Ophthalmology. 
UNDER THE CHARGE OF 
L. WEBSTER FOX, M. D., 
Ophthalmic Surgeon to the Germantown Hospital, Philadelphia. 
FROM * 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. 
October, 1887. American Journal of the Medical Sciences fftr October, 1887. 
Extracted from 
OPHTHALMOLO GY. 
UNDER THE CHARGE OF 
L. WEBSTER FOX, M.D., 
OPHTHALMIC SUBGEON TO THE GEBMANTOWN HOSPITAL, PHILADELPHIA. 
Etiology of Ocular Paralyses. 
In the Recueil d' Ophthalmologic for March, 1887, Prof. Fournier sets out 
the distinctions between the symptoms of ocular paralyses, caused by ataxia, 
and those from lesions of the ocular nerves. If symptomatic of tabetic disor- 
ders, he finds the following distinctive points: 
1. The paralyses are almost always single or in groups, and partial; the 
pupil is often implicated in a peculiar manner. 
2. There is either the Argyll-Robertson pupil or myosis. 
3. The paralyses are often of short duration, sometimes for an instant only. 
4. They are especially liable to recur, and often cease spontaneously and 
quickly. 
If of the following characters, a lesion of the nervous system is probable: 
1. If the paralysis be complete. 
2. If persistent. 
3. If relieved only by specific treatment, long continued. 
Of 62 cases of tabetic paralysis, the author found but a single one with total 
paralysis of the ocular muscles. Of the 62 cases the pupil was affected in 37, 
of which 28 had no other muscles implicated. Of the 9 remaining cases out 
of the 37, in which other muscles were affected, there were 3 cases of paralysis 
of the levator and of the internal rectus, 2 of the levator, 2 of the internal 
rectus, 1 of the inferior rectus, and 1 of the levator and inferior rectus. Of 
the 62 cases there were 15 myoses, 11 of which were without implication of 
other muscles. The author emphasizes the existence of a passing strabismus 
or of temporary diplopia, as thus often indicative of locomotor ataxia. 
The Bacillus of Catarrhal Conjunctivitis. 
Dr. J. E. Weeks {Arch. f. Augenheilkunde, xvii. 3, p. 318) describes a 
bacillus obtained from an acute case of catarrhal conjunctivitis, that he thinks 
the source of the infection. Two kinds of bacilli were found in the cultures, 
but the rod-like variety was proved by cultures to have no pathogenic quality. 
The one producing the inflammation was shorter than the tubercle bacillus, 
but of about the same thickness. The period of incubation after inoculation 2 
OPHTHALMOLOGY. 
was about forty-eight hours; inoculation always produced the characteristic 
conjunctival symptoms, and the bacillus in every case, when there was 
yellowish secretion, was always present. 
Tuberculosis of the Conjunctiva. 
In Grdfe's Archiv, Band xxxii. Abth. iii., Dr. Stolting reports three cases 
of this serious affection, and bespeaks a more hopeful prognosis than has 
heretofore been considered possible, and, especially, if the treatment be com- 
menced at an early date. The diagnosis of the disease was rendered certain, 
in one case by the production of the characteristic bacillus under the micro- 
scope, in the second by inoculation and proof of the existence of the bacilli 
in the animal, and in the third case by both methods. The tuberculous 
ulcers were situated respectively upon the upper lid, the cheek, and the 
lower lid. The single and effective therapeutic measure advocated is the 
complete destruction of the tuberculous centre and deposit by the thermo- 
cautery. In some cases this may have to be repeated, or more thoroughly 
carried out at successful periods, but in each of the three cases cited, com- 
plete success was finally attained by this means. The author cautions against 
unnecessary destruction of healthy adjacent tissue, such as would cause cica- 
tricial contractions, disfigurement, etc. 
Injuries of the Eyes by Dynamite. 
