The table given above is instructive both as regards the diagnosis and prognosis in cases of double optic neuritis with headache. It shows the necessity for careful examination before giving either a diagnosis or prognosis, and the clinical group of cases No. X. ought always to be borne in mind whenever the diagnosis is obscure and localizing symptoms are absent.
There are two other points to which we would draw attention. In ten out of the one hundred cases the patient recovered completely from the headache and general cerebral symptoms and regained perfect health, but the optic neuritis was followed by atrophy and complete blindness. In the face of this terrible termination we cannot help thinking that simple trephining of the skull and the removal of bone, without any interference with the brain, as suggested and practiced by Mr. Victor Horsley for the relief of optic neuritis and pressure symptoms, is a method of treatment worthy of more frequent trial when vision is failing markedly. Dr. James Taylor has published cases which appear to show that this method of treatment may be of service in checking the optic neuritis and failure of vision. In the class of cases in Group X. if there should be a suspicion that the symptoms may be due to serous meningitis of the ventricles, lumbar puncture appears to be worthy of trial, since several cerebral cases are now on record in which this treatment appears to have been of great service, and in which the cause of the cerebral symptoms was probably that just mentioned.
Deady.
Murrell, W.—A Case of Double Optic Neuritis from Serous Effusion (Quincke’s Disease).—Lancet, April 28, 1900.
A schoolboy, aged seven years, was admitted into Westminster Hospital on January 28, 1900, the only history obtainable being that on the previous morning he had been brought home in a “fit,” which lasted the greater part of the day. On admission he was perfectly sensible and talked freely, but on being put to bed he passed into a condition of semi-consciousness which lasted for many days. He took no notice when spoken to, and remained absolutely mute. The face and upper extremities exhibited choreiform movements of a slow and coarse type. These movements were apparently purposive in character, and at times he endeavored to clutch at objects within his reach. Sometimes the arms were widely extended, and then slowly flexed, as if performing the act of embracing. Sometimes the movements conveyed the idea that he was feebly endeavoring to strike those around him. There was no paralysis of the face or of the muscles of the limbs. The movements were, as a rule, bilateral, although sometimes the facial movements were unilateral, but not always on the same side. There was no rigidity of the muscles, retraction of the head, or opisthotonos. There was nothing to indicate that the patient suffered from headache, although at times the brows were contracted and the face wore a worried and anxious appearance. The bowels were open twice a day and urine and fæces were passed in bed. The motions were normal in character. The patient was unable to swallow, and had to be fed by the nasal tube. There was no nystagmus, the pupils were normal in size and contracted well to light. There was well-marked double optic neuritis. The temperature was 99.8° F., and the pulse was 108. There was no tenderness or swelling of the joints, and there was no rash on the skin. No tache cérébrale could be obtained. There was a little cough, but there was no expectoration. The breath and heart-sounds were normal. The urine was acid, had a specific gravity of 1018, and contained neither albumen nor sugar. The spleen was not enlarged. The patient showed no signs of anæmia, but the blood was not examined. There was no wasting of the muscles, and the knee-jerks were present, although somewhat sluggish. The tongue was clean, and presented no sign of having been bitten. The patient would not protrude it voluntarily, and it had to be examined with the spatula.
The condition of the patient remained practically unchanged for twelve days. The highest temperature recorded was on the second day, when it reached 100°; on the following day it was 99.8°, and from that time onward it was normal. The double optic neuritis continued, and the disks were observed to be getting paler. On February 13 (the seventeenth day of the illness) the patient was much more sensible, and recognized his mother, putting his arms round her neck. He was still unable to talk, although apparently he endeavored to do so, from time to time uttering a few unintelligible words. On being asked if he would like an orange he nodded his head, and he showed some signs of interest in a watch which was shown to him. The incontinence of urine and fæces continued, but food was taken with less difficulty. The movements gradually subsided. On the 17th the patient could say his own name, but beyond that could utter only inarticulate sounds, and failed to recognize letters or words, either written or printed. On the 20th he was able to speak plainly, although incoherently. He endeavored to get out of bed, and during the night was so noisy that he had to be removed from the ward. Urine and fæces were still passed under him. On the 22d he was quieter, and for the first time indicated that he wanted the bed-pan. The optic neuritis was less marked. On March 1 the patient was able to get up, and seemed to be quite well. On the 8th the following note was furnished by Mr. G. Hartridge, who had frequently examined his eyes during the course of his illness: “Pupils five millimeters each. React well to light, to convergence, accommodation, and consensually. Right vision 6
6, left vision 6
9. Right disk getting white; not much swelling of the disk; edges clearing. Retinal vessels, specially veins, very full and tortuous. Left disk pale (less so than right), dim; edges blurred.” The only medical treatment adopted was the administration for a few days of 15 minims of liquor arsenicalis three times a day.
Deady.
Stephenson, Sydney.—Concussion of the Retina.—Brit. Med. Jour., January, 1900.
Several years have elapsed since Dr. R. Berlin described a series of cases in which he had observed a peculiar retinal change after the eye had been struck with a blunt object, as, for example, a stick or a stone. Under those circumstances he noticed a cloudiness of portions of the retina, not involving the retinal blood vessels. The milky appearance reached its height in twenty-four to thirty-six hours, and disappeared in two or three days. Berlin pointed out that the rapidity with which the cloudiness developed, and the length of time that it persisted, stood in direct relationship with the severity of the original injury. This curious condition, which Berlin called commotio retinæ, was associated with some reduction of sight, episcleral congestion, and a difficulty in getting the pupil to dilate when atropine was dropped into the eye. Small retinal hemorrhages were sometimes present. Berlin explained the ophthalmoscopic picture by supposing that a rupture of the choroid was followed by bleeding and œdema of the retina. This theory has recently been opposed by Denig. That observer, as the result of experiments upon rabbits, believes that the blow upon the eyeball causes the vitreous to impinge upon the retina, to tear the internal limiting membrane, and to force the vitreous into the nerve-fiber layer. The alternate elevations and depressions thus brought about in the nerve-fiber layer of the retina are, according to Denig, the cause of the ophthalmoscopic appearances.
Since the publication of Berlin’s original paper few cases of commotio retinæ have been recorded. Indeed, the retinal changes are of so fleeting a nature that an opportunity for observing them must occur comparatively seldom. This fact leads me to place upon record brief notes of a somewhat interesting case: