REPORT OF A CASE OF 
OPHTHALMIA ALBUMINURIOA. 
By S. POLLAK, M.D., St. Louis, Mo. 
WITH A REPORT ON THE HISTOLOGICAL 
EXAMINATION OF THE EYE. 
ADOLF ALT, M.D., St. Louis, Mo. 
Reprint from The American Journa of Ophthalmology, May, 1893, OPHTHALMIA ALBUMINURICA 
S. POLLAK, M. D., ST. LOUIS. 
There is much in a diagnostic name which will surprise the 
reader, who may intuitively express a doubt as to its correct- 
ness. This surprise and doubt cannot be greater than my 
own. I refrained from making it until after many days of 
careful and assiduous observation, the conclusion forced itself 
upon me. In active ophthalmic practice, both clinical and 
private, of one-third of a century, I never met a parallel case, 
nor could I find one similar to it in the literature, whether for- 
eign or domestic, within my reach. 
Two of my esteemed colleagues saw the case with me, un- 
fortunately not early enough, when the peculiar features were 
very demonstrative and unmistakable, but which they had to 
take on trust from me. When they were related to them in 
the presence of Clara's very intelligent mother, they both ac- 
knowledged never having seen any case just like it, or met 
with it in their readings. 
I am fully prepared for, and earnestly invite the critical 2 
judgement of, the active and intelligent workers in the field. 
A total loss of sight was manifest at my very first visit, a fatal 
result to her life, was once seriously apprehended, which, 
however, was happily averted. 
I shall now proceed to give briefly the history of the case. 
January 2,1 was called to see Clara Harris, aged 7 years, the 
oldest child of very healthy parents, a bright and favored pu- 
pil of the public schools. She had enjoyed perfect health un- 
til the day after Christmas. It happened that her mother took 
her to a church to see a richly illuminated Christmas tree, the 
church was densley packed so that she could not get farther 
than the ninth or tenth pew from the door. This was the 
coldest night of this winter, the temperature ten degrees below 
zero. Clara was well enough wrapped, but the constant open- 
ing and closing of the door made her feel cold. She slept 
well that night, but next morning she asked her mother to let 
her sleep a little longer. She remained in bed that day and 
also the next day, complaining of being tired. Thursday, 
the third day, she cried out: "Mamma, the house is on fire." 
The mother tried to quiet her, but she insisted "the house is 
on fire; don't you see everything looks red?" She became 
restless, had some fever and a slight cough. The family phy- 
sician, a very able man, was sent for. He saw her diligently 
for several days. He thought the hallucination was probably 
caused by some meningeal irritation. She grew worse, fever 
increased, but no more hallucinations. Not until Monday, the 
second of January, was it noticed that though she did not 
open the eyes, she shielded them always from the light. The 
lids were forcibly separated, and the physician saw at once that 
the eyes were seriously implicated. He directed that an oculist 
be sent for. I saw her Monday after dark; found temperature 
103, pulse 112, tongue very coated, the buccal cavity filled with 
glary, tenacious mucus, which she in vain tried to expectorate. 
It had to be literally drawn out in long streaks by means of 
dry cotton or a piece of cloth, which was immediately con- 
signed to the fire. This had to be repeated nearly every five 
minutes. There were no deposits left on the tonsils and fau- 3 
ces. She could breathe and swallow without trouble; no 
cough. Thirst great, appetite none, bowels constipated, abdo- 
men not tender nor tympanitic. Urine scant, skin dry. After 
this general examination, the condition of the eyes was looked 
into. The lids looked normal, she could but would not open 
them, but when I separated them I recoiled. 1 saw only a per- 
fectly chalky white globe, resembling nothing so much as the open- 
ing boll of a cotton plant-, cornea and sclerotic both perfectly 
white alike, the line of demarcation between them obliterated, 
a slight polish of the cornea made the only distinction. Not 
the smallest bloodvessel was seen. Conjunctiva moveable, not 
chemosed; tension normal, ball rather anaesthetic. No trace 
of the iris to be seen. The anterior chamber seemed to be 
filled with a white homogeneous substance, whether fluid or 
semi-solid indeterminable, neither was it certain that the par- 
enchyma of the cornea was not involved. Motions of the eye 
unaffected, but there was not the least perception of light. The 
anaesthesia of the eye and of the surroundings rendered hand- 
ling them easier. Yet, with all this, there was photophobia, 
for she always wanted to have the lamp removed. The same 
condition in both eyes alike. I was very much at a loss about 
the diagnosis. I only knew that she was totally blind, but 
whether from an organic disease of the eye or from a metasta- 
sis of some strongly saturated opaque fluid, and that what of 
and where from, I could not tell. She complained only of the 
trouble which the ever recurring accumulation of tenacious 
mucus in the buccal cavity gave her, which provoked slight 
cough, nausea, and the absolute necessity of drawing it out. 
