101

Original Articles.

pupil was distorted and closed by a dense white membrane, which toward

SYMPATHETIC OPHTHALMITIS, the inner side, fell back a little from the WITH KERATITIS; RECOVERY margin of the iris, indicating that the AFTER EXCISION OF THE EX was absent from its normal position. CITING EYE.* The tension of the globe was below JUN 20 188 dermal. Good central light per18option, but with the field narrow in BY EDWARD JACKSON, OF RA all directions, especially upward. The Sympathetic ophthalmia, like?s history of this eye was that, six years before, it had been struck by a fragment pox, is now more rare than formerly, of steel flying from the edge of a cold because we have for it a reliable prophy-chisel. This was followed by severe inlactic. That cases still occur is due to flammation, which subsided_in few the fact that prophylaxis is sometimes a neglected; and the continued diminu- weeks, and the eye has never been at all tion of their number depends, as with tenderness or other symptom of inflamsore since. It was now free from undue smallpox, upon keeping alive a just ap-mation. The treatment ordered was preciation of the serious character of the disease, and the necessity for prophy- silver nitrate to the palpebral conprophy-applications of a 1 to 120 solution of lactic measures. Though this is sufficient, there are additional reasons for atropia, with dark glasses. junctiva, and recording the following case:

continuance

12.

of the

George M., aged thirty-nine, a carTwo days later the eye became depenter, came to me for inflammation of dark room, atropia solution 1 to 60 was He was confined to a cidedly worse. the left eye, which had commenced two instilled every two hours, a saline caweeks earlier, the eye having before that thartic was given, and he was put on been perfectly well. It presented a the use of mercuric chloride and potasmoderate conjunctivitis, the cornea was sium iodide. I saw him at the end of a slightly hazy throughout, and there was week. There was now general hypea superficial ulcer near its lower margin ræmia of the eyeball. The mass of the and another near the upper outer border. There was a marked pericorneal zone, keratitis punctata and distinct vitreous cornea was clearer, but there was slight broadest opposite the ulcers. The iris seemed normal, the pupil was 5 mm. in opacities; vision, ; great pain and diameter, circular, and immovable (he photophobia. I enucleated the right had been using atropia by the advice of eye, finding it free from evidences of Dr. P. C. Hoskins, of West Chester, recent inflammation; but presenting in Dr. P. C. Hoskins, of West Chester, the ciliary region, below, with whom I continued to see the case) lymph the size of a split pea, in which and subsequent trials showed that 5 mm. was the widest dilatation of his pupil was embedded a splinter of steel 3 mm. that atropia or similar mydriatics would long, and weighing between two and produce. The media back of the cornea three grains. The socket healed norwere normal. The optic disk was very and still five hours later, the left eye mally. At the close of the operation, decidedly reddened, but not swollen or indistinct of outline; the fundus other was decidedly paler than before the wise normal. The patient and Dr. Hos- right was excised. The only change in kins agreed that the eye looked decidedly better than it had a few days

before.

The right eye presented an adherent leucoma near the outer margin of the cornea, which was otherwise clear. The

*Read before the Philadelphia County Medical Society, April 27, 1887.

a

mass of

treatment was the application of a blister to the temple, and the use of a drop of a four per cent. solution of cocaine with each instillation of the atropia solution. Next day the eye was worse but after that it improved.

One week after the excision the general hyperæmia and the photophobia had greatly decreased, but the lower

