Volume 4 — MEDICAL OPHTHALMOLOGY.

MEDICAL OPHTHALMOLOGY.

BY WM. F. NORRIS, M.D.

INTRODUCTION.—The object of the following essay is to give, as far as practicable in the limits of an encyclopædic article, an account of the eye symptoms which may be seen in the course of diseases of the general system and in connection with the pathological conditions of the various organs of the body. The eye has always been looked on as a valuable indicator of general systemic disturbance. Its expression has been noted as showing the general vigor or feebleness of the patient, as well as his varying mental moods, while paralysis of its external and internal muscles has in all times been regarded as a sign of disturbed intracranial action or disease. In order to judge of the state of the circulation the physician habitually looks at the lips, the tongue, and the nails, where the capillaries are covered by translucent material, to appreciate the state of the circulation. How much better are we enabled to do this when, by the use of the ophthalmoscope, we look at the interior of the eye and see the blood-columns in the veins and arteries of the head of the optic nerve and the retina laid bare to our view without any opaque covering whatever! Such an examination, besides showing the state of the circulation, will frequently reveal a neuritis which may be due to some intracranial disease, or show a degeneration of the optic nerve which may point to impaired power and tissue-change in the spinal cord or the brain; or there may be characteristic retinal changes associated, as, for instance, with disease of the kidneys, or extravasation of blood which may be dependent on general or local causes; these frequently serving as important indices of the state of the nerves and vascular tissues in other organs in the body.

In so vast a field, and in one so new as regards ophthalmoscopic appearances, there remains still much to be accomplished. Useful knowledge has accumulated slowly, but numerous enigmatical appearances have been referred to their true causes, while many which at first sight seemed important have been proved to be either anomalies of formation or to have no pathological import. A complete and accurate description of all the eye symptoms in all diseases is an herculean task, because it presupposes the careful study of vast numbers of cases in every department of medicine: it is therefore out of the question for any one man to complete such a description from his individual efforts, and he must either remain content with a mere sketch or collate the combined experiences of many observers in different fields in order that it may be in any way reasonably perfect. To keep such an article within any moderate limits it has been necessary to condense much, and to consider only those points which the combined testimony of many observers shows to be important and of frequent occurrence. For similar reasons the writer has abstained from giving a complete list of all authorities treating of the subjects herein discussed, and has referred only to those which appeared to him to be some of the most important. Those readers who wish a more complete bibliography can readily obtain it by referring to the various monographs hereinafter quoted, and also by consulting the well-known essays of Foerster,¹ Robin,² and of Mauthner,³ or the treatises of Albutt⁴ and of Gowers.⁵

¹ "Beziehungen der Allgemein-Leiden und Organ-Erkrankungen zu Veränderungen und Krankheiten des Sehorgans," in Graefe und Saemisch's Handbuch der Augenheilkunde, Bd. vii., 1877.

² Des Troubles oculaires dans les Maladies de l'Encephale, Paris, 1880.

³ Lehrbuch der Ophthalmoscopie, Vienna, 1868, and Gehirn und Auge, Wiesbaden, 1881.

⁴ On the Use of the Ophthalmoscope, London, 1871.

⁵ Medical Ophthalmoscopy, London, 1879.

Such an article is necessarily a chapter on symptomatology, giving the eye symptoms in various diseases and pathological conditions, and the reader will therefore look in vain in it for any directions as to the treatment of such maladies, or for formulæ showing advantageous modes of administering medicines. The writer has intended, by describing and grouping eye symptoms, to enable the practitioner more readily to diagnosticate the various pathological conditions of other parts of the economy. The reader should look for a description of treatment in the various articles of this work which are devoted to the discussion of such diseases and morbid states. Local diseases of the eye, except so far as they are manifestly related to or caused by general disease, have been avoided in this paper, these topics being appropriate to a treatise on the diseases of the eye.

Changes in the Eye-ground and its Appendages due to Diseases of the Circulatory Apparatus—Heart, Blood-vessels, and Blood.

The ophthalmoscope has laid bare to our view a living nerve of special sense, the highly-developed end-organ in which it terminates, and the blood-columns circulating in them. In no other part of the body has Nature vouchsafed to us so clear an insight into her mysteries. In a state of health the index of refraction of the walls of the retinal blood-vessels is so nearly coincident with that of the surrounding media that they either entirely escape our observation or are only slightly indicated, thus allowing us to see only the blood-columns which circulate within them. Owing to the distance from the heart and to the restraining influence of the intraocular pressure, as well as to the minute size of the vessels in question, the pulse-wave has so far died out as to be ordinarily invisible, even by the aid of the eye-lenses which Nature has so kindly placed as magnifying-glasses to assist us in the study of intraocular phenomena. Even where we avail ourselves of the upright image in examining the normal eye-ground, by which an amplifying power of seven to fifteen diameters is obtained, we cannot usually detect any pulsation in the vessels, although exceptionally we may observe pulsation which is always venous and confined to the larger twigs of the venæ centrales as they pass over the disc and dip into the nerve-substance. By slight pressure on the eyeball with the finger venous pulse can always be produced. This phenomenon consists of an emptying of the vein from the optic pylorus toward the periphery, followed by a rush of return blood in an opposite direction, which takes place in eyes where the intravenous and intraocular pressures are nearly balanced. Under these circumstances the injection of a fresh quantity of arterial blood into the eye causes a temporary increase of intraocular pressure, which is transmitted through the vitreous to the main trunks of the veins, compressing them at the point nearest the heart (where the intravenous pressure is least) before the column of entering blood which has been hindered by the capillary resistance has had time to flow around to re-establish the current. Stronger pressure on the eye will produce an arterial pulsation by causing the intraocular pressure to become so high that the blood enters only during the systole of the heart and diastole of the arteries. This is not infrequently seen in glaucoma, where there is an augmentation of the intraocular pressure, but is never visible in the normal eye of a healthy individual. It should be kept in mind that the venous pulse often produces a slight change in the adjacent arteries which ought not be mistaken for arterial pulsation.⁶ Wadsworth and Putnam⁷ describe an intermittent variation in the size of the retinal veins independent of the pulsation produced by the heart's action, and having a period of about five respirations, analogous to the variation of arterial tension found in animals. Besides the arterial pulse already alluded to, produced by augmented intraocular tension, where the normal force of the circulation is not sufficient to drive the blood in a continuous stream into the tense eyeball, we have an analogous condition where the intraocular tension may be normal, but the arterial tension is diminished, and a full stream of blood can enter only during the diastole of the arteries or maximum of intravascular pressure. We may notice examples of this in insufficiency of the aortic valves, and in some very rare cases described by Quincke⁸ and Becker,⁹ who found it accompanied by an alternate flushing and pallor of the optic disc analogous to the capillary pulse which may at times be observed in the finger-nail under similar conditions of the general circulation. The arterial pulse may also accompany any cause which permanently or temporarily reduces the blood-pressure in the arterial system, such as pressure of a tumor on the ophthalmic artery or of a swollen nerve on the central retinal artery (as in neuritis): or, again, by feeble impulse of the heart, as in cases of fainting or in degeneration and dilatation of the walls of the blood-vessels.¹⁰ Becker relates¹¹ a case of arterial pulsation in a left eye, supposed to be due to aneurism of the aorta at a point where the left carotid is given off, whilst the other eye presented the usual appearance of healthy retinal circulation: an aneurism at the origin of the innominate might reverse this and give arterial pulsation in the right eye. Usually, the pulse-phenomena in the retina are confined to the vessels on the optic disc and its immediate vicinity, but both Jaeger¹² and Becker¹³ give cases where it was visible over the entire eye-ground. In cases of congenital malformation of the heart with cyanosis, such as defective closure of the foramen ovale or stenosis of the pulmonary artery, the retinal vessels show markedly the general distension of the veins and the change of color of the blood. Liebreich¹⁴ gives a striking picture of such a case, and Leber¹⁵ remarks that in two cases observed by him the dilatation affected the arteries as well as the veins. Knapp¹⁶ describes a case of swelling of the discs, with a vast number of thickened arteries and veins which radiated from them, many twigs reaching the fovea centralis. The autopsy showed general enlargement and hypertrophy of the whole vascular system without disease of the heart. Arcus senilis is often an accompaniment of fatty heart and an indication of extensive fatty degeneration of other tissues of the body, such as the small arteries of the brain and the recti muscles of the eye.¹⁷

⁶ For a minute study of the phenomenon, vide Jaeger, Med. Zeitschrift, 1854. See also his Ergebnisse des Untersuchung mit dem Augenspiegel, etc., 1876, pp. 60, 61. See also Becker, Arch. f. Oph., vol. xviii., part 1, p. 270.

⁷ Vide Trans. of the Amer. Oph. Society, 1878, pp. 435-439.

⁸ H. Quincke, Berl. klin. Wochenschrift, No. 34, 1868.

⁹ O. Becker, Arch. f. Ophth., vol. xviii., 1, pp. 207-296.

¹⁰ Wordsworth, R. L. O. II. Rep., vol. iv. p. 111.

¹¹ Loc. cit., pp. 253-256.

¹² Ophth. Hand Atlas, p. 75, Fig. 52.

¹³ Loc. cit., pp. 220, 221.

¹⁴ Liebreich's Atlas, Tab. ix. Fig. 3.

¹⁵ Graefe und Saemisch, vol. v. pp. 524-526.

¹⁶ Trans. Amer. Ophth. Soc., 1870, p. 120.

¹⁷ Canton, The Arcus Senilis, London, 1863.