While a diagnosis had to be left in abeyance I had to insti- 
tute therapeutic measures, partly with the object of giving re- 
lief and partly to arrive thereby at a diagnosis. 
I ordered bathing the eye with absorbent cotton dipped in 
hot water every hour, which she seemed to like and called for 
often. Instilled into the eye atropine sulph., gr. iv to §j; one 
drop hourly until I could get a sight of the pupil. Internally, a 
triturate of calomel gr. ^io every hour, rincing the mouth with 
strong solution of boracic acid. She slept well that night, 4 
even the regular application of the above treatment did not 
rouse her. For the next two days the condition and the treat- 
ment was unchanged. Thursday, I learned that her bowels had 
been freely moved,and the buccal mucorrhcea was considerably 
less, but temperature yet 100, pulse 96. The mother also suc- 
ceeded in furnishing me with some urine voided during the 
night, which on testing showed specific gravity 1024, was very 
acid, and on boiling a large quantity of albumin coagulated, so 
that on cooling nearly one inch of it remained in the test tube. 
The albuminous urine furnished the first clue for a reason- 
able understanding of the case. I inferred therefrom that the 
exposure on Christmas night to a temperature of ten degrees 
below zero, caused an acute nephritis and general albuminuria, 
which by metastasis found a suitable soil in the eye, saturated 
strongly the aqueous humor and, perhaps made deposits of al- 
bumin on the tissues of the eyes. I made no change in the 
local treatment but suspended the triturates of calomel, and 
substituted the following: 
It Acetate of Potassium, - Sss. 
Tr. of Digitalis, _ _ _ _ gj. 
Water, - §iij. 
M. 
Sig. Dessertspoonful every two hours. 
The effect of this change of treatment was promptly manifest- 
ed by the lowering of the sp. gravity of the urine, diminution of 
of the albumin, and of the acid. On the other hand a notable 
increase in the quantity of urine, also an abundant perspiration 
set in. Not until Jan. 12, the tenth day of my attendance, did I 
discern the slightest change about the eyes. That day the 
chalky white cornea of the right eye became opalescent at the 
apex. This portion became even translucent the next day. 
This gradual clearing up from the center to the periphery of 
the cornea progressed with every succeeding day, until the 
pupillary margin of the iris came in view. The same clearing 
up process now commenced also in the other eye, and kept it 
up in proper ratio, so that in about two weeks both corneae 5 
were clear and the pupils dilated ad maximum, and yet not 
the least perception of light. The ophthalmoscope disclosed 
an opaque fundus; optic papilla and retinal vessels were not 
discernable. The external aspect of the eyes was normal, 
except mydriatic pupils. 
In the meantime the general health had greatly improved. 
Temperature, pulse and respiration normal. The mucorrhoea 
and albuminuria entirely subsided. Her physical condition 
good, except the total absence of sight, and no change in the 
fundus of the eyes. I substituted now: 
R; Bichloride hydrarg., - - - gr. j. 
Potassi iodide, - - §ss. 
Water, - _ _ - §vj. 
M. 
Sig. Teaspoonful every four hours. 
I hoped thereby to effect the absorption of a probable al- 
buminous deposit on the retina and other tissues of the eye. 
I made daily ophthalmic tests, both with direct and oblique 
illumination, but always with negative results. 
Up to February io the condition of the eyes remained sta- 
tionary, but a most unexpected change now set in, and the 
disease in both eyes assumed a new phase. That day, the 
conjunctiva of the right eye became hyperaemic,not chemosed, 
and the eye lachrymated a good deal; the pupil became smaller, 
though still under the use of mydriatics, the balls seemed to 
protrude, and for the first time she complained of bulbar, cir- 
cumorbital and occipital pains. The pupil of the left eye be- 
came oblong, the anterior chamber very shallow, the capsule 
of the lens opalescent, but no pain. The motility of either eye 
somewhat impaired. All these symptoms were more intensi- 
fied the next day, especially the protrusion of the right eye. 
This new inflammatory process was a painful surprise to me. 
