SELECTIONS 
FROM RECENT 
OPHTHALMIC LITERATURE. 
BY 
HENRY I). NOYES, M. I)., 
NEW YORK. 
[REPRINTED FROM THE N. Y. MEDICAL JOURNAL, JUNE, 1873.] 
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1873. PROSPECTUS FOR 1873. 
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TIEiiE 
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D. APPLETON & CO., 549 & 551 Broadway, N. Y SELECTION" S 
FROM RECENT 
OPHTHALMIC LITERATURE. 
BY 
HENRY D. NOYES, M. I)., 
NEW YOKE. 
[REPRINTED FROM TEE N. Y. MEDICAL JOURNAL, JUNE, 1873.] 
NEW YORK: 
I). APPLETON AND COMPANY, 
549 & 551 BROADWAY. 
1873. SELECTIONS FROM RECENT OPHTHALMIC 
LITERATURE. 
1.—Du Zona Ophthalmique et des Lesions Oculaires qui s'y rattachent. 
Parle Dr. Albert Hybord. [Paris—Adrien Delahaye, 1872, pp. 161.] 
The above brochure gives a complete account of what is yet known of 
herpes zoster ophthalmicus. It is founded upon a review of ninety- 
eight cases, of which six are contributed by the author. The clinical 
features of the disease are so well known that they need not be here 
repeated; but the following statements, drawn from the large number of 
cases, are worth reading. The eruption takes place a few hours or days or 
even three months after the outbreak of neuralgia; in a few cases it occurs 
without any precedent neuralgia. In thirty-two cases, that is, one-third 
of the whole, the eye was not affected. In the remaining two-thirds, the 
ocular lesion was in the eyelids, conjunctiva, cornea, iris, or muscles, or 
lachrymal gland. The corneal diseases were vesicular eruptions, ulcera- 
tion which might go on to perforation and suppuration, or simple intersti- 
tial keratitis. The pupil in a few cases was dilated. The iris and cornea 
were commonly inflamed together, and their inflammation presented itself 
in one-half the cases. Iritis may occur without corneal inflammation, 
while severe keratitis is accompanied by iritis. 
In fifty-three cases, the herpetic eruption appeared on the nose, and in 
thirty-five of these the iris and cornea were inflamed. In only seven 
cases did kerato-iritis occur when the eruption was confined to the fore- 
head. Mr. Hutchinson’s remark about the association of kerato-iritis with 
the irritation of the nasal branches of the ophthalmic nerve is substan- 
tially verified. The reason is found in the fact that the nasal branch of the 
ophthalmic nerve supplies the filaments which enter into the ciliary 
nerves. 
The most interesting part of the paper is the discussion of pathological 
anatomy. The disease we are considering belongs to the general category 
of herpes zoster, and several interesting autopsies are quoted—one case by 
Baerensprung was an infant a year old who died of pulmonary tuberculosis, 
and during forty days before death had herpes of the sixth, seventh, and 
eighth intercostal spaces of the left side. The cord was healthy; the sixth, 
seventh, and eighth intercostal nerves healthy up to the intervertebral 
foramina, where they became thickened and injected; the ganglia of the 
roots were enlarged, anti the surrounding connective tissue presented in- 4 
flammatory redness. By the microscope, unmistakable traces of inflam- 
mation were found in the ganglia and the roots of the nerves up to their 
place of junction. Substantially the same lesions have been found by 
Charcot in a case of zona of the neck. Weidner gives an examination of a 
woman who died of pneumonia while having an attack of herpes on the 
left shoulder and arm. On the sensitive root of the first thoracic nerve 
was found a small tumor of the neurilemma, which penetrated and sepa- 
rated the fibres of the nerve. It consisted of fusiform cells, and nuclei and 
corpuscles impregnated with phosphate and carbonate of lime. Weidner 
also gives another autopsy which conducts to our present subject: an old 
man, who had had zonaophthalmica, died five years after of pneumonia; at 
the dissection, the fifth nerve was found to he shrunken at its emergence 
from the pons Varolii, and the pia mater hypersemic; and again there were 
contraction of the nerve and hyperaemia at its entrance into the ganglion of 
Gasser. In the ganglion the filaments of the nerve were dissevered from 
one another, and the interstices filled by a red and thickish liquid. The 
ganglion-cells were of unequal size, and contained abundance of yellow- 
ish-brown pigment: the connective tissue was replete with nuclei. 
The most detailed autopsy in ophthalmic zoster is given by Wyss. The 
chief lesion was in the ganglion of Gasser, which was enlarged, softened, and 
injected. On its inner border was a red spot, one millimetre in diameter, 
lookinglike extravasation of blood, and the ophthalmic nerve was surround- 
ed by bloody extravasation up to its entrance into the orbit. It was both 
thicker and tvider than the opposite nerve, and of a soft, gelatinous consist- 
ence. The second and third branches of the fifth nerve were normal. By 
the microscope, the tissue of the nerve before entering the ganglion was 
found filled with extravasated blood, the capillaries distended and multiplied. 
Only the internal part of the ganglion which gives origin to the ophthal- 
mic nerve was altered in structure. Here were extravasations and en- 
larged capillaries. At many points the ganglion-cells were disintegrating, 
some were entirely destroyed, while pus-cells were present in abundance; 
changes of a similar kind were traced down the nerve-trunlc. The fibrous 
tissue was the structure chiefly damaged, but many nerve-fibres also 
exhibited lesions in the coagulation of their myeline, and conversion 
of the axis-cylinder into fat and granular matter. Of the peripheral 
lesions in the case may be mentioned abscesses in the ocular muscles, in 
the upper lid, in the subconjunctival connective tissue, and phlebitis of 
the ophthalmic vein—purulent infiltration of the cornea and iris, and ex- 
travasation of blood in the choroid and retina. The ciliary nerves were 
abundantly surrounded with pus-cells and extravasations. 
