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traction increases. In simple glaucoma, however, central acuity may not diminish in proportion to the progress of the disease as the nerve fibers partially accommodate themselves to the slowly increased pres
Occasionally, a central scotoma develops, which spreads to meet the advancing contraction, or, central vision may remain normal, or nearly so, until a large part of the field is lost.
Following iridectomy, visual acuity may greatly increase and the fields become largely restored, the restoration being more marked in the inflammatory type. The ophthalmoscope in the early stage of glaucoma shows hyperemia with perhaps pulsating arteries. Later, marked cupping and atrophy appear.
In choked disc, the fields are not proportionately affected, although a considerable increase of the blind spot is generally seen. If the disease progresses and atrophy follows, the fields are similar to those of simple atrophy and they gradually decrease to blindness. Early treatment, surgical in tumor, or medical in syphillis, et cetera, may bring about partial restoration of the fields.
In tabes dorsalis and dementia there is in fifteen to eighteen per cent of cases, a progressive optic atrophy, in which the fields are contracted irregularly, and central acuity is diminished. This is associated with disturbed pupillary reflexes, in which the pupil looses its light reaction through retaining that for accommodation. When atrophy is present the pupils are dilated, often irregularly. The ophthalmoscope shows atrophy of the nerve head, with vessels reduced in size, and slight cupping, as in simple atrophy.
In central and spinal syphilis, the fields may show partial or concentric reduction with areas of retention in the periphery. There may be unilateral blindness with temporal hemiopia in the other eye. The central vision is variable and there may, in localized gumma of the tract, be a complete central scotoma. The ophthalmoscope may show neuroretinitis, papillitis, choked disc, simple atrophy, or there may be very little change. The pupils are affected proportionately as vision is lost, being dilated and inactive in the advanced atrophic stage.
In multiple sclerosis there are central scotomatą, usually relative with very little, if any, contraction of the periphery. The scotomata may disappear, reappear, or there may be complete recovery of central vision; on the other hand, the field may diminish as in tabes, or atrophy may follow. The results of ophthalmoscopic examination are characteristic only of the secondary condition. The visual acuity is lowered in proportion to the gravity of the lesion. The pupillary reaction may or may not be disturbed.
Retrobulbar neuritis often gives a large central scotoma which may increase or become stationary. There may be concentric scotoma or a central color scotoma. Visual acuity is variable. The pupil is sluggish with the reflexes present. The ophthalmoscopic examination is not characteristic, unless the atrophic stage is reached, when there will be paling of the temporal portion of the disc.
In hereditary neuritis, the conditions are similar to those in retrobulbar neuritis.
In tobacco and alcohol and other toxic amblyopias, there is an oval scotoma for red and green located between the point of central fixation and the blind spot. Absolute scotomata are rare. There is little or no contraction. There may be complete loss of perception of red or green. while white is normal in extent. Where caused by alcohol, the periphery may be contracted. In poisoning by methyl alcohol there is a more marked descending neuritis with quite often complete blindness accompanied by atrophic changes, the fields varying proportionately and the prognosis being relatively bad. In other forms of toxic amblyopias the prognosis is generally good with proper treatment. In toxic amblyopias the ophthalmoscope gives paling of the temporal half of the discs, with some retinal congestion, particularly to the nasal side. The visual acuity is lowered in proportion to the severity of the neuritis but it is much better in poor light, owing to the dilated pupil and the greater number of cones stimulated.
In disease of the chiasm there may be one of the hemiopias present, which, because of the arrangement and crossing of the nerve fibers varies according to the location of the lesion. If the lesion is at the anterior portion, at the location of the crossed fibers, the nasal halves of the retina will be affected and there will be bilateral temporal hemiopia. If the outer portion or uncrossed fibers are diseased there will be unilateral nasal hemiopia. A few cases of bilateral nasal hemiopia have been reported. In these cases, there are symmetrical lesions.
In hemiopia, the macula may not be at all involved, which is explained by supposing a double inervation from each cortex, that is, both sides of the macula may have crossed and uncrossed fibers. There may be temporal blindness of one eye, and only partial temporal blindness of the other, or, it may be partial in both eyes, or one eye may be blind with temporal hemiopia of the other. The ophthalmoscope may show a choked disc, neuroretinitis, or intraocular disease not dependent upon the lesion of the chiasm. Visual acuity may be lost, diminished or retained, in one or both eyes according to the extent of the process, and whether the macular bundle is destroyed, merely compressed, or is unaffected.
