TWO CASES OF INTERESTING SYPHILITIC LESION OF THE EYE. By CHARLES S. BULL, M.D., New York. THE first case was an external growth involving the subconjunctival or episcleral fascia and sclera, accompanied by an intraocular growth. The patient was a woman 36 years of age, married, and the mother of six children, three of whom are living. She volunteered the statement that she had contracted syphilis from her husband, and she probably had the primnary lesion about ten years ago, as shortly after that period thereS appeared an eruption of the skin over the whole body, though most marked onl the face and chest. She was treated with mercury, and the spots gradually grew better, but have left a very distinct discoloration of the skin behind thern. During the next two years she suffered from ulcers of the fances and pharynx, alopecia and periosteal rheumatism, buLt her eyes remained perfectly well until seven years ago, wheil the left eye became very red and painful, and vision was so reduced that she had barely perception of light. She was treated in the New York Infirmary for a number of weeks, for what was probably an irido-choroiditis, and her vision improved somewhat, so that she could distinguish large objects, her right eye remaining perfectly well through the whole couirse of the disease. In the latter part of March of this year, the left eye again commenced to bevery painful, the eyeball became very much congested, and vision again sank to perception of light. When she presented herself at the infirmary for treatment, an examination showed a general ciliary injection, a clear cornea, a discolored iris with movable pupil, and great tenderness on the slightest pressure upon the globe. The ciliary and conjunctival redness was most marked over that portion of the ciliarv region lying between
196 -the insertions of the superior and external recti muscles, and here there was a swelling or outgrowth, of about 2"' in height, rounded at the periphery, and extending back about half an inch in a straight course. The overlying conjunctival vessels were immenlsely engorged and tortuous, and there was some .lchemosis of the conjunctiva immediately surrounding the growth. After dilating the pupil, the vitreous was seen to be so opaque with inflammatory products, that the fundus could not be seen. Some of these membranes were floating free in the vitreous, and were of all shapes and sizes. In the upper and ouiter part there was seen a dark-brown mass, about the size of a pea, which was stationary, and oceupied a position corresponding exactly to that of the scleral growth outside. This intraocular neoplasm probably dates back to the preceding inflammation seven years ago, and is probably a gummiy tumor of the sclera, and perhaps of the choroid. From the position of the extra-scleral growth being just over it, it seems not improbable that the two are directly connected through the sclera. It is rather strange that the iris should not be affected bv a similar growtlh, inasmuch as gummata of the iris are so common in syphilitic lesions of the eye. Vision in this eye was reduced to movements of the hands, but in the right it was normal, anid this eye was perfectly healthy. The second was a case of choroiditis disseminata, with unusual ophthalmoscopic appearances. The patient .was a man, married and 45 years of age, who had conitracted the initial lesion of syphilis thirteen years ago. The primary ulcer was followed by a cutaneous eruption, ulcerated fauces, alopecia, and most obstinate and painfuil periostitis of the frontal bone, clavi,cles, and tibiao. About one year after the inception of the disease, the right eye became violently inflamed and very painful, zand vision was nearly entirely lost. He was treated for six months before the inflammation entirely subsided. He has had several recurrences of inflammation in this eye, and though he had regained his vision almost entirely after the first attack, yet under the repeated onsets it has steadily diminished. In the sunmmer of 1871 he suffered from a stroke of cerebral hemorrhage, was unconscious for seven days, and was paraplegic, his arms remaining entirely unaffected. About six months ago the vision of the left eye began to fail, and has
197 steadily grown worse. An examination showed in the right eye, V. ; in the left eye, V. = 2, with no improvement by any glasses. The pupils were moderately dilated but extremely sluggish, and the irides were normal in color and appearance. The ophthalmoscope showed marked choroiditis disseminata in both eyes, the signs of atrophic degeneration being most advanced in the right eye. Both nerve-disks were the seat of progressive atrophy, with a central atrophic excavation, which in. the right eye reached down to the lamiira cribrosa. The arteries were very much diminished in calibre, and the results of a retinal perivasculitis were well marked. All over the retina, though most marked in the region of the equator, were scattered irregutlar, shapeless masses of pigment, as is usual in this form of choroiditis. But in the neighborhood of the posterior pole of the eye, in the region of the macula and optic disk, the pigmentary deposit was very abundant and arranged in a very peculiar manner. The spots of pigment were nearly all of the same size and shape, hexagonal in form, and arranged exactly as the hexagonal pigment cells of the external surface of the retina, and to the ophthalmoscope presented the same appearance as the microscopic drawings of these cells which we see in the anatomical descriptions of the minute structure of the eye. The appearance was about the same in both eyes, and was very peculiar. Most of the masses were posterior to the retinal vessels, but some of them were in the most anterior layers of the retina, and covered the vessels. It is the only case I have seen where there was such an arrangement of the pigmentary depos its in the retina and choroid.
