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Clinical Lecture ON SOME EFFECTS OF BLOWS UPON THE EYEBALL.
JUNE 19, 1880. to the blow, since the signs of central nervous very obscure. system is
bability,
Clinical Lecture
disease of the
were
more especially to draw My object to-day, however, your attention to another series of cases in which an injury, of just the same kind, has an entirely different SOME EFFECTS OF BLOWS UPON apparently I allude to the cases or sometimes an additional effect. which havebeen described under the title of " Commotio THE EYEBALL. retinae," in which the defect of sight, sometimes temporary, Delivered in the Eye Department of St. Thomas’s occasionally permanent, caused by a blow, is accounted for Hospital, Oct. 1879, neither by paralysis of accommodation nor visible intraocular hsemorrhage or rupture, and in which there are someBY EDWARD NETTLESHIP, times really no ophthalmoscopic changes. Berlin of StuttOPHTHALMIC SURGEON TO THE HOSPITAL. gart was, I believe, the first to give a full account of the ophthalmoscopic changes and clinical and pathological chaGENTLEMEN, - Severe blows on the eyeball by blunt racters of these cases. He disbelieves in " commotio retinse" objects are very often followed by dilatation of the pupil as the cause of the visual defect, and attributes the moderate and paralysis of the accommodation. It seems that in many amblyopia, which he states is usually noticed, to transient cases both the circular and radiating fibres of the iris are irregular astigmatism from changes in the form or position of the crystalline lens consequent on the blow. Immediately affected, since not only is the pupil somewhat enlarged after the blow, according to Berlin, central vision is lowered (paralysis of sphincter), but the use of atropine fails to effect from -î-%to or 15 This is followed in an hour or two complete dilatation (paralysis of radiating fibres). It may by a cloudy white opacity of some part of the retina, or be added that the pupil is often oval or subangular, instead sometimes of two separate areas, occasionally with minute haemorrhages ; this haze attains its maximum in twenty-four of round. to thirty-six hours, and in from forty-eight to seventy-two is not often that we have of the It the opportunity noting has usually quite disappeared. The same changes were interval between the blow and the onset of the symptoms andin these produced the eyes of referred to. In the case of an old man of seventy-one animals a layer of blood was always found between the (Wm. W——), however, whom I saw within twenty minutes choroidand scleroticcorresponding tothe area or areas of of a tipcat blow, I found the pupil inactive to light, and retinalhaze; the hazy retina wasin a state of "simple with foldingsand fissuresrunning perpendilating incompletely to atropine. At his age paralysis of acutecedema,"surfaces. His reasons for dissociating the the ciliary muscle would of course be undiscoverable. Whatfailure of vision from the observed changes in the retina, and ever may be the pathology of this condition, there is little from their cause, the subchoroidal haemorrhage, are-(1) that reason to doubt that the paralysis or paresis of the ciliary vision improves rapidly (to a certain point) within the first muscle and iris usually passes away completely, for patients day or two, at the very time when the retinal opacity is still with uncomplicated traumatic cycloplegia seldom remain on the increase; (2) that this improvement does not afterwards pace with the disappearance of the visible retinal long on our hands. The symptoms, however, may be pro- change,keep vision as low as fromz toremaining for some longed, and even permanent, as the following two cases days after the retina has cleared ; (3) he has seen a precisely show :— similar defect of vision in two cases after blows, without the CASE 1. Mydriasis persisting three months after a severe slightest ophthalmoscopic change, and therefore, as he supblow on the eye.