwards. In each field there is a
very ill-defined central scotoma for red and green, closely
limited to fixation point. These scotomata could not be
mapped out at all accurately.
Ophthalmoscopic examination. — Media clear. Doubtful
pallor of optic discs on yellow-spot side. No other
changes. No evidence of former papillitis. Movements
of eyes full in all directions. No strabismus.
28th.-V. f R- f/°d 4 J- barely.
( L. -f^Q and 1 0 J.
December 1st —Y I ^' ^^ ^''^ ^ ^' ^^^'''^^-
(^ L. y^ and 4 J. slowly.
p ., r R. b\ mm. for distance, 4 mm. for A<" .
^ ( L. 6 mm. for distance, 4^ mm. for 4".
CENTRAL AMBLYOPIA. 231
Both act well to light.
R., F. unaltered ; L,, F. slightly enlarged downwards
and inwards.
Colour vision (each eye tried separately) is perfect.
No evidence now of central scotomata.
8th —V I ■^" "50 partly; 1 J. slowly, incorrectly.
• ( L. f§ partly ; 1 J. slowly.
Pupils equal, rather large, act well to light. Has now
been at work for a week.
15th —V I ^- ^ p^^*^^ ' ^ '^' si^^iy-
t L. |§ ; 1 J. slowly.
R., F. of full extent except outwards ; the limit in this
direction being 70°. L., F. of same extent outwards ;
full in other directions.
f R. ^ ; reads 1 J. with each eye, prefers
22nd.— V. \ right eye.
( L. 1^ partly.
There is now no appreciable difference in the grasp of
the two hands, but there is considerable tremulousness of
right hand when any complicated movements are attempted.
^ R. |-^ partly ; 1 J. Pupils equal
Jan. 5th, 1884. — V. < and normal in reaction.
(. L. f§ partly ; 1 J.
V 1 fi 1/^ i" ^* slightly contracted outwards,
visual neiQs. ^ -r f> p n . ,
(^ L. 01 lull extent.
Improvement steadily progressed. On March 1st,
1884, V. = f^ and 1 J. with each eye. The fields of
vision were of full extent. Ophthalmoscopic examination
revealed no changes. Patient said he felt well. The
tremulousness of the right hand had entirely disappeared.
The only treatment was the administration of iron and
nux vomica.
The chief points of interest in this case from an oph-
thalmic standpoint are —
1. The existence coincidently of central visual defect
and peripheral contraction of fields.
2. The central scotomata, which were at first absolute
scotomata for form, became in th« process of recovery
232 DISEASES OF OPTIC NERVE.
scotomata for colour only, and eventually disappeared, while
there was still considerable peripheral contraction of fields.
In the central defect of vision from tobacco the
scotoma for colour may be absolute, but is never, so far
as I know, absolute for form. It is probable that there
is in these cases disease of certain bundles of fibres in
the optic nerves ; but in the case just read it is likely
that the functions of some cerebral centre were in abey-
ance ; that no such disease of optic nerves existed.
The exact nature of this case seems doubtful. There
are several objections to its being a case of hysteria, but
it is very difficult to explain all the symptoms by intra-
cranial lesions.
(July 4th, 1884.)
4. On a case of acute optic neuritis associated with
acute myelitis.
By Seymour J. Sharkey, M.B., and J. B. Lawford.
G-. T — , set. 17, kitchen-maid, was admitted into the
Royal London Ophthalmic Hospital, under the care of
Mr. Streatfeild, on November 22nd, 1883.
There was nothing noteworthy in the patient's family
history, except that she was one of sixteen children, seven
of whom died as infants. Eight were alive and well, four
of whom were younger than the patient. There were no
grounds for suspecting syphilis. She had always been
delicate, but never seriously ill. Menstruation was regular
but profuse.
Vision began to fail on the 9th of November, about a
fortnight before she came under observation, and b}^ the
13th sho was quite blind. She had had neither head-
ache, sickness, paralysis, nor fits, nor could she suggest
any cause which might have given rise to her illness.
ACUTE OPTIC NEURITIS. 233
On admission she was found to be a well-nourished
girl, looking tolerably healthy, but anaemic. She had no
complaint to make except of her blindness. All the
functions seemed to be well performed. The thyroid
gland was the seat of a simple hypertrophy, and the
patient said it had been large as long as she could recol-
lect.
On examination of the eyes the pupils were found to be
unduly dilated and motionless to light, but there was no
paralysis of ocular muscles. Well-marked optic neuritis
was seen in both eyes, accompanied by much swelling of
the discs and of the retina immediately surrounding them.
The veins were very tortuous, but there were no haemor-
rhages and no choroidal changes. She had no perception
of light. She was given a mixture containing ten grains
of iodide of potassium, and in addition two grains of grey
powder, and three of Dover's powder, three times a day.
On December 6th the pupils were found to act well to
accommodation, but not to light.
On the 10th it was noted that no marked salivation had
been produced. Both optic discs were decidedly swollen and
their outlines lost, but the veins were not so tortuous as
on admission, nor did the inflammatory swelling extend
so far. There were no haemorrhages. Five grains of
blue pill and a quarter of a grain of the extract of opium
were now given twice a day.
On the 12th, i.e. thirty-three days after her vision began
to fail, she complained of weakness of the left leg, though
she said she had noticed it coming on four days previously.
On examination she was found to be unable to walk,
although she could do so the day before. The left leg
was almost powerless and slightly rigid, and sensation in
it was impaired. The knee-jerk was much more marked
than in the right leg. She had no pain in the head or
elsewhere, no paralysis except in the left leg, and no
abnormal mental symptoms.
13th. — Sensation almost absent in left leg and much
impaired in right. Complete paralysis of left leg, slight
234 DISEASES OF OPTIC NEEVE.
loss o£ power in right. Plantar reflex absent on left side,
fairly marked on right. Knee-jerk very marked on both
sides. Slight oedema of both legs, more marked in left.
No paralysis of arms or face ; no headache, pain in back,
or incontinence of urine.
14th. — Anaesthesia extending up the left side of the
trunk, reaching as high as the nipple in front and to a
finger's breadth below the spine of the scapula behind.
Left leg powerless and quite anaesthetic ; right partially
anaesthetic and more or less paralysed. Urine passed in
bed for the first time. No paralysis or anaesthesia of
arms, no headache, delirium, or fits, and no paralysis of
cranial nerves. In the mornings shortly after the fore-
going note was made, the patient became very excited,
tossing her arms and right leg about, while the left leg
remained motionless. When questioned she said that she
had no pain, but that she could not speak. She appeared
in great mental distress, but answered questions rationally
and used the proper words. Soon she had a fit, but only
the right arm and leg were convulsed, and she was not
unconscious. The fit lasted about ten minutes.
In the afternoon of the same day she was much quieter,
but still tossed her arms and right leg about ; the latter
was quite anaesthetic, while the left had not only lost
sensation, but was likewise completely paralysed. There
was marked flushing of the face during the period of
excitement ; the pupils were equal and dilated. The
temperature at 5.30 p.m. was 100*2° F., the pulse 96 and
regular, the bowels constipated.
15th. — Quiet all night ; paralytic conditition the same
as yesterday. Emotional and excited at times. Evacua-
tions passed involuntarily. No sickness, no headache ;
tongue coated. Pulse 106, regular; temperature 100° F.
Lungs and heart normal. The patient was now admitted
into St. Thomas's Hospital under the care of Dr. Bristowe.
19th. — Seventy-six ounces of urine were drawn off, and
it was found to be clear and acid, but offensive and
containing a trace of albumen.
ACUTE OPTIC NEURITIS. 235
22nd. — Examination showed that there was complete
paralysis of both legs and loss of control over the evacua-
tions, and, in addition, evident weakness of the left hand.
Loss of sensation was found not only in the legs and over
the greater part of the trunk, but likewise in the left
forearm and hand on the ulnar side. There was no ankle-
clonus ; the knee-jerk was excessive on the left side,
about natural on the right. No tendon reflexes obtained in
the arms.
23rd. — Sensation impaired in right forearm and hand.
Complaints made of pain in the lower part of the
abdomen.
26th. — Urine muddy, offensive, alkaline, and containing
triple phosphates, mucus, red blood-corpuscles, and leuco-
cytes.
January 4th. — The condition of legs remained the same.
Sensation was impaired in the forearms. The urine was
offensive and contained pus. Dr. Kilner examined the
muscles and nerves electrically and reported that they
presented the " reaction of degeneration.^'' The tempera-
ture, which had been only moderately raised up to December
29th, after that became very high and of an intermittent
type, ranging from about 101'' F. to 104° F. or 105° F.
The patient also complained of pain in the epigastrium and
right side.
After this but little alteration occurred except that the
presence of peritonitis became evident, and slight double
external strabismus was noticed. The patient died on
January 10th, sixty- two days from the time when her
vision first failed and twenty-nine days after the first
appearance of symptoms of paralysis.
Autopsy (twenty-nine hours after death). — Body well
nourished ; subcutaneous fat abundant. On opening the
abdominal cavity, acute peritonitis was found, though the
inflammation was most intense in the pelvis. When the
abdominal wall above the pubic symphysis was cut through
the subperitoneal connective tissue in that region was
seen to be infiltrated with pus ; and this inflammation,
236 DISEASES OF OPTIC NERVE.
though external to the bladder, appeared to have been
caused by the acute cystitis which was present, the in-
flammatory process having spread through the wall of the
viscus and attacked the connective tissue around. The
peritonitis too seemed to have had a similar origin.
The ovaries were swollen and hyperaemic and the
mucous membrane of the uterus was intensely congested.
In addition to very acute cystitis there was inflamma-
tion of the ureters and of the pelvis of both kidneys. The
latter were much enlarged, hyperaemic, soft, and juicy.
Their capsules were thin and peeled off easily, and groups
of suppurating points were seen in the cortex beneath them.
These were the terminations of inflammatory streaks and
lines of suppuration which radiated from the pelvis.
The left ventricle of the heart was slightly enlarged,
but with this exception the intra-thoracic viscera were
healthy.
The thyroid gland was considerably hypertrophied, but
contained no cysts.
The liver was pale and soft, but otherwise normal.
The brain was in every respect normal except that the
soft commissure was absent. No inflammation could be
detected anywhere. The pituitary body was large, pale,
and mottled.
The cerebral sinuses were natural and no abnormality
of any of the cranial nerves was observed.
The spinal cord presented no abnormal appearances
except over a space of two or three inches in length in
the lower cervical and upper dorsal regions. Here it
was intensely congested and much softened, but not
diffluent. The section-surface was bright pink, and blood
oozed from a great number of distended vessels. The
cervical region above, and the dorsal and lumbar regions
below, the softened part presented no evidences of disease.
The membranes of the cord seemed healthy.
Microscopical examination of the spinal cord. — -Sections
of the spinal cord were cut, stained, and mounted in the
usual way. Four regions were selected for this purpose :
ACUTE OPTIC NEURITIS. 237
1. The lower cervical region^ where naked -eye changes
due to disease were observed at the autopsy.
2. The upper cervical region^ above the area of evident
disease.
3. The upper lumbar region ; and
4. The lumbar enlargement.
1. Lower cervical region. — On holding up a prepared
section of this part of the cord towards the light it was
seen to be almost homogeneous in appearance and to stain
imperfectly. One could scarcely distinguish even the
grey matter from the white. On further examination
with the microscope the whole area of the section was
seen to be crowded with small cells, apparently leucocytes,
which stained deeply with logwood. The vessels were
greatly dilated, their sheaths were occupied by leucocytes,
and many of the smaller ones were filled with these cells.
The white substance of the nerves themselves was granular,
and the large stellate and other cells were seen with great
difficulty. Those which could be made out presented no
processes, and their protoplasm in many instances had lost
its natural granular appearance and was transformed into
a homogeneous hyaline substance. All the nerve-cells
and their nuclei took the staining either imperfectly or
not at all. The pia mater had shared but slightly in
the general inflammation. In short, that part of the cord
which was soft and hyperaemic to the naked eye was the
seat of an intense inflammatory process which had not,
however, gone so far as to produce gross disorganisation.
2. Cervical region above the seat of disease. — Although
at the post-mortem examination this part of the spinal
cord presented no abnormal appearances, it did so after it
had been hardened, and still more clearly after it had
been stained and mounted. The columns of Goll, and
these columns alone, were the seat of an acute inflamma-
tory process, which was in an earlier stage than the
myelitis below. Its distribution was just that of ascending
degeneration.
3. Upper lu7nhar region. — Neither with the naked eye
238 DISEASES OP OPTIC NERVE.
nor by the aid of the microscope could any disease be
detected in this part of the cord^ either in the lateral
regions or elsewhere.
4. The lumbar enlargement presented morbid appear-
ances to the naked eye (but only after the sections had
been stained and mounted) in the columns of Goll. They
appeared to be more transparent than the rest of the
posterior columns, and resembled the central grey matter.
The microscope showed that this was due to complete
granular degeneration of the nerve-fibres ; some of the
vessels in this region were crowded with leucocytes, but
otherwise there was but slight evidence of inflammation.
In the anterior cornua some of the vessels contained an
abnormal number of leucocytes, and some of the ganglion
cells were more homogeneous than they are in health.
The membranes were everywhere healthy except in the
lower cervical region, where the pia mater was seen to
share in the general inflammation of the spinal cord.
Microscopical examination of the under surface of the
frontal lobes of the brain, of the meninges about the
chiasma and optic tracts, of the chiasma and tracts, and
of the right optic nerve, disc, and retina.
Under surface of frontal lobes of brain, — Slight signs of
inflammation were evident in the pia mater and in the small
vessels entering the cortex, but the morbid changes could
not be traced deeper tlian the two superficial layers of the
grey matter. In the first and second layers, especially in
the former, there seemed to be a larger number of connec-
tive-tissue corpuscles than usual.
Meninges about chiasma and optic tracts (teased)
presented evident though slight signs of inflammation.
Optic tracts (transverse section). — Changes of equal
degree were seen in both tracts. There was increase in
the number of staining nuclei throughout them ; near their
periphery these nuclei formed a border two or three deep,
which encircled the tracts. The small vessels showed
ACUTE OPTIC NEURITIS. 239
distinct inflammatory changes. The larger nerve-cells
in the brain substance on which the tracts rest appeared
to be normal.
Ghiasma (transverse section). — Marked signs of inflam-
mation present. There was a great increase in the
number of connective-tissue corpuscles throughout, and
surrounding the small vessels were large accumulations of
these cells. The coats of the small vessels were thickened^
and studded with stained nuclei. Around most of the
vessels were clear spaces, oedema spaces (?).
Right optic nerve to the naked eye appeared normal.
In a transverse section, on a level with the optic
foramen thickening of the sheaths, especially of the inner,
was observed. In the sheath-space there was a consi-
derable amount of recent inflammatory material, as there
was also in the small vessels. The trabeculae in general
were thickened, though they appeared more so in some
places than in others. They enclosed many stained nuclei.
The latter were also present in largely increased numbers
throughout the bundles of nerve-fibres. Alongside the
trabeculae, between them and the nerve-fibres, were spaces
containing a very faintly granular material which did not
stain. These, which were probably lymph-spaces, were of
greater width than is usually observed.
In transverse sections close to the globe were changes
similar to those just described. The increase of stained
nuclei appeared to be greater in the peripheral than in
the central parts of the nerve.
Bight disc and retina. — The sheath-space close to the
disc was very slightly distended. Swelling, considerable
in degree, involved the disc and the nerve-fibre layer for
some distance towards the periphery. The stained nuclei
were very numerous in the disc and in the two inner layers
of the retina. Inflammatory changes were present in the
vessels, and a large haemorrhage was seen in the retina
close to the disc, which involved all its structures except
the nerve -fibre layer.
In short, microscopical examination proved that there
240 DISEASES OF OPTIC NERVE.
was intense inflammation of the optic discs^ nerves, and
chiasma, and that it involved, though less severely, the
optic tracts. The meninges about the chiasma and on the
adjacent under surface of the frontal lobes presented slight
evidences of inflammation.
The interest of the case just related lies in the
association of an acute optic neuritis with acute inflam-
mation of the spinal cord. Growers in his work on
' Medical Ophthalmoscopy '' refers to five cases recorded
by Clifford Allbutt, Seguin, Noyes, Steffen, and Erb, in
which spinal symptoms, apparently due to myelitis, were
present in connection with changes in the optic discs.
Some of these, however, appear to have been uncertain
in their pathology. It has long been known that affec-
tions of sight, which are generally due to slight changes
in the discs and retina, occasionally occur in cases of
spinal injury, and especially in injuries of the higher
parts of the spinal column. But it is not so well known
that optic neuritis is sometimes associated with spinal
myelitis where no injury has been sustained.
In the 'Archives of Ophthalmology,^ for 1882, No. II,
edited by Knapp and Schweigger, a very interesting case
is recorded by Julian J. Chisholm, M.D., which appears to
correspond with ours except that it was much more rapidly
fatal. Unfortunately an autopsy was not obtained. The
patient was a man, set. 28, healthy and robust. Without
evident cause he suddenly felt pain on movement of the
eyeballs, and his vision became slightly cloudy. By the
third day he was completely blind. Then loss of power
and sensation in the lower extremities supervened, and
paralysis advancing upwards, similar to that in our patient,
proved fatal on the twelfth day from the first sign of
illness. His brain remained clear until a few hours
before his death.
Dr. Dreschfeld published two cases, with accounts of
the post-mortem examinations, in the ' Lancet ' for 1882,
and these are quoted by Dr. Gowers.
ACUTE OPTIC NEURITIS. 241
Case 1 was that of a married woman, aet. 38, in whom
numbness and weakness occurred in the legs after exposure
to cold three weeks before she came under observation.
On admission into the hospital the lower extremities were
found to be completely paralysed and the upper partially
so, and she had retention of the evacuations. There was
marked double optic neuritis, but vision was good.
Post-mortem examination revealed congestion of the
cerebral membranes and excess of fluid in the ventricles.
One and a half inches of the spinal cord at the cervical
enlargement were exceedingly soft and of a yellowish
colour.
Case 2 was that of a man, aet. 41, who had been
intemperate and had had syphilis. One month before
admission his sight failed and his legs began to get weak.
On October 5th (apparently about a fortnight after he
was taken ill) he was examined at the Manchester Eye
Hospital and found to have optic neuritis, and at that
time he could walk with the aid of a stick. On 13th he
was quite blind, but could still walk with support. On
22nd he was admitted into the general hospital. He was
quite blind, and the optic nerves were atrophied. He
had complete paraplegia with analgesia of the legs, and
with an86sthesia and analgesia of the trunk as high as the
fourth rib. There was no affection of the arms but he
had retention of urine and involuntary action of bowels.
On November 2nd the patient died in a comatose con-
dition, the legs having become anaesthetic, the patella
reflexes having disappeared, and the intercostal muscles
having ceased to act.
At the autopsy the membranes of the brain were
normal and the brain itself quite healthy. The mem-
branes of the cord were also intact. There was extensive
central myelitis in the middle of the dorsal and in the
upper lumbar regions, extending over about one and a
half inches in each situation. The cord between these
spots was slightly softened. The microscope showed that
the brain, the chiasma, and the proximal part of the optic
VOL. IV. 16
242 DISEASES OF OPTIC NERVE.
nerves were healthy ; the peripheral portion of the latter
contained an excess of fibrous tissue. Besides the patho-
logical changes just mentioned there were patches of
acute myelitis in the right side of the lower cervical and
upper dorsal regions ; a second patch just below this, and
a third in the lower lumbar region affecting the posterior
columns.
The conclusion which both Gowers and Dreschfeld draw
with regard to these cases is that the optic neuritis and
the myelitis are associated phenomena due to a common
cause, but that neither depends directly on the other.
Our case seems to point very strongly in this direction.
For the acute optic neuritis was present certainly one
month before any symptoms of disease of the spinal cord
appeared. Moreover, post-mortem examination showed
that the spinal cord between the lower cervical region and
the lumbar region was healthy, so that these centres of dis-
ease must have originated independently one of the other.
The same may probably be asserted with regard to the optic
nerves and the seat of disease in the cervical region, as
there was no evidence of continuity between the inflamma-
tory processes going on in these situations. Unfortunately,
absolute proof of this is not at hand as the medulla
oblongata was not kept for microscopical examination.
Still the case may with great probability be said to be
one of acute optic neuritis associated with acute dissemi-
nated myelitis. The cause which gave rise to these
morbid changes, however, remains quite obscure.
Clinically such cases as these are of considerable im-
portance. Before attention had been called to them the
association of acute optic neuritis with paralytic phenomena
would have justified the diagnosis of cerebral disease.
And in the present instance, although the symptoms were
not very intelligible from that point of view, the case was
looked upon as probably one of brain disease. Acute
optic neuritis will therefore have to lose some of its signifi-
cance as a sign of intracranial affection.
With reference to prognosis our data are insufficient to
RECOVERY FROM AMAUROSIS IN YOUNG CHILDREN. 243
allow any definite conclusions to be drawn. But as far
as observations at present go, it seems that where acute
disease of the optic nerves is associated with acute disease
of the spinal cord the chances of a favourable termination
are not great.
{June hth, 1884.)
5. On cases of recovery from amaurosis in young children.
By E. Nettleship.
Cases of blindness, or of very defective sight, in infants
or young children, due to disease of some part of the optic
nerve or of its central connections, although rather rare,
are probably familiar to all the members of this Society.
I am half afraid lest, in stating that some of these babies
recover good, perhaps perfect sight, I may be saying what
is equally familiar, but at any rate the subject, although
one of considerable interest, has not hitherto been brought
forward here. It may be as well to state that the following
cases do not include any examples of local ocular disease,
such as choroido-retinitis in the early stage of inherited
syphilis, or cases of recognised papillitis.
Excluding these conditions I was not myself aware that
amaurotic babies ever recovered their sight until the occur-
rence of Case 1 (below), which was under my care about
seven years ago, and the notes of which were not very
full. This child saw well till he was nine months old,
then, without any other symptoms, he lost his sight. When
seen, three weeks later, there were no ophthalmoscopic
changes. Under two months^ treatment with grey powder
his sight returned. The child had had no recognised
symptoms of disease of the nervous system, but he was
probably syphilitic and had had hooping-cough and " in-
flammation of the lungs. '^
244 DISEASES OP OPTIC NERVE.
Case 1. — Francis M — , aet. 10 months, was brought to
the South London Ophthalmic Hospital in August, 1877,
his mother stating that he had not ^^ taken notice '^ well
for the last two or three weeks though he had previously
seen quite well. A careful ophthalmoscopic examination,
made under chloroform after the use of atropine, showed
no changes whatever ; the state of the pupils before
atropine was not noted.
The child was the first born, and the mother said that
when three or four weeks old he had thrush, eruption
about the buttocks, and snuffles ; there were, however, no
signs of syphilis when he was brought. He had " inflam-
mation of the lungs '^ when four months old and hooping-
cough afterwards.
I ordered a grain of grey powder every night, and this
he took for two months, when it was left off on account of
a bad cough.
In December, four months after admission, the note is
'^ he evidently sees much better.'^
The next case which I saw was about two years later
(November, 1879), and was as follows :
Case 2. Blindness at, or soon after , birth; recovery of
sight at about the age of nine months ; marked pallor of
one disc ; no cause ascertained. — Herbert T — , was brought
to St. Thomas's Hospital (T. 3, 1) in November, 1879, at
the age of three months, because he had ^^ never taken
notice. '^ The pupils did not act to light but dilated well
to atropine. The right disc was very grey all over but
quite clear with the exception of one or two small white
spots at its centre ; the vessels not diminished. The left
disc was much less grey, perhaps normal ; refraction H. in
each eye ; no nystagmus. The child was healthy and well-
grown and had had no fits, but was born three weeks before
time, soon after the mother had received a fright from
a fire in the house. No evidence of syphilis. His hearing
was good and he sucked well. The sutures were rather
ridged and fontanelles small, I thought. The parents were
RECOVERY FROM AMAUROSIS IN YOUNG CHILDREN. 245
young, healthy, not related by blood, and gave no family
history of mental or nervous diseases ; they had one other
child and it was in good health. A first cousin of the
mother (patient's first cousin once removed) had been
nearly blind since childhood from " weakness of the nerve,''
but I did not see him. I gave an unfavourable opinion
and the parents then sought other advice. A few months
later the child began to notice things, and it was observed
that at first he would hold objects to one side rather than
straight before him. I saw him again in July, 1880 (eight
months after he was first brought to me), and it was
evident that he could then see very well ; there was some
irregular movement of the eyes, however, and vision was
therefore probably not perfect.
At the meeting of the British Medical Association at
Worcester, in 1882, cases of the kind we are considering
were referred to,* and more than one speaker mentioned
having seen such. I have more lately learnt from Dr. David
Lees and Dr. Barlow, that they have for some time been
quite familiar with cases of recovery from temporary blind-
ness in young children affected with ^' posterior basic menin-
gitis." In a paper by Drs. Gee and Barlow, " On the Cervi-
cal Opisthotonos of Infants,''t ^ title which seems to be the
clinical equivalent of ^^ posterior basic meningitis," I do not,
however, find amongst twenty-five cases any in which the
sight was noticed to be defective ; but in many of these
cases the children were, no doubt, too ill for their sight
to be examined. Leaving the pathological questions, how-
ever, to others, my present object is to ask what facts, in
the history and present state of an amaurotic infant, point to
the probability of his recovering his sight ?
There is one group, long known but not I think yet
fully examined, in which a favourable prognosis should
probably never be given ; in these patients the sight is
* See • Brit. Med. Journ.,' 1882, vol. ii, p. 1081, " On the Value of Eye
Symptoms in the Localisation of Cerebral Disease."
t ' St. Bartholomew's Hospital Reports,' vol. xiv, 1879.
246 DISEASES OP OPTIC NERVD.
defective or absent from birth, several children of the same
parents are often affected, and there is frequently kinship
between the parents. Some of the patients are quite
idiotic from birth, others decidedly stupid or weak, though
some are quite intelligent. The discs may be healthy or
more or less atrophied. In the milder cases, when the
sight is not very bad, we often find total colour-blindness,
and it is probable that most cases of total congenital colour-
blindness are really instances of congenital disease of the
optic nerves.
Cases 17, 18, and 19 given below illustrate this irre-
coverable infantile amaurosis, and I may refer to
others.*
It is interesting to observe that in some of these irre-
coverable cases, although the child may seem to be abso-
lutely blind, the pupils act well to light ; this was so in Case
1 7, a perfectly blind youth of seventeen years old and good
intelligence ; the same is also noted in Case 19, an idiot of
twenty-one months old, apparently quite blind. In the
latter case the fact might perhaps be explained by the
retention intact of the reflex centre for pupillary action in
or near the corpora quadrigemina, although the higher
centres were wasted or atrophic. This supposition seems
borne out by a case published by Dr. Walter Edmundsf
of a totally blind idiot, aet. 2^, without definite ophthal-
moscopic changes, in which I had noted that the pupils
acted well to light. At the post-mortem Dr. Edmunds
found external hydrocephalus, the cerebral hemispheres
and optic thalami very small and ill-developed, but '^ the
corpora striata, cerebellum, and other parts of the brain
were normal.f'' On inspecting the specimen, which is
in the museum of St. Thomas's Hospital, I find that the
corpora quadrigemina are quite healthy looking and
plump, contrasting most markedly with the adjacent optic
thalami.
* Nettleship, * St. Thomas's Hospital Reports/ vol. x, 1880, and references
therein to Landolt and Bonders.
t Walter Edmunds, ' Path. Trans.,' xxxii, p. 4, (for 1881).
RECOVERY FROM AMAUROSIS IN YOUNG CHILDREN. 247
Returning to the subject of the paper. We may say
that recovery of sight is likely, though far from certain if
we get some such history as the following : — That the
child could see well till some months after birth, some-
times, indeed, for a year or more (Cases 4, 5, 6, 7), occa-
sionally as long as three years (Case 8), and that then
sight was lost during an illness with cerebral symptoms,
often diagnosed as meningitis. When the child has
become well enough it is brought because it cannot see ;
in some cases the blindness seems absolute, but in others
the child follows with its eyes a bright light in a darkened
room, although in ordinary light it does not notice objects.
I do not think much help is to be got from the pupils ;
they are often rather too large, but they act more or less
to light in the cases of imperfect blindness ; in one (Case 9)
the natural contraction during sleep was noticed to occur.
In the majority the ophthalmoscope shows either no
changes at all (Oases 1, 4, 5, 8, 9) or merely doubtful
pallor of the discs (Cases 6, 11, 12). In two (Cases 2,
7), one disc was very pale and suspicious of previous
inflammation, whilst the other was perfectly healthy ; and
in Cases 3 and 8 there was also some difference between
the two eyes. The child when brought generally seems
pretty well, though sometimes very fretful ; often, how-
ever, he is unable to stand or even to sit up, though he
may have learnt to run before the illness. Occasionally
the blindness is the only symptom that has been noticed,
and of this the two first cases, those just narrated, were
examples. I could not get either a syphilitic or tuber-
cular history in any large number of my cases.
It is impossible to say how long the blindness lasts,
but so far as can be ascertained it seems usually to be
from one to six months before improvement begins, and
recovery takes place rather slowly. In Case 8 the whole
process, however, did not take more than a month at
most, though severe convulsions, &c., occurred. In Case
10, altogether anomalous, complete blindness lasted only
five or six days, and there were scarcely any other
248 DISEASES OF OfTIC NEtlVE.
symptoms ; the case is given in detail below. Recovery
of sights more or less complete, was proved in Cases 1, 2,
4, bj 6, 7, 8, 9, 10. In two cases (Cases 11 and 12) a
cerebral illness occurred without subsequent improvement
of sight, and one of these (12) died shortly after she was
seen, but no post-mortem could be made. In another
(Case 3) the child was thought to see well till aged 5
months, when she became very nearly blind and remained
so ; she never learnt either to stand, sit up, or speak, and
was soon evidently idiotic ; later (about two to three years
of age), the left arm and leg became paralysed and con-
tracted, and the left disc, previously healthy like the right,
became atrophic. In Case 8 also the damage both to
limbs and eye was chiefly on one side (the left).
