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. Graefe[140] 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, Nagel[141] 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 {764} attack, there may
be the development of the characteristic form of retinitis albuminuria.
[Footnote 139: J. N. Fischer, _Lehrbuch der Entzündungen und
Organischen Krankheiten des Menschlichen Auges_, Prag, 1846, p. 275.]
[Footnote 140: _A. f. O._, xii., 2, p. 138.]
[Footnote 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. Martini[142] remarks that only in one case in twenty is there
any inflammation of the eye. Beer[143] 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. Bonman[144]
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
eye[145] 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.
[Footnote 142: _Von dem Einflusse des Secretions Flussigkeiten_, vol.
ii. pp. 267, 268.]
[Footnote 143: _Lehre von dem Augenkrankheiten_, Bd. i. pp. 536, 537.]
[Footnote 144: _Lectures on the Parts concerned in the Operations in
the Eye_, London, 1870, p. 110.]
[Footnote 145: _Krankheiten des Auges_, vol. i. pp. 211-213.]
Considering the frequency of acute nephritis in this disease, the
retinal lesions are comparatively rare. Schreiber[146] gives two
interesting plates of chorio-retinitis after scarlatina. Ebert[147] 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. Hirschberg[148] has recorded a
case of blindness following meningitis, where light-perception failed
to return, although the pupillary reaction lasted several weeks.
[Footnote 146: _Veränderungen des Augenhinter-grundes_, Plates iii. and
iv., Figs. 7 and 8.]
[Footnote 147: _Berliner klin. Wochenschrift_, Jan. 15, 1868, pp.
21-23.]
[Footnote 148: _Ibid._, 1869, p. 387.]
{765} 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 {766} 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, Blessig[151] gives an account of an epidemic in St. Petersburg,
while Logetschnikow[152] describes an epidemic in Moscow in which he
encountered over 700 cases of this form of ophthalmia. Larionow[153]
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. Estlander[154] 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. Arlt[155] 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 {767} 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.
[Footnote 149: "An Essay on a Peculiar Inflammatory Disease of the Eye,
and its Mode of Treatment," _Trans. Med.-Chir. Soc. of London_ (read
Dec. 11, 1827).]
[Footnote 150: "Post-febrile Ophthalmitis," _Monthly Journ. Med. Sci._,
1845, pp. 723-729.]
[Footnote 151: _Congrès internationale d'Ophthalmologie_, Paris, 1868,
pp. 114-117.]
[Footnote 152: "Entzündung der Vorderen Abschnitten der Choroidea als
Nachkrankheit der Febris Recurrens," _A. f. O._, Bd. xvi., 1, S.
352-363.]
[Footnote 153: _Klinische Monatsblätter f. Augenheilkunde_, 1878, pp.
487-497.]
[Footnote 154: _A. f. O._, xv. 2, pp. 108-143.]
[Footnote 155: _Klin. Darstellung der Krankheiten des Auges_, 1881, pp.
289-291.]
[Footnote 156: Vol. I. p. 399.]
Exanthematous typhus fever is occasionally followed by the same train
of symptoms as pointed out in discussing Larionow's statistics, who
gives vitreous opacities as the most frequent forms of the eye
affection. Out of a total of 57 fever patients with typhus
exanthematicus, he found 1 case each of iritis, keratitis, and
neuro-retinitis, 2 cases of contraction of the field of vision, 5 of
subconjunctival ecchymosis, and 2 of conjunctival catarrh.
Abdominal Typhoid Fever.--Severe eye complications are less frequent in
this disease than in either of the foregoing affections. During
convalescence from this, as from all other exhausting diseases, there
is usually feebleness of the accommodation, and occasionally the
development of vitreous opacities, with or without the formation of
cataract. The most common eye affections show as an optic neuritis or
paralysis of some of the muscles supplied by the third pair of nerves,
and are due to a complicating meningitis.