Professor A. von Hippel (Grafe's Archiv, Band xxxii. Abth. iii.) de- 
scribes the ocular injuries from explosions of dynamite in twenty cases 
that have come under his care. The most characteristic changes are in the 
cornea, and in all instances consist in a great number of grayish-white, punc- 
tate opacities, the result of the penetration of particles of sand, stone, etc., 
into the more superficial or deep corneal strata. The corneal epithelium was 
in all cases burnt or severely injured. The most serious and frequent com- 
plication of the many that may occur is, besides the loss of superficial sub- 
stance, the perforating wounds of the cornea. The sclerotic was seldom 
perforated. In only one instance was any considerable fragment of stone, 
etc., found within the globe. The more severe injuries ended in loss of the 
eye by panophthalmitis or irido-choroiditis. Of the twenty cases, eight 
became blind in both eyes, seven in one eye, the vision of the remaining eye 
being very bad. 
Ocular Injury by Lightning. 
Dr. M. Knies [Grafe's Archiv, Band xxxii. Abth. iii.) describes a case of 
this rare occurrence. A ten year old boy was struck with what might be 
called a spent bolt, while standing by an open window. He at once turned 
around several times slowly and in a peculiar manner, fell backward to the 
floor, and was unconscious for two hours. Upon the return of consciousness, 
both eyes, especially the right, were found much swollen and flowing with 
tears. The child was weak, dazed, slept a great deal, but had no headache. 
Four days later the oculist found fresh irregular wounds of the forehead and 
temple, and these extended down the right sterno-mastoid and the side of the 3 
OPHTHALMOLOGY. 
body to the foot. The skin of the forehead was in folds from the constant 
contraction of the frontalis muscle. The eyebrows and lashes were burned 
upon both sides, and there was incomplete ptosis with ciliary injection and 
diffuse corneal opacity. Upon the right side there was a large posterior stellar 
polar cataract and further lenticular opacity from the equator to the anterior 
cortex. There was complete amaurosis, but a normal-sized and acting pupil. 
In the left eye there was beginning cataract and a normal fundus, with vision 
one-half, not improved by lenses. The ocular motility was not interfered 
with upon either side. The right cataractous lens was partially removed at a 
later date, but the patient passed from observation, and the final results are 
not to be had. Two sets of consequences are, therefore, to be distinguished: 
First, the direct, consisting in the burning of the lashes, the flesh wounds 
made by the electric stream, the injuries to the nerves or muscular tissues by 
the same; second, the indirect, the iritis, the irido-cyclitis, the cataracts, etc. 
Bourgeois and Tscherning (Annales d' Oculistique, xcvi. p. 203), from the 
measurements of 203 soldiers, found that the radius of corneal curvature 
varied in proportion to the circumference of the head. Whilst the first rose 
from 7.78 mm. to 7.92 mm., the cranial measurements were from 54 to 60 cm. 
Relations of Corneal Curvature to Cranial Circumference. 
Irido-cyclitis Tuberculosa. 
Tuberculosis of the uveal tract is a rare disease occurring not more fre- 
quently than once in about 5000 cases of ocular disease. Therefore, the 
case described in detail by Dr. August Wagenmann (Graft's Archiv 
Band xxxii. Abth. iv.) posesses a peculiar interest. The patient was a man 
of forty-four years of age (February 3, 1886), had no tuberculous family 
history, and syphilis was excluded. The anterior chamber was partially filled 
•with pus, there was prolapse of the upper portion of the iris, the tarsal con- 
junctivae were extremely congested. There was no fundus reflex, the ciliary 
region was very sensitive to pressure, the visual acuity, -to - . The eye 
was enucleated on February 5, and the suspected tuberculosis was proved by 
finding the characteristic bacilli, and by the inoculation of animals with the 
pus. Dr. Wagenmann finds from a review of the literature of the subject, 
that the disease is usually chronic and monocular, generally limited to the 
age of childhood, and may be painful or not according to circumstances. 
Early enucleation is always advisable, since, the diagnosis being certain, there 
can be no hope of saving the eye, and by this measure as well as by general 
treatment, a great improvement in health is at once observed. 
