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neuro-retinal edema. 2. Provided a choked disk has not pro-
gressed to one of the later stages in which there is extensive
new tissue formation due to the organization of hemorrhages
and exudates, its rapid subsidence can usually be assured by
the mere relief from pressure afforded from a decompression
operation — a measure which is now daily serving as a means
of preserving vision for many of these unfortunates, even
though the growth itself remains untouched. It is notable,
furthermore, that the swelling subsides more rapidly in the eye
homolateral to the decompression, owing to the greater relief
from pressure on this side, even though it be the side occupied
by the tumor. The routine daily examination with the electric
c^thalmoscope of patients after such cranial injuries as basal
fractures, has shown that a choked disk in the so-called stage
of "optic neuritis," is of frequent occurrence, due, in all prob-
ability, to the cerebral edema which follows concussion or
contusion. The neuro-retinal swelling in these cases, together
with the other existing pressure symptoms, usually subsides
promptly after the establishment of a suitable subtemporal
opening in the cranium. It may be mentioned, further, that
we have evidence in support of Byrom Bramwell's view that
"albuminuric retinitis," so-called, may be in a large part de-

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pendent upon a similar cerebral edema. It may indeed be
difficult or impossible to distinguish this condition from the
choked disk of tumor, the latter often showing hemorrhages
and exudates exactly comparable to those supposed to typify
the changes that accompany nephritis.

In addition to the familiar triad of headache, vomiting and
choked disk, with certain other general pressure manifesta-
tions of less moment, such as vertigo, dizziness, convulsions,
and the like, there occurs in most cases of tumor, a further
sign, to which I desire to call particular attention, for it seems
to be one of the earliest and most rehable indications of an
increase in intracranial pressure.

Dyschrotnatopsia. — In affiliation with Dr. James Bordley, it
has been customary with us, in the study of the eyes of the^e
patients, to test the visual acuity and to plot the fields for form
and color, in addition to the usual observations upon retina,
pupil, movement, and so on. It was an early experience to
find the existence in many cases of an inversion, or a tendency
towards inversion (interlacing), of the ocular fields, a process
which almost invariably affects the blue more than the other

In agreement with Charcot and his school, this condition
has been commonly regarded as one of the most characteristic
signs of hysteria, and we were inclined to believe at first that
in our patients it was merely an evidence of some functional
disturbance superimposed on the organic lesion, the presence
of which we were often able to demonstrate. However, as we
began to see the tumor cases at an earlier and earlier stage,
the majority of the patients betraying no neurotic tendency
whatsoever, we came to regard the dyschromatopsia as
definitely characteristic of the pressure of tumor — so charac-
teristic, indeed, that we have become somewhat skeptical of
the diagnosis *1iysteria,'' when based upon these long-recog-
nized alterations in the color fields, particularly in view of the
fact that a large percentage of our patients ultimately show-
ing a typical brain tumor symptom-complex have at one time
or another, in the course of their disease, been considered

The dyschromatopsia, it may be added, bears no apparent
relation in these cases to the degree of choked disk, and in a
number of instances the characteristic distortion of the color

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fields has actually been demonstrated before the ophthalmo-
scope disclosed the presence of the expected neuro-retinal
changes. We have, indeed, come to place so much confidence
in this phenomenon as an early indication of increased intra-
cranial tension, that in a few cases we have ventured to oper-
ate at a stage before choked disk has occurred, and, in two
instances at least, the successful extirpation of a small tumor
at an early date has been due to our growing faith in the relia-
bility of this sign.

The probable relation of these alterations in the color fields
to intracranial tension is indicated by rapid return to the nor-
mal configuration of their boundaries after relief from pres-
sure has been afforded by the usual palliative operation. It
seems to be a more delicate gauge of tension even than choked

Varying grades of dyschromatopsia may be associated with
cr may precede an accompanying contraction of the field for
form. Thus, as is often the case with other of the signs of
general pressure, these color changes may possess at times a
certain localizing value. For example, with an intact form
field, we have observed in a number of instances a half loss
of the color fields (hemiachromatopsia), which foretold a sub-
sequent total hemianopsia. But even in these cases, more or
less complete inversion has been present in the half fields of
retained color vision.

