est period, which may be placed at twentysix years or more. The period beween the sixth and twelfth week after the injury is the most dangerous, and the usual limit may be considered past after the fourth month. It must be remembered, though, that years after the original injury has been received and the resulting inflammation has run its course and ended in a blind and shrunken ball, that traumatism inflicted on the shrunken ball may rekindle inflammatory action, and this in turn give rise to sympathetic irido-choroiditis in the seeing eye.

FREQUENCY OF OCCURRENCE.

My experience coincides with that of other writers, that the disease is of infrequent occurrence, and in my own practice, extending over a quarter of a century, I have records of but the three following

cases:

CASE I.-R. O. B., aged nine years, a resident of Petersburg, Ind., was brought to my office April 27, 1901, because of threatened blindness. Some thirteen months previously he accidentally ran a knife blade into the right eye, a perforating wound resulting at the outer and lower corneo-scleral margin. The eye inflamed but did not become blind until some three months later. He finished one school term, and had entered upon a second when he became unable to study. The seeing eye reddened, but was scarcely painful. At my first examination I noted injured eye, occlusion of the pupil, adherent leucoma with cicatricial shrinkage of the ball at the seat of original injury. The tension of the eye is minus, and without light perception. Left eye, vision reduced to the counting of fingers at eight feet. The eyeball somewhat injected, pupil contracted and bound down by broad circular adhesions so that instillation of atropia produces no dilatation. An older brother who accompanied the patient was told the nature of the disease and its seriousness, that the right eye was hopelessly blind, and that it was absolutely necessary that he leave his brother here in a hospital where the most active treatment could be instituted. Because I could not promise that the disease would be arrested, my advice was not followed, and I did not see the patient again until April 16, 1906, five years later, when he was for the second time brought to my office. The left cornea was opaque in many places from deposits of lymph upon its posterior surface, the lens was cataractous, the iris tissue atrophic with seclusion and occlusion of the pupil. The tension of the eye decreased, but

there remained light perception. The projection of light being fairly good, the following operative measures were undertaken.

April 17, 1906, two discission needles were passed into the lens through the original pupil and semi-cheesy matter evacuated into the anterior chamber. But slight reaction followed this procedure, and at the end of a week the boy returned home with a collyrium of dionin to be used night and morning.

July 5, the discission operation with two needles repeated, and more semi-fluid cheesy substance evacuated.

January 5, 1907, with a Landolt keratome an incision was made at the upper and outer corneal periphery, this being the most transparent zone of the cornea, and before withdrawing the knife its point was pushed through the iris and strongly resisting underlying membrane. A De Wecker scissors was next inserted, and with it the tough obstructing diaphragm cut across from without inward. Fortunately the opening did not close again, and on March 5 the patient counted fingers at five fcet. It is noteworthy that under the prolonged use of dionin instillations many of the deposits on the membrane of Descemet have undergone absorption.

September 30, 1907, the vision having diminished and the opening in the iris being a narrow one, a von Graefe cataract knife was passed from the outer corneal side through the anterior chamber and counter-puncture made to the inner side, and partial section made of the circumference of the cornea ere the knife was withdrawn. Next the De Wecker scissors was inserted, and a V-shaped incision made through the iris, cataractous lens and underlying membrane. A Liebrich iris forceps was inserted through the inner corneal opening and a piece of capsule extracted and cut off with the scissors. The operation, being done under cocaine anesthesia, was painful, but only slight reaction followed, and we have succeeded, as you see in the patient I am permitted to show you, in creating a good-sized pupil, so that with+11.00 +4.00 cyl. ax. 90 lens he has vision 1560.

CASE II. December 19, 1893, I was asked by Dr. G. W. Varner to see the five-year-old son of Mr. A. K., who was injured in the eye by particles of glass through an explosion. The cornea had been penetrated in a number of places, the anterior chamber obliterated and the sight destroyed. I advised enucleation, and pointed out to the parents the danger of sympathetic ophthalmia where foreign bodies were permitted to remain in the eye chambers. The father replied: "You are treating my neighbor's sen, about the same age as my boy, for an

eye injury, and have not advised the removal of his eye, and I will not consent to its being done in my child's case." The advice was given in case the seeing eye became reddened, with failure of sight, to consult an oculist at once. Within six months sympathetic ophthalmia occurred, and instead of consulting an eye surgeon the child was taken to a faith doctor. The result was absolute and permanent blind

ness.

