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Accommodative Asthenopia is one of the first symptoms. Reading for any length of time gives rise to fatigue, though the patient can read No. 1 type. Soon distant vision becomes impaired, and bright light gives rise to dazzling. Later the patient becomes unable to see fine print, and he may suffer from photopsia and muscæ.
The author remarks that ocular symptoms are at first limited to one eye-the left eye in 60 per cent. of the casesbut they appear in the remaining eye after a period of two to six months, rarely after two or three years, and exceptionally after ten or fifteen years.
The Light Sense is early disturbed. The light minimum is normal, but the light difference is much higher than normal.
Colour Vision is very generally defective, and this may be the initial symptom. The defect is generally partial, and affects red, which appears black, and green, which appears grey. Erythropsia has been known to precede all other symptoms
Sensory Disturbances—periorbital neuralgia, and anæsthetic patches may occur at all stages of the disease, but as a rule they are noticed in the initial period. The pains are generally one-sided, and may simulate glaucoma. Anæsthetic areas may be found in the course of the fifth nerves. They generally follow in the course of neuralgias and hyperæsthetic patches.
Palpebral Myosis and Epiphora precede or accompany atrophy. The former may degenerate into a spasm of the orbicularis. The epiphora is common, and generally bilateral. It may be due to slight eversion of the lid or lachrymal hypersecretion.
Pupillary Changes.-Myosis or some myotic rigidity is present in half the cases. The pupil assumes an ellipsoidal
Argyll Robertson pupils are of great semeiological value in the early stages of the disease. Gowers's sign, which consists in the alternate contraction and dilatation of the pupil, has only a moderate diagnostic value, and is very often wanting.
The Ocular Muscles occasionally show clonic spasms, which are often confounded with mystagmus (Friedreich).
The Fields of Vision are generally normal in the early stages, and it is exceptional to find central scotoma.
Ophthalmoscopically, no appreciable changes are visible in the disc in the early stage. The first sign is generally some hyperæmia of the disc, whose appearance is more dull and less transparent. Sometimes the papilla is pale, and later on a bluish hue before any incipient atrophy can be said to have taken place.
When any of these signs have been observed, careful search should be made for others, and the diagnosis should be confirmed by a cytological examination of the cerebrospinal fluid, so as to establish an early diagnosis and apply prompt treatment, which has an infinitely better chance of success in this stage than in the atrophic stage.
The Treatment, which is highly recommended on the authority of Galezowski, Fournier, and others, is vigorous mercurial treatment, preferable by means of daily inunctions in doses of about 2 grms. This treatment should be continued for two years. By this means, cases relatively little advanced have been definitely stayed, whilst others have been sufficiently cured to allow them to resume their occupations for some years, whilst in others, though the symptoms have been favourably modified, the progressive evolution of the disease has not been interrupted. Antisyphilitic treatment has no effect in old confirmed tabes.
Nettleship (Royal London Ophthalmic Hospital Reports, October, 1903) points out that albuminuric retinitis is more apt to occur in chronic interstitial and chronic parenchymatous nephritis than in other forms of kidney disease. A few cases have been recorded in connection with lardaceous disease, in nephritis due to inflammation of the bladder, ureter, and pelvis of the kidney, and in some cases of acute nephritis of previously healthy kidneys, e.g., after scarlet fever. The chief exception, however, is seen in the albuminuric retinitis of pregnancy.
The nephritis of pregnancy is characterised by rapid degeneration of the epithelium (c.f. blood-poisoning). This may pass with unusual rapidity into a state of chronic nephritis and contraction. Chronic nephritis may, of course, be present before the first pregnancy. A more favourable prognosis is justified in pregnancy cases. The author's statistics show that of twenty-two cases of pregnancy retinitis, only one died within two years. Six others were known to have lived for from five to twenty-four years, and several of these had subsequent pregnancies. Of the pregnancy cases, therefore, at least 41 per cent. lived for two years or more after the retinitis was first noted, whilst of forty-two nonpregnancy cases 21 per cent. only lived for more than two years, and no less than twenty-five (59.5 per cent.) died within a year. "So that it seems that if pregnancy patients survive at all, say, two years, they are likely to live for several years, and sometimes for the full term of life."
