A CLINICAL STUDY OF A CASE OF DOUBLE 
CHORIO-RETINITIS IN THE MACULAR REGIONS, 
FOLLOWING A FLASH OF LIGHTNING AND A 
FLASH FROM BURNING LYCOPODIUM. 
READ BEFORE THE 1896 MEETING OF THE AMERICAN OPHTHALMOLOGICAL SOCIETY. 
BY 
CHARLES A. OLIVER, A.M., M.D., 
One of the Attending Surgeons to the Wills Eye Hospital; one of the Ophthalmic Surgeons 
to the Philadelphia Hospital, etc. 
Reprinted from the International Medical Magazine for October, 1896. I. 
Right eye. A CLINICAL STUDY OF A CASE OF DOUBLE CHORIO- 
RETINITIS IN THE MACULAR REGIONS, FOL- 
LOWING A FLASH OF LIGHTNING AND 
A FLASH FROM BURNING 
LYCOPODIUM. 
On the 27th of April, 1894, A. P., a twenty-year-old engraver and 
artist, came to my clinic at the Wills Eye Hospital, complaining of mus- 
cular and accommodative asthenopias. A week later the total error of 
refraction was most carefully and repeatedly obtained during several days' 
time by the use of atropine. Two weeks were then allowed to elapse 
before the formula for glasses was given. During the intervening time 
medium smoked coquilles were constantly worn, and no manner of near 
work was attempted. The correction ordered, which was for low grade 
or compound hypropic astigmatism, gave an acuity of vision aud a power 
of accommodation that were normal in each eye. Extra-ocular muscle 
balance for both far and near was restored from a slight esophoria to proper 
equilibrium. 
Just after the patient left the hospital with the formula for his glasses 
a violent electric and rain-storm suddenly appeared. The details of what 
now happened cannot be better given than in the exact words of the 
patient's own intelligent account. 
a On May 28, after being at the hospital to have the glasses examined 
which were ordered by Dr. Prendergast, of Dr. Oliver's clinic, I started home 
at 3.30 p.m. A heavy storm came up and there was a great deal of lightning. 
" While I was walking on Filbert Street, between Ninth and Tenth 
Streets, a flash of lightning which appeared like an electric arc light (that 
is, it was a blinding flash) passed from left to right in front of me. 
a A queer sensation came over me, and I thought every bone in my 
body was being wrenched from its joints, and I staggered. A horse, which 
was on the opposite side of the street fell, but regained his feet a moment 
later. For several moments I could not see ; ray eyesight came partially 
back, first in the left eye only. Gradually, in a minute or more's time, the 
sight returned in the right eye. I walked home apparently all right. 
" That evening, about half-past nine o'clock, I was exposed to a flash 
of light from lycopodium coming in contact with burning alcohol. I went 
to bed and was so restless that I could not sleep. 
" The following day I went to my work, which is that of engraving. 2 
CHARLES A. OLIVER, M.D. 
I noticed on my work, or wherever I looked, that there was a small gray- 
ish spot. In the centre of this spot there was a second one about the size 
of a pin's head, and which was of the brightness of the sun. The central 
bright spot was fixed, while the grayish boundary moved rapidly in the 
direction shown by the arrows in the sketch.1 (Plate I., No. 1.) 
"At noon on the second day the spot changed to the shape shown in 
No. 2. The central spot was still bright, but the boundary was darker. 
The same character of motion continued as in No. 1, but it occupied a 
different position, as shown by the arrows. 
"During the evening of the same day No. 2 spot changed entirely. 
The central spot, which remained bright, divided into four parts that kept 
constantly revolving in and through each other. The outer area had 
become fainter, and seemed to be made up of radiations, which rapidly 
moved from the centre to the edge in radiary waves. Both varieties of 
motion with the rapidity." (No. 3.) 
The patient later stated that, during the time that these three figures 
were present, any series of narrow or closely-placed vertical lines would 
appear unequally corrugated like broken waves. The lower extremity of 
each broken line seemed to vibrate both to the right and left and to the 
left and right in a similar manner to the movement of a pendulum of a 
clock. Each excursion was short and the motion was very fast. The 
upper portions of the broken lines remained stationary. 
