Volume 4 — MEDICAL OPHTHALMOLOGY. (continued 3)

²⁷⁷ Brain, ii. 1878, p. 168.

Foerster has most justly called attention to the remarkable mental cheerfulness of persons laboring under this malady, and states that he has frequently seen cases where the patients would insist that they were improving, while examination of the acuity and of the field of vision showed steady failure of the eyesight. The writer's personal experience has on several occasions substantiated this statement. According to Cyon,²⁷⁸ tabes presents three varieties: First, tabes dorsalis. This variety commences with paralyses of the eye-muscles and amblyopia. The pupils are not contracted. The amblyopia progresses. Cramp-like disturbances of innervation are always present, with a want of co-ordination of movements and anæsthesia of the upper extremities, while mental disturbances are often demonstrable. Second, tabes cervicalis. Myosis, with intense boring pains in the extremities and impotence, are its chief characteristics. Ataxia is rare, and disturbances of vision develop only late in the course of the disease. Third, a class which he considers the true form of tabes dorsalis, in which there are marked anæsthesia, formication, bladder and rectal symptoms, associated with motor disturbances which often end in paralysis. In such cases there are no eye symptoms except occasional dilatation of the pupil. The same writer has collected 203 cases reported by various authors, and gives the following tables as showing the relative frequency of eye symptoms:

Amblyopia 33 times.

Paralysis of eye-muscles 30 times.

Mydriasis 3 times.

Myosis 9 times.

75 times.

Amaurosis with affections of eye-muscles 16 times.

Amaurosis with mydriasis 8 times.

Amaurosis with myosis 1 time.

Affections of the eye-muscles with mydriasis 4 times.

Amaurosis with mydriasis and affection of the eye-muscles 2 times.

He remarks²⁷⁹ that the number of reported cases of mydriasis is probably excessive, and says that dilatation has been improperly noted, as, for instance, where one pupil is normal and the other contracted. As regards the frequency of the Argyll-Robertson symptoms, Vincent²⁸⁰ found it present in 40 cases out of 51, in which there were 7 cases of amaurosis with immobile pupils, 5 being marked exceptions to the rule. Out of 51 cases of tabes, the same author found myosis in 27. The statements of Vincent (as will be seen) differ materially from those of Cyon. Erb²⁸¹ found that in 56 cases, there were only 7 in which the optic nerves were affected (12½ per cent.), while in 17 there were affections of the eye-muscles (30.3 per cent.). He considers myosis a frequent symptom, but thinks that the stage at which it develops is not yet determined. The anatomical cause of the want of sensitiveness of the pupils to light, while they retain their movements of convergence and accommodation, has not been well made out. Vincent²⁸² attributes it to a paralysis of the excito-motor filaments which supply the iris, and which he locates at the upper portion of the spine; while Wernicke thinks it due to degeneration of the filaments which go from the third pair to the optic nerve. Hughlings-Jackson²⁸³ tells us that the pupils which fail to react to light often act but slightly with convergence, and in a note gives two cases of absolutely immobile pupils where the accommodation was nearly normal for the age. In fact, much remains to be accomplished in the study of the innervation of the iris and ciliary muscle in tabes. The proportion of cases in which cycloplegia occurs, and what relation it bears in point of time and frequency to the presence of iridoplegia, are far from being well made out. Jackson also insists that tabes does not necessarily follow in all cases of long-standing optic atrophy. On a basis of 72 cases Gowers says that some formal ophthalmoplegia interna was present in 92 per cent. He groups these cases into three stages: No. 1, where there is loss of knee-jerks, lightning pains, difficulty of standing with toes out and heels together, there being a want of ataxic gait; 2, where there is an ataxic gait, but the patient can still walk by the aid of a stick; 3, where the patient cannot walk without the assistance of another person. In 23 of his cases in the first stage (84 per cent.) symptoms of palsy of some of the intraocular muscles were found; in the second stage, 29 cases (93 per cent.); in the third stage, 18 cases (100 per cent.). Erb has called attention to the fact that reflex dilatation of the pupil from sharp stimulation of the skin of the temple is usually absent where we have the Argyll-Robertson pupil. Gowers admits that this is the rule, but has seen several cases where, although there was no attempt at myosis on exposure to light, yet there was marked dilatation on stimulating the skin.