-Henry W-, aged forty-six, was knocked poses, without the occurrence of the subchoroidal haemorinsensible for ten minutes by the rebound of a piece of wood rhage. as thick as the wrist which he was chopping, the stress of’ It appears to me, however, more probable that the changes the blow falling, as he believed, on the left eye. There in the retina (doubtless due, as Berlin states, to cedema with was some swelling of the lids, but no "blackening" foldings and fissures of the rod- and cone-layer, and proeither of them or eye. He had always considered the duced by the subchoroidal haemorrhage) do, after all, furnish left the better eye. Two and a half weeks after the acci- the true explanation of the failure of sight without appealdent the pupil of the injured eye was considerably dilated, ing to traumatic changes in the lens. I am the more inirregularly oval, and motionless to light ; eyeball rather clined to this view since in one of the cases I shall relate a congested, and a patch of infiltration in the cornea. Myopia temporary opacity of the retina, like that described by 1 ; vision= 7 ° ; accommodation not carefully tested. Right Berlin, with some amblyopia, was followed in three weeks patch of disease in another part of the fundus ; eye : myopia 2B; vision= No ophthalmoscopic changes by a definite in the injured eye. Six weeks after the accident the left although in the interval between the resolution of the pupil, still dilated, was now circular, and acting a little to primary retinal haze and the appearance of this patch the light; and the eye showed no defect either of visual acute- amblyopia persisted, during which no visible changes were ness or of accommodative power, as compared with its fellow. present. The first case of the so-called "commotio retinae" that I At the end of three months the pupil had not altered from the last note; it was observed also that it dilated very saw was published in THE LANCET, Aug. 21st, 1875 :CASE 3.-A man, aged thirty-seven, received a severe little more when covered, whilst its fellow acted freely and on his left eye from a lump of iron ; ten days later blow quickly. The next case was of considerable interest and importance, vision (with H. i3, corrected) =; six months after the inand 6 Jaeger, the other eye 219, and 1 Jaeger ; no the question being whether the state of his eye was due to a jury former injury or was a sign of disease of the nervous system. ophthalmoscopic changes ; eye believed to havebeen perfect CASE 2. Se1-’cre fist-blow on right eye, eleven ycars; en- until the blow. In this case there is no precise note as to largC1ncnt of pupil and paresis of accommodation ; doubtful the character of the defect of sight, but in the next case the S notes and examination were much more complete. sg7aptous of syphilitic disecase of ne>voussJstena.-Vm. CASE 4.-Master W-, aged fourteen, was sent to me by aged thirty-four, avery ansemic man, easily fainting, was sent over to me by Dr. Greenfield, for my report on the cause of the! Dr. Bristowe on Oct. 1st, 1879,just fifteen hours after a blow inequality of his pupils, the man having lately been an in- on his right eye by the ferule end of a walking-stick thrown patient of the hospital for nervous symptoms of uncertain endwise across the room. The eyewas congested and very and nature. Eleven years ago he had had a severe blow on his tender, no abrasion of cornea, tension normal ; vision right eye by a fist. Both the pupils acted fairly to light, words of 3 Jaeger; pupil rather smaller than the other even in both together and separately; but whilst the left was of bright light, dilating very little when shaded, though expandaverage size, the right was alwaysnearly twice as wide. ing widely to one drop of atropine, but not quite round ; iris The accommodation was difficult to test since he was looking healthy. Iedia clear; retina over a wide area in astigmatic, and the refraction differed in the two eyes ; as, the lower outer part towards the periphery, quite hazy however, after allowing for this difference, he required a and whitish, the change being beneath the vessels, rather stronger glass for reading with the injured eye, the: consequently were preternaturally distinct. By the most accommodation was probably affected. There were no oph- careful estimation of the refraction, however, I was unable thalmoscopic changes. Though he did not know how long. to prove that the whitened area was elevated (H. 2’T in all the condition had been present, I thought the change in the parts) ; slight doubtful haze of retina at yellow spot. Six pupil and accommodation attributable, with great pro- days later (after leeching, ice, and confinement in the dark), ON
experimentally
in
*
rabbits,
dicularly to its
the
.
,
.
