H97 .-j^^ \. -"k^ .. CORNELL UNIVERSITY LIBRARY Gift of Dr. George M. Go\ild Deposited from the Van Cleef Litrary Digitized by Microsoft® __ . CorneJI University Library RC 201. H97 A clinical memoir on certain diseases of 3 1924 000 289 706 Date Due Library Bureau Cat. No. 1137 Digitized by Microsoft® This book was digitized by Microsoft Corporation in cooperation witli Cornell University Libraries, 2007. You may use and print this copy in limited quantity for your personal purposes, but may not distribute or provide access to it (or modified or partial versions of it) for revenue-generating or other commercial purposes. Digitized by Microsoft® Digitized by Microsoft® Digitized by Microsoft® A CLINICAL MEMOIR ON CERTAIN DISEASES OF THE EYE AND EAE, OONSEQDBNT ON INHEEITED SYPHILIS. Digitized by Microsoft® Digitized by Microsoft® A CLINICAL MEMOIR OS CEBTAIN DISEASES OF THE EYE AND EAR, CONSEQUENT ON INHEEITED SJPHILIS; WITH AN APPENDED OHAPTEE OP COMMENTARIES ON THE TRANSMISSION OF SYPHILIS FROM PARENT TO OFFSPRING, AND ITS MORE REMOTE CONSEQUENCES. f . BY '■ ■ , ' / •\J _ ■ JONATHAN gUTCHINSON, F.R.C.S., 8ENJ0B ASSISTANT-SURGBON AND LECTURER ON SURGERY AT THE LONDON HOSPITAL; SURGEON TO THE METROPOLITAN FREE HOSPITAL; AND ASBISTANT-6URGE0N TO THE BOTAL LONDON OPHTHALMIC HOSPITAL. LONDON: JOHN CHUECHILL, NEW BUELINGTON 8TEBET. 1863, H, Digitized by Microsoft® LONDOK : PRINTED BY ^AEBISON AND SONS, BT. MAETIN'S lane. i?N..\ Digitized by Microsoft® THB AUTUOB (aMONOST MASY OTHER ADMIRABLE WOKKs) OF " A TREATISE ON THB VENEREAL DISEASES OF THB EYE." William §ofomait, ^sq., Jf.§l.S., |, Jf. SteatfHto, ®sq., |. ®. f uIKe, @sq., (gjorgc ^atosort, €sq., MT SITKQIOAL COLLEAGUES AT THB ROYAIi LONDON OPHTHALMIC HOSPITAL, THIS WORK IS DEDICATED, IN SBATBFUL APPBEOIATION OP MANY ACTS OF KINDNESS AND ESPECIALLY OF MUCH VALUABLE ASSISTANCE AFPOBDED IN THB COLLECTION OP THB PACTS UPON WHICH ARE BASED THE CONCLUSIONS STATED IN ITS PAGES. Digitized by Microsoft® Digitized by Microsoft® TABLE OF CONTENTS. Inteoduohon PAGE. ix CHAPTER I. AouTB Ibitis dependent upon Hebbditaet Syphilis Cases I. to XXIII Stjmmaby* of Conclusions . . Tabulab Statement of Cases DIAON8SIB, Tbeatment, &o. Afhobisiis bespeotino the Disease 1 1 18 20 23 24 CHAPTER II. Chbonio Interstitial Kbbatitis . . Cases I. to CII Gbnebal Comments and Scmmaet Tabulab Statement of Cases Tbeatment, Pbognosis, &c. 26 31 109 110 125 CHAPTER III. Inflammations op the Choboid and Retina dependent dpon Hbrb- ditabt Syphilis Cases I. to XIY. 129 130 CHAPTER IV. On Cataeaot and Inflammation of the Viteeods Body in con- nexion with Inherited Syphilis .. .. .. .. ..150 Cases I. to III. .. .. .. .. .. .. .. .. 151 CHAPTER V. On the so-callBd Aquo-Capsulitis Casbs I to VI 154 156 Digitized by Microsoft® vm TABLE OP CONTENTS. CHAPTBE VI. On Amaubosis with White Atrophy op the Oraio Nerves is CONNEXION' WITH INHERITED StPHILIS . . . . . . . . 161 Cases I. TO VII 162 CHAPTEE VII. On Dbatness in Connexion with Inherited Syphilis . . . . 17i Cases I TO XXI 175 CHAPTER VIII. On Diseases oe the Ooulae Appendages when dependent upon Hereditary Syphilis 183 CHAPTBE IX. MlSOELLANEOrS CASES AND OBSERVATIONS 193 CHAPTEE X. On the means of eecosnition op the Sdbjbots op Hbebdito-Syphilis DURING THE TeRTIAEY StAGE .' 203 Aphorisms and Commentaries respecting CoNSTiroTioNAt Syphilis AND its transmission PROM PARENT TO OPPSPRINQ . . . . 206 APPENDIX. On Retinitis, Choroiditis, &o., in connection with Acquired Syphilis 223 Cases I. to XVII 224 Tabular Statement op Twenty-pive Cases . . . . . . . . 242 General Remarks, Diagnosis, Treatment, &o. 250 Index . . . . ' 255 Digitized by Microsoft® INTRODUCTION". The subject of inherited venereal taint in its causal re- lation to various diseases occuring in periods of life more or less advanced from those of infancy, has, for the last fourteen years, engaged my close attention. My interest in it was first awakened by a verysevere case of so-called "strumous'^ disease of the bones of the skull in a young gentleman whose mother had suffered from syphilis. The very important practical question was raised, as to whether any specific remedies should be used. I could find in books little or no information by which to be guided, in a differential diagnosis between the remote effects of hereditary syphilis, and those of ordinary " struma." The symptoms of syphilis, as met with in the infant, were well described, but nothing definite appeared to be known, as to the signs by which to recognise the sub- jects of taint at more advanced ages. Many authors ap- peared to suspect that this taint was really at the bottom of a large proportion of the so-called scrofulous diseases, but in none could I find any attempt, either to prove the fact, or to define the limits of its extent. Some cases which, during the years 1850 to '54, came under my observation at the City Hospital for Chest Diseases, and others amongst Mr. Startin's patients at that for Diseases of the Skin, convinced me that in young persons, in associa- tion with other suspicious symptoms, and with a peculiar physiognomy, it was not very unusual to meet with evi- dences of past Iritis. In 1852, 1 ventured to suggest in print, that Infantile Iritis was a more frequent disease than usually supposed ; the sug- gestion being chiefly based on thefrequentdiscovery of synechise in those too young to have suffered from acquired syphilis. Digitized by Microsoft® X INTRODUCTION. . In 1859, I read at the Edinburgh Meeting of the British Medical Association, a paper entitled "On the means of recognising amongst young persons the subjects of Inherited Syphilis." For some years previously, I had been in the habit of carefully noting, in all- suspected cases, the general condition of the physiognomy, and also of the interior of the mouth, examining especially the tonsils, palate, &c. In conducting these examinations, I had been led to notice the very frequent occurrence of malformed teeth. With the help of my friend, Mr. Coleman, who zealously undertook to make casts, &c., of the mouths, I soon accumulated evidence which led me to consider the state of the upper central incisor teeth, by far the most reliable amongs^; the indications of inherited taint. My conclusions on these matters, were embodied in several communications made to the Pathological Society during the sessions 1857-8 and 1858-9, and published in its transactions for those years. About the same time, the fact that the disease hitherto known as " Strumous Corneitis," was, in practice, never met with, except in conjunction with peculiarities of physiognomy and malformed teeth, came prominently before me. In 1858, I commenced in the Ophthalmic Hospital Reports, a series of papers on the general subject of Inherited Syphilis in its relation to Diseases of the Eye. Of these papers, the present work is a much extended reprint. The unintended delay which has taken place in bringing it out, I cannot regret, since it has enabled me to accumulate a large amount of additional evidence in reference to most of the conclusions therein advanced ; more than this, also, it has given time for other and far higher authorities to form their own opinions respecting them. I have now the great pleasure of being able to state, that the facts which appeared conclusive to my own mind, have also had the same effect on others who examined them without that bias, which almost necessarily warps more or less the judgment of one who sup- Digitized by Microsoft® INTRODUCTION. XI poses himself to liave noted something new. With respect to the " Strumous Corneitis/' Mr. Dixon, in his able article on Diseases of the Eye, in Holmes' system of Surgery, has stated his conviction that the syphilitic origin of this disease, has been so clearly established, that it is desirable to discard the old name, " and designate it by the shorter one of syphilitic keratitis." In reference to the degree of confidence which may be placed in the dental malformations, Mr. Paget has stated, in a clinical lecture at St. Bartholomew's, that he regards them as amongst the most trustworthy of all symptoms. That " chronic interstitial keratitis " is essentially an heredito-syphilitic disease, and that dental peculiarities, of a certain kind, are, when cautiously examined, a reliable indi- cation of inherited taint, are, indeed, the principal assertions met with in the following pages. That both should be re- ceived with incredulity, by those who have not had large opportunities for examining the facts, is what ought not only to be expected but strongly desired.* In the wish to place both on as strong a basis as possible, I have ventured to record, in considerable detail, a large number of cases. These will, however, it is hoped, have also another and a more extended use in illustrating various other questions in relation to the more remote effects of inherited taint. Some general conclusions on this matter, I have appended in a Chapter of Commentaries, on most of which, at some future time, I hope to adduce numerical evidence. For the present the reader is requested to accept them for what they may seem worth. * To any one inclined to test the correctness of these assertions I would beg respectfully .to insist on the necessity for great caution and attention to detail. In many cases with which J have bfien made acquainted, and which have been believed to be exceptional to my views, mistakes have been made as to the character of the dental malformations, the set of teeth affected, or the special form of ophthalmia. I cannot too strongly urge that I am in no way responsible for diagnostic errors consequent upon inattention to my descrip- tions. I should not make this remark were it not that the subject is one of great importance, and that I am very desirous not to mislead even the hasty. Digitized by Microsoft® Xll INTKODUCTION. It has happened to me to be accused of entertaining and endeavouring to induce in others far too wide suspicions as to the prevalence and injurious effects of hereditary taint, I must assert that no accusation could be less just. Very early, indeed, iu the history of syphilis surgeons, began to suspect that the inherited taint of this disease was most direfuUy and extensively influential. But there was no cer- tainty; all was vague conjecture.* The result of my en- quiries, upon my own, mind has been very much to limit niy belief in its extent. Whilst there are peculiar forms of disease which I believe to be its special results, I feel con- fident respecting the great majority of the chronic diathetic diseases of early life, that they have nothing whatever to do with it. As with acquired syphilis, so with the hereditary, it produces only its own special and peculiar results, and to the trained observer these are for the most part easily distinguishable from all others. In presenting this little work to the profession, I must not neglect to acknowledge my great obligation to my colleagues at the Moorfields Hospital for assistance given in the prose- cution of my enquiry. To Mr. Startin I am also much in- debted for the permission (some years ago) to take notes of cases under his care at the Hospital for Skin Diseases, and for much valuable information respecting them. My friend. Dr. Hughlings Jackson, has, throughout the preparation of the work, rendered me assistance of a kind and quality which I cannot too warmly acknowledge. * Modern authors of much repute have also, in many instances, adopted similar view s. M. Eicord has asked, " Is not all struma of syphilitic origin ! " and Mr. Erasmus WUson has repeated the same question, and extended it in detail to lupus, and several other special skin diseases. In the works of Daniel Turner and other old English surgeons similar hints are found. 4, Finghury Circws, January, 1863. ^ 'i '. 1 1 1 Digitized by Microsoft® ON DISEASES OF THE EYE, OONSBQUBNT UPON HEUEDITAHY SYPHILIS. CHAPTER I. ACUTE IRITIS DEPENDANT UPON HEREDITARY SYPHILIS. This affection was first described in connexion with its true cause by Mr. Lawrence, and it is, I believe, the only inflammation of the eye which has hitherto been recognised, with any degree of precision, as dependant on inherited syphilis. Since Mr. Lawrence's notice of it, cases have been recorded by Dr. Jacob, by MaunseU and Evanson, Mr. Walker, and Mr. Dixon. The latter gentleman espe- cially has given an excellent account of its peculiar features. I can, however, find but six cases on record, and, as my own experience supplies but sixteen others, it will be necessary to cite the whole in order to obtain sufficient data for trust- worthy inferences. Of previously published cases a short abstract will be enough. To commence with the earliest I shall take first the one recorded by Mr. Lawrence.* Case I. — Iritis of but one eye occurring in a syphilitic infant. Jane M., aged 16 months. Acute iritis of the left eye commenced at the age of 15 months. The iris lost its bril- liancy and assumed a dark tint. The pupil was a little con- tracted, and there was some intolerance of light. There was * Treatise on Venereal Diseases of tiie Eye, 1830, p. 306, B Digitized by Microsoft® 2 IRITIS IN INFANTS. some sclerotic redness^ and also the upper lid was slightly swollen. The infant had at the same time a vaginal discharge and flat condylomata about the anus and on the perineum. Its mother had contracted syphilis three months prior to her confinement. The infant, healthy at birth, was stated to have had afterwards purulent ophthalmia and an eruption on the skin. Mr. Lawrence employed a mild mercurial treat- ment, and states that the eye recovered completely. It must be noted as perhaps accounting for the unusually delayed appearance of the iritis, that the infant probably contracted the taint only very shortly before birth. Case Il.^Iritis of but one eye in a syphilitic infant. An infant, aged 11 months, of whose antecedents nothing more is stated than that its father had at the time a syphi- litic tubercular eruption. "Well marked iritis" occurred in one eye. No details are given. This appears to have been the only example of the disease which had come under the notice of the writers (Maunsell and Evanson) .* Case III. — Pupil obliterated by iritis in a syphilitic infant.f In this case the child did not come under Dr. Jacob's care until about three years after the inflammation. It then presented a soft condylomatous elevation at the anus, and numerous small fissures and clefts in the tongue. The diagnosis of syphilis was clear. No suspicion had, however, been entertained as to the true nature of the case previously, and the child was brought to Dr. Jacob to be cured of sup- posed cataract. On examination of the eye "the pupil was found contracted and adherent to an opaque lens and capsule. Vision was irreparably lost." The other symptoms dis- appeared under the mercurial treatment which Dr. Jacob adopted. The inflammation of the eye was stated to have occurred at the age of "a few months." * Practical Treatise on the Management and Diseases of Children. 1847' p. 534. ' t Treatise on Inflammations of tjie Eyeball, 1849, p. 97. Digitized by Microsoft® CASES. 3 Case IV. — Iritis of one eye in a syphilitic infant.* Mary O., aged 6 months, had been, when six weeks old, the subject of a copper-coloured rash on the hands and legs. It had been partially cured by medicine, but enough still remained to identify it. At the age of five months the right eye inflamed. The iris became muddy, and showed three or four whitish masses of lymph on its surface. The pupil was all but motionless : the conjunctiva and sclerotic were much congested, and the cornea hazy. After a fortnight's mercurial treatment both the iritis and the rash " had almost wholly disappeared.'' The attack of iritis had lasted altogether about six weeks. The next two cases are from Mr. Dixon's work, and were treated under that gentleman's care at the Moorfields Ophthalmic Hospital. Case F.f — Iritis of one eye in a syphilitic infant — Deposit of lymph on the capsule of the lens in the other eye — Recovery of both. Mary Ann W., aged 3 months. Healthy when bom, but at the age of seven weeks had a scaly syphilitic eruption. The iritis had set ia in the ninth week, and the acute stage had passed by, when, three weeks later, the child was placed under Mr. Dixon's care. The accompanying symptoms were, loss of the eyelashes, aphthae in the mouth, scaly eruption on the face, copper-coloured patches on the belly and thighs, and desquamation of the cuticle in different parts. Although both parents denied syphilis, yet the real nature of the disease was beyond doubt. It appeared that there had never been much congestion of the tunics of the eyes, the earliest symptom noticed by the mother having been "a pearly appearance in each pupil." The left iris was dotted over with grains of lymph, its pupil contracted and adherent. * Provincial Medical and Surgical Journal, 1845, p. 293. + On Diseases of the Eye, p. 149 Digitized by Microsoft® 4 IRITIS IN INFANTS. The right iris was clear, but on the capsule of the lens was a crescentic patch of effused lymph. Under a three months' steady employment of small doses of mercury, every trace of deposit disappeared in both eyes. The eflSciency of mercury in effecting the removal of lymph, which had evidently been some time effused, was very conclusively marked. Case VL* — Double iritis in a healthy -looking infant, but with a clear history of hereditary syphilis — Permanent occlu- sion of one pupil. William J. J., aged 4 months. Healthy when born, but when a month old had a dusky red eruption over the body, which disappeared under mercurial treatment. His mother owned to having had sores, followed by secondary symptoms, a few weeks before her pregnancy. When admitted under Mr. Dixon's care, the right eye only was affected. The child was then healthy, well grown, and lively, and displayed no other symptoms of syphilis. There was, however, '' a certain dusky tinge of the skin,'' which disappeared under the sub- sequent treatment. The iritis had existed only a week, and at first the mother had noticed the white of the eye to look " pinkish." AH sclerotic congestion had, however, passed away at the time of admission : the cornea was quite clear, but the lower half of the anterior chamber was occupied by pale yellow lymph. The pupil was misshapen, but the upper half of the iris was clear. Five days later, the eye was much worse, the iris being discoloured, and much additional lymph effused. The left iris was also slightly inflamed. Mercury was now commenced, and in about a month the effused ymph had been absorbed. The pupil of the right eye was, however, permanently occluded. In the left the restoration was perfect. The above six cases are all the examples of syphilitic iritis in infants I have been able to find recorded. The * Op. cit., p. 145. Digitized by Microsoft® CASES. 5 following are those which have fallen under my own obser- vation : — Case VII. — Double iritis in a syphilitic infant — Recovery of both eyes. Harriet H., aged 8 months, an illegitimate infant, was brought by her mother to the Hospital for Skin Diseases in July, 1853. She was wasted and cachectic, and about the anus were excoriated condylomata: there were also ulce- rated fissures extending from the alse nasi. Her mother was covered with syphilitic rash. It was stated that, when a few weeks old, the child was affected by severe shuffles, after which double otorrhoea and a rash on the nates occurred. The right eye only was affected at first. Its anterior cham- bers contained much brownish lymph, and the iris, where visible, was muddy and discoloured. There was a very faint sclerotic zone, and no intolerance of light. Mercurial treat- ment was at once adopted, and the lymph was slowly absorbed. The mother attended irregularly,, and two months later a slight attack of iritis occurred in the infant's left eye. Four months from the date of admission all lymph had been absorbed from both eyes, excepting that some slender adhe- sions of the pupillary margin remained in the right. The complete though slow absorption of so large a quantity of lymph was a result very encouraging to the long-continued use of mercury in similar states. Case VIII. — Iritis in one eye in a syphilitic infant — Result not known. Emily C, aged 3 months, attended in the out-patient's room at St. Bartholomew's Hospital, under the care of Mr. Wormald, in the summer of 1852. Her mother denied having had sores or other suspicious symptoms, but she had, she said, greatly lost her health since marriage, and had had one miscarriage. This was her first living infant. The child was stated to have been healthy when born, and to have Digitized by Microsoft® 6 IRITIS IN INFANTS. remained so until aged two months, when there appeared almost simultaneously an eruption of psoriasis on the face, patches of erythema marginatum about the thighs and body, aphthae in the mouth, snuffles and emaciation. Quickly following on these was inflammation of the left eye. The iritis had existed about a month when first brought under notice. The pupil was then irregular, fixed, and partially occluded by lymph. The iris was discoloured. There was no sclerotic congestion. A mercurial course was commenced, but the mother did not attend, and I am, therefore, unable to state the result. Case IX. — Slight iritis in a syphilitic infant who had been some months Under treatment — Perfect recovery of the eye. Christopher, T., aged 8 months, had been attending for four months, under Mr. Startin's care at the Hospital for Skin Diseases, on account of syphilitic rash, etc., before the iritis shewed itself. Mercurials had been ordered, but the attendance had been very irregular. His mother had also been under treatment for the same disease. This was her first living child. When born he was stated to have been healthy, but at two weeks old unmistakeable symptoms shewed themselves. They consisted in papular rash over the whole body, snuffles, and muco-purulent ophthalmia. AU these were nearly well when the iritis supervened. A zone of sclerotic redness was present during the first four days of the attack, but afterwards wholly disappeared. The iris became muddy, and of a sea-green hue, but there was no great eflFusion of lymph upon its surface. The mercurial treatment, which had been disused, was resumed, and in the course of a fort- night the iris was perfectly clear. Case X. — Iritis in one eye in a syphilitic infant— No treat- ment — Permanent occlusion of the pupil. Sarah P., aged 8 months, a pallid puny infant, was admitted under Mr. Wormald's care at St. Bartholomew's Hospital, on April 20th, 1855. Her mother had lost five Digitized by Microsoft® CASES. 7 infants with suspicious symptoms, and this was her only- one living. She was stated to have appeared quite healthy at the time of birth, but had begun to suffer from snuffles and rash on the skin when a fortnight old. There was a copious eruption of psoriasis on the body, a crop of condylo- mata around the anus, and the odour peculiar' to syphilitic children was very distinct. The right eye only had suffered. Its pupil was wholly occluded by a large deposit of reddish lymph, which had become organised. The cornea was unduly prominent. The disease had existed for some months, and no treatment had as yet been adopted. Unless restored at some future time by an operation for artificial pupil vision was totally lost. Case XL — Slight double iritis in, a syphilitic infard — Result not known. Alice Kate C, aged 3 months, was admitted under Mr. Critchett's care at the Moorfields Hospital, on Septem- ber 25th, 1855. Her mother had borne eight children, of whom this was the only one surviving. Six of the others had been stillborn, and one had died with well marked syphilitic symptoms. The patient was, according to report, and as is quite usual, of fair skin and very healthy aspect at the time of birth. When a week old, psoriasis of the palms and soles was. noticed, and shortly afterwards general psoriasis and severe snuffles. She was now a cachectic puny baby. The psoriasis for an infant was unusually well marked, the patches being thickly crusted with shining white scales ; it was also very symmetrical. The skin of the palms and soles was peeling ; all the lids were affected by tinea tarsi, and both irides, which were stated to have been blue, had assumed a sea-green colour. Both pupils were notched at their margins and had slender films of lymph attached to them, but there was no visible deposit of lymph on either iridal surface. A deli- cate pink zone was perceptible in each sclerotic when looked for, but might have easily escaped notice. A mercurial treat- ment was commenced, but the irregularity of the mother's Digitized by Microsoft® 8 IKITIS IN INFANTS. attendance prevented me from becoming acquainted with the result of the case. Case XII. — Iritis of one eye in a syphilitic infant — Anterior chamber wholly occupied by lymph — Result not known. Anna L., an infant Jewess, aged 3 months, was ad- mitted under Mr. Critchett's care at the Moorfields Hospital. Her mother denied having ever had venereal disease. Both her previous infants had, however, died, and she herself had fissures at the angles of the mouth of very suspicious aspect. Healthy at the time of birth, the infant was stated to have begun to snuffle on the third day, and it was now puny and wasted, with fissures at the corners of the mouth, and psoriasis over the arms, hands, and fingers. The right eye only was afi'ected, and had been inflamed for one month. The scle- rotic zone was now faint, but the pupil was wholly obliterated and the cornea rendered opaque by a mass of lymph which adhered to it and occupied the anterior chamber; the lids were inflamed. Mercurial treatment was commenced, but I lost sight of the case and have no further note of its progress. Case XIII. — Iritis of one eye in an infant, believed to be syphilitic — Permanent occlusion of the pupil. Emily W., aged 1 year, came under notice amongst Mr. Critchett's out-patients at Moorfields. Her mother denied having ever had any form of venereal disease. She had borne seven children, of whom three only were living ; the last five had all been born prematurely. Several had, she said, sufifered in infancy from severe and protracted snuEEles, but beyond this all suspicious symptoms were denied. The infant her- self was stated to have had a sore mouth and sore anus when a few weeks old ; she had never thriven, and, to use her mother's expression, " was still as much of a baby as at the time of birth ;" she was a little, puny infant, and the bridge of her nose was much expanded, but she presented no positive symptoms beyond the iritis. The right eye alone was in- fiamed, and two months had elapsed since the commence- Digitized by Microsoft® CASES. 9 ment of the attack, during which no treatment had been adopted. The pupil was occluded by^ reddish-yellow lymph, which appeared vascular and organised, and did not look at all as if likely to be absorbed. There was no material scle- rotic redness. Mercurial treatment (inunction) was prescribed, and, contraiy to expectation, in about two months absorption was so far complete that only a thin white membrane re- mained. The child had both grown and greatly improved in health during the treatment. It is intended shortly to per- form an operation for artificial pupil on the occluded eye. Case XIV. — Iritis. of one eye in a syphilitic infant — The other eye attacked eight months afterwards — Permanent occlusion of one pupil and much damage to the other eye. The subject of this case was a girl aged 2, to whom my attention was called by Mr. Wormald at St. Bar- tholomew's Hospital. The left eye had first inflamed at the age of sixteen months ; the attack being a pure iritis without any aflFection of the cornea; much lymph was effused, but the sclerotic congestion was but slight. Mr. Wormald ordered mercury, and under its influence most of the lymph was removed, leaving the pupil, however, permanently occluded. The treatment was pursued very irregularly, owing to the child's parents living in the country. After having ceased to attend for about six months she was ad- mitted for a second' time, on account of iritis of the right eye, with acute inflammation of the cornea, and a central ulcer which threatened perforation. Unfortunately, I have preserved no note of the other syphi- litic symptoms presented by the child ; I know, however, that they were unmistakeable. Mr. Lawrence as well as Mr. Wormald saw the case and coincided in the diagnosis. The mother confessed to having had syphilis, and if I remember right, had been herself treated by Mr. Wormald for constitu- tional symptoms. When I last saw the case, the inflammation was subsiding under specific treatment. It appeared certain, however, that the eye would be permanently much damaged. Digitized by Microsoft® ]0 IRITIS IN INFANTS. Case XV. — Iritis of both eyes in a syphilitic infant — Perma- nent occlusion of the left pupil — Operation for artificial pupil. James C, of Irish parents, aged 4 months. [This case as also cases 13, 13, and 16, were under Mr. Critchett's care, at the Moorfields Hospital, but the patients were, through that gentleman's courtesy, transferred to myself.] He was when born, to all appearance, a healthy infant, but at the age of one month began to snuffle badly, and was soon afterwards the subject of a scaly rash. After this the mouth and anus became very sore ; iritis set in when he was two months old, and began in the left eye. My note, on December 29, 1857, states " The boy still looks fairly healthy, but has bad snuffles and the remains of a rash. The left eye has been noticed to be inflamed for two months and was formerly ' bloodshot.' At present there is no sclerotic zone, but the pupil is occupied by a white film, and in the outer part of the anterior chamber is a large irregular mass of yellow lymph. The lymph is adherent to the cornea but the latter structure is not in itself involved. The mother is not aware that the right eye has ever been inflamed, but on inspection its pupil is seen to be irregular from adhesions, and the iris is decidedly dull." The treat- ment adopted consisted in mercurial inunction and was efi'ective in procuring the absorption of all the lymph, excepting that occupying the pupU itself He improved greatly in health, grew rapidly, and got fat. On June 7, the eye having been quite quiet for four months past and the process of absorption being evidently at a stand still, I determined,, with Mr. Critchett's concurrence, to attempt the reraoval^of the occluding membrane. Our decision against any longer waiting was chiefly grounded on the fact, that the eye was already beginning to assume those oscillatory movements so common in the eyes of young children when perception of light is lost. The occluding membrane was evidently very tough and thick and it was feared that unless light could be let in, the globe would Digitized by Microsoft® CASES. 11 not develope. The operation was accomplished by the simultaneous use of a cutting needle and Leur's forceps, introduced from opposite sides of the cornea. The opaque material, which was exceedingly tough, was seized by the forceps and then cut free at its margins by the needle. A good clear pupil was thus gained for the time. The subse- quent effusion of lymph will, however, necessitate recourse to the needle again at some future time. Case XVI. — Slight iritis of one eye in a syphilitic infant — Recovery of the eye, though with some adhesions. " Wm. John J., aged 9 weeks. Healthy when born, and remained so, according to his mother's account, until six weeks old, when he had ' smaU-pox' j after this his eyes in- flamed. Of the so-called small-pox not a single scar now remains, but the buttocks are covered with syphilitic eczema and ulcerated condylomata surround the anus. He has also snuffles. His mother looks ill and has an eruption of psoriasis. During the first week of pregnancy she had, she states, much soreness and pain in micturition and a bad discharge; after this her hair fell off; she has been liable also to cracks at the angles of the mouth. She is not aware that she has had any venereal disease, and has never been treated for such." The iritis in this instance was of the left eye only, and there was so little either of effused lymph or of sclerotic congestion, that several of those present were inclined to doubt my diagnosis. The use of atropine, however, removed all incredulity by leaving the pupil obhque and deeply notched in several directions. It was the peculiar green tint of the iris which had led^me to believe that it had been inflamed. All acute symptoms had evidently subsided. The lids were swollen, and there was some mucous discharge. Mercurial inunction was ordered and the, infant got rid of its rash. The iris also, to a considerable extent, regained its normal colour and brilliancy. The adhesions, or most of them, still remained at the time the child was last seen. Digitized by Microsoft® 13 IRITIS IN INFANTS. Case XVII. — Iritis in one eye in a syphilitic infant. James W.,- aged 14 months, was admitted an out-patient at the Moorfields Infirmary under Mr. McMurdo's care, on July 2, 1856, with iritis of the left eye. The inflammation had been going on for about three weeks. On examining the affected eye, the iris was found discoloured j there was a faint sclerotic zone and slight hypopyon. In the right eye there was observed a deep-seated yellowish appearance, as if from strumous deposit. The child was born at seven months, and looked sickly. Six weeks after birth there was an eruption of red spots, which the mother attributed to taint from the father. Hydrargyrum c. cretS, was prescribed in one-grain doses every night, and three minims of liquor cinchonse were given twice a-day. Alum lotion was also ordered to be used. July 5. The left eye very much better. Condition of the right unchanged. July 12. The left eye is still improving. The right continues the same. July 31. Doing well as regards the right. No improve- ment in the left. The child is now suffering from an attack of diarrhoea. The above notes were taken by Mr. Moon, who was at the time House Surgeon to the Hospital, and are unfortu- nately incomplete. Case XVIII. — Insidious attack of double iritis in a syphilitic infant — Partial exclusion of both pupils. The following case came under my notice a few months ago amongst Mr. Dixon's out-^tients, at the Moorfields Infirmary. A healthy-looking woman, florid, and not bearing the slightest indication of being the subject of specific cachexia, brought with her an infant who nearly equalled herself in its, aspect of good health. The infant was a girl, aged six months, and was believed by her mother to be nearly, if not quite blind. It was the discovery that she could not see, Digitized by Microsoft® CASES. 13 which had been made for the first time about six weeks ago, which had excited the mother's anxiety. On superficial ex- amination nothing was observed to account for blindness, though it was evident from the manner in which the globes were rolled, and the absence of steady direction of them, that the suspected condition was really present in consider- able force. It appeared on careful trials, however, that vision was not wholly lost. There was not the least conges- tion of the eyes, the irides were of normal brilliancy, and the pupils round. As just stated, the aspect of the infant was quite that of average health, the skin of its face, neck, and arms,.was perfectly free from rash or discoloration. I noticed, however, that the bridge of its nose was rather suspiciously broad, and this led to the question being asked whether it had suffered from snuffles. The mother replied that its nose had been " dreadfully stopped," and on further questioning it was ascertained that the child had ulcers on the nates, that it had, a few months ago, had a rash on the skin, and that two of its nails (thumb and forefinger), had come off " dry- like." The ulcers on its buttocks proved to be condylomata, about the anus of a most unmistakeable character. The mother admitted at once, on being further questioned, that she had contracted a sore from her husband about eleven months before the birth of her infant, that she had a rash and sore throat after it. No mercury had been given either to mother or child as far as could be ascertained. During the greater part of her pregnancy the mother had been attending the Victoria Park Hospital, under Dr. Edwards' care on account of repeated slight attacks of haemoptysis. She had, however, quite regained her health, and was now wholly free from specific symptomg. Mr. Dixon having obtained the above history, inspected the infant's eyes more closely, and discovered evidences of past iritis in both, some small tags of adhesion between the pupillary margin and the capsule of the lens existing in each. Atropine having been used, the pupils dilated very irre- gularly, but not sparingly, and a thin film of false membrane Digitized by Microsoft® 14 IRITIS IN INFANTS. was seen occluding the pupil almost entirely in each eye. The child had never before been under any medical care for her eyes, and the mother denied, most positively, having ever observed any signs of inflammation in them. She admitted, however, on its being suggested, that she had once for a day or two noticed them a little red, " at least a kind of pink." This was about two months ago. Case XIX.-^History of primary syphilis in both parents — Infantile syphilis in child — Acute iritis in right eye. Caroline W., an infant aged 8 months, was admitted on March 1, its right pupil being closed by red organized lymph. She was a puny child, with a large hydrocephalic head. The peculiar " snuffles " was well marked, and the mother stated that there had been a rash out on its nates and thighs, which was now well. It was an eight months' infant, but notwithstanding was when first born healthy looking and of good size. When three weeks old it began to fail and suffer from snuffles, and soon afterwards blotches broke out. The eye was not noticed to have anything the matter with it until two weeks ago and it had never been much bloodshot, nor has there seemed to be much pain attendant on the attack.- At present the colour of the affected iris was green, the healthy one being blue, there were no masses pi lymph excepting in the pupil itself which were quite closed thereby. The lymph was very red, there was when carefully looked for a faint sclerotic zone of redness, the cornea was quite clear. On being questioned, the mother, who was herself quite healthy, excepting being pallid and liable to leucorrhaea, stated that in March 1858, she had a miscarriage and about the saine time suffered from sores on the genitals, which her medical man said was due to disease from her husband. She had since had several bad sore throats, but no rash. Her husband an engine driver was' she said a fine healthy looking man, but she knew that he had lately suffered from a bad sore throat. The patient was their first living child.* * Med. Times and Gazette, 1859, Ap. 23, p. 420. Digitized by Microsoft® CASES. 15 Case XX. — Acute syphilitic iritis in the right eye of a syphilitic infant — History of syphilis in the father. Emma D., a fairly grown infant aged 4 months, was ad- mitted under my care at the Ophthalmic Hospital on May 7. Although of average size the nature of the disease was made manifest by most marked symptoms. She was covered with a copper-coloured scaly rash, had bad snuffles, and a sore mouth, with white patches on the tongue, her anus was also sore, and superficially fissured. She was stated to have been quite without symptoms at the time of birth and to have con- tinued so tUl a month old. The snuffles began in the fourth week and the rash showed itself in the middle of the third month. The mother was a florid and fairly healthy woman. She stated that she had never had any suspicious symptoms and that she knew nothing as to what was amiss with the infant until a medical man whom she consulted told her. After this she accused her husband who admitted having had "the disease" shortly before marriage. They had been married eighteen months, and this was the first child. The husband was stated to have been ever since the marriage apparently in perfect health. The iritis afi'ected the infant's right eye, the pupil of which was wholly closed by red lymph; there was no increased vascularity of the sclerotic, and the outer part of the iris was not obscured ; the cornea was quite clear ; a drop of blood appeared to have been recently extravasated into the lymph. The stage during which treatment could be expected to pro- duce restoration of vision had evidently passed by. Case XXI. — Acute iritis in a$well-grown child — The subject of infantile syphilis. M, L., aged 7 weeks, was admitted at the Moorfields Ophthalmic Hospital September 30, 1859. She was mode- rately well grown, and,, though pallid, not by any means approaching the condition of syphilitic marasmus. Her nates. Digitized by Microsoft® 16 IRITIS IN INFANTS. arms, hands, and face, were however covered with patches of copper-tinted psoriasis of unmistakeable aspect.. There was psoriasis plantaris, and the nails both of fingers and toes were all of them diseased, shrivelled, and in process of sepa- ration (syphilitic onychia). She had bad "snuffles." Her mother stated that when born the infant was fat and ap- parently healthy, and that she remained well until three weeks old, when the snuffles, eruption, etc., made their appearance. The state of the eyes was such, that by a cursory exami- nation the real nature of the disease might very easily have been overlooked. There was scarcely a trace of that zonular injection of the sclerotic which is so common a symptom of syphilitic iritis in the adult. It appeared that the child had been under mecurial treatment. The attack in the eyes had commenced ten days before, and, as the mother described it, " a circle had formed round the black spot of the eye." A Surgeon to whom she applied, ordered some powders to be taken night and morning. The left pupil had now cleared, but in the right some distinct specks of white lymph still remained". Both irides were muddy and deficient in brilliancy. There was no intolerance of light. Mr. Dixon ordered a quarter of a grain of calomel every night and morning. On September 24, the rash on the body was much better, and the lymph on the right pupil, with the exception of one little speck, was whoUy absorbed. The calomel was now suspended, and the mild mecurial ointment was ordered to be used every night. On November 3, the note states that the eyes appeared to have whoUy recovered. Atropine was used, and the pupils dilated fairly, without exhibiting any remains of adhesions. Case XXII. — Effects of double iritis, with history of syphilitic symptons, one pupil occluded — Disease of the vitreous body in the other eye. Anne R., aged 2 years and 10 months was admitted under my care on August 20, 1860. Her mother stated Digitized by Microsoft® CASES. 17 that the child was first noticed to be \AinA wheu five months old, but that no special attack of inflammation was ever observed, nor anything which directed attention to the eyes, excepting an eruption on the eyebrows. The mother had had no miscarriages; she lost one child older than the present patient at the age of two and a -half years, " from cutting her teeth." The present patient was the second. She was delicate from birth, and when a week old had " a rash all over." The rash only lasted a few days. Next it was supposed that her head was afi'ected. A Medical man prescribed some grey ointment to be used on a rag applied to the thigh, but it was only used for one day. She was told that nothing could be done for the sight, and had there- fore not applied at any Institution before. The following was the conditipn of the child's eyes, as noted on her admission. < Left Eye. — The pupil is almost closed by a dense white patch of lymph, from the centre of which rays extend to the iris in various directions. Only a very small aperture appears to exist in the upper and outer part. The pupil dilates a good deal with atropine, but is still occluded by adhesions. Riffht Eye. — When the pupil is widely dilated by atropine, ophthalmoscopic examination shows a moving white membrane deep in the eye which often rises in front of the pupil. There are numerous floating hair-like bodies seen in the vitreous humour. The lens and cornea are clear. Both irides are steel-grey and thinned. In this case the infant appeared to retain only perception of large objects, but it was difficult to estimate accurately her degree of vision. No direct questions were asked of the mother, but from the child's appearance and from the syjnptoms which had previously occurred there could be no doubt as to the diagnosis of hereditary syphilis. The condi- tion of the vitreous in the right globe exactly resembled what I have repeatedly seen in cases of deep-seated inflamma- tion of the eye consequent upon the acquired syphilis of adults. C Digitized by Microsoft® 18 IRITIS IN INFANTS. Case XXIII. — Iritis of both eyes in an infant — History of syphilis in its mother. My friend Mr. S. W. North,. of Tork, has mentioned to me the particulars of a case of infantile iritis recently under his care. The infant, was a girl, aged 7. weeks. Her mother, had been treated for syphilis hy.Mr. North, and had, sub- sequently given birth to, several dead born children. The subject of the case was her only living child. The iritis was severe in the left, eye, but the pupiljof the other was irregular, no doubt from the effects of inflammation which had passed off. The child suffered at the time: from snuffles and a characteristic eruption on the nates. Summary, of. the Twenty-three Cases. 1; Age. — The average age of the. patients at .the time the iritis commenced was five mouths and a half. The oldest was sixteen,. months at the time of the outbreak (Case 14), the youngest six weeks ; (Cases 21 and^23:). 3. Sex. — Five of the infants were males and sixteen;' females; the sex of the remaining two is not specified. 3. Eye attacked. — In Cases 3 and 4 there is no statement as to which eye suffered,,, but, in both it was one only. Of the others, both eyes ;sFere affected in eleven, the right alone in sesen, and; the left alone in three. We have, therefore, twelve cases in which but one and eleven in which both suffered. It is quite possible, however, that in some of the cases recorded as single, a transitory inflammation of , the other eye had occurred before the patient came under jobservation. 4. Phenomena of the attack — a. Congestion of tunics, etc. The pink zone of sclerotic congestion appears to have heen well marked in only two instances ; in ten others it was presenty but only faint and iU-charaeterised : in two cases no note on this point is recorded, and in, one it is expressly stated that, during the acute stage of the iritis, there was no increased vascularity of the tunics. In seven cases the acute stage had Digitized by Microsoft® SUMMARY OP THE CASES. 19 wholly subsided when the patient came under observation. In but three c^ses does it appear that any redness of the eyelids was noticed, b. Effusion of lymph. — If in those cases seen late, or in which the pupil was wholly occluded, it is fair to assume that there had been free effusion; we have fifteen cases in which the pouring out of lymph maybe said to have been copiousi Of the others, in four it was moderate, in three the iris was merely tumid and discoloured, 'whilst in one we have no note as to its state, c. Keratitic complication. — In one case the cornea is described as "hazyj" in one it ulcerated without any dififusied ' haziness ; ' in one it became prominent without haziness; and in one lymph effused into the anterior chamber becjame adherent to its posterior surface, its proper structure being unimpaired. In all the other cases (fifteen eyes) the cornea remained perfectly clear throughout the attack. In one case Mr. Moon's notes state that slight hypopyon occured. 5. Result to the organ. — In seven cases (ten eyes) the cure may be said to have been complete, every trace of lymph having been removed ; in two or three other cases it was complete^ excepting that slender adhesions remained. In three cases (four eyes) the result is not knpwn. In twelve cases one pupil was permanently occluded by org'anized false membrane. In nearly the whole of the last cases, in which the effusion was never absorbed, the patients came under care only at a late period of the disease, after the lymph had become organised and hut very little chance of its removal remained. To Cases 7 and 13, I may point as interesting illustrations of the efiSciency of mercurials in procuring the removal of lymph which already appeared to be vascular, and the absorption of which was by no means expected. 6^ Other symptoms of syphilis' present at the lime of the iritis. — ^In several of the cases the account of coexistent symptoms is either AvhoUy wanting or very imperfect. The specific cachexia is stated to have been present in twelve in- stances, and its having been absent is specially noted in five. Psoriasis of the general surface was present iu ten instances ; c 2 Digitized by Microsoft® 20 TABULAR STATEMENT OP TWENTT-THEEE Ho. Name, Hospital, SUrgeou, etc. Age. Farenta' Histoi;. Interval between Pr. Svph. in Parents and Birth of Child. WhichEye Affected f 1 JaneM.; 16 months The mother had contracted 3 months The left only Mr. Lawrence. syphilis three months he- fore her confinement 9 Sex not stated; Maunsell and Hvansou. 11 months Its father had at the time a tubercolai syphilide Probably short In one eye only 3 "Achad;" Dr. Jacob. A few months No details No details No note 4 MaryO.; Mr. Walker. 5 mouths No details No detaUs The right only 5 Mary Ann W. ; the OpUlial- mic Hospital. 9 weeks Both parents denied having had syphilis Not known Both eyes 6 William J. J.; the OpMhal- i months The mother had had sores, fol- 2 mouths (?) The right first; sub- mic Hospital. lowed by rash, a few weeks before her confinement sequently the left 7 Harriet H.; the Hospital for Diseases of the Skin. 8 months Mother covered with a second- A few months The right first, and ary syphilitic rash. Child two months later illegitimate and first-horn the later S EmilyC; St.Bartholomew'B. S months The mother denied all history, father not seen Not known The left only 9 Christopher T. ; Hospital for Diseases of the Skin. 8 months Mother under treatment for A few months One eye only a syphiUtic rash. A first- born child 10 SarahP.; St.Bartholomew's. 5 mouths The mother had lost five in- fants with suspicious symp- toms, and this was her only Not known (probably six years) The right only living child 11 AUce K. C; the Ophthal- 2 months Her mother had borne 8, 6 of Not known (probably seven or eight years) Both mic Hospital. whom were still-born, and one died with suspicious symptoms. The patient was the only living one 12 Anna L. ; the Ophthalmic Hospital. S months Two previous infants had died; the mother showed suspicious sores at the angles of the mouth All history denied ; but four Not known (probably two or three years) Right eye only 13 Emay W.; the Ophthalmic 10 months Not known (probably Bight eye Hospital. infanta had died with sus- several years) picious symptoms U A girl: St.Bartholomew's. 16 months The mother confessed to probably only a few Left first ; the riglil having had syphilis months, but un- certain wards 15 James C; Ophthalmic Hos- pital. 2 months No notes Not known Both 16 Wm. John J. j Ophthalmic 9 weeks Mother suffering from sus- Not known (probably a few months) Left only Hospital. picious symptoms, but not aware of primary sores 17 James W. ; Ophthalmic Hospital. (Mr. Moon's notes.) 14 months Father known to have had syphilis Not known Both 18 A girl; the Ophthalmic Hospital. 4 moiiths Both parents had had syphilis 11 months Both 19 A girl; the Ophthalmic Hospital. 7 months Both parents had suffered from primary syphilis four months before the iuiunt's birth 4 months Bight only 20 Emma D. ; the Ophthalmic Hospital. i months The father had had syphilis fourteen months before the infant's birth 14 months Bight only SI Mary L.: the Ophthalmic Hospital. Annie K. ; the Ophthalmic Hospital. 