In regard to the local cause, we may infer that intra-
cranial inflammation certainly takes place, and perhaps
spinal mischief as well ; as evidence we have the extreme
weakness of the legs and back, which often remains long
after recovery from the illness and after recovery of sight
(Cases 5, 6, 7, 9). The arms do not seem to suffer, or if
they do, they recovery quickly. But before we can ex-
plain the mechanism of the blindness, ophthalmoscopic
examinations must be made in the early stage of the
blindness, and microscopical examination after death in
cases proving fatal while the sight is still lost. It is
possible, though unlikely, that papillitis occurs and quickly
passes off;* but if so there must be some other local
cause for the long continuance of blindness after the discs
have recovered, and perhaps this may prove to be pres-
sure by fluid in the ventricles. Such an accumulation of
fluid was found after death in several of Dr. Gee^s and
Dr. Barlow's cases of posterior basic meningitis before
* In a letter answering some questions about Case 12, below, Dr. David
Lees writes as follows : — " In cases of posterior basic meningitis (non-tuber-
cular), in which retraction of the head is a pathognomonic symptom, amaurosis
is not unfrequently present, often with pallor of discs, whilst papillitis is
exceedingly rare. In some of these cases perfect recovery of sight occurs,
but I have notes of one, at all events, in which the amaurosis continued after
recovery in other respects."
RECOVERY FROM AMAUROSIS IN YOUNG CHILDREN. 249
referred to. Mere pressure, however, does not seem to
afford a satisfactory explanation when either the ophthal-
moscopic change, or the recovery of sight, is unequal in
the two eyes, or when hemiplegia is observed on the
same side as the more affected eye (Cases 2, 3, 7, 8, 9).
The following are the cases (in addition to the two
already detailed) on which the foregoing remarks have
been based :
Case 3. Failure of sight at age of five months {?) j pre-
mature closure of fontanelles ; no ophthalmoscopic change.
Later J idiocy ; paralysis of left limhs and pallor of left disc ;
? improvement of sight. — (T. 1, 210.) Frances U — , brought
to St. Thomas's Hospital July 24th, 1878, ^t. 16 months.
Youngest of two children ; the eldest is alive and well.
Is believed to have seen well till age of about five months.
Has had no fits ; seldom cries but sometimes starts,
Fontanelles are said to have closed very early. No con-
sanguinity in parents, and no known history of idiocy in
family. Patient is well grown and placid. Cranium
rather small across the temples and the sutures ridged ;
cannot stand, sit up, or speak. It is doubtful whether
she perceives light -, other senses good. Pupils not noted
till after atropine, when they were well dilated. Oph.
quite negative.
September, 1880. — (Aged 3^). Cannot speak, feed
herself, or walk, but screams when interfered with ;
cranium does not seem very small. Right hand strong
and she kicks with right leg ; but left hand is kept flexed
and ^left leg hangs limp ; she has '^ a sort of little fit
when she opens the left hand and stretches herself.'^ Is
very constipated and lives chiefly on brown bread and butter.
Oph. (examination under chloroform), both discs normal.
Another child has been born since former visit, and is
healthy.
February, 1882. — (Aged 5). Quite idiotic ; good
tempered ; hears well and makes noises, but cannot speak
or stand ; limbs in same state as at last note and still has
250 DISEASES OP OPTIC NERVE.
the ^^ little fits.'' Now evidently has some sight for she
looks promptly at the light with each eye separately.
Pupils too large^ but both act quite decidedly and sepa-
rately to light. Oph.^ right optic disc quite healthy, of
good colour and not too sharply defined ; left disc much
clearer and greyer, evidently partly atrophic.
In this case I have no note as to syphilis.
Case 4. Failure of sight with fits and vomiting at seven-
teen months old- ; no ojohthalmoscopic changes ; rajpid im-
provement of sight i no evidence of syphilis. Death of pre-
vious child from ^' fits J' — Joseph Gr — , set. 18 months, was
brought to St. Thomas's Hospital on December 18th,
1881. (T. 4, 14.) He looked healthy but was fretful;
head well formed and neither large nor small ; fontanelles
closed. The pupils were of ordinary size and acted well
to light, though the child took but imperfect notice even
when bright light was suddenly thrown into his eyes.
The eyes were examined after atropine and under chloro-
form, but no changes could be made out.
The child was suckled for fifteen months, had begun to
speak and to run about, and had had no children's com-
plaints, when, about a month before admission, he had
four or five fits within a fortnight. He was ill and
vomited a little between the fits ; when he got better, a
fortnight before admission, his mother found that he
seemed blind and had become very fretful. His sight
and his temper had previously been good.
A month after admission (January 17th, 1882), he
evidently saw better, took notice of the light quite well,
and sometimes seemed to see large objects.
The patient was the youngest of five, all born alive ;
the fourth died at a year old of '^ fits ; " the third of
scarlet fever at three years ; the two eldest were living.
There was no obvious history or evidence of syphilis.
Both pareixts were alive and well ; a sister of the father
died of ^' consumption.'^
RECOVERY FROM AMAUROSIS IN YOUNG CHILDREN. 251
Case 5. Blindness during severe cerebral illness, probably
meningitiSf at age of fourteen months , followed by prolonged
weaJcness of legs and irritability of temjoer ; no ophthal-
moscopic changes ; recovery of sight. — Greorge H — , 83t.
16 months, was sent to St. Thomas's Hospital by Dr.
Purkiss, of Brentford, who has favoured me with the fol-
lowing information as to the previous part of the case :
On June 26th, 1883, Dr. Purkiss was sent for and
found the child ill with constipation and frequent vomit-
ing, but with no characteristic symptoms of meningitis.
On July 4th he was worse and emaciation well-marked.
Dr. Purkiss diagnosed tubercular meningitis.
On 19th and following days he was extremely low, much
emaciated, and had some slight convulsions with clenching
of hands and turning of eyes. He continued in a very
critical state for about a fortnight, but gradually rallied
under the very frequent use of concentrated liquid food
and stimulants. As soon as consciousness returned the
child was found to be '^ blind.'"' In reply to further
inquiry. Dr. Purkiss writes that for about three weeks of
the illness there was marked retraction of the head and
rigidity of the muscles at the back of the neck. Tem-
perature not recorded.
The child was brought to me on August 30th (two
months from the onset of the illness), because he was
believed to be blind. He had then regained his usual
health, except that he was still fretful, that he could not
stand, and could not see. He took no notice of ordinary
things, but when the light of the lamp was thrown into
his eyes by the mirror, he generally looked at it and
began to cry. Pupils rather large (about 5 mm.), but
contracted a little to light. Before the illness he had
been good-tempered and able to run and to see well.
Though so fretful 1 found that he was at once and per-
fectly quieted by the jingling of a bunch of keys ; and
the fundus, examined at leisure with this help, was found
perfectly healthy in each eye. I have never seen a baby
quieted in such a very marked way by sound, and the
252 DISEASES OP OPTIC NERVE.
fact is the more curious as the effect of the ophthal-
moscopic light without the sound was to make him cry.
There was nothing particular in the appearance of the
child j the head was of ordinary size, the fontanelle not
quite closed. No signs or history of syphilis. No his-
tory of fits. Three weeks before the illness began he
fell out of bed and hit his head, but nothing was thought
of the occurrence at the time.
Ordered a grain of mercury and chalk twice a day.
September 13th. — Much better in health and temper.
Sight seems unaltered.
October 8th. — Sight much improved ; mother thinks he
can now see as well as most children.
30th. — Seems to see quite well ; pupils act well to light,
but are larger than is usual at his age. Disc well seen
in one eye, and is quite healthy. Is beginning to stand
again, but cannot do so without being held. Has cut four
double teeth since admission.
August, 1884. — I have heard since the above was
written that the child remains well.
Case 6. Blindness during severe cerebral illness, probably
meningitis, at the age of tivelve months ; blindness and,
weakness of legs remaining six months later ; complete re-
covery of sight. — Bathsheba D — , set. 18 months, was sent
to me by my then colleague, Dr. Lubbock, at the
Hospital for Sick Children (p. 62).
She was the youngest of five children, all living, and
there had been one miscarriage. No history pointing to
syphilis in the family. One of the other children had
'' consumption of the bowels,^' but recovered ; the maternal
grandfather died of *' consumption '' get. 38.
The patient, who was suckled, was perfectly well till
twelve months of age, and had begun to walk and talk
when she was taken ill with what the medical attendant
(Dr. A. r. Stevens) considered to be undoubted menin-
gitis. According to the mother the child was *^ insensible^'
for three months, and used to lie quiet ^^ as if dead,''
RECOVERY FROM AMAUROSIS IN YOUNG CHILDREN. 253
but " never lost her hearing^'; there were no convulsions.
Though she could hear, the mother found early in the
illness that she could not see, and the blindness remained
after the child had recovered in most other respects.
Her speech returned early.
When Dr. Lubbock sent her to me on June 14th, 1882,
she was eighteen months old, a fine, fat, good-tempered
baby with sixteen teeth, and still at the breast. The
mother said the child had quite regained her intelligence,
but was only just beginning to get back the use of her legs.
Head rounded ; anterior fontanelle, situated on the top of
the cranial arch, still open. Had been ^^ blind ^' for six
months, but as she sometimes looked at the ophthalmo-
scopic mirror during examination in the dark room she no
doubt had some perception of light. Pupils usually got
smaller when she looked at the light, but did not always
dilate when covered. I could not tell satisfactorily whether
their action was reflex or only associated with movements
of the eyes ; they dilated to 6 mm. under atropine. Oph.,
discs rather pale, central vessels normal, no other changes.
July 18th (five weeks later). — Mother thinks child has
begun to see a little for about the last three days. She
now, on trial, seems to follow objects if placed in the
middle of the field of vision.
August 1st. — Seems to see better. Pupils now act well
to light.
July, 1884. — Now 83t. SJ ; very intelligent and good-
tempered, but excitable. Walks and runs well, can see
perfectly so far as can be ascertained, and has been able
to do so for about eighteen months ; sight was very bad
for about nine months, and then returned gradually and
was as good as it is now about twelve months after the
illness began.
Further particulars of the illness and recovery. — Hlness
came on suddenly with sickness one night ; had no
previous warning except that she had stopped growing for
three months before. Was insensible for at least three
months, quiet, never crying, and unable to suck because
254 DISEASES OP OPTIC NERVE.
jaw dropped. First sign of recovery was that she started
at noises ; next she regained speech. Was '^ paralysed '^
in legs and back for a long time ; recovered very gradually
and could not walk again well, until a few months ago,
though she had been able to sit up for some time before.
Has had measles and bronchitis since the meningitis.
Case 7. Fits and vomiting a few weeks after scarlet fever
at the age of fifteen months ; blindness and- prolonged
weakness of legs ; gradual recovery of one eye ivith healthy
disc ; blindness of other eye with atrophy of disc twelve
months later. — Charles M — had scarlet fever when fifteen
months old ; the other children in the house had it at the
same time. He was not thought dangerously ill by the
doctor. Three weeks after recovery he began to vomit,
and continued to do so during the next fortnight, after
which he had a number of fits during about a month ; he
became stiff in the fits. He became blind sometimes
during the fits. The mother gave some account of swelling
of the right hand and arm at about the same time.
He was brought to St. Thomases Hospital in February,
1881 (T. 3, 153), five months after the scarlet fever. He
was then twenty months old, and though looking well was
very fretful. He could use his hands well, but could not
stand. He did not take the slightest notice of the light
from the ophthalmoscope mirror in the dark room. Pupils
quite motionless and dilated (about 6 mm.). Oph., left
o. d. quite healthy, central vessels normal ; right o. d.
rather pale, decidedly different from left, vessels normal.
Before the illness he had been able to stand.
February, 1882 (twelve months later). — Can now see
very well with left eye and has been able to do so for
several months ; can pick up small things with this eye
open ; o. d. normal. Right eye seems quite blind when
tried with left covered ; o. d. very pale and rather hazy.
Pupils not noted. Is well ; talks and uses his hands well,
but has not regained power of standing.
RECOVERY FROM AMAUROSIS IN YOUNG CHILDREN. 255
Case 8. Blindness ivith paralysis of left arm and leg,
following convulsions, vomiting, and unconsciousness of a
wee¥s duration, at three years of age ; recovery of sight
first in right eye, then in left ; permanent weahiess of left
arm ; no ophthalmoscopic changes. — Ada K — , aet. 4>, was
brought to St. Thomas's Hospital on May 24th, 1883, with
the following history : She had had good health (with
the exception of an attack of chicken-pox at the age of
two) till ten months before admission, when one Saturday,
as she seemed '^ feverish," her mother gave her a powder
at bedtime. Next day (Sunday) the child vomited several
times, and in the evening went off in a fit and was con-
vulsed for ten hours. After this she was unconscious
(*^ did not know anyone '') for a week. When she came
to herself again she was blind of both eyes and unable to
use the left arm and leg. When there was a light in the
room she would say it was dark, and when they told her
there was a light she would ask where it was. The
mother believes that the sight of the right eye soon
returned, for before long she found out by trying one eye
at a time that the child saw with the right and not with
the left. Even the left (worse) eye got to see again in two
or three weeks.
When I saw the child she appeared to see quite well
with each eye, picking up pins readily when either eye
was covered ; the pupils were active to light, and the
fundus (examined under atropine) showed no changes in
either eye. The left arm was still weak, and it shook
when she tried to use it, and she was lame of the left leg.
The child was the fourth of six ; she had chicken-pox
two years before, and measles several months after the
attack above described. No history of characteristic
syphilitic symptoms. The first child (male) died at two
years of '^ consumption,' ' second (male) died at eleven
months, '^ consumption and water on the brain," third
(female), set. 10, is delicate, and has been under treatment
at Brompton Hospital ; fifth, miscarriage ; sixth (female),
set. 2J, in good health. Parents living ; the father had
256 DISEASES OP OPTIC NERVE.
lost two brothers, two sisters, and his own father of con-
sumption ; the mother lost a brother by the same disease.
In this case it is, of course, impossible to say that
papillitis did not occur and end in rapid and perfect
recovery.
Case 9. Blindness during illness ^ ''basic meningitis/* at
10 months old ; slow recovery of sight in left eye, doubtful
improvement in right ; toasting of right side of face ; no
ophthalmoscopic changes ; prolonged weakness of legs and
back. — Ada Knight was well till niue months of age, then
she became ill and was " insensible " for a week, and
during the illness became blind. She was admitted at
the Hospital for Sick Children under my then colleague
Dr. Bridges, who diagnosed '' basic meningitis,'^ and after
a time transferred her to me on April 5th, 1881.
My notes are substantially as follows (p. 23) : She is
now twelve months old, head enlarged, and fontanelles very
widely open. " Has been blind about two months,'^ no
other note as to vision. Pupils are partly under atropine.
Oph., right o. d. slightly pale, but quite clear, left o. d.
normal ; refraction H. in each. To take cod-liver oil and
mercury and chalk.
May 10th. — No change.
June 14th. — Much better in health and more lively ;
head no larger. Pupils now act well to light when child
is awake, they are small during sleep and dilate naturally
as she wakes. Oph., same.
July 25th. — No change. Cannot sit up.
October 13th. — Mother says child has been able to see
for a month past, but she thinks right eye does not see so
well as left. On trial with both eyes open the child evi-
dently sees an object held straight in front of her ; she
seems not to see it so well in the lower part of the field.
Fontanelles smaller, but not closed. Can now sit up better,
but cannot raise head when lying down, and has not the
least power of standing.
January 10th, 1882. — Still cannot raise her bead when
RECOVERY FROM AMAUROSIS IN YOUNG CHILDREN. 257
lying down, cannot stand, but has improved in health and
general strength.
February 7th. — Sees a threepenny-bit quite well. Has
begun to talk, and is stout and good-tempered. Anterior
fontanelle nearly closed. Uses both hands well, but cannot
stand. Right side of face is smaller than left, and right
eye (thought to be the worse of the two) sometimes
deviates outwards and upwards. Pupils act well to light.
Oph., left o. d. (better eye) now thought to be clearer and
more grey than right (note made before referring to note
of former examination).
October 31st. — Still cannot walk or get up if lying
down, but talks well, can repeat some verses, and is quick
at imitating people. Can see to pick up a pin. She
fixes with both eyes when looking attentively, but the
right often deviates as at last note, when her attention is
not roused. Reflex action of ps. full and brisk.
Case 10. Rapid and complete hliyidness with dilated
pupils in a child of three and a half years. No ophthal-
moscopic changes. Complete restoration of sight in tivo to
three weeks. No marked cerebral symptoms. Old rickets.
— Thomas B — , aet. 3^, was sent to St. Thomas's Hospital
on May 18th, 1880, by Dr. Bott, and the following his-
tory was obtained :
The child has been pretty healthy except for hooping-
cough and bronchitis when a year old, and occasional
attacks of sore throat since. Had rickets badly, and there
is still slight bowing of the tibia3 and beading of the ribs.
Has had no fits.
For the last six weeks has not seemed well ; has been
drowsy and listless, and has ground his teeth. No history
of injury to the head. On the night of Friday, May 14th,
he suddenly screamed. Nothing particular was noticed
on 15th, but on Sunday 16th towards midday his mother
noticed that his eyes looked ^^ peculiar,' ' and the child
said he could not see properly ; by evening he was so
nearly blind that he could only just tell where the window
VOL. IV. 17
258 DISEASES OF OPTIC NERVE.
was. The next day his parents thought he was totally
blind, and the father, an intelligent man, noticed that the
pupils were large and did not act when exposed to the
light. He was brought to the hospital the following day.
Condition on admission 2 'p.m. on Tuesday j May 18th. —
An intelligent quiet child ; walks well ; slight bowing of
tibiae, ribs beaded ; head flat and square, a depression
between the frontal eminences, a ridge along the sagittal
suture. He appears, on careful trial, to have no percep-
tion of light j pupils large (right 6 mm., left 5 mm.) ; they
seem to act a little to light, but he is difl&cult to test. Oph.,
appearances normal, except doubtful haze at (real) upper
border of right o. d. Ordered three grains of iodide of
potassium and two grains of grey powder each thrice
daily.
21st. — Oph,, still normal. Temperature at 3.30 p.m.
99-6° F.
25th. — For the last three days sight has been returning,
and parents have noticed that pupils have acted to light.
He now evidently sees all ordinary things fairly well, and
goes about the room without knocking against things ; he
called attention to a gaspipe on the wall. Pupils now act
freely to light, but right is still rather larger than left.
28th. — Sight still imperfect ; can see people, but has to
be told in which direction to look for them.
June 1st. — To-day can see to pick up a pin; and sees
a shilling. Oph., still normal.
15th. — On the 10th, at breakfast, he vomited, and
afterwards got drowsy and slept half the day. Now,
appetite bad ; bowels open three times a day, stools pale.
Oph., still normal. Omit the iodide, continue the grey
powder.
July 23rd. — Is still '' peculiar ^' in his manner. Con-
tinue grey powder; to take also steel wine.
October 15th. — Has attended only once since last note.
Is now quite well and sees perfectly.
Family history. — The patient is the seventh of eight
children ; the youngest, like the patient, is rickety. The
RECOVERY FROM AMAUROSIS IN YOUNG CHILDREN. 259
first died at eight years old of broncliitis after hooping-
cougli ; the second of *' consumption of the bowels and
bronchitis ^' at nine months ; the third of '^ croup '^ (age
not stated) ; he was also rickety. There has been one
miscarriage. The other three children are said to be
healthy. The father denies ever having had any venereal
disease.
In this puzzling case I had the assistance of my
colleagues Dr. Payne and Dr. Barlow, neither of whom
could find in the patient any signs of brain disease.
Dr. Barlow thought the head rickety. The urine
unfortunately was not examined ; but there was no
reason for supposing it unhealthy, and certainly none
whatever for ascribing the blindness to ursBmia. Com-
pression of the chiasma by rapid temporary effusion into
the third ventricle seems to offer almost the only explana-
tion of the ocular symptoms, and it might perhaps account
for the drowsiness and other slight symptoms which lasted
for several weeks. I do not, however, know whether we
are justified by pathological knowledge in assuming that
such effusion might occur, and, after remaining a few
weeks, be completely removed.
August, 1884. — Child, now set. 7, is quite well, and
sees perfectly. Goes to school. Oph., o. d. very
clear in each eye, almost too clear, and perhaps rather
pale.
Case 11. Blind^iess during acute illness , pr oh ahly menin-
gitis at 6 months old. Doubtful pallor of discs, no im-
provement in six months. — Walter C — , set. 9 months, was
sent to the Hospital for Sick Children by Dr. Piggot, of
Beckenham, in March, 1881 (p. 13). The child saw well
till an illness which began in December, 1880. Dr. Pig-
got then found him extremely restless, with twitching of
limbs, rolling of head from side to side, and temperature
103° F. ; during January he had three severe convulsions,
and at Dr. Piggot^ s next visit after these the child was
found to be blind (took no notice of the gaslight, &c.).
260 DISEASES OF OPTIC NERVE.
On admission (March) the child seemed by the usual
tests quite blind, pupils not noted, oph._, o. d. pale but
clear in bofch eyes, retinal vessels normal, no other changes.
Fonts nolle large.
Patient is youngest of seven living children ; all are
reported in good health. There were, besides one mis-
carriage, one child which died a few hours after birth, and
one which died at five months in convulsions after three
days' illness.
July 26th. — Still takes no notice. Pupils of ordinary
size (action not noted) . Oph., left o. d. clear, perhaps too
grey ; vessels normal. Right o. d. not seen. Head no
larger, fontanelle still open, is very fretful. No later
information obtainable.
Case 12. Failure of sight at age of 4 months, (?) after a
long series of fits dating almost from hirth. Discs normal
{? grey). Death soon after admission. — Daisy G — , was
sent to me for examination by Dr. David Lees when five
months old, on July 18th, 1882. The mother thought
the child had been " blind '' for about a month, but
admitted that she looked at the fire and the sunlight.
She took no notice of objects in daylight, but in the
dark room she followed the light of the mirror accurately
with the left eye, but less uniformly with the right. The
pupils were of ordinary size, certainly not too large, they
became distinctly larger when shaded, and contracted
again when exposed ; under atropine they dilated to 5*5 or
6 mm. The discs were sharply defined, perfectly clear, and
rather pale or grey, '^ as I think babies^ discs often are ''
(note made at the time), the vessels were normal, and no
changes were found in other parts of the fundus. Head
of ordinary size, fontanelle perhaps too small.
The patient was the sixth child and born at full time ;
would not suck, and had to be brought up by bottle.
When a day old she began to have very numerous fits,
being especially convulsed on the left side, followed by
general spasmodic twitchings.
RECOVERY FROM AMAUROSIS IN YOUNG CHILDREN. 261
On admission in March, Dr. Lees noted '' discs normal ;"
later, *' slight retraction of head j'^ at age of 1 1 weeks,
"pupils equal; no paralysis or strabismus."
The two children before the patient died at ten and
eleven months old of measles and hooping-cough. The
patient was the only one who had had fits.
Early in the mother^ s pregnancy with the patient she
was much upset by the death of the fifth child from
measles, but she was not definitely ill. I could not find
any other facts of importance in the history. The child
died a few days after her last visit to the hospital, but the
fact was not known to us till a year and a half after-
wards.
Case 13. Amaurosis from birth in an infant; post-
papillitic atrophy of discs ; no history of cerebral symptoms
or of syphilis ; no recovery of sight. — Susan S — , set. 14
months (Hospital for Sick Children, March, 1881 p. 20).
Mother married two years, only one pregnancy. Father
healthy. No consanguinity. No known neuroses.
Has never taken notice. No fits or illness. No (in-
direct) history of syphilis except that she had a very little
thrush round anus.
March 29th, 1881.— Child is considered intelligent (?).
Is pale, thin, ill-fed, fairly good-tempered. Fontanelle
very little open. Pupils usually rather large (about 4
5 or mm.), apparently do not act to light, but act
with movements of eyes. Oph., discs very grey and
decidedly hazy, (?) swollen ; retinal veins enlarged ; no
other changes.
February 25th, 1882. — Takes no notice; pupils 4 mm.,
they act irregularly, but probably only from association
with the ocular movements, not from effect of light; they
dilate to 6 mm. under atropine. Eyes roll about irregu-
larly, but usually look down, and upper lids droop over
them. Child is passionate but intelligent ; she constantly
kneads her eyes with her fists. Can talk and walk well ;
nothing special about the cranium. Discs (seen only for
262 DISEASES OP OPTIC NERVU.
a moment at a time), hazy and of dirty yellowish grey
colour ; retinal vessels seem normal ; choroid surrounding
discs much paler than elsewhere ; rest of fundus normal
so far as seen.
This case is incomplete ; but it is interesting as papil-
litis had evidently occurred, possibly before birth.
Case 14. Blindness with doubtful pallor of discs coming
on at about three months old, during illness with convulsions ;
syphilis probable. — George Gr — , set. 5 months (Hospital
for Sick Children, May, 1881, p. 28). Mother says he
could see well till a month ago, when he had convulsions,
and was ill and languid and got blind. Has had snuffles
and an eruption of spots. Patient is the second born ;
first (born nearly five years ago) died at three months of
convulsions. No history of syphilitic symptoms in either
parent.
May 10th. — Takes no notice. Pupils not noted. Oph.
(after atropine), o. d. rather pale and doubtfully hazy,
vessels normal.
No later note ; patient could not be traced.
This child was only seen once ; the notes are meagre,
and, especially in regard to syphilis, are inconclusive.
Case 15. Defective sight without changes in an infant;
history incomplete ; result unlcnown ; no evidence of syphilis,
— Alfred F — , aet. 8 months, was brought to the South
London Ophthalmic Hospital in December, 1874. His
mother said that he would not ^' take notice,'' but the notes
do not state how long this symptom had been present. The
pupils were of ordinary size (their activity not noted).
The child looked at the lamp, but not promptly. After
atropine, the discs were " perhaps pale, but perfectly
clean, and the central arteries and veins normal ; " no
disease was made out in other parts of the fundus.
The child was the younger of two, the elder being alive
and reported well. But for doubtful snuffles there were f
no signs of syphilis.
fiECOVEHY FROM AMAUROSIS IN YOUNG CHILDREN. 263
He was only brought twice, and there are no subsequent
notes.
Case 16. Advanced atrophy of discs in a hoy of ten j
history of bad sight from infancy j hereditary syphilis in
an elder sister. — Wm. W — , aet. 10, but looking only 7,
the fourth of eight children, was brought to St. Thomases
Hospital in May, 1878 (T. 1, 64), almost absolutely blind
of both eyes. The discs were atrophied, of a greyish-
white colour, clear and sharply defined ; the central veins
normal, the arteries rather small. There was no proof
of previous papillitis. The left pupil was the larger and
quite motionless to light ; the right acted a little.
The statement given was that he had always been very
backward at school "because he could not see.^^ His
senses, except sight, were good ; his memory was said to
be good ; his temper was '^ very uncertain.^' He had
very bad health in infancy, but there was no history of
characteristically syphilitic symptoms. Nor was there
any proof in his teeth or physiognomy. But it should be
mentioned that a sister three years his senior was after-
wards under care with interstitial keratitis and very
typically notched teeth.
Though his sight had always been thought defective it
had become much worse since the previous November, i.e,
for about six months before I saw him.
Although the origin of the blindness was not in this
patient proved to date from infancy, the case may fairly
for the present be placed with the others in this
paper.
Case 17. Blindness from birth; active pupils; no
changes at optic disc, but peculiar superficial changes in
choroid ; conical cornea. Family history of had sight ; con-
sanguinity of parents. — Edward C — is believed to have been
born blind, and is in the South wark Blind School. He was
brought from there to St. Thomases Hospital in July, 1880
264 DISEASES OF OPTIC NERVE.
(T. 3, 100), for aching of the right eye, and on examination
the cornea was found to be very conical, and its centre
nebulous ; these appearances had been noticed for some
six months. He had been in the school a year. He was
intelligent, and all the senses except sight were good ; he
was growing fast.
There was nystagmus, and he had no perception of
light whatever so far as we could judge, yet the pupils
acted pretty briskly to light and shade in the ophthalmo-
scope room, where the contrast was very strong ; in day-
light, with much less contrast between the light and shade,
they acted scarcely at all ; in daylight they measured
about 2*5 mm. T. n. Oph., o. d. and retina normal in
each eye ; doubtful diminution of retinal arteries. At the
periphery in each the choroid showed a number of small
pale spots, a sort of '' dappled ^' appearance. This change
in the superficial choroidal structures (or retinal epithe-
lium only ?) may have been induced by retinal atrophy,
itself secondary to disease of the optic nerves ; or it may
have indicated a congenital defect in the development of
the retina and choroid. The healthy appearance of the
discs does not bear out the former view.
Family history. — Is the seventh of eight children, and
two others have bad sight. The parents were first
cousins, father is living, mother died of ^^ rheumatism at
the heart. ^^ No history of blindness, or of nervous affec-
tions or idiocy, in other branches of the family. The family
was as follows :
1 . Male, aet. 29 ; nearly blind, but can tell colours, was
born so.
2. Female, ast. 27 j ^' near-sighted, but can see a great
deal.''
3. Female, died aet. 22, of " consumption.''
4. Female, comes with patient ; sight perfect.
5. Male, sight perfect.
6. Male, died aet. 18, of '^ consumption."
7. The patient.
8. Female, sight perfect.
RECOVERY FROM AMAUROSIS IN YOUNG CHILDREN. 265
Case 18. Congenital amblyopia with doubtful changes at
discs ; defective intellect ; family history of blindness ;
consanguinity of parents. — Cyril G — , aet. 12 (St. Thomas's
Hospital, September, 1881, T. 3, 190).
Has never seen better than now ; had good health till
mild scarlet fever at age of 8, since then has been weak.
