to the left as he could and again measured by the If I sum up all the clinical facts, I should say light reflex on its cornea the position of the glass evisceration has nothing to show in its favor, while eye. As the artificial eye follows as well as it can it compares decidedly unfavorably with enucleation the rotations of the natural eye, I believe these meas¬ in the frequent violent reaction and slow recovery, urements thus obtained represent the extreme limits and therefore does not deserve to take the place of of motion the artificial eye was capable of in every enucleation. case. The results of my tests are given in the fol¬ lowing instructive table : FERIMETEIC MEASUREMENTS OP THE LATERAL MOVEMENTS OF ARTIFICIAL EYES. PANOPHTHALMITIS—FATAL MENINGITIS FOLLOWING ENUCLEATION OF WHEN OPERA- ¡DEGREES OF ROTATION. PATIENT'S AGE. TION WAS PER- I- THE EYE. FORMED. INWARD. OUTWARD. Read in the Section on Ophthalmology at the Forty-fourth Annual

L. S.,. 45 Enucleation . 10 yeai s ago. 15 25 Meeting of the American Medical Association. F. . 21 Evisceration. 3 months - S., . . ago. 20

. 21 1 15 15 BY A.C.,.. . Enucleation year ago. S. D. RISLEY, M.D. Mrs. 4 months 15 25 M., . . ago. ATTENDING SURGEON AT THE WILLS EYE LECTURER ON OPH¬ Mrs. .30|Evisceration months 20 25 HOSPITAL; E., . . .50¡Enucleation a% ago.¡ THALMOLOGY IN THE UNIVERSITY OF PENNSYLVANIA ; PROFESSOR G. . 24¡Enucleation 1 month 20 L., . . . ago. OF OPHTHALMOLOGY' IN THE PHILADELPHIA POLICLINIC M. 20 10 J.,.42¡Atrophic. Eye. years ago. 15 AND COLLEGE FOR GRADUATES IN MEDICINE, L. H.,. 22 Enucleation 6 weeks ago. 15 20 Mrs. 10 15 PHILADELPHIA. L.,.20|Atrophic. . . Eye. years ago. John M., age 47, but appearing at least 67, presented him¬ These measurements show there is absolutely no self at the Wills Eye Hospital Dec. 12, 1892, bearing a letter difference in the extent of the lateral movements of from his physician, Dr. 1). T. Laini of Media, Penn., under whose care he has been for a severe attack of iritis in the the worn on an evisceration and glass eye, stump, left eye. The disease proving rebellious, he was advised to worn on an in case that enucleation stump ; either seek hospital treatment. He was in feeble health, suffering the inward movements (adduction) varied between from severe pain in the eyeball and with violent left hemi- 15 and 20 degrees and the outward movements (ab¬ crania; vision was reduced to quantitative perception of between 15 and 25 These results light. There was deep ciliary injection, small pupil, slight duction) degrees. haze of the cornea and the remnant of a blood clot was still were not surprising to me ; for though I have heard lying in the lower angle of the anterior chamber. There so much about the larger, better stumps gained by were numerous posterior synechia and dilated blood vessels evisceration I have found these stumps shrink could be seen coursing over the surface of the iris. Ten¬ sion was normal the anterior chamber shallow. He was so much that three months after the but away operations placed in bed, blood extracted from the left temple and no of what we there is more them left than find after calomel and soda purge given, eserin being instilled locally. a suppuration of the globe, and that it is difficult to He experienced very prompt relief and one week later tell by the stump whether enucleation or eviscera¬ vision was somewhat improved, the blood clot absorbed, and tion has been This observation I have the ciliary injection less marked but no view of the fundus performed. could be obtained. There was simply a gray-red reflex from made not in own but also in only my .cases eyes the pupil. "When-seen two days later, there was a fresh red which had been eviscerated by other surgeons. blood clot lying in the pupil and on the upper and inner But even granting a larger permanent stump to the pupillary rim of the iris and a large blood vessel could be seen it was I still maintain the artificial eye does entering from which the blood apparently issuing. evisceration, As yet there was no pain, but the hemorrhage was soon fol¬ not gain any material advantage by it. The largest lowed by decided increase of tension and the ball became and iDest movable stumps, superior to any furnished tender to pressure and with it his headache returned. He by evisceration, undoubtedly are those slightly lost appetite, became sleepless and the general health with well but rapidly declined. Under a careful regimen, however, the atrophie eyeballs preserved