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Ophthalmic Hospital Reports^ ^Z-^ 

nnir ginurnal of (J" , 2 

Vol. VIII. Part 1. October, ]874.,«,,„^^^ 

Part I. / r pn .^ o lOi^A 

SUGGESTIONS FOR FUTURE CLINICAL WORK IN . 

OPHTHALMOLOGY. , « -» o r r 

h9225h 

By Jonathan Hutchinson. 

(Continued from vol. vii, page 438.) 

A PAPER of much clinical value might be written on the 
symptomatic value of retinal haemorrhage, and on the various 
conditions under which the retinal vessels suffer rupture. The 
following forms are, I suppose, recognised by most observers, 
and distinguished from each other ; — 

I. True Retinitis hcemorrhagica, characterised by innume- 
rable small streaks of blood, all of them flame-shaped. It 
occurs for the most part to one eye only : it happens to 
seemingly healthy persons at middle or senile periods of life, 
and is very often associated with gout. It is rare. 

II. Heemorrhages in connection with evidences of Alhu- 
Tnenuric retinitis, and with renal disease. Here the blood-spots 
are blotchy ; very various in size ; at or near the yellow spot 
and disc. They are probably due in part to pressure on the 
vessels by the deposit in the retina, and the disease may be 
distinguished at a glance by the presence of the latter. 

VOL. VIII. B 



2 HUTCHINSON'S SUGGESTIONS FOR FUTURE 

III. Hemorrhages in connection with neuritis and 
swollen disc. Here again the extravations result from pres- 
sure, but they usually occur as streaks, often as very delicate 
almost linear ones, and are placed on or in the new material 
which has accumulated about the disc. 

IV. Haemorrhages from senile degeneration of vessels. 
These are not unfrequently seen in senile or pre-senile 
periods of life. They are often of large size, and either single 
or few in number. They have their analogues in the ecchy- 
mosis often seen in the conjunctiva. It is chiefly in this 
group of cases that what is known as hcemorrhagic glaucoma 
occurs. 

V. Purpuric hcemorrhages. These are only a local part of 
the general disease, known as purpura hsemorrhagica, and as 
it is rare they are very seldom seen. 

VI. Haemorrhages in connection with Pyoimia. These 
result from thrombosis and impediment to the circulation. It 
is not often that opportunities occur for examining eyes when 
attacked in pysemia. 

VII. There is a form of syphilitic retinitis often attended 
by haemorrhages which occur repeatedly. 

VIII. There are certain very rare cases in which large 
retinal haemorrhages occur in young persons without evident 
cause, and which sometimes by recurrence, lead to blindness. 
There is some reason to suspect that this happens occasionally 
in connection with masturbation, or excessive nocturnal emis- 
sions. Very often the blood finds access to the vitreous, and 
it is perhaps diificidt to feel sure that the primary rupture 
is not rather in the choroid than the retina. 

IX. In the retinitis of diabetes hasmorrhages are some- 
times met with. The changes are, I believe, usually sym- 
metrical. 

X. Lastly, we must mention the occurrence of extravasa- 
tion into the retina as the direct result of blows on the 
eyeball. 

I do not know that I have omitted any group which is as 
yet well recognised, but very probably more careful investiga- 



CLINICAL \YORK IN OPHTHALMOLOGY. 3 

tion Avoiild succeed in separating some of the cases which are 
usually counted under one or other of these heads, and showing 
that they deserve to constitute special groups to themselves. 
No doubt more correct and detailed observation would add 
much to our knowledge of the peculiarities of each group. 
Such questions as is the rate of absorption, the same in all 
examples of each group, and does it differ much in the 
different groups ? can the form of the patches be relied on 
as evidence as to the special form, and is it tolerably 
constant in each ? and what are the conditions usually left 
after absorption ? should be kept in mind. The form and size 
of the patches are no doubt chiefly influenced by the size of 
the vessel ruptured, and its exact depth in the retinal layers. 

HEMORRHAGIC IrITIS. 

Hsemorrhagic iritis or hsemorrhage in connection with 
iritis is a far rarer event than its parallel in the retina. We 
observe blood in the anterior chamber, with proof of iritic 
changes as the cause, chiefly, I think, under the following 
circumstances : — 

I. After operations. Bleeding is not unfrequent in cases 
of iritis after extraction of cataract. I do not recollect 
w^hether it was noticed in the days of the old method when 
the iris was not cut, nor do I know whether it happens to 
those who practice the Brussels or similar operations. In 
the common plan, which includes an iridectomy, it is possible 
that the wound of the iris has something to do with it, and 
in support of this view we notice that it happens now and 
then after iridectomy for glaucoma. Undoubtedly, however, 
it often occurs at considerable periods after the operation 
and when it might be supposed that the tissues were quite 
healed. This is by very far the conmionest form of h&emor- 
rhagic iritis. The next is, I think, 

II. Sympathetic iritis. This is itself a rare disease, and 
it is only in a small proportion that the hsemorrhage is ob- 
served. "When it occurs the blood is usually very dark, and 

B 2 



4 IIUTCfflNSONS SUGGESTIONS FOR FUTURE 

it liaugs in threads instead of gravitating to the bottom of 
the anterior chamber. It is one of the very worst signs, and 
almost always implies total destruction of the eyeball. With 
it we usually find the iris-structure full of dilated vessels. 

III. Certain rare forms of destructive iritis in elderly 
people are attended by haemorrhages of the same kind as that 
which occurs in sympathetic iritis (dark strings). The blood 
is very slow to absorb. From the resemblance just noted, a 
suspicion arises that these cases may be due to a nervous 
cause of a similar kind to that which evokes sympathetic 
ophthalmitis. The cases are, however, very rare, and they 
require more study before any trustworthy opinions can be 
formed. 

IV. There is a form of arthritic iritis whicli is attended 
by haemorrhage. Successive attacks of iritis occur in the 
same individual, each attended by bleeding. In these the 
blood, or blood-stained lymph, is very rapidly absorbed, and, 
as a rule, the eye is but little damaged. The appearances at 
first are, however, most alarming. I have seen but very few 
examples of this form. 

The power of absorbing blood effused into the anterior 
chamber varies very much in different cases. In some cases 
of chronic iritis after operations when the eye is unsound, it 
may remain for very long periods, weeks, or even months. 
The slowness of its absorption is always a very bad sign. 
My impression is that slowness of absorption is usually 
in ratio with darkness of tint, and that whenever it is of 
an unusually deep purple colour, the very worst may be 
prognosticated as regards the eyeball. 

Amblyopia Potatorum. 

Is there in English practice any form of amblyopia 
(neuritis, retinitis, or primary atrophy), met with in drinkers, 
and due to alcohol ? We must exclude cases in which renal 
disease is first induced and in which the retinal mischief is 
secondary to the changes in the kidneys. 



CLINICAL WORK IX OPHTHALMOLOGY. 5 

If, as there seems some reason to believe, the so-called 
amblyopia of drunkards is more common in France and 
Belgium than amongst ourselves, is it probable that something 
is due to the medication of spirituous liquors so common in 
those countries ? Possibly absinthe and similar drinks may 
be injurious to sight, independently of the alcohol which they 
contain, and in virtue of other ingredients. It is very desirable 
to keep sejDarate, as much as possible, the shares taken by 
alcohol and tobacco when both are used. If a man smokes 
heavily and drinks hard, is he more likely to suffer from the 
injurious effects of the tobacco or the alcohol than if he were 
to indulge in either alone ? Cases in proof of the supposed 
ill influence of alcohol on sight must, if possible, be taken 
from those who have not been smokers. There are plenty of 
cases of tobacco amblyopia to be found in which the patients 
have never been drinkers. 

If alcohol alone, and unmedicated, can cause amblyopia, 
what are the special symptoms which distinguish examples 
of its effects from those due to tobacco ? Is there neuritis ? 
Is there retinitis ? To what stage does the disease usually 
advance ? 

If there are cases of amblyopia potatorum, are they 
usually complicated with other disorders of the nervous 
system, or is it defect of sight alone ? It is a very remark- 
able feature of the cases of tobacco amaurosis that, as a rule, 
no other indications of nervous disorder are present. The 
patient will often declare that he feels perfectly well in all 
respects, and in fact ails nothing whatever if he could but 
see. 

Mackenzie's Sceofulous Sclerotitis. 

It is often a very useful practice to look up some of the 
less frequent maladies Avliich have been carefully treated of 
by the best of our predecessors and note whether our own 
experience confirms their views. I do not recollect to have 
ever made, or known made by others, the diagnosis of " scrofu- 



6 HUTCHINSON S SUGGESTIONS FOR FUTURE 

loiis sclerotitis," yet Mackenzie, who was an admirable ob- 
server, has described a malady under this name, which he 
asserts to be well marked and of great importance. In the first 
instance, he had named it "choroiditis," and subsequently 
" sclerotico-choroiditis," but at length in the belief that the 
sclerotic is the part first and principally affected, he has pre- 
ferred the name mentioned. He admits that the presence of 
scrofula cannot be proved in all cases. He states respecting 
it that it is rare in children, and more frequent in women 
than in men ; that it sometimes follows other forms of disease, 
as corneal ulcer, syphilitic or arthritic iritis,, &c. ; that it is 
sometimes local and at others general, and that it usually 
ends in ciliary staphyloma. He adds that the iris is seldom 
inflamed, but that yet the pupil almost always undergoes a 
remarkable displacement which he attributes to some affection 
of the ciliary or iridal nerves. He states that it is difficult of 
arrest and prone to relapse, and mentions one case in which 
after much temporary improvement it ultimately, after many 
relapses in the course of twenty years, destroyed both eyes. 
It is not without interest to note further that Mackenzie's 
experience had led him to rely chiefly on blood-letting to 
arrest the disease. He took blood from the temple to the 
amount of twenty or thirty ounces, or applied twenty-four 
leeches around the orbit. Counter-irritation in some perma- 
nent and severe form he also thought well of, but he had 
been disappointed in mercury. 

It is a good illustration of some of the tendencies of modern 
investigators that one of om' most recent systematic writers, 
instead of describing the disease clinically as a whole, takes 
simply its most conspicuous pathological result, and writes a 
chapter on " Anterior Sclerotic Staphyloma." He goes back to 
Mackenzie's first creed, and states that this condition is in a 
great majority of cases due to irido-choroiditis. 

Ought Mackenzie's term to be retained in our nosologies ? 
Do we still recognise the disease which he describes ? Have 
we ascertained anything further as its cause or as to the best 
measui-es of treatment ? I suspect that what he meant is now 



CLIMCAL WORK IN OPHTHALMOLOGY. 7 

usually diagnosed as " Cyclitis," and possibly that term is 
really a more correct designation. 

"What are the Trophic Nerves of the Eyeball ? 
Can any observer supply facts which favour the belief 
that in the human subject the vaso-motor nerve exerts any 
influence over the nutrition of the eyeball ? The following 
quotation is from the handbook of physiology in most general 
use : — " It is not at present possible to say whether the in- 
fluence on nutrition is exercised through the sensitive or 
through the sympathetic nerves." * * * * « xhe truth 
perhaps is, that it may be exerted through either or both of 
these nerves. The defect of nutrition which ensues after lesion 
of the spinal cord alone, the sympathetic nerves being unin- 
jured, and the general atrophy which sometimes occurs in 
consequence of diseases of the brain, seem to prove the 
influence of the cerebro-spiual system ; while the observations 
of Majendie and Meyer, that inflammation of the eye is a 
constant result of ligature of the sympathetic nerve in tlie 
neck and many other observations of a similar kind exhibit 
very well the influence of the latter nerve in nutrition." 
Now I feel certain that ophthalmic surgeons have here the 
opportunity of helping physiologists. The experiments which 
the latter require are often furnished by disease ready to our 
eyes. So far as I have observed them, they point to a more 
definite conclusion than is indicated in the quotation given. 
That conclusion is that the vaso-motor nerve wliilst it (1st), re- 
gulates blood supply, and thus slightly and temporarily alters 
temperature ; (2iid), affects the action of the dilating fibres of 
iris ; and (3rd), regulates in some way, not easily explained, 
the degree of prominence of the eyeball, — has no further share 
in modifying the nutrition of the eyeball. Wlien the vaso- 
motor is paralysed the palpebral aperture is a little narrowed, 
and the globe looks sunken, and the pupil loses the power of 
dilatation, remaining motionless and of medium size. How- 
ever long these conditions persist, no derangement of the 
nutrition of the eyeball, so far as I am aware, occurs. I have 



8 HUTCHINSON'S SUGGESTIONS, ETC. 

seen several cases, and have watched some for long periods, 
and I never witnessed any ulceration of the cornea or conges- 
tion of the eyeball. I do not believe that the eye is in any 
danger, and thus far the statement of Majendie and Meyer, 
from experiments on animals, is not borne out by what is seen 
in human pathology. 

If, however, the fifth nerve be involved in disease, or only 
its ophthalmic division, then the results are very different. 
The cornea, if deprived of sensation, is in gi"eat danger, 
and the risk is, I believe, in ratio with the completeness of 
the loss of sensation. It would appear that this paralysis of 
the fifth does not cause defects of nutrition, for the eye may 
remain anaesthetic yet in a state of perfect integrity for weeks 
or months. What occurs is an inability to control inflam- 
mation if inflammation is once set up. The slightest attack 
of corneal ulceration, however originated, is almost sure to 
run on to destruction. Thus, in some sense, it may be said 
to be a chance whether or not inflammation is set up ; but 
once begun, there is then no uncertainty as to its progress. 

It is just possible that after all the fifth nerve is "trophic" 
in no other sense than that the perception of pain is perhaps 
necessary in order to prevent the inflammatory process from 
running too liigh. It may be that the vessels are prevented, 
to some extent, from dilating by the reflex influence of pain, 
and that thus an anaisthetic condition leaves them without 
control. The phenomena which occur in herpetic inflamma- 
tion of the eye would, however, seem to imply that the fifth 
has a more direct power in reference to the nutrition of the 
eyeball, and that, under some conditions, it can develop in- 
flammation. 

The questions, however, which I chiefly wish to ask are — 
Is there any reason to believe that in the human subject any 
other nerve than the fifth can, either by its irritation or its 
paralysis, influence the nutrition of the eyebaU ? and, secondly, 
are there any facts which imply that the vaso-motor can pro- 
duce any other consequences than those which I have 
mentioned ? 



EMBOLISM OF CENTRAL ARTERY OF RETINA. 
MICROSCOPICAL EXAMINATION. 

By Edward Nettleship, F.R.C.S., 
Late Curator of the Moorfields Museum. 

Sudden Partial Loss of Sight in One Eye. — Emholisni of Art. 
Centr. Betinoi diagnosed hy Ophthalmoscope — Valvular 
Disease of Heart, and History of Bheumatic Arthritis. — 
Glaucoma three months after first symptoms ; Iridectomy 
folloioed hy temporary benefit ; Recurrence of Glaucoma, 
and Total Loss of Sight four weeks after Iridectomy. 
— Excision of Eye four montlis after first symptoms. — 
Microscopical Examination. — Organised Clot in the tvjo 
terminal divisions and trunk of Art. Centr. Eetince. — 
Relation sJwivn hetiveen Symptoms caul Structure of various 
parts of the, Clot. — Inflammatory Growths from inner 
surface of Optic Disc. — CEdema of and Hocmorrhages in 
Retina and Choroid. — Elongation of Rods and Cones. 

The following is one of considerable interest. The com- 
parative infrequency of cases which present the symptoms 
believed to indicate embolism of the central artery of the 
retina ; the extreme rarity of opportimities for dissecting eye- 
balls in which these symptoms have occurred ; the fortunate 
demonstration of a perfectly definite, organised fibrinous ob- 
struction in the trunk and some branches of this artery, in an 
eye where embolism had been diagnosed by the ophthalmo- 
scope ; and lastly, the developmental changes undergone by 
fibrin deposited in small arteries, so far as these are illustrated 
by this specimen; all these reasons make a minute and even 
long account of the case desirable. 

I have been able to find only three recorded cases in 
which the diagnosis of embolism of this artery has been 
confirmed by subsequent dissection of the eye. 



10 NETTLESHIP ON EMBOLISM 

Schweigger* figures the appearances found in the art. 
centr. retince a year and a half after embolism of the vessel had 
been diagnosed. The embolus is shown under a very low 
power, as a small, round, highly refracting mass, lying just at 
the level of the lamina cribrosa ; it completely fills the vessel. 
The artery is slightly'contracted both above and below it, and 
is filled by a thrombus on the proximal side of the embolus. 
The retina was atrophied. I^Totwithstanding Stellwag's^f* 
adverse criticism of this drawing, it seems most likely that 
the appearance depicted was really produced by an embolism, 
a view to which its author^ adheres in a more recent publi- 
cation. 

The second case, an important but rather doubtful one, is 
given by A. Sichel.§ It is accompanied by a drawing of 
no great merit. Here the left art. ccntr., for a distance of 
6 mm. {\ inch), in the substance of the nerve, was shrunken, 
and filled by unorganised material, partly consisting of yellow 
granules, and partly of an amorphous substance, which alone 
became stained by carmine. This ceased at 3 mm. behind 
the law., crib. A plug also filled 2^ mm. of the lower main 
arterial branch in the recina. The symptoms were complex, 
and their interpretation is doubtful, laying between embo- 
lism, tln'ombosis of an atheromatous vessel, and h?emorrliagic 
retinitis. The author inclines to embolism. The patient, 
aged 54, suddenly became blind of her left eye after a fright, 
which made her start. Next day a very large recent haemor- 
rhage was found at the y. s. region, and also many small 
peripheral ones of various dates, and in both eyes. The disc 
and retinal vessels normal. Vision extremely defective from 
a large central scotoma. Systolic bruit at heart's apex. No 
albuminuria. Sight improved in three months to 17 J. At 
four months it rapidly failed, and the disc was found partly 
atrophied; the arteries on and near it reduced to grayish- 

* Vorlesungcn ii. d. Gebrauch des Augenspiegels, 1864, p. 147. 
f Stcllwag, Diseases of the Eje (American Translation, 18G8), p. 665. 
X Scliweigger. Handbuch d. Speciellen Augenheilkunde, 1871, p. 477, 
foot note. 

§ Arch, do Pliysiol. Paris, t. iv, 1872. 



OF CENTRAL ARTERY OF RETINA. 11 

white cords, but beyond the equator increased in size as they 
approached the era serrata (this was confirmed at the post- 
mortem). The large central blood-patch now decolorised. 
Deep-seated pain had occurred behind the left eye. Later, 
the atrophy of the disc became complete, and the arterial 
shrinking extended to the peripheral branches. After four- 
teen months she died. There were small hemorrhages and 
miliary aneurisms in the brain (no aneurisms found in the 
retina). The bicuspid valve was incompetent, but had no 
vegetations. No disease of intracranial part of left carotid or 
ophthalmic artery. The eye was removed sixty hours after 
death, in summer, and kept for five months in Miiller's fluid 
before dissection. The symptoms differed much from those 
usually ascribed to embolism of ar^. centr., and the author thinks 
this may point to partial obstruction as the cause of the ordi- 
nary cases, This conjecture seems to be borne out by the 
case which forms the subject of this paper, in which the 
accredited symptoms of embolism accompanied an imperfect 
block to the retinal blood-supply. 

The third case is recorded by Mr. Priestley Smith.* 
The eye was examined with the ophthalmoscope seven 
days after the occurrence of sudden and complete loss of 
sight in it, and the diagnosis of embolism of the art. 
centr. retinae given. Just four months after the loss of sight 
the man died, and the optic nerve was examined microsco- 
pically. In a transverse section of the nerve, immediately 
behind the eye, the canal of the central artery was found to 
be quite obliterated, its position being indicated " by a well- 
defined circular mass of concentrically arranged fibrous tissue 
adjacent to the vein." The vena centralis was patent, but 
much smaller than in health, and the optic nerve in its whole 
course was somewhat shrunken. In this case the loss of 
vision had been quite sudden, complete, and final ; no other 
symptoiiLS followed, except the ophthalmoscopic changes com- 
monly ascribed to embolism of tliis artery, of wliicli a very 
graphic description is given. 

* British Medical Journal, April 4, 1874, p. 452. 



12 NETTLESHIP OX EMBOLIS.AI 

The subject of the following account was at Moorfields 
under the care of Mr. Wordsworth, to whom I am indebted 
for permission to publish the case. 

The patient, a clerk, aged 54, w^as standing at his desk at 
half-past three o'clock on the afternoon of December 24, 
1872, when he suddenly "lost his sight." He thought both 
eyes were dim and said " they became puzzled." In a few 
minutes, however, after washing his face, he found that only 
the left was affected ; it was not quite blind, but there was "a 
kind of bright mist" before it. 

He remained in this condition for four .days, when (on 
December 28th) he came to Moorfields, and was seen by 
Mr. Wordsworth, by whom " oedema of left retina and embo- 
lism of the arteria centralis retinae" was diagnosed. Very 
distinct mitral and aortic systolic bruits were heard on auscul- 
tation. 

There was no history of rheumatic fever, but the patient 
said that in the autumn of 1872 he had had an attack of acute 
and very painful inflammation of his right wrist, which his 
medical attendant called " rheumatic gout." He had out- 
growths on the condyles of liis right femur. 

Small doses of iodide of potassium were ordered, and 
atropine used on the day of his admission. The iodide was 
continued with tolerable regularity for three months (tiU 
]\Iarch 24th, 1873), but it is probable tliat the atropine was 
used only ab his first visit to the hospital. At his visit 
on March 24th, increased tension and other symptoms of 
acute glaucoma was present. On the 27th these had in- 
creased ; he could not then count fingers, and the visual field 
was so contracted that he described only "a diamond shape" 
of light as remaining at the temporal side. Iridectomy was 
accordingly done at this date. The operation was followed 
by temporary relief from pain, enlargement of the visual 
field, and improvement of sight, so that he became able to 
count fingers. On April 21 (between three and four weeks 
after the iridectomy), however, great congestion of the eye 
came on, and a day or two later he began to suffer severe pain 



OF CENTRAL ARTERY OF RETIXA. 13 

in the left temple and side of head, though not, he said, in 
the eyeball itself. Sight rapidly failed, and was soon quite 
lost. On the 26th there was no perception of light, the globe 
was intensely congested, the cornea so steamy that only a 
glimpse of the optic disc could be seen, and the pain still 
continued. Under these circumstances, ]\Ir. Wordsworth 
excised the eyeball. 

The eye was divided into halves at the equator, a minute 
or two after its removal from the orbit. The vitreous was 
perfectly transparent and apparently normal, with the excep- 
tion of being perhaps slightly too fluid in the centre. It 
separated much more readily from the posterior half of the 
retina than is tlie case in healthy eyes, a change which is 
common in cases when there is inflammatory oedema of the 
retina and choroid. The retina was in situ everywhere, and 
showed slight but decided haze for some distance all around 
the disc ; there was, however, no especial milkiness around 
the yellow spot. The follo^\ing appearances were noted at 
the fundus in the still perfectly fresh specimen under a mag- 
nifying power of 30 diameters. All the chief retinal vessels, 
both arteries and veins, contained blood, and in both sets of 
vessels the column was frequently broken, leaving small 
empty spaces. This appearance, at least in the veins, was 
probably due to the post-7nortem coagulation and shrinking of 
the blood. The principal veins in the retina were somewhat 
engorged, especially the one coming from the lower part of 
the eye ; but at the margin of the disc, and on its surface, 
they became suddenly and considerably diminished in size. 
The column of blood in the arteries was very much smaller 
than that in the veins, while their coats were much whiter 
and appeared thicker than normal, a change due probably 
to simple contraction in consequence of the diminished column 
of blood. On the area of the disc, following the course of, 
and apparently enveloping the main upper and lower divisions 
of the artery, was a densely white structure, thickest near the 
centre where it disappeared in the " physiological pit," and 
tapering off above and below until it disappeared just within 



14 JfETTLESHIP OH EMBOLISM 

the margin of the disc, at which point the cohmm of arterial 
blood first became visible. It coidd be seen by the un- 
aided eye as a minute white streak extending across the 
centre of the disc. It had about three times the diameter 
of the arterial branches which it obscured, and appeared to 
be an exudation around these vessels. The remaining part 
of the disc was slightly milky, but did not obscure the other 
vessels. Two arterial branches, of about the third magnitude, 
dipped into the disc at a little distance from its margin, and 
without joining the obscured trunks above described ; one of 
these ran towards the macula lutea, the other towards the 
nasal side. In the retina, close to the temporal side of the 
disc, was a group of very small round haemorrhages. Besides 
these blood-spots, there were three groups of glistening white 
deposits in the retina ; one formed almost a single line of dots 
below and parallel to the nasal arterial branch mentioned 
before, another and larger group formed a narrow oblong patch 
in the same relative position to the above-mentioned temporal 
arterial branch, the third was a small gi'oup of very minute 
dots just below and to the nasal side of the yellow spot. 

The posterior hemisphere of the vitreous was now removed 
and the corresponding half of the eye placed for four hours in 
a solution of chromic acid ('25 per cent.), and afterwards 
for three weeks in a filtered mixture of equal volumes of 
Miiller's solution and methylated alcohol. As soon as the 
retina had become opaque a number of small, slightly raised 
dots came into view all over its surface, from which they were 
distinguished also by their somewhat whiter colour. They 
resembled, in naked-eye appearance, the elevations seen on 
the retina in early stages of general ophthalmitis from injuries 
and other causes, and were doubtless of the same nature. 

Microscopical Examination. — Numerous tliin longitudinal 
sections were made through the disc (including the neigh- 
bouring retina) and optic nerve, as nearly as possible 
parallel to the ascending and descending arterial branches 
and the white streak on the disc. They were stained 
in carmine. Four of these sections contained more or 



OP CENTRAL ARTERY OF RETINA. 15 

less complete longitudinal sections of the arteria centralis 
and its main branches on the disc. The accompanying- 
figures (PI. I, figs. 1, 2, 3), were taken from two of these spe- 
cimens. Fig. 1 is made up from two sections, those portions 
of the artery shown in thick black outline being added from 
another section : a careful study of all the sections having 
shown the arrangement depicted to be correct. Fig. 2 is a 
half-diagrammatic representation of the arteries alone, show- 
ing the relative position and extent of the fibrinous plug and 
the blood in them. Fig. 3 is a very correct copy of the 
embolus and neighbouring parts in the specimen from which 
the greater part of Fig. 1 was taken, but without the addition 
of the vessels d and e, the continuation of the trunk upwards 
beyond the branch c being only just indicated. These figures 
show that the art. ccntr. from a little below the lam. crib, to 
its division into the three main branches c, d, and e, is occupied 
by a pale substance, which passes also into e as far as this 
branch is included in the section, and extends for some distance 
into d, where it has a well-defined conical termination. Its 
lower extremity {cmh. 1) is tapering and bifurcated. It quite 
fills the artery everywhere except on one side at the lower 
part Qi, Fig. 3), where it gradually leaves the arterial wall. 
This separation begins just on the proximal side of the point 
from which the branch a is given off. The artery below the 
point, ciiib. 1, in the section figured, is empty ; but in other 
and more nearly axial sections this part contains some ill- 
defined granular substance and near the proximal end of the 
specimen red blood reappears. When more highly magnified 
(^112 to 400 diams.), this pale substance is resolved into a 
filjrinous and corpuscular structure having different characters 
in different parts. The most proximal part {emh. l,Fig. 3), is 
composed entirely of rounded ill-defined corpuscles, about as 
large as white blood-ceUs, having finely molecular contents 
and large nuclei stained by carmine ; these are separated by 
a small quantity of similar molecular substance, probably 
recently precipitated fibrin. A little higher up the corpuscles 
are more or less oval and often show two or more long pro- 



16 NETTLESeiP ON EMBOLISM 

cesses, and the intercorpuscular substance looks indefinitely 
fibrous, being either reticulated or arranged in parallel layers 
according to the plane in which it is viewed. From the most 
central part of the axial portion (/, Figs, 1 and 3) to the end 
in d and e, this structure is slightly rust-coloured, finely 
granular and contains many irregular rounded meshes. These 
meshes are formed by fibrous bands and threads with nucleated 
nodal points. One or two of these bands in the branch d look 
very like capillary loops, but as they contain no blood I 
cannot be certain that they are blood-vessels. The whole of 
this organised fibrinous plug from/ forwards is closely adherent 
to the tunica intima of the artery ; indeed, in the branches 
d and e, the arterial coat enclosing the plug is reduced to a 
single thin layer which is quite continuous with the bands 
and threads of the organised contents. 

The blood in the arterial brancli d beyond the plug is ex- 
tremely dark ; its corpuscles being shrunken, finely granular 
and ill-defined, while just at their point of contact with the 
embolus they are changed into large vesicular bodies. The 
artery d becomes suddenly much smaller just beyond the 
embolus, and its coats simultaneously much thicker, so that 
at the point g, quite within the margin of the disc, its internal 
diameter is only \ what it is just after its origin from the 
trunk. The blood in the three branches, a, h, and c, is, on the 
other hand, quite normal in all parts, even where in contact 
with the embolus at the mouths of these branches. The branch 
a appears contracted at its point of origin, but this is probably 
due to the section having passed to one side of its axis at 
that point. The embolus seems to pass for a short distance 
into c, but it is doubtful whether this is not a false appear- 
ance due to the mouth of this branch being seen through the 
main trunk. The only notable change in the coats of the 
art. centr. is a considerable annular puckering of its tunica 
intima at the upper part, and a corresponding change in 
the outer coats. The separation of the intima shown at 
the lower part of the figures probably occurred in making 
the section. Neither the vena centralis nor the two small 



OF CENTRAL ARTERY OF RETINA. 17 

arteries mentioned at p. 5 were identified in any of the 
sections. 

BcmarJcs. — The appearances above described are evidently 
due to plugging of the upper part of the art. centr. and its two 
most distal divisions by fibrin, which has become more or less 
completely organioed. It is clear also, from the altered state 
of the blood in the branch d, and the sudden and great con- 
traction of its coats, no less than from the fact that organisa- 
tion has advanced further in the clot in d and e than any- 
where else, that the arterial obstruction occurred earliest in 
these two last-named vessels. Possibly the embolus was 
broken into two at the point where these terminal divisions 
of the artery arise nearly at right angles from the trunk. The 
obliteration of the vessel between cmh. 2 and cinh. 1 no doubt 
occurred gi-adually afterwards, by the deposition of fibrin and 
white corpuscles. There is nothing in the structure of the 
organised fibrinous contents of the artery by which to distin- 
guish the embolus from the subsequently deposited fibrin 
(thrombus). The structure of the proximal part {emb. 1) 
shows clearly that it is more recent than the parts / and 
evib. 2 ; whilst from the unaltered state of the blood in a, b 
and c, it is probable that blood had passed into these branches 
from the main artery not many days before the eye was 
excised. The existence of the lateral channel, h (Fig. 2), and 
its partial closure by the most recent part of the thrombus, 
also support this view. Tliis complete occlusion of the 
vessel whose mouth had longest remained pervious (pro- 
bably a), may have caused the total loss of sight which came 
on about four days before excision, though it is diflicult to 
see why this occlusion should have given rise to the recur- 
rence of glaucomatous symptoms and pain from which the 
patient then also suffered. The relapse of glaucomatous in- 
flammation would explain the pain and loss of sight equally 
well without the thrombosis. It is perhaps possible that the 
increased tension which formed part of the final glaucomatous 
attack may have predisposed to the final thrombosis by 
obstructing the flow of blood into the still pervious branch or 
VOL. vni. c 



18 NETTLESHIP ON EMBOLISM 

branches, and thus producing a partial stasis in the upper- 
most portion of the aH. centr. 

Changes in the Optic Disc, and other Structures. — One side 
of the disc is somewhat swollen. The opposite side shows, 
just within the choroidal ring, slight depression, which may 
possibly have been caused by the increased tension, but is 
just as likely to have been physiological. Several sections 
show portions of small tumours projecting from the disc. 
The largest of these begins near the centre and has a length 
in the sections where it appears, of haK the radius of the disc ; 
it is on the swollen side of the disc. Another, though not so 
extensive, is thicker and its surface slightly nodulated. None 
of these little growths happen to occur in the sections con- 
taining arteries ; there can, however, be little doubt that they 
(or the largest of them) were visible to the unaided eye as a 
part of the little white streak already described on the disc, 
the embolus in the two terminal branches probably com- 
pleting this appearance. These little growths are composed 
of embryonic tissue in various stages, their most superficial 
parts being formed altogether of roundish cells with large 
nuclei and the inner parts consisting of more or less de- 
veloped fibres and fusiform cells. Some of the very smallest 
of these growths are entirely cellular, and in these the cells 
are arranged in groups which tend to become spherical ; so that 
the smallest tumours form single nodules and the larger ones 
present a nodular surface. The hyaloid membrane (itself, in 
some parts on the disc, containing many large corpuscles) 
covers the free surface of these little tumours. Their relation 
to the limitans interna of the retina is not clear. In the 
largest of them there is visible a short portion of a small 
blood-vessel containing well-formed blood-corpuscles, and near 
to it are a number of higlily coloured granules, probably the 
remains of a small hsemon-hage. In the swoUen part of the 
disc there appear to be many nucleated corpuscles between the 
nerve-fibres. This appearance is no doubt due largely to 
varicose swellings of the nerve-fibres, but probably also to an 
exudation of inflammatory corpuscles. There are similar, but 



OF CENTRAL ARTERr OP RETIXA. 19 

less marked, clianges in the nerve-fibre layer of the retina 
near the disc. One section of retina, near the disc, includes a 
small extravasation of blood, the corpuscles of which are 
much altered and very irregular in size and colour; it is 
e\ddently of considerable age. The other retinal structures 
show signs of prolonged general oedema. This is especially 
marked in the rods and cones, which have undergone in a 
high degree the lengthening and swelling which are common 
in eyes whose tissues are inflamed and cedematous.* There 
is also oedema of the choroid, and its epithelium is slightly 
pushed aside and heaped up at the edge of the swollen side 
of the optic disc. I did not succeed in tracing any anasto- 
moses between the vessels of the choroid and those of the 
disc or retina, so that probably no extensive collateral circu- 
lation had been established. 

* Oplithalmic Hospital Reports, vol. vi, p. 620. See also Index to same. 



2 



20 NETTLESHIP ON ESIBOLISM, ETC. 



DESCRIPTION OF PLATE I. 
Fia. 1. — X 38. (Partly cliagrammatie) . Longitudinal section through 
retina, &c., and optic nerve, including a section (nearly axial) of the art. 
centr. retincB and its chief divisions. The branches indicated by thick black 
outline are added from another section. 

«1 

b \ Branches of art. centr. containing normal blood. 

c J 

<i\ Terminal divisions of art. centr. given off nearly at right angles to 
e\ it. 

Emb. 1 and 2. — Organised fibrinous clot occupying upper part of art. 

centr. and commencement of branches d and e. Its conical end 

seen in d, but owing to engraver's error is not so plain in the figure 

as in the specimen. 

/. Central part of thrombus. This letter, owing to engraver's error, 

is not clearly shown. 
g. Extremely shrunken portion of artery d, containing shrivelled and 

degenerated blood-corpuscles. 
The disc is seen to be somewhat swollen on one side, and slightly 
depressed on the other side. 

EiG. 2. — Diagram of the arteries shown in Fig. 1, showing extent and 
shape of embolus and thrombus. The plugged vessels shaded light. Vessels 
containing blood coloured black. Lettering as in Fig. 1. 

Fig. 3.— X 112. L^pper part of art. centr. anA some of its branches 
from same section as Fig. 1, but without addition of branches d and e. 
Lettering as in Fig. 1. 

Emb. 1. Most recent part of thrombus, entirely corpuscular. 
Emb. 2. Older and more organised part of thrombus. 

h. Space between newest part of thrombus and wall of main 
artery. It extends nearly as far as mouth of branch a, 
and was probably the last to receive blood from art. centr. 
Tun. Int. The wrinkled Tunica intima of art. centr. 



Ophthalm:R. 



; emJb-Z 




O-jri (yit- 



I 



^'1: 



Art: 

CM: Re 




TuJi:lr:. 



1000 w. i~liz 



Embolism of Arteria- Centralis 



-^tiCTith, 



21 



SOME EEMAEKS ON THE TREATMENT OF CERTAIN KINDS 
OF CONICAL CORNEA BY OPTICAL MEANS, ILLUSTRATED 
BY A CASE. 

By H. Bendelack Hewetson, M.R.C.S., Leeds. 

The occurrence of regular astigmatism in cases of conical 
cornea which present themselves for treatment is so rare, that 
the thought hardly ever suggests itself of making any attempt 
to correct the optical confusion caused therefrom by cylin- 
drical glasses. 

Moreover, the success which has attended some of the 
various operations in such cases on the apex of the cone 
appears to have eclipsed all other modes of correction, and 
has seemed to give no other alternative to the patient but 
operation. 

The following case shows, however, that it is well in all 
non-progressive cases of conical cornea to negative the exist- 
ence of corrigible astigmatism before deciding upon an opera- 
tion. 

Doubtless, such instances are few and far between ; or 
possibly they are overlooked, from an omission to test optic- 
ally all cases of non-progressive conical cornea. 

Notes of the Case. 

Nov. 1872. — Mr. H. S., residing at Huddersfield, consulted 
Mr. PridginTeale in November, 1872, who entrusted the test- 
ing of his optical condition to myself 

His history is as follows : — 

Several of his relations- are myopic, and he himself has 
always been " weak-sighted," but in other respects healtliy, 
never having had any severe illness or attack of inflammation 
in the eyes. 

By profession he is an engineer, and consequently has 
constantly been employed in mechanical drawing, which 
frequently caused great pain in the eyes. 



22 HEWETSON ON THE TREATMENT OF 

Two-and-a-lialf years ago lie was obliged to discontinue 
his employment, and was advised to undergo an operation for 
the relief of his defective sight, which was found to be de- 
pendent upon conical cornea. However, he was dissuaded 
by his friends, since he managed to get about in moderate 
comfort with the aid of concave glasses. 

His vision was not accurately tested at that time, from 
the idea that the conical cornea would progress, and render 
optical correction useless. His sight up to tliis time remained 
unchanged. 

June, 1873. — With the unaided right eye vision was ^, 
and he read Jaeger No. 1 at 2 inches with difficulty. In the 
vertical meridian, tested by the stenopceic sht, there was -^-^ 
hypermetropia, and in the horizontal meridian myopia -^ ; so 
that with the following combination of cylindrical j'g- O — 
cyl. _>^, Vision was raised to f ^, and reading to Jaeger 1 at 
8" distance. 

In the left eye, the unaided vision is f ^, hypermetropia 
existing to the extent of -^^ in the vertical meridian, in the 
horizontal myopia, -^. 

The combination of ^V cyl. O — tt ^yl- raised vision to 
If, and the reading to Jaeger 1 at 12" distance. 

May 23rd, 1874. — These glasses have now been worn 
nearly a year, during which time, from becoming used to 
them, the acuteness of vision has much improved, and has in 
fact rendered his sight, as he says, " perfect." 

I must add, that the astigmatism in this instance is mixed 
and regular in each eye, and the conicity of the cornea is 
very evident upon profile inspection ; also, that the pupil of 
each eye corresponds accurately in area with the apex of the 
cone, so shutting off rays of light passing through the sides of 
the cone, which, were they permitted to enter from dilatation of 
the pupil, would probably have prevented all optical con-ection. 
So that it seems as if two principal curves existed in the cornea 
at the apex of the cone, limited to the area of the pupil, a 
curve of short radius corresponding, with the myopic meridian 
and that of a longer with the hypermetropic meridian. 



CERTAIN KINDS OF CONICAL CORNEA, ETC. 23 

The dijEference in the improvement of vision between the 
two eyes seems to depend upon some amount of amblyopia 
existing in the right, for on an examination with the erect 
image, with the glasses adjusted before the eyes, the fundus 
appears regular. 



24 



ON A VISIBLE STELLATION OF THE NORMAL AND OF THE 
CATARACTOUS CRYSTALLINE LENS OF THE HUMAN EYE. 

By John Tweedy, M.R.C.S., 

Assistant Medical Officer in the SJdn Department of University 
College Hospital, London ; and Clinical Assistant at the Royal 
London Ophthalmic Hospital. 

The striation, or, more correctly speaking, the stellation of the 
normal crystalline lens of the human eye is well Imown as a 
post-moi'tem appearance, but few persons are aware that it can 
readily be seen by oblique illumination in the living eye. 
Nearly three years ago I described elsewhere* this stellation 
as observed in the healthy human eye, and endeavoured to 
explain the method by which it may be brought into view. 
The latter \vas by no means an easy task, for I could only 
give general directions as to plan to be adopted, and could 
not definitely state how ihe rays of the stella could be surely 
and certainly seen. The mode of procedure, however, is that 
employed in ordinary oblique illumination of the anterior 
parts of the eyeball by the aid of artificial light. The 
observer must endeavour to obtain the greyish glistening 
reflection from the anterior capsule, and must look more 
obliquely along the anterior surface of the crystalline lens from 
the side opposite to that on which the light falls than in the 
ordinary oblique illumination. If by this means a view be 
obtained of the anterior stella of the lens it will be found to 
consist of fine, dark, radiating, and slightly undulating lines, 
about ten in number, extending from near the centre of the 
anterior surface of the crystalline lens to its extreme peri- 
phery. It wiU be seen in Fig. 1, which has been taken from 
a normal eye, that, although the rays are united towards the 
centre of the anterior surface, they do not all start from 

* Lancet, 1871, vol. ii, p. 776. 



TWEEDY ON A VISIBLE STELLATION, ETC. 25 

exactly the same point, as is usually represented in drawings 
taken from the lens after death. 

Fig. 1. 




The precise manner in which the rays unite at the centre 
varies very much, but in every case a conformity to a parti- 
cular plan may be observed. I have never yet seen the 
arrangement figured in Strieker's Histology.* In the accom- 
panying woodcut (Fig. 2), for which I am indebted to the 
Council of the New Sydenham Society, it will be seen that 
all the rays of the stella, except one, are represented as con- 
verging to the same point in the centre of the anterior surface 
of the lens. 

Without wishing to impugn the accuracy of the repre- 
sentation in this particular instance, I must say that such an 
arrangement is exceedingly rare, and has never been seen by 
me in the large number of examinations which I have made. 

But in addition to main rays which converge towards the 
anterior pole there are secondary rays which branch from the 
primary ones, and wdiich have their vertices at varying dis- 
tances from the pole. Sometimes there are tertiary branches, 
and in the diseased eye I have seen even quaternaiy rays. 

* Strieker's Histology, vol. iii, p. 364. New Sydenham Society's transla- 
tion. 



2G 



TWEEDY ON A VISIBLE STELLATION OF THE 



Pig. 2. 




Before proceeding further in the consideration of the rela- 
tion which the rays of the stella bear to the nutrition of the 
lens and of their influence on vision, I must in justice to 
others and to myself refer to a question which has been 
raised as to my claim to have been the first to describe these 
rays as objectively seen in the living eye. At the time that 
I published ray first article on this subject I had reason to 
believe, from the assurances of some of the most eminent 
anatomists and ophthalmic surgeons in London, whose names 
I need not here mention, that a visible striation of the living- 
normal crystalline lens had never before been described. But 
within two days of the appearance of my article I found, in 
reading the chapter on Entoptics in Professor Bonders' work, 
what I believed to be a confutation of my priority ; for, after 
describing certain entoptic appearances of his own crystalline 
lens. Bonders says, " These phenomena are connected with 
the composition of the lens of the so-called sectors, which, 
as Helmholtz showed, can be verv well seen wnth the mag- 



NORMAL AND THE CATARACTOUS CRYSTALLINE LENS. 27 

nifying glass, with lateral focal illumination in the living 
eye. * 

Now, although I knew that the sectors could be seen with- 
out the line rays themselves being distinguished, I felt that 
the excellent observer referred to could scarcely have failed to 
see the rays when examining with a high magnifying power 
the lens sectors ; but being unable to find any satisfactory 
statement in Professor Helmholtz's work on Physiological 
Optics, I, at the recommendation of Professor Sharpey, wrote 
to Professor Helmholtz to ask him where he had described 
the visible normal striation of the living lens, as I was 
desirous of pubhcly disavowing my claim. In the kind and 
speedy reply to my query I was assured that, although the 
lines which I had figured were evidently identical with those 
described by Listing,-f- and mentioned by Helmholtz himselfj 
as entoptic images, yet not only had he never seen them 
objectively in the living eye, but that, as far as he knew, they 
had not been seen in such a manner by any other observer. 
But Professor Bonders, whose acquaintance 1 subsequently 
had the honour to make, and to whom I am indebted for 
several of the subjoined references, has informed me that he 
was well acquainted with the stellation which I had figured, 
and that he had been led into the error of ascribing the first 
description of them to Helmholtz by the fact that the latter 
had stated that by oblique illumination he was able, in some 
instances, to make out the sectors of the lens, and that it was 
in looking for these that Dr. Bonders had observed the rays of 
the Stella, and naturally concluded that Helmholtz had also 
seen them. 

But apart from these trivial concerns, the lines have I 
think an importance which has hitherto been imperfectly 
understood. This, therefore, must be my excuse for bringing 
before the members of the profession, and especially before 

* Refraction and Accommodation of the Eye. New Sydenham Society's 
ti'anslation, p. 201. 

t Beitrag zur Physiologischeu Optik, Grottingen, 1845. 
t Physiologische Optik, p. 152. 



28 TWEEDY ON A VISIBLE STELLATION OP THE 

Ophthalmic surgeons, some of tlie results of my examinations 
and the conclusions which I have drawn therefrom. 

In the normal eye the rays of the Stella vary in number 
from eight to twelve, including the primary and secondary 
rays. In a child two and a half years of age I was able to 
count nine rays, but I have not, for obvious reasons, suc- 
ceeded in seeing any rays in yoanger cliildren, so that I 
cannot say when the three primary rays found in the foetus 
besdn to divide, or at what rate the division and ramification 
of the rays take place. 

In children of about five or six years of age I have, how- 
ever, frequently seen the commencement of the branching of 
a primary ray, and I am inclined to believe that the ramifica- 
tion is always centrifugal, that is, commences from near the 
pole, or in the case of a secondary ray, that it commences 
from a primary ray and extends towards the periphery-, and 
never from the periphery towards the centre. In the diseased 
eye, however, especially where the lens is beginning to 
undergo cataractous changes, the number of the rays may 
become greatly increased. For insta.nce, in a patient whose 
lens showed signs of the commencement of posterior cataract 
from disease in the posterior segments of the globe, there 
were twenty of these rays. 

The rays also may be shown objectively and sub- 
jectively to be of a different refractive power from the inter- 
linear sectors. But at present I wish to speak only of the 
objective appearance, and shall refer more in detail to the 
subjective phenomena in a subsequent part of this article. 
In an ordinary eye the rays appear black or brown in colour, 
the particular shade varying with the general pigmenta- 
tion of the eyel)all, but in the albino they are red. In the 
first albino that I examined they appeared as clear red 
lines on a duller red ground, and in an albino that I re- 
cently saw they sliowed themselves as clear red lines without 
the glistening satiny haziness which the interlinear portions 
of the lens presented. 

Perhaps the most interesting result of the regular and 



NORMAL AND THE CATARACTOUS CRYSTALLINE LENS. 29 

methodical examination of the rays is the knowledge afforded 
of the inception of cortical striated opacities at the anterior 
part of the lens. But before we can profitably engage in 
the consideration of this question, we must stop to consider 
briefly the anatomical structure of the healthy lens. The 
earlier histologists, Henle, Kolliker, but especially Becker,* 
asserted that the ends of the fibres of the lens do not come 
in immediate contact at the rays of the stella, but that there 
is an intervening space, filled with structureless or granular 
matter, to which and to the supposed interfibrillary passages, 
Becker attributed great importance in the changes undergone 
by the lens in accommodation. But this has been shown by 
Zernoff,'!' Babuchin, j and others, to be erroneous. The micro- 
scopical examinations of these gentlemen have proved that 
the rays of the stella are merely the seams formed by the 
apposition of the ends of the fibres, and that imder high 
powers these rays appear as fine sinuous lines, without the 
interposition of any material whatever. With the statement 
made by the latter authorities, the result of my examinations 
of the living lens in situ entirely accord. 

The error of regarding the stellate fissures as spaces filled 
with gi-anular matter doubtless arose from the fact that " the 
superficial fibres are usually very soft and deMcate, and easily 
break up in macerating fluids into detached drops of various 
sizes (hyaline drops), but partly also into a finely granular 
or structui'eles mass. This breaking-up occurs also spon- 
taneously after death, and inasmuch as it chiefly affects in 
the first instance the extremities of the fibres, it is intelligible 
that the products of the breaking up must principally accu- 
mulate in the stellae of the lens."§ From this it will be 
evident that the opinion of those who regard the rays of the 
stella as actual structures, and capable of undergoing cata- 
ractous changes, cannot now be accepted, the rays themselves 

* Arch, fiir Ophthal., t. ix, A 2. 
t Arch, fiir Ophthal., t. xiii, A 2, p. 521. 
t Strieker's Histology, vol. iii, p. 365. 
§ Strieker, vol. iii, p. 369. 



.>() rwl'.KPV (>\ A VISIIU.K STKIJi.VnON OK TUK 

bcinu. !is it \V(M'i\ iu>!::iti\i' stniclun's. nuM'c lissiircs or scams, 
i'oniu'tl by ilic ;i]i|uisii ion of ilic (MhIs oI' tlio lil>res. Never- 
(lioloss, ovorv oplitlialinir suvuooii is !U't[iiiiiultnl \vith radiating 
striatoil opacitios, Nvhich boar a oloso rolation to iho rays of 
(lu> n.Miu;iI s(i-ll;i. How are theso to be accounted for ? What- 
ever may bi> iho inijxMi'eetions; in (mu" knowledge of the actual 
puK'osses w hit h determine ilu> moleenhn' ehanges that give 
rise to rataniitous opiu'ity. wo know thai llioy are. directly or 
indiivetly. the result of aitored. i>iMverled, or inijKiiivd nutri- 
tion ; and as the lens is entirely extravascular. it nnisl de]HMHl 
ou tlie stnu'iuros miuI lluids i\miu'diait>ly su.rr(>nnding it for 
its nutrilion-su|>i>ly. I'he intereliange ot" material between 
tho lens and the snrroundiuu' tissues, therefore, talces place by 
processes o\' endosmosis and e\osuu>sis. and il" either o\' these 
pnn'esses be interfered with by the im|nisitiou o[' meehanieal 
and i>hysical obstacles, or by an alteration in the surronuiling 
tissues or tluids, we can easily undovstand that the i^arts 
most liktdy io be primarily alVeeted are those which adjoin 
the nvYs of the stella — the tissvires iVunned. as it were, by the 
discontinuity of the leus fibres, where ihe iiulosmotic pro- 
cess aiv most active. 'Ihese are in fact the }^arts of greatest 
vulncnd»ilitY, and a.re most liable to become alfected by dis- 
turbed nutritive changes. As a proof of this we may note 
(hat in the earliest stages of senile cortical opacities, or of 
opacities accom]>anying intlammation of the vascular tunics of 
the eyeball, that these are always the parts primarily atVected. 
{H' this I have become conviuooil by numerous examina- 
tions. 

The earliest ]vrceptible cataractous changes in the cortical 
layei-s v^f thi> lens, especially* of old people, show thenuselves 
in the enils o\' the fibres adjoining the mys. and the clear 
dark line of fissure may fivipuMitly be seen to Innxler tho 
opa«pu? cutis of thefibrevs. or even to pa«s between the opaque 
eiuls of the two opposing sets o\' libres. Kven in the cortical 
opavMties of yi>in»g children, a ray o( the stella may often 
be obser\ ed boidtMing a cutamctous stria, or passing down its 
noddle if the libres on both sides be involved. OWcw in iritis. 



NORMAL AKD THE CATARACTOUS CRYSTALLINE LENS. 31 

where the aqueous humour becomes turbid, a haziness may 
be observed in the end of the lens fibres, adjoining the rays 
of the anterior stella, and in choroiditis, and acute affections of 
the vitreous, a similar condition may be observed in the pos- 
terior stella. This haziness often, however, entirely disappears 
when the inflammatory condition has subsided. The tem- 
porary haziness is evidently due to altered nutrition con- 
ditions existing during the inflammatory state of the sur- 
rounding parts. But sometimes the haziness thus induced 
continues steadily to advance to thick opacity. Quite recently 
an interesting case of posterior polar and stellar cataract 
came under my observation, through the kindness of Mr. John 
Couper. The patient was a man aged 32, who had suffered 
from nystagmus and impaired vision for about 16 years. On 
examining the crystalline lenses, a well defined posterior stellar 
cataract could be seen in each eye. In the right eye, includ- 
ing secondary and tertiary branches, there were fom^teen rays, 
and in the left eye there were twelve. The rays were of a 
dark grey tint, and extended from an opaque mass at the 
posterior pole outwards to the periphery, where they abruptly 
terminated, none of them passing round the margin of the 
lens on to the anterior surface. Kunning down one or two of 
the opacities, a fine dark line could be seen, but whether these 
dark lines were the remains of the original fissures, I can- 
not say. Although the interlinear sections appeared slightly 
hazy by oblique illumination, the fundus oculi could easily 
be seen by direct examination with the ophthalmoscope. In 
both retinae and choroids there were large irregular prolifera- 
tions of pigment. It is, therefore, in the highest degree pro- 
bable that the cataractous changes were primarily induced by 
the altered nutrition relations existing between the vitreous 
and the posterior segment of the globe and the lens, and that 
the effects of these showed themselves in the parts of greatest 
vulnerability, namely, the rays of the posterior steUa. 

But it is only up to a certain stage that the original rays 
of the Stella may be distinguished in cataractous striae, for, 
sooner or later, the retrogressive changes extend, so that the 



32 TWEEDY ON A VISIBLE STELLATION OF THE 

line of the ray ultimately becomes obliterated by the disrup- 
tion of the lens tubule, and destruction of its contour. 

From what I have alleged, it will be seen that I dissent 
from Professor Stellwag who, in speaking of the senile changes 
of the lens, says : " Most frequently we meet radiated striae 
which usually follow the course of the lens-filaments, and 
depend on cloudiness of the lens-filaments themselves, and on 
depositions of molecular masses in the interspaces."* If what 
I have asserted be correct, it follows that the " radiated strise " 
are formed by the opacity of the ends of the lens fibres, and 
that they do not follow the course of the lens-filaments which 
would really give them a bi-penniform arrangement with the 
ray of the stella as a stem, unless the opacity were confined to 
the few fibres which converge to the pole. I must also pro- 
test against the strict accuracy of the following statement 
made by Professor Stellwag in the last edition of his excellent 
and learned work : — " In rare cases . . . some or all of 
the rays of the star-shaped figure become bluish-white and 
hence become distinct from the stiLL transparent surrounding 
parts."t But here I cannot but think that the illustrious 
Vienna professor refer., to the same appearances which I have 
described, but has not recognised the real relation which the 
rays of the stella bear to the opacity. 

With all humility I must also demur to the opinion of that 
accomplished physiologist and ophthalmic surgeon, Mr. Bow- 
man, who, in speaking of the cataractous striations of the lens 
in middle or declining age, says : — " Now I can entertain no 
doubt that the streaks in these cases are sets or bundles of 
the superficial layer of lenticular fibres reduced to a state of 
opacity by some nutritional change. There seems to be a 
disposition in the fibres of the lens to become opaque in their 
entu-e length when once they are altered at a single point, 
and hence the linear figure of the opacity. The opacity pro- 
bably commences in the middle part of the fibres near the 
margin of the lens ; and the arrangement of the fibres would 

* Diseases of the Eye ; 4tli edition, p. 591. American translation, 
t Loc. cit., p. 604. 



NORMAL AND THE CATARACTOUS CRYSTALLINE LENS. 33 

account for the different length of the streaks, some approach- 
ing nearer than others to tlie central p(_)int of the surface."* 
Now although I grant that when a fibre is once affected at one 
point, the change is liable to extend itself through the entire 
length of the fibre, yet I believe that in most cases the opacity 
occurs primarily in the ends of the fibres adjoining the rays, 
and that the different lengths of the cataractous striae are to 
be accounted for by the different length of the primary, second- 
ary, and tertiary rays. But it is only just to add that 
Mr. Bowman seems to have been the first to recognise the 
multiplicity of the rays of the stella, and has indeed given a 
very accurate representation of them,-f- with the exception that 
he has not followed the divisions of the rays to the periphery 
of the lens. ]\Ir. Bowman did not, moreover, overlook the 
significance of the rays in formation of cataract, for he says, 
" In another variety of opacity in adults, there are streaks 
visible either on the anterior or posterior surface, before the 
nucleus manifests any tendency towards dulness, but instead 
of converging from the border of the lens, they rather diverge 
from the central point. These streaks are also ii-regular in 
number and du'ection, and it has never occurred to me to dis- 
tinguish in them any exact representation of the edges of the 
mesial planes as they are seen on the surface of the prepared 
lens ; never, certainly, any trilinear figure. But a glance at 
the representation above given of the complex arrangement 
of the mesial planes of the adult human lens, will suffice to 
explain why they are rarely seen in such opacities. In the 
healthy lens they are in reality too near together, and too 
irregular to be detected without a glass. The triple divergence 
can even then only be recognised for a short distance, beyond 
wliich the planes seem to diverge and branch without any 
attempt at geometrical precision. We cannot, therefore, 
wonder that an opacity, spreading from the centre of the 
lens, and wliich consists of broad, ill-shapen streaks, should 
fail to disclose the radiation of the mesial planes, although it 

* The parts concerned in the operations of the eye ; 184:9, p. 72. 
t Loc. cit., p. 68. 

YOL. vm. D 



34 TWEEDY ON A VISIBLE STELLATION OF THE 

seems highly probable that its seat is, primarily and essentially, 
rather in the edges of those planes than in tlie fibres them- 
selves."* From this extract it will be seen how near, twenty- 
five years ago, Mr. Bowman approached what I now maintain 
to be the fact. My own experience corroborates that of 
Mr. Bowman with respect to non-occun-ence of trilinear 
opacity in the adnlt lens. I must, however, observe that in 
one or two instances in old persons, where the nucleus of the 
lens had become opaque and amber-coloured, I have noticed 
a gaping of the rays apparently from shrinking of the cortical 
layers, and that this gaping assumed the trilinear form, the 
rays of which had the same direction as those of the foetal 
lens.-f- 

The most remarkable case I have ever met with is one, an 
enlarged representation of which is given in the Figure 3. 
Such a condition as is there shown is, I l:)elieve, unique. By 

Fig. 3. 




* Loc. cit., pp. 72 and 73. ^ 

t Since the above was writfen, my attention has been called by Mr. Buller 
to a well-marked trilinear opacity in the adult lens. But in this case tlie 
streaks had the appearance of an inverted Y, and could not therefore have 
been due to an 0])acity extending along the edges of the planes of the trilinear 
figure of the fcctai lens, unless we imagine the lens to have been inverted. 



NORMAL AND THE CATARACTOUS CRYSTALLIXE LENS. 35 

au examination of this figure, it will be seen that the most 
superficial fibres of the anterior portion of the lens are opaque, 
while the rays of the normal steUa and the periphery of the 
lens are quite transparent. The clear lines which are evi- 
dently identical with the normal rays, consist of primary, 
secondary, and even tertiary rays. It wdll be seen that the 
secondary ray from the horizontal line to the right of the 
figure is not yet complete, and only extends a short distance 
along the anterior surface of the lens. By transmitted light, 
all the parts shaded black in the engraving allowed the red 
reflex of the fundus to be seen through them. The opacity 
was, as I have said, very superficial, for when the pupil was 
fully dilated wath atropine, as represented in the figure, the 
lens behind the opacity could be seen to be quite transparent. 
With this eye the patient could read No. 2 Snellen and 
V = -^^\. The only history I could obtain from the patient, 
who was a woman aged 42, was that the sight of this eye had 
become dim after a blow which she received twenty-two years 
ago. I can offer no explanation as to nature of the cataract, 
or as to its exact seat, but wish only to relate the facts. 
The opacity was not capsular or sub-capsular, for then the 
stellation would have been invisible. I have frequently met 
with instances in which one or two sectors were affected, and 
Ruete* has also figured such cases ; but, as far as I know, no 
case at all resembling the one now figured has been recorded. 
I shall now refer to a phase of this subject which is 
better known, namely, the subjective examination of the 
rays, their functions, and their influence on vision. If we 
throw homocentric light into the eye, we may observe an 
entoptic figure of the radiating lines of the crystalline lens, 
as was first pointed out by Listing.-f This observer also 
descril)ed an umliilicated radiating body, which he regarded 
as ])eing due to the separation in the foetal state of this 
part of tlie capsule from the inner surface of the cornea ; 

* BilJlicIie Darstfllung Krankheiten des Menschliclien Auges, Leipsig, 
1854. 

t Loc. fit., \). 17. 

D 2 



36 TWEEDY ON A VISIBLE STELLATION OF THE 

but concerning tliis, Bonders says, " In examining the 
entoptic phenomena I found that multiple images, lines 
radiating from points of light, and the entoptic image of 
Listing, pass imperceptibly into one another, and therefore 
have one and the same origin; but respecting the proper 
cause in the structure of the lens, I could form no satisfactory 
idea, and even now I have not been sufficiently successful in 
my attempts to make known the result."* Whether this 
umbilicated body is a constant element, or whether, indeed, 
it be not the result of an erroneous observation, I do not pre- 
tend to know ; but it must not be forgotten that many of 
Listing's observations w^ere made on persons who were not 
acquainted with the subject of ophthalmology or of physio- 
logical optics, and that, therefore, they may not have correctly 
interpreted their subjective sensations. Nor can I offer any 
other explanation of the case which is mentioned by Listing, 
in which there were no radiating lines seen entoptically. 
From what we know of the anatomy of the lens, it seems 
highly probable that their alleged absence was the result of 
the negative fallacy of non-observation. Professor Bonders 
has, however, informed me that some time ago he also had a 
case in which no radiating entoptic lines were seen. And 
two years ago, Mauthner recorded a case in which a star was 
seen as a point of light, and in which the vision at this dis- 
tance was acute, that is, no rays w^ere observed. Beyond the 
explanation I have given of such cases I can form no opinion, 
for it is difficult to conceive a condition of the crystalline lens 
wliich will allow of normal acuteness of vision, but in which 
the rays of the stella, at least, the primary rays do not exist ; 
because the trilinear rays seem to be essentially associated 
with the formation of the lens, while the multilinear ones are 
as closely connected with its development and growth. 

Many of the phenomena of irregular astigmatism have 
their origin in the rays of th^ stella. Monophthalmic 
polyopia, for instance, has been shown to be the same con- 
dition as that which gives rise to the rays of a bright star or 

* Loc. cit., p. 650. 



NORMAL AND THE CATARACTOUS CRYSTALLINE LENS. 37 

point of light at a distance for which the eye is not accommo- 
dated. We know, also, that by passing a small point of light 
into the eye, we may observe the rays proceeding from a point 
of light to pass into the well known radiating entoptic image. 
The monophthalmic polyopia, rays of stars, and radiating lines 
of light in the entoptic images are, therefore, all dependent on 
the same pecnliarity in the strncture of the lens, namely, the 
existence of the stella. Bonders has, moreover, pointed out 
the fact that the sectors of the lens which are divided off by 
the rays of the stella form distinct images of a point of light, 
for by moving a small aperture before the pupil, he has 
observed that when the aperture is opposite a sector, a single 
image is formed ; but when it is moved to the boundary 
between two sectors, two faint images appear, of which, on 
further displacement, the one first seen disappears. On 
rapidly moving the small aperture before the pupil, the little 
images of light jump as it M^ere from one sector to another.* 

We may also determine subjectively the influence of the 
rays of the stella in vision by regarding a large number of 
fine concentric and equidistant circles, such, for instance, as 
those figured in Helmholtz plates.^f In that figure the inner 
circle is about the fiftieth of an inch in diameter, and the 
outer one about 2 inches in diameter, the intervals between 
the peripheries of the intervening circles being about the 
fiftieth of an inch. If the eye be made myopic by placing 
before it a convex glass of, say, 6 inches focal length, and the 
figure placed at about 5 inches in front of the eye, all the 
fine circles will be seen clearly defined, that is, if the eye of 
the observer be otherwise emmetropic. At about 5y2_ inches 
the small inner circle becomes obscured on one side, and at 
about the fifth of an inch further, a second small circle 
appears at the obscured side. Further still, the circle becomes 
crenated by the multiplication of images, passing through 
many sectors. At about 6 inches the circles will no longer 
be clearly seen throughout their whole circumference, but 
become divided into sectors, which at 6-jL inches are dis- 

* Loc. cit., p. 546. + Fig. 4, plate ii. 



38 TWEEDY ON A VISIBLE STELLATION, ETC. 

tinctly separated. At this distance a large number, from 10 
to 15 sectors, consisting of irregularly shaped cones of well- 
defined portions of the circumferences of the circles may be 
observed, with intervals of a greyish neutral tint, in which 
the lines of the circles cannot be made out, so that gaps 
appear at intervals across the peripheries of the circles. 
Towards the periphery of the figure secondary and tertiary 
divisions may be detected in the radiating cones of clear 
lines, corresponding, 1 believe, to the divisions of the stellar 
rays. With my eyes, wliich are astigmatic to about -j-i-g-, I 
can at the greatest distance of distinct vision see clearly the 
rays in and adjoining the vertical and horizontal meridians, 
while those in the oblique meridians are less distinct, but 
may nevertheless be made out. Towards the centre of the 
figure the obscured intervals are not so well marked, and the 
circles are broken up into crenated and polygonal figures. It 
must be noted that if the observer's eye be astigmatic, the 
anomaly must be corrected, in order to make out the phe- 
nomena, which I have here attempted to describe, as seen by 
myself. 

It will be seen that my remarks have applied exclusively 
to the examination of the living crystalline lens. The oppor- 
tunities of making a microscopical examination of the com- 
mencing cortical opacities are so rare, that it has never fallen 
to my lot to meet with a cataractous lens after death which 
was not already advanced far beyond the stage to which my 
remarks on the formation of cortical opacities apply. 1 have 
also confined myself to the consideration of cortical striae, and 
do not pretend to offer any explanation of the causes which 
determine some of the other varieties of cataract, such as the 
dotted, the zonular, or the nuclear, all of which are probably 
due to entirely different conditions from those which give 
rise to the radiated cortical striae, and many of which are 
caused by formative changes of various kind, and by the 
proliferation of the nuclei of the lens fibres, 



39 



ECTOPIA TARSI : A CASE OF CONGENITAL MISPLACEMENT 
OF THE EYELIDS OP ONE EYE. 

By J. F. Steeatfeild. 

The case of deformity I am about to describe is perhaps 
the oiily one of the kind recorded ; at any rate, for its rarity, 
it is a case worth recording in a special journal in which 
practical matters are of primary but not of exclusive import- 
'ance. My drawing, made at the time when I used to see the 
patient, is here reproduced, and I may add that in all the 
principal dimensions, and especially of the misplaced eyelids, 
as to their relations to the nose and as to their depression 
below the level of the normal eyelids of the other eye, my 
portrait was corrected by accurate measurements, made upon 
the face of the patient, and transferred to the paper. Besides 
the drawing, the description of the case is rather uninterest- 
ing, and the history negative • but even so, they answer some 
questions that very likely might be asked by anyone who 
saw the case for the first time, or who now regards the repre- 
sentation of it. 

]\Iartha Sanders, aged 21, single, a needlewoman, came to me 
at the Moorfiekls Hospital on the 16th of June, 1872, for the 
first time. She was a worker in black crape, and had been 
obliged to give it up ; her eyesight was too bad, she said, the 
work made her eyes painful. The right eye, she thought was 
the more painful. She " cannot see for long together." She was 
hypermetropic, and read for half an hour comfortably with weak 
convex glasses, whereas she could only read for ten minutes 
without their aid. She was thin and pale, and said she had been 
living low, having been out of work lately, and had fallen away. 
But she seemed to be in good general health. A quinine and 
iron mixture was ordered, and was continued for some time with 
benefit. Finally she had a pair of glasses — convex No. 18. Her 
right eye was amblyopic ; with it she could only read -^^ and 
3^ of Snellen's test types. With the left eye she read fJA and 



40 STREATFEILD ON ECTOPIA TARSI. 

1| of the same types. The right eye, I may say, in limine^ 
seemed, neither in external appearance, nor by ophthalmoscopic 
examination, to be any waj^ different to the left ; there was no 
perceptible distinguishing trace of disease, past or present, in it 
of any kind. 

But the remarkable characteristic of the case was in the 
sloped direction of the right palpebral aperture, the lids 
being, in appearance, drawn down wholly and evenly at the 
inner or nasal side of the right eye. But there was neither 
any puckering of the skin, nor thickening of any subcutaneous 
part, nor any appearance of cicatrisation in the neighbour- 
hood of the right eye, or the right side of the nose. The skin 
was everywhere as soft and pliable as is natural. The patient 
thought nothing of the deformity ; " it was always so." She 
came only for the failing eyesight. 

The position and movements of the right eyeball seemed 
to be quite natural and symmetrical with the other, and not 
to be in any way involved in the misplacement of the eyelids. 
The movements of the eyelids, as regards the opening and 
shutting of the right eye, were complete and perfect. The 
eyelids themselves of ine right eye, speaking generally, were 
like those of the other eye, no way defective. But when 
the eyelids of the right eye were drawn forcibly outwards 
(in this case also somewhat upwards) over the eyeball, in the 
way to demonstrate the tendo palpebrarum, by making it teuse 
and prominent through the thin skin beneath which it lies, 
it was found to be divided or double, two cords, one to each 
tarsal cartilage, going inwards and downwards, quite sepa- 
rate thioughout, not convergiug, to be attached to the bone ; 
parallel in their direction to separate points of attachment, 
with an interval of about two lines. The tcndines were then 
to be felt, as well as seen, distinctly through the skin as 
two rounded cords ; the interval between them was felt as a 
considerable depression, and it showed a deep shadow when 
viewed in a strong side light. One other small peculiarity 
was discovered by a particular examination of the right eye- 
lids ; in the place of the right upper punctum was a slit- 



Opkthalm. Reports Vol.YIE.Pl.IL 




-^ 



"^^"2'*«a 



"^^g- 






-^ 




treatfeild del 



'W.West£C°iMiji. 



Ectopia. Tarsi 



STREATFEILD ON ECTOPIA TARSI. 41 

shaped aperture along the canaliculus (ju.st as if it had 
been slit by operation, and kept patent afterwards) to the 
extent of two lines from the punctum itself. The patient 
was sure that the operation in question had never been 
done, and it is hard to conceive why it ever should have been 
required, as the much more important lower punctum was 
in its normal condition. Both puncta of the left eye were of 
the usual shape, and in the natural position. When I in- 
quired of the patient as to any former lacrymation of the 
right eye, she said that when her eyes watered, the right was 
the more watery of the two, but that was all, and I suppose 
that it would bs so, of course, because, by gravity, any small 
quantity of tears in the right eye, instead of resting on the 
lower lid, must have run at once into the lacus lacrymalis, 
which was drained by the downward direction of tlie acute 
angle of the inner canthus in this particidar case. 

In regard to the bones of the face, I could not detect 
anything abnormal, or any difference in the conformation of 
the two orbital apertures, in which both eyes alike seemed to 
be rightly and symmetrically placed, unless it were that the 
right upper maxillary bone was ill-developed, dwarfed, or 
defective ; this, I am inclined to think, was in some degi'ee 
the case, at least as regards the nasal process of that bone. 
The roof of the mouth was very high, but not aj)parently 
higher on the right than on the left side. The posterior 
pillar of the soft palate seemed to be somewhat longer and 
further back on the right than on the left side. The alveolar pro- 
cesses of the upper maxillary bones seemed to be equal and 
regular on the two sides. The upper and lower gTinder teeth 
of the right side were very thickly coated with tartar, which was 
not the case on the left side of the mouth. The nasal pro- 
cess of the right upper maxillary bone seemed to me to be 
congenitally dwarfed, because of the heiglit of the bridge of 
the nose on that side, which was decidedly much greater than 
the height on the left side of the face. (Had it been acci- 
dentally depressed at the time of her l)irth ? See below.) 
The tendo palpebrarum is attached to the upper maxillary 



42 STREATFEILD ON ECTOPIA TARSI. 

bone, and that the inner angle of the riglit palpebral aper- 
tnre was so much drawn down was the pathognomonic sign of 
this singular case. The right ala nasi, as seen in the draw- 
ing, was also much drawn upwards in this patient, and was 
also thinner than on the left side. The septum of the nose 
was much displaced to the right side. When the moutli was 
shut, and the right nostril closed with the finger, she could 
l)reathe, but not when, under the same circumstances, the left 
nostril was so closed ; some little air did pass by the right 
nostril. The nasal bone of the right side did not seem to be 
out of place. 

The exact position of the inner canthus of the right eye 
was on the edge of the orbit, at its inner and lower part, 
three-eighths of an inch below the level of the left inner 
canthus. Sensation, on either side of the face, in all parts, 
was equally good. The patient said she was the eldest of 
the family ; after her there were three or four still-born chil- 
dren, then came her brother, and three younger children. Of 
her brother, aged 10, she told me he had precisely the same 
distortion that she had, but of the left eye, that his eyelids 
were not so much drav.'n down as hers, and that his nose was 
nor like hers, awry. He could not come, she said, that he 
was ill in bed, dying of consumption. Except her brother, 
she said, none of her relations had any peculiarity about the 
eyes. She herself had no other peculiarity. Her irides, like 
her father's, she said, were hazel ; her mother's eyes were 
blue. 

I was naturally anxious to see her brother, and as he 
could not come to me, I asked where I could see him, and 
got her mother's address, in Hackney, and made an appoint- 
ment. When 1 got there, the mother denied having any but 
the very young and healthy-looking children 1 saw in her 
(sitting) room, besides her eldest, Martha, who was gone out 
just then. She denied having a boy of 10 years old, ill of 
consumption. When the eldest daughter was born, her 
mother said she had a bad time of it, and that it was a foot 
presentation. She said also that the deformity about the eye. 



STREATFEILD ON ECTOPIA TARSI. 43 

in her daughter's case, was nothing now to what it had been 
when she was little ; all the right side of her face, her eye, 
nose, and month, were then " all drawn up together." "We 
thought she never could live." " She had no snuffles, or any 
skin eruption." If she had a son ill in bed, I was not allowed 
to see him, and I never again saw her daughter. 



44 



MISCELLATS^EOUS CASES AND OBSEEVATIONS. 

By Jonathan Hutchinson, E.R.C.S. 

(Continued from vol. vii, p. 47.) 

The following cases will, it is hoped, sufficiently explain 
themselves, and do not require much comment. The first 
seven illustrate some of the conditions in which, inde- 
pendently of renal disease, sudden lipemorrliages take place 
into the retina. None of them are supposed to be good 
examples of the special form known as retinitis hsemor- 
rhagica, though one or two are perhaps allied to it. In the 
latter the blood spots are almost always pointed (flame- 
shaped), very numerous, and many of them very small, but 
in the foUowmg group these featm-es for the most part did 
not occur. I have been tempted to record some of them ; 
case LXXIX for instance, on account of the absence of 
any clue to the diathetic cause of the haemorrhages. 

In case LXXX we seem to have an instance of which I 
have often noticed, the association of glaucoma with an 
antecedent history of long-continued liability to very severe 
neuralgia. I have on former occasions published several 
cases illustrating this, and supporting the behef that the fifth 
nerve takes a considerable share in the production of this 
cm-ious malady. As regards the relation between the 
haemorrhages and the glaucoma, we may suppose that in all 
probabihty they preceded it, and that we have in the case 
an example of what has been called " secondary hiiemor- 
rhagic glaucoma." 

Case LXX^V illustrates a very curious group of symp- 
toms in connection with brain disease, an important element 
being the remarkable ease with which the circulation was 
disturbed. It seemed also very probable that in one eye tlie 
central vein had been obliterated. 



Hutchinson's miscellaneous cases, etc. 45 

Cases LXXXVII and LXXXIX concern questions in 
connection with inherited syphilis, and case LXXXVIII 
illustrates the very remarkable feilure of sight which occurs 
with sick headaches, and especially in the subjects of 
xanthelasma palpebarum. 

Kg. LXXVII. — Retinitis with Hremorrhages in Left Eye only ; 
Consecutive Atrophy of Optic Disc — Casts in Urine hut no 
Alhuynen — History of Jaundice in Childhood and Side Head- 
aches ever since — No Arthritic History. 

Catherine Gr., ret. 57, came in December, 1871, complaining 
that her left eye had suddenly become dim six days before. She 
asserted that she noticed the defect when both eyes were open, 
and was confident that it had existed no longer than six days. 
She had no symptoms of cerebral haemorrhage. Vision (with 
her spectacles) right eye, 4 J. ; left eye, 20 J. 

On examining her left eye with the ophthalmoscope, I found 
the disc and neighbouring retina swollen, opaque, and pale, the 
veins large and tortuous, with numerous retinal haemorrhages 
near to the disc and between it and the yellow spot. Several of 
them wei'e large, but none were striated. There were also 
patchy, cloudy, white deposits in the retina. There was a very 
large blood patch between the disc and the yellow spot. 

Three months later (March 21, 1872) the optic disc had be- 
come pale, and its margins much clearer. The arteries were 
diminished, the veins large, but not larger than in the opposite 
eye. There were still many haemorrhages, some of which were 
decolourised. 

This patient's urine, examined a few days after her first 
attendance, was found free from albumen, but contained a good 
many hyaline casts of various sizes, mostly, however, small. 
She complained, when I first saw her, of palpitation. She had 
never had rheumatism. Sick headaches trouble her a good deal. 
In childhood she had jaundice, and had often since then had 
" the whites of her eyes yellow." She was accustomed to get 
very dark around the eyes at times, and her complexion is 
sallow. 



46 HUTCHINSON'S MISCELLANEOUS CASES 

No. LXXVIII. — Hcemorrhages into Retina of Bight Eye only — 
The Symptoms coming on a week after a rather Severe Bloiv on 
the Eye and adjacent parts — No Albumen or Casts in Urine. 

Elizabeth B., set, 46, married, was admitted at the end of 
January, 1872, with defect of her right eye. The condition was 
shortly noted down as " a patch of white, with blotches of extra- 
vasated blood in the region of the yellow spot, right eye," and no 
subsequent examination was made. Her urine contained no 
albumen and no renal casts. 

She stated that eight weeks previously she had received a 
blow on the right eye and neighbouring parts from a partridge, 
which, being thrown across the room for some one to catch, acci- 
dentally struck her. A little bleeding from the nose followed, 
but the eye was not painful, nor did it become " black." A week 
later, as she was sewing in the evening, she noticed that the 
right eye suddenly became dim. Neither pain nor redness 
followed the failure of sight, the eye remaining just the same to 
the date of admission. 



No. LXXIX. — Hceniorrhage into Retina of Left Eye only — Tli^ 
Vitreoiis stained ivith Blood — No Alhumimiria. 

Richard E., set. 44, a heal thy- looking country milkman, gave 
a history which furnished the following notes, when I saw him 
for the first time. " About six weeks ago he noticed ' three 
or four black streaks ' before the left eye. He tried it, and 
found that he could not see well. It rapidly got worse, and for a 
fortnig-ht it has been as it is now. He now cannot see the ' black 
streaks,' only 'a dim black fog.' He can just count fingers. 
With the other eye he can spell out J. 1 ; no muscas before it. 
Both pupils are large, and both very sluggish, so that scarcely a 
trace of movement can be observed. Neither is perfectly round. 
No synechias. He has had no pain." The ophthalmoscope 
showed " retinal^apoplexies " in the left eye, but unfortunately I 
did not record any details until a week later. At the latter 
date the fundus had become so much obscured by vitreous 
opacities and general haze (haemorrhage into the vitreous, with 
blood staining) as to make an accurate record of the retinal 
changes impossible. There were, however, numerous blood 



AND OBSERVATIONS. 47 

patches of considerable size i^pon and near to the disc. His 
urine, examined at this date, contained no albumen. 

No. LXXX. — Painless Doable Glaucoma, affecting BigJit Eye first, 
with abundant Retinal Hcemorrhages in the Left, in addition to 
Glaucomatoiis Tension, and probable Excavation of the Disc— 
Eight Fundus not examined — History of Side Headaches many 
years before, cured by going to Seaside, giving place of late 
years to severe Dental Neuralgia. 

George A., aet. 69, a tall thin man, dark complexion, a 
butcher, came to me at Moorfields in August, 1872, with abun- 
dant retinal haemorrhages and glaucoma of his left eye, and old 
glaucoma of the right. Tension of the left was slightly in- 
creased, that of the right 4-2. The left had been failing for 
more than a year ; it had not been painful, but he found strong 
light annoying. With his glasses he could just spell 20 J. The 
haemorrhages were very abundant, dark, and abruptly defined, 
not striated. There was a good deal of swelhng of the retina 
around the disc, and I could not determine quite satisfactorily 
whether or not there was glaucomatous cupping of the disc ; pro- 
bably there was a shallow glaucomatous cup. The fundus of the 
right could not be well seen. 

He had had no pain whatever in his eyes except " a pricking 
sensation during east winds." The right began to be dim with 
" colours round flames." 

Many years ago he used to suffer from very bad sick head- 
aches, and was often bled for them. They were always cared 
by going to the seaside, and since he has lived at Southampton 
(20 years) he has had no sick headaches. He has, however, 
suffered dreadfully fi'om " neuralgia " since the sick headaches 
left him, and has had many teeth removed for it. It never 
affected his eyes. He has had a little sciatica and lumbago. He 
knows of no arthritic history in his family. 

No. LXXXI. — Retinal Hjemorrhages in Left Eye only — Rheumatic 

Arthritis in the Patient and his Father — No Albuminuria. 

John C, aet. 66, a seaman, was admitted in September, 1871. 

Unfortunately only very short notes were kept of his case. He 

said that his left eye had been failing about three or four months. 



48 hutchixson's miscellaxeous oases 

With his spectacles (probably they were too weak) he saw with 
the rkjM eye, 8 J. ; left, 16 J, 

In the left the ophthalmoscope showed numerous extravasa- 
tions of blood in the region of the yellow spot. The urine was 
examined one week and again two weeks after admission, and 
found free from albumen on each occasion. 

He stated that he had had rheumatism in his knees several 
times during the last seven years ; his knees were examined and 
found to present large lips on each femur ; there was also grating 
in each joint on movement. He had never had rheumatic fever 
or dropsy. His father had been subject to rheumatism in the 
knees. 

N'o. LXXXII. — Retinal Hcemorrhages in Right Eye only — No 
Albuminuria — History of rapid onset of Amblyopia {doubtful) 
— Patient's Daughter nearly blind from Infantile Choroiditis, 
possibly Heredito-syphilitic. 

Joseph H., aet, QQ, came to me on May 22, 1871, with the 
story that his right eye had failed about a month before ; it had, 
he said, improved a little for a few days after the first onset, but 
had afterwards again worsened, and had been for the last fort- 
night as bad as when h-^ came to the Hospital. He could only 
see shadows with this eye ; the left was good. 

The ophthalmoscopic examination showed numerous haemor- 
rhages in the right eye only. They were to be seen in all parts of 
the field, but were most numerous below (erect) the disc : there 
were comparatively few in the yellow-spot region. The blood 
patches were mostly circular, but a few were striated. Besides 
the hcemorrhages, there were many white patches. His urine 
was examined a week later, and found to be pale, clear, and free 
from albumen. Two months later (July 24) vision was about 
the same (with right he then managed to count figures at 1 foot); 
there were many fresh haemorrhages between the disc and yellow 
spot and around the latter part, but none actually at the macula 
itself. The blood-spots in other parts of the field were somewhat 
less strongly marked than at the first examination, but were no 
less numerous. The disc at this date was pale and the retinal 
vessels smaller than normal. 

He had never had rheumatic fever or scarlet fever, as far as 



AND OBSERVATIONS. 49 

he knew. He suffered from palpitation. One of his daughters is 
nearly blind from extensive choroiditis. She is possibly the sub- 
ject of hereditary syphilis, but shows no other signs of it. The 
father denies syphilis in himself. 

Wo. LXXXIII. — Double Neuro-retinitis {(Edema of Disc and sur- 
rounding Retina) tvith ahundant Hcemorrhages in the left Eye 
only — Xanthelasma paljjebrarum. 

Mrs. G., get. 60, admitted on May 1, 1871. She said that her 
left eye had been failing for about a fortnight, but that both eyes 
had been defective for years. As she could not read and was 
presbyopic, it was impossible to ascertain exactly when the 
amblyopia from retinitis began. Vision was very defective in 
each eye. When her presbyopia was corrected she saw with 
right eye 12 J. ; left eye, 14 J. 

Ophthalmoscopic Examhiation. — In each eye the retina was 
oedema tous around the disc and the veins were much distended. 
In the left eye there were numerous hiBmorrhages in the retina, 
chiefly above the disc (erect) and in the neighbourhood of the 
yellow spot. There was whitish deposit, in the form of irregular 
patches and streaks, in connexion with some of the blood patches ; 
there were, however, none of the bright white dots seen in renal 
retinitis. 

She had also two small xanthelasma spots near the left inner 
canthus on the upper lid. 

Mrs. G. had never had gout or rheumatic fever, but was sub- 
ject to slight rheumatic pains. She had not been liable to sick 
headaches. 

No. LXXXrV. — Double Neuro-retinitis, beginning in left and at 
present much more advanced in that Eye — Gradual occurrence 
of num,erous Retinal Hcemorrhages in the left ; none in right — 
Patient under observation for a year and a half — Chronic 
Rhe^irnatic Arthritis — No Albuminuria. 

Eliza R., £et. 46, married ; she is stout, of dark sallow 
complexion, gray irides, and almost black hair. Her left eye 
began to fail early in the year 1870, but she did not come to me till 
a year later, February 16, 1871. Some months after the failure 
began she was troubled a good deal by frontal headache and 
VOL. VIII. ' E 



50 Hutchinson's miscellaneuus cases 

vomiting ; she had not previously been subject to sick headaches. 
N"o xanthelasma. Her right eye had begun to fail somewhat a 
few weeks before admission, and this brought her to the hospital. 

Vision Avith right eye = 8 J. and f ^ ; left eye = 20 J. 
and ^V^. 

The following note of ophthalmoscopic appearances was 
made : — " Double neuro-retinitis ; much more advanced in the 
left. Each disc hazy, the left much more so, and showing abun- 
dance of effusion. Veins of retinae very dilated and tortuous, 
and the arteries look of pale colour, and in some cases show a 
very distinct white line along the centre. The effusion in the 
retina is more abundant below the disc (erect) than above it in 
each eye. The region of the yellow spot in each eye is hazy and 
whitish ; in. the left there is a haemorrhage just below the yellow 
spot and one or two minute bright dots a little lower still." 
There was no colour-blindness. 

The nrine tested a week later and found to be pale, but to 
contain no renal casts and no albumen. 

At the end of three months vision in rlglit eye was normal, 
and has so remained ever since (2 J. and \%; 1 J. with a low 
convex glass). The left eye has, however, not improved in the 
least, and the examinations repeated at intervals up to present 
date (Auf/usf 26, 1872} have shown in it a gradual increase in the 
number of blood-spots and the swelling of retina. The notes of 
the last examination state, " Left, the disc can hardly be made out, 
except by the convergence of the vessels. Veins much as before ; 
arteries can with difficulty be made out, probably from their pale 
colour combined with the retinal haze. There are- now very 
numerous hgemorrhages about the disc and around the yellow 
spot. Those in the former position are often large, more or less 
completely decolourized, and are frequently situated over veins. 
Those about the yellow spot are punctate, and for the most part 
dark coloured. Biyht eye much as at first : disc a little pale ; 
surrounding retina oedematous ; no haemorrhages ; veins con- 
gested and tortuous. 

Fifteen years before I saw her, and three weeks after her fifth 
confinement, Mrs. B. had an attack of what she called " rheumatic 
gout " in her right upper extremity ; it affected the hand most 
severely, and lasted about a fortnight. Since then she has often 
had similar but milder attacks in the same hand and shoulder ; 



AND OBSERVATIONS. 51 

the hand becoming swollen. She often also has aching and stiff- 
ness in the knees, and on examining these joints I fonnd crack- 
ling, synovial thickening, and, in the right, lips on the femur. I 
could not detect changes in any other joints. During her earlier 
pregnancies she suffered much from toothache and " gum-boils," 
and bad many teeth extracted. She is subject to stiff neck and 
to sudden attacks of sharp pain in the loins followed by stiffness. 
She does not know of any arthritic complaints in her relatives, 
but as she does not know nearly all of them, there is much room 
for fallacy here. 

No. LXXXV. — Atrophy of Discs and great Diminution of Retinal 
Arteries, the vein in one turgid, in the other nearly invisible and 
substituted by a Netioorh of ( ?collateral) small vessels on the 
Disc — History of Bleeding from. Throat from slight cause (^cough- 
ing) — Subsequently two attacks of Temporary Blindness, one of 
the Right Eye for six weeks, the other of both Eyes for only an 
hour — Later J attack of threatened Right Hemiplegia, leaving 
some permanent Numbness, Sfc, and folloioed by gradual Failure 
of Sight in both Eyes and by Deafness of Right Ear. 

Captain W., set. 59, came to me in October, 1872, on account 
of his sight. With his right eye, he could only see shadows at 
the upper and outer part of the field ; with the left he could see 
18 J., but only to the temporal side. The pupils were of normal 
size, and moderately active. Ophthalmoscopic examination dis- 
closed a curiously dissimilar state of the discs. Both were gray- 
white and atrophic ; in the right, the central vein was large and 
the artery small ; but in the left, the chief vein could only just 
be distinguished, and the artery could not be detected at all, 
while the disc itself in this eye was covered by a beautiful net- 
work of minute tortuous vessels, some of which were varicose in 
parts. The obscurity of the vena centralis was partly due to 
these small vessels lying over it, partly to a great reduction in 
its size. There were no retinal changes except here and there 
streaks along the vessels. 

The patient is a retired sea-captain ; he is a very stout, florid 
man, with dark hair, short neck, and of middle stature, — a very 
"punchy" man. The blood always rushes to his head if he 
stoops; "the least thing makes him as red as possible." The 

E 2 



52 HUTCHINSON'S MISCELLANEOUS CASES 

history of his eye and other head symptoms extends over several 
years, and is very curious and interesting. 

Six years ago, on coming ashore from, a vessel, after an acci- 
dental cough from walking fast, he had haemoptysis. The 
doctor who attended him said the blood was not from his lungs 
but from his throat. He continued to spit a good deal of blood 
(rarely less than a teacupfull) each day for a fortnight. The 
bleeding came on if he got excited or talked much. He attri- 
butes the first bleeding to a single violent cough, and probably 
the blood came from the rupture of one vessel. He had no bleed- 
ing from the nose and no headache. He kept the house a fort- 
night for that attack. A few months later the sight of his right 
eye failed almost completely ; he thinks it was nearly blind. He 
was under M. Desmarres' care at Paris, and in about six weeks 
regained the sight almost perfectly. On another occasion, three 
years ago, he stooped for a few minutes over the side of a vessel, 
to examine the damage done by a collision, and on raising his 
head found himself in a mist, and had to be led ashore. In about 
an hour the sight returned, but again failed almost completely, 
whilst he was on his way to the doctor's a little later in the day. 
He was under treatment for several months, and got slowly 
better, but never quite well. A third time, te7i months ago (in 
December), he was (> 'ddenly attacked by prickly feelings and 
numbness in the right side of his body, arm, and hand, but not in 
the leg. ThLs was accompanied by loss of memory and noises in 
the right ear, but he ne^er lost consciousness. He was bled freely 
after this attack. Gradually since then his sight has failed in 
both eyes. He has regained his memory, and does not now have 
the numbness, &c., in his right arm, but complains that his right 
buttock becomes numb and " cold " if he sits for long ; the cold- 
ness is subjective only. It should be mentioned that before the 
attack he had been slightly deaf in his right ear for several years ; 
the deafness has greatly increased since December, and he has an 
increasing noise in the ear. With the left ear he hears well. Of 
late he has b^en liable to fall asleep on all occasions, but he thinks 
it is simply because he does not see the gestures of the persons he 
is talking to. Formerly for many years he was subject to attacks 
of " erysipelas," usually twice a year. They ceased about ten 
years ago, and since the first failure of sight, he has never had 
any. The "erysipelas" used to begin in the legs and pass 



AND OBSERVATIONS. 53 

upwards to his head. His face became enormously swollen and 
disfigured, and his eyes were closed. There were some watery 
vesications. The attacks usually lasted ten days, and were fol- 
lowed by desquamation, " peeling like a cuckoo," and great 
itching. Captain W. says that he never had a headache in his 
life, at least not since boyhood. He has always been liable to 
perspire freely, especially about the head. Formerly he suffered 
much from hot feet, but now they are often cold. He is the only 
child of his parents : his father died at 63 of dropsy, his mother 
died young. When I saw him his urine was normal ; specific 
gravity 1030, and contained neither albumen noi sugar ; there 
was no deposit at all. His bowels were regular. 

No. LXXXVI. — Paralysis of Portio Dura of right side, ivith Deaf- 
ness occurring suddenly — Paralysis of Lachrymal Gland and 
Temporary Paralysis of Loiver Extremity on same side — Slight 
Defect of Sensation on same side of face — No Pain. 

Mrs. Sophia Cobbins, £et. 34, is the subject of complete 
paralysis of the right portio dura. She cannot move her face in 
the least on that Side nor shut her eye. Her hearing is abso- 
lutely lost on that side, and, as she believes, her taste. Her 
tongue feels, she says, always as if scalded on that side. No tears 
ever flow when she cries. The symptoms came on suddenly 
one night, two days after her last confinement. She had had 
a favourable time, and was considered to be getting on well ; but 
she had been previously for nine months under care at St. Bar- 
tholomew's Hospital. She then had dreadful giddiness, and 
used to stagger in walking. 

After the night during which she lost the portio dura she had 
also defect in the right leg. It used to twist under her and feel 
weak, and for more than a month she could not stand. For years 
she has been liable to have her feet " die with cold," never her 
hands. 

She can feel in all parts on the right side of face, but not so 
well as on the other. The slight defect of sensation seems equal 
in all parts. There is no subjective numbness, and no pins and 
needles. The light is annoying to her. 

Her sight has failed lately. She is very susceptible to light. 
Atropine acted well. The discs ai'e red, but no abnormal changes 



54 Hutchinson's miscellaneous cases 

are noticed. Mrs. C. is pale and feeble. She is now nursing a 
healthy infant. 

No. LXXXVII — Choroido-Betinitis as the result (possihly Intra- 
utenne) of Hereditary Syphilis —Besemblance in some points 
to Retinitis Pigmentosa — Important History of a Syphilitic 
Family. 

Alice Barrett, aet. 8 years, was brought to the hospital by her 
father on account of oscillation of globes, with defective sight. 
There was nothing in her aspect to lead me to suspect syphilis, 
but on my examining her teeth, which were of the " mercurial 
type," her father volunteered the statement that she had suS'ered 
in infancy from the " disease from her mother." It appeared that 
both parents had suffered from syphilis 15 years ago, and had 
secondary symptoms. The father, who now appears to be in 
perfect health, got rid of the disease in six months, but his wdfe 
continued to suffer, more or less, for years, and is now in an 
asylum with symptoms which possibly indicate syphilitic brain 
disease. 

After the syphilis there were two live births, and two mis- 
carriages before the birth of our patient, who, being now eight 
years old, was born eight years after the primary disease in her 
parents. The two infants alluded to as live births, both died 
very young, one a few hours, the other three weeks old. 

Our patient suffered fi'om " a severe peeling rash" during the 
first months (" her feet all peeled") but afterwards got a clear 
skin. It was suspected that she was blind, and the oscillation 
was noticed almost from the first- At the age of three years, 
she having been throughout " a delicate little thing," she had a 
brain attack, was very delirious, and was believed to have a 
tumour on the brain. She was ill two or three months, and then 
got well, but remained thin and weakly. She has had no recent 
symptoms, excepting occasional attacks of pain in the right eye. 

On examination with the ophthalmoscope, I found evidences 
of extensive choroido-retinitis in both eyes. The discs were 
rather pale, hazy, and waxy-looking, and the arteria centralis in 
each much diminished. In the central parts of the fundus, a 
few small round specks of brown pigment were seen at wide 
intervals, and usually surrounded by an ill marked patch, where 



AND OBSERVATIONS. 55 

the epithelium was absorbed. Towards the periphery these 
patches increased in numbers, and there occurred large groups 
of white spots, like worm-eaten cloth, where the choroid was dis- 
organised. There were a few very large pigment accumulations, 
and many groups of small dots and lines, exactly like those of 
retinitis pigmentosa. Her hearing is good, and she has had no 
keratitis. Her head is large, but not of the characteristic form 
most usual in heredito-syphilis. The twitching of her globes ren- 
dered minute examination difficult. In addition to the features 
mentioned above, I noticed in one or two places very peculiar 
long red streaks, which I could not interpret. 

Since the birth of this child, two miscarriages and two live 
births have occurred. One, a girl, is three years old, and has had 
no suspicious symptoms ; the other is an infant of seven months 
old, and is now covered by a bad rash, and not expected to live. 

The following date-table will give a clear view of the family 
histoiy : — 

1859. Syphilis acquired by husband, and communicated to 

wife. Both suffered severely, but the father got 
perfectly well, and has remained so ever since. 

1860. A child born dead. 

1861. A child born, which lived three weeks. 
1862. 

1863. A miscarriage. 

1864. A miscarriage. 
1865. 

1866. The patient (a girl) born, supposed to be blind ; had 

a severe infantile rash. ^t. 3, meningitis. 
1867. 
1868. 

1869. A miscarriage. 

1870. A girl born, still living ; free fi'om symptoms. 
1871. 

1 872. A miscarriage. 

1873. A boy born ; at present seven months old. Covered 

with rash, and not likely to live. Mother, after 
mnch ill health, the subject of brain disease, and 
in an asylum. 



56 HUTCHINSON'S MISCELLANEOUS CASES 

No. LXXXVIII. — Additional Particulars of a Case of Xanthe- 
lasma Palpebrarum, ivith Blindness of one Eye. 

The following notes are in continuation of a narrative 
published in vol. vii, page 275. I have been able to give 
some additional particulars as to the kind of headaches, &c., 
from which the man had suffered, and also to carry the 
account of the eye symptoms four years further. 

The case is an example of the very peculiar and rare form 
of loss of sight which occurs in those who are the subjects of 
xanthelasma, and liable to severe bilious headaches. 

In my report on xanthelasma palpebrarum I have espe- 
cially mentioned this liability, and since that Report was 
published (see " Medico-Chirurgical Transactions "), several 
additional cases ha^ve come under my observation. I have 
not, however, seen any . quite parallel to the following, in 
wliich the blindness (in one eye) has been permanent. 

William Savage, set, 49. He attended me at the Ophthalmic, 
from April 19, 1869, to July 19, and, being no better, then left off. 
He had, however, regained sight in the right eye from bare per- 
ception of shadows up to being able to make out letters of No. 20, 
when he held the book to his right side. This note was made on 
May 10. He then complained of occasional raist before the 
left eye. 

During the four years since his last attendance, he has not 
been under any medical care. He has had fev/er headaches, and 
not such severe ones as formerly. He has had headaches, but 
has never been laid up by them. He often wakes with a dreadful 
headache, but usually can relieve it by a cup of tea. On several 
occasions, six or eight times, he has lost the sight in the left eye. 
The attacks have never lasted more than three or four minutes, 
and usually in ten minutes he can see as well as ever. Often he 
has attacks of partial blindness, during which he cannot see the 
lower half of an object. He has had rheumatic fever four times ; 
has never had jaundice. The headaches have often been morning 
ones. He would, he says, often wake up with a headache, of 
dreadful severity, and with perspiration pouring from him. The 



AND OBSERVATIOXS. 57 

perspiration was not only from the head and face, but from the 
shoulders also. 

His severe headaches began at aet. 28, two years after his 
marriage, and soon after his first attacks of rheumatic fever. His 
father suflTered much from liver complaints, and bad headaches ; 
he took much medicine, was often under doctors, but lived to 
75. Six or seven years ago, whilst at work, he was suddenly 
seized during a headache by an attack of " twitter," which ran 
down the left side, limbs, face, and trunk. He thought he was 
going to be paralysed, and at once left his work, and got a little 
brandy, when it passed oiJ". 

He is of dark complexion, florid, and healthy looking ; he 
suffers extremely from cold feet ; is a bad sleeper, and often is 
two or three hours before he gets to sleep ; dreams much ; bowels 
usually regular, but he finds that aperients are very necessary to 
keep off his headaches ; has never lived out of London, and is 
by occupation a gold-beater ; has been accustomed to smoke all 
his life a little. His impression is that smoking did his head- 
aches harm rather than good. He attends now (October, 1873) 
because his left eye has become more dim, and has had threatening 
headaches recurring every morning, and attended by severe per- 
spiration, as happened before he lost the right. 

Atropine has acted but slightly. His xanthelasma is much as 
it was. The patches are plentiful on leftside over inner canthus ; 
on right side they occur at both canthi, but are very small. 

He still has perception of shadows on the temporal side with 
right eye. The disc of this eye is white and atrophied, present- 
ing a shelving cup in the side next the yellow spot. Its large 
vessels are very much reduced in size, the artery being traced 
with difficulty. The disc of the left eye is, excepting slight and 
doubtful pallor on the side next yellow spot, of healthy appearance, 
and its vessels are of good size. 

The following points may be especially noticed as regards his 
headaches. They have been sometimes limited to one side of 
forehead, and sometimes to a single spot, at others the whole fore- 
head, or even the entire head, has been afiected. 

He has been very apt to wake with one. Often they have 
been relieved by tea, or by a walk in the fresh air. 

When bad they have been attended by profuse sweating. 
They have always been worse if the bowels were not freely open. 



58 Hutchinson's miscellaneous cases 

They have been attended by remarkable liability to cold feet. 
The liability to them appears to be inherited, his father having 
suffered from similar symptoms. 

He does not think that they have been materially influenced 
by sexual causes, but admits that he has not been " a very strong 
man," and that his liability to headaches did not show itself much 
before his marriage. 

No. LXXXIX. — Symptoms of Inherited Si/jMUs in Infancy with 
Opaque Lens and others Changes in one Eye — Keratitis of the 
other Eye at the Age of Thirteen — Absence of the usual Physio- 
nomic indications of Inherited Taint — Important preservation 
of Written Evidence — Deafness and Epilepsy — Nodes on Long 
Bones. 

The following case i>s of much interest in reference to the 
recognition of the subjects of inherited syjiliilis, and to the 
diseases of the eye which are in connection with that cause. 
When the girl, who is its subject, came to me at the age of 
13, she had keratitis of one eye and very unusual changes 
(old) in the other. Neither her teeth nor her physiognomy 
indicated syphilis, and as both parents were healthy and 
there was no history of suspicious symptoms to be got from 
them, anyone believing that interstitial keratitis of the 
typical form can occur independently of inherited taint, 
might have claimed the case as one in support of his 
opinion. Fortunately, however, the child's mother had 
preserved an old hospital letter which in Mr. Dixon's hand 
writing recorded that in infancy the patient had been 
treated for inherited syphihs. This was conclusive, and 
this fact being established, we are now entitled to attribute 
to this special cause all the conditions of disease which the 
patient displays, 

Cath. Ellis was treated by Mr. Dixon during infancy for 
disease in the left eye. She had also at the same time (set. 4 
months) symptoms of inherited syphilis, snuffles, eruptions, peel- 
ing of soles and palms. The pupil of the left eye was largely 
dilated, and the lens hazy. Mr. Dixon's notes of the case extend 



AND OBSERVATIONS. 59 

from Nov. 24, 1856, to Dec. 1857, and during miach of this time 
she took small doses of grey powder. 

The girl was brought to me in June, 1869, with keratitis of 
the right eye. I excised the left eyeball, and afterwards she 
remained under treatment from 1869 to 1872. The cornea never 
■well cleared. In the summer of 1872 she had a node form on the 
right tibia, and one also on the right humerus. At this date she 
was much troubled by unusual sleepiness. 

In September, 1873, she had her first epileptic fit. It occurred 
during sleep. After this she had several minor fits, and one 
severe one. She complained of being always tired. 

In December, 1873, the question of the propriety of doing an 
iridectomy was raised. The object proposed was to get a pupil 
opposite a clear part of the cornea, as the middle remained very 
hazy. She could make out No. 13 after use of atropine. The 
anterior chamber is large ; all the central parts of the cornea 
clouded, periphery clear. No iritic adhesions. I could not 
manage to see the fundus. 

The exact nature of the disease which destroyed the left eye 
is somewhat uncertain. When she came to me twelve years 
later, the iris was quite lost by retraction, and the lens, dense 
white, could be seen reposing in a yellow-grey bed a little to 
the outer side of the middle of the fundus. The vitreous was 
clear, but the choroid and retina were wholly disorganised and 
replaced by a dense yellow structure. The displacement of the 
lens, assisted by the entire removal of the iris, allowed me to see 
the fundus without optical aid. I much regret that I have 
misplaced my notes of the examination after removal. 

When her deafness was coming on her hearing varied much 
from day to day. She had almost constant noises in the ears. 

Her father is living, and believed to be in excellent health. 

Mother the same. Neither parent has had any illness since 
marriage. They were married 18 years ago, and the following is 
a list of their children : — 

1. F., 17, the patient, born a year after marriage. Infantile 

symptoms of syphilis. Loss of left eye. Keratitis of right 
at set. 12. Deafness at a3t. 16. Epilepsy at set. 17. 

2. M., 15, born two years later. He is healthy, and has had 

no keratitis. Liable to " stoppage in nose." 



60 HUTCHINSON'S MISCELLANEOUS CASES, ETC. 

3. F., 7, one of twins (the other dead born). In good health, 
No miscarriages. 

In all probability the taint in this case Avas derived as 
is usual from tlie father. It wiU be seen that it soon 
apparently ceased, and that the first child only (born within 
a year of marriage) showed symptoms. The mother, 
whom I have often seen, is apparently in excellent health, 
and asserts that she has always been so. 

I have little doubt that the disease which destroyed the 
left eye in infancy was one of those rare forms of chororditis 
with free lymph effusion which are now and then met with 
in young children, and are apt to be mistaken for tumours. 
There is the yellow or metallic glare from the fundus, 
the dilated pupil, and, if left long enough, the secondary 
cataract. I have several times excised such eyes, expect- 
ing to find on dissection a new growth, and found only 
the results of inflammation. Such eyes are indeed rarely 
left, as in this case, to go through their final changes. 
Those changes were absorption of the fluid effusion and 
matting together of choroid and retina in a dense yellow 
membrane, with dislocation of the opaque lens, and dis- 
appearance (by retraction) of the iris. In this case probably 
the syphilitic taint was the cause of the effusion, but I have 
seen other similar ones where no history of that cause 
could be made out. 



Gl 



ON THE TREATMENT OF CERTAIN AFFECTIONS OF THE EYE 
BY MEDIAN INCISION OF THE CORNEA. 

By T. Pridgin Teale, M.A., F.R.C.S., 

Surgeon to the General Infirmary at Leeds. 

The object of this paper is to advocate a method of dealing 
with certain acute disorders of the eye, which, for wide range 
of applicability and constancy of result, seems not unlikely to 
rank as second only to iridectomy, as a means whereby we 
may rapidly, often instantaneously, relieve intolerable pain, 
arrest the progress of formidable disease, and preserve the 
eye from irreparable damage. 

The principle of making an incision through the cornea 
into the anterior chamber has already been established in 
abscess of the cornea* (Bader), and in lilacs cornece serpens^ 
(Saemisch) ; and the value of median incisions of the cornea 
has been urged by M. Lebrun;]: in the extraction of cataract. 
It does not, however, appear to have attracted the attention 
of ophthalmic surgeons as much as it deserves, nor to have 
been established as a broad rule of treatment capable of such 
a wide range of application as I propose in this paper. 

The following principles seem to be indicated by the 
cases in which I have tested the operation during the last 
year and a half. 

* Bader, on Diseases of the Eye, p. 169. " Opening of the abscess 
(corneal) by incision has proved of great advantage in cases in which no per- 
foration has occurred. This little operation consists in thrusting the point of 
a cataract knife close to the suppurating part, through the healthy cornea 
into the anterior chamber, carrying it on so as to make an incision through 
the largest diameter of the suppurating portion, and bringing it out again iu 
the healthy cornea." 

t Williams. Report of 4th International Ophthalmic Congress, p. 102. 
" Saemisch's fi'ee incision splitting the ulcer is still more effectual thau simple 
paracentesis. To secure thoroughness and permanency in its effects, the 
incision should be made freely, and the wound sprung once or twice a day for 
a week or more." 

J Lebrun, on New Mode of Operating for Cataract by Median Sphero- 
cylindi'ical Flap. Report of 4th International Ophthalmic Congress, p. 205. 