We have endeavored to eliminate every source of error in
making these observations, and should they be corroborated by
others the phenomenon may prove valuable as an early sign
of tumor, for if we are to look forward to more frequent
operations upon these cases, the earlier, within reason, they
are undertaken, the greater will be the likelihood of their suc-
cessful termination, either as palliative or radical measures.

The pathological anatomy of tumors is then taken up, fol-
lowed by operative methods and results. N. M. B.

Graphic Records of Njstngmuf*.

Buys, E., and CoppKz. H. (Ophthalmoscope, December,
1909). A new instrument for the graphic recording of the
diflFerent varieties of nystagmus has been devised by the
authors and called "the nystagmograpli." Nystagmus is
classified and some of their findings given. Photographs of

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a series of their tracings are shown, illustrating the normal
nystagmus obtained by successively turning the head to the
left and right, together with several cases of other forms of

The instrument devised by one of the writers (Buys) allows
tracings to be taken in any position. It consists of a "statif"
monocular or binocular, according as we wish to register the
movements of one eye or of both eyes simultaneously. The
"statif" bears a cupule, of shape and capacity according to the
case. There is an oval cupule which measures 10 mm. by 14
mm. and two circular cupules of 10 mm. and of 14 mm. diam-
eter, respectively. The cupule, closed by a fine membrane of
gold-beater's skin, is articulated upon a mobile arm. It may
thus be displaced horizontally or obliquely in such a way as to
be applied at will to all parts of the eyeball.

The relations between the globe and the membrane may be
regulated to a nicety by means of a couple of pressure-screws.
The apparatus is fastened to the head by an elastic band. The
cupule is connected with a writing apparatus, provided with
one or two stylets, according to the case, by means of a caout-
chouc tube.

Cases of both vestibular and ocular nystagfmus are illus-
trated and described. Nystagmus is defined as short and jerky
movements of the eyes, which are repeated very rapidly and
always in the same direction (Fuchs).

Nystagmus is divided into two chief varieties, "Undulatory"
or "Pendulatory Nystagmus," in which the movements of go-
ing and coming are identical, and "Rhythmic Nystagmus" or
"Nystagmus a ressort," in which the movements are of diflFer-
ent rapidities.

The authors disagree with UhthofF that only undulatory
nystagmus is real and the other form a pseudo-nystagmus,
nystagmoid jerks depending upon the paresis of the muscles.
They believe with Barany that the rhythmic form is a true
nystagmus and not exclusively myopathic. Pendulatory nys-
stagmus is characterized by movements of equal rapidity in
both senses, the nystagmus a ressort by movements of un-
equal rapidity in the two senses. "The essential difference of
the two kinds of nystagmus lies in the relative rapidity of the
two movements, and not in the position of a point of rest or
of fixation in resi>ect to the movements."

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Either variety may be subdivided into rectilinear (vertical^
horizontal, oblique) and rotary. In cases of unequal move-
ments it should be denominated in accordance with the
more rapid movement, and if rotary, after the most rapid
I^ase of movement of the superior extremity of the vertical
diameter of the cornea.

Pendulatory nystagmus was found to be especially an optical
nystagmus. The voluntary nystagmus, miner's nystagmus,,
and the nystagmus caused by opening the lids when photo-
I^obia is present, or in affections of the conjunctiva are of this
form, as also the congenital forms of nystagmus, such as
albinism, amblyopia from high hyperopia, and opacities of the
transparent media of the eye.

Nystagmus a ressort is met with in the physiological state
only in extreme lateral deviation of the eyes. In affections
of the vestibule and cerebellum, it is altogether characteristic,

In the vertigo due to stomach or uterus and in acute alco-
holism, the nystagmus probably depends upon the vestibule
(Barany). It is found equally in some cases of congenital

The two varieties of nystagmus may occur in affections of
the central nervous system. The pendulatory form has now
and then been found in tabes. One of the essential symptoms
of Freidrich's hereditary ataxy is "nystagmus a ressort." In
insular sclerosis the two forms may be met with. Lastly^
"nystagmus a ressort" may be noted in all processes, the effect
of which is to reduce the capacity of the posterior cerebral

The nystagmograph is presented as a really good method by
which the different modalities of nystagmus may be analyzed
and a precise classification of the affection established.

