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Joint Meeting of the Chicago Ophthalmological and the Chicago Neurological Societies
SOCIETY PROCEEDINGS D I S C U S S I O N . — D r . Stanford said t h a t the tension w a s the s a m e in each eye and advised r e m o v a l . D r . S i m p s o n advised the s a m e . D r . F a g i n said t h a t this boy had been in the s t a t e school for the blind, altho left eye vision w a s 20/20. Faint Opacity of Cornea and Chorioretinitis. DR. FAGIN presented a young man of 16, w h o had only light perception in r i g h t eye. T h e p a t i e n t denied ever h a v i n g had pain or inflammation in the eye and claimed t h a t the vision had been poor all his life. T h e left eye w a s normal'. T h e r i g h t pupil was dilated with h o m a t r o p i n a n d a faint opacity of the cornea in its center was visible. T h e r e w a s a m a r k e d chorioretinitis in the m a c u l a r region. T h e teeth were p e g shaped and a l m o s t typically H u t c h i n son in character. F a m i l y history nega tive. W a s s e r m a n n t o d a y negative. D I S C U S S I O N . — D r . L e w i s t h o u g h t it a beautiful and typical case w i t h H u t c h i n s o n teeth. D r . Ellett said that t h e r e was a healed interstitial k e r a t i t i s and said t h a t we p r o b a b l y overlook t h e eyeg r o u n d in cases of interstitial kerati tis. l i e thinks n o t h i n g of one negative Wassermann. Dr. Blue s u g g e s t e d the exhibition of K I and t h e n t r y i n g a n o t h e r W a s s e r mann. EDWIN
D.
WATKIXS,
Secretary.
J O I N T M E E T I N G OF T H E CHICA GO O P H T H A L M O L O G I C A L A N D T H E CHICAGO N E U ROLOGICAL SOCIETIES. D e c e m b e r 16, 1920. DR.
ALFRED N.
MURRAY, C H A I R M A N .
Polioencephalitis Superior and Inferior. D R . G. B. H A S S I N reported the case of a y o u n g m a n , 21 y e a r s of age, an imbecile since early childhood, w h o entered the neurologic service of the Cook C o u n t y H o s p i t a l , c o m p l a i n i n g of inability to swallow (six w e e k s ' dura t i o n ) , to j u d g e distance (since child hood) and speech troubles. T h e ex a m i n a t i o n revealed a p a r a l y s i s of all the cranial nerves (from the third to
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the t w e l f t h ) , inability to j u d g e distance ( d i s t u r b a n c e of spatial s e n s e ) and m a r k e d defects in speech ( d y s a r t h r i a ) and deglutition (dysphagia). The clinical picture w a s t h a t of o p h t h a l m o plegia and b u l b a r paralysis. T h e sen sibility reflexes, including the pupil lary, the g e n i t o u r i n a r y o r g a n s were all normal. T h e p a t i e n t died s u d d e n l y t w o d a y s after his admission to the hospital. T h e histologic e x a m i n a t i o n of v a r i o u s por tions of the brain s h o w e d m a r k e d de g e n e r a t i o n of the g r a y m a t t e r , especial ly of the m i d b r a i n and medulla, and proliferative c h a n g e s in the glia tissue. T h e l a t t e r s h o w e d a g r e a t w e a l t h of p r o t o p l a s m i c glia cells, various t y p e s of gitter-cells, m a n y gliogenous forma tions, such as m y e l o p h a g e s , and abundance of fat like substances with in g i t t e r cells. Infiltrative inflamma tory phenomena and hemorrhages were absent. Occasionally scattered red cells, m o s t l y enclosed with glioge n o u s formation, could be seen w i t h i n the c h a n g e d glia cells. T h e d e g e n e r a t i v e c h a n g e s in the g r a y s u b s t a n c e were in the form of c h r o m a t o l y s i s , n e u r o p h a g i a , fat infil t r a t i o n , broken up myclin, etc. T h e cortical a r e a s were also involved, es pecially in the occipital lobe, the a n g u lar g y r u s , c u n e u s a n d p r e c u n e u s . T h e pia arachnoid, in this region of the brain, showed e n o r m o u s l y distended m e s h e s infiltrated with mesothclial cells, g i t t e r cells and a b u n d a n c e of hemorrhagic foci. Fat like substances were also found in the choroid plexus. T h e third nerve showed signs of sec o n d a r y d e g e n e r a t i o n , in its early s t a g e s ; n a m e l y , an a b u n d a n c e of socalled Marchi globules enveloped by proliferated glia tissue (Schwann cells). T h e h i s t o p a t h o l o g i c c h a n g e s gener ally resembled those to be found in de g e n e r a t i v e diseases of the n e r v o u s sys tem, such as a m y o t r o p h i c lateral scler osis, s u b a c u t e cord d e g e n e r a t i o n , mul tiple sclerosis, etc., being, however, es pecially p r o n o u n c e d in the midbrain and medulla. T h e conclusions to be derived from the h i s t o p a t h o l o g i c studies of this case are, (1) t h a t the s u b a r a c h n o i d space
