HYALINE BODIES (DRUSEN) 
IN THE 
NERVE-HEAD. 
By G. E. DE SCHWEINITZ, M.D., 
PHILADELPHIA, PA. 
(PHOTO MICROGRAPHS BY WILLIAM M. GRAY, M.D.) 
| Reprinted from American Ophthalmological Society Transactions, 1892.] HYALINE BODIES (DRUSEN) IN THE 
* NERVE-HEAD. 
By G. E. DE SCHWEINITZ, M.D., 
PHILADELPHIA, PA. 
(Photo-micrographs by William M. Gray, M.D.) 
Since Heinrich Mueller* found in preparations from eyes of 
elderly people, globular masses, 0.0008 to 0.003 mm- in diame- 
ter, close to the inner margin of the optic nerve ring, and also 
that the circular tissue around the optic nerve trunk very often 
contains a peculiar formation of globular masses, which he sug- 
gested might be discovered with the ophthalmoscope,! to the 
most recent communication upon this subject by Terson,J more 
than a score of communications have appeared concerning an 
affection of the nerve-head characterized by the formation of 
small excrescences in its tissue, which have been called globular 
masses, hyaline bodies, hyaline verrucosities, and “drusen” of 
the optic papilla. 
It is evident from an examination of the cases which have 
been reported that they may be variously classified. For ex- 
ample, Nieden, § writing from the ophthalmoscopic standpoint, 
shows that the globular formations may arise : (1) As a non- 
senile occurrence in young persons; (2) As wholly confined to 
* Archiv.f Ophth., Bd. II, 2, p. 25, and Ibid., Bd. IV, 2, 13. 
t Compare Nieden’s paper, Archives of Ophthalmology, Vol. XVIII, p. 198. 
X Archiv d'Ophthalmologic, June, 1892, p. 367. This paper contains a complete 
bibliography. 
§ Loc. cit. 4 
De Schweinitz : Hyaline Bodies in the Nerve-Head. 
the optic nerve; and (3) As confined to the optic nerve, with 
good vision, and in an otherwise normal fundus. That is, they 
may occur in association with retinitis pigmentosa, choroido- 
retinitis, optic neuritis, and with alterations incident to Bright’s 
disease (Nieden, Stood, Ancke, Remak, Oeller, and Gurwitsch); 
or they may appear in an eye free from other pathological' 
changes (Nieden, Jany, Iwanoff). So far as our knowledge of 
the nature and origin of these bodies is concerned, the reported 
cases naturally divide themselves into those in which the bodies 
have been found incidentally in the examination of sections of 
eyes, and those in which they have been submitted first to 
ophthalmoscopic and afterwards to microscopic examination. 
To the latter class the case which I present for your considera- 
tion belongs, although the bodies occurred in a nerve-head that 
was notably diseased independently of their presence. 
Daniel Fix, aged 45, married, a na ive of France, and a cabinet-maker, was 
admitted to the Insane Wards of the Philadelphia Hospital June 21, 1890. Physi- 
cal condition negative, with the exception of “a linear scar one-half inch long, 
beginning two inches above the external angular process of the frontal bone, and 
running backward ” His mental condition was apathetic and forgetful, but no evi- 
dences of insanity were present. “ His eyesight was poor.” 
He was discharged to the Nervous Wards, May 8, 1891, a short time before 
which I examined his eyes thoroughly and on many occasions. The V. equaled 
counting fingers at three and six feet, respectively. The pupils were round and 
acted equally, though slowly, to the reactions of shade and light. The form field 
was concentrically contracted; the color field was not measured 
In each eye the ophthalmoscopic appearances were closely similar: An oval, 
slightly prominent papilla, grayish white in color, and largely devoid of capillarity. 
In a circle, slightly within the apparent margin of the nerve-head, were a number 
of globular masses. These were most prominent above, where they seemed to 
overlap the border, and, particularly in the right eye, were capped with shining 
particles which glistened like cholesterin crystals. The center of the disc was 
filled in, the lamina cribrosa was obscured, the vessels were not much changed in 
size, and the veins exhibited about their usual degree of tortuosity. Some white 
tissue was apparent at the emergence spot of the arteries. There was no change 
in the surrounding eye-ground; and no evidence of former inflammatory or hemor- 
rhagic condition. 