62 TEALE ON THE TREATIMENT OF 

a. That siij)purative affections of the cornea and iris, which 
do not rapidly yield to atropine and opiates, ought to be dealt 
with by direct incision through the median 'part of the cornea 
into the anterior chamber, just as much, as a matter of course, 
as one would incise a whitlow or a thecal abscess. 

h. That such an incision may be made crucial or T-shaped, 
if it be thought desirable that the wound should not heal up 
rapidly, thereby avoiding the necessity of "springing the 
wound once or twice daily for a week or more." Williams, 
loc. cit. 

c. That an incision near the centre of the cornea, in length 
about one-third of its diameter, passing vertically througli the 
lamellae into the anterior chamber, does not as a rule produce 
any serious damage to the cornea by w^ay of opacity, nor to 
the iris by way of prolapse or synechia anterior. Vide Cases 
II, IV, V, VI, IX, XL 

d. That in hypopyon a median incision of the cornea gives 
exit to pus and purulent lymph lodged in the anterior chamber 
more readily, certainly, and completely than a marginal in- 
cision. Vide Case VIII. 

e. That an incision into the anterior chamber, through 
suppurating cornea, can arrest destructive suppuration and 
sloughing, where iridectomy has been already employed un- 
successfully. Vide Cases I, IV 

/. That on incising in its early stage a circumscribed 
abscess in the layers of the cornea, a small white body some- 
times escapes from the opaque spot, which, when placed 
under the microscope, proves to be broken down corneal 
fibre, infiltrated with pus corpuscles. Bader (p. 169) has 
observed that the opaque material forming hypopyon often 
contains dihris of corneal tissue, but I am not aware that the 
corneal slough escaping from the incised spot, like the core out 
of a hoil, has been identified. Vide Cases I, II, III. 

Operation. — The patient having been put under the influ- 
ence of an anaesthetic, an incision, in length about one-third 
of the diameter of the cornea, and penetrating the anterior 
chamber, is made by a Graefe's knife. The incision should be 



CERTAIN AFFECTIONS OF THE EYE, ETC. 63 

made not valvular, but vertical to the curve of the cornea, travers- 
ing " in its longest diameter (Bader)," any abscess or specially- 
diseased portion of cornea, and tending towards the pupillary 
portion of the cornea, where the risk of prolapse of the iris will 
be least. When the site or du^ection of the incision is not de- 
termined by a specially damaged spot, it is better to carry it 
across the middle of the cornea, slightly above the centre of 
the pupil. This suggestion to avoid the centre of the pupil 
is made, because I have not yet been able to ascertain whether 
an incision such as I have described can be made across the 
centre of the healthy cornea without impairment of vision. 

It is often well to provide against too rapid closure of 
the wound by making it conical or T-shaped. As this second 
step cannot easily be made by Graefe's knife without risk of 
injming the lens, it is safer to make the cross cut by iridec- 
tomy scissors. 

Case I. — Abscess of Cornea — Failure of Iridectomy — Immediate 
relief from Incision — Escape of Slough from the Abscess. 

Mrs. Windale's child, Darlington, set. 11, a patient of 
Mr, Arrowsmith. 

Right eye. Central two- thirds of the cornea opaque from 
sloughing, &c. 

February 11th, 1873. An iridectomy, letting out purulent 
lymph, with aqueous humour. Gradual improvement. 

December 3rd. There is central haziness of the cornea. 

July 22nd, 1874. Slight opacity ; reads 20 at 1 foot. 

The left eye having commenced in like manner with the right, 
the boy was brought to me again on March 1st. A nearly 
central white spot had formed in the cornea, which was increas- 
ing, and caused most acute pain. Fearing a result like that La 
the right eye, I immediately performed iridectomy, in hopes of 
arresting the threatened abscess. 

March 7th. As the disease was increasing, and the symp- 
toms were not in any way mitigated by the ii'idectomy, the pain 
being most distressing, I put him under the influence of chloro- 
form, and made a crucial incision through the opacity, pene- 
trating the anterior chamber. On the first incision being made, 



(U TEALE ON THE TREATMENT OF 

pus escaped with tlie aqueous humour ; on the second, a round 
body, of the size of a hemp-seed, was enucleated from the corneal 
opacity, which, when examined by the microscope, pi'oved to be 
corneal tissue infiltrated with pus. 

The relief to pain was immediate ; and his improvement was 
so rapid, that in five days he was able to return home to 
Darlington. 

December 3rd, 1873. There is hardly a trace of central 
opacity, or of the incision. 

July 22nd, 1874. Synechia anterior (?) ; reads 6 at 7 inches. 

Case II. — Abscess of Cornea — Hypoijyon — Crucial Incision — 
Escape of Corneal Slough. 

Mrs. Gill's child, ast. 4, a patient of Mr. C. Richardson, of 
Leeds. 

BiijM eye had been inflamed three weeks. There is a whitish 
spot in the centre of the cornea and hypopyon. 

July 12ch, 1873. A crucial incision was made through the 
opacity, penetrating the anterior chamber. On the first incision 
being made, a white substance escaped with the aqueous humour, 
probably the pus of the hypopyon ; on the second, another smaller 
white body, which seemed to have been adherent to the posterior 
surface of the cornea. The first substance, under the microscope, 
showed very little definite structure ; the latter showed corneal 
fibres, infiltrated with pus. 

July 21st. Going on well. Has had much less pain since 
the operation. 

July 16th, 1874. There is a leucoma resulting from the 
abscess, across which a tJiin white line, indicating the incision, 
is visible. No synechia anterior. 

Case III. — Corneal Abscess and Hypopyon — Incision and Escape 

of Corneal Sloucjh. 
» 
Patrick Culican, sst. 40, a patient of Mr. Oglesby, in the 

Leeds Infirmary. 

Left eye had been ailing ten weeks, and during the last three 

weeks his sufferings had been so gi'eat, and his strength so much 

reduced, that he was made an in-patient March 2nd, 1874. 



CERTAIN AFFECTIONS OF THE EYE, ETC. 65 

March 8tli. Fiuding central corneal opacity and hypopyon, 
Mr. Oglesby made an incision through the centre of the cornea 
and of the opacity, and gave exit to a round, very distinct body, 
of the size of a small pea, which was distinct from opaque matter 
of the escaping hypopyon, and was of such consistency that it 
appeared to be capsulated, and could be handled by forceps. 
Unfortunately, it was not examined by the microscope. Relief 
to pain was immediate. 

March 10th. No pain ; coruea bright. 

June 27th. Opacity clearing. 

Case IV. — Circumscrlhed Corneal Opacity — No relief from Iridec- 
tomy — Kapid improvement after Median Incisioii. 

Mrs. Wathen's cbild, ret. 3. January, 1873. The left eye 
began to inflame, and rapidly growing worse, with the formation 
of central opacity of the cornea ; an iridectomy was performed. 

March 10th. No improvement having resulted from the 
iridectomy, a crucial incision was made through the opaque part 
of the cornea. There was no hypopyon, and no pus was seen to 
escape. After the incision, rapid improvement set in. 

June 14th, 1874. Pupil visible through bluish opacity. No 
trace of the crucial incision except four dots of pigment. No 
synechia anterior. 

Case V. — Gircumscrihed Abscess of Cornea — Crucial Incision. 

Mr. S., patient of Mr. Wm. Hall, Leeds, consulted me 
February 15th, l'^73, on account of an apparently superficial 
affection of the cornea, attended with much ciliary congestion. 
Treated by atropine and turpentine. 

March 12th. The eye had steadily become worse, and the 
pain was intense, disturbing his rest at night. A white spot 
had formed near the margin of the cornea. A crucial incision 
was therefore made into the opaque spot, giving exit to aqueous 
humour and a small quantity of pus. A white slough being 
adherent to the cornea, was not removed at the operation. 

The puncture gave great relief, and he said " he began to 
mend straight away." 

June 22nd, 1874. Cornea opalescent at the seat of the 

VOL. vm. F 



66 TEALE ON THE TRExVTMENT OF 

abscess. No synechia anterior. No trace of the incision to be 
detected, even by a + 2J lens. 

Case VI. — Diffuse Keratitis, dotihle — Edr/ht Eye treated hy Iridec- 
tomy, Left by Corneal Incision, 

A. W., aat. 13, suffering from specific diffuse keratitis of left 
eye, of three weeks duration. Central third of cornea opaque, 
outer two-thirds dull red. 

June 10th, 1873. A T-shaped incision of the centre of the 
cornea. 

A month later the right eye became affected in the same way, 
the disease progressing still more rapidly. 

July 23rd. Iridectomy of right eye. 

June 2ord, 1874. Both eyes had become slowly quiescent 
after the operations. The left cornea, treated by incision, was the 
best of the two, the outer two-thirds having regained trans- 
parency, the centre being dotted with streaky opacities. Vision, 
nearly counts fingers. Grood anterior chamber. No trace of 
incision visible. Biyht cornea clearing at the margin. Vision, 
shadows. 

This case is valuable, not from any distinct improvement to 
be traced to the opera h"on, but as showing absence of synechia 
anterior, and of trace of the crucial incision. 

Case VII. — Oj;>hthalmitis caused hy Iridectomy, ivith Wotmd of 
Lens, arrested hy T-sJtajjed Incision. 

Mrs. L., S3et. 62, was iridectomised for glaucoma five weeks 
before I saw her. The operation gave no relief, but caused in- 
creased suffering, owing to suppurative iritis, the result probably 
of wound of the lens during the operation. There was hypopyon, 
and the area of the pupil and iridectomy was filled with pus. 
She was almost worn out by the pain and the sleepless nights 
of the previous five weeks. 

April •4tli, 1874. A T-shaped incision was made, opening 
the anterior chamber in the centre of the cornea. Relief to pain 
was immediate. " She entered the house in pain, and went out 
easy," and had good nights ever after until a relapse of pain at 
the end of April, when Mr. Oglesby, in my absence from home, 
repeated the incision across the middle of the cornea, after which 



CERTAIN AFFECTIOXS OF THE EYE, ETC. 07 

the pain gradually subsided, though less rapidly than on the first 
occasion. 



Case VIII. — OpMludmitis after Extraction of Cataract arrested by 
Median Incision. 

Peter Hall, set. 68, of shaken constitution, had a cataract 
extracted by myself, March 11th, 1874. Eight days after, irido- 
cylitis set in, causing closure of the pupil, constant pain, and bad 
nights. 

May 14th. Finding the cornea hazy, and the conjunctiva 
swollen, and of a deep red colour, I made a T-shaped incision 
across the middle of the cornea. 

May 22nd. Eye quiescent; conjunctiva nearly natural ; two- 
thirds of the sclerotica white. Has had good rest nearly 
every night since the operation, aided on three occasions by 
opiates. 

July 4th. Line of incision to be detected by a 2|- convex 
lens as a fine white line only. 

Case IX. — Suppuration of Cornea from a Bloiv — Median Incision. 

Henry Storr. The right coi'nea was injured by a piece of 
mortar which fell from the ceiling as he was looking upwards. 
November 23rd, 1873. 

December 7th. A cloudy opacity of the cornea, and hypo- 
pyon. Has had hardly any rest at night since the accident. No 
improvement from the use of atropine. A T-shaped incision of 
the coi'nea into the anterior chamber. " He had good nights ever 
after." The eye rapidly recovered. No synechia anterior, but 
a white line indicating the position of the incision. 

Case X. — Siipjjuration of Cornea from a Bloiv — Median Incision. 

Charles Plummer, ast. 49, was admitted into the Leeds 
Infirmary, April 20th, 1874, with corneal opacity and hypopyon, 
the result of a blow on the eye by a stone a month previously. 
He had suffered intense pain, and could not rest at night. 

April 22nd. An incision was made across the centre of the 
opacity, and a second cut was made by scissors at right 

F 2 



68 TEALE ON THE TREATMENT, ETC. 

angles to tlie median termination of the first. After the first 
incision, the mass of purulent lymph escaped with the aqueous 
humour. 

May 11th. Cornea clearing. After the operation he had 
uniformly good nights, and lost his pain. 

Case XI. — Extensive and severe Suppuration of Cornea arrested 

hy Incision. 

Henry Walworth, get. 68, was admitted into the Leeds 
Infirmary, under the care of Mr. Oglesby, with severe keratitis 
on April 23rd, 1874, and was treated for five days without any 
relief by leeches, belladonna lotion, and opium- in full doses. 

April 27th. Pain intense. A small central portion of opaque 
cornea was just visible between the folds of overlapping che- 
mosed conjunctiva. Mr. Oglesby made a horizontal incision 
through the cornea, letting out a large quantity of pus, and 
giving immediate relief to the pain. 

May 5th. Chemosis gone. 

May 8th. Upper half of the cornea bright. 

July. A diffuse but not dense opacity over th.e pupil. No 
synechia anterior. Scar of incision hardly perceptible. 

Concluding remarks. — The foregoing cases go far towards 
proving the main points of this paper, viz., the comparative 
harmlessness of a median incision into the anterior chamber, 
as far as opacity of the cornea and embarrassment of the iris 
are concerned, the great power of such an incision in arrest- 
ing acvite affections of the cornea, and the extensive range of 
disorders in which this treatment can be beneficially em- 
ployed. May we not hope that the same treatment may 
prove to be of equal value in threatened slougliing of the 
cornea from purulent ophthalmia, in the exceptional cases of 
glaucoma which iridectomy fails to relieve, and in most 
acute affections of the eye w^liich threaten the vitality of the 
cornea ? 



69 



KEPOETS OF VARIOUS CASES. 

By Charles Higgens, F.R.C.S., 
Assistant Oj^^ithahmc Surgeon, Ginfs Hospital. 

Case [. — Becun-eni Ulceration of Cornea in both Eyes. 

Sarah ^asb, aet. 55, a married woman, came to the Royal 
London Ophthahnic Hospital, July 8th, 1872. The patient had 
always enjoyed good health ; had four living children, the 
youngest 16 years of age ; all were healthy. 

Since her last living child was born she had had five mis- 
carriages, each at about the third month, the last being seven 
years ago. 

Patient presents no symptoms of syphiHs, and with the excep- 
tion of the miscarriages, there was no suspicious history ; there 
was no history of gout or rheumatism, hereditary or personal. 

She had been subject to attacks of inflammation in both eyes 
(sometimes one only being affected, at others both) for the last 
15 years. She said that the inflammation always appeared to 
her to be of the same character ; it usually came on at intervals 
of about three or four weeks, the attack lasting as many months. 
There was severe smarting pain, profuse lachrymation, and great 
intolerance of hght. During an attack she had good and bad 
days ; perhaps at the beginning of the week being pretty well, 
and towards the end as bad as ever again. 

At the present time (July 8th) the attack has lasted about a 
week. There is extreme photophobia, much lachrymation, and 
the peculiar smarting pain. On opening the eyes (which is 
attended with much difficulty) there is a crescentic patch of 
ulceration at the upper border of the cornea in each eye ; the 
surface of the ulcer is opaque and looks rough ; its edge, which 
is uTCgular and marked by whitish-looking patches, of almost 
calcareous appearance, extends about two-thirds of the way to 
the upper margin of the pupil. There is a well-marked arcus 
seen through the ulcer at the upper margin of the cornea, and 



70 HIGGENS ON RECURRENT ULCERATION, ETC. 

existing also at the lower mai'gin ; the iris is healthy and the 
pupil normal. There is much injection of the ocular conjunctiva 
(a portion of the opaque chalky-looking material examined under 
the microscope showed only epithelial scales and debris). Ordered 
atropine and sulphate of zinc drops. 

Aug. 1st. Slight improvement. 

Aug. 12th. Worse than ever. Chloride of zinc w^as sub- 
stituted for the sulphate of zinc in conjunction with the atropine, 
and she was ordered a mixture containing sulphate of iron and 
quinine. 

Sept. 19th. No improvement. The drops were continued, 
and colchicum and iodide of potassium given internally. 

Sept. 30th. No improvement. Alum and bella-donna lotion 
was ordered, and an ointment of one part of nitric oxide of 
mercury to four of lead ; a small piece to be placed on the con- 
junctiva of lower lid at bed-time. A quinine mixture was given, 
and a blister ordered to be applied to each temple. 

Oct. 10th. There is considerable improvement : the injection 
of the conjunctiva has disappeared, the intolerance of light gone, 
and the pain much less ; the ulcers appear to have nearly healed, 
and their margins have receded from the pupil. 

Oct. 17th. Both eyes ulcers vascular; the large loops of the 
conjunctival vessels beiag plainly visible, passing for a short dis- 
tance over their outer margins, the rest of the surface of each ulcer 
being traversed by innumerable quantities of very minute ves- 
sels ; there is much intolerance of light, watering, and smarting 
pain. 

Jan. 13th, 1873. Ulcers have entirely healed, there being a 
dull white cicatrix gradually shading off into transparent cornea, 
marking their former situation. 

ReTnarks. — Tliis peculiar form of ulceration is perhaps 
more properly described as ulcus corniffi serpens ; the term 
recurrent certainly calls attention to a very prominent 
symptom in the above case. Eelapsing ulcer would also be 
an appropriate name. In a somewhat similar case, at present 
under treatment in Guy's Hospital, the affection has been 
marked by constant relapses. This patient is the subject of 
syphilis, and had at the time of admission sore throat and a 



HIGGENS ON SYPHILITIC IRITIS IN INFANTS. 71 

scaly eruption. Treatment seems to be almost powerless 
against this form of ulcer ; it appears to spread in spite of 
everything, but as a rule does not invoh^e more than half 
of the cornea. In exceptional cases it attacks the lower 
margin of the cornea as well as the upper, and then the two 
ulcers, spreading upwards and downwards, will render the 
greater part of the cornea opaque, a partially clear portion 
being left in the centre. Such has been the case in the right 
eye of the patient at present under treatment in Guy's 
Hospital. 

Case II. — SijphiUUc Iritis in an Infant. 

Ada KiammerofF, set. 8 months, brought to the Royal London 
Ophthalmic Hospital, February 6th, 1873. Mother stated that 
child was perfectly healthy till within the last two months, since 
which time it had suffered from cough, wheezing in the chest, 
and smiifles. Mother had been married two years ; had never 
had a miscarriage or other child, and with the exception of two 
attacks of rheumatic fever, the first eight and the second five 
years ago, had always enjoyed good health both before and since 
marriage. The child's father was said to be quite healthy. 
Attention was first called to the child's right eye, three weeks 
ago, from the mother noticing a white spot above the pupil ; 
this was pointed out to a medical man who was treating the 
child for a cold. 

At present time, February 6th, 1873, the child gives no sign 
of pain or discomfort, there is no intolerence of light, but the 
right eye waters a good deal, and there is some slight injection 
of the conjunctiva. The iris is cloudy, somewhat swollen, the 
colour is altered (that in the fellow eye being blue), the pupil is 
moderately contracted and oval in shape, its outline irregular, 
and there is considerable posterior synechia; there is a large 
nodule of lymph upon the surface of the iris, above the margin 
of the pupil ; the pupil is pressed downwards by the lymph 
nodule, the cornea is clear. 

The child is well nourished, and with the exception of the 
iritis and a rather square forehead, presents no sign of congenital 
syphilis. (It has no teeth.) The mother appears healthy. 



72 HIGGENS OX SYPHILITIC IRITIS IN INFANTS. 

A ^'ain of grey powder was ordered niglit and moi'ning and 
belladonna lotion to be constantly applied. 

Feb. 17th. Lymph nodule had increased in size; there was an 
abcess in the lower lid of left eye, which was opened, and dead 
bone felt at lower margin of orbit. The powders were continued, 
and steel wine and cod-liver oil ordered twice a day. 

Feb. 27th. An ulcer has formed at upper margin of cornea, 
cornea ruptured during ^examination, and large prolapse of iris 
occurred. There is a conical elastic swelling in front of neck 
(glandular?). Treatment to be continued; eye to be kept 
bound up. 

March 6th. Large staphyloma at upper margin of cornea. 
(Treatment the same.) 

March 13th. Staphyloma removed with scissors ; found to 
communicate with vitreous chamber, and consisted of portion 
of iris thickly coated with lymph. 

In beginning of July, 1873, the child came under my treat- 
ment at Guy's Hospital. 

July 14th. Iridectomy performed in right eye ; the iris much 
atrophied and very rotten ; only a small portion could be got 
away. The tension of eyeball good ; a small bulging cicatrix 
marks position of previous staphyloma at the upper margin of 
cornea. 

Aug. 4th. A cicatrix in position of the abscess, opened Feb. 
17th, is causing ectropion of left lower lid ; cicatrix dissected up. 
Some dead bone removed from lower margin of orbit ; lids 
united for about one-third of their extent, beginning at outer 
canthus. 

Aug. 15th. Firm union has taken place between the margins 
of the lids ; there is no tendency to e version ; the child sees well 
through the inner two-thirds of the palpebral aperture. 

Case III. — Syphilitic Iritis in an Infant 

Joseph Nurry, set. 2 months, was brought to the Royal London 
Ophthalmic Hospital, March 10th, 1873. 

The child had never been well ; since birth had constantly 
sulTered from snuffles ; when a fortnight old the feet and legs 
were much swollen. The mother was told by a medical man 
that the child was suffering from dropsy ; the swelling lasted till 



HIGGENS ON PARALYSIS OF THE FIFTH NT5RVE, ETC. 73 

witliin the three last weeks, but has now entirely disappeared ; no 
eruption has been noticed on any part of the body. The mothier 
has been married 15 years, and enjoyed good health both before 
and since marriage ; presents no sigTi of syphilis, and denies 
having ever suffered from anything of the sort ; has bad eight 
children all born alive, and with the exception of f wo, the fourth 
and seventh, all are now living ; the fourth, a girl, three years 
old, died from abscess in the side ; the seventh, a boy, died at 
11 months from convulsions. All her children have had snuffles 
in infancy, lasting until they were about six months old, and 
then getting well spontaneously. The eldest child, a boy 14 
years old, the mother states, is crippled from some affection of 
his joints; all the remaining children, with the exception of the 
patient, are said to be quite healthy. (All have been vaccinated, 
and lymph has been taken from all to vaccinate other children.) 
The father is said to be a healthy man. 

At present time (March 10th) the child appears fairly 
nourished; it has snuffles badly; there are a few copper- coloured 
spots on the left side of the nose, and elsewhere about the face, 
otherwise the skin is clear ; there are no sores or condylomata 
about the anus. 

There is iritis in both eyes, but the child does not appear to 
suffer pain ; there is no ciliaiy redness or photophobia. In the 
left eye the pupil is blocked by greyish lymph, the iris is swollen 
and discoloured. In the right eye there are considerable pos- 
terior synechise, some lymph in the pupil, discoloration, and 
some swelling of the iris. The irides look as if they should be 
blue. 

Ordered a grain of grey powder in sugar every night and 
morning and belladonna lotion to both eyes. 

Mother was requested to bring the whole family at her next 
visit, but has never attended since. 

Case IV. — Paralysis of the Fifth Nerve ivith Ulceration of 
the Cornea. 

Wm. H., aet. 29, a weakly, anaemic-looking man, had for some 
time past noticed numbness of the left side of face His general 
health had been fairly good ; he was not recovering from any 
acute disease. 



74 HIGGEXS ON PARALYSIS OF THE 

March 3rd, 1873. Four days ago the left eye became inflamed, 
but was not painful. There is a Jarge superficial ulcer occupying 
the centre of the cornea and extending a considerable distance 
on all sides, its surface is dull and opaque, there is pus in the 
substance of the cornea, and in the anterior chamber the con- 
junctiva is red and swollen. The eyeball, and all other parts 
supplied by the sensory division of the fifth, are more or less 
numbed, there is total anaesthesia of the parts supplied by the 
first division, some sensation of parts supplied by second division, 
and considerably more of parts supplied by third division, especi- 
ally in the course of the auriculo-tempoi-al branch. There is 
some loss of pov^er of muscles of mastication on the left side. 

Treatment. — Eye to be bound up with lint soaked in bella- 
donna fomentation; a mixture containing perchloride of iron 
ordered, and half a grain of opium every night and morning. 

March 31st. Sensation somewhat increased in parts supplied 
by second division of fifth, quite re-established in parts supplied 
by third division, still some weakness of muscles of mastication ; 
cornea perfectly anaesthetic, destruction of its tissue seems to be at 
a standstill ; considerable hypopyon ; tension of globe normal, per- 
ception of light ; no sensation over any branches of first division 
of fifth. 

Patient did not attend after this date. 



Case V. — Paralysis of Fifth and other Nerves — No Affection 
of Cornea, 

Elizabeth A., set. 47. Married, no children, one miscarriage, 
(had syphihs ?) ; health generally good. 

Oct. 10th, 1873. Patient is a florid, healthy-looking woman. 
Five months ago she began to suffer from pain in the head, 
the left upper eyelid drooped suddenly ; she began to experi- 
ence some difficulty in biting hard food, and some impairment of 
vision of right eye ; these symptoms have continued about the 
same up to present time. 

On the left side there is total loss of sensation of all parts 
supplied by first division of the fifth, including the cornea, with 
numbness of parts supplied by second and third divisions ; con- 
siderable weakness of muscles of mastication, paralysis of the 



FIFTH AND OTHER NERVES, ETC. 75 

tliii'd with ptosis and divergent strabismus, but no dilatation of 
the pupiL The cornea is in a perfectly noi'mal condition, with 
the exception of the anassthesia ; vision is unimpaired. There is 
entropion of the lower lid. 

On the right side there is paralysis of the facial and sixth ; 
the facial paralysis is well marked, and the soft palate is seen to 
be drawn to one side, the uvula being considerably to the left of 
the median line. 

The ophthalmoscope shows only slight hyper metropia. 

Ordered ten grains of iodide of potassium thrice daily in 
infusion of quassia. 

Oct. 13th. Entropion of lower lid operated on ; some slight 
pain was felt. 

Nov. 1st. Wound made by operation, which continued open 
for some time, has healed ; the entropion is not remedied. Con- 
dition of all nerves about the same. 

Dec. 2nd. No improvement ; admitted into a medical ward ; 
remained till Dec. 31st, taking bichloride of mercui'y and iodide 
of potassium. 

At time of discharge there was some improvement of sensa- 
tion, but muscular paralysis remained about the same ; the 
cornea still clear, the ptosis continued. 

EemarJcs. — To account for tlie occurrence of destructive 
corneitis in cases of paralysis of the fifth nerve, two theories 
have been advanced : — 1st. That it is dependent on irritation 
by foreign bodies, and constant exposure of the cornea, con- 
sequent on its anffisthetic condition not calling for the normal 
movements of the eyelids. 2nd. On the absence of the influ- 
ence of the fifth nerve on the nutrition of the part. 

The two cases given above do not appear to favour either 
theory, for whilst both causes were more or less in operation 
in each, the cornea was destroyed in one, and in the other no 
change took place. 

In the first case there was the anaesthesia with a normal 
condition of the eyelids, and opportunity for the lodgment of 
foreign bodies and exposure ; in the second the anaesthetic 
cornea, although covered by the drooping lid and thus pro- 



76 HIGGENS ON PARALYSIS OF THE 

tecteJ from external influence, was subject to a source of 
constant and severe irritation, viz., friction by the lashes of 
the inverted lower lid, but its integrity was retained unim- 
paired during the whole time that the patient was under 
observation, viz., from Oct. 10th to Dec. 31st. 

With regard to the first theory, the cornea of one eye 
being anaesthetic, does not prevent the movements of the eye- 
lids in concert with those of the fellow eye, consequently the 
ansesthetic cornea has the same opportunity of cleansing itself 
as if it were in a normal condition ; it may be argued that 
there is failure of the lachrymal secretion in paralysis of the 
fifth, but in the above cases the moisture was plentiful. 
Again, in cases of old glaucoma where the cornese have both 
become totally anaesthetic, there must be much greater oppor- 
tunity for the lodgment of foreign bodies and exposure, as 
neither eye feels inconvenience from either cause, but though 
some haziness and roughness of the cornea is met with, no 
form of destructive corneitis is set up, the lids closing over 
the eyes without stimulus quite frequently enough to keep 
the cornese free from undue irritation. 

It is not intended for a moment to argue that exposure 
and contact of foreign substances are not causes of destructive 
corneitis, as this form of inflammation is frequently met with 
in cases of ectropion, destruction of the eyelids, and occasion- 
ally in extreme exophthalmos, but merely to show that it is 
not alone the cause of the affection met with in paralysis of 
the fifth nerve. 

Eespecting the second theory. Case II shows that removal 
of nervous influence does not alone cause destructive cor- 
neitis ; the anaesthesia of parts supplied by the first division 
of the fifth was most complete, but, as above stated, there 
was no corneal affection, neither was the sight impaired, 

From all this it would appear that some other cause must 
be sought for the occurrence of so-called " neuro-paralytic 
ophthalmia," which is prol^ably a combination of the two 
above given in conjunction with a third, which does not 
appear very evident, but is posaibly to be found either in 



FIFTH AND OTHER NERVES, ETC. 77 

some constitutional condition or in the seat* of a local lesion 
causing the paralysis ; of these constitutional debility, from 
whatever cause arising, appears most likely to be the third 
factor required for the production of the disease under con- 
sideration. 

* It lias been found that destruction of the eye ensues more rapidly after 
division of the fifth beyond the Casserian ganglion, than when it is divided 
between this and the brain ; the same also occurs on extirpation of the 
superior cervical ganglion of the sympathetic. 



78 



Part TI. 



OF 



CONTEMPORARY OPHTHALMIC LITERATURE. 



APPARENT ACCOMMODATION WITH APHAKIA. 

Professor Bonders in this paper refutes the assertion of Forster, 
tliat there is true accommodation present in cases of aphakia. 
He proves this by showing that the acuteness of vision does not 
remain the same for different distances, which he says ought to 
be the case if accommodation were present. To Forster's state- 
ment, that the accommodation was greater after the operation in 
young persons than in old, and on which Forster lays great stress, 
and that the accommodation increased for some time after the 
operation. Bonders says the explanation is to be found in the 
greater acuteness of vision which is present in the young, and 
which increases for a time after the operation. He further shows 
that the size and form of the pupil must be taken into account, 
and says that what may after extraction seem a good pupil, may, 
on examination by the ophthalmoscope or oblique illumination, 
show an unclean edge, or streaks running across it dividing it 
into two or more pupils. Experiments were made as to the 
influence of the circles of diffusion on the acuteness of vision, 
which showed that the size of the diffusion circles, whereby the 
aphakial eye discriminates, does not oblige us to assume that a 
true accommodation is present. This was still further proved by 
causing a normal eye to be artificially mydriatic, when with abso- 
lute want of accommodation, an apparent accommodation was 
present, as great as in the cases of aphakia related by Forster. 
In concluding, Professor Bonders denies that the changeability 
of the astigmatism by aphakia, which Reiiss and Woinow had 
found, could be dependent on the form of the sclera, and thinks 
it may have depended upon the want of proper adjustment of the 
axis of the cylindrical glass to the patient's eye. — (Graefe's " Arch, 
f. Ophth.," Bd. xix, Abth. i, p. 5G.) 



STEREOSCOPY WITH DEFECTIVE VISION, ETC. 79 

STEREOSCOPY WITH DEFECTIVE VISION, ETC. 

Dr. S. G. van der Meulen has given in this paper the results of 
numerous observations made on artificial ametrops by different 
methods, electric sparks in a darkened chamber, electric sparks in 
a dark box, momentary lighting in the stereoscope, and the fall 
apparatus of Hering, the last of which methods he considers 
most suitable for clinical purposes. Hering's apparatus, a descrip- 
tion of which will be found in the Arch. f. Anat. Physiol, ii. 
Wissenchaftl. Medicin, Jahrgang, 186-5, s. 153, has been some- 
what improved by van der Meulen, so that care is taken that (1) 
the time during which the balls are in the field of vision, is 
sufficiently short to prevent any movement of the eyes; (2) the 
balls fall from such a height that, at different distances from the 
eye, they pass through the field of vision in the same space of 
time ; and (3) the angle under which the balls are seen is always 
the same. By this improved apparatus he thinks every indica- 
tion for the judging of distance by one eye is pi'operly guarded 
against. 

JS^o case of strabismus which was examined, either before or 
after operation, possessed stereoscopic vision. In one case of 
relative strabismus divergens by trifling, and relative strabismus 
convergens by greater distances, the power of judging distance 
was perfect. 

Having caused anisometropia, it was found that by the 
difference of about -f some mistakes were made, that by different 
persons greater differences were required ; by some the difference 
of -i-, and by others even greater than ^, to give the results 
obtained by monocular vision. He thinks that when by aniso- 
metropia the convergence is right, and the worst ametropic eye 
still receives an impression, this is always of assistance in the 
judging of distance. 

Simple astigmatism with the ametropia in the vertical meridian 
did not prevent the judgment of the distance of the falling ball, 
while this power hj astigmatism with the ametropia in the hori- 
zontal meridian ^as lessened by slight changes of distance. 

By cases of artificial insufiiciency, so long as the fixation point 
was seen single, the judging of the distance was perfect, whether 
the refracting angle was towards the outside or the inside. The 
judging of trifling differences of distance was indeed easier when 
the refracting angle was to the outside than with the naked eyes, 
while when the angle was to the inside, a correspondingly oppo- 
site effect was produced. If the prisms were so strong, that it 
was with difficulty they were overcome, and sometimes a double 
fixation point appeared, a trifling difficulty was felt in deter- 
mining the distance, and pi'isms which were so strong that the 
fixation point no longer appeared single, completely destroyed 
the judging distance power. 



80 PERISCOPE:— stokes' LEXS AND ITS APPLICATION, ETC. 

In cases of artificially defective vision of one eye of y^Q, the 
power was somewhat less perfect than with two normal eyes ; 
that of "2^0^ decreased the power slightly ; while an eye with yo^-g- 
only, gave no more advantage to the normal eye than it possessed 
alone. Van der Meulen conclndes from this, that where one eye 
is normal, and the other suffers from some opacity, by improving 
the acuteness of vision to -^^ by iridectomy or otherwise, the 
patient will have been rendered a great service by enabling him 
to judge of the distance of large objects. 

In cases of torpor of the retina, artificially simulated by 
means of " London smoked glass," having previously measured 
by Forster's apparatus for determining the light perception, how 
much greater a mass of light was necessary to distinguish with 
these smoked glasses the same figure as the same eyes could 
distinguish unarmed, he found that the torpor must be very great 
to destroy the power of judging distance. 

When stereoscopic vision without the corresponding half 
image was produced by means of prisms, so that half the image 
of a line fell upon the upper part of one, the other half upon the 
lower part of the other retina, so that the two half images in no 
stereoscopic sense could have corresponding points, a proper 
stereoscopic representation could be produced. — (Grsefe's "Ai'ch. 
f. Ophth.," Bd. xix, Abth. i, p. 101 and 187.) 

stokes' lens and its application to the anomalies of 
refraction. 

Since Professor Stokr^, in 1849, gave the lens to the scientific 
world which has since then borne his name, many attempts have 
been made to make it of use in determining the amount of re- 
fraction in astigmatic cases, the purpose for which Professor 
Stokes proposed it. Schweigger and Javal especially devoted 
tlieir attentions to it, but on account of some technical difficulties, 
the Avant of having constant axes to the glasses probably being 
the greatest, it has not come into use in the ophthalmological 
cliniques. 

Taking a hint from the movement of Wecker's double prism, 
Dr. Snellen has had made a Stokes' lens whose axes move equally 
from each other, and by ai'ranging the axes to start from 45° from 
the vertical, the one axis becoming horizontal and the other ver- 
tical, a power is obtained from each glass, which acts according 
to the direction of its axis. This he proposed to use in the way 
that Stol^;es' lens had always been used, by placing a spherical 
lens, or a combination of spherical lenses, as in the usual Dutch 
telescope, before the Stokes, so as to obtain a focus by the 
spherical lenses, which would be at midpoint between the greatest 
and least refractive meridians, and then by moving the Stokes 
ah-eady placed in the proper axis, the concave cylindrical lens 



stokes' lexs, etc. 81 

would act on the former, and the convex on the latter, in eqnal 
degrees, and so bring the rays passing through both meridians 
to a point on the retina. Only in cases where the meridians 
were equally ametropia and of opposite ametropias, was the 
instrument applicable by itself, and as these cases were excessively 
rare, it was virtually by itself useless. 

The difficulties, however, which still presented themselves 
were the time required to find the exact meridians of greatest 
and least refraction, and their degrees of refraction, and prefer- 
ence was everywhere given to Douders' stereopceical apparatus, 
or Javal's optometer. To obviate these objections to the use of 
the lens, Mr. Laidlaw Purves proposes to determine only one 
meridian at a time, or by means of the lens reducing the case to 
one of simple hypermetropia or myopia, and then finding its 
degi'ee in the usual way. He also determines the degree of cases 
of simple hypermetropia or myopia by the Stokes. The method 
proposed is as follows. It is first determined what kind of 
ametropia is present by asking the patient to look towards a 
dark screen having two or three apertures, standing in the same 
line, behind which a bright light is placed. Should each aperture 
give a round light to him, astigmatism, except where there are 
equal degrees of opposite kinds of ametropia present, is negatived, 
and the kind of ametropia is determined by placing a piece of 
cardboard before one side of the pupil which shuts off the light 
on the same side if myopia is present, and on the other side if 
hypermetropia is present, or by the position of the line which 
the lens gives on being moved before the eye. Astigmatism not 
being present, it is immaterial in what position the lens is placed 
before the eye, and all that is required is to note at what angle 
the axes of the two lenses stand to each other to convert the 
diffusion images given by the light into the sharpest line that can 
be obtained. This angle gives by the usual method the amount 
of the ametropia. Should, however, astigmatism be present, 
which is known by the patient saying that the lights in the dark 
screen are longer in one axis than in another, the position of the 
meridian of greatest ametropia is determined by revolving the 
screen till the long axes of the different lights stand end to end, 
the point at which this happens being marked off by a graduated 
scale at the outside edge of the revolving screen. The lens is 
now placed in the same axis, and moved till each light becomes 
a sharp line, and then placing the lens axis at right angles to its 
former position it is moved till a sharp line is there obtained, and 
the two angles at which these lines are obtained will give the 
degrees of refraction of the two chief meridians. This method 
may be applied by using lines instead of points of light, or by 
using small apertures in a screen behind the lens. Mr. Laidlaw 
Purves uses a modification of the same lens as a refractoscope, 
and by enabling the ophthalmoscopist to determine by what power 

VOL. vni. G 



82 PERISCOPE: — TATTOOING OF THE CORNEA. 

lie obtains the different mei'idiaus of the retina, not of the vessels 
on the disc, clearly, gives him objective information of the state 
of the refraction in, he believes, a speedier manner than by the 
nse of different spherical lenses. — (Greefe's "Arch. f. Ophih.," 
bd. xix, Abth. i, pp. 78 and 89.) 

OPERATION FOR CICATRICIAL ENTROPION AND TRICHIASIS OF THE 
LOWER LID. 

Dr. Schneller places Jager's horn spatnla between the lid and 
the ball, and makes two incisions through the entire skin down 
to the muscle parallel to the edge of the lid, the upper from two 
to one and a-half millimetres removed from it, and the under 
from two to four millimetres lower, according as the effect is 
desired to be w^eaker or stronger. These horizontal incisions are 
joined at their two ends by two oblique incisions, so that the 
piece of skin between the incisions is entirely circumscribed by 
them. The skin around this circumscribed part is loosened from 
the subjacent tissue in all directions for about half a millimetre, 
so that it will be easily movable, the circumscribed portion being 
left intact and hurt as little as possible. The upper edge of the 
upper incision is now joined by sutures to the lower edge of the 
lower incision, bringing the two loosened edges over the circum- 
scribed piece of skin, which is hid as by a curtain. The sutui'es 
must only be drawn sufficiently tight to bring the edges close to 
each other, but not to cause them to fold inwards. The length 
of the incisions ought to cori'espond to the length of the portion 
of lid implicated, and should extend slightly beyond it at both 
ends. The enclosed portion of skin acts favourably as a w^edge 
in every direction, presses the cartilage inwards towards its 
proper position, shoves the lower portion of the bridge of skin 
upwards, and presses the upper portion with the lid edge outwards. 
The after treatment consists in a dressing of char^jie with a 
bandage over it, which is removed in 24 hours, dressing the 
wound every 12 honrs thereafter. The sutures are removed in 
96 hours, and English plaster is laid on the cicatrix for one or 
two days, with a bandage over it. — (Grsefe's "Arch. f. Ophth.," 
bd. xix, Abth. i, p. 250.) 

TATTOOING OF THE CORNEA. 

In an examination as to the most useful colours with which to 
tattoo the cornea, made by means of experiments on rabbits and 
frogs, Mr. Archer came to the conclusion that ultramarine, 
sienna, and Chinese ink are good ; indigo and Bei^lin blue fairly 
good; but that gamboge is not in any case to be used, as it 
causes great irritation and a speedy desquamation of the tattoed 
part of the cornea. Further experiments were made by means of 



DIVISION OF THE CILIARY NER^T^S, ETC. 88 

ultramarine as to what befell the pigment particles in the tattooed 
cornea. When the pigment had been introduced some time, and 
after the needle punctures were closed, and the continuity of the 
tissues had been again restored, the ultramarine particles were 
found removed from the original punctures, lying singly or in 
groups, distributed amongst the epithelium or the tibrous tissue. 
The pigment granules were found within the protoplasm of the 
epithelial cells, but never within the epithelial nucleus. The 
"wandering cells" of the cornea gradually accumulated round 
the tattooed spot, and carried off particles of the ultramarine. On 
the twenty-fifth day from tattooing the blue could be seen lying 
amongst the fibrous tissue at the spot whei'e the punctures were 
made in " sharply bounded small spaces, whose dimensions not 
seldom considerably surpassed those of corneal corpuscles." The 
total amount of pigment was lessened to the half, and solitary 
"wandering cells" were only found, none of which contained 
pigment. After this time the mass of pigment in the cornea 
was not noticeably diminished. — (Grgefe's "Arch. f. Ophth.," 
bd. XX, Abth. i.) 

DIVISION OF THE CILIARY NERVES ON ACCOUNT OF CONTINUED 
NEURALGIA IN AN AMAUROTIC EYE. 

A FOIL having penetrated the orbit, causing among other affec- 
tions blindness and pain, the patient thirteen years afterwards 
consulted Dr. Snellen on account of the excessive pain of the 
amaurotic eye, which was very sensitive to the slightest pressure 
over a sharply circumscribed spot at the upper and outer ciliary 
region. There were no inflammatory symptoms, and light per- 
ception was completely absent. The pupil, of the same width as 
the other, was drawn a little upwards, but dilated fully under 
atropine. Ophthalmoscopic examination showed the optic disc 
entirely white and the retinal vessels normal. Tension was not 
exalted. The other eye was emmetropic and healthy. Atropine, 
&c., having failed to lessen the pain, and enucleation being- 
objected to, Dr. Snellen divided the ciliary nerves in the follow- 
ing manner : — The patient being under chloroform, a conjunctival 
incision was made along the upper border of the rectus externus 
from before backards, and Tenon's capsule was divided in like 
manner. The tendon of the muscle was then separated from the 
sclera, and a pair of curved scissors passed behind the globe, the 
arms being shut, to the optic nerve, on feeling w^hich small snips 
were made down to the nerve, which were followed by bleeding 
from the ciliary vessels. The conjunctival wound was joined by 
three stitches. The sensitiveness on pressure was relieved, com- 
plete anaesthesia being found on the spot which was before so 
iiTitable. — (Grsefe's "Archiv. f. Ophth.," bd. xix, Abth. i, p. 
257.) 

G 2 



84 PERISCOPE: — THE ACTION OF INIUSCARIN, ETC. 



OPHTHALMOMETRY AND MICRO-OPTOMETRY. 

Dr. M. E,eich, of Petersburg, gives in this paper the results of 
some ophthalmometrical and micro-optometrical measurements 
by Helmholtz's and Schoeler and Mandelstamm's methods. He 
finds, like Schoeler and Mandelstamra, that the posterior surface 
of the lens changes its position during accommodation. The 
amount of movement by his measurements is less than that given 
by them, being from 0"0715 to 0'1529 of a millimetre. He far- 
ther agrees with them in stating that the radius of curvature of 
the posterior surface of the lens is shortened during esxcessive 
attempts to accommodate. For fairly accurate and quick deter- 
mination of the position of the plane of the pupil and of the 
posterior lens surface he recommends Schoeler and Mandelstamm's 
method, while for the most perfect measurements he prefers 
Helmholtz's ophthalmometer. — (Grr^fe's "Arch. f. Ophth.," bd. 
XX, Abth. i, p. 207.) 

THE ACTION OF MUSCARIN ON THE ACCOMMODATION AND THE 
PUPIL. 

Dbs. Krbnchbl and Mulder give the I'esults of experiments made 
in the physiological laboratory at Utrecht on the action of must 
carin on the accommodation and the pupil. They fully support 
the assertions of Schmiedeberg and Koppe that muscarin causes 
a spasm of the accommodation, which shows itself as a quickly 
increasing myopia, and disappears in from one to two and a half 
hours. This spasm of ihe accommodation begins after the appli- 
cation of the muscarin to the conjunctival sac in from five to ten 
minutes, and reaches its maximum in from fifteen to thirty 
minutes. The action upon the pupil is not uniform in propor- 
tion to the accommodative spasm, the contraction being great in 
some and small in others. Its entrance was somewhat later than 
the nearing of the far point, but increased regularly, and was at 
its maximum when the accommodative spasm had subsided, and 
only disappeared in from three to twenty-four hours. He there- 
fore thinks that these two actions are independent of each other. 
In further proof of this, by using atropine and muscarin together 
in certain proportions, he could produce spasm of the accommo- 
dation with a dilated pupil. The pupil so acted upon by mus- 
carin Dr. Krenchel has always found to act under the influence 
of light, which negatives the h^ypothesis of a spasmodic condi- 
tion of the antagonistic muscles. He found in opposition to 
Schmiedeberg and Koppe's statements that the relaxation of the 
spasm of accommodation lasted nearly double the time that the 
production did, and that he could not entirely abolish accom- 
modation. In these two respects he finds muscarin and Calabar 
bean to agree. But the two difier in their action in that while 



RETINITIS PIGMENTOSA, ETC. 85 

Calabar bean acts most easily on the pupil, and only by greater 
doses on the accommodation mnscarin acts most easily on the 
refraction, and with more difficulty on the pupil ; and also that 
•while Calabar bean causes in the first place an exalted capability 
of action, and onlj^ by stronger doses a true spasm of the ciliary 
muscle, the muscarin produces first the spasm and afterwards 
the exalted capability. As a supplement to the above paper 
Dr. Krenchel gives the results of some experiments undertaken 
at Professor Donder's invitation to test the statements given out 
last year by Rossbach and Frohlich which were in opposition to 
former authorities on the action of atropine and Calabar bean, but 
which are denied in every particular by Dr. Krenchel. — (Greefe's 
"Arch. f. Ophth.," bd. xx, Abth. i, p. 135.) 



ON THE DEVELOPMENT OF LIVING TISSUES PLACED IN THE EYE. 

Dr. Dooremaal finds that dead bodies placed in living tissues 
cannot grow. Pieces of cork or paper passed into the cornea 
or anterior chamber were sometimes extruded by perforation of 
the cornea and with prolapse of the iris, or were enclosed as a 
capsule consisting either solely of fibrous tissue or of fibrous 
tissue with layers of epithelium developed inside the capsule. 
Hairs placed in the anterior chamber did not cause much irrita- 
tion, and one passed through the cornea, which remained 
almost free from irritable appearances. Of the living tissues 
introduced into the eye, a piece of cornea and a piece of perios- 
teum were extruded, and panophthalmitis resulted in a dog 
into whose eye human epidermis had been introduced ; but 
other portions introduced became true constituent parts of the 
eye, deriving their nourishment from them, and furnished with 
vessels. A portion of the skin of ear which was introduced 
seemed to become encapsulated the same as a dead tissue. A 
piece of mucous membrane from the lip developed into a tumour 
resembling the cholesteatom-perle or epidermidom of Rothmiind 
and Biihl, and ^he epithelioma-perle of Moneyer, differing from 
them in that the cells here showed more the character of epithe- 
lial than of epidermal cells. — (Grsefe's " Arch. f. Ophth.," bd. xix, 
Abth. i, p. 359.) 



CLINICAL COMMUNICATIONS ON RETINITIS PIGMENTOSA, ETC. 

In a paper entitled " Clinical Communications," Dr. Baumeister 
gives some observations made in the Utrecht Private Ophthal- 
mic Clinique of Professor Donders. One case of tinilateral 
retinitis ingmentosa, with deafness on the same side, occurred in 
a man aged 44. A case of acute amblyopia, with general paralysis 
of the muscles of the eye, in which the ophthalmoscope gave no 



86 PERISCOPE:— SYPHILITIC CHOROIDITIS. 



indications of disease or of ametropia, was restored from — — 

CO 

20 
to =^^r^ by artificial leeching and the external application of tlie 

tincture of iodine. Two cases of mjstagmus, in which the refrac- 
tion, media, and retina seemed normal, improved their acuteness 

15 15 

of vision in the one case from — to -— — and in the other from 

L XX 

15 15 

-rp— to by an oblique position of the head, the improve- 

Li XXX 

ment not being due to the acting of the angle of the lids on the 
pupil as a stenopaic apparatus, as a stenopaic apparatus did not 
improve the acuteness of vision when the head was kept up- 
right. — A woman of 21 years, with congenital amaurosis which 
prevented her determining light fi*om dark, had her pupils influ- 
enced by light, dilating in from 15 to 20 seconds from 3| milli- 
meters to 5 millimeters, and contracting as slowly. There was, 
however, no consensual action. — (Grasfe's " Arch, fiir Ophth.," 
bd. xix, Abth. ii, p. 261.) 



SYPHILITIC CHOROIDITIS. 

Professor Forster in a paper in "Grasfe's Archives," gives the 
results of his clinical observations on choroiditis syphilitica. 
Objective 8ijviptoms. — He thinks the complication of very fine 
dust-like opacities of the vitreous are seldom absent, and is a 
very early symptom, x iiese opacities are especially found at the 
posterior, lowei-, and central portions of the vitreous humour, the 
upper and lateral portions being generally freer from them. 
This he has observed to pass into such a dense opacity that the 
optic disc was no longer visible, though more frequently he has 
had the opportunity to observe the clearing of the vitreous. It 
is usually very obstinate, and some remains of the opacity are left 
after the diseased process is passed, causing the vessels of the 
retina, the inner side of the optic disc, and the central portion of 
the retina to have a grey veiling over them, the periphery being 
generally free. The changes of the retinal vessels, apart from 
this veiling of the central ones, he thinks are trifling, and not to 
be relied upon. Circumscribed changes in the red colour of the 
retinal ground, he says, are present in at least a third of the cases, 
are more frequent in the region of the macula, and consist of 
groups of light red or white spots, and sometimes of larger light 
grey spots. These must be carefully looked for, as they are not 
always very apparent. The usually recognised pigment changes 
come much later. Subjective Symptoms. — These are important. 
The acuteness of vision is in mild cases lowered to f or ^, but 
without much objective change may go to y-^ or y^-^. The pecu- 



SYPHILITIC CHOROIDITIS. 87 

liarity of the defective vision is, that the fixation point itself is 
fairly seen, while there is a more or less regular ring-formed 
defect round it, the periphery still acting properly. The defect 
may run out to the periphery of the field of vision here and there, 
leaving the visus reticulatus, which is the result of this affection 
more often than of any other. In the first stage small defects of 
vision towards the blind spot may be seen, which do not give a 
bad prognosis. Hemeralopia is a highly constant symptom, 
which Professor Forster measures by means of his " Lichtsim- 
messer." The light perception he finds much more lowered than 
the acuteness of vision, and the light perception can undergo 
considerable deterioration, although the a,cuteness of vision is 
vei'y little altered. Sometimes the hemeralopia is present only 
on certain parts of the field of vision. Another very constant 
symptom he believes to be subjective light sensations, generally in 
the region of the fixation point, consisting of transparent spots in 
the form of discs, rings, or oval figures, which move with a shaky 
velocity. These, if lasting, prove a defect, which may be found 
if carefully looked for. This photopsy passes away if the patient 
is kept at rest, but any excitement of the circulation is sufficient 
to call it up. Micropsy, as noticed by Mooren and vSchweigger, 
is also sometimes present, depending, Forster thinks, on the 
retinal change, and not on the accommodative apparatus. The 
accommodation is lessened, and he thinks he has observed a 
degree of myopia developed during the course of the affection, 
but never any hypermetropia. Iritis is not uncommon, either 
before the choroiditis or succeeding it, but it does not produce 
lasting posterior synechiae, does not go the length of the 
closure of the pupil, and has no inclination to become chronic. 
The choroid is thought to be the chief seat of the disease and the 
tissue first involved. 

The course of the afTection is very varied and subject to 
relapses, which are diagnosed by loss of acuteness of vision, a 
return of the hemeralopia and photopsy, before the ophthalmo- 
scope gives any a]ipreciable changes. The results he has obtained 
have been mostly favourable, with a more or less lowered acute- 
ness of vision, sometimes a high degree of amblyopia with visus 
reticulatus, and rarely perfect restoration. Where the acuteness 
of vision is under f or |, vitreous opacities of different forms, 
small or great changes in the choroidal pigment, atrophy of the 
retina, or white spots of round or radiating forms in the region 
of the macula lutea are found. The optic disc is of a homo- 
geneous yellow white, with the vessels few and thready, giving 
so exactly the appearances seen in retinitis pigmentosa, that the 
differentiation of the two affections by the objective appearances 
onlj- may be very difficult. He avers that it comes much moi'e 
frequeutlj' in later life than in youth. Of 55 cases two were in 
their 24th year, and the remainder were over 27, 14 of them being 



88 PERISCOPE: — DOUBLE PARALYSIS, ETC. 

between 51 and 60. It occurs equally in males and females in 
hospital practice, both together giving a proportion of 2^ in every 
thoiTsand ophthalmic cases. 

The treatment he relies upon is the mercurial, with simul- 
taneous residence in a dark room for at least four weeks. Cor- 
rosive sublimate or calomel he has seen benefit from, but relapses 
■were frequent after the former, and always after the latter, while 
all those cases where no relapse occurred were those in which 
mercurial inunction had been employed till the beginning of 
mercurial stomatitis was observed wdth a sojourn in a dark 
room, for the most of the time in bed. He thinks the use of the 
artificial leech, and large blisters on the neck are useful secondary 
means, but to be used in connection with the mercurial treat- 
ment and not to be relied upon alone. — (Graefe's " Arch. f. 
Ophth.," bd. XX, Abth. i, p. 33.) 

ACCOMMODATION WITH APHAKIA. 

Dr. Woixow describes the means he used to determine the truth 
of Forster's assertion that with aphakia there may be accommo- 
dation present, and comes to the conclusion that in aphakia! eyes 
certain changes are observed, which mnst be considered as 
appearances of accommodation, but he cannot explain what the 
mechanism is by which these appearances are brought about. — 
(Greefe's " Arch. f. Ophth.," bd. xix, Abth. iii, p. 107.) 

THE NODAL POINTS FOR ECCENTRIC RAYS. 

Drs. Landolt and N'uel relate the experiments which they made 
on rabbits by means of the ophthalmometer to determine the 
nodal points of rays passing eccentrically into the eye. They 
found that the nodal point for peripheral rays lies from 1'07 to 
1'09 nearer to the retina than that for axial rays, and, that the 
former lies somewhat, though very slightly, in front of the latter. 
The more peripheral the image is, the smaller it is, but this re- 
duction of the image is more trifling than the reduction of the 
acuteness of vision towards the periphery, and the latter is not 
explained by the former. They think this loss depends on 
defective light, the lessened number of ganglionic cells in the 
periphery, and the limited use which is made of this portion of 
the retina. — (Graefe's " Arch. f. Ophth.," bd. xix, Abth. iii, 
p. 301.) 

DOUBLE PARALYSIS OF THE THIRD NERVE. 

In the Journal of Mental Science, July, 1874, Dr. Hughlings Jack- 
son records a case of syphilitic brain disease, in which the earliest 
symptom was paralysis of both third nerves. According to the 
patient's account these palsies came on suddenly. The patient 



DOUBLE OPTIC N:EURITIS, ETC. 89 

had other nervous symptoms not of special ophthalmoh^igical 
interest. At the autopsy there was found extensive gummatous 
disease of the cerebral arteries. " Both posterior cerebral arteries 
and both superior cerebellar arteries, and the two third nerves, 
were all fixed to one another by material similar to that thickening 
the arteries." 



DOUBLE OPTIC NEURITIS FROM SYPHILITIC BRAIN DISEASE. 

In the same paper he records the case of a patient who had 
double optic neuritis, and afterwards other nervous symptoms, 
from intracranial syphilis. Thei'e was paralysis of the left third 
nerve. There was also the symptom lateral deviation of the two 
eyes ; they turned to the left. The case is too long for abstract ; 
the above note shows that it will repay reference. 

The following quotation is from the remarks preceding the 
case. Dr. Hughlings Jackson thinks that few medical men, 
excepting ophthalmologists, believe that a patient with severe 
neuritis, can read the smallest type. He therefore keeps urging 
the truth of that statement : — 

" I would here remark that, as this case illustrates, double 
optic neuritis frequently exists when there is no evidence to show 
that sight is affected, and indeed when there is clear evidence 
that it is good. 

" I have asserted this over and over again, but it is a thing hard 
to believe. Besides other reasons, the importance of recognising 
this is that we shall often discover optic neuritis too late for suc- 
cessful treatment — too late, I mean, for the prevention of amau- 
rosis— unless we examine the eyes by routine. If a patient has 
any kind of nervous symptoms, especially pain in the head, we 
must not wait until his sight begins to fail ; we should use the 
ophthalmoscope by routine. If we do we shall discover optic 
neuritis in its pre-amaurotic* stage. 

" Another thing to be mentioned is that optic neuritis from 
syphilitic disease in the brain difiers in no way from optic neu- 
ritis the result of a glioma or other ' foreign body.' Optic 
neuritis tells us vjothing more than that there is coarse organic 
disease of some kind within the cranium. Its diagnostic value 
is the same whether sight be affected or not. There is no 
difference in the optic neuritis, whether the tumour or other 
foreign body causing it be in the cerebrum or cerebellum. It is 

* In the next (the fourth) volume of Crichton Browne's West Riding 
Asylum Reports, Dr. Hughlings Jackson will publish two chromolithographs 
of the fundus oculi, by Biu-gess. One of them shows acute and extreme 
neuritis in a patient who could read the smallest type ; the other shows the 
optic nerve and fundus after recovery fi-om the neiu-itis. The clianges left 
by the neuritis are insignificant. The patient did not recover from amau- 
rosis ; he had no defect of sight to recover from. (See on " Recovery from 
Neuritis," p. 518 of the last number of this Journal.) 



00 PERISCOPE: — OPHTHALMOSCOPIC EXAMINATION, ETC. * 

of no value whatever in localising beyond that it points to disease 
within the cranium." 



OPHTHALMOSCOPICAL EXAMINATION DURING AN ATTACK OF EPILEPTI- 
FORM AMAUROSIS, 

Dr. Hughlings Jackson communicates the following to the Lancet, 
February 17, 1874 :— 

" This patient had attacks of what I used about ten years 
ago to call epilepsy of the retina, but which I have for some time 
called epileptiform amaurosis. It is the most striking case of the 
kind I have seen. The most common clinical association of 
paroxysmal defects of sight is convulsion beginning unilaterally, 
as I have long noticed. There was no such association in this case. 
The phenomena are sometimes positive, e.g.., colours, sparks, &c. ; 
in other cases, as in the following case, negative. Another pecu- 
liarity of this case is that there was neuritis, and that too with 
considerable impairment of sight. 

" Henry G , aged thirty-four, was an in-patient under 

my care June 27th, 1870, for symptom_s which I believed to 
depend on intra-cranial tumour, certainly on severe encephalic 
disease. Very careful notes were taken of his case by my col- 
league, Dr. Gowers, but I extract from them only so much as 
bears on one point — namely, paroxysmal loss of sight. I first 
give what my colleague gathered from the patient as to this 
phenomenon. 

" ' June 16th. — During the last two or three days he has had 
occasional attacks of loss of sight coming on gradually and last- 
ing several minutes — he says, five or ten ; there is not complete 
darkness, but a degree sufficient to prevent him from distinguish- 
ing any object. Headache, frontal, and aching in the limbs 
accompany the attacks ; the headache continues afterwards.' " 

" It is to be noted that at this time he could read No. 1-^ 
Snellen with each eye. There was, however, double optic 
neuritis. I have for years insisted on the fact that sight may 
be good when the optic discs are very bnd. He continued sub- 
ject to the above described paroxysms, and by July 1st his sight 
had failed so that he could at no time read No. 20 of Snellen. 
Now comes the part to which I wish particularly to draw atten- 
tion. Mr. Burgess had made me a drawing of the fundus of one 
of the patient's eyes, and I went to the hospital to compare it 
with the " specimen " itself. The following is an account of 
what took ^lace : — 

" July 4th. — This morning, when I was speaking to him, he 
said nervously, ' The blindness is coming on.' We put him in 
a chair; he said he could see vofhing. To test this I put my 
fingers before his eyes, jobbing Ihem forwards, as if I would put 
them into his eyes; this produced no efi'ect until I touched the 



COLOURED VISION, ETC. 91 

lashes. In about lialf a minute Le said be could see a ' Hgb.t 
object,' but furtbev impi'ovement was slow and the blindness 
returned. I took him, in this second attack, to the gas-lamp ; 
he ' thought he saw a light' when I threw tbe light into his 
eye for ophthalmoscopic examination. I discovered no change 
of importance. As just before I had been comparing his left 
disc with Burgess's drawing, a notable difference could not have 
escaped me. The large veins in the left eye were, perhaps, 
darker than before the pai'oxysm, an observation of no definite- 
ness. It Avas curious to note the difference in his ' ocular 
manner ' from that during a former examination. From habit, 
I kept saying", ' Look at my little finger ; ' and now, he being 
temporarily blind, no result followed. After writing down the 
latter part of the above I returned to him. He then said he 
could see objects, and he counted my fingers and followed quickly 
and very correctly the movements of my hand — that is, he 
directed his eye to the finger I asked him to look at. At that 
examination, i.e., after the second paroxysm instanced, I felt sure 
that the veins (I speak only of the left) were not as before the 
first attack ; tbey were not so dark, and seemed as if slightly 
collapsed, being, to use an exaggerated expression, beaded. A 
few minutes later he could puzzle out jS^o. 20 of Snellen. 

" Under treatment by large doses of the iodide of potassium 
he improved, and on August 1st left the hospital feeling quite 
well. He could read No. 1. However, he soon got worse again, 
and bad a severe illness, with palsies of ocular nerves, &c. He 
recovered from these symptoms too, except that he remained 
blind. He is still suffering, having occasionally pain in the head; 
but his general health is good." 

COLOURED VISION AS AN " AURA " IN EPILEPSY. 

In the Hospital Reports of the " British Medical Journal," Feb- 
ruary 7, 1874, are remarks by Dr. Hughlings Jackson on this 
subject. 

It is said that, in cases of colour-blindness from disease, red 
is, in most cases, the first colour to go ; and that the further 
progress in loss of colour-sight is towards the violet end of the 
spectrum. [In the great majority of cases of congenital colour- 
blindness, red is the fundamental colour not seen. All people 
are red-blind in the most peripheral parts of the retina, and more 
extensively so to its nasal side.] Loss of power to see colours is 
one of the sensory analogues of palsy of muscles (motor nerves). 
Now, just as palsies have their mobile opposite in spasm, so, in 
opposition to loss of colour-sight, there are cases of development 
of coloured vision. [Of course the physiological comparison is, 
strictly speaking, betwixt excitations in motor and sensory 
nerves.] Thus, occasionally, a patient who is subject to epi- 



92 PERISCOPE: — PARALYSIS OF THE THIRD, ETC. 

leptic or epileptiform seizures, may have, as a first symptom 
(so-called aura), a colour, or " all manner of colours," before his 
eyes. It is well, when the patient is intelligent, to ask which 
colour is first developed, and the order in which they come. 
Theoretically, one would expect that tbe first colour to be de- 
veloped would be red, because it is the one first lost in cases of 
colour-blindness. For, returning to paralytic symptoms for an 
analogy, we find that those very movements which are first lost 
in destruction of nervous organs, are those which are first de- 
veloped in epileptic discharges of nervous organs. Dr. Hughlings 
Jackson thinks, so far as limited and recent inquiries enabled 
him to judge, that red is usually the colour first developed when 
colour-development is a " warning " of an epileptic seizure. It 
is not always so ; one of his patients has blue vision before severe 
epileptic fits; and she has had attacks of the blue* vision, fol- 
lowed by temporary and complete darkness, without anything 
further. To ask patients to note the order of development of 
colours would, however, avail little in the majority of cases; 
probably there is, in most cases, a development of colour, rapidly 
becoming complex ("rainbow"). The order of frequency in 
which the higher senses suffer in epilepsies is. Dr. Hughlings 
Jackson believes, sight, smell, hearing. An aura of taste, is very 
rare; a "sting," or other non-gustatory aura, from the tongue, 
is not so uncommon. It is not easy to say where touch comes. 



NOTE ON THE DIAGNOSTIC VALUE OF PARALYSIS OF THE THIRD NERVE 
WITH HEMIPLEGIA. 

Dr. Hughlings Jackson contributes the following to the Hospital 
Reports of the Lancet, September 6, 1873, under the heading 
London Hospital : — 

" It is well known that a lesion of the crus cerebri can pro- 
duce paralysis of the third nerve on the same side as the lesion, 
and of the face, arm, and leg on the other side. But it would be 
a great mistake to suppose that when we find paralysis of the 
third nerve on one side, and of the face, arm, and leg on the 
other, there is necessarily disease of the crus cerebri. In a case 
[at the London Hospital] manifestly of intraci-anial syphilis, 
there was the association of symptoms mentioned ; but it was 
pointed out that, as the ocular loalsy came on at a different time 
from the hemiplegia, there were no doubt two lesions — syphilitic 
disease of, the right third nerve (a neuroma), and disease of the 
right side of the brain. At the autopsy the two lesions were 
found. 

* Blue, according to Maxwell, is the fundamental colour most i-emoved 
from red. ndmholtz adoj^ts the theory of Thomas Young, that the three 
fundamental colours are red, green, and violet. 



LATERAL DEVLITION OF THE TWO EYES, ETC. 93 

" If the third nerve be paralysed on the same side as the face, 
arm, and leg, there are of course two lesions — one of the trunk 
of the nerve, and the other of the motor tract on the opposite 
side." 

Dr. Hughlings Jackson has recorded a case in which there 
was paralysis of the right third nerve and hemiplegia of the left 
side, in this Journal, vol. iv, p. 442. In that case there were 
two lesions, one at the base and one of the right cerebral 
hemisphere. 

LATERAL DEVIATION OF THE TWO ETES FROM DISEASE OF THE BRAIN. 

In an article* in Crichton Browne's West Riding Asylum 
Reports, vol. iii, Dr. Hughlings Jackson speaks of certain ocular 
symptoms which are not likely to come often under the notice 
of the ophthalmic surgeon. 

" In some cases of hemiplegia there occurs a symptom which 
shows that there are in the brain, at any rate in the corpus 
striatum and adjoining convolutions, nervous processes fur highly 

specialf movements of the two eyes The symptoms 

are, turning of the two eyes from the side paralysed in hemi- 
2)legia, and, correspondingly, turning of the two eyes to the side 
convulsed in cases of hemi-sjyasm. This lateral deviation of the 
eyes was first described by Yulpian and Prevost.J 

* " Observations on the Localisation of Movements in the Cerebral Hemi- 
epheres, as revealed by cases of Convulsion, Chorea, and ' Aphasia.' " 

t The following remarks from an article (on the Anatomical Investigation 
of Epilepsy and Epileptiform Convulsions) " British Med. Journal," May 10, 
1873, may be given as showing the nature of this ocular symptom : — 

" Before we pass to speak of convulsion in man, it is necessary to state 
certain principles as to the constitution of nervous centres. 

" The nervous centres represent movements, not muscles ; chords, not 
notes. This is evident from the effects of destroying lesions of tlie corpus 
striatum. From a small lesion of this body there does not result paralysis 
of a small jjari of the arm, nor of any such group of muscles as flexors, or 
extensors ; there results j^artial paralysis of the whole arm, the most special 
parts of it suffering most. There is loss oi a cevtyln mmiber of movements 
of the limb. Let us take a more striking example : in cases of very grave 
lesion of the corpus striatum (that is, of a centre far above the supposed 
deep origins of the ociilar motor-nerves), there is, besides palsy of the face, 
arm, and leg, an ocular j^alsy Xow tliis palsy is not of the sixth nerve, nor 
of the third nerve, nor of the foiu-th, nor of any one muscle, nor of any 
random grouping of nniscles. It is a loss of a highly special and widely 
issociated movement ; the patient has lost power to look to that side on which 
-lis body is paralysed ; there is what is commonly called lateral deviation of 
he eyes. Sunilarly, in convulsion there is a development of movements. In 
I convulsion beginning in the hand, the spasm creeps up the whole limb, 
leveloping first the movements of the most special parts of it, but not 
picking out such groups of muscles as flexors or extensors. Among other 
movements, there is at a certain stage a development of that of the eyes for 
" looking " to one side. In this case the two eyes are turned to the side of 
the body convulsed." 

X In this country by Humphry, Lockhart Clark, Hutchinson, Broadbent, 
BusseU Reynolds, and bymjself in the " Lond. Hosp. Rep.," vol. iv, 1868, &c. 



94 PERISCOPE: — LATERAL DEVIATIOX, ETC. 

" The occurrence of this symptom from disease of the brain 
is of very great importance for mental physiology;* movementsf 
of the eyes enter into the anatomical substrata of our visual 
' ideas.' The significance of the occurrence of this symptom 
(in severe lesions and strong discharges) along with affection 
of our diief tactual organs, is very great. Donders supposes, 
with Hering, that there are movements of the eyes together for 
direction (upwards, downwards, inwards, and outwards), and 
also of adduction and abduction for distance. He shows from 
Adamiik'sJ experiments that ' au moins chez le chien et chez le 
chat, les deux yeux ont une innervation commune, qui part des 
tubercules anterieurs des corps quadrijumeaux. L'eminence 
droite regit les mouvements des deux yeux vers le cote gauche, 
et vice versa. En irritant des points differents de chaque 
eminence, on pent provoquer le mouvement .dans une direction 
quelconque, mais toujours les deux yeux se meuvent simultane- 
ment et en conservant entre eux une relation determinee.' But 
such movements are also represented in the corpus striatum and 
adjacent convolutions (perhaps I should say, re-represented), 
and in direct relation with movements of our chief tacttial organ. 
The movement is lost in hemiplegia, and is developed at a certain 
stage in convulsion beginning unilaterally. I was long puzzled 
by the fact that in the lateral deviation of the eyes in hemiplegia 
and in convulsions beginning unilaterally the eyes were parallel. 
As the act of accommodation (in which the eyeballs are con- 
verged) is a very important one, I expected to find the movement 
of convergence the first of the ocular movements to suffer. For, 
as I shall mention more particularly in my next article, the most 
special movements suffer first in cases of cerebral lesions. (See 
' West Riding Lunatic Asylum Medical Reports,' vol. iii, 
pp. 315 — IG.) But I now see that convergence,§ as it has to do 

* I am surprised that Vulpiaii's important statements on this ocular 
symptom have received so little attention in this countiy. Lateral deviation 
of the two eyes is valuable clinically as evidence of a gross lesion in cases of 
apoplexy ; enabling us sometimes to tell cerebral hajmorrhage from drunken- 
ness (Prevost). I have found it a most important help towards completing 
the parallel betwixt hemiplegia and bemi-sjiasm (see " Lancet," Februaiy, 
16, 1867). Thirdly, as suggested in the text, the symptom is one of extreme 
importance for mental physiology. 

t See Spencer's " Psychology," second edit., vol. i, chap. xiii. 

X I take these extracts from a translation of a paper by Donders in 
" Robin's Journal," September and October, 1872. In a very brief statement 
in the " Lancet " (February 15, 1873), of what is given at more length above, I 
represented t)onder8 as speaking only of the lateral movements of the eyes. 

§ The following is a quotation from Dr. Hughlings Jackson's paper on 
" Localisation of Movements in the Brain." " Lancet," February 15, 1873 : — 

" There are other conjugate deviations of the eyes besides lateral. Thus in 
lesions of the right middle peduncle of the cerebellum the right eye is turned 
upwards and outwards, the left downwards and inwards. Just as there is an 
association of lateral movements of the eyes with movements of our tactual 



CORRELATIONS OF MOVEMENTS, ETC. 95 

with distances, belongs to tlie locomotor series (cerebellum) and 
not to tlie tactual series (cerebrum). The movements for carry- 
ing the retina? over objects, are just as special in the cerebral 
series as those for convergence are in the cerebellar series. I 
say " cerebellar series," because my inference has been that the 
movements of convergence are cbicfly represented along with 
movements of our spine, arms, and legs for locomotion. At any 
rate, according to Bonders and Adamilk, the two kinds of ocular 
movements (the j^a.rallel and the converging) are differently 
represented in different parts of the corpora quadrigemina. I 
continue the quotation, ' Par I'irritation de la partie posterieure, 
soit de I'eminence droite, soit de I'eminence gauche, on obtient 
une forte convergence, avec abaissement simultane des lignes 
visuelles et retrecissement de la pupille.' In the corpora quad- 
rigemina we should not expect any very great differentiation 
of the two classes of movements, any more than of movements 
for articulation and deglutition in the medulla oblongata. But 
betwixt the mode of representation of movements in the cere- 
brum and in the cerebellum, we should expect the differentiation 
to be carried to its extreme."* 

In healthy looking at near objects, of course, both classes 
of ocular movements will be developed. The eyes must be 
adjusted; when "fixed together" so as to "reach" the object, 
they can be carried over the object; the retinae can then 
"feel" it. 

CORRELATIONS OF MOVEMENTS OF THE EYE AND HAND AS SHOWN BY 
CERTAIN CASES OF HEMIPLEGIA AND CONVULSION. 

The following is from a lecture by Dr. Hughlings Jackson 
(" Brit. Med. Journal," July 18 and 25, 1874) on Hemiplegia. 
The extract is given, as it shows the relation of the lateral 
movements of tl;e eyes to other movements, especially those of 
the arm and hand. It thus shows what is meant by the expres- 
sion in the last note, " in direct relation with movements of our 
tactual organs." 

It must be premised that Dr. Hughlings Jackson makes three 
degrees of liemiplegia from disease of the corpus striatum, or 
rather three degrees of symptoms from lesions of three degrees 

organs for ideas of objects, so we may suppose that there will he associations 
of ocular movements of convergence and divergence (the former especially 
downwards, tlie latter especially upwards) with those movements of the 
spine, legs, and arms in locomotion, represented in tlic cerebellum, for ideas 
of distance ; hence the importance of studying particular ocular deviations in 
association with accompanying disorder of movement." This agrees with the 
conclusions of Ferrier on the functions of the Cerebellum. 

* It does not follow that movements represented in a lower centre, are 
not also represented in the higher centre. Are we to believe that the move- 
ments by which a headless frog rubs vinegar off its back, are not also repre- 
sented, and that more specially in the detached head ? 



96 PERISCOPE: — CORRELATIONS, ETC. 

of gravity of this part. The distinction of coiarse is arbitrary. 
In the first degree there is paralysis of the face, tongue (or 
rather T\'eakness of these parts), and of the arm and leg. This 
was the degree of paralysis in the patient whose case was the 
text of the lecture. It is with the second degree of hemiplegia 
that we are concerned : 

" Second Degree of Eemvplegia. 

" We now pass to that hemiplegia of greater range, which I 
shall call the second degree of hemiplegia, or, as I sometimes 
say, complete hemiplegia. Our patient's hemiplegia was as com- 
plete in range as we usually see hemiplegia. His face, tongue, 
arm, and leg, were paralysed on one side. But, from a graver 
lesion than that our patient had, there is a compound effect ; there 
is not only (1) increase in the paralysis of the" face, arm, and leg, 
but also (2) spreading of palsy to more automatic parts. Thus 
the shoulder and trunk muscles are involved. There are also 
cei-tain other prominent and very interesting symptoms which 
show extension of paralysis to movements of more automatic 
parts. These are (a) deviation of the two eyes, and (6) of the 
head — in both cases, from the side of the body paralysed. The 
following is a list of the chief symptoms in complete hemiplegia 
of the right side (those additional to symptoms in the first degree 
of hemiplegia being in italics). 

"1. The head turns to the left. 

" 2. Both eyes turn to the left. 

" 3. The muscles of the chest and helhj are weakened on the 
right. 

" 4. The muscles passing from the trmik to the right limbs are 
paralysed. 

" 5. The face is paralysed on the right side. 

" 6. The tongue, on protrusion, turns to the right. 

" 7. The right leg is paralysed. 

" 8. The right arm is paralysed." 

Dr. Hughlings Jackson does not hold that the lateral only of 
the parallel movements of the e3'eballs are represented in the 
region of the corpus striatum. The lateral parallel movements 
are the most special of the parallel movements ; and they there- 
fore suffer first and most in hemiplegia and hemi-spasm. This 
accords with a widely-bearing principle, referred to in the next 
extract. Stated generally, that principle is — 

" Froih lesions of the Cerebral nervous centres, parts suffer the 
m,ore as they are voluntary or special, and the less as they are 
automatic or general. Recovery follows the reverse order : the 
more automatic parts recover first." (This statement, however, 
is not made of the cerebellum.) 

We may conclude this note with a quotation from Dr. Hugh- 



LATERAL DEVIATION OF THE EYES, ETC. 97 

lings Jacksou's paper on " Localisation of Movements in the 
Brain," Lancet, Feb. 15, 1873. 

" Both in hemiplegia and in convulsions beginning unilaterally 
we note certain associations, e.g., affection of the orbicularis 
palpebrarum along with affection of the limbs. Bonder's re- 
searches give an explanation of this association. The most im- 
portant, however, is the association of affection of certain move- 
ments of the eyes with affection of those of our limbs. Signi- 
ficantly (and in accordance with the principle spoken of 
throughout this paper) the movements of the eyeball which are 
first affected are the lateral. We can overcome a prism of from 
20° to 30° with its base placed outwards, and one of 6° to 8° 
with its base placed inwards ; but few persons can overcome 
more than a prism of 1° or 2° with its base turned upwards or 
downwards. There is then greater variety or independence in 
the lateral movements of the eye. (The internal rectus is the 
strongest of the ocular muscles). In association with this 
greater independence of the lateral movements we may note that 
the sensibility of the retina diminishes less rapidly outwards than 
upwards and downwards. 

" That the movements of our chief tactual organs should have 
close and direct associations in the highest nervous centres with 
certain movements of the eyes is what one would expect if, Jis 
Spencer says ('Psychology,' Part 24, p. 358), ' tactual impres- 
sions are those into which all other impressions have to be 
translated before their meanings can be known.' I sup- 
pose visual impressions and ocular movements may be said 
to ' stand for ' tactual impressions and movements in the sense 
that the strong excitation of the nervous processes of the former 
leads to faint excitation of those of the latter (movements of the 
hands, &c.). The study of cases of hemiplegia and convulsion 
shows us, not only that there is an association, but the order in 
which eye movements and limb movements are associated. Of 
course a coarse lesion of a nervous centre, or a sudden discharge 
of one, is not a very neat experiment. In hemiplegia the parts 
suffer in degree, [ believe, in the following order: arm, leg, side 
efface and tongue, orbicularis palpebrarum, lateral movements 
of eyes, latei-al movements of head. The difficulty obviously is 
that several systems are damaged all at a blow — the movements 
of lifting, by which we have ideas of weight, the eye to hand 
movements of writing, the movements of speech, &c." 



LATERAL DEVIATION OF THE EYES, OCCURRING WITH OTHER SYMPTOMS 
IN A CASE OP LIMITED CONVULSIONS FROM DISEASE OF THE BRAIN. 

As remarked in a previous note there occurs deviation of the eyes 
in cases of convulsive seizures caused by disease of the brain. 
VOL. VIII. H 



98 PERISCOPE: — LATERAL DEVLVTIOX OF THE EYES 

The following is an example, and although recorded some time 
ago, is worth re-publication now that the researches of Hitzig and 
Terrier are attracting so much attention. Dr. Hughlings Jackson 
says of it in his remarks following the report, " Medical Times 
and Gazette," January 29, 1872 :— 

" In this case the lesion was not sufficiently local to enable 
one to conclude that fits beginning in the face show damage to 
any particular ccmvolutional region. For instance, the fits may 
have been owing either to discharge of the grey matter of the 
convolutions of the temporo-sphenoidal lobe, or of the island of 
Reil. In most cases of convulsion beginning unilaterally the 
cerebral lesion is veiy extensive. I shall shortly, however, report 
a case of convulsion beginning in the left thumb, in which there 
was a tubercular tumour the size of a hazel nut, in the hinder 
part of one convolution — the third right frontal convolution. 
By numerous observations of this kind we may confidently 
expect to arrive at clearer notions on localisation of move- 
ments." 

The case itself is reported in the " Medical Times and 
Gazette," January 6, 1872. It is as follows : — 

" December 7, 1871,. 5. 30 p.m. — I sa\y a patient, 41 yeai's of 
age, who had been admitted under the care of Mr. Hutchinson 
for phosphorus-necrosis of the left upper jaw, and who had very 
frequent attacks of spasm, afi^ecting chiefly the left side of the 
face. I saw six attacks in about half an hour. The description 
of what was observed in the third (apparently the severest) is as 
follows : — There was drawing of the mouth to the left almost 
horizontally ; the spa.~i i gradually spread over the left side of the 
face, and even to both sides of the forehead. After the face was 
well in action, both eyes turned far to the left, and the head 
turned a little, but very decidedly, to the same side. Later still 
both eyelids blinked (shutting and opening), but the left much 
the more, ■i.e., they closed more completely, but whether more 
frequently was not noted. The mouth was closed throughout 
the attack, and respiratory efforts — for a time at least — were 
suspended. At one time, early in the fit, a slight snapping 
sound was heard, believed to indicate occasional action of the 
masseter and temporal muscles. When towards the end of the 
fit, the arm was felt (by taking gentle hold of the upper arm and 
forearm), there was the very faintest movement of the limb — 
apparently of the limb as a whole. 

" After this and after subsequent attacks there was no affection 
of speetfh proper, i.e., of speech in the sense of ' propositionising,' 
nor was there any considerable defect of speech in the sense of 
talking; there was only the slightest muffling of articulation. 
This muffling no doubt depended on paralysis of the face, for tlio 
face was paralysed on the left in the intervals of the fits. It was 
much drawn to the right, and when he spoke the cheek ' bagged' 



OCCURRING IN CASES OF LIMITED CONVULSIONS. 99 

on the left. He could not close the left eye nearly so firmly as 
the right, and when the lids of the right eye were separated, in 
order to use the ophthalmoscope, there was very great resistance, 
but none, or scarcely any, on the left side. In the attacks the 
patient did not speak, for his mouth was closed, and he was no 
doubt unconscious, although we fancied that in one attack he 
nodded to his wife, who called him by name. 

" The above does not pretend to be a full account of what took 
place in the seizure. The observation was begun after the very 
beginning of the attack. It is impossible to observe all the 
details of the very complex march of a fit affecting even so small 
a part as one side of the face. In another attack, whilst I 
observed the left arm (which in this attack did not suffer at all) 
and the face, Mr. Haydon kept one of his hands on the chest, and 
the other on the abdomen. He reported that at first there was 
action of the abdomen (diaphragm) at shorter intervals ; the 
chest stopped moving two inspirations before the abdomen. 
This — the stoppage of both — we may suppose was the climax ; 
then (to continue Mr. Haydon's observations) there were little 
jerks, a sigh, and lastly deep inspirations, in which both chest 
and abdomen shared. 

" In this attack I observed, further, that the two eyes were 
well turned to the left before the eyelids were closed — the eyelids 
were indeed at that time very widely open — and that later the 
eyelids rapidly opened and closed, the left eye closing very much, 
the right eye not closing completely or strongly, at all events. It 
was not noted whether the left eye cloised oftener than the 
right. 

" In still another attack the fit was noticed from the very be- 
ginning. It was then seen that there was, at the very first, 
confused movement (so to speak) of the mouth, as if the orbicu- 
laris oris all round was in action — not the left half of this muscle 
only. There were slight, perhaps doubtful, movements of the 
lower jaw up and down. Distinctly after the "mouthing," the 
horizontal drawing of the face to the left began, and the face 
part of the fit occurred as before. 

" In one attack the left arm was raised from the body — rather, 
it was observed raised — and there was seen the very slightest 
movements of the fingers bachwards. 

" The spasm was clonic. It cannot be affirmed that there was 
no transient tonic spasm before the clonic spasm began ; probably 
there was. The movements were supposed to be at more rapid 
intervals the later the tit, so far as the horizontal drawing was 
concerned. There is, however, very great ditficulty in observing 
this point ; the wider the movement the more obvious it is. 

" 9.30 p.m. — I saw him again with the House- Surgeon, Mr. 
E. W. Parker. I saw one fit, and in it the fingers of the left 
hand were slightly moved ; the hand itself was thrown back in 

H 2 



100 PERISCOPE: — LATERAL DEVL\TIOX OF THE EYES, ETC. 

slight jerks. The face as before. He had, it was said, not had 
one fit since I left him, but little had been seen of him. Fara- 
disation was tried, but it could not be tried fairly, as he cried 
out, and there was no justification for disturbing him. The left 
side did act, at least equally, if not slightly more than the right. 
The cheek near the angle of the mouth was faradised. He had 
one very trifling fit ; there was only a little "mouthing," pre- 
ceded by a deliberate up-and-down moYement of the lower jaw. 
He died on the 9th. 

" Autopsy. — On cutting the dura mater on the right* side, 
there was a spirt of dirty thin pus, and when this membrane was 
cut round in the usual %yay so much of the right hemisphere as 
was then exposed was seen to be covered with pus, which lay 
above the arachnoid. On geiitly raising the brain a vein was 
seen passing from the right lateral sinus to a patch to be pre- 
sently spoken of over the lower wall of the Sylvian fissure. The 
vein was like a white, tough cord. When cut into it exuded, not 
blood, but a thin, ci-eamy fluid. 

" The pia mater and ai-achnoid were thickened and infiltrated 
with lymph for about two square inches (but the limits were 
very ill-defined) over the upper and outer parts of the parietal 
and anterior lobes. On removing the brain no abnormality was 
seen on the under surface of the posterior lobes, and none on the 
part of the brain which lay over the lateral sinus. There was a 
little pus over the optic nerves, also under the right anterior lobe 
and over the fissure betwixt it and the left lobe ; but the mem- 
branes were not thickened. The pus lay above the arachnoid. 
The chief disease of ^ he brain-substance itself was at the patch 
above spoken of. Here the membranes were thickened and 
adherent to the convolutions ; not firmly adherent, but the con- 
volutions were so soft that they tore when the membranes were 
removed. It was supposed at first that the large quantity of 
pus was the result of rupture of a cerebral abscess ; but, although 
the convolutions of the lower wall of the Sylvian fissure (about 
opposite the lower end of the fissure of Rolando) — that is, the 
convolutions subjacent to the patch — were softened into a dirty 
mixture of brain and pus, no abscess was discovered — that is, no 
walled abscess — rupture of which coiild have caused a large 
" efl^usion of pus." At this point the overlying veins were turned 
into thick, dark cords — cylindeis of coagulated blood — and one 
vein, with thin, creamy contents, passed, as aforesaid, to the 
right lateral sinus. The extreme damage was very limited. 
There was purulent softening of about a cubic inch of the lower 
boundary of the Sylvian fissure, and very little extension deeply 
in the fissure. In the convolutions near to the p.art most affected 
were, however, many red specks (red softening). The hinder 

* Erroneously printed " left" in the original. 



ON HEMIOPIA IN HEMIAN.l^STHESIA AND HEMIPLEGIA. 101 

part of the island of Reil was affected ; it was affected as the 
convolution under the patch, for about the size of two peas, but 
doubtfully by direct continuity. The convolutions of the 
anterior, posterior, and temporal lobes all round the principal 
lesion were slightly softened, and of a slightly greenish hue, such 
as is seen in decomposing brain. The corpus striatum and the 
optic thalamus, crura cerebri, pons, and cerebellum were normal. 

" The convolutions of the left — the comparatively sound hemi- 
sphere — were flattened and pressed together. The arachnoid 
surface was greasy-looking, and through it was seen a little — but 
very little — dirty serous fluid in the angles of the convolutions. 
The substance of this hemisphere was normal. 

" The superior longitudinal sinus contained pus mixed with 
blood, and a soft yellowish-looking clot. In the right lateral 
sinus were chiefly flakes of purulent matter, and a soft yellowish 
clot. The right cavernous sinus seemed to contain nothing but 
pus. The left cavernous sinus was normal. Mr. Parker removed 
the left (sic) superior maxillary bone, and saw that the bone was 
extensively necrosed. The disease had extended to the body of 
the sphenoid. The dura mater over it was raised, and on 
removing it the bone was seen to be dark and slightly rough. 
All the organs in the chest and belly were normal, except the 
lungs and spleen. The lungs contained numerous infarctions. 
They were nearly all in the " apoplectic" stage, and one or 
two Avere (on section) large, raised, and quite like those more 
commonly seen in cases of heart disease. In the centre of 
two or thi^ee of the smaller ones only was there any purulent 
matter, and this was but slight in amount. The spleen was 
lare-e and soft." 



ON HEMIOPIA IN CASES OF HEMIAN-ffiSTHESIA AND HEMIPLEGIA. 

The following remarks were made by Dr. Hnghlings Jackson, 
after the reading of a case of hemiopia by Mr, J. Hogg, at the 
Medical Society of London : — 

Dr. Hughlings Jackson thought the case narrated by 
Mr. Hogg an interesting one. In that case there must have 
been two lesions, one for the hemiplegia, and another for the 
hemiopia. Dr. Hughlings Jackson had seen several cases in 
which hemiopia had come on at the same time as hemiplegia, and 
here there was probably but one lesion. The hemiopia was 
such that the patient could not see to his paralysed side ; the 
disease causing these two intelligibly associated symptoms would 
be of the side of the brain opposite the side of the body pai^alysed. 
A tailor* now under his observation has left hemiopia (field) and 

* This case is reported in the " Lancet " for August, 29, 1874. 



102 PERISCOPE: — EMBOLISM OF THE CENTRAL ARTERY, ETC. 

left hetaiplegia ; there is in this case comparatively little affection 
of motion, but significantly there is very great defect of sensa- 
tion ; there is indeed defective sensation of the left half of the 
bodv. One day he burnt his left hand with the " nose " of his 
tailoring iron; he burnt it severely, because, being unable to see 
to his left, and his left hand being insensitive, he had no know- 
ledge of his mistake. Cases of this sort are the sensory ana- 
logues of cases of hemiplegia in which there is lateral deviation 
of the two eyes ; in the former there is loss of power to see to the 
side paralysed, and in the latter loss of power to look to the side 
affected. In tlie latter, however, the lateral deviation of the eyes 
is a temporary .symptom ; yet it may be that there is not unfre- 
qnently a temporary hemiopia with hemiplegia. Right (field) 
hemiopia is more troublesome than left, as we read and write 
fi-ora left to right. Dr. Hughlings Jackson has discovered a 
right hemiopia in several cases of affection of speech (partial 
aphasia) ; it then, by a quasi-mechanical difficulty, adds to the 
mental difficulty the patient has in writing. The cases of hemiopia 
with hemiplegia appear to Dr. Hughlings Jackson to be the per- 
manent analogues of certain cases of migraine described by 
Anstie, Latham, and Liveing. In some of these cases there is 
temporary hemiopia with temporary defect of speech, and tem- 
porary defect of sensation in the limbs. In no case of hemiopia 
has Dr. Hughlings Jackson seen any morbid ophthalmoscopical 
appearances ; he has, however, had no opportunity of examining 
a case of temporary hemiopia. In one case of hemiopia complete 
blindness occnrred, and then the signs of simple atrophy ap- 
peared. — " Medical Press and Circular," March 4, 1874, p. 
177. 

EMBOLISM OF THE CENTRAL AETERT OF THE RETINA. 

Dr. J. Samelsohn, of Cologne, writes at length on this subject. 
A woman, aged 62, came under his care complaining that fourteen 
days previously she woke up one morning unable to see with her 
left eye, though she could see well when she went to bed. She felt 
as though the eye were shut, and asked her husband to look at 
it. She could not even tell light from dai^cness. The right eye 
was normal, but she said she saw objects smaller than usual. In 
the left eye there was some perception of light upwards and in- 
wards. The tension of the globe was increased, the retinal 
vessels were threadlike, there was no cloudiness, the veins were 
narrowed on the disc and enlarged towards the periphery. One 
artery passing upwards and outwards showed a spindle-shaped 
swelling. The macula lutea showed a bloody tinge, but was not 
at all hazy. The strongest pressure on the eyeball excited no 
pulsation, but gave rise to phosphenes. There was no affection 
of the heart. The arteries were atheromatous. In discussing 



EMBOLISM OF THE CENTRAL ARTERY. 103 

the question of treatment, it is pointed out that the slight but 
uniform fulness of the vessels gave good reason for believing that 
the collateral circulation proceeded from the ciliary vascular 
plexus, and indicated an attempt to stimulate this, which was 
sufficient to prevent destruction of the retina, but not to carry on 
its function. The increased tension present suggested that the 
collateral circulation might be interfered with, and that an iri- 
dectomy might lead to a greater affiux of blood. In the eye, the 
greater or less rigidity of the sclero-corneal capsule, the tension 
of which is maintained by the vitreous, offers a very appreciable 
resistance to the establisliment of a collateral current. The 
amount of blood in the retinal vessels undoubtedly adds to the 
amount of the intraocular pressure, but the choroid and ciliary 
body are the real source of the fluids that create the inti'aocular 
pressure. "When an embolism of the central vessel occurs, at first 
the tension decreases, but this diminution is neutralised by the 
elastic contraction of the envelope of the globe. The blood soon 
also passes along the latei'al (ciliary) branches of the artery with 
increased rapidity, the process of filtration is thus hastened, and 
the intraocular pressiire increased. This temporary increase 
hinders the quick completion of the collateral circulation in the 
region of the optic disc, and the blood hence rushes with con- 
stantly growing rapidity into the posterior ciliary arteries. The 
tension is more increased and the supply to the disc shut off. The 
operation was performed, and the vessels became decidedly fuller. 
The patient became able to count fingers. The improvement did 
not continue to progress, but remained stationary while she was 
under observation (three months). In reviewing other cases 
recorded, the author remarks that the varying amount of opacity 
of retina, &c., noted, depends on whether the artery occluded be 
a terminal one or not, that is, whether behind the coagulum, be- 
tween it and the dependent capillary tract, there is given off an 
arterial branch that directly inosculates with any other artery, 
or whether such an anastomosis is wanting. If the latter be the 
case, that is, if the artery be a terminal one, its embolic occlusion, 
according to Cohnheim, may give rise first to necrosis, the natural 
consequence of the cessation of the circulation in an animal organ ; 
secondly to engorgement due to the reversed action of the cur- 
rent of the neighbouring vein, a current impeded in the retina 
by no venous valves. The combination of both chains of deranged 
symptoms is the infarctus. Authorities differ as to whether the 
centra] artery is terminal or not ; at any rate its branches are 
terminal. In proportion to the readiness with which a collateral 
circulation can be established will the retina recover its trans- 
parency, or not become opaque at all. In two cases recorded in 
which the arteries were said to be decidedly fuller at their peri- 
pheric distribution than at the centre, it might seem that the 
diagnosis of embolism was excluded, but they were clearly cases 



104 PERISCOPE: — TRANSITORY LOSS OF SIGHT, ETC. 

iu wliicli the occluded artery had become replenished by means 
of an arterial anastomosis from the ciliary plexus of the optic 
nerve. It is remarked that the greater fulness of the very small 
arteries began immediately beyond their passage over the edge of 
the optic disc, that is, at the point where, according to Leber, 
branches of the ciliary arteries directly enter the retina. The 
rapidity with which the occlusion takes places exercises an influ- 
ence on the symptoms. Of the fact that a process of embolism 
may occur gradually, leading to an entire closure of the canal of 
the vessel, we find sufl&cient proof in the records of cases in which 
obscurations preceded the attack of absolute blindness. The 
haemorrhages met with in many cases come from the veins or 
capillaries as the result of venous accumulation combined with 
necrosis of the tissue or vascular walls, and are to be regai-ded as 
paving the way to an infarctus. Knapp was the first to describe 
such a condition. In addition to what he observed, and the ex- 
planation he ofiers, must now be added a retrogressive venous 
current from a neighbouring vein pointed out by Cohnheim. The 
red spot at the macula lutea which is almost pathognomonic of 
embolism of the central artery is due to hyperaBmia produced by 
collateral choroidal circulation showing through the transparent 
retina. It is both theoretically probable and practically esta- 
blished that the primary impairment (cloudiness, necrosis,) will 
be in the region of the macula lutea, a spot which, in the normal 
state, is particularly devoid of vessels. — ("Archives of Ophth. 
and Otol.," vol. iii, No. 2, pp. 44-74.) 



TRANSITORY LOSS OF SIGHT IN CONNECTION WITH EMBOLISM OF THE 
CENTRAL ARTERY, 

Maqthnbr (" Medic. Jahrb. v. Strieker," 1873, liv. 2, p. 195- 
212) explains the temporaiy attacks of loss of sight which 
often precede embolism of the central artery of the retina. 
He naiTates the case of a man sixty years of age who, one morn- 
ing, found the sight of his left eye become defective and then 
abolished, and in which an embolism was diagnosed with the 
ophthalmoscope, good sight returning when the arteries resumed 
their proper size. He suggests that the extremity having become 
infarcted in the central artery at its origin at one time impedes 
the entrance of the blood and thus impairs the sight ; at another 
may be forced on by the current, till it block up the artery and 
again may be washed away entirely. — (" Annales d'Oculistique," 
Sept.— Oct., 1873, p. 208.) 



COiDIOTIO RETINA. 105 



EMBOLISM OF BRANCHES OF THE CENTRAL ARTERY OF THE RETINA. 

Dr. Barkan narrates the case of a female patient who suddenly 
became blind in both eyes for half-an-hour. The left remained 
SO for an hour, and then she was able to see large objects 
with it. At the end of a fortnight, the field of vision of the 
left eye was limited downwards, and the tipper half of the disc 
appeared pale, and the upper branches of the artery reduced to 
mere threads. Some months later the state of aUairs had not 
altered. The region of the yellow spot appeared normal. There 
was no cardiac mischief. (A figure is given.) 

Dr. H. Knapp records three cases, and gives an illustration. 
One patient was a lady, aged 36, who suddenly felt a dimness of 
the right eye, which cleared up in the lower half of the field. 
The lower main branch oE the retinal artery was reduced to a 
thread. There was no affection of the heart. The other two 
cases were very similar. Dr. Knapp sums np the characteristic 
features in all these cases of embolism of branches of the central 
retinal artery, as : (1.) The sudden appearance of the impairment 
of sight, which at first manifests itself as an obscuration of the 
whole visual field of the affected eye, but more or less rapidly 
disappears in one part leaving a defect in the upper or lower 
half (2.) When a primary branch ot the central retinal artery is 
obstructed, it results in superior or inferior hemiopia ; but when 
a secondary branch only is obstructed a sector-like defect in the 
upper or lower half of the visual field is observed. At least one 
border line of both the hemiopic and sector-like defects coincides 
with the horizontal meridian. (3.) The portion of the optic 
nerve lying in the opposite direction to the defect in the visual 
field becomes white and punctate ; there is partial atrophy of the 
optic nerve, which is well set off by the remainder of the nerve 
retaining its usual appearance unchanged. (4.) The obstructed 
arteries become thin, seamed with while streaks, and disappear 
a short distance from the disc. He thinks embolism is the only 
diagnosis possible in these cases. In cases in which the arteries 
remain moderately well filled collateral circulation has become 
established. — ("Arch, of Ophth. and Otol.," vol. iii, No. 1, p. 
33-9.) 

COMMOTIO RETINA. 

Dr. Berlin writes on the eff'ects produced on the eye by blows 
from blunt objects, not causing any apparent injury. The first 
symptom is considerable diminution in the acuity of vision in 
the centre of the field, and marked resistance of the sphincter 
pupillse to the influence of atropine. Within a short time a 
distinct haziness of the fundus over a considerable area becomes 
developed ; sometimes small haemorrhages result. The changes are 



lOG PERISCOPE: — HEMORRHAGIC RETINITIS WITH DIABETES. 

most marked around the disc and yellow spot. In one case there 
were two separate patches. The ophthalmoscopic appearances 
reach their highest development in 24 or 36 hours, and disappear 
in two or three days, in proportion to the violence of the injury 
inflicted. The sight improves greatly at first, and then remains 
stationary ; some defect remaining after the retinal haze has 
vanished. The deficient reaction of the pupil to atropine lasts 
about as long as the defect of sight. Dr. Berlin gives an account 
of experiments he has tried on the lower animals. A direct 
blow on the eye produces changes in the portion of retina directly 
opposite. An indirect blow produces changes in the portion of 
retina which would be cut by a line continued in the direction 
taken by the foreign body. On examining the eyes experimented 
on, he found that extravasation of blood had occurred between 
the choroid and sclerotic. The chief injury consisted in a 
rupture of choroidal vessels. He thinks the transitory character 
of the symptoms accounts for their not having hitherto attracted 
attention. He has come to the conclusion that the defect of 
sight, in many cases, has no connection with the retinal haze. 
In his opinion it is due to " transitory, irregular astigmatism." 
He discusses the whole question at great length. The blow may 
easily influence the lens, and may lead to haemorrhage in its 
neighbourhood, which may also influence its form. He dis- 
believes in "commotio retinje " altogether. The blow directly 
influences the part struck in front (lens, iris, &c.), and drives 
the eyeball against the wall of the orbit. The back of the eye is 
therefore affected as if by a direct blow from the wall of the orbit; 
that is a blunt object. T'he blow in front would not produce any 
changes in the fundus, unless the back of the eye struck some 
object.— (" Klin. MonatsbL," Feb., Marz, 1873, pp. 42—78.) 



HiEMORRHAGIC RETINITIS WITH DIABETES, 

Dr. Haltenhoff records the following case : — An unmarried 

woman, aged 29, came under his care March 10, 1873. She had 

had good sight till fourteen days previously, when, on waking in 

the morning, she noticed a dense fog before the left eye, with 

black specks floating in front of fixed objects. No cause could 

be assigned. She had had some pain in the head. She had had 

no oedema and no loss of blood. She had been quire regular. 

The left pupil was dilated, oval in shape, and quite inactive. 

The eyelids and eyeball were movable. There was no diplopia. 

12 
She could see -y:^. The right eye was normal. The ophthal- 
\j 

moscope showed opacities in the left vitreous, and a haze for 

some distance around the optic disc, especially marked along the 

vessels. There were numerous ecchymoses, some rounded in 



AMBLYOPIA WITH DIABETES. 107 

shape, others irregular. There were no spots suggestive of 
Bright's disease. The optic disc was not prominent, and there 
was no infiltration on it. A week later there was some improve- 
ment, the haze being less. At one part a large, radiating extra- 
vasation following the course of a vessel was detected. A week 
later the patient could read TV Sn. at ten inches, and the pupil 
acted well, but was still oval. Bichloride of mercury had been 
administered. On examining the right eye a number of very small 
ecchymoses were discovered along an arterial branch upwards 
and outwards. The urine was now examined for albumen, but 
none was detected. A few days later the patient mentioned that 
she had for long (four or five years) been exceedingly thirsty, 
and was getting thinner. She had noticed that a drop of her 
urine left a white spot on any coloured fabric. The urine was 
now examined again. Its sp. gr. was 1039 ; it was very pale, 
strongly acid, contained no albumen, but gave evidence of much 
sugar. It was frequently tested, and never contained albumen. 
The quantity of sugar did not diminish in spite of treatment, 
but the thirst was less troublesome. The haemorrhages became 
slowly absorbed. There was no affection of the macula. Some 
fresh small haemorrhages made their appearance along the retinal 
arteries. The sight improved. At the end of two months, a few 
slight vitreous opacities remained in the left eye ; the pupil 

acted, but was still oval ; she could read No. 2 J. at 8", V. = ^. 

In the I'ight there were a few ecchymoses, and the upper border 
of the disc was hypergemic and slightly hazy. She could read 

1 J. at -Si", V. -^-T. Tbe choroid and lens showed no alteration 
^ 20 

in either eye. The precise amount of sugar present is given. 

The author alludes to previous cases published. He thinks, in 

his case, the retinitis clearly followed the heemorrhages. The 

disturbance of normal osmosis, owing to presence of sugar in the 

blood, might explain the tendency to haemorrhage. He admits 

that hiemorrhagc'S (other than retinal) are very rai'e in diabetes. 

Possibly the peculiarities of the retinal structure may account 

for its being specially affected. He was at a loss how to explain 

the irido-plegia which was pi-esent. — (" Annales d'Oculistique," 

Juillet, Aout, 1873, p. 20. " Klin. Monatsbl. f. Augenhlk.," Oct. 

1873, p. 291. 

AMBLYOPIA WITH DIABETES. 

PiECHAUD (" Journal d'Ophthalmalogie," Aout, 1872) records 
the case of a woman, aged 28, who suffered from diabetes and 
considerable defect of sight. The ophthalmoscope showed pallor 
of discs, haze of retina around the discs, normal arteries, and 



108 PERISCOPE: — EXTRAVASATION, ETC. 

dilated veins. No haemorrhages ; no eiiusion. — (" Aunales 
d'Ocnlistique," Jan., Feb., 187o, p. 54.) 



OPTIC ATROPHT IN A FATHER IN ONE EYE FROM CHILDHOOD — CON- 
VERGENT STRABISMUS AND NYSTAGMUS, WITH GOOD VISION IN THE 
ELDEST DAUGHTER, WITH A PECULIAR CONDITION OF THE OPTIC 
NERVES — TYPICAL RETINITIS PIGMENTOSA IN TWO OTHER CHIL- 
DREN; A GIRL OF 21, AND A LAD OF 17, AND IN THE GIRL 
NYSTAGMUS, CONVERGENT STRABISMUS AND HIGH HYPERMETKOPIA. 

(Dr. Herm. Schmidt "Klin. Monatsbl.," Jan., 1874, p. 29.) 



AFFECTIONS OF THE OPTIC NERVES IN THREE BROTHERS. 

Dr. Alexander, of Aix-Ia-Cbapelle. The disease was of a similar 
character in each, and made its appearance in February, March, 
and July, respectively, in the same year. The ages of the 
patients were 29, 23, and 20. There was haziness of the margins 
of the disc, and of the surrounding portion of the retina. The 
vision was greatly impaired. No atrophy resulted while under 
observation. A brother of their mother had some defect of 
sight. Dr. Alexander regarded the malady as a. retro- ocular 
neuritis.— ("Klin. Monatsbl.," Feb., Marz, 1874, p. 62.) 



HYPEREMIA, AND INFLAMMATION OF THE ORBITAL PORTIONS OF THE 
OPTIC NERVES. 

Dr. Schweigger. Six cases. There were no ophthalmoscopic 
signs. The subjective symptoms varied. There was consider- 
able amblyopia limited to one eye in each case. — (" Klin. Mo- 
natsbl.," Jan. 1874, p. 18.) 

INJURY OF THE OPTIC NERVE. 

Dr. Schweigger narrates two cases in which blindness followed 
injury to an optic nerve. — (" Klin. Monatsbl.," Jan. 1874, 
p. 25.) 

extravasation between the optic nerve AND ITS SHEATH ON 
BOTH SIDES WITHIN THE ORBIT AND IN THE LEFT VITREOUS IN 
CONSEQflENCE OF FRACTURE OF THE SKULL AND RUPTURE OF THE 
MIDDLE MENINGEAL ARTERY. 

A REPRESENTATION of a section of the left eyeball and nerve 
(hardened) is given. The extravasation commenced in the con- 
nective tissue uniting the outer and inner nerve sheaths, and 



TEMPORARY BLINDNESS AFTER SCARLET FEVER. 109 

reached from tlie optic foramen to the lamina cribrosa. The clot 
in the vitreous came from a ruptured vein. — (Talko, " Klin. Mo- 
natsbl.," Nov. 1873, p. 341.) 

AMAUROSIS IN CONSEQUENCE OF POISONING WITH MORPHIA. 

Dr. Wagner was called to a gentleman, aged 82, whom he found 
in a very drowsy condition, unable to be roused except to give a 
very deliberate account of himself, with frequent intei'ruptions. 
He complained chiefly and bitterly of loss of sight, but also of 
severe pain in the head. It appeared that he had suffered, for 
five j^ears, from periodic vomiting, and had used sub-cutaneous 
injections of morphia, himself, to check the sickness. Five days 
previously he had an attack, which probably did not yield to 
the remedy, for he used, in that time, thirty grains of the acetate 
of morphia ; the apothecary's reckoning showed he had had four 
doses of eight grains each, which he had obtained without a 
medical order. His pupils were very small and quite motionless. 
The discs were slightly hazy, the veins were normal, the arteries 
much diminished in size. The light of a bright lamp could not 
be seen at all. His pulse was 64, firm and small. He had had 
the last injection twenty-four hours previously. His sight was 
said to have slowly failed from the first. Dr. Wagner saw him 
for two days, during which he remained in the same state, and, 
then, in spite of his condition, he was removed by rail, and 
Dr. Wagner lost sight of him. Cold applications were used to 
the head, and draughts of strong coffee ordered. — (Zehend. 
"Klin. Monatsbl.," x, p. 335.) 

