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In the second grade the outlines of the disc are hidden by broad, striped hæmorrhages, which extend in all directions, but chiefly toward the macula. The veins are large, dark, and winding, the arteries faintly seen as thin threads; both can, however, be followed to their exit. The further changes resemble in diminished degree those of the first grade.
In the third grade there are few striated hæmorrhages at the edge of the disc, or denser ones covering a vein, but there is a remarkable disproportion between the size of the arteries and veins; the latter are larger, more tortuous, and darker than ever in choked disc. No change is found in the macula. That the thrombus is here in the central vein rather than in some of its branches is indicated by the nearly uniform venous dilatation. The result may be permanent complete closure of the vein, partial closure, or complete removal of the thrombus. In Michel's cases it seemed possible to assume the latter eventuality only when the thrombus had been small. With complete closure the hæmorrhages are at first partially absorbed, the opticus becomes more visible, and the arteries and veins may be followed farther toward the disc, but soon and repeatedly new extravasations occur, with farther depression of vision. The retina becomes more opaque, the vitreous turbid, whitish folds or threads are seen stretching across the fundus, and vision is almost wholly extinguished.
In the second grade, also, fresh hæmorrhages follow a fuller condition of the arteries, with renewed visual disturbance; but gradually the hæmorrhages are in part absorbed, in part take on a yellowish-white color ; the space between opticus and macula is dotted with yellowishwhite points, the macula region grayish-white, the disc less indistinct. The veins remain large, dark, and tortuous, and disappear suddenly here and there beneath elevations of the retina. The vitreous becomes hazy. Still, vision improved in one such case from counting fingers at 6' to V }
In the third grade the hæmorrhages disappear; the outline of the disc becomes sharp, but it assumes a whitish tint, as of atrophy, and careful examination yet reveals a disproportion in size between arteries and veins, while vision remains moderately impaired.
In one case, presenting clinically a type of the first grade, there was found an organized thrombus filling the vena centralis shortly before its emergence from the opticus into the orbit, hæmorrhages and results of hæmorrhages in the retina, atrophy of the nerve fibres and ganglion cells, proliferation of the radial fibres of the retina, development of blood-vessels and membranes in the vitreous. Considering the character of the changes in the circulatory system, that the condition of the arterial walls was such as to offer obstruction to the free flow of blood, it may properly be assumed that the thrombosis was spontaneous, the clot forming where a bend in the vein caused a slightly increased impediment to the current, that is, at its exit from the opticus into the orbit.
In striking contrast to the cases described by Michel are two cases of thrombosis of the vena centralis reported by Angelucci. The first patient, a man of twenty-three years, noticed while at work blindness of his left eye. Two months later he entered the hospital, when insufficience of the aortic, and insufficience and stenosis of the mitral valves were discovered. Examination of the blind eye showed the media clear, the disc whitish and somewhat irregular in outline, the arteries narrow, the veins moderately enlarged and winding; no hæmorrhages. In the other eye vision was good; there was slight enlargement of the veins, and one small hæmorrhage on the disc No further changes took place till death, three weeks later. The microscope discovered in the blind eye evidence of atrophy of disc and opticus; no trace of hæmorrhage in the retina. There was marked periphlebitis of the vena centralis, and a thrombus close behind the lamina cribrosa completely closed it. The central artery was compressed at this point, as it seemed, rather by the thickening of the wall of the vein than by the thrombus. In the right eye was also plilebitis and periphlebitis of the vena centralis, but nowhere so far advanced as in the left, nowhere involving the whole circumference of the vessel. The other organs presented the pathological changes usual with valvular disease of the heart. In the kidneys and in patches of softening in the cerebral hemispheres phlebitis and endarteritis of the small vessels.
The second case was very similar. A woman of twenty-four years, with acute rheumatism and insufficience of the mitral valve, lost the sight of the left eye during the night. Examination showed total blindness of this eye, the arteries narrow, and in places apparently empty. But on the next day the irregularity in the blood column had disappeared; the disc was somewhat veiled. Nothing else abnormal was
Death two months later. Here again was thrombus completely plugging the vena centralis, periphlebitis of the vein, and compression of the central artery.
