MARCH 31, BRTTTSH 7 , 19341 MEDICALL Tns JOtURNAL 567

THE VALUE OF EYE SYMPTOMS IN THE DIAGNOSIS OF GENERAL DISEASES * BY HARALD G. A. GJESSING, M.D. DRAMMEN, NORWAY

It is often said that the ophthalmologist is merely a quently found it to be bilateral. Not uncommonly this specialist. This, however, I hope to be able to contradict. neuritis appears years before the other symptoms of this He is and must be-if he really wishes to fill his place- insidious disease: in the literature th'ere are cases up to a general physician just as much as the general practi- eighteen years. The 'in 'this neuritis is always tioner. Sir Archibald Garrod impressed this upon us in central. In this it differs from the intoxication amblyopias, his speech at Oxford in 1927. His subject was the con- where the 'always commence paracentrally. It nexion between internal medicine and ophthalmology. may arise not only in an acute but also in a subacut( "What is the difference between a specialist and a quack? and insidious chronic form. Authors differ widely as Just one little thing. The real specialist thinks always in a regards its percentage of incidence. The lowest figure general way. He therefore is able to understand the medical I have found is 13 per cent.,' the highest 70 per cent. process in question. The quack knows merely the symptoms, Personally, I believe 50 per cent. to be the right figure. and is therefore in danger of becoming a symptomatician." Passing palsies of the eye muscles not uncommonly Even if the eye is the most differentiated organ of the appear, either isolated or together with other symptoms, body, it is nevertheless merely a single, although a- very in multiple sclerosis. They are stated to occur in 25 to important, part of the united organs constitutin-g the 45 per cent. of cases. They may be one-sided or bilateral. animal body. In my lecture I hope to prove that- a series Most frequently we find paralysis of the abducens, not of symptoms in the eye are due to diseases somewhere uncommonly coupled with paresis of the facial nerve. else in the body. Thinking of the histology of the eye, The nuclei of these nerves are located,' as you remember, it must be evident that the pathology of the central below the floor of the fourth ventricle. Their root fibres nervous system is rich in eye symptoms. The visual run together with the pyramidal fibres through the pons, fibre system forms a continuity of axons from the ganglion which is the common- site of selection of the sclerotic cells of the to its ending in the pole of the accipital plaques. Therefore we frequently notice pheniomena from lobe. On its way it is in touch with a lot of very impor- these. Any facial palsy,'where all the chief branches are tant nerve nuclei. Because of this any pathological pro- engaged, should always make the physician think of a cess here is sure to show itself in the visual organ. In possible disseminated sclerosis as the underlying cause. passing, I must call attention to the transient pareses of Without doubt, a lot of the so-called " rheumatic " facial the eye muscles-especially of the abducens-in tabes, and abducens palsies are due to this disease in its earliest lues cerebri, encephalitis, and disseminated sclerosis. Still stages. At least such an origin ought to be kept in mind more important as a very early symptom in late syphilitic in all cases of passing eye-muscle paralyses, especially disease is the Argyll Robertson reaction. I think when they are coupled with " rheumatism " somewhere this is the first ocular eye symptom the young medical else in 'the body. Again, we must never forget tabes as student is taught when entering a general medical ward. a cause. The oculomotor and trochlear nerves are less It is superfluous to mention that an exact examination often attacked by the multiple sclerosis. Their nuclei are of the pupil reaction may often prevent the overlooking situated below the bottom of the aqueductus Sylvii, and of tabes in recurrent attacks of colic and vomiting. thus are above the pons. Recurrent , however, is often observed together with paresis of the internal rectus DISSEMINATED SCLEROSIS muscles. In tabes an isolated paresis of the fourth nerve Charcot taught that the cardinal symptoms of dissemin- is not uncommon as a very early symptom. ated sclerosis were scanning speech, intention tremor, and . No greater obstacle to the early diagnosis of EYE SIGNS IN this common disease could be met with than a reliance on Argyll Robertson were previously considered as this statement. This " classical " triad is found complete, a sure indication of an earlier metaluetic infection. At according to Marburg, in only about 15 per cent. of all the present time we know that this phenomenon may arise cases. Most of them are immature, " formes frustes." In in the different varieties of encephalitis. This disease is the Nordisk Medicinsk Tidsskrift (1929) I published a paper itself characterized by a number of eye symptoms ptosis, about the eye symptoms of this affection. I emphasized nystagmus, and paralysis of the are par- therein that if we still were to accept a diagnostic triad ticularly common, and these eye symptoms may make the this ought to be: (1) pronounced fatigue following insignifi- diagnosis infinitely easier. Time does not allow me to go cant body exercises and at the same time accentuation of more fully into details of the pupillary symptoms in symptoms already present (I hold that the symptom of general diseases. I merely note that, according to Uhthoff, Uhthoff-passing reduction of vision after a' short but in more than 80 per cent. of tabetic cases and in general quick walk-must come in this class); (2) increase of the paralysis in about 70 per cent. there is the characteristic tendon reflexes; and (3) passing eye symptoms, frequently reaction of Argyll Robertson. With lues cerebro-spinalis, with a recurring tendency. W. A. Adie reaches the same however, it is comparatively seldom noticed. In this conclusion in his excellent work in the British Medical disease an internal ophthalmoplegia, combined with palsies Journal (1932). Acute scotomatous retrobulbar neuritis of other cerebral nerves, is more often found. Defects of is the most important eye symptom in this disease. the field of vision-mostly hemianopic-are also com- Traquair characterizes this neuritis, in his noteworthy monly seen in cerebral syphilis. A distinct Doyne Memorial Lecture in 1923, in the following way. is always bound to attract the attention of the physician It commences quickly, and is of a changing tendency to a previous infection with the Spirochaeta pallida, or- during its run, ending' almost with complete cure of the as Sir -William Macewen showed so early as 184-if this initial attack. However, it is apt to recur. As a rule is excluded, to an increasing brain pressure, 'especially a it is one-sided, although in my experience I have fre- growth in the temporal lobe. On the contrary, an in- * Lecture delivered on January 5th, 1934, in Mlanchester, at the significant difference of the pupils with normal reaction is request of the North of England Ophthalmological Society. not rare. Probably this is brought about by traumata [3S21] t THE BRITI61 568 MARCH 31, 193413 EYE SYMPTOMS IN DIAGNOSIS OF GENERAL DISEASES MEDICAL JOURNAL