TEMPORARY BLINDNESS IN CONNEXION WITH DISEASE OF THE KIDNEY 
AFTER SCARLET FEVER RECOVERY. 

By R. FoRSTER. ("Jahrb. f. Kinderheilk. und phys. Erzie- 
hung." Jhrg. v, p. 325. June, 1872.) 

A CHILD, two years old, who was recovering from scarlet fever, 
again became feverish, and had albumen in the urine twenty-five 
days after the commencement of the illness. Eight days later 
the child became blind, and continued so for sixteen days, when, 
in the course of a few days, the sight became completely re- 
stored. The author remarks : — 1. On the date at which the 
blindness came on, quite after the expiration of the exanthe- 
matic period ; 2. It came on eight days after tlie appearance of 
albumen in the urine, and when this was already disappearing ; 
8. It only disappeared after the albumen, &c., had vanished for 
some days ; 4. Oedema and ursemic convulsions did not occur 
at all. 

Three analogous cases have been recorded in typhus, and 
four in scarlet fever. The former, during the fever ; the latter. 



110 PERISCOPE ; — GALVAXO-CAUTERY, ETC. 

15, 20, 25, 26, and 32 days respectively after the appearance of 
the eruption, co-existing with Bright's disease, and, except the 
last case, with ur^aiic convulsions. The duration of the blind- 
ness Avas, in Ebert's case, from 20 — 60 hours ; in Henoch's, 
24 — 48 hours; Tolmantschew's, 7 days; Forster's 16 days. In 
all, except the last, the kidney disease persisted after the re- 
storation of sight. Ebert recorded one case in typhus and three 
with scarlet fever (" Klin. Monat. f. Augen.," vi, p. 91) ; Henoch, 
one case with typhus and one with scarlet fever. — (Berlin, " Klin. 
Woch.," Nr. 2, 1868) ; Tolmantschew, one case in typhus 
(" Jahrb, f. Kinderheilk," p. 219, 1869) ; (" Zehend. Klin. 
Monatsbl.," x, p. 346). 

SPONTANEOUS ARTERIAL RETINAL PULSATION IN EXOPHTHALMIC 
GOITRE. 

Prof. Becker has met with sj^ontaneous pulsation of the retinal 
arteries in several cases of Basedow's disease. It indicates the 
severity of the disease. The arteries have lost the power of con- 
tracting by muscular action (tonicity) but not their elasticity. 
They therefore dilate and contract more than normally, and the 
heart's action being also increased, pulsation becomes apparent in 
arteries of smaller calibre than usual. — (" Annales d'Oculistique," 
Juillet— Aout, 1873, p. 42.) 

GALVANISM IN THE TREATMENT OF BASEDOW'S DISEASE, 

By MORITZ Meyer. (" Berlin Klin. Wochen.," Nr. 39, Sept. 23, 

1872.) 

The author details four cases in which bronchoceles diminished 
after galvanisation of the sympathetic. The pulse and the pal- 
pitation underwent no change. Chrostek (Wien. Med. Presse, 
Nr. 19, bis 46, 1869) had already published results which 
attracted his attention. In the first case, 52 applications ; in the 
second, 72 ; in the third, 60 ; and in the fourth, 84 were made. 
In all, the right side was more affected than the left. 

GALVANO-CAUTERY IN OPHTHALMIC SURGERY, 

Dr. J. Samelsohn has found the galvano-cautery serviceable: — 
(1) in closing lacrymal fistula; ; (2) in obliterating the lacrymal 
sac ; (•)) in the treatment of trichiasis and distichiasis ; (4) in 
blepharitis ciliaris ulcerosa ; (5) in destruction of various new 
formations ; and (6) in old and obstinate cases of trachoma coii- 
jundivce. * In the latter he has been very successful. The 
cauterisation excites no irritation, and, if the conjunctiva is not 
touched, no pain, and leaves very small scars. He uses a fine 
platina wire, and at first touched only two or three granulations 
at a time ; subsequently he found more might be attacked with 
impunity. — (" Archives of Ophth. and Otol.," vol. iii, No. 2, 
p. 124.) 



RETIXAL AFFECTION'S IX TRAUMATIC FEVER. Ill 

OX THE TREATMENT OF SOME EYE DISEASES BY MEAXS OP THE 
CONSTANT CURRENT. 

Bj Dr. Driver, of Chemnitz. (" Archives of Ophth. and Otol.," 
vol. iii, K'o. 1, p. 226.) 

GLAUCOMA SIMPLES 'WITH A PECULIAR OPACITY OF THE CORNEA. 

Dr. Schiess-GtEMUSEUS narrates a case of simple glaucoma with 
clilfased opacity of the cornea. The opacity was of a very 
pecuUar character. The surface had not lost its brilliancy. The 
cornea looked like shagreen, somewhat as if one had sprinkled a 
smooth, shining surface of ice with small drops of water, and the 
whole surface had again frozen. The fundus could not be seen, 
owing to the condition of the cornea. The author distinguishes his 
case from forms mentioned by Grrtefe. After iridectomy, the 
opacity quickly disappeared, and the vision improved from 
ToW to aVo-— C' Zehend. Klin. Monatsbl.," x, p. 332.) 

A particular form of HaiMORRHAGIC GLAUCOMA IRIDECTOMY 

FAVOUKABLB RESULT. 

Dr. Shrceder records the case of a patient (female), aged 62, 
who came under his care on account of sudden blindness and 
violent ciliary neuralgia, which had set in two days previously ; 
the appearances were those of acute glaucoma, and iindectomy 
was performed on the following day. The fundus could not be 
examined, owing to the opacity of vitreous. This disappeared 
three days later. An intensely red, round haemorrhagic spot, 
half the size of the disc, could then be detected between the disc 
and the yellow spot. The retina in its vicinity was slightly 
clouded and swollen, and the two arteries which generally run 
parallel from the disc to the macula were not to be seen. The 
hsemon'hage slowly disappeai'ed, and left no trace. This case 
differs from most recorded in the absence of any prodromal stage. 
Other diflPerences are pointed out in detail. The author names his 
case one of " acute" or " primary " hsemorrhagic glaucoma. He 
thinks glaucoma due to a diminished power of absorption, leading 
to accumulation of fluid and increase of tension. — (" Archives of 
Ophth. and Otol.," vol. iii, No. 2, p. 75.) 

RETINAL AFFECTIONS IN TRAUMATIC FEVER. 

By !M. Roth. ("Deutsche Zeitschr. f. Chirurgie," bd. 1, p. 471, 
Sept., 1872.) 

Embolic PanopJithalmitis. A woman, aged 32, was seized with 
an affection of her ejes three days after the birth of a child. 
Three davs later she died. The result of the examination led to 
the diagnosis of retinitis enibolica dextra, with secondary pan- 
ophthalmitis of a puerperal origin. The starting-point appeared 
to have been the retina, in which, below and at the outer side 



112 PERISCOPE: — RETRO-OCULAR ANEURISM. 

of the optic disc, were numerous extravasations, and the vessels 
■were extensively plugged w^ith masses partly homogeneous and 
fragile, partly granular. The granular masses consisted of small, 
round, and biscuit-shaped corpuscles. The vessels which were 
plugged had undergone marked fatty degeneration. The pos- 
terior part of the retina was opaque, and infiltrated with isolated 
extravasations ; the whole of the choroid was thickened and in- 
filtrated with pus. The ciliary body and the vitreous contained 
pus-cells. In the anterior chamber were pus-corpuscles and 
granular clots. The conjunctiva was swollen and ecchymosed. 
Grayish yellow deposits were found on the mitral valves, which 
were thickened. No microscopic examination of the deposits was 
made. 

Retinitis septlca, in consequence of traumatic fever. This 
form is distinguished from the preceding by (1) its more frequent 
occurrence: (2) its comparatively harmless -character ; and (3) 
by the fact that it is not generally embolic. In the neighbour- 
hood of the optic disc and of the yellow spot there are a number 
of small, white, or it may be red spots, which are mostly present 
in both eyes. The white spots, anatomically, consist of thickened 
and hypertrophied nerve-fibres ; the red spots, of accumulations 
of extravasated red blood-corpuscles. Similar accumulations are 
met with in the retina in Bright's disease, and in cerebral affec- 
tions, as well as in other chronic or acute diseases. Pyaemia 
seems, however, to be more specially connected with these 
changes, and more frequently than other affections. The author 
thinks these collections depend on a chemical change in the 
blood, and proceed fr m multiple abscesses containmg apparently 
good pus ; particularly, however, from septic conditions and 
widely spread putrefactive changes. The earliest period at 
which the retinal changes appeared was, in one case, eleven days 
after the commencement of the disease ; in the other cases, the 
disease had lasted several months. Nine cases are related. The 
author alludes to a case communicated by Virchow, in his " Ar- 
chiv.," as the only notice of the subject he can find, and this has 
not attracted much attention. — (" Zehend. Klin. Monatsbl.," x, 
p. 346.) 

RETRO-OCULAE ANEURISM (iN A MAN AGED 21), WITH EXTREME 
PROMINENCE OF THE RIGHT EYE, AND LOUD BRUIT AFTER AN 

INJURY TO THE HEAD. COMPRESSION WITHOUT AVAIL. LIGATURE 

OF RIGHT COMMON CAROTID TEN WEEKS AFTER THE ACCIDENT. 

IMMEDIATE CESSATION OF BRUIT AND DIMINUTION OF PROPTOSIS. 

RECURRENCE OF BRUIT IN THREE-QUARTERS OF AN HOUR. PER- 
SISTENCE OF BRUIT AND (aLMOST) TOTAL SUBSIDENCE OF JX- 
OPHTHALMOS. PRESERVATION OF GOOD VISION. 

The narrator. Dr. A. v. Hippel (Graefe's " Archiv. f. Ophth.," 
XX, Bd. Abth., i, 1874), says this is the first case of the kind in 



RETRO-OCULAR ANEURISM. 113 

German}^ in wliich the carotid has been ligatiu'ecl. The patient 
was a man, aged 21, who came under Dr. Hippel's care for ex- 
ophthalmos, October 28, 1873. On the 14th of September (6 
weeks previously) he had fallen from a horse, and his foot catch- 
ing in the stirrup, he was dragged along for some distance. He 
struck the left side of his head. When picked up he was insen- 
sible, and was bleeding from the nose, mouth, and left ear. Both 
eyes were bloodshot, and the right pupil was very small in com- 
parison with the left. In a Pew hours the left eye was said to 
have become prominent, and both eyes converged considerably. 
During the next five or six days the prominence of the left eye 
passed away, and the right was observed to project and to become 
very much congested. The patient remained feverish and insen- 
sible for three weeks, and it was not until the end of that time 
that he was able to take any notice of his own symptoms. He 
found that he could open the right eye very little. When the 
upper lid was lifted he noticed that the eye was very prominent 
and red, and that the pupil was very small. He could move the 
eyeball but very little, and sometimes saw double. The exoph- 
thalmos increased slowly and without any pain during the next 
few weeks. He had repeated attacks of epistaxis, and one attack 
was very troublesome. At the same time that the eye became 
more prominent he noticed a loud humming noise in the left ear, 
and this increased. In the beginning of October he suffered from 
pain in the left side, and, at the end of a week, a quantity of 
bright red and very fluid blood (subsequently mixed with mucus) 
escaped. Oq admission, a fracture of the left clavicle was found 
to have occurred. He was quite deaf in the right ear, and no 
cause for this could be detected. He was stated to have been 
deaf in that ear from the age of four years, when he had an attack 
of inflammation of the brain. He complained of a buzzing in the 
left ear, which had a sort of rhythm. There was considerable 
defect of hearing. The membrana tympani showed a recent scar, 
was much thickened and uneven. The left eye was normal. The 
right projected about half-an-inch, the upper lid was motionless. 
There was extreme congestion of the conjunctiva, chiefly venous. 
Enlarged veins could be seen radiating from the upper margin of 
the cornea, and there was still more marked congestion below. 
There was great chemosis. There was a slight ulceration com- 
mencing in the centre of the cornea. The pupil was very small, 
but acted on exposure to light. It only became moderately di- 
lated after the instillation of atropine. The globe was motionless 
and diverged considerably. There was no diplopia. Vision was 
good. The ophthalmoscopic examination showed the retinal 
veins to be dilated and tortuous. There was no neuritis, &c. 
Pressure on the globe caused it to recede considerably, and did 
not give rise to pain. No pulsation could be detected anywhere, 
nor any tumour, nor any affection of the orbital walls. A loud 
VOL. vm. I 



114 PERISCOPE : — RETRO-OCULAR ANEURISM. 

bruit could be beard all over tbe bead. Dr. Hippel tbougbt tbe 
absence of pain and fever, and tbe slow course, showed tbat tbere 
was no inflammatory miscbief, and there was no evidence of tu- 
mour. An extravasation of blood would bave caused symptoms 
at once, and would bave slowly subsided. Tbe presence of tbe 
bruit pointed definitely, be tbougbt, to aneurism somewhere. It 
was loud, blowing, and systolic, was continued into tbe diastole, 
and then ceased for a moment ; loudest over tbe rigbt tample. 
Compression of tbe rigbt carotid stopped it and also tbe noise m 
tbe ear at once and completely. Tbat tbe aneurism was not m 
tbe orbit be concluded from the fact tbat tbere was no pulsation 
or tumour, tbat great exophthalmos bad developed painlessly, 
and because it was probable from tbe nature of tbe injury tbat 
tbe internal carotid itself, or tbe opbtbalmic artery at its origin, 
bad been involved. Tbe marked exophthalmos did not contra- 
indicate an intra-cranial aneurism, as observation has sbown tbat 
it is caused by obstruction to tbe return of venous blood from tbe 
orbit. Tbe great venous congestion present in this case would 
point in tbis direction. It was most probable from tbe severe 
injury sustained, and tbe sudden onset of tbe symptoms, tbat a 
diffused aneurism had formed. 

Tbe patient was watched for a time, and a compressive 
bandage applied over tbe rigbt eye. At tbe end of a fortnigbt 
the eye was mucb less prominent. The venous congestion was 
unaltered. The corneal affection bad increased. Tbe bruit was 
unaltered. Digital compression of tbe rigbt carotid was now 
practised for several hours a day from November 16 to 21, but 
only for two hours continuously, owing to tbe pain caused. On 
tbe 19tb the bruit bad diminished considerably, but it increased 
ao-ain, and was never afterwards checked. Tbe buzzing in the 
ear altered in character. As local treatment of tbe aneurism was 
impossible, and tbere was a danger tbat it migbt burst, or tbat 
be would lose tbe sigbt of the rigbt eye, it was determined to 
ligature tbe carotid. Tbis was done on November 21st (about 10 
weeks after tbe accident) by Prof. Scbonborn. No difficulty was 
experienced. A catgut ligature was used and cut sbort, and tbe 
wound dressed antiseptically. The bruit stopped at once, and a 
marked diminution in tbe venous congestion was noticed, in 
tbree- quarters of an bour tbe bruit bad returned, but was feebler 
than before. Prof. Scbdnborn, tbinking tbat possibly tbe bgature 
ini<3-ht bave given way. opened tbe wound in tbe evening, under 
chloroform (antiseptically), but found tbe ligature in place. 
Compression of the left carotid (for an bour) stopped tbe bruit 
but it returned directly tbe pressure was removed. On tbe second 
day compression was tried for a quarter of an hour, but caused 
giddiness. On tbe tbird day the conjunctiva was less congested, 
tbe exophthalmos less, and tbe globe was more movable. The 
corneal afltection was diminisbmg. Some pus was let out from 



RETRO-OCULAR ANEURISM. 115 

the wound, and a drainage tube inserted. On the fourth day 
compression was practised for an hour in the morning, and two 
hours in the afternoon. The intensity of the bruit varied. On 
the sixth day compression was again tried. The congestion and 
the prominence of the globe diminished. On the seventh day 
compression for several hours. The bruit was as loud as ever. 
The right eye was steadily improving. As the compression did 
not seem to influence the bruit, it was discontinued. On the 
eleventh day the congestion was less, and the bruit more feeble. 
On the sixteenth day the congestion had almost disappeared. 
The globe no longer diverged, and was fairly movable. The bruit 
was unchanged in loudness, but the pitch varied. The patient 
only heard it occasionally. In a few days moi-e the wound was 
almost healed. On the twenty-third day the patient sat up. An 
attempt at compression caused giddiness. The patient could 
read the smallest print with the right eye. ISTo abnormal changes 
were detected on ophthalmoscopic examination. Six days later 
the patient went home. At the end of another month (January 23, 
1874), he returned (as directed) for another trial of compression! 
There was still very slight projection of the right globe ; the con- 
gestion of the conjunctiva had slightly increased. ' The pupil was 
still smaller than the other, which was larger than natural. Both 
acted well. The bruit was unaltered. xTo pulsation was de- 
tected beyond the seat of ligature, but the right superior thyroid 
was much enlarged. Compression of the left carotid did not 
stop the bruit, but simultaneous compression of the right superior 
thyroid did almost stop it. An hour's compression of the carotid 
was borne, but the compression of the right superior thyroid had 
to be given up. Compression was tried for two or three hours 
daily till sixth day ; then for six days six hours daily. It seemed 
to cause congestion of the conjunctiva and pain in the eye, and 
was therefore discontinued, and the patient sent home. 

In reviewing the case, the author remarks that the rapid di- 
minution of the exophthalmos and congestion which followed the 
ligature contra-indicated an iutra-orbital aneurism. The latter 
would have taken time to shrivel up. The exophthalmos was 
clearly due to obstruction to the outflow of venous blood from the 
eye and orbit to the cavernous sinus. In all probability the case 
was one of arterio-venous aneurism ; there was a direct commu- 
nication between the right carotid and the cavernous sinus. In 
support of this opinion, he adduces (1) the nature of the injurij. 
The symptoms, free bleeding from the mouth, nose, and left ear ; 
extravasation beneath the conjunctiva in both eyes ; projection of 
the left globe ; sudden convergence of the eyes, and contraction 
of the right pupil, made it probable that a fracture of the base 
of the skull had occurred, running from the left petrous bone 
across the sphenoid, and rupturing the right carotid within the 
cavernous sinus. (2.) The slow and painless development of the 

I 2 



IIG PERISCOPE: — RETRO-OCULAR ANEURISM. 

exoplithalmos of the right eye, without any defect of sight. An 
extravasation would have occurred suddenly, and a circumscribed 
aneurism would not be likely to result from such an accident. (3.) 
The absence of any cerebral symptoms. (4.) The almost com- 
plete disappearance of the pathological conditions after ligature 
of the carotid, notwithstanding the persistence of the bruit, it 
the bruit proceeded from an aneurismal tumour, one cannot un- 
derstand how it could recur (showing that blood still flowed) 
with continued diminution of the other symptoms. On the other 
hand, if arterial blood were flowing into the caveruous sinus, the 
diminished flow consequent on the ligature would explain the 
subsidence of the venous congestion, though the bruit might 
continue. He calls particular attention to the rapid re- establish- 
ment of circulation (denoted by the recurrence of the bruit) 
within three-quarters of an hour. The previous compression ot 
the carotid probably led to establishment of the collateral circu- 
lation The vessel specially concerned seemed to be the superior 
thyroid. He discusses the cases of treatment by compression 
recorded (especially Galezowski's case), and does not think that 
this plan has been attended with notable success ; whereas it pro- 
bably leads to the rapid establishment of the collateral circulation, 
and therefore interferes with the success to be expected from 
ligature which may subsequently be required. He does not 
think, however, that a sufficient number of cases have yet been 
recorded to enable us to arrive at a definite conclusion on the 

^" Though in his case the bruit persisted, he is well satisfied 
with the result, for tiie operation certainly prevented the total loss 
of the right eye, which was imminent, and reduced the congestion 
and exophthalmos. The patient's intra-cranial circulation is now 
in a more favourable, or less dangerous, condition than before the 
operation, and we must remember that "in the few cases of com- 
munication between the internal carotid and the cavernous sinus 
hitherto recorded, death has followed within a short period ;^ the 
procrnosis, therefore, is of a very unfavourable character. A 
tabular statement of cases in which the common carotid was 
lio-atured for orbital aneurism up to the yea,r 1868 is given m the 
"Klin. Monatsbl. f Aughlk," vi, 1868, p. 114. Since then 
the only published cases known to the author are, (Ij Kichet, 

1868, "Heidelberg Ophth. GeselL, 1868," fatal result; (2) bocm, 

1869, "Kim. Monatsbl.," viii, 1870, p. 56 ; (3) Schmidt, Odessa, 
" Klin. Monatsbl," ix, 219, 1871 ; (4) Schonborn, 1873 (present 
case). 



TRAUMATIC ORBITAL ANEURISM. 117 

TRAUMATIC ORBITAL ANEURISM (? FRONTAL ARTERY) EXOPHTHALMOS 

TUMOUR (pulsating AND THRILLING) FELT ABOVE AND TO INNER 

SIDE OF EYEBALL — LOUD BRUIT SUBCUTANEOUS INJECTION OF 

ERGOT— DIGITAL COMPRESSION LIGATURE OF THE CAROTID AT THE 

END OF SIXTEEN MONTHS PARTIAL IMPROVEMENT AT THE END OF 

SEVEN MONTHS. 

Dr. Schiess-GtEMUSEUS records the following case (" Klin. 
Monatsbl. fiii-. Augenlilk.," viii, p. 57, 1870). A woman, aged 
40, was kicked on the head by a horse in December, 1867. Her 
symptoms commenced soon afterwards, but the first description 
dates April, 1869. The left eye was then very prominent, and the 
conjunctival veins enlarged. Under the upper lid a tumour was 
evident in the middle line which passed deeply backwards. In- 
wards it could be traced over the orbital margin in the direction 
of the frontal artery. It pulsated strongly and a thrill could be 
felt over it. The eye was lifted by each pulsation. The patient 
could hear a loud bruit. A loud systolic bruit, chiefly systolic but 
also diastolic, could be heard with the stethoscope. Compression 
of the carotid on the left side stopped the pulsation and the bruit. 
Compression of the continuation of the tumour upwards and 
inwards checked the subjective bruit, but not the pulsation. The 
patient's vision was reduced to one-half in the left eye. On 
ophthalmoscopic examination the left optic disc was found con- 
gested, prominent and ill-defined, and the arteries and veins were 
tortuous, the latter dilated. At the end of three weeks the tumour 
was larger and the exophthalmos and the venous congestion had 
increased. Ergotin was injected under the skin of the upper 
eyelid after the plan advocated by Prof. Langenbeck. Consider- 
able oedema of the lid, &c., followed, and the patient felt sick. 
The injection was repeated next day, and on the third day 
the oedema had almost disappeared. Another injection was fol- 
lowed by sickness and by swelling of lids, &c. In the evening 
an injection of double quantity. On the fourth day no further 
injection, on account of the great oedema. The tumour subse- 
quently increased. Thirteen days after the first injection digital 
compression was tried for eight days, for from one to five hours 
daily, and then at the end of another week renewed for a week. 
As no impi-ovement resulted, the left common carotid was ligatured 
by Prof. Socin on June 15th. All the symptoms at once subsided, 
but half an hour later there was slight pulsation in the sac, and 
it seemed to be filling again. The pulsation continued. The 
ligature separated at the end of three weeks. Secondary hgemor- 
rhage a week later. It was stopped by pressure below the seat of 
ligature. A strong solution of nitrate of silver was injected also. 
At the end of five weeks fi-om operation the pulsation, bruit, and 
thrill had returned. Fresh haemorrhage occurred, but was again 
checked by pressure as before. It recurred three days later. 
The wound healed at the end of two months. At the end of five 



118 PERISCOPE : — EXOPHTHALMOS WITH PULSATING TUMOUR. 

months the state of affairs was much the same as before the ope- 
ration. An attempt was made to ligature the frontal artery, but 
a network of vessels was encountered. Several of them were 
tied. Later a compressive bandage was applied. January 29, 
1870, the tumour pulsated but feebly, and was very compressible. 
It seemed to contain only fluid. Its continuation forwards was 
less marked, but there was distinct pulsation in the right frontal 
region. Possibly the posterior part of the tumour may have 
consolidated. 

EXOPHTHALMOS WITH TUMOUR HAVING A " THRILL " AND BRUIT. 

liV Prof. Richet's case which was brought before the Ophthalmic 
Congress in 1868 by Dr. Wecker, the patient was a woman aged 
63. The first symptom was a loud bruit on the left side, heard by 
the patient. Various ocular paralytic symptoms developed. 
Three months later the eyeball was prominent, and there was 
marked venous congestion both externally and on ophthalmo- 
scopic examination. An elongated tumour (an enlarged vessel) 
could be felt at the upper and inner part of the orbit which com- 
municated a peculiar thrill to the touch. A loud systolic bruit 
could be heard. The exophthalmos increased and the eyeball 
pulsated. The sight of the left eye failed. Compression of the 
carotid not succeeding, a ligature was applied by Prof Richet at 
the end of two months. A soft bruit could still be heard. The 
patient died, with cerebral symptoms, 52 hours later. No affec- 
tion of any artery was found, but there was considerable dilata- 
tion of the ophthalmi':' vein. 

EXOPHTHALMOS WITH PULSATING TUMOUR. 

Dr. Schmidt's patient was a man aged 25. — (" Klin. Monatsbl." 
ix., p. 220, 1871.) While at home one evening he was taken 
with a fainting fit, and bled from the mouth. He became insen- 
sible. At the end of three months, when he came under care, the 
right eye was very prominent and the conjunctiva conjested. 
The margins of the optic disc were indistinct, the veins full and 
tortuous. Pressui-e on the upper eyelid, especially inwards, de- 
tected pulsation and a thrill. The pulsation was also visible. 
There was a loud bruit audible also to the patient. Compression 
of the right carotid only partially removed the symptoms, and 
compression of both did not completely check them. Ligature 
was resorted to without trial of any other plan, as the only mea- 
sure of diminishing the blood- current, &c. After the operation 
the pulsation and thrill ceased, and the bruit became altered in 
chax'acter, but continued. Six weeks afterwards there was still 
slight exophthalmos and venous congestion. There was no pul- 
sation or thrill to be detected, but the bruit could be heard faintly. 



EXOPHTHALMOS, ETC. 119 

The patient left the hospital. The ligature had separated on the 
thirteenth day. 



EXOPHTHALMOS — PULSATING OKBITAL TUMOUR — LIGATURE OF THE 
COMMON CAROTID. 

Dr. CEttingen, of Dorpat, records the following case : — A lad, 
aged 14, came under his care for exophthalmos, with the history 
that when a year old he struck his head on a step, and that sub- 
sequently (during thirteen years) the left eye had gradually 
become very prominent. The upper eyelid was greatly swollen, 
the eyeball projected considerably, and a tumour could be felt 
above and to the outer side of the eyeball. It pulsated and could 
be emptied by pressure, but quickly filled again. Compression 
of the carotid checked the pulsation. There was no bruit to be 
heard. The left side of the head was curiously misshaj^en, and 
there was an occipital meningocele of small size, and having a 
very narrow channel of communication with the interior of the 
skull. The author discusses the question of diagnosis, chiefly as 
to whether it was a spheno-orbital meningocele (which is very 
rare), or an erectile tumour of some sort, which communicated 
with the inside of the skull by wearing away of the oi'bital wall. 
Langenbeck's plan of injection of ergotin and compression of the 
carotid having been tried without avail, the left common carotid 
was tied. The tumour diminished in size and ceased to pulsate. 
The pulsation returned in four hours, but not so evidently. lu 
a few hours pain was complained of in the opposite chest, and in 
a few days it was evident the patient had an attack of pneumonia. 
The ligature came away in a fortnight, and the wound was healed 
in a month. The tumour did not become more solid. Pressure 
on it made the occipital tumout' swell out, and tapping the 
former with the finger produced a corresponding impulse in the 
latter. Compression of both jugular veins made both tumours 
very tense. Compression of the right carotid checked pulsation 
in the tumour, but when continued for a time had no curative 
effect. The author discusses cases of pulsating orbital tumour 
hitherto recorded, and mentions the case of an old woman who 
came under his care, in 1866, for exophthalmos with pulsation 
and diastolic bruit, and in which he was led to the diagnosis of 
some inflammatory misclrief within the orbit, leading to plugging 
of the veins. He obtained a post mortem two years later, and 
found no changes- in the arteries, but evidences of past inflam- 
mation of the orbital tissues and partial obliteration of the orbital 
veins. In the present case he suspected there was a meningocele 
associated with some arterial angiomatous tumour. The ligature 
of the carotid was followed by considerable improvement. — 
("Klin. Monatsbl.," Feb.— Marz, 1874, p. 58.) 



120 PERISCOPE : — EFFECTS OF STRYCHNINE ON THE EYE. 

EXOPHTHALMOS OF THE RIGHT EYE APPEARING DURING INCLINATION OF 
THE BODY FORWARDS, AND DISAPPEARING IN THE ERECT POSITION. 

Dr. Gruening. The patient was a man, aged 45. Five years 
previously, wliile stooping, he noticed the right eye slip forwards. 
It went back when he stood up. He tied a handkerchief over 
the eye, and went on stooping. Afterwards the eye invariably 
protruded when he stooped. It could be pushed back. No bruit 
could be heard. Prof. Knapp suggested the symptom was caused 
\)j gravitation of blood into pathologically cavernous retro-ocular 
tissue. — (" Ai'ch. of Ophth. and Otol.," vol. iii, No. 1, p. 23.) 

THE ACTION OF CALALAR IN PARALYSIS OF ACCOMMODATION. 

BuROW, sen., writes on this subject. He has, experimented on 
himself, his accommodation having been completely paralysed for 
thirty years, and his pupils dilated. His eyes were sHghtly 
myopic, without astigmatism ; his acuity of vision normal. Cala- 
bar would contract his pupils, but not influence his accommoda- 
tion in the least. In cases of transitory loss of accommodation 
he has found that Calabar exercised material influence on the 
refractive condition of the eye. He mentions cases showing 
what influence small pupils may have in alloT^^ng persons to see 
well whose eyes nevertheless show considerable anomalies of 
refraction. One man, who had myopia -yV, could see as much 
without a glass (with very small pupils) as he could with 12. 
Another man, who had quite lost his accommodation, could 
nevertheless read small print (with or without glasses), owing 
to his having very small pupils. Seeing the influence wbich 
Calabar exercises in transitory paralysis of accommodation, he 
recommends its use in cases in which the paralysis threatens to 
become permanent. — ("Klin. Monatsbl.," Feb., Marz, 1873, 
p. 78.) 

EFFECTS OF STRYCHNINE ON THE HEALTHY EYE. 

Dr. Hippel gives the results of a number of obversations on the 
effects of strychnine on the healthy eye. — (" Berlin, Klin. Woch.," 
1873, Nr. 17.) He injected 2 to 3 milligr. (-030 — "045 grain) in 
one or other temple alternately. He concludes: — (1) That 
strychnine has no influence on the perception of light. (2) It 
augrlients the sensibility of peripheral portions of the retina for 
blue only. (3) It considerably increases the extent of the field 
of vision, the acuity of sight, and in indirect vision allows the 
eve to perceive distinctly objects situated peripherally at a greater 
distance from each other than in the normal condition. (4) It 
has no appreciable influence on the accommodation ; nor (5) on 



MELANOTIC SARCOMA OF THE IRIS. 121 

subjective visual sensations. — ("Annales d'Oculistique," Sept., 
Oct., 1873, p. 209.) 

CASES OF SYPHILITIC GUMMODS TUMOURS OF THE SCLEROTIC, IRIS, 
CILIARY BODY, AND OP GUMMOUS TUMOUR OF THE BEAIN, WITH 
SYPHILITIC DISEASE OF THE OPTIC NERVES, 

WILL he found noted in the "Annales D'Oculistique," Sep., Oct., 
1873, pp. 209-14, in an account of an inaugural thesis by 
Dr. Barbar, of Zurich. 

CYSTIC DEGENERATION OF THE IRIS. 

Dr. Wecker enumerates cases which have come under his notice 
in which "cystic degeneration" of the iris has resulted after 
injury to the eye, followed by retraction of the iris. Owing to a 
folding of the iris, glueing of the parts together, and distension 
of the folds with aqueous, "cysts" are formed. It remains to 
be proved whether cysts of the iris ever form independently of 
folding of the iris. — ("Annales d'Oculistique," Juillet, Aout, 
1873, p. 34.) 

CYSTS IN THE IRIS. 

Dr. Feuer narrates two cases in which microscopic examination 
seemed to show that cysts had developed in the tissue of the 
iris itself.— (" Klin. Monatsbl.," Ap., Mai, 1873, p. 110—123.) 

MELANOTIC SARCOMA OF THE IRIS. 

By Dr. Argyll Robertson (Edinburgh), and Dr. H. Knapp. 
(New York). 

The patient was a woman aged 24. The symptoms had begun 
as a slight inflammation in the right eye fourteen months pre- 
viously. Six months later she noticed she could not see with 
that eye, and it became painful. When seen there was a small 
light brown tumour about a line in length and half a line in 
breadth in front of the iris at the upper and outer part. She 
could only count fingers. There was distinct glaucomatous cup- 
ping of the disc, and the tension was increased. Treatment was 
refused till two months later when several smaller tumours had 
developed by the side of the first. The eyeball was excised. 
Two years after the operation there had been no recurrence. Pro- 
fessor Knapp gives a detailed account of the examination of the 
tumour (with illustrations). There was no doubt that it was a 
melanotic sarcoma of the iris. " Not mentionmg the rarity of 
such tumours in general, the case shows some features of par- 
ticular interest, especially the development of the pseudo-plasm 



122 PERISCOPE : — IRIDOTOMY. 

from the anterior layer of the iris and the great number of small 
tumours." " There is only one case of melano-sarcoma of the 
iris on record (by Graefe)." The present case differs from that 
in the number of tumours, and that the eye had become glauco- 
matous, which shows that the tumours of the iris follow the 
same clinical course as those of the ciliary body, choroid, and 
retina, viz., no irritation in the first stage, glaucoma in the second. 
All the coats of the eye, except the iris, were healthy. The 
prognosis was considered favourable as the disease, though 
malignant in its nature, was still limited. — (" Archives of Ophth. 
and Otol.," vol. iii, No. 2, p. 106.) 

IRIDOTOMT. 

Db. Wecker writes an article on this subject, and proposes 
important modifications as regards the method of performing the 
opei'ation, and the cases adapted for it. He gives a sketch of its 
history from the time of Cheselden. Mr. Bowman, at the Opthal- 
mological Congress in London, excited fresh interest in the sub- 
ject by advocating a plan of incising the iris in cases of zonular 
cataract, &c., instead of performing iridectomy. In iridectomy 
the widest part of the artificial pupil is at the periphery, where 
it is not wanted; in iridotomy the broadest part is central. 
Mr. Bowman makes a small incision in the cornea opposite the 
intended pupil, and then introduces a small knife, blunt at the 
point and back, between the pupillary edge of the portion of iris 
to be cut and the front of the lens, and then cuts forwards 
against the cornea. The incision in the iris gapes, and forms a 
new pupil — (Report of the Ophth. Cong, in Loud, in 1872 ; 
Soelberg Wells' Treatise, 3rd edit.). Dr. Wrecker uses a trian- 
gular keratome with a stop and a pair of forceps scissors. The 
blades are bent at an angle to the shaft, and are introduced 
closed, occupying very little space, by pressure on the handle. 
When this is relaxed the blades separate, but without tearing 
open the corneal wound. These do away with the necessity of 
cutting fi'om behind forwards and risking the cornea. The 
instruments are figured and illustrations of cases are given. He 
either simply incises the ii'is (simple iridotomy) or cuts a trian- 
gular piece out (double iridotomy). Simple incision of the 
pupillary margin of the iris is adapted for cases in which the 
central part of the lens or of the cornea is the seat of opacity, or 
whefe the cornea is abnormally curved, that is, in cases in which 
the patient can see best through the peripheral portions of the 
cornea, &c. An incision is made in the cornea with the stop 
keratome opposite to where the artificial pupil is intended to be 
made, and the knife carefully withdrawn. The scissors are then 
introduced cloGcd till opposite the margin to be cut, when they 
are slightly opened and one blade is passed in front of the iris 



A METHOD OF ADVANCING A MUSCLE. 123 

and the othei' behind ; one snip divides the sphincter pupill®, 
and the scissors are carefully withdrawn closed. A drop of 
atropine is applied and the eye covered. When the aqueous 
becomes re-secreted, the cut edges of the sphincter will be found 
to have separated, lea\T.ng a good artificial pupil. Every care 
must be taken not to injure the lens. Double h-idotomy is neces- 
sary where the lens is absent owing to operation or accident, and 
the pupil has become closed owing to inflammation. The corneal 
incision is made at the point towards which the stretched fibi'es 
of the iris converge. The stop kei-atome is thrust in within the 
corneal margin through the iris and false membrane, its point 
then running parallel with the posterior surface of the same, and 
is then carefully Avithdrawn. The scissors are introduced so 
that one blade passes in front and the other behind the ii-is and 
membrane, and these are cut with a quick snip. A second cut is 
now made, so that the two form a tiiangle with the apex at the 
wound. The flap thus formed is retracted by the action of the 
remaining healthy iris, and an opening remains. In some cases 
where the iris is much stretched and fairly healthy a simple inci- 
sion is suflicient. There is very little bleeding. Simple iridotomy 
is contra-indicated where the iris is wholly adherent to a scar, or 
hidden behind a dense leucoma, which prevents the operator see- 
ing what he is doing, or where the iris is paralysed. Double 
iridotomy should only be performed in cases where the lens is 
absent. — (" Annales d'Oculistique," Sept., Oct., 1873, p. 128.) 

A METHOD OF ADVANCING A MUSCLE BY MEANS OF A DOUBLE THREAD. 

Dr. Wecker contributes a paper on the advancement of muscles. 
He alludes to the rarity of the operation at present, its difficul- 
ties and its advisability. He simplifies the proceeding by (1) 
not cutting the antagonist muscle, and (2) by the way in 
which he applies the sutures. He simply detaches the tendon 
of the muscle which is attached too far back and applies two 
sutures. It is difficult to draw the upper and lower ends (for 
instance) of the tendon towards the cornea equally. He makes 
an incision five or six lines in length in the conjunctiva near the 
cornea over the tendon to be divided, separates the conjunctiva 
for some di.stance, introduces the hook under the tendon and 
divides it thoroughly. He then takes a piece of silk threaded 
with three needles; one in the centre and one at either end. 
He picks up the tendon and conjunctiva and passes the 
middle needle from within outwards, through the centre of the 
tendon at a little distance from the cut margin and through the 
conjunctiva. The two other needles are passed (from within 
outwards) through the conjunctiva at either end of the incision. 
The thread is cut close to each needle and two sutures remain. 
In order to seize correctly the ends belonging to the same suture 



124 PERISCOPE : — ABSORPTION OF A DISLOCATED LENS. 

tliey may be of different colours. To prevent the terminal 
needles falling off, they should have two eyes, one above another. 
The thread being passed through both eyes the needle cannot 
slip. He leaves the sutures in generally three or four days. 
(The figure given makes his plan quite evident.) He thinks 
this plan of advancement is indicated (1) in cases of (myopic) 
divergent strabismus resulting from insufficiency of the internal 
recti. Advancement of the internal rectus is preferable to 
division of the external, because the latter is irrational and often 
insufficient. (2.) In cases of paralytic strabismus where a 
partial return of function has occurred but the cure stops short. 
(3.) In cases of secondary strabismus, when the action of the 
antagonistic muscle is not too marked and allows (during com- 
plete relaxation of this muscle, that is, when the patient looks as 
far as possible to the same side to which the muscle first cut 
belongs) the cornea to be carried as far as the middle line. If 
this does not occur, the antagonislic muscle must be divided in 
addition to bringing forward the one at fault. — (" Annales 
d'Ocuhstique," Nov., Dec, 1873, p. 225.) 



ON THE CONNECTION BETWEEN CATARACT AND DISEASE OF THE 
NERVOUS SYSTEM. 

(Letter from Dr. S. Logetschnikow, to "Zehend. Klin. Monatsbl.," 

X, p. 351.) 

Having met with fifteen patients, all of whom were women (from 
the age of 16 to 37) who suffered from clonic convulsions and 
also from complete cataract, Dr. Logetschnikow thinks there must 
be some common brain mischief causing both. The patients 
asserted that their sight was good before the convulsions came 
on. In one, only, did the convulsions follow the first ap- 
pearance of cataract. It is well known that there is a connection 
between convulsions in childhood and tlie occurrence of zonular 
cataract. The cataract which comes on in middle life in con- 
nection with disease of the nervous system is not at all like the 
local, and for the most part stationary, zonular cataract of child- 
hood, but is complete and soft. 

ABSORPTION OF A DISLOCATED LENS (TRAUMATIC CATARACT). 

Dr. Haltenhoff records the case of a man, aged 58, who re- 
ceived a blow on one eye from a fragment of stone. When seen 
the lens was cataractous and dislocated backwards and down- 
wards and caused the iris to bulge forwards. It finally (in the 
course of three months) became quite absorbed and the patient 
could see with the aid of cataract glasses. " This case shows 



EXTRACTION OF CATARACT. 125 

that we may sometimes delay operative interference even in old 
persons." — (" Anuales d'Occulistique," Jan., Fev., 1873, p. 71.) 

COMPLETE ABSORPTION OF A DISLOCATED LENS. 

Dr. Lindner records the case of a man, aged 25, who came 
tinder his care complaining of a dull pain in the left eyeball, set 
up by a blow on the left temple, received from a sack of flour he 
was unloading from a waggon. A bruise was still evident. 
There was blood in the anterior chamber, considerable episcleral 
congestion and numerous subconjunctival extravasatious. Ex- 
amination by daylight and by oblique illumination excited no 
irritation but gave no positive information. Atropine was in- 
stilled, rest enjoined, &c. A week later the blood had in great 
part disappeared fx'om the anterior chamber, the lens was visible 
in the anterior chamber, covering the pupil and projecting beyond 
the pupillary border of the iris. Vision was limited to quanti- 
tative perception of light. During the next ten days the treat- 
ment was continued, the lens remained transparent but became 
oblique in position, sloping from below, upwards and forwards. 
Opacities could now be made out in the vitreous. The patient 
counted fingers at 14". The vitreous cleared up and the lens 
diminished in all directions. At the end of three weeks pain 
was complained of in the left globe, and the right eye became 
.sensitive to light. Both eyes were covered up and the patient 
kept in the dark. In five days the symptoms vanished. In a 
month from the time of admission the patient returned home. 
At the end of six months he was again seen. The lens was 
wholly absorbed, the vitreous clear, the fundus normal, and the 
patient read well with convex glass (+ 4). — (" AUg. Wien. Med. 
^eit.," Ap. 15, 1873.) 

EXTRACTION OF CATARACT BY SMALL FLAP, EXTENDING FROM THR 
CENTRE TO THE JUNCTION OF THE UPPER AND MIDDLE THIRDS OF 
THE CORNEA, AND WITHOUT IRIDECTOMY. 

Dr. Warlomont discusses the various methods which have been 
proposed for the extraction of cataract, and advocates the follow- 
ing : — He enters a Grsefe's knife at the outer mai'gin of the cornea, 
one millimeti'e (half a line) below the centre, passes it straight 
across the anterior chamber, and makes a counter-puncture exactly 
opposite. Tlie blade is held with the edge slightly inclined 
forwards (making an angle of 20 to 30 degrees with the iris) so 
as to avoid cutting the iris if the aqueous should escape rapidly. 
After the counter-puncture has been made, the section is made 
upwards by see-saw movements of the knife, in a direction 
curving forwards, till the level of the junction of the middle and 
upper thirds of the cornea, when the knife is brought out almost 



12 G PERISCOPE : — ^INTRA-OOULAR HEMORRHAGE 

perpendicular to the cornea. In order to give the flap a regular 
curve, its whole breadth shou.ld not be cut at once, but the heel 
and point of the knife should be used alternately. The flap is 
about 3 mm. (a line and a half) in height, and as broad as the 
cornea, and its apex is about 3 mm. from the upper margin of 
the cornea, and forms a tangent to the circle formed by the 
pupil when moderately dilated. ISTo speculum or fixation forceps 
should be used. Owing to the shape of the flap, prolapse of the 
iris is not likely to occur. The lens is readily made to present 
at the wound, and escapes through it easily. The pupil is dilated 
as widely as possible with atropine before beginning the operation. 
The scar is very slight, and is situated above the pupil. Loss of 
vitreous is not likely to occur. The edges of the wound lie in 
accurate apposition. The section is made at the least sensitive 
part of the cornea. Suppuration of the flap is a possible accident, 
but is very rare. Iritis is little to be feared. There is no risk 
of irido-choroiditis or of sympathetic mischief. Iritic adhesions 
only occur occasionally, and are not necessarily connected with 
the operation. The operation difi'ers from that proposed by 
Liebreich in several points. Figures are given, showing the 
steps of the operation. — (" Annales d'Oculistique," Jan., Feb., 
1874.) 

EXTRACTION OF CATARACT. 

Zehender gives an account of the various operations which have 
been proposed of late years for the extraction of cataract. — 
(" Khm Monatsbl.," Nov., 1873, p. 313.) 

report on sixty-four cataract extractions according to the 

METHOD of von GR^EFE. 

Compiled by Dr. Hasket Derby. ("Archives of Ophth. and 
Otol.," vol. iii, No. 1, p. 74.) 

intra-ocdlar haemorrhage, with formation of amyloid bodies 
IN the extravasated blood, and amyloid degeneration of 

THE choroidal ARTERIES. 

By Dr. Knapp. 

The patient was a man, aged 47. A few days previously he had 
noticed uneasiness and nearly total loss of sight in the left eye. 
On examination, the signs were those of opaque vitreous, pro- 
bably from haemorrhage. It was supposed that a melanotic 
sarcoma had been the starting point. As the sight was lost and 
the globe painful, excision was performed. The microscopic 
conditions found in the eyeball are given in detail with illustra- 
tions. The retina and choroid were in their normal positions. 
Between the choroid and sclerotic, and between the choroid and 
retina, there were collections of blood containing amyloid cor- 
puscles. The latter remained unchanged on addition of acetic 



COLOBOMA OF THE FUNDUS OCULI. 127 

acid, ellier, aud alcohol, but were coloured iutensely brown-red 
by iodine. Addition of sulphuric acid rendered the hyaline 
globules violet. The arteries of the choroid gave the charac- 
teristic iodine reaction in their middle and inner coats. This is 
the first time that amyloid formations have been described as 
occurring in the eye. Here they were only met with in con- 
nection with the choroid. No special cause for the amyloid 
degeneration could be detected in the patient's condition. — 
(" Archives of Ophth. and Otol.," vol. iii, No. 2, p. 115.) 

CONTIBUTIONS TO THE PATHOLOGY OP CHOROIDITIS. 

By Dr. Kortum. 

1. Choroiditis congenita (three cases). 2. Choroiditis specifica 
(four cases). — ("Archives of Ophth. and Otol.," vol. iii. No. 2, 
p. 91.) 

INTRA-OCULAR ENCHONDROMA. 

Dr. Chishdlm records the case of a man, aged 25, who came 
under his care for a tumour of the left eyeball. It was first 
noticed at the age of three years. When he came under care 
the left eyeball was represented by a rounded mass as large as a 
fist. The whole moved slightly when he moved the other eye- 
ball. The tumour was elastic, but did not fluctuate. It was 
removed without special difficulty and without marked hgemor- 
rhage. On the fourth, fifth, and ninth nights, haemorrhage 
occurred, and, on the latter occasion, the left common carotid 
was ligatured. The next day tetanic symptoms appeared, and 
on the fourth after the ligature, the patient died. A micro- 
scopic examination of the growth was made by Prof. H. Knapp, 
and the result is given in detail, with illustrations. He con- 
siders that the tumour originated in the sclerotic and spread 
towards the vitreous. — ("Archives of Ophth, and Otol.," vol. iii, 
No. 1, p. 1.) 

COLOBOMA OF THE FUNDUS OCULI WITHOUT COLOBOMA OF THE IRIS. 

In an inaugural dissertation, Dr. Hofmann describes a case. The 
patient was a shoemaker, aged 44, who came under Prof. 
Saemisch's care. In the left eye there was a coloboma of the 
fundus oculi with a perfectly formed iris ; in the right eye there 
was a coloboma of the iris as well as of the fundus. These were 
the only defects of development which could be discovered in 
the patient. The inconvenience which they caused the patient 
seemed very slight. He could see better with the right eye in 
the evening than in broad daylight. This would be accounted 
for by there being less dazzling produced. The left eye. He 



128 PERISCOPE : — MYDRIASIS SPASTICA. 

could read well ; the field of vision was limited upwards, a mov- 
ing object being indistinctly seen in the whole of the left upper 
quadrant. (A figure is given.) The iris was of a clear blue 
colour. In one portion at the lower part the tissue appeared 
somewhat thinned on focal illumination. On ophthalmoscopic 
examination in the inverted image, a coloboma, glistening like 
mother-of-pearl, was visible in the lower part of the fundus. 
Close to the lower margin of the disc was a crescentic zone just 
like a commencing staphyloma. Beyond this was a portion of 
healthy choroid, and then at about the distance of two diameters 
of the disc from the disc there was a round, excavated, glistening 
white patch rather smaller than the disc. This formed the real 
beginning of the staphyloma. Lower still was a bridge of choroid, 
and then the most extensive portion of the coloboma distinguish- 
able into three parts. (A representation is given.) The most 
anterior part reached nearly to the cihary processes. The right 
ewe. He could only read 15 (J.) with this eye. The field was 
very defective in the upper half. The lower part of the iris 
showed an ordinary coloboma. The edge of the lens could be 
made out. In the fundus the coloboma stretched from about the 
distance of a diameter and a half from the optic nerve entrance 
without any interruption into the neighbourhood of the ciliary 
processes. A case is also mentioned under the care of Prof. 
Saeraisch, the patient being a woman, in which a coloboma 
existed in each eye in the lower part of the choroid without any 
affection of the iris. A brother of hers had a complete coloboma 
in each eye. 

In the case just noted it is remarkable that a fissure of the 
inner tunics of the eye existed without any affection of the iris, 
and that the coloboma was divided into two portions which were 
separated by a bridge of choroid. 

MTDRIASLS SPASTICA, 

By Dr. HiRSCHLER. (" Wien. Med. Woch.," April 26, 1873.) 

Du Bois-Retmond, by observations on himself, has established the 
fact that pathological irritation of the cervical sympathetic is 
accompanied by dihitation of the pupil on the same side. He 
ar^ved at this conclusion as the result of reasoning and not by 
accident, or from any defect of sight being produced. He de- 
scribes the symptoms attending an habitual migraine recurring 
every three or four weeks, and which he regarded, not, as is cus- 
tomary, as a neuralgia, but as a tetanic affection of the muscular 
walls of the vessels on the affected side of the head or of the 
cervical portion of the sympathetic on the right side. The cord- 
like hardness of the temporal arteries, the pallor of the face 
and the sunken condition of the right eyeball pointed to a con- 



SYMPATHETIC OPHTH.iLMIA. 129 

tracted condition of the muscular structure of the vessels. After 
this idea had suggested itself to him he looked for the dilatation 
of the pupil which ought to go with this state of things ; and 
"when his next attack of migraine occurred, he found his pupil 
was dilated. He obtained confirmation of this by getting a friend 
to look at his pupils, and his friend at once told him that the 
right pupil was dilated. The difference in the size of the pupils 
appeared more evident in proportion as the eyes were shaded. 
Just as is the case when the cervical portion of the sympathetic 
is irritated. 

Dr. Hirschler has lately had an opportunity of seeing a marked 
case of hemicrania, in which dilatation of the pupil was present. 
It caused the patient no particular inconvenience, and was not 
detected till he consulted Prof. Lobl. In spastic mydriasis there 
is no loss of accommodation as occurs in paralytic mydriasis ; nor 
do objects appear smaller as is the case in the latter, and the 
size of the pupil varies. The patient was a man, aged 31, who 
had, for three years, been liable to intense pain in the forehead. 
The trunk of the left temporal artery was visible, whilst the right 
was not, and it pulsated more strongly than the latter. When 
seen by Dr. Hirschler the left pupil was 3-^"' in width, and almost 
wholly immovable. The sight was unaffected excepting that 
print did not appear so clear nor so black as with the other eye, 
but this difference vanished on making the patient look through 
a pin-hole aperture. The patient said the pupil was more dilated 
when he had severe pain, and this was confirmed by subsequent 
observation. Both Calabar Bean and Atropine were applied, and 
the results are detailed. The ophthalmoscopic examination was 
without result as to alteration in size of vessels. The left ear 
showed a lower temperature than tlie right when the attacks of 
pain were severe. The difference amounted to about 2" 7° (F) 
as tested by the thermo-electric multiplier. 

SYMPATHETIC OPHTHALMIA. 

Prof. Arlt discusses the anatomical changes met with in sym- 
pathetic ophthalmia, the causes which give rise to it, and its 
treatment. He also gives a historical summary of the literature 
of the subject. He mentions the case of a lad who was stabbed 
in the left eye. The wound involved the cornea, iris, and lens, 
and the latter swelled up, and the pupil became closed. Sub- 
sequently sympathetic irido-cyclitis attacked the right eye. Iri- 
dectomy was performed on the left eye, and then on the right, 
and subsequently on the left again, with success. The lad was 
under care for four years. The author remarks that, had he 
enucleated the left eyeball, he would not only have done what 
was useless, but even what was unjustifiable. In any case in 
which the onset of sympathetic ophthalmia is likely to occur, 
VOL. VIII. K 



130 PERISCOPE: — TREATMENT OF EPICANTHUS. 

or in wliich it has already set in, lie insists strongly on absti- 
nence from any employment of the eyes and the avoidance 
of exposure to strong light. — ("Wien. Med. Woeh.," Feb. 1, 8, 
and 15, 1873.) 

WOUND OF ONE EYE — SYMPATHETIC IRIDO-CHOROIDITIS OF THE OTHER 
— ENUCLEATION OF THE INJURED EYE — FATAL MENINGITIS. 

Dr. Pagenstecher narrates the case of a man, aged 42, who had 
wounded the left eye severely six weeks before he came under 
care. For a fortnight he had had pain in the head and ciliary 
neuralgia on the injured side, and for five days he had noticed 
the right eye affected. When seen, the injured eye was atrophic 
and painful. The other eye showed marked evidences of sym- 
pathetic irido-cyclitis. The atrophied globe was removed. The 
patient experienced great relief the following night ; but at the 
end of twenty- four hours a rigor occurred followed by pain in the 
head, febrile symptoms, delirium, &c. He died fifty hours after 
the shivering, seventy-four after the operation. Evidences of 
suppurative meningitis, chiefly of the base were found. An 
examination of the orbits did not reveal any special connection 
between the operation wound and the intracranial mischief. A de- 
tailed description of the different conditions is given, and also of the 
microscopic examination of the eyeballs. The author thinks it 
is probable that the suppurative choroiditis set up in the injured 
eye may have excited meningitis, which was aggravated by the 
operation. The way in which such irritation could have been 
brought about he is qitite unable to point out. Eyes affected 
with suppurative choroiditis are so often removed without any 
ill effects following, that he cannot admit any direct connection 
between the opei'ation and the meningitis. The original wound 
was inflicted with a knife covered with blood. Can this have 
had any influence? — ("Klin. Monatsbl.," April, Mai, 1873, 
p. 123.) 

EPITHELIOMA OF THE CHEEK AND LOWER EYELID REMOVAL — 

BLEPHAROPLASTY. 

Dr. POOLEY. 

Flaps were taken from the nose and from the forehead. The 
latter sloughed. The result was good. — ("Arch, of Ophth. and 
Otol.," vol. iii, No. 1, p. 40.) 

EPICANTHUS AND ITS TREATMENT, 

Professor H. Knapp reviews the literature of tlie subject and 
notes cases. He prefers excising a portion of skin from the 
nose. He describes one operation. A rhomboidal piece of skin 



TREATMENT OF EPIOANTHUS, ETC. 131 

on the root of tlie nose was first circumscribed and excised. It 
was over an inch in length, and nearly two-thirds of an inch in 
width at its broadest part. The skin of both sides was carefully 
undermined, in long strokes with a very sharp knife. When the 
bleeding had subsided, the vt^ound was united carefully. The 
region of the wound was strapped to relieve stretching. He sums 
up that epicanthus of a higher degree, which does not diminish or 
disappear during the first four or five years of life is not likely to 
do so later in life, and should be removed by operation. The 
operative procedures which attack the integumental fold itself 
are apt to fail, as the subsequent cicatricial contraction frequently 
produces relapses. Von Ammon's rhinorrhaphy — removal of a 
rhomboidal piece of skin from the root of the nose, and uniting 
the edges with sutures, is a reliable method for the removal of 
epicanthus. We must endeavour to obtain union by first in- 
tention, on account of the disfiguring scars which are left 
on the back of the nose when suppuration ensues. To obtain 
primary union, the excision of skin should be done carefully, the 
adjacent skin undermined without any bruising, and the wound 
well united by delicate and closely-set sutures. Strapping with 
court-plaster may help to diminish the tension of the skin. 
During the first days after operation great care is to be recom- 
mended, lest by restlessness of the patient, or some accident, a 
separation of the wound ensue, the consequence of which would 
be a bad looking scar. — ("Archives of Ophth. and Otol.," 
vol. iii, No. 1, p. 48.) 

Dr. Landbsberg contributes a case of ^perforating scleral wound 
followed by complete recovery. A case of glatocoma fulminans 
followed by good vision (after iridectomy) and no contraction 
of field. Two cases of ribbon-shaped corneal opacity complicated 
with intra-ocular changes (glaucoma). — ("Archives of Ophth. and 
Otol.," voh iii, No. 1, p. 58.) 

Dr. Martin reports from Dr. Wecker's clinique on : — 

1. Trephining the Cornea in partial staphyloma of the Cornea. 
— The object of this operation is to allow of the slow formation 
of a cicatricial tissue which will tend to diminish the curvature 
of the cornea. Dr. Wecker's trephine is figured. 

2. In complete cicatricial leucoma of the cornea, trephining is 
resorted to in order to create a corneal fistula. Two cases are 
noted in which some benefit resulted. 

3. Neurotomy. — The cases in which the sheath of the optic 
nerve had been incised in neuritis were too far advanced to allow 
of any amelioration. No harm resulted. A neurotome cache 
for the purpose is figured. 

4. Tattooing the Cornea. — Lately, Dr. Wecker had adopted a 



132 PERISCOPE: — ULCUS CORNER SERPENS. 

plan resembling those recommended in England (Bader and 
Taylor). After having spread a thick layer of Chinese ink over 
the opacity, a number of punctures are made in it by means of 
an instrument consisting of four or five needles fastened together. 
(Figures are given.) The ink is washed oflP to see the result, 
and the process repeated till it is satisfactory. The ink is finally 
left in contact for a quarter of an hour, the speculum being 
retained. The conjunctiva should not be pricked, or else black 
spots will result there also. A good black colour ought to result 
after two tattooings. 

5. On the Treatment of Ectropion by Snellen's Sutures. 

6. Operation for Entropion of the upper Eyelid hy Snellen's 
method (with figures). 

7. On Grafting in the treatment of Ectropion. 

8. Forceps-scissors. 

(" Annales d'Oculistique," Mars— Avril, 18.73, pp. 101—15. 

INSTRUMENT FOR TREPHINING THE CORNEA OR FOR USE AS AN 
ARTIFICIAL LEECH. 

Dk. Warlomont figures and describes a simple and cheap instru- 
ment for use, either as a trephine (for the cornea), or for the 
abstraction of blood by the artificial leech. — ("Annales d'Oculis- 
tique," Juillet — Aout, p. 31, 1873.) 



abscission OF TOTAL STAPHYLOMA OF THE CORNEA. 

Dr. Wecker recommeri:is the following plan. He divides the 
conjunctiva all round tlie corneal margin, as if for excision of 
the globe, and then introduces four sutures from below upwards, 
through the conjunctiva, and passing across the opening made 
in it. He draws these to either side out of the way, transfixes 
the base of the staphyloma with a Grsefe's knife, and then cuts 
the staphyloma away with scissors close to the corneal margin. 
The conjunctival sutures are now tied. The threads may be of 
diff'erent colours. A figure showing the mode of applying the 
sutures is given. — (" Annales d'Oculistique," Janvier — Fevrier, 
18V3, p. 51.) 

ULCUS C0RNE.a; serpens. 

Dr. Nieden contributes a paper on the treatment of ulcus corneae 
serpens. He notes fifty cases in a table. They all occurred in 
the practice of Prof. Saemisch. The ulcers were in the centre. 
As soon as it was ascertained either immediately or after a day's 
observation that the ulcerative process was still progressing, the 
whole base of the ulcer was slit in the following manner, no 



ULCUS CORNER SERPENS. 133 

chloroform being administered : — The eyeball being steadied by 
the fixation forceps, Greefe's knife was thrust into the anterior 
chamber through the healthy tissue of the cornea on one side 
near to the edge of the ulcer, and carried so far as the opposite 
edge, the counter-puncture being made in the normal tissue too. 
The fixation forceps being taken away the base of the ulcer was 
slit by gentle to-and-fro movements of the knife, the edge being- 
directed straight forward. The cut was always performed in 
such a manner that it divided the edge of proliferation in its 
middle, or at least one segment of it. The aqueous humour 
escaped slowly from the puncture and counter-puncture, the 
hypopyon mingling with the last drops. The rest of the hypop- 
yon, if any remained, was left except when it consisted of 
fibrinous coagulations which protruded into the wound, in which 
case they were i-emoved by a pair of forceps. If the coagulations 
did not protrude no effort was made to coax them out by gently 
rubbing the lids, but they were left in the anterior chamber to 
undergo absorption. Only in cases where the nicer occupied a 
considerable part of the cornea, the cut was modified in such a 
way that only one end lay in normal tissue at some distance from 
the actual or the supposed place of the edge of infiltrati<)n, while 
the other end was located in the middle, or more toward the 
margin of the nicer according* to its dimensions. A sudden 
evacuation of aqueous occurred twice without ill-effect. An hour 
after atropine was instilled and repeated four or eight times daily, 
the patients being kept in bed. l\o compressive bandage was 
applied. As long as the ulcer showed any tendency to spread 
the cut was opened daily by Grtefe's knife without fixing the eye- 
ball ; the patient lying down and the eyelids being kept open by 
an assistant. The signs indicating that the treatment may be 
discontinued are : the total disappearance of the zone of infiltra- 
tion, the base of the nicer being sharply defined, the raised edge 
of the proliferating tissue having sunk to the level of the surface 
of the ulcer, a uniform greyish hue of the wound and of the base 
of the nicer, the latter clearing up, and all the symptoms of irri- 
tation of the eye having subsided. This occui'S ordinarily within 
three weeks. The average number of slittings performed in the 
same case was between six and seven. In some, only one slitting 
was performed, and in one case twenty. The cases in patients be- 
tween thirty and forty years of age required the longest treatment. 
More than one slitting was never perfoi'med in the same day ; it 
was never necessary to make a crucial incision. In two cases 
the reappearance oJ' the ulcerative process made it necessary to 
slit a second time after the reopening of the wound had been dis- 
continued. The first slitting was suflScient to arrest the disease 
immediately in 84 per cent. In 70 per cent, the pupillaiy margin 
was absolutely free when the treatment was discontinued. — 
(''Archives of Ophth. and Otol.," vol. iii, No. 1, p. 288.) 

K 2 



134 PERISCOPE: — ON SUPPURATIVE KERATITIS 

ON SUPPURATIVE KERATITIS AFTER SMALL-POX. (" Inaug. DisS.") 

By Dr. Hackenburg. 

An epidemic in Berlin afforded opportunity for studying tlie 
ocular affections in connection with small-pox. He mentions 
two. The^rs^ is a primary iritis associated with cloudiness of 
the vitreous. The prognosis, apart from the -^atreous opacities 
which may remain is good ; the treatment does not differ from 
that of other forms. Occasionally it develops into an irido-cho- 
roiditis which is of serious import. Sometimes opacities are 
noticed in the vitreous without any pre-existing change in the 
u*is or the formation of adhesions. He, unfoi^tunately, does not 
adduce any cases of this first affection. The second is a suppura- 
tive keratitis, occasionally associated vpith secondary iritis and 
irido-choroiditis, the complications making the unfavourable 
prognosis of the corneal affection still worse. Eleven cases are 
detailed. Of these eight were recent ; in seven only one eye, and 
in one both eyes were affected with keratitis ; in four of them 
iridectomy was performed. In the other three cases the mischief 
was old ; in one there was a leucoma (adhaerens), and in the 
other two, leucoma and staphyloma. He also mentions two other 
cases (Xn and XIII) in which previously damaged eyes were 
attacked ; in one there was a perforating ulcer coming on about 
three weeks after the small-pox, in the other, scars on both 
cornese. 

The author remarks that the severity of the eruption has no 
connection with the affection of the eye. For the most part the 
keratitis occurs after v. .viola; in six of seven cases noted it fol- 
lowed variola ; in the seventh varioloid. Generally the keratitis 
occurs from eight to fourteen days after the commencement of 
the disease, but occasionally during re-convalescence. The 
symptoms are discussed. The prognosis is very unfavourable, 
and the disease resists all ordinary treatment. In one case (VI), 
Saemisch's plan of repeated incision of the ulcer was adopted, 
but failed. Iridectomy was then performed, and great improve- 
ment resulted. The ulcer was healed in nineteen days. In ano- 
ther (V) case of severe ulceration of the upper half of the cornea, 
hypopyon, &c., supervening, a small iridectomy was performed 
six weeks after admission. The iris was " rotten " and the ope- 
ration was a troublesome one, but the corneal ulcer filled up 
rapidly at first, and the hypopyon diminished. The healing 
proceeded more slowly afterwards. At the end of five weeks 
the cornea had cleared so as to be almost transparent and 
the ulcer was healed, but the sight had not improved from 
the time of a week after the operation. Before the operation the 
patient could only detect movements of the hand at 3 in. from 
the eye, a week later he could detect them at 8". On admission 



AFTER SMALL-POX. 135 

he could count fingers at 4 — 5'. In a third (VII) case the opera- 
tion was performed for perforating ulcer, prolapse of iris and 
fistula of the cornea. Other treatment had been employed for 
six weeks. The fistula healed and the patient left the hospital 
in fourteen days. In a fourth case (VIII) extensive keratitis was 
the cause. The whole of the lower half of the cornea was infil- 
trated with pus, and was ulcerated on the surface, the upper 
half was diffiisedly opaque, and also ulcerated on the surface. 
Iridectomy was performed upwards. The advance of the disease 
was at once checked, the infiltration slowly diminished, and the 
cornea cleared on the nasal side. Twelve weeks after the opera- 
tion the patient could count fingers at 8' and spell words of 16"2 
with naked eye. " These cases show, manifestly, the good results 
which follow iridectomy in suppurative keratitis. This proce- 
dure is indicated in all cases in which the disease takes an acute 
course, and is of great extent, as by it alone the process can be 
checked, and healing established." The operation may also be 
performed in cases (IX) of opacity for optical purposes. In one 
case a staphyloma (XI) diminished after the operation. The 
cases were under the care of Prof. Schweigger : — Case I. — Kera- 
titis suppurativa clextra. M. 36. Variola began five weeks 
previously ; the eye afiection three weeks later. Conjunctivitis ; 
cornea, except a small portion at the upper and outer part, 
ulcerated to its deepest layers. Treatment, atropine, and com- 
press for a fortnight, then aqua chlori. Rapid improvement 
followed. The patient left a month later. Vision not noted. 
II. — Keratitis suppurativa sinistra. F. 31. Variola seven 
weeks before ; eye affected one week later. Conjunctivitis, cornea 
infiltrated with pus. She could only tell light from darkness. 
Treatment, atropine, and compress, then aqua chlori, then Tinct. 
Opii. Simp. (1 to 9). After 6 — 7 weeks she could count fingers 
at 4'. III. — Keratitis suppurativa sinistra. M. 29. A month 
before had variola ; and, within a fortnight, eye affection. Atrophy 
of the globe resulted in spite of treatment. When seen patient 
could only detect glimpse of light. IV. — Keratitis siippurativa 
dextra — Panophthalmitis. Date not known. Eye affection came 
on only after some time. M. 8. V. — Keratitis suppurativa 
dextra. M. 26. Variola slight, began a month before, left 
hospital a fortnight. During re-convalescence. YI.— Keratitis 
suppurativa dextra. Iritis. M. 36. Variola two months before. 
Eye affection nine days later. Patient could only see light. 
Superficial ulcer, upper and inner third of coi-nea. In twelve 
days Saemisch's plan. Eight days later iridectomy. In three 
weeks the ulcer was healed, and patient counted fingers at 15". 
VII. — Keratitis suppurativa dextra^ prolapsus iridis, fistula cornea\ 
F. 27. Variola three weeks before. Eye affection fourteen days 
later. VIII. — Keratitis suppurativa duplex — Ahscessus corneoi 
dextrce — Destructio cornece sinistrce. M. 40. Variola one month, 



136 PERISCOPE : — REMOVAL OF A FOREIGN BODY. 

eye afEection in eight days. — 35. IX. — Leucoma adhmrens. 
Variola lasted a month, then loss of sight. The leucoma covered 
the pupil which was adherent. Movements of the hands at 2 — 3'. 
Iridectomy upwards and inwards. Five days later patient read 14 J. 
X. — Eight sfaph/loma cornece ; Ifift, cicatrices cornece. JEt. 19. 
XI. — Bight, partial staphyloma ; left, leucoma. ^t. 11. Variola 
three weeks before Christmas. In the middle of July seen. 
Double iridectomy ; left, inwards and outwards ; right, upwards 
and outwards. Fourteen days later, fingers across the room, 
rio-ht at 1". The staphyloma was checked. XII. — TJlciis cornece 
perforans. M. 30. Artropine ; cure in ten days. The eye had 
small opacities from childhood. XIII. — Corneal opacities. F. 21. 
Eyes affected from childhood. Both again from small-pox. Ung. 
Rub. Precip. Cure in two months. On this subject we may 
refer to Mr. Marson, Reynold's system, vol. i, p. 443 ; Mackenzie's 
Treatise ; Mr. Hutchinson on " Inflammations of the Eye occur- 
ring some little time after small-pox " Roy. Loud. Ophth. Rep. 
vol. iii, X). 333. (At p. 369 is an abstract of Mr. Marson's remarks). 
In the " Brit. Med. Journ." Feb. 18, 1871, p. 169, are noted cases 
of" Post Variolous Corneitis " under the care of Mr. Hulke and 
of Mr. Hutchinson (with remarks on the whole subject). 

BLEPHAEOPLASTIC OPERATION ERYSIPELAS SLOUOmNG OF THE 

CORNEA ATROPHIA BULBI. 

By Dr. Wagner. ("Zehend. Klin. Monatsbl.," x, p. 337.) 

Two days after the disappearance of the erysipelas, an ulcer, the 
size of a pin's head, appvr-red on the cornea, and five days later 
signs of sloughing of the cornea. This was probably due to the 
irritation of the brancli of the fifth produced by cutting a flap 
from the cheek, and by the subsequent erysipelas and the cornea 
atfected in a reflex manner. 

REMOVAL OF A FOREIGN BODY FROM THE ANTERIOR CHAMBER. 

By Dr. Wagxer. 

The foreign body was of small size, and lay in great part on the 
iris, but projected slightly into the pupil. The scar in the 
cornea was slight. It Avas intended to remove the foreign body 
through a downward, peripheral section of the cornea, but an 
attempt to fix the eye resulted in the opening of the corneal 
wound and prolapse of iris. An incision inwards was made with 
a lance-shaped knife, and after a great deal of difiiculty and 
repeated trials (which are mentioned) the piece of iron was 
extracted. It was from 2 to 2^ mm. ( 08" — •1") across, and \ m. 
("02) in thickness. After five days the patient was sent home 
with good vision. The patient said he could see as well as 
before. — ("Zehend. Klin. Monatsbl.," x, p. 339.) 



CYSTICERCUS BENEATH THE CONJUNCTIVA. 137 

CORECTOPIA. 

Dr. Pooley records a case, and notices the literature of the sub- 
ject.— (" Arch, of Ophth. and Otol.," vol. iii, No. 1, p. 26.) 
Dr. Alexander (of Aix-la-Chapelle) records a case. — ("Klin. 
Monatsbl.," Feb., Marz, 1874, p. 66.) 

ON CAUTERISATION OF THE REFLECTED FOLD OF THE CONJUNCTIVA 
WITH SOLID NITRATE OF SILVER IN AFFECTIONS OF THE CORNEA. 

In certain cases of chronic inflammation of the cornea, attended 
by ulceration of an atonic character. Dr. Hosch (following 
Grgefe) advocates the use of nitrate of silver. The upper eyelid, 
being well everted, it will often be found that the reflected fold 
of conjunctiva thus exposed is swollen and injected. It should 
be touched with a pointed stick of nitrate of silver, and the eye 
should then be washed with water. It is advisable to dry the 
surface first of all before applying the caustic. Cases are 
narrated. The treatment is only advocated in those cases in 
which the fold of conjunctiva is manifestly swollen. — (" Zehend. 
Klin. Monatsbl.," x, p. 321—31.) 

INOCULATION IN CASES OF PANNUS. 

A FULL notice of a paper by Dr. Briers (in the " Bull, de Ther. 
Med. Chir.," 1873, 15 Sept.) will be found in the "Annales 
d'Oculistique," Sep., Oct., 1873, p. 215.) 

LEPTOTHRIX IN THE UPPER CANALICULUS. 

Dr. Gruening records a case. — ("Arch, of Ophth. and Otol.," 
vol. iii. No. 1, p. 17.) 

SPONGY EXUDATION IN THE ANTERIOR CHAMBER. 

Dr. Gruening. (" Arch, of Ophth. and Otol," vol. iii. No. 1, 

p. 20.) 

SARCOMATOUS ECTROPION OF THE CONJUNCTIVA OF BOTH EYES IN A 
CHILD, CURED BY EXCISION OF A PORTION OF CONJUNCTIVA. 

A LARGE fleshy tumour projected downwards from each upper 
eyelid and was found to be swollen mucous membrane. A figure 
is given.— (Talko, " Klin. Monatsbl.," Nov. 1873, p. 321.) 

CYSTICERCUS BENEATH THE CONJUNCTIVA. 

Dr. Briere reports a case occurring in the clinique of Dr. Sicbel 
(" Gaz. des Hop.," 19 et 29 Juillet, 1873). A tumour near the 
caruncle had been noticed five weeks. It was about the size of a 
kidney-bean, fluctuating and tense. Dr. Sichel diagnosed a 
conjunctival cyst, probably containing a cysticercus, but was 



138 PERISCOPE : — FOREIGN BODY ENCAPSULED. 

doubtful, on account of the absence of pain, which he had 
always found present. The tumour was removed, and proved to 
be a cysticercus. — (" Annales d'Oculistique," Sept., Oct., 1873, 
p. 294, with figures.) 

PEDUNCULATED SARCOMATOUS TUMOUR OF THE CONJUNCTIVA PALPEBR^ 
SUPERIORIS, CURED BY EXCISION. 

A figure is given. (Talko, "Klin. Monatsbl.," Nov., 1873, 

p. 326.) 

EPITHELIOMA OF THE OCULAR CONJUNCTIVA — REMOVAL OF THE 
TUMOUR WITH A PORTION OF CONJUNCTIVA — CURE. 

An illustration is given. (Talko, "Klin. Monatsbl.," Nov. 1873, 

p. 330.) 

TELANGIECTASIS OF THE OCULAR CONJUNCTIVA TREATED BY EXCISION 
AND CAUTERISATION. 

The nsevus passed deeply. As much was removed as possible. 
No irritation followed ; but, shortly after, the tumour had re- 
sumed its original size. In three months it had quite dis- 
appeared.— (Talko, " Klin. Monatsbl.," Nov. 1873, p. 335.) 

PERSISTENT REMNANT OF THE HYALOID ARTERY. 

Dr. Schapringer records and figures a case. The patient was 
11 years of age. The right eye only was affected. There was a 
vascular loop taking its origin near the centre of the optic disc 
projecting into the vitreous. Its two branches emerged sepa- 
rately from the area of the disc and were twisted round each 
other. The loop seemed firmly fixed, for movements of the 
eyeball did not affect it.— (" Arch, of Ophth. and Otol," vol. iii, 

No. 1, p. 251.) 

Dr. Kipp contributes (1) a case of persistent hyaloid artery m 
both eyes. There was a thin cord projecting into the vitreous and 
ending in three short branches, the free extremities of which 
were bulbous. The other end immediately in front of the 
centre of the optic disc formed a small loop and then dis- 
appeared. Pressure on the globe produced pulsation in the loop 
as well as in the retinal arteries. The author thinks this the 
only case on record wbere the anomaly existed on both sides. 
(2) A case of syphilitic iritis with gelatinous exudation. — (" Arch, 
of Ophth. and Otol.," vol. iii, No. 1, p. 70.) 

foreign body ENCAPSULED IN THE VITREOUS WITH PRESERVATION 
OF GOOD VISION. 

A MAN came under the care of Prof. Arlt six days after his left 



OPHTHALMOSCOPIC OPTOMETRY. 139 

eye had been struck by a piece of steel. The eye was somewhat 
irritable and there was a dark line radiating from the sclero- 
corneal margin indicating where the foreign body had entered. 
The iris was slightly discolom-ed. The lens capsule was not 
wounded and there was no opacity of the lens. A glistening 
slightly movable opacity was visible in the vitreous. The 
foreign body had probably entered at the extreme periphery of 
the iris and had entered the vitreous without touching the lens. 
The patient was under observation for nine months, and the eye 
had undergone no material change. He had resumed work for 
some time. — ("Klin. Monatsbl.," Feb., May, 1874, p. 59.) 

SMOKED GLASS PREFERABLE TO BLUE GLASS IN ORDER TO PROTECT 
THE EYE FROM TOO STRONG SUNLIGHT. 

Dr. Dobrowolski advocates the use of smoked glass instead of 
glass of a blue colour in order to relieve the eye from the glare 
of strong light, because the smoke glass diminishes the intensity 
of all the colours ; whereas the blue glass leaves the eye 
exposed to the blue rays without any protection. The blue 
would relieve an eye sensitive to yellow and green, or exposed to 
yellow and green rays, but does not affect the red, blue, and 
violet rays. The smoked glass on the contrary diminishes the 
intensity of colour of all the rays. Anyone accustomed to wear 
blue glasses cannot leave them off easily. — (" Annales d'OccuHs- 
tique," Sept., Oct., 1873, p. 156.) 

A METHOD OF INCREASING THE MAGNIFYING POWER OF THE UPRIGHT 
IMAGE, WITH OBSERVATIONS ON THE SIZE OF THE FIELD OBTAINED. 

Dr. Stammethaus. 

As in a case of myopia the erect image obtained (by correction) 
is more highly magnified than in emmetropia or hyper-metropia, 
in the latter cases the patient should be made myopic by a 
convex glass. — (" Klin. Monatsbl.," Jan., 1874, p. 1.) 

OPHTHALMOSCOPIC OPTOMETRY AND DESCRIPTION OF A NEW 
OPHTHALMOSCOPE. 

By Prof. H. Knapp. 

A CONCAVE reflector is screwed on one side an oblong plate 
with the ends rounded off and two discs on the other. The 
discs revolve and overlap each other opposite the perforation in 
the mirror, and are provided with a series of concave and convex 
lenses which admit of great variety of combination. The focus 
of the combination used can be read off in each case. It weighs 
two ounces. Its price is 40 dollars (81.) — ("Arch, of Ophth. and 
Otol.," vol. iii. No. 2, p. 1.) 



140 PERISCOPE :— NEW INSTRUMENTS. 

OPHTHALMOSCOPE FOR ESTIMATING REFRACTION. 

Dr. Wecker's ophthalmoscope, manufactured by Cretes, of Paris, 
is figured in the " Annales d'OcuHstique," Sep.-, Oct., 1873, 
p. 207, ten + lenses from 60 to 6 inches focus and fourteen — lenses 
from 60 to 2 inches focus are arranged round a disc which is 
made to revolve by pushing up or down a vertical rod. By this 
means an observer can try the whole series of lenses quickly. 
Its price is forty francs. 

NEW INSTRUMENTS. 

Dr. Warlomont figui'es and describes (" Annales d'Oculistique," 
Nov., Dec, 1873.) 

(1) A cijstotome with concealed barb. After the introduction 
of the cystotome, the barb is made to project from one side by 
pressure on a small lever-handle. 

(2) A concealed hook for use in iridodialysis. The hook is 
pushed out, when required, by the same mechanism as in the 
former instrument. 

(3) A needle-Jiook for tearing false membranes, Sfc, in the pupil. 
This was suggested in connection with the plan advocated by 
Mr. Streatfeild at the London Ophth. Congress, for tearing 
through membrane, &c., without exercising traction on otlier 
parts. He introduces two needle-hooks from opposite sides of 
the cornea through the same opening in the membrane and 
then separates them. Dr. Wecker introduces a stop-needle on 
one side, and then his i^oedle-hook on the other. The hollow of 
the hook part of the needle, when introduced, is filled by another 
sharp point which is pushed down inside it. When about to cut, 
this latter is drawn back a little by a lever-handle, and the hook 
is available for use. 

An improved lid-forceps, especially for the operation of 
entropion. Dr. H. Knapp has devised a modification of the 
clamp forceps in general use. He makes the ring surround the 
margin of the plate, instead of resting on it. When the ring is 
screwed down it is larger than the plate, and there is a narrow 
interval between the ring and the plate, so that the eyehd is 
bent and compressed between them. The same clamp is made 
available for both eyes. It gives a larger space in which to 
operate. — -"Arch, of Ophth. and Otol." vol. iii, No. 1, p. 25. At 
p. 220 of No. 2, vol. iii. Dr. Knapp notes a further improvement, 
and at p. 221, Dr. Argyll Robertson describes forceps which he 
has been using for some time, which are essentially similar to 
those of Dr. Knapp. 



Cfie aao^al ilonticm 
Ophthalmic Hospital Reports, 

una ^Durnal at 

©pl^tfialmtc #TtiJicute antr ^uvgerg* 

Vol. VIII. Part 2. September, 1875. 



Part I. 

©ligiiral ^ontriljutiottsf, 

SUMMAEY OF 192 CASES OF ASTIGMATISM. 
By J. W. HULKE. 

A SUMMARY of 192 cases of astigmatism occurring, mostly 
during the past two years, in my hospital and in private 
practice, "will, I venture to think, prove not altogether un- 
instructive. I must, in limine, beg the reader's indulgence 
for the incompleteness of my notes ; it will be accorded, I 
am confident, by all who personally know the pressure of 
ha^v^ng, rmassisted, to prescribe for many patients within 
limited hours — my lot during a great part of this time. The 
data in the tables are, I believe, as exact as clinical work 
permits, and are close approximations to truth, but I may not 
claim for them that rigorous exactness which is expected of 
experiments conducted at leisure in the physiological labora- 
tory. 

Without undervaluing other means of diagnosis, I refer 
particularly to various forms of optometer, each of which has 
its advantages, I have a decided preference for Snellen's half- 
circle of radiating lines and + and — spherical glasses. As 
regards the opthalmoscope, the presence of even a slight 
VOL. vin. L 



142 HULKE ON ASTIGMATISM, 

degree of astigmatism will seldom, I tliink, escape the recogui- 
tion of a fairly practised observer, but the directions of the 
principal meridians are only very roughly determinable with 
it, and I j&nd that a suificiently close measure of their respec- 
tive ]\I or H is only attainable with it by an inconvenient 
expenditure of time. With a fan of radiating lines separated 
by angles of 10°, and + and — s. glasses, not only the presence 
of astigmatism, but the directions of the principal meridians 
and their refraction are, in general, promptly and very closely 
ascertainable. For those whose sight is very blunt, I .use a 
larger fan then Snellen's, with stouter lines, and where, as 
occasionally happens, a patient is bewildered by an im- 
conscious shifting of his accommodation, and he says at one 
moment that this line is the sharpest and at anotlier moment 
another line becomes so, and I find that he cannot form a 
consistent judgment, I replace the fan by a single pointer 
bearing three black lines separated by equal w^hite intervals, 
revolving, like the hand of a clock, across a white sheet on 
which a graduated circle is so faintly traced as to appear to 
the patient to be blank. It is seldom that any difficulty is 
experienced in deciding in which position the striped pointer 
appears clearest and where it is least clear. A series of black 
and white striped circular discs, such as those in Burchardt's 
Internationale Sehproben, but larger, is a very useful control 
test. Their uniform figure makes them a fairer object than 
the similarly striped letters of Orestes Pray. Cylindric 
olasses I have used only as a final control and for correction. 
It is convenient to record cases in a uniform manner, and 
I have found that a sort of graphic notation lessens the 
perplexities of the subject for students and for medical 
practitioners who are not familiar with eye-disease. An 
illustration by an actual case wdll best explain the plan I 
usually foUow. 

Case.— Oc. d. AM ^V II Oc. S. M a. + Am 3V. 
A young naA^al officer, let. 20, consulted me in October, 



HULKE ON ASTIGMATISM. 143 

1873, saying that from childhood he had been aware that he 
saw less distinctly then some other persons, but that which 
seriously distressed him was the difficulty he found in 
recognising signal-flags, especially those composed of crossed 
bands. 

With the right eye I found that he could read No. 1 of 
Snellen's type at 8 inches distance, but he hesitated at No. 50 
on Snellen's test-sheet 16 feet off. With the left eye he read 
No. 1 at 9 inches, but could not distinguish CC (No. 200) at 
16 feet. — s. glasses scarcely assisted the right eye, but 

— -g- s. gave the left eye V. nearly -f^, this eye had then 
M of i. Placed before Snellen's fan at 20 feet (with head 
erect, face square to the test-sheet, eyes widely open, and the 
test- sheet in the level of his eye), with the right eye he saw 
the vertical rays sharply, the inclined rays dimly, and the 
horizontal rays were scarcely visible. The horizontal meridian 
of liis cornea was therefore emmetropic. A weak -f s. glass 
dimmed the inclined rays yet more, but a — s. glass cleared 
them, — J^ s. making the horizontal ray as black and sharp 
as the vertical ray had appeared without the glass. Tlie 
vertical meridian of the cornea was therefore M -J^. To the 
left eye, armed Avith — ^ s., ray 160° * was black and 
sharp, the 70° corneal meridian was therefore M -i-. 70° ray, 
previously pale and dim, was brought out quite sharply|l)y 

— -j-^j-, superposed 160° corneal meridian was therefore 



M 



V9 36/ 36 7J:- 



Stated shortly, the case runs as below : — 
fet. 20, Naval Officer. 



Oc. d. reads No. 1 Snellen, at 8" ; stumbles over No. 50 
Snellen at 16'. Weak ■+ s. glasses confuse and — s. scarcely 
help. 

90° in fan sharp. 0° — 180° very scarcely visible. 

* I graduiite the lialf circle from 0" to 180^, counted from loft to right. 

L '2 



144 



HULKE ON ASTIGMATISM. 



'160 




■IBOB 



• . • Astigmatism, and 

• . • CM. 0°— 180° is E. 

+ s. dims yet more 0°— 180° ray, 
but — s. clears it, and — -jj s. most. 

• . • CM. 90° is M ^. 

With — ^V c. axis in CM.* 
0° — 180°, all rays vmiformly clear, 
and V. almost ^. 



Oc. s. reads No. 1, at 9'', but only No. 200 at 16', and not 
at 20'. 

— i- s. best, V. almost fa. 

•••Mf 

With — i s. 160° ray in fan sharp. 

• . • CM. 70° M i. 



i s. O — -gig- s. clears 70° ray. 
CM. 160° is M (i + 3^6). 



__ ^ 1 

36 — U 




(_ ^ s. O-gV c. axis in CM. 70°) clears whole fan and 
V. — f nearly. Ordered spectacles. 

Left. Rioht. 



^s. 




- yV c^yi. 



* C.M, — Coi Ileal inori'-iuu. 



HULKE OX ASTIGMATISM. 145 

These gave much satisfaction, and removed what had 
threatened to be a serious disability. I Avas agreeably 
surprised to find that, contrary to that which frequently 
obtains where the refraction of the two eyes so greatly 
differs, when their ametropia was neutralized he saw better 
with both eyes than with either alone. 

Of late years one thing has increasingly impressed itself 
on me — the frequency of astigmatism in degrees sufficiently 
great to appreciably diminish the acuteness of sight. 1 had 
formerly thought this to be relatively rare. I refer to regular 
astigmatism. With respect to sexual proclivity I find, so 
far as my numbers reach, that males and females occur in 
nearly equal proportions, the former slightly preponderating. 
Bonders, in his incomparable treatise on " The Anomalies of 
Accommodation and Eefraction," has remarked the preponder- 
ance of astigmatism in males. As regards the social status 
of astigmatics, I find that my private patients, who repre- 
sent a higher social position, are to my hospital cases, as 
119 : 73. 

AVith a very few exceptions, my tables contain only 
examples of congenital origin. I hope, at a future time, to 
contribute a summary of cases of acquired astigmatism, in- 
cluding that which follows extraction and, in some cases, 
reaches -f or even i 

Of all the forms of regidar astigmatism compound myopic 
M. + Am. greatly preponderates. It constitutes 44'271 per 
cent, of all the cases included in this series. Next in frequency 
is the compound hypermetropic, H. -|- Ah. 26'562 per cent. 
Simple myopic Am. makes 13'002 per cent.; simple hyperme- 
tropic Ah. 9"375 per cent., and mixed astigmatism Ah. -f Am. 
"and Am. + Ah. only 6'718 per cent. In half the cases tabu- 
lated below, one eye only had an abnormal amount of 
astigmatism. In many of these, however, the other eye was 
simply myopic or hypermetropic. In several instances more 
than one member of a family was astigmatic, generally under 
the same or a similar form. The subjoined Table explains 
itseK. 



146 



HULIiE ON ASTIGMATISM. 



I. — Tahle of Different Forms of Astigmatism. 











S 






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25 

85 


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84 

42 

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31 


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17 

54 


8 
28 
18 
39 


10 
23 

7 
42 


1 

3 


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26 

8 

27 


16 


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Ah + Am 
























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8 


5- 


8 




10 


3 


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320 


64 


128 


98 


90 


4 


73 


119 



In the following table (II) the quantities under Ah were 
determined, after the ciliary muscle had been paralysed, with 
a solution of sulphate of atropine (gr. iv. ad ^iO^ dropped 
into the eye three times. In many cases Ahm. only was de- 
termined. Tliis frequently arose from patients being unable 
or unwilling to submit, for a few days, to the inconvenience 
entailed by suspension of accommodation. Some were clerks 
and others seamstresses, who would have forfeited their 
situations by absence from work. In most cases, however, 
the complete correction of the Ahm. sufficed to greatly im- 
prove v., and toremove the asthenopia. Under " Eemarks," s. 
means that the glass is spherical, c. that it is cylindrical. 
Upon a comparison of this with the table of AM, it -will be 
seen that high degrees of Ast. are more frequent in Ah. 



HULKE OX ASTIGMATISM. 



147 



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Asthenoiiic. Sight always defective. 
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With + -jJj c. V. |§, and she reads 
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Son of a late physicist celebrated for 
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ultimately broke in two." 

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she said, never before seen so 
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Right very amblyopic. Corneal ne- 
bulse and synech. post., wide my. 
crescent. Left, with (— t^'b s. O — 
3TJ c.).V. = |§. Ordered specta- 
cles, right, plane, smoked glass ; left 
(— -^ c), axis vertical, to equalize 
m. (^V) , for reading ; ( _ J^) g. C - 
-^ c.) for outdoors ; and (— ^'^ s. 
O — To ''O for music. With these 
she saw comfortably and sharply. 

A surgeon's wife. Her left eye had 
been twice inflamed in early life, 
and a third time three years ago, 
after variola. The lens was catara^"- 
touF, nucleus large and hard. qt. 
p.l. Field good. Tension perhaps 
+ ? With (- Of s. C - ^V C-) 
left eye bad V. almost |g ; {- ^%. 


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and CO., quickly reoognized at 16 

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shown any of the usual tests. The 
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PARALYSIS OF ACCOMMODATIOISI, AFTEE A FALL, ON THE 
HEAD, IN A CASE IN WHICH A HIGH DEGREE OF LATENT 
HYPERMETROPIA WAS PRESENT. 

By Henry Power, 
Senior Ojjhthalviic SiLvgcon to St. Bartholomeids Hospital. 

The following notes w^ere made at my request by Mr. 
George Ernest Alford, late house-surgeon of the Royal West- 
minster Ophthalmic Hospital : — 

J. G., set. 41, a coachman, came to the Westminster 
Ophthalmic Hospital on the 28th of February last. He said 
that a year ago, whilst hunting, his horse fell with him and 
he struck his head somewhat violently against the ground. 
Two months afterwards the same thing occurred and his 
head w^as struck on the same spot. His sight had alw^ays 
been very good until the first accident, but afterwards it 
became rather dim ; and since the second accident it had 
been much w^orse, and he had been unable to read the news- 
paper, or to see anything clearly. He had violent headaches 
frequently, and stooping caused great pain in the head. He 
said that he only saw shadows of objects, that everything 
seemed to wave about, and that sometimes liis sight w^ent 
away completely for a short time. He always felt very giddy. 
None of these sensations were experienced until after he met 
with the accidents. On admission the pupils were both 
rather dilated and sluggish, but the movements of the eyes 
were perfect and there was no ptosis. On ophthalmoscopic 
examination the media were clear and the vessels of the 
retina congested. Hypermetropia of a high degree was 
evidently present. His vision Avas as follows (after the 
instillation of atropine) : — 



POWER OX A CASE OF CYCLOPLEGIA. 179 

llifjlit Eye. — Y. = ^f Q, and reads Xo. 15. 

With + 4^, Y. = fo. With + 3^ reads No. o\ at 6 
inches. 

Left Erje.—y. = ^i-„ only. 

With + 4i Y. = ^\%. With f 3 reads No. 11. 

His movements were rather strange, but the great defect 
of vision was considered sufficient to account for this. 

Nothing fm'ther was discovered the next day by Mr. 
Power, save that the lenses were both in their proper position, 
as shown by the reflections of a candle from their anterioi- 
and posterior surfaces. Quinine and iron were ordered, and 
the pupils kept dilated with atropine. His vision was taken 
daily and remained the same. 

On the loth of March he was again examined by Mr. 
Tweedy of University College Hospital, who, w4th Mr. Power, 
was quite satisfied that the lenses were in position. Tlie 
vision of the left eye was then found to be with + 4| 



3 
1 00- 



With + 4^ and - 42 cylindrical \ Y. = fa. 



On the supposition that his accommodation had been 
paralysed by the accident, whilst a high degree of hyperme- 
tropia existed which had been previously undiscovered, he 
was kept in a darkened room for some days, a couple of 
leeches applied to his left temple, some iron and strychnine 
given to him, and atropine was also discontinued. He 
suffered from violent head-aches and great giddiness for the 
next few days, probably owing to the long strain upon his 
eyes, as they recurred after each examination. 

On March 21st, the man, having been again carefully exa- 
mined by Mr. Hutchinson, with Mr. Power, and feeling much 
better in health, having no headache or giddiness, a solution 
of Calabar bean in distilled water (gr. iv., ad. *^i.), at Mr. Hut- 
chinson's suggestion, was dropped into both eyes. In half an 
hour he could read a newspaper with ease, and could see better, 
he said, than he had done for twelve months. The improvement 
effected by the drops was slightly less the next morning, so 
they were repeated with an equally good result. His vision, 
one hour after the drops had been instilled, was as folloM's : — 



180 POWEB ON A CASE OF CYCLOPLEGIA. 

Right Eye. — V. = -f-g-. Reads No. 2 easily, and No. 1^ 
with difficulty. 

AVith + 6 reads No. 1 and V. = f^. 

Left %e.— V. = yVo. Reads No. 2, 

With + 6 reads No. 1^ and V. = f ^. 

On March 31st he was discharged, and the following note 
was taken — 

" He has had no headache or feeling of giddiness during 
the last week. The effect of the Calabar bean is sufficiently 
lasting to enable him to read the newspaper on the third day 
after its instillation, 

The high degree of hypermetropia here present in both 
eyes, which had been entirely overlooked by the patient, is 
very remarkable. The injuries to the head he received in 
his falls obviously weakened his voluntary and involuntary 
power of accommodation, and impaired vision was the result. 
At the first glance the high degree of hypermetropia gave a 
haziness to the margins of the optic disc, when examined 
with an ordinary Liebreich's ophthabnoscope, that coupled 
with the account of the injuries, led to the belief that double 
optic neuritis was present, and suggested serious intracranial 
mischief. When, however, the hypermetropic condition was 
recognised, and such material improvement in the vision found 
to be effected by a convex glass of four and a half inches focus, 
it was thought that there must have been complete disloca- 
tion of both lenses, highly improbable as this might be. This 
momentarily-entertained idea was, however, set at rest by the 
application of Purkinge's catoptric test, which showed clearly 
that both lenses were in place ; besides which, there was no 
tremulousness of the iris, nor any indication of their being 
dislocated on ophthalmoscopic examination. The case 
may prove serviceable in relation to railway cases when con- 
siderable loss of vision is complained of after comparatively 
trifling injury. 



CASE OF SUDDEN AMAUROSIS, ASSOCIATED WITH CHOREA. 

By H. R. SwANZY, A.M., M.B., F.R.C.S.I., 

Surgeon to the National Eye ami Ear Infirmary, OpMhalmic 
Surgeon to the Adelaide Hospital, Dublin. 

Lizzie B., set. 10, was brought to the National Eye and 
Ear Infirmary on 1st May last, complaining of the sight of 
her left eye. On 15th April the child had been out all day 
watching a public funeral, and came home in the evening 
suffering from frontal headache. Xext morning, while 
washing her face, she discovered that the left eye was 
blind. The parents did not seek medical advice for a fort- 
night afterwards, believing that the affection would wear off. 
The headache continued for nine days, and has not returned 
since then. 

Upon making a functional examination I found that 
vision was absolutely wanting in the eye, bright light not 
being distinguished from darkness. The pupil, which was 
dilated, reacted sluggishly when the light fell into the eye. 

The ophthalmoscope revealed those appearances which 
until lately were generally accepted as characteristic of 
embolism of the central artery of the retina. The artery 
in all its branches was pale and diminished in calibre, but 
not quite bloodless. The vein was also somewhat smaller 
than in the normal. There was some haziness of the retina 
around the optic disc, especially above and to the outside, 
but this haziness did not advance quite up to the margin 
of the disc. At the macula lutea there was the well- 
known crimson spot, surrounded by a broad zone of retinal 
cloudiness. 

I observed that the child was affected with chorea, whicli 
was more marked in the left leg and arm than elsewhere, and 



182 SWANZY 0\ A CASE OF 

\vas informed by the mother that this had made its ap- 
pearance almost simultaneously with the blindness. No 
cardiac disease could be found. The patient has never had 
any illness, beyond mild attacks of whooping cough and 
measles. 

lOtli May. A bright light is distinguished to-day from a 
dark shadow. 

14th May. Fingers are counted centrally at a distance 
of 3'. The haziness around the disc is now quite gone, and 
that near the macula lutea very much lessened. The crimson 
spot has become more diffused and less intense in colour. 
The chorea is also better. 

20th May. Fingers counted at 5'. The lower third of 
the field of vision is still wanting. The optic disc is 
becoming white. The crimson spot continues, and also 
the nebula surrounding it. The appearance of the vessels 
remains in general similar to that observed at tlie first 
examination, but there is one arterial branch passing 
downw^ards and inwards, wdiich seems to be completely 
obliterated, and presents the appearance of a thin white 
thread. 

1st June. Since the last visit the obliterated branch has 
recovered so far as to differ in no way from its fellows. 
Very slight chorea still remains. 

14th July. The functions continue unaltered. The optic 
disc is whiter. The crimson spot is fainter, as likewise the 
surrounding nebula. The chorea has quite disappeared, the 
patient's mother having seen nothing of it for a fortnight. 

The treatment consisted in bromide of potash and iodide 
of potash. 

I am rather at a loss to indicate the nature of the fore- 
going case. No doubt it was either embolism of the central 
artery of the retina, or heemorrhage of the optic nerve. 
Since the aj)pea,rance of Dr. Hugo Magnus' work {Die 
Schncrven-Blutmagen : Leipsig, 1874) we are obliged to dis- 
tinguish between these two very different conditions, which 
produce such similar oplithalmoscopic appearances. One of 



SUDDEN AMAUROSIS WITH CHOREA. 183 

the most important points for the diagnosis (the period at 
wliich the infiltration of the retina appears) can only be ob- 
served within the first few days after the occurrence of the 
blindness, and the patient in this instance did not come under 
notice for a fortnight. According to Magnus, in cases of 
h;T?morrhage of the optic nerve the retinal veins are dis- 
tended, while in embolism they are contracted, as they were 
in this case. The complete but temporary blocking of one 
branch, as noticed on 20th May, would also speak for em- 
bolism. The recovery of partial sight in a large portion of 
the field of vision, one-third of the field still remaining 
defective, is a circumstance which 1 am unable to explain. 
There is now no branch of the retinal artery more blocked 
than another, nor when one branch did seem completely 
blocked did the defect in the field correspond to the portion 
of retina supplied by this vessel. 

A chief point of interest in this case, and my principal 
reason for bringing it forward, is the coincidence of the 
chorea. The readers of this journal are acquainted with 
Dr. Huglilings Jackson's hypothesis, that the proximate 
cause of chorea is embolism of capillary vessels in the 
region of the corpus striatum. Were I competent to discuss 
this theory, this would not be the place to do it. I have 
wished merely to publish the above case as a clinical obser- 
vation, which may be taken, so far as it goes, as a proof of 
the theor}^ I refer to. 



CASE OF ANOPHTHALMUS. 

By Henry Wilson, 

Professor of Oidhahnic and Aural Surgery, Royal College of 
Surgeons, Dublin. 

The following instance of absence, or apparent absence 
of eyeballs came under my notice in 1873, the subject of it 
having been brought to me on account of an aural affection : 

A. K., aged 13, the daughter of cousins and one of four 
children, one of whom is said to have died of water on the 
brain, presents a pecuHar physiognomy (reminding one of 
Guepin's* forcible though coarse description) in which the 
prominent mouth, small badly developed lower jaw, high cheek 
bones, and absence of eyes, are the most striking features. The 
teeth are irregularly set, but present no other peculiarity. The 
hands are cramped, the fingers bent on the carpus, and the 
whole bent towards the forearm. This condition was attributed 
to the infant always holding something in its hands, but this 
explanation is doubtful, m.ore particularly when it is considered 
that there was also flexion of the feet ; the left foot had been 
turned inwards, but was now cured by operation. The child 
had been bom blind, and now presented the following ap- 
pearances: — Breadth of forehead 5', height 2", span of open 
eyelids -^, eyelids are fairly developed, but the palpebral 
opening is very small, and the edges of the eyelids generally 
in apposition ; the eyebrows are very badly marked and the 
hair scanty ; the punctum in each lower lid is present, but 
I could not see it in the upper lids ; the lids are constantly 
in motion, though the upper oue is not raised ; inside is a 
conjunctival space lubricated with tears ; occasionally tears pour 
over showing the lachrymal' gland to be present ; the muscles 
also are present, and are evidently attached to the conjunctiva 
or something (? Tenon's capsule) behind it, and are seen to 
move much as they behave after enucleation. The girl can dis- 
tinguish between bright sunlight and darkness by the heat of 

the former. 

* Annales cVOculiBtique, t. vii. 



A CASE OF CONJUGATE DEVIATION OF THE EYES. 

By Priestley Smith, 
Ojphthalmic Surgeon to tlte Queen's Hospital, Birminghxim. 

The foUo'\\^ng case is recoTdecl as an illustration of the fact 
that there exist in the brain, centres which preside over the 
lateral parallel movements of the eyes, which centres are 
distinct from those which govern the movements of con- 
vergence. 

Should the symptoms appear not to warrant the interpre- 
tation given to them, their unusual nature will, I think, 
justify publication. 

George M., ret. 17, a well-gi-own, intelligent, healthy 
looking lad, by trade a milkman, came to the Eye Depart- 
ment of the Hospital, on April 27th, 1875. 

The case, at first glance, looked like paralysis of the left 
sixth nerve. Both eyes were turned somewhat to the right, 
to counteract which the face was turned to the left. It was 
found, however, that not one only, but both eyes, deviated 
fijxdly towards the right, and that neither had any poM^er of 
movement toward? the left. 

The history given by tlie patient was this : — About a 
week Ijefore, he had had " a bad bilious attack," viz., violent 
vomiting and retching, continuing for several days, accom- 
panied by great pain in the head, giddiness, and after the 
vomiting had lasted three days, " something wrong with the 
eyes." 

A more thorough examination of the ocular symptoms 
than was possible during the Hospital visit, was made the 
same afternoon. 

Right eye V. = 1 (-ff ) ; emmetropia ; near point at 4^ 



186 PRIESTLEY SMITH OX 

inclies ; pupil medium size, active ; medi?i clear ; fundus 
normal. 

Left eye V. = ^f ; emmetropia ; near point at 5 inches ; 
pupil medium size, active ; media clear ; fundus differed from 
that of the right eye in having a well marked atrophic 
crescent on outer side of disc ; no other difference was 
observed to account for the imperfect vision — no astig- 
matism. 

There was frequent winking of the right eyelids, accom- 
panied by a similar, though incomplete, winking of the left. 
The lids were rather more widely open on the left side than 
on the right, the fault being probably in the right, for the 
right upper lid appeared to droop slightly, and the skin of 
the right haK of the forehead was in horizontal wrinkles. 
Each eye was examined separately as to its deviation. 
The right maintained a constant deviation of 20" to the 
right, the effect of which the patient neutralised by carrying 
the head turned towards the left. A prism of 20°, base 
towards the nose, enabled him to carry his head in the 
natural position. If the prism was removed while the eye 
was fixed on a disiciiit object, the liead immediately rotated 
as before. No effort on the part of the patient to follow an 
object moved slowly in front of him towards his left, induced 
any movement of the eye. On attempting to follow the 
object further towards the right, on the contrary, the eye 
made an excursion of about J-^jth or ^th of an inch, not, 
however, in a natural manner, but with a jerking movement, 
returning at once to its former position. Upward and down- 
ward movements appeared easy and of normal, or very nearly 
normal, extent. 

The left eye presented an exactly parallel deviation ; viz., 
a constant deviation of 20° towards the right ; an absolute 
loss of voluntary movement towards the left ; a slight power 
of further rotation towards the right; and, finally, normal 
upward and downward movements. There was no diplopia 
in any position of the head. To ascertain that both eyes 
were actually concerned in vision, a prism, base downwards, 



COXJUGATE DEVIATION OF EYES. 187 

was placed before the left ; double vision was at once pro- 
duced. 

Here, then, was total loss of the parallel associated niove- 
inent of the eyes tavjards the left, and impairment of the 
correspondiiuj movcnunt toicards the right. 

The deviation seemed identical with that described by 
Dr. Hughlings Jackson, as one of the symptoms in what he 
calls the " second degi-ee of hemiplegia." (See Part 1, 
vol. viii, of this Journal, p. 96.) 

In referring to Dr. Jackson's paper, I now observe an 
additional point of resemblance, of which I was ignorant 
when the notes of this case were taken, namely, the un- 
symmetrical action of the eyelids. I quote the following 
paragraph (p. 99.) " In this attack I observed, further, that 
the two eyes were well turned to the left before the eyelids 
were closed — the eyelids were indeed at that time very 
widely open — and that later the eyelids rapidly opened and 
closed, the left eye closing very much, the right eye not 
closing completely or strongly, at all events. It was not 
noted whether the left eye closed oftener than the right." 
My case was the converse of this ; the eyes tm^ned to the 
right, and the right lids closed more completely than the left. 
In my case it was noted that the movements on the two 
sides, though unequal, were synchronous. 

The impaii'ment of lateral movements having been ascer- 
tained, it next became interesting to discover whether the 
movements of convergence were impaired also, a question 
which, in case of hemiplegia with conjugate deviation, cannot, 
I imagine, be decided, requiring, as it does, intelligent 
volition on the part of the patient for its solution. 

