SYMPATHETIC IRRITATION 
AND 
SYMPATHETIC SEROUS IRITIS, 
WITH 
CASES. 
A Clinical Lecture in the Jefferson College Hospital. 
BY 
G. E. DE SOTWEINITZ, M.D., 
Clinical Professor of Ophthalmology in the Jefferson Medical College; 
Ophthalmic Surgeon to the Philadelphia Hospital. 
REPRINTED FROM THE THERAPEUTIC GAZETTE, MARCH /j, /S03. 
DETROIT, MICH. : ' , 
GEORGE S. DAVIS, PUBLISHER. 
i 893. Sympathetic Irritation and Sympathetic 
Serous Iritis, with Cases. 
GENTLEMEN:—We are concerned this 
morning with the affections in which 
one eye is implicated as the result of disease 
or injury to the other; in other words, with 
sympathetic irritation and sympathetic ophthal- 
mitis. 
You are probably aware that it is customary 
—indeed, it is important and scientifically ac- 
curate—to apply these terms to two essentially 
different conditions; but whether we deal with 
sympathetic irritation or with the more serious 
condition of inflammation, the eye which is 
implicated as the result of disease or injury of 
its fellow is described as the “sympathizing 
eye,” and the one which is affected by the dis- 
ease or injury which causes the implication as 
the “exciting eye.” Bear these two terms 
in mind, as I shall have occasion to use them 
again in the descriptions which follow. 
The first patient, a man, aged thirty, was 
injured by the premature explosion of a dyna- 
mite cartridge, causing such extensive laceration 
of his right foot that amputation was necessary. 
At the same time his left eye sustained injuries 
resulting in the lesions which I shall presently 
demonstrate to you. He has been under the care of Dr. William Forbes, and as the leg has 
entirely healed, Dr. Forbes has very kindly 
transferred him to the Eye Department for fur- 
ther treatment. You observe that there is a 
large scar in the lower and outer portion of the 
cornea of the left eye, passing through the ciliary 
region, to the margins of which the iris is at- 
tached, while the lens is cataractous, the aque- 
ous humor turbid, the general eyeball coarsely 
injected, the tension slightly below normal, and 
there is marked tenderness in the upper portion 
of the ciliary zone. In other words, we have 
the lesions of traumatic irido-cyclitis and cata- 
ract. Vision is entirely obliterated, and there 
is not the faintest trace of light perception in 
any portion of the field. 
Ever since the injury the eye has been pain- 
ful, but in the last few weeks this pain has 
markedly increased, being present not only on 
pressure, but constantly. More than this, the 
other eye, while not tender to the touch, is 
sensitive to the light; there is increased lachry- 
mation, impaired amplitude of accommodation, 
occasional shoots of pain through the brow and 
temporal region, and slight veiling of the 
margins of the optic nerve. The pupil is 
larger than one would expect in a patient at 
this age of life and with this exposure to light, 
although I have not been able to observe oscil- 
lation of the iris, a symptom which Mr. Gunn 
has stated to be present when a sympathetic 
irritation, which is the condition now presented 
to us, is about to give place to an actual 
inflammation. 
The symptoms are sufficiently pronounced, 
and have been sufficiently persistent, to make 
enucleation of the excitor a proper surgical pro- cedure. While it is true that a sympathetic 
disease of this character is a functional disturb- 
ance, and is by no means the necessary precursor 
of a sympathetic ophthalmitis, such an outcome 
is occasionally the case, and, even if it were not, 
the evident indication is to remove the cause 
which is exciting the functional disturbance 
which you here witness, and to relieve the pain 
which is occasioned by the traumatic irido- 
cyclitis of the left eye. 
