CLINICAL COMMUNICATIONS 
by 
GEORGE REULING, of Baltimore 
Prof, of Opthalmic and Aural Surgery in 
Baltimore Medical College. 
[Reprinted from the Archives of Ophthalmology, Vol. xvi., No. 2, 1887] CLINICAL COMMUNICATIONS. 
By GEO. REULING, of Baltimore. 
I.-Cyst of Iris Destroyed with the Galvano-Cautery. 
(With a •wood-cut.') 
Joseph Seipp, twenty-eight years of age, was wading, during 
the summer of 1879, through an almost dried-up stream, and in 
separating the high grasses and bullrushes to see his way clear, he 
was struck in his left eye by one of the sheaths. The eye became 
at once inflamed, and remained very irritable and painful for 
several weeks, but finally ceased to be troublesome, and sight was 
apparently undisturbed. Very gradually, however, vision be- 
came cloudy, which fact induced the patient, after nearly four 
years of waiting, to seek medical advice. 
On the 28th of September, 1883, the examination of the eye 
showed at once its characteristic affection-a cyst occupying the 
whole outer half of the anterior chamber of the left eye. It 
emanated from a small cicatrix in the outer and upper sclero- 
corneal margin, to which a small piece of iris was adherent. 
From this matrix a thin blood-vessel was accompanying the inner 
surface of the completely transparent cyst-wall until it almost 
reached its floor. At this point it ended apparently with a free 
opening, it evidently having been ruptured, as a few particles of 
Reprinted from the Archives of Ophthalmology, Vol. xvi., No. 2, 1887. Clinical Communications. 
211 
coagulated blood were deposited upon the floor of the cyst. This 
small coagulum changed its position according to the position of 
the patient's head, similar to a hypopyon. The exact measure- 
ment of the cyst was 7.5 mm in greatest length, and 4.2 mm in 
its greatest width. The liquid contained in the cyst was perfectly 
clear, and showed only as a sediment the small blood-coagulum 
mentioned before. The iris was atrophic at the starting-point of 
the cyst, but showed no residue of former iritis. The crescent- 
shaped pupillary space reacted almost normally to light, and the 
lens appeared clear and slightly pushed forward and inward. 
The operation for its removal consisted in a broad iridectomy, 
the incision for which was entirely made within the scleral border 
and immediately behind the cicatrix from which the cyst had 
started. The operation was not quite as simple of execution as I 
here described it, inasmuch as the cyst could not be removed 
without being pierced by the Graefe knife, so that the removal of 
the atrophic iris and the exceedingly fine and collapsed cyst-wall, 
especially around the matrix, required repeated piecemeal remov- 
als of these very fragile tissues. After having completely cleared 
the broad coloboma of every visible particle of cystic tissue, I 
finally cauterized the matrix with a pointed caustic stick, and 
applied a pressure bandage. 
The process of healing was comparatively kind ; the wound 
closed within twenty-four hours, and neither iritis nor serious 
ciliary symptoms were observed during the fifteen days the 
patient spent at the Institute. On his dismissal his vision had im- 
proved to nearly one half, and No. 7 Jaeger could be read with 
+ Later I saw him from time to time, and for nearly a year 
I was under the firm impression of having permanently relieved 
him of his dangerous new formation. On the 15th of September, 
1884, when I had not seen the patient for over three months, he 
came again, complaining of his eye, which had become exceedingly 
painful and nearly blind. The examination by oblique illumina- 
tion revealed the presence of a new cyst starting from the same 
old point within the cicatrix caused by the first accident. Feel- 
ing confident that the extirpation of the cyst in the usual way 
would afford no permanent relief, and being anxious to save the 
eye if possible, I made a small incision through the matrix and 
immediately in front of the former incision for the iridectomy. 
Having introduced through this opening Liebreich's iris-forceps 
and pulled out the cyst in toto, I clipped off the latter as close as Geo. Reuling. 
212 
possible to the incision. I then introduced the platina needle of 
the galvano-cautery, and by moving it gently up and down 
within the narrow area of the matrix I destroyed all the tissue 
that I reasonably could expect to be capable of producing a new 
cyst. On the removal of the needle, which I had kept at white- 
heat and in contact with the cicatrix for about half a minute, I 
found that an oval defect had been caused, preventing the com- 
plete apposition of the corneo-scleral wound. I therefore united 
the wound by a silver suture. A pressure-bandage was applied, 
and strict rest enjoined. During the first night the patient com- 
plained of severe ciliary pain and copious lachrymation. After 
the first twenty-four hours the anterior chamber was not yet re- 
established and there was considerable chemosis around the 
wound. The wound, however, closed completely without disa- 
greeable symptoms, for on the fourth day the suture was found 
lying in the fornix of the conjunctiva, with particles of exfoliated 
tissue resulting from the burning of the lips of the wound. The 
lens remained clear throughout the process of healing, and vision 
had again returned to nearly its former degree. The patient was 
dismissed twenty-one days after the operation, and was seen by 
me about every month for the next six months, when I could 
notice a steady improvement of his eye until Jaeger No. 5 could 
be read with -J- Aj. 