I am indebted to Dr. Francis X. Dcrcum for the following additional notes: 
The man had been an immoderate drinker. About two years ago he had severe 
head-pains which confined him to bed for five months, during which time he had 
one convulsion. Neither fever, delirium, nor loss of consciousness was present. 
There is a history that he was shot in the head twenty years ago.* He had a pecu 
* Iwanoff found globules 13 out of 5) in eyes which had lost their vision from injury. 
In several of Nieden’s patients there had been severe injury to the skull. The same condition 
has been noted by Gessner. "Hate I 
Figure i. Hyaline bodies or drusen on each side of the central 
vessels, showing their position anterior to the lamina cribrosa 
and their relation to the choroid, from which, how- 
ever, they are distinctly separated. ( X 75). 
Figure 2. Drusen more highly magnified; also change in the vessel 
wall most marked upon the right side. (X 200.) Figure 3. Single, large hyaline body showing concentric markings, 
and several smaller bodies detached from the main one. (X 500.) De Schweinitz : Hyaline Bodies in the Nerve-Head. 
5 
liar, shuffling gate, while his shoulders were stooped and his head bent forward. 
Apparently all functions were normal except the eye sight, although, as before 
stated, there was some mental apathy, and occasionally he complained of pain in 
the head. During the latter part of the winter of the present year, he died quite sud- 
denly. The autopsy was performed by Dr. Dercum and myself, and the brain and 
posterior halves of the eves reserved for microscopical examinationby preservation in 
Muller’s fluid. Longitudinal sections of the nerve entrance were prepared by Dr. 
William M. Gray, and the following lesions were found: 
Microscopic Examinations : Anterior to the lamina cribrosa, 
and on either side of the central vessels, are two oval masses, 
of whitish color, and composed of a series of smaller bodies in 
which the markings with concentric lines is very distinct. The 
mass to the right side is the larger, measuring in its long diam- 
eter of a mm., and in its short diameter of a mm. The 
measurements of the other mass are respectively of a mm. 
and of a mm. (Figure I). In other words, these sections 
are compound hyaline bodies. In immediate proximity to 
these masses are several smaller bodies of like structure, but of 
somewhat pinkish tint, owing to the absorption of the staining 
fluid (Figs. I and II). From an examination of a series of 
sections, it seems likely that these masses represent cross cuts 
of a ring of hyaline tissue which, of varying circumference, 
occupied the tissue of the nerve-head in advance of the lamina 
and surrounded the central vessels, but did not pass beyond the 
outer margin of the papilla. Even in those sections which 
have not included the vessels, small hyaline bodies can be seen 
in the upper central part of the cuts. This arrangement repre- 
sents what Hirschberg and Cirincione have called a “drusen 
ring.” The tissue surrounding the cavity in which the “ drusen ” 
lie is somewhat matted and condensed, probably by pressure. 
The hyaline body for the most part is separated from immediate 
contact with the adjoining structures by a clear space, no doubt 
the result of contraction of the hardening process Most of 
the sections show the well marked concentric lines, and exhibit 
the appearance which has led to a comparison between these 
bodies and the corpora amylacea (Fig. Ill), but in some slides 
the concentric lines and glass-like structure are replaced by a 
yellowish and more granular composition interspersed with 
dark granules, indicating a calcareous change. 
The optic nerve, in general, exhibits the lesions of well 6 
DeSchweinitz: Hyaline Bodies in the Nei-ve-Head. 
marked atrophy : Increase in connective tissue, thickening of 
the bloodvessel walls, and wasting of the nerve fibers. There 
is marked alteration in the vessel walls, consisting chiefly of 
thickening of the adventitious coat, and in some of the smaller 
arterioles in the body of the nerve below the lamina this 
thickening and condensation of the fibrous coat presents a well- 
nigh homogeneous appearance. Above the lamina, near the 
right branch of the central artery, the wall is greatly increased 
in size, nearly homogeneous, of whitish color, except on the 
margins, which have imbibed some of the carmine stain, and 
contains here and there, particularly near the lumen of the 
vessels, some small semi-transparent drops. This condition 
seems to be analogous to the hyaline change which has been 
found and often described in the adventitious coats of arteries.* 
(Fig. II.) 