No. 2964.
which
942
congested; the retinal haze described above has was natural; the hazy area was not measurably raise4 quite disappeared; at the yellow spot region just above and above the surrounding level. At the next visit (Sept. 23rd; outside the fovea centralis, a small patch of doubtful change the retinal haze was less marked, and a few days later it of the choroidal epithelium; vision (under atropine) 12 had further much diminished in extent. He did not attend H. -io = H, + 10 6 or 8 Jaeger barely, and only at the again, and I have been unable to trace him. I will conclude this lecture by citing some cases which sides of the page. He now told me that there was a mist over the middle of everything he looked at, and that if he were less completely noted, but were probably all instance!looked at the middle of his finger he could not see it. On of the same kind. As, however, none of them came under trial with two candle flames, the one at which he looked ap- care until after the period assigned for the disappearance of peared duller than the other placed a few inches apart from the transient retinal opacity in commotio retinue," this it, but nowhere on the defective part was perception of light point remains unproved. It would seem that usually the damage to sight in "comanything like abolished. With the perimeter the defect (scotoma) was easily mapped out; it was nearly round, of motio retinae " is but temporary, for the cases do not remain about 3° aperture, and almost central, its densest part under care long, nor do we find them returning for advice being downwards and inwards from the fixation point-i.e., long afterwards. But before we can pronounce with certo thelittle spot of doubtful choroidal tainty it will be necessary that a larger number of case change. The scotoma was only relative, nowhere absolute ; should be carefully followed up. within itsareawhitelookedvery dull ; red was invisible on CASE 7. Blow by a piece of iron; defect of sight 1ât1Wllt its densest part, elsewhere on its S--, aged forty ; a week ago right eye changes.-Ellen beyond area "reddish," its area "bright red green on the densest struck by a piece of iron as large as half a walnut; the eye part, elsewhere "greenish"; dark blue was scarcely visible was red but not "black." On admission, Aug. 11th, 1877, on any part of the scotoma. A fortnightlater (Oct. 21st) eye irritable; vision : right, 6 Jaeger badly, p. 8" and .2k,; remains larger than the other (as 4’5 mm. to 3 mm.), vision : left, 1 Jaeger fairly, p. 8" or 10" and 2-161. No change but circular and quite active (no atropine for fourteen days). in cornea, aqueous, or iris ; pupil and accommodation Vision 4 slowly, and words of 10 Jaeger slowly ; the scotoma normal. No ophthalmoscopic changes (erect image), except just covers short words such as " when," and in order to see rather pronounced white lines along the arteries on the disc, he looks a little to his right of the object. The little patch which were probably normal. Only attended once. CASE 8. Slight defect following a blow)’ doubtful haze of of doubtful choroidal change at yellow spot has now become retina at yellow spot.-Henry F-- (boy), severe blow on a well-defined white patch of the same size (? choroidal On Nov. 19th (seven weeks after blow) right eye by a stone eight days ago. On admission (June, or deposit). atrophy vision 12slowly, and 1 Jaeger well; the scotoma still ap- 1877), complains that he sees " a skin" over everything with parent as " a little white spot" if he looks for long at any- the injured eye; yet he makes out 1 Jaeger with it as well thing, and seen most easily when looking at distant objects. and at as short a distance as with the other (cannot read The pupil is still rather larger than the other; it acts well fluently); pupils equal and quite active. with accommodation, but dilates and contracts less actively 26th.-Ophthalmoscopic examination (eye fully atropised), to light than the other. The white spot of disease at retina around yellow spot unusually grey and reflecting, but the macula lutea is smaller, and is now quite bright, like a the appearance may be no other than the natural "halo’’ spot of fatty change in the retina; close to it the choroid is or watered-silk appearance so common in children. No rather disturbed. On Dec. l8th (nearly three months after later note. It is quite possible that the " skinmentioned the accident) scotoma still apparent as a little white spot, or by this boy was caused by a central scotoma, slight in spot of mist, on the limb of a letter of 20 Snellen, seen at degree. twelve feet. The spot of disease still present, but smaller ; CASE 9. brow on eye, followed by a fixed musC( (? cent1Y!C He considers his sight perfect. no disease elsewhere. scotoma); doubtful ophthalmoscopic changes.