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A CLINICAL LECTURE DELIVERED BEFORE THE CLASS OF THE POST- GRADUATE MEDICAL SCHOOL, MARCH 34, 1897. By CASKY a. wood, M.D., Professor of Ophthalmology in the Chicago Post-Graduate Medical School ; Fellow of the Chicago Acaden^y of Medicine. Illustrated with stereopticon views. [Reprinted from International Clinics, Vol. II., Seventh Series.] f 1 I I rriBiiTiiMipriBn ._ 1 11 The Relations of Optic Nerve Atrophy to General Medicine. * * w.H A CLINICAL LECTURE DELIVERED BEFORE THE CLASS OF THE POST- GRADUATE MEDICAL SCHOOL, MARCH 24, 1897. By CASEY A. WOOD, M.D., Professor of Ophthalmology in the Chicago Post-Graduate Medical School ; Fellow of the Chicago Academy of Medicine. Illustrated with stereopticon views. [Reprinted krom International Clinics, Vol. II., Seventh Series.] THE RELATIONS OF OPTIC NERVE ATROPHY TO GENERAL MEDICINE. BY CASEY A. WOOD, M.D., . 1 ^M 1 .., . Vfwt Clnuluato MofUoul School ; Fdlow P„r..„ „f op''*';"'";"";;;^^.^ 1 " "1 »'ti. .w-.pt,.o„ view.. of the Chicago Academy ot .Muluiiii. T .mrs WD GEXTT.EMKN,^Tt vlll, of course, l.e impossible for Ladh^s and I..EN ..ourseof an evoning ... 1' ■ 1* .; i...ii... Al'itiv cross aiioiiitiinT ui tue tissue uiMuimii „.,. know tliero s somcl urns an structure «e are Imuiliur witli. Hn >, «t l-n< « ""-'•^ absenee of the optie oonuuissure, ami that s«t>ons <■< the optu .. . c t fl o„„.,..nhall.v dolVvtive, as seen in crtain eyes «-'- "'^ ante and »o»( .«o,to.. We may postulate an al,s..nec ol ^•^■•^"■' (^ ; nllefinod) fiUres in «,n,eui.al color.l.lind,u.ss, and ""^^^^ Lrtain that in those individuals vhose visual nu.n.orxs » " -W«' « there e..is.s a eorrespou.liu,. detieieney ol-c.nu.K-tn,, In.ks M^c.n the visual and intolleetl.al eeutres. But. apart from these c«,s,deratu.ns the distril,u,i„n of the llbres and tissues that eon.pose .lie een , 1 orpms tliat tal'h l'«'«il'ty M-U8 proved to be its true situation in at leastoneca.se rei>ortea by Hen- 178 ^ RELATIONS OF OITIC NEIIVK ATROPHY TO GENEKAL MEDICINE. 179 schen. A man liavinj^ u well-marked left liDmonvmous hemianopsia was fouiul, j)ost mortem, with a eorti<'al Hofteniufji; extending seven millimetres from the posterior end of and along both sides of the right Flos. 1 and 2. IROMTAt lofj 81 TlMPOSAk LO»t r^fjf'^^j, !^'^i The calcarine fissure in the occipital h)be and its related areas. calcaritK^ fissure, a few niiliiinetres on the cinieus, downward on the lingual lobe, and forward into the hippocampal lobe. Previons expe- riences enul)le lymph space, but that the septic character of the effusion (de Wecker) has much to do with it. Fiu. 5. I Enlarged view of n lu>ri/"iitiU -ccti.iu ui' tlie ui-tic iicivo uiitnitu'i; into the eyeball. The central artery and vein enter the nerve-substanee about eight millinu'trcs behind the eyeball. The tral^'cnhe or connective-tissue framework of the oi)tic nerve is of considerable importance because it is that structure which, as in diseases like cirrhosis of the liver, kid- ' Most lit' thf mits usi'1.1 in tlii-; Ici'turc iiiv tiikfii from tho (tnicfi'-Saeiiiiscli Ilatidhuch dor ije.s. Au-ri'iiin'ilkuiul" iiiul the di' WtvluT-Laiidult Tniito Coiuplet -biindle8 and tJiolr relation to the conneo tivt'-lissue I'raniewurli. Fio. 7. Showing the distribution of the optic fibres in tlie right retina ; /', fovea centralis. (Kniei.) It has been earofully estimated that there are five millions of nerve- fibres in the optiei s, ai:d that at least onc-foiirth (»f them is snpplie ,> RELATIONS OF OlTlO NEUVK ATUOl'IIY TO OKNEKAL MEDICINE. 