On the afternoon of the 6th of June, just nine days after the accident, 
he came to me at the hospital, and I had my first opportunity of examining 
him. At this time he gave me the first seven sketches. He told me that 
the flash of lightning, which appeared purple, seemed to strike the pave- 
ment directly in front of him, and for several hours aftewards a grayish- 
colored area, which prevented him from seeing a man's head, persisted 
before each eye and then gradually disappeared. The lycopodium flash did 
not seem to leave any immediate after-effects. As noted in his own account of 
the case, the central scotomatous and irritation-area appeared on the follow- 
ing day and continued for seventy-two hours. For a period of three days 
he had very little if any trouble, although his employer had several times 
complained that his engraving was imperfectly done. 
On the 3d of June, three days before I saw him, the irritation-scotoma 
again appeared before the right eye. As shown in No. 4, the patient 
stated that " the small brilliant spots had increased to seven, and the 
surrounding grayish area had become somewhat Maltese-cross shaped. The 
bright spots were constantly moving through one another like minute 
electric balls, without leaving any trail." 
1 " The spots are as I look at them, and are the exact size and shape. I have 
taken great pains in preparing these drawings, and they are correct." 
(All of the succeeding subjective studies were made with the objects situated at 
twelve or more metres' distance from the eye.) II. 
Right eye. CASE OF CHORIO-RETINITIS IN THE MACULAR REGIONS. 
3 
On the following day "the large spot, as partly shown in No. 5, which 
still remained fixed, became darker, and the included bright spots were 
changed into a great number of rapidly and irregularly moving hair-lines 
of brilliant light." 
The succeeding day showed (No. 6) that a great change had taken 
place. The scotomatous area had become somewhat fainter, had increased 
in size, and had become stellate in form. The radii were massed into 
bundles that were situated upon different planes. The contained bril- 
liantly-lighted lines were converted into eleven small spots of the same 
shape and size as the seven shown in No. 4. Like those in No. 4, the 
spots had become aggregated centrally, and were undergoing the same 
character of inosculating motion. 
Early in the morning of the day that I saw him the remarkable 
change shown in No. 7 appeared. To quote from the patient's own 
written statement: " This change came suddenly. I had retired early the 
night previously, at which time the spot was like that shown in No. 6. I 
could not sleep much until towards morning. I arose at seven o'clock, 
when, to my surprise, the spot was like that shown in No. 7. The 
slightly eccentric light area was not brilliant, but had the appearance of 
frosted glass. The surrounding area was as black as ink. The large faint 
peripheral area seemed to me like a fog. The entire mass was motion- 
less." 
He stated that any decided movement of the left eye produced a deep- 
seated pain in that organ. 
Central vision for form with the right eye was reduced to one-fortieth 
of normal. The field of vision, which was normal in size, gave marked 
evidences of a large irregular central scotoma that was absolute for both 
form and color. The pupil was the same size as that of the fellow appar- 
ently undisturbed eye, and the iris was as freely mobile to light-stimulus, 
accommodation, and convergence as its fellow. The left eye seemed normal 
in every respect. The ophthalmoscope revealed a most striking and never- 
to-be-forgotten picture in the right retina. Directly in the macular region 
the retinal tissue seemed to be slightly puffed into an irregularly flattened 
mass. The tissue itself did not appear to be discolored or opaque, but 
glistened in places as though the underlying material were composed of an 
extremely thin coating of cicatrizing, almost transparent jelly. No hemor- 
rhages of any character could be detected, and no signs of degeneration of 
any type, except that the nerve-head was a trifle hazy and gray, could be 
deterjuined. 
The retina of the left eye apparently was not affected in any way, ex- 
cept that here, too, the nerve-head was a trifle too gray for age and was 
somewhat hazy. 
The patient, who seemed strong and hearty, strenuously denied any 
syphilitic infection, and after the most careful physical examination failed 
to present any evidence of the disease. The only obtainable history of 4 
CHARLES A. OLIVER, M.D. 
systemic disturbance was that of infrequent attacks of muscular rheuma- 
tism. 
In order to study the rapidly-changing symptoms, and to give his eyes 
a thorough rest, I admitted him into the hospital, put him to bed, and 
lightly, though effectually, bandaged his eyes, so as to exclude all extra- 
neous light from their interiors. I immediately placed him upon the free 
use of alteratives, thoroughly purged him, and gave him light, nutritious diet. 