As the eyeball is somewhat soft, and the 
conjunctiva closely adherent to it on account 
of the previous inflammation, I will enucleate 
the eye by Bonnet’s method, although, as you 
know, by the Vienna plan the operation can be 
more rapidly accomplished. A stop speculum 
being inserted, I divide the conjunctiva with 
scissors in a circle close to the margin of the 
cornea. The tendons of the ocular muscles are 
now successively raised upon a strabismus-hook 
and severed. When the tendon of the external 
rectus is reached, I allow a small stump to re- 
main, which may be utilized afterwards as a 
point of application for the forceps. By insert- 
ing the stop speculum somewhat more deeply, 
the eye, as you see, is made to start forward, 
the stump of the external rectus is seized with 
forceps, the eye drawn forward, the curved 
scissors introduced between it and the severed 
conjunctiva until the optic nerve is reached, 
which is cut squarely off. The attachments 
remaining are the oblique muscles, and these 
are now readily divided. Hemorrhage, you 
observe, is only moderate in quantity, and has 
practically ceased after the irrigation of the 
socket with a bichloride solution (i to 8000). 
Iodoform is dusted over the surface of the 
3 wound and an ordinary antiseptic dressing 
applied. For a few days I shall exclude the 
light from the right eye in order that the 
symptoms of irritation may more readily sub- 
side. 
On opening the eyeball, you notice the fol- 
lowing interesting lesions : The cataractous lens 
and iris are firmly bound together, the ciliary 
body is thickened, the retina detached, and 
the centre of the vitreous occupied with this 
firmly-encysted abscess. I cannot find a for- 
eign body, although we might reasonably ex- 
pect a small portion of the cap. It is possible 
that it has not only penetrated, but passed en- 
tirely through the coats of the eyeball; in its 
course, however, lodging some infecting mate- 
rial, which has resulted in the suppuration which 
is so beautifully shown here. 
This is a fair example of a very constant re- 
sult of injury to the ciliary region, the wound 
being generally found in a zone about a quar- 
ter of an inch in width, surrounding the cornea, 
which Mr. Nettleship has aptly called the “dan- 
gerous region.” Plastic or purulent cyclitis re- 
sults, in our case followed by a purulent hya- 
litis. The sympathizing eye presents a series 
of phenomena which are of the nature of a 
neurosis, and to which the term sympathetic 
irritation is applied. Under circumstances such 
as I have shown you to-day, the proper treat- 
ment is enucleation of the exciting eye, or, if 
not enucleation, one of the substitutes for this 
operation, particularly that one which is called 
evisceration. The result is almost uniformly a 
cure, and I doubt not that at a subsequent 
lecture I will be able to show you this patient, 
not only well in so far as the operation is con- 
4 cerned, but relieved of the symptoms in the 
sympathizing eye.* 
The next case is of a much graver nature, 
not only on account of the lesions which have 
taken place, but in relation to the preservation 
of vision. The patient, a young man, aged 
twenty-nine years, eleven weeks ago was injured 
by a piece of steel striking the left eye. The 
sight was lost at the time, and, as you see, there 
is a large cut through the upper ciliary region, 
which has healed with a puckered cicatrix ; the 
iris is inflamed and bound down to the capsule 
of the lens, the anterior chamber shallow, the 
eye slightly shrunken, soft to the touch, and 
very tender on pressure ; in other words, a trau- 
matic irido-cyclitis with beginning shrinking. 
No symptoms of trouble in the right eye ap- 
peared until a few days ago, when he presented 
himself at the clinic. Then, unfortunately, not 
an irritation, but a true inflammation had al- 
ready begun. The entire eyeball was slightly 
injected, while around the margin of the cor- 
nea there was a zone of fine, pinkish injection. 
The iris was mobile, but at the lower margin of 
the cornea there was a faint haze, and one spot 
on the iris was a little thickened. The vision 
was normal, the optic nerve hyperaemic, the 
field of vision uncontracted, but there was 
slight tenderness in the ciliary region. The 
patient was at once put upon small and fre- 
quently-repeated doses of calomel, atropine was 
instilled into the right eye, and the light ex- 
cluded. For twenty-four hours he appeared 
better. At the end of that time, in spite of 
5 
* The symptoms of irritation rapidly subsided, and 
the patient is now entirely well. treatment, the spot of infiltration in the cor- 
nea deepened, and a characteristic triangular 
deposit of opaque dots appeared in Descemet’s 
membrane, and a soft synechia formed in the 
lower margin of the iris. He was now freely 
leeched from the temple, atropine was more 
vigorously applied, and protiodide of mercury 
was given in place of the calomel, together with 
tonic doses of quinine. These measures fortu- 
nately resulted in the tearing loose of the syne- 
chia which had formed, so that the pupil is 
round and widely dilated and the ciliary injec- 
tion has somewhat subsided, although, as you 
see, the eye is red, inflamed, tender to the touch, 
and there is a patch of keratitis punctata. 