This was

CASE III.-This case did not occur in my own practice, but I have seen the patient and have his history from the father, and since it illustrates the care one should exercise in sacrificing an injured eye that still possesses vision after sympathetic disease has been set up, its relation is of interest. The eleven-yearold son of Mr. H. accompanied a relative to Europe, and while in Dresden injured his eye slightly with an arrow. A physician residing in the house, it was deemed wise to have him see the injury, notwithstanding its apparently trivial appearance. He pronounced the wound not serious, but advised as a precautionary measure that an oculist be called. done, and the oculist stated that the injury was not a serious one. However, he asked that the boy be taken to his sanitarium where he could daily observe the case. This was agreed to, and the boy entered the hospital, from whence he wrote his father two weeks later that he was sitting up in bed and the eye was making a rapid recovery. In a short time the oculist recognized sympathetic inflammation in the other eye, and forthwith recommended that the injured eye be enucleated. The relative in charge of the child at once proceeded to Berlin and had a noted eye specialist go with her and see the patient in consultation. He likewise made a diagnosis of sympathetic inflammation in the uninjured eye, and agreed with the surgeon in charge that the first eye be removed without delay, which was done. The sympathetic irido-choroiditis progressed, notwithstanding everything was done to arrest it, and the patient to-day walks our streets absolutely and permanently blind.

PATHOGENESIS.

Eye surgeons are not at all agreed on this, and I shall not attempt a discussion of the theories advanced to explain the disease before this society. Suffice it to say, it is my opinion that a toxin forms in the injured eye and makes its way to the sympathizing eye either through the blood-vessels or the lymphatics.

PROGNOSIS.

This is always grave, and well-estab

lished cases of complete recovery of sight are rare. Relapses are frequent, and have been known to occur at a period later than one year. As a rule, however, after twelve months' freedom from signs of the disease the patient may be considered out of danger. Recovery is oftenest seen in papilloretinitis and after the exciting eye has been removed. Serous iritis gives the next most favorable prognosis, but it is always best to warn patients of the great danger of blindness if they elect to have an attempt made to save the injured eye.

TREATMENT.

This embraces prophylactic treatment and treatment directed to relieve the inflammation in the sympathizing eye. Prophylactic enucleation or one of its substitutes, according to the following rules laid. down by Dr. de Schweinitz, is the proper rule of procedure.

1. An eye with a wound so situated as to involve the ciliary region, and so extensive as to destroy sight immediately, or to make its ultimate destruction by inflammation of the iris and ciliary body reasonably

certain.

2. An eye with a wound in this region. already complicated by severe inflammation of the iris or ciliary body, even if sight is not destroyed; or an eye containing a foreign body which judicious efforts have failed to extract and in which severe iritis is present, even if sight is not destroyed.

3. An eye, the vision of which has been destroyed by plastic irido-cyclitis, or one which has atrophied or shrunken, provided there is tenderness on pressure in the ciliary region and attacks of reccurring irritation, or without waiting for signs of irritation.

4. An eye whose sight has been destroyed, even though sympathetic inflammation has begun in the sympathizing eye, in the hope of removing a source of irritation and thus rendering treatment to the second eye more effectual. Statistics show that the earlier the injured eye is removed under these conditions the more favorable the prognosis for the arrest of the sympathetic disease. According to Fuchs, it is best to operate during the recession of inflammation in the sympathizing eye, since enucleation of the blind eye during the acme of the disease in the seeing eye is apt to aggravate the trouble.

5. An eye in which the wound has involved the cornea, iris or ciliary region,

either with or without injury to the lens, and in which persistent sympathetic irritation in the fellow eye has occurred, or in which there has been repeated relapses of sympathetic irritation.

