ARTICLE XVIII.

ON THE RELATION OF EYE DISEASES TO DISEASES OF THE KIDNEYS.

BY DR. C. OTTILLIE, OF LA CROSSE.

In this essay I hope principally to serve the interest of a general practitioner, if I attempt to explain the relation between the general pathological condition and the diseased organs to the lesions and diseases of the eye instead of demonstrating and illustrating cases to a specialist or oculist.

The standpoint is a practical one for every physician, because diseases of the eye cannot be discussed without taking into account diseases of other or remote organs and the general system. The separation of ophthalomology is an artificial and unjust separation from the internal medicine and has in late years by its wonderful development demonstrated, that its relations to and dependence upon general pathology are more manifest now than ever and nobody will and can defend this separation except by the necessity of more positive and thorough examination and knowledge, of the in crease of all branches of the medical science. How often does the examination of the eyes throw light upon the pathology of other parts of the body, lead us to an exact diagnosis of very difficult and obscure conditions, and show the manifold relations between diseases of the eye and general pathological conditions, especially if we search for the causes and not for the essence of the diseases of

the eye.

Even if to the present time, in spite of all endeavors to extend the limits of the exact knowledge of the science, our knowledge is not sufficiently extended to understand each feature of a disease in itself and connections,it is to be expected, that by exact and scientific exploration we will and must gradually obtain such a degree of

information, as will enable us to solve the problem of diagnosticating and treating on general basis.

The importance of general pathological condition and structural changes that appear in the eye by lesions of remote organs, cannot be ignored by any general practitioner, if he for instance, considers "Retinitis albuminuria," a term designating a disease of the retina, but which is only one symptom of that complex series of pathological process, called "Bright's disease."

If abnormalities in the eyes occur simultaneously with diseased conditions of the respiratory and circulatory organs the general practitioner should know the effects of these local lesions in relation to the condition of the whole organism as well as an oculist should be informed concerning general pathology. It belongs to both to discover the causes of disease, to define correctly its course and bring the process to a favorable issue.

During the last thirty years it has appeared to an untrained eye that the connection between special and general medicine has dissolved; but not to a practitioner of broad education, who follows the lines of scientific researches and particularly those of general and special pathological anatomy which explain the processes of disease in one part, and trace out their nature, cause, course and combination with other parts of the body.

I do not think, that any more appropriate method could have been devised than to undertake the treatment of some special subject in connection with ophthalmology and I therefore proceed at once, to the best of my ability to speak of "the relations which exist between the eyes and Bright's disease."

I am somewhat doubtful, whether the ophthalmoscope can or ever will be used by a general practitioner. I thought, remembering the practical character of our meetings, that it would prove acceptable to the members of our society, if, instead of attempting to give a description of some exceptional form of internal disease of the eye, I should discuss some of those affections, which are of every day occurrence and which the general practitioner may be called upon

to treat.

The general character of Bright's disease must be familiar to all my colleagues and I therefore do not intend to enter very minutely into the general symptoms and special pathology. We know that Bright's disease embraces severe degenerative changes or lesions of

the kidneys and is generally characterized by albuminuria. The permanent loss of albumen produces deficiency of albumen in the body, and the amount secreted in cases of renal diseases has a most important bearing upon the symptoms of uræmia, shown by specific gravity of the urine and clinically in the functional disturbance, especially in the insufficiency of the excretory functions of the kidneys, causing an overcharge of blood by this excrementitious

matter.

If the quantity of urine be diminished and the specific gravity be proportionally increased, there is no probable ground for apprehension; if the specific gravity be low and the quantity of urine be proportionately increased, the same conclusion is warrantable. The connection of the specific gravity with the quantity of the urine, passed within a certain time, is very important and indicates more or less the degree of danger.

In the urinary changes there are notable points of contrast and the examination of these should not be neglected by a general practitioner. I mention this for the purpose of impressing the necessity of it upon every physician in cases of troubles relating to vision. and uræmic coma and convulsions. Sudden and complete loss of vision may either precede or follow uræmic coma and convulsions, and is a very important symptom. Double vision, myopia, hemeralopia, amblyopia are attributed and amaurosis complete or not complete is not of rare occurrence. Generally both eyes are affected differently at different periods of the disease; it is persistent and due to the degenerative conditions seated in the retina, which we designate as retinitis albuminurica. A separate amaurosis from the retinittis albuminurica is the amaurosis uræmica, which developes suddenly and attacks both eyes and never occurs without severe symptoms of the brain, intense headache, vomiting, convulsions and coma. The blindness lasts not longer than 24 hours. The differential diagnosis is not very difficult, because persons with retinitis albuminurica come to the physician, but with uræmic amaurosis the doctor goes to the patient.

