[COMPLIMENTS OF THE AUTHOR.] 
Sympathetic Ophthalmia. 
GEORGE E. FROTHINGHAM, M. D., 
Professor of Ophthalmology, 
UNIVERSITY OF MICHIGAN. 
(Reprint from Transactions of the Michigan State Medical Society. foi: lS7f>.) Sympathetic Ophthalmia. 
I 
GEORGE E. FROTHINGHAM, M. D., 
Professor of Ophthalmology, 
UNIV ERSITY OF MICHIGAN. 
(Reprint from Transactions of the Michigan State Medical Society, for 1876.) SYMPATHETIC OPHTHALMIA. 
GEORGE E. FROTHINGHAM. M. D., OF ANN ARBOR. 
The disease now known as sympathetic ophthalmia is one 
that should receive the earnest attention of all practicing phy- 
sicians. The general practitioner may at any time be called 
to treat those diseases and injuries of the eye most likely to 
give rise to this affection, and unless he thoroughly understands 
the causes and the means of preventing this insidious and un- 
controllable inflammation, the golden opportunity may pass and 
his patient be doomed to perfect and irremediable blindness. 
And yet there are few diseases of so grave a nature that receive 
so little attention. The reason for this is obvious, for it is a no- 
torious fact that only in a few recent text-books is this subject 
referred to except in a very brief and superficial manner. Of 
the special works commonly used in this country as text-books, 
there is but one that treats of this subject in that thorough and 
■comprehensive manner that its importance deserves. 
In the chapters on diseases of the eye, contained in works on 
general surgery, there is but the briefest allusion to this dis- 
ease,-a fact to be all the more regretted since it is upon these 
meager chapters that most general practitioners depend for 
their knowledge of ophthalmic diseases. 
Although Demours and Wardrop described this disease so early 
as 1818, little or no notice was taken of it either in England or 4 
France, and it was not until the publication of Mackenzie's 
work in 1844, and its translation into the French language in 
the same year, that attention in either country seemed to be 
generally directed to sympathetic iritis,-the form of disease 
described by this celebrated Scotch oculist.* 
By some the credit of first describing sympathetic iritis has 
been given to McKenzie; but this is certainly a mistake, for 
he himself says: "The fact that disease in one eye is liable to 
be followed by similar disease in the other, has long attracted 
attention." 
Lawrence, in his work published eleven years prior to McKen- 
zie's, mentions this form of disease. He says, "The influence 
of one eye upon the other is not confined to cases of disease. 
When one eye has been lost by accident, the other eye often 
becomes diseased sooner or later without any imprudence or 
external influence that would be injurious under ordinary cir- 
cumstances. This kind of occurrence is so common that it is 
necessary to warn those who have lost an eye of their danger, 
and to point out the necessary precautions for avoiding it; 
for this affection of the sound eye, if it is not noticed and properly 
treated in the early stage, often destroys sight. Its most com- 
mon form is slow inflammation, which may affect the iris, the 
retina or the internal tunics generally.'" These remarks, and 
the cases cited by this author, show that not only was the dis- 
ease familiar to him, but that its importance was fully appre- 
ciated; although to McKenzie is due the credit of giving a 
more accurate and elaborate description of cases, and of recom- 
mending the treatment first brought to notice by Wardrop in 
1818. 
To Wardrop belongs the honor of not only being the first 
among those-to call attention to the disease, but of proposing 
the most efficient remedy known for more than thirty years 
after the publication of this book in 1818. 
* See article by T. K. Pooley, New York Med. Jour., Vol. 11, p. 242. 5 
CHARACTER. 
The onset of sympathetic ophthalmia is often sudden and 
unaccompanied by any premonitory symptoms whatever; but 
in a large per cent of the cases a state of sympathetic irritation 
precedes for a long or short period the development of actual 
inflammation. This premonitory sympathetic disturbance is 
characterized by symptoms of asthenopia, ciliary neuralgia, 
photophobia, lachrymation, amblyopia, and periodical interrup- 
tions of vision. Sometimes the trouble goes no farther than 
these functional disturbances; but at other times it passes 
gradually from this state of simple irritation into that of actual 
inflammatory action. It is, from this tendency, one of the 
most insidious as well as dangerous affections of the eye, and 
it should always be remembered in the treatment of cases where 
there is long persisting sympathetic irritability in one eye, the 
result of incurable disease and blindness in the other, the only 
safe course to pursue is promptly to enucleate the primarily 
diseased eye, and in all cases where the sight of the eye first 
affected is hopelessly lost, it is decided malpractice to delay its 
removal when it thus keeps alive an irritable state of the other 
eye. 
Almost every form of inflammation of the eye, whether of 
the external or internal structures, is liable to produce inflam- 
mation in the other eye through sympathy. But there are 
some structures and some varieties of inflammatory action more 
liable to be accompanied by this complication than others are. 
The disease most likely to involve the other eye through sym- 
pathy is irido-cyclitis of the plastic or exudative variety. This 
form of disease is characterized by a great tendency to posterior 
synechia, inflammatory cloudiness of the vitreous, and conse- 
quent impairment of vision, episcleral injection of the ciliary 
region, increased tension of the globe in the early stage, and 
tenderness upon pressure over the ciliary body, and sometimes 6 
keratitis punctata, phakitis, capsulitis, and other inflammatory 
complications. 
Decided pain is not always present, and, when it does exist, 
is very varied in its character. It is sometimes constant, hav- 
ing periods of remissions and oxascerbations, the latter gener- 
ally at night. It is sometimes intermittent, returning at regular 
or irregular intervals. It is not' always referred to the eye 
itself, but is felt in the form of neuralgia, affecting the 
branches of the fifth pair. There is often severe photophobia, 
and excessive lachrymation, and as the disease progresses other 
structures are involved, and the eyelids become puffed, the con- 
junctiva especially becoming much swollen and injected. 