In the retina gross lesions are absent, and with the excep- 
tion of some oedema of the various strata, particularly of the 
nuclear layers, there is no very evident pathological change. 
The layer of the rods and cones is entirely absent, or so defi- 
cient that it cannot be effectively studied. Wherever vessels 
are manifest their coats are thickened, but a hyaline change 
cannot be seen. 
The layers of the choroid are well preserved. The lamina 
vitrea is everywhere intact, and with the exception of somewhat 
undue filling of the larger bloodvessels, many of which are 
plugged with blood-clots, there is no special pathological change. 
The hyaline excrescences which have so often been seen and 
described in this membrane are nowhere present. 
Dr. Dercum has made a most thorough examination of the 
brain. I append the notes which he has kindly furnished: 
“ Examination of a large number of sections of the angular 
gyrus and cuneus of either hemisphere yielded a negative 
result. The nerve cells, their contents and their processes, are 
well preserved. Here and there the peri-ganglionic lymph 
spaces seem a little dilated, but even this appearance is infre- 
♦In the sections stained by Weigert’s method, the “drusen” have been colored a deep 
black, but the coat of the vessel has not been affected by the coloring material, indicating 
that the “ drusen ” and the altered tissue in the adventitious coat are not composed of the 
same material. De Schweinitz : Hyaline Bodies in the Nerve-Head. 
7 
quent. The neuroglia has undergone no change. The vessels 
also are normal, although a few of the larger ones appear to 
have slightly thickened walls. No distinct degenerative change 
is anywhere present.” 
I also removed portions of the other cranial nerves and ex- 
amined them microscopically without finding the slightest 
lesion. 
The notes of the general post-mortem examination follow : 
Calvarium normal. Dura much thickened ; pia and arachnoid 
thickened, especially at the base. Brain tissues soft and oedem- 
atous. Extensive dilatation of all ventricles due to ependymitis. 
Walls of the ventricles velvety. Infundibulum and floor of the 
third ventricle cystic and oedematous. In the position of the 
optic tracts nothing but a slight increase in density in the sur- 
rounding oedematous tissue is observed. The optic nerves are 
apparently shrunken. In the other organs of the body, thoracic 
and abdominal, no gross lesion is present save very general ven- 
ous congestion, most marked in the lungs, together with oedema 
of the bases. Some spots of atheromatous change are present 
in the aorta and coronary arteries. The spinal cord was not 
examined. 
From these examinations it is evident that the following le- 
sions are present: 
(1) Compound hyaline bodies, or “ drusen,” in the nerve- 
head, situated in their seat of predilection, within the tissue of 
the papilla, anterior to the lamina cribrosa. 
(2) Atrophy of the optic nerve, which may or may not 
have antedated the formation of the “ drusen,” but which evi- 
dently was not caused by them. 
(3) Thickening of the coats of the arterioles in the optic 
nerve below the lamina, and above, in the central artery, in the 
neighborhood of the “ drusen,” a change in the adventitious 
coat of the vessel, suggesting the appearance of hyaline degen- 
eration, but shown by a differential stain to be of different com- 
position from the “drusen.” 
As negative results it may be stated that : 
(1) The retina and choroid exhibit no distinct pathological 
lesion, save some thickening of the vessel walls. Hyaline 
bodies springing from the lamina vitrea are absent. 8 
De Schweinitz : Hyaline Bodies in the Nerve-Head. 
(2) The other cranial nerves, so far as examined, were 
normal. 
(3) The investigation of the structure of the brain yielded 
a negative result, and hyaline changes in the bloodvessels were 
not present (Dercum). 
Nature of the Pathological Material. In the series of sec- 
tions which I present for your consideration, the ordinary stain- 
ing fluids have been employed, without special endeavor to 
utilize reagents that would give some information in regard to 
the exact pathological nature of the material which has been 
designated “hyaline.” About a year ago Hirschberg and 
Cirincione * published a communication in regard to “drusen” 
in the nerve-head. These investigators carefully employed 
differential reagents, and as their case in many respects is 
singularly like the one which I report to-day, I may quote some 
of their results in this respect: 
“ Concentrated hydrochloric acid affects the yelloyvish frag- 
ments slowly, developing large gas bubbles which form in a 
wreath around each single piece, but the pieces are not dis- 
solved. This acid does not have any effect upon the more 
peripheral, round, reddish, rough flakes. On the addition of 
concentrated acetic acid, exactly the opposite results seems to 
take place, the acid leaving the central fragments intact and at- 
tacking the peripheral flakes. But this is only apparent. The 
influence of the acid extends only to the tissue between the de- 
posits, which becomes transparent and invisible in the greater 
part of the microscopical visual field, and not to the concre- 
ments, which, on the contrary, become more distinct, due to 
their power of absorbing light. The concentrically striped 
pieces do not give any amyloid reactions with saffranin and 
methylviolet; tincture of iodine imparts a yellowish color to 
them.” 