I during birth. Irregularities of the pupillary margin-- specialist. During a short space of time a psychosis developed without synechiae-have in earlier days been considered with sensations of inferiority. He died two years afterwards from had entirely for the diagnosis of cerebral lues. The impor- apoplexy. In the meantime, the important disappeared, and he grew hypermetropic again. taince of this has been overrated, except when it is coupled with disturbances of the pupillary reaction. Time does not allow me to enter into the different Spinal in tabes is frequently noticed owing to theories about these passing anomalies. With reference affection of the sympathetic in the spinal medulla. It is to the myopia I refer tp the work of Ask, published in the caused by secondary contraction of the sphincter pupillae, Biochemische Zeitschrift (1913). As to the transitory and may be very pronounced. As a rule it is one-sided. hypermetropia, I draw attention to Granstrom's great In this way it differs from the contraction observed in work in the Acta Ophthalmologica (1933). He seeks to certain chronic cases of poisoning-especially morphinism. prove that a sodium chloride retention is to be found in In this latter, however, there is always a normal pupil the in diabetics, causing a retention of fluid and reaction. In cases of one-sided miosis Horner's syndrome alteration of the index. Generally speaking, chemical -must always be remembered. As you know, this is alterations of the blood-speaking broadly-may be associated with tumours in the cervical region or even followed by eye symptoms. Of the greatest importance lower-for instance, aneurysm of the aorta-causing to the general practitioner is, I think, chronic conjunctiv- paralysis of the sympathetic. itis. WA'ithout using tonics we often are not able to cure this type of eye trouble, and there is no doubt that many EYE SIGNS IN INFECTIONS an eve doctor would have better results in his treatment colour Not only in lues cerebri and metaluetic diseases is the of if he were to investigate the index remarkable symptom caused by pupillary reaction of great diagnostic importance, but also of the blood. A anaemia in chronic as well as the fairly in a number of other brain diseases. The same is the conjunctivitis, is a oedema of the lids. This with an ophthalmoplegia interna. With a feverish commnon asthenopia, slight case is in the morning, disappearing later patient a paralysis of the pupil reaction as well as the mostly pronounced in the This is probably caused by the accommodation may be the single sign of a commencing day. peculiarity massage effect of repeated blinking. meningitis. In most of such cases, however, other cere- the last decade a many works have been bral nerves will also be affected. These pareses we find During great on the of alteration in the blood as an most often in luetic and tuberculous inflammation, and published subject cause of diseases. By using the Reid more seldom in otogenic meningitis. underlying eye Hunt acetonitril reaction it has been held that certain I have already mentioned that in certain chronic cases troubles are due to a hyper- of poisoning-such as morphinism-the size of the pupils eye (for example, ) iodaemia. This be of great practical consequence. may be altered, while their reaction remains normal. In a might We should in such cases be most careful in the use of number of acute toxaemias in febrile diseases there may or hormone prepara- be paralysis of the pupil. Especially well known is the iodides and thyroid extract other tions in our treatment of and arteriosclerosis. post-diphtheritic paralysis of accommodation. After an hypertonia is the first to have declared that glaucoma is no- influenza the same occurs, but not so commonly. Both Lagrange local but an evidence of a constitutional conditions give rise to a bilateral palsy. Cyclitis is not disease, merely state. and have formed the opinion infrequently observed after influenza. Here I may mention Magitot Angelucci that all are people with diseased vessels. that a number of acute infectious diseases, during their glaucoma patients term such a " un vascutlaire," an individual febrile stage, are accompanied by a more or less pro- They person with a disturbed circuit. Others, such as nounced conjunctivitis. During a measles epidemic, con- capillary von Hesse, and Meller, have sought the junctivitis is a most important diaginostic feature. It Eppinger, Leube, cause in a disturbance of the equilibrium between the may be the first prodromal symptom. Botulism, and and the They support the and fish poisoning, may all be followed by paralysis sympathetic parasympathetic. meat aggravate of the pupil and of other eye muscles. This is also the, opinion by the fact that psychic disturbances an also that sometimes, like case with grave gastro-enteritis and paratyphoid fever. existing glaucoma, glaucoma considerably when the The picture is similar to the one seen in acute general ophthalmic migraine, improves poisoning. patient is put on a salt-poor diet and gets sufficient atropine exercise to develop free perspiration. METABOLIC DISTURBANCES CHANGES IN THE RETINA It is well known that diabetes mellitus during its pro- the diseases of the retina, we find that in no gress may be accompanied by passing myopia as well as Taking are due to disease, not by transient hypermetropia. Every sixth diabetic has, small percentage they general a disease of the blood. An orbital haemor- as a rule, eye complications. Iritis with occurs uncommonly in infants and with black-red discoloration of con- It is, as regards the general condition, a very rhage seldom. and is not infrequently the first severe symptom. All cases of iritis ought, therefore, to be junctiva of a Moller-Barlow's disease, scurvy, or haemophilia. examined for sugar. Sigurd Hagen is probably the first sign An examination will very often disclose to have emphasized strongly that a transitory hyper- ophthalmoscopic a . All things considered, every metropia never arises in the case of an untreated diabetic. diathesis will tend towards bleeding in the On the other hand, a transitory near-sightedness is not haemorrhagic external as well as the internal parts of the eye. Haemor- inifrequently the very symptom causing the detection o, of the retina often appear with purpuric diseases, a previously overlooked diabetes. Of special interest is rhages taken. From life we know that persons the following case. The myopia reached here the highest generally daily exist who are liable to haemorrhages into the skin after figure I have noticed, afterwards completely passing away. small traumatisms. For this reason many a young girl On June 19th, 1920, a gentleman, 67 years of age, called at a dance resents what she considers too brutal a grip me to get spectacles. With + 3.5 the vision was 6/4 both on if such a tendency is present eyes. On October 12th, 1921, he returned again, because for from her partner However, the last eight days the vision had faded for d-istance. With his in the retinal vessels the- results are likely to be much spectacles for near vision he was just able to read. Used + 6.0. more serious. normal externa and interna were found. UTpon examination Pernicious anaemia is the typical blood disease generally The left eye showed emmetropia, the right 1.5 myopia. associated with retinal alterations, in contrast to the A proniounced positive sugar reaction was found in the urine --also traces of albumin. He was advised to see a diabetes secondary anaemias. These almost never lead to such. Here MARCH 1934 EYE SYMPTOMS IN DIAGNOSIS OF GENERAL DISEASES r THE BRITISH 569 31, j JOUNA - ~ ~~~~~~~~~~~~~~~ _