-Sarah W-, This case is instructive as a good example of Berlin’s aged forty-five, struck her right eye with a stick ten days "commotio retinae,"typical both as to the early and wide- ago, and has since then seen " a little black thing like a bit spread retinal haze and the rapidity with which this dis- of dirt floating at a distance from the eye." On admission appeared. It is also important on account of the gradual (Aug. 13th, 1877), lower lid shows remains of ecchymosis. appearance, some days after the injury, of a very limited Vision: right, 2 Jaeger and 2 ; left, 1 Jaeger easily and but perfectly defined ophthalmoscopic change (expressing H (sic). On ophthalmoscopic examination (after atropine) itself subjectively by a corresponding patch of dimness in no opacity can be found by the most persevering search in the visual field). Moreover this change occurred at a part the vitreous. Doubtful slight haze about yellow spot; reof the fundus where the haze typical of " commotio retinae" fraction hypermetropic. had never been present. Probably this spot of disease reCASE 10. Blow on eye; mydriasis and weakening of acpresented a little patch of choroiditis leading to exudation c01nmodation; defect of sight at first sligld, butincreasiufj upon its inner surface, but whether set up by a subchoroidal afew dayslater.-Susan A-, aged twenty-four. Severe extravasation or not remains doubtful. blow by the fist on the right eye ten days ago. On admisCASE 5.-In September, 1876, I was asked to examine a sion (April 21st, 1875), there was ecchymosis of lids and of policeman who was under the care of Mr. Brudenell Carter, ocular conjunctiva at outer part ; pupil wide ; the outer my then colleagues at the South London Ophthalmic part of the iris, corresponding to the ecchymosed conHospital. About three months before he had received a junctiva, is greenish. Vision : right, 1 Jaeger at 12" only, blow on the eye by a stone. Between the disc and yellow and 5 ; left, 1 Jaeger, p. 9", r. 12", and 4 s. No opacities spot were two small well-defined patches of superficial dis- in vitreous.-28th : Sight of right much worse, and has had ease of the choroid, on which the epithelium was disturbed burning pain at the back of the eye. Pupil now of same and partly removed. Though the case is incomplete, it may size as and active. Vision of right only 18 Jaeger be placed side by side with those just narrated. badly, and 20/200, not improved by glasses. Ophthalmoscopic The next is a very good instance of uncomplicated appearances (after atropine) normal. No later note. "commotio retinae" seen quite early, but of which the final state is not known with certainty. ROYAL MEDICAL BENEVOLENT FUND SOCIETY Of CASE 6.-Joseph M-, aged nineteen, came to the Eye Department towards the end of last September, four hours IRELAND.-The annual meeting of this society was held after having received a blow on one eye by a portion of a last week at the College of Physicians, and from the annual large iron "nut,""about as large as two walnuts," which report it appears that there has been a falling off in the and income and an increased number of applicants. The total he was cutting out. Vision with the damaged eye 10 Jaeger at from 3" to 9", an abrasion of the lowest part of number of applications for relief this year was 115, twenty the cornea not encroaching on the pupil, and a small non- of which were new ones, seven being from medical men, perforating wound at the sclero-corneal junction; aqueous thirteen from widows, and two from orphans. The comrather blood-stained; pupil partly dilated (4’5 mm.) and mittee have allocated grants to the amount of 1165, which, oval downwards, dilating fully to atropine; media clear; together with £ 280 7s. 6d. of anticipatory grants, make the well-marked white deep-seated opacity of the retina over distribution of the year i1445 7s. 6d. Dr. Denham, in the lower half of the yellow-spot region, the vessels standing seconding a resolution, lamented the apathy of the proout by contrast with excessive distinctness; towards the fession in the provinces in respect of the Society, and fovea centralis (which was unaffected) the opacity was suggested that in an Act dealing with medical matters sharply defined, but towards the periphery it faded away a clause should be introduced to compel dispensary prac. quite gradually; the upper half of the yellow-spot region titioners to subscribe to the Fund. eye not