The patient was told to fix his eyes on an object held at 
10 feet distance and somewhat to his right, and to continue 
to look at it as it approached his face. Binocular fixation 
was accomplished without difficulty up to 5 inches from the 
face ; in short the mover/ients of convergence were intact. TJiis 
involved a remarkable phenomenon, viz., the right eye which 
had before refused to move towards the left, now made a 



188 PRIESTLEY SMITH OX 

considerable excursion (about 15") in this direction ; in fact, 
the right eye seemed to converge rather more freely than the 
left. Fmther attempts were then made to induce the eye to 
perform the same excursion by lateral movement of an object 
in front of the patient, but, as before, absolutely without 
success. To state this phenomenon in other words, the right 
internal rectus muscle contracted perfectly, or not at all, 
according as the attempted movement associated it with the 
internal, or the external, rectus, respectively, of the other eye. 
The unavoidable inference from this is that the branch of the 
third nerve, which is, in either case, the channel of com- 
munication, connects the muscle with two distinct centres in 
the brain, one of A^diich presides over the parallel lateral 
movement of the eyes (which has been compared to the hand 
of a driver tiu^niDg a pair of horses by one rein), and the other 
over the differently associated movements of convergence. 

That such centres actually exist in ascertained localities, 
appears to have been well established both by clinical and 
experimental investigation. In the paper by Dr. Hughlings 
Jackson above referred to, may be found references to the 
WTitings and experiinents of Bonders, Terrier, Hitzig, 
Adamlik, and others, bearing on this subject. 

The progress of the case recorded in the present paper 
was as follows : — 

Ten grains of iodide of potassium were given thrice daily. 
A week later the condition of the eyes was again investi- 
gated and appeared unchanged. The pain in the head was 
much less severe. It was felt chiefly in the left temporal 
and frontal regions, in which situation it had throughout been 
the most severe, though spreading sometimes " over the whole 
head." 

At the end of a second week the pain was almost gone ; 
power of movement towards the left was beginning to re- 
appear in each eye, though much more in the right than in 
the left ; in both the movements were of a jerking character, 
the oscillations being performed around the vertical axes of 
the eyes, and therefore, attributable to the lateral muscles. 



COXJUGATE DEVIATIOX OF EYES. 189 

Three minims of liq. strychnia were given thrice daily, 
and the iodide was discontinued. 

On May 27th, a month after his first visit, the conditions 
were as follows : — the pain was entirely gone. The riglit eye 
followed an object easily to either side, making an excursion 
of normal, or nearly normal, extent, in each direction, but 
oscillating considerably when turning its maximum in either. 
Tliis eye now maintained its natural position, fixing objects 
in front of the patient, who consequently carried his head in 
the natural position. 

Tlu left eye still retained a position of deviation to the 
right. In following an object moved laterally, it turned 
inwards to the normal extent, but oscillated with extreme 
inversion. Outwards, on the other hand, it turned scarcely 
beyond the middle line, and oscillated on attempting to do so- 

Parallelism was now lost for all positions. 

The left eye had a constant inward deviation, increased 
by looking towards the left, diminished by looking towards 
the right ; in accordance therewith, the patient complained of 
constant and troublesome diplopia, the images standing nearer 
together in looking to the right, farther apart in looking to 
the left. The horizontal folds before observed in the right 
forehead had disappeared, and winking occurred only to a 
natural extent, and equally on the two sides. The acuity 
of vision, and the ophthalmoscopic appearances were un- 
changed. 

In this condHion the patient remains at the present time 
(June 25th). If, after an interval of time, and the employ- 
ment of Faradisation over the left eye, the strabismus still 
remains, it is my intention to resort to tenotomy. 

Although during recovery, the conditions in this case 
have become unsymmetrical, I believe the symptoms recorded 
justify the diagnosis of a lesion of a centre, or centres, frc/- 
siding over lateral 'move7nents of the eyes. To venture farther 
than this, beyond the province of ophthalmology, I feel to be 
unsafe, but I may make one or two quotations which bear on 
the case. 

VOL. VIll. 



li)(.) PRIESTLEY SMITH ON CONJUGATE DEVIATION OF EYES. 

Dr. Hughlings Jackson, in the article before alluded to, 
says that the eyes turn/row^ the side paralysed in hemi-jilegia 
(i.e. to the side of the brain lesion), while they turn to the 
side con\'ulsed in hemi-sprtswi (i.e. from the side of the brain 
lesion). 

Dr. Terrier states that the centre presiding over lateral 
deviation of the eyes and head is " situated in the convolu- 
tions of the frontal region." ( West Eiding Eeports, vol. iv, 
p. 52.) 

The centre for convergence of the eyes is stated by 
Dr. Jackson and Dr. Terrier to be situated in the cerebellum. 

From these data, it would seem that the deviation in my 
case must have been due to tonic spasm, rather than to 
paralysis as I had surmised. 

The pain was chiefly in the left forehead and temple ; the 
eyes turned to the o^ight ; the corrugation of the right fore- 
head and the winking of right lid coincide with a supposed 
lesion of the left brain, as similar symptoms on the left side 
coincided with an actual lesion of the right brain in 
Dr. Huglilings Jackson's case of hemi-spasm ; and finally, 
the supposition of toni^- spasm of the right lateral muscles of 
the eyes, accounts for the impairment of further movement 
towards the right, as well as for the loss of movement 
towards the left, which would not be explained by a supposed 
imralysis of the left lateral muscles of the eyes. On this 
latter point, however, I do not venture to speak with any 
confidence. 



REPORT ON THE FORMS OF EYE DISEASE WHICH OCCUR 
IN CONNECTION WITH RHEUMATISM AND GOUT. 

By Jonathan Hutchinson. 

(Coutinued from vol. vii, page 4iJ3.) 

Case LXXXVIII. — Relapses of Iritis first in one Eye, then in the 
other, attended by much inflammatory swelling of Conjunctiva 
and Lids, and effusion of Blood into Anterior Chamber; the 
blood coagulatincj and not gravitating — Rapid recovery tinder 
Treatment — No Syphilis or Gonorrhoea — Slight Arthritic history. 

Francis T., had liis first attack of iritis, in one eye only, at 
tlie age of 17 ; two yeai'S later the other eye suffered in the same 
way, and a year later a third unsymmetrical attack is noted. On 
these occasions he was under Mr. Dixon's care, and states that 
after treatment (iodide of potassium with full doses of bichlo- 
ride of mercury) his eye had improved so much that whereas 
on admission he was not able to read the largest type, in a week 
he could see the smallest. 

His eyes then remained well for five years, when he came 
under my care (/Sepf. — Oct., 1869) with a fresh and severe attack 
of inflammation in the right eye (this was his fourth attack). 
There was patchy congestion in the ciliary region. The attack had 
begun ten days before, and about two days after he had been out 
shooting on a cold day. For the first week he had no great 
pain, but after that he was kept awake by its increasing severity. 
The state of the eye was peculiar ; there was great chemosis ; 
the iris was much thickened, and there was dark coloured 
blood effused into the anterior chamber. It had not gravitated 
to the lowest part of the cavity, but occupied the inner and 
lower third, adhering to the angle between cornea and iris, and 
following their circumferential curve. The lids were also 
swollen. The general aspect of the case resembled iritis from 
injury or from sympathy; there was, however, no history of 
any hurt to the eye. He could barely count fingers. I pre- 
scribed mercury and opium pill twice a day, atropine, a leech 
and a blister to the temple. The pain was relieved almost 
immediately by the leech. Three days later the pupil was 

o 2 



192 HUTOIIIXSON ON ARTHRITIC IRITIS, ETC. 

fairly dilated, he had much less pain, and the !^blood in the 
chamber had partly disappeared ; a week after I first saw him 
there was no trace of Wood remaining. 

Before his first attack, Francis T. had never had any form of 
venereal disease ; four months before the second attack he had a 
chancre, but it soon got well and was not followed by any known 
secondary symptoms. He married at 20, and when I. saw him he 
had three children, all reported to be in good health. He denied 
ever having had gonorrho3a. There was no history of arthritic 
disease known in his family, but his father had had some eye-affec- 
tion ; he himself was subject to occasional pains and stiffness in 
his hips and knees, but these never were enough to lay him up ; 
he had not had rheumatic fever. There were no lips on the 
condyles of his femurs. 

In JDeceniher, 1871, he had his 5th attack, again accompanied 
by hcemorrhage. The 6th, a very slight one, occurred in the 
winter of 1872—73 ; the 7th and last, so far as I know, was in 
Septemher, 1873, after exposure to cold and wet at the sea-side, 
when he had been swimming a long distance and also tiying the 
eyes by long looking at the float in fishing. It was similar in all 
respects to the one above described (the 4th) but rather less 
severe, and like it and the other attacks, very raj^idly passed oif, 
leaving no synechise. A week after its commencement he was 
discharged well, the only evidence of iritis then to be found 
being a ring of small dots of pigment on the lens capsale. The 
pain had been very severe in the early stage. 

1 did not elicit any fui"ther facts of great importance as to 
his own or his family history. He stated, however, that he was 
subject to a very slight form of recurrent gleet with only the 
very smallest quantity of discharge, and that he had been sub- 
ject for some little time to repeated rheumatic pains in his hips 
and knees. He has never suffered from epistaxis. 

Case LXXXIX. — Severe Wieumathm of three months' duratioi. 
before any Venereal Disease — Gonorrhoea several times aftenvards 
— Syi)hilis and jierhaps Syphilitic Iritis folloiced hy Rheumatism 
— Four years after the Syiihilis, doiihle Iritis, ivith interval of 

2 mos. betiveen the tivo Eyes; spontaneous Urethritis, noc- 
turnal 'pains in Bones — Mother very Rheumafic. 

Horace G., ajt. 2G, was under care in January, 1872, and 



ORIGINAL CASES. 193 

again two months later, in March, for iritis, first of the right 
then of the left eye. He was under care a month or five weeks 
each. time. The first attack was attended by slight chemosis 
with a gray rim round the cornea, and considerable haze of 
cornea. It was also attended by much nocturnal aching in the 
tibias, and for a few days by slight spontaneous urethritis ; he 
had never before had urethral discharge without contagion. 
The iritis in the left eye came on the day after a drive in 
an open trap through a snow-storm. He attributed the escape 
of the right on this occasion to its being shaded. The patient 
had been married two years when I saw him and had one child 
reported to be in good health. He is a stout, rather flabby 
man with black hair*, a commercial traveller in provisions. 

At the age of 20, before he had had any venereal disease, he 
was laid up for three months with " rheumatic fever ; " his joints 
were very painful and somewhat swollen ; his medical attendant 
examined his heart and told him it was not affected during the 
rheumatic attack. This attack came on after a walk in cold 
weather with unusually few clothes on. Soon after this he had 
gonorrhoea, and two years later a chancre followed by " quinzy." 
Several months after the chancre he was again laid up for three 
months with rheumatism, brought on as he thinks by sleeping in 
a damp bed. He had slight inflammation of his eyes about the 
same time, and the doctor who attended him for the rheumatism 
told him that the eye disease was syphilitic. He got perfectly 
well of his rheumatism and remained without further trouble 
till the iritis for which I treated him. 

His mother at the age of 26 had " i-heumatic fever " and 
ever afterwards suffered very much from "rheumatism" and 
"rheumatic gout." No other relatives were known to have had 
rheumatism or gout. The patient said that he resembled his 
mother more than his father. 

XC. — Unsymmeirical Iritis iv a Man ivlio had suffered from repeated 
attacks of '^ Ehenrnatic GoiW — No family history of Arthritis. 

John G., aged 43, has a pale complexion, sea- weed congestion 
of the cheeks and sandy hair. He has been subject to attacks 
of inflammation and swelling of his knees and feet at times 
during the last fourteen years. He believes that it was caused 



194 HUTCHINSON ON ARTHRITIC IRITIS, ETC. 

in the first instance by working at an iron foundry where the 
rooms are very hot. His medical attendant told him it was 
"rheumatic gont." In November and Decemher, 1871, he had 
iritis of his left eye lasting for about two months, and as the 
inflammation of his eye was getting better the knee and ankle on 
the same side swelled. The eye has been damaged as to sight 
since he had a blow on it from a shutter twelve years ago. He 
has doubtful lips on his left femur, none on the right. Neither 
his parents nor grand-parents had either gout or rheumatism so 
far as he knows. 

Case XCI. — Severe Articular Bhenviafism attributed to living in 
a daonj) house — Siibsequent liability to slight Joint AttacJcs and to 
Neuralgia — Iritis of one Eye six years after the first KJieuma- 
tism ; severe, prolonged and remittent — Iridectomy tivice 
during Acute Inflammation, folloived by much relief. History 
of Syphilis many years before either the Rheumatism or the 
Iritis — Tertiary Symptoms complicating his Rheumatic Affec- 
tion. 

Rudolph A., aged 40, a gas-meter prover, was admitted at 
Moorfields, at the end of January, 1872, vnth severe acute iritis 
of his left eye. There were many synechias and much conges- 
tion. There were no nodules in the iris. It had been going on 
for three weeks. He was a florid, light-haired. German, well 
made and very healthy looking. He remained under my care 
for four months, and was finally discharged with much damaged 
vision in the left eye. During this time, several remissions took 
place, but the inflammation never entirely ceased. For some 
time there was haze of the cornea, with dots on its posterior 
surface. The inflamed eye gave him, on the whole, a great deal 
of pain. He sufibred also on and ofi" from rheumatic pain in his 
right shoulder, and from severe neuralgia of the right side of 
fiice, head, and neck. I ordered him iodide, bicarbonate and 
nitrate of potassium with colchicum, repeated local blistering 
and leeching, and atropine. He always bore strong testimony to 
the great relief to pain aSbrded by leeching the temples ; he had 
about twenty-four leeches during the first three months. His 
eye improved rapidly for the first week or two, but then got 
worse and remained so. At the end of two months, finding 
his eye, if anything, rather worse than better, still very painful 



ORIGINAL CASES. 195 

and acutely inflamed, I performed iridectomy upwards. Much 
relief followed tlie operation, and for the next three weeks he 
had little or no pain in the eye, and less congestion. Then 
another relapse of pain and inflammation came on and a second 
iridectomy (downwards) was done, in my absence, by Mr. Streat- 
feild. The efl:ect was quite as marked as that of the first opera- 
tion and lasted till he ceased attendance six weeks later. It 
should be mentioned that, at the time of the second iridectomy, 
he was taking bichloride of mercury in one-sixteenth of a grain 
doses, with five grains of iodide of potassium ; as, howevei*, he 
had been taking this mixture, instead of the one ordered at first, 
without benefit, for a week before the operation, it is fair to 
attribute the relief to the surgical procedure. The mercury was 
continued till he was discharged in May. 

He had a slight relapse (in the opposite eye) about three 
months after his discharge from hospital (in August, 1872). I 
saw him again in December of the same year, and found that 
the attack had left no traces of iritis. 

Six years before the iritis began he was laid up for two 
months with "rheumatic fever;" many large and small joints 
were swollen. It came on soon after he had gone into a new 
damp house. Since this attack he has remained liable to occa- 
sional swellings of the knees, wrists, and fingers. He has, 
probably, also had rheumatic inflammation of his jaw ; for a year 
before the iritis, he was under care at a hospital for stiffness of 
this joint, and had it forcibly moved under chloroform. It is 
possible that the inflammation was located in his left eye by a 
severe blow on the corresponding eyebrow, which occurred four 
years before ; it " blackened " the eye, and has left a scar on the 
eyebrow. He has slight lips on the condyles of his femurs. 

It is almost certain that he had syphilis many years before 
his rheumatism (at about the age of 18, or twenty-two years 
before the iritis). The chancre does not appear to have been 
followed by secondary symptoms; but during the two years 
preceding his iritis, he had swellings on his shin-bones and a 
considerable swelling over the right lower jaw, which was 
diagnosed by a surgeon to be a tumour requiring excision ; it 
quite disappeared, however. He is married and his wife has 
had several miscarriages and has lost three children, but none 
have died below the age of eighteen months. There is no history 



19(3 HUTCHIXSON ON ARTHRITIC IRITIS, ETC. 

of syphilitic symptoms in any of tliem. I have tried to follow 
him np recently {July, 1875) but without success. 

Case XCII. — Five attacJis of severe Gonorrlimal Rheumatism, 
foUotved by several attacks of unsymmetrical Iritis — Patient the 
fifth child — His elder brothers and sisters slightly Rheumatic — 
Inheritance of Arthritis from both Parents — Patient probably 
the subject of Syphilis acquired after his first Iritis. 

Edwin G., get. 29, bookbinder, has light brown hair and 
gray eyes. He was admitted at the Moorfields Ophthalmic 
Hospital on February 1, 1872, for his first attack of iritis ; the 
left eye was affected. There was considerable sclerotitis as well. 
He was under care for about six weeks, using iodide of potas- 
sium, blisters, and atropine, but was quite well for three weeks 
before he left off attending. There was no iritis of the other eye. 

This patient is the youngest but one in a family of six ; some 
of his brothers and sisters have had slight rheumatism, but 
none have had it severely. His father (a coachman) has had 
several attacks of gout in the great toes, while his mother is 
crippled Avith rheumatism in her hip and has it also in her 
hands and arms. He thus inherits the arthritic diathesis from 
both parents. He himsolf has had five attacks of rheumatism, 
always accompanying or following gonorrhoea ; he has never had 
rheumatism without gonorrhoea. The first of these illnesses 
occurred at the age of 20, the last in July, 1871, six months 
before I saw him. He has sometimes been laid up for nine 
months with the rheumatism. The parts chiefly selected are the 
knees, elbows and hands ; these joints swell up a good deal. 
He is well betweenwhiles, excepting occasional pains ; he 
sometimes notices that the day after he has been using a 
hammer, his hands get stiff and he is obliged to put them into 
hot water before he can open them. He has never had urethritis 
without contagion. He has always drunk beer moderately. 
There was no articular rheumatism when he had his iritis. 

Subsequently during the summer of 1872 {May to November) 
he was again laid up for six months by rheumatism in his feet, 
knees, hands and shoulders ; the wrists and many small joints of 
the hands were affected ; this attack was not connected with 
gonorrhoea, from which, indeed, he had not suffered for three or 
four yeai's. 



ORIGINAL CASES. 197 

In January, 1873, he was again at Moorfields for iritis in the 
right eye (its first attack), and was under care till the end of 
Ajjril. During this time the eye was once nearly well, but 
relapsed, apparently because he began to use it again ; he said 
that it became red within an hour of his resuming work (book- 
binding). While under care, he had some rheumatism in the 
right hand and right hip. 

In September, after a blow on the left eye, a relapse of iritis 
occurred in it. 

On October 2nd, there was a ciliary congestion and irrita- 
bility of both eyes, and flying rheumatic pains in the knees, 
ankles, &c. The eyes were examined with the ophthalmoscope 
at this date, and it was noted that there were no opacities in the 
vitreous of either. 

In February, 1874, the left again inflamed; he attributed it 
to a blow from a potato. 

On February 15, 1875, he again applied for acute iritis of the 
left, of three days' duration. It had come on whilst standing in 
a draught, two or three evenings before ; there was also some 
recent swelling of the elbows. The iritis came on the evening 
after a night's drinking. There was no gonorrhoea. 

With regard to syphilis, no evidence of it was present 
during his first attack of iritis. While under care for the 
second attack (in March, 1873), however, I found that he had a 
sore place within the lower lip and a scar on the tongue. They 
were undoubtedly of tertiary syphilitic character. He was not 
aware that he had ever had a chancre or any secondary symp- 
toms, unless an ulcerated throat which had occurred during a 
gonorrhoea six or seven years previously, was of that nature. 
If, as seems highly probable, he did suffer from syphilis on the 
above mentioned occasion, it must still be observed that he had 
no iritis whatever until several years later ; his first iritis was in 
February, 1872 ; whilst, if his account is correct, the ulcerated 
throat must have occurred in 1867 or 1868. 

Case XCIII. — Kerato-Iritis of one Eye. A very prolonged attach 
of Mheumatic Arthritis several years earlier — No Gonorrhoea — 
Family history of Arthritis. 
Edward G., a labourer, set. 40, has a pale complexion, brown 

hair, and gray eyes. He came under care for kerato-iritis of the 



108 HUTCHINSON ON ARTHRITIC IKITIS, ETC. 

left eye, the lower part of the cornea being hazy; this was in 
February, 1872. For sevei^al days before the eye inflamed he 
had had some rhenmatism in his shoulders and elbows. 

He stated that five or six years before the iritis he had been 
laid up for thii-ty-six weeks with " rheumatic fever;" his joints 
were much swollen, very red, and painful. He got perfectly 
well and had only had slight reminders of it since. He 
denied ever having been exposed to the risk of catching any 
venereal disease. He was not aware of any history of arthritic 
diseases, although he said that he had known both his parents 
and all his grand-parents. He attributed his rheumatism to 
damp and cold. 

Case XCIV. — Slight Rheumatism in Joints, folloioed in five or six 
years by JJnsymmetrical Iritis — One year later severe Joint 
attach, folloived aftqr fotir years by the second Iritis — 
Gonorrhcea many years before any Rheumatism loliatever — 
Severe Rheumatism in his sisters. 

William H., ffit. 40, formerly a sailor, now a shoemaker, had 
his second attack of inflammation in the left eye in March, 1872 ; 
there was well-marked iritis (excluded pupil), and a good deal 
of conjunctival congestion. This attack came on a day or two 
after he had had a blow on the eye from an open hand. The 
former attack had occurred in the same eye five years before. 
On neither occasion had he any rheumatism. He was under 
care for about three weeks ; he obtained much relief from the 
artificial leech and free blistering, together with iodide and 
bicarbonate of potassium. He is a florid spare man, with blue 
eyes, and light brown (almost sandy) hair. 

Four years before 1 saw him, and about a year after the first 
inflammation of the eye, this patient was laid up for nine 
months with rheumatism in the right knee, left foot and both 
shoulders ; five or six years previously, however, he had begun 
to sufl'er from rheumatism in his joints. Since then he has 
often had slight rheumatism. Two of his sisters have suffered 
severely from arthritis; one, when young, had "rheumatic 
fever," the other has rheumatism in the hands and knees. No 
other relatives are known to have had rheumatism or gout. 
Several (six or seven) years before he had the least sign of 



ORIGINAL CASES. 199 

rheumatism lie had gonorrhoea and a chancre, but nothing 
else. This was seventeen years before the severe arthritic 
attack. 

Case XCV. — Itepecded attacks of Acute Joint • Inflammation 

( ? Goitt or Eheumatic Arthritis) ; two of Unsymmetrical Iritis 

— Urethral discharge of douhtful character hetiveen the Arthritic 

attacJcs — Family history of Arthritic Diseases, 

Robert B., set. 32, a collector, has had three attacks of 

" rheumatic gout" in bis great toes and ankles, and two of iritis 

in the I'ight eye. He describes the joint attacks as coming on 

suddenly in the night, and as accompanied by swelling, shining 

of the skin, redness and severe pain. The first was in one great 

toe, the fellow toe becoming affected a week later. The second, 

his worst attack, laid him up for six weeks, and was followed in 

a short time by the first iritis. It was for the second iritis that 

I treated him in April, 1872 ; he had then no joint inflammation, 

nor had he had any for a year. The iritis was accompanied by a 

good deal of corneal haze. About twelve months after the first 

attack of " rheumatic gout " he had a urethral discharge ; his 

doctor said it was due to a vaginal discharge after miscarriage in 

his wife and that it was not gonorrhoeal. It may possibly have 

been spontaneous (arthritic) urethritis. 

The patient's sister was laid up for six or seven weeks with 
"rheumatic fever" when fifteen years old; her joints are stated 
to have swelled. She has ever since " been troubled with rheu- 
matics," being every now and then obliged to keep her bed from 
an attack of swelling of joints. A maternal uncle of the patient, 
a publican, suffers from " rheumatic gout." There is no other 
known history of joint affections in the family. The patient's 
mother is living, det. 70, and said never to have been in the least 
rheumatic. 

Case XCVI. — Unsymmetrical Iritis in an Arthritic Patient, at 30 
— Gonorrhoea followed by Ankylosing Rheumatism of one elbow, 
at 20; 710 other joints affected then or since — Gout inherited 
from his father — Patient's brothers and sisters not Arthritic. 
Charles T., ast. 30, was admitted at the end of August, 1872 

with slight iritis of his right eye; he had never had it before. 

There was no reason to suspect syphilis, nor anv evidence of it. 



200 HUTCHINSON ON ARTHRITIC IRITIS, ETC. 

His left elbow was completely ankylosecl and had been so 
for about ten years since an attack of "rheumatic gout " in the 
joint, which followed soon after he had caught a gonorrhoea. 
He is the eldest of six, all are sons ; none, excepting himself, 
have had rheumatism or gout. His father suffered badly from 
" gout " in his feet ; he was a miller, and died at 42, of " typhoid 
fever." 

When admitted, the patient was also suflPering from vesicating 
erythema (? hydroa) of the ears and hands. On the backs of 
the hands were a number of wheals, some small and separate, 
others large, irregular and made up by the coufluence of smaller 
ones; they were permanently white and on many of them there 
were vesications. There were some similar spots on the anti- 
helix of each ear and one or two small ones on the lower lip. 
The vesicles were always much smaller than the wheals. 

He stated that his eye began to inflame on Atigust \?>th, and 
that on the \^th he consulted a medical practitioner, who ordered 
some medicine which he began to take the same evening. After 
he had taken four doses, the rash began to appear ; this was 
during the night of 20th; he was woke up by the smarting of 
the eruption. The vesicles foi'med afterwards. I have not been 
able to ascertain the composition of the medicine. 

Case XCVII. — Iritis in one Eye eighteen months after the loss hy 
injury of the other — Diagnosis between Sympatlietic and 
Arthritic Iritis difficult; the latter reordered lorohahle hy the 
result and the previous history — Strong family history of Gout 
— Iritis ivith Corneal Ulcers in a hr other. 

George W., £et. 36, had his left eye wounded by the ferrule 
at the end of a stick during the summer of 1869; it is impro- 
bable that any foreign body remained in the eye. He suffered 
from inflammation and much pain in the eye and was under my 
care for nine months. At first he had some sight in it, but this 
was quite lost before he ceased attendance. He visited the 
hospital as long as the lost eye continued painful, and after nine 
months' attendance it became quiet and remained so. He had 
never had anything amiss with his eyes before this accident. 

He was a very steady man, drinking a little beer daily ; 
spirits he could not take. His incisor teeth were very bad and 



ORIGINAL CASES. 201 

he attributed tliis to liis having taken much calomel for " croup," 
between the ages of five and twelve years. 

In Decemher, 1870, eighteen months after the accident, he 
again presented himself with inflammation of the right eye ; the 
eye had begun to get " i-ather painfal and inflamed" two or 
three weeks before, but had suddenly become much worse six 
days ago. It had been attended by great pain, especially at 
night. There had been no pain or ii'ritation in the left (injured) 
eye whatever since his last attendance nine months before, nor 
was there any when he applied on account of his right eye. 

There was, at the above date, well-marked iritis with exclu- 
sion of the pupil in the right ; great congestion of the ocular 
and palpebral conjunctiva ; steaminess of cornea and a line of 
slight chemosis around it ; extreme tenderness of the globe to 
pressure ; T. normal. Three weeks later indectomy was done 
in both eyes, with the result, after some weeks, that vision 
increased, from being able only to count fingers with the right eye, 
to 6 J. This improvement was gradual but steady, the whole 
case occupying about six weeks from the date of operation. The 
injured eye was not improved materially ; with it after the 
operation he could just see shadows. 

Three years before the iritis of his right, he was laid up for 
three months by severe articular rheumatism accompanied by 
great pain in the joints, but not by much swelling. His father, 
a man of 70, began to sufier at about 69 from " rheumatic 
gout " in his hands and feet, and his fingers had become some- 
what deformed by it. His father's mother is believed to have 
had gout badly, and the patient's own mother, now tet. 71, has 
quite lately had " gout " in her feet and hands. 

The completeness of the cure of this patient's iritis, together 
with his own and his father's arthritic history, makes it 
extremely probable that his attack was of arthritic and not 
of sympathetic nature. 

He was discharged at the end of February, 1871. In 
December, 1872, he again came complaining that the right was 
getting dimmer ; he could see only 12 J. with it ; there were no 
definite symptoms of inflammation, but the eye was watery and 
he complained of waving muscse. He was suffering at the time 
from rheumatism in the neck and loins. 

Between the patient's visits to the Hospital, in November, 



202 HUTCHINSON ON ARTHRITIC IRITIS, ETC. 

1871, a brother of his, set. 42, carae under my care for increasing 

failure of sight. I found that he had old corneal opacities and 

incomplete areus, in consequence of prolonged marginal ulcers of 

cornea in childhood, and also iritic adhesions (cyclo-kerato-iritis). 

He said that his eyes had been very bad for three years at about 

ret. 7, and weak for several years longer, but that he had had no 

relapses since then. He was a stout, rather florid man, with 

brown haii' and irides and good teeth, and was, like his brother, 

partly bald. He had had no rheumatic or gouty symptoms, 

unless we include as rheumatic an attack of left " pleurisy " 

many years before, and some years later (nine years before I saw 

him) occasional attacks of " neuralgia " of the left flank, the 

pain of which was different from that of the " pleurisy," and was 

treated by hypodermic injections. He was in the habit of taking 

a little beer regularly but could not drink either stout or spirits. 

Case XCVIII. — Relapsing Iritis and slight Rheumatic pains in 

a Woman of 29, the subject of Tertiary Syphilis — Rheumatic 

Arthritis and Catarrho- Rheumatic Ophthalmia in her grand- 

onother, who also has Xajithelasma and Hcemorrhagic Retinitis 

— Rheumatism in grandmother^s mother — Tendency to left- 

sidedness in diseases of the patient and grandmother. 

(The cases of Mrs. B. o.d Mrs. J., her grandmother, hare been published 

Terj briefly already, see Nos. LXX and LXXI of this series, toI. vii, p. 482.) 

Mrs. B., aet. 29, first had iritis of her left eye in December, 

1869. During the next 2^ years she suffered repeated relapses 

of inflammation in the same eye, recovery (perfect as regards 

the inflammation) taking place between each attack. During 

about the same time .she had several patches of ulceration on the 

left side of her scalp, and fresh gummous tumours formed thei'e 

during her attendance. She had formerly had similar ulcerations 

on the left thigh. 

She states that fourteen years before the iritis, and soon 
after maiTiage, at about the age of 15, she had syphilis from 
her husband. The primary disease was followed by eruption 
on the skin, sore throat and falling of hair, but not by any 
affection of the eyes. 

This patient considered that she had been liable to " rheu- 
matic pains " for several years, and stated that a short time 
before her eye inflamed she suffered severe neuralgic pain in the 
left side of her face. Although her own rheumatic symptoms 



ORIGINAL CASES. 203 

were thus slightly marked, her family history furnished abundant 
evidence of arthritic tendencies. 

The patient had not known anything of her father for many 
years and was not able to give any evidence as to his health. 
Her father's mother, Mrs. J., a florid stout old woman of 72, 
with dark hair like the patient's, was laid up for several 
months at the age of 50, with what she called rheumatism 
in her ankles, knees and hands. In after years she had 
numerous attacks of " rheumatic gout " in many small and 
large joints ; she described the great toe joints as being suddenly 
affected with swelling, redness, and glossiness of skin. This 
old lady stated that she had frequently had inflammation of 
her eyes. The attacks were accompanied by intense pain, but 
neither by impairment of vision, nor discharge ; they were of 
short duration and generally preceded a rheumatic attack in the 
joints. In early life she was a great sufferer from sick head- 
aclies, but they left her at about 40 years of age. She had lived 
freely, and had drunk beer and port wine. 

Mrs. J. herself came under my care early in 1871, for 
retinitis with very extensive hajraorrhages in the left eye only. 
The h£emorrhages were very numerous and occurred all over the 
fundus. The eye had failed about a month before, without pain. 
She had a single small patch of xanthelasma on her left 
upper lid close to the inner canthus. With regard to her joints, 
the articulations of many of her fingers were enlarged and 
stiffened. The knees were stiff and weak ; there were well- 
marked lips on the femoral condyles, much synovial thickening, 
and many pedunculated bodies in the knee-joints ; the right 
knee grated disunctly on movement. Her urine contained a 
large number of hyaline and slightly granular casts of various 
sizes, but no albumen. 

Mrs. J. stated that her mother had formerly su.ffered from 
what was called " rheumatism in her shoulders and side, and in 
her teeth." 

Returning to Mrs. B. (Mrs. J's. grand- daughter), it seems 
highly probable that she inherits a tendency to arthritic diseases, 
and her relapsing iritis and severe neuralgia are most likely 
early manifestations of it. There seems to be no sufficient reason 
for thinking that her tertiary syphilis had anything to do 
with tlie iritis, for the nature of the iritic attacks, taken in con- 



204 HUTCHINSON ON ARTHRITIC IRITIS, ETC. 

JLinction with the strong family history of arthritis, would have 
supplied an efficient cause had the patient not been syphilitic. 

With reference to asymmetry in pathological tendencies, it is 
interesting to note the occurrence on the same side (the left) of 
iritis and tertiary syphilitic ulcerations in Mrs. B., and of the 
retinitis hgemorrhagica and xanthelasma in her grandmother. 

Case XCIX. — Painless Rheumatic Arthritis and Chronic Iritis in 

an old tvoman, ivho (^prohahly) does not inherit the Arthritic 

Diathesis— Severe Deforming Arthritis in her daughter; her 

sons not Arthritic. 

Ann E., iet. 73, has had chronic ii-itis of both eyes for several 
months ; it has been attended by considerable photophobia ajid a 
chronic catarrhal state of the conjunctiva has remained after the 
subsidence of active iritic inflammation. It is her first attack 
and began in April. 

She has never had any noticeable rheumatism, but she lias 
distinct lips on her femurs and grating in the knee joints, both 
conditions being more marked in the right knee. 

She has had four children, only one of them being a daughter. 
Her sons have had, so far as she knows, no arthritic symptoms. 
The daughter, at about the age of 40 and after having borne 
several children, began to suffer from rheumatism in her fingers, 
and now she is said to have many joints affected by the disease. 
Her knees, ankles, and shoulders have suffered, as well as her 
hands : the hands are said to be " as thick as two should be." 

There is no history of any kind of arthritis in the patient's 
ancestors. She knew both her own parents, and all her grand 
parents excepting one, and is certain that none of them had 
any joint disease of consequence. Her father was a small farmer 
and di^ank very moderately of malt liquors. The patient herself 
has always been obliged, from poverty, to use as little beer as 
possible, and considers that she " has had less than she ought to 
have had ;" she is a healthy looking old woman and in tolerable 
vigour for her age. 

Case C. — Gout in the father — Rheumatic Arthritis and unsymme- 
trical Iritis withvaHous symptoms of fascial Rheumatisin, in a 
son; severe Arthritis {probally goid and rlieumatic arthritis) 
in a daughter. 
Samuel S., aged 37, had his first attack of iritis in August, 



ORIGIXAL CASES. 205 

1871 ; it was in his right eye. About 12 years ago hft liad a 
prolonged gonorrhoea lasting two years, but denies having had 
symptoms referable to syphilis. He has often had pain and 
" stiffness " in his loins, and " stiff-neck ; " he used formerly to 
suffer a good deal from cramps in his legs and sometimes the 
pain would wake him up at nig"ht. The only symptom of articu- 
lar disease has been aching in the knees, he has often had 
this bat took little notice of it. He now has decided, but 
small, lips on the condyles of his femurs, and there is effusion 
into the bursa beneath the ligamentum patellae in each knee. 
He had no rheumatic pains when the eye inllamed, nor was the 
iritis attended by much redness or by severe pain. 

The patient is a brush-maker ; he is not well off and does 
not live verj- well. He has dark hair and a pale face, and says 
that he resembles his mother. 

His father suffered severely from gout and was often laid up by 
it ; he was a stout light-haired man, by occupation a gardener and 
coachman. The patient is the fifth in a family of seven ; the 
eldest, a sister, is said to have had " rheumatic fever " several 
times. The last severe attack laid her up for five months, 
but she still often has transient attacks lasting two or three days. 
These are chiefly in her feet and are severe enough to lay her 
up for short periods. She is said to be a stout heavy woman with 
dark hair ; she has been a cook since she was 10 years old, and 
has always lived well, and these facts in her history make it 
extremely probable that her attacks of "rheumatism," at least the 
latter ones, are reall}' attacks of gout. No other relatives known 
to be aithritic. 

Case CI. — A single severe attacJc of Arthritis {? goitt) in one foot, 
folloiced by various slighter Arthritic symjotoras — Sabsequently, 
Chronic Iridocyclitis first in one eye, then in the other; Secondary 
Glaucoma and complete blindness of the eye first affected — 
History of a fit, folluived by Semiplegia, several years before 
the other symptoms — The severe Arthritis, lost JEye, aiid Hemi- 
plegia all on the same side — No hereditary Arthritic history — 
Possible influence of lead. 

William H., aged 42, a coach-painter; he has a pale com- 
plexion, blue irides and light brown hair. Two winters ago he 
VOL. VIII. P 



206 HUTCHINSON ON ARTHRITIC IRITIS, ETC. 

was laid np for two months by pain and great swelling of the 
left foot. He has besides this attack, often had slight rheumatic 
pains in his knees, feet, ankles and hands, but with the above 
exception he says that he has never had to leave off work for 
more than a few hours on account of the joint affection. The 
left foot is now well but is rather weak. He has no lips on the 
femoral condyles. 

He comes on account of his eyes, and gives the following 
account of their failure. About twelve months ago he had an 
attack of inflammation in both eyes, they were " blood-shot " but 
not painful. The redness soon disappeared after the application 
of some leeches, and the right eye soon got quite well and re- 
mained so for many months. The left, however, pi-ogressively 
failed, still without pain, until at the end of six months from the 
commencement of the attack this eye was quite blind. It has 
remained so ever since. For the last six weeks the right eye, 
which had recovered, has begun to fail gradually and without 
pain, just as the left did. Present condition : Left eye no per- 
ception of light, tension increased, pupil excluded, iris bulged 
forwards and tremulous at its periphery, sclerotic dusky from 
congestion. Eir/ht, pupil excluded, slight ciliary congestion and 
duskiness of the globe ; vision just 2 J. I excised the right 
eye, and performed iridectomy on the left with the result of 
improving the sight slightly. (A detailed accotint of the excised 
eye has already been published in vol. vii,p. 377.) 

Although he is a coach-painter and works constantly with 
colours containing lead, he has never had any of the ordinary 
symptoms of lead poisoning ; I unfortunately omitted to examine 
his gums with reference to the presence of a blue line. He de- 
nies all history of syphilis and of gonorrhoea in a most positive 
manner, and apparently has every motive for telling the truth. 
Six years ago he had some kind of "fit;" it was a sudden 
seizure consisting in loss of consciousness, and was followed by 
imperfect paralysis of the left side of his body which lasted for 
a long time. He has never had another fit. 

There is no family history of arthritis in his parents or 
grand-parents, nor in any of his brothers or sisters. He knew 
both parents and all his grand-parents, except his father's father, 
whose history he is not sure about. The patient is the third of 
a family of eleven ; five of the number, chiefly the younger ones, 



ORIGIXAL CASES. 207 

died, for tlie most part iu early infancy. His father died of 
"decline" at 60; his mother is living and 70 years old. He 
says that two of his brothers are liable to " scurvy." 

Case CIT. — Iritis in one Eye, subacitte and recurring for the first 
time in a ivoman at the age of 72 — History of several attaclcs 
of " Blieumatie Fever " since girlhood — Presence of Lijjs on 
Condyle of one Femur — Her children slightly Bheurnatie. 

Sa.rah B., a healthy old woman of 75, -with brown irides and 
dark haii', turning gray, has had iritis of her left eye, subacute 
in character and leaving synechise. The eye inflamed for the 
first time about three years ago. She also had cataracts in each 
eye. 

She has had three attacks of "rheumatic fever." The first 
occurred in girlhood, the last about twelve years ago. She 
was laid up for three months with the last attack, but on that 
occasion the joints did not swell much. She believes that the 
doctors never considered her heart to be diseased. There are 
decided lips on the right external condyle, but doubtful ones on 
the left. 

She says that her children (most of them boys) often have 
"rheumatics" in their joints, but are not laid up by it. She 
does not know of any arthritic history in other relatives, nor has 
any one excepting herself had bad eyes. 

Case CHI. — Gonorrhceal Bheumatism and Gonorrhoeo-Bheicmatic 
Iritis in a patient tvho had had several attaclcs of severe Bheu- 
matism before he had Gonorrhoea — Lips on the Femoral Con- 
dyles — Bhezimatic Fever in a younger brother, and Gout in the 
father of the patient. 

George P., set 24, a coachman, was admitted on November 
9, 1871, when the following notes were made : — " Looks re- 
markably healthy ; has sandy brown hair, fair complexion and 
many freckles. He comes with iritis of his right eye. It is of 
twelve days' duration, and is accompanied by much conjunc- 
tival congestion and steaminess of the cornea. There has been 
great pain from the beginning. He has never had it before." 

The patient is highly rheumatic. He has had three attacks 
of what he calls "rheumatic fever," the first of which laid him 
up fi'om November to April, and was, as he believes, caused 

P 2 



208 HUTCHINSO^r ON ARTHRITIC IRITIS, ETC. 

by Ills having by cliance put on damp clothes a few days 
before its commencement. The last attack confined him to 
bed for two months. All these attacks occurred between the 
ages of about eighteen and twenty, and before he had any 
gonorrhoea. He had his first gonorrhoea at about twenty, 
soon after the last attack of "rheumatic fever;" he had no 
gonorrhoeal rheumatism with this gonorrhoea. A year before his 
admission he again had gonorrhoea, and this time it was accom- 
panied by great swelling of the left foot. His last gonorrhoea 
was in September, two months before the iritis; it was not 
followed by rheumatism, nnless the iritis may be considered as 
taking the place of some joint affection. He has decided lips on 
the condyles of his femurs. There is no reason to think that he 
has syphilis. Since childhood he has been subject to a dry 
scaly rash on his arms, legs, chest, and head. He has always 
drunk beer, and formerly more freely than he now does. 

His father, a gamekeeper, aged about fifty, who drinks freely, 
has lately had " gout " (his doctor's diagnosis) in his great toes 
two or three times. A younger brother of the patient's had rheu- 
matic fever at twelve years old. None of his grand-parents are, 
so far as -he knows, arthritic, and there is no rheumatism, &c., on 
his mother's side. He resembles his mother and mother's father. 

Case CIY.—Kerato-Iritls recurrimj in one Eye only -Family 
history of Bheumatisvi on father's side-No evidence of Syphilis 
or Gonorrhoea. 

Charles L., set. 20, spare, with blue eyes and light hair, 
sufiered for the second time from kerato-irltis of his left eye in 
November, 1872. There was general haze of cornea from 
steaminess of surface, and, at the lower part, small deposits in 
its substance. There was a small pink nodule of lymph on the 
pupillary edge of the iris. There was no evidence of either 
syphilis or gonorrhoea, although I examined him carefully every- 
where ; and he very candidly denied ever having been exposed 
to the risk of contagion. 

He has had no arthritic symptoms in his joints or fascia at 
any time, but his father had " rheumatic fever " at the age of 45, 
and has since then often had rheumatism " in his knees and in 
his head." 



ORIGINAL CASES. 209 

There is iiu other family history of arthritic comphiints, and 
none of skin diseases. 

Case CV. — ^o farailij history of Arthritis — Exposure to cold during 
an attack of Gonorrhoea, followed by Rheumatism and Acute 
Iritit — Numerous attacTcs of Iritis, subsequently eliding in great 
damage to the Eyes. Iridectomies. 

Wm. W., £et. 56, has been more or less frequently under 
my observation for ten years past. He was Mr. Dixon's patient 
in 1859 and 1860, by whom, in the latter year, an artificial pupil 
was made in the right eye. In 1864 he passed under the care of 
Mr. Bader at Guj-'s Hospital, by whom iridectomy was done on 
both eyes for artificial pupil, both pupils being closed by ii-itis. 
At present date {April, 1871) his left eye is all but blind, and 
has been so since the last operations. With it he can see only a 
glimpse of light when the eye is directed strongly outwards. 
There has been a relapse of irritation in it during the last few 
weeks on account of which he now comes under care ; there is 
now recent iritis with discoloured iris ; iris in apposition with 
the cornea ; ciliary congestion. This is the first relapse of in- 
tiammation in either eye since Mr. Bader's operations. The 
right still wears well, and with it he can still, by effort, read a 
newspaper. Both globes are firm. 

The patient is a stout muscular man, but his skin has the 
pallor so often seen in arthritic persons. Thirty years ago, while 
suffering from gonorrhoea, he was put into a damp bed, after 
which he had pain in one foot, and, a week later, in the eyes. 
This was his first attack in joints or eyes. Since then he has 
had altogether about twenty attacks of recurrent iritis. He has 
never been laid up by rheumatic fever, but has often had rheu- 
matic pains. He now has large lips on the condyles of both 
femurs, but no crippling of small joints. Has taken much 
mercury at different times, but there is no history of syphilis. 
His appetite is moderate and he has taken beer all his life from 
boyhood. Has no stricture. No family histoiy of arthritis. 

Case CVl, — Rheumatic Iritis in left eye of three tceeks' duration — 
Mother crippled by Rheumatism — Frequent attacks of Gout in a 
paternal uncle — Recovery under use of Quinine and Aconite. 

Miss D., set. 32, was sent by Mr. Cooke of Stoke 



210 HUTCHINSON ON ARTHRITIC IRITIS, ETC. 

N'ewington, May 22, 1873, with rheumatic iritis of the left eye. 
Her mother was said to be crippled by rheumatism, and to have 
had it very severely in the hands. A paternal uncle often 
suffered from gout. May 26th, it is noted, there was a much 
better pupil. June 4th the eye had quite recovered. The treat- 
ment had consisted in the internal administration of quinine and 
aconite (a grain and seven minims). Some giddiness was sup- 
posed to have been caused by the aconite. She had had no 
previous attack. 

Case CVII. — Gouty Iritis in left Eye — Gout in paternal grand- 
father — Prohally in father. 

Mr. Ernest T., £et. 17, was sent by Dr. J. M. Bright, July 16, 
. 1873. Both eyes were fully under the influence of atropine. In 
the left, at the upper edge of the pupil, there was a single tag of 
adhesion. His grandfather, on the father's side, suffered much 
from true gout, and the father himself had had repeated attacks 
of what he thought was gout-pain in the wrists, but never in the 
great toe. The lad himself had had no arthritis. An elder 
brother, set. 19, had a bad knee for long, and had inflam- 
mation in both eyes. He got rid of the latter when sent to 
Switzerland two years ago, and has had no relapse. His eyes 
were examined but no iritic adhesions could be detected. 

A2Jril 17, 1874, it is noted that he was said to be quite well, 
and was then in Germany. (See his aunt's case, Mrs. T., Case 
XCV.) 

Casb CVIII. — Iritis in one Eye — Rheumatic Fever at the age of 
12 — No history of Gout in the family — Rheumatic Fever in a 
hrother — History of liability to Bilious Attacks, hut no other 
ailment. 

Mrs. M., £et. 40, was seen September 3, 1873. She had never 
conceived. She was very bilious and liable to violent vomiting. 
For a year she had been liable to a darting pain in the left eye 
with blood-shot appearance, but no loss of sight. The attacks 
lasted about a week, and passed away spontaneously. When 
she came under care her right eye was painful for the first time. 
The eye had begun to inflame three weeks previously without 



ORIGINAL CASES. 211 

any known cause. The attack was acute, and .she almost lost 
her sight. The eye was much, blood-sliot. No iritic adhesions 
could be detected, but there were a large number of pigment 
dots near the middle of the lens. She said that at the age of 12 
she had rheumatic fever, but had not since then been subject 
to any rheumatic symptoms. She had never had gout, and no 
history could be obtained of any gouty symptoms in members 
of the family. A bi'other has had rheumatic fever. With the 
exception of the bilious attacks noted above, she was not aware 
that she had had any illness since she was a girl. 

Case CIX. — Iritis in one Eye — History of two previous attacks — 
Attacks of Gout in a maternal uncle — ''''Enlarged joints ^^ in 
the mother — Other maternal relatives ^''martyrs" to Gout. 

Mr. W. G., a3t. 40, sent by Mr. Carter, Chelmsford, September 
15, 1873, a brewer. Fourteen years pi-eviously he was said to have 
had an attack of " iritis " (which eye not stated), and another 
seven years later. He came under care for a third attack in one 
eye (not stated which) of about a month's duration. He went to 
bed well, but feeling a little weak, and the attack began suddenly 
about four in the morning. The eye had not been very painful. 
"The remedies had been more painful than the disease." A 
maternal uncle had had gout, and always prophesied that the 
patient (his nephew) would have it. His mother has suffered 
from " enlarged joints." Others of his mother's relatives have 
been "martyrs to gout." He himself was very lame once with 
pain in the backs of the heels. This was ten years before he 
came under care, and soon after the attack in his eye. He had 
never had rheurcatic fever, nor any special joint affection, ex- 
cepting that during the attack of heel-pain his ankles were 
swollen and he had to have larger boots than usual. His urine 
was said often to be thick, and he had sometimes noticed " bits 
of gravel " in it. He had never noticed that any special article 
of diet had disagreed with him, and had been in the habit of 
taking port wine and beer in regular moderation. 

Case CX. — Adhesions resulting from Rheumatic Iritis. 

Mrs. G., ast. 70, came under care October 13, 1873. There 
were iritic adhesions in both eves. She had had "rheiimatism in 



212 HUTCHINSON ON ARTHRITIC IRITIS, ETC. 

the head "' and attacks of rheumatism in various parts for three 
or four veal's. The attacks of inflammation of the eyes had 
extended over two years. 

Case CXI. — Iritis in one Eye in a patient wJio liad had Bhcumatic 
Fever after Gonorrhoea at the age of 20, and some (?) gouty 
pain at the age of 17 — Gomplahit of always having Rhevmatic 
pains about him — Remote history of Goat, hut none of Rheu- 
matism in the family — Improvement, in one attach, hy the use of 
Aconite. 

Mr. G. was seen with Mr. Savory, of Stoke Newington, in 
May, 1873, with iritis of the right eye. He got well under use 
of aconite. He was seen again December 17. He was a florid, 
healthy-looking man. He had then taken two grains of quinine 
and four minims of tincture of aconite for three weeks, that is, 
from the commencement of the fresh attack of iritis. He had 
had rheumatic pains changing from hip to hip. He complained 
that he was never well, always irritable and with more or less 
rheuiuatic pain about him. He said gout was quite unknown in 
the family excepting as regards a maternal grandmother who 
had it in old age. ISTo one was known to have had rheumatic 
fever. At the age of 1? he had pain in a toe- joint very like gout. 
At the age of 20 he had rheumatic fever after gonorrhoea. The 
rheumatic fever left him with various aches for a long time ; he 
was Dr. Fuller's patient. When seen his pupil (left) was fairly 
dilated, but with adhesions. There was still much congestion of 
the ciliary region. He could sleep well, but was liable to severe 
neuralgic attacks in the eye. 

Case CXII. — A first attach of Iritis in one Eye at the age of 34 — 
History of Gout in a p)aiernal iincle and of Rheumatism in a 
paternal aunt — Cure in a short time by the use of Atropine and 
Iodide of Potassium. 

George B., ffit. 34, a warehouseman, came to Moorfields, 
November 6, 1873, with a first attack of iritis, of twelve days' 
duration. It affected the left eye. The pupil dilated fairly, but 
with tags of adhesion. He stated that he had never had rheumatic 
fever or any form of rheumatism, excepting once when it affected 



ORIGINAL CASES. 213 

his left hand. He had never had syphilis, but had had gonorrhoea 
twice; no rheumatism followed the gonorrhoea. Under the use 
of iodide of potassium internally and atropine drops to the eye, 
he soon recovered from his attack of iritis. The pupil became 
quite round, and only the very smallest specks of pigment 
remained on the lens. Subsequently a few small streaks of 
opacity were found in the extreme periphery of each lens — a 
mere rim, almost exactly alike in the two eyes. There was no 
arcus senilis. His arteries were not tortuous. He had brown 
hair. 

He told us that an uncle (paternal) died of gout in the 
stomach when more than sixty years of age. An aunt (paternal) 
who w^as living, was reported to suffer from rheumatism, and 
was confined to bed by paralysis. His father died at th.e age of 
34, of "typhus fevei'." His mother died young. He had no 
brothers or sisters. 



Case CXIII. — Insidio^is Iritis ivitli Vitreous Opacities — No reason 
for suspecting Syphilis — A sister crippled with Rheumatic Gout. 

Mrs. H., 8et. 49, was seen with Mr. Blewitt, January 22nd, 
1874. She had been aware that the left eye was failing for a 
yea.r or more. She often had an aching pain at the backs of the 
eyes ; more so on the left side than on the right. In the right 
eye there was a single ii'itic adhesion, some specks on the lens, 
the lens hazy and large, and numerous films in the vitreous. 
The left lens was a little hazy. She had lost her husband in 
September, of phthisis. She had no family. There was no 
reason for suspecting syphilis. She sometimes had pain in the 
left arm, so that she would lose all power. There was no history 
of gout in the family to be obtained. A sister had been crippled 
for nine years with rheumatism and could scarcely :|)"alk. She 
herself had never had any definite rheumatism. She was a fair 
complexioned, florid, rather delicate looking woman. 

April 1st, it is noted, that she had " a good deal of rheuma- 
tism" in the left hand and arm. It leaves her "powerless." 
In bed she usually keeps the left arm outside, because it gets so 
painful when hot. She has had some slight pain in the other. If 
she walks much she does not perspire, but gets hot and faint. 



214 HUTCHINSON ON ARTHRITIC IRITIS, ETC. 

Tlie rheumatism in the lower extremity (as in the upper) is worse 
ou the left side. She generally sleeps badly. She enjoys her food. 
The tongue is quite clean. The eye is in much the same con- 
dition as before. After she had taken perchloride of iron for 
some time she was better in all respects. There was no relapse 
as regards the eye. On August 28th she was very much better, 
in fact almost well. The steel had been taken regularly. There 
had been no relapse, but she had occasionally had pain in the 
back of the neck. On November 20th, it is noted, that she was 
much better in all respects. She had not taken any remedy for 
some time. 

Case CXIV. — Gouty Iritis (first aftacl-) at the age of 62— J. 
oiepheiu also the subject of Gout]/ Iritis. 

Mrs. T., set. 62, sent by Dr. Bright, A^ml 16, 1874. (See her 
nephew, Master T.'s case CVII.) She was suffering from iritis of 
two week's duration. There was no history of gout or rheuma- 
tism. Her mother was alive, aged 87. She herself had always 
had excellent health. The first symptom noticed was a feeling 
as if grit were in the eye. The eye seemed easier w^hen exposed 
to cold air. She couVl barely see to count fingers. For a 
year she had been liable to attacks of profuse lachrymation, so 
that the tears would fall as if in crying very freely. The attacks 
would last five minutes, and would occur once a week. She 
could assign no cause for them. She had been in the habit of 
taking port wine and malt liquors. 

Case CXV. — Iritis in one "Eye in a Woman aged 57, tchose father 
and brother had suffered severely from true Gout. 

Mrs. P., aged 57, came on May 1 7th, 1874, with an attack of 
iritis in the right eye. The iris was scarcely muddy, and it 
acted well under atropine, but showed many adhesions. She 
had never had an attack before. It began ten days previously, 
and the eye had been very painful. The disc was normal. She 
stated that her father was a " martyr " to chalk-gout. He lived 
to the age of 67, and died of paralysis. His father had asthma, 
but no gout. One of her brothers (the only one living) was 
suffering from gout at the time she came under care. Both of 



ORIGINAL CASES. 215 

tiiem drank freely, especially port wine. She had herself taken 
stout all her life. She had never had any form of rheumatism, 
excepting an attack, of three or four weeks' duration, in the 
shoulders and arms, and occasional lumbago. None of her joints 
had ever been affected. 

Case CXVI. — Iritis in a young Man icho had had Syphilis some 
time previously, hut who had had Bheumatic Fever, and whose 
father teas laid up ivith Rheumatic Gout. 

Mr. B., set. 23, of dark complexion, came under care, June 
1st, 1874. He had married in the previous November. He had 
had a chancre three or four years previously, and had had 
sores several times. He had iritis at Christmas, 1873. He 
believes he never had any rash, but he had sore mouth. The 
date of Ihe real inoculation was uncertain. The left pupil was 
excluded and there was a thin membrane covering the greater 
part of it. It was doubtful whether the iritis was syphilitic or 
rheumatic. He had had two attacks. His father was laid up 
with rheumatic gout (or chronic rheumatism), and was quite 
crippled. He had himself had rheumatic fever three years pre- 
viously. With the left eye he could read ^^. The eye was 
steadily improving. He was liable to herpes on the penis. On 
the whole, the iritis was considered to be more likely to be 
rheumatic than syphilitic. 

Case CXVII. — Gonorrhoeo- Bheumatic Iritis — Five attacks of 
Rheumatic Fever, the first, folloiving on an attack of Gonorrhoea 
and associated with Inflammation of the Fyes, at the age of 21 — 
No special Rheumatic tendency in family. 

Mr. W., ffit. 55, a publican, came under care, Novemlier 7th, 
1874, for an attack of iritis in the left eye, of seven or eight 
weeks' duration. He had had two attacks previously in the 
same eye, and one in the right eye. The pupil of the right eye 
was freely moveable when he came under care, that of the left 
was adherent all round, and there was considerable conjunctival 
and ciliary congestion. The history he gave was, that he had 
had five attacks of rheumatic fever since the age of 21, when his 
first attack occurred, while suflering from gonorrhoea, and after 
exposure to cold and wet. His left eye was inflamed at the 



216 HUTCHIXSOX ON ARTHRITIC IRITIS, ETC. 

same time. His second rheumatic attack was five years after the 
first. His third six years later. His fourth five years after the 
third ; and the last four years later. Tour years after the last 
attack of rheumatic fever, his left eye was inflamed a second 
time. Eight years after that (two years before he came under 
care) he had an attack of inflammation in the right eye. His 
relations had not suffered especially from rheumatism, but his 
father used to complain of rheumatic pains. The patient has 
eleven children, and none of them have suffei'ed excepting his 
eldest son, who has had a good deal of rheumatism. He has no 
brothers or sisters. He has been a " martyr to bile." He never 
has sick headaches, but has frequent attacks of " stomach cough." 
His shoulders were both stiff, and could only be lifted slightly. 
He never thought that diet made much difference to him. He 
had taken beer freely and wine moderately. Gin and water 
always suited him best. Moist, foggy weather suited him very 
well, but not cold, clear weather. Five years previously he had 
had had a severe attack of neuralgia, affecting both sides of the 
head ; the pain was terrible and lasted six weeks. Twenty- 
five years previously he had an attack of lumbago. He said he 
was scarcely ever an hour free from pain of some sort, excepting 
when asleep. 



A GEOUP OF CASES OF SEVEEE IRITIS IN YOUNQ CHILDEEN 
ABOVE THE AGE OF INFANCY. 

Bj Jonathan Hutchinson. 

The five cases recorded below have occurred in my prac- 
tice at Moorfields at considerable intervals during the last 
nine or ten years ; they include all of which I have notes, 
excluding the iritis which occurs definitely in the secondary 
stage of inherited syphilis, and the iritic complication wbich 
often takes place in association with interstitial keratitis. 

The first four cases resemble one another in several 
particulars ; Case V, in which there was perforating ulcera- 
tion of both corner, is more doubtfully related to the others ; 
it is, however, a very unusual case and may for the present 
be included with them. 

The following are some of the points in regard to which 
the first four of the cases may be compared with each other : 

Asymmetry. — In each of the four cases only one eye was 
affected ; the E. only in three cases, the L. only in the 
remaining one. 

Character of the Disease. — In all four the iritis was plastic, 
resulting in the formation of much new tissue in the iris, 
either with or without nodular growths from its surface. In 
three of the four there was steaminess or slight ulceration of 
the cornea during some part of the case ; in the fovnth the 
state of the cornea is not noted. In the two worst cases 
(I and II) it is especially noted that there was scarcely any 
pain or intolerance of light. The degree of ciliary con- 
gestion was, as a rule, very moderate, and less than might 
have been expected from the extensive changes going on 
within. 

Result. — In two of the four (cases I and II) the eye was 



218 HUTCHINSON: CASES OF IRITIS 

quite disorganised and had to be excised ; in case III the eye 
was probably destroyed for practical purposes. Case IV was 
seen only once and the result is unknown. 

Sex. — All of the four cases were in girls. It may be 
noted here that the majority of cases of iritis in the 
secondary stage of inherited syphilis occur in girls.* 

Age. — The age at which the disease began varied from 
about 15 months (case III) to 6 years (case I). 

Hereditary Syphilis. — In case I, an elder sister of the 
patient is undoubtedly syphilitic, having had severe inter- 
stitial keratitis, and at an unusually early age. In case II 
it is very probable, but not certain, that the child is tainted 
Avith syphilis. In cases III and IV no enquiries were made. 

Other Diseases. — It was stated that tlie father of the 
child in case II had lately died, set. 36,. of " consumption," 
and that the mother in case III also died of the same 
disease. 

Case I. — Disorganising Iritis, ivith Nodules of Lymph lohicli 
afterwards suppurated, in one Eye of a Girl, cet. 6. Other Eye 
not affected. Syphilitic (^Interstitial) Keratitis in an elder 
Sister. 

Kate J., set. 6 years, a fair-haired, rather delicate-looking 
child, was sent to me by Dr. Bentliam, of Sonthsea, on March 
26, 1874. She had severe iritis of the right eye, accompanied 
by nodnles of lymph of reddish colour and with numerous 
vessels at their bases ; one or two of the nodules were yellow at 
their apices, as if containing pus. The iris was very much 
disorganised and the cornea steamy, but there was very little 
pain or intolerance of light, and only moderate ciliary congestion. 

At the first visit I did not succeed in making out anything as 
to the cause of this very peculiar form of iritis. There seemed 
no reason to suspect either acquired or inherited syphilis. The 
treatment adopted consisted of atropine, a blister and small 
doses of iodide of potassium. The inflammation, however, pro- 
gressed, and the nodules on the iris subsequently suppm-ated, 

* See p. 18 of mj work on Diseases of the Eye and Ear consequent on 
Inherited S'l/philis. 



IX CHILDREN ABOVE TIIE AGE OF IXFAXCY. 219 

burst and discliarged puriform matter into the anterior chamber. 
Still, however, no pain was complained of, but as the eye was 
evidently lost, I advised its removal, and excised it on May 18. 

At this date, an elder sister, the second in the family, was 
also brought with dense cloudy opacities and a general steamy 
condition of her left cornea, typical interstitial keratitis in fact ; 
her teeth and physiognomy, however, showed nothing to corro- 
borate the suspicion of hereditary syphilis, but there was the 
history of a previous attack of keratitis at between 3 and 4 
years of age. The eldest in the family, and two others whom 
I did not see, were reported never to have had inflamed eyes, 
and there was no history of suspicious infantile symptoms in 
any of the children. Thus in a family of five children, none of 
whom appear to have suffered in infancy from syphilitic symp- 
toms, one suffered at an unusually early age from interstitial 
keratitis, which relapsed in one eye some years later, while a 
younger chUd lost an eye fi"om a very rare form of severe iritis. 
It must be observed, however, that the iritis in our patient did 
not come on until long after the usual period at which secondary 
iritis occurs in inherited syphilis, and that the form of disease 
was very peculiar. 



Case II. — Disorga7iising plastic Indo-Cyclitis of one Eye in a Girl, 
cet. 2| years, perhaps the subject of inherited Syphilis. Excision 
of the Eye and Microscopical Examination. Very marked 
changes in Iris, Ciliary Body and Vitreous ; the Ciliary 
Muscle remaining perfectly free from change. Cornea scarcely 
affected. 

Margaret E. Z. was brought to Mr. Hutchinson at Moorfields, 
on April 15, 1872, when the diagnosis of " vascular ulceration of 
left cornea with iritis " M^as made. 

She was a healthy-looking child, get. 2j years, and her mother 
considered that she had always had good health, with the excep- 
tion of some snuffles soon after birth and a slight eruption (pro- 
bably, from the descriptioii, red-gum) at the age of three or foui' 
months. 

There was a suspicious history as to syphilis in some of the 
pregnancies ; the mother, however, denied all knowledge of 



220 HUTCHINSON: CASES OF IRITIS 

venereal disease in lierselP, and stated that her husband, who 
liad died a year before of "consumption," get. 36, had been a 
vei'y steady man. The mother had been pregnant five times. 

1. (/.) living, set. 8 years. This child was afterwards 
brought at request and showed no signs of hereditary syphilis in 
teeth or elsewhere. . 



I] 



Both miscarriaores. 



4 (m.) Died, £et. 6 weeks. Was very thin and had snuffles 
and thrush, but no rash. 

5. The patient. 

Thus the family history aifords some ground for the suspicion 
of syphilis having been introduced between the fir.st and second 
pregnancies. 

Atropine and one grain doses of iodide of potassium were 
ordered. 

On May 6, " iris very vascular, and probably in contact with 
cornea." Mercury and chalk, in one grain doses, to be taken 
every night, and to continue the iodide and the atropine. 

On 3Ia7j 1(5, it was observed that there appeared to be slight 
bulging in the ciliary region. A month later (Jtine 12) the iris 
was still very vasculaj and ])ushcd forwards ; there was con- 
siderable congestion of the globe and some redness of the lids, 
the latter due to the child's rubbing them. There was no 
material photophobia at any time. 

The eye being evidently lost, and the symptoms getting 
worse, Mr. Hutchinson excised it on June 13, and she was dis- 
charged on the 14th. 

The eye was examined by Mr. Nettleship, and the following 
is his report : — 

It was noted after excision that there were " numerous very 
large and tortuous veins on the iris." The eye was hardened in 
Miiller's fluid until October, 9, 1872, when the sclerotic was 
moderately firm and an equatorial section was made. Vitreous, 
converted into a semi-opaque, brittle, soft gelatinous substance, 
much the consistence of calves'-feet jelly. Near its centre a string 
or line extended from the fundus, probably from the 0. D., for- 
wards, and spreads out into a cone whose base was attached at 
the ora .serrata. This cone did not differ from the rest, except 
in being rather firmer. Tlie remainder was easily removed by 



IN CHILDREN ABOVE THE AGE OF INFANCY. 221 

brushing, washing, and forceps. The greater part of the vitreous 
was nearly structureless, showing only a moderate sprinkling of 
round or multipolar inflammatory cells. At the central part, not 
far from the 0. D., however, the " string " mentioned consisted 
of, or was surrounded by, masses of cells. Most of these were 
round, some, however, were beautifully spindle-shaped, and there 
were all stages between these extremes. All showed a large 
nucleus. In a rough examination it seemed as if the spindle- 
cells were arranged along the central part of the string and the 
round ones near to it. Outer surface of hyaloid examined not far 
from the O. D., and showed a moderate number of round cells 
(somewhat larger than pus), and many patches of highly re- 
fracting coagulated albuminous substance. Ciliary body and iris, 
much thickened and yellowish. 

No further examination was made at this date, and its com- 
pletion was deferred till May, 1875, when the front of the eye 
was further hardened in spirit and carefully examined in thin 
sections. 

It was found that the disease was mainly a plastic irido- 
cyclitis or cyclo-iritis, involving the whole of the iris and the 
entire ciliary body, excepting the ciliary viuscle. Thenars ciliaris 
retinae, and the Zomde of Zinn, and suspensory ligament of the lens, 
were also implicated in the inflammatory action, while numerous 
corpuscles were present in the adjoining part of the vitreous, 
whence they passed in streams or parallel lines to the back of the 
lens. There were changes in the lens which will be mentioned 
again. 

The whole iris, and the ciliary processes, were enormously 
thickened, and converted into a more or less round-celled granu- 
lation-like structure. The cells throughout these parts, and also 
in the ciliary retina, adjacent vitreous, &c., being rather small 
and round, or oval. There was little if any development into 
spindle-cells or fibrous tissue ; but, on the other hand, no 
appearance of fatty degeneration nor of suppuration. The cells 
were closely packed, but not eveiywhere in contact, being im- 
bedded in an ill- defined granular matrix among the remains of 
the normal structures of the parts. The inner boundary of the 
ciliary processes was sometimes destroyed and its pigmented 
epithelium scattered by the intruding cells ; in other parts it was 
more or less well preserved, the processes being even in such 
VOL. VIII. Q 



222 HUTCHINSON: CASES OF IRITIS 

parts, however, mucTi enlarged, and filled almost to bursting. 
Furtlier back, in tlie pars plana, there were some circum- 
scribed collections of inflammatory corpuscles forming minute 
spherical tumours, which, partly imbedded in the stroma of the 
ciliary body, projected also, more or less, into or through its pig- 
ment epithelium. A neighbouring blood-vessel, of considerable 
size, was narrowed by the pressure of one of these growths. 
I could not detect any aperture in the elastic lamina at 
the seat of these nodules ; this membrane, in the section which 
showed it best, and which showed every appearance of haviug 
passed through the centre of the nodule, was continued across 
the middle of the little tumour without any perceptible breach of 
continuity. The front part of the choroid was included in many 
sections ; it was not involved in the change, being neither 
cedematous, nor infiltrated with cells, nor atrophied. The iris 
was for the most part almost in contact with the cornea, in 
parts quite touching it, a shallow, irregular anterior chamber 
alone remaining and being occupied by coagulated albuminous 
fluid. The pupil, which was small, was completely covered in 
by a thick fibrous membrane, with nuclei in the fibres or fibre- 
cells ; development would appear to have gone further here than 
anywhere else. In on-' place a small cyst had been formed in 
the posterior layers of the iris between its uveal (epithelial) 
layer which adhered to the lens, and the jiroper structure of the 
iris which had hei'e been pushed forward by the effusion of 
fluid. The cavity of the cyst was subdivided by two or three 
pillars or bands of highly pigmented uveal cells, which passed 
obliquely from back to front. Although the iris appeared in life 
to be very vascular, only a few vessels were seen in the sections ; 
there was, however, much general staining of some parts of it 
with blood-colouring matter. As has been observed, the ciliary 
imiscle was free from cell infiltration, with the exception of a very 
few scattered corpuscles in its deepest (choroidal) layer. The 
abruptness with which the inflammatory changes were limited to 
the tissue of the ciliary processes, and the sudden disappearance 
of the crowded corpuscles as soon as the inner surface of the 
ciliary muscle is reached, are very remarkable ; the inner boun- 
dary of the muscle was thus marked out with far greater 
distinctness than in health. The tissue of the muscle appeared 
healthy, but its fibre-bundles were straighter than usual, as if 



IN CHILDREN ABO\^ THE AGE OF INFAXCr. 223 

they had. been stretclied, wliicli was probably the case, owing to 
the great increase in size of the parts immediately beneath. 
With the exception of a very small spot of cell-infiltration close 
to Schlemm's canal, the cornea and sclerotic were also free from 
change. The anterior epithelium of the cornea was thin and 
somewhat irregular, and the posterior epithelium showed signs 
of proliferative increase in some parts, but to no great extent, 
while it was also covered with the spherical and oval myeline- 
like globules so commonly found in inflamed eyes which have 
been preserved in Miiller's fluid. 

The retina, immediately behind the ova serrata, was separated 
by a thin layer of clear (coagulated) albuminous fluid from the 
choroid ; it was somewhat thickened and folded ; its tissues 
thi'oughout dim and ill-defined, the rods and cones degenerated 
into globules. The hyaloid covering this part of the retina was 
much thickened and contained abundant corpuscles and myeline- 
like globules. Tliese changes increased in intensity in the outer 
layer of the vitreous in front of the ora serrata, and in the 
suspensoiy ligament of the lens and pars ciliaris retinse. 

Between the fibres of the susj^ensory ligament, and in the 
most anterior layers of the vitreous immediately behind the 
lens, the cells and globules were arranged rudely into lines more 
or less parallel with the back of the lens, and gave the impres- 
sion of streams of cells passing from all parts of the circum- 
ference at this part inwards towards the axis of the eye. This 
tendency is often shown in diseased eyes under various forms, 
notably in cases where, after long-standing slow inflammatory 
changes, a more or less complete diaphragm of fibrous or even 
bony tissue is thrown across the vitreous chamber immediately 
behind the lens. 

The changes in the lens were first, its separation by a con- 
siderable distance from the ciliary processes, by the inflammatory 
products, while its size was much diminished and its shape 
much altered. Its posterior surfatje was almost flat, the curva- 
ture of the anterior surface being unaltered ; thus, its thickness 
was much lessened. Its diameter at the equator was little if 
at all diminished, and the space between the lens and the ciUary 
processes was gained by general bulging in the ciHary region (see 
notes during life), aided by displacement of the lens backwards. 
There were, secondly, changes in its structure ; its capsule 

Q 2 



224 MUTCHIXSON: CASES OF IRITIS 

was much thickened, and there was some puckering at the equator 
and for some distance behind it, i.e., just where the changes in 
the suspensory ligament and vitreous were greatest. The layer 
of fibres immediately beneath the anterior capsule was converted 
into or replaced by a laminated fibrous-looking tissue ; this on 
one side extended quite up to and slightly beyond the equator, 
where it spread out into a coarse mesh-work, apparently com- 
posed of branching fibre-cells which contained round faintly 
granular nuclei ; these fibres were separated by clear coagulated 
albuminous fluid, which extended quite round the lens at the 
equator. The hindermost layers of lens fibres were much broken 
up and replaced by myeline-like globules and masses ; the bulk 
of the lens-substance was healthy. 

Remarks. — There can be no doubt that the disease in this case 
began in the iris or ciliary processes (probably in the iris), whence 
it spread backwards and inwards towards the ora serrata and into 
the vitreous. In respect to the vitreous, it is noteworthy that 
the principal changes occurred in the part immediately within 
the ciliary body and behind the lens, and in the axial part 
extending from the posterior pole of the lens to the optic disc, 
■i.e., in the position of the central (arterial) canal. This fact is 
of interest as iilustrati'ig the direction taken in all probability 
by the nutritive currents of the vitreous and posterior layers of 
the lens in health. 

The complete freedom of the cornea and ciliary muscle from 
disease is also remarkable in the presence of fuch very advanced 
changes in the iris and ciliary processes ; and it will here be 
observed that the inflammatory changes were bounded by the 
posterior continuations of Descemet's membrane and the inner 
face of the ciliary muscle, a plane of tissues which may perhaps 
offer considerable resistance to the outward passage of inflam- 
matory products. It may be compared with the case of Miss T., 
p. 227, in which inflammation of the uveal tract began at a 
point rather behind the choroidal attachment of the ciliary 
muscle, and crept forwards in its tissue, particularly in its outer 
(scleral) part, as far as the canal of Schlemm, and from thence 
was beginning to invade the cornea, althoagh the ciliary pro- 
cesses and iris were affected to an incomparably less degree than 
in the present instance. 

As regards cause nothing was proved. It appeared rather 



IN CHILDREN ABOVE THE AGE OF INFANCY. 225 

more probable tban not that the child inherited a syphilitic 
taint ; but if this were the case the iritis occurred at a much 
later stage of the disease than usual, and produced changes 
unlike those usually seen in the iritis of the secondary stage of 
inherited syphilis. The disease of the eye took place at a time 
when condylomata occasionally foi'm at the anus as late secondary 
manifestations. 

Case III. — A single Vasctilar Nodule, of large size, on Iris, accom- 
panied hij general Iritis of the same Eye, in a Girl cet. 18 months. 
Gradual diminution of the Nodule, but the Pupil remaining 
occluded. Other Eye not affected. No diagnosis of cause. 

Mary Anne D., set. 18 months, was brought to me on 3Iay 
15, 1871, with a growth on her right iris. It was as large as a 
split pea, somewhat lobulated, of a light pink colour, and 
showed several distinct vessels of considerable size on its surface. 
The friends stated that the growth had been first noticed about 
three months before, and that it had been at one time much larger 
than when I first saw it. The child was the youngest of three, 
all girls ; the two elder ones were reported to bo healthy. The 
question of syphilis could not be gone into as the mother was 
dead (of phthisis), and the father did not attend. 

On 3Iay loth, there was slight general haze of the cornea 
and a small central ulcer ; the iris was discoloured and greenish 
(the other being blue), and the sclerotic and conjunctiva were 
slightly congested. At this date my colleague, Mr. Hulke, was 
kind enough to see the case with me, and discussed the question 
of the growth being a syphilitic gummous tumour ; nothing 
further was proved in this direction, but we determined to try 
the effect of iodide of potassium, which was accordingly ordered 
in one grain doses three times daily, with a little sal-volatile. 
A month later {June 26) there was no change, but the pupil 
was partly dilated and oval (no doubt from the use of atropine, 
though this is not stated in the notes). 

On April 18, 1872 (nearly a year after admission), the 
growth was rather smaller, but the evidence of iritis had 
increased, the pupil being both excluded and occluded. The eye 
was stated to become frequently very red, but was not so when 
seen. The medicine had been discontinued for some months. It 



22(5 HUTCHINSON: CASES OF IRITIS IN CHILDREN. 

was ordered again, but the child did not again attend, and 
I have failed to trace her since the above date. 

Case TV. — Iritis, severe, and unsymmetrical, in a Girl of h. 

Emma H., set. 5 years, was admitted on May 28, 1866. In 
this case my notes are extremely short, and I have no record 
of the case after the first visit. It was stated that something- 
had been noticed amiss with the right eje for about a week, 
and that a few days later (three days before admission) she 
had begun to be ill, with vomiting and pains in the head. 
When I saw her, the iris of the right eye was swollen ; there 
were adhesions to the lens-capsule and a rim of gray lymph 
was present just behind the pupillary margin. 

Case V. — Perforating Ulceration and Purulent Infiltration of both 
Cornece, with Lymph in Anterior Chamber, and severe Iritis, in 
a Boy of 8. One Eye probably lost, the other much damaged.. 

George G., set. 8 years, was under care in 1871-72 for 
ulceration of each cornea, with severe disorganising iritis. The 
notes are unfortunately imperfect and nothing is recorded as to 
the previous history of the case, or the probable cause of the 
symptoms. 

On Nov. 20, 1871, it was noted that the right cornea had 
perforated, and that its tissue was infiltrated with purulent 
deposit. 

On Dec. 22, iridectomy was attempted, but the iris was so 
adherent that none could be removed. Some opaque masses of 
lymph, which had previously been adherent to the back of the 
cornea, were, however, loose, and escaped when the incision was 
made. On 25/7i, it is stated that both irides were disorganised, 
and showed numerous large vessels. The last note is on Jan. 
11, 1872. The right eye was then soft, the iris much changed 
in texture and probably in contact with the cornea, and the eye 
probably lost. In the left there were still some punctate deposits 
on the back of the cornea and a central opacity ; the anterior 
chamber was of good depth. I have seen nothing of the child 
since his discharge on February 2. 



EXCISION OF EYE FOR SrSPECTED IXTRA-OCULAR TUMOUR 
(DETACHilEXT OF RETIXA) IX A &IRL OF 9. CHROXIC 
CYCLITIS NEAR ORA SERRATA WITH VASCULAR AXD 
FIBROUS GROWTHS INTO YITREOUS, PRODUCING DETACH- 
MENT OF RETINA BY CONTRACTION. EARLY STAGE OF 
INFLAMMATORY PROCESS IN ANTERIOR PART OF CILIARY 
BODY AND IN IRIS; RELATION SHOWN IN THESE PARTS 
BETWEEN BLOOD-SUPPLY AND DEGREE OF INFLAJVIMA- 
TORY CHANGE. 

Bj J0XA.THAN HUTCHIXSOX. 

Miss T., ffit. 9, was brought to me in January, 1875, for 
advice as to her left eye. She was quite blind of this eye 
(having no perception of hglit with it), but it was not, nor 
had it been, inflamed or painful, nor was there any history of 
the duration of its blindness. On examination the retina 
was found to be detached, but no further details could be 
established. There was no history of injury, and in the 
absence of any obvious cause I advised excision as a pre- 
cautionary measure. 

The operation was done on January 29, 1875. There 
was no sign of malignant disease in the cut end of the 
optic nerve, but I opened the eye at once, so as to 
ascertain whether, from the presence of a tumour "udthin the 
globe, there was any possibility of the nerve being even 
slightly affected. The retina was found to be detached in 
umbrella fashion and almost or quite transparent. The 
vitreous, considerably diminished in quantity, was clear, but 
a great part of its outer surface was streaked with fine lines, 
or thin, "svide bands of tough, glistening tissue having a 
tendinous or scar-like appearance. Towards the front of 
the eye these tough strings became continuous with an 
ill-defined white mass, as large as a small bean, attached 
by a broad base to the retina in front of the ora 



22^ HUTCHINSON ON A CASE OF DISEASE OF VITREOUS 

serrata. This mass (or rather masses, for it was composed 
of several partly separate portions) occupied about half the 
circumfereuce of the eye in the or a serrata region, and 
was attached to and blended with the ciliary retina and 
the vitreous, while the detached umbrella retina was partly 
in contact with it. The appearances were suggestive of slow 
inflammatory change rather than malignant growth. A 
subsequent more careful examination was made by Mr. 
Nettleship both before and after the specimen had been 
hardened. He reports as follows : — " Examination failed to 
discover any foreign body. The largest part of the mass 
described above had a slightly yellowish tint in its centre, 
and without much difficulty this portion could be separated 
from the rest as an ill-defined roundish body. It was 
thought possible that this might be or contain a degenerated 
cysticercus, but careful examination failed to detect any 
trace of one, the mass being entirely made up of inflam- 
matory corpuscular elements. The lens was transparent. 
The other parts, choroid, sclerotic, and cornea, appeared 
healthy to the naked eye. In the manipulation most of the 
tough threads and bands on the vitreous were cut away, and 
the sections subsequently made included, besides the tunics 
of the eyeball, only the whitish growth and the more central 
adjoining part of the vitreous. The specimen having been 
hardened in spirit, sections were made, including the cornea, 
sclerotic, ainl parts internal to these. The lens, during 
removal, brought away with it a quantity of pigment from 
the back of the iris, the result of iritis, as subsequent 
examination showed. 

It should have been mentioned that no scar or other sign 
of past injury could be found anywhere. 

Examination of the thin sections showed that the 
changes had resulted from inflammation of the anterior part 
of the uveal tract, and especially of the pars plana of the 
ciliary hody with its underlying ciliary retina, whence the 
morl)id action had extended to tlie neighbouring vitreous and 
produced the ill-defined masses or growths already described. 



RESEMBLING TUMOUR. 229 

The morbid tissue elements varied slightly according to 
their situation. The growth in the vitreous consisted chiefly 
of round corpuscles of rather large size and containing large 
nuclei ; in some parts development into spindle-cells and 
tibrous tissue was going on, this being chiefly in the parts 
furthest from the ciliary body and therefore presumably of 
greatest age. The gxowth contained some thin walled blood 
vessels near its centre, but no connexion was seen between 
them and the vessels of the ciliary body. In the ciliary 
l)ody and iris the corpuscles were for the most part smaller, 
about as large as the nuclei of the large vitreous cells above 
descriljed, and about the size of white blood cells. They 
occurred in greater or less abundance throughout the wdiole 
ciliary body (including ciUary muscle) and iris, but were 
excessively abundant in certain spots. Thus in the hinder 
part of the ciliary body, posterior to the ciliary muscle, they 
were so numerous as almost to hide the proper structure, and 
this condition was present as far back as the section extended, 
i.e., nearly to the ora serrata, and probably further ; it was just 
at this part that the chief disease of the vitreous occurred. 
Another, but much smaller focus of inflammation was 
present at the junction of iris and ciliary processes and 
around Schlemm's canal ; while a third existed close to the 
pupillary border of the iris, its most vascular part. Between 
these three foci the corpuscular elements were scattered in 
greater or less abundance ; in the ciliary muscle they were 
rather more numerous among the bundles of fibres forming 
its outer (scleral) surface than in its deej^er parts ; and they 
again appeared more thickly studded just beneath the pig- 
ment epithelium of the ciliary Ijody, the intermediate tissue 
of ciliary process and muscle being somewdiat less affected. 
From the region of Schlemm's canal the cells were beginning 
to intrude into the deep layers of the cornea. 

In this case a chronic inflammatory process began pro- 
bably near the ora serrata, posterior to the ciliaiy muscle ; it 
affected (chiefly the neighbouring vitreous, where it resulted 
in the fcrmation of partly vascularised embiyonic tissue in 



230 HUTCHINSON ON A CASE OF DISEASE OF VITREOUS. 

large quantity ; the inflammatory action, however, spread in 
a sligliter degree to the whole uveal tract in front of this 
part, apparently rather preferring the looser tissue of the 
outer surface of the ciliary muscle and the tissue imme- 
diately beneath the pigment epithelium of the ciliary pro- 
cesses. It was concentrated in front chiefly in the very 
vascular regions of Sclilemm's canal and the inner circle of 
the iris. 

The anatomical condition of things in this case may be 
instructively compared with that found in the case of 
Margaret Z. (case II, preceding series). In the latter the 
stress of the morbid action had fallen on the ciliary pro- 
cesses and iris, which were enormously tliickened ; the 
vitreous was invaded, but from a different part and with a 
different result, while the ciliary muscle and front part of 
the choroid were quite free from disease. 



SYMMETEICAL CENTEAL CHOEOIDO-EETINAL DISEASE 
OCCUEEINa IN SENILE PEESONS. 

By Jonathan Hutchinson. 

The following cases belong to a group of whicli several in- 
stances have been under care of late, cliiefly in elderly people, 
and in which the choroid becomes speckled with minute dots 
of yellowish white deposit. Most of these spots are round, 
and they occur chiefly in the neighbourhood of the disc, 
although a few single ones may be seen near the equator. 
They are comparatively inconspicuous, not being attended by 
any disturbance of pigment and being usually of very small 
size. In some instances they are arranged in groups and 
sometimes become confluent over a considerable area. They 
appear to affect, for the most part, the choroid only, and 
nothing special is to be noted in the disc, excepting perhaps 
shght pallor. 

It appears very difficult to suggest any constitutional 
cause. There is no reason for suspecting syphilis and the 
patients appear to be in good health. 

With regard to the precise seat and nature of these spots, 
I have no further information than that gathered from 
ophthalmoscopic examination. There is no doubt that the 
disease is confined to the choroid in the first instance, while 
the great defect of sight which accompanies it points to 
implication of the retina secondarily. In the late stages 
there appears to be more or less atrophy of choroidal tissue 
and production of some pigment. Both from the appearance 
of the spots and the serious defect of sight which occurs, 
it is probable that the changes take place in the super- 
ficial structures of the choroid, and it may be suggested 
as not improbable, that the small round white spots are 



232 HUTCHINSON ON CHOROIDITIS 

allied in seat and structure to the so-called "colloid" ex- 
crescences from the lamina dastica. These little bodies 
are said to be common in old age in eyes otherwise healthy, 
but are then found near the ora serrata ; they are also very 
often found in eyeballs which have been long blind, and in 
which inflammation of the deep structures of the globe has 
occurred, and in such cases they are not confined to any 
special part of the eye. It may be remarked that in the 
region affected by the disease under consideration, the blood- 
supply to the choroid is somewhat peculiar, the short posterior 
ciliary arteries entering the eyeball in this region, wdiile there 
are no emergent veins corresponding to them. 

Attention may be directed to the following cliief points 
in the clinical liistory of the disease : — 

1. Limitation of the disease to the region of yellow spot 
and disc. 

2. The disc itself almost healthy. 

3. Eetinal vessels not reduced in size. 

4. No accumvilation of black choroidal pigment, but blue- 
black pigment deposits sometimes remain at the yellow spot, 
probably the results of haemorrhage. 

5. Both eyes affected and in remarkably similar con- 
ditions. 

6. The choroid in the periphery quite healthy. 

7. All the patients past middle life and for the most part 
in good iiealtli. Slight deafness, incipient opacities of the 
lens, and symptoms of failure or senile disease of the nervous 
system are noted in several. 

The disease appears to go through stages : — 

1st. Scattered very minute yellow^- white spots of deposit 
in the choroid around the disc ; sometimes in groups. 

2nd. Coalescence of these minute spots and the formation 
of patches with iiTegular borders. 

3rd. Haemorrhage at the yellow spot and absorption of the 
blood. It is not certain at what period this occurs. 

Cases I, II, and III of the following occurred in three 
sisters, in each of whom a symmetrical disease of the clioroid 



IN SENILE PERSONS. 233 

around the disc and yellow spot occurred after middle life. 
The extent and character of the disease were almost precisely 
alike in the three patients. Two of them had at former 
times suffered from weakness of one or more limbs apparently 
amounting for a time to paralysis, slowly passing off, and 
leaving some permanent weakness. Their family history is 
criven after Case III. 

o 

Case I.—Spnnietrical Disease of Choroids in central part of 
Fundus in a Woman of 67 — Interval of 2\ years between the 
two Eyes — History of Sudden Onset in Eye first affected — 
? Hcemorrhage — Slight deafness. 

(Notes by Mr. Wareu Tay.) 
Ellen G., set. 60 (the eldest of the three sisters) stated 
that one day, rather suddenly, three years ago, she found tliat 
she could not see well with the left eye. She was busy ironing 
and was obliged to give it up as a cloud was before her sight. 
After this she had a good deal of pain, " pricking and shooting," 
and "hot pain." It was worse at night and often kept her 
awake. She had no pain elsewhere. She never had rheumatism. 
It was not until six months before coming under care that her 
right eye began to suffer. She had had just the same sort of 
pain in it, but it had not yet advanced neai'ly so far as in the 
left. She was rather stout and looked well. She had had good 
health through life with the exception of two attacks of "fever. " 
The first was a "low fever" after a confinement, and the last an 
attack of " typhoid," two years before coming under care (a year, 
therefore, after her first eye failed). She considered that her 
hearing had failed a little since her eyes had been affected, but 
she was not deaf to any material degree. With the right eye (her 
better one) and with a + glass she only saw the letters of 20 J. 
She was born in the country and was accustomed to field M'ork. 

Ojyhfludinoscopic Examination. — In the left eye there was 
extensive disorganisation of the choroid in the region of the 
yellow spot and of the optic disc. At other parts tlie structures 
seemed quite healthy. The disc was of good colour and its 
vessels of good size. At the yellow spot, there was a large 
irregularly stai'-shaped, or rather windmill-sail-like, blot of 
bluish pigment, probably the remains of blo(9d-clot, and adjoining 



234 HUTCHINSON ON CHOROIDITIS 

it were some stained fringes from which the colouring matter 
had not been wholly removed. There were a few other isolated 
spots of pigment of the same character at other parts. The 
aggressive edge of the patch external to the yellow spot was 
very abrupt and definite. It showed a number of jags and 
crescents like the irregular border of a serpiginous ulcer. It 
was white and there was no disturbance of the choroidal 
pigment. Very similar, but less advanced, conditions were found 
in the right eye. 

The pigment bears but a small proportion to the whole area 
of disease, the prevalent change being more or less complete 
thinning of the choroid ; the atrophy is nowhere so complete 
as to leave bare sclerotic. 

Since her first attendance she has failed in health consider- 
ably ; become feeble, and vacant, and her memory has become 
very bad. These changes came on rapidly in one day, and she 
seems to have been from the first partly demented. She has had 
no fit and no paralysis. 

Her sight is now {Aug., 1875) just the same as when she 
first came in April, 1874, and the ophthalmoscopic appearances 
agree with the description then given. 

The urine was tested at her first admission and found free 
from albumen. 

She has had ten children; seven were either still-born or 
died in a few days ; three are living and reported healthy and 
with good sight. Her youngest was born about fourteen years 
ago. 

Case II. — Symmetrical Disease of Choroid and Retina in central 
parts of the Fundus in a Woman cet. 48, and in association 
with Teniforary Partial Paralysis of all the Limbs — All the 
symptoms coming on during prolonged anxiety and at about the 
time when Menstruation ceased. 

(Notes by Mr. Waren Tay.) 

Anne J., aet. 50, a widow, the second sister, stated that 
two years before she came under care she lost the use of her 
limbs. One day when she got up she found that she could not 
see with her right eye. She could not see to cut out a dress. 
She tried first one eye and then the other. The left eye had 
only been known to fail for six months, and since the loss of her 



IX SENILE PERSONS. 235 

husband whom she had uursed for a year-and-a-half before his 
death. She was then laid up in bed for four or five weeks, 
unable to dress or undress herself ; her joints were weak, and 
she could not lift hand or foot. She gradually regained power. 
There was neither swelling nor pain of the affected limbs. The 
illness was attributed to change of life. At the date of admission, 
she now and then had a feeling of pins and needles in the right 
hand and arm, and sometimes she could not pick up a pin. She 
considered she had always had good health. She had never 
been laid up, nor unable to attend to her business, keeping a 
greengrocer's shop. She lost a good deal of blood per vaginam 
soon after the right eye failed, and had not menstruated since. 
She had always menstruated very Httle and irregularly. Slie 
had been married twenty-two years before her husband died of 
phthisis, but had never been pregnant. 

There was a large central scotoma before the right eye and 
she could not read 20 J. with it. She could read No. 6 J. slowly 
with + 10 with the left eye. She complained of having felt a 
sharp pain now and then going round the right eye, and lately 
had felt the same on the left side. 

In the right eye, the choroid near the yellow spot was spotted 
over with yellowish-white, minute, ill-defined patches. ISTear 
the disc they were almost everywhere irregularly confluent and 
were so extensive as to leave very little healthy choroidal tissue 
remaining. At the cu-cuinference of the diseased patch, how- 
ever, the spots were very distinct, presenting a moth-eaten 
appearance. Neither at the margins of the spots nor in their 
centres was there any accumulation of pigment ; but near to the 
yellow spot there were some long, conspicuous streaks of pig- 
ment of a bluish-black colour and very irregular in arrangement. 
They were remarkable for being thin and in parts almost gauzy 
in appearance. At most parts, the retinal vessels were very dis- 
tinctly in front of both the white and the black patches, but in 
a few places their trunks were obscured both by white and by 
dark deposit. The disc itself was quite clear, its vessels of usual 
size, and their trunks, with the exceptions just alluded to, were 
easily traced. In the left (without atropine) the conditions were 
much the same as in the right, but not so advanced. At the 
yellow spot, there was a white patch with blotches of pigment 
of the same colour as in the ricrht. 



236 HUTCHINSON ON CHOROIDITIS 

This patient was seen again in August, 1875, when the state of 
her sight and the ophthalmoscopic appearances were about the 
same. 

Her hands, arms, and ankles are still weak, and have, accord- 
ing to her statement, never become so strong as before the first 
onset of the symptoms. Her fingers become stiff", and in the 
morning on waking up she always finds them partly bent into 
the palms, and her hands and arms are then so weak that she 
has much difficulty in dressing herself. The act of clasping 
anything with her hands causes pain in the flexor tendons and 
muscles of the forearms, so that she either cannot or dare not 
clasp firmly ; the grip of her hand is very feeble ; these symptoms 
are symmetrical. The weakness, &c., of the arms and hands is 
always worse in cold weather, and she then often has pins and 
needles in them. 

She persists in calling the whole complaint "rheumatism." 
There has, however, never been either swelling or stiffness of 
the joints nor any pain in them. There is no grating in her 
shoulders, and she says the knee joints never either crack or 
become stiff*. Weakness and pain in muscles during their con- 
traction, aggravated by cold, are the leading symptoms. 



Case III. — Similar changes in the Uges, but in an earlier stage, in 
a third Sister. History of ijartial Paralysis. 

Mrs. M., ajt. 40, applied at Moorfields in June, 1875, com-- 
plaining that her sight had been failing for about a year. On 
examining the eyes, Mr. Tay noted " extensive choroidal disease 
of the central parts ; at the circumference of the patches there 
are isolated spots. The changes are like those in the two sisters 
formerly seen, and in some others." At this time it had not 
transpired that the patient was a third sister of the two cases 
referred to in Mr. Tay's note ; on enquiry as to her history, &c., 
however, she told us that her two sisters, Mrs. G. and Mrs. J., 
had previously been under my care. 

Mrs. M. is a sallow, spare woman, with black hair (just 
turning gray, regular, well-formed features and a good figure ; she 
is nervous and emotional, and looks care-worn, but appears in 
fairly good health. She states that her sight began to fail 



IN SENILE PERSONS. 237 

about a year ago, without any cause apparent to her ; the change 
appears to have been gradual and symmetricaL Her sight is 
better in the evening than by daylight. 

With regard to previous illnesses, she stated that five years 
ago, and five months after her last confinement, she had an 
attack of pain and weakness in her left lower linib ; there was 
no swelling of any part of the limb or of any joints, but the 
pain was very severe and " as if it was being cut to pieces ; " 
the illness lasted three months, and was considered by her 
medical attendant to be " rheumatic fever," but no other parts 
than this limb were affected. The limb has remained weak and 
more or less painful ever since. She had never had anything 
like it before, nor have similar symptoms occurred again. The 
confinement referred to had occurred after an interval of nine 
years from the preceding pregnancy. There is no indrrect 
evidence of syphilis to be obtained. Her husband died six 
months ago of an accident. 

She states that at the age of 18, seven years before marriage, 
she had an abscess followed by a " fistula " at the anus ; there is no 
history of syphilitic symptoms at that time, and from the frank- 
ness with which she mentioned the " fistula," I think that she 
had no suspicion of my object in questioning her. She has never 
been considered "consumptive." 

Mrs. M. has had four children, the first and fourth are living 
and reported to have good sight and good health ; one of the 
others was still-born and the other died of convulsions whiie 
teething. 

The changes in her eyes very closely resemble those in the 
two elder sisters, but are evidently in an earlier stage. An 
immense number of small circular spots of choroidal disease 
enclose the disc and the yellow spot in an ill- defined oval belt. 
They are of a dull white colour, very closely packed, and in some 
parts (especially near the disc) are partially confluent. The 
belt of spots represents only the part where they are most 
thickly set; all around and Avithin it there are less numerous, 
but still very abundant, spots, spreading for a short distance on 
every side and covering the Y. S. region. There is as yet 
scarcely any pigmentation. Most of the spots are beautifully 
distinct. When examined with the ei'ect image, it is possible to 
see a very minute dot of pigment on the centres of some of 
VOL. vm. R 



238 HUTCHINSON ON CHOROroiTIS 

tliem, while an extremely narrow ring of pigment, darker tlian 
the neighbouring choroid, often surrounds them. In these 
respects they closely resemble some forms of minute growths 
projecting on the inner surface of the choroid as seen in the 
dissected eyeball, especially the tubercles of acute tuberculosis, 
and the so-called " colloid " excrescences. It is probable, there- 
fore, that the spots in this patient's eyes are minute elevations of 
the choroid, though the ophthalmoscopic appearances do not 
enable us to form any move precise idea of then' nature and 
exact situation in the choroidal tissue. The disc and retinal 
vessels are healthy in each eye. 

The following facts were ascertained from her as to the family 
history of the three sisters. Her father had what was called very 
"short" sight, and a brother of his was similarly affected ; the 
defect would appear not to have been myopia, unless extreme and 
complicated, for she says that both the father and the uncle ulti- 
mately became so bad " that they could hardly see to do any- 
thing;" it may, however, have been merely cataract ; they had 
no treatment. This uncle was considered "curious" in his 
manner or intellect. A third brother of her father became 
insane (" tried to be reiigiovis "), and committed suicide ; he had 
been under medical care for mental disorder for two or three 
months before death. She believes that her parents were not 
blood-relations ; she can give no information as to her grand- 
parents, except than one of them was gouty. 

The three amblyopic sisters do not resemble one another 
specially ; the two elder take after their mother, the youngest 
one is like her father. Their parents had ten children, of whom 
nine are living and several have families ; none of the next 
generation (nephews and nieces of the patients) are known to 
have bad sight or any intellectual or nervous defects. 

The children are as under : — 

1. (f.) Died, £et. 40, of "cancer of the womb." 

2. (f.) 60, Mrs. G., the eldest of the three amblyopic sisters. 

3. (m.) Living, set. about 5-5. 

4. (f.) Living, 

5. (f.) JEt. 50, Mrs. J., the second amblyopic sister. 

6. (f.) Living. 

7. (m.) Living. 



IN SENILE PERSONS. 239 

8. (f.) ^t. 40, "Mj-s. M., the youngest of the amblyopic sisters. 

9. (f.) Living. 

10. (f.) Living. 

None except the three have any defect of sight. 

Case IV. — Choroidal disease in Minute White Dots in the neigh- 
bourhood of the Disc ill each Eye — Gommeiicing Haze of Lenses. 

(Notes by Mr. Waren Taj.) 
Mrs. L., ret. 60, single, a cook, came under care at Moorfields, 
March 28th, 1874. She has enjoyed good health. 

She could still see to read. Her sight began to fail about 
twelve months before she came under care. In both eyes, on 
ophthalmoscopic examination, a number of very small white 
spots were to be seen, apparently behind the retinal vessels. In 
the right eye they were chiefly present on the real inner side 
of the disc ; in the left on both sides. Probably there were 
slight ones all round. In the inverted image it was very difficult 
to see them. The lens in each eye was slightly hazy and with 
here and there a line in it. She had worn glasses for twenty 
years. There was no trace of hemorrhage anywhere, nor any 
change at the yellow spot in either eye. The spots were in 
groups in a circle around the disc, passing between it and the 
yellow spot. In the right eye the margins of the disc seem to 
shade off, but the vessels can be seen clearly. There is venous 
pulsation. 

Case Y. — Symmetrical disease of Choroid in central parts ofFundios 
in a Man cet. 60 — Minute White Snots — Commencing Opacity 
of Lens — No obvious cause. 

(Notes by Mr. Waren Tay.) 

John L., set. 60, came under care March 23, 1874, at Moor- 
fields. He seemed an intelligent man and told us that he had 
noticed a dimness of both eyes just alike for six weeks. He had 
liad excellent sight previously. He had had pains in the tips 
of the shoulders and down the muscles of the arms. He 
could see ^ with both eyes open. He was ordered grey powder 
and quinine three times a-day. A week later he had much pain 
in his arms. 

It is noted that his mother and all her family were subject to 
cataract ; one of her sisters was operated on successfully. One 

R 2 



240 HUTCHINSON OX CHOROIDITIS 

of the patient's brothers, now aet. 65, had cataract in one eye, 
and was operated on 17 or 18 years ago successfally at Moor- 
fields. He fancies something is now " dropping down " from the 
other eye. The patient has had two daughters, the yonnger of 
whom had " bad eyes." He has fonr sons who have no defect of 
sight. He used to drink much and smoke when young ; he was 
rather wild, but never caught any venereal disease. He had 
never had any swelling of feet or ankles, but has been liable to 
"lumbago." He had jaundice 11 years ago, for three weeks, 
with numbness of the two middle fingers of the riofht hand 
coming on regularly for an hour in the morning. • When the 
jaundice came out the numbness went off. The pains in the 
shoulders did not come on till his sight failed; he mentioned 
them as very troublesome. In the fundus of each eye there were a 
number of small spots, some of a glistening white, but the majority 
of a faint white colour. They all seemed on a level posterior to 
the retinal vessels ; they were of irregular size and shape, and 
were chiefly situated above and below the disc. In the right 
eye they were fewer in number and distinct from another ; 
there were none visible at the periphery, nor at the yellow spot. 
In the left eye they were much more numerous and were fused 
together, showing a tendency to form patches above and below 
the disc ; there were a few at the yellow spot, and some faint 
ones in the periphery. There was a slight central opacity at the 
posterior pole of the lens. 

In May 1875 the ophthalmoscopic appearances had not mate- 
rially changed, and his sight was the same as before, the right 
being rather the better of the two. The sight is very defective, 
and he cannot see anything smaller than 20 J. with any glass. 

Case VI. — Central Choroido- Retinal Disease in small ivliite sjpotx 
in a Woman of 62 — Failure of sight, six months — Incipient 
Cataracts — Deafness — Choroidal Disease of an earlier date at 
Periphery — No Alb u minuria. 

Mary Anne J., jet. 62, applied at Moorfields in January 1873. 
She was in good health. Her sight had been failing for six 
months. She had been somewhat deaf for three years, but for 
six or seven -months this had increased, and, on admission, she 
was very deaf indeed. The urine (tested a few days later) was 
pale, clear and free fi"om albumen. 



IX 8EXLLE PERSONS. 241 

Ou ophthalmoscopic examiiiatiou a number of very small 
white spots were found to be scattered widely over the central 
part of the fundus, being especially numerous in the yellow-spot 
region. Near the yellow spot in the right eye they had become 
partly confluent and formed a large white patch. The spots 
varied much in clearness of shade, some being of a glistening 
white, others of .various somewhat duller white tints ; they also 
differed in size to some extent and were not all cii-cular ; the 
duller coloured ones were especially noted to have somewhat ill- 
defined borders. Many of them were distinctly behind the 
retinal vessels and none were proved to be in front. Those 
near to the yellow spot were, as a rule, of a brighter white 
than those elsewhere. There was not the slightest pigmentation 
of any of the white dots. In each eye the optic disc was perhaps 
slightly pale and hazy, but these appearances may have been due 
to the incipient general haze of the lenses which was observed on 
oblique illumination. At the extreme lower part of the peripheiy~ 
in each eye were several round patches of old choroidal disease ; 
atrophic choroid with some pigment accumulation. 



Case YII. — Central Choroido-Betlnal disease in a Man of 74; 
sviall white sjiots — Failure of sight several years — Deafness 
— Incipient Cataracts — No Albuminuria — No evidence of 
Syphilis. 

Benjamin P., set. 74, was admitted in January, 1873. The 
sight had been failing in his right eye for four or five years ; and 
in the left two or three years. He was very deaf and had been 
so more or less for many years. His wife said that in other 
respects he was in good health. About 30 years previously, and 
before mai-riage, he had had some eruption on the face and head 
which had caused the loss of much of the scalp hair and jDroduced 
a number of small acne-like scars on some parts of the scalp. 
There was nothing to show that this eruption was syphilitic, nor 
was there anything confirmatory of that suspicion in the history 
which his wife gave of their childrens' health. 

The pupils were inactive. Ophthalmosc. exojn. showed com- 
mencing cataracts and a number of well-defined white spots in the 
fundus of each eye at the yellow-spot region. These spots were 



242 HUTCHINSON ON CHOROmiTIS 

more uumerons in tlie right than in the left eye, but had the 
same general characters in each. By careful inspection it was not 
difficult to see that they were of two varieties — (1), very small cir- 
cular bright white dots probably situated in the deep layers of the 
retina ; (2), spots for the most part rather larger and less regular 
in outline than the former, and of a duller tint ; sometimes 
abruptly defined, in other cases showing somewhat diffused 
borders, for the most part unpigmented but sometimes inclosed 
by a thin collar of black pigment. These were undoubtedly 
seated in or on the choroid. It was difficult to feel certain 
whether they were deposits, or spots of partial atrophy ; it was 
certain that they were not of the same character as those abruptly 
defined circular patches of atrophy, seen in old eases of dissemi- 
nated choroiditis, which look as if bits of choroid had been 
punched out. The urine was found to be quite free from 
albumen. 

Case VIII. — Central Choroidal (or ? Uetinal) disease in small 
icJiite dots in a Man of 64 — Slight Albuminuria. 

John B., set. 64, a labourer, applied on March 18, 1875. His 
complexion was pale and sallow, and his face somewhat pufiy ; 
he said that his legs swelled, and were more swelled in the 
morning than later in the day. He had never had rheumatic 
fever and never been dropsical. 

On ophthalmoscopic examination some small white spots were 
found in the fundus on the nasal side of the disc (none on the 
yellow-spot side). They were arranged in a curved line. They 
were very white. One of them was crossed by a retinal vessel, 
but there was some difierence of opinion as to whether they wei-e 
seated in the choroid, or in the deep layers of the retina. 

His urine contained a small quantity of albumen, just enough 
to give a definite reaction. 

Case IX. — Central Retinal Disease in minute white dots in a very 
senile Man of 48, in bad health — Failure of sight, two months 
— Deafness — Slight Albumimcria — Old ruptare of Choroid in 
other Eije. 

Wiliam C, 48, a carpenter, applied on account of failure of 
his right eye in J^di/, 1875. It had been failing for about two 



IX SENILE PERSONS. 243 

months, aud lie could only see letters of 18 J. wiili it ; pupil 
active and of ordinary size. The othei' eye (left) had been defec- 
tive ever since he received a kick on the corresponding eyebrow 
by a horse in childhood ; with it he could barely see letters of 
20 J. ; pupil rather dilated and scarcely dilates more when 
covered. He is a stoutish man, but is feeble aud bent, looking 
at least 10 years older than he is; memory bad, manner confused. 
About four or five years ago he went out for some months to the 
West Coast of Africa to build a house; he had " fever and ague " 
there and brought the disease home with him. Although, he got rid 
of the fever six months after his retuim home (three — four years 
ago), he has never been strong since, aud he says he has aged very 
much since going to Africa. For the last year and a half he has 
been somewhat deaf, and this gets worse. He has had no head- 
ache, only " a little dulness about the forehead " since his sight 
failed. The pupils did not dilate widely under atropine. In the 
right eye we found numerous minute very white dots in the 
fundus between the disc and the yellow spot, and involving the 
yellow- spot region to some extent ; they were apparently in the 
retina. There was also some greyish opacity of the retina along 
the large vessels. No changes elsewhere. In the other eye 
(defective since the kick) there was a very large area at the 
yellow- spot region where the choroid was atrophied and the 
exposed sclerotic partly obscured by abundant pigment ; changes 
probably resulting from an extensive rupture of choroid with 
haemorrhage from its vessels, caused by the injuiy. 