I except the very rare amauroses and amblyopias follow- ing the differential diagnosis, a very exact functional ing in the wake of heavy losses of blood. They are generally examination is of vital importance. In a real choked seen after abortions and haematemeses-much more in- disk the vision is, to begin with, less reduced than would frequently after a normal birth. Their clinical picture is be expected in view of the very pronounced ophthalmo- the same as that of embolism of the central artery of th(; scopic picture.' With inflammation of the the retina. At the peak of pernicious anaemia retinal haemor- vision is quickly reduced on account of a central scotoma. rhages are very rarely lacking. White degenerative spots -Trhie pseudo-neuritis of hypermetropia must always be are also commonly noted in the oedematouis retina. The kept in mind. There is n2o reduction of vision and no finding of these alterations is niot only of diagnostic but c'-ntral scotoma. Bleedings in the actual pupillary tissue also of prognostic importance. They may disappear witih- and the surrounding retina speak for choked disk and out trace when the patient recovers by the use of the liver against pseudo-neuritis. diet of Minot. In leukaemias-both the myelogenous and I cannot here enter further into a description of the lymphatic-there may be characteristic alterations ol embolism and thrombosis of the central retinal vessels; the eye. In the lymphatic type as well as in pseudo- I just want to point out that in more than one case the leukaemia we may have orbital tumours of lymphatIc dise-ase apparently starts with these affections. The tissue. For this reason all orbital tumours demand an ophthalmologist often chances on this condition in an exact examination of the blood. As youi know, the retina elderly patient calling to obtain reading glasses. An often reveals in leukaemia a characteristic light colour, exact examiination of his urine, heart, and blood pressure t-hus contrasting vith polycythaemia and congenital heart is required in such a case. It cannot be emphasized too failure. Anv fever of doubtful origin calls for ophthalmo- stroii-ly that an cptic neuritis must never be taken for a scopy. I just mention the diagnosis of septicaemia, morbus sui generis. This also applies to choked disk, in which is so very often difficult. Septic will, in which latter condition we must remember that more than these cases, make the diagnosis absolutelv conclusive. 80 per cent. are due to an intracranial growth. According to the literature it should be observed in about 35 per cent. of all cases. More than one case of maligniant HEMIANOPIA endocarditis has been diagnosed by aid of the ophthalmo- Although hemianopia has been known for a period of scope. about 150 years, its true significance has only beeni DIABETES AND NEPHRITTS realized since 1855. Barthelomeo Panizza of Padua then Two very common diseases in which the finding of proved clinically, pathologically-anatomically, and experi- retinal haemorrhages and exudative spots is of the greatest mentally that the location of the vision centre is the importance-not onily in the diagnosis but also as regards cortex of. the occipital lobe. I canniot here enter into prognosis-are nephritis and diabetes. The double- the importance of- the interpretation of the different types sidedness of the affection is characteristic of the retinal of hemiianiopias with reference to a fecal diagnosis I am picture. As a rule it is more developed in one eye than merely going to mention that the-bitemnporal hemianopic in the other. The papilla shares in the affection to a scotomata are a very early sign of tuniours of -the hypo- greater or less extent. In the retina are to be seeni physis. I take the occasion' to call attention to the oedema, scattered haemorrhages, and spots of white excellerit work of Traquair, regarding the initerpretation of exudates. These last are often arranged like a star in such scotomata. I must, however, 1) permitted to the macular region. The retinitis in nephritis and diabetes mention, very shortly, two cases from my own practice, is often without any symptom in its earliest stages. In where an exact scotoma investigation decided