The Pupillary Immobility of Progressive Paralysis. 
Mcelli's study of this subject (ArcAw f. Psych.., xviii., 1887) is based upon 
500 cases. In about half of the cases the light-reflex was destroyed or much 
below the normal. In only twenty-eight per cent, was there good reaction. 
Mydriasis is much more infrequent than myosis. There were twenty cases 
of pupillary immobility in non-paralytic patients. In the majority of these 4 
OPHTHALMOLOGY. 
cases syphilis or alcohol was the probable cause. Binocular immobility ex- 
isted in twelve cases without cerebral or paralytic disease, and in half of these 
cases syphilis was the undoubted source. 
The Relation between Choroidal and Astigmatism. 
Georges Martin (Annales d' Oculistique, Mars, Avril, 1887) gives the results 
of his studies of the relation of the choroidal crescent about the papilla to 
the axis of astigmatism, and finds in the great majority of cases, perhaps in 
all, that the crescent is situated at the extremity of a partial contraction of 
the ciliary muscle, and that this contraction is the cause of its appearance 
and development. All eyes with a crescent, he finds, are astigmatic, and the 
direction of the lesion is in a plane parallel to one of the principal meridians, 
generally, in the one of least refraction. In 358 cases of regular or vertical 
astigmatism, 336 crescents were external and 22 inferior. In 24 cases of 
horizontal astigmatism, the crescent was vertical in every case. Of 22 cases 
of oblique astigmatism, the crescent was vertical 15 times, and 7 times was 
parallel to the axis of corneal astigmatism. In dynamic or lenticular astig- 
matism of the 9 cases reported, the crescent and spasmodic astigmatism had 
the same direction. In 413 cases, therefore, of all kinds examined, the rela- 
tion was proved to exist in 384 instances, or in about 93 per cent. In 77 cases 
that are tabulated, 13 were emmetropes, 7 hyperopes, and 55 myopes, 2 cases 
not being determined. 
Cases of Primary Glaucoma in the Young. 
Two interesting cases of glaucoma in young people are reported by Dr. O. 
Lange in Grafts Archiv, Band xxxiii. Abth. i. The first was in a man 
of twenty, and had continued with the usual symptoms of clouded vision, 
rings about lights, frontal headaches, etc., for over a year, with many sub- 
acute attacks. Latterly the abnormal increase of intraocular pressure had 
the peculiarity of an exact rhythmical occurrence. In the morning the pres- 
sure was high, decreasing toward noon, and disappearing entirely during the 
latter part of the day. At first, eserine controlled the glaucomatous symp- 
toms, but it finally became powerless to affect the periodical rise and fall of 
the pressure. A sclerotomy, according to de Wecker's method, gave perma- 
nent relief for several years, when the attacks again came on, and, eserine 
once more proving of no avail, an iridectomy was made with the desired 
result of relief up to date. In the second case, a girl of twenty-two, the 
primary attack was connected with an amenorrhoea of seven months' standing. 
A de Wecker sclerotomy gave complete relief from what had been severe and 
frequent attacks of the usual glaucomatous symptoms. The author also 
adduces an instructive case of recurring glaucoma in a clarionet player, who 
was always seized with an attack after playing upon his instrument. Eserine, 
previous to an evening's engagement, always aborted the attacks. From 
these instances Lange argues that the glacomatous tension may be superin- 
duced by circulatory disturbances, though he is so far from exclusively 
accepting this, or any other theory, that he sharply, and with much effective- 
ness, criticises those who thus accept any exclusive dogma of the etiology of 
the affection. Eserine, which enlarges the vessels, is, for this reason, deemed 5 
OPHTHALMOLOGY. 
to have its good influence in reducing the tension, but the author seems to 
forget that amyl nitrite has no such effect upon the intraocular tension. 
