SOME RECENT THEORIES REGARDING THE 
PATHOGENY OF SYMPATHETIC OPHTHAL- 
MIA, VIEWED FROM A MACRO- 
SCOPIC STANDPOINT 
6Y 
SAMUEL THEOBALD, M.D., 
PROFESSOR OF DISEASES OF THE EYE AND EAR IN THE BALTIMORE POLYCLINIC AND POST- 
GRADUATE MEDICAL SCHOOL; SURGEON TO THE BALTIMORE EYE, EAR, 
AND THROAT CHARITY HOSPITAL 
[Reprinted from the Archives of Ophthalmology, Vol. xiii., No. i, 1884) SOME RECENT THEORIES REGARDING THE 
PATHOGENY OF SYMPATHETIC OPHTHAL- 
MIA, VIEWED FROM A MACROSCOPIC STAND- 
POINT* 
SAMUEL THEOBALD, M.D., 
PROFESSOR OP DISEASES OF THE EYE AND EAR IN THE BALTIMORE POLYCLINIC AND POST- 
GRADUATE MEDICAL SCHOOL; SURGEON TO THE BALTIMORE EYE, EAR, 
AND THROAT CHARITY HOSPITAL. 
PROBABLY among the members of the Society present 
this evening there are some who can recall an amusing 
and not less instructive incident which happened in one of our 
local medical societies not very many years ago. A patient 
who had exhibited somewhat obscure symptoms, to obtain 
relief from her sufferings, sought medical advice. A suspi- 
cious-looking mass was discovered blocking up the posterior 
nares, and was removed without difficulty, having sloughed 
off, apparently, from its former attachments. The sup- 
posed neoplasm being regarded as probably of malignant 
character, it was, of course, deemed of the first importance 
that its histological structure should be determined ; a por- 
tion of the tissue, therefore, was teased out, and submitted 
to microscopic examination. This completed, the growth 
was exhibited to the society in question, its histological 
characteristics were duly set forth, and the clinical facts of 
the case were related. An animated discussion followed, 
and more than one hypothesis was advanced to account for 
the unusual features which the case presented. While this 
was in progress, an inquisitive individual, with macroscopic 
proclivities, inspected the tumor with more care, it would 
seem, than had been previously thought requisite ; and the 
* A paper read before the Clinical Society of Maryland, Feb. 15, 1884. 
Reprinted from the Archives of Ophthalmology, Vol. xiii, No. 1, 1884 63 
Pathogeny of Sympathetic Ophthalmia. 
debate was presently cut short by the announcement that 
the suspicious neoplasm was, after all, but a half-digested 
oyster, a harmless specimen of our should-be-familiar bi- 
valve, which, probably, during a previous spell of vomit- 
ing had become lodged at the point where it was discov- 
ered. 
There is a resemblance, not altogether fanciful it seems to 
me, between this oyster episode and the study of the path- 
ogeny of sympathetic ophthalmia, as recently conducted by 
certain microscopists. Intent upon the “threads of fibrin,” 
the “ emigrant round cells,” and the “ microphytal organ- 
isms ” which their microscopes reveal, these investigators 
appear to have lost sight of the macroscopic picture of the 
disease, with which, as clinicians, they should have been 
familiar, and as a consequence they have promulgated 
theories regarding its nature which are satisfactory only 
when viewed from the narrow standpoint of their authors. 
Although Mackenzie and the other earlier writers upon 
sympathetic ophthalmia were disposed to regard the optic 
nerves as the probable route by which the inflammation 
extends from the primarily to the secondarily affected eye, 
this view, as is well known, was afterwards universally 
abandoned, and it was taught by all authorities, among 
them Von Graefe, Bonders, and Bowman, that the ciliary 
nerves are the medium through which the sympathetic in- 
fluence is transmitted, and that the inflammation in the 
second eye is not the result of direct extension from the 
one first affected, but is due to a morbific influence reflected 
through certain of the nervous centres. In support of this 
latter view, numberless observations have been recorded : 
as, for instance, the cases reported by Bowman and by 
Von Graefe, in which the starting-point of the sympathetic 
inflammation in the second eye occurred at a spot of the 
ciliary region which corresponded symmetrically to that at 
which the first eye had been injured; the numerous dissec- 
tions, by Donders and a host of other competent observers, 
of eyes enucleated for sympathetic irritation or inflamma- 
tion in the fellow-eye, in which the ciliary nerves exhibited 
signs of inflammation, were found torn, compressed, em- Samuel Theobald. 
64 
bedded in the traumatic cicatrix, or subjected to unusual 
traction1; and the concurrent testimony of all ophthalmic 
surgeons, that sympathetic ophthalmia is especially prone 
to occur as a consequence of injury to those parts of the 
eye to which the ciliary nerves are chiefly distributed—the 
ciliary body and iris. So convincing, indeed, was the testi- 
mony offered from every quarter, that the mode in which 
sympathetic inflammation is propagated seemed settled 
beyond peradventure. 
Within the past five or six years, however, all this has 
been changed, and now, if one may judge by the current 
literature upon the subject, the pathogeny of sympathetic 
ophthalmia is the one point in ophthalmology concerning 
which we are most in the dark, and hold views which are 
least defined. On the one hand, the disciples of Cohnheim 
would have us believe that it is impossible for an inflamma- 
tion to be excited by an irritation reflected through the 
ciliary nerves ; on the other, the germ theorists tell us of 
septic choroiditis, of microphytic organisms, and of peri-neu- 
ral lymph-sheaths opening wide for their ready transmission. 
Now we are assured, in spite of all that we have been taught 
to the contrary, that in the exciting eye the ciliary nerves 
are rarely, and the optic nerve and retina almost invariably, 
the seat of pathological changes ; and again we are reminded 
of the circle of Willis, and of the facility with which altera- 
tions in the choroidal vessels of one eye may be transmitted 
by way of the ophthalmic arteries, the internal carotids, 
and the circle of Willis to the corresponding vessels of the 
other. 