The above facts give the explanation of herpes zoster, whether it afFect 
the ophthalmic nerve or any branch coming from the cord. But it must 
also be stated that the eruption occurs from lesions not oidy of the gan- 
glion on the sensitive root, but from inflammation of the peripheral part 
of a nerve as in traumatic cases, and from changes both in the gray sub- 
stance of the posterior cornua of the cord and in its posterior columns. 
In reasoning upon the facts discovered, Dr. Hybord distinguishes be- 
tween the lesions now considered and those which result from paralysis of 
the fifth nerve. In the present case, the nerve is in active irritation when 
mischievous effects appear at its peripheral distribution. The impaired 
nutrition which sometimes attacks the cornea after paralysis of the oph- 
thalmic branch of the fifth is evidently a very different condition ; it is a 
suspension of function. In the latter case Dr. Hybord attempts to show 
that the eye suffers only when there are both anaesthesia and destruction of 
certain trophic filaments which come from the inner part of the ganglion 
Gasser. In the case of herpes zoster ophthalmicus the same fibres, both 
sensitive and trophic, are the seat of an active irritation. 5 
2.—A Report on the Forms of Eye-Disease which occur in Connection 
with Rheumatism and Gout. By Jonathan IIuTcnixsoN. [Oph- 
thalmic Hospital Reports, vol. vii., pp. 287.] 
The author deems it wise to call attention to rheumatism and gout as 
causes of iritis and scleritis, because this etiology is important to be recog- 
nized in treatment. He thinks the prevalent practice of the present time 
has disregarded this connection in an unfair degree. He fortifies his posi- 
tion by quotations from standard authors, and recounts seventeen cases 
which have come under his own observation. He takes., pains to note the 
instances in which the patient has had gonnorrhoea as well as rheumatism 
or gout, prior to the eye-inflammation. Mr. Hutchinson does not assert 
his belief in a causal connection between gonorrhoea and rheumatism, or 
vice versa, but many of the authors do whom he quotes. This point is not 
quite in order to the discussion, but it deserves attention, that the present 
uncertain belief of the profession about it may be made more decided either 
for or against the theory. As to the influence of rheumatism and gout in 
causing scleritis and iritis, there can be no doubt; and that the form of 
inflammation is often both severe and obstinate is true; and this is the fact 
even when strictly anti-rheumatic or anti-gouty remedies are resorted to. 
Perhaps the purpose of Mr. Hutchinson’s report can be best enforced 
by relating a case in which the necessity of attending to the rheumatic 
diathesis was signally illustrated. 
Mr. S., a lawyer, aged about forty, of plethoric habit, and very active 
mentally and physically, had abused himself by many excesses, had had 
syphilis and gonorrhoea, had had several attacks of iritis before I saw him, 
and they had been treated by mercurials and iodide of potassium as well 
as by sulphate of atropia. In some of the attacks he had been sick two 
months. He consulted me in one attack of iritis, and expressed an ex- 
treme aversion to submit to the former constitutional treatment. I judged, 
from the ruddy hue of his face and his full habit, that rheumatism might 
be to a great degree responsible for his iritis; especially because he com- 
plained of wandering muscular pains, and stated that his eve-trouble was 
apt to follow excesses in eating and drinking. He had iritis serosa. I 
directed the sulphate of atropia, grs. ij ad | j, every three hours, in the 
eye; and a drachm of Rochelle salts three times daily, with free use of 
diluent drinks. In forty-eight hours the symptoms ameliorated, and in a 
-week the eye wras well. 
In less than a year another attack occurred. For this he himself tried, 
for a few days, the sal Rochelle and atropia, but with little benefit. I sub- 
stituted liquor potassa) for the salt, and the good effect appeared promptly. 
The iritis wras gone in a week, and by the atropia the pupil was fully 
dilated. The kidneys were in both instances excited to free action. In 
this case it was natural to suppose that syphilis might be the cause of the 
attacks, but the frequency of their occurrence, and the patient’s appearance, 
impressed me with the idea that they were due to rheumatism, and this 
belief was fully confirmed by the success of the treatment. 
3.—Contribution to the Pathology of Keratitis. By Dr. S. Talma. [Ar- 
chiv fur Oph., Bd. xviii., Abth. 11, S. 1-9.] 
The purpose of the author’s experiments was to ascertain whether pus- 
cells are developed from the corneal corpuscles or are exclusively the 
white blood-corpuscles which have passed out of the capillaries. He ex- 
cited traumatic inflammation in the cornea of frogs and white mice, rab- 
bits and Guinea-pigs, by carefully touching it with nitrate of silver. After 
periods varying from half an hour to several days, the eyes were excised, 
and the cornea examined under the microscope. In all cases, the first per- 6 
ceptible change.s in tissue began in the circumference of the cornea, not in 
the vicinity of the centre where the caustic was applied. The test-sub- 
stance relied upon to distinguish between corneal corpuscles and pus-cells 
was a strong solution of sugar. By it, the former are not affected, while 
the latter shrink to a nearly spherical form, and refract the light very 
strongly, and thus become conspicuous in the transparent tissue. The 
strength of the solution varies from to 10 per cent. 