The examinations were continued unremittingly each day, care being 
taken to give each eye a thorough rest before every new procedure. 
On the second day of his stay in the hospital he observed that the 
scotomatous area had undergone a marked change for the better. This is 
shown in No. 8. In his own words, "There is some change in the general 
shape of the spot. The small white spot is a little larger, and the sur- 
rounding black area is a little lighter. The foggy appearance around the 
spot has disappeared." He complained that the eyeball pained him con- 
siderably. Both central and peripheral vision practically remained as 
before. 
To his great dismay, he, for the first time since the primary momentary 
blinding at the time of the accident, noticed a central scotoma before the 
left eye. (Plate V., Fig. A.1) He informed me that "it had appeared 
synchronously with the twisted, snake-like appearance before the right eye. 
To him it closely resembled drawing No. 3 seen with the right eye, and 
had the same characters of motion. 
On the 11th of June, at my suggestion, he presented me with two very 
interesting sketches. 
The scotomatous areas, studied in his ordinary way of projecting 
them against a distant white background,-as, for example, the clouds, a 
white shutter, or a pane of ground glass,-now gave him the peculiar ap- 
pearance shown in No. 9. As he remarked in his report, " The color is 
the same as that in No. 8, but the light place in the centre is larger, and I 
can see a very little through it." Acting upon this suggestion, I thought 
that I would try and see whether any increase in the distant illumination 
would make a change. To his great surprise, when I had him gaze at a 
large area of rather brilliant orange-yellow light obtained from ordinary 
illuminating gas, he found that the previous light central area iu the sco- 
toma became absolutely black, and the peripheral area, which was ex- 
tremely black in the previous experiment, now became quite faint and 
"pearl-colored." No. 10 shows very well what is meant. Several times 
during the experimentation, when the patient looked away from the flame, 
several brilliant triangular bodies which were in rapid vibration appeared 
in the scotomatous area. 
1 In order to more readily differentiate the varying scotomata in the two eyes, 
all those that belong to the right eye have been numbered, and all those that were 
seen by the left eye have been alphabetically arranged. III. 
Right eye. CASE OF CHORIO-RETINITIS IN THE MACULAR REGIONS. 
5 
A careful drawing of the appearance of the same series of vertical 
lines that he had experimented with before his admission into the wards of 
the hospital gave the projection of a scotomatous area that was similarly- 
shaped to No. 9 directly upon them. A peculiarity, however, that he 
noticed was that the lower extremity of every one of the lines above the sco- 
toma was barbed upwardly and to the left, and the upper extremity of each 
of the lines below the scotoma was barbed downwardly and to the left. 
On this day the general form of the scotoma before the left eye had 
changed to the area shown in Fig. B. The six small brilliant spots kept 
moving in the same manner as the spots in No. 7. 
At his own request, I discharged him from the wards to the dispensary 
service of the hospital, ordering him to take twenty grains of iodide of 
potassium three times daily. 
On the next morning (the 12th of June) the scotoma presented the 
appearance shown in No. 11. As can be seen, " the foggy atmosphere," 
as he was wont to call it, in which the scotoma was situated, had dis- 
appeared. The central light area had greatly cleared, and the entire spot 
had become fainter, this being marked by " a heavy dark vein" which ran 
through the central portion of the larger dark area. 
At 1 p.m. of the same day the patient made a sketch shown in No. 12, 
and noted : " There is some change in shape, but not in color. There are 
two bright spots, like miniature suns, in the lower portion of the spot, and 
these, which are constantly vibrating, are exceedingly annoying. The eye 
pains me, and seems quite inflamed." 
Half an hour later the sketch of No. 13 was made. In the patient's 
diary I find: " The dark spot is about the same shape, but it is lighter* 
One bright spot has disappeared. The remaining one, instead of vibrating, 
throws a light up across the light area beyond the scotomatous area, leav- 
ing a series of overlapping concentric rings, somewhat like the tail of a 
comet." 
At 5 p.m. of the same day he made the sketch for No. 14, writing: 
" This makes the fourth change in one day,-the most that have taken 
place in one day. The bright spot has gone. I can see through the small 
central opening, but very dimly, as though it were covered with frosted 
glass. Everything seen through it, though not distorted, seems to be small 
and very far away." 