7 weeks No notes Not known Both 23 6 weeks None obtained Not known Both 23 A girl under the care of Mi.S.W. North, of York. 7 weeks Mother had had syphilis Some years Both Digitized by Microsoft® 21 CASES OF IRITIS IN SYPHILITIC INFANTS. ' Symptoms present at the time in the Infant. Treatment and Kesult. Kemasks. Vaginal discharge and condylo- ^ mata at the anua yNo details given Jifo details. The child had un- '^ mistakeahle symptoms when under notice A copper-coloured rash, of four months' duration Scaly, copper-coloured eruption ; loss of eyelashes; peehug of f cuticle ; sore mouth lA dusky, red eruption l^maciation; cachexia; ulcerated % condylomata Snuffles; emaciation; soremouth; syphilitic psoriasis Had heen attending for 4 months on account of a sy^ihilitic rash, I which was disa]^peanng Syphilitic psoriasis ; condylomata ; emaciation Emaciation and cachexia; syphl- s,litic psoriasis; tinea tarsi; psoriasis palmaris !] in 1853, I showed to a friend of mine, who had then for fifteen years held a Hospital appointment, which brought under his notice vast ntimters of the poor, the first case of syphilitic iritis in an infant which he had seen. The disease was new to him, and he was much interested in it. Since then he has had, in exactly the same field of observation^ no fewer than five cases. Yet in proof, that, however care- fully looked for, it is really very rare, I may mention, that during seven years' practice at the Metropolitan Free Hospital I have never treated a single case in connexion with that Institution, although numbers of congenito-syphilitie patients present themselves, and I have scmpulbusly looked at the eyes in all. DIAGNOSIS, TREATMENT, AND PEOGNOSIS. On account of the very slight symptoms which often attend it, iritis in the infant is very liable to be overlooked. Its diagnosis however, when once attention has been called to the little patient's eyes can scarcely be considered difficult. In two cases however, I have known considerable difference of opinion to prevail as to its existence. These were cases in which the iris was simply tumid and discoloured, in which no perceptible masses of lymph had been effused, and no congestion of the sclerotic vessels existed. In each instance by the use of atropine I was enabled to demonstrate great Digitized by Microsoft® 34 IRITIS IN INFANTS. irregularity of the pupil; and thus to remove the doubts of those -who had at first hesitated to concur in my diagnosis. In like cases the employment of the solution of atropine should always be resorted to. It will also often be necessary in young infants to use a spring speculum to keep the lids open in order to procure a satisfactory inspection. Irregu- larity of the pupil, the presence of -white, yellow, or red lymph, tumidity, loss of lustre, and alteration of colour in the iris itself are the symptoms upon which the diagnosis is to be based. Generally also there wiU be seen on minute inspection a faint pink zone in the sclerotic. There is very rarely much congestion of the conjunctiva and the cornea is almost always clear. The measures of treatment are simple. The daily use of atropine drops* to dilate if possible the pupil, and the rapid exhibition of mercurials are the two all important measures. I usually employ the mild mercurial ointment, direct- ing it to be rubbed into the soles of the feet, nape of neck, and calves of legs, about a scruple being employed daily. The infant's general health should be carefully watched and instructions given as to a proper dietary. Syphihtic infants need animal food in the form of broths, beef tea, etc., at an earlier age thg,n others. If there be diarrhoea, or if the mercurial induce it, a carminative draught containing opium may be given, but the mercurial must not be laid aside whilst any lymph is present in the pupil, unless the child's state should absolutely necessitate it. In these cases, however, mercury almost always agrees well and the infant gains flesh under its use. The prognosis of these cases depends upon the stage at which they come under treatment. If the lymph is recent, however free its effusion may have been, absorption may be confidently expected under the mercurial treatment. If indeed it be of some weeks' duration, and already organized, mercury will yet in some cases effect wonders, and in almost * One grain of sulphate of atropine to an ounqe of distilled water. Digitized by Microsoft® SUMMARY OP THE CASES. 25 all it is worth while tq give it a fair trial. A cautious opinion must always be given as to the restoration of the child's, sight, since it is very possible that disease of the vitreous or retina may co-exist. In cases in which the pupil has been excluded and no hope of improvement by constitutional treatment remains, much may yet be done by the instru- mental removal of the false membrane. I have but limited faith in mercurial treatment as prophylactic either against this or any other of the pheno- mena of infantile syphilis. A great point will, however, have been gained if the attention of the profession generally is directed to the occasional occurrence of this insidious affec- tion, and to the efficiency of mercury in its cure. APHORISMS RESPECTING IRITIS IN INFANTS. 1. The subjects of infantile iritis are much more frequently of the female than the male sex. 3. The age of five months is the period of life at or about which syphilitic infants are most liable to suffer from iritis. 3. Syphilitic iritis in infants is often symmetrical, but quite as frequently not so. 4. Iritis, as it occurs in infants, is seldom complicated, and is attended by but few of the more severe symptoms which characterise the disease in the adult. 5. Notwithstanding the ill-charcterised phenomena of acute inflammation, the effusion of lymph is usually very free, and the danger of occlusion of the pupil great. 6. Mercurial treatment is most signally efficacious in curing the disease, and, if recent, in procuring the complete absorption of the effused lymph. 7. Mercurial treatment previously adopted does not prevent the occurrence of this form of iritis.* * In many of the cases the patients had preyiously been treated by mercury for other symptoms of hereditary syphilis. In one instance the second eye was attacked while the patient was taking mercury for the cure of iritis in that first affected. This I have known occur more than once in adults. In the latter, in five instances I have seen acute syphilitic iritis set in during actual ptyalism. Digitized by Microsoft® 26 INTEESTITIAIi KERATITIS 8. The subjects of infantile iritis, though dften puny and cachectic, are also often apparently in good condition.* -9. Infants sufferingfrom iritis almost always showoneor other of the well-recognised symptoms of hereditary taint. 10. Most of those who suflfer from syphilitic iris are infants horn within a short period &£ the date of the primary disease in their parents. CHAPTER II. CHRONIC INTEBSTITIAL KEBATITIS. This form of keratitis, respecting which I hope to be able' to sustain the proposition that it is almost always a direct result of inherited syphilis is a well-marked disease^ the individuaUty of which has long been recognised. In Dr. Mackenzie',s excellent work he devotes a section to it under the name of " Scrofulous Corneitisy" and states tha/t " it is spe- cifically diffeirent from every other ophthalmia.'* Dr. Jacob, in his " Inflammations of the Eyeball," gives a description of it which, as with all that comes from his pen, bears the stamp of careful observation ; and more recently, Mr. Dixon, in his work on " Diseases of the Eye," and Mr. Critchett, in his pub- lished Clinical Lectures, have devoted special attention to it. The manner in which, by interstitial deposit, the cornea is made to assume the appearance of ground glass; the absence of ulceration, and of any tendency to pustules ; the comparatively small amount of sclerotic or conjunctival con- gestion ; — are facts in its history as to which all observers agree. Nor is the testimony of writers much less unani- mous as to its being hardly ever met with except between * The more ill-nourished of the gubjects of hereditary syphilis are cer- tainly not those most prone to iritis. In several of the cases given, the pa,tients, despite the presence of indubitable indications of herediiary taint, T^ere in remarkably good condidon. The puny class of syphilitic infants, are those in whom the disease falls with its chief stress on the organs of assimila- tion, on the mucous surfaces, or very severely on the skin. Digitized by Microsoft® ITS SYPHILIIIC OKI GIN. 27 the ages of fiye £^nd eighteep,— as to its almost invariably affeqting first one.^e and thea the othef,— as to its (being usually of very slow pi;ogress,— or, lastly, as to the faqt that the ultimate result is almost alw^s very much better than could have bqqn hoped for, judging from the condition of the coi-jt^e^ in its early stages. I may here premise that to tho^Pv^viho^efiqld of observation does notinQlude an ophthal- rnic l^Qgpjital it is a very rare disease. As some gauge of its infrqqi^iqncy, I .may mention that at the Metropolitan Free Hospital, where the average daily admission of new surgical cases ^s b^t^veen twenty and thirty, I have not had to treat niore than one case a yeiar. The .description of the class of patients in whom this disease .usually presents itself is given by D.r. Mackenzie in terms which, whilst they bear evidejace to the closeness of the clinical observation from which he wrote, are also of very great value to my argument, as being the testimony of one who had no theory to support. He writes,- — f^The subjects _pf g|Crpfu^ous corneitis ape in general from .eight to eighteejj yea^s pf agej and in the female the complaint frequeiitly appears in connexion with amenorrhoea. In the female as Tifpll as the male, ^he sjkin of those affected with corneitis i? peculiafly coarse and flabby, with the sebaceous follicles of the face much developed, and I have in many instances pljsprypd it cqijicidjent with a peculiar hoarse-, ness of voice, pthpr scrofulous symptpuis are generally preseut, especially sjjKoln lyjiiphaj;ic glands under the jaw, and uodqs PO the tibia." Having niade so accurate a gener- alisation qf its diatjietic concomitants. Dr. Mackenzie has evidently approached very closely to the discovery of the real nature of this peculiar form of ophthalmia, and one cannot but feel surprised that he should have missed its ex- planation. I will not make so s\!iteeping an assertion as that interstitial keratitis of typipal fijrm never occurs but in the subjects of inherited taint, yet I cannot conceal from myself, and have no wish to do so from my reader, that such is my present beliqfi I havp proved it now in so many Digitized by Microsoft® 28 INTERSTITIAL KERATITIS. cases to the full satisfaction of much more able observers than myselfj and have waited so long without either finding myselfj or being shewn by others an instance in which no grounds for such a diagnosis existed, that the attitude which my mind has involuntarily assumed is as just stated. It seems, moreover, improbable that a disease, very peculiar in its features, differing greatly from all its congeners, both in its symptoms and its progress, should acknowledge a specific cause in nineteen instances, and in the twentieth present precisely the same phenomena in total independence of such origin. It is only fair that I should ask of those who are inclined to test the accuracy of this opinion that care be taken in the diagnosis. Only typical cases of chronic diffuse keratitis must be chosen, for although the affection is un- mistakeable to the practised observer in a great majority of instances, yet it has like all other diseases a border ground on which errors may easily be committed. In certain cases of diffuse corneal inflammation occurring as a sequel to small pox or some other of the exanthems, I have observed a combination of symptoms more or less closely simulating that presented by some of the less characteristic examples of the disease in question. I have never, however, in any such instance, witnessed a simulation of the typical and more common form of the latter. As I have done in the case of Infantile Iritis, I shall append to the series of cases which is to follow a statement of the numerical frequency with which the different phenomena of this disease were actually pre- sent. I shall also attempt to elucidate in the same manner several other facts respecting its progress and events. It will be convenient, however, here to introduce a brief enu- meration of its symptoms, etc. Chronic Interstitial Keratitis usually commences as a diffuse haziness near the centre of the cornea of one eye. There is at this stage no ulceration and exceedingly slight evi- dence of the congestion of any tunic. The patient, however, almost always complains of some irritability of the eye, as well Digitized by Microsoft® ITS SYPHILITIC OEIGIN. 29 as of dim sight. If looked at carefully, the dots of haze are seen to be in the structure of the cornea itself, and not on either surface j they are also separate from each other like so many microscopic masses of fog. In the course of a few weeks, or it may be more rapidly, the whole cornea, ex- cepting a band near its margin, has become densely opaque by the spreading and confluence of these interstitial opacities. Still, however, the greater density of certain parts, — centres, as it were, of the disease, — ^is clearly perceptible. Early in this stage, the comparison to ground -glass is appropriate. There is now almost always a zone of sclerotic congestion, and more or less intolerance of light with pain around the orbit. After from one to two months, the other cornea is attacked and goes through the same stages, but rather faster than the first. A period in which the patient is so far blind that there is but bare perception of light now often follows, after which the eye first affected begins to clear. In the course of a year or eighteen months a very surprising degree of improvement has probably taken place. In milder cases, and under suitable treatment, the duration may be much less than this and the restoration to transparency complete, but in many instances patches of haze remain for years, if not for life. In the worst stage, the corneal surface looks slightly granular and from the very beginning it has lost its polish, and does not reflect ima;ges with definite outlines. In certain cases after the ground-glass stage is passed, a yet more severe one ensues, in which the whole structure of the cornea becomes pink or salmon-coloured from vascularity, and in these, crescentic fringes of vessels are often noticed at its circumference. In the best recoveries the eye usually remains somewhat damaged as to vision, and often a degree of abnormal expansion of the cornea is apparent. Only in one or two cases have I ever observed ulcers of distinguishable size on the surface of the cornea, and I have scarcely ever seen pustules on any part of it. My reasons for believing that this disease is dependent upon an inherited syphilitic taint are the following : — Digitized by Microsoft® 30 TNTEESTITIAL KERATITIS 1. Ttat in certain instances patients whom I knew befoie- ha-Hfl to be tte subjects of inherited disease have, whilst under my'obseirvatioii, been attacked by it. 2. That in a lar^e nutnbdr'of other cases I have obtained from -the parents df the patient a free confession as regards themselves and a distiirc* history of specific symptoms in the child during-infaricy. ' 3. That in almost all cases the silbjects of it present a very' peculiar ph'^sibgnbmy, of which' a' coarSe flabby skin,' pits and scars on the face and folrehead, cicatrices of old fis- sures at the angles of the mouth, a sunken bridge to the nose, and a set of petrdanent teeth pSciiliar for their smallness, bad colour, and the verticalli/ riotcJied edges of the ' central upper incisors, are the most striking charabters.' 4i That in many cases one or more of the following sus- picious forms of disease have either been coincident with it, or have occurred previously: — ulcerative lupus, nodes on the long bones, psoriasis on the face, oto'rrhoea, chronic enlarge- ment and stibsecfuenH; atrophy of the tonsils, ulcers in the throat/ a thickened condition of the parts under the tonjgue, and chronic ien'gbrgements of the' lyinphdtic glands.* 5. That the eflFect of specific treatment in mitigating the severity of these inflammations, and in shortening their dui'ation,' is sometimes very marked, whilst ' mere tonic and dietetic plaaisare of comparatively little avail. 6. That it is often either accompanied or preceded by iritis, t" 7; That it is often followed by certain changes in the cho- roid which are frequently seen in hei-edito-syphilitic patieiits. * For a more full account of the symptoms upon whiph, in the child or yoiiiig adult, a diagnosis of hereditary syphilis may be baked, the reader" ia referred to a paper by the writer in the "Medical Times and Gazette" for September, 1858. A yet more detailed description of i 74 INTERSTITIAL KERATITIS. Joseph E., is the fourth of the family, and also suffered from suspicious symptoms in infancy. He has one younger sister, who is reported to be healthy. His mother has lost only two, one of which was a stillbirth and the other died of brain disease at the age of ten weeks. Joseph B,., continued under my care for upwards of two years. He took a long course of the bichloride in small doses, but with scarcely any benefit. The iodides were also used. The deposits were, however, too well organized to yield, and he gained only sufficient sight to see shadows. No relapses of inflammation occurred. At length as his condition was evidently hopeless ; he was (January, 1861), sent to a Blind School. It is the only instance of permanent blindness, as the result of keratitis, which I have seen. Case LVI. — Permanent opacities after a severe attack of interstitial keratitis — Characteristic physiognomy and teeth. Louisa W., aged 17, a pallid girl of flabby tissues but well grown, was admitted under Mr. Dixon's care nearly three years after the first onset of the disease. The attack had evidently been a most severe one, and had left large permanent opacities in both cornese which greatly interfered with sight. In the right eye Mr. Dixon performed an opera- tion for displacement of the pupil in order to bring it oppo- site a clearer part of the cornea. Great benefit was obtained. The right eye was the first attacked but the left soon followed. This was about three years ago. She attended a surgeon who, according to her account, admi- nistered medicines which made her mouth very sore. For six months she was so nearly blind that she could- only just see the light. Her aspect and teeth, the latter especially so, are characteristic of the diathesis. She states that she is the fourth child and the only living girl in a family of nine. Six boys are living and reported healthy j two girls died in infancy. Digitized by Microsoft® CASES. 75 Case LVII. -^Remains of opacities from interstitial kera- titis — Characteristic physiognomy and teeth — Deafness. Archibald MTST., aged 13, a boy wbose notched and stunted upper incisors and puckered angles of mouth suffi- ciently denoted his specific diathesis, was admitted on May 8th, 1859. Both comese were extensively hazy from the effects of chronic keratitis. The disease had begun three years before, and had been so severe that for fifteen months, according to his own statement, he was blind excepting as to perception of light. He had attended at the Charing Cross Hospital throughout the whole time. He was the eldest child of three, and had not lost any brothers or sisters. The two younger were aged respectively nine and four years. He had suffered from otorrhoea which had left him very deaf. Case LVni. — Remains of opacity from chronic keratitis in the right eye only — Characteristic teeth and suspicious family history, William S., aged 13, from Yorkshire, was admitted on May 8th, 1859. He was of suspicious physiognomy and had characteristic teeth. His mother stated that he had been very delicate when a baby, and that of four older than him- self three had been dead-born and one had died in infancy. He had suffered from otorrhoea in childhood which had left him rather deaf. The left eye had never been affected, and its cornea was still quite clear. The right had been attacked by interstitial keratitis four years ago. The upper central incisors presented a condition which I had never before seen. Although they had been cut for more than three years, neither of them had grown more than a line or two above the level of the gum. They were of very bad colour, and had notched irregular edges. His mothei stated that the upper incisors of his first set had dropped out very early, and that for a series of years he had been without Digitized by Microsoft® 76 INTEKSTITIAL KERATITIS. any. Only one brother was living (aged 6), and he had never suffered from inflammation of the eyes. Case LIX. — Chronic keratitis in both eyes — Disease of retina, etc. — Characteristic physiognomy and teeth — His- tory of syphilis in parents and of symptoms in infancy. Charles B., aged 26, of most characteristic teeth and physiognomy, was admitted for a second time in February, 1859. He had previously attended for a long time six years ago, probably for interstitial keratitis, but unfortunately no notes had been preserved. His corneae, although still exten- sively hazy, had cleared sufficiently to permit of an ophthal- moscopic examination of the deep parts, which was made on account of his complaining that the sight of the right eye had recently failed. The media were seen to be hazy, as was also the retina, and the blood supply was decidedly below that of health, and the optic entrance was flat and sharply defined. The family history, as I obtained it from his mother, was that she had contracted " the disease" from her husband a few years before C. B.'s birth. Prior to this she had borne several children, all of whom had been healthy. Her. first child subsequent to the infection' died with rash about the nates and other specific symptoms. The patient suffered severely from the same in infancy, and was not expected to live. Five younger children are living and fairly healthy. Almost immediately after his second admission a rather sharp relapse of the keratitis occurred. Treatment by the inunction of mild mercurial ointment and the exhibition of iodide of potassium was ordered, and he made slow improve- ment during the several months that he remained under notice. Case LX. — Double kerato-iritis — Characteristic physi- ognomy, etc. Thomas H., aged 12, a boy from the workhouse whose "father is dead and mother run away," and respecting Digitized by Microsoft® CASES. 77 whose early history no information can therefore be obtained. He states that he has one elder sister, and that she, like himself, has suflPered from badly inflamed eyes for a long time. In himself the attack commenced two years ago, and affected both eyes. The pupil of the left eye is almost occluded by the effects of iritis, and both cornese are extensively hazy. He is of marked syphilitic aspect; the nose being broad and sunken, and there being deep puckerings about the angles of the mouth and pits in the skin of the face. His teeth, instead of being stunted, are very large, but the upper incisors are marked by a furrow crossing their front surfaces. The left upper canine is not yet cut, but its right fellow, which has only been through for about a month, presents a most remarkable constriction near its apex. This constriction I have often seen near the apices of the canines, both in syphilitic and other patients ; but never to such a remarkable extent as in this instance. The cases in which it has been most developed have all been syphilitic persons, and I therefore regard it as a suspicious though by no means conclusive condition. Case LXI. — Bygone double keratitis — Characteristic teeth. The following case was one of peculiar interest to me. In most of the others the patients have come under care on account of their eyes, and from observing the form of kera- titis I have been induced to inspect the teeth. In this, however, my suspicions were aroused by noticing the teeth, and from the latter I passed to the eyes, there to find a full confirmation of the opinion that notched upper incisors and interstitial keratitis usually go together. Mary Ann W., aged 17, a well grown and moderately florid girl, applied to me at the Metropolitan Free Hospital on May 6th, 1859, on account of a sore under her upper lip. The whole lip was swollen, and the sore which was quite superficial had whitish borders. Although Jier aspect was that of a delicate girl, and her nose was rather broad, I should certainly have suspected nothing had she not in Digitized by Microsoft® 78 INTEESTITIAL KERATITIS. raising her lip exhibited her upper teeth. The central incisors had a wide space between them and were stunted and notched. All the four canines showed the constriction near the apex referred to in the preceding case. The incisors were indeed quite typical. I at once looked at the eyes, and found both cornese slightly hazy throughout from the remains of interstitial deposit. The corneae were expanded and flat- tened in their centres ; the anterior chambers were unduly large, and the irides of impaired lustre. She told me that her eyes had been first attacked about four years ago, that she had attended a few months at an Ophthalmic Hospital, but getting rapidly worse had become a patient of the late Mr. Alexander, under whose care she remained for more than two years. It was eighteen months before any material improvement occurred, and for four of that time she was so nearly blind that she had to be led about. The right was the one first afi'ected. She had sufi'ered in infancy from otorrhoea, which had left her rather deaf. All that I could learn as to her family was that her mother had lost seven daughters during their infancy, and that two brothers, both older than the patient, were, with herself, all who now remained. Case LXII. — Double interstitial keratitis in a Jewess — Teeth notched and typical —History not obtained. Priscilla B., aged 15, a Jewess, from Portsmouth, was admitted in July 1859. Both cornese were afi'ected with interstitial inflammation; the left having been attacked about three months and the right one month. Her central upper incisors were notched in a most typical manner. I did not see her mother, and consequently could obtain no history of infantile symptoms. I learnt, however, that she was the eldest of her family, of whom eight were living and three had died. One of those dead was older than herself. This case is the only one in which I have as yet witnessed interstitial keratitis in a patient of Jewish parentage. Prior to its occurrence I was in the habit of adverting to the fact Digitized by Microsoft® CASES. 79 of the rarity of this affection amongst Jews, as one which remarkably coincided with the theory of its syphilitic origin since, as I have elsewhere proved, syphilis is comparatively rare amongst that people. Case LXIII. — Interstitial keratitis and typical teeth — History of syphilis in both parents and of infantile symptoms in the patient. The following case is of much value as bearing upon the degree of confidence which may be given to malformations of the teeth as indicative of hereditary syphilis : — Charlotte S., ag^d 12, presented herself one morning amongst other patients at my table at the Ophthalmic Hos- pital. Her eyes were kept firmly closed on account of exces- sive intolerance; and as is not unfrequent under such circum- stances, she was showing her upper teeth. Seeing that her upper incisors were notched, I examined them carefuUy. They were an exceedingly well characterized set, and presented the features which are roughly shown in the appended wood-cut. There was nothing very note- woi?lhy i«L' her physiognomy apart from her teeth. Her skin was ralhef flabby and pale, and the bridge of the nose was broad, but not remarkably so. I observed to the students who were looking on that the teeth were so typicail that I wished, for the sake of putting the value of that sign to the test, to pledge myself to the opinion, founded on their state alone, that the girl was the subject of hereditary syphilis. We now examined her eyes and found them both affected by interstitial keratitis in a well characterized form. I took her mother aside, and having put no other leading question to her beyond asking whether her husband was a healthy man, she spontaneously informed me that he had contracted the venereal disease fifteen years ago, and had communicated Digitized by Microsoft® 80 INTERSTITIAL KERATITIS. it to her. She was ill for at least seven months with it. At the time of her receiving it, she was two months pregnant. The child was born at the full time, and looked healthy, but wasted away and died at a month old. Her next conception ended at six months in a miscarriage, and the third in a simi- lar event at the eighth month. Her fourth was our present patient who was puny and delicate in infancy and suffered from snuffles, etc. . No subsequent births had occurred. With regard to the keratitis in this case, it commenced in the girl's left eye, about six weeks before her admission, and in the right two weeks later. She is still under treat- ment. Case LXIV. — Interstitial keratitis and typical teeth — Tertiary syphilis in the mother. The subject of the following case was a girl, aged 12, whom I saw casually in going through the wards of one of our larger hospitals. The surgeon under whose care she was, was just dictating to his clinical clerk a diagnosis of " Strumous ophthalmia," when I remarked to him that the teeth were such as I was in the habit of considering charac- teristic of hereditary syphilis. My observation would, I be- lieve, have been regarded only n« an in^+ariPP nf Tinbbv. These teeth (the wp^er set ) are excsftional in as an mstance oi noooy- ^jj„„„j„y, j,^^^^^^ „„^ „„5„^i/,j (.ja^aj rirlinff Tinrl if nnt fTiariPPrl tTint incisors is notched, thji other tfina of good size riamg nan it not Cnancea inai and form. The lateral Indsor ani the canine of *\,n »n«1>c -rv.n^'l.a'n Trr-'kn V. o J thc right sidc are also notchcd. It is remarlcalle the girl S mother, who had, t^at the notching occur, in three teeth on one with her, been admitted that 'i^'' -""'« "one on the other. morning, occupied the adjacent bed. The woman's scalp was seamed with the depressed scars of old nodes, and over her right shoulder, arm, etc., were large serpiginous ulcers, about the true nature of which there could be no doubt whatever. She denied, however, having ever to her own knowledge, suffered from primary disease. The nodes had occurred nine years ago. The patient was her eldest and only living child. Three younger ones had died in infancy. Digitized by Microsoft® CASES. 81 Case LXV. — Keratitis of the right eye — Recovery — Keratitis of the left eye six months later — Aspect of heredi- tary syphilis and suspihious family history. William H. H., aged 7, was brought to the Hospital by his father, a remarkably robust-looking policeman^ Dec. 1, 1858. The boy's puny and delicate aspect contrasted most remarkably with that of -his father. He had a large head, a broad nose, scars on the lips, and a fissure on the dorsum of the tongue. He was stated to have been always delicate, and was much under medical treatment in infancy on account of snuffles and an eruption on the forehead and about the nates. The first attack in his eyes had occurred about eight months ago when the right eye was affected, and he attended at this Hospital for four months. The right cornea had now perfectly cleared, but during the last ten days the left had become hazy and opaque '(ground glass). The iris was not affected. History of the patient's family. — No direct question was asked of either parent. His father was healthy looking, but his mother was rather delicate. His mother had borne six children, of whom only two were living. The eldest was a girl and died in infancy, and the patient was the second. One born subsequently suffered ' from rather suspicious symptoms. Under mild treatment by iodide of potassium and the mercurial ointment the left cornea quickly recovered. Case LXVI. — Double keratitis — Aspect of hereditary syphilis — Tonic treatment — Severe and prolonged attack. James W. O., an orphan and only child, aged 15. Aspect of hereditary syphilis most marked, skin pale and earthy, numerous small scars about the mouth, slight psoriasis on the cheeks. He was deaf of the right' ear, from which he had formerly had purulent discharge. During six months past he had had enlarged glands in the neck. The keratitis began almost simultaneously in the two eyes in Digitized by Microsoft® 83 INTERSTITIAL KEBATITIS. May, 1857, and the attack was a very severe one. There was no evidence that the iris had been implicated. In January, 1858, both cornese were still hazy, although they had greatly improved j the left was the worse. The boy had attended for six months at the Hospital. The treatment had chiefly been tonic and expectant. He had not been under my own treatment. Case LXVIL — Double keratitis — Aspect of hereditary syphilis and history of infantile symptons — Specific treatment -r-Rapid recovery of the cornea — Node on the ulna. George B., aged 16, was admitted in January, 1858. His aspect and teeth were very characteristically those of hereditary syphilis. He was hoarse and rather deaf. His mother stated that he had been a very ailing baby, and had suffered from snuffles very badly, with sore mouth and ulcerated lips. At the same time he had sores at the anus. Being exceedingly puny he was not weaned until three years old, and it was not until that age that he first began to walk. He had more recently suffered from ulcerated sore throat, and a large scar remained on the soft palate. His eyes had never been inflamed until the present attack which commenced about a month ago. Both eyes were affected. In both, the condition of diffused keratitis was well marked, but in the centre of the left cornea was a small scooped-out ■ ulcer. Iodide of potassium in seven-grain doses three times a day was prescribed together with the inunction of the mild mercurial ointment behind the ears and on the neck. Within a fortnight there was very decided improvement, and ultimately both corneae cleared. In the following July, George B., came under my care on account of a node on the left ulna. Both his cornea were at that date perfectly clear with the exception of a slight film in the centre of the left. History of the patients family. — George B,, was the eldest living in a family of three. Four had been born Digitized by Microsoft® CASES. 83 before him, all of whom died in early infancy. Of three born since, one had died. Case LXVIII. — Double keratitis — Aspect of hereditary syphilis — Typical teeth — History of syphilis in the father. Sarah Matilda G., aged 8, of very marked physiognomy and with most characteristic teeth. Her right eye had suffered slightly two years ago, at which time the left also became inflamed. The right cornea wholly cleared, but a large interstitial opacity remained in the left, and several re- lapses have subsequently occurred. When admitted (in February, I860) it was on account of a relapse in the left eye. It was attended with much intolerance of light. Under treatment by full doses of iodide of potassium the opacity cleared to a considerable extent, but whilst under observation a slight relapse in the right occurred. It lasted however only a short time. The patient's family history. — Her mother was dead, and a very imperfect history as to her infancy was attainable. She was the fourth child in the family, but the only living one. Three older than herself and one younger had aU died in infancy, and in several, suspicious symptoms were stated to have occurred. Her father stated that he had twice before marriage suffered from chancres, and on one occasion from badly ulcerated sore throat. He had been quite well for several months before his marriage, and had had no symptons since. Case LXIX. — Double keratitis of great severity — History of infantile syphilis — Keratitis in one of the patienfs sisters. George C, aged 10, was admitted February 13, 1860, with very extensive interstitial opacities in both cornese. In the right the centre of the cornea was thin'ned over the opacity and on the point of giving way. The attack had commenced four months ago, and had been very severe. The upper central incisor teeth were long and divergent, with Digitized by Microsoft® 84 INTERSTITIAL KERATITIS. their corners rounded off, and a broad notch in the centre of each. . The other teeth were not much deformed. Patient's family history. — His mother had been married twice. By her first husband she had had thirteen children of whom the three last born were living, the eldest of them being the subject of this case. The ten were born at the full time, but none lived longer than a few days. By the second husband she had three children. The first of these was born dead, and the others died soon after birth. She herself had bad eyes when an infant, and there remained large opacities in the cornea. She had lost part of the left upper jaw and several teeth. George C.,.was born a fine healthy baby, but at the age of one month he began to suffer from rash on the nates, arms, legs, and face. He had "bad snuffles, and had the throat very bad for two or three months." His father was stated to be a very healthy man, except that he suffered from " scurvy." One of this boy's younger sister's subsequently came under care at the Hospital for interstial keratitis. Case LXX. — Double keratitis — History of infantile syphilis — History of constitutional syphilis in the boy's father. Hugh L., aged 8, admitted for interstitial keratitis, November 3, 1859. A boy of fair complexion and delicate looking. He had then only the temporary teeth except the two lower central incisors. The keratitis was in the typical ground-glass condition. It began in the right eye one month before admission. His father who brought him was a very robust-looking man. He admitted however that he had had chancres followed by constitutional symptons before marriage (fourteen years ago). He was salivated mildly, and was, as he believed, quite cured, and had been well ever since. He was not aware that his wife ever suffered from any specific symptoms. She never had good health after her marriage, and died of pleurisy five years subsequently. She never mis- carried. She bore six children of whom the first four died Digitized by Microsoft® CASES. 85 within a mouth after their birth. Of the two living, Hugh IS the eldest. When an infant he had symptons for which he was treated at the Hospital for Diseases of the Skin, by- Mr. Startin. The younger child was quite weU, but had had a slight rash. Case LXXI. — Double keratitis — Typical teeth, S^c. — History of constitutional syphilis in the boy's father. Charles B., aged 15, admitted October 10, 1859. The right eye became affected first, about one month before admission, and a fortnight later the left also. The disease became well marked, and the teeth were typical. Iodide of potassium was given, and mercurial ointment was directed to be rubbed in. On March 29, he was nearly well. Patient's family history, — His father owns to having had a chancre followed by bubo, for which he took mercury. He had afterwards a rash. He subsequently married, being at the time in good health. His wife was pregnant six times. On the first occasion she had a girl, who lived to the age of 15, and then died of " consumption." The second was a girl, who was still living aged 18, and reported healthy. The third was still-born. The fourth lived three months, " it had no tongue or roof to its mouth." The fifth, a boy living, aged 16, and reputed healthy. The sixth, the subject of this case. Case LXXII. — Remains of double keratitis — Adhesions of iris — Characteristic teeth. Harriett H., a girl from a workhouse, aged 16. Large, permanent, symmetrical opacities in both corneEe. Irides of good colour. The pupils are large and irregular, and pig- ment is deposited in their centres. The attack of keratitis began when she was five years old. She then attended at the Ophthalmic Hospital for some months. Teeth notched, peggy, and very characteristic. She has two brothers and one sister, all younger than herself. Digitized by Microsoft® 86 INTERSTITIAL KEEATITIS. Case LXXIII. — Remains of double keratitis — History of infantile syphilis — Disease of the knee joint, Eliza B., aged 8. Remains of double keratitis with bulging of the cornese. Fissures at the angles of the mouth. Her teeth were considered typical of hereditary syphilis. The child had had destructive inflammation of the right knee joint. She was the second child bornj when six weeks old she began to suflFer from rash all over^ and had snuffles very badly. She was treated by Dr. Rees, who said that her complaint was venereal. The mother stated that she had said (as she said to me), that " she knew nothing about such a disease/' yet Dr. Rees persisted in his opinion, and treated the child by grey powder, under which treatment he recovered. The mother was very cachectic. She had borne four children. The first died at the age of 4f years of dropsy. The second was the subject of this case. The third died of dropsy after scarlet fever. The fourth was an eight months' infant, and died at the age of ten days " wasted away." Case LXXIV. — Double keratitis — History of infantile symptoms, and also of syphilis in both parents. Elizabeth M., age 13, was admitted June 15. Keratitis of the right eye, with very little vascularity and no iritis. It began a fortnight before. She had never previously sufifered' from bad eyes. Her teeth were very irregular, stumpy, and the central upper incisors were notched, her nose was sunken, features heavy, and forehead protuberant. Iodide of potassium and mercurial inunction were prescribed. A month later the left eye also became afi'ected. Patient's personal and family history. — Her mother had had two children before this one. She then had sores on her genitals "very badly," and afterwards ulcerated sore throat, but no rash. Pour years later, during which interval she had been ill on and ofl', Elizabeth M. was born. Within a few weeks of birth " the disease " broke out in the baby, and " she was a terrible sufferer from it." She had a very Digitized by Microsoft® CASES. 87 severe and lasting eruption on the nates, and also " thrush" in the mouthy which " went through her," and made both mouth and anus very sore. Next an abscess formed on her side, which discharged for three months, and has left a puckered scar. This scar looked like that of a discharsed empyema. There was, however, very little flattening of me side. She had ever since been liable to cracks on the lips, &c. The mother took mercury, and she thinks the child did too. The disease in both was considered by their medical attendant to be syphilitic. Case LXXV. — Opacities in both cornets — Aspect of here- ditary syphilis, and history of suspicious symptoms in infancy — Teeth of good size and form. The following is a case exceptional in some particulars to the usual history of insterstitial keratitis, more especially in that the teeth were large and well formed. I only saw the patient on one occasion, and the following is an exact copy of the hurried notes then taken. Ellen T., aged 19, single. Left cornea with dense cicatrices. Right cornea diffusely hazy. Fissures and scars at angles of mouth. Nose broad; complexion pale and peculiarly faded. Several small scars on the forehead. Teeth very good, large, and weU formed. Liable to much pain in the bones. Scars on the soft palate, extending to each tonsil. Constantly liable to eruption of impetigo, and to soreness at angles of mouth. Mother has had eleven children, of whom eight are living. Ellen is the fourth. As a baby she was healthy, and her mother does not recollect that she had either rash or snuffles. The keratitis began at the age of nine, and has relapsed within the last month. Case LXXVL — Remains of double keratitis — Charac- teristic teeth — History of suspicious symptoms in infancy. Thomas C, aged 33. In this case the suspicion as to the history of hereditary syphilis was caused by the state ot Digitized by Microsoft® 88 INTEESTITIAIr KERATITIS. the. teeth. The mau's physiognomy was not suspicious. He was tall and well developed. His teeth were, however, of the syphilitic type. The jaws. were contracted, the teeth were of very bad colour, and the gums were much absorbed. There were large corneal opacities, the result of keratitis at an early age. He was then " nearly blind " for some time. His face was well formed, and the bridge of the nose was not in the least sunken. His eldest sister, who nursed him, stated that in infancy he had very troublesome sores at the anus, and was for long under medical treatment on account of them. The skin at the verge of the anus still shows numerous linear scars, the result of bygone fissures. He also had " thrush" in the mouth. He was liable to psoriasis about the anus and on the thighs, and often had small ulcers ou the skin, and had much aching in the shins. There were also scars in the velum palati. He had taken mercury for his eyes. He is the third of nine living out of thirteen births. All of them are described as having been ailing, very delicate infants, many of them liable to rashes. Mr. Bowman, Mr. Critchett, and Dr. Bader saw this patient, and all considered that the diagnosis was fuUy established. Case LXXVII. — Double keratitis — Characteristic physioff- nomy — History of infantile symptoms, and of syphilis in both parents. Honora P., aged 9. Of pale complexion, and physiog- nomy typical of hereditary syphilis ; admitted October, 1859. Her teeth were remarkably peggy. The upper incisors were not notched, but the angles were worn away, and the teeth stood apart. Both cornese were hazy. The anterior cham- bers, especially the right, were very large. She could not see to read, but could distinguish colours. She is rather deaf when she takes cold. She has never had any discharge from the ear. History. — For the first month after birth she appeared healthy, and after that she had a violent " stoppage in the Digitized by Microsoft® CASES. 89 nose ' and " lumps " in the sides of the neck. She had a discharge of yellow matter from each nostril. About the age of 2 or 3 her legs "came out in ulcers," below the knees. She was treated by mixtures and powders, and recovered, and remained weU until a little before her eyes became " bad." Before this, too, she had measles, of which she got quite well. She then (about February, 1858), had a very sore throat and enlarged glands. Before attending at Moorfields, she had been treated for the keratitis for a period of more than a year, at various institutions. At one of them iodide of potassium was prescribed. JBamily history. — Her mother had been separated from, her husband for five years, on account of his giving her " the disease" twice. She had had sore throat and discharge, but no rash. Her husband had had both rash and ulcerated throat. The first time the mother had discharge was before the birth of her first child. She had had no mis- carriage. She had had three children; the first was still- born, the second was the subject of this case, and the third was born with " ulcers on the hands," and died the next morning. Case LXXVIII. — Keratitis of the right eye — Hydro- cephalus and idiocy — Characteristic teeth and physiognomy. Mary F., aged 8, was admitted September I, 1859, for specific keratitis 6f the right eye. She was hydrocephalic, partly idiotic, and very talkative. Her first teeth were very- small and much decayed. .She had just cut one permanent upper central incisor, which was characteristic. Her nose was sunken and very broad. She had small scars on the skin of the face, and fissure.s at the angles of the mouth. Her tonsils were large, and much puckered. The glands under the jaw were swollen. Dr. Bader confirmed my diagnosis of hereditary syphilis. The cornea quite cleared under treatment by cod liver oil, and she could see well with both eyes at the date of her discharge. Digitized by Microsoft® 90 INTERSTITIAL KERATITIS. History.— Wkea. a week old she had fits, and her head rapidly increased. She was five years of age before she was able to walk. Her mother had had eight children, of whom three only are living. Of those living, the two eldest, aged 25 and 22, are healthy. One is in the army and one in the navy. The third living is the present patient. The five dead died in infancy of "fits." The mother denied any history of syphilis, but stated that her husband was a very drunken man. LXXIX. — Characteristic teeth and suspicious physiog- nomy — History of an attack of ophthalmia, probably keratitis. Henry P., aged 18, applied at the Hospital in April, 1859, for displaced puncta. His cornese were then perfectly clear, and he could see the smallest type. He said that more than a year ago he had been blind for some time from inflammation of the eyes (probably double interstitial keratitis). Although he was well grown and florid, I recog- nized certain peculiarities in his physiognomy which I thought characteristic of syphilis. On looking at his teeth this sus- picion was amply confirmed. They were most characteristic. Dr. Bader agreed with me that there was no doubt as to the diagnosis, as far as teeth and physiognomy could go to estab-> lish'it. I did not see the lad's parents, and no history as to infantile symptoms was therefore obtained. Case LXXX. — Insterstitial keratitis in both eyes — History of infantile symptoms — Characteristic teeth — History of syphilis in the patient's father. The following narrative is of especial interest, from con- taining the history of a brother and sister, both the subjects of inherited syphilis in a severe form, and only the elder of whom has as yet sufiered from interstitial keratitis. Anna P., aged 15, and Robert P., aged 13. The history which their mother gave was as follows : — Her first con- ception resulted in a miscarriage at a very early period. Digitized by Microsoft® CASES. 91 Anna P., this elder of the two patients, was the first living child, and was born about fourteen months after marriage. On account of symptoms presented by the baby, Mrs. P.'s husband was questioned, and he acknowledged that he had had the venereal disease before his marriage, but stated that he believed himself quite cured. He had been under a long course of treatment. He had shown no symptoms whatever since his marriage, nor had his wife had any. Robert P. was the second living child. After that twins were born, both of whom died "of measles" in childhood. The last infant was bom about four years ago, and died at the age of six weeks " of a kind of wasting," suffering at the time from severe inflammation of the eyes. Thus it will be seen that the two children are the only living ones out of six conceptions. Anna P., the elder one, when a few weeks old, had " a dreadful bad mouth and sore face." " The disease ialso broke out below, and she was very sore." She had "thrush," but no snufiles. Although she is now quite deaf, her mother does not recollect that she ever suffered from otorrhoea. The deafness began about three years ago. Her eyes first infiamed when she was eleven years old. She was in Australia at the time. The attack was a severe one, and she was blind, or nearly so, for upwards of five weeks. At present she is a well-grown girl, and has a fair complexion and a good nasal development. In both cornese are clouds of opacity. There are scars extending from both angles of her mouth. Her upper central incisors are notched in a very characteristic manner. Robert P. (two years younger than his sister), is of most marked physiognomy, his nose being sunken and skin pale and earthy. When a baby he is said to have had large sores round the mouth, which were long troublesome j he had also " very bad snuffles." Afterwards, at the age of two years, he had jaundice, and was treated by grey powders. His upper teeth of the first set decayed early, and fell out. He was for some years without incisor teeth in the upper jaw. About two years ago, he had a badly ulcerated throat, by Digitized by Microsoft® 92 INTERSTITIAL KERATITIS. whicli his uvula, soft palate, etc., have been extensively destroyed. At present there is only a small opening, about capable of admitting a quill, which communicates with his nares, the palate being united by cicatrix to the posterior pharynx. During the last two years he has often com- plained of aching pain in the right, arm, and the lower part of his right humerus is greatly enlarged and very hard. Many of his cervical glands have enlarged, and a few have ulcerated. As might be expected in a younger child, his teeth are not nearly so characteristically malformed as those of his sister. His upper permanent incisors are long and almost craggy looking, as if of hard structure. They present, however, crescentic portions in their free edges, which are thin and broken. His lower incisors are deeply serrate, and are also coated with yellow fur, as if mercury had been used in early life.* LXXXI. — Keratitis of one eye — Typical teeth — History wanting — Node on the tibia. Julia C, aged 11, admitted June 30, 1858, for keratitis of the left eye only. She did not exhibit any marked pecu- liarities of physiognomy, except that her complexion was brownish-yellow, and that there were a few faintly marked fissures at the corners of her mouth. Her teeth were however well marked. The left cornea was veiy opaque, with dots of white in some parts of considerable size. There was some sclerotic congestion, and much intolerance of light. Her mother had died five years ago. - There were in the family three older than herself, and two younger. One brother had lost the sight of one eye. Her elder sister who brought her was very healthy looking. She does not re- member that Julia ever suffered from any particular symp- toms until the age of six years, when a swelling formed over • For some , remarks on " Mercurial Teeth " see my Paper in the Transactions of the Pathological Society for 1858-9, page 211, and Tig. 8 ia riiite IX, of that volume, Digitized by Microsoft® CASES, 93 the left tibia and broke. There remained, when I saw her, a large osseous node, ulcerated at its most prominent part. LXXXn. — Effects of by -gone keratitis in both coi'nete — History of infantile symptom — Typical teeth. Mary B., aged 8. Remains of keratitis in both cornese. The eyes first inflamed two years ago.' She was florid and of good complexion; forehead large. The teeth were very irregular, and the upper central incisors were deeply notched. She had also fissures at the angles of the mouth and on the lips. When a month old she had a rash on the nates and body, and very bad snuffles, and a sore mouth. She was treated by a surgeon, who gave her a powder every night and morning. Case LXXXIIL — Severe Double keratitis — History of infantile symptons, and of syphilis in the child's parents. George M., aged 6. Double keratitis with much bulging of the cornese. Both cornese opaque. Enlarged glands under the jaw. Teeth typical. Excepting that he had had purulent ophthalmia in. infancy, his eyes had been quite good until three months before his admission. Whilst a baby he had thrush very badly. He had also a troublesome eruption and snuffles. He was, according to his mother's statement, treated for the venereal disease. His mother stated that during her first pregnancy she had sores on the genitals, and afterwards a badly ulcerated throat, which the surgeon who attended her said was vene- real. She was still liable to ulcerated sore throat, and had when I saw her, syphilitic sores on the. gum and cheeks. The subject of this case was her first child. The second died sixteen hours after birth. The third was living, aged 4, and except being liable to " dry scurvy " on the head, was quite well. The fourth, a baby whom she brought with her looked quite healthy. Digitized by Microsoft® 94 INTEBSTITIAL KERATITIS. Case LXXXIV.