From these experiments Hirschberg and Cirincione conclude 
that the deposits should be regarded as hyaline masses whose 
more exact composition is unknown, and which are partly calci- 
fied secondarily in the interior of the papilla. With the assist- 
ance of Dr Perles, still other reactions were utilized in this in- 
♦Centralbl. f. prakt. Augenheilk., June and July, 1891. De Schweinitz : Hyaline Bodies in the Nerve-Head. 
9 
vestigation. The transparent, faintly yellowish bodies in the head 
of the optic nerve were proved with the polarization microscope 
to be, very probably, not crystalized. Viewed simply with the 
direct and transmitted light, they appeared as broken fragments, 
with sharp corners, generally provided with acute angles, fre- 
quently resembling rhomboiclal tables, with a fine substance ly- 
ing in lamellae. On single, small pieces, a very fine concentric 
drawing, with faintly colored rings, could be observed, which 
were evidently due to interference, and pointed to a stratiform 
arrangement of thin lamellae. To still further investigate their 
nature, Hirschberg and Cirincione had recourse to micro-chem- 
ical reactions, for the details of which I must refer to their 
original paper. Suffice it to say, that these investigations 
seem to prove that the bodies were amorphous and organic, but 
that they did not partake of the nature of cells, neither did they 
yield albumin, fat, nor glue reactions, and on account of their 
indifferent behavior toward the most usual solvents, their com- 
position appeared most to resemble that of elastin. 
Assuming that the bodies in the case which I describe to- 
day are exactly analogous to those which were so thoroughly in- 
vestigated by these two observers, it is reasonable to believe 
that their composition is identical, and these results have been 
quoted as the most authoritative opinion in regard to the nature 
of the tissue in question. However, the observation with 
Weigert’s stain (see foot note, page 352) should be taken into 
consideration. 
Origin of the “Druseu" and Nature of the Process which 
Caused them. Two views have been prominently maintained in 
regard to the origin of the “drusen.” 
1. They are hyaline excrescences of the vitreous lamina of 
the choroid, imbedded in the head of the optic nerve and have 
there become partly calcified, in this respect presenting a senile 
change. (Muller, Iwanoff, Wedl and Bock, Nieden.*) 
2 They have nothing in common with the choroidal excres- 
cences, but are the expression of a pathological process con- 
* This observer, basing his belief on Kuhnt’s observation of the relation of the lamina 
vitrea to the optic nerve and choroid ring, considers the hyaline bodies as a degeneration 
product of the lamina elastica of the choroid. His own investigations of this disease, however, 
depend alone upon ophthalmoscopic examination. 10 
De Schweinitz : Hyaline Bodies in the Nerve-Head. 
fined to a small portion of the optic nerve, possibly on account 
of local anatomical reasons, and finding their counterpart in the 
calcification of other tissues, particularly the cheesy nodules in 
the lung. (Hirschberg, Cirincione, Gurwitsch.) 
The first view depends largely upon the support which was 
given to it by previous observers, especially Muller and Iwa- 
noff, and also upon topographical relations, inasmuch as the 
lamina vitrea approaches very near to the optic nerve tissue, 
the fibres of which curve around this structure on their way to 
form the retina. In my own specimens it is easy to see 
the very close relation of the hyaline bodies to the vitreous 
lamina, and yet, in spite of their immediate proximity, the 
boundary between the two is unbroken and distinct. Person,* 
although admitting the intimate connection which has just been 
stated, thinks that it is not safe to base an argum nt upon 
these topographical relations, but that a decision must be 
reached by the aid of convincing histological preparations. 