an other- this regard it is different from the usual optic nieuritis, wise difficult diagnosis. where the vision fails very rapidly on account of a central A very hypoclhonidriacal business mani in lis sixties had for scotoma. Therefore -ophthalmoscopy is of such great im- a number of years been a worry to his doctor. One day he portance in any case of nephritis, and especially in th- came to me telling me that he-iirabille dictu-was unable chronic cases. In particular, the retinitis in pregnancy to read types of ordinary size, while, oIn the contrary, he could read the smallest pr-int just as -wiell as before. -HeHdated' his may for a long time lack subjective symptoms. Upon troubles from a passing blindness lasting for about one minute examining 8,400 pregnant womien Ingolf Schidtz found three \%ee iks before.. Normal externlal and intfernal conditions forty cases of retinitis gravidarum. Of these twenty-seven were fouind. Nlision 6-/.4 O.U. The-peripheral field completely had chronic nephritis. Several of these had no subjective normal. Examined vithi the scottometer of -Ilaitz a right- sided wedge-shaped. hemi'anopic scotoma was founcd. It was symptoms. Their vision was 6 / 6 or about 6 6. The -about 5 degrees in,--length, anld lay w-!ith its edge, only one prognosis in retinitis gravidarum, he found, is good, or at dtegree from the fixationi point. It was absolute for colours least fairly good. The alterations of the retina genierally and relative for white. Up)on letting- the intfelligent man read disappear entirely after birth or when an evacuatiotn of the from right to left; he did so to hi's- own great. astoniishment. uterus has taken place. On the contrary, a usual retiniitis Here we have a case of the macular hemianopic reading albuminurica is a very bad prognostic sign. Elaborate disturbance of WVildbrand. Larger retinal pictures-in statislics from large clinics have shown that only 10 per this case printed matter-are covered by the scotoma. cent. of the affected patients are still alive more than two .Small retinal pictures are recognized between the fixation years after the appearance of the retinitis. And the prog- point and the edg-e of the scotoma facing them. The nosis is even worse the younger the individual is. Accord- case shows how careful one must be with the diagnosis of ing to Ascher the same may be said about the retinitis neurasthenia and hypochondria. But for the field in diabetics. This, like the iritis, appears only in grave examination-with small objects-the fresh complaints of cases. the patient mi-ght easily have been -indexed among his I must point out that even if the diagnosis of such a usual " nervous " ones. In this case, I think, a punctate neuro-retinitis is easy in some cases, it may in some pre- bleeding was really present in the left cuneus. A few sent very great difficulties. The papillitis may be so months later he suffered from a new passing amaurosis, developed that the displacement of the papilla may be showing considerably greater hemianopia. equal to the choked disk in a cerebral tumour. As these In the next case I am going to mention mental disease cases not uncommonly may show a star figure at the might easily have been- diagnosed but for the examination macula, even the most expert ophthalmologist -may go of the ophthalmologist. wrong. As in both cases albuminuria may be presenit, A painter, 54 years of age, was sent to me by a county and this periodically even may be absent in granulated colleague in March, 1920. It was stated that he had had kidney, the diagnosis may prove more difficult. Regard- hallucinations for a period of fourteen days after a short MARCH EYE IN DIAGNOSIS OF [THHEBRITISH ,570 31, 19,1,341 SYMIPTOMS GENERAL DISEASES IMEDICAL JO-URNAL unconsciousness. He imagined he saw the left part of the reom unconsciousness. He imagined he saw the left part of the room hold that vigorous antisyphilitic treatment has influenced filled with a number of whom he knew well I people, I this niystagmus in a favoura-ble direction. name. He himself had, however, an idea that I " I thing was a "! He admitted abuse of del'usion EYE SYMPTOMS IN POISONING denied lues. Upon investigation the eyes were normal,