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derives its contents, in this case fat, from the brain tissues proper; (2) that the choroid plexus is probably not so much concerned in the production of the cerebrospinal fluid as in aiding in its purification and rendering it more passable. DISCUSSION.—Dr. Hiram J. Smith said that the causal sites of ocular par alysis in general might be divided into orbital and intracranial. The intracranial might be considered as supernuclear. Nuclear fascicular—that is, fiber from nucleus or deep origin to the sur face, or superficial origin and lesions of nerve trunk between superficial origin and the orbital fissure. In extensive progressive ophthalmoplegia the lesion was nearly always nuclear. Supernuclear lesions, that is, of cortex association centers and intracerebral tracts, caused conjugate paralyses of eye muscles, seldom isolated paralysis, with the exception of ptosis. In this type of conjugate paralysis, the eyes usually were able to turn toward the affected side of the brain, but not to ward the opposite, that is, "look to the lesion," as contrasted with conjugate paralysis of pontine origin, where the eyes might turn from the lesion. Bilateral ophthalmoplegia was not necessarily due to bilateral involve ment of the nuclei. Fibers from the nu clei of a given side passed to the nu clei of the opposite side so that a lesion of the right third nucleus might cause a disturbance of the muscles of the op posite side as ptosis. The affection of the opposite side in a case under ob servation, cleared up in 48 hours, prob ably thru compensatory action of the unaffected nucleus, as the paralysis on the side of the lesion persisted. In progressive nuclear involvement, one would naturally look for adjacent nuclei to be affected at the same time, or in succession, and this happened. The third and fourth, or sixth and sev enth, were involved together, as well as adjacent nuclei of other cranial nerves. The diagnosis of the cause of ocular paralysis might be suggested by the type and extent of the trouble. In nu clear paralysis the underlying neuro
logic affection would be cleared up, us ually thru the finding of other manifes tations than the ocular. The charac teristics of multiple sclerosis were readily perceived. In bulbar paralysis the early involvement of hypoglossus and glossopharyngeus was met with. In myasthenia gravis double ptosis was seen early, but the rapid fatigue of muscles of head and neck, especially muscles of mastication, was character istic. Nevertheless, many obscure clin ical pictures presented themselves. In Dr. Hassin's case he had an opportu nity to observe, postmortem, what was actually taking place during the course of the disease. Dr. Peter Bassoe thought it would be profitable if Dr. Hassin would em phasize the distinction between that disease, polioencephalitis superior and inferior caused by other infections, and the purely degenerative affections of the same regions, A similar problem had been worked out in the case of the spinal cord. For a long time every thing was called myelitis without suffi cient distinctions between inflamma tions, degenerations, and vascular le sions. Dr. H. Douglas Singer stated that according to the statement of the es sayist, the spinal fluid was absorbed apparently both thru the arachnoid villi and thru the choroid plexus. l i e wondered what was the source of the spinal fluid—if it was true that it was absorbed at both sides of the brain. The usual view was that the choroid plexus acted as a gland to secrete the fluid, but Dr. Hassin apparently had an altogether different view. Dr. Michael Goldenburg said that he was under the impression that the spi nal fluid was secreted by the choroid plexus, and that the epithelium cover ing it was merely a filter. Dr. Hugh T. Patrick asked how the fat and epithelial cells in the choroid plexus got there from the spinal fluid, and if anybody had ever found fat in the spinal fluid in this sort of a case. Dr. Hassin, in closing the discussion, said that he did not intend to consider in detail the important physiologic points suggested by the pathologic
SOCIETY PROCEEDINGS
studies of a remarkable case. He merely wished to demonstrate their probable significance. The masses of lipoid substances in the gray matter of the midbrain and medulla were striking, but nobody ever stated the fact of their presence in the subarachnoid space and the choroid plexus. Evidently, fat like substances had not been looked for in these re gions, or proper methods were not used. In fact, very few histopathologic studies of so called hemorrhagic supe rior polioencephalitis had been record ed, the authors contenting themselves with repeating what Wernicke said. Schroeder and Spielmeyer were the first to point out that Wernicke's po lioencephalitis was not an encephalitis at all. In his (Dr. Hassin's) opinion the only true superior polioencephalitis was represented by epidemic (lethar gic) encephalitis in which the inflam matory phenomena were principally, though not exclusively, confined to the midbrain; in the Wernicke's type the morbid process had the same localiza tion, but is of a degenerative, and not of inflammatory character. As to the probable function of the choroid plexus and the spinal fluid, he wished to state that according to some authors, the cerebrospinal fluid origi nates partly in the brain, partly in the choroid plexus. The abundance of fat in both these structures indicated that their contents were wholly derived from the brain tissues. In the case under discussion, these contents were lipoid substances; in cerebral hemor rhage they would be blood pigment and so forth. The choroid plexus, therefore, was to be looked upon as a filter for the cerebrospinal fluid which it rendered passable thru the various channels of absorption. Generally speaking, the study of pathologic brain conditions might help to solve prob lems which so far defied the efforts of the ablest experimental workers. The Pupil in Health. DR. E. V. L. BROWX stated that ac cording to Salzmann the pupil in health had a diameter of approximately 4 mm. The consensual reaction depended