vitreous, health the blood clot once more absorbed and loss of the cornea and iris the result of improved, complete (as the eye became quiet but showed a tendency to frequent sloughing or surgical operation). Glass eyes can be recurrences of increased tension and ciliary redness. Dur¬ worn over such but do not ing one of the intervals of freedom from acute symptoms a atrophie globes, they iris show In my table there are broad iridectomy was made upward. The was found any superior mobility. friable ; the operation was smooth and successful, but bleed¬ two such cases and we see that the one shows an ; ing was profuse and the eye was bandaged with the an¬ unusually limited movement; and the other (the terior chamber filled with blood. There was no undue last in the list) shows no better adduction (15 degrees ) reaction and the blood clot slowly absorbed, but the wound In a than we get by enucleation or evisceration cases and refused to heal. ten days there was pouting black best 5 mass lying in the wound, but slightly elevated above the exceeds their abduction by degrees only. corneal limbus, and occupying the entire line of incision. These atrophie eyeballs had an excellent rangé of The operation was done under antiseptic precaution and lateral rotation ; and if the artificial eye could be the eye was subsequently kept bandaged, being thoroughly the it washed with bichlorid solution at each dressing and dusted ___cfij»ented onto atropic globe would, of course, of follow the rotations of the and the cosmetic with iodoform. There were no visible signs suppuration latter, but his health steadily failed, his hands were hot and there effect would be perfect, because the artificial cornea was a hectic flush on his ckeeks, but only slight if any rise would describe lateral rotations as perfectly as the in his temperature. The eyeball was soft ; there was no of no was natural cornea. But as the artificial is not fas¬ dread light and pain or headache. He greatly eye in was to tened to latter does not depressed spirts, felt that he going die and begged the stump, the impart its to allowed to return to his home. The was then the be eye motions to the super-imposed glass shell and enucleated on Jan. 25. 1893, and found filled with pus. The axis of rotation of the glass eye lies much in front of nerve was severed well back, the orbit thoroughly drenched with the When, therefore, the eye seems to with bichlorid of mercury solution, well dusted iodo¬ stump. glass form and for twelve hours. He made a rapid and turn to the or its cornea shows little bandaged right left, very favorable recovery without suppuration of the stump. The real lateral movement, its principal motion being a infiltration of the tissues of the orbit absorbed rather more rotation on its vertical axis so that its center faces slowly than usual but his health rapidly improved so that he to the or left. On this account the movements on the fourteenth day, February 7, was discharged from right the with no of an artificial will be confined to narrow hospital apparently well, certainly symptoms eye always to awaken apprehension regarding his future. One week limits, whether the glass shell be inserted after enu¬ later, February 15, twenty-one days after the excision of the cleation or evisceration. eyeball, he sent for his physician, Dr. Lainé, but in his absence

Downloaded From: by a University of Missouri - Columbia User on 01/06/2018 was seen by Dr. J. H. Fronfield, to whom I am indebted for fatal meningitis was infectious and that it was set the following history: He complained only of weakness up germs the cut tissues and and for the was normal and by conveyed through disgust food, temperature vessels the membranes and ven¬ throughout the subsequent history, remained either normal open in the orbit to or sub-normal; although taken twice daily at no time was ous sinuses of the brain. It would be a comforting there any rise. There was at this time some suppuration of view of the case could we feel assured that the first the stump, he was anemic, the tongue pale, large, flabby proposition was a correct solution of the unfortunate and indented. He was not considered seriously ill. Calomel and soda were to move the bowels and he received sequel. prescribed between elixir of iron, quinin and strychnia as a tonic. The very close relation that exists the eye¬ February 18, 10 a.m. Bowels have been freely moved but ball and the intracranial mass would lead us to antici¬ can not take the tonic. Urine free from albumen. 