The sketch of No. 15 was made at ten o'clock the next morning. To 
use the patient's own language: "This morning another change has taken 
place, both in size and shape of the spot. It is larger, but is not any 
darker, than that of the previous sketch. The whole area appears like a 
piece of isinglass, but I cannot trace the shape correctly. By closing the 
eye rapidly I can see the shape. The opening is a little clearer. All ob- 
jects are very small and dim. The eight small spots outside appear as 
though they were broken-off* particles of the large spot. They are fixed." 
At 12.30, at noon, he made another most interesting sketch, shown in 6 
CHARLES A. OLIVER, M.D. 
No. 16, and wrote: "Another change both in shape and size has appeared. 
The light spots have lessened to six, and instead of one large opening in 
the central blind area there is a more irregular and dimmer somewhat cen- 
tral one, surrounded by six little ones, four of which are situated in the 
prolongations." 
Two hours later sketch for No. 17 was made. Describing it, he said, 
" Another change, both in size and shape; all of the small areas have dis- 
appeared from the outside of the spot. The sieve-like openings in the 
large area have all, with the exception of the lower inner one, broadened 
into a large central light area partaking somewhat of the same general con- 
figuration of the large dimmed area." 
During this day he made two very instructive sketches, one of which 
was practically No. 17 projected against a series of narrow vertical lines. 
Not only was the scotomatous area present, but the lines themselves in the 
region of the scotoma were smaller, finer, and more closely packed together, 
thus substantiating his assertion that all objects looked at through the spot 
were smaller. 
A curious sketch showed that a vertically held string bulged forward 
and appeared somewhat attenuated in front of the scotomatous area. A 
drawing of a horizontally placed rectangle, made while looking at the object 
with the right eye, exhibited the same characteristic metamorphopsia and 
micropsia. The ophthalmoscope showed that the macular region was sur- 
rounded by a most curiously irregular and shining rim, the enclosed area 
being markedly depressed in places and quite pallid, especially the fovea itself, 
v On the 18th of June the left scotoma, as shown in Fig. C, appeared to 
be divided into four dull areas " which are in constant motion. The six 
vibrating, brilliantly-lighted spots have disappeared." 
Three days later (21st of June), at 4 p.m., the sketch shown in No. 18 
came into existence. As the patient wrote : " This is the most peculiar shape 
and motion that I have had. It is about as dark as drawing No. 5. The 
small central clear spot which is fixed is about as bright as an electric arc 
light. The dark coma-like area surrounding it moves around the light 
spot in the direction shown by the arrows at about the rate of two revolu- 
tions per second. In a dark room the small central spot appears jet black 
and the large surrounding area is pearl white in tint. The same motion 
persists." 
The appearance of the vertical lines at this time was so extraordinary 
that they are here reproduced in No. 19. 
At this visit it was found that vision in the right eye had tripled -fa 
whilst that of the left eye equalled full -f. Although there were some 
evidences of iodism, I continued the drug just as before. 
On the following day (22d of June) the spot appeared as if split into 
two sections and the bright area had gone (No. 20). The patient's notes 
state: "I cannot draw the shape of the spots unless I close the eye rapidly. 
They are in constant motion, like the one shown in drawing No. 3." IV. 
Right eye. CASE OF CHORIO-RETINITIS IN THE MACULAR REGIONS. 
7 
The vertical lines had undergone a marked change. They were not so 
broken, and the heavy, dense, horizontal thickenings were replaced by six 
broad, faint horizontal smudges. 
The right fundus in the macular region seemed to have regained its 
natural tint, though careful focussing revealed the presence of a few faint 
and almost imperceptible, deeply-seated pigment splotchings and aggrega- 
tions. 
On the 24th of June a most curious parsesthetic area, represented in 
No. 21, appeared. Of this the patient wrote, "This shape stayed only for 
about one hour, fading to the shape shown in drawing No. 18. It has 
the appearance of waves of light composed of fixed radii which pass out- 
wardly from the centre. These waves elevate and depress themselves from 
the centre just the same as if one threw a stone into the water,-the waves 
flowing from where the stone struck the water; so here the spot is similar 
to the waves, except that being water they are waves of light. Central 
vision with the right eye equalled eccentrically it rose to r 
On the 29th of June the sketch shown in No. 22 was made. The fig- 
ure is that of a roan smoking a cigar and carrying a cane as he was leaving 
the patient. " The white area represents the man as he appeared with the 
right eye while I was looking at the middle of his back. The surround- 
ing shaded area shows him as I know what he should be." 