W. R. P.

Some Cases DemonstrAting the Existence of the Filtering Cicatrix.

Elliot, R. H. (Ophthalmoscope, December, 1909). The
author reports four cases in each of which a filtering cicatrix
had accidentally been obtained following iridectomy, with re-
sulting lowering of the intraocular tension.

The cases selected appear to be iris-free and were seen
eighty-six days to ten years after the operation. The cases
were operated by four different suregons, and in only one is

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there any inference that a filtering cicatrix was aimed at. The
writer believes with Herbert and Lagrange that if a perma-
nent filtration can be obtained at times accidentally, there
should be little difficulty in obtaining it regularly, if we first
study the condition necessary to secure the filtering cicatrix.
All four cases show an elevated swelling immediately above
the limbus, not over 1 mm. in depth and of varying length and
breadth. In three cases minute dark spots could be seen,
which were evidently fistulous openings. The blade of a spud
or probe could be buried in the edema of the infiltrated con-
junctival patches, and the resulting pits would last for some
time.' In each case the edema would become more marked
upon massage of the eyeball, and the tension of the eye dis-
tinctlv lowered. W. R. P.

A Prellmiiiary Note on a New Operative Procedure for the Estab-
lishment of a Filtering Cicatrix in the Treatment
of Glaucoma.

Elliot, R. H. {Ophthalmoscope, December, 1909). The
author's operation for the establishment of a filtering cicatrix
in glaucoma is described in a preliminary paper, the conclusion
being drawn from fifty cases operated upon during the last
four months. The assumption is made that Herbert and La-
grange have established their contention that it is possible to
form a permanent filtering cicatrix between the anterior cham-
ber and the sub-con junctival space which will permanently re-
duce a raised intraocular pressure.

A large triangular conjunctival flap is dissected up from
above or below the cornea in the vertical meridian, the at-
tached base lying at the corneo-scleral margin. The flap is
dissected right to the margin and turned back over the cornea,
the sclerotic scraped to prevent the conjunctival tissue catch-
ing in the trephine. A small disk of sclerotic tissue is now
removed close to the corneal margin by means of a corneal
trephine. The disk may be left "in situ." cut out with the
trephine completely, or the removal may be completed v^rith fine
scissors and forceps. When the anterior chamber is reached
the aqueous wells up, and a peculiar, characteristic sucking
feeling is noticed by the operator. The trephine used had a
diameter of 2 mm. The iris may not present and then iridec-
tomy may be omitted. Iridectomy was performed in twenty-

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one of fifty cases, only a tiny buttonhole of iris being removed.

In two cases it was necessary to reopen later to remove a
bulging iris, which did not present at the time of operation.
In two other cases there was slight displacement of the pupil
toward* the trephine hole ; in the other forty-six the pupil re-
mained central. Eserine was instilled after each operation.

The anterior chamber had reformed on the day following
operation in thirty-seven cases ; on next day in five cases ; and
from the fourth to twelfth day in the remaining eight cases.
''In no case has the operation failed to relieve tension." No
septic accidents occurred in the fifty cases. The one danger
is that of making the trephine hole too far from the limbus
and tapping the suprachorioidal space instead of the anterior
chamber, in which case the anterior chamber is not emptied,
the tension is not well lowered, and if an effort is made to ex-
cise the bulging sclerotic, a loss of vitreous will occur. This
happened in three of the fifty cases.

The author is convinced that the operation is founded on
sound principles, and the technique is within the reach of all.

W. R. P.

The Recoipyttoii and Measurement of Low Degrees of Njstaipnas.