ternally and iinternally. Vision wvith +1.5, 6/6 O.U. Tension Time prevents me from entering into the eye symptoms 5.5 O.U. By perimetry a typical homonymous hemian- which follow a number of poisonings. I merely mention opia was The entire left half of the fields founid. a few points about santonin poisoning. Here the ophthal- appeared, with only a large rest for the macula left. mologist may happen to fill the important role as legal- The cause of the hemianopia, as as of his well- Nyell physician. In the case of such poisoning-as also with developed hallucinations, is one and the same: a focus misuse of digitalis-xanthopsia not infrequently appears.

some right temporal lobe. This brain lesion kind in the Less well known to most of you may possibly be that must be subcortically located. It must be so placed that Bruneche has described hallucinations of red vision, it produces a state of irritation both of his optical centre rhodopsia, with this poisoning: " Everything is floating of memory as well as of his association province. It is in blood"! At the same time the poisoned person further necessary that the cortex cerebri must be un- describes terrible murder scenes! damaged, as it is able to transfer the hallucinations Acute poisoning from methyl alcohol is well known in consciousness of the patient. Before passing from tlle so-called " dry " countries. Acute gastro-enteritis

subject of the diagnostic of the hemianopias I must valuie supervenes-often some little time after the drinking. In merely mention that quite a few authors (for exa-mple, addition to this a rapidly developing amaurosis, resulting Ingolf Schiotz and Bauer) have demonstrated that passing from an acute degeneration of the ganglion cells of the homonymous hemianopias may arise in a number of retina, and a secondary atrophy of the optic nerve, is auto-intoxications, especially the nephritis in pregnancy. often observed. In the most pronounced cases an NYSTAGMUS aniaurotic loss of the pupil reaction is seen. The ex- trinsic eye muscles are always intact. In this respect In the beginning of my paper I mentioned nystagmus this poisoning differs from the similar picture in meat is a link of Charcot's triad in the diagnosis of dis- poisoning. Less well known is perhaps that clinical 3eminated sclerosis. Marbuirg holds that real nystagmus, picture described by Louis Ziegler in 1920. In Phila- however, is only seen in at most 12 per cent. of all cases. delphia society a number of young society women were Nystagmoidal are, according to seen tremblings BairTny, attacked by an insidious atrophy of the optic nerve. in 60 per cent. of normal people when looking extremely Over a long period they had taken eau-de-Cologne poured 3ideways. But even if this symptom is of no especial on pieces of sugar. The American scenits at that time diagnosis of the above-mentioned importance in the contained 25 per cent. of methylated alcohol. These lisease, it is, however, as expressedl by the Belgian Coppez, infinitesimal doses were not sufficient to produce the Une importance conside'rable en otologie, en neurologie common-poisoning picture. Where the Wassermann reaction et en generale." When he does not add "enl hygiene is negative and tumour may be excluded in a chronic optic ophtalmologie," although it is an eye symptom, it is in, atrophy, it may therefore be of interest to examine for my opinion to emphasize that the specialist must never formic acid in the blood and urine. It is also necessary be one-sided! He must never lose sight of the organism incases of chronic retrobulbar neuritis to think of poison- in favour of the organ. The otologist Adrian de Kleijn ing with lead or carbon disulphide, especially in cases ol

Utrecht is probably the man who has done the most of concentric shrinkage of the field. I pass over the acute B valuable work onnystagmus next to Robert rirany and quinine amaurosis in women endeavouring to cause Mario Camis. He meant to have a good reason for sacri- abortion. ficing two years in the stuidy of ophthalmology before DEFICIENCY DISEASES becoming purely an otologist. must of necessity be connected with a This is not the place to eniter upon the large subject retinal nutritive disturbance-not yet quite detected.

of general medicine. I merely mention that in this domain Here I exclude anatomical retinal diseases such as retinitis

'the British surgeons have produced works of the highest pigmentosa or siderosis. Only during the last few years

lasting. valtue. Thus the English doctor G-llot, in has the cause of this rather obscure condition been found. Sheffield in the year 18;58, described miner's nystagmus It is due to a lack of vitamin A. This circumstance -that is, threeyears ahead of the Belgian ophthalmologist explains whv cod-liver oil has such a good effect, and why

Deconde. As we in Norway h-ave no coal mines I have the spring fast-time predisposes to the outbreak of the not personally seein this disease. Later on, very impor- sickness. Such night-blindness is followed, moreor less, by tant studies on this subjectwere published in different xerosis conjunctivae. Suitable diet cures the trouble. countries. From the German side I only mention Much more dangerous is keratomalacia in infants. It Johannes Ohm; from the British, Maitland Ramsay, was the great paediatric star of Breslau, Czerny, togethet

Priestley Smith, sen., Elsworthv, Stanley Percival, and with Keller, who introduced the term "Mil.hnaihrschaden."