My expectations of regaining a moderate amount of sight 
were always very feeble, and these were ended now. Panoph- 
thalmitis had set in in the right eye, and to save the form of it 
or even her life became now a paramount question. 6 
I will here mention that Dr. Wolfner, who had just returned 
from a year's visit to the great clinics of Europe, saw her with 
me,and stated that he never saw a case like it, nor did his read- 
ing acquaint him with one, as he wrote me a few days later. 
My friend Dr. Alt also accompanied me to see this extraordi- 
nary case when the characteristic whiteness had totally disap- 
peared, and declared he never saw or read of one parallel to 
it. The prominent symptoms at that day were entirely 
different, as if they were those of another patient with no 
relation to what I dealt with so long. It presented now a 
clear painful panophthalmitis, with high tension, considerable 
exophthalmus, with a yellowish white glistening fundus, lim- 
ited motility, high temperature, rapid pulse, with life in dan- 
ger. A glioma of the retina, or a retrobulbar tumor seemed 
to be present. Enucleation of the eye was considered indicat- 
ed in order to save life. The intelligent mother yielded to 
the suggestion. I removed the eye, aided by my clinical 
assistant Dr. Keene, and gave it to Dr. Alt for microscopic 
and bacteriological examination. He preserved it in Mueller's 
solution for hardening. 
My health was somewhat impaired in consequence of an 
attack of the grippe in January. I had to go South, to Cuba. 
On my return in April, I went to see little Clara, found her up 
and about, enjoying perfect health. The hyperaemia of the 
left eye, which also threatened to become like its mate, had 
subsided, but she is totally blind with a cataractous lens, dis- 
torted pupil and posterior synechia. 
Having given a faithful and succinct history of this very 
strange case, I now appeal to the enlightenment and experi- 
ence of the medical profession for a free and candid expression 
of their views on the following points: 
i. Am I correct in crediting the exposure to the intense 
cold of Christmas night with causing the acute nephritis and 
rapidly ensuing albuminuria? 
2. Was it ever known that amblyopia would develop in three 
days after any other cause but traumatism? I take it that 
Clara's statement that everything in the room looked red was an 7 
actual fact, not a hallucination. It is known that a slight haem- 
orrhage in the vitreous body will cause a red reflex to every 
object in the field of vision, which does not subside until com- 
plete absorption of the blood has taken place. 
3. Am I coincided with in ascribing the chalky white ap- 
pearance of the cornea to the metastasis of albumen into the 
aqueous humor, and not into the parenchyma of the cornea? 
The eyes never exhibited any phenomena of inflammation nor 
redness, pain and swelling, yet she was totally blind, without 
an appreciable organic change. 
4. The adage "post hoc ergo propter hoc' was proven in this 
case. In proportion as the quantity of albumin in the urine 
decreased, and micturation and activity of the skin increased, 
the density of the opacity of the cornea diminished, and when 
the urine became clear, transparency of the cornea ensued. 
5. Was the subsequent advent of panophthalmitis in the 
right eye a mere coincidence, or the result of a new inflam- 
matory process, or was it due to the agglutinated condition 
caused by the presence of albuminous deposits? 
6. Did the timely enucleation of the right eye save the left 
eye from a destructive sympathetic ophthalmia? for from that 
moment not only the left eye but the general health commen- 
ced to improve rapidly. 
7. Will I be credited with having described a faithful and not 
an exaggerated picture of the case? Those who know me 
will vouch for it, but with the large majority, to whom I am a 
stranger, a doubt might arise on that score. 
I am also aware that this report is not made in a standard 
classical style, but I trust it bears the stamp of honesty and 
truth in every line of it. 8 
CROUPOUS IRIDOCHOROIDITIS. 
Remarks to Dr. S. Pollak's Case.-Results of the Histo- 
logical Examination. 
ADOLF ALT, M. D., ST. LOUIS. 
On February n, 1893, I saw C. H., with Dr. Pollak. She 
was then considerably emaciated and weak. There was fever 
and the pulse was somewhat fast and small. There was some 
exophthalmus. Photophobia rendered the illumination of the 
eyes very irksome to the patient. There was a great deal of 
episcleral injection of the eyes. The corneae were clear. The 
right eye showed a large, irregular pupil, behind which a par- 
tially dim lens was seen. Iris and lens were almost pressed 
against the cornea by a yellow lobulated substance. V.=o; 
tension increased. The condition of the left eye differed but 
immaterially from the right one and its tension was not as 
high. The possibility of glioma having attacked both eyes 
was discussed, and the higher tension of the right eye prompt- 
ed the decision of its enucleation. The chief point, if there 
was no glioma, was to find an explanation for the clinical 
symptom of the cotton-ball-like appearance of the eyes at an 
earlier period, as described by Dr. Pollak. 