—Kerato-iritis in the right eye— History of an attack in the left two years before — Destruction of the soft palate^Glandular disease — Characteristic physiognomy. William S., aged 15, admitted for keratitis of the right eye. The cornea was flattened^ and very opaque in patches. The iris looked ragged, and spots of lymph are apparent in the anterior chambers. The globe was slightly softened, as was also the left. He could with the right eye only just distinguish light. All active inflammation had passed by. Two years ago he had attended at the Hospital for inflamma- tion of the left eye. This eye was now well, but chronic inflammation of the lachrymal sac had remained ever since. He could, however, see perfectly with the eye. He was a pale unhealthy looking lad. There were many scars and pits about the face. He had never had small-pox. There were scars at the oral angles. Head ill-shapen. The soft palate was destroyed, and a large dense cicatrix occupied its place. He had had glandular swellings in the neck, and one year ago he had tdceration of the throat, which lasted for twelve months. His mother had been married twice. By her second husband she had had four children, of whom two were dead. Of the two living, the elder was grown up, strong and healthy, the younger was the subject of this case. Case LXXXV. — Double keratitis of mild form — Typical teeth, but good physiognomy. Eliza S., aged 20, florid and healthy looking, of good physiognomy, admitted November 17, 1859, for specific keratitis of the right eye. She stated that the left eye had begun to inflame in March. It got well in six weeks. In May both were affected in the same way. She says that they again got well in June. The attack for which she attended now commenced in October. The cornea was hazy, the teeth were typical. Two had been born before herself, and had died in childhood. There were six living of whom she was the eldest. Digitized by Microsoft® CASES. 95 Case LXXXVL — Remains of interstitial keratitis — Indi- cations of hereditary syphilis well marked in an elder sister. The boy who is the subject of the following case is a younger brother of the patient in Case XXXIII. Although he also had suffered from keratitis^ the diathesis of hereditary syphilis wasj as might be expected, much less marked than in his elder sister. Daniel B., aged 14, of florid complexion, features tumid, fissures at the angles of the mouth. As to teeth, complexion, and in other respects the conditions were much less marked than in his sister. His eyes began to be affected three years ago. He said that they were at one time, when he was in the workhouse, very bad, and that he was then blind for months. When admitted the left cornea was quite clear, but the right remained hazy in the centre. He did not wish to be treated considering that his eyes were as well as usual. Case LXXXVII. — Interstitial keratitis in both eyes at the age of eight — Relapse eight years afterwards in the right eye ^Characteristic physiognomy and teeth — flistory of syphilis in the patient's parents. Elizabeth P., aged 18. The aspect of hereditary syphilis was not well marked. She had, however, scars at the angles of the mouth, in the palate and on both tonsils. Ten years ago she attended at Moorfields, for what appeared to have been keratitis, and was " blind for three months." When I saw her, very slight opacity of the left cornea remained, but the right was acutely inflamed. Her teeth were very typical. Elizabeth F., was the seventh child, but was the eldest living, the previous six having all died in infancy. She had one brother and two sisters living. Her mother told me that twenty-four years ago she contracted "the venereal disease " from her husband, which was followed by a rash. It did not appear that any of her children except one, who died in infancy, had ever had any rash. Digitized by Microsoft® 96 INTERSTITIAL KERATITIS. Case LXXXVIII. — Opacities from interstitial keratitis — Typical teeth and characteristic physiognomy — History wanting. The subject of the following case, a young lady aged about 12, was sent to me by my friend Mr. A. Coleman, who con- sidered her teeth to be characteristic of hereditary taint, an opinion in which I fully agreed with him. I obtained the following particulars (Feb. 6, 1860). She was born quite healthy looking, but began to Traste at a month old, and had snuffles. She was ever afterwards a puny fretful baby, she had "water on the head," and took mercury, (the head is now very large). She did not walk until two years old. She subsequently had discharge from the left ear, and is still slightly deaf on that side. When five years old she had double and severe ophthalmia, which — as it made her prac- tically blind for several months ; lasted a long time ; never relapsed, when once well; and had left dots of opacity still present in the substance of both cornese, — was in aU proba- bility interstitial keratitis. When I saw her her irides were of steel metallic hue, and wanting in lustre. She had a long-drawn physiognomy and a bad scurfy skin with some appearance of fissures at the angles of the mouth. She was the eldest child. Her mother, whom I saw, had well-shaped teeth, and her father also was reported to have good teeth. Taking all these facts together, I considered that the diagnosis was fully made out. No direct questions were asked. A year later, I learnt from Mr. Coleman that several nodes had made their appearance on the child's head. Case LXXXIX. — Severe interstitial keratitis — Typical physiognomy and teeth — History of infantile syphilis — Great benefit front specific remedies. Ann W., aged 10. Was admitted August, 1857, for severe interstitial keratitis of both eyes, with some vascu- larity. The attack commenced four months previously. The pupil did not dilate well under atropine. She had the Digitized by Microsoft® CASES. 97 best marked syphilitic physiognomy that I ever saWj and the teeth were most characteristic. Her skin was dry and stretched looking, the features were pinched, and there were deep fissures at the angles o,f the mouth. During about four months' treatment by mercurials and iodides this girl received great benefit. She was before so nearly blind that her friends were using interest to get her into an asylum for the blind. She could at the date of my last note see to read large letters, and I believe she afterwards improved much further. I learnt from her mother that, as an infant, when sixteen months old she was under Mr. Macmurdo's care for severe attack in which the right eye only was affected. At a that time she had a very sore mouth ("fifteen or- sixteen gashes in the lips all laid open" is her mother's expression). Seven elder children all died under the month. They all died with rash and thrush, which latter " went- through them." In infancy Ann W. had thrush very badly, rash in the skin " dreadfully," and " snuffles in the nose very bad." Case XC. — Double keratitis. Characteristic physiognomy and teeth. George C, aged 13, admitted for double keratitis of two months' standing. The bridge of the nose was much sunken, and his physiognomy and teeth were very markedly cha- racteristic of hereditary syphilis. His mother had had seven children. The present patient was the first born. The next two died. The other four are reported healthy. Of the deaths, one infant was still-born, and one died nine weeks after birth. Case XCI. — Double keratitis — Characteristic physiognomy and teeth — History of syphilis in the patient's mother. Ann H., aged 8^, was admitted for double keratitis of one month's duration. Her eyes had never been affected before. The right began first. Both cornese were extensively opaque, the inflammation had advanced very rapidly, and H Digitized by Microsoft® 98 INTERSTITIAL KERATITIS. there was extreme intolerance. Her nose was broad^ and her aspect generally was tolerably well marked. Her mother had been married twice. Soon after the first marriage she had sores, followed by rash, and was treated for it by a surgeon who salivated her ; she had ever since been in usual health. Her husband soon after the first symptoms appeared to be in good health. He was killed by an accident. Her first child, a boy, died with specific rash, wasting, &c., at the age of twenty months. The second, a girl, died at the age of three weeks, " she wasted away." The third, (Ann), had rash, sore anus, &c., and was very ill for long. Case XCII. — Double keratitis — Good teeth and physiog- nomy — No history. Elizabeth M., aged 11, admitted November 13, 1860, for keratitis in the left eye, and commencing disease in the right. The left began three weeks before. Her teeth were quite perfect, the. physiognomy presented nothing remarkable, except that the skin was coarse. The patient, when a baby at the age of six months had a rash (four or five spots on one arm), which continued for twelve months, she was however,. otherwise in good health, and until her eyes became inflamed had never been HI. Her father denied having ever had the venereal disease. Her mother was in good general health, but was subject to ulcers on the legs, from the knees to the ankles. "When I saw her she had them in one leg only, but she had had them on both. She had been subject to them for seven years. She had been pregnant nine times j the first, resulted in miscarriage^ the second and third in still births at the fuU time ; the fourth child died one month after birth, of " inflammktion of the chest;" the fifth (the eldest living), is the subject of this case; the sixth and seventh are living and healthy; the eighth died of small-pox ; the ninth and last, a baby eleven months old, is living and healthy. Digitized by Microsoft® CASES. 99 This case approaches the nearest to aa exception to the rule that I have yet seen. Although the form of keratitis was certainly interstitial^ yet the patient's teeth and physiog- nomy were not peculiar, and no history could be obtained. I felt in much doubt as to the diagnosis. XCIII. — Interstitial keratitis of the right eye — Typical teeth — History wanting. Jane B., aged 11, was admitted in December 1860. Her physiognomy was suspicious, but by no means typical. Her upper central incisors were, however, characteristically notched ; her head was large, the bridge of the nose sunken, and there were patches of psoriasis on the face. The right cornea only was afPected, and the inflammation which had existed two months was not severe, not having passed beyond the ground-glass stage. History of patients family. — I did not see her mother, and the following facts were all I could obtain from her aunt, who came with her. Her mother's first conception resulted in miscarriage. The patient was the eldest child, the second and third were living, but two born subsequently had died in infancy. Case XCIV. — Latent hereditary syphilis — Keratitis at the age of twenty-one — A single Typical tooth. William P., a boatman, aged 31, a tall young man, extremely pitted by small-pox. Mr. Dixon, drew my atten- tion to him on accpunt of well-marked keratitis of the right cornea, and old iritic adhesions in the left pupil. The kera- titis was interstitial, and of a week's duration. The adhesion of the left pupil was a single broad band, and in the adjacent iris was a portion in which the structure was deficient by dragging, looking much as if there had been a wound. The man, however, said that he had never had an injury. Both eyes had, he said, been excellent until a week ago, with H 2 Digitized by Microsoft® 100 INTERSTITIAL KERATITIS. the left he could still read No. 1 ("btuiiant"). His nose was good, but his face was so universally and deeply pitted by small-poxj that the other features of the syphilitic physiog- nomy were masked. I ventured the opinion that the keratitis was specific, and that he had probably had iritis of the left eye in infancy. On looking at his teeth we found that the lower set were good in form and colour, and all the upper ones also, excepting the right central incisor, which was narrow and notched, and a. most typical one. The left central incisor was broad and of good colour and length, and without the slightest trace of notch. I learnt that he was the eldest of his family, and that he had two brothers and a sister younger than himself, none of whom had ever suffered from their eyes. He had had small- pox at the age of one month, before vaccination, and very severely. At that time he was blind for a month. He had had good health ever since infancy, and presented no other symptoms. He had not been out of health lately. This case suggests the question as to what might be the probable effects of small-pox at the age of one month in modifying^ the state of constitution in a syphilitic infant. Here the attack of keratitis had been unusually delayed. I rest the diagnosis on the facts that the form of keratitis was typical, that it occurred in conjunction with a typical tooth, and, with evidences of bygone iritis in the other eye. Many observers saw the case, which excited at the time much interest. XCV. — History of iritis n infancy— Extensive synechits — Interstitial keratitis at the age of four — History of infantile iritis. Emma C, aged 6^ years, was admitted September 1857. She was not well grown, and had the iaspect of congenital syphilis, moderately well marked. Both corner were exten- sively nebulous. She could but just see to go about. Both irides were adherent, and the pupils irregular, and there were Digitized by Microsoft® OASES. 101 films of lymph crossing both pupils. There was no conges- tion, and the state was quite that of past disease. Her eyes " gummed-\ip " early in infancy, and very soon after she had inflammation " of the balls, not of the lids." She used to cry and lie awake at night, and never could bear the light. She attended under Mr. Bowman's care when an infant, and at intervals had been a patient at the hospital ever since. Her health when I saw her was better than it had ever been before. On September 5th, iodide of potassium in doses of one grain three times a day was prescribed. On December 4th, the eye was much clearer, and she could see to read large print, and to sew. XCVI. — Opacities in both cornece, with synechim from iritis — Typical teeth and suspicious physiognomy — History imperfect. Elizabeth J., aged 27. She was almost stone deaf. The defect in hearing commenced at the age of six, and her eyes began to inflame about the same time. She was well grown, her nose was wide and misshapen ; the teeth were very typical. She spoke hoarsely. Her palate was tied up on each side of the uvula by adhesions. Both cornese were hazy from interstitial deposit, and the pupils were small and irregular, and dilated very little by atropine. She could find her way about in the day, but not in the dusk or by candle- light. She had never learned to read, but said that she could see the letters. I learnt the following facts from the patient's stepmother. Elizabeth had measles when six years old. Up to that time she was believed to have been healthy. Her mother (now dead), had seven children, of whom Ehzabeth is the eldest. Three of them died. Four are now living, and all these latter, except Elizabeth, are healthy. Of the three deaths, one died in infancy, another recently of " consump- tion " it is not known what the third died of. Digitized by Microsoft® 102 INTERSTITIAL KERATITIS. Case XCVIL— Double interstitial keratitis— Teeth and physiognomy characteristic — History of symptoms in infancy — An elder brother also the subject of the same diathesis. David McK., aged 10, was admitted under my care in February 1861. Both his comese were in a well charac- terised state of interstitial inflammation. His central upper incisors were dwarfed and notched, and his physiognomy was very marked. In going into his history, I learnt that he had an elder brother, and requested that the latter might be brought to see me. On April 14 both brothers attended, and excited much interest amongst all who were present. The elder George McK. (aged 12), presented in all his physiognomical peculiarities an exaggeration of those seen in his brother. His skin was thicker, and of a more earthly pallor, and that of his face was covered with psoriasis ; his nose was broader, the scars at the angles of his mouth were more conspicuous, and his upper central incisors were more deeply notched. He had, however, good sight, and it did not appear that he had ever suffered from interstitial keratitis ; his hearing was also good. The following is the family history, as obtained from their maternal aunt, who brought them to the Hospital. Their mother is dead, and father living in India, The mother's first conception resulted in a miscarriage. George K. was the first born alive; he was very ill during the whole of infancy, suffering from rashes, &c. When four years old he had a severe inflammation of one eye, but the other was not affected ; the inflamed eye recovered perfectly, and no traces of the attack are now visible. David K. was the second child, and like his brother, suffered much in infancy. His eyes remained sound until the present attack. No other children were born. It is a circumstance of much interest that the elder brother in this instance should hitherto have escaped an attack of keratitis. In all probability he will at some future time suffer from it. It is scarcely likely that the attack Digitized by Microsoft® CASES. 103 described, since it affected but one eye, occurred so early, and has left no trace behind it, was the true form of the disease. In David K., the use of the iodide of iron, and of inunc- tion of the mild mercurial ointment was productive of great benefit. His cornese have now (May, 1861), almost cleared. Case XCVIII. — Interstitial keratitis at the age 0/ 21 — Typical teeth and physiognomy — Latent hereditary taint, brought into activity by Asthenia lactantium. My attention was drawn to the subject of the following case by Mr. Beddard, Mr. Streatfeild's clinical assistant. Mrs. M., a fairly healthy-looking woman, age 21, applied at the hospital in May, 1861, on account of interstitial keratitis of the left eye. The left cornea was rendered wholly opaque by clouds of interstitial deposit, and a broad fringe of vessels spread over its upper part. The attack had lasted six weeks. the other eye was rather irritable, but nothing more. This was the first attack at the time of its commencement ; Mrs. M. was much reduced by nursing her second baby. As stated above, Mrs. M. was a fairly healthy-looking woman. Her physiognomy presented nothing peculiar. The condition of the teeth, however, fully confirmed the suspicions excited by her eye. Her upper central incisors were most charac- teristically notched and dwarfed. Most of the other incisors and canines, both of upper and loWer sets, were also dwarfed and of very peculiar type. Mr. Dixon saw the case, and expressed himself as not feeling any doubt as to the correct- ness of the diagnosis. Mrs. M. stated that she was the second of her family now alive. An elder brother was, as far as she knew, quite healthy. She had herself had good health until the present inflammation of the eye. She had been married three years ; her first infant died at the age of five weeks ; her second one, aged twelve months, is living, and of very healthy appearance. This case is one of extreme interest j 1st, as an example Digitized by Microsoft® 104 INTERSTITIAL KERATITIS. of latent hereditary taint, for the patient had not suffered from any special symptom until adultagej 2ndly, as an instance of hereditary taint, brought into activity by a debilitating influence (over lactation) ; Srdly, an account of the usefulness of the teeth as a means of diagnosis, the woman's physiognomy not presenting any peculiarities, while the state of the teeth was most characteristic. It must be borne in mind that no opportunity occurred for enquiry as to symptoms in infancy. Case XCIX. — Heredito-Syphilis — Epileptiform, fits with peculiar symptoms — Double keratitis — Characteristic teeth Alfred O., aged 19, a well-grown lad, but of charac- teristic physiognomy and teeth. He states that he had good health until he was about eleven years old, when he became liable to a peculiar form of epileptic paroxysms beginning in the left side. His account of these fits is as bllows : — The fit seized him suddenly one day when out valking ; his left leg was affected by painful spasm, which in I short time passed up his side. He did not on that occasion ose consciousness. Since then the fits have recurred with .'ery varying frequency. Once whilst residing in the country le was a year without having any attack. All the fits begin jy spasm either in the left leg or left arm. The limb ittacked shakes violently, and the muscles are drawn into aiots. This is very painful, and after a while he falls and becomes insensible. The insensibility has on some occasions lasted several hours, and he always has sickness and head- ache on recovery. He has never experienced the slightest spasm in the right side of the body. Most of his attacks are not attended by unconsciousness, but consist only of spas- modic contortions of the leg or arm, which after from three to five minutes ceascj and the limb drops. Any slight excitement, a false step in the street, a sudden noise, &c., will bring on these spasms. He feels a constriction Ibout Digitized by Microsoft® CASE?. 105 his throat during thenij and is obliged to tear open his neck- handkerchief. He is not aware of the existence of any par- ticularly irritable spotj pressure on which will cause the spasms. His muscles are well developedj and I can discover no wasting or want of symmetry. The teeth are as typical as any I have ever seen. Eyes. — Until a year ago his sight in the right was perfect, , the left being not so good. He was then attacked by inter- stitial keratitis. It began in the right and soon afterwards affected the left also. He attended at Moorfields for some flaonths. At present both cornea are diffusedly opaque, the right much the more so. He can see to read with the left. History of his family. — His father died ten years ago, mother still living. An elder sister, who would now have been 24, died of phthisis a few years ago. The second child died young. The third, a boy, is now living, aged 31, is in bad health, has according to report malformed teeth and a cataract in one eye, for the latter he has been under much surgical treatment. He was not born with it, and it did not form until he was some years old. The fourth, a girl, died young. The patient, Alfred O., is the fifth and youngest living. One younger than himself died. There is a second family of young children. Alfred O. is weU-grownj bridge of nose good; head symmetrical ; skin thick, yellow, and pitted ; deep fissures in lips. He has been under my care for a month, and thinks he has been much better since taking the iodides of potas- sium and iron. He had previously been under Dr. Parker's care for the fits. He has been accustomed to work in tobacco, but does not think it injures him. Case C. — Aspect, ^c, of constitutional syphilis in a married woman — Remains of keratitis and iritis in both eyes. — Typical teeth — Deafness. In the following some of the conditions present might easily have been referred to acquired syphilis, the patient Digitized by Microsoft® 106 INTERSTITIAL KERATITIS. being an adult. The state of the teeth, however, enabled me to arrive at a confident opinion as the hereditary origin of the taint. Susan B., aged 26, a married woman was admitted on account of impaired vision. Both cornese were extremely opaque, especially in their lower halves, and both pupils were irregular from adhesions. The right pupil was very much contracted, but the left, although puckered at its margin, was of full size. The bridge of her nose was sunken, as if bone had been lost. Her hair was very thin, and she was quite deaf, having formerly suffered from otorrhoea. The thinness of hair, the adherent pupils, suggested acquired syphilis, and the flattened nose might have been caused by loss of bone. On looking at her teeth, however, I found them stumpy, pegged, and notched, indeed of a most charac- teristic type. Her complexion was of a faded yellow, and the skin of the face shewed numerous little pits, there were also fissures at the angles of the mouth These conditions, taken together with the deafness and the keratitis confirmed the diagnosis which the teeth had indicated. The woman had come up from the country, and I could obtain only the following imperfect facts as to the history of her family. Her mother had borne seventeen children, of whom seven were still living. Of those living three are older than the patient herself, and three younger. One child was stated to have died at the age of ten, being nearly blind, and of complexion, teeth, &c., closely resembling the patient. Mrs. B. herself had been married five years, but had never conceived. Case CI. — Double interstitial keratitis — History of syphilis in both parents — No history of infantile symptoms. The cases detailed in the following narration affords us an instance of deviation from the ordinary rule in respect to hereditary syphilis, that the oldest child born after the acquirement of the taint suffers most. Digitized by Microsoft® CASES. 107 Susan C, aged 12^ was admitted May 9, 1861. Both cornese were extensively opaque from interstitial keratitis. Her teeth were very irregular in development, but not typically notched. Their malformations were, however, symmetrical. The upper central incisors were both of them marked by a sort of crescent, but were more of the " craggy " type than of the usual form in syphilis. The lateral incisors had wholly escaped, but both canines showed truncated extremi- ties and small central gemules. The lower incisors were all of them peggy in form and foliated at their extremities. Her head was large and hydrocephalic, and there were patches of psoriasis on her face. Her mother told me that Susan C. was her fifth child ; the three elder ones had all died in infancy, and the fourth was a boy now living and reported healthy. I asked to see her brother, and he was accordingly brought at the next visit. Thomas C, aged 13, was a well- grown lad of healthy aspect. His cornese were perfectly clear, and he had never suffered from any form of, ophthalmia. His teeth were large and of good colour ; the only suspicious point about any of them being that the angles of the central upper incisors were somewhat rounded off. The right lower canine showed a central gemule, but all the others had good crowns. His nose was a little broad, and there were a few pits in the skin of his forehead. Taken altogether, however, there was nothing either in his physiognomy, teeth, or eyes, to warrant a suspicion of hereditary syphilis. His tongue presented a very peculiar condition. It was somewhat swollen, and fissured deeply in all directions across the dorsum, with bald patches and white markings exactly like what we so often see on the tongues of those suffering from acquired constitutional syphilis. Such being the puzzling state of symptoms in the two children, I thought it warrantable to put a direct question to their mother. It will be seen that one child had the typical form of keratitis, but no other symptom, and the other a syphilitic tongue and no other symptom. Their mother at once admitted that she had suffered from syphilis soon after her marriage. She had "sores, followed by rash and Digitized by Microsoft® 108 INTERSTITIAL KERATITIS. sore throat, and was treated at an hospital and salivated. Both her hushand and herself had, since their recovery from secondary symptoms, remained quite well. The mother denied that either of her children had presented any sus- picious symptoms in infancy. This statement was quite in accordance with the absence in both of the usual features of the syphilitic physiognomy. Case CIl. — Interstitial keratitis — Typical teeth and physi- ognomy — History of infantile symptoms of syphilis in the father. The following case is one of especial value as an illustra- tion of the accuracy with which in certain cases the peculiar form of struma, which is consequent on hereditary syphilis, may be recognized. A stout, well-grown girl (Mary T.), aged 18, was brought up from Norfolk by her father on account of her eyes. She presented herself amongst Mr. Dixon^s out-patients on May 34, 1861. Her cheeks were pallid and flabby, bridge of nose flattened, and there were fissures at the angles of her mouth. Her forehead was large and misshapen. Both cornea were difi'usely opaque from interstitial deposit. Mr. Dixon stated to the students that from the state of her eyes and her peculiar physiognomy he felt no doubt that her teeth would be found of the syphilitic type. Before looking at the latter, he also gave me an opportunity of joining in the confident expression of the same opinion. On inspection the teeth proved to be most characteristic. The father of Mary T. attended with her; he was a robust countryman, the picture of good health. I took him aside, and at once put the direct question to him. He told me that prior to his marriage (twenty years ago) he con- tracted a chancre, for which he was treated by mercury, and after which secondary symptoms followed. He thought himself well when he married, but during his wife's preg- nancy he had sores on his toes, which a medical man told him were venereal, and for which he was again salivated. From that time to the present he had never had any Digitized by Microsoft® CASES. 109 symptoms whatever. His wife's first pregnancy resulted in a dead birth, her second about a year later in the birth of Mary T. The latter in infancy suffered from the usual symptoms. Seven children had been bom subsequently, and were all living. Some of the elder ones had also suffered from suspicious symptoms. The father denied most positively that he had ever communicated the disease to his wife. It appeared probable that an attack either of iritis or of choroidal disease had occurred in the left eye in infancy, as the girl said that she had never been able to see with it. She had now no perception of light when the right was covered. The right cornea had been inflamed only eight months. General Comments and Summary. I have already remarked that the preceding series of 98 cases has a certain claim to a statistical character inas- much as I have, without selection, taken all the cases which have come under my notice. The desire to include all must be my excuse for recording several the data of which are very imperfect. In now proceeding to analyze the series, my task divides itself naturally into three parts. In the first place, I wish by the strict application of the numerical method to obtain a more closely accurate account of the disease known hitherto as " Strumous Corneitis," its symptoms, its usual course, and its ulterior results. Having thus sketched its natural history, I shall, secondly, ask the reader's attention to the statement of my reasons for believing that it is a direct consequence of hereditary syphilis, and occurs solely in the children of parents, one or both of whom has suffered from venereal disease. The question as to treat- ment will lastly come under notice, and I shall have to show that the prognosis may be materially bettered by the adop- tion of mild specific measures, instead of, or in addition to, the usual remedies for " struma." Before proceeding with this examination, however, I shall consult the reader's convenience by placing the cases before him in the following table. Digitized by Microsoft® no Tabular statement of one hundred and tw? i Sex 1^ i Which Eye affected. Patient's position in his or her family. Whole numher of births in family. Number Grounds ol In order of hivth. Amongst those no* liYing. of ChUdren now Jiving. Concomitant Diseases in the Patient. 1 M 4 4 Soth 10th 6di 11 7 2 3 4 6 P F P M 2 11 1 14 12 12 14 Both Both Both Both Not noted Not noted 2nd No note 1st 2na 1st No note 10 10 6 No note 6 6 4 5 Tinea tarsi. Deafiiess 6 7 8 9 P F F P 18 11 12 13 18 11 16 15 Both Both Both Both No note 2na No note No note 1st 1st 1st No note 10 4 7 7 2 2 4 4 Nodes. Lachrymal abscess. Swelling of both Itnee joints. Headaches and epi- lepsy 10 11 12 M M P U 18 12 11 18 16 Both Both ffl.L.) Both (L.E.) No note 2nd 1st 1st 2nd 1st 11 7 Nu note 3 3 No note Node on the tibia No note 13 F 5 6 Both No note No note 6 2 Konote 14 15 M M 16 8 16 8 Eight Both 1st 1st 1st 1st No note 3 No note 1 Nodes. Chronic abscessei and enlarged glands 16 F 18 ;18 Left No note 3ra No note 7 17 M 14 Both No note 3ra No note 4 18 P 20 Both 1st 1st No note No note 19 F 1 6 Both 4th 1st 4 1 - 20 F 2 4 Both 4th 2na 5 3 21 22 M F 14 8 14 8 Both Both 1st 1st 1st 1st 6 3 4 3 Nodes. Suppurated glandsS Exfoliation of alveolus \ Deafness {after otorrhoea) ' 23 F 19 19 Both (EX.) Note No note No note No note ■i 24 25 M F 8 23 21 23 Both Left No note No note No note 2na No note No note No note No note Complete deafiiess (after i otorrhoea) 26 M 10 12 Both 2na 1st 4 2 27 28 29 30 31 M F F M F 8 8 9 18 8 8 8 20 22 8 Both Left Both Both (E.L.) Both (L.E.) 1st No note 7th No note Ko note 1st 2nd 1st No note 1st 3 14 11 No note 9 3 7 S No note 2 DeaftiesB (after otorrhtea) Nodes 32 33 34 35 P P M F 11 14 3 11 17 6 15 Both (E.L.) Both (EX.) Both Both No note No note 3rd lat 1st No note 3ra 1st 8 15 5 13 2 5 6 8 Partially deaf (after otorrhoeal Suppurated glands in the necn 36 F 4? 9 Both 4th 1st 9 1 Nodes. Laryngeal and pha- ', geneal ulceration. Tinea tarsi Digitized by Microsoft® Ill ^SES OP INTERSTITIAL KERiTITIS. Lognosist Eemarke. 6 1 t Infantile o Teeth. Phyfiiognomy. History. Parents' History. i_ first set CharaoteriBtic Very suspi- cioufl Denied The comeae cleared in about two months. 1 pharacteristic SuBpicious Characteristic Denied Syphilis in hoth ) Two sisters ; the diathesis most f charaeteriscic in the elder. 2 Characteristic Denied Syphilis in both 3 ■Jo note Characteristic Conclusive Suspicious No direct questions asked. 4 attend, so that no history could ) he obtained. 8 9 !?haractei-istlc Characteristic Suspicious Not enquired into 10 Characteristic Suspicious Suspicious Syphilis hi the father Rapid improvement under specific treatment. 11 /haracteristic Characteristic ConcluBiye Syphilis m hoth •Great improvement under specific treatment. 12 'Irst set Characteristic Very suspi- Not enquired into Very decided improvement under 13 \i8picious cious treatment by iodides. Characteristic Conclusive Syphilis in both Great benefit from specific treat- ment. 14 Dharacteristic Normal Conclusive Syphilis in the mother The mother had had syphilis before her marriage. 15 Characteristic Characteristic Not enquired into Not enquired into Her eldest brother had probably had keratitis. ~ A sister had also had inflamed eyes. 16 Characteristic Suspicious Not enquired into Not enquired into 17 Characteristic Not character- istic SuspidouB History of syphilis in the father 18 first set Characteristic Conclusive Syphilis in both It is donbtfiQ whether the disease 19 was true interstitial keratitis at its commencement. First set Characteristic Conclusive No direct questions asked Her elder sister had also suffered from infantile syphilis. 20 Exfoliated Characteristic Conclusive Syphilis in the father The cornea cleared perfectly under specific treatment. 21 j second set not Characteristic Conclusive Conclusive 22 cut Characteristic Characteristic No note No note The patient was married, and kera- titis appeared to have been in- duced by suckling 23 Auspicious Suspicious Conclusive Conclusive 24 Suspicious Suspicious Not enquired into Not enquired into Her elder sister had also suffered from inflamed eyes. 25 Characteristic Characteristic Denied Denied A relapse in the left eye occurred a year after apparent recovery. 26 ^(haracteristic Characteiistic Suspicious Denied 27 Jfo note Characteristic Suspicious No direct questions asked 28 Characteristic Characteristic Conclusive Syphilis in both parents 29 Characteristic Characteristic No note No note 30 UXXU4 uK> uuL ja i/AU B7o note Characteristic Suspicious Not enquired into Effects of specific treatment very decided. 31 Sfo note Characteristic Suspicious Not enquired into 32 1^0 note Characferistic Suspicious Not enquired into 33 Tirst set Vo note Characteristic Characteristic Suspicious Conclusive Not enquired into Syphilis in hoth parents Some of the other children had also suffered from symptoms of infan- tile syphilis. 34 35 .Mo note Characteristic, Suspicious Not enquired into The right cornea was staphylo- 36 ilV" """*" nose wholly *• destroyed Digitized by Microsoft® 113 TABTTLAE STATEMENT OP OSE HUNDRED AND TW ■s d 03 S i Which Eye Patient's position in his or her femily. Whole Number Groimdjl tS^ ote No note 42 J note Characteristic Not enquired into Both parents dead 43 b note Characteristic Very suspi- Suspicious 44 Saracteristic Characteristic cious No history Suspicious Mother in a lunatic asylum. 45 baracteristic Characteristic Not enquired into Not enquired into Mother in a lunatic asylum. 46 baracteristic Suspicious No note No note 41 naracteTi&tic Characteristic Conclusive Syphilis in both parents 48 baracteristic Characteristic Not enquired into Syphilis in father His sister also had suffered from 49 jiaracterifitic Characteristic Conclusive Suspicious (denied) His elder sister had also suffered from eye disease. 50 t jmost normal baracteristic Characteristic No history Not enquired into CThe patients were a brother and < sister. The elder one as usual had 61 Characteristic No history Not enquired into (. suffered much the more severely. 5t ttaracteristic Suspicious Not enquired into Not enquired into His elder brother had his physiog- nomy and teeth yet more charac- 53 teristic of hereditary taint. baracteristic baracteristic Almost healthy Characteristic Not enquired into ConduBive Not enquired into Syphilis in both parents His elder brothers and sister had suffered from infantile symptoms with one exception. See page 73t. 5< 55 baracteristic Characteristic No note No note 5( baracteristic -baracteristic Characteristic No note No note 5' eg _ Characteristic No note No note 0! 4iaracteristic Cbai-acteristic Conclusive Syphilis in both parents Several children bom prior to the disease in the parents. See page 76. 59 iculiar (see page 77) laracteristic Characteristic Not enquired into Not enquired into 60 Almost that of Not enquired into Not enquired into 61 health . laracteristic No note No note No note 6. laracteristic Characteristic Conclusive Syphilis in both parents 61 laracteristic Characteristic Not enquired into Syphilis in the mother 6' rst set ' Characteristic Suspicious Not enquired into OO 1 laracteristic laracteristic Characteristic Characteristic No note Conclusive No note Not enquired into Both parents dead. Great benefit from specific treat- ment. 6E 6- jiracteriLtic Characteristic No note History of syphilis in the father Very suspicious Her mother was dead. 6£ laracteristic Characteristic Conclusive A younger sister also suffered from mterstitial keratitis. m rst set Suspicious Conclusive Syphilis in father ■J- laracteristic No note No note Syphilis in father 7' Laracteristic Characteristic Not enquired into Not enquired into An orphan. 1 £ 73 laracteristic laracteristic Characteristic Characteristic Conclusive Conclusive Denied Syphilis in both The patient was the first child bom afterthe parents had bad syphilis. 74 good form Characteristic Denied Not enquired into 71 1 j|racteristic Not character- istic SuspiciouB Not enquired into I € Digitized by Microsoft® 114 TABULAE STATEMENT OF ONE HUNDEED AND TVa .NDTVi Groundsil Sex. 77 78 79 SO 81 82 83 Bi 85 86 87 89 90 91 92 94 95 96 97 98 100 101 F F M F F F M M F M F F F M F F F M F ' F M Whicli Eye affected. 9 Both 8 Eight Both Both Left Both Both Both (L.E.) Both (L.E.) Both Both Both Both Both Both, E.L. Both, E.L. Eight Bight Both Both Both Left Both, E.L. Both Both Both Patient's position in his or her family. In order of birth. 2nd No note No note 1st 4th No note 1st No note Srd No note 7th No note 8th 1st 3rd 5th 2nd 1st No note let 2nd No note 5th No note 2nd Amongst those now living. 1st Srd No note 1st 4th No note 1st 2nd Ist 2ud 1st No note Ist 1st 1st 1st Ist 1st No note Ist 2nd 2nd 2nd 4th 2nd 1st Whole number of births in family. Number of Children now llfing. No note 6 No note 8 15 10 No note 8 7 3 9 6 4 No note 7 2 No note 6 17 I a No note 2 6 No note 3 2 6 5 4 No note I 5 1 4 No note 4 2 iduif Concomitant DisefueB in the Patient..' Bather deaf. glands Hydrocephalic and idiotil Enlarged glands Complete deafiiess Osseous node on the tibia i Enlarged glands in neck i Destruction of the softpalal Enlarged glands. In^aoifl lachrymal sac Ulceration of palate Nodes on the head. cephaluB. SUghtdei Psoriasis in the fEice i Iritic adhesions in the o] eye ■ Both pupils closed by b adhesions a Bea&ess; adhesion o^ palate after ulce^tic^ Epilepsy T Deafnes;; Iritic adhedoi Choroidal and iritic c in the eye 1. Affe. — It would appear that in a very large proportion of cases this form of keratitis occurs in patients between the ages of 8 and 15. Thus we find that in seven instances the disease began before the age of 5, in thirty between 5 and 10, in thirty-nine between 10 and 15, in sixteen between 15 Digitized by Microsoft® 115 &.SBS OF INTEESTITIAL KERATITIS. agnoBis. Remarks. Teeth. Physiognomy. Infantile History. Parents' History. •s iiEpidous ChBraoteristio Condusive Syphilis in both 77 Iharacteristic x Characteristic Suspicious Denied by mother It is probable that syphilis was con- tracted subsequent to the births of the elder children. 78 haraoteristic Suspicious Not enquired into Not enquired into A younger brother also suffered 79 haiacteristio Not character- istic ConclusiTe Syphilis in father from hereditary syphilis. A brother had lost one eye 80 liaracteristic Not character- istic Not enquired into Not enquired into 81 haracteristic Not character- istic Very suspi- cious Not enquired into 82 iharacteriBtic Characteristic Conclusive Syphilis in both parents 83 to note Characteristic Not enquired into Not enquired into 84 haiacteristio Not character- istic Not enquired into Not enquired into 85 iaracteristio Characteristic Very suspicious Not enquired into His eldest sister (see Case 33) had also had keratitis. 86 Itiaracteristilc Nob character- istic Characteristic Denied Syphilis in both parents 87 ihajacteristic 1^' Very suspicious Not enquired into 88 laracteristic Characteristic Conclusive Not enquired mto A very severe case 89 tlaraolieriatio Characteristic Not enquired into Not enquired into 90 onote Characteristic Conclusive Syphilis in both parents 91 annal Not character- istic Doubtful Denied Some doubt as to diagnosis (see page 98) 92 iiaracteiiBtlc Suspicious Not enquired into Not enquired into 93 itie typical Suspicious Small pox when a Not enquired into An unusually mterestmg case (see tootli year old page 99) JImt set Characteristic Suspicious Not enquired mto Has had iritis in infancy 95 gnaracteristic laracteiiBtic Characteristic Not enquired into Not enquired into Has had iritis in childhood 96 Characteristic Conclusive Not enquired into His elder brother also shewed the 97 characteristic physiognomy and teeth of hereditary syphilis laracteristic Normal Not enquired into Not enquired into 98 aracteristio Characteristic Not enquired into Not enquired into The epileptiform seizures were peculiar (see page 101) 99 jlaraoteristic Characteristic Not enquired into Not enquired into This patient was married 100 aplcious Suspicious Denied Syphilis in both parents Her elder brother suffered also from hereditary syphiUs 101 iiaracteristic Characteristic Suspicious Syphilis in the father 102 and 20, and in the remaining six between 20 and 25 j the average age for the whole series being 10. The disease would appear to be comparatively rare in early childhood, and still more so after adult age has been reached. I have never seen it commence in any one beyond the age of 26. i2 Digitized by Microsoft® 116 INTEBSTITIAL KERATITIS. (Case 100). With regard to several cases in the series in which it is stated to have begun in infancy, I feel some doubt as to the correctness of the history, as I did not see the patients until some years after its commencement. No doubt the eyes were inflamed at the date assigned by the mothers of the patients, but whether the affection was from the firist true interstitial keratitis is open to some question. I have never myself witnessed its occurrence earlier than the age of two years. (Case 20.) When it occurs in very young patients its course is rarely so typical and regular as it usually is in older children. 3. Sex. — It would appear that girls are more liable to this disease than boys. Thus in sixty-four of the cases before us the patients were females, and in only thirty-eight males, being a ratio of 1 of the latter to 1-7 of the former. This disproportion, though not so great, coincides with what I have shown to be the fact in respect of the acute iritis of syphilitic infants. Of the latter disease I am in possession of the particulars of twenty-three cases in which the sex is specified, and of their subjects eighteen were female infants, and only five males.* 3. State of health at the time of outbreak. — In none of the preceding cases is it stated that the outbreak of kera- titis had occurred during recovery from small-pox or any other exanthem, nor is there any note of other causes of ill health supposed to have acted as predisponents. In none of the cases was there any reason to suppose the patient to be the subject of phthisis or other tuberculous affection, and amongst the coincidents " conspicuous by their absence " (supposing •the affection to be " strumous,") is enlargement of the lym- phatic glands. In only eight cases did any affection of the cervical glands exist, and in several of these it was very slight. On the other hand, the series presents very few exceptions indeed to the following statements : a. That the patients were * Twenty-one of the cases referred to are recorded iu a previous chapter. Two other cases have come under treatment whilst these sheets were passing through the press. Digitized by Microsoft® COMMENTS ON THE CASES. 117 of peculiar pallor. In most the complexion was of a pale earthy or sallow hue, without a vestige of colour, and in none of the exceptional cases was there any degree of the excessive floridness so commonly seen in the subjects of glandular struma, b. That the skin generally, and that of the face especially, was thick, coarse, and flabby. These conditions are intended to be comprised whenever the term "syphilitic physiognomy" is used. I have never employed the latter expression except to denote a striking and remark- able condition, such as would, from its peculiarity, have arrested the attention of the most cursory observer, c. That the bridge of the nose was wide and depressed. This also is included whenever the above term has been used. d. That in the skin of the face there were numerous small pits and scars, and about the angles of the mouth the radiating scars of former ulcerations. The common non-specific erup- tions of childhood, — impetigo, porrigo, and eczema, — leave no perceptible scars whilst their syphilitic congeners almost invariably do. Small-pox, chicken-pox, and herpes, undoubt- edly do cause pits and scars which are often undistinguish- able from those of the syphilides : the conjunction of fissures at the oral angles with little pits in the skin of the face, a history of no one of these three aflfections being obtain- able, is, however, very suspicious, e. That, in those who had cut their permanent set, the condition of the upper central incisor teeth was very peculiar, both in form, colour, and size. As diagnostic of hereditary syphilis, various pecu- liarities are often presented by the other teeth, espe- cially the canines, but the upper central incisors are the test, teeth. When first cut these teeth are usually short and narrow from side to side at their edges. In the edge is a crescentic portion, thinner than the rest, which after a time breaks away, leaving a broad, shallow, vertical notch (see figures. Cases 50 and 53), which is permanent for some years, but between twenty and thirty usually becomes obliterated, by the premature wearing down of the tooth. The two teeth often converge, but sometimes they stand Digitized by Microsoft® 118 INTERSTITIAL KERATITIS. widely apart. In certain instances in which the notch is either wholly ahsent or but slightly marked, there is still a peculiar colour, and a narrow squareness of form, which are easily recognised by the practised eye. In a considerable number of the cases cited, no mention is made of the teeth, the notes having been taken before I was aware of the value of these peculiarities as a symptom. I have latterly, however, made it a rule always to look into the mouth, and, as yet, I have not met with a single example of well characterized inter- stitial keratitis, occurring in both eyes, in which the teeth were of normal size and shape. Indeed there can be no doubt what- ever, as to the truth of the assertion, that this malformation of the upper incisors (permanent set) is all but invariably found in the subjects of this disease. A few months' obser- vation at any large Ophthalmic Hospital will, I think satisfy any one of this clinical fact. The following special affections were coincident with the ketatitic disease. Large scars in the soft palate and pharynx, in eleven instances. Deafiiess, consequent on otorrhcea^ in seventeen. Nodes in nine (tibia, four ; radius, two ; head, two; ulna, one). Psoriasis on the face in four. Destruction of the nose by erosive lupus in three. Suppurated glands in the neck in three. Laryngeal disease in four. Tinea tarsi in four. Swelling of the knee-joint in three. Inverted eye- lids in one. Lachrymal abscess in three. Exfoliation of the alveolus of the upper jaw in two. 4. Previous history, more especially as regards infancy. In more than half the cases, a clear history of the occurrence of symptoms of inherited syphilis in infancy (rash, sore mouth, ulcers at anus, prolonged snuffles, etc.) was obtained. This proportion would probably have been much increased, but that in many cases I was unable to see the patient's mother, or any one who could answer questions on this head. In several, which I have not included in it, there was a history of one or more very suspicious symptoms; the group, however, not being sufficiently complete to allow of a con- fident statement. In numerous instances the mothers Digitized by Microsoft® COMMENTS ON THE CASES. 119 admitted that some of their other children had also suf- fered from similar symptoms in infancy. Many of those cases in which I was unable to obtain a history or to make inquiry as to infantile symptoms, are those in w hicLthe physiognomy, teeth, etc., were most characteristic. The frequency of otorrhoea, ulceration of the palate, etc., has already been stated. 5. History of syphilis in parents. — Those who have engaged in similar inquiries will feel no surprise at the fact that in twenty-nine cases only, did I obtain from the parents a free admission that one or both had, prior to the birth of the cJiild, suflPered from Tenereal disease in a consti- tutional form. Of these, in eighteen instances, the mother had been infected by her husband, and both were conse- quently diseased; in eight the father only was known to have had the disease j in two the mother had had syphilis before marriage, and believed the husband to be healthy; and in the remaining one there was a statement (probably untrue) about the communication of the disease to the infant by a tainted nurse. In about half of the cases, I either had no opportunity of asking questions on this score of either parent, or did not avail myself of it. In several instances syphilitic symptoms existed in one or other parent at the time that the notes were taken, and this class includes some in which, notwithstanding, all history of primary disease was denied. In a few cases, in which I could obtain no confession, the mother admitted that other medical men, who had attended her children in infancy, had asked the same questions. 6. Estimate pf viability of the patients^ family. — Very im- portant information may be reflected upon many of the ques- tions connected with inherited tendencies to particular forms of disease, by data as to the mortality which has prevailed amongst the brothers and sisters of the subjects of them. If the death-rate during childhood has been excessive there are grounds for believing that the taint is of a kind which mate- rially diminishes the vital power and predisposes to the Digitized by Microsoft® 130 INTERSTITIAL KERATITIS.- attacks of fatal diseases. "With the view of aflfording infor- mation on this point in relation to the subjects of interstitial keratitis I have inserted columns in the preceding Table showing how many children had been born in each family, how many were still living, and the position of the patient amongst them, i.e., whether eldest, second, third, etc. The latter datum, as will presently be shewn, is of especial import- ance. In calculating the average I find . seventy-seven only of the cases sufficiently complete to be used. In counting the number of children born to any one mother, I have included dead births, if at the full time. Miscarriages and premature births have been, of course, omitted. Proceeding on this plan, we find that seventy-seven mothers of subjects of interstitial keratitis, (the latter being at the time of inquiry of the average age of nine and a-half), had born families averaging seven in number, but which had been reduced by death to an average of 3*4. Seventy- seven mothers had born a total of 547 children, and of these only 284 remained alive. In other terms, seventy-seven patients suffering from interstitial keratitis pass before us, and we find, on enquiry that, taking one with another, they have all lost in early life nearly half of their brothers and sisters. There can be little doubt, despite the many fallacies to which statistics expose us, that this rate of mortality is high. 7. The patients are generally the eldest in their respective families. By examination of the seventh column in the tabular series, we find that there are 82 cases in which information is given as to the patient's position amongst the other living children of his parents. Of these 82 cases the patient was. The Eldest in 55 instances, a proportion of 1 in 1-5 Second in 14 „ „ 1 in 6 Third in 9 „ „ 1 in 9 Fourth in 3 „ „ 1 in 27 Fifth in 1 „ „ 1 in 83 This curious fact is made yet more impressive if we turn- Digitized by Microsoft® COMMENTS ON THE CASES. 