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In brain tumor we find either papillites or optic nerve atrophy. Papillitis is evidenced by a swelling of the intra-ocular end of the nerve. The clean-cut boundary line between the optic disk and retina is lost, the nerve seeming, on account of exudation, to overlap the adjacent retina, or the change may not be so well marked, the only abnormality noticed being a slight engorgement of the veins without swelling of the disk and with blurring of its edges. As a rule, however, the neuritis of brain tumor is a pronounced condition known by the term "choked disk." In typical cases the picture, when once seen, is easily remembered. The swelling of the papilla, great enlargement of the veins from compression by the swollen nerve fibers, the arteries diminished in size, the change in color of the nerveall are present in a marked case. This disease runs a chronic course and after many months the signs of inflammation are succeeded by those of atrophy. In atrophy the ophthalmoscopic appearance is the very opposite of that of papillitis. In atrophy the nerve head presents different appearances according as the atrophy is simple, i. e., non-inflammatory, or secondary, i. e., inflammatory. As we may be called upon to examine a case in the atrophic stage, it is of great importance that the ophthalmologist be able to distinguish the simple from the secondary form of optic nerve atrophy.
In simple atrophy the optic papilla is pale, often of a bluish-white color, its edges well defined, the gray dots of the lamina cribrosa are distinctly seen over a large area, and the retinal vessels are unchanged in size. The optic nerve head presents the excavation of atrophy. This excavation is to be distinguished from the excavation of glaucoma on the one hand and from a physiological cupping of the disk on the other. The physiological excavation can be at once excluded by stating that it never involves the entire papilla; if there be an excavation involving the whole papilla, it is either glaucomatous or aucomatous or atrophic. If glaucomatous, there will be recession of the lamina cribrosa, and the central retinal vessels are seen climbing over the edge of the excavation, but they cannot be focused at this point, and also at the bottom of the excavation at the
same time. The edge of the excavation in glaucoma is overhanging. The tension of the eye is increased except in glaucoma simplex and the retinal arteries either pulsate spontaneously or on moderate pressure. The atrophic excavation, while involving the entire papilla, is not so deep as that of glaucoma. There is no recession of the lamina cribrosa; the optic nerve is white; there is no increase of tension; the arteries do not pulsate spontaneously.
In inflammatory atrophy the papilla is traversed by connective tissue formed by the organization of an exudate. At first the papilla is grayish white; its margins hazy; the veins distended and tortuous; later the papilla is bluish-white or pure white, but the lamina cribrosa is not exposed to view (Fuchs). At this stage the papilla is small, irregular and shrunken; the arteries and veins are contracted and often enclosed in white streaks (Fuchs).
The causes of simple atrophy are, (1) spinal disease, particularly locomotor ataxia, which also generally presents the Arglyll-Robertson. pupil and absence of patellar reflex; (2) brain affections, among which are disseminated sclerosis, tumor, and progressive paralysis of the insane, and (3) orbital disease, as orbital tumor, fracture involving the optic foramen, etc. In injuries to the nerve there are at first no ophthalmoscopic signs except the site of the lesion be so far forward that the central vessels are severed. In that case the picture is similar to the one found in embolism, viz., the retina is bloodless.
Valuable as is the ophthalmoscope in brain affections, the information it conveys is general, not localizing. Although double optic neuritis is present in 80 or 90 per cent of all cases of brain tumor, its absence does not exclude brain tumor, for these reasons: (1) the eyes may not be involved, the growth being remote from the optic tracts; (2) optic neuritis may have been present and have disappeared before the ophthalmoscope is used.
Other conditions causing optic neuritis are meningitis, lead encephalopathy, Bright's disease, cerebral abscess, hypermetropia, ovarian and uterine derangements, exposure to great cold, anæmia, acute infections, febrile diseases, syphilis, heredity, hydrocephalus, inflamma
tory processes in the orbit (caries, erysipelas extending from face, periostitis, orbital cellulitis), rheumatism, multiple sclerosis.
Valuable as is double optic neuritis as a sign of brain tumor, we must remember that in some few rare instances all the rational signs of cerebral tumor have been present during the life of a patient on whom post mortem examination failed to reveal anything wrong. Such a case occurred in the practice of Dr. Hughlings Jackson, and Dr. Sutton made the autopsy.