Jackson, E. {Ophth. Rev., January, 1910), describes a
method of observing nystagmus which consists in noting the
character of the movements executed by definite structures in
the ocular fundus as seen in the erect ophthalmoscopic image.
Withdrawing the observer's eye until the optic disk appears to
occupy the whole of the pupil one observes the apparent extent
of the movements, whether a given vessel appears to pass
entirely across the width of the pupil v/ith each excursion of
the eyeball, or only one-half or one-fourth of that distance.
From this, by brief calculations, or from the tables given, the
real extent of lateral or vertical movement is to be deduced.
Perhaps it is not necessary that all cases of nystagmus shall
have the extent of movement exactly measured. Yet this can
properly be required for cases reported to take their place in
the literature of the subject ; and it will be found very satis-
factory, in attempting to judge by the extent of the move-
ments as to the progress of anv case under treatment.

N. M. B.

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Intraocular Injection and Irrigation in the Treatment of Unripe


KiixiAN, Wm. AIarcus (Ophth. Rev., December, 1909).
"The principle of irrigation is the possibility of converting at
the time of operation a surgically unripe into a practically ripe
cataract. The essentials of the operation are that the solution
(4 grains of common salt in each ounce of distilled water)
should be absolutely sterile, and of about blood-heat, that a
high pressure be not used, that the integrity of the vitreous be
preserved, and that the cases be suitable ones for this method.
The cases likely to benefit are those chiefly of incomplete cor-
tical cataract at any age after the formation of a nucleus, espe-
cially where a shallow anterior chamber shows cortical swell-
ing. The cases where it is frequently unnecessary are pure
nuclear cataracts, such as the amber and dark-brown varieties,
where we suspect sclerosis of the cortex, even if this is still
clear to some extent, from observing a deep anterior chamber.
Occasionally in incomplete nuclear cataract one meets a trou-
blesome cortex which will benefit by irrigation."

The apparatus consists of a flat-bottomed Florentine flask
fitted up like an ordinary laboratory wash bottle, the pressure
being obtained with an India rubber bellows, the air passing
through sterile cotton contained in a bulb. Rubber tubing is
attached to the nozzle of the flask, and to this are attached the
needles and pii>ettes for irrigating.

The procedure is divided into two stages, either or both of
which may be used, as the case indicates. A very perfect
light must be concentrated on the cornea. After the usual
sclero-corneal section and iridectomy, and before capsulotomy,
the irrigating needle is introduced, through the wound and
made to i>enetrate superficially the capsule. If the cortex be
soft the needle enters readily and the solution diffuses itself
under and near the capsule. Transi>arent cortex is rendered
opaque and striated flaky or mother-of-pearl substance is rap-
idly broken up and separated from the capsule. In soft cases
the needle may be made to move about quickly, and thus assist
the action of the fluid. The needle should penetrate the cap-
sule about half-way between the corneal section and the center
of the pupil, so as to avoid penetration of the edge of the lens
or of the zonule. It must be kept well in front of the nucleus.
The use of the irrigating needle gives us a valuable indication

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of the consistence of the lens. If it do not penetrate the cap-
sule readily, but be seen instead to push the whole lens before
it, we are here dealing with a sclerosed cataract, and must at
once withdraw the instrument lest we dislocate the lens. We
know that we shall not require any irrigation to complete the
operation in such a case. In some patients the cortex be-
comes so semi-fluid during injection that a condition very
similar to Morgagnian cataract is produced. Section of the
capsule is now performed in the usual way and the lens de-
livered, after which we remove the needle from the India rub-
ber tube and substitute the nozzle. We have now to deal with
any residual cortex by massage and further irrigation.

The author thinks that in the hands of an experienced
operator who has got over the trial stage of this method the
immediate results are probably as good as those obtained by
other surgeons of equal operative experience, while patients
have earlier relief, with fewer secondary operations. Dr. Mc-
Keown's analysis of 154 cases showing only four total failures,
145 successes with vision varying from 20/200 to 20/20, and
these all cases of incomplete or unripe cataract, proves what
can be done by experience and care in detail. With great
care in the sterilization of the apparatus and the solution we
ought not to have a larger percentage of cases of infection of
the wound than by the older methods.

The author acknowledges that there seems to him to be,
"notwithstanding previous remarks, certain grave risks at-
tached to intra-ocular irrigation which must be weighed
against the advantages which can undoubtedly be derived
from its practice. To my mind, the most serious of these by
far is the possibility of injuring the vitreous body, even though
it do not show at the time of the operation." N. M. B.