In short, gentlemen, we have here the very 
serious condition of traumatic irido-cyclitis of 
the left eye, which, in all probability, contains 
a foreign body, and sympathetic serous iritis of 
the right eye, and we stand in the presence of 
a grave question for solution,—namely, whether 
or not to excise the excitor in the hopes that 
this, by relieving a source of irritation, may 
modify the dangerous organic disease which 
has already seized hold of the sympathizer. 
In order to understand why there should be 
any hesitancy, we must revert for a moment to 
the probable explanation of sympathetic oph- 
thalmitis. No doubt you will remember that 
formerly it was almost universally taught that 
this disease was due to a reflex action through 
the ciliary nerves, and therefore the name “sym- 
pathetic” was applied. Now, while we are not 
sure of the exact nature of this malady, nor 
thoroughly acquainted with the path of the 
morbid changes, the old hypothesis of trans- 
mission by the ciliary nerves has been largely 
6 abandoned and the theory of infection has 
been revived and, perhaps I may say, proved. 
The micro-organisms from the seat of original 
injury find their way, probably by the sheaths 
of both optic nerves, to the sympathetic eye, 
and there set up an ophthalmitis, which may 
present itself in the form of an irido-cyclitis, a 
serous iritis, such as I show you to-day, or, more 
rarely, as a choroido-retinitis, while in many, 
if not in all, of the varieties of sympathetic 
inflammation the primary symptom is a low- 
grade neuritis or neuro-retinitis, although this 
symptom is not the one which first attracts the 
attention of the surgeon. 
With these facts in mind you can readily 
understand that when the tissues of the sym- 
pathizer are infected, though excision of the 
excitor removes the original focus of infec- 
tion, it does not destroy the morbid changes 
which have already seized upon the sheath of 
the optic nerve and the coats of the eye upon 
the opposite side. The question to be decided, 
therefore, is, Will the ultimate result be better 
if the medicinal treatment of sympathetic oph- 
thalmitis is employed to the exclusion of opera- 
tive interference upon the blind but exciting 
eye, or will the chances of recovery be improved 
by removal of the excitor ? At the first blush 
it would seem that there is only one answer to 
this question,—namely, to remove the original 
cause,—but in certain instances the sympathetic 
disease has apparently been aggravated by this 
procedure, and a serous iritis has changed into 
a plastic type; at least this is the assertion of 
one or two very high authorities. 
We must hence base our line of conduct to- 
day upon the teaching and experience of the 
7 best-known ophthalmic surgeons and upon the 
statistical information which has been gathered 
to elucidate this very point. We find that Noyes, 
Berry, Schweigger, Swanzy, Schmidt-Rimpler, 
De Wecker, and many others that I might 
mention were I so inclined, are in practical 
accord that efficient help is gained in the treat- 
ment of sympathetic ophthalmitis by the re- 
moval of an exciting blind eye, provided the 
enucleation is performed when not more than 
two, or at most three, weeks have elapsed since 
the appearance of the sympathetic disease. 
Moreover, we are in possession of a great deal 
of statistical information. In 1886 a commit- 
tee was formed in England to gather informa- 
tion on the subject of sympathetic ophthalmitis, 
and for this purpose the literature of the subject 
was examined and a circular containing a num- 
ber of questions was sent to many prominent 
ophthalmologists. The very first question upon 
this circular is, When sympathetic inflammation 
has begun, does excision of the exciting eye 
influence its progress ? And the following piece 
of evidence was presented in reply : Among two 
hundred cases, there were sixty-four in which 
the excitor was removed within a short time 
(that is, within three weeks) of the onset of 
the sympathetic inflammation, and of these the 
sympathizing eye was known to be lost in 
only eight. In an almost identical number 
(sixty-five) the excitor was either not removed 
at all, or not until long after the sympathetic 
disease had set in, and in no less than twenty-six 
of these the sympathizer was lost. From these 
data the committee concluded that whether 
early removal of the exciting eye be positively 
useful in staying the disease or no, it certainly 
8 is not injurious, although no less an authority 
than Mauthner has asserted that it is when the 
sympathetic disease is of the serous form. 