In retinitis albuminurica the changes come on gradually and the patients gradually feel well, except that they are tired. Amaurosis uræmica is mostly a consequence of acute nephritis, especially in scarlatina, chronic interstitial nephritis, in the chronic inflammatory swelling and occurs more rarely than the retinitis albuminurica.

Under these circumstances the impairment of vision varies from day to day, occurs suddenly and as suddenly disappears, the immediate causative condition is cerebral and the ophthalmoscope should be used for diagnosis. Why? Because the peculiar pathological changes in the retina are mostly marked and constant in this form of retinitis. The affection commences with a fullness in the retinal veins, the optic disc is hyperæmic and soon followed by infiltration. The retinal hyperæmia may extend to a considerable distance and extravasation of blood is often noticed. As the disease advances the feature will be gradually changed, the venous hyperemia will be more marked and the veins become contorted and more or less considerable disturbance in the circulation produces swelling of the optic nerve, owing to the hypertrophy of the left ventricle of the heart and the increased arterial tension consequent thereupon, which is so frequently met with Bright's disease. White spots in different portions of the retina will appear, which did not exist before; they gradually increase in size and finally form a broad white wall around the optic disc. The infiltration of the disc and of the retina is of serous character and gives the parts faint grayish white striæ, probably due to sclerosis of the connective tissues and especially in those, which support the optic nerve-fibres. The retinal vessels are frequently interrupted at various points and covered by the exudation. Numerous extravasations of blood are noticed on the retina and optic disc, which lie in the internal layers of the retina and are of considerable size by reason of extensively diseased vessels, by sclerosis or fatty degeneration. The tunica adventitia is often hypertrophied, causing hypermetropy due to the thickening of the retina. This form of optic neuritis occurs only in the later and last stages of Bright's disease after extensive degenerative changes have existed for a long time and atrophy of the nervus opticus effects the complete amaurosis.

Up to date uncertainty still exists as to the connecting link between the affection of the.kidneys and that of the retina, but if we follow the different stages of Bright's disease and compare the affections and changes with those of the retina, etc., etc., we clinically find some relations and I therefore give in few words the clinical symptoms of the different stages of Bright's disease.

STAGE I.-Acute Nephritis: small quantity of urine, great abundance of albumen and casts, white and red blood, corpuscles, œdema.

STAGE II.-Parenchymatous nephritis-chronic: small quantity of urine, abundance of albumen and casts, no blood, no hypertrophy (or exceptional) of the heart, seldom uræmia, retinitis albumninurica, general dropsy present and usually large.

STAGE III.-Chronic interstitial nephritis: Very abundant quantity of urine; very small quantity of albumen and casts; hypertrophy of the heart, very often uræmia; changes on the retina, none or shortly before death appearing œdema.

The ophthalmoscope does not prove distinct form of the diseased kidneys, more of such diseases resulting in the loss of albumen of the blood and in the retention of urea.

The disorders of the retina appear first in the chronic inflammatory parenchymatous nephritis and produce largely extended hydropia, exudates in the cellular tissues and serous cavities, a symptom connected with the cardio-muscular system. Hypertrophy of the left ventricle is according to Traube an almost constant concomitant of granular, contracted kidney. The destruction of secreting structure in these organs leads to the diminution of the amount of blood passing from the arterial into the venous system and of the quantity of fluid withdrawn from the arterial system for the formation of urine, increases the tension in the arterial system and consequently increases the resistance, which the left ventricle has to overcome in discharging its contents. If the compensation be complete the increased tension in the arterial system occasions a larger transudation of water and even of urea and other urinary solids through the kidneys and so materially aids in warding off dropsical effusion and uræmic symptoms.

Johnson thus explains the production of the hypertrophy; "In consequence of the degeneration of the kidneys the blood is morbidly changed, it contains urinary excreta and is unsuited more or less to nourish the tissues. The minute arteries throughout the body resist the passage of this abnormal blood. The result is that the muscular walls of the arteries and those of the ventricle of the heart become hypertrophied. The persistent over-action of the muscular tissue, both cardial and arterial, produce hypertrophy."

Gull and Sutton believe, that there exists in these cases a peculiar pathological change-named, "arterio-capillary fibrosis." It consists in the deposit of a "hyalin-fibroid" material in the fibrous coats of the arterioles and capillaries. This change may prevail