To whom and to what, then, are we indebted for this 
astonishing change, for this sudden subversion of views 
which had been accepted and taught for the last quarter of 
a century by all the great masters of ophthalmology? If I 
mistake not, Dr. Adolph Alt, now of St. Louis, is entitled 
to the credit of having initiated the movement, by the pub- 
lication, in December, 1876, in the ARCHIVES OF OPHTHAL- 
MOLOGY and Otology,2 of a paper “ On the anatomical 
1 Wells’ “ Diseases of the Eye,” fourth Am. edition, note by the editor, Dr. 
C. S. Bull, p. 339. 
3 Vol. v., Nos. 3 and 4. 65 
Pathogeny of Sympathetic Ophthalmia. 
causes and the nature of sympathetic ophthalmia”; in 
which he gave a description of the pathological changes 
found in 112 eyes that had been enucleated on account of 
“sympathetic affection” of the fellow-eyes, and expressed 
the opinion that the statistics which he had accumulated 
“ strongly sustained ” the views of the earlier authors, “ that 
the optic nerve plays a great part in the transmission of 
sympathetic ophthalmia.” The all-pervading influence of 
the germ theory of disease has also played an important 
part; and still more important in favoring the change has 
been the influence of the theory of inflammation at present 
most in vogue, which regards “ molecular alteration of the 
vascular walls as the indispensable condition for the de- 
velopment of inflammation,” and “ busies itself but little 
with the influence which the nerves may exert upon inflam- 
mation, or denies it entirely.” 1 
Let us now consider the data brought forward by Dr. Alt, 
and see to what extent his conclusion, that they strongly 
sustain the view “ that the optic nerve plays a great part in 
the transmission of sympathetic ophthalmia,” is justified ; 
and this it is the more important to do with care, because 
his statistics are quoted by all those who oppose the old 
theory of transmission, and are used as the basis of many of 
their strongest arguments. It is to be observed, in the first 
place, that the view he favors is that of direct transmission 
of the inflammation by way of the optic nerve itself, and not 
by way of the peri-neural lymph-space, as Leber and others 
have since suggested. Since he bases this conclusion upon 
the large percentage of “ changes” in the retina and optic 
nerve, and the relatively small percentage of “ changes” in 
the ciliary nerves, which he states the enucleated eyes ex- 
hibited, we shall direct our attention more especially to these 
points. “ The percentage of changes in the retina and the 
optic nerve is remarkably great—79 per cent.,” he states, and 
this he thinks “should engage very earnest consideration— 
the more so, as there are but i6f- per cent, which present 
changes in the ciliary nerves.” 2 
1 “ Sympathetic Diseases of the Eye ” : Mauthner, Am. edition, pp. 109 
and 1x2. 
2 Page 474, vol. v., Nos. 3 and 4, Archives of Ophthalmology and 
Otology. Samuel Theobald. 
66 
In attempting to verify these figures, an unexpected dif- 
ficulty presents itself at the outset, which is significant be- 
cause of its bearing upon the accuracy of his methods. 
Although at the commencement of his paper Alt states that 
his statistics relate to i io eyes enucleated on account of 
sympathetic affection of the fellow-eyes, 32 of which had 
been placed at his disposal by his colleagues, and the data 
regarding 78 had been compiled from literature, a careful 
count shows that 112 such eyes are described in the tabular 
compilation (80 derived from literature). His percentages, 
however, are based upon a total of 110 cases. Accepting 
the data given in the tabular compilation, we find, as re- 
gards the ciliary nerves, that in 66 of the 112 cases no 
mention is made of their condition. In these cases it is 
probable that no attempt was made to ascertain whether 
they had undergone pathological changes or not ; for, 
though one may cut open an enucleated eye, and detect at 
a glance the existence of detachment of the retina (and this 
condition, as we shall presently see, constitutes a very large 
part of the “ retinal changes ” to which so much importance 
is attached), a much more elaborate examination, involv- 
ing usually the making of microscopic sections, is necessary 
to determine whether the ciliary nerves are the seat of 
pathological changes. 
Disregarding, therefore, these sixty-six cases, and taking 
account only of the forty-six cases in which the condition of 
the ciliary nerves is mentioned, we find them described 
as “ normal ” thirty-one times, as presenting pathological 
changes of histological character six times, gross pathologi- 
cal changes (torn, compressed, lying in tissue of scar, etc.) 
seven times, both histological and gross pathological changes 
once, and “ not discoverable ” (apparently having been 
entirely destroyed) once. Considering the condition of the 
nerves in this last case as pathological, we have fifteen cases 
presenting either histological or gross pathological changes 
in the ciliary nerves in a total of forty-six, or 32.6 1 per 
cent, instead of i6f- per cent, as given by Alt. The 
1 In my calculations I have not thought it necessary to carry the fractions be- 
yond the first decimal. 67 
Pathogeny of Sympathetic Ophthalmia. 
discrepance arises from the fact that he has taken account 
only of those cases (seven) which present histological 
changes.1 It is a bad rule, however, which does not work 
both ways, as the old proverb tells us, and so we can not 
help thinking, since he uses the percentages of “ changes ” 
in the ciliary nerves, and in the retina and optic nerve, for 
comparison, that it would have been better for him to fol- 
low the same plan in obtaining the former that he adopted 
in calculating the latter. This, however, has not been 
done, for the 79 per cent, of changes in the retina 
and optic nerve, which he gives, includes the many cases in 
which only gross changes (chiefly detachment) of the 
retina are described. Moreover, although no intimation is 
given of the fact, the i6-| per cent, of changes in the 
ciliary nerves has reference to only the forty-three cases in 
which their histological condition is mentioned, while the 
79 per cent, of retinal and optic-nerve changes refers 
to the whole series of one hundred and ten (as given 
by him) cases. Furthermore, he certainly does not mean 
what he says, when he speaks of 79 per cent, of 
the eyes exhibiting changes in the “optic nerve and 
retina,” a for a careful survey of the table shows that only 
27, or 24.1 per cent, of the one hundred and twelve eyes, 
exhibit changes in both the retina and optic nerve. The 
condition of the retina itself is mentioned in eighty-one 
cases ; once it is spoken of as “ wanting,” and in every other 
instance pathological changes, either histological or gross, 
are described, partial or complete detachment being named 63 
times. That is to say, the retina is in an abnormal condi- 
tion in 100 per cent, of the cases in which its state is re- 
ferred to, or 72.3 per cent, of the whole number of eyes. 