=
corresponding exactly
was "bluish"
pupil
"
"
left,
bability,
Clinical Lecture
disease of the
were
more especially to draw My object to-day, however, your attention to another series of cases in which an injury, of just the same kind, has an entirely different SOME EFFECTS OF BLOWS UPON apparently I allude to the cases or sometimes an additional effect. which havebeen described under the title of " Commotio THE EYEBALL. retinae," in which the defect of sight, sometimes temporary, Delivered in the Eye Department of St. Thomas’s occasionally permanent, caused by a blow, is accounted for Hospital, Oct. 1879, neither by paralysis of accommodation nor visible intraocular hsemorrhage or rupture, and in which there are someBY EDWARD NETTLESHIP, times really no ophthalmoscopic changes. Berlin of StuttOPHTHALMIC SURGEON TO THE HOSPITAL. gart was, I believe, the first to give a full account of the ophthalmoscopic changes and clinical and pathological chaGENTLEMEN, - Severe blows on the eyeball by blunt racters of these cases. He disbelieves in " commotio retinse" objects are very often followed by dilatation of the pupil as the cause of the visual defect, and attributes the moderate and paralysis of the accommodation. It seems that in many amblyopia, which he states is usually noticed, to transient cases both the circular and radiating fibres of the iris are irregular astigmatism from changes in the form or position of the crystalline lens consequent on the blow. Immediately affected, since not only is the pupil somewhat enlarged after the blow, according to Berlin, central vision is lowered (paralysis of sphincter), but the use of atropine fails to effect from -î-%to or 15 This is followed in an hour or two complete dilatation (paralysis of radiating fibres). It may by a cloudy white opacity of some part of the retina, or be added that the pupil is often oval or subangular, instead sometimes of two separate areas, occasionally with minute haemorrhages ; this haze attains its maximum in twenty-four of round. to thirty-six hours, and in from forty-eight to seventy-two is not often that we have of the It the opportunity noting has usually quite disappeared. The same changes were interval between the blow and the onset of the symptoms andin these produced the eyes of referred to. In the case of an old man of seventy-one animals a layer of blood was always found between the (Wm. W——), however, whom I saw within twenty minutes choroidand scleroticcorresponding tothe area or areas of of a tipcat blow, I found the pupil inactive to light, and retinalhaze; the hazy retina wasin a state of "simple with foldingsand fissuresrunning perpendilating incompletely to atropine. At his age paralysis of acutecedema,"surfaces. His reasons for dissociating the the ciliary muscle would of course be undiscoverable. Whatfailure of vision from the observed changes in the retina, and ever may be the pathology of this condition, there is little from their cause, the subchoroidal haemorrhage, are-(1) that reason to doubt that the paralysis or paresis of the ciliary vision improves rapidly (to a certain point) within the first muscle and iris usually passes away completely, for patients day or two, at the very time when the retinal opacity is still with uncomplicated traumatic cycloplegia seldom remain on the increase; (2) that this improvement does not afterwards pace with the disappearance of the visible retinal long on our hands. The symptoms, however, may be pro- change,keep vision as low as fromz toremaining for some longed, and even permanent, as the following two cases days after the retina has cleared ; (3) he has seen a precisely show :— similar defect of vision in two cases after blows, without the CASE 1. Mydriasis persisting three months after a severe slightest ophthalmoscopic change, and therefore, as he supblow on the eye.