7 p.m. pate serious to life from its excision. Such weaker is sure he will die. danger Decidedly ; very melancholy ; would moreover be No pain in the eye ; pupil reacts promptly. expectation greatly strengthened the with which we observe ocular February 19. In bed ; very drowsy ; is aroused with much by frequency difficulty ; rapid pulse; reflexes are normal. The right eye disease as secondary to disease of the brain and its shows no muscular deviation ; there is no ptosis or dread of membranes. But however we may wit¬ There is no increased of the and frequently light. suppuration stump ness ocular disturbances as to intracranial no swelling of the orbital tissues; respiration very irregu¬ secondary lar, at times normal and then extremely rapid, subsiding inflammations, experience shows that the reverse is once more to normal. No tenderness of the spine ; hearing extremely rare, except in the case of malignant good ; no pain and no vomiting. Obstinate constipation. disease. Furthermore it has been shown by ample February 20. Only partially aroused and that with great that excision of the is •difficulty and lapses immediately into unconsciousness. experience eyeball fraught The head is drawn backward. From this time he remained with but little danger to the patient. That it is not in a state of profound corna with irregular breathing and entirely devoid of danger to life, however, is evi¬ the backward traction of the head developed into marked denced in the fact that there have been forty-six re¬ man heels and head tonic opisthotonos, the resting upon his cases of which until the 26th when he died. ported meningitis, forty-two of proved fatal. Four of these, all fatal, should possibly be ex¬ No autopsy could be secured. At my request Drs. cluded as having been subject to malignant disease. G. C. Eilet and W. R. Parker, resident surgeons at These cases have been again and again tabulated the Wills Eye Hospital, made for me a careful ex¬ and reviewed, so that it is not necessary for me to go amination of the excised ball, and I append their over this well-known field again, except to add to report : "In the region of the corneal wound the the number already known. Individual cases were epithelium has proliferated considerably and the collected by Nettleship to the number of thirty-four superficial layers of the cornea are thickly infiltrated in 1886, ( Transactions Ophthalmological Society with round cells. There is no union of the lips of United Kingdom 1886) including a case occurring the wound, the space between them being occupied in his own hands at the Moorfields Hospital, and by iris tissue covered with organizing inflammatory which he made the basis of an admirable review of products. The iris is pushed forward, adherent to the subject. In the discussion which followed, the cornea by heavy organizing bands in the neigh¬ McHardy reported two cases of fatal meningitis fol¬ borhood of the wound, the anterior chamber being lowing the removal of the eyeball, and a third where reduced to a slit. The portion of the iris which is the meningitis and death followed suppurative pan- not prolapsed is covered with a layer of lymph and ophthalmitis, the ball having been freely opened but pus, and where the pupillary space is visible it is not removed. Dr. Joseph A. Andrews, in the New filled with a heavy membrane continuous with that York Medical Journal, Dec. 29, 1888, has again tabu¬ in the iris. This is continued backward on the under lated the cases, omitting the four non-fatal cases of surface of the iris, filling the posterior chamber, and Nettleship and adding others finding thirty six fatal passing with a mass of pus which fills the vitreous cases. My own case here reported, Mr. McHardy's chamber. The ciliary body seems but little affected, two cases and three others occurring in the practice but the retina and choroid are thickly infiltrated of my colleagues in Philadelphia but not heretofore with pus as far anteriorly as they can be identified. reported make a total of forty-six cases of meningi¬ The inner layers of the sclerotic are also attacked. tis following enucleation. Further back, the retina is lost from the specimen. H. D. Noyes, M. D., has again briefly reviewed the Toward the posterior part of the eye the choroid is subject in the Transactions American Ophthalmologi¬ represented by a thick layer of pus thrown into folds, cal Society for 18b8-89, with the intention of study¬ and stellate pigment cells scattered through it