183 To ubtiiin a {jropcr cotu'cptidn of the rnniin«atinns of the <)i»tio oon- noctions it must Ik; rcmfmlKictl that the ('((mmissmcH of Giulckii and Mi'ViHTt (diitUMt the corticiil ccntn's dim-tly, that optic fil)irH aro siip- plicd to the ('('Pel i^Umii ami pons, aii nuclei of tlu! third nerve in tiie afpiinluct of Sylvius. This last fact explains how we obtain the classic! Hymptom-coniplex known as the Ar^'yll-liobcrtson pupil, and how we oflen have paral- ysis of the extrinsi«! «)cular muscles and optic nerve atrophy as eonunon signs (»f the 80-callci gummom in 1, other specific lesions in 10. — •^*« 184 INTEllNATIONAL CLINICS. Apart from these siicoific changes, wcll-ostahlisluxl cases of optic nerve atroj)hy are facial erysipehis, fevers, hemonhages of all kinds, persistent anjoniia, the various forms of Uriiilit's diseas(>, dialx'tes, embolism and thrombosis of the arterial supply, hysteria, typhoid, measles and scarlatina, toxic a<;ents, menstrual disturbances, arterio- sclerosis, and la grippe. Quite a large piM'centage of atrophic changes must be placed in tiie "unknown" colunm. T'le optic nerve is the victim of many and varied morbiHc influences whose exact character is as yet ill defin«l. Many a person, apparently lu-aithy, has become blind jis a result of a progressive disease of the 0}>tic nerve when it has been impossible, even with the aid of a post-mortem examination, to discover any reason why the atrophy should have st-t in. The microscopical changes in the nerve itself vary somewhat in the different forms of atroj^hy. The fibres supplied to the ])eriphery of the re( ; those that usually sutler first, and the evidence of this early eht, )est supplied by tlie perimeter. Fig. 8. The limits (from without inward) of the nnrnial nel more generally used than it is, especially by the general piaetitionei", iijr whom, to my mind, it is particularly adapted. I would strongly advi.'^e those of you who desire to have a valuable aid in the diagnosis of optic nerve atrophy — par- ticularly if you are not expert in the u.se of the ophtlialmoscoiK! — to invest in a good perimeter, so that you may map out the field of vi,si(»n, for white as well as for colors, in all cases where you suspect h'sions, central or peripheral, of the optie nerve. I shall have occasion to project ]>ieturcs of a number of defective «1 RELATION'S OF OITIC NEHVE ATROl'HY TO GENERAL MEDICINE. 185 fields upon the scmm, and yon will readily understand the diagnostic value they jwssess. A supreme advantajjie that the perimeter exhibits for tlie busy practitioner is that it recpiires no particular skill in its emi>loymeut. It is a purely mechanical device, and almost any one, alter a few lessons, may Icaru how to use it. Indeetl, it is mainly for the purpose of insisting upon tlie p;reat value of the perimeter and of an examination of the visual fields as an aid to diagnosis in general praciice tiiut this lecture has been prepared. The perimeter chart of a visual lleM for Uie snn.e colors, showing the contractions often seen in atrophy of the optic nervo. There are numerous good perimeters, obtainable from any optician. I hai.pcn to prefer Mcllardy's, and now show his instrument, as well as a .-hart of the normal field of vision, tbr small white and colored objects. 11- The hi^tologv of optic nerve atrophy may be summed up by saying that the true nerv.ms tissue is either absolutely destroywl (by being converted into fattv irranulcs or myeloid corpuscles), while the tra- bccula) either undcVgo atrophic' changes, or, as in the cirrhotic forms r(>ferr<'rvous tissues are reduc(>d i„ size and numb(>r, the calibre of the opticus m-tually decreases m size, an,l the blood-vessels disappear. In tlie interstitial or cirrhotic fi.rm tlie nervc-iibrcs are S(,ueeml together by the thickened trabeciihe, but the in.'reasc in the number or si/e of the trabecuhir nude, fibres, and