-Henry W-, aged forty-six, was knocked poses, without the occurrence of the subchoroidal haemorinsensible for ten minutes by the rebound of a piece of wood rhage. as thick as the wrist which he was chopping, the stress of’ It appears to me, however, more probable that the changes the blow falling, as he believed, on the left eye. There in the retina (doubtless due, as Berlin states, to cedema with was some swelling of the lids, but no "blackening" foldings and fissures of the rod- and cone-layer, and proeither of them or eye. He had always considered the duced by the subchoroidal haemorrhage) do, after all, furnish left the better eye. Two and a half weeks after the acci- the true explanation of the failure of sight without appealdent the pupil of the injured eye was considerably dilated, ing to traumatic changes in the lens. I am the more inirregularly oval, and motionless to light ; eyeball rather clined to this view since in one of the cases I shall relate a congested, and a patch of infiltration in the cornea. Myopia temporary opacity of the retina, like that described by 1 ; vision= 7 ° ; accommodation not carefully tested. Right Berlin, with some amblyopia, was followed in three weeks patch of disease in another part of the fundus ; eye : myopia 2B; vision= No ophthalmoscopic changes by a definite in the injured eye. Six weeks after the accident the left although in the interval between the resolution of the pupil, still dilated, was now circular, and acting a little to primary retinal haze and the appearance of this patch the light; and the eye showed no defect either of visual acute- amblyopia persisted, during which no visible changes were ness or of accommodative power, as compared with its fellow. present. The first case of the so-called "commotio retinae" that I At the end of three months the pupil had not altered from the last note; it was observed also that it dilated very saw was published in THE LANCET, Aug. 21st, 1875 :CASE 3.-A man, aged thirty-seven, received a severe little more when covered, whilst its fellow acted freely and on his left eye from a lump of iron ; ten days later blow quickly. The next case was of considerable interest and importance, vision (with H. i3, corrected) =; six months after the inand 6 Jaeger, the other eye 219, and 1 Jaeger ; no the question being whether the state of his eye was due to a jury former injury or was a sign of disease of the nervous system. ophthalmoscopic changes ; eye believed to havebeen perfect CASE 2. Se1-’cre fist-blow on right eye, eleven ycars; en- until the blow. In this case there is no precise note as to largC1ncnt of pupil and paresis of accommodation ; doubtful the character of the defect of sight, but in the next case the S notes and examination were much more complete. sg7aptous of syphilitic disecase of ne>voussJstena.-Vm. CASE 4.-Master W-, aged fourteen, was sent to me by aged thirty-four, avery ansemic man, easily fainting, was sent over to me by Dr. Greenfield, for my report on the cause of the! Dr. Bristowe on Oct. 1st, 1879,just fifteen hours after a blow inequality of his pupils, the man having lately been an in- on his right eye by the ferule end of a walking-stick thrown patient of the hospital for nervous symptoms of uncertain endwise across the room. The eyewas congested and very and nature. Eleven years ago he had had a severe blow on his tender, no abrasion of cornea, tension normal ; vision right eye by a fist. Both the pupils acted fairly to light, words of 3 Jaeger; pupil rather smaller than the other even in both together and separately; but whilst the left was of bright light, dilating very little when shaded, though expandaverage size, the right was alwaysnearly twice as wide. ing widely to one drop of atropine, but not quite round ; iris The accommodation was difficult to test since he was looking healthy. Iedia clear; retina over a wide area in astigmatic, and the refraction differed in the two eyes ; as, the lower outer part towards the periphery, quite hazy however, after allowing for this difference, he required a and whitish, the change being beneath the vessels, rather stronger glass for reading with the injured eye, the: consequently were preternaturally distinct. By the most accommodation was probably affected. There were no oph- careful estimation of the refraction, however, I was unable thalmoscopic changes. Though he did not know how long. to prove that the whitened area was elevated (H. 2’T in all the condition had been present, I thought the change in the parts) ; slight doubtful haze of retina at yellow spot. Six pupil and accommodation attributable, with great pro- days later (after leeching, ice, and confinement in the dark), ON
experimentally
in
*
rabbits,
dicularly to its
the
.
,
.