²⁷⁸ Tabes Dorsalis Berlin, 1866, p. 43.

²⁷⁹ Loc. cit., p. 71.

²⁸⁰ Thèse de Paris, cited by Robin, p. 20.

²⁸¹ Nagel's Jahresbericht der Ophthalmologie, 1872, p. 150.

²⁸² Thèse de Paris.

²⁸³ Transactions of the Ophthalmological Society of the United Kingdom, vol. i. pp. 139-154.

Unclassified Nerve Diseases.

DIABETES.²⁸⁴

²⁸⁴ This affection has been placed here for convenience of classification, and because there is a form of the disease which is of neurotic origin.

DIABETES MELLITUS.—This disease, which affects so profoundly all tissues of the body, necessarily manifests its influence on the tissues of the eyes. It frequently impairs the nutrition of the vitreous and causes the formation of cataract. The presence of grape-sugar is readily detected in such lenses by chemical examination. Mitchell and other experimenters have produced cataract in frogs by placing them in a solution of sugar. In such instances the lens tissue is said to become transparent when the animal is removed from its sugar bath and placed for a time in water; therefore, it is probable that the cataract has been developed by the simple abstraction of water. Diabetic cataracts are often extracted successfully, and the wound usually heals well; but we occasionally have intraocular hemorrhage during the course of healing. At times the nutrition of the patients is so impaired that a slight accident is dangerous, such as happened in a patient of the writer, where the striking of the hand against an iron bedstead caused gangrene and death. Nettleship²⁸⁵ has recorded an analogous case, where accidental injury during convalescence caused death from gangrene. At times marked retinitis and hemorrhages with clear media have been encountered; thus, Jaeger in 1855 gave us an admirable picture of such a case, in which there was retinal swelling so great as to hide the outlines of the nerve, it being accompanied by numerous hemorrhages and yellow splotches. In his description of the case he also states that there was a marked central scotoma (a denser inside of a lighter one) in the field, while the periphery of the retina was so little affected that the patient could still decipher large letters (No. 18 of Jaeger's test-types). We might perhaps think that the scotomata are accidental and due to the location of the retinal changes in the given case, but later researches seem to show that we may have them in diabetes without retinal changes, Nettleship and Edmunds describing two such cases. In one of these cases there seems to be some doubt whether it was not a tobacco amblyopia which had been developed in a diabetic subject; but in the other case there was no such complication. The retinal changes which have been recorded in some cases have much resembled those due to albuminuria, but these alterations in the eye-ground have been seen in a number of cases where no albumen in the urine could be obtained.

²⁸⁵ Transactions of the Ophthalmological Society of the United Kingdom.

Diabetes also may, by impairing the nutrition, diminish the power of accommodation in the young and cause a rapid increase of presbyopia in old persons (Graefe, Nagel, Foerster). Horner²⁸⁶ proved that a hypermetropia of ¹/14 in a patient of fifty-five years of age rapidly diminished to H. = ¹/48, and the amount of presbyopia remained unaltered, while the general health had improved and the quantity of sugar had diminished. He attributes this rapid increase and subsequent diminution of the hypermetropia to a change in the amount of the fluid contents of the eye. Were this reporter any less careful an observer, one might be inclined to suspect swelling of the lens; but he specially mentions that there was no trace of cataract formation.

²⁸⁶ Klin. Monatsbl. f. Augenheilkunde, 1873, p. 490.

EPILEPSY.