Maurice Barthon. Every one of them has held that it By this is meant that the infant is supernourished on ce n particularly withbad mine hbrgiene. In this carbohydrates. It is all right for three to six months, or Percival's blue-blindness pre- iiexion statement regardi'lg even longer. Then a conjunctivitis suddenly appears. To ceding thenystagmus is of theutmo-t hygienic importance. begin with it doesnot look dangerous. But an observant ThaLshock releases a latentnystagmus was demonstrated surgeon will even then notice the white spots near the during the world war by Elliot and Stirling. Priestley limnbus, described by Bitot. This xerosis rapidly spreads,

Smith has shown that certaini poisonis (for example, iodo- anid if the case is not properly treated necrosis of one

form and morphine) may play a part. This also indicated or both ccrneae may occur. In Norway this disease is

that the cerebrum muist have some nystagmogenous in- seldcm observed. In Denmark it was relatively frequent fluence. The fact that it is also seen in febrile diseases duiring the war. Here it was described by Professor Block points in the same direction. Before leaving nystagmus and Edmund Jenisen. But its real cause was first found I cannot but mention the great credit due to BArflny bv Saunte, and later studied by R6nne and Blegvad.

the finding of caloric nystagmus in the diagnosis of Supported by the findings of Monrad they have demon- number of braini diseases, especially acoustic tumours. strated the almost magic effect of sweet milk together

I also call- your atte-ntion to the fact that Igersheimer and wvith carrots and a little cod-liver oil. It may, though

Heine have found that in not a few cases of congenital seldom, attack adults living on a diet poor in vitamin A.

