16. A man, aged forty years. Double optic neuritis, headache, and vomiting. Recovery, but with complete blindness. (Eighteen months.)
17. A youth, aged seventeen years. Double optic neuritis, headache, and vomiting. Recovery, but with total blindness. (Five years.)
18. A woman, aged twenty-two years. Double optic neuritis, headache, and vomiting. Recovery, but with total blindness. (Two and three-quarter years.)
19. A girl, aged fourteen years. Double optic neuritis, headache, and vomiting; internal strabismus (left) for fourteen days. Recovery, with normal vision. (Two years.)
The following are brief notes of the cases in Group IX.:
20. A girl, aged twelve years. Headache, vomiting, and double optic neuritis in December, 1893. Recovery in twelve months, but vision was much impaired. She remained well with the exception of occasional headache until December, 1899. Then the severe headache returned. She became ataxic and optic neuritis reappeared. In April, 1900, the headache was much less and the patient felt much better, but she was completely blind. (Six and a half years.)
21. A young woman, aged seventeen years. Headache, vomiting, and double optic neuritis. Vision was impaired. Vomiting ceased; the headache continued for over two years, but recently disappeared after lumbar puncture. (Two and a quarter years.)
In all cases of double optic neuritis a systematic and careful examination of the patients should be made. The urine and cardio-vascular system should be examined for signs of chronic interstitial nephritis; the gums should be examined for the lead line and other indications of lead poisoning should be sought for; the question of chlorosis or other “blood disease” should be considered; and the ears should be examined for signs of otitis. But when all these conditions have been excluded and when the symptoms are apparently due to a cerebral affection, there is one group of cases in which localizing brain symptoms are absent and in which the chief indications of disease are headache, double optic neuritis, and often vomiting. In most of these cases syphilis can be also excluded. A diagnosis of brain tumor is given, and the growth is thought to be situated in some region in which the localizing symptoms are at first indefinite—cerebellum, temporo-sphenoidal lobe, or prefrontal region. Such a diagnosis often proves to be correct. Localizing symptoms may develop later and a necropsy may show the accuracy of the opinion expressed. But sometimes, to the surprise of the medical man, a fatal termination does not occur; the symptoms sometimes disappear and the patient recovers, though very often impairment or loss of vision remains. The patient may continue in good health for years or for a lifetime afterwards. Most medical men who have paid much attention to cerebral diseases will have met with a case or cases of this kind. The chief object of our article is to call attention to this class of cases and to indicate the frequency of their occurrence. Nineteen out of one hundred cases of double optic neuritis with headache in the table just given could (after careful examination) be placed in this group (X.).
What is the cause of the symptoms in this group of cases? Possibly in some cases the symptoms are caused by a non-malignant tumor (or tuberculous mass) which ceases to extend and becomes quiescent and encapsuled. One of us has recorded a case in which symptoms of cerebral tumor (including Jacksonian epilepsy and hemiplegia) gradually subsided and temporary recovery ensued; but three years later symptoms of cerebellar tumor developed and death occurred. The necropsy revealed a recent large tuberculous mass in the cerebellum and an old capsuled tuberculous mass just beneath the motor cortex in the right cerebral hemisphere. The latter had evidently been the cause of the early cerebral symptoms from which the patient had recovered. An instructive case has been recorded by Dr. T. K. Monro of Glasgow. The patient, at the age of sixteen years, suffered from severe headache with failure of vision which passed on to complete blindness. For thirty-three years he was an inmate of a blind asylum, ophthalmoscopic examination showing double optic atrophy. He died at the age of sixty-three years, from cancer of the stomach, and the post-mortem examination also revealed a large myxomatous tumor in the left half of the cerebellum. In all probability the early cerebral symptoms had been associated with optic neuritis which had passed on to optic atrophy and the cause had been the myxoma in the cerebellum which had remained quiescent for forty-six years.
In some cases of double optic neuritis with headache and general cerebral symptoms, when recovery occurs the cause is probably distention of the ventricles of the brain with fluid—serous meningitis of the ventricles (Quincke). This condition was present at the necropsy, and no tumor growth could be found in two out of the one hundred cases tabulated. It is probable that a number of the cases in which a diagnosis of cerebral tumor has been made, but in which recovery has occurred, have been due to this condition—serous meningitis of the ventricles. Probably the two cases in Group IX. and possibly some of the cases in Group II., in which death did not occur for several years after the onset of symptoms, were of this nature. Other cases which recover may be due to a basal meningitis.