Has lately been under treatment in the surgical wards for
contraction of plantar fascia of right foot which seems to
have begun, or become worse, about a year ago. Is half
imbecile. Constant rapid nystagmus. Pupils act mode-
rately to light. Oph., little if any change (discs
greyish ?) ; refraction slightly M., V. 19 J. at ^" . Colour
vision cannot be properly tested.
Family history. — Parents are first cousins, but see
well. Mother's father had an eye removed for " tumour
of the eyeball'' at age of 54, and lived to be Q1.
Father's brothers and sisters, and their father (patient's
paternal grandfather) were all ^' very short-sighted."
Patient is seventh of ten children, as follows :
1. Male, aet. 22 -, sees well ; good health.
2. Female, set. 21 ; sees well, but '^has one eye blue,
the other brown ;" good health.
3. Male, died set. 2^ of ^' croup ;" was very nearly
blind.
4. Female, died aet. 14 of typhoid fever; sight perfect.
5. Male, aet. 17; seen. Hypermetropic; left eye
defective from old squint.
6. Female, aet. 14, sight and health good.
7. The patient.
8. Female, aet. 9, sight good.
9. Male, died aet. 6 weeks of hooping-cough.
10. Male, aet. 4, sight defective. Not seen.
Case 19. Congenital blindness and idiocy with active
pupils ; fits from early infancy ; contraction of feet and one
hand; death. — Jessie M — , female, was sent for opinion
to me at St. Thomas's Hospital in the summer of 1881 by
Dr. Chabot (T. 3, 43). She was then nearly two years
266 DISEASES Of OPTIC NERVE.
old. She was evidently idiotic, and could neither walk
nor speak ; she kept the fingers of the right hand in the
" accoucheur^s position " and the hand itself flexed on the
forearms ; both feet also flexed. Nothing special in
appearance of head. Had never taken notice. When four
months old began to have fits, and was still liable to
them.
On admission, she took no notice of light or shade, and
never followed even the light from the mirror in the dark
room, but sometimes just when the light was flashed into
her eyes she would turn her head away as if annoyed by
it. Probably, therefore, there was some perception, at
least in the lower optic centres ; and this was confirmed
by the fact that the pupils, which usually measured about
4 mm., acted well to light. Ophthalmoscopic examina-
tion, after wide dilatation of the pupils by atropine, showed
no changes except a single small spot of pigment near the
disc in one eye ; the discs and retinal vessels were well
seen and quite natural.
She was the youngest of ten children, eight of whom
were living, healthy, and intelligent. Family history not
fully taken.
I heard from the mother that the patient died a few
weeks later without showing any peculiar symptoms.
{June 1th, 1884.)
5. Injury to the head ; immediate and permanent blindness
of the left eye and deafness of the right ear j subsequent
atrophy of the left optic disc.
By Waren Tay.
John P — , set. 40, was admitted into the London Hos-
pital, October 25th, 1883. He was standing on a ship's
deck and was knocked down into the hold by a cask
INJURY TO HEAD. 267
which was being let down. He fell on some casks, a
distance of about twelve feet. He fell on to his head.
He was unconscious about three quarters of an hour.
Patient was conscious on admission. Blood was oozing
from the left nostril and the right ear. The left pupil
was noticed to be insensitive to light. There was no
facial paralysis and no other paralysis. He was sick and
brought up blood-stained fluid. There was a semicircular
laceration of soft parts in the left fronto-temporal region
above and to the outer side of the orbit. The wound
was stitched with catgut. The bone was not bare.
There was a fracture of the lower jaw on the right side
between the lateral incisor and the canine teeth. There
was slight ecchymosis of the upper eyelid (left), but no
subconjunctival ecchymosis. There was no serous dis-
charge. The haemorrhage from the ear soon ceased.
October 27th. — Left side of face slightly swollen.
Left upper eyelid somewhat swollen. He cannot see the
light of the lamp. The pupil dilates when the other eye
is covered and remains fixed. It acts with the other.
The fundus is normal. There is pigment at the inner
margin of the disc in each eye. He is quite deaf in the
right ear.
November 12th (eighteen days). — Left disc paler than
right.
18th (twenty-four days). — The left disc is now certainly
becoming pale, especially towards the yellow spot. There
is, however, a decidedly pink tinge on the inner side.
No appreciable diminution of artery. Pressure on the
globe gives rise to well-marked arterial pulsation.
December 13th. — He says he can hear a watch tick
when held quite close to the right ear, but without absolute
contact. This, however, is not very certain.
It is now seven weeks since the accident. The disc is
uniformly white. Atrophy is commencing. Both discs
are pigmented at the margin ; the right more than the
left. These changes were noted from the first.
Leber and Deutschmann (' G-raefe's Archiv,' Bd. xxvii,
268 DISEASES OF OPTIC NERVE.
Abth. 1, 1881) note the case of a lad, set. 15, who was
admitted into the Gottingen Hospital after a fall of twenty
feet. He immediately became blind in the right eye, was
unconscious for a short time and bled from the nose,
mouth, and left ear (there was also fracture of the left
radius and effusion into the left knee). Two days later,
the lids of the right eye were swollen with blood effusion
and the eye became slightly prominent. There was some
ptosis and slight paresis of the superior rectus. The
fundus of each eye appeared quite normal on ophthal-
moscopic examination. After fourteen days, the first
slight trace of pallor was noticed in the right optic disc.
At the end of three weeks it was undoubted, though still
slight. He could not hear well with the left ear (noticed
at first). The right disc subsequently became markedly
atrophied. He was seen five years later and the vessels
still seemed normal in size. This last feature is commonly
noted whenever a patient is seen after a long interval
who has been the subject of simple atrophy from injury.
Loss of sight in one eye in connection with an injury
to the head on the same side has become more explicable
of late (as is well known), since the observations of
Holder quoted by Berlin (G-raefe-Samisch).
Fracture involving the apex of the orbit is now known
to be sufficiently frequent to allow us to quote the proba-
bility of its occurrence in explaining the symptoms in
any particular case. In fifty-four out of eighty-eight
instances of fracture of the base of the skull there was
injury to the optic foramen, and in eighty out of the
eighty-eight there was fracture involving some part of
the orbit. This proportion seems very much larger than
would be found in any post-mortem room in London. It
should be borne in mind that in forty-two instances out
of the fifty-four the injury had been from gunshot, and
in thirty-four the injury was inflicted through the mouth.
There can be no question, however, that the explanation
of immediate one-sided blindness after some injury to the
skull, mostly the anterior part, on the same side is to be
CONCUSSION OF THE BRAIN. 269
found in damage to the nerve in connection with a fracture
involving the apex of the orbit.
That the disc shows no change at firsts but begins to
be decidedly pale in about three weeks has been noted
now by various observers in a number of cases.
The only special interest attaching to the patient now
shown is the fact that there is probably a diagonal frac-
ture as was surmised in Deutchmann^s case, involving one
orbit and the opposite petrous bone.
{Living specimen. December 13thj 1883).
6. A case of severe concussion of the hrain followed by
temporary blindness luith papillitis and anosmia.
By W. Spencer Watson.
Henry D— , aet. 18, a potman, after a severe drinking
bout threw himself out of window and fell a distance
of forty feet on to some gravel, striking his head on an
iron bar in his descent. He was picked up unconscious,
and when brought into the Great Northern Central Hos-
pital was still unconscious, and I am indebted to the
house surgeon of that institution for the notes of the
case. He had a wound of about two inches long in a
vertical direction on the forehead. This wound exposed
the bone, but there was no depression. There was
bleeding from the nose and mouth. The eyelids were
swollen and the left eyeball seemed somewhat more
prominent than the right. There were also severe bruises
of both elbows and a fracture of the left clavicle.
Symptoms of concussion being present (on April 24th)
he was put to bed, an ice-bag was applied to the head,
the scalp wound dressed, and the fractured clavicle put up
in the usual manner. Eight grains of calomel were given
and a senna draught ordered to be taken in the morning.
270 DISEASES OF OPTIC NERVE.
For the next three days he was in violent delirium,
sleepless in spite of the use of opiates, bromide and chloral
in large doses, tearing off all his dressings and bandages,
and complaining loudly of severe pain in his head.
On April 27th he seemed a little more conscious, having
slept a little. The eyelids were still oedematous and some
subconjunctival and subcutaneous ecchymoses were noticed
at the upper parts of both orbits, the discolouration not
extending into the lower eyelids.
April 30th. — Vision tested. No response to simulated
aims with the fingers pointed at his eyes. He seems blind
absolutely. Pupils half dilated and not responding to the
stimulus of light.
May 4th. — Much more conscious this morning, complains
of his head still. Has lost the power of smell. On oph-
thalmoscopic examination of the eyes the optic nerves
showed traces of engorgement.
5th. — The sight has somewhat returned, but he cannot
distinguish colours and still has a vacant stare.
18th. — The optic discs had the same appearance of
engorgement, the margins being swollen and shaded off
into the surrounding fundus. Has no pain in the head.
20th. — Still better ; sight much improved.
24th. — Ophthalmoscopic examination revealed no abnor-
mal condition ; sight much improved. He can now read
small print.
29th. — Says his sight is as good as before the accident.
He feels well with the exception of the loss of smell.
June 4th. — Discharged. There is still anosmia. His
sight is not quite so good as on the 29th May.
The blow on the head seems to have ruptured some
vessels in the base of the cranial cavity, and judging from
the ecchymosis in the upper part of the orbits it is pro-
bable that there was a fracture in the anterior or middle
fossa or in both.
On account of the patient's violence and the swelling
of his eyelids no attempt at an ophthalmoscopic examina-
tion was made for about ten days. At the end of that
CEREBEAL HAEMORRHAGE. 271
time traces of choked disc were found indicating pressure
upon the optic nerves. Both being affected at once and
both recovering about the same time we may conclude
that the pressure was intracranial and at or beyond the
commissure. The loss of smell points to a lesion due to
the same hasmorrhage and causing a separation of the
olfactory filaments from the olfactory bulbs.
Anosmia from blows on the head is not very uncommon,
but it has been noticed to follow blows on the occiput
more frequently than blows on other parts of the head.
This was pointed out by the late Mr. Hilton, and also by
Dr. Wm. Ogle.
[July 4th, 1884.)
7. Cerebral hsemorrhage with passage of blood into both
optic nerves.
By Priestley Smith (Birmingham).
(With Plate IX, fig. 1.)
I AM indebted to Dr. Leslie Philips, lately house phy-
sician to the Queen's Hospital, for the opportunity of
recording this case ; he had charge of the patient during
life, and made the post-mortem examination.
A mechanic, aet. 38, was admitted into the hospital on
March 20th, 1883. His wife stated that twelve days pre-
viously, during a frost, he had slipped off a step and
slightly hurt his foot ; the next morning he had a fit, but
otherwise appeared well until the 18th, ten days after the
accident, when he complained of headache for the first
time. On the morning of the 20th he vomited twice, and
she thought his mental faculties seemed affected ; he
walked to the hospital.
On admission he complained of intense pain in the
272 DISEASES OF OPTIC NERVE.
occipital region ; pupils equal, diameter 2 mm. ; no optic
neuritis ; mental impairment evidenced by moodiness and
difficulty of eliciting answers ; tongue white and breath
foul ; urine free from albumen, and radial arteries not
thickened.
Same evening. — Temperature 100° F., pulse 48, irre-
gular in time, respiration not hurried. Could be made
to speak only with great difficulty.
On the following morning (21st) at 4 a.m. he had a fit
and died in it.
Autopsy. — Trunk viscera healthy. On removal of the
dura mater a large quantity of blood-clot escaped ; on
examination of the brain this was found to have come
from a cavity in the left frontal lobe about as large as a
walnut. There was no contusion of the brain-surface over
the cavity, but simply a clean rupture of the cortex in
the inferior frontal convolution ; through this the blood-
clot protruded. Subsequent examination with the micro-
scope showed no new tissue around the cavity, which
appeared to be due simply to hasmorrhage. The clot was
confined to the left side of the skull, but extended back-
wards to the cerebellum both on the convexity and at the
base. The optic nerves showed bulbar enlargements
behind the globes, and appeared from their colour to con-
tain blood. One nerve was at once opened ; its anterior
part contained fluid blood, which was easily washed away
by a gentle stream of water. The other, together with
the back of the eye, was placed in Miiller^s fluid.
It appears probable that the fall caused an extravasa-
tion in the substance of the frontal lobe, which at first
produced no decided symptoms, and that a further hgemor-
rhage occurred eight days later, extending over the sur-
face of the brain, forcing its way into the optic nerves,
and quickly causing death.
The hardened optic nerve was frozen, and divided by a
horizontal longitudinal section. Within the distended
nerve-sheath, near to the eyeball, lies a blood-clot, and
the precise relations of this are of some interest. In his
I
--€
DESCEIPTION OF PLATE IX.
Fig. 1 illustrating Mr. Priestley Smith's case of Cerebral
Haemorrhage with Haemorrhage into the Sheaths of the Optic
Nerves (p. 273).
Shows a horizontal section of the optic nerve with blood in the subdural
space. Magnified 8 diameters. From a drawing by the author.
Fig. 2 illustrates Mr. Arthur Benson's case of Coloboma of
the Choroid, Iris, and Lens (p. 352).
Fig. 3. Sketch of Mr. Priestley Smith's model to illustrate the
Conjugate Movements of the Eyes (p. 353).
CEREBEAL HEMORRHAGE. 273
chapter on the Microscopical Anatomy of the Optic
Nerve, Retina, and Vitreous, in the ' Handbook of Graefe
and Saemisch/ Schwalbe describes the optic nerve as
having three distinct sheaths, viz. an external or dural
sheath prolonged from the dura mater, a pial sheath pro-
longed from the pia mater and closely attached to the
surface of the nerve, and between the two an arachnoidal
sheath, corresponding to the arachnoid membrane of the
brain. The latter lies usually in close apposition with the
external or dural sheath ; the space between the two, or
sub-dural space, which is at most of capillary dimensions,
is the continuation of the sub-dural or arachnoid space in
the meninges. A second and larger space, corresponding
to the sub -arachnoid space of the meninges, separates the
arachnoidal from the pial sheath of the nerve ; this space
is bridged across by numerous fine trabeculge and septa of
fibrous tissue. The arachnoidal sheath consists of a fine
network of fibrous tissue, the meshes of which are filled
in with endothelial cells. There are thus, according to
Schwalbe, two distinct tubular spaces, a sub-dural and a
sub- arachnoidal, but the two are probably connected to
some extent by minute apertures. By other observers the
existence of two distinct spaces is denied. In the speci-
men before us there appears to be decisive evidence of their
existence (see Plate IX, fig. 1). The blood-clot lies entirely
external to the arachnoidal sheath, while the sub-arach-
noidal space is nevertheless widely distended. Disease
appears here to have performed a double injection ; the
blood passing over the surface of the brain immediately
beneath the dura mater has forced its way along the sub-
dural sheath of the nerve, while at the same time the sub-
arachnoidal space has been injected with colourless fluid,
doubtless the cerebro-spinal fluid forced into it from the
sub -arachnoid space of the brain by the increased pressure
within the skull.
We do not yet know to what extent a distension of
the optic nerve-sheath with blood is a cause of ophthal-
moscopic changes and visual impairment. Unfortunately
VOL. IV. 18
2^4 DISEASES OP OPTIC NERVB.
the present case gives no information on these points.
Eighteen hours before death, at the time probably when
the second and more extensive haemorrhage was taking
place, Dr. Phillips examined the discs and found them
unaltered in appearance, but it is by no means certain that
the blood had at this time found its way into the optic
nerves.
{December }3th, 1883.)
8. Case of hxmorrhage into the sheaths of both optic
nerves after a fracture of the shulL
By A. QUAERY SiLCOCK, M.D.
The specimens exhibited were taken from a man, ast.
28, who died in St. Mary^s Hospital from the effects of a
fracture of the skull eight days after the infliction of the
injury. Whilst in the hospital he was more or less
delirious and maniacal ; consequently no ophthalmoscopic
examination was made. At the autopsy a fissured frac-
ture was found traversing the posterior inferior angle of
the right parietal bone and the right half of the occipital,
extending from a point two inches above and four inches
behind the right external auditory meatus to the jugular
foramen of the same side. The middle and anterior fossae
were intact, no fracture in these regions being evident,
although such was carefully sought for. In the cavity of
the arachnoid was much extra va sated blood, more espe-
cially over the base of the brain, about the crura cerebri,
anterior perforated spot, and adjacent parts. The brain
was bruised ; the tip of the left temporo-sphenoidal lobe,
left orbital convolutions, and the right occipital lobe in
marked degree. The sheath of the left optic nerve was
discoloured and considerably distended near the eyeball,
evidently from effusion of blood into it. In the specimens,
tiiEMORRHAGE INTO THE SHEATHS OF THE OPTIC NERVES. 275
the clot is seen to occupy the subdural space of the nerve,
into vs^hich the blood had found its way from the arachnoid,
the two spaces being continuous. The fact that the
extravasation was of larger extent close to the eyeball
than elsewhere, is probably to be ascribed to the greater
looseness of the connections of the outer and inner sbeaths
at this part. The same description applies equally to the
right nerve, but tbe sheath of the latter contained less
blood-clot. Microscopical examination of the nerve shows
it to be inflamed, and the disc to be swollen ; the haemor-
rhage is seen to be confined to th.e small space wbicli exists
between the sheaths of the dura mater and arachnoid.
Berlin* thinks that such an extravasation is only caused
by a fracture of the base of the skull involving the optic
foramen ; in the present instance I could not discover
any fracture of this kind ; nor does he mention the fact
that the extravasation may be found in and confined
to the subdural space of the nerve as in this case. It
seems reasonable to suppose that the blood found its way
thither much in the same way that injection fluid would
if artificially forced into the cavity of the arachnoid.
Similarly, if the haemorrhage in the cranial cavity be
confined to the subarachnoid space, it would naturally be
met with in the prolongation of that space around the
optic nerves — here designated subvaginal or intervaginal
— should the effusion reach so far. Probably a systematic
post-mortem examination of the optic nerves would show
that such an extension of the haemorrhage, whether due
to fracture of the skull or otherwise, is far more common
than is generally supposed.
{January ]Oth, 1884.)
* Graefe and Saemisch, * Handbuch/ article, " Vorletzungen der Orbita."
276 DISEASES OP OPTIC NERVE.
9. A case of homonymous hemianopia probably due to a
cortical lesion.
By Seymour J. Sharkey, M.B.
S. F — , aet. 51, came under my care as an out-patient
at St. Thomas's Hospital on July 5tli, 1883. She said
that she was a married woman, that she had enjoyed good
health until the previous two and a half years, and that
she had had six strong children. Her last confinement
took place eight years ago, when she was delivered of a
dead child. Her catamenia ceased at the age of forty-
eight, and at that time she had rather profuse '^ flooding.^'
About two and a half years ago she was walking across a
hayfield when she was seized with a fit, and since then
she has had many more of an exactly similar nature, but
they ceased nine months before she came to me. The order
of events in these attacks was as follows : — Suddenly there
appeared " in the right eye '^ (probably right side of field
of vision) a play of colours embracing all the tints of the
rainbow ^' quivering '' and '' fluttering '' before her. Then
the right arm became convulsed, and the forearm and
hand rotated inwards. Soon the right leg was rigidly
extended backwards and outwards, then loss of conscious-
ness supervened and she bit her tongue. She remained
two or three hours unconscious of her surroundings,
and when she did recover her senses she found that she
had a severe pain in the top of her head and weakness of
the right arm, but none of the right leg. Moreover, she
could see nothing on her right side without turning her
head in that direction. She had no loss of sensation or
of speech.
In each of the subsequent fits the phenomena have
been similar and have observed the same order, and from
the first her right arm has remained weak, the defect of
sight has persisted, as well as the pain in the head, and
HOMONYMOUS HEMIANOPIA. 277
her memory has deteriorated. Her bowels have been
regular, she has had no vomiting_, her sleep has become
very heavy, and she has not lost much weight.
On her first appearance in the out-patient room, she
seemed a well- nourished woman, with grey hair, and a
face free from lines and rather expressionless. She was
quite intelligent, and complained considerably of pain in
the head. Its seat was a circle of about two or three
inches in diameter on the vertex posteriorly, and this
region was tender on percussion. She walked well, and
had no apparent loss of power in the leg. The patella
reflex was feeble in both legs, and if anything less marked
in the right than in the left. The right arm was decidedly
weak, and the grasp of the right hand enfeebled. The
face and tongue were free from paralysis ; there was no
loss of sensation. The right side of the field of vision was
evidently defective, the left intact. There was no optic
neuritis, and no abnormality to be detected with the
ophthalmoscope. There was no defect in hearing, taste,
or smell, nor did the heart or other viscera present any
signs of disease.
I sent the patient to Mr. Nettleship, who confirmed my
observations as to the normal condition of the fundus of
the eyes, and also as to the presence of homonymous
hemianopia, but in addition to this he took great trouble
in the determination of the exact field of vision, and I
have to thank him for the accompanying perimeter charts.
It will be seen that the right half of the field of vision
in each eye is very defective, and that the defect does not
reach as far as the vertical line drawn through the fixation
point. There is an irregularly-shaped area of normal
vision in the right half of the field of vision of the right
eye, extending to a distance varying from 15° to 55° from
the fixation point, and in the left eye there is a similarly
situated area extending from 15° to 70° from the fixation
point.
The unaltered remnant of the right half of the visual
field in each eye is most extensive near the fixation point,
278 DISEASES OF OPTIC NERVE.
Left. Right.
Fields of vision of S. F. In the right eye the results varied slightly
on two diflferent occasions, as shown by the inner line.
and gets smaller and smaller as the periphery of the visual
field is approached, so that, roughly speaking, it has the
shape of a triangle, the base of which is the vertical line
through the fixation point, the apex being situated in the
left eye on the horizontal line, drawn through the fixation
point and about 25° distant from the latter ; while in
the right eye the apex is situated in the middle of the
upper quadrant at a distance of about 45° from the fixation
point.
Mr. Marlow was kind enough to test the condition of
colour vision for me, and he has supplied me with peri-
meter charts. Both Mr. Nettleship and Mr. Marlow are
of opinion that there is little to be said about this point,
except that colour vision is absent in the blind area.
This case is one in which I cannot show the Society a
post-mortem specimen to prove the correctness of the
diagnosis, and so far the nature and position of the intra-
cranial lesion may be considered as open to doubt. At
the same time I think I am safe in saying that physicians
who have paid special attention to cerebral diseases will
agree with me that the diagnosis of a lesion of the left
hemisphere, affecting the cortical centre for the arm and
its neighbourhood, is as nearly certain as any diagnosis
can be which is not subjected to the test of a post-mortem
examination.
The succession of fits commencing with convulsions of
HOMONYMOUS HEMIANOPIA. 279
the left half of each retina^ if I may so express it, and of
the right arm, then extending to the right leg, finally
terminating in loss of consciousness and biting of the
tongue, and followed by permanent paralysis of the right
arm and left side of each retma, presents a vivid and
typical picture of cortical lesion.
The centre for the arm occupies probably about the
middle third of the two ascending convolutions, and
extends to an uncertain distance upwards in the same
convolutions. Just posterior to this region are the
angular gyrus and occipital lobe, both parts which are
supposed to be connected with sight. It is very probable
therefore that the lesion in this case is situated about the
middle of the two central convolutions, and extends into
the parts posterior to them. Whether this be accurately
the situation of the lesion or not, the case may be con-
sidered to be one of cortical disease producing lateral
homonymous hemianopia, in which the defect in the visual
field is not limited by a vertical line through the fixation
point, but by an irregular line passing to the right of it.
Ferrier showed by experiment years ago that injury to
the angular gyrus in lower animals produced amblyopia in
the opposite eye, thus establishing the fact that the cortex
of each hemisphere of the brain is in some way connected
with the vision of the opposite eye. Munk and others
subsequently proved that each occipital lobe has definite
relations to both eyes, being in connection with the lateral
portions of each retina on its own side, so that lesion of
the left occipital lobe, for example, produces blindness of
the left side of each retina, or, in other words, right
lateral hemianopia.
These physiological experiments are confirmed by
pathological observations. Thus it has been proved by
post-mortem examination that lesions of the posterior part
of the internal capsule produce blindness of the opposite
eye, indicating a crossed connection between the cerebral
hemispheres and the organs of vision.
Other lesions of one hemisphere have been shown to
280 DISEASES OF OPTIC NERVE.
give rise to homonymous hemianopia. Westphal after
relating some cases of hemianopia concludes that with a
probability bordering on certainty disease of the posterior
part of the hemispheres, and probably disease situated
mainly or exclusively in the occipital lobes, can produce
hemianopia.
In 'Brain' for October, 1880, Ferrier after reviewing
the known facts says, '^ From these facts it would appear,
therefore, that there is a twofold relation between the eyes
and the cortical visual centres ; the one mainly cross — the
central portion of the retina probably bilaterally repre-
sented— by the angular gyrus ; the other bilateral — the
corresponding side of both retinae being represented by
the occipital lobe, not alone, however, but in conjunction
with the angular gyrus/'
A very interesting observation is quoted by Dr.
Hermann Willbrand in his ' Monograph on Hemianopia,'
which supports the view that each retina contains fibres
derived from both hemispheres. A woman had been quite
blind in the left eye for fifty years. After death atrophy
was found in the following parts — the left optic nerve, left
corpus geniculatum externum, both the corpora quadri-
gemina on the left, the left pulvinar, and both occipital
lobes, the right being more atrophied than the left. Thus
physiological experiment and pathological observation
combined point decisively to the view that each hemi-
sphere is connected with both eyes, and that there is to
some extent a separation between the area in the cerebral
cortex which receives the peripheral fibres of the corre-
sponding halves of the retinae, and the area which
receives the central fibres of the opposite retina.
The question then suggests suggests itself. What is the
course of the fibres which link the retinae to the cerebral
cortex ? This is best answered, as far as it can be
answered at present, by appealing to pathological obser-
vations.
The optic nerve on each side contains all the fibres
going to the corresponding retina. As Mr. Nettleship
HOMONYMOUS HEMIANOPTA. 281
and others have shown by their cases pressure by a
tumour on one optic tract produces homonymous hemi-
anopia in which the dividing line passes vertically through
the fixation point. That is to say, that although in the
optic nerve all the fibres from the corresponding retina
were present,, in the optic tract both the peripheral and
central nerves o£ the nasal half have crossed to the oppo-
site tract. Hence each tract contains the fibres — both
peripheral and central — which run to the temporal half of
the eye of its own side, and to the nasal half of the
opposite eye.
This arrangement holds as far as the corpora genicu-
lata at any rate, as lesions in this position produce results
which are similar to those produced by lesion of the optic
tract.
But it has been proved by my case as well as by others
that disease of some portion of the cerebral cortex pro-
duces homonymous hemianopia confined to the peripheral
portions of the retinsB, their central parts retaining clear
vision. Hence the fibres of the optic tracts as they pass
into the hemispheres must separate in some such way
that those which come from the periphery of the retinae
enter the cortex at a point which is, at least to some
extent, distinct from that which receives the central
fibres.
Pathological and experimental observations prove that
each hemisphere has an essential and well-marked special
connection with the opposite eye ;* and as separate areae
in both hemispheres supply the peripheral fibres of each
eye, this special connection can only take place by means
of the central fibres.
* Cf. * Med.-Chir. Trans./ 1883, vol. Ixvi, p. 293, a paper by the author
entitled " A Case of Asymmetry of the Brain presenting Peculiarities which
bear upon the Question of the Connection between the Optic Nerves and
certain definite areas of the Cerebral Cortex." Also cf. * Med.-Chir. Trans.,'
1884, vol. Ixvii, a paper by the author entitled " Embolism of the Right
Middle Cerebral Artery producing Left Hemiplegia and Hemiana3sthesia.
Absorption of a large portion of the Right Hemisphere. Death Seven Years
later.'*
282
DISEASES OF OPTIC NERVE.
Now^ lesions of the optic tracts, as already stated, prove
tliat the central fibres of each retina are contained partly
in the tract of the corresponding side, and partly in that
of the opposite side. Therefore those in the tract of the
same side must cross beyond the corpora geniculata in
order to reach the cortex of the hemisphere opposite to
the eye from which they come. If this reasoning is
correct the state of affairs may be graphically represented
by the accompanying diagram.
aa'. Cortical centres for the peripheral fibres of the retina.
bb'. Cortical centres for the central fibres,
cc'. Optic nerves.
dd'. Optic tracts.
Charcot's original diagram, of which mine is merely a
modification, was constructed at a time when the crossed
connection between the hemispheres and the eyes was
known to exist, but the facts regarding hemianopia had not
attracted the attention which they now have. His dia-
HOMONYMOUS HEMIANOPIA. 283
gram represented the knowledge of that time well enough,
and even now it merely needs the slight alteration which
is necessitated by the facts pointing to the subdivision of
the cortical visual centre ; without this his diagram does
not explain the occurrence of hemianopia from cortical
lesions.
(The diagram constructed by Munk, representing the
results of his extremely able experiments on animals, was
also exhibited at the meeting. However correct it might
be for the latter, it was seen at a glance that it did not
correspond at all with our present knowledge as regards
man.)
So far back as 1880 Ferrier wrote in ' Brain ' as follows :
— '^ There are many cases of homonymous lateral hemi-
anopia, in which, though the lateral defect has been of
indefinite duration, central vision is retained in both eyes
for some distance on all sides of the fixation point. This
is a point of great importance and signification, and one to
which I would direct special attention as likely to furnish
a means of diagnosis between central and peripheral
hemiopia. In cases where central vision is retained for
some degrees on all sides of the point of fixation, I should
regard the cause of the hemianopia as central. '^ The case
I have reported to-night supports this view.
Grreat variety in the shape of the visual defect will,
however, probably be observed in the cases of hemianopia
due to cortical or sub -cortical lesions. For one can hardly
doubt that the visual centres extend over considerable
area3 of the cortex, and are expansions of grey matter in
which is represented every spot on the retinae, each point
of the latter being connected with a corresponding point
in the cortical visual expansion ; and if this be so every
variety of hemianopia may be produced according to the
situation of the diseased area in the visual centre. Indeed,
Munk has experimentally proved this to be so in the dog,
for by removing different parts of a certain area of the
cortex he has succeeded in causing blindness in different
regions of the retinae.