The optic nerve is mentioned 32 times, or in 28.5 per cent, 
of the cases, pathological changes—including atrophy 
14 times, and optic neuritis 6 times—being described in 
each instance. In 76.7 per cent, of the cases (or upon his 
basis of no eyes in 78.1 per cent.) pathological changes 
affecting either the retina or optic nerve, or both, are found, 
and it is to this, probably, that the 79 per cent, of changes 
1 As he states on p. 472. 
* Op. cit, pp. 472 and 474. Italics my own. Samuel Theobald. 
68 
in the optic nerve and retina, as he expresses it, refers. Had 
he followed the same rule in regard to the optic nerve and 
retina that he did with the ciliary nerves, and taken account 
only of those cases in which histological alterations are men- 
tioned, his percentage of pathological changes would have 
been reduced from 79 to about 40. 
A striking contrast, as regards the condition of the ciliary 
nerves, is brought out, if we group separately Alt’s own 
cases, and those which he has taken from literature. Thus, 
in the 31 cases of his own in which the ciliary nerves are 
mentioned, they are described as normal 26 times, or in 
83.8 per cent, of the eyes, and as presenting histological or 
gross pathological changes 5 times, or in only 16.1 
per cent.; while in the 15 cases from literature in which 
they are spoken of, they are described as normal in but 
33|- per cent, of the eyes, and as pathological in 66J per 
cent. 
In the Archives of Ophthalmology, September, 1881/ 
Dr. W. C. Ayres, of New York, gives the notes of 4 eyes 
enucleated for sympathetic inflammation, and 3 for sym- 
pathetic irritation, which he examined microscopically, and 
in every one of which he discovered pathological changes in 
the ciliary nerves. If we add these to the 15 cases 
taken from literature by Alt, we have a total of 22 cases, 
in which the ciliary nerves are pathological 17 times, 
or in 77.2 per cent., and normal only 5 times, or in 22.7 
per cent. In the same paper there is reported also a case in 
which an eye containing a gun-cap was enucleated for 
iridocyclitis purulenta. In this instance the fellow-eye 
“ had manifested no sympathy, and the examination of the 
enucleated eye revealed the very significant fact “ that every 
[ciliary] nerve-bundle * * * examined was completely de- 
generated, and divided somewhere in its course by accumu- 
lations of small round cells.” 
The next point worthy of comment is, that Alt should 
have found the ciliary nerves histologically normal (and 
showing gross pathological changes but twice) in fourteen 
of the fifteen eyes enucleated on account of sympathetic 
1 Vol. x., No. 3, p. 277 et seq. 69 
Pathogeny of Sympathetic Ophthalmia. 
irritation, which were submitted to him for examination, 
their condition in the one remaining eye not being men- 
tioned. Here, it seems to me, he is unfortunate in proving 
too much ; for even the most uncompromising opponent of 
the doctrine that sympathetic inflammation is transmitted 
through the medium of the ciliary nerves, admits, at least, 
that sympathetic irritation is propagated in this way. So 
that we are forced to conclude, either that an eye in which 
the ciliary nerves are entirely normal may excite sympa- 
thetic irritation of such serious character as to justify its 
enucleation ; or else, what is much more likely, that patho- 
logical changes capable of causing such sympathetic symp- 
toms may exist in the ciliary nerves of the exciting eye 
(affecting most probably not their trunks, but their terminal 
filaments in the iris and ciliary body), and yet be entirely 
undetectable with the microscope. 
As to the 79 per cent, of pathological changes in the 
“ retina and optic nerve/' to which Alt and those who quote 
his statistics attach so much importance, they are clearly 
of little significance in so far as they have any bearing upon 
the question of the mode of transmission of sympathetic 
ophthalmia. In the first place, it is manifest that almost 
every eye in which these changes were discovered had 
been the seat of disorganizing inflammation, which had, 
indeed, involved the retina and optic nerve, but only in 
common with all the other important structures of the eye, 
including the iris, ciliary body, choroid, lens, and vitreous 
humor. Indeed, Alt himself admits 1 that in the whole 
series of cases there is but one “ in which there was an 
affection of the retina without coincident affection of the 
uveal tract.” In the second place, when we examine into 
the character of the changes which go to make up the total 
of 79 per cent, (as given by Alt, but 76.7 per cent, according 
to my calculation), we find that in a large majority of the 
cases they consist in detachment of the retina, or in atrophy 
or excavation of the optic nerve, optic neuritis and retinitis 
being mentioned each but six times, and being concurrent, 
moreover, in five instances. That detachment of the 
1 On p. 474. Samuel Theobald. 
70 
retina, by causing traction upon the ciliary body, might 
influence the development of sympathetic ophthalmia 
(supposing that it is propagated through the ciliary nerves), 
may readily be believed, but it will scarcely be maintained 
that it could do so, if the hypothesis that the sympathetic 
affection is the result of a progressive optic neuritis be 
accepted as correct. And it is quite as manifest that the 
excavated and atrophic optic nerves, which figure so fre- 
quently in the tables, are incapable of producing such a 
result. If it be urged that the atrophy indicates antecedent 
neuritis, it may be said, in reply, that the condition of optic- 
nerve atrophy occurs with especial frequency in the eyes 
which were enucleated on account of sympathetic irritation ; 
so that in these cases, at least, the neuritis must have run 
its course, and disappeared, without the inflammation having 
extended to the second eye. With these three classes of 
cases thrown out, the percentage of retinal or optic-nerve 
changes, dwindles into insignificance, especially when the 
graver pathological alterations with which these changes 
were in almost every instance associated are taken into 
account. 