The result of many experiments, made at all stages of the inflammatory 
action, was to establish the fact that the corneal corpuscles have no part in 
the production of nus-cells; even when the cornea was deeply infiltrated, 
the corneal cells showed no signs of breaking up with or producing pus- 
cells. The conclusion is, that the pus was originated by emigration of the 
white blood-corpuscles from the vessels—that, in other words, they are 
“wandering cells.” To substantiate this view, another experiment was 
made, by which, in two hours after irritation of the parts, the vessels in the 
immediate neighborhood of the cornea, in the eye of the porpoise, and 
white mice, and rabbits, were examined, and found to be crowded full of 
white blood-corpuscles, some of which had passed out of the walls of the 
vessels. 
4.—Epithelioma Perle ou Margaritoide de VIris. Par Prof. F. Monoyee. 
[Paris, 1872, pp. 22.] 
The case described is one of tumors of the iris which appeared some 
time after the eye had been wounded by a piece of wire. Vision con- 
tinued at two-thirds. One tumor was about the size of a kernel of wheat, 
and at the lower and outer part of the iris; the other, diametrically oppo- 
site, and about as big as a hemp-seed. The color was peculiar, like mother- 
of-pearl, and the anatomical structure exhibits why it should have this 
reflex, because, like mother-of-pearl, it was made up of lamellae. 
The diagnosis was that the tumor was a cyst, and the operation for its 
removal was begun under this belief. Serious difficulties made its removal 
troublesome, and the eye was roughly treated. The effects of chloroform 
were unpleasant. The issue of the operation was panophthalmitis. 
The tumor proved to be solid throughout, and to have no outer envel- 
op. Its histological structure was epithelial, and the large cells resembled 
the epidermoid layer of the skin. They were without nuclei, and over- 
lapped each other like layers of an onion; mingled with them were crys- 
tals of cholesterine. The attempt to explain why the tumor should grow 
is not satisfactory, but the practical fact that it proved to be solid is mem- 
orable, and that its shiny, iridesceut surface betokened its solid structure 
is valuable for diagnosis. 
Prof. Monoyer expresses his judgment in favor of a flap-wound in pref- 
erence to a linear wound by which to remove such tumors, because it can 
be most easily enlarged if needful, lie also incidentally states his pref- 
erence for a wound of the cornea which is midway in character between a 
flap and the peripheral linear of Graefe, for extraction of cataract. 
A tumor something like the above was reported by Prof. Rothmund, 
Klin. Monatsbl., October, November, December, 1871. 
5.—Muscular Asthenopia and Myopia. By J. Manxiiaedt. [Archiv 
fur Ophth., Bd. xvii., Abth. 11, S. 69-97.] 
The gist of this paper is found in an attempt to give a more correct 
means of measuring muscular insufficiency than we possess. Before com- 
ing to this, some observations are made as to the general subject of myopia 
and hypermetropia, and their relations to muscular troubles. The author 
is an Italian, and asserts that, while about 80 per cent, of his countrymen 7 
are unable to read, in the remaining 20 per cent, myopia is extremely fre- 
quent, and it occurs only among this class. He says that he operates for 
strabismus divergens twenty times more frequently than for strabismus 
convergens. 
The point which the author emphasizes is that, in determining muscu- 
lar asthenopia, the distance between the centres of rotation of the eyes 
must he taken into account. This is sufficiently obvious, and as is seen by 
an illustration that, if the ocular centres are 56 millimetres apart, an angle 
of convergence of 211° will make the optic arcs cross in the median line at 
7 centimetres from the base line, while, if the intraocular distance is 72 
millimetres, the place of crossing will he 9 centimetres distant with the 
same angle of convergence. Hence, in the latter case, a convergence for 
the same distance demands a greater angle and muscular effort. 
On this point are some observations as to the formation of the skull and 
types of race in originating these differences. The author calls the power 
of diverging the visual lines heyond a state of parallelism the facultative 
divergence. He gets it by means of prisms with the base inward, while 
the person regards a distant object. He takes 8 centimetres as the average 
distance from the base-line to which the normal power of convergence 
should attain. He takes the average amount of facultative divergence at 
for each eye, and the total converging power (C), which includes the 
facultative divergence (f. d.), at 24° for each eye. 
The visual intraocular distance he takes at 64 millimetres. The greater 
this width, the greater does he find the facultative divergence, and upon 
simple anatomical grounds. In a given case the author’s method is to 
measure the distance from the centre of one pupil to the centre of the 
other (how, he does not say) ; to take half this distance as a hase-line ; to 
erect upon one extremity a perpendicular of 8 centimetres ; and then, by a 
protractor, find the angle of inclination of the eye to effect this conver- 
gence ; next, hy prisms, to find the degree of facultative divergence. For 
instance: if the hase-line be 82 millimetres, the angle of convergence will 
be 21-ijf0. If facultative divergence be 2-J-0, there will be no symptom of 
asthenopia—in this case, the sum total of convergence being 24°. But, if 
with the same base-line, the facultative divergence he greater, and, added 
to the other angle, reach 28° or more, then he expects to find asthenopia. 
The assumption in the above reasoning is, that the average converging 
power is 24°, and that intraocular separation is the essential element in 
musculiar asthenopia. We are not prepared to accept the first stateiuent 
as a general principle. It is emphatically not true of many persons ; some 
of whom have far more muscular power, and some rather less; while both 
show no signs of asthenopia. As to the second proposition, while it de- 
serves weight, it fails utterly to account for many cases of the trouble as 
we see them in this country. We find the disease without any refractive 
error, and oftenest in women in whom the intraocular distance is small. 
