placed in position, and the child not excited by the use of painful caustic applications. There is no difficulty in replacing the lid, but each time the child cries the lid becomes again displaced. The case should be faithfully followed up with mild local treatment. I would use the alum crayon, three or four times a day, as it causes little or no pain and does not distress the child, as would any strong or caustic solution.

Dr. E. WILLIAMS, of Cincinnati, said:-While I agree with the doctrines of the paper just read in many particulars, I disagree with them in regard to some essential points of treatment. It has been my custom to treat these cases much more energetically than is advocated in the paper, and I have never had a single case of ulceration occur during treatment in an infant. I evert the lids, thoroughly cleanse them, and brush them with a solution of nitrate of silver of the strength of from five to ten grains to the ounce, washing it off with salt water. Scarcely without exception the patient returns the next morning with eyes greatly improved. I continue this for three or four days, once a day, and when I have the disease under control continue the treatment by the use of astringents. I believe that in some cases the sulphate of atropia is very useful, but in infants half a grain to the ounce is as strong a solution as it is prudent to use.

Dr. H. W. WILLIAMS said :-I agree that in some cases it is well to use the stronger astringents, and perhaps an application or two of sulphate of copper. Sometimes I find it necessary to use active astringents, but even then, when danger is past, I return to the milder applications. I have known cases in which, lunar caustic having been used by the family physician, the eyes have been spoiled.

Dr. C. R. AGNEW said:-I would ask Prof. Williams how he would treat the worst typical case of gonorrhoeal conjunctivitis, if called in within twenty-four hours, there being as yet no corneal lesion?

Dr. H. W. WILLIAMS said :-I have seen cases of that kind, with serous bloodstained discharges, in which I have thought it well to apply a strong astringent. I would say that I do not mean to limit myself or any other gentleman too strictly to the rules laid down. Every case must be treated by itself; but I have aimed to lay down a rule which is generally applicable.

Dr. JOHN GREEN, of St. Louis, said :-Prof. Williams's paper conveys the impression that in the purulent ophthalmia of new-born children success is uniformly to be expected if the case is treated early enough; nevertheless cases sometimes occur which do not turn out so well. I have seen two such cases in which the cornea was lost although carefully treated from the beginning of the attack.

Dr. GEORGE STRAWBRIDGE, of Philadelphia, said:-The modes of treatment which have been advocated are totally different, and yet have both been pursued by gentlemen of large experience. I have faithfully tried both methods. That which Prof. Williams, of Boston, proposes, is a good method when it can be carried out, but it is impossible to do that except in a hospital, or in a rich family, whereas these cases mostly occur among the poorer classes. My experience has been that after the acute stages have passed by, much benefit may be obtained from the use of the mitigated nitrate of silver.

Dr. S. D. RISLEY, of Philadelphia, said:—I have been struck with the extreme mildness of the treatment recommended by Prof. Williams. In the ophthalmia of new-born children, it has been my custom to use the mitigated stick, neutralizing any excess, as I can thus confine its action to the conjunctiva and spare the cornea. One other application which I have used with equally satisfactory results, is a twenty per cent. solution of carbolic acid in glycerine. It has the advantage of causing less pain than the nitrate of silver. Although painful at first, the pain subsides in a moment, and the child is subsequently more comfortable than after the use of the nitrate.

Dr. GEORGE C. HARLAN, of Philadelphia, said:-I see many of these cases at the Children's Hospital. Until four years ago, I never used nitrate of silver

of a strength greater than four grains to the fluidounce, but since then I have used as strong a solution as ten grains to the fluidounce, and so far from giving excessive pain it seems to give relief, and the children are more at ease after the immediate effects have passed off. In addition, I give directions for the use of an alum solution of the strength of five grains to the fluidounce as often as may be necessary to prevent the accumulation of pus.

Dr. J. H. POOLEY, of Columbus, Ohio, said :-I employ the sulphate of copper, and it seems to me the better remedy for chronic conjunctivitis. I am not in the habit of using as strong solutions of nitrate of silver as Dr. Williams, of Cincinnati; using but five grains to the ounce. Stronger solutions I think very objectionable, and the mitigated stick cannot always be used without leaving a scar on the conjunctiva. I prefer to cleanse the eyes with a sponge rather than with a syringe, and I order the use of cold water.

