VI. Chronic interstitial nephritis; neuritic form of albuminuric
retinitis (fatal), 3.
VII. Toxic conditions and blood diseases: Chronic lead poisoning, 3.
Ulcerative endocarditis, (fatal), 1. Purpura hemorrhagica (fatal), 1.
Henoch’s purpura (fatal), 1. Chlorosis with cerebral symptoms
(recovery), 3.
VIII. Headache and double optic neuritis (without localizing symptoms);
probably syphilitic (recovery, with blindness, 2; with impaired vision,
4), 6.
IX. Headache and double optic neuritis (without localizing symptoms); no
evidence of syphilis; duration six and two and a quarter years,
respectively. Termination still uncertain, 2.
X. Headache and double optic neuritis (without localizing symptoms); no
evidence of syphilis; recovery with blindness, 8; with impaired vision,
3; with good vision, 8, 19.
The following are brief abstracts of the notes of the cases in Group X.
which have come under our observation and which we have followed for a
considerable period of time. The number of years during which each case
has been followed is given in parentheses after the brief note.
1. A boy, aged ten years. Double optic neuritis, headache, and vomiting;
slight internal strabismus of the left eye. Recovery with normal vision.
(Seven years.)
2. A young woman, aged seventeen years. Headache, vomiting, and double
optic neuritis. Recovery, but with impaired vision in one eye and
blindness in the other. (Five and a half years.)
3. A young woman, aged eighteen years. Double optic neuritis, headache,
and vomiting; several epileptic fits. Recovery, with useful vision in
one eye; vision in the other is very defective. (Seven years.)
4. A young woman, aged eighteen years. Double optic neuritis, headache,
and vomiting. Recovery, but complete blindness followed. (Four years.)
5. A young woman, aged nineteen years. Double optic neuritis, headache,
and vomiting. Recovery with good vision. (Three years.)
6. A man, aged twenty years. Double optic neuritis, headache, and
vomiting. Recovery, but complete blindness followed. (Two and a half
years.)
7. A girl, aged ten years. Double optic neuritis, headache, and
vomiting; knee-jerks were absent. Recovery, but complete blindness
followed. (Three years.)
8. A boy at the age of thirteen years had double optic neuritis and
headache; recovery ensued. At the age of fifteen years he had a return
of headache and double optic neuritis; also vomiting. At a later date
there was partial anæsthesia in the distribution of the right fifth
cranial nerve; the right cornea was opaque; there was complete blindness
in both eyes. Partial anæsthesia of the face and blindness remained, but
otherwise the patient recovered and felt quite well nine months after
the second attack.
9. A girl, aged sixteen years. Double optic neuritis, headache,
vomiting; slight internal strabismus of the right eye. Recovery with
normal vision. (Four and a half years.)
10. A boy, aged ten years. Double optic neuritis, headache, and
vomiting. The head had increased in size. Recovery, but with complete
blindness. (Three years.)
11. A woman, aged nineteen years. Double optic neuritis, headache, and
vomiting. Recovery with normal vision. (Three years.)
12. A boy, aged fifteen years. Double optic neuritis, headache, and
vomiting. Recovery. (Two and a half years.)
13. A woman, aged twenty-one years. Double optic neuritis, much swelling
of the disks, headache, and vomiting. Complete recovery with normal
vision. (Four and three-quarter years.)
14. A girl, aged fifteen years. Double optic neuritis, headache, and
vomiting. Recovery with good vision. (Five and a quarter years.)
15. A boy, aged twelve years. Double optic neuritis, headache, and
vomiting; slight internal strabismus of the right eye. Recovery with
good vision. (Four years.)
16. A man, aged forty years. Double optic neuritis, headache, and
vomiting. Recovery, but with complete blindness. (Eighteen months.)
17. A youth, aged seventeen years. Double optic neuritis, headache, and
vomiting. Recovery, but with total blindness. (Five years.)
18. A woman, aged twenty-two years. Double optic neuritis, headache, and
vomiting. Recovery, but with total blindness. (Two and three-quarter
years.)
19. A girl, aged fourteen years. Double optic neuritis, headache, and
vomiting; internal strabismus (left) for fourteen days. Recovery, with
normal vision. (Two years.)
The following are brief notes of the cases in Group IX.:
20. A girl, aged twelve years. Headache, vomiting, and double optic
neuritis in December, 1893. Recovery in twelve months, but vision was
much impaired. She remained well with the exception of occasional
headache until December, 1899. Then the severe headache returned. She
became ataxic and optic neuritis reappeared. In April, 1900, the
headache was much less and the patient felt much better, but she was
completely blind. (Six and a half years.)
21. A young woman, aged seventeen years. Headache, vomiting, and double
optic neuritis. Vision was impaired. Vomiting ceased; the headache
continued for over two years, but recently disappeared after lumbar
puncture. (Two and a quarter years.)
