
 
 
 <U^ 
 
 DR. HENRY REDMOND; 
 
 1224 WALNUT STREET, 
 
 PHILADELPHIA, PA,
 
 THE 
 
 EYE 
 
 Bt 
 
 \J/ 
 
 LTIDWIG MAUTHNEK, M.D 
 
 YAL PEOFESSOB IN THE TINIVERSITY OP 
 
 TRANSLATED FROM THE GERMAN 
 
 fly 
 WARREN WEBSTER, M.D. 
 
 BURGEON, UNITED STATES AliMT 
 AND 
 
 JAMES A. SPALDIKG, M.D. 
 
 MEMBER OF THE AMERICAN OPHTHALMOLOOtCAt SOCIETY J OPHTHALMIC SCB- 
 OEON TO THE MAINE GENERAL HOSPITAL. 
 
 NEW YORK 
 WILLIAM WOOD & COMPANY 
 
 1881
 
 ranriivi ,ftunc
 
 TRANSLATORS' PREFACE. 
 
 THIS comprehensive monograph, on the SYMPA- 
 THETIC DISEASES OF THE EYE, is the first of a series 
 intended to embrace the whole province of Ophthal- 
 mology. The author, Dr. Ludwig Mauthner, of 
 Vienna, a well-known specialist, has two objects in 
 view Tone, to compile, for the ophthalmic surgeon, 
 the widely diverse opinions on the subjects under 
 discussion ; the other, to enable the general practi- 
 tioner, and the student in ophthalmology, to gain an 
 insight into the pathology, and especially into what 
 should be the practical treatment, of the more im- 
 portant diseases of the eye. 
 
 Although the number of learned, conscientious, 
 and skilled oculists in America is daily increasing, 
 yet there will be exigencies in civil life, as well as in 
 the military and naval service, when their assistance 
 cannot be obtained. A large majority of patients 
 affected with diseases or injuries of the eye, should, 
 and naturally will, turn at once to their family physi- 
 cian for advice. The latter, with this monograph at 
 hand, or others of the series as they shall appear, will
 
 iv TRANSLATORS' PREFACE. 
 
 be enabled immediately to judge of the triviality or 
 of the serious nature of the case. He will then de- 
 cide either to treat it himself, according to the latest 
 light which scientific research and experience, as set 
 forth in books, have thrown upon it, or to refer it, if 
 haply he can, to a trustworthy specialist for more 
 minute treatment, or for an operation, if necessary. 
 
 In so far as regards the subject of the present 
 monograph (SYMPATHETIC DISEASES or THE EYE), we 
 may truly say that it is one of the most important 
 with which the oculist is ever concerned. Upon his 
 correct judgment will generally depend the future 
 vision of the patient. Much more urgent, therefore, 
 must be the necessity for general practitioners in the 
 country, and for medical officers of the army and 
 navy, to have at hand a clear and reliable descrip- 
 tion of the multiform symptoms, and the treatment, of 
 Sympathetic Ophthalmia, so that they may at once 
 recognize its presence, and treat it from the outset 
 appropriately and effectually. Although cases of this 
 nature are comparatively rare, their importance is 
 sufficiently great to account for the appearance of this 
 excellent work in an English version. 
 
 WARREN WEBSTER. 
 JAMES A. SPALDING. 
 
 PORTLAND, MAINE, September 1, 1881.
 
 AUTHOE'S 
 
 THESE " Lectures on Ophthalmology " cannot fully 
 succeed in their professed object of popularizing, 
 among practitioners of general medicine, the specialty 
 to which the author belongs, unless he assumes that 
 the readers have but slight acquaintance with oph- 
 thalmological terminology. He regrets, however, that 
 he has occasionally been obliged to overstep the 
 bounds of general description, and to adopt, for a 
 time, the necessary minutiae of his specialty. 
 
 MAUTHNER. 
 VIENNA, March 27, 1878.
 
 CONTENTS 
 
 ETIOLOGY, . 
 
 PAOE 
 
 9 
 
 PRELIMINARY REMARKS, . 
 
 SECTION I. 
 
 12 
 ANATOMY, 
 
 SECTION II. 
 
 . 17 
 
 
 SECTION III. 
 
 
 . 5G 
 
 PATHOLOGY, 
 
 
 
 SECTION IV. 
 
 
 . 105 
 
 PATHOGENY, 
 
 
 
 SECTION V. 
 
 
 146 
 
 THERAPEUTICS, , 
 
 
 INDEX, 
 
 209
 
 THE 
 
 SYMPATHETIC DISEASES OF THE EYE. 
 
 IT is a terrible thing when some constitutional dis- 
 ease, or a local disease outside the eye perhaps of 
 the brain or some definite disease of the eye itself, or 
 a traumatic agent, destroys the sight of both eyes at 
 once. Then, again, it is lamentable when one eye is 
 destroyed, at a greater or less interval after the other, 
 from a repetition of the original injury, as has twice 
 occurred in my experience, from the explosion of gun- 
 powder, and the thrust of a cow's horn. The misfor- 
 tune, however, is even more aggravated when the 
 second eye is totally lost, simply from some disease or 
 injury of the first eye; or when a surgical operation 
 on the one eye not only fails of its object, but subjects 
 the opposite eye to serious mischief ; or when, after a 
 successful operation on one eye, wa attempt at a later 
 date to gain some vision for the other, and not only 
 
 find that the second eye is unimproved by the attempt, 
 1*
 
 10 SYMPATHETIC DISEASES OF THE EYE. 
 
 but also that, as a direct consequence of the last opera- 
 tion, the sight once happily restored to the first eye is 
 again imperilled. 
 
 " Sympathetic ophthalmia " is a general term, which 
 serves to designate, not a particular affection, but a 
 whole series of ocular lesions, which differ from one 
 another in their seat and manifestations, but always 
 have a common origin. When an eye is laboring un- 
 der injury or disease, it frequently happens that the 
 other eye, which has hitherto been healthy, becomes, 
 after a certain time, and without apparent cause, the 
 seat of various functional or structural disturbances. 
 The latter are called sympathetic affections, and, taken 
 together, constitute sympathetic ophthalmia. Those 
 diseases, therefore, which are superinduced in the 
 second eye, upon an injury, or a disease, of the first 
 eye, and which can be traced to no other cause than 
 the original injury or disease, are regarded as sym- 
 pathetic diseases. 
 
 Hardly any other province of ophthalmology is of 
 more practical importance, and in no other are greater 
 demands made, as -well on the personal experience of 
 the practitioner, as on his acquaintance with the expe- 
 rience of others; in hardly a second field is greater 
 good to be expected from treatment, or greater evil 
 from neglect, than in the one comprising the svmpa- 
 thetic diseases of the eye. Here it is not tlie fate of 
 a single eye that is at stake, but the question that ;il-
 
 SYMPATHETIC DISEASES OF THE EYE. 11 
 
 most always confronts us is: Shall the individual suf- 
 fer utter loss of sight, or shall the vision of at least one 
 eye be wholly, or in part, preserved ? 
 
 Before describing the symptoms of sympathetic 
 affections of the eye, and their treatment, we must 
 notice the primary injuries and diseases of the eye 
 which most commonly excite sympathetic disturbances. 
 First, however, it will be well to refresh, in a brief 
 manner, our remembrance of the anatomical structure 
 of the eyeball.
 
 SECTION I. 
 
 ANATOMY. 
 
 THE eyeball is composed of several investing tunics, 
 as well as of fluid and solid contents, called the refract- 
 ing media. The most important of the latter is the 
 crystalline lens, which is a double convex body, situ- 
 ated immediately behind the pupil, and having its 
 axis in the same line with that of the eyeball itself. 
 It is retained in its position chiefly by the suspensory 
 ligament (zonula Zinnii), which connects its periph- 
 ery with the anterior margin of the retina. The sus- 
 pensory ligament is also attached to the ciliary body 
 by a series of radiating folds or plaitings, into which 
 the corresponding ciliary processes are received. 
 
 The vitreous humor, which occupies about four- 
 fifths of the eyeball posteriorly, is surrounded by the 
 retina as far forward as the termination of the latter, 
 at the ora serrata, and is bounded, in front, by the cil- 
 iary body, the zonula of Zinn, and the posterior cap- 
 sule of the lens. 
 
 That portion of the cavity of the eyeball which lies 
 in front of the lens, between the latter and the cornea,
 
 ANATOMY. 13 
 
 is occupied by the aqueous humor. This space is di- 
 vided into the anterior and posterior chambers by the 
 iris, a thin, membranous curtain, hanging vertically in 
 front -of the lens, and perforated by the pupil for the 
 transmission of light. The iris may be regarded as a 
 process of the choroid, with which it is continuous, 
 although there are differences of structure in the two 
 membranes. The anterior chamber is bounded in 
 front by the cornea, a perfectly transparent tissue, the 
 innermost layer of which is a single stratum of flat, 
 epithelial cells, which rest on the membrane of Desce- 
 met, and are bathed by the aqueous humor. The 
 anterior chamber is bounded posteriorly by the ciliary 
 ligament and the iris, and by that portion of the an- 
 terior capsule of the lens which lies free in the pupil. 
 
 At the place where the periphery of the cornea is 
 overlaid, like a watch-glass, by the free edge of the 
 sclerotica, a multitude of stiff fibrillse stretch across, 
 in a curved direction, from the inner surface of the 
 cornea to the front of the iris, and constitute collect- 
 ively the ligamentum pectinatum iridis. The epithe- 
 lial cells covering the membrane of Deecemet are 
 continued upon the ligamentum pectinatum, where 
 they form, in conjunction witli the fibrillse of the 
 latter, a cellular plate, which separates the anterior 
 chamber from the ciliary body. 
 
 The whole posterior surface of the iris does not lie 
 directly in contact with the anterior capsule of the
 
 14 SYMPATHETIC DISEASES OF THE EYE. 
 
 lens, but only the central portion, that is to say, the 
 pupillary border. Hence, as the iris occupies a nearly 
 level plane, its periphery is separated from the ante- 
 rior convex surface of the lens, and the space known 
 as the posterior chamber is formed. The individual 
 ciliary processes project into the angle of the posterior 
 chamber, in the region of the sclerotica. The poste- 
 rior chamber is bounded in front by the iris, with its 
 thick covering of pigment ; whilst its posterior wall is 
 made up of the anterior capsule of the lens, the zonula 
 of Zinn, and the ciliary processes. 
 
 Inasmuch as the pupillary margin of the iris, in a 
 healthy eye, moves freely over the anterior capsule of 
 the lens, no obstacle exists to an interchange of the 
 fluid contents of the anterior and posterior chambers ; 
 indeed, if the pupil be dilated by the instillation of 
 atropia, so that the border of the pupil can no longer 
 touch the anterior capsule, the two chambers become 
 practically blended into one. 
 
 The retina is a delicate, semi-transparent expansion 
 of the optic nerve, and extends nearly as far forward 
 as the ciliary muscle, where it terminates by a jagged 
 margin, the ora serrata. Its outer surface lies in con- 
 tact with the pigmentary layer of the choroid ; its 
 inner surface, with the vitreous body. The optic nerve 
 pierces the sclerotic and choroid coats at the back part 
 of the eyeball, and enters its cavity at a spot called the 
 optic papilla < a little to the nasal side of its posterior
 
 ANATOMY. 15 
 
 pole. On examining the concave inner surface of the 
 retina, we observe, directly in a line with the axis of 
 the globe, and situated about three millimetres out- 
 ward from the optic papilla, a circular .yellow spot, 
 which presents a central depression (fovea centralis), 
 in which the sense of vision attains its* greatest per- 
 fection. A horizontal section of an eyeball, accurately 
 dividing the optic papilla into an upper and a lower 
 half, would not bisect the fovea centralis, which lies in 
 a plane slightly below the papilla. 
 
 The clioroid is the vascular membrane of the eye, 
 and, with the ciliary body and iris, constitutes the uve- 
 al tract. It is interposed between the sclerotica and 
 the retina, and is thinner than either of these tunics ; 
 but its important appendage, the ciliary body, which 
 lies next to it in front, attains a considerable size, 
 being about four millimetres thick from before back- 
 ward. This body which is made up of the zonula of 
 Zinn, the ciliary processes, and the ciliary muscle -is 
 divisible into two parts : the inner portion consists of 
 the zonula and the ciliary processes; the outer por- 
 tion (which was formerly regarded as a ligament, but 
 in which the existence of muscular fibres has been 
 demonstrated by Briicke, Bowman, and Miiller) oc- 
 cupies the space between the scleral insertion of the 
 cornea and the periphery of the iris. The ciliary mus- 
 cle is united externally with the cornea and sclerotica, 
 and, internally, merges into the ciliary processes ; be-
 
 16 SYMPATHETIC DISEASES OF THE EYE. 
 
 hind, it is continuous with the choroid, and, in front, 
 is inserted, by a portion of its fibres, into the iris, 
 whilst by others it is attached to the wall of the canal 
 of Schlemm and to the ligamentum peetinatuiu iridis. 
 The contraction of the ciliary muscle draws the cho- 
 roid forward 9,nd (by aid of its circular fibres) inward, 
 toward the equator of the lens. 
 
 During youthful life, or so long as the lens remains 
 soft, its form is regulated by the degree of tension 
 maintained in its capsule by the suspensory ligament. 
 When the latter is relaxed, by the action of the ciliary 
 muscle, the lens retracts by its own elasticity, and 
 becomes more globular in shape, thereby increasing 
 the refractive power of the dioptric apparatus of the 
 eye. In a word, it is the office of the ciliary muscle 
 to effect that adjustment of the eye (accommodation) 
 for near and remote objects, which enables it to pro- 
 duce distinct images on the retina. 
 
 If we pass a probe from the outermost edge of the 
 anterior chamber, through the ligamentum pectinatum 
 iridis, into the ciliary body, we penetrate, beneath the 
 cellular plate, a coarse-meshed net-work, lined with 
 cells, analogous to the canal of fbntana, as found in 
 the ox. This structure is to be distinguished from a 
 circular canal, filled with venous blood, and called the 
 canal of Schlemm, which is tunnelled out of the scleral 
 tissue, around the margin of the cornea, and resembles, 
 in places, a plexus of veins.
 
 SECTION II. 
 
 ETIOLOGY. 
 
 THE ciliary body is copiously supplied with nerves 
 and vessels, and may be called the dangerous region 
 of the eye the one from which most of the sympa- 
 thetic affections of the second eye proceed. 
 
 The diseases of the ciliary body may arise either 
 spontaneously or from traumatic causes. The asso- 
 ciation of a wound with the morbid process does not 
 necessarily expose the second eye to increased danger. 
 Nevertheless, a graver danger has been attached to the 
 traumatic affections of the ciliary body, not only be- 
 cause they are more frequent than the idiopathic, but 
 from the fact that when a foreign body remains in the 
 eye the traumatic affections are less easily controlled, 
 or, when apparently under control, are more readily 
 rekindled. Wounds of the ciliary body should, in- 
 deed, excite solicitude, for they may, at longer or 
 shorter intervals, inflict on both eyes the most unfor- 
 tunate consequences. On the other hand, very serious 
 accidents to the ciliary body have, under surgical
 
 18 SYMPATHETIC DISEASES OF THE EYE. 
 
 treatment, or through some lucky and unforeseen acci- 
 dent, or even spontaneously, terminated in the recov- 
 ery of the injured eye, without the implication of its 
 fellow. 
 
 A patient came to me complaining that he had in- 
 jured himself at smith- work, and that a piece of iron 
 had certainly entered his eye. A small wound was 
 visible in the upper and outer part of the sclerotica, 
 near the margin of the cornea. The eye wept, showed 
 slight episcleral injection around the cornea, and was 
 sensitive to pressure at the wounded spot. A more 
 careful examination showed that the lens was appar- 
 ently clear and uninjured ; no deeper wound nor per- 
 foratipn of the anterior chamber could be discovered. 
 It was possible, however, that a small foreign body 
 had penetrated the eyeball and still remained at the 
 bottom of the wound. Perhaps it was lodged in the 
 ciliary body, and, in that case, the inflammation ex- 
 cited therein (cyclitis) might endanger both the in- 
 jured and the sound eye. A fine bistouri, introduced 
 into the wound, under anaesthesia, encountered some 
 metallic body. The wound was at once enlarged, and 
 a small chip of iron removed with delicate forceps. 
 All the signs of irritation disappeared with exceeding 
 rapidity, the wound healed in a few days, and no sen- 
 sitiveness whatever of the ciliary body remained. 
 
 In a second case, the patient had severely wounded 
 his right eye while discharging a musket. He avenvd.
 
 ETIOLOGY. 19 
 
 with the utmost confidence, that no foreign body was 
 lodged in the eye. But it was evident that a perfora- 
 tion, located in the centre of the cornea, had been 
 made by a bit of an exploded percussion-cap. Had 
 the fragment rebounded from the capsule of the lens, 
 or had it, perchance, penetrated the lens itself ? These 
 points could not be then determined, for a large amount 
 of pus occupied the anterior chamber and concealed the 
 pupil. The iris was prolapsed into a puncture, which 
 had been made in the lower border of the cornea for 
 the purpose of evacuating the pus. ' It was in this con- 
 dition that I first saw the patient. It was impossible, 
 at that time, to decide whether the purulent masses 
 which still occupied the pupil were nodules of exuda- 
 tion upon the anterior capsule, or were swollen and 
 suppurating fragments of the wounded lens ; the lat- 
 ter condition, however, seemed the more probable. 
 Nevertheless, the pus gradually disappeared, and al- 
 though the pupillary border of the iris was found ex- 
 tensively adherent to the anterior capsule, neither the 
 latter nor the lens had been wounded. The eye con- 
 tinued to improve, but, along with some lachrymation 
 and pain, a slight subconjunctival injection persisted 
 around the dark-colored spot where the iris had pro- 
 lapsed. One day, while examining the eye more care- 
 fully, in order to discover the cause of the obstinate 
 irritation, I noticed that the dark prolapsed iris had 
 a distinct metallic lustre, so that 1 at once suspected
 
 20 SYMPATHETIC DISEASES OF THE EYE. 
 
 the presence of a piece of metal: With a pair of fine 
 forceps I extracted, from a small excavation in the 
 corneal edge of the sclerotica, where it lay imbedded, 
 a rolled up piece of copper cap, 4 mm. long and 2^ 
 mm. wide. All the signs of irritation now disap- 
 peared in a very short time. A fortunate accident 
 had saved both the wounded eye and its mate. The 
 piece of metal had penetrated the cornea, struck the 
 anterior capsule of the lens without opening it, and 
 had then rebounded to the bottom of the posterior 
 chamber, where it lay directly upon the ciliary body 
 and excited a severe inflammation of the whole ante- 
 rior part of the eyeball. The puncture of the cornea, 
 which had been made for the removal of the pus from 
 the anterior chamber, having luckily been unskilfully 
 performed, a portion of the iris fell through the inci- 
 sion, and into the pocket-like duplicature thus made 
 the piece of metal was received. After necrosis of the 
 prolapsed iris the metal lay freely exposed at the edge 
 of the cornea. Had the operation been made accord- 
 ing to rule the iris would not have prolapsed, and the 
 foreign body left within the globe would, in all prob- 
 ability, have produced a dangerous cyclitis, with the 
 chance of involving the second eye. 
 
 The good results attained in the two injuries just 
 described were due to surgical interference : in the 
 one case, intentional, and, in the other, accidental. 
 But sometimes severe wounds of the eye may termi-
 
 ETIOLOGY. 21 
 
 Date favorably, without any surgical interference what- 
 ever. A boy, twelve years old, was shot in the left 
 eye with an arrow from the cross-bow of a playmate. 
 The arrow stuck fast in the eye until pulled out by his 
 companion. The eye reddened, but was not painful 
 at first, and, immediately after the accident, the boy 
 said that his sight was as good as ever. Four days 
 later, on awaking from sleep, he noticed that he could 
 see very little with the wounded eye, and, later in the 
 same day, pain supervened, with almost complete blind- 
 ness of the eye. On the next day the eye was exam- 
 ined by a surgeon, who found a small, round wound in 
 the sclerotica, behind the lower and inner edge of the 
 cornea. There was also pericorneal injection ; the pu- 
 pil was contracted ; the unwounded lens was in its 
 proper position ; but the vitreous humor was clouded 
 throughout. The tension* of the eyeball was normal, 
 and no spot manifested any sensitiveness to the touch ; 
 but the vision was so reduced that light and darkness 
 could barely be distinguished. The inflammatory 
 symptoms soon became more marked, and pus, which 
 must have come from the ciliary body, inasmuch as 
 both cornea and iris were uninflamed, appeared in the 
 
 * By the word tension, which will be of frequent recurrence in 
 these pages, we mean the feeling of hardness or softness of the 
 eyeball, when we press upon it through the closed lids with the fin- 
 gers. If the eye feels softer than the normal organ, we say the 
 tension is diminished ; if harder, the tension is increased. TR8.
 
 22 SYMPATHETIC DISEASES OK THE EYE. 
 
 anterior chamber. Gradually, however, all the inflam- 
 matory symptoms subsided, and the turbid vitreous 
 again became clear. Two years later, when I^saw the 
 boy for the last time, the ophthalmoscope revealed a 
 very striking condition of things in the fund us of the 
 eye. The retina, as well as all the rest of the interior 
 of the eye, was visible, although somewhat indistinct. 
 A large, dark cord extended from the optic papilla, di- 
 rectly through the vitreous body, to the point where 
 the arrow had entered the eye. Immediately before 
 its termination at this point, the cord divided into nu- 
 merous slender threads. Its direction indicated the 
 exact course of the arrow-head, which had, therefore, 
 traversed the whole vitreous humor and become fixed 
 in the optic papilla. A vascular neoplasm, which pro- 
 jected toward the vitreous, from near the insertion of 
 the cord, appeared to have been due to the irritation 
 in the papilla by the foreign body. The eye was free 
 from any symptoms of irritation, and showed two-sev- 
 enths of the normal amount of vision, with a perfectly 
 clear visual field. 
 
 We now have to note another important point. A 
 foreign body imprisoned in the eye may prove a source 
 of constant irritation for years, exciting from time 
 to time severe inflammation of the wounded eye, and 
 justifying the fear that sympathetic disease may at any 
 time break out in the sound eye. If, however, during 
 a violent attack of inflammation, the eyeball should
 
 ETtOLOGY. 23 
 
 unexpectedly open at some point, and the foreign 
 body, so long present, be expelled from the eye, either 
 spontaneously or by surgical assistance, a new and 
 happy turn may be given to the case, affording perma- 
 nent rest to the injured eye, and assuring the other 
 from threatened destruction. I have, however, seen 
 this favorable result but twice, the offending body, in 
 each instance, being a fragment of glass. 
 
 In one case, a piece of glass so large as to ex- 
 cite wonder that it could have either entered or occu- 
 pied the cavity of the eyeball came to light, after a 
 violent inflammatory attack, and was finally extracted 
 through the sclerotica, after the spontaneous opening 
 had been greatly enlarged. 
 
 The second case was that of a woman who applied 
 for an artificial eye. A splinter of glass had flown into 
 her left eye, in early youth, and had ever since been a 
 source of constant irritation, provoking severe inflam- 
 matory attacks in the affected eye, and greatly impair- 
 ing the vision of the opposite eye. She reported that, 
 during a violent inflammatory exacerbation, the splinter 
 had appeared at the surface and been spontaneously 
 expelled. After that event the injured eye gave no 
 further trouble, and the second eye could be used for 
 all sorts of work. 
 
 The injuries of the ciliary ~body and its vicinity, 
 known to give rise to sympathetic disease, are appro- 
 priately classified as accidental and operative injuries.
 
 24 SYMPATHETIC DISEASES OF THE EYE. 
 
 Thejirst of these divisions comprises : penetration of 
 foreign bodies into the ciliary body, with lodgement 
 therein ; punctured or incised wounds of the ciliary 
 body, without lodgement of a foreign body; contused 
 or lacerated wounds of the ciliary body, inflicted by 
 blunt agents ; incised, punctured, and lacerated wounds 
 of the periphery of the cornea, with or without injury 
 of the ciliary body, whereby the periphery of the iris 
 alone, or along with it a portion of the ciliary body, 
 becomes incarcerated in the wound ; and finally, con- 
 tusions of the ciliary body, from mechanical violence 
 applied to the eyeball, without opening it. 
 
 A foreign object lodged in the ciliary body may some- 
 times become eucapsuled, and so be made innocuous. 
 When this happens, the diagnosis of its presence is 
 certainly very difficult. Bowen, however, has observed 
 (1875) that such an object, after a long and harmless 
 stay, may suddenly and dangerously announce its 
 presence. A particle of iron, the size of a pin-head, 
 lay among the fibres of the ciliary muscle for nine 
 years, causing extensive thickening in its neighbor- 
 hood, as was found at a subsequent examination. After 
 this long period, pain in the ciliary body was felt, on 
 pressing the spot where the injury had been inflictedj 
 and, a few weeks later, sympathetic ophthalmia super- 
 vened, which only ceased after enucleation of the 
 wounded eye. 
 
 It thus appears certain that a foreign body, either
 
 ETIOLOGY. 25 
 
 free or encapsuled, may harmlessly remain for a long 
 time, and even for life, not only in the ciliary body, 
 but in any other part of the eye. It is, on the other 
 hand, no less clear, from another case, also reported 
 by Bo wen (1875), that the wounded eye, even after a 
 very protracted interval of quiescence, gains no certain 
 immunity from severe inflammation and ensuing 
 sympathetic disturbance, liable, as they both are, to be 
 caused by the presence of the original foreign body. 
 In the latter case, a piece of metal, two and a half 
 millimetres long, lay imbedded in the optic nerve for 
 seventeen years, and it was only after it had produced 
 inflammation and disorganization of the uveal tract, 
 that sympathetic phenomena intolerance of light, cil- 
 iary injection, and discoloration of the iris appeared 
 in the uninjured eye. 
 
 Although the injuries of the ciliary body are much 
 more dangerous than analogous injuries of other parts 
 of the eye, from the greater proneness of the former 
 to develop the severe train of symptoms presently to 
 be described, yet a simple injury of the ciliary body, 
 when not complicated by prolapse of the iris, or in- 
 carceration of some portion of the ciliary body in a 
 penetrating wound, is not often followed by serious 
 consequences. 
 
 Violent contusions and concussions, inflicted upon 
 the eye by blunt bodies for example, the naked fist, 
 
 or one in which the fingers are covered with heavy 
 
 2
 
 26 SYMPATHETIC DISEASES OF THE EYE. 
 
 rings play relatively the most frequent part in the 
 etiology of cyclitis, and its associate diseases, irido- 
 cyclitis and irido-cyclo-choroiditis. Next in order 
 of frequency come penetrating and cutting wounds, 
 without prolapse or constriction of any of the parts ; 
 and least frequently of all (whatever may be their in- 
 herent danger), the penetration and permanent loca- 
 tion of small foreign bodies within the ciliary body. 
 
 The symptoms and anatomical changes set on foot 
 l>y injuries of the ciliary body may be so insidious and 
 painless, at the start, as to be quite unrecognizable. 
 Soon, however, more marked symptoms appear : the 
 injured eye becomes intolerant of light and bathed in 
 tears, while a ring of blood-vessels environs fhe cornea. 
 If we touch the ciliary region with a blunt probe, or 
 simply press with the finger through the .closed lids, 
 the patient complains of its sensitiveness, and, in par- 
 ticular spots, of acute pain. The cornea becomes hazy 
 and dull on its external surface, and the iris, if visible 
 through the cornea, is seen to be discolored, its nat- 
 ural lustre gone, and its striated appearance obscured. 
 The pupil is still open, but atropia no longer exerts 
 any influence upon its size. We soon discover foun- 
 dation for our suspicion that the pupillary edge of the 
 iris is adherent to the capsule of the lens ; while the 
 whole posterior chamber is filled with inflammatory 
 exudation, gluing the iris, the ciliary body, and the an- 
 terior capsule firmly together. Pus may occupy the
 
 ETIOLOGY. 27 
 
 floor of the anterior chamber, having forced its way di- 
 rectly thither from the ciliary body, through the liga- 
 mentum pectinatum iridis and its cellular plate. If the 
 pupil be still sufficiently clear to permit of the use of 
 the ophthalmoscope, we can with difficulty distinguish 
 the fund us of the eye through the intervening tur- 
 bidness. So long as this opacity is still-diffuse, it is 
 hard for the observer to decide how much of it de- 
 pends on the cornea, as well as on the turbid aqueous 
 full of pus-corpuscles, or how much on the vitreous. 
 But when dark objects, of varying size and shape, 
 float about in the affected eye upon its being quickly 
 moved to and fro, we know that the vitreous humor is 
 involved in the pathological process. Vision, mean- 
 while, has diminished exceedingly. 
 
 The eyeball now becomes ominously soft to the 
 touch, and the acuteness of vision markedly diminished. 
 The anterior chamber is narrowed, inasmuch as the 
 lens is pushed forward toward the already turbid and 
 flattened cornea. The periphery of the chamber may, 
 however, appear deeper at places than normal, inas- 
 much as the masses of exudation which occupy the 
 posterior chamber have formed a cicatricial tissue be- 
 tween the iris and anterior capsule, become consoli- 
 dated, and so dragged the ciliary border of the iris 
 backward toward the lens. The iris itself, having 
 passed through its stage of proliferation and soften- 
 ing, is now atrophied, and turned to a dirty yellow
 
 28 SYMPATHETIC DISEASES OF THE EYE. 
 
 color. The black pigment which lines its posterior 
 surface is visible through the anterior layer, giving it a 
 dotted appearance, while here and there tortuous veins 
 are displayed, owing to the inflammatory swelling 
 of the ciliary body, whereby the venous blood of the 
 iris is now impeded in its passage to the choroid. The 
 pupil may, at this stage, be still permeable for light, 
 but more frequently it is blocked with masses of ex- 
 udation. 
 
 The morbid process culminates when the inflam- 
 mation of the ciliary body (cyclitis) is communicated 
 backward to the choroid (choroid itis), which, in turn, 
 involves the contiguous retina (retinitis), whilst the 
 nutrition of the deeper structures of the eye becomes 
 BO disturbed that a marked reduction in the mass of 
 the vitreous humor takes place. The direct conse- 
 quence of the atrophy of the vitreous is the loss of 
 the normal tension of the globe, which now feels soft, 
 and may become so flaccid as to be indented at the 
 places corresponding to the recti muscles. But even 
 after phthisis of the entire eyeball, with total inflam- 
 matory destruction, or even detachment, of the retina, 
 and. consequent extinction of vision, the eye does not 
 subside into quiescence. The offending ciliary region 
 may still be tender and irritable to the touch, painful 
 upon the slightest occasion, and a source of constantly 
 impending danger to the other eye. 
 
 We have, moreover, to mention Mooren's assertion
 
 ETIOLOGY. 29 
 
 that after the introductory symptoms, such as peri- 
 corneal injection, photophobia, lachrymation, and par- 
 tial sensitiveness of the ciliary body, in a typical case 
 of simple acute cyclitis, we first see an increase of 
 depth in the anterior chamber, due to the inflamma- 
 tory adhesion of the periphery of the iris to the ciliary 
 body. We are also struck by the fact that no iritic 
 adhesions to the anterior capsule, even at the ^>upil- 
 lary border, exist at this time, the pupil being readily 
 dilatable by the instillation of atropia. Should the 
 retraction of the periphery of the iris progress, then 
 the veins of the iris dilate, the aqueous humor becomes 
 cloudy, pus appears in the anterior chamber, and opa- 
 cities quickly and copiously form in the vitreous humor. 
 When, in connection with an injury of the ciliary 
 body, the eyeball is opened by a punctured or incised 
 wound, or is lacerated and contused by some blunt 
 instrument (cow's horn), or a projectile, the injury is 
 usually complicated by a prolapse, into the wound, of 
 a portion of the ciliary body, or the periphery of the 
 iris, or both together. In the majority of such cases, 
 the cyclitis, or irido-cyclitis, is directly produced by 
 the injury, and not by the incarceration of the ciliary 
 body or iris. Wounds of this kind are sometimes very 
 remarkable. I once saw an eye that had been bitten 
 by a horse, so that the organ was lost, after violent 
 symptoms of cyclitis, and the other eye subsequently 
 suffered from severe sympathetic ophthalmia. Lebrun
 
 30 SYMPATHETIC DISEASES OF THE EYE. 
 
 (1870) reported a case in which a leech, applied to the 
 neighborhood of an eye for therapeutical purposes, 
 strayed to the edge of the cornea, where it inflicted a 
 bite that was followed by sympathetic symptoms in 
 the other eye. We have already mentioned (page 20) 
 an extraordinary case in which a foreign body flew 
 through the cornea, as far backward as the anterior 
 capsule, from which it fell to the floor of the posterior 
 chamber, and there rested in menacing contact with 
 the ciliary body. 
 
 Both contusions and perforations of the eyeball may 
 cause cyclitis in an indirect way. Thus, a contusion 
 may partially lacerate the suspensory ligament (zonula 
 Zinnii), so that the lens may either sink downward 
 upon the ciliary body, and excite irritation by its con- 
 tact with the latter, or it may drag upon the ciliary 
 body through its remaining attachments to the zonula, 
 and produce a similar effect. Again, when a foreign 
 body has penetrated the lens, or extensively lacerated 
 its capsule, the fragments of the mutilated lens may 
 fall into the bottom of the posterior chamber, and 
 cause severe inflammation of the iris and ciliary body. 
 If, however, the fragments of the lens fall into the 
 anterior chamber, their presence usually provokes 
 much less inflammation. Thus may injuries of the eye 
 lead indirectly, through lesions of the lenticular appa- 
 ratus, to disease of the uveal tract, and, later, to sym- 
 pathetic affections of the opposite eye.
 
 ETIOLOGY. 31 
 
 We must here remind ourselves that it is not only the 
 accidental injuries of the eye, but also those which are 
 incidental to surgical operations, that may initiate 
 sympathetic ophthalmia. Among the operative inju- 
 ries, the one called iridodesis, and the various opera- 
 tions for cataract, occupy the first rank. Critchett 
 (1858) devised the operation of iridodesis, with a view 
 to provide the disabled eye, under certain circumstan- 
 ces, with better vision than could be gained by iridec- 
 tomy. 
 
 The operation called iridectomy consists in making 
 a new opening in the iris for the rays of light to enter 
 the eye, when the natural pupil is covered by a central 
 opacity of the cornea, or when the pupil lies in front 
 of a stationary central cataract. A piece of the iris is 
 excised, so that a portion of the still transparent cornea, 
 or lens, faces the artificial opening. This operation, 
 when performed for optical purposes only, has not 
 usually given satisfactory results. It is, indeed, in- 
 valuable when the central opacity of the cornea wholly 
 conceals the pupil, and is at the same time completely 
 or nearly opaque, provided that the outer portion of 
 the cornea, which appears normal, is really so, as re- 
 gards both transparency and curvature. Moreover, in 
 the rare disease called stationary nuclear cataract, in 
 which the central portion of the lens lying directly 
 behind the pupil is totally opaque, and a considerable 
 margin of the lens beyond the opacity is perfectly
 
 32 SYMPATHETIC DISEASES OF THE EYE. 
 
 transparent, iridectomy is a reliable resource. But 
 such clear indications for the operation are seldom 
 met with, for the offending spot in the centre of the 
 cornea oftentimes falls far short of complete opacity, 
 whilst the central cataract, on account of which the 
 patient demands " more light," is almost always of the 
 so-called lamellar variety, in which an opaque lamella 
 or zone intervenes between the nucleus and cortical 
 portion, which are both clear. In many cases the 
 impairment of vision is so slight as not at all to inter- 
 fere with ordinary pursuits, and no surgical operation 
 is warrantable under such circumstances. Further- 
 more, the lamellar variety of cataract, even in its ex- 
 treme degree of development, still permits a certain 
 amount of light to enter the interior of the eye. If, 
 therefore, an iridectomy is performed on an eye affect- 
 ed with an incomplete opacity of the cornea or lens, 
 the retina receives light not only through the newly 
 made aperture, but through the old pupil. The fail- 
 ure of the opacity to prevent the transmission of light 
 through the original pupil is a source of disturbance 
 to the eye as an optical apparatus, because in the eye, 
 as" in the camera obscura, clearly defined images are 
 only produced when all irregularly refracted rays are 
 excluded. When diffused light is thrown over the 
 retinal image, the latter becomes indistinct. For the 
 foregoing reasons, the performance of iridectomy, 
 under the circumstances above mentioned, does not
 
 ETIOLOGY. 33 
 
 enable the eye to see well ; for not only does diffused 
 light continue to reach the retina, but the dazzling 
 sensation caused by too brilliant illumination of the 
 field of vision is aggravated by the operation, inas- 
 much as the pupil is thereby not only deprived of its 
 contractile power, but its area is greatly enlarged. 
 