Dr. E. WILLIAMS said :—I wish to say by way of explanation that, when I spoke of treating all infants uniformly, I did not mean to imply that I always employed solutions of the same strength. I have never seen more than two cases of diphtheritic conjunctivitis, and they were in children, not infants; each lost one eye. When we invert the lids, we see on the surface a somewhat grayish and consistent film, but this is easily removed and is not at all connected with diphtheria. I make it a point always to get this off. In speaking of my success I do not mean to disparage that of any one else, but I have found my plan of treatment successful, short, and certain.

Dr. WILLIAM THOMSON, of Philadelphia, said:-It seems to me that there is no difference of opinion with regard to the successful use of nitrate of silver, but only as to the mode of its application and the strength of the solutions to be employed. Applications made to the whole conjunctival sac, and so coming in contact also with the cornea, should not be stronger than two grains to the fluidounce; and I believe that it is generally better thus to bring the solution in contact with the whole conjunctival surface, than to make stronger applications to a part only of the diseased membrane.

Dr. C. R. AGNEW said :-I feel somewhat embarrassed in telling what my views are, because I find that when we come to the subject of the report, we find cases behind the paper in which mild applications are confessedly not sufficient. We should stand ready to treat particular cases according to particular phases. If I find the eyelids sticky, and without much purulent discharge, my common direction is to bathe with a solution of common salt. If I find inflammation increased, and the discharge more watery, and winecolored, I take the head of the child between my knees, bathe the eyes with water applied by a sponge, apply a solution of nitrate of silver, and then give some simple ointment to prevent the adhesion of the eyelids and the collection of pus. If the case goes on to a still worse condition, and it is evident that the cornea is to give way, I anticipate the evacuation of the aqueous humor by paracentesis. With regard to gonorrheal ophthalmia, it is oftenest the case that it destroys the cornea within thirty-six hours, and that when it is not destroyed in this time, the case gets well. What we need to know is what to do when the lids begin to stiffen, and the fluid turns reddish or winecolored. In a case of that kind I would give an injection of morphia in the corresponding temple, and run a pair of scissors into the external canthus, and cut down to the orbit, hoping to get a good spouting of blood. I would then pour water on the corresponding side of the head to encourage the bleeding, and finally repeat the application of morphia to produce sleep. Unless there is a decided improvement, I evert the eyelids and make an application of nitrate of silver, and afterwards apply iced cloths, which should be damp and cold, but not wet.

The President, Mr. R. BRUDENELL CARTER, of London, said:-The differences in the treatment recommended are far more apparent than real, and would melt away in the presence of individual cases. Prof. Williams without doubt desires to show the danger of very strong astringents and caustics, and I believe that the Section will generally agree in his conclusions.

ON TUMORS OF THE OPTIC NERVE.

BY

H. KNAPP, M.D.,

OF NEW YORK.

A VERY limited number of tumors of the optic nerve has hitherto been recorded. W. Goldzieher, in a very valuable paper on the subject, published in Graefe's Archiv für Ophthalmologie, 1873, states that in modern medical literature he has found only six cases of the kind, to which he himself adds three others. I have found records of a few additional cases, and have seen three myself, two having been under my own. care and one under that of Dr. E. Gruening at the New York Ophthalmic and Aural Institute. I shall give a brief sketch of some of these cases, in order to obtain the data necessary for a general description of the affection.

CASE I. (Described by A. von Graefe, in his Archives, vol. x. part 1, p. 193 etc., 1864.) A farmer, æt. 23, had first noticed, two years previously, diplopia and protrusion of his right eye. The exophthalmos increased steadily, but the diplopia subsequently disappeared from the sight of that eye becoming lost. No pain was felt until a few weeks before the patient was first seen, when secondary infiltration of the cornea set in. On examination, there was found exophthalmos of 9', in the direction of the orbital axis; the lids could not be closed; the mobility of the globe was restricted inward, but in other directions was free; the centre of motion coincided with that of the globe. Behind the globe, a soft, elastic tumor was felt; S.0. The retinal veins were tortuous and dilated, the arteries attenuated. The inner half of the optic disk was swollen, with abrupt, slightly overlapping borders, reddish, and concealing the blood vessels; the outer half was level.