284 DISEASES OP OPTIC NERVE.
Besides amblyopia and hemianopia, concentric contrac-
tion of tlie field of vision has been noticed in certain
patients. The facts at present at our disposal are hardly
sufficient to warrant a consideration of the pathology of
such cases. They are, as far as I know, either cases of
hysteria, and are then accompanied by anaesthesia of parts
of the body, or else cases of haemorrhage or other lesion
in or about the central ganglia. The explanation of the
hysterical cases which appears to me to be most likely is that
there is a general depression o£ nerve power, and that this
affects principally though not exclusively one hemisphere.
This results in a diminution or absence of those parts of
sensation for the perception of which the most vigorous
action of the cerebral centres is required. Thus in these
cases the sensation of pain is often absent when that of
touch is retained, for the central cells require much
more violent peripheral stimulation to produce pain than
they do to give rise to tactile sensation. Hence when the
function of these cells is abnormally depressed it may be
impossible to stimulate them sufficiently to evoke pain.
Similarly in the case of the retina, the impulses from
the periphery of the field of vision are much feebler than
those from the central parts, and require an active condi-
tion of the cells of the visual centres to be perceived at
all. Hence in such cases of nerve depression peripheral
vision is the first to go.
In cases of haemorrhage in or about the central ganglia
the contraction of the field of vision may be due either to
a similar depression from shock, or possibly to pressure
on the optic fibres, which in that part of the brain are
gathered closely together. Suggestions like these, how-
ever, are mere guesses.
In bringing this paper, already far too long, to a close,
I should like to say a word about diagrams. It may by
some be thought absurd to portray in straight and curved
lines the course of visual impulses in so complicated an
organ as the brain ; and so it would be if it were meant
that such diagrams were anatomically correct. They are
HEMIANOPIA AND CEREBRAL TUMOUR 285
simply useful as representing in a concrete form present
knowledge or opinions about certain points in physiology,
which can then be more easily criticised, disproved, cor-
rected, or confirmed.
{October nth, 1883.)
10. Failure of left eye (to hlindness) 'passing into atrophy
of disc J later, paralysis of left third nerve and
loss of right half of right visual field with evidence
of atrophy of disc ; discharge of bloody mucus from
left nostril, and late appearance of tumour behind left
angle of jaw. Death seven years after onset of sym'ptoms ;
large tumour compressing left optic nerve, chiasma, and
tract, and left third nerve.
By E. Nettleship.
James P — , a short, stunted, round-headed man, with
dark hair, a blacksmith, from near Exeter, came under my
care at the South London Ophthalmic Hospital in Sep-
tember, 1876, for failure of his left eye. He was then
30. The sight of the left eye had been going for four
months. A well-known ophthalmic surgeon told him that
there was ^^inflammation of the nerve ^' at first, but at a
subsequent visit said that the nerve looked healthy again.
On admission, with the affected eye he could only read
20 J. with and without lenses ; the visual field and colour
perception were not tested. The temporal half of the disc
was pale, the nasal half of good colour, the central vessels
normal ; but the whole disc was less transparent than the
other, as it might well have been if recently inflamed.
The other (right) eye was healthy in all respects and its
sight perfect.
He said that after the eye began to fail he had a good
deal of pain '' at the back of the eyeball '' in attacks
'^86 DISEASES OP OPTIC NERVE.
lasting an hour or more. He had had a blow over the
same eye a year before. But he stated that as long as
six years before I saw him, after having measles, he had
become subject to pain in the same (left) cheek ; this
after troubling him on and off for a couple of years, seems
to have ceased. There was no history of syphilis. No
enlarged glands or tumour in the neck.
During the next year or two the sight of the defective
eye seems to have improved somewhat (I did not see the
patient). About the middle of 1878 the left nostril
began to discharge bloody fluid. He now said that he
" could not bear to sneeze/' and was liable, if startled,
to sudden darts of pains through the head.
Early in 1879 he thought the other eye failing ; Dr.
Harris, of the Exeter Hospital, where the patient was
attending under the care of Mr. Bankart, wrote to me
that vision was -|§ and 1 J. with difficulty, and that some
epileptiform attacks had lately occurred.
In July, 1879, I saw him again. With the right, vision
was 2 J. with difficulty, no H.m. ; disc now somewhat
pale on the temporal side, its vessels normal ; visual field
not noted. The left disc now showed advanced grey-
white atrophy ; its central vessels slightly diminished.
There was still bloody discharge from the left nostril.
I heard no more of him till September of the present
year, 1883, when he wrote asking whether he might come
up as he was not so well.
On readmission (at St. Thomas's Hospital) on Septem-
ber 14th Mr. Marlow made the following notes : — The
man said that he had been getting weaker all the summer,
though still able to walk four or five miles, that his head
was drowsy and heavy, and that he was troubled with
attacks of trembling even while sitting still ; for several
years he had been subject at irregular intervals to "fits,''
which consisted of a sudden feeling of suffocation in the
nose and mouth, followed by pain in the front or back of
the head but no loss of consciousness (once he *' talked
a lot of nonsense without knovnng what he was saying ") .
fiEMIANOPIA AND CEREBRAL TUMOUR. 287
He did not know when a '^ fit '^ was coming on. The
bloody fluid from the left nostril continued,, and lie thought
that tlie ^^ fits ^' were worse when the discharge was less
abundant. There was never any large amount of fluid from
the nose. For a year or more he had not been able to open
his mouth widely, and for some months the acts of mastica-
tion and yawning had given pain, especially behind the
left jaw ; the jaws could now only be separated half an
inchj and eating was difficult. A hard, rounded, fixed
tumour, as large as a walnut, could be felt behind the
angle of the lower jaw, apparently touching the mastoid
process ; nothing could be felt behind the right jaw.
Nothing abnormal could be seen in the nose, throat, or
mouth. The nostrils were both pervious, but smell, espe-
cially with the left nostril, was found to be affected though
not abolished. He was nervous and easily agitated ; e.g,
mere examination of the movements of the eyes would
bring on spasm of the lids.
As regards the eyes. — There was almost complete para-
lysis of all the branches of the left third nerve, ptosis
being the least marked symptom ; pupil 5*5 mm. and
quite fixed ; he had been aware of a squint for two or
three years. Vision of the right eye was ^^ fairly and
1 J. well at 10'' j on examining the visual field very com-
plete hemiopia was found, the right half of the field being
lost up to within 1° or 2° of the fixation point {see Fig.) -,
Field of vision of right eye of James P.
the inner (left) half of the field was of full size. He
288 DISEASES OF OPTIC NERVE.
knew that he had been unable to see things to tbe right
of him for a couple of years or so, and had once knocked
a lady down on account of the defect. The disc of this
eye was now very pale all over, vessels normal ; disc
substance opaque and its border softened by a little baze
^' as in early ataxic atrophy/^ Pupil 3 mm., acting to
light and accommodation.
With the left eye he still had p. 1., but only in a small
part of the temporal half of the field ; the disc was highly
atrophic and quite clear and clean cut.
There were no other nervous complications and no
evidence of any visceral disease.
Up to this date I had not attempted any accurate
diagnosis of the cause of the optic nerve atrophy. It was
now clear that there was a tumour at the base of the
skull chiefly on the left side. The order in which the
symptoms had developed (progressive disease of left optic
nerve, paralysis of left third nerve and loss of the right
half of the right field of vision) made it probable that the
growth had begun a little in front and to the left of the
chiasma, had destroyed the corresponding optic nerve, and
had then implicated the left side of the chiasma and left
optic tract causing loss of the right half of the remaining
(right) field of vision. And, so far, the case seemed to
confirm Dr. Ferrier^s suggestion that in hemianopia due
to lesion of the optic tract the boundary of the blind half
might be expected to run straight through the fixation
point, whilst if the lesion occurred at the visual centre an
area of central vision would probably remain and the
hemianopia be thus less complete.
As the patient when readmitted had no urgent sym-
ptoms I did not expect to get a post-mortem examination.
A few days after admission (September 21st) he had a slight
shiver (thought he had caught cold in having a bath), his
temperature went up to 103°, and he brought up a quantity
of aerated blood-stained sputum resembling that of pneu-
monia. But there were not then or afterwards any
symptoms or physical signs of pneumonia, and the
HEMIANOPIA AND CEREBRAL TUMOUR. 289
patient^s own idea that the stuff came from the back of
his nose was no doubt correct.
On the 23rd he was better, and temperature was normal.
24th.— Temp. 103-2'', pulse 120 ; darting pains in left
upper jaw.
25th. — Complained of numbness of upper and lower
lips, and of right half of tongue, but no anaesthesia was
proved on testing.
26th. — In the afternoon began to mutter and wander in
his mind, and complained much of pain at back of head ;
brought up larger quantities of bloody sputum all day.
Urine, no albumen or sugar. Evening : Left eye seems
more prominent and ptosis complete.
27th. — Morning : Semi-comatose and muttering; seems
quite blind of right eye. Left eye decidedly more pro-
minent, right slightly so ; both eyes fixed. No evident
loss of power in limbs, but much twitching of hands. He
became steadily more comatose, and died quietly in the
evening. At the time of death the left pupil had become
smaller than the right ; immediately after death the
temp, was 107° F.
The body was examined the next day by Dr. Sharkey.
There were no changes of importance except within the
skull.
A large, soft, excessively vascular tumour was found
' attached to the base of the brain occupying the inter-
peduncular space, and involving the subjacent bones.
I There was meningitis all around the tumour, but nowhere
at all intense. The vessels both of dura and pia mater
were generally congested, and the upper surface of the
brain was rather dry ; but there was no meningitis of the
convexity.
The tumour had pushed its way more to the left than
!the right, the optic nerves, tracts, and chiasma being dis-
placed towards the right. The left optic nerve was flattened
out into a thin band on the antero-inferior surface of the
front of the tumour, and the chiasma, or its anterior part,
the only part visible, was similarly pressed upon. The
VOL. IV. 19
1
290 DISEASES OP OPTIC NERVE.
right tract was also pressed upon by the growth, but the
right optic nerve looked natural and was quite free. The
tumour had eaten away the whole body of the sphenoid, ^
the apices of the petrosal bones, especially the left, and
the neighbouring part of the occipital. Small offsets of
growth were found in each orbit amongst the fat.
After hardening Mr. Fell made for me a sketch
of the base of the brain,* from which and from sub-
sequent dissection it appears that the cerebral part of the
tumour consists of three chief portions ; one, continuous
with the main growth from the bones, obscures the
greater part of the chiasma, left tract and crus, and
extends back to and presses upon the pons ; a second
small, well-defined nodule projects from the front of this
mass and compresses the hinder end of the left olfactory
nerve ; a third rounded mass, probably a blood-cyst,
covered by a firm fibrous capsule, projects from the left
(outer) side of the main mass upwards against the lower
surface of the middle lobe of the brain, from which, how-
ever, it is quite separate. On the upper and hinder part of
the last-named lobe of the tumour the posterior part of the
optic tract is found running as a flattened band, but
anteriorly the tract cannot be followed so far as the situa-
tion of the chiasma, being lost on or in the growth. The
growth had thus intruded itself between the left crus and
optic tract. The two left corpora quadrigemina are con-
siderably smaller than those on the right side. The left
third nerve is seen as a thin band running across the upper
surface of the third lobe of the growth. The left fifth was
just touched by the growth, but not adherent or flattened.
No section has been made to ascertain the state of
the crus and other parts above the most central part of
the tumour, but they appear to be merely compressed, not
invaded, by the growth.
{October Uth, 1883.)
* This sketch was shown at the meeting.
CEREBRAL TUMOUR. 291
1 1 . Fundus oculi from case of cerebral tumour ; appear-
ances like those of retinitis alhuminurica.
By Walter Edmunds.
(With Plate VII, fig. 2.)
The drawing represents the fundus of the right eye of
Mrs. Eliza C — , aet. 40. Patient was suffering from
severe headache, vomiting independent of food, and epi-
leptiform fits ; no albuminuria, no history of syphilis.
Well-marked double optic neuritis. Right eye (Plate
VII, fig. 2) : Great swelling of optic disc ; all round edge of
swelling numerous radiating haemorrhages ; large vessels
on disc altogether obscured, large veins on retina not tor-
tuous j bright radiating lines at yellow spot on the side
towards the optic disc ; macula red. Left eye : Changes
similar, but fewer haemorrhages ; no peripheral changes in
either eye ; media clear.
-^. . r R. eye reads 4 N.
(^ L. eye rends 2 N.
There is contraction of the outer part of the field of
the right eye.
{July 4>th, 1884.)
292 FUNCTIONAL DISEASES.
XI.— FUNCTIONAL DISEASES.
1. A case of nerve disease with ocular symptoms , including
alleged uniocular diplopia.
By K. Maecus Gunn and James Anderson, M.D.
We venture to bring this case before the Society
mainly because of the occurrence of the unusual symptom,
uniocular diplopia. This symptom being purely subjective
ought to be received with caution, even if it were readily
explicable. But if difficult to substantiate, the symptom
is still more difficult to explain, and therefore, as may be
supposed, we have throughout investigated the case with
a considerable amount of scepticism.
The patient, William D — , aet. 34, a painter, came to
Moorfields Eye Hospital on the 20th of October last com-
plaining of seeing several images of an object, especially
when he looked to his left.
On examination it was seen that his left external rectus
was deficient in abducting power by about an eighth of
an inch, allowing therefore a slight convergent strabismus
of the left eye. He had the usual homonymous diplopia
of abducens paralysis, but with the right eye shut he
asserted that he still saw things double. The tension of
both globes was normal. The pupils were unequal, E. =
34 mm., L. = 44 mm. ; both acted to light and with
accommodation. With the exception of the paralysis
of the left external rectus already noted, the move-
ments of the globes were fan^y normal. On looking
upwards the right globe made a slight excursion inward
on its way, and when he looked to the left his right eye
UNIOCULAR DIPLOPIA. 293
was directed very slightly upward as well as to the left.
There was no nystagmus. He had ^, and 1 J. with each
eye separately, the reading with the left eye not being
quite so ready as with the right. There was no Hm. The
cornea, media, and fundus of each eye were healthy, no
abnormality being present except a small crescent down
and out from the disc. There was no irregularity in cornea
or iris, no opacity or dislocation of either lens. Testing him
now with both eyes open, an object appeared single in the
right half of his field, occasionally double in the middle line,
and constantly double in the left half of his field. The dip-
lopia, as stated, was homonymous, the right image clear, the
left dim, parallel, and on the same level. The object being
still held to the patient^s left and the right eye closed, he
asserted that he still saw two images, nearer together than
before, the right clear and the left dim, as with binocular
vision. Tested with the perimeter the field of vision of
the left eye was fairly normal, and the uniocular diplopia
was found to extend over the left half of the field, and
also over the upper part of the right half. The images
got farther apart as the object neared the periphery, and
he said very distinctly that it was not a mere blurring at
the edges, that he really saw two separate objects. By
the use of a prism we sought to separate the images
given by the two eyes, and so to ascertain if he saw three
images with the two eyes, but he never did so. He was
repeatedly examined with prisms and coloured glasses, and
in our examination we had the benefit of Mr. Nettleship's
experience, but his answers, although varying on such
matters as apparent distance, were substantially consistent.
He is a fairly intelligent man, answered with the manner
of perfect bona fides, and so far as we could discover had
no interest whatever in deceiving us.
As to the patient^s previous history we may simply
state that he has been married eleven years, has three
children alive, and five have died of '^ convulsions " within
three months of birth. He had gonorrhoea sixteen years
ago, denies having had a chancre or any symptom of
294 FUNCTIONAL DISEASES.
secondary syphilis. He has been a painter for seven
years, and was in the London Hospital in 1879 and again
in 1882, believed to be suffering from lead-poisoning or
progressive muscular atrophy. In 1882 he had wasting
of the right upper limb and the left lower limb with loss
of left knee-jerk. The wasting of the right upper limb
is now but little manifest except in the muscles of the
scapula and of the thenar eminence. The quadriceps
muscle of the left thigh is greatly atrophied, and the left
knee-jerk is completely absent, the right being prompt
and vigorous. The cremasteric reflex is present on both
sides, the plantar reflex absent on both sides ; there is no
ankle-clonus. Notwithstanding that he says the left leg
feels weak, there is nothing noticeably abnormal in his
gait. Sensation in the upper and lower limbs is equal and
apparently normal. He has no blue line, has not for the
last ten years had anything like colic, the extensors of the
forearms are perfect, and there is no atrophy of the
interosseous muscles of either hand. He has now, how-
ever, developed well-marked wasting in the left temporal
and zygomatic fossae. The temporal muscle can scarcely
be felt, the masseter is fairly good. The facial muscles
act well, but when he opens his mouth or raises his upper
lip to show his teeth, the left corner of his mouth is drawn
down, giving his mouth the lop-sided appearance charac-
teristic of paralysis of the trigeminus. Sensation on the
right side of the face is normal, that on the left side is
extremely imperfect, the points of a pair of compasses
feeling like the point of the finger. All three divisions of
the fifth are affected. Since he was in the London Hos-
pital taste and smell have become very defective, and the
hearing distance of the left ear, with a fairly normal, perhaps
slightly too concave membrana tympani, is 2^ feet as com-
pared with 4 feet for the right ear. The right cornea and
conjunctiva are normally sensitive, the left are quite in-
sensitive. Dr. de Watteville kindly examined the elec-
trical reactions of the muscles. The results were negative,
that is the reactions were simply diminished (or absent as
UNIOCULAR DIPLOPIA. 295
in the case of the temporal muscle) with no qualitative
changes.
From the multiformity of the lesions and the affection
of the trigeminus^ the diagnosis was made of syphilitic
nervous disease and the patient was put upon iodide of
potassium. The paralysis of the sixth nerve gradually
disappeared, and as it did so, the diplopia, both binocular
and uniocular, got less and less marked. Three weeks
after the commencement of treatment, when the paralysis
of the sixth was just observable, he still saw two images
at the left side with his left eye alone, but the images
were not perfectly distinct from one another, the flame of
the candle being ^^ fringed at the left side.^' He ceased
to attend at Moorfields in the middle of December, when
there was neither paralysis nor diplopia. He was seen
again in February, when he said he had had several
" fits '' within the previous three weeks, similar to one he
had had in the London Hospital. The exact nature of
these fits could not be ascertained. He falls down sud-
denly without warning, is quite unconscious, and believes
he remains so for about ten minutes, but has been told
nothing of what happens meanwhile.
Three cases of uniocular diplopia have been recorded
in the Society^s ' Transactions ' for 1882 (pp. 201 et seq.),
in addition to two mentioned by Mr. Adams, both of
which he believed to be spurious. Considerable doubt is
thrown upon the first of Dr. Ord^s cases by the facts
recorded of it by Dr. Hughlings Jackson, and we shall
therefore for the present refer only to Dr. Ord's second
case and to Dr. Abercrombie's, in both of which there
was an autopsy.
Dr. Ord's case was that of a boy, aet. 13 years, suffer-
ing from mitral disease and admitted into St. Thomas's
Hospital after an epileptic fit affecting the left arm and
left side of the face. Mr. Nettleship, who examined the
case, found optic neuritis, rather more marked in the right,
complete paralysis of the left and incomplete of the right
external rectus, the pupils large and the left acting
296 FUNCTIONAL DISEASES.
scarcely at all. There was binocular diplopia with lateral
and some vertical separation of the images, also uniocular
diplopia with each eye separately. In the progress of the
case the right external rectus recovered power, and with
this recovery the uniocular diplopia of the right eye dis-
appeared, persisting, however, in the left eye in which
the abducens paralysis persisted. His vision was ■§-§, and
he read 1 J. with each eye throughout the period of obser-
vation. He died suddenly a year later, and at the post-
mortem examination was found to have an old cerebral
haemorrhage external to the right lateral ventricle pro-
ceeding from a small aneurysm.
In Dr. Abercrombie's case, a girl, aet. 10, admitted into
Great Ormond Street Hospital with loss of power on the
right side and impairment of speech, there was also para-
lysis of the right external rectus with slight obscuration
of the edges of the discs and turgidity of the retinal veins.
There was binocular diplopia and also uniocular diplopia
with the right eye alone, the false image being always
{i.e. always in the uniocular diplopia, as Dr. Abercrombie
informs us privately) above and to the left of the 'true
one. The autopsy showed an abscess lying external to
and communicating with the descending horn of the right
lateral ventricle.
In will be seen that the present case agrees with both
those summarised in the occurrence of paralysis of the
external rectus, and it is specially interesting to note that
in this case, as in Mr. Nettleship's, the uniocular diplopia
disappeared with the disappearance of the abducens para-
lysis. In another important point also, this case resembles
Mr. Nettleship's, namely, the dilated condition of the
pupil of the affected eye, a condition frequently but by no
means invariably present in abducens paralysis, as we
have recently had opportunities of observing at Moorfields.
As in Mr. Nettleship's case, this dilatation of the pupil
persisted in our patient after all diplopia, both binocular
and uniocular, had disappeared. In both the recorded
cases there was coarse cerebral disease. In our case there
UNIOCULAR DIPLOPIA. 297
was at the time no optic neuritis and there almost cer-
tainly had been none. The evidence of coarse central
nervous disease afforded by the epileptic seizures and the
affection of the fifth and sixth nerves is not decisive.
The cases recorded are too few for generalisation, and
we shall, therefore, without occupying the time of the
Society with theories, simply emphasise the three following
points :
1. The occurrence as a concomitant in Dr. Ord^s two
cases, in Dr. Abercrombie^s, and also in the present case,
of abducens paralysis, accompanied, in the two cases where
the pupil condition is noted, by a dilated pupil.
2. The disappearance of the uniocular diplopia in two
of the cases pari passu with the disappearance of the
abducens paralysis — a concomitant variation which tempts
to the generalisation that either abducens paralysis and
uniocular diplopia are cause and effect, or that both
phenomena are due to a common central cause.
3. The presence of coarse cerebral disease in the two
cases where there has been a post-mortem examination,
and the occurrence in the other two of nervous symptoms
consistent with, although not decisive of, coarse cerebral
lesion — the lesions in the two cases recorded being of such
a nature and extent as to be unavailable for localisation,
while our own case, as we have said, furnishes no assistance
on this head.
Dr. Brailey remarked that he had under his care in
Guy^s Hospital at that present moment a case with a
history of uniocular diplopia, in association with which
were found all the other eye symptoms to which the
authors had called attention, viz. paralysis of right rectus
and slight dilatation of the pupil. But there were also
some general ataxic symptoms. He would show the case
at the next meeting of the Society.
Mr. JuLER stated that a similar case to that mentioned
by Dr. Brailey had recently come under his care at the
Westminster Ophthalmic Hospital. It occurred m a
2&8 FUNCTIONAL DISEASES.
woman about forty years of age. She had paresis of the
left external rectus with double vision. The interesting
point of the case was that when the patient's right eye
was covered she positively and persistently stated that she
saw two images with the left eye.
Mr. Nettleship had lately seen another case (under
the care of Dr. Gulliver), in which the patient (a young
man) alleged that he had uniocular diplopia. Like all the
cases hitherto brought before the Society, this patient had
paresis of the external rectus, accompanied by symptoms
of cerebral disease, and, as in Dr. Anderson's case, the
uniocular diplopia was present chiefly, if not only when
great effort was made by the paralysed muscle. Refer-
ring to Dr. Anderson's observation of an enlargement
of the pupil in paralysis of the sixth nerve, he said
he had observed a slight degree of such dilatation in a
large number, though not in all, of his cases of this
affection.
{May Sth, 1884.)
2. Case of paralysis of external rectus and mydriasis with a
recent history of uniocular diplopia.
By W. A. Beailey, M.D.
David P — , aet. 42, admitted to Guy's Hospital on
April 25th, 1884.
He says he has had right internal strabismus since boy-
hood, but that he had fair sight in this eye on covering
the left till one year ago. Then it began to fail, and he
noticed, when testing it thus, that he saw two images
always, both being in the same horizontal plane and only
visible in the outer part of the field. This eye has now
only perception of light, and its optic disc is white with
its lamina cribrosa unduly apparent ; also its blood-vessels
are smallish. The pupil is rather dilated and quite
PARALYSIS OP EXTERNAL RECTUS AND MYDRIASIS. 299
immoveable. There is almost total paralysis of the
external rectus. Myopia = about 7 D. There are some
small opacities in the posterior lens capsule.
The left eye has about the same degree of myopia.
When corrected,, V = fingers at three feet. The optic
disc is white with lamina cribrosa too visible and vessels
too small. The pupil is smaller than the other, but like
it is also inactive both to light and accommodation.
There is no diplopia with this eye. He says that this eye
has only failed during the last six weeks.
His field for form in both eyes seems of about normal
size. He has total loss of vision for green, which he calls
dark red. His field for red appears to be of the usual
size.
His lungs, heart, urine, and superficial reflexes are
normal. There is a very distinct difference now in his
knee-jerks, the left being perhaps stronger than normal,
whereas the right is almost absent. There is no ankle-
clonus. With feet together and eyes closed he is a little
unsteady. His muscles show normal electrical reactions.
Those round the mouth are decidedly unsteady always.
He has occasional pains in his temples and also nocturnal
pains in his bones. He appears to have had syphilis
twenty years ago, and has till recently been a heavy smoker
and drinker. For the last three years he has had occasional
incontinence of urine at night. This has been relieved by
taking alcohol before going to bed.
{June bth, 1884.)
300 AFFECTIONS OF MUSCULAR AND NERVOUS SYSTEMS.
XII.— AFFECTIONS OF MUSCULAR AND
NEEVOUS SYSTEMS.
1. Case of complete paralysis of accommodation and con-
vergence, persisting for ten months, in a girl aged thir-
teen years, who presented no other evidence of disease.
By Henry Eales (Birmingliam) .
My excuse for bringing the following case before this
Society is that, so far as my own experience and researches
go, it is unique. It is that of a little girl, set. 13, who
has been for ten months past afflicted with complete para-
lysis of accommodation in both eyes, together with
absolute loss of power to converge the eyes ; the pupils
also remaining motionless on any attempt at near vision
though they respond well to the stimulus of light.
The patient, the daughter of a well-to-do gentleman,
consulted me first on June 1st last, by the advice of the
family medical attendant, in consequence of having become
rapidly afflicted as it was thought with short-sight, a sup-
position supported by the fact that her father was short-
sighted, while she herself during the previous three
months had taken to putting her books very close to her
eyes, and had suffered during the same period from aching
about the eyes after any attempt to read.
As regards her family history, the medical attendant
writes : ^^ Her mother died of tubercular phthisis of four
years' duration ; phthisis is on both sides of the family.
She has tnree brothers and one sister, all alive and all
delicate and strumous. Patient has had no special ill-
ness, enteric fever slightly, no relapses and no sequelas.
COMPLETE PARALYSIS OP ACCOMMODATION, ETC. 301
She is not strong, and suffers slightly from lateral curva-
ture. Gout is on the father's side, but no syphilis. '^
On inquiry I ascertained that she had suffered from
measles, chicken-pox, scarlet fever, and hooping cough,
but none of these about the time of the onset of her eye
troubles ; nor could I get any history of sore throat about
this time to lead to the suspicion of her having had diph-
theria, indeed, for the twelve months previous to her eye
trouble, her general health had been better than usual.
A cousin of her mother is '^ insane with general ner-
vous disease.'' There was no blood relationship between
her parents.
Her father (who has consulted me on account of myopia
with astigmatism) I found subject to gout. Her paternal
grandfather has recently been under my care in conse-
quence of retinal hgemorrhages in each eye. He, however,
presented no evidence of cardiac disease or granular
kidney, but is very subject to gout, being in other
respects hale and hearty, though aged seventy-four years.
Her eye troubles set in three months previous to her
first visit to me, and two months previous to her mother's
death. At the onset her father noticed that '' her eyes
were all pupil unless opposite the light."
She has never menstruated. Her bowels are habitually
regular, she does not suffer from dyspepsia, sickness,
or headache except slightly of late after reading. Once
or twice she has felt ^^ a thumping in the head and con-
fused feeling" on being hurried in walking, and under
these circumstances her father has noticed her to stagger
a little, each time forwards.
Her governess wrote to me in September, 1883 : " She
is always full of life and spirits, and her appetite never
fails. She is perfectly unreserved with me, and I should
certainly know if she were suffering in any way."
8tate on examination. — She is a slight, spare, but
healthy -looking child, remarkably intelligent, of a cheerful
disposition, and presents no evidence of anaemia or of
hereditary syphilis. Both pupils, in a dull light, ar^* un-
302 AFFECTIONS OF MUSCULAR AND NERVOUS SYSTEMS.
usually large, the right pupil being smaller than the left ;
both pupils contract fairly well to light, though perhaps a
little slowly. The right eye is emmetropic, the left eye
presents slight myopia (M. = -^g")- Her central vision is
normal in acuteness in each eye. V. = ^^ with either eye.
With + 12'' glass the near and far points are both at
ten inches, apparently with the right eye as well as the
left. There is no range of accommodation apparently in
either eye.
Without the aid of + glasses she cannot read 'No. IJ
Snellen at all, and only 2^ Snellen with great difl&culty
on bringing the type up to about five inches from her eye,
and even then it is very pale and indistinct she says.
Whether with or without glasses the pupils do not con-
tract on looking at near objects, and under both conditions
she '^ sees double/^ no convergence of the eyeballs what-
ever taking place.
So absolute is the loss of power to converge that
objects even six feet distant appear double, but at ten feet
and beyond there is no obvious double vision.
The bilateral movements of the eyes upwards, to either
side and downwards (and, indeed, in all directions except
convergence), were normal in kind and extent. The field
of vision was normal in extent (hand test). Vision for
colours was normal.
On ophthalmoscopic examination the fundus of each eye
was normal. There was not even a suspicion of previous
papillitis. Patellar tendon-reflex was normal.