Since 1859, when Graefe¹⁸ by means of the ophthalmoscope first diagnosticated this condition of the retina (which Schweigger¹⁹ a year and a half later substantiated by anatomical proof, demonstrating a closure of the central artery by an embolus in it just behind the lamina cribrosa), embolism of the central artery of the retina has been a favorite explanation of all cases of sudden one-sided blindness. Since that date Sichel,²⁰ Nettleship,²¹ Priestly Smith,²² and Schmidt²³ have all published careful clinical studies of similar cases with autopsies. Embolism is less frequent in this situation than in many other parts of the body, and this, as has been pointed out by Foerster, is probably due to the fact that the ophthalmic artery is given off from the external carotid nearly at a right angle, and while it in turn again sends off its smallest branch—the central retinal artery—at nearly the same angle; consequently, emboli are more readily carried past their orifices into some other vascular area supplied by the main stem. Mauthner has suggested that the transitory but complete blindness which sometimes precedes embolism of the central artery may be due to the stoppage of the orifice of the artery (where it comes off from the ophthalmic artery) by a previous embolus which has been too large to enter the artery, and which, owing to the favorable position of the orifice, has been washed beyond into some of the other branches. In the majority of such cases the ophthalmoscope shows that the retinal arteries are diminished in size and partially filled with blood, while a white opacity of the fibre-layer of the retina extends centrifugally from the disc and between it and the macula lutea. When the opacity surrounds the latter, the fovea centralis (where the fibre-layer dies out) shows by contrast as a reddish or at times a cherry-red spot. The state of the disc itself appears to differ in different cases: some authors have described it as unusually pallid, whilst others claim that it still retains more or less of its natural pinkish hue. In cases reported,²⁴ where the disc is said to be of normal color, this circumstance is probably due to collateral circulation which has been established with the ciliary vessels at the optic entrance. Where the obstruction of the artery is complete the blindness is permanent, and the disc and retina become atrophic. Embolism also occurs in the branches of the central retinal artery, and in such instances there is loss of a corresponding part of the field of vision. In some cases there is hemorrhagic infarction.²⁵ It is never present in embolism of the main stem of the central retinal artery. Inasmuch as this latter vessel is an end-artery, the absence of infarction and subsequent sphacelus is interesting. The intraocular pressure probably prevents the back current of venous blood into the obstructed area, while the nearness of the vessels of the chorio-capillaris allows the retina to obtain sufficient nutriment to prevent death without allowing it to carry on its functions. In the case of embolism of a branch, all the retinal blood being under the intraocular pressure, there would be no hindrance to the entrance of venous blood from the areas of the retina supplied by other arterial branches, although, as above mentioned, the infarction is not present in all such cases. Thrombosis of the central retinal vein is also a rare affection, only recognized and diagnosticated of late years. Michel²⁶ reports 7 cases, with plates of the ophthalmoscopic appearances in 4 of them. The patients were all between fifty-one and eighty-one years of age, and all had rigidity of the peripheral arteries. The suddenness of the attack recalls the symptoms of embolism, but in thrombosis the blindness is said never to be absolute. The ophthalmoscopic appearances are described as consisting of a diffuse and intense reddish haze of the fibre-layer of the retina, hiding the outlines of the disc and usually extending one and a half disc-diameters from it. This area of haze shows numerous small hemorrhages, mostly linear, in the direction of the retinal fibres, and beyond it the arteries and veins of the retina again become visible. The veins are dilated, excessively tortuous, and carry dark blackish blood. In the periphery of the retina the hemorrhages are rounded and splotchy, whilst a dark rounded hemorrhage occupies the fovea centralis. There is no swelling or prominence of the disc. When the thrombosis has been complete, atrophy of the intraocular end of the optic nerve follows. Zehender²⁷ makes two classes of cases—the marasmic in old people, and the phlebitic in young—reporting an interesting case in a patient twenty-six years old. Leber²⁸ details a case of hemorrhagic retinitis with thrombosis of some of the venous trunks in the retina, which were swollen to two or three times their usual calibre, and filled with very dark, almost blackish, blood: as they approached the disc they rapidly diminished in size, and were almost thread-like as they dipped into it. Galezowski²⁹ cites two instances—one in a case of injury to the ciliary region, and one after injury to the eye by steam. In the latter, the thrombosis affected the artery, and the subject was forty-nine years of age.

¹⁸ A. f. O., v. 1, S. 136.

¹⁹ Vorlesunqen über den Gebrauch des Augenspiegels, S. 140.

²⁰ A. Sichel, Archiv der Phys. Norm. et Path., No. 1, pp. 83-89 and pp. 207-218 (quoted by Leber).

²¹ R. L. O. H. Rep., vol. viii., pp. 9-20.

²² Brit. Med. Journ., 1874, April, p. 452.

²³ H. Schmidt, A. f. O., xx., 2, pp. 287-307.

²⁴ Vide case by Schmidt, Archiv f. Ophthalm., xx., 2, p. 288.

²⁵ Knapp, Archives of Ophthalmology and Otology, vol. i. p. 84 (with plates), and Landesberg, in same journal, vol. iv. pp. 39, 40, have each given cases of embolism of a branch of the retinal artery, with infarction.

²⁶ A. f. O., xxiv., 2, pp. 37-70.

²⁷ In clinical lecture reported by Angelucci, Klin. Monatsblätter f. Augenheilkunde, 1880, p. 23.

²⁸ Graefe und Saemisch, vol. v. p. 531.

²⁹ Gaz. méd. de Paris, 1879, p. 217.

Retinal hemorrhage is of frequent occurrence. It is often associated with inflammation in cachectic conditions of the system, as in the various forms of symptomatic retinitis, but is also found where there is not any demonstrable constitutional disease. Here, as in the other tissues of the body, apoplexies are favored by disease of the coats of the vessels, by alteration in the state of the blood, and by increased intravascular pressure. Anatomical examination has shown in the most common form of disease in the retinal vessels fatty degeneration of their walls, with calcareous deposits in them, and a condition (denominated sclerosis) in which the coats become thickened, homogeneous, and of a higher index of refraction. In this hardened tissue there is a condition similar to amyloid degeneration, but no reaction is to be obtained from iodine (Leber). No ruptures can be seen with the ophthalmoscope, but the vessels appear to pass on in contact with the hemorrhage without change of course or calibre. These circumstances have led Leber³⁰ to suppose that most retinal hemorrhages are due to diapedesis, and not to rhexis. When the blood escapes into the fibre-layer of the retina, it frequently diffuses itself along the course of the fibres and between them, and gives rise to linear and striated hemorrhages, while in the deeper layers its progress is barred by the connective-tissue elements—notably by the radiating fibres of Müller—and forms irregular masses which appear as more or less rounded clumps when looked at by the ophthalmoscope. Such extravasations of blood are frequently absorbed, or, again, they may leave black spots of pigment as the only marks of their presence. At other times they produce yellowish-white masses which disappear slowly, and often leave connective-tissue cicatrices behind them, dragging upon and displacing the retinal elements. When the hemorrhage is considerable, it may cause primary distortion of the images and impairment of vision by pressure on the rods and cones. At times it breaks through the limitans interna into the vitreous, giving rise to floating opacities, more rarely spreading itself out in a layer between the vitreous and the retina. The writer well remembers such an instance in the case of an apparently healthy woman about forty years of age, who, while sitting quietly in church, noticed that objects looked red and that a dense cloud came before the eye. Examination with the ophthalmoscope showed a large hemorrhage which covered the entire region of the macula and extended far beyond it, overlapping the temporal edge of the disc. This hemorrhage was slowly absorbed, and four years later the patient had a vision of ²⁰/xx, and no trace of hemorrhage was visible in the entire eyeground. Liebreich³¹ gives a good illustration of a similar case in a woman of forty-five years of age who, after suppression of the menses, had a similar state of affairs. Leber³² has seen several such cases, in one of which the hemorrhage was changed into a brilliant white mass. This was entirely absorbed, leaving only a small pigmented stripe at its lower border as the sole trace of the previous large extravasation of blood. Occasionally retinal hemorrhage ushers in glaucoma. Retinal apoplexies, like extravasations of blood in the conjunctiva of the eyeball, often come without apparent cause. In many cases they are finger-posts pointing to grave disease of the vessels in other parts of the body. The writer recalls a patient of seventy years of age who believed himself in perfect health until alarmed by a retinal hemorrhage, which a few months later was followed by a cerebral apoplexy which caused his death.

³⁰ Graefe und Saemisch, vol. v. p. 554.

³¹ Atlas, Table viii. Fig. 2 (1863 ed.).

³² Graefe und Saemisch, v. p. 553.

Aneurism of the central retinal artery is of excessively rare occurrence. Sous of Bordeaux quotes³³ the elder Graefe and Scultetus as having anatomically demonstrated the existence of the lesion, and Mackenzie refers³⁴ to a pathological specimen in the collection of Schmidler of Friburg where there was an aneurism of the central artery of each retina. Sous was the first who recognized it with the ophthalmoscope, and describes it as a red egg-shaped, pulsating dilatation of one of the main branches near the disc. Vision was so far destroyed that the patient was unable to recognize the largest letters. Martin describes³⁵ a similar case, while Magnus records what he supposed to be an arterio-venous aneurism following severe contusion of the eyeball, and Mannhardt a case of rupture of the choroid with a gray pulsating mass in the disc, which was also supposed to be aneurismal in nature. Schirmer has recorded³⁶ a case of widely-spread congenital telangiectasis of the face with a similar condition of the retinal veins of one eye. Liebreich³⁷ has pictured curious bead-like dilatations of the veins in a glaucomatous eye. Jacobi³⁸ gives three woodcuts of varix-like tortuosities of the retinal veins. Offsets extending from the retinal vessels forward into the vitreous have been observed during life and described by Coccius,³⁹ Becker,⁴⁰ Jaeger,⁴¹ Samelsohn,⁴² Jacobi,⁴³ and Norris.⁴⁴ They probably occur to some extent in many severe inflammations of the eye, and have been not unfrequently found and described in anatomical examinations of that organ; but their development is usually attended with so much cloudiness of the media as to prevent accurate ophthalmoscopic examination.

³³ Annales d'Oculistique, 1865, pp. 241-243.

³⁴ Practical Treatise on the Diseases of the Eye, London, 1854, 4th ed., p. 1042.

³⁵ Atlas d'Ophthalmoscopie.

³⁶ A. f. O., vii., 1, pp. 119-121.

³⁷ Atlas Plate xi. Fig. 1.

³⁸ Klin. Monatsblätter, 1874, pp. 253-260.

³⁹ Glaucom., 1859, p. 47.

⁴⁰ Bericht der Wiener Auqenklinik, 1866, pp. 65-74.

⁴¹ Ophth. Hand-Atlas, Table xv. p. 72.

⁴² Klin. Monatsblätter, 1873, pp. 216-218.

⁴³ Klin. Monatsblätter, 1874, pp. 252-260.

⁴⁴ Trans. Amer. Oph. Soc., 1879, p. 548.

When carefully examining eyes with the ophthalmoscope, it is not a very unusual circumstance to see a small grayish tag arising from the lymph-sheath of the central retinal vessels and extending a short distance forward into the vitreous. These tags usually present slow, sinuous movements, following motions of the eyeball. It is, however, rare to have such obliterated vessels extend through the vitreous and show their previous distribution in the posterior capsule of the lens, as in the instances reported by Zehender,⁴⁵ Liebreich,⁴⁶ and Becker;⁴⁷ in Zehender's case the artery was patulous and blood-bearing. Little⁴⁸ has also depicted a case where the hyaloid artery was filled with blood. The central canal of the vitreous, which is occupied in the foetal eye by the artery in question, is readily demonstrated in pigs' eyes by allowing colored fluid to flow into it from its central end. According to H. Müller,⁴⁹ atrophied remnants of the artery are always present in the eyes of oxen. Manz⁵⁰ gives an anatomical description and plate of a continuance of the lymph-sheath of the central artery through the vitreous forward to the capsule of the lens, the remnants of the artery being found only in its proximal portion: observation had been impossible during life on account of corneal opacities. The same writer describes a convolution of vessels as penetrating the posterior part of the vitreous from the retina in the eyes of some Australian reptiles (Trachyeaurus and Lygosoma), and regards it as a similar formation to the pecten of the bird's eye. According to Ammon, some forms of congenital cataract are connected with the too early obliteration of the hyaloid artery, which is so important in furnishing nutriment to the growing lens.

⁴⁵ Klin. Monatsblät. f. Augenheilkunde, 1863, pp. 260-349.

⁴⁶ Ibid., p. 350.

⁴⁷ Annales d'Oculistique, 1865, p. 350.

⁴⁸ Trans. Amer. Ophth. Soc., 1881, pp. 211-213.

⁴⁹ Gessamm. Schriften, p. 365.

⁵⁰ Graefe und Saemisch, vol. ii. pp. 97-99.

Von Graefe remarks, however, that this very unusual yet incomplete development of the retinal vessels is common in congenital amaurosis. He reports⁵¹ an instance in a blind eye of a boy ten years of age, who also exhibited a convergent squint and nystagmus. Mooren⁵² also gives a case of entire absence of the retinal blood-vessels in a child seven months old. Pathological conditions of the blood often give rise to visible changes in the eye-ground.

⁵¹ Arch. f. Ophth., vol. i., part 1, pp. 403, 404.

⁵² Ophthalmiatrische Beobachtungen, 1867, p. 260.

