April 1,
89
LECTURES ON DISEASES OF THE IHIS.-BY C. MACNAMARA.
18G7-]
of the iris is so
Congestion
frequently
associated with or merges
into iritis, that I shall describe the treatment to be adopted in this form of disease when considering that of inflammation of
ORIGINAL COMMUNICATIONS.
the iris.
I propose following Dr. Wecker's nomenclature, and bing iritis under three heads : first, the simple or plastic secondly, the serous; and lastly, the parenchymatous or
LECTURES ON THE DISEASES OF THE IRIS. By C.
MACNAMARA,
Stjpdt., Calcutta Ophthalmic Hospital.
of
of the same color, but we occasionally meet with instances congenital nature in which they appear to differ, although
a
otherwise perfectly normal. Whatever the color of the healthy iris may be, it has a brilliant shining fibrous appearance, and in this respect are symptomatic of disease, any alterations
although
the
changes
may be so slight that they can only be the diseased with the healthy eye.
appreciated by comparing The state of the
pupil again
is
an
important
element for con-
sideration ; it frequently happens that from inflammatory
or
other causes adhesions form among the fibres of the iris, or Under these circumstances, the between it and the lens. actions of its contractile
elements, and consequently the mobility impeded. I may, however, mention that affections of the choroid, involving the long ciliary nerves, will also influence the sensibility of the iris ; alterations, therefore, in the activity or form of the pupil are by no means to be taken as pathognomonic of disease of the fibrous structures of the of the
pupil,
are
iris, for they may depend upon many other influences, into which it would be foreign to our purpose to enquire at present. Hyperemia of the Iris is very seldom met with, unless as a result of injury, or from wounds involving the cornea ?, it more
as a premonitory symptom of iritis or of conchoroid, in which case the ophthalmoscopic
often occurs
gestion
of the
the eye, the increased tension appearances of the fundus of of the eyeball, and the pain on pressure over the region of the
choroid, all point to the nature of the disease. In uncomplicated hyperemia of the iris there is always some congestion of the vessels at the junction of the sclerotic and cornea ; the extent and depth of this zone vary according
It is important to notice that to the progress of the affection. in these cases the cornea remains perfectly transparent, so that there can be no mistaking this sclerotic zone of vessels in hvperaemia of the iris for a symptom of keratitis. The patient seldom complains of pain in his eye, but of more or less dimof vision, which is most marked after sunset. This symptom of hyperemia of the iris depends on the of its
ness
impairment
functions, caused by the pressure of its congested vessels on the contractile and nervous elements of the iris, the consequence of which is that the pupil fails to dilate after nightfall, thus preventing a sufficiency of the rays of light from reaching the retina to stimulate it to action. During the day the patient sees differ from iritis, in that very well, for these cases of hyperemia there is no turbidity of the aqueous. On examining the iris by transmitted light, we shall be able distinctly to trace the distendits surface.
The
pupil responds but mydriatics. The fibrous elements of the iris, however, remain unaltered in colour; except in some few instances in which, after long-continued hvperemia, changes take place in its pigment cells similar to those noticed under analogous circumstances in the choroid ; they become of a darker colour and shrink up ; these alterations usually commence at the margin of the pupil, in the uvea covering the contractile fibres of the iris, which then present an uneven and spotted appearance, small dark excrescences projecting from them into the pupil. But even after long-continued hyperemia, the integrity of the contractile elements of the iris seldom appear to become impaired ; and no sooner does the congestion subside, than it again actively performs its functions. ed vessels
slowly
to
coursing
over
the stimulus of
light
or
to weak
iritis ; suppu-
rative iritis.