Treatment. — Iodide of Potassium with strychnia and cod-
liver oil had produced no effect on the eye condition, which
was in all respects precisely the same when last seen on
January 3rd, 1884. Eserine drops enabled her to read
for about ten minutes without glasses shortly after they
were instilled.
Dr. Gowers, who has seen the patient, wrote to me on
November 1st last : '^ I failed as you did to find any
other indication of organic brain disease than the singular
ocular loss ;" and further on, ^' I think it most improbable
COMPLETE PARALYSIS OP ACCOMMODATION, ETC. 303
that the symptom is due to any gross disease. The pro-
gnosis is certainly unfavorable. In a case so unusual, as
it certainly is, one can be guided only by analogy and the
fact that a somewhat similar paralysis may occur in diph-
theria and be recovered from, renders the prognosis not
altogether hopeless. Nevertheless, I confess the duration
of the case renders it unwise to place much reliance in
this analogy.^'
On November 28th Dr. Gowers wrote : " There is no
change in her condition, and I feel confident that there is
no organic brain disease, such as tumours or the like. It
must be a degenerative change in the special part of the
nucleus of the third nerve. Although such a case may
never have been seen before, we must remember that
some other degenerative diseases, such as disseminated
sclerosis, muscular atrophy, and even locomotor ataxy,
have been known in extremely rare instances to occur in
childhood. I can find no indication of any extension of
the disease beyond its original limits, and think that the
probability is that it will remain limited. Certainly we
are justified in assuring the friends that there is no indi-
cation that the function of the optic nerve is likely to
suffer. I hope you will publish the case.''
So much discussion has taken place at this Society
since its foundation as to the probable seat of disease
in cases of intra-ocular palsy that it is not desirable that I
should go into the question at any length.
Mr. Hutchinson's suggestion of disease in the lenticular
ganglion would hardly seem a satisfactory explanation of
the phenomena present in this case, for, apart from the
improbability of symmetrical degeneration taking place
in each ganglion, it seems difficult to believe that the
ganglion is so differentiated anatomically or functionally
that disease in it could cause loss of accommodation with
so slight impairment of the function of the iris, while it
is impossible to see how disease so situated could cause
loss of convergent power.
Mr. Hulke's theory of disease in the intra-ocular nerve-
304 AFFECTIONS OF MUSCULAR AND NERVOUS SYSTEMS.
ganglia is for similar reasons not applicable to this case,
though, like Mr. Hutchinson^s, a sufficient explanation of
the symptoms in some cases of intra-ocular palsy which
occur ; but as I understand the views of both Mr.
Hutchinson and Mr. Hulke, they would not apply them to
a case in which the palsy is so partial, or of such a kind,
as is found in this case. I feel therefore compelled to
seek the cause in the central nervous system at the centre
for accommodation, which has been shown by Hensen and
Volckers to be situated in the posterior part of the floor
of the third ventricle.
Physiological observations and clinical experience both
tend to indicate that these centres are probably double,
each eye having its own centre, but the centres for the
two eyes being closely associated in action.
The inequality of the pupils in this case is slight
evidence in favour of the centre for each eye being distinct
from its fellow.
The fact that both her far and near points appeared to
be at ten inches with + 12'' glasses with each eye is
satisfactorily explained as regards her left eye by the pre-
sence of myopia -^^j ^^^ ^^ seems to suggest slight power
of accommodation in the right eye, which is emmetropic.
Though it is possible, bearing in mind the age of the
patient, that the observations as to the far and near points
in this eye were slightly wanting in accuracy, the fact of
the pupil of this eye being less dilated coincides with the
view that the affection is less complete on this side.
A case of uniocular reflex iridoplegia with double optic
neuritis, without loss of accommodation, published by me
in the ^ Ophthalmic Review ' for August, 1883, and similar
cases published by others, seem to indicate that the centres
for each eye are distinct.
Probably the centre for convergence is distinct from,
though closely associated with, the centre for accommoda-
tion, for iu is known that either function can be used to a
limited extent without the other, and clinical experience
shows that one may be lost without the other.
COMPLETE PAEALYSIS OF ACCOMMODATION, ETC. 3C5
In diphtheritic paralysis of accommodation, speaking
from my own experience of several cases, I should say
that convergence is seldom or never lost.
That the pupil is not more affected in this case would
seem to indicate that the centre for convergence in man
is near the centre for accommodation, and not near the
centre for the other movements of the eyeballs, which
have been shown by Hensen and Yolckers to be most
posterior, in the aqueduct of Sylvius, the centre for the
movements of the iris being placed between them and
the centre for accommodation.
The limited loss of function present in this case, im-
plying as it does only a limited area of disease, the fact
of its remaining absolutely in statu quo for ten months,
the absence of cerebral vomiting, severe headache, and of
optic neuritis, make it difficult to accept the view that
tumour or any coarse central disease is present. I am
therefore compelled, like Dr. Gowers, to consider the
cause to be a local degenerative change. The long and
absolute persistence of the loss of function, and its com-
plete limitation, together with the entire absence of any
history of diphtheria, are against the view of its being
caused by that disease ; while the age and sex of the
patient, and the absence of any other symptoms of disease
of the nervous system, make it impossible for me to
place this case with certainty under any of the classes of
central nervous disease with which we are familiar.
Future experience of this case can alone determine
under what category of disease it should be placed, and
with the assistance of the family practitioner I hope some
day to be able to do this.
Does not this case in which the pupil contracts to light,
but not on looking at a near object (I cannot say during
accommodation and convergence, for both were absent in
this case), and its counterpart cases in which the pupil
contracts in accommodation and convergence but not to
the light, justify us in thinking that in man there are two
centres for the contraction of the pupil, in spite of the
VOL. IV. 20
306 AFFECTIONS OF MUSCULAR AND NERVOUS SYSTEMS.
assumption of Hensen and Volckers, founded on experi-
ments on animals, that there is only one centre for the
contraction of the pupil ?
I cannot conclude without expressing my thanks to Dr.
Growers for his letters referring to this case, and for his
permission to publish them.
(January 10th, 1884.)
2. On certain forms of spasm of the ocular muscles.
By W. E. GowERS, M.D.
I PROPOSE to ask attention to three forms of spasm of
the ocular muscles, viz. : the occurrence of such spasm in
chorea; partial convulsion affecting a single ocular
muscle ; and a singular case of convulsive nystagmus.
1. Spasm of the ocular muscles in chorea. — In chorea
the head and eyes may participate in the irregular move-
ments, being moved to one side by consentaneous spasm
of the quick jerky form characteristic of chorea. But the
point to which I would especially call attention is that this
spasm may be so unequal in the two eyes as to cause
brief diplopia, although it is insufficient to produce a
visible variance of the ocular axes. The point is chiefly
of diagnostic importance, as was well illustrated by the
case that first directed my attention to the symptom.
The patient was suffering from choreic movements, and
also from optic neuritis and headache. The two latter
symptoms suggested that the movements might be sym-
ptomatic of organic brain disease, and therefore not true
chorea. The doubt was increased when the patient
shortly afterwards complained of occasional double vision,
although no defective movement of the eyes could be
detected. The case ran the ordinary course of chorea,
and the patient made a good recovery. Hence I was con-
strained to regard the diplopia as the result of irregular
SPASM OF THE OCULAR MUSCLES. 307
spasm of the ocular muscles. The patient has since
verified the diagnosis by having a second severe attack of
very characteristic chorea, for which she is still under
treatment,, and her sister was brought to me yesterday
with distinct choreic movements. I have since inquired
for diplopia of patients suffering from chorea, and find
that it is by no means infrequent, although, not being
constant, little attention is paid to it, and it is rarely if
ever mentioned spontaneously.
2. Partial convulsion of the ocular muscles. — Partial
convulsions may, as is well known, affect only the side of
the face, the arm, or the leg. The two cases that I am
about to mention show that an ocular muscle may be
affected in a similar manner. This is not surprising when
we consider that the ocular muscles participate almost
uniformly in unilateral convulsion.
The first case was that of a man, aet. 36, without
neurotic heredity, without any personal history of
syphilis or other predisposing disease. He had suffered
for six months from attacks of the following character.
Two of them I saw. Each began by a hot rushing sensa-
tion, commencing at the inner canthus of the left eye, and
extending over the eye and adjacent parts to the temple.
As this spread, the sight of both eyes became dim, the
degree of defect of sight varying in different attacks from
slight dimness to absolute loss. Very rarely there was a
mementos loss of consciousness. During the attack the
left eye moved outwards about half way to the outer
canthus, the right eye remaining still. The pupils were
of medium size ; during one attack they dilated slightly,
during another they remained unchanged. The duration
of the attack was only a few seconds, too short to permit
the action of the pupil to light to be tested. At other
times this was normal. If walking he always deviated to
the left during the attack, perhaps from erroneous pro-
jection of the left field, since he was unconscious of
vertigo, and we cannot regard a lateral movement of one
eye only as the effect of vertigo. Such attacks occurred
308 AFFECTIONS OF MUSCCJLAR AND NERVOUS SYSTEMS.
many times daily. In the intervals no defective power in
any ocular muscle could be discovered. Vision was
reduced in the left eye to ith without any defect of
refraction, field, or colour vision. The attacks gradually
ceased under treatment by tonics.
The second case was that of a man, aet. 47, also with-
out neurotic heredity or syphilitic history. He com-
plained only of occasional double vision. There was,
however, some permanent weakness of the ocular muscles
— of the left external rectus and right internal rectus, and
also slighter 'weakness of the left internal rectus. The
paroxysmal diplopia of which he complained was due to
brief attacks, one of which I witnessed. Bach com-
menced with an epigastric sensation like that so common
in epilepsy. Then the left eye moved outwards nearly to
the external canthus, the right remaining still. At the
same time there was blinking of both eyes. This he said
was voluntary " to try and get the eye right,'' but
nevertheless he could not help doing it. The attack lasted
only a few seconds, and when it was over the left eyelid
fell about a twelfth of an inch lower than the other, and
remained so for about a minute, and then became normal.
Vision was unaffected, and a careful search revealed no
other nervous symptom. Such attacks occurred almost
every day, and were sometimes brought on by excitement.
Iodide and bromide of r)otassium and tonics were given,
and the attacks became less frequent, but did not cease.
It is probable that the seat of the disease in this case was
the centres for the movements of the eyes, in the pons,
or beneath the corpora quadrigemina, but its exact seat
and nature are uncertain.
3. Convulsive nystagmus. — A man suffering from ad-
vanced Bright' s disease was seized with symptoms indi-
cating a lesion of the pons, loss of consciousness, general
paralysis with relaxation of muscles, and hyperpyi'exia
which mcreased up to death, twelve hours after the onset.
In addition there was a singular condition of spasm of the
eyeballs. Both eyes deviated strongly to the left. From
SPASM OP THE OCULAR MUSCLES. 309
time to time they were turned still farther to the left, and
at the same time were agitated by violent nystagmus, in
which the quick movement was to the left, the slow return
to the right. In some of the attacks there was quick
clonic spasm of the eyelids, in others, of the corrugators.
After death the only lesion was a well-marked anaemic
area on the right side of the pons, extending above the
nucleus of the sixth nerve for about half an inch, from near
the floor of the fourth ventricle behind, to the fillet in front,
and from the middle line through about half the lateral
extent of the pons. It was apparently an area from
which the blood supply had been cut off, but death had
followed too soon for the occurrence of softening. The
area ajffected was in the position in which a lesion
commonly causes loss of movement towards the side
affected and deviation of the eyes from the side of the
lesion, paralysis of the external rectus of the same side,
and internal rectus of the opposite side. But the devia-
tion could not be regarded as simply paralytic, because it
was increased during the convulsive nystagmus, in which
the quick movement was in the direction of deviation — i.e.
to the left. We must regard the increased paroxysmal
movement to the left, and therefore also the quick move-
ment of the nystagmus, as liberated from the unaffected
left side of the pons under the influence of the lesion of
the right side. No doubt the centres for the lateral
movements are intimately connected, and mutually
influenced each other. This case shows first that we
cannot always regard conjugate deviation as purely para-
lytic, even when it corresponds in direction to a paralytic
deviation, since it may be in part due to irritation exerted
by a lesion of one side on the corresponding centre on the
other side. Secondly, it shows the significance of the direc-
tion of the quick movement of nystagmus. This point is
too often neglected, if we may judge by recorded cases,
but it must be carefully observed, if nystagmus is to acquire
a higher localising value than it at present possesses.
{March 13th, 1884.)
I
310 AFFECTIONS OF MUSCULAR AND NERVOUS SYSTEMS
3. A case of paresis of upward movement of eyes.
By J. A. Ormerod, M.D.
Patient is a gardener, set. 44. The upward movement
of the eyes is impaired ; they rise but little above the
horizontal plane. It is most impaired in the right eye,
and that more particularly when he looks , to the right
(affection of right superior rectus ?) ; so that on moving
the eyes horizontally to the right, the right eye sinks below
the horizontal plane. There is vertical nystagmus as he
tries to look upwards, and the same to a less extent as he
looks downwards. Downward and lateral movements,
and movements of convergence in other respects normal.
He has some drooping of the eyelids and diflSculty in
opening them when closed ; he sometimes has had to open
them with his finger. The forehead is constantly wrinkled,
and the eyes, especially the right, screwed up. The
lower part of the face is rather expressionless. He com-
plains also of difficulty in speech ; it is rather slurring and
hesitating. There is sometimes tremor of the tongue and
lips. He has also had some difficulty in walking.
Patellar tendon reflexes present ; pupils rather small, con-
tracting under light. A largish white patch (choroidal
atrophy ?) above right optic disc ; edges of discs a little
indistinct, but no definite neuritis.
Was under Dr. Reynolds and Dr. Bastian at University
College some fifteen years ago with the same symptoms;
but he states that this is a second attack, which came on
about ten months ago.
{Living specimen. March 13th, 1884.)
ACUTE SPASM OF THE ACCOMMODATION. 811
4. Acute spasm of the accommodation.
By C. E. Fitzgerald, M.D. (Dublin).
The following cases are good examples of this somewhat
rare affection :
Case 1. — Mr. H — came to me in July, 1873, complain-
ing of a dimness in the right eye which he had first
noticed ten months previously. Two months prior to his
consulting me he had gone out shooting, when to his
surprise he found that on closing his left eye he was un-
able to see some rabbits at a distance of about fifty yards.
He did not think the dimness had increased much since.
He had always enjoyed excellent health, had never to his
knowledge received any injury in the eye, and had never
contracted venereal disease.
On testing his acuteness of vision I found he could read
CC (Sn.) at the length of my consulting room, which at
that time was not twenty feet. With 3 D. he could read
the XX. li (Sn.) he read at 8^'. The left eye was
emmetropic.
On examining the eye with the ophthalmoscope I
thought there was a slight haziness of the fundus, and
quite close to the margin of the lens I detected some
small, opaque specks evidently situated on the posterior
capsule. In order to examine these more particularly, I
dropped in a solution of atropine, and to my no small
surprise when this had acted he could read the XX just
as well as he had previously done with the lens. Direct
illumination with the ophthalmoscope now showed that
the specks above alluded to formed a sort of circlet at the
margins of the lens. They could also be well seen with
the oblique illumination and presented a slightly brownish
colour closely resembling the small pigment masses seen on
the anterior capsule in cases of iritic adhesions which have
been broken up. I could not find any trace of them m
312 AFFECTIONS OF MUSCULAR AND NERVOUS SYSTEMS.
the other eye. I have frequently seen this appearance
since, as I suppose have many others, and I presume it
has no pathological significance.
The case was clearly one of spasm of the accommoda-
tion, and consequently the eye was kept for some days
under the influence of atropine. When the effects of the
latter had passed off the spasm returned. Again the
atropine was resorted to, but with a similar result on its
being discontinued. Thinking that possibly the resistance
to the treatment might be due to both eyes not being
completely at rest, I desired the pa.tient to desist from all
work for a fortnight, during which time he was to keep
the eye thoroughly under the influence of atropine. This
proved equally unsuccessful after it was discontinued. The
artificial leech was also applied, but with no good effect.
I have since seen this gentleman on various occasions and
he reports that the eye is in exactly the same condition,
and the last time I had an opportunity of testing his
vision I found it to be so.
Case 2. — Miss W — , ast. 18, consulted me on the 19th
of last February ; she stated that for a fortnight previous
to her visit she had not been able to read except by
bringing the book up very close to her eyes. Up to this
time she had always had long sight. Just before she
noticed the change in her sight she had suffered from an
attack of facial neuralgia.
With each eye V. = -^ ; and 0*5 (Sn.) at 10 cm.,
but with — 2*25 D., V. rose to |-. An ophthalmo-
scopic examination showed the refraction was hyperme-
tropic and that H. = + 2* D.
I prescribed two drops of Liq. Atropias Sulph. to be
put into each eye three times daily.
March 4th. — Under the influence of atropine. Right,
V. without lens = -^ some letters, but with + 1*25 D.
= -| ; left, V. without lens = ^ some letters, but with
+ 0-75 D. = f . Ophthalmoscope H. = 2-5 D.
Spasm of the accommodation in connection with H.
and M. is a matter of daily observation ; in fact in young
ACUTE SPASM OF THE ACCOMMODATION. 313
persons who are affected with either of these anomalies
it is, I fancy, almost invariably present to a greater or
less extent. This, however, is a condition which in these
cases may be considered as chronic, and in hypermetropic
patients, whose visual acuteness for distance is greatly
reduced, but on the addition of a very low lens is at once
raised to the normal standard, is quickly recognised.
The sudden accession of apparent myopia dependent on
on acute spasm of the accommodation is, however, so far
as I am aware, extremely rare,* and very little information
on the subject can be gleaned from the ordinary ophthal-
mological text-books. Professor Bonders in his im-
mortal treatise devotes a section to it, but expresses
considerable scepticism regarding some cases recorded by
earlier writers and collected by Ruete. He says : '' Acute
spasm of accommodation, such as, for example, is pro-
duced by calabar, is undoubtedly very rare. I myself
have never met with a clear case of it, and this may
excuse my scepticism. My task is confined to quoting
those few cases which afford satisfactory evidence.'^* He
gives three cases, two reported by Von Graefef and one by
Liebreich.J
The first is that of a man who had received an injury
of the cornea of the right eye. When the irritation from
this had quite subsided the patient saw indistinctly with
the eye. Accommodation was almost entirely lost, and
the eye at the same time was myopic. The left eye was
almost emmetropic. The patient had often previously
satisfied himself that both eyes were equal. A rapid cure
ensued after a few applications of the artificial leech.
Von Graefe regarded the condition in this case as a
reflex neurosis and analogous to the tonic spasm some-
times excited in ordinary voluntary muscles by injury of
sensory nerves.
* Bonders, * Accommodation and Refraction of the Eye,' New Sydenham
Society, p. 622, 1864.
t Graefe, • Archiv fur Ophthalmologie,' B. ii, H. 2, p. 304.
X Liebreich, * Archiv fiir Ophthalmologie,' B. viii, H. 2, p. 259.
814 AFFECTIONS OP MUSCULAR AND NERVOUS SYSTEMS.
The second case is that of a girl, aet. 18, affected with
painful spasm of the orbicular muscle of the right side,
which on tension of the eyelids, and also sometimes spon-
taneously, became more violent. Slight pressure on the
facial nerve increased the pain and spasm, strong pressure
lessened both. Leeches were applied with brief improve-
ment, followed by aggravation of the symptoms. Kefrac-
tion appeared to be increased with diminution of the
accommodation. The right pupil was somewhat narrower
than the left with slight reflex, and without any accom-
modation movement. Left eye normal. Sulphate of
atropia was employed endermically behind the ear, and
then the left eye exhibited the same conditions in every
respect. Belladonna symptoms presented themselves on
the third day, with diminution of the spasm and pain,
and on increase of the intoxication the accommodation
was almost restored. The symptoms returned when the
drug was suspended, and the final result is not recorded.
Von Graefe looked upon this case as a combination of
spasm of the muscles of accommodation with neurosis of
the facial nerve.
In Liebreich's case, that of a young lady set. 21, fatigue
on exertion and near-sightedness had set in a year before
she consulted him after constant work. There was an
apparent M. equal to about — I'D.; atropine was put in
and the M. gave way to H. = + 1'5 D.
In the Italian 'Annals of Ophthalmology^ for 1879, a
case of acute spasm of the accommodation is reported by
Professor Kava.* It occurred in the right eye of a man,
aet. 30, after a very severe attack of neuralgia of the fifth
nerve on the right side, and after eight days' use of
atropine completely subsided.
The two cases of high degree of spasm reported by Mr.
Adams fco the Society in 1882 are, I presume, fresh in
the minds of most of the members present. The first of
these cases is, I take it, an example of this acute form of
* Vide ' Centralblatt fiir Augeuheilkuude,' Marz, 1880, p. 98.
MINERS^ NYSTAGMUS AND ITS CAUSE. 315
Spasm, but the second could hardly be considered so.
These are the only cases I have been able to collect.
As I before remarked the ordinary text-books devote
little or no attention to the subject, in fact the only work
that I am acquainted with that deals at all fully with it,
is the admirable monograph of Professor Nagel on the
^ Anomalies of Refraction and Accommodation,' and which
was published in 1866.* In speaking of this form of
spasm he states that it is rare, and that few well -recorded
observations of it are to be found in ophthalmic literature.
Closely allied to it is a form of clonic spasm of the ciliary
muscles, lasting for a moment or so, which he states
he has sometimes noticed in the prodromal stage of
glaucoma. He looks upon it as due to an irritation of
the ciliary nerves caused by increased tension. The
observation is an interesting one, and so far as I am
aware, has not been alluded to by any author.
(May 8th, 1884.)
5. Observations on miners^ nystagmus and its cause.
By Simeon Snell (Sheffield).
(With Plate X, figs. 1, 2.)
Within comparatively recent years, the nystagmus,
found in the workers in coal mines, and commonly called
miners' nystagmus, has received a good deal of attention.
The experience of most observers indicates the peculiarities
of pit life and the mode of employment of the miner, as
the direction in which the cause of the affection is to be
sought.
At the meeting of this Society, however, in July, 1882,
* Nagel, 'Die Refractions und Accommodations Auomalien des Auges
1866, p. 202.
816 AFFECTIONS OF MUSCULAR AND NERVOUS SYSTEMS.
my friend, the late Mr. Oglesby_, advanced the theory that
the disease was of central origin, and partook of an epi-
leptiform character. A perusal of his paper, published in
the ' Transactions,' vol. ii, p. 243, will, I believe, be found
not to support the theory indicated, and in the discussion
which ensued after it was read, I intimated my dissent
from the author's conclusions, and briefly stated my con-
viction that the affection depended for its causation on the
position the miner assumed whilst at work. This opinion
I have long held, and it is the object of this paper to
more unfold the manner in which, I believe, the nystagmus
is occasioned.
The peculiar characteristics of the affection have been
so often well described that I need only make reference
briefly to them. The oscillations are of two kinds, to and
fro and rotatory, round the antero-posterior axis ; the
rapidity of the movements varies much in different cases.
A miner coming under treatment for this affection will
mention that for a varying time he has suffered from the
lights and other objects dancing before him, and may
complain of giddiness. Many of the patients are able to
bring the oscillatory movements to a standstill by looking
fixedly, generally in front or below the horizontal line,
and this even in moderately bad cases. On the other
hand, any movement above the horizontal line will increase
the rapidity and distinctness of the movements, and par-
ticularly if the eyes are turned obliquely upwards to the
right or left. Movements of the patient's body, running
or walking quickly, will also bring on or aggravate the
condition, as will also bending low the head and raising
it rapidly. Cases vary much in severity, some there are
in which the movements apparently never cease, and then
again, there are others in which the disease may be called
latent. It is not evident to casual observation ; the
patient complains of objects dancing before him, but still
there is no apparent nystagmus, and it is only after
pursuing the methods already mentioned to induce the
oscillations that any movements are to be detected.
MINERS* NYSTAGMUS AND ITS CAUSE. 317
Whilst, moreover, these may suffer a good deal of dis-
comfort, occasionally others are met with who have been
the subjects of the disease, it may be for many years, who
think little of the inconveniences it occasions.
Many have been the causes assigned for the production
of this kind of nystagmus. The impurities in the atmo-
sphere of the pit have been credited with occasioning it,
and so has the employment of '' safety '* lamps, but to
this further reference will be made.
My residence in a district where collieries abound,
first in Leeds, and for the last ten years in Sheffield, has
afforded me excellent opportunities of becoming conversant
with the affection of which we are speaking. A varying
number of such cases are always under treatment. I
have seen nothing to lead to a supposition that the affec-
tion was dependent upon central disease. I have never
seen a case which raised such a question. There has
never been any optic neuritis, and the nervous symptoms
when present, such as vertigo, are readily enough explained
by the ocular condition. The fundus oculi has not shown
abnormal changes. The disease may be found, moreover,
in the emmetropic, the myopic, and hypermetropic. Thus
one case had a myopia of 5 D. and another a hyperme-
tropia of 7 D.
My experience has led me always to regard the mode
of working of the miner as directly causing the nystagmus
whatever subsidiary parts other influences may play in its
production.
It will be readily understood that the men engaged in a
coal pit are of various classes, and the kind of work per-
formed by each class is very different. Thus there are
labourers and trammers, the former occupied in the dif-
ferent cuttings in clearing them, &c., and the latter in
attending to the cars on the tram lines, these are not
employed in coal getting, and do not, I believe, suffer
from nystagmus, or at least I have not met with cases
among men so occupied. Then there are coal-getters, some
of these are employed '' cutting to make the headings,''
318 AFFECTIONS OF MUSCULAR AND NERVOUS SYSTEMS.
and they work directly forwards with the pickaxe ; others
are employed a good deal at what is called " holing/'
This consists in driving a cutting underneath the seam
of coal which is afterwards brought down by wedges.
Work of this kind necessitates the men lying on their
sides, as the " hole " they make may only be about
eighteen inches to two feet high, and may reach inwards
for a yard or more underneath the coal. In this '^ hole ''
the miner will lie at work on one or other of his sides.
There are many men whose principal or entire work
consists in '^ holing ; '' other men work at this as well as
other ways of coal getting. There are some men, again,
probably also some from both classes I have already men-
tioned, who work in parts which are more ^' open '^ on
what is called the " bank.^'
It is with the coal-getters, whose work necessitates
their lying on their sides, that in my experience the
nystagmus is associated. Later on I shall explain the
manner in which, I believe, the position assumed tends to
produce the oscillation of the eyeballs.
Observation of cases of nystagmus soon taught me that
the patients so suffering had worked on their sides, and I
believe that of all the many instances at different times
which have come under my notice, without exception, as far
as my memory and records go, the miners attacked have
been those whose work has been done on their sides more
or less. The evidence in support of this contention may
be thus detailed :
1. In a letter of mine to the 'Lancet,^ 1875, vol. ii,
p. 81, the following sentence occurs : — " Four cases of
miners' nystagmus have come under my observation
during the last few months, and from these and other
cases previously noticed, it seems to me that the disease
occurs chiefly, if not entirely, in those colliers who are
compelled to do their work whilst lying on one of their
sides.''
My further experience corroborates the opinion thus
expressed in 1875, and I recollect no case of nystagmus
miners' nystagmus and its cause. 319
occurring in a miner whose work was not of this cha-
racter.
2. I felt tolerably certain that if I had an opportunity
of seeing miners at work in the pit, I should find the
ones suffering were those already alluded to. Accordingly,
last June (1883), I went down a coal pit in the neigh-
bourhood of Sheffield to test the opinion I had formed.
The pit, I may say, was a well ventilated one ; several
hundreds of hands were employed ; Davy's safety lamps
were used and no naked lights. My guide, a former
patient, at first took me to the '^ coal-getters/' Three
sets of these men were examined who were engaged in
" cutting the headings,'' working with the pick directly
forwards in the manner I have already described. In
none of these men was any nystagmus discovered. Then
I was taken to the men engaged in " holing," and four of
the six men working at the situations I went to, suffered
from nystagmus ; the two who were not affected were
young men. It was this class of miners, who had to work
whilst lying on their sides, often creeping underneath the
coal ', these were the men I expected to find affected.
Trammers, and men otherwise engaged in the pit
were examined, and nystagmus was not found among
them.
It cannot be asserted that my examination of the
workers in this pit was a thoroughly exhaustive one.
The time at my disposal did not admit of it, and it will
readily be understood, by those in any way familiar with
a coal pit, that a regular and systematic examination of
the miners at their work in a fair sized colliery, means
an immense expenditure of time, and a long distance to
be travelled. My observations are, however, of value, as
they distinctly confirmed the impressions gleaned from
clinical experience as to the men I should find affected.
An overlooker, a very intelligent man who accompanied
me, wrote subsequently saying ^^ that I am nearly of the
same opinion as yourself that the men who suffer most
are those you spoke of." Other men have also given
320 AFFECTIONS OF MUSCULAR AND NERVOUS SYSTEMS.
confirmatory opinions, and this, in spite of the deeply-
rooted conviction that nearly all colliers have, as to the
malady being caused by the ^' safety lamps." Another
miner, himself a sufferer from nystagmus,* recently ex-
pressed himself in the following manner : — ^^ I think you
are right," he said, ^^ about the position causing it
(nystagmus) and I will tell you why. A young man
suffered like me from his eyes, but for the last year he
has given up working on his side, and he has been getting
coal by digging straightforwards " ribbing and packing "
all leg work, ribbing down to make the roads, and he has
got considerably better."