serv¬ ing the dangers attending excision in suppurative ing to identify it as choroid, none of the vascular panophthalmitis. He there collects 3,742 enucle- structures being visible. The optic nerve is in a ations at the various clinics with but one death, and state of inflammation, the round celled infiltration suggests that the deaths which have occurred are being pronounced as far back as the specimen shows. probably about one for 4,000 enucleations. There A few lymph corpuscles are present in the nerve. have, however, been 1,131 enucleations at the Wills There are no changes in its vessels." Hospital in Philadelphia in twenty years, eighty-five Dr. Fronfield's careful report leaves no room for of which are recorded as for suppurative panophthal¬ question but that this man's fatal illness was due to mitis, and one death here reported. Three of my cerebro-spinal meningitis. The consideration of colleagues report each one case of fatal meningitis great interest to the ophthalmic surgeon is its pos¬ as having occurred in their practice there during the sible relation to his suppurative panophthalmitis years mentioned, but no details of them could be and the enucleation of the eyeball. The exact char¬ found on the hospital records by the House Surgeon, acter of the intracranial lesion must, in the absence Dr. Parker who kindly went over the books for me. of an autopsy, remain in doubt. This would make a total of 4,873 enucleations and Two possible explanations are at hand : first, that five deaths if these three cases and my own are the meningitis was a mere coincidence, having no included. On the other hand, there has been no relation to the ocular conditions ; the other, that the case of meningitis at the large clinical service at the

Downloaded From: by a University of Missouri - Columbia User on 01/06/2018 University Hospital since it was established. In any It must be remembered, however, on the other hand case it is plain from these figures that the operation that all the conditions were here present which have for excision of the eyeball is more free from danger in these cases seemed to favor the production of this than one would expect, having in view its critical disease. There was the inflamed and suppurating anatomical relations. ball, and more than all a ball which had been The fear which is entertained regarding the danger recently opened, a condition, as has already been from the excision of suppurating balls, moreover, pointed out, which was present in nearly all of the does not seem to find support by reviewing the testi¬ reported cases where it was mentioned at all. mony furnished by the reported cases, since only half of the cases, where the point is mentioned were suppurating eyes. This statement, it is true, loses INTRA-OCULAR INJECTIONS OF SOLUTIONS- some of its force by the fact that the teaching of von OF VARIOUS ANTISEPTIC SUBSTANCES; Graefe as to the to be from danger apprehended AN EXPERIMENTAL INQUIRY. excising suppurating eyes has doubtless had a Read before the Section on Ophthalmology, at the Forty-fourth Annual restraining influence over the practice of surgeons in Meeting of the American Medical Association. such cases. The fact that the excised had eye been BY G. E. DE SCHWEINTTZ, M.D. opened, either by accident, operation or inflamma¬ CLINICAL PROFESSOR OF OPHTHALMOLOGY, JEFFERSON MEDICAL COLLEGE; as out seems to be of PROFESSOR OF OPHTHALMOLOGY, PHILADELPHIA POLICLINIC ; tion, pointed by Nettleship, OPHTHALMIC SURGEON, PHILADELPHIA AND CHILDREN'S more significance than the presence of visible pus, HOSPITALS. for in a of all the cases where the large majority A number of researches have been published con¬ history is sufficiently complete to determine the cerning the effect of the introduction of various sub¬ point, the eyes had at some time been opened. stances, solid and liquid, into the vitreous chamber. In the of own case study my here reported, in the These may be summariztd as follows: light of the published experiences one finds much 1. The introduction into the vitreous of In the the foreign confusing testimony. first place length bodies of wire, lead, or of irritat¬ of time which intervened between the excision and (pieces glass, etc.), ing liquids (croton oil, tincture of iodin, etc) ; 2, the the onset of the meningitis favors the view which injection of sterilized blood into the vitreous humor; would regard the meningitis as a coincidence. The 3, intra-ocular injections of various antiseptic longest