No! If we would discover the true significance of Alt’s 
statistics, we must not look to the data bearing upon the 
condition of the optic nerve and the retina, but to those 
which have reference to the cornea, iris, and ciliary body. 
Here we meet with the old familiar story—iritis and cyclitis, 
plastic or purulent, recurring again and again; foreign 
bodies in the ciliary region ; corneal wounds with incarcera- 
tion of iris; sclerotic wounds with involvement of ciliary 
body;—these are the conditions which are enumerated in an 
almost unbroken series from the beginning to the end of 
his tables. Only once in the whole series of one hundred 
and twelve cases is evidence wanting of the uveal tract 
being the seat of pathological changes,1 and but for the 
scantiness of the information given in regard to this case 
(in which there seems to have been a gunshot wound of the 
eye), even this single exception would probably not have to 
be noted. 
1 Waldeyer’s Case (31), p. 426. 71 
Pathogeny of Sympathetic Ophtahlmia. 
In a word, we fail to find any justification, whatever, for 
the conclusion reached by Alt (and which has been accepted 
by so many), that the data he has brought together strongly 
sustain the view that the optic nerve plays an important 
part in the transmission of sympathetic ophthalmia ; but, 
on the contrary, we are convinced that if his statistics be 
examined in an unbiassed spirit it will be found that it is the 
old theory, which attributes to the ciliary nerves the impor- 
tant part in the production of sympathetic ophthalmia, that 
is, in reality, “ strongly sustained.” 
As to the clinical evidence which has been relied upon to 
support the view that sympathetic ophthalmitis is the result 
of a progressive optic neuritis which extends from the 
primarily to the secondarily affected eye, it proves upon 
examination to be as inconclusive as the pathological testi- 
mony which we have just examined. Vose Solomon and 
Mooren, for example, each report a case in which sympa- 
thetic inflammation appeared after enucleation of the ex- 
citing eye, and as they had the misfortune to employ 
defective scissors to divide the optic nerve with, they rush 
to the absurd conclusion that the sympathetic affection was 
due to the bruising of the optic-nerve fibres, and hence that 
the inflammation must have spread by this route. It is 
scarcely necessary to point out, as Brudenell Carter has 
already done in alluding to Solomon’s case,1 that the ciliary 
nerves must have participated in the unusual laceration to 
which the optic nerve was subjected; so that as far as the 
question of transmission is concerned, these cases are with- 
out significance, and may be quoted with the same show of 
reason in support of either the ciliary-nerve or the optic- 
nerve hypothesis. It may be remarked also in regard to 
these cases, as well as of the frequently quoted cases of 
Colsmann and Hugo Muller (in which a neuro-retinitis 
developed in the uninjured eye a few days after the enucle- 
ation of the other), that not only is there no ground for 
supposing that the sympathetic outbreak was in any way 
dependent upon the cutting of the optic nerve, but that it is 
not improbable that the attack would have occurred, exactly 
“ Diseases of the Eye,” Am. edition, p. 115. Samuel Theobald. 
72 
as it did, had the exciting eye not been enucleated. Indeed, 
it would be entirely unjustifiable to assume, in the cases of 
Colsmann and Hugo Muller, that the operation bore any 
such relation to the inflammatory outbreak in the second 
eye as usually exists between a traumatism of an eye and 
the sympathetic disease which it induces, because of the 
briefness of the interval that separated the two events. 
The most that can be claimed is, that the sympathetic 
attack, which was imminent, was precipitated by the shock 
of the operation ; and admitting this, it seems much more 
likely that the determining influence was transmitted through 
the ciliary nerves than through the optic. As to the inter- 
esting case reported by S. C. Ayres,1 in which a sympa- 
thetic inflammation that had made its appearance some 
time after enucleation of the other eye was cured by resec- 
tion of the optic-nerve stump, it is evident, since the patient 
suffered severe and persistent pain in the empty socket, 
which certainly could not have been dependent upon irrita- 
tion of a nerve of special sense, such as the optic, that some 
of the orbital branches of the fifth nerve, probably the 
remains of the ciliary nerves which had become involved in 
the cicatricial tissue about the optic-nerve stump, were in a 
pathological condition ; and it is equally certain, since the 
resection relieved both the pain and the sympathetic inflam- 
mation, that it included these branches as well as the 
extremity of the optic nerve. Probably a condition existed 
here not unlike that which Dr. Poncet found on enucleating 
an eye for sympathetic mischief, upon which an optico- 
ciliary neurectomy had been previously performed without 
beneficial effect. The case was reported by him to the 
Ophthalmplogical Section of the International Medical 
Congress, London, 1881. The ciliary nerves were embedded 
in a dense mass of cicatricial tissue, which had formed 
about the posterior pole of the eye as a consequence of the 
previous operation, and exhibited marked inflammatory 
changes. In commenting upon the features of this case, 
Dr. Poncet alluded to the possibility of a similar condition 
occurring after enucleation, and suggested that the devel- 
Archives of Ophthalmology, vol. xi., No. 2, p. 199. 73 
Pathogeny of Sympathetic Ophthalmia. 