Mauthner's astounding theory that the increased tension does not necessarily 
belong to the glaucomatous symptoms, is as sharply criticised as the reverence 
due to great names will allow. As to the relative frequency of glaucoma in 
hyperopia and myopia, the author would modify the common belief that it is 
indiscriminately and excessively higher in hyperopia. Of his 163 cases of 
primary glaucoma, he finds that of 69 cases of glaucoma simplex, 30 were in 
myopic eyes, and 38 in hyperopic. In glaucoma cum injectione, the proportions 
were about as commonly given: 10 in myopes and 81 in hyperopes. In the 
Archives of Ophthalmology for June, Dr. R. L. Randolph reports a case of 
glaucoma in both eyes in a child of eleven years that had existed for over a 
year. No clew was obtained as to a family history. Vision was in the 
Ov 
right eye, - in the left, both eyes were under abnormal intraocular pressure, 
60 
the left being of a stony hardness to the touch. The papillae were cupped, 
and there was venous pulsation. The disease was not complicated with any 
other that could be learned. Operation was declined. 
The Pathological Anatomy of Glaucoma. 
Birnbacher and Czermak (Graft's Archiv, xxxii. 2 and 4) present an 
excellent account of the minute anatomy of seven glaucomatous eyes. The 
general results are in harmony with Schiilten's experiments, viz., that any 
causes that increase the difficulty of the venous outflow, or that increase the 
arterial supply, tend to raise the intraocular tension. It is shown that the 
eyes under study give evidence of circumstances operating toward increased 
pressure, in that there is lessened lumen of the veins, caused by inflammatory 
changes and thickening of their walls, which changes also had the effect of 
cutting off the ready escape of lymph and other fluids. The primary source 
of the mischief is thought to consist in injuries of the uveal tract consequent 
upon inflammation, which prevent the escape of lymph and venous blood. 
The Influence of Mydriatics and Myotics upon 
Intraocular Pressure. 
In Gr life's Archiv, Band xxxiii. Ab th. i., Dr. Friederich Stocker pub- 
lishes the results of his numerous experiments with the principal mydriatics 
and myotics upon the intraocular pressure of cats, under normal or physio- 
logical conditions. Morphine and chloroform were found ill-adapted as nar- 
cotics, and curare alone was resorted to. The tension was measured with a 
manometer, especially constructed for the purpose. The reader may be 
astonished to learn that the invariable result of the extended experiments 
was, that, under the influence of atropine, there was a slow diminution of the 
intraocular pressure. With cocaine there was also a lessening of the tension 
in every instance,1 preceded, however, in the majority of cases, by a slight 
1 Elizabeth Sargent, M.D., in Archives of Ophthalmology for June, reports a case of diminution of 
intraocular pressure in a woman, and relief from pain and other glaucomatous symptoms for six or 
seven months, by the instillation of cocaine. 
* 6 
OPHTHALMOLOGY. 
temporary increase of the tension. With eserine there resulted an increase 
of tension without any stage of diminished tension, but the final effect of 
eserine was to reduce the pressure to a greater degree than it had been raised. 
Pilocarpine slowly reduced the tension after a preliminary stage of strongly 
varying pressure, during which there was an average elevation of pressure in 
both eyes. In all the experiments it was proved that the pupillary play 
stands in no necessary and essential relation either to the increase or decrease 
of tension. This result is in direct contradiction to the conclusions of Hblztke 
and Graser, who found (No. 13, Verhandl. d. physiol. Gesellsch, zu Berlin} that 
the pressure was raised with the widening, and fell with the narrowing, of the 
pupil. Regarding the radius of the corneal curve, the experiments show that 
the mydriatics atropine and cocaine have no influence upon it, in so far as 
may be learned by the ophthalmometer. The myotics eserine, and pilocar- 
pine have the effect of shortening the radius during the myosis by one-tenth 
to two-tenths of a millimetre. 
Subconjunctival Scleral Fistula in Glaucoma. 