 On account of the excessive size of the pupil, its loss 
 of reactionary power, and the disturbance of the re- 
 tinal image by diffused light, which follow iridectomy, 
 an attempt was made to obviate these evils by substi- 
 tuting the operation called iridodesis, in performing 
 which a small incision is made in the cornea, close to 
 the sclerotica, and the peripheral portion of the iris 
 seized and drawn out of the wound, with such precau- 
 tions that the entire pupillary border is left within the 
 anterior chamber. A loop of thread is afterward tied 
 around the prolapsed iris, to prevent it from slipping 
 back into the eye ; the strangulated piece then rapidly 
 necroses, falls off with the thread, and the wound is 
 soon healed. The pupil has thus been transformed 
 into an oval or longitudinal opening, and moved in 
 toto toward the place of incision, the portion of the 
 iris directly opposite the place of incision having been 
 stretched to permit of the dislocation. The displaced 
 pupil, with its constrictor pupillae intact and its reac- 
 tionary function unimpaired, covers a scarcely greater 
 area than it did before the operation. Moreover, a 
 
 portion of the iris is interposed, as a diaphragm, be- 
 
 2
 
 * SYMPATHETIC DISEASES OF THE EYE. 
 
 hind the semi-opaque corneal spot, or in front of the 
 partly translucent cataract, thereby protecting the re- 
 tina from diffused rays of light ; so that, barring the 
 sacrifice of some trueness of the corneal curvature (an 
 evil which Pagenstecher sought to aroid by removing 
 the incision into the verge of the sclerotica), we now 
 have an eye which, although not projecting an abso- 
 lutely perfect image upon the retina, certainly pos- 
 sesses better vision than it would have, had an iridec- 
 tomy been performed. 
 
 Wecker practises iridodesis in those cases in which 
 the lens, from whatever cause, has become dislocated, 
 so that its centre no longer corresponds to the centre 
 of the pupil, or, more strictly speaking, to the axis of 
 vision. If, for example, the zonula has been torn at 
 its lower and inner insertion, the lens is displaced up- 
 ward and outward, so that the space thus left between 
 the lower internal border of the lens and the adjacent 
 ciliary processes is partly visible through the pupil 
 when dilated with atropia, or even when of normal 
 size. Two images of an object, seen with such an eye, 
 are thus projected upon the retina: one of them by 
 the cornea, aqueous humor, lens, and vitreous humor ; 
 and the other, by a refractive system from which the 
 lens is absent. If the image made without the aid of 
 the lens be, for any reason, the more useful of the two, 
 the operation of iridodesis enables us to transfer the 
 pupil permanently to a part of the cornea behind
 
 ETIOLOGY. 35 
 
 which, the lens is absent, whilst, by the same proce- 
 dure, .the iris on the opposite side -is stretched over the 
 dislocated lens, so as to cut off the second image, which 
 would otherwise interfere with distinct vision. 
 
 Iridodesis was at first regarded as a perfectly safe 
 operation. But, in 1863, Alfred Graefe published the 
 following significant case, in which iridodesis was per- 
 formed on the eyes of a workman, aged twenty-three. 
 Both eyes of the patient were affected with lamellar 
 cataract, which, however, still permitted him to read 
 No. 3 of Jaeger's test-types. Vision was improved im- 
 mediately after the operation ; but eight weeks later 
 Graefe found the man Mind in both eyes, with occlu- 
 sion of the pupils, in consequence of irido-cyclitis. 
 The eyes, however, were not soft. The patient could 
 see well with both eyes during the first week, at the 
 end of which time, without any apparent cause, the 
 sight diminished, first in one eye, and very soon there- 
 after in the other, until it was reduced, at the time of 
 the examination, to a merely quantitative perception of 
 light. The exciting cause of the irido-cyclitis, in each 
 eye, was attributed by Graefe to the stretching of the 
 iris, incident to the iridodesis. Did not, however, sym- 
 pathetic inflammation play its role in this case ? It is 
 possible that the operation had directly excited irido- 
 cyclitis in one eye only, and the inflammation had ex- 
 tended sympathetically to the other, so that the same 
 lesions would have appeared in the second eye even if ic
 
 36 SYMPATHETIC DISEASES OF THE EYE. 
 
 had not undergone the operation. Although the nearly 
 simultaneous involvement of the two eyes, in G'raefe's 
 case, makes the latter opinion less trustworthy, never- 
 theless, as we know from experience that irido-cyclitis 
 is prone to be followed by sympathetic disease, and as 
 Graefe established the existence of irido-cyclitis de- 
 pending on the iridodesis, it must be admitted that this 
 operation is not devoid of both primary and sympa- 
 thetic danger. In fact, soon after Graefe's case came 
 to light, one was reported by Steffan (1864), in which 
 a girl aged nineteen, who had undergone iridodesis in 
 one eye only, was affected, five weeks after the opera- 
 tion, with irido-cyclitis in both eyes. The disease may 
 have first appeared in the wounded eye so insidiously 
 as to receive no attention ; but it was not until the 
 affection had, some weeks later, extended to the hith- 
 erto perfectly sound eye, that the patient applied for 
 relief. 
 
 When, during a visit to London in 1864, I men- 
 tioned to Critchett that the unfortunate cases of 
 Graefe and Steffan had produced a want of confidence 
 in iridodesis, among German oculists, he was not a lit- 
 tle surprised at the two failures, as he had never en- 
 countered like results in his very large personal expe- 
 rience with the operation. My own operations have, 
 likewise, been successful. But, on the other hand, 
 unsuccessful cases and unfavorable criticisms of irido- 
 desis have been sufficiently frequent in ophthalroolo-
 
 ETIOLOGY. 37 
 
 gical literature, since 1864, to place the operation where 
 it now remains in discredit. 
 
 Of far greater importance than iridodesis, as regards 
 the danger of exciting inflammation, which may be 
 propagated sympathetically to the second eye, are the 
 operations for the relief of cataract. 
 
 One of the fundamental methods of operating for 
 this disease, that of depression or reclination, by which 
 a hard cataract is forcibly thrust away from the axis 
 of the visual rays into the vitreous body, is now almost 
 totally abandoned on account of the destructive con- 
 sequences that ensue, not only in the operated eye, 
 but, secondarily, in its fellow. The displaced lens 
 often plays the part of a foreign body resting, it may 
 be, in disagreeable contact with the ciliary body and 
 choroid. It may thus lead to inflammation of the 
 uveal tract, if, indeed, this condition has not already 
 Jbeen set up by the operation itself. The bad repute 
 into which reclination has fallen is, however, due rather 
 to the danger incurred by the eye undergoing opera- 
 tion than to an appreciation of the sympathetic dis- 
 turbances that may subsequently develop. 
 
 Nor are the two operations of division and extrac- 
 tion, so extensively employed in our days, wholly de~ 
 void of analogous risks. The object of division or 
 disci ssion of a cataract is to lacerate the anterior cap- 
 sule and break up the substance of the lens, so that the 
 latter shall come into contact with the aqueous humor.
 
 f3S SYMPATHETIC DISEASES OF THE EYE. 
 
 If the lens be only partially opaque, as in lamellar 
 cataract, it becomes wholly so soon after exposure to 
 the aqueous, and its fragments are gradually dissolved 
 and absorbed until the cataract disappears. It some- 
 times happens, either when proper precautions have 
 not been taken during the operation, or in spite of 
 them, that the lenticular fragments imbibe a great deal 
 of aqueous humor, swell considerably, press upon the 
 iris, and cause severe iritis, followed rapidly by cycli- 
 tis and possibly by sympathetic disturbances. Al- 
 though division is regarded by oculists as a very im- 
 perfect surgical procedure, there are, nevertheless, a 
 few forms of cataract to which no other is so well 
 adapted. Among these are the lamellar cataract and 
 the extremely rare variety called stationary nuclear 
 cataract, in both of which the transparent periphery 
 of the lens adheres so intimately to the capsule that it 
 cannot be removed by the extraction method, with sat- 
 isfactory results. 
 
 Extraction by the flap operation^ and v. Graefe's 
 method of modified linear extraction , are the two 
 most important of the different surgical operations 
 for the removal of cataract. In operating by the first- 
 named method, a semicircular flap, involving the whole 
 upper half of the cornea, is made by incising the lat- 
 ter close to its scleral border. A large, patulous wound 
 is thus produced, through which the lens is evacuated 
 by gentle compression of the globe. In v. Graefe's
 
 ETIOLOGY. 39 
 
 method of modified linear extraction the peculiarity 
 of the incision is that it lies entirely in the sclerotica, 
 and does not form a flap, its only curve heing that of 
 the eyeball itself. The incision is from ten to twelve 
 millimetres long its middle point lying at the topmost 
 point of the corneal margin. Through this incision 
 the lens is removed, after a preliminary iridectorny 
 and laceration of the anterior capsule. The operations 
 now most in vogue are a sort of compromise between 
 the old flap operation, and the genuine peripheral lin- 
 ear extraction as modified by v. Graefe. 
 
 When the old method of removing the opaque lens 
 by the flap operation was generally practised, very 
 little was said of sympathetic ophthalmia after op- 
 erations for cataract. Now and then we heard of 
 irido-cylitis and sympathetic affections, after the op- 
 eration, and, in fact, a few such cases are matters of 
 record ; but we undoubtedly hear much more of sym- 
 pathetic disturbances in connection with operations 
 for cataract, since the era of linear extraction. 
 
 In all probability the first enucleation of an eyeball, 
 upon which the method of linear extraction had been 
 practised, was one that I performed in 1867, on ac- 
 count of sympathetic ophthalmia of the other eye. A 
 cataractous lens had been removed with complete suc- 
 cess, by the flap operation, in 1865, from the left eye 
 of a man fifty years old. One year later Jaeger op- 
 erated on the right eye by a linear method (the curved-
 
 40 SYMPATHETIC DISEASES OF THE EYE. 
 
 lance section). Although the operation was skilfully 
 performed, without any prolapse of the vitreous hu- 
 mor, irido-cyclitis set in, and was followed by atrophy 
 of the eyeball. Thirteen months after the second op- 
 eration the patient again applied for relief, the atro- 
 phic eye having never become quiescent, and being 
 still affected with pain and photopsies. Six weeks 
 prior to his reappearance pain commenced in the left 
 temple, and, later, invaded the whole side of the head, 
 undergoing exacerbations and remissions, but never 
 complete suspension. Along with these symptoms, 
 the vision of the left eye (which, as the patient declared, 
 had been better, with the aid of cataract-glasses, since 
 the first operation, than ever before) became impaired, 
 and, at the date of examination, was reduced to one- 
 fourteenth of normal, whilst the whole field <ff vision 
 was obscured by a thick mist. The tension of the left 
 eye was natural ; both cornea and iris were of healthy 
 appearance; but the vitreous humor, when illuminated 
 by the ophthalmoscope, was seen to be turbid through- 
 out. After enucleation of the right eyeball, the 
 sympathetic symptoms and the ophthalmoscopic ap- 
 pearances gradually improved ; but no amendment of 
 vision had taken place at the time of the patient's dis- 
 charge, nine weeks after the operation. In the enu- 
 cleated eye the anterior portion of the choroid, with 
 the neighboring part of "the ciliary muscle, could be 
 easily detached from the sclerotica, whilst the connec-
 
 ETIOLOGY. 41 
 
 tion between the retina and the vitreous body was 
 likewise abnormal. In this unfortunate case the ex- 
 traction of a cataract from the second eye had not only 
 failed of its immediate object, but had seriously en- 
 dangered the restored sight of the first eye. 
 
 Knapp reported a similar unfortunate case in 1869. 
 He operated successfully, after v. Graefe's method, on 
 the left eye of a man sixty years of age. The eye 
 healed in a favorable manner, and, six days after the 
 first extraction, the operation was repeated upon the 
 other eye. The repetition, however, was less fortu- 
 nate. There was haemorrhage into the anterior cham- 
 ber, with subsequent iritis, and, later, sympathetic iritis 
 of the first eye. Six weeks after the. operation, both 
 pupils had become occluded, and both eyeballs some- 
 what soft. 
 
 When the subject of sympathetic ophthalmia, occur- 
 ring after cataract operations, was introduced by Klein, 
 at the Heidelberg Ophthalmological Congress in 1874, 
 a whole series of cases, wherein sympathetic affections 
 had proceeded from the linear, or the various modifi- 
 cations of the linear, extraction, were communicated 
 by oculists present. Becker collected (1875) twenty- 
 two cases (neglecting, however, to include Knapp's 
 case) of sympathetic disease, resulting after cataract 
 operations. Seven of these cases followed the flap op- 
 eration, four of the latter being well-recognized speci- 
 mens of simple senile cataract ; and fifteen occurred
 
 42 SYMPATHETIC DISEASES OF THE EYE. 
 
 after operations by the linear method. Since that 
 time further reports have been made of cases of sym- 
 pathetic disease resulting from v. Graefe's extraction 
 method. 
 
 The various causes of the original irritation in an eye 
 that has been subjected to an operation for cataract 
 are: incarceration of the iris in the wound, with or 
 without visible prolapse of the iris (Klein, v. Arlt) ; 
 imprisonment in the wound of a portion of the capsule 
 of the lens, so that the suspensory ligament and ciliary 
 body, at the opposite side of the eye, are dragged upon, 
 or detachment of the ciliary body at the same spot 
 (Horner) ; shrivelling of the capsule of the lens (caused 
 by inflammatory, exudation, or the development of a 
 secondary cataract), with subsequent stretching of the 
 iris and ciliary body (Hanel, Becker) ; and lastly, di- 
 rect injury of the ciliary body, when the incision has 
 been made too far out in the sclerotica (Ed. Meyer). 
 
 Shall we include simple iridectomy among the 
 surgical operations that may cause sympathetic oph- 
 thalmia? Individual cases, showing this origin, are on 
 record. 
 
 "We have, so far, seen how traumatic affections of the 
 uveal tract may endanger the integrity of the unin- 
 jured eye, and it is now time for us to inquire what 
 importance those affections of the same regions, which 
 are not due to injuries, may have in the production of 
 sympathetic phenomena. The affections not due to
 
 ETIOLOGY. 43 
 
 inj ury are divisible into two classes : the one embracing 
 diseases excited by mechanical irritation of some por- 
 tion of the uveal tract by bodies which cannot, strictly 
 speaking, be designated as traumatic agents ; and the 
 other, comprising the purely idiopathic affections. 
 
 In the first class belong those lesions which are pro- 
 duced by spontaneous dislocations of the lens, as well 
 as by cysts of the iris, choroidal sarcomata, retinal gli- 
 omata, and intra-ocular cysticerci. Mooren believes 
 that irido-choroiditis is produced by a spontaneously 
 dislocated lens, only when the latter has fallen into 
 the anterior chamber. Hulke, Knapp, and Nagel saw 
 cases in which cysts of the iris had caused irido-choroi- 
 ditis, with sympathetic irritation ; and moreover, impli- 
 cation of the second eye, even where the first eye never 
 became inflamed. An eye affected with choroidal sar- 
 coma is prone to be succeeded by sympathetic disease 
 (Pagenstecher, Norris, Steffan, Nettleship, Salvioli, 
 Hirschberg, Knies) ; but it should be borne in mind 
 that choroidal sarcoma is very frequently due to a 
 traumatic agency. Steinheim reports a case of sym- 
 pathetic irido-choroiditis ensuing upon traumatic gli- 
 oma of the retina. The cysticerci are analogous to the 
 neoplasms, in their causal relations to primary irido- 
 choroiditis and its sympathetic sequelae. 
 
 Idiopathic cyclitis, or irido-cyclitis, is a rare disease. 
 When its attacks upon the two eyes are not synchro- 
 nous, but are separated by a certain interval, it is not
 
 44 SYMPATHETIC DISEASES OF THE EYE. 
 
 always easy to determine whether the second eye is 
 sympathetically affected, or the disease in both eyes 
 is due to a common cause. The same may be said of 
 irido-choroiditis occasioned by the syphilitic poison, 
 inasmuch as the disease of the second eye may be 
 a sympathetic, and not a syphilitic lesion. When 
 attacks of that variety of irido-choroiditis, which 
 sometimes attends cerebro-spinal meningitis, occur 
 simultaneously in both eyes, the operation of a com- 
 mon cause is evident ; but if, on the other hand, 
 one eye is first destroyed, and, later in the disease of 
 the nervous system, the other is attacked in a similar 
 way, it is probable that sympathetic influences have 
 been at work. Noyes has reported a curious case of 
 herpes zoster ophihalmicus of the left eye (that variety 
 of herpes zoster in which the eruption follows the dis- 
 tribution of the chief cutaneous branches of the trige- 
 minal nerve), in consequence of which both eyes were 
 destroyed by.subsequent irido-choroiditis, beginning in 
 the right eye ten months later than in the left, and 
 without herpetic disease of the former. Jeffries, like- 
 wise, saw a case of temporary sympathetic disturbance 
 transplanted from an eye that had been destroyed by 
 the same variety of herpes zoster. 
 
 If prolapse, or incarceration of the iris or ciliary 
 body, within a traumatic opening of the eyeball, near 
 the corneal margin, may provoke irritation of the 
 nveal tract and sympathetic phenomena, it is easy to
 
 ETIOLOGY. 4:5 
 
 understand how the same effect may be produced 
 when one or other of these structures is prolapsed or 
 incarcerated within a similarly situated opening, made 
 in the eye by an ulcer ative process. In the latter con- 
 dition very much the same relation of parts exists as 
 after iridodesis ; and indeed, this sort of natural dis- 
 placement of the pupil is quite frequent. * But we 
 must guard ourselves against an exaggerated concep- 
 tion of the danger involved in the accident. I cannot 
 recollect a case, in my personal experience, in which I 
 have seen serious results to the second eye ensue upon 
 this kind of cicatrization of the iris, even of its periph- 
 eral portion, in the cornea. 
 
 Where the ciliary body is thus imprisoned, a much 
 more encouraging prognosis can be made than after a 
 traumatic injury, inasmuch as the latter very fre- 
 quently superadds a direct wound of the ciliary body. 
 The danger of sympathetic inflammation is further di- 
 minished when the ulcerated perforation of the cornea 
 is very large, so that, instead of a small strangulation, 
 a great part of the iris protrudes through the cornea, 
 becomes indurated and thickened from exposure, and 
 forms a permanent protuberance (staphyloma) through- 
 out the area of the absent cornea. In the same way, 
 severe chronic inflammatory processes in the eye may 
 cause the sclerotic zone, just outside the margin of the 
 cornea, to become relaxed and softened, so that the in 
 tra-ocular pressure pushes it forward in such a manner
 
 46 SYMPATHETIC DISEASES OF THE EYE. 
 
 as to present a series of small staphylomata, surround- 
 ing a greater or less arc of the corneal periphery, and 
 in some cases even its whole circumference. If, under 
 such circumstances, sympathetic symptoms should de- 
 clare themselves, they must be attributed, not so much 
 to direct stretching and laceration of the ciliary body, 
 as to a defect in the suspensory ligament, somewhere 
 around the equator of the lens, permitting the disloca- 
 tion of the latter, and the consequent development of 
 sympathetic phenomena in the manner before de- 
 scribed (page 30). 
 
 So far as we have at present proceeded, it has ap- 
 peared that the inflammatory lesions of the uveal tract 
 threaten most danger to the second eye. None of the 
 forms of uveal inflammation here brought under no- 
 tice have followed a turbulent course, nor have they 
 been attended with any acute purulent process. Their 
 character has been insidious, and the ciliary body has 
 been always more or less directly involved. 
 
 Glaucoma, simply as such, possesses no inherent 
 power to awaken sympathetic disease. When, how- 
 ever, in the last stages of glaucoma, cyclo-choroiditis 
 sets in, and the eye, hitherto abnormally hard, becomes 
 soft, as well as painful over the ciliary region, the sec- 
 ond eye becomes as much endangered sympathetically 
 (Mooren, v. Arlt) as if the cyclo-choroiditis had its 
 seat in a non-glaucomatous eye. Moreover, when we 
 see a case of sympathetic ophthalmia ascribed to a de-
 
 ETIOLOGY. 47 
 
 tachment of the retina in the first eye, or to a haem- 
 orrhage into the vitreous humor, we should incline 
 toward the belief that a cyclitis had supervened upon 
 the primary lesion, and had itself been the cause of 
 the sympathetic derangement; as Mooren expressly 
 argues, in the case of retinal detachment. 
 
 Some important questions which we next have to 
 answer are : Does purulent inflammation of the 
 uveal tract, also, lead to sympathetic ophthalmia ? 
 Can sympathetic ophthalmia supervene when the dis- 
 ease of the first eye is confined to the iris or to the 
 choroid alone, produces no tenderness over the ciliary 
 region, does not implicate the ciliary body, and pur- 
 sues an unobtrusive course ? Finally, can sympathetic 
 ophthalmia be set on foot without lesion, of any part 
 whatever of the uveal tract of the first eye ? 
 
 It has been generally held that acute purulent in- 
 flammation of the uveal tract .(better termed panoph- 
 tfialmitis, inasmuch as the purulent process, accompa- 
 nied by great swelling, is not confined to the uveal 
 tract, but attacks all the tunics of the eye, as well as 
 the vitreous humor) is devoid of sympathetic danger to 
 the second eye. But exceptional cases to the contrary 
 have been reported (Mooren, Rossander). Alt, who 
 ascertained the pathological histories of one hundred 
 and ten eyes, which had been enucleated on account 
 of sympathetic disease (thirty-two of them under his 
 own observation), found that twenty-one of the
 
 48 SYMPATHETIC DISEASES OF THE EYE. 
 
 ber, or nineteen per cent., had been affected with typi- 
 cal panophthalrnitis. 
 
 Again, it has been established that sympathetic af- 
 fections may occur independently of any disease of 
 the ciliary body, and even without any well-defined 
 lesion of the uveal tract. Mooren (1869) cites among 
 the diseases which may lead to sympathetic trouble, 
 not only lesions of the ciliary body, but also those of 
 the conjunctiva, sclerotica, cornea, iris, choroid, retina, 
 and lastly, atrophy of the globe. It should be added, 
 however, that he gives the most etiological importance 
 to cyclitis, and lays particular stress upon the stretch- 
 ing, or laceration of the ciliary body, whereby a sim- 
 ple, minute prolapse of the iris becomes fraught with 
 danger to the second eye. Peppmiiller (1871) re- 
 ported a few cases of sympathetic iritis following 
 simple prolapse of the iris, without symptoms of 
 cyclitis. Liiders (1872) saw a case of injury of the 
 e} r e, in which the iris and anterior capsule of the lens, 
 in the second eye, became agglutinated together seven 
 weeks after the injury, although there had been no 
 sensitiveness to pressure or softening of the injured 
 eye. 
 
 From a series of cases brought forward by Warlo- 
 mont (1872), it appeared, in one case, that an obstinate 
 sympathetic kerato-conjunctivitis could only be cured 
 after enucleation of the first eye, which had been for 
 a long time atrophied, but never sensitive. In another
 
 ETIOLOGY. 49 
 
 case, that of a veteran, Warlomont speaks of a " severe 
 external inflammation of the right eye " as an expres- 
 sion of sympathetic disease, although the stump of the 
 other eye, which had been destroyed by a wound, was 
 " perfectly painless." Other cases of the series give 
 abundant evidence that phthisical eyeballs, which have 
 never manifested pain, either spontaneously or on 
 pressure, can, nevertheless, set up sympathetic disease. 
 Out of ninety cases of sympathetic ophthalmia, pub- 
 lished by Rossander in 1876, two originated in pain- 
 less atrophy of the fellow eye ; and out of ninety sim- 
 ilar cases, reported by Vignaux in 1877, eight could 
 be clearly referred to the same condition. The state- 
 ment, therefore, is not entirely warrantable, that when 
 a phthisical eye has seemed perfectly quiescent, a de- 
 posit of bone within the degenerated globe, irritating 
 the choroidal tract in a purely mechanical way, and 
 thereby renewing the tenderness and pain in the atro- 
 phic eye, must invariably be present in order to pro- 
 duce sympathetic disease. 
 
 Cohn (1871) met with two cases of sympathetic im- 
 pairment of vision, after gunshot wounds, without 
 symptoms of iritis, or cyclitis, in the wounded eye. In 
 one of his cases the blind and offending eye had un- 
 dergone extensive inflammation of the choroid and 
 retina, as was established both by the ophthalmoscope 
 and by anatomical examination after enucleation. In 
 
 the other case, only a superficial grazing wound from 
 3
 
 50 SYMPATHETIC DISEASES OF THE EYE. 
 
 a fragment of shell, had been inflicted upon the eye, 
 which showed no internal lesion other than an effusion 
 of blood between the yellow spot of the retina and the 
 choroid. Brecht (1874) also saw a case in which dis- 
 turbance of sight in the right eye hachbeen transmitted 
 sympathetically from its injured fellow, which latter, 
 however, was " absolutely quiescent, showed no trace 
 of unnatural redness, and was wholly devoid of pain, 
 either spontaneously or under pressure." Pfliiger 
 (1875) traced a sympathetic affection of the one eye 
 to a wound made by a piece of stone on the other, 
 whilst the ciliary body of the injured organ seemed to 
 be normal in every respect. He also reported another 
 case, at the same time, in which an eye that had been 
 destroyed by gonorrhoaal ophthalmia, proved treacher- 
 ous to its mate a few weeks later ; nevertheless, when 
 enucleated, it showed no sign of cyclitis, but simply 
 an inflammatory infiltration of the iris. 
 
 Indeed, if we give credence to general pathologico- 
 anatomical reports, we shall not need to search out 
 individual cases in order to prove that sympathetic 
 affections of the eye may arise quite independently of 
 any disease of the ciliary body. Out of one hundred 
 and ten dissected eyes upon which Alt reported, m 
 the " Archiv fur Augen- und Ohrenheilkunde, 1877," 
 only seventy-six and one-half per cent, disclosed any 
 disease of the ciliary body. Alt's words are as fol- 
 lows: "The iris is altered in sixty-eight per cent, and
 
 ETIOLOGY. 51 
 
 the choroid in seventy-three per cent, of the cases ; so 
 that the alterations found in the individual parts of 
 the uveal tract are about equally distributed those 
 in the ciliary body very slightly exceeding in number 
 those in each of flfte other parts." 
 
 The iitting of an artificial eye upon a painless stump 
 has been known to develop sympathetic ophthalmia 
 (Lawson, Mooren, Keyser) ; and reports of cases are at 
 hand where the insertion of an artificial eye into an 
 orbit, from which a diseased eye had been removed to 
 abolish sympathetic irritation, has again excited the 
 same morbid condition (Salomon, Warlomout). Fi- 
 nally, it has happened that the enucleation of an in- 
 jured eye, or the sequelae of the operation, performed 
 for the especial purpose of preventing the sympathetic 
 implication of its partner, have produced the appre- 
 hended condition (Mooren, -Colsmann); or that the 
 amelioration first following the enucleation of the 
 offending eye has afterward disappeared, and the 
 sympathetic disturbance been reinstated by the agency 
 of the surgical operation itself (Hasket Derby). 
 
 While it is already evident, from our superficial 
 notice of facts, which will receive further considera- 
 tion as we proceed, that manifold forms of sympathetic 
 disease may arise without the presence of cyclitis at 
 the time, or even without disease of any portion of the 
 uveal tract, there remains a question which should be 
 answered in this place. Assuming that an injured
 
 52 SYMPATHETIC DISEASES OF THE EYE. 
 
 eye, in which no foreign body lies concealed, recovers 
 perfectly, so far as we can ascertain by clinical exam- 
 ination, from an attack of severe cyclitis Recovers 
 even without degenerating into a state of atrophy 
 can such an eye, nevertheless, excite symptoms of sym- 
 pathetic ophthalmia in the fellow eye ? This question, 
 be it understood, can only be put where the cyclitis is 
 of traumatic origin for if, after the recovery of an 
 eye from spontaneous cyclitis, the same disease be set 
 up in the second eye, we cannot have absolute proof 
 of its sympathetic character. In answer to the fore- 
 going question, I communicate the following case : 
 
 A common laborer, sixty years of age, presented 
 himself at the Ophthalmic Clinic, October 3, 1875. 
 He stated that he had been struck on the right eye, 
 five years previously, by the rebounding branch of a 
 tree, and that the sight of the injured eye had been 
 instantaneously lost. He also complained that for 
 about five years preceding his appearance he had been 
 unable to read with his left eye, and that during the 
 last year the sight of this eye had rapidly decreased. 
 Both eyes showed signs of cataract. In the totally 
 opaque lens of the right eye sparkling crystals of cho- 
 lesterine, the product of a prolonged process of degen- 
 eration, justified the inference that the cataract had 
 existed even a considerable period previously to the 
 infliction of the injury. In the left eye the cataract 
 was of more recent formation. In each eye the per-
 
 ETIOLOGY. 53 
 
 ception of light corresponded to the degree of opacity 
 of the lens. Both cataracts were extracted at one 
 sitting, by v. Graefe's method, but both operations met 
 with impediments to their perfect performance. In 
 the right eye fragme'nts of the lens remained behind 
 in the capsule, and after the removal of the speculum 
 the patient squeezed his lids together, causing escape of 
 vitreous through the incision. In the left eye vitreous 
 humor escaped before the extraction of the lens, so 
 that the latter had to be removed with the spoon. The 
 right eye recovered with but slight inflammatory re- 
 action ; the left, however, developed irido-cyclitis. Of 
 the latter (left) organ, it was noted, on October 3d : 
 " Cornea and aqueous cloudy ; pupil occluded by ex- 
 udation masses, and displaced upward ; ciliary region 
 painful ; abnormal softness of the globe ; perception 
 of light." And again, on November 22d : " Tension 
 of eye has become normal ; the ciliary region is but 
 slightly sensitive to the touch; a small opening has been 
 cleared through the upper and outer part of the pupil ; 
 the patient can count fingers, with this eye, at a dis- 
 tance of three feet." On the day of the patient's dis- 
 charge, December 1st, no vestige of irritation, sensi- 
 tiveness, or softness remained in the left eye ; the 
 cyclitis had completely vanished, and vision was ^ 
 normal. In the right eye the pupil was clear, and the 
 fundus of the globe distinctly visible, but floating 
 opacities in the vitreous were scattered over the field
 
 54 t SYMPATHETIC DISEASES OF THE EYE. 
 
 of vision. These opacities, however, could not be 
 taken as evidence of cyclitis, because the ciliary body 
 in the right eye had not been painful, and the / eyeball, 
 after the week first following the operation, had been 
 perfectly free from injection, painless, and of normal 
 tension. It possessed one-eighth of the normal amount 
 of vision. No portion of the iris, in either eye, was 
 included in the cicatrix. The patient was discharged 
 in the forementioned condition. 
 
 On January 18, 1876, he returned, with the com- 
 plaint that, without any external provocation, his right 
 eye now suffered. The left eye the one that had 
 been affected with cyclitis had not been in the least 
 degree painful or reddened during the seven weeks 
 succeeding the discharge of the patient, and on the 
 day of his return showed no trace at all of vascular 
 injection, or of tenderness, on pressure, over the ciliary 
 body ; its vision was normal. The right eye, on the 
 other hand, showed all the symptoms of a highly acute 
 irido-cyclitis : intense episcleral injection environed 
 the corneal border, the pupil was plugged with a 
 mass of pus, and displaced toward the place of inci- 
 sion, the globe was soft, the sight was dwindled to a 
 mere perception of light and darkness, and the al- 
 ready spontaneously acute pain became maddening 
 when pressure was made over the ciliary body. 
 
 Here an operation, performed for the relief of cata- 
 ract, had excited primary cyclitis in the left eye. The
 
 ETIOLOGY. 55 
 
 disease, however, had not advanced to atrophy of the 
 globe, but recovered most perfectly. About six weeks 
 later, after all the symptoms of the previous cyclitis 
 had disappeared from the left eye, the right eye, with- 
 out any external cause, and without any symptoms of 
 the reappearance of disease in the eye originally af- 
 fected, was visited with an attack of irido-cyclitis, 
 greatly surpassing in severity the primary affection of 
 the first eye. Thus, even after the complete recovery 
 of one eye from an attack of cyclitis a recovery not 
 ending in atrophy of the globe the other eye is not 
 thereby absolutely assured of immunity against an 
 outbreak of sympathetic ophthalmia. 

 
 SECTION III 
 
 PATHOLOGY. 
 
 IN the preceding section we have considered, so far 
 as is practicable in the preliminary stage of our work, 
 the various individual lesions from which originate the 
 
 c? 
 
 sympathetic diseases usually grouped under the name 
 of sympathetic ophthalmia. We now pass to a more 
 accurate description of the manifold forms in which 
 sympathetic ophthalmia appears. The more knowl- 
 edge we acquire of this class of affections the more 
 multiplied they become. Many forms of ophthalmic 
 disease, whose sympathetic character was formerly 
 and even but recently denied, are now permanently 
 settled in the category of the sympathetic affections ; 
 and many others, which are still involved in great 
 doubt, and whose acceptance as sympathetic diseases 
 is properly deferred, may hereafter come to be re- 
 garded as integral links in this dangerous chain of 
 maladies. 
 
 The following list comprises the sympathetic dis- 
 eases of the eye : neuralgia of the ciliary nerves ; irri-
 
 PATHOLOGY. 57 
 
 tation of the retina, and of the optic nerve ; functional 
 disturbance of the retina; inflammation, severally, of 
 the conjunctiva, cornea, and choroid ; inflammation of 
 the uveal tract, with or without participation on the 
 part of the ciliary body, so that there may be both a 
 sympathetic iritis and a sympathetic choroiditis, with- 
 out coexisting cyclitis; inflammation of the retina, 
 alone or in conjunction with inflammation of the cho- 
 roid ; inflammation of the optic nerve ; glaucoma ; 
 disease of the vitreous, and of the lens. Whether all 
 the diseases above enumerated are legitimate occu- 
 pants of the list of sympathetic affections or not, we 
 shall see in the sequel. We will first describe the 
 symptoms of sympathetic irritation. 
 
 The ciliary nerves play so important roles in the 
 pathogeny of the sympathetic diseases that, before dis- 
 cussing the subject of ciliary neuralgia, we shall de- 
 vote a few lines to the anatomical description of these 
 nerves. 
 
 The naso-ciliary nerve enters the orbit through the 
 sphenoidal fissure, as the third branch of the ophthal- 
 mic (sensitive) division of the trigeminus. In the first 
 part of its course it lies on the temporal side of the 
 optic nerve and then passes obliquely over toward the 
 inner wall of the orbit, between the optic nerve and 
 the superior rectns muscle. As it crosses the optic 
 nerve, the naso-ciliaris, having previously given off the 
 
 long sensory root (radix longa) to the ciliary ganglion, 
 3*
 
 58 SYMPATHETIC DISEASES OF THE EYE. 
 
 sends off from one to three filaments, called the long 
 ciliary nerves, which run straight forward to the eye- 
 ball. The ciliary ganglion, an oblong flattened body, 
 of about the size of a pin-head, situated between the 
 optic nerve and the external rectus muscle, receives 
 motor fibres (radix brevis) from the third cranial 
 nerve (oculo-motor), and sympathetic fibres (radix 
 sympathetica) from the cavernous plexus, which sur- 
 rounds the internal carotid artery. The three roots 
 just mentioned enter the posterior border of the gan- 
 glion ; whilst the anterior border gives off the short 
 ciliary nerves, which then pass forward to enter the 
 eye. The long and short ciliary nerves split up into 
 fifteen or twenty filaments before piercing the sclero- 
 tica around the periphery of the optic nerve, and di- 
 viding still further as they advance, run forward, be- 
 tween the choroid and sclerotica, to the ciliary muscle, 
 in which they form a fine net-work, from which nu- 
 merous fibres are distributed to the iris and cornea. 
 The ciliary nerves, by reason of their triple composi- 
 tion, confer sensibility upon the individual parts of the 
 eye, as well as motility upon the ciliary muscle, the 
 muscles of the iris, and those of the parietes of the 
 vessels. They are, moreover, probably endowed with 
 other functions , which will engage our attention far- 
 ther on. 
 
 In connection with the phenomena of sympathetic 
 irritation, it should be remembered that, when one eye
 
 PATHOLOGY. 59 
 
 becomes inflamed and painful, from whatever cause, J 
 the other can no longer, as a general rule, be used 
 without showing unmistakable symptoms of weariness. 
 In certain inflammations for example, those phlycten- 
 ular lesions of the cornea which accompany the so- 
 called scrofulous affections of the eye the photophobia 
 of the diseased eye is often propagated to the second, 
 even when the latter is perfectly well, so that both eyes 
 are held tightly closed, and are totally incapacitated 
 for use. Or, if the case does not exhibit such extreme 
 symptoms as these, the second eye, in consequence of 
 severe irritation, pain, or inflammation of the first, can- 
 not be employed at fine work without soon becoming 
 tired and strained. Every considerable effort, perhaps 
 for a longer, perhaps for a shorter period, causes the 
 second eye to redden and become irritable, and pro- 
 vokes so painful sensations as seriously to impede 
 its function. Indeed, the presence of a particle of ? 
 coal-dust in the conjunctival sac of the one eye often- 
 times suffices to set up a whole train of symptoms of 
 irritation in the other. 
 
 I do not know exactly what name to give to this 
 striking form of " fellow-suffering " (as it were " sym- 
 pathy ") in the well eye. " Sympathetic irritation " is 
 rather objectionable, for, although these words really 
 define the state of things as just described, we feel 
 justified in reserving this expression to indicate a con- 
 dition which closely borders upon sympathetic ophthal-
 
 60 SYMPATHETIC DISEASES OF THE EYE. 
 
 mia, or, indeed, constitutes its preliminary stage. For, 
 while the irritation in the second eye, which is due to 
 pain in the first, usually vanishes with the subsidence 
 of the original pain, or very simple means, such as the 
 application of a compress-bandage to the diseased eye, 
 generally relieves the spasmodic closure of the lids in 
 the other, and enables the patient to separate them 
 freely, this simple form of irritation in the second eye 
 and here is the main point may persist for a long 
 time without danger of involving tJie organ in sub- 
 stantial lesions. 
 