opment of sympathetic inflammation after removal of the 
exciting eye might be explained in this way.1 Upon this 
point Mauthner remarks: “I think that in every case in 
which we have been obliged to ascribe the outbreak of 
sympathetic symptoms to the enucleation itself, or to the 
introduction of an artificial eye, we have, so far, observed 
that the region in the bottom of the orbit which was occu- 
pied by the stump of the excised nerve, and its accompany- 
ing ciliary nerves, was sensitive to the touch, as well as that 
the conjunctiva lining the cavity was swollen, red, and 
painful.” 3 
But, even supposing there are no evidences of inflamma- 
tion in any of the orbital branches of the fifth nerve, it is 
still quite unnecessary to adopt the progressive optic 
neuritis hypothesis in order to account for the origin of 
sympathetic inflammation, or the persistence of sympathetic 
irritation, after enucleation of the exciting eye ; for it is 
altogether probable that the disturbances of nutrition in the 
second eye are preceded by, and are dependent upon, 
molecular alterations (perhaps a slight myelitis, as suggested 
by Brecht) in the vaso-motor or “trophic” centres, and that 
these again are secondary to alterations of similar character 
in the Gasserian and ophthalmic ganglia; so that we need 
only suppose that in exceptional instances these changes 
have progressed so far as not to be arrested by the enuclea- 
tion of the eye, to obtain an entirely satisfactory explana- 
tion of the etiology of these anomalous cases. 
The occasional occurrence of sympathetic “ neuro-retinitis ” 
is urged as an additional argument in favor of the view that 
the optic nerve is the route by which the inflammation 
reaches the second eye. It is worthy of remark, however, 
that it is always a neuro-retinitis, and never a pure neuritis or 
papillitis, that is spoken of. Mauthner refers to a number of 
cases of sympathetic choroido-retinitis, a few cases of retin- 
itis, and a still smaller number diagnosticated as neuro-retin- 
itis ; but, though he devotes a paragraph to “ sympathetic af- 
‘See Transactions of the Seventh International Medical Congress, vol. iii, 
P- 39- 
* “ Sympathetic Diseases of the Eye," Mauthner, English translation, p. 136. Samuel Theobald. 
74 
fections of the optic nerve,”1 he alludes only to a few doubtful 
cases of simple atrophy, and makes no mention whatever of 
neuritis. It is safe to say, I think, that no case of sympa- 
thetic optic neuritis has yet been recorded in which there 
were not indications of the coexistence of inflammation of 
at least the adjacent portions of the choroid and retina. 
Now, it is well known that an intimate anastomosis exists 
between the blood-vessels of the optic disc and those of the 
surrounding choroid, and that hyperaemia of the former and 
indistinctness of its outline frequently accompany even the 
slightest grades of choroiditis. It is also known that the 
short ciliary nerves, which enter the eyeball around and in 
close proximity to the optic nerve, give off many branches 
to the neighboring choroid—in fact, that the posterior 
segment of the choroid is especially rich in its ciliary-nerve 
supply.3 That sympathetic inflammation, therefore, which 
usually commences as an irido-cyclitis, should occasionally 
begin as a posterior polar choroiditis, the inflammation 
quickly involving the retina and optic nerve, is exactly 
what we might expect, if it be dependent upon an influence 
reflected through the ciliary nerves; and this, we believe, is 
the true explanation of most, if not all, of the cases of so- 
called neuro retinitis of which we have of late heard so 
much.3 
A further objection which may be urged against the 
theory of a progressive optic neuritis is this: If the inflam- 
mation which has spread from the exciting eye reaches the 
second eye as a simple descending neuritis, we should 
expect only such results as usually follow neuritis of this 
character, that is to say, ultimate atrophy, perhaps, of the 
optic nerve and retina, but little, if any, implication of the 
uveal tract, certainly none of its anterior portion—the ciliary 
1 Op. cit., p. 92. 
3 H. Muller, Schweigger, Stellwag, Pope, etc. See “Anatomy and Histology 
of the Human Eye,” Metz, p. 39. 
3 Even a pure sympathetic neuritis might, of course, be produced by a reflex 
influence dependent upon irritation of the ciliary nerves. Anatomists (Hirzel 
and Tiedemann) assert that a twig from the ophthalmic ganglion enters the optic 
nerve with the arteria centralis retinae. In view of this fact, we should heed 
the advice which Alt gives (upon other grounds), to remove a large piece of the 
optic nerve when we enucleate an eye for present or threatening sympathetic 
disease.  Pathogeny of Sympathetic Ophthalmia. 
body and iris. It is scarcely necessary to say, however, 
that such is not the case, but that even when the inflamma- 
tion commences at the posterior pole of the eye, it usually 
spreads to the anterior portion of the uveal tract, and 
terminates in a malignant irido-cyclitis. 
In regard to the case of sympathetic iritis reported by 
Alt in the Archives of Ophthalmology, vol. viii, No. i, 
in which he thinks the inflammation was “mechanically” 
transmitted to the second eye by way of the optic nerve, 
because there was found in the enucleated eye “ a very active 
inflammatory process in the optic nerve and retina, while 
the ciliary nerves appeared perfectly unaltered,” 1 we think 
it would be difficult for him to explain, in accordance with 
this view, how the inflammation reached the iris of the 
second eye ; and still more difficult to explain how, when 
it had reached this point by “mechanical extension,” it 
was arrested, as he claims it undoubtedly was, by the enu- 
cleation of the other eye. On the other hand, these difficul- 
ties at once disappear, if we assume that the influence 
which determined the development of the iritis in the sec- 
ond eye was reflected through the ciliary nerves, and was 
dependent upon an irritation of their terminal filaments in 
the inflamed iris and ciliary body of the exciting eye, the 
normal condition of their trunks in this eye being, in fact, 
conducive to such reflected action ; for not only is the ques- 
tion of the origin and location of the sympathetic inflamma- 
tion disposed of at once, but we are enabled to comprehend 
how the enucleation of the primarily affected eye favorably 
influenced the condition of the fellow-organ, by relieving it 
of a continuously acting source of irritation. 