A few days later his urine was tested and found to contain a 
small quantity n{ albumen. At the end of August he was no 
better. Iodide of potassium had been given. 

Case X. — Central Choroidal Disease in small ichite sjiots — Slight 
failure of Sight one or two weeTcs — No Albuminuria — Patient 
perhaps remotely Syphilitic. 

Ellen H., 38, a widow for the last 12 months, found her 
sight failing slightly for a week or two before admission on June 
28, 1875. Her sight was found, on trial, to be nearly perfect, 
and her complaint of slight dimness was at first referred to hyper- 
metropia. The defect was, however, not remedied by any glasses ; 
and, on ophthalmoscopic examination, it was found tliat in each 



■244: HUTCHINSON ON CHOROIDITIS IN SENILE PERSONS. 

eye a large area in the central part of the fundus was occupied by 
numerous, small, round, yellowish- white spots. They occupied 
each yellow-spot region, and extended also in the form of an ill- 
defined broad belt inwards around the optic disc ; their arrange- 
ment thus much resembled that in Case III already desci-ibed. 
The spots were not sharply defined at their edges, nor were they 
of a glistening bright white, but rather yellowish- white ; from 
these characters there seemed no doubt that they were choroidal 
and not retinal. There was no albumen in the urine (tested a 
few days later). At the end of August she considex'ed her sight to 
be better, and could read 1 J. She had taken the iodide. 

The woman showed no outward evidences of syphilis ; and, 
although she said that her husband had been unsteady and that 
she believed he had had venereal disease after marriage, she was 
not aware that she had ever had any local or general symptoms 
of the disease. The history of her children rather tends to con- 
firm her belief that her husband had the disease after marriage 
(? between the 1st and 2nd pregnancies). 

Her 1st child died at aet. 18 months, later than the usually 
fatal period in infantile syphilis. 

The 2nd died at two months of " teething." 

The 3rd still-born. 

The 4th died at 10 months of " teething." 

There was, however, no history of syphilitic symptoms in any 
of them, nor did it appear that she herself had ever sufiered. 

The last of the series differs in some important features 
from the others, more especially as regards the age of the 
patient and the probaljility of sj'^hilis. It resembles them, 
however, in respect to the ophthalmoscopic appearances, and 
thus I have thought it well to print it in juxta-position. 

It is only right that I should state, in concluding my 
report, that I was indebted to my friend and colleague, 
Mr. Waren Tay, for m\ich more than the mere notes of the 
first cases. The patients were under my care, but it was he 
who made the ophthalmoscopic examination, and drew my 
attention to the peculiarities presented. I have failed to find 
in our standard works and atlases any description of similar 
cases. The disease is not improbably a well characterised 
and important form of senile amaurosis. 



FIRM FIBRO-CELLULAE, TUMOUR OF UPPER LID, INVOLV- 
ING THE SUBCONJUNCTIVAL TISSUES ABOVE THE 
TARSUS, AND NOT IMPLICATING THE SKIN. 

REMOVAL ABOUT 14 MONTHS AFTER FIRST APPEARANCE 
OF ENLARGEMENT OF EYELID. 

By Jonathan Hutchinson. 

Charles Eeese, «t. 38, a liglit-haired, blue-eyed German, 
began to notice an enlargement of his right upper eyelid, 
about 9 months before he came under my care at Moorfields. 
He stated that the enlargement was first observable near to 
the eyelashes. 

For the first 6 months he had no advice ; the swelling 
having continued to increase, he went to a medical man 3 
months before admission, and saw him at intervals all the 
time. He was directed to pinch the swelling firmly several 
times a-day, a proceeding which was repeated by the medical 
attendant at his visits. 

He was admitted at Moorfields on Novemher 11th, 1872, 
with " hypertrophy (?) of upper tarsal cartilage of right ; no 
fluctuation" was noted. Lead ointment was ordered. A 
fortnight later, iodide of potassium, in five-grain doses with 
ammonia, was ordered; and, on December 19th, the dose of 
iodide was increased to ten grains. On January SOth, 1873, 
the swelling was noted to be " rather less," but on Fehriiary 
20th, " it is again swollen." Iodide of lead ointment was 
directed to be rubbed into the swelling and the medicine 
continued. 

On A2)ril 17 ih, no improvement having taken place, 
determined to operate. There was at this time a "firm, 
uniform swelling of the eyelid," along its whole length, with 
some oedema of the skin- 
On passing the finger up between the eyeball and the 



24:6 HUTCHINSON ON A RARE TUMOUR 

lid a firm substance was felt, attached above to the lid, but 
projecting downwards for some distance as a tongue or 
lobe which thus lay free between eyelid and globe. 

The tumour was removed at this date, 14 months after its 
commencement, by an incision corresponding to its upper edge. 
Its lower part passed insensibly into the tissue of the tarsal 
cartilage, with whose inner surface, near the upper edge, the 
tumour seemed to be continuous. Part of its inner surface 
was covered by closely adherent conjunctiva, and from this 
part a duplication or tongue of the tumour passed downwards 
between lid and eyeball. Tire adherent .conjunctiva was 
removed with the tumour, leaving a considerable gap in the 
palpebral part of the meml^rane. The gap did not, however, 
take the whole length of the tumour. The part removed was 
about a quarter-of-an inch thick, and an inch wide from 
above downwards. It extended from the conjunctiva deejoly 
into the cellular tissue of the eyelid, reaching close to the 
muscular bundles of the orbicularis. It was very firm, but 
on section did not prove to be gritty or ossified or cartila- 
ginous in any part. Divided vertically while quite fresh, it 
showed a mottled surface of yellow, pinkish, and grey- white, 
the pinkish prevailing ; near its upper (thickest) border was a 
considerable yellowish patch. The greatest part of the surface 
was finely granular, but intersected by shining, apparently 
fibrous, lines. These were most obvious and abundant at and 
near its line of fusion with the upper edge of the tarsal 
cartilage. Scraping gave a little dryish material but no 
proper juice. The texture was moderately firm and tolerably 
uniform. The tints were like a myeloid tmnour, but the 
granular surface more resembled gland tissue. The tumour 
was thickest at its rounded upper border, and became gradually 
thinner towards its (virtual) edge where it joined the tarsal 
cartilage. Its anterior sm-face was convex, its posterior sur- 
face, on the whole, concave. 

Dr. BuUer examined teasings of the fresh tumour ; he 
found fibrous tissue and numerous small round nuclei or 
corpuscles. 



OF THE UPPER LID. 247 

A coloured drawing was made of the cut surface of one 
half w^hile fresh; the remainder was hardened in Miiller's 
fluid for further examination, when sections were made 
antero-posteriorly through the thickness of the tumour, and 
examined by Mr. Nettleship. Some v/ere stained in carmine ; 
part of the sections were mounted in glycerine, others in 
dammar. 

The growth was found to consist essentially of imperfectly 
developed fibro-cellular tissue, not unlike granulation tissue 
in some parts. The supply of blood-vessels was relatively 
scanty. The cellular elements were small, round, and each 
almost filled by a large nucleus and small nucleolus. In the 
deeper parts the proper fibrous tissue of the eyelid was infil- 
trated ]jy the new cells, to a varying extent in different parts, 
and in a few spots even the cells of adipose tissue found in 
this region were separated by small collections of similar 
round cells. The conjunctival surface of the growth was 
covered by a very thin layer of flattened epithelial cells. 

The only indications (and these doubtful ones) of glan- 
dular structure were seen in two or three cross sections of 
small tubes, lined by large cokimnar cells ; these were quite 
near to the mucous surface of the mass, and looked like 
sections of small gland-ducts. 

The characters of the tumour varied somewhat in different 
parts ; no great degTce of development, however, had taken 
place anywhere ; and, on the other hand, nowhere was there 
the least sign of fatty or other degeneration. Immediately 
beneath the conjunctival surface there was a thick stratum, 
consisting entirely of the round cells described, w'ithout any 
trace of intercellular substance ; there were also several 
similar collections, purely cellular, more deeply seated, one or 
two of them of large extent, others small and in the im- 
mediate neighbourhood of blood-vessels. In the deeper (more 
central) parts, however, the cells were everywhere separated 
from one another by a reticulated network of finely dotted 
and faintly fibrous tissue. Thicker bands were formed by 
the union of the fine meshes which separated individual cells 



248 HUTCHINSON ON A RARE TUMOUR 

or small groups ; while in parts where the fibrous element 
was most developed, it consisted of rather wide tracts or bands, 
enclosing comparatively few cells, these being either in small 
groups or scattered singly. There was very little, if any, evi- 
dence of development of round cells into spindle cells, and 
of these, again, into the intercellular fibrous tissue. On the 
other hand, even in parts where the fibrous change had gone 
furthest the remaining cells preserved their nearly round forms, 
or were at most only angular from pressure. The inter- 
cellular tissue was indistinctly fibrous, being more nearly 
hyaline, but with a slightly striated wavy appearance, and 
also more or less finely dotted. The larger bands ran some- 
times at right angles, at other times more or less parallel to 
the conjunctival surface, and thus often inclosed rudely rec- 
tangular spaces. The general structure was more suggestive 
of the subconjunctival filjrous tissue having become closely 
packed with indifferent cells, than of a growth in w^hich the 
fibrous elements had been developed from the newly-formed 
cells. 

I saw the man again in June, 1875, three years after the 
removal of the tumoux. There had been no return at the 
seat of the operation, but there was a small growth at the 
outer canthus between the lids aud the eyeball. It was very 
firm, of pinkish colour and flattened, with a free, somewhat 
lobulated border, and looked not unlike a much enlarged 
carbuncle ; it was attached to the inner surface of the lid. The 
operation had been followed by considerable puckering of 
the inner surface of the upper lid. The ptosis had not been 
relieved. The skin of the lid was extremely lax and abun- 
dant, and there w^as still some slight thickening about the 
free border of the lid. A gap coidd be felt easily in the 
position formerly occupied by the tumour. 

Fibroma of the upper eyelid is mentioned in the ophthal- 
mic treatises (WeUs and Wecker), the disease apparently being 
described on the strength mainly of two cases. In the first 
of these, recorded by Greefe, a young woman of twenty came 
under care for a circumscribed ovoid tumour of cartilaginous 



OF THE UPPER LID. 249 

consistence imbedded in the submucous tissue of the upper 
lid ; it was covered by smooth conjunctiva. It bulged the 
skin, and, on eversion of the lid, it projected from the sulcus 
of the conjunctiva, being about as large as a hazel nut. 
Some swelling was known to have existed for many years, 
but only during the last few years had any diagreeable symp- 
toms (a feeling of pressure) been present. The tumour was 
excised and Schweigger found that it contained a central 
portion of true bone a quarter of an inch (6 mm.) long, sur- 
rounded by thickened cellular tissue, and covered on its free 
surface by healthy conjunctiva. 

The second case is related by Wecker.* The patient was 
again a young woman of twenty. Below the left upper eye- 
brow she presented a tumour four-fifths of an inch long by 
about two-fifths wide ; there was very little elevation of the 
skin, but when the lid was everted the tumour projected from 
the conjunctival sulcus like a second tarsal cartilage. It was 
covered by healthy conjunctiva. It felt as hard as a plate 
of bone. The patient had noticed it for three years, but con- 
sidered that it had increased very Little during that time. 
She declined operative treatment. 

In the Ophthalmic Hospital Eeports, vol. i, page 35 
(Mr. Bader's Report of Operations), it is stated that " a pecu- 
liar warty-looking growth, causing ptosis, was removed by 
Mr. Bowman from the upper cul-de-sac of the conjunctiva," 
in 1857. Unfortunately no further details are given, and 
Ave are scarcely warranted, from the above account, in con- 
fidently classing this with the two preceding cases. 

Talkoi* recently met with a case where, in a boy aged 12, 
a pedunculated tumour grew from the palpebral conjunctiva 
of the upper lid. Although the case did not resemble the 
one here recorded, a short abstract of it may be of interest 
in connection with rare tumours of the uj)per lid. 

The patient, a peasant boy of twelve, was admitted in 

* Traite des Mai. des Yeux, vol. i, p. 650, 1867. 

t Zehender's Klin. Monatsbl. f. Augenlieilkunde, 1873 (N'ovember) , 
p. 326. A woodcut representing the tiiraonr hi silit, is given. 



250 HUTCHINSON ON A RARE TUMOUR OF THE UPPER LID. 

June with an oval tumour as large as a hazel-nut lying be- 
tween the eyeball and the upper lid and attached to the 
palpebral conjunctiva; its base extended from the tarsal carti- 
lage to the oculo-palpebral fold where the pedicle spread out 
on either side. It was, when first seen, covered with clotted 
blood, but, on examination, was found to be soft, elastic, of 
dark red colour, its surface being smooth as if covered by 
mucous membrane; it bled when touched. The boy's mother 
stated that in the preceding autumn he had received a blow 
on the eye which was followed by considerable bleeding, and 
that soon afterwards a tumour began to grow. This the 
mother tore off' with her fingers as soon as it appeared exter- 
nally ; finding that it grew again she cut it off with scissors ; 
and, lastly, this not being successful, she tied a pig's bristle 
round its stem two weeks before she brought him to the 
author, the ligature being still present on admisssion. Having 
everted the lid. Dr. Talko cut off the tumour, together wdth 
the surrounding somewhat thickened conjunctiva. The 
wound, which occupied a large part of the conjunctival sur- 
face, healed well. Six weeks later a little nodule as big as a 
hemp-seed which had formed in the scar was removed, and 
since then the patient had not been heard of. In shape and 
mode of attachment the tumour resembled a polypus ; it was 
tolerably soft and easily torn by pressure ; its cut surface 
grey and quite smooth ; after hardening in spirit a number 
of holes like needle-pricks were visible. Microscopical exa- 
mination showed a stroma of connective tissue inclosing 
small spindle-shaped cells. Tlie growth contained blood- 
vessels. The spindle-cells formed its chief constituent, and 
the author regards it as a small-celled, fusiform-celled sar- 
coma ; not, as its coarser features suggested, a polypus. It is 
stated that he was a strong boy of healthy parentage. 



A CASE OF EMBOLISM OF THE CENTEAL AETERY OF THE 
EETINA. — SUBSEQUENT GLAUCOMA, TEMPOEAEILY EE- 
LIEVED BY lEIDECTOMY.— EECUEEENCE OF GLAUCOMA. 
—ENUCLEATION.— MICEOSCOPIC EXAMINATION OF THE 
OPTIC DISC AND NERVE. 

By Messrs. W. Spencer Watsok, F.R.C.S., and 
Edw. JSTettleship, F.R.C.S. 

Esther W., eet. 62 years, unmarried, applied at the South 
London Ophthalmic Hospital, and was under Mr. Watson's 
care in April, 1874. 

History. — Six years ago she had a severe attack of epis- 
taxis, which necessitated plugging of the anterior nares ; 
three years ago she had bronchitis, but has never suffered 
from any other serious illness till April 5th, when sudden 
acute pain came on in the right eye, the sight of which was 
immediately lost. 

During a few days before this, she had suffered from 
slight pain in the side of the head, and this became suddenly 
extremely severe when the sight was lost. 

Condition on Admission on April ^tli. — She is a short, 
stout, somewhat pallid woman. She states that she suffers 
occasionally from palpitations and shortness of breath on 
making any sudden or unusual exertions. There is a bruit 
heard over the precordial region and the heart sounds are 
feeble. 

The right eye is absolutely sightless, there being no 
evidence of even the faintest perception of light. The pupil 
is fixed and dilated, but partially contracts in concert when 
light is acting on the sound eye. With the opldludmosco'pe, 
the following appearances were noted in the affected eye : — 
Margin of optic disc blurred by a liazy pink discoloration ; 
veins large and tortuous ; arteries small and threadv. 



252 CASE OF EMUOLISM 

Aiwil 15. — Vision remains as before. The movements of 
the eyeball are much limited in every direction, but least so 
downwards. There is no noticeable protrusion .of the eye- 
ball. Slight tenderness is observed on the upper, inner 
and outer margins of the orbit. The ophthalmoscopic ap- 
pearances are scarcely at all changed, but the arteries are a 
little more distinct, and the veins are still large and inter- 
rupted here and there by deposits. 

At first the condition somewhat resembled that of 
retinitis, and a short course of mercury was given with the 
eti'ect of making the gums slightly tender. • Ice-balls were at 
the same time applied to the eye. She was relieved so far 
as pain was concerned, but sight was not restored. On the 
evening of April 17th, she became suddenly insensible, and 
was laid up in bed for a fortnight under the care of 
Dr. Green, of Peckham. On June 10th, I again saw her ; 
she had then congested sclerotic, discoloured and turbid an- 
terior chamber, increased tension of the globe, pain in tlie 
eye and across the head, and, in fact, .all the symptoms of 
glaucoma. An appearance as of a deposit in the upper 
and outer part of the vitreous was seen with the ophthalmo- 
scope. 

June 16th. — Severe pain and tension continuing, I per- 
formed iridectomy upwards. Por some months after this 
there was no return of pain nor of tension, but on October 
2nd these symptoms having both returned, paracentesis of 
the cicatrix was performed by Mr. McHardy, in my absence. 

This operation gave only temporary relief notwithstanding 
the administration of opium in large doses, and frequently ; 
and on October 6th, the pain continued so severe that I ad- 
vised enucleation. To this the patient consented, and ether 
having been administered by Mr. McHardy, the ojjeration 
was performed in the usual way. 

The relief experienced by the poor woman was complete, 
and she was truly thankful to be rid of her very painful and 
troublesome eye. 

On the 23rcl October an artificial eye was fitted, and slie 



OF THE ARTERIA CENTRALIS RETINA. 253 

has worn it ever since with comfort. There is some im- 
pairment of sight of the remaining eye, and at one time the 
patient complained of seeing a black stringy spectrum before 
her. This, however, has passed off, and her sight remains 
good enough to enable her to read large print and do coarse 
needlework. 

With a biconvex glass of 11-inch focal length she could, 
on March 18th, 1875, read J. 4 easily; the tension was 
normal and no pain nor chromopsiffi were complained of: 
general health good ; heart sounds normal. 

w. s. w. 

Examination of the Specimen, and Remarks. 

The eye was kept for several weeks in Mliller's fluid 
and then hardened in alcohol. Its size and shape were 
normal. The only change visible to the unaided eye was 
slight and irregular detachment of the retina, a result which, 
I think, is sometimes due to the effect of Mliller's fluid. 

Sections of the optic disc and the ocular end of the optic 
nerve were made parallel with the optic nerve fibres, and as 
nearly as possible in the direction of the main divisions of 
the central vessels. 

Two of the slices contain longitudinal sections of the 
central artery long enough to be of use, the most extensive 
being rather more than -^ inch (1 mm.) in length. In a 
third section the continuation of one main division of the 
trunk upwards can be followed as far as the commencement 
of the retina. No section, however, shows the actual point 
of division of the main trunk into branches, though this 
would probably be at e, where the branch d begins. 

The whole of the portion of the arteria centralis included 
in the specimen shows very striking changes. Its calibre is 
throughout much diminished, and the tunica intima is 
strongly and irregularly wrinkled, the latter change being by 
far the most marked at a point a little above the lamina 
cribrosa, where it is extreme (a). Immediately above this 

VOL. VIII, s 



254 CASES OF EMBOLISM 

point the vessel contained in the section rapidly becomes 
smaller, while the \\T.'inkling of its intima as suddenly ceases 
altogether ; no doubt this diminished vessel (d) is, as already 
mentioned, really one of the main terminal divisions of the 
artcria centralis, the remaining branches not being included 
in the section. The tunica adventitia, both of the a.rteria cen- 
tralis and of the above-mentioned branch, is everywhere 
thickened in proportion to the diminished calibre of the 
vessel, and infiltrated with finely granular substance, but the 
sheath of the vessel is not increased in absolute size. The 
viiisciilar coat follows the puckerings of the intima, and can 
be recognized everywhere, except at the uppermost part of 
the trunk, where the \\Tinkling, as mentioned already, be- 
comes extreme {a). This tunic in the branch d is oedema- 
tous. The branch d, as well as a secondary branch given off 
further and not shown in the figure, is everywhere very 
much smaller than in health ; it appears slightly narrowed 
just at its origin, e, afterwards dilating a little. 

The whole of the portion of artcria centralis included in the 
specimen is occupied by fibrous-looking material mixed with 
a molecular substance, containing scattered corpuscles. The 
corpuscles almost all look like white blood-cells, but here 
and there is a red corpuscle. The fibrous substance is irre- 
gularly distributed, and does not everywhere fill the vessel, 
having long spaces in its own substance, or bridging over 
one or several of the foldings of the intima. Both the fibrous 
and the granular substance are slightly stained by carmine. 
At the point of greatest distortion {a), where the arterial 
tunics are extremely puckered, the lumen of the vessel is, I 
think, quite filled by these pink substances. 

The branch d is either quite empty, with the exception 
of an occasional corpuscle, or it is uniformly filled by a 
perfectly homogeneous and colourless substance. As its 
lumen is seen for the most part through superjacent tissue, 
it is difficult to decide upon this point, but the pink contents 
ol' the trunk appear to cease at c. 

No attempt is made to show the cliaracter of tlie arterial 



OF THE ARTERIA CENTRALIS RETIN^aE. 



255 



contents in the wood-cut ; the outline of the vessel is how- 
ever accurately represented. 

There can be no douLt, I think, from the changes shown 




Longitudinal section of the Arteria Cerdralis BetincB 6 mouths after the 
occurrence of Embolism. 

by this artery and its contents, that it had ceased to carry 
blood for a considerable time before the eye was removed ; 

s 2 



250 CASES OF EMBOLISM 

and although, partly from imperfections in the sections, 
partly from the small and puckered lumen of the vessel, it 
is not possible to give so definite a description of the fibrous 
and granular contents as is desirable, I think enough can be 
seen by careful examination to warrant the conclusion that 
they are probably of fibrinous nature. 

It is quite possible that some of the spaces and channels 
in the contents of the artery may be new vessels developed 
in organized fibrin, but I cannot be sure of this. The 
extreme puckering seen at the upper end of the artery, 
Avhich is at or close to its division into branches («), suggests 
this point as the seat of the earliest changes, while, on 
d priori grounds, it is a point at which an embolus of 
sufficient size would be likely to be arrested. 

The changes seen in the other structures of the nerve 
and neighbouring parts are indicative of chronic inflam- 
matory cedema. There is an old extravasation in the disc, 
cedema and atrophy of the retina, inflammation and thick- 
ening of the hyaloid membrane, oedema of the choroid, and 
finally inflammatory changes in the subvaginal space leading 
to almost comj^lete obliteration of its cavity. The rods 
and cones are quite atrophied on one side of the disc, 
but on the other side seem healthy, or only slightly 
elongated. 

The vena centralis is shown in one section, and is filled 
with finely granular cells, resembling white blood-cells and 
stained by carmine, mixed with a few rust-coloured granules ; 
an appearance probably due to thrombosis. The vein is not 
shown in the sections which contain the artery. 

I think I should hesitate in ascribing the changes found 
in this specimen to embolism of the arteria centralis retinoihsid 
I not previously examined another specimen in which the 
appearances were much better marked than in the present 
case, the changes not having advanced so far and the sections 
fortunately giving a better view of the artery and its branches. 
Read by the liglit of that specimen, however, I have no doubt 
that the present case is one of embolism. It seems j^robable 



OF THE ARTERIA CENTRALIS RETIX.^. 257 

that the occlusion of the artery Avas complete from the first, 
and that the subsequent congestive and inflammatory changes 
were as a consequence more considerable than in the former 
case, where these changes were slighter and the symptoms 
pointed to the occlusion having been only partial in the first 
instance. 

Professor Schmidt has lately published a case (Graefe's 
Archiv.), in which the presence of an embolus in the central 
artery of the retina was proved by post-mortem examination. 
The vessel was plugged completely soon after piercing the 
nerve sheath, and a branch given off near its entrance into 
the nerve and running parallel with it was also occluded. 
There was also a distinctly circumscribed embolus in a small 
retinal artery. Tlie more distal part of the arUria centralis and 
its branches in the disc were filled with partly decolorised 
clot (" yello\^dsh hyaline thrombus "), and the vena centralis 
was also partly filled with clot. At one part of the artcria 
centralis a small vessel containing blood- corpuscles had 
become developed in the thrombus. The nerve-fibres of 
the optic nerve between the eyeball and the part at which 
the plugging began were much atrophied ; there were some 
psammomata in the meshes of the connective tissue forming 
the nerve-sheath near the sclerotic, and lastly, consider- 
able changes in the central parts of the retina and choroid. 

The specimen was obtained from a man, a^t. 58, who died 
10 months after sudden, complete, and permanent blind- 
ness of his left eye. 

The case was complicated by symptoms of irido-cho- 
roiditis, opacities in the vitreous, chemosis and protrusion 
of the eyeball, due probably to emboli in the ciliary arteries. 
Several of the smaller branches of the oplithalmic artery 
arising near the arteria centralis retince were found completely 
plugged in the specimen. 

Ophthalmoscopically the retina and disc showed changes 
lilce those met with in other cases of embolism. 

With respect to the cause of the permanent loss of sight 
in cases of embolism of the artcria centralis retinm the recent 



258 CASES OF EMBOLISM 

examinations of specimens show that this may be due both 
to clianges in the retina and in the optic nerve. 

As regards the retina. (1) In AVordsworth's case (recorded 
by Nettleship) the rods and cones were much swollen and 
lengthened, the nerve-fibres of the disc were swollen, and 
inflammatory cells probably lay between the individual 
fibres ; minute growths projected from the disc into the 
vitreous, the outer sm^face of the latter (hyaloid) was 
altered, and the retinal tissues generally showed signs of pro- 
longed oedema ; four months having elapsed since symptoms 
began. (2) In the case recorded in the present paper it has 
been already mentioned that there was oedema and atrophy 
of the retina, with complete atrophy of many of the rods 
and cones and thickening of the hyaloid," six months after 
symptoms began. (3) In- Schmidt's case (ten months after 
symptoms began) there were considerable changes in the 
central parts of the retina and choroid. The optic nerve and 
its sheath in Wordsworth's case (four months' interval), I 
have found, on further examination of the sections since 
the former description was written (vol. viii, pt. 1, of these 
Keports), that the subvaginal space, close to the eyeball, 
contains a great number of rather large, oval, or nearly 
round corpuscles, imbedded in a fibrinous-looking material, 
which is interposed between, and wraps round, the normal 
connective tissue trabecula3 of this part, and is often pro- 
longed into processes stretching from one part of the 
space to another. The corpuscles have thin, sharply defined 
outlines, and a single bright nucleolus. In Watson's case 
(the subject of the present paper), (six months having 
elapsed since symptoms set in), the subvaginal space 
was quite obliterated on one side of the nerve and very 
much diminished on the other side by a fibro-cellular 
tissue, consisting of long spindle, or fibre-cells and branched 
cells, enclosing the normal trabeculce, and containing oval 
clearly defined nuclei of the same characters as those in 
the earlier specimen. It was the observation of these 
very marked alterations which led me to examine more 



OF THE ARTERIA CENTRALIS RETINiE. 259 

carefully the sections from ]\Ir. Wordsworth's case. These 
changes in the subvaginal space are clearly of the same 
nature in both cases, being more advanced in the case which 
had lasted six months than in that of only four months' dura- 
tion. (4) Priestly Smith records that the " optic nerve was 
found to be somewhat shrunken throughout the whole of its 
length " in his specimen, which was obtained at an interval 
of four months after the symptoms began. In Schmidt's 
case, fourteen months after commencement of symptoms, 
there were psammomata in the nerve-sheath, near the 
sclerotic. (5) The specimen examined by Sichel (fourteen 
months after symptoms set in) was removed so long after 
death that no inference could be draM^n from the minute 
structure of the retina ; the disc was, however, completely 
atrophied, and the retinal arteries reduced to grayish white 
threads, even to the peripheral branches. 

When the above was printed, I had not seen Dr. Loriug's 
"Eemarks on Embolism" (Amer. Jour. Med. Sci., April, 
1874), in which he records Dr. Delafield's report on an eye- 
ball excised for glaucomatous .symptoms eleven weeks after 
the supposed occurrence of embolism. In this case the 
central artery and vein were " nearly empty," there were signs 
of connective-tissue hypertrophy in the lam. crib., atrophy 
of nerve-fibres of retina and changes in the rods and 
cones, increase of lymphoid corpuscles in the choroid, and 
thrombi in some of the large choroidal veins. Beyond the 
fact that the art. centr. was nearly empty no details of its 
condition are given. 

E. N. 



NOTE ON THE RETINAL BLOOD-VESSELS OF THE YELLOW- 
SPOT REGION. 

By Edward ISTettleship, F.R.C.S., 
Sui'geoii to the Soutli London Ophthalmic Hospital. 

The wood-cut accompanying thia note does not illustrate 
any new facts. Everyone is aware that no blood-vessels cross 
the fovea centralis, while everywhere else the retina is abun- 
dantly supplied with them. I have not, however, seen any 
illustration showing the precise distribution of the capillaries 
and minute arteries and veins of this part of the retina, and 
as statements are occasionally made which imply some want 
of certainty on the point, a copy of a tolerably well injected 
specimen of the part in question may still be of some interest 
in relation to morbid clianges occurring there. 

Some good ophthalmoscopic drawings of the blood-vessels 
in the region of the yellow spot are given by Delorme, in an 
article on this part of the retina,* where he states that a 
greater number of the smallest arterial and venous twigs can 
be seen with the ophthalmoscope in the region of the macula 
lutea than in any other part of the retina. His figures 
represent only the larger twigs, the minutest divisions and 
the capillaries being invisible. Dr. Loring also, speaking of 
the yellow spot in his " Eemarks on Embolism,"-f- believes 
that " contrary to the general opinion, which would have this 
region Imrren of vessels, it is the place of all others of the 
whole retina which is most supplied with minute vascular 
twigs." On the other hand, a recent writer, in ascribing the 
well-known haziness of the yellow-spot region in cases of 
embolism of the arteria centralis, to necrosis of the retinal 

* Journal d'Ophtlialmologie, 1872, p. 92, &c. 

t American Journal of Medical Sciences, April, 1874, pp. 313 — 328. 



NETTLESHIP ON THE VESSELS, &C. 



261 



tissue, says that " it is both theoretically probal tie and prac- 
tically established that, in a necrosis of this kind, the 
primary impairment will be in the region of the macula 
lutea, a spot ivhich in the normal state is particularly devoid 
of vessels"*' (my own italics). While fully admitting the 
occurrence of a permanent degeneration of tissue in the cases 
alluded to, I cannot accept the above explanation of it, 
restino- as it does on an error of fact. 




Blood-vessels of the jellow-spot region of the Human Eetina, injected. A, 
Arteries ; V, Veins. N, Nasal side of yellow-spot (towards optic disc) ; 
T, Temporal side. The shaded area in the middle is the Fovea centralis. 
X 49. 

The above figure is taken from a specimen of human 
retina which I injected in 1871 with an acid carmine fluid 
containing a very small proportion of gelatine. It is a 

* J. Samelsohn, of Cologne, " Embolism of the Central Artery of the 
Retina," Knapp's Arcliives of Ophthalmology and Otology, vol. iii, No. 2, 
pp. 44—74. 1874. The quotation is from p. 62. 



262 NETTLESHIP ON THE VESSELS 

tolerably complete injection, and the fluid has run through 
the capillaries into the veins, so that all the vessels can be 
easily traced. A few of the capillary loops are broken or 
distorted, and some others are not filled; but the general 
plan of their arrangement, the closeiiess of the netv/ork, 
and the comparatively short length of capillary A'-essel which, 
in this part of the retina, intervenes between the finest 
arterial and venous twigs, are well shown. The capillary 
network is closer in this region than in any other part of the 
retina, its meshes gradually becoming larger towards the 
ora serrata. At the ora serrata the capillaries end, as is 
well-known, in wide loops, Avhilst a great length of capillary 
often separates the smallest arteries from the venous radicles. 
On comparing different parts of the retina, I find that while 
on an area of -jgV tt sg'i^are inch in the yellow-spot region 
at least 40 complete meshes can be counted, not more than 
from six to nine are included on the same area at a spot 
Jq inch behind the ora serrata, the injection being equally 
complete in both places. The area of the fovea centralis, 
which is destitute of vessels in the specimen here figured, is 
equal to about ^-^Vo square inch, and is irregularly oblong; 
it is scarcely larger than the single capillary meshes at the 
ora serrata. 

There are no direct anastomoses between the arterial 
branches, but on the temporal side of the part (T in the 
figure) two or tlu-ee of the smallest arteries are indirectly 
and rather closely united by capillaries. Such a slight com- 
munication as this is almost certain to vary in different eyes, 
and can scarcely have any general importance ; when present, 
however, it may exert some influence on the changes oc- 
curring after embolism of single branches of the retinal 
artery. 

The above figure and facts enable us to assert that the 
part of the retina which becomes most hazy after embolism 
of tlie central artery, viz., the area immediately surrounding 
the fovea centralis, is also the part which is most freely 
supplied with arteries, capillaries and veins ; while the very 



OF THE YELLOW-SPOT REGION. 263 

spot which, in the t}"pical cases, is quite free from opacity, 
viz., the fovea centralis itself, is also the only part devoid of 
blood-vessels. We may therefore conclude, on anatomical 
grounds, that the haze in question is probably due, as sug- 
gested by Loring,* to transudation into the inner layers of 
the retina, which occurs when the circulation is brought 
more or less to a standstill, and takes place most freely 
where the vessels are most numerous ; and that it is not 
caused, as Samelsohn implies, by rapid death of the tissues 
owing to the stoppage of a normally very small supply of 
1 )lood. 



Loc. cit., p. 316. 



THREE CASES OF MALIGNANT TUMOUR PRESENTING SOME 
POINTS or UNUSUAL INTEREST. 

By Edwabi) Nettleship, F.R.C.S., 
Surgeon to the SotUh London Ophthalmic Hospital. 

The specimens described in the following cases came into 
my hands whilst Curator of the Moorfields Hospital Museum, 
and ought to have been recorded in an earlier number of 
these Ileports. I had not time to examine them imtil re- 
cently, and am now indebted to the kindness of the members 
of the Staff under whose care the cases came for permission 
to make use of them. 

Case I. — A case in ivhich a Sarcomatous Tumour {pigmented 
and spindle-celled) formed in the Ciliary Body, at the seat of a 
former injury, in a girl cet. 18 — The Eye removed for inflam- 
mation and pain four months after operation for Traumatic 
Cataract, no Ttiviour being su,spected. 

Lavinia Barnes, living at Avon, near Ringwood, Hampshire, 
Mr. Hulke's patient, wounded her right eye in the summer of 
1871, by suddenly knocking a sharp stick against it as she was 
stooping. Very little pain or inflammation followed, but the 
sight of the injured eye was impaired and became gradually 
worse, and she never saw to read with it after the accident. At 
the end of twelve months Mr. Hulke removed a traumatic 
cataract by suction ; there was at the time great limitation of 
field and bad perception of light. The eye remained quiet for about 
four months after the operation ; then pain came on, and after 
enduring this for a fortnight she came up again and Mr. Hulke 
removed the eyeball. The other eye was at the time becoming 
irritable, but its sight was good. The lost eye was removed 
in December, 1872, a year and a half after the injury, the patient 
being 18 years old. 

State just before Excision. — " Right eye, pujoil acts somewhat; 



NETTLESHIP ON CASES OF MALIGNANT TUINIOUR. 265 

it is irregular and of moderate size, and its area white ; iris 
brown and not discoloured. There is a linear slightly depressed 
scar about a ^ inch (6 mm.) long at the upper and outer part 
of the sclero- corneal junction, and there appears to be a slight 
deficiency of the peripheral part of the iris at that spot. Good 
p. 1. ; T. slightly + ; eye very tender ; all the visible vessels 
intensely congested, the upper ciliary veins especially so." 

No suspicion of tumour being entertained, enquiries were 
not made as to her family history ; nor was the eyeball examined 
further until it had been for four months in Miiller's fluid, 
when it was divided at the equator. The vitreous was fluid 
(excepting a thin peripheral layer) and clear ; it became nearly 
solid from coagulation on addition of nitric acid, but scarcely 
coagulated at all when boiled without addition of acid. Retina, 
showed a number of little foldings at ora serrata and also in the 
posterior half of eye, and was perhaps somewhat thickened. A 
rounded dark tumour, the size of a small cherry, but somewhat 
less globular, occupied the position of the ciliary body at the 
upper aud outer part of the globe. An antero-posterior section 
through the middle of the tumour passed through the centre of 
the scar before mentioned, which was now recognisable as a 
narrow whitish band at the sclero -corneal junction. The tumour 
had a wide base of attachment extending from the ciliary border 
of the iris in front nearly up to the ora serrata behind, and in- 
creasing in width from before backwards. It occupied the 
position of a large part of the lens and neighbouring vitreous, 
and extended quite to the axis of the eye, so that had the pupil 
been clear the growth would have been partly visible without 
looking obliquely into the eye. Its base in front extended in 
the form of a little prominent roll just in front of the ciliary 
margin of the iris, which was here depressed ; and it was this 
dai'k advancing projection which I mistook before excision for a 
gap in the iris. There were some black patches and streaks, 
probably old blood extravasations, in the outer surface of the 
vitreouri, both near the base of the tumour and in the posterior 
part of the eye. There was a small button of whitish substance 
in the position of the lens. 

The tumour was composed of the fusiform aud spindle cells 
which form the majority of choroidal tumours. They were of 
rather large size. The colour of the growth, which in thin 



266 NETTLESHIP ON CASES OF MALIGNANT TUMOUR. 

sections was brownish, was caused partly by nnmeroas dark 
brown granules and granular masses, partly by a general brown 
colouration of tlie cells, wliicb varied in degree in different parts. 
The ciliary muscle was entirely replaced by the morbid growth 
which had pushed forwards between sclerotic and iris and was 
just beginning to present in the anterior chamber. This part of 
the tumoui' presented a convex outline and was marked off very 
sharply from the iris, the tumour being composed of spindle 
cells very closely packed and at this point very highly pigmented ; 
while the iris immediately adjoining, although thickly infiltrated 
with cells, showed no similarity in the colour, or refraction, oi' 
arrangement of its elements to those of the tumour. The ciliary 
processes were free, being pushed forwards and somewhat com- 
pressed on the front surface of the tumour ; the growth had 
only just begun to intrude into the bases of some of them. 
Nothwithstanding the large size of the growth, the layer of pig- 
ment epithelium of the ciliary body was still present over the 
greater part of the tumour, although in many parts thinned. 
The overlying thickened and highly pigmented hyaloid was in 
parts invaded by the growth. The iris was somewhat thickened 
and abundantly infiltrated throughout with cells. Although, as 
already mentioned, th'^re was no continuity of structure between 
the iris and the advancing border of the tumour, yet from 
the characters of the cells in the iris, I think they are in all 
probability sarcoma cells and derived from the main tumour ; 
not of an inflammatory nature, and merely due to an increase 
of the lymphoid corpuscles of the healthy ii'is. Thus, their 
average size is larger than that of white blood cells ; they are of 
irregular forms, some even spindled-shape or fusiform, and some 
have double nuclei. A few similar cells, some of them highly 
pigmented, were found in the deepest layers of the corneal 
circumference close to Descemet's membrane, and some similar 
groups in the deepest layers of the sclerotic immediately adjoin- 
ing ; with these exceptions, both sclerotic and cornea were 
healthy. Sarcoma cells were therefore scattered in front of the 
advancing border of the tumour itself. 

There was no evidence in the sections examined (and they 
were taken through the centre of the scar) of a former per- 
foration of the sclerotic, but immediately behind the sclero- 
eorneal junction the conjunctiva became suddenly reduced to 



NETTLESHIP ON CASES OF MALIGNANT TUMOUR. 267 

almost a single layer of squamous epithelial cells, adhering to 
the outer surface of the sclerotic, an appearance which would 
be accounted for by the healing of a conjunctival ulceration 
such as might have followed the injury. It is of course possible 
that at some other part of the scar-patch evidence of wound of 
sclerotic might have been found, had the entire scar been cut 
into thin slices. 

The lens capsule was partly shrivelled and still contained 
some altered lens matter. Its epithelium was present over a 
considerable extent at and about the equatorial part. 

The tumour contained numerous very large blood-vessels. 

On July 6, 1875, the patient wrote, in reply to a note, that 
she was in good health and had had no inconvenience or pain 
since the operation. 

Case II. — Wliite Sarcoma of the Choroid in a Qirl, cet. 12. 
Numerous small Nodular Groivths in Choroid and Retina, and 
commencing Affection of the Iris. 

Miss Gr., a pale flabby girl of 12, was brought to Mr. Hutch- 
inson on June 1, 1871, for pain and inflammation of her right 
eye. It was stated that the eye had been painful for three 
weeks, and that when the pain began she found she could not 
see with the eye ; but she did not know whether or not it had 
been blind before. The pain had been almost continual and very 
severe, " like tooth-ache in the eye." 

On admission, the right eye was very intolerant of light and 
there was some ciliary congestion and corneal haze ; a deeply 
seated grayish reflexion was thrown from the back of the eye- 
ball, but the photophobia made an accurate examination very 
difficult. The other eye was hypermetropic. 

On enquiry, it was stated that a relative of the patient's 
mother died of cancer. The patient herself was stated to have 
been ricketty in infancy; and her brothers and sisters had had 
bad health. 

June 21. The photophobia is extreme; much conjunctival 
and scleral congestion and some swelling of eyelids ; cornea 
clear or very nearly so ; iris of gray-blue colour like the other, 
its margin adherent by one or two points to the lens-capsule ; 
pupil somewhat dilated, rather oval vertically and slightly 



2G8 NETTLESHtP ON CASES OF MALIGNANT TUMOUR. 

irregular. The gray-green reflex seen as before, bnt sbe will 
not allow a careful examination. Tension not accurately esti- 
mated owing to the swelling of lids, apparently not increased. 
The eye is quite blind and the other eye somewhat irritable. 
The right eye excised at this date. 

The optic nerve was cut at a quarter of an inch (6 mm.) 
behind the globe and its proximal end looked quite healthy. 
The eye transmitted light. Behind the lens a greenish semi- 
opaque substance could be seen, and on it a number of opaque 
yellowish spots, especially abundant at the periphery. 

After slight hardening for a day or two in Miiller's fluid, the 
globe was opened in the antero-posterior direction through the 
cornea and optic nerve. There was no visible disease of the 
cornea, lens, or optic nerve. Retina detached from choroid 
excepting at the lower-outer part ; it was for the most part 
shrunken into a tube containing a small cord of vitreous ; in 
front it spread out as usual into a diaphragm behind the lens, 
attached all round at the ora serrata, and pressed forwards into 
close apposition with the ciliary retina and back of lens. The 
cJioroid showed very remarkable changes ; at the lower and outer 
part about the equator it was converted into an ill-defined 
tumour a fifth of an inch (5 mm.) thick and with a wide 
diffused base ; the growth adhered intimately to the sclerotic, 
while its inner surface blended with the retina, which in this 
part of the eye remained in proper position. The precise limits 
of the growth were hidden by the retina, but it occupied more 
or less definitely the lower and outer quadrant, not, however, 
reaching either the ora serrata in front or optic disc behind. 
The greater part of the remainder of the choroid was seen on 
section to be very obviously thickened ; its cut edge was white. 
Its inner surface at the lower and outer parts, where the 
thickening was greatest, was thickly studded over with little 
spois, the smallest white, the larger ones more or less pig- 
mented at their centre ; many of them were slightly prominent, 
and appeared to be minute nodules of new growth. Around the 
outskirts of the main tumour, over which the retina was still in 
situ, long strings were stretched from several parts of the outer 
surface of the detached retina to some of these spots on the 
choroid ; one or two of these appeared just on the point of giving 
way. On now again turning to the retina, it was found that the 



NETTLESHIP ON CASES OF MALIGNANT TUMOUR. 269 

■whole of the outer surface of its detached portion was thickly 
studded over with little nodules, the size of small pins' heads, 
and resembling the white dots on the choroid. Some of these 
were clean and rounded, others more or less ragged. The ciliary 
muscle at the lower part was decidedly thicker than at the upper 
part, while on the back of the iris, behind its pigment epithelial 
layer, at the lower part, were two minute white nodules. The 
iris itself in this region appeared, to the naked eye, somewhat 
too thick. 

From the naked-eye appearances of this eye, there can be 
little doubt that a morbid growth of some kind began in the 
choriod, at the lower-outer part, at or about the equator ; 
that it rapidly invaded almost the whole choroidal tract, giving 
rise to a general white thickening, but with a tendency some- 
Avhat later, to the production of little nodules which projected 
towards the retina ; that the retina also became infected, in part 
by intrusion of the primary choroidal growth, bat probably, in 
part also by direct extension from the numerous secondary 
choroidal nodules with which it was in contact before it became 
detached. That the disseminated infection of the retina occurred 
chiefly while it was still in situ is almost certain, from the 
existence of the strings already mentioned as passing from its 
outer surface to spots of diseased choroid, proof that when the 
general separation of retina from choroid took place, morbid 
adhesions already existed between them at these spots ; the rag- 
gedness of many of the retinal nodules on their choroidal aspect 
is also suggestive of the same fact. Some of the retinal nodules, 
however, appeared quite smooth, and these were probably pro- 
duced by extension from the other parts of the retina, and a 
corresponding origin must be assigned to the two little growths 
on the back of the iris. 

Microscopical examination of several different parts gave 
substantially similar results. The primary growth at the lower 
and outer part of the globe was composed mainly of rather large 
cells, of shapes not departing widely from tbe circular and 
oval, but variously modified by pressure, and often possessing 
one, two, or more rather short processes. None were really 
spindle-shaped. They often contained a nucleus about as large 
as a white blood-corpuscle. In some parts there were groups 
or little islands of very large, almost giant, cells, but none of 
VOL. VIII. T 



270 XETTLESHIP OX CASES OF MALIGNANT TUMOUR. 

these contained, so far as seen, moi'e than a single nucleus. The 
central cells of these groups were loose enough, in some cases, to 
drop out, having a little central cavity. There were, besides, 
great numbers of small and perfectly round cells, almost filled 
by their contained nuclei ; these could not be distinguished from 
young granulation tissue. They were often mixed with the 
larger cells, but in many parts at a distance from the primary 
growth and where the disease had made comparatively little 
progress, by far the greater part of the morbid change consisted 
in the close packing of the tissue with these indiiFerent cells. 
There was no fatty degeneration, nor did the primary growth 
contain many blood-vessels. 

Parts Afected. — At the seat of the primary growth the inner 
layers of the sclerotic, the choroid and retina were blended 
together, so as to be scarcely distinguishable. In the innermost 
layers of the growth, indications of the overgrown connective 
tissue framework of the retina were distinguishable ; deeper down 
was a much broken line representing choroidal epithelium, while 
still deeper (i.e., more externally) the growth was intersected 
by numerous bands of fibrous tissue from the sclerotic. It was 
in the part representing choroid that the largest cells were most 
abundant, and it is for this reason, no less than on a priori grounds, 
most likely that the growth began in the choroid. Sections of 
choroid from several parts of the eye showed everywhere the 
same condition ; moi'e or less increase, often amounting to several 
times its thickness in health ; its tissue replaced almost com- 
pletely by the new cell-growth ; its epithelium often dotted over 
with little groups of similar cells or with single ones ; the 
epithelial cells, in parts, multiplied and mixed with the sarcoma 
cells, at other parts hfted up by little nodules of new growth 
between the epithelium and elastic lamina ; in other places again, 
where the retina was adherent, the epithelium quite absent over 
considerable spaces, so that the choroidal and retinal growth 
were here separa>ed only by the elastic lamina of the choroid. 
I did not anywhere succeed in finding apertures in this mem- 
brane, though the appearances were highly suggestive of their 
being present in some parts. The detached retina was largely 
infiltrated with sarcoma cells, especially in its outer (choroidal; 
layers ; a section of one of the little ragged nodules already men- 
tioned was composed entirely of the same cells. The sarco- 



NETTLESHIP ON CASES OF MALIGNANT TU:M0UR. 271 

matous infiltration extended in the choroid and retina quite up 
to the ora serrata. In front of this line sections taken through 
the ciliary region at the lower and outer part, i.e., as near as 
possible to the main growth, showed the disease to be continued 
along the pars ciliaris retinsG and suspensory ligament of the lens 
to the inner surface of the ciliary processes, and thus to the ciliary 
mai'gin of the iris. In one section the passage of the growth 
thus into the iris itself was clearly shown, the uveal j)igment 
being pushed aside and dispersed by the intruding growth, the 
cells of which were directly continuous with those in the iris. 
The iris itself consisted chiefly of small round cells, and these 
caused slight ragged prominences, here and there, on its front 
surface. Passing outwards the infiltration had reached the loose 
tissues around Schlemm's canal, and from thence had begun to 
intrude into the corneal tissue and to creep along the posterior 
surface of Descemet's membrane. There was also irregular 
increase of cells on Descemet's membrane, at some distance 
from the corneal margin, and probably some of these were 
derived, by direct transplantation, from the iris. 

The parts in this region of the eye which were least affected 
were the ciliary muscle and ciliary processes. In front of the 
ora serrata the infiltration of the choroid rapidly diminished, 
being confined, even in sections taken as near as possible to the 
chief growth, to an irregular layer of cells close to the limiting 
membrane, and even these disappeared at some distance behind 
the ciliary processes. The tissue of the ciliary processes, includ- 
ing their uveal epithelium and the greater part of the ciliary 
muscle were quite free from morbid growth. Immediately 
behind the ora serrata the outermost layer of choroid was quite 
unaffected, being thus sharply distinguished from the inner 
(much diseased) layer ; the continuity of this outer layer with 
the outermost layer of the ciliary muscle accounted for the 
absence of any infiltration of the lamina fusca between that 
muscle and the sclerotic. 

A case in some respects resembling this one was published by 
Knapp and Williams, but there the little growths on the choroid 
were considered to have been derived from germs disseminated 
from the outer surface of the detached retina ; the latter having 
been infected by the primary choroidal growth. The patient was 
40 years old.— (Archives of Ophth. and Otol., IV, 1, p. 2.) 

T 2 



272 NETTLESHIP ON CASES OF MALIGNANT TUMOUR. 

Case III. — Small-celled Sarcoma of theLacnjmal Gland. 

Mrs. Hallett, get. 42, was admitted under Mr. Lawson's care 
at Moorfields on Januanj 30, 1873, when it was noted that there 
svas proptosis of the right eye, and a firm tnmour at the upper 
and outer part of the orbit. On ophthalmoscopic examination 
neuritis of the right optic nerve was found. The patient stated 
that she had first noticed a " lump in the corner of the right eye " 
about seven weeks before. At about the same time she suffered 
from aching in the right upper jaw, of moderate severity, for a 
few days, and the eye itself was painful and gritty. Nine months 
before admission she had had a "polypus " removed from her 
rio-ht ear. She considered that she had lost flesh lately. She 
knew most of her relatives and was not aware of any family 
history of cancer or tumours. 

Mr. Lawson made an incision throngh the upper lid and re- 
moved a flattened and somewhat lobulated tumour, between twice 
and thrice as large as a health}' lacrymal gland, from the upper 
and outer part of the orbit. No other tumour could be felt 
further back in the orbit, but the proptosis was not obviously 
diminished immediately after the operation. The wound healed 
well and the eyeball gradually receded. There was slight en- 
largement of a lymphatic gland below the angle of the jaw a few 
days after the operation, but it soon subsided and was therefore 
probably only inflammatory. A considerable convergent squint 
was developed afterwards, due probably to accidental division of 
the external rectus at the operation. 

The tunionr was flattened like the lacrymal gland, and more 
or less lobulated. While fi-esh all parts of it were somewhat firmer 
than healthy lacrymal gland, but unequally so, one lobe being 
almost as hard to the touch as scirrhus. No microscopical exami- 
nation was made until it had been hardened in alcohol, when thin 
sections were cut. It was then found to be a small-celled sarcoma, 
by far the larger number of cells being round, or only slightly 
fusiform or angular from mutual pressure, some in the older 
parts being however spindle-shaped. The healthy follicles of the 
lacrymal gland-structure were present in abundance in some 
parts, while in others no trace of them was left. The cells were 
most uniformly round in those parts where the lacrymal gland 
follicles still remained, i.e., presumably in the newest parts of 



NETTLESHIP ON CASES OF MALIGNANT TUJrOUR. 273 

the growth. In other parts the cells were packed in the meshes 
of a reticulum of fine branching fibres, coutainiug nuclei in their 
nodal points, the remains of tlie healthy connective tissue of the 
gland. There was no trace of epithelial growth. 

I have lately (July, 1875) tried to find the patient, but have 
failed to ti-ace her, and the final result of the operation must 
therefore remain uncertain. 



A CASE OF ACUTE GLAUCOMA. 
WITH EEMARK8. 

By Charles Higgens, F.R.C.S., 
Assistant Ophthalmic Surgeon Guys Hospital. 

December 9tli, 1874. Catherine P., set. 62, three weeks 
ago went to bed in her usual health ; during the night was 
seized with violent pain in the right eye, severe headache 
and vomiting ; in the morning she found that the right eye 
was quite blind, the pain and sickness, however, had passed 
off ; she fancied she had had a bilious attack, and that the 
sight would return as she got better. As vision has not im- 
proved she came to the Hospital to-day for advice. 

The right eye is stony hard (T -f 3), the pupil dilated 
and fixed, the anterior chamber shallow and the media 
cloudy ; examination with the ophthalmoscope gives only a 
dull red reflection ; perception of light doubtful. 

The left eye appears normal, the ophthalmoscope shows 
no change, visual field good ; v. |-a 

I admitted her, intending to perform iridectomy in the 
right eye on the following day. 

December 10th. During the night has had a similar acute 
attack in the left eye ; the pain in the eyeball and head were 
very severe and the vomiting most distressing. The pain 
and sickness have passed off, but now the sight of the left 
eye is almost gone ; T -1- 3 ; media hazy ; pupil dilated and 
fixed ; she can just distinguish shadows. 

An ansesthetic was administered and a large ii-idectomy 
performed upwards in each eye ; the structures in the right 
eye were found to be rotten, and some difiiculty was ex- 
perienced in removing the desii'ed amoimt of iris. 



HIGGEXS ON A CASE OF ACUTE GLAUCOMA. 275 

December 14. Both eyes T. nearly normal ; counts fingers. 

January 4tli, 1875. Some return of increased tension, 
iridectomy downwards in both eyes. 

February 15th. Both eyes T. normal, reads Sn 3 at 18," 
■with ease ; vision of the right eye appears rather the better 
of the two. 

April 10th. L. Eye reads Sn. 61 ; E. Sn. 2| ; T. n. Good 
field in both. Some haziness of lens in left. 

Bemarks. — There are several points of interest in this 
case. 

1st. The acuteness and violence of the attack. 2nd. The 
immediate, lasting, and almost total extinction of vision. 
3rd. The entire absence of premonitory symptoms. 4th. The 
length of time that the retina was subjected to extreme 
pressure, and yet recovered its function upon the pressure 
lieing removed. 5th. The complete success of iridectomy, 
notwithstanding that a second operation was required. 
Vomiting and headache are not unfrequent accompaniments 
of acute glaucoma. 

Acute glaucoma, as is well known, may frequently 
destroy sight in a comparatively short space of time, but it 
is extremely rare to find such total and lasting blindness 
])roduced by a single attack. 

As a rule the attack passes off, vision returns to a greater 
or less extent and may remain stationary for a time ; but if 
no relief be afforded will be entirely lost, after two or three 
subsequent outbreaks of the disease. Moreover, certain 
premonitory sjTnptoms usually make their appearance before 
;in outbreak of acute glaucoma ; patients often complain for 
some time before the attack of transient obscurations of the 
visual field, some pain, intolerance of light, coloured vision, 
inability to continue long at any kind of near work, &c. 
But in this case no warning was given ; the jDatient had had 
no trouble whatever with her eyes until the night on which 
she lost the sight of the right. As a rule it is not to be 
expected that vision will return in an eye that has been to 
all intents and purposes Ijlind for three weeks from acute 



276 HIGGINS ON A CASE OF ACUTE GLAUCOMA. 

glaucoma. As noted in the report, it was doubtful whether 
the right eye had perception of light or not; when the 
patient was examined she was uncertain whether the lamp 
was exposed before the eye, or shaded, or turned nearly out. 

When iridectomy was performed in this eye, no very 
marked result was looked for, excepting a reduction of 
tension. But contrary to expectation, extremely good 
vision was restored ; indeed the vision of the right eye, 
wliich had been blind for weeks, was subsequently better 
than that of the left, which had only been attacked a few 
hours before the operation was performed. • 

A case showing in a more marked manner the efficiency 
of iridectomy in glaucoma could hardly have occurred, the 
patient was certainly rescued from complete and irreme- 
diable blindness by its performance. 



CTJRATOR'S PATHOLOGICAL REPORT, 

By Wm. a. Brailbt, M.D., 
Cicrator of the Royal London Ophthahnic Hospital Museum. 

The following tables contain a statement of all eyes 
removed on account of injuries during tlie first six months 
of the year 1875. Some account is given of the symptoms 
preceding the excision, and also of the principal pathological 
changes observed. No results of microscopical examination 
are here recorded, because some of the specimens are de- 
scribed in full among the cases following these tables, and 
others are awaiting examination and will be described in 
another report. Those cases that exhibit no pathological 
change of any microscopical interest will not extend beyond 
the summary given here. 



■21S 



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VOL. VIII. 



rj 



2oG CITRATOTl'S PATHOLOGICAL REPORT. 

435. Enquiry into tlie Nattire of a Mass removed from the front 
of the Cornea by Mr. Gotoper. 

A. D., £et. 43, single. In lier right eye she has posterior 
synechia and a capsular opacity. 

There is a history of some inflammatory attack in it twelve 
years ago, since which date the vision has been very defective. 
Now she barely counts fingers with it. 

Some inflammatory symptoms occurred first in the left eye 
six years back, after which it recovered to be again attacked three 
and-a-half years ago. Now vision with it = -^^. Tension 
— . There is a ciliary staphyloma at the lower part, with a 
large opacity caused by a white opaque mass on the free corneal 
surface. All but the lower quarter of the pupil is free and 
mobile. After removal of the opacity, an examination shows it 
to have no microscopical structure and not to react for any 
metallic compound. With nitric and hydrochloric acids it gives 
reactions for albuminoiis substances. 

The patient has never used to this eye any local application 
whatever. 

432. Case showing the Microscopical Structure of Material found 
in the Anterior Chamber of an Eye injured many years ago. 

Emma Meeks, fet. 25, servant maid, under care of Mr. 
Wordsworth. 

History, &c. Her general health is good. Eyes blue. Hair 
light coloured. 

Her eye-sight was good till seventeen years ago, when she 
received a blow on her left eye from a stone. For six months 
the eye was bad and tied up, and though during this time she 
could discern light from darkness, yet at the end it was entirely 
blind. After that, except for occasional attacks of inflammation 
and pain in and around the eye, it was quiet till four months 
ago. Then, after an attack which was not more severe than 
usual, she noticed a change in the look of the eye, and this 
change has been going on since, notwithstanding tha since then 
she has had no inflammatory attack. These used to come two 
or thrje times yearly and she attributed them to cold. 

She now asks for the excision, simply on the ground of per- 
sonal appearance. 



curator's pathological report. 287 

Tension -f 2. No perception of light. 

The eye was excised November 28, 1874. A vertical antero- 
posterior section shows the retina to be detached except from 
the optic disc and the ora sei^ata, and a brownish-yellow fluid to 
be contained between it and the choroid. The lens is imper- 
fectly transparent, with a brownish nucleus. The cornea is 
uniformly thick and free from opacities. The anterior chamber 
is filled round its circumference with a yellowish material, which 
in front ends abruptly at the posterior elastic lamina to which 
it is so closely adherent that on teasing the two separate 
together from the cornea proper. The epithelium of the aqueous 
humour is absent. Microscopicallij the yellowish material is 
almost continuous behind with the iris, in the neighbourhood 
of which it contains a little scattered pigment ; in front it 
presents an obscurely laminated or fibrillated structure, the 
laminae being arranged nearly perpendicularly to the posterior 
elastic lamina. The front also presents a few very rare pigment 
cells, and nuclei, generally spindle-shaped and stained by log- 
wood, are scattered throughout the mass. It is very tough and 
resists teasing, but with much trouble it can be torn into fibres, 
which are large but have their edges fringed with smaller fibi'es ; 
all these swell up and lose their defined outline under the action 
of acetic acid. 

The conjunctival epithelium is not squamous, but the cells 
stand oiTt as distinct processes. Some of these are long and 
slender, others short and stumpy. They all contain well-marked 
nuclei. 

469. Case shoving the Microscopical Structure of the Trephined 
Apex of a Conical Cornea. 

F. "W., set. 24, clerk, under care of Mr. Bowman. 

A pale complexioned man, but he says he has generally good 
health and is physically strong. He is a teetotaller. 

History, &c. He has been shortsighted for many years, but 
did not notice anything particular till early in September, 1871, 
Avhen he accidentally found that his left eye was very defective, 
for he could only read with it at about the distance of an inch. 

He was soon after seen by a surgeon and then the left corneal 
apex was found to be nebulous. Things remained in the same 

U 2 



288 curator's pathological report. 

condition till Marcli 18, 1875, when, after exposure in the train, 
the same eye inflamed and became very painful. These 
symptoms have now subsided but there is still some injection. 

When he came here on March 26, 1875, the left cornea was 
conical. Its apex presented a central bluish- white opacity, with 
a rough, soft, apparently vesicated surface. There was still 
some ciliary injection, but there was pain only when the lid 
touched the rough surface. Reads J. 16 at one inch only. The 
right eye has normal tension. Its cornea is clear, but slightly 
conical at apex. V. =: -j^, but with an aperture about one line 
in diameter, V. = f^. Without the aperture he reads J. 1 at 
7 inches. Round the ciliary region of this eye there is a vascular 
zone. The sight is only deteriorating very slightly, but he has 
motes. 

April 2. Left eye. An elliptical vertical piece of the cornea 
Avas removed through the centre of the cone and a stitch was 
put in. Iridectomy downwards and inwards was also done. 
No irritation followed. 

April 26. Left. Tension normal, reads J. 14 at 3 inches. 
May 17. With left reads J. 16 at 6 inches, or J. 8 at 2 inches. 
A vertical cicatrix exists down the centre of the cornea. The 
iris is wanting on the lower and a little on the inner side. 

June 29. Left with - \, V. = -^. Without the glass 
V. = 2-^^ badly, reads J. 1 at 3 inches. 

Jan. 26, 1875. Right eye. Three days ago sudden opacity 
of the whole corneal cone came on, reads only J. 19 at 2 inches. 
Field complete. T. — 1. With left reads J. 1 at 3 inches. 

Feb. 2. R. trephined to-day. Anterior chamber opened. 

Feb. 5. Now good anterior chamber. Some injection. No 
anterior synechia. No pain. Feb. 9. Anterior synechia below. 
T. — 1. Feb. 12. Antei'ior synechia divided. Feb. 16. T. — 1. 
Good anterior chamber. No adhesions. He has not been seen 
since. 

On microscopical examination in water of the trephined piece 
(from right eye) immediately after the operation, it is seen to be 
made up, as to its deeper portion, of the lamellar tissue of the 
cornea, superimposed upon which is the anterior elastic lamina, 
which bears on its front surface the epithelial cells of the con- 
junctiva. The deepest epithelial cells are in situ, but the 
round ones superficial to these arc wanting in one place, so as to 



CURATORS P-\THOLOGICAL REPORT. 



289 



leave an interspace or gap, tlie roof of the interspace being 
formed by the more superficial flattened epithelial cells. (See 
figure.) 




Cavity in the Epithelial layer covering the Apex of a Conical 
Cornea.— X 220. 

Note by Mr. Bowman. — When the apex of the cone at a 
certain stage becomes opaque, it is further liable after a time 
to have its anterior epithelium thickened, rough, elevated, and 
even detached in flakes, and to become a source of irritation for 
the first time. The specimen seems to show that such elevation 
may consist of a separation of the superficial from the deeper 
layer, a small cavity being formed between them. 

486. Microscopical Examination of the recently Trephined Apex of a 
Cornea, shoicing the results of a previoxis Trephining. (See figure.) 

M. W., get. 26, female, under care of Mr. Bowman. 




X 110. 

Note by Mr. Bowman. — This figure is taken from a vertical 
section through a portion of cornea removed by a trephine on 
February 9, 1875, h is the margin of the specimen cut by the 
trephine. 

The anterior epithelium, the anterior elastic lamina, and the 
superficial lamellae are each seen as far as a, where the anterior 
elastic lamina ends abruptly, the epithelium and lamellated 
tissue continuing. The ex2Dlanation of this is, that by an 
operation with the same sized trephine, fifteen months previously, 



290 curator's pathological report. 

the epithelium, the elastic lamina, and the lamellated tissne from 
a to c (and beyond this to the opposite side of the circle not 
here represented) have been excised and only the epithelium and 
lamellated tissne reproduced in the cicatrix. The anterior 
elastic lamina does not seem to have been reformed. 

It is also seen that the cicatrix resulting from the excised 
tissue is a contracted one, inasmuch as the same sized trephine, 
viz., of 2^ m.m., has, at the second operation, included the 
cicatrix and a portion of the clear cornea all round. The second 
operation was undertaken to complete the reduction of the cone 
only partially effected by the first. 

535. Case of Microscopical Examination of the Apex of a Conical 
Cornea., Trephined by Mr. Laic-son. 

S. W., aet. 24, single, pai-lour maid. She is a pale, delicate 
looking girl, with red hair, a low forehead, a narrow chin, a flat 
bridge to her nose and a particularly white skin. She has been 
near-sighted since childhood. For the last few years the sight 
has got closer, and she has been troubled with black specks. 

The left eye was trephined three months ago, with marked 
benefit, for before the operation it was the worst, and she had to 
hold any print quite close in order to read with it, whereas now 
she reads J. 2 at 8 inches. The rigid eye was trephined on 
May 24, 1875, nearly down to the posterior elastic lamina. The 
crown of the trephine was 3 mm. in diameter. 

Microscopi'-al Examination of the Apex of the Cornea. — The 
epithelium of the corneal surface is thicker in the centre than 
towards the circumference of the trephined piece ; the nuclei 
are well marked and the cells seem to be elongated almost solely 
in a horizontal direction. The anterior elastic lamina is entire. 
The lamellar tissue towards its centre has its nuclei much drawn 
out at the ends. They are finer, rarer, and more irregular in 
their distribution than in the normal coi-nea. Towards the 
circumference the nuclei are more regularly distributed, and 
more numerous. Their long axes lie for the most part in a 
horizontal direction. No interspaces among the epithelial cells 
can be detected in any of the sections. 



curator's pathological report. 291 

437. A case of long-standing double anterior Synechia, of ivliich a 
drawing has heen made for the Museum, occurring after 
Oj^hthalmia early in childhood, the shape and position of the 
adhesion being almost exactly symmetrical in the two eyes. 

The patient is a girl now set. 21, under care of Mr. Streatfeild. 

In each eye the ii'is, where it forms the lower and slightly 
inner margin of the pupil, is prolonged into a pointed process, 
whose base is continuous with the rest of the iris, while its apex 
is attached to the centre of the posterior surface of the cornea. 
A slight bluish- white corneal nebula marks this point of attach- 
ment. The mai'gin of the pupil acts freely. There is a slight 
internal strabismus of the right eye. The only history is that the 
eyes were quite right at birth, but that, at the age of nine weeks, 
they were bad with a discharge of matter. The girl makes no 
complaint, except that the vision is a little defective. She was 
operated on for the strabismus, and discharged from the hospital 
with her synechite untouched. 

42-5. Perforating wound of all Tunics — Excision of Eyeball contain- 
ing the foreign body B5 years after the date of entry. 

Previous History. — Edwin C, aet. 48, right eye excised Sept. 
18, 1874, by Mr. Couper. When set. 13, while standing near a 
shoemaker at work, something flew off from the striking and hit 
him in the right eye. No foreign body was found at the time, but 
a scar was noticed on the front of the eyeball, which appears to be 
the same as the one described below. His work, that of toy- 
making, Avith intervals during which he made fireworks, has 
never exposed him to being struck by fragments of metal, &c., 
at any time, nor does he ever remember any accident to the eye 
since the one above described. Eight yeai^s ago, i.e., 27 years 
after the accident, the first symptom which drew his attention 
to the eye came on, viz., a smokiness before it without any pain. 
From that date the sight very slowly faded, till at length he 
became quite blind of this eye. Three years after this the eye 
began to be occasionally irritable and slightly painful. These 
symptoms have returned occasionally since, and seem to have 
been more marked lately, and the eye was therefore excised. 
The other eye has never suffered. 

Examination of eyeball after excision. T. +• Iris tremulous. 



292 curator's PATHOLOGIC.Vl, REPORT. 

On the exterior of the globe, beyond the outer margin of the 
cornea, a slight scar is seen. This corresponds with a spot on 
the interior of the globe, just external to the ciliary processes, 
which is translucent. On the internal surface of the posterior 
half of the globe, to the outer side of the optic disc and midway 
between it and the equatorial line, is seen a dark spot of pigment, 
and projecting from near its centre a small semi-transparent pro- 
cess of organized lymph. Directly below this, in the line of 
gravity, is a patch devoid of pigment, except that a few very 
small dark specks are scattered about, in the centre of which 
the foreign body was found lying unattached. The retina, 
cJioroid, and vitreous appeared in all other places healthy. 

It would appear as if the foreign body, which was found to 
be a small piece of iron, remained attached for a long time to the 
pedicle of lymph, till, from some cause, it became detached, and, 
falling down, set up irritation in the eye. 

442. Case of Cyst formed hy sejjaratioi of the Lamellce of the 
Cornea, probably in the seat of an old leucoma. 

Emily H., set. 30, under care of Mr. Hutchinson. 

History. — An explosion of gunpower, twenty years ago, 
injured her face, right arm, and hand. Scars remain now on 
her forehead and left eyebrow, and the bridge of her nose is 
destroyed. After the accident she was blind of both eyes for a 
fortnight. Then she got better, and thought she had sight in 
both. She never noticed any deficiency till two years ago, when, 
on her friends drawing attention to a difference in colour 
between the eyes, she found that she was totally blind of the 
left. Her schoolfellows had long before told her that she had 
different coloured eyes, but she then thought nothing of it. 
There was no other trouble with the eye till four months ago, 
when a small, white, shining speck appeared on the lower part 
of it ; this increased in size very quickly till, in two months, 
it formed a projection beyond the margin of the lids, and since 
then it has gone on increasing. Three or four weeks ago there 
was considerable pain for a short time, but it has now ceased. 

On the day of excision, January 7th, 1875, the upper ^ of 
the cornea was somewhat steamy, but otherwise nearly normal. 
The lower -I presented a semi-transparent, rather pearly looking, 



CURATORS PATHOLOGICAL REPORT. . 203 

bulging, covered by rather rougli looking epithelium, which 
contained a few transparent and easily ruptured vesicles. Sensi- 
bility of the part seemed diminished, but by no means absent. 
A zone of ciliary redness corresponded with the bulged part, 
but along the remaining circumference of the cornea a slight 
blush only extended. T. rather increased. No p. 1. The eye 
was, after excision, cut longitudinally through optic disc and 
corneal centre, the section dividing the cyst. The vitreous was 
extremely fluid, the retina in situ, and apparently normal. The 
choroid exhibited marked changes. There was atrophy of its 
pigment, chiefly at the outer side, just behind the ora serrata, 
and at the corresponding place on. the inner side similar slighter 
changes were seen. At one spot, just on the inner side of the 
optic nerve entrance, there was slightly increased dotted pig- 
mentation. The iris was apparently healthy, as was also the lens. 
The cornea, in the upper part, appeared to be healthy. Then its 
thickness gradually increased downwards, till the margin of the 
bulged portion, where it attained its maximum. From this 
point downwards it was divided into two layers, of which the 
posterior was thin, while the anterior was of the thickness of the 
normal cornea, and semi-opaque. The two layers formed between 
them a sort of cyst or cavity, which extended nearly to the 
lower margin of the cornea and corresponded to the bulging on 
its surface. 

Microscopically. — Vertical sections of the cornea, including 
the part involved in the cyst, show that the conjunctival epithe- 
lium is thicker towards the lower corneal margin, and that its 
deepest cells are increased in number, so as to form irregularly 
conical projections which depress the anterior elastic lamina ; 
the latter is at times wavy and interrupted in its course. The 
lamellar tissue exhibits a tendency throughout its entire thick- 
ness to have spindle-shaped empty spaces between its constituent 
lamellae, and this tendency is more marked towards its deeper 
parts. The posterior wall of the cyst is formed by a thin layer 
of deep corneal tissue, having on its posterior surface the mem- 
brane of Descemet and the epithelium of the aqueous humour. 
The nuclei of the cornea proper are more abundant than usual, 
especially where the separation into layers occurs. 



294 curator's pathological report. 



615. Case of umisual Inflammatory Changes in Vitreous aynd 
JRetina, together tvith Keratitis Punctata^ after an injury. 

John H., jet. 56, labourer, under care of Mr. Hutcliinson. 

His account is that, on the evening of March 16, 1875, whik; 
hedging, a twig struck him in the left eye. He had much pain 
at the time, and that night he got no sleep, on account of aching 
pain. On the three following days he worked as usual, but on 
the fourth day (Saturday) he went to Guildford dispensary. 
From then till he came here the pain continued much the same. 

Diagnosis, ^x. — On admission, March 16, 1875, there was, in 
the left eye, traumatic iritis and cataract. T. +. Aqueous dull. 
Cornea steamy. Good p. 1. A mark, probably the scar of the 
wound, was seen at the upper part of the cornea. The right eye 
sees J. 1 with a glass. On March 29, the globe was much con- 
gested. The iris was very much discoloured, but not vascular. 
The pupil was irregular in shape and of medium size. Anterior 
chamber somewhat shallow. Still p. 1. Much pain at night. 
April 1st. Pain relieved by leeches. Some chemosis. Iris 
clear. No sleep. April 15th. Much pain still. Some chemosis. 
April 22nd. Eye excised to-day. 

After the excision, tiie unopened globe was found to exhibit, 
on the posterior surface of the cornea, a number of spots, so dis- 
tributed as to form a cone, of which the apex nearly reached 
to the centre of the cornea, while the base rested on the lower 
circumference. A very few more scattered similar spots were 
seen near the inner margin of the cornea. On the conjunctival 
epithelium, just inside the upper corneal border, were seen a few 
blood-vessels. On an equatorial section, some fluid escaped from 
the cavity of the globe. The retina was in sitti, and studded 
with yellowish- white nodules, which were mostly a little smaller 
than pins' heads, though some were considerably larger. Run- 
ning forwards from the optic disc was a cord which, expanding 
anteriorly into a funnel, was united there to the back of the 
lens capsule. This represented the vitreous^ and from the cord- 
like part of it hung down several filaments, each of which 
supported, as a stalk does currants, one or more globules similar 
to those studding the interior of the retina. The cornea was 
loft in position till May 11th, when on its removal, its lower 



curator's pathological report. 295 

part was found covered, on the inner surface, with a thick 
layer of whitish-yellow substance, rather like coagulated lymph. 
This was thicker below where some parts of it adhered 
closely to the cornea, while others separated readily leaving 
it smooth. At the upper part of the cornea, a layer of the 
same substance existed, though it was here less consistent and 
adhered more closely to the iris. Sections through parts of 
the cornea from which the material in the anterior chamber has 
not separated, show that there is no deviation from the normal 
structure till we come to the posterior surface, where we find, as 
usual, the single layer of epithelium of Descemet's membrane. 
Lying upon this there is a network of very fine fibres, unstained 
by logwood, and enclosing in its meshes some nucleated cells. 
This network sometimes forms a continuous layer, but more 
frequently separate globes, which contain rather numerous cells. 
They sometimes, whether globes or a continuous layer, are in 
such close relation with the epithelial layer as to appear to be 
simply a multiplication of its cells, but more frequently the two 
are divided by a little gap. Sections through the retina, and the 
nodules lying on it, show the rods and cones to be replaced by an 
unstained layer, having no visible structure, and the outer and 
inner granular layers to be not much altered. The nerve-cell 
and -fibre layers are about equal in thickness to the rest of the 
retina, and show the cut orifices of blood-vessels near their inner 
surface. Stained nuclei, possibly of nerve-cells, can be seen, but 
no nerve-fibres can be made out. The inner boundary of the 
retina is clearly distinguishable, except where a mass of closely- 
packed bodies, rather like the retinal gi^anules, lies upon it. 
These masses are sometimes defined from the retinal structures 
by a difference in their shade, but at other times the two appear 
to run into one another without any definite line of demarcation 
between them. The nodules hanging to the altered vitreous have 
the same structure as those of the retina, and the funnel-shaped 
vitreous already described has the same microscopical appearance. 

503. Case shotohig the Pathology of Colloid degeneration of the 
Choroid and of Strice running horizontally across the front 
surface of the Cornea. 

Ellen W., £et. 11, under care of Mr. Bowman. 



296 curator's pathological report. 

Her right eye appears to have been lost tlirough some form 
of oplitlialmia, for which she is said to have had an operation 
performed elsewhere, when two months old. Her mother also 
declares that the patient conld see till then, bnt that the opera- 
tion destroyed the sight, and " tnrned " the colonr of the eye. 
It has lately been painful. On admission here shortly before the 
excision of the right eye, the left was found to read J. 1 at 14 
inches, and the right to have T. + 2, and to present no scar of a 
wound anywhere, but there were seen, running across the front 
of the lower half of the cornea, some transverse bands or lines, 
apparently superficial and calcareous. The media behind the 
cornea were opaque. The right eye was, excised March 16th, 
1875. The eyeball was, after the excision diA^ded longitudinally, 
and the retina was seen to be detached everywhere, except from 
the optic disc behind and from the ora serrata in front. Its 
posterior part has simply the appearance of a thin cord, and its 
anterior part is folded in so abruptly from the ora serrata as to 
lie parallel with the posterior layer of the lens-capsule till it 
reaches its centre, where it becomes continuous with the cord- 
like remainder of the retina already described. The lens-capsule 
contains scarcely any remains of the shrunken and opaque lens. 
At the lower part "^f the eye the choroid appears, for a short 
space, to be less pigmented than elsewhere. Generally, over its 
whole surface it appears to have undergone the colloid change. 

Microscopical JExaraination of the Cornea. — Sections cut at 
right angles to the direction of the strise on its surface ( x 423) 
show that the conjunctival epithelium presents, at places, an 
increase in the number of its cells, while here and there the 
anterior elastic lamina is depressed so as to give room for them, 
Avhile the level of the free surface remains the same throughout. 
The deeper cells are oval, their long axes being at right angles to 
the anterior elastic lamina, while the long axes of the superficial 
cells are nearly transverse. The cells between these two are 
more nearly round in sha]>e. The posterior surface of the cornea 
has the iris closely adherent to it, and at one part the iris tissue 
runs continuously into that of the cornea. Microscopical exami- 
nation of the choroid shows the epithelium on its interior to be 
bulged out in places by detached masses lying between it and the 
basement membrane. In them, sometimes, no structure can be 
detected, but in other places the masses can be seen to be made 



curator's pathological report. 297 

up of cells somewliat resembling the pigmented epithelium layer, 
except that they are usually without pigment. Occasionally 
nuclei can be seen in these cells. 



323. Case of Glioma of Retina. 

Bertie Turner, 93t. 2|, under care of Mr. Streatfeild. The 
patient on March 14, 1873, the date of the excision, appeared in 
good health, but had two or three moveable slightly enlarged 
glands under the left angle of the lower jaw, none being notice- 
able on the right side. History, Sfc. — The mother first noticed, 
one year and-a-half ago, a " shine " from the interior of the 
eye, just after the child had had a bad attack of modified small- 
pox. She says that it was then red, and that it began to 
enlarge from that time. Lately he has lost fl.esh somewhat, 
and the pain has kept him awake much at night. A female 
third cousin of the patient died as a young woman of a " tumour 
in the womb." She "bled to death." No other history of 
tumour or cancer is known on either side, but the mother does not 
know all her husband's relatives. At the time of excision the 
pupil was round and wide. There was slight ciliary congestion. 
A whitisli-yellow reflex was visible, which, on closer examina- 
tion, was seen to be due to a convex mass, over the surface of 
which one or two considerable vessels ran ; it appeared to shake 
freely when the eye was moved. The rest of the fundus was 
obscured by uniform dense whitish haze of vitreous. The lens 
was clear. 

Microscopical Examination. — The sclerotic is healthy. The 
cJioroid also shows no trace of cellular infiltration, though the 
cells of the tumour lie in places immediately in contact with the 
pigmented cells of the epithelial layer lining its surface. The 
ojjtic nerve through the entire extent of its section is infiltrated 
with cells. From the optic disc projects a mass, into which runs 
from the nerve a large blood-vessel. The entire tumour-mass 
presents sections of blood-vessels of all sizes. The cells are, on 
the average, rather larger than white blood-corpuscles. They 
are round, faintly granular and indistinctly nucleated. No inter- 
cellular structure is discernible, except in the neighbourhood 
of the optic disc, where some fine fibres are found appa- 



298 curator's pathological report. 

rently projecting from the disc into tlie tumour. At one or 
two places, generally near the choroidal epithelium, there is 
seen running up into the tumour-mass a structureless sub- 
stance which is unstained by log-wood. No remains of the 
retina can be detected. No information as to the result of 
this case could be obtained, owing to the family having gone 
away. 



438. Case of Tumour of the Choroid. 

J. P., female, set. 63, married. Right eye excised by 
Mr. Streatfeild on December 10, 1874. 

History, ^c. — She can call to mind, though she never noticed 
it particularly at the time, that when she covered her left eye up 
two years ago, on account of a slight attack of inflammation in 
it, things looked dim to the right. She thought no more of this 
till about November 1, 1874, when a similar slight attack of 
inflammation of the left eye, with a little aching pain, caused her 
to cover it with her hand, and then she found that all she could 
see with the right eye was a little glimmer of the fire-light. 
Since then she has had no pain in either eye, except perhaps 
a momentary dart after examination with the ophthalmoscope 
since her admission here. She has always done a good deal of 
needlework, especially lately. Her health has been good, except 
for occasional dyspepsia. Her father died from an accident 
when he was 75 years old. Her mother died of natural decay 
when over that age. The patient has now six brothers and 
sisters alive, and seven have died, four of decline and three in 
infancy. She has had eight children, of whom four are alive. 
The youngest was born 23 years ago. The Notes at the time 
of excision were: — Pupil of medium size, immoveable, except 
with that of the sound eye. There is no pain. T. n. Good p. 1. 
A large yellowish-grey mass, extending from the inner side of 
the eye half way through the interior, is distinctly visible by 
daylio-ht. It seems to reach in front as far as the ciliary pro- 
cesses, and towards the outside to slant away from the front of 
the eye. There are to be seen on its surface vessels which are 
probably retinal. On the outer side of the growth there is a 
clear space, but no details of the fundus are visible. 



curator's pathological report. 299 

After the excision the media were found to be clear and the 
retina in situ, except where it was bulged by the tumour beneath it. 

The mass appeared to spring from the choroid on the inner 
side of the eye, and extended backwards so as to overhang the 
optic disc. It filled nearly two-thirds of the vitreous space. 

MicroscoijicdUii . — Sections (half an inch in length) were made 
of a part of the retina which was free from the tumour, and 
approaching the neighbourhood of the ora serrata ; they showed it 
to be raised up at times into folds. The outer layers showed no 
rods and cones, but a number of fibres extremely well-marked 
running perpendicularly to the external surface, and having 
between them bodies like the granules. These granules near the 
exterior form a thin layer, which is separated by a very narrow 
intergranular stratum from a second internal much thicker layer 
of granules ; internal to this the perpendicular fibres are scarcely 
marked, and we have a layer not much thinner than the rest of 
the retina containing a few nuclei, and also internal to them 
some indistinct indications of a fibrous structure running parallel 
with the free surface. 

The part of the choroid under the tumour contains very 
numerous, deeply-pigmented, spindle-shaped cells or fibres. In 
contact with these lie the cells of the tumour, which are mostly 
round and unpigmented, with beautiful dot-like nuclei. Cells like 
these are mostly arranged in groups, each group being surrounded 
by more deeply-pigmented elongated cells, which, together with 
a few fibres, map out the tumour into loculi or spaces containing 
the above-described groups of round cells. The tumour has 
running through it numerous blood-spaces. 



541. Case of Pir/mcnted Tumour of the Choroid, under care of 
Mr. Hulhe. 

M. H., set. 36, married, bricklayer. He is a healthy well 
nourished man ; complexion light ; eyes blue. He says that he 
thinks he is wasted now from what he was 14 months ago, when 
he weighed 14 stones. 

History, ^"c. — Eighteen months ago he remembers to have 
had slight pain over his left brow, which troubled him so little 
that he kept on at his work as usaal. A year ago while luokiiig 



300 curator's pathological report. 

with his left eye at the edge of a pier that he was building to see 
if it was level, he found that he could only see a little distance 
down it. He noticed afterwards that he could see better in a 
downward than in an upward direction, and that when the right 
eye was shut he had to " cock his head up," in order, with his 
left eye, to see the things on the table. He has had occasional 
pain in the eye. Up to five weeks ago it was slight and i-are. 
Since that time it has been worse, and has continued till now. 
Till a fortnight ago he never made much of an attempt to test 
the eye as it gave him pain, and then he found on trying that he 
could not even see shadows. He has felt nothing the matter 
with the right eye except that it has " flashed " lately, and that 
it cannot bear the sun. Family History. — His father is alive 
now, set. 75. His mother died worn out three years ago, when 
set. 70. They had five children, of whom the eldest died from 
accident ; he would now have been aet. 42 ; at his birth the 
father was 33, and the mother 31 years old. A sister died in a 
decline. The youngest of the family died also from an accident ; 
at his birth the father was £et. 41, and the mother set. 39. The 
present patient was the one next above the youngest, and his 
mother was 37 years old at his birth. He himself is the father 
of six children, of whom the eldest is 1 1 years and the youngest 
11 months old. All of these are alive and well. 

The eye was excised on June 2, 1875. 

Microscojncal Examination., ^r. — A pigmented tumour was 
found growing from the lower part of the globe, which it almost 
entirely occupied. The retina was detached and quite soft, and 
had no resemblance to its normal structure. The tumour was 
only connected with the lower one-third of the choroid. 
Between it and the lens-capsule is a layer of thick membrane 
containing nuclei but having no other structare. The lens was 
displaced upwards and backwards from its capsule. On cut- 
ting through the tumour its unattached margin was found to be 
made up of a white layer, and running from the centre of the 
attached part obliquely forwards to join this white rim was a 
similar white line. Where the two meet the white material is 
thicker. 

On picking to pieces the pigmented part of the tumour, it is 
found to be made up of cells with scarcely any intercellular 
material. These cells are round in shape and all nucleated. 



curator's pathological report. 301 

The nuclei in some are tolerably distinct, but in others the 
granules obscure them. The white part of the tumour differs 
from the other only in its cells containing fewer pigment gra- 
nules. The whole mass is very vascular, and we meet witli 
places where the vascularity is extreme, and where some parts 
of the section present a yellowish brown colour, which is made 
up of an immense quantity of red blood corpuscles, lying among 
and almost entirely concealing the other elements of the tissue, 
j'hese extravasations correspond to reddish brown hasmorrhagic 
spots that are visible to the naked eye. 



547. Case of Tumour of the Choroid. 

E. M., jet. 57, a married female, under care of Mr. Streatfeild. 

Her hair has been of a light colour, but now she is bald. 
Her eyes are grey. 

Her mother was married twice, and there was a family of 
five children by each marriage. She appears to have been older 
than her husband. The patient was the youngest but one of 
the last family. The youngest seems to have died of phthisis. 
Two more are dead, but she does not know from what cause. 
There is no history knoAvn of any tumour in either family. 
The patient was married when aat. 24. Her age is now 57, 
and that of her husband 70. She has had two children, both 
of whom are now alive, the youngest being 19 and the eldest 22 
years of age. Since her marriage she has done no other work 
than house-wcrk. Her general health has always been good. 

Twelve months ago she noticed black spots floating before 
her right eye, and then rings and stars of light during the day, 
but more particularly at night, when her eyes were shut. She 
never observed any coloured rings round a light. Eight months 
ago she came here. The eye was much the same except that 
the sight had become dim. It still continued to get more dim, 
and lately she has not been able to distinguish light from 
darkness. She had no pain till June 9th, five days before the 
date of excision. On October 5, 1874, when she was first seen 
here, the retina was detached and the lens was cataractous. 

At thu time of excision the tension of the globe was much 
increased. On opening the globe the retina was found quite 
VOL. VIIL X 



302 cur:Vtor's pathological report, 

detached, except from the optic disc behind, and from its attach- 
ment to the back of the lens capsule in front, to the posterior 
surface of which it was folded in from the ora serrata. The eye 
was veiy hard. A yellowish fluid escaped when the sclerotic 
was cut. A small tumour, the size of a haricot bean, was found 
at the upper part of the interior of the globe. 

Microscopical Examination. — Th.e choroid near the tumour 
does not deviate materially from the normal condition. Its 
epithelial layer runs unchanged over the thickening of the choroid 
which constitutes the tumour. The tumour appears to be due 
to the very abrupt transition of the normal choroid into a great 
mass of cells, with large vascular interspaces, round which the 
cells appear to have somewhat of a radiate arrangement. Many 
of the cells contain pigment granules, but these vary in number 
and intensity of colour very much in different places, for in some 
sections almost the whole is pigmented, while in others com- 
paratively few cells contain pigment, ft appears as if the pig- 
mented cells were more numerous where the vascular spaces are 
larger and more frequent. In some parts these spaces are in 
area almost equal to the solid part of the tumour. They are 
irregular in shape and impart to it quite a cavernous appearance. 
The individual cells are round or oval in shape, and have no 
intercellular matter, or if there be any it has only the appear- 
ance of a little granular clehris. Surrounding many of the 
vascular spaces are seen a few large highly pigmented cells of 
somewhat irregular shape ; elsewhere, however, the pigmented 
and un pigmented cells are arranged in masses, which thus have 
the appearance, except at their edges, where they run into the 
surrounding cells of the tumour, either of being uniformly mode- 
rately pigmented or almost entirely free from pigment. 

This patient was heard from on July 24, 1875. She then 
was reported as being free from any symptoms of its return. 



474. Case of a large Tumour removed from the cavity of the Orlit. 

F. R., ffit. 32, single, cook, under care of Mr. Couper. A 
stout, florid, coarse- looking woman. 

She lives well, and is allowed 1^ pints of beer daily. She 
says that she suffers from a sluggish liver, and that at times she 



curator's pathological report. 303 

lias no appetite. Her father, fet. 63, and her mother, eet. 62, 
are alive and healthy. There has been a family of nine children, 
of whom only one is dead, and this from typhoid. There is no 
history of any severe illness of any sort, or of any tumour or 
cancer in any member of the family. 

In February, 1874, she first noticed the right eye becom- 
ing enlarged. There was also much pain over that side of the 
head. On September 29, 1874, she came here as out-patient, 
when the diagnosis was : Eight eye, Proptosis and a somewhat 
swollen optic disc. Optic neuritis was also noted, together with 
an obstruction to the outflow from the retinal veins ; reads J. 
16 barely. Movements of eyeball perfect. Left, V. = f^ barely. 
Since then the proptosis has gradually increased, and now 
(Feb. 6, 1875) the eye can easily be dislocated from the orbit, 
and a firm mass can be obscurely felt behind the eyeball. 
On the same day the eye was excised, and a fleshy-looking, 
well-defined, somewhat lobulated mass was removed from the 
apex of the orbit. It was situated on the outer side of the optic 
nerve, which was not involved in the tumour, though it was flat- 
tened by the pressure. The tumour was enucleated entire. Its 
measurements were : — Antero-posterior diameter =: 9 lines; 
longest transverse = 6 lines; vertical diameter = 8 lines. 

Microscopical Examination. — Sections made after it has been 
hardened in alcohol show a fibrous stroma, which resists teasing, 
and, after much trouble, only separates into small lumps. It 
contains a great many small nuclei, of which some are round, 
while others are oval or more elongated in shape. In many of 
the nuclei, especially the round ones, one or two dot-like nucleoli 
can be detected. 

In July, 1875, she was seen by Mr. Couper, and there were 
no indications whatever of the return of the tumour. 



499. Casein vjMcJi a small Tumour removed from under the Con- 
junctiva presented, microscopically, a bony structure. 

Annie Langdill, set. 14, under care of Mr. Bowman. 

On March 9, 1875, a small hard moveable growth, about the 
size of a pea, was removed from under the ocular conjunctiva of 
the right eye, near the outer canthus. It is reported by the 

X 2 



.^04 curator's patitot.ogtcal report. 

mother to have been noticed almost directly after the birth of 
the child, and to have been the same size as now when first seen. 
A fragment of it, when treated with a drop of strong nitric 
acid and examined under low powers of the microscope, is seen 
to effervesce strongly. Then the tumour was put into half per 
cent, chromic acid solution, and a section was made on 18th March, 
1875. It is seen to be made up of Haversian' systems which are 
neither very complete nor very regularly disposed. The lacunae 
are angular. The canaliculi cannot often be traced to unite 
with those of neisrhbouring; lacunee. 



443. Groivth from Sclero- corneal Junction, occurring in a private 
patient of Mr. Lawson, cet. alout 70, on account of which the 
Eijehall tvas excised. 

Half of the specimen, showing the relation of the tumour to 
the sclero-corneal junction, is preserved and mounted. A. draw- 
ing was made by Mr. Burgess, showing two aspects of the pre- 
served half. Descriftion, ^'c. — A growth, about the size of a 
bean, whose surface is slightly fissured into irregular lobules, 
springs, by a rather constricted neck, from the sclero-corneal 
junction on the outer side of the pupil, which it partly over- 
hangs. The eye in other respects appears healthy. A similar 
growth has been previously removed from the same spot. The 
patient died, from other causes, six months after the operation, 
and then no return of the tumour was reported. 

A microscopical examination of the attached part of the 
tumour shows that some of the superficial bundles of fibrous 
tissue, passing from the sclerotic into the cornea, separate a little 
from each other, and contain, in their interstices, cells which are 
generally of round or oval shape, and rather large size, and con- 
tain a nucleus and one or two dot-like nucleoli, besides some 
faintly granular matter. More superficially, the bands are 
ari'anged more looselj^ and by their union and interlacement, 
often form irregularly shaped loculi, containing cells similar to 
those already described, but generally a little larger. These 
cells, moreover, are nearly always unpigmonted, whereas, in the 
deeper layers of the tumour, many of tlie cells contain pigment. 
Deeply also are seen the cut orifices of many large blood-vessels. 



cltrator's pathological report. 305 

(This specimen was exhibited by Mr. Lawson at the Patho- 
logical Society, and will, therefore, be found mentioned in the 
" Transactions " of that Society for 1874-75.) 



544. Case of Tumotu- filling the cavity of the Globe and forming a 
large mass outside the Sclerotic — Death from hceniorrhage a 
feiv days after operation. 

_ Samuel C, aet., 43, plasterer, under care of Mr. Wordsworth. 

History, 6,-c. — He is a fair complexioned, well nourished 
man, rather under the medium height. Has been married 
eighteen years, but has had no family. He is the eldest of 
fourteen children. His mother died apparently of heart disease, 
in 1861, at the age of 47, having been aboiit seventeen years old 
at the time of his birth. His father was aet. 24 at marriage, and 
died of phthisis in 1868. Of the fourteen children of this union, 
six died in infancy, one, an imbecile, died get. about 20, and two 
others of phthisis about the same age. 

The. patient liad good health up to August, 1871, when he 
first noticed a smokiness before the right eye. The sight gradu- 
ally failed, and in about six weeks was entirely gone, but with- 
out any other symptom. On November 25 he caught a bad 
cold and was laid up four months in consequence of the cold 
having flown to the eye, which was then painful and red but not 
enlarged. After the cold got well, the eye remained blind, but 
without other symptoms, up to last Christmas, when it began to 
swell and be painful, and it soon assumed its pre.«ent condition. 
About a fortnight after Ash-Wednesday he had an attack of 
severe pain in it, lasting several weeks. 

On examination, on June 1st, the eyeball was bulged for- 
wards. Its apex, corresponding in position with the cornea, was 
covered with a dry yellowish- brown scab, surrounding which 
was the tumid congested conjunctiva. The palpebral fissure 
was 2 inches long and 1^ inches wide. The tumour, which 
could be felt beyond the globe, was firm, somewhat elastic, and 
appeared pretty free from the surrounding tissues. No enlarge- 
ment of neighbouring glands could be detected. 

On June 5th the tumour was removed, after division of the 
outer canthus. It completely filled the orbit, and was attached 



306 curator's pathological report. 

far back and closely at tlie apex of the cavity, so that it could 
not be separated cleanly there. There was very little bleeding. 
Next day violent htemorrhage occurred on removing the plugs 
of lint in order to apply chloride of zinc. After that it bled 
on several days, and the man died, apparently from exhaustion, 
a few days after the operation. , 

On a horizontal section of the mass, the globe is found to 
be directly underneath the brown scab described earlier as repre- 
senting the cornea. The eye-ball is somewhat shrunken and 
completely filled with a moderately pigmented softish tumour 
mass, the pigmentation being more decided towards its centre. 
The sclerotic is continuous all round the globe, the tumour appear- 
ing to have traversed it without making any obvious hole, 
though it is thinner on one side than the other. The 02^tlc nerve 
extends in the excised mass about 1^ inches backwards from 
the optic disc. It has all. round, and, in fact, almost continiious 
with it, the posterior part of the tumour mass. 

That part of the tumour lying on one side of the horizontally 
cut mass is tolerably firm and lighter in colour, apparently 
possessing no pigment. That on the other side is softer and a 
little darker, though even here the pigment is very scanty. 

The measurements of the mass are : extreme transverse 
diameter, 20 lines. Broadest diameter included transversely 
in the Sclerotic, 7^ lines. Long diameter of entii-e mass, about 
24 lines. Long diameter of remains of globe, 8| lines. 

Mtcwscopically : — The contents of the sclerotic when teased 
out, yielded well marked caudate cells, which contain a little 
granular pigment and generally one nucleus, though sometimes 
two are seen. The central layers of the sclerotic remain unaltered, 
and in no specimen that has been examined can cells be seen 
perforating its whole thickness, though on both its outer and 
inner surfaces, especially the latter, its superficial fibres are 
raised up by masses of cells which lie beneath and between 
them. As this is more marked on the inner side of the sclerotic, 
it seems likely that the tumour extended outwards from the 
interior of the globe. The cells outside the sclerotic are round, 
nucleated, and scarcely ever contain even a trace of pigment. 



curator's pathological report. 307 

450. Case of partially Firjmented Sarcoma of tlie Chorid xvitli de- 
tachment of the JRetina — History of a jprevious Blach Tumour 
near the Eye. 

History, 4'c. — Fanny Youens, aat. 61, married, has had nine 
childi-en, of whom' five are now alive ; the youngest was born 
21 years ago. Of the remaining four, one was still-born and 
three died, each about three years old, of " water on the brain." 
These had convulsions, but their heads were not noticeably large. 
The jDatient is a large made woman ; hair slightly grey. Her 
father committed suicide. Her mother died from an accident. 
One brother is now alive. Three have died, two of consumption, 
and one of dropsy. One sister only has died, and this in child- 
birth. The remaining four are alive and well. There is no 
history of tumours, &c., in the family, except that fifteen years 
ago she had a "black " lump cut out from the inner angle of 
the left eye by Mr. Critchett. It was a year or two in coming 
and appears from her description to have been just inside the 
inner canthus. She heard it called a tumour here, but I can 
find no record of it in the Hospital books. She was operated on 
as an out-patient. 

Three years ago she found that the sight of the left eye was 
more dim than usual. The dimness increased for a year and 
then she came here. The diagnosis, &c., on her out-patient 
paper, says : — ^^ Left eye has been nearly blind for twelve months, 
but lately has become much worse. There is now a very large 
detachment of the retina of nearly the whole lower half. Ophthal- 
moscopicaUy are seen on its surface some black patches — other 
parts are glistening white — others give the usual greyish reflex. 
R. Hyp. ^, has been wearing -f 8 with which V. = |-g. " 

At the end of about another year, i.e., towards the end of 
1874, she could not distinguish light from darkness. She had 
no paiu whatever till about January 1st, 1875. On January 14 
she came here again, and her paper says " Glaucomatous con- 
dition of the eye after detachment of the retina [? tumour]." 

The eye was excised by Mr. Lawson on January 15, 1875. 

After the excision, the retina was found to be completely 
detached, except from optic disk behind and from ora serrata in 
front, but it is folded inwards so abruptly from its attachment 



308 curator's pathological report. 

to the ora serrata, as to lie pretty close to the back of the leus 
capsule, from which it is only separated by the much shrunken 
remains of the vitreous lying there. When the fold of the retina 
has neai'ly reached the centre of the lens capsule so as to have 
the appearance of springing from there, it proceeds backwards 
as a tube containing the rest of the vitrecus to its attachment to 
the optic disc. 

A tumour, about the size of a small bean, is fou.id outside the 
detached retina, springing from the choroid by a peduncle, the 
attachment of which extends from close to the disk outwards to 
the equatorial line. The body of the tumour supported by this 
peduncle reaches nearly to the back of the lens capsule. There 
is but very little constriction between the peduncle and the body 
of the tumour. 

Transverse microscopical sections through the optic disk 
show that the tumour begins but a very little way from the disk 
as a thickening of the choroid, and that the epithelium of the 
choroid rises so as to lie over the surface of the tumour, and is 
here folded in occasionally so as to fit into depressions. Towards 
the free surface, the growth is made up of cells, which for the 
most part appear to be circular, possibly from their being trans- 
verse sections of elongated cells ; while others are oval. They 
have large nuclei, and in some are seen again dot-like nucleoli. 
Most of the cells are unpigmented, a few only contain a small 
number of pigment granules. Nearer to the sclerotic, however, 
the pigment is more abundantly distributed, so as to resemble 
the cells of the pigment layer (lamina fusca) lining the normal 
choroid. In places numerous pigmented cells are ari'anged so 
as to form indistinct wedges running among the unpigmented 
cells of the tumour. 

On July 24, 1875, this patient was reported to have no return 
of the tumour. Her health was good. There was still a 
discharo-e from the wound. 



447. — Case of Glioma of the Eetlna of the Left Eye. 

Sarah Leach, set. 2, under care of Mr. Hutchinson. History 
taken January "IG, 1875. The patient's mother is thirty-six 
years old. She has been married eleven years, and has had 



curator's pathological report. 309 

three cbildreu, of whom the eldest is five years old, and the 
patient is the jouBgest. All three are now alive. She is a 
delicate-looking woman, eyes blue ; complexion fair. She mis- 
carried four years ago The father is a labourer, aet. 41 ; health, 
good ; hair, eyes, and complexion, dark. There is no consumption 
known on his side of the family. His aunt is reported to. have 
died of a tumour in the breast. The mother's mother, set. 58, 
is now alive and well ; she was married when under twenty 
years old; she had a sister who died of consumption. The 
mother's father died from an accident. He was over twenty 
years old when he was married. One of his brothers died in 
consumption. There is no history of any glandular disease in 
either family. 

The mother noticed in Whitsuntide, 1874, that the eye under 
examination was of a darker colour than the other. Soon after 
that the child had the measles. Two months ago she fell 
with the brow of this eye against a scraper, then the white 
became bloodshot, though there was no blackness round the eye. 
She had no pain till a mouth ago ; then she did not make much 
complaint, but simply held her hand over the eye, and said it was 
not well. 

On December 2nd, 1874, the lens was opaque and yellow. 
The aqueous was bright yellow, and the pupil dilated to a mere rim. 
On January 15th, 1875, the left eye was somewhat enlarged, 
the lens as before, and the pupil so dilated that no iris was 
visible. The cornea was perhaps enlarged a little in circum- 
ference, and the lens shrunken, so that the fundus could be seen 
through a wide zone all round the equator of the lens. Reflex 
a bright yellow. 

The eye was excised January 15, 1875. An equatorial section 
showed the tnmour to be pale yellow' in colour, and of very soft 
consistence. It filled up the whole of the cavity of the vitreous, 
except a small part above and in front. It was traversed by 
'ramifying blood-vessels. A part, which was of a more full 
yellow colour than the remainder, lying on the outer side, ap- 
peared to be separated from the rest by a thin dark line which 
was found on microscopical examination to be the epithelium of 
the choroid. This visible separation of the choroidal epithelium 
from the sclerotic appears in this equatorial section to extend 
over about one-third of the circumference of the globe. The 



310 curator's pathological report. 

optic nerve, except just where it enters the globe, is swelled to 
twice its usual size, and on transverse section its contents are 
seen to bulge out beyond the level of the cut : longitudinal 
stained sections show^ the nerve sheath to contain many more 
nuclei than usual, while internally no nerve fibres can be seen, 
their place being taken by a mass of stained nucleated cells 
mixed with which there is abundance of fibrous tissue. The 
same structure is shown in transverse sections. Sections 
through the tumour and optic disc show the cells which existed 
in the optic nerve to protrude as a solid funnel-shaped mass 
from its apex at the disc into the cavity of the globe. Into 
this mass blood-vessels run continuously from the optic nerve. 
On either side of this mass is seen a gap, the outer boundary 
of which is formed by a layer of pigmented epithelial cells, and 
tinder this a mass of cells similar to those in the optic nerve and 
in the funnel-shaped mass, through which are scattered rare 
branching pigment cells. This thick layer represents the choroid. 
External to this the sclerotic contains many blood-vessels, some 
cut across and filled with blood-corpuscles, and others perforating 
the sclerotic, and running directly into the tumour. The number 
of nuclei found usually in the sclerotic is increased, but no cells 
can be detected here. 

From the anterior surface of the tumour there can be 
removed (after hardening) several fragments of tough mem- 
brane and coarse and reticulated fibres, representing the vitreous. 
These, when examined microscopically, are seen to have an indis- 
tinctly fibrous structure, and to have clinging to them many 
stained cells like those of the tumour, and also still more 
numerous unstained cells arranged principally in clusters, which 
are probably red-blood corpuscles, 

The pigment layer of the ciliary processes appears to be 
intact, but the ciliary muscle has its place occupied almost 
entirely by stained tumour-cells. Close inside the ciliary pi'o- 
cesses are seen similar cells loosely distributed. 

The child is reported as having run about nicely after the 
operation, and as having had no return till about March 15, 
1875. On March 31, a woman called and said that there was 
projecting from the inner corner of the orbit a lump the size of 
an orange. On April 5, the child came, and the tumour Avas 
found to be as above described, but the cloth was not removed as 



curator's pathological report. 311 

there had been severe bleeding from it. She was weak, wasted, 
and had a bad congh. She died in the country on April 30, 
1875, three months and a half after the opei'ation. No examina- 
tion of the body was made. 



456. Case of Glioma of Retina nearly filling ^ip the cavity of the 

globe. 

Julia Hester, tet. 22 months, under care of Mr. Streatfeild. 

Family History, Sfc. — The father, a barrister's clerk, is said to 
be consumptive. He has had haemoptysis twice, eacb time 
bringing up about a pint of blood. He and a sister survive out 
of a family of four, of whom one died phthisical and the other 
of acute rheumatism. 

The mother is one of a family of seven, of whom five died 
young. She suckled this child till it was fourteen months old, 
but began to feed it at three months. The marriage took place 
eight years ago, but this is the only child. 

The patient is fairly well nourished, complexion fair, hair 
light brown, cheeks red, irides blue. There is no history of any 
pain in or near the eye. The mother first noticed something 
wrong ten months ago, when she thought the child had a cast in 
the eye. She took her first to Gray's Inn Road Hospital six 
weeks ago. 

Before excision, a yellow reflex was clearly visible not far 
behind the lens. The surface of the tumour appeared to have on 
it red vessels. Eyeball excised January 21st, 1875. 

The tumoui' is found to nearly fill up the cavity of the globe, 
except a little space in front and above. It is yellowish in 
colour, soft and pulpy in consistence. To the naked eye the 
optic nerve does not appear to be involved. The clioroicl appears 
to be entire and distinct from the other tunics through its whole 
extent. Microscopically , the choroidal epithelium is seen to form 
an unbroken layer, and the stroma is tolerably normal in ap- 
pearance, though but very slightly pigmented. The sections 
of cut vessels are very large and numerous. No cells resembling 
characteristic glioma-cells can be detected in the choroid, nor is 
there in it any appearance of an abnormal aggregation or multi- 
plication of cells of any sort. Sections of the optic disc show a 



312 curator's pathological report. 

mass of glioma-cells protruding from it into the cavitj' normally 
occupied by the vitreous. This mass is rather funnel-shaped, 
being narrow Tvhere it springs from the disc, and rapidly 
widening after it leaves it. For a short distance on one side of 
the disc the retina and choroid are wanting in all the sections, 
and on the other they are in situ. In the latter part the choroid. 
is healthy. With regard to the retina; the Membrana Jacobi 
is quite normal. The outer layer of granules in the same 
part of the eye is normal, and begins a little way from the 
optic disc, as a thin layer. The inner granular layer is in 
places diffused a little, so as to extend almost to the outer 
granular layer in one direction, and to the nerve-cell layer in 
the other, but there seems to be really no multiplication of the 
granules here, only they are less closely distributed. The 
granules, at their commeucement close to the disc, merge 
gradually into the glioma cell-mass which projects from the 
disc, there being no apparent distinction between the granules 
and the glioma-cells, as to structure. It is interesting to note 
that, though the two seem liere to be continuous, yet that the 
part where they pass from one into the other, though consisting 
of cells resembling them both., is not so dense or so highly- 
stained as is either the gi-anular layer or the glioma mass. 