By way of recapitulation, a quotation from 
Noyes is apropos: “The removal of the cause 
is the only effective treatment, and that means 
enucleation of the exciting eye. The operation 
is by far more satisfactory in the irritative forms, 
and there rarely does it fail. When the inflam- 
matory condition is once begun, an early oper- 
ation may check its progress, but this is not 
to be absolutely counted on, even if done on 
the very first day (Hirschberg). Enucleation, 
when the inflammatory process has gained de- 
cided headway, has little control over it; yet 
it does not aggravate it, as claimed by Mauth- 
ner. Sometimes it mitigates a patient’s suffer- 
ings, and cases of effective relief are recorded.” 
The weight of opinion, therefore, being in fa- 
vor of operative interference, if for no other 
purpose than to check what De Wecker would 
call the transmission of impulses, I will excise 
this exciting eye. 
This I do in precisely the same manner as in 
the previous case, and need not repeat the 
details of the operation. While Dr. Phillips 
is applying the dressings, I will open the eye 
and demonstrate the lesions. You observe 
that the ball is slightly shrunken and begin- 
ning to assume a quadrate shape, the retina is 
detached in folds, the ciliary body thickened, 
the vitreous slightly purulent, and lying in the 
long axis of the eyeball, stretching between 
the posterior surface of the lens and the optic 
nerve entrance, and entangled in the meshes 
of the detached retina, is a piece of steel twelve 
millimetres in length and three millimetres in 
9 width. In short, we have here conditions 
potent above all others to produce sympathetic 
ophthalmitis,—namely, traumatic irido-cyclitis 
and retained foreign body. The subsequent 
treatment of this case will consist of rest in 
bed, exclusion of light from the right eye, the 
frequent use of an atropine solution, and the 
internal administration of the protiodide of 
mercury to the point of tolerance, together 
with tonic doses of quinine.* 
Now, gentlemen, I beg you to understand 
that I have been describing to you the proper 
course of treatment in a case of sympathetic 
ophthalmitis, under the circumstances which 
this patient presents, provided the exciting eye 
is blind. A very different line of procedure is 
necessary if the excitor retains sight, even in 
very moderate degree. Then it is not justifi- 
able to operate for its removal, because in the 
end it may be the eye which will retain the 
more useful vision, or, in other words, the 
treatment of the original injury may result in 
the preservation of vision, perhaps even useful 
vision, while the sympathetic disease may ter- 
minate in blindness. 
Let me repeat some rules to you which cover 
the ground as well as it is possible to do so, 
with reference to the various problems that 
may be presented in the treatment of sympa- 
thetic ophthalmitis and your relations as sur- 
geons to the case. Bear in mind that I speak 
of ophthalmitis now, not of the disease which 
I described in connection with the first case. 
* The iritis steadily improved, and one month after 
operation there has been no relapse, the eye being white 
and quiet. These rules are quoted from those which are 
given by Mr. Swanzy, because I think they are 
clear, to the point, and represent the published 
experiences of the best authorities. 
You should perform enucleation, or one of 
its substitutes, on,— 
(1) An eye with a wound which involves the 
ciliary region to such an extent that sight is 
immediately destroyed, or that its ultimate 
destruction by the process of inflammation is 
practically certain. 
(2) An eye which has been wounded in the 
dangerous region, and in which severe inflam- 
mation of the iris or ciliary body has already 
begun, even if sight is not destroyed. 
(3) An eye which contains a foreign body 
which judicious efforts have failed to extract, 
and when much iritis is present, even if sight 
is not destroyed. 
These three rules, you will observe, apply to 
preventive enucleation,—that is to say, the 
operation is performed in order to check sym- 
pathetic disease. 
Now let me quote you two which should be 
your guide, provided the sympathetic disease 
has already begun, as in the case which we 
have been considering. 
1. You should perform enucleation, or one of 
its substitutes, on an eye whose sight has been 
destroyed, even though sympathetic inflamma- 
tion has begun in the sympathizing eye, be- 
cause by this means you remove a source of 
irritation and hope to render the treatment 
of the sound eye more effectual. 