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upon the stimulation of the rods and cones in the relatively small area of the macula. The stimulus was then car ried by the optic nerve to the chiasma, where partial decussation took place, thence via the tractus opticus with the pupillary fibers lying dorsolateral to the corpora quadrigemina, and finally to the nucleus of the oculomotor nerve, which functioned as the pupil nucleus as well, thru the fibers which crossed over from the right to the left side. Therefore any stimulus of the right macula went to the left pupil, as well as to the right and was then sent down the left oculomotor to the sphincter of the iris on each side, the left pupil nar rowing at the same time the right did. This test was of the greatest value in establishing the functional integrity of the most vital part of any injured eye. Many a patient who had just suffered a severe accident to a considerable por tion of the front of his eye could easily and quickly, and honestly, be told that the eye was not lost, even when the cornea was cut, the anterior chamber full of blood, the iris prolapsed or the lens dislocated, for the pupil of the fel low eye narrowed when light was thrown into the injured eye. One ol the uncanny things about the consen sual pupil reaction was the fact that ir. rare instances of disease of the cortex such as tumor of the occipital lobe, etc. the one eye really did not see, or rathei the cortex of neither side saw, yet the pupil motor stimulus was sent up the one optic nerve, across to the other side and down that oculomotor nerve and the pupil of the opposite side narrowed as perfectly as if the light and color and form perception were perfect. Widening of the pupil took place thru irritation of the sympathetic. The pupil widening fibers left the spinal cord at the level of the upper two dor sal and the lower cervical vertebrae. Fibers from the upper thoracic gan glion join with some from the inferior cervical ganglion. Here there is a union with the hypoglossal. The carotid branches were then given off and the pupillodilatator fibers proceeded in the skull to the Gasserian ganglion and united with the first branch of the tri-
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g e m i n u s . So united, t h e y proceeded to the eye via the two long ciliary nerves to the dilator sheet of muscle in the back layers of the iris. T h e y did not p a s s t h r u the ciliary g a n g l i o n at all. A n y irritation of the cervical sym pathetic could, therefore, produce dila tation of the pupil. F u r t h e r m o r e , the irritation or s t i m u l a t i o n of a n y s e n s o r y nerve m i g h t produce a dilatation of the pupil. T h e p a t h here w a s to the cere bral cortex, the oculomotor nucleus and to the iris via the third nerve, cil iary ganglion a n d s h o r t ciliary n e r v e s to the spincter pupillae, which relaxed and allowed the dilatator to w o r k un opposed. F u r t h e r m o r e , the pupil wid ened upon a n y p s y c h i c s t i m u l u s , and volitional impulse and a n y vivid men tal concept. DISCUSSION.—Dr. H. Douglas Singer stated t h a t he often found recorded, " P u p i l s sluggish to light," a n d he had never been able to satisfy himself as t o w h a t m o s t people m e a n t by sluggish ness. Did it m e a n t h a t the reaction w a s slow or t h a t the degree of c o n t r a c tion w a s diminished? In his opinion, as to the pupillary light reflex p a t h w a y , the fibers t h a t conveyed the s t i m u l u s for the light re flex left the optic t r a c t before it reached the pulvinar. T h e y appar ently left in the region of the t h a l a m u s and traveled a l o n g the inner side of t h e t h a l a m u s . T h i s seemed proven to him by t w o cases of t u m o r s seen m a n y y e a r s ago, involving the back p a r t of the third ventricle and d a m a g i n g the optic t h a l a m u s on both sides, in both of which there had been A r g y l l - R o b ertson pupils. D r . H u g h T . P a t r i c k stated t h a t t h e dictum of Uhthoff t h a t even if t h e r e w a s more illumination of the pupil on one side, the pupils remained equal, w a s w r o n g . H e had once v e n t u r e d this opinion in G e r m a n y , and had been corrected with c h a r a c t e r i s t i c Prussian a b r u p t n e s s , but had m a n y times since then c o r r o b o r a t e d his o b s e r v a t i o n s . A n o t h e r curiosity could be referred to as a normal p u p i l : It w a s k n o w n t h a t occasionally an individual could voluntarily dilate his pupil, by pictur ing to himself some peculiarly horrible