corneal ulcer was much deeper, with a never happens that foreign bodies, after gray base. The application of cocaine having been long encysted, or an exudaand the internal use of mercuric chlo- tion long since ossified, cause a symparide and potassium iodide was discon- thetic affection of the other eye without tinued. At the end of the second week symptoms of inflammation or irritation the eye had improved in every way. in the eye first attacked." Then it grew worse. The hyperæmia And recently, M. Dianoux, in openand photophobia increased greatly, and ing a discussion of the subject before the very severe pain recurred every after- Société Francaise Francaise d'Ophthalmologie, noon. Leeches applied to the upper lid makes a similar rejection of cases like gave no relief. When I saw him again, this by his definition of the disease. But on the twenty-first day, the corneal ul- this is simply begging the question. cer was deeper than ever with an in- In this case there were neither history, filtrated base, the pupil was contracted, symptoms, nor collateral evidence to inand the surface of the iris exhibited dicate syphilis or rheumatism. It preplastic exudation, vision reduced to sented Eyperæmia of the disk, serous counting fingers at twelve feet, and his iritis, keratitis punctata, vitreous opaciappetite impaired and circulation feeble. ties, plastic iritis, and repeated relapses. He was placed on small doses of mer- What other symptom save the one under curic chloride, with tincture of chloride discussion could have helped to make of iron and quinine; and locally the in- the diagnosis more certain? Nor is this stillations of atropia were again in- case entirely exceptional. Among the creased in frequency to once every two 211 cases collated in the report on hours, hot stupes were applied twice sympathetic ophthalmitis made by its daily, and the conjunctiva was washed committee to the Ophthalmological Soout every hour with a solution of mer-ciety of the United Kingdom, in March curic chloride 1 to 5000. Improvement of last year, 23 cases of this kind are was immediate, and from this time included. Ten of these may be disresteadily progressive. Two weeks later garded because the supposed sympathe corneal ulcer was nearly filled with thetic disease assumed an unusual form, cicatricial tissue, the remainder of the or ran an unusual course; but the recornea clear, iris normal, pupil dilated mainder are not open to this kind of and circular; the vitreous almost clear, criticism. In one the interval was eighand fundus apparently normal. At the teen years, in another fourteen, in anend of six weeks, vision with the cor- other ten, and in another eight. In all recting glass was partly. At eight of these, however, the patient does not weeks after enucleation, vision full, seem to have come under observawith+0.75 spherical lens; and, except tion until many months after the onset the corneal opacity, and a couple of of the sympathetic disease, except the specks on the anterior lens capsule, the last, which was seen some five or six eye seemed normal in every respect. weeks from its beginning. A case, howFive months later it continued so; and ever, coming on four or five years after recently, thirteen months after the the cessation of symptoms in the injured enucleation, I was told he was working at eye, was seen by Nettleship, both at the his trade, and that his eye continued well. time of the original injury, and within In discussing this case, the first ques- five days of the first indication of symtion that arises is, was this opthalmitis pathetic disease. The other cases mostly due to the injury of the other eye, which occurred within two years of the subfor six years had given no evidence of sidence of inflammatory symptoms. active disease? Arlt says: "In order Not only did this committee find that to establish the sympathetic nature of an cases of this kind occur, but they also affection, there should be a continuous, or say: "Though the series is small, we at least a temporary, increase in the in- may safely conclude from it that flammatory or irritative condition of the sympathetic opthalmitis occurring uveal tract of the eye first attacked." after a long interval, and without Again, "According to all experience, it any fresh inflammation of the exciter,

20 XXV

20

XX

is by no means likely to be mild."

It may well be questioned if the corneal ulcer and conjuctivitis had any necessary connection with the sympathetic disease. Yet I find that in three

Society Reports.

THE CLINICAL SOCIETY OF
MARYLAND.

The 191st meeting was called to order by the Vice-President SAMUEL T. Earle, M.D., in the chair.

cases which form the basis of the report STATED MEETING, HELD APRIL 1ST, 1887. mentioned, corneal ulcer was noted, and, in one, conjunctivitis. And at the meeting of the American Ophthalmological Society, in 1880, Dr. D. Webster reported as sympathetic a case of catarrhal conjunctivitis which had occurred in the service of Dr. C. R. Agnew, and stated that Dr. H. D. Noyes had "pre- NOTES FROM FURTHER EXPERIMENTS ON sented a case of sympathetic conjunctivitis to the New York Ophthalmological Society."

Dr. F. Donaldson, Jr., read a paper entitled

THE RECURRENT LARYNGEAL NERVE.

DISCUSSION.

Dr. G. H. Rhoé asked if ether was used in the experiments.

Dr. Danaldson, Jr., replied no. Morphia was the agent employed.

Dr. H. Rolando asked what theory,

The above points bear upon the diagnosis of sympathetic ophthalmitis. Of equal importance are certain questions of treatment. Atropia, I think, saved this eye from the baneful effects of posterior synechiæ. The use of tonics was symptomatic. Mercury was given in- if any, was brought forward to explain terally on the strength of tradition; but the action of the strong and weak curit may be noted that improvement oc- rent on adduction and abduction. curred under its use; and that the re- Dr. Donaldson, Jr., replied that exlapse, running into plastic iritis, hap- periments were being conducted, but pened some days after its administration that no definite conclusions had yet been had been suspended. Its local use sent forth. In reply to Dr. Rolando's caused no notable irritation, and was question as to the relative strength of followed by rapid healing of the corneal the adductor and the abductor muscles, ulcer. But the most important point he said that evidence seemed to be in in regard to treatment is the question of favor of the adductors being the strongremoval of the exciting eye. Here re- er ones.