IDIOPATHIC EPILEPSY.—In idiopathic epilepsy—that is, in those cases where no gross changes in the brain can be demonstrated by autopsy—the eye symptoms are numerous and interesting. Wecker²⁸⁷ tells us that at the commencement of the spasm there is contraction of the pupils. Usually, soon after the tonic spasm sets in or coincident with it, we have marked dilatation of the pupil and an abolition of the eye-reflexes, this being shown by the want of contraction of the orbicularis or of the pupil when the conjunctiva is touched. Reynolds, Echeverria, Clouston, and Hammond have called attention to a development of hippus (an alternate contraction and dilatation of the pupil) at the end of the convulsive paroxysms; but this is exceptional. The last author considers a state of alternate contraction and dilatation of the pupils, or a contraction of one pupil with dilatation of its fellow, to be characteristic of the convulsive stage. When the convulsions are unilateral the head and eyes are often turned toward the convulsed side. Although ophthalmoscopic examination is favored by dilatation of the pupil, yet the convulsions make it so difficult that we have quite conflicting accounts of the state of the disc and retina during the paroxysm. Six cases have been accurately examined by Albutt during the convulsion, in three of which there was congestion of the disc, and pallor in the remainder. Jackson also reports cases of pallor during the convulsion. More lately, Schreiber²⁸⁸ has examined three cases in which he found pallor in the convulsive stage, this being very marked in one case, where the convulsion was violent. Gowers, on the other hand, maintains that in convulsions which commence locally without initial pallor of the face he was unable to perceive any alteration of the calibre of an artery which he kept continuously in view during the convulsion. The same author tells us that during the stage of cyanosis the veins of the retina become distended and dark, and that once in the status epilepticus he has seen a congestion of the discs with oedema, which subsequently disappeared. He does not consider that there is any abnormal appearance of the discs in the intervals between the attacks, while both Albutt and Bouchut hold that they are congested. In several of the chronic cases which the writer has had an opportunity of examining there has been a low grade of atrophy of the discs with concentric limitation of the field of vision. That this, at least, is common in advanced cases is well shown by the observations of Michel,²⁸⁹ who in 1867 published careful examination of the eye-ground, acuity, and field of vision of 58 epileptics. In 15 of these cases there were no visible changes; in 10, hyperæmia; in 1, hyperæmia with oedema; 1 of hyperæmia passing into atrophy; 10 of unilateral atrophy (9 of the right nerve and 1 of the left); 13 cases of atrophy of both optic nerves; the remaining cases showing changes in the eye-ground which were probably attributable to other causes. Auræ which affect the special senses have been recorded, and have been usually described as flashes of light or balls of fire. Maisonneuve (quoted by Robin) gives an instance where the auræ consisted in convulsions of the eyelids. Gowers gives 119 cases of auræ which affected the special senses, 84 of these being of the sense of sight. He divides the latter into five classes: I. Sensation in the eyeball; II. Diplopia; III. Apparent increase or diminution in the size of objects; IV. Loss of eyesight; V. Distinct visual sensations, consisting sometimes of flashes of light, colored spectra, and rarely some more specialized sensation, such as an apparition. The only one of these cases in which there was an autopsy appears to have been one of symptomatic rather than idiopathic character, as there was found a tumor of the occipital lobe which had extended as far forward as the angular gyrus.

²⁸⁷ G. u. S., Bd. iv. p. 565.

²⁸⁸ Ueber Voränderungen des Augenhintergrundes, etc., 1878 (S. 42).

²⁸⁹ Inaug. Diss., von Dr. Julius Michel, Würzburg, 1867.

HYSTERO-EPILEPSY.—The remarkable co-ordinated convulsions which are associated with hemianæsthesia, and which have been so minutely described by Charcot as characteristic of this disease, are constantly accompanied by subjective or objective disorders of the visual apparatus. Visions of animals, such as rats, vipers, crows, cats, etc., frequently precede the convulsive seizure, followed by a transient loss of sight; a return of the illusions (sometimes pleasant and gay, at others erotic in their nature, or again sad or terror-striking) coming on in a later stage. It is said that processions of animals are often seen, which usually come and go on the hemianæsthetic side as the attack passes off and the patient becomes quiet. The objective symptoms have been carefully studied by Landolt in Charcot's wards. They were found by him to consist in a diminution of the acuity of vision and a concentric limitation of the field for form and color. All these symptoms are bilateral, and much more marked on the anæsthetic side, they occurring before any ophthalmoscopic changes are visible. These are followed later by alterations in the eye-ground, which consist at first of slight congestion and oedema of the discs, followed by partial atrophy. The difference in the affection of the two eyes was so marked that Charcot at first described it as a crossed amblyopia, but he admits that the lesion is bilateral, as above described.²⁹⁰

²⁹⁰ Leçons sur les Localisations dans les Mal. du Cerveau, vol. i. p. 119 (foot-note), Paris, 1876.

EXOPHTHALMIC GOITRE.

