be soft, pulpy and rather innocuous. Now is the time for a wide and deep incision through capsule and cortex, followed by the same medication used after the first discission. This will usually cause complete absorption. If the posterior capsule remains opaque after all cortex is absorbed, discission for secondary cataract may be done, and usually with complete and final success.

The following case illustrates many of the points touched upon above: F. A., aged 24 years, was struck in the right eye on May 18, 1906, by a breaking violin string. In a week the lens was entirely opaque and the slight inflammation of the eye had subsided. There was no evidence of injury to the cornea, conjunctiva or anterior capsule when the patient first came for examination, Aug. 2. On Sept. 27 a needle-knife was entered near the outer limbus of the cornea, an incision of 2 1-2 millimetres was made in the capsule, and the cortex was gently stirred. The slight reaction was readily subdued with 1-2 per cent atropia solution used for a few days. Absorption commenced at once, and, aided by instillations of 5 per cent dionin solution three times a week, progressed favorably for two months, when it seemed at a standstill. Vision had risen to recognition of hand movements and ability to enter or leave a room.

On Dec. 3, a broad horizontal discission was made through both capsules. The mushy lens matter which gushed out and covered the lower third of the iris and filled two-thirds of the pupil, caused only a moderate iritis, easily controlled by atropia. A week later instillations of 5 per cent dionin every two days were commenced and continued for four weeks; then followed the use of 2 per cent dionin every three days for three weeks.

Examination on Jan. 7 showed that all lenticular cortex and one-third of the capsule had been absorbed, and that visjon had risen to 1-2 for distance and near, with the use of appropriate lenses. On March 16, 1907, vision was normal for all distances, with proper glasses, the pupil was black, the iris reacted normally, and only a very narrow peripheral ring of capsule remained, being visible when the pupil was dilated.

NUCLEAR OCULAR PARALYSIS.

By E. W. STEVENS, M.D,,

Denver, Colo.

Under the names of polioencephalitis superior, ophthalmoplegia and nuclear palsy is described a primary disease of the orbital nerve nuclei in the central gray matter of the aqueduct of Sylvius and floor of the fourth ventricle.

The term ophthalmoplegia was first used by Brunner in 1850, while von Graefe, in 1856 (Arch. f. Oph.) first pointed out the nature of these cases. In 1868 von Graefe (Berl. Klin. Woch.) described the disease under the name of ophthalmoplegia progressiva and compared it with labio-glossal palsy. The cases seen by von Graefe were those of bilateral paralysis of all the exterior ocular muscles without involvement of the sphincter irides and ciliary muscles, and he therefore fell into the error of believing this condition to be constant and characteristic of the affection.

The first published case presented, according to von Graefe, the following clinical picture:

"Gradually all the muscles concerned in the movements of the eye become paralyzed, causing first a diminution in the range of sight, and finally resulting in complete immobility of the eyeballs. The levator palpebrae superioris is wont to be implicated, although the consequent ptosis is rarely as marked as that occurring in complete oculo-motor paralysis. It is remarkable that, on examination for reaction to light and accommodation, the sphincter pupillae, as well as the ciliary muscles, present no changes. This condition, which we very rarely find in other extensive oculo-motor paralyses, seems here constant and characteristic of this disease. Another feature which distinguishes this form from other associated paralyses in the distribution of the third, fourth and sixth nerves, is the progress of the disease pari passu in the antagonizing muscles. Thus we never find a marked strabismus divergens owing to a dominating oculo-motor paralysis, because here the external rectus muscle loses its functions sufficiently to neutralize the tendency to deviation, and the sight of the patient is therefore, in spite of the associated paralysis of the eye muscles, affected much less than in simple oculomotor or abducens paralysis.

Still a certain degree of asymmetry in the affection of the different muscles of one eye, as well as in the development of the whole disease in the two eyes, may at times be found."

Wernicke (Lehrbuch der Gehrink., II. S. 229) first accurately described the acute form of this affection, and believing

it was caused by an inflammation of the nuclei of the muscles, applied to it the term polio-encephalitis superior to distinguish it from a similar disease of the lower nuclei in the medulla, polio-encephalitis inferior. Gowers (Diseases of the Nervous System, Vol. II, p. 194) thinks this name open to many objections, both theoretical and practical, and points out that the affection may be due to toxic influences without causing visble changes on post mortem. In 1878, Jonathan Hutchinson (Med. Chirg. Trans.) first used the term ophthalmoplegia interna to designate those cases in which the interior muscles only of the eyeball-the sphincter irides and cliiary muscles-were paralyzed, and in 1879 he directed attention to ophthalmoplegia externa (Med. Chirg. Trans., Vol. 62, page 308), applying this term to these cases characterized by symmetrical progressive paralysis of the external muscles.

Hutchinson's classification is not now very generally maintained, because the two sets of muscles may be affected at the same time. Neither does the symmetrical character of the palsy always exist, innumerable combinations and varieties being encountered as one or more nuclei are partially or completely affected.

The term nuclear palsy as employed by Gowers is open to few objections and appears to be coming into general use.

Nuclear ocular palsy is usually met with as a primary disease, but it sometimes occurs as a complication of other diseases of the nervous system, as locomotor ataxia, disseminated sclerosis, general paralysis and exophthalmic goitre.