No. 2964.
which
942
congested; the retinal haze described above has was natural; the hazy area was not measurably raise4 quite disappeared; at the yellow spot region just above and above the surrounding level. At the next visit (Sept. 23rd; outside the fovea centralis, a small patch of doubtful change the retinal haze was less marked, and a few days later it of the choroidal epithelium; vision (under atropine) 12 had further much diminished in extent. He did not attend H. -io = H, + 10 6 or 8 Jaeger barely, and only at the again, and I have been unable to trace him. I will conclude this lecture by citing some cases which sides of the page. He now told me that there was a mist over the middle of everything he looked at, and that if he were less completely noted, but were probably all instance!looked at the middle of his finger he could not see it. On of the same kind. As, however, none of them came under trial with two candle flames, the one at which he looked ap- care until after the period assigned for the disappearance of peared duller than the other placed a few inches apart from the transient retinal opacity in commotio retinue," this it, but nowhere on the defective part was perception of light point remains unproved. It would seem that usually the damage to sight in "comanything like abolished. With the perimeter the defect (scotoma) was easily mapped out; it was nearly round, of motio retinae " is but temporary, for the cases do not remain about 3° aperture, and almost central, its densest part under care long, nor do we find them returning for advice being downwards and inwards from the fixation point-i.e., long afterwards. But before we can pronounce with certo thelittle spot of doubtful choroidal tainty it will be necessary that a larger number of case change. The scotoma was only relative, nowhere absolute ; should be carefully followed up. within itsareawhitelookedvery dull ; red was invisible on CASE 7. Blow by a piece of iron; defect of sight 1ât1Wllt its densest part, elsewhere on its S--, aged forty ; a week ago right eye changes.-Ellen beyond area "reddish," its area "bright red green on the densest struck by a piece of iron as large as half a walnut; the eye part, elsewhere "greenish"; dark blue was scarcely visible was red but not "black." On admission, Aug. 11th, 1877, on any part of the scotoma. A fortnightlater (Oct. 21st) eye irritable; vision : right, 6 Jaeger badly, p. 8" and .2k,; remains larger than the other (as 4’5 mm. to 3 mm.), vision : left, 1 Jaeger fairly, p. 8" or 10" and 2-161. No change but circular and quite active (no atropine for fourteen days). in cornea, aqueous, or iris ; pupil and accommodation Vision 4 slowly, and words of 10 Jaeger slowly ; the scotoma normal. No ophthalmoscopic changes (erect image), except just covers short words such as " when," and in order to see rather pronounced white lines along the arteries on the disc, he looks a little to his right of the object. The little patch which were probably normal. Only attended once. CASE 8. Slight defect following a blow)’ doubtful haze of of doubtful choroidal change at yellow spot has now become retina at yellow spot.-Henry F-- (boy), severe blow on a well-defined white patch of the same size (? choroidal On Nov. 19th (seven weeks after blow) right eye by a stone eight days ago. On admission (June, or deposit). atrophy vision 12slowly, and 1 Jaeger well; the scotoma still ap- 1877), complains that he sees " a skin" over everything with parent as " a little white spot" if he looks for long at any- the injured eye; yet he makes out 1 Jaeger with it as well thing, and seen most easily when looking at distant objects. and at as short a distance as with the other (cannot read The pupil is still rather larger than the other; it acts well fluently); pupils equal and quite active. with accommodation, but dilates and contracts less actively 26th.-Ophthalmoscopic examination (eye fully atropised), to light than the other. The white spot of disease at retina around yellow spot unusually grey and reflecting, but the macula lutea is smaller, and is now quite bright, like a the appearance may be no other than the natural "halo’’ spot of fatty change in the retina; close to it the choroid is or watered-silk appearance so common in children. No rather disturbed. On Dec. l8th (nearly three months after later note. It is quite possible that the " skinmentioned the accident) scotoma still apparent as a little white spot, or by this boy was caused by a central scotoma, slight in spot of mist, on the limb of a letter of 20 Snellen, seen at degree. twelve feet. The spot of disease still present, but smaller ; CASE 9. brow on eye, followed by a fixed musC( (? cent1Y!C He considers his sight perfect. no disease elsewhere. scotoma); doubtful ophthalmoscopic changes.