In both these cases the patients were young, the occurrence of blindness sudden and complete. Though there was disturbance of the circulation from the heart disease, no atheroma or pronounced sclerosis of the arteries existed. The demonstration in the first case of periphilebitis also of the vein in the right eye, without thrombus, and in the second case of periphlebitis of other parts of the vein than that which was plugged, is strong evidence that the thrombosis was secondary to the affection of the wall of the vein. Whether the absence of extensive extravasations, such as Michel's cases presented, was owing to the different method of production of the thrombosis per se, to the possibly
1 Monatsblätter für Augenheilkunde, October, 1878.
simultaneous compression of the arteria centralis, or to the lack of pathological changes in the arteries, is not easily to be decided.
Diagnosis of Intra-Ocular Tumor by Probing.– Fraenkel observed in the eye of a girl of sixteen an elevation of the retina, which extended in the form of a grayish fold from the optic disc downward and inward, till its anterior end was lost to view. On each side of this elevation was a shallow separation of the retina. The central fold near the disc was little wider than the latter, but gradually doubled in width as it ran forward; it showed no movement. The media were clear; central vision = 1; a defect in the field corresponding to the separation. During six weeks' observation the only change consisted in an increase of prominence of the fold. To decide if a solid growth were present, a cataract needle was passed into the eye six mm. to the outer side of the cornea, and directed by help of the ophthalmoscope through the vitreous toward the fold. Sudden clouding of the cornea, probably produced by pressure or dragging, caused failure of the first attempt, but a second, two weeks later, was successful, and the operator could satisfy himself, both by touch and sight, that the grayish ridge offered firm resistance to the needle, and could even feel along one side of the growth. The eye was enucleated, and a gliomatous development between the layers of the retina found which reached from the disc to the ora serrata in the form of a narrow band, widening toward its anterior extremity, and projecting one and one half to two mm. into the vitreous.
The Optical Constants of the Eye. — Reusso made careful measurements of the curves of the cornea and lens and the distance of the surfaces of the lens from the cornea in twenty-one eyes. From the results of these measurements and the calculations based on them he draws the following deductions:
(1.) The dioptric apparatus of two eyes of the same refraction may be very
different, whether the eyes be emmetropic or in high degree ametropic.
(2.) This difference does not depend only upon a difference in the curve of the cornea, but equally upon varying refractive power in the lens.
(3.) The depth of the anterior chamber is in general less than previous measurements lave shown ; it is not always of the same depth in emmetropes, and in myopes bears no direct relation to the amount of the myopia.
(4.) The distance of the posterior pole of the lens from the summit of the cornea is less than has been assumed. (5.) Emmetropic eyes have a longer axis, a shallower anterior cham
1 Centralblatt für practische Augenheilkunde, December, 1878.
ber, and a lens of much greater focal distance than hitherto supposed. The newer values of the schematic eye of Listing-Helmholtz are therefore still too small.
(6.) In myopic eyes the radius of the anterior surface of the lens is, as a rule, much greater than in emmetropia, and the same is in general true as to the posterior surface of the lens. In correspondence with this the focal distance of the lens is almost without exception greater in myopes than in emmetropes. Among the eyes measured was none in which an excess of focal power in the lens was the cause of myopia.
(7.) The thickness of the lens in myopes is, with few exceptions, less than in emmetropes.
(8.) The principal focal distances of the eye average to be greater in myopes.
(9.) In most myopes both nodal points lie behind the lens, or at least the anterior nodal point lies very near the posterior surface of the lens.
Horstmannmeasured the depth of the anterior chamber in forty-one eyes by means of an instrument contrived by Donders. He found the depth to be less than that given by nearly all previous observers, but his results agreed very nearly with those of Reuss. The depth varied in eyes of the same refraction, while the average depth was greatest in myopic, least in hypermetropic eyes.