196 -the insertions of the superior and external recti muscles, and here there was a swelling or outgrowth, of about 2"' in height, rounded at the periphery, and extending back about half an inch in a straight course. The overlying conjunctival vessels were immenlsely engorged and tortuous, and there was some .lchemosis of the conjunctiva immediately surrounding the growth. After dilating the pupil, the vitreous was seen to be so opaque with inflammatory products, that the fundus could not be seen. Some of these membranes were floating free in the vitreous, and were of all shapes and sizes. In the upper and ouiter part there was seen a dark-brown mass, about the size of a pea, which was stationary, and oceupied a position corresponding exactly to that of the scleral growth outside. This intraocular neoplasm probably dates back to the preceding inflammation seven years ago, and is probably a gummiy tumor of the sclera, and perhaps of the choroid. From the position of the extra-scleral growth being just over it, it seems not improbable that the two are directly connected through the sclera. It is rather strange that the iris should not be affected bv a similar growtlh, inasmuch as gummata of the iris are so common in syphilitic lesions of the eye. Vision in this eye was reduced to movements of the hands, but in the right it was normal, anid this eye was perfectly healthy. The second was a case of choroiditis disseminata, with unusual ophthalmoscopic appearances. The patient .was a man, married and 45 years of age, who had conitracted the initial lesion of syphilis thirteen years ago. The primary ulcer was followed by a cutaneous eruption, ulcerated fauces, alopecia, and most obstinate and painfuil periostitis of the frontal bone, clavi,cles, and tibiao. About one year after the inception of the disease, the right eye became violently inflamed and very painful, zand vision was nearly entirely lost. He was treated for six months before the inflammation entirely subsided. He has had several recurrences of inflammation in this eye, and though he had regained his vision almost entirely after the first attack, yet under the repeated onsets it has steadily diminished. In the sunmmer of 1871 he suffered from a stroke of cerebral hemorrhage, was unconscious for seven days, and was paraplegic, his arms remaining entirely unaffected. About six months ago the vision of the left eye began to fail, and has
197 steadily grown worse. An examination showed in the right eye, V. ; in the left eye, V. = 2, with no improvement by any glasses. The pupils were moderately dilated but extremely sluggish, and the irides were normal in color and appearance. The ophthalmoscope showed marked choroiditis disseminata in both eyes, the signs of atrophic degeneration being most advanced in the right eye. Both nerve-disks were the seat of progressive atrophy, with a central atrophic excavation, which in. the right eye reached down to the lamiira cribrosa. The arteries were very much diminished in calibre, and the results of a retinal perivasculitis were well marked. All over the retina, though most marked in the region of the equator, were scattered irregutlar, shapeless masses of pigment, as is usual in this form of choroiditis. But in the neighborhood of the posterior pole of the eye, in the region of the macula and optic disk, the pigmentary deposit was very abundant and arranged in a very peculiar manner. The spots of pigment were nearly all of the same size and shape, hexagonal in form, and arranged exactly as the hexagonal pigment cells of the external surface of the retina, and to the ophthalmoscope presented the same appearance as the microscopic drawings of these cells which we see in the anatomical descriptions of the minute structure of the eye. The appearance was about the same in both eyes, and was very peculiar. Most of the masses were posterior to the retinal vessels, but some of them were in the most anterior layers of the retina, and covered the vessels. It is the only case I have seen where there was such an arrangement of the pigmentary depos its in the retina and choroid.