Sometimes this form of inflammation is arrested, but very 
generally it progresses with less or greater rapidity; the pupil 
becomes occluded, and the iris altered in structure and bound 
down by firm adhesions to the anterior surface of the lens ; the 
globe atrophies, and sight is destroyed. This disease in the great 
majority of cases is at first confined to one eye, but has so great 
a tendency to involve the other through sympathy that it is con- 
sidered "the sympathetic ophthalmia par excellence." 
Serious irido-cyclitis is also liable to be followed by sympa- 
thetic ophthalmia, but far less so than the plastic form of 
inflammation. In the early stage of this affection often the 
only symptom the patient complains of is dimness of vision; 
everything has a misty appearance, and this is most marked in 
a dim light, so that it is not infrequently mistaken for night 
blindness. The circum-corneal tenderness and redness are 
often absent, but as the disease advances the vitreous becomes 
cloudy; floating bodies appear in the field of vision; the iris 
changes color and fails to respond to light or the action of my- 
driatics; posterior synechia may occur, but not so frequently 
nor to such extent as in the plastic variety; the optic disk be- 
comes excavated in many cases, and the eye assumes a glauco- 
matous condition. 7 
Pain is often absent throughout the whole or a greater part 
of the progress of the disease. This variety is less destructive 
to vision and more amenable to treatment than the plastic form. 
Besides these varieties sympathetic inflammation may take the 
form of conjunctivitis, keratitis, iritis, choroiditis, choroido- 
retinitis, and irido-keratitis. The latter variety has more 
recently taken its place among the sympathetic affections, and 
by some its existence is doubted. 
Rheindorf and Agnew have reported cases (Archives of Oph- 
thalmology, Vol. IV., p. 389), but in none that I have seen re- 
ported are the symptoms so marked as in a case that occurred 
in my own practice. In Agnew's case the only change reported 
in the cornea was opaque spots on posterior surface,-a condi- 
tion that often occurs in iritis from deposit of lymph upon the 
membrane of Descemet. In my own case the corneal changes 
were extreme. As I have seen the report of no case more 
marked I subjoin some brief notes descriptive of it. On the 
night of August 16, 1875, a young man received a severe injury 
from the effects of some powder exploding in a burning build- 
ing. He was standing in front of the window, and with many 
others was thrown several feet toward the center of the street, 
and severely cut in several places by small fragments of glass 
and other hard substances with which the air was filled. Among 
the various wounds, one of which involved the common carotid, 
were two of the right eye, both penetrating the globe in the 
ciliary region, one about a line from the sclero-corneal junction 
just above the horizontal meridian, the other about three-quar- 
ters of a line from the cornea, and situated at the lower ex- 
tremity of the vertical meridian. 
The anterior chamber was completely filled with blood, and 
a bead of vitreous was protruding from the outer and lower of 
the two wounds. I supposed at the time that a fragment of 
glass had entered at each of the wounds and was then lodged 
in the eye, and that enucleation would soon be demanded. In 8 
two days the clot filling the anterior chamber had absorbed 
and the patient could now count fingers with the wounded eye. 
Much pain was experienced in it from this time on for the 
next ten days, though the vision was not diminished in any 
marked degree, nor did the vitreous become cloudy. A wide 
dilatation of the pupil had been obtained early, and by the free 
use of atropine it was maintained to a considerable degree 
throughout the attack. The change of color and appearance 
in the iris was not marked, but there was great redness and 
tenderness in region of the inner wound, and photophobia was 
extreme. The absence of symptoms of disorganization, and the 
considerable amount of vision possessed by the eye, forbade any 
radical procedure, and encouraged the expectant plan, although 
it seemed then certain that two foreign bodies wore lodged in 
the eye. 
At the end of ten days severe pain commenced in the left 
eye, and the pain in the injured eye began to diminish. By 
prompt use of atropine a partial dilatation of the pupil was 
obtained; the iris rapidly changing in its color, the aqueous 
becoming turbid and the cornea opaque in the central and 
lower portions. The pain continued all the time almost intol- 
erable, requiring the fullest doses of morphine to procure any 
rest. By the 4th of September, nineteen days after the injury 
to the first eye, and seven days after the inflammation began 
in the second eye, a considerable collection of pus having formed 
in the anterior chamber, and the lower part of the cornea being 
infiltrated with pus, I made an opening with the keratome 
through the lower margin of the cornea and evacuated the pus. 
The operation was followed by immediate relief of the pain and 
amelioration of all the symptoms. The iris gradually resumed 
its natural appearance and the cornea recovered, with a slight 
opacity that still remains: vision now equals one-quarter. 
The right eye also began to recover about the time that dis- 
ease commenced in the left, and has also perfectly recovered 
from any inflammatory affection : vision equals one-half. 9 
The remarkable feature of this injury being that no foreign 
bodies could be detected by ophthalmoscopic examination after 
recovery, nor was there any indication that they had passed out 
of the posterior part of the globe, but must have entered at 
the inner, and escaped at the lower opening. 
This explanation is confirmed by the fact that a fragment of 
glass or some other hard substance had struck the right side of 
the root of the nose, and cutting down to the nasal bone had 
glanced in the direction of the innermost of the two wounds 
of the eyeball. 
How this body could have traversed this region and not de- 
stroy the lens is an enigma to me, even after much careful 
study of the case and inspection of the eye and situation of 
the wounds received. The case is to me one of unusual inter- 
est, and at my request the patient has kindly consented to 
present himself here for your examination. 