121 our attention to the ninth column also. We there find that these 82 subjects of keratitis are the representatives of 284 brothers and sisters, or in other words that the number in each family averaged 3-4. We of course count only those living at the time the notes were taken. Now it is clear, that supposing the 284 children put together and a group of 82 drafted from them without any selection, this group ought to contain, of the eldest of their respective families, a pro- portion of only 1 in every 3-4. The tabular statement just given shows how different is the result in the cases before us, and demonstrates that interstitial keratitis in choosing out its victims, has some principle which guides its selection. It would appear, moreover, that not only does the disease select the eldest in a large majority of instances, but that it proceeds downwards by the same rule, preferring the second to the third, and so on. This statement of fact, strong as it is, would be yet further strengthened if two sources of fallacy could be removed : 1 st, that in certain instances, the primary disease had probably been contracted by the parent after the birth of part of his family, and that thus the patient, although not the eldest of the whole, was the eldest of those born subsequent to the taint beirg acquired. — 2nd, that in several instances in the series, both the eldest and the second child suffered from keratitis, and are in- cluded in the table. Why the first born should suffer most often, and most severely, from a disease consequent upon syphilis in the parent, we can easily understand ; it is in keeping with all that we know respecting the transmission of that disease. On the " strumous" hypothesis, however, to the exclusion of inherited syphilis, I think I may fairly challenge any one to offer a shadow of explanation of the remarkable facts just adduced. 8. Phenomena of the attack. — ^The phenomena of intersti- tial keratitis have been well described by several authors. I have given a brief resum6 of them at page 29, and need not here attempt any lengthy description. ,The series under Digitized by Microsoft® 122 INTERSTITIAL KEEATITI8. consideration, however, supplies us with several cases, in which less usual, and hitherto but little noticed, conditions were presented. The cases in fact divide themselves into four groups, according as one or other of the special symptoms of inflammation were in prominence. Group A includes the more common cases, in which inter- stitial deposit, without any great degree of sclerotic or con- junctival vascularity, is the prominent symptom. Group B comprises those cases in which, in addition to the interstitial deposits of lymph, crescentic firinges of capillaries are seen spreading from the circumference over the surface of the cornea. These fringes usually commence at the lower part, hut subsequently encroach from all parts, and sometimes nearly, or altogether, meet in the centre of the cornea. In the latter event, I have seen produced a remarkably vivid colouring of the whole surface. The degree of lachrymation and of intolerance of light, presjent in any given case, will usually be found proportionate to the extent of these fringes. Group C has been described at page 72, and is illus- trated by three or four cases only in the present series. In these there is a large effusion of lymph, in all probabilHy from the posterior surface of the cornea, moulding itself in the concavity of the latter, and causing for the time com- plete blindness. Hitherto I have never seen the superficial vascularity characteristic of Group B, coexistent with this state of things. After this form of disease, I suspect that the eyes are always more or less damaged permanently. Group D is characterized by the punctate effusion of lymph, in circumscribed dots on the posterior layer of the cornea. This condition is often seen in iritis, consequent on acquired syphilis; it also constitutes a most characteristic feature of what is known as aquo-capsulitis,' as distinct from interstitial keratitis. In a few cases of the latter affection however, it occurs as the first stage, to be followed sooner or later by effusions into the substance of the cornea itself. Although I have mentioned these varieties as distinct Digitized by Microsoft® COMMENTS ON THE CASES. 123 groups, yet it must be understood that they not unfre- quently stand in the relation of stages one to the other. The more severe conditions included in Groups B and C are, for instance, rarely produced, without either those of A or of D having preceded them. The occurrence of iritis, as a complication in cases of in- terstitial keratitis, although not unfrequent, is, I believe, far from being usual. The obscuration of the cornea is com- monly so quickly produced, that it becomes impossible to inspect the state of the iris, after the first week or two of the attack, and during that period, I have very rarely indeed been able to detect any evidence of the iris being affected. On recovery, the pupil is usually quite round and mobile, though not unfrequently the iris structure itself has lost much of its lustre, and looks dull and leaden. I have but rarely seen the pupil occluded. When iritis does occur, it is usually of but slight severity, and attended with but little tendency to effusion. In most cases interstitial keratitis affects both eyes, and with almost equal intensity. Both were involved in ninety- one of the one hundred and two cases under consideration ; in six the left alone, and in five the right alone. Out of thirty-five, in which the notes inform us as to which was first attacked, we find the left to have been so in seventeen instances, and the right in eighteen. Of twenty-six, in which like information is given, as to which was most severely affected, it is the left in seventeen, and the right in nine. As in most other symmetrical diseases, it is rare that the two organs are attacked quite simultaneously. The second is, I believe, usually affected from a few days to a few weeks subsequently to the first; Now and then, however, the interval is much longer. Thus in Case 43, a period of two years intervened, and in Case 31, one of four months. Case 36 is interesting as an instance of acute relapse in one eye, two years after the beginning of the attack, and when both had seemed to he nearly recovered. Several other instances Digitized by Microsoft® 124 INTERSTITIAL KERATITIS. of relapses, more or less acute, are scattered through the series, but they are decidedly exceptioiial. Ordinarily, when once the process of clearing has set in, it is remarkable how steadily it advances. I will now place in concise juxtaposition the chief reasons which induce me to regard interstitial keratitis as a direct result of inherited syphilis, 1st. From its being a very well-marked and peculiar form of ophthalmia, it is a priori probable that it acknowledges some single and definite cause. 3nd. Its subjects are almost invariably of very peculiar physiognomy, and usually bear the most marked similarity to one another. 3rd. Its subjects almost invariably have their upper central incisor-teeth, of the permanent set, dwarfed and notched in a, peculiar and characteristic manner. 4th. In most cases the features alluded to under the last two heads bear no resemblance whatever to those of ''struma'' properly so called. On the contrary, the subjects of tuber- culous struma, usually have large white teeth, and are often of a florid complexion. 5th. I have not yet seen a single case in which the patient was the subject of phthisis, and but very few in which suppuration of the glands of the neck had occurred. 6th. It affects by preference the eldest living child of the family, a circumstance to be expected under the syphilitic hypothesis, but wholly inexplicable under that of struma. 7th. It affects female children in preference to males, and usually occurs in families in which a large infantile mortality has taken place. 8th. It occurs in all classes of the community, the well- fed and under-fed, and the residents in the most healthy situations (sea-coast, etc.), as well as those of crowded cities. 9th. In a large proportion of those cases in which I thought it right to make direct inquiries on the subject, I obtained a confession that one or other parent had suffered Digitized by Microsoft® COMMENTS ON THE CASES. 125 from constitutional syphilis prior to the birth of the patient. 10th. In a very large majority of those cases in which I obtained information as to the health of the patient during early childhood, a clear history of the usual symptoms of infantile syphilis was given. 11th. In many instances there was a clear history of symptoms of infantile syphilis having been observed in brothers or sisters of the patient. 12th. Whilstj as above observed, enlargements of the lymphatic glands are unusual, other affections far more closely connected with syphilis than with true struma, such as nodes, ulceration of the palate, and erosive lupus, are not infrequent in the subjects of this disease. 9. Treatment. — The treatment which I usually adopt consists of the cautious use of mercurials and iodides, at the same time supporting the system by tonics and a liberal diet. The mild mercurial ointment rubbed in behind the ears, in the neck, or under the axillae, every night at bedtime, is the best mode of employing that agent, and one which in these cases I never omit. A mixture con- taining iodide of potassium, iodide of iron, and tincture of nux vomica is also usually prescribed at the same time. If the patient be very feeble, and if the case be one belonging to group B (page 122), that is, with much super- ficial vascularity, more direct tonics, such as quinine and the various preparations of iron, are indicated. The induc- tion of ptyalism ought certainly to be avoided. Although in one instance I witnessed most rapid improvement coinci- dent with its occurrence (Case 12), yet I feel sure that it is unwise to run the risk of so much reducing the patient's strength. Unless, indeed, the surgeon is certain that his patient is well fed and well protected from cold, the utmost caution ought to be used in ordering mercury. In Case 48 a rapidly induced ptyalism in a half-starved feeble girl cer- J;ainly did harm. If the intolerance of light be great the occasional employment of blisters behind the ears may do Digitized by Microsoft® 126 INTEESTITIAL KERATITIS. good, but some of the worst cases I have seen had become so in spite of setons which had been inserted into the temples. To Cases 14, 31, and 49, 1 would appeal in proof of the superior efficiency of a combined tonic and specific plan of treatment over a merely tonic one. Although, however, I have no doubt as to the superior efficacy of specifics, yet I would carefully guard my readers against expecting too much from their use. This {oipoo. of keratitis runs but too often a very protracted course, in spite of the best contrived plan of treatment. Neither mercurials nor iodides- wiU, as a rule, cut it short. If given to patients in fair general health at a very early period of the attack, they wiU, I believe, prevent the efiiision from being copious, and very much limit both the extent and duration of the disease. Bat if the surgeon expect from them such proof of specific efficacy as we often see displayed in the various forms of acquired {i. e., not hereditary) syphilis, he wiU be disappointed. I have not as yet tried mercurial fumigation in a suffi- cient number of cases of inherited syphilis to be able toi report on its efficacy as compared with other modes of administration. It is, however, weU worthy of more atten- tion than it has yet received. Of its superiority in acquired, syphilis there can be no doubt. 10. Prognosis. — If a case of interstitial keratitis be seen early, and before any large extent of the cornea has become' opaque, a very favourable opinion may be given. If intole- rance of light is an early symptom and is extreme in degree,, the prognosis must be much more guarded. In proportion as the intolerance is slight the prospect is favourable. Even in the most severe cases a hope that a certain amount of clear- ing will take place may be expressed. The patient and his friends must, however, be informed that the recovery wiU be very slow, and at best imperfect. Although the absorption of interstial opacities is often accomplished to a surprising extent, yet when they have been large, and have existed for a long time, they are seldom wholly removed. During pro- Digitized by Microsoft® COMMENTS ON THE CASES. 127 tracted inflammation the structure of the cornea often suflers, and when the intolerance of light passes off, and the deposits; clear away, it is then found that the cornea is misshapen. The alteration in shape, as far as I have observed, is usually" a flattening; that is, the state ultimately produced is the reverse of conical cornea. It must always be remembered that during a severe attack of keratitis there may also be inflammation of the choroid or retina going on. The state of the deep textures cannot be ascertained on account of the opacity of the cornea. Under these circumstances, a quivering motion of the globes on exposure to light is to be regarded as a symptom of Hi- import. It is quite common for a patient with this form of keratitis, in both eyes and of a severe type, to be for a month or two practically blind. The blindness is partly due to the corneal opacity, and in part to the intolerance of light, which prevents his giving the eyes a fair trial. If this stage should last more than a few weeks, it becomes a legi- timate cause for anxiety. The duration of these cases is very unequal. I have seen the cornese cleared, and the attack over within two months, or even less, from the date of the commencement, but this is rare. More frequently from six to eight months are consumed before the cornea is restored to fair trans- parency. In many cases the duration is yet longer, and we have not a few patients attending at Moorfields in whom slow improvement is still taking place after the lapse of several years. I am persuaded that most of our systematic works understate the risk of permanent damage to the eye which attends this disease^ and also give the average duration of its attacks as considerably shorter than they will be found to be in reality. It is necessary to keep careful notes, of all cases if we would avoid erroneous conclusions on those points. 11. Diagnosis. — Facility in the diagnosis of this disease can only be acquired by careful clinical observation. It most Digitized by Microsoft® 128 INTERSTITIAL KERATITIS. especially requires a trained eye. The conditions which I have most frequently known to be mistaken for it are certain forms ©f inflammation following small pox, and very super- ficial ulcers in a healing stage. Cases of vascular conjimctiva may now and then present themselves, the aspect of which is not easily distinguished from that of the more acutely congested stages of the disease in question. The ground glass appearance prior to the more vascular stage, and the pink or salmon-coloured hue assumed by the cornea during the latter stages are, however, very characteristic, whenever they are present in a well-marked degree. T have seen two cases in which the cornea passed into a well-marked " ground glass " state of opacity, but in which there was no reason to consider the disease syphilitic. In neither of these, however, was more than one eye affected, and in both the congestion of the conjunctiva was excessive. To those who have not had opportunities for observation at an Ophthalmic Hospital, I would recommend that the diagnosis shoiild be held to be doubtful if the patient does not present the peculiarities of teeth and physiogonomy which I, have des- cribed, since we find that the latter are almost the invariable concomitants of the true disease. It may not be out of place to quote here the brief par- ticulars of the following case, against which, in my note- book, I find written: — " The left eye as closely simulates the condition of syphilitic keratitis as any that I have ever seen." The grounds on which the differential diagnosis was based will become apparent in the narrative. Thomas B., a well-grown lad, was admitted on account of inflammation of both eyes. He often had it before, and from infancy his eyes had been weak. The left cornea was diffusely hazy, but on careful inspection its opacities were seen to be superficial rather than interstitial, and instead of being chiefly in the centre were most numerous near the circumference. On the right cornea, near to its circum- ference, was a white-margined superficial ulcer. In both there was considerable conjunctival congestion, and th^ Digitized by Microsoft® COMMENTS ON THE CASES. 139 intolerance of light was extreme^ being quite out of propor- tion to the visible changes. The lad's aspect was very characteristic of non-syphilitic struma. He was florid, his alse nasi were very thick, and his upper lip was tumid and presented a deep inflamed fissure in its median line. His teeth were large, of good colour, and perfect as to form. His mother stated that he was quite healthy in infancy ; ran alone early ; and never had either rash, thrush, or snuffles. He was the fifth of seven living children. 13. Prophylaxis. — I shall consider, in a separate chapter, the question of the management of children known to be the subjects of inherited taint, with a view to the anticipation of the diseases to which they are liable. The remark may, however, be suitably introduced here that mercurial treat- ment in infancy certainly does not prevent the risk of inter- stitial keratitis at a more advanced age. Very many of the eases I have given are in proof of this. As to what might be the influence of a course of mercurials or iodides given just prior to the outbreak, it is impossible to say. In a few instances I have known the other eye to be attacked subse- quently to the commencement of specific treatment for that first afi'ected. These have, however, been but few, and I have witnessed precisely similar occurrences during the treatment of iritis from acquired syphilis. If mercurial treatment will not prevent the liability to syphilitic keratitis, neither will the utmost attention to diet, or the most judicious and liberal use of tonics. 1 have had several cases under care in private in which the patients were of wealthy families and had enjoyed every advantage which country air, change of air, and the habitual use of a liberal regimen could give. Digitized by Microsoft® 130 INFLAMMATIONS OF CHOROID AND RETINA. CHAPTER III. INFLAMMATIONS OP THE CHOKOID AND RETINA DEPENDANT UPON INHERITED SYPHILIS, That in tlie forms of inflammation of the eyeball which resvilt from acquired {i.e., not congenital) syphilis the choroid and retina are not unfrequently aflfected, has been placed beyond all doubt by the introduction of the ophthal- moscope. White patches of lymph may, by. its aid, frequently be seen occupying various positions in the fundus of the eye, and their removal may often be effected by mercurial treatment. That these deposits are in the choroid coat is proved by the fact that the retinal vessels may usually be seen upon their surfaces; The inflammation however by no means confines itself to the choroid. The retina often becomes congested and hazy, and sometimes a condition of general cloudiness is observed, which can be explained by no other hypothesis than that the delicate frame- work of the vitreous itself is the seat of inflammatory deposit. In fact, syphilitic ophthalmitis, although most frequently met with as a form of sclero-iritis, may involve any one or all of the different structures of the eyeball.* This, then, being the established fact in the acquired syphilis of adults, we might conjecture that nearly the same would be observed in the inherited disease of children ; —and such is indeed the case. Were it not that in them the deeper lesions generally occur either with or after an attack of keratitis, 1 have no doubt but that they would be much more frequently noticed. It is the hazy state of cornea which not seldom prevents an ophthalmoscopic inspection and also at the sime time furnishes an apparent explanation of the impairment of vision. Every now and then, however, * To Dr. Jacob, of Dublin, much credit is due for the strenuous assertion of this doctrine many years ago. Digitized by Microsoft® GENERAL REMARKS. 131 we meet with examples of choroidal disease of this type, in which either the cornese have escaped or have cleared suffi- ciently to allow of examination. In such the disease may be traced through several distinct stages. The first of these is characterized by much dimness of vision, and by the presence of diifused patches of lymph in the choroid, the retina being hazy and now and then the vitreous also. After a while the sight improves and the patches become more defined, and in the third stage, that of cure, the latter are seen abruptly circumscribed and unattended hy any deposit in the adjacent tissues. The cases to follow exemplify chiefly the two latter stages of the disease. Although, as I shall have to show subsequently, the changes chiefly involve the choroid, yet they are seldom limited to it. Even if they were, it could scarcely be expected but that the overlying retina should also suffer in some degree. The amount of vision, which the subjects of most extensive choroidal disorganisation of this kind often retain, is however proof that the retina is some- times but slightly and secondarily involved. (See Case III, Charles M.) It must not be supposed that this form of disease is invariably of one type, for although in most instances such is the case, in a few remarkable deviations occur. The first case which I shall adduce is one in which the eflusion was unusually extensive. Case I. — Hereditary syphilis — Free effusion of lymph into the choroid of the left eye with detachment of retina and com- plete blindness — Sotted Deposits of lymph in the right choroid. Frederic C. B., aged 17 months, was admitted in Decem- ber, 1857. His mother stated that she had sufi'ered from sores, followed by a rash,, soon after marriage. Of her first three infants, two had been born dead, and one had died soon after birth ; the patient was her fourth, and the only one now living. At the age of three weeks he had "dreadful K 2 Digitized by Microsoft® 133 INFLAMMATIONS OP CHOROm AND RETINA. snuffles" and discharge from the nose, and although at first a fine bahy, rapidly fell away and became miserably puny. When three months old a rash broke out, and the mouth and nates became very sore. He was now treated by a physician for inherited syphilis, and had mercury freely given, with the result that all external symptoms passed away. When his mother brought him to the Ophthalmic Hospital, it was on account of her fear that he was going blind. She had noticed that his eyes rolled about much, and had fancied she saw "a, white skin" on the left. The child now had a clear skiu, but there were puckered scars at the angles of the mouth; his teeth were small, of bad colour, and very irregular, and the bridge of the nose was sunken. Even without the use of the ophthalmoscope, it was easy to see that a yellow white substance occupied the fundus of the left eye. Both irides were perfectly clear, and there was no sclerotic congestion. Light was borne well, and both pupils were fairly active. Atropine having been used, it was seen with the ophthalmoscope that an extensive layer of lymph was smoothly spread out over almost the whole of the central part of the choroid. No vessels were seen on its surface, and the presumption, therefore, was that either it was upon the retina, or, more probably, that it had led to its detachment and destruction. Its smooth surface opposed the idea that it had been effused free into the cavity of the globe. In the right eye numerous white spots of lymph were seen, but the retina itself was not disorganised, and the entrance of the optic nerve was distinct and normal. The infant, as far as could be ascertained, was all but sightless. The iodide of potassium internally, and mercurial inunction were prescribed; but, owing to the mother's irregularity of attendance, the treatment was very imperfectly carried out. On June 18th, six months after admission, the note states that " he can see with the right better than he did, but only very imperfectly. In it the spots remain in statu quo, and are still plainly visible. In the left the large patch of lymph is more easily seen than it was, because it has become much Digitized by Microsoft® CASES. 1S3 wMter and more glistening. As to prominence and extent it is much as it was." Case II. — Large cicatrices in the choroid of the right eye — Teeth and physiognomy typical of hereditary syphilis. For permission to make use of this case, I am indebted to Mr. Dixon, under whose care the hoy was. Charles H., aged 14, from Croydon. The lad was brought to the Hospital on account of very defective sight in th^ right eye. His left had almost perfect sight, and with it he could read easily. On examination of the right eye with the ophthal- moscope, numerous patches of various shades, from red and pink to white, were seen beneath the retina. One of these, which was nearly circularj very much resembled the optic entrance, and excepting for the absence of vessels, might easily have been mistaken for it. By the margins of the white patches, were many small masses of pigment. The right eye diverged considerably, and he could see but very little with it. His mother stated that he was her only child, and that in infancy he had suffered severely from rash, thrush, snuffles and sores at the anus. The medical man who attended him at the time said that his symptoms were " due to disease derived from his father." His mother had had one miscarriage prior to his birth, but had never since conceived although now for six years married to a second husband. The boy^s aspect and teeth were most characteristic^ He was of bad complexion, and had psoriasis on the face. The affection of the right eye was believed to date almost from infancy. As the choroidal changed were evidently those of long passed and now retrograde disease, Mr. Dixon did not adopt any treatment. Case III. — Extensive cicatrices in the choroid of both eyes — Physiognomy and teeth suspicious — History suspi- cious. Charles M., aged 30, a pale cachectic lad. On his Hospital letter was a memorandum by Dr. Bader, who Digitized by Microsoft® 134 INFLAMMATIONS OF CHOEOID AND RETINA. had previously seen him, " specific changes in both eyes ; of six years' duration." The ophthalmoscope showed abruptly circumscribed patches, of a dead white colour, on various parts in the fundus of each eye. In both, the retinae, where not involved by the patches, were very pale, and the optic entrances were irregular. The patient, notwithstanding these changes, stated that he was still able to work as a shoe maker, though he could see but very imperfectly. His physiognomy was very suspicious, and his teeth, although by no means typical, were small and much worn down. There were fissures extending from the angles of the mouth. His father was dead, and was reported to have been a dissipated man, although as far as his mother knew, neither he nor herself had ever suflfered from venereal disease. His mother had borne sixteen children, of whom the patient was the only one now living. An elder brother, who had died at the age of seven- teen, had attended this Hospital with " bad eyes," for many months. Case IV. — Hereditary syphilis — Interstitial keratitis, with iritis, cataract, and choroiditis — Complete loss of vision in one eye — Excision of the globe and subsequent dissection of it. Mary Ann R., single, aged 31, under the care of Mr. Poland, during 1859 and 1860. Her aspect was most characteristic of hereditary syphilis. Her teeth, both upper and lower sets, were horizontally notched and most exten- sively deformed, but the upper incisors (the test teeth), had been so much broken away by caries, that the vertical notches were scarcely recognizable. Her right globe had been excised by Mr. Poland, haviiig been disorga- nized and rendered sightless, by the results of syphilitic choroiditis, etc. It appeared from her history that she had had a cataract in this eye. At another hospital four operations had, she said, been performed for the removal of the cataract. (See Dr. Bader's Report below.) Her left Digitized by Microsoft® CASES. 135 cornea had opacities in its structure, and the pupil was adherent at two or three points. She could just manage to see to readj but only with difficulty. It appeared that she had had excellent sight, up to the age of 17, when an attack of inflammation occurred, in which both eyes were involved, and which rendered her blind for some weeks. She was the eldest living in her family. The first infant had died at three days' old. Two younger than herself, and aged respectively, 20 and 17, were living, and reported to have good sight. The following account of the ophthalmoscopic examina- tion and of the dissection of the globe after excision, has been obligingly supplied to me by Dr. Bader. I am not aware that any other opportunity of examining after removal the exact state of the choroid, retina, etc., in this form of disease has been obtained. The report is, therefore, pecu- liarly valuable. Report of the state of the eyes at the date of the excision. Left Eye. — Portions of the cornea are slightly misty; its convexity is increased ; the anterior chamber is large, the iris has the peculiar steel-blue colour ; several posterior synechise exist but interfere only slightly with the activity of the pupil. With the ophthalmoscope the optic nerve is seen to be of a gray-pink colour, as is frequently observed in similar cases; the coats of the fundus are thinned, and staphylomatous near the optic nerve. Portions of the choroid are sprinkled with minute black dots. The sight of this eye, considering the state of the cornea, pupil and fundus, is good. The eye is irritable from sympathy with its fellow. The RIGHT EYE has no perception of light. The iris can only be seen here and there, owing to the extensive opacity of the cornea, and, where seen, is in apposition with the latter. The greater part of the cornea is replaced by opaque tissue, portions of which are staphylomatous. The Digitized by Microsoft® 136 INFLAMMATIONS Off CHOROID AND EETINA. tension of the eye is normal. It has occasionally beeii painful and red since vision was lost ; and during the last month there has been constant pain and inflammation. Report of the dissection of the right globe. The right eye was excised by Mr. Poland and was immediately examined. It was generally enlarged^ but the transverse diameter exceeded the anterior one. The anterior surface of the rotten and atrophied iris was adherent to the tissue which replaced the cornea, and was in apposition with the translucent portions of the cornea. The opaque thickened suspensory ligament was adherent to the posterior surface of the iris ; the thickened, empty lens capsule adhered to the pupillary margin and to the tissue which replaced the cornea. The vitreous space was occupied by a chocolate coloured turbid fluid, which consisted of debris of the . framework of the vitreous humour, of blood-corpuscles and of a highly albuminous fluid. The inner (vitreous) surface of the membrane, which intervenes between that part of the tunics known as the ora serrata and the vitreous space, was sprinkled with smaller and larger gray opaque patches of fibrous tissue. The choroid _ surrounding those patches and the neighbouring ciliary processes were (Edematous. The retina was in apposition with the choroid, it was slightly hazy, but admitted of a good view of the choroid. Minute grayish-white and yellowish opaque dots were seen in its substance, especially round the optic nerve. The optic nerve itself ahd the yellow spot appeared healthy. The choroid appeared much thinned, and was of a pale brown colour. Its retinal surface was sprinkled with minute, black, roundish spots ; these were most numerous on the portion situated between the equator of the eye and the ora serrata. Some of these spots projected from the choroid, but without afi"ecting the surface of the retina. Portions of the ktter remained adherent to the choroid when Digitized by Microsoft® CASES. 137 peeled off- this occurred chiefly to those portions of retina which were situated over or near the black spots. Microscopic examination of the diseased Tissues, a, — The choroid and the hexagonal cells. The stellate pigment of the choroid and the large choroidal vessels offered no peculiarities. Numerous clusters of cells were deposited round the capillaries and round those of the larger choroidal vessels, which are near the elastic lamina; these clusters had a roundish shape. The cells were of crown-glass colour and strongly translucent, being in size somewhat larger than blood corpuscles. Some of the blood vessels were entirely surrounded by cells, others only on the side nearest the elastic lamina. The latter had in many places disappeared, and the cells had passed through the gaps and occupied the place of the adjoining rods ; these latter were in other places distorted, bent, etc., by similar clusters of cells. In no instance had these cells passed beyond that part of the retinal framework. The cells were in immediate apposition with each other, and separated from the surrounding parts by a thin layer of obscurely librillated tissue ; the fibrUlse were lost sight of in the surroundipg pigment of the choroid ; in the retina they mingled with the rods. The margins of the apertures in the elastic lamina of the choroid were thickened by a tissue similar in appearance and transparency to that of the lamina. The hexagonal cells appeared normal, except those over portions of choroid which were occupied by clustered cells, and those which immediately surrounded the apertures in the elastic lamina. The former had lost theii* hexagonal shape j they were rounded oflF, and their pigment granules, instead of being of a pale brown colour as the remainder, appeared, some deep brown, others black ; which, seen with the naked eye, gave Digitized by Microsoft® 138 INFLAMMATIONS OP CHOEOID AND RETINA. the choroid the appearance of being sprinkled with black dots. The latter were heaped up round the apertures in the elastic lamina ; they were round, and their pigment granules were black j at many places these cells had been displaced among the rods. The clusters of cells were most numerous in the portion of choroid at the equator of the eye ; the choroid round the optic nerve and yellow spot appeared healthy. b. — The retina. The framework of the retina, the rods excepted, appeared not changed, the latter were, as above mentioned, displaced, distorted, etc., by the morbid, products emanating from the choroid. Many of the loculi, formed by what are called the radial fibres, were empty, others were occupied by healthy looking ceUs, others were filled with what appeared to be oil globules. The greyish white and yellowish opaque dots, seen in the retina with the naked eye, were due to these accumulations of oil (?) globules in the loculi of the retinal framework. The place of the delicate cell-layer, , immediately beneath the optic nerve fibres, was occupied by an amorphous mole- cular greyish deposit. The walls of the retinal blood vessels were thickened. The layer of true optic nerve fibres which overlays the retina appeared healthy. Case V. — Entire loss of vision in both eyes in a boy, the undoubted subject of Hereditary Syphilis — Ophthalmo- scopic examination wanting. Edward W., aged 10, a boy of fairly healthy aspect, but pale. Bridge of nose rather broad, and some psoriasis about the skin of face. The incisor teeth were not notched, but were of very peculiar form, being so much narrowed late- rally, that they almost resembled canines. Their form was such that, despite the boy's healthy aspect, and the absence, of notches, I at once suspected the true nature of the case. Digitized by Microsoft® CASES. 139 The history -was, that in infancy he had had purulent ophthalmia, after recovery from which, however, he enjoyed perfect sight, and retained it until a year ago. The left eye began to fail first, and subsequently the other ; and after a few months he became, as he was when these notes were taken, totally blind. On inspection, the left pupil was seen to be much larger than the other, and both were very slug- gish. There was not the least congestion about any part. His tonsils showed cicatrices, and were atrophied. His mother stated that she had had syphilis soon after her marriage, and had suffered severely from it. I have unfortunately mislaid my notes of the ophthalmo- scopic examination in this interesting case, and, not knowing the boy's address, am unable to complete the account. Case VI. — Numerous cicatrices in the choroid — Syphilitic physiognomy and teeth — History of infantile symptoms. Charles D., aged 9, the second of three living children (a fourth having died), attended under Mr. Bowman's care during 1859. His mother denied all history of syphilis, but she did not appear to speak openly, and against her denial were the facts. In infancy he had suffered from severe and prolonged snuffles, attended with a rash on the body, for the cure of which, the late Mr. Gossett ordered a small pUl night and morning for many months, (probably mercury). His mother stated that he took the pills almost continuously for nearly two years. His aspect was characteristic J nose very much sunken indeed: head large : teeth separate, narrowed, and slightly notched (quite typical) . In both eyes the ophthalmoscope showed numerous round patches under different tracts of the retina, of various sizes and quite white and glistening. Around many of them was seen a minute crescent of iron-black pigment. The patches were totally destitute of vessels. The choroid on other parts was paler than normal, and as if thinned. On many large. Digitized by Microsoft® 140 INFLAMMATIONS OP CHOROID AND BETINA. ill-defined patches, slender networks of vessels, were seen coursing over surfaces destitute of pigment, and looking as if on paper. In each eye the cornea, lens, and vitreous body were perfectly transparent, and allowed of the deeper structures being very clearly seen. The boy had great difficulty in directing his eyes, and there was a slight squint, but he could see sufficiently to have learnt his letters. He always looked sideways at any- thing he wished to see — never straight. The history given as to his eyes was that in infancy he always had a peculiar rolling motion of the globes, and did not appea;r to see well. On account of this symptom many surgeons were consulted. No external inflammation of the eyes had ever been noticed. It thus appeared probable that the choroiditis dated back from early infancy, about the age when iritis usually occurs. Very possibly the boy may, in the secLuel, suffer also from keratitis. Case VII. — History of hereditary syphilis — Numerous cicatrices in the choroid of the right eye. Samuel B., aged about 12, of fair complexion, and characteristic aspect. His four upper incisor teeth were want- ing ; the canines and lower set presented as marked features as are fever seen in those teeth, being remarkably peg-shaped and notched. His mother had borne six children, of whom three had died, Samuel B. being the second of those living; When an infant, he attended the hospital on account of inflamed eyes; the attack, according to his mother's description, not having been one of purulent ophthalmia. He had at that time bad snuffies and a troublesome rash on the body, as well as a very sore mouth. His mother stated that she had contracted syphilis from her husband subsequent to the birth of her second child; and that, although treated, by mercury, she had suffered afterwards from ulcerated sore throat and rash. All her children born since bad had specific symptoms in infancy, excepting the last. The sight of the Digitized by Microsoft® CASES. 141 boy's right eye was all but lost. The ophthalmoscope showed many circular white patches, not a few of which had black dots in their centres. The patches were of glistening white and the choroid and retina appeared to be wholly disorganised and absorbed at these parts. My note, as to their condition, was taken July 8, 1859 ; unfortunately it is very incomplete, and I have no mention of the state of the other eye. Case VIII. — Hereditary syphilis in a severe form — Keratitis in both eyes at the age of two years — Entire loss of sight in the left from choroidal disease at the age of twenty. Emily H , aged 23, bearing the physiognomy of here- ditary syphilis most unmistakeably, came under my care in January, 1859. She had often been a patient at the hos- pital previously — ^indeed, almost the whole of her life. The bridge of her nose was sunken and broad, there were large cicatrices at the angles of the mouth, and many pits in the skin of the face and forehead, the skin itself being thick, oily, and of bad tint. Her teeth were small, peggy, of bad colour, and the upper- incisors notched. Her tonsils were wasted, and she was somewhat hoarse. Her mother told me that she was herself separated from her husband on account of his having several times given her venereal diseases, from which he had himself suflFered very severely. Emily H. was the only one now living, and the eldest born. Two born subsequently had died (the first of hydrocephalus, under the care of Dr. Conquest ; the second " of consumption," much wasted, at the age of nine months). In infancy Emily H. had purulent ophthalmia, and " bad snuffles," a rash over the body, and a very sore mouth. She was treated for hereditary syphilis; and subsequently, when two years old, she was for three months under the, late Mr. Scott's care at the Ophthalmic Hospital, for what, from the history would appear to have been keratitis. From this she recovered so far as to be able to learn to read, but her sight was ever afterwards much- impaired. About eighteen months ago her left eye began to get rapidly worse. Digitized by Microsoft® 143 INFLAMMATIONS OF CHOROID AND RETINA. She had severej long-continued, and deep-seated pain in the globe, and after the lapse of a fevr weeks was so blind that she could but just perceive the window. At the date of my note she could not detect the shadow of a hand passing before the eye. The cornea bulged and was hazy : the pupil dilated and fixed. She had been accustomed to see black muscse floating before it, whilst she retained sufficient power of vision to perceive them. The state of the cornea pre- vented ophthalmoscopic inspection* Case IX. — Disease of the vitreous body and deposits in the retina of the right eye — Cataract in both eyes — Physiognomy and Teeth typical as regards hereditary syphilis. Caroline G., aged 13, was admitted as an out-patient on October 14th, 1858. 1 saw her for the first time on March 10th, 1859. Her hospital letter had the following note on it, written by Dr. Bader, at the date of her first admission : " Vision failing for a year past. In the right eye numerous black patches on the retina and some around the entrance of the optic nerve. Some opacity of the lens. Cataract in the left eye." Fully recognising her diathesis. Dr. Bader had prescribed the bichloride of Mercury, in doses of one- twentieth of a grain three times a day. On March 10th, 1859, her condition was much the same as when first described by Dr. Bader. There was a well- formed homogeneous, bluish cataract in the left eye, which according to her statement, had been present for several years. She was quite positive that it had formed within her recol- lection, and had not existed in infancy. The sight of the right eye was so defective that she could not see to read; she expressed herself as quite certain that three years ago she could read easily. On ophthalmoscopic inspection of the right eye, black strise were seen in the lens and there were also floating films in the vitreous humour. On the retina were many dark spots of deposit. This girl's teeth and physiognomy were most typical. Digitized by Microsoft® CASES. 143 Her face was covered with patches of psoriasis, and presented small pits. She had had small pox when nine years old. Case X. — Extensive inflammatory changes in both choroids — Aspect and teeth characteristic of hereditary In April, 1860, Dr. Bader was good enough to hring under my notice the following case, a good instance of cho- roidal disease dependant upon hereditary syphilis. William N., aged 13, a boy of very dark complexion, and of markedly syphilitic physiognomy. His mother stated that he was her only living child, but she was herself so deaf that it was impossible to obtain any history of his infancy. His eyesight had been failing for many years, but he had never had any attack of external inflammation. His cornese were both perfectly clear; his upper incisor teeth were charac- teristically notched. His vision was so far impaired that he could only read large print with great difficulty; his left eye was the worse of the two, and both were somewhat improved by the use of concave glasses. On ophthalmo- scopic examination the optic entrances in both eyes were seen to be ill-defined ; the vessels of the retina were small, and in the choroids were numerous small white patches, interspersed with deposits of pigment ; the choroidal patches were not abruptly defined, but merged off gradually into the more healthy structure. The morbid conditions were most advanced in the left eye. Case XI. — Physiognomy of hereditary syphilis charac- teristically marked — History of a bygone attack of double interstitial keratitis — Choroidal changes in both eyes. The notes of the following case are from those kindly supplied to me by Dr. Bader. In it the choroidal changes were well marked. It is from the left eye of this patient that the drawing (see Plate I, fig. 5) was taken. Emily D., aged 18. She was a delicate girl up to the Digitized by Microsoft® 144 INFLAMMATIONS OP CHOROID AND RETINA. age of ten years ; she has suffered much from headaches ; at the age of 16 she had an attack of rheumatic fevey. It was stated that her sight began to fail twelve years ago, and that seven years ago both eyes were inflamed, but as far as can be ascertained, by the patient's account, without implication of the retina. There was then, it was stated, merely the power of perceiving light, and this continued for some months, after which the inflammation subsided, and the sight gradually improved, the eyes being left in the condition described below. August, 1859. — "The patient bears the typical marks of hereditary syphilis ; the teeth are stumpy, the corneas hazy, the tonsils swollen, and the general aspect clearly indicative of. the diathesis. It may be remarked that her sister presents similar characteristics. The cornese' of both eyes are slightly hazy and irregularly oval; the pupils are active but irregular ; the irides have the character- istic steel-blue colour; with the righi eye she can read the smallest type, and can tell the time on a distant clock ; with the left, which was always the weaker and smaller, she can see, but cannot read, large type — she can see the face of the clock but cannot tell the time. It appears, by this examina- tion, that she can see better with some of the lateral portions of the retina. In both eyes, with the ophthalmoscope, the lens and the vitreous humour are transparent. When the examination is not assisted by the lens numerous black muscae appear as if floating in the vitreous space (this appearance is due to the oscillation of the eye bringing to view different pigment patches on the fundus). The optic discs are small and slightly oval, greyish pink, hazy, indis- tinct, not well defined, and shade off into a whitish ring which separates the rest of the optic nerve entrance from the fundus. Passing through the left, a few retinal vessels only are dimly seen, but in the right they are more numerous. The fundus round the optic nerve, and at the yellow spot is hazy and red, and is sprinkled with irregular white and brown patches, and with minute pigment granules. On the lateral parts the large choroidal vessels are well seen, and here also Digitized by Microsoft® CASES. 145 the fundus is sprinkled with numerous large well-defined black patches." Case XII. -^Double keratitis with choroidal disease — Physiognomy of hereditary syphilis — Ophthalmoscopic exami- nation. I quote the following interesting case and the observations appended to it, from a paper by Dr. Bader, published in the Ophthalmic Hospital Reports for Octoberj 1858. It will be seen that the observations contain some important state- ments in corroboration of the views I have advanced in this memoir. "Ann SimmonSj aged 17, a strong girl, suffered from purulent discharge and bleeding from the nose when two years old. Loss of substance and subsequent changes in the nasal cavity appeared to have caused the deformity that now exists, the roof of the mouth being drawn up, and the bridge of the nose fallen in. " Eighteen months ago both eyes spontaneously inflamed — ^the left first. They were painful and red at the time, and recovered after six weeks without medical treatment. Vision in the right eye was normal. In the left eye she had mere perception of shadows, but with it she had never seen more than she does now after the inflammation. " Present state. — The patient suffers from head-ache (since childhood). The physiognomy (fissures in the skin round the mouth, the teeth, tonsHs, etc.,) are those of secondary (here- ditary) syphilis. The greater part of the soft palate and the uvula have disappeared. The tension and movements of both globes are normal ; both corneas are large, and so, in propor- tion, are the globes, and slightly hazy at places : the anterior chambers are large. The iris is of a peculiar steel-blue colour, -the pupils irregular, but active. " The patient reads the smallest type with the right eye, but does not recognize small objects at a distance, and can only perceive shadows with the left eye. She complains of Digitized by Microsoft® 146 INFLAMMATIONS OF CHOROID AND RETINA. occasional pains in both globes. Her vision is not improved by glasses, and in the left eye it has been defective as long as she recollects. " Ophthalmoscope. — Both eyes. The cornea is slightly hazy (greyish patches) ; the other media are transparent, and the entrance of the optic nerve and neighbouring parts are well seen in either eye, without using the convex lens. " The entrance of the optic nerve appears larger than usual, of normal colour in the right, and of slight grey colour in the left eye. The retinal vessels are normal in number in the right ; somewhat tortuous in the left eye. They appear to advance, as if the optic nerve entrance and the white patch surrounding it were level beneath it, with the remainder of the retina. The patch surrounding the optic nerve entrance is of brilliant white, and is well defined by a line of pigment between it and the choroidal red. It shows on its surface some large (choroidal ?) vessels. The network of large choroidal vessels which subtends the neighbouring transparent retina and its vessels is represented correctly in the sketch of the left eye, but is too minute in the other. Similar pins' -head- sized sharply-defined white patches, some with a black dot in the centre, are seen further distant from the optic nerve entrance. The yellow spot appears normal in either eye. " It is probable that the defective vision of the left eye is due to some change in the optic nerve. The white patch, though it surrounds the whole of the optic nerve entrance, does not considerably impair the conveyance of visual im- pressions. " I have not yet seen through a normal retina in a young subject the large choroidal vessels in that portion of choroid next to the entrance of the optic nerve ; at this part it appears in young healthy eyes of an equal redness, whereas in this case the large choroidal vessels are seen next to the white patch, and the small white patches further distant are sur- rounded by brilliant equal redness. The occurrence of inflammation of the eyes during early infancy is probably the Digitized by Microsoft® CASES. 