tissues of the body, necessarily manifests its influence on the tissues
of the eyes. It frequently impairs the nutrition of the vitreous and
causes the formation of cataract. The presence of grape-sugar is
readily detected in such lenses by chemical examination. Mitchell and
other {797} experimenters have produced cataract in frogs by placing
them in a solution of sugar. In such instances the lens tissue is said
to become transparent when the animal is removed from its sugar bath
and placed for a time in water; therefore, it is probable that the
cataract has been developed by the simple abstraction of water.
Diabetic cataracts are often extracted successfully, and the wound
usually heals well; but we occasionally have intraocular hemorrhage
during the course of healing. At times the nutrition of the patients is
so impaired that a slight accident is dangerous, such as happened in a
patient of the writer, where the striking of the hand against an iron
bedstead caused gangrene and death. Nettleship[285] has recorded an
analogous case, where accidental injury during convalescence caused
death from gangrene. At times marked retinitis and hemorrhages with
clear media have been encountered; thus, Jaeger in 1855 gave us an
admirable picture of such a case, in which there was retinal swelling
so great as to hide the outlines of the nerve, it being accompanied by
numerous hemorrhages and yellow splotches. In his description of the
case he also states that there was a marked central scotoma (a denser
inside of a lighter one) in the field, while the periphery of the
retina was so little affected that the patient could still decipher
large letters (No. 18 of Jaeger's test-types). We might perhaps think
that the scotomata are accidental and due to the location of the
retinal changes in the given case, but later researches seem to show
that we may have them in diabetes without retinal changes, Nettleship
and Edmunds describing two such cases. In one of these cases there
seems to be some doubt whether it was not a tobacco amblyopia which had
been developed in a diabetic subject; but in the other case there was
no such complication. The retinal changes which have been recorded in
some cases have much resembled those due to albuminuria, but these
alterations in the eye-ground have been seen in a number of cases where
no albumen in the urine could be obtained.
[Footnote 285: _Transactions of the Ophthalmological Society of the
United Kingdom_.]
Diabetes also may, by impairing the nutrition, diminish the power of
accommodation in the young and cause a rapid increase of presbyopia in
old persons (Graefe, Nagel, Foerster). Horner[286] proved that a
hypermetropia of 1/14 in a patient of fifty-five years of age rapidly
diminished to H. = 1/48, and the amount of presbyopia remained
unaltered, while the general health had improved and the quantity of
sugar had diminished. He attributes this rapid increase and subsequent
diminution of the hypermetropia to a change in the amount of the fluid
contents of the eye. Were this reporter any less careful an observer,
one might be inclined to suspect swelling of the lens; but he specially
mentions that there was no trace of cataract formation.
[Footnote 286: _Klin. Monatsbl. f. Augenheilkunde_, 1873, p. 490.]
EPILEPSY.
IDIOPATHIC EPILEPSY.--In idiopathic epilepsy--that is, in those cases
where no gross changes in the brain can be demonstrated by autopsy--the
eye symptoms are numerous and interesting. Wecker[287] tells us that at
the commencement of the spasm there is contraction of the pupils.
Usually, soon after the tonic spasm sets in or coincident with it, we
have marked dilatation of the pupil and an abolition of the
eye-reflexes, this {798} being shown by the want of contraction of the
orbicularis or of the pupil when the conjunctiva is touched. Reynolds,
Echeverria, Clouston, and Hammond have called attention to a
development of hippus (an alternate contraction and dilatation of the
pupil) at the end of the convulsive paroxysms; but this is exceptional.