Another cause of sympathetic ophthalmia is the irritation of 
the ciliary nerves caused by calcareous deposits in an eye long- 
diseased, or the production of true bony formation in the choroid. 
Time does not admit of a full discussion of this interesting fea- 
ture of sympathetic disease; but a single recent case will illus- 
trate how pain may be lighted up in an eye which has been 
<[uiet for years, and how it may then suddenly affect the other 
through sympathy. A. G., residing in Coldwater, Michigan, 
at the age of six was injured in the left eye by the explosion of 
a chemical mixture. He is now twenty-four years of age. 
At the age of seven he was completely blind in the injured eye ; 
but the sight was perfect in the other, and there was never any 
pain or tenderness of the sightless one. 
On the 17th of January, 1876, pain commenced in the blind 
eye, and a few days-after the right eye began to be affected 
with pain also. The disturbance in both eyes steadily increas- 
ing, he was advised by Drs. Cutter and Wurtz, whom he con- 
sulted, to have the blind eye removed. He presented himself 
to me shortly after, and the right eye was then found to be 10 
in a state of inflammation; the vision was blurred; the iris 
responded sluggishly to light and atropine. There was great 
photophobia, and the eyeball was much injected, sensitive to 
pressure, and increased in its tension. Enucleation being 
strongly indicated, I performed this operation on the 5th of 
February, nineteen days after pain commenced ip the sight- 
less eye. 
The sympathetic disease in the right eye began from that 
time to improve, and in a few weeks the patient returned to his 
work, and has remained well ever since. On the 24th of Apr# 
I examined the patient and found the eye presenting a perfectly 
normal appearance,-tension normal and vision perfect. On 
examining the enucleated eye a thick bony formation was 
found in the choroid, and had undoubtedly as it increased slowly 
in size, begun to press unduly upon some of the ciliary nerves 
and given rise to the pain in it, and the sympathetic disturb- 
ance in the other eye. 
The traumatic cause of sympathetic ophthalmia includes all 
injuries of the eye, but more particularly such as are very lia- 
ble to set up plastic inflammation of the ciliary body. Simple 
blows are sufficient, and are particularly liable to this accident, 
if by them the lens has become dislocated in any way so as to 
cause pressure upon the ciliary body. Penetrating wounds of 
the eye arc very liable to cause this affection, and are more 
dangerous when they involve the ciliary region or are in close 
proximity to it. Simple incised wounds in this region which 
do not wound the lens and allow of perfect co-aptation of the 
edges and union by first intention, are not so likely to be fol- 
lowed by this complication. Yet it cannot be denied that even 
clean cut wounds of this region that heal readily by first inten- 
tion are somewhat liable to this accident. It has been observed 
in cataract extraction by that extreme peripheric incision that 
followed the introduction of Von Graefe's method, and the 
present tendency to carry the incision further forward and 11 
thus remove it somewhat from the ciliary region is a step in 
the right direction. A wound of the cornea alone is not likely 
to produce sympathetic disturbance, except in those cases where 
the iris prolapses, and then, from the dragging and traction 
upon the ciliary attachment, the danger is much increased, 
and if the wound is peripheral and the prolapse considerable, 
as is apt to occur after cataract extraction when a large iridec- 
tomy has not been performed, the danger is often great, and 
requires prompt treatment of the cyst that is formed by the 
iris and bulges between the lips of the incision. Otherwise 
the continued traction upon the ciliary region will keep up sym- 
pathetic irritation of the other eye, if it does not light up 
actual inflammation in it. From the great liability to pro- 
lapse of the iris after extraction, and the serious consequences 
that are thus liable to result, the safest mode of extraction 
always includes a large iridectomy. 
It is from this traction of the iris upon the ciliary body that 
synechia, both anterior and posterior, is a source of so much 
danger, and that the use of atropine when this condition exists 
is often followed by great pain in the eye. to which it is applied, 
and sympathetic disturbances of the other. Anterior staphyl- 
oma, including the iris, is a source of great danger, and the 
old operation of ablation of the cornea for its relief, involving, 
as it does, the ciliary region of the eye in a puckered and con- 
tracted cicatrix, is, in my opinion, an operation that should be 
abandoned. Punctured wounds of the eye which lacerate the 
capsule of the lens and produce traumatic cataract are very 
dangerous, and should be watched with the utmost care and 
the injured lens promptly extracted if it produces any consid- 
erable oi' continued pain in the injured eye or sympathetic dis- 
turbance in the other. This tendency of traumatic cataract to 
produce disorganization of the injured eye, and through sym- 
pathetic complication to destroy the other also, is greater in 
'adults than in children. Indeed, destructive action of a 12 
wounded lens may be said to have an exact ratio to the age of 
the patient, and is a matter that should always be borne in 
mind by the physician attending such a case. 
Another cause of sympathetic ophthalmia is mutilation of an 
eye by the operation of couching or reclination of cataract. 
This operation, giving less than fifty per cent of successful 
results, and so often, when failing, destroying the other eye as 
well, ought in these times to be completely abandoned; but 
that it is not I am often reminded by patients who consult me 
and upon whom this operation has been performed. And often 
I find any operation on the other eye hopeless by reason of the 
destructive changes sympathetically induced by the previous 
operation. 
I hope all members of this Society will remember that a 
senile cataract operated upon in this way acts as a foreign 
body, and is liable at any time, within years after its displace- 
ment, to set up destructive inflammatory action liable to 
destroy both eyes before it terminates. With this fact before 
them, and the fact that extraction affords about ninety per 
cent of success and hardly any danger of sympathetic action 
upon the other, they will see that couching and reclination of 
cataract is decidedly malpractice. 