In truth, this paper professes to deal wdth muscular asthenopia only in its" 
relations to myopia, and a very large contingent of cases with which 
American practitioners are familiar is quite left out. 
6.— On the Diagnosis of Muscular Insufficiency. By Dr. L. Ktjgel. 
[Archiv f. Ophth., Bd. xviii., Abth. 11, S. 163-200.] 
The writer has special qualifications for the work which he undertakes, 
in being himself afflicted by the malady which he describes. He contrib- 
utes highly-valuable suggestions on the question of diagnosis, and shows a 
more penetrating insight into the matter than is evinced by any paper 
written since Graefe’s contributions. A desideratum which he does not 
satisfy is, to give precise indications for the use of prisms, what determines 8 
their degree, and how they are to be employed. But we may congratulate 
ourselves on what Dr. Kugel has given, and hope he has more in reserve. 
Dr, Ivugel places the highest value upon Graefe’s test for the near, by 
causing vertical diplopia; and in this we agree with him, in opposition to 
Mannhardt. The facts of his own case are a complete refutation of Mann- 
hardt’s assumption that all persons possess an arc of movement of the eye 
of 24°, and that insufficiency consists only in an undue distribution of the 
total, between divergence and convergence. Dr. Kugel has for six inches 
insufficiency of 24°, for ten inches of 18°, and for six feet equilibrium; in 
which case Dr. Mannhardt would pronounce him not a subject of insuf- 
ficiency. He has in one eye a mixture of regular and irregular astig- 
matism, and vision equals oue-tenth. He gives the practical hint that, for 
cases like his own, of monocular amblyopia, a large dot be used, or, for con- 
siderable distances, the flame of a candle, in testing the muscles. The symp- 
toms, to which he specially calls attention, are the following: 
1. That by putting a colored glass before one eye, and especially before 
the better one, he secs crossed double images. 
2. That, because of the increase of the insufficiency of the interni, 
when the eyes are turned upward, a marked diminution of the acuteness 
of vision will be noticed in those patients when they attempt to read 
with the eyes turned upward. For himself the difference is so great 
that, while with downcast eyes he reads Ho. 1 -without glasses at ten inch- 
es, with visual lines turned up he reads only Snellen Ho. 7. The converse 
is true that, when the look is strongly directed downward, visual acuity 
increases. 
Turning the eyes sidewise has the effect'to diminish muscular insuf- 
ficiency, and, in the case of Dr. Kugel, from 18° to 14°. This was also 
noticed by Graefe. 
3. An experiment to which Dr. Kugel attaches importance is, the effect 
produced by rotating a prism in front of one eye. If there be no muscular 
trouble, the appearance will be that the image seen through the prism will 
move iu a circle around the true image as a centre. If insufficiency exist, 
the false image will describe a circle, leaving the true image either on its 
periphery, or outside of it, or inside of it, but eccentric. 
4. To detect irregularities in the muscle, he employs the following test 
with a vertical line: He places obliquely across its centre a card about 
eight inches wide and long, with its edge on the paper so that one eye 
shall see only the upper half of the line, and the other eye only the lower 
half of the line. The two halves of the line fail to appear continuous, but 
separate into parts laterally displaced—this discovers lateral insufficiency. 
He discovers errors in the muscles which move the eyes up and down, by 
putting a similar piece of card edgewise and vertically across the middle of 
a horizontal line—the right half being visible only to the right eye, and 
the left half only to the left eye. To Dr. Kugel the line breaks into two 
halves, displaced laterally and vertically, so that one appears above the 
other, and the two not parallel. A prism correcting the insufficiency of 
the interior restores the correct lateral position, while a prism of 2° base 
vertical brings down the halves to a common level. This discovers the 
vertical deviation of the eye and its degree. The experiment may be car- 
ried further by drawing a line perpendicular to each Half; then, incase 
the muscles rotating the globes, if at fault, will make the separated crosses 
to stand awry—either diverging or converging at the top. These and all 
the tests should be made with the eyes in the usual reading position, 
slightly turned downward—Listing’s primary position—and, with them, 
elevated and depressed; when elevated, divergence is promoted, and, 
when depressed, convergence is favored. 
The author states that he is presbyopic, and uses, for reading, +24. 9 
He naturally raises the inquiry as to the influence of glasses in insufficiency, 
lie finds that with his glasses the muscular defect is increased at 10" by 4°, 
and advises that the state of the muscles should be determined with the 
half of the glasses proper to the refraction. A fact not mentioned by the 
author, and corroborating his general statement, is, that in myopes, who 
have insufficiency, concave glasses will abate or remove the apparent mus- 
cular defect, the seeing-distance not being changed. 
7.— Contributions to a Better Knowledge of the Deeper Lymphatic Ves- 
sels of the Eye.—By Dr. Julixjs Miguel. [Graefe’s Archives, B. xviii., 
Abtlu I., S. 127-154.] 
Contribution to the Histology of the Lamina Cribrosa Sclerce. By Dr. 
Wolfring. [Graefe’s Archives, B. xyii., Abth. 11, S. 10-24.] 