The influence which the germ theory of disease has exerted 
upon the question of the pathogeny of sympathetic ophthal- 
mia, to which reference has been made, is exhibited in the 
now-popular septic choroiditis and perineural lymph-space 
doctrine advanced by Leber, and advocated, notably, by 
Snellen, before the Ophthalmological Section of the London 
International Medical Congress, (i881). Concerning this 
JPage 106. Samuel Theobald. 
76 
doctrine, which regards sympathetic ophthalmitis as an in- 
flammation of septic character, that has spread from the 
primarily to the secondarily affected eye by zvay of the hiter- 
vaginal lymph-space of the optic nerve, it is to be said : 
that the evidence adduced in its favor is extremely meagre ; 
that the arguments by which it is supported are inconclu- 
sive ; and that, at best, it is of but limited application. 
Leber, for example, adopts this theory mainly in conse- 
quence of having found pronounced hyperplasia of the 
inter-vaginal connective tissue of the optic nerve, with pro- 
liferation of the endothelium, in four eyes enucleated for 
sympathetic trouble1; and Snellen, though he points out 
how the coincidence of an infective plastic inflammation of 
the uveal tissue, with closure of the anterior and dilatation 
of the posterior lymphatic spaces of the eye, might produce 
such septic transferrence, has little additional testimony to 
offer, beyond the statement that the tension of the exciting 
eye constantly increases before the second eye is affected, 
and his observation, in a freshly prepared microscopic speci- 
men from an eye just enucleated on account of a serious 
traumatism received three weeks previously, of a mass of 
moving molecules, which were presently recognized as 
being for the most part pigment molecules from the uveal 
tissue, though “ several somewhat larger bodies showed by 
their ampler movements all the characteristics of micro- 
cocci.” 2 The former argues that the pertinacity of sympa- 
thetic ophthalmitis, its frequent relapses, and its involve- 
ment of so many different parts of the eye, render probable 
its infectious origin ; but this certainly is an unwarrantable 
conclusion, since the severer forms of herpes zoster ophthal- 
micus (which is perhaps more nearly related to sympathetic 
inflammation, and in some respects resembles it more 
closely, than any other variety of ophthalmia) present just 
such characteristics. The occasional occurrence of sympa- 
thetic inflammation after enucleation of the exciting eye, he 
also alludes to as having a similar bearing; but of this we 
1 Archiv fur Ofhf/ialmologie, vol. xxvii, i, p. 325 et seq. 
2 Transactions of the International Medical Congress, Seventh Session, 
London, 1881, vol. iii. p. 31 et seq. Pathogeny of Sympathetic Ophthalmia. 
have already spoken, giving it quite a different interpreta- 
tion. 
The first and most obvious objection to this doctrine 
(which Leber himself appreciates) is, that sympathetic in- 
flammation almost always begins in the anterior portion of 
the uveal tract, and not in the region of the optic nerve, as 
should be the case if this view were correct. Leber, indeed, 
suggests that neuritis may always be present without being 
recognized, owing to the turbidity of the vitreous humor ; 
but, as the neuritis should manifest itself first, it ought to be 
more frequently observed before the inflammatory process 
has extended to the uveal coat and rendered the media 
cloudy. Indeed, if there beany truth in Leber’s other theory, 
that papillitis, or choked disc, is dependent upon the pres- 
ence of a phlogogenic fluid in the optic-nerve intervaginal 
space,1 then, if his view of the etiology of sympathetic 
ophthalmia were correct, it would seem that just this con- 
dition of a well-marked neuritis should be the most frequent- 
ly met with and the most characteristic feature of the dis- 
ease ; but, as has been said, papillitis, or choked disc, 
appears to be the one form of sympathetic inflammation 
which has not been recorded. Moreover, if papillitis and 
sympathetic ophthalmitis resemble each other as closely in 
their etiology as Leber would have us believe, it seems not 
impertinent to inquire why they should differ so absolutely 
in their clinical history. Again, it may be said, that if the 
description usually given by anatomists of the intervaginal 
space of the optic nerve be correct, namely, that it ends 
abruptly in the sclerotic tissue about the optic-nerve en- 
trance, being cut off from the deeper tissues of the eye by 
the interposition of the pial sheath, which at this point 
turns out to blend with the inner third of the sclerotic, the 
dural sheath being lost in the outer two thirds, it is diffi- 
cult to understand how the inflammatory process spreads 
hence to the ciliary body and iris. Some authorities claim 
that there are lymph-spaces in the lamina cribrosa which 
communicate directly with the intervaginal space, but this 
Leber, himself, has denied.2 The occurrence of dropsy of the 
1 Op.cit., p. 52 et set/. 
8 Trans. Seventh International Med. Congress, (1881), vol. iii., p. 55. Samuel Theobald. 
intervaginal space, with distention of the ocular end of the 
nerve-sheath, seems also to indicate the absence of any di- 
rect communication between this cavity and the interior of 
the eye.1 
Another serious objection to this theory is, that in many 
instances the condition of the exciting eye, at the time of 
the sympathetic outbreak, is not such as to warrant the as- 
sumption that it is the seat of a plastic or septic uveitis. 