Except in the neighbourhood of the optic disc, the tumour 
separates readily from the choroid, leaving it in situ. It is 
friable and soft, even after long immersion in alcohol, but its 
outer part is a. little more consistent than the rest, and gives the 
impression of an indistinct membrane. Microscopically , sections 
cut at I'ight angles to the plane of the normal i-etinal surface 
show an outer layer unstained by logwood, which, over the 
greater part of its extent, cannot be made out to have any 
precise structure, but which exhibits, in one cr two spots, dis- 
tinct rods, and thus declares itself to be the Membrana Jacobi. 
Internal to this is a layer deeply stained by the logwood, made 
up of cells arranged generally in rows, which run inward. 
Inside this is a layer of cells more lightly stained, and within 
this again are the cells of the general tumour-mass, which stain 
less deeply than those of the layer just inside the Membrana 
Jacobi, but more deeply than those cells just described as 
separating these from the tumour. It would appear, therefore, 
as if here the deviation from the normal condition of things 



curator's pathological report. 313 

nilglit have occurred iu the internal granular layer, by reason of 
the great multiplication of its granules. The cells of the tumour 
are seen to he mostly round in shape, though some are angular, 
and others are dra^wn out a little at one end. They vary con- 
siderably in size. Nearly all can be made out to have a dot-like 
nucleus, and in some of the larger cells two, and even three, can 
be seen. There appears to be extremely little intercellular 
matter, but occasionally a few fine fibres can be detected. 

It cannot be seen where the implicated retina passes into that 
part near the optic disc which has been described as being nearly 
healthy. 

Proceeding backwards from the optic disc, the first part of 
the optic nerve is infiltrated with stained bodies, resembling 
glioma-cells. Further back the stained bodies are smaller and 
fewer, and resemble in appearance the nuclei seen in stained 
sections of tlie healthy optic nerve. 

July 22, 1875. The patient is reported as having had no 
return of the tumour, and her general health is said to be good. 



426. Ca.se m ivJiich an Eye, which had been quite blind for many 
years, was found on excision to be filled with a growth of doubt- 
ful character, and the choroid converted into a dense fibrous 
layer. 

Henry Battram, set. 55, woodman, admitted under care of 
Mr. Hutchinson, November 2, 1874. 

Historij, 4'c. — On looking through a telescope ten years before 
admission the patient found, to his surprise, that the field of 
vision of the right eye presented nothing but a green colour. 
The perception of light gradually faded, till, at the end of two 
years, it was totally gone. He had no medical advice about it. 
Soon after this, there came on gradually a shooting pain in 
the same eye lasting for a few hours at a time, and more espe- 
cially occurring in the evening. This continued almost daily 
for a fortnight. For the next six months he was free from pain, 
but, at the end of this time, he had a second attack which lasted 
for a month ; and then after another interval of a year's duration 
a third attack came on and lasted six weeks. 

He has since been the subject of similar occasional fits of 



314 curator's pathological report. 

pain, but they have been gradually getting more lengthy and 
nioi'e severe. He is now suffeiing from one which began four 
months ago. During the attacks there is slight sympathetic 
affection of the left eye, and, in the intervals between the 
acute pain, there remains in the right eye a slight pricking 
sensation. 

The left eye has always been healthy and has never been the 
subject of any blow or other accident. 

He drinks beer rather freely, but does not smoke. There 
is no history of syphilis, or any severe illness, except variola 28 
years ago. He is a large healthy florid looking man. 

The eye was, after excision, divided into upper and lower 
halves. The lower half was drawn by Mr. Burgess. The globe 
was found to be somewhat shrunken, and to be rather elongated 
transversely. 

The vitreous was absent, being apparently replaced by a solid 
growth, which was of a pale yellow colour behind, while in front 
it was a little browner. It was not very friable. On removing 
this very gradually, by gently brushing it Avitli a camel's hair 
pencil, it was found not to spring from any special part of the 
tissues external to it, but to be generally pretty uniformly con- 
nected with them. The sclerotic is thickened in places and a 
little puckered. Immediately within it is a layer of pigment, 
then a bluish-white tough layer thickened into nodules in places, 
and apparently fibrous or cartilaginous in structure. It is 
extremely hard in places. Next, internally to this, the tumour, 
or mass, already mentioned begins, the precise line of demarca- 
tion not being very clear. The cornea is much thickened and 
opaque. The lens-capsule is whitish and opaque ; and the lens is 
of the colour and consistence of glue. 

MicroscopicaUy the growth is found to consist entirely 
of very small cells, some of which are drawn out into slender 
prolongations at both ends, while more are drawn out at one end 
only. All are nucleated. The bluish- white layer, external to the 
tumour, is found to consist apparently of white fibrous tissue very 
tough and difficult to tease out, and enclosing at places a few 
nucleated cells ; this layer is in many places as thick as the 
sclerotic, while, at other points, it is barely recognizable ; it 
appears to have no special connection with the optic disc, and 
extends over the back of the lens capsule as a thin layer. A 



curator's pathologiCxVl report. 315 

little brown pigment forms a thin much interrupted layer near 
the internal surface of the bluish-white fibrous layer described 
above, and the outer part of the morbid growth contains here 
and there a little scattered brownish pigment ; this is the re- 
mains of the choroidal epithelium. On the exterior of the 
fibrous layer there is found (as already mentioned) another layer 
of pigment which is generally well marked, though it is inter- 
rupted a little occasionally ; it is thickened in the position of the 
ciliary processes, and it extends into the iris ; its cells are more 
highly pigmented than those above described ; its thickness is 
equal to about a quarter of that of the normal sclerotic ; it 
would appear to represent the deeper layers of the choroid. 
External to this is a layer of fibres loosely interlaced, and con- 
taining, in their interstices, cells which are frequently branched 
and moderately pigmented ; this layer is in many places two- 
thirds of the thickness of the normal sclerotic, but in other 
parts it is much thinner; it appears to represent the much 
thickened lamina fusca. Next, externally, we have the scle- 
rotic and cornea which, in their minute structure, are normal. 
No ossification has taken place in any part of the dense 
fibrous layer, which, however, is evidently an extremely 
altered choroid, and might, therefore, be expected to develop 
into bone sooner or later. Of the mass filling the globe, it is 
impossible to say with certainty whether it has been formed from 
the retina or the vitreous, and whether it should be looked upon 
as an imperfectly organized tissue, the result of long-continued 
subacute inflammation, or as a morbid growth in the stricter 
sense of the word. 



316 



Part II. 



fl ^Pdi'iscopc 



OF 



CONTEMPORARY OPHTHALMIC LITERATURE. 



HUGHLINGS JACKSON, ON RECOVEEY FROM SEVERE DOUBLE OPTIC 
NEURITIS, IN A CASE IN WHICH THERE WAS NO DEFECT OF SIGHT. 

This case, and the chromolitliograplis by Burgess (see Plate III), 
have already appeared in Vol. IV of Crichton Browne's West 
Riding Asylum Reports. By Dr. Browne's permission the 
illustrations are reproduced. The upper one shows a disc during 
the acute stage of ner^itis, the lower the same disc after recovery. 

It is an exceedingly common thing to see neru'itis, and 
nenritis as extreme as that here illusti-ated, with good vision. 
Hence, as Dr. Jackson has been urging for many years, the 
ophthalmoscope should be used by routine in cases of intracra- 
nial disease. Ophthalmic surgeons admit that optic neuritis may 
occur with very good sight ; but Dr. Jackson wishes to urge that 
in physician's practice it does so occur very often. Indeed, there 
is in the cases of optic neuritis which come under his care 
rarely enough impairment of sight to prevent the patient reading 
the smallest type.* 

But, so far as I know, he says, I have convinced very few 
persons of the truth of my assertion, that sight is often unaffected 
in optic neuritis. It seems mere nonsense to some io assert that 
when there is severe optic neuritis the patient can read '»""'"'« type. 
Hence I continue to insist on the fact whenever a legitimate 
opportunity presents itself. I assert that we have frequently 
the pathnlogical condition, optic neuritis, without the symptom, 
defect of sight. This is not a mere pathological curiosity. 
Those who ignore this fact naturally do not in cerebral cases 

* What follows is almost a verliatini reprint from Dr. Browne's West 
Riding Asylum " Reports." 



OplitkHosp Reports Vol. Vni PI III, 




^■Btuyess dda. ch luk 



%covery from Optic Keuntis 



WWisiiC'imf,. 



NEURITIS ^YITHOUT DEFECT OF SIGHT. 317 

look at their patient's optic nerves until sight fails, a^tcl ihus tJicij 
overlooli the early and remecliahle stages of neuritis. 1 believe that 
we sbonkl prevent amaurosis frequently if we always discovered 
the prse-amaurotic stage of optic neuritis and treated the affec- 
tion energetically. 

Those who wait until the patient's sight begins to fail, may 
err in taking as an early what is really a late stage of optic 
neuritis. So far as I know there is but one kind of optic 
neuritis from intracranial tumour (and other adventitious pro- ' 
ducts). The opthalmoscojjical appearances vary extremely 
according to stage. Making conveniently, although arbitrarily, 
four stages, sight commonl}' fails in the third stage — a stage 
which is, I believe, by some called the " swollen disc."* 

The uppermost drawing shows that in speaking of optic 
neuritis with good sight one does not mean a mere slight change 
such as might be vaguely called "congestion." The more one 
uses the ophthalmoscope the less confidently one speaks of " con- 
gestion," and " ana?mia." Sight may be quite good when the disc 
is very much swollen (and so much altered that there is really 
no true disc discoverable), when the arteries are scarcely trace- 
able in the swollen ci-devant disc, when the veins, which are 
dark and partly concealed, give clear evidence of swelling by 
knuckling over the edge of the diseased patch : there may be 
scattered blotches of blood. 

Those who do not look at the optic discs unless there be 
failure of sight will not only overlook the earlier stages of optic 
neuritis, they may overlook it altogether. For sight may not 
fail. 1 have seen not a few cases in which sight did not fail.f 

* I mar here refer to a lecture on " Optic Neuritis from Intracranial 
Disease" which I published in the "Medical Times and Gazette," August 26, 
1871. The following extract from that lecture refers to stages : — 

" 4. The Stages of Optic Neuritis. — I now tell you what jou see in cases 
of optic neuritis at difierent stages. In the sense that there are abrupt 
differences, there are no stages; there are gradual changes from the beginning 
of the process thi-ough its ascent to a climax of acute change, and in its de- 
scent to the pei-maiii'nt change — atrophy. Nevertheless, although the changes 
are gradual, the appearances are strikingly different at different times, and 
most unlike at the two extremes — the height of acute change and pennanent 
atrophy. We will make four stages. You will hare gathered from what I 
have just said that this division into four is arbitrary. I used to make two 
stages only. It is, I think, convenient to make four, for leai'ners, at all 
events. The following is an account of what is seen at different stages of a 
severe case. I use the expression ' severe ' advisedly, as cases vary so much 
in degree and progress that I do not pretend to be able to describe ' typical' 
eases. Particularly observe that cases do not always run through these 
stages. There may be retrocession from either the first or the second stage, 
and not a progress to atrophy. I speak of what you may see by the indirect 
method of examination." 

+ I have recorded a case showing this strikingly in the " Medical Timea 
and Gazette," Dee. 7, 1872. A reaume of the chief points of it is given in 
the " Eoy. Lond. Ophth. Hosp. Eep.," vol. vii, part iv, Feb., 1873, p. 518, in 
section 4, " Recovery from Optic Neuritis." 

VOL. YIII. ' Y 



318 PERISCOPE:— OPTIC NEURITIS 

In the case I liave to relate it did not. A common termination 
of optic neuritis is atrophy — what I call its fourth stage — but 
occasionally the swelling of stage 1 or 2 clears up, and, as in the 
case here illustrated, the disc resumes a normal or nearly a 
noi-mal appearance. In this case the optic neuritis would never 
have been inferred ; there was nothing whatever in the man's 
complaints or bearing to lead to a suspicion that his optic discs 
were abnormal. On the contrary, it would be said by most 
people that there " could not be " anything the matter with them. 
Had I not used the ophthalmoscope by routine the case would 
have been little more than one of paral^^sis of the third nerve. I 
shoiild have ignored the/a?' more important si/mjHom (or, correctly 
speaking, pathological condition) optic neuritis. 

I purposely give the case briefly, for without an autopsy it is 
of little value except as showing — 

(1). That sight may be good ivhen there is extreme neuritis, and 

(2). That the neuritis may disappear, the disc resuming ivhat is 
practically a normal appearance. 

The patient did not recover from amaurosis ; he never had 
any amaurosis to recover from. He took very large doses of 
iodide of potassium. My opinion is that this treatment pre- 
vented amaurosis, but as I always give large doses of iodide of 
potassium in such cases I cannot show more than a post hoc. 
Whenever I see optic neuritis I always give large doses of iodide 
of potassium. 

A remarkably robust and healthy-looking Swedish seaman, 
40 years of age, was admitted into the London Hospital on June 
20, 1878. He had had a chancre many years ago, but appa- 
rently no secondary symptoms. He had had pains in the right 
side of his head for nine weeks, and after admission he had 
a little deafness of the right ear. One day, ten days before 
admission, he had some vomiting. 

There was complete paralysis of the right third nerve which 
came on the day before admission. There was double optic 
neuritis. With the left eye he could read the smallest type, and 
denied that there was anything the matter with that eye ; on the 
riglit side there was of course the defect of sight producible by 
palsy of accommodation. The first drawing of the left disc was 
made by Burgess on June 30. The patient could then as always 
read No. 1^ Snellen. 

He went out apparently quite well on August 19. The palsy 
of the third nerve had disappeared rapidly under the administra- 
tion of iodide of potassium; the neuritis had not disappeared. 
He went to sea. 

He came to show himself on October 23. He looked quite 
well and felt well. The morbid changes in his discs were insig- 
nificant. Those on the left side are represented in the second 
drawing, which was taken by Burgess, October 23. Seen for 



WITHOUT DEFECT OF SIGHT. 319 

the first time, a good oplitlialmoscopist would hesitate to say that 
there had ever been any important acute change in that disc. 

Such a case leads one to study carefully minute changes in 
the discs (as seen by direct examination), in order to make a 
retrospective diagnosis of optic neui'itis.* 

It is probable that the case I have related was one of intra- 
cranial syphilis. But as there was no autopsy it is not worth 
while commenting on this aspect of the case. I have reported 
several cases of optic neuritis from syphilitic disease of the brain, 
as proved post-mortem. ("Medical Times and Gazette," 1872- 
73-74.) 1 have recorded a marked case in the July number 
(1874) of the " Journal of Mental Science." I will now only say 
that optic nmritis from syphilitic disease of the brain is not 
syphilitic optic neuritis. Optic neuritis does not occur in such 
cases because syphilitic disease affects the optic nerves directl3^ 
There is a syphilitic tumour in the brain, and this causes optic 
neui-itis, not in its character as a syphilitic lump, but in its 
character as a " foreign body." Any sort of mass in either the 
cerebrum or the cerebellum will cause optic neuritis. 

I showed the original of the chromolithograpli No. 1 at the 
meeting of the British Medical Association in August, 1873, 
The following is cut from the museum catalogue. I extract it to 
show that 1 then believed that the neuritis would disappear leav- 
ius: siofht good. 

O O o 

" Ophthalmoscopic drawing hj Biirgess. The patient, a man, 
could read the smallest tyjie (No. 1^ Snellen) on the day (June 
30, 1873) the drawing was made. His sight is still (July 21st) 
good. It is believed that the abnormal change will pass away, 
and that sight will remain good. — Dr. Hughlinys Jachson.'" 

In looking up this entry I come across the catalogue notes of 
cases by my colleague. Dr. W. R. Gowers. As Dr. Gowers' 
opinion on any point in medical ophthalmoscopy is most valuable, 
I try to strengthen the position I have taken up by his testimony. 
I italicise those parts which bear on the point I have been 
urging, The cases Dr. Gowers relates have numerous other 
important bearings. 

The following is cut out of the catalogue. (Drawings 176, 
177, 178). 

" Ft. Gowers on Optic Neuritis. 

"1. Optic Neuritis, tvith preservation of acuity of vision. Left 
optic disc of a woman, aet. 35, suffering from headache, epilepti- 
form convulsions, and paralysis of the right arm, due probably to 
syphilitic disease of brain. The position of the optic disc is 

* On this matter I have written in the " Medical Times and Gazette," 
Nov. 10, 1872 ; a reproduction of those remarks will be found in the " Roy. 
Lond. Ophth. Hosp. Eep.," vol. vii, part iv, Feb., 1873, in SvCtion 5, p. 520, 
" Slight Changes in the Optic Discs in cases of Cerebral Disease." 

V o 



320 PERISCOPE : — EYE SYMPTOMS AND DISEASE OF 

occupied by a greyish-red swelling, the redness being pnnctiform 
in the centre, striated on the peripheral portion. Vessels of 
nearly normal calibre, tortuous, and partly concealed on the 
swelling. The eye could read No. 1 Jiiger. Field of vision of 
normal extent ; blind spot of about three times the normal size. 
Both discs similar. The neuritis cleared completehi under a,di- 
syphilitic treatment, leaving no atrophy. 

" 2. Slight optic nenritis, from a girl, set. 15, suffering from 
epileptiform convulsions. Outlines of disc lost under a reddish 
swelling of moderate prominence, and of about twi6e the normal 
diameter of the disc. Redness punctiform in the centre. Vessels 
of normal size. Connective tissue about the vessels in the centre 
of the disc unduly conspicuous. Goidd read the smallest test-type. 

" 3. Early stage of neuritis. Left optic disc of a girl, 
eet. 25, suifering from right-sided convulsions, right hemiplegia 
and aphasia, due to a gliomatous tumour of the left hemisphere. 
A reddish swelling occupied the position of the disc, and con- 
cealed its outlines ; the outer part was paler than the centre, and 
striated. Veins distended ; arteries of normal size, partly con- 
cealed by the swelling. The eye could read No. 1 Jdger. Both 
discs tvere similar." 

Here Dr. Gowers gives the further course of the case. The 
girl became blind. 

ETE-STMPTOMS IN PATIENTS THE SUBJECTS OF CONGENITAL SYPHILIS 
AND WITH DISEASE OF THE NERVOUS SYSTEM. 

In the " Journal of Mental Science," January, 1875, Dr. Hugh- 
lings Jackson relates a case of dementia occurring in a lad who 
had choroiditis of one side. The boy died but no autopsy was 
obtained. The mental condition need not be detailed ; only so 
much is reproduced as bears on the value of the ophthalmoscope 
in diagnosis. 

The following notes of the case were taken in the summer of 
1872 :— 

" Samuel L., aet. 15, is the subject of congenital syphilis. 
The evidence supplied by his own person is (1) that he has that 
malformation of the upper central incisor teeth which has been 
described by Mr. Hutchinson as characteristic of congenital 
syphilis. The lad's upper central incisors are small, and 
narrowed at their cutting edges ; they are not notched. (2) 
There are in the left eye remains of choroiditis ; there are 
numerous pigmented patches. The left optic disc is atrophic 
(gi'eyish). The cornea is clear." 

Dr. Hughlings Jackson makes the following remarks on the 
one-sided choi-oiditis : — 

" The striking thing was that in the right eye there was 
nothing abnormal, although the left was much diseased Both 



NERVOUS SYSTEil IN CONGENITAL SYPHILIS. 321 

Mr. Hutchinson and Mr. Waren Tay agree in this. Obviously 
this non-symmetry in a disease so very ' constitutional ' as 
syphilis is of marked interest to students of disease of the 
nervous system. The choroid is the pia mater of the eje. 

" At first glance the one-sidedness of the morbid condition 
appears to go against the diagnosis of congenital syphilis. 
Mr. Hutchinson, however, considers it to be the rule for cho- 
roiditis in connection with tertiary syphilis to be unsymmetrical, 
and this remark applies alike to that resulting from inherited 
and to that from acquired disease. It is not, however, he tells 
me, usual to find, as in this boy's case, that one eye is qidte 
free from changes. He has, however, seen a few similar cases 
The common condition is for one eye to be severely aifected and 
the other only slightly. And he thinks that in some cases of 
choroido-retinitis in connection with hereditary syphilis, in which 
the changes simulate those of retiuitis pigmentosa, the non- 
symmetry is a valuable point in diagnosis. Mr. Swanzy, of 
Dublin, has published an interesting example of this in the 
' Dublin Quarterly Journal,' May, 1871. Mr. Swanzy there 
quotes a letter from Mr. Hutchinson." 

The following are further facts in this case warranting the 
diagnosis of congenital syphilis and thus confirming the diagnosis 
of the syphilitic nature of the choroidal disease. 

" Family History. — -Two years before his marriage the father 
had a skin disease, and had a bad sore throat. He is dead; hence 
the vague history. Moreover, he died insane in Colney Hatch. 
The boy's mother, six or seven months after marriage, lost ' all 
her hair ' (no doubt an exaggerated expression) ; soon after 
marriage she suffered fi'om a severe sore throat, which lasted 
seven or eight months ; her tongue was very sore ; she had a 
skin disease 'like small boils or pimples.' 

" The mother had seven childi-en born alive. The following 
gives the results of all her pregnancies : — (1) Still-born. 
(2) Died at age of one month. (3) Samuel L., the subject 
of this report. (4) A child who now suffers from a skin disease. 
(5) Miscarriage. (6) Died at the age of five months ; suffered 
from 'snufiles,' and had a skiii disease. (7) A miscarriage. 
(8) A child who has a skin disease. (9) Died at the age 
of six-and-a-half months: 'used to break out in the head,' and 
suffered from snufHes. Nearly all the children, including' our 
patient, suffered from a rash on the buttocks when infants. 

" It is important to note that our patient is the eldest living. 
This boy has not had keratitis. He may yet have it. There is 
in my mind no doubt that this lad was the subject of congenital 
syphilis. The dental malformation, to say nothing of the 
choroiditis and of the family histoiy, is, I think, decisive. A 
good many years ago I had the inestimable advantage of working 
with Mr. Hutchinson, and as a result of seeing many cases with 



322 PERISCOPE : — SYPHILITIC AMAUROSIS. 

him 1 was convinced that he was right in his assertion as to the 
diagnostic value of the malformation of the teeth he describes. 
So far as it goes, the family history supports the diagnosis 
founded on the dental malfoi'mation and the choroiditis. 

" Of course it is not said that congenital syphilis does not 
exist without either the dental malformation or the interstitial 
keratitis. On the contrary, it has been stated that these signs 
usually exist only in the eldest living of a syphilitic offspring. 
The younger children, no doubt, suffer in slighter degrees. 

" We are justified in concluding that this boy's right choroid 
had at one time suffered from syphilis, and thus the hypothesis 
was, for the sake of treatment, warrantable that his pia mater, 
the 'brain's choroid,' had suffered similarly, — had been the 
seat of a ' pia matritis,' analogous to the choroiditis. My 
speculation is that there was local syphilitic disease, followed by 
general atrophy of the hemispheres. It is well known tliat 
extensive local damage (clot, softening, or tumour) in a hemi- 
sphere leads slowly to general wasting of that hemisphere." 

In the July No. (1875) of the "Journal of Mental Science," 
Dr. Hughlings Jackson, in dealing with Syphilitic affections of 
the Nervous System, mentions several facts of ophthalmological 
interest. The first of the following extracts is partly to the same 
effect as the note of Dr. Hughlings Jackson's remarks in our last 
Periscope, p. 89. 

SYPHILITIC AMAUROSIS. 

" Sight. — Amaurosis occurring with other symptoms attri- 
butable to syphilitic disease of the brain may be put down, as 
a matter of course, to syphilitic changes in the deep tissues of 
the eyes, choroido-retinitis, by those who do not use the ophthal- 
moscope. This is a very grave error. It is true that amaurosis, 
in such cases, may be due to sypliilitic changes localised in the 
fundus octdi, but as a mere matter of fact, it scarcely ever is. 
It is nearly always owing to optic neuritis or to atrophy, the 
sequel of that neuritis. Now, ' optic neuritis from syphilis ' is 
not 'syphilitic optic neuritis.' The optic neuritis produced by 
a sypliilitic tumour is just like that produced by a glioma, or by 
any other adventitious product in the cerebrum or cerebellum. 

" I know of no evidence to prove that optic neuritis is pro- 
duced either by syphilitic disease actually involving the optic 
nerve trunks inside the cranium or by syphilitic meningitis at 
the base.* I speak of post-mortem evidence ; clinical evidence 
is not sufficient. 

" I never saw a neuroma of the optic nerve. I do not re- 
member seeing simple atrophy of the optic nerve (atrophy not 
the sequel of neuritis) in a patient who had other nervous symp- 

* " I know nothing of sypliilitic meningitis. Need I say that I excei)t 
cases of meningitis from lone disease, the result of syphilis." 



PARALYSIS OF OCULAR NERVES AND VERTIGO. 323 

toms infei-eutially due to syphilis, to say notlaing of never seeing 
post-mortem evidence of intracranial syphilis in such a case. 
The other kind of optic atrophy* is often seen. 

" Here it is important to remark that amaurosis from syphilitic 
choroido-retinitis is really a syphilitic disease of the nei^vous 
system, quite as much so as a syphilitic neuroma is. There is 
syphilitic disease of connective tissue of a nervous organ, the 
nervous elements suffering secondarily. He who speaks of 
amaurosis from optic neuritis due to syphilitic gumma in the 
cerebrum, and amaurosis owing to syphilitic choroido-retinitis, 
as if they were alike, calling them ' Syphilitic Amaurosis,' 
without qualification, is not speaking scientifically. It would 
be like speaking of a whale and a salmon as being zoologically 
alike." 

The following is from the same paper :— 

" PARALYSIS OF OCDLAR MOTOR KERVES AND VERTIGO. 

"Paralysis of an ocular motor nerve is a cause of vertigo. 
Now, the vertigo may be the symptom which the patient has 
first of all ; that is, he has vertigo before there is actual double 
vision, or obvious strabismus. It would be a great blunder to 
say of such a case in a patient the subject of syphilis, 'In this 
case the vertigo was the first symptom of the syphilitic disease 
of the brain, and then palsy of the sixth or third nerves 
occurred.' In reality the vertigo would, in all probability, be 
owing to paresis of an ocular muscle, before actual demonstrable 
palsy of it occurred. The vertigo continues, of course, when 
the palsy is established. 

" Anyway it would be very misleading to call vertigo, so 
caused in a syphilitic patient, ' syphilitic vertigo,' for all 
syphilis does, in such a case, is to damage a nerve bundle, and 
vertigo would attend paralysis of an ocular motor nerve, how- 
ever caused. It is an error easy to fall into. If the motor nerve 
affected be the fourth, the ocular palsy is not obvious, and may 
be overlooked. And when there is evident paralysis of the third 
nerve, the vertigo resulting from it may be erronously put down 
as a symptom independent of that palsy, and due to implication 
of a nerve centre. But be it remarked that the expression 
'syphilitic vertigo' is just as wai'rantable as is the expression 
'syphilitic epilepsy.' The expression sounds more grotesque, 
simply because it is novel." 

* " I may here remark that I ouly know of one kind of change in the optic 
nerves fi*om intracranial tumour, syphilitic or other, and this I call ojjtic 
neuritis. There are all degrees of this cliange, from a climax of great swelling 
with haemorrhages to white atrophy. I do not recognize a swollen or choked 
disc, from raised intracranial pressure. There is a swelling of the disc in 
some eases of tubercular meningitis and pyaemia. The swelling is, I believe, 
from venous thrombosis ; but I have had no demonstration of it." 



324 PERISCOPE :— OCULAU VERTIGO. 

ON OCCTLAR VERTIGO; ITS BEARING ON THE INTERPRETATION OP THE 
GAIT OF LOCOMOTOR ATAXY, AND THE REEL OF DISEASE OP THE 
CEREBELLUM. 

Dr. Hughlings Jackson thinks that from consideration of certain 
symptoms in cases of palsy of ocular muscles we obtain a cine to 
the interpretation of the real nature of disorders of co-ordination, 
such as the reel in disease of the cerebellum and locomotor ataxy. 
He finds that this has in effect been already stated by Wundt. In 
the " Medical Press and Circular," May 12, 1875, Dr. Jackson 
writes : — 

" The term disorder of co-ordination is frequently used ; but 
it is applied to diseases which are fundamentally different ; for 
example, it is applied to chorea and to locomotor ataxy. Of 
course, both these are disorders of co-ordination; but the term 
is used without qualification, and this leads to the two different, 
indeed opposite, states being considered as alike in their physio- 
logical or functional causation. Chorea and locomotor ataxy are 
not only unlike in that different parts of the body are affected, 
but unlike in the functional affection. In the former there is 
' over- function ;' in the latter there is loss of function. In view 
of the active motor disorder of the ataxic patient, the statement 
that there is loss of function of the nervous centres for loco- 
motion seems, at first glance, absurd. But is there not wasting 
of nerve fibres in the posterior column of the cord ? And what 
could this ' cause ?' It would ' cause ' nothing active. It could 
not ' cause ' the disorderly gait — in fact, it could ' cause ' nothing. 
The disorder of co-ordination in locomotor ataxy and in sonae 
other affections is owing to a double difiiculty consequent on loss 
of function of nerve tissue ; there is really paralysis. There is 
(1) over-estimate of a movement intended to be executed by the 
centre diseased, but not accomplished, and (2) by healthy 
centres, increased action of associated movements in accordance 
with the over-estimate. The explanation given of the disorder 
of co-ordination in locomotor ataxy applies mutatis 'mutandis to 
the reel from disease of the cerebellum." 

The following is a quotation from the Mirror of the Lancet, 
January 30, 1875 : — 

" At first glance it seems absurd to speak of there being loss 
of power in locomotor ataxy, at any rate in an early stage of 
this disease. The patient has great power in his legs. Dr. 
Hughlings Jackson believes that there is paresis, and this only 
of certain highly special movements. As a centime (the posterior 
column of tiie cord) is affected, there could not be loss of power 
in single muscles or gi'oups of muscles, but loss or defect in 
moveme?its, in which several muscles co-operate. Dr. Hughlings 
Jackson believes that the fii'st movement to fail in cases of loco- 
motor ataxy is that in which the peroiieus longus is the muscle 



LATERAL DEVIATION OF THE EYES. (^26 

cliiuflj concerned. In ofcliei" words, there is weakening of that 
most important locomotor movement which serves in throwing 
the body over on to the other foot, pivoting on the ball of the 
great toe. But by this the erratic gait of ataxy is not explained. 
We can, however, show that from local palsy or paresis we get 
secondanj effects ; it is here that we get the explanation. To 
show this, we must take a simple case from another department 
of clinical medicine — from ophthalmology. 

" In a case of paresis of the external rectus we find more 
than diplopia. The patient's giddiness and reeling gait are not 
due, as is commonly supposed, to double vision. There is, from 
an attempted but not accomplished movement of the eyeball, 
erroneous estimation of the ^^'^sitiou of objects. This is because, 
to use metaphorical language, the mind judges, not by the 
ocular movement accomplished, but by the effort to move the 
eyeball — judges, to use an expression of Bain's, by the ' out- 
going c^^rrent.' We note next that the strong attempt to move 
the pai^alysed or weakened external rectus leads to over-move- 
m.ent of an associated muscle — viz., of the internal rectus of the 
healthy eye ; there is ' secondary deviation ' of that eye. Ap- 
plying the principle to locomotor ataxy, we should say that 
there is a double difficulty to be considered in the patient's walk 
— erroneous estimate of the locomotor movement intended and 
over-action of associated movements. 

" In an early stage of locomotor ataxy these ill-consequences 
can, whilst the eyes are open, be partly corrected by great 
voluntary effort, by stiffening the back and certain parts of the 
legs, by throwing out the arms, &c." 

LATERAL DEVIATION OF THE EYES PROM DISEASE OF THE PONS 
VAROLII. 

In this Journal, Feb., 1873, there are reproduced facts and 
remarks from Dr. Hughlings Jackson's series of cases of inti-a- 
cranial tumour, from the " Medical Times and Gazette," 1872, and 
seq. The series is being continued, and contains many facts of 
interest to ophthalmic surgeons. 

"One case (Case 9, 'Medical Times and Gazette,' January 3, 
1874,) is both interesting and rare. As mentioned in the last 
Periscope, p. 93, lateral deviation of the eyes is not a very 
uncommon symptom in cases of brain disease, but this was a 
case unusual in three respects The deviation was persistent ; it 
was from the side of the lesion ; it was owing to disease of the 
pons varoUi. The case is worthy of reference by those in- 
terested in loss of ocular movements from disease of nervous 
centres. A careful examination of the disea.sed brain by Dr. 
Gower is given. The following remarks appear in tlie number 
following that containing the report of the case : — 

" In disease of the corpus striatum (a gi-avc lesion) there 



326 PERISCOPE: — he:\iiopia wna 

occurs lateral deviation of the two eyes, but the eyes turn then 
towards the side of the lesion, not from it, as in Case 9. It is 
better, however, to say that in the lateral deviation from lesion 
of the corpus striatum the patient cannot turn the eyes to the 
side paralysed. In Case 9 the patient could not turn them to 
the side not paralysed, or rather to the one least paralysed. 
Moreover, in cases of disease of the corpus striatum the devia- 
tion is usually transitory, unless the lesion be very extensive 
indeed. In Case 9 it was persistent. This is the only case in 
which I have known lateral deviation of the eyes in a chronic 
case. This is the only case of disease of the pons varolii in 
which I have encountered lateral deviation of the eyes. I have, 
of course, several times seen palsies of the sixth nerve, or of 
both of them, in cases of disease of the pons ; but lateral devia- 
tion, as are other conjugate deviations, is a symptom of a very 
different kind from paralysis of a nerve trunk — it is due to 
lesion of a centre where complex movements are represented. I 
need not pursue this subject here. For a knowledge of such 
deviations, Vulpian's ' Physiology of the Nervous System,' and 
Pre vest's monograph on ' Conjugate Deviations of the Head 
and Eyes ' should be studied." 

AUTOPSY IN A CASE OF HEMIOPIA WITH HEMIPLEGIA AND 
HEMIANESTHESIA. 

A SHORT note on this subject was made in the last " Periscope," 
p. 101. The following i-^ the case then alluded to in a foot- 
note as having appeared in the "Lancet," August 29, 1874. 
The patient died subsequently to that report ; the account of the 
autopsy is reproduced from the " Lancet," May 22, 1875 : — 

"It is now well known, thanks to Vulpian and Prevost, and 
to Humphry, Lockhart Clarke, Broadbent, Russell Reynolds, 
and others, that from a grave lesion (a large and sudden lesion) 
of the higher divisions of the motor tract (corpus striatum and 
optic thalamus) there results hemiplegia, in which there is not 
only paralysis of the face, arm, and leg, but also deviation of 
the two eyes and frequently of the head. [See last ' Periscope,' 
p. 93, and p. 95.] The eyes, head, and face turn from the 
side paralysed, because muscles of these parts on the side para- 
lysed can no longer balance those of the non-paralysed side. 
Tl>e patient has lost power to Jooli towards the side paralysed. 

" It is interesting to observe that hemiopia occurs in some 
cases of hemiplegia, and these cases seem to be the ' sensory 
analoo-ues ' of the above-mentioned cases in which the two eyes 
and the head are deviated. In the one (when the eyeballs are 
deviated) the patient is unable to looh to the paralysed side ; in 
the other, when there is hemiopia, he is unable to see to the 
paralysed side. The lateral deviation, with rare exceptions, is a 



HE]\nPLEGIA AND HEMIANESTHESIA. 327 

transitory symptom : the hemiopia Dr. Hugliliugs Jackson lias 
discovered in a few clironic cases of hemiplegia ; possibly it is 
sometimes transitory. Of course, cases in which the hemiopia 
has come on at the same time as the hemiplegia — cases of a 
single lesion — are alone spoken of. When the two symptoms 
are found after a sudden seizure, as in the case to be narrated, 
we may assume that they are owing to a single local lesion. 

" Dr. Hughlings Jackson has had no* autopsy on any case of 
this kind. But since he thinks hemiopia in cases of hemiplegia 
may be overlooked, especially when the lateral fields of vision 
are not blind but only obscured, it is permissible to draw atten- 
tion to the clinical association. We should examine the field of 
vision in all cases of hemiplegia when the patient's condition 
permits. These examinations will be of very limited value 
unless we at the same time note the kind of hemiplegia. In the 
few cases of which Dr. Hughlings Jackson has notes there has 
been considerable defect of sensation in the paralysed parts — 
face, arm, and leg. There has been hemiansesthesia as well as 
hemiplegia. It is true that in many cases of hemiplegia there 
is some defect of sensation soon after the attack, but it is rare to 
find great loss of sensation in a chronic case of hemiplegia ; the 
cases of hemiplegia with hemiopia above spoken of were chronic. 
Another thing to be noted is, the relative degree of loss of power 
in which the several paralysed parts suffer. In hemiplegia, the 
rule is that the arm sufiers more than the leg ; but in some, at 
any rate, of tlie cases of hemiplegia with hemiopia, the leg 
suffers more than the arm — or, rather, suffers more in proportion 
than is common. 

" Dr. Hughlings Jackson, having had no autopsy, refers to the 
tenth of Charcot's Lectures on Diseases of the N'ervous System. 
From that lecture we take the following : — ' In short, we muy 
conclude, I think, from what has been said, that there is, in the 
cerebral hemispheres, a complex region, lesion of which deter- 
mines hemiana3sthesia. We know approximatively the limits of 
this region; but, actually, the localisation cannot be pushed 
further, and no one has the right to say whether, in the region 
indicated, it is the optic thalamus which is implicated rather 
than the 'capsule interne,' the centrum ovale, or the third 
nucleus of the corpus striatum.' In ' Le Progres Medical,' 
Nov. 1st, 1873, is a valuable paper by Bourneville, entitled " De 
I'hemianesthesie liee a une lesion d'un hemisphere du cerveau.' 

" Cases like the one to be now narrated have interest with 
regard to the elucidation of those remarkable cases of fniigraine 
in which temporary hemiopia and temporary one-sided sensation 
disorder are symptoms. 

* The autopsy was obtained subscqxient to the publication of the life 
history of the case. 

t See note on " Hemiopia and Coloured Vision," &c., p. 331. 



328 PERISCOPE: — HEMIOPIA WITH 

'■'• Ancesthesla of the right halves of the tivo retince and con- 
responding loss of sight in the left fields of vision ; hemiplegioj of 
the left side (of the side to which he sees imperfectly) ; very con- 
siderable defect of sensation of that side. — -Thomas R , aged 

sixty-five, on November 24tli, 1871, at 8 p.m., felt sick, and 
vomited in the backyard of his honse. He then went up-stairs, 
but after three steps he had suddenly to stop, fell against the 
railing of the stairs, and next became unconscious. He felt as 
if (with the left foot) he were treading on sponge. He was 
' unconscious ' for two weeks, but whether deeply so all the 
time is uncertain. He talked in three weeks, but for six weeks 
he was too ill to be left night or day. We have evidence of a 
sudden seizure with loss of consciousness, evidence pointing to 
a ' grave ' lesion somewhei-e. The probability is, that that 
grave lesion is clot, but it is possibly softening from thrombosis 
of the trniiJi or of a large branch of a cerebral artery* — a large 
branch, because the lesion must have been a very ' grave ' one. 

" There has been no albuminuria to support the diagnosis of 
clot. It is clear, at any rate, that there was a sudden and local 
lesion of the right side of the patient's brain, and probably the 
disease is in the hinder part of the optic thalamus. The hemi- 
plegia was discovered when the patient came round from the 
insensibility, but during the first fortnight it was observed that 
his left leg and thigh were 'as cold as a stone.' 

" March, 1873. — Examination by Dr. Hughlings Jackson. — 
Motor : There is now no paralysis of any part supplied by 
cranial (motor) nerves, except that there is a very trifling- 
drawing of the face to the right. The eyeballs and the head 
move well, in extreme movement in all directious He can exe- 
cute all large movements of the upper limb (shoulder on trunk 
and downwards), but they are all imperfect, feeble, and slow. 
The leg is more paralysed than the arm ; he can walk, however, 
a great distance. — Sensory : There is gi'eat diminution of sen- 
sation of the left side of the body, face, trunk, and limbs. This 
does not follow the distribution of any nerve in particular. The 
whole of the left half of the head has less feeling than the 
right, the anaesthesia not being limited to those regions supplied 
by the fifth nerve. It is to be observed that the defect of sensa- 
tion does not come q^^ite up to the middle line of the trunk ; 
there is about half an inch to the left of the middle line in 
which the feeling, if not as good, is nearly as good as on the 
right. (Probably the sensory nerves of the two halves of the 
body interlace at the middle line. Herpes zoster occasionally 

* " The posterior cerebral artery has, according to Duret (' Arcliives de 
Pliysiologie,' Janvier, 187I-, p. 81), ten branches, of which one is, in Duret's 
nomenclature, ' Artere interne et post§rieure de la couche optique,' and 
another ' artere moycnne des tubercles quadrijumeaux.' Duret's researches 
are of great value both for the pathology and physiology of the brain." 



he:\iiplegia and hemian^esthesia. 329 

passes tlie middle line slightly.) "VYlien severely pinclied with 
the nails on the trunk or arm he has only an unpleasant sensa- 
tion, and when he is pinched on the hand he feels it up the arm ; 
' up the mari'ow of the bones ' is his expression. He often 
drops things out of the left hand — e.g., if he places his stick in 
it in order to open the garden-gate with the right hand, the stick 
often falls out. He is a tailor. One day when ironing he 
brought the ' uose ' of the hot iron against his left hand, and 
yet had only an ' unpleasant sensation,' although he discovered 
later that the skin had been severely burnt ; the skin was 
' pushed up ' he said. He accounted for this mishap by saying 
that he could not see to the left. The left leg feels to him cold, 
and he has, since his illness, slept with one ' leg ' of a pair of 
drawers on it. I have at the hospital a series of balls of the 
same size and appearance, but varying in weight irregularly 
from one of which the inside is lead to one of covered cork. 
He readily arranged these balls with his non-paralysed arm, but 
though he can lift each with the partially paralysed arm, he does 
not, so he says, know any difference by weight betwixt them. 
Dr. Tibbits assisted me in investigating the condition of electric 
sensibility of muscle, but we could arrive at no trustworthy con- 
clusion. 

" He is a snuff-taker, but has ceased to take snuff up the left 
nostril as ' it is of no use,' he does not feel it on that side. 
Snuff, of course, is an irritant, and is appreciated by common 
sensation, but his snuff-taking is important, as possibly the habit 
may have blunted the sense of smell proper. It is only possible 
to say from my examinations that I think his sense of smell 
proper is diminished. There is, as stated, hemiopia, and this is 
on the left (i.e., the left fields, the right halves of the two 
retinee being affected.) This defect of vision he found out when 
he came round from the insensibility. He occasionally sees only 
part of a word. He one day saw ' land,' the real word being 
'Midland.' He remarked to his son that 'Liver' was a 
' queer name,' but his son pointed out to him that it was 
' Oliver.' These words weie in capitals on carts in the street. 
I could not come to any conclusion as to taste ; if affected on 
the left side it must be so only slightly. He is said to have 
been deaf of the right ear thirty-five years, and as to the left, it 
can only be said that his wife is sure that he does not hear so 
well as before the illness. He seems to me to hear well on both 
sides. 

" 1874.— His condition seems to be still practically the same. 
He has had what was probably a slight paralytic attack early 
this year, but no clear account of it was obtainable. It left no 
obvious permanent eff'ects. 

"The following from the 'Lancet,' May 22, completes the 



330 PERISCOPE: — HE.AIIOPIA WITH HEMIPLEGIA. 

" ' In our ' Mirror ' of August 29tli, 1874, we reported a case 
of left (field) hemiopia with left hemiplegia, and heniianajstliesia. 
The patient has since died. He died after a few days' illness, 
which, from his friends' account, presented no further definite 
local symptoms of nervous origin. His brain was examined hy 
Dr. Gowers, who found hut one lesion. It was, as was stated in 
our ' Mirror ' of August 29th to be probable, ' in the liinder part 
of the thalamus opticus.' Dr. Gowers, who did not know the 
history of the case, also made a diagnosis of hemiopia — a retro- 
spective diagnosis from his examination of the brain. His report 
is as follows : — 

" ' The right optic thalamus presented a considerable depres- 
sion over its posterior half, where it was much softer than that 
of the opposite side. On section the tissue was seen to be 
softened, greyish-yellow in tint. The amount of softening was 
greatest on the inner side, the posterior tubercle (pulvinar) 
being broken down and destroyed, and here the softening ex- 
tended up to the ventricular surface. It did not extend beyond 
the limits of the thalamus into the white substance of the hemis- 
phere or the cms, and the anterior Jialf of the thalamus and 
posterior extremity of the corpus striatum were intact. Tlie 
microscopic cliaracters were those of simple softening. The 
vessel at the base were moderately atheromatous ; no occluded 
vessels near the softened ai'ca could be discovered. Convolu.- 
tions healthy. No disease elsewhere.' " 

GENERAL REMARKS ON CASES OF HEMIOPIA OCCURRING ALONG WITH 
HEMIPLEGIA. 

"Hemiopia is not, Dr. Hughlings Jackson thinks, so rare a 
nervous symptom as is commonly supposed. This and the fol- 
lowing remarks only apply to cases seen in physician's practice, 
and therefore to hemiopia associated with other nervous symp- 
toms. It occurs mo.st often with hemiplegia. Dr. Hughlings 
Jackson has seen eleven* cases of this kind. Significantly the 
association is such that the patient cannot see to his paralysed 
side. To this rule Dr. Hughlings Jackson has seen no exception. 
He has now two patients in the London Hospital who are 
hemiplegic on the left, and who have lost sight entirely in their 
left ' fields.' They have been carefully examined by Mr. Couper. 

" The hemiopic patient in the street runs up against people ; 
when going out of a room he strikes his hand against the door- 
post ; he pushes glasses off the dinner-table. Hemiopia is more 
especially incapacitating when it is right-sided (field), as we read 
and write from left to right. It is discovered in some cases of 
partial aphasia, but is easily overlooked. In such cases the 
patient's wi'iting, or rather attempts at writing, are a series of 
lines begun from the left and ending on the right, after a few 

* Also two others since this note appeared. 



H£:miopia and coloured ^^SION. 331 

syllables or syllable-like scrawls. Hemiopia was discovereil in 
one of the two bemiopic patients in the hospital becanse he read 
words of the test-types on the right side of the page only. At 
that time it was difficult to investigate his case on account of a 
mental defect which Dr. Hughlings Jackson calls ' impercep- 
tion.' It was very difficult to explain to him that he could read 
from the left side of the page by holding his book in a properly- 
adapted position. 

" Such cases, Dr. Hughlings Jackson thinks, disprove the 
recent assertions as to the total decussation of the optic nerves 
in man." 

HEMIOPIA AND COLOURED VISION PRECEDING ONE-SIDED EPILEPTIFORM 

SEIZUBES. 

Temporary hemiopia and temporary one-sided development 
of colour are well-known symptoms of migraine. Temporary 
development of colours (usually red, see p. 333) is a common 
" warning " of an epileptic seizure as well as an initial symptom 
of naigraine. In the following case the kinship of migraine to 
epilepsy seems to Dr. Hughlings Jackson to be illustrated. The 
report is fi-om the "Lancet," August 14, 1875 : — 

" Dr. Hus^hlinofs Jackson believes that cases of misTaine, 
and certainly those in which there are ocular phenomena with 
one-sided sensation disorder are (that is, according to his defini- 
tion of the word epilepsy) epilepsies, for he thinks that the 
symptoms depend on a local excessive cerebral discharge. How- 
ever, he thinks that whilst the ocular phenomena and the 
unilateral sensation disorder are parts of the paroxysm, the head- 
ache and vomiting are post-paroxysmal symptoms. Moreover, 
he believes it to be most likely that the " discharging lesion" in 
this epilepsy is of some parts of the cortex of the posterior lobe, 
that it is of convolutions, or of parts of them, which are deve- 
loped out of the optic thalamus. The reason for so thinking is, 
that these ' sensory epilepsies ' bear the same relation to hemi- 
anaesthesia with hemiopia from disease of the optic thalamus, as 
unilaterally bc;^inning convulsions do to the ordinary kind of 
hemiplegia from destruction of the corpus striatum. Dr. Latham 
thinks that the paroxysm of migraine is owing to arterial con- 
traction in the region of the posterior cerebral ; Dr. Liveing, 
that there is in the paroxysm a ' nerve storm ' traversing the 
optic thalamus and other centres. Dr. Hughlings Jackson's 
view as to localisation will be supposed to be a compromise 
betwixt these two opinions. It may here be pointed out that 
this localisation of the ' discharging lesion ' in migraine accords 
with an old conclusion of Dr. Jackson, viz., that the anterior 
part of the cerebrum is the chiefly motor, and the posterior the 
chiefly sensory region. This speculation agrees with Ferrier's 



832 PERISCOPE: — IIEillOPIA WITH COLOURED VISION. 

experiments. Dr. Jackson does not, liowever, suppose that the 
separation of motor and sensory regions is abrupt. The case 
which follows is mixed sensory and niotory. Discharging lesions 
may no doubt be developed in any part of the cortex cerebri 
from front to back. 

" Whether the word epilepsy be used in the commonly 
accepted sense or in the novel sense, the case bere reported 
shows the relationship of certain symptoms of migraine to 
epilepsy. The hemiopia is especially interesting. 

" Colour development is not an uncommon preciirsory 
symptom in cases of epileptiform or epileptic seizures. It is 
common in migraine. In this girl's case, if her memory serves 
her, the colours began on the side which does not correspond to 
the side convulsed ; one reason for thinking her account errone- 
ous is that the transitory hemiopia was left-sided (field), as was 
the convnlsion at its onset. 

" M. B., ret. 16, consulted Dr. Hughlings Jackson in August, 
1873, having had fits for six years. She walked at the age of 
16 months, and talked very early. It is said that she had spas- 
modic croup at the age of 10 months. She was subject to 
attacks every winter until the age of 13. An attack would 
come on about ten o'clock at night, and last for two hours, when 
vomiting and relief came. What the real nature of this illness 
may have been is matter of doubt ; the mother said the girl 
made a noise like croup, and imitated the noise of laryngismus 
stridulus very closely. At the age of three years it seems clear 
that she had a bad attack of jaundice; she was, her mother 
averred, delirious and insensible for two or three weeks. She 
had never had scarlet fever nor rheumatic fever ; she had had 
measles, chicken-pox, and whooping-cough. 'No facts bearing 
on hereditary tendency to any kind of nervous affection were 
obtained. 

" She seemed to be in good health She had begun to men- 
struate at the age of twelve and a half years, and for the last 
twelve months tlie catamenia had been regular. There was no 
heart disease ; there was no ear affection, nor had there been any. 
She had thread-worms. 

" It is interesting to note that there was a clear account 
of gradual development of her seizures. She had at first attacks 
of coloured vision only for some months before anything further. 
There is circumstantial evidence of this. Her mother thought 
the child was bilious, and waited until her holidays began to give 
her physic. Further evidence that these mere attacks of coloured 
vision were really rudimentary or incipient fits was that later on 
she occasionally had these attacks, sometimes followed by con- 
vulsions, sometimes not. As she says, ' if the colours do not 
leave, the fit comes on.' After having several attacks of coloured 
vision only, she would have a severe fit. The colour began sud- 



COLOUR. 333 

denly. There were red and gi'een. The red comes first and the 
green was tinderneath the red. The background was black and 
the colours moved fast. Her mother said the girl always loohed 
to the left when the colour appeared. This is significant, because 
'when the colonrs do not go away,' and when the full fit comes, 
the head turns to the left, the left hand shakes, the arm works ; 
there is left-sided convulsion. Later there is convulsion of the 
right side, and she is unconscious ; occasionally there is tongue- 
biting. But here is to be stated further evidence as to gradual 
development of the fits. For some years she did not lose con- 
sciousness ; the strong presumption is that at that time the con- 
vulsion did not pass beyond the left side, the side first convulsed ; 
moreover, in some seizures, when she was uuder Dr. Hughlings 
Jackson's care, she did not lose consciousness, even when the fit 
was so severe that the left arm was invaded. 

" She is certain that the colour began in the right side of her 
field of vision, and spread to the left. Moreover, some years 
before — no accurate date could be given — she had transitory 
hemiopia before the fits, but never immediately before. She 
might, for example, see '.half a face ' at breakfast-time, and have 
a fit in the evening, but then in the interval the ' colours would 
keep coming and going.' According to the mother, the child 
could see to the light when hemiopic' — that is, the left was the 
blind field. On one occasion she, over a period of a few days, 
occasionally saw on Ihe left side an object of about the shape and 
size of an octavo page, dotted all over with rounded dots closely 
set. This was, she said, 'instead of the colours.' " 

COLOUR. 

In some-chapters on Epilepsy (" Med. Press and Circ." 1874 — 75), 
■Dr. Hug'hline's Jackson adverts to the double use of the word 
Sensation. It is used both for mental states acd for the 
physical states of the nervous system which persist dm-ing those 
mental states. Thus it is used for colour and for the molecular 
changes which occur in the retina optic nerve and higher centres 
when there is the mental state, colour. Similarly, a sudden 
development of coloured -visions is sometimes erroneously com- 
pared with spasm of muscles, as if the two things were analogous. 
Speaking of sudden and paroxysmal development of the colour 
red as being equally as convulsive the result of a cerebral 
discharge (and in his nomenclature an epilepsy). Dr. Hughlings 
Jackson writes : — " The word ' red ' is really a name for a mental 
state. The proper comparison is therefore not betwixt the 
sensation of redness (mental state) in an epileptic discharge 
in a convulsion (physical state). This would be to compare 
two things which are utterly different. The comparison, phy- 
siologically, would be betwixt abnormal excitations of optic 
centres and nerves and abnormal excitations of motor centres 
VOL. VIII. Z 



334 PERISCOPE :— COLOUR. 

and nerves. We cannot observe tlie results of excitation of 
' sensory ' nerves and centres. We have to rely on what the 
patient tells us, and, of course, he can only tell us of what occurs 
before he loses consciousness ; we can observe the results of 
excitation of motor centres and nerves after he he has lost 
consciousness," 

The comparison is not betwixt colour and any kind of physio- 
logical conditions of a motor nerve. Psychologically, the com- 
parison is betwixt colour and shape, and physiologically betwixt 
excitations of sensory nerves and centres and excitations of motor 
nerves and centres. 

Speaking more generally (" Med. Press and Circular," Dec. 2, 
1874) on the distinction betwixt mental and physical states, 
Dr. Huschlinors Jackson shows how the distinction is neglected 
in cases of vertigo, as well as in cases of coloured vision. As 
the illustration of vertigo given is ocular vertigo, the remarks 
may be fitlv reproduced here. — " If we consider the facts of the 
vertigo attending palsy of the ocular motor nerves, we see 
plainly that it is a motor symptom. It is, however, sometimes 
spoken of as a sensory symptom, because a ' sensation ' attends 
it. It is one of those disorders of co-ordination which has a 
subjective side. But the ' sensation ' in this case is a state of 
mind, and states of mind may arise during energising of motor 
as well as of sensory nerves and centres. Our direct concern is 
with the physical process which goes on in the nervous system 
whilst the ' mental state,' which is a feeling of vertigo, con- 
tinues ; it is the physical nrocess which is a disorder of motion — 
actual or nascent. Thex'e is as much difference betwixt the 
sensation or feeling the giddy man has and the physiological 
process which goes on in his nervous system, as there is betwixt 
pain and the changes in the sensory (alferent) nerve which exist 
whilst the pain lasts, or as there is betwixt the colour red and 
the changes in the optic nervous sj^stem associated with it." 

Dr. Hughlings Jackson then quotes John Stuart Mill on the 
matter ; colour and its physical substratum being the illustration 
Mill gives. This quotation should be carefully considered by 
those who write as if what begins as molecular vibration, or some 
physical change, in the retina and optic nerves, fines away into 
sensation of coloui'S, i.e., a physical into a mental state. 

" Let it be shown, for instance, that the most complex series 
of physical causes and effects succeed one another in tlie eye and 
in the brain to produce a sensation of colour; rays falling on the 
eye, refracted, converging, crossing one another, making an 
inverted image on the retina, and after this a motion — let it be a 
vibration, or a rush of nervous fluid, or whatever else you are 
pleased to suppose, along the optic nerve — a propagation of th is 
motion to the brain itself, and as many more different motions as 
you choose; still, at the end of these motions, there is something 



ANATO:\nCAL SUBSTRATA OF VISUAL ffiEAS. 335 

which is not motion, there is a feehng or sensation of colour. 
Whatever number of motions we m.ay be able to interpolate, 
and whether they be real or imaginary, we shall still find, at 
the end of the series, a motion antecedent, and a colour con- 
sequent." — (^Mill's Logic, vol ii, p. 436.) 

THE ANATOMICAL SUBSTRATA OF VISUAL IDEAS. 

Dr. Hughlings Jackson has long taught that the convolutions, 
like the inferior nervous centres, represent impressions and move- 
ments. In other words, he believes that the unit of composition 
of the nervous system from the lowest to the highest centres 
is a sensori-motor arrangement. He thinks it to be clearly so in 
the case of the substrata of visual ideas. He urges that, in 
actually seeing, there is concerned a retinal impression and an 
ocular movement ; in thinking of (ideal seeing) an object there 
is concerned a nervous arrangement which represents these two 
elements, the motor as necessarily as the sensory. 

There are three qualities in bodies : secondary or dynamical, 
primary or statical, and secundo-primary or statico-dynamical. 
The secondary or dynamical properties are estimated by sensory 
nerves and centres ; the primary or statical are estimated by 
motor nerves and centres. Dr. Hughlings Jackson supposes 
the secundo-primary or statico-dynamical properties to be esti- 
mated by impressions and movements represented in the cere- 
bellum ; of these, nothing is said in this note (see p. 338). 

The colour of an object is, on its physiological and ana- 
tomical side, simply an affair of the retina and other higher 
sensory centres therewith associated ; on the other hand, its size 
and shape are estimated by ocular movements.* So far for 
acquiring visual ideas of objects for actually seeing them. But 
when we have seen an object we can see it again ideally, or, 
in synonymous terms, "think of it." Dr. Hughlings Jackson 
believes (in accordance with the opinions of Spencer and Bain) 
that the ideal seeing is a repetition of the actual seeing, Avith a 
difference corresponding to the difference that one is a faint 
mental state, the other a vivid mental state. In thinking of 
objects the central discharge is (1) sight, and (2) limited to the 
centre. In actually seeing them it is (1) strong, and (2) spreads 
from periphery to the centre and from centre to periphery. 

In short, he believes that the anatomical substratum of the 
idea of an object consists of two elements, a sensory and a 

* It is understood, of course, tliat the estimation by the eye is symbo- 
lical. On the association of ocuiar movements witli tactual movements, as 
evidenced by cases of hemiplegia with lateral deviation of the eyeballs, see 
last Periscope, p. 97. The association of hemiopia with hemi-ansEsthesia is 
similarly significant (see last Periscope, p. 101, and note in this Periscope on 
Autopsy in a case of Hemiopia witli Hemiplegia and Hemi-anaesthesia). 

z 2 



36 PERISCOPE: — VISUAL IDEAS. 

motor. Speaking of visual ideas, the substratum represents a 
particular retinal impression and also a particular ocular move- 
ment. 

The following, from the "Medical Times and Gazette," May 
29, 1875, refers to the same subject. As the opening sentences 
show, it is from a paper dealing generally with the representa- 
tives of movements in the cerebral convolutions : — 

" To myself, who have for more than ten years been teaching 
that convolutions represent movements, it naturally comes easy 
to believe that the experiments of Hitzig and Terrier are a 
demonstration that this is the anatomical constitution of certain 
of them. Those who have read the quotations above given, will 
not accuse me of affectation when I say that I was surprised that 
any one hesitated to accept the conclusions of the recent experi- 
ments. My own opinion is that the prevalent confusion of 
psychology with the anatomy and physiology of the nervous 
system is much to blame for the incredulity. 'Centres for ideas' 
are often spoken of, but nothing at all is said of the amatomical 
substrata of any class of ideas. I hold, that the anatomical sub- 
strata of ideas are sensori-motor arrangements. It seems to me 
to be plain, almost to demonstration, that there must be a motor 
element in the substratum of a visual idea. How else could we 
possibly have ideas of the shape and size of an object ? I beg the 
reader to take note that this is not an after-thought. I do not 
WTite this because Hitzig and Terrier find that they develope 
movements of the eyes by electrical excitation of certain parts of 
the cerebral cortex. T believe that movements of the eyes must 
be represented in the cerebral hemispheres before their experi- 
ments w^ere begun. Before it was surmised that movements 
could be produced by artificial excitation of the brains of healthy 
animals, I wrote as follows ('Medical Times and Gazette,' 
October 23, 1869) of the anatomical substrata of visual ideas: — 
' In the organised forms which serve as the mental representa- 
tives of objects when the objects are absent, there will therefore 
be comprised not only impressions of surface, tut residua of 
onovevienfs. . . . The speculation supposes that we have 
particular visual impressions in fixed association with particular 
ocuJar movements. A convulsion in which the eyes are strongly 
deviated is owing to an excessive discharge of a part where the 
motor elements of the substrata of visual ideas are largely 
represented." 

ON THE MOST GENERAL MODE OP REPRESENTATIONS OF THE MOTOR 
AND SENSORY ELEMENTS OF VISUAL, ETC., IDEAS. 

In the same series of paper. Dr. Hughlings Jackson puts forward 
a speculation as to the most general mode of representation of 
the motor and sensory elements which enter into the substrata 
of ideas — visual ideas being the illustration. He thinks (quoting 



VISUAL IDEAS. 337 

from an abstract of one of his Gulstonian Lectures, " Brit. Med. 
Journal," March 6, 1869), that ^^ facts seem to show that the fore 
2'>art of the brain serves in the motor aspect of mind, and we inay 
fairlij speculate that the posterior serves in the sensory." 

This speculation seems to him to accord with one of Ferrier's 
conclusions from his experiments. The following is a quotation 
from a summary of Ferrier's researches, " Med. Record," 
March 18, 1874 : — " The whole brain is considered as divided 
into a sensory and motor region, corresponding to their anato- 
mical relation to the optic thalami and corpora striata and the 
motor and sensory tracts." 

Thus, Dr. Hughlings Jackson thinks that, for the most part, 
the sensory and motor elements of the substrata of ideas are 
represented apart. The meaning of this separation, Dr. Hugh- 
lings Jackson suggests, is that the sensory and motor elements 
which enter into the physical side of what is, psychologically 
speaking, our perception of the statical and dynamical qualities 
of objects, can be, so to speak, transposed — can enter into new 
combinations. After seeing a red circle and a blue square, we 
can tluml: of a red square and a blue circle. The separation is 
never absolute. It is impossible, for example, to think of redness 
only. In accordance he speaks of the chiefly motor and sensory 
regions. Yet we can think of red things of innumerable forms. 

The principle Ih, he thinks, capable of extension in various 
degrees to all the higher mental operations — to all complex 
states betwixt the organism as acted on (chiefly sensation side), 
and the organism as reacting (chiefly motion side),* and 
accounts for what takes place, anatomically and physiologically, 
during the mental process, which, beginning as metaphor, ends 
in abstraction. 

ON COLOUEED VISION AND SPASM OP OCULAR MUSCLES IN EPILEPTIC 
OPv, EPILEPTIFORM SEIZURES. 

It was stated in a former note, p. 335, that when we see an 
object (vivid mf.ntal state) there is both a sensory and a motor 
process, and that what is left when the object is removed, is also 
a permanent modification in both a sensory and motor element. 
When (faint mental state) we think of the object (" remem.ber 
it," "become again conscious of it," "see it ideally," &c.) what 
occurs is a slight and central excitation or discharge of these two 
modified elements. Now, having re-stated this we can consider 
what occurs when there is an excessive discharge of centres con- 
taining crowds of these elements. It is to be noted that (see 
p. 336) the two elements are supposed to be represented widely 
apart. Hence from cerebral discharges we may have- almost 
solely sensory phenomena (ocular spectra, and unilateral dys- 

* All modes of consciousness can be nothing else than incidents of the 
correspondence betwixt the organism and its euTii'onment. — Spencer. 



338 PERISCOPE: — REPRESENTATIONS OF 

assthesia, as in some cases of migraiae. See note, p. 332) or wo 
may have almost solely motor phenomena, as in lateral devia- 
tion of the eyeballs and convulsion of the face, arm, and leg. 
— (See note in last Periscope on Correlations of Movements of 
Eye and Hand, p. 95.) 

We consider now what occurs when there is such a discharge 
of the substrata of visual ideas as occurs in an epileptic fit. The 
following extract (Med. Press and Circular, Nov. 4, 1874) gives 
Dr. Hughlings Jackson's views on the subject. After con- 
sidering what occurs daring the discharges when we have vivid 
visual ideas (see things actually) and also what occui's during 
the discharges when we have faint mental states (see things 
ideally) he writes : — 

"Now for the epileptic discharge. It must never he for- 
gotten that it is an excessive discharge. Not only is it very much 
more excessive than the discharges which occur when we have 
faint mental states, but it is very much more excessive than 
those occurring in vivid mental states. Besides being excessive, 
it is of a limited part of the brain. It is raj^id, and it is soon 
over. In such excessive discharges as the epileptic discharge of 
our supposed centres for visual ideas there could not be a de- 
velopment of ideas of obje'cts either of such ideas as occur in 
health or of such as occur in delirium and insanity. We have, 
however, to do with what occurs physically. We have to do 
with epileptic discharges of those sensori-motor processes which 
• are the anatomical side of ideation. There is in some cases of 
epilepsy evidence of txcessive excitation of parts of the brain 
representing retinal impijessions, as the patient has clouds of 
coloui' before his eyes. There often occm'S also, as part of a 
larger fit, that clotted mass of movements of the ocular muscles 
which we call spasm (for example, strong lateral deviation of the 
eyes). In the first case there is, I believe, a sudden and exces- 
sive discharge of a limited part of the cerebral hemisphere, 
which contains crowds of the sensory element, and in the second, 
of a limited part of the cerebral hemisj)here which contains 
crowds of the motor element, in the highest processes of the 
series for visual ideas. The discharge in the epilepsy being 
very strong, rapidly spreads down to the lower centres, and by 
these to the muscles, and thus produces innumerable ocular 
movements at once, or rather jams innumerable ocular move- 
ments into one stiff sti'uggle. 

By the severe discharges which hegin in the substrata of 
visaal ideas the substrata of other ideas are reached ; but it is 
convenient to limit the illustration. 

KEPRESENTATION OF OCULAR MOVEMENTS IN THE CEREBELLUM. 

As stated in the Periscope of last No. (foot note pp. 94 and- 95), 
Dr. Hughlings Jackson believes that certain of the ocular move- 



OCULAR MOVEMENTS IN THE CEREBELLUM. 3oD 

■-» 
ments — those for the estimation of distance are represented iu 
the cerebellum. This to some extent accords wiih certain of 
Ferrier's conclusions. The following is part of a preface to a 
reprint of Dr. Hughlings Jackson's paper on " Localization of 
Movements in the Brain." — (Reprinted from the "Lancet," 1873.) 
" I believe that all the muscles of the body are represented 
in the cerebellum, as all are in the cerebrum but in diilerent 
order. I spoke chiefly of the representation in the cerebellum 
of movements of the eyes, and at the same time for the sake of 
contrast of the representation of ocular movements in the cere- 
brum. I quoted Adamiik and Donders to show that the parallel* 
movements of the eyes Avhich Hering and Donders think are 
for dii'ection, are represented in parts of the corpora quadrige- 
mina different from those parts of these nervous centres, where 
movements of adduction and abduction of the eyes, which they 
suppose to be for estimating distance, are represented. I sug- 
gested that the former, which I consider to be the movements 
for estimation of Extension, are -j-e-represented in the cerebrum. 
It has, indeed, long been well known that lateral movements of 
the eyes ai'e represented in the cerebrum (Vulpian, Prevost, &c.). 
I suggested also that the movements for cUstance,f and I would 
now add for dej)th and resistance, are re-represented in the cere- 
bellum (see Section 17). J These two orders of movements 
occur together in health, but disease separates them. Thus 
there is loss of the lateral movements of the eyeballs in some 
cases of disease of the cerebrum ; from extensive disease of one 
side of the cerebrum, we have loss of one half of the lateral move- 
ments of the two eyes. In order to understand loss of one half of 
the occular movements for estimation of distance by disease of one 
side of the cerebellum, we mnst note that there is something 
more than mere convergence. The movement of the eyeballs in 
estimating distances is a complex one. Besides alteration in the 
size of the pupil, and difference in tensiuu of the ciliary muscle, 
there is convergence and divergence v'i the visual lines. § It 
must be particularly noted that in co:ivergeuce the eyes arc 

* Unfortunately I said " side to side" movements, instead of " p irallel." 

t FeiTier's experiments seem to me to show that this speculation is 
correct. 

J These ociilar movements are supposed to be f:i/mholic of distance, depth, 
and resistance, statico-dyuamical properties, estimated by locomotor move- 
ments. I use the word locomotor in an unusually wide sense. When I put 
out my hand to feel the surface of a book, my putting forth the hand is, I 
consider, an act of locomotion, and it is, I think, a cerebellar movement. 
The moyements of my finger ends over the book (tactual) are cerebral move« 
ments, and serve in the physiological process of giving me notions ot" superficial 
size and shape. The former go with an act of convergence of the eyeballs, 
the latter go with the concomitant sweeping movements of them. 

§ It seems to me that Loring's experiments demonstrate that the external 
recti are in action in looking into the distance. Indeed, it would be a very 
exceptional thing if there were not aclion of boLh external and internal recti. 



340 PERISCOPE: — EYE AND EAR IN 

e 

directed slig'litly downwards, and in divergence upwards. Nnv 
it is an old-establislied fact that, as is stated in Section 17, in 
lesions of the right middle peduncle of the cerebellum there is a 
skew deviation of the eyes. The right eye is turned upwards 
and inwards, the left downwards and inwards. This seems to 
me to be loss of one-half of the movement for the estimation 
of distance. Only one-half, for there is a one-sided lesion only. 
It will, 1 think, be seen that the speculation as to the repre- 
sentations of these ocular movements, see Section 17, is verified 
by some of the results of Perrier's experiments on the cerebellum. 
And the further speculation (Section 17) that these movements 
are by nervous arrangements in the cerebellum, associated with 
movements of locomotion, goes also with Mr. Spencer's hypo- 
thesis that the cerebellum is the organ for doubly compound co- 
ordination in space." 

THE EYE AND EAR IN THE ESTIMATION OF SPACE AND TIME. 

In tlie Hospital Reports of the " Medical Times and Gazette," 
August 7, 1875, are some remarks by Dr. Hughlings Jackson, 
on the movements associated with hearing. In a former note 
(p. 325), it was pointed out that movements of the eyes are 
essential in the estimation of Extension (size and shape). In the 
following exti'act movements associated with the auditory nerve 
are spoken of as being essential in the estimation of Intervals. It 
is given here as it bears indirectly on the matter discussed in the 
note on the Anatomical Substrata of Visual Ideas. (See p. 335.) 

The auditory nerve is in two divisions ; one, the cochlear, 
■Dr. Hughlings Jackson thinks (having regard to Lockhart 
Clarke's researches) is afferent to centres in the medulla oblon- 
gata for movements of the heart, and the other (the tripartite 
division for the semi-circular canals) is afferent to centres for 
locomotion in the cerebellum. 

" So far we have spoken separately of the two divisions of the 
auditory nerve as if one were an auditory and the other a sensory- 
locomotor nerve. We now consider their possible relations to 
one another. If it be, as above suggested, that the cochlear and 
the canal divisions of the auditory nerves are aiferent respectively 
to the heart and to the movements of the head and neck (and 
thus indirectly to locomotor movements), we see that the com- 
pound nerve which is called ' auditory ' has, saying nothing of 
the tensor tympani and stapedius muscles, much muscularity in 
dependence on it. Yet it differs notably from the eye, for the 
movements of the eyes are comparatively independent of those 
of the rest of the body — require translation into them, — wliile 
the movements which we are supposing to be associaited with the 
car are those constantly serving the organism as a whole. That 

both in divergence and convergence. There is, as Duclienne points out, a 
co-ordination of antagonism, as well as a co-ordination of co-operation. 



THE ESTIMATION OF SPACE AND TIME. 341 

is to say, the movements of the head and neck, arc the first and 
most important of locomotor movements ; the heart is the most 
central of all organs. It is exceedingly important to note the 
double association of movement. For the fact of association of 
the ear and circulation bears on the anatomico-physiological 
process which goes on whilst we acquire ideas of Time. The 
ear is not merely for the estimation of sounds, but of Intervals ; 
just as the eye is not merely for the estimation of colours, but of 
Extension. That the ear has to do with time as the eye has to 
do with space, is, of course, a truism ; but we wish to point out 
the importance of rhythmical movements in the estimation of time 
by the ear. Let us first consider the analogous case of the eve and 
space. We could have no notion of extension by mere impres- 
sions on the retina ; there must be movements of the eyeballs. 
(See note p. 3oG). To suppose t licit we know the shape of an 
object by the merely sensory process of an object, as it ivere, im- 
printing itself on the retina, is to suppose that the position of the 
several retinal elements in relation to one another is known already. 
These can only be learned by movements. Similarly, to say 
that, since the ear receives sounds in succession, this kind of 
reception gives one an idea of their time-relation, assumes that 
particular intervals are already known. Dr. Hughlings Jack- 
son believes that intervals are learned by movements of the 
heart ; that our ideas of time have final, although unconscious, 
reference to the rhythm of the heart, as our ideas of space 
have to movements of our locomotor organs. 

" If this hypothesis be true, its bearing on the process for the 
estimation of distance is important and obvious. The auditory 
is a nerve which is partly afferent to a rhythmical, time-dividing 
organ, and partly afferent to leading locomotor movements 
of the whole body. To those born blind, Platner says, time 
serves instead of space ; those who can see, as it were, sum up 
by the eye large space travelled over by successive movements of 
the whole body. Those born blind estimate distance by the time it 
takes to pass irom place to place ; and the time will, the hypo- 
thesis is, be measured by the duration, number, and intervals 
of locomotor movement, estimated by movements of the heart, 
associated with the division of the auditory nerve for the semi- 
cu'cular canals. 

" The above speculation seems to Dr. Hughlings Jackson to 
harmonise with what Spencer has written as to the estimation of 
time by organic rhythms. The following quotation may be 
read in connection with the foregoing ; it is from the first 
volume of ' Spencer's Psychology,' page 217 : — ' A stationary 
creature without eyes, receiving distinct sensations from ex- 
ternal objects only by contacts which happen at long and irregu- 
lar intervals, cannot have in its consciousness any compound 
relations of sequence, save those arising from the slow rliythm of 



342 PERISCOPE :— COLOURED VISION. 

its faiidioiis. Even in ourselves the respiratory intervals, joined 
sometimes with, the intervals between the heart's pulses, fui-nish 
part of the materials from which our consciousness of duration 
is derived ; and had we no continuous perception of external 
changes, and consequently no ideas of them, these rhythmical 
organic actions would obviously yield important data for our 
consciousness of time — indeed, in the absence of locomotive 
rhythms, our sole data.'" 

COLOURED VISION IN AMAUROSIS AND EPILEPSY. 

The following may be read in common with previous remarks 
on Coloured Vision, in our last Periscope, page 91. It is from 
the Hospital Reports of the " Lancet," January 16, 1875. 

" Patients who are blind or partly blind from atrophy of the 
optic nerves are not always in darkness ; they may be in redness. 
The following is a note by Dr. HughHngs Jackson of a case he 
saw in private : — " Some years ago I saw a patient with defect, 
not loss, of sight, from simple atrophy of the optic nerves, who 
said his sight sometimes became ' blood-red,' and would be so 
all day. He was tormented by this, and spoke of it as being 
' frightful,' ' terrible.' He had not always the coloured vision. 
One day he remarked to me : ' To-morrow is not a red day — 
it is a dull, dark day.' So that it would seem there was some 
kind of order in the intermissions. It is worth notice that his 
coloured field was broken by black lines and dots. Most un- 
fortunately I had no j:ote of the patient's power of seeing 
colours, which might, perhaps, have been roughly tested in the 
intervals of his coloured sight. The probability is that the 
patient would at no time during his defect of sight have been 
able to see red. The attacks of red sight were analogous to 
attacks of spasm. Now, it is certain that spasm attacks, as it 
were, by preference those parts which are most subject to para- 
lysis, and will attacJr. parts already partially or even completely 
paralysed. Thus we should by analogy expect that the colour 
first lost and the one first developed would be the same." 

It is understood, of course, that the compai-ison spoken of is, 
strictly speaking, betwixt excitations of sensory and motor nerves 
and centres ; the comparison of development of colour with 
spasm of muscles is nonsensical, for colour is a state of mmd. 
[See note on Colour, p. 3oo.] 

" When colour development is a warning of an epileptic 
seizure, the colour developed is. Dr. Hughlings Jackson thinks, 
generally red. It is not always so." 

This was remarked on in the last Periscoiic, p. 91. Dr. 
Hughlings Jackson says he finds that Falret has long since 
noticed that a premonitory symptom or beginning of an epileptic 
seizure is often red vision, but then Fabret says too, " or purple," 



COLOURED VISION IN EPILEPSY — MYOPIA. 343 

whicli colour is a mixture of the extreme colours red and blue 
(see next note). 

WARNING (aUKA) OF COLOURED VISION IN RELATION TO EPILEPTIC 
*' DREAMS," AND TO EPILEPTIC MANIA. 

The following is from the same number of the " Lancet," but 
contains additional sentences : — 

" In chronic conditions of mental impairment it seems certain 
that ' subjective ' sensations are factors in producing delusions. 
Thus a lunatic who has subjective smells may think his food is 
poisoned. He imagines the smell to be in the food itself. So 
far for chronic cases. The tempoi'ary subjective sensations 
which usher in an attack of epilejDsy probably give a tui'n to the 
temporary mental disorder at the onset of and after the paroxysm. 
One of Dr. Jackson's patients had fits beginning in his tJuimb, 
and used, as he became unconscious, to cry out that his thumb 
was coming oif and that blood spurted out of it. The presump- 
tion is that he had an ' aura ' of red vision. After the tit, but 
before he was fully himself, he saw blood all over his clothes. 
Another patient who had an aura of colour next ' saw faces,' 
and then went off into convulsions. The probability is that such 
subjective sensations, which are practically external, develop or 
give a turn to dream-hke states preceding complete loss of con- 
sciousness, or to the delirium or mania sometimes following the 
paroxysm. To make this clearer let us state the usually ac- 
cepted theory of dreams. It is believed that they are developed 
by some external irritation, as for example, a noise, or by some 
peripheral irritation, for example a sore throat or a cramp in the 
finger. Taking the last illustration ; the cramp developes a dream 
that a cat is biting the dreamer's finger. Similarly when a 
patient after an epileptic fit is in a condition which is the patho- 
logical analogue of the condition in sleep, the development of 
the colour red pi'obably caases dreadful dreams of blood, 
flames, &c. (Vide infra quotation from Falret,) 

" Colour sensations are far commoner than sensations referred 
to the other senses, that is to say, the most special sense is the 
one most often affected. And of colour, as stated, ' red ' is the 
one most often developed. Dr. Hughlings Jackson finds that 
Falret has remarked on the frequency of red vision in epileptic 
maniacs. He says ' they constantly see luminous objects, flames, 
circles of fire, and what is vjorthij of remark the colour red or the 
sight of blood frequently predominates in their visions.'" 

THE CAUSES OF MYOPIA. 

Dr. Schnabel (of Vienna), in a long paper on this subject, 
discusses the views already held. That myopia does not depend 



344 PERISCOPE: — CAUSES OF MYOPIA. 

on over-work of tlie eyes merely, he thinks is shown by the 
number of myopes who have never used their eyes for observing 
small objects at all. He objects to the view that spasm of 
accommodation causes myopia. The number of those who nse 
their eyes constantly on fine work (and who would be liable to 
spasm) and the hereditariness of myopia, would make myopia the 
prevalent condition, emmetropia, &c., the exception. The theory 
of inflammatory changes is not sufficient. The external condi- 
tions under which myopia may develope may differ in toto. We 
must look at the cases in which no strain of accommodation has 
occurred to find an explanation of the cause of myopia. He 
believes that in all cases there must be a congenital predisposi- 
tion, which may remain latent for years. The fact of hereditary 
transmission supports this view. It is remarkable that myopes 
should be so liable to spasm of accommodation, because they use 
their accommodation so little. In hypermetropia, or where the 
accommodation is used, we get asthenopia. He criticises 
Dobrowolsky's statements as to the degrees of myopia most com- 
monly associated with spasm. Dr. Schnabel gives the results of 
his examination of 210 eyes. He did not select the patients. 
They were young people in various occupations, mostly requiring 
steady-looking at fine objects, and whom he could examine 
repeatedly. He found 120 myopic, 40 hypermetropic, and 50 
emmetropic. In only 89 did he use atropine, as he found ho 
could estimate the refraction exactly with the ophthalmoscope 
without atropine. In none of the hypermetropic eyes was there 
any permanent spasm c5 accommodation, though he found one 
in which a sixth of hypermetropia (manifest to the ophthal- 
moscope) was not ap23arent when the patient looked at distant 
objects. The exercise of accommodation which enables a hyper- 
metrope to see in the distance does not come under the character 
of " spasm." It is called forth in the attempt to see, and 
relaxed as soon as the attempt is deviated from. The inability 
to use the convex glasses corresponding to the amount of the 
hypertropia never depends on inability to relax accommodation, 
but on the relation between convergence and accommodation, in 
consequence of which a certain amount of accommodation is 
exercised in fixing a distant object, and this is neutralised by. the 
use of convex glasses. As soon as a hypcrmetrope looks vaguely 
into the distance without fixing any object, the accommodation is 
at once relaxed, and the highest degrees of hypermetropia may 
be estimated by the ophthalmoscope. If during this examination 
the patient looks at a definite object, the hypermetropia ceases to 
be manifest, but becomes apparent immediately the patient ceases 
to fix. This shows how very little habitual spasm of accommo- 
dation will account for the symptoms. Ho did not meet with 
any case of myopia (ophthalmoscopic) which after the use of 
atropine was found to be emmetropia or hypermetropia. He has 



CAUSES OF MYOPIA. 345 

never met with a case of persistent inyolnntary spasm of accom- 
modation. He criticises cases already recorded, and tlie symp- 
toms generally given of spasm. In many, the difference in 
refraction before and after atropine was exceedingly small. Dr. 
Schnabel thinks it qnite probable that a young, soft lens, after 
repeated compression in the exercise of accommodation in hyper- 
mietropia, may take some time to recover its proper shape when 
the accommodation is relaxed. When speaking of the estima- 
tion of refraction by the ophthalmoscope, he points out that con- 
siderable differences often exist between the disc and the yellow 
spot, and even between different parts of the same disc. Dr. 
Schnabel then passes on to consider whether myopia depends at 
all on exercise of accommodation. He uses the term " Staphy- 
loma posticum " to indicate elongation of the eyeball, and 
" conns " to indicate the so-called " crescent." He does not 
believe that the cone depends on inflammatory changes, or on 
the traction exercised on the choroid in accommodation. The 
cones often exist in eyes which have never been used for fine 
objects. Moreover, the traction, when exercised, would nob 
account for the cone. The part where the cone is invariably 
situated is that least aflFected by the traction. The mode of 
increase is different from that which traction would explain. 
The cone should be commonest in hypermetropia where the 
greatest accommodation is exercised. Out of 210 eyes examined 
cones were present in 135, and 99 of these were myopic, 18 
emmetropic, and the other 18 hypermetropic. He only met with 
twenty-one myopic eyes without cones. It is certainly more 
common to meet with non-myopic eyes with cones than myopic 
eyes without them. It is exceptional to meet with them in 
hypermetropia where accommodation is constantly exercised, 
and the custom in myopia where accoramodation is not required. 
Cones are present in hypermetropia without asthenopia, and 
absent in myopia with most troublesome asthenopia ; present in 
myopic eyes only used for large objects, and absent in those used 
for fine work. The theory that the cones depend simply on 
atrophy of the choroid dependent on elongation of the sclerotic, 
and, for anatomical reasons, most developed to the outer side of 
the disc, meets many of the difficulties. This will not account 
for the presence of cones in hypermetropia and emmetropia ; for, 
if the size of the cone bears any relation to the elongation, in 
many cases the latter would have to be so extreme as to be 
incredible. He thinks we must fall back on a congenital 
anomaly. The cone represents an enlarged blind spot, the 
margin of which accurately corresponds to that of the cone. 
The percipient elements, as well as the pigment layer, are want- 
ing. The congenital cone is analogous to a coloboma. In the 
acquired cones, the pigment layer is wholly wanting over the 
interval between the margin of the disc and the semicircular 



346 PERISCOPE :- CAUSES OF MYOPIA. 

pigment line forming the boundary of the cone. The stroma of 
the choroid is not infrequently still in good preservation. It is 
impossible to explain this on the theory that the ati'ophy of the 
choroid is the sole cause of the formation of the cone. Dr. Schnabel 
thinks that, in consequence of the stretching of the sclerotic the 
margin of the pigment layer is drawn away from the disc by the 
pigment layer moving over the choroid. . When the elongation 
occurs, the pigment layer is insufficient to cover the strf tched 
subjacent membranes, and a kind of window is formed at the 
margin of the disc. The part of the fundus deprived of the pig- 
ment layer will therefoi-e be bounded on the one side by the disc, 
and on the other by a semicircular pigment line, and will be 
situated on the side of the disc corresponding to the summit of 
the staphyloma. It is usually on the outer side, because the 
greatest elongation occurs in the region of the macula lutea. 
In a congenital conns the choroid also is wanting. It is often 
easy to detect that a cone is spreading by the differences which 
can be made out between different parts of it. There are other 
changes liable to be confounded with cones. In the latter the 
margin of the disc next them has no pigment, and the area of 
the cone is insensible to light. He describes certain changes 
met with in the eyes of old persons which may be mistaken for 
cones. In regard to the causes of the acquired stretching of the 
schlerotic, Dr. Schnabel gives reasons for disbelieving in an 
inflammatory origin. Increased intra-ocular pressure he cannot 
regard as a cause, because this would take effect at the lamina 
cribrosa. He can only r.ttribute the staphyloma to a congenital 
predisposition ; that is, to a particular condition of the sclerotic. 
The hereditariness of the affection points in this direction, and 
it often goes with a particular build of the frame. It is very 
common in certain countries. In Italy, for instance, and yet 
there 80 per cent, of the people cannot read or wi-ite. It is w^cll 
recognised that certain physical peculiarities which have been 
inherited may not develop till a certain age, and so it may be 
with myopia. A predisposition being granted, it is of course 
comprehensible that various causes may hasten the development : 
such as application to fine work, but the precise influence of each 
factor involved is unknown. If the predisposition is great, the 
myopia will develop, though the ej^es have not been used for 
fine objects at all. This explains the apparent anomaly that the 
largest " cones " may be met with in such people. An eye which 
was originally hypermetropic or emmetropic may ultimately 
develop myopia in obedience to predisposition. He mentions a 
case in which a patient, 18 yeai\s old, was found to be emmetropic, 
whilst, five 3'ears previously, he was distinctly hy|3i;rmetropic 
(tV^^O- There was no "cone" present. — (" Grjefe's Arch. f. 
Ophth." Bd. XX, Abth. ii.) 



APPARENT MYOPIA. 347 



APPARENT MYOPIA. 

A CASE of apparent myopia in a lad, 17 ycai'S old, is recorded by 
Dr. Leopold Weiss. The myopia amounted to about g^^^ on trial 
with glasses before and after atropine, but the ophthalmoscope 
showed emmetropia. The patient could see better in the distance 
after atropine. He was not sufficiently long under care to show 
results of treatment. — (" Zehend. Klin. Monat.," xiii, April, 
p. 124—132.) 

THE T-EXGTH OF THE AXIS, AND THE RADIUS OF CURVATURE OF THE 

EYE. 

Dr. Landolt gives a method of calculating the length of the eye, 
and thus of distinguishing between myopia from elongation and 
that from excess of refraction. — ("Annates d'Oculistique," Jan., 
Fev., 1874, p. 49.) 

PARESIS OP ACCOMMODATION, WITH APPARENT MYOPIA. 

A PATIENT, aged 39, under the care of Dr. Schapringer, had a blow 
on one eye, after which he appeared slightly myopic for distance, 
but unable to read small print. Convex glasses were given for 
reading, and weak concaves for the distance. In a short time he 
could see well without concaves for distance. — (" Archives of 
Ophth. and OtoL," vol. iv, No. 1.) 

CHANGES IN REFRACTION IN A CASE OF IRITIS SEROSA. 

Dr. Pflugee records a case of serous iritis, in which the refi-ac- 
tion varied from myopia 3V ^o |.— ("Zehend. Klin. Monat.," 
xiii, April, p. 108.) 

TWO CASES OF MYOPIA ARISING FROM ACCIDENTAL LUXATION OF 
THE LENS. 

The eases arc recorded by Dr. Pfluger. In the first, after some 
other effects of the injury had passed off, it was found that the 
lens occupied an obhque position slanting downwards and back- 
wards. The patient could read 1^ Sn. at 3^". With — 4 s. and 
— 2 cyl. axis, horizontal V. = f§. In the second case, the lens 
was rotated on its vertical axis, the inner margin being posterior 
and the outer anterior. The patient was not sufficiently intelli- 
gent to allow of an examination for astigmatism being carried 
out. He saw small objects best at 4^", and best in the distance 
with — 6. In each case the pupil was widely dilated.^ The 
author alludes to two similar cases recorded by Manfrcdi, and 
says the cases give support to Helmholtz's theory of the 
mechanism of accommodation.— (" Zehend. Klin. Monat.," xiii, 
April, p. 109.) 



348 PERISCOPE: — CILIARY MUSCLE, &G. 



THE CILIARY MUSCLE. 

Dk. Warlomont publislies an article on the ciliary muscle 
(writen for the " Dictionnaire Encyclopediqne des Sciences 
Medicales ") in the " Annales D'Oculistique, Mai, Juin, 1875, 
p. 195^249. He discusses its anatomy (with illustrations) in 
the human subject, in various states of refraction ; its compara- 
tive aaatomy, its physiology and pathology. Under the latter 
heading he treats (1) of insufficiency — physiological (excited and 
spontaneous) and pathological ; the latter, again, including 
paralysis (diphtheritic, &c.) and paresis, with the treatment of 
these aifections. (2) Excessive tonicity — physiological (excited 
and spontaneous) and pathological — including "dynamic my- 
opia." (3) Hypergesthesia of the ciliary muscle. (4) Neuralgia 
of the ciliary muscle, acute and chronic. 

THE UNIT OF ACCOMMODATION. 

Prof. Hasner, of Prague, in a paper ("Ueber die Accomoda- 
tion seinheit") in "Zehcnd. Klin. Monat.," xiii, Jan., Feb., 
Marz, p. 1 — 4 and 88 — 90, advocates a new forjnula for repre- 
senting the amount of accommodation exercised. 

EMPLOYMENT OF CALABAR IN THE TREATMENT OF ASTHENOPIA 
ACCOMMODATIVA. 

Dr. Hugo Magnus contributes a paper on ihis subject. — 
(" Zehend. Klin. MonaL," xii, Aug., Sept., p. 303.) 

SPASM OF ACCOMMODATION, 

Dr. J. Stilling records five cases of spasm of accommodation. 
In three, the affection occurred in connection with febris inter- 
miltens larvata. The first patient was 67 years old. During the 
attacks of spasm, symptoms were produced like those after 
instillation of Calabar in cases of paralysis of accommodation. 
The second patient was 30 years of age. The spasm occurred in 
connection with supra-orbital neuralgia, of an intermittent type. 
The third patient was a man, aged 22, suffering from conjunc- 
tivitis attended by severe pain in and around the eye, of an inter- 
mittent type. The fourth was a gii4, aged 12, suffering from 
spinal irritation, orbital neuralgia, &c. In the fifth case, the 
patient, a man, could excite the spasm at will, by pressure on a 
particular part of the eye. — ("Zehend. Klin. Monat.," xiii, 
Jan., Feb., Miirz. p. 5—30.) 

THE CLINICAL DETERMINATION OF ASTIGMATISM. 

In the "Annales d'Oculistique," Mai, Juin, 1875, p. 298, is an 
abstract of a thesis, by Dr. Justin Weil, in which it is mentioned 



ESTIMATION OF REFRACTION. 349 

that M. Bravais (of Lyons) has suggested a new test for astigma- 
tism. If, when examining an eye with the ophthalmoscope and 
the disc is in view, we move the lens from side to side we shall 
find that the image of the disc moves also. The degree of 
movement will depend on the state of the refraction. If the eye 
be myopic, the image moves less than the lens ; if the eye be 
hypermetropic, the image will move more than the lens ; if the eye 
be emmetropic, the image wall still be seen through the centre of 
the lens, as the movements will be equal. This test may be applied 
in the direction of the different meridians and thus astigmatism 
may be detected. The movement of the image is recognised by 
its relation to the borders of the lens. M. Bravais has also con- 
structed an apparatus — a monocular astigmometer which lenders 
the eye myopic — consisting of a tube with a convex lens of 
shorter focus than the tube. The latter is terminated by a 
screen pierced by a small round opening giving passage to the 
rays of a lamp. If the eye is astigmatic, the aperture wall appear ' 
oval, the long axis corresponding wath the direction of the 
meridian of greatest curvature. In the interior of the tube is a 
second lens which rotates on a pivot and can be turned from 
the outside. The axis of rotation of this lens is placed in the 
same du'ection as the long axis of the oval, and the lens is rotated 
till the aperture appears round. The degree of obliquity of the 
lens is shown by a needle, and the focus of the cylindrical lens 
represented by the obliquity of the lens is read off on a scale 
previously calculated. Or, the observer (if emmetropic) him- 
self looks in the tube when the asymmetry is corrected, and of 
course sees the aperture oval in the opposite direction, and may 
then find the cylindrical glass required to enable him to see it 
round. 

THE ESTIMATION OP THE STATE OP THE EEFRACTION BY THE 
OPHTHALMOSCOPE. 

Dk. J. Stilling contributes an article on this subject in which 
he gives rules for estimating approximately all varieties and 
degrees of refraction by the aid of the images obtained with the 
reflector, only, at different distances, or when a ten-inch convex 
glass has been placed before the patient's eye. He thus obviates 
the necessity of using many glasses. (" Zehend. Khn. Monat.," 
xiii, !Mai, Juni, p. 143 — 183.) 

THE RELATION OF THE SURFACE OF THE RETINA TO THE DIOPTRIC 
SYSTEM OF THE HUMAN EYE. 

Dr. Stammeshaus finds that the peripheral portion of the retina 
in emmetropic eyes (central vision) appears hypermetropic ; in 
myopia the difference is very great ; in hypermetropia, slighter. 
— (" Graefe's Archiv.," Bd. xx, Abth. ii, p. 147—170.) 
VOL. vni. 2 A 



350 PERISCOPE : — INJECTION OF CHLORAL. 

INJECTION OF CHLORAL INTO THE VEINS AS AN ANiESTHETIC AGENT. 

Dr. Warlomont writes an article on this subject in the " Annales 
d'Ocnlistiqne," Sept., Oct., 1874. He discusses the history and 
quotes cases recorded. Ten grammes (154 grs.) in 30 grammes 
(about an ounce) of water is the usual quantity in an adult 
(12 or 15 grammes 184 — 231 grs.) may be given. Dr. Jos. 
Casse's instrument for transfusion of blood is figured and recom- 
mended for use. Chloral may be useful where inhalation of 
ether, &c., may not be applicable on account of the patient, or 
the operation having to be performed on the nose, mouth, &c., or 
where it is necessrry for the patient to remain perfectly quiet 
for some time afterwards. In the Annales for Mars, Avril, 
1875, p. 190 — 192, a case of death after the injection of chloral 
is noted from the records of the Academie de Med. de Belgique, 
Sceance du 24 Avril, 1875. The patient was a woman, aged 45, 
and the operation, extraction of cataract. It was considered 
that the chloral could not really be blamed for the result. 

wound of the EYE BY A SHOT. 

Dr. Fuckel records a case in which a shot entered the eye to 
the inner side of the cornea, was supposed to have passed through 
the eye and made its exit to the outer side of the disc. At first, 
no ophthalmoscopic examination could be made and the patient 
could not see, then on the third day the media were quite clear, 
and a rent in the chor^'id could be made out to the outer side 
and above the disc. There were also two extravasations. A 
representation is given. On the twelfth day the vitreous be- 
came opaque. The patient was then lost sight of. — (" Zehend. 
Klin. Monat.," April, Mai, xii, p. 161.) 

extirpation of both lacrymal glands for sarcomatous 
degeneration. 

Dr. Alexander records the case and alludes to others published. 
The patient was a man aged 72. — (" Zehend. Klin. Monat.," xii, 
April, Mai, p. 164.) 

hypertrophy of the LACRYMAL GLAND. 

Dr. Savary records a ease in a man aged 59. The tumour was 
removed with great difficulty by a prolonged operation, which is 
described in detail. The patient recovered well. — ("Annales 
d'Oculistique," Mars, Avril, 1874 p. 130.) 

FOREIGN BODY IN THE ORBIT OF A CHILD. 

Dr. Haltenhof records a case in wliich a piece of wood remained 



CONICAL CORNEA. 351 

in the orbit of a child for a year, and was then let out on 
making an incision to give exit to pus. — (" Bull, de la Soc. Med. 
de la Suisse romande," Oct., 1873, and " Annales d'Occulistique," 
Mars, Avril, 1874, p. 180.) 

OPERATION FOR CONICAL CORNEA. 

Dr. Wecker prefers Graefe's operation with modifications. He 
removes a small flap of cornea from the apex of the cone with a 
Grjefe's knife, taking care not to penetrate the anterior chamber. 
The second day after this operation a stick of (mitigated) nitrate 
of silver is applied to the wound, only, and any superfluous 
silver is removed. This cauterisation is repeated for a fortnight, 
and then the ulcer is slit up with a Graefe's knife, as in Samisch's 
operation for spreading ulcer of the cornea, and the slit is kept 
open for another fortnight. Atropine is used throughout the 
whole treatment, which extends over a month. At the end of 
that time, the ulcer may be allowed to cicatrise. If the opacity 
does not clear up after a time, the cornea may be tattooed. 
Dr. Wecker thinks this treatment might be simplified by omit- 
ting the preliminary cutting of a corneal flap, as the ulcer might 
be producd by cauterisation. He has not followed out this sug- 
gestion however. A case in which the operation above described 
was carried out successfully is detailed.^ — (" Annales d'Ocu- 
listique," Mars, Avril, 1874, p. 121). In the number for Mars, 
Avril, 1875, a note of the condition of this patient after a con- 
siderable interval is recorded and another case noted. 

KERATITIS VESICULOSA WITH SECONDARY GLAUCOMA. 

Dr. J. R. PooLET ("Arch, of Ophth. and Otol.," vol. iv. No. 1) 
records a case and alludes to two others on record. (See this 
Journal, vol. vii, p. 65, for Graefe's case, the other one is re- 
corded by Samisch.) 

THE ACTION OF HYOSCTAMINE ON THE EYE. 

In the "Arch, of Ophth. and Otol," vol. iv. No. 2, is a paper by 
Rosa Simonowitch, M.D., detailing some experiments made on 
the action of hyoscyamine on the eye. They were carried out 
under the superintendence of Prof. Dor, who appends some 
remarks. Tlie results obtained were interfered with by the 
difiiculty in obtaining hyoscyamine. There is a substance in the 
extract of hyoscyamine which has a strong mydriatic action, but 
the article commonly sold as pure hyoscyamine is without any 
mydriatic action. If these preparations really are hyoscyamine, 
the latter has no mydriatic action, and the mydriatic must be 
sought in the residue ; or the real hyoscvamine is in the residue. 

2 A 2 



352 PERISCOPE: — POSTURES SYMPTOMATIC 

POSTURES SYMPTOMATIC OF PARALYSIS OF THE OCULAR MUSCLES. 

M. Giraud-Teulon points out tlie important aids to diagnosis in 
cases of paralysis of tlie ocular muscles by noting the position in 
which the patient holds his head, &c. When an ocular muscle 
is paralysed, the least attempt to look at an object in the 
direction in which this muscle would act excites diplopia. The 
patient endeavours to avoid this by putting his head and eyes 
in such a position that he can see objects without using the 
affected muscle. If the movement of the left eye to the right be 
impaired, the patient turns his face to the right. He tries to 
supply the place of the left internal rectus by complementary 
movements of the muscles of the neck. The explanation of the 
position of the head when movements in a vertical direction are 
impaired is more complicated, and still more so in reference to 
oblique movements. The latter w^ill not be considered. It will 
be sufficient to deal with the cardinal movements. "When we 
look straight upwards or downwards with both eyes, the vertical 
meridians of the two eyes are kept vertical to each other by the 
simultaneous action of one rectus (superior in looking up, or 
inferior in looking down) associated with one of the obliques 
(the «'H/'e?-ior in looking up and the superior in looking down). 
For the action of each of these muscles, representing a force 
applied to a bent lever, may be regarded as the resultant of three 
movements, vertical, horizontal (lateral and oblique) inducing a 
rotation or inclination of the principal meridians of the eye. 
Inability to look upwa;'ds causes double images; of unequal 
height (vertical), separated laterally (horizontal) and placed 
obliquely to one another (rotation). The attitude assumed by 
the patient is characteristic of this diplopia. (1) The face is 
raised, the orbital planes are not horizontal, to compensate for 
the inability to move one eye upwards. (2) The direction of 
the axes of the eyeballs do not correspond with those of the 
orbits ; the one eye is adducted, the other abducted to com- 
pensate for deficient lateral movement of one eye. (3) The face 
is not merely raised, but the head is inclined to one shoulder to 
compensate for the deficient power of moving the eye obliquely. 
Besides this, however, the face is turned to one side. The other 
movements noted would give single vision in one direction only ; 
to the extreme right or left of the field. The patient is in the 
position in which he would be placed by a complete paralysis of 
one or other lateral muscle. The face is turned in the opposite 
direction to the line of vision. Graefe also noted a peculiar 
rigidity in the aspect of the patient which is easily explained. 

In simple cases, therefore, the attitude of the patient affords 
a clue to the kind of paralysis. It is necessary to ascertain in 
the first place which eye is affected. This is done (in the ab- 
sence of testing by coloured glass) by getting the patient to cover 



OF PARALYSIS OF OCULAR MUSCLES. o5o 

first one eye and then the other. "When the eye on the paralysed 
side, alone, is uncovered, vertigo, or inability to walk sti'aight 
will be evident. Say that we find the left eye is paralysed and 
that the head is thrown back, we conclude that the patient can- 
not move the left eye upwards. Secondly, we ascertain that the 
left (paralysed) eye is aclduded. This shows that the muscle 
affected is an adductor as well as an elevator ; because the ad- 
duction is complementary of a deficiency. The superior rectus, 
alone, of the two elevators, has also adducting power. So that 
is is the left superior rectus which is paralysed (and supple- 
mented). Instead of looking at the position of the eyes we may 
consider that of the head. We may often observe that the head 
is inclined ; the right ear being depressed towards the shoulder 
of the same side. This is done to carry the vertical meridian of 
the left eye in the same direction, that is, the summit of the 
meridian to the right or inwards. The superior rectus is the 
only elevator muscle which produces this rotation. After the 
paralysis has existed some time, the position of the head is no 
longer characteristic, and before coming to any diagnosis from 
position alone the duration of the aifection must be ascertained. 
— (" Annales d'Oculistique," Juillet, Aout, 1874.) 

ACTION OF STRYCHNIA ON THE EYE. 

A DETAILED abstract of a memoir on the action of strychnia on 
the eye in health and disease, by Dr. Von Hippel, is given in 
the "Annales d'Oculistique," Mars, Avril, 187-4, p. 186 — 194. 

THE LYMPHATIC SPACES IN CONNECTION WITH THE EYE. 

A SUMMARY of the recent literature of the subject, and a list of 
papers, is given in the "Annales d'Oculistique," Mars, Avril, 
1874, p. 208—12. 

ENTROPION. 

Dr. Warlomont describes and figures a new operation for entro- 
pion and a new spatula (" Blepharospathe-eventail") in the 
"Annales d'Oculistique," Mai, Juin, 1874. 

advancement of the INTERNAL RECTUS DIVIDED IN AN ACCIDENT. 

Dr. Wecker narrates a case in which a man received a blow on 
the eye which divided the internal rectus. An external stra- 
bismus resulted. Owing to the density of the cicatricial tissue, 
there was some difficulty in exposing the divided muscle. He 
then passed a double thread through it, according to the plan 
described in last Periscope (see p. 123). Instead of tying the 
corresponding threads, however, he joined the lower thread to 



354 PERISCOPE: — TENOTOMY. 

the one passed throngh the conjnctiva at the upper border of 
the cornea, and vice versa with the other. By this means one 
knot is tied without causing any traction or pain, and it is only 
when the second is tied that the muscle is pulled forwards. 
There is, therefore, less risk of pulling the muscle a little 
upwards or downwards instead of straightforwards. When the 
suture has to be removed it is only necessary to divide the 
thread in one place, and then the whole sutui'e can be drawn 
away. (" Annales d'Oculistique," Mai, Juin, 1874, p. 229.) 
In the number for Mars, xWril, 1875, p. 122, Dr. Masselon 
describes and figures a double hook which Dr. Wecker has 
devised for the purpose of holding the muscle at the time of 
passing the suture through it. The hook is constructed on the 
principle of a lithotrite. It is used in the same manner as an 
ordinary strabismus hook, but care is taken to get the whole of 
the muscle on it. Then the conjunctiva is held out of the way 
with forceps, and the second portion of the hook is pushed down, 
grasping the muscle between it and the first branch, just as a 
stone is held between the two blades of the lithotrite. The 
second branch has little projections fitting into perforations of 
the other one. 

TENOTOMY OF THE SUPERIOR AND INFERIOR RECTI. 

Dr. H Knapp records three cases in detail, to which we can only 
refer. In the first case, the superior and inferior recti of the 
same eye were divided, at difierent times, for paresis of the 
superior rectus. The result was good. In the second case, the 
external rectus in each eye, and the inferior rectus of the left, 
were divided for strabismus and diplopia. In the third, the 
superior rectus was divided, and then a suture was applied. A 
cure resulted after advancement of the inferior rectus. There 
was not only paralysis of the main depressor oculi, but in- 
creased contraction of the superior rectus and inferior oblique. 
('•Archives of Ophth. and OtoL," vol. iv, No. 1.) 

NYSTAGMUS, INTERMITTENT, IN A MINER. 

Dr. Leon Noel records the case of a miner, aged 22, who was 
subject to lateral oscillation of the eyes when he looked up as 
high as possible. He also had rotatory nystagmus in certain 
positions, and clonic spasm of the upper eyelids and upper 
extremities. ("Annales d'Oculistique," Nov., Dec, 1874, 
p. 211.) 

DIPLOPIA — STRABOTOMY" CUKE. 

The patient was a woman aged 52, under the care of Dr. 



TUMOUR OF BASE OF SKULL. 355 

Savar}'. The diplopia followed a blow over tlie eyes fonr montlis 
previously. There was couvergent strabismus. There was no 
anomaly of refraction, and no cause for the diplopia could be 
assigned. The symptoms were quite relieved by division of the 
internal recti, an interval of twenty- four hours intervening 
between the two operations. (" Annales d'Oculistique," Nov., 
Dec, 1874, p. 212.) 

OPHTHALMOSCOPIC PHENOMENA OP THE SIGNS OF DEATH. 

Dr. Gatat gives a summary of a work of his in the " Annales 
d'Oculistique," Jan., Feb., 1875. He lays most stress on the 
disappearance of the central vessels where they cross the disc ; 
disappearance of the column of blood in the arteries at various 
parts of the fundus ; infiltration of the retina, and the ap- 
pearance of a small red spot in the situation of the macula 
lutea. 

BROMIDE OF POTASSIUM IN ALCOHOLIC AMBLYOPIA. 

An abstract of a paper by Dr. Quaglino ("Annali di Ottal- 
mologia,") is given in the "Annales d'Oculistique," Jan., Feb., 
1875, p. 26. He has found bromide of potassium very effi- 
cacious. 

CARTILAGINOUS TUMOUR OP THE BASE OF TH^ SKULL. 