scene, generally from his o w n experi ence. D r . P a t r i c k said he would be b e t t e r pleased if D r . B r o w n w o u l d speak of the s e g m e n t s of the cord instead of the vertebrae. D r . Ralph C. H a m i l l said t h a t in t e s t i n g the pupils, especially of colored men with very dark irides, it w a s dif ficult to tell w h e t h e r there w a s a light reflex or not. Dr. B r o w n had men tioned the fact that the near sighted individual had large pupils and he w o n d e r e d w h e t h e r in some individuals where the pupil w a s u n d e r more or less spasm small changes of size would be visible. Also, in t e s t i n g the pupils of a g r e a t m a n y m e n in a s h o r t space of time, as w a s done with some of the m e n in the t r a i n i n g c a m p s , it was ob served t h a t t h e r e were certain kinds of pupils t h a t c o r r e s p o n d e d to the degree of p i g m e n t a t i o n of the iris. Dr. I. T.eon M y e r s t h o u g h t t h a t the influence of the s y m p a t h e t i c n e r v o u s s y s t e m and especially t h a t which w a s noted in e m o t i o n a l d i s t u r b a n c e s , fright, etc., w a s not the only one t h a t b r o u g h t a b o u t dilatation of t h e pupil. I t had been noted m a n y y e a r s a g o t h a t in s t i m u l a t i n g t h e cortex of an animal while it w a s completely a n e s t h e t i z e d and the stimulation w a s s t r o n g e n o u g h to produce epileptiform fits, the pupils would p r o m p t l y dilate. T h i s h a d n o connection w i t h s t i m u l a t i o n of the cor tex, w h e n it produced conjugate devi ation of the head and eyes. Dr. R o b e r t von der H e y d t stated t h a t as to light and dark irides, t h e r e were at least t w o reasons w h y eyes with dark irides did not respond to light as well as those with lighter col ored irides. O n e w a s a s l u g g i s h n e s s in response on account of the weight of the a d d e d p i g m e n t a t i o n in the dark irides. In addition light would pene t r a t e a light colored iris m o r e readily on account of its g r e a t e r t r a n s p a r e n c y , and the retina would receive more stimulation for that reason. D r . I I . W . Woodruff spoke of the s t a t e m e n t m a d e in the s t a n d a r d text books on o p h t h a l m o l o g y t h a t "inequal ity of the pupils w a s a l w a y s p a t h o logic." Reference had already been
SOCIETY PROCEEDINGS made t o the l a r g e r pupil in m y o p i a . T h i s also held when one eye w a s m y opic and one hyperopic, n a m e l y , in anisometropia. In such a case one pupil was distinctly larger t h a n t h e other. W h e n he first b e g a n the practice of o p h t h a l m o l o g y he did not k n o w this and supposed a patient with inequality in t h e pupils m u s t have a serious nerve lesion. F o r this reason, in e x a m i n i n g these cases t h e refraction should be known. Dr. Charles P . Small said t h a t t h e difference in t h e reactions in t h e nor mal pupil were illustrated in a case seen recently. T h e p a t i e n t w a s a m a n in perfect health, with all t h e labora t o r y e x a m i n a t i o n s negative, w h o w a s refused an increase in life i n s u r a n c e because he w a s said t o have an A r g y l l R o b e r t s o n pupil. T h e pupils were widely dilated a n d almost immobile b u t they did react very sluggishly when carefully examined. H e did not know w h y he had such a very feeble reaction, a n d wished some of t h e neu rologists would explain it to him. D r . C. \V. H a w l e y w a s r e m i n d e d of a case similar to D r . Small's which he had reported. H i s patient h a d widely dilated pupils all her life w i t h o u t p u pillary reaction. S u d d e n l y t h e Uft pu pil w a s contracted to t h e usual size and developed reaction. She came t o have t h e pupil dilated to look like t h e other. H e told her to go h o m e a n d p r a y t h a t t h e other would c o n t r a c t like the left. A s to one pupil dilating m o r e w h e n it w a s receiving more light t h a n t h e other, he. had seen a similar case with in t w o or three m o n t h s . D u r i n g t h e e x a m i n a t i o n a friend of t h e p a t i e n t asked w h y one pupil w a s dilated m o r e than t h e other, a n d he t h o u g h t it might be because t h a t eye w a s receiving more light than t h e other. O n t u r n i n g t h e patient a r o u n d he got the opposite ef fect and proved that this t h e o r y w a s correct. Dr. Brown, in closing t h e discussion, in reply to Dr. Singer said he had al w a y s u n d e r s t o o d s l u g g i s h n e s s t o refer to the rate of reaction r a t h e r than t h e degree. H e w a s glad to h e a r Dr. Pat rick emphasize the fact t h a t direction
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of light influenced reaction, d u e to t h e fact t h a t one eye had more s t i m u l u s . D r . von der H e y d t h a d a n s w e r e d t h e question a b o u t t h e p i g m e n t a t i o n and t h e h y p e r m e t r o p i c eye with t h e small pupil. I t should also be noted t h a t iridocyclitis was more frequent in lightly p i g m e n t e d eyes t h a n in heavily p i g m e n t e d ones. ROBKKT V o x
IJKR H E Y D T , Corresp.
Sec.
COLORADO OPHTHALMOLOGICAL SOCIETY. J a n u a r y 15, 1921. W . F. MATSON, presiding.
Capsulotomy After Thirty-three Years. C. E . W A L K E R , D e n v e r , p r e s e n t e d a m a n aged fifty-five y e a r s u p o n whose left eye a c a p s u l o t o m y had been suc cessfully performed t h i r t y - t h r e e y e a r s after injury by a piece of wire, which had passed t h r u t h e cornea and lens. T h e vision of the eye with a plus 11 sphere w a s 20/200. Spontaneous Rupture of L e n s Capsule. C. E . W a l k e r , D e n v e r , presented a m a n , aged sixty-one y e a r s , in w h o m , sixteen y e a r s after c a t a r a c t e x t r a c t i o n , complete s p o n t a n e o u s r u p t u r e of t h e posterior capsule of the lens w a s found to h a v e occurred. T h e posterior cap sule had been u n r u p t u r e d a t t h e origi nal operation. T h e vision of t h e eye at t h e time of report w a s light percep tion. Retrobulbar Neuritis. W . C. a n d W .
M.