In syphilitic cases, the fluctuation of the visual defects should lead to suspicion of a specific cause, when appropriate treatment may restore the field.
Homonomous hemiopia is produced by lesions of the optic tracts, primary ganglia, optic radiations, or cortical center in the cuneus. is never seen in hysteria, unless as a complication. Homonomous hemiopia may result from disease, pressure, irritation or extension of a disease process, the prognosis depending upon the character and duration of the cause. If the lesion is in the right visual apparatus, the left fields are hemiopic and vice versa. The line of separation may bisect the visual axis or the axis may in those cases of double innervation be
unaffected. A double innervation is the only plausible explanation for the overshot field. If only a partial homonomous hemiopia exists, the lesion but partially destroys the affected portion. There may be symmetrical scotomata from the same cause. The defects are absolute if typical but relative changes for red and green, and sometimes for blue are seen. Visual hallucinations may occur in the blind fields. The color fields, in the unaffected portion may be, and usually are, normal. Homonomous hemiopia from involvement of the primary centers is usually associated with hemiplegia and hemianesthesia of the same side as the hemiopia, and is further characterized by absence of the hemiopic pupillary reaction sign; this is also absent when the tract is affected, but if the lesion is back of the primary ganglia the pupillary reaction sign is present. In these cases, the color fields may be hemiopic while that for white is altered but little, or not at all. In destruction of both cortical centers, pupillary reaction is retained if the primary ganglia and tracts are unaffected.
The prognosis in field disturbance is unfavorable when the contraction of the field is increasing or the scotoma spreads; when the color fields are constantly diminishing, and when red or green are not perceived. The disease process has a tendency to improve when the limits of the fields for white and colors increase; when white improves and the colors remain stationary; when red and green sight is regained after having been lost; when the field remains of the same size when using a smaller-sized object in testing. The effect of strychnine must be considered if the patient is taking it. When the retrogression ceases the condition may remain permanent at this point.
In functional disturbances of the fields of vision, concentric contraction with reduction of the color fields is characteristic. In these conditions there is a nervous asthenopia, in which letters run together or disappear, or there is photopsia, visual hallucinations, sudden diplopia, megalopsia, micropsia, epiphora and blindness in bright light, while pupillary reactions and ophthalmoscopic pictures are normal. There is, in these cases, concentric contraction of all the fields, but the contraction is regular instead of markedly irregular or tooth-shaped, as is general in organic affections. The limits for blue, red, or green, may approach or cross, or replace each other in some portion of the field. The power to distinguish color is diminished. There is rapid retinal tiring with production of fog-like fading of the fields. The size of the fields is changeable from day to day. One field may be large and the other small.
In hysteria, considerable stress is placed upon the replacement of red by green. Though this may be regarded as pathognomonic, it is generally present only in limited portions, and the red almost as frequently overlaps or approximates the blue field. All grades of amblyopia to total amaurosis may be associated with hysteria though the pupillary reactions are unaffected. Spasm of the accommodation may stimulate amblyopia in an hysterical subject as well as in the non
hysterical. It must be eliminated. Hysterical fields are rarely if ever hemiopic, nor are there scotomata. They differ from those of neurasthenia only in that the colors replace each other more completely in hysteria, although some fields of people suffering from neurasthenia are remarkably similar to those of hysteria.
REPORT OF CASE OF ANEURYSM OF THE ABDOMINAL AORTA.
PAUL S. MILLER, A. B., M. D.
[FROM THE CLInic of internal medicine, unIVERSITY OF MICHIGAN.]
It is entirely probable that abdominal aneurysm was recognized by Vesalius himself, while in 1719 Valisneri made a diagnosis of aneurysm most important will be mentioned.