The palsy may be either acute, sub-acute or chronic. It is sometimes congenital and non-progressive, cases of congenital ptosis which are so frequently combined with loss of power in the superior rectus, being of this nature. Primary nuclear palsy may be limited to one eye, but in the majority of cases both eyes are affected. It may affect the interior muscles only, or the exterior muscles only may be involved, or both of these sets of muscles may be paralyzed. The paralysis of both sets of muscles may be complete or incomplete, giving almost innumerable combinations and varieties as one or more nuclei are partially or completely affected.

Probably the most common case is that of chronic complete palsy of the external muscles of both eyes (Swanzy). Chronic nuclear palsy may appear soon after birth or in the early years of life and may remain stationary all through life or become progressively worse, until all the nuclei are involved. Rarely it extends to the lower nuclei in the medulla. Usually the internal muscles of the eye escape and ptosis is

also rather uncommon. At the beginning diplopia is complained of, but after a short time it usually disappears. The progress of chronic nuclear palsy generally covers a number of years, during which time the general health is not affected, excepting in isolated cases, where the disease spreads to the bulbar nuclei, and the symptoms of bulbar palsy with a fatal result is seen. In partial cases the ocular palsy may be unilateral. The sixth nerve may at first escape or be first involved. The evolution of the disease is one of its most distinctive features. Commencing with a squint or a slight ptosis, the other features of this affection are added during perhaps several years. Stationary periods often of long duration-twenty-five years in a case of Strampell-may intervene, and finally the disease take up its progressive course until the nuclei of all the external and internal ocular muscles are affected, when, as Gowers graphically says, the immobile eyes and inactive pupils are like those of glass in a mask of wax.

The disease may appear, however, as a complication of some spinal or cerebro-spinal disorder. It is not an uncommon symptom in the prodromal stages of locomotor ataxia. It is also met with in multiple sclerosis and in general paresis.

Acute or sudden nuclear ocular palsy is the form first described by Wernicke under the name of polio-encephalitis superior. The position taken by Wernicke that the disease is a wholly analogous affection to poliomyelitis and other inflammatory affections throughout the brain stem has been amply borne out by subsequent observations. Chronic alcoholism and influenza are its nearly constant causes. The onset of this form of nuclear palsy is very rapid and is usually accompanied by headache, somnolence, delirium, vertigo, vomiting, painful cramp in the extremities and unsteadiness of gait. In a few of the reported cases there was optic neuritis. The symptoms increase rapidly in violence and the patient dies in from two to fifteen days, recovery having occurred in but a few cases.

The sub-acute form of the disease comes on less suddenly, progresses more slowly, and is capable of terminating in complete or partial recovery within a few weeks or months.

The primary cases of nuclear palsy have as their most common cause syphilis and alcoholism. The sub-acute forms are found in infections as diphtheria, scarlatina, typhoid fever, influenza, lead intoxication and tobacco poisoning. In many cases no cause can be assigned, as no lesion has been discovered on post mortem.

In chronic nuclear palsy there may be found on post mortem examination simple atrophic degeneration of the cells of

the nuclei, but the entire motor neuron often undergoes degeneration. In the acute and sub-acute forms there has been found hemorrhages, softening the result of thrombosis, acute hemorrhagic inflammation, and acute or chronic inflammatory degeneration of the cells of the nuclei. In both forms, cases have been observed which presented no visible post mortem changes. Nuclear ocular palsies are to be differentiated from derangements of the motions of the eyeballs, due to lesions situated in the following situations: (1) Central lesions-lesions situated in the cortex cerebri, or between the latter and the nuclei of the ocular nerves; (2) fascicular or radicular lesions-lesions which attack the roots or fibers of the ocular nerves in the crus cerebri or pons after they leave their nuclei and before they appear at the base of the brain at their apparent origins; (3) basal lesions-lesions which attack the trunks of the nerves at the base of the brain between the pons and the sphenoidal fissure; (4) orbital lesions.

All motions of the eyeball which are governed by the cerebral cortex are binocular and associate, or as they are more commonly termed, congugate, i. e., both eyes look upward, downward, to the right or left simultaneously and in equal degrees, hence cortical lesions cause derangements of congugate movements of the eyeballs, but never of isolated eyeball muscles. (There can be no doubt, however, that a separate cortical center for the levator palpebrae superioris exists. This center is situated, according to Kines, in front of the upper extremity of the ascending frontal convolution. close to the arm center. A destructive lesion of this center causes ptosis of the opposite eyelid. According to Swanzy, cortical ptosis is not uncommon).

The importance of the symptom of congugate deviation of the eyes due to an apoplectic attack was first pointed out by Prevost in 1868. Congugate deviation may be due to tumor or other diseased state. It is usually a fleeting symptom and in cerebral hemorrhages passes away as a rule in a few hours. Congugate deviation is to be distinguished from congugate paralysis due to lesions involving the nucleus of the seventh nerve. The rule is, according to Prevost, that in destructive lesions of the hemisphere the eyes are drawn away from the paralyzed side, but in destructive lesions of the sixth nucleus the eyes are drawn towards the paralyzed side. According to Swanzy, congugate lateral paralysis is the only form of congugate paralysis which is caused by primary nuclear disease. The cortical forms, other motions of the eyes being retained, have been noted with tumors of the quadrigeminal region only.

Fascicular or radicular paralysis of the third nerves is