The last author considers a state of alternate contraction and
dilatation of the pupils, or a contraction of one pupil with dilatation
of its fellow, to be characteristic of the convulsive stage. When the
convulsions are unilateral the head and eyes are often turned toward
the convulsed side. Although ophthalmoscopic examination is favored by
dilatation of the pupil, yet the convulsions make it so difficult that
we have quite conflicting accounts of the state of the disc and retina
during the paroxysm. Six cases have been accurately examined by Albutt
during the convulsion, in three of which there was congestion of the
disc, and pallor in the remainder. Jackson also reports cases of pallor
during the convulsion. More lately, Schreiber[288] has examined three
cases in which he found pallor in the convulsive stage, this being very
marked in one case, where the convulsion was violent. Gowers, on the
other hand, maintains that in convulsions which commence locally
without initial pallor of the face he was unable to perceive any
alteration of the calibre of an artery which he kept continuously in
view during the convulsion. The same author tells us that during the
stage of cyanosis the veins of the retina become distended and dark,
and that once in the status epilepticus he has seen a congestion of the
discs with oedema, which subsequently disappeared. He does not consider
that there is any abnormal appearance of the discs in the intervals
between the attacks, while both Albutt and Bouchut hold that they are
congested. In several of the chronic cases which the writer has had an
opportunity of examining there has been a low grade of atrophy of the
discs with concentric limitation of the field of vision. That this, at
least, is common in advanced cases is well shown by the observations of
Michel,[289] who in 1867 published careful examination of the
eye-ground, acuity, and field of vision of 58 epileptics. In 15 of
these cases there were no visible changes; in 10, hyperæmia; in 1,
hyperæmia with oedema; 1 of hyperæmia passing into atrophy; 10 of
unilateral atrophy (9 of the right nerve and 1 of the left); 13 cases
of atrophy of both optic nerves; the remaining cases showing changes in
the eye-ground which were probably attributable to other causes. Auræ
which affect the special senses have been recorded, and have been
usually described as flashes of light or balls of fire. Maisonneuve
(quoted by Robin) gives an instance where the auræ consisted in
convulsions of the eyelids. Gowers gives 119 cases of auræ which
affected the special senses, 84 of these being of the sense of sight.
He divides the latter into five classes: I. Sensation in the eyeball;
II. Diplopia; III. Apparent increase or diminution in the size of
objects; IV. Loss of eyesight; V. Distinct visual sensations,
consisting sometimes of flashes of light, colored spectra, and rarely
some more specialized sensation, such as an apparition. The only one of
these cases in which there was an autopsy appears to have been one of
symptomatic rather than idiopathic character, as there was found a
tumor of the occipital lobe which had extended as far forward as the
angular gyrus.
[Footnote 287: _G. u. S._, Bd. iv. p. 565.]
[Footnote 288: _Ueber Voränderungen des Augenhintergrundes, etc._, 1878
(S. 42).]
[Footnote 289: _Inaug. Diss._, von Dr. Julius Michel, Würzburg, 1867.]
{799} HYSTERO-EPILEPSY.--The remarkable co-ordinated convulsions which
are associated with hemianæsthesia, and which have been so minutely
described by Charcot as characteristic of this disease, are constantly
accompanied by subjective or objective disorders of the visual
apparatus. Visions of animals, such as rats, vipers, crows, cats, etc.,
frequently precede the convulsive seizure, followed by a transient loss
of sight; a return of the illusions (sometimes pleasant and gay, at
others erotic in their nature, or again sad or terror-striking) coming
on in a later stage. It is said that processions of animals are often
seen, which usually come and go on the hemianæsthetic side as the
attack passes off and the patient becomes quiet. The objective symptoms
have been carefully studied by Landolt in Charcot's wards. They were
found by him to consist in a diminution of the acuity of vision and a
concentric limitation of the field for form and color. All these
symptoms are bilateral, and much more marked on the anæsthetic side,
they occurring before any ophthalmoscopic changes are visible. These
are followed later by alterations in the eye-ground, which consist at
first of slight congestion and oedema of the discs, followed by partial
atrophy. The difference in the affection of the two eyes was so marked
that Charcot at first described it as a crossed amblyopia, but he
admits that the lesion is bilateral, as above described.[290]
[Footnote 290: _Leçons sur les Localisations dans les Mal. du Cerveau_,
vol. i. p. 119 (foot-note), Paris, 1876.]
EXOPHTHALMIC GOITRE.