2. You should not perform enucleation, or one 
of its substitutes, on an eye which has been 
injured, but which retains some vision, when 
11 sympathetic inflammation has begun in the sym- 
pathizing eye, because in the end it may prove 
to be the more useful organ. 
Under the last-named circumstances you must 
employ the medicinal treatment suited to the 
excitor, as well as that needed by the sympa- 
thizer. Generally this treatment consists in the 
frequent instillation of atropine, local blood- 
letting, and, if the patient is sufficiently robust, 
the use of mercury in some form, preferably, 
I think, protiodide by the mouth, or inunctions, 
to the point of tolerance, but not to that of 
salivation, tonic doses of quinine, and concen- 
trated, nourishing food. The light should be 
excluded, if necessary with a bandage, but there 
is no objection to the patient having proper ex- 
ercise, which usually may be given in the room 
to which he is almost of necessity confined. 
Should this not be practicable, he may be taken 
out with eyes properly protected with bandages. 
Of course you understand it is possible to 
give only a general outline of the treatment; 
in the details you must be guided by circum- 
stances surrounding each case. At some future 
lecture I will point out to you the treatment of 
scleral wounds and the great advances which 
have been made in the management of badly- 
injured eyes, even with penetrating wounds of 
a serious nature and trenching upon the ciliary 
region, or actually passing through it. Time 
does not permit me to do so to-day. I must, 
however, refer to one treatment of sympa- 
thetic ophthalmitis, which has, perhaps, not 
had sufficient trial to take its station among 
the best-recognized surgical procedures, and 
yet which has much to commend it and has been 
advocated by surgeons of great experience and 
12 sound judgment. I refer to injections of anti- 
septic solutions into the sympathizing eye. 
Abadie and several other French and also 
Italian surgeons have published cases where 
marked improvement occurred by injecting two 
to five drops of a strong solution of the bichlo- 
ride of mercury into the vitreous chamber; for 
example, in one recently reported case of stub- 
born sympathetic irido-cyclitis the strength of 
the solution was i to 500. The injection was 
twice repeated, and good results are recorded. 
Recently, in England, Mr. Berry and one of 
his assistants have undertaken a series of exper- 
iments to prove the tolerance of the vitreous 
humor to various types of injection, and their 
results seem to show that aqua chlorinata was 
the most acceptable. At present, Dr. Hare and 
myself are engaged in a similar series of experi- 
ments in the Laboratory of Experimental Ther- 
apeutics, because the exact therapeutic relation 
of these fluids, when introduced into the eye, 
to a microbic disease, and especially the rela- 
tion of the chemical composition of the vitreous 
to that of the fluid injected, are points that 
require considerable elaboration. 
Finally, gentlemen, I do not wish to close 
this talk without in my last sentences empha- 
sizing one point,—namely, that while sympa- 
thetic inflammation may be preceded by symp- 
toms more or less analogous to those which I 
described as a neurosis, this is by no means 
always, nor, indeed, is it commonly the case, 
and therefore a sympathetic irido-cyclitis, serous 
iritis, or choroido-retinitis may arise insidiously, 
practically without warning, and the lesions 
become pronounced before the gravity of the 
situation is appreciated. Nowhere more than in 
13 this disease does the law of preventive surgery 
apply. An incubation period, varying from 
three to six weeks, is common, but recollect 
that the disease may develop sooner or may be 
delayed for a long time. From the day on 
which the conditions arise that are liable to 
cause sympathetic ophthalmitis until they are 
removed the patient is not safe from this grave 
malady. 
14 JANUARY 16, 1893. 
WHOLE SERIE9. VOL. XVII. 
THE 
Therapeutic Gazette 
A MONTHLY JOURNAL 
— OF— 
General, Special, and Physiological Therapeutics. 
No. I. 
THIRD 9BRIE8, VOL. IX. 
GENERAL THERAPEUTICS, 
H. A. HARE, M.D., 
Prafaaaor of Tharapauika U iba JcSenoa Medical Collage. 
0. E. DB SCHWBINITZ, M.D.. f 
Clmlcal Prof...,,, of Ophthalmology la *• ' 
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