147 reason why we so frequently meet with its results— the white patches. I have in this latter case no evidejice either from the girl or her parents to prove the syphilitic origin of this eye-disease, but I believe it to be a case of syphilis. " 1st. Because, when a student, I was taught that if a child loses its nasal bones, its uvula and palate by ulceration, if the skin round the mouth is fissured, if the hair falls oflP, etc., the case is one of secondary syphilis. " 2nd. Because 1 have had (since 1856) an opportunity of examining ten cases (four with hydrocephalus), in which the well-defined brilliant white and black patches in the cho- roid were visible, and in all these cases the specific symptoms before mentioned existed j moreover, in most of these cases, I was enabled to trace syphilis back to the parents. " 3rd. Because I have met with a case which in itself renders the specific origin of these patches most probable. "A child, {patient of Mr. Streatfeild), has been under ob- servation among the out-patients. The mother of the child had primary syphilis during the eighth month of pregnancy. She bore a healthy, strong child, and at the full time. For two months it had no signs of disease, and then purulent discharge from the nose, spots on the skin, etc., appeared. It was brought to the hospital when five months old. The bridge of the nose was considerably depressed, the tonsils were swollen ; it had tinea and psoriasis and fissures in the skin, radiating from the angles of the mouth. The circulation in the extremities was slow, the veins very turgid. A private examination of the father and mother showed fresh cicatrices in both cases, and secondary symptoms, tinea, psoriasis, falling oflf of the hair, etc., in the case of the mother. " The child soon died, and I had the opportunity of exa- mining its nasal cavities and the eyes ; the bones of the former were exfoliating, and the surrounding mucous mem- brane ulcerated ; the eyes, the choroid and retina excepted, appeared normal : the latter was unfit for microscopical examination. The retina was greyish, and softened ; at several places, chiefly around the entrance of the optic nerve, l'2 Digitized by Microsoft® 148 IKPLAMMATIONS OF CHOKOID AND RETINA, it was elevated by small pins'-head-sized nodules of lymph (?), which on removing the retina were found to be attached to the (retinal) surface of the choroid (beneath the hexagonal cells). When scraped ofij the choroid devoid of pigment was seen beneath them. Decomposition was too far advanced to examine these nodules satisfactorily/' C7ase XITI. — Double ierato-iritis — Aspect of hereditary syphilis — Symptoms of choroidal disease — Repeated relapses during ten years. In the following case, although on account of the state of the cornea no satisfactory ophthalmoscopic examination could be made, there was no doubt that the choroids were diseased. Ann E., aged 30, the eldest of three living sisters (having lost six brothers and sisters), has been under care at the Ophthalmic Hospital for upwards of ten years. Her aspect is most marked. She is slightly deaf in both ears> and states that she formerly had discharge from both. Her tongue presents abraded patches on the dorsum. Head ill- shapen ; upper central incisor teeth notched and character- stic. Both her cornese are hazy throughout, and in the right the opacity is very extensive. With the left she can just see to read large letters. Both pupils are irregular, and the irides thinned. Both globes are rather soft and the sclerotics thin, allowing the dark choroid to be seen through. She describes the first attack as having aflPected both eyes, and states that for some time she was so nearly blind that she could not tell hght from darkness. Since that she has had many relapses, attended with considerable pain in the globes. The tendency to relapse which has occurred in this case, is a symptom strongly indicative of choroidal affection, and is rarely observed when the cornea alone has suffered. Digitized by Microsoft® CASES. 149 Case XIV. — Reredito-syphilitic diathesis well marked- Primary syphilis acquired at adult age — Iritic adhesions — Disease of choroid and vitreous body. In the following case the patient, besides being the sub- ject of inherited syphilis, has also suffered from the acquired disease. It does, not appear, however, he had any true constitutional symptoms from the latter, and the history makes it clear that the attacks of inflammation of the eyes have been dependant upon the inherited taint, and not the acquired one. William B., aged 36, was admitted early in 1861. His aspect, teeth, &c., were most characteristic. The bridge of his nose was flattened down, and had been so since boy- hood. There were large flssures running from the angles of his mouth. Face pitted, upper incisors narrow and notched. His sight has been imperfect since early boyhood, the first inflammation, his mother told him, being at the age of four years. With the right eye he has never been able to see much. The right cornea is hazy, the iris dull, and the pupil much notched by adhesions. The left eye had been the better one until the attack of inflammation, for which he came under my care. In it, too, there had, moreover, always been a corneal haze. He had, when I saw him, an acute ulcer on the outer part of the left cornea, attended by hypopyon. Under atropine the right pupil dilated widely but with some notches, the other also dilated weU. It was not practicable to illuminate his fundus at all well. The vitreous appeared to contain floating films, and there were large and numerous black spots on the choroid. Five years previous to his admission at Moorfields he had attended the Lock Hospital for two months. He had then " clap and chaneres,^^ " a bubo formed and broke." After this, and during his attendance he had a rash on one leg. He took pills night and morning for a month or two and was salivated. After ceasing to attend he had no further symp- Digitized by Microsoft® 150 INFLAMMATIONS OF THE LENS AND VITREOUS. toms. Two years ago he had gonorrhoea again and. was salivated by a chemist. He subsequently married and his first child was bom a few months before he came under my care. I was very anxious to see his infant^ but my curiosity did not seem agreeable to him and I could not press the matter. I have as yet had but few opportunities of seeing the offspring of heredito-syphilitic subjects. CHAPTEE IV. ON CATARACT AND INFLAMMATION OF THE VITREOUS BODY IN CONNECTION WITH INHERITED SYPHILIS. In preceding chapters several cases have been reported in which, in conjunction with other lesions, there was opacity of the lens or films in the vitreous body. These latter conditions, when in connection with inherited taint, are indeed but rarely met with alone. Almost always there is also disease of the choroid or retina. Thus in Case IX, at page 142, a girl, aged 13, was the subject of double cataract, and of floating opacities in one vitreous, in con- junction with syphilitic retinitis. The cataracts were not con- genital but had formed simultaneously with the occurrence of inflammation in the other structures. In Case XIV, of the same Chapter, page 149, the patient, a man of 36, had float- ing films in his vitreous in conjunction with iritic adhesions and extensive disease of the choroids. In cases of keratitis inflammation of the lens or vitreous appears to be much more rare than in those of choroiditis, but it is quite possible that it is not so really. The opacity of the cornea usually prevents examinatipn of those structures, and this may easily account for the apparent infrequency of disease in them. I have never yet seen an instance of congenital cataract in a syphilitic infant. In all the instances which have come Digitized by Microsoft® GENERAL REMARKS, 151 under my otaservation the opacity of the lens has commenced some time, usually several years, after birth. This is quite what might be expected, for there is good reason to believe that the syphilitic taint does not usually cause intra-uterine disease. In almost all cases syphilitic infants are at the time of birth of healthy appearance, and the diseases to which they are liable do not commence tiU. some time after their assumption of independent vitality. When cataract occurs in these it is, no doubt, due to an alteration of nutri- tion analogous to inflammation, and it is, as we have seen, usually coincident with inflammation of other structures of the eye. As to the ordinary causes of cataract in children, whether congenital or formed during the first few years of life, but little is yet known with any degree of accuracy. It is, however, a matter of common observation with Ophthalmic Surgeons that such patients rarely present the appearance of vigorous health. More especially, I think, does this remark hold good in respect to those patients in whom the condition is not congenital. That hereditary syphilis is the true cause, in a certain number of these the facts to be adduced suffi- ciently prove. Further investigations on the subjects are, however, wanting. Mr. Dixon has mentioned to me, that in several cases recently under his care the teeth of his patients were much and irregularly malformed, although not always presenting the type- of inheri-ted syphilis. The same remark has also been made by Mr. T. P. Peale, jun,, of Leeds, who, in a letter to me on the subject, states that he has "rarely seen a case of cataract in a child who had well developed teeth." At some future time I shall hope to possess more accurate and extended data on this question. Case I.— Strabismus, cataract, and partially adherent pupil after an attack of kerato-iritis— Typical teeth. Elizabeth G., aged 30, the youngest but one of a family of five. This patient was admitted on June 30th. With her Digitized by Microsoft® 153 INFLAMMATIONS OF THE LENS AND VITREOUS. right eye she could see to distinguish large objectSj and could even read large print. Its iris was of steel-grey tint, concave and partially adherent at its pupillary margin, but fairly mobile. There was a semi-lunar portion of opaque membrane visible just -within the area of the pupil in its lowest part. Her left eye was slightly divergent and pro- minent. Its pupil was wholly excluded by adhesions and immobile, its area. being occupied by greyish white glistening material, evidently the remains of a disorganized lens. The history given was, that she had enjoyed perfect sight up to the age of nine years, when, during an acute attack of inflammation (keratitis?), she was blind for six months. This slowly passed off and left her sight much impaired. Her cornese had now so far cleared that only a few inter- stitial films were visible. Her teeth, both upper and lower sets, were narrow, peg-shaped, and quite typical of heredi- tary syphilis. I had no opportunity of obtaining any history of her infancy, but my notes state that both. Mr. Dixon and Dr. Bader fully agreed with me in considering that the diagnosis of hereditary Syphilis was established. Case II. — Hereditary syphilis — Supervention of a cata- ract in the eye at three years of age^—Iritic adhesions — Full history of syphilis, treated by mercury, in the parents. Sarah Ann C, aged 3. — This child was brought for the first time on September 3rd, 1858. In her right eye^^as a well-formed blueish-white cataract. The pupil was fairly mobile. The other eye appeared perfectly healthy, and there was not the slightest congestion in either. Although well-grown and stout, the sunken bridge of her nose and some fissures at the angles of the mouth, at once attracted my attention. There was also a patch of psoriasis on one cheek, and all her central upper teeth were affected by that peculiar form of black caries, which I had previously noticed in several syphilitic cases. The lower teeth were, with slight exceptions, free from caries. Her mother, who brought her, Digitized by Microsoft® CASES. 153 was a woman of pale earthy complexion. On enquirjTj I ascertained respecting the child, that in infancy she had suffered long and severely from snuffles, had had a very sore mouth, and sores at ^he anus, which lasted a long time, with also an eruption on the body. Her eyesight had been con- sidered to be good in both eyes, until within a few months. She had several times had gumboils, and once her tongue had been very sore. The child's mother told me that her husband was dead, that this was her only child, and that she had miscarried twice since its birth. Her own health, she said, had never been good since marriage, and on my asking the direct question, she at once confessed to having had venereal disease from her husband prior to her confinement. The medical man who treated her, gave mercury to salivation, and subsequently a copious eruption appeared. The disease was contracted only about two months before her confine- ment. The infant was not subjected to any; special treat- ment, and beyond the symptoms above mentioned, was not considered an ailing child. It was at the breast during the time that her mother was under the mercurial course. The mother still sufiers from periosteal pains in the head, etc. Atropine dilated the pupil very imperfectly, and it was then appareiit that there were rather extensive adhesions of the inner border of the iris. Spots of uvea were seen on the surface of the lens, and in its structure were several small masses of yellow cretaceous deposit. Case III. — Cataract with iritic adhesions in the left eye of a girl known to be the subject cf inherited syphilis. Miss H., aged 14, came under notice in , consequence of her elder brother being under my care for weU-inarked inter- stitial keratitis. Her father had lost one eye by syphilitic iritis before his marriage, and his eldest son had suffered severely from infantile symptoms, and now presented the various indications of the diathesis ; — notched teeth, etc., in Digitized by Microsoft® 154 ON SO-CALLED AQUO-CAPSULITIS. a very well-characterized form. I requested to see his younger sister, and she was brought at the next visit. She was three years younger than her brother, and the account was that in infancy she was fairly healthy. Her teeth showed horizontal notches, but no vertical ones, and there was little or nothing in her physiognomy to have excited suspicion. She could see but very little with her left eye. On inspection I found the lens in a condition of bluish- white haze. It was not densely opaque in any part, but sufficiently so to prevent the transmission of light. The pupU was fairly mobile, but there were numerous small tags of adhesion between it and the capsule of the lens j the other eye was quite unaffected. I did not obtain any clear history of the attack of inflammation during which the changes described had taken place, but her mother said that in eaxly childhood she was quite sure that both eyes had perfect sight. She believed that the changes in the left had occurred within the last few years. CHAPTER V. ON THE SO-CALLED AQUO-CAPSULITIS. There can, I think, no longer be any doubt that a large majority of the affections hitherto classed as "Aquo- capsulitis," or cases in which both iris and cornea are slightly inflamed, are due to hereditary syphilis. Although it is time that this term — alike barbarous in its terminology and erroneous in the anatomical theory which it suggests — fell iato disuse; yet a short space may suitably be here granted to affections which have been so designated < It has been applied much too widely by many writers. If we were to allow it to include all cases in which the posterior layer of the cornea and the surface of the iris were simul- taneously inflamed, a large class would be formed, and respecting a majority, indeed almost all, there would be Digitized by Microsoft® GENERAL REMARKS. 155 little diflSculty in proving a syphilitic history, either heredi- tary or acquired. In many cases of interstitial keratitis when the cornea has regained its transparency sufficiently to allow of inspection of the iris, the latter is seen to have partially lost its lustre, looking thin and of steel-gray aspect, and not unfrequently to have contracted a few slender adhe- sions. Although the severity of the disease has fallen on the cornea it is clear that the iris has also suffered. During the attack, however, the iris has been shut off from view, and the disease consequently designated as keratitis. In the cases of acute iritis in syphilitic infants, the cornea, as I have shewn, is. but rarely implicated. The only cases to which the term "aquo-capsulitis" ought ever to have been applied, are those in which with finely-dotted deposit on the posterior layer of the cornea the structure of that tissue remains transparent and allows of a tumid and inflamed iris being freely inspected. Cases in which this conjunction of phenomena exists, do occur, but as far as my observation has gone they are but rare. I am speaking, of course, of cases in which the iritic affection and the inflammation of the posterior layer of the cornea are nearly equal in degree. In almost all cases of iritis from acquired syphilis, the sprinkled sand-like dottings behind the cornea are present ; but in these the stress of the morbid process is so evidently upon the iris that we never hesitate as to their designation. Now and then, however, after acquired syphilis the affection which supervenes in the eyes might fairly be called " aquo-capsulitis," the iris being affected but very slightly. Limiting the term under consideration as above proposed, I have seen but few examples of the disease. About seven years ago I had under care for some weeks a girl of about 13, of Jewish family, in whom one eye was affected by slight iritis with punctate deposits behind the cornea. The proper corneal tissue never became opaque, and there was never any free eflusion of lymph in the iris ; the condition proved very intractable, but the opposite eye was never affected. There was no reason for suspecting heredi- tary syphilis. The following six cases comprise all that I Digitized by Microsoft® 156 ON SO-CALLED AQUO-CAPSULITIS. have had under care at the Ophthalmic Hospital, in which this affection shewed itself in patients^" at an age to suggest the suspicion of hereditary syphilis. In one of these I did not see the patient during the attack, but only formed my opinion as to its nature by the permanent con- dition which had been left. In only one of the six was there much reason to suspect hereditary syphilis, and I am therefore inclined to the opinion that cases of this type are for the most part not dependent upon that affection. Further evidence is, however, needed on this point. Case I.- — Dotted deposit on the posterior layer of one cornea, with slight iritis — No suspicion of hereditary taint. Alice Gr., single, aged 20, of clear complexion, rather pretty, and not presenting any trace of the physiognomy of hereditary syphilis, was admitted on June 9th, 1859. She had a perfectly regular set of teeth, of good form, and although pallid, considered herself in excellent health. Men- struation had always been regular. She was the sixth of her family, and all her brothers and sisters were reported to be in good health. The affection for which she applied con- sisted in a group of dotted deposits on the posterior surface of the right cornea. The largest were near the centre, and but few extended higher than the equator of the eye, whilst downwards they occurred almost as low as the margin of the cornea. The pupil acted very sluggishly but was of normal size. Several tags of adhesion between the pupillary margin and the capsule of the lens were visible, but the iris itself was of good colour, and did not look as if it had ever been acutely inflamed. From the history given it appeared probable that these deposits had been present for about two months. Six months ago the eye had been inflamed but the sight did not at that time suffer. The other eye had never been in the least affected. The remedies prescribed were blisters and mercury, the Digitized by Microsoft® CASES. ^57 latter in grain doses of calomel every night. Under these, in the course of three weeks, great improvement resulted, and the deposits were so far absorbed as to allow of her reading the smallest print. Still, however, although much diminished in thickness, the individual dots of deposit were, at the time of the girPs last visit very easily discernible. Case II. — Double iritis {slight) with punctate deposits in the posterior layers of each cornea in a healthy girl — Suspended menstruation — Improvement under the iodide of potassium. Emily B., aged 16, was admitted on March 3rd, 1859. In both eyes exactly similar conditions existed, the posterior layers of the corneae presenting numerous punctate deposits, and the irides being slightly discoloured, more especially near their free margins. The deposits in the cornese were more numerous in their lower halves than their upper ones, and occupied nearly the same position as those in Case I, being, however, much less extensive. The attack had commenced two weeks before admission. The eyes were irritable, but there was no great intolerance of light. She had not men- struated for three months. With regard to her diathesis, my notes state " she is tall, well grown, florid, and fairly healthy looking ; teeth good in every respect." The treatment adopted consisted of the exhibition of the iodide of potassium in five-gTain doses three tipies a-day. Under this she improved very decidedly. Menstruation occurred about a fortnight after her admission, and on March 24th the notes state that the corneal opacities had almost disappeared. Case III.— Dotted deposits {permanent and earthy) on posterior layers of both corneae — Evidences of past iritis — Hereditary syphilis probable. Edwin R., aged 14, came under my care in June, 1859. On the posterior layer of each cornea were numerous isolated Digitized by Microsoft® 158 ON SO-CALLED AQTJO-CAPSUHTI8. dots of white deposit, which looked as if they consisted, in part at least, of chalk (Mr. Dixon quite agreed with me in this opinion). These had resulted from an inflammation which had occurred four years ago. There were also some slender tags of adhesion between the pupillary margin and the capsule of the lens. He had fair vision, and what of imperfection existed, was fully accounted for by the state of the comeae. The condition of the latter was so peculiar and illustrated so well the disease under consideration that I had a sketch taken (see Plate I, Fig. 3). The boy was very decidedly of syphilitic physiognomy as was also his elder brother who came with him. Unfortunately I had no oppor- tunity of obtaining any history of his infancy. As the changes were undoubtedly permanent no treatment was adopted. Case IV. — Dotted deposits probably permanent in the posterior layer of the cornea — Incomplete history — Diagnosis as to syphilis doubtful. The following imperfect notes of an example of the disease now before us I copy verbatim from my note-book. The diagnosis must be held to be very doubtful as to the existence of hereditary taint. It will be seen that the irides were free from adhesions : — "Edward Roberts, set. 10. Numerous white specks; permanent. It is difficult to locate them, but they are pro- bably in the posterior layers. In both cornese the opacities are symmetrical, and in groups which occupy the central part, just below the equator. There is a diffused slight haze over other parts also. Under atropine both pupils dilate freely. Both eyes are slightly irritable. The attack is referred to infancy. Teeth suspicious, but not characteristic. The second of four children." Digitized by Microsoft® CASES. 159 Case V. — Iritis with deposits in posterior layer of cornea — No reason for suspecting hereditary syphilis — Disease con- fined to one eye. John Earle, aged 16^ a stoutj florid lad, but of flabby tissues. He is the eldest of his family; four younger brothers and sisters are living. His teeth are of good form and colour, though irregu- larly placed. There are scars of ulcers at the angles of mouth and of the nose. His nose is small and iU formed. There is, however, no particularly suspicious appearance in his physiognomy. About six weeks ago his right eye inflamed. The cornea is now extensively dotted with patches of deposit in its posterior layer. There is a decided sclerotic zone of vessels. The iris is discoloured, and on using atropine the pupil dilates very irregularly. The opapities in the cornea are chiefly about its centre, but extend in degree over its whole posterior surface. He can see but little. The other eye was quite normal, and had never been flamed. He stated that his eye had never been painfiil. Notes taken at his first admission, July 2, 1860. Case VI. — Iritis of one eye with dotted deposits in pos- terior layer of cornea — No reason to suspect syphilis •^Perfect absorption of the effusions. Clara H., aged 20, a German goveruess. She was the eldest in her family, fairly healthy looking, but of patchy coloration of cheeks, and liable to bad chilblains ; light- brown complexion, and yellow-brown irides j her teeth were honeycombed, and much marked by horizontal furrows. Her aspect was not that of hereditary syphilis. She believed that she was quite healthy when a girl. She had never once been salivated. Four years ago, when in Germany, her right eye was inflamed, but the left was never affected until the Digitized by Microsoft® 160 ON SO-CALLED AQUO- CAPSULITIS. present attack. In the right there was no trace of inflam = matory products, and with it she could see perfectly. The left had been rather weak for a month or so, but only began to inflame a,cutely three weeks ago. In the beginning she had severe circumorbital pain, but it passed off. She had been leephed, and. had taken pills. The attack was subsiding when admitted. She had never had rheumatism. The left iris was discoloured, and extensive adhesion existed in the lower half of the pupil. The texture of the iris in the upper part was plainly discernible, and there were no nodules of lymph. The sclerotic was but slightly con- gested, as the attack was passing off. Behind the cornea at the lower and outer part were numerous little dots; three of these were round and much larger than the rest — they were white ; the smaller ones were brown. By atropine the pupil dilated very little and very irregularly ; large tags with brown pigment were left on the capsule of the lens. The pupil was occluded by effused lymph. She was treated by calomel and opium and iodide of potassium. She improved rapidly, and was soon well. In about a month she could read as well with one eye as the other. The lymph had disappeared from the pupil, and the cornea was quite clear. I was not without a suspicion that this might be a case of iritis from acquired syphilis. The history of a previous attack four years before, and the entire absence of all the usual concomitants of secondary syphilis, were, , however, against this view. The type of disease was, moreover, exactly similar to that presented in several other cases in this chapter. Digitized by Microsoft® CA9JCS, 16] CHAPTER VI. On Amaurosis with white Atrophy of the Optic Nerves IN CONNEXION WITH INHERITED SyPHILIS. Amongst the best marked of the groups into which the ophthalmoscope has enabled us to classify cases of amaurosis is that in which we find evidences of atrophy of the optic nerve itself. The dead white, or bluish optic disc, with arteries shrunk to extreme minuteness, are the constant characters by which we recognize the advanced stage of this disease. Instances of it are by no means rare. They occur at all ages and in very various conditions of health. Some- times, as in a case now under my care, the disease follows an attack of fever. In some instances patients tell us that they have had no illness but have gradually become blind. In several, excessive drowsiness has been mentioned to me as the only other brain symptom which could be recollected. The disease usually advances in the course of from six to eighteen months to almost complete blindness. It usually affects both eyes, bat in some remarkable instances I have seen it in one only. The choroid is rarely affected. Retinal apoplexies very rarely occur. The disease seems limited to the optic nerve itself and the artery supplying it. There can be little doubt but that the cause is to be sought for within the cranial cavity, and as the disease is usually sjmimetrical, the probability is that its source is deeply placed. Whether in the tubercula quadrigemina or the cerebellum we are to place the real site of the morbid process future investigations must decide. I have several times known this form of amaurosis occur in the subjects of tertiary syphilis, but it is met with so frequently in others, that I have not been inclined to lay i?iuch stress on the coincidence. Until quite recently I had never seen an example of it in connexion with inherited tainti M Digitized by Microsoft® 162 AMAUROSIS WITH WHITE ATROPHY. In the second and fourth of the following cases it will be observed that the margins of the optic discs were not, as is usual in this disease, abruptly defined, and that there appeared some reason to suspect actual inflammation of the nerve, as a stage proceeding the atrophy. In the sixth there was a condition analagous to glaucoma, and in the seventh the chloroid also sufi'ered. In cases I and III the disease was well marked, but in neither of theni could ihe diagnosis of hereditary taint be rendered conclusive. These cases are, however, quite sufficient to awaken our suspicions, and to induce us, in the event of meeting_with atrophic changes of the nerve in yoimg persons, to make special investigations as to the possible existence of a syphilitic diathesis. Case I. — Defediiie sight from infancy — White atrophy of both optic nerves — History suspicious, but by no means conclusive^Some improvement in sight during boyhood. The following case is one of great interest as an example of very defective sight from infancy dependant upon white atrophy of the optic nerves. It furnishes an exception to what is usual in this form of amaurosis, in that the disease did not advance to entire blindness, but that, on the contrary, vision slightly improved. Whether or not there was any taint of inherited syphilis in the boy must be considered very doubtful. Erom the form of his head, his impaired intelligence, and the history of his infancy, there is good reason for suspecting defective cerebral develop- ment. William T., set. 13, admitted June, 1859. He is stated to have been a delicate baby, but does not appear to have had either snaffles or rash. He had " thrush " very badly, and it lasted long and " went through him," causing such soreness at the anus that the medical attendant repeatedly examined the part. He never had any inflammation of the Digitized by Microsoft® CASES; 162 eyes, but frora the earliest infancy his sight waa verj defective. He was very feeble in childhood, and did not walk till three years old. He was a twin, but his twin sister was still-born. He is the eldest of the family, and the three younger ones are all delicate. His mother is pale and eachetie, and states that, although without any specific symp- toms, yet during three or four years after marriage she had very poor health, having previously been robust. The boy has good-sized teeth, without notches, but they are of very bad colour. He has a slight rash of serpiginous psoriasis on the chin and cheek. His eyes are of good size and healthy appearance, but have a peculiar half-amaurotic look, and he is continually rolling them as if striving to see. He can see the clock-face but cannot tell the time. By placing large capital letters almost close to the eyes and moving the paper from side to aide, he can just see them, but cannot read. In the street " he is continually running against people." He often suffers much from headache. Glasses do not help him. The above notes were taken in 1859. Two years later, in September, 1861, the boy again attended, at my request. He was now fourteen years old. On the former occasion he had remained und^ treatment for a month or two, and not finding any benefit he had ceased to attend. On examina- tion with the ophthalmoscope I now found that the case was one of white atrophy of the optic nerves. Unfortunately no note of an ophthalmoscopic inspection during the previous attendance had been preserved. In both eyes the state was similar, but in the left ib was most advanced. The optic discs were abruptly margined and white, the retinal vessels being small. In the left the arteries were considerably smaller than in the right, and the whiteness was also greater in degree. In neither were the conditions so extreme as we not ujifrequently see them in eyes which have lost all perception of light. It seemed certain that he had made slow improvement since his last attendance. He can M 2 Digitized by Microsoft® 164 AMAUROSIS WITH WHITE ATROPHY. now spell out No. 16 of Jaeger's types at a distance pf two inches and a-half. The right is decidedly the better eye. He is now allowed to go about alone in the streets, and even goes to school, though not able to learn to read. The enquiries made on the second occasion con- firmed the statements previously given. I noted, however, the following additional facts. Both pupils are of normal size, and move freely on exposure to light. The globes twitch about but do not oscillate so much as they did two years ago. He is a well-grown moderately intelligent lad, but his forehead is peculiarly narrow and his ears very large. Both his mother and himself agree in the belief that he never at any time saw better than he does now, so that the condition would appear to be one which supervened in early infancy. When very young he attended Mr. France, at Guy's Hos- pital, for many months, on account of his defective sight. In infancy he never had fits, nor was a tendency to " water on the brain" suspected. He was never remarkably sleepy, but on the contrary a very restless infant. Case II. — Almost total blindness coming on at the age of nine, in a boy of heredito-syphilitic aspect — Clear history of infantile syphilis — Ophthalmoscopic examination — White atrophy of the optic nerves. Thomas R., a half idiotic boy of very marked syphilitic physiognomy was brought to the Hospital in August, 1861. He was quite bHnd excepting the mere perception of strong light and shadow. His cornese were, however, brilliantly clear, and there were no adhesions of the iris. The irides were of normal lustre, and it did not appear that he had ever had any external inflammation of his eyes. His mother stated that his sight had been good until last October, when it began rather rapidly to fail. He had no other symptoms, no pain in the globes, no headache or drowsiness, but the failure of vision advanced until in about six months he had become, as be is now, all but blind. His head is large and Digitized by Microsoft® CASES. 165 mis-shapen; nose, broad; complexion, pale and earthy; teeth, typically malformed. In answer to a direct question, his mother told me that she had had "the disease from her husband " soon after marriage, and in the beginning of her pregnancy with this boy. She was treated with mercury and got well in the course of a few months. Four months before the birth of her child she had got quite rid of symptoms and she had remained quite free ever since. Her husband had also remained well. Two miscarriages had occurred sub-.- sequently but no living births. The baby appeared healthy when bom and remained so for two months, when he had a rash, and suffered from " water on the brain." The rash after about two months got well. Whilst teething he was subject to "convulsion fits." After reaching the age of two years he remained without special symptoms, although delicate. Until the time that his eyes began to fail. His mother considered him clever, but he had never learnt to read, and her surgeon had frequently urged upon her that the boy should not be allowed to work his head. He was tall and well-grown. Ophthalmoscopic Examination. — Both pupils dilated well with atropine. In both eyes the media were clear, with the exception that a few, abruptly defined, black bodies could be seen floating in the vitreous. Those in the right eye were the larger and more conspicuous. The constant move- ments of the globes, which he could not be got to restrain^, prevented a satisfactory examination of the fundus in either. In both, however, the optic discs were seen to be ill- defined, very white, and with exceedingly minute vessels. The choroids in both were pale but free from patches, and the retinal vessels were everywhere small. The changes disclosed by the Ophthalmoscope, although great, are scarcely sufficient to satisfactorily account for the boy's entire loss of sight. Probably there is also disease within the cranium to which the white atrophy of the optic nerves is secondary. Postscript. — Since the above notes were in type this Digitized by Microsoft® 166 AMAUROSIS WITH WHITE ATROPHY. boy's eyes have been attaefced by interstitial keratitis. He is at present suffering from a wdl marked attack of that disease. This fact is of importance in reference to the diag- nosis of hereditary sypMMs. Although previous to the inflam- mation of the cornese he could but just perceive tiie strongest lights, he has since suffered from extreme photophobia^ There is no reason to think that he can really siee any better than he did. Case ni.^~White atrophy of the optic nerve with anemic retina {one eye snly)-^History vf iong-'Continued ophthalmia in chiidhood^^A^peci and teeth suspicious, Ellen E,.j aged 23. Very delicate and chkwotic looking. Features and teeth a little suspicions, but by no means characteristic. Has never had good- health. Family phthisical. At the age of four she had badly inflamed eyes, for which «he was ten months an inmate of the Salisbury Infirmary. The eyes remained inflamed, and for long she was almost blind. She was afterwards brought up to London, and attended at this Hospital from the age of 7 years till 16, Since the age of 16, she has earmed her livelihood at needle- werk. She can now just discover light with the left, and states that she has been practically blind in it since aet. 14. She now comes under care on account of tinea of the lids. She is dyspeptic, and has had swollen glands and sore throat frequently. Both puj)ils are round and of equal size. The corneae are not actually opaque, but look thinned, and, to a very slight degree indeed, hazy, as if they had formerly been the seat of interstitial inflammation. This condition is much more marked in the left. Ophthalmoscopic Examination. — The left optic disc has a narrow crescent on the inner side. It is very white, and its vessels are mere hair-like threads. The retina is pale and non-transpareut. Digitized by Microsoft® CASES. 167 Dr. Bader agreed with me that the disease had probably begun in the retina. "There were no choroidal patches. The fund as of the other eye was healthy. Remarks. — ^The history in this case does not support more than a suspicion of syphilitic taint. No leucomata whatever had been left as the result of the long-continued inflammation of the eyes, stated to have occurred in child- hood, a fact which considerably favoured the supposition that the disease had been interstitial keratitis. I had no opportunity of obtaining a history from the girl's parents. Case IV. — Congenital sypJiilis- — Aspect and teeth typical — Excellent sight up to the age of nine — Amaurosis, ending in total blindness — 'White atrophy of the optic nerves. The following are the particulars of a very interesting case which was sent to me by Mr. Vose Solomon, of Birmingham, by whom an exact diagnosis as to the nature of the disease had already been made. Becember 8, 1861. Master S., aged 9, is a pale com- plexioned boy of very marked syphilitic physiognomy. His central upp^ incisors are just cut, and are notched and narrow. There are deep scars about his mouth and nostrils, and his mother states that in infancy he suffered from most troublesome ulcerations on these parts. He is the eldest living of a family of four, the three younger being girls. One bom before him died " of wasting " at the age of one month. He was very delicate in infancy, and had a troublesome eruption with sores on the nates." At about a year old he appeared to strengthen, and remained after- wards, until he became blind, without any special symptoms although always puny. His ey^ight had been quite good until August last, at least as far as his parents knew. One day they noticed that he was feeling for something and upon enquiry found that he could not see weU. On further examination he proved to be quite blind of -his left eye. Probably the disease had Digitized by Microsoft® 168 AMAUROSIS ,WiT^ WHITE ATROPHY. been for some time advancing without being discoveted. Immediately on this discovery he was taken to Mr. Solomon^ who recognised his diathesis and prescribed accordingly. The disease^ however, steadily advanced, and without any pain in the eye or any external congestion he became quite blind. At present (December, 1861) he is so blind that he often mistakes the dark for .daylight. His corneae are clear and irides of good lustre. Pupils moderately dilated and totally insensible to light, even to that of a strong sun-glare. He is rather deaf and has been so, with intermissions, for some months. It was a feature of his blindness during its de- velopment that it varied much at different times. On some days he would see pretty well and then on the next relapse into almost total blindness. For some weeks however the ages have been quite insensible to light. Ophthalmoscopic Examination. — The state of the fundus in the two eyes was almost exactly similar. In each the optic disc was flat and of a bluish white, the vessels being of exceedingly small size. Only the trunks of the large arteries and veins were visible, all the smaller ones ha,ving wholly disappeared. The margins of the optic discs were iU-defined and jagged, with dots of black pigment. The retinse were pale and rather hazy. In different parts of the choroids were thinned patches, iU-defined, where the reflex of the sclerotic was visible through. In these, no doubt, some effusion of lymph had formerly taken place. Owing to the boy's total blindness and consequent inability to fix the eyes, the examination was attended with some difficulty. Case V. — Congenital syphilis — Total amaurosis from white atrophy of the optic nerves — Choroidal changes — Partial idiotcy. Flora C, aged 10, was brought by her mother to the Ophthalmic Hospital on March 17th, 1862, having been Digitized by Microsoft® CASES. 169 brought over from Australia on account of her eyes. She was placed under Mr. Dixon's carcj who kindly drew my attention to the case, as he considered the teeth and physiog- nomy quite characteristic of inherited syphilis. She was totally blind in both eyes. I obtained from her mother the following history of her case : — When an infant, she was puny, but had no special symptoms, -excepting that " water on the head" was at one time suspected. As she grew up she was precociously .intelligent. She had excellent sight until about seven years of age. During 1859, she was at a boarding school at some distance from home. Her parents heard from time to time that she did not get on well with her lessons, and appeared to see badly. At Christmas they fetched her away and were distressed to find that she was in reality almost blind. No pain in the eyes had ever been felt, she had had no symptoms, excepting the failure of sight and occasional squinting. Within a month of her return home she wholly lost the little remains of vision which she had preserved, and was reduced to her present condition of total amau- rosis. 1 Ophthalmoscopic Examination. — The ]iupils dilated well with atropine. Both optic discs were of a dead bluish- white colour, and their vessels shrunk to extremely minute size. The choroid in each eye was extensively dotted by small patches, some of them white (exposure of sclerotic), others black (aggregations of pigment). The conditions were precisely similar in the two eyes, and denoted advanced white atrophy of the optic nerves with the results of choroidal inflammation and subsequent absorption. The cornea in each was beautifully transparent, and the iris lustrous and free from adhesions. Physiognomy and Family History. — Flora C, was of pale complexion, narrow forehead, deeply notched upper incisor • teeth. Her moth.er said that she was not aware that either herself or her husband had suffered from syphilis since marriage, but, added that she thought it likely the latter Digitized by Microsoft® 170 AMAUROSIS WITH WHITK ATROPHT. had had it prenriously. The following is a statement of their offspring : 1st. A girl : lived but one month. 2nd. A boy : died almost immediately after birth. 3rd. A girl : died during birth. 4th. A girl : died at nineteen months. 5th. A girl : died at four months. 6th. A girl : died " of atrophy," aged t^ months. 7th. A gifl : Flora C, our patient. 8th. A girl : died at ten months. 9th. A girl : now aged 7, living, reported healthy. Several of the infants had suffered severely from blotches, &c,, dui'ing .the first five months of life. St-ate of Intellect. — At the time Flora C, was under our observation, she was evidently partially idiotic. She was exceedingly fretfal and restless, frequently crying or laughing, often dancing about the room. Ske answered questions in a wild manner, wandering off to some other subject directly. Her mother assured us that these symptoms had come on since her arrival in England, that is within a few weeks ; but of this I felt much doubt. Case VI. — Heredito -syphilis — Keratitis in childhood — White atrophy of optic nerves with glaucomatous symptoms at the age of twenty-jour — Iridectomy — Temporary benefit. In the foUowiing case, in conjunction with other changes, w€ had a state of eyes very closely similar to that known as glamjoma. The tension of the globes became greatly increased, the optic discs were cupped by the intra-ocular pressure, and the patient suffered from the peculiar tensive pain characteristic of glaucoma in its more typical forms. These symptoms were also -temporarily much relieved by iridectomy. There is no dOubt tha* the whole series of morbid changes was really due to inherited taint, and it must be noted that they occurred at an age ^ which true glaucoma is exceedingly rare, if not unknown. Digitized by Microsoft® GASES. 171 Apart from tlae interest connected with the inflamtaation of the eyes, the case presents another feature worthy of comment. The man in addition to having inherited syphilis in a severe form, had also exposed himself to contagion de novo, and had suffered from a venereal sore. In the British Medical Journal for September 21, 1861, I published a short paper on the question as to whether inherited syphilis is protective against subsequent contagion. Three cases which I cited went in support of the belief that those who have suffered from the hereditary disease in a severe form, are not liable to contract the indurated chancre. Since then, I have seen two other cases in which the subjects of inherited taint had exposed themselves to contagion, and had contracted sores, and in neither of these did the sore become indurated. Of these two, the following case is one. The mauj when he came under my care, presented a well marked syphilitic toTigue. There were numerous fissures extending about the organ, bordered by white markings, together with some swelling and -hardenirig of the structures. Was this state due to the acquired, or to the inherited taint ? It is certainly rare as a eonsequence of the latter, nevertheless I have seen it in an undoubted form in two or three instances. As the man in this case asserted that his tongine had begun to be sore before the date of his chancre, and as no other constitutional symptoms had followed the latter, I am strongly indiaed to the belief that it was due to inherited taint. This opinion is also strengthened by the feet that the .form of diseased tongue exhibited was one which is usually a late tertiary manifestation, whereas, his acquired disease was of recent date. William F., a single man, aged 24<, was admitted into the Metropolitan Free Hospital on November 28th, 1861. Both comese were hazy foom did deposit, the sclerotics thin and dusky, the pupils large. His physiognomy and teeth con- firmed the suspicion that he was the subject of inherited taint. BotTi Mr. Dixon and Mr. Critchett, who at my request were subsequently kind enough to examine him, agreed most fully in Digitized by Microsoft® 172 AMAUKOSIS WITH WHITE ATROPHY. this diagnosis. He was deaf in tlie left ear, and had been so as long as he could remembefj having, however, never had any discharge. About three years ago, he had, he stated, sulBfered from ulcerated sore throat, and afterwards his tongue became sore and had remained so ever since. It now presented a most typical condition of the syphilitic tongue, being fissured, corrugated and patched over with white markings. It was swollen and indented by the teeth at the edges. Four months ago he contracted a sore under the foreskin, which was attended by much discharge and swelling. He soon got well of it, and had no secondary symptoms, I examined his penis and could find no trace of chancre or of scar. History of Family and of Childhood. — He was the seventh child, but all older than himself, excepting two brothers, had died in childhood. A younger brother was also living. In childhood he was always delicate and did not run alone till three years old. When fourteen he had " St. Vitus' dance." At the age of six he had inflamed eyes, and was for six months almost blind. Had imperfect sight ever after, but could see enough to read the newspaper easily. During the last nine months his sight has got much worse, especially in the right eye, and during the last fortnight it has obliged him to give up his work. Ophthalmoscope. — In both eyes the optic discs were deeply cupped. In passing out into the retina the vessels curved over as if turning up a bank : the depression was, indeed, so great that it was almost like looking into a funnel. The discs were white, and the vessels small, Arterial pulsa- tion could be distinguished without pressing on the globes. Slight pressure increased the pulsation, but if augmented stopped it altogether, and emptied the arteries. The media were clear, the globes egg-shaped, so that the fundus was easily brought into focus without using a lens. The condi- tions were similar in both, but most marked in the right. Both globes were decidedly harder than natural, and the right much so. Digitized by Microsoft® CASES. 173. Having kept the man about a fortnight under observation, and finding that in spite of specific treatment, his sight was getting rapidly worse, I determined to perform iridectomy. He had suffered much froni tensive pain in the globes, and for several nights had scarcely slept. His sight was so far lost that with the right he could not count fingers, and with the left could with difficulty read the largest capital letters. On December 14th, I performed iridectomy in both eyes, taking away a large portion of iris in a direction upwards. During the night following the operation he slept well, and continued to do so during the next week. The globes' lost their abnormal tension, and when I first tried his sight on the third day he could read ordinary print with the left easily, and could spell out capital letters with the right. About a fortnight afterwards the pain recurred, and his sight again began to fail, and he is at present in statu quo. Case VII. — Congenital syphilis — Keratitis — Iritis in right eye. — Atrophic changes in optic nerves, retina and choroid of both eyes. Edward H., set. 15, of syphilitic physiognomy and typical teeth. Forehead large, lower jaw dwarfed, and the front lower incisors three-quarters of an inch behind the upper ones. He is an only child, and he believes that he never had any brothers or sisters. Six years ago he attended at this Hospital on account of inflamed eyes, and was under care for some months. He was readmitted under my care February 20th, 1863. He now has divergent strabismus with twitching globes : both cornese slightly hazy, the right especially so. Both pupils large and very sluggish, almost insensible to light. He says that he has been almost as blind as at present for the last" four years. He can with the best eye (his left), just see the face of the clock and large capital letters of print.. Ophthalmoscope. — In both eyes the optic disc is much too white and the vessels small, this condition being most Digitized by Microsoft® 174 DEAFNESS WITH INHE KITED SYPHILIS. adTanced in the right. The margfins of the optic discs are very irregular, owing to atrophy of the adjacents part of choroid. There is much pigment scattered about the fundus in abrupt black patches, and the choroid generally is thinned. The choroid of the left is maoh less diseased than that of the right. The right pupil is partially adherent, the left quite free. CHAPTER VII. ON DEAFNESS IN CONNEXION WITH INHERITED SYPHILIS. Deafness in greater or less degree is frequent in the subjects of inherited syphilis. In some instances it advances to the almost total abolition of the perception of sound. These extreme cases are however exceptional, and more com- monly the hearing is only partially lost. In the Eye, one or other of the various structures maybe attacked by the specific inflammation, whilst the others remain almost free, and thus distinct groups of cases are afforded. In like manner in the Ear we might expect to meet with dissimilar forms of disease depending upon the same cause. And the clinical fact would appear to be so. In some cases of deaf syphilitic patients, the history given is of otorrhoea, pain, &c., and other evidences of external inflammation, in others no such symptoms have been present. A form of deafness which occurs in these patients and which, as fax as what little observation I have made on the subject goes, appears to be peculiar to them, is one in which the function fkils without any external disease. It is usually symmetrical. Not unfrequently its stages are rapidly passed through, and a patient who six months ago could hear almost perfectly, becomes — without otorrhoea and without any marked degree of pain— utterly deaf. Digitized by Microsoft® CASES. 