HANK,
Denver,
p r e s e n t e d a w o m a n aged forty-three y e a r s w h o had been presented a t t h e D e c e m b e r m e e t i n g on account of re t r o b u l b a r neuritis, which had begun a b o u t N o v e m b e r 22, 1920. T h e con sensus of opinion at t h e D e c e m b e r m e e t i n g h a d been t h a t t h e e t h m o i d s and sphenoids should be drained. On D e c e m b e r 7 the vision had been R. al most nil, I.. 5/30 —. O n D e c e m b e r 22 s u b m u c o u s resection of the s e p t u m was done, a n d t h e sphenoids were drained. O n D e c e m b e r 23 t h e vision w a s R. c o u n t i n g fingers at t h r e e feet, L. 5/20 —. T h e r e w a s steady i m p r o v e m e n t in the vision, which on Decem ber 30 was R. 2/60, L. 5/7.5 — 2. O n
D.
WATKIXS,
Secretary.
J O I N T M E E T I N G OF T H E CHICA GO O P H T H A L M O L O G I C A L A N D T H E CHICAGO N E U ROLOGICAL SOCIETIES. D e c e m b e r 16, 1920. DR.
ALFRED N.
MURRAY, C H A I R M A N .
Polioencephalitis Superior and Inferior. D R . G. B. H A S S I N reported the case of a y o u n g m a n , 21 y e a r s of age, an imbecile since early childhood, w h o entered the neurologic service of the Cook C o u n t y H o s p i t a l , c o m p l a i n i n g of inability to swallow (six w e e k s ' dura t i o n ) , to j u d g e distance (since child hood) and speech troubles. T h e ex a m i n a t i o n revealed a p a r a l y s i s of all the cranial nerves (from the third to
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the t w e l f t h ) , inability to j u d g e distance ( d i s t u r b a n c e of spatial s e n s e ) and m a r k e d defects in speech ( d y s a r t h r i a ) and deglutition (dysphagia). The clinical picture w a s t h a t of o p h t h a l m o plegia and b u l b a r paralysis. T h e sen sibility reflexes, including the pupil lary, the g e n i t o u r i n a r y o r g a n s were all normal. T h e p a t i e n t died s u d d e n l y t w o d a y s after his admission to the hospital. T h e histologic e x a m i n a t i o n of v a r i o u s por tions of the brain s h o w e d m a r k e d de g e n e r a t i o n of the g r a y m a t t e r , especial ly of the m i d b r a i n and medulla, and proliferative c h a n g e s in the glia tissue. T h e l a t t e r s h o w e d a g r e a t w e a l t h of p r o t o p l a s m i c glia cells, various t y p e s of gitter-cells, m a n y gliogenous forma tions, such as m y e l o p h a g e s , and abundance of fat like substances with in g i t t e r cells. Infiltrative inflamma tory phenomena and hemorrhages were absent. Occasionally scattered red cells, m o s t l y enclosed with glioge n o u s formation, could be seen w i t h i n the c h a n g e d glia cells. T h e d e g e n e r a t i v e c h a n g e s in the g r a y s u b s t a n c e were in the form of c h r o m a t o l y s i s , n e u r o p h a g i a , fat infil t r a t i o n , broken up myclin, etc. T h e cortical a r e a s were also involved, es pecially in the occipital lobe, the a n g u lar g y r u s , c u n e u s a n d p r e c u n e u s . T h e pia arachnoid, in this region of the brain, showed e n o r m o u s l y distended m e s h e s infiltrated with mesothclial cells, g i t t e r cells and a b u n d a n c e of hemorrhagic foci. Fat like substances were also found in the choroid plexus. T h e third nerve showed signs of sec o n d a r y d e g e n e r a t i o n , in its early s t a g e s ; n a m e l y , an a b u n d a n c e of socalled Marchi globules enveloped by proliferated glia tissue (Schwann cells). T h e h i s t o p a t h o l o g i c c h a n g e s gener ally resembled those to be found in de g e n e r a t i v e diseases of the n e r v o u s sys tem, such as a m y o t r o p h i c lateral scler osis, s u b a c u t e cord d e g e n e r a t i o n , mul tiple sclerosis, etc., being, however, es pecially p r o n o u n c e d in the midbrain and medulla. T h e conclusions to be derived from the h i s t o p a t h o l o g i c studies of this case are, (1) t h a t the s u b a r a c h n o i d space
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derives its contents, in this case fat, from the brain tissues proper; (2) that the choroid plexus is probably not so much concerned in the production of the cerebrospinal fluid as in aiding in its purification and rendering it more passable. DISCUSSION.—Dr. Hiram J. Smith said that the causal sites of ocular par alysis in general might be divided into orbital and intracranial. The intracranial might be considered as supernuclear. Nuclear fascicular—that is, fiber from nucleus or deep origin to the sur face, or superficial origin and lesions of nerve trunk between superficial origin and the orbital fissure. In extensive progressive ophthalmoplegia the lesion was nearly always nuclear. Supernuclear lesions, that is, of cortex association centers and intracerebral tracts, caused conjugate paralyses of eye muscles, seldom isolated paralysis, with the exception of ptosis. In this type of conjugate paralysis, the eyes usually were able to turn toward the affected side of the brain, but not to ward the opposite, that is, "look to the lesion," as contrasted with conjugate paralysis of pontine origin, where the eyes might turn from the lesion. Bilateral ophthalmoplegia was not necessarily due to bilateral involve ment of the nuclei. Fibers from the nu clei of a given side passed to the nu clei of the opposite side so that a lesion of the right third nucleus might cause a disturbance of the muscles of the op posite side as ptosis. The affection of the opposite side in a case under ob servation, cleared up in 48 hours, prob ably thru compensatory action of the unaffected nucleus, as the paralysis on the side of the lesion persisted. In progressive nuclear involvement, one would naturally look for adjacent nuclei to be affected at the same time, or in succession, and this happened. The third and fourth, or sixth and sev enth, were involved together, as well as adjacent nuclei of other cranial nerves. The diagnosis of the cause of ocular paralysis might be suggested by the type and extent of the trouble. In nu clear paralysis the underlying neuro