Central vision directly ahead with the left eye equalled one-half of 
normal (T 
I did not see the patient again until the 2d of July. He said that he 
had taken the tri-daily dose of twenty grains of iodide of potassium faith- 
fully and had not attempted to use his eyes in any way, being careful to 
wear his smoked glasses constantly. 
At this visit he drew the sketch represented in Nos. 23 and 24. The 
scotomata had become fixed and all objects appeared "'very small." His 
comments as to the sketch are as follows: " Now you can see a great differ- 
ence in the two areas in regard to shape and size and the dense dark spots 
over them. No. 23 has eight small black spots; No. 24 has eight 
also, but they cut across the whole area from left to right as a series of 
stripes. When these bands or stripes first appeared it seemed to me that 
the spots actually lengthened themselves out to become stripes." 
Four days later I had him make a sketch of my card of test-type which 
was hanging on the wall at about two metres' distance. The result is 
shown in No. 25. The noting at the side of the drawing read : " This 
shows the appearance of Dr. Oliver's card while I am looking at the letter 
' O' in the upper right-hand corner." 
On the 8th of July he came back very much disturbed, saying that, 
although the size of the general area was diminished and the dense super- 
imposed spots reduced to five, yet these were in such a state of constant 
motion, just as they had been in No. 3, as to be annoying. The appearance 
of the fixed and superimposed mobile scotomata is shown in Fig. 26. 8 
CHARLES A. OLIVER, M.D. 
He voluntarily stated that during heavy thunder-storms, where there is 
much lightning, he gets demoralized and " must get into a dark room so as 
to prevent the right eyeball from jerking and twisting in its socket." 
The next day, to his gratification, the five spots disappeared, but the gray 
area upon which they had seemed to rest had grown somewhat larger. 
No. 27 shows this very well. 
On account of pronounced iodism I stopped the iodide, ordering him 
full doses of strychnine instead. 
I missed him for another wTeek, when he came back with the assertion 
that he had ignored the strychnine and had unremittingly continued his tri- 
daily dose of twenty grains of iodide of potassium. In spite of the marked 
iodism I persisted in the use of the drug. 
The bright mobile spots had once more come to trouble him. The 
morning of his visit he had the appearance shown in No. 28. 
He said that while sketching the scotomatous boundary " several bright 
spots shot in towards the centre from the outer edge like roman candles; in 
fact, they resembled them very much. After striking the centre they dis- 
appeared. This phenomenon lasted for about one minute." 
Some hours after this he accidentally found that, while gazing down 
upon a white marble floor and drawing the scotomatous area, two eccentri- 
cally situated and fixed bright areas of light, just as "when the sun shines 
through the slat-work of a shutter," were projected upon the floor. The 
position of these light areas and the central scotomatous area are shown in 
No. 29. 
Notwithstanding the scotoma, the eccentric vision up and in in the right 
eye had increased to about two-thirds of normal (A). 
On the succeeding second and third days the central dim area which 
stayed fixed became larger. The eccentric light areas, first noticed on the 
16th of the month, remained equally bright, but had become a trifle smaller. 
At the upper border of the large dim area a brilliant and serrated worm- 
like mass kept in constant motion. This can be seen in No. 30. 
" During the afternoon of the third day the two bright spots in the 
lower right-hand corner disappeared," and immediately the dense black 
strokes shown in No. 31 came on, they first being " lightish" and gradually 
becoming "darker." By the 18th of the month the four faint scotomatous 
areas before the left eye had practically gone. I found, however, by refer- 
ence to his notes, these words: " While lying in bed on the night of this 
date, and being unable to sleep and very restless, I looked up at the moon, 
when slightly down and out from it there were two somewhat luminous 
objects in the sky. These were stretched out vertically, quite close to each 
other, and moved around the moon as I moved my head in the same direc- 
tion." 
