A CASE OF 
Bilateral Recurrent Inflammation 
of Tenon’s Capsule 
IN CONNECTION WITH 
PROFOUND MERCURIAL POISONING, 
By CHARLES J. KIPP, M.D., 
NEWARK, N. J, 
| Reprinted from American Ophthalmological Society Transactions, 1893.] A CASE OF BILATERAL RECURRENT INFLAM- 
MATION OF TENON’S CAPSULE IN CONNEC- 
TION WITH PROFOUND MERCURIAL POISON- 
ING. 
By CHARLES J. KIPP, M.D., 
NEWARK, N. J. 
Louis Oxfurth, a German, 39 years of age, came to the New- 
ark Eye and Ear Infirmary for the first time March 3, 1890. 
According to his statement, his right eye was wounded by 
pieces of glass in an explosion of an electric incandescent lamp, 
the day before. Immediately after the explosion he visited an 
infirmary in New York, where he was told that the injury was 
insignificant, and that the eye would get well if he applied cold 
compresses to the lids. I examined the eye very carefully, but 
could discover only a very small wound of the cornea, close to 
its outer margin. I advised him to bathe his eye with a warm 
solution of boric acid. The patient did not return to the infirm- 
ary till the 29th day of March, twenty-six days after his first 
visit. He stated that his eye had not troubled him much till a 
few days ago, and that he had been working at his business since 
his first visit. His right eye was now in the following condi- 
tion : The lids were oedematous but not markedly red, and a 
broad fold of swollen conjunctiva protruded from the palpebral 
fissure. On opening the lids, the whole ocular conjunctiva was 
found to be intensely congested and greatly swollen, and sur- 
rounded the cornea like a wall. The eyeball was considerably 
protruded, and its motility was greatly impaired in all direc-' 
tions. Attempts to move the eyeball in any direction caused 
much pain. There was absolutely no muco-purulent secretion 
in the conjunctival sac. The cornea was transparent, only a 
small macula indicating the site of the wound. The anterior 
chamber was of normal dimensions; the aqueous was clear. 
The iris and lens showed no evidence of disease. The vitreous 
was transparent, and no disease of the optic nerve, retina, or 2 
Kipp : Inflammation of Tenons Capsule. 
choroid could be discovered. The eye was slightly myopic 
(i-5 D-) and vision was The left eye was apparently 
normal. In addition to the eye disease, I noticed that he 
was affected with what, at first glance, seemed to be shaking 
palsy. His very fetid breath, of which I had become aware 
during the examination of his eye, now induced me to ex- 
amine his mouth, and I found that he was salivated, the gums 
were inflamed and ulcerated, and the teeth were loose. The 
tongue was very tremulous. Inquiry as to his occupation now 
revealed the fact that he was, and had been for many months, 
employed in exhausting the air from the glass bulbs of electric 
incandescent lamps, which is done by means of metallic mercury 
falling from a height. More or less of the mercury is spilt in 
this process and becomes volatilized, and is inhaled by the per- 
sons employed in the room. Considerable of the metallic mer- 
cury is also handled by the men, and, unless they are very 
cleanly, is thus introduced into the system through the mouth 
and skin. The patient admitted that he rarely washed his 
hands before eating, and he seemed to think that the tremors 
and the other symptoms from which he was suffering, were una- 
voidably associated with his occupation. With this knowledge 
before me, I now made another and more thorough examination 
of the man’s condition, and found that he had the usual symp- 
toms of profound mercurial cachexia. 
I admitted the man into the wards of the infirmary on the 
1st of April, and prescribed for him a generous diet, iodide of 
potassium in five-grain doses three times daily, six leeches to 
the temple, and fomentation of a warm two per cent, solution of 
boric acid to the eye. Under -this treatment the chemosis and 
the congestion of the ocular conjunctiva gradually subsided. 
The eyeball resumed its normal position in the orbit, and the 
eye could be moved again in all directions. About the tenth 
day after his admission to the infirmary, the eye was so nearly 
well that I thought of discharging the man. At this time the 
man began to complain of pain in the left eye, which up to this 
date had been entirely healthy. An examination of this eye 
showed considerable injection of the ocular conjunctiva, especially 
at the equator, and slight oedema of the same, otherwise it ap- Kipp : Inflammation of Tenon s Capsule. 