175 It is only reeentfy tkat I have thougM of specially in- vestigating the disorders of hearing in reference to hereditary taintj and in many of the cases cited in this work in which deafaess is recorded I have unfortunately preserved no details as to that symptom. Quite lately, however, my friend Mr. Hinton has allowed me to avail myself of his special knowledge of ear diseases, and has kindly examined for me the ears of several patients who are the subjects of the form of deafness alluded to. I will briefly adduce all the evidence on this mattej: which I possess. Case I. — The details of this case are given at page 33. Its subject, a girl^ aged 13, who had suffered severely from inherited syphilis, is stated to have been for long very deaf. She had also had sore throat. There is no further note as to the deafness. Case II. — A girl, aged 8 (See page 49), whose symptons had been severe. The notes state, " She is deaf and has for a long time suffered from otorrhoea." Case in. — In this instance the patient, a man, aged 21 (see Case 34, page 54), with a history of inherited syphilis, is stated to have been quite deaf since the age of 8 years. He had had otorrhoea in the first instance. Case IV. — A boy, aged 8 (Case 27, page 53), of cha- racteristic physiognomy and teeth. He was deaf in both ears, and had been so some time. There had been otorrhoea. Case V. — Elizabeth H., aged 15 (Case 37, page 60), a child who had suffered most severely from syphilitic symp- toms. She had lost her soft palate by ulceration, and was also the subject of laryngeal disease. She was quite deaf, but I have no note as to the symptoms which had preceded her loss of hearing. Case F7.— Matilda P., aged 19 (Case 41, page 62). In childhood she had suffered from otorrhoea, and was now quite deaf. Case VII. — ^Archibald McN., aged 13 (Case 57, page 75). He had suffered from otorrhoea which had left him very deaf. Digitized by Microsoft® 176 DEAFNESS WITH INHERITED SYPHILIS. < Case F///.— WiUiam S., aged 12 (Case 58, page 75). He had suflfered from otorrhoea in infancy, which had left him rather deaf. Case IX. — Mary Ann W., aged 17 (Case 61, page 7?). She had suffered in childhood from otorrhoea, which had left her rather deaf. Case X. — James W. O., aged 15 (Case 60, page 81). He was deaf of the right ear, from which he had formerly had purulent discharge. Case XL — George B., aged 16 (Case 67, page 82). He was rather deaf. Case X//.— Anna P., aged 15 (Case 80, page 90). The notes state, " Although she is now quite deaf, yet her mother does not recollect that she ever suffered from otorrhoea. The deafness began to come on at the age of twelve." Case XIII. — A young lady aged 12 (Case 88, page 96) . Slight deafness in the left ear after otorrhoea at the age of five. Case X/F.— Elizabeth J., aged 27 (Case 96, page 101) She was utterly deaf. The defect in hearing had com- menced at the age of six years. My notes do not expressly state that she had not had otorrhoea, but if my memory serves me, such had never been the case. Case XF.— Susan B., aged 26 (Case 100, page 106). This woman was quite deaf, and had in childhood suffered from otorrhoea. In none of the above fifteen cases was any examination of the ears made, an omission which I much regret. All the patients had suffered from syphilitic keratitis, and all were the undoubted subjects of inherited taint. In all of them the patient came under treatment on account of disease of the eyes, and the deafness was only incidently noticed, a circumstance which must apologize for the imperfection of the details. As the fifteen cases are taken from the series of one hundred and two examples of syphilitic keratitis they afford us some measure of the frequency of diseases • of the ear in heredito-syphilitic patients. They certainly are less common than diseases of the eye. Still I think no one Digitized by Microsoft® CASES. 177 would assert that the proportion of 15 deaf in a group of 103 is not very large^ and quite sufficient to prove that these patients are especially prone to diseases of the auditory as well as of the visual organ. It will be noted that in all the fifteen cases excepting two, the loss of hearing was symmetrical. In nine cases the patients were utterly deaf, whilst in most of the others the loss of hearing had advanced to a very considerable degree. In almost the whole of them otorrhoea is mentioned as having occurred early on in the case. Judging, however, from similar cases which I have of late examined more care- fully I should not be surprised if, had more detailed histories been obtained, it would be found that in most the discharge had been a very trivial symptom. In all- except one it had quite ceased before the patient came under notice. I have never yet seen a case of profuse otorrhoea attended with ulceration, growths of granulations, etc. (such as are common in cachectic or ''strumous" children), in an heredito-syphilitic patient. In two of the cases no otorrhoea had it is believed ever occurred, the gradual failure of hearing having been the only symptom. The age at which deafness is most liable to come on appears to be about the same as that at which interstitial keratitis is most frequent, i. e. from five years before puberty to five years after that period. In nine out of the fifteen cases the patients were females, and in the six to follow all were so, giving a proportion of more than two- thirds females to one-third males. In five of the six following cases the ears were ex- amined. I have little doubt but that it is a fair inference that similar conditions existed in most of the preceding ones. Case XVI. — Physiognomy of inherited syphilis — Typical teeth — History of infantile symptoms and subsequently of inter- stitial keratitis— Total deafness without any important lesion of the external ear or membrana tympani, Eliza T., aged 15, was admitted under my care into the ^ Digitized by Microsoft® 178 DEAFNESS WITH INHEKITED SYPHILIS, Metropolitan Free Hospital, on October 33, 1861. The aspect of hereditary syphilis was well marked, teeth typical. The irides were steel grey, pupils irregular, and the cornese dim, from an attack of kerato-iritis at the age of three years. For this attack she attended at Moorfields for one year, under the care of Mr. Critchett. She regained fair sight, and was able to read easily. She had good hearing until about three years ago ; she had then some pain and much noise in the ears. The right ear began to fail first, but the other followed soon after ; and in the course of a year she had completely lost all hearing. There was at no time the least discharge, until the last few months, when a little watery fluid has at times run out. She is now quite deaf, and can be conversed with only by the fingers (the deaf and dumb alphabet). Since her deafness she has got to speak thickly and almost in a whisper. She never had much pain in the ears but the " singiug and noises" were very troublesome. On November 27, Mr. Hinton at my request made an examination of the ears. The membrana tympani in each was found drier than natural, and rather too concave, but there was nothing discovered to account for the state of extreme deafness. The eustachian tubes were pervious. Family History. — Her mother has had six children, of whom the patient is the youngest living. She (the patient), when an infant, had a slight rash; when nine months old she had for two months a fit of illness, but no special symptoms of it are recollected. Three brothers, older than the patient, are well, and have never ailed any thing par- ticular. Two girls, one born before and one after herself, died in infancy. I saw one of the girl's elder brothers, and a more striking contrast in physiognomy could scarcely have been presented than between his and her own His teeth were of good size and form, and he was well grown and in perfect health. I have not the slightest doubt that the taint had been con- tracted by one of the parents between the date of his birth and that of his sister. No direct questions were asked. Digitized by Microsoft® CASES. 179 Case XVII. — Heredito-syphilitic teeth, keratitis, i^c, in a married woman— Clear history— Deafness at the age of 35— Examination of the ears — No adequate changes in the external parts or membrana tympani. Mrs. E. H., aged 35, of stunted growth and of well-marked syphilitic physiognomy, came under my care in September, 1861. Her teeth were' typical. She had a large misshapen . headj a shallow sulcus extending up the centre of the forehead. She had evidently been the subject of hydro- cephalus in infancy. The Eyes. — She came on account of a recent attack of keratitis in the left eye. The deposit was interstitial and in considerable quantity. Six or seven years before both eyes had suffered, but the cornese had cleared pretty completely. There was no iritis and but little sclerotic congestion. The opacity of the left cornea was confined to the outer half and abruptly circumscribed, leaving the inner part perfectly clear. In the centre of the white opaque patch were some spots of salmon-coloured lymph. The Ears. — She has been very deaf for four or five months. Formerly, though often a little deaf during colds, she had on the whole good hearing. She never had any discharge nor was ever troubled with collections of wax. The deafness came on gradually and was attended by noises and singing in the head. It was much worse some days than others. Even up to the present time she can some- times for a day or two hear enough to notice the striking of the clock, and then will relapse into total deafness. The state of the external parts as shewn by the speculum closely resembled that noted in the previous case. The lining membrane of the meatus was covered by desquamated epithelium and the membrana tympani was drier and rather more opaque than usual. The eustachian tubes were pervious, and nothing was discovered to account for her con- dition of deafness. I obtained a clear account from this patient's mother of the facts as to her own family history. N 3 Digitized by Miorosoft® 180 DEAFNESS WITH INHEEIXED SYPHILIS. Her husband suffered from venereal disease both before and after marriage^ but did not infect herself. The following is a statement as to her successive pregnancies : 1st. A girl : died aged eighteen months, of " a sort of decline^" having always been ailing. 2nd. The subject of the present case. In infancy ■ always delicate and puny, rash on face. She never had fits nor any cerebral symptoms. 3rd. A girl : died aged ten months " of a sort of con- sumption." 4th. A girl : born dead at full time. 5 th. A girl : now living, and aged 16, has suffered from inflammation of the eyes. [I afterwards had an opportunity of seeing this girl, her physiognomy and teeth were most characteristic. Her head was large and evidently hydrocephalic. Not deaf. Both cornese were hazy.] This patient was herself married, and had been so for five years. She had had one miscarriage and one live birth. I saw her child, a girl aged 3, who appeared in excellent health, and was well grown. Case XVIII. — Heredito-syphilitic diathesis • — Typical teeth, ^c. — Total deafness — Examination of ears — No adequate disease detected. Abigail H., was for some months during 1860, under my care in the London Hospital. She was suffering from a large gummous swelling of the tendon of the quadriceps extensor of the right thigh. This resulted in an abscess, which after much sloughing of tendon and cellular tissue slowly healed. In aspect, teeth, &c., this girl presented one of the most marked examples of the heredito-syphilitic diathesis I ever saw. She was an only child and an orphan, and no family history could be obtained. Both her cornese were extremely hazy from by-gone keratitis. Digitized by Microsoft® CASES. 181 Whilst in the Hospital the girl's hearing began to fail, and in the course of nine months, without either pain or discharge, she became totally deaf. On November 37, 1861, we examined her ears with the speculum. In both there was an accumulation of white, dry, epidermic scales not easily detached. In both the membrana tympani although dryish and rather opaque was entire. The eustachian tubes were pervious. As in the previous cases there was therefore nothing discovered adequate to account for the utter deafness. Case XIX. — Hereditary syphilis, with clear history — Deafness without otorrhcea at the age of ten — Examination by speculum. Honora P., aged 10. This child's case is recorded at page 88, Case 77. At the time the notes there given were taken she was a little deaf, the failure of hearing generally coming on when she took cold. Since then, and more especially during the last two months, she has got much worse. She is now (November, 1861) totally deaf in the right ear, and almost so in the left also. She has never had any otorrhcea. Both tonsils are enlarged, but the eustachian tubes are pervious. Mr. Hinton found in each ear that the membrana tympani was somewhat collapsed and sunken. Both membranes were also opaque and dryish. Case XX. — Hereditary syphilis — Double keratitis — Deafness in the right ear. Kate W., aged 13, has been under Mr. Dixon's treat- ment for syphilitic keratitis since December 10th, 1860. Her aspect, teeth, &c., most characteristic. The treatment has consisted in the use of the syrup of iodide of iron, and of mild mercurial inunction. Deafness. — In November, 1861, she began to lose hearing in the right ear. There was no discharge from the Digitized by Microsoft® 182 DEAFNESS WITH INHERITED SYPHILIS. ear and no ear-ache, but a constant noise in the ear " as if some one was shouting in it." December 9th, she is now very deaf in the right ear : can but just hear any sound when a watch is pressed over it. Hears fairly well with the other. The outer ear is dry. Case XXI. — Congenital syphilis — Double keratitis ■ — Deafness at the age of 13, without otorrhma. Susan S., aged thirteen : aspect of syphilis fairly marked, and teeth characteristic. Numerous white deposits of long standing in both cornea. Both pupils notched and irregular when dilated with atropine. Nine brothers and sisters are living, none have died. The patient is the third, the two elder ones being girls ; one of the elder ones has had inflamed eyes. Dea/we«5.j— She began to lose her hearing in February, 1861. There was no discharge, and not any material ear- ache. She was very much troubled with noises and singing in her ears. ■ The left was rather the worse, but both were aflfected. She can now just hear a watch pressed over her right ear, but cannot hear it on the left. The ear is dry internally, but there is no other visible peculiarity. The tonsils are not enlarged. General Comments, It will be seen that all of the cases in which the ears were inspected go to support the belief that the deafness of syphilitic children is dae either to disease of the nerve itself, or to some changes in non-accessible parts of the auditory apparatus. Its symmetry in all the cases would point to a central cause. In none were there found adequate changes in the membrana tympani, although in none was that membrane quite normal. In all the eustachian tubes were pervious, my belief therefore is, that the deafness in these cases is Digitized by Microsoft® CASES. , 183 due either to disease of the nerves or of theit distributiou in the labyrinth. The cases constitute the analogues of syphilitic retinitis and of white atrophy of the optic nerves. With regard to the prognosis of heredito- syphilitic deaf- ness, I believe that is very unfavourable. When the disease was progressive I have rarely witnessed any permanent improvement or arrest. In most it has gone on to total loss of hearing, and this in several instances in spite of the cautious use of specific remedies almost from the beginning. From six months to a year would appear to be the usual time required for the completion of the process and the entire abolition of the function. CHAPTER VIII. ON DISEASES OF THE OCULAK APPENDAGES WHEN DEPENDENT UPON HEREDITARY SYPHILIS. The wish to notice in this work all the affections of the eye and its appendages, which I have hitherto observed in connexion with inherited syphilis, induces me to devote a short chapter to diseases of the lids, the lachrymal sac, and the palpebral conjunctiva. None of these affections are by any means peculiar to the subjects of hereditary taint. Of iritis, choroiditis, kerato-iritis, and interstitial keratitis, as met with in infants and young persons, I venture the assertion that in a vast majority of instances, they are directly due to that cause. With tinea tarsi, etc., however, it is wholly different, they are very commonly simple affections, and very rarely syphilitic. Tinea #om.^— When this disease is of syphilitic origin, whether inherited or acquired, it may usually be distin- guished by the circumstance that small abruptly-margined patches of excoriation extend away from the lashes upon the cutaneous surface of the lids. These patches are irregular in shape, and are most commonly observed near Digitized by Microsoft® 184 DISEASES OP THE OCULAE APPENDAGES. the canthi. They give to the lids an appearance of great irritation and soreness. Syphilitic tinea tarsi is apt to be very obstinate in treatment^ unless constitutional specifics are employed. It is interesting to remark, that when tinea tarsi, in a severe form, is not syphilitic, it is still usually a secondary phenomenon to some other specific disease. Mea^ sles is undoubtedly a most frequent cause j scarlet fever and small-pox are so more rarely. In connexion with hereditary syphilis it is by no means rare, and often complicates cases of keratitis. Muco-purulent Ophthalmia, — The reason why purulent ophthalmia is so common in syphilitic infants is, no doubt, to be found in the fact that the mothers of such usually sufifer from syphilitic leucorrhcea. The contagious secretion is thus conveyed to the infant's eyes during birth, and the disease is to be regarded as a local one. I- have, however, seen so many instances of muco-purulent ophthalmia beginning in infants at intervals of a month or two after birth, and in asso- ciation with other symptoms of inherited syphilis that I cannot but think that this form is often of constitutional origin. The conjunctivitis is probably of the same character as the inflam- mation of the Schneiderian membrane of the nose, to which the snuffles, nasal discharge, etc.^ is due. It is rarely so acute as the true purulent ophthalmia. Case I.— Obstinate tinea tarsi following a syphilitic rash in a young infant. A pallid but fairly stout boy, aged 2, was brought to me at the Metropolitan Free Hospital in June, 1858, on account of what looked like catarrhal ophthalmia with severe tinea tarsi. The tinea had existed for eighteen months, the mucous discharge and conjunctival congestion for only a fortnight. Had the disease followed the measles, I asked, " No," was the reply, " but he had a bad rash out on his body before the eyes came sore." There was that in the way the mother spoke of the rash which made me think that she wished the term to convey something of particular and Digitized by Microsoft® CASF,S. 185 mysterious importance. Having observed also that the boy's nose was sunken, and that the little excoriated patches on the edges of the lids to the diagnostic import of which I have above alluded, were present, I at once asked as »o syphilis. A full history of the disease both in the mother and infant was at once freely given, and the requisite remedies were accordingly prescribed. Falling of the lashes. — I need say no more of this symptom than that it occasionally happens in syphilitic infants. It has, no doubt, the same relation to the original disease as the alopecia which is not unfrequently observed in adults as a secondary symptom. Not unfrequently loss of the lashes is consequent on neglected tinea tarsi. Case II. — Sevet'e tinea tarsi in a syphilitic boy — Ulcerated node on the forehead. Charles S., aged 5, the subject of severe tinea tarsi. No iritis or keratitis. Fissures at the angles of the mouth. Psoriasis on the face. Teeth broken and very bad. Ulce- rated node on the forehead. When an infant he had for four months, very bad snuflBes and thrush, "which went through him" and caused sores at the anus. He had no rash. He was a delicate baby, always ill. He had always complained of pain in the lump on the fore^- head, especially at night. It had existed from very early infancy, and he had been treated for it at several hospitals. He had a blow on it a month ago, after which it ulcerated on the surface. Case III. — Double purulent ophthalmia, with sloughing of the right cornea — Congenital syphilis — Exfoliation of the crowns of several teeth. AnnaP.,aged 7weeks,a pale puny baby of marked syphilitic cachexia. Her mother had a patch of tubercular syphilitic Digitized by Microsoft® 186 DISEASES OF THE OCULAR APPENDAGES. eruption on the lips. The child was her twelfth. Of the eleven, four only were living. Aniia was a fine child at birth, and her skin was quite clear until the age of five days. Her eyes began to suffer with purulent ophthalmia on the fifth day. (The right cornea had sloughed). When a week old she began to snuffle badly. Two teeth were found loose in her mouth and one other afterwards fell out. I also took out the crown of another loose molar. She had syphilitic blotches on the buttock. Case IV. — Large symmetrical leucomata in a syphilitic infant — History of muco-purulent ophthalmia in both eyes at the age of three months. - The condition in which the cornea was left in the follow- ing case was not that which is usual after sloughing from purulent ophthalmia. There did not appear to have been any destruction of corneal tissue, but a general bulging of the whole. Henry E.P., aged 7 months, a little puny child with papular syphilitic rash on nates, which had ulcerated in patches. The cornea of each eye was much bulged almost as if staphy- lomatous, and occupied with dense white deposit. Whether there had been effusion behind the corneae or not was a matter of doubt. The condition was remarkably sym- metrical. All inflammation had long been past. He was ordered to be brought up again in a year or two for an artificial pupil. His mother had been twice pregnant before, the first child was born dead, and the other (second) died soon after birth. The third (Henry) began to snuffle very badly when three months old. Before that age he was a very fine baby. Soon afterwards his eyes inflamed and there was some muco- purulent discharge. The "water-rash" "went through him," leaving large syphilitic papulae about the nates. Digitized by Microsoft® CASES. 187 Case V. — Chronic purulent ophthalmia of one eye only in a syphilitic infant— Opacity of the cornea. Maria P., a puny baby aged 5 weeks, was admitted in April, 1859, with chronic purulent discharge from the left eye; the lids were not swollen but the discharge was con- siderable ; the entire cornea was opaque and granular. The other eye had never been in the least affected. The ophthal- mia had commenced on the third day after birth, at which time also the child began to snuffle. The infant still had snuffles, and on its neck was a dry and' red patch of psoriasis. The mother, a delicate looking woman, told me confidentially that her husband had been " gay before marriage." They had married a year ago, and soon afterwards she was under care for discharge and swellings in the groins. She was suffering severely from leucorrhoea at the time the child was born. I felt no doubt that the patient in this case was the subject of inherited syphilis. The exact relation of the ophthalmia to that taint is, however, less clear. I quote it, however, as a good example of what we not very unfrequently observe, the coincidence of chronic purulent discharge from the conjunctiva with opaque cornea and a syphilitic history. With regard to the treatment of purulent or muco-purulent ophthalmia when occurring in syphilitic infants both local and constitutional remedies are requisite. The local ones are however of, by far, the greatest importance. Drops containing one or other of the mineral astringents, nitrate of silver, acetate of lead or alum should be prescribed. The two latter are preferable on account of the freedom with which they may be employed. The great point is, that plenty of the lotion should be brought into actual contact with the inflamed mucous membrane, and this is better accomplished with one which may be used ad libitum than with one which on account of staining, etc., must be applied cautiously. From diseases of the lids and conjuctiva I now pass to Digitized by Microsoft® 188 DISEASES OF THE OCULAR APPENDAGES. inflammations of the lachrymal sac. These latter are not at all uncommon in the subjects of inherited syphilis. In some cases the disease consists in inflammation of the sac, but in the majority it is complicated by periostitis of the adjacent bones. Very often there is at the same time evidence of a tendency to periosteal affections in the exis- tence of nodes or other bones. It is essential to employ the iodide of potassium internally in the treatment of these diseases. Their local management as regards the opening of abscessesj the use of probes, etc., for the nasal duct does not differ from that of similar diseases when not in connection with syphilis. When the bone is involved they are often protracted and difiicult to manage. Case VI. — Fibrinous conjunctivitis in a syphilitic child — Destructive inflammation of the globe two years later. Clara T., aged 8, a well-grown girl, but of marked syphilitic physiognomy was admitted for a second time, in August, 1857. Her first attendance had been in 1855, and respecting it, I am sorry that I possess only the following notes: — "Admitted October, 1855, with fibrinous ophthalmia, and abscess in the cornea. A layer of croupal membrane was on two occasions peeled oft" from the ocular conjunc- tiva. No specific treatment was adopted until December, when two. grains of grey powder were ordered to be taken three times daily. Her mouth became sore in a fortnight, and the mercurial was then reduced to a single dose in the day, and was wholly discontinued a fortnight later. On February 9th she ceased attendance, the eye was then well but had a white cicatrix in the cornea; she could see with it." When re-admitted in August, 1857, there was bulging of the sclerotic in the upper part of the globe as if from intra- ocular abscess. It had commenced suddenly with sickness and fever, and much headache. Digitized by Microsoft® CASES. 189 On September 4tli, the eye was clearly lost and the cornea was giving way in its upper half. The globe was sub- sequently excised. The history of the child's infancy is as follows : — She was an eight months' child, but a clear skinned baby when born. Soon afterwards she had snuffles and a troublesome rash on the lips, face, and nates. At the age of three months she had inflammation of one eye but it got well again, and soon afterwards she had swellings of some joints, and " tenderness of her bones." The mother's first child died of convulsions at the age of ten weeks, having pined away and suffered from rash ; the patient is the second. The third lived only five weeks and " was bad with eruptions on the lower parts." The mother herself is delicate but without specific symptoms; she has had five miscarriages; and considers that since marriage she • has had much worse health than before. Her husband she reports healthy. Case VII. — Heredito-syphilitic struma with clear history but without malformation of the teeth. EUen C, set. 9, a puny, pale-faced girl, the subject of angular curvature of the spine was brought to me at the Ophthalmic Hospital on August 27th, 1861. Ihe bridge of her nose was sunken, and the alse nasi and upper lip (the latter especially) were swollen. Her teeth were not in the least malformed. She. had suffered from enlarged glands under the jaw which, however, never broke. She had also had otorrhoea. When a baby she had an abscess in the thigh. Her aspect, excepting the earthy pallor and the sunken nose, was rather that of thick-lipped struma than that of heredito-syphilis. She came to the hospital on account of inflammation of the right eye, and I found the cornea of that eye very slightly hazy. The haze was diffused but so slight that it could not be called characteristically interstitial. Digitized by Microsoft® 190 DISEASES OP THE OCULAR APPENDAGES. It had only existed a week, and might or might not prove the initial stage of the true interstitial form. i ascertained the following facts of her histoiy. Her mother was married at the age of 18, and soon afterwards con- tracted sores from her husband, which were followed by a bubo and sore throat. She was treated for these affections and was assured by her medical attendant that they were venereal. An infant of which she was pregnant at the time was dead born. After this her husband and she were on account of this occurrence separated for nine years. Our patient was born soon after they rejoined each other. The husband left the country when the baby was nine months old and no children have been born since. The patient when a baby suffered much from rash on the buttocks, with peeling of skin, also troublesome sickness, and very severe and protracted snuffles. Quite lately the mother has been under the care of a medical man for sore throat, and was then told that the affection was venereal. This history would appear to shew that parents may nine years after the primary disease produce syphilitic off- spring. I could not ascertain with accuracy whether either parent had been treated by mercury. Case VIII. — Suppuration of lachrymal sac in a syphilitic infant — Hydrocephalus — History of the syphilis in the parents. Ellen H., aged 4, was admitted for suppurated lachrymal sac. She had a large protuberant forehead, and a very wide, flat bridge of nose. The skin on the cheeks and forehead was stretched, the lips cracked, &c. Her nails were broken and badly formed; the teeth small, carious and much broken. She was, however, well-grown, and her mother considered that she was fairly healtjiy. She had had snuffles very badly as an infant, and also thrush and a sore anus. Her father was dead. He was " a very gay man," and his wife confessed that she had suffered from the disease Digitized by Microsoft® CASES. 191 soon after marriage. She had had six miscarriages before the birth of the present^ her only living child. Case IX. — Abscess in lachrymal sac — Physiognomy and teeth characteristic of syphilis — Effects of bygone keratitis — History of partial paralysis of one arm. Elizabeth K., aged about 10, of most marked physiognomy and teethj was admitted with acute suppuration of the right lachrymal sac. The bridge of her nose was sunk level with her face as if from, a blow, but there was no history of injury. Her forehead was large and protuberant. She could not use her right hand well, and I was told that in early life she had for a time entirely lost the power of moving it. It had gradually recovered but was still not nearly equal to her left. Both her cornese were hazy from keratitis, but as to the exact date of the attack no reliable information could be obtained. Case X. — Abscess in one lachrymal sac in a boy aged eleven — Typical teeth — History of syphilis in infancy — Syphilis in his father. Victor C, aged 11, was placed under my care on March 25, 1861. He came on account of inflammation of the right lachrymal sac, attended by a fistula. The disease had existed from early childhood. He was of pale sallow com- plexion, with a few scattered pits in different parts of the integument of the face, otherwise there was nothing particularly indicative of hereditary syphilis in his physiog- nomy. On looking at his teeth I found his central upper incisors characteristically narrowed and notched. They were also very irregularly placed. He complained of sore throat, and both tonsils were enlarged and ulcerated. His corneBB were perfectly clear, and he had never had inflamed eyes. Mrs. C. his mother, an intelligent Jewess, told me Digitized by Microsoft® 192 DISEASES OF THE OCULAR APPENDAGES. that all her family (four children) had been born in Algiers. Victor C, her first-born, suffered much in infancy from spots on his body, from closed nostrils, and from sore mouth. These symptoms her medical attendant assured her were due to disease which her husband had had before marriage. Her husband admitted this and the child was treated accordingly. The symptoms shewed themselves a week or two after birth, he having been born " quite healthy looking." Mrs. C. herself never suffered from any thing whatever, and she now looks quite healthy, though rather pale. The other children are reported healthy. Her husband has had no symptoms since Ms marriage ; he told me, however, that he had never felt so strong since he had the disease. Eighteen months elapsed between his attack and his marriage. When he married he believed himself quite well, and after- wards he never had a suspicious symptom excepting a little psoriasis in the palms. He confirms his wife's statement that she never had a symptom of any kind. His own attack was a severe one. He is now a very robust looking man, but his palms still shew some traces of psoriasis. — March 25th, 1861. CHAPTER IX. MISCELLANEOUS CASES AND OBSERVATIONS. I HAVE collected into the present chapter various examples of disease of the eye or its appendages, in con- nexion with inherited syphilis, which could not suitably be allotted to any of the preceding chapters. I have also adduced certain cases which are more or less exceptional to general rules, as for instance two in which the teeth were not mal- formed. The headings to the cases themselves will, how- ever, for the most part sufficiently explain the special points illustrated. , Digitized by Microsoft® MISCELLANEOUS CASES. 193 Case I. — Iritis with some keratitis after a blow — Ulcer in cornea — One eye only affected. Mary A. D., aged 6, a delicate, puny, withered-looking child, a twin. Her face was covered in its lower half by psoriasis with fissures, and at the bends of the elbows were patches of psoriasis. Her twin sister/^ied when a year old. She came on account of the right eye which was acutely inflamed. The zone of sclerotic congestion was well marked, the iris tumid, muddy, and of sea-green tint instead of light blue. The cornea showed in its centre a superficial abrasion, and was superficially slightly opaque. She could not sleep on account of pain about the eye. Her mother said that the child had had a blow on the eye with a stick about a inonth ago, which caused inflammation. It, however, cleared off entirely, and was quite well for a fortnight before the present attack, which began a week ago. She was admitted on September 29th. Mercurial ointment was directed to be rubbed behind the ears. October 2. — There was much less lymph, and she was in every respect very much better. October 5. — Ulcer in the cornea heaUng j iris clear. Her mother had slight appearance of fissures about the mouth, but denied all suspicious symptoms. She had had eight children, but three only were living. I could not obtain any history of suspicious symptoms in infancy in any of them. Mary A., had been delicate since infancy, and at the age of one year had been liable to rash on the face and at the bends of the elbows. She had never had snuflBes or thrush. Case II. — Acute pustular ophthalmia of the relapsing type in a Boy the subject of inherited syphilis — Disease of the Michael R., aged 6, was admitted for acute pustular ophthalmia, of four or five months' duration on and off. He o Digitized by Microsoft® 194 MISCELLANEOUS CASES. was a little emaciated boy with diseased hip joint. His nose was broad and sunken; face, dry and withered -looking. Scattered here and there over the face were patches of psoriasis ; the teeth (first set) were bad and broken ; lips cracked and irritable. On the scalp were patches of porrigo,!. Both cornese were superficially ulcerated, and there was extreme intolerance of light. There was no diffuse keratitis. There were pustules round the edges of both cornese. It appeared that he had had- severe and long-continued snuffles in infancy, and that he had " thrush " badly, " which went through him " and '' came out " at the anus, which was very sore ; there was also a rash on the general surface. He was then extremely ill, and was admitted into St. Bartholomew's Hospital, under the care of Mr. Stanley. About three years ago his hip became diseased. For this he was treated in St. Thomas's Hospital. His mother denied that she had ever had any venereal disease, but was certain, that her husband had had it. She had two younger children who had had snuffles very badly. Case III. — Extreme Intolerance of light, with history of syphilis. B,achael H., aged 6. Extreme intolerance of light, was the chief symptom. There did not appear to be either pustules or ulcers on the cornea. Her eyes had been in- flamed and irritable for a year, having improved in the summer and relapsed in the autumn. She had an expanded^ nose, and a pale flabby complexion, large misshapen head.. Her upper central incisors began to decay as soon as • they were cut. She had been without them two or three years. The lateral incisors were decayed and the canines were becoming peggy. In the lower jaw some of the teeth were decayed or much discoloured, but the central incisors had been shed, and the permanent ones were just visible. They were deeply serrate. She was treated by iodide of pota^um, iodide of iron, and inunction of mercurial ointnient, and Digitized by Microsoft® MISCELLANEOUS CASES. 195 fomentation of belladonna. On January 26, she was reported by her mother as being quite well. The mother of the child had contracted syphilis from her husband soon after marriage. A rash and sore throat followed. She had when I saw her^ margined syphilitic sores on the tongue and lining of lips, and also ulcers about the knees. She had been pregnant three times. The first child was born dead, it had been apparently dead some time before birth. The second pregnancy ended in a miscarriage at five months. The third child was Eachael, the only one living. Rachel had rash, snufilesj thrush, sore anus, etc., in infancy, and had been under medical care nearly all her life. Case IV. — Subacute iritis with hypopyon and ulcer in the centre of the cornea — No syphilitic history — Hydrocephalus and great emaciation — Tuberculosis ( ? ) James GoUey, aged 2^, admitted February 18th, 1861. A pale, delicate, emaciated child, the youngest of five. He had a large head, and coursing over the forehead were large veins. He had been suspected to have " water on the brain." He had never been in a healthy state since birth. He had never had any exanthem, and had not been vaccinated. About one month before admission, his left eye iuflamed, and a fortnight later, as it had become worse, a surgeon was consulted. A lotion and a few poWders were given. He had not appeared to suffer much, and there was no evidence of his having any pain. The left eye only was afFected. The iris was unusually discoloured, and there was a belt of a cinnamon tint near its pupillary margin. Its brownish-red colour contrasted most strongly with that of the other iris, which was grey. There were no visible masses of lymph. In the lowest part of the anterior chamber there was a drop of pus. It was very difliuent and changed position easily, as the head was inclined. The conjunctiva was much congested, and there was some mucous discharge. On the centre of the cornea was a large superficial ulcer. There was no intole- o 2 Digitized by Microsoft® 196 MISCELLANEOUS CASES. ranee of light. Under the use of atropine the pupil dilated somewhat. His mother was in consumption whilst pregnant with him, and died two years after his birth. The other four children were reputed healthy. It did not appear that the patient had had any suspicious symptoms during infancy. I adduce this case as an instance of iritis in a young child without suspicion of syphilis. In all probability the hydrocephalus was of tubercular origin. The iritis was only part of the general inflammation of the eye consequent on thfc acute corneal ulcer. It must be uoted that ouly one eye was affected. Case V. — Adhesions of the iris in both eyes in a young girl — No history of the iritic attack — Su^icious symptoms in infancy — History of syphilis in parents. Harriet S., aged 10, a fairly healthy-looking girl, whose physiognomy did not show any marks of the syphilitic diathesis. Her nose was well-formed, there was healthy coloration of cheeks, and no scars at the angle of the mouth. Her teeth, however, were of a very suspicious type, and the tongue was fissured. She was brought on account of imperfect sight. Bands of adhesion, from the iris to the capsule of the lens, were seen in each eye. The pupils acted fairly, and the irides were of good bright colour. ' By atropine the little tags of adhesion were made very ap- parent. In early infancy she had had sores at the anus which lasted a long time. The mother said that the sores were of " a particular kind" such as she had never seen in any other infant. This appeared to have been the only suspicious symptom. She never had snuffles or thrush. She never had any inflammation of the eye in infancy. Her mother had had seven children ; the first five were still-born, and the patient was the sixth. On the question being put, her Digitized by Microsoft® MISCELLANEOUS CASES. 197 mother at once informed me that she had suflPered from " the disease," which 'she contracted from her husband almost immediately after marriage. This confession, taken with the fact of the five still births, leaves, I think, little doubt but that Harriet S., was the subject of remote taint. It will be observed that she was born at least seven years after the disease in her parents. Case VI. — Entire loss of sight in a syphilitic infant — Occlusion of both pupils by iritis — Hydrocephalus — Irregular dentition {1st set) — Syphilis by conception in the mother — History of syphilis in the father. Elizabeth B., aged 31 months, was brought to the Hospital on October 12, 1860. She was a wasted, puny infant, the very type of syphilitic dyscrasia, with scaly patches on the nates and cracks at the anus, palmar psoriasis, and large patches of psoriasis on the scalp. Her dentition had been peculiar. She first cut three upper incisors, then an upper double tooth. She had fits whilst cutting her lower ones, and the gums were lanced. All the teeth cut were puny and decayed, and several of them had rotted down to the level of the gums. The upper incisors were loose and the gums inflamed. In the lower jaw on the left side all the teeth were cut, whilst in its right only two incisors had appeared. The child's head was large, so as to present a very positive, but not extreme condition, of chronic hydrocephalus. The mother said that it began to enlarge at a month old, and that it had not increased lately. She was reported to have been healthy when born, and very fat, but began to fall away and had blotches on her face when a month old. She had snufQes almost directly after birth. Has been under medical treatment ever since the first month, and was for some time at St. Bartholomew's Hospital. She has been blind for 9 months, having become so, according to her mother's account, after fits. Her mother^ Digitized by Microsoft® 198 MISCELLANEOUS CASES, thought that she coiild still see " a glimmer of the candle," hut on trial she was evidently all but insensible to light. The mother brought with her her eldest (aged 6), and only other child. She was very healthy-looking, without the slightest suspicious feature, and was said to have always bpen so. It appeared that the father of the children had, subser quent to the birth of the eldest, suffered from "a, secret disease," but the mother denied that she herself had ever had any symptoms. During her last pregnancy she was very ill, and had for a long time a " bad ulcerated throat." Of the latter there still remained evidences, the uvula being tied up on one side to a cicatrix in the soft palate. The state of her gums resembled that of a person who had taken much mercury, With this histpry I thought it probable tJiat tl^e mother had derived the taint from the infected fpetus. Her symptoms had wholly subsided since her deli- very, and she was now of fairly healthy aspect. State of the Infant's Eyes. — Both irides were deficient \T0, lustre. On usiitg atropine neither pupil dilated beyond a very little, a;nd very irregularly. Thin membr^aes were seen occluding the pupils. "We were obliged to give chloror form in order to use the ophthalmoscope, an,d even then it was exeeediflgly difficult. The occluding films were very thin indeed, and not at all sufficient to account for the: almost complete loss of perceptiojai of light. We were, how- ever, unable to bring into view any of the deeper ' parts,. It seemed, not improbable that the ease was similar to. one Vhicli I have elsewhere published^ in whichj after infantile iritis, both retinae were detached. As to the date at which the iritis had occurred, the mother slated that, about three months ago, she had; noticed the eyes a little blood-shot, but this had been the*; only symptom. It will be seen that both the preceding cases are examples of infantile iritis They furnish two more facts in support of Digitized by Microsoft® MISCELLANEOUS CASES. 199 the statemetit that this disease is more frequent in female infants than in males. {See page 18.) Case VII. — Hereditary syphilis — Interstitial keratitis -^^ Very peculiar development of teeth. Jane B., aged 31, an orphan, the eldest of two, her younger sister being 14. Several brothers and sisters (13 or 14) died in infancy. She can give no history of her child- hood, except that she remembers having had inflamed eyes. Her sight continued good until a month ago. She was admitted a fortnight ago under Mr. Dixon's care, on account of specific keratitis. Her teeth are very peculiar indeed. There are five upper incisors, one projecting back into the palate. Of these five, only one is typical, and it is exceedingly well marked. It is the left central incisor. The other central incisor is cut ofif not much above the gum level. She is well grown, ^tout : flabby and pale physiognomy, not well characterised. Some white markings are seen in the buccal mucous membrane. Mr. Dixdn had given a positive diagnosis of inherited syphilis before I saw the case. Case VIII. — Interstitial keratitis in two childreUj a brother and sister-^SypUlitic physiognomy— Teeth, Sfc, extremely well maried in the elder one, and less so in the yoimger. March, 18p62. John D., a boy of 13 : most characteristic feeth : phy^ognomy typical. Enormous nodes on tibia of left leg, and on ulna and radius of left arm, also on tibia of right leg. Biiring the commencement of the nodes, he was put to great torture by the use of apparatus at a special hospital, under the idea that his disease was " ricketts." His eyes inflamed duriiig^ teething, and again about three Digitized by Microsoft® 200 MISCELLANEOUS CASES, years ago. Both corneae muddy. Nose sunken. He suf- fers from ozena so badly that he cannot mix with othef children. His father is a stout, florid, healthy Scotchman : six living children: one died, and one or two miscarriages occurred. His sister was brought to Mr. Streatfeild a fortnight ago for keratitis, and as her teeth were suspicious, but not typical, we asked the father to bring his eldest child. In this ease we have a most valuable illustration of the importance of seeing the elder children, in order to an accurate diagnosis as to inherited taint. Case IX. — An exceptional case — Hereditary syphilis with keratitis and iritis, but without malformed teeth. October 7, 1861. Charlotte B,., aged 8, was sent to me by my friend Mr. Robertson. Both eyes were affected with keratitis, and in both the iris was also inflamed, the condi- tions being quite characteristic. The inflammation had existed for about four months. The girl was moderately florid, but of patchy coloration j her nose was rather broader than usual, and there were small fissures at angles of mouth ; but her physiognomy presented no other peculiarities. Her teeth were extensively blackened, and their enamel bad, but they were all of full size and presented no peculiarities as to shape. Their edges were unduly thin. Her mother told me that Charlotte R., was her eldest living, and second born. The first (born two years after marriage) lived only six weeks, and died of "black thrush." Under the latter designation, the woman said she meant to imply that it had very bad thrush in its mouth, which went through it and caused a breaking out on the buttocks. It had also a rash which almost covered its body, and caused the skin to peel. Our patient was born three years after her parents' marriage. She was very ailing for the first year, and constantly under medical treatmeut. Her ailment con- Digitized by Microsoft® MISCELLANEOUS CASES, 201 sistedof " bad breakings out/' and the surgeon who attended her gave " a great many greyish powders." A year or two ago she had discharge from the right ear, but with this exception, between the time of her infantile symptoms and the attack of keratitis, she had pretty good health. Case X. — -Severe kerato-iritis^Typical teeth in a sister eight years older than the patient. The following case illustrates the fact, that the influence of syphilis in the parents may be transmitted to children born many years after the primary disease : Caroline Backwell, a little girl, aged 5, was brought to me in December, 1861, with both cornese opaque, one very extensively so. The keratitis had commenced ten months before, and was now in the retrogressive stage, all congestion having disappeared. Her physiognomy showed nothing noticeable, her skin being clear and free from cicatrices. The state of her cornese suggested interstitial rather than superficial disease, and this view was confirmed by finding that both pupils were very irregular from tags of adhesion. Her teeth, being the first set, displayed nothing characteristic. The upper incisors were rapidly decaying. Her elder sister came with her, a girl aged 13, well grown, and without any disease of her eyes. The central incisors of this girl were most typical. She was so much pitted with small pox that all other features of the physiognomy were obscured. She was deaf (slightly) and rather hoarse. Mr. Dixon and several other observers saw the patients, and agreed in the opinions I had formed as to the type of the teeth in the elder sister, and of the kerato-iritis in the younger one. The younger child must, therefore, have been born at least eight years later than the contraction of the disease by her parents. It is interesting to note that the inflammation of her eyes appears to have been the only specific affection from which she has suffered. Digitized by Microsoft® 202 MISCELLANEOUS CASES. I learnt respecting the family that there were six in all. The eldest was a boy of fifteen. Case XI. — Loss of sight in both eyes — JSostensive choroidal disease in both — Retinal apoplexies — Teeth, etCj, rather suspicious. Lucy Crutchfield, aged 27. Nervous and delicate. A single woman. Her teeth show a horizontal notching near their crowns, but no vertical notches. They are rather peggy and of had colour, contrasting most remarkahly with her elder sister's, which are regular, white, and hroad. She is the fourth of a family of five. She has a yellow, faded complexion, hut no other signs of syphilitic cachexia. She states that six months ago she had good sight ; then her eyes gradually failed, and a fortnight ago the sight sud- denly got much worse. Now she can see very little, only large ohjects. On both retinae are numerous extravasations of blood, and many white patches from which the choroid has been absorbed and where the sclerotic is now exposed. She says thatshe has had only very transient and slight attacks of pain in the eyes. Ten years ago she was liable to fits. In this case, the diagnosis is not very strongly supported. "The changes were, however, exactly those which I hav6 seen very often in syphilitic eyes, and the physiognomy, etc., were, to say the least, suspicious. Digitized by Microsoft® 303 CHAPTER X. ON THE MEANS OF RECOGNITION OF THE SUBJECTS OF HEREDITO-SYPHILIS DURING THE TERTIARY STAGE.