Remarks on the Blood- Vessels of the Optic Nerve and Retina, and their 
Relations.—By Prof. Th. Leber. [Graefe’s Archives, B. xviii., Abth. 11, 
S. 25-87.] 
The researches of Schwalbe and Schmidt have done so much to estab- 
lish an intimate connection between the optic papilla and the brain, both 
in anatomy and pathology, that the subject cannot be dropped until it has 
been completely exhausted. In fact, it is imperative that we should pos- 
sess the most absolute and complete knowledge of the whole matter. 
Without it our inferences from the phenomena of the optic disk must be 
uncertain and vague. On the one hand, we should fail to properly appre- 
ciate all that occurs in intraocular pathology, and still more egregiously 
must we miss the mark when we begin to reason from these data to intra- 
cranial lesions. The papers above quoted supply us with important facts. 
But, with the most exact knowledge we can have, can any critical and logi- 
cal observer with the ophthalmoscope be willing to use the word cerebro- 
scopy when he is studying only the optic papilla ? 
The papers of Wolfring and Leber relate more to the blood-vessels than 
to the lymph-vessels, and they make more complete the classical studies 
of Leber on the same subject in 1864. The facts made prominent are as 
follows: 
That the lamina cribrosa is neither a region of the sclera bored with 
many holes for the passage of optic nerve-fibres, nor a single hole partially 
filled up by a net-work of connective tissue thrown across it from the 
scleral margins, through which the fibrilke of the nerve are transmitted. 
It is made up of—1. Fibres of connective tissue derived from the optic 
nerve-fibres, which at this point part with their neurilemma; and 2. Of a 
plexus of fine vessels which interpenetrate the bundles of nerve-fibres. 
The origin of these vessels is an important point in the paper. About the 
connective tissue it must be added that a large number of cells are found 
in the lamina, which Wolfring calls lymphoid cells, but which Leber in- 
clines to think are only connective-tissue corpuscles : they are abundant in 
new-born children. 
The optic nerve is invested in the orbit by two fibrous sheaths, one en- 
closing the other, and between them is a space which Schwalbe calls a 
lymph-space. The outer sheath at the eye fuses with the sclera; the inner 
sheath passes through the foramen opticum, and attaches itself to the 
sclera at the innermost lip of the opening. We will first consider the 
blood-vessels belonging to the nerve. At the lamina cribrosa a large num- 
ber of capillary vessels interlace and form a plexus. These are fur- 
nished from several sources: 1. From a circlet of vessels which sur- 
round the optic nerve at its entrance into the eye, and come from the 
posterior ciliary arteries. 2. Some come from the arteria centralis retinee. 10 
8. Fine vessels come down from tlie pia mater and brain-substance along 
with the optic nerve-fibres and contribute something to the plexus. 4. On 
the inner sheath of the nerve, vessels ramify, which penetrate the lamina 
cribrosa. In reality the blood-supply is from three sources: by very fine ves- 
sels direct from the cavity of the cranium—these are the fewest; by branch- 
lets from the arteria centralis retinae, which penetrate the nerve about 
one-half an inch behind the eye; by twigs from the circlet derived from 
the posterior ciliary arteries, and these the most important. This circlet 
around the nerve was described by Zinn, as Leber tells us, but we well 
remember the stress laid upon it by Prof. Ed. Jaeger, who in reality redis- 
covered it fifteen years ago. It establishes an anastomosis between a lim- 
ited region of the choroid and the papilla and the inner sheath of the 
nerve, and remotely with the brain. This circlet also supplies twigs to the 
outer sheath, and in reality is the great fountain of nutrition to the optic 
papilla. A finely-executed engraving shows these relations perfectly. 
Leber very correctly draws some inferences from the above facts. One 
is, to abate some of the exaggerated stress which Galezowski and others 
have laid upon the vascularity of the papilla, as being a direct prolonga- 
tion of the cerebral circulation. Behind the place of entrance of the ar- 
teria centralis retinas, the optic receives vessels from its sheath and among 
its fibres and small vessels, all of which come from the brain; but the 
ocular end of the nerve is far more richly supplied from the additional 
sources mentioned. 
While the blood-supply of the papilla is manifold, this does not help 
the circulation of the retina. The latter must depend on the arteria cen- 
tralis, and, if this be plugged by embolus, the retinal nutrition is neces- 
sarily much impoverished. 
This vessel is a terminal artery, as Colmheim calls it in his paper on 
embolic process, and for this reason, if it be obstructed, infarctus ensues. 
This takes place for two reasons: 1. The withdrawal of the circulating 
fluid has a damaging effect on the walls of the vessels; and 2. The venous 
blood regurgitates through the capillaries, and, because of the softened state 
of the walls of the arteries, it bursts them and causes infarctus. This 
may be seen in retinitis apoplectica. 
Besides the above studies of the blood-vessels, the lymphatics are to be 
considered. All that was claimed by Schwalbe is not confirmed. It is 
admitted that the intervaginal space of the optic sheath communicates with 
the cavity of the arachnoid, and fluid may be forced through from the cra- 
nium so as to pass the optic foramen along the intervaginal space to the 
eyeball; but the fluid did not find its way beneath the inner sheath, nor 
among the fasciculi of the optic fibres, nor into the lamina cribrosa. 
The only way in which, without great violence, the fluid could be pushed 
into the lamina cribrosa, was, by putting the point of the canula just un- 
derneath the inner sheath of the nerve. To put it simply into the inter- 
vaginal space, or deep into the substance of the nerve, was quite ineffectual. 
It appears that the lymphatics course about the outside of the bundles of 
nerve-fibres, while the blood-vessels enter into the inside of these fasciculi. 