When the well hardened eyeball was opened, no tumor pre- 
sented itself, and what appeared behind the lens was seen to be 
the totally detached retina firmly united with cyclitic newfor- 
mations. The posterior chamber is totally obliterated; that 
portion of the anterior chamber which corresponds to the iris- 
angle is filled with a uniformly transparent gelatinous sub- 
stance, while in the pupillary area the lens lies close to the 
cornea and obliterates this portion of the anterior chamber. 9 
The space between the solid strand of the detached retinal 
tissue, which runs from the optic nerve forward to the cyclitic 
membrane, and the swollen choroid and also the suprachoroi- 
dal space, are filled with congealed exudation. Upon the in- 
ner surface of the choroid yellowish masses are deposited in 
thick layers and in smaller lumps. These masses are thicker 
near the ciliary body than in the posterior portions. 
Microscopically the changes are peculiar in the uveal tract 
only. The iris and ciliary body are so filled with round cells 
that their normal tissue is almost invisible. The choroid is 
many times its normal thickness. Its inner parts (choriocap- 
illary layer) are made up solely of round cells, which are sev- 
ered from the exudation lying inwardly by the lamina vitrea. 
Its outer parts (venous layer) and the suprachoroidal tis- 
sue and space are filled with a network of fibrine containing 
the remnants of the normal tissues and round cells. This pe- 
culiar network reaches forward on the outer surface of the 
choroid and the ciliary body to the insertion of the latter into 
the corneo-scleral tissue. 
This condition resembles closely that found in the lungs in 
croupous pneumonia, and the spongy exudation in the anterior 
chamber seen in some cases of iritis. The latter I described 
years ago, and considered it as the result of a hcemorrhagic 
iritis, as the iris was filled with haemorrhages in the case I had 
examined microscopically. Dr. S. M. Burnett afterwards 
called the iritis with spongy exudation into the anterior cham- 
ber croupous iritis. In the case under consideration a croup- 
ous cyclitis and choroiditis still existed when the eyeball was 
enucleated. I think, therefore, that it is not too far-fetched to 
explain the strange clinical aspect, described by Dr. Pollak, as 
produced by spongy (croupous) exudation in both anterior 
chambers due to croupous iridochoroiditis. When I saw the 
case this exudation, as it always does, had melted away and 
had been mostly absorbed. There were, also, no haemorrha- 
ges visible. 
I do not remember ever having seen such a general croup- 
ous inflammation of the uveal tract in man. 10 
I have seen it, however, as the result of the experimental 
injection of jequirity infusion into rabbit's eyes, corresponding 
in all its details to the condition of the eye under considera- 
tion. (See this Journal, Vol. I, No. 4, page 97, et ss.). The 
croupous membrane produced by jequirity on the-conjunctiva 
looks microscopically exactly like it. 
In retinae with albuminuric retinitis due to chronic nephritis 
a similar croupous exudation is often found lying in small 
cavities within the retinal tissue. In the eye under considera- 
tion the retina, however, is free from any such exudation. 
In order to study the bacteriological side of the question 
both Dr. L. T. Riesmeyer and I stained with methyline blue 
and after Gram's method, a considerable number of specimens 
taken from the yellow masses which were deposited upon the 
inner side of the choroid. I also stained in the same manner 
a number of sections of the tissues of the eye. In all of these 
specimens we found micrococci. They are, however, more 
numerous in the exudations than in the tissues, yet I found 
them also in the tissue of the choroid. These micrococci are 
usually arranged in clusters, and do not seem to differ from the 
staphylococcus pyogenes aureus. Besides these clusters a 
large number of cocci lie singly or in small groups of three or 
four disseminated through the exudation. I have found none 
in the other tissues of the eyeball. 
From the history of the case it would then seem that we 
had to deal with a croup oils nephritis and a croupous irido- 
choroiditis, perhaps both due to the immigration of the same 
microbe, which in the eye resembles most to the staphylococ- 
cus pyogenes aureus. 
Choroiditis with spongy exudation has been clinically seen 
once by Knapp. I do not know that it has ever been histolog- 
ically described in man.