One week later the spot before the left eye again came into evidence. 
At this time all objects immediately below the fixation point were obscured. 
A drawing of a man's face in profile made while he was looking at the V. 
Left eye. Fig. 1. 
Ophthalmoscopic appearance of right eye-ground. 
Fig. 2. 
Ophthalmoscopic appearance of left eye-ground. CASE OF CHORIO-RETINITIS IN THE MACULAR REGIONS. 
9 
top of the model's nose placed the mouth and chin in the scotomatous area. 
Fig. D, showing the appearance of my card of distant test-type when the 
patient was looking at " E" " O" on the top line, will explain very well 
what is meant. 
On the 30th of the month he told me that the objects seen through the 
comparatively clear areas were much larger and more nearly what they 
should be than before. 
The notes of the 5th of September state that he was taking eighty 
grains of iodide of potassium daily with impunity, he having a good appe- 
tite. Nothing noteworthy was apparent until this date, when a minute, 
fresh hemorrhage, with its convexity directed upward, could be seen just 
below the left fovea, between the retina and the chorioid. The macular 
region of the right retina was faintly granular and slightly pigmented. 
He stated that the left eye had become painful during the previous 
night, and when he had gotten up and lit the gas he found that there was 
a dense black spot in the centre of its field of vision. 
On the 10th of September he found that the left scotoma had become 
reduced, in his own words, " to a lot of faint spots, which, as near as I can 
explain, look like drops of water slowly flowing down a pane of glass, one 
trying to beat the other." 
On the same day, without warning, a dim representation of No. 21, 
seen on the 24th of June, appeared before the right eye, and lasted for 
about twenty-four hours. 
On the following morning he noticed that the large, dim scotoma before 
the right eye, which has been so persistent and fixed during the summer 
months, recurred ; but, curiously, its edges seemed broken away, and lost. 
Through this area, and in no other position in the field of fixation, was 
there any complaint of micropsia. The scotoma gradually became faintly 
mottled, and at last decreased in density, until a drawing made on the 9th 
of October showed that the area was barely discernible. 
At this visit he brought sketch of Fig. E, which, as he said, showed 
" the shape, size, and shade of the spots in the left eye. There is no motion 
whatever." 
After a most rigorous examination no cardiac or renal lesion could be 
determined. Vision in the right eye had risen to one-half of normal, 
while that in the left eye was normal. When the patient regarded any 
object fixedly with the left eye the image of the object became alternately 
larger and smaller, and seemed distorted upon its edges, just "as though it 
were viewed through a convex lens which is successively elevated and de- 
pressed." The subretinal hemorrhage in the left eye was beginning to 
manifest evidences of beginning absorption. 
Two weeks later the ophthalmoscope showed that there were a few 
faint pigment-spots in the right retina, and that the minute hemorrhage in 
the left subretinal tissue was nearly gone, the retina in the macular region 
being elevated and depressed into several almost imperceptible striae. The 10 
CHARLES A. OLIVER, M.D. 
patient stated that he had not used any alterative for more than a week. 
He was told to discontinue its use. 
On the 17th of October he returned with the statement that the day 
before he had attempted to resume his work, but found that he was com- 
pelled to desist on account of the annoying distortion and dimness of 
objects. A most careful correction of his minor degree of astigmatism, 
obtained both with and without the employment of a mydriatic, failed to 
relieve the condition in any way. 
During the month of November he returned several times. On the 
26th of the month he made some sketches showing the contracting effects 
upon long, narrow, rectangular forms placed at different angles in the 
scotomatous areas. These, which were most numerous and ingenious, will 
be reserved for another paper upon a related subject. 
In January, 1895, the scotoma in the right eye could be just seen. 
He wrote, "Vertical lines are not broken or drawn together, and objects 
seem very little distorted." The accompanying reproductions of two faith- 
ful water-color sketches (Figs. 1 and 2) by Miss Margaretta Washington, 
of this city, were secured about this time. The relative conditions seen are 
so self-evident that written description is rendered unnecessary. The 
iodide of potassium was persistently continued, as much as possible, attacks 
of iodism, coming on very quickly and persistently, requiring constant 
counter-medication. 