The lodgment of foreign bodies in the eye is one of the most 
frequent causes of this disease. These bodies may possibly 
become encapsulated and remain for a long while without pro- 
ducing sympathetic disturbance, but the eye is never safe. 
Dr. Wells reports a case in which the disease was induced 
twenty-six years after the foreign body had been lodged in the 
eye. 
In this case the injured eye had shrunken to one-fourth of 
its original size, but was painful upon pressure. 
Mr. Lawson (Injuries of the Eye) also reports a case where 
sympathetic ophthalmia was induced fourteen years after the 
lodgment of a piece of gun-cap in an eye. It should be 13 
remembered that suppurative inflammation following the lodg- 
ment of a foreign body in the eye affords no immunity from 
sympathetic inflammation unless by chance the foreign body is 
discharged with the matter, and even then the immunity is not 
complete. 
The wearing of an artificial eye has been known to cause sym- 
pathetic ophthalmia. This should always be borne in mind, 
and the patient advised to lay aside the eye whenever there is 
disturbance of the other eye, and on no account to wear one 
which causes pain, or to have one fitted to a stump that is pain- 
ful or tender upon pressure. 
As regards the pathogeny of this disease, the theory first 
advanced by Henri Muller is now generally conceded, that 
sympathetic disturbance of the second eye, of whatever char- 
acter, is brought about through the agency of the ciliary 
nerves. The modus operand! is not known, and it is not the 
object of this paper to present and discuss the theories that 
have been put forth to explain this phenomenon. 
TREATMENT. 
In the treatment of an eye threatened with sympathetic oph- 
thalmia complete rest should be enjoined, not only while the 
injured or primarily diseased eye is painful or suffering from 
inflammation, but also for a long time after. It is a common 
remark with patients suffering from disease in one eye that the 
use of the other, or even its exposure to light, is productive of 
pain in the affected eye. And not only does it have a tendency 
to prolong and aggravate the attack in the first eye, but has 
also a strong tendency to induce sympathetic derangements 
which it otherwise might escape. 
While either eye remains irritable light should be excluded, 
either by confining the patient to a darkened room, or, if the 
patient goes out, by the use of a bandage or dark blue glasses, 
as the severity of symptoms may call for. A wide dilatation 14 
of the pupil should be obtained as early as possible, and the 
irritability of the eye should be relieved by the use of atropine, 
and inflammatory action combated by appropriate measures, 
never forgetting that rest of any inflamed part is a very im- 
portant antiphlogistic measure. 
Time does not admit of an extensive and thorough review of 
all the forms of this disease, and the measures appropriate to 
combat them in all the various phases that may be presented, 
and I shall dismiss the question of medical treatment by declar- 
ing the disease to be exceedingly intractable and little influ- 
enced by any system of medication that has yet been tried, 
and shall pass on to the consideration of the surgical treatment, 
often sadly neglected, and sometimes, I fear, as badly abused. 
The chief surgical procedures that have been resorted to are: 
1st, induction of suppurative destruction of the globe; 2d, iri- 
dectomy ; 3d, division of the ciliary nerves; and 4th, enuclea- 
tion of the globe. To some of these modes I shall but briefly 
refer. 
It is a fact that has long been observed, that when an eye 
has been lost by suppuration (and the ciliary nerves thus de- 
stroyed), the eye is not so likely to suffer from sympathetic dis- 
turbance as when an eye is lost or affected by internal non-sup- 
purative inflammation. The practice of inducing suppurative 
inflammation in the human eye as a means of preventing sym- 
pathetic ophthalmia was first suggested by Wardrop, in 1818, 
and was first put in practice by Mr. Barton of Manchester, 
England, who published his cases in the Crompton Medical 
Gazette, in 1837 (see McKenzie's work, p. 410, note 8). 
As injustice has sometimes been done Mr. Wardrop in this 
matter,* I quote a few passages from the work of Mr. William 
McKenzie, which show not only the exact nature of Wardrop's 
suggestions, but also McKenzie's claim. He says : "There is 
* See Dr. Poole.y's Article, New York Med. Journal, Vol. 11, p. 254 15 
a disease, Mr. Wardrop informs us, frequent in the eye of the 
horse, having the appearance of a specific inflammation, which 
usually affects one eye and then the other, and sooner or later 
destroys vision. It is known to farriers that if the eye first 
affected suppurates and sinks in the orbit, the disease does not 
attack the other, or subsides if it had commenced in it. They 
therefore adopt the practice of destroying the diseased eye in 
order to save the other. They do this rudely by putting lime 
between the eyelids or by thrusting a nail into the eyeball, so 
as to excite violent inflammation and suppuration. Mr. War- 
drop has frequently succeeded in saving one eye of the horse 
by adopting this practice ; but he destroyed the eye by making 
an incision in the cornea and discharging through it the lens 
and vitreous humor. Tn some of the diseases of the human 
eye,' says he, 'where the disease makes a similar progress, first 
affecting one eye and then the other with complete blindness, 
the practice so successful in animals might, by judicious dis- 
crimination, be beneficially adopted.' 'J 
"The practice thus hinted at by Mr. Wardrop has actually 
been adopted, though with a somewhat different view, by Mr. 
Barton of Manchester, in cases of injury of the eye with frag- 
ments of percussion caps. * * * * Mr. Barton, it is true, 
opens the injured eye, with a view of extracting the fragment 
of the cap, on the pressure of which he considers the sympa- 
thetic inflammation to depend. He not only opens the cornea, 
but he cuts away a large flap of it. He then applies a poultice, 
and waits till the fragment is discharged. In the cases pub- 
lished by Mr. Crompton, this practice appears not only to have 
relieved the patients of the pain they were suffering in the 
injured eye, but to have arrested the reflex disease which threat- 
ened the other. 