Some Orbital Complications of Injuries of the Head and Face.

Evans. J. Jameson {Ophthalmoscope, February, 1910). A
series of twenty-eight cases of the various ocular complica-
tions following injuries of the face and head is reported.

I. Atrophy of the Optic Nerve, — The most frequent com-
plication found was atrophy of the optic nerve, generally of
the primary type and showing no sign of a previous neuritis
and little or no diminution in the size of the retinal vessels.
Twenty-two cases, thirteen of which are included under the

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first subdivision, showed this condition. The patients often
complained of failure of sight in one eye immediately after
the accident, as soon as they recovered consciousness, or after
the bandages had been removed. Both eyes may be affected
in injuries of the median region of the face and head, but as
a rule the lesion and defect of vision are on one and the same

Unilateral optic atrophy may result in complete or partial
blindness of the affected eye. The partial blindness may take
the form of a contraction of the field, which is often most ex-
tensive in that part of the field which corresponds to the
direction of the blow, i. e., temporal contraction when the force
has been applied to the external orbital margin ; the upper part
of the field diminished when the blow has been from above
downwards, which, however, is by no means constant. In a
lew cases there is a central scotoma, generally associated with
some peripheral contraction of the field.

It was noted also that in the great majority of cases of uni-
lateral optic atrophy, there was slight contraction of the field
on the other side, although no apparent change in the disk
on that side.

II. Atrophy of the Optic Nerve Associated With Direct
Injury of the Orbital Contents. — Four cases were observed in
which hemorrhage into the orbit was largely accountable for
the symptoms, proptosis, more or less complete ophthalmo-
plegia, loss of pupillary reflex, ptosis and, in one case, kera-
titis, followed by ulceration. These symptoms were of a more
or less temporary character, but there remained a permanent
and non-progressive atrophy of the optic nerve, whether due
to direct injury or to hemorrhage into the sheath or nerve
structure Hie author was unable to determine definitely.

III. Optic Neuritis, — Only one case showed optic neuritis
following injury to the head. A spurious optic neuritis was
noted in two other cases.

IV. Atrophy of the Optic Nerve Associated With Intra-
ocular Lesions, — Injury to the outer part of the rig^it eyebrow
resulted in paling of the right disk associated with stellate
rupture of the chorioid. A similar injury in another case was
followed by complete atrophy of the disk, the retinal vessels
reduced to threads and the whole fundus dotted with small
black spots of retinal pigmentation.

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A third case in which the left eyebrow was bruised by. a
stone, and the cornea and sclera abraided, showed vitreous
hemorrhage, ruptured iris and dislocated lens. Three years
later the disk showed temporal pallor with contracted field
and vision 6/60.

Glaucomatous atrophy of the optic nerve was observed in
one patient who had been kicked on the nose by a horse nine-
teen years ago. R. T. = +1. R. V. = 6/60.

V. Injuries of Oculomotor and Other Orbital Nerz'^s.-r-lt
is not uncommon to find traumatic atrojrfiy of the optic nerve
associated with injury to some of the oculomotor nerves, espe-
cially the sixth, and in the case of direct injuries also with
lesions of branches of the ophthalmic division of the fifth
nerve. One case, however, showed a paresis of the sixth
nerve on the left side following injury of the right side of the
face. The probability was that the petrous bone had been
fractured, thus leading to injury to the abducens nerve, which
is in intimate relationship to the apex of that bone. The con-
dition cleared up after four months.

VI. Injuries to Ocular Muscles, — In one case the lesion was
an indirect one and almost confined to one muscle^ — the left
superior rectus — probably caused by a hemorrhage into the

VII. Some Complex and Delayed Orbital Complication^, —
Paralysis of the third (with ptosis), fourth, sixth and seventh
cranial nerves resulted in a case of scalp wound. The condi-
tions improved after a fortnight.

A puncture wound from an umbrella rib, of the left lower
lid, was followed one month later by pulsating exophthalmos,
the eye proptosed, congestion of all the ocular vessels and a

Online Librarysciences et arts de la Dordogne Société d'agricultureThe Annals of ophthalmology → online text (page 29 of 82)