3. The cases referred to by Mr. Oglesby in his paper,
though recorded with a different intention, afford, I
believe, confirmatory evidence as to the class of miners
who suffer from nystagmus. In the first case he states
" that it would appear that when the head and neck were
bent on the right shoulder, f the discharging lesion, so to
speak, was at full pressure ; but when the head and neck
were flexed on the left shoulder, the nystagmus ceased
altogether. Then comes a time when the left shoulder
flexion was useless." Respecting his second case, he
says " A peculiarity in this case is that the man is left-
handed, and when getting coal the head and neck are
flexed on the left shoulder. At the present time he had
much difficulty in getting coal when in that position, but
by flexing the head and neck on the right shoulder he
can still do a fair amount of work.^^
4. Dransart, whose painstaking observations on the
affection we are discussing are well known, alludes in a
footnote, attached to his paper in the ^ Annales d^Ocu-
listique,' 1877, vol. ii, p. 121, to the men working in the
* He has done nothing but " holing ;" his eyes have become aflPected, especially
lately, since he has made a change in his mode of work. He still " holes
but where he had nine inches, he now has two feet to get out and cleai' down,
which necessitates a good deal of turning of the head when he is on his side.
f It is presumed the right was the side he was most accustomed to work
upon.
miners' nystagmus and its cause. 321
shallow '' inclines '' constantly lying, and adds,* '' We
ought to note this fact, that all our workers attacked with
nystagmus worked in these inclined bearings/'
6. The following very complete report by my friend,
Mr. C. S. Kilham, is valuable, as testifying to the absence
of nystagmus, in a colliery district where the conditions
I have before described were wanting. As formerly a
resident in the Sheffield Infirmary, and assisting me with
the ophthalmic patients, he was very familiar with miners'
nystagmus, and was thus well suited for the work he
kindly performed. I wish to record my appreciation of
the readiness with which, at my suggestion, he undertook
a by no means slight task. In reply to my inquiry as to
the frequency of nystagmus among the miners in the
district in which he was then residing (County of Durham),
he immediately stated that the percentage must be very
small, as he must have seen cases if there had been any,
but he had noticed none ; and referring to their mode
of work, he said that they did not work on their sides
but sat on a low stool instead. The other medical
men in the district had never seen anything of the disease,
and a like answer came to his inquiries of several managers,
viewers, and others.
The following is Mr. Kilham's detailed report. He
examined only men engaged in the pit and not those
employed at the mouth of it or on the pit bank.
" I have examined the men of four pits in this district,
more than 500 in number, made up as follows :
a. Coal-hewers . . . 324
h. Putters and drivers . 149
c. Labourers .... 33
506
" I have examined those men and boys who work down
the pit {i.e. excluding those engaged up the mine, at the
* Nous devons uoter ce fait que tous nos ouvriers atteints de nystagmus
travaillant dans des. gisements inclines.
VOL. IV. 21
322 AFFECTIONS OF MUSCTJLAR AND NEBVOUS SYSTEMS.
bank; &c., in day light), and I examined tliem as they
came out from work. The seams in these pits average
from two feet ten inches to six feet or so. Naked lights
(candles) are used excepting in a very few places in one
pit where Davy^s lamps are employed. The miners as a
rule are very healthy, though rather anemic, and many
of the hewers are flat -backed. They work eleven shift ?
of six hours every fortnight.
^^ a. Coal-hewers. — In the large seams they stand at
work, in the smaller ones even (2 ft. 10 in. to 8 ft.) they
sit on crackets or small stools bent forward, hewing from
above downwards in front of them, with theii' eyes directed
forwards and up or down as may be necessary. They
place their candles in lumps of clay on one side of them
so that the light is steady. In these pits they never
work on their sides.
^' h. Putters are strong youths up to eighteen or twenty
years old, who push the tubs (little waggons containing
the coal) fi'om the hewers to the larger workings, where
ponies are fastened to them. The drivers are lads who
look after the ponies.
^^ c. Labourers or off-hand men. — They are men who
are unable to hew from age or infirmity, and they go
down the pits generally during the night, and make
all the workings safe for the others, and clear up
generally. I was not able to examine all the labourers
employed, as they mostly come up at 4 a.m. or irregular
hours.
'' 1 have not seen a single case of nystagmus among the
men examined ; in fact it seems to be an unknown thing
in this immediate district, as many of the oldest men have
never heard of it, or seen anv cases.'^
He closes his report by remarking that the results of
his examination are entirely negative, and, he thinks, prove
that in pits where the men can sit or stand to hew and the
light i^ good enough to prevent great straining of the
eyes, nystagmus is very rare indeed.
I have said enough, I conceive, to support my cont^n^
miners' nystagmus and its cause. 323
tion that the miners who suffer from nystagmus are those
" whose work necessitates their lying on their sides. '^
Before, however, considering how this position occasions
the nystagmus, let us say a few words as to influences
assigned by others for its causation.
A great deal has been said by some writers as to the
unhealthy condition of the miners, and it cannot be
denied that their occupation is prejudicial to health, and
that a large number suffer from anaemia. But the
patients who come for treatment for nystagmus are, in my
experience, by no means an unhealthy looking lot of men.
On the other hand it is not unusual for them to express
their opinion as to their health being good. Thus the
most recent case I have treated has more than once
alluded to his robust state of health.
Neiden (^ Transactions of International Congress,'
London), who has extensively studied this disease, has
come to the conclusion that its cause is to be found in the
employment of the '^ safety lamps."* Anyone familiar
with a coalpit well knows, of course, the poor illumina-
tion given by these lamps. Neiden states that an
examination with Bunsen's photometer displayed the
differences between the light from an open lamp, a freshly-
lighted safety (Davy) lamp, and one in use in the coal-
dusty air as lO'O : 4*0 : 3*0. It is possible that the
effect the feeble light has in the accommodation, as
Neiden suggests, may have an influence in occasioning the
disorder ; but I believe it cannot but be a very secondary
one. Otherwise why should the disease be confined to the
hewers of the coal, and not be found among the trammers
and labourers, considering that all workers in the pit
employ equally the safety lamp ? Certainly if this were
the prime cause the disease should be more equally
diffused amongst the various classes of miners. The fact
of the sufferers from this disorder being, as I have stated,
found in one particular kind of workmen, ought of itself to
* Nystagmus has been found to exist amongst workers in mines where
safety lamps were not employed.
324 AFFECTIONS OF MUSCULAR AND NERVOUS SYSTEMS.
indicate, as the cause of the nystagmus, some peculiarity
in their work.
Dransart,* to whom allusion has previously been made,
has most fully and ably studied this disease. He has
expressed his belief that the disorder is due to the fatigue
induced in the elevator muscles in consequence of the
cramped position of the miner producing strain and a con-
stant upward movement of the eyes. ^^ The myopathy,^'
he says, ^' will have its principal seat in the superior rectus
and inferior oblique ; alone it occasions a weakness in the
organs. The pair of elevators having a feebleness cannot
overcome its antagonist ; it is obliged to attempt it
several times by means of a series of little successive and
rapid contractions. It then produces nystagmus, or
rather gives occasion to the vertical oscillations. To
explain the horizontal oscillations which are noticed
in miners' nystagmus we have recourse to the paresis
of the internal recti and the accommodation. The im-
portance of the internal recti may suffice to explain the
horizontal oscillations ; they are produced by the above-
mentioned mechanism. But the accommodation contri-
butes to increase the muscular disorders by virtue of the
relations which exist between convergence and accommo-
dation, or, in other words, between the ciliary muscle and
the internal rectus. '^
Now, if the miners suffering from nystagmus are those
employed in the position mentioned by me, the '^ constant
upward movement of the eyes '' is not, as I shall show, the
direction in which the eyes move and is not therefore the
cause of the nystagmus. A miner lying on his side, engaged
in ^^ holing,'^ either whilst making the ^^ hole ^' or whilst
continuing his work in it, will of course fix his gaze at
different parts according as it is necessary to strike, but the
tendency will be for the eyes to assume a direction obliquely
upwards. This is rendered evident to anyone seeing a man
assume on the floor the position occupied in the pit. The
engraving (Plate X, fig. 3) illustrates this. A man in this
* • Annales d'Oculistique,' 1877, vol. ii, p. 128; ib., 1882, vol ii, p. 150.
miners' nystagmus and its cause. 325
position cannot well look directly upwards ; he may look to
a point in front of him as he strikes, but not so well beyond
the vertex of his head. The miner, therefore, occupied in
" holing '' will lie on his side, sometimes the left and
sometimes the right, as is most convenient; his legs will
be crooked up, his head thrown back, and the eyes will
have the tendency to look in a direction obliquely upwards.
Simply looking upwards may be tiring, but it may be
safely asserted we are more accustomed to fix our gaze in
that direction than in an oblique one. Most persons will,
I conceive, feel the strain greater of looking obliquely than
if they merely gaze directly upwards, and the difference
will be evident if the eyes are turned for a little time in
the direction indicated.
Dransart, as has been pointed ouo, assigns the muscles
suffering and occasioning nystagmus, as the elevator, the
superior rectus, inferior oblique, and internal rectus, but
of course it would chiefly be the first-named, aided by the
inferior oblique and in a less degree by the internal
rectus. Now, if the position — obliquely upwards — be
correct, it follows that the muscles suffering from chronic
fatigue will be somewhat different to those indicated by
Dransart. Thus, if a miner be working on his left side,
and fixing his gaze upwards and to the right, he will be
using in the left eye the superior rectus, inferior oblique,
and internal rectus ; in the right the same two first-
mentioned muscles, and substituting the external for the
internal rectus. If he lie on his opposite side of course
the arrangement would be reversed. Besides the more
complete employment of the internal recti than the mode
of Dransart allows for, we have, in addition, the external
recti at work, and it need hardly be said that the inferior
obliques are much more used than in the arrangement he
suggests. The to and fro movement is thus accounted
for by the weariness of the outer and inner recti ; the
, rotatory oscillations by the inferior oblique, and the supe-
rior rectus aids here, or in occasioning the vertical move-
ments.
326 AFFECTIONS OF MUSCULAR AND NERVOUS SYSTEMS.
A point worthy of remark is the ready manner in which
the nystagmus is occasioned by placing the eyes in the
obliquely upward direction. The miner whose position is
represented in Plate X, figs. 2, 3, was for several months
previous to his picture being taken '^ cured/^ and after
leaving the pit followed another occupation^ gardening,
without discomfort. When he placed himself in " posi-
tion'^ for the photograph he felt discomfort in his eyes
and could not bear it long.
The cause I have mentioned is, I conceive, the main
one acting in the production of nystagmus. Dransart
refers to paresis of accommodation and other points which
I must now leave without further reference.
Writers who have not assigned the affection to the
attitude of the miner, but rather to the effect of the
insuflB.cient light on the accommodation, have, as well as
Dransart, thought the consequent strain on the ocular
muscles induced a weariness in them similar to that known
as writers' cramp. This seems to me the correct patho-
logy. The muscles of the eye are employed in keeping
the globe in an unusual position for many hours together.
There is thus prolonged strain, chronic fatigue results,
and, atony of the muscles being induced, oscillation of the
globes is caused.
A few words as to treatment. It has been my practice
to advise the discontinuance of pit life, and their finding
some other employment, and after a variable time, according
to the severity of the case and the length of its duration,
recovery has ensued. Strychnia has been my favourite
internal remedy. An important point is, however — and
Dransart discusses it — whether as nystagmus is infrequent
or, in my experience unknown, in other miners than coal-
getters, whether it is not possibly sufficient for the miner
to change his mode of work, but still be employed under-
ground.
And, moreover, if the manner of work discussed in this
paper is the prime factor in the causation of this disease
it may be possible to hereafter encourage managers of
DESCRIPTION OF PLATE X.
Fig. 1 illustrates Mr. Snell's case of CoQgenital Cyst of the
(Left) Lower Eyelid (p. 334). From a photograph of the
baby.
Figs. 2 and 3 illustrate Mr. Saell's paper on Miner's
Nystagmus (p. 325). Both are taken from photographs of the
miner.
Fig. 3 shows the coal miner lying on his left side iu position for work.
Fig. 2 shows, on a larger scale, the position of the head and eyes only.
Trans. Opktli.Soc.Vbl. rv^Pl. 10
^4
i // ■■/
Econi. PI, oto graph s
^-
vro nt .N»»%vi «i ,^ii & » ".' ii t]i .
miners' nystagmus and its cause. 327
collieries to attain by other means the ends they have in
view. Comparatively, many miners suffer from nystag-
mus, and if a relinquishment of the manner of employment
spoken of, stamped out the disease or lessened its frequency
it would be a matter of great thankfulness to many workers
in the pit.
Mr. Priestley Smith (Birmingham) said that in Bir-
mingham a good many cases of miners' nystagmus came
under notice from the mines of South Staffordshire. In
looking for the causes we should not, he thought, entirely
dissociate this form of nystagmus from those which arise
under other circumstances. Nystagmus, however arising,
must, in his opinion, be regarded as a sign of disturbance
of function in the centres which governed the combined
movements of the two eyes, for the oscillations were
bilateral and synchronous, and, though not always of
equal extent on the two sides, were clearly due to efforts
acting bilaterally. They were sometimes horizontal,
sometimes vertical, and sometimes rotatory around the
antero-posterior axes, but in all cases expressed, not the
failure of an individual muscle, but a disturbance of the
co-ordinated action of certain pairs or groups of muscles.
The functional activity and nutrition of the co-ordinating
centres appeared to depend largely upon the stimulus
supplied by retinal impressions. This stimulus was cer-
tainly essential to the normal development of these centres
in early life, for children born with diseased optic nerves
or with opaque lenses became nystagmic ; if vision were
not early improved by operation the nystagmus became
confirmed and irremediable, while on the other hand, it
disappeared if the opaque lenses were removed at a very
early age. This fact proved, the speaker thought, that
the nystagmus was essentially dependent in such cases
upon the absence of retinal pictures. He had himself
noticed that it was difficult to maintain a steady prolonged
fixation of a '^ luminous matchbox 'Mn a perfectly dark
328 AFFECTIONS OP MUSCULAR AND NERVOUS SYSTEMS.
room. In the case of the coal miner the same essential
cause was, he thought, in operation. The miner worked
by a very feeble light surrounded by " black walls/ ^ con-
ditions in which the stimulus to fixation must be very
feeble. The facts with regard to the horizontal position
during work, so well illustrated by Mr. Snell, would
explain how it was that certain men acquired nystagmus
while the large majority escaped. The strain involved
in looking obliquely upwards was greater than in other
positions, hence the energy available would be sooner
exhausted.
In reply to a question by Mr. Nettleship as to how the
occurrence of nystagmus in one eye only could be recon-
ciled with the theory of central exhaustion, Mr. Priestley
Smith said that when we spoke of a bilateral ocular move-
ment being governed by a single centre, we probably
meant two centres, one on each side of the brain, con-
nected by commissural fibres, and ordinarily incapable of
separate action. It was not unlikely that in exceptional
cases one half of such a compound centre might undergo
atrophy while the other remained intact ; such cases of
unilateral nystagmus were, however, extremely uncommon.
Dr. Stephen Mackenzie said the President had appealed
to the experience of physicians as to the nature of " writers'
cramp " and similar disorders, and whether they were or
were not to be regarded as of central origin. His own belief
was that ^' writers^ cramp ^' and other ^' fatigue paralyses ''
were of central origin. He thought that the physiological
action of the muscles could not be dissociated from the
energising centres. He instanced holding out the arm at
right angles from the body ; after a time, in the strongest
person, tremor took place, but this could be controlled
for a time by a stronger effort of the will. In ordinary
circumstances there was a balance of antagonism between
groups of muscles physiologically associated, and when
one group was overworked this balance was disturbed and
the antagonists came into action, often in a fitful and
miners' nystagmub and its cause. 3^9
irregular manner. All influences that led to exhaustion
of the nervous centres tended to produce tremor and other
uniocular disturbances, and thus excessive sexual inter-
course, as had been alluded to in one case, chronic alco-
holism, febrile and protracted diseases, &c., tended to
bring about these motor disturbances.
As regarded the particular condition that had been so
carefully described by Mr. Simeon Snell that evening, he
thought Mr. Priestley Smith had advanced conclusive
arguments as to its dependence on central disturbance.
He thought that Mr. Snell had established that it was the
oblique position of the head and neck that led to the
nystagmus of miners. But the element of imperfect illu-
mination perhaps contributed to the result, and from Mr.
SnelPs description it appeared to him that miners who
were engaged in " holing " had to concentrate their gaze
more accurately and adjust their movements more exactly,
and thus the imperfect light might contribute in pro-
ducing the nystagmus. He further pointed out that in
insular sclerosis and other nervous diseases nystagmus
was clearly dependent on localised disease of the central
nervous system.
Mr. Eales (Birmingham) had seen many cases of
miners' nystagmus, and while willing to concede a due
share in the causation of this affection to faulty position
causing unusual strain on the ocular muscles, attached
much more importance than Mr. Snell did to the visual
conditions under which the miners worked. He had
recently seen a case in which a miner, who had worked for
many years with a naked light, at once became affected
with nystagmus on having to work with a Da^^ lamp, and
many of these patients immediately became nystagmic on
the light failing, as in walking home in the twilight.
Moreover, some complained that they were practically
blind for some moments on passing from a lighted room
into the dull light. He thought that the black character
of the object looked at, the bad illumination, and probably
330 AFFECTIONS OF MUSCULAR AND NERVOUS SYSTEMS.
a failure in retinal sensibility were the the most important
factors in the causation.
If mere muscular strain would cause nystagmus, why
did not many other classes of persons who put great strain
on their ocular muscles get nystagmus ? Moreover, all
other forms of nystagmus (except certain rare cases due
to central nerve lesion) were associated with faulty per-
ception from some cause. He thought the chief cause
was loss of sufficient retinal stimulus to fixation, necessi-
tating greater strain on the nerve-centres controlling the
muscular movements resulting in their exhaustion, and
consequent loss of co-ordination. This view was further
supported by the conjugate character of the affection.
When once induced, any attempt to direct the eyes as
when at work, at once caused nystagmus by calling on
the particular nerve-centres affected, and so faulty position
became a common excitant of the nystagmus.
Mr. W. Adams Frost suggested that possibly in those
mines in which the Davy lamp was not used ^^ holing ^'
was not practised. In the collieries of North Stafford-
shire ^^ holing'^ was practised and nystagmus occurred.
The position of the miner during the operation was very
faithfully depicted in the photographs exhibited.
Mr. Snell, in replying, said that he should himself have
discussed in his paper many of the subjects which had
been raised had he not felt that he had trespassed as it
was sufficiently on their patience. He could hardly agree
with Mr. Priestley Smith in his statement that both eyes
were invariably equally affected, for Dransart found in some
of his cases that the nystagmus was well marked in one
eye and less so in the other. The effect of the darkness
of the pit and the black walls must have a very secondary
influence in causing nystagmus, to the '^ position " indi-
cated, for i;he miner " holing '' worked, he thought, in no
worse light than the coal-getter in other ways. As to any
marked loss of power of muscles, Mr. Snell stated that
miners' nystagmus and its cause. 331
Dransart believed there was paresis of the internal recti,
but he had not himself sought particularly for any such
condition. He was pleased to have Dr. Brailey's support
to his proposition, that it was the position assumed by the
miner that occasioned the nystagmus, as well as his corro-
boration of his belief that when the eyes were fixed in an
oblique position for any time they became '^ jerky.-" He
gathered, moreover, from the statements of Messrs.
Priestley Smith and Eales that ^' safety ^' lamps were not
employed much in the neighbourhood of Birmingham, and
yet as they saw instances of the disease, it followed that
the importance of this imperfect illumination as a cause
was discounted. It was possible that the man Mr. Eales
mentioned as not suffering whilst working with naked
lights and becoming affected when he used ^^ safety "
lamps, might on inquiry be found to depend in reality on
a change in his mode of work. For instance, Mr. Snell,
referred to the case of a miner who did not suffer whilst
coal getting, until his work compelled him to assume the
position, on his side, described. It was then that he com-
plained of his eyes and suffered from nystagmus. He
imagined, though his knowledge of the working of other
mines did not yet allow him to speak with perfect confi-
dence, that it would be found that the manner of work he
had described, as undertaken by miners, " holing,' ' was
peculiar to collieries. It would appear to be less neces-
sary in other mines where there were not the same objec-
tions to boring that there were in a coalpit, and, more-
over, the hard metals could not perhaps be got down with
a wedge like coal. If this were so it would account for
the absence of nystagmus amongst the workers in other
mines.
{Jidy Uh, 1884.)
332 CONGENITAL DEFECTS.
6. Concomitant squint following severe scalp wound, compli'
cated by slight paralysis of the right external rectus.
By Anderson Ceitchett and Henry Juler.
Samuel D — , aet. 14, healthy boy, sustained a severe
scalp wound on February 7th of the present year, for
which he was under the care of Mr. Norton at St. Mary^s
Hospital. Four days after the accident the eyes became
convergent, and he suffered from double vision. There
was no loss of consciousness at any time. He made an
excellent recovery from the severe scalp injury, but the
squint still remained. He first came under our notice
about three weeks ago, and his condition then was much
the same as at the present time, viz. marked convergent
strabismus and slight paralysis of the right external rectus.
Both the primary and secondary deviations are excessive
(over 45°) ; they are also apparently equal.
In each eye there is hypermetropia to the extent of
5 D.
The vision when corrected by convex glasses is |- in
the right and -j^ in the left eye.
On testing the muscular power by means of the peri-
meter we find the field of fixation in the left eye to be good,
whilst that of the right shows a deficiency in the power of
the external rectus.
Our first impulse was to attribute the convergence to
paralysis of the sixth nerve as the result of the head injury ;
indeed there is evidently some deficiency of the right
external rectus. Taking into account, however, the high
degree of hypermetropia, the equality of the primary and
secondary deviations, and the shock he must have received
from the severe scalp-wound, we consider the squint to be
chiefly due to the hypermetropia.
P.S. — Tenotomy of the internal rectus of each eye was
performed on June 6th, and the patient was exhibited at
the meeting of the Society on July 4th, the eyes being
then parallel. {Living specimen, June 6th, 1884.)
CONGENITAL CYSTS IN THE LOWER EYELIDS. 333
XIII. CONGENITAL DEFECTS.
1. Congenital cysts in the lower eyelids in one case
with (apparent) anophthalmos, and in the other with
microphthalmos ; a case also of coloboma of optic nerve
sheath, with other cases of congenital defects.
By Simeon Snell (Sheffield).
(With Plate X, fig. 1.)
1. Congenital cysts in the loiuer eyelids with apparent
anophthalmos. — On the 7th of May (1883), a child was
brought to me at the Sheffield Infirmary, by its mother
in consequence of its not having looked about like other
children, nor indeed did the eyes appear like those of
others. Fearing something was wrong she sought advice.
The baby was just a month old, having been born on
April 11th.
Attention was at once attracted to a swelling in the left
lower eyelid. Beyond this the appearance and formation
of the eyelids were normal, as was also the palpebral fissure.
The upper eyelids seemed to fall in as if wanting support
from within. A similar swelling, only very small, existed
also in the right lower eyelid ; except this the eyelids, &c.,
were normal on this side. On separating the lids there
seemed an entire absence of anything resembling an eyeball
in either orbit. Chloroform was, however, administered
to enable one to make a full and satisfactory examination.
The orbital cavities and their bony walls were properly
formed, but nothing like an eyeball was discovered.
Towards the back part (cone) of each orbit a feeling of
resistance was noticed. The conjunctiva lined the entire
334 CONGENITAL DEFECTS.
cavities. In the left lower eyelid, as before mentionedj
was a distinct swelling, about as large as a bantam^s
egg. It occupied tbe whole breadth of the eyelid, being
continued into the inner corner of the orbit. Its appear-
ance was bluish, and the integument covering it seemed
thinned. It was distinctly fluctuating. In the front at
its middle it appeared to be a trifle constricted and bulged
more on either side. With the infant under chloroform
this cyst, as it seemed to be, was found to be well confined
within the orbit, not reaching beyond its lower margin,
but passing to the posterior part of the cavity. It was
traced along the floor of the orbit beneath the conjunctiva
by its bluish colour and the swelling it occasioned. The
engraving (Plate X, fig. 1) is from a photograph taken
shortly after the child was first seen and well exhibits the
appearance of the left side. On the right side there was
some ectropion, and the cyst in the lower eyelid was
considerably smaller than the one on the other side.
The infant was a healthy, well-developed child, its head
and limbs were well formed, and there was an absence of
any deformity beyond the ones described. The mother of
the child was aged twenty-six, and the father, a farm
labourer, twenty-seven. Both were stated to be free from
deformities. They had been married two years, and there
have been two children ; the eldest, born not long after
marriage at full time, was eighteen months old and was
healthy and strong. The mother was the second child of
a family of twelve ; six of these were dead (four being
premature and two dying early) ; none were, it was said,
malformed in any way. The father was the second child
of a family of five, all being healthy, and none deformed.
The diagnosis made in this case at the outset was that
the congenital tumours were serous cysts, and were asso-
ciated with absence of the eyeball. To verify the opinion
formed as to the nature of the cysts it was decided to punc-
ture the one in the left orbit, and examine the fluid removed
in the manner mentioned by Wecker and Van Duyse.
On July 2nd ether was administered, and the cyst in
CONGENITAL CYSTS IN THE LOWER EYELIDS. 335
the left orbit was tapped with a small aspirator. The
quantity withdrawn was about two teaspoonsful, but some
of it was lost, and the quantity was too small to permit
me to ascertain the specific gravity. The cyst was not
completely emptied. The fluid corresponded closely, ac-
cording to the chemical examination to the analysis by De
Wecker and Van Duyse (page 344) of the contents of the
cysts in their cases and confirmed the diagnosis already
made. The fluid was, however, redder than mentioned in
other cases, and this is accounted for, I fancy, by the
admixture of blood at the time of puncture, as the aspi-
rator was in reality at work before the needle had actually
penetrated the cyst. Blood-cells were plentiful under the
microscope. The fluid contained albumen, and chlorides,
but no sugar.
23rd. — The cyst has refilled, and it was now opened
and the wall partially dissected out. A very small rounded
body was detected at the back part of the orbit, and was
presumed to be a rudimentary eye, but it was not thought
advisable to prolong the dissection to render this opinion
positive. Nothing was done to the small cyst in the right
lower eyelid. I can find no note of the fact, but my
recollection is that at the emptying of the left cyst the
second time it was of decidedly lighter colour than on the
previous occasion.
The child has thriven well, and when seen a short time
after the last note the left orbit was still free from the
cyst, and that on the right side had not become larger.
June 23rd, 1884. — The child was seen to-day. There
is a little fluid in-the cyst in the left lower eyelid at its
inner part, and it is still bluish on its surface ; it is very
insignificant to what it formerly was. A small trocar
was passed into it, and a small quantity of straw-coloured
fluid escaped.
The appearance of what was thought to be a very small
cyst in the right lower eyelid (it was never tapped) has
just gone. There is, however, at the lower part of the
orbit a rounded swelling, not distinctly fluctuating; it is
336 CONGENITAL DEFECTS.
deep under the conjunctiva ; this may be the cyst or a
rudimentary globe. No dissection to solve the point could
be made.
The child is in the enjoyment of perfect health.
Congenital orbital cyst with microphthalmos, — My friend,
Mr. W. Mackerg Jones, of Wath, near Rotherham, has
kindly given me particulars of this case, which he per-
mitted me to see with him on one occasion. It is of
particular interest in connection with the one already
related. I give the case in Mr. Jones's words :
"During the latter end of May, 1883, a child, six
weeks old, was brought to me to see if anything could be
done for its left eye, which was reported to be absent.
" The parents had a large family of healthy children,
and there was no history of congenital deformities.
" On examination the child was apparently healthy
and well developed, with the following exception. The
left lower eyelid was the seat of a firm dense swelling,
with indistinct fluctuation, more prominent on its conjunc-
tival aspect and bulging out between the eyelids. It so
completely filled the orbit that I was unable to introduce
a retractor between it and the upper lid, which I attempted
to do, thinking that perhaps the eye might be found com-
pressed behind it. The conjunctiva over it was in two
places slightly raised into blue-looking protuberances.
" Never having seen anything like it before, I concluded
it was either a displaced disorganized eyeball, or some sort
of tumour growing in the lower lid pressing back the eye.
Whatever it was I advised it should be removed and so
lessen the deformity. The child was brought again in a
few days, and as the swelling had considerably increased
the parents wished for something to be done.
" On June 1st, 1883, I dissected back the conjunctiva,
causing the tumour to appear as a tense cyst, which I
attemptec? to extract whole, but accidentally pricking it
with the knife, it discharged a considerable quantity of
clear straw-coloured fluid and then collapsed. Following
I
CONGENITAL CYSTS. 337
back the cysfc wall I found it was attached deep down in
the orbit, and fearing it was a meningocele I cut it off
with a pair of scissors as far back as I could reach. On
replacing the conjunctiva I then found deep down in the
orbit an exceedingly small eye, having an inferior coloboma
of the iris. With the exception of this and its size it
appeared quite normal. Cold-water dressings were applied
and the orbit was ordered to be syringed out regularly
with warm water. In about a week the wound had quite
healed and the eye could be seen deep down when the
child opened the lids.
'^ On June 1 6th the child opened the lids freely, and the
eye was not nearly so deep down. The conjunctiva on
the upper side appeared very tight, pulling the eye
forwards.
" In August the eye had grown considerably and had
come forward to its proper place.
^' In October Mr. Snell came over to see the child, whom
we found in the last stage of tubercular peritonitis ; the
eye had grown since I last saw it, but it was still much
smaller than the other. The child could move it about
freely in any direction and could evidently see with it.^'
Any examination with the ophthalmoscope at the time
of my visit was attended with the greatest difficulty.
The child was nearly moribund and died a few days
later. The coloboma in the lower part of the iris, men-
tioned by Mr. Jones, was well marked, and with the
ophthalmoscope it was ascertained to extend into the
choroid, but I am not certain whether or not it reached
the optic disc. The media were perfectly clear. The
eyeball had all the appearances of a normal globe, except
for its small size and the coloboma. Perhaps it was about
a third the size of the normal eye.
We were unable to obtain the eye for examination.
The cases I have just related are among the rarer
ocular anomalies. Others, in many respects similar, are
on record, and various suggestions have been made io
VOL. IV. 22
338 CONGENITAL DEFECTS.
account for these congenital cysts. They have been
found associated with cases either of microphthalmos or
anophthalmos^ but in this latter condition careful exami-
nation after emptying the cyst has often disclosed the
presence of a rudimentary organ. Mr. Jones's case is
of interest on account of the discovery under these circum-
stances of a comparatively good eye. Without emptying
the cyst it would have passed as a case of anophthalmos.