* Having now considered the various forms of disease of the eye and its appendages, which occur in connexion with inherited syphilis, it may he convenient to add a few words respecting several questions in reference to diagnosis, &e., which have been incidentally mentioned. The establish- ment or otherwise of a diagnosis of inherited venereal taint must always be treated as a matter involving great and peculiar responsibility. It is often one of great difiiculty, and requiring the cautious use of much special knowledge. In most cases the surgeon is precluded either by moral obliga- tions or by motives of kindness from asking any direct questions, or even such as may excite suspicion. If it is the mother of the patient to whom such questions are put it is very possible that they may be the means of inducing her to suspect that which she had never before dreamed of, and which whether true or otherwise may poison the happiness of her life. There can be no duty more imperative in the exercise of our profession than that of abstaining from needlessly exciting in the minds of our patients suspicions as to conjugal purity.f In a general * The remarks in this chapter apply only to the recognition of the heredito-sypMlitic diathesis at ages considerably advanced from infancy. In infancy and during the occurrence of secondary symptoms, rash, etc., the diagnosis is comparatiyely easy. + This consideration must be my excuse for the many cases in this -work in which the history is much less complete than it would have been had direct, questions been asked. In the commencement of my inquiries, I allowed myself to put questions of this kind much more frequently than I now do. The importance of ajscertaiaing the real value of certain symptoms seemed to warrant this. Digitized by Microsoft® 204 ON THE RKCOGNITION way there is much less need of caution in seeking informa- tion from the father of such a patient than from the mother. Still no one would willingly be guilty of the cruelty of leading a father, however correctly, to attribute the sufferings of his child to his own faults, who had previously not suspected the connexion. These considerations greatly in- crease the importance of those objective symptoms upon which we are accustomed to base a diagnosis of this nature. I shall endeavour to be as explicit as possible in defining the degree of value which I believe to attach to some of these, and should any of the expressions used appear too dogmatic I must beg my reader to believe that it has arisen solely from a desire to write clearly on a very complicated subject, and not from the slightest wish to stereotype my conclusions either as regards my own mind or his. In any case in which a syphilitic taint is suspected we must seek certainty, first by inspection of the patient's symptoms and developmental peculiarities^ and secondly by inquiries as to infantile history. By far the most reliable amongst the objective symptoms is the state of the permanent teeth, if the patient be of age to show them. Although the temporary teeth often, indeed usually, present some peculiarities in syphilitic children, of which a trained observer may avail himself, yet they show nothing which is pathognomonic, and nothing which I dare describe as worthy of general reliance. The central upper incisors of the second set are the test teeth, and the surgeon not throughly conversant with the various and very common forms of dental malformation will avoid much risk of error if he restrict his attention to this pair. In syphilitic patients these teeth are usually short and narrow, with a broad vertical notch in their edges, and their corners rounded off. Horizontal notches or furrows are often seen, but they as a rule have nothing to do with syphilis. If the question be put, are teeth of the type described pathognomonic of hereditary taint ? I answer unreservedly, that when well characterised, I believe they are. I have met with many Digitized by Microsoft® Digitized by Microsoft® Syphilitic Malformations of the Permanent Teeth. (To face Page 205. j Fig 1. An upper permanent central incisor of a boy, the snbject of in- herited syphilis. The tooth has been very recently cut, and shows a broad vertical notch, in which are several small projecting spines (the sole remains of the atrophied mid-lobe). Pig 2. Two upper and four lower incisors (permanent) of a girl, the subject of inherited syphilis, all but recently cut. The upper teeth are narrow from side to side, at their edges, and show a thin middle lobe, bounded above by a crescentic line. The lower teeth are rounded, and show foliated extremities. All the teeth are small, and spaces occur be- tween the adjacent ones. In the upper ones, the crescentic thin mid- lobe, and In the lower ones, the foliated extremities will before long, break away, and the upper teeth will be left in the state shown in Fig. 3. Fig. 3. The central upper incisors of a lad, aged IS, the subject of in- herited ^philis. The teeth are short, convergent, narrow from side to side at their edges, and show in each a vertical notch. Fig. 4, In these teeth almost similar characters as in Fig. 3 are seen. The notches are, however, less deep, whilst the narrowing from side to side is very marked. Fig. 5. The upper incisors of a girl of 17, the snbject of inherited syphilis. There is a wide space between the central ones, and both these teeth, although of nearly normal length, are narrow, and show deep vertical notches. The lateral incisors are, as is usual, of normal size and foriu. These teeth are much less typical of hereditary syphilis than those in Figs 3 and 4. Fig. 6. The upper incisors and canines of a girl of 12, the subject of here- ditary syphilis. The right canine is a temporary tooth : all the others are permanent. The incisors are remarkable for great ine- quality of size and difference of form. The right central incisor is very small and notched. The right lateral incisor is of normal size, all the others much below it. Fig. 7. The upper permanent incisors of a boy of 12 (syphilitic). This sketch shows a condition of extreme dwarfing of the central ones, which, although cut four years ago, have never grown higher than a line or two above the gum. Fig. 8. An exceedingly weU-characterized set of syphilitic teeth (upper and permanent), from a girl aged 16. The central incisors are dwarfed, narrow, and notched ; the lateral ones of normal size ; and of the right canine, the apex is replaced by a notch, in the centre of which is a small tubercle. Digitized by Microsoft® lens Aldnus iel T'offen Tfest si ITfest ck-a Digitized by Microsoft® Digitized by Microsoft® OF THE HEREDITO-SYPHILITIC DIATHESIS. 205 cases in whicli the type in question was so slightly marked, that it served only to suggest suspicion^ and by no means to remove doubt, but I have never seen it well characterised without having reason to believe that the inference to which it pointed was well founded. The appended plate will illustrate better than any verbal description can the characters of the syphilitic teeth. Figs, 3, 3, 4, 5, and 8, show typical malformations. The tooth in Fig. 1, had been only very recently cut, and some small spines are seen occupying the notch, which in a short time would be broken away, leaving a state resembling that shown in Fig. 3. Figs. 6 and 7'show exceptional conditions : — In the former, the teeth are not symmetrically malformed, and in the latter is illustrated the very interesting fact of almost total arrest of growth in the two test teeth. Next in value to the malformations of the teeth are the state of the patient's skin, the formation of his nose, and the contour of his forehead. The skin is almost always thick, pasty, and opaque. It also often shows little pits and scars, the relics of a former eruption, and at the angles of the mouth are radiating linear scars running out into the cheeks. The bridge of the nose is almost always broader than usual and low, often it is remarkably sunk and expanded. The forehead is usually large and protuberant in the regions of the frontal eminences ; often there is a well marked broad depression a little above the eyebrows. The hair is usually dry and thin, and now and then (but only rarely) the nails are broken and splitting into layers. If the eyes have already suffered, a hazy state of the cornese, and a peculiar, leaden, lustreless condition of the irides, with or without synechise, may be expected. If, however, the eyes have not yet been attacked by syphilitic inflammation, they will present no deviation from the state of perfect health and brilliancy. The occurrence of well characterised interstitial keratitis is now considered by several high authorities as pathognominic of inherited taint. It is almost invariably coincident with the syphilitic type of teeth, and when these. Digitized by Microsoft® 206 APHORISMS AND two conditions are found together in the same individual, I should certainly feel that the diagnosis was beyond doubt. As a general rule, however, it is only by the careful estimate of various physiognomical conditions and symptoms con- sidered together, and mutually supporting each other that the diagnosis of this diathesis can be established. I must especially beg of those who have not previously made the deformities of the teeth the subject of special study, to be very careful in their inferences. Mistakes, leading to painful and much regretted consequences, may ensue from too hasty reliance upon misinterpreted symptoms. Aphorisms and Commentaries respecting Constitutional Syphilis and its Transmission prom Parent to Oppspring. I. An individual who has once suffered from self-acquired constitutional syphilis, is not liable to contract the disease a second time.* II. It is as yet doubtful whether a person who in infancy has suffered from well characterised secondary symptoms, is protected thereby fi?om future liability to syphilis. It is, however, in a high degree probable that inherited taint does, if not actually protect, at least tend much to modify the liability to acquired diseaseif Analogy as well as clinical experience lead to this belief. • There are exceptions to thigj but these are as rare as in the case of other specific exanthemata, and only serve to illustrate and confirm the rule. + See pages 149 and 171. See also a paper by the author in thfe " British^ Medical Journal^ " for September 21, 1861. Digitized by Microsoft® COMMENTARIES. 207 in. Constitutional syphilis once acquired may exist in the system for indefinite pmods, and even for a whole life. IV. After the secondary symptoms have been once passed thraughj periods of latency may occur in the course of consti- tutional syphilisj during which the patient may consider himself in perfect health, and be whoUy free from symptoms, but in which the taint still exists. Latent syphilis may be aroused into activity after long periods (several or even twenty years), by any influences which diminish the vis conservatrix of the patient's system^, e.g. illness, impoverished diet, the climacteric period, the debility of advancing age, &c. VI. In all stages of constitutional syphilis, — whether during the secondary or tertiary symptoms, and even during a protracted period of absolute latency, — an individual may become the parent of a tainted child. VII. The degree of severity with which a child suffers from inherited taint is usually in proportion to the shortness of the period which has elapsed since the primary disease in the contaminating parent.* *• This law maybe interfered with byseveral circumstances about to Be referred to. (See Aphorism XVIII). Digitized by Microsoft® 208 APHORISMS AND VIII. When both parents are the subjects of syphilis the child is more certain to suffer, and more likely to suffer severely than if only one is so. IX. A child may inherit syphilis in a most severe form from but one parent — ^from its father alone, or from its mother alone. X. No data are as yet on record to warrant any opinion as to whether a child is more likely to suffer severely when its father is the source of contamination than when it derives the disease from its mother, or the reverse. XI. When a wife is the subject of constitutional syphilis and her husband is healthy there is a better chance that healthy offspring will eventually be produced than when the reverse, is the case, since the father will remain without taint, and the mother's system will in the course of time gradually eliminate it. XII. When a healthy woman is pregnant with a syphilitic foetus her system suffers (in slight and variable degrees) from- the re-sorption of the foetal fluids. This process (foetal contamination) is repeated during successive pregnancies if the father's system has not meanwhile been freed from the taint. Digitized by Microsoft® COMMENTARIES. 309 XIII. "Women who acquire syphilis by foetal contamination only, rarely suffer from symptoms belonging to the secondary group. In most instances their symptoms are ill developed, and of the tertiary class — palmar psoriasis — sores on the tongue — ^cachexia — nodes, &c. Usually these symptoms make their appearance during a pregnancy, and often wholly vanish after delivery, to recur again when the woman is again pregnant. XIV. In a large proportion of the cases of inherited syphilis met with in practice, the taint is derived from the father only. In most of these the mother has suffered more or less from foetal contamination during her pregnancy, but has rarely presented any special symptoms. XV. A woman who has borne to a syphilitic husband a suc- cession of syphilitic children, will often declare that she herself is in good health, and will be wholly without suspicion as to the real cause of her infants' ailments. It is exceptional, however, in such cases to find on careful enquiry that the mother has been entirely free from the evidences of foetal infection. XVI. A woman under the circumstances supposed in the pre- ceding commentary may be the mother of a large family and yet show no specific symptoms herself, until the climacteric period, or even later. At the latter period psoriasis palmaris, syphilitic sores on the tongue, or cellular indurations in the legs not unfrequently occur without having been preceded by any other symptoms. Digitized by Microsoft® 210 APHORISMS AND XVIT. Provided that both parents be of robust constitution, and that no irregular or enfeebling course of treatment have been adopted, it is to be expected that each successive child will suffer less than the preceding one. This will be the case whether both or only one of the parents have suffered. XVIII. Exceptions to the general law, that the later children suffer the least occur: 1st, whenever the stamina of the infecting parent (or parents) is gradually giving way under the morbid taint ; or 2ndly, when, the father remaining in statu quo, the mother's system is gradually becoming con- taminated by foetal infection during successive pregnancies. Under the latter circumstances the first child had but one diseased parent, whilst the later ones had two, the taint in the mother having been gradually developed. XIX. It is probable that in some cases constitutional syphilis (in either sex) prevents fertility, but, unfortunately, it does so but rarely. Many syphilitic persons (both women and men) are very prolific. XX. When a long succession of children all suffer severely from syphilis, it is probable, but by no means certain, that both parents are diseased. XXI. "When there is clear proof that the elder children of a family are in perfect health, whilst the younger ones are Digitized by Microsoft® COMMENTARIES. 211 syphilitic, it becomes exceedingly probable that the disease has been contracted by one or other parent subsequent to marriage.* XXII. Should a single child in the middle of a healthy family present indubitable symptoms of syphilis — ^the older ones and the younger ones being wholly free — the only conclusions to which we can come, are, either that the sufferer is probably not the offspring of the reputed father, f or that accidental contagion of primary disease occurred in infancy. XXIII. The efficacy of specific remedies in eradicating a late remaining taint of constitutional syphilis, and thus enabling the father of syphilitic children to have healthy offspring has, I think, been much over-rated. In many cases the lapse of time alone well accounts for any improvement which may have been noted in the condition of succeeding children. In many cases, in spite of careful treatment, no such improve- ment is obtained. XXIV. The preceding commentary is by no means intended to discourage the employment of specific remedies, but only to repress a too confident reliance on them. Mercury is, I believe, the only trustworthy remedy under such circum- stances. The utmost care should be taken that the patient's * I am glad to be able to state that in my own experience cases of this kind have been very exceptional. + I have seen one instance of this, and one only. It was a rer remarkable one, the affected child being in a most miserable condition, and the symptoms well characterised whilst the other children were of good development and in, excellent health. The woman was a sailor's wife and attributed the child's illness to her having been very badly off during the whole pregnancy, owing to her husband's absence. p 2 Digitized by Microsoft® 213 APHORISMS AND constitutional powers be not too mucli depressed. Fresh air, change of air, and a fuU meat diet, are of great importance. XXV. A woman who has borne tainted children to a diseased husband may be treated carefully by specific measures during almost the whole of a subsequent pregnancy, and yet in spite of such treatment bring forth a child who will suflFer very severely. XXVI. A husband who is himself wholly free from symptoms, and has been so for years, may yet beget tainted children. XXVII. At whatever-stage the disease may be in the parent, and however long the interval since the date of the primary disease, the children will, if they suffer at all in infancy, present one, and the same class of symptoms, those namely of the secondary stage, and consisting in afl'ections of the cutaneous and mucous surfaces. XXVIII. The foetus in utero may suffer from syphilitic inflammation, and may perish in consequence. It may so perish at any period of its intra-uterine life, but its death is most common either during the first three months or shortly before the completion of full term. XXIX. A very large majority of syphilitic infants are quite free froioa symptoms at the time of birth, and present every appearance of full development and good health. Digitized by Microsoft® COMMENTARIES. 213 XXX. Syphilitic infants usually begin to present symptoms at the age of from one to two months. The earliest symptom is usually inflammation of the schneiderian membrane with snuffles; then follow a papular, blotchy, or scaly rashj stomatitis and marasmus. XXXI. It is a mistake to suppose that syphilitic infants always present a withered "old -man -like" aspect. In many instances although manifesting specific local symptoms, they grow well and remain plump and fat. If the cutaneous surface be extensively affected, however, and especially if there be disease of the liver the child usually wastes very remarkably. XXXIT. It is a very remarkable fact, that although many syphilitic infants are dead born, yet it is extremely rare for them to be bom alive and presenting at the time specific symptoms. XXXIII. The fact that syphilitic infants almost invariably present at birth the aspect of good health, points to the conclusion that the specific taint does not directly retard development. XXXIV. A syphilitic infant is born with a peculiar condition of its blood and solid tissues, which render it liable at various periods of life to certain peculiar forms of inflammation of special organs and parts. Unless these inflammations occur, there will be little or no evidence of the existeiiee of the taint. Digitized by Microsoft® 214 APHORISMS AND XXXV. At one time (in March, 1861), the stoutest and healthiest looking baby which was presented during several weeks amongst the large numbers attending my out-patients- room at the London Hospital was a syphilitic one. XXXVI. That heredito-syphilis does not always impede develop- ment is not unfrequently seen to be illustrated in patients between fifteen and twenty, who are in every respect well grown. Whenever, however, the infantile symptoms have been extensive and severe the growth is impeded, and often in a very remarkable manner. XXXVII. It is probable that the arrest of growth, when it does occur, is not due immediately to contaminated blood, but to the indirect influence upon nutrition of impaired organs (more especially the skin and the liver) which have been damaged by syphilitic inflammation. XXXVIII. It is quite possible that a syphilitic infant may show no symptoms in early life (or such slight ones as to attract no notice), and yet at a later period sufl'er from tertiary ones. If, however, any occur in infancy, they will be of the secondary group, and if none of this group occur at that age, they will not appear at a later one. XXXIX. It is probable that many children show no symptoms in infancy who yet suffer in later life. In these the taint is usually slight. They are often the younger part of the family. Digitized by Microsoft® COMMENTARIES. 315 XL. The anus may become abraded and sore during the first outbreak of syphilitic rash in infancy, but the true condyloma does notj as rule, show itself until the child is from eight months to three years old. Condyloma is often at the time of its occurrence a solitary symptom. XLI. That in the form of stomatitis to which syphilitic infants are subject, the alveolus and dental sacs often suffer, is proved by the fact, that every now and then actual necrosis and exfoliation of those structures take place. In almost all cases the gums are red and swollen. XLII. In the inflammation of the Schneiderianmucous membrane, to Tfhich the snuffles of infantile syphilis is ,due, the inner periosteum of the nasal bones usually suffers, and the develop- ment of the bones is usually interfered with. XLIII. When acute iritis occurs in consequence of inherited syphilis, it usually shows itself at an early period (three to six months), in conjunction with rash, &c. XLIV. Waxy disease of the liver is not uncommon in , sjrphilitic infants. XLV. In conjunction probably with liver disease, a yellow pallor of the skin is also common in these infants, and now and then positive jaundice is met with. Digitized by Microsoft® 216 APHORISMS AND XLVI. Chronic arachnitis as evinced in a tendency to Hydro- cephalus is very common in syphilitic infants, and occurs in almost all who suflfer severely from the taint in question. XLVII. Nodes are not common in young infants, hut do every now and then occur. If periostitis occurs at a very early age, the humerus is almost always the bone affected. I have never seen nodes in the head of an infant. XL VIII. At a more advanced age (two to six years), Nodes are not very uncommon. The humerus is still the bone most liable to suffer. Next to it the tibia, and then the ulna or radius. Excepting after contusions the bones of the cranium are rarely attacked.* XLIX. Nodes of the humerus in syphilitic children usually affect its lower part, are attended by great enlargement, involve the condyles, and often encroach on the elbow joint so as to limit its motions. L. Phagedenic ulceration of the palate occurs but rarely in heredito-syphilis. The patients in whom it does occur usually present other peculiar features, and are the subjects of extensive periosteal disease and extreme cachexia. Destruc- tion of the alveolus of the upper jaw often accompanies it. * I hare, however, witnessed some cases of very extensive nodes of the skull bones in syphilitic children. In one instance almost the whole calvaria was involved. The patient, a boy of 8, was the son of a clergyman. His mother had been twice married : in the first instance to an officer in the anny> from whom she contracted syphilis; Digitized by Microsoft® 0OMMENTAEIE8. 217 LI. There is not the least nlinical evidence in support of the belief that the common, tubercular, forms of Lupus {Lmpus exedens and lmpus non exedens), has any connexion Mith inherited taint of syphilis. LIT. The only form of disease resembling Lupus to which these patients are liable is, an erosive, almost phagedenic ulceration, which rapidly destroys a large extent of surface, and after which when once arrested, sound cicatrisation speedily ensues. It is quite distinct from true Lupus. It is of comparatively unfrequent occurrence. LIII. The diseases remotely dependent upon inherited syphilis are throughout specific and peculiar. With due care they may easily be distinguished from all other forms of scrofula. LIV. The physiognomical, dental, and other peculiarities, by which we recognise the subject of inherited taint when advanced- Beyond the period of infancy, are all of them the direct consequences of special inflammations from which the patient has sufi'ered at former periods, e. g. the synechise and lustreless iris, of iritis — the malformed teeth, of periostitis of the alveolus and dental sacs — lihe protuberant forehead, of hydrocephalus — ^the flattened nose, of snuffles — the pale, earthy, opaque skin, of cutaneous inflammation and eruptions. LV. If in infancy a syphilitic child chance to escape one or Digitized by Microsoft® 218 APHORISMS AND more of the special inflammations which are usual at that age, the corresponding physiognomical peculiarities will be wanting in older life. Thus if no stomatitis occur, the permanent teeth will be well formedj if no inflam- mation of the schneiderian membrane, the bridge of the nose wiU not be sunken. LVI. It is very important to recognise the fact that the peculiarities adverted to in the last two commentaries, are not produced by general ''arrest of development," but by local inflammatory processes. LVIl. There is no reason to suppose that heredito-syphilis in the least predisposes to phthisis, or to the tubercular forms of scrofula.* LVIII. If a syphilitic child live through the specific maladies of its early infancy (from which a very large mortality occurs), no special liability to any diseases involving risk to life will subsequently be shown.f LIX. Syphilis, like all other specific diseases, tends to manifest itself in certain well recognised stages. The symptoms • Of the cases mentioned in this book, -which comprise the hifitory of more than 200 individuals, not one was the subject of phthisis, and but few of any of these forms of struma which are usually tubercular. I recollect, however, many years ago to have seen a girl under Mr. Startin's care for symptoms which we believed to be due to inherited syphilis, and who was the subject of advanced pulmonary disease. Unfortunately I have mislaid my notes of _ the case. The girl's mother had died of consumption. ■f- I have never known one of these patients the subject of acute internal disease, nor have I had an opportunity for post-mortem examination in any single case. Digitized by Microsoft® COMMENTARIES. 216 characteristic of its early stages, do not recur in its later ones. LX. The sequence of stages in the course of syphilis is as well more marked when the disease is the result of hereditary transmission as when acquired. In both it is not unfrequent for the tertiary stage to be wholly omitted. In proportion to the severity of the early symptoms is, in both, the pro- bability that later ones will occur. LXI. The duration of the several stages of syphilis, even when the evolution of the disease is not interfered with by specific treatment, may vary very considerably, but still within certain limits. LXII. In its early stages syphilis usually affects superficial tissues, and their most external layers (tonsils, skin, and mucous membrane). In its later stages it attacks deeper tissues or organs (periosteum, bone, muscle, tendon, cellular tissue, substance of tongue, Kver, nerves, brain, &c.), or the deeper layers of the same tissues as were previously affected. LXIII. Why should Iritis always occur out of order ? Both in the infant suffering from inherited taint, and in the adult from acquired disease; iritis if it occur at all, shows itself early and amongst the secondary phenomena.* * This is the rule ; exceptions of course occur, but they are rare. Digitized by Microsoft® 230 APHORISMS AND LXIV. In acquired syphilis when the deeper tissues of the eye, choroid, retina, vitreous body, &c., are affected by syphilitic inflammation, it is usually in the early stage of the disease. This does not, however, apply to the inherited form, ffir although syphilitic children if they have iritis almost alVays have it within the first year, they rarely present any form of deep-seated disease of the eye until .within a few years of puberty, LXV. In heredito-syphiUs the interval between the secondary and tertiary stages is as a rule longer than it is in the acquired disease. LXVI. If a person who has suffered from acquired constitutional syphilis have passed two years from the commencement of this disease and have had no inflammation of any tissue of the eyes, he may be tolerably sure that these organs will not suffer in the future. Relapses of inflammation after previous iritis, choroiditis, &c., are common even after very long periods, but it is exceptional for any of these to originate after the interval mentioned. LXVII. The subject of heredito-syphilis is not free from the risk that some form of inflammation of the eye may occur until he has passed the age of thirty years. LXVIII. Of the tertiary diseases of the eye to which the subjects of inherited syphilis are liable. Interstitial Keratitis is the Digitized by Microsoft® COMMENTABIES. 221 most common. It is a very remarkable fact that this affection, has, no analogue amongst the phenomena of the acquired disease. LXIX. The entire absence of Interstitial Keratitis from the role of tertiary symptoms of acquired syphilis, although the most remarkable, is not by any means the only point in which the latter differs in its phenomena from those of the hereditary form. The following may also be mentioned: 1, a peculiar form of deafness occurs in the inherited syphilis ; 2, indurations or ulcers in the tongue are common in acquired syphilis, and very rare in inherited ; 3, osseous nodes are sometimes in the course of inherited syphilis developed to an extent never witnessed under other circum- stances ; 4, psoriasis palmaris in a chronic form is scarcely ever seen in inherited syphilis. LXX. Time is the great agent in the cure of syphilis. The system, if kept in health meanwhile, wiU by slow degrees eliminate the morbid poison. LXXI. The assertion that the syphilitic poison tends in the course of time to be eliminated by natural processes, must be limited to some extent. In exceptional cases the vis conservatrix of the patient appears to yield under the morbid influence, and to permit a gradual accumulation of diseased material and corresponding intensification of the diathesis, LXXII. That the early stages of syphilis may be shortened and that most of the special symptoms may be for the time Digitized by Microsoft® 322 APHOEISMS AND COMMENTARIES. removed by the use of mercury is fully established by clinical evidence. Whether, however, the patient's system sooner gets rid of all taint under that remedy than when it is not used is a question more open to doubt. LXXIII. It is probable that the laws of embryonic development (of certain organs and tissues from special layers), may be made to account to some extent for the sequence of symp- toms in different tissues, both in syphilis and other specific diseases. Some of the facts well established by clinical observations, more particularly concerning the eye are, how- ever, not easily so explained. Digitized by Microsoft® 223 APPENDIX. I AM induced to append the following report on Choroi- ditis, Retinitis, &c., as met with in connexion with acquired syphilis, partly on account of the great importance and comparative novelty of the subject and partly because of its close bearing upon the chief subject matter of the present work. In describing the affections of the eye which occur in heredito-syphUitic patients I have had to shew, that inflammations of the deep-seated tissues are by no means un- common a,nd I have repeatedly alluded to their analogues as met with in connexion with acquired disease. It is desirable, therefore, that the reader should be supplied with data by which to estimate the correctness of such allusions. I am not aware, that, with the exception of a few scattered cases recorded in the Journals, any English author has as yet examined this subject.* ON CERTAIN FORMS OF INFLAMMATION OF THE DEEPER STRUCTURES OF THE EYE IN CONNEXION WITH ACQUIRED SYPHILIS. It had long been suspected, even prior to our knowledge of the ophthalmoscope, that inflammation of the iris was not the only form of disease to which the eye is liable during secondary syphilis. f Iritis being, however, the only form which we could really demonstrate, our conjectures as to syphilitic retinitis, choroiditis, etc., were always more or less vague. The subjective phenomena were, for the most part, all that we had to guide us. The not unfrequent occurrence of loss of vision in the subjects of secondary syphilis, and without external disease, however, left little room for doubt as to the fact that the deeper tissues did sometimes suffer. * Some cases by Dr. Bader will be found in the Journal of the Oph- thalmic Hospital, together with an excellent illustrative plate. t I well recollect cases in which the diagnosis of " Syphilitic Eetinitia " was made at least ten years before the introduction of the ophthalmoscope. Digitized by Microsoft® 234 APPENDIX. The ophthalmoscope has now afforded us the power of inves- tigating these forms of disease with great accuracy. There are few diseases of the eye the recognition of which is of greater importance. Very frequently they are attended by no congestion of the outer tunics of the eye, and by little pain ; but if neglected, they often lead to destruction of the organ. The influence of specific treatment upon them is most marked and decisive. The following group of cases will include instances in which the retina, the choroid, and the vitreous body were either alone or together the seat of inflammation. In some cases all these structures suffer simultaneously, whilst in others the inflammatory processes are restricted to one only; as a rule, but little pain and no intolerance of light attends them, and ophthalmoscopic inspectiou is easily borne. In some cases the iris inflames simultaneously, and then the examination of the deeper parts may become impracticable, as pain, dimness of the cornea, and intolerance of light are usually added. Like iritis, these forms of inflammation appear to occur usually amongst the secondary phenomena of syphilis much more often than among the later ones. This point, however, as well as some others, I shall endeavour to establish by numerical statements at the conclusion of the report. In certain instances of Amaurosis with white atrophy of the optic nerve, a syphilitic history is given. In these, how- ever, the disease usually comes on long after the secondary period, and whether it is really connected with the taint may be held doubtful. Of the relation between cause and effect in the cases of which I am now about to speak, there is, however, no more doubt than there is in the instance of syphilitic iritis. Case I. — Syphilitic retinitis of one eye a few months after the primary disease — Recovery under prolonged specific treatment. The following are my very imperfect notes of a weU- marked case. George F., aged 30, was admitted on March 31, 1859, complaining of impaired vision in his left eye. His left retina was found by the ophthalmoscope to be congested and hazy, looking as if thin gauze were before it. There was no iritis. He said that he had suffered from chancre a few months before, and that rash and sore throat had followed. The rash was now gone, but healing ulcers were still visible Digitized by Microsoft® SYPHILITIC CHOROIUIXIS, &C. 225 in his tonsils. His other eye was not affected, I prescribed a pill containing half a grain of calomel and the same of opium, to be taken three times daily. In a week, he being slightly salivated, the pill was limited to once a day. Sub- sequently, as the progress was slow, he again took it twice a day. With some intermissions mild mercurial treatment was continued until the beginning of September. During the latter part of the time, however, he took the pill only every other night. When the course was relinquished he had regained almost perfect sight. I saw him again on. Jan. 2nd, he could then see almost equally well with either eye ; but the right was still rather the better. All ophthalmoscopic evidences of disease had vanished. Case II. — Syphilitic choroiditis of the left eye with films in the vitreous — History of a similar attack in the right eye three months previously — Primary syphilis a year before, Mrs. P., aged 24, was admitted in Feb. 1860, on account of impaired sight and ''dreadful forcing pain'' in her left eye. There was no iritis, nor any visible sclerotic congestion. With the ophthalmoscope floculi were seen floating in the vitreous humour, and numerous patches of lymph, some white and some slightly brown, were visible on the choroid in various parts. The attack had commenced three weeks before. She stated that she had contracted sores from her husband during her previous pregnancy, and that subse- quently a rash shewed itself. Her confinement was in March, 1859, and she was now again pregnant (two months). Her right eye had been inflamed three months before her present admission, and according to her account the symp- toms had been much the same as those now existing in the left ; she then attended Mr. Critchett, and although at first all but blind regained perfect sight.' I prescribed mercurials but unfortunately have no note as to the progress of the case. Case III. — Extensive turbidity of the vitreous in both eyes. — History of primary and constitutional syphilis four months before. Mrs. M., aged 36, was admitted in July 1859. The two eyes were equally affected. She complained of dimly-seen muscae and clouds of smoke before them, and was unable to Q Digitized by Microsoft® 236 APPENDIX. tell the time by the clock or to read the largest type. The attack had, she said, commenced about four months ago rather suddenly. The left was first affected, and soon afterwards the right also. With the ophthalmoscope the vitreous in each eye was seen to be turbid and full of white silvery films floating in its structure. The choroids and retinae could with difficulty be seen. Mrs. M. was the mother of nine children, and was now nursing her youngest, a baby ten months old. On her shoulders was a well-marked syphilitic rash, and she stated that her husband had communicated the disease to her in November last. Excepting being reduced by nursing she was in fair health. A mercurial course was ordered : the baby to be weaned. I have no record of the result. Case IV. — Syphilitic choroiditis in both eyes, commencing two or three years after the primary disease — Advanced atrophic changes. Mrs. B., aged 27, from Scotland, came under my care on May 16, 1861. She said she was blind of the right eye, and feared that the other was also failing. I found that with the right she could just distinguish large objects. She stated that her sight had begun to fail more than three years ago, and had been much as at present for a year past. She had been married seven years, but had borne no children. Excepting that she was rather pale her aspect was that of good health. With the ophthalmoscope I found very extensive atrophic changes in the right choroid. The margins of the optic entrance could not b.e distinguished, and its position was only ascertained by tracing the convergence of the retinal vessels. The latter were extremely small. Irregular and ill-defined whitish grey patches were seen in various parts,, but in none was the choroidal tissue wholly absent. The humours were clear and there were no iridal adhesions. In the left eye the same state was seen, but in a much, less advanced degree. As the state of the choroids was such as to render the diagnosis of syphilis almost certain, I put a direct question, a,nd was reluctantly informed that she had contracted the disease from her husband about six months after her mar- riage. A rash followed, and she was treated by mercury to salivation. Since then she had believed herself well. She had borne no children, but had had two miscarriages. Digitized by Microsoft® SYPHILITIC CH0B01I>ITI8j &C. 227 Case V. — Syphilitic iritis in an old person — Inflammatory opacity of the lens and vitreous body in each eye. Mrs. B.J aged 65, came under my care, in the first instance, on account of acute syphilitic iritis in both eyes. This was in August, 1860. The iritis had been noticed for a Vreek, but she said that her sight had been getting dull for about a month. She had married for a second time five months before, and her husband had given her syphilis. She had a copious and most characteristic rash at the time. Her sight had in every respect been perfect up to the date of the syphilis. Treatment by iodides and mercurials was pursued, but although the iritis was arrested and the rash disappeared, the eyes did not progress satisfactorily. On Nov. 15, three months from the commencement of the iritis, the state of her eyes was described in the following note : — " Both pupils dilate fairly under atropine, but in both are seen tags of adhesion at several spots. In both lenses there are striae of opacity, but the changes are not such as to prevent the examination of deeper parts. In both eyes the vitreous substance is turbid, and presents innumerable floating films. In the right the turbidity is greater and the films larger. The retina cannot be examined in either eye, owing to the turbid state of the vitreous. She is obliged to be led about, and can only just distinguish large capital letters." Unfor- tunately, I had no opportunity for following this case further, I could not avoid the suspicion that the peculiar course taken by the disease was partly consequent on the advanced age of the patient. It is very unusual to have an opportunity of watching the course of true secondary syphilis attended by acute iritis in a patient of so advanced an age, and it may easily be supposed that at such a period of life, when the nutrition of the organ is impaired, infiammatory processes once established would be apt to run on to serious changes. Respecting the iritis it may be noted that it was never attended by any large effusion of lymph. The treatment was as active as the woman's age and state permitted. Mercurials were given cautiously, but on more than one occasion she was slightly salivated. Case VI. — Syphilitic psoriasis p^lmaris and sores on the tongue — Iritis in the riff hi eye — Diseased vitreous and choroid in the other eye—History denied. Prances S., a feeble woman, calling herself 53, but look- ing ten years older, was admitted in October, 1860. She Digitized by Microsoft® 228 APPENDIX. assured us that she had had good sight until a year ago. Latterly her right had failed, and she had become somewhat myopic. Both her iriides were deficient in lustre, and of steel grey aspect. The left pupil dilated widely, but the right showed numerous tags of adhesion. The iritis was evidently recent, and some sclerotic congestion was still present. She stated that the attack had begun three months ago, when both eyes became bloodshot ; there was dimness of sight and great pain in the back of the head, preventing sleep for several nights. After this her hair fell off. With the ophthalmoscope the left globe was found to be much lengthened, so that the fundus came into view without need for the lens. A very extensive ring of white was seen surrounding the optic disc. The choroidal pigment was irregularly scattered in patches. A single floating film was seen in the vitreous. In the right the optic disc was oval, and there was a long narrow crescent on its temporal side. No other changes. The history as to syphilis was as follows : Mrs. S. had been married 28 years, and had one living child now aged eighteen. She had not lost any children, nor had she had any miscarriages. Her husband she believed healthy, and she denied having ever had any primary sores. There existed, nevertheless, a most characteristic form of psoriasis palmaris in both her hands, and her tongue shewed white patches and fissures which were unmistakable. These con- ditions had she said been present only four months. Treatment. — When admitted the iodide of potassium in ten grain doses three times a day was prescribed, and a blister applied behind the right ear. The iritis soon passed off, and her vision much improved. She continued the iodide until Deo. 3, and with great benefit in every respect. On several occasions she had left it off for a time, but always found that she relapsed when she did so. Case VII. — Double retinitis two years after primary syphilis — Films in the right vitreous — Sight much impaired — Irregular ienefit from specific treatment. Heary B., aged 28, admitted Nov. 1, 1860. His sight had been gradually failing since Christmas 1859. He ascribed it to night work, the flame of the lamp blowing towards his face most of the night. He first found that he could not see so well in the dusk, but his sight got gradually worse, so that on his admission he could not see to read Digitized by Microsoft® SYPHILITIC CHOROIDITIS, &C. 229 small print. He had slight supra-orbital pain, but sufficien to prevent sleep at night. He could see better in strong artificial light, but in strong sunlight his sight left him until he had been in it for a little time. Three years ago he had syphilis and a "sloughing bubo." He took pills for a fortnight before the bubo appeared, but his mouth was not made sore. It is two years and a half since he got rid of these symptpms. He remained well a year and a half, and then hoarseness came on. On admis- sion there was seen the remains of ulceration in the tonsils, and well marked syphilitic ulceration at the right corner of the mouth. On superficial examination the eyea appeared normal, and the pupils dilated well by atropine. He was pale but not thin. Tongue red at tip and edges. On examination by the ophthalmoscope it was noted that the margins of the optic entrance were very indistinct and of a pink colour, which tint extended over the whole uniformly-congested retina. There were films floating in the right vitreous. Ten grains of the iodide of potassium were ordered three times a day, and a blister was applied behind each ear. He took the iodide to Jan. 3. On Jan. 3 one grain of calomel and half a grain of opium were given twice a day, and continued for one week. His gums were touched, and during the salivation he was decidedly better, and remained so for a week, but subsequently he relapsed. The calomel and opium were then again (Feb. 7) given every night, and were continued until Feb. 12, when in addition to the pill ten grains of the iodide of potassium were given three times a day. On Feb. 14 it was noted that his sight was but little improved since admission. The tdceration at the comers of his mouth and on his lips were still present. There were some blotches about the forehead, and chest. His gums were still swoUen. He was pale and cachetic. With the right eye he could read large letters, but not with the left. Feb. 26, no better. Case VIII. — SynechitB of both pupils with extensive choroidal disease in both eyes — History of repeated inflam- matory attacks between the ages of 22 and 25 — No reason to suspect hereditary syphilis. December, 1861.— Miss S. B., aged 25, florid, healthy looking, from the country, a farmer's daughter, and of respectable family. Neither teeth nor physiognomy present Digitized by Microsoft® 230 APPENDIX. any peculiarity suggestive of hereditary taint ; on the con- trary, she is of good complexion and well-formed features. Three years ago her left eye inflamed for the first time. A year later the right eye was attacked, and at the same time the left also again suffered. Since that she has had several distinct attacks, one, in which both suffered severely, was about two months ago. She has several times been profusely salivated, but denies having ever had any rash or sore throat. At the time of the first attack Miss B. states that she was much out of health — suffering from dyspepsia and debility, — but she denies having had any rash whatever. State of the Eyes. — -Both pupils are extensively adherent and dilate very irregularly on the use of atropine. There are in both thin films extending across the pupil, and it is with difficulty that the fundus can be inspected. In the choroid are numerous white patches (sclerotic), some of them abruptly circumscribed, others with ill-defined borders. The choroids generally are thinned, and in some places large masses of black pigment are scattered about. There is no congestion of the globes at present. As to vision, she can still see to read ordinary print, but only very slowly and with much difficulty. Another surgeon examined the patient at my request, and agreed with me that no doubt could be felt as to the specific nature of the diseased conditions. The throat, mouth, and skin of arms, &c., were inspected, but nothing discovered which bore out the diagnosis. Notwithstanding the entire absence of corroborative history, yet from the nature of the disease — iritis and choroiditis in combination — its symmetry, and the age at which it began, I cannot feel any doubt that in this case the patient is really the subject of acquired syphilis. The case is a very interesting and important one. Had either the iritis or the choroiditis occurred singly, there would have been more room for doubt. For obvious reasons no direct questions were asked. April, 1863.— The changes being considerable no very great improvement can be expected. Under a three months' course of iodide of potassium her sight has however been decidedly benefited. Case IX. — Constitutional Syphilis — Inflammation of the Retina and Hyaloid Membrane of One Eye Four Months after the Primary Sore. Mary J., aged 22, married, was admitted under my care, at the Metropolitan Free Hospital, on April 9, 1861. She Digitized by Microsoft® SYPHILITIC CHOEOIDITIS, &C. 231 caine on account of constitutional syphilis, and acknowledged having had primaiy sores four months before. Her symp- toms when a,dmitted were — condylomatous patches on the dorsum of the tongue, on the lower lip, and on the pharynx. She also coniplained of much headache, and had profuse leucorrhoea. It was not until a fortnight later that I knew of her eye being affected. On April 23, I quite accidentally noticed that her right pupil was nearly twice the size of the other, and found on trial that it was insensible to light. There was not the slightest external congestion, the mydriasis being the one symptom which drew my attention to the eye. On being questioned, she told me that for two months this eye had been " dim and misty," and that she had had a good deal of pain in her forehead and through the globes, " like needles sticking thj-ough the eyes." The pain had not, how- erer, been enough to keep her awake at nights, and as she could still see perfectly with the other eye, she had not thought the symptoms described worth mentioning. I found on trial that she could not count fingers with the affected eye. There was no iritis and not the slightest intolerance of light. The pupil dilated widely under the influence of atro- pine. "With the ophthalmoscope the following conditions were discovered and were demonstrated to numerous observers who were present : — The retina was congested and deficient in transparency, looking as if seen through gauze. In the vitreous was a single large floating body, which in some positions looked black and opaque, in others filmy and whitish. There was no diffused turbidity of the vitreous. As usual, the retina bore the examinaton without appearing in the least irritated by it. In the other eye no morbid con- ditions were observed. Up to the date at which I discovered the state of her eye, no specific treatment had, for special reasons, been adopted. We now at once commenced the emplojonent of mercurials. A pill containing half-a-grain of calomel and half-a-grain of opitim was ordered three times a day, together with a draught containing five grains of iodide of potassium. On May 7, she was so far improved as to be able to make out large letters. Her gums were slightly affected by the mercury, and the pill was consequently omitted. May 28. — The pupils are now of equal size, and equally sensitive to light. She can see to read ordinary type with the affected eye. The iodide of potassium is still continued. With the exception of the leucorrhoea, the other symptoms have disappeared. Digitized by Microsoft® 232 APPENDIX. Case X. — Syphilitic Retinitis in one Eye — Opaque con- dition of the Vitreous Body — Syphilitic Rash, etc. Mrs. v., aged 23, had been for some time, several years ago, under my treatment, on account of contracted cervix utesi. On August 6, 1861, she applied to me with the statement that she had lost the sight of her right eye. I found her now with a very well characterized syphihtic rash on the arms, trunk, and neck. This rash, she said, had been out for about six months. Before it came out she had suffered from discharge, but was not aware that there were any sores ; afterwards her throat was very sore. According to her account no specific treatment had been adopted until a fortnight ago. She had lost much flesh, and her aspect was decidedly that of syphilitic cachexia. She stated that her eye first began to be dim about five months ago, and she then applied at an Ophthalmic Hospital. "It was as if she looked through dirty water." She had no material pain at first, but the dimness increased ; no specific remedies were used. Ten days ago she rather suddenly became quite blind in the affected eye, and had also severe pain in the globe. August 6. — ^The right eye is slightly congested and irritable. The pupil dilates well with atropine, and there are no adhesions. The iris is, however, somewhat muddy. The reflex obtained is one uniform yellow grey ; no vessels are visible, nor can the optic disc be discovered ; no floating portion can be seen. The fundus of the other eye is normal. In September the eye again was carefully examined at the Moorfields Hospital. She could now just see the shadows of fingers. The whole vitreous was opaque and of a foggy, white-grey appearance. On looking closely without the lens its dissepiments were easily seen; they were somewhat tremulous ; not the slightest glimpse of the retinal vessels or ojitic disc could be obtained. Although Mrs. V. asserted that she could see well with the other eye, yet on oph- thalmoscopic inspection I found a large, abruptly-circum- scribed patch of effused lymph between the choroid and retina, very near to the yellow spot. Its surface was greyish yellow, its margins yellow and fringed ; several retinal vessels were seen crossing it. On being again questioned, Mrs. V. admitted that her sight with this eye was not so good as usual; for instance, she could not thread her needle, but Digitized by Microsoft® SYPHILITIC CHOROIDITIS, &C. 233 comparing it with the left she had not considered that there was anything worth mentioning. A week after the last note, the right eye was attacked with acute iritis attended with most severe ciliary pain. For this the patient is still attending. Great difficulty has been experienced in influencing either the disease or the constitu- tion by mercury ; although four grains of calomel have been given daily in divided doses for nearly a month, yet no ptyalism has been induced. The eye is slowly improving as to pain, but there appears great reason to fear that sight will not be restored. Case XI. — Syphilitic Inflammation of Retina and Hyaloid Membrane — History of Primary Disease Three Months before — Recovery under Mercurial Treatment. Mrs. W., aged 34, the wife of a commercial traveller iu Yorkshire, came under my care in March, 1861. She was palid and out of health. Her left eye only was inflamed, but ia the right cornea was an old opacity which had for years prevented any useful vision, and which now also pre- vented ophthalmoscopic examination. The sclerotic of her left eye was considerably congested, but there was no per- ceptible iritis. She complained that she saw a fog before the eye, and described severe circumorbital pain, from which she had suff'ered for about a fortnight. Previous to the attack her sight had been perfect in the inflamed eye. At present she could not read No. 16, and could only just distin- guish capitals. On using atropine the pupil dilated widely, but with a single tag of adhesion at its lower part. The vitreous was hazy, and it was with some difficulty that the fundus could be seen distinctly. The margins of the optic disc were ill-defiaed, owing to the effusion of a thin deposit of lymph. The trunks of the vessels were here and there concealed by minute dots of lymph. The area of inflamed retina extended widely but irregularly around the optic disc, including the yellow spot. These conditions, of course, suggested a syphilitic history. I found, on enquiry, that she had had what she learnedly termed " pruritus " about three months ago, after which a rash made its appearance, and was attended by sore throat. On her arms were still to be seen numerous copper-coloured blotches, the remains of the rash, and both tonsils showed the evidences of recent ulcera- tion. The Surgeon under whom she had been treated Digitized by Microsoft® 234 APPENDIX. had considered the disease venereal, hut she had not been salivated. At my request Mrs. W.'s husband came to see me ; but he stoutly denied having had any venereal affection. The treatment consisted in local bleeding and the use of calomel and opium, with full doses of iodide of potassium. Ptyalism was rapidly induced, and the sight improved sur- prisingly. On April 11 (about a fortnight after the treat- ment was begun), she could read wm„i.