 On the other hand, where true "sympathetic irrita- 
 tion " is present, we have a very different and infi- 
 nitely more serious state of matters. For example, an 
 eye that has received an injury, and been very speedily 
 attacked with irritation and inflammation, may excite 
 almost simultaneously, in the opposite eye, so acute and 
 painful phenomena that it is by no means uncommon 
 to hear the patients complain that, for the first day or 
 two after the injury, they were blind in both eyes. 
 When the inflammation and pain subsequently subside 
 in the injured eye, the second becomes again quiescent 
 and serviceable, and remains so during a certain inter- 
 val. After a time, however, without the necessity of 
 any especial exacerbation of the disease in the first eye, 
 and even when the eyeball is no longer spontaneously 
 painful, but only painful or sensitive to the touch, the 
 symptoms of irritation may reappear in the second eye,
 
 PATHOLOGY. 61 
 
 so that it becomes sensitive when exposed to a brighter 
 light than usual, and fatigued by work that makes but 
 slight demands upon its accommodation. The patient, 
 moreover, may occasionally have noticed, even from 
 the date of the original injury, that the employment 
 of the eye, at the accustomed distance from the work, 
 required a certain effort, which was relieved by holding 
 the work farther from the eye. If the exercise of vi- 
 sion is persistently prolonged, the eye becomes bathed 
 in tears, pain is felt, as well in the neighboring regions 
 as in the eye itself, objects are seen as if through a fog, 
 and if the work be pushed to an extreme limit, the eye 
 becomes utterly disabled for a time. We can, further, 
 often learn by inquiry, that the e} 7 e, even when not 
 taxed by exertion, is subject to temporary obscuration 
 of its field of vision. Sometimes, also, during this irri- 
 tative stage, the patient complains of subjective sensa- 
 tions of light, in the form of sparks or flashes of fire. 
 
 It is not probable that these symptoms of " sympa- 
 thetic irritation " depend, in their early stage, upon 
 textural alteration already present in the eye, for they 
 promptly disappear, once for all, as soon as the oppo- 
 site eye is enucleated. In those cases in which the 
 symptoms of irritation do not cease in the second eye, 
 notwithstanding the enucleation of the injured eye, 
 but, on the contrary, give place to those of violent in- 
 flammation, or in which the inflammation is lit up in 
 the sympathetic eye after the operation, without any
 
 62 SYMPATHETIC DISEASES OF THE EYE. 
 
 preliminary stage of irritation, we must assume that 
 some structural disease, without salient symptoms, 
 had already invaded the second eye at the tiin when 
 its partner was removed; or that some insidious dis- 
 ease, which did not depend directly upon the disease 
 itself, was on its way toward the second eye, and could 
 not be prevented by the operation ; or, finally, that the 
 very operation, practised for the relief of the irritated 
 eye, was itself the cause of the sympathetic oph- 
 thalmia. 
 
 If no textured alteration exists in the second eye at 
 the time of the " sympathetic irritation," the latter 
 must be ascribed to an irritated condition of the ciliary 
 nerves, as well as of the retina and optic nerve. Under 
 such circumstances, it appears to me that the primary 
 involvement is to be sought for in the retina, inasmuch 
 as the sensitiveness of the eye to light, the quick exhaus- 
 tion of the retina by work, the transitory obscuration 
 of the field of vision, and the subjective sensations of 
 light, all point toward this conclusion. This primary 
 irritation or hyperaesthesia of the retina begets a sec- 
 ondary or reflex neurosis in the tract of the ciliary 
 nerves, which consist in great part of sensory filaments 
 from the trigeminns. In consonance with this view, 
 we do not believe that these symptoms depend upon a 
 hidden affection of the muscles, or upon asthenopia of 
 accommodation, such as appears in consequence of the 
 weakness of the muscle concerned in this function.
 
 PATHOLOGY. 63 
 
 is it our opinion that the holding of the work at a far- 
 ther distance than usual from the eye is so much a proof 
 that the affection of the ciliary muscle is the primary 
 one, from which the other phenomena of sympathetic 
 irritation proceed, as that the ciliary nerves labor under 
 a reflex neurosis propagated from the primary affec- 
 tion of the retina, so that the contractions of the ciliary 
 muscle, which necessarily provoke pain in the sensory 
 filaments of the sympathetic nerves, are avoided so far 
 as possible. 
 
 It is certainly not our intention, in what we have just 
 said, to deny that primary ciliary neuralgia may ini- 
 tiate sympathetic disease. This affection, which has its 
 seat in the ciliary and circumorbital branches of the 
 trigeminus, is characterized by violent pain, which is in- 
 creased by work, so long as work is possible, as well as 
 by light ; while, at the same time, the pain does not 
 disappear, even if the patients abandon all exertion on 
 the part of the eyes, and exclude them wholly from 
 the influence of light. Although we cannot discover 
 any definite lesion of the eye, it is evident that the 
 neuralgia of the eyeball is principally located in the 
 ciliary body (the very locality of the chief distribution 
 of the nerves), because even the slightest pressure over 
 the ciliary region exaggerates the pain to an intoler- 
 able degree. To diagnosticate cyclitis under these 
 circumstances would be quite unjustifiable, for not a 
 trace of inflammation exists in the ciliary body a
 
 64 SYMPATHETIC DISEASES OF THE EYE. 
 
 this period, but simply an exquisitely painful and vio- 
 lent neuralgia of the region involved. 
 
 The same irritative condition which has been wit- 
 
 / 
 
 nessed in the tract of the ciliary nerves, may also as- 
 sume a violent type in the retina and optic nerve ; so 
 that the symptoms of sympathetic irritation vary ac- 
 cording to the functions of the parts involved. The 
 eye affected by sympathy may exhibit the most intense 
 photophobia, which, in turn, may develop spasmodic 
 action of the orbicularis muscle, which now presses 
 the eyelids so tightly together that the patient cannot 
 open his eyes at all, and often imagines himself to be 
 blind. Douders has related several cases of this form 
 of severe sympathetic irritation. The fact that the 
 photophobia disappears, and the normal power of vi- 
 sion returns, after enucleation of the opposite eyeball, 
 goes to prove that the spasm of the lids was due to the 
 photophobia alone. We are here to remark, moreover, 
 that the sympathetic irritation of the retina may de- 
 generate not only into intense photophobia, but into 
 the worst phase of photopsia, in which the patient is 
 beset with subjective sensations of the most torment- 
 ing character. We have already mentioned that the 
 patient may often suffer from transitory sensations of 
 light during the ordinary forms of sympathetic irrita- 
 tion ; but it sometimes happens that this phenomenon 
 reaches an extraordinary height, and then constitutes 
 an affection of the most serious importance.
 
 PATHOLOGY. 65 
 
 An eyeball is wounded by a penetrating fragment of 
 a percussion-cap. About one year afterward, Alfred 
 Graefe enucleates the injured eye (although its vision 
 is but slightly deteriorated), on account of the distress- 
 ing subjective sensations in the other eye, which are, 
 however, entirely independent of any demonstrable 
 morbid alteration, while, furthermore, the vision of 
 this eye is absolutely unimpaired. Leber examines 
 the enucleated eye and discovers the fragment of cap 
 adhering firmly to the inner surface of the apparently 
 normal ciliary body. That portion of the retina which 
 covers the ciliary body, and is called the pars ciliaris 
 retinae, is thickened where it lies applied to the for- 
 eign body, and a new formation of connective tissue 
 is found at the intra-ocular extremity of the optic 
 nerve. The subjective sensations are not ameliorated 
 by the operation, but reach so extreme a grade 
 that fears are entertained for the life of the patient. 
 A violent degree of photopsia may certainly ac- 
 company simple irritation of the optic nerve, but in 
 that case the photopsies vanish after the enucleation 
 of the first eye. "Was there not, therefore, in this case 
 of Graefe's, some substantial lesion already present in 
 the sympathizing eye ? We shall resume this question 
 in a subsequent place. 
 
 But photophobia and photopsies are not the only 
 subjective symptoms of irritation of the optic nerve 
 and retina ; for the sympathy may express itself in the
 
 66 SYMPATHETIC DISEASES OF THE EYE. 
 
 form of distinct functional disturbances, or marked 
 impairment of vision, without our being able to dem- 
 onstrate the presence of any definite structural lesion 
 in either the percipient or the conducting apparatus 
 of the eye. We should first mention, in connection 
 with this form of sympathetic irritation, that we may 
 observe not only momentary obscuration and limitation 
 of the field of vision, but even longer intervals of sus- 
 pension of the normal function of the retina. Lie- 
 breich gives instances in which the sympathetic irrita- 
 tion of the retina manifested itself by photophobia 
 and obscurations of the field of vision, which lasted 
 from half a minute to a minute, appearing and disap- 
 pearing at regular rhythmical intervals. A still more 
 important form is that sympathetic disturbance of vi- 
 sion which bears some relation to the affection to 
 which v. Graefe gave the name of anaesthesia of the 
 retina (proceeding from hypersesthesia), while Stef- 
 fan did not hesitate to call it genuine hypercesthesia of 
 the retina. This is the same malady for which Schil- 
 ling proposed the name of " contraction of the field of 
 vision, without anatomical lesion." This disease is 
 characterized, on the one hand, by a diminution of the 
 acuteness of central vision, and on the other by anaes- 
 thesia of the peripheral portion of the retina, so that 
 the field of vision is concentrically contracted, and in 
 a very uniform manner in all directions. The func- 
 tion of accommodation may also be impaired. The
 
 PATHOLOGY. 67 
 
 ophthalmoscope reveals nothing abnormal, either in the 
 retina or in the optic nerve. Mooren has reported 
 several cases of this form of sympathetic disease, and 
 a case described by Brecht (1874) may here serve for 
 an example. 
 
 The injured left eye is very soft at the time of the 
 first examination, but is entirely free from irritation. 
 With the right eye, which appears normal, the patient 
 can count fingers, in ordinary light, at a distance of 
 only eight feet. If the eye is fixed upon a given point 
 on a black-board nine inches away, it cannot distin- 
 guish the traces of a piece of white chalk at a greater 
 distance than two and a half inches in any direction 
 from the point of fixation. The field of vision is, 
 therefore, concentrically contracted, so that, at a dis- 
 tance of nine inches from the eye, it embraces only 
 a circle two and a half inches in diameter, described 
 around the point of fixation. There are no pathologi- 
 cal alterations visible with the ophthalmoscope. After 
 enucleation of the left eyeball, both central and per- 
 ipheral vision begin to show a decided improvement, 
 and ten weeks after the operation, central acuteness of 
 vision, as well as the peripheral field of vision and the 
 function of accommodation, are all nearly normal. A 
 black splinter of metal is found imprisoned within the 
 enucleated eyeball. 
 
 Colin has reported two cases which, as Leber be- 
 lieves, should be included in the present class of sym-
 
 68 SYMPATHETIC DISEASES OF THE EYE. 
 
 pathetic affections. We have previously alluded to 
 the pathological changes in eyes that have been sub- 
 jected to contusions from gunshot wounds (page 49), 
 so that we may here briefly state that the sympathetic 
 disturbance of vision in Cohn's cases was character- 
 ized by reduction of central vision, as well as by im- 
 pairment of the function of accommodation, and, in 
 one of the cases, by severe photopsies, which were re- 
 peatedly produced by the most trivial exercise of the 
 eye. Cohn says nothing about the state of the field of 
 vision, so that we do not know whether it was con- 
 tracted concentrically, if contracted at all. The enu- 
 cleation of the injured eye completely dissipated the 
 sympathetic troubles. Hyperaesthesia of the retina 
 (not necessarily accompanied by photophobia and pho- 
 topsia) would appear to be the cause of similar sympa- 
 thetic disturbances of vision without any structural 
 alterations in the eye. 
 
 We now turn our attention from the manifold as- 
 pects of sympathetic irritation, to the still more varied 
 forms of sympathetic inflammation. In what causal 
 relationship with the inflammation does the irritation 
 stand? Is sympathetic irritation the forerunner of 
 sympathetic inflammation ? There is no doubt that 
 the complex of symptoms, characterized by sensitive- 
 ness of the eye to light and work, slight transitory 
 congestion of the pericorneal region, painful sensa-
 
 PATHOLOGY. G9 
 
 tions in and around the eye, and periodical haziness of 
 the field of vision, is to be regarded in the light of a 
 premonitory stage of sympathetic inflammation, which 
 now lies close at hand. It is, however, still an open 
 question, whether the uncomplicated ciliary neurosis, 
 or pure photophobia and photopsia, as well as func- 
 tional disturbances of the retina without structural 
 lesions (although these affections can, as a matter of 
 fact, continue, simply as such, for a long time), do not 
 finally become transformed, on the one hand into 
 cyclitis, or on the other into inflammation of the retina 
 or of the optic nerve. It would, however, be incur- 
 ring a very bold risk to base our therapeutical meas- 
 ures on the assumption that such a state of irritation 
 never becomes transmuted into one of inflammation, 
 
 In proceeding to consider the different manifesta- 
 tions of sympathetic inflammation, as it affects the in- 
 dividual parts of the eye, we must first notice the cornea. 
 Sympathetic keratitis is described by Warlomont as 
 being marked by inflammatory cloudiness of the super- 
 ficial layers of the cornea, and a profuse development 
 of vessels therein, conjoined with pain in the periorbital 
 region and head, on the affected side, together with in- 
 tense monocular conjunctivitis. We have already re- 
 ferred to a case in which an eye was destroyed by the 
 thrust of a cow's horn. The eyeball was reduced to a 
 small stump, and, for ten years afterward, remained 
 painless and inoffensive to its mate. After that period
 
 70 SYMPATHETIC DISEASES OF THE EYE. 
 
 keratitis appeared in the second eye, underwent con- 
 tinual relapses during several years, and was rebellious 
 to all treatment until the atrophic stump was finally 
 enucleated, when the sympathetic affection disap- 
 peared, as if by magic. In further proof of the 
 sympathetic nature of the disease, it may be stated 
 that an artificial eye, worn after the operation, excited 
 inflammation of the palbebral conjunctiva, with which 
 it came in contact, as well as a fresh outbreak of 
 vascular keratitis in the remaining eye, and that when 
 the artificial eye was thrown aside and poultices were 
 applied to the inflamed cavity for several days, the 
 sympathetic keratitis disappeared without the neces- 
 sity of having recourse to any other treatment. 
 
 Rossander has reported one case of sympathetic in- 
 termittent keratitis; while Galezowski, Bheindorf, 
 Ledoux and Yignaux have seen cases of sympathetic 
 Jcerato-iritis. Vignaux (1877) observed the latter condi- 
 tion eight times among ninety cases of sympathetic oph- 
 thalmia. " In this form of keratitis," writes the last- 
 named observer. " the cornea becomes the seat of a very 
 diffuse (sometimes circumscribed) infiltration, which 
 becomes transformed into superficial ulcerations : while 
 one ulcer heals, another makes its appearance. The 
 iris always becomes implicated in the inflammatory 
 process, and pus is occasionally found in the anterior 
 chamber. The ciliary pain is acute, and the photo- 
 phobia is almost as excessive as that which we meet
 
 PATHOLOGY. 71 
 
 with in scrofulous inflammation of the cornea." We 
 must especially notice that tne ciliary body does not 
 seem to be affected during these forms of inflamma- 
 tion, which are generally milder than all others. Al- 
 though not infrequently met with by French writers 
 (constituting as they do almost ten per cent, of Vig- 
 naux's series of cases), they are, nevertheless, seldom 
 reported in German medical literature. Perhaps this 
 hiatus has hitherto been due to a lack of vigilance ill 
 observation. 
 
 Sympathetic ophthalmia may also manifest itself by a 
 genuine attack of sclerotitis, unaccompanied by inflam- 
 mation of the ciliary body. Rossander, for instance, 
 mentions two such cases, in which sympathetic sclero- 
 titis was happily relieved by the enucleation of the in- 
 jured eye. 
 
 Of the various sympathetic inflammatory processes 
 that may affect the individual structures of the eye, 
 those which primarily have their seat in the uveal 
 tract vastly exceed all others in importance, and they 
 are, further, the ones which most often come under 
 observation and treatment. By reason, therefore, of 
 their great significance and frequency, as well as their 
 destructive effects, it is of the first moment that they 
 should be promptly and accurately diagnosticated, with 
 a view to their timely and appropriate treatment. 
 
 Iritis serosa is the least severe of the different forms 
 of sympathetic inflammation of the uveal tract. Sup-
 
 72 SYMPATHETIC DISEASES OF THE EYE. 
 
 pose that the patient complains of a slight failure of 
 vision in his well eye, whilst the opposite eye, which 
 had, perchance, been destroyed by an injury, is still 
 pairjful, or, perhaps, only sensitive to pressure. The 
 characteristic symptoms of sympathetic irritation are 
 not present : the worst that the patient complains of 
 is, that for some time past every object has appeared 
 to be covered with a thin cloud. If the medical at- 
 tendant is not alert, the actual pathological process 
 may be overlooked, and perhaps mistaken for a sym- 
 pathetic functional disturbance of the retina. Careful 
 investigation, however, by daylight, or by the oblique 
 illumination of the eye (the image of a lamp-flame 
 being projected upon the cornea by a strong convex 
 lens), will reveal small, grayish, punctated opacities on 
 the posterior surface of the lower half of the cornea, 
 while, if the pupil be illuminated by the ophthalmo- 
 scope (the patient looking downward), its area will 
 appear to be filled, as it were, with fine dust, inter- 
 spersed here and there with small, dark specks, vary- 
 ing in size from a pin-head to almost microscopical 
 minuteness. It may, indeed, happen that with the 
 unaided eye, or even with oblique illumination, nothing 
 unusual can at first be discovered, and that it will re- 
 quire the use of the ophthalmoscope before the punc- 
 tated appearance of the cornea can be accurately 
 recognized by the incident light. We shall, moreover, 
 now begin to notice that although the eye had been
 
 PATHOLOGY. 73 
 
 pale before the examination, the irritation incident to 
 this procedure has of itself sufficed to provoke a faint 
 rosy zone of episcleral injection around the margin of 
 the cornea. We shall also, perhaps, see that the pupil, 
 although perfectly free, and nowhere adherent to the 
 anterior capsule, does not react so promptly to the in- 
 fluence of light and shade, as when in a normal con- 
 dition, and that, although a comparison with the 
 other eye may not now be practicable, the pupil is 
 evidently rather larger, and the anterior chamber 
 much deeper than in the mate. Sensitiveness of th'j 
 ciliary body is not necessarily educed by pressure. 
 The tension of the globe is, on the whole, quite normal : 
 sometimes it may be increased, but it is never dimin- 
 ished. Such, then, are the most simple indications of 
 serous iritis. 
 
 We have already mentioned that the tine opacities 
 in iritis serosa are situated on the posterior surface of 
 the cornea. We assume that there is an increased ex- 
 udation of serum (with the addition of pus-corpuscles 
 and coagulable material) from the iris into the anterior 
 chamber, which latter is consequently deepened, owing 
 to the pressing backward of the iris and lens by the 
 superabundant fluid. The pus-corpuscles and small 
 masses of coagulable lymph gravitate downward, and 
 become deposited on the posterior surface of the cor- 
 nea ; so that we need not be at all surprised at the 
 
 general absence of these " precipitates " on the upper 
 4
 
 74 SYMPATHETIC DISEASES OF THE EYE. 
 
 portion of the cornea. The presence of these puncti- 
 form deposits is pathognomonic of iritis serosa. Al- 
 though, strictly speaking, they are not always deposits 
 precipitated from the aqueous humor, nevertheless, 
 the difference in their origin does not alter their diag- 
 nostic value. If we puncture the anterior chamber 
 and catch in a watch-glass a portion of the contents, 
 together with some of the precipitates upon the pos- 
 terior surface of the cornea, we may experimentally 
 convince ourselves that these opacities are, as a rule, 
 actual deposits, consisting of particles of coagulated 
 fibrin, enclosing pus-corpuscles in greater or less num- 
 ber. On the other hand, it has been found, during his- 
 tological investigations, that these punctiform spots on 
 the posterior surface of the cornea may also be caused 
 by inflammatory changes in the epithelial lining of the 
 membrane of Descemet, and even in the posterior 
 laminae of the proper corneal substance. It need not, 
 therefore, surprise us that these " precipitates " should 
 now and then be observed, not only on the lower por- 
 tion of the posterior corneal surface, but also opposite 
 the pupil, and sometimes even scattered over the upper 
 half of the cornea. Nevertheless, true inflammation 
 of the membrane of Descemet, or genuine keratitis 
 postica, is always to be regarded as characteristic of 
 the serous form of iritis, inasmuch as it is directly 
 excited by the morbid and irritating contents of the 
 anterior chamber. It is chiefly the accompanying
 
 PATHOLOGY. 75 
 
 turbidity of the aqueous which causes the hazy ap- 
 pearance of all objects seen with the affected eye. 
 
 It is important to note, in this connection, that while 
 sympathetic iritis serosa usually appears under the 
 unobtrusive symptoms above described, those forms of 
 this affection which are independent of a sympathetic 
 origin, are wont to be more distinctly and prominently 
 expressed. In the latter, we not unfrequently notice 
 very marked pericorneal injection, extreme deepening 
 of the anterior chamber, and, instead of the fine punc- 
 tated exudation on the membrane of Descemet, coarse, 
 grayish, or even yellow, nodules, as large as pin-heads 
 or hemp-seeds. It should, moreover, be distinctly 
 borne in mind that we are not directly to diagnosti- 
 cate iritis serosa, on account of the presence of nod- 
 ules of exudation, but to look about for other 
 alterations in the eye. If, for example, we have 
 simultaneously, an inflammatory adhesion of the mar- 
 gin of the pupil to the anterior capsule of the lens, it 
 would be wrong to call the case one of iritis serosa. 
 The precise difference between a serous and a plastic 
 iritis lies in this fact, that in the serous form there is 
 not a sufficient degree of plastic inflammation to effect 
 any such adhesion between the edge of the pupil and 
 the capsule. On the other hand, however, it is by no 
 means uncommon, in a case of violent iritis plastica, 
 to observe flocculent masses of pus or lymph floating 
 about in the aqueous humor, as well as considerable
 
 76 SYMPATHETIC DISEASES OF THE EYE. 
 
 proliferation of the epithelial cells of the membrane 
 of Descemet. 
 
 It is further important for us to insist upon an ac- 
 curate discrimination between the plastic and the 
 serous form of sympathetic iritis. Sympathetic iritis 
 plastica closely simulates, at the outset, common plastic 
 iritis, which, as a rule, leads to only partial adhesions 
 of the pupillary edge to the anterior capsule, but not 
 tc a marked agglutination of the posterior surface of 
 the iris to the capsule of the lens. Sympathetic iritis 
 plastica is, on the contrary, very prone to develop into 
 that more severe grade of iritis in which the adhesion 
 rapidly involves the whole circumference of the pupil- 
 lary border, so as to shut off all communication be- 
 tween the anterior and posterior chambers, producing 
 the condition technically termed exclusion of the pupil. 
 Under these circumstances, the central portion of the 
 anterior capsule, opposite the pupil, may still remain 
 perfectly clear, or, at the most, be covered with so scanty 
 a morbid product as not essentially to obstruct the pas- 
 sage of the rays of light. "When, on the other hand, 
 the pupil is filled with a thick pseudo-membrane, or 
 even with a dense plug of exudation, so that the pu- 
 pillary area is completely abolished, the condition is 
 called occlusion of the pupil. As the exclusion of the 
 pupil may exist without its occlusion, so, conversely, oc- 
 clusion may not necessarily involve exclusion. For it 
 is easy to comprehend that a false membrane may
 
 PATHOLOGY. 77 
 
 wholly Cover the pupil without necessitating a con- 
 tinuous adhesion between the entire circumference of 
 the pupil and the anterior capsule; so that, at one 
 point or another, beneath the edge of the membrane, 
 an opening, however small, may still remain, and so 
 preserve the communication between the two chambers. 
 Occlusion of the pupil, although obstructing the 
 passage of the rays of light, may cause no real dam- 
 age to the eye itself ; but exclusion of the pupil, while 
 presenting no direct barrier to the vision, very fre- 
 quently destroys the affected eye. We may conceive 
 that the aqueous humor is secreted by the ciliary pro- 
 cesses and iris, or perhaps only by the posterior 
 surface of the latter. We know, besides, that the 
 aqueous normally finds its way out of the anterior 
 chamber, by filtration and diffusion into the veins 
 immediately adjacent to its periphery. If, now, the 
 communication between the anterior and posterior 
 chambers is abolished by exclusion of the pupil, the 
 fluid secreted into the posterior chamber, from the 
 ciliary processes and the posterior surface of the iris, 
 is deprived of its normal means of escape into the an- 
 terior chamber, and then into the pericorneal veins, as 
 well as into the sinuses of the ligamentum pectinatum 
 iridis, so that an abnormal accumulation of aqueous 
 takes place in the posterior chamber. It happens, 
 therefore, as soon as the pressure of the fluid in 
 the posterior chamber exceeds that in the anterior,
 
 78 SYMPATHETIC DISEASES OF THE EYE. 
 
 that the inequality manifests itself by the bulging for- 
 ward of the iris into the anterior chamber, except at 
 those points where it is held back by the adhesions. 
 The protrusion forward of the periphery of the iris, 
 accompanied by a crater-like depression of its pupil- 
 lary edge, is, therefore, a sign of exclusion of the pupil. 
 So long as this phenomenon is absent we cannot diag- 
 nosticate exclusion of the pupil ; for, even with the 
 assistance of mydriatics, we are unable to declare 
 positively that some minute hole does not exist, at one 
 point or other, around the apparently completely ad- 
 herent margin of the pupil. 
 
 Now, this imprisonment of the aqueous humor be- 
 hind the iris, with the jutting forward of the periph- 
 ery of the latter membrane, almost invariably leads to 
 a complex set of symptoms, which are comprised un- 
 der the name of secondary glaucoma, in which, with 
 more or less violent attacks of inflammation, the ten- 
 sion of the eye increases and vision diminishes; or the 
 globe remains hard, while vision gradually decreases 
 to utter blindness, without any intercurrent inflam- 
 matory phenomena whatever. The extinction of vi- 
 sion then depends upon a lesion of the optic nerve, 
 producing its total atrophy. Glaucoma is that af- 
 fection of the eye which, with evident hardness of the 
 globe, and with or without inflammatory exacerbations, 
 leads to blindness. When the glaucoma depends 
 upon some affection previously present in the interior
 
 PATHOLOGY. 79 
 
 of the affected eye as in our case, for example, upon 
 a bulging iris, produced by accumulation of fluid 
 behind it the disease is called secondary glaucoma. 
 It follows, therefore, that secondary glaucoma may 
 sometimes occur 'in a sympathetically diseased eye, 
 and cannot always be regarded as a part of the sym- 
 pathetic process. For when sympathetic iritis plastica is 
 followed by continuous circular adhesions (exclusion 
 of the pupil), and finally produces secondary glaucoma, 
 the latter disease depends wholly upon the adhesions, 
 aud not at all upon the sympathetic origin of the latter. 
 We should here incidentally remark that an inclina- 
 tion prevails, whenever sympathetic ophthalmia is met 
 with, to diagnosticate a cyclitis / or when the signs of 
 a plastic cyclitis are wanting, to find, at least, a serous 
 cyclitis. But we are not of those who believe that 
 the bulging forward of the periphery of the iris, in 
 sympathetic ophthalmia, or in secondary glaucoma, 
 furnishes sufficient ground for inferring the existence 
 of a,ny sort of cyclitis, inasmuch as aji analogous con- 
 dition of the iris may likewise be developed in com- 
 mon inflammations of this membrane (which are quite 
 independent of any sympathetic foundation), without 
 properly exciting any suspicion of even serous cyclitis. 
 The idea of assuming the presence of cyclitis, in the 
 generality of cases of sympathetic ophthalmia, is just 
 as unnecessary as the possibility of establishing the 
 fact of its presence is questionable.
 
 80 SYMPATHETIC DISEASES OF THE EYE. 
 
 The mildest form of sympathetic disease of the uveal 
 tract is serous iritis / plastic iritis comes next in order 
 of severity, chiefly on account of the annular/posterior 
 synechise, or exclusion of the pupil, to which it is so 
 prone to give rise ; but incomparably the most serious 
 manifestation of sympathetic uveal disease is the so- 
 called iritis maligna, which is nothing else than a 
 plastic irido-cyclitis. In iritis serosa, adhesions do not 
 commonly take place between the iris and anterior 
 capsule ; in plastic iritis adhesions occur, but they are 
 as a rule, limited to the pupillary border of the iris ; 
 whilst iritis maligna is characterized by extensive ag- 
 glutination of the posterior surface of the iris to the 
 anterior capsule of the lens. Inasmuch as, in iritis 
 maligna, choroiditis is almost always superadded to 
 the irifjfr-cyclitis, and the integrity of the retina be- 
 comes thereby threatened, sympathetic nveitis attains, 
 in iritis maligna, its culminating degree of severity. 
 For when the iris, ciliary body, and choroid are all 
 involved in the inflammatory process, the eyeball is 
 usually consigned to atrophy. 
 
 It is not necessary for us at this point to sketch the 
 symptoms of sympathetic iritis maligna, inasmuch as 
 we have already (pages 26, 27, and 28) clearly de- 
 scribed irido-cyclitis, as well as irido-cyclo-choroiditis, 
 of the primarily affected eye, as they occur either spon- 
 taneously or in connection with injuries; and the sym- 
 pathetic forms do not differ materially froin the primary,
 
 PATHOLOGY. 81 
 
 except in the more frequent opportunities we have for 
 observing the former. In other words, the genuine 
 form of the disease in question is much oftener seen in 
 the eye affected by sympathy, than in the eye originally 
 affected, in which latter the regular type of the disease 
 is frequently obliterated by the immediate effects of 
 the injury. 
 
 What relationship and mutual dependences do we 
 find among the different forms of sympathetic iritis f 
 What are their course and issue ? It is true that iritis 
 maligna is more frequently met with than the serous 
 or the plastic form of iritis ; nevertheless, the two last- 
 named species of this malady are not so rare as is 
 commonly supposed. Statistical inflammation touch- 
 ing the comparative frequency of iritis serosa is not 
 easily obtainable, because the great majority of indi- 
 viduals who are affected with this variety of sympa- 
 thetic disease certainly do not come under the notice 
 of a medical attendant. It may be inquired how this 
 is possible ? Is not serous iritis merely a forerunner 
 of the more important kinds of inflammation of the 
 iris? Is it not the pioneer of iritis maligna? We 
 must promptly answer this question in the negative. 
 Then, again, if the serous form of iritis were transmu- 
 table into iritis maligna, we should probably find few 
 opportunities to observe the former, for the reason 
 that only the severer grades of iritis are likely to bring 
 
 the sufferer under professional observation. The recog- 
 4*
 
 82 SYMPATHETIC DISEASES OF THE EYE. 
 
 nition, therefore, of sympathetic iritis serosa, as a dis- 
 tinct affection, is not, in some respects, of great practical 
 moment. It is, however, of importance for us to know 
 that iritis serosa has no inherent tendency to lapse into 
 the worst forms of iritic inflammation. Whenever a 
 surgeon enucleates an injured eye, on account of sym- 
 pathetic serous iritis, and, upon subsequently seeing 
 amelioration of the symptoms, flatters himself that his 
 well-timed interference has happily prevented a sym- 
 pathetic plastic irido-cyclitis, and blindness of both 
 eyes, he has, in all probability, been the victim of a 
 self-pleasing error. However, we do not here desire to 
 anticipate a discussion of the indications for enuclea- 
 tion, but only parenthetically to remark, that iritis 
 serosa has nothing in common with iritis maligna, 
 and, as a very general rule, runs a favorable course 
 \vithoutextirpationofthe eye first affected ; and fur- 
 thermore, that when a case of sympathetic iritis serosa 
 has degenerated into a worse form of iritis, after the 
 enucleation of the first eye, the operation itself has, 
 in all probability, been the cause of the new sympa- 
 thetic process. 
 
 The relationship which exists between iritis plastica 
 and iritis maligna calls for some comment. It is very 
 generally stated in connection with iritis maligna that 
 adhesions between the greater portion of the posterior 
 surface of the iris and the anterior capsule of the lens 
 need not be present in order to establish the diagnosis,
 
 PATHOLOGY. 83 
 
 but that, in the beginning, the adhesion may be limited 
 to the pupillary border, while the periphery of the iris 
 is, at the same time, bulged forward by the serum 
 confined behind it. It is further averred that at a 
 later stage of the affection the serous gives place 
 to a plastic exudation, which then firmly and exten- 
 sively glues together the iris and anterior capsule, and, 
 by subsequent contraction, retracts the periphery of 
 the iris. I will here place no significance upon the fact 
 that I have never, in my personal experience, witnessed 
 this transition from a protrusion to a retraction of the 
 periphery of the iris ; but I must openly say, that 
 when I see total circular posterior adhesions, with 
 bulging of the periphery of the iris, in a case of sym- 
 pathetic ophthalmia, I do not think of diagnosticating 
 iritis maligna, but only the common form of plastic 
 iritis with exclusion of the pupil, especially as the ten- 
 sion of the eyeball so affected is not diminished, but 
 is either normal or augmented. Such an iritis, if 
 secondary glaucoma should not supervene, might run 
 a relatively favorable course. Nevertheless, I do not 
 like to take the risk in such cases, but let the bulging 
 of the iris be to me the signal for surgical interference. 
 It is quite a matter of course that errors of diagnosis 
 may sometimes occur in these cases, for the iris may 
 not only be thrust forward by the aqueous humor im- 
 prisoned in the posterior chamber, but likewise, by 
 extensive plastic exudation in the same locality, as I
 
 84: SYMPATHETIC DISEASES OF THE EYE. 
 
 was once convinced upon dissection of an eye. In the 
 case here instanced, it was easy to see how the iris might 
 have first been bulged forward, and then retracted at 
 its periphery by the shrinking of the exudation. 
 
 The course of iritis maligna varies according to the 
 different structures involved in the inflammatory pro- 
 cess. Sometimes it is almost wholly confined to the 
 iris and ciliary body, so that the integrity of the vitre- 
 ous and choroid (and consequently of the retina), is 
 mostly spared. The eye, under the latter condition of 
 things, retains perfectly or tolerably well its normal ten- 
 sion (even when the inflammation has covered the pupil 
 with a pseudo-membrane), is frequently promptly sen- 
 sitive to light and shade, and in cases where the pupil 
 remains clear, or is obstructed by only a thin film, 
 preserves a corresponding degree of vision. The 
 majority of cases of iritis maligna, however, terminate 
 in atrophy of the globe, on account of the consecutive 
 inflammation of the choroid, so that perception of 
 light is either totally extinguished, or reduced to an 
 insignificant amount. 
 
 In the form of sympathetic ophthalmia now under 
 consideration (plastic irido-cyclitis), we sometimes no- 
 tice a remarkable phenomenon, which is of great value 
 in connection with the patkoyeny of this, as well as of 
 other sympathetic affections in which it occurs, and 
 which will, therefore, be further discussed in another 
 place.
 
 PATHOLOGY. 85 
 
 
 
 It consists of the manifestation of pain, either spon- 
 taneously or on pressure, at a spot on the sympathetic 
 eye, corresponding symmetrically to a point on the 
 injured eye, which is still spontaneously painful, or 
 painful only to the touch. If, for illustration, the most 
 painful place of the eye first affected is situated near 
 the upper and outer edge of the cornea, perhaps at the 
 spot where a scleral wound, with incarceration of a 
 portion of the iris, has occurred, the chief or even ex- 
 clusive seat of pain in the second eye will likewise be 
 located at a precisely corresponding point on the 
 supero-temporal margin of the cornea. 
 
 In the present relation another phenomenon which 
 has been observed in several cases of sympathetic cy- 
 clitis deserves mention. Schenkl discovered several 
 silvery-white eyelashes on the temporal half of the 
 upper left eyelid of a boy, nine years of age, at a 
 time when this eye was sympathetically inflamed, in 
 consequence of an injury received by the right eye. 
 On the upper lid of the right eye all the eyelashes 
 were perfectly white, with the exception of a minute 
 portion of their extremities, which was very dark. 
 Jacobi also noticed in an eye, sympathetically affected 
 with irido-cyclitis, that the lashes of the nasal half of 
 the upper lid were altered in color to snow-white, 
 whilst on the outer half of the same lid the lashes were- 
 black and white in about equal proportions, the lower 
 lid presenting merely a few white hairs.
 
 86 SYMPATHETIC DISEASES OF THE EYE. 
 
 Have we now exhausted all the forms of sympathetic 
 disease that may invade the uveal tract f It would 
 seem not. Let us first notice a case reported by Hor- 
 ner (1873). In an eyeball which has long cpncealed 
 a foreign body, symptoms of irido-cyclitis set in. In 
 the opposite, heretofore healthy, but somewhat myopic 
 eye, a rapidly progressing impairment of vision takes 
 place. The ophthalmoscope reveals, in explanation of 
 the latter defect, & peculiar form of patches in the cho- 
 roid, chiefly in the neighborhood of the macula lutea. 
 Very numerous, minute, yellowish white, imperfectly 
 defined specks, are seen behind the retina. The dis- 
 ease progresses painlessly and without signs of irrita- 
 tion. The spots of exudation, in the choroid, enlarge 
 and coalesce. After a year vision has become so much 
 reduced that fingers cannot be counted at a greater 
 distance than four feet with the central portion of the 
 retina, and seven feet with excentric vision. The 
 function of the retina suffers, in this case, in conse- 
 quence of the extension of the choroidal exudation to 
 the layer of cones at the yellow spot. There was no 
 well-defined primary sympathetic affection of the 
 retina. 
 
 Yignaux (1877) discovered, with the ophthalmo- 
 scope, a commencing atrophic choroiditis of sympa- 
 thetic origin, which was the cause of a very pronounced 
 disturbance of vision. 
 