M. Motais communicated to the French Ophthalmological Society (Seance 
of May 4-v. Recuil d'ophth., June, 1887) his method of operation in cases of 
hopeless glaucoma. When iridectomies are impossible, or have been proved 
of no avail to lessen the abnormal tension, and when other devices have failed, 
and an enucleation seems inevitable, M. Motais recommends the establishing 
of a fistula. He rotates the globe downward and inward, and plunges a knife 
into the vitreous at a point between the tendons of the superior and external 
rectus. The pressure of the eye prevents the healing of the sclerotic wound, 
but the conjunctiva soon heals, and a subconjunctival fistula is formed, so 
that the intraocular fluids are in communication with the subconjunctival 
pocket. In the fifteen cases so treated in the past three years, there was a 
temporary relief in but two, owing to the failure of the fistula to become per- 
manently established. In the thirteen successful cases the tension has re- 
mained normal, and the pain and other glaucomatous symptoms have not 
returned. 
The Spontaneous Absorption of Senile Cataract. 
Dr. Paul Meyer, in Grafts Archiv, Band xxxiii. Abth. i., reviews the 
literature of the reported cases of spontaneous absorption of senile cataract. 
He finds that many are open to doubt and discussion, but that others, and 
especially the more recent cases, are so carefully observed, and with such 
intelligence, that denial of the fact is no longer possible. There is, of course, 
no question that juvenile cataract is frequently so absorbed, but as to senile 
absorption, conservative thought has heretofore been inclined to doubt either 
the accuracy of the previous diagnosis, or the trustworthiness of the report of 
reinstated vision. In the June number of the American Journal of Ophthal- 
mology, Dr. Charles J. Kipp supplements the meagre literature with another 
case of spontaneous absorption of senile cataract without injury to the cap- 
sule of the lens, and with a restoration of excellent vision. The case is well 
reported, and there seems to be no doubt of the accuracy of the statement. OPHTHALMOLOGY. 
7 
The Relation of Accommodation-strain to Glaucoma and 
Cataract. 
To the ophthalmic surgeon the three ocular affections of exceptional im- 
portance are certainly those mentioned in the above title, and in uniting 
the three in a nexus of cause and effect Dr. W. Schoen (Gr life's Archiv, Band 
xxxiii. Abth. i.) decidedly justifies his happy motto: simplex sigillum veri. 
There can be little doubt that we are only beginning to realize the wide- 
spread and variously injurious effects of eye-strain upon the organism gener- 
ally, and upon the eye in particular. That the accommodation-strain of 
ametropic eyes may produce glaucoma and cataract is the thesis that Dr. 
Schoen renders far more than plausible. In hyperopic, astigmatic, and pres- 
byopic eyes (the ones peculiarly strained) the persistent and irritating strain 
of the ciliary muscle upon its two attachments leads to the accommodative 
excavation on the one side, and to folding of the lens capsule with radial 
opacity on the other. Eighty per cent, of the patients subjected to accommo- 
dation-strain showed the expected accommodative-excavation. Of 95 cases of 
equatorial cataract, 92 showed the excavation, and there were in these 95 cases, 
39 astigmatics, 39 hyperopes, 11 presbyopes, and 4 whose refraction could not 
be determined-nearly or quite 100 per cent, showing uncorrected refractive 
error. There was no case of nuclear opacity without equatorial cataract, and 
90 cases of the latter without the nuclear sclerosis, showing that the equator 
is the starting point of the opacity. Besides refractive errors, leucoma of the 
cornea, extremely fine work, wearing too strong convex glasses, etc., may 
produce the strain. The consequences are, accommodative excavation, cap- 
sular folds, and hypertrophy of capsular epithelial structure, with other sub- 
sidiary injuries, such as overcorrected astigmatism (by the lens), halo, venous 
pulsation, blepharospasm, inflammation, etc. The final results are glaucoma 
simplex, cataract, glaucoma acutum. 
Visual Disturbances Resulting from Cauterization of the 
Nasal Passages. 