The color of the iris, depending as it does upon the amount and hue of the particles contained in its pigment cells, naturally varies in different individuals. As a general rule, the irides are
descri-
Inflammation of the iris is accompanied by certain symptoms which may be best described under distinct headings, so as to save the necessity for recapitulation when giving the characteristic features of each form of the disease. Pain in the affected eye is a constant, but in degree a variable, symptom of iritis. In many instances the patient complains
slight uneasiness extending from the eye over the corresponding side of the forehead, whereas in other cases the pain is excruciating and of a throbbing, lancinating character, involving not only the affected eye, but the side of the head and faceUnder any circumstances the pain is intermittent, usually increasing towards evening, and gradually growing worse as the night advances. In other cases, however, in which the iris is not much swollen, nor the inter-ocular pressure gr?atly increased, the patient will hardly notice this symptom, unless special inquiries aro made respecting it; it is always, however, increased when pressure is made on the eyeball. A zone of congested sclerotic vessels invariably surrounds the junction of the cornea and sclerotic in cases of iritis ; hyperasmia of the iris must exist, in fact, in instances of iritis, and consequently congestion of this sclerotic zone of vessels, since they anastomose with those of the iris and choroid. The amount of the sclerotic congestion will of course vary with the severity and stage of the inflammation, and in some cases may be concealed to a great extent by the injected and chemosed conjunctiva. Ultimately, as the iritis passes off, and tho balance of the circulation is restored, the zone of vessels gradually disappears, and the sclerotic assumes its normal appear-
of only
ance.
of sight is another marked symptom of iritis ; in the first instance upon turbidity of the aqueous more than on alterations in the iris ; subsequently synechia or bands of adhesio form between the iris and the lens and Dimness
it
depends
occasionally close the pupil, the sight being completely destroyed. Another cause of the haziness of vision complained of by patients suffering from iritis, arises from changes which take place in the epithelium of the posterior elastic lamina of the cornea, and which are best detected by the lateral method of examination. These cells often present a hazy appearance, similar to that of the anterior layers of the cornea in keratitis. In instances of this description flakes of degenerated and detached epithelium may usually be seen floating about in tne aqueous.
Changes of iritis
;
in the colour a
blue
or
of
the iris are
grey iris
becoming
noticeable in all more or
less
cases
greenish,
a
green iris yellowish green, and a dark brown iris of a reddish hue : its brilliant fibrous aspect is also destroyed, becoming converted into a confused and muddy appearance. This state of
things is usually rendered more marked by comparing the state of the diseased with that of the healthy eye (provided only one eye is affected), but under any circumstances the change in the colour and brilliancy of the iris is unmistakeable in all instances
of inflammation, and is due not only to alteration in its fibrous structure, but also to turbidity of the aqueous humour. Alteration in the Mobility of the Iris and the form of the
Fupil.?The congested serous
the
effusion that
vessels, together with the early stages of inflammation of
state of the
occurs
in the
iris, necessarily impairs
the functions of its contractile
elements, and hence its mobility; consequently in the sensibility of the iris to the stimulus of light symptom of
iritis.
Subsequently,
as
alteration is an
early
adhesions form between
90
THE INDIAN MEDICAL GAZETTE.
the iris ami the
lens, they
not
only impede
the action of the
former, but, when under the influence of atropine, the pupil assumes
an
iiregular figure
;
or, it may
be,
is unable to dilate at
all, being closed by organised bands of neo-pla'stic tissue. From the commencement, therefore, and throughout the course of an attack of
inflammation, the iris responds light or to mydriatics.
but
slowly,
if at
all,
to
the stimulus of
Intolerance of light and increased lachrymation are sympso frequently met with in iritis, that they may be consider-
toms
being common to all its forms. In chronic or sub-acute whereas in the cases, however, they may be hardly noticeable, active stages of the more acute forms of the disease, the patient complains bitterly of the exacerbation of pain which he exthe instant he approaches the light, and is perpetually
ed as
periences
in wiping away the tears that flow down over his The conjunctiva is always congested to some extent cheek in iritis, and in many instances its vessels are so deeply injected that it is well nigh impossible to define the sclerotic zone of vessels surrounding the cornea, and in these cases, if the posterior
engaged
of the cornea are also affected, the condition of the iris, which is the real source of the disease, is apt to be overlooked. Any doubts that may exist as to the nature of the
layers
disease may be at once cleared up solution of atropine to the eye ; the
by applying a few drops of irregular way in which the
pupil dilates will then be apparent. Increased tension of the eyeball is always present in the serous form of iritis, and is one of the chief causes of the pain from which many patients suffer ; for no sooner is the intra-ocular pressure removed by puncturing the cornea, and allowing the aqueous to escape, than the pifient experiences instantaneous relief. Constitutional symptoms.?Complications of this kind are frequently met with in cases of iritis ; the patient complaining of fevcrishness, and it may be of obstinate vomiting, the result of sympathetic irritation. Many instances of iritis, however, run their course without the manifestation of any such symptoms, and under any circumstances they are of trivial importance in comparison with the state of the eye ; in fact they are hardly worthy of consideration, disappearing the instant the mischief going
on
in the eye subsides.