LEUCÆMIC RETINITIS.—Liebreich⁵³ was first to call attention to a retinitis which is due to leucæmia. In his Atlas he gives an interesting picture of it, and states that he had then already had an opportunity of seeing six cases in the splenic variety of the disease. His plate shows a diffuse retinitis with scanty hemorrhages, with marked change in the color of the eye-ground and of the blood in the retinal veins and arteries. The blood-columns, especially in the veins, have acquired a slight rose tint, and have become less intense in color, whilst the hemorrhages appear slightly redder. He also describes white splotches like those of the retinitis of Bright's disease, differing from the latter only in the more peripheral situation. In one case these splotches were examined by Recklinghausen, and found to consist of patches of sclerotic degeneration of the nerve-fibres. Becker has pictured⁵⁴ two interesting cases, where, besides the diffuse retinitis with scanty hemorrhages, the main characteristics were the yellow color of the eye-ground and large white plaques with a red hemorrhagic border in the periphery. In the few cases, which the writer has had an opportunity of studying in the wards of his colleagues, the most striking change has been that of the color of the eye-ground and of the blood. In none of these were there either the white patches with red border or any extensive hemorrhage. We probably must not expect them in all cases and at all stages. In one of the patients, a negress, who was examined at the time of her admittance to the hospital, before any diagnosis had been made, the change in the color of the blood and fundus was so marked that he was able to call attention to it, as a probable case of leucæmia, and had the satisfaction of having the diagnosis confirmed by subsequent careful examination. Leber⁵⁵ states that the disease sometimes assumes the form of hemorrhagic retinitis, such as is often seen in cases of disease of the heart and blood-vessels. Gowers⁵⁶ thinks that there is a much greater tendency to hemorrhage in leucocythæmia than in simple anæmia, and that the effused blood is of a pale chocolate color, while white or yellowish splotches, often edged by a halo of blood-extravasations, are commonly present. Immermann has seen the retinal affection occurring in mylogenic leucæmia, but in most of the instances above cited they accompanied the splenic form of the disease. In one of Becker's cases, in which Stricker examined the blood, the bulk of the white corpuscles exceeded that of the red ones, whilst some individual white corpuscles were so much increased in size that one white one might readily contain fifty red ones. Leber⁵⁷ describes a leucæmic tumor of the lids with exophthalmos, and marked leucæmic retinitis with hemorrhages, which affected both eyes of a patient who had enlargement of the liver and spleen. He quotes Chauvel as having recorded a somewhat similar case. In both of Leber's and Chauvel's patients there was also disease of the kidneys, as evidenced by the presence of albumen and casts in the urine. Another leucocythæmic tumor of the orbit has been described by Osterwald.⁵⁸

⁵³ Atlas, Plate x., 1863.

⁵⁴ Archives of Ophthalmology (Knapp and Moos), vol. i., 1869, pp. 341-358, Tab. B. and C.

⁵⁵ Graefe und Saemisch, vol. v. p. 599.

⁵⁶ Medical Ophthalmoscopy, 1879, p. 192.

⁵⁷ Arch. f. Ophth., xxiv., 1, pp. 295-312.

⁵⁸ Ibid., xxvii., 3, pp. 202-224.

PERNICIOUS ANÆMIA.—Biermer (1871) was the first to call attention to the retinal changes in this grave and rare disease. Since that date Horner⁵⁹ and Quincke⁶⁰ have given us the results of the careful study of a considerable number of cases. The former had seen 30 cases, and remarks that the color of the blood, the distension and tortuosity of the veins, and the numerous hemorrhages recall the cases of leucæmic retinitis: in all of his cases the discs were entirely white. The latter, in his latest paper on the subject, records 17 cases, and gives a careful chromo-lithographic picture of one of them. He describes the affection as an oedema of the retina with numerous hemorrhages, many of which have white or grayish centres, whilst others envelop the blood-vessels, and by irregularly distending their lymph-sheaths cause them to appear varicose. The oedematous condition of the retina produces an appearance as if a thin bluish-white film had been spread over the fundus oculi. The writer has had an opportunity of observing three cases of this rare affection: in each there was a diffuse retinitis, the veins were distended, the blood pallid, and the disc was dirty white with a faint greenish tint, whilst the eye-ground was decidedly yellow in hue. In one of them there were no other pathological appearances; in the second, only a few small hemorrhages into the lymph-sheath of some of the vessels near the macula; in the third, numerous irregularly round or ovoid hemorrhages with yellowish-white centres. It is evident, however, from the reports of Quincke, that any one case might in its various stages present all these phases. Horner considers⁶¹ the colorless centre of the hemorrhages to be due to a commencing absorption of the blood, while Manz⁶² holds that these yellowish-white spots are the dilated extremities of retinal capillaries.

⁵⁹ Klinische Monatsblätter für Augenheilkunde, 1874, pp. 458, 459.

⁶⁰ Deutsches Archiv f. klinische Medizin, 1877, pp. 1-31 (with plate).

⁶¹ Quoted by Quincke, loc. cit., p. 23.

⁶² Med. Centralblatt, 1875, pp. 675-677.

HEMORRHAGE.—Loss of blood may be the cause of impaired vision from transient anæmia of the retina or of the cerebral centres, but not unfrequently, in some manner which we are not yet able satisfactorily to account for, it gives rise to permanent blindness. This failure of sight may come on immediately after the hemorrhage, but it is usually noticed at periods varying from two to fourteen days after the loss of blood. Fries⁶³ has written an admirable monograph on the subject, and gives 26 cases collected from various authors. According to his tables, 35½ per cent. of the cases are due to hemorrhage from the stomach or intestines; 25 per cent. to uterine hemorrhage; 25 per cent. to abstraction of blood; 7.3 per cent. to epistaxis; 52 per cent. to bleeding from wounds; and 1 per cent. each to hæmoptysis and urethral hemorrhage. Many of these cases are preopthalmoscopic, and consequently the exact pathological changes in the retina and optic nerve are necessarily matters of conjecture. Jaeger has given us two most interesting cases of blue degeneration of the optic nerve, with comparatively little change in the calibre of the main vessels of the disc and retina.⁶⁴ In both, the loss of blood occurred during labor; in the first, two births happened without accident; at the third and fourth labor there was severe hemorrhage, each followed by considerable and lasting impairment of vision, leaving ability to read Jaeg. No. iii. for a short time, and only by close approximation. In the other case there were four confinements, all accompanied by hemorrhage, each leaving the vision more and more impaired, until after the fourth labor there was no light-perception. At this time the ophthalmoscope showed only blue discoloration of the nerve, followed six years subsequently (after recurrent headaches from taking cold) by a more complete atrophy of the disc and retina, the former appearing of a dirty-green color and having acquired a saucer-like excavation, whilst the retinal vessels had undergone great diminution in their calibre. In most recorded cases no examination of the fundus has been made until long after failure of sight, and then there has generally been found some stage of atrophy; but when the ophthalmoscope has been used early in the case the eye-ground seems to have presented various appearances. Thus, Jaeger⁶⁵ says that soon after the hemorrhage the eye-ground presents a diminution in the calibre of the veins and arteries, with a light-blue discoloration of the optic disc, without any other demonstrable tissue-change. Graefe⁶⁶ saw slight diminution of the calibre of the retinal arteries and an increased pallor of the disc in a case where blood was vomited and passed by stool fourteen days after the occurrence of the blindness. On the other hand, Schweigger⁶⁷ (in two cases), Nagel,⁶⁸ Hirschberg,⁶⁹ Nägeli,⁷⁰ Horner,⁷¹ and Landesberg⁷² have all noted the occurrence of neuritis.

⁶³ Sigmund Fries, "Diss. Inaug." in Klin. Monatsblätter f. Augenheilkunde, 1878.

⁶⁴ Ergebnisse der Untersuchung mit dem Augenspiegel, 1876, p. 87.

⁶⁵ Loc. cit., 1876, p. 87.

⁶⁶ Arch. f. Ophth., vol. vii., part 2, p. 146.

⁶⁷ Handbuch der Augenheilkunde, 1875 (3d ed.), p. 522.

⁶⁸ Behandlung der Amaurose und Amblyopie mit Strychnine, 1871, p. 51.

⁶⁹ Bericht über die zehrite Vorsammlung der Ophth. Gessellschaft Heidelberg, 1871, pp. 53-60.

⁷⁰ Jahrbuch f. Ophthalmologie Literatur, 1879, p. 253.

⁷¹ Klin. Monatsblätter f. Augenheilkunde, 1877 (supplement), pp. 53-60.

⁷² Ibid., 1875, pp. 98, 99.

PROGNOSIS.—The prognosis is very unfavorable, and but few cases are recorded where there has been any improvement of sight.

PATHOLOGY.—The pathology of the affection is not well made out. Samelsohn,⁷³ who has reported a number of interesting cases, supposes that where there is a great loss of blood the brain becomes anæmic and occupies less room in the skull, and serum exudes from the blood-vessels to fill the vacuum. As the patient regains strength and blood is re-formed, the increased intracranial pressure drives the fluid into the subvaginal space of the optic nerves and causes neuritis. In other cases a hemorrhage into the sheath of the nerve is assumed as the cause. For those very exceptional cases where, after slight loss of blood, there is sudden and complete blindness without marked changes in the optic nerves and retinæ (and prompt reaction of the pupils to light), we are obliged to assume some lesion of the optic centres. Samelsohn⁷⁴ attempts to explain it by comparison with the observations of Lussana, Brown-Séquard, Ebstein, and Schiff, who found that wounds of the brain involving the anterior prominences of the corpora quadrigemina and the thalamus opticus may cause hemorrhage into the mucous membrane of the stomach; consequently, he assumes a central lesion which produces simultaneously the blindness and the hemorrhage. All this is, however, but ingenious speculation, and the true pathology is still to be made out by careful autopsies.

⁷³ A. f. O., xviii., 2, pp. 225-235.

⁷⁴ A. f. O., xxi., 1, pp. 150-178.

The study of the eye-ground after death is difficult; for, apart from any hindrances due to the position of the body or to social customs, Nature soon interposes an efficient barrier to such examination by the rapidity with which cloudiness of the corneal epithelium and of the lens substance sets in. These optical hindrances advance sufficiently soon to make it impossible to focus accurately any object in the eye-ground. Poncet⁷⁵ asserts that this may be remedied to a certain extent by dropping water into the conjunctival sac, which will render the cloudy epithelium sufficiently transparent to permit examination from two to five hours after death. Most observers agree that in the human eye there is an immediate blanching of the disc and choroid, causing the latter to assume a pale-yellowish hue with a faint tint of rose, and that the arteries (by promptly emptying themselves) escape observation, while the veins retain for a time a considerable amount of their contents, the blood-columns often being discontinuous and broken. Later, these changes are followed by a gradually increasing haze of the retina, which gives the appearance of a bluish-white veil spread over the fundus. Schreiber⁷⁶ gives an instructive picture of the eye of a patient dying of phthisis, and another of the same eye five minutes after death. Gayat, who had the opportunity of studying this subject in the eyes of five individuals recently decapitated by the guillotine, describes the formation of a small red spot at the fovea centralis similar to that seen in embolism of the central artery.⁷⁷ On the other hand, Becker⁷⁸ thinks that the emptying of the vessels after death is rather the exception than the rule, basing his observations not on ophthalmoscopic examinations, but on the fact that in opening freshly enucleated glaucomatous eyes, and in the eyes of those who had been hung, he had observed all the vessels, arteries as well as veins, full of blood. Weber⁷⁹ also, while admitting that the vessels both in men and animals usually empty themselves soon after death, describes as an exception a case in which there was no visible change in the blood-columns of the retinæ of the eyes of a patient with brain tumor, and a consequent optic neuritis, who was gradually dying of paralysis of the organs of respiration. This circumstance, in the opinion of the narrator, was very probably due to the obstruction to the escape of blood from the eye which would naturally be caused by the swollen and prominent optic nerve. Landolt and Nuel⁸⁰ assert that there is an increase in the refraction in rabbits' eyes after death, causing any existing hypermetropia to approach emmetropia. They call attention to the difficulty of such determinations, owing to rapidly-forming haze on the corneal epithelium and to more or less complete emptiness of the retinal vessels.