In the Archiv fiir Augenheilkunds, xvii-iii., E. Berger describes a case 
believed by him to be unique, where the application of the galvano-cautery to 
the nasal passages produced a decided amblyopia (''everything as if through a 
thick fog"). The subsequent spontaneous recovery was gradual. In the Gen- 
tralblatt fiir praktische Augenheilkxmde for May, 1887, Dr. Zien presents three 
similar cases of ocular troubles. In the first case cauterization of the hyper- 
trophied mucous membrane of the middle turbinated bone of the right side 
20 
was followed by indistinctness of sight of the right eye. Sph. + 4.5 gave V. - 
20 
with the right eye; sph. + 4.00, V. - of the left. There was pulsation of the 
veins of the right papilla; none in the left. There was also slight limitation 
of the right visual field as compared with that of the left. In the second case, 
cauterization of a small tumor in the inner canthus of the left eye was fol- 
lowed by impaired vision and decided hypenemia of the papilla of the left 
eye. In the third case cauterization of the nasal passage, followed by some 
hemorrhage, seemed to reduce the intraocular tension, and to produce pro- 
nounced venous pulsation and papillary hyperaemia. 8 
OPHTHALMOLOGY. 
Epidemic Hemeralopia. 
In the Archiv fur Augenheilkunde of June, 1887, Dr. Theodore Kubei re- 
counts a curious phenomenon occurring in Russia in connection with the 
church fasts before Easter. Meats and even eggs are forbidden, and, as the 
period of fasting lasts for seven weeks, there is a great deal of resultant ill 
nutrition of the body. With other organs, the eye feels the effects of this 
regimen. Out of 19,588 cases of ocular affections in one hospital in St. Peters- 
burg, from 1882 to 1887, there were 320 cases of hemeralopia, nearly every 
patient being of the orthodox faith, and the hemeralopia appearing during the 
fasting season. During the other fasts, extending over much shorter periods 
of time, there were but few cases presented. As concerns the ages, the older 
the person the greater the immunity. Of 200 cases of men there were 61 cases, 
each, from 10 to 20 and from 20 to 30 years of age; 43 from 30 to 40; 18 from 
40 to 50; 12 from 50 to 60; 5 from 60 to 70. Among the number many had 
had the hemeralopia every year from youth. Pregnancy predisposes, but it 
is noteworthy that of the 320 cases 241 were men. Other ocular symptoms 
than the hemeralopia were, of course, frequently present, as epiphora, bleph- 
aritis, conjunctivitis, xerosis, keratitis, etc., but there were no considerable 
ophthalmoscopic changes, and the range of accommodation was not affected. 
The field [?] and the color sense were also normal. Diminished reaction to 
light was the distinguishing symptom. With Forster's photometer 15 cases 
had less than one-half the normal sensitiveness, 9 cases less than one-tenth, 
11 less than one-twentieth, 8 less than one-fiftieth, and seven less than one- 
hundredth. The hemeralopia at once disappears with the resumption of a 
better diet. Other therapeutic measures were ineffectual. The popular re- 
medy is therefore the best, and this is cooked liver, an article of food not held 
to be meat by the rigorous devotees ! 
Miners' Nystagmus. 
In his interesting lecture on this affection {Brit. Med. Journ., July 16,1887) 
C. S. Jeaffreson brings both clinical facts and general logic to show that 
the theory of the local character of the disease advocated by Mr. Simon Snell 
and others is no longer tenable. Many facts go to show that the disease is of 
central origin, and that the general system may largely share in the morbid 
process. Choreic movements of the face and extremities, frontal headache, 
epigastric fluttering, spinal pain, general distress, and even a kind of cardiac 
nystagmus are some of the symptoms noted, and also go far to disprove the 
theory of Dr. Dransart, of Belgium, that the essential feature of the disease 
is a myopathy of the elevator muscles of the globe. The lecturer's theory is 
that the miners' position produces an interference of vascular supply of the 
head generally, but chiefly of the parts supplied by the basilar arteries. 
Hence the ill-nutrition of the visual centres, and the frequent hemianopsia. 