 The conjunction of choroiditis with retinitis (cho-
 
 PATHOLOGY. 87 
 
 roido-retinitis) as a form of sympathetic ophthalmia, 
 was described by v. Graefein 1866 ; although, accord- 
 ing to the statement of Laqueur, a sympathetic neuro- 
 retinitis had been previously noticed by Rheindorf 
 (1864). After the extraction by v. Graefe of a dislo- 
 cated chalky lens from the anterior chamber, cyclitis 
 ensues in the same eye. Six weeks after the operation, 
 the sight of the other eye, which has hitherto been per- 
 fectly good, begins suddenly to be impaired, although 
 no pain is noticed. JThe ophthalmoscope discloses a 
 delicate and diffuse cloudiness of the retina all around 
 the entrance of the optic nerve. Soon afterward, 
 slight symptoms of iritis serosa are noticed, in the form 
 of very delicate punctiform opacities in the membrane 
 of Descemet. After vision has sunk to one-eighth of 
 the normal amount, and the disease has continued at its 
 acme for several weeks, a gradual but uninterrupted 
 improvement takes place. The morbid appearances 
 visible with the ophthalmoscope recede less rapidly 
 than the functional disturbances. Disseminated patches 
 of exudation are conspicuous on the choroid, for a con- 
 siderable time, while the fine punctiform deposits on 
 the posterior surface of the cornea are the slowest to 
 disappear. The field of vision is complete in every 
 direction, and vision is increased to four-fifths nor- 
 mal. 
 
 In the secona of v. Graefe's cases, a patient, twenty 
 years of age, blind in one eye since childhood, coin-
 
 80 SYMPATHETIC DISEASES OF THE EYE. 
 
 plains that the ruined eye has been painful during the 
 last few months. The globe of the best eye is moder- 
 ately sensitive to the touch, and there is some impair- 
 ment of vision. A slight haziness is diffusedly spread 
 through the retina, circumscribed opacities are seen in 
 the vitreous, and the choroid exhibits trivial alterations 
 of structure. After enucleation of the blind eye, the 
 sympathetic manifestations slowly disappear from the 
 other. 
 
 Schweigger (1875), however, aljudes to the foregoing 
 diagnoses of v. Graefe only to throw doubt upon them, 
 and adds that it requires a number of analogous cases 
 to supply satisfactory evidence of the correctness of 
 such a diagnosis (sympathetic retinitis). For that 
 reason we must here notice similar cases. 
 
 Pooley (1871) reports two cases of sympathetic oph- 
 thalmia, distinguished by the occurrence of nenro- 
 retinitis. In both of them the injured eye was still 
 abnormally sensitive ; whilst iritis, and molecular 
 opacities in the vitreous, were conjoined with the 
 retinal affection, in each case. Galezowski (1871) di- 
 agnosticates sympathetic retinitis, characterized by 
 whitish exudations and hsemorrhagic extravasations 
 into the retina, followed by recovery, but with perma- 
 nent obliteration of some of the implicated vessels. 
 He supports his diagnosis by a similar case of Pol- 
 bean's, which he observed with the latter. Gosseliii 
 (1872) speaks of a case of sympathetic inflammation
 
 PATHOLOGY. 89 
 
 of the retina and choroid, marked by pigment spots, 
 ecchymoses, and inflammatory exudations, together 
 with a small posterior adhesion. The vision of the 
 sympathizing eye became suddenly impaired, at a time 
 when the stump, to which the opposite injured eyeball 
 had become reduced, was the seat of an unusual ex- 
 acerbation of pain. H. Miiller (1873) relates that 
 Jacobson saw a sympathetic choroido-retinitis localized 
 in the neighborhood of the entrance of the optic nerve, 
 the other eyeball being at the time in a state of 
 painful atrophy, ensuing upon cyclitis produced by a 
 cataract operation. Hirschberg (1874) recognizes a 
 sympathetic retinitis, characterized by great hyperse- 
 mia of the retinal veins, together with slight diffuse 
 cloudiness of the retinal structures, at a period when 
 the opposite phthisical eye was still very painful to the 
 touch over the ciliary region. Pfliiger (1875) meets 
 with sympathetic symptoms in the form of inflamma- 
 tion of the intra-ocular extremity of the optic nerve 
 and the circumjacent portion of the retina. We have 
 already mentioned this case, in which it was found, 
 upon dissection, that an inflammatory infiltration of 
 the iris, unaccompanied with cyclitis, was the lesion 
 affecting the primarily diseased eye. Among the 
 ninety cases adduced by Eossander (1876), sympathetic 
 choroido-retinitis figures three times, although one of 
 these cases holds its position with doubtful propriety, 
 according to the opinion of Eossander himself. In
 
 90 SYMPATHETIC DISEASES OF THE EYE. 
 
 Leber's work (1877), " Ueber die Krankheiten der 
 Netzhaut und des Sehrierven " (On the Diseases of the 
 Retina and Optic Nerve), only a single paragraph is 
 devoted to sympathetic retinitis. " The affection;" says 
 Leber, " is usually conjoined with serous irido-cyclitis 
 and haziness of the vitreous; after the media clear up 
 the ophthalmoscopic evidences of the affection are 
 sometimes unmistakable." The sympathetic retinitis 
 is usually characterized by a diffuse cloudiness of the 
 structures of the retina, to which a redness of the disc 
 of the optic nerve is usually superadded. But, accord- 
 ing to Leber, the retinitis is not simply associated with 
 irido-cyclitis, but is dependent upon the latter ; for he 
 commences by saying that "sympathetic irido-cyclitis 
 also leads, now and then, to the development of reti- 
 nitis." Finally, Vignaux (18 77) narrates several cases 
 of sympathetic choroido-retinitis, as well as of retinitis, 
 without iritis or irido-cyclitis. In some of the latter 
 cases the ophthalmoscopic changes are described so 
 meagrely as to throw doubt upon the positive pres- 
 ence of either choroiditis or retinitis, and the sympa- 
 thetic affection in these cases might as well, or better, 
 be accepted as amblyopia without underlying struc- 
 tural changes. Nevertheless, the existence of retinitis, 
 as an expression of sympathetic disease of the eye, can 
 no longer be regarded as an open question. This kind 
 of retinitis is very generally characterized by diffuse 
 cloudiness of the retina ; but whether the sympathetic
 
 PATHOLOGY. 91 
 
 nature of such forms of retinitis as Galezowski and 
 Gosselin describe, is to be established rather by the 
 presence of other and deeper changes in the retina, 
 cannot 'to-day be decisively settled. 
 
 We should here notice a certainly very important 
 point in connection with sympathetic retinitis. Schna- 
 bel (1876) has stated (and Leber has likewise expressed 
 a similar opinion) that common iritis is frequently 
 complicated with diffuse retinitis. If, therefore, reti- 
 nitis does not really appear as an independent sympa- 
 thetic affection, but is only superinduced upon sympa- 
 thetic iritis, the sympathetic character of the affection 
 fails as absolutely as does that of secondary glaucoma, 
 when the latter malady supervenes upon a complete 
 posterior synechia of the pupillary margin of the iris, 
 resulting from sympathetic iritis. Notwithstanding 
 the occurrence of this complication, however, there is 
 no doubt that retinitis, without iritis and cyclitis, may 
 arise in a wholly independent manner, from sympathy 
 with the offending eye. I go even farther, and say : 
 the frequent presence of irido-cyclitis, interfering with 
 
 %. 
 
 the employ men t- of the ophthalmoscope, prevents the 
 clinical establishment of the fact that retinitis is a 
 very common manifestation of sympathetic disease ; 
 or, in other words, that many more cases of retinitis 
 are sympathetic than those in which clear and unmis- 
 takable evidence of the fact can be obtained. The 
 last suggestion is of importance in connection with
 
 r 
 
 92 SYMPATHETIC DISEASES OF THE EYE. 
 
 the pathogeny of the sympathetic diseases, and \ve 
 shall have occasion to resume it farther on. 
 
 We leave the sympathetic diseases of the retina with 
 the remark that the case of typical pigment-degenera- 
 tion of the retina (retinitis pigmentosa\ described by 
 Robertson (1871) as a sympathetic affection, was mani- 
 festly connected (Leber) with a binocular disease, 
 which existed previously to the injury to which the 
 supposed sympathetic disease was attributed. 
 
 We now pass into an uncommonly dark province, 
 viz., that of the sympathetic affections of the optic 
 nerve. Sympathetic retinitis may, as we will here at 
 once state, be propagated to the second eye along the 
 path of the optic nerve ; but is the same statement ap- 
 plicable to the other diseases of the optic-nerve tract ? 
 Dransart has added, much to the description of this 
 subject : but we shall only mention his assertion that 
 simple atrophy of the optic nerve is to be ranked as 
 one of the sympathetic affections. But he certainly 
 weakens his statement very much when he includes 
 "atrophy of the choroid, posterior synechise, and 
 cataracts" among the "frequent accompaniments" of 
 sympathetic atrophy of the optic nerve. Mooreii saw 
 a case in which atrophy of the optic nerve of one eye, 
 caused by a contusion, was followed by atrophy of the 
 optic nerve of the opposite eye. This last case is clearly 
 entitled to be called an example of sympathetic dis- 
 ease, in so far as every affection is to be regarded as
 
 PATHOLOGY. 93 
 
 sympathetic, the reproduction of which in the second 
 eye is ascribable only to a pre-existent disease in the 
 first eye. The question, however, of practical signifi- 
 cance is : "Whether we can have simple sympathetic 
 atrophy of the optic nerve in the second eye, under the 
 same circumstances in which other sympathetic affec- 
 tions generally become developed ? I would not like 
 to deny off-hand the possibility of the occurrence of 
 such a phenomenon. Indeed, from my personal ob- 
 servation of two somewhat enigmatical cases, I cannot 
 wholly avoid the belief that we may occasionally dis- 
 cover the ophthalrnoscopical picture of simple atrophy 
 of the optic nerve, which is directly of sympathetic 
 origin. 
 
 We have already alluded to the danger of implica- 
 tion of the second eye which now and then attends the 
 enucleation of the first eye, when performed for prophy- 
 lactic purposes, and it is now our purpose to describe 
 the sympathetic phenomena which are sometimes 
 seen in the second eye after the surgical removal of its 
 mate. Colsmann (1877) removed an eyeball which had 
 atrophied in consequence of an injury, and was omi- 
 nously painful. . A few days after the operation, the 
 acuteness of vision in the remaining eye sank to one- 
 seventh of the normal amount. Three days later the 
 ophthalmoscope revealed distinct cloudiness of the op- 
 tic disc and of adjacent parts of the retina, the cloudi- 
 ness being especially conspicuous in the vicinity of the
 
 94 SYMPATHETIC DISEASES OF THE EYE. 
 
 yellow spot. The field of vision was at the same time 
 concentrically contracted. Under appropriate treat- 
 ment pursued for six months, vision became normal 
 and the visual field complete in every direction. Cols- 
 maun also reported a second case of the sort, from 
 Mooren's clinic. A few months after the prophylac- 
 tic removal of an injured eyeball, the patient com- 
 plained of subjective flashes of light in the remaining 
 eye, but vision was still normal. Six months later, 
 the acuteness of vision was exceedingly diminished, 
 the patient only being able to read print the size of 
 No. 19 of Jaeger's test-types (one and one-half to two 
 centimetres in height). Inflammation of the optic 
 disc, with very extensive cloudiness of the retina, was 
 discovered with the ophthalmoscope. The final result 
 of this case is not known. Colsmann states that Hugo 
 Miiller had, at an earlier date (1873), described a case 
 in which, five days after the removal of a degenerated 
 and enlarged eyeball, the patient, without previous 
 symptoms of sympathetic disease, began to complain 
 of the periodical envelopment of the whole field of 
 vision with a shining white cloud, accompanied by 
 subjective sensations of light. In .the intervals of 
 these attacks, no impairment of vision could be ascer- 
 tained, but the retina was cloudy in the neighborhood 
 of the optic papilla. Later, however, without change 
 in the ophthalmoscopic appearances, the power of vis- 
 ion began to deteriorate rapidly, but was restored after
 
 PATHOLOGY. 95 
 
 a course of treatment consisting of local abstractions 
 of blood and the administration of mercury. We must 
 not forget to add that, several months afterward, the 
 patient experienced an attack of cyclitis, with increase 
 of intraocular pressure (sympathetic glaucoma ?), 
 which was successfully treated by iridectomy. 
 
 "We are here led to seek an answer to an important 
 question : fs there a sympathetic glaucoma ? The 
 question is not whether a sympathetically diseased eye 
 can lose its sight while laboring under the character- 
 istic symptoms of glaucoma (the glaucomatous symp- 
 toms being, in such a case, simply superadded to those 
 of the sympathetic disease), but it is whether primary 
 glaucoma can be developed in the second eye, solely 
 from sympathy with the eye first diseased. In other 
 words, can a disease, whose symptoms, briefly expressed, 
 are persistently increased tension of the eye, pulsation 
 of the central vessels of the retina, and an affection of 
 the optic nerve usually characterized by excavation of 
 its intra-ocular extremity, arise directly from a disease 
 or injury of the other eye, and continue, with or with- 
 out inflammatory phenomena which have their seat in 
 different parts of the eyeball, until the sight of the 
 affected organ is destroyed ? 
 
 Still another limitation must be made. It some- 
 times happens, after the operation of iridectomy has 
 been performed for the relief of glaucoma of the one 
 eye, that the other, hitherto perfectly healthy eye, is
 
 96 SYMPATHETIC DISEASES OF THE EYE. 
 
 attacked with the most violent symptoms of acute glau- 
 coma, so that the patient, upon whom the operation 
 on the first eye was, perhaps, undertaken merely for 
 the removal of pain, and with no hope of restoring its 
 lost sight, becomes totally blind. The question whether, 
 under these conditions, the outbreak of glaucoma in 
 the second eye is of sympathetic origin, and ensues 
 upon the operative injury inflicted on the first eye, in 
 the same mode in which sympathetic disease may pro- 
 ceed from any other kind of traumatic injury of the 
 organ, is here answered in the negative, its fuller dis- 
 cussion being postponed until we publish our work on 
 the theory of glaucoma. 
 
 Let us reduce our statement and inquiry to the fol- 
 lowing terms : An eye is destroyed by irido-cyclitis, 
 and the opposite eye becomes, in consequence of the first 
 lesion, affected with sympathetic serous iritis. Every 
 serous iritis, of whatever origin, may possibly cause 
 secondary glaucoma. I have never personally seen this 
 effect produced by sympathetic serous iritis ; but, even 
 admitting its occurrence, the fact is beside our ques- 
 tion. Then, again, instead of serous iritis, the sympa- 
 thy may manifest itself in the shape of plastic iritis, 
 which may excite secondary glaucoma by the round- 
 about way of exclusion of the pupil. We cannot deny 
 that this complication really may occur in the sympa- 
 thetic eye, but the admission does not answer our ques- 
 tion, which is: Can primary glaucoma be sympatheti-
 
 PATHOLOGY. 97 
 
 cally produced in the second eye by an irido-cyclitis, 
 or an irido-cyclo-choroiditis of the first eye? 
 
 Sympathetic glaucoma appears to have been first 
 described by v. Graefe (1857). After narrating a par- 
 ticular case, he superadds the remark that he has " re- 
 peatedly met with a similar condition of things, viz. : 
 absolute arnaurosis of one eye, due to the destructive 
 effects of choroiditis ; and amblyopia of the other eye, 
 without any signs of irritation whatever, although the 
 affection was accompanied with progressive limitation 
 of the field of vision, as well as^ Excavation of the 
 optic nerve, visible with the ophthalmoscope." V. 
 Graefe thought it possible that " disturbance in the cir- 
 culation and secretion of the choroid might cause in- 
 creased intra-ocular pressure and consequent cupping 
 of the optic nerve entrance ; " in other words, a true 
 sympathetic glaucoma. Many other published accounts 
 of sympathetic glaucoma are extant (Homer, Mooren, 
 Coccius, Carter, II. Muller, Pomeroy, Rossander, "Vig- 
 naux); and divers authors who have, perhaps, no per- 
 sonal knowledge of sympathetic glaucoma, accept it 
 on the ground of v. Graefe's early observations. Nev- 
 ertheless, this form of sympathetic ophthalmia falls 
 somewhat short of general recognition. Maats (1805) 
 refuses to concede it, and JBrecht (1874) expresses his 
 opinion that in v. Graefe's cases the supposed affection 
 was mistaken for sympathetic amblyopia with limita- 
 tion of the field of vision, without alterations of strnc- 
 5
 
 98 SYMPATHETIC DISEASES OF THE EYE. 
 
 ture. But the most powerful antagonist of v. (rraefe's 
 observations is v. Graefe himself. For in 1866, in 
 connection with his first description of sympathetic 
 choroido-retinitis, he emphasizes only two forms of 
 sympathetic inflammation, viz., iritis maligna and iritis 
 serosa, and positively asserts that sympathetic irido- 
 cyclitis " never, or only in the rarest exceptional cases, 
 shows any tendency to produce an increase of the 
 intraocular pressure, or an excavation of the optic 
 nerve." 
 
 It now seems doubtful whether typical simple glau- 
 coma without inflammatory symptoms, can be uncon- 
 ditionally admitted into the group of sympathetic 
 affections, especially since v. Graefe himself abandoned 
 this theory, which he at first constructed upon the basis 
 of a few cases which seemed to support it. I would 
 further suggest that there is a manifest inconsistency 
 in acknowledging the existence of this kind of sym- 
 pathetic glaucoma, so long as it continues to be regarded 
 as a secondary glaucoma following serous cyclitis. 
 For the presence of serous cyclitis would, under the 
 latter restriction, only be revealed by the glaucomatous 
 symptoms; and in case the glaucoma were viewed 
 simply as a product of serous cyclitis, the very nature 
 of a primary sympathetic glaucoma would be preju- 
 diced. Primary glaucoma simplex would then be 
 nothing else than a serous cyclitis ; but to designate 
 as a primary sympathetic glaucoma, a secondary glau-
 
 PATHOLOOY. 99 
 
 coma resulting from serous cyclitis, would be quite 
 inadmissible. 
 
 The existence, as a sympathetic affection, of acute 
 glaucoma, i.e., primary glaucoma with all its peculiar 
 inflammatory phenomena (which we shall not stop to 
 describe in this place), must be regarded as extremely 
 problematical, and as not hitherto satisfactorily dem- 
 onstrated. Even the case reported by Jany (1877), 
 who saw the right eye affected by what he supposed 
 to be sympathetic acute glaucoma, during an attack 
 of scleritis and iritis of the left eye, is lacking in. 
 some of the indispensable characteristics of a sym- 
 pathetic disease. But. the case is quite different, 
 where increase of tension is superadded to those in- 
 flammatory symptoms which are diagnostic of irido- 
 cyclitis. Even where increase of intraocular pressure 
 is noticed in connection with ciliary injection, sensi- 
 tiveness of the ciliary body to the touch, adhesions be- 
 tween the iris and anterior capsule, and opacities of the 
 vitreous, glaucoma is not necessarily present, and cer- 
 tainly not a sympathetic glaucoma. Augmented in- 
 traocular pressure may Represent during every acute 
 inflammation of the eye, of whatever kind or origin. 
 But if the increased intraocular pressure, under the in- 
 fluence of which vision is sooner or later destroyed, 
 is not permanent, although it may be variable, the 
 disease is not glaucoma. The heightened intraocular 
 pressure, which may be present at one stage in irido-
 
 100 SYMPATHETIC DISEASES OF THE EYE. 
 
 cyclitis, subsides in the generality of cases ; but even 
 if this were not the case if the eyeball remained ab- 
 normally hard until vision were destroyed the case 
 would evidently be one of secondary glaucoma, en- 
 suing on irido-cyclitis. The inflammatory symptoms 
 of irido-cyclitis differ so widely from those of glau- 
 coma, that there can be no risk of mistaking a pri- 
 mary glaucoma for an irido-cyclitis. It is the irido- 
 cyclitis, and not the secondary glaucoma developed 
 from it, which is the sympathetic affection. 
 
 A very peculiar form of sympathetic glaucoma, 
 called sympathetic hcemorrhagic glaucoma, was de- 
 scribed by H. Pagenstecher (1877). Hsemorrhagic 
 glaucoma is characterized by the extravasation of blood 
 into the retina, accompanied by the most violent symp- 
 toms of glaucoma, so that -the disease has sometimes 
 been called a secondary glaucoma. According to the 
 description given of Pagenstecher's case, however, the 
 glaucomatous phenomena were first noticed, and sub- 
 sequently followed by the retinal effusions. The left 
 eye, from which the sympathetic affection in the 
 opposite eye was supposed to proceed, showed at the 
 time when its partner was affected nothing more than 
 an ulceration of the cornea, which had not yet caused 
 perforation. Later, a perforation of the cornea en- 
 sued, and led to phthisis of the globe. At the date 
 of the enucleation of the left phthisical and blind 
 eye, its tension was augmented ; it was only moder-
 
 PATHOLOGY. 101 
 
 ately sensitive to heavy pressure (consequently less 
 sensitive than a healthy eyeball), and the cornea, 
 which was flattened, and mostly converted into cicatri- 
 cial tissue, was extremely anaesthetic. The same an- 
 aesthetic condition was noticed in the conjunctiva. 
 The operation was followed by a decided improve- 
 ment in the condition of the right eye, which, however, 
 again became worse several weeks after the enucleation, 
 during the course of a lobular pneumonia. It again 
 improved ; but, in consequence of the passing of the 
 patient from observation, the case was not followed to 
 its conclusion. Can any positive causal connection 
 between the diseases of the two eyes be here made 
 out ? The improvement of the abnormal tension and 
 impaired vision, which followed the enucleation is 
 very striking, and favors this view. But did not the 
 rest and restricted diet (to which the " plethoric sex- 
 agenarian, who was not averse to the pleasures of the 
 table," must certainly have been submitted, for a time 
 at least, after the operation) have an influence in pro- 
 ducing the (possibly only transitory) change for the 
 better? Certainly, the condition of the primarily dis- 
 eased eye, as well at the time of the first " sympa- 
 thetic " glaucomatous attack of the right eye, as at the 
 time of the enucleation, was not such as to establish 
 beyond a doubt its agency in exciting the disease of 
 the second eye. 
 
 To fill the complete catalogue of sympathetic dis-
 
 102 SYMPATHETIC DISEASES OF THE EYE. 
 
 eases, we will further mention that Schmidt /(1874:) 
 discovered a few opacities pervading the vitreous, in 
 the form of grayish-black filaments, which he ascribed 
 to a sympathetic source. There was no trace of ac- 
 companying iritis, nor of other inflammatory processes 
 in the nveal tract. 
 
 Finally, Briere (1875) reports a case of sympathetic 
 cataract. The opinion expressed by Briere, however, 
 that the cataract described by him should be grouped 
 among the sympathetic affections, is arbitrary. A 
 well-authenticated case of sympathetic cataract re- 
 mains for future discovery.* 
 
 The severest forms of sympathetic disease are in- 
 flammations of the iris, the ciliary body, and the 
 choroid, on the one hand, and those of the optic nerve 
 and the retina on the other. The serious lesions of 
 the latter structures are usually concealed by the in- 
 flammatory processes that simultaneously occur in the 
 uveal tract. Among the sympathetic affections of the 
 nveal tract, iritis serosa constitutes a remarkable ex- 
 ception to their generally dangerous character. It 
 sounds paradoxical, bnt it is nevertheless true, that the 
 existence of sympathetic serous iritis need excite less 
 anxiety than that of sympathetic irritation, for the 
 
 * Kriickow (1880) has, however, described two cases, in which 
 the sympathetic cataract revealed itself, in each instance, in the 
 form of an opacity, confined exclusively to the anterior capsule of 
 the lens. TRS.
 
 PATHOLOGY. 103 
 
 latter affection frequently sets on foot the worst forms 
 of sympathetic ophthalmia, proceeding to the destruc- 
 tion of the eye ; while genuine simple iritis serosa 
 possesses very little inherent tendency to destructive 
 results. 
 
 Sympathetic ophthalmia is especially prone to be 
 caused by injuries of the eye, because those morbid 
 processes which constitute it are much more fre- 
 quently of traumatic than of spontaneous origin. 
 Modern ophthalmology, instead of diminishing the 
 sources of sympathetic disease, has increased them. 
 The linear method of extracting cataracts is one of 
 these sources ; although, happily, when we place in the 
 balance the advantages and the evils of this operation, 
 the former outweigh the latter. The operation of irido- 
 desis is less fortunate, and raises doubts. The more 
 recent operative procedure of drainage of the eye 
 awakens still graver doubts concerning the propriety 
 of its employment. Drainage of the eye consists of the 
 insertion and retention of a gold wire through the tunics 
 of the eyeball, with a view to causing a continuous es- 
 cape of the fluid contents of the globe along the canal 
 occupied by the wire. It was the hope of the advo- 
 cates of this method of treatment that it would, on the 
 one hand, prevent the re-accumulation of subretinal 
 fluid, in cases of detachment of the retina, and on the 
 other, keep within normal limits the intraocular pres- 
 sure in glaucoma, and thereby become an effective
 
 104 SYMPATHETIC DISEASES OF THE EYE. 
 
 therapeutical agent in both these affections. But the 
 injury to the eyeball incident to this operation will 
 seldom be tolerated, and notwithstanding the transi- 
 tory relief obtained, an insidious inflammation of the 
 nveal tract will be set up in the great majority of 
 cases, with imminent danger of sympathetic disease. 
 I have, in fact, learned without surprise, that where 
 eyeballs have been drained by this process, it has often 
 become necessary to enucleate them, on account of 
 the sympathetic affections which they have induced.
 
 SECTION IV. 
 
 PATHOGENY. 
 
 WE will first make -a few general remarks on the 
 pathogeny of the subject under discussion. The fact 
 that a disease of any part of the body should be the 
 cause of disease in a symmetrical member must in any 
 event seem something extraordinary. Human pathol- 
 ogy up to this day has revealed but few phenomena 
 of this nature. N orris, however, in his paper on sympa- 
 thetic affections of the eye, speaks of a few analogous 
 occurrences in other regions ; for example, one case 
 by Mitchell, Morehouse, and Keen, in which, after a 
 gunshot wound on the outer side of the thigh, com- 
 plete anaesthesia was noticed on the corresponding 
 side of the other thigh ; and another by Annandale, in 
 which, after a wound on one hand had healed with a 
 painful cicatrix, a similar condition developed on 
 the other. 
 
 Let us confine* ourselves, however, to the eye, and at 
 once inquire in what manner inflammation expends 
 from one eye to the other. It would be an error to 
 
 answer such a question in a general way. Entering 
 5*
 
 106 SYMPATHETIC DISEASES OF THE EYE. 
 
 / 
 
 therefore into details, we soon discover that the expla- 
 nation is surrounded with difficulties of various degree, 
 depending upon the locality of the inflammation. If 
 we assume for example that the ophthalmoscope re- 
 veals an inflammation of the optic nerve and retina 
 in the sympathetically affected eye, and that we are 
 justified in assuming a similar inflammation in the in- 
 jured eye (whose deeper structures we are usually un- 
 able to examine on account of entensive alterations in 
 its anterior portion), we shall have no need of pro- 
 found theories or the dragging in of obscure symptoms 
 from other provinces of pathology, in order to under- 
 stand what is going on. 
 
 In case pathological anatomy does/ not plainly in- 
 form us of any other way, we can assume in such a 
 case, that the inflammatory process in the optic nerve 
 of the offending eye propagates itself centripetally 
 (toward the brain); the moment that the chiasma is 
 reached, the optic nerve of the second eye is threatened. 
 It is of no consequence whatever, in so far as concerns 
 the explanation of the phenomenon, whether we are of 
 those who claim a total, or of those who claim a par- 
 tial crossing of the optic nerves at the chiasma ; or 
 whether we defend the view that all the fibres from 
 one optic tract cross over at the chiasma to the optic 
 nerve of the opposite side, or that &part of these fibres 
 remaining on the same side, go to compose the optic 
 nerve of the same side. For, in every case, the fibres
 
 PATHOGENY. ] 07 
 
 of both nerves lie so close together at the chiasraa, 
 that it would be miraculous if the extension of an in- 
 flammatory process (particularly of the connective- 
 tissue elements) were to confine itself, at the chiasma, 
 to the fibres of one optic nerve, and carefully avoid 
 the fibres of the second nerve which are so closely in- 
 terwoven with those of the former. So far as con- 
 cerns our present considerations, it is all one and the 
 same, whether the process, after reaching the chiasma, 
 advances or does not advance still further into the cen- 
 tre of the organ of vision, along the corresponding op- 
 tic tract. But this much is certain : that, so soon as the 
 fibres of the second optic nerve are attacked in the 
 chiasma, the inflammatory process may extend not 
 only toward the optic tract, but also toward the eye, 
 and finally reach the terminal expanse of the optic 
 nerve in the retina. 
 
 The appearance of typical irido-cyclitis in the eye 
 originally affected, accompanied with the develop- 
 ment of optic neuritis in the second eye, does not in- 
 terfere with the explanation just given, for in such a 
 case we take it for granted that neuritis (or neuro-re- 
 tinitis) is simultaneously associated with the irido- 
 cyclitis in the first eye. But how can we explain a 
 sympathetic inflammation of the whole choroidal tract, 
 and above all, sympathetic irido-cyclitis plastica, which 
 many oculists consider the most important, if not the 
 only significant symptom of the sympathetic affection ?
 
 108 SYMPATHETIC DISEASES OF THE EYE. 
 
 / 
 
 "We might imagine that under such circumstances, also, 
 the inflammation was propagated per contiguum. 
 Thus, irido-cyclitis may always be the primary affec- 
 tion in the eye first affected, while retinitis may be 
 superadded to the original disease. The inflammatory 
 process would then be simply transmitted along the 
 tract of the optic nerves into the retina of the second 
 eye, in which it could finally extend from the retina 
 to the choroid. It is so common to see the choroid in- 
 vaded by inflammation from the retina, that were a 
 corresponding view permissible in the case of sympa- 
 thetic affection of the uveal tract, all obscurities would 
 be removed from the latter disease, and- sympathetic 
 inflammations could be regarded as simply transmitted 
 continuously and per contiyuum from the irritating 
 eye through the chiasma. 
 
 Although the affection of the optic nerve, first in 
 the one eye, and subsequently in the other, is still too 
 little appreciated, it is nevertheless a fact that sympa- 
 thetic irido-cyclitis does not originate by this agency. 
 For, at the time when the premonitory symptoms of 
 this latter affection appear, the retina is very rarely, if 
 at all inflamed. Otherwise, why should not the most 
 typical symptoms appear in the choroid proper, which 
 lies throughout in immediate and extensive contact 
 with the retina ? In point of fact, it is the most 
 anterior segment of the uveal tract (the ciliary body 
 and the iris) which first suffers ; that very portion
 
 
 
 PATHOGEUY. -jf. 109 
 
 which is covered by a merely theoretical part of the 
 retina, the so-called pars ciliaris retinae. As it thus 
 appears that inflammation cannot be transmitted to 
 the chorokl of the opposite eye by the intermediation 
 of the optic nerve and retina, we must either seek 
 another path of communication, or else assume some 
 remote and mysterious action. 
 
 .There is, however, one possible path of direct coin- 
 man ication between the two eyes. I refer to the vas- 
 cular circle of Willis, lying in the region of the 
 chiasma, at the base of the brain, corresponding to the 
 sella turcica, and embracing the chiasma as well as 
 the tuber cinereum and corpora mamillaria. Altera- 
 tions in the choroidal vessels of one eye might be 
 transmitted to the chief arterial trunk (the ophthalmic 
 artery) ; from there into the internal carotid, and so 
 to Willis's circle : thence alonw the anterior arch of 
 
 7 O 
 
 this circle into the opposite ophthalmic artery, and so 
 to the choroidal region of the second eye. 
 
 Cohnheim has already shown us what an important 
 role is played in inflammatory processes, by alterations 
 in the vascular walls ; indeed in his opinion, " molec- 
 ular alteration of the vascular walls," is the indis- 
 pensable condition for inflammation. The only pecu- 
 liarity with which we should meet in considering 
 such a theory (even if all necessary assumptions were 
 fulfilled) would be that the process in the second eye 
 is never exhibited throughout the entire choroidal
 
 110 SYMPATHETIC DISEASES OF THE EYE. , 
 
 tract, but chiefly, or even exclusively, in its most ante- 
 rior segment. Moreover, in the present state of our 
 knowledge, we know nothing definite of any such 
 direct transmission of inflammation along the vessels. 
 By this, however, I do not mean to assert that the 
 question of the participation of the vessels has yet 
 been finally settled. 
 
 "We have, therefore, nothing else to do than to keep 
 to the nerves, under which term we of course mean 
 simply the ciliary nerves. The short ciliary nerves 
 contain motor, sensitive, and sympathetic fibres ; and 
 we shall assume that every short ciliary nerve is com- 
 posed of fibres of each of these three varieties. The 
 long ciliary nerves which arise directly from the naso- 
 ciliaris have no motor fibres ; of their sympathetic 
 fibres we know nothing. Nevertheless, Strieker's ex- 
 periments, which prove that hyperseraia is caused 
 whenever we irritate the sensitive roots of the spi- 
 nal cord (i.e., that an irritation of the sensitive roots 
 excites the nerves which dilate the vascular walls), 
 would seem to show that the long ciliary nerves are 
 made up in part of vascular nerves, which conduct 
 irritation from the nerve-centre. 
 
 We are not inclined to acknowledge that the real 
 motor nerves of the internal muscles of the eye, viz. : 
 the corresponding fibres of the third pair, which sup- 
 ply the sphincter iridis and the ciliary muscle, as well 
 as those fibres of the sympathetic which supply the
 
 PATHOGENY. Ill 
 
 dilator pupillse, have anything to do with the transmis- 
 sion of sympathetic inflammation. There remains, 
 therefore, for consideration only the sensitive fibres of 
 the trigeminus, and the vascular nerves of the sympa- 
 thetic. The question then arises, if the ciliary nerves 
 are the only ones which act as conductors, does the 
 capacity for transmission belong to each sort of fibres, 
 or only to one, and to which ? So far as concerns 
 the motor nerves, I would say that we sometimes 
 meet with simple paresis of accommodation, as the 
 only symptom of sympathetic irritation (Pageustecher, 
 Mooren, Schiess-Gemuseus). This symptom, how- 
 ever, does not compel us to accept any action on the 
 part of the motor roots. On the contrary, it can be 
 explained in a very simple manner. The muscles of 
 accommodation in both eyes contract synergically. ' If 
 the contraction of one ciliary muscle becomes ex- 
 tremely painful on account of some morbid affection 
 . which has attacked it, contraction at once ceases, and 
 with it also the contraction of its partner. But just so 
 soon as the injured eye is enucleated, the ciliary mus- 
 cle of the second eye at once resumes its function. 
 
 If it is the sensitive nerves which conduct the in- 
 flammation, we must assume that either some indefina- 
 ble irritation, or an unknown molecular alteration, or 
 a distinct inflammatory condition passes along the 
 fibres into the brain, and reaches the central nerve- 
 cells from which the fibres proceed ; that this morbid
 
 112 SYMPATHETIC DISEASES OF THE EYE. 
 
 process then "springs over" (or is perhaps transmitted 
 by fibres) to the corresponding nerve-cells of the other 
 side, and so, in turn advancing from the brain, reaches 
 the terminal filaments of the sensitive nerves in the 
 second eye. If the sympathetic fibres act as conduc- 
 tors, then the irritation must cross over to the other 
 side, in the vaso-motor centre, i.e., in the medulla ob- 
 longata, or, if we give any credence to Strieker's ex- 
 periments, beneath the medulla oblongata. 
 
 It is relatively easy to assume some such state of 
 things, for we thus safely avoid the dangers of " re- 
 flex" action. But, admitting that all this is proved, 
 many difficulties still confront us, in o\ir endeavor to 
 explain the origin of inflammation in the sympatheti- 
 cally affected eye. The development of inflammation 
 presupposes the fact that the irritation or inflamma- 
 tion of sensitive nerves can produce the most violent 
 inflammation in the tissues to which they are distrib- 
 uted ; or, relatively, that irritation of the sympathetic 
 fibres which dilate the vessels, or paresis of the fibres 
 which contract the vessels, not only causes an enlarge- 
 ment of the vessels (hypersemia), but even true inflam- 
 mation. 
 
 General pathology now busies itself but little with 
 the influence which the nerves may exert upon inflam- 
 mation, or denies it entirely. It is well worth observ- 
 ing that, from this point of view, so little attention, or 
 even none at all, has been paid to sympathetic ophthal-
 
 PATHOGEN Y. 113 
 
 inia. Herpes zoster a disease in which inflammation of 
 the 8R in extends along the filaments of sensitive nerve- 
 fibre? is the only well-known example of the possible 
 connection between an affection of the nerves and in- 
 flammation, especially since the so-called neuro-para- 
 lytic inflammations pneumonia after division of the 
 par vagum, and keratitis after paralysis of the trige- 
 minns have been banished into the province of trau- 
 matic inflammation. And even as regards herpes 
 zoster, Cohnheim thinks that we ought to wait for 
 further and more careful anatomical or experimental 
 investigations, before building conclusions of so great 
 an amplitude upon a very few facts. On the other 
 hand, no one has ever yet observed the development 
 of a genuine inflammation as the outcome of that 
 hypenemia which depends upon division of the sym- 
 pathetic nerve. 
 