GRAVE'S DISEASE; BASEDOW'S DISEASE.—The most prominent characteristics of this affection are an irritability of the heart with increased frequency of the pulse, and enlargement of the thyroid gland and a swelling of the tissues of the orbit, which cause the eyeballs to become prominent. The size of the goitre and the amount of protrusion of the eyeball vary very much in different cases. Frequently there is a symptom to which Graefe was the first to call attention—namely, a disturbance of the usual consensual movements of the eyeball and upper eyelid. When the patient looks downward below the horizontal line, the lid no longer accompanies the eyeball in its motion, but halts in its course. This derangement in the action of the lid is supposed to depend upon some defect in the innervation of the orbicularis, as it is not present in cases of equal prominence of the eyeball from other causes. The amount of secretion from the tear-glands and from the conjunctival surface is also at times much diminished. Owing to the prominence of the eyes and the relaxation of the orbicularis, the fissure of the lids is wider open than usual, and the eye has a peculiar stare. At times, when the prominence of the eyes is very great, the lids fail to cover the balls during sleep, and the cornea becomes inflamed and ulcerated from exposure to air and dust. The disease rarely develops till after puberty, and is more frequent in females than in males: in the former it often develops after childbirth. It is so frequently accompanied by disease of the reproductive organs that Foerster, in his paper on the "Relation of Eye Diseases to General Disease,"²⁹¹ places it in the section devoted to eye symptoms from diseases of the sexual organs. Ophthalmoscopic examination usually shows a slight thickening of the fibre-layer of the retina in and around the disc, with dilatation and tortuosity of the veins—a state of affairs which may often be fairly attributed to venous stasis caused by the swelling tissues. In addition to these symptoms there is sometimes, as Becker has pointed out, a dilatation of the arteries, which may almost equal the veins in calibre. At times there is an arterial pulse. As found by autopsies, the anatomical changes are usually enlargement and dilatation of the heart, hypertrophy and various degenerative changes in the thyroid glands, and a state of hyperæmia at times associated with hypertrophy of the fat tissue of both orbits.

²⁹¹ Graefe und Saemisch, vol. vii. p. 97.

Affections of the General System.

CHOLERA.—In this disease the eyelids are said to show an early development of cyanosis, which becomes more marked as this symptom develops in other parts of the body. The contents of the orbits shrink and the eyes are drawn back in their sockets, there being an imperfect closure of the lids, which leads at times to necrosis of the exposed lower part of the cornea. There is a marked diminution in the secretion of tears, and often a dilatation of the veins of the exposed part of the conjunctiva bulbi, which are turgid with the black blood, this state being at times accompanied by subconjunctival hemorrhages. The pupils are usually contracted. The retinal arteries are much diminished in size, and the veins although not dilated, are filled with blackish blood. Owing to the great feebleness of the circulation, the slightest pressure with the finger on the eyeball produces arterial pulse; Graefe²⁹² in some cases describes a pulsating movement of interrupted blood-columns in the veins, such as is sometimes seen in incomplete embolism of the arteria centralis.

²⁹² A. f. O., xii. 2, p. 210.

RHEUMATISM AND GOUT.—In the older books on diseases of the eye we constantly meet references to rheumatic and arthritic forms of inflammation of that organ. In the later works on the subject the list has been greatly reduced, partly because an anatomical classification has been attempted, and partly because many such affections have been attributed to other causes, such as syphilis, etc. Catarrho-rheumatic ophthalmia, rheumatic iritis, rheumatic paralysis of the eye-muscles, etc. have been so classified, not on account of their occurrence in the course of attacks of acute rheumatism, but because the writers have been unable to attribute them to any other source than that designated as having taken cold. That recurrent attacks of iritis are frequent in some individuals who have recurrent attacks of chronic inflammation of the joints is a fact familiar to many practitioners, amply attested by the cases published by Hutchinson²⁹³ and by Foerster.²⁹⁴ As regards gout, the direct proofs of its relations to eye disease are still less manifest, and most cases supposed to be attributed to this cause by both the older and more modern writers are to be classed as primary or secondary glaucoma.

²⁹³ "A Report on the Forms of Eye Disease which occur in connection with Rheumatism and Gout," by Jonathan Hutchinson (R. L. O. H. Reps., vol. vii. pp. 287-332; also vol. viii. pp. 191-216).

²⁹⁴ "Beziehungen der Allgemein-Leiden, etc., zu Veränderungen des Sehorgans," Graefe u. Saemisch, vol. vii. pp. 155-160.