There is probably also an injurious pressure of the tentorium cerebelli upon 
the pons, caused by the miners' position, and the cerebellar function being 
the coordination of muscular action, it also may be interfered with by the 
causes mentioned. DR. A. E. FOOTE 
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9 
Dr. d'Oench's report of 500 enucleations by Dr. Knapp [Archives of Ophth., 
June, 1887) is remarkable for the quantity of clinical material shown. As re- 
gards the causes: 234, or about 45 per cent., were enucleated on account of 
injury, 48 of which were because of a foreign body in the interior. "In 8 of 
them an attempt at removal was made." Tumors ranked next to injuries; 
glioma, 18 cases (11 in males, 6 in females, 1 unknown); sarcoma led to 30 
enucleations; carcinoma to 9; enchondroma to 1. A "slow cyclitic process" 
led to 74 enucleations; phthisical eyeball to 40; painful stump to 8; staphy- 
lomas to 41 (16 anterior, 15 total, 10 ciliary); absolute glaucoma to 8; ossifi- 
cation of the choroid to 6, etc. In answer to the question whether it is safe 
to remove an eye in which panophthalmitis has developed, the statistics given 
show 20 successful cases out of 21 operated upon. 30 cases of death are re- 
ported after enucleation. 
Report on 500 Enucleations of the Eyeball. 
Dr. W. Uhthoff's noteworthy article upon this subject in Grafe's Archiv, 
Band xxxii. Abth. iv., gathers to a focus the clinical and anatomical results 
of the study of 1000 cases of chronic alcoholism. As regards the pathological 
anatomy, the conclusions are based upon the dissection and microscopical 
examination of seven cases, and the lesion is found to consist of a retrobulbar 
optic neuritis with secondary atrophy of the fibres. There is a wedge-shaped 
massing of the nerve fibres about the macula pointing to the central vessels. 
At this point there is an interstitial neuritis and degeneration, which is more 
severe in the retrobulbar portions of the nerve and extending to the cranial 
part of the same. There is a pronounced increase of the intraneural con- 
nective tissue, though healthy nerve fibres are always found running through 
this network, and in the majority of cases the greater part of the fibres main- 
tain their functional activity. From this fact is explained the common 
observation that even with positive ophthamoscopic lesions, vision usually 
remains normal or but slightly impaired. 
The cranial portions of the optic nerve and its branches were not examined, 
but the degenerative changes became less marked the further they were 
followed from the eye. They were generally of a crescentic shape in the 
retrobulbar portions of the nerve. No formation of new vessels was noted. 
The degenerate fibres were those of the inferior and external quadrant of the 
papilla, those, therefore, supplying the upper and inner quadrant of the visual 
field, and were wholly made up of the direct or uncrossed fibres. The macula 
fibres were, if at all, only slightly implicated. Paleness of the temporal half 
of the papilla was a constant, and the most pronounced ophthalmoscopic 
symptom in the cases that were subsequently examined post-mortem. In four 
out of the seven such cases, there had been little or no previous visual dis- 
turbance ; in the others vision was more or less below the normal. Simple 
gray degeneration of the optic nerve was not observed. 
Of the total 1000 cases that came under observation, 139 had pronounced 
temporal paleness of the papilla, and of these, there were 60 instances of 
visual impairment, either existing at the time or that had been previously 
noted. Of these 60, five only had had visual trouble for but two months or 
The Influence of Chronic Alcoholism upon the Eye. 10 
OPHTHALMOLOGY. 