⁷⁵ Archives générales de Médecine, Série 6, t. xv., 1870, pp. 408-424.

⁷⁶ Separat Abdruck aus dem Deutschen Arch. f. klin. Med., Bd. xxi. pp. 100, 101, Plates vii. and viii.

⁷⁷ Annales d'Oculistique, 1875, pp. 1-14.

⁷⁸ "Sitzungsbericht der Ophth. Gesellschaft," in Klin. Monatsblätter f. Augenheilk., 1871, p. 385.

⁷⁹ Klin. Monats. f. Augenheilk., pp. 383-385.

⁸⁰ A. f. O., xix. 3, pp. 303, 304.

Diseases of the Organs of Respiration.

Diseases of the organs of respiration appear to have little direct influence upon the nutrition of the eye, except in so far as they cause venous stasis by obstruction of the circulation through the lungs. Jaeger was the first to call attention to this fact in cases of pneumonia and pleurisy. The stasis manifests itself by an increase in the calibre of the veins, with a broadening of the light-reflex from them and a marked change in the color of the blood, causing the venous columns to become dark bluish-red. The writer has often seen this condition well marked in cases where there was not sufficient interference with the oxidation of the blood to cause an appreciable cyanosis of the skin. A higher degree of impeded circulation in the lung doubtless gives rise to the retinal hemorrhages, which, according to Foerster, are not infrequent in emphysema. Schreiber⁸¹ mentions that in the hectic fever of phthisis the dilatation of the retinal vessels causes a congested appearance of the eye-ground, in marked contrast with the anæmic pallor of the skin of the patients. In 1871, Horner⁸² published 31 cases of herpes corneæ occurring either during the course of severe catarrhal affections of the respiratory organs or immediately following such attacks. The eruption, which first appeared upon the lips, and then upon the eyeball, usually took place after the culmination of the febrile symptoms. The progress of the affection is slow, the ulcers left by the bursting of the vesicles healing in a period varying from two to six weeks. The herpes was monolateral, except in one case of double pneumonia in a drunkard, where the eruption occupied the entire central area of both corneæ. In preophthalmoscopic times Sichel called attention to blindness after pneumonia and bronchial catarrh, which he thought was due to cerebral congestions occurring in the height of these diseases.⁸³ He considered these congestions harmless so long as the patients remained quiet under antiphlogistic treatment, but deemed them noxious in their influence upon the eye as soon as freedom was allowed. Seidel⁸⁴ relates cases of amblyopia with contracted pupils and eyeballs which were painful on the slightest pressure. He says that coincident with croupous pneumonia on the fifth day there was color-blindness, followed two days later by a disappearance of the amblyopia, with a return of the pupils to their normal size.

⁸¹ Veränderungen des Augenhinter-qrundes bei Internen Erkrankungen, 1878, p. 87.

⁸² "Bericht der Ophth. Gesellschaft," in Klin. Monatsblätt., 1871, pp. 326-328.

⁸³ Zehender, Handbuch der Augenheilkunde, vol. ii. pp. 188, 189.

⁸⁴ "Sehstörungen bei der Pneumonie," Deutsches Klinik, 1862, No. 27.

Affections of the Eye caused by Diseases of the Digestive Organs.

TEETH.—Ophthalmic literature furnishes many instances of diseases of the eye said to be caused by affections of the teeth. These vary in severity from slight conjunctivitis and photophobia, or temporary failure of accommodation, to absolute amaurosis. It is natural to suppose that affections of the dental division of the trigeminus might readily give rise to reflex disorders in parts supplied by branches of the same main trunk. Although the writer has been on the lookout for such affections, he has seen very few cases of eye disease which could be logically attributed to disease of the teeth, and has known at least two sound teeth which were uselessly sacrificed to mistaken theories of pathology. Perhaps the most noteworthy effort to assign dental neuralgia as a cause of amaurosis is the well-known paper of Jonathan Hutchinson in the Royal London Ophthalmic Hospital Reports for 1865. An attentive study of the interesting cases there recorded shows that but few of them can be considered as affording convincing evidence of the point which he desires to prove, and few are probably more keenly aware of this fact than the distinguished surgeon himself when he writes: "I am quite alive to some of the sources of mistake which attend the attempt to prove the occurrence of paralysis from reflex irritation consequent on a peripheral cause: chief among them we have, of course, the possibility that the neuralgia itself may have been due to central disease, and that the extension of the latter may have complicated other nerves."⁸⁵ That amaurosis does, however, sometimes follow dental irritation is proved by Hutchinson's first case in the above-quoted paper, where neuralgia of the eyeball with great intolerance of light was cured by extraction of a carious molar tooth. Perhaps the most striking case on record is that of Galezowski,⁸⁶ where a small fragment of wood which had entered the cavity of a carious tooth (probably from picking the teeth with a wooden toothpick), lodged at the extremity of one of the fangs, is said to have caused absolute blindness of the eye, with dilatation of the pupil on the same side. After a blindness of eleven months the tooth with the foreign body was extracted, causing the evacuation of a few drops of thin pus from the antrum; after which the patient improved and vision gradually returned, so that on the ninth day after the operation he could see with the affected eye as well as with the other. Schmidt, after an examination of 96 patients with carious teeth, formulates the following conclusions: "1. That we may have a more or less considerable limitation of the accommodation in consequence of pathological irritation of the dental branches of the trigeminus. 2. This may occur on both sides. Where the affection is one-sided, it is always on the side of the affected tooth. 3. It is usually an affection of the young, very seldom or never occurring in old age. 4. That the diminution of the power of accommodation is due to increased intraocular pressure caused by reflected irritation of the vaso-motor nerves of the eye." These conclusions are interesting, but cannot be considered absolutely correct, in consequence of the fact that there are no recorded tests for astigmatism or insufficiency, and that accurate examination of the state of refraction was impossible through want of a mydriatic which may in measure have accounted for the existent diminution of accommodation. More extended and minute investigations of the subject are desirable.

⁸⁵ "A Group of Cases illustrating the Occasional Connection between Neuralgia of the Dental Nerves and Amaurosis," by Jonathan Hutchinson, F.R.C.S., R. L. O. H. Rep., vol. iv. pp. 381-388.

⁸⁶ Archives générales de Médecine, t. xxiii. pp. 261-264.

STOMACH, INTESTINES, AND LIVER.—Amblyopia and amaurosis with severe gastric symptoms are not very uncommon, but, although such cases are made much worse by the ingestion of indigestible substances, constipation, etc., it has nevertheless always appeared to the writer that the primary lesion lay in the nervous system. Galezowski, however, lays stress on this subject, and discriminates between a true and false locomotor ataxia; the latter being, according to this author, symptomatic of stomachic and intestinal lesions. Many of the older writers relate cases of amaurosis from worms in the intestines. Thus Laurence⁸⁷ gives an instance of sluggishness and partial dilatation of the pupils with dim vision which promptly disappeared after the evacuation of seat-worms consequent on an enema of turpentine. Hays calls attention⁸⁸ to a case recorded by Welsh of Massachusetts where complete amaurosis in a child instantly ceased on a worm being puked up. Many similar instances might be adduced which in modern books are either passed over in silence or looked at with a shrug of incredulity. Although the writer has had no personal experience with such cases, he can readily understand that in children the irritation of worms might easily give rise to enough reflex disorder of the spinal cord and brain as to cause impairment of the accommodation and partial dilatation of the pupils. (The effects of hæmatemesis and hemorrhage from the bowels have been already discussed.)

⁸⁷ Amer. ed. by Hays, 1847, p. 554.

⁸⁸ Ibid., 1847, p. 555.

That jaundice shows readily in the conjunctiva is well known to all practitioners, and yellow vision is described as an occasional symptom of severe icterus, Jaeger calls attention to a light-yellow color of the eye-ground and retinal vessels under these circumstances. Junge,⁸⁹ Stricker,⁹⁰ and Buchwald⁹¹ have all recorded cases of retinal hemorrhage in cases of grave disease of the liver. Litten⁹² says that for ten years he has examined every case of liver disease under his charge with the ophthalmoscope, and found retinal hemorrhages only in fifteen cases. These occur only when icterus is present, but are not due, as Traube assumes, to the action of the biliary acids on the blood-corpuscles. If they were so, we should have blood-stained lymphatic sheaths instead of corpuscular diapedesis and massing of the exuded blood. Of these 15 cases, 4 were cases of congestive jaundice, 4 of carcinoma, 1 each of acute fatty degeneration and phosphorus-poisoning, 1 of abscess, 2 of cirrhosis, 1 of hydrops cystides filleæ. The hemorrhages were usually in the nuclear layers, and seldom presented white centres, as in leucocythæmia. In the case of phosphorus-poisoning there were large white plaques with marginal inflammation. Litten considers that the pigment-spots reported in the retina in cases of liver disease (his own cases and Landolt's) are due not to cirrhosis hepatis, but to a congenital or acquired disposition to connective-tissue hyperplasia [syphilis?]. Foerster⁹³ has called attention to a group of cases which he ascribes to hyperæmia of the liver and plethora abdominalis, where we find discomfort in the use of the eyes from the accompanying retinal hyperæmia and diminution of the range of accommodation, and where the ophthalmoscope frequently shows premature senile degeneration of the lens, manifested by striæ occurring in the extreme periphery. Every careful observer will doubtless agree to the accuracy of this description, and to the advantages of proper hygiene, exercise, and the alterative mineral waters (Karlsbad, Saratoga) in such cases.

⁸⁹ Heinrich Müller's Gesammelte Schriften, pp. 331-335.

⁹⁰ Berliner klin. Wochenschrift.

⁹¹ Foerster, loc. cit.

⁹² Deutsche med. Wochenschrift, 25 März, 1882, pp. 179-182.

⁹³ G. u. S., vol. vii. p. 74.

SPLEEN.—The effect of disease of the spleen in causing disease of the eye has already been alluded to in the discussion of leucæmic retinitis.

Xanthopsia appears to be a very infrequent complication of liver disease. Moxon,⁹⁴ who records seven cases of fatal obstructive jaundice, has never seen it. He remarks that in these cases the vitreous and lens remained perfectly clear, while the blood-serum was saffron-yellow and the sclerotic deeply stained (yellow or olive-green). Rose⁹⁵ gives the only case with which the writer is familiar, in which it was carefully studied and demonstrated with the spectroscope. Here the violet end of the spectrum was shortened as in poisoning by santonin, and the blue blindness was so marked that a few days before his admission to the hospital the patient had excited the astonishment of his fellow-workmen by mistaking the color of a door which had been freshly painted blue. The autopsy showed here also that the vitreous and aqueous were colorless, but the cornea was clearly yellow. This Rose thinks insufficient to have caused the xanthopsia, and therefore attributes it to the effect of the jaundice in the nerve-centres.