Graefe diagnosticated a relatively benign, orbital tumor, probably of a fibrosarcomatous nature. From the fact that the centre of rotation corresponded with the centre of the globe, he concluded that a stratum of loose connective tissue separated the tumor from the globe. The freedom of the outer half of the optic disk led him to the supposition that the blindness was not caused by compression, but by the immediate transition of the tumor to the nerve, or possibly by its origin in the nerve itself. The tumor being situated within the muscular funnel, and surrounding the optic nerve, its extirpation with preservation of the eyeball, he said, could not be thought of. He enucleated the eyeball, slit the stratum of connective tissue in front of the morbid growth, laid the bluish-red looking tumor bare, and removed it without difficulty. The operation was followed by alarming cerebral symptoms, intense headache and nausea; the pulse fell from 80 to 52 beats, and the temperature rose to 40° C. (104° F.). These symptoms subsided upon the appearance of an extensive suppuration in the wound. The patient recovered.

The tumor, examined by Recklinghausen, was pear-shaped, a little larger than a pigeon's egg, partially soft and gelatinous, and partially fibrous. The bulk of the optic nerve lay as a compact cord on one side of the tumor, and was covered, together with the whole tumor, by a tough, fibrous capsule. The limit of the nerve which looked toward the tumor, was ill-defined. The fibres of the cord-like portion of the optic nerve were preserved in their whole course, the others entered the tumor and were lost in it. This condition was found

in both the cut ends of the nerve, that is at its entrance into and its emergence from the tumor. The growth therefore was a myroma of the optic nerve, originating in the inner sheath and perineurium internum. The swelling of the inner half of the intra-ocular end of the optic nerve was caused (according to the examination of Schweigger) "by a proliferation of indifferent (lymphoid) cells, as might be expected in so young a formation."

CASE II. (Described by A. Rothmund, Zehender's Klin. Mon., 1863, S. 261.) The patient was a healthy looking girl of fifteen years. At the beginning of her second year, her left eye began to be pushed forward and downward, and was excessively painful. She could see with that eye. In the course of four or five months the eye became blind, but kept free from pain; yet the lids were swollen every now and then. From that time to her sixteenth year, she felt no annoyance from the eye, though it slowly but constantly grew larger. When seen by Dr. R., the orbit was occupied by a roundish, faintly fluctuating tumor, the size of a large hen's egg. The tumor was totally covered by congested conjunctiva, but incompletely by the lids, and moved harmoniously with the healthy eye in every direction. Remnants of the cornea were recognizable at its apex, which was very tender to the touch. The palpebral fissure was two and a half inches in length, and the orbit was greatly distended.

Dr. Rothmund removed the tumor in the manner of an ordinary enucleation. Its pedicle was severed near the optic foramen. In some weeks the orbital wound was closed by granulations. The patient recovered.

At the posterior end of the tumor a piece of the optic nerve, 3'' in length, was preserved. The growth was a total degeneration of the optic nerve, consisting of fibrous tissue which inclosed smaller and larger cysts, the cavities of which were pervaded by a network of white, delicate fibres containing a vascular, gelatinous substance. The microscopic examination, made by Prof. Buhl, showed the characteristics of a myxoma, which is frequently met with in other nerves. The eyeball had been flattened by the tumor in such a way that the optic disk touched the cornea.

CASE III. (A. von Graefe, Arch. f. Ophth., x. 1, S. 201, 1864.) The patient was a young lady, æt. 24, who for two years had noticed a slight exophthalmos with amblyopia and contraction of the visual field of her left eye. With the ophthalmoscope Graefe discovered choked disk and spontaneous arterial pulsation. During the next five years the exophthalmos slowly increased, while sight was reduced to quantitative perception of light. The exophthalmos measured 8'', and showed a marked deviation outward. Mobility preserved, but reduced in every direction. The centre of rotation corre

sponded approximately to the centre of the globe. A soft tumor was located immediately behind the eye, more on the nasal than on the temporal side. Between the upper and inner recti muscles it could be seen through the conjunctiva as a smooth, reddish-yellow intumescence. In the outer part of the field of vision, there was no perception of light. The optic disk was atrophic. The patient was operated on by Langenbeck, who first enucleated the eyeball, and then the tumor, which did not extend to the apex of the orbit. It was as large as a pigeon's egg. The optic nerve passed as a flattened cord along its nasal side, but a considerable part of it entered the tumor and was lost in it. The posterior part of the eyeball was flattened by the pressure from the tumor.