I propose to add here some particulars of other cases
which have been recorded.
Wicherkiewicz* has related a case of double anoph-
thalmos_, with cysts in the lids, in a child of eight weeks.
Apparently the cysts were situated between the con-
junctiva and external layers of the palpebral tissues.
The orbit was lined with conjunctiva and had a normal
depth. The upper lids and lacrimal puncta were normal.
There was complete absence of the rudiments of eyes.
The cystic fluid was not able to be collected.
He explains the origin of these palpebral cysts in
the following manner :— As a consequence of the void
occasioned in the pre-formed orbits by the total absence,
little development, or intra-uterine resorption of the
globes the eyelids yield to the external pressure and
turn themselves into the empty cavities. As they do not
fill the void there is formed in the cellular tissue of the
lower eyelids a serous transudation to fill the void in ques-
tion. The liquid encysts itself in a membrane formed from
the connective tissue in its own immediate neighbourhood.
Subsequently the cysts, partly by their weight, and partly
by the dragging of the orbicular muscle, detach themselves
from the internal wall of the orbit. He gives no opinion
in this as to the anophthalmos.
De Weckerf has also recorded a case of anophthalmos
with congenital serous cysts in each orbit. The tumours
* Zehender's 'Monatsb. f. Augenheilkunde/ Oct., 1880. Analysed in
* Annalea d'Oculistique,' 1881, vol. i, p. 69.
t " Cas d' Anophthalmos avec Kystes Congenitaux des Paupieres inferieurea
simulant une ectopic des Yeux." 'Annales d'Oculistique/ 1877, vol. i, p.
151.
CONGENITAL CYSTS. 339
were situated in the lower eyelids, and had a bluish tint.
The cysts were tapped and the fluid examined chemically
and found to correspond with the usual contents of these
cysts, to be mentioned further on, when treating of the
diagnosis of these tumours. Microscopically they did
not exhibit any histological element. Examination did
not discover anything corresponding to an ocular globe.
The article is accompanied by an engraving of the case
described.
Streibitzy* met with a case of anophthalmos with con-
genital cyst developed in the lower eyelids. The patient
was a girl, aged six months. There was ectropion of the
lower eyelids and the conjunctiva was raised by two
tumours of the size of normal eyes, which were prominent
in front, fluctuating and moveable to a limited extent,
and through the thinned skin exhibited a bluish tint.
No examination of the liquid was made, and the absence
of a rudimentary globe does not appear to be proved.
A case by Michel,t of bilateral anophthalmos differs
materially from the foregoing ones. There was an absence
of both optic nerves and both olfactory lobes ; a little
cartilaginous cul-de-sac was present into which were
inserted numerous muscular striae ; lids sufficiently deve-
loped ; arrest of development of half the cranium —
orbits very small. The author believes that the non-
development of the brain was the primary anomaly.
Talko has recorded no less than seven cases of palpebral
cyst associated with microphthalmos or anophthalmos.
I cannot here give a resume of each of the cases.
They are briefly analysed by Van Duyse in his very
valuable article entitled '' Le Colobome de TCEil et le
Kyste Sereux Congenital de rOrbite,^^{ and in which he
deals very thoroughly with the subject.
* Zehender's * Monatsb. f. Augenheilkunde,' Nov., 1881. Analysed in
' Annales d'Oculistique,' 1881, vol. ii, p. 267.
t Graef e's ' Arcliiv,' vol. xxiv, 2. Analysed in * Annales d'Oculistique,*
1879, vol. i, p. 78.
X 'Annales d'Oculistique,' 1881, vol. ii, p. 114.
340 CONGENITAL DEFECTS.
Talko draws the following conclusions from his cases :
1 . The serous intra-orbital cysts of the newborn are ordi-
narily complicated with faulty development of the eyeball.
2. They are localised always between the globe and
the lower, or lower and internal wall. They are ordinarily
covered by the conjunctiva ; they pass in the direction
of the lower eyelid, which they push in front of them, and
give rise to the bluish grey colour of the cyst.
3. They are ordinarily filled with a yellowish serosity,
which contains much albumen.
4. They are not ordinarily in connection with the con-
junctival sac, nor with the bulb when one exists.
5. They can be punctured or excised.
6. Their size is variable. They produce generally
ectropion of the lower eyelid, and hinder the development
of the eye, which is very little, and which lies deeply
in the orbit. These cysts are not produced after birth,
but during intra-uterine life.
Talko, moreover, expresses his opinion that these
vesicles have nothing in common with the ocular globe
(les vesicles n^ont rien de commun avec le globe oculaire) .
Formed during intra-uterine life, these cysts place an
obstacle to a complete development of the eye (microph-
thalmos), or hinder entirely its evolution (anophthalmos) .
Talko would, moreover, appear to admit, on the hypo-
thesis of Hoyer, that these cysts arise in the foetus by
the entanglement of the upper part of the lacrimal sac
during the process of welding the lacrimal fork, and are
cysts by retention.
Yernueil has also described these cysts as occasioned
by an ectasia of the lacrimal sac.
Yan Duyse in the article to which reference has already
been made, together with notices of other cases, reports
one by Chlapowsky. The patient, a boy of 16 years, pre-
sented on the left side an intra-orbital fluctuating cyst,
the movements of which coincided with those of the fellow-
eye. Provided in front with a swelling corresponding to
the cornea, and behind a pedicle representing the optic
CONGENITAL CYSTS. 341
nerve, the tumour, rounded, smooth, and colourless filled
the whole orbit. Extirpation demonstrated the adherence
to the cyst of muscular fibres, and at the bottom of the
orbit a white lenticular body, representing the rudimentary
eye. The cystic liquid was not examined, but Biesiadecki
found in the walls of the cyst some epidermic elements and
fatty tissue which made him diagnose "atheroma.''
Sogliano has also reported a case which would seem to
have been one of a high degree of congenital hydroph-
thalmos.
Manz* has recorded the two following cases. The first
in a young man, aged 16 years, the other eye was normal.
The congenital cyst filled the entire orbit, and was in re-
lation by its inner wall with a rudimentary ocular globe
rich in connective-tissue vessels and had a pigmented
choroid ; there was a sclerotic also and a pedicle (optic
nerve without nervous tissue). The internal surface
presented a thick epidermic covering and some down.
In the second the eyeball was reduced in all directions,
with ciliary body and retina very rudimentary. A cyst
was situated at the lower part and extended just to the
optic nerve, of which the sheaths were hypertrophied.
The cyst developing in the sclerotic had induced atrophy
of the globe.
Van Duyse relates in the paper I have before referred to
the following interesting case of his own, which he details
at length : The patient was 22 years of age ; others in his
family had suffered from harelip, cleft palate, &c.
The left globe was diminished in size (-5-) ; coloboma of
iris below. He gives a detailed account of the appear-
ances of the fundus and the following results of his exami-
nation : There existed on this (left) side a certain degree of
microphthalmos and a markedly staphylomatous coloboma
of the inferior posterior wall ; the eye appeared to have
compensated, by the development of its posterior half, the
* " Deux cas de Microphthalmos Congenital et Considerations sur la degene-
rcscenee cystoide du Bulbe Foetal.' Graefe's Archiv,' xxxvi, i. Analysed in
' Annales d'Oculistique/ 1881, vol. i, p. 259.
342 CONGENITAL DEFECTS.
volume wliich was wanting in its anterior region. The
coloboma affected specially tlie choroid, the sheath of
the optic nerve, and at least the pigmentary layer of the
retina.
Bight eye. — Elastic fluctuating tumour in lower lid not
adherent to skin. The eyelid normal as its fellow ; the
upper eyelid was rudimentary. The cyst extended into the
orbit J was covered by the conjunctiva, and had a bluish tint.
Eyeball was thought to be absent, and diagnosis made
was " serous cyst of orbit with anophthalmos.^' The fluid
was withdrawn from the cyst ; it was like ascitic fluid, the
colour of urine. Microscopical examination, negative.
The cyst was subsequently opened and a rudimentary
globe discovered which was separated with difficulty from
the cyst ; traction on the cyst occasioned movements of the
globe, showing a very intimate connection between the
congenital cyst and the eye. The latter followed all the
movements of the fellow-eye.
From a consideration of recorded cases, and his own
case. Van Duyse considers that the cysts have a diverse
origin, and may be divided into three classes :
1. Cysts corresponding to hydrophthalmos, to a high
degree of foetal cystic degeneration of the bulb, very pro-
bably due to an intra-uterine chronic inflammatory process
of the uveal tract.
2. Dermoid cysts, arising from an invagination of the
external germinal vesicle, in connection with the eye
(Manz, Chlapowski).
3. Subpalpebral serous cysts with microphthalmos or
anophthalmos, such as Talko, De Wecker, Wicherkiewicz
have described, which appeared to be derived from an
encysted coloboma.
Eespecting his own case. Van Duyse came to the
conclusion that the left eye (slight microphthalmos)
presented a sclerectasia, caused by the expansion of a
coloboma of the choroid of the optic nerve sheath, itself
staphylomatous. The right eye constitutes a degree more
pronounced of the same anomaly. It has remained rudi-
CONGENITAL CYSTS. 843
mentary (microplitlialmos) as a result of the extraordinary
development of the coloboma. The latter, encysted itself,
and filled the orbit, pushing before it the conjunctiva and
lower eyelid.
Of the different theories advanced by various observers,
and referred to in the foregoing summary, to account for
the origin of these interesting and peculiar congenital
cysts, the one which Yan Duyse has suggested appears
to me to be based on the firmest grounds. The
frequent, almost constant association of these cysts with
a rudimentary or ill-formed eyeball of itself suggests
some causal relationship between that condition of globe
and the cyst pressing forward the eyelid. Another point
that may be mentioned is the presence of these cysts in the
inferior part of the orbit, and the ordinary position for
colobomata of the eyeball is at the lower side. Mr.
Jones's case is of particular interest from the discovery of
such a comparatively speaking well-formed eyeball in the
orbit. It is instructive also as demonstrating the possi-
bility of overlooking, an eyeball, and much more so, a
very rudimentary globe, if the cyst be not tapped or dis-
sected out, before a final conclusion is arrived at. It is
possible that in this way cases described under the
heading of ^' serous cysts with anophthalmos '' might have
been ascertained not to be so, if the cystic tumour had
been treated in the manner indicated, and an eyeball as
good as in Mr. Jones's case or merely rudimentary might
have been discoA^ered.
Another important question arises in any case in which
a fluctuating tumour in the orbit is diagnosed. I refer to
its nature. The wiser plan would seem to be to puncture
the cyst in the first instance, and then analyse the fluid
removed. This was the procedure adopted in my case,
and Wecker and Van Duyse have acted in like manner,
and urged the importance of doing so.
If the tumour should chance to be a meningocele an inci-
sion would be clearly not advisable, for as Van Duyse men-
tions, ^' In the first stages of development the connection
344
CONGENITAL DEFECTS.
between the sac and tlie cranial cavity is direct,, it ceases
in a manner sometimes wlien it exists as an extracranial
cjst.'' A tumour situated at the inner side of the orbit
would always lead one to consider the possibility of having
to deal with a meningocele. This is the situation where
such a tumour would seem to be apt to occur,
A high degree of congenital hydrophthalmos is mentioned
as being a condition which it is possible to confound with
a palpebral serous cyst. If the general characteristics did
not suffice^ a chemical analysis of the fluid removed would
enable a correct diagnosis to be made.
Dermoid cysts have a varied situation in the orbit. A
microscopical examination and the general features of the
growth would point out its nature.
Hydatid tumours occur in all parts of the orbit^ and are
generally attended with pain. If the tumour were tapped,
the microscopical and a chemical examination of the fluid
would remove any doubt.
Annexed is a table of the various contents of tumours
from which it is essential to be able to distinguish the
serous cysts. I take it from Yan Duyse's article. The
fluid in my case corresponded to the features mentioned
by Yan Duyse as pertaining to the liquid of these con-
genital cysts.
Fluid of cyst (encysted
coloboraa).
Aqueous
humour.
Alkaline
reaction
Cerebro-spinal
fluid
Hydatids.
Contents of
dermoid cysts.
No foi'med
elements. Colour
lemon yellow.
Very slightly oily
Feebly alkaline
reaction
By heat the fluid
thickens, becomes
Alkaline
reaction
Little crowns
of booklets ;
little sacs
Fatty crystals,
notably plates
of choleste-
rine; fatty
globules ;
epidermic
elements ;
soft hair
CONGENITAL CYSTS.
345
Fluid of cyst (encysted
Aqueous
Cerebro-spinal
Ilydatide.
t
Contents of
coloboma).
humour.
fluid.
dermoid cysts.
gelatinous and
milky, and the
condition does not
disappear with
nitric acid
.
White precipitate
Albuminoid
Not
Absence of
very abundant
matters
coagulable
albumen
with nitric acid,
(fibrine, &c.)
(according to
increased by
very feebly
G. Gautier)
boiling (albumen)
precipitated
by acids
White precipitate
—
—
—
—
very abundant with
chlorhydric acid ;
application of heat
causes then the
coagulation of all
the liquid
No effervescence
No efferves-
Slight effer-
^_
with acids
cence with
acids
vescence with
acids
(carbonates)
The addition of a
Contains 7%
Chlorides
Contains
__
solution of nitrate
of chlorides
absent
chiefly chlo-
of silver, 1%, pro-
ride of sodium
duces a white pre-
cipitate, soluble in
ammonia, insoluble
in nitric acid
No deposit with
No effect on
The alcapton
Often grape
_
Fehling's solution
cupro-potassic
(Bodiker) or
sugar; some-
■
reagent
glucose (CI.
Bernard) con-
tained in this
fluid throws
down Feh-
ling's solution
times succinic
acid (Heintz.
Honij, &c.),
inosite(Wijss)
Congenital ahsence of one eyeball. — Several years ago a
little baby was brought to me on account of one eye only
being visible. On separating the eyelids no globe could bo
found. The conjunctiva lined the orbit. The palpebral
fissure appeared narrower than on the other side ; the lids
346 CONGENITAL DEFECTS.
were well formed. There was a tliin muco-purulent dis-
charge. The other eye was normal. The baby has since
grown to a girl of seven or eight, and is strong and quite
intelligent. The narrowing of the palpebral fissure now
is most decided ; and the eyelids are less developed than
those on the other side, where the eye and its surroundings
are in every way normal.
Colohoma of optic nerve-sheath tvith microphthalmos {left) ;
colohoma of choroid {right). — Ellen G — , set. 7, was brought
to me at the Sheffield Infirmary in July, 1882, in conse-
quence of the left eye being so much, smaller than the
right. This condition had existed since birth, the mother
stating that at first the eye ^' was so small one could scarce
see it, but that it had since grown."'^
The eyelids were well formed on both sides, but the
great disparity in size between the two eyes was most
distinct. The left, which was the smaller one, presented
no abnormal appearances of its structures. The cornea
and sclerotic were healthy, and though the eyeball retained
its rounded form yet the front of the eye had tbe appear-
ance of being somewhat flattened. The cornea measured
only about 6 mm. across, but the measurement was difficult
in consequence of the nystagmus which, existed in both
eyes. The iris was a lighter-coloured hazel than in the
well-formed, right, eye. Generally speaking, the left
eye presented the appearance of being diminutive, but not
otherwise ill formed.
The pupil dilated well to atropine. With the ophthal-
moscope one noticed a large white mark at the fundus.
Careful examination showed it to be of the following
description (inverted image) : — A portion only of the optic
disc was apparently seen, the upper part merging into a
large white surface above. This was equal in size to six
or eight times that of tlie optic disc. Its broader part was
above and it was somewhat heart shaped. At points it
was brilliantly (pearly) white, at others more grey. Its
surface was apparently undulating, and tlie course of the
CONGENITAL CYSTS. 347
vessels indicated that it was situated at a lower level than
the surrounding tissues. Numerous vessels ramified over
it, some passed beyond it and rose over the edges ; and
whilst some were traced to the optic disc, others were
lost on the white surface ; some appeared to run to its
edges and then disappeared. Over its expanse were seen
several little corkscrew vessels. The margins were well
defined and more or less pigmented, but particularly so on
the inner side.
In the right eye, some little distance above the disc,
about midway between the optic nerve entrance and the
periphery, was observed a large, rather oval- shaped patch.
It was pearly white, but towards the centre it was less
pearly ; it corresponded to quite three optic discs in size.
With a little care vessels were traced over it, one (artery)
ran its whole length, coming from the optic disc, and
another vessel, also from the papilla, skirted its border, at
one point making a bend over the white surface, and giving
one or more small branches which coursed over it. The
borders were well defined and pigmented, especially the
right.
The refraction in both eyes was hypermetropic. AYith
the left vision = fingers, and perhaps more ; with the
right ^ was made out with the aid of + glasses. In the
left eye there was convergent squint.
The case I have just related presents in the left eye an
example, I believe, of that rare mal-development described
as coloboma of the optic nerve-sheaths. Until quite
recently very few cases of the kind were placed on record,
and now their number is very limited. Neiden, writing
in Knapp's ^ American Archives of Ophthalmology ' for
1879, was thus enabled to say in publishing the four
instances of the defect which had come under his obser-
vation, '^ the number of cases hitherto reported is
increased more than twofold. ^^ The cases published pre-
viously to the date of Neiden's paper were by Amnion,
Liebreich, and Wecker. Other cases, however, since then
have been recorded by Galezowski, Pooloy, and A. H.
348 CONGENITAL DEFECTS.
Benson, and, moreover, in the ' Annales d^Oculistique '
for the present year,* Van Dayse had added another to
the list. In Benson's and Van Duyse's cases both eyes
were affected, and the same was the case in one of
Neiden's. In one eye of the case reported by Benson,
the size of the coloboma is given as being equal at least
to six times the size of the papilla ; in mine I believe it was
larger. In the cases reported by Neiden and Van Duyse it
was much smaller. The latter observer mentions the size of
the coloboma as being at least equal to three disc diameters
in the right, and in the left to two. In Neiden's first case, in
the right and left eye respectively the size is given as twice
and two and a half to three times, and in another it is two
to three times the diameter of the papilla. One of
Neiden's cases occurred, like mine, in a microphthalmic
eye.
The condition observed in the right eye must also, I
believe, be considered to be congenital, and to be occa-
sioned by arrest of development. Coloboma of the choroid,
without accompanying cleft in the iris and ciliary body,
has been described, among others, by Benson. The condi-
tion in this instance is interesting in connection with the
coloboma of the optic nerve-sheath in the opposite eye.
Coloboma of ujp^er eyelid. — The subject of this defect is
a young woman, aet. 26 (June, 1883). She is an only
child. Enjoys good health, and has no other deformities ;
the same remark applies to her father and mother. She
is married, and has given birth to three healthy, well-
formed children.
The '^ cleft '^ is in the left upper eyelid, and is situated
at the junction of the inner with the middle third. It
hardly extends to as much as a third of the depth of the
eyelid ; it is particularly noticeable when the eye is closed,
as a distinct notch is then left. From the termination of
the *^ cleft '' a well-marked ridge (raphe) extends upwards
in the eyelid almost to the orbital margin. The eyeball is
* Mars and Avril, 1884, p. 117.
CONGENITAL CYSTS. 349
normal looking, beyond a nebulous condition of the cornea
at its outer side. Underneatb. the conjunctiva, also, at
the outer part is an aggregation of fat (lipoma).
Ophthalmoscopically the eye appears normal, but thero
is a degree of amblyopia ; the refraction is hypermetropic,
V. + 4 D. = -cfi^Q. The other organ is normal.
I would merely remark respecting this case the absence
of any other abnormality. Harelip or other deformity is
often associated with coloboma of the eyelids. Van
Duyse* has tabulated the cases recorded, in all about
twenty-six, by twenty-three different observers, and he
appends remarks as to the causation of the cleft. ^
Remains of hyaloid artery. — Charles K. S — , aet. 11,
was brought to me in September, 1883, on account of
defective sight in the right eye. Beyond some divergence
the external appearances were normal. Vision = fingers
at one foot. There was myopia of about 8 D. With the
naked eye, an opacity in the posterior pole of the lens was
noticed. After dilating the pupil with atropine, it was
ascertained, with the aid of focal illumination, that the
opacity was situated in the posterior capsule, and was
made up of fine striae. It was also discovered that run-
ning backwards from the opacity was a light grey trans-
lucent cord, and it was noticed to change sides as the eye
was turned. With the mirror this band appeared dark, and
gave a peculiar appearance, from its darting about, some-
times to one place and sometimes to another (all radiating
from the opacity in lens capsule), accordingly as the eye
was moved. With the direct method it was seen as a hollow
cord. It reached from the lens to the optic disc, and its
connection with a vessel in the centre of the papilla was
clearly made out. At this point also it somewhat widened
out like a funnel. Between these points of attachment
it was a little wavy. It did not appear to contain blood.
Dr. E. J. Gardiner, in Knapp's ' American Archives '
for 1880, p. 473, relates a most interesting case of per-
* * Anuales d'Oculisti^ne,' 1882, vol. ii, p. 101.
350 CONGENITAL DEFECTS.
sistent hyaloid artery. Its attacliment at tlie disc, and
anteriorily at the lens were made out, as well as a trans-
lucent sheath (Cloquet's canal) around the artery. It
spread out in many minute branches on the posterior sur-
face of the lens, and contained blood. The drawing
illustrating the case will explain also the kind of fine
striated opacity found in my own case.
Gardiner remarks on his inability to find a similar case
on record to his own. It is rare also to find the attach-
ment of an impervious cord to the optic disc and to the
lens capsule.
(July Uh, 1884.)
2. Congenital unilateral absence of lacrimation.
By A. Stanfoed Morton.
Bertie L — , eet. 6, has been noticed by his parents
never to shed tears from the right eye. On several occa-
sions I have seen him crying, and though the tears flowed
copiously from the left eye, they never came from the
right. That they were not secreted was demonstrated by
drawing away the lower lid from the globe, when there was
not any accumulation of tears in the cul-de'Sac thus formed.
In the left eye the vision is normal, but in the right, even
with the necessary correction of + 0*5 D. sph. + 2 D. cyl.,
it was not more than -|-^. The pupils act well and equally
and there is not any impairment of colour vision or of the
senses of touch, taste, or smell on the right side. The
boy's face is somewhat flatter and the external orbital
angle and malar bone less developed on the right side
than on the left. The right eye also appears smaller than
the other. The right ear is slightly '' lopped,'' and the
upper part of the cartilage is thinner than on the left
side. The mother has '' harelip " on the right side, but
MONOCULAR COLOBOMA.. 851
there is no other history of deformity, and there are two
younger children quite healthy. The lacrimal gland can-
not be felt on either side, but it seems a reasonable
assumption that it is congenitally absent on the right side.
(January 10th, 1884.)
3. A case of uniocular coloboma of the choroid, iris, and
lens, with a bridge of iris tissue over the coloboma.
By Arthur Benson (Dublin).
(With Plate IX, fig. 2.)
J. J — , aet. 12, was sent up to me through the kindness
of my friend Dr. Piggott.
Iris. — The right eye shows an imperfect coloboma of
the iris, a bridge of normal-looking iris tissue connecting
the sides of the coloboma about half way down, leaving a
short coloboma above it and a second pupil below it.
Lens. — The lens border is pretty deeply notched, corre-
sponding with the position of the iris coloboma. It is,
however, transparent up to the border, but a linear opacity
exists near the posterior pole.
Choroid. — The choroid shows a large oval white area,
corresponding with the position of the foetal fissure in the
retina. It comes to within about half a disc's breadth of
the disc and extends into the ciliary region, but there is
not apparently a coloboma of the ciliary body. The border
of the coloboma is darkly pigmented, especially below.
Large veins and other vessels ramify over the whole sur-
face of the coloboma. Two remarkable flat red bands of
choroidal tissue run out into the coloboma at opposite
sides below.
The refraction of the eye is myopic in all parts, at the
disc — 4 D., on the coloboma — 8 D.
352 . CONGENITAL DEFECTS.
Field. — The field is contracted everywhere, but espe-
cially above, as seen in tbe perimeter chart (exhibited at
the meeting).
The area of the coloboma does not seem to possess
vision, though a thin pencil of light projected on it is
perceived with readiness, probably in consequence of being
reflected from the white surface of the colobomatous area.
The other eye is hypermetropic, but without a coloboma.
{March ISth, 1884.)
4. Persistent hyaloid vessel and choroido-retinal changes.
By M. M. McHardy.
Persistent hyaloid vessel, extending as a continuous
opaque filament from the posterior pole of the lens to the
optic disc, fine at its attached extremities, thicker near its
middle, which may be seen floating or waving about dur-
ing movements of the globe. There are well-marked
patches of advanced disseminated choroido-retinal change.
The above-mentioned ophthalmoscopic appearances are
confined to the right eye.
The patient came under treatment on account of recent
retinitis in the left eye, which is making favourable pro-
gress under antispecific treatment.
The ophthalmoscopic morbid appearances, other than
the foetal relic, are judged to be attributable to an inherited
specific taint.
{Livvng specimen. March 13th, 1884.)
MODEL FOR CONJUGATE MOVEMENTS OF THE EYES. 353
XIV.— NEW INSTRUMENTS.
1. Model illustrating conjugate movements of the eyes.
By Priestley Smith (Birmingham).
(With Plate IX, fig. 3.)
The eyes are represented by two discs of wood covered
with paper, and painted so as to represent horizontal sec-
tions of the globe ; these rotate about their centres upon
screws fixed into a black board.
The motor apparatus, so far as horizontal movements of
the eyes are concerned, is represented by silk threads
attached to the sides of the wooden discs like the tendons
of the recti to the eyeballs ; these pass backwards, as the
nerves pass to the brain, each of the four nerve-trunks
being represented by a double thread. Each thread then
separates from the other thread of its own nerve, and
joins a thread from another nerve, so as to represent the
combination in the brain by means of which all motor
impulses to the eyes are made bilateral. The brain-
centres are represented by four brass weights hung upon
the threads. One of these combines the threads coming
from the two third nerves, and produces movements of
convergence ; another combines the threads coming from
the two sixth nerves, and produces movements of divergence,
or rather of diminished convergence. Each of the others
combines a thread from the third nerve of its own side
with a thread from the sixth nerve of the other side and
produces movements of both eyes towards the opposite
side.
The model has been found useful for class demonstia-
voL. IV. 23
354 NEW INSTRUMENTS.
tion. It serves to explain the production of any compound
movement of the eyes in the horizontal plane.
The phenomena of ordinary convergent strabismus may
be imitated by pressing first upon the weight for con-
vergence, then upon one of the weights for conjugate
lateral movements, or upon these two weights simulta-
neously. This illustrates the mode in which strabismus,
though really a bilateral affection, is transferred entirely
to one or other eye, or to each in turn, but is never
manifested in both eyes at once.
Paralytic deviation due to central lesions may be repre-
sented by supposing one of the weights to be in abeyance,
and causing its antagonist to act as though through loss
of opposition. Thus if one centre for lateral movement
be paralysed the other will draw both eyes towards the
side of the lesion, as in some cases of hemiplegia. Both
eyes being drawn to one side in this manner, the move-
ments of convergence and divergence may still be imitated
by acting on the weights which produce those movements ;
this shows how a muscle (the internal rectus, for example)
may, at one and the same time, be paralysed for one form
of combined movement and active for another. Cases
illustrating these forms of paralysis of ocular movements
are recorded in the ' Royal London Ophthalmic Hospital
Reports,^ vol. ix, pages 22 and 428.
(Note. — The model exhibited has been placed in the
hands of Messrs. Pickard and Curry, who have made
others like it.)
(December ISth, 1884.)
APPARATUS FOR DEMONSTRATIONS. 355
2, A large apparatus for demonstrating some of the prin-
cipal operations on the eye.
By J. F. Streatfeild.
It is a part of my duty not only to operate on the eye
but also to show and explain to many others what is done
in eye operations and also how it is done. But the eye is
altogether so small an organ and deep-set in the orbit,
and the parts of the eye concerned are therefore even
smaller, and partly hidden by the coats of the eye or
obscured by the manipulative processes, that it has been
constantly in my mind that students interested in an ope-
ration, except a few who are assisting me, or who are
specially privileged in standing near the couch, cannot
possibly see what I am doing. If the patient is under the
influence of an anassthetic one can '* think aloud,'^ and
describe the various stages of the operation whilst it is
being done, but actually to see the performance of eye
operations is not possible to the majority of students.
They crowd around one in order to see the operation, and
go away disappointed.
Looking at the matter in another light, one may desire
to demonstrate all the operations, or any one of them,
when very likely it may happen that no patient or patients
requiring these operations have presented themselves at
the time required for the demonstration. It has occurred
to me that what was wanting was a gigantic eye on which
to imitate the various processes of the principal eye ope-
rations. No such model on a very large scale, nor indeed
any mechanical apparatus, could exactly resemble the living
eye of real operating, but I thought that, in a general
way and in an elementary manner, some mechanical con-
trivances and arrangements might be made to imitate the
modiis operandi so well as, at least, to teach the students
in a large lecture-room much that is done, what is to be
356 NEW INSTRUMENTS.
done, and what is not to be done, in our operations,
although nothing of course can perfectly educate and
complete the eye-surgeon but actual surgical practice. If
for convenience sake we constantly vary the scale of dia-
grams, &c., for lecture and educational purposes — e.g. in
our old friend ' Gray's Anatomy,^ the femur is well repre-
sented of a size to go into his page, and in smaller
anatomy books it is also shown well enough to be under-
stood j and, on the other hand, we bave illustrations of
microscopic objects, and enlarged diagrams and models,
for the better information of students, of small parts of
the body ; thus Grray has enlarged figures of the ossicles
of the ear — why should we not have for elementary educa-
tional purposes a gigantic eye model on which to demon-
strate to students, mechanically, the minute eye operation
processes ? The obstetricians, I believe, use life-sized dum-
mies, and art students study the human figure, and those
of horses and other animals from well-shaped jointed
models of various small sizes. It is quite feasible so to
demonstrate eye operations, if we do not expect to imitate
these processes exactly in every respect.