Iritis.?The characteristic feature of this form of disease is that it gives rise, both on the surface and in the substance of the iris, to a neo-plastic element, the tendency of
Simple
or
plastic
become developed into fibrous tissue ; bands of thus formed between the iris and lens (synechia), and in the contractile tissue of the iris itself. Plastic iritis is frequently met with among persons suffering from rheumatism, which is to
adhesio
are
consequently it has often been described as rheumatic iritis j this deduction, however, is hardly correct, and is likely to lead to errors in practice ; for nothing is more common than to meet with instances of this affection occurring among individuals and
who are perfectly free from rheumatism. In the case of lepers, for instance, plastic iritis is of common occurrence, and also as a result of wounds or inj-iries of the eye. Under very favorable ciicum&tances, this form of disease may run its course in from ten to fifteen days, and then gradually Instan-
disappear.
of this kind are, however, exceptional, unless the patient has been brought under treatment at any early stage of the affec-
ces
tion ; the majority of cases of plastic iritis, if left to nature, terminate in synechia ; slight adhesions form in the first instance between the papillary margin of the iris and the lens. Avhich, however, are sufficiently tight ot tie the iris firmly down to the more points, and every time that the pupil dilates contracts, these tags of adhesion pull on the iris, thus keeping of irritation and disturbance in the up a constant state part, which ultimately induces a fresh attack of inflammation ; more extensive adhesions then form, until after repeated attacks of
capsule at one or t>r
this kind the iris becomes nerative
changes
firmly place
then take
bound down to the lens ; degein its fibrous structure, which
[April 1, 1867.
becomes atrophied ; unfortunately, the mischief that under these circumstances does not stop here, hut the communication between the anterior and posterior chambers of the eye being closed, an abnormal collection of fluid t;ikes place
ultimately occurs
iris, which exercises on the deeper structures of the injurious pressure of a glaucomatous character, too often terminating in atrophy of the globe.
behind the eye
an
As a general rule, the zone of congested vessels surrounding the circumference of the cornea is well marked in cases of plastic iritis, the hyperseinia of the conjunctiva not being suffito completely hide it. It was formerly supposed that the whitish grey band surrounding the cornea and situated iuternally to the zone of sclerotic vessels, was a characteristic symptom of rheumatic iritis. This band, however, depends
ciently great
simply upon the anatomical relations of the parts, the sclerotic overlapping the bevilled margins of the cornea in this situation; the grey band surrounding the cornea, and seen in many cases of iritis, is therefore a symptom of no importance. In the early stage of plastic iritis, the mobility of the iris is affected, its free margin appears to be swollen and thickened, its fibrous structure also loses the distinctness, and its color is likewise altered. The formation of neo-plastic tissue, which is the cause of all these changes, varies in quautitv in different cases; it seldom forms flakes or deposits on the iris, so that in fact we cannot detect its presence in the living subject except by its effects on the iris, which it ultimately glues down to the capsule of the lens, and by the pressure ic exerts in con-
tracting upon its fibrous, vascular, and nervous structure, leads The amount to atrophy and complete degeneration of the iris. of pain frotn which a patient affected with this form of iritis suffers, is by no means constant ; in some cases, it is not a prominent symptom, whereas in others it is most excruciating, extending from the affected eye over the temple and side of the face, and almost always increasing in intensity towards evening, and growing gradually worse as the night advances.