Dr Leon Noel records the case of a man, aged 20. A fortnight 
previously he awoke one morning unable to see at all with one - 
eye and but imperfectly with the other. He had had pain in his 
head and vertigo for some time. He also complained of pain in 
the eye in which he still had sight, and heard a noise on the 
same side of his head. No clue whatever could be obtained as 
to the origin of these symptoms. The right eye was prominent, 
the lids and conjunctiva swollen. The disc and surrounding 
parts showed evidences of neuro-retinitis, and the veins were 
much dilated. On the left side the symptoms of venous ob- 
struction were less marked. The disc was in a state of advanced 
atrophy. A bruit was heard by the patient on the right side 
synchronous with the pulse, but no bruit could b9 heard with 
the stethoscope. His sense of smell was lost. He could still 
taste. He had no loss of sensation or of motion. The diagnosis 
made was that of a tumour about the body of the sphenoid, 
more especially affecting the right side, pressing on the right 
carotid, and giving rise to the bruit heard by the patient. As 
the case progressed, the vision in the right eye failed more and 
more, the exophthalmus on both sides became more marked, and 
a hard tumour could be felt inside the right orbit, and then 



356 PERISCOPE: — CYSTICERCUS OCULI. 

within the left ; a tumour was noticed pressing down the soft 
palate. The history extends over thirteen months. At the 
post mortem, an immense cartilaginous tumoui', growing from 
the base of the skull, was found. It varied greatly in con- 
sistence, and was composed of hyaline cartilage, undergoing 
colloid or mucous degenei-ation in places. The case is in- 
teresting as showing how far ocular symptoms throw light on 
affections of the base of the skull, and to what an extraordinary 
degree of compression the brain may be subjected if the 
pressure be gradual. The patient retained consciousness, sensi- 
bility, and power of motion till nearly the last. ("Annales 
d'Oculistique," Nov., Dec, 1874, p. 201.) 

CYSTICERCUS CELLULOSE BENEATH THE OCULAR CONJUNCTIVA. 

In "Zehend. Klin. Monat.," xiii, Jan., Feb., Marz, p. 11, is 
an account of a case by Hock (Vienna.) The patient was a 
child, aged 8. 

CYSTICERCUS IN CONNECTION WITH THE EYE. 

PoucET ("Gaz. Med. de Paris," 1874, No. 10,) records a case 
in which a cysticercus developed between the choroid and the 
retina. He gives a list of cases of cysticercus in the eye, &c., 
which have been recorded. In three cases, the eyelids were 
affected ; in ten, the cellular tissue of the orbit ; in nine, the 
anterior chamber ; in thirteen, the conjunctiva and the cornea; 
in nineteen, the vitreous: total, fifty-four cases. ("Annales 
d'Oculistique," Mars, Avi'il, 1874, p. 182.) 

A PECULIAR AFFECTION OF THE OCULAR CONJUNCTIVA. 

Camuset (" Gaz. des Hop.," 1874, No. 39,) records the case of 
a lad aged 16. On opening the eyes, the conjunctiva presented 
a very unusual appearance, and scarcely any cornea was visible. 
The globe was covered by a membrane of a yello\vish- white 
colour, and crossed by .a few vessels. It covered the cornea as 
far as the pupil, which it limited irregularly. The affection was 
said to have begun when the child was five years old. Treat- 
ment was not of any avail. The growth was considered to 
depend on hypertrophy of the epithelial layer of the conjunctiva, 
and " leucophthalmos epithelial," proposed for its designation. 
("Annales d'Oculistique," Mars, Avril, 1874, p. 183.) 

CONJUNCTIVITIS DIPHTHERITICA. 

Under this title, Dr. J. Hirschberg records the case of a lady, 
aged 20, who came under his care with very severe conjunc- 



OPHTHALMIA. 357 

tivltis, attended by great cliemosis, sei'O-mucons discharge, and 
swelling of lids. One eye only was affected. There is no men- 
tion of any membranous formation. It was suspected that the 
disease might be due to infection from leucorrhoea, from whicli 
the mother was then sufferingf. As it is a well-known fact tliat 
non-specific matter brought in contact with the conjunctiva is 
able to produce a severe inflammation even of a diphtheritic 
character, it was thought possible that the young lady might 
have contracted her eye disease while superintending the family 
washing, which she had done a short time previously. The 
unafliected eye was covered up. Compresses of iced water and 
leeches were used for the other eye. As the cornea was 
threatened, the patient was rapidly mercurialised. On the 
ninth day, nitrate of silver was used with manifest advantage, 
but was left off" on account of the cornea, on which a deep 
spreading ulcer had formed. It was determined to form a 
fistula through the ulcer, and for this purpose an emetic was 
given to rupture the cornea. It had the desired effect. The 
cornea was afterwards cauterised. An adherent leucoma re- 
sulted, and in consequence of this, secondary glaucoma developed, 
rendering iridectomy necessary. Finally the patient could read 
No. iv Sn., and count fingers at 9'. In reference to the develop- 
ment of glaucoma, in consequence of adherent leucoma, a case 
is mentioned in which a deep glaucomatous cup rapidly de- 
veloped in a young woman from this cause. (" Archives of 
Ophthal. and Otol.," vol. iv, No. 2.) 

GRANULAR AND CONTAGIOUS OPHTHALMIA. 

Mr. Nettleship thinks there are some points in relation to tlie 
diseases commonly known as contagious ophthalmia about 
which there is still a certain amount of misapprehension. The 
importance of the subject is apt to be overrated by some and 
underrated by others according to the sense in which the 
word is used, and the view taken as to the probability of bad 
results occurring in mild cases. The degree of contagiousness, 
the amount and kind of injury caused by the ophthalmia 
in large schools, &c., at the present day, and some points 
in the details of treatment and prevention, form the subjects to 
which most attention is directed, the writer having lateh^ had 
special opportunities for studying the malady on a large scale in 
connexion with the Anerley (Poor-law) School. The two main 
elements of the mixed condition known as ophthalmia in such 
establishments, are treated separately at considerable length, 
viz. : granular disease of the conjunctiva, or trachoma, and 
the various forms of conjunctivitis. The chief stages of the 
granular disease are described, and scarring of the conjunctiva is 
stated to be the natural result of spontaneous cure in severe 



358 PERISCOPE : — OPHTHALMIA. 

cases. Symptoms are often almost absent even in tolerably bad 
cases ; there is no fixed relation between the degree of change 
in the lids and the subjective symptoms in different cases, 
though this relation is as a rule constant in each patient. The 
author thinks that permanent inconvenience or damage to sight 
from the results of the disease (corneal opacities, entropion, &c.,) 
occur less often than would be supposed if our attention 
were confined to the worst cases, such as apply at the 
ophthalmic hospitals ; and a table of 2i cases is given in 
support of this view. The prognosis in granular disease is 
difficult if we see the patient only once ; attention is directed to 
the main points by which we should be guided in making it. 
In discussing the causes of the gi^anular disease the writer goes 
in some detail into its history, especially in respect to its alleged 
introduction into Europe from Egypt ; he considers that it 
existed in Europe long before the Egyptian campaign, and that 
it is not either infections or contagious. A resume of several 
different views on this subject is given, and the author comes 
to the same conclusion as already arrived at by Welch, in 
thinking that the disease is caused hj prolonged exposure to the 
action of warm, moist air, made impure by animal matter (not 
organised particles), and he regards it as impossible to prevent 
mild degrees of the disease from being" common in crowded, damp 
countries. The results of some inspections of children in various 
parts of the country are given in this connexion. The disease is 
slowly produced and varies in degree, ccet. par.^ with the length of 
exposure to its causes ; ivi time it becomes partly hereditary, as 
is seen in the Irish and some other races. Under contagious 
ophthalmia are included all forms of conjunctivitis, producing 
muco-purulent or purulent discharge, attention being drawn to 
some of the chief varieties, and to the vagueness with which 
the term " catarrhal ophthalmia " is often used. Some account 
is next given of the chief vaiueties of mixed ophthalmic disease, 
which the author found it convenient to distinguish in pi'actice 
among the cases (about 400) of which he had charge in con- 
nection with the Anerley School, six groups being distinguished. 
In discussing the causes of the various forms and degrees of 
contagious ophthalmia, particular attention is called to the fact 
that every case of contagious ophthalmia is not the result of 
contagion ; conjunctivitis of every possible degree may be pro- 
duced by other causes than contagion ; he disbelieves in the 
spread of purulent ophthalmia by aerial infection, except when 
many cases of the disease are crowded together ; nor does he 
think it at all probable that clothes, &c., which hang in the 
wards act as air-filters arresting the contagious particles which, 
according to some authors, are abundantly given off from the in- 
flamed conjunctiva into the air, and thus becoming potent sources 
of contagion. The disease cannot be compared in this respect 



OPHTHALMIA.. 359 

with ringworm, in which the contagium is dry and almost 
powdery. The writer has come to the conclusion, from ob- 
serving the children under his own care, that, as a matter of 
fact, a good many cases of the mild muco-purulent ophthalmia of 
schools are not due to contagion, but to other causes, especially 
cold wind, dust, and measles, acting on children whose eyelids 
were predisposed to inflammation by a previously existing 
granular condition. Each of the chief causes of conjunctivitis 
is discussed in some detail. The severe ophthalmia which 
ravaged the British Army early in the century was probably due 
less to direct importation from Egypt than to the epidemic of 
influenza of 1803 acting on Irish soldiers with unhealthy lids, 
the army having been increased in size and the barrack system 
recently introduced. 

Under the heading of local treatment we find remarks on the 
selection of cases requiring it, the effects to be expected, and 
the length of time that it must be kept up, together with a 
consideration of the relative usefulness of weak and strong 
remedies and of the best methods of application, stress being 
laid on the necessity of applying the remedy thoroughly to the 
oculo-palpebral fold of the upper lid, above the tarsus. Many 
careful trials were made with powdered acetate of lead, and the 
writer concludes that whilst it does no good, it is often injurious 
by rendering the granulations harder and thus setting up 
corneal ulceration, and he thinks that its use for this purpose 
should be given up. Some suggestions are given for the general 
management of schools, &c., in respect to the disease, and the 
practical points of the paper summed up in some short con- 
clusions. A list of authors is given. ("Brit, and Foreign 
Med. Chir. Review," Oct., 1874, and Jan., 1875, pp. 74.) 

OPHTHALMIA IN THE METROPOLITAN PAUPER SCHOOLS. 

A Report on this subject, made by Mr. N'ettleship in the autumn 
of 1874, to the Local Government Board, has been printed 
(pp. 1 L8, with Appendix) . It is based on an inspection of the eyes 
of every child in the 17 Metropolitan Pauper Schools, together 
with such facts in the construction, administration, degree of 
crowding, &c., in each school, as time allowed him to collect. 
The total number of children inspected was 8,798, of whom 
20 per cent, were found to have healthy, or practically healthy, 
eyelids ; 35 per cent, eyes predisposed to ophthalmia by the 
existence of more or less granular lids ; 15 per cent, with active 
ophthalmia of some kind or degree; and 30 per cent, with bad 
granular lids, but without present symptoms. 9 per cent, of all 
the children showed some damage to one or both corner, esti- 
mated as directly or indirectly due to ophthalmia ; many of these 
were however extremely slight. 



oGO PERISCOPE : — BLEPHAROPLASTY. 

The subject is treated from the practical and administrative 
aspects mainly, for the purpose of ascertaining — 1st. The actual 
state of the schools separately and en masse in respect to the 
varieties of affection which are commonly grouped together 
as " ophthalmia ; " 2nd. The relation borne by the '' ophthalmic 
state " of the children to the conditions of their life in the 
schools, to age and sex, and to conditions independent of school- 
life, respectively ; ord. How best to remedy the present state 
of things ; for although there is less ophthalmia in these schools 
than there used to be, their condition as to this disease is still 
admitted to be very unsatisfactory. The last statement is 
abundantly supported by details of various kinds, and by the 
fact that nearly two-thirds of the 945 children who were on the 
sick lists when the inspection was made were under care for 
ophthalmia ; while for reasons which are explained this pro- 
portion does not represent all, or nearly all, who ought to be 
isolated and under treatment. 

The importance of local epidemics of measles in originating 
severe outbreaks of ophthalmia is well illustrated by the schools 
at Sutton, Hanwell and Leytonstone, and the facts recorded in 
this connexion confirm the opinion expressed on the same subject 
at p. 56 of the article in the " Med. Chir. Review." The method 
of inspection and some other technical details, together with 
various tabulated statements, &c., are placed in an Appendix. 
This Report probably contains the most complete and uniform 
information on the state of these schools, in respect to oph- 
thalmia, that has yet been collected. 



TRANSPLANTATION IN STMBLEPHAEON, &C. 

Dr. Wecker describes his plan of performing conjunctival trans- 
plantation from the rabbit in cases of symblepharon, &c. He 
objects to Dr. Wolff's process. — ("Annales d'Oculistique," 
Mars, Avril, 1874, p. 127. In the number for Nov., Dec, 
p. 219, is a translation of an article by Prof . Otto Becker on the 
same subject. In the number for Jan., Fev., 1875, p. 28, is an 
article by Prof Raymond. — (" Annali di Ottalmologia.") In the 
number for Mars, Avril, 1875, are some remarks on Dr. Wecker's 
latest experience in dermic grafting and transplantation from 
the rabbit. In " Zehend. Klin. Monat.," xiii, Jan., Feb., Marz, 
p. 75, is an abstract of a paper by Otto Becker, in which he 
narrates two cases of transplantation of conjunctiva from the 
rabbit. 



BLEPHAROPLASTY. 

Dr. Jul. v. Siklosy details successful cases of blepharoplastic 



DISLOCATION OF LENS. 3C)1 

operations, and gives illustrations. — (" Zehend. Klin. Monat.," 
xii, Jnni, Juli, p. 228.) 

FOREIGN BODY IX THE ANTERIOR CHAMBER FOR FIVE YEARS. NO 

SYMPATHETIC MISCHIEF. 

Dr. Sayary records the case of a woman, aged 58, who came 
nnder care for pain, &c., in the left eye. Five years previously 
the eye had been struck by a piece of stone ; great pain followed, 
but this passed away after a time, till shortly- before she came 
under care. A whitish mass could be seen in the anterior 
chamber, and was suspected to be a foreign body covered with 
lymph. The sight was lost. The foreign body was i-emoved 
with some trouble, and a piece of iris snipped off. The pain 
was quite relieved. — (" Annales d'Ocnlistique," Juillet, Aoiit, 
1874, p. 17.) 

SDB-CONJUNCTIYAL DISLOCATION OF THE LENS. 

Dr. Andre records the case of a woman, aged Q7, who came 
under his care. He found the right lens dislocated upwards 
beneath the conjunctiva. The pupil was of the shape of a 
battledore. The patient had received no injury. Ophthalmo- 
scopic examination showed a glaucomatous cupping of the disc. 
The patient had not felt any particular pain, and the date of the 
displacement was not known. In the other eye there was a 
large prolapse of the iris upwards, and the lens was partially 
displaced and opaque. The displacement in each was considered 
to depend on glaucomatous tension. When seen, the tension of 
the globes was normal. — (" Annales d'Ocnlistique," Sep., Oct., 
1874, p. 111.) 

SI-ONTANEOUS SUB-CONJUNCTIVAL DISLOCATION OF THE LENS. 

Dr. "W. Zehender ("Klin. Monat.," siii, Jan., Feb., Mjirz, 
p. 84) narrates a case in which the left lens was displaced 
beneath the conjunctiva between the superior and inferior recti 
muscles. The patient, aged 58, did not know of any accident, 
nor when the displacement occurred. The conjunctiva was 
incised and the lens removed. No ill result followed. 

PARTIAL SUB-CGNJUNCTIYAL DISLOCATION OF THE LENS. 

Dp. J. Lederle records the ca.se of a man, aged 56, who received 
a blow on the eye a month before he came under care. The lens 
of the injured eye was found to be partially displaced upwards 
and outwards nnder the conjunctiva. Vision only amounted to 
quantitative perception of light. The lens was removed through 
the conjunctiva, as there were symptoms of irritation. The 



362 PERISCOPE: — EXTRACTION OF CATARACT. 

latter subsided, but no improvement resulted as regards the 
sigbt. — ("Zebend. Klin. Monat.," xiii, Jan., Feb., Marz, p. 
30.) 

SPONTANEOUS DISLOCATION OF THE LENS AND ITS CONSEQUENCES. 

Dr. Fritz Raab quotes tbe literature of tbe subject ; sums up to 
tbe effect that the greatest number of cases are congenital ; some 
depend on chronic choroidal inflammation ; some on senile pro- 
cesses in the lenticular system; and others on various processes, 
such as buphthalmos, staphyloma, &c. He narrates a case of dis- 
location of the lenses in which glaucomatous symptoms came on 
in one eye. The lens in this eye was dislocated into the anterior 
chamber. It was transparent. It was removed, but no useful 
vision was regained. The dislocation in the other eye was 
upwards and inwards. A detailed description is given of the 
naked eye and microscopic appearances of an eyeball (sent to 
him), showing tlie lens dis-placecl foncards and adherent to the 
cornea. A representation of a section of the hardened eyeball is 
given. (Graefe's "Archiv.," Bd. xxi, Abth. i, pp. 190—222. 

NEW OPERATION FOR CATARACT. EXTRACTION BY PERIPHERAL FI-AP. 

Dr. Wecker describes a new method of extraction of cataract. 
An operation for extraction of cataract should fulfil the follow- 
ing conditions :—l. The section should be in the part best 
adapted for coaptation and cicatrisation ; therefore, at the sclero- 
corneal junction. 2. Tt should allow of easy removal of the lens 
without having recourse to enlargement of the pupil. 3. 
Strangulation and prolapse of iris to which peripheral sections 
predispose ought to be avoided as much as possible. 4. Advan- 
tages to a few cases should not be attained at the price of dis- 
advantage of a considerable number. The operation he proposes 
is performed thus : — 1st step. An assistant raises the upper 
eyelid with his finger, or a small speculum with which he holds 
the eyelids away from the globe. The operator having fixed the 
eye with forceps near the middle of the inner border of the 
cornea, detaches very exactly the upper third of the cornea at 
its junction with the sclerotic. (If the cornea has a diameter of 
12 mm. ('48"), a flap is formed 4 mm. ('16") in height, and 
11'32 mm. (•4528") across at the base.) When the counter 
puncture is made, and the iris does not lie over the edge of the 
knife, the operator lays aside the fixation forceps and finishes 
the section without forming any conjunctival flap. When the 
section is finished, the upper lids are shut and the speculum 
withdrawn. (The knife which he uses and figures is half the 
width of the old cataract knife, and double that used for the 
linear operation.) 2nd step. The eye is covered with a cold 
sponge, and the patient remains quiet. Then the capsule is 



EXTRACTION OF CATARACT. 363 ' 

opened with an ordinary cystitome, whilst the operator raises 
the upper hd. 3rd step. An assistant takes charge of the npper 
eyelid, and the operator, whilst pressing the lens (through the 
lower eyelid) towards the opening made, depresses the peripheral 
insertion of the iris by means of a fine caoutchonc spatula 
(figured), so as to free the lens from the iris, which tends to 
envelop it at the moment of exit. 4th step. The pupil is freed 
from cortical substance, &c., by pressure from below upwards 
exercised outside the lower lid. During this process of cleaning 
the pupil little attention is paid to the iris ; but, when the pupil 
is clear, if the iris has not spontaneously assumed its natural 
position, the prolapse must be reduced by passing the little 
spatula between the edges of the wound, and pres.sing the iris 
before it. 5th step. The iris being thoroughly in place, two or 
three drops of a solution of neutral sulphate of eserine (| p. c. 
solution) are instilled, and the operator waits for five minutes 
till the myotic has acted, the pupil contracted, and the iris has 
no longer any tendency to prolapse. The patient is then told to 
look down. (The neutral sulphate of eserine does not cause any 
irritation. It should be a freshly-prepared solution.) The 
bandage is then applied. It is prudent to remove the bandage 
one or two hours after the operation, and instil some more 
eserine, if the former application does not seem to have taken 
.sufficient effect. Considerable contraction of the pupil is pro- 
duced, which lasts more than twenty-four hours, during which 
time the wound will have united, and recourse can then be 
had, if necessary, to mydriatics without any danger of prolapse 
of iris. — (" Annales d'Oculistique," Mai, Juin, 1875, p. 264.) 

Extraction of Cataract. — A translation of Jaeger's pamphlet, 
with illustrations, on his new method of extracting cataract by 
" a concave section," is given in the " Annales d'Oculistique," 
Jan., Fev., 1874, p. 56. 

Extraction of Cataract. — Dr. Classen passes in review the 
different methods now in use for extraction of cataract, and 
sums up in favour of Weber's operation. — (Graefe's "Archiv." 
Bd. XX, 2 Abth., p. 123.) 

Extraction of Cataract. — Dr. Masselon notes two modifica- 
tions introduced by Dr. Wecker into his method of performing 
Graefe's operation. The iris is divided by the scissors which he 
uses for iridotomy, without drawing it out through the wound, 
as is ordinarily done. The iris by this plan does not get en- 
tangled in the edges of the wound. During the manipulation of 
the lens, the lids are held away from the eye, and the patient is 
thus prevented exerci.sing any pressure on the globe, by an 
assistant, by means of the speculum. This should be small, and 
placed over the nose. (A figure is given.) The loss of vitreous 
has been much less since the adoption of this manoeuvre. 
(" Annales d'Oculistique," Mars, Avril, 1874, p. 113.) 



304 PERISCOPE: — CYSTS OF IRIS. 

SHOHT REPORT ON TWO HUNDRED SCLEROTIC EXTRACTIONS (CATARACT). 

Dr. Scliiess-Gemuseus. He lias already reported a previous 
hundred cases. — (" Graefe's ArcMv.," Bd. xxi, Abth. i, p. 47.) 

AN UNUSUAL CASE OF LAMELLAE CATARACT. 

Dr. H. Beesgen notes a case of lamellar cataract, in a man 40 
years of age, in which the anterior part of the lens was trans- 
parent as well as the nucleus, but around the latter was a 
circular bluish-white layer, and in the posterior part of the 
lens, two shell-like zonular opaque portions symmetrically 
placed in reference to the posterior half of the perinuclear 
layer, but each opacity was separated from the rest by clear 
lens substance. — (" Zehend. Klin. Monat.," xii, Juni, Juli, p. 
263.) 

THE NOURISHMENT OF THE LENS. 

Dr. Zehender communicates to his journal (April, Mai, xiii, 
p. 152), an account of Dr. Bence Jones's experiments on the 
absorption of lithium carbonate by the lens. A solution of the 
salt was given to the patient a certain time before extraction 
of cataract was performed, and the latter afterwards tested. 
Lithium was found in all parts of the cataract, when the salt 
was given three-and-a-half hours before the operation. The 
lens, owing to its isolated position, is the last part of the body 
to receive any substance introduced into the blood. 

CONGENITAL SYMMETRICAL DEFECT OF BOTH LENSES. 

Dr. H. Bre&gen records the case of a lad aged 15. There was 
myopia i in each eye. V. = fg. "With a widely dilated pupil 
there was seen a symmetrical defect in the inferior part of each 
lens. The defect was limited by a dark curved line, the con- 
vexity of which was upwards. The whole thickness of the lens 
was involved. Otherwise the lenses were normal in situation and 
continuity. The iris Avas not at all tremulous. The entire pupil 
appeared red by transmitted light, but interrupted by a dark 
curved line. ("Archives of Ophth. and Otol.," vol. iv. No. 2.) 
See also Hirschberg, further, on Coloboma. 

SEROUS CYSTS OF THE IRIS. 

Dr. Fr. Hosch gives an account of a case with a careful micro- 
scopic examination, and an illustration. The cyst was in the 
iris, and had followed an iniury. — (" Zehend. Klin. Monat.," xii, 
April, Mai, p. 119—27.) 

At pp. 128 — 151 of the same number. Dr. Hubert Sattler 
treats of the same subject, and narrates three cases which were 



IRIS — CYSTS — IRIDOTOMY. 365 

under the care of Prof. Arlt. In each there had been a slight 
wound ; there was a scar at the sclero-corneal junction, the cystic 
formation occurred long after the injury, and, in each, symptoms 
of iri-itation came on in consequence of increase in size in the cyst. 
The operative treatment, in the first case, consisted of an incision 
at the sclero-corneal junction opening the cyst, the wall of which 
was then drawn out with forceps and cut off with scissors. A 
good deal of inflammation followed, and two iridectomies were 
necessary. The cyst did not recur. In the second and third 
eases, incision in the selero-corneal junction, withdrawal of the 
cyst, and snipping it off, succeeded well. The author treats at 
length of the nature and origin of the cysts. He sums up to the 
effect that the following points are of special importance: — (1) 
The previous occurrence of a wound of the eye which may be of a 
very trifling character. (2) The peripheral position of the (often) 
inconspicuous scar. (3) The well-established fact that portions 
of tissue may be carried in from the front to the iris by the pene- 
trating foreign body. Eyelashes, for instance, have been carried 
in. He thinks the iris- cysts would most properly come under 
the class of cystic tumours, known as exudation- cysts. As to 
treatment, he thinks Prof. Arlt's.plan satisfactory ; no coloboma 
is left, and the scar is not increased. It is quite sufficient to 
remove the anterior and lateral portions of the cyst. 

SYPHILITIC IRITIS. 

Dr. Deognat-Landee reports the statistics of a number of cases 
of syphilitic iritis, in the " Annales d'Oculistique," Mai, Juin, 
1875, p. 250—264. 

CONGENITAL ABSENCE OF IRIS — INHERITED. 

Manz, of Freiburg, records the case of a boy, aged 6, who had no 
iris in either eye. The right was afiected with symptoms of 
cyclitis, &c., and cataract. An attempt to remove the cataract 
led to loss of vitreous and shrinking of the globe. Manz had 
operated on the father for cataract. He also had no iris in either 
eye, and the operation failed. The cases support previous 
experience in leading operators to be cautious in dealing with 
eyes affected with congenital malformations. — (" Zehend. Klin. 
Monat.," xiii, Jan., Feb., Miirz, p. 35.) 

IRIDOTOMY. 

Dr. L. Grorsmann carried out the principle of Wecker's opera- 
tion successfully, in one case, with a small lance- shaped knife 
and a pair of Une, straight scissors. He afterwards obtained 
Wecker's instruments, and operated successfully in a second 
VOL. VIII. 2 B 



366 PERISCOPE : — MYOSIS. 

case. In a third case he was disappointed, owing to the leather- 
like condition of the false membrane present. In a fourth, he 
was again successful. — ("Zehend. Klin. Monat.," xiii, April, p. 
101—8.) 

In the "Annales" for Mars, Avril, 1875, Dr. Masselon 
records a case of congenital dislocation of the lenses, in which 
iridotomy was successfully performed by Dr. Wecker. A figure, 
showing the result, is given. When looking through the lens, 
the patient was myopic |-, and the acuity of vision was only \ 
with — 3| ; when looking by the side of the lens, the patient was 
hypermetropic V, and the acuity of vision was ^ with + 2|. 

Dr. Wecker, during 1873, performed 39 iridotomies, 22 of 
them being in cases of secondary capsular cataract with oblitera- 
tion of pupil, and 17 "simple," that is, mere incision of ii'is. 
(See last Periscope, p. 122). Iridotomy may replace iridectomy 
where it is necessary, at the same time, to perform needle opera- 
tions on the lens. A case is narrated. The case is also narrated 
of an old woman who had been operated on for glaucoma 
(iridectomy followed by extraction of cataract). The pupil had 
closed. Iridotomy was performed with an excellent result. (A 
figure is given). — ("Annales d'Oculistique," Mars, Avini, 1874, 
p. 115, &c.) 

Kriiger, having found Wecker's plan inefficient in cases 
where the membrane is very dense and the iris will not retract, 
has had an instrument constructed which consists of two small 
sharp spoons, which are made to meet and cut out a piece of the 
membrane. The piec^ is brought away when the instrument is 
withdrawn. The action of the instrument, therefore, somewhat 
resembles that of the punch used by railway-guards to mark the 
tickets. — (" Zehend. Klin. Monat.," Oct., Nov., Dec, 1874, p. 
429.) 

MYOSIS CAUSED BY PARALYSIS OF THE LEFT CERVICAL SYMPATHETIC 
. IN CONSEQUENCE OF A GUN-SHOT WOUND. 

The symptoms did not come on for more than two years after 
the injury, and began as neuralgia of the arm, on the injured 
side. The left pupil was very small and immoveable. V. = -^-^^ ; 
with — 18 = 1^-. At three inches he could read the smallest 
print. Atropine dilated the pupil. The treatment consisted in 
the instillation of atropine, rubbing in mercurial ointment to the 
scar, and the application of leeches. Some relief was experienced. 
— ("Archives of Ophth. and Otol.," vol. iv, No. 2.) 

A SMALL PIECE OF STEEL PENETRATING THROUGH THE CORNEA AND 
PUPIL INTO THE LENS SUCCESSFULLY REMOVED BY THE EXTRAC- 
TION OF THE CATARACTOUS LENS FIVE MONTHS LATER. 

Dr. Barkan records the case. — ("Archives of Ophth. and Otol.," 
vol. iv. No. 2.) 



SYMPATHETIC OPHTHALMIA. 367 



EPITHELIAL CANCER OF THE CONJUNCTIVA. 

The patient, a man aged 70, was under the care of Dr. Cliapman. 
Dr. H. Knapp gives the details of the microscopic examination. 
The growth originated from injury ; was an instance of primary 
epitheHal cancer of the conjunctiva which is rare ; the exten- 
sion of the neoplasm, by uninterrupted rows of epithelial cells, 
could be demonstrated in the cornea, and the young elementary 
parts in the corneal portion of the tumour had the characteristics 
of the original pseudoplasm. — ("Archives of Ophth. and Otol.," 
vol. iv. No. 2.) 



SYMPATHETIC OPHTHALMIA AFTER EXTRACTION OF CATARACT. 

Dr. Klein (of Vienna) brought two cases under the notice of 
the Ophthalmic Congress at Heidelberg, in 1874. He attributed 
the onset of the afPection to prolapse and strangulation of the 
iris. During the discussion, fourteen other cases of sympathetic 
ophthalmia following operations were noted. Prof. v. Arlt 
mentioned a curious case. A man, aet. 40, had complete glau- 
coma of right eye, and it was commencing in the left. Iridectomy 
was done in the latter, but could not be done on the right. He 
had good sight for two or three years. The right eye became 
painful and enucleation was refused. Six or eight weeks later 
the left eve was attacked with sympathetic ophthalmia. — 
(" Zehend. "Klin. Monat.," xii, Oct., Nov., Dec, p. 334—344.) 



SYMPATHETIC OPHTHALMIA THREE WEEKS AFTER A WOUND FOREIGN 

BODY LODGED IN THE SCLEROTIC NEAR THE DISC TURNING GRAY 

OF THE EYELASHES ON THE SAME SIDE. 

Dr. Jos. Jacobi records the case of a man, aged 29, whose eye 
was wounded on October 22nd, by a piece of metal. The next 
day, as the lens had become cataractous, it was removed with a 
free iridectomy. No foreign body was discovered. On October 
27th, well-marked sympathetic ophthalmia was present in the 
other eye, so that it must have developed within twenty-five 
days. He had been recommended excision ten days or so before, 
but had simply been frightened away. Enucleation did not 
check the progress of the sympathetic ophthalmia. Some 
months later, the eyelashes on the eye sympathetically affected 
were noticed to have turned white (suddenly, as is supposed). 
Examination of the eyeball, removed, showed that a foreign 
body had traversed the eyeball, pierced the retina and choroid 
behind, and lodged in the sclerotic near the disc, which showed 
partial atrophy ; there were no signs of neuritis. — (" Zehend. 
Kdin. Monat.," xii, April, Mai, p. 163 — 61.) 

2 B 2 



368 PERISCOPE : — EJilBOLISM 



SYMPATHETIC OPHTHALMU. 



De. Schmidt records two cases following injury. In the first, 
enucleation was practised twenty-four days after the accident, 
on account of pain. Four days later, symptoms of sympathetic 
iritis, &c., appeared in the other eye, and developed to a severe 
degree. Mercury was given internally ; atropine used. At the 
end of six weeks from the onset of the sympathetic mischief, the 
patient was discharged, with perfect vision, and no synecliia?. 
A detailed microscopic examination was made, and is recorded. 
An eyelash had been seen in the anterior chamber before removal, 
and was now found to be imbedded in the lens. In the second 
case, the symjmthetic mischief appeared in the form of circum- 
scribed opacities in the vitreous, without a trace of iritis. Enu- 
cleation was not practised till after the sympathetic aflection had 
become M^ell established. After the use of atropine, rest, and 
leeches, the vitreous cleared, and vision became quite good. — 
("Zehend. Klin. Monat.," xii, April, Mai, p. 177.) 

A CASE OF EMBOLISM OJ" THE ARTERIA CENTRALIS RETINJ). 

By Prof. Herm. Schmidt, of Marburg. 

The patient was a man, aged 58, who came under care on 
account of incomplete left hemiplegia. This was probably due 
to embolism, as a complicated aS'ection of the heart was dis- 
covered. During the r.'plit between 23rd and 24th July (while 
in hospital), the left eye suddenly became blind. He was on the 
night-stool at the time. On examination the next morning, the eye 
was found to be quite blind. In the evening, the eye presented 
a normal appearance externally, and the media were quite trans- 
parent. The optic disc was fairly defined, and of a normal 
colour. The arteries on it seemed quite empty, and were 
scarcely distinguishable. They could, however, be followed for 
some little distance beyond the disc. On pressure, no pulsation 
could be excited. The veins were of a dark colour, and fair 
size. There was a remarkable absence of the fine curves usunsUy 
met with. The column of blood was interrupted here and there. 
The region of the macula lutea and the part between it and the 
disc was of a slightly gray colour and opaque, and the yellow 
spot itself could not be distinguished (as is usually the case in 
the inverted image) as an (transversely) oval brownish-red spot, 
of a deeper colour than the rest of the fundus. At one pai-t, cor- 
responding to the lower border of the macula, was a broadish, 
dark red, horizontal line, about the length of a half diameter of 
the disc. The other eye was quite normal. On the following 
morning, there was slight chemosis, which increased greatly 
during the day; the globe became prominent and tense; the 



OF ARTERIA CEXTRALIS. o69 

eyelids, &c., somewhat oedematous ; the iris slightly discoloured, 
the pupil scai'cely dilating under the. influence of atropine ; the 
vitreous slightly hazy ; the disc ill-defined, congested, hazy ; 
the veins appearing as dai^k streaks, with interruptions here and 
there ; the arteries exceedingly small, but possibly fuller than 
the day before. The retinal haze had increased, and the dark 
red spot in the neighbourhood of the macula lutea had disappeared. 
During the next few days, the appearances of retinitis increased, 
but there was no swelling of the disc, nor opacities in the 
vitreous. On the ninth day ( August. 1) the other symptoms 
seemed diminishing, but the vitreous had become very opaque ; 
six days later there was still exophthalmos, moderate cheniosis, 
and congestion of the conjunctiva ; the pupil dilated but slightly. 
The vitreous was more transparent, and distinct opacities were 
perceptible. The situation of the optic disc could be made out 
by the convergence of the vessels, but its margins were lost in 
the surrounding retina. From that time the sj^mptoms of irido- 
choroiditis gradually diminished. On November 26th, the eye 
externally appeared normal, except that the pupil was small and 
adherent. Ophthalmoscopically, the vitreous had recovered its 
transparency, the retina and disc showed signs of advanced 
atrophy. There were a few apoplexies and pigment spots 
There was no quantitative perception of light. The patient 
died on May 27th, 1872. There was the remains of an embolic 
patch in the right hemisphere. The left optic nerve seemed 
rather thinner than the right; there were changes in the 
medulla, and the heart was diseased. The left globe, nerve, 
ophthalmic artery, &c., were removed and hardened The 
ophthalmic artery and its chief branches were empty, save here 
and there a little blood- clot. At the seat of origin of the 
central artery was some blood-clot, and some of the smaller 
vessels arising near here were completely plugged. The canal of 
the arteria centralis was patent as far as the optic nerve sheath, 
bat there were a few blood corpuscles attached to the wall here 
and there. It passed through the sheath at a distance of ten 
mm. ('4") from the globe. Nearer the globe the nerve fibres 
w'^ere much atrophied. Soon after piercing the nerve sheath, 
the artery, and a branch given ofi" and running parallel -with it, 
Avas plugged. The artery seemed diminished in size. The 
intima forming the margins of its canal on section, appeared 
thrown into folds (undulating). In the interior was a yellowish, 
and for the most pai't hyal-ine, mass, completely filling the 
vessel, and split up into different parts. Though for the most 
part homogeneous, there were some cell-like bodies at the peri- 
phery, a few of which resembled white blood corpuscles, whilst 
others were larger and contained granules and nuclei. At one 
part there was a section of a vessel containing blood corpuscles. 
Sections in other parts showed small arterial branches also filled 



370 PERISCOPE : — EMBOLISM, 

with clot. The vein was collapsed and partly filled Wth clot. 
Sections of the disc showed atrophy and arteries filled with the 
yellowish hyaline thrombus. In the meshes of the connective 
tissue forming the optic nerve sheath near the sclerotic wei*e 
some psammomata. Considerable changes were found in the 
central parts of the retina and choroid ; whilst the peripheral 
changes were slight. 

The author remarks that the ophthalmoscopic appearances in 
this case resembled those met with in other, cases recorded and 
alluded to, more especially the haziness noticed between the disc 
and macula within twenty hours. The microscopic examination 
unfortunately threw no light on the cause of the red spot or 
streak in the neighbourhood of the yellow spot. To judge by 
its shape and situation, he should incline to the opinion that it 
was an extravasation rather than the effect simply of conti-ast. 
It was situated at the margin, not in the centre, of the macula. 
As early as the second day, it had disappeared, owing to in- 
creasing opacity of the retina ; it was probably situated in the 
deeper layers of the retina or in the choroid. The case is 
peculiar, however, in the probable association of ciliary embolisms 
(as shown by irido-choroiditis), with embolism of the arteria 
centi'alis. He argues that the mass found in the arteria cen- 
tralis was chiefly an embolus, but that this did not wholly fill 
the vessel ; and at one part of the section there was evidently a 
vascular thrombus which had developed out of a blood-clot, and 
completed the plugging. There was also a distinctly circum- 
scribed embolus in a small :^etinal artery. The anthor discusses 
the question of the establishment of the collateral circulation in 
different cases. The presence of the vessel he mentions as run- 
ning parallel to the course of the arteria centralis retina, its 
relation to the embolus in the central artery, or its independent 
plugging (as in the present case), have an important bearing on 
the collateral circulation. As this lateral branch is often found, 
it is fair to suppose that, in cases where the collateral circulation 
becomes quickly established, the embolus is situated beyond the 
origin of this branch, which is therefore available to carry on 
the circulation. — (Grraefe's " Archiv." xxiii, pp. 287 — 307, with 
plate.) 

EMBOLISM OF THE AETERTA CENTRALIS RETINA, OR HAEMORRHAGE 
WITHIN THE OPTIC NERVE. 

Dr. Zehender records a case which presented some of the 
typical symptoms generally referred to embolism of the arteria 
centralis retinse. A patient with heart disease was seized with 
sudden blindness of the right eye. Ophthalmoscopically were 
the signs so well depicted by Liebreich in his Atlas. There was 
one symptom present, however, which, in Dr. Zehender's opinion. 



OR H.EMORRHxVGE WITHIN OPTIC NERVE. o71 

completely set aside the diagnosis of embolism of the central 
artery ; tliere was well onarked venotis pulsation. About twelve 
days from the commencement, two small extravasations appeared, 
and soon vanished again. The venous pulse gradually dis- 
appeared. When last seen, the signs were exactly those of past 
emboHsm. — ("Zehend. Klin. Monat.," xii, Aug., Sep., p. 310.) 

In the same n amber, p. 314, is an abstract of an inaugural 
dissertation by Heinrich Meyhofer, on embolism of the artei-ia 
centralis retinte. He narrates a case of sudden blindness of the 
right eye in which an early ophthalmoscopic examination re- 
vealed small arteries, interrupted blood currents and venous 
pulsation. The latter vanished away within a fortnight. The 
heart was diseased. 

At p. 319 is an abstract of a treatise (illustrated) by Dr. 
Hugo Magnus, on hgemorrhage into the optic nerve (" Die 
Sehnervenblutungen mit zwei nach der Natur entworfenen 
Abbildungen," Leipzig, 1874). The author deals with the 
literature of the subject of evtravasation into the optic nerve or 
within its sheath, and says the symptoms are so like those of 
embolism of the arteria centralis, that it is very difficult to draw 
the distinction. One most important point of distinction is the 
early appearance of a grayish-white retinal haze around the 
macula. This indicates some affection of the nerve trunk. In 
embolism, this gray patch would appear much later, and is 
accompanied by a peculiar red spot at the macula ; the arteries 
and the veins must be quite empty. If the artery is merely 
plugged, the venous blood can easily escape ; if the artery is 
ruptured, and extravasation of blood has occurred, not only is 
the entrance of blood interfered with, but also the outflow is 
obstructed, and the venous trunks will be over full. Another 
symptom of distinction would be furnished if the peripheral 
portion of the field remains sensitive. This would contra- 
indicate embolism. The author has carried out numerous 
experiments on animals to elucidate the subject. By the in- 
jection of small quantities of blood into the nerve trunk, he 
could produce transitory changes. He was tempted to explain 
many cases of transitory amblyopia and amaurosis by slight 
extravasations into the optic nerve. By larger injections, 
marked changes in the circulation were produced. In six hours 
retinal haze appeared. This generally was situated in the inner- 
most layers of the retina. The macula had the appearance of a 
dark red spot. 

REMARKS ON EMBOLISM. 

LORING records five cases, agreeing in general symptoms and 
course with cases ordinarily diagnosed as embolism. They are 
published chiefly because, in their further development, pheno- 



372 PERISCOPE : — EMBOLISM, 

mena occurred which, in the anthor's judgment, threw some 
doubt on the correctness of the original diagnosis, a doubt 
which he is inclined to think may also be allowed to include 
some similar cases observed by others. The paper is illustrated 
by five -wood-cuts of the ophthalmoscopic appearances. 

Case I is considered by the author to tit better with the 
occurrence of thrombosis than of embolism. The eye was 
excised and no plug found in the arterla centralis, but there 
were thrombi in some choroidal veins. 

In Case II, the patient had experienced very numerous 
sudden temporary losses of sight in one eye dui-iug twenty-five 
years ; and finally a similar attack occurred which was per- 
manent and accompanied by extreme oedema and milkiness of 
retina, followed by slow shrinking of the vessels. He inclines 
to explain the case by an unsound condition of the retinal 
vessels in conjunction with disturbances of circulation due to 
heart disease. 

Case III reads like embolism, but the author inclines to the 
hypothesis of stasis from other causes. He describes and figures 
a vessel of some size as running " through the red spot at the 
macula." 

Case IV is an unusual one, in which a relapse occurred, 
followed by some improvement. 

Case V is also quite unusual, both as to the degree of 
recovery which took place, and in the occurrence of a relapse. 

The comments on the cases are well worth careful study. — 
(" Amer. Jour. Med. SJ.," April, 1874, pp. 313—328.) 

EMBOLISM OF THE CENTRAL ARTERY OF THE RETINA OR ITS 
BRANCHES. 

Dr. Landesberg records four cases — two of the central artery ; 
one of the lower branch in the right eye, the left being blind 
from old embolic disease ; and one of a small branch with 
haemorrhage in the retina. — ("Archives of Ophth. and OtoL," 
vol. iv. No. 1.) 

A CASE OF HEMORRHAGE WITHIN THE OPTIC NERVE, 

Dr. Leopold Weiss records the following : A man, £et. 54, 
came under Professor Nagel's care twelve days after sudden loss 
of sight in the right eye. He noticed a cloud before the eye 
while sitting in a chair and looking at the sky. The cloud in a 
few hours (six) became almost complete darkness. When exa- 
mined, he could still recognize movements of the hand quite 
close to the eye. Ophthalmoscopic examination showed opacities 
in the vitreous ; the disc obscured, with a large extravasation in 
its centre ; numerous extravasations in various parts of the 



OR H.-EMORRHAGS WITHIN OPTIC NERVE. 373 

fundus. The central veins very small near the disc, much 
larger at a distance ; two bright red arteries, the one going 
upwards, and its branches were mere white lines. There were 
numerous hgemorrhages in the yellow spot region, but no special 
haze could be detected. There was no cardiac mischief. The 
arteries were rigid, and there was the history that he had often 
suffered from bleeding at the nose. 

The author summarises to the effect that as the patient was old 
and had suffered in youth from cerebral congestion and fi'equent 
bleedings at the nose ; as his arteries were rigid and the heart 
suspected, it was probable that a hiemorrhage had occurred, and 
in the coui'se of the right optic nerve, having such a position as 
to affect the fibres passing to the centre of the retina, and 
gradually enlarging ; ultimately those going to the periphery, 
the clot having attained a certain size, would of course compress 
the central vessels. The thin- walled veins would be more easily 
compressed than the arteries, and for a time there would be 
distension of the distal veins giving rise to the hgemorrhages 
scattered over the retina, possibly also to the extravasation on 
the disc, though this may have been connected with a larger one 
in the nerve. Finally, the compression would become so great 
as to prevent entrance of arterial blood. This would account 
for the ophthalmoscopic appearances. The white appearance of 
the arteries would be produced by a change in the vascular 
wall, probably a perivasculitis. 

The one difficulty consists in the localisation of the clot so as 
to compress the fibres going to the centre of the retina. Where 
are these situated in the trunk of the nerve ? Liebreich con- 
siders they are on the outside. Magnus holds the contrary. 
Leber, on anatomical grounds, supports the former view. Schon 
holds that central scotoma depends on compression of the retinal 
vessels, and consequent imperfect supply of blood to the yellow 
spot. When the collateral circulation by the short posterior 
ciliary arteries becomes established, this may be the first part to 
show effusion. Berlin's experiments show the importance of the 
retinal vessels in reference to symptoms evinced by the yellow 
spot region. 

The author's reason for thinking that, in this case, the retinal 
vessels had little to do with the loss of sight, and that certain 
nerve fibres were compressed, was, that his patient could still see 
for six hours in the peripheral portion of the field, whilst the 
centre was whoUy obscured. This supposition, however, does 
not by any means exclude the idea that a disturbance of the cir- 
culation also occurred. The author is unable to decide the 
locality of the extravasation, because the course of the nerve 
fibres is not yet decided. Michel has just published the observa- 
tion, that the fibres going to the region of the macula may have 
a, peculiar arrangement, viz., that fibres go to the outer side of 



374 PERISCOPE: — HEAHOPIA 

the yellow spot, not only from the outer, but also from the inner 
talf of the disc. His observations only refer to the disc and 
retina ; but as the fibres in the nerve trunk are generally sup- 
posed to have a straight course, what applies to the disc will 
also apply to the nerve truuk. — ("Zehend. Klin. Monat.," xiii, 
April, pp. 114—123.) 

HEMIOPIA IN CEREBEAL AFFECTIONS. 

Dr. Hermann Cohn details five cases, givmg very careful 
diagrams of the field of vision. In all, the line of demarcation 
was not a straight line, but d.ecidedly irregular ; it did not pass 
through the "blind spot; " there were always considerable peri- 
pheral defects in the half of the field which was not affected. 
This has been noticed in other cases. In four of the cases the 
hemiopia was left-sided, and followed apoplectic attacks. He 
gives a diagram, showing the position of a clot which would 
cause the hemiopia on Miiller's scheme of the decussation, but 
not accounting for the peripheral defect in the right half of the 
field opposite that in the left. To account for this, one would 
have to suppose a second clot affecting the left optic tract. The 
rare cases of nasal hemiopia are also inexphcable on Miiller's 
hypothesis. He prefers Mandelstamm's hypothesis (Graefe's 
" Archiv.," 1873, Bd. xix, Abth. 2), based on the total crossing 
of the fibres, first demonstrated by Biesiadecki. Pressure on 
one side of the chiasma would thus account for the hemiopia 
and for the peripheral defect of the other half of the retina, the 
pressure would only bave to be a little greater. Michel has 
made some experiments, based on a discovery of Biesiadecki, 
showinp- that pressui^e may be exercised on the chiasma owing to' 
distension of the third or latei'al ventricles. In the fifth case, 
tlie hemiopia followed injury, and passed off in about six months ; 
bat differently in the two eyes. The theory of a semi-decus- 
sation will scarcely answer for this case ; whereas Mandel- 
stamm's will answer as in the other cases. The total crossing 
will also explain the cases of " nasal " hemiopia, but still leaves 
some points doubtful. Some authors have recorded cases in 
which the fibres did not cross at all. — (" Zehend. Klin. Monat.," 
xii, Juni, Juli, pp. 203—228.) 

Michel (on the structure of the optic commissure, Graefe's 
" Archiv.," Bd. xix, Abth. 2, pp. 59 — 84), confirms Biesiadecki's 
observations as to the total crossing of the fibres of each tract. 
He has examined the commissure in fishes, amphibia, birds, and 
mammalia. Much the same arrangement exists in man as in 
the lower mammalia. He has never found the fibres of one 
optic nerve bending round to the tract of its own side. They all 
cross to the opposite tract. The commissure in man is made 
VLV} of the fibres of both nerves arranged into a kind of basket- 



IN CEREBRAL AFFECTIONS. 375 

■work, whose meshes form more or less irregular squares. He has 
devoted attention chiefly to the upper surface of the commissure, 
and its relation to a layer of gray matter over it containing a 
recessus or cavity communicating with the third ventricle in the 
middle line and the lateral ventricles at the sides in such a way 
that fluid injected into one lateral ventricle would distend this 
cavity, and so press on the commissure, in a different manner to 
Avhat occurs when the third ventricle is distended. The com- 
munication of this recessus with the lateral ventricles is of great 
importance pathologically, as in this way the front lateral or 
posterior parts of the commissure may be pressed on. If no 
coai'se changes have occurred in the nerve fibres, recovery from 
amblyopic or hemiopic symptoms may follow. In answer to 
the objection that hemiopia is often observed in association with 
one-sided paralysis from apoplexy, whilst, if the nerve fibres 
wholly cross, one would espect blindness of the eye on the same 
side as the paralysis, the author appeals to the uncertainty of our 
knowledge in regard to the origin of the fibres going from the 
brain to the tract, and thinks it possible to give s'atisfactory 
explanation.—^" Zehend. Klin. Monat.," xii, Jan. p. 32.) 

Dr. Mandelstamm writes on hemiopia (" Zehend. Klin. Mo- 
nat.," xiii, Jan., Feb., Miirz, pp. 94—100). He defends the 
views advocated by him in Graefe's "Archiv.," 1873, Bd. xix, 
Abth. 2, p. 39, which agree with those of Michel. He considers 
that the whole of the fibres cross to the other side. As to the 
bearing of his researches clinically, he sums up that : 1. Disease 
in front of the commissure (in the middle line) will affect the 
inner halves of the retinae, producing hemiopia, with blindness of 
the temporal half of each field. 2. Disease (in the middle line) 
behind the commissure will aiFect the inner half of each field, 
a form of hemiopia which has been met with and recorded, bat 
was inexplicable on the former hypothesis. 3. Disease in- 
fluencing either outer angle of the commissure, if involving the 
nerve leaving the chiasma as well as the fibres from the^tract 
entering it, will produce mono-lateral hemiopia, similar to that 
produced on the former hypothesis by disease affecting the optic 
tract. 4. Disease involving the "tract" on one side^will pro- 
duce total blindness on the opposite side.— (" Zehend. Klin. 
Monat.," xii, Jan. p. 35.) 

Dr. Schon rephes to Dr. Mandelstamm in the number for Mai, 
Jnni, 1875, p. 230. In the ordinary cases of lateral hemiopia, the 
defect is precisely the same in each field. This is easily accounted 
for on the theory of semi-decussation, whereas it is diflicult to see 
why an extravasation should press equally on the optic tract and 
nerve trunk. The absence of optic neuritis in the ordinary cases 
of hemiopia, also, in his opinion, militates against any affection 
close to the commissure. The cases of temporary hemiopia 
seem difficult to explain on Mandelstamm' s hypothesis. In his 



37 (J PERISCOPE: — NERVE FIBRES — RETIXA. 

oijinion, there must be semi-decussatioii somewhere, if not in the 
commissure. Probably there is some centre in the cerebrum for 
co-ordinating the impressions derived from identical halves of 
the retinge. 



MODE OF DISTRIBUTION OF THE OPTIC NERVE-FIBRES IN THE 
HUMAN RETINA. 

Michel ("Beitriige zur Anat. u. Phys.," Leipzig, 1875), after 
noticing previous observations recorded, states tliat he has found 
that the nerve-iibres on the disc are laid more thickly over one 
another on the nasal side and thinnest on the temporal side, and 
that, in the former position, they are grouped in broad bundles, 
in the latter (towards the yellow spot) only in very small 
bundles, and often have very small intervals between them. 
Their course here is straight, whereas, in all other parts, the 
bundles have a curved direction. It is especially noteworthy 
that the bundles in the immediate vicinity of the disc are still 
somewhat closely arranged together and in thick layers, whilst, 
in other parts of the retina, with the exception of one spot, they 
occur singly. Directly after leaving the disc, the bundles of 
fibres going to the yellow spot have slit-like spaces between 
them, and anastomose at acute angles ; the further above and 
below, the broader and thicker are the curved bundles, and 
the spaces between them become greater. The bundles going 
directly to the macula are lost in the layer of ganglion cells ; 
those at a little distance surround the macula and anastomose so 
completely that the transition cannot be made out; those still 
further become less and less curved, and, at last, instead of 
anastomosing, curve in the opposite direction. Above the space 
between the yellow spot and disc is the only part where the 
))undles are placed over one another ; the one layer giving off thin 
bundles to the other. The number of bundles crossing over one 
another here, at this single spot, varies from 8 to 10. The mode 
of distribution of the fibres in the retina resembles that of a 
plexus. Towards the periphery, the thickness of the bundles 
diminishes, and the shape of the intervening spaces changes, 
becoming less slit-like and more quadrangular. At the ora 
serrata,,the fibi-es generally terminate by free ends. On the disc, 
the vessels lie between the nerve bundles, and run parallel with 
them, occasionally, however, the fibres running in the direction 
of the macula course over the central artery or its branches. 
The author thinks this affords an exjjlanation of the muscee 
complained of. As a rule, the larger vessels follow the course 
of the nerve bundles, and generally are more or less definitely 
included in such a bundle. — (" Zehend. Klin. Monat.," xiii, 
April, p. 140.) 



FIELD OF VISION. ' 377 



ON THE DECUSSATION OF THB NERVE FIBRES IN THE OPTIC 
COMMISSURE. 

Prof. Gudden describes and figures a series of preparations 
sliowing that (1) tlie so-called ganglion opticum basale is not 
a ganglion opticum. (2) In all animals whose visual fields are 
quite separate, the optic nerves cross completely. (3) In all 
animals (including man) whose fields correspond, the fibres 
cross partially. (4) No anterior commissure of the chiasma can 
be demonstrated. (5) The posterior commissure exists, but has 
no physiological relation to the nerves, and, on the contrary, is 
rather wholly independent of them. — (Graefe's " Arch.," Bd. xx, 
Abth. ii, p. 2-19— 2G8.) 

THE FIELD OF VISION AND ITS ANOMALIES. 

In " Zehend. Klin. Monat." Aug., Sept., p. 321, is an abstract 
of a treatise by Dr. Willi. Schoen (Die Lehre vom Gesichtsfelde 
und seinen Anomalien. Eine physiologisch-klinische Studie. 
150 pp. 12 lith. Tafeln, 17 Holzschnitte.) He discusses the 
extent of the field in its normal and abnormal conditions. In 
considering the extent of the field in disease, the delicacy of 
perception of colours must be gauged. In progressive atrophy 
and atrophy after neuritis, at the commencement, the area of 
perception of colours diminishes from the periphery. The per- 
ception of green is limited first, then lost ; then red and yellow ; 
last of all, blue. Inability to perceive a colour and limitation 
of the fields of dififerent colours are bad sig-ns. Accordins: to 
Schoen, atrophy does not affect any special colour, but the 
sensitiveness for colour fails, step by step, with the extent of 
field, since the excitability of all the fibres is equally diminished. 
Green requires the highest excitability of the fibres. The action 
of santonin, he considers, is to increase the sensitiveness of all 
the fibres equally. He has used it successfully in two cases, with 
this view. The author has recorded examinations of the field of 
vision and perception in colour, in transitory amblyopia, from 
various causes — glaucoma, neuritis, retinitis, retinitis pigmentosa, 
ansesthesia, &c., retiuse detachment, choroiditis, scotomata, &c. 
The histories of some 80 cases are given, and 37 charts of fields. 
See, also, a paper by him in " Zehend. Klin. Monat.," 1873, 
p. 171. 

On Perception of Colours. 
Dr. M. Woinow.— (Graefe's "Arch.,Bd. xxi, Abth, l,p. 223—50.) 

On the Perception of Colours in Indirect Vision. 

Dr. Ferd. Klug. — (Graefe's "Arch.," Bd. xxi, Abth. 1, p. 251 

294.) 



378 PERISCOPE :— SCLEROTOMY. 

The Perception of Colours at the Periphery of the Betina. 

Dr. Edm. Landolt publishes an account of observations of his, 
showing that colours are recognised at the periphery of the 
retina, if they be sufficiently intense. — ("Annales d'Ocuhs- 
tique," Jan., Fev., 1874, p. 44.) 

The Determmation of One of the Three Fundamental Golotirs of the 
Normal Bye. 

Dr. H. Scholer. — (Graefe's "Arch.," Bd. xx, Abth, ii, p. 87.) 

The Influence of Fatigue on the Sensitiveness for Colours. 
Dr. W. Schon.— Graefe's " Arch.," Bd. xx, Abth. ii, p. 273.) 

The Opposition letioeen the Two Fields of Vision. 

Dr. Schoj^ and Dr. Mosso. We are in the habit of looking, at 
short intervals, first at one field and then at the other. If one eye 
be shut, the portion of the other field common to the two eyes will 
be found to become darkened every now and then, and the colour 
of this dark portion may be altered by allowing a little light to 
enter the covered eye. We may say that an observer regards 
the field of the uncovered eye seven-tenths of the time of the 
experiment, and three-tenths that of the eye which is covered. — 
vGraefe's " Arch.," Bd. xx, Abth. ii, p. 269—272.) 

SCLEROTOMY. 

This operation is recommended by Dr. Wecker, in cases of 
absolute glaucoma, in which the presence of severe pain would 
otherwise lead the operator to perform excision of the globe. In 
the case of a woman who had suffered pain in a lost glaucoma- 
tous eye for four years, sclerotomy was followed by complete 
cessation of the ])ain and diminution of tension. Where any 
vision remains, and the iris is well preserved, iridectomy should 
be performed. — ("Annales d'Oculistique," Mars — Avril, 1874, 
p. 120.) 

GLAUCOMA. 

Dr. J. HiRSCHBERG Contributes a case in which a single instilla- 
tion of atropine into the eyes caused double acute glaucoma in 
an apparently healthy lady, aged 64. Also a case of glau- 
coma malignum (Graefe, see vol. vii of this Journal, p. 100.) — 
("Archives of Ophth. and Otol.," vol. iv; No. 2.) 

DOUBLE CHRONIC GLAUCOMA IN TWO BROTHERS, AGED 19 AND 20 
RESPECTIVELY. 

The cases are recorded by Dr. Pfliiger, in " Zehend. Klin. 
Monat." xiii, April, p. 111. 



DISEASE OF THE VITREOUS. — GLAUC0:MA. 379 

SOME SUBJECTITE SYMPTOMS IN CASES OF INCREASED INTEA-OCULAR 

PRESSURE. 

Dr. M. Rei€H, in a paper on certain subjective symptoms of 
increased intra-ocnlar pressure, treats (I) of enhyptic pulsation. 
When be fixes bis eye on the clear sky, or a wbite wall, or a sbeet 
of white paper, and exercises pressure on bis eyeball with a 
blunt object, be sees (1) a dark round spot close to the outer 
side of the point of fixation, and (2) on the inner side of the 
fixation point, and close to it, a grayish patch with stripes. In 
this patch be clearly detects phenomena attributable to pulsa- 
tion. The patch appears and disappears synchronously with the 
radial pulse. The patch increases in size after a few seconds, 
and, if the pressure be properly regulated, pulsation will be seen 
to occur at the point of fixation. The various shapes and 
appearances the patch takes, according to the pressure used, are 
described, and the diffei'ent colours seen, according to the colour 
of the surrounding light. He alludes to the observations of 
Purkinge and others. He thinks be has shown conclusively that 
the phenomena are due to pulsations of the ciliary arteries, and 
not of the central vessels. (II) Perception of colours tinder the 
influence of increased intra-ocular pressure. He finds that green 
fails to be perceived before red, and blue last. The various 
transitions through which each colour passes are given. He 
appends some observations on the normal perception of colours 
in the peripheral portions of the field. Red, blue, green, and 
yellow were recognised at the outer portion of the field, for a 
distance of from 73° — 85°. Red was recognisable still further : 
light further still. The perception of colour did not extend 
anything like so far from tbe centre on the inner half of tbe 
field, but further than has been recorded by other observers. 
The temporal portion of tbe retina was shown to have a certain 
degree of inability to recognise red. — (" Zebend. Klin. Monat.," 
xii, Juni, juli, p. 238 — 255.) 

disease OF THE VITREOUS FOLLOWING ON GENERAL ARTERITIS 

THROMBOSIS OP THE BASILAR ARTERY DEATH. 

Dr. Fr. Poucet records tbe case of a man, aged 45. The 
vitreous in eacb eye was so opaque that the fundus could not be 
seen. One eye was quite blind, the other had perception of 
light. There were no floating masses. Tbere was no history of 
syphilis obtained. Tbe first and only symptom in the case, was 
opacity of the vitreous. Iodide of potassium gave no relief, nor 
iridectomy. Three months later he was seized with vertigo and 
fell, and afterwards had left hemiplegia. He recovered conscious- 
ness. Four days later be had a second attack, which proved 
fatal. At the fost rnortem, a firm plug was found occupying the 



380 PERISCOPE :— ORBITAL ANEURISM. 

"wtole length of the basilar artery. The aorta and the cerebral 
arteries were atheromatous. A detailed account of the micro- 
scopic examination of the basilar artery and the eyes is given, 
with six woodcuts. The retina was much altered. There was 
evidence of arteritis and much pigmentary change. The epithe- 
lium of the choroid was altered, and the arteries in the deeper 
layers showed evidences of inflammation. In some places, there 
were no vessels, only fibrous tissue. A careful examination was 
made of the cicatrices of the iridectomies, and the author calls 
particular attention to the conditions found, as possibly throwing 
light on the efficacy of iridectomy in glaucoma. The new 
tissue would allow of filtration better, &c. The author discusses 
the bearings of this case on retinitis pigmentosa and choroido- 
retinitis. The optic nerve was unaffected, and the disc was not 
atrophied ; the central artery was not involved. The epithelium 
of the choroid had undergone colloid degeneration, and the pig- 
ment had left the cells and penetrated, by degrees, into the 
retina. He thought the commencement was a chronic inflam- 
mation of the arteries generally, which, attacking the basilar 
artery, caused the death of the patient, and, in the retina and 
choroid, caused gradual failure of sight, loss of pigment from 
the choroid, and subsequently the passage of pigment granules 
into the vitreous and opacity of it. The failure of sight probably 
extended over five or six years. — ("Annales d'Oculistique," 
Mars, Avril, 1875.) 

A CASE OF EETEO-OCULAP: ANKURISM, WITH EXTEEME EXOPHTHALMOS 
— LIGATURE OF THE COMMON CAROTID. 

Dr. Nteden records the case of a man, £et. 19, who received a 
severe injury to the head, and on the next day noticed a loud 
singing noise on the left side of his head, and which subsequently 
increased. The left eye became prominent and blood-shot. Five 
months after the accident he came under care. The exoph- 
thalmos was the most striking symptom. He could still see 
with the eye, and there were no special changes ophthalmo- 
scopically. Pressure on the globe excited visible ptilsations ; 
the noise heard by the patient was altered in character, and the 
hand was conscious of a purring sensation. A loud intermittent 
bruit could be heard. Pressure on the carotid stopped the 
pulsations but not the bruit. The author discusses the probable 
causes of these symptoms, and decides in favour of a retro-ocular 
diffused anem'ism. Compression of the carotid was tried for ten 
weeks without any good result. The left carotid was then tied 
on Lister's plan of antiseptic dressing for the wound. Pulsation 
ceased, and the bruit was scarcely perceptible. The wound 
healed by first intention. The prominence of the eyeball 
gradually diminished. The bruit somewhat increased. After 



RETINITIS PIGMEXTOSA — RUPTURE OF CHOROID. 381 

some time it was evident tliat the left superior thyroid was much 
enlarged ; when it was compressed, the bruit ceased. The state 
of the patient when seen after a considerable interval had elapsed 
was very favourable. Di'. Nieden reviews the statistics of ligature 
of the carotid for pulsating orbital tumours. He manages to 
quote the results of 113 cases. In 79 (or 69'9 per cent.) a cure 
resulted; in 14 (or 1'2'3 per cent.) the condition was unaltered; 
in 7 (or QS per cent.) improvement followed ; and in 13 (or 11 "5 
per cent.) a fatal result occurred. — (" Zehend. Klin. Monat.," 
xiii, Jan., Feb., Marz, p. 38 — 55.) 

RETINITIS PIGMENTOSA. 

Dr. Schiess-Gemuseus records a case in which the central vision 
and the extent of field improved. Diagrams of the fields are 
given. — (" Zehend. Klin. Monat.," xiii, Mai, Juni, p. 200.) 

A careful examination of eyes in which the changes, charac- 
teristic of retinitis pigmentosa were found, after removal post- 
mortem, is given by Dr. Hosch in "Zehend. Klin. Monat.," xiii, 
Jan., Feb., !Marz, p. 58. The previous history was not known. 
The patient, a woman, while in hospital a few days before 
death did not complain of any defect of sight, so the eyes were 
never examined. 

NEW GROWTH OF VESSELS AND CORKSCREW-LIKE VESSELS (WITHOUT 
dilatation) in THE RETINA. 

Dr. Jos. Jacobi describes and gives illustrations of three cases 
in which he met with small corkscrew-like, or variously tortuous 
vessels (veins), in the neighbourhood of the disc, and one case 
in which there was a real vascular new growth. They all 
appeared superficially placed. — ("Zehend. Klin. Monat.," xii, 
Juni, JuH, p. 255—260.) 

RUPTURE OF THE CHOROID — ANEURISM IN THE OPTIC DISC. 

Dr. Mannhardt records three cases. In one of them the rupture 
was above and to the outside of the disc ; there was pulsation in 
the ascending artery and descending vein, and in the outer quad- 
rant of the disc there was a round grayish excavation as if cut 
out with a punch. It nearly reached the mai-gin of the disc. In 
the bottom of it could be seen a slight, rounded projection. 
Pulsation was visible over the whole surface. This was regarded 
as an aneurism, probably aneurisma spurium. In the second case, 
the rupture was unusually extensive, reaching obliquely almost 
across the whole fundus. In the third case, the scotoma present 
did not correspond with the situation of the visible cicatrix. 
This was supposed to be due to the contraction having displaced 
VOL. VIII. 2 C 



382 PERISCOPE : — CHOROIDITIS. 

the scar, while the scotoma corresponded to the original situation 
of the rupture and interference with the retina. — (" Zehend. 
Klin. Mouat.," xiii, April, p. 132.) 

RUPTURE OF THE CHOROID AFTER BLOWS OF THE EYE FROM BLUNT 
OBJECTS. 

Prof. Arlt argues that the eyeball suffers greatest extension in 
the equatorial diameter, that the choroid is fixed in the ciliary 
region and at the disc, and where the vasa vorticosa leave the 
eye ; therefore, the region most affected is limited ; the rent 
occurs at right angles to the extension, and concentrically to 
the posterior pole. — ("Zehend. Klin. Monat.," xii, Oct., Nov., 
Dec, p. 382.) 

CHOROIDITIS AND ITS INFLUENCE ON VISION. 

Dr. Otto Bergmeister, in a paper in Graefe's " Archiv.," Bd. xx, 
Abth. ii, p. 95 — 122, passes in review the different methods of 
grouping cases of choroiditis adopted by different authors, and 
their views as to prognosis. It is the general opinion that the 
ophthalmoscopic appearances afford very little guide as to pro- 
gnosis. The author, from his extensive experience in Prof. Arlt's 
" Clinic," has arrived, he believes, at certain conclusions, which 
may be of some value in reference to prognosis. He quotes 
Schweigger to the effect that the ophthalmoscopic appearances 
and the diagnosis depend in great measure on the condition of 
the pigment layer. He describes the changes met with in recent 
choroiditis without exudation under the term choroiditis dis- 
seminata simplex. In these cases we commonly meet with local 
defects of the field of vision, but great general defect of vision 
may rapidly set in owing to the changes affecting the neighbour- 
hood of the disc, or their spreading forwards to the ciliary region. 
Good vision exists only when the changes are limited to a zone 
between the equator and the posterior pole of the eye. If changes 
make their appearance near the disc we find one of two series of 
ophthalmoscopic changes ; first, congestion of the disc, either in 
the form of a deeper colouring shown through a lightish gray 
cloudiness of the tissue of the well-defined disc, or in the form of 
a grayi.sh-red streaking of the disc with haze of its margins. 
This participation of tlie disc is produced by the share taken by 
the peri-neural wreath of vessels in the circulation in it. The 
quicker the hyperfemia disappears, the more rapidly will the 
vision improve ; the longer it lasts, the more doubtful is the 
prognosis, because atrophy will gradually result entailing per- 
manent loss of vision. Secondly, we find ojiacities in the 
posterior part of the vitreous, perhaps coming into view in front 
of the disc. In many cases the vitreous remains perfectly clcnr, 



CHOROIDITIS. u83 

and the author thinks one chief reason for its becoming affected, 
at any rate in the posterior part, depends on the locahty of the 
disc being affected with co-existent disturbance in the circulation 
in the region of the perineural wreath of vessels. In another 
series of cases fresh patches of choroiditis make their appearance 
more peripherally, and thus encroach on the ciliary region. As 
results, we have opacity of the anterior part of the vitreous, 
chiefly in the form of very small points best seen by feeble illumi- 
nation. Dots are also found at the posterior part of the lens. 
The disease may extend to the iris, leading to deposits on 
Descemet's membrane, synechia and exudation into the pupil. 
This occurs more especially in connexion with syphilis. In con- 
tradistinction to the simple disseminate choroiditis we have 
choroiditis circumscripta exsicdativa, with scotomata, chromatopsia, 
metamorphopsia, sensation of pressure on the eye, and pain felt 
on pressure. Choroiditis dissemminata exsudativa occurs in the 
form of one (or more) extensively diffused patch (diffuse 
exudative syphilitic choroido-retinitis). Such a patch may 
appear in the course of another form of choroiditis, or the 
disease may commence as such. The prognosis is very doubtful. 
A fourth form of choroiditis spreads from the periphery in small 
distinct patches towards the centre, and is associated with pig- 
mentation of the retina, and a progressive diminution of field, 
with preservation of central vision. Finally, atrophy of the disc 
dependent on progressive atrophy of the nerve fibres of the 
retina is observed. Inability to see in a dull light is a not 
unfrequent symptom. The author sums up as follows: — 1. The 
atrophic form of choroiditis usually met with may run its course 
Avithout great defect of sight so long as the ophthalmoscope 
reveals changes confined to a zone between the ^equator and the 
posterior pole. The prognosis depends chiefly on the way in 
which the disease spreads, that is, where fresh patches make 
their appearance. When they encroach on the neighbourhood of 
the disc, vision is affected by the disturbances set up in the 
circulation in the optic nerve and by opacities in the posterior 
part of the vitreous. If the disease spreads forwards, vision is 
then interfered with by anterior vitreous opacities. 2. Circum- 
scribed exudations lying on the surface of the choroid produce 
local scotomata, photopsia, chromopsia, and metamorphopsia. 
The degree of the defect of vision essentially depends on the 
part affected ; for instance, the yellow spot. 3. Vision will be 
most severely affected when changes in the outer retinal layers 
are added to persistent changes in the choroid, or where the 
Avhole uveal tract is affected. Atrophy of the optic nerve follows. 
If exudation persists at the posterior pole, central vision is 
destroyed. 4. Pigmentation of the retina, in consequence of 
choroidal atrophy progressing from the equator to the posterior 
pole of the eye, causes diminution of field and hemeralopia ; whilst 

2 c 2 



384 PERISCOPE : — OPTIC NEURITIS, ETC. 

central vision may remain, even though, the nerve may show 
signs of atrophy at an early period. — (Graefe's " Archiv.," Bd. 
XX, Abth. ii, p. 95—122.) 

ANEURISMA ARTERIOSO-VENOSUM RETINALE. 

Dr. Hugo Magnus describes and figures a remarkable condition 
of the retinal vessels following an injury. The central vessels 
were enormously enlarged ; the arteries and veins of very similar 
colom', &c., and communicating with one another. That is, the 
principal venous and arterial trunk passing upwards could be 
seen to communicate, and also the two passing downwards. This 
intercommunication would account for the similarity between 
the arterial and venous trunks. — (Virchow's "Archiv.," Bd. 60, 
p. 38, 1874, and (with fig.) " Zehend. Klin. Monat.," xii, Juni, 
Juli, p. 265.) 

STATISTICS OP OPTIC NEURITIS IN INTRA-CRANIAL TUMOURS. 

Dr. M. Reich has collected together the statistics of 45 cases of 
cerebral tumour (recorded), in which an ophthalmoscopic exami- 
nation was made. In 41, there was double neuritis, or con- 
sequent atrophy ; in one, single neuritis, and in 3, no changes 
existed. Adding the 43 cases noted by Annuske (" Archiv. f. 
Opth.," Bd. xix, Abth. 3), he finds, that of 88 cases, in 82 there 
was double neuritis ; in 2 single neuritis (the tumour being 
situated on the opposite side) ; and in 4, there were no ophthal- 
moscopic signs. — (" Zehender's Klin. Monat.," xii, Juni, Juli, p. 
274.) Annuske says, that experience, hitherto, shows that in 
the majority of cases of " intra-ocular neuritis " there is no 
defect of sight, at any rate at the commencement, and he sums 
up to the effect that " optic neuritis is an almost invariably con- 
stant symptom in connection with cerebral tumours." 

COMPLETE TRANSITORY AMAUROSIS AFTER INSTILLATION OP ATROPINE 
AND CALABAR BEAN. 

The patient was a child 10 years of age. Atropine having 
caused dilatation of the pupils to the great alarm of the parents, 
a calabarised gelatine disc was inserted. The friends were soon 
tranquillised, and took the child away. Some hours later they 
returned, saying the child had become quite blind. He could 
not distinguish light from darkness. The ocular muscles were 
not afiected. The patient complained of pain in the head, and 
was drowsy. The next day vision was partially restored, but 
was again lost. The cure was not complete till the end of six 
days. — (Carreras Arago, " Cron. Oftalm," 1874; "Annales 
d'Oculistique," Mars, Avril, 1875, p. 185.) 



GLIOMA, ETC. o^D 



PUNCTURE IN DETACHMENT OP THE RETINA. 

Dr. Wecker records a case in which a considerable portion of 
the retina was detached in each eye, and in which good vision 
was restored by pnncture in each eye (at diiferent times). The 
retina, though detached, had not lost its transparency. The 
patient was myopic. Mercurial inunction was practised at the 
same time, and iodide of potassium given internally ; but this 
treatment had no effect on the eye not operated on. — (" Annales 
d'Oculistique," Mars, Avril, 1874, p. 124.) In the number for 
Mars, Avril, 1875, another case is noted. The detachment was 
more advanced, and the result negative. 

GLIOMA. 

A CASE of glioma of the retina with numerous subperiosteal 
metastatic tumours is recorded by Dr. Charles S. Turnbull and 
Dr. H. Knapp. The microscopic examination of the growth 
was made by the latter. The patient was a girl aged 3. The 
metastatic tumours differed from those on record by the peculiar 
and novel feature that they did not originate in the diploe, but 
between the periosteum and the surface of the bone. A re- 
markable observation furnished by this case was that in some 
places intra-cranial tumours corresponded to extra-cranial oues, 
e.g., in the two temporal fossae, which, at first sight, gave the 
idea of their originating from the diploe. This idea Dr. Knapp 
was obliged to discard, as not only the diploe, but even both 
tables of the cranium which separated two smaller tumours, were 
found to be but little changed. 

A second case, in a girl twelve months old, is also recorded 
by Dr. J. Thompson and Dr. H. Knapp. There was a family 
predisposition to glioma. A brother to the patient and a cousin 
on the father's side were said to have suffered in a similar way, 
and the father's aunt also lost two children exactly in the same 
manner. The disease obviously originated in the inner granular 
layer.— ("Arch, of Ophth. and Otol.," vol. iv, I^o. 1.) In No. 2, 
two other cases of ghoma are given by Dr. Williams and 
Dr. H. Knapp, p. 241. 

SARCOMA OF THE CHOROID. 

Dr. E. Williams and Dr. H. Knapp record a case of sarcoma of the 
choroid with infection of the retina and dissemination of germs 
from the degenerated retina upon healthy portions of the choroid. 
Also, a case of melano-sarcoma of the choroid extending to the 
retina and optic nerve. The subject of the latter case was young 
for pigmented sarcoma. — (" Arch, of Ophth. and Otol.," vol. iv, 
No. 1.) 

2c3 



386 PERISCOPE : — AMAUROSIS. 



SUDDEN AMAUROSIS AFTER LOSS OF BLOOD. 

J. Samelsohn contributes a second paper on this subject, the first 
being in Bd. xviii, Abth. ii, p. 225. Amaurosis following on 
loss of blood from the intestinal tract depends on various 
causes. When it follows severe haemorrhage it may be due to a 
purely mechanical cause (peripheral) dependent on the rela- 
tion between the blood- and lymph-pressure and distension of 
Schwalbe's intervaginal space. When it follows slight loss of 
blood, the cause must be central and produces both the loss of 
blood and the amaurosis. The activity of the pupil in this group 
of cases is a symptom of hopeful significance as regards prognosis. 
— (Graefe's Arch.," Bd. xxi, Abth. i, p. 150—178.) 

amaurosis in puerperal women. 

Dr. F. Weber ("BerL Klin. Woch.," 1873, Nos. 23 and 24) records 
four cases of amaurosis in puerperal women. In two of the 
cases, convulsions preceded the amaurosis ; in a third, the amau- 
rosis was followed by convulsions, and in the fourth no con- 
vulsions occurred, but there was some spasmodic condition of the 
uterus. The three who had convulsions had albuminuria and 
other symptoms of kidney mischief, which disappeared shortly 
after delivery. The amaurosis either came on suddenly or was 
first noticed after coma. The pupils were dilated and pain in 
the eyes complained of. No ophthalmoscopic examination was 
made. Vision was rest'^red after an interval varying from six 
days to some weeks. Only one of the patients was a primipara ; 
the others having had several children. Convulsions are far 
commoner in primiparae. In the three cases in which uraemia 
existed, there did not seem to be any direct connection between 
the severity or duration of the uraemia and the amaurosis. — 
(" Annales d'Oculistique," Sept., Oct., 1874, p. 176.) 

neuro-eetinitis resulting from a gummous tumour of the 
dura-mater. 

Dr. H. Knapp says that retinitis in syphilitic persons has mostly 
no peculiar features, two conditions, however, may be mentioned 
as generally being of syphilitic origin. 1st. Irregular white 
stripes radiating from the disc in the course of the blood-vessels, 
sometimes fiat, sometimes considerably raised ; 2nd. Small, 
roundish, white patches of fatty appearance, dispersed in some 
cases over the whole retina ; in others limited to certain places, 
in which they are so densely crowded as to resemble a piece of 
mosaic work. In the region of the yellow spot, he has seen 
striking pictures of this second condition, which is totally dif- 
ferent from the well-known radiating figures so frequently 



CHIASTOMETRE. 387 

witnessed in this region in cases of Bright's disease and neuro- 
retinitis, the consequence of morbid processes in the orbital or 
cranial cavities. He narrates the case of a married woman, 
aged 32, who came under his care a fortnight before death with 
signs of ordinary neuro-retinitis passing into atropliy of the optic 
nerves. There was a distinct history of syphilis. Death occurred 
"unexpectedly after epilepiform seizures. At the anterior portion 
of the anterior lobe of the left hemisphere was a large gummous 
tumour of the dura-mater extending into the brain substance (a 
sketch is given). The central portion of the tumour was yellowish- 
white, opaque and hardish, like fibre- cartilage, whereas the peri- 
pheric portion (next the brain substance, the pia-mater interven- 
ng) was transparent, hyaline, and softer than the central portion, 
which it lined to a nearly uniform thickness of '12 inches. The 
m.icroscope revealed an accumulation of small cells embedded in a 
moderate quantity of homogeneous basis- substance. The majority 
of the cells were round and contained large nuclei. There was a 
moderate amount of fat granules. The hard portion had much 
the same structure, but, in addition, a considerable quantity of 
spindle-shaped cells. Here and there was a network of anas- 
tomosing stellate cells. — ("Ai'ch. of Ophth. and Otol., vol. iv, 
No. 2.) 

RETINITIS APOPLECTICA ALBUMINURICA — NEURITIS ALBUMINURICA. 

Dr. Magnus records a case of numerous small apoplexies in the 
retina in connection with albuminuria ; a case of neuritis and 
retinitis apoplectica albuminurica, and a case of neuritis albu- 
minurica. In these cases the fatty changes so commonly met 
with were not present. — (" Zehend. Klin. Monat.," xii, April, 
Mai, p. 171.) 

THE CHIASTOMETRE. 

Under this name, Dr. Landolt describes and figures an instru- 
ment for measuring the distance between the two eyes. It con- 
sists of a long box, having at one end two openings (like those 
of a stereoscope) for the eyes and a notch for the bridge of the 
nose. Exactly in the middle of the box is a partition with a 
vertical slit. At the opposite end are two metallic plates 
moveable one on the other from side to side, and each provided 
with a vertical slit. The person examined looks through the 
eye-holes, one of which (say the left) is shut. He then looks 
with the right eye through the vertical slit in the middle of the 
box, and the left plate at the other end is moved till he can 
see light through the slit in the middle ; the left end slit is then 
in a line with the right eye. The process being repeated for the 
left eye gives its position. As the vertical slit is exactly midway 



38y PERISCOPE : — COLOBOMA. 

between the eyes and the end slits, the distance between these 
two gives the distance between the two eyes. The same result 
may be obtained by lookmg at a needle in the centre of a card 
with each eye separately and placing one of two needles (moving 
laterally at the opposite end of the card) in a direct line with 
the right eye and the other Avith the left. — (" Annales d'Ocu- 
listique," Jan. — Fev., 1874, p. 46.) 

CONGENITAL COLOBOMA IN THE HUMAN ETE. 

J. HiRSCHBERG contributes a paper on this subject. He gives 
woodcuts of a coloboma retinae et choroidis centr. circumscr, 
(Dictyoschisma centrale.) and coloboma inferius circumscr. 
He narrates two cases of diffused coloboma. In all the cases 
when the field was tested, it was found deficient over the area of 
the coloboma. He gives in all, three cases of coloboma with- 
out any aiSection of the iris. When the disc is involved, he 
has not found the great defect of sight mentioned by Manz. 
Coloboma lentis. Cases recorded are quoted and a fresh case 
mentioned. Prof. Becker is also quoted as having often seen 
such cases. — (" Graefe's Arch.," Bd. xxi, Abth., i, p. 179—189). 

Dr. Talko (" Zehend. Klin. Monat." xiii, Mai, Juni, p. 202— 
222) records two cases of congenital coloboma palpebrarum, with 
an illustration. A case of (Sclerophthalmia') congenital opacity of 
the right cornea — congenital anomaly in the radiation of the left 
iris— Talipes equinus (with illustrations). A case of melanismus 
iridis partialis (with ilj jstration). A case of albinismus and 
leucosis oc2ilorum. A case of coloboma of the choroid, ciliary body 
and iris in the right eye. A case of coloboma of both irides and of 
the right choroid (with illustration). A case of coloboma of the 
choroid in the right eye ivithout any affection of the iris (illus- 
trated). 

• Ophthalmoscope. 

Dr. H. Knapp describes and figures a new ophthalmoscope with a 
single disc. The price is twenty dollars. There are twenty- 
three lenses. He finds the best size for the aperture is 3"50 to 
375 mm. ('14 — '15 in.) in diameter. — (" Archives of Ophth, and 
Otol., vol. iv. No. 1.) 

Monophthalmos and Microphthalmos. 

Dr. Jos. Jacobi records a case of monophthalmos and also one 
of microphthalmos. — (" Zehend. Klin. Monat.," xii, Juni, Juli, 
260.) 

Absence of both inferior Puncta Lacrymalia. 

Dr. Magnus records the case. — (" Zehend. Klin. Monat,," xiil, 
Mai, Juni, p. 199.) 



LIST OF PAPERS. 389 

On the Theory and Construction of Stereoscopic Instruments for 
Scientific Diagnosis. 

Dr. Boettcher (" Graefe's Archiv.," Bd. xx, Abth. ii, p. 182 — 
204.) 

The Absorption of Liquids hij the Cornea. 

Dr. Krukow and Prof. Th. Leber publish a continuation of 
tbeir account of their researches. They have experimented on 
freshly excised corneee and on cornese of living animals. Certain 
fluids are readily diffused through the cornea proper ; the epi- 
thelium offers great resistance to their passage. When it is 
removed, absorption takes place much more readily. — ("Graefe's 
Archiv.," Bd. xx, Abth. ii, p. 205—48.) 

Sasners Theory of " Inversion" (^" RucJcconstniJction ") of Retittal 

Images. 

J. Jacobson writes in opposition to Hasner's theory. (" Graefe's 
Archiv.," Bd. xx, Abth. ii, p. 71.) 

Prof. Hasner replies to these observations. — Bd. xxi, 
Abth. i, p. 43. 

Suppurative Inflammation of the Lacrymal Gland. — Abscess 
opened in the Conjunctival Cul-de-sac. 

Dr. -J. Gazat records the case. (" Annales d'Oculistique," Jan. 
— Fev., 1874, p. 26.) 

The Dioptrics of the Eye, 

The paper of Messrs. Landolt and Nuel, of which an abstract 
is given, p. 88, last Periscope, is given in full in the " Annales 
d'Oculistique," Jan. — Fev., 1874, p. 30. 

Blind — Cataract (Staar.) 

A Philological Study, by Prof. J. Zacher, on the words " blind " 
and "Staar" will be found in Zehender's "Klin. Monat.," xii, 
Aug.— Sept., p. 277—302. 

Corectopia Binocularis. 

Dr. LandesberCt records a case (" Archiv. of Ophth. and 
Otol.," vol. iv. No. 1.) 

On notation of the Eye. 

Dr. ScHoN seeks to explain and amplify Helmholtz's state- 
ments in his "Physiological Optics." ("Graefe's Archiv.," 
Bd. XX, Abth. ii, p. 171—81, and 308—14.) 



390 PERISCOPE : — LIST OF PAPERS. 

A Gontrihutlon to the Calculations of OjctJithalmomctrij, by Dr. eT. 
HiRSCHBERG, and the Co-efficients of Befraction of the Fluid 
Media of the Human Eye, by Dr. J. Hirschberg. — (" Archives 
of Oplith. and OtoL," vol. iv, No. 2.) 

The Nerves of the Arteria Centralis Retinoi and on a Fovea 
Centralis in Frogs. 

Prof. W. Krause. (" Graefe's Arcliiv.," Bd. xxi, Abth. i, 
p. 296.) 

Opaque Retinal Nerve Fibres. 

Dr. Schmidt records a case in wbich a microscopic examination 
was made, (Zeliend. "Klin. Mouat.," xii, April — Mai, p. 186.) 
In " Graefe's Archiv.," Bd. xxi., Abth. i,are also the fol- 
lowing papers : — - 

On the Histologij of the Conjunctiva. 

De. M. Retch considers that the so-called flask -shaped cells 
are pathological products — not merely mucous cells. He 
treats (1) of the epithelium of the conjunctiva tarsi and cul-de- 
sac ; (2) of the so-called flask-shaped cells (Becherzellen) ; (3) 
of the papilla9 and "tubular glands;" (4) of the conjunctival 
tissue proper. The paper is well illustrated. 

Observations on the ^^ FmjpiricaV Theory of Vision (p. 28 — 42.) 

By J. Hirschberg. A detailed account is given of the way in 
which a child gradually learnt to see after being operated on 
for congenital cataract. 

Parallel Rotatory Movements of the Eyes. 
Dk. M. E. Mulder, (p. 68—124.) 

The Law of Relation of the position of the Retina to that of the line 
of Vision (p. 125.) F. C. Donders. 

On the Movements of the Head employed in looking at objects in 
various positions (p. 131 — 149). 

Dr E. Ritzmann treats first of the quantitative relation 
between the movements of the head and of the eyes, and 
secondly, of the direction of the movements of the head. 
We constantly move the head in association with the eyes, 
and these movements are in proportion to the distance 
of the object, and differ in different directious. The relation 



CORRESPONDENCE. 391 

between the moveroents of the eyes anrl of the head varies in 
different persons. On looking down, the movements of the eyes 
are disproportionately greater than those of the head. The 
movements of the head in a vertical or horizontal direction were 
in relation to the same axis as that of the ocnlar movements ; in 
a diagonal direction, on the contrary, the axes of the two did 
not correspond. The degree and direction of the divergence 
varied for different persons. 



TO CORRESPONDENTS. 



We have received, in reply to our " Suggestions, &c.," vol. vii, 
p. 438, some interesting notes from Dr. Swan M. Burnett, of 
Knoxville, Tennessee, on the relation between race and diseases 
of the eye in that part of the United States. Dr. Burnett con- 
siders that arcus senilis occurs much earlier in negroes of pure 
blood than in either mulattoes or whites. He does not remember 
ever to have seen inijopia in a negro, though in some of them the 
eyes are, from the formation of the skull, decidedly prominent. 
Phlycteimlar ophthalmia is more common among the mulattoes 
than either among the whites or pure negroes ; and in this con- 
nexion Dr. Burnett observes that scrofulous diseases and rapid 
tuberculosis are extremely common in mulattoes ; this cross is 
not so strong constitutionally as that between tlie negro and 
Red Indian. The most marked difference, however, is in the 
extreme rarity o^ granular lids among the negroes. Dr. Burnett, 
in a considerable ophthalmic practice during five years, among a 
population one-third of whom are negroes, has never yet seen 
a case of granular lids, or any of the results of this disease, in 
a negro or mulatto. He concludes that this must be due to race, 
for the surrountiing white population, especially the Irish, suffer 
largely from the disease ; he thinks that the exemption of the 
negroes is certainly not due to better hygienic conditions, for 
they are poorly housed, not too well fed, often overcrowded, and 
not very clean. Dr. Burnett states that the exemption from 
granular ophthalmia extends to half-caste negroes, although 
they are specially prone to scrofulous and tuberculous diseases. 
Cystic tumo2ors of the lids are. Dr. Burnett states, much com- 
moner among the negroes than among the whites ; the same is 
true of tumours of the lobe of the external ear in the negro 
women, but this is due, he considers, to their h^bit of wearing 
brass earrings. 

Dr. Burnett refers to some " Climatoloorical Notes on 



392 CORRESPONDENCE. 

Trachoma and Glaucoma," from Costa Rica, by Scliwalbe, in 
Zehender's Monatsblatter, Augxist, 1866, where the author 
notices the same immnnity of the negroes from trachoma. 

Dr. H. Sattler, assistant to Professor Arlt in Vienna, sends 
us some observations made during a recent toui" through the 
chief European countries. He considers that interstitial hera- 
titis is much less common in France, Holland, Germany, and 
Austria, than in England ; and that it is less frequently asso- 
ciated with malformed teeth than in our country. Dr. Sattler 
finds that diphtheritic ophthalmia is as rare in Austria as in 
England, and that when it occurs it is usually in close relation 
with scarlet fever ; he states that in North Germany it is 
common. Dr. Sattler found that the relative frequency of 
trachoma varied much in different countries. Eheumatic Kera- 
titis and iritis are not infrequent in Austria, although gout is 
somewhat rare. The frequency of cijsticercxis in the eye varies 
much in different parts of Europe. 



Optth. Hosp. Reports Vol. VIU. PL IV. 




Fig I. 




Fi6 II 




JJStrwafeiU M 



Congenital Malposition of the Liens 



•■If:- 






Fi^.m 



f 



I i . . ) -^ ■ L- 



Optic Neuritis vy-ithout Intra crajiial Tumour. 



Ophthalmic Hospital Reports, 

Vol. VIII. Part 3. MAY, 187G. 



Part I. 

TWO SINGULAR CASES. 

Reported, with Remarks, by J. F. Streatfeild. 

Case I. Congenital malposition of lenses; Iridectomies; 
Improvement of vision. 

In this case I first saw the patient, Louisa Durant, 
aged nine years, on the 29th of March, 1875. She was brought 
by her mother from Crayford, in Kent, and complained 
that she could not see far, and that there was a dancing in 
her eyes. Her mother had noticed her imperfect vision, 
and that she screwed up her eyes, and wished to know if 
she ought not to have glasses to make her see well. She 
could see in the distance, with either eye, only -^-i^, and 
read, with either eye, at a short distance, \\ Snellen. Slie 
was, by the ophthalmoscopic test, myopic. She could 
not see with any convex, but saw better with concave 
glasses, best with — 12 : with them, however, she could 
only be brought up to f ^. The dancing in her eyes seemed 
to be explained by a frequent, almost continual, shaking or 
tremulousness of the lovjer part only, perliaps one-half, of 
VOL. VIU. 2 D 



394 STREATFEILD ON A CASE OF IRIDECTOMY FOR 

each iris. In her efforts to see she used much compression 
of the globes by means of the orbicularis muscles. The 
eyes were rather prominent. The pupils, at rest, were of 
medium size. A drop of a weak solution of sulphate of 
atropine was applied to each eye. When the pupils were 
dilated, the ophthalmoscope, by any method of its use, 
showed, as I had surmised, a nearly s}Tnmetrical and very 
considerable misplacement of the lenses. Indeed, when 
the patient faced the window, now that the pupils were 
dilated, the faulty position of either lens could be seen 
very distinctly without any aid whatever, by its faint 
uniform gi-eyness* in comparison with the rest of the area 
of the pupil, which was black, and in which there was no 
lens (see Eig. I). The greyness of the lenses was equally 
diffused, not greater in the centre, and without any shade of 
an amber colour ; otherwise it was such as is often seen in the 
lenses of old people, in which, as in the lenses of this little 
patient, there is no trace of cataract whatever. They 
transmitted light perfectly well, and showed no striae or 
other opacity by any method of ophthalmoscopic examination. 
In the present case, moreover, the greyness of the lenses, 
faint as it was, was made conspicuous by force of contrast 
with the black crescentic area which the lens left vacant in 
each pupil. The other ophthalmoscopic signs usual in such 
cases as this were present ; the brilliantly reflected light, 
by oblique illumination with an ophthalmoscope lens, from the 
exposed portion of the edge of each lens ; and, on the other 
hand, with the mirror, the black border of total refraction 
of the light in the same situation ; while the doubled image 
of the fundus of each eye was remarkable, the refraction 
being myopic when seen through the lens, and hypermetropic 
in the other part of the pupil where the lens was absent. 

* Mr. Dixon says the lenses were elondy in his four cases o£ malposition, 
(in one family) reported (" Ophthalmic Hospital Reports," vol. i, p. 54). In 
two such cases, repoi-ted by Mr. Bowman, there were actual striae in the 
margin of the misplaced lens in one case, and a nuclear lamellar cataract in 
the other. Ibid. vol. v, pp. 3 and 13. 



CONGENITAL MALPOSITION OF LENSES. 395 

Thus by any slight movement of the head of the observer the 
vessels of the fundus seemed to move, in the same pupillary 
area, in two contmry ways at once. There was also in this 
case, in each eye, a narrow myopic crescent in an unusual 
situation. (See Fig. II, — the left eye). There was nothing 
else abnormal to be seen in the fundus of either eye. The 
amount of misplacement was in each eye almost, but not 
quite, enough to bring the margin of the lens opposite to 
the centre of the pupil, so that the margin of the lens was 
behind the iris when the pupil was contracted. The mis- 
placement was about equal in amount in the two eyes, but 
in the right eye it was directly upwards, in the left 
upwards and a little inwards. 

With no glasses could her vision be improved more 
than I have said. She went to school and still complained 
much of her difficulty of vision, in reading especially — of 
the dancing, etc. She always continued to screio U2} her 
eyelids in reading, etc. She was a highly intelligent, thin, 
pale, excitable child, and for some time I did nothing more. 
She took an iron mixture. Wlien, a second time, I had used 
atropine, and dilated both her pupils, I observed that in order 
to see anything she now held down her head and screwed v.j} 
her eyelids more than ever before, in order, it seemed to me, not 
only (as myopic persons do) to shorten the antero-posterior 
axes of their eyes, but as a substitute for the pupils, now 
fuUy dilated, round, and constant in diameter. The lower parts 
of the irides still were tremulous. When she thus forcibly 
(almost) closed the eyelids she could see almost as well as 
with the concave glasses No. 12, viz. (|o). The marked 
greyness of the lenses, and the difficulties of the case generally, 
suggested to me that it might be better for her if, instead 
of her seeing, as she had hitherto very imperfectly seen, 
through a marginal part of her lenses, she were made to 
see through the lower part of her pupils, in which tlie 
grey lenses were absent, treating her afterwards v/ith glasses 
as a case in which the lenses have been extracted Iridectomy 

2 D 2 



39G STREATFEILD ON A CASE OF IRIDECTOMY FOR 

I thought %vould do this best (for I never now will do 
iridesis, by which synechias are artificially produced, and 
then, like all synechia, have many ill consequences likely to 
follow them) ; and moreover, I thought that by an iridec- 
tomy, extending the pupils in the direction in wliich the 
lenses were absent, I should perhaps also check the 
tremulousness in the corresponding parts of the irides, a part 
being there excised, and so obviate the annoyances of the 
dancing, which I believed to be caused by this to and fro 
agitation of the unsupported irides at their lower parts. 
The gTeyness of the misplaced lenses, " now occupying parts 
of the pupillary areee, suggested to me the iridectomy 
operation done for central lamellar cataract ; the greyness, as 
I have said, was in no degree or kind a cataractous opacity, 
and, the lenses being transparent, the case could not be 
treated by their removal, as the extraction of transparent 
lenses is dangerous, and needle operations are not devoid 
of some risks. I proposed to leave the lenses and ignore 
their existence. She had depended on her misplaced lenses, 
and as she was myopic, on her concave glasses. I proposed 
to open out an entirely new way of ^dsion to her, with the use 
of so-called cataract glasses for the future. The mother was 
more than willing that I should do what I thought woidd 
improve her daughter's sight, especially as in her opinion 
it had been getting worse of late. 

I had no longer any room for doubt when, on the 7th 
of July, I tried the efifect of strong convex glasses, the pupils 
at the time being fuJly dilated. I found she could see 
very much better with them now than in any other way. 
With + 3^ she could see f g, and with + 2| she read 
1^ Snellen. Wlien she began to read with the convex 
glasses the eyes seemed to be turned a little more upivards 
than before, a line perhaps. 

She was admitted into University College Hospital on 
the 16tli of July. I did iridectomy in each eye, excising 
symmetrically downwards a small section of the iris, not 
quite up to its gi'eater circumference. In both, after the 



CONGENITAL aiALPOSITION OF LENSES. 397 

excision, a small bead of vitreous (having less than its usual 
support in front) protruded through the outer wound, but, 
the lids being closed, these soon went back, and no escape 
of vitreous took place in either eye. A pad of wool over 
each and a bandage over both eyes were applied. All did 
well after the operation, but for two or three weeks there 
existed a small and slight cystoid protrusion of the cicatrix of 
the external wound of each eye. She left the hospital, and 
these protrusions disappeared soon after. In a few weeks she 
had two pairs of convex glasses, 3|, with which she could 
(as on July 7th) see |^, and also 2h, with which (as before) 
she could read 1^ Snellen. With them she read comfort- 
ably, and at a good distance. No otlier glasses suited her 
better. She liked them very much. She said she could 
now see to thread her own needle, which she never could 
do before the operation. She no longer screws tip her eyes 
to see to read or work. When lier glasses are put on and 
she tries to see anything she immediately holds up her head 
a little more than before. 

Cases of congenitally misplaced lenses are not very 
uncommon. The patients are generally myoj)ic and amblyopic. 
The amount^ and I think the direction (upwards), of the 
misplacement are not unfrequently such as they were in the 
above case. If, therefore, some of these cases of malposition 
may be materially benefitted by an iridectomy, it is worth 
noting. It is, as far as I know, the first time the operation 
has been done for this defect. I have since ascertained that 
M. de Wecker, twelve years ago, did iridesis in a case very 
much like the one I now report (" Anuales d'Oculistique," 
vol. xlix,p. 159). His patient had had, before the operation, 
double vision in one eye. My patient did not complain of 
this. If, after the operation, she still saw at all (indistinctly) 
tlirough her misplaced lenses, she obtained so much better 
images as soon as the strong convex glasses were put on, 
that she was not troubled by double vision at all. 

Case II. Anomalous larrje, loose, floating hody in the 
anterior chamber. 



398 STREATFEILD ON A CASE OF ANOMALOUS 

Mr. H. E. 0. Sankey, medical student, of University 
College, spoke to me one day, about Midsummer, 1875, at 
University College Hospital, about Lis right eye. He asked 
me to examine it, as it was rather uncomfortable ; lie had 
been that day long working at the microscope, and using 
that eye particularly, and wished to know if I observed 
anything wrong in it. I found nothing worth noticing, and, 
by any of the ordinary methods of examination, however 
minutely I had examined the eye, I could not have made the 
discovery, as he afterwards proved to me when he showed 
me the singular phenomenon which his eye presented. 
The answers to all my inquiries of him by word of mouth 
were negative. It may be worth specifying that he said 
the eye was never red or watery ; he could read with either 
eye No. 20, Snellen, at 20 feet distance, and I5 at 3 feet; 
and he made no complaint of any imperfection of vision in the 
eye to which he directed my attention. 

He told me there was something in his eye wliich he 
would show me : he then held his head down, the face 
being in a horizontal position, for about a minute, and 
asked me again to look into his eye. He sat facing the 
window, and I soon saw a large dark body slowly descending 
in the anterior chamber. It was soon again out of sight 
in the very lowest part of the chamber, where it usually 
rested. He then gave me the following history. His age was 
25. He first noticed a smaU speck in the right eye during 
the year 18G7. At that time he supposed it to be a scale of 
dried ink from a pen which he had been scraping. He 
tried to remove it from the eye, and, as it was soon lost 
sio-ht of, he supposed he had succeeded. Some months after 
this he saw it again (after he had been holding his head 
over a basin of water for awhile) in a looking-glass as 
before ; he then saw it was not in front of the cornea, as he had 
before supposed, but behind it. It then appeared to be a flat 
oval body of dark brown colour. He thought it had then no 
indentation in its outline. It was rather smaller than a poppy 
seed. He found that it could be lu'ought into view by inclining 



BODY IX THE ANTERIOR CHAMBER. 399 

the head, as it had been on this occasion. It sank more or 
less slowly, and was finally quite lost to view behind the 
lower margin of the sclerotic. It caused no inconvenience 
by its presence. Xo history of an injury to the eye could 
be obtained on inquiry. It was shown to several medical 
men, and some of them strongly recommended its removal. 
Since it was first seen Mr. Sankey informed me it had 
slightlj" enlarged ; it was, he said, when I examined his eye. 
perhaps one-third or one-half larger than it was at first. It 
was always quite free and moveable. It was on a sub- 
sequent occasion seen to be indented on one side. This 
indentation sometimes presented itseK on one side and at 
other times on the other. The eye had not troubled him, 
though for the last three or four years it has been the one 
chiefly used at microscope work for at least an hour daily. 

On two subsequent occasions I made more particular 
inquiries and observations of this strange and unaccountable 
body, and of the eye itself. His irides were light bluish- 
grey, against which the floating body was well seen, but 
they were marked with darker patches, and on the inner 
side of the iris of the right eye was a large dark jjatch, and 
when the body was in front of this, or of the pupil, it was 
hardly discernible. It appeared to me, as it always appeared 
to him, of a brownish colour, flat and oval in shape, with an 
indentation on one side. Mv. Sankey had no doubt at all 
in his own mind that it was larger than it had been some 
years before, and that its shape had changed, that it was now 
longer and nanower in the middle as compared with what 
it had been when he first discovered it. He was fond of 
shooting, but neither in this nor in any other way had he ever 
had any injury of any kind, that he knew of, to the eye. 
Nor was any report obtained of any accident to the eye 
in his infancy. He thought about eight years ago he had 
had for a few days a slight ophthalmia of a phlyc- 
tenular character, hut this was in the left eye, and not 
in the right. The first time he saw the floating body, to 
recognize it as such, it was only in the looking-glass that he 



too STREATFEILD ON A CASE OF ANOMALOUS 

saw it. He never saw it on his book or writing paper or 
wherever it might be he was looking. He saw it afterwards 
not only sometimes in the looking-glass, but also when he 
was using Hartnack's camera (a double-prism arrangement), 
in drawing microscopic objects, when the head was held 
very much down. Then he saw it on the paper, and it 
appeared ill-defined, kidney-shaped, and brownish, the "hilus " 
not being always turned the same way ; it seemed to him to 
turn quite freely, and he thought it turned over sometimes. 
When in usmg the camera he saw it, it occupied the wdiole 
or nearly all the field, and he could not tell which way it 
moved. When his vision had been thus obstructed, he 
then began to use the other eye instead. I inquired how 
long did it take, when it was opposite his pupil, if he 
watched it in a looking-glass, to disappear from view 
behind the sclerotic margin ? He said he thought about 
three quarters of a minute, but he liad known it take a 
minute and a half when he was not holding his head up 
much. We proceeded to make the following observations : — 

1. He held his head horizontally down and looked on the 
ground till the floating body appeared to him in the centre of 
his pupil, then he he]'^. up his head vertically and looked 
straight before him, and it fell rather rapidly at first (query, till 
it touched the back of the cornea), then more slowly ; in all it 
was fifty-five seconds before it had passed out of my view. 

2. He then held his head horizontally down as before ; 
the floating body took seventy-five seconds in falling forwards, 
before it had reached the centre of his pupillary area, and so 
obstructed vision in that eye. 

3. The first observation being repeated, the time occupied 
was the same as before. The floating body in descending (and 
I made many more observations than these few typically 
noted) always took the same course, the long axis being 
vertical at first, and the indentation to my right hand. In 
descending it rotated a little, slowly and continuously, in 
such a manner that it reached the bottom of the anterior 
chamber, or rather disappeared from view behind the 



BODY IN THE ANTERIOR CHAJIBER. 401 

sclerotic margin, with its convex side, not its end, down- 
wards. I presume therefore that one end of the floating 
body was decidedly heavier than the other, and this being of 
course the lower end, as it slid over the incline of the back 
surface of the cornea it met with some slight frictional 
resistance, and so got a tendency to rotation ; so that of 
the two sides the convex being of course the heavier, the 
body always fell with that side downwards. 

4. The head having been held horizontally, and the 
floating body being thus by gravity brought opposite to the 
centre of the pupil as before, the head was suddenly brought 
up again and held somewhat backwards beyond the vertical 
position. It then fell much more rapidly and was out of 
sight in sixteen seconds. 

5. To determine its actual size approximately, I got a 
large concave mirror, and in a good light collected and 
reflected by it into his eye and face, which was inclined 
downwards (but not in the horizontal position), so as to retain 
the floating body in view and in one place against the back of 
the cornea. Mr. Sankey held my small ivory French measure 
vertically and close beside his eye on the temporal side, at 
the level, as near as we could judge, of the floating body in the 
anterior chamber ; the two being then at rest and side by side 
and well illuminated, he found the length of the floating body 
to be a millemeter, and its breadth one half. 

6. With my head resting on the back of an arm-chair, 
and face vertically upwards, I examined the floating body 
with my hand microscope (Bruecke's lenses). For this 
purpose Mr. Sankey, standing on a footstool beside my chair, 
and stooping over me, brought his face vertically downwards, 
and at the same time threw the strong light of an ophthal- 
moscope mirror obliquely into his eye ; so that the floating 
body was at rest, well illuminated, and easily examined and 
magnified. It was exactly kidney-shaped, perfectly regular 
and smooth in its curved outlines, everywhere brownish, of the 
colour of uvea, except in the concavity, where it was colour- 
less or pale ; of a deep brown elsewhere, especially around the 



402 STREATFEILD ON A CASE OF ANOMALOUS 

margins, deepei' brown at the ends ; the direction of its long 
axis was the same as ah-eady mentioned for the same part 
of the anterior chamber, that is to say almost vertical. I 
thought it to be a flattened body, but I never could see it edge- 
ways ; we tried many ways of getting it to turn over, but 
always unsuccessfully, and perhaps the not being able to get it 
to turn over is the best evidence we can have of its being some- 
what flattened ; it was perfectly free and had no band any- 
where connecting it with any of the parts of the anterior 
chamber. 