Double optic neuritis does not help us in localizing the growth. Bramwell says: "Perhaps tumors of the medulla are less often attended with double optic neuritis than tumors in other parts." Starr's opinion is that: "Tumors of the cerebellum and corpora quadrigemina, and tumors upon the base of the brain and in the basal ganglia, produce optic neuritis more constantly and earlier in their course than tumors situated in the cortex or centrum ovale. Optic neuritis is usually double, though it always appears first in one eye, and is rarely equally intense in both eyes, but in a few cases it has been found in one eye only, and then is thought to indicate disease of the nerve in the orbit or in front of the optic chiasm, rather than a distant tumor." (Am. Text Book of Nervous Diseases, p. 484.)
calling the partial decussation of fibers in the chiasm, we are prepared to profit by a study of hemianopsia in brain tumor. Hemianopsia. is a deficiency of one-half of the field of vision, the dividing line being vertical. It is called homonymous when the same side of each field is lacking, and the terms right and left are further descriptive of the part of each field which is blank. If both temporal fields are wanting, we speak of temporal hemianopsia; if both nasal, nasal hemianopsia. We speak of superior and inferior hemianopsia when the dividing line is horizontal. Such hemianopsias are due to local causes, i. e., plugging of the artery supplying the upper or lower half of the retina. Inasmuch as rays of light cross in the eye, inability to see objects in the right half of the field indicates a lesion of fibers supplying the left half of the retina, and vice versa. In superior hemianopsia the lower half of the retina is at fault.
The localizing value of hemianopsias may be expressed as follows: Bilateral temporal hemianopsia indicates an antero-posterior division of the chiasm, as occurred in Weir Mitchell's case, in which an aneurism had entirely divided the chiasm in the median line. The outer half of each retina retained the power of vision. Quite a number of cases of this form of hemianopsia have been published. Hemianopsia, however, is rare in diseases of the chiasm, and then is sharply defined only for a time, since we have to deal with progressive processes, as tumors, syphilitic and tubercular growths. (Kines.)
Nasal hemianopsia is extremely rare, as may be judged from the anatomical facts. A single lesion could produce it only under very peculiar conditions. It might result from bilateral symmetrical lesions. Nasal and temporal hemianopsias, so far as known, are due. to lesions in the anterior fossa of the skull, involving the chiasm. One-sided nasal hemianopsia would come from a lesion of the outer part of the chiasm on the same side as the eye affected.
Lesion of the optic tract, between the optic chiasm and geniculate bodies would cause lateral hemianopsia. Lesion of the central fibers of the nerve between the geniculate bodies and cerebral cortex would produce lateral hemianopsia.. Lesion of the cuneus causes lateral hemianopsia. Lesion of the an
gular gyms may be associated with hemianopsia, sometimes crossed amblyopia, and the condition known as mind blindness. (Osler.)
Given a case of brain tumor in which there is hemianopsia, where is the lesion? To determine whether the lesion be in the tract between the chiasm and the geniculate bodies, or in the central portion of the fibers between these bodies and the visual centers, Osler says this can be determined in some cases by Municke's hemiopic pupillary inaction. The pupil reflex depends on the integrity of the retina, the fibers of the optic nerve and tract, and the nerve center in the geniculate bodies, which receives the impression and transmits it to the third nerve, along which motor impulses pass to the iris. If a bright light is thrown into the eye and the pupil reacts, there is no question about the integrity of this reflex arc. In lateral hemianopsia the light can be thrown so as to fall upon the blind half of the retina. "If, when this is done, the pupil contracts, the indication is that the reflex arc above referred to is perfect, by which we mean that the optic nerve fibers, from the retinal expansion to the center itself, and the third nerve are uninvolved. In such a case the conclusion would be justified that the cause of the hemianopsia was central; that is, situated behind the geniculate bodies, either in the fibers of the optic radiation or in the visual cortical centers. If, on the other hand, when the light is carefully thrown on the hemiopic half of the retina, the pupil remains inactive, the conclusion is justifiable that there is an interruption in the path between the retina and the geniculate bodies, and that the hemianopsia is not central, but dependent on a lesion situated in the tract." (Osler, p. 848.)
"In all cases where the defect in the visual field is contained in one eye only, or in which, while there are defects in both eyes, they are not symmetrically situated, the lesion must be situated in the optic nerve itself that is, in front of the chiasm-since all interruptions on the farther side of the chiasm result in the production of symmetrical defects in the visual fields." (Fuchs.)