Serous Iritis ?In place of the neo-plastic formations which are characteristic of the last described form of iritis, in that now under consideration a serous exudation takes place from the vessels of the iris, which, accumulating in the anterior chamber, pushes the iris backwards ; so that in well marked cases of serous iritis the iris appears to be further away from the cornea than in health, the depth of the anterior chamber being apparently from the pressure exercised on the vessels and nerves by the accumulation of this serous fluid in the anterior chamber. The functions of the iris are impaired, and increased
of the iris
the
pupil responds but slowly, if at all, to the stimulus of light; unless, however, in chronic cases the pupil, when it dilates, does so regularly, there being no synechia in the stages of In this serous iritis to impede the action of its contractile fibres. respect, therefore, there is a marked difference between serons and plastic iritis. In the more advanced stages of the disease, the accumulation of serous fluid in the chambers of the eve such an amount of increased inter-ocular pressure, that its effects begin to tell on the choroid and long ciliary nerves ; and the innervation of the iris being thus impaired, it is not causes
respond to the stimulus of light, mydriatics are without effect on it.
unable to ful
only
but the most power-
Serous iritis is a common form of disease among the natives of India, and as it excites no urgent symptom in the early stages, it, is likely to be overlooked or disregarded until it has effectep irreparable changes in the deeper structures of the eye, or has merged into a combined form of serous and plastic iritis of a the very dangerous character, the neo-plastic formations
binding
iris down to the lens, and thus effectually keeping in the serous effusion poured out into the posterior chamber, which is certain in its turn to induce glaucomatous changes in the retina and choroid.
Attacks of serous iritis are apt to recur ; at first
they
April 1,
1867.]
FUNCTIONAL PARALYSIS IN CHILDREN.?BY A.
are but slight and of comparatively short duration, iasting probably from three weeks to a month, and then gradually passing away ; it may be for several months or a year before another attack, generally of increased severity, comes on. The intra-ocular pressure, which is hardly augmented in the early stages of the disease, becomes a more prominent feature in cach successive attack; the tension of the eyeball, however, increases so gradually, that it is unaccompanied with that intense pain noticed in the more rapid effusions which occur in serous choroiditis; the parts, in fact, have more time to adapt themselves to the distending force, and consequently the pain, though often severe, is not of so excruciating a character as that noticed in the instance of acute glaucoma. In the early stages of serous iritis, the zone of congested sclerotic vessels surrounding the cornea is noticeable, but there is seldom much hyperemia of the conjunctiva; the patient complains of only slight pain in the affected eye, and will frequently tell you that he is altogether free from pain ; pressure, however, exerted on the globe of the eye generally causes the patient to wince, if not to exclaim in very decided terms, on account of the pain thus produced ; subsequently, as I have before remarked, the intra-ocular pressure increasing, the pain in the eye generally becomes a prominent symptom, and is not at all likely to be overlooked. Dimness of vision is always an early complication of serous iritis, and depends on turbidity of the aqueous, which frequently assumes an appearance as though small particles of very finely powdered chalk had been suspended in it, and of course prevents many of the rays of light, which would otherwise reach
the retina, from arriving at their destination ; and hence the haziness of vision from which the patient suffers. This state of things is augmented by a semi-opaque condition of the
epithelial cells lining the posterior elastic lamina of the corin the epithelium of the anterior nea, analogous to that noticed layers in instances of keratitis. These diseased epithelial cells drop off from the cornea after a time, and may then be about in the turbid seen as small white particles floating aqueous. The state of the iris itself is consequently generally obscured to a considerable extent, even in the early stages of serous iritis, by the hazy condition of the cornea and the muddy of the aqueous humour; it will be found, however, to but slowly, though regularly, to the stimulus of light, under the influence of atropine the pupil dilates to its extent, although it muy require the frequent application state
res-
pond
and full of
a
strong solution to effect this object. As the disease advances, and the structures constituting the iris become altered, the action of its contractile fibres is impaired, and the pupil can 110 longer be made to expand, or it may be that from a combination and serous form of the disease, synechia forms, of the
plastic subsequently the pupil assumes all manner of shapes under the dilating influence of atropine. It is impossible to arrive at any precise conclusion as to the causes which induce serous iritis ; it is certainly more common from derangement among women, particularly those suffering of the menstrual functions, than it is among men, and in the majority of cases the patient is in a low state of health, having probably been reduced by malarious or some other debilitating influences. The disease, as a general rule, runs a very protracted course ; each attack being more severe than the preceding one, until in the course of months, or it may /be years, some of those serious complications above described come on, and the patient's sight is ultimately destroyed, and
y
J
GARDEN, M.D.