I now used atropine to dilate the pupil of the right eye 
sufficiently for ophthalmoscopic examination ■ in due time this 
being effected, and the pupil well and fully dilated, it was 
found not to be quite circular. On the outer (and a little 
towards the lower) side there was a slight flattening of the 
circumference of the pupil, and the width of the iris in that 
situation was slightly greater than elsewhere, but there was 
no adhesion of the iris, nor was there any evidence of a 
former adhesion having existed; there was no serration of 
the pupil, and no uvea left on the front of the lens or on 
the back of the cornea. He was slightly hj'perme tropic; no 
abnormal appearance could be seen in the fundus or in any 
part of the interior of the eye; especially was there nothing 
abnormal in that peripheral part of the fundus seen when 
he looked out and a little downwards to the right (in the 
direction in which the slight irregularity in shape of the pupil 
was seen). The pupil of the left eye was not dilated with 
atropine, but the eye was examined, and showed no abnormal 
appearance with or without the ophthalmoscope. 

7. In order carefully to examine the floating body, 
when it was at rest, with the ophthalmoscope mirror, and to 
determine if it were at all transparent, I now laid myself 
down on my back on the floor, with the ophthalmoscope lamp 
also on the floor a little to the right of my head, and Mr. 
Sankey knelt on the floor beside me, with his face horizontal, 
looking downwards, and in various directions. The loose 
body appeared, with the strong light of the ophthalmoscope 



BODY IX THE ANTERIOR CHAMBER. 403 

behind it, to transmit no light. Thus quietly observed with 
direct light, it appeared brown (uvea) coloured as before 
observed, its convex side to the left of the observer, as I had 
always seen it. j\Ir. Sankey now several times, whilst I was 
lying on my back and ready with the ophthalmoscope, held his 
head so much back as to ])e in the same position as mine was 
then, and again quickly held his face down as before for me 
to observe the floating body as it fell forwards. I however 
could never get a view of it edgeways, if it had an edge. I 
could never see it with the convexity or concavity towards 
me, I always saw both the sides described. It seemed to me 
to be a flat body. Once in this way of experimenting 
with it I saw the concavity downwards. It was never seen 
to change in shape whilst it was being examined by mo ; nor 
had this been observed by Mr. Sankey on any previous 
occasion w^hen he had been observing it. 

My advice was that at this time nothing should be done; 
j\Ir. Sankey complained of no inconvenience, he readily 
employed the left eye if the floating body, in using the 
camera, obstructed vision in the right eye. And the loose 
liody had probably not, at least for some time, increased or 
changed in size or shape. But if in the future there were to 
arise the slightest evidence of any irritation or inflammation 
in the right eye-ball, or if the floating body were to grow (and 
we now know its dimensions), I would then recommend that 
it should be evacuated by an incision of the cornea, with the 
aqueous humour in which it so freely moved. Mr. Sankey 
of course would be loath to have any operation done. And the 
loose body has existed where it is so many years without any 
ill consequence arising, that one can hardly expect that any 
harm will come of it. 

I hope it will not call for operative interference, but, at 
the same time, I should be very glad of an opportunity of 
ascertaining with certainty, after its evacuation, what is the 
nature of this anomalous body. And in that case I sliould 
have the pleasure of overcoming the difticulty of operating in 
the recumbent position, for I am sure that in no other way 
could the loose body ha deliberately and certainly evacuated. 



TREPHINING THE SCLEROTIC— i NEW OPERATION 
FOR GLAUCOMA. 

By D. Argyll Robertson, M.D., F.R.C.S.E., F.R.S.E., 

Ophthalmic Surgeon to the Royal Infirmary, Edinhurgh. 

Ophthalmic surgeons at the present day generally agree 
in viewing the symptoms present in most cases of glaucoma 
as dependent upon increased intra-ocular pressure. How this 
increase of tension is produced, whether by augmented 
secretion of vitreous humour, by serous transudation or 
inflammatory exudation into the chamber of the vitreous 
humour, by alteration in the structure of the sclerotic, or 
by other pathological states, has not yet been satisfactorily 
determined. It is not my object in this paper to discuss 
these points, although personally I incline to the view that 
the increased tension is due in some cases to increased 
secretion of vitreous humour, in others to serous transudation 
into the chamber of the vitreous humour. All the other 
symptoms of the disease, including the impairment or loss of 
vision, can readily be explained by the pressure to which all 
the structures in the interior of the eye that lie between the 
vitreous humoar on the one hand, and the resisting sclerotic 
and cornea on the other, are subjected. All measures, there- 
fore, that are undertaken for the cure of this disease, have for 
their object the reduction of the increased intra-ocular 
pressure. 

The following are the operations that have hitherto been 
practised for the alleviation or cure of glaucoma. 1st, para- 
centesis of the cornea ; 2nd, incisions into the chamber of the 
vitreous humour (known as " division of the ciliary muscle " 
and " intra-ocular myotomy ") ; and 3rd, iridectomy. 

Paracentesis of the cornea is by far the simplest procedure, 



ROBERTSON ON TREPHINING, ETC. 405 

and is attended with considerable benefit, but unfortunately, 
as was pointed out by Von Graefe, its effect is only temporary, 
each successive evacuation of aqueous humour producing 
less and less benefit, so that this method has been almost 
entirely abandoned. 

The operation of division of the ciliary muscle, or intra- 
ocular myotomy, has undoubtedly a very marked effect in 
reducing the tension of the eye, and although the benefits arising 
from the operation have been attributed by the gentlemen 
who proposed it to a division of the ciliary muscle, I am 
more inclined to consider the evacuation of a small quantity 
of the humours of the globe and the presence of an aperture 
in the resisting coat of the eye as the main factors in bringing 
about that result. This operation never obtained very general 
favour, and has of late fallen much into disuse, chiefly I 
believe on account of the temporary character of the benefit 
following it, and also partly from the liability of all wounds 
in the ciliary region to be followed by chronic insidious 
cyclitis leading to loss of vision in that eye, and even by 
sympathetic ophthalmia in the neighbouring eye. 

Thus it happens that at the present time iridectomy is 
the prevailing remedy for all glaucomatous affections, and 
should the removal of one portion of iris fail to produce the 
desired effect, the only further measure to be resorted to is 
the excision of another piece. In many cases of glaucoma 
iridectomy is undoubtedly followed by excellent effects, and 
I would be the last to decry its application in suitable cases, 
but it must accord with the experience of most oculists that 
there are occasionally cases in which the iridectomy, owing to 
extensive adhesions between the iris and capsule of the lens, 
or degenerative changes in the structure of the iris itself, cannot 
be effected, and others in which that operation instead of 
benefitting seems almost to aggravate the disease. 

It is in these classes of cases particularly that some other 
means besides iridectomy of permanently reducing the tension 
of the eye, and thus allaying the severe pain that accompanies 
these affections, and even restoring some vision, or at any 



406 ROBERTSOX ON TREPHINING 

rate retaining the vision that remains, is desiderated. This 
I imagine I have siicceeded in obtaining by the operation of 
trephining the sclerotic, whereby a circular aperture about 
^ of an inch in diameter, is drilled through that membrane, 
permitting the escape of soine of the superabundant fluid in 
the chamber of the vitreous humour. This of course at once 
reduces the intra-ocular tension, but I further believe the 
reduction in tension thus produced is likely to be of a 
permanent character, as the circular opening in the sclerotic 
must be filled up by new tissue which is of less firm texture 
than the original sclerotic, and will thus readily yield to any 
pressure from within, and act the part of a safety valve 
should the contents of the vitreous chamber be at any 
future time again increased in amount. 

The point I have hitlierto chosen for perforating the scle- 
rotic is at or about the junction of the ciliary processes with the 
choroid, so as to avoid as far as possible the more anterior parts 
of the ciliary processes, injury of which experience has shown 
is apt to produce insidious inflammatory and degenerative 
changes. The instrument with which I have in all cases as 
yet performed the ope-^ation is the corneal trephine devised 
by Mr. Bowman for operating on cases of conical cornea; 
but I found that it was not in all respects well adapted for 
perforating the sclerotic, and have therefore had a similar 
instrument made with certain modifications. I found that 
with Mr. Bowman's instrument it was very difficult to recog- 
nise when perforation was effected if the central brass rod 
was left in the cylinder, and if this central brass rod were 
removed before trepliining, that a considerable quantity of 
vitreous humour was necessarily ejected through the cylinder 
whenever the coats were perforated, owing to the amount of 
pressure necessary to force the tapering cutting extremity of 
the cylinder through the thickness of the sclerotic. I further 
found that the smooth surface of the narrow cylinder did 
not afford the fingers a firm grasp during the necessary 
rotatory movements. I therefore had an instrument made 
by Messrs. Weiss and Son, consisting of a steel cylinder, the 



THE SCLEROTIC FOR GLAUCOMA. 



407 



cutting extremity of which for the length of j"^ of an inch 
was made very thin, tlie other extremity of the cylinder, 
to the extent of fully ^ an inch, being surrounded by a ring 
of german silver roughened on its outer surface so as 
to afford a good hold for the lingers. The alteration in 
the cutting extremity is to enable perforation to be more 
readily effected, while the projecting shoulder prevents 
the instrument passing too far into the interior of the eye. 
When not in use there is a cap to fit over the cutting 
end of the cylinder to prevent it being injured. The accom- 
panying woodcuts (drawn to the natural size) indicate the 
points of difference I have described. 




1. Mr. Bow-man's Cornea 
Trephine, with Eod. 



2. The Sclerotic Trephine, 
with Cap. 



I have only performed the operation on four cases, and as 
each case presented certain distinctive peculiarities, I shall 
now give a shurt account of them. 

Case I. M. A. M., a short-built ill-developed looking 
girl 22 years of age, liaving the physiognomical characteis 
of inherited syphilis, came to me for advice on the 3rd of 
March, 1875; she was then suffering from the results of recent 



408 ROBERTSON ON TREPHINING 

interstitial keratitis. In the left eye there had been corneal 
ulceration, for the treatment of which a saturnine lotion 
had been employed, whereby a dense white centrally-situated 
opacity (due to deposit of chloride of lead) had been pro- 
duced. In the TigM eye the cornea was nebulous throughout, 
but also showed some more dense opaque spots, especially 
towards its centre. There had also been severe iritic com- 
plication in the course of the keratitis, as was indicated 
by extensive adhesions between the iris and capsule of lens. 
"With the rigM eye she could count fingers at three feet, with 
the left she could only do so when the fingers were held 
close in front of the eye. A slight degree of injection 
existed in both eyes. She was ordered drops to apply to the 
eye, consisting of gr. ij of sulphate of atropine to ^iij of 
wine of opium, and ^v of distilled water. A drop to be 
applied to each eye night and morning. 

She returned on June 26th, complaining especially of 
pain and irritation in the Uft eye, caused by a stapliy- 
lomatous protrusion of the sclerotic opposite the upper 
margin of the cornea. The staphyloma was pretty sharply 
defined, was about 4 lines in diameter at its base, and 
projected so much as materially to interfere with the 
movements of the upper lid. There was a slight degree of 
injection of conjunctival and sub-conjunctival vessels. There 
was complete pupillary exclusion, and the iris bulged for- 
wards towards the inner surface of the cornea. The tension 
of the eye was very much increased (T. + 3). She had still 
perception of light with the eye. 

The right eye presented much the same appearance as 
when she first came under observation, except that the 
cornea had cleared at its upper and inner part, but she was 
still unable to see sufficiently to guide herself. The tension 
of this eye was normal. On June 27th, the patient having 
been placed under the influence of chloroform, I removed, 
by means of Mr. Bowman's cornea trephine, a circular disc 
of the sclerotic from the most protruding part of the 
staphyloma of the Uft eye. A small quantity of abnormally 



THE SCLEROTIC FOR GLAUCOMA. 409 

fluid vitreous humour (or serum in the chamber of the 
%dtreous humour) escaped through the opening. The lids 
were closed, and a cold compress applied. 

At the same time I performed an iridectomy inwards in 
the right eye. 

Very little irritation followed either operation, the left 
eye being, however, a little tender to the touch for a few 
days. The t)pening in the sclerotic became gradually cica- 
trised over. 

Her condition on discharge, on July 10th, was as follows : 

Left eye. The staphylomatous protrusion has completely 
subsided, the general curvature of the eye having become 
re-established. Tlie position- of the staphyloma is still 
evident by the blueish colour of the sclerotic at that part. 
The tension of the eye is slightly less than normal (T. -1). 
The eye is no longer tender to the touch. The spot where 
the sclerotic was trephined can now scarcely be distinguished. 
The iris is still bulged forwards towards the cornea. There 
is still a very slight degree of injection of the conjunctival 
and the sub-conjunctival vessels, but she expresses herself 
free from all pain and irritation in the eye. She can now 
count fingers \\dth it at one foot distance. 

Right eye. There is now an oval-shaped pupil opposite 
a moderately clear portion of cornea. The tension is 
normal. There is no abnormal injection. She can count 
fingers at four feet, and see to guide herself easily. She 
cannot read (not knowing the letters), but readily points 
to and counts letters of No. XX Snellen. 

The patient returned on October 4th, complaining of pain 
and irritation in her left eye. There was a considerable 
amount of sub-conjunctival injection (which became much 
increased when the eye was touched), and the eye was tender 
on pressure. The tension was diminished (T. — 1), and she 
could, though with difficulty, count fingers held close to 
the eye. The trephined spot was only visible as a minute 
circular grey dot, level with ' the adjacent sclerotic. There 
was no bulging of the coats of the eye any^\'here, the part 
VOL. VITI. 2 E 



410 ROBERTSON ON TREPHINING 

that was foriiierl}' stapliylomatous presenting a bluish-grey 
colour. As the left eye was painful and tender to the tou.ch, 
and might sympathetically afiect the other eye (in which the 
vision remained as at last report), while the patient came 
from a distance, and could not thus be kept under obser- 
vation, I recommended enucleation, which was efi'ected on 
October 6. 

On examining the eye after removal, the vitreous humour 
was found quite clear, and of almost normal consistence, and 
the chief pathological change noticed in the parts posterior 
to the iris was an irregular arrangement of the pigment of 
the choroid, patches of considerable pigmentary deposit 
alternating with spots from which the pigment was almost 
absent. This was especially the case at the most anterior parts 
of the choroid. The trephined spot was only to be recognised 
by the coats of the eye being thinner at that point. There 
was no trace of exudation, nor any increase of the patho- 
logical condition of the choroid in the neighbourhood of that 
spot, while the vitreous humour lying against it was quite 
transparent. 

Case II. John Pearson, 59 years of age, a packer by 
occupation, came to the Eoyal Infirmary on the 25th of June 
last, complaining of severe pain in his left eye, attended by 
loss of vision. 

He stated that his sight was good in both eyes till about 
five or six years ago, when he had an attack of inflammation 
in the left one, accompanied by pain in the eye and dimness 
of sight. The eyelids at that time were gummed together 
during the night, and the inflammation soon yielded to a 
lotion " containing zinc." He has had similar, but milder, 
attacks of inflammation in both eyes (probably conjunctival) 
at intervals since that time, but vision was not impaired 
during these attacks. About a month ago he noticed that 
his left eye was slightly inflamed and painful. He bathed 
it frequently with warm w^ater, which afforded temporary 
relief to the pain, but the inflammation did not diminish ; the 
pain, which was intermittent, became more constant and 



THE SCLEROTIC FOR GLAUCOMA. 411 

more severe, and his vision became rapidly impaired, so 
that in three days his sight in that eye was completely lost. 
" He was unable with it to distinguish light from darkness." 

On examination the affection of the left eye presented 
all the characters of acute glaucoma. Both the superficial 
and deeper vessels were much engorged, the pupil was some- 
what dilated and immobile, there was a green reflection 
from the interior of the eye, the tension was greatly increased 
(T. + 3). There was no perception of light with that eye. 
The media were so turbid as to prevent ophthalmoscopic 
examination of the fundus. The other eye was normal. 

On the following day (June 26th) T performed an iridec- 
tomy upwards. Considerable relief followed the operation, 
but the injection of the vessels did not diminish to any 
marked degree, the corneal incision showed no tendency to 
heal, and within a week the tension became increased to as 
great a degree as before, and the pain in the eye so severe at 
night as to prevent sleep. With the view of inducing a 
healing action in the wound, the edges of the incision were 
gently touched with a solution of nitrate of silver (gr. x. — ^l) 
which application however occasioned great irritation, and 
did not effect the desired result. 

The suffering endured by the patient was such as to 
necessitate some • further remedial measure. A second 
iridectomy was precluded by the coraj)lete absence of the 
anterior chamber ; it was therefore necessary either to have 
recourse to some other means of reducing the increased 
intra-ocular pressure, or to remove the eye. Having 
observed such a great diminution in the tension follow 
trephining the sclerotic in the case of M. A. M., I deemed 
it advisable to test the efl&cacy of the operation in this case 
rather than proceed at once to enucleation. Accordingly on 
July 5th I trephined the sclerotic at the distance of about 
two lines from the upper margin of the cornea. A consider- 
able amount of very fluid vitreous humour escaped through 
the opening ; a cold wet compress was applied. The pain 
from the operation soon subsided, and he slept well that night. 

2 E 2 



412 ROBERTSON ON TREPHINING 

The following day the incision was found closed, and the 
anterior chamber filled \Aith blood. The injection of the 
conjunctival and sub-conjunctival vessels was still consider- 
able, the eye was tender to the touch, and the tension much 
diminished (T.-2). 

July 11th. The injection has been becoming gradually 
less, and the blood in the anterior chamber is in process of 
absorption, but a little still remains. The tension is still much 
diminislied (T. — 2). The pigment of the choroid is visible 
at the point where the sclerotic was trephined, but the 
aperture is becoming cicatrised over. The lens appears to be 
slightly opaijue, and no red reflection can be obtained on 
ophthalmoscopic examination. The patient has been free 
from pain. 

On July 23rd Pearson presented himself again, and com- 
plained that severe nocturnal pain had returned. The tension 
was found to be increased (T. -|- 2), and the lens had become 
decidedly opaque. To relieve the symptoms, on the following 
day the eye was punctured at the point where the sclerotic 
had been trephined ; a considerable amount of serous fluid 
escaping. This gave great relief to the patient, and 
for a week he was free from pain; when once more the 
tension -became increased and pain returned. This speedy 
recurrence of increased intraocular tension suggested to my 
mind the probable presence of a rapidly growing tumour in 
the interior of the eye, which view w^as strengthened by the 
cataractous changes in the lens and the persistence of con- 
junctival and sub-conjunctival injection. As the symptoms 
however had been so markedly alleviated for a time by 
paracentesis, I determined to repeat that measure once more, 
but recommended that should permanent benefit not follow, 
the eye should be enucleated. The paracentesis again effected 
a reduction of the tension and a relief from pain. 

On August 25tli, however, the pain returned (although 
the tension remained rather minus), and the right eye began 
to show symptoms of sympathetic irritation, becoming injected 
and watering and the sight becoming dim after use of the 



THE SCLEROTIC FOR GLAUCOMA. 413 

eye in reading, &c., for a short time. As these symptoms did 
not materially abate, the left eye was enucleated on the 31st 
of August. 

Examination of the eye. The circular trepliined spot 
was filled up by firmly organised new fibrous tissue, wliich 
projected slightly beyond the adjacent sclerotic. The eye 
was cut open by a vertical incision through the centre of the 
cornea. On perforating the sclerotic some abnormally fluid 
vitreous humour escaped, and immediately a rounded tumour 
of light grey coloin- and of soft consistence came into view. 
This growth was found to be about the size and shape of a 
small bean ; it was attached by one end to the extremity of 
the optic nerve, and to the retina, choroid and sclerotic at the 
outer side of the nerve (with which coats at that part it had 
become more or less incorporated), and bulged forwards, occu- 
pying about two-thirds of the chamber of the vitreous humour. 
On examining the growth microscopically, it was found to 
consist mainly of small oval and spindle-shaped cells, varying 
in diameter from about 3 oVo ^^ "aoVo" ^^ ^^^ inch, and having 
nuclei and granular contents. There was no abnormal 
appearance or trace of inflammation in the coats of the eye 
immediately adjacent to the trepliined spot, which was just 
at the junction of the ciliary processes with the choroid. 
The nerve at the point where it was divided appeared 
healthy. 

The patient made a speedy recovery from the operation, 
and all symptoms of sympathetic irritation rapidly subsided, 
and as yet there are no signs of any new growth in the orbit. 

Case III. Angus McLaren, a farm-servant, 57 years of 
age, came to the Royal Infirmary on the 21st of July last, 
complaining of severe pain in the left eye. 

Rather more than a year ago he had an attack of acute 
inflammation of the left eye, attended with severe pain in the 
temple, and resulting in complete loss of vision. Since May 
last he has suffered periodically from severe pain in the left 
eye, extending to the left temporal and frontal regions, 
frequently preventing sleep. 



414 ROBERTSON ON TREPHINING 

Upon examination, the left eye was found to be affected 
with advanced glaucoma ; there was injection of both 
conjunctival and sub-conjunctival vessels, the pupil was 
dilated and immovable, the iris of a slaty-grey colour, and 
from the interior of the eye a greenish reflection was 
observable. There were two or three minute staphylomatous 
protrusions of the sclerotic near the margin of the cornea, and 
the tension of the eye very much increased (T. + 3). There 
was no sight in the eye. Ophthalmoscopic examination 
revealed deep cupping of the optic disc. 

On July 22nd the sclerotic was trephined at the distance of 
about 2 lines from the upper and inner margin of the cornea. 
A small quantity of vitreous humour, of normal consistence, 
escaped through the opening, and some bleeding occurred 
under the conjunctiva. A cold wet compress was applied. 
The patient's sufferings were at once relieved, and he slept 
well that night. 

The following day the tension was decidedly diminished 
(T. — 2), and the eye slightly tender to the touch at the point 
of perforation ; but the patient expressed himself much 
relieved. 

On August 8th, the tension of the eye was found a little 
less than normal (T. — 1), the vascular injection had dimi- 
nished, and a little lymph was observed to protrude slightly 
from under the conjunctival flap covering the trephined spot. 
The staphylomatous protrusions had receded, the position 
they formerly occupied- being only marked by slightly 
pigmented spots, and the iris presented a more healthy 
colour. The patient has been entirely free from pain since 
the operation. 

On the 14th Novemlier the patient returned, by request, 
for examination. In the eye that had been operated on, the 
pupillary margin of the iris is adherent at the lower and inner 
side to the capsule of the lens. At the upper and outer side 
of the eye there is a plexus of distended tortuous sub- 
conjunctival veins ; two especially large ones emerge from 
the interior at the point where the sclerotic was trephined. 



THE SCLEROTIC FOR GLAUCOMA. 415 

The new tissue occupying the aperture in the sclerotic bulges 
slightly forwards, and the small pigmented spots corresponding 
to the staphyloniata that previously existed are also very 
slightly raised above the level of the neighbouring sclerotic. 
The tension of the eye is about normal, rather diminished 
than increased, and there is no tenderness of the eye to touch. 
The pupil of the left eye contracts when light is admitted 
to the neighbouring one. 

Vision in the right eye is normal. On directing the light 
with the ophthalmoscope into the left a dull grey reflec- 
tion is alone obtained, which is produced by a greyish 
coloured membrane that appears to stretch from the point of 
aperture in the sclerotic across the chamber of the vitreous 
humour a little posterior to the lens, and prevents a view of 
the fundus. This membrane has a reddish tint at one point, 
and I think probably owes its origin to blood-extravasation. 
The patient states he has remained quite free from pain in 
the eye. 

Case IV. Jessie Pringle, aged 21, was admitted to the 
Ophthalmic wards of the Eoyal Infirmary on the 22nd 
September last, complaining of defective vision. 

She states that she saw perfectly till about six months 
ago, when she noticed a mist in front of the left eye, 
accompanied by pain in the eye. The obscuration of sight 
lasted only about a day, but after an interval of a few days 
returned, and she has had recurrent attacks of impaired sight 
and pain in the eye and temple since. Latterly vision in this 
eye has not been completely restored during the intervals 
between the attacks. The right eye began to trouble her six 
weeks ago, exactly in the same way as the left had formerly 
done. Before the sight became dimmed in either eye, an 
appearance of coloured rings round the gas light or other 
bright object was noticed. She never observed any appearance 
of inflammation in either eye. 

The patient is a dark complexioned girl, with dark brown 
irides, and of very diminutive stature, owing chiefly to angular 
curvature of the spine. In both eyes there is apparently a 



416 ROBERTSON ON TREPHINING 

slight degree of turbidity of the aqueous humour, but more 
marked in the left eye. The pupils are of medium size, and 
contract readily under the influence of light. In both eyes 
there are a few enlarged sub-conjunctival veins. The 
tension of both eyes is markedly increased (T. + 2 in the left, 
and nearly + 2 in the right). Vision in the left eye = f^ ; 
both convex and concave lenses impair distant vision. 
Vision in right eye = f^ ; a convex lens of 80 inches focus 
does not impair distant vision. In the left eye the field of 
vision is almost entirely absent to the inner side, and slightly 
contracted below. In the right eye the field of ^dsion is 
about normal, perhaps slightly contracted inwards. Ophthal- 
moscopic examination revealed deep cupping of both optic 
discs, and slight pressure sufficed to produce pulsation in the 
retinal arteries. 

On the 23rd September I performed iridectomy upwards 
on the right eye, and trephined the sclerotic about 2 lines 
from the upper and inner margin of the cornea in the left. 

The patient recovered rapidly from both operations 
neither of which was attended with almost any irritation, and 
she left the hospital in a week. 

On October 28th she returned to report progress. In the 
left eye the spot corresponding to the portion of sclerotic 
trephined bulges considerably forwards, and is of a blueish- 
black colour, with a little ring of vascularity round it. In 
the right eye there is scarcely any abnormal injection. The 
media in the left eye appeared a little dim on ophthal- 
moscopic examination. The optic disc was still deeply 
cupped, and slight pressure produced arterial pulsation. 

In the right eye the media were transparent, but the 
cupping of the disc also deep. 

The distant vision in each eye was = f ^, and was not 
improved in either eye by concave or convex lenses. Yet 
while with the right No 1 (of Jaeger's types) could be read at 
7 inches, only No. 12 could be read with the left. 

The field of vision in both eyes was the same as previous 
to the operations. The tension in the left eye was less than 



THE SCLEROTIC FOR GLAUCOMA. 417 

before the trephining, but still greater than normal (T. + 1), 
while in the right it had almost returned to the healthy- 
standard. 

Her eyes were again examined on November 26th, the 
pupil of the left eye having been previously dilated by 
atropine. 

Ze/K eye. V. = -^^, but with a vertical stenopceic slit, 
V. = if. With + 12 reads No. 4^ with difficulty. 

Right eye. V. = |-|, but with a vertical stenopceic slit, 
V. = \l. Eeads No. 2 with difficulty. 

The new tissue at the trephined spot in the left eye still 
bulges freely forwards. A very fine pigmented filament was 
observed crossing the upper part of the dilated jji-^pilj 
attached at both extremities to the anterior surface of the 
iris, probably remains of the pupillary membrane. The 
media were clear. The fundus as near the trephined spot as 
could be seen with the ophthalmoscope appeared normal. The 
optic disc was still deeply cupped. The tension still slightly 
above the normal (T. + 1). The field of vision still remains 
almost entirely absent to the inner side, and slightly 
contracted below as before the operation. 

In the right eye the tension is normal. 

The patient was examined on December 3rd, 7th, and 
21st, and on each occasion the tension in both eyes was 
found normal. On the last date she was tested with 
cylindrical lenses with the following result : — 

Left eye with — 34 cyl. V. = jf. Eeads readily No. 6 of 
Jaeger, but only for a short time, fatigue and dimness of 
sight soon ensuing. Cylindrical lenses do not materially 
improve her near vision. 

Bight eye with — 16 cyl. V. = ^f. With + 16 cyl. reads 
No. 1 of Jaeger. 

In the first two cases in which I operated, I did not bare 
the surface of the sclerotic before applying the trephine. In 
the first case this did not give rise to any inconvenience, as 
the conjunctiva was tightly stretched over (and perhaps 
adherent to) the bulging sclerotic ; but in the second case I 



418 ROBERTSON ON TREPHINING 

experienced a little difficulty in applying the trephine from 
the ease with which the conjunctiva slid over the subjacent 
membrane, so that in the last two cases I turned \\\) a flap of 
conjunctiva with a cataract knife before proceeding to 
trephine, and afterwards replaced it over the aperture. I 
have always made the opening through the upper part of the 
sclerotic, as being the part most easily got at, and as the eye 
during the trephining could be pressed against the firmly 
resisting inferior orbital plate. The lids were kept asunder 
by means of an ordinary spring speculum, and the eye was 
fixed in the usual way with toothed forceps. The only after 
treatment necessary was the application of cold wet com- 
presses, frequently changed, for the first eight or ten hours, 
and thereafter the wearing of a shade and attention to 
cleanliness. 

The first case subjected to the operation was one of exten- 
sive staphyloma of the sclerotic. I have previously in 
several instances of this disease punctured the projecting 
coats of the eye with considerable benefit, and this was a 
mode of treatment that used formerly to be frequently 
employed ; but as a ^^nle, the benefit is of only short dura- 
tion, the coats of the eye after a short time bulging forwards as 
much as before. It was with the view of producing a more 
permanent effect that I conceived the idea of forming a 
circular aperture in the sclerotic which would be slow of 
healing. The result in this case exceeded my expectations, 
as in addition to the subsidence of the staphyloma, the 
tension, which was previously excessive, remained per- 
manently diminished, and vision was slightly improved. 
Such improvement having occurred in an eye so much 
diseased, encouraged me to hope for still greater benefit 
in more favourable cases. No doubt, after the lapse of 
about three months, I deemed it advisable to enucleate the 
trephined eye, on account of some sympathetic irritation in 
the other ; but the occurrence of this sympathetic irritation, 
may, I think, more reasonably be attributed to the diseased 
state of the eye that existed prior to the operation 



THE SCLEROTIC FOR GLAUCOMA. 419 

than to the operation itself. This is rendered the more 
probable by the consideration of the comparatively healthy 
state of the coats of the eye around the scar of the operation. 

In the second case the most marked feature was the 
constant recurrence of increased intra-ocular tension after 
the healing of the trephined opening, and after the little 
wounds by which paracentesis was effected had closed. 
This peculiar feature of the case led me to suspect an 
intra-ocular growth. On eventually having recourse to 
enucleation, the presence of a tumour was demonstrated. 
That, even in such a case as this, where the increased ten- 
sion was due to a rapidly growing tumour, and where 
iridectomy had completely failed to give relief, the trephining 
should have been of such decided benefit, ridding the patient 
of pain, and diminishing tension, is irresistible proof of the 
efficacy of the operation. 

In the third case the operation effected all that was 
desired ; it at once relieved the pain, and caused diminished 
intra-ocular tension, which relief has persisted up to a recent 
date. I must not, however, overlook the presence of the 
membranous film in the vitreous humour revealed by 
ophthalmoscopic examination when the patient was last 
seen. This I think most probably resulted from extravasa- 
tion of blood into the chamber of the vitreous humour after 
the trephining. I cannot help considering this as possibly 
one drawback to the performance of the operation in cases 
of glaucoma where there still exists a chance of recovery 
of vision. That some extravasation should ensue is to be 
looked for, when we consider that some] of the blood-vessels 
of the choroid must be divided, and that on the sudden 
diminution of the intra-ocular tension, the previously com- 
pressed vessels will become distended with blood. How 
far this may invalidate the employment of this operation 
for the restoration of vision in cases of glaucoma, further 
experience will alone determine. 

In the last case the trephining was performed on one 
eye, and iridectomy on the other. It was the only one of 



420 ROBERTSON ON TREPHINING, ETC. 

the four in which the retention or restoration of vision could 
be hoped for, and I think in it a highl}'- satisfactory result 
has been obtained. The eye subjected to trephining was 
the worst one, the vision in it considerably impaired, and 
gradually becoming worse, threatening to end in total 
blindness. After the operation we find the sight about as 
good as it was before, and the increased tension (in the 
persistence of which the danger depended) removed. I 
think I may fairly say that the operation was relatively as 
successful as the iridectomy in the other eye. One marked 
feature in the course of the recovery from the trephining 
which still remains to a certain degree, was a diminution in 
the power of accommodation. This may probably be ex- 
plained by the injury to which some of the fibres of the 
ciliary muscle are subjected by the operation, and to the in- 
flammatory exudation into the parts in the neighbourhood 
of the perforated spot that presumably occurs during the 
process of reparation. 

On reviewing these cases, and summing up the result of 
my experience, I can as yet only say that in this operation 
we possess an effectual means of reducing increased intra- 
ocular tension. I further believe that in most cases it will 
be found effectual in preventing a return of increased tension, • 
or, at any rate, in warding off the evil consequences of that 
condition. 

In what cases it should not be employed, and in which 
cases it will prove most beneficial, further experience and 
observation will indicate. In the meantime I have deemed 
it right to bring this operation under the notice of the 
profession, so that its merits may be tested. 



AJf OPERATION FOR THE RELIEF OF XEROPHTHALMIA. 
By F. BuLLER. 

Late Senior House -Surgeon, Royal London Ophthalmic 
Hos^ntal. 

The treatment of xerophthalmia has hitherto been found 
so unsatisfactory, that when the condition becomes well 
pronounced probably no surgeon would venture to hold out 
any hopes of restoring useful vision, and even the so-called 
palliative remedies hardly afford sufficient relief to make it 
worth the patient's while to persevere in their use ; so that we 
find these cases steadily advancing from bad to worse, until 
at last the cornea frequently becomes covered by an unsightly 
mass of yellow incrustations, which when removed reveals this 
structure so altered in texture that it resembles more the 
surface of an ordinary fresh scar produced by the process 
called " healing by scabbing " than anything else, and for all 
visual purposes it may be said to have ceased to exist. 

That, however, the most desperate case remains for a long 
time capable of undergoing very considerable improvement 
when placed under favourable circumstances, is, I think, 
sufficiently proved by one which I have recently had the 
opportunity of observing, and of which a few words may 
serve to give some idea. 

Case I. G. B., a^t. 11, admitted February 2, 1874, bears 
unmistakable signs of hereditary syphilis, and is a puny but 
rather precocious lad. 

Eyes became affected at 6 years of age, during an attack 
of measles, and have never been well since ; both conjunctival 
sacs almost entirely obliterated and destitute of any trace of 
moisture; the lids are adherent to the eyeballs, except for about 



422 BULLER ON AN OPERATION 

one line in width of tlie lower, and a line and a half of the 
iippev. The conjunctiva both ocular and palpebral, if such 
may be said to exist, is more or less rough, dry, and in parts 
covered with scales of epithelium. Cornea covered by thick 
yellowish crusts. When these were removed the cornea 
appeared somewhat pitted, and exuded in parts a small 
quantity of coloured serum. Standing in front of a window, 
the patient could tell when the hand was passed between it 
and the eyes, but could not perceive movements of the hand 
with his back to the light. 

Under the use of a lotion containing bicarbonate of soda 
and glycerine, constantly applied on compresses of lint, the 
cornea could be kept free of dried epithelium, and vision so far 
improved that patient was able to count fingers at one foot 
distance. 

After the eyelashes had been removed, the lids of the 
right eye detached from the globe, sewn together for ten days 
and then separated, some further improvement in vision was 
found to have taken place. The lids of the right eye were again 
sewn together carefully, and after t]iey had become firmly 
united the patient w"'^ sent home with directions to return in 
twelve months, there being at the date of discharge a small 
aperture at the inner canthus, from which a certain quantity 
of moisture exuded when friction and pressure were applied to 
the closed lids. 

Ee-admitted January 1, 1875. The left eye in about the 
same condition as when last seen, the surface being covered with 
thickened and dry epithelium. The right lids still adherent to 
each other all along their borders, except for a short distance 
at the inner canthus, at which part a small quantity of yellowish 
mucus collects in the morning. Lids freely movable upon 
the globe, and perception of light through them good. When 
separated along the line of union, the cornea was found to 
have so far cleared that by focal illumination the iris could 
be seen behind an apparently normal aqueous, and with his 
back to the window patient could count fingers at about six feet 
distance. The lids were kept apart by means of oiled lint. 



FOR XEROPHTHALMIA. 423 

for several days, and the patieut seemed to have no difficulty 
in finding his way about the ward. As soon as tlie edges of 
the lids had healed, all treatment was discontinued in order 
to observe the result. Unfortunately but too short a time 
elapsed before this became determined in an unmistakable 
manner ; from the very day that the eye was left to itself 
the old enemy began to make its appearance. 

The conjunctival sac, which had increased in dimensions 
to the extent of the separation effected between lids and globe 
at the previous operation, now began visibly to diminish ; the 
moisture which pervaded it became less and less, and in 
proportion to the re-establishment of the xerosis, vision 
became more and more imperfect, and had sunk, at the date 
of his discharge from the Hospital, January 15th, to counting 
fingers at one foot, with every prospect of a speedy relapse 
into the same deplorable condition as obtained when first 
seen twelve months previously. 

This case, and several other observations of a similar kind, 
induced me to hope that something might be done for their 
permanent relief by closing the lids, and then establishing a 
small aperture through them, opposite the centre of the cornea. 

In September last a favourable case for the proposed 
operation was admitted, and I obtained permission to try 
what could be done, the result of which it is the object of 
this paper to relate. 

Case II. The patient, M. C, set. 45, labourer, of Irish 
extraction, had suffered for many years from granular oph- 
thalmia. At length vision becoming so defective that he 
could no longer gain a livelihood, he determined as a last 
resort to seek advice in London, and accordingly begged his 
way from Wales to the metropolis. 

When admitted, September 3, in a half-starved condition, 
he was still able to see wdth the left eye sufficiently well 
to get about, but a dense pannus occupied the upper half of 
the cornea, nearly liiding the pupil, whilst the lower half, 
though traversed by blood vessels, was still tolerably clear. 
The conjunctival mucous membrane had lost its normal supple- 



424 DULLER ON AN OPERATION 

ness, was much wasted, and the retrotarsal fokl ahnost 
obliterated ; the mner surface of the lids was smooth, ex- 
cepting here and there a few firm elevations, the remains of 
shrunken granulations. Notwithstanding the constant accu- 
mulation of mucus at the inner canthus, the eyeball did not 
appear to be properly lubricated and was evidently tending 
towards the condition of xerosis. This state was already 
considerably advanced in the right, where there was no 
longer any secretion of mucus, the moisture present seeming 
to consist entirely of lachrymal fluid and meibomian secre- 
tion ; the fluid was not uniformly diffused, but collected on 
the cornea in small beady drops, like water sprinkled upon 
a piece of oiled paper. The conjunctiva was even more 
wasted than in the left eye, but smooth and lustreless ; 
punda lachrymalia obliterated ; cornea not vascular but 
uniformly opaque, like ground glass. There was also en- 
tropion enough to cause many of the lashes to rub upon the 
corneal surface notwithstanding the limited movements of 
wMch the eyelids were capable. Vision = perception of 
shadows. 

On September IGt'w I excised all the lashes of the right 
upper lid with as little loss of tissue as possible ; pared the 
upper border of the lower lid without removing the eye- 
lashes ; and united the two with four fine sutures, leaving 
ununited only about \ of an inch at the inner canthus. 

The parts healed well, and nothing further was done until 
October 14, just four weeks later. 1 then made an incision 
about -1- of an inch long in the line of union between the lids, 
and another vertical cut through the skin across the middle 
of the first ; the crucial incision thus made was as neaily as 
possible opposite the centre of cornea. Having dissected 
back the four skin flaps thus marked out, I passed the 
flattened end of a probe between the cornea and the lids from 
the aperture which had been left at the inner canthus, and 
with Bowman's largest corneal trephine, which is 4 mm. in 
diameter, cut through the remaining thickness of the lids 
down upon the probe. As the opening seemed rather small, 



FOR xerophthal:mia. ' 425 

I removed another crescentic piece of tissue with the same 
instrument from its upper aspect, thus obtaining an oval 
cleanly cut aperture through the lid. To prevent such an 
aperture from closing, it is obviously necessary to furnish it 
with a mucous or cutaneous lining, and for this purpose the 
materials were at hand, in the shape of the four little skin flaps 
already mentioned. Through the point of each flap I now 
passed a small curved needle, armed with a fine silk thread, 
at the extremity of which was a small pellet of lead, serving 
as a knot to prevent the suture from slipping through the 
skin ; each needle was then carried through the. deep edge of 
the aperture in the lids upon the same side as the skin flap to 
which it belonged, up through the lid and the base of the flap. 
This arrangement enabled me, by gentle traction on the threads, 
to draw the four flaps of skin in towards the bottom of the 
woimd, and retain them in place by the little pieces of lead, 
all of which rested in the aperture when the four sutures 
were tied together crosswise. As each thread emerged throuo-h 
the base of its flap of skin far out in the eyelid, the effect of 
tying them crosswise was necessarily to pucker the surround- 
ing skin in towards the aperture in the lids, and thus undue 
traction upon the points of the flaps lining it was pre- 
vented. 

On the following day there was some swelling of the eye- 
lids, and discharge from the wound, so I removed all four 
sutures, and after cleaning the wound found the skin flaps 
satisfactorily united to its walls. 

In a few days all swelling and redness had subsided, leaving 
an oval opening opposite the centre of the cornea, 5 mm. long 
from above downwards, and 3^ mm. wide ; and the cornea was 
seen to have recovered a considerable degree of transparency, 
with a corresponding improvement in vision, for the patient 
could now count fingers at 18 inches. 

It soon, however, became evident that the aperture had 
not been made' too large, for it diminished in size from 
day to day, so that by the 10th of November it had con- 
tracted to 2 mm. in diameter, and was nearly circular. With 
VOL. VIII. 2 F 



426 BULLER OX AX OPERATIOX FOR XEROPHTHALMIA.. 

this contraction, vision, as might be expected from the 
incomplete transparency of the cornea, progressively improved, 
the patient being able, when the aperture had reached the 
size just indicated, to find his way about comfortably with 
this eye alone, and to count fingers at 10 feet distance. It 
nad in fact become the more useful eye of the two, and the 
tendency on the part of the cornea to clear up to all appear- 
ance still continued. By focal illumination it was possible 
CO see the edge of the pupil and a small portion of the iris. 
No further diminution in the size of the aperture in the 
lids had taken place between the date last-mentioned and 
that of his discharge from the Hospital on Novemher 24, 
about six weeks after the establishment of the opening). 

I have thought the case worth recording, first, because it 
has been asserted on good authority that a permanent small 
aperture through the eyelids cannot be established on account 
of the strong tendency evinced by all artificial openings in 
soft parts to close up whilst healing ; secondly, because the 
operation to a certain extent restored the function of a 
useless organ, for there is a wide interval between the mere 
perception of light and the ability to count fingers at 10 feet ; 
thirdly, tlie subjective sensations of the patient were vastly 
more comfortable after the operation, for he experienced 
complete relief from the feeling of pricking, burning, and 
dragging commonly associated with xerophthalmia. 

At the same time I am inclined to think the operation is 

only suitable for typical cases of this kind, with firm tissues 

to work upon, and shrunken conjunctiva. In all other 

cases where it is thought advisable to close the eyelids in 

order to promote removal of corneal opacity, a more simple 

methocJl iJiay with advantage be adopted, viz., that of 

parinCT aLi^d uniting the edges of both lids, except for a short 

distance hx: the middle, thus leaving a narrow slit opposite 

the pupil. ' 



SUPEENUMEEARY LACHEYMAL PUNCTA. 

Bj C. E. Fitzgerald, M.D., Ch. M. (Dublin). 

Ojjhthalmic Surgeon to the Richmond Hospital ; Surgeon 
to the National Eye and Ear Infirmary ; Lecturer 
on OphthaJmic Surgery, Carmichacl School of Aledicine, 
Dublin. 

Judging from the few recorded cases of this anomaly 
either in anatomical or ophthahnological literature, it cannot 
but be regarded as of comparatively rare occurrence ; and in 
support of this it may be mentioned that Graefe, notwith- 
standing his enormous field of observation, only reported one 
case of it.* On the other hand Galezowski, who has devoted 
a good deal of attention to the affections of the lachrymal 
passages, says he does not believe it is so rare an anomaly as 
is generally supposed, and that he, for his part, has met with 
as many as four examples of it. i* A case reported by Eau 
("Cornaz. Abnormites Congdn. desyeuxetde leurs annexes," 
1848) is quoted by Desmarres, :]: and Henle refers to two 
cases recorded by Foltz. § Weber has also reported two 
cases,j| Zehender one,^ and Professor Manz mentions a case 
in the "Handbook of Ophthalmology,"** now being published 
in Germany. As far as I know these are the only cases on 
record. 

During the early part of the past 'year I have seen 

* " Arcliiv. fiir Ophthal," i, 1, 288. 

t " Traite des Maladies des Yeux," Paris, 1872, p. 125. 

I " Traite des Maladies des Yeux," toI. i, p. 281. 

§ " Handbuch der Systematischen Anatomie." Bd. II, jJ. 708. 

II " Archiv. fiir Ophthal.," viii, 1, 352. 
IF " Klin. Monatsbl.," 1863, p. 394. 

** " Handbuch der gesammten Augenheilkunde," Bd. IT, i, p. 113. 

2 F 2 



428 FITZGERALD ON CASES OF SUPERNUMERARY 

two examples of this anomaly, one in a patient at the 
National Eye and Ear Infirmary, the other in a patient 
attending the Eye and Ear Dispensary at the Eichmond 
Hospital. In both cases it was the lower lid of the left eye 
which presented the anomaly, and in each the supernumerary 
punctum occupied a different position. In the first case the 
supplementary punctum was situated between the normal 
punctum and the outer margin of the lid (Fig. 1), and in the 





Fig. 1. Fig. 2. 

second it was placed between the normal punctum and the 
inner canthus (Fig. 2), lying directly over the normal 
canaliculus, but not communicating with it. In both instances 
there was little to distinguish the supplementary from the 
Jiormal puncta. excepi'ng that the former were somewhat 
smaller and that they did not form the centre of any elevation 
resembling the normal papilla lachrymalis. There was in both 
cases a distinct and separate canal leading from each punctum 
into the lachrymal sac ; this could be easily demonstrated by 
passing fine probes, one through the normal, and the other 
through the supplementary punctum. Moreover, by introduc- 
ing the nozzle of an Anel's syringe into these supernumerary 
puncta it was possible to inject a stream of water into the 
sac and nasal canal. In both cases the distance between the 
supernumerary and the normal puncta was about l'5mm. In 
a communication wliich I have received from Professor Manz of 
Freiburg on the subject, he seems to regard the occurrence of 
the anomaly in the same light as Galezowski, namely, that it 
is not so rare as is generally supposed, and he believes that 
many cases have been overlooked or not thought worth 
publishing. 



LACHRYMAL PUNCTA. 429 

The position of the supplementary punctum in the first of 
my cases, he says, is more uncommon than in the other. In 
answer to the question whether there was anything in the 
process of development which could account for the occurrence 
of the anomaly, Professor Manz says we have no special 
information respecting the development of the ductus 
laclirymalis, " all that we know is that it is at first a 
short furrow in continuation of the ductus naso-lachrymalis, 
which is closed in the fourth or fifth month," the mode in, 
which the closure takes place is still unknown. 

We must trust to a further and more minute study of the 
embryology of the part to enlarge our knowledge on this 
subject, but in the meantime, Professor Manz concludes, " it 
is well to register all cases of congenital anomalies, with a 
description as detailed as possible." 



SCLEROTOMY VERSUS IRIDECTOMY. 

By C. Badbr, 
Ophthalmic S^irgeon to Chti/'s Hospital. 

The object of the operation of sclerotomy is to relieve 
abnormal tension of the eyeball by an incision through the 
sclerotic, close in front of the insertion of the iris. A per- 
manent communication between the aqueous chambers and 
the sub-coujunctival space adjoining the sclerotic wound is 
the desired result. 

■ Cases. 

1. Mr. G., age 65, seen in consultation with Dr. Kennedy, of 
Bermondsey, suffered from an acute and very painful attack of 
inflammation in the right eye. 

Bight Eye. — Extreme cliemosis, conjunctiva projecting 
between the eyelids ; T. + , difficult to ascertain as to degree 
on account of chemosis. Iris in contact with cornea, pupil 
irregularly dilated, cornea slightly nebulous. Ophthalmoscope : 
dull red reflex from the interior of the eye. Bare perception of 
light. 

Left Eye. — Fifteen years ago sight was lost within 24 hours 
by an attack of inflammation similar to the one in the right eye. 
Now T. +2, cornea hazy, no iris visible ; ciliary staphylomata. 
No perception of light, 

October, 1875. Six days after the attack in the right eye, the 
patient was brought to my house, and both eyes were (under the 
anaesthetic) sclerotomised. 

January, 1875. Right eye, T. — ^ ; slight bulging of scleral 
incision ; puj^il drawn upwardsig^g^ if the eye had been iridec- 
tomised. Conjunctiva and c Qg^ea healthy ; good aqueous 
chamber. Ophthalmoscope : optic ,disc whitish ; vessels as thin 
in the disc as in the retina ; no cup visible. Field of vision good, 
tells time on watch at 10" with co vex lens. 

Left Eye. — T. — ^. Largish bulging of conjunctiva over 



BADER OX .SCLEROTOMY. ' 431 

sclerotic incision (conjunctival staphyloma) ; this is no trouble 
to the patient, and is not seen unless the lid is considerably 
raised ; pupil displaced upwards ; portions of the iris well seen ; 
good aqueous chamber ; no pain ; no perception of light. 

2. Mrs. B., age 75, patient of Dr. Dickson, of Dorset Square. 
Right eye, sight lost suddenly 10 months ago. Left eye, 
not able to read, barely able to guide herself ; cataract in both 
eyes, fully formed in the right eye. 

Both eyes T. + 1 and all the other outward signs of chronic 
glaucoma. Ophthalmoscope : no details visible. 

September, 1875. Sclerotomy of both eyes under anaesthetic. 

December, 1875. Right eye T. — 1; left eye T. and elasticity 
normal ; botb eyes, cornea clear, good aqueous chamber ; scar of 
incision in left eye a dark line, in right eye slightly staphylo- 
matous ; pupils very contracted, especially left, and cataract 
increasing, tells time on watch with a convex lens ; field good. 

3. Mrs. E., age 65, patient of Dr. Jackson, of Church Street. 
Spitalfields. When called to see Mrs. E. (October, 1875), I found 
her in bed suffering from acute glaucoma (preceded by glauco- 
matous symptoms for several years) of three days' standing, in the 
right eye ; much chemosis, iris in contact with cornea, pupil 
irregular, dilated ; T. + 2 ; bare pex'ception of light. On the 
day of my visit the sight of the left eye began to fail rapidly ; 
she was able to count fingers with that eye ; T. + 2 ; pupil 
slightly dilated. 

Both eyes were sclerotomised (under the anaesthetic). 

January, 1875. Both eyes much alike ; T. — ^ ; slight bluish 
bulging of line of incision ; slight oedema of conjunctiva adjoining 
incision ; pupils clear, slightly drawn up ; good aqueous chambers. 
Ophthalmoscope : both optic discs pink, no trace of cup ; vessels 
full in disc and retina ; no displacement of vessels at margin of 
optic disc. Right with + 15, left + 2-i, reads 2^ of Snellen well. 

4. T. G., age 24, admitted into Guy's Hospital with sloughing 
of both corneae. 

When I saw the patient there was in one eye T. -|- 1, with a 
large staphyloma of the entire iris. 

Large sclerotomy of this eye. Three weeks later T — | ; 
semitransparent scar where sclerotomy had been made, staphy- 
loma entirely gone, a flat smooth, partly black (uvea), partly 
brown (iris) surface occupying its place. 



432 BADER ON 

Two months later tlais same favourable condition existed. 

Genei'al remarTcs. — I have performed sclerotomy for the last 
three years, in many cases in which iridectomy, and in some, 
in which excision of the eyeball, would have been practised by 
others. 

The result has been a gradual decrease of the number of 
iridectomies, with a proportionate increase of sclerotomies ; 
especially in grave cases of glaucoma, in which iridectomy 
would have been surrounded by great difficulties, or in which it 
might have been followed by loss of vitreous, etc. 

The ojperation. — ^Most of the patients were operated upon 
while under the anaesthetic (alcohol, ether, and chloroform), 
though very unfavourable cases of glaucoma were successfully 
sclerotomised without an anaesthetic. 

The patient is placed as for ii'idectomy ; the eyelids are kept 
open with the spring speculum until the completion of the 
operation ; the eyeball is fixed with the screw fixer near the 
lower margin of the cornea ; the fixation is continued until the 
sclerotic incision is completed. For the right eye a Graefe's 
. knife, for the left a bent cataract knife is used ; thus, standing 
behind the patient, both eyes can be sclerotomised with the 
right hand. 

To make the sclerotic incision the knife is thrust through 
conjunctiva and sclerotic into the aqueous chamber as near as 
possible to and in front of the insertion of the iris, is carried 
across the aqueous chamber without sparing the ii'is should it 
interfere with the course of the knife, and is again thrust out 
through the sclerotic and conjunctiva (as near as possible to and 
in front of the insertion of the iris). Having thus made the 
puncture and counterpuncturc, the incision through the sclerotic 
is completed (in the same manner as is usual when making a 
corneal flap for the extraction of cataract) slowly, especially when 
near completion, so that the knife escapes from the sclerotic beneath 
the conjunctiva without any jerk. Having reached the conjunctiva, 
the blade is placed flat upon the outer surface of the sclerotic, 
the cutting edge directed backwards, and while slowly with- 
di-awing the knife from beneath the conjunctiva some of the 
latter is separated from the sclerotic. 

As large a bridge of conjunctiva as possible should be left, 
stretching across the sclerotic incision. It is beneath this con- 



SCLEROTOMY. 433 

junctiva'that the aqueous liumoui' escapes ; the iris sometimes 
protrudes, etc. The extent of sclerotic to be divided is equal to 
nearly a third of the circumference of the cornea, forming a 




sclerotic flap, similar in size and shape to a small corneal flap, 
as used to be made for extraction of a small hard cataract. 

Sclerotomy has been performed in different directions ; it 
gives least trouble when made along the upper margin of the 
cornea. 

When made behind the iris, or from before backwards through 
the ciliary muscle, it may be followed by shrinking of the eye- 
ball. 

Immediate relief of tension in the most hopeless cases of 
glaucoma has been the usual result of the operation. 

The after treatment as to binding up, using the eyes, etc., is 
the same as after iridectomy. 

The only troublesome sequel of the operation has been the 
occasio'nal occurrence of much bulging (staphyloma) of the 
conjunctiva, which may become so troublesome as to require 
operative treatment. It should be borne in mind, that the 
staphyloma is not one of sclerotic, but of conjunctiva, or of 
conjunctiva and iris only. 

P.S. — In five cases of sclerotomy, followed by large con- 
junctival staphyloma, or so-called hemorrhagic glaucomatous 
eyes (high tension, great vascularity of tissues, much blood in 
vitreous chamber), a very satisfactory result was obtained by 
the frequent application of linseed-meal poultices. The pain, 
redness and staphyloma rapidly subsided : the eye, apparently 
doomed to excision, assumed a healthy appearance, the tension 
sinking below par. 



CASE OF LARGE CEREBRAL TUMOUR WITHOUT OPTIC 
NEURITIS, AND WITH LEFT HEMIPLEGIA AND IMPER- 
CEPTION. 

By J. HuGHLiNGs Jackson, M.D. 

Physican to the London Hospital and to the Hospital for the 
Ejnleptic and Paralysed. 

It would, I think, be better to say in this case (of 
Eliza T., see page 438), that the patient died before optic neuritis 
had supervened. T shall, I think, give good reasons for this 
statement by references to cases I have published. During 
the life of this patient I made the diagnosis of tumour, and 
therefore kept looking at her optic discs. I diagnosed tumour, 
and tumour of the right posterior lobe, I may here remark, 
from the following facts — the kind of mental defect, and from 
its preceeding the hemiplegia, from the hemiplegia being left 
sided, and because the arm suffered less than the leg. 

In some cases of cerebral tumour, optic neuritis comes on 
late (I refer of course to cases completed by autopsy in saying 
this). 

In a case of glioma of the hinder part of the first (upper- 
most) frontal lobe I discovered no optic neuritis, although, 
having diagnosed tumour, I carefully looked for it.* But 
then this patient had only been iU about ten weeks when 
I last saw her. She lived close upon twelve weeks more, 
and thus it is not at all unHkely that optic neuritis should have 
come on. She had no defect of sight it is true, but that goes 
for nothing as evidence against the existence of optic neuritis* 

* This case is recorded in " Medical Times and Gazette," 5th June, 1875 — 
" Convulsions nearly always limited to the right arm ; tumour of hindermosf 
part of the uppermott frontal convolution on the left side." 



HUGHLINGS JACKSON 0\ CEREBRAL TUMOUR. 435 

It would be absurd to draw such a conclusion as that a 
tumour in the uppermost frontal convolution did not produce 
optic neuritis. I might be supposed to be as likely as 
anyone to draw that conclusion, because I had seen another 
case in wMch when I saw the patient there was no neuritis.* 
However, I think it probable that the patient in this 
second case (see last foot note) had had optic neuritis, for I 
noted, " The optic discs are probably whiter than they 
should be, and their margins are not sufficiently clear. 
The arteries (sic) are slightly tortuous, the veins are not." 
This is a poor description of changes which were trifling. 
But I have, since I saw that patient, seen many cases of 
disappearance of severe double optic neuritis — disappearance 
so far, I mean, that even very good ophtlialmoscopists 
could not say there had been optic neuritis. 

Now let me mention a third case of tumour in the same 
region, M'ith other tumours in other positions,*!- all of the same 
cerebral hemisphere, which case also shows very late onset of 
neuritis, and also nearly complete disappearance of these morbid 
changes. Tliis man was under my care first in December, 1873. 
It was only on September 19, IST-l, that changes in his optic 
nerves were seen. His discs had been examined scores of 
times before, the diagnosis of tumour having been made 
months previously. Now I saw this man in August, a month 
before the outset of the neuritis, in a condition which I 
thought would probably soon end fatally ; had it done so, the 
record would have been of a case of tumour of the brain 

* Eecorded, " Medical Mirror," IstSept., 1869, and also " Medical Times 
and Gazette," 2'Jth Oct., 187-i — " Convulsion, limited to the right arm, 
followed by paralysis of that arm ; tumour of the hinder part of the upper- 
most frontal convolution; tumour of both lobes of the cerebellum; no 
symptom referable to the cerelellum." 

t Case recorded in " Medical Times and Gazette," 19th June, 1875 — 
" Might-sided fits, most of them limited to the right arm ; subsequently 
hemiplegia; double optic neuritis ; tumours of the left cerebral hemisphere. 
The examination of the brain was made by Dr. Gowers." In the " Medical 
Times and Gazette," 21st July, is a wood-cut from a drawing of the brain 
by Dr. Gowers, showing the tumours appearing on the surface; there was one 
below the surface in the hindermost part of the uppermost frontal convolution. 



436 HUGHLINGS JACKSON ON CEREBRAL TUMOUR 

which had not produced neuritis. As the actual progress 
of the case showed, the statement^ " which had not yet 
produced neuritis," would have been better, for, as I have said, 
it did come on late. In about six weeks after the onset of 
the neuritis the discs were again normal. Had I examined 
for the first time the discs only shortly before death, which 
occurred in December, 1874, I might have supposed too that 
the tumour had not produced optic neuritis. It is a very 
common thing for the changes of severe optic neuritis to pass 
off, so far at least as to leave only slight changes recognisable 
by careful direct examination, and such slight changes which 
we should not (without of course knowing that there had 
been optic neuritis) dare to call relics of neuritis. 

Let me now mention a still more striking case of late 
onset of neuritis. The man had had symptoms of brain* 
disease (convulsions) for about nine years before his death. 

As from first to last his motor symptoms were all 
local, the probability is that the patient had had cerebral 
tumour nine years ; he was under my care three years. He 
died March 29, 1875, and yet it was only about the middle 
of February of that je-ax that the neuritis was discovered. His 
discs had been previously examined scores of times. It may, 
however, be well to give direct evidence as to the state of his 
eyes so late in his case as December, 1874. At this time he had 
some difficulty in reading. I could not determine whether 
this was part of his aphasia (for his articulation was at that 
time ataxic), or owing to defect of sight; his optic discs were 
normal. Mr. Couper was so good as to examine the patient 
for me. He too considered the discs normal, but he discovered 
(by the ophthalmoscope) a high degree of hypermetropia. When, 
on Mr. Couper's suggestion, we used a f convex, the patient 
read very much better, but there was a residuum of aphasic 
difficulty. When the optic neuritis came on, no difference 

* Case recorded in " Medical Times and Gazette," 4tli Sept., 1875 — " Con- 
vulsions mostly beginning in the right leg ; several years later right 
hemiplegia and aphasia ; late onset of douhle optic neuritis ; autopsy ; 
tumour of the left cerebral hemisphere^ (The examination of the brain in 
this case also was made for me by Dr. Gowers.) 



WITHOUT OPTIC NEURITIS. 437 

was noticed in the patient's manner as regards sight, but we 
could not, at that stage of his ilhiess, test it properly. 

Here again we see the importance of knowing that there 
may he no defect of sight with optic neuritis. In the 
cases of the two men last noted above, there was no particle of 
evidence to indicate neuritis, except that supplied by the 
ophthalmoscope. Without the oplithalmoscope the defect of 
sight in one case, really the result of hypermetropia, might 
have been erroneously attributed to something wrong with 
the optic nerves. Again in this case it was simply imprac- 
ticable to determine the h}^ermetropia without using the 
ophthalmoscope. 

The mode of onset in the following case is noteworthy. 
The first symptoms were those of what I call Imperception. 
She often did not know objects, persons, and places. To 
the statement that there was only " confusion of mind," I do 
not object, for I should say that her mental confusion showed 
itself in inability to recognise objects, persons, and places. 
Nor do I object to its being called " only loss or defect of 
memory ;" it was a loss or defect of memory for persons, 
objects, and places. Nor do I mind it being said that there 
was " only imbecility ; " imbecility, like confusion of thought 
and defect of memory, is nearly always a matter of defect 
in percei^'ing things (persons, objects, and places). 

There was what I woidd call " Imperception," a defect as 
special as Aphasia. The case did not correspond however to 
loss of speech, bat to defect of speech. Total imbecility 
would correspond to loss of speech. There was partial 
Imperception. 

I may add to the above that I am well aware that the 
character of the mental defect this woman had is that of 
delirium in acute disease, and also therefore that it is a 
defect of a common kind. These admissions leave the 
^statement that she had Imperception untouched. 
\ I think, as Bastian does, that the posterior lobes are the 
seat of the most intellectual processes. This is in effect 
saying that they are the seat of visual ideation, for most of 



488 HLTGHLINGS JACKSON ON CEREBRAL TUMOUR 

our mental operations are carried on in visual ideas. I think 
too that the right posterior lobe is the " leading " side, the left 
the more automatic. This is analogous to the difference 
I make as regards use of words, the right is the automatic side 
for words, and the left the side for that use of words which is 
speech. I confess, however, that I have little direct evidence 
as to the localisation of the n.orbid changes causing Imper- 
ception. 

Summary of Case. — Impercejytion, folloioed by left Hemiplegia, in 
which the upper arm suffered more than the lower arm, and the 
leg more than the arm — No OpHc Neuritis ; only trifling changes 
in the Optic Discs — Autopsy : -arge Glioma of the right posterior 
lobe. 

(Yov the Notes of the Case I am indebted to Mr. Charles Mercier.) 

Eliza T., set. 59, was adtnitted under Dr. Down's care, 
March. 2, 1875. The following- account was derived from the 
patient's daughter, an intelligent woman. 

Patient has been a healthy woman up to the time of her 

present illness. Has never had, rheumatic fever. For two 

months before this illness set in she had pain in the head and 

" neuralgia," but never did anything odd until about Christmas 

time. She was going from her own house to Victoria Park, a 

-^5 gijstance and over roads that she knows quite well, as she 

snort u., -,,i|^^ "-ime house ior 30 years, and has had frequent 

has lived m the t>u^ park ; on this occasion, however, she could 

occasion to go to th^^g^ aj^d after making several mistakes she 

not find her way the: though the park' gates were just in front 

had to ask her way, abed to return she was utterly unable to 

of her. When she wisi- be taken home by a country relation to 

find her way, and had to <. Park for the first time. When she 

whom she was showing th,al, but from this time she began to 

got home she seemed as usbree or four weeks she seemed to age 

alter, and during the next thg feeble. Now and then too she 

rapidly, got weaker and moiid put sugar in the tea two or 

would do odd things, she wou^takes m dressing herself ; put 

three times over, she made mi, and did little things of that 

her things on wrong side before, 

kind. 



WITHOUT OPTIC NEURITIS. 489 

Five weeks ago she complained of feeling sick, and vomited ; 
the next day she seemed dull, and less cheerful than usual ; on 
the third daj she astonished her friends by keeping her eyes shut 
the whole day ; she sat by the fire with her eyes shut and never 
moved ; yet she spoke and answered sensibly when questioned. 
She did make mistakes, but was never bad enough to make her 
friends think she was losing her wits. When she went to bed 
she was in the same condition. In the middle of the night her 
husband spoke to her, and found that she did not answer him, 
and the next morning when my informant saw her, she was 
lying quite senseless, making a kind of snoring noise. Her eyes 
were closed, she did not know anybody, and did not say anything, 
not even yes or no. She lay thus two days, and then became 
light-headed, talked a great deal of nonsense, and what she said 
she could not say distinctly except short in sentences. It was now 
noticed that her left arm and leg were paralysed ; she could not 
move either of them in the least. From that time she has been 
gradually getting more herself. As she recovered she showed 
that her mind was still defective ; she could not remember events 
from one hour to another. She mistook the people about her. 
When she came into the Hospital, she called all the nurses 
"Annie" (her daughter's name). She would say to one nurse 
" Are you the one that came just now ?" when she had been pre- 
viously visited by another nurse. She asked the under nurse 
how she was to know her from that one who had long tails, i.e., 
strings to her cap. 

March 9. She names a penny and a shilling, but slowly. 
A new penny she says is a sovereign, then that it is a two-shillino- 
piece, only gold, then a new penny or a new half-penny, a florin 
and a shilling. " Are you sui'e ?" " Well, I think so " (a long 
pause.) If it's not a shilling, it's a two-shilling piece." 

After considering for some time, she names a watch. " What 
is the time ?" (seven minutes past three) " A quarter past three, 
twenty ruinutes past three, ten minutes past three." When asked 
to read " Beef tea " in three-quarter inch letters, she spelt out 
" JO AD " for the Beef, and " E L I Z A" for the tea. (Her maiden 
name was Eliza Joad). 

When told to read Snellen's test types, she did not know how 
to set about it, began at the right lower corner and tried to read 
backwards ; when asked if it was because she could not see, she 



440 HUGHLINGS JACKSON ON CEREBRAL TUMOUR 

said, " No, she didn't think it was, she didn't seem to know 
how." 

When set to read 12 Snellen, she read, pointing to the letters, 
"'The name colony' and 'name' again." Having got to the 
end of the line, she did not know where to go, and after hovering 
about at last she pointed to the and said, " that's ' the,' and to 
me they look all 'the's, the's, the's.'" I asked her "Is this 
word (took) book ? " She replied " B double K, book." 

"She names the colours of letters correctly, though she 
mistakes the letters themselves. Names a cap and other familial' 
objects. 

She states correctly various facts about her native town, 
which town the reporter knows well, the directions of the roads 
and the towns to which they lead. She is not always correct, 
and she thinks a long while before answering, and seems very 
much puzzled. 

In describing the way from her own house to Victoria Park, 
she speaks of going at the back of the barracks. This is so. 

March 13. She is elderly and degenerate ; thin, wrinkled 
skin, ectasia of vessels on cheeks, grey hair, barrel-shaped chest, 
teeth few and worn, no or very little arcus senilis. She has 
physical signs of emphysema, and her heart sounds are feeble, 
diffused, and tic-tac, but there is no other evidence of thoracic 
disease. Pulse 100, fair volume, regular. 

Temperature ranges between 99° and 100°. Urine s. g. 
1030, neutral, yellow, clear, no albumen. Appetite fair. Bowels 
open. Sleeps fairly. She had two bedsores. 

The upper part of the face is symmetrical as regards motion, 
but the left upper Mp droops to a trifling extent. Tongue in 
middle line, symmetrical. Ocular movements good in all direc- 
tions. The left arm has impaired power, which is worst above 
and diminishes downwards. She does not move the arm from 
the shoulder in the least. The elbow she moves to a trifling 
extent in flexion and extension. Pronation and supination are 
pretty good. Movement of the fingers, though uncertain, is pretty 
free, most so at the metacarpo-phalangeal joint, the other move- 
ments being somewhat stiff. Movement of the thumb considerable, 
but that member is kept close to the index. Thus the loss of 
power is very much less comparatively in the hand than the arm. 

The left leg, too, suffers much more in comparison than the 



WITHOUT OPTIC NEURITIS, 441 

arm. She can only jnst draw it up and push it down in the 
bed. Cannot raise it fi"om the bed. Movements of the toes, 
however, are pretty free. 

There is no discoverable ansDsthesia on the left side. There 
are occasional tremblings of the left fingers and hand. 

No head-ache or vomiting. Her discs are slightly ill-defined, 
streaked, not swollen ; at the upper part of the right are several 
very minute haemorrhages. The changes altogether were very 
slight. The eyes were often examined. 

She does not pass motions or water under her, bixt always 
calls for the bed-pan. 

On trying her very carefully on March 20 for hemiopia, no 
results were obtained, for it was impossible to make her keep her 
eye fixed on the central point. The only noticeable thing 
was that she sometimes kept her eye on the central point when 
asked if she could see an object on her right, but invariahhj 
looked at one placed on her left. 

After being in the Hospital about a fortnight, her mental con- 
ditions improved very much. Indeed one day Dr. Hughlings 
Jackson took a medical friend to see her and could demonstrate 
no mental imperfection of consequence. 

March 21. She looks as if asleep, but it is found impossible 
to rouse her. Her pulse is rather rapid and small, her face 
is unaltered, and she has ju.st taken hold of her left hand witli 
her right. From this she gTadually faded out, passing from 
sleep into coma, and from coma into death. She died the same 
evening (21st). At 10 p.m. Mr. Smith made a note. " Patient 
lying on her back insensible, cannot be roused. Conjunctiva 
insensible. Reppiration slow, tracheal i^ales. Pupils equal and 
contracted." 

Autopsy — March 23. Permission was given to open tlie 
head only. On removing the calvaria the dura mater was found to 
be tightly stretched. When it was slit up, the convolutions were 
found to be tightly pressed against it, very much flattened, the 
sulci wholly obliterated, and a few of the larger veins only were 
visible on the surface. The brain sul)stance looked strikingly 
anasmic, a dull greyish- white, with scarcely the slightest shade 
of pink. On lifting the brain from the base of the skull, a 
portion was found strongly adherent to the right petrous bone 
or dura mater, and when the encephalon was wholly removed, 
this proved to be the surface of a tumour which here emerged 
from the interior. 

VOL. VIII. 2 G 



442 HUGHLIXGS JACKSON ON CEREBRAL TUMOUR 



Examination of the Brain, hy Dr. (Jotvers. 

SuMMAiii' — A large Glioinatous Tuiaour in hinder part of 
Right Temporo-Sphenoidal Lobe : other smaller grovjtJis 
near and in Bight Hippocampus Major. 

The largest mass lay beneath the posterior cornii of the right 
lateral ventricle, in the floor of which it caused a prominence, 
almost filling np the cornu. The commencement of the 
descending cornu was one inch further from the posterior 
extremity of the hemisphere than on the opposite side. In 
the floor of the descending cornu was a rounded projection, 
the size of a walnut, in contact with the hippocampus 
major but not continuous with it. On the under and inner 
aspect of the hemisphere the tumour had broken through, 
forming a soft projection 2 in. by lin., the anterior extremity 
of which was close to, but did not involve, the termin- 
ation of the gyi'us fornicatus (in the uncinate convolution) 
in front of the extremity of the parieto-occipital fissure. 
Thence it extended downwards and backwards. A trans- 
verse section through the hemisphere, just in front of the 
junction of the calcarine and parieto-occipital fissures, showed 
the tumour to involve the whole area beneath the pos- 
terior cornu and calcarine fissure, as far as the grey matter 
of the surface on , both tlie outer and inner sides ; while 
below, it came through the convolutions as already de- 
scribed. The section of the tumour measured Ih inch from 
above down, 2 inches from side to side. Behind this spot 
it rapidly lessened in size, extending along the inner side, 
so that in a section across the hemisphere at the extremity 
of the posterior it was only lialf an inch in each 
diameter, and occupied the inner half of the section, 
beneath the calcarine fissure. It ceased immediately behind 
thi^ spot. 

The section of this tumour was greyisli-red, soft, in places 
somewhat spongy in appearance, very vaseuhir, mottled with 



WITHOUT OPTIC NEUKITIS. 443 

red lines and conspicuous vessels. In many places, and every- 
where in the posterior portion, it passed insensibly into the 
brain tissue, but^ at some places was bounded by a narrow 
translucent line. The prominence in the descending cornu 
was covered on the surface by a thin layer of nervous 
substance, beneath which was new growth and much 
extra vasated blood, as if luemorrhage liad taken place into the 
tumour. 

On the inner surface of the temporo-sphenoidal lobe a 
second smaUer outgrowth of tumour existed in front of the 
other, less prominent, involving the middle and inferior 
oceipito-temporal convolutions in an area of about a square 
inch. It was separated from the other mass by about lialf 
an inch of healthy convolution. On section this was found 
to be part of a second growth, about the size of a walnut, 
lying beneath and in the lower extremity of the hippocampus 
major. Although very near the other, the tv\ o were not con- 
tinuous. The lower extremity of the hippocampus was much 
larger than that of the opposite side, forming a swelling one 
inch long and three quarters of an inch across, while that of 
the opposite side was only half an inch across. The surface 
was normal in appearance. On section it was infiltrated with 
new growth, moderately firm, and uniformly reddish-grey in 
aspect. Neither with the naked eye or the microscope 
could any of the normal structure of the hippocampus be 
distinguished, except the layer of fibres on the outer surface 
and the curved layer of fibres which courses across it from 
its junction with the outer side of the ventrule (and are 
some of the prolonged fibres of the tapelum). These 
appeared to the naked eye to divide the otherwise uniforjn 
mass into two portions, but under the microscope the ncM^ 
growth was continuous from one part to the other. 

Anterior to this second growth was another still smaller 
nodule in the white substance of the temporo-sphenoitlal lobe, 
about a third of an inch in diameter, pink in tint, and 
passing gradually into tlie adjacent cerebral substance. 

The structure of the tumours approached most nearly to 

•2q2 



444 HUGHLINGS JACKSON ON CEREBRAL TUMOUR. 

that of a glioma. They were composed of small round nuclei, 
apparently free, and of -g-oVo" i^^*^^^ diameter average size ; of 
larger rounded and angular, cells, and of nucleated fusiform 
cells with delicate prolongations. In some parts the fusiform 
cells formed the chief part of the grow^th, but in others the 
nuclei and small round cells were scattered in the meshes of 
a delicate fibrillar tissue. At the edge at which the smallest 
growth was extending, on passing from the healthy tissue to 
the new growth, the minute nuclei of the grey matter of the 
convolution became more numerous, more densely aggregated, 
until they constituted a compact mass, in which a few larger 
cells were scattered. The vessels were everywhere numerous 
and distended with blood. 

The corpus striatum and optic thalamus were unaffected ; 
no abnormity could be found elsewhere in the brain. 



A CASE OF DOUBLE OPTIC NEURITIS WITHOUT 
CEREBRAL TUMOUR. 

By J. HuoHLiNGs Jackson, M.D., F.R.C.P. 

In the case I have to relate there was well marked double 
optic neuritis with blindness. At the autopsy no morbid 
intra-cranial changes were seen except those of very great 
congestion of the brain, and these were doubtless recent. In 
this regard the case is exceptional. In most cases of 
double optic neuritis there is tumour, or some kind of 
" coarse "* disease. In the case I am about to relate there 
were (see Dr. Sutton's examination, p. 452) minute morbid 
changes ; but still the case is very exceptional. 

It must be remarked too, that although I speak chiefly 
of the optic neuritis, the lohole tenor of the case was that of 
a case of intra-cranial tumour. 

It would, I believe, have been considered a case of 
cerebral tumour by physicians who do not value ophthalmo- 
scopic evidence. 

I have now seen several cases of double optic neuritis 
in cases without cerebral tumour. 

Nevertheless I think that optic neuritis is the most 
valuable of all signs of coarse organic disease within the 
cranium ; but it is not decisive evidence. The following 
quotation from a " Lecture on Optic Neuritis," published in 

* The expression " coarse disease " is used as a general term to include 
new growtlis (gliomata, syphilomata, &c.) cysts, abscess, and in fact all kinds 
of adventitious product, or to use a common word, all sorts of lumps witliin 
the cranium. These are all " foreign bodies," and each of them may lead to 
changes in the optic nerves. 

I think too that there is but one kind of change produced by intra-cranial 
growths ; I call this optic neuritis. I do not make the distinction into optic 
neuritis and " slauuiigs papilla" ('' choked disc " of Allbuti.) 



446 HUGHLINGS JACKSON ON OPTIC NEURITIS 

1871, embodies the opinious I still hold on the diagnostic 
value of neuritis. I begin by speaking of the limitation 
of my experience of optic neuritis.* 

" I have spoken above of a Physician's experience, and I 
hasten to qualify my remarks. I see those patients who 
have severe cerebral disease. No one ever consults me for 
defect of sight only, but for such symptoms as severe head- 
ache, convulsion, and hemiplegia, with which optic neuritis 
often occurs. To me defect of sight is but one symptom, 
and not the most important one, in a series. I admit, then, 
that my experience is of necessity one-sided. Further, 
I admit that in a few cases of severe cerebral disease where 
I have discovered double optic neuritis, I have found no 
kind of coarse disease post-7nortem. 

" 1 have been wrong several times in the diagnosis of an 
adventitious product within the skull in cases where there 
had been found double optic neuritis, hut I have far oftener 
been ivrong by neglecting the inferences above stated to be 
dedueible from the presence or absence of optic jieuritis — wrong 
m saying there vms an adventitious product when the discs 
were normal, and ^A'ruiig in saying there was not when there 
was double optic neuritis. I feel, therefore, justified in 
saying that double optic neuritis does point very strongly 
indeed to coarse disease inside the head. 

" You will not misunderstand me to imply that you are 
to diagnose tumour or other coarse disease of the brain solely 
by the ophthalmoscope. You have, in most cases, no need 
to rely on this one condition. You do not diagnose phthisis 
by the physical signs alone. You may say that you would 
bo right in most cases if you did trust to physical signs alone. 
I may go so far as to the ophthalmoscopical signs. You 
would be right in most cases, I believe, if you diagnosed 
coarse disease within the skull hy the presence of optic 
neuritis." 

*'This and the five subsequent jjai'agraphs liflve already bet n jJublished 
in a pamphlet printed for private circulaiion. Thev appeared in this way 
before the case related in the text was seen bv me. 



WITHOl'T CEREBRxVL TUMOUR. . 447 

In some cases Ave find with optic nenritis (I now speak of 
cases in which post-mortem examination reveals intra-cranial 
tumour) changes in the retina very like, sometimes quite 
like, those occurring with chronic Bright's disease. On the 
other hand, in some cases of Bright's disease the disc is 
SM^ollen to a degree equalling that found in some cases of 
intra-cranial tumour, and there are lustr-eless and shapeless 
white spots about the disc, and also blotches ; not only streaks 
of blood like those which are seen in very many cases of 
neuritis from intra-cranial tumour. Dr. Herm. Schmidt and 
Dr. Wegner (" Archiv. f. Oph.," Bd. xv, Abth. iii, s. 253—275) 
rei^ort a case of cerebral tumour in which the ophthalmo- 
scopical signs were quite like those in a case of kidney 
disease. (See Dr. Noyes' report on " Ophthalmology," 
"New York Medical Journal," February, 1871, p. 210.) 

Hutchinson (''Eoyal London Ophthalmic Hospital Eeports," 
vol. v, p. 308) in some cases of optic atrophy in children, 
no doubt the sequel of neuritis, has seen at the yellow-spot 
region groups of highly refractive globules, resembling at 
first glance clusters of spider's eggs. 

The following is an extract from ]\Ir. Brudenel Carter's 
recently published work. I fear I blundered in not liavint? 
examined the patient's urine in the case of renal disease 
to which he refers. 

" Many attempts have been made by various writers 
to distinguish ' neuritis optici ' from ' perineuritis,' and 
both from mechanical obstruction ; but I have never been 
able to satisfy myself of the validity of the distinctions 
which have been drawn. Dr. Hughlings Jackson, who has 
investigated the subject wath infinite pains and care, and 
who has followed a large number of his cases to the post- 
viortevt table, will not say more than that ' optic neuritis,' 
his general expression for the changes under consideration, 
is an evidence of some coarse intra-cranial lesion, and 1 
myself can only say that it is frequently associated with 
such lesion. 

"We had a little boy in St. George's Hospital in 1872, 



448 HUGHLINGS JACKSON ON OPTIC NEURITIS 

who was transferred from my care to that of Dr. Fuller, and 
who had choked discs of the most typical character. Dr. 
Hughlings Jackson saw him, and entertained no doubt that 
he was the subject of some form of brain disease; 
and the same opinion was expressed by Dr. Noyes, of New 
York, and by several members of the International Ophthal- 
mological Congress, which was then assembled in London. 
Tlie boy died of pleurisy supervening upon advanced kidney 
disease, and no trace of mischief in his brain could be 
discovered by the most careful examination. 

" Nearly at the same time we had in the Hospital a young 
woman whose eyes presented t}qjical examples of the 
changes often associated with albuminuria, but who died 
^\dth healthy kidneys, of a tumour in the cerebellum." 

One peculiarity in the case I am about to relate is the 
absolute amaurosis. This is a rare thing in physicians' practice. 
I rarely see such discs as this patient had, with loss, or even 
with extreme defect, of sight. On tlie other hand I very 
often see optic neuritis wathout impairment of vision. The 
patient was sent to me by Mr. James Adams, it was then 
essentially an ophthalmic surgeon's case. 

I would say, too, that during the woman's life I had no 
doubt that Me should find an intra-cranial tumour (or other 
kind of coarse disease). I ought to have been less confident, 
because I once before felt certain that I should find an intra- 
cranial tumour in a case of double optic neuritis, and found 
only general cerebral atrophy ; there was no adventitious 
product, nor any trace nor relics of it. I did not examine any 
of the brain of that patient microscopically. 

In the case about to be narrated we cannot invoke raised 
intra-cranial pi^essure as a cause, for there was no evidence of 
it ; the congestion of the brain was certainly no evidence 
of it ; it was simply owing to the mode of death. I cannot do 
better here than quote what Wilks and Moxon say of cerebral 
congestion. 

" There is no doubt that congestion of the brain is the cause 
of serious svmptonis, and even of death. We particidarly ask 



WITHOUT CEREBRAL TUMOUR. 449 

you not to suppose that we are den}dng the existence of con- 
gestion of the brain as a fatal disease, what we wisli to say 
is, that a fulness of the vessels after death cannot frove, the 
occurrence of the primary congestion, and in fact 'post mortem 
fulness of the vessels of the hrain and its memhraries is of no 
pathological value whatever (italics in original) as showing- 
brain disease, because asphyxia produces it. On the other 
hand anaemia of the brain does exclude congestion, and also 
proves that death was not through asphyxia, which always 
produces congestion. Our reason for saying all tliis so con- 
fidently, when even now you find wTiters in systems of 
medicine speaking of redness of the cerel^ral membranes as 
the great sign of inflammation, &c., is that we have seen all 
degrees of intensity of such congestion when there \vas no 
trace of cerebral disturljance during the life of the individual, 
and . this we have seen, not occasionally, but as a common 
occurrence. Again, it is not only the experience of morbid 
anatomists which declares intra-cranial congestion to be thus 
valueless, we will quote for you a passage from Kussmaul 
and Tenner's account of their elaborate researches on the 
effects of haemorrhage as causing epilepsy. They say, ' We 
could never deduce any results from the post mortem 
examinations undertaken with a view to determine the state 
of fulness before death of the most important parts of the 
vascular, system, viz., of the arteries and arterial capillaries, 
and even in the most favourable instance, when similar 
inquiries were directed towards the veins, our results could 
only be looked upon as approximate.' 

" Thus you will see that it is only for lack of information 
that any one would speak of congestion of the brain as a 
proof of a cause of death. You may infer reasonably from 
the circumstances of particular cases that death occurred 
from congestion of the brain, but you cannot p)rove it after 
death by inspection. We shall presently endeavour to show 
you in what degree certain appearances of the Ijrain are 
evidences of congestion." (" Pathological Anatomy," Wilks 
and Moxon, pp. 202-3.) 



450 HUGHLINGS JACKSON ON OPTIC NEURITIS 

Summary of Case. — Headaches nearly all life — Attack of Vertiiio 
with Unconscioufiness — Intense Headache, Vomiting and Double 
Optic Neuritis — No Paralytic Symptoms — Death in Asphyxia — 
Autopsy — No " Coarse " Disease — Extreme Cerebral Congestion. 
(Abstract of Notes by Mr. Cbarles Mercier.) 

Henrietta S., set. 34, admitted December 19, 1874, married. 
Her family history presented nothing of importance. 

Ever since she could remember she had suffered with pain in 
her head, which she described as of two kinds — headache, and 
peculiar pain, darting like neuralgia or " rheumatics." The former 
occurred generally about once a-week, the latter usually after 
her menstrual periods, No history of syphilis. 

Three years before admission her husband came home from 
a long absence at sea, and three months later she had a mis- 
cari'iage. From this time her menstrual flow became exceedingly 
irregular, coming on at the slightest provocation at any time, and 
lasting for weeks together. A year and three quarters later she 
had another miscarriage, and a year before admission her head 
began to be very bad. The first occun-ence of her illness was 
an attack of severe vertigo, with momentary unconsciousness, 
followed by severe headache which lasted for four days. At the 
end of this time she h.xi another attack, after which the head- 
ache lasted for three weeks, with occasional remissions, during 
which she vomited. The vomiting was usually followed by a 
feeling "as if she were going down into a pit," and by hot sweats. 

At this time also she used to have " dark shadows coming 
over her eyes, and popping noises all about her head, and such 
dreadful whistling and howling in her ears." 

After three months the condition of her sight was as follows. 
Sometimes she had an appearance of darkness, and at such times, 
although her sight was very deficient, she could, although with 
difliculty, recognise people's faces. At other times she had an 
appearance of light, with he^vy shadows waving in front of her, 
and although, from the sensation being one of light, she thought 
that her sight was better at these times, it is probable that vision 
was quite absent, for she used to run against objects. At 
length, three months before admission, she rather suddenly had 
an impression of brilliant light which remained permanent, and 
since that hour she was completely blind. 



WITHOUT CEREBRAL TUMOUR. 451 

On admission, she was a well nourished woman, of exceedingly 
dark complexion ; very intelligent, giving her answers with 
unusual precision and directness for a hospital patient, and she 
showed great dexterity in making up for her loss of sight by 
employing her ears, &c. She was by no means an emotional 
woman, was very patient under her suffering, which was evidently 
great, explained and described naturally the subjective sensations 
which affected her without any exaggeration of expression or 
gesture. Her organs and functions were all in good order, her 
vital condition good. Pulse regular, but very small, hard and 
singularly incompressible. There was no local paralysis what- 
ever, no defect of voice, articulation or speech. She suffered 
occasionally from attacks of most severe pain in the head, 
frequently accompanied by vomiting. There was extreme 
double optic neuritis. Mr. Couper (January 3) reported, 
" The condition approaches the choked disc, there is very great 
swelling and extreme tortuosity of the veins. The distance 
between the apex and the base of the disc is represented by a 
+ g- glass." This referred to only one eye, the other was 
similar. 

On January 6 a very severe attack of pain began. She des- 
cribed it as being at the vertex, and " like anything splitting my 
head right in two." An injection of morphia gave great 
relief for three or four hours. At the end of that time she had 
ten leaches applied, five behind each ear. After this the pain 
became rapidly more severe. 

Temperatui-e 99-4°— 98-4". Pulse 102—96. Respiration 
20 — 24. For the next four days she suffered the most extreme 
pain in her hepd, which made her toss from side to side holding 
her head in her hands and crying, " Oh, my head ! I don't know 
what 1 shall do." From time to time she gained relief and even 
sleep from morphia and chloral. She retched and vomited very 
frequently. Her temperature varied between 98'4° and 99'4°. 

On January 10 her head was actually steaming, vapour 
rising from it visibly. She had had no application to it. From 
this time she gradually sank, first into what appeared to be 
natural sleep, then into heavy sleep, and finally on January 12, 
into coma, in which she died. The immediate cause of death 
appeared to be failure of respiration. Her breathing became 
extremely laboured, her face excessively livid, her hand? and 



452 HUGHLINGS JACKSON OX OPTIC NEURITIS 

arms also blue and her whole body was bathed iu sw^eat. Pulse 
excessively "weak, 202. Heart's action loud and tumultuous. 

Autopsy hy Dr. Stdton. — A well developed body. No cedema ; 
fairly nourished. Scalp normal. Very little diploe of skull, 
bone mostly compact. Dura mater healthy. Sinuses full of 
blackish blood; even the veins in the bone seemingly dis- 
tended, and giving the bone over the longitudinal sinuses a 
deep red appearance. Arachnoid healthy. Pia mater vessels 
enormously distended and of a blackish colour. It is rare to see 
the vessels of the pia mater so very much engorged. This was 
the case mostly over the posterior half of the brain. No 
wasting of convolutions, nor were they unduly flattened, as is 
usual in abnormal intra- ci'anial pressure. On section no 
disease was appreciable in the brain. Its substance was 
moderately firm. The grey matter had a pinkish-red, unduly 
vascular appearance. The central ganglia seemed normal. 
The pons, medulla, cerebellum, and spinal cord had also in 
their grey matter the same unduly red hyper^mic appearance. 
They were firm throughout. No appreciable change in mem- 
branes. The optic discs looked swelled, prominent, and their 
edges lost. 

Pleura) normal. One lung was oedematous. No other 
change in it. The other was very crepitant, and of a bright 
red colour. When squeezed only a little blood escaped. On 
the whole the lungs contained comparatively little blood. 

Pericardium normal. Heart normal ; left ventricle very 
firmly contracted, almost empty ; right auricle distended with 
blood. 

The other organs were normal, venously congestion only. 
The following account of the microscopical appearances of the 
brain also is by Dr. Sutton. 

On examining a section of a convolution of the anterior lobe 
of the cerebral hemisphere, and contrasting it with a section 
of healthy brain-convolutions about the corresponding part, 
it is clear that there is morbid change. It is first noticed 
that the spherical nuclear bodies in this woman's brain are 
much more numerous than in the healthy one, whilst the 
pyramidal cells are very much less numerous. Here and there 
well foi-med pyramidal cells are seen with their lateral processes ; 
and immediately adjoining them, where other pyramidal cells 



WITHOUT CEREBRAL TUMOUR. 453 

are usnally found in a somewhat regular orderly manner, are 
a large number of well-stained nuclei, about the size of white 
blood cells, with pale unstained parts (apparently cell-bodies) 
around them. This paler material is bounded by an ill-defined 
but unmistakable border. In the border, in some parts, a 
stellate or spindle shaped nucleus is seen. Although these 
nuclear bodies have mostly the size just named, sorhe are larger 
and others much, smaller. By the side of some of the larger 
ones, smaller ones are sSen, one or two ; as if a larger one had 
divided, and the smaller were ofF-sboots. This is a very notice- 
able feature in many places, and those nuclear bodies seem 
collected in groups in parts ; in other words, they are much 
more numerous in some parts than in others. 

Where more numerous there is very little of the paler 
substance around them, and around some it is not at all 
ap2)reciable, the nuclear bodies lying so close as to touch or 
almost touch each other. Ten or twenty of these may be thus 
aggregated. These bodies seem to lie mostly in the second and 
third layers of the convolutions ; that is dividing the grey 
matter of the convolutions into five layers, as is done by 
Meynezt and others. 

The neuroglia as contrasted with that of healthy brain, the 
sections being about equally thin, is observed to be much more 
granular; the fibre arrangement is much less distinct, it has 
a more uniform, gramdar aspect. ' The capillaries are for the 
most pai't full of red corpuscles. The capillary walls look 
normal, the perivascular space being very distinct ; in parts 
seemingly wider than normal. There is no appreciable 
thickerdng around the larger vessels, and for the most part there 
is no nuclear growth along the borders of the perivascular spaces, 
only here and there. There is no decided collections of leucocytes 
around the capillaries to indicate very active and recent 
exudation. Here and there, however, two or three round 
bodies like white Ijlood cells are seen lying on the capillary 
wall. It is further observed that in some places the neuroglia 
seems to be disorganised ; there are irregularly shaped spaces 
in which the neui'Oglia seems to be broken down, whether 
artificial or otherwise. 



454 HUGHLIXGS JACKSON ON OPTIC NEURITIS 

Examination of the Backs of the Eyes, by Dr. Goxmrs. 

The backs of the eyes examined after preservation in 
Miiller's fluid. 

Eye 1. — The optic nerve entrance is the seat of a swelling 
of moderate prominence, which extends on each side beyond 
the edge of the disc, and then gradually subsides to the 
retinal level. The subsidence is so gradual that it is difficult 
to measure its diameter ; it probably is about the Jpth of an 
inch. There is a central depression with rather steep sides, 
the bottom of the depression being -',7 th of an inch below the 
highest portion of the swelling. The greatest thickness of 
the latter is opposite the edge of the choroid, and there 
amounts to ^j^^th of an inch. 

The central vein and artery are both hirge, the vein 
especially ; they show no trace of constriction in passing 
through the sclerotic ring. They divide close to the bottom 
of the central pit, the branches approaching close to its 
surface as they pass up its steep sides, and keeping near the 
surface over the swelling, but dipping a little at the outer 
boundary of the swelling. 

Section of the sweUing shows that it is everywhere infil- 
trated with small round nucleus-like bodies, -goVo ^^ s'o'o tt 
inch in diameter, which are aggregated densely in the 
neighbourhood of the vessels. They are scattered among 
abundant delicate fibres of connective tissue, which compose 
the chief bulk of the swelling, and course in various directions. 
Numerous small vessels exist throughout its substance, and 
many of the connective-tissue fibres are arranged concentri- 
cally around these. Others are distinguishable only by their 
direction and wavy character from the nerve fibres, which 
may be traced uninterruptedly through the swelling. 

The retina on each side is pushed away from its normal 
place of commencement, being -^^^^ ^^ ^^ ^^^^ 0^ Q^^oki side 
from the edge of the choroidal ring. For a little distance it is 
greatly thickened, measuring 7 oth of an inch in thickness at its 
commencement. The increased thickness depends chiefly on 



WITHOUT CEREBRAL TUMOUR. 455 

thickeiiing of the inner and outer nuclear layers, the inter- 
nuclear layer being much narrowed. The nuclear layers 
present only a dense aggregation of such round corpuscles as 
those already described, and which resemble those normally 
constituting these layers. The layer of nerve fibres is also 
thickened, and contains similar nuclei. The retina further 
outwards gradually assumes perfectly normal characters. 

The optic nerve contains many similar corpuscles, some 
avgreyated alono- the vessels, others lying between the bun- 
dies of nerve fibres, others scattered through these bundles. 
They are more abundant just Ijehind the sclerotic than farther 
back, but are present in about ecj^ual numbers throughout the 
whole length of optic nerve received. 

The section of the bundles shows a granular appearance, 
the separate nerve fibres being less distinct than usual, but 
there are no other evidences of degeneration. 

The amount of connective tissue between the bundles is 
not noticeably increased. That in the intervaginal space is 
however very abundant, the trabeculee being numerous and 

thick. 

Eye No. 2.— The appearances of this disc, retina, and optic 
nerve are essentially similar, except that the amount of 
swelling is rather less (Plate IV, Fig. 3). The height of 
swelling above the level of the choroidal ring is -glpth of an 
inch on the side on which the swelling is greatest, and rather 
less on the opposite side. The commencement of the retina 
is not displaced outwards so far as in the other eye. There 
is the same infiltration of the new connective-tissue and of 
the nerve-fibre laver with minute nuclei. 



KEPOKT ON THE PROGNOSIS IN TOBACCO AMAUROSIS. 
By Jonathan Hutchinson. 

For some years past I have taken mucli interest in the 
study of tobacco amaurosis, or that form of ■ amUyopia which 
is so frequently met with in smokers. In 1864 I published, 
in the " London Hospital Eeports," my first report on the 
subject; my second appeared in 1867, in the " Medico-Chi- 
rurgical Society's Transactions;" and a third in 1871, in 
vol. vii of these Eeports. All these were more or less statis- 
tical, and comprised all the facts which I had been able to 
collect during each series of years. As years have passed on 
and experience has accumulated, my opinions respecting the 
malady in question have become more precise, and I have 
become able, I think, to exclude some sources of fallacy. It 
is not my intention, in tlie present report, to again examine 
the whole question, nor to add any additional series of cases. 
I propose to restrict my attention to one point — that of the 
estimation of the probability of recovery. As a rule, cases 
of this kuid, being essentially chronic, are lost siglit of as 
soon as the patient finds himself definitely improving. For 
many years, indeed, ever since I first recognised the import- 
ance of insisting upon the disuse of tobacco, I have been 
impressed with the fact that the disease of which formerly we 
thought most seriously did not appear to be a progressive one, 
and that at any rate we had no cases which continued under 
care and steadily got worse. I did not, however, until the 
last few years appreciate so fully as I do now tlie fact that 
most' of them make hond fide recoveries. I thought it pos- 
sible that many who ceased attending at the hospital might 
have gone to other hospitals, and been obliged to return to 



IN TOBACCO AMAUROSIS. 457 

their homes in the country without having been much bene- 
fited. An inquiry which I undertook in 1874, however, 
convinced me that the results had been much better than I 
had been ready to suppose. In that year, assisted by Mr. 
Nettleship, I wTote to all patients who had been under my 
care for tobacco amaurosis whose address I possessed, asking 
that they would either come up for examination or write and 
let me know their condition. The result was that we found 
that a large majority had quite recovered, and that scarcely 
any had got worse. Another remarkable and somewhat un- 
expected result was, that we found that many of those who 
had recovered had resumed the use of tobacco without detri- 
ment, most of them only to a small extent, but some almost 
to their former quantities. Those who had recovered had, 
all of them, — for a time at least — either abstained or greatly 
diminished their wonted consumption. The facts elicited in 
this inquiry and in another similar one which we have made 
this year in connection with my course of clinical lectures at 
Moorfields, are embodied in the following tables. Columns 
will be found devoted to the statement in precise terms of the 
degree to which sight had failed, and the extent to which it 
subsequently improved. 

I have been, of course, from the beginning of my interest 
in this subject, emphatic in my advice as to the disuse of tobacco 
as a paramount measure of treatment, and I have therefore 
had very few cases under observation in which it has been 
possible to study the natm^al history of the disease wdien its 
cause is left in operation. I cannot say wdth any confidence 
whether in any large number of cases blindness would be the 
result under such circumstances or not. A few have, how- 
ever, every now and then, come under observation at late 
periods of the disease, which support the belief that, at any 
rate in some, the disease is aggTessive, and a few in wliich the 
patient had become blind. At the present time I have under 
care a coal-porter from Ipswich, who has gone blind to mere 
perception of light with all the usual symptoms, and who has 
continued to smoke throughout. I am inclined, therefore, to 
VOL. VIII. 2 II 



458 HUTCHINSON ON THE PROGNOSIS 

believe, althoiigh my evidence is only fragmentary, that the 
prognosis is very bad if tobacco be not forbidden. Mackenzie 
pithily recorded his experience many years ago, that there 
were those " who would rather smoke than see ;" and although 
I cannot say that I have met with many who showed quite 
that degree of obstinacy, yet I* have little doubt that many of 
my patients who to me professed obedience, had really con- 
formed only in part. It would appear, therefore, that reduc- 
tion in quantity is efficacious and that abstinence is not abso- 
lutely necessary. I do not recollect for many years to have 
seen a single case diagnosed as tobacco amaurosis, which, in 
spite of treatment, went on from bad to worse. This is a 
very strong fact, and one which gives great support to the 
belief that tobacco is in these cases the real cause. 

Although, as stated above, I do not intend here to discuss 
the general question, yet it may be convenient just briefly 
to record my present impressions respecting it. 

I count as tobacco amaurosis those cases only in which the 
failure is absolutely equal in the two eyes. As a rule, the 
failure is gradual, and it is two or three months before tin 
patient seeks advice. Indistinctness of sight and a " constant 
mist" are usually his complaints. In most there is no 
headache nor any other cerebral symptoms ; usually there are 
no ophthalmoscopic signs, but sometimes the disc looks 
slightly hazy. Sometimes the digestion and general health 
have been somewhat disturbed, but more often the patient is 
in excellent vigour and has ailed nothing. Shag tobacco is 
the kind which has usually been employed, and the quantity 
usually not less than half an ounce (= about 15 grammes) a 
day. Total abstainers from stimulants are more liable to 
suffer than others, and although we sometimes meet with the 
disease in the intemperate, I have a strong impression that 
on the whole alcoliol counteracts tobacco. 

If the restricted description of tobacco amblyopia which 
I have suggested be accepted, I believe that no cases what- 
ever will be found amongst women, and none in men who do not 
smoke. A few cases of primary white atrophy are met with 



IX TOBACCO AMAUROSIS. 459 

in women in which the disease resembles the tobacco cases in 
the early stages very exactly, but they always progress and 
end either in total blindness or in a condition nearly ap- 
proaching it. It is probable that these very rare cases re- 
semble the true tobacco cases in every respect excepting the 
cause, and that the reason why they never improve is simply 
that we are unable to remove the cause. A few parallel cases 
occui' in male non-smokers, and it is possible that amongst 
smokers now and then a case may occur which is not wholly 
due to tobacco, and in which the prognosis may be much less 
hopeful. I may repeat that I do not recollect ever to have 
seen a woman threatened with failure of sight from primary 
atrophy, in which, after the symptoms had consideraljly ad- 
vanced, recovery took place. It is in smokers only that the 
prognosis is so hopeful. Hence a strong additional argument 
in favour of the behef that tobacco is really the main — if not 
in most cases the sole — cause of the disease. 

The annexed tables contain the facts as to progress in all 
the cases, 64 in number, of tobacco amaurosis, in which my 
notes are complete enough to give information on this point. 
Many of the cases have been published before, and are 
repeated here either without alteration or with the addition of 
notes made since their publication. 

As the object of this summary is not to establish 
diagnostic points, but to helf) in the prognosis of the 
affection, no cases are given excepting those of which my 
notes extend uver some time. In this way 63 of the cases, or 
just one half, are excluded as imperfect ; the total number of 
which I have notes (including those given in my former 
reports) being 127. 

The tables speak for themselves, but a few general 
statemer^ts drawn from a view of all the cases will, perhaps, 
serve to bring the more important facts into greater 
prominence. 

I. Becovcry or great improvement of sight took place in 
48 of the 64 cases (just ^^ per cent) (Table I) ; the cure 

2 H 2 



460 HUTCHINSON ON THE PROGNOSIS 

being perfect, or almost so, in 31 of these (viz., Nos. 4, 6, 
7, 8, 9, 11, 12, 13, 16, 17, 19, 23, 24, 25, 26, 27, 28, 31, 32, 
34, 35, 36, 39, 40, 41, 42, 44, 45, 46, 47, 48) ; and of the 
remaining 17 all excepting 1 either lived at a distance and 
did not in writing gi"s^e full information, or were under care 
for so short a time (from one to three months) that complete 
recovery could not be expected. 

In 4 cases the disease was arrested, sight remaining 
stationary after a certain degree of failure (Table II). 

In 7 cases sight became worse while under care (Table III), 
and 5 others were quite blind when first seen, and are 
believed to have continued so (Table IV). 

II. The relation between the duration and degree of the 
amblyopia and the rate and comjyleteness of recovery. The 
cases which come under care quite early get well quickly 
and completely (Nos. 17, 24, 32, 35, 39, 42, 45, 46) ; and 
this although there is no constant relation between the time 
and the degree of failure (see Nos. 17, 35, 42, 46) ; and cases 
of long duration may recover perfectly or very nearly so 
(Nos. 8, 11, 16, 19, 23, 34, 41. 47, 48), but their rate of 
improvement is usually slow in proportion to the degree of 
the defect. (The same cases.) 

III. RaMts of the ijatients in regard to the use of tobacco 
before and after coming U7icler care. 

Of the 48 patients who improved, 26 ceased smoking 
entirely wliile under care or for a longer time ; and 13 others 
continued to smoke, but very much less than before. Of 
those who entirely left off tobacco for a time, 6 are known to 
have taken to smoking more or less some time after the sight 
had recovered, and in none did the sight again fail (Nos. 9, 
17, 24, 28, 35, 41). Probably many others of whom this 
question was not asked would have given the same reply. 

The quantity of tobacco had been increased before the 
sight began to fail in several cases (Nos. 3, 17, 20, 24, 43, 53, 
58) ; in some others although there had l^een no increased 
quantity, symptoms of greater susceptibility to its influence 
had attracted the patients' attention (Nos. 31, 35, 64) ; whilst 



IX TOBACCO AMAUROSIS. 461 

a third group are noted as having been always comparatively 
intolerant of tobacco (Nos. 34, 36, 45, 54, 58, 63). Let it be 
noted especially that increased quantity, or disagreement, or 
habitual susceptibility were present in several of the cases 
which became worse or did not improve. 

In not one of the cases in which improvement took place 
had the patient continued to smoke his full quantity. Of the 
11 patients in whom the disease either did not improve, or 
became worse, no fewer than 8 had persisted in smoking their 
usual allowance throughout. This is a very strong fact. 

IV. Influence of otiier habits and previous state of health 
on the severity or course of the tobacco awMurosis. 

Those who are specially mentioned as in particularly 
good health, furnish several of the best and quickest 
recoveries (Xos. 13, 23, 26, 31, 40). 

Several were either total abstainers from alcohol, or took 
so little as to be almost such (Nos. 1, 5, 14, 36, 38). 
Another (No. 24) had been an abstainer till a few years 
before, but had since taken a little beer on medical advice. 

No doubt some of the patients were drinking to excess, 
but most of these were also smoking to excess, and such 
cases prove nothing as to the direct power of alcohol in 
causing amblyopia (Nos. 6, 15, 23, 32, 33, 35, 40, 42, 43, 45, 
46, 53). 

In a certain number besides those who were known 
drinkers, habitual indigestion or failure of appetite is noted 
(Nos. 18, 20, 27, 28, 31, 34, 44, 50, 51). 

A history of special anxiety or trouble of some kind, or of 
overwork, was given by several patients, and would probably 
have been even more common if always asked for (Nos. 21, 
22, 35, 39, 40, 41, 46, 48, 61). Another smaU group are 
noted as constitutionally nervous (Nos. 14, 30, 36, 39, 47). 
Only 2, however, complained of sleeping badly (Nos. 18, 44), 
and 3 others of too great sleepiness (Nos. 21, 41, 62). 

V. Influence of age. Excellent recovery took place in 
several patients aged from 55 to 65 or more, and no special 
danger seems to be attached to advanced age in this malady. 



4:62 HUTCHINSON ON THE PROGNOSIS 

Two of the worst cases, however, both of whom ceased 
smoking entirely, were old men (Nos. 58 and 59). 

VI. Other possible causes and special points. 

A few patients attributed the failure to exposure to great 
sun-heat or glare, and in all of these excepting one, the onset 
of amblyopia had been sudden or very rapid (Nos. 31, 32, 43, 
54, 63). Sudden onset, however, occurred without mention 
of any special exposure to the sun in a few others, but even 
most of these occurred either in late spring or summer 
weather (Nos. 1, 10, 35, 42, 46, 55). 

Several of the cases in Tables II, III, and IV, presented 
some points of diffarence from the ordinary cases of tobacco 
amblyopia. Thus there were other nerve symptoms in Nos. 
56 and 62 ; much aching of the eyes was complained of in 
No. 55 ; and the disease was not quite symmetrical in onset 
or progress in Nos. 49, 50, 57, and 59. Whether such 
unusual symptoms are to be attributed to the influence of 
tobacco on certain constitutions, or whether their occurrence 
makes it probable that the amaurosis in such cases is really 
due to some other cause than tobacco, must for the present 
remain an open question. 



IX TOBACCO AMAUROSIS. 



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IN TOBACCO AMAUROSIS. 487 



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white ; vessels of 


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it has made 
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