"It is not generally appreciated that hemianopsia is a symptom often entirely overlooked by a patient, a case having been recently re
ported by Bleuler', in which, though wellmarked hemianopsia existed, the patient was entirely unaware of any visual defect. It is therefore exceedingly important that the extent of the visual field in both eyes should be carefully tested in every case of suspected brain disease, each eye being tested separately." (Text Book of Nervous Diseases, by American Authors, Philad., 1895, p. 492.)
. DISCUSSION OF DR. BALL'S PAPER.
Dr. C. D. Wescott, Chicago: Dr. Ball has given us a most excellent resume of our knowledge of this subject. In fact, he has covered all the points so far as they occur to me, and I have absolutely nothing to add in regard to the eye symptoms of brain tumor. I want to call attention, however, to the fact that this paper emphasizes better than anything else could have done, perhaps, the point that our increasing knowledge of the relation of the eye to the nervous system is augmenting our possibilities of diagnosis in brain and nerve lesions. It also emphasizes the necessity for the study of the ophthalmoscope and familiarity with its use in the practice of general surgery and medicine. When most of us were students we had no opportunity to study the ophthalmoscope; we were not encouraged by our teachers to use it in general diagnosis. To-day in our best schools a practical course in ophthalmology is a requirement for graduation. In Rush Medical College we have had such a course for the last two years, and it has been obligatory. It is surprising with what readiness the students acquire a practical knowledge of the use of the ophthalmoscope. I have risen chiefly to suggest that we all do more in this direction; that we all study the simple means by which we may acquire the use of this important aid in general diagnosis. And while on this point, I want to mention the eye model which has been furnished by Queen & Co. of Philadelphia, as an aid to the acquirement of ophthalmoscopy. This company has put upon the market a paper model, with which we may imitate the various conditions of refraction of the eye and with which, if we are the patient, we may easily acquire the habit of relaxing our accommodation, which is the essence of ophthalmoscopy. After a few hours' practice with the ophthalmoscope and
*Archev für Psychiatrie, Vol. XXV, p. 39.
this model one is prepared to examine a patient's eye.
The best text book is Gower's Medical Ophthalmoscopy. It is written in a very pleasing style and unfolds the possibilities of the ophthalmoscope in such an attractive way that you will all be pleased to take it up, I am
BY J. T. BROOKS, ESQ., OF PITTSBURG, SECOND VICE-PRESIDENT OF THE PENNSYLVANIA LINES WEST OF PITTSBURG.
Mr. President and Gentlemen: I have long
looked forward with interest to an opportunity of meeting the claim agents of the American railways. I was promised that pleasure two years ago, but events which I could not control made it impossible for me to realize my wishes at that time. I am entirely within the bounds of truth when I say that I have looked to the coming of this event with pleasure, because I knew it would bring me face to face with a body of men whose labors are worthy of record, and who, I know, are performing work for the great American railway systems which is of the very highest importance.
My only regret is that I have been so busy that I could not prepare myself worthily for this occasion. Your duties are incessant in railway service, and you know that all men who are engaged in that service are also busy. You have also learned that nothing of much value can be produced in this world without labor and a certain amount of thought, not even a speech. However, there are several points connected with the particular duties to which you are assigned with which I am familiar, and I hope to be able to speak in reference to them in a manner that will not be unsatisfactory to you.
The position you occupy is properly one of evolution. The human race itself, and every branch of human industry, so to speak, is in a stage of progress or decline. As time advances, it meets new conditions and must provide for new troubles. The progress or retrogression of the enterprises, in which men are engaged depends entirely upon the character of the men who are engaged in them. If they are intelligent, if they are devoted to the work
* Delivered at the Convention of Claim Agents held at Pittsburg, Pa., May 28, 1896
in which they are engaged, if they engage in that work with a personal interest-not merely a perfunctory interest-and if they have a sincere desire to promote the good of the cause in which they are employed, nothing is more natural than that ideas should occur to them, which will enable them to make their work more interesting to themselves and more valuable to their company. Therefore, railway managers, railway representatives and employes, in the prosecution of their work, which has been going on in this country for half a century, have come to the conclusion that a well-organized claim department is indispensoperation. You claim agents are, therefore, able to the highest degree of success in railway just as reasonable a product of the process of evolution as can be found in any department of human industry.