It is entirely probable that abdominal aneurysm was recognized by Vesalius himself, while in 1719 Valisneri made a diagnosis of aneurysm. of the abdominal aorta, and verified this subsequently by section (Morgagni). Despite this earlier recognition, our first accurate knowledge of this condition dates from the publication of Beatty's case in 1830. ("Dublin Hospital Reports," Volume V. A synopsis of the case may be found in Stokes' work, “Diseases of the Heart and Aorta," 1838.) The value of Beatty's work is due to the accuracy and realism with which the symptoms are described, and the careful observation of the order of their appearance. The case was under observation continuously during the years 1827, 1828, and 1829, during that time being seen and examined by many noted physicians. In 1836 we have the report of an interesting case by Sir David J. H. Dickson, physician to the Royal Naval Hospital at Plymouth ("Medico-Chirurgical Transactions of the Royal Medical and Chirurgical Society of London," Volume XXI.) This case was one of enormous ventral aneurysm of the abdominal aorta, with findings at necropsy. A great number of cases have been reported in the literature since, but Beatty's case still remains as a classic in the symptomatology of aneurysm of the abdominal aorta. Stokes has collected a number of cases in his work on the "Heart and Aorta," and his consideration of the entire subject is one of the most complete and accurate to be found in the literature today.
Aneurysm of the abdominal aorta itself is not of frequent occurrence. It is hardly possible to give a definite ratio between this condition and the concurrence of aneurysm elsewhere in the body, because the comparative figures differ so in various localities. In Vienna, according to Schrötter, in two hundred twenty-two cases of aneurysm, only three were of the abdominal aorta. At Saint Bartholomew's Hospital the figures are placed by Oswald Browne at one to twenty. About sixteen per cent of cases of aneurysm occurring at Guy's Hospital between the years 1854 and 1900 were of the abdominal aorta (J. H. Bryant in Clinical Journal, 1903). Osler, in his article in the Lancet of October 14, 1905, places the comparative occurrence at about one
in ten. These figures would seem to indicate that the condition, while comparatively rare, is not so infrequent in its occurrence as is commonly supposed. The disease, however, is not often recognized, and in a large number of cases the diagnoses is only made at autopsy.
The symptoms of aneurysm of this portion of the aorta are often very obscure, and the physical signs misleading. In the case reported by Beatty the patient was repeatedly seen and examined by Graves, Cheyne, Brodie, Colles, Townsend, Wilson Phillip, and Andral, during the years 1827, 1828, and 1829. Andral made a diagnosis of a "rare form of intestinal neurosis." The real condition was only discovered at autopsy. Bryant, in his article (Clinical Journal, 1903), says that in only eighteen out of the fifty-four cases, on which his lecture was based, was a correct conclusion arrived at during life. Analysis showed that an abdominal tumor was detected in thirty-one, pulsation in thirty-five, expansile pulsation in eight only, and a systolic murmur in twenty-six. Incorrect diagnoses of a variety of conditions were made. R. Travers Smith (Dublin Journal of Medical Sciences, 1905, Volume CXX) reports a case of proving at autopsy to be aneurysm of the abdominal aorta, in which diagnosis had been made of "renal calculus with hydronephrosis." Often in cases such as this operative procedures are undertaken, and the results, while unavoidable, are regrettable in the extreme.
The great majority of cases occur in the male. Aneurysm of the abdominal aorta in the female is rare. This is of importance because of the frequent occurrence of pulsating aorta in nervous or hysterical women, which has often led to a diagnosis of aneurysm.
Etiologically, Osler considers syphilis as the all important factor in cases occurring before the age of forty years A general atheromatous condition is usually present in the arteries, while the heart is seldom affected. Alcoholism is the rule. Nephritis, gout, and rheumatism are factors to be considered, while manual labor has apparently but little relation with the condition. A great majority of cases occur before the fiftieth year.
The following case is of interest, because of the misleading symptoms which characterized the beginning of the trouble.
The patient was admitted to Doctor Dock's clinic in the University Hospital, at Ann Arbor, late in the afternoon of October 14, 1905. The following notes were made by myself a short time after his admission. Patient, male, age forty-five years, occupation, that of laborer. His chief complaint at the time of admission is of a feeling of pressure in the epigastrium, and about the heart, stomach trouble, and inability to sleep because of constant pain of a dull, boring character, also paroxysmal pains of a sharp, cutting nature in the left lumbar and iliac regions. Concerning the patient's family history nothing worthy of note can be obtained. During the past ten years the patient has had trouble with stomach and bowels. The stomach trouble is described as a feeling of fulness and distress after eating. This has gradually become