The last time I saw the patient was fourteen months after the 
galvano-caustic destruction of his cyst. His eye did not show 
the slightest symptoms of a return of the trouble. The other eye 
had been free from irritation. The patient, an intelligent and 
prudent man, was desirous to establish a mercantile business in 
the West. I saw no objection to his doing so, but asked him 
to inform me at once if there should be a recurrence of his eye 
trouble. Not having heard from him since, I fairly consider his 
case as an instance of a permanently successful removal of a trau- 
matic cyst of the iris. 
II.-Syphiloma at the Sella Turcica Causing Engorged Papilla 
and Ending in Complete Recovery. 
On the first of February last, Judge R., aged forty-six years, an 
ex-member of Congress and one of the most prominent lawyers 
of a Southern State, was brought to my office in the following con- 
dition : Left upper lid was in a state of complete ptosis, both eye- 
balls were considerably protruding, so that the intact lids of the 213 
Clt'11 ica I Co in munications. 
right eye could not be closed completely. Every eye muscle in 
both eyes was either paretic or paralytic, with the exception of the 
external recti, which caused both eyes to occupy a divergent posi- 
tion in which they were almost immovable (oculomotor-paralysis). 
Both pupils were dilated ad maximum, a most singular circum- 
stance, as usually in cases of paralysis of the third pair the dilata- 
tion of the pupil is only moderate. On questioning the patient 
whether atropia had been used, he answered in the negative. His 
facial expression was staring and reminding one of animal stupidity. 
His gait was staggering, his speech heavy, and his sentences fre- 
quently disconnected. The latter symptom was even more pro- 
nounced before the Judge left his home, so that his physicians 
expected at any moment an outbreak of acute mania. The 
examination of his eyes revealed the following condition : The 
greatly enlarged pupils completely irresponsive to light, optical 
media transparent and normal, mobility of the eyeballs reduced to 
a minimum, position of both eyeballs divergent, conjunctiva con- 
siderably hypersemic and suffused by subconjunctival serous infil- 
tration, as also was the orbital tissue. Vision in each eye amounted 
yet to field of V showing in each eye a central scotoma. On 
examination with the ophthalmoscope the most pronounced neuro- 
retinitis was observed. Both optic discs were positively globular 
and greatly enlarged, so as to bulge considerably above the level 
of the retina. The discs as well as the retinae were dotted all over 
with innumerable hemorrhages, the largest ones being close to the 
macula lutea, without covering it however. The line of demarca- 
tion between the optic disc and retina had disappeared, and it was 
a source of considerable interest to have so large an amount 
of vision retained yet in an optic nerve and retina so thoroughly 
pathological in their appearance. 
A prominent oculist in Washington who kept this case under 
the closest observation for four days, diagnosed it as neuro- 
retinitis morbi Brightii, and prepared the wife for a speedy fatal 
termination. As I could find only mucine and neither albumen 
nor renal casts of any description, and further, in the absence of 
hydropic symptoms and any heart affection, and further, in view 
of the immense protrusion of both optic nerves, the serous infil- 
tration into the orbital tissue, owing evidently to stasis in the 
ophthalmic vein and its tributaries, I was convinced of the pres- 
ence of a tumor on the base of the brain, most likely on the sella 
turcica, and very probably of syphilitic origin. Geo. Reuling. 
214 
My treatment, therefore, consisted in the removal of two ounces 
of blood from each temple by Heurteloup's artificial leech, and the 
systematic inunction of the blue mercurial ointment in half-drachm 
doses into arms and legs, with the internal administration of iod. 
potassii in ten-grain doses three times a day, for the purpose of 
producing speedy action. 
An improved condition of the patient set in almost with the 
moment treatment began. Twelve hours after the blood-letting 
and first inunction, the ptosis (of the left lid) had diminished, and 
the excruciating headaches which had existed for weeks, and 
which had been ineffectually combated with the strongest doses 
of chloral and various narcotics, had ceased for the first time. In 
twenty-four hours mobility of both eyes had perceptibly increased, 
and the infiltration of the conjunctiva and orbital tissue disap- 
peared visibly, so that both eyeballs had perceptibly receded into 
their orbits. After two days the right eye had taken its central 
position and showed the returning activity of the internal rectus 
muscle, as convergence'could be produced at will. The ptosis 
had now completely disappeared, and both lids could be closed 
normally over the eyeballs. With all these improvements of the 
external symptoms the recovery of both retinae and optic discs 
held even pace. The swelling and infiltration of the disc was 
considerably lessened, and more than one half of the hemorrhagic 
spots had disappeared. As both pupils had so far remained 
largely dilated, I instilled a one-half-per-cent solution of eserin 
into each conjunctival sac. The contraction which followed this 
application represented the pupils at their normal size, in which 
condition they remained and acted normally toward light. On 
the fifth day the paretic condition of the eye muscles had almost 
disappeared, and there was never a recurrence of the much- 
threatened headache since the moment treatment began. These 
headaches had appeared daily for weeks, and had made existence 
almost unbearable ; they produced all the symptoms of severe 
brain-pressure, vomiting, comatose deliria, and complete exhaus- 
tion from agonizing pain. The mental faculties of the patient 
had reached their normal status, so that I felt safe in dismissing 
the case on the sixth day of treatment, with a letter to his 
physician, and with the advice to continue specific treatment and 
report once every week at my office for examination and further 
advice. The improvement in the visual power was as rapid as 
any of the other symptoms, so that five days after the beginning 215 
CHnicaI Communications. 