"This, then, affords good ground for following a similar plan, 
not only in cases where we have reason to believe that some for- 
eign body is lodged in the eye, but even in other cases, where the 16 
one eye being disorganized and deprived of sight, the other eye 
seems likely to be destroyed by sympathetic inflammation. Where 
there is a suspicion that some foreign body is lodged within the 
injured eye, there can be no question but that Mr. Barton's 
practice ought to be adopted; but even in other cases, why 
should we hesitate to lay open an eye in which vision is extin- 
guished, if the operation affords a reasonable hope of our thereby 
saving the other F" 
This treatment was soon put into practice in France, and in 
Germany Von Graefe accomplished the same result by the use 
of the seton, a practice which he introduced and advised. 
It was the best treatment known until 1854, and was the 
only one recommended by Dr. Gross in his system of surgery 
until his edition of 1872, when lie wisely employed a specialist 
to revise his chapter on diseases of the eye. 
The large number of cases of sympathetic ophthalmia which 
arose from painful or tender stumps of eyes lost by suppurative 
inflammation showed that this mode of treatment was not a 
sufficient one, and led thoughtful men to look for some more 
successful operation. 
Section of the ciliary nerves was recommended by Von Graefe, 
but the operation did not meet with a success that warranted 
adoption, and has never come into general practice. Section 
of the optic nerve, also recommended at one time by the same 
author, failed to recommend itself to general adoption. Nei- 
ther has iridectomy, strongly recommended by some, proved 
beneficial. Indeed, the weight of authority is now against 
attempting the operation upon the eye threatened with the 
disease, since it is more likely to hasten and aggravate the 
attack than to prevent or ameliorate it. And if the disease is 
propagated, as is at present conceded, through the agency of 
the ciliary nerves, it is irrational to suppose that an iridectomy 
upon the injured eye will have any tendency to prevent the 
disease, since it cannot remove the source of irritation, unless 17 
by the mutilation of the eye suppuration be induced, and the 
ciliary nerves destroyed. Even Von Graefe deprecated this 
operation after the inflammation was fully declared, and a 
recent writer on the subject says: "In the cases I have had 
to deal with I have never resorted to it. I have seen the result 
in the hands of others, but with such uniform want of success 
as to deter me from ever undertaking it myself." 
The occurrence of intra-ocular hemorrhage is very likely to 
follow this operation, and this, a cause of itself, can but add 
to the danger of sympathetic disturbance of the other eye, and 
insure or hasten that which it is intended to avert. 
The following case (see Mich. Univ. Med. Jour., 1871-2, p. 
531), reported by Dr. Eugene Smith of Detroit, illustrates the 
effect of this operation : 
The eye, lost by plastic irido-choroiditis, was reduced to 
quantitative perception of light, and was increased in its ten- 
sion. The Dr. advised and performed an iridectomy June 23, 
1871. lie says: " The anterior chamber filled with blood not- 
withstanding the utmost care to prevent it, and would refill as 
fast as permitted to escape." At the end of 17 days inflamma- 
tory reaction occurred, and by Aug. 2d, the other eye having 
become sympathetically affected, the eye was enucleated, with 
the effect of relieving the sympathetic symptoms to such an 
extent that the patient writes, twelve days after the operation, 
that his remaining eye is nearly as well as ever. 
In 1851 White Cooper published an article on lacerations of 
the sclera, and after calling attention to the inefficiency of all 
known treatment, suggested the propriety of enucleating the 
injured eye as soon as its fellow showed the slightest symptoms 
of becoming affected. 
In October of the same year Augustine Prichard, Surgeon 
to the Royal Hospital at Bristol, published a report of twenty 
cases treated by him, in which he had extirpated the injured 
eye as soon as the other showed serious signs of inflammation. 18 
He stated that, although his opinion as to the value of this 
treatment needed confirmation, he should continue to recom- 
mend this operation to all who applied to him for relief from 
this disease. * 
The questions for us to consider are : What has the experi- 
ence of the past twenty-two years taught us concerning the 
value of this operation? and what are the conditions that call 
for its performance ? 
As to its value we may say: 1st, that experience has proved 
enucleation to be a sure preventive of sympathetic ophthalmia 
if the injured eye is removed before the other eye has become 
at all affected; 2d, that it is almost equally sure to relievo all 
merely functional derangements or sympathetic irritation; 3d, 
that in milder forms of sympathetic inflammation-e. g. serous 
irido-choroiditis-enucleation usually arrests the intensity of 
the inflammatory action and often affects a cure; 4th, that in 
the severe plastic forms of irido-cyclitis, although it may often 
retard the progress of the disease, it seldom arrests and cures 
it. 
Enucleation is positively indicated in all cases where severe 
or continued inflammatory action exists in an eye the sight of 
which is hopelessly destroyed. In such cases it is not wise to 
wait for premonitory symptoms to arise in the other eye, as 
cases have been observed in which in four days, without pre- 
monitory' symptoms, an eye became so affected with sympa- 
thetic irido-cyclitis that vision was reduced to 3-200, and 
where all efforts failed to save it from complete destruction. 
Such cases show the folly of retaining diseased and sightless 
stumps at such risk to the remaining eye. If a foreign body is 
lodged in the eye this Operation becomes imperative if the sight 
is destroyed and the foreign body cannot be safely removed, so 
as to prevent severe or recurrent inflammations. Although 
*See Article on Sympathetic Ophthalmia, by T. R. Pooley, M. D., N. Y. Med. 