As a rule, the retinitis of pregnancy occurs once only, and generally after several pregnancies and repeated attacks of pregnancy dropsy. When it occurs during the first pregnancy, subsequent pregnancies may occur without any return of the renal or eye trouble. Apart from pregnancy cases, renal retinitis is more common in the male than in the female (2-1), except in juvenile retinitis, in which the ratio is 10-14. The age of onset in both sexes ranges between thirty and sixty, the most common age being between fifty and fifty-nine. It would appear, from Nettleship's statistics, that the prospect of life is better when renal retinitis comes on after than before fifty-five years of age. The principal factors
in the production of renal retinitis are—
(a) A morbid state of the blood;
(b) A diseased condition of the retinal arteries.
The first condition is predominant in acute cases, and the second in less violent cases. In most cases both factors are concerned. The surgeon is justified in suspecting an early stage of granular kidney disease whenever he finds hyaline thickening of the retinal arteries and compression of the veins where they are crossed by the arteries, and especially
if the patient is comparatively young. In older patients this sign is not a reliable sign of chronic nephritis, but it must still be regarded as a sign pointing to the danger of possible cerebral hæmorrhage.
Gunn records some cases where marked arterial disease with albuminuria appeared quickly after influenza. He considers these to be cases of somewhat rapid poisoning similar to those occurring in pregnancy, but more acute.
Nettleship insists that there is only one sort of renal retinitis, and the varieties of appearances seen are only different stages and degrees of
(a) General oedema;
(b) Exudation into the nerve fibre layer; and
(c) Spots or patches of opacity in the deeper layers, due to degeneration of fibrinous or albuminous effusion in the inter-granule layer, and perhaps to changes in Muller's fibres.
The optic neuritis and retinal hæmorrhages so often present in varying degrees are not characteristic. The general appearance of the retinitis does not afford any guide to the kind of chronic nephritis which is the cause of it. West, however, considers that the inflammatory or exudative retinitis indicates parenchymatous nephritis, whilst the degenerative variety-star figures and white dots in the macular region-with little or no general retinal haze and often with decided thickening of retinal arteries, points to granular kidney. Diabetic retinitis closely resembles albuminuric retinitis in ophthalmoscopic appearances. It differs from the latter in the absence of the soft-edged or woolly patches and of the radially-arranged figures in the yellowspot region, and there is usually no oedema of the retina. The hæmorrhages so often present in diabetic retinitis are more often punctate and deeply seated than linear and superficial, as is usual in renal retinitis. The white deposits take the form of irregular masses or clumps rather than dots, and are often arranged in a more or less complete ring around the macular area. Though albumen is often present in the urine, as well as sugar, there can be no doubt but that
retinitis can be caused by diabetes alone. Diabetic retinitis seldom occurs before the age of thirty, and is generally noticed between fifty and seventy. The prospect as to life is better in diabetic than in albuminuric retinitis.
Renal retinitis, though generally symmetrical, may be unilateral, especially when hæmorrhage is the chief sign. Pigmentation of the retina, night-blindness, formation of new blood-vessels in the vitreous, choroiditis, and iritis have been noted in connection with albuminuric retinitis. Such signs are anomalous, and in no way characteristic of renal disease.
THE RELATIONS BETWEEN INTRA-OCULAR TENSION AND
J. Herbert Parsons and Thos. Snowball (Royal London Ophthalmic Hospital Reports, January, 1903).--In this series of observations the blood-pressure was taken in the femoral artery, and occasionally in the carotid of the side opposite to the eye observed. The intra-ocular pressure was taken by means of a fine canula inserted into the anterior chamber, and occasionally into the vitreous. This canula was connected with a Hürthle manometer and pressure bottle. Sources of variation in intra-ocular blood-pressure other than variable blood-pressure-e.g., contraction of the extrinsic muscles of the eye-were carefully eliminated. Stimulation of the peripheral end of the sympathetic in the cat was invariably followed by a rise in intra-ocular pressure, irrespective of any change in blood-pressure. This was found not to be due to vascular changes in the eye or changes in the iris, but to contraction of nonstriped muscle in the orbit; stimulation of the peripheral end of the fifth nerve gave no result. The blood supply of the eye in the dog and cat is mainly derived from the terminal branch of the external carotid (internal maxillary). Tying the external carotid cutting off the main blood supply to the eye-caused a slight rise in general blood-pressure, but a well-marked fall in intra-ocular pressure. Ligature of the internal carotid, which is much smaller than the external carotid, caused no change in intra-ocular pressure if the external was patent. Changes in general