91
89
LECTURES ON DISEASES OF THE IHIS.-BY C. MACNAMARA.
18G7-]
of the iris is so
Congestion
frequently
associated with or merges
into iritis, that I shall describe the treatment to be adopted in this form of disease when considering that of inflammation of
ORIGINAL COMMUNICATIONS.
the iris.
I propose following Dr. Wecker's nomenclature, and bing iritis under three heads : first, the simple or plastic secondly, the serous; and lastly, the parenchymatous or
LECTURES ON THE DISEASES OF THE IRIS. By C.
MACNAMARA,
Stjpdt., Calcutta Ophthalmic Hospital.
of
of the same color, but we occasionally meet with instances congenital nature in which they appear to differ, although
a
otherwise perfectly normal. Whatever the color of the healthy iris may be, it has a brilliant shining fibrous appearance, and in this respect are symptomatic of disease, any alterations
although
the
changes
may be so slight that they can only be the diseased with the healthy eye.
appreciated by comparing The state of the
pupil again
is
an
important
element for con-
sideration ; it frequently happens that from inflammatory
or
other causes adhesions form among the fibres of the iris, or Under these circumstances, the between it and the lens. actions of its contractile
elements, and consequently the mobility impeded. I may, however, mention that affections of the choroid, involving the long ciliary nerves, will also influence the sensibility of the iris ; alterations, therefore, in the activity or form of the pupil are by no means to be taken as pathognomonic of disease of the fibrous structures of the of the
pupil,
are
iris, for they may depend upon many other influences, into which it would be foreign to our purpose to enquire at present. Hyperemia of the Iris is very seldom met with, unless as a result of injury, or from wounds involving the cornea ?, it more
as a premonitory symptom of iritis or of conchoroid, in which case the ophthalmoscopic
often occurs
gestion
of the
the eye, the increased tension appearances of the fundus of of the eyeball, and the pain on pressure over the region of the
choroid, all point to the nature of the disease. In uncomplicated hyperemia of the iris there is always some congestion of the vessels at the junction of the sclerotic and cornea ; the extent and depth of this zone vary according
It is important to notice that to the progress of the affection. in these cases the cornea remains perfectly transparent, so that there can be no mistaking this sclerotic zone of vessels in hvperaemia of the iris for a symptom of keratitis. The patient seldom complains of pain in his eye, but of more or less dimof vision, which is most marked after sunset. This symptom of hyperemia of the iris depends on the of its
ness
impairment
functions, caused by the pressure of its congested vessels on the contractile and nervous elements of the iris, the consequence of which is that the pupil fails to dilate after nightfall, thus preventing a sufficiency of the rays of light from reaching the retina to stimulate it to action. During the day the patient sees differ from iritis, in that very well, for these cases of hyperemia there is no turbidity of the aqueous. On examining the iris by transmitted light, we shall be able distinctly to trace the distendits surface.
The
pupil responds but mydriatics. The fibrous elements of the iris, however, remain unaltered in colour; except in some few instances in which, after long-continued hvperemia, changes take place in its pigment cells similar to those noticed under analogous circumstances in the choroid ; they become of a darker colour and shrink up ; these alterations usually commence at the margin of the pupil, in the uvea covering the contractile fibres of the iris, which then present an uneven and spotted appearance, small dark excrescences projecting from them into the pupil. But even after long-continued hyperemia, the integrity of the contractile elements of the iris seldom appear to become impaired ; and no sooner does the congestion subside, than it again actively performs its functions. ed vessels
slowly
to
coursing
over
the stimulus of
light
or
to weak
iritis ; suppu-
rative iritis.