Once in February he returned with a slight, though temporary, increase 
in dimness in the right scotoma. At this visit he told me that the left 
one " had preserved the same shape and shade, but that the smaller spots 
were plainer (darker) and seemed to be increased in number." 
His statement that at times there was some supraorbital neuralgia, and 
that frequently there was an irregular and vibrating mesh-work thrown 
between the left eye and the object looked at, induced me to make a most 
careful, though fruitless, examination of the media and muscular apparatus 
of the organ. Central vision with the right eye had steadily risen to one- 
fourth of normal (/q-), while that of the left eye was practically normal. 
The dose of iodide of potassium, which had been taken with mon or 
less regularity, was reduced to five grains three times daily. 
On March 27 of last year, in order that I should better realize the rela- 
tive difference between the two sights, he gave me two rough sketches of 
the same object studied from the same objective point, nearly four blocks 
away (the statue of William Penn upon the City Hall in Philadelphia). 
When study is made of these, which are reproduced in the full-page photo- 
type (Plate VI.), it will be instantly noticed that (with the same minor 
degree of refractive error) the image of the right eye is much the smaller, 
thus substantiating in another and most graphic way his constantly-repeated 
assertions of micropsia. The projections of the faint scotomatous areas 
against the head and back of the figure and the larger size of the left 
scotoma are all most interesting and instructive. VT. CASE OF CHORIO-RETINITIS IN THE MACULAR REGIONS. 
11 
In September, 1895, he returned for the removal of some dirt that 
had blown into his left conjunctival cul-de-sac. At that visit I embraced 
the opportunity of restudying his case. His vision, which was central in 
each eye, had risen to two-thirds of normal in the right eye and to full 
acuity in the left. Accommodative power and play were equally good in 
each eye. 
He considered his right eye well. At times water-like globules would 
appear in the centre of the left field of vision. Careful focussing with the 
ophthalmoscope revealed the faintest traces of the macular changes shown 
in Miss Washington's sketches. 
An extended re-examination the beginning of this month (July, 1896) 
gave practically the same findings as were noted ten months previously. A 
final series of characteristic sketches of geometrical forms, in which the 
distance between any two parallel lines (especially the horizontal ones) was 
made very small, showed minor degrees of bulging just at the fixation- 
point with the right eye, and rather more marked elevation and depression 
of the entire widths between the two lines away from the fixation-point 
with the left eye. He is now unable to project any scotoma, "any mark, 
blur, or spot" with the right eye, " except by looking up at a clear sky, and 
then only a very faint outline of the old spot appeared." 
With the left eye he can project a few extremely attenuated and almost 
invisible grayish scotomata around and especially above the macular region, 
these in the carefully taken corresponding field of vision being evidenced 
by the faintest dim areas for color and form. The field of vision of the 
right eye fails to show any scotomata, but in a small area about three de- 
grees above the fixation-point extremely minute and circular test objects 
appear elongated into a vertical oval 
The fields of vision, which were frequently repeated during these 
studies, at no time evidenced any contraction in the peripheral boundaries, 
the central scotomata, which were constantly absolute for color and at times 
negative for form, always agreeing with those that the patient made in the 
sketches from which the figures were taken. 
Remarks.-The present case is here given in its minutest details in 
order that an almost unique instance of intelligent subjective study, in com- 
bination with a fairly well-made series of clinical researches and an exact 
graphic reproduction of the intraocular lesion found, might be made use 
of by others in their studies upon such comparatively rare and quickly 
evanescent symptom-groupings. Uncomplicated, having been seen but a 
few minutes before the accident, studied carefully, and watched almost 
incessantly, the case assumes a certainty that entitles it to consideration. 
Although the literature upon the subject has been well searched over, 
and much that has been done by others has not been attempted here, yet 
with this latter shortcoming, this clinical study is given to the ophthalmic 
world in the hope that it may be not altogether fruitless and useless. 12 
CASE OF CHORIO-RETINITIS IN THE MACULAR REGIONS. 
The writer here desires to express his obligation to the patient himself 
for his untiring aid and conscientious study of the constantly varying 
symptoms, without which help much of the interest and value of the paper 
would have been lost. To the writer's several clinical assistants, especially 
to Dr. William Campbell Posey, his official assistant at the hospital, much 
credit must be given for their skilful and careful clinical handling of the 
case. International 
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