nystagmus the Wassermann reaction is positivve. They The aetiology of the phlyvctenule is greatly disputed.. rTHE ITtIS 571 - OF GENERAL DISEASES MARcH 31, 19341 EYE SYMPTOMS IS DIAGNOSIS MEDICAL JOURNAL L MEDI<:AL JOURNAL Some, such as Maitland Ramsay, hold entirely too bigoted -best helper, not only to the physician, but also to the a view that it is caused by a chronic digestive dis-turbance. surgeon. An examination of the field of vision is' always Others hold, quite as certainly, that the singular cause is strongly called for where amenorrhoea exists without any scrophulo- tuberculosis. One thing is sure. Bad hygiene " physiological " reason, or in impotence of a too early plays a great part in its pathogenesis by preparing the appearance. It is hardly too much to say that but for soil. Wessely has emphasized that patients suffering from his ophthalmological helper Harvey Cushing would not phlyctenular kerato-conjunctivitis are liable to catch have been able to build up his splendid technique as a catarrhs because of being supersensitive. However, the brain operator. diagnosis of phlyctenular conjunctivitis must always It is still disputed whether the syndrome osteo- remInd the doctor that the child does not belong to a psathyrosis idiopatica-fragilitas ossium-is due to an in- robust type. herited endocrine disturbance. This ailment is character- OCU!LAR TUBERCULOSIS ized by the triad: persistent blue , fragility of the A must always be regarded as a sign of a bones, and early labyrinth deafness. In any case the general disease when no external infection can be found. school physician finding a pupil with blue sclerae must Because of that a uveitis-and also the much more later on have his attention directed towards the ears and infrequent -is always reason enough for a close bones. internal examination. There is hardly any general disease The importance of trauma as a releasing factor with which may not be the cause of it. But tuberculosis and luetic parenchymatous is still sub judice. At syphilis are the predominant causes. The investigations least so much is certain, that it is not merely the vagrant Qf the last few years by Schieck and Werdenberg seem spirochaetes in the lymph streams in the corneal tissue to have proved that ocular tuberculosis must not be which are the cause. If so, it would be supposed that regarded as a disease sui generis. It is to be considered an energetic antisyphilitic treatment would prevent an as a metastasis in the eye. As a rule the glands at the attack'of the keratitis in the second eye. On the contrarv, hilus are the starting-point. As we do not know for this is rather the exception than the rule. There must certain what " rheumatism " really is, it is very probable therefore be an unknown x. Supported by a very minute that a number of cases of so-called " rheumatic " uveitis investigation, clinically as well as serologically-after are of a tuberculous origin. The entire chapter of " rheu- the method of Abderhalden-Zederkreutz, Johanson, and matism " has now to be recast. I may recall that a disease Enroth have attempted to prove that an endocrine dis- such as erythema nodosum was regarded as " rheuma- turbance may be found in more than 60 per cent. of all tismus acutus mitis cutis." Probably the general opinion cases of luetic parenchymatous keratitis. Investigations- is that it is a toxic skin affection in a tuberculous patient, particularly German ones-have 'demonstrated that about of the same kind as von Pirquet's skin reaction. It is 90 per cent. of all cases of deep keratitis are due to lues, held that it appears simultaneously with the manifestation especially congenital. According to von Michel tubercui- of a previously latent tuberculosis of the bronchial glands. losis is the cause of the remaining 10 per cent. In our But, on the other hand, we must remember that in a time of accident insurance it is certainly correct to accept certain percentage the reaction of von Pirquet is negativCe. Schieck's and von Szilly's opinion as to questions about It is advisable to maintain