blood-vessels neutralizes this partial atrophy of the conducting 18G INTERNATIONA L CLINICS. REL. media SO that the opticus in chronic interstitial neuritis (seen in tobaeco intoxication, for exainpU^) presents about the same «>xternal apj)earanee as the normal nerve. In true atmphy the intra-vaginal lymph-space, FiQ. 10. Method of mnppintr out tln' tiuld of vision. n<>rv awa^ just shown, often (nilarL^cs thronirh shrinkatie of the mass of the nerve and can be very readily traced into the arachnoid sjiaces. Sometimes only a jxtrtion of the nerve is allected, while the re- mainder continues to be sound and well nourished ibr vears. This is a common experience, an(l is reflected in the j)erimeter charts. Again, one may have scatternl uerve-binidli^s that have stdlered (as in tobacco and alcohol amblyopia) |»artial or total atrophy, and these, too, will be detected by a cart^rul examination of the visual field. Tlie opIdlKi/iiKm'opt is, perhaps, the most eftieient agent we possess for the detection of tlios(> changes in th" optic nerve that show them- selves in the nerve-luiid and n tin:i, but it not iufre(juentlv hajiixns that the jtapilla, retinal vessels, and the n tiua itself appear with the mirror to be ai)Soliitely normal. Sooner or later, however, the organic lesions in the opticus fibres, as well as occasionally those changes beuin- ning in the visual centres, show themselves witiiin the eyeball. The nerve-head becomes i)aler, the vascular supply diminishes, and the vessels decrease in size The papilla loses its semi-transi>arent, rosy apj)earance, bevomes blurred in outline, and presents, from time to time, every shade of col.. r from dirtv n.l to blui-,h white. The lamina cribrosa nmy be seen more plainly than in the normal condition of the 4 » a 1 RELATIONS OF OPTIC NERVE ATROPHY TO GKNERAL ^MEDICINE. 187 nerve, chiefly because the superimposed nerve-elements have wasted II way. Fios. n and 12. ^'''S'i^^^!M>^iJ:£s::%:^^'&^3Sii'^ Cso;v H'utiuiis oi' putily atifi'liicd iiervea. 188 INTERNATIONAL (LrNRS. Tlio purclv siil)jc('tivc synij^toins of optic atrophy are of little value in the diagiuisis of this discaso, although misty ami iniporfect central vision (not improved 1)\ gUisscs), night blindness, aiul inability to see at the side or in any part of the field shi>uld make one snspec^t this disease. The patient aiVeet^'d by most forms of optic atrophy will not be able to read BJerriun's test-types (gray or gray-brown letters on j>apcr of the same hue but lighter tint) as well as he does the ordinary black letters oii white })aj)er, lie may have a liiirly g(tod iield for white, bnt the color areas will be decidiiUv diminislntl. I do not know of any nu»re eU'eetive method of impressing npon your minds this brief sketch of optic atroj>hy in its relation to genend diseases than to read yon a few illustrative histories. Case 1. — ^liss W., aged iii'tv vears. Her health had alwavs \)wi\ good until an attack of le years. Four years afterwards there were total failure of near vision, oct-asional ocular i mwmmm mm)»0M)i0if" 1 RKT.ATIONS OF OPTIC NERVE ATUOPHY TO GENERAL MEDICINE. 189 pains, " fogjry" sif!;ht, color-blindness, and night-hlindness. Vision in the loft evc'^is now reduced to -4^^ and Jaeger XVI. V. U. finger- counting 'at 10 feet, eccentrically. The field has become much im- provwl und.-r large doses of potassic iodide and strychnine given hypo- dcrmically. (Figs. 14, 15, and IG.) Flo. 11. Fleldfor white, colors (Inubtful. V. Angers at three feet, uu Jiieger. September 28. Field for white , red color-blind for green. October 15. FlQ. 16. Field for white Atrophia nervl optlrl a XuL V. L. = , :«. Jaeger XVI. : -'-^''l"-' ^^^J*"; ^J^J^, • _ .....iK, . ,..>!. ,r.m.r(..