GRAVE'S DISEASE; BASEDOW'S DISEASE.--The most prominent characteristics
of this affection are an irritability of the heart with increased
frequency of the pulse, and enlargement of the thyroid gland and a
swelling of the tissues of the orbit, which cause the eyeballs to
become prominent. The size of the goitre and the amount of protrusion
of the eyeball vary very much in different cases. Frequently there is a
symptom to which Graefe was the first to call attention--namely, a
disturbance of the usual consensual movements of the eyeball and upper
eyelid. When the patient looks downward below the horizontal line, the
lid no longer accompanies the eyeball in its motion, but halts in its
course. This derangement in the action of the lid is supposed to depend
upon some defect in the innervation of the orbicularis, as it is not
present in cases of equal prominence of the eyeball from other causes.
The amount of secretion from the tear-glands and from the conjunctival
surface is also at times much diminished. Owing to the prominence of
the eyes and the relaxation of the orbicularis, the fissure of the lids
is wider open than usual, and the eye has a peculiar stare. At times,
when the prominence of the eyes is very great, the lids fail to cover
the balls during sleep, and the cornea becomes inflamed and ulcerated
from exposure to air and dust. The disease rarely develops till after
puberty, and is more frequent in females than in males: in the former
it often develops after childbirth. It is so frequently accompanied by
disease of the reproductive organs that Foerster, in his paper on the
"Relation of Eye Diseases to General Disease,"[291] places it in the
section devoted to eye symptoms from diseases of the sexual organs.
Ophthalmoscopic examination usually shows a slight thickening of the
fibre-layer of the retina in and around the disc, with dilatation and
tortuosity of the veins--a state of affairs which may often {800} be
fairly attributed to venous stasis caused by the swelling tissues. In
addition to these symptoms there is sometimes, as Becker has pointed
out, a dilatation of the arteries, which may almost equal the veins in
calibre. At times there is an arterial pulse. As found by autopsies,
the anatomical changes are usually enlargement and dilatation of the
heart, hypertrophy and various degenerative changes in the thyroid
glands, and a state of hyperæmia at times associated with hypertrophy
of the fat tissue of both orbits.
[Footnote 291: _Graefe und Saemisch_, vol. vii. p. 97.]
Affections of the General System.
CHOLERA.--In this disease the eyelids are said to show an early
development of cyanosis, which becomes more marked as this symptom
develops in other parts of the body. The contents of the orbits shrink
and the eyes are drawn back in their sockets, there being an imperfect
closure of the lids, which leads at times to necrosis of the exposed
lower part of the cornea. There is a marked diminution in the secretion
of tears, and often a dilatation of the veins of the exposed part of
the conjunctiva bulbi, which are turgid with the black blood, this
state being at times accompanied by subconjunctival hemorrhages. The
pupils are usually contracted. The retinal arteries are much diminished
in size, and the veins although not dilated, are filled with blackish
blood. Owing to the great feebleness of the circulation, the slightest
pressure with the finger on the eyeball produces arterial pulse;
Graefe[292] in some cases describes a pulsating movement of interrupted
blood-columns in the veins, such as is sometimes seen in incomplete
embolism of the arteria centralis.
[Footnote 292: _A. f. O._, xii. 2, p. 210.]
RHEUMATISM AND GOUT.--In the older books on diseases of the eye we
constantly meet references to rheumatic and arthritic forms of
inflammation of that organ. In the later works on the subject the list
has been greatly reduced, partly because an anatomical classification
has been attempted, and partly because many such affections have been
attributed to other causes, such as syphilis, etc. Catarrho-rheumatic
ophthalmia, rheumatic iritis, rheumatic paralysis of the eye-muscles,
etc. have been so classified, not on account of their occurrence in the
course of attacks of acute rheumatism, but because the writers have
been unable to attribute them to any other source than that designated
as having taken cold. That recurrent attacks of iritis are frequent in
some individuals who have recurrent attacks of chronic inflammation of
the joints is a fact familiar to many practitioners, amply attested by
the cases published by Hutchinson[293] and by Foerster.[294] As regards
gout, the direct proofs of its relations to eye disease are still less
manifest, and most cases supposed to be attributed to this cause by
both the older and more modern writers are to be classed as primary or
secondary glaucoma.
[Footnote 293: "A Report on the Forms of Eye Disease which occur in
connection with Rheumatism and Gout," by Jonathan Hutchinson (_R. L. O.