time heretofore reported is eight days while liquids.1 in mine it was twenty-one days. The rapid recovery, Researches to the first class, from the without orbital with his belonging inflammation, together time of the publication of Pagenstecher's essay on great improvement in general health immediately the of the vitreous2 to Leber's superb- after the all seem to pathology operation point strongly against work,3 are chiefly concerned with the behavior of the any causal relationship between the enucleation and vitreous towards these foreign substances, and with the meningitis. the complex problems which surround the pathology A very important inquiry at this point is as to the of inflammation. Researches of the second class, possible secondary nature of the eye disease. In which date from the imperfect experiments of reviewing the man's history it now seems possible, Legros,4 to the thorough investigation of the subject if not probable, that his severe headache and im¬ of blood injections into the vitreous by Pröbsting,5 paired health may have been due to a low grade of have been undertaken to the of and I was study deportment meningitis, that at fault in regarding the the retina under these circumstances, and to add to head as due to his severe symptoms entirely eye our knowledge of the mechanism of retinal detach¬ disease. Although I did not suspect any cerebral ment and the production of proliferating retinitis. complication, nevertheless the treatment directed for Researches of the third class have been conducted blood his relief viz. :—local letting, the calomel and to test the value of the soda iod. et. chiefly therapeutic injection purge, potas, bromid, and later mercu¬ of fluids into the vitreous of an were antiseptic directly rial inunctions well devised to relieve a men¬ inflamed for one from had been with eye ; example, suffering hya- ingitis they directed that purpose in or from or to view. afforded litis, sympathetic ophthalmitis, try Certainly they him prompt relief their in an inflammation of this from his severe both in and efficacy preventing very pain head eye. character after the eye has been exposed to the The absence of orbital symptoms at the onset of influences likely to produce it. the meningitic symptoms affords but little comfort, Abadie,6 in 1890, suggested the propriety of inject¬ since in four of the cases as far as I can only find 2 of a solution of sublimate, 1 to 1000, into "was there inflammation or irritation ing drops any of the a wounded eye which has caused orbital tissues while in it is sympathetic oph¬ present, many more dis¬ thalmitis of the other eye, which should also be stated that no connection could tinctly be traced. treated with a similar injection directly into the The inflammation of the optic nerve and its sheaths vitreous humor. According to him, these injections is noted in four cases, three of which are the same were of use in checking and the inflam¬ as noted with orbital inflammation. The of ameliorating report matory process. Subsequently he published7 three Drs. Eilet and Parker shows that in my case also the nerve was in a state of active as 1 Experiments to determine the effects of injections into the anterior optic inflammation chamber, for example those performed by Nuel (Revue G\l=e'\n\l=e'\raled'Oph- far back as the specimen extended. Whether this thalmologie, T. viii, 1889, p. 343) do not belong to the present classifica- had invaded the tion. As Dr. Berry pointed out. injections into the anterior chamber process eye from within the cranium and into the vitreous can scarcely be compared. or had invaded the brain from the must forever 2 Archives of Ophthalmology, Vol. I, p. 500. eye 3 Die Enstehung der Entz\l=u"\ndungunddie Wirkung der Entz\l=u"\ndunger- remain in doubt. I am free to say that I incline to regenden Sch\l=a"\dlichkeiten. Leipzig, 1891, p. 177 et seq. the for the reason besides 4 Journal de la Anatomie et de la Physiologie. 1873. first, those already stated 5 Archiv f. Ophthalmologie. iBd. xxxviii, Abt. III, 1892, p. 114. that the which ushered in the fatal illness 6 Pathog\l=e'\nieet nouveau Traitement de l'Ophthalmie Sympathet- symptoms ique. Annales d'Oculistique, Vol. ciii, 1890. p. 183. were the same as those I had observed in the hos¬ 7 Nouveaux cas d'Ophthalmie Sympathique, Gu\l=e'\ripar les Injec- before the excision. tions intra-oculaires de Sublim\l=e'\.Annales d'Oculistique, Vol. civ, 1890, pital p. 229.

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