 In considering sympathetic cyclitis, however, we 
 must suppose some such direct influence of the cili- 
 ary nerves in the production of inflammation. In a 
 clinical point of view, we have cases which afford 
 such a hypothesis. In 1866 v. Graefe said : " It may 
 be of interest to note the fact that in two cases of in- 
 jury, in which I did not enucleate the wounded eye 
 because it still retained some traces of vision, I was 
 able, at the outbreak of the sympathetic affection, to 
 prove that the second eye showed increased sensitive- 
 ness at a point, symmetrically to which a similar condi-
 
 114 SYMPATHETIC DISEASES OF THE EYE. 
 
 / 
 
 tion was present in the first eye during the whole 
 period of observation." Bowman has also made one 
 observation of the same nature. 
 
 Such exact symmetry as this is supposed to be ex- 
 tremely rare in ophthalmology, and even authors who 
 have had at their command a large amount of mate- 
 rial for the study of sympathetic ophthalmia, cite only 
 the three cases of v. Graefe and Bowman. Despite 
 this fact, I am, nevertheless, firmly convinced that 
 this phenomenon is by no means rare. Still, it is 
 always remarkably striking, no matter how often it 
 may be observed. I have seen it in genuine iritis 
 maligna, as well as in severe plastic iritis, in which the 
 circumference of the iris had become bulged forward. 
 It is also sometimes noticed in that sympathetic irrita- 
 tive condition which is usually regarded as ciliary 
 neuralgia (page 63). If we carefully touch the region 
 of the ciliary body of the sympathetically affected eye 
 in these cases, we succeed in finding at some spot a 
 pressure-point which is chiefly or exclusively sensitive 
 ox painful to the touch. If we then test the eye first 
 affected, we are almost always sure to find an exactly 
 corresponding spot over the ciliary region, which is 
 chiefly or exclusively sensitive or painful. Although 
 the originally affected eye frequently possesses but one 
 painful spot, while the rest of the ciliary body re- 
 mains quite insensible to the touch, or even to gentle 
 pressure, so that, under these circumstances, it is suf-
 
 PATHOGEJSTY. 115 
 
 ficiently easy to discover the pressure-point in the eye 
 first affected, we think it best to suggest that, in testing 
 the sensibility of the ciliary body, we should begin in 
 the eye affected secondarily. For the eye originally 
 affected is sometimes so extremely sensitive to pain, 
 that the attempt to discover if there be any especi- 
 ally painful spot in the ciliary region, without know- 
 ing exactly where to seeJc for it^ is barbarous, to say 
 nothing of the fact that it may be impossible of ac- 
 complishment. But the circumscribed pain from pres- 
 sure, in an eye affected sympathetically, is not precise]y 
 the same sort of pain as that which is produced by 
 pressure in an inflamed region of the body. It is much 
 oftener discovered, on the contrary, as has already 
 been suggested, even where we have nothing but a 
 neuralgia of the corresponding ciliary nerves a neu- 
 ralgia which may disappear without passing into a 
 state of inflammation. 
 
 "If we reflect upon these facts, we can hardly do any- 
 thing else than assume that the inflammatory irritation 
 passes from the ciliary nerves of the one side to the 
 corresponding ciliary nerves of the other, so that, 
 finally, inflammation can be excited in the tissues to 
 which these nerves are distributed. At present, how- 
 ever, in these cases, it is absolutely impossible for us 
 to tell whether the inflammation is transmitted by the 
 sensitive nerves, which are evidently affected, or by the 
 sympathetic fibres. Herpes zoster seems to show an
 
 116 SYMPATHETIC DISEASES OF THE EYE. 
 
 active participation on the part of the sensitive fibres ; 
 but we must not forget that, as sympathetic fibres are 
 undeniably present in the ciliary nerves, we cannot, 
 without further proof, deny the presence of the same 
 sort of fibres in the sensitive nerve-trunks generally, 
 as was demonstrated by Strieker's experiments, pre- 
 viously mentioned. 
 
 Having thus given a hasty and general glance at 
 the subject, let us now see how the theory of the 
 pathogeny of sympathetic inflammation has been built 
 up in the course of time, upon the foundation of 
 hypotheses, supported by clinical and pathological 
 observations. 
 
 If Mackenzie was not the first oculist to recognize 
 sympathetic ophthalmia, we may claim for him that 
 he was the first author who published any papers 
 that show deep insight into this terrible disease. 
 As early as 1844 he had already developed various 
 hypotheses concerning the pathogeny of this affection, 
 which contain very nearly all that has been discov- 
 ered in this province in the last forty years; while his 
 works show that he had studied this obscure branch 
 of ophthalmology much more carefully than is nowa- 
 days generally believed. For, in looking over his 
 writings, we see at once that he had already consid- 
 ered the three paths along which sympathetic inflam- 
 mation may possibly be transmitted: Firstly, through 
 the vessels, by means of their anastomoses within the
 
 PATHOGENY. 117 
 
 skull ; secondly, along the ciliary nerves ; and thirdly, 
 through the retina and optic nerves. Nor do we now 
 know much more about the manner of transmission 
 than he did, for he says : " The vessels on the side of 
 the injured eye, being in a state of congestion which 
 may increase to inflammation, perhaps communicate a 
 disposition to similar disease to the vessels on the 
 opposite side, with which they anastomose inside the 
 cranial cavity." "The ciliary nerves of the injured 
 eye might be the paths along which the irritation is 
 conveyed, through the mediation of the third and fifth 
 pairs, to the brain, from which it is reflected along 
 the corresponding nerves of the opposite side." And 
 finally, speaking of the, optic nerves, Mackenzie says : 
 " It is extremely probable that the retina of the in- 
 jured eye is in a state of inflammation which advances 
 along the corresponding optic nerve to the chiasma. 
 From there, the irritative condition to which the in- 
 flammation was due crosses over to the retina of the 
 opposite eye, along i'ts corresponding optic nerve." 
 
 Correct as this last view must appear, even in our 
 days, Mackenzie undoubtedly erred in regarding the 
 " union of the optic nerves " as the " chief medium " 
 by which sympathetic inflammation is produced. For, 
 although there is not the least doubt that sympathetic 
 neuro-retinitis is often developed in the manner which 
 Mackenzie pointed out, sympathetic inflammation of 
 the uveal tract, as we have already seen, cannot be ex-
 
 118 SYMPATHETIC DISEASES OF THE EYE. / 
 
 plained by the extension of an inflammation of the re- 
 tina to the region concerned. So far back as 1849, 
 Tavignot, as I learn from Mooren, regarded sympa- 
 thetic iritis in the same light as if a sympathetic cili- 
 ary neuralgia were the primary affection, leading 
 finally to hypersemia and inflammation. Y. Arlt 
 also showed, at a later date, that conduction along the 
 ciliary nerves was the more probable path : "We can- 
 not decide, in the present state of our knowledge, 
 whether, in such cases, the optic nerve (the neurilemma 
 as far as the chiasma) or the trigeminus and sympa- 
 thetic ciliary nerves are the intermediate agents, al- 
 though a majority of facts speak in favor of the latter." 
 Heinrich Miiller (1858) was tlje first to awaken the 
 attention of the ophthalmological world to tho role 
 that is played by the ciliary nerves. It is interesting 
 also to note the fact that, from this time onward, the 
 pathological views of sympathetic inflammation under- 
 went very radical changes, although Miiller's views 
 differ so slightly from those held by Mackenzie. 
 Miiller, as well as Mackenzie, acknowledges that both 
 the ciliary and optic nerves participate in transmitting 
 the sympathetic irritation, but the former expresses 
 himself in such a way that it seems as if he denied 
 any such action on the part of the optic nerve. "Al- 
 though I will grant that the ciliary nerves may often 
 fan the fatal sympathy into flame, it is plain enough, at 
 the same time, that I do not deny that sympathy
 
 PATHOGENY. 119 
 
 (which assumes so many mysterious forms) cannot be 
 transmitted by the optic nerve." 
 
 Although II. Mtlller followed in the general direc- 
 tion which had been indicated by his predecessors, 
 his opinions seemed the more trustworthy because 
 they were for the first time based on anatomical con- 
 ditions. Among others of this sort, Miiller found the 
 ciliary nerves in a condition of partial atrophy, in an 
 eye which had been enucleated on account of the 
 premonitory symptoms of sympathetic ophthalmia. 
 But, as the nerves had only lost their medulla, he 
 thought that they might still have preserved " in a 
 greater or less degree " their capacity for transmitting 
 irritations toward the centre. " On the other hand," 
 continues Miiller, " the optic nerve, in many cases, is 
 in such a condition of excessive atrophy, from the 
 retina as far as the main trunk, that it could hardly 
 have the power of transmitting an irritation, or any 
 other process, from the eye." Nevertheless, we must 
 emphasize the fact that Miiller now spoils the effect 
 of his last remark, by hastening to add that " we can 
 hardly say, of certain fibres in the region of the 
 lamina cribrosa, whether they are nervous or not." 
 We must here carefully remark that Miiller had not 
 discovered any anatomical condition by which the 
 propagation along the ciliary nerves could in any 
 way be demonstrated ; but that he simply based his 
 conclusion upon the fact that the ciliary nerves are
 
 120 SYMPATHETIC DISEASES OF THE EYE. / 
 
 less liable than the optic nerves to degenerate into 
 complete atrophy. 
 
 As years passed by, the opinion that sympathetic 
 inflammation was transmitted by the ciliary nerves 
 grew more and more fixed, while, during the same 
 period, the theory of the participation of the optic 
 nerves in the sympathetic process fell into oblivion. 
 Pagenstecher (1862) was probably the first observer in 
 Germany who wholly opposed the participation of the 
 optic nerves, and referred the transmission exclusively 
 to the ciliary nerves, chiefly to their "nutritive" 
 sympathetic fibres. For many years thereafter the 
 ciliary nerves were regarded as* the sole conductors of 
 irritation from one eye to the other. Nevertheless, 
 a few men (among them Mooren) could not but notice 
 many facts that tended to show some transmission 
 along the optic nerve. In these exceptional cases 
 only a secondary role was attributed to the optic 
 nerves. Thus, in 1869, Mooren says that every sym- 
 pathetic disturbance depends upon an irritation of 
 the ciliary nerves, but that the trigeminus may affect 
 the optic nerves in the following manner : the irri- 
 tation transmitted from the trigeminus to the optic 
 nerve of the eye first affected, might be carried along 
 this optic nerve to the second eye ; from the latter, 
 in turn, it might extend from the optic nerve to the 
 trigeminus, "so that the solution of transmitted irrita- 
 tive processes takes place in the ciliary ganglion.""
 
 PATIIOGENY. 121 
 
 But, beyond this obscure reflex action, it seemed to 
 Mooreu that a third factor was needed, in order to 
 explain the origin of sympathetic affections : " one 
 which fixes the relations of nutrition, secretion, and 
 accommodation" one which involves a co-operation 
 of the sympathetic nerve, no matter whether the 
 transmission is effected along the main branches, or 
 directly along those sympathetic fibres which are said 
 to accompany the optic nerve. 
 
 The first observer, of recent date, to claim that the 
 optic nerve plays the chief role in the transmission of 
 sympathetic ophthalmia is Alt, who bases his opinion 
 on anatomical discoveries, which show a large per- 
 centage of alterations in the retina and optic nerve 
 of the eye originally affected. We must not forget, 
 however, that a large portion of these changes, such 
 as the frequent occurrence of detachment of the 
 retina, are nothing but the sequences of uveal dis- 
 eases. We should mention, as an additional point of 
 interest, that Alt also observed three cases of sym- 
 pathetic neuro-retinitis. Finally, the same observer 
 subscribes to the extraordinary opinion, that the 
 whole nervous apparatus shares promiscuously in the 
 transmission of sympathetic irritation to the second 
 eye, and that the various types of the disease in ques- 
 tion show only a difference of degree. 
 
 According to Mooren's theory, the nerves of special 
 
 sense (that is to say, the optic nerves) would have 
 6
 
 122 SYMPATHETIC DISEASES OF THE EYE. ' 
 
 to be additionally endowed with the capacity for con- 
 ducting irritation. But if we assume that, at the time 
 when the sympathetic symptoms appeared, there was 
 no nervous connection between the foreign body and 
 the optic nerve, and that it would lie impossible to 
 prove any conduction through the optic nerve, we 
 should have to rely upon a different sort of (reflex) ac- 
 tion between the ciliary and optic nerves, in order to 
 explain certain sympathetic disturbances which are not 
 of an inflammatory character. In the case already 
 cited (page 67) of sympathetic contraction of the 
 field of vision without any changes recognizable with 
 the ophthalmoscope, JBrecht expressed his opinion, on 
 anatomical grounds, that the optic nerves could not act 
 as conductors. Nor could he imagine any other path 
 for the transmission of sympathy than through the 
 ciliary nerves. Brecht also thought it quite probable 
 that the foreign body might have excited inflammation 
 in some of the ciliary nerves, which have the property 
 of transmitting irritation toward the brain ; that this 
 inflammation extended step by step, and finally in- 
 duced a hyperaemic condition in t"he medulla ob- 
 longata, with myelitis or some slight inflammatory 
 process in the region of the vaso-motor centres. Sub- 
 sequently, this inflammatory process caused paresis of 
 the vascular walls, and hypersemia of the retina in the 
 second eye, which was the one at fault so far as con- 
 cerned the disturbance of its function. Brecht based
 
 PATHOGENY. 123 
 
 his argument on three experimental trials : first, 
 those of Lewison on frogs (1869), from which the 
 experimenter concluded that violent irritation of 
 sensitive nerves paralyzes the reflex activity as well 
 as those voluntary movements which are dependent 
 on the medulla spinalis ; secondly, on Leyden's opin- 
 ion (1865) that the so-called reflex paralysis (para- 
 plegia, paralysis of the sphincters), which is often 
 observed after chronic affections of the bladder and 
 other tedious diseases, may depend upon an inflam- 
 mation of the sensitive nerves of the organ affected, 
 which duly ascends into the spinal cord, and gives 
 rise to a myelitis ; and thirdly, on the experimental 
 studies of Feinberg (1871), who observed paralysis of 
 the bladder and paraplegia in a rabbit, a few days 
 after cauterizing the ischiatic nerve, while at the 
 post-mortem examination he discovered that the re- 
 flex action was due to a myelitis, the central stump of 
 the cauterized ischiatic nerve being quite intact. 
 This goes to show that a similar inflammation can 
 gradually extend along the nerve. Moreover, it is to 
 be regarded as an experimental fact, which confirms 
 Leyden's discovery in man, that whenever he had diag- 
 nosticated, during life, a neuritis ascending into the 
 spinal cord, he always found, after death, a cor- 
 responding myelitis at the place where the nerves 
 entered, but no tokens whatever of an ascending 
 neuritis.
 
 124 SYMPATHETIC DISEASES OF THE EYE. 
 
 We may here mention still another possible hy- 
 pothesis. The well-known experiment of Golz, in 
 which a frog's heart ceases to beat when one strikes 
 a few rapid blows over the region of the belly, may 
 be interpreted to mean that the centripetal sympa- 
 thetic nerves of the viscera conduct a reflex irritation 
 through the- medulla oblongata to the vagus, which is 
 the retarding nerve of the heart. Now, in the same 
 way, we might agree with Brecht in supposing that 
 the irritation due to the foreign body is simply trans- 
 mitted, by reflex action, along the sympathetic fibres 
 of the ciliary nerves which lead to the Ijrain (are 
 there really any fibres of that sort?} through the 
 medulla oblongata to the ciliary nerves of the second 
 eye, which lead from the brain, and that the latter 
 then interfere with the function of the retina itself, 
 just like any other retarding nerves. Leber also 
 (1877) is of the opinion that, inasmuch as the reflex 
 paralysis of motor nerves has been abundantly dem- 
 onstrated, as well by clinical observations as by expe- 
 riments on animals, the occurrence of a reflex paralysis 
 u of sensitive nerves, especially of the optic nerve or 
 retina," cannot at present be denied without further 
 argument. 
 
 Those observers who defend reflex neuroses in the 
 province of sympathetic affections, imagine, on the one 
 hand, that the inflammatory irritation is undoubtedly 
 conducted along the optic nerves, but that in the eye
 
 PATHOGENY. 125 
 
 affected by sympathy the irritation crosses from the 
 optic nerve to the ciliary 7 nerves, by which the inflam- 
 mation is first ushered in. Or, on the other hand, they 
 assume that the sympathetic symptoms which reveal 
 themselves on the part of the retina and optic nerve, are 
 not produced in the second eye by direct conduction 
 of the irritation from one optic nerve to the other, but 
 by conduction along the ciliary nerves, and from the 
 latter to the optic nerve. According to these views, 
 therefore, the whole series of symptoms, such as sensi- 
 tiveness to light, rapid weariness of the eyes during 
 work, rhythmical indistinctness of the field of vision, 
 periodical obscuration of vision, dread of light, sparks 
 before the eyes, degenerating occasionally into exces- 
 sive photophobia and photopsia, anaesthesia of the 
 retina with concentric limitation of the field of vision, 
 and finally typical retinitis (the latter separated from 
 the other symptoms, at least by Leber, and regarded 
 by him as the consequences of sympathetic irido- 
 choroiditis) all these symptoms, we say, are to be 
 regarded simply as a series of reflex neuroses, the pri- 
 mary affection having its seat in the ciliary nerves. 
 
 The foregoing summary shows that we were right in 
 designating our general views as relatively simple. 
 But we will now go farther, and examine whether 
 these relatively simple views will not satisfactorily ex- 
 plain all the phenomena of sympathetic ophthalmia 
 without compelling us to enter upon the obscure pro-
 
 126 SYMPATHETIC DISEASES OF THE EYE. 
 
 vince of reflex neuroses. "When Mackenzie thought 
 that there was very little doubt that the retina of the 
 injured eye was in a state of inflammation, it seems as 
 if he hit the mark precisely. Without being forced to 
 assume some mysterious influence on the part of the 
 ciliary nerves upon, the optic nerves, it has now been 
 proved that the injury itself is capable of exciting va- 
 rious inflammatory processes in the interior of the eye, 
 and that they may (oftentimes, perhaps, from some 
 definite lesion of the parts involved) rapidly attack the 
 optic nerve. In this point of view, we find a very in- 
 teresting fact in an insignificant remark of Brailey's, 
 in his " Pathological Report for 1876." A boy, four 
 years old, falls with a knife in his hand, and pierces 
 the lower eyelid, and then the cornea, as well as a 
 portion of the sclerotica right and left from the cornea. 
 Four days later the eye is enucleated. The retina 
 and choroid are both in situ. The entrance of the 
 optic nerve is swollen and completely surrounded by 
 a whitish opacity, near which lies a small capillary 
 hemorrhage. The microscopic examination leaves no 
 doubt of the swelling of the optic nerve. E. Williams 
 reported at the International Congress in New York, 
 in 1876, two recent cases in his own practice, in which 
 the wounded and enucleated eye had been attacked, in 
 the most surprising manner, by a very pronounced 
 neuro-retinitis. In the first case (in which enucleation 
 was performed a few weeks after the inj ury), Williams
 
 PATHOGENY. 127 
 
 observed the most extensive swelling of the optic nerve 
 that he ever had seen. Hirschberg also expresses as- 
 tonishment over a similar case in the same year. In 
 this case also, as in the one reported by Brailey, the 
 eye was wounded by a knife-blade, although eimclea- 
 tiou was not performed until nine months after the in- 
 jury. The optic papilla was very much swollen, and 
 surrounded by a well-developed wall, evidently due to 
 hyperplasia of the inner granular layer, and the radi- 
 ating fibres of the retina. Inasmuch as the develop- 
 ment of the neuro-retinitis in the injured eye has been 
 demonstrated by Brailey, at an early date after an in- 
 jury, as well as at a later date by both E. Williams and 
 Hirschberg, and since the, frequent participation of 
 the optic nerve in the inflammatory process in the in- 
 jured eye has generally been confirmed by Alt, we 
 have on the whole to take it for granted that the retina 
 and optic nerve in the eye first affected are either ir- 
 ritated or inflamed by the wound itself, or by the mor- 
 bid processes which follow the latter. It is, of course, 
 hard to say wherein the " irritative condition " con- 
 sists ; but it is a fact that the irritation can propagate 
 itself to the second eye, or be produced in the second 
 eye by inflammation in the first eye, as well as that 
 the irritation can disappear after the removal of the 
 original source of disturbance in the sympathetically 
 affected eye. 
 
 Just in the same way as the obscurations of the
 
 128 SYMPATHETIC DISEASES OF THE EYE. 
 
 field of vision, as well as the diminution of central 
 vision with concentric limitation of the field of vision, 
 do not depend on diminished, out on increased irri- 
 tability of the retina not on anaesthesia, but on hy- 
 percBsthesia of the retina, so the sensitiveness to light, 
 rapid weariness of the eye at work, photophobia, fiashes 
 of light and sparks before the eyes, are manifestations 
 of irritation propagated from the one optic nerve to 
 the other. The eye wjiich has become over-irritated by 
 the sympathetic process refuses periodically, or perma- 
 nently, to react in various portions of its field of vision, 
 to the irritation of an amount of light which would 
 be plenteonsly sufficient for an eye in a state of 
 normal excitability. Anc^ further in this connection, 
 we must remember that v. Graefe long since rightly 
 referred to hypercesthesia of the retina, that anaesthesia 
 of the retina, with concentric limitation of the field of 
 vision, which we observe in cases where there can be 
 no question of sympathetic irritation. 
 
 Some one may ask how it is possible for such a con- 
 nection to exist between the eyes, by means of the op- 
 tic nerves, in those cases in which the optic nerve of the 
 e} r e first afi'ected is in a state of total atrophy. A cord 
 of connective tissue cannot transmit such a sensorial 
 irritation ! Granted ; but even if this is so, we can- 
 not, in my opinion, assume with absolute certainty, in 
 all those cases in which similar functional disturb- 
 ances are observed, without any material foundation
 
 PATIIOGENY. 129 
 
 in the second eye, that all the fibres of the optic rerve 
 of the firsfc eye are atrophic. How could we decide, 
 even with the microscope, that some minute fibres 
 which still had the capacity of acting like nerve-ele- 
 ments, or axis-cylinders deprived of their medulla, 
 might not still be present in the connective- tissue 
 cord into which the optic nerve had become trans- 
 formed ? When Brecht, therefore, thinks it impossi- 
 ble that the optic nerves could have transmitted the 
 sympathetic irritation in his case, and falls back on 
 the ciliary nerves in order to support a theory of his 
 own, he raises an unanswerable argument against him- 
 self, by saying that the eye first affected was perfectly 
 free from pain and irritation. In other words, his 
 supposition of an irritative condition of the ciliary 
 nerves falls to the ground. We do not, however, 
 mean to assert that the functional disturbances of the 
 retina, which have been previously mentioned, do not 
 depend upon alterations in the tissue concerned, even 
 when the ophthalmoscopic image is negative. For we 
 shall be compelled to assume some structural changes, 
 even though they be coarse, when the irritation does 
 not disappear after the source of irritation has been 
 removed. Thus, in Alfred Graefe's terrible case 
 (page 65), in which the tormenting photopsies did not 
 yield after enncleation of the injured eye, I cannot 
 doubt that they originated in, and were kept up by, 
 
 the products of inflammation which had already 
 6*
 
 130 SYMPATHETIC DISEASES OF THE EYE. 
 
 taken firm hold of the optic nerves. The microsco- 
 pist, in these cases, gives us an important clue in this 
 direction, when he finds proliferated connective tissue 
 in the intraocular end of the optic nerve belonging 
 to the enucleated eye. Such a proliferation of inter- 
 stitial connective tissue in. the tract of the optic nerve 
 would gradually compress the bundle of nerve-fibres 
 more and more closely, and finally give rise to mere 
 mechanical irritation. 
 
 In previously speaking of evident inflammation of 
 the optic nerve and retina of the second eye, we took 
 occasion to emphasize the fact that there is no hinder- 
 ance whatever to the transmission of such a process 
 from one eye to the other. We had only to prove 
 that such a neuro-retinitis was really present in the 
 eye first affected. Indeed, I should like to believe 
 that, when the retina and optic nerve of the first eye 
 have been found intact after enucleation in a few 
 cases of assumed sympathetic neuro-retinitis, this very 
 fact alone takes away every point of support in favor 
 of the sympathetic origin of the affection in question. 
 
 We now see why I so long ago emphasized the 
 opinion that inflammatory affections of the nervous 
 apparatus of the second eye really occur -more fre- 
 quently than observers have hitherto been inclined to 
 admit, as well as that their presence is frequently hid- 
 den by the simultaneous appearance of irido-cyclitis ; 
 and, finally, that there is no necessity whatever for as-
 
 PATHOGEN Y. 131 
 
 suming that they simply indicate the extension of the 
 inflammatory process from the choroid of the same 
 eye. Nor should we forget, in speaking generally of 
 the transmission of inflammation along the optic 
 nerves, that this might also happen in case the optic 
 nerve of the eye first affected were completely trans- 
 formed into a thread of connective tissue. For, even 
 in such a structure as this, the inflammation might 
 creep onward to the chiasma, and then appear in the 
 trunk of the second optic nerve in the shape of a dan- 
 gerous peri-neuritis, embracing and crushing the fibres 
 of the optic nerve by proliferation of connective 
 tissue (a process which might finally reveal itself to 
 the ophthalmoscope by partial or total atrophy of the 
 optic papilla) ; or it might advance as far as the optic 
 papilla, and there present itself to the eye of the ob- 
 server under the form of optic neuritis. If we once 
 hold fast to the fact that the optic nerve offers a very 
 productive territory for the propagation of inflamma- 
 tion, we can then oomprehend why optic neuritis may 
 appear in the second eye after enucleation of the first, 
 as in Colsmann's three cases previously cited (page 
 93). For, in these cases, the inflammation was either 
 under way at the time when the operation was per- 
 formed, and was only rapidly increased by the opera- 
 tion, or else the operation led to the neuritis by crush- 
 ing the nerve during its division. Such a crushed 
 condition of the nerve was indeed directly acknowl-
 
 132 SYMPATHETIC DISEASES OF THE EYE. 
 
 edged by Moore n, in a case which he observed long 
 before (1860) the cases cited by Colsmann. The pa- 
 tient began to complain of increasing dimness of 
 vision, photopsia, and slight pressure in the forehead, 
 a few weeks after the enucleation of the injured eye. 
 Corrosive sublimate was exhibited internally, and a 
 seton placed in the neck ; but several months passed 
 before the subjective symptoms disappeared entirely. 
 The final history of the case showed that, two years 
 later, atrophic alterations in the optic nerve (as con- 
 firmed by the ophthahnoscopic examination) had re- 
 duced the patient's vision so much that he felt for- 
 tunate in being able to read Jaeger's test-types >.'<>. 
 12, with difficult}'. Who would not seek to explain 
 such a case as this in the most simple way, by imagin- 
 ing that the operation gave rise to a peri-neuritis 
 which extended to the second optic nerve, and pro- 
 duced partial atrophy? 
 
 We have, on the whole, no right at all to aslc 
 whether the sympathetic affection is transmitted along 
 the optic nerves, or along the ciliary nerves ; nor can 
 we ask whether the transmission takes place along t/ie 
 one path more frequently than along the other. For 
 the transmission may be effected in both ways. But 
 by this, however ^ we are not to understand that one 
 and the same morbid process can be transmitted, now 
 along the one path, and now along the otlier. On the 
 contrary ) irritative and inflammatory conditions are
 
 PATHOGEN Y. 133 
 
 transmitted from the optic nerve and retina, along 
 the optic nerves; whilst those inflammatory processes 
 which are chiefly observed in that portion of the eye 
 which is nourished by the ciliary nerves, and espe- 
 cially in the uveal tract, are transmitted along the 
 ciliary nerves. There is not the least doubt that the 
 sympathetic inflammation may frequently he trans- 
 mitted along both paths at once, or at short intervals, 
 so that many symptoms in sympathetic affections of 
 the uveal tract (amongst others, the functional dis- 
 turbances) are not to be attributed to the inflam- 
 mation of the uveal tract, but to a simultaneous in- 
 flammation of the retina and optic nerve. 
 
 This, of course, does not exclude the possibilit} T of 
 detachment of the retina, appearing in connection 
 with the irido-choroiditis, involving the sympatheti- 
 cally affected eye, just as it may he observed in every 
 irido-choroiditis. In the same way, when we see sym- 
 pathetic neuro-retinitis in this same eye, the final de- 
 tachment of the retina is not due to a sympathetic 
 inflammation of the latter tissue, but to the process 
 which is going on in the choroid. 
 
 Moreover, as any irritation of the stump of the 
 nerve, external to the eye, can induce sympathetic 
 neuro-retinitis, it is easy to see (if we once acknowl- 
 edge that the ciliary nerves, or, in a wider sense, the 
 branches of the trigeminus, can transmit the irritation) 
 not only how cyclitis of the one eye can prod' 1 -
 
 134: SYMPATHETIC DISEASES OF THE EYE. 
 
 affections of the whole choroidal tract in the other, 
 but also how the same morbid processes, which excite 
 sympathetic affections in the ciliary body by irritat- 
 ing the ciliary nerves, can similarly become an irri- 
 tating cause in other regions of the eye, as well as 
 outside the eye, so soon as the filaments of the trige- 
 rninus, which are distributed to the regions concerned, 
 are affected in an analogous manner. From all this 
 we see that it is by no means extraordinary for irrita- 
 tion (incarceration), or inflammation of the iris, or of 
 the choroid itself, or for the irritation caused by an 
 artificial eye resting upon a stump, or finally, for the 
 mere introduction of an artificial eye into the orbit 
 after removal of the eye, to develop in the second 
 eye about the same train of symptoms that we observe 
 after a genuine cyclitis in the first eye. In the latter 
 point of view (the influence of an artificial eye), 
 Mooren was distinctly able to prove, in a case with 
 great tenderness over the whole region of the stump 
 of the optic nerve, how even a slight touch, upon the 
 inner wall of the orbit, produced excessive pain a 
 fact which would go to demonstrate that the region 
 to which the naso-ciliaris nerve is distributed was 
 irritated by the sharp edges of the artificial eye. 
 Moreover, a case of Snellen's, in which the sympa- 
 thetic phenomena of irritation could at pleasure be 
 excited and then dissipated, depending upon whether 
 the artificial eye was inserted or again removed, shows
 
 PATHOGENY. 135 
 
 how much these phenomena in the second eye may 
 depend upon the irritation of the empty orbit by the 
 glass shell. 
 
 Furthermore, we can see how enucleation itself, by 
 crushing the ciliary nerves (and optic nerve) during 
 their division, can become the starting-point of sym- 
 pathetic inflammation, as well as how the curative 
 reaction after a normal enucleation can excite the 
 destructive disease in question by contracting the 
 stump of the nerve in the cicatrix. In the same way 
 it is easy to understand that, when the process in the 
 first eye has once overstepped the rubicon, and is 
 already advancing toward the chiasma along the ex- 
 tra-ocular tracts, enucleation cannot prevent its en- 
 trance into the interior of an eye which is still intact ; 
 and finally, that even when the cyclitis (or neuro- 
 retinitis) in the first eye is entirely cured, the same 
 process may subsequently appear in the second eye, 
 and there continue its devastating course. The enemy 
 had indeed wholly evacuated his first camping-ground, 
 but at the same time he was already advancing rap- 
 idly upon the second eye. 
 
 Now, just as I have seen cyclitis appear in the 
 second eye after complete recovery from the same 
 disease in the other, or seen the second eye exhibit 
 the most violent type of cyclitis despite the fact that 
 the other eyeball was perfectly free from spontaneous 
 pain, as well as insensible to the touch, it might not
 
 136 SYMPATHETIC DISEASES OF THE EYE. 
 
 be at all impossible, after a normal recovery from 
 enncleation, for some source of irritation to remain in 
 the orbital or intracranial fibres of the nerve in- 
 volved. I think that, in every case in which we have 
 been obliged to ascribe the outbreak of sympathetic 
 symptoms to the enucleation itself, or to the introduc- 
 tion of an artificial eye, we have, so far, observed, that 
 the region in the bottom of the orbit which was occu- 
 pied by the stump of the excised nerve, and its ac- 
 companying ciliary nerves, was sensitive to the touch, 
 as well as that the conjunctiva lining the cavity was 
 swollen, red, and painful. On the other hand, it 
 would seem unjustifiable for us not to recognize the 
 characteristic appearances of sympathetic irritation, 
 as such, simply because up to this time we had never 
 observed them in the absence of tenderness in the 
 orbit, as well as at the stump of the nerve. I allude 
 now to the following case : 
 
 o 
 
 March 25, 1878, I saw, for the first time, a farmer, 
 aged forty-three, who had been wounded more than a 
 year before, in the right eye, by the thrust of a cow's 
 horn. A few days after the accident, violent pain was 
 felt all over the corresponding side of the head. The 
 injured eye was enucleated at a later date, but the pain 
 did not cease. A year has passed since the enucleation, 
 but the patient lias never been free from exacerbat- 
 ing attacks of pain on the right side of his head. Still 
 lie does not seek advice so much for the pain, as be-
 
 PATHOGEN Y. 137 
 
 cause his left eye is totally unfit for loorJc. He can 
 use it so little, that it is only with the greatest difficulty 
 that he can carry on his farm-work. He cannot read 
 at all for more than a moment or two at a time. The 
 eye looks normal externally and the ophthalmoscope 
 does not help me to discover any internal alterations. 
 The patient can read diamond type (Jaeger No. 1), and 
 his field of vision is normal. The only definite anom- 
 aly which one can discover in the eye is that the 
 power of accommodation is somewhat less than is 
 usual at the patient's age. Despite, however, this 
 nearly normal condition of the eye, the patient cannot 
 work for any length of time, even with a convex glass 
 to support his accommodation. We are therefore led 
 involuntarily, in such a case as this, to assume the pres- 
 ence of a sympathetic neurosis. But when we exam- 
 ine the right orbit, we find that the cavity is lined with 
 a conjunctiva which is neither red nor swollen, while 
 neither in the bottom of the orbit, nor over the loca- 
 tion of the stump of the optic nerve, can we discover 
 any tenderness, nor even any special sensitiveness to 
 pressure with a blunt probe. These various reasons 
 had led several oculists to deny the possibility of any 
 sympathetic affection in this case ; but I do not regard 
 it as entirely impossible. The irritative cause, even if 
 the peripheral ends of the nerves show no distinct 
 anomaly, may lie anywhere in the nerve-tracts ; possi- 
 bly even in the orbital portion of the optic nerve. In
 
 138 SYMPATHETIC DISEASES OF THE EYE. 
 
 such a case, some remedy may yet be discovered by 
 scientific investigation. 
 
 o 
 
 Another question now arises in considering the 
 pathogeny of sympathetic affections : If we take it 
 for granted that the nerves transmit the irritation, do 
 we know anything more accurate regarding the method 
 of transmission ? We need not trouble ourselves be- 
 cause, in the present state of our knowledge, " it is im- 
 possible for us to know anything " about the molecular 
 alterations which may be present in the nerves during 
 the conduction of the irritation. But it is a more 
 striking fact that we really know nothing more pre- 
 cise as regards the manner in which inflammation is 
 transmitted. But even in this point of view we must 
 distinguish between the ciliary nerves and the optic 
 nerve. 
 
 Alt searched for alterations in the ciliary nerves in 
 one hundred and ten cases in our province, but found 
 only forty- three which offered any direct testimony. 
 Thirty-four of these cases showed normal ciliary 
 nerves. The remainder showed various lesions of the 
 nerves in question, such as tearing, crushing (without 
 histological alterations), incarceration in a cicatrix, fatty 
 degeneration, atrophy, thickening of Schlemm's canal, 
 and one case of calcareous degeneration in the same 
 canal. 
 
 Goldzieher (1877) thought that he had unravelled 
 the mystery, when he discovered in a given case
 
 PATHOGENY. 139 
 
 (which in my opinion is very doubtful, so far as re- 
 gards its genuinely sympathetic origin) such extensive 
 alterations in the ciliary nerves of the enucleated eye 
 as no other observer had ever before seen. The whole 
 thickness of the choroid was filled with fresh inflam- 
 matory swelling and proliferation of cells ; whilst the 
 sheaths of the ciliary nerves were thickly infiltrated 
 with round cells, and the inter-tibrillar tissues crowded 
 with granules. Inflammatory nodules composed of 
 round cells were also seen here and there compressing 
 the trunks of the optic nerves. If such a condition as 
 this were more generally observed, we should have at 
 least some anatomical proof that the ciliary nerves 
 are capable of propagating the inflammatory process 
 within the eye, as has already been proved in the case 
 of the optic nerves, even if we have, so far, been wholly 
 unable to determine with exactitude the paths along 
 which the inflammatory process is transmitted, outside 
 the eye. But Goldzieher's discovery is very excep- 
 tional, and it cannot be denied that, in a vast major- 
 ity of cases, the ciliary nerves of the eye which excites 
 the sympathy show no alterations whatever. Goldzie- 
 her takes it for granted that the inflammatory altera- 
 tions which he observed in the ciliary nerves are in- 
 variably present in such cases, and assumes, in corre- 
 spondence with the experiments made on animals by 
 Tiesler, Feinberg, Klemm, and Niedieck, that the in- 
 flammation in these nerves does not advance continu-
 
 140 SYMPATHETIC DISEASES OF THE EYE. 
 
 ously, but by fits and starts, and that when it has 
 reached the central organ it extends still farther in a 
 similar manner. When the inflammation has finally 
 crossed over to the nerve-tracts of the opposite side, it 
 propagates itself in the same way, and so reaches 
 in due season the network of nerves in the interior of 
 the second eye, along which, in turn, the dangerous in- 
 flammation is conducted to the various membranes in 
 correspondence Avith the distribution of the nerves 
 concerned. So much for Goldzieher's opinion, to 
 which we may reply that the theory of a wandering 
 neuritis, as the anatomical cause of sympathetic in- 
 flammation, lacks at present any satisfactory basis, 
 from the very fact that in almost every case the in- 
 traocular ciliary nerves are decidedly intact, to say 
 nothing of the fact that no one has ever yet demon- 
 strated such a wandering neuritis, nor proved how 
 such an inflammation in a nerve (even were- it demon- 
 strated anatomically) could cause violent inflammation 
 in a connective tissue. 
 