H. Reps._, vol. vii. pp. 287-332; also vol. viii. pp. 191-216).]
[Footnote 294: "Beziehungen der Allgemein-Leiden, etc., zu
Veränderungen des Sehorgans," _Graefe u. Saemisch_, vol. vii. pp.
155-160.]
SYPHILIS.--All the tissues of the eyeball and eyelids may at times
manifest the signs of this dread and searching dyscrasia, although it
is {801} rarely so marked in its character as to be distinguished with
certainty from other forms of eye disease by its appearance alone.
Primary syphilis of the lid is rare, but when it occurs it is liable to
be mistaken for epithelioma, where there is absence of a distinct
history of infection. In the eyeball itself the uveal tract (iris,
ciliary body, and choroid) is the favorite seat of disease. Iritis is
said by Fournier[295] to be developed in from 3 to 4 per cent. of all
cases of syphilis, and, according to Coccius, 11-6/10 per cent. out of
7898 cases of eye disease in Leipzig were due to this cause. Syphilitic
iritis certainly constitutes a large proportion of the cases of
inflammation of the iris seen in hospital practice: Coccius places the
percentage at 46-6/10 per cent., while Wecker puts it at 50 to 60 per
cent. It usually develops during the subsidence of the secondary skin
affections, and is often to be distinguished by its insidious course
and the amount of plastic exudation which accompanies it. There is
ciliary injection and sluggishness of the pupil, with the formation of
synechiæ, before there is any very decided pain or photophobia, this
latter being usually strongly developed at a later period. The
formation of gummata in the iris, which are generally seen in the
smaller circle, is much rarer, generally developing in the tertiary
stage of the disease; occasionally they are developed in the ciliary
body. In the former situation they usually disappear under active
treatment, leaving fair vision in the eye, but when situated in the
latter place they usually lead to shrinking and atrophy of the eyeball,
even under the most vigorous treatment. When iritis occurs in infants
it is generally specific in origin. When they are born with posterior
synechiæ and complicate cataract, similar occurrences during
intra-uterine life may be suspected. Syphilitic choroiditis is
frequent, but its frequency is probably overrated on account of a
disposition to assume syphilis as a cause of cases of choroiditis in
which the pathology is not evident. Foerster has very properly pointed
out that a majority of the cases of disseminate choroiditis are not due
to this cause, and that the changes are developed slowly, and remain
stable for a long time even when not treated; while the usual form of
specific choroiditis shows rapid progress, with failure of the sight,
photopsies, vitreous opacities, hemeralopia, and zonular defects in the
field of vision. Opinion, however, is divided on this point: Wecker
thinks that two-thirds of the cases of disseminate choroiditis are due
to syphilis. In many of the chronic cases of syphilitic choroiditis
there is a wandering of the pigment out of the cells of the choroidal
epithelium, and a distribution of it into the lymph-sheaths of the
retinal vessels and capillaries, these changes producing
ophthalmoscopic appearances which closely resemble those of typical
pigmentary degeneration of the retina. Affections of the head of the
optic nerve and superficial layers of the retina, such as are
represented by Liebreich,[296] are much more rare, but the writer has
repeatedly seen them both at Liebreich's Paris clinic and in our own
hospitals. They are characteristic, and usually accompany the tertiary
symptoms. There is a dense haze which seems to lie partly in front of
the retina, and to extend around the disc for a space of one and a half
to two disc-diameters, generally including the macula lutea, and
rapidly diminishing as it approaches the equator. Vision is usually
much reduced, and even under persistent {802} antisyphilitic treatment
it is slow to clear up. Hereditary syphilis frequently manifests itself
in an interstitial keratitis, which begins with small
irregularly-rounded dots near the centre of the cornea. They gradually
become more numerous, and coalesce, until the membrane appears as if a
thin layer of ground glass had been imbedded in its tissue, leaving the
epithelium clear and bright. Although there is no ulceration, yet there
is a great tendency to the formation of new blood-vessels, which often
goes on until the entire cornea is permeated by them and becomes of a
dull venous blood-like red color. These vessels are continuous with
superficial and deeper shoots which pass in from the two layers,
normally forming loops in the corneal periphery. This form of keratitis
is usually accompanied by marked photophobia, pain, ciliary injection,
and low grades of iritis. The pathological processes which take place
in the cornea during the disease generally leave it more or less
clouded, and often much misshapen by softening and alteration of its
curvature.