Yellow Fever.--In this disease most writers have called attention to
the accompanying ocular symptoms--flushing and injection of the
conjunctiva with increase of lachrymation, followed later by a change
of the color of this membrane to a yellow hue, which precedes a similar
change of the color of the skin of the face and other parts of the
body. The first epidemic of the disease in Philadelphia occurred in
1762. Redman,[157] in describing it, says: "The patients were generally
seized with a sudden and severe pain in the head and eyeballs, which
were, I think, often, though not always, a little inflamed or had a
reddish cast." Another severe epidemic of the disease visited the city
in 1793, of which Rush[158] has given us a valuable account. Among the
premonitory signs he enumerated "a dull-watery-brilliant, yellow or red
eye, dim and imperfect vision;" and he defines his meaning by saying
that the dull eye was found among the severe cases, and the brilliant
one where the poison was less intense. Later in the disease there was
"preternatural dilatation of the pupil," and in one case "a squinting
which marks a high degree of morbid affection of the brain." There were
hemorrhages, chiefly from the nose and uterus, and in but one case "a
dropping of blood from the inner canthus." A dimness of sight was very
common in the beginning of the disease, and many were affected with
temporary blindness. In some there was a loss of sight in consequence
of gutta serena or a total destruction of the substance of the eye. The
eyes seldom escaped the yellow tinge. There were a number of cases of
uncommon malignity without this symptom, but sometimes the yellow color
appeared on the neck and breast before it invaded the eyes. Wood,[159]
who witnessed a later epidemic (also in Philadelphia), says that even
in the earliest period of the disease the white of the eye is often
reddened and turbid, and in bad cases appears sometimes as if
bloodshot. As before stated, in the course of the disease {768} this
redness yields to a yellow or orange color. Féraud,[160] in speaking of
the symptoms of the second stage, lays great stress on the brilliancy
of the eyes, their lachrymose condition, the fulness and nicety of the
conjunctival injection, the dilatation of the pupil, and the presence
of photophobia; adding that this congestion is diminished during the
remission of the fever if the attack is not severe, but that if the
conjunctiva darkens and assumes an icteric aspect, which becomes more
and more intense, the case is undoubtedly severe. He adds that ocular
hemorrhages occur in some grave cases during the second stage,
producing subconjunctival suffusion and a flow of blood from the
neighborhood of the commissure of the lids. Such "hemorrhages have
frequently caused conjunctivitis, keratitis, and even such an accident
as phlegmon." Fernandez[161] gives three cases of delirium, suppression
of urine, and loss of vision. One of these cases was examined with the
ophthalmoscope, but no changes were found in the eye-ground. One case
recovered, having entirely regained his eyesight; the other two died.
[Footnote 157: "An Account of the Yellow Fever of 1762," by John
Redman, M.D. (read before the College of Physicians of Philadelphia,
Sept. 7, 1793).]
[Footnote 158: _An Account of the Bilious Remitting Yellow Fever as it
appeared in the City of Philadelphia in the Year 1793_, by Benjamin
Rush, M.D., Philada., 1794.]
[Footnote 159: G. B. Wood, _Treatise on the Practice of Medicine_, vol.
i. p. 321, 1858.]
[Footnote 160: Béranger-Féraud, "La Fièvre jaune à la Martinique,"
quoted by Juan Santos Fernandez, _Archiv. of Ophthalmology_, x., 4,
1881, pp. 440-445.]
[Footnote 161: _Loc. cit._]
Intermittent Fever.--Intermittent ophthalmia is but rarely encountered
in countries where only a mild form of intermittent fever is present;
in fact, it was so rare in Scotland that Mackenzie in the earlier
editions of his work denied its existence, but a larger experience
enabled him (in 1854) to give three cases. In 1828 and 1829 it was so
infrequent in Marburg that Hueter devoted two papers to its study--one
of a case of the quotidian type, and the second of the septan form of
the ophthalmia. In countries where the malarial poison exists in more
intense form, we have quite a different state of affairs; thus
Levrier[162] describes it as of common occurrence in the district of
Landes in France, and says that its most frequent form is a periorbital
and ocular neuralgia, accompanied by intense congestion of the
conjunctiva, with increased flow of tears and a greater or less degree
of photophobia, occurring in those who have had frequent attacks of
intermittent fever. Wehle, whose observations were made in Hungary,
describes an erysipelatous swelling of the lids with small hemorrhages
in the palpebral conjunctiva, redness and swelling of the bulbar
conjunctiva with intense photophobia, and occasional clouding of the
cornea. Arlt[163] relates eight cases of chronic interstitial
keratitis, all occurring in emaciated patients who had had severe
malarial fevers, in Slavonia and Hungary. Only three of these stayed
for prolonged treatment, which consisted of the use of Karlsbad water,
followed by the preparations of quinine and iron; all of these
recovered, and their eyes cleared, leaving only the faintest trace of
corneal opacity. Galezowski[164] gives a case of malarial keratitis,
and Griesinger,[165] after describing the usual symptoms of the disease
(similar to that noted by Levrier), speaks of cases of long duration
accompanied by clouding of the cornea and atrophy of the eyeball. He
has also encountered an intermittent form of iritis. Mackenzie
describes a case of it (one of those above referred to) which
eventually ended in amaurosis. While affections of the retina and optic
{769} nerve from malarial fever would seem to be rare in temperate
latitudes, Guéneau de Mussy,[166] however, relates a case of optic
perineuritis with retinal apoplexies. Macnamara, observing in India,
says the serous retinitis is not uncommon in malarial fever, and that
in severe cases of this disease amaurosis is not infrequent. Galezowski
and Kohn each reports a case of atrophy of the optic nerves after a
severe attack of intermittent fever, but it is not quite evident from
the clinical history whether the blindness might not be attributed to
the large doses of sulphate of quinia which had been administered.
[Footnote 162: J. F. Levrier, _Thèse de Paris_, 1879, "Des Accidents
oculaires dans les Fièvres intermittentes," p. 56.]
[Footnote 163: _Klinische Darstellung der Krankheiten des Auges_, 1881,
pp. 121, 122.]
[Footnote 164: Quoted by Levrier, _loc. cit._, p. 39.]
[Footnote 165: _Traité des Maladies infectueuses_.]
[Footnote 166: _Journal d'Ophthalmologie_, p. 1, 1872.]