 Dark and complicated, therefore, as must seem the 
 possible way in which inflammatory processes are trans- 
 mitted along the ciliary nerves, the matter is relatively 
 simple in the case of the optic nerves, for in the lat- 
 ter we have only to picture the transmission of an in- 
 flammation from nerve to nerve. Under such cir- 
 cumstances as these, the inflammation of the optic 
 nerve, in the injured eye, is anatomically proved in
 
 PATHOGENY. 141 
 
 the eye affected sympathetically, it is directly proved 
 with the ophthalmoscope ; so that here, \viththe union 
 of the optic nerves at the chiasma, we may calmly as- 
 sume that we have to do with a connected or discon- 
 nected neuritis, passing from one nerve to the other 
 through the chiasma. 
 
 Another important question for us to decide is this : 
 How long does it take for the irritation which ad- 
 vances along the nerve-tracts to reach the second eye ? 
 This is about the same as to ask when the sympathetic 
 inflammation is liable to appear. We may at once 
 reply that we cannot fix the latest period at which the 
 disease in question may make its appearance. If an 
 eye is totally destroyed by an injury, the possibility of 
 its reacting upon the second eye continues, not only 
 so long as the eye is painful, but in case a foreign 
 body has remained harmlessly in the eye (even at any 
 region whatsoever), it may at any indefinite future 
 time be followed by a reaction due to the presence of 
 the foreign body (page 24). Or further, in an atro- 
 phic eye which, being utterly free from irritation, 
 seems an extremely harmless neighbor, some un- 
 known cause, or the development of a plate of bone 
 in its interior, may give rise to renewed sensitiveness, 
 and consequently develop a posthumous source of irri- 
 tation (page 49). Finally, there can scarcely be any 
 doubt that, in & painless and unirritable stump or eye- 
 ball, the seeds of sympathetic irritation can rest un-
 
 142 SYMPATHETIC DISEASES OF THE EYE. 
 
 germinated for an indefinite period (pages 48 and 67). 
 In point of fact, literature gives us the history of cases 
 in which tens of years, even half a century, or longer 
 periods, have elapsed between the original injury, or 
 exciting cause, and the development of sympathetic 
 ophthalmia. 
 
 It is much more important, however, for us to de- 
 termine the earliest period at which the sympathetic 
 affection may appear. In this point of view a pro- 
 portionately long interval seems, in our opinion, to 
 exist between the cause and the result. A priori, this 
 interval cannot be measured. We have no precise 
 starting-point from which to discover how long it 
 takes for the morbid condition in the ciliary and optic 
 nerves to be transmitted to the opposite side. So that, 
 while the earliest appearance of neuro-retinitis in the 
 injured eye has been precisely demonstrated, we do 
 not know, so far as regards the ciliary nerves, how 
 long a time must elapse before the ciliary nerves in 
 \\\e primarily affected eye are excited to the necessary 
 irritative condition. We might even believe that 
 sympathetic neuro-retinitis must necessarily be devel- 
 oped in a ranch shorter time than sympathetic cyclitis, 
 because the path along which the cyclitis advances is 
 much longer than in the case of the neuro-retinitis ; 
 nevertheless, we could by no means affirm that our 
 experience corresponds to our expectation. Macken- 
 zie stated that from one month to a month and a half
 
 PATHOGENY. 143 
 
 separated the original from the induced affection, and 
 I must emphasize the fact that, in my own experience, 
 I know of no case in which I ever saw sympathetic 
 ophthalmia appear sooner than in four weeks after 
 the injury. I grant, indeed, that this period of four 
 weeks might be somewhat shortened, in occasional 
 cases, but I will not grant that the necessary period 
 can be reducetl to a few days, as is alleged to have 
 been observed by several authors. There are, however, 
 some observations after enucleation, which would 
 seem to argue in favor of the possibility of the rapid 
 development of the sympathy, although they deserve 
 to be carefully examined. We saw (page 94r) how 
 Colsmann and Hugo Miiller both observed one case 
 each of neuro-retinitis in the uninjured eye a few 
 days after enucleation of the other, and similar ob- 
 servations are at hand in respect to uveal inflamma- 
 tions (v. Graefe, Mooren, Schmidt, Pagenstecher, and 
 Genth). But before we accuse enucleation of being 
 the cause of the sympathy in these cases, we must 
 prove that such an interval had not elapsed since the 
 injury, as would have enabled the sympathetic inflam- 
 mation to appear at that very same time, even if the 
 enucleation had not been done, owing to the fact that 
 the sympathetic irritation had long ago started on its 
 path, and was just on the point of making its appear- 
 ance in the other eye when the enucleation happened 
 to be performed. "When, in the case of the last two
 
 144 SYMPATHETIC DISEASES- OF THE EYE. 
 
 authors, the first symptoms of sympathetic iritis re- 
 vealed themselves in the previously healthy eye nine 
 days after the enucleation, we must remember that 
 thirty-six days had already passed since the original 
 injury a period in which the outbreak of sympathetic 
 ophthalmia cannot surprise us, for it could not, at that 
 late period, have been restrained by an enucleation 
 performed only nine days before. Scfimidt's case is 
 somewhat similar: sympathetic inflammation appears 
 in four days after the enucleation ; but hero, also, 
 nearly four weeks have elapsed since the injury. 
 When enucleation is performed in the case of eyes 
 which have for a long time been phthisical and pain- 
 ful (Colsmann and II. Miiller), the sympathy which 
 appears in a few days after enucleation can, with all 
 the less certainty, be referred to the operation. So, if 
 we have pure cases i.e., if one of two previously 
 healthy eyes is seriously injured, sympathetic irrita- 
 tion will rarely appear before the fourth week ; nor. 
 when fairly under way, can it be restrained by enuclea- 
 tion. 
 
 The fact that a certain interval must elapse between 
 the affection of the one eye and sympathy in the other 
 is of great importance in establishing our diagnosis of 
 a sympathetic disease. In order to make such a 
 diagnosis in any given case, we must weigh well all 
 that has previously been given in detail in these pages, 
 under the sections of Etiology and Pathology. Fur-
 
 PATHOGENY. 145 
 
 thermore, as we have already given a sufficient ac- 
 count of the general course and results of the more 
 important types of sympathetic ophthalmia, especially 
 as regards irritation, and the manifold forms of 
 affections of the uveal tract, we can at this place dis- 
 pense with any special remarks on the prognosis of 
 the disease in question. And so much the more read- 
 ily, as several points in this respect will be mentioned 
 under the title of Therapeutics, to which we will now 
 give our attention.
 
 SECTION V. 
 
 THERAPEUTICS. 
 
 WE finally turn our attention to th-3 therapeutics of 
 sympathetic ophthalmia, and instantly we hear the 
 cry I might almost say the battle-cry, " Enuclea- 
 tion." Scarcely twenty years have passed away since 
 v. Graefe said : " I should never think it necessary to 
 undertake the complete extirpation of an eye affected 
 with traumatic irido-choroiditis, in order to ward off 
 a sympathetic affection from the other eye, and 1 
 only mention this operation because, as I hear, it is 
 performed by some English oculists.^ Since then, 
 thousands upon thousands of eyes have been sacri- 
 ficed, and where is the oculist who feels wholly inno- 
 cent of having operated under the philanthropical 
 mantle of preventive enucleation, just for the sake of 
 gaining some especially desirable specimen for his 
 pathological collection ? 
 
 Let us, however, enter calmly upon our discussion 
 of this highly important subject. Before showing the
 
 THERAPEUTICS. 14:7 
 
 beneficial results which enucleation may win for 
 the patient, let us first inquire into the harm which it 
 may cause. The most terrible result of enuclea- 
 tion (an operation which consists in shelling out 
 the eyeball from its surrounding capsule of Tenon, 
 sparing as much as possible of the conjunctiva of the 
 globe, as well as of the external muscles of the e} r e) 
 is deatli ! V. Graefe witnessed two deaths, when he 
 enucleated during the period of purulent panophthal- 
 mitis, but none under any other circumstances. On 
 the other hand, however, several fatal cases have been 
 reported after enucleation of an eyeball which was 
 not affected with purulent panophthalmitis (Mann- 
 hardt, Horner, Just, H. Pagenstecher, Yerneuil, and 
 Yignaux). The fatal cases reported by Horner, Pa- 
 genstecher, and Yerneuil were due to meningitis, as 
 was demonstrated at the post-mortem examinations, 
 although in the first two cases there was no evident 
 proof that the process had extended from the orbit ; 
 while in Yerneuil's patient a pblegmonous inflamma- 
 tion of the orbit was proved to be the connecting 
 link. 1, also, once saw a fatal result after enucleation, 
 in the case of an old woman whose right eye, after 
 having undergone an iridectomy, continued painful, 
 and had to be enucleated on account of absolute 
 glaucoma. Profuse hemorrhage followed the opera- 
 tion, and death ensued in a few days. The orbit ex- 
 hibited traces of suppuration, but there were no signs
 
 148 SYMPATHETIC DISEASES OF THE EYE. 
 
 of meningitis. On the whole, there was no discover- 
 able cause of death. There have undoubtedly been 
 many more cases of death after enucleation than 
 have ever appeared in print. For all that, we 
 shall see how mere chance may play its role in 
 this accident, from a case of my own, which will not 
 easily be erased from my memory. An old woman 
 had suffered for years with violent pain in a blind 
 glaucomatous eye, which, with loss of sleep and appe- 
 tite, had reduced her to a very feeble condition. At 
 last she made up her mind to have the enucleation 
 performed, ancl was received into the hospital. I post- 
 poned the operation for some reason or other, to the 
 following day. But the operation was never performed, 
 for on the morning of the day appointed, the patient 
 was found dead in her bed. Had I operated on the 
 day before, who is there who conld not have said that 
 the operation killed the patient ? The autopsy in this 
 case, as usually happens, revealed no cause for death.* 
 We are next to notice that the enucleation of eyes 
 which are sacrificed in order to protect the second eye 
 does not always progress without accidents, leaving 
 
 * As partially bearing on the question of chance, let us recall a 
 case of our own, in which an iridectomy was appointed for a cer- 
 tain day, in a case of glaucoma. On the morning of the day ap- 
 pointed, the patient was found dead in her bed. Ought not the 
 extremely few cases of reported death from iridectomy to be attri- 
 buted to some other than the alleged cause ? TRS.
 
 THERAPEUTICS. 149 
 
 aside the very distant possibility of death. We may 
 have extensive purulent inflammation of the orbital 
 tissues without being able to discover any cause for 
 such a course of events in the case itself, or in the 
 operation ; intense phlegmonous swelling, accompa- 
 nied with violent pain, may be developed in the orbit 
 and lids, compelling us to make an exit for the pus 
 by extensive incisions into the orbital tissues and sur- 
 rounding parts. At the same time, the general condi- 
 tion of the patient is weakened, and we can congratu- 
 late ourselves when the process confines itself to the 
 orbit, so that all fear of its spreading into the cranial 
 cavity is removed. 
 
 Again, enucleation always causes a local disfigure- 
 ment, respecting the degree of which there may, 
 however, be different opinions. Moreover, in so far 
 as the eye removed had a certain size, and the opera- 
 tion was performed on a child, enucleation has con- 
 siderable influence upon the configuration of the orbit 
 concerned, as well as of the corresponding side of the 
 face. There may of course be some discussion, in 
 so far as regards the local disfigurement, as to which 
 is the more comely, an empty orbit with sunken eye- 
 lids (which, however, every one will cover with a 
 handkerchief or bandage), or a misshapen stump, 
 which cannot easily or agreeably be kept constantly 
 covered. To be sure, we shall hear in reply that the 
 difference really consists in this : that an artificial eye,
 
 150 SYMPATHETIC DISEASES OF THE EYE. 
 
 fitted upon the stump, satisfies the cosmetic demands 
 more perfectly than when it is inserted into a vacant 
 orbit. The artificial eye, a hollow glass-shell, with its 
 concavity applied in corresponding size and curvature 
 to the convex stump, deceives every one by the com- 
 plete mobility which is imparted to it by the muscles 
 still fixed to their normal attachments a real eye, so 
 true to nature as often to deceive even the specialist, 
 if he does not look very carefully. It may, indeed, 
 happen that the specialist himself mistakes the one 
 for the other, the artificial for the natural, and the 
 natural for the artificial eye. tff the concave shell of 
 the artificial eye is inserted into an orbit which has 
 been deprived of its eye, the mobility of the former is 
 not, as is generally supposed, completely abolished, 
 although the motion which it really has is extremely 
 slight. The operation of enucleation consists in re- 
 moving the eyeball from Tenon's capsule. Xow, the 
 external muscles of the eye, in their course from their 
 origin to their insertion on the globe, cross over to 
 Tenon's capsule, and have to penetrate it in order to 
 reach the sclerotica. Bnt, at the very places where 
 this penetration occurs, the tendons of the muscles 
 become firmly united to the capsule. The investing 
 membrane of the vacant orbit is chiefly composed of 
 the conjunctiva of the eyeball, which now covers 
 the capsule of Tenon ; the latter in turn grasps the 
 muscles firmly at the fissures through which they
 
 THERAPEUTICS. 151 
 
 originally passed. Now, if the remaining eye moves, 
 the corresponding muscles on the enucleated side also 
 contract, so that some slight movements are still 
 noticeable in the lining membrane of the empty orbit. 
 These, then, are the motions which are partly trans- 
 ferred to the artificial eye, which is held firmly against 
 Tenon's capsule by the pressure of the eyelids. 
 
 Although this tends to show that complete enuclea- 
 tion renders it impossible for us so well to satisfy the 
 demands of good looks as in the case of a stump which 
 still remains in situ, we must nevertheless remark 
 that this circumstance is of but little importance in 
 the particular series of cases with which we now have 
 to deal. For, if we have the slightest dread of sym- 
 pathetic irritation or inflammation in the well eye, 
 we shall never dare to place an artificial eye upon a 
 stump which is more or less painful ; and even if we 
 should by any means succeed in entirely freeing the 
 eye from pain and irritation, we could never be sure 
 of being able to apply the artificial eye directly upon 
 the stump without the possibility of exciting sympa- 
 thetic symptoms. Again, so long as the dangerous 
 eye has a cornea, as may often happen, an artificial 
 eye cannot well be worn ; and besides, if the atrophic 
 eyeball has not diminished considerably in size, the 
 glass shell cannot be used. 
 
 Now, this cry of " mutilation " which has been 
 raised by the opponents of too frequent enucleation,
 
 152 SYMPATHETIC DISEASES OF THE EYE. 
 
 or of enucleation in general, cannot be accepted with- 
 out a few words of explanation, for the early insertion 
 of unbreakable artificial eyes may greatly compensate, 
 in the case of a child, for the disadvantages of a va- 
 cant orbit, accompanied with a deformity of the face, 
 or, more correctly speaking, for the inequality of de* 
 velopment in one orbit and half of the face, in com- 
 parison with the other side. And, on the other hand, 
 we must not forget that a minute stump will permit the 
 very same aspect of things that we dread so much in 
 the case of an entirely empty orbit. Thus, I have re- 
 peatedly seen so small a stump after blennorrhoea in 
 the eyes of infants, that I was sure enucleation had 
 been performed, and only after positive assurances to 
 the contrary, was I able to discover in the bottom of 
 the orbit a stump about as large as a pea, the con- 
 vexity of which could not be seen, but only felt, 
 beneath the enveloping conjunctiva. It is therefore a 
 matter of no account whether a stump of such a size, 
 or even somewhat larger, lies at the bottom of the 
 orbit or not. 
 
 Death, cellular inflammation of the orbit, and a 
 staring cavity (as well as other disadvantages of enu- 
 cleation, such as excess of tears, and inversion of the lids, 
 accompanied with irritation of the mucous membrane 
 by the eye-lashes), have no direct relation to enucleation 
 for sympathetic ophthalmia, but only to enucleation 
 generally. The most important and most interesting
 
 THERAPEUTICS. 153 
 
 question for us is whether enucleation in and by itself 
 can do any harm ; that is to say, can it endanger the 
 other healthy eye by producing sympathetic irritation ; 
 or by increasing a slight form of sympathetic inflam- 
 mation already present, to a more violent, or even the 
 most violent form of all ? 
 
 We have previously alluded to preventive ennclea- 
 tion in those cases in which the sympathetic affec- 
 tion appeared so quickly after the operation, that we 
 could not but admit the possibility that the inflam- 
 mation was already under way when the operation 
 was performed. In such cases we can only say that 
 the enucleation, at the most, hastened the sympathy, 
 but did not really produce it. But the affair is quite 
 different in those cases in which weeks or months 
 elapse after enucleation) before the sympathetic symp- 
 toms appear. Thus, for example, enucleation was the 
 starting-point of sympathetic neuro-retinitis in the two 
 cases of Mooren's previously me ntioned (pages 94, 132) ; 
 it also caused a sympathetic " hyperaesthesia ciliaris " 
 in a third case of Mooren's, in which the enucleation 
 of an eye destroyed by a gunshot-wound had been 
 long before performed. " The starting-point of the 
 irritation in the present case must be sought for in 
 the inflamed end of the optic nerve of the enucleated 
 eye." 
 
 It seems to me, however, that we have much more 
 
 important facts in those which tend to show that enu- 
 
 7*
 
 154 SYMPATHETIC DISEASES OF THE EYE. 
 
 cleation may increase those insignificant types of 
 sympathetic affection which would never have greatly 
 endangered the eye, to the most violent forms of 
 sympathetic inflammation. --Mooren (1869) enucleated 
 an eye affected with cyclitis, because the premonitory 
 symptoms of iritis serosa " there were merely a few- 
 dots on the posterior wall of the cornea" had ap- 
 peared in the other eye. In the fifth week after the 
 enucleation, Mooren for reasons unknown to us, made 
 an iridectomy on the remaining eye, which was still free 
 from pain. All went well for a time, but three 
 weeks later two months in all after the enncleation 
 a new and intense inflammation appeared, developed 
 finally into a genuine plastic irido- cyclitis, and de- 
 stroyed the eye. 
 
 flasket Derby (1874) enucleated the eye of a youn^ 
 man with vision of ^ normal, because three months 
 after an injury the other showed simple iritis serosa 
 (fine precipitates on the posterior wall of the cornea 
 and slight dimness of vision). The deposits disappeared 
 after the enucleation, and the eye, with normal vision, 
 became again fit for work. But two months later 
 irido-cyclitis appeared. Derby, suspecting irritation of 
 the stump of the nerve in the region of the cicatrix, 
 excised a quarter of an inch of the nerve, with its sur- 
 rounding tissue. Improvement again followed, but did 
 not last long. After several months, repeated attacks 
 of iritis, combined with opacities in the vitreous, had
 
 THERAPEUTICS. 155 
 
 reduced vision to ^ normal. The final result must 
 have been very sad. 
 
 Alt (1877) described the condition of an eye (in the 
 case of a boy, aged nine years, injured seven years 
 before by a needle) which was enucleated by Knapp 
 for sympathetic iritis serosa. The behavior of the 
 case after euucleation is interesting. The iritis serosa 
 disappeared rapidly, but a plastic irido-choroiditis soon 
 developed; vision sank to T ^ , then increased to ^ s . 
 The termination of the case was unknown. 
 
 This transformation of simple iritis serosa into gen- 
 uine irido-cyclitis after enucleation, is an extremely 
 suspicious event. We have already drawn repeated 
 attention (page 81) to the fact that iriti* serosa, if not 
 treated too heroically, does not seem to have any 
 tendency to develop into the more severe forms of 
 iritis, and I must confess that I cannot understand 
 how Mooren (and others after him) can cite this 
 case of his, as just quoted, as an argument against 
 the opinion of v. Graefe and Bonders, that iritis 
 serosa never develops into iritis maligua under ordi- 
 nary circumstances. Leaving entirely aside the fact 
 that, in Mooren 's case, an operation (iridectomy) was 
 performed in the eye affected with iritis serosa, the 
 ominous interval of two months between the enuclea-^ 
 tion and the violent inflammation, gives us a suffi- 
 ciently distinct indication, not that the iritis serosa 
 spontaneously increased to iritis maligna, but that the
 
 156 SYMPATHETIC DISEASES OF THE EYE. 
 
 latter vras caused by the enncleation (and would, per- 
 haps, have appeared in precisely the same manner, 
 even if the second eye, up to that time, had never 
 been operated upon). 
 
 We see the same state of things in Derby's, Alt's, 
 and in many other cases, in which enncleation in 
 iritis serosa has been "fruitless" that is to say, in 
 which the second eye has been destroyed by plastic 
 irido-cyclitis after enncleation of the first. 
 
 Samelsohn's case offers us a very instructive con- 
 trast to that of Derby, who, animated as he was with 
 the best intentions, and guided by the opinions then 
 prevalent, sacrificed an eye which still possessed vision, 
 in order to sa*e its partner, but lost both of the eyes ; 
 while, if he had not operated at all, both eyes might 
 possibly have been saved. In Samelsohn's case, which 
 is very similar to those just referred to, both eyes were 
 really saved ; not, however, by the skill of the sur- 
 geon, but by the persistent refusal of the relatives of 
 the patient to have the proposed operation performed. 
 We need hardly say, at this point, that we do not in- 
 tend, in the slightest degree, to reproach the surgeons 
 in question, but simply to utter our condemnation of 
 those axioms according to which enncleation must be 
 performed under such and such circumstances. 
 
 Here is Samelsohn's case in brief (compare Knapp's 
 Archives of Ophthalmology and Otology, vol. v., 
 p. 48): A boy of fourteen injures his left eye by a
 
 THERAPEUTICS. 157 
 
 blow from the rebound of an elastic cord. Six weeks 
 later fine dotted opacities appear on the posterior wall 
 of the cornea, and, subsequently, a few delicate adhe- 
 sions are noticed at the border of the pupil. The in- 
 jured eye shortly before the last inflammatory attack 
 could still read large letters (Jaeger, No. 23) with an 
 excentric portion of the field of vision ; finally, only 
 fingers can with difficulty be counted. When the last 
 attack in the left eye begins to decrease in intensity, 
 the first symptoms of pericorueal injection, together 
 with the characteristic opacities on Descemet's mem- 
 brane, are noticed in the right eye. Enucleation of 
 the left eye is now proposed, but energetically refused 
 by the friends of the patient. Six weeks after the 
 first appearance of the serous iritis, both eyes are not 
 only free from inflammation, but from the least signs 
 of irritation. The eye which had been affected by 
 sympathy is perfectly normal. The injured eye has 4 
 of normal vision, and shows only a slight contraction 
 of the visual field. 
 
 In my opinion, there cannot be the least doubt that 
 iritis serosa may become transformed into iritis maligna 
 by the operation of enucleating the other eye. But, even 
 as regards a slight attack of iritis plastica, enuclea- 
 tion cannot, under certain circumstances, be wholly ac- 
 quitted of blame in furthering the transformation of 
 the plastic into the malignant form of iritis. We must, 
 however, make a separation between serous and plastic
 
 158 SYMPATHETIC DISEASES OF THE EYE. 
 
 iritis. For, when we find a few adhesions in the second 
 eye, before euucleation, while plastic irido-cyclitis de- 
 velops itself afterward, we can say, with incomparably 
 greater justification than if the case had been one of 
 iritis serosa, that the posterior adhesions did indeed 
 indicate the beginning of plastic irido-cyclitis, but 
 that emicleation was simply unable to retard the pro- 
 cess. We may be justified, moreover, in saying that the 
 operation did not exercise any unfavorable influence. 
 This is undeniably correct in some cases, but not in 
 all. For we frequently observe cases in which the 
 iritic process increases to irido-cyclitis at such an in- 
 terval after the enucleation, that there can be no 
 doubt that the plastic iritis, if left to itself, would 
 have passed off as a mild attack, whereas the enuclea- 
 tion excited it to irido-cyclitis. We will here insert 
 an appropriate case from Viguaux's rich experience : 
 The eye causing the sympathy is blind, but entirely 
 free from pain ; the eye affected by sympathy is 
 spontaneously painful, as well as painful to the touch 
 over the ciliary region, and is affected with iritis ac- 
 companied with slight adhesions at the lower edge of 
 the pupil. Yision is ^ normal. With the help of 
 atropia the iritis disappears after the emicleation. A 
 month later, vision is fully i normal. Two months 
 after the enucleation a terrible inflammation 'appears 
 in the eye, and, after persisting for ten months, leaves 
 the organ in an incurable state of total blindness.
 
 THERAPEUTICS. 159 
 
 We have now uttered the paramount condemna- 
 tory opinion against enucleation i.e., that it may 
 cause sympathetic inflammation in a previously healthy 
 eye, as well as increase a mild inflammation to the 
 most ^evere ; or, more correctly speaking, that it may 
 frustrate the permanent cure of a slight inflammation, 
 by causing one of the most severe type. Hence, it is 
 really only of secondary importance for us to add that, 
 after the outbreak of a genuine iritis maligna, enuclea- 
 tio'n is not only of no benefit whatever, but that occa- 
 sionally, when the sympathizing eye is extremely irri- 
 tated, it really does harm ; it even accelerates the 
 disastrous process. Those cases of genuine iritis 
 maligna which have recovered after enucleation, prove 
 nothing at all in favor of the curative agency of enu- 
 cleation, for no one will dare to say that in these ex- 
 traordinarily exceptional cases, the process would not 
 have proceeded in a possibly favorable manner even 
 without enucleation, to say nothing of the fact that 
 many such cases of perfect recovery rest upon an 
 error in diagnosis : the case was riot a genuine plastic 
 irido-choroiditis. 
 
 Now that we have thus learned the disadvantages 
 attached to enucleation, and the dangers which it may 
 possibly have in store for the patient, it will be much 
 easier for*us to decide upon the importance of enu- 
 cleation in the therapeutics of sympathetic affections 
 of the eye.
 
 160 SYMPATHETIC DISEASES % OF THE EYE. 
 
 The fatal results of eunclcation do not trouble us 
 much when we are deciding upon the operation, for 
 the cases of subsequent death are altogether too rare. 
 But, under certain circumstances, we still have some 
 reserve in this respect. Almost all the German* ocu- 
 lists hesitate to enucleate during the height of fla- 
 grant panophthalmitis, standing as they still do in 
 dread of v. Graefe's two fatal cases (1863). This feel- 
 ing goes so far, that a German operator even excused 
 himself for having enucleated two panophthalmitic 
 eyes with the best results, because he did not know at 
 the time what v. Graefe had said on this point. Per- 
 sonally, I stand in awe of v. Graefe's advice never to 
 operate if the panophthalmitis is distinctly pronounced. 
 1 have never enucleated an eye under such circum- 
 stances, and I doubt if I shall ever make up my mind 
 to do so. The terrible apparition in v. Graefe's cases 
 impresses me so deeply, that at the very sight of any 
 eye in a state of panophthalmitis, and the thought of 
 enucleating it, the dread of a fatal result is conjured 
 up before me. By this, I do not mean to say that it 
 is entirely justifiable for us to abstain from the opera- 
 tion, for the English oculists never pay any great at- 
 tention to panophthalmitis when they desire to enucle- 
 ate. Thus Critchett (of whom, as he himself laugh- 
 ingly said, the story goes that he cannot go to bed 
 without having enucleated at least one eye during the 
 day) told me that he had never seen an accident under
 
 THERAPEUTICS. 161 
 
 the above circumstances. Yignaux also praises enucle- 
 ation when thus performed ; still he lost one case out 
 of nineteen, although we must consider the great age 
 (eighty-one) of the patient in this fatal case. 
 
 We do not mean in this place to treat of the general 
 indications and centra-indications of enucleation, bat 
 only of enucleation as a therapeutical resource in 
 sympathetic affections of the eye. Hence, we must 
 justify ourselves for discussing enucleation in panoph- 
 thalmitis. "We have here brought up the subject, be- 
 cause, in our opinion, panophthalmitis cannot be wholly 
 acquitted of the fault of producing sympathetic symp- 
 toms (although it is generally assumed to be innocent, 
 on the ground that the acute purulent inflammation 
 entirely destroys all the nerves in the interior of the eye). 
 On the contrary, we are sure, that flagrant panophthal- 
 mitis may sometimes induce sympathetic inflammation, 
 so that a few weeks after the outbreak of the original 
 disease, and even at the time when it has by no means 
 entirely disappeared, the premonitory symptoms of 
 sympathy may reveal themselves in the other eye. 
 Moreover, we mention enucleation in this place be- 
 cause when the panophthalmitis is excited by the pres- 
 ence of a foreign body remaining in the eye, we can- 
 not expect a permanent condition of rest in the 
 atrophic eyeball, even after the process has ended, but 
 on the contrary, permanent or occasional spontaneous 
 pain, or pain upon pressure, as well as the over-threat-
 
 162 SYMPATHETIC DISEASES OF THE EYE. 
 
 ening danger of sympathetic ophthalmia. So, if we 
 venture to enucleate during the stage of panophthal- 
 mitis, we may not only put an end to the sufferings of 
 the patient, produced by the acute inflammation, but 
 secure him from the danger of sympathetic disease in 
 the other eye for the rest of his life. But if any one 
 is restrained from the enucleation of a panophthal- 
 initic eye by the dread of a fatal result, the reasons 
 which we have just suggested in favor of enucleation 
 daring this period, will not be urgent enough to over- 
 come his fears. For the appearance of sympathetic 
 ophthalmia during flagrant panophthalmitis, although 
 observed by a few oculists, is so extremely rare as not 
 to offer any general indications for the operation. In 
 case, therefore, that the enucleation of the eye appears 
 desirable as a precaution against sympathy in the fu- 
 ture, we can wait until the panophthalmitis lias grad- 
 ually diminished under suitable treatment in case we 
 did not prefer to enucleate, or could not enucleate di- 
 rectly after the injury and previously to the appear- 
 ance of the panophthalmitis. 
 
 Experience teaches us that when the irritation of the 
 nerves has not yet extended to their extra-ocular 
 branches, it is one of the rarest of exceptions for enu- 
 cleation to lead to dangerous irritation in these latter 
 filaments ; and that whenever this does occur, the im- 
 perfect execution of the operation, or the crushing of 
 the nerves during their division, is directly to blame in
 
 THERAPEUTICS. 163 
 
 a considerable portion of the cases. "We have, more- 
 over, for the purpose of tabulation; only a very small 
 number of cases in which we can say that the operator 
 unwittingly caused the stump of the optic nerve con- 
 cerned to become constringed in the cicatrix. From 
 all these remarks we see that there is but slight proba- 
 bility of an intact second eye being endangered by 
 enucleation of the first. And finally, so long as it 
 has not been satisfactorily demonstrated, in any great 
 number of cases, that enucleation increases a con- 
 dition of simple irritation or mere disturbance of func- 
 tion to distinct inflammation, then, from this point of 
 view also, enucleation is, on the whole, by no means to 
 be dreaded. 
 
 To sum up our remarks, we have the following in- 
 dications and contra-indications for enucleation. 
 
 If the second eye is still perfectly normal, oculists 
 generally have not, up to this time, agreed upon the 
 point whether preventive enucleation is admissible. 
 My rule in such cases is as follows : if the patient 
 is moderately intelligent, has good surroundings at 
 his home, and can at any moment summon the 
 counsel of a skilful oculist, preventive enucleation 
 is not necessary. Some ophthalmologists claim that 
 sympathetic inflammation can appear suddenly, and 
 without any warning ; but such is not my belief. 
 The intelligent patient, warned of the threatening 
 danger and notified to appear at once upon the
 
 164 SYMPATHETIC DISEASES OF THE EYE. 
 
 slightest disturbance on the part of the sound eye, 
 will hardly come to us with a pronounced irido-cycli- 
 tis, but at the first appearance of the slightest symp- 
 tom of irritation. If, on the other hand, we have 
 before us one of the lower classes, a patient defective 
 in intelligence and in whom carelessness and mistrust 
 of medical assistance are narrowly united ; one whose 
 remaining eye is liable to be overburdened with severe 
 labor, and who cannot, even with the best intentions, 
 get the advice of an oculist ; then we may employ 
 all our eloquence in favor of a preventive enucleation. 
 For, notwithstanding our most earnest warnings, as well 
 as all our representations that the patient will be totally 
 blind for life if he neglects to report at the proper 
 moment despite all sorts of promises on the part 
 of the patient that he will seek advice when the slight- 
 est irritation appears, we may never see such a patient 
 again until vision shall have been irrevocably de- 
 stroyed by a genuine attack of irido-cyclitis. Of what 
 avail, then, to overwhelm t^e unfortunate patient with 
 reproaches, to remind him of his promises, and even 
 to fly into a passion, or to melt into pity, when he 
 mildly says that he thought the eye would get well of 
 itself, or that he sought help at the hands of some old 
 woman ! 
 
 The fact that the eye which is liable to cause sym- 
 pathetic diseases at some future time still possesses a 
 certain amount of vision, never contra-indicates the
 
 THERAPEUTICS. 165 
 
 performance of PREVENTIVE enucleation. Those who 
 resort to preventive enucleation on principle, or who 
 regard it as a necessary duty to advise the enucleation of 
 an eye in any special case, should never let themselves 
 be led astray by the circumstance that the injured or 
 irritated organ still possesses some remnant of vision. 
 The enucleation of an eye which still possesses the 
 faculty of sight, or one in which some degree of vision 
 might possibly be restored at a later date, may be an 
 unjustifiable deed in the general province of ophthal- 
 mology, but it can never serve as an argument in favor 
 of abandoning preventive enucleation. For the removal 
 of this eye assures the safety of the other, and no one 
 should fear any subsequent objection to the operation. 
 But frightful must be the silent accusation of one's 
 conscience, when the patient in whom we regarded 
 preventive enucleation as a necessity, but in whose 
 case we were so weak as to be false to our convictions 
 (simply because he still retained some vision in the in- 
 jured eye), reappears before us with both eyes irre- 
 trievably lost. Read, for example, this case of Vig- 
 naux's : " A child about ten years old has received a 
 blow on one of his eyes. Gayet is of the opinion that 
 the eye should be enucleated, but abandons the opera- 
 tion because the eye still possesses a certain amount of 
 perception of light, and it is very hard to deprive such 
 a young person of an eye which still offers some hopes 
 for recovery of sight. After a short time the child re-
 
 166 SYMPATHETIC DISEASES OF THE EYE. 
 
 turns with the fully developed symptoms of sympa- 
 thetic inflammation. The injured eye is enucleated ; 
 but it is too late; blindness becomes total." Gayet 
 recalls this case to mind two years later, and says : " I 
 shall regret this during the whole of my life." And I 
 add, we hope that at the time when enucleatiori was 
 finally performed, vision was really wholly lost in the 
 injured eye, for if it were not, Gayet added to his 
 previous error of abandoning preventive enucleation 
 (one, by the way, in which, on account of the prevalent 
 di&'erence of opinions, he might find easy absolution) 
 a second more grievous and much less excusable error, 
 as shall soon be dilated upon more fully. 
 
 While discussing this point, I would like to add 
 that I cannot see how Yignaux, while still depressed 
 in mind by this case of Gayet's, could make such a 
 remark as the following, one of the chief reasons 
 against preventive enucleation : " Preventive enuclea- 
 tion is generally contra-indicated in case the second 
 eye exhibits perfect organic and functional integrity, 
 and the originally injured eye still retains a certain 
 amount of sight, or could obtain useful vision by 
 operative interference at a later date." 
 
 If the general symptoms of sympathetic irritation 
 are already present, enucleation must be performed 
 at once. For, although cases have been known in 
 which sympathetic irritation of the eye has lasted for 
 years, and even decades, without really endangering
 
 THERAPEUTICS. 167 
 
 vision, yet the physician cannot rely upon such a 
 rare possibility in his own special case, in thinking 
 over what remedy he shall employ. He must, on the 
 contrary, regard the irritative symptoms as premoni- 
 tory of the sympathetic inflammation, and, keeping in 
 mind the danger that irido-cyclitis may be developed 
 in a few weeks, even if no organic alterations are as 
 yet present, he must decline all responsibility in the 
 case, if enucleation is proposed to the patient, but re- 
 fused. The oculist may act under such circumstances 
 with, energy and confidence ; for, notwithstanding the 
 few exceptional cases in which the inflammatory pro- 
 cess is already under way, even here enucleation gen- 
 erally acts safely. 
 
 When the other eye is in a state of irritation, an 
 eye which still possesses vision must be unhesitatingly 
 sacrificed : success is too certain, and too much is at 
 stake, for the oculist to hesitate. If, in such a case, he 
 meets the rare misfortune of seeing the irritation be- 
 come developed into inflammation despite the enu- 
 cleation, he can say with confidence : " All is lost, 
 but not my peace of mind." The surgeon cannot act 
 differently, and such a tragic accident as just sug- 
 gested is so rare that the vast majority of operators 
 pass through life without meeting with such a lament- 
 able experience. 
 