.Jour., Vol. 11. 19 
foreign bodies may become encysted, and remain in the eye for 
a long*time without exciting action in the other eye, yet they 
have been known to do so after many years, and an eye con- 
taining a foreign body is never safe. The history of numer- 
ous cases teaches us that there is but one safe course to pursue, 
and that is promptly to enucleate the injured eye. Not only 
should this course be pursued in cases in which foreign bodies 
are lodged in the eye, but in all cases where there are repeated 
attacks of inflammation in eyes that have been destroyed by 
disease. Such patients frequently consult us for relief from 
the effects of a cold they think they have caught in their eye. 
In such cases no time should be lost in temporizing prescrip- 
tions ; but the eye should be promptly enucleated before the 
other has become involved in the disease. In cases of severe 
inflammatory action in such ah injured or diseased eye, some 
authors advise waiting until the severe inflammatory action has 
subsided, fearing the operation may excite excessive reaction, 
and lead to meningitis.* 
In a recent report of a case of this disease the writerf states that 
'•'if too much time has elapsed and suppuration begun, it would 
be very dangerous to enucleate the eye.'' I regard this teach- 
ing as incorrect and injurious, without foundation in experi- 
ence or correct principles of surgery as applied to other parts 
of the body. If amputation should be decided upon in disor- 
ganization of a knee joint, no one would think of deferring it 
for fear of excessive reaction following its removal. On the 
contrary, every experienced surgeon knows that amputations 
performed under these circumstances arc followed, as a rule, by 
complete relief, and arc much safer than primary amputations. 
The system, rid of the irritation of the disorganizing structure, 
rallies at once. Just so is it in suppurative or other inflamma- 
tions of the eye. Instead of increasing the tendency to brain 
* Stellwag, pp. 261, and 485-6. 
t Dr. Eugene Smith, Det. Kev., March, 1S76. 20 
inflammation, the removal of such a diseased and painful stump 
is marked by the most rapid relief and convalescence, and the 
tendency to extension of the inflammation to the meninges of 
the brain is actually lessened by removing a source of irritation 
that affects the brain sympathetically, just the same as it does 
the fellow eye. It should be remembered that the dura-mater 
is supplied with branches from the ophthalmic division of the 
5th, and the intimate connection of the ciliary ganglion with 
the cavernous sympathetic plexus causes inflammation of an 
eye .to disturb the brain, and may, in febrile states of the sys- 
tem, be an exciting cause of cerebral or meningeal inflamma- 
tion. In such cases enucleation must be a safeguard against 
brain complications, and we arc sometimes called upon for the 
removal of painful eyes merely for this effect of relieving irri- 
tation of the brain. 
The following case will illustrate this fact: Miss C of 
Marshall, Mich., consulted me June 6th, 1875, for severe head- 
aches that rendered her existence miserable. Both eyes were 
blind, and had been for years. The left eye still retained the 
perception of light; the other was stone blind, and very 
painful. She had herself noticed that the pain began in the 
eye first, and the headache commenced almost immediately 
afterwards; and without consulting any physician on the sub- 
ject, asked me to enucleate the eye, if I thought it advisable. 
After hearing the history of the case I was convinced that the 
headaches were caused by pain in the eye, and recommended 
the enucleation as a means of relieving the pain in both it and 
the head as well. I accordingly enucleated the right eye on 
the same day, with the effect of relieving the patient almost 
completely of the paroxysms of headache, and the relief has 
continued permanent up to the present time. 
The following cases will illustrate the rapid convalescence 
after enucleation of an eye affected at the time with destructive 
suppurative inflammation, a condition which, left to its natural 21 
course, is often tedious and painful almost beyond the point of 
endurance: 
Case 1. J N of Otter Lake, Mich., received an 
injury to the left eye in July, 1872. The injury was received 
while hammering a piece of steel, and the patient noticed the 
sigVt was impaired and that vision was double, lie consulted 
a physician in a few days, when some pain appeared and the 
eye looked red and slightly swollen. The physician gave him a 
collyrium of nitrate of silver, which only aggravated the pain 
and swelling, and on the 29th the patient consulted me, with the 
eye tense and swollen, pain extreme, the anterior chamber full 
of pus, conjunctiva swollen and overlapping the cornea and 
protruding between the edges of the swollen lids, the appetite 
gone, tongue heavily coated, pulse full and bounding, and all 
the symptoms, general and local, that usually accompany the 
severer forms of Pan-ophthalmitis. After several days of con- 
tinued suffering the patient consented to have the eye enucle- 
ated, and I performed the operation at 3 P. M., Aug. 3d. 
The effect was immediate relief of all pain; a night of perfect 
rest followed the operation. A considerable breakfast was 
taken the next morning, and in the afternoon the patient was 
up and dressed. The following day he walked out into the 
yard, and left for home, a journey of about 150 miles, in six 
days after the operation. At the time of the operation;, and 
for several days previous, the patient was severely ill, exacting 
from me four or five yisits a day, and obtaining no rest except 
when under the influence of half-grain doses of morphine, and 
these mtly secured a brief period of ease. 
Case 2. J S , Ann Arbor, was attacked with a severe 
inflammation in the right eye. This eye had been the seat of 
several inflammatory attacks, sight having been destroyed more 
than a year previous to this attack. At this time the inflam- 
mation assumed a suppurative character and was very painful. 
The patient required the largest doses of morphine to procure 22 
any rest, and even with these, and free opening of the cornea 
for the purpose of allowing pus to escape, the pain was so con- 
tinuous and severe that the patient begged to have the eye 
enucleated, saying he would rather die than bear his sufferings 
longer. I accordingly made the operation on the 27th of 
March, 1873. The eyeball at the time was so intimately 
adherent to the surrounding structures that every portion had 
to be dissected off with the curved scissors. The operation 
afforded the most complete and immediate relief, and recovery 
was so rapid that only two visits were required afterwards. 