The tumor, examined by Recklinghausen, was found to be a myxo-sarcoma of the optic nerve. Its anterior part contained a cyst, around and behind which there was a soft, partly gelatinous substance, consisting of very delicate, interlacing fibres which inclosed round and oval cells. The gelatinous liquid which could be pressed out of the tumor grew very opaque on addition of acetic acid. Larger portions of the tumor showed a substance almost entirely composed of cells, between which some larger blood vessels ramified.

CASE IV.—(Described by E. Neumann, in Archiv für Heilkunde, xiii. S.

310.) The patient, æt. 20, had suffered from headache for six years, and had noticed a protrusion of her eye for three years. The mobility of the eye was preserved, and was only a little restricted in an upward direction. The vision was almost normal. On palpation a hard immovable tumor was felt surrounding the posterior part of the globe on all sides. Dr. Jacobson, of Königsberg, removed the eye together with the tumor.

The tumor was three-quarters of an inch in length, the size of a walnut, and immediately behind the eye surrounded the optic nerve, which passed quite loosely across it. The neoplasm was connected with the outer sheath, which on section showed itself as a distinct, white border-line. The inner sheath was smooth and shining. Between the two sheaths, delicate cords were stretched when the nerve was drawn away from the tumor. The microscopic examination discovered that the structure of the tumor was partly compact, partly alveolar. The alveolar part had a stroma which resembled that of a cancer, inclosing accumulations of fusiform cells in concentric layers. The centres of many cells were incrusted. Teased preparations showed that these fusiform elements were flat endothelioid cells. The compact part of the tumor consisted of coarse fibrils, here and there inclosing numerous accumulations of sarcomatous cells. The periphery of the tumor consisted of adipose tissue. The tumor is styled by Neumann apsammoma, on account of the prevalence of the incrusted, arenoid bodies in the alveolar part of the tumor.

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CASE V. (Described by H. Knapp, in Archives of Ophthalmology and Otology, vol. iv. pp. 323–354, 1875, with four plates.) Mrs. J. K., æt. 40, was first examined in August, 1871. Her left eye was normal in function and structure; the right protruded about 5'' in a forward and slightly downward direction. The protrusion had begun six months previously, and the sight of that eye had gradually become impaired. She suffered from occasional headaches, which always increased the protrusion of the eye. The movements of the globe were somewhat restricted, chiefly in an upward direction. There was no pulsation, nor bruit. S. with 10 Sn. ; F. complete. The optic disk showed a steep elevation, arteries small, veins dilated and tortuous. The ophthalmoscopic condition did not materially change for three years. In June, 1874, a hardish tumor was felt, on palpation, on the inner and upper side of the posterior part of the globe. It moved with the eye. A free space was felt between the tumor and the orbital wall. The globe was dislocated slightly outward, and considerably downward (4''-5"), but mostly forward (6). Inversion was perfect, whereas the strongest eversion brought the corneal margin no nearer than 2' from the outer commissure; downward rotation was free, but upward rotation moved the eye no higher than the horizontal median plane; S. 20. F. complete. Media clear, pupil responsive. Papilla raised, with abrupt borders, like a "jockey-cap." Venous hyperemia marked. General health good. For the last years, great pain in eye and head. The diagnosis of orbital tumor could now be more specifically revised into that of a tumor of the optic nerve, and acting upon this supposition I attempted, on June 10, 1874, to enucleate the tumor while preserving the eyeball. I succeeded in the following

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manner:

I opened the conjunctiva by a circular section between the inner and supe. rior recti muscles, and laid the anterior portion of the tumor bare. Then I introduced my left forefinger into the wound, and under its guidance freed the hardish tumor from the soft, surrounding orbital tissue. After that, I dissected the mass from the posterior part of the globe, with which it was connected by a thin layer of connective tissue. Further, I severed the optic nerve, and then introduced my finger as deeply into the orbit as possible. Not being able to reach the apex of the tumor, which was close to the optic foramen, I cut the tumor across as near the summit of the orbit as I could reach. Now I rotated the growth on its antero-posterior axis, and severed such connections with its surroundings as had before escaped. All this was done with a pair of strabismus scissors. Then I introduced the closed blades of a stronger pair of