The lymphatics make a pretty close net-work just beneath the inner sheath, 
from which some trunks pass out through the united sheaths into the 
orbit; but the chief outlet is into the arachnoidal space. The sub- 
stance of Dr. Michel’s experiments is, that the intervaginal lymph-space 
communicates by apertures in the outer sheath with the extravaginal 
lymph-space, and by similar apertures in the sclera with the supra-cho- 
roidal lymph-space. The last, by means of lymphatic passages about the 
venao vorticosa?, communicates with the capsule of Tenon. By these sev- 
eral intercommunications fluid may under some circumstances find its 
way from the arachnoid cavity so far forward as to make a sub-con- 11 
junctival oedema; but this is not to be considered a common event in 
pathology. 
Another point is that, under severe pressure, an injection may be forced 
from the intervaginal space into lymphatic vessels, which exist in a narrow 
space in the sclera around the optic entrance. When distended they make 
a small path closely resembling the forms sometimes assumed by the cho- 
roidal atrophy in myopia, the so-called sclerotic choroiditis posterior, a 
noteworthy fact in Michel’s injections. 
8.— Upon Hereditary and Congenital Disease of the Optic Nerve. By 
Dr. Tiieodor Leber. [Arcliiv f. Oplith., vol. xvii., part xi., p. 249.] 
The foundation of this article is a careful account of four families, num- 
bering nine patients, whom Dr. Leber has examined and treated for optic- 
nerve disease, which has had an unmistakable hereditary character. 
There is a general similarity in the affection and the pathological character 
of the nature of the disease, which Dr. Leber pronounces to be retro-bulbar 
neuritis. This diagnosis is not based upon autopsy of any of the cases, but 
upon the chemical resemblance of the cases to those which are thus recog- 
nized. Before relating the account of his cases, reference is made to simi- 
lar facts found in the older literature, showing that such observations have 
been made before. It is, however, impossible to discriminate, in the cases 
recorded in pre-ophthalmoscopic times, retinitis pigmentosa from optic 
neuritis. Both in clinical features, in treatment, and in prognosis, the two 
classes of diseases materially differ/ 
1 A case quoted by Leber from Monteath’s translation of Weller was seen by him 
only in condensed form, as contained in Laurence “On the Eye.” I find the autopsy to be 
interesting, both as regards (he optic veins and the state of the cerebral arteries. The 
conjecture respecting the effect of pressure of the atheromatous carotids on the optic nerves 
has occurred to my own mind in another case, and is worth remembrance. I give Dr. 
Monteath’s note in full [Weller “ On the Eye,” vol. ii., page 79, note] : 
“ In 1817 I was requested by my friend Dr. Brown, an eminent physician of this city, to 
inspect the head of a lady who had been affected with amaurosis for many years. The 
state of the optic nerves was very peculiar, and, as her sister and daughter were affected 
with the same disease, I have thought the leading circumstances of their cases worthy of 
being inserted here. The following; statement has been obligingly sent me by Dr. Brown : 
“"Mrs. , aged eighty-three, had been completely blind from amaurosis for thirty 
years, before her decease in 1817. She had also been subject to irregular gout, which as- 
sumed a variety of forms, and, some months before her death, she was attacked with palsy 
of one side. 
“ ‘ On opening the head, aqueous effusion was found below the tunica arachnoidea and 
in both ventricles. One part of the cerebrum was observed to be of a pulpy texture ; but 
these appearances were most probably connected with the recent paralytic attack, and not 
at all with the amaurotic. 
“ ‘All the nerves, with the exception of the optic, had the usual appearance. On exam- 
ining the membranous sheaths of these nerves, it was ascertained that their medullary mat- 
ter had been completely removed, and this change had taken place even nearer to the brain 
than where the nerves cross each other. 
“ ‘ The arteries of the brain were in most parts altered in their structure; their coats 
were speckled with white spots, and their texture was more rigid and Arm than natural. 
Both the carotids, where these vessels are in contact with the optic nerves at the foramen 
opticum, were found to be remarkably dilated, suggesting the idea that the absorption of 
these nerves was connected with the enlarged state of the arteries. 
“ ‘ The absorption of the optic nerves nc arer the brain, however, could not be accounted 
for on this notion, so that it is not easy to conjecture whether the enlarged state of the ves- 
sel was the cause or the effect of the absorption of the optic nerve. 
“ ‘ A similar tendency to enlargement of the arteries was noticed where the cerebral 
arteries enter the cranium, and perhaps it might have been traced in other situations, if a 
more minute search had been made. 
“ ‘ It is, perhaps, worth remarking that in both of those situations, where the arteries 
were found dilated, these vessels make a sudden turn, and from this cause their coats are 
exposed to a full stream of blood from the heart. We can readily conceive, therefore, that 
amaurosis may occasionally depend on the enlargement of this turn of the carotid artery, 
producing, by its pressure, absorption of the medullary matter of the optic nerves. 
“4 The twin-sister of this lady died in the eighty-first year of her age, and, for eight or 
ten years before her death, she also had been completely amaurotic. Though her general 
health was more entire than is usual at such an advanced age, she had lost not only her 
eight, but also her senses of taste, of smell, and of hearing. She could not distinguish ani- 
mal from vegetable food, or one sort of fluid from another. 12 
Besides the instances which Dr. Leber has carefully noted, there are 
nine more of which he has knowledge, and from the total of eighteen he 
draws certain deductions. He regards the affection as inflammation of the 
stem of the optic nerve, with which retinitis is sometimes associated, and 
which terminates in partial and rarely in total atrophy of the nerve. Both 
eyes are commonly affected either at once or in succession, and the first 
symptom is central scotoma, which is apt to continue to be characteristic. 