6. An eye either primarily lost by injury or in a state of atrophy, associated with signs of sympathetic irritation in the fellow eye.

I cannot too strongly urge upon you, after the appearance of sympathetic disease, not to enucleate the injured eye so long as it retains vision, which it is possible in the end may prove to be the more useful of the two eyes. In Case III we have an object-leson corroborative of the correctness of this position that no amount of argument can overthrow. Sympathetic disease made its appearance notwithstanding early prophylactic enucleation, and the explanation given is that the exciting toxin had already been carried to the second eye, or at least along the optic nerve, before enucleation was executed. Thirty-two days is the longest period of record of such outbreak. Operations upon the sympathizing eye for the improvement of vision should not be attempted until the eye has been quiet at least for one year. We have no drugs or other remedy that is capable of exerting a specific action in sympathetic ophthalmia.

The treatment recommended is confinement to a darkened room, atropia instillations as long as the pupil will react to a mydriatic, hot compresses, inunctions of mercury, aspirin and salicylate of soda; as much of the latter as one grain for each pound of bodily weight has been given in the twenty-four hours. Quinine and pilocarpine are used by others. I cannot recommend sub-conjunctival injections of bichloride of mercury, which are painful and not more beneficial than inunctions of mercurial ointment. For the relief of intra-ocular tension dionin may be used with morphia hypodermically. Eserine, because of the adherent pupil and active inflammation, has no value, and an iridectomy is almost sure to aggravate the condition. Failing to give relief otherwise, a sclerotomy may be made.

DISCUSSION.

DR. KNAPP: This is certainly a very interesting matter. The cases reported follow completely the description of the earliest history of sympathetic inflammation. The first case of sympathetic inflammation was reported in the early part of the seventeenth century. These cases are so rare that I would say this is the

first case of sympathetic inflammation I ever saw. I never saw a case in any of the clinics of New York City or Europe. I have seen cases of sympathetic irritation, but I have never had much fear of sympathetic inflammation. There are two cases reported of sympathetic inflammation from a rupture of the eye where the conjunctiva was not ruptured, leaving the thin skin over the sclera where it was not commonly exposed. I try to use all the caution possible in injuries from foreign bodies. If there is a foreign body absolutely within the orbit, the best thing to do is to enucleate. Occasionally you may miss it, but it is very seldom. It is a very safe procedure, particularly when it is over the region of the ciliary body.

DR. FLOYD: Sympathetic ophthalmia follows an iridocyclitis in the exciting eye, and it was once thought that the inflammation was carried by the ciliary nerve. But the ciliary nerves of the two sides are not connected with each cther directly as are the optic uerves through the chiasm, and therefore the inflammation could not be a direct one. Hence, the inflammation was thought to be carried by the ciliary nerves to the nerve centers and then transmitted reflexly to the ciliary nerves of the other side, thus setting up the trouble in the sympathizing eye. I do not think this theory is maintained at the present time, for it would be difficult to conceive of a reflex septic inflammation when you have a direct route by which it may travel and involve the other eye. While it has thus far been impossible to excite in an animal sympathetic ophthalmia from an injury in the exciting eye, Deutschman has been able by the injection of staphylococcus in the optic nerve sheath to find that this infection has traveled along the nerve to the brain and thence down the other optic nerve to the eye and set up inflammatory trouble. Whether this inflammation that Deutschman produced in the second eye is identical with sympathetic ophthalmia in man has not as yet been established to a certainty, but it does seem to throw a flood of light on the great probability of the infection being by direct transmission from one optic nerve through the chiasm and down the other optic nerve to the sympathizing eye. As the time clapsing between the injury and the outbreak of sympathetic ophthalmia in the other eye is not less than two weeks, one has that much time to watch the eye and determine what is best to do under the circumstances. Sympathetic ophthalmia is mostly due to traumatic conditions in the region of the ciliary body, and is more prone to occur where the iris or ciliary body is entangled in the cicatrix. This is especially true of the young, for they are more prone to this trouble than are the middle-aged and old

to one's satisfaction that it does not exist. These cases may be classed under nervous dyspepsia or neurasthenia gastrica, in which the eye strain is the underlying

cause.