⁹⁴ "Clinical Remarks on Xanthopsia and the Distribution of Bile-Pigment in Jaundice," Lancet, Jan. 25, 1873. p. 130.

⁹⁵ "Die Gesichtsläuschungen im Icterus," Virchow's Archiv, vol. xxx. pp. 442-447.

HEMERALOPIA.—The curious affection hemeralopia, which we well know to be a constant accompaniment of some forms of congenital nerve-atrophy (retinitis pigmentosa), and also to affect, at times, considerable numbers of persons exposed to the glare, overwork, and exposure of an active campaign, is probably always due to some form of malnutrition or disorder of the digestive apparatus, and in many cases it is associated with jaundice and disease of the liver. That glare of light is not necessary to its production is shown by its development in convalescent hospitals. Reymond of Turin reports it as developing in an individual affected by pellagra on whom he had operated for cataract, and who during the four weeks subsequent had never been out of his room. Cornillon⁹⁶ reports 5 cases of hemeralopia during jaundice, and of these 4 came under his observation in a single winter in the hospital in Vichy. It never appeared early in the congestion of the liver, but always after jaundice had existed for some time, and disappeared without special treatment—often to recur when the disease of the liver became more marked. Parinaud⁹⁷ has reported 4 such cases in all, with jaundice, the conjunctiva being yellow, but the media not tinged. There were no ophthalmoscopic changes. One of these cases was malarial hepatitis, the other three probably cirrhosis. A curious change in the ocular conjunctiva has been noted in many of these cases of hemeralopia, and attention was first called to it by Bitot.⁹⁸ He observed 29 cases at the Hospice des Enfants Assistés at Bordeaux. The bulbar conjunctiva in the palpebral fissure, usually at the outside of the cornea, becomes dry and anæsthetic (epithelial xerosis), and a number of minute points form in it, and the little patch becomes like mother-of-pearl, iridescent and silvery. They become paler before they disappear, and come and go with the advent and cessation of the hemeralopia. Pressing on the conjunctiva over the spot by rubbing the lids over it often causes little fragments of the dry patch to crumble off. The adjoining conjunctiva is dry and less pliant, more like parchment. The extensive occurrence of hemeralopia during the severe Easter fasts of the Greek Church has been noted by Blessig. There is frequently diarrhoea associated with this condition. Teuscher also speaks of conjunctival xerosis and hypopyon keratitis in the young slave-children in the Brazilian coffee-plantations, associated with gastric catarrh and diarrhoea.

⁹⁶ Le Progrès médicale, No. 9, Fèvrier 26, 1881, pp. 157-159.

⁹⁷ Archives générales de Médecine, April, 1881, pp. 403-414.

⁹⁸ Gaz. méd. de Paris, No. 27, 4 Juillet, 1863.

Diseases of the Kidneys and Skin.

DISEASES OF THE KIDNEYS.—As has been abundantly proved by careful autopsies, inflammation of the retina may be developed during any form of Bright's disease, either with the enlarged mottled kidney of acute parenchymatous nephritis, the large white kidney, the amyloid kidney, or the cirrhotic kidney of chronic disease. In the vast majority of cases the retinal inflammation appears during the later stages of the last-named form of disease, and seems to be in some way dependent upon blood-poisoning, which has been caused by the degenerating kidney.

The retinitis presents various aspects, not only in different cases, but also in the different stages of its development in the same case, and distinguishes itself mainly from other forms of inflammation of the retina by its marked tendency to fatty degeneration. As seen at an eye hospital the disease usually presents a type quite different to that which predominates in the wards of a general hospital. In the former class of cases the blood-poisoning seems to fall with peculiar intensity on the nervous system, and the patients come complaining of headache, dizziness, and dim vision, these being the only marked symptoms of the malady, while the anæmia, dropsy, and other symptoms are either absent or present in so slight a degree that the patients have not supposed themselves to be suffering from any constitutional malady or to need any medical advice. In the walking cases the retinal changes are usually very extensive (and those in the cerebrum would possibly be found equally developed if we had only as accurate a method of investigating them), whilst among hospital inmates we often see only a few white splotches in the retina, either with or without hemorrhages, and occasionally only a slight atrophy of the optic disc due to a previous retinitis. In the wards of a general hospital we have a much better opportunity to study the early development of the retinitis, and it is there most frequently encountered among those suffering from dropsy and dyspnoea—patients whose waxy skin and general appearance indicate at a glance how seriously their nutrition has been impaired by the ravages of the disease. When the individual lives and is not markedly relieved by the rest and treatment adopted, we frequently have an opportunity of seeing the development to a greater or less degree of the typical form of the affection.

In typical cases the retinal changes commence with slight oedema of the disc and surrounding retina, associated with a few irregular white splotches and striated hemorrhages in the fibre-layer. These white patches multiply and extend, but are usually confined within an area of two or three disc-diameters from the optic entrance. In high grades of the affection they coalesce and form a broad zone around the disc, which is itself swollen and prominent, its outlines being hidden by the opaque nerve-fibres which diverge from it. From time to time fresh hemorrhages occur, which are striated when in the fibre-layer, and of irregularly rounded outline when they invade the deeper portions of the retina. These were formerly supposed to be absolutely characteristic of the disease, but it is now asserted by several good observers that similar appearances have been seen in the neuro-retinitis caused by brain tumor or by basilar meningitis where there was no accompanying disease of the kidney. Graefe,⁹⁹ Schmidt and Wegner,¹⁰⁰ Magnus,¹⁰¹ Leber,^>102 Carter,¹⁰³ and Eales¹⁰⁴ have each reported such cases. The hemorrhages are usually either entirely absorbed or leave behind them a fatty clot, which adds an additional white patch to the splotches already existing in the retina. In many cases occurring in the last stages of the disease, a remarkably yellowish tint of the fundus is observed, together with decided alteration in the color of the blood-columns in the retinal blood-vessels, the blood in the arteries being too yellow, and that in the veins presenting too little of its usually pronounced red-purple tint. In short, there is a state of affairs approximating in some degree to that which we find in cases of pernicious anæmia.

⁹⁹ A f. O., xii. 2.

¹⁰⁰ Ibid., xv. 3.

¹⁰¹ Ophth. Atlas, Taf. vi. Fig. 2.

¹⁰² Graefe und Saemisch, Bd. v. p. 581.

¹⁰³ Diseases of the Eye (Am. ed.), p. 382.

¹⁰⁴ H. Eales, Birmingham Med. Review, Jan., 1880, p. 47.

Exceptional forms of albuminuric retinitis have been recorded where the only change seen in the fundus oculi was a pronounced choking of the disc similar to that with which we are familiar in cases of brain tumor. The writer has seen cases which at the start could not be diagnosticated by the ophthalmoscope from cases of retinal hemorrhage due to other causes. Magnus has published similar cases.

In the course of Bright's disease uræmic amaurosis is much more rarely encountered than albuminuric retinitis. It is, however, occasionally developed in cases in which albuminuric retinitis already exists. It is rapid in its development, and in its subsidence is without retinal changes, the blindness being evidently due to some transient affection of the cerebral centres.

DISEASES OF THE SKIN.—The eczema of the lower lid, nose, angle of the mouth, and external meatus of the ear which so frequently accompanies the phlyctenular conjunctivitis of scrofulous children is probably the most common example of coincident skin and eye disease. Lepra is a frequent cause of severe affections of the eye in localities where it is endemic. Bull and Hansen¹⁰⁵ assert that the cornea is frequently attacked. They divide the manifestations of the disease upon this membrane into two varieties—the one in which there is a diffuse infiltration of the tissue, and the other where there is a formation of tubers. The first variety is a gray opacity limited to the border of the cornea, not separated from its circumference by any such clear area as is found in arcus senilis. This opacity becomes vascularized, and may remain quiet for years till another attack of hyperæmia occurs, which, also in time receding, leaves the tissue more opaque than before. In the second there are nodes which appear to start at the margin of the cornea and to accompany either its superficial or its deep layer of vessel-loops: this latter form is more dangerous to vision. The paralysis of the orbicularis muscle which is a frequent attendant upon the smooth form of the disease allows an exposure of the membrane to irritants which often produce a third form of inflammation. The iris also exhibits the smooth and the tuberous forms of the disease. Iritis occurring in lepra is, however, by no means pathognomonic; 50 per cent. of all cases exhibiting synechiæ are the result of extensions of corneal inflammations due to orbicular paralysis. The superciliæ and the eyelashes are said to be frequent seats of leprous tubercules. In the lids the first symptom is the falling of the eyelashes, which is dependent upon the formation of the tubers before they become manifest to sight and touch. Mooren¹⁰⁶ maintains that chronic skin eruptions favor the development of cataract by causing creeping inflammatory processes which alter the character of the exudations into the vitreous humor, and moreover claims that when such skin eruptions have their seat in the scalp they favor the occurrence of retinitis by maintaining a constant hyperæmia of the meninges. He further cites a case where he observed a decrease in the acuity of vision corresponding with the breaking out of a skin eruption, and an increase in the power of vision coincident with the disappearance of the eruption. Foerster¹⁰⁷ agrees with Mooren in the statement that cataract may be formed in cases where chronic skin affections favor the development of marasmus. Rothmund¹⁰⁸ reports a noteworthy curiosity to the effect that cataract followed a peculiar degeneration of the skin in three families living in separate villages in the Urarlberg. The skin of these patients showed a fatty degeneration of the rete Malpighii and of the papillæ, with consecutive thinning and atrophy of the epidermis: this was most marked on the cheeks, chin, and the outer surfaces of the arms and legs. In the individuals thus affected the skin disease commenced between the third and sixth months of life, whilst the cataract appeared in both eyes between the third and sixth years. Rothmund thinks that the same congenital predisposition to disease exists in both organs, because the lens is developed out of an unfolding of the external skin.

¹⁰⁵ The Leprous Diseases of the Eye, Christiana, 1873.

¹⁰⁶ Ophthalmologische Mittheilungen, 1874, p. 93.

¹⁰⁷ Graefe und Saemisch's Handb., vol. vii. p. 152.

¹⁰⁸ A. f. O., xiv., 1, p. 159.

Disturbances of Vision caused by Disease of the Sexual Organs.

The eyes and their appendages frequently exhibit the effects of perverted function or diseased conditions of the sexual organs. As might be expected, these ocular effects are most marked in the female, whose generative apparatus is so much more complex and extensive. While it is true that there are thousands of women with grave disease or derangement of these organs who are free from any uncomfortable eye symptoms, still, clinical experience shows that there are crowds of others who present eye lesions due entirely to such causes. Still more frequently do we see some slight optical defect (previously scarcely noticed) become so unbearable that the patient is unfitted for any useful employment. In fact, at most eye hospitals, and still more markedly in private practice, we find an excess of female over male patients. This excess becomes more palpable when we throw out of consideration the large number of male patients who are under treatment for injuries of all sorts the result of mechanical occupations not pursued by females, and the inflammations due to direct exposure to storm, cold, and intense heat.