The lesion appears suddenly as a cloud before the sight, and sometimes the 
scotoma readies out from the centre to some part of the periphery. The 
development of the full extent of the mischief may he rapid or slow. 
Color-blindness is a regular symptom, but not always to be detected in 
the region of scotoma when the latter is dense. At evening, or in cloudy 
weather, they see better, and subjective luminous appearances are com- 
mon. 
By the ophthalmoscope some morbid change could almost always he 
seen—exceptions occurred, although seldom. A little haziness of the mar- 
gin of the nerve, and hyperaunia of its vessels, could be seen, or even a 
slight neuro-retinitis might appear. The occurrence of fine, white streaks 
along the vessels was frequent, or a peculiar spot of exudation might be 
deposited in the disk, as is represented in one case by a chromo-lithograpli. 
At this stage the arteries are not reduced in size, as is ordinarily the case 
in neuritis optica, but are either normal or enlarged. After a time a de- 
cided white or bluish-white decoloration of the nerve ensues, the vessels 
become small, and the lamina cribrosa may or may not become conspicuous. 
The white color of the nerve may be confined to its temporal half, or over- 
spread the whole. As this stage occurs, the degree of vision deteriorates; 
hut, when it is fully established, a change for the better may he noted, while 
the looks of the optic nerve continue unchanged. This fact has much 
practical value, and encourages attempts at treatment by a prospect of suc- 
cess despite atrophic appearances. The influence of hereditary tendency is 
undoubted, but does not always come in the direct line of parentage. In 
the first family, where three sons were born of one father, and two sons 
and a daughter bom of another father, the hereditary tendency came ex- 
clusively from the mother; she was unaffected, but her brothers were 
victims. So the disease cropped out upon the nephews. Men are much 
more often affected than women. The time when the disease appeared 
was between the ages of thirteen and twenty-eight years. In many pa- 
tients there were other neurotic symptoms, such as headache, migrain, 
dizziness, palpitation of the heart, etc. In one case there was epilepsy. 
The treatment which seemed to be most useful was a mild course of 
mercurial inunction. Even the inception of the atrophic stage need not 
deter one from the practice. Iodide of potassium does very little good. 
Local bloodletting was employed in the more hyperremic cases, but with- 
out the manifest good effects so promptly witnessed in ordinary cases of 
amyblopia. Galvanization of the sympathetic in one case was followed by 
surprisingly good results ; but such was not the experience in other cases. 
But Dr. Leber recommends further trials of this remedy, in the belief that 
good may come of it. Tonics were found ineffectual, and injections of 
strychnia equally valueless. 
“ ‘ No opportunity was obtained of inspecting tbe head. The only daughter of Mrs. 
is at present alive, and has been totally blind from amaurosis Lr several years ; she is at 
present in her fifty-sixth year.’ 
“ I have been consulted by the son and grandson of Mrs. , who have both weak eyes. 
The grandson, in particular, lias a very distressing degree of congenital amblyopia. 
“ Any exertion of his eyes induces temporary blindness ; and, though he can sometimes 
see a minute object, at others he will walk directly against a chair or table.—Trans- 
latob.” 13 
9.—Embolism of a Branch of the Central Retinal Artery. By Dr. A. 
Barkan, San Francisco. 
Embolism of Branches of the Central Retinal Artery. By Dr. H. Knapp. 
[Archives for Ophth. and Otology, vol. iii., part i., 33-39.] 
The cases are clearly described, and present very characteristic appear- 
ances. A summary of the symptoms is given by Dr. Knapp : 
1. 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 of the central retinal artery is obstructed, 
it results in superior or inferior hemiopia; but, when a secondary branch 
only is obstructed, a sector-Wce 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 papilla lying in the opposite direction to 
the defect in the visual field becomes white and punctate—partial atrophy 
of the optic nerve—which is Avell set off by the unchanged appearance of 
the remainder of the papilla. 
4. The obstructed arteries become thin, seamed Avith white streaks, 
and disappear a short distance from the papilla. The veins are not changed. 
10.—Intraocular Enchonclroma. By Dr. J. J. Chisholm, of Baltimore, 
and Dr. H. Ivnapp, of New York. [Archives for Ophth. and Otology, 
vol. iii., parti., 1-16.] 
A case in many respects important—a tumor which had been twen- 
ty-two years growing, which was of a nature hitherto not known to occur 
in the eye, viz., a cartilaginous structure, and which, while it was enu- 
cleated without particular difficulty, yet became indirectly the cause of 
death in consequence of secondary haemorrhage nine days after the opera- 
tion. To control the haemorrhage, the common carotid was tied. The 
only explanatory remark in connection with the death is that irregular 
tetanic symptoms supervened—no autopsy reported. 
The patient was a farmer, twenty-five years old, and in good health. The 
tumor attained the size of a large egg, being two and a half inches in the 
short diameter, and three and a half inches in the long diameter. It was 
sometimes painful, but chiefly inconvenient because of its magnitude. It 
was naturally supposed to be a cancerous mass, despite its long continuance 
and its confinement within the tunics of the eye. After its removal the tis- 
sues of the orbit were found to he healthy. 