SYPHILIS.—All the tissues of the eyeball and eyelids may at times manifest the signs of this dread and searching dyscrasia, although it is rarely so marked in its character as to be distinguished with certainty from other forms of eye disease by its appearance alone. Primary syphilis of the lid is rare, but when it occurs it is liable to be mistaken for epithelioma, where there is absence of a distinct history of infection. In the eyeball itself the uveal tract (iris, ciliary body, and choroid) is the favorite seat of disease. Iritis is said by Fournier²⁹⁵ to be developed in from 3 to 4 per cent. of all cases of syphilis, and, according to Coccius, 11.6 per cent. out of 7898 cases of eye disease in Leipzig were due to this cause. Syphilitic iritis certainly constitutes a large proportion of the cases of inflammation of the iris seen in hospital practice: Coccius places the percentage at 46.6 per cent., while Wecker puts it at 50 to 60 per cent. It usually develops during the subsidence of the secondary skin affections, and is often to be distinguished by its insidious course and the amount of plastic exudation which accompanies it. There is ciliary injection and sluggishness of the pupil, with the formation of synechiæ, before there is any very decided pain or photophobia, this latter being usually strongly developed at a later period. The formation of gummata in the iris, which are generally seen in the smaller circle, is much rarer, generally developing in the tertiary stage of the disease; occasionally they are developed in the ciliary body. In the former situation they usually disappear under active treatment, leaving fair vision in the eye, but when situated in the latter place they usually lead to shrinking and atrophy of the eyeball, even under the most vigorous treatment. When iritis occurs in infants it is generally specific in origin. When they are born with posterior synechiæ and complicate cataract, similar occurrences during intra-uterine life may be suspected. Syphilitic choroiditis is frequent, but its frequency is probably overrated on account of a disposition to assume syphilis as a cause of cases of choroiditis in which the pathology is not evident. Foerster has very properly pointed out that a majority of the cases of disseminate choroiditis are not due to this cause, and that the changes are developed slowly, and remain stable for a long time even when not treated; while the usual form of specific choroiditis shows rapid progress, with failure of the sight, photopsies, vitreous opacities, hemeralopia, and zonular defects in the field of vision. Opinion, however, is divided on this point: Wecker thinks that two-thirds of the cases of disseminate choroiditis are due to syphilis. In many of the chronic cases of syphilitic choroiditis there is a wandering of the pigment out of the cells of the choroidal epithelium, and a distribution of it into the lymph-sheaths of the retinal vessels and capillaries, these changes producing ophthalmoscopic appearances which closely resemble those of typical pigmentary degeneration of the retina. Affections of the head of the optic nerve and superficial layers of the retina, such as are represented by Liebreich,²⁹⁶ are much more rare, but the writer has repeatedly seen them both at Liebreich's Paris clinic and in our own hospitals. They are characteristic, and usually accompany the tertiary symptoms. There is a dense haze which seems to lie partly in front of the retina, and to extend around the disc for a space of one and a half to two disc-diameters, generally including the macula lutea, and rapidly diminishing as it approaches the equator. Vision is usually much reduced, and even under persistent antisyphilitic treatment it is slow to clear up. Hereditary syphilis frequently manifests itself in an interstitial keratitis, which begins with small irregularly-rounded dots near the centre of the cornea. They gradually become more numerous, and coalesce, until the membrane appears as if a thin layer of ground glass had been imbedded in its tissue, leaving the epithelium clear and bright. Although there is no ulceration, yet there is a great tendency to the formation of new blood-vessels, which often goes on until the entire cornea is permeated by them and becomes of a dull venous blood-like red color. These vessels are continuous with superficial and deeper shoots which pass in from the two layers, normally forming loops in the corneal periphery. This form of keratitis is usually accompanied by marked photophobia, pain, ciliary injection, and low grades of iritis. The pathological processes which take place in the cornea during the disease generally leave it more or less clouded, and often much misshapen by softening and alteration of its curvature.

²⁹⁵ Quoted by Foerster, Graefe und Saemisch, vol. vii. p. 189.

²⁹⁶ Plate 10, Fig. 2, ed. 1863.