Passing from that point to the one which is most prominent in my mind, what do you find it is in the prosecution of your work that has contributed most essentially and most happily to your success? Precisely what wise and thoughtful men find in the pursuit of other employments. That you register greater progress, that you attain to a higher degree of success, in proportion as you confer with other men engaged in similar work; contrast your ideas with theirs, give your experience and get theirs, and, acting together, agree upon certain principles of action and rules of procedure, which will guide you individually when you go forth to the four corners of the world to carry on your work. Therefore, your annual meeting here is the second step in a process of evolution, the credit for which belongs exclusively to yourselves.
Passing from these general considerations to others more particular, what do you findyou have been for years in the service of railway companies-it is in the discharge of your daily duties that conduces most to your own ease of conscience, and results in the greatest degree of good to your company? Without stopping to consider the result of your efforts in any particular case which is under consideration, what do you find is the finest incentive to high and noble action? Surely it is that you will be loyal to the company which employs you.
The executive officers of railway companies are busied incessantly with a certain class of
railway topics, and men in the other departments have their particular questions to consider and decide; men who are charged with the responsibilities of transportation have their work to perform, and those who are in charge of freight and passenger traffic have their special duties to attend to. Now the claim agents, who are a part-and a vital part of the law department of a company, have their special functions to perform, and each of these departments which make up the whole of a railroad system is charged for the time being with the responsibilites and the cares of the particular class of railroad business which is assigned to it. Therefore, my proposition on this point is, that a man who is a good claim agent and who aspires to be an honorable man in that profession, and to win the highest success possible, should be inspired with the strongest sense of loyalty to his employer, conscious of the fact that his associates in other branches of the railway service look confidently to him, without a thought, without a suspicion that he will serve the company other than faithfully in every respect in which the company's interests are committed to his charge. We all recognize the fact that when a man is entrusted with the performance of a duty--when children, decrepit people, women unversed in business, or business men whose time and thoughts are engrossed in other matters, turn over to this man or to that man the care of a particular branch of business, they have a right to expect from him steadfast loyalty and perfect integrity. You all concede that thorough uprightness is expected of that class of persons who are known so widely as trustees, executors and administrators. In the same sense, you, in the discharge of your duties, for the time being hold the key of the treasury of the railway company. When your decisions are made and your bills are rendered in favor of an injured party, nobody doubts that you have done as fairly, as wisely and as properly for the railroad company you represent as it is possible to do; therefore, your bills go through without a question, because we say, we know that John Smith, or William Jones, or whatever our claim agent's name may be, is as loyal to our company as we are, and we may be certain that he has exercised his best patience, industry, ingenuity and judgment to get our company out of trouble. Now there,
I say, is an illustration of the fact that you occupy a high and responsible position in the railway service, since your drafts at sight, on the treasury of the company, are honored without a question.
Now, what does that loyalty that I speak of require you to do? I have no fear of the answer which any man in this assembly will make to the question I am going to put. Does it require you always to exact the last cent or the last dollar that you can in a settlement with a person who has been injured, or with the representatives of one who has been killed, regardless of every consideration, regardless of all circumstances? Does your strict sense of duty, your high sense of honor, in a case where the interests of the company are committed entirely to yourself, and where the company is manifestly in the wrong, does it require you to yield the lowest possible sum to an injured party, without any regard to the injuries or circumstances of the injured one? I know I am treading on delicate ground, but I am ready to answer the question to my own conscience and say that justice should always be done. I say that among intelligent men, and especially men who have attained to high standing and good character in business life, there rests at the bottom of the heart of every one of them a thought that there is a fitness of things which every man's conscience should recognize, and that you should come as near doing justice to the injured as you can, just as much as you should come as near as you can doing justice to your employer.
I shall not take time to prove to you what justice is or that justice is due to all men. In what I have to say on this branch of the subject I shall confine myself simply to the politic side of the question. What is the consequence in the course of years of a claim agent disregarding the principles of right in settling with parties who have claims against a railroad company, who feel it to be his duty, and rejoices when he can perform it, to wring the last cent of concession out of an injured person, or the representative of a deceased person, on the one hand; or who, on the contrary, tries to shed the beneficent rays of an enlightened conscience over the subject that is under consideration, and yields to that sentiment of justice which, by common consent, prevails among men, and enables you to say