The color of the iris, depending as it does upon the amount and hue of the particles contained in its pigment cells, naturally varies in different individuals. As a general rule, the irides are
descri-
Inflammation of the iris is accompanied by certain symptoms which may be best described under distinct headings, so as to save the necessity for recapitulation when giving the characteristic features of each form of the disease. Pain in the affected eye is a constant, but in degree a variable, symptom of iritis. In many instances the patient complains
slight uneasiness extending from the eye over the corresponding side of the forehead, whereas in other cases the pain is excruciating and of a throbbing, lancinating character, involving not only the affected eye, but the side of the head and faceUnder any circumstances the pain is intermittent, usually increasing towards evening, and gradually growing worse as the night advances. In other cases, however, in which the iris is not much swollen, nor the inter-ocular pressure gr?atly increased, the patient will hardly notice this symptom, unless special inquiries aro made respecting it; it is always, however, increased when pressure is made on the eyeball. A zone of congested sclerotic vessels invariably surrounds the junction of the cornea and sclerotic in cases of iritis ; hyperasmia of the iris must exist, in fact, in instances of iritis, and consequently congestion of this sclerotic zone of vessels, since they anastomose with those of the iris and choroid. The amount of the sclerotic congestion will of course vary with the severity and stage of the inflammation, and in some cases may be concealed to a great extent by the injected and chemosed conjunctiva. Ultimately, as the iritis passes off, and tho balance of the circulation is restored, the zone of vessels gradually disappears, and the sclerotic assumes its normal appear-
of only
ance.
of sight is another marked symptom of iritis ; in the first instance upon turbidity of the aqueous more than on alterations in the iris ; subsequently synechia or bands of adhesio form between the iris and the lens and Dimness
it
depends
occasionally close the pupil, the sight being completely destroyed. Another cause of the haziness of vision complained of by patients suffering from iritis, arises from changes which take place in the epithelium of the posterior elastic lamina of the cornea, and which are best detected by the lateral method of examination. These cells often present a hazy appearance, similar to that of the anterior layers of the cornea in keratitis. In instances of this description flakes of degenerated and detached epithelium may usually be seen floating about in tne aqueous.
Changes of iritis
;
in the colour a
blue
or
of
the iris are
grey iris
becoming
noticeable in all more or
less
cases
greenish,
a
green iris yellowish green, and a dark brown iris of a reddish hue : its brilliant fibrous aspect is also destroyed, becoming converted into a confused and muddy appearance. This state of
things is usually rendered more marked by comparing the state of the diseased with that of the healthy eye (provided only one eye is affected), but under any circumstances the change in the colour and brilliancy of the iris is unmistakeable in all instances
of inflammation, and is due not only to alteration in its fibrous structure, but also to turbidity of the aqueous humour. Alteration in the Mobility of the Iris and the form of the
Fupil.?The congested serous
the
effusion that
vessels, together with the early stages of inflammation of
state of the
occurs
in the
iris, necessarily impairs
the functions of its contractile
elements, and hence its mobility; consequently in the sensibility of the iris to the stimulus of light symptom of
iritis.
Subsequently,
as
alteration is an
early
adhesions form between
90
THE INDIAN MEDICAL GAZETTE.
the iris ami the
lens, they
not
only impede
the action of the
former, but, when under the influence of atropine, the pupil assumes
an
iiregular figure
;
or, it may
be,
is unable to dilate at
all, being closed by organised bands of neo-pla'stic tissue. From the commencement, therefore, and throughout the course of an attack of
inflammation, the iris responds light or to mydriatics.
but
slowly,
if at
all,
to
the stimulus of
Intolerance of light and increased lachrymation are sympso frequently met with in iritis, that they may be consider-
toms
being common to all its forms. In chronic or sub-acute whereas in the cases, however, they may be hardly noticeable, active stages of the more acute forms of the disease, the patient complains bitterly of the exacerbation of pain which he exthe instant he approaches the light, and is perpetually
ed as
periences
in wiping away the tears that flow down over his The conjunctiva is always congested to some extent cheek in iritis, and in many instances its vessels are so deeply injected that it is well nigh impossible to define the sclerotic zone of vessels surrounding the cornea, and in these cases, if the posterior
engaged
of the cornea are also affected, the condition of the iris, which is the real source of the disease, is apt to be overlooked. Any doubts that may exist as to the nature of the
layers
disease may be at once cleared up solution of atropine to the eye ; the
by applying a few drops of irregular way in which the
pupil dilates will then be apparent. Increased tension of the eyeball is always present in the serous form of iritis, and is one of the chief causes of the pain from which many patients suffer ; for no sooner is the intra-ocular pressure removed by puncturing the cornea, and allowing the aqueous to escape, than the pifient experiences instantaneous relief. Constitutional symptoms.?Complications of this kind are frequently met with in cases of iritis ; the patient complaining of fevcrishness, and it may be of obstinate vomiting, the result of sympathetic irritation. Many instances of iritis, however, run their course without the manifestation of any such symptoms, and under any circumstances they are of trivial importance in comparison with the state of the eye ; in fact they are hardly worthy of consideration, disappearing the instant the mischief going
on
in the eye subsides.