MENSTRUATION.—When menstruation is profuse its effects are with difficulty distinguished from those of anæmia and loss of blood, but where it is retarded, irregular, or scanty the effects are more readily traced. All surgeons of experience are agreed that it is undesirable to perform operations for cataract or to make iridectomy at the menstrual period, and it is well known that eyes which have been progressing favorably after operations become congested and irritable during the monthly period. In trachomatous eyes retardation of the catamenia often causes the eruption of a fresh crop of granules, while in cases of phlyctenular and interstitial keratitis there are still more frequently relapse and exacerbation of the disease. Vaso-motor disturbances connected with the period of puberty and with that of cessation of the menses are of daily occurrence: we constantly see cases at these epochs where some slight astigmatism or hypermetropia, which has previously given no practical annoyance to the patient, becomes absolutely unbearable. The eyes become watery and sensitive to light; there is marked congestion of the retina with tortuosity of its veins, together with serous infiltration and swelling often sufficient to obscure the margins of the disc. These symptoms frequently entirely disappear when the menses have either become established or have permanently ceased. In some rare cases the symptoms are anomalous and striking: thus the writer has seen vicarious menstruation from the lachrymal caruncle, and a case of pemphigus of the upper lid occurring regularly at each menstrual period for some months. In another patient menstruation came on during the thirteenth year with intense headache, epistaxis, and photophobia, and for a long time afterward there was utter inability to use the eyes for school-work even during the catamenial interval. At almost every menstrual epoch during a period of eight years there has been a recurrence of these symptoms, although they subside sufficiently in the interval to allow the patient to use her eyes for a very limited amount of near work. At the first examination the ophthalmoscope showed that the retinal fibres were swollen and oedematous, hiding the outlines of the discs, while the lymph-sheaths of the retinal vessels at their point of emergence from the disc presented an almost snow-white appearance. The discs and the retinæ have never quite resumed a normal appearance.

Disturbances in the circulation of the eye and its appendages are frequently associated with the menopause. The writer recalls a case where for years there was headache with intense congestion of the palpebral and bulbar conjunctiva, with a fulness and pressure on the orbits at each menstrual period, all these symptoms disappearing with the cessation of the menses. The most striking examples of the influence of the menses on the eyesight are those where the flow has been suddenly checked. Rejecting examples from the older authors, where the want of exact helps to diagnosis might leave room for a different interpretation of the symptoms, we will content ourselves with two examples where the testing of the eyesight and the ophthalmoscopic examination were made by skilled observers. Thus, Mooren—to whom we are indebted for a careful discussion of the relations between uterine disease and disturbances of sight—recites¹⁰⁹ the case of a peasant-woman aged twenty-three years who had complete stoppage of the menstrual flow from exposure to wet during the catamenial period: this was accompanied by high fever and delirium, with pain in the region of the right ovary. When these symptoms subsided, she noticed that there was absolute loss of sight in the right eye, and so great a diminution of it on the left that she could only distinguish movements of the hand. The ophthalmoscope showed in the right side a multiple detachment of the retina, and on the left an intense neuro-retinitis. Rest in bed, inunctions of mercurial ointment, and cataplasms over the region of the ovaries, with leeches to the septum of the nose and the neck of the uterus, gradually brought about amelioration of the symptoms, with restoration of the eyesight in the left eye. As might be expected, the retinal detachment and consequent loss of vision in the right eye remained permanent. In confirmation of this case, but in contrast with it as regards the retinal symptoms, is the one related by Samelsohn.¹¹⁰ The patient (a peasant-girl) by standing in a cold running brook while at work had her menses suddenly stopped. There was no marked uterine or abdominal pain. The patient complained of a feeling of pressure on the orbits, and experienced a gradual failure of sight with contraction of the field of vision. In five days there was absolute amaurosis of both eyes (no sensation of light and no phosphenes to be obtained by pressure). The sight gradually returned in each eye, this being preceded by a copious flow of tears, so that in sixteen days the patient could read small print fluently. In seven weeks the menses returned. There were no ophthalmoscopic symptoms: each eye, both during the attack and subsequent to it, showed only striation of the retina and tortuosity of its veins, the calibre of the retinal arteries being unchanged. Unfortunately, any pupillary changes that might have been recognized were annihilated by previous instillation of atropine into the eye. In the first case there was every probability in favor of a serous effusion into the subarachnoidal and the intravaginal spaces. The latter case is more difficult to explain: if it were due to orbital or intracranial neuritis, why should there not have been some ophthalmoscopic changes during the time that the patient was under observation? If to effusion within the cranium or to local circulatory disturbances in either the corpora quadrigemina or the occipital lobes, why were there not other symptoms of intracranial disturbance?

¹⁰⁹ Arch. f. Augenheilkunde, Bd. x., 1881.

¹¹⁰ Berliner klin. Wochenschrift, Jan., 1878, pp. 27-30.

In further illustration of the effects of a stoppage of menstruation, Mooren¹¹¹ cites the case of a peasant-woman aged thirty-one who had complete suppression of the menses after the birth of her fourth child, and where subsequently an almost continuous headache, dimness of vision, and eventually epileptiform attacks, followed. The ophthalmoscope showed a double neuritis so intense as to lead to the supposition of a possible cerebral tumor. Mercurial inunctions with seton to the back of the neck were resorted to without result. Emmenagogues also failed to give relief. An examination of the uterus was now made, which showed great enlargement and hyperplasia, especially of its mouth and neck, for which scarifications and sitz-baths were employed with good result. The headache and epileptoid attacks disappeared, and the vision improved so far that the patient (who when admitted to the hospital could only decipher Jaeger No. xviii.) could read fluently Jaeger No. iii.

¹¹¹ Loc. cit., p. 551.

DISPLACEMENTS OF THE UTERUS.—Anteflexion and retroversion of the uterus are frequent causes of retinal hyperæsthesia. In this connection we may quote from the same author two cases, as showing how slight mechanical irritations of the uterus may cause eye disturbance—one where a patient had an episcleritis and a chronic metritis with malposition of the uterus, in whom there was an exacerbation of the ciliary neuralgia and of the local eye inflammation every time that the ulcerated os uteri was cauterized or a pessary introduced; and a second with an adhesive kolpitis, in whom the introduction of a pessary caused unpleasant feelings about the head and oppression in the cardiac region, accompanied on two separate occasions by capillary hemorrhages into the retina, all of these symptoms disappearing rapidly after the removal of the pessary. Mooren¹¹² has also seen a double neuro-retinitis caused by retroversion of the uterus. The sight was so much impaired that the patient could with difficulty decipher Jr. No. xx.; but it was entirely regained within a few months after the uterus had been replaced in its proper position. No other treatment was employed.

¹¹² Ophthalmologische Mittheilungen, 1878, p. 97.

PELVIC CELLULITIS.—Still more frequently are the reflex eye disturbances caused by parametritis and the various forms of pelvic cellulitis. Every practitioner has had abundant opportunity of studying the easy fatigue of the eye, the burning and stinging conjunctival sensations, the orbital and periorbital pains, the retinal hyperæsthesia and sensitiveness to artificial light, which characterize the early stages of the affection, accompanied later on by symptoms of retinal anæsthesia. Inasmuch as the cause of these symptoms is irremediable, we find in the majority of cases that it is impossible to relieve the sufferings of the patient; this cause consisting in the cicatricial shrinking of the parametrium and the pelvic connective tissue. Sleep gives relief only so long as it lasts, and the patients upon awakening, instead of feeling rested, often experience their greatest pain and discomfort. Foerster¹¹³ and Freund, who were the first to demonstrate this form of parametritis, call special attention to the fact that the patients have their good and bad days entirely independent of any use of the eyes. In many of the milder cases, however, we find that the sufferings of the patients are enhanced and aggravated by the presence of some defect, such as astigmatism, hypermetropia, or insufficiency. Although the careful correction of such defects will give considerable relief and enable the patients to use their eyes for near work for a much longer period, nevertheless the pain and discomfort are out of all proportion to the amount of error. Of course, we are very far from having converted such eyes into useful instruments for every-day work or for long-continued labor, but we have removed an appreciable source of irritation from an oversensitive nervous system, and done much to relieve the toedium vitæ in cases which perhaps for months previously have been unable to amuse or occupy themselves by the use of their eyes in either reading, writing, or sewing.

¹¹³ "Allgemein-Leiden und Veränderungen des Sehorgans," in Graefe und Saemisch, vol. vii. pp. 88-96.

MASTURBATION is also an occasional cause of reflex eye disturbances. Mooren¹¹⁴ relates two aggravated cases in women who for years had been excessively addicted to the vice. In both of these there were accommodative asthenopia and tenderness in the ciliary region, dread even of moderate illumination, which increased from year to year. In both cases there were attacks of dyspnoea and other disturbance of innervation of the pneumogastric nerve. Cohn has also published a number of cases of eye disease in the male sex due to the same cause. The main symptoms were a feeling of pressure on the eyes, bright dots moving before them, and a sensation as if the air between the patient and the object looked at was wavy and trembling. In some of the individuals a discontinuance of onanism and a moderate indulgence in sexual intercourse effected a complete cure. Travers¹¹⁵ gives a case of loss of sight from excessive venery, and another from masturbation. Mackenzie¹¹⁶ quotes Dupuytren as relating the case of a man who lost his sight on the day after his wedding, but where it was promptly restored by the use of a cold bath with stimulants and the application of counter-irritation to the skin of the lumbar region. Foerster¹¹⁷ has recorded a case of kopiopia hysterica in a man where, from the eye symptoms alone, he diagnosticated disease of the genital organs, and where it was afterward proved that there was inability to copulate, the patient having extremely small testicles and there being a thin whey-like discharge from the urethra.

¹¹⁴ Loc. cit.

¹¹⁵ Synopsis of Diseases of the Eye, 1820, p. 145.

¹¹⁶ Diseases of the Eye, 1854, p. 1075.

¹¹⁷ G. u. S. Handb., vol. vii. p. 95.

CONGESTION AND INFLAMMATION OF THE OVARIES.—Disease of the ovaries is frequently associated with retinal oedema and hyperæsthesia. In women complaining of weak and painful eyes pressure in the ovarian region often causes pain. Where only one ovary is tender to the touch, we often notice that the patient complains more of the corresponding eye, although there may be no difference or abnormality in the ophthalmoscopic appearance of the two eyes. Under this head may be appropriately mentioned the eye symptoms of patients affected with hystero-epilepsy, a disease which is always associated with ovarian trouble, of which Charcot has given us so graphic a picture. He says that previous to the attack the patient experiences an aura which starts from the abdomen. The convulsion is ushered in by a loud cry, which is accompanied by pallor of the face and loss of consciousness. These symptoms are succeeded by twitching and rigidity of the face-muscles, with foaming at the mouth, followed by contortions of the muscles of the trunk, abdomen, and lower limbs, the paroxysm terminating with sobbing, weeping, and laughing. Landolt has given us a careful description of the eye symptoms in such cases, and groups them into four stages. In the first, the outer and inner tunics of the eye appear healthy and the acuity of vision is normal, but there is a contraction of the form- and color-folds, always more marked on the affected side. In the second group the acuity of vision begins to fail, and the symptoms become more marked on the hitherto sound side. In the third with the more affected eye fingers can scarcely be counted, while the field of vision is limited to a few degrees from the fixation point; at this stage the ophthalmoscope shows a serous swelling of the retina, with fulness and tortuosity of its veins. In the fourth stage there is a partial atrophy of the optic nerve on both sides.