moval was followed by recovery. In Dr. Clinton McSherry thought that other cases recovery has occurred with- Dr. Donaldson deserved great credit for out removal. Or, again, as in a case re- his work on this subject, and he felt ported here some years ago, by Dr. A. greatly obliged to him for it. He D. Hall, removal has been followed by thought, though, the doctor laid too very great permanent damage or com- much stress on Hooper's statement replete loss. Referring again to the re-garding consciousness. He knew from port above quoted, we find that of its a clinical standpoint, standpoint, only, that cases the exciter was removed early in when in a state of unconsciousness, the 64, of which 8 were lost; and it was re- abductors are in abeyance. He then moved very late or not at all in 65, of enumerated the nervous supply of the which 26 were lost. From their inves- larynx and quoted Claude Bernard and tigations that committee draws the very others to show that if the spinal accesmoderate conclusion, "that whether sory nerve be torn from the medulla early removal of the exciting eye be oblongata that adduction is lost and all positively useful in staying the disease of the motor branches are injured. They or no, it is certainly not injurious, as no all have to be affected to effect respiraless an authority than Mauthner has as- tion. Therefore, when there is much serted that it is when the sympathetic dis-anesthesia great stimulus is required, ease is of the 'serous' form.” Less anæsthesia, less stimulus.

ENEMATA,

Dr. J. H. Branham said that Gray APPARATUS FOR ADMINISTERING GASEOUS made the statement that the superior laryngeal nerve aided in the action of the larynx.

Dr. Donaldson, Jr., replied that when operating he always divides the cricothyroid muscle and fails to get the slight action of the cords that he used to before he practiced it.

Dr. Wm. Pawson Chunn read the next paper, entitled

A CASE OF CANCER OF THE VAGINA.

DISCUSSION.

for the treatment of phthisis. As such favorable reports had come from its use, he hoped that the members of the Society would test its merits. The apparatus consisted of a rubber bag filled with carbon-dioxide, this was connected by a rubber tube with a bottle containing three pints of water, in which there is placed 10 grains each of the sodium. chloride and sodium sulphide. The corbon-dioxide is made to pass through this, thus producing the gaseous compound to be used. He said that reports on it so far claimed that it had decided Dr. G. H. Rhoé said that as he was influence on the cough and expectoraresponsible for the statistics of Dr. tion and it seemed to arrest suppuration. Morris, quoted by Dr. Chunn, he wanted It does not destroy bacilli. The enema to say that since they were compiled he should be administered two or three times had found that there were 12 other in 24 hours, and care should be taken cases on record, including Dr. Chunn's not to give an over dose. Osler reportcase, making 52 cases in all. He had ed a case where a patient came near seen one case in a girl about 25 years of dying from an over dose of sulphuretted age. The vaginal wall was infiltrated hydrogen. and it caused great pain. The mass was scraped out. It recurred in a short time and the patient died from the recurrence. Microscopical examination showed it to be an epithelioma. The rarity of glands in the vagina, he thought, accounted for the rarity of cancer there. The seat of the disease is nearly always in the posterior wall. Cancer of the vulva cannot be explained in the same way, though glands are present there.

Dr. J. E. Michael thought there was a lack of fullness in statistics regarding cancer of the vulva. He cited three cases which had occurred in his experience, none of which were included in the statistics above given.

DISCUSSION.

Dr. McSherry only knew of one case where it had been tried in Baltimore. His friend, Dr. H. M. Wilson, Jr., had tried it with one case and reported good results from its use.

Dr. 1. E. Atkinson said that the subject seemed so attractive as to make us almost prejudiced in its favor. This is not the first cure we have had for consumption. Only a few years ago benz. of soda was claimed to cure the disease. The experiments now being done offer improvement from the fact that the patients have the stimulus of new treatment, are surrounded by good hygiene, Dr. Rhoé replied that probably Dr. and have the spring of the year in their Michael's experience had been an un- favor. Up to this time the results are usual one. He quoted numerous no better than the benz. of soda. authors to show that the proportion of does not feel sanguine as to the ultimate cases seen by them was very small com- results. It seems to prevent pus formapared with their experience. He had tion, and prevent pyæmic infection and seen two cases himself, one of which for that reason ought to be used. died, and in the other the growth recurred on the pubis.

Dr. Frank Donaldson, Sr., exhibited an

He

Dr. Clinton McSherry had once read of a celebrated sulphur factory in Germany where the proprietor said no case of phthisis had ever been there. He