We have in nervous dyspepsia disturbances of sensation, secretion and motor function, and the diagnosis may be difficult. We must take into consideration the general symptom-complex, and eliminate, if possible, by the various means at our command, any organic disease which may cause the gastric symptoms. In many instances the diagnosis of gastric neurasthenia or nervous dyspepsia is arrived at too early, and later, on more careful study of the condition, it is possible to make out the real pathological condition of the alimentary tract which has caused the syndrome.

There are many other causes as remote as eye strain which influence the alimentary tract in a like manner. Among these are, first of all, reflex irritation from the female sexual organs or from other over-sensitive viscera, mental overwork, anemias, alcoholism, shock and many other conditions. There are those whose congenital or acquired predispositions to gastric neurosis is such that the stomach is marked as the point of least resistance. and when the nervous system is. subject to any kind of stress this point gives way to the over-pressure (if you will allow the expression), and we have the gastric symptoms due to eye strain, or whatever else may have brought about the stress. There are more frequent disturbances of secretion in these cases due to eye strain than in those due to other causes, and the tendency is toward an increased amount of free hydrochloric acid. Many cases in which the exciting cause has not been the eye strain, which through other causes have become cases of gastric neurasthenia or disturbed function due to actual disease of the stomach, are benefited by the correction of an existing astigmatism, which has not in the past during the normal condition of the patient given rise to any symptoms or needed attention, but which under the changed conditions of the function of the digestive glands acts as an irritant to the nervous system in such a way as to materially change the secretions and cause these symptoms, annoying if not serious. Following this line of thought, it is my custom to require all patients undergoing a rest cure for any cause to wear the glasses prescribed for them,

during their rest in bed, while they are awake, and I am thus able to avoid headaches and other annoying symptoms.

CASE I-Mrs. S., aged forty-five. I mention this case first, as it is the most aggravated so far as the stomach conditions are concerned. Had been suffering from stomach disturbances for twelve years, with a gradual increase in the severity of the symptoms and frequency of the attacks. Had considerable ep gastric tenderness and an excess of free HCl secretion, headache and vomiting. Tenderness was relieved by rest in bed and a suitable diet, but the vomiting and headache continued. Patient insisted that she had no eye trouble. An ophthalmologist was called in consultation by me, and as the patient was still in bed we prescribed an instillation of the usual solution of the hydrobromate of homatropine, with the result that the vomiting and headaches were discontinued at once. After one week, during which time mydriasis was continued, the errors in refraction were corrected, and the patient's stomach secretion had by this time returned to the normal, the headaches and vomiting did not return, and the patient has remained in good health.

Examination by Dr. Heckel.-Has total hyperopia of one and one-quarter diopter in the right eye and the same in the left eye, combined with a half diopter of hyperopic astigmatism, axis 90 degrees. At first ordered full correction to be used constantly, but after a few months reduced her correction one-half diopter for constant use. For close work she uses a stronger glass to overcome her presbyopiathat is, two and one-quarter diopters over each eye, with half-diopter, cylinder axis 90 degrees, added to the left eye. Her extra-ocular muscles are quite perfect in balance.

CASE II.-Case of Dr. H. D. Jamison's, May 19, 1905. Miss E., five and one-half years old. History: Case of asthenopia. Child complains of headaches, pains in the eyes, radiating to the back of the head, and of vomiting daily for past six months. Was treated by reputable family physician with negative results. Loss of weight, fifteen pounds. Examined and found child to have full one diopter of hyperopic astigmatism, axis 90 degrees both eyes. On that date gave child correction of one-half diopter, child not knowing the alphabet. Instructed parents to return in September.

September 12. Vomiting ceased from May 19 to July 16. Weight was regained. No nausea. July 16 vomiting began, has been increasing up to September 12, when three-fourths diopter, axis 90 degrees, was prescribed, which again controlled the vomiting as before. Parents to return with child in April.