The symptoms of sympathetic irritation which existed in the 
other eye rapidly disappeared, and tire vision in. it has remained 
perfect ever since. On section of the enucleated eye the 
interior was found to be undergoing purulent disorganization, 
and so far advanced that nearly half the contents consisted of 
pus. 
Many such cases have occurred in my own practice, but time 
does not permit even the briefest description of them. 
To show' that such instances are not confined to my own 
practice, I quote one of the many cases I have seen reported. 
The following I give in exact words of the author, Prof. J. J. 
Chisholm, of the University of Maryland, surgeon in charge of 
the Baltimore Eye and Ear Institute (reported in Virginia 
Medical Monthly, August, 1875) : 
"F. G., aged 02, came to the Baltimore Eye and Ear Insti- 
tute from his country home, two hundred miles distant. He 
had lost his eye three years since. For the past six weeks he 
had been suffering intense pain in the lost eye, which has kept 
him from writing, and which has recently made the good eye 
weak and dim. I found the eye in a state of acute inflamma- 
tion, with the cornea in a sloughy state and the anterior cham- 
ber apparently full of pus. He was anxious for relief, and 
walked the room restlessly on account of his severe suffering. 
Chloroform was administered, the patient went quietly to sleep, 23 
the eye was enucleated in accordance with the method already 
described, and the patient put to bed. Four hours after the 
operation I found the patient free from all pain and feeling so 
well that he desired to accompany a friend who had some busi- 
ness in a distant portion of the city. He had experienced no 
nausea from the anaesthetic. Eight hours after the operation 
he was enjoying such perfect relief that he took cars to return 
to his home." 
I would not have spent the time on this point that I have 
only that this theory of waiting for acute inflammation to sub- 
side, originally put forth by Von Graefe, is blindly followed by 
so many, and leads them to subject' their patients to prolonged 
torture and suffering, jeopardizing the only remaining eye, 
often keeping those who can ill afford the time incapacitated for 
labor for months, when by prompt enucleation they might re- 
sume their labor in a few days. 
There is one point in the last quoted case worthy of a mo- 
ment's reflection. This patient visited Baltimore from his 
country home, 200 miles distant, for this simple and safe oper- 
ation. Why was this necessary? Had a limb been crushed he 
would not have gone so far to receive the needed surgical aid. 
Ambitious surgeons would hardly have allowed him to escape 
from his home unrelieved. And yet the pain and danger call 
for no more prompt relief in one case than in the other. The 
real secret is that too many of our profession have imbibed 
their notions of ophthalmic surgery from such teaching as the 
following, extracted from the fourth edition of Gross, and only 
corrected within the last few years: 
"The question may here be asked what should be the treat- 
ment when a foreign body lodged in the eye cannot be extract- 
ed? Should the humors be evacuated, or the organ itself be 
extirpated, as some have recommended; or should the case be 
managed upon general principles? Manifestly the latter, 
unless there be great local and general suffering, or the integ- 24 
rity of the sound eye be seriously threatened by sympathetic 
action, in which event no time should be lost in effecting col- 
lapse, the extraneous substance almost invariably escaping 
along with the contents of the organ. As to the excision of 
the eye, I can hardly conceive of any case, however severe, 
warranting so ruthless a procedure." 
To this teaching, long adhered to after modern surgery had 
shown it to be a dangerous error, and the discouraging remarks 
of this much read author concerning cataract extraction, and 
his unwarranted recommendation of couching after the oper- 
ation had become obsolete with all good surgeons, many a case 
of sympathetic ophthalmia -has probably been due, and many a 
patient has suffered prolonged and unnecessary torture. It 
teaches us, also, how early impressions prevent the adoption of 
new truths, and lead to a persistence in error by one whose 
opinions are upon many points so valuable, and who has done 
so much to disseminate correct principles of general surgery. 
When the sight of an eye is hopelessly destroyed we have a 
safe rule to follow; and that is always to enucleate the diseased 
eye if painful upon pressure, severely inflamed, or subject to 
recurrent attacks of inflammation, waiting, in recent cases of 
injuries, until such a degree of inflammatory action has fol- 
lowed that any prospect of restoring sight is past. 
When sight is retained in the injured eye the case is far more 
perplexing. So uncertain are any rules in guiding us, and so 
fallible is the most experienced and mature judgment in decid- 
ing the propriety of enucleating an eye retaining some degree 
of sight, as a means of protecting the other eye, that after 
many departures from it there is a manifest tendency to return 
to the practice advised by Von Graefe, viz.: it To abstain from 
enucleation in all cases in which the least vestige of sight yet 
remains in the injured eye."* 
* See Dr. Samelsohn's article in Archives of Ophthalmology and Otology, Vol. 
5, p. 56. 25 
There are, no doubt, many cases where this advice should 
be departed from, but at the present time no therapeutic rules 
can be laid down sufficiently certain to guide us in departing 
from it, and not until a larger number of cases shall have been 
carefully recorded and studied can such rules be deduced. 
Cases have been recorded in which after the eye secondarily 
affected has been completely lost, useful vision has remained in 
the injured or primarily diseased eye. A case once came under 
my observation in which irido-choroiditis originating in the 
right eye affected the left through sympathy and led to its com- 
plete destruction. The right, however, still retained good per- 
ception of light, although the pupil was occluded and the iris 
firmly bound down by adhesions to the lens. At the earnest 
solicitation of the patient I operated upon this eye, performing 
a large iridectomy and extracting the lens, which was found to 
be opaquch The result, I am informed by his physicians (Drs. 