logic affection would be cleared up, us ually thru the finding of other manifes tations than the ocular. The charac teristics of multiple sclerosis were readily perceived. In bulbar paralysis the early involvement of hypoglossus and glossopharyngeus was met with. In myasthenia gravis double ptosis was seen early, but the rapid fatigue of muscles of head and neck, especially muscles of mastication, was character istic. Nevertheless, many obscure clin ical pictures presented themselves. In Dr. Hassin's case he had an opportu nity to observe, postmortem, what was actually taking place during the course of the disease. Dr. Peter Bassoe thought it would be profitable if Dr. Hassin would em phasize the distinction between that disease, polioencephalitis superior and inferior caused by other infections, and the purely degenerative affections of the same regions, A similar problem had been worked out in the case of the spinal cord. For a long time every thing was called myelitis without suffi cient distinctions between inflamma tions, degenerations, and vascular le sions. Dr. H. Douglas Singer stated that according to the statement of the es sayist, the spinal fluid was absorbed apparently both thru the arachnoid villi and thru the choroid plexus. l i e wondered what was the source of the spinal fluid—if it was true that it was absorbed at both sides of the brain. The usual view was that the choroid plexus acted as a gland to secrete the fluid, but Dr. Hassin apparently had an altogether different view. Dr. Michael Goldenburg said that he was under the impression that the spi nal fluid was secreted by the choroid plexus, and that the epithelium cover ing it was merely a filter. Dr. Hugh T. Patrick asked how the fat and epithelial cells in the choroid plexus got there from the spinal fluid, and if anybody had ever found fat in the spinal fluid in this sort of a case. Dr. Hassin, in closing the discussion, said that he did not intend to consider in detail the important physiologic points suggested by the pathologic
SOCIETY PROCEEDINGS
studies of a remarkable case. He merely wished to demonstrate their probable significance. The masses of lipoid substances in the gray matter of the midbrain and medulla were striking, but nobody ever stated the fact of their presence in the subarachnoid space and the choroid plexus. Evidently, fat like substances had not been looked for in these re gions, or proper methods were not used. In fact, very few histopathologic studies of so called hemorrhagic supe rior polioencephalitis had been record ed, the authors contenting themselves with repeating what Wernicke said. Schroeder and Spielmeyer were the first to point out that Wernicke's po lioencephalitis was not an encephalitis at all. In his (Dr. Hassin's) opinion the only true superior polioencephalitis was represented by epidemic (lethar gic) encephalitis in which the inflam matory phenomena were principally, though not exclusively, confined to the midbrain; in the Wernicke's type the morbid process had the same localiza tion, but is of a degenerative, and not of inflammatory character. As to the probable function of the choroid plexus and the spinal fluid, he wished to state that according to some authors, the cerebrospinal fluid origi nates partly in the brain, partly in the choroid plexus. The abundance of fat in both these structures indicated that their contents were wholly derived from the brain tissues. In the case under discussion, these contents were lipoid substances; in cerebral hemor rhage they would be blood pigment and so forth. The choroid plexus, therefore, was to be looked upon as a filter for the cerebrospinal fluid which it rendered passable thru the various channels of absorption. Generally speaking, the study of pathologic brain conditions might help to solve prob lems which so far defied the efforts of the ablest experimental workers. The Pupil in Health. DR. E. V. L. BROWX stated that ac cording to Salzmann the pupil in health had a diameter of approximately 4 mm. The consensual reaction depended