of treatment vision had improved to one half, and No. n Jaeger 
could be read with -j- tV The central scotomata appeared now 
as a fine haze overhanging objects in the centre of the visual 
field. The inunction treatment, as well as iod. potass., was con- 
tinued for nearly two months with short intermissions, and at 
present, three months after the beginning of treatment, not a 
trace of the former pathological lesions can be observed. Vision 
is normal, as is also the action of the muscular apparatus of the 
eyes and eyelids. The mental capacity of the patient may be 
judged from the fact that in the first week of May he tried a case 
involving many hundred thousand dollars, in which his speech of 
defence lasted fully two days and was followed by the success of 
his client. 
III.-Granuloma. Sarcomatosum Cornea of Seven Years' Standing. 
Herman Miller, of Uniontown, Md., (twenty-two years of age), 
applied to me for the removal df a growth situated at the inner 
margin of the cornea of his left eye. The growth was hemispher- 
ical in shape, and of the size of a small pea. It had a fleshlike 
granular appearance, and consisted of many little lobuli, between 
which a great many fine blood-vessels formed a dense network. 
The color of the growth was that of a deep red, and became paler 
on pressure ; it was succulent, and the epithelium was evidently 
thickened. 
About two thirds of the tumor was firmly attached to the super- 
ficial layers of the cornea, and the balance to the superficial 
layers of the sclerotic. On examination the eye itself was found 
normal, the anterior chamber remained uninfluenced by the pres- 
ence of the corneal growth, and ciliary injection existed only in its 
immediate surroundings. The examination of the conjunctiva did 
not reveal granular conjunctivitis, or any inflammatory changes. 
This tumor evidently owed its origin to traumatic injury, in the 
absence of any other more plausible cause. 
The patient informed me that seven years ago a little brother of 
his ran a pointed stick of wood into his eye, after which consider- 
able irritation, sensitiveness to light, and lachrymation existed, 
which gradually subsided, but was followed by a red spot in the 
place of the former injury, from which very gradually the above- 
described tumor developed. There was only occasionally some 
shooting pain, and slight lachrymation accompanying the growth. 
Of late the progress of the tumor was somewhat more rapid, and Geo. Reuling. 
216 
on various occasions small, mostly punctiforme, capillary hemor- 
rhages made their appearance upon its surface. 
As the patient desired to be relieved of the tumor, which had 
caused him much uneasiness during the last few weeks, I extir- 
pated it together with the superficial layers of the cornea as far as 
blood-vessels would extend. After cauterizing the flat loss of cor- 
neal substance left on removal, I applied atropia-solution, and 
pressure bandage. The patient remained at the institution seven 
days, during which time I had carefully destroyed by galvano- 
cautery every capillary vessel that made its appearance within the 
scar, in order to prevent a return of the growth, and finally 
dismissed him with a slight corneal opacity in the place of 
the tumor. 
The growth itself appeared considerably smaller after re- 
moval, owing to the emptying of its blood-vessels. I placed 
at once a small particle of it under the microscope, and after 
tearing it with needles on the object glass in a drop of 
distilled water, I noticed that the structure consisted of sar- 
coma cells in the different states of development, and espe- 
cially of large mother-cells, containing often three to four 
round daughter-cells with divided nuclei. The exceedingly 
fine and transparent connective tissue formed denser strata 
around the large cells, and made them appear as imbedded 
in capsules. There were none of the lobular formations de- 
scribed by Iwanoff and Berlin in such tumors, nor were 
tubular glands of the conjunctiva extending into the interior 
of the growth; a few of the latter were visible on the 
surface, as crypt-like excavations (Papillar-Vertiefungen). 
I do not doubt that the tumor in question was a granular 
sarcoma (Sarcoma globocellulare mixtum), as the compara- 
tive scarcity of the multiple small round cells, and the 
prevalence of spindel cells in every state of development in- 
dicates the pathological substratum of mixed sarcoma. G. P. PUTNAM'S SONS, PRINTERS 
NEW YORK