A CASE OF BASEDOW'S DISEASE, 
TF.HMIN VTINti IN TOTAL LOSS OF SIGH F FltOM | NKUKO-l’AK ALYTH’I IN- 
FLAMMATION OF THK OOIINKA. 
r.v 
HENRY G, CORNWELL, M, D„ 
OK poUMHIS. OHIO. LATE RESIDENT St HOEoN BROOKLYN KYK \\D K A It HOSPITAL; 
CLINICAL I.EUTVKKK ON OKU I’H ALXOLOOY AND OTOLOOY, NTAKHNO 
MEDICAL COLLEUK. OoLlMBI'H, OHIO. 
Koprintod from The American .Iouknal of the Medic u. Scienckn, for October, l*s t. 
YOUNGSTOWN, OHIO: 
DULY HKOISTKH BOOK AND JOB PRINTIN')! HOUSE. 
1S*1. A CASE OF BASEDOW'S DISEASE, 
TERMINATING IN TOTAL LOSS OF SIGHT FROM |NEURO-PARALYTIC] IN- 
FLAMMATION OF THE CORNEA. 
tnr 
HENRY G. CORNWELL, M, D„ 
OF COLUMBUS, OHIO. LATE RESIDENT SUHOEON BKOOKLYN EYE AND EAK HOSPITAL; 
CLINICAL LEOTUKER ON OPHTHALMOLOGY AND OTOLOGY, STALLING 
MEDICAL COLLEGE. COLUMBUS, OHIO. 
Reprinted from Tut American Journal ok the Mrdioal Sciences, for October, 1880. 
YOUNGSTOWN, OHIO: 
DULY BEUISTKK BOOK AND JOB PRINTING HOUSE. 
1881. PREFATORY NOTE. 
Destruction of the globes of the eyes as a sequel of Basedow's 
disease is one of the rarest conditions observed in ophthamalogy. 
I have been unable, thus far, to find any record of a parallel case 
to the one here reported in American medical literature. Those 
coming under the notice of foreign authors are referred to in the 
text. 
I believe this case illustrates those changes which take place in 
the