TUBERCULOSIS.—Except in children, the eyeball is rarely the seat of a deposit of tubercles, and even then it is much more likely to give evidence of their seat in the membranes of the brain by its secondary affection than to be itself directly affected by them. When they form in the eye, they may affect the choroid, the intraocular end of the optic nerve, the retina, or the iris. Jaeger was the first to call attention to their ophthalmoscopic appearances. Their favorite seat, as is well shown in one of Jaeger's plates, is the macular region and its vicinity. They develop in the stroma of the choroid, and appear as whitish-yellow spots varying from one-eighth the diameter of the optic disc to the size of the disc itself, and by aggregation may form even larger masses. They are usually seen in cases of well-marked acute miliary tuberculosis, although doubtless they are often overlooked, on account of not giving rise to any symptoms; besides, thorough ophthalmoscopic examination of such sick and restless children is difficult, and the general diagnosis is usually well made out from other symptoms. They may, however, precede all other symptoms, as in the cases reported by Steffen²⁹⁷ and Fraenkel.²⁹⁸ Development of tubercular masses in the intraocular end of the opticus has been described by Chiari,²⁹⁹ Michel,³⁰⁰ and Gowers.³⁰¹ In the case cited by the last author the growth extended from the disc to the ora serrata, which during life gave rise to the peculiar reflection from the eye so often seen in intraocular tumor. According to Cohnheim,³⁰² tubercle is to be found in the choroid in all cases of acute miliary tuberculosis. Other observers, however, have not been able to support him in this assertion: Albutt,³⁰³ who repeatedly searched for them both in living and dead subjects, failed to find them; Garlick³⁰⁴ during two years' experience at a children's hospital found them but once; Heinzel³⁰⁵ in ten cases of general tuberculosis in children was at the autopsies unable to find any tubercles of the choroid. According to Stricker, they may at times develop very rapidly, coming on in from twelve to twenty-four hours. Tubercles have been found in the retina in the cases of papillary tuberculosis already referred to, and also with cases of tubercle in the iris (Perls, Manfredi). At times, tubercles in the iris occur in scrofulous and feeble children, appearing as growths in all respects closely resembling syphilitic gummata. As in the latter case, they are accompanied by severe iritis, and at times with hypopyon. Tuberculosis of the conjunctiva is a very rare affection. It is described as commencing with swelling of the lids, and when these are everted exuberant granulations of the conjunctiva are seen which are most frequently situated in the retrotarsal folds. These granulations are at first of a grayish-red color, but when they have existed for some time, superficial erosion of their surface occurs, and uneven yellowish-red ulcers are formed. The disease usually occurs in young people, and generally affects but one eye. Haab³⁰⁶ has given a description of six cases of it, with reference to a few instances described by other authors.

²⁹⁷ Jahresbericht f. Kinderheilkunde, 1870 (Gowers).

²⁹⁸ Berliner klinisches Wochenschrift, 1872, pp. 4-6 (Foerster).

²⁹⁹ Wien. Med. Jahrbucher, 1877, p. 559.

³⁰⁰ Archiv der Heilkunde, 1873.

³⁰¹ Medical Ophthalmoscopy, 1879, p. 250.

³⁰² Virch. Arch., 1867, Bd. xxxix. p. 49 (Foerster).

³⁰³ Quoted by Gowers, p. 203.

³⁰⁴ Quoted by Gowers, Med. Ophth., p. 200.

³⁰⁵ Quoted by Foerster, p. 99, Jahrbuch der Kinderheilkunde, Neue Folge, viii., 3, p. 331.

³⁰⁶ "Die Tuberculose des Auges," A. f. O., xxv., 4, p. 163.

Toxic Amblyopiæ.

TOBACCO AND ALCOHOL.—These two lesions strongly resemble each other, and it is impossible to differentiate them when we find them in persons who are addicted to the abuse of both of these drugs; consequently, for a time, in Germany, there was a disposition to underrate the potent destructive agency of the latter drug, but every practitioner of experience in eye disease must have seen cases of tobacco amblyopia in which there has been no abuse of alcohol. The best proof of the deleterious influences of tobacco on the eyesight is the improvement which results by simple abstinence from its use where the vision has been seriously affected by its influence. In the earlier stages of both forms of amblyopia there is a contracted pupil and a slight dimness of vision, the patients claiming that they see better in feeble light and twilight. The ophthalmoscope shows a slight oedema of the disc with tortuosity of the veins, the rest of the eye-ground appearing normal. Later, the usual appearances of blue-gray atrophy set in. In the earlier stage there are often color scotomata, which are usually ovoid in form and lie between the disc and the macula lutea. Unless carefully looked for with color squares of one to two millimeters in diameter, they are apt to be overlooked. Later, there is a marked reduction of central vision. When the atrophy has progressed farther, there is decided contraction of the field.