PREGNANCY.—Cases of amaurosis occurring during pregnancy, in which the vision was impaired after delivery, are recorded by Beer, Ramsbotham,¹¹⁸ and other writers of the preophthalmoscopic period. Some of them, at least, may probably be accounted for by the occurrence of albuminuric retinitis in the puerperal state, but no such interpretation can be put on the more recent cases reported by Lawson¹¹⁹ and Eastlake,¹²⁰ which in their main features strongly recall the amaurosis after loss of blood, although there is no history of any similar hemorrhages. In Lawson's case, we have an amaurosis which commenced during the gestation of the eighth child, and recurred during the ninth and tenth pregnancies. After the eighth labor the patient recovered sufficient sight to be able to sew; the amount of vision being gradually lessened after each gestation until finally complete atrophy of the optic nerve ensued. In Eastlake's case, the patient (æt. thirty-four) had borne nine children at full time. The labors were normal in character, and the amount of blood lost was not excessive. On the second or third days after the second and each subsequent delivery, sudden loss of vision occurred, and the woman became insensible. On recovering her consciousness, her sight did not at once return, the amaurosis remaining from three to five weeks. After the last labor there was complete and permanent loss of sight in both eyes: Z. Laurence examined this case with the ophthalmoscope, and reports only a slight contraction of the retinal arteries, without other positive lesion. Zehender,¹²¹ in treating of the subject, remarks that "almost every busy eye-surgeon has encountered similar sad cases."

¹¹⁸ Med. Times and Gazette, March 7, 1834.

¹¹⁹ R. L. O. Hos. Rep., vol. iv. pp. 65, 66.

¹²⁰ Obstet. Trans., vol. v. p. 79 (1864).

¹²¹ Handbuch der Augenheilkunde, vol. ii. p. 180.

PUERPERAL PHLEBITIC OPHTHALMITIS.—According to Mackenzie, this dread malady, which, as a rule, causes the death of the patient, may develop at any time from the third to the thirtieth day after delivery. It frequently attacks both eyes, and in those cases which do not terminate fatally eyesight is usually lost. Hall and Higginsbottom,¹²² Mackenzie,¹²³ Fischer,¹²⁴ Arlt,¹²⁵ and Hirschberg¹²⁶ have all given good clinical descriptions of the disease, with careful autopsies. As in other forms of metastasis, it is ushered in with a chill. Soon after, transient darting pains are felt in the eye, which are sometimes associated with photopsies and followed by serous infiltration of the conjunctiva bulbi. Later, owing to effusion in the capsule of Tenon and to the swelling of the orbital tissues, the eye projects forward and its motility is impaired, these symptoms being accompanied by a clouding of the cornea and the formation of pus in the anterior chamber. If the patient lives, we may have either discharge of pus through the cornea or sclera, or its gradual absorption: in either case, the eyeball shrinks to a small stump. Anatomical examination shows that the starting-point of these symptoms is a septic embolism of either the choroidal or central retinal blood-vessels. According to Hirschberg, "In other pyæmic affections in which the eye is attacked with septic embolism life is dangerously threatened, but there is a larger percentage of recovery with permanent blindness (single or double) than in the puerperal form."

¹²² Medico-Chirurgical Transactions, 1829, vol. xv. p. 120.

¹²³ Treatise on Diseases of the Eye, London, 1854.

¹²⁴ Lehrbuch der Entzündungen und Organischen Krankheiten des Menschlichen Auges, 1866, p. 285.

¹²⁵ Die Krankheiten des Auges, 1863, Bd. ii. pp. 167, 269.

¹²⁶ Archives of Ophthalmology, 1880, vol. ix. p. 177.

Influence of Lactation.—The asthenopia, feeble accommodation, photophobia, and obstinate phlyctenular inflammations of the conjunctiva and cornea which occur during prolonged lactation are subjects of daily observation to every ophthalmic surgeon. They unfrequently fail to yield to appropriate remedies so long as the patients continue to nurse their children. Besides these symptoms, Critchett¹²⁷ has called attention to the sudden unilateral affection of sight which occurs during lactation, and is due to hemorrhage situated either in or behind the retina. This author has frequently seen such cases coming on without pain.

¹²⁷ Medical Times and Gazette, 1858, p. 118.

PATHOLOGY.—As regards the pathology of these affections we are still very much in the dark. Mooren in his elaborate paper (previously quoted) considers that the reflex disturbances of the retina and optic nerve may either be transmitted directly, or may cause primarily a spinal myelitis, which in its turn affects the eyes. He points out that the subperitoneal connective tissue of the pelvis and the uterus is so rich in blood-vessels, lymphatics, and nerves that Rouget has likened it to cavernous tissue. He asserts that the uterine and pelvic nerves re-enter the lumbar cord, while the veins anastomose freely with the veins of the spinal column; and quotes Röhrig to show that electric stimulation of the ovary causes a rise in the general blood-pressure and a diminution of the heart's action—effects which he attributes to irritation of the vagus. He further maintains that any long-standing or often-repeated congestion of the visual centres, of the optic nerve, or of the retina would cause increase of connective tissue and a subsequent tendency to contraction, while the lymph which is poured out, acting on the cylinder axis of the nerves, causes them first to swell, and finally to absorb (Rumpf,¹²⁸ Kuhnt¹²⁹).

¹²⁸ Untersuchungen am d. Physiol. Institut. d. Univ. Heidelberg, Bd. ii. Heft 2.

¹²⁹ Ueber Erkrankung der Sehnerven bei Gehirnleiden, 1879.

Febrile and Post-febrile Ophthalmitis.

VARIOLA.—Various affections of the eye which at times impair its functions, and at others destroy vision, frequently arise during the course as well as during the subsidence of smallpox. When pocks form in the skin of the eyelids, they cause the lids to swell to such an extent as to completely close the eye: many patients so affected relate how, after being blind for a week or ten days, they again recovered their eyesight. The cicatricial processes which ensue often produce falling of the eyelashes with incurvation of the tarsus, which changes the direction of the ciliæ and causes the lashes to rub against the eyeball. During the first stage of the disease there is always flushing and congestion of the conjunctiva, frequently associated with increased flow of tears and sensitiveness to strong light. In some cases we find small elevated yellowish spots, often in groups of two or three, surmounted by an area of vascularization on the edges of the lids and in the tarsal conjunctiva. Similar efflorescences are at times seen in the conjunctiva bulbi and on the limbus corneæ. These coincide in the time of their appearance with the eruption on the skin, and are probably of the same nature, although from the difference in the anatomical structures they do not present the same appearance as the pocks in the skin. Hebra, who has observed and analyzed twelve thousand cases, says that 1 per cent. of the total number presented efflorescences in the conjunctiva. Neumann, Knecht, Schely, Buck, and other German authorities describe them; and Adler in his able monograph (On Eye Diseases during and after Variola) gives an accurate account of them. In opposition to the above statement it should be mentioned that Gregory maintains that no mucous membranes except those of the fauces, larynx, and trachea are capable of taking on variolous inflammation. Marson¹³⁰ also, who from his position at the London Smallpox Hospital had unusual opportunities for witnessing the disease, maintains "that pustules never form on the conjunctiva;" Coccius¹³¹ is also of the same opinion. These authors call attention to the fact that the well-known abscesses of the cornea which occur during the drying and desquamation of the eruption, and which have frequently been described as pocks by the older authors, cannot in any sense be considered as pocks. Beer, however, while calling these formations pocks, distinctly states¹³² that they occur during the suppurative or drying stage. There seems to be no good reason why the above-described conjunctival efflorescences, which come on simultaneously with the skin, should not be considered as analogous in their natures, although from the absence of the corium in the conjunctiva they cannot assume the well-known form of the skin eruption. At times the conjunctivitis becomes catarrhal, and even purulent, leaving in some cases an acute dacryo-cystitis (Adler), and more frequently a low grade of blenorrhoea of the lachrymal duct. Beer states that "those authorities may be right who suppose that there is a real eruption of pocks in the mucous membrane of the tear-sac, because no other sort of inflammation of it is so apt to cause complete closure in its entire length."¹³³ The cornea may present either diffuse or interstitial keratitis. Malacia or abscesses are more frequent in the severe cases, where there are evidences of metastases to other organs. They usually form in the outer quadrant of the cornea, and are accompanied by marked ciliary injection, the patients complaining of stitches in the ball with frontal and temporal neuralgia. Prolapse of the iris and often the formation of a staphyloma are produced by the perforation of resultant ulcers; sometimes the entire cornea is swept away. Marson declares that he has seen this last condition occur within forty-eight hours from the time of the commencement of the corneal affection. Iritis is a less frequent complication. It is of the seroplastic variety, and, according to Adler, comes on only after the twelfth day and in cases where the progress of the disease is slow and insidious. It is always accompanied by some degree of cyclitis and by vitreous opacities. Four cases of glaucoma are on record as occurring during variola; and one (that of Adler) is noteworthy from the fact that the prodroma of glaucoma coincided with those of the smallpox. It was successfully operated on, notwithstanding the fact that the incision was made difficult by the necessity of avoiding a pock on the limbus of the cornea. Fortunately, the present generation has rarely an opportunity of seeing great numbers of eye affections from smallpox, and when they do occur, the partial protection from previous vaccination often modifies their severity. In these days of antivaccination societies, it is interesting to turn back to the accounts of the disease given by those who were in active practice at the time of Jenner's great discovery, and to see how serious the matter appeared when viewed through their spectacles. Thus, Andreæ says, "No disease is so dangerous to the eyesight as the smallpox, and before the introduction of vaccination it caused as much blindness as all other eye inflammations put together."¹³⁴ Benedict¹³⁵ also bears testimony to the great diminution in the intensity of variolous ophthalmia after the introduction of vaccination.

¹³⁰ London Med. Gazette, 1838-39, pp. 204-207.

¹³¹ De Morbis Oculi humani que e Variolis exedi, etc., Leipzig, 1871.

¹³² Lehre von den Augenkrankheiten, vol. i. p. 527.

¹³³ Op. cit., p. 525.

¹³⁴ August Andreæ, Grundriss der Gesammten Augenheilkunde, vol. ii. p. 260.

¹³⁵ P. W. G. Benedict, De Morbis Oculi humani inflammatorii, lib. iii. p. 367.

Writing later, Himly¹³⁶ says: "Smallpox, formerly a rich source of all eye diseases by which the doctor was most busied, is at present only feebly represented by the varioloids (i.e. smallpox modified by cowpox)." Mackenzie¹³⁷ states that "in former times smallpox proved but too often the cause of serious injury to the eyes, and even of entire loss of sight. It was by far the most frequent cause of partial and total staphyloma." Dumont in his work on blindness, the result of his own observations at the Hospice des Quinze-Vingts at Paris, and from its extensive statistics in previous years, records that out of a total of 2056 blind, 262 were blind from variola (or 12.64 per cent.); and, further, that the old records of the hospice showed 17.9 per cent., whilst at present (1856) it was 12 per cent. amongst the older inmates, and but 7 per cent. amongst the more recently admitted. He quotes Carron du Villars as giving the ratio before Jenner at 35 per cent. From immunity we become careless, so that when an epidemic breaks out (as that in Mayence in 1871) we have a state of suffering which forcibly brings back our remembrance of old times. Thus, Manz asserts that "the pestilences of the last (Franco-German) war have revived the remembrance of a disease which in the beginning of this century was a terror to humanity, but which in the last decade was so rare that many now living physicians know it only by the writings of the older authors: the late epidemics, however, have enlarged their experience, and added a new contingent to the almost extinct army of the smallpox-scarred blind."¹³⁸

¹³⁶ Krankheiten u. Missbildungen des Auges, Berlin, 1843, p. 481.

¹³⁷ Diseases of the Eye, p. 500.

¹³⁸ Jahresbericht f. Ophth., 1873, pp. 178-183.