The model of an eye, which I have here, in every part,
and in all its dimensions, is exactly ten times the scale of
that which it actually represents. The models of the eye
instruments which are here are also made in like propor-
tion, viz. enlarged ten times ; this scale has been adhered
to througbout, as regards all the parts concerned in the
operations, but tbe handles of the instruments have been
altered and shortened for tbe sake of convenience in
manipulating such weapons. The large apparatus of
course is intended to represent the human eye, it has
motion of rotation in every direction, and may be fixed in
any desired position. The front hemisphere only of the eye
is thus represented as no more than this is generally seen
in eye operations. The sclerotic and the eyelids also are
constructed of thick and thin, hard and soft, white felt.
The eyelids have their own proper motion of sliding over
the eyeball. The cornea is made of stout glass of the
APPARATUS FOR DEMONSTRATIONS. 357
right curvature (as the felt sclerotic also was made, on a
mould of the exact curvature of the natural coat of the
eye). Through the cornea may be seen the iris, and
behind the pupil a white opaque lens ; the iris is imitated
in thin sheet india rubber, with a round hole for the pupil
— it might be coloured grey if it were desirable ; the lens
(cataract) is made of xylonite (a white, hard, and light
material), and is made hollow for the convenience of less
weight ; it is made of the normal shape, and of exactly
the right curvatures of the natural lens. The internal and
external rectus muscles of the eye, with which we have
only to do in squint operations, are represented by pieces
of linen bandage of the actual width in proportion, and
they are, as it were, inserted in their right places into
the sclerotic.
So far I can represent the modus operandi of peripheral
section of the cornea, of iridectomy, of extraction of cata-
ract, and of squint ; I shall be able to do more than these.
As to the details of the apparatus, which has been made
for me by Mr. Hawksley, of Oxford Street, no doubt they
are quite capable of modification and improvement.
The whole apparatus, as you see, is mounted on a thick,
oblong piece of wood as a base, which is clamped to make
it firm and to steady it on a table. In the centre is a
strong iron upright with a ball at its upper end. The
hemisphere of thick felt is attached to a strong equator of
brass. Two plates of steel cross its diameter at a short
distance apart, and between these two the ball which I
have mentioned fits, so as to make a ball-and-socket joint,
which is capable of being clamped by two winged nuts.
Another upright at the back part of the apparatus, behind
the central upright and in the same axis as the ball-and-
socket joint, is attached to the equator, so as to permit
the eye to move in lateral directions only, or with a milled-
head screw to fix it and restrain it in all its movements.
This screw must be removed altogether to get the free
movements of the eye in all directions. Two supports
from the upper diametral bar carry the wire cradle and
368 NEW INSTRUMENTS.
guides, wliicli carry and direct the exit of the lens, and
two other supports on the same bar carry the double ring
(made like the " drum '' with which we test the cutting
edges and points of our cataract-knives and needles) on
which the rubber iris is stretched ; it is easily removed
from behind and a fresh " iris " put in its place. On a
line with the horizontal diameter of the cornea are the
two uprights on which the glass cornea is hinged, and to
the axis of which are attached the counter-balance weights
which bring the cornea back into its right position after
it has been temporarily displaced by the introduction of
instruments, or by the exit of the lens. Three brackets
from the lower part of the equator before referred to sup-
port the simple lever and the compound levers, five pairs,
in parallel series (as a ^^ lazy -tongs '') which extrude the
lens ; to the upper ends of these lazy-tongs are attached a
pair of wire forks which are made so that when the lens is
in sitiiy just behind the plane of the iris it rests on the
guides, and its lower edge touches the upper ends of the
forks, but as (by the action of the levers) it is made to
travel outwards upon the guides the lower edge of the
lens is tilted gradually more and more backwards, and made
to fall into the bottom of the forks, and so the lens is carried
upwards and forwards as well as outwards. To the simple
lever is attached a loosely-hinged plate, which, being-
depressed, through the sclerotic below the cornea from
the outside, by manipulation with the model curette, moves
the whole series of levers, and thus the lens is moved
along the guides in the forks to the aperture between the
cornea and sclerotic, and ultimately through the aperture,
which then closes itself. By the relation of these levers
to each other the motion of the whole is reduplicated five
times, a movement of half an inch, at the plate, giving a
much as two and a half inches movement to the lens. On
either side, external to the eyeball and quite independent
of it, are two iron uprights upon which the eyelids arc
hinged. In the hem of the folded felt (eyelid) is a spiral
spring. Within these two uprights, on each side, a hori-
APPARATUS FOR DEMONSTRATIONS. 859
zontal bar is hinged to the base of the apparatus, to which
bar on the outer side (external rectus) are attached two
spiral springs below the broad strip of bandage, which is
sewn at the place of insertion of the muscle to the scle-
rotic. To represent the other muscle (internal rectus)
which is to be cut through (as in the common squint ope-
ration), a broad curved plate of brass, attached to the
equator, external to the sclerotic of course, is made to pro-
ject forwards in contact (at the place of insertion of this
muscle) with the sclerotic ; over this plate is folded the
piece of linen bandage to represent the muscle to be cut
through, and this bandage is again folded over the hori-
zontal bar below, and then being made tight, so as to draw
the eyeball inwards, the bandage is secured with an ordi-
nary buckle to secure the double (folded) material for the
temporary purpose of the demonstration. The anterior
chamber in this apparatus can only be entered for iridec-
tomy, cataract extraction, &c., in the usual place, at the
sclerotico- corneal junction. Here at any part of the upper
half circumference, even so as to make a semicircular
flap, if it were desired to show the manner of doing the
old-fashioned extraction operation, the knife, forceps,
pricker, curette, &c., can be entered between the felt
sclerotic and the glass cornea, which gives way for their
admission and resumes its natural position when nothing
is in the way intervening (like the natural cornea, but not
quite in the way in which the natural cornea does so).
The place of the imitation iris is a little behind the level
of the sclerotico-corneal junction, and of somewhat larger
diameter, as in the natural eye. The sheet india rubber
of which this imitation iris is made may be seized with the
(model) iris forceps at any part, drawn out of the eye,
more or less, and so much is cut off as may be desired in
the demonstration. (There is never any prolapse of iris.)
In imitating the extraction operation in this apparatus,
the section being made at the margin of the cornea, an
iridectomy must always be made to give exit to the lens,
but I suppose that in describing (and demonstrating) ope-
360 NEW INSTRUMENTS.
rations we should, most of us, recommend an iridectomy
before extracting tlie cataractous lens, so the apparatus is
riglit in this particular.
The instruments here which I have already had made,
chiefly of wood, of the ten times magnified scale, are a
spring speculum, forceps, strabismus hook, cataract knife,
pricker, curette, iris forceps and scissors.
I may add the remark that I think, with this large
apparatus, I can see my way to demonstrating other
matters besides the operations only, e.g. I could show how
one judges of the comparative depth at which anything,
perhaps a foreign body, is situated in the eye, by looking
sideways, e.g. is it on the front or at the back of the
transparent cornea ? T could represent anterior and
posterior synechias very fairly by making the elastic imita-
tion iris to be partly adherent to the cornea or lens, and
then, surgically by the way, I could detach these poste-
rior synechias in my own way of operating.
[July 4th, 1884.)
3. An improved microtome {made by Katscli, of Munich),
and a new method of mounting eyes in celloidin.
By W. Jennings Milles.
Method of embedding eyes in celloidin. — Celloidin is
obtained in cakes or shavings from Zimmermann & Co.,
chemists, Maiden Lane, E.C.
A saturated solution of celloidin is made by dissolving
celloidin in absolute alcohol, methyl, ether, aa to the
consistence of treacle.
1. The eye is to be hardened (unopened) in Muller's
fluid for about a month.
2. Freeze the eye and make (usually) an antero-pos-
terior section to one side of the optic disc.
AN IMPROVED MICROTOME. 861
3. Extract the Muller's fluid by a solution of chloral
hydrate (gr. xl and 3j)^ with frequent changes of the
solution.
4. Place in methylated spirit for three or four days.
5. Then in a rather weak solution of celloidin for
another three or four days.
6. Place the eye in a paper box and pour the concen-
trated solution of celloidin over it ; leave it exposed for
about fifteen minutes_, till a film forms on the surface of
the solution.
7. Place the box containing the eye in methylated
spirit, sp. gr. '82. The spirit hardens the celloidin to the
required consistence. The embedded eye can be kept for
an indefinite period in this spirit.
This method of embedding was, I believe, first used
by Otto Becker and his assistants in the laboratory at
Heidelberg.
The only modification in staining and mounting the
specimens for microscopical examination, consists in sub-
stituting oil of bergamot for oil of cloves, as the latter
dissolves the celloidin out of the section. This, however,
is sometimes desirable ; it is then preferable to dissolve
the celloidin out by a mixture of equal parts of absolute
alcohol and methylated ether. Methylated spirit, and not
absolute alcohol, should be used for getting rid of the
water, if it is desired to retain the celloidin.
The advantage that is gained by combining the use
of Katsch''s microtome with the above-described method
of embedding in celloidin is especially applicable to the
eye. By this means thin sections of the whole eye can
be made without disturbance of the mutual relations of ita
various structures.
(December 13^/«., 1683.)
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•
REPORT OF THE COUNCIL.
The Council are able to congratulate the members upon
the continued prosperity of the Society. During the
Session that is now closing 21 new members have been
elected, so that the total number of members is now 190,
including 23 non-residents.
Since the last annual meeting the Society has last one
member by death, Dr. Hudson, of Redruth, and three by
resignation ; four members who had not paid their sub-
scription for last year have been struck off the list in
accordance with the rules.
Owing to the generosity of Sir William Bowman the
financial position of the Society is most satisfactory, and
the Council have been enabled to make arrangements with
the Medical Society by which the Society can have
accommodation for a small library, the members having
the right to use the reading room of the Medical Society
at such times as it is open to the Fellows of that Society.
A handsome bookcase has been provided by Sir William
Bowman, and a cabinet is in course of construction also at
his expense, and the Council would remind members that
any presents of books or drawings relating to ophthalmo-
logy, or any instruments or apparatus that have been used
in ophthalmic practice, would be gladly received.
Last autumn the Council decided to establish a Bowman
Lectureship to commemorate the Presidency of Sir William
(then Mr.) Bowman. Such lecture to be delivered
864 EEPOET OF THE COUNCIL.
annually or from time to time at the discretion of the
Council, the lecturer being nominated by the Council.
The Council have great pleasure in announcing that at
their special request the first lecture will be delivered in
November by Mr. Jonathan Hutchinson.
During the past session a large number of papers have
been communicated, and the meetings have been well
attended. Two Committees have been appointed, one on
the prevention of blindness from ophthalmia neonatorum,
the report of which was read at the June meeting of the
Society ; the other appointed to investigate some points in
connection with sympathetic ophthalmia is still at work,
but hopes to have its report ready by October.
APPENDIX.
I
The following list of abbreviations, drawn up by a
committee* at the request of the Council, is recommended
for use in communications to the Society.
The list is not intended as final, and the Council will be
glad to receive suggestions for its improvement or exten-
sion.
It will be noticed that the same abbreviation is never
used for more than one term ; that abbreviations have not
been introduced for terms which are but seldom used,
although abbreviations for many such terms are to be
found in literature ; and that whilst abbreviations have
been introduced for the names of such of the more impor-
tant parts of the eye as could be readily shortened, no
contractions are suggested for the names of diseases or
morbid states.
ABBREVIATIONS.
Ace.
Accommodation .
Aq.
Aqueous humour.
As.
Astigmatism.
A.O.
Anterior chamber.
C.
Cornea.
Ch.
Choroid.
cm.
Centimetre.
Cyl.
Cylindrical lens.
* Consisting of Mr. Cowell, Dr. Qowers, Mr. Frederick Mason, and Mr.
Nettleship.
I
366 APPENDIX.
D. Dioptre or Dioptric; a lens of one metre focal length. (See
Notef.)
E. Emmetropia.
P. Field of Vision.
H. Hypermetropia.
H. 1. Latent hypermetropia.
H. m. Manifest hypermetropia.
I. Iris.
L. Left eye (and R., right eye). (See Note a.)
m. Metre.
mm. Millimetre.
My. Myopia.
M. L. Macula lutea (and Y. S., yellow spot).
Oph. Ophthalmoscope, ophthalmoscopical examination, ophthalmo-
scopical appearances. (See Note h.)
O. D. Optic disc •) ^g^^ j^^^^ ^^
O. P. Optic papilla )
P. Pupil. (See Note d.)
Pr. Presbyopia.
P. L. Perception of light; vision equal only to perception of light.
p. p. Punctum proximum ; nearest point of distinct vision.
p. r. Punctum remotissimum ; furthest point of distinct vision.
R. Right eye (and L., left eye). (See Note a.)
Ret. Retina.
Scl. Sclerotic.
Sph. Spherical lens.
T. Tension of the eyeball. T. n., tension normal.
T. + 1, T. + 2, T. + 3 ") Degrees of increase and decrease of
T. — 1, T. - 2, T. — 3 ) tension. (See Note e.)
Vit. Vitreous humour.
Y. S. Yellow spot (and M. L., macula lutea).
V. Visus, acuteness of sight, power of distinguishing form.
SYMBOLS.
+ Symbol for a convex lens.
— Symbol for a concave lens.
Foot.
" Inch.
'" Line.
APPENDIX. 367
NOTES.
Note a. — R. and L., not R. E. and L. E. *' E." might be taken for
" Emmetropia," and at best it is unnecessary. The abbreviations O. D. and
0, S., for the Latin Oculus dexter and Oculus sinister, are also less con-
venient than R. and L.
Note h. — " Oph." is more explicit than Bowman's abbreviation " O.S."
The context will prevent "oph." from being taken as short for " ophthalmic "
or " ophthalmia.''
Note c. — " 0. D." (or " 0. P.") applies only to the part we can see, and is
therefore better than O. N. (optic nerve), which refers to a part the state of
which we can only infer.
Note d. — The various modes of activity of the pupil to light (direct and
indirect, or crossed, light reflex; associated action; skin reflex) should be
specified ; the use of contractions for these states would probably lead to
confusion.
The size of the pupil when stated should be given in millimetres.
Note e. — In the notation originally proposed by Bowman the - sign was
placed before the sign for " tension," to indicate lowered tension, and the +
sign was not used at all ( — Tl, - T2, &c. ; Tl, T2, &c.). The contractions
now suggested are more explicit; they also seem more natural, because
agreeing with the order in which the terms would be spoken, thus Bowman's
*' Tl " (our T. + 1) is usually spoken " tension plus one;" Bowman's " - Tl "
(our "T. — 1") is spoken "tension minus one."
Note f. — It is desirable that the metrical system of notation be always
used. Decimals, when not following a whole number, should be preceded by
"0," in order to prevent mistakes (" 0-5 D.," not " '5 D.").
It is intended that the abbreviations sbould be written
either in capitals or small letterSj with the exception of
" punctum proximum '^ and " punctum remotissimum/^
''metre/' '' centimetre '^ and ''millimetre^'' which never
need be indicated by capitals. When the contraction indi-
cates two words (as for "anterior chamber") both letters
should be of the same kind, capital or small (A. C. or a. c.
not A. c.) ; but the combination of capital and small letters
for manifest and latent hypermetropia (H. m. and H. 1.) is
so generally known and adopted that it has been retained.
When a single word is indicated by more than one letter,
the final letter or letters should always bo small (Ace,
Ch., or ace, ch., not ACC. or CH.).
I
INDEX.
Abbreviations, list of .
Accommodation, spasm of the (C. E, Fitzgerald)
and convergence, paralysis of (H. Eales) .
Address, introductory (J. Hutchinson)
Amaurosis, recovery from, in young children (E. Nettleship)
Amblyopia, a case of central (J. B. Lawford)
Anderson (James and R. M. Gunn), a case of nerve disease with
alleged uniocular diplopia
Anaemia as a cause of retinal haemorrhage (Stephen Mackenzie)
Anosmia after concussion (W. Spencer Watson)
Arterio-venous communication on retina (R. M. Gunn)
Atrophy of optic disc after an injury (Waren Tay)
Benson (A. H.), coloboma of iris, choroid, and lens
jequirity as a therapeutic agent .
Blindness after concussion with papillitis and anosmia (W. Spencer
Watson) .....
of left eye and deafness of right ear following an injury to the
head (Waren Tay) ....
prevention of, from ophthalmia neonatorum (Report of Com
mittee) .....
Brailey (W. a.), remarks on naevus of choroid
remarks on uniocuh.-.r diplopia
glaucoma following a blow
remarks on retinal glioma
paralysis of ext. rect. and mydriasis
conjunctivitis of sympathetic origin
case of sympathetic neuritis
VOL. IV. 24
page
365
311
300
1
243
226
292
132
269
156
266
351
19
269
266
32
170
297
113
54
298
73
S7
370
INDEX.
PAGE
Brailey (W. a.), transmission of sympathetic ophthalmitis . 62
and Pigeon (H. W), the relation of bacilli to jequirity oph-
thalmia . . . . . .28
Brockman (Prof.), remarks on a case of proptosis
Brown (G. A.) conjunctivitis caused by whisky thrown into the
eyes
Cant (W. J.) serous cyst of iris
Cataract extraction, on (C. Higgens) .
cystoid cicatrix after (J. B. Story)
a preliminary precaution in (J. Y, Streatfeild)
Choroid, coloboma of (A. H. Benson)
nsevus of (W. Jennings Milles) .
ossification of (W. Adams Frost)
peculiar lines in (E. Nettleship)
remarks on (Stephen Mackenzie)
sarcoma of (George Cowell and Henry Juler)
tubercle of (P. H. Mules)
Choroidal atrophy, central senile areolar (E. Nettleship)
Choroiditis, central guttate (E. Nettleship)
senile guttate (E. Nettleship)
disseminated (Anderson Critchett and Henry Juler)
Coloboma of choroid, iris, and lens (A. H. Benson)
of upper eyelid (Simeon Snell) .
of optic nerve and choroid (Simeon Snell) .
Conjugate movements of the eyes, model illustrating (Priestley
Smith) .....
Conjunctiva, bony tumour of (Simeon Snell)
papilloma of (Anderson Critchett and Henry Juler) .
Conjunctival affection, peculiar (Anderson Critchett and Henry Juler)
Conjunctivitis of sympathetic origin (W. A. Brailey)
caused by whisky thrown into the eyes (G. A. Brown)
Convergence and accommodation, paralysis of (H. Eales) .
Council, Report of ... .
Cowell (George and Henry Juler), sarcoma of choroid
Critchett (Anderson and Henry Juler), disseminated choroiditis
papilloma of conjunctiva
peculiar conjunctival affection
a case of concomitant squint following a scalp wound
Cyclotomy in acute glaucoma (G. E. Walker) .
Cyst, congenital, in lower eyelid (Simeon Snell)
of iris, serous (W. J. Cant)
INDEX. 371
PAGE
Cyst of iris, serous (W. A. Frost) . . . .58
Cjstoid cicatrix after cataract extraction (J. B. Story) . . 126
Deafness of right ear following an injury to the head (Waren Tay) . 266
Diplopia uniocular, alleged (James Anderson and R. M. Gunn) . 292
Eales (Henry), a case of complete paralysis of accommodation and
convergence
remarks on miners' nystagmus
on a case of proptosis
Ectropion, two cases of (J. 1\ Streatfeild)
Edmunds (Walter) appearances at fundus oculi in a case of cerebral
tumour
and Lawford (J. B.), optic neuritis in relation to intracranial
tumour ....
Emrys- Jones (A.), orbital tumour
Eyelid, coloboma of upper (Simeon Snell)
EiTZGERALD (C. E.), acutc spasm of accommodation
Frost (W. Adams) ossification of choroid
serous cyst of iris
remarks on miners' nystagmus .
sympathetic neuritis
ophthalmitis
sympathetic ophthalmitis appearing after enucleation
two cases of total detachment of retina. .
Glaucoma following a blow (W. A. Brailey)
acute, treated by cyclotomy (George E. Walker)
chronic, with new connective-tissue growth in vitreous (W
Lang)
chronic iridectomy in (M. M. McHardy)
haemorrhagic specimen of (E. Nettleship)
with retinal haemorrhages (E. Nettleship)
Glioma retinal, two cases of (Simeon Snell)
^-^ remarks on (W. A. Brailey)
GowERS (W. R.), spasm of the ocular muscles
Gunn (R. M. and James Anderson), alleged uniocular diplopia
• ^(R. M.), arterio-venous communication on retina
Haemorrhage into the sheaths of the optic nerves (A. Q. Silcock)
in a case of cerebral haemorrhage (Priestley Smith)
Hemianopia homonymous, a case of (Seymour J. Sharkey)
300
329
43
15
291
172
45
348
311
171
58
330
88
76
80
89
113
100
113
93
108
111
49
54
306
292
156
274
271
976
372
INDEX.
Hemianopia and cerebral tumour (E. Nettleship)
HiGGENS (C), on cataract extraction .
Hodges (F. H.), granular-looking body on iris
Hutchinson (Jonathan), introductory address
proptosis with enlargement of glands
Hyaloid artery, remains of (Simeon Snell)
Hyaloid vessel, persistent (M. M. McHardy)
Hypermetropia with tortuosity of retinal vessels (Stephen Mackenzie)
Intracranial tumour, optic neuritis in relation to (W. Edmunds and
J. B. Lawford)
Iris, serous cyst of (W. J. Cant)
(W. A. Frost) .
granular-looking body on (F. H. Hodges)
growth on (W. Lang)
Iridectomy in glaucoma (M. M. McHardy)
Jequirity as a therapeutic agent (A. H. Benson)
ophthalmia, relation of bacilli to (W. A. Brailey and H. W
Pigeon)
Jones (H. Lewis), a case of pseudo-glioma
Jtjler (Henry), remarks on uniocular diplopia
and CowELL (George), sarcoma of choroid
and Critchett (Anderson), disseminated choroiditis
papilloma of conjunctiva .
peculiar conjunctival affection
a case of concomitant squint
Lacrimation congenital, unilateral absence of (A. S. Morton)
Lang (W.), growth on iris ....
• connective-tissue new growth in vitreous in a case of chronic
glaucoma
Laweord (J, B.), a case of central amblyopia with contraction of
field of vision
and Edmunds (W.), optic neuritis in relation to intracranial
tumour
and Sharkey (S. J.), acute optic neuritis associated with acute
myelitis .....
Lens, coloboma of (A. H. Benson) . .
Mackenzie (Stephen), anaemia as a cause of retinal htemorrhage
remarks on peculiar lines in choroid
INDEX. 373
PAGE
Mackenzie (Stephen), remarks on nsevus of choroid . 170
tortuosity of vessels in connection with hypermetropia . 152
remarks on retro-ocular neuritis . . . 22i
miners' nystagmus . . . . 328
a case of proptosis . . . .42
McHaedy (M. M.), iridectomy in glaucoma . . .93
persistent hyaloid vessel. .... 352
remarks on sympathetic ophthalmitis . . .78
Microtome, an improved (W. J. Milles) . . . 360
MiLLES (W. J.), naevus of choroid .... 168
an improved microtome .... 360
Miners' nystagmus (Simeon Snell) .... 315
Model illustrating the conjugate movements of the eyes (Priestley
Smith) . . . . . .353
MoETON (A. Stanford), unilateral absence of lacrimation . . 350
haemorrhage in region of macula . . . 148
Movements of the eyes, model illustrating conjugate (Priestley Smith) 353
of eyes, paresis of upward (J. A. Ormerod) . . 310
Mules (P. H.), tubercle of choroid .... 159
Mydriasis and paralysis of external rectus (W. A. Brailey) . 298
Myelitis, acute, with acute optic neuritis (S. J. Sharkey and J. B.
Lawford) . . . . . .233
Nsevus of the choroid and temporal and orbital region (W. Jennings
Milles)
remarks on (W. A. Brailey)
(Stephen Mackenzie)
(E. Nettleship) .
Nsevus of eyeball (E. Nettleship)
Nerve disease, a case of, with alleged uuiocular diplopia (James
Anderson and R. Marcus Gunn).
remarks on (W. A. Brailey)
(H. E. Juler) ....
(E. Nettleship) ....
Nettleship (E.), recovery from amaurosis in young children
peculiar lines in choroid
■ remarks on nsevus of choroid
senile areolar choroidal atrophy .
central guttate choroiditis
senile guttate choroiditis .
remarks on uniocular diplopia
glaucoma with retinal haemorrhage
168
170
]70
170
47
292
297
299
298
343
167
170
165
164
162
298
HI
374
INDEX.
Nettleship (E.), specimen of hsemorrhagic glaucoma
hemianopia and cerebral tumour
naevus of eyeball ....
cases of retro- ocular neuritis .
remarks on retinal haemorrhage .
syphilitic retinitis ....
remarks on sympathetic ophthalmitis
case of sympathetic ophthalmitis
with whitening of eyelashes
Neuritis, acute optic, associated with acute myelitis (S. J. Sharkey
and J. B. Lawford) ....
optic, in relation to intracranial tumour (W. Edmunds and J
B. Lawford) ....
retro-ocular (E. Nettleship)
remarks on (Stephen Mackenzie)
sympathetic, a case of (W. A. Brailey)
Nystagmus miners' (Simeon Snell)
remarks on (H. Eales)
(W.A.Frost) .
(Stephen Mackenzie)
(Priestley Smith)
Ocular muscles, spasm of (W. R. Gowers)
Ophthalmia neonatorum, prevention of blindness from (Report of
Committee) .
Ophthalmitis sympathetic, appearing after enucleation (W. Adams
Frost)
■ case of (E. Nettleship)
with whitening of eyelashes (E. Nettleship)
treatment of (G. E. Walker)
transmission of sympathetic (W. A. Brailey)
Optic nerve-sheath, coloboma of (Simeon Snell) .
nerves, haemorrhage into the sheaths of (A. Q. Silcock)
haemorrhage into, in a case of cerebral haemorrhage
(Priestley Smith) ....
Optic neuritis in relation to intracranial tumour (W. Edmunds and J
B. Lawford) ....
Orbital tumour (A. Emrys-Jones)
Ormerod (J. A.), paresis of upward movement of eyes
Pigeon (H. W. and W. A. Brailey), the relation of bacilli to jequirity
ophthalmia . . . . . .28
PAGE
108
285
47
186
149
150
76
85
83
INDEX.
375
Proptosis, case of, with enlargement of glands (Jonathan Hutchinson)
remai ks on by (Prof. Brockman)
(Henry Eales) .
(Stephen Mackenzie)
Pseudo-glioma, a case of (H. Lewis Jones)
Retina, arterio-venous communication on (R. M. Gunn)
total detachment of, two cases (W. Adams Trost)
Retinal haemorrhage in anaemia (Stephen Mackenzie)
in region of macula (A. Stanford Morton)
remarks on (E. Nettleship)
Retinitis syphilitic (E. Nettleship)
Sarcoma of choroid (George Cowell and Henry Juler)
Sharkey, (S. J.), a case of homonymous hemianopia
and Lawford (J. B.), acute optic neuritis associated with
acute myelitis ....
SiLCOCK (A. Q,,), haemorrhage into the sheaths of the optic nerves
Smith (Priestley), remarks on miners' nystagmus
model illustrating the conjugate movements of the eyes
cerebral haemorrhage with passage of blood into both optic
nerves ....
Snell (Simeon), congenital cysts and other defects
bony tumour of conjunctiva
two cases of retinal glioma
miners' nystagmus
Spasm of the accommodation (C. E. Fitzgerald)
of the ocular muscles (W. R. Gowers)
Squint concomitant following a scalp wound (Anderson Critchett and
Henry Juler) ....
Story (J. B.) cystoid cicatrix after cataract extraction
remarks on sympathetic ophthalmitis
Steatfeild (J. E.), two cases of ectropion
a preliminary precaution in some cases of cataract extraction
apparatus for demonstrating the principal operations on the eye
Sympathetic neuritis (W. A. Brailey) .
remarks on (W. Adams Frost) .
ophthalmitis appearing after enucleation (W. Adams Frost)
case of (E. Nettleship)
with whitening of eyelashes (E. Nettleship)
transmission of (W. A. Brailey)
remarks on (W. Adams Frost)
PAGE
30
44
43
42
90
156
89
132
148
149
150
55
276
232
274
327
353
271
333
31
49
315
311
306
332
126
75
15
118
355
87
88
80
85
83
62
76
376
INDEX.
Sympathetic ophthalmitis, remarks on (M. M. McHardy)
(E. Nettleship)
(J. B. Story)
(W. Spencer Watson)
treatment of (G. E. Walker)
Syphilitic retinitis (E. Nettleship)
PAGE
78
75
74
82
150
Tay (Waren) blindness of left eye, deafness of right ear after an
injury to the head, atrophy of the optic nerve . . 266
symmetrical changes at the yellow spot in an infant . .158
Tortuous vessels in hypermetropia (Stephen Mackenzie) . . 152
Tubercle of choroid (P. H. Mules) , . . .159
Tumour cerebral, appearances at fundus in a case of (W. Edmunds)
with hemianopia (E. Nettleship) . . . 285
intracranial, optic neuritis in relation to (W. Edmunds and
J. B. Lawford) . . . . .172
Upward movement of eyes, paresis of (J. A. Ormerod) . .310
Walker (George E) cyclotomy in acute glaucoma . . 100
treatment of sympathetic ophthalmitis . . .82
Watson (W. Spencer), blindness following concussion with papillitis
and anosmia ..... 269
remarks on sympathetic ophthalmitis . . .74
Yellow spot, symmmetrical changes at, in an infant (Waren Tay) . 158
PRINTED BY J. E. ADIAED, BABTH GLOME W CLOSE.
o
I
4
u^uiitu ;;**.wi.rwi ly 1968
PS Ophthalmological Society of
1 The United Kingdom
067
cop. 2
* Medicai
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