LEAD-POISONING.—The deleterious effects of lead on the eyesight are undoubted, although rare in proportion to the cases of colic and wrist-drop produced by this metal. When amaurosis develops, it is usually either in acute lead-poisoning or after a gradual saturation of the system, as is shown by repeated attacks of lead colic. In either case the amaurosis is usually accompanied by dilatation of the pupils, delirium, and convulsions. The amaurosis generally passes off, and the pupils contract with the return of vision, although it may remain permanent, and leaves the patient with atrophic nerves, as in a case observed by Trousseau, where the patient was subsequently transferred to the Salpêtrière. The only two cases which the writer has had an opportunity of witnessing showed marked choking of the discs and severe cerebral symptoms. One of these cases died and one recovered: both were results of the use of white lead as a cosmetic. Rognetta³⁰⁷ quotes Vater as reporting a case of hemianopia produced by lead-poisoning, which recovered when the lead colic was cured. Trousseau³⁰⁸ quotes Andral as giving a case of diplopia due to the same cause, and disappearing as the patient recovered.

³⁰⁷ Recherches sur la Cause et la Siège d'Amaurose.

³⁰⁸ Thèse de Concours.

QUININE.—Over-doses of quinine seriously impair the eyesight, and in some cases have produced temporary but absolute blindness. The usual symptoms are a deterioration of central vision and a contraction of the field. The ophthalmoscopic examination reveals a pallid disc with marked diminution in the size of the retinal arteries and veins. In many of the reported cases it is difficult to decide positively how much of the amaurosis is due to the quinine and how much to the disease for which the patient is under treatment. This is especially true where the patient has been suffering from severe intermittent fever or from exhausting hemorrhages complicating uterine disease, which are well known frequently to produce more or less complete atrophy, with shrinking of the vessels. There are, however, a sufficient number of well-observed cases on record to satisfactorily establish the lesion. One of the most striking is a case of poisoning recorded by Giacomini, where the patient took at one dose three drachms of sulphate of quinia by mistake for cream of tartar. This was followed by severe headache, pain in the stomach, dizziness, unconsciousness, with slow and scarcely perceptible pulse and infrequent respiration. The pupils were widely dilated. On regaining consciousness the patient found that he was almost blind, the weakness of sight lasting a long time. As the poisoning occurred in the preophthalmoscopic era, there is of course no description of the eye-ground. In all recorded cases, while central vision has been either partially or entirely regained, the field of vision has remained permanently contracted.

SANTONIN.—In very large doses santonin produces dilatation of the pupil, amblyopia, and complete color-blindness. Smaller doses produce a shortening of the violet end of the spectrum and cause yellow vision. The disturbance of vision usually lasts only a few hours. The poison seems to be eliminated by the urine, as the sight is said to become normal while traces of the drug can still be seen in the secretion of the kidneys. Rose has given us a most careful study of this subject in his papers entitled "Color-Blindness from Santonin"³⁰⁹ and "Hallucinations in Santonin Intoxication."³¹⁰

³⁰⁹ Virch. Arch., Bd. xx., 1860 (Separat Abdruck, S. 48).

³¹⁰ Ibid., Bd. xxviii., 1863 (Separat Abdruck, S. 12).

SALICYLATE OF SODIUM.—Gatti³¹¹ reports a case of transient amblyopia, due to the ingestion of one hundred and twenty grains of salicylate of sodium, in a sixteen-year-old peasant-girl who had acute articular rheumatism. There were no changes in the eye-ground except a fulness of the veins, which persisted after the eyesight had returned. There was mydriasis. No phosphenes could be produced. As the urine did not present any traces of salicylate of sodium, it would seem to show that it was not eliminated by the usual emunctories.

³¹¹ Gaz. d. Ospital Milano, p. 129, 1880; Nagel's Jahresbericht, 1882 (Lit. 1880), p. 245.