I have already alluded to a case in my own experience, in 
which a sympathetic neuro-retinitis (or more accurately, 
perhaps, a posterior polar choroido-retinitis) developed in 
consequence of a very severe and obstinate traumatic 
keratitis of the opposite eye. The corneal inflammation was 
caused by the instillation into the eye of aqua ammonia, 
which had been mistaken for a collyrium, and, although for 
months the keratitis persisted, and the eye remained ex- 
tremely irritable and photophobic, there was certainly at 
no time any serious implication of the uveal tract. My 
notes show that a short while before the sympathetic in- 
flammation made its appearance, the vision of the injured 
eye was tested, and that, in spite of a very considerable 
amount of corneal cloudiness and irregular astigmatism, the 
patient was able to read with it J. No. 8. The irritability 
of this eye gradually disappeared, and after a protracted 
treatment, which consisted chiefly in the administration of 
iodide of potassium and biniodide of mercury, and the ap- 
plication of the artificial leech, the sympathetic inflamma- 
tion slowly subsided.2 
The irritation caused by the incarceration of a tag of iris 
in a corneal scar, as in the now discredited operation of 
1 Dr. Win. F. Norris, of Philadelphia, using the bodies of young children, 
succeeded without difficulty in filling the intervaginal space of the optic nerves 
by injecting fluids through the anterior fontanelle into the subarachnoid space. 
But, though his injections “ filled also the lymph-spaces of the spinal cord and 
of the nerves given off by it,” only in a few instances, “ with high pressure,” 
did they penetrate from the subdural to the perichoroidal space.—Phila. Med. 
Times, vol. ix., p. 567. 
2 Brailey, speaking of the possibility of sympathetic inflammation travelling 
along the intervaginal space, states, “that the inflammation of this is usually 
extremely slight, compared with that of the uveal tract itself, and that sym- 
pathetic inflammation may occur without any implication of the choroid in the 
neighborhood of the papilla of either eye.” Trans. Seventh International Med. 
Congress (1881), vol. iii., p. 38, 79 
Pathology of Sympathetic Ophthalmia. 
iridodesis, has not infrequently provoked a sympathetic 
ophthalmitis, without exciting in the primary eye a serious 
amount of inflammation 1 ; and a shrunken stump, in which 
all inflammation that could possibly be regarded as of in- 
fectuous character had long since subsided, has often done 
the same. 
Lastly, it may be said, that there is one well-recognized 
form of septic inflammation of the uveal tract—suppurative 
or metastatic choroiditis,—and that the clinical history 
which it presents is wholly unlike that of sympathetic in- 
flammation. In order to fortify his theory Leber at- 
tempts to explain the well-known fact that suppurative pan- 
ophthalmitis rarely gives rise to sympathetic inflammation, 
by assuming that the septic germs “ are partly gotten rid 
of by purulent perforation of the eyeball, and partly 
destroyed or rendered inert by enormous development of 
pus.” I submit, however, that the etiology of this disease, 
and the consequences which hot infrequently flow from it, 
prove it to be the typical infectious ophthalmitis, and that 
it, above all other forms of ocular inflammation, would 
be most apt to excite sympathetic ophthalmia, were the 
theory of its pathogeny which Leber has promulgated 
true. 
Finally, to the many, ever ready to follow each swing of 
the pendulum of popularity, who would cast aside as of no 
value all that clinical observation has taught us concerning 
the pathogeny of sympathetic ophthalmia, because it hap- 
pens not to harmonize with the latest dictum of the latest 
school of pathology, I would say: that though the pre- 
dominant school of pathology at the present day may busy 
itself but little with the influence which the nerves may 
exert upon inflammation, as Mauthner remarks, it is cer- 
tainly not in a position to demonstrate that no such influ- 
ence is exerted ; and that while the experiments of Professor 
Ludwig, showing that the chorda tympani conveys to the 
submaxillary gland a specific stimulus to secretion, re- 
1 Compare “ Sympathetic Diseases of the Eye,” Mauthner, English transla- 
tion, p. 48. Samuel Theobald. 
80 
move all a priori objection to the theory that inflamma- 
tory changes of texture may be produced by centrifugal 
“ trophic ” nerves,1 there are many clinical facts, beside 
the almost convincing ones which the phenomena of sym- 
pathetic ophthalmia furnish, that go far to prove that either 
through “ trophic ” or vaso-motor fibres, or through both, 
nerve influence does determine such tissue changes.3 I 
would also remind them, that though it is the fashion of the 
day to accept as conclusive the well-known experiments by 
which Snellen supposed he had demonstrated that the 
sloughing of the cornea which follows division of the 
trigeminus is a traumatic, and not a neuro-paralytic phe- 
nomenon, others (Samuel, Meissner, Schiff) have experi- 
mented in this same field, and have obtained results which 
led them to adopt directly opposite views ; and that so 
close an observer and logical a reasoner as Von Graefe re- 
jected absolutely Snellen’s conclusions, (as very many 
ophthalmologists have done since,) because he found them 
opposed to facts with which his clinical experience brought 
him into daily contact ;3 also, that in the reports of nearly 
all eye hospitals there are recorded cases of neuro-paralytic 
keratitis, and that within the past few years ophthalmic 
surgeons have shown a disposition to attach more and more 
importance to diseases of this type—diseases, as Brudenell 
Carter aptly expresses it, which are essentially neuropathic 
in their character, and differ from neuralgia chiefly in this 
JSee article on Inflammation in “ Holmes’ System of Surgery,” vol. I., p. go. 
3 Among the most striking may be mentioned the well-known observations re- 
corded by Mitchell, Morehouse, and Keen,) Gunshot Wounds and other Injuries 
of Nerves, Phila., 1864; Circular No. 6, Surgeon-General’s Office, 1864); 
the cases of reflex structural changes due to dental disease, described in Guy’s 
Hospital Reports (third series, vol. xiii.) by Mr. Salter ; and the ulceration 
of the duodenum which occurs so frequently in consequence of extensive burns 
of the surface of the body, and which Brown-Sequard succeeded also in produ- 
cing experimentally, The statement of Mooren that he has seen cases of optic 
neuritis which were dependent upon uterine displacement, and which dis- 
appeared when this was corrected, may also be mentioned in this connection. 