Supporters of the second view place no faith in an argu- 
ment based upon topographical relations. Indeed, according to 
them this, as has just been intimated, is not corre t The 
choroid does not exist in the place where the change developed, 
and consequently there is no vitreous lamina. Moreover, it 
would seem reasonable, if this view were accurate, that the 
hyaline bodies should not be located alone in one sm ill confined 
portion of the optic nerve, and that certain transition st iges 
should be found. Again, a similar process in the c ioroi 1 as 
a point of origin ought to be present. Independently of these 
considerations, the histological aspect of the dis ase is the 
one upon which a differential consideration should be based. 
The choroidal excrescences are more or less extensiv n isses in 
concentric layers, attached with a broad base to th vitreous 
lamella of the choroid, and always project toward t interior 
of the bulbus. Their surface is covered with epit 1 lid cells 
more or less developed, and they frequently contain x 11in th.ir 
interior one or more cells. Their consistency is th r f fib ous 
tissue, but they are not so firm as to prevent an ranee of 
connective tissue cells and even secondary ossifi • . The 
* Loc. cit De Schweinitz : Hyaline Bodies in the Nerve-Head 
11 
most satisfactory investigation in regard to their nature seems 
to indicate that they are a colloid transformation of the proto- 
plasm of the pigment epithelium. The argument just recited is 
the one employed by Hirschberg and Cirincione in the paper 
several times quoted, and seems to be convincing, especially 
when taken into consideration with the differential stains and 
micro-chemical reactions which these observers employed. 
The hyaline bodies in question, as they occur in the optic 
nerve, lack every trace of epithelial covering, and contain 
neither cells, nuclei, nor pigment. They are not attached with 
broad base, but are practically free in the tissue. So far as 
my own examinations are concerned, they point very distinctly 
to a confirmation of the results which have just been quoted 
and of the arguments which are so forcibly used by the 
observers from whose research they have been abstracted. It 
may be interesting at this point to refer to the paper of Gur- 
witsch, who has described these bodies in eyes which were re- 
moved from cases of Bright’s disease. He is quite in accord 
with the view that the bodies have nothing to do with the 
choroidal excrescences. He suggests that possibly the hyaline 
degeneration precedes an amyloid transformation. 
My own case tends to confirm the views of those who be- 
lieve that the “drusen” in the nerve-head represent a disease 
entirely distinct from excrescences springing from the lamina 
vitrea of the choroid. It adds somewhat more to our knowledge 
of this disease than we have previously been able to obtain, be- 
cause the examinations include not only the nerve-head, but in 
addition, the entire optic nerves, the other cranial nerves and 
the brain, with the practically negative results that have already 
been recorded — results which seem to emphasize the local 
nature of the process. 
The apparent hyaline transformation of the adventitious 
coat of a part of the central artery of the retina does not, it 
seems to me, count for very much when we consider the inflam- 
matory process which must have been present in the optic nerve 
at some earlier date. According to Hirschberg, in those cases 
in which the “drusen” occur in the head of the optic nerve in 
connection with pigmentary degeneration of the retina, their 12 
De Schweinitz : Hyaline Bodies in the Nen’e-Head. 
deposition is favored by the stenosis of the vessels in the retina, 
and they do not contribute anything to the disturbed vision. 
Perhaps in this case a similar argument might apply, but I 
hardly think so, and am constrained to believe that the optic 
atrophy and the“drusen” are two entirely distinct processes, 
the atrophy being a condition which probably came on after the 
compound hyaline bodies had been formed. Moreover, the 
differential stain to which I have referred before, gives evidence 
that the “drusen” and the change in the vessel wall are not 
analogous tissues. 
Cirincione, in concluding his report on the microscopy 
lesions of this disease, says, “ the first cause of this hyaline 
transformation and subsequent calcareous deposit in the papilla, 
however, remains to be determined, and likewise the reason why 
it remained confined to this small territory alone, instead of ex- 
panding or appearing scattered in other parts of the bulbus. 
We have not found sufficient proofs to solve this question and 
therefore, instead of indulging in more or less probable hy- 
potheses, leave the solution of this question to future ex- 
aminations.” Unfortunately, the present case does not give 
any information which helps to solve the question which this, 
observer, as well as others before him, have found it impossible 
to answer.