>iiiu)ii lost. HO Held lor grceii or rn Atrophia nervl optlrl a I.k;.- V. U = , .9. Jaeger a> .. . . »- ,T ":::" .,, ,^,1 De- red --- -. V.K. ttngers ecceutrieally ; color-pi-rcepliou lost, no tleld for green or red. De- cember 1. Case III— J. C. L., fiftv years of age, referred to me by Dr. Richard Dewey, who had made the diagnosis of senile dementia. 190 IXTEUNATIOXA L CLINICS. I: There is a history of <>r;i(hia! liiiliire oC vision for several years past. The patient's vision is | in each eye and words of Jaeger II. can l>e Fig. 17. distinu'uished by the aid of L^asses. The stc story of the visual and t-olor fiehls. Dimbtful perception of reopticon will toll the Cask IV.— (jirl, ajjod tt > "»'- n years. Ihree years ajjjo had a sev I'm. 18. ere optic nerve atrophy following severe attnek „r sn.rl.tina. V.l fu both eye«. White KTteii , re>l . ' attaek of searlatina. There was „o .ni.Ml.. .ar or n.-al eoniplic-ation, but some time afterwards slu. eo.nplained of h.-a-iarln. ..n using her ^ RELATIONS OF OPTIC NEUVK ATKOPHY TO GENERAL MEDICINE. 191 eyes. She return.Kl t) soliool, l)iit was oblij^n-cl to desist from study on ueooiint of blurring' of tlu' letters and eonfiision of the print. She also l)e.'an to liold her luxik elose to her eyes. No other eaus.^ than le seal he assi"-ned for the ojitie nerve disease, Drineipa let fever esni 1 sipl is the defective field of vision. w iiosc p Case v.— a. M., aiicd twenty-nine yeara Vision perfectly j^oixl nntiT ei-ht' months before I saw liim. Followii)}? a severe attack of rhetiiiKUie fever, eomplieateil contracts to stron;^^ liiiht all over the held. Cen- tral vision is normal, and there are no fundus changes. Fio. 19. . . o,>.rn,.Mf<> rh.Minialli- iirtliritis mid "nervous prostration, optic nerve atrophy '»>•---;-:-';-:; '^^::'Z^, L^^^.. Case V^.-^ran, f.rtv-six vears of a.u.-. Had syphilis at twenty- five There are no marUaus.s in the dise;vse-proc(>ss so c-haracteristic of tabes and so eneouia,nig to those ignorant patiiologists who, IVom time to time discover cures ot this disease. I show a pictuiv of his visual tield. (b ig. Z^.) I \ f 192 INTERNATIONAL CLINKS. Case VII.— D. S., agt^l lorty-Hix. Doulttl'iil Ijistory of lues in early manhocKl. No ocular symntoni^ excrpt misty vision, not cleared ' up by any glass. lie can, however, read words of Jaeger I. llis Fio. -JO. ZI" IIS Optic nerre atrophy in a case of tabes. V. ^ J. bnth eye«. !• idd fur white, isolated spots seen as K'niy. FlO. 21. LE. Beginning atrophy of optic nerve In tabes doraallB. V = |. White red . _ . ., trreen • eves are easily fatigued, and he suffers from frontal hcjidaches. Well- marked symptoms of posterior myelitis. The left disk is decideelbre, he had ridden an unusually long distance Fio. 22. LS. HE. Nonritl. optica, early .ta«e. b<,U. ey<.. V. L. - IS , V. R = flngc. at three ^-t. - J'J^f '. -f' icotoma at centre and whitu seen as gray or green. White red' - -, gnreea July 29. FiQ. 23. zs. ns. Optic nerve atrophy followlnt; optic neuritis. Field for white. on his bicycle, which had then broken down. He was consequently obligetl to tramp for nianv miles with the disablctl machine and reacluHl his destination c'-^-ely exhaustal. This experience was re- Vol. II. Ser. 7.-13 wmm 194 INTERNATIONAL CLINICS. peatctl the next dav, on liis lioinc-journoy, from which ho did not recover for over a uwk. I saw him four weeks afterwards ; there was a well-developcil luniriti.s optica in botli eyes. Peripheral vision was affected on the k'ft side, botii central and peripheral in the right eye. Now both ])apillie are pale, woolly, and present indistinct out- lines, and all signs of the ac-ute process have disappeared. The fields of vision present these pictures. (Fij^s. 22 and 23.) Case IX.