 If iritis serosa, and iritis serosa alone, is already 
 present in the second eye, enucleation is, in my opinion,
 
 168 SYMPATHETIC DISEASES OF THE EYE. 
 
 contra-indicated ; and the enucleation, under these cir- 
 cumstances, of an eye which is not totally blind, is ab- 
 solutely unjustifiable. I shall never again perform 
 enucleation for sympathetic iritis serosa, for, as on the 
 one hand this form of inflammation never shows any 
 tendency to develop into irido-cyclitis, so, on the 
 other, we have already offered proof of the deleterious 
 influence of operative interference during the pres- 
 ence of this disease. In such cases, in all probability, 
 enucleation does more harm than good to the second 
 eye. Nor could I decide to enucleate in a case 
 of simple plastic iritis with a few adhesions, or 
 even with adhesions entirely around the margin of 
 the pupil. We see a case like Vignaux's (page 158) 
 in the one reported by Hirschberg (1874), in which 
 enucleation was performed within a few hours after 
 the outbreak of a simple plastic iritis in the second 
 eye. The iritis proceeded favorably, but, about three 
 weeJes after the enucleation, a relapse occurred and 
 the eye was finally lost. Even if Hirschberg is cor- 
 rect in assuming that the enucleation in this case was 
 simply incapable of cutting short the irido-cyclitis 
 which was already under way, the inexpediency of the 
 operation would be evident. Under such circumstan- 
 ces enucleation cannot be of any advantage; it can 
 only do harm. But we have already explained that 
 plastic iritis is far from being synonymous with the 
 primary stage of irido-cyclitis. For other reasons,
 
 THERAPEUTICS. 169 
 
 however, a similar case of this sort will be mentioned 
 farther on. 
 
 Inasmuch as enucleation undertaken during a vio- 
 lent inflammatory condition of the first eye is of no 
 benefit in the presence of sympathetic irido-cyclitis ^ 
 and may even rapidly increase the pernicious inflam- 
 mation, it follows that, when we still desire to enu- 
 cleate, we should wait until the inflammatory process 
 in the eye which has been first affected begins to show 
 some relative pause. There is no general indication 
 for enucleation in cases of sympathetic irido-cyclitis. 
 If, notwithstanding this, the eye is enucleated in this 
 stage, the main idea can only be that where all is ir- 
 redeemably lost, there is nothing more to lose. Every 
 one will admit that it is a crime in a case of pro- 
 nounced sympathetic irido-cyclitis , to enucleate an eye 
 which still possesses vision, or in which vision might 
 at a later date be restored. It ought to be absolutely 
 impossible for any oculist to have the opportunity of 
 congratulating himself, at the refusal of the proposed 
 enucleation of an eye which still possesses vision while 
 the other eye is affected with sympathetic irido-cycli- 
 tis ; because the omission of enucleation under such 
 circumstances should never be due to a lucky chance, 
 but be dictated by the sagacity of the surgeon in 
 charge of the case. Every one ought to know, and 
 must know in such a case that enucleation cannot 
 be of any avail. The oculist ought to know, even
 
 170 SYMPATHETIC DISEASES OF THE EYE. 
 
 if there are several well-known cases in which irido- 
 cyclitis has not led to total blindness after enuclea- 
 tion, that this favorable result was not obtained by 
 the enucleation, but despite it. Moreover, he should 
 be aware, on the other hand, that numerous cases 
 have been reported, in which the eye causing sympa- 
 thy has saved the patient from everlasting darkness, 
 for the very reason that this eye still retained some 
 useful vision after the eye affected by sympathy had 
 become totally destroyed. Y. Graefe said, after 
 seeing two cases in which he refused to enucleate be- 
 cause the first eye was not totally blind : " I was ex- 
 tremely interested in these cases, by seeing perfect 
 recovery from the sympathetic affection." 
 
 My creed in the question of enucleation runs 
 briefly thus : It MAY be performed as a preventive ; 
 it MUST be performed in the stage of irritation ; it 
 CANNOT be performed in iritis serosa and iritis plas- 
 tica ; it CAN be performed in irido-cyclitis plastica, 
 provided the eye causing sympathy is totally Hind, 
 but not in a state of violent irritation. 
 
 The most important point, so far as the general prac- 
 titioner is concerned, is that he shall know the indica- 
 tions and contra-indications for enucleation. It is a 
 matter of minor importance, whether, after having 
 made a correct diagnosis, he can himself perform the 
 operation, or feels obliged to refer the patient to a 
 specialist for its performance. Still, I will in this
 
 THERAPEUTICS. 171 
 
 p]ace describe the details of the operation, as well as 
 its after-treatment. Augustus Pritchard, of Bristol, 
 England, was the first to enucleate a human eye for 
 sympathetic ophthalmia (1851). The term "enuclea- 
 tion " owes currency in speech to v. Arlt, who pro- 
 posed to use the term " enucleation of the eye " instead 
 of " exeriteration of the orbit ; " that is to say, " the re- 
 moval of the globe from Tenon's capsule," in contra- 
 distinction to the complete evacuation of the orbit, or 
 the removal of the eyeball with all that lies behind it 
 in the orbit. Y. Arlt reserves the expression " extir- 
 pation " for the removal of some definite structure, such 
 as a new-growth, from the orbit, with preservation of 
 the eyeball. The shelling out of the eye from its 
 envelope was first proposed by Bonnet (1841), and is 
 performed in the following manner by v. Arlt. 
 
 Suppose that we intend to enucleate the left eye. 
 The eyelids are kept apart by a stop-speculum, or, still 
 better, by two lid-elevators in the hands of the assist- 
 ant. In the latter case, by pushing the elevators along 
 the lid, the assistant can separate the lids wherever 
 the operator, for the time-being, requires the most 
 room. The surgeon seizes the conjunctiva just over 
 the insertion of the rectus externus muscle, with the 
 forceps, divides it vertically with a pair of straight, 
 blunt-pointed scissors, and then continues the incision 
 in the conjunctiva half-way around the cornea and 
 close to its upper edge, until he reaches the insertion
 
 172 SYMPATHETIC DISEASES OF THE EYE. 
 
 of the internal rectus. He then returns to the origi- 
 nal opening in the conjunctiva, and divides that mem- 
 brane in a similar manner all around the lower margin 
 of the cornea, but leaving a bridge of conjunctiva still 
 standing at the inner side of the cornea, just over the 
 insertion of the rectus interims. The next step con- 
 sists in seizing the external rectus with the forceps, 
 and dividing it completely; not, however, between the 
 forceps and the insertion of the muscle on the scle- 
 rotica, but outside the forceps ; or, more plainly still, 
 between the forceps and the outer angle of the eyelids. 
 In this way we have the stump of a muscle still at- 
 tached to the eyeball, so that by seizing this with the 
 forceps we can rotate the eyeball in any desired direc- 
 tion. One blade of the scissors is now directed up- 
 ward beneath the tendon of the rectus superior, so that 
 on closing the scissors the tendon of this muscle is 
 completely divided from its attachment. After sever- 
 ing the rectus superior, the rectns inferior is treated in 
 a similar manner. If we use a common stop-specu- 
 lum, the assistant, having his hands free and possess- 
 ing a sufficient degree of dexterity, can help the oper- 
 ator a great deal by taking up the tendons of the vari- 
 ous muscles with the common strabismus-hook, and 
 lifting them awa} 7 from the sclerotica, so that it takes 
 but an instant for the surgeon to pass the blade of the 
 scissors between the sclerotica and the tendon, and to 
 divide the latter completely. An operator of little
 
 THERAPEUTICS. 173 
 
 skill, with an assistant of less skill, will of course 
 help himself by taking up one muscle after another 
 with the hook, before dividing them. 
 
 The three recti muscles (the rectus internus yet 
 stands), with the conjunctiva which still covers them, 
 have now been divided, or, more correctly speaking, 
 the tendons of the muscles, as well as the conjunctiva, 
 have been loosened from the eyeball. Now comes 
 the most important step, the festal moment of the 
 operation the division of the optic nerve. 
 
 The optic nerve is inserted into the horizontal plane 
 of the eye, but not precisely at its posterior pole ; not 
 at the posterior end of the antero-posterior axis of the 
 eye, but a little toward the nasal side. In order, 
 therefore, to pass deeply into the orbit with the scis- 
 sors, the eye must be first turned toward the nose by 
 means of the stump of the external rectus. But if 
 the eye rolls at all on its antero-posterior axis, the in- 
 sertion of the optic nerve no longer lies in the trans- 
 verse axis of the eye, but approaches either the upper 
 or the lower wall of the orbit. In order to strike di- 
 rectly across the optic nerve on introducing the scis- 
 sors, we must be sure that the optic nerve remains in 
 the transverse plane of the eye, which can only hap- 
 pen when we turn the eye precisely inward by seizing 
 the stump of the external rectus. Hence, we must be 
 sure to notice, when turning the eye inward, whether 
 it rotates at all on its antero-posterior axis. If this
 
 174: SYMPATHETIC DISEASES OF THE EYE. 
 
 should take place, we are to move the eye back again 
 to its original position, and repeat the manoeuvre until 
 the correct position is reached. While the left hand is 
 thus engaged, the right hand seizes a pair of strong, 
 blunt-pointed scissors, curved on the flat, passes them 
 (still closed) a short distance into the orbit along the 
 horizontal plane of the eye, opens them, so far as is pos- 
 sible without resistance, pushes them forward, and 
 closes them rapidly. A certain resistance on closing 
 the scissors, a distinct, grating sound, extremely agree- 
 able to the ear of the operator (for nothing is more dis- 
 agreeable, in the operation of enucleation, than to miss 
 the optic nerve), and the possibility of immediately 
 lifting the globe out from between the eyelids, show 
 that the operation has succeeded. But, if we have 
 been so unlucky as to miss the optic nerve, we should 
 not attempt to reach it by repeatedly opening and 
 closing the scissors while in the cavity of the orbit. 
 For the optic nerve now lies outside the scissors ; it 
 lies either above or below the latter. We should 
 therefore remove the scissors entirely, once more care- 
 fully rotate the eyeball inward, and then repeat the 
 manoeuvre with the scissors. 
 
 When the optic nerve has been divided, and the 
 eyeball drawn out from between the eyelids with the 
 forceps, we take it in our left hand, divide the inser- 
 tions of both oblique muscles, then the rectus interims, 
 next the bridge of conjunctiva which still stands at
 
 THERAPEUTICS. 175 
 
 the inner edge of the cornea, and the operation is 
 completed ; the eyeball, smooth and bare of all its at- 
 tachments, with the optic nerve cut off close to the 
 sclerotica, lies in our hand. 
 
 If the right eye is to be enucleated, we begin the 
 operation over the insertion of the rectus iriternus, 
 then divide the rectus superior and rectus inferior, 
 leaving the bridge of conjunctiva standing at the outer 
 side of the cornea. We should also remember that, on 
 account of the insertion of the optic nerve on the nasal 
 side of the antero-posterior axis of the eye, the nerve 
 is found at a much less depth when we operate on the 
 right eye, than is the case with the left. 
 
 The hemorrhage after the operation is generally 
 slight. We may lay a couple of small plugs of char- 
 pie, cooled by contact with ice, into the cavity, apply 
 charpie over the closed lids, and over all v. Graefe's 
 compress - bandage (three or four turns of flannel), 
 which is to be changed after twenty-four hours, and 
 removed on the second day after the operation. In 
 the course of recovery, the capsule of Tenon gradually 
 becomes covered with conjunctiva, and in about a 
 week we see at the bottom of the orbit nothing but a 
 small suppurating and granulating surface, which soon 
 cicatrizes completely. 
 
 The first thing of which we should be absolutely 
 sure in operating for sympathetic ophthalmia is to 
 enucleate the right eye. This may seem idle advice,
 
 176 SYMPATHETIC DISEASES OF THE EYE. 
 
 and even a joke ; but, whoever like myself has once 
 stood shudderingly by, while the eye which still pos- 
 sessed vision was about to be enucleated instead of the 
 blind eye, will not see a jest in these words of mine. 
 The error is not inexplicable when we reflect that 
 enucleation is frequently performed even when sym- 
 pathetic cyclitis is already fully developed, so that 
 there is really no obvious difference between the two 
 eyes. Moreover, the operator is directing all his at- 
 tention to the operation, and, being willingly led by 
 the assistant, begins the operation on the eye to which 
 the latter by mistake applies the speculum. The pa- 
 tient makes no protest for he is under the influence 
 of anaesthetics. 
 
 Anaesthetics have generally been resorted to in enu- 
 cleation because the operation has been considered 
 excruciatingly painful, especially during the division 
 of the optic nerve, as well as of the ciliary nerves. I 
 had always believed in this idea myself, and would 
 scarcely have dared to enucleate without anaesthetics, 
 had I not been compelled, in the case of a drunkard 
 who really could not be chloroformed, to operate upon 
 him in a conscious condition. I was not a little 
 amazed when I found that the section of the various 
 nerves was accompanied with no more acute expres- 
 sions of pain on the part of the patient than during 
 the first incisions in the conjunctiva. Since then I 
 have repeatedly enucleated without anaesthetics, and
 
 THERAPEUTICS. 177 
 
 have usually discovered, on questioning the patients 
 after the operation, that the first incision (in the con- 
 junctiva) was more painful than the division of the 
 nerves. Mooren once went so far as to say that, " in- 
 asmuch as the operation is quickly performed, chloro- 
 form is used only when the patient expressly desires 
 it ; " and again : " besides this, I can operate much 
 more easily if the patient is not chloroformed." At 
 the time when I read these sentences, I was so firm in 
 the belief that the division of tho nerves was extremely 
 painful, that I could not credit what Mooren had said. 
 But recent experience of my own has shown me how 
 true it all is. 
 
 Thus far for enucleation. The next question that 
 comes up for our consideration is this : Inasmuch as 
 the whole significance of the operation of enucleation 
 depends upon the interruption which it causes in the 
 conduction of irritation from the infra-ocular nerve- 
 fibres to the extra-ocular branches, can we not gain 
 precisely the same result by simply dividing the optic 
 nerve (neurotomy) ? 
 
 The history, in brief, of neurotomy for warding off 
 or curing sympathetic ophthalmia is as follows : In 
 1857, v. Graefe said: "In order to decide whether 
 the optic nerve takes an active part in the sympathetic 
 processes of amaurosis, I have proposed in similar 
 cases to substitute neurotomy for extirpation of the 
 
 eye. Under precisely analogous circumstances we 
 
 8*
 
 178 SYMPATHETIC DISEASES OF THE EYE. 
 
 should, by adopting neurotomy, gain the advantage of 
 preserving the eye." In 1865, Rheindorf reported a 
 case of neurotomy performed for sympathetic neuro- 
 retinitis, with scissors bent exceedingly on the flat, 
 and rounded off at the points. Four days later the 
 vision had increased by four numbers of Jaeger's test- 
 type, and the recovery was permanent. The influence 
 of the operation in this case could not be denied, for 
 the excessive diminution of vision had persisted for 
 months, during which period all treatment had been 
 useless. The operated eye, at a later date, showed 
 considerable injection of the anterior ciliary veins. 
 
 In 1866, v. Graefe returns to the question once more. 
 Nine years previously he had proposed to divide 
 the optic nerve, not as Mooren thinks, because " the 
 celebrated suggester of this procedure meant also to 
 divide the ciliary nerves," but because in these cases 
 it seemed to him that the optic nerve served as a con- 
 ductor. At this time, however, it is the section of the 
 ciliary nerves which v. Graefe proposes, although he 
 doubts the propriety of dividing all of them out- 
 side the eye, "on account of the necessarily exten- 
 sive denudation, and especially on account of the si- 
 multaneous division of the vessels." On the other 
 hand, in case of circumscribed sensibility of the ciliary 
 nerves, we might divide such as were implicated, out- 
 side the eye, or perhaps better still, inside the eye, 
 behind the flat portion of the ciliary body. Ed.
 
 THERAPEUTICS. 179 
 
 Meyer first performed such an intra-ocular division in 
 1866, and in 1867 and 1868 he reported this case, as 
 well as several others in which en ucleation would have 
 been indicated as a preventive, or on account of irri- 
 tation already present. A narrow knife is passed 
 through the sclerotica into the vitreous; and a section 
 six to eight lines long (depending upon the extent of 
 the painful region), and parallel to the margin of the 
 cornea, is completed by simple counter-puncture, and 
 division of the overlying bridge of tissues. In 1868, 
 Secondi also reported a case of radical cure of sympa- 
 thetic neurosis by intra-ocular ciliary neurotomy. All 
 the tunics of the eye were completely divided over a 
 space of a centimetre or two in extent, between the in- 
 sertion of the rectus externus, and that of the rectus 
 superior. Lawrence also reported a similar case in 
 1868. Ed. Meyer afterward continued to operate in 
 this same manner, and in 1873 speaks of twenty-two 
 cases of which he has heard. He thinks that intra- 
 ocular neurotomy is really indicated as a preventive, 
 as well as in cases of actual sympathetic neurosis. 
 
 In considering the question of division of the ciliary 
 nerves outside the eye, we are to distinguish between 
 their division with preservation of the optic nerve, 
 and the simultaneous division of both the ciliary 
 and optic nerves. Snellcn (1873) reports a success- 
 ful division of some of the ciliary nerves behind 
 the eye without doing any injury to the optio nerve.
 
 180 SYMPATHETIC DISEASES OF THE EYE. 
 
 The eye was totally blind, with excessive and cir- 
 cumscribed tenderness to pressure at the upper and 
 outer margin of the cornea. Y. Wecker (Therapeu- 
 tique Oculaire) recommends this operative method for 
 cases in which the injured eye possesses better vision 
 than the one sympathetically affected whose vision is 
 totally lost. In his opinion we ought not to enucleate 
 under such circumstances, but we may divide the 
 ciliary nerves which surround the trunk of the optic 
 nerve. Nevertheless, it is not plain from v. Wecker's 
 account that he ever really performed the operation. 
 
 The division of both ciliary and optic nerves behind 
 the eyeball, as a general substitute for enucleation, 
 was recommended by Boucheron in 1876, and subse- 
 quently by Scholer and Schweigger. Scholer thinks 
 that this operation is entirely safe in all cases of threat- 
 ening sympathetic ophthalmia, while Schweigger is of 
 the opinion that enucleation is only beneficial as a pre- 
 ventive operation, and that, from this point of view, 
 neurotomy is just as available as enucleation, which in 
 his judgment has hitherto been opposed by the patient, 
 on account of the dread " which the mutilation of one 
 of man's noblest organs " must naturally arouse. 
 Finally Hirschberg, although he once published a 
 paper opposing neurotomy, subsequently convinced 
 himself, in two cases, that it succeeded in relieving 
 ciliary pain. 
 
 I would like in this place to make a few preliminary
 
 THERAPEUTICS. 181 
 
 remarks on neurotomies in general. It seems to me 
 that it is only a complete extra-ocular division of all 
 the ciliary nerves, as well as of the optic nerve itself, 
 that can be relied upon in cases of sympathetic affec- 
 tion of the eye. It must be extremely doubtful 
 whether intra-ocular neurotomy, i.e., the partial slitting 
 open of the eye as above described, ever permanently 
 relieves the eye so treated, or offers absolute security 
 against sympathetic irritation in the other, even if it 
 is performed several times in succession or in one dis- 
 trict after another. Spencer Watson (1874:) cites a 
 case which was operated upon by Ed. Meyer's method, 
 in which the primary result was very satisfactory, but 
 it was not permanent, and enucleation had to be per- 
 formed at a later date. On the other hand, there is 
 no operation by which we can be sure of dividing all 
 the ciliary nerves without doing any injury to the 
 optic nerve. As for myself, I can see no indications 
 for such an operation ; for, in the case suggested by 
 v. Wecker, we must not only postpone enucleation, but 
 every operation on the injured eye, for it may still be 
 saved ; whilst if this eye is blind, we must at the same 
 time divide both ciliary and optic nerves for the pur- 
 pose of terminating the irritation which they inces- 
 santly keep up. 
 
 Among the opinions of various operators, on the 
 division of the ciliary and optic nerves, we may quote 
 that of Mooren (1869) : " I can hardly believe, in any
 
 182 SYMPATHETIC DISEASES OF THE EYE. 
 
 case, that division of the ciliary nerves in the orbit can 
 attain the purpose which its supporters claim for it ; 
 for, after fifty or sixty experimental operations for the 
 division of various branches of the trigemirms, although 
 I have usually seen a momentary and brilliant result, 
 yet it has rarely been permanent. The desired effect 
 disappeared as soon as the ends of the nerves reunited." 
 Y. Arlt also cites a case in the Zeitschrift der Wiener 
 Aerzte, " in which he was sure that the ciliary nerves 
 became reunited after once being divided." We have 
 a perfect right to look at the subject from this point 
 of view, for up to this time we have had no satisfac- 
 tory assurance of the length of time during which the 
 favorable result continues in cases of division of the 
 nerves outside the eye. We can only assume that the 
 ciliary nerves have been successfully divided when the 
 cornea and ciliary body become totally insensible to the 
 touch (or pressure) after the operation. Restoration 
 of sensibility in either of these regions shows that the 
 branches of these nerves had subsequently reunited. 
 I will at this place report a case recently under my 
 own observation, in which reunion did take place, and 
 at a relatively early period. 
 
 A young man had been wounded in the left eye a 
 short time before by a flying chip of wood. This eye 
 now shows diminished tension ; the ciliary body is 
 sensitive to pressure. There is slight ciliary injec- 
 tion, the cornea is perfectly normal, the iris is dull in
 
 THERAPEUTICS. 183 
 
 color, its periphery is bulged forward in knob-like 
 processes, and the margin of the pupil is attached to a 
 thick membrane which covers the pupil. Perception 
 of light is entirely destroyed. The patient now comes 
 for advice, complaining that for some time his right 
 eye has been momentarily sensitive to light, and that 
 he cannot use it for any close work. The objective 
 examination of this eye shows that it is normal in 
 every respect. As the left eye is liable at any time to 
 excite sympathetic irritation, while the complaints 
 which the patient now makes may be regarded as the 
 commencement of this condition, optico-ciliary neu- 
 rotomy (as Scholer proposes to call the operation which 
 we are now discussing) is performed October 30, 
 1880 instead of enucleation. 
 
 I open the conjunctiva over the tendon of the rectus 
 externus, and extend the incision in an upward, and 
 afterward in a downward curve, toward the insertions 
 of the superior and inferior recti. 1 next take up the 
 tendon of the rectus externns on the strabismus-hook, 
 and carry the two ends of a catgnt thread, No. 
 (armed with a needle at each end), through muscle and 
 conjunctiva. I then divide the tendon, and hand the 
 threads with the muscle and conjunctiva to the assist- 
 ant, to draw down into the external angle of the eye- 
 lids. The next step consists in rotating the eyeball 
 toward the nose, after which I penetrate, with scissors 
 curved on the flat, into the cavity of the orbit, divide
 
 184 SYMPATHETIC DISEASES OF THE EYE. 
 
 the optic nerve, and then alternately opening and 
 closing the scissors, I denude the whole posterior sur- 
 face of the globe as thoroughly as possible. The scis- 
 sors are now laid aside. I then take a curved teno- 
 toine, push it into the orbit, and denude the posterior 
 portion of the globe still more thoroughly, turning the 
 eye again and again as far as possible toward the nose. 
 The subsequent hemorrhage is comparatively slight. 
 The rectus extern us is now replaced and advanced by 
 sutures ; the two needles are passed through the con- 
 junctiva (which was previously left standing near the 
 margin of the cornea), then removed, and the ends of 
 the sutures tied. Finally, a pressure-bandage is ap- 
 plied. 
 
 November 2, 1878, three days after the operation, 
 the cornea has lost all its sensitiveness, and the ciliary 
 body is insensible to pressure. The ciliary region is 
 now considerably injected, and the patient complains 
 of violent pain. The conjunctiva also is extremely con- 
 gested and very sensitive to the touch. The sensibility 
 of the entire cornea soon returns. The ciliary body con- 
 tinues insensible for a considerable length of time. On 
 the last examination, however December 10, 1878 
 the upper and outer portions of the ciliary body are 
 distinctly painful to pressure. The eyeball is rather 
 pale, deviates slightly outward, and is decidedly soft 
 to the touch. The vague complaints about the unin- 
 jured eye continue. Finally, enucleation is performed
 
 THERAPEUTICS. 185 
 
 by Prof. v. Jaeger. And what did we then discover? 
 The stump of the optic nerve attached to the globe 
 consisted of two parts. The optic nerve had been 
 wholly severed by the neurotomy, but the two ends had 
 reunited; not indeed in perfect apposition, the two 
 surfaces of the original incision being still in part 
 plainly visible. 
 
 The history of this case has also taught us the method 
 by which the operation is performed. Schweigger 
 divides the internal rectus in the middle of its inser- 
 tion, instead of the external rectus, and reunites it af- 
 ter the operation with sutures, as previously described. 
 After dividing the optic nerve, he rotates the posterior 
 pole of the eye forward, by means of a small, sharp 
 hook inserted into the sclerotica near the optic nerve, so 
 that the insertion of the nerve is brought forward into 
 view. In this way we can carefully denude the whole 
 sclerotica, so that the ciliary nerves shall be divided 
 without the shadow of a doubt. But are we sure that 
 some branches do not reunite? If this should happen, 
 it is not necessary for our purpose to take it for granted 
 that the divided ends of the same nerve should always 
 reunite with each other. The case which we have just 
 cited does not testify absolutely in favor of the com- 
 plete reliability of optico-ciliary neurotomy. There- 
 fore the operation must be tested further, perhaps 
 improved a great deal, before we can employ it with 
 confidence as a perfect substitute for enucleation,
 
 186 SYMPATHETIC DISEASES OF THE EYE. 
 
 Meanwhile, we hope that no operator who puts full 
 trust in it, and employs it as a preventive, in the be- 
 lief that he thus insures the other eye from danger as 
 thoroughly as he would do by enucleation, may ever 
 be terribly undeceived by seeing a patient, in whom 
 he has thus performed optico-ciliary neurotomy, reap- 
 pear for advice at a later date, with all the symptoms 
 of a genuine irido-cyclitis ! 
 
 Among other operations proposed as substitutes for 
 enucleation, we may next mention the production of 
 purulent choroiditis by the early introduction of a 
 thread into the threatening eye. It is said that, by 
 passing a thread through all the tunics of the eye, 
 and letting it remain until a slight serous swelling 
 (chemosis) of the conjunctiva indicates that purulent 
 choroiditis (panophthalmitis) has begun, the eye gradu- 
 ally shrivels and becomes insensible. Moreover, it is 
 said that the danger of sympathetic irritation is thus 
 entirely removed, owing to the fact that the purulent 
 inflammation has more or less completely destroyed 
 the ciliary nerves. Y. Graefe refers, at three differ- 
 ent periods (I860, 1863, and 1866), to this manner 
 of producing artificial atrophy, which had, however, 
 long before been resorted to for an entirely different 
 purpose, in the case of hypertrophied eyeballs. Feuer 
 also has lately revived the same proposition. Just 
 here, however, we have nothing to do with the influ- 
 ence of this procedure in diminishing the size of en-
 
 THERAPEUTICS. 187 
 
 larged eyeballs, but only with its relations to enucle- 
 ation. In spite of v. Graefe's recommendations, based, 
 moreover, as far as we can see, on entirely theoretical 
 grounds, we must emphasize the fact, which is easily 
 evident from his own last words on this point, that he 
 had never made any practical use of this method in 
 cases of sympathetic ophthalmia. These are his re- 
 marks in 1866 : " It might, perhaps , be rational under 
 certain cir 'cumstanf.es ; especially after wounds or op- 
 erations, when nothing more can be hoped for in the 
 eye in question, to increase the diffuse purulent inflam- 
 mation already present, by inserting a thread for two 
 or three days. The patient suffers far less from the 
 panophthalmitis (if soothed with cataplasms) than he 
 would suffer from a subacute cyclitis, gains a less 
 sensitive stump, which bears an artificial eye excel- 
 lently, and finally is saved from the danger of trans- 
 mission of irritation to the other eye." 
 
 But if this method really offers so great advan- 
 tages, why had v. Graefe, up to that time, never re- 
 sorted to it ? It seems to me that he had some fear 
 that it might act as a double-edged sword. For, say- 
 ing nothing of the fact that even panophthalmitis, 
 and the " less sensitive " stump, do not offer complete 
 security against sympathy, the thread, although it 
 might not increase the inflammation to genuine pan- 
 ophthalmitis, might cause cyclitis of a much more 
 severe and dangerous type. Under such circumstances,
 
 188 SYMPATHETIC DISEASES OF THE EYE. 
 
 this method might not only not remove the danger of 
 sympathetic ophthalmia, but even favor the outbreak 
 of this affection in the same way as, when a foreign 
 body lies hidden in the eye, we cannot hope for a con- 
 dition of permanent rest. 
 
 Is there any need of my giving anything more than 
 a hint of the method proposed by Barton, which con- 
 sisted in abscising the cornea, removing the lens, and 
 subsequently applying poultices to the remnant of an 
 eye in which a foreign body still lies encapsuled ? Or 
 shall I mention the proposition of Verneuil (1874:), who, 
 after unfavorable experience in four cases of enuclea- 
 tion, advises us to close the eyelids by uniting their 
 edges (blepharoraphy), and illustrates the useful re- 
 sult of this method by two pertinent cases ? 
 
 Barton tells us that, after abscising the whole ante- 
 rior portion of the eyeball, and applying poultices for 
 a few days, the foreign body, which has previously 
 been lodged in the vitreous, is generally found lying 
 somewhere in the conjunctival sac. This operation 
 will, however, hardly take the place of enucleation, 
 from the fact that it may possibly be followed by 
 excessive secondary hemorrhage, as well as by violent 
 and tedious panophthalmitis, so that the eyeball is 
 gradually reduced to a minute stump. In Verneuil's 
 cases, the irritation of the eye which led to sympathy 
 on the part of the other, depended, as Laqueur has 
 already remarked, on a lack of suitable protection.
 
 THERAPEUTICS. 189 
 
 Under similar exceptional circumstances, therefore, this 
 operation may also be employed. 
 
 Iridectomy is the last operation to be mentioned. 
 Are we to perform it on the eye which causes sym- 
 pathy ? Under one circumstance only : when the iris 
 (the eye being otherwise unharmed) has become incar- 
 cerated in the peripheral wound in the cornea, after 
 an injury or operation, as well as after spontaneous 
 perforation of the cornea. In such cases we may have 
 neuralgia of the eye first affected, or sympathetic in- 
 flammation of the second eye. Iridectomy is then of 
 great benefit, for by this operation we can abscise the 
 imprisoned bit of iris, as well as the crushed ciliary 
 nerves, and succeed in saving both eyes from danger. 
 But when the incarceration of the iris has already 
 induced irido-cyclitis, or when the latter affection has 
 originated from any cause whatever, iridectomy is of 
 no avail, and cannot in any respect be advantageously 
 resorted to as a substitute for enucleation. 
 
 When the sympathetic symptoms can be attributed 
 to the crushing of the nerve during enucleation, or to 
 secondary imprisonment of the stump of the nerve in 
 the cicatrix, we may endeavor to remove the irritating 
 cause by subsequent excision of the cicatrix. But 
 even then we shall only gain permanent results under 
 the same circumstances under which enucleation would 
 originally have been beneficial. Thus, Hasket Derby 
 reports a case of fully-developed irido-cyclitis which
 
 190 SYMPATHETIC DISEASES OF THE EYE. 
 
 could not be cured by resection of the stump of the 
 nerve (page 154) ; while, on the other hand, Mooren 
 succeeded in permanently relieving the ciliary hyper- 
 sesthesia in his case (page 153) by some peculiar 
 method (which may really have consisted in exsecting 
 the stump of the nerve). In my own case (page 136) I 
 proposed an operation to the patient, intending to dis- 
 sect the optic nerve away from all its surrounding tis- 
 sues as far back as the optic foramen, and then to 
 abscise it. If the irritating cause were situated in the 
 orbital portion of the nerve, we might, perhaps, suc- 
 ceed in relieving the tormenting pain from which the 
 patient has suffered. Up to this time, however, my 
 patient, to whom, of course, I could not guarantee per- 
 fect success, has not been able to make up his mind to 
 consent to the operation. 
 
 We have now finished our discussion of the opera- 
 tions which may be practised upon the eye originally 
 affected, but we have not yet exhausted our account 
 of the operative therapeutics of sympathetic ophthal- 
 mia. We still have to inquire what operations, if any, 
 are permissible on the eye which has become affected by 
 sympathy. In these cases also it is important for us 
 to separate the various forms and stages of sympathy. 
 We cannot operate on the second eye so long as it is 
 intact, or merely exhibits simple irritation, or slight 
 functional disturbances. 
 
 Iritis serosa is the first affection of the uveal tract
 
 THERAPEUTICS. 191 
 
 that we are to consider. In general, this type of 
 iritis will not need any heroic treatment, and we 
 ought to act toward it with much greater reservation 
 than in a case of the same disease which does not de- 
 pend upon sympathetic irritation. For the sympa- 
 thetic form is evidently dependent upon some irritation 
 of the nerves, an irritation whose increase we dread so 
 exceedingly that we always energetically oppose enu- 
 cleation of the irritating eye, so long, at least, as the 
 iritis serosa persists. When the common form of 
 serous iritis continues for a long time, and will not 
 yield to the usual remedies, we cannot do anything 
 better than to perform iridectomy. But, just as we 
 should not operate on an eye affected by sympathy so 
 long as there seems to be no real danger from delay, 
 so we should not be too hasty in performing an iridec- 
 tomy in cases of sympathetic serous iritis. As v. 
 Graefe said, in 1866 : " I remember only two cases in 
 which I felt obliged to perform paracentesis of the 
 cornea, and once to perform iridectomy upward, in 
 cases of obstinate iritis serosa. In all of these, how- 
 ever, the desired purpose was effected." 
 
 Simple plastic iritis with but few posterior adhe- 
 sions of the pupillary margin, the intermediate por- 
 tions of the iris reacting well to atropia, is to be 
 placed on the same level with serous iritis, so far as 
 the abstinence from operative treatment in sympa- 
 thetic irritation is concerned.
 
 192 SYMPATHETIC DISEASES OF THE EVE. 
 
 "We have, however, an exceptional state of affairs 
 in cases of total exclusion of the pupil Ijy circular pos- 
 terior adhesions. Let us at this point recall our pre- 
 vious remarks on this subject (pages 76 and 80). The 
 differential diagnosis between the condition in which 
 the iris is bulged forward by the fluid of the posterior 
 chamber on the one hand, or by the masses of exuda- 
 tion dependent on plastic irido-c} T clitis on the other, 
 lies chiefly, in our judgment, in the degree of hardness 
 or softness of the eyeball, in comparison with the nor- 
 mal condition. If the fluids of the posterior chamber 
 have bulged the iris forward, the eye will be doubt- 
 fully, or perhaps distinctly harder to the touch ; if exu- 
 dations have been at work, the eye will be decidedly 
 soft. When the periphery of the iris is bulged for- 
 ward in knob-like masses, the eyeball, however, being 
 soft to the touch, the case is quite different from that 
 in which, with similar appearances on the part of the 
 iris, we can prove that the eye is harder than normal. 
 This latter condition only is the one with which we are 
 now concerned. 
 
 The literature at our command does not give a su- 
 perfluity of advice for cases in which sympathetic sec- 
 ondary glaucoma is apprehended, or in the presence of 
 symptoms which denote its approach. V. "Wecker 
 (1879) thinks that, "on account of the violent pain 
 from which the patients often suffer in case of an at- 
 tack of glaucoma after the development of complete
 
 THERAPEUTICS. 193 
 
 posterior adhesions," we should confine ourselves ex- 
 clusively to paracentesis of the cornea or sclerotomy ; 
 we should never think of touching the iris, or of per- 
 forming iridectoniy. " We shall hot, as a rule, suc- 
 ceed," says he, " in loosening those fragments of the 
 iris which adhere to the anterior capsule of the lens, 
 and if we are so fortunate as to succeed in a few cases, 
 the eye will be so much irritated by the contusion, that 
 the momentary benefit which we seem to have won will 
 be lost again by closure of the new pupil, and deterio- 
 ration of the function of vision." 
 
 Unfortunately, I cannot assent to this view; for in 
 cases of simple iritis, iridectomy is unnecessary, while 
 in those in which the posterior surface of the iris has 
 become adherent to the anterior capsule, the oper- 
 ation is hardly practicable. But in that condition 
 of affairs which we are now discussing, there is no 
 doubt that we can excise a piece of the iris with the 
 effect of restoring the communication between the an- 
 terior and posterior chambers. By this means we may 
 also successfully oppose the inflammatory attacks of 
 secondary glaucoma, as well as of glaucoma itself, by 
 removing the inducing cause. The following instruc- 
 tive clinical history niay serve to throw light upon 
 what we have just said. 
 