the old cause in those cases. the importance of trauma in keratitis parenchymatosa. In the same manner we must still believe in " rheumatic " Parenchymatous keratitis is due to two factors which act uveites in a not insignificant percentage. In this group together-infection + disturbed metabolism. An incidental we also include the gonorrhoeal cases, and these must be cause-such as a trauma-releases the disease. Before considered as due to metastatic inflammation. Thus any finishing my remarks on the disturbances of metabolism violent iritis in an adult-especially combined with pain and consequent eye symptoms, I merely mention the great in the joints-ought always to direct the physician's diagnostic value they have in Graves's disease. attention towards a Neisser infection as the cause. This is not the place to go into the differential diagnosis M. Piani (These de Paris, 1934, No. 29) states that in between tuberculous and syphilitic iritis. The Wasser- spite of the excellent climate, temperate winters, and mann reaction has greatly facilitated the diagnosis as mild autumns Corsica suffers considerably from three regards syphilitics when the clinical picture is typical. serious epidemic diseases-namely, malaria, undulant On the other hand, it may be more difficult in all cases fever, and tuberculosis. The almost complete absence of due to the and lack of education of to be quite sure about the origin of a tuberculous iritis. hygiene, poverty the native population, is to a large extent responsible Axenfeld and Stock particularly deserve the greatest for their spread. Malaria has always been prevalent in praise for their minute experimental investigations of Corsica, especially on the east coast, where it has assumed uveal tuberculosis. By injecting attenuated tubercle alarming proportions. The average parasitic index for bacilli into the ear veins of rabbits tuberculous nodules the whole of Corsica is 18.56, and the splenic index 38.84. were developed. The retina remained histologically free, These figures, however, do not represent the true state just as in miliary tuberculosis. They showed also how of affairs, as they are merely the result of investigations the not uncommronly recurring haemorrhages in the corpus carried out in certain parts of the island. Undulant fever In 1929 the annual vitreum in young-especially male-persons were caused is also remarkably prevalent. average number of cases was estimated at 200, while in 1932 by a periphlebitis. Often they succeeded in thus demon- 600 cases were notified. Corsica is one of the French strating directly a tuberculous process. In others they departments which pay the heaviest tribute to 'tubercu- had to suppose as cause a toxic effect. The most recent losis. During the period 1925 to 1930 the deaths from explanation by Meller, in regard to sympathetic oplh- the disease have more than doubled (140 deaths in 1925 thalmia, is that it is due to attenuated tubercle bacilli. and 291 deaths in 1930). The principal causes of the He has supported this clinically as well as experimentally. spread of tuberculosis are the almost complete absence of anti-tuberculosis services, the yearly return of a large MISCELLANEOUS CONDITIONS number of Corsicans who have contracted tuberculosis During later times the importance of the internal in France, the ignorance of the most elementary rules the to numerous cases secretory disturbances in aetiology and pathogenesis have of hygiene, and failure diagnose which are mistaken for undulant fever or malaria. been minutely studied. The description of these examina- Seasonal diseases such as pneumonia and pleurisy are not tions would call for an entire evening. I must restrict uncommon, owing to lack of precautions against changes myself to mention of the vast importance of eye symptoms in the winter. As regards mental diseases, constitutional in the diagnosis of tumours in the region of the hypo- states such as idiocy, imbecility, and cretinism are the physis. In diseases here the ophthalmologist will be the only conditions which are at all frequent.