less, whilst with the rest it had existed from six months to fifteen years. In 
26 patients that were certain of a previously existing visual defect, there had 
taken place a reinstatement of visual acuity so that they could read Sn.l, 
though central scotomata for green and red were often found present. Indeed, 
as is well known, color-sense was much more affected than simple light reac- 
tion, green and red sometimes producing no peripheral response. In only 2 
cases was the amblyopia excessive, being the measure in 1 case, and in 
the other an absolute central scotoma with a perimacular zone only slightly 
sensitive to light. There was no case of absolute blindness. In 8 cases the 
atrophic portion of the papilla was only one-fourth, or less, of its surface. In 
every instance (of the 60) the lesions were of both eyes. In the remaining 
cases, 65 of the 139, there was no complaint of amblyopia. 12 had the 
whitened papilla in but one eye; in 15 cases it was only slightly pale. In 10 
cases it was characteristically and decidedly whitened, without producing 
any visual disturbance; in 8 cases tests were impossible, owing to the patient's 
condition, etc. In 4 cases, in addition to the temporal change of color of 
the papilla, there was also paleness of the inner half, though less in degree, 
coexisting twice with, twice without, defective vision. 
In the 1000 cases there were 9 of amblyopia without any ophthalmoscopic 
changes of the papilla, and 53 in which there was a general cloudiness of the 
same. There were 6 cases of hypersemia of the papilla, 7 of retinal hemor- 
rhage, and 60 of pupillary abnormality. Of the latter there were 25 with 
decided differences of pupillary diameter, 10 with destroyed retie x to light, 
and 25 in which it was very slight. Convergence-reaction was almost always 
preserved. There were 22 cases of paralysis and anomalies of the ocular 
muscles, 4 of partial xerosis of the conjunctiva, 29 of congenital anomalies 
of the eye, 15 cataractous lenses, 27 corneal opacities, etc. 
The second and concluding article of Dr. Uhthoff (ArcAw, Band xxxiii. 
Abth. i.) treats of the special aspects of alcohol amblyopia, and of its relations 
with other, and especially with tobacco amblyopias. We at last find some- 
thing authoritative as regards the much-mooted question of the differential 
diagnosis between tobacco and alcohol amblyopia, and of the relative injury 
of the eye by these two agents. But it will be regretted that this definiteness 
is purely negative. Up to this time there has been discovered no reliable 
ophthalmoscopic sign or other symptom enabling one to decide in any given 
case. Neither the living fundus oculi, nor visual tests, nor anatomical dissec- 
tion of the tissues, give any trustworthy answer. The attempt by Poetschke 
to show a difference in form of the central scotoma (paracentral in pure 
tobacco amblyopia, pericentral in the alcohol type) is not found to hold. 
The following, then, remains the symptom-complex either of tobacco or 
alcohol amblyopia, so far as concerns visual disturbances: There is central 
scotoma for red and green in the great majority of cases, and sometimes, also, 
a failure in response to the same colors in the periphery. In a minority of 
cases there is a blue scotoma, but it is less extensive than the red and green 
one. In a very few cases there is an absolute central scotoma-i. e., no re- 
sponse to either color or light, surrounded, first by a zone of blue blindness, 
and other more extended zones of red and green blindness. The periphery 
is always sensitive to white light. Few exceptions were found to these rules. OPHTHALMOLOGY. 
11 
There was complete blindness in no instance, and the greatest amblyopia 
6 
(highly exceptional) was 
Out of 30,000 cases of eye-troubles examined by the author, there were 204 
of retrobulbar optic neuritis; of these 204, there were 64 clearly due to ex- 
cessive use of alcohol, 23 as clearly due to tobacco, and there were 45 that 
were either due to the combined use of the two, or in which it was impossible 
to distinguish between the two agents. 3 cases were caused by diabetes, 
1 by lead, and 2 by carbon disulphide. Of the remaining cases not specifically 
traceable to toxic agents, syphilis and heredity are credited with 7 each; 
multiple sclerosis with 5; menstrual abnormality, 3; pregnancy, 4; loss of 
blood in abortion, 2; vitium cordis and periostitis, each 1; and for 32 cases 
no distinct etiology could be found. Our space will not permit consideration 
of many interesting questions treated, such as the relative frequency of tobacco 
and alcohol amblyopia in different countries, the differential diagnosis between 
these and other toxic and systemic forms of amblyopia, etc. THE MONTHLY PUBLICATION OF 
The American Journal of the Medical Sciences. 
To be issued in 1888 at the beginning of each month. Over 1OO large 
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