RUBEOLA.—Preceding the outbreak of the skin eruption, or coincident with it, every case of measles presents a greater or less degree of catarrhal conjunctivitis, often accompanied by lachrymation, itching, and burning of the lids, slight pain, and photophobia. In from two to three weeks the catarrh usually disappears of itself, but in many cases leaves behind it an asthenopia and sensitiveness to light which often lasts for months. In some fortunately rare cases the catarrh increases, and we have a severe muco-purulent inflammation of the eyes, causing partial or total sloughing of the cornea, and thus leading either to the formation of a staphyloma or to the total loss of the eye. Moreover, we often have the development of phlyctenular keratitis as one of the sequelæ, especially among the weak and badly nourished. Some authors (Rilliet and Barthez, Mason, Schmidt-Rempler, De Schweinitz, etc.) relate cases where diphtheritic conjunctivitis, with all of its well-known symptoms—yellow, ropy-like secretion, great bulbar chemosis, and hard board-like infiltration of the lids—set in during the course of the disease. Kerato-malacia (a rapid sloughing of the cornea with marked anæsthesia of the ball, without swelling of the lids) was probably first observed as a consequence of measles by Fischer.¹³⁹ He had seen three cases, each accompanied by suppression of the skin eruption, severe fever, and delirium. The corneæ were entirely destroyed in twenty-four to forty-eight hours, and the children died soon after the development of the eye affection. Beger and Begold (Leber) have each reported similar cases. Sometimes in the course of this disease, amaurosis, either permanent or transient, is doubtful. Graefe¹⁴⁰ gives a case where failure of sight came on during convalescence, and where for a week there was absolute loss of perception of light, without any other ophthalmoscopic appearances than a slight neuritis, the patient gradually recovering his eyesight. In an epidemic of measles with severe cerebral symptoms, Nagel¹⁴¹ records a case of a child where on the third day sopor, convulsions, opisthotonos, and dilatation of the pupils set in. The patient remained soporose for ten days, and then, on regaining consciousness, was found to be entirely blind. On the twenty-fifth day from the setting in of the convulsions, perception of light was dubious, and the pupils, which remained insensitive to the reflection from the ophthalmoscopic mirror, contracted slightly on exposure to the full glare of daylight. There was eventually complete recovery both of health and eyesight, the return of the latter being apparently hastened by the use of strychnia. The same author relates two other cases, in one of which the ophthalmoscope showed neuritis. One of them was fatal, the other terminated in recovery, and in neither was there any return of eyesight. In some cases of measles where Bright's disease of the kidneys is pre-existent or sets in during the attack, there may be the development of the characteristic form of retinitis albuminuria.

¹³⁹ J. N. Fischer, Lehrbuch der Entzündungen und Organischen Krankheiten des Menschlichen Auges, Prag, 1846, p. 275.

¹⁴⁰ A. f. O., xii., 2, p. 138.

¹⁴¹ Behandlung der Amaurosen, pp. 24-30.

SCARLATINA.—In scarlatina we have usually a hyperæmia of the conjunctiva coincident with the skin eruption. Inflammatory affections of this membrane and of the cornea are much less frequent than in measles. Martini¹⁴² remarks that only in one case in twenty is there any inflammation of the eye. Beer¹⁴³ informs us that the tears are more irritating than in morbillous ophthalmia, and that the photophobia is more persistent. When ichorous ulcers form, they attack not only the cornea, but also the white of the eye, and spread much more rapidly in this situation than in the conjunctival leaflet of the cornea. Kerato-malacia occurs more frequently than in rubeola. Bonman¹⁴⁴ relates that in a severe epidemic of scarlet fever five boys in one family were taken sick, and that two of them lost their sight from sloughing of the cornea within a week of their seizure. Of these, one died, and the other was brought to him with a shrunken globe and without light-perception. The eyes of the other three children were not affected. Arlt in the first volume of his work on diseases of the eye¹⁴⁵ has given us a clinical description of this form of kerato-malacia. The patient, a boy of four and a half years, was first seen by him on the eighth day of the disease. The child was very pallid, with a burning-hot skin, hoarse voice, slight diarrhoea, and flat abdomen. The right cornea was evenly clouded throughout, swollen, and softened, while the left had lost its brilliancy and was slightly clouded, presenting the appearance of an eye thirty-six hours after death. The conjunctivæ of both eyes were white, with a few vessels and ecchymotic spots in their lower parts. On the tenth day, the right cornea was converted into a mass as soft as schmeer-käse, and was beginning to be thrown off on the centre, where there was a hernia of the hitherto unaffected membrane of Descemet. Both eyes eventually had the cornea completely destroyed, and the patient died on the seventeenth day. Iritis is more frequent than after measles.

¹⁴² Von dem Einflusse des Secretions Flussigkeiten, vol. ii. pp. 267, 268.

¹⁴³ Lehre von dem Augenkrankheiten, Bd. i. pp. 536, 537.

¹⁴⁴ Lectures on the Parts concerned in the Operations in the Eye, London, 1870, p. 110.

¹⁴⁵ Krankheiten des Auges, vol. i. pp. 211-213.

Considering the frequency of acute nephritis in this disease, the retinal lesions are comparatively rare. Schreiber¹⁴⁶ gives two interesting plates of chorio-retinitis after scarlatina. Ebert¹⁴⁷ at a meeting of the Berlin Medical Society in 1867 called attention to some cases of transient blindness in the course of scarlatina without ophthalmoscopic changes; and Graefe, who presided at the meeting, remarked that in all these cases of absolute blindness there was still reaction of the pupil to the light, and that therefore there could be no neuritis or decided lesion between the corpora quadrigemina. He considered the prognosis favorable so long as there was pupillary reaction, and not necessarily bad where it was wanting. Although this is the rule, the prognosis is certainly more favorable when the pupil reacts promptly and to moderate light. Hirschberg¹⁴⁸ has recorded a case of blindness following meningitis, where light-perception failed to return, although the pupillary reaction lasted several weeks.

¹⁴⁶ Veränderungen des Augenhinter-grundes, Plates iii. and iv., Figs. 7 and 8.

¹⁴⁷ Berliner klin. Wochenschrift, Jan. 15, 1868, pp. 21-23.

¹⁴⁸ Ibid., 1869, p. 387.

Relapsing typhus fever is frequently followed by amblyopia and inflammation of one or both eyes. Considerable variety in the intensity and in the symptoms of the disease has been manifested in different epidemics, and the ratio of the percentage of eye cases has greatly varied. In most outbreaks of relapsing typhus fever amblyopia is followed by inflammation. This was the sequence of the symptoms in the epidemic in Dublin in 1826, in Glasgow in 1845, and in Finland in 1865, although in the last-mentioned the inflammatory symptoms were less prominent and severe than in the first two. The eye symptoms rarely develop during the first attack of the fever, but usually occur after a second or third attack or during convalescence. The earliest careful study of the eye symptoms in a severe epidemic is that of Wallace,¹⁴⁹ who tells us that "there is often that haggard and worn aspect, that sickly, mottled, pallid hue of skin, that sleepy, exhausted, and oppressed appearance of the eye, which is more easily observed than described. The patient only half opens the lids of the affected organ. They are of a purplish-red color and humid. Their subcutaneous vessels are preternaturally enlarged. The vascularity of the sclerotic and conjunctiva is greatly increased. The vessels of the former describe a reticulated zone round the cornea, and those of the latter run in a direction more or less straight to the edge of this membrane, and sometimes appear to pass on the edge. The hue of the redness is peculiar; it is a dark brick-red. The pupil is generally much contracted, and its edge thickened and irregular. The iris is altered in color, generally greenish, and incapable of motion. There exists dimness of the cornea, which may be compared to the appearance glass assumes when it has been breathed upon. There is often a turbidness of the aqueous humor, and a pearly appearance of the parts behind the iris may be observed by looking through the pupil. There is great intolerance of light, and a copious, hot lachrymal discharge. The vision will be found for the most part so extremely imperfect that the patient can merely distinguish light from darkness, and he is often tormented by flashes of light which shoot across his eye, and these occur more particularly in dark places; or he is troubled by brilliant spectres or by the constant presence of muscæ volitantes. There is very considerable pain, which returns in paroxysms, and these are almost always more severe at night. The pain is sometimes referred to the ball of the eye, sometimes to one of the lids, sometimes to the temple or to the circumference of the orbit." Mackenzie agrees in the main with the foregoing description: his cases were also accompanied by severe inflammation, with hypopyon and copious precipitates in the membrane of Descemet and on the anterior capsule of the lens. He also called attention to the diminution of the intraocular tension and the consequent flabbiness of the eyeball, and states that out of 1877 cases of fever admitted to the Glasgow Infirmary during the epidemic of 1843, 261 (one-seventh) were attacked by the disease of the eye. Anderson,¹⁵⁰ who describes the same epidemic later in the course, takes exception to Wallace's statement that there is always an amaurotic stage at the outset of the disease. He computes these cases at two-thirds of the entire number, and tabulates five cases of inflammation without amaurosis. He also describes and gives plates which show opacities of the vitreous, posterior synechia, pigment on the anterior capsule, posterior polar cataract, and other forms of lenticular degeneration; these conditions ensuing not only in this disease, but in all other affections where the circulation in the ciliary body and the constitution of the vitreous are profoundly involved. Schweigger, in describing an epidemic in Berlin, says that in one-third of the cases of ophthalmia there was simple unilateral iritis, and that in a second third there was diffuse punctiform or flocculent vitreous opacities without any trace of iritis or external symptoms of disease; while in the remaining third there was iritis with vitreous opacities in common: when it ensues in its usual form the effects of annular synechiæ or detachment of the retina; rarely from suppuration of the corneæ. Although of late years the Russian writers have materially added to our knowledge of the affection, nevertheless in most essentials their observations agree with those above quoted. Thus, Blessig¹⁵¹ gives an account of an epidemic in St. Petersburg, while Logetschnikow¹⁵² describes an epidemic in Moscow in which he encountered over 700 cases of this form of ophthalmia. Larionow¹⁵³ relates the history of a mild epidemic in the Russian army of the Caucasus, and tabulates 767 cases of the fever, in which are also included a number of cases of exanthematic typhus and a few cases of typhoid fever. Exclusive of the ischæmia of the retina and feebleness of the accommodation which were present in every case during convalescence, there were 3 cases of serous retinitis, 2 of hemeralopia, and only 3 of iritis; while in 10 per cent. of these there were vitreous opacities. He did not see a single case of genuine irido-choroiditis in the entire number. Estlander¹⁵⁴ has given a masterly description of two epidemics which he observed at Helsingfors in Finland, both of which occurred after a failure of the crops and consequent famine. In the first of these epidemics, which was of a mild type, only 3 out of 222 patients died, and the concomitant eye affections were few in number; while in the latter, 18 out of 242 patients died, and extensive vitreous opacities with severe inflammation of the eyes were frequent. He agrees with Mackenzie that the fever attacks few children under ten years of age, and says that although the disease is much more liable to attack people between twenty and thirty years of age, here it is less frequent than it is in patients between ten and twenty years of age, where it exists in one half of the cases. Arlt¹⁵⁵ agrees with this, and says that it is due to the fact that hunger and malnutrition are in general much worse borne by adolescents than by adults. As regards the period of the disease at which the eye symptoms come on, Estlander says that out of 28 carefully observed cases it developed 6 times during the fever or a week after its cessation, 11 times between the second and fourth week, 5 times in the second month, and 6 times from the third to the fifth month. These figures agree well with those given by Mackenzie, and show that there is both a feeble state of constitution and a prolonged convalescence from this severe fever. Pepper,¹⁵⁶ in a previous volume of this work, has given an interesting account of an epidemic in this city in which he states that eye affections were of rare occurrence.