[Footnote 295: Quoted by Foerster, _Graefe und Saemisch_, vol. vii. p.
189.]
[Footnote 296: Plate 10, Fig. 2, ed. 1863.]
TUBERCULOSIS.--Except in children, the eyeball is rarely the seat of a
deposit of tubercles, and even then it is much more likely to give
evidence of their seat in the membranes of the brain by its secondary
affection than to be itself directly affected by them. When they form
in the eye, they may affect the choroid, the intraocular end of the
optic nerve, the retina, or the iris. Jaeger was the first to call
attention to their ophthalmoscopic appearances. Their favorite seat, as
is well shown in one of Jaeger's plates, is the macular region and its
vicinity. They develop in the stroma of the choroid, and appear as
whitish-yellow spots varying from one-eighth the diameter of the optic
disc to the size of the disc itself, and by aggregation may form even
larger masses. They are usually seen in cases of well-marked acute
miliary tuberculosis, although doubtless they are often overlooked, on
account of not giving rise to any symptoms; besides, thorough
ophthalmoscopic examination of such sick and restless children is
difficult, and the general diagnosis is usually well made out from
other symptoms. They may, however, precede all other symptoms, as in
the cases reported by Steffen[297] and Fraenkel.[298] Development of
tubercular masses in the intraocular end of the opticus has been
described by Chiari,[299] Michel,[300] and Gowers.[301] In the case
cited by the last author the growth extended from the disc to the ora
serrata, which during life gave rise to the peculiar reflection from
the eye so often seen in intraocular tumor. According to Cohnheim,[302]
tubercle is to be found in the choroid in all cases of acute miliary
tuberculosis. Other observers, however, have not been able to support
him in this assertion: Albutt,[303] who repeatedly searched for them
both in living and dead subjects, failed to find them; Garlick[304]
during two years' experience at a children's hospital found them but
once; Heinzel[305] in ten cases of general tuberculosis in children was
at the autopsies unable to find any tubercles of the choroid. According
to Stricker, they may at times develop very rapidly, coming on in from
twelve to twenty-four hours. Tubercles have been {803} found in the
retina in the cases of papillary tuberculosis already referred to, and
also with cases of tubercle in the iris (Perls, Manfredi). At times,
tubercles in the iris occur in scrofulous and feeble children,
appearing as growths in all respects closely resembling syphilitic
gummata. As in the latter case, they are accompanied by severe iritis,
and at times with hypopyon. Tuberculosis of the conjunctiva is a very
rare affection. It is described as commencing with swelling of the
lids, and when these are everted exuberant granulations of the
conjunctiva are seen which are most frequently situated in the
retrotarsal folds. These granulations are at first of a grayish-red
color, but when they have existed for some time, superficial erosion of
their surface occurs, and uneven yellowish-red ulcers are formed. The
disease usually occurs in young people, and generally affects but one
eye. Haab[306] has given a description of six cases of it, with
reference to a few instances described by other authors.
[Footnote 297: _Jahresbericht f. Kinderheilkunde_, 1870 (Gowers).]
[Footnote 298: _Berliner klinisches Wochenschrift_, 1872, pp. 4-6
(Foerster).]
[Footnote 299: _Wien. Med. Jahrbucher_, 1877, p. 559.]
[Footnote 300: _Archiv der Heilkunde_, 1873.]
[Footnote 301: _Medical Ophthalmoscopy_, 1879, p. 250.]
[Footnote 302: _Virch. Arch._, 1867, Bd. xxxix. p. 49 (Foerster).]
[Footnote 303: Quoted by Gowers, p. 203.]
[Footnote 304: Quoted by Gowers, _Med. Ophth._, p. 200.]
[Footnote 305: Quoted by Foerster, p. 99, _Jahrbuch der
Kinderheilkunde_, Neue Folge, viii., 3, p. 331.]
[Footnote 306: "Die Tuberculose des Auges," _A. f. O._, xxv., 4, p.
163.]
Toxic Amblyopiæ.