Hayden and Metcalf of Eaton Rapids, Mich.), was such as to 
enable the patient to read, and the operation, performed five 
years since, has continued a permanent success. The patient, 
then a young man of about 25, has since engaged in successful 
business. The following case, reported by Dr. Pooley, of New 
York (Archives of Ophthalmology, Vol. I., No. 2, p. 553), is 
so instructive in this connection, that I quote it entire, in his 
own language, as follows : 
"V. M. R., age 32, a merchant, consulted me July 6, 1869. 
Seven years ago, while breaking stone with a hammer, a piece 
of steel flew off from the hammer and struck him forcibly upon 
the left eyelid, through which it penetrated and entered the 
eye. The foreign body remained for some weeks in the eye 
(exactly how long he does not remember), and was then 
removed by his family physician. The wound healed, but two 
weeks later the eye began to be painful, red, and swollen. A 
week after the commencement of the trouble in the left eye the 
right eye began to show signs of sympathetic irritation. He 26 
first noticed lachrymation, and then temporary obscurations of 
the visual field; subsequently this eye also became painful, red, 
and swollen. In two years the right, or sympathetically 
affected eye, had lost all perception of light. The sight in 
the other, the injured eye, now began steadily to improve. 
"His condition at the time he came under my observation was 
as follows: There was a scar upon the upper sclero-comeal 
margin of the left eye, in which the iris was engaged, so as 10* 
form an anterior syncchia and a pyriform pupil. The iris 
throughout its entire pupillary border was attached to the cap- 
sule of the lens, immovable, and somewhat discolored; the 
pupil, with the exception of a small aperture, filled with a 
false membrane. 
"In the right eye the color of the iris was changed to a dirty 
green, and a dense opacity occupied the lower border of the 
cornea. The pupil was completely occluded by a false mem- 
brane, and the whole globe somewhat atrophied. 
"Vision in the right eye was completely abolished, there being 
not evenperception of light. Sight in the left eye equals two- 
fifths. Tn. in left eye. T. somewhat diminished in the right. 
The fundus of the left eye could be illuminated with the oph- 
thalmoscope, but no details were discernible. For the last four 
or five years hp has had recurrences of ciliary inflammation, 
with more or less pain in both eyes, but always commencing in 
the right or non-injured eye. 
"The last attack took place about four months before I saw 
him. 
" I advised enucleation of the right eye, inasmuch as it evi- 
dently was now the source of irritation, and after its removal 
an iridectomy might with advantage be performed upon the 
other. 
"Dr. Knapp, who saw him with me in consultation, confirmed 
this opinion. The patient, however, refused to submit to the 
operation and passed from under my observation." 27 
Another still more instructive case, bearing upon this point, 
is reported by Dr. J. Samelsohn of Cologne. The case is too 
lengthy to include in detail in this paper, but it can be found 
in full in the 5th Vol. of the Archives of Ophthalmology and 
Otology, should any one desire more complete notes. 
This patient, a lad of fourteen, was injured by a blow upon, 
the left eye on April 1st, 1874. The next day the eye was* 
found to have a slight prolapse of the iris through a small per- 
ipheral rupture of the cornea, symptoms of irritation were pres- 
ent, and vision was reduced to such an extent that fingers could 
not be seen nor counted at any distance. Six days after the 
accident pus was detected in the anterior chamber, and a low 
grade of inflammation followed until the first week in May, 
when the sight slightly improved, so that fingers held to the 
outer side of the eye could be counted at the distance of a foot. 
A violent relapse then occurred, which on the 9th of May sud- 
denly abated, and on the same day symptoms of sympathetic- 
ophthalmia appeared in the right (or uninjured) eye. By the- 
15th it had reduced the vision of this eye to f. In consider- 
ation of the undoubted sympathetic nature of the disease in 
this eye and evident loss of sight in the injured eye, enucleation 
was recommended, but not submitted to. Soon the disease in 
the second eye showed absolute symptoms o^ plastic irido- 
cyclitis, and the proposition to enucleate was again urgently 
repeated, but the parents' consent was absolutely refused. The 
patient was taken into the hospital and treated by confinement 
to bed in a darkened room, and free use of atropine in both 
eyes. Under this treatment the case so far recovered that by 
May 29 vision of the right eye was normal, and of the injured 
eye was 1-23. The patient was then discharged with a doubt- 
ful prognosis. By June 20th all symptoms of irritation had 
disappeared, vision of each eye as before. After more than a 
year had elapsed, the patient having part of the time attended 
gchool and the balance of the time had been apprenticed at a 28 
work requiring constant use of the eyes, the doctor made an 
examination and found the right eye perfectly normal, and the 
sight of the injured eye restored to one-half normal vision. 
In commenting upon this case the doctor says : " That 1 did 
not enucleate in this case under the existing circumstances, 
was owing wholly to the unconquerable opposition of the pa- 
tient's relatives, and that they were finally right, proves amply 
that wc are yet at the alpha as to prognosis in sympathetic dis- 
turbances, and that the therapeutic rules which at this day 
govern prophylactic enucleation are still very uncertain." 
The length to which this paper has already been carried for- 
bids further discussion of the many interesting questions con- 
nected with this disease, but if, by what has been said, the 
.attention of those who have listened has been called to the 
importance of this subject, and if they shall thus be led to 
■contribute to that abundant report of cases from which only 
■can be derived those principles that must guide us in the most 
perplexing of this class of cases, the object of the writer will 
be accomplished and the time of this society will not have been 
.spent in vain.