In all cases of double optic neuritis a systematic and careful
examination of the patients should be made. The urine and
cardio-vascular system should be examined for signs of chronic
interstitial nephritis; the gums should be examined for the lead line
and other indications of lead poisoning should be sought for; the
question of chlorosis or other “blood disease” should be considered; and
the ears should be examined for signs of otitis. But when all these
conditions have been excluded and when the symptoms are apparently due
to a cerebral affection, there is one group of cases in which localizing
brain symptoms are absent and in which the chief indications of disease
are headache, double optic neuritis, and often vomiting. In most of
these cases syphilis can be also excluded. A diagnosis of brain tumor is
given, and the growth is thought to be situated in some region in which
the localizing symptoms are at first indefinite—cerebellum,
temporo-sphenoidal lobe, or prefrontal region. Such a diagnosis often
proves to be correct. Localizing symptoms may develop later and a
necropsy may show the accuracy of the opinion expressed. But sometimes,
to the surprise of the medical man, a fatal termination does not occur;
the symptoms sometimes disappear and the patient recovers, though very
often impairment or loss of vision remains. The patient may continue in
good health for years or for a lifetime afterwards. Most medical men who
have paid much attention to cerebral diseases will have met with a case
or cases of this kind. The chief object of our article is to call
attention to this class of cases and to indicate the frequency of their
occurrence. Nineteen out of one hundred cases of double optic neuritis
with headache in the table just given could (after careful examination)
be placed in this group (X.).
What is the cause of the symptoms in this group of cases? Possibly in
some cases the symptoms are caused by a non-malignant tumor (or
tuberculous mass) which ceases to extend and becomes quiescent and
encapsuled. One of us has recorded a case in which symptoms of cerebral
tumor (including Jacksonian epilepsy and hemiplegia) gradually subsided
and temporary recovery ensued; but three years later symptoms of
cerebellar tumor developed and death occurred. The necropsy revealed a
recent large tuberculous mass in the cerebellum and an old capsuled
tuberculous mass just beneath the motor cortex in the right cerebral
hemisphere. The latter had evidently been the cause of the early
cerebral symptoms from which the patient had recovered. An instructive
case has been recorded by Dr. T. K. Monro of Glasgow. The patient, at
the age of sixteen years, suffered from severe headache with failure of
vision which passed on to complete blindness. For thirty-three years he
was an inmate of a blind asylum, ophthalmoscopic examination showing
double optic atrophy. He died at the age of sixty-three years, from
cancer of the stomach, and the post-mortem examination also revealed a
large myxomatous tumor in the left half of the cerebellum. In all
probability the early cerebral symptoms had been associated with optic
neuritis which had passed on to optic atrophy and the cause had been the
myxoma in the cerebellum which had remained quiescent for forty-six
years.
In some cases of double optic neuritis with headache and general
cerebral symptoms, when recovery occurs the cause is probably distention
of the ventricles of the brain with fluid—serous meningitis of the
ventricles (Quincke). This condition was present at the necropsy, and no
tumor growth could be found in two out of the one hundred cases
tabulated. It is probable that a number of the cases in which a
diagnosis of cerebral tumor has been made, but in which recovery has
occurred, have been due to this condition—serous meningitis of the
ventricles. Probably the two cases in Group IX. and possibly some of the
cases in Group II., in which death did not occur for several years after
the onset of symptoms, were of this nature. Other cases which recover
may be due to a basal meningitis.
The table given above is instructive both as regards the diagnosis and
prognosis in cases of double optic neuritis with headache. It shows the
necessity for careful examination before giving either a diagnosis or
prognosis, and the clinical group of cases No. X. ought always to be
borne in mind whenever the diagnosis is obscure and localizing symptoms
are absent.
There are two other points to which we would draw attention. In ten out
of the one hundred cases the patient recovered completely from the
headache and general cerebral symptoms and regained perfect health, but
the optic neuritis was followed by atrophy and complete blindness. In
the face of this terrible termination we cannot help thinking that
simple trephining of the skull and the removal of bone, without any
interference with the brain, as suggested and practiced by Mr. Victor
Horsley for the relief of optic neuritis and pressure symptoms, is a
method of treatment worthy of more frequent trial when vision is failing
markedly. Dr. James Taylor has published cases which appear to show that
this method of treatment may be of service in checking the optic
neuritis and failure of vision. In the class of cases in Group X. if
there should be a suspicion that the symptoms may be due to serous
meningitis of the ventricles, lumbar puncture appears to be worthy of
trial, since several cerebral cases are now on record in which this
treatment appears to have been of great service, and in which the cause
of the cerebral symptoms was probably that just mentioned.