-Sarah W-, This case is instructive as a good example of Berlin’s aged forty-five, struck her right eye with a stick ten days "commotio retinae,"typical both as to the early and wide- ago, and has since then seen " a little black thing like a bit spread retinal haze and the rapidity with which this dis- of dirt floating at a distance from the eye." On admission appeared. It is also important on account of the gradual (Aug. 13th, 1877), lower lid shows remains of ecchymosis. appearance, some days after the injury, of a very limited Vision: right, 2 Jaeger and 2 ; left, 1 Jaeger easily and but perfectly defined ophthalmoscopic change (expressing H (sic). On ophthalmoscopic examination (after atropine) itself subjectively by a corresponding patch of dimness in no opacity can be found by the most persevering search in the visual field). Moreover this change occurred at a part the vitreous. Doubtful slight haze about yellow spot; reof the fundus where the haze typical of " commotio retinae" fraction hypermetropic. had never been present. Probably this spot of disease reCASE 10. Blow on eye; mydriasis and weakening of acpresented a little patch of choroiditis leading to exudation c01nmodation; defect of sight at first sligld, butincreasiufj upon its inner surface, but whether set up by a subchoroidal afew dayslater.-Susan A-, aged twenty-four. Severe extravasation or not remains doubtful. blow by the fist on the right eye ten days ago. On admisCASE 5.-In September, 1876, I was asked to examine a sion (April 21st, 1875), there was ecchymosis of lids and of policeman who was under the care of Mr. Brudenell Carter, ocular conjunctiva at outer part ; pupil wide ; the outer my then colleagues at the South London Ophthalmic part of the iris, corresponding to the ecchymosed conHospital. About three months before he had received a junctiva, is greenish. Vision : right, 1 Jaeger at 12" only, blow on the eye by a stone. Between the disc and yellow and 5 ; left, 1 Jaeger, p. 9", r. 12", and 4 s. No opacities spot were two small well-defined patches of superficial dis- in vitreous.-28th : Sight of right much worse, and has had ease of the choroid, on which the epithelium was disturbed burning pain at the back of the eye. Pupil now of same and partly removed. Though the case is incomplete, it may size as and active. Vision of right only 18 Jaeger be placed side by side with those just narrated. badly, and 20/200, not improved by glasses. Ophthalmoscopic The next is a very good instance of uncomplicated appearances (after atropine) normal. No later note. "commotio retinae" seen quite early, but of which the final state is not known with certainty. ROYAL MEDICAL BENEVOLENT FUND SOCIETY Of CASE 6.-Joseph M-, aged nineteen, came to the Eye Department towards the end of last September, four hours IRELAND.-The annual meeting of this society was held after having received a blow on one eye by a portion of a last week at the College of Physicians, and from the annual large iron "nut,""about as large as two walnuts," which report it appears that there has been a falling off in the and income and an increased number of applicants. The total he was cutting out. Vision with the damaged eye 10 Jaeger at from 3" to 9", an abrasion of the lowest part of number of applications for relief this year was 115, twenty the cornea not encroaching on the pupil, and a small non- of which were new ones, seven being from medical men, perforating wound at the sclero-corneal junction; aqueous thirteen from widows, and two from orphans. The comrather blood-stained; pupil partly dilated (4’5 mm.) and mittee have allocated grants to the amount of 1165, which, oval downwards, dilating fully to atropine; media clear; together with £ 280 7s. 6d. of anticipatory grants, make the well-marked white deep-seated opacity of the retina over distribution of the year i1445 7s. 6d. Dr. Denham, in the lower half of the yellow-spot region, the vessels standing seconding a resolution, lamented the apathy of the proout by contrast with excessive distinctness; towards the fession in the provinces in respect of the Society, and fovea centralis (which was unaffected) the opacity was suggested that in an Act dealing with medical matters sharply defined, but towards the periphery it faded away a clause should be introduced to compel dispensary prac. quite gradually; the upper half of the yellow-spot region titioners to subscribe to the Fund. eye not
=
corresponding exactly
was "bluish"
pupil
"
"
left,