— A. K.. younj; lady, agwl seventeen years, had delicate health, but did not complain of her eyes until a month W fore I saw her. She th.-n m)ticed that she could not see well in the dis- tance or read ordinary print with her right eye. There are no fundus Field for red larger than that for white i white , red . V. = Ig, Jaeger VL changes. Patient is distinctly hysterical : has attacks of weeping without apparent cause, pharyngeal aiuesthesia, lump in her throat, etc. Has spasm of accommodation in the right eye, but no monocular polyopia. 1 wish you would espei^ally notice that her jidd for red is larger than that for tchitc, one of the most pronounced of the ocular stigmata of hysteria. I J ■ "S TfiiriiiiiiirBJiiiiiWirimr 11 1 f p" ¥%' L- r ■ ;i I' -- i '! INTERNATIONAL CLINICS. Seventh Scrigs. A Qtmrterly Collection of Clinical T.octtires on Medicine. NeuroloRy, Pediatrics, vSurgery, Genito-Urinary Snrgery and Veiie- ■ ,,. ***^ Diseases, Gyniecology and Obstetrics, Ophthalnioloj{y, Laryngology, Pharyngology, Rhinology and Otology, and Dermatology. By Professors and LecUirers in the Leading Medical Colleges of the United States, Great Britain, and Canada. KIMTKI) HY JUDSON DALAND, M.D., I'liilmlflphia, I'n. J. MITCHELL MRUCE, M.D., F.R.C.P, London, Kniftniid. DAVID W. FINLAY, M.D., F.R.C.P., Ahcrdecn, Sc»)tlim(l. Illustrated. Price per volume : Cloth, $3.75 ; Half Leather, $3.00. Each volume con- tains about 350 pages, octavo, is printed from large, clear type on good paper, and is neatly bound in Cloth and Half Leather. A copious index is con- tained in each volume ; and Volume IV. of each series contains in addition a general index of the four volumes for the year. Seven th Series commences April, 1897. /ty SUBSCKfPT/ON ONLY. "This work, as the title sets forth, is a collection of the best and most prac- tical clinical lectures delivered in the leading medical colleges of the United vStates, (ireat Britain, and Canada. These lectures, after having been reported by competent medical stenographers, are arranged by the editors in a form l)est sniteil for the purpo.sesof this work, and afterwards they are returned to the professors and lecturers for their personal, revision. The reader is thus given the final thoughts and most advanced practical ideas of our ablest professional teachers These hand.some and well-printed volumes, whicii are issued with great regularity ever>' quarter, contain a vast amount of instructive and readable matter. The range of snbjects is as wide as that of medicine itself and the lectures upon them are gathered from the' clinical schools on l>oth sides of the Atlantic. The publication of such a repertory of bedside experience cannot fail to exercise a marked influence on thought and practice, whilst the fact that a venture of this magnitude should have attained its seventh year of existence demonstrates that its volumes have obtained a recognized und sure place in periodical medical literature. liach volume contains some fifty or sixty lecture and commentaries upon casesofdi.sea.se; a certain numl>er of the forms are elaborated into general disquisitions, but the majority are purely clinical-that is. they are based upon cases under obser%'ation at the time of the delivery of the lecture. In our opinion, this is the only right form into which a clinical" lecture should be cast. It does not and ontvht Mot to aim at being an exhaustive survey of the topic with which it deals, st-. .a ■. e' : w should l^e reserved for the mono- graph or thesis ; but it should brins; out , n clear detail the clinical facts attaching to the patient and deduct therefrom the lessons they convey. " -London lancet * i 4 *■ k • '1 i ^ 1 it's.- A w*-^ 4 I