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upon the stimulation of the rods and cones in the relatively small area of the macula. The stimulus was then car ried by the optic nerve to the chiasma, where partial decussation took place, thence via the tractus opticus with the pupillary fibers lying dorsolateral to the corpora quadrigemina, and finally to the nucleus of the oculomotor nerve, which functioned as the pupil nucleus as well, thru the fibers which crossed over from the right to the left side. Therefore any stimulus of the right macula went to the left pupil, as well as to the right and was then sent down the left oculomotor to the sphincter of the iris on each side, the left pupil nar rowing at the same time the right did. This test was of the greatest value in establishing the functional integrity of the most vital part of any injured eye. Many a patient who had just suffered a severe accident to a considerable por tion of the front of his eye could easily and quickly, and honestly, be told that the eye was not lost, even when the cornea was cut, the anterior chamber full of blood, the iris prolapsed or the lens dislocated, for the pupil of the fel low eye narrowed when light was thrown into the injured eye. One ol the uncanny things about the consen sual pupil reaction was the fact that ir. rare instances of disease of the cortex such as tumor of the occipital lobe, etc. the one eye really did not see, or rathei the cortex of neither side saw, yet the pupil motor stimulus was sent up the one optic nerve, across to the other side and down that oculomotor nerve and the pupil of the opposite side narrowed as perfectly as if the light and color and form perception were perfect. Widening of the pupil took place thru irritation of the sympathetic. The pupil widening fibers left the spinal cord at the level of the upper two dor sal and the lower cervical vertebrae. Fibers from the upper thoracic gan glion join with some from the inferior cervical ganglion. Here there is a union with the hypoglossal. The carotid branches were then given off and the pupillodilatator fibers proceeded in the skull to the Gasserian ganglion and united with the first branch of the tri-
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g e m i n u s . So united, t h e y proceeded to the eye via the two long ciliary nerves to the dilator sheet of muscle in the back layers of the iris. T h e y did not p a s s t h r u the ciliary g a n g l i o n at all. A n y irritation of the cervical sym pathetic could, therefore, produce dila tation of the pupil. F u r t h e r m o r e , the irritation or s t i m u l a t i o n of a n y s e n s o r y nerve m i g h t produce a dilatation of the pupil. T h e p a t h here w a s to the cere bral cortex, the oculomotor nucleus and to the iris via the third nerve, cil iary ganglion a n d s h o r t ciliary n e r v e s to the spincter pupillae, which relaxed and allowed the dilatator to w o r k un opposed. F u r t h e r m o r e , the pupil wid ened upon a n y p s y c h i c s t i m u l u s , and volitional impulse and a n y vivid men tal concept. DISCUSSION.—Dr. H. Douglas Singer stated t h a t he often found recorded, " P u p i l s sluggish to light," a n d he had never been able to satisfy himself as t o w h a t m o s t people m e a n t by sluggish ness. Did it m e a n t h a t the reaction w a s slow or t h a t the degree of c o n t r a c tion w a s diminished? In his opinion, as to the pupillary light reflex p a t h w a y , the fibers t h a t conveyed the s t i m u l u s for the light re flex left the optic t r a c t before it reached the pulvinar. T h e y appar ently left in the region of the t h a l a m u s and traveled a l o n g the inner side of t h e t h a l a m u s . T h i s seemed proven to him by t w o cases of t u m o r s seen m a n y y e a r s ago, involving the back p a r t of the third ventricle and d a m a g i n g the optic t h a l a m u s on both sides, in both of which there had been A r g y l l - R o b ertson pupils. D r . H u g h T . P a t r i c k stated t h a t t h e dictum of Uhthoff t h a t even if t h e r e w a s more illumination of the pupil on one side, the pupils remained equal, w a s w r o n g . H e had once v e n t u r e d this opinion in G e r m a n y , and had been corrected with c h a r a c t e r i s t i c Prussian a b r u p t n e s s , but had m a n y times since then c o r r o b o r a t e d his o b s e r v a t i o n s . A n o t h e r curiosity could be referred to as a normal p u p i l : It w a s k n o w n t h a t occasionally an individual could voluntarily dilate his pupil, by pictur ing to himself some peculiarly horrible
scene, generally from his o w n experi ence. D r . P a t r i c k said he would be b e t t e r pleased if D r . B r o w n w o u l d speak of the s e g m e n t s of the cord instead of the vertebrae. D r . Ralph C. H a m i l l said t h a t in t e s t i n g the pupils, especially of colored men with very dark irides, it w a s dif ficult to tell w h e t h e r there w a s a light reflex or not. Dr. B r o w n had men tioned the fact that the near sighted individual had large pupils and he w o n d e r e d w h e t h e r in some individuals where the pupil w a s u n d e r more or less spasm small changes of size would be visible. Also, in t e s t i n g the pupils of a g r e a t m a n y m e n in a s h o r t space of time, as w a s done with some of the m e n in the t r a i n i n g c a m p s , it was ob served t h a t t h e r e were certain kinds of pupils t h a t c o r r e s p o n d e d to the degree of p i g m e n t a t i o n of the iris. Dr. I. T.eon M y e r s t h o u g h t t h a t the influence of the s y m p a t h e t i c n e r v o u s s y s t e m and especially t h a t which w a s noted in e m o t i o n a l d i s t u r b a n c e s , fright, etc., w a s not the only one t h a t b r o u g h t a b o u t dilatation of t h e pupil. I t had been noted m a n y y e a r s a g o t h a t in s t i m u l a t i n g t h e cortex of an animal while it w a s completely a n e s t h e t i z e d and the stimulation w a s s t r o n g e n o u g h to produce epileptiform fits, the pupils would p r o m p t l y dilate. T h i s h a d n o connection w i t h s t