Iritis.?The characteristic feature of this form of disease is that it gives rise, both on the surface and in the substance of the iris, to a neo-plastic element, the tendency of
Simple
or
plastic
become developed into fibrous tissue ; bands of thus formed between the iris and lens (synechia), and in the contractile tissue of the iris itself. Plastic iritis is frequently met with among persons suffering from rheumatism, which is to
adhesio
are
consequently it has often been described as rheumatic iritis j this deduction, however, is hardly correct, and is likely to lead to errors in practice ; for nothing is more common than to meet with instances of this affection occurring among individuals and
who are perfectly free from rheumatism. In the case of lepers, for instance, plastic iritis is of common occurrence, and also as a result of wounds or inj-iries of the eye. Under very favorable ciicum&tances, this form of disease may run its course in from ten to fifteen days, and then gradually Instan-
disappear.
of this kind are, however, exceptional, unless the patient has been brought under treatment at any early stage of the affec-
ces
tion ; the majority of cases of plastic iritis, if left to nature, terminate in synechia ; slight adhesions form in the first instance between the papillary margin of the iris and the lens. Avhich, however, are sufficiently tight ot tie the iris firmly down to the more points, and every time that the pupil dilates contracts, these tags of adhesion pull on the iris, thus keeping of irritation and disturbance in the up a constant state part, which ultimately induces a fresh attack of inflammation ; more extensive adhesions then form, until after repeated attacks of
capsule at one or t>r
this kind the iris becomes nerative
changes
firmly place
then take
bound down to the lens ; degein its fibrous structure, which
[April 1, 1867.
becomes atrophied ; unfortunately, the mischief that under these circumstances does not stop here, hut the communication between the anterior and posterior chambers of the eye being closed, an abnormal collection of fluid t;ikes place
ultimately occurs
iris, which exercises on the deeper structures of the injurious pressure of a glaucomatous character, too often terminating in atrophy of the globe.
behind the eye
an
As a general rule, the zone of congested vessels surrounding the circumference of the cornea is well marked in cases of plastic iritis, the hyperseinia of the conjunctiva not being suffito completely hide it. It was formerly supposed that the whitish grey band surrounding the cornea and situated iuternally to the zone of sclerotic vessels, was a characteristic symptom of rheumatic iritis. This band, however, depends
ciently great
simply upon the anatomical relations of the parts, the sclerotic overlapping the bevilled margins of the cornea in this situation; the grey band surrounding the cornea, and seen in many cases of iritis, is therefore a symptom of no importance. In the early stage of plastic iritis, the mobility of the iris is affected, its free margin appears to be swollen and thickened, its fibrous structure also loses the distinctness, and its color is likewise altered. The formation of neo-plastic tissue, which is the cause of all these changes, varies in quautitv in different cases; it seldom forms flakes or deposits on the iris, so that in fact we cannot detect its presence in the living subject except by its effects on the iris, which it ultimately glues down to the capsule of the lens, and by the pressure ic exerts in con-
tracting upon its fibrous, vascular, and nervous structure, leads The amount to atrophy and complete degeneration of the iris. of pain frotn which a patient affected with this form of iritis suffers, is by no means constant ; in some cases, it is not a prominent symptom, whereas in others it is most excruciating, extending from the affected eye over the temple and side of the face, and almost always increasing in intensity towards evening, and growing gradually worse as the night advances.