„. with the affected eye, and the pain was wholly gone. The haziness of the vitreous and retina was very much less. A mild specific treat-, ment was, still continued. On May 16, she returned into Yorkshire, having almost perfectly regained her sight. A slight occasional mistiness was now her only symptom. The margins of the optic disc were now clearly defined, and the retina had to a great extent recovered its normal condition of transparency. Case XII. — Double Iritis with Inflammation of the Vitreous Body and Retina in Both Eyes — Opacity of the Vitreous with Floating Film in the Left — Treatment by Iodides — Left Vitreous still Opaque a Year after. The following case is valuable on account of the prolonged period over which the notes extend. It appears probable that one of the eyes has been permanently lost by inflamma- tion of the vitreous body : — A. J. L., a pale young man, aged 21, of fair complexion and delicate appearance, was admitted under my care on October 18, 1860. He came on account of subacute iritis in the left eye, and stated that he had had an attack in the right one month before. The right pupil dilated fairly under atropine, but some tags of adhesion with much pigment were made visible. The left dilated very irregularly, being adherent by recent lymph at several spots. The symmetry of the disease and the age of the patient left little doubt that syphilis was its cause; but the history obtained was im- perfect. About a year ago he had " a running," but no symptoms for which mercurial treatment was thought neces- sary, nor was it followed as far as could be made out, by any secondary symptoms, the iritis excepted. He had been salivated for the iritis in the right eye. The left had been inflamed about a week. In neither had the attack been attended by much pain. Atropine drops were ordered, and Digitized by Microsoft® SYPHILITIC CHOKOIDlTISj &C. 235 a grain of calomel with a quarter grain of opium twice a-day. On October 22, I dictated the following note :— " Both pupils widely dilated without adhesions visible to the un- assisted eye. With the ophthalmoscope, pigment patches are seen in front of right lens, and the right vitreous body is dim and full of opaque moving films. In the left eye the vitreous is muddy, and some very fine films are seen. The left retina is hazy. The right retina cannot be seen." Ordered, ten grains of iodide of potassium three times daily. Omit pill. October 25. — Much better ; pupils well dilated. November 1. — Sight much improved. Repeat the mix- ture. 8th. — The right retina can now with difficulty be brought into view. It is hazy and greatly congested. The edges of the optic disc cannot be distinguished. 15th. — He is now quite free from pain. Can read with the left, but not with the right. With some omissions he continued the full dose of iodide of potassium regularly, from October 22 to January 3, greatly improving both in health and in sight during its use. At the latter date it was changed for. a draught containing five grains of iodide of potassium, and five mimiras of tinc- ture of iodine, which was continued steadily until April 1. At the last date he still remained without any useful vision in the right eye, and its vitreous was still opaque and con- taining films. During the summer of 1861 he did not attend, but on October 14, he again presented himself. He now complained that his right eye was getting worse, and that he could scarcely see at all. On examination it was found that he could but just distinguish shadows with it. The pupil was clear and the iris dilated fairly. He said that the eye had been getting worse for a month. It was not congested, and beyond a little aching, there had been no pain. He could read easily with the left. On ophthalmoscopic examination I found his left vitreous so opaque that the optic disc could not be brought into view. Here and there a retinal vessel could just be distinguished, as if through thick fog. In all parts of the vitreous were slender filaments of opaque mem- brane, which were thrown into quivering motion by all move- ments of the globe. In the left eye both retina and vitreous had wholly recovered. Digitized by Microsoft® 236 APPENDIX. As the opaque state of the vitreous of the right eye has now existed for a year, with relapses and in spite of treat- menti it is much to be feared that it will be permanent, at any rate in some degree. It will be observed that reliance was chiefly placed on iodide of potassium in the treatment, the man's feeble state of health being held to discourage the use of mercury. He had, however, been salivated before coming to the Hospital, and calomel was given during the first three days of his attendance. No other symptoms of constitutional syphilis have occurred, but I feel no doubt as to the correctness of the diagnosis in this respect. Case Xlll. — Primary Syphilis followed by Rash— Failure of Sight Three Months later — Opaque Condition of the Vitreous in both Eyes. Thomas R., aged 36, a sailor, of dark complexion and healthy aspect was admitted in April, 1861. He stated that his sight had been perfect until the preceding September, when it began to fail in the right eye, and soon afterwards in the left also. He had no material pain. Three months before the failure of sight he had a chancre, which was followed by rash on the legs, thighs, and scrotum. He was laid up for six weeks, and was salivated. He considered that his sight had been as bad as at present since March last. By aid of the ophthalmoscope the reflex was found to be of a dull reddish-brown. There was a diffusedly opaque con- dition of the vitreous in both eyes. He was .examined by several observers, and none could see the optic disc in either eye. There was no effusion of blood. I have no note of further progress. Specific remedies were, of course, ordered. It will be noticed that he had been salivated for the original disease. Case XIV. — Syphilis, Primary and Constitutional — Failure of Sight in One Eye, Three Months after the Primary Disease — Retinitis. Mrs. L., a pale woman, aged 23, was admitted May 27, 1861. The sight of the right eye had been failing for about three months and a fortnight. It came " as a little flufi'," which she " attempted to brush off." She was con- fined a month before admission. The child was a large one, but it had been, she said, " dead for ten days before birth." She, poor woman, ascribed her illness to grief,. which "turned her blood, and caused her to come out in sores on the Digitized by Microsoft® SYPHILITIC CHOEOIDITI8, &C. 237 privates and blotclies on the skin " five months ago. She was under Medical care, and was improved by treatment. She never saw well with the left eye. There are extensive white-margined superficial sores on the tonsils and velum, scars of deep ulcers in the tonsils. A general haze of the vitreous and choroid was aU that was seen by the ophthal- moscope. Iodide of potassium, ten grains three times a day, was given. June 10.; — Improved. Can now read >.-ii""' fairly. Not the least congestion of tunics. On July 17 the mistnra ferri composita was given instead of the iodide. On August 13 she complained that she could not see so well as a few weeks ago. She could see objects below the axis, but not well above ; thus, she could read No. 1 easily when looking downwards, but not No. 30 when held above her. There were still margined patches on the velum. The iodide was again prescribed. September 23. — She had much improved since resuming the iodide. Can read No. 1 with either eye — irides clear and lustrous. She looks well, and has gained colour whilst taking the iodide. Case XV. — Right Eye almost Sightless for Ten Years — History of Constitutional Syphilis treated, by Mercury Eleven Years ago, and followed by Loss of Sight — No Evidence of Iritis^-Other eye not affected. Louisa H., aged 34. She says she is a widow. Eleven years ago she had sores, followed by rash, all over the body, and was salivated. During this treatment her eyes began to suffer, but in a little time the inflammation " settled in the right,'' and the left quite recovered. In about a year the right eye was reduced to about the same state as it is now. She is well aware that her loss of her right eye was con- sequent on "the disease," and told me so spontaneously. She now is florid, and, excepting acne of the face of rather a suspicious tint, looks healthy. She says that her sight has not varied for ten years, and by the help of the sounder eye she has been able to get her living as a tailoress. "With the right she can only see a hand passing before it. She has lately been anxious about the left, but I cannot make out that there are any evident symptoms of failure. She can read easily. Ophthalmoscope — The right pupil dilated freely with atro- pine without showing any adhesions. The fundus of the eye was cloudy, the media being perfectly clear. The vessels entering at the optic disc were extremely minute, almost Digitized by Microsoft® 238 APPENDIX. thread-like, and the margins of the latter were merged in the surrounding fundus, except here and there, where a segment of distinct rim could be seen. The optic disc was very pale. In all parts of the fundus were extensive patches of glisten- ing white, nowhere well defined, and crossed irregularly by tufts of choroidal vessels. Many pigment patches were also seen, and at the yellow spot, and around it the exposure of black pigment, in caudate patches resembling small beetles, was especially noticeable. In the other eye I did not observe any peculiarity except that the optic disc here also was rather indistinctly margined ; no patches, and no exposed pigment. Case XVI. — Syphilis during Pregnancy — Congenital Syphilis in the Child — Inflammation of the Choroid and Retina in the Mother. Mrs. H. and her infant were admitted under the care of Dr. Hughlings Jackson, at the Metropolitan Free Hospital, the mother labouring under the efi'ects of acquired, and the child of congenital syphilis. During her pregnancy with this child she had primary syphilis from her husband, and subsequently a secondary rash all over the body, the stains of which remain. The child was, as usual, born healthy, but he soon had a breaking out of " ulcers " on his head, and when Dr. Jackson saw him, then six months old, the child had cellular nodes and evident marks of congenital syphilis. As to the mother, one week after the birth of the child she began to suffer severe pains in the vertex and temples. She next had pain in the eyes and dimness of sight, and was treated for iritis at the Moorfields Ophthalmic Hospital with mercurials, iodide of potassium, and blisters. She then attended at a General Hospital, and was treated for debility. The pupils dilated well by atropine, leaving, however, a little pigment on the lens. The vitreous and choroid were very hazy, the margin of the optic entrance indistinct, and the vessels small. Dr. Bader, who examined the eyes with the aid of the ophthalmoscope, at once pronounced the affection to be syphilis. Iodides were again given, and Hummer's pill, five grains, three times a day. She attended only twice. During that time a little improvement took place. Digitized by Microsoft® STPHILITIC CHOROIDITIS, &C. 239 Case XVII. — Ilistory of Primary Syphilis — Inflammation of the Deeper Structures cf the Eye. Henry W., aged 25, admitted April 10, 1860. The left eye had been failing six weeks. One evening, on going out into the street,, he saw a halo, like a rainbow, all round a street lamp. The lamp was about fifty yards away. The halo got less as he neared the lamp. This continued for a week. He could then read pretty well, but it was dim. A fortnight before admission, whilst reading with a shade over his candle, the shade fell off, and the " light came with such force that it sent a shock from the eye to the back of the head." Ten days ago pain " came over the temple, and went right to the back of the head." It was relieved by pressure. For two days before admission his eyes had been bloodshot. The superficial tunics of the eyes were congested, and he com- plained of occipital pain. The pain was only at intervals; he thought it was from the light. When he looked at the light in the morning it came on. Under atropine the pupil dilated round. On April 12 the pupil was oval, and under atropine it dilated (still oval), from above downwards. No adhesions were seen. The sclerotic looked much congested. He complained of pain in his temple. The history of venereal disease was as follows : — ^He had gonorrhcea a year ago, for one week. At the same time he had a chancre on the glans, which continued for five weeks. He took pills until his mouth was slightly sore. He had at thei same time an enlarged gland in the groin. He had had no rash. On April 19, Mr. Hutchinson examined him by the'ophthalmoscope, the pupil being well dilated by atropine. " Retina is clouded, as, if seen through a medium not perfectly transparent. No evidence of patching, nor any evidence of floating bodies in the vitreous." He still has pain in the temples, and now the occipital pain seems to have come forward to about the attachment of the sterno -mastoid muscle. The pain in the temple prevented him sleeping for two nights. The pain was, he said, attended by pulsation, like his pulse. There is no note of any previous treatment. At this date four leeches were applied, and iodide of potassium, five grains three times a day, was given, and atropine used. He con- tinued attending until November 15. The pupil when under the influence of atropine was always oval, and when not was much smaller than the other. He had occasional attacks of pain around the orbit. On January 18 he began Digitized by Microsoft® 340 APPENDIX. to notice a central black speck in the eye, which increased when he looked in the distance, so that probably it was due to some more local impairment of the retina. Unfortunately there is no note of any ophthalmoscopic examination. He took, for a short time, pills of calomel and opium, but did not improve much in sight. He had less pain. TABULAR STATEMENT, &c. In the following tabular statement I have included the seventeen cases above given, as well as those of eight others, the full details of which I abstain, out of regard for my reader's patience, from printing. The remarks upon the entire series will be found at page 350. Digitized by Microsoft® ABULAR STATEMENT OF TWENTY-FIVE CASES OE SYPHILITIC CHOROIDITIS, RETINITIS, &c. Digitized by Microsoft® 242 TABULAE STATEMENT OE TWENTY-FIVE CASl No. Name, Date of Admission, Occupation, State of Health. Age Histoiy of the primary disease, and of its treatment. Interval between primary and the affection of the eyes. Other symptoms present at the time of admission. History of the Ophthalmitis George F. March 31, 1859 Mrs. P. Feb. 1860 Married Mr. M. July, 1859 Married Mrs. B. May, 1861 Married Mrs. B. August, I860 Married Frances S. October 8, 1860 A feeble cachec- tic woman Henry B. Nov., 1860 S. D., a farmer's dau(i;hter, healthy-look- ing 27 28 Had had a chancre, rash, and sore throat Sores fallowed by rash Primary sores followed by rash. No note as to treatment Married 7 years ago, and had sores followed by rash six months after- wards. Was salivated Primary sores, followed by rash and sore tlu'oat. She had been treated by mercury She denied having had any primai7 disease. Married 28 years; one living child, set. 18. Subject for four months past to syphilitic psori- aais palmaris, and sores on tongue Primary sores and open bubo three years before. Treated by mercury No primary disease ac- knowledged "A few months" 8 months right eye, 11 months left eye Ulcers in the tonsils None. Pregnant I months A copper-tinted rash on the shoulders. Debi- litated by nursing 3 years 4 months Doubtful 2 years Not known. She ap- peared in fair health when admitted Syphilitic psoriasis and double iritis Psoriasis palmaris and syphilitic patches on the tongue, both of them most character- istic Cachexia. Ulcerations in the tonsils, and at the comers of the mouth No other symptoms at the time of admission The left eye had be i failing in sight foi r week or two Her right eye had si | fered three mont | before, and had qui i recovered. The li i was attacked thr weeks before adm sion The left was first affe« ed, and soon afte wards the right. Tl loss of sight rapid increased The right was, flral^ fected, andpro^ slowly. The |g not begin tosul a year later It commenced in b^ \ simultaneously, ^ j progressedalmost^ ' passu "^ Her sight had been fa ing for a year. S was admitted iritis of the right ey His sight had been £ ing for eleven moi^ with but little drm orbital pain. No in Three years ago the Jj eye inflamed, ani" year later the i^ and at the same-j the left for a i time. Seyeralatt^ since. Has b^ several times fusely salivated Digitized by Microsoft® 243 k^ SYPHILITIC CHOROIDITIS, RETINITIS, &o. State of the Eyes at the date of Admission Treatment, Progress, and Besults Remarks No. P retina congested and hazy. ^HGk much ohBCured fift choroid patched over with ' lymph, and the vitreous contain- ^ing films. Impaired yisiou and ■much tensive pain 3. films floating in all parts of "i vitreous humours. Vision ^17 much impaired. Musc^ Biye effusions of lymph into _^P choroids, followed by ab- ^^jilbnand atrophy. Changes ^at^advanced in the right eye fiiWe iritis with much intole- iace. Ophthalmo&cox>e not used Btil some weeks later aibth irides. steel grey, right pupil *irregular. Staphyloma posticum, i^atrophy of choroid, and film in S^e.vitreDUE of the left eye i^slSptic discs ill-defined and ^|a*ed. Both- retinaa hazy gested. Films in the i^i^^vitreoiu -J pupils extensively adherent, gid' dilate very irregularly by mpine. FilmB across the Ml; the fundiM seen with jffilteulty. NnmerouB white ultdhes in the choroid; some ftruptly circumscribed, others pth ill defined borders. Can see M read ordinary jnint, but very llowly, and with much difficulty A mild mercurial course was persevered in with some intermissions for five months. He recovered almost perfect sight The right eye had perfectly recovered under mercurial treatment. No note as to the left No note as to the results of treatment No specific treatment appeared to have been adopted for the eyes. The dis- ease was of three years standing when I saw her Mercurials and iodides were freely used. The iritis passed off, but both lenses became partially opaque, and there were extensive (Ganges In the vitreous in both eyes She was greatly benefited by a course of iodide of potassium He was treated by mercury and iodides, and derived some benefit, but subse- quently relapses occurred She was treated with iodides and mildly with mercurials, and with considerable benefit The disease affected but one eye A mild case of retinitis. The turbidity of the vitreous prevented satisfactory exami- nation of the retina and cho- roid The disease appeared to have been insidious and gradual, but I doubt much whether the interval (Col. 4) had been as long as she stated When lEist seen the woman was almost blind from the turbid state of the vitreous in both eyes This is the only example of ex- tensive staphyloma .posticum which I have seen in con- nexion with syphilitic changes In this case the disease had come on late and had been long neglected Although no history could be obtained in this case of the primary disease, yet the con- dition of the choroids, and the coincidence of iritis, left no doubt on my mind R 2 Digitized by Microsoft® 244 TABULAE STATEMENT OE TWBNTY-EIVE CASI Interval 1 between 1 No. Kame, Date of AdtniSBion, Oooapation, State of Health. Age History of the primary disease, and of its treatment. primary disease and the affeotionof the eyes. Other sifmptoms present ' at the time of admission. History of the . k Ophthalmitis. » 9 Mary J.., 22 She had primary disease 2 mbnths Gondylomatud patches Dimness and mist b^9 AprU9,'l861, four months ago on the dorsum of the the eye (the ri^ tongue, lower lip, and pharynx; leucorrhoea Pain in the fore^ and pain like ' 'neeoefl in the eyes | 10 Mrs. v., 23 She had had syphilitic rash Doubtful Well characterised syphi- 1 The right eye. She sal that aboutfive montq August 6, 1861 six months before her litic rash on the arms. admission, but did not trunk, and face, for six ago ,the rightjiS know whether she had months began to be diiMJJ had sores or not "looking tV^ dirty water." «^M dimness incre^seo and ten days agp bU rather suddenly- Im all sight init,andn had severe paiKl the globe. TheotM eye was a litn effected, e. g., a could not see with, to thread her needli 11 Mrs. W-j 34 She had had what shfe 3 mths. (?) Copper coloured blotches She had had a "fi^, Marcb 28, 1861, called "pruritus" three before the ese,.et Pale ana out of months a^o, followed by evidence of recfent severe oircumorlii^ healtb copper - coloured rash. Her Surgbon considered it venereal. She had notbeen^vated. Her husband denied having had any syphilitic affec- tion ulceration in the ton- sils. pain for a fortnSg (In the right eyeiW an old corneal op^ which had prevS useful vision for if^ 12 A. J. R., 21 A year ago he had a 1 year None He attendedfor subwl Oct. 18, 1860, " running," but no mer- i.e., 1 year iritis in the left.^ PaJte »ad deli- curial treatment was before He had had iritis T; cate thought heceasarybyhis the iritis. the right a mont before " Surgeon. He had no secondary symptoms. except the iritis, etc. Digitized by Microsoft® 245 gg SYPHILITIC CH0B0IDITI3, EETDiTITIS, &o. State of the Eyes at the date of Admission. Treatment, Progress, and Results. Bemarks. No. ffiere was no iritis and no intole- "^ce of light. One pupil was ''feore dilated than the other ; it "dilated ftiHy by atropine, and without showing any adhesions. The retina was congested and deficient in transparency, looking aa if seen through a gauze. In the vitreous was a single large floating hod^y, which in some positions looked hlack and opaque; in others, filmy and whitish. No diffused turbidity in the vitreous. She could not count flngers'with the affected eye"' Ihe whole right vitreous was 'opaque and of foggy white grey appearance. Not the slightest 'glimpse of the optic disc nor retinal vessels could he obtained. 'Ijuite blind with this e^e. In the ^'"wt eye there was found a laj'ge, "Sfiruptly-circmnscribed patch of [^teised lymph between the retina f^l^ choroid, very near the yellow JmM; butW stated, she averred Kit her sight' with this eye was ^bd for ordinary purposes hte jjupil dilated widely, but with ^a Single tag of adhesion at its; lower port. The vitreous was hazy, and it was with some difl&culty that the fundus could be distinctly seen. The margins of the optic nerves were ill- defined, owing to the effusion of a thin deposit of lymiph. The truulcs of the vessels were here and there concealed by minute dots of lymph. The area of inflamed rJBtimi extended widely, but irregifl^fly round the optic disc. . She could not read No. 16 n Octobter 18 there were'adbesions in bot& pupils, but on the 22nd none were seen except by the ophthalmoscope, and these as pigment patches on the lens. The right vitreous was dim, and full of opaque moving films. In the left the vitreous was muddy, and some very fine films seen. The left retina hazy; the right not to be seen. No specific treatment for the eye was adopted until April 23 ; then calomel and opium were given three times arday, and iodide of potassium. She improved, the other symptoms dis- appeared, and on May 28 she could read ordinary type Calomel was freely ^ven, but there was great difficulty in producing any effect on the disease or the usual constitutional influence of mercury Local bleeding, calomel, and opium, and the iodide of potassium. On April 11 she could read No. 1 (brilliant). On May 16 she could see almost as well as ever. The margins of the optic nerve were now clearly defined, and the retina had to a great extent recovered its trans- parency For the first few days he took calomel and opium, but on October 22, ten grains of the iodide of potassium were given three times a-day instead. This he took, improving much in health and strength, to Januarys, when five grains of the iodide with tincture of iodine were given. This he took to April 1, and then ceased to attend. He had notrecovered any useful vision in the right eye She had subsequently an attack of iritis in the right &ye. There is little hope of way improvement of vision in this eye He again attended October 14, 1861. The right eye was still pretty much in the same state ; in tiie left, both the retina and the vitreoiM had wholly re- covered U 12 Digitized by Microsoft© 246 TABULAE STATEMENT OF TWENTY-EIVE OASESI Interval between No. Name, Date of Admission, Occupation, State of Health. Age History of the primary disease, and of its treatment. primary disease and the affection of Other symptoms present at the time of admission. History of the i* Ophthalmitis. ' the eyes. 13 Thomaa E., A sailor, April, 1861 36 About nine months ago he had chancre^ followed by rash on the legs, thighs, and scrotum. He was salivated. 3 months None Six or seven months agj i^ his sight began to fa ^ in the right eye, an * soon afterwards i * the left also ) q c 14 Mrs.L. 23 She was coniined three Nearly Extensive white mar- The right eye: the sidf* Married, months ago of a chUd 3 months gined superficial ulcers ' had been falling ahoflt Fair health. which, the Doctor told on the tonsils and two months andafoi^M May 27, 1861 her, had been dead ten days. Although she was not aware of it, there is velum palati. Soars of deep ulcer, in the tonsils night. It began by J* sort of " fluff" befaw'* the eyes, which sh; tried to remove clear evidence that she had primary syphilis five months ago 15 • L. H., 34 Eleven years ago she had During She was well aware that Duringthetreatmentloiii Widow (?), sores, followed by rash treatment the loss of the right the primary diseasjip Tailoress, all over the body, and for the eye was due to "the eleven years ago, h \i Healthy was salivated. (See primary disease," and told me eyes began to Buffi^s col. 6.) symptoms so spontaneously, but except acne of the face of rather suspicious tint, she looked healthy butinalittletimsthSji! inflammation "setHMir in the right," and tl n left quite recoveH W In about a year tl i$ right eye was redua n to about the state n now is 16 Mrs. H. 35 She had primary syphilis Less than Stains of a rash which One week after the birllB during her pregnancy 9 months she had after the of the child(sixmontlIa with a child now six primarysyphilis. Her ago), shehadiri1ia,f(!(i| months old, and suffer- infant had cellular which she was treatHjUi ing from congenital nodes, etc. by mercurials, ioffldeiM syphilis. No note as to et«. ,T, the treatment of the primary disease. 17 Hy. W., April 19, 1860 25 Gonorrhoea and a chancre a year ago. He took pills until his mouth was 11 months None Lefteyeonly. Sixwel^d before, he saw a hal « round a lamp in tb q^ street. Ten days agq^ he had severe pain int. ', slightly sore. He had then also an enlarged gland in the groin. No the head, and the ey^ became congested, jig, secondary symptoms ex- cept the disease of the eye. 18 Mrs. P., Married, Cachectic, B. page 36 31 Had syphilis eleven years ago, and had since borne seven syphilitic children Nodes and extreme cachexia She had been quiteitt^i, of the right eyeM," many years >||i^ Digitized by Microsoft® 247 OF SYPHILITIC CHOEOIDITIS, RETINITIS, &c. State of the Eyes at tlie date of Admission. Treatment, Progress, and Results. I- By aid of the ophthalmoscope, the I reflex was found to be of a dull I reddish-hrown. There was a I diffosedly opaque condition of the vitreous in both eyes. He was examined by several ob- servers, and none could see tlie optic disc in either eye '■ The sight was not much impaired. ^, The pupil dilated well by atro- ' pine and nothing except a httle i haziness of the vitreous humour was observed. She had no pain. ' The right pupil dilated freely with atropine without showing any I adhesions. The fundus of the , eye was cloudy, tlie media being T> perfectly clear. The vessels en- i tering at the optic disc were -\ esti-emely minute — almost :. thread-like— and the margin of 1 the optic disc was merged in the i surrounding fundus. Optic disc i-. very pale. Many pigment patches at the yellow spot Li Vitreous and choroid very hazy: ■I margin of optic entrance in- distinct, and the vessels small. f Dr. Bader, from the ophthal- moscopic appearances only, diag- nosed syphilis ;[^ Pupil dilated well without adhe- iii sions. "Eetina clouded, as if ;!■ seen through a medium but im- :.r perfectly transparent. No evi- j dence of patching, nor any :'. evidence of floating bodies in the vitreous. He had much pain shooting into tlie eye from the occipital regions of the head. There is, unfortunately, no exact note as to sight, but there was no useful vision .' The vitreous body of the right eye was so opaque, that I could not illuminate the fundus. In the left eye the media were perfectly clear, and the stmctures of the fundus norma Specifics were ordered, but unfortu- nately there is no further note of progress Under the use of the iodide of potas- sium in ten grain doses, the sight improved ; so that on June 10 (a fort- night after admission) she could read No. 1 type. On July 17, mist. ferri. CO. was substituted. She again relapsed, and on August 12, she could not read No. 20, when the board was held above her, but could still read No. 1 when it was held above her. By specifics she again rapidly improved. No note of treatment It ivill be remarked that he had been salivated for the original disease Iodide of potassium and mercurials (Plummer's pill) were given, and a little improvement followed, but she only attended twice He took iodides and mercurials, but the pain, although often better for a time, was often severe. He did not improve materially She said that for ten years the sight has been about the same, and by the left eye she has been able to earn her living as a tailoress. She had recently been anxious about the latter, but I could not make out any evidence of failure. She could read easily. The optic disc was rather indistinctly margined This patient was under the care of my friend Dr. Hughlings Jackson, at the Metropolitan Free Hospital Specific treatment was adopted for the other symptoms, hut as regards the eye no hope cf benefit could be entertained Digitized by Microsoft© g4d I TABULAR STATEME:N"T OF TWENTT-TTVE CASES 1 Interval 1 between No. Name, Date of Admission, Occupation, State of Health Age History of the primary disease, and of its treatment. primary disease and the affection of the eyes. Other symptoms present at the time of admission. History of the 'i Ophthalmitis. 19 Mrs. J., Married, Good health, B. page 37 25 Had primary syjihilis five years ago, which was followed hy rash and double iritis. Treated by mercury, and re- covered perfectly 5 years None She had retained excelH lent sight until a fortnight before ad- mission, when with- out any pain she began to see dimly- The attack com- menced rather sud- denly. ■i 20 Mary A. W., 29 She had syphilis from her Inten-al None. (Three years 1 Her eyes have been fail- Married, husbaodthree years ago, probably had elapsed since the ing for a year, but Dark com- and had rash afterwards 2 years primaiy disease). more for the last live. plexioned, months [ Pale, No family ■ March 24, 1S62, » B, page 3i 1 21 Jesse W., 33 Had a " dry sore " four 18 months None. (Four years had i He first noticed two A Bargeman years ago, which was elapsed since the years and a half ago from Shrop- followed by a rash. He primary disease.) a dimness, and waa shire, beheved that heha-d not after^^'ards troubled Healthy, tdlcen mercury. After withphotopsia. These March 17, 1862, the rash disappeared, he symptoms steadily B. page 32 remained wholly with- and slowly progresseol until in the course of out symi'toms, with the exception of the eyes two years he became almost blind. Pro- bably no specific treat- ment. 22 Mrs. B., 30 She had had sores followed Nearly None. (Nearly two years A little pricking, shoot- In excellent by rash two years ago. 2 years had elapsed). ing pain in the globe health. and was freely treated for a few weeks before E. page 50 both by mercury and iodides admission, accompa- nied with dimness of sight, which bad varied much at dif- ferent times 23 Elizabeth C, 30 She denied all history of Doubtful A few suspicious looking Eleven months ago a A cook. primary disease, but blotches on the arms "mist came over the Nov., 1861, B. page 21 there were at the time a few suspicious-looking right eye." There was a good deal of circumorbital aching, blotches on the arms but no acute pain Digitized by Microsoft® i 249 P SYPHILITIC CHOEOIDITIS, RETIIflTIS, &o. On'^the nse of atropine fine tags of h^fi4hesions were digcorered in i both pupils. The media were f^ajpBpfectly clear, but the retina in ^-^ eiich was slightly hazy, that of tiie right being escLeclally so Pupils of normal size, and fairly mobUe, the right perhaps a little Sl^sltLggish. Large patiches of ex- posed sderotic in both, bordered by pi^ent. In the left, one of the patches was close to the optic disc. Disorganisation of the choroid was extensive, the patches being large and very definite. She cannot now with the left see the largest letter on the boards ; with th$ right can spell out capital letters ■ffupils of normal size, fairly active; ^ no adhesions. In both eyes the media cljear, but the choroids extensively atrophied and thin. In both were numerous patches, ' in which the sclerotic was seen through ; some of them abruptly '^ defined, othera not so. The ■' optic disc not easily distingnish- able from the surrounding . choroid. Numerous pi^ent spots in various parts Pupils dilate well. No adhesions in either e^e. The media were clear, but the retina, especially near to the optic disc, was con- fused and bazy. The margins of the optic discs were indistinct. She could read No. 8, but only with difficulty Both globes congested and Irritable, Iritic adhesions in both, and chronic iritis still present. The pupils dilated irregularly under atropine. In the left there vrax too much opacity of the vitreous body to permit of the fundus being seen. In the right the I retina was hazy. She still re- I tained sufFcienfc sight for her oi^inary occupation. Iodide of potassium in four grain doses three times a day was continued for four months, and with steady im- provement. She regained almost perfect sight, but the right was still not quite so strong as the other. When examined by the ophthalmo- scope in April, the retina of the right, near the optic disc, was still slighUy hazy Mercurials and iodides. TTnder treat- ment the sight improved a ^at deal The iodide of potassium in full doses was prescribed together with the bichloride of mercury. The disease wa^, however, in too adyauQcd, a stage to permit of much hope of benefit Iodide of potassium and mercurials. Two months later she could see to read No. 4 (minion) at ordinary dis- tances, and had been whoUy free from pain in the globes since treat- ment was commenced The bicholoride of mercury with the iodide of potassium was prescribed, and atropine used locaUy. She re- mained under treatment for several months, but the benefit obtained was not very marked In this case the interval was unusually prolonged From the state of the eye^, I sus- pected that the diseased pro- cesses must have commenced at an earher period than the patient assigned In this case the true nature of the disease had never been sus- pected. The man appeared in good health, amd had no syphi- litic symptoms smce the rash disappeared. He was reduced to a state of almost entire blindness, which will probably be permanent In this case the patient was slightly, hjTpermetropic, and the subjective symptoms of which she complained might easily have been attributed to that condition had she not volunteered a statement as to her syphilitic history, which led to an examination by the ophthalmoscope This case somewhat resembles ■' Case 9, in the entire absence of history. The disease in the eye was, however, symmetrical, and, as it was complicated by iritis in both, I could feel no doubt as to the diagnosis Digitized by Microsoft© 250 TABULAR STATEMENT OF TWENTT-EITE CASBSi 25 Name, Date of Admission, Occupation, State of Healtb. Age EUen a., A dressmaker, Stout and florid, B. page 16 Elizabeth S., In service. Health good B. page 36 22 History of the primary disease, and of its treatment. Had had a bubo, fallowed by a rash two years ago She had primary syphilis in January of this year, and was salivated. No secondary symptoms ex- cept the disease of eyes Interval between primary and the affection of the eyes. 20 months 6 months Other symptomB present at the time of admission. None. (Two years had elapsed). History of the l< Ophthalmitia. For three or fonrmou she had noticed 1 her right pupil wa| larger than the othew Her sight had ^iledi])! both, but especially ii;i the left. During thdl last fortnight she had) been unable to follow her occupal^on, bid previously she could see to thread a needli She complained '/i^ gradual failure ofsiglt^ during the lastjtjrw months. There fwa'i no congestion of thai globes, nor had thei4 been any pain what^i ever GENERAL REMARKS ON THE SERIES. The cases which I have cited, show in a strong li^ht how important is a good clinical knowledge of these insidious forms of disease. In a considerable proportion, one or both eyes had been permanently damaged by inflammatory pro- cesses, which, had they been recognised in an early stage, might have been arrested. It is a remarkable fact that but few of the patients were suffering at the time from other symptoms of syphilis in a severe degree. In iritis, very fre- quently the patients present at the time a form of rash, and of throat disease, which at once reveal the taint under which they suffer. In not a few of the cases under consideration, no external manifestations of the specific disease were present, and it was only by entering carefully into the history, that a correct diagnosis was established. The importance of em- ploying the ophthalmoscope, in all cases of impaired vision, can scarcely be overrated. In several of my cases the degree of impairment present, was not so great but that it might Digitized by Microsoft® 251 W SYPHILITIC CHOEOIDITIS, EETINITIS, &a State of the Eyes at the date of Admission. Treatment, Progress, and Results. Bemarks. No. light pupil widely dilated and Specific treatment was adopted, but The mydriasis was an interesting 24 quite motionless; no synechia I have no note as to the subsequent symptom in this case; it oc- in the right, but several in the progress curred in the eye in which the left. The retinte in hoth eyes retina waa less involved than were hazy; in the left very much in the other BO. She could see fairly with the right eye, but not sufficiently to read small print. To synechia were visible unta the Calomel in half-grain doses twice a day, In this case there was nothing in 25 and iodide of potassium vras ordered. the patient's appearance to pine, when several came into Under this treatment the eyes im- suggest a diagnosis of syphilis. ' view. In both eyes the media proved very much and it was only on examination were transparent with the ex- of the eyes tbat the suspicion ception of several floating films arose. On being questioned. in the right vitreous. In both J the patient at once confessed choroids were numerous patches that she had the primary of greyish-white lymph. She disease could not read large .capital letters have been attributed to some other cause, had not the retinal disease been demonstrated, in one indeed, hypermetropia had been diagnosed, and the patient had been instructed to wear glasses. If this precaution be taken, the surgeon is in little risk of OTerlooking syphilitic affections of this class, for, like syphilitic iritis, when once seen these changes are easily recognised. If patches of recent lymph are seen in the choroid, the suspicion of syphilis ought to be entertained just as promptly as it usually is in cases of iritis, I do not say that all cases of iritis, or all of choroiditis, are due to syphilis, but I am sure that a very large proportion of both are so. The coexistence of iritis with inflammation of the deeper textures of the eyeball, would appear to be exceptional. It is true that choroiditis, &c., may be present more frequently than we suppose in cases of acute iritis, since in most of these we are precluded by the state of the pupil, the into- lerance of light, &c., from making a satisfactory exammation with the ophthalmoscope. It is, however, tolerably certain Digitized by Microsoft® 253 GENERAL. REMARKS. that it is not so in the majority of cases. In a majority of the choroiditis cases, on the other hand, it is certain that no iritis is present. Of the twenty-five cases cited, in eleven there had been iritis, but in most of them it had not been severe. In four it had affected but one eye, whilst ia seven it had been double. A glance at column 10 of the Tabular Report, will sufiice to show that but little clinical advantage would be gained from attempting to classify the cases too accurately according to the special tissue affected. The assertion on this point, made long ago by Dr. Jacob, is fully borne out, and we find that the inflammation rarely limits itself to one tissue. It is true that in most cases the stress of the disease falls upon one tissue, but stiU is exceptional to find it strictly limited to one. With regard to prognosis, we must be guided by the stage and the severity of the disease, If choroid, retina and vitreous are all affected, the prospect of anything like resto- ration of perfect sight is not great. Opacities in the vitreous are, according to my experience, the most difficult of absorpT tion. If the disease consist only in a haziness and congestion of the retina itself, and. if the patient have not been recently under specific treatment, there is then a fair probability that by resort to mercurials, a perfect restoration may be brought about. The absorption of large quantities of lymph from the choroid, may often be procured by like means, but in these cases the tissue is rarely restored to a normal condition, and very often the super-imposed retinal elements have had their relations too much disturbed to permit of complete recovery of function. The duration of the disease is, however, by far the most important element in forming an opinion as to probable future results. If the case be quite recent, there is everything to hope, though, of course, with a somewhat restrained confidence. Cases 4, 7, 8, and 21, illustrate the lamentable terminations, when no specific treatment is re- sorted to, and cases 1, 3, 9, 11, 14, and 19, on the other hand, show the excellent results of its timely adoption. The treatment which I prefer is the use of large doses of iodide of potassium (gr. x to gr. xv, t. d.) and of small ones of mercurials. If, however, the patient have been recently salivated, the iodide may be employed alone. It is, I believe, very desirable to begin with large doses. If the case be of old standing, a long course of the bichloride of mercury, in combination with the iodide of potassium, is, I think, 'the Digitized by Microsoft® GENERAL REMARKS. 253 best plan. Should there be any tensive pain in the globe or orbit, evidencing a turgid state of vessels, the application of relays of leeches to the temple may be found useful. As in all cases of constitutional syphilis, the patient's general health should be most carefully attended to. Although as the result of extended and careful observation, I entertain the most unbounded confidence in the power of mercurials and iodides in procuring the absorption of syphilitic lymph ; yet I must confess, that I hold a very guarded opinion as to their efficiency in preventing relapses, or in securing immunity from future manifestations of the taint. The avoidance of these seems to depend very much upon the condition of the patient's health. With regard to the stage in the course of constitutional syphilis, at which the patient is liable to suffer from inflam- mations of the deep textures of the eye, it may be noted that they are most common during the secondary phenomena. Of the cases before us, in nine, the interval from the date of the primary sore was less than six months ; in four, more than six and less than twelve months ; in four, between one and two years ; in three, it was more than two years ; whilst in five, owing to imperfect history, it could not be calculated. We may, therefore, safely conclude that these forms of syphilitic inflammation rarely originate later than two years after the primary disease. Syphilitic iritis, as is generally acknowledged, and as I have ascertained by the examination of a lengthened series of cases, is mostly earlier still in the r61e of constitutional symptoms. The age at which these affections are most frequent will, of course, be in correspondence with that at which primary syphilis is most frequently contracted. That they may occur at almost any age is illustrated by our series, for in one of the cases the patient had attained the age of 65. In six- teen out of the twenty-five, the patients had not passed the age of 30 ; in seven, they were between 30 and 40 ; but in two only, were they beyond 40. It is a curious fact, possibly nothing more than a coinci- dence, but still worthy of note, that only seven of the patients were men, whilst eighteen were females ; a relative proportion the reverse of what might have been expected. Syphilitic iritis is certainly met with much more frequently in men than in women. Digitized by Microsoft® Digitized by Microsoft® INDEX. TAOZ Amaurosis, in connexion with heredito-syphilis .... 161 Anus, inflamed in heredito-sypMliB 215 AphoriBms respecting infantile iritis 25 „ „ constitutional syphilis 206 „ „ inherited syphilis 207 Appendages, ocular heredito-syphilis, diseases of 183 '* Acpo capsulitis," remarks on .... 154 „ cases of 156 Arachnitis, chronic, in heredito-syphilis 216 Atrophy of optic nerres, cases of 162 Bader, Dr., cases reported by 133, 134, 143, 145 Bowman, Mr., cases under care of 139 Oataraot, in connexion with hereditary syphilis 150 „ „ with malformed teeth 151 „ cases of 152 Caution, necessity for, in diagnosis 206 Choroid, heredito-syphHitic, inflammation of 130 Choroiditis, heredito-syplulitic, oases of .... 131 „ from acquired syphilis 223 „ cases of • 224 „ table of cases of 241 „ comments on 250 Condyloma as a symptom 215 Conjunctivitis, fibrinous 188 Cornea, dotted deposits in 158 „ inflammation of, see Keratitis. Comeitis strumous, see Keratitis. Critchett, Mr., cases under the care of 7,8 Digitized by Microsoft® 256 INDEX. DeafiiesB, in heredito-syphilis „ coses .... ...* •>■ „ comments on cases Dixon, Mr., cases of infantile iritis „ opinion on syphilitic keratitis „ cases under tlie care of ,.;. Ear, diseases of, in heredito-sypliilis Embryonic development, reference to .... Foreiead, conformation of, as a symptom Eibrinous conjunctivitis .... G-lauooma in heredito-sypMis BBnton, Mr., .otoscopic examinations hy..:. Hyaloid membrane, opacity of .... itu Hydrocephalus in hereditary syphilis ...; idiotoy and heredito-syphilis, cases of Infants, heredito-syphilitic shew no symptoms at birlti „ „ „ not always puny Inherited syphilis, protective against primaiy contagion Iodide of potassium, use of Ifidectomy in heredito-syphilitio glaucoma Iritis, a secondary symptom Iritis, infantile, introductory remarks .... cases of summary of cases age liable to .i sex liable to .... .... which eye usually affected by symptoms of .... ..a results ,. table of cases .... „„ infrequenoy of n diagnosis and treatment aphorisms respecting , Iritis in an infant, case of .... .... . . Jackson Hughlings, Dr., case by.. Jacob, Dr., strumous comeitis „ his views on ophthalmitis „ case of infantile iritis .... .... Jaundice in heredito-syphiliB 174 175 182 3 xi 12, 74, 99, 108, 183 174 .... 205 .... 188 .... 170 <*.■ ■■■ 174 r, 230, 233 234 .... 190 216 .... 164, 168 ■>.'• ■.. 813 ■..* .... 214 • »• ••.. 206 I... .... 250 .... ...'. 170 .... .... 220 .... 1 1, 18 18 .... .n. 18 18, 198 «,. .... 18 ".. .... 18 »... ..» 19 .... .... 20 .«. .... 23 -.... ».. 23 ...i 25 ...t 197 238 .... ...; 26 .... .... 130 "i 2 215 Digitized by Microsoft® INDEX. 257 Keratitis interstitial, introductory remarks „ description of „ reasons for believing it to be syphilitic „ cases of „ comments and summary of cases „ table of cases „ age most liable to „ sex most Hable „ condition of health in „ history of subjects of „ history of syphilis in parents „ liability of patient's family „ phenomena of „ treatment of „ prognosis „ diagnosis .... „ prophylaxis „ Mr. Dixon's opinion respecting „ never met with in acquired syphilis „ a tertiary symptom Lachrymal sac, inflammation of Latency, possible duration of in inhabited taint Latent syphilis, acquired ,, „ ■ inherited tawrence, Mr., cases of infantQe iritis Leucomata in syphilitic infants Liver, waxy disease of, in infantile syphilis Lupus, not due to hereditary syphilis „ phagedoenio form of, cases of Mackenzie, Dr., description of scrofulous comeitis MacMurdo, Mr., caae under care of MauuseU and Evans on infantile iritis Mercury, use of, in acquired syphilis „ „ in hereditary syphilis " Mercurial teeth" Metropqlitan Free Hospital, average of keratitis cases „ „ „ rarity of infantile iritis .... Moon, Mr., case reported by Nails, diseased, in heredito-syphUis Nodes, instances of „ degree of frequency of North, Mr., case of infantile iritis FAOE 26 ... 2S ... 30, 124 ... 31 to 108 '..t 109 110 ■ •• 115 116 ... 116 118 .... 119 118 ... 121 125 .... 126 127 129 221 220 190 220 .'.'! Z 220 1 ... 186 ... 215 ... 217 ... 60,61,63 27 12 ... 2 ... 211, 222 92 .•• .... 27 23 12 205 ... 48, 63, 185 ... .... 216 18 Digitized by Microsoft® 358 INDEX. Oplitli,almoscope, value of Optic nerves, wliite fitropty of „ „ „ ,. in tertiary sypkaiB Q/borsuhoi^ absence of, in heredito-syphilic deafiiaaB PAGE . 250 . 161 , 161 , 174 Pliagedsena, in teredito-sypliilis Photophobia, extreme case of .... 217 194 Phtbiais, not induced by sypbilitijP tajiiit Physiognomy of hereditary syphilitjio diaitt^eis Poland, Mr., case under the care of ,... ... Pupils, occlusion of, in infants , Purulent ophthalmia, case of Pustular ophthalmia, case of ;. .... 218 30, 205 .... 134 .... 197 185, 187 .... 193 Questions, direct, should not be put 204 Retinitis, from heredito-syphilis „ from acquired syphilis 923 Scrofula quite distinct from heredito-syphilis Skin, important influence of disease of '. „ condition of, in heredito-syphilis Stages of syphilis Startiu, Mr, cases under the care of Stomatitis in infantile syphilis .... Syphilis, congenital and acquired, in same patient by conception hereditary, recognition of „ stages of latent infantile, first symptoms of „ laws of evolution of symptoms Syphilitic diathesis usually dies out in time 217 213 205 216 5,6 215 149 197 203 216 267 213 213 aio Teale, Mr. T. P., Jump., on cataract andmalfcn^ed teebk 151 Teeth, exfohation of 185 „ value as symptoms 204 1. .1 M Mr. Paget's opinion , „ description of syphilitic malformationB- (rf' 204 „ malformations of, absent in syphilitic children' (aases)! 188j 200 Digitized by Microsoft® INDEX. 259 Teeth, very peculiar development of 'l99 „. wrest ofdevelopmest of the "test t«»tK" „» .... .J 205 „ luftuenee of mercury on ' gg Time, the great means of tjure " 221 Tinea tarsi, ia heredito-syphUis 184 Vitreous body, sy^alitiQiaQa^iiBe^ion of ..... ...225,227 236,234 Titreous body, heredito-syphaifcfci disease of .... 130,149,167 Vose Solomon, Mr., case sent by ' jgy Walier, Mr., cases of infantile iritis 3 Worm^ld, Mb., cases ef isfiHjIjle, iritis &, 6, 8 PBINTED BY HAEBISOK AND SOITS, ST. MAETIN'S-LANE, W.C. Digitized by Microsoft® Preparing for Publication, by the same Author. CLINICAL SUKGERY, LECTURES, EEPORTS, COMMENTARIES, AND MEMORANDA ON SUBJECTS CONNECTED WITH THE PRACTICE OF SURGERY. ATLAS OF POETRAITS, SKETCHES AND DIAGEAMS, IN ILLUSTRATION OF CLINICAL SURGERY. TO BEPUBLISHED IN FASCICUL. Digitized by Microsoft® Digitized by Microsoft® Digitized by Microsoft® Digitized by Microsoft® Digitized by Microsoft® Digitized by Microsoft®