occurrence. Sous of Bordeaux quotes[33] the elder Graefe and Scultetus
as having anatomically demonstrated the existence of the lesion, and
Mackenzie refers[34] 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 describes[35] 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 recorded[36] a case of widely-spread congenital
telangiectasis of the face with a similar condition of the retinal
veins of one eye. Liebreich[37] has pictured curious bead-like
dilatations of the veins in a glaucomatous eye. Jacobi[38] 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.
[Footnote 33: _Annales d'Oculistique_, 1865, pp. 241-243.]
[Footnote 34: _Practical Treatise on the Diseases of the Eye_, London,
1854, 4th ed., p. 1042.]
[Footnote 35: _Atlas d'Ophthalmoscopie_.]
[Footnote 36: _A. f. O._, vii., 1, pp. 119-121.]
[Footnote 37: _Atlas_ Plate xi. Fig. 1.]
[Footnote 38: _Klin. Monatsblätter_, 1874, pp. 253-260.]
[Footnote 39: _Glaucom._, 1859, p. 47.]
[Footnote 40: _Bericht der Wiener Auqenklinik_, 1866, pp. 65-74.]
[Footnote 41: _Ophth. Hand-Atlas_, Table xv. p. 72.]
[Footnote 42: _Klin. Monatsblätter_, 1873, pp. 216-218.]
[Footnote 43: _Klin. Monatsblätter_, 1874, pp. 252-260.]
[Footnote 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. Little[48] 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 {744} 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. Manz[50] 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.
[Footnote 45: _Klin. Monatsblät. f. Augenheilkunde_, 1863, pp.
260-349.]
[Footnote 46: _Ibid._, p. 350.]
[Footnote 47: _Annales d'Oculistique_, 1865, p. 350.]
[Footnote 48: _Trans. Amer. Ophth. Soc._, 1881, pp. 211-213.]
[Footnote 49: _Gessamm. Schriften_, p. 365.]
[Footnote 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 reports[51] an instance in a blind eye of a boy ten years of age,
who also exhibited a convergent squint and nystagmus. Mooren[52] 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.
[Footnote 51: _Arch. f. Ophth._, vol. i., part 1, pp. 403, 404.]
[Footnote 52: _Ophthalmiatrische Beobachtungen_, 1867, p. 260.]
LEUCÆMIC RETINITIS.--Liebreich[53] 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 pictured[54] 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. Leber[55] states that the disease sometimes assumes the
form of hemorrhagic {745} retinitis, such as is often seen in cases of
disease of the heart and blood-vessels. Gowers[56] 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. Leber[57] 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]
[Footnote 53: _Atlas_, Plate x., 1863.]
[Footnote 54: _Archives of Ophthalmology_ (Knapp and Moos), vol. i.,
1869, pp. 341-358, Tab. B. and C.]
[Footnote 55: _Graefe und Saemisch_, vol. v. p. 599.]
[Footnote 56: _Medical Ophthalmoscopy_, 1879, p. 192.]
[Footnote 57: _Arch. f. Ophth._, xxiv., 1, pp. 295-312.]
[Footnote 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
Horner[59] and Quincke[60] 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 considers[61] the colorless centre of the
hemorrhages to be due to a commencing absorption of the blood, while
Manz[62] holds that these yellowish-white spots are the dilated
extremities of retinal capillaries.
[Footnote 59: _Klinische Monatsblätter für Augenheilkunde_, 1874, pp.
458, 459.]
[Footnote 60: _Deutsches Archiv f. klinische Medizin_, 1877, pp. 1-31
(with plate).]
[Footnote 61: Quoted by Quincke, _loc. cit._, p. 23.]
[Footnote 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
{746} 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. Fries[63] 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, Jaeger[65] 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.
Graefe[66] 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, Schweigger[67] (in two cases), Nagel,[68]
Hirschberg,[69] Nägeli,[70] Horner,[71] and Landesberg[72] have all
noted the occurrence of neuritis.
[Footnote 63: Sigmund Fries, "Diss. Inaug." in _Klin. Monatsblätter f.
Augenheilkunde_, 1878.]
[Footnote 64: _Ergebnisse der Untersuchung mit dem Augenspiegel_, 1876,
p. 87.]
[Footnote 65: _Loc. cit._, 1876, p. 87.]
[Footnote 66: _Arch. f. Ophth._, vol. vii., part 2, p. 146.]
[Footnote 67: _Handbuch der Augenheilkunde_, 1875 (3d ed.), p. 522.]
[Footnote 68: _Behandlung der Amaurose und Amblyopie mit Strychnine_,
1871, p. 51.]
[Footnote 69: _Bericht über die zehrite Vorsammlung der Ophth.
Gessellschaft Heidelberg_, 1871, pp. 53-60.]
[Footnote 70: _Jahrbuch f. Ophthalmologie Literatur_, 1879, p. 253.]
[Footnote 71: _Klin. Monatsblätter f. Augenheilkunde_, 1877
(supplement), pp. 53-60.]
[Footnote 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
{747} 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. Samelsohn[74] 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.
[Footnote 73: _A. f. O._, xviii., 2, pp. 225-235.]
[Footnote 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. Poncet[75] 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. Schreiber[76] 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, Becker[78] 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 {748} blood. Weber[79] 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 Nuel[80] 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.
[Footnote 75: _Archives générales de Médecine_, Série 6, t. xv., 1870,
pp. 408-424.]
[Footnote 76: Separat Abdruck aus dem _Deutschen Arch. f. klin. Med._,
Bd. xxi. pp. 100, 101, Plates vii. and viii.]
[Footnote 77: _Annales d'Oculistique_, 1875, pp. 1-14.]
[Footnote 78: "Sitzungsbericht der Ophth. Gesellschaft," in _Klin.
Monatsblätter f. Augenheilk._, 1871, p. 385.]
[Footnote 79: _Klin. Monats. f. Augenheilk._, pp. 383-385.]
[Footnote 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. Schreiber[81] 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,
Horner[82] 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. Seidel[84]
relates {749} 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.
[Footnote 81: _Veränderungen des Augenhinter-qrundes bei Internen
Erkrankungen_, 1878, p. 87.]
[Footnote 82: "Bericht der Ophth. Gesellschaft," in _Klin.
Monatsblätt._, 1871, pp. 326-328.]
[Footnote 83: Zehender, _Handbuch der Augenheilkunde_, vol. ii. pp.
188, 189.]
[Footnote 84: "Sehstörungen bei der Pneumonie," _Deutsches Klinik_,
1862, No. 27.]
Affections of the Eye caused by Diseases of the Digestive Organs.