 A man about thirty-one years of age was seen at the 
 Clinic April 30, 1876. On January 24, 1876, a cramp- 
 iron had been projected against his left eye. The
 
 194 SYMPATHETIC DISEASES OF THE EYE. 
 
 patient suffered but little pain after the injury; the 
 sight of the wounded eye was diminished, but he could 
 still see pretty well. The eye was very sensitive to light, 
 and a few days thereafter it began to redden. The 
 "inflammation" passed off in a fortnight, but vision 
 had at that time diminished still further. The patient 
 kept at his work for another fortnight, but as it made 
 the eye congested and painful, he applied a bandage 
 over it and stopped work. Still a fortnight later, six 
 weeks in all, after the injury, the right eye became 
 affected, and was injected and painful. The inflam- 
 mation continued with occasional exacerbations, so 
 that vision was gradually reduced to its present amount. 
 The examination shows the following state of things 
 in the left eye : A cicatrix, three or four millimetres in 
 length, in which the iris has become incarcerated, lies 
 in the sclerotica, at the outer edge of the cornea, just 
 above its horizontal diameter. The iris, which is al- 
 tered in color, and has partially lost its striated ap- 
 pearance, is tied down to the anterior capsule of the 
 lens by numerous adhesions, whilst the pupil has been 
 elongated toward the cicatrix in such a manner that it 
 seems as if a regular iridectomy had been performed. 
 The ophthalmoscope reveals the bright edge of the 
 crystalline lens at the place where the iris is deficient. 
 We know, therefore, that the lens was not dislocated 
 by the injury. The vitreous is so full of floating 
 opacities that we cannot get an image of the back-
 
 THERAPEUTICS. 195 
 
 ground of the eye. The whole ciliary region is slightly 
 congested. The tension of the eye is not noticeably 
 changed ; i.e., the eye is neither too soft nor too hard. 
 Tactile exploration shows that the outer and upper 
 portion of the ciliary region (not precisely in corre- 
 spondence with the place where the iris is incarcerated) 
 is sensitive to pressure. The sight of this eye has 
 decreased to one-fourth, or, with a very weak concave 
 glass, to one-third of the normal amount. 
 
 The right eye shows slight injection of the ciliary 
 region. The pupil is completely excluded by poste- 
 rior adhesions, and the periphery of the iris bulged 
 forward, especially in the upper half of the iris, which 
 is altered in color and appearance. The pupil is filled 
 with a membrane which is thin and transparent at the 
 centre, but thick at the circumference. The tension 
 of the eye is perceptibly increased, but not to a high 
 degree. A sensitive spot, corresponding precisely in 
 location to the one discovered in the left eye, is found 
 oy careful palpation. Vision is reduced to one-seventh 
 of the normal amount. 
 
 What are we to do ? We cannot enucleate the in- 
 jured eye, even did it possess only the slightest possible 
 trace of vision. It is as clear as possible that we can- 
 not enucleate one eye with one-third of normal vision 
 in order to save the other, which at present has only 
 one-seventh of normal vision, not even if we had any 
 faith whatever in the efficacy of enucleation under
 
 196 SYMPATHETIC DISEASES OF THE EYE. 
 
 such circumstances. On the other hand, I am re- 
 strained from operating on the eye sympathetically 
 affected, by the dread which such an operation should 
 always inspire. 
 
 The patient is sent to bed, receives a solution of 
 atropia for his left eye (without, however, dilating the 
 pupil), and a course of inunction is begun. A week 
 later (May 6th), after three inunctions (not to these, 
 but to the suitable regimen do I ascribe the benefit) 
 the ciliary injection has disappeared from both eyes. 
 The ciliary body in each eye is no longer sensitive to 
 the touch. On the next morning, however, pain is felt 
 in the right eye, increases all day long, and at night 
 becomes very violent. May 8th. The tension of the 
 right eye (the one affected by sympathy) is noticeably 
 increased, the lids are slightly swollen, ciliary injection 
 is excessive, the cornea is slightly hazy, and the iris is 
 bulged forward much more than at any previous time. 
 Pain is also felt at the sensitive spot in the ciliary region 
 (while the corresponding spot in the wounded eye is free 
 from pain), and vision is reduced to counting fingers 
 at one metre. In brief, the right eye exhibits all the 
 symptoms of acute glaucoma. May 12th. As vision 
 has not increased, an iridectomy is made inward, a 
 large piece of iris being excised. The incision heals, 
 and the anterior chamber is restored. The iris no 
 longer bulges forward at its periphery, but lies in a, 
 plane. The blood in the anterior chamber is soon
 
 THERAPEUTICS. 197 
 
 absorbed, pain and sensitiveness of the ciliary body 
 disappear, and tension becomes normal ; but the ciliary 
 injection is still present (May 18th). 
 
 June 9th. Both eyes are perfectly free from irri- 
 tation, and their tension is normal. Right eye : The 
 cornea is slightly cloudy near the cicatrix left after 
 the incision, but is otherwise transparent. The newly 
 formed pupil is partially covered with a membrane, 
 which, however, permits light to enter the eye at its 
 periphery. The iris lies in its normal position. Left 
 eye: The floating opacities in the vitreous have de- 
 creased so much that the retinal vessels and optic papilla 
 can be dimly seen by means of the ophthalmoscope. 
 
 The result of the case may be thus formulated in 
 brief : The injured left eye has one-half of normal 
 vision; the sympathetically affected right eye, one- 
 tenth of normal vision. 
 
 " I always operate when the periphery of the iris 
 bulges forward," as I said before in speaking of sec- 
 ondary glaucoma produced by sympathetic iritis. This 
 operation consists, as is evident from the foregoing 
 clinical case, in iridectomy, which has an undeniably 
 beneficial effect. Sclerotomy, i.e., the formation of a 
 large wound in the sclerotica at the edge of the cornea, 
 cannot be performed under the above circumstances 
 (bulging of the iris), owing to the excessive protrusion 
 of the periphery of the iris ; while, on the other hand, if 
 it could be performed, it would not fulfil the indication
 
 198 SYMPATHETIC DISEASES OF THE EYE. 
 
 of restoring the communication between the anterior 
 and posterior chambers. 
 
 Secondary glaucoma after sympathetic iritis seems 
 to me to be the only condition that allows of operative 
 interference. For, as serous iritis, as well as plastic 
 iritis, does not demand such treatment, in the same 
 way we cannot operate during the height of irido- 
 cyclitis, because by so doing we increase the morbid 
 process which in turn rapidly leads to atrophy of the 
 eye. The unfavorable results which I had obtained 
 from iridectomy, when performed under such circum- 
 stances, led me over to the side of the large majority 
 of oculists of the present day, who will not resort to 
 any operation, not even to an iridectomy, in cases of 
 plastic irido-cyclitis. When v. Graefe performed iri- 
 dectomy " even in a simple condition of affairs," but 
 like all other operators gained no beneficial results, he 
 asked himself whether " the iridectomy might not have 
 been performed at too late a date." Or whether " a 
 broad excision of the iris toward the extreme peri- 
 phery might not be of greater benefit, especially if 
 we reflect, that when the iris has once begun to ad- 
 here to the anterior capsule of the lens, the adhesion 
 advances rapidly toward the ciliary processes." In 
 other words, v. Graefe inquired whether, if he made 
 the incision in the sclerotica as in the cataract oper- 
 ation which goes by his name, the iris would not pre- 
 sent itself more broadly, and in a more suitable po-
 
 THERAPEUTICS. 199 
 
 sition for being grasped by the forceps, so that a much 
 larger piece might be excised. 
 
 V. Graefe's recommendation of such a method is 
 based on the favorable result which he obtained in one 
 case of this sort the only one which he had oppor- 
 tunity of reporting up to that date. But many ocu-. 
 lists have since discovered that v. Graefe's hopes were 
 too sanguine. Mooren, for example (1869), expresses 
 doubt whether even the earliest and most successful 
 iridectomy can be of any avail at all in the malignant 
 type of plastic irido-cyclitis, for in two cases in which 
 he performed the operation at the very outbreak of 
 the disease, and under relatively favorable circumstan- 
 ces, the result was fatal to vision. 
 
 Although a few cases of the favorable effects of one 
 or repeated iridectomies in iritis maligna have since 
 been reported (Hugo Muller, Grossmann, Pfliiger), we 
 must hold firm to the axiom, that only after the pro- 
 cess has become entirely extinct (by no means sooner 
 than a year after the outbreak of the sympathetic in- 
 flammation) can we decide whether an operation is to 
 be undertaken or not. The condition of the eye after 
 such a lapse of time is frequently a great deal more 
 favorable than we should have deemed possible at the 
 outbreak of the affection, and many an eye that a few 
 weeks after the appearance of iritis maligna seemed to 
 have fallen a prey to total atrophy, offers itself, at the 
 end of a year, free from irritation, with proportionally
 
 200 SYMPATHETIC DISEASES OF THE EYE. 
 
 fair tension, and prompt quantitative reaction to light, 
 even when the pupil is blocked up; or, when the pu- 
 pil is clear, or but slightly veiled, exhibits a surpris- 
 ing degree of vision. In the latter case, we should 
 be well on our guard against operating with the inten- 
 tion of improving sight. In the former, on the con- 
 trary, we should not delay in our attempt to make a 
 path for the rays of light to reach the retina. In such 
 cases, however, we cannot expect any benefit from 
 simple irideetomy, for the whole surface of the iris 
 being adherent to the capsule of the lens, it is impos- 
 sible to draw or tear away the iris with its adherent 
 membranes. We can then only attain our object by si- 
 multaneously opening and removing the anterior cap- 
 sule, giving rise at the same time to traumatic cata- 
 ract. In other words, we must resort to " extraction 
 of the lens, with simultaneous iridectomy and lacer- 
 ation of the false membranes." (V. Graefe.) 
 
 A narrow knife e.g., v. Graefe's cataract-knife is 
 entered at the upper and outer edge of the cornea, 
 nearly on a level with the tangent of the highest point 
 of its upper margin. It is next to be pushed through 
 the iris, afterward behind the iris, and finally through 
 the lens to a corresponding point of counter-puncture, 
 so that the sclerotic coat is opened at the upper edge 
 of the cornea by a linear incision ten millimetres in 
 length. We then introduce the forceps in such a 
 manner that one branch passes in front of the iris, the
 
 THERAPEUTICS. 201 
 
 other behind it (really into the lena behind the ante- 
 rior capsule, which is adherent to the iris), and try to 
 draw the whole membranous mass between the lips of 
 the incision, in order to excise it. In case the mem- 
 branes will not follow the traction (we should not 
 pull too forcibly), we must cut through the mem- 
 branes, with a pair of fine scissors, in such a manner 
 that a free triangular bit of membrane lies between 
 the branches of the forceps, by means of which the 
 bit can be removed from the eye. Then follows the 
 evacuation of the lens, which, during this manipula- 
 tion has already been broken up into small pieces. If 
 the opening in the membranous iris closes again after 
 the operation, or if irido-cyclitis attacks the eye which 
 has lost its lens, we should (after opening the an- 
 terior chamber with v. Graefe's knife) simply divide 
 the diaphragm by v. Wecker's forceps-scissors, one 
 branch being passed through the iris and behind it, 
 and the other lying in front between the cornea and 
 the iris (iritomy). In the case described on pages 52 
 to 55, double iritomy enabled the eye affected by sym- 
 pathy to see fingers at six feet (with proper cataract- 
 glasses), while the other eye gained vision equal to one- 
 eighth of the normal amount.* 
 
 * Pagenstecher (1881) is of the opinion that such an operation 
 as is here described is a mistaken one, and that we can win much 
 better results by making an iridectomy, and then removing the 
 
 lens, together with its capsule, with a flat spoon. TKS. 
 9*
 
 202 SYMPATHETIC DISEASES OF THE EYE. 
 
 Little as we can expect from the operative treat- 
 ment of sympathetic inflammation when this disease 
 has once become well defined, and extremely probable 
 as it is that more benefit can be obtained by refrain- 
 ing from operative interference, we have no reason to 
 boast of the results of medical treatment. Serous 
 iritis and simple plastic iritis (in and by themselves 
 by no means greatly to be dreaded, as we have .repeat- 
 edly urged) behave toward therapeutical measures like 
 other types of iritis which are not of sympathetic 
 origin. But therapeutics have no power over a genuine 
 sympathetic irido-cyclitis. It is, indeed, extremely 
 doubtful whether even the most energetic measures, 
 whether mercurialization, or even acute mercurializa- 
 tion, in a case of the latter type, can save an eye, 
 which, on the other hand, may recover without any 
 employment of mercury whatsoever. 
 
 We may thus sum up our therapeutical resources in 
 cases of injuries of the eye which may subsequently 
 lead to sympathetic inflammation. If an eye is badly 
 injured, a large portion of its contents evacuated, 
 vision totally lost, and a foreign body undoubtedly 
 present in its interior, it is best to enucleate at once, 
 before the impending panophthalmitis makes its ap- 
 pearance. If the wound embraces a large extent of 
 the eye, and we are sure that no foreign body remains 
 behind (or, if the shape of the eye as well as a partial 
 amount of vision has been preserved, even if it is
 
 THERAPEUTICS. 203 
 
 probable that a foreign body is still lodged within the 
 eye), we are not to be in too great haste to enucleate. 
 We should rather put the patient to bed in a darkened 
 room, and drop a solution of atropia into the eye at 
 regular intervals. If we think it can still be of any 
 avail, we should further add a compress-bandage ; and 
 lessen whatever pain is felt, by hypodermic injections 
 of morphia. The application of iced compresses, as 
 well as of leeches, notwithstanding their frequent 
 employment, is really of doubtful benefit. It is only 
 in the exceptional cases in which the patient cannot 
 bear the pressure-bandage that we should resort to 
 cold applications. We should, however, remove them 
 the moment that they begin to feel disagreeable to 
 the patient, and simply cover the eye gently with a 
 bit of cotton cloth. If panophthalmitis ensues, we 
 should leave the pressure-bandage on as long as the pa- 
 tient can bear it ; afterward warm fomentations (thin 
 compresses dipped in warm tea, or poultices of farina- 
 seed or wheat-bread boiled) are indicated. We may 
 also try Lelievre's new poultice-papers, which are 
 strongly recommended by Fronm tiller. 
 
 When the eye becomes purulent, excessively pain- 
 ful, and greatly swollen, we may attempt relief by 
 opening it. But when the panophthalmitis begins to 
 show signs of relapse, we should, as soon as possible, 
 insist upon the renewed application of the compress- 
 bandages.
 
 204 SYMPATHETIC DISEASES OF THE EYE. 
 
 If several weeks have passed since the injury (the 
 patient having been kept perfectly quiet in the inter- 
 val) and the panophthalmitis has diminished propor- 
 tionately, we must examine the eye thoroughly to see 
 whether it is now perfectly quiescent or not. If it 
 should be quiescent, the patient may have our consent 
 to resume his usual occupation, but should be warned 
 most earnestly to take notice of the least return of pain 
 in the injured eye, and to report for advice without a 
 moment's loss of time. If, on the other hand, the eye 
 is no longer spontaneously painful, but still continues 
 sensitive to all slight external influences, as well as 
 sensitive or painful to pressure, we should enucleate it 
 at once. We should also enucleate the eye, even if it 
 still possesses a slight amount of vision, provided that 
 it cannot be securely guarded from noxious influences, 
 or if we cannot rely upon the intelligence of the pa- 
 tient. But if the patient be thoroughly intelligent, 
 we can point out to him the various symptoms and 
 circumstances under which he should at once seek 
 surgical advice. 
 
 As soon as the stage of sympathetic irritation has 
 become pronounced, we should instantly enucleate, 
 even if the injured eye still preserves vision. In 
 serous iritis, as well as plastic iritis with only a few 
 adhesions, we should never enucleate, but keep the pa- 
 tient under the most guarded regimen : rest in bed in
 
 THERAPEUTICS. 205 
 
 a darkened room, regulation of the diet, together with 
 care for easy evacuation of the bowels. Locally, we 
 should resort to solutions of atropia. If the eye is 
 painful, and the circumcorneal injection well pro- 
 nounced (which conditions are, however, very rare in 
 iritis serosa), we should try bloodletting at the tem- 
 ples, as well as poultices applied to the eye. Weeks, 
 or even months later, when the iritis has wholly disap- 
 peared we may enucleate as a preventive of future 
 evil, in case the exciting eye has not become wholly 
 free from pain. If the inflammation has culminated 
 in posterior adhesions, with bulging of the peripheral 
 portions of the iris, and subsequent secondary glau- 
 coma, we cannot rely upon the usual anti-glaucorna- 
 tous remedies, such as eserin sulphate, pilocarpin mu- 
 riate (in one per cent, solutions), but we must try to 
 restore the communication between the two chambers 
 by an iridectomy. 
 
 Genuine plastic irido-cyclitis demands, of course, 
 the above-mentioned strictness of regimen, and the 
 most abundant patience, as well on the part of the 
 surgeon as of the sufferer. Bloodletting and atropia 
 seem to do more harm than good in this type of the 
 disease. "We can best resort to repeated poultices, 
 and (if necessary) to morphia injections. If the pa- 
 tient consents, we may try acute mercurialization, aim- 
 ing to saturate the system with mercury in the shortest
 
 206 SYMPATHETIC DISEASES OF THE EYE. 
 
 possible time. For this purpose, from six to ten 
 grammes ( 3 iss.- 3 iiss.) of gray mercurial ointment 
 should be rubbed in daily, conjoining this treatment 
 with the internal exhibition of calomel in one to two 
 decigramme doses (grs. iss.-iij.) every two hours until 
 salivation is produced. But inasmuch as irido-cyclitis 
 rarely leads precipitately to unfortunate results, a com- 
 mon well-regulated course of inunction seems to me 
 altogether more suitable. We ought to try this treat- 
 ment in order to satisfy our consciences. But we should 
 not expect too flattering results. If we carefully 
 analyze the few reported cases of rapid and perfect 
 cure effected by acute mercurialization after previous 
 enucleatiori, we shall discover, without the shadow of a 
 doubt, that the cases were not genuine irido-cyclitis, 
 and that therefore this type of disease was not cured 
 by mercury. Nor can we attribute any decidedly favor- 
 able influence to the enucleation. This operation, by 
 the way, we can omit with a calm conscience under 
 the circumstances here mentioned. The sympathetic- 
 ally affected eye may, if it has not become blind, be 
 subjected to an operation at a future time. 
 
 "We Have now finished our account of the therapeu- 
 tical measures which may be adopted in the severest 
 forms of sympathetic ophthalmia (affections of the 
 uveal tract), but we have yet to say something of the 
 remedies which may be employed in the secondary or
 
 THERAPEUTICS. 207 
 
 minor forms of this insidious affection. Sympathetic 
 retinitis or neuro-retinitis, which ensues in company 
 with inflammations of the uveal tract, cannot, on the 
 whole, have any influence in inducing us to change our 
 indications for operative interference, notwithstanding 
 the few reported cases of sympathetic keratitis and 
 scleritis have always been known to disappear after 
 enucleation. This form of sympathy should be treated 
 by rest, darkness, bloodletting, inunctions, and the 
 iodide of potassium. Shall we enucleate if it is diag- 
 nosticated as being independent of any uveal affec- 
 tion ? I am of the opinion that sympathetic neuro- 
 retinitis is due to a similar morbid process in the oppo- 
 site optic nerve and retina. Inasmuch, therefore, as 
 the division of an inflamed nerve does not seem any 
 too seductive to me, and as a relatively great number 
 of these cases have been observed directly after 
 enucleation (showing that the deleterious influence of 
 the division, or of the cicatrix, upon the nerve can 
 hardly be denied), I would not like to enucleate in 
 a case of sympathetic neuro-retinitis, despite those 
 favorable results which have been reported. Several 
 cases of sympathetic retinitis were reported at the In- 
 ternational Ophthalmological Congress, in New York 
 (1876), by Alt, Derby, and Bisley. Alt saw rapid im- 
 provement and recovery after enucleation in one of 
 his three cases. But it seems to me that the sympa-
 
 208 SYMPATHETIC DISEASES OF THE EYE. 
 
 thetic origin of these cases was not accurately demon- 
 strated, for the optic nerve of the enucleated staphy- 
 lomatous eye showed deep glaucomatous excavation 
 and atrophy. Moreover, several observers besides 
 myself have seen a sympathetic retinitis disappear 
 spontaneously, under suitable circumstances.
 
 INDEX, 
 
 A BSCISSION of cornea as a substitute for enucleation, 188 
 ~^^ Accommodation, 16 
 
 asthenopia of, 62 
 impairment of, 68 
 Amblyopia, sympathetic, 97 
 Anaesthesia of retina, 66, 128 
 " sympathetic, 105 
 Anaesthetics during enucleation, 176, 177 
 Anatomy of ciliary nerves, 57, 58 
 
 " eye, 12 
 
 Anterior capsule, 13 
 
 " incarceration of, in wound of eye, 42 
 " chamber, 13 
 Aqueous humor, 13 
 
 " imprisonment of, behind iris, 78 
 " normal means of escape of, 77 
 Artificial eyes, description and mode of adaptation of, 150, 151 
 
 " as cause of sympathetic ophthalmia, 51, 70, 134, 136, 151 
 Atrophic choroiditis, 86, 92 
 Atrophy of ciliary nerves, 119 
 " eye, 28 
 
 " optic nerve, 119, 128 
 Atropia, 196, 203 
 
 ~O AND AGE, compress, 175 
 
 Blepharoraphy as a substitute for enucleation, 188 
 Blepharospasm, 59 
 
 Blindness, total, from repetition of original injury, 9 
 Blood effused into retina, 88 
 Blows on eye, 25, 52
 
 210 
 
 /^ANAL of Fontana, 16 
 ^ " Schlemm, 16 
 
 Capsule of Tenon, 150 
 " lens, 13 
 
 u " shrivelling of, 42 
 
 Case of arrow-wound of eye (Mauthner), 21 
 
 " bit of iron encapsuled nine years in ciliary muscle (Bowen), 24 
 " metal lodged seventeen years in optic nerve (Bowen), 25 
 " cataract operation producing sympathy (Mauthner), 39 
 " double operation for cataract (Knapp), 41 
 " enucleation after linear extraction of cataract (Mauthner), 39 
 
 for iritis serosa (Mooren), 154 
 " " " " (Derby), 154 
 
 " " " " (Knapp), 155 
 
 " refused by patient (Samelsohn), 156 
 " with unsuccessful result (Gayet), 165 
 
 *' haemorrhagic glaucoma (Pagenstecher), 100 
 " herpes zoster ophthalmicus producing sympathy (Jeffries), 44 
 
 (Noyes), 44 
 
 " horse bite of eye producing sympathy (Mauthner), 29 
 " injury of ciliary body from bit of iron (Mauthner), 18 
 " " eye by a cramp-iron (Mauthner), 193 
 
 " " " from a bit of glass (Mauthner), 23 
 
 " iridodesis producing sympathy (A. Graefe), 35 
 " " " " (Steffan), 36 
 
 " leech bite of eye producing sympathy (Lebrun), 30 
 " lodgment of bit of metal in posterior chamber (Mauthner), 19 
 " neurotomy for sympathetic neuro-retinitis (Rheindorf), 178 
 " peri-neuritis of optic nerve producing sympathy (Mooren), 132 
 " persistent photopsies, despite enucleation (A. Graefe), 65 
 " poliosis arising from sympathy (Shenkl, Jacobi), 85 
 " primary lesion of optic nerve (Brailey), 126 
 
 " neuro-retinitis (Williams), 126 
 " resection of stump of optic nerve after enucleation (Derby), 
 
 154 
 
 ' reunion of nerves after neurotomy (Mauthner), 185 
 u sudden death associated with a proposed iridectomy (Trans- 
 lators), 148 
 
 " sympathetic choroido-retinitis (v. Graefe), 87 
 i u > u u 88 
 
 " " contraction of field of vision (Brecht), 67 
 
 " ophthalmia after recovery from cyclitis (Mauth- 
 ner), 52 
 
 " sympathetic ophthalmia from enucleation (Colsmann), 93 
 " " " " " (Mooren), 94
 
 INDEX. 211 
 
 Case of sympathetic ophthalmia from enucleation (Miiller), 94 
 " " " , " (Vignaux), 158 
 
 " gunshot wound (Cohn), 49 
 " wound of eye by a cow's horn, producing sympathy (Mauth- 
 
 ner), 136 
 
 Cataract, cases of cyclitis after operations for, 39, 40, 41 
 u causes of original irritation in eyes treated for, 42 
 " depression (or reclination) of, 37 
 " division of, 37 
 " extraction of, 37 
 44 flap operation for, 38 
 44 lamellar, 32 
 
 44 modified linear extraction of, 39 
 
 " operations for, causes of sympathetic ophthalmia, 31, 39, 103 
 44 stationary central, 31 
 14 sympathetic, 102 
 
 Cellular plate of ligamentum pectinatum iridis, 13 
 Chiasma, relations of optic nerves at, 106 
 Choroid, 15 
 
 44 peculiar form of morbid patches in, 8G 
 Choroidal sarcoma, 43 
 Choroiditis, 28 
 
 atrophic, 86 
 
 purulent, production of, as a substitute for enucleation, 186 
 Choroido-retinitis, 87, 88 
 Ciliary body, 15 
 
 44 44 detachment of, 42 
 
 44 41 diseases of, 17 
 
 44 " foreign" objects encapsuled in, 24 
 
 44 4l injuries of, 17, 23, 25, 26, 42, 65 
 
 44 " 44 spontaneous cure of, 17, 18 
 
 44 symptoms and anatomical changes caused 
 by, 26 
 ganglion, 58 
 44 muscle, 15 
 44 nerves, anatomy of, 57, 58 
 
 41 as conductors of sympathy, 110-120 
 44 atrophy of, 119 
 
 44 composition and functions of, 57, 58 
 4 ' reunion of, after neurotomy, 182 
 44 neuralgia, 63 
 Circle of Willis, 109 
 Compress bandage, 175 
 Cornea, 13 
 
 14 abscission of, as a substitute for enucleation, 188
 
 212 INDEX. 
 
 Cornea, curvature of, impaired by iridodesis, 34 
 
 " paracentesis of, 193 
 
 " phlyctenulae of, 59 
 
 u staphyloma of, 45, 46 
 
 Creed (Mauthner's) prescribing and limiting enucleation, 170 
 Crystalline lens, 12 
 Cyclitis, 26, 29 
 
 " acute, Mooren's definition of, 29 
 Cyclo-choroiditis as a cause of sympathetic ophthalmia, 46 
 Cysts of iris as a cause of irido-choroiditis, 43 
 Cysticerci, intra-ocular, 43 
 
 T^EATH, after enucleation, 147, 160 
 Descemet's membrane, 13 
 
 deposits on, in serous iritis, 74 
 Detachment of retina, 38, 103 
 
 ciliary body, 43 
 
 Diagnosis of sympathetic ophthalmia, 144 
 Diffused light, disturbance of vision by, 33 
 Diseases, sympathetic, list of, 56 
 
 relative severity of, 103 
 
 Drainage of eye, as a cause of sympathetic ophthalmia, 104 
 u operation of, described, 103 
 
 ~Cp ABLIEST advent of sympathetic ophthalmia, 142, 143 
 Enucleation, accidents from, 147, 149, 153, 159 
 " after-treatment of, 1 75 
 
 anaesthetics during, 176 
 " as a cause of death, 147, 160 
 
 " " " disfigurement, 149, 151 
 
 " " sympathetic ophthalmia, 51, 63, 
 132, 155 
 " creed indicating and contraindicating, 170 
 
 crushing of optic nerve during, 163 
 " indications for and against, 163-170, 202-206 
 
 " in irido-cyclitis, 169 
 
 " iritis maligna, 159 
 " u i. piagfcjca^ 168 
 
 " " " serosa, 167 
 
 " " panophthalmitis, 160 
 
 " of left eye, 171 
 
 " right eye, 175 
 " " wrong eye, 175
 
 INDEX. 215 
 
 T ENS, crystalline, 12 
 " dislocation of, 34 
 
 as a cause of irido-choroiditis, 43 
 Ligament, suspensory, 12 
 
 laceration of, 34 
 
 Ligamentum pectinatum iridis, 13 
 Linear extraction of cataract, 39 
 
 " " " causing sympathetic ophthalmia, 41, 103 
 
 "A/TEMBRANE of Descemet, 13 
 
 "* " " deposits on, in serous iritis, 74 
 
 Mercury in sympathetic ophthalmia, 196, 202, 205 
 
 Motion of artificial eye, 150 
 
 Motor fibres of ciliary nerves, 58 
 
 "VTEOPLASM attached to optic papilla, 22 
 Nerves, ciliary, anatomy of, 57, 110 
 
 41 as conductors of sympathy, 110-120 
 " atrophy of, 119 
 Nerve, naso-ciliary, 57 
 " optic, 14 
 
 " " as conductor of sympathy, 110, 118, 120, 122 
 " " atrophy of, 119 
 
 " " excavation of intra-ocular end of, 97 
 " " hyperplasia of intra-ocular end of, 65 
 Neuralgia, ciliary, 63 
 Neuro-retinitis, sympathetic, 133 
 
 " " " treatment of, 207 
 
 Neurotomy, 177 
 
 f " as a preventive of sympathetic ophthalmia, 186 
 
 " ciliary, 181 
 
 extra-ocular, 180 
 
 general remarks on, 181 
 " " history of, 177 
 
 method of performing, 183, 184 
 reunion of nerves after, 182 
 " intra-ocular, 178, 181 
 
 /^\BLIQUE illumination of eye, 72 
 ^^^ Occlusion of pupil, 76 
 Optico-ciliary neurotomy, 180 
 Optic nerve, 14 
 
 " " as conductor of sympathy, 65, 108, 121, 126, 130, 132
 
 216 INDEX. 
 
 Optic nerve, atrophy of, 119, 128 
 
 " " excavation of intra-ocular extremity of, 95, 97 
 
 " " mode of crossing of, at chiasma, 106 
 
 " " sympathetic affections of, 92 
 
 " papUla, 14 
 Ora serrata, 14 
 Orbital cellulitis after enucleation, 149 
 
 TDANOPHTHALMITIS, 47, 147, 203 
 
 " enucleation during, 160 
 
 Paracentesis of cornea, 193 
 Pars ciliaris retinae, 1 09 
 Pathogeny of sympathetic ophthalmia, 105 
 Pathology of sympathetic ophthalmia, 56 
 Phlyctenulae of cornea, scrofulous, 59 
 Photophobia, 59, 64, 128 
 Photopsia, 59, 64, 128 
 Phthisis of eye, 23, 100 
 Pigment spots in retina, 89, 92 
 Pilocarpin, muriate, 205 
 Plastic iritis, 75, 80, 157, 168, 191 
 Poliosis, sympathetic, 85 
 Posterior capsule, 12 
 " chamber. 14 
 Poultice-papers, Lelievre's, 203 
 Preliminary remarks, 10 
 Pressure points, 84, 85, 113, 195 
 Prognosis of sympathetic ophthalmia, 145 
 Pupil, exclusion of, 76, 192 
 " occlusion of, 76 
 
 QUESTION of enucleation in sympathetic ophthalmia discussed, 
 146-177 
 Question of neurotomy in sympathetic ophthalmia discussed, 177-186 
 
 "OEFLEX action in conduction of sympathy, 112 
 
 Refracting media of eye, 12 
 Retina, 14 
 
 " anaesthesia of, 66, 128 
 
 " detachment of, 28, 103 
 
 u hasmorrhagic extravasations into, 50, 88 
 
 " hypersesthesia of, 62, 66, 68, 128
 
 INDEX. 217 
 
 Retina, irritation of, 62 
 " pars ciliaris of, 109 
 " pigment spots in, 89, 93 
 
 Retinal gliomata, 43 
 
 Retinitis, sympathetic, 87-92 
 
 ^ " treatment of, 207 
 
 C ARCOMA. of choroid, 43 
 
 Schlemm's canal, 16 
 Solera. See Sclerotica. 
 Sclerotica, 13 
 
 softening, or relaxation of, 45 
 staphylomata of, 45, 46 
 Scleritis. See Sclerotitis. 
 Sclerotitis, 71, 207 
 Sclerotomy, 193, 197 
 Serous iritis, 71, 75, 80, 102, 167, 190 
 Sight, impairment of, without structural lesion, 66 
 
 " restored, of first eye, jeopardized by operation on other eye, 41 
 Staphyloma of cornea, 45 
 Staphylomata of sclerotica, 45, 46 
 Strieker's experiments, 110 
 Suspensory ligament, 12 
 
 Symmetrically painful points on eyeballs, 84, 85, 113, 195 
 Sympathetic anaesthesia, 105 
 
 " atrophy of optic nerve, 92 
 
 " cataract, 102 
 
 kl choroiditis, 86 
 
 " choroido-retinitis, 88 
 
 " cicatrix, 105 
 
 " diseases of eye, varieties of, 56 
 
 " " relative severity of, 80, 102 
 
 " fibres of ciliary nerves, 58 
 " glaucoma, 95-101 
 
 " acute, 99 
 
 hsemorrhagic, 100 
 
 without inflammatory symptoms, 9b 
 " iritis, from enucleation, 82, 93 
 
 " maligna, 80 
 " " mode of propagation of, 107 
 
 u plastica, 76 et seq. 
 " " serosa, 71 el seq. 
 
 " irritation, 58-67 
 
 " " after foreign bodies in eye, 59
 
 3 L8 INDEX. 
 
 Sympathetic irritation, as affected by enucleation, 166 
 
 " causes of, 61 
 
 " " condition of second eye in, 62 
 
 44 " diflFerent forms of, 59, 60 
 
 " of optic nerve, 64, 65 
 " of retina, 63, 64, 66 
 44 removed by suppurative choroiditis, 186 
 " with limitation of field of vision, 67 
 " impaired vision; 6b' 
 " phlyctenulae, 59 
 44 keratitis, 48, 70, 307 
 " opacities of vitreous humor, 102 
 44 poliosis, 85 
 " retinitis pigmentosa, 93 : 
 44 aclerotitis, 71, 207 
 14 ophthalmia, after recovery from cyclitis Without atrophy 
 
 of eyeball, 52-55 
 
 u ophthalmia, diagnosis of, 144 
 " ". definition of, 10 
 
 _ " from artificial eye, 51, 70, 134, 151 
 
 44 atrophy of optic nerve, 92 
 " bit of iron encapsuled nine years in cil- 
 iary muscle, 24 
 44 bit of metal lodged seventeen years in 
 
 optic nerve, 25 
 
 1 ' cerebro-spinal meningitis, 44 
 " " " cyclo-choroiditis, 46 
 
 " " cysticerci, 43 
 
 " " detachment of retina, 47 
 
 ' " drainage of eyeball, 104 
 
 44 " " enucleation of eye, 51, 62, 93, 132, 155 
 
 44 " " glaucoma, 46 
 
 " " glioma of retina, 43 
 
 " gonorrhoeal ophthalmia, 50 
 44 " ' 4 gunshot wounds, 49 
 
 " haemorrhage into vitreous humor, 47 
 " herpes zoster ophthalmicus, 44 
 44 " " horse bite, 29 
 
 44 u 4t iridectomy, 42 
 
 14 " 4l irido-cyclitis, 43 
 
 " " " iridodesis, 35, 103 
 
 44 " " leech bite, 30 
 
 * 4 " mechanical injuries of ciliary body, 48 
 
 " operations for cataract, 31, 39, 103 
 44 panophthalmitis, 47, 161
 
 INDEX. 219 
 
 Sympathetic ophthalmia from prolapse of iris, 48 
 
 44 sarcoma of choroid, 43 
 14 syphilis, 44 
 44 ulcers of cornea, 45 
 44 exsection of optic nerve in, 189, 154 
 " iridectomy in, 189 
 " medical treatment of, 202 
 " relative frequency of, in the various cataract 
 
 operations, 41 
 
 "' relative frequency of traumatic agencies pro- 
 ducing, 26 
 
 " 44 time of appearance of, 141 
 
 44 without cyclitis, 51 
 44 " disease of uveal tract, 51 
 
 44 injury of ciliary body, 50 
 Sympathy, means and methods of transmission of, 105, 132, 138 
 
 transmitted by the ciliary nerves, 110, 111, 115, 117, 118, 
 
 120, 139 
 
 transmitted by the circle of Willis, 109 
 
 44 44 by the optic nerves, 1C6, 117, 119, 127, 140 
 
 44 44 by reflex action, 120, 125 
 
 rpENON'S capsule, 150 
 
 Tension of eye, definition of, 21 
 Therapeutics of sympathetic ophthalmia, 146 
 Transmission of sympathy by ciliary nerves, 110-120 
 
 44 44 circle of Willis, 109 
 
 44 " optic nerves, 65, 108, 121, 126, 130, 133 
 
 Traumatic complications, in diseases of ciliary body, 17 
 Tunics of eye, 12 
 
 TTLCERATIVE process permitting prolapse of iris or of ciliary 
 
 body, 45 
 Uveal tract, 15 
 
 14 44 acute purulent diseases of, 46, 47 
 
 44 ' 4 idiopathic affections of, 43 
 
 44 44 mechanical irritation of, 43 
 
 "YTISION, impairment of, without anatomical changes, 66 
 
 u restored, of first eye, endangered by operation on second, 41 
 Vitreous humor, 12 
 
 " '* filamentous opacities of, 102 
 
 44 " molecular opacities of, 88
 
 220 INDEX. 
 
 "TTTILLIS, circle of, 109 
 * Wounds of ciliary body, 17 
 " eye, arrow, 21 
 " " gunshot, 49, 50 6S 
 
 -y 
 
 ELLOW spot, 15 
 
 ONULA of Zinn, 12 
 
 u " laceration of, '-' 
 
 THE EM>.

 
 Date Due 
 
 PRINTED IN U.S.A. CAT. NO. 24 161
 
 ,.!?.?. U . REGIONAL LIBRARY FACILIT 
 
 A 000510444 3 
 
 4 
 
 WW525 
 
 1881 
 Mauthner, Ludwig. 
 
 The sympathetic diseases of the 
 eye 
 
 WW525 
 
 1881 
 Mauthner, Ludwig. 
 
 The sympathetic diseases of the eye 
 
 MEDICAL SCIENCES LIBRARY 
 
 UNIVERSITY OF CALIFORNIA, IRVINE 
 
 IRVINE, CALIFORNIA 92664