The microscopic examination, very carefully made by Dr. Knapp, and 
illustrated by many drawings, showed that there was an enveloping fibrous 
capsule; within were numerous hard nodes separated by fibrous septa, and 
about one-fiftli of its bulk consisted of softer substance of a fibro-granular 
appearance. 
In the nodes were found two varieties of cartilage, the hyaline and the 
fibrous, in very characteristic pictures. The fibro-granular part was com- 
posed of fat, granular bodies, connective tissue, and formative cells, with 
blood-vessels. 
Dr. Knapp convinced himself that the enchondroma originated from 
some part of the inner layers of the sclerotic, and that the cartilage in- 
creased not by cell-multiplication of its elements but by the conversion of 
formative cells into cartilage-cells. lie thinks the tumor entirely benign 
in a clinical sense, and has not found in literature a similar case. 14 
11.—Report upon Fifty Extractions of Cataract according to Webers 
Method. By Dr. Cap.l Driver, in Chemnitz. [Graefe’s Archivfiir Opli., 
vol. xviii., 11, 200.] 
Weber proposed a method of operating for cataract by making a 
section at the upper margin of the cornea with a hollow lance-knife. 
The knife is of the exact size to make a wound which will permit easy exit 
of the lens. Its point is thrust completely to the opposite side of the an- 
terior chamber. An iridectomy is sometimes made and sometimes is not 
made, according to the difficulty of removing the lens and the dilatability 
of the pupil. After opening the capsule freely, the expulsion is effected by 
pressure and counter-pressure, as usual—the counter-pressure being made 
by a small shovel of Dr. Weber’s invention. This brief explanation may 
not be out of place notwithstanding the announcement of the method was 
made in an elaborate article so long ago as 1867 in the Archives, because 
few persons have adopted the proceeding, and scarcely any statistics besides 
Weber’s have been published. The technical difficulty of correctly using 
the knife is, according to Weber, considerable, while the manipulation of 
Graefe’s knife is easy, and few have been willing to try to attain the skill 
for a new operation until the experience of Graefe’s method had been 
completed. 
Dr. Driver reports the following facts : “ He operated on thirty-nine per- 
sons and made fifty extractions. He made iridectomy in twenty-six opera- 
tions—in the first fourteen cases without exception, and in the subse- 
quent operations using discrimination as to special indications. In so 
far as a circular pupil may be secured, the operation may justly claim 
an advantage for acuity of vision. But the special claim put forth is in 
behalf of rapidity of healing as well as safety. The average stay in the 
institution we are told was one week, and eight cases were dismissed in 
from three to five days without the presence of the slightest irritation.” 
The healing process in forty cases was perfectly normal; in three cases 
iritis occurred. 
As the general result: in forty-four eyes, S = 2%o to 20/ioo; in three 
was quantitative perception capable of improvement by iridectomy; in three 
total loss. Total fifty. 
The above figures make an excellent showing, and further facts will be 
gladly welcomed, but, in the present attitude of the subject of cataract ex- 
traction, a new method must present very strong arguments before it 
will secure adoption. 
While the form of Weber’s cut is greatly in its favor, the operation re- 
quires an accurate estimate of the size of the cataract, so as to choose the 
knife of proper size, and this is not always easy. 
12.— Cataract Extraction, 200 Cases. By David Little, M. D. [British 
and Foreign Medico-Chirurgical Review, January, 1873.] 
The author performed Graefe’s operation, and in reckoning his results 
has: 
Total loss 7 
Quantitative perception of light 9 
Count fingers 1 
Read Jaeger 1 146 
“ Jaeger 2 to 4 25 
“ Jaeger 6 to 8 5 
Jaeger 10 to 19 7 
The author reckons his good results to be one hundred and eighty-three 
cases, giving 89 per cent. He certainly was fortunate to save more than 15 
70 per cent, able to read Jaeger 1, but this means acuteness of vision, 
ranging between 2%0 and 2%o or even more. Every oculist knows that 
many patients whose distant vision is highy amblyopic will do remarkably 
well in reading small type, and we therefore regret that the test was not 
taken for distant print. 
He gave chloroform in only four cases, which shows that his patients 
possess more self-control than belongs to Americans. In twenty-seven 
cases, iritis took place; the average duration of cure is not given. Sec- 
ondary operations on the capsule wrere done seventeen times. Loss of 
vitreous happened twenty-two times, yet he endeavors, he says, “ to lay 
the centre of the section just within the cornea, and thereby diminish 
the risk of rupturing the hyaline membrane.” It is thus evident that 
our author, like so many others, does an operation called by Graefe’s 
name, but not strictly after his method. A noteworthy and sensible ob- 
servation is, that he puts in atropine early after the operation—as early as 
six or eight hours after, which is sooner than the general practice, but, he 
asserts, not so soon as to be dangerous, but greatly helpful in warding off 
iritis. 
13.—Report on Sixty-four Cataract Extractions according to the Method 
of Von Graefe, performed at the Massachusetts Charitable Eye and 
Ear Infirmary. Compiled by Hr. H. Derby. [Report of the Infir- 
mary for 1872.] 
Of the whole number, the resulting vision was ascertained in only 
fifty-four; but, of the remaining ten, eight were known to be good results. 
The summary gives thirty-one with vision and better; and fifteen be- 
tween and There were seven failures. In seven cases, secondary 
operations were done. One patient died of pyaemia, upon whom a normal 
operation was done, and no account is given of the character of the mor- 
bid process in the eye. 
The successes foot up, 84 per cent, vision above ; and failures 11 per 
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