Serous Iritis ?In place of the neo-plastic formations which are characteristic of the last described form of iritis, in that now under consideration a serous exudation takes place from the vessels of the iris, which, accumulating in the anterior chamber, pushes the iris backwards ; so that in well marked cases of serous iritis the iris appears to be further away from the cornea than in health, the depth of the anterior chamber being apparently from the pressure exercised on the vessels and nerves by the accumulation of this serous fluid in the anterior chamber. The functions of the iris are impaired, and increased
of the iris
the
pupil responds but slowly, if at all, to the stimulus of light; unless, however, in chronic cases the pupil, when it dilates, does so regularly, there being no synechia in the stages of In this serous iritis to impede the action of its contractile fibres. respect, therefore, there is a marked difference between serons and plastic iritis. In the more advanced stages of the disease, the accumulation of serous fluid in the chambers of the eve such an amount of increased inter-ocular pressure, that its effects begin to tell on the choroid and long ciliary nerves ; and the innervation of the iris being thus impaired, it is not causes
respond to the stimulus of light, mydriatics are without effect on it.
unable to ful
only
but the most power-
Serous iritis is a common form of disease among the natives of India, and as it excites no urgent symptom in the early stages, it, is likely to be overlooked or disregarded until it has effectep irreparable changes in the deeper structures of the eye, or has merged into a combined form of serous and plastic iritis of a the very dangerous character, the neo-plastic formations
binding
iris down to the lens, and thus effectually keeping in the serous effusion poured out into the posterior chamber, which is certain in its turn to induce glaucomatous changes in the retina and choroid.
Attacks of serous iritis are apt to recur ; at first
they
April 1,
1867.]
FUNCTIONAL PARALYSIS IN CHILDREN.?BY A.
are but slight and of comparatively short duration, iasting probably from three weeks to a month, and then gradually passing away ; it may be for several months or a year before another attack, generally of increased severity, comes on. The intra-ocular pressure, which is hardly augmented in the early stages of the disease, becomes a more prominent feature in cach successive attack; the tension of the eyeball, however, increases so gradually, that it is unaccompanied with that intense pain noticed in the more rapid effusions which occur in serous choroiditis; the parts, in fact, have more time to adapt themselves to the distending force, and consequently the pain, though often severe, is not of so excruciating a character as that noticed in the instance of acute glaucoma. In the early stages of serous iritis, the zone of congested sclerotic vessels surrounding the cornea is noticeable, but there is seldom much hyperemia of the conjunctiva; the patient complains of only slight pain in the affected eye, and will frequently tell you that he is altogether free from pain ; pressure, however, exerted on the globe of the eye generally causes the patient to wince, if not to exclaim in very decided terms, on account of the pain thus produced ; subsequently, as I have before remarked, the intra-ocular pressure increasing, the pain in the eye generally becomes a prominent symptom, and is not at all likely to be overlooked. Dimness of vision is always an early complication of serous iritis, and depends on turbidity of the aqueous, which frequently assumes an appearance as though small particles of very finely powdered chalk had been suspended in it, and of course prevents many of the rays of light, which would otherwise reach
the retina, from arriving at their destination ; and hence the haziness of vision from which the patient suffers. This state of things is augmented by a semi-opaque condition of the
epithelial cells lining the posterior elastic lamina of the corin the epithelium of the anterior nea, analogous to that noticed layers in instances of keratitis. These diseased epithelial cells drop off from the cornea after a time, and may then be about in the turbid seen as small white particles floating aqueous. The state of the iris itself is consequently generally obscured to a considerable extent, even in the early stages of serous iritis, by the hazy condition of the cornea and the muddy of the aqueous humour; it will be found, however, to but slowly, though regularly, to the stimulus of light, under the influence of atropine the pupil dilates to its extent, although it muy require the frequent application state
res-
pond
and full of
a
strong solution to effect this object. As the disease advances, and the structures constituting the iris become altered, the action of its contractile fibres is impaired, and the pupil can 110 longer be made to expand, or it may be that from a combination and serous form of the disease, synechia forms, of the
plastic subsequently the pupil assumes all manner of shapes under the dilating influence of atropine. It is impossible to arrive at any precise conclusion as to the causes which induce serous iritis ; it is certainly more common from derangement among women, particularly those suffering of the menstrual functions, than it is among men, and in the majority of cases the patient is in a low state of health, having probably been reduced by malarious or some other debilitating influences. The disease, as a general rule, runs a very protracted course ; each attack being more severe than the preceding one, until in the course of months, or it may /be years, some of those serious complications above described come on, and the patient's sight is ultimately destroyed, and
y
J
GARDEN, M.D.
91