PROCEEDINGS OF THE NEW YORK COUNTY MEDICAL
SOCIETY. March 24th. Laryngeal Phthisis. — Dr. Frank H. Bosworth read a paper on Laryngeal Phthisis, in which he maintained the non-tubercular character of the affection, but regarded impaired vitality as the most important element in its causation. He considered the appearances always noted in the first of its three stages as pathognomonic of the disorder, and believed that it was curable in the majority of instances when recognized sufficiently early. Even when in the stage of ulceration he thought many cases could be cured, although chronic laryngeal catarrh was apt to remain. He divided the treatment into four procedures : (1.) Thorough cleansing of the parts, preparatory to other measures. (2.) The application of mild astringents, alterauts, etc. (3.) Adodyne applications to relieve the pain and irritation sometimes caused by the latter. (4.) The use of iodoform as a specific in the ulcerative stage. Dr. Bosworth thought the applications could be most satisfactorily made by means the Sass spray, and occasionally in the form of powder by the insuflator. The steam atomizer he condemned in this as in all other chronic affections of the throat. Dr. Flint stated that he had always been accustomed to regard the prognosis as bad in laryngeal phthisis, and Dr. Lincoln said that although a certain proportion of cases were curable under appropriate treatment, he
1 Bericht der ophthalmologischen Gesellschaft, Heidelberg, 1878.
could not agree with Dr. Bosworth in his statement that this was the case in a majority of instances. - Drs. Beverly Robinson and Andrew H. Smith spoke in favor of tracheotomy, which the author of the paper had advocated in cases where the other measures recommended failed to be of service; but the latter urged great caution in the procedure, as he believed that fatal catarrhal pneumovia was more or less likely to occur after the operation. After expressions of opinion by two or three other members, Dr. Bosworth brought the discussion to a close, and in the course of his remarks mentioned incidentally that although the most of his patients had been cured of laryngeal phthisis, nearly all of them had subsequently died of pulmonary disease.
Abuse of Medical Charities. Dr. F. R. Sturgis read a paper on The Responsibility of the Medical Profession for the Abuses of Medical Charities, which had been presented at the recent meeting of the State Medical Society, and was by it referred to the county societies for consideration. In consequence of the lateness of the hour, the discussion of this paper was made the order of a special meeting of the society to be held April 14th.
Metric System. — The same evening was adopted the report of the committee on the metric system, whose recommendations were embodied in a series of resolutions to the effect that the system shall henceforth be used in the minutes of this society and in all the papers published under its authority ; that the society request the medical boards of the New York hospitals and dispensaries to adopt the system in prescribing; that the faculties of the medical colleges in the city be also requested to order its adoption in their didactic and clinical departments; and that the Medical Society of Kings County (Brooklyn) be invited to coöperate with it in the means of insuring rapid and safe transition from the old to the new system of weights and measures.
FERRIER ON THE LOCALIZATION OF CEREBRAL DISEASE.
The name of Dr. Ferrier has already been long known to the medical public as the author of The Functions of the Brain, and these lectures, which appeared first in the English journals a year ago, were looked for with much interest, as promising to give the last clinical word about a subject on which the writer, by his experimental researches, had earned a right to speak with authority.
There is no reason to be disappointed as to the manner in which this expectation has been met. The work throughout deserves the highest praise. The reasoning is clear and fair, and the materials have evidently been collected with industry and discrimination. The turning-point of the book is of course an attempt to account, on physiological principles, for the symptoms observed clinically in cases of destruction or irritation of the so-called “motor” and “sensory” centres, recently discovered in the convolutions adjacent to the fissure of Rolando, and elsewhere; in other words, to establish the cortical paralyses, etc., on a firm basis.
1 The Localization of Cerebral Disease. (Soulstonian Lectures for 1878.) By David FERRIER, M. D., F. R. S., etc. New York : G. P. Putnam's Sons. 1879. Pp. 142.