3 
peared to be normal. On the following day, the left eye was 
found to be worse, there was greater congestion and oedema of 
the ocular conjunctiva, and both the upper and the lower lids 
were somewhat oedematous. I prescribed ice to the lids and 
leeches to the temple, but this treatment did not prevent the 
progress of the disease. The oedema of the ocular conjunctiva 
increased till a broad fold of the swollen conjunctiva protruded 
from the palpebral fissure. The eyeball was gradually pushed 
out of the orbit till it was protruded about two lines, and the 
eyeball could hardly be moved in any direction. In the mean- 
time the right eye had become entirely normal in appearance 
and had resumed its normal position. Finding that cold appli- 
cations to the lids did no good, I substituted fomentations of a 
warm two per cent, solution of boric acid. Frequent examina- 
tion of the eye with the ophthalmoscope failed to reveal any 
change in the fundus oculi, and the cornea and iris were not 
involved in the disease at any time. The eye remained in the 
condition above described for about four days, and then grad- 
ually improved, so that about the twentieth day from the begin- 
ning of the disease in this eye, only very moderate congestion 
and oedema of the ocular conjunctiva remained. The other 
symptoms having disappeared, I discharged the man April 29th, 
but advised him to continue the iodide of potassium, as the 
symptoms of mercurial poisoning", although much improved 
compared to the condition when he was admitted, were still well 
marked. 
May 1st, the patient returned with the right eye again pain- 
ful and red. The lids of this eye were puffy, and the ocular 
conjunctiva was intensely congested and oedematous. The left 
eye was nearly normal. The right eye was treated as in the 
first attack, but this did not stay the progress of the affection. 
To be brief, this attack did not vary from the first in any par- 
ticular, and lasted about twenty days. After the subsidence of 
this second attack of the right eye, the left eye again became 
painful, and went through the same process a second time, 
the second attack, like the first, lasting about twenty days, 
and then passing away without any material damage to the eye. 
June 12th.— Both eyes are now in their normal position in 4 
Kipp : Inflammation of Tenon s Capsule. 
the orbit. The eyelids are normal and the ocular conjunctiva is 
still a little congested, though no longer swollen. The vision of 
both eyes is the same as before the attacks. The gums are 
more healthy looking and the tremors have subsided in a con- 
siderable degree. The man felt sufficiently well to go to work, 
and although I advised him to seek other employment, re- 
turned to his old occupation, and continued at this work till 
July 31st, when another attack of inflammation of his right eye 
compelled him to give it up. This attack did not differ greatly 
from the previous attacks, but was not quite as severe as the 
others ; it passed away under the treatment above described. 
He again went to work in the same place and had no further 
trouble with his eyes till October 18th, when another attack 
brought him back to the infirmary. This time the left eye was 
affected. The attack was not as severe in character nor as long 
in duration as the previous ones. After his recovery from 
this attack, he found employment elsewhere, and since then 
he has had no return of the eye disease. I have seen the 
patient several times during the last year, and on his last 
visit to me, about six months ago, I found that the tremulous- 
ness of his hands was hardly noticeable. His health was fair. 
I have called the eye affection here described, an inflamma- 
tion of Tenon’s capsule, but think it very probable that more or 
less of the cellular tissue of the anterior part of the orbit was 
involved in the morbid process. The inflammation of the right 
eye undoubtedly followed an injury to this eye, but the inflam- 
mation of the left eye was not due to such a cause. Whether, 
in this case, the disease germs traveled from the right eye, 
through the sheath of the optic nerves, to the capsule of Tenon 
of the left eye, and then set up the same morbid process, or, 
whether the mercurial cachexia which was present was the cause 
of the inflammation of both eyes, I am unable to decide. I 
have not seen another case like it during the thirty years that 
I have practised medicine, and a somewhat careful search of 
the literature has failed to find anything similar to it.