3 One can readily believe that the corneal inflammation and ulceration that 
supervene upon division of the trigeminus might be favorably modified by 
keeping the lids closed over the eye ; but the suggestion that the ulcerative and 
necrotic changes which result in the destruction of the cornea within forty-eight 
or seventy-two hours after the section of the nerve are due simply to the 
injury to which the eye is exposed, owing to its anaesthetic condition, seems 
preposterous. Certainly, if we may reverse the usual order, and reason from 
man to the rodentia, we should be warranted in so regarding it. Pathology of Sympathetic Ophthalmia. 
respect, that they declare themselves by abnormal tissue 
change instead of by abnormal sensation.1 And, lastly, I 
would point out to them, that though the pathologists of the 
Cohnheim school contend that the reflex congestion which 
follows stimulation of sensory nerves is not inflammation, 
and does not lead directly to it, they admit that when this 
condition has existed for some time (as in the premonitory 
stage of sympathetic ophthalmia) it places the cells of the 
part in a condition of instability, lowers the vitality of the 
capillary walls, and offers facilities for the emigration of 
leucocytes ; so that at any moment, upon the slightest prov- 
ocation, (in the case of the eye, for example, from the 
irritation caused by overwork or undue exposure to light3) 
inflammatory changes may be precipitated.3 So that, after 
all, they may accept the Cohnheim doctrine in its entirety, 
and at the same time, without being illogical, they may 
believe what clinical evidence so plainly declares—that 
sympathetic ophthalmitis is dependent, if not directly, at 
least secondarily, upon a reflex influence transmitted 
through the ciliary nerves. 
Briefly summarized the conclusions which seem to me to 
be warranted by the facts we have examined are : 
1st. That the doctrine that sympathetic ophthalmia is the 
result of a progressive optic neuritis, which spreads from the 
primarily to the secondarily affected eye, is supported by 
no facts worthy of serious consideration, but is the out- 
1 “ Diseases of the Eye,” Am. edition, p. 113. Also compare Noyes : “ Diseases 
of the Eye,” p. 190 ; and see an interesting article in the Am. Journal Med. 
Sciences, July, 1881, by Dr. Jas. L. Minor : Anaesthesia of the Cornea, and 
its Significance in Certain Forms of Eye Disease, in which he makes the sig- 
nificant statement that ‘ ‘ amesthesia of the cornea existed in six [of his] cases 
without keratitis ; and in those cases that presented both ancesthesia and 
inflammation, complete protection of the eye did not materially alter the course of 
the disease.” 
2 Brailey (Trans. London Med. Congress, 1881, vol. iii., p. 38) mentions that 
sympathetic inflammation frequently occurs shortly after patients leave the 
hospital ; and he attributes this to the exposure of the second eye to light. He 
also states that the records of Moorfield’s Hospital “show that a wound 
occurring in the summer months is more liable than one in the winter to be 
followed by sympathetic disease ” and ‘ ‘ that sympathetic inflammation is more 
likely to break out in summer, irrespective of the time when the first eye was 
injured.” 
3 See the very interesting (Bradshaw) lecture on The Influence of the Sympa- 
thetic on Disease, by Dr. Edward Long Fox, British Med. Journal, Aug. 26, 
Sep. 2, 1882. Samuel Theobald. 
growth of grossly misinterpreted clinical and pathologico- 
anatomical observations. 
2d. That the septic choroiditis theory of Leber rests upon 
evidence which is scarcely more substantial ; and from both 
an anatomical and a clinical point of view is open to serious 
objection. 
3d. That there is an overwhelming preponderance of testi- 
mony, both clinical and pathologico-anatomical (which, 
however, for obvious reasons, it has been the fashion of late 
to systematically belittle), in favor of the-one-at time uni- 
versally accepted doctrine that sympathetic ophthalmitis, 
like sympathetic irritation, is a reflex neurosis, dependent 
upon irritation of the ciliary nerves of the exciting eye 
(probably for the most part of their terminal filaments in 
the ciliary body and iris) 1 ; and that as this testimony goes 
far to show that inflammatory changes of texture, as well 
as abnormalities of sensation, may be produced by reflex 
nerve influence, it has a very important bearing upon the 
theory of the etiology of inflammation at present most in 
favor. 
4th. That, as the history of the last quarter of a century 
plainly shows, experimental pathologists, as well as clini- 
cians, are liable to fall into error, and that for this reason 
it behooves the latter to be less eager to cast aside as un- 
trustworthy the lessons they have learned from the daily 
observation of disease, because they may seem to conflict 
with the dicta which the laboratories from time to time 
give forth. 
1 That in some instances inflammatory changes occur in the second eye with- 
out well-marked sympathetic irritation, and that in others sympathetic irritation 
of the most marked character exists for a long time without inflammation, does 
not militate against the view that both of these conditions are dependent upon 
a reflex influence transmitted through the ciliary nerves, as some would have us 
believe. In the first place, the ciliary nerves contain sympathetic as well as 
sensory fibres, and it is probable that the former have most to do with trophic 
changes, the latter with disturbances of sensation. In the second place, in view 
of the astonishing difference in the degree of pain inflicted in different persons 
by the same amount of violence done to the nerves, we are justified in assuming 
that in the eye, as well as in other parts of the body, these two kinds of fibres 
do not always exist in the same relative proportion, or, at least, that in different 
individuals, sometimes the influence of one set, and sometimes the influence of 
the other, may predominate. Admitting this much, we shall have no difficulty 
in comprehending why a given lesion of the ciliary body, for example, should 
give rise, in one instance, to pronounced sympathetic irritation unaccompanied 
by structural changes ; and in another, to trophic changes in the sympathizing 
eye with little or no accompanying irritation. G. P. Putnam’s Sons, Printers 
27 and 29 West 23d Street 
New York