i m u l a t i o n of the cor tex, w h e n it produced conjugate devi ation of the head and eyes. Dr. R o b e r t von der H e y d t stated t h a t as to light and dark irides, t h e r e were at least t w o reasons w h y eyes with dark irides did not respond to light as well as those with lighter col ored irides. O n e w a s a s l u g g i s h n e s s in response on account of the weight of the a d d e d p i g m e n t a t i o n in the dark irides. In addition light would pene t r a t e a light colored iris m o r e readily on account of its g r e a t e r t r a n s p a r e n c y , and the retina would receive more stimulation for that reason. D r . I I . W . Woodruff spoke of the s t a t e m e n t m a d e in the s t a n d a r d text books on o p h t h a l m o l o g y t h a t "inequal ity of the pupils w a s a l w a y s p a t h o logic." Reference had already been
SOCIETY PROCEEDINGS made t o the l a r g e r pupil in m y o p i a . T h i s also held when one eye w a s m y opic and one hyperopic, n a m e l y , in anisometropia. In such a case one pupil was distinctly larger t h a n t h e other. W h e n he first b e g a n the practice of o p h t h a l m o l o g y he did not k n o w this and supposed a patient with inequality in t h e pupils m u s t have a serious nerve lesion. F o r this reason, in e x a m i n i n g these cases t h e refraction should be known. Dr. Charles P . Small said t h a t t h e difference in t h e reactions in t h e nor mal pupil were illustrated in a case seen recently. T h e p a t i e n t w a s a m a n in perfect health, with all t h e labora t o r y e x a m i n a t i o n s negative, w h o w a s refused an increase in life i n s u r a n c e because he w a s said t o have an A r g y l l R o b e r t s o n pupil. T h e pupils were widely dilated a n d almost immobile b u t they did react very sluggishly when carefully examined. H e did not know w h y he had such a very feeble reaction, a n d wished some of t h e neu rologists would explain it to him. D r . C. \V. H a w l e y w a s r e m i n d e d of a case similar to D r . Small's which he had reported. H i s patient h a d widely dilated pupils all her life w i t h o u t p u pillary reaction. S u d d e n l y t h e Uft pu pil w a s contracted to t h e usual size and developed reaction. She came t o have t h e pupil dilated to look like t h e other. H e told her to go h o m e a n d p r a y t h a t t h e other would c o n t r a c t like the left. A s to one pupil dilating m o r e w h e n it w a s receiving more light t h a n t h e other, he. had seen a similar case with in t w o or three m o n t h s . D u r i n g t h e e x a m i n a t i o n a friend of t h e p a t i e n t asked w h y one pupil w a s dilated m o r e than t h e other, a n d he t h o u g h t it might be because t h a t eye w a s receiving more light than t h e other. O n t u r n i n g t h e patient a r o u n d he got the opposite ef fect and proved that this t h e o r y w a s correct. Dr. Brown, in closing t h e discussion, in reply to Dr. Singer said he had al w a y s u n d e r s t o o d s l u g g i s h n e s s t o refer to the rate of reaction r a t h e r than t h e degree. H e w a s glad to h e a r Dr. Pat rick emphasize the fact t h a t direction
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of light influenced reaction, d u e to t h e fact t h a t one eye had more s t i m u l u s . D r . von der H e y d t h a d a n s w e r e d t h e question a b o u t t h e p i g m e n t a t i o n and t h e h y p e r m e t r o p i c eye with t h e small pupil. I t should also be noted t h a t iridocyclitis was more frequent in lightly p i g m e n t e d eyes t h a n in heavily p i g m e n t e d ones. ROBKKT V o x
IJKR H E Y D T , Corresp.
Sec.
COLORADO OPHTHALMOLOGICAL SOCIETY. J a n u a r y 15, 1921. W . F. MATSON, presiding.
Capsulotomy After Thirty-three Years. C. E . W A L K E R , D e n v e r , p r e s e n t e d a m a n aged fifty-five y e a r s u p o n whose left eye a c a p s u l o t o m y had been suc cessfully performed t h i r t y - t h r e e y e a r s after injury by a piece of wire, which had passed t h r u t h e cornea and lens. T h e vision of the eye with a plus 11 sphere w a s 20/200. Spontaneous Rupture of L e n s Capsule. C. E . W a l k e r , D e n v e r , presented a m a n , aged sixty-one y e a r s , in w h o m , sixteen y e a r s after c a t a r a c t e x t r a c t i o n , complete s p o n t a n e o u s r u p t u r e of t h e posterior capsule of the lens w a s found to h a v e occurred. T h e posterior cap sule had been u n r u p t u r e d a t t h e origi nal operation. T h e vision of t h e eye at t h e time of report w a s light percep tion. Retrobulbar Neuritis. W . C. a n d W .
M.
HANK,
Denver,
p r e s e n t e d a w o m a n aged forty-three y e a r s w h o had been presented a t t h e D e c e m b e r m e e t i n g on account of re t r o b u l b a r neuritis, which had begun a b o u t N o v e m b e r 22, 1920. T h e con sensus of opinion at t h e D e c e m b e r m e e t i n g h a d been t h a t t h e e t h m o i d s and sphenoids should be drained. On D e c e m b e r 7 the vision had been R. al most nil, I.. 5/30 —. O n D e c e m b e r 22 s u b m u c o u s resection of the s e p t u m was done, a n d t h e sphenoids were drained. O n D e c e m b e r 23 t h e vision w a s R. c o u n t i n g fingers at t h r e e feet, L. 5/20 —. T h e r e w a s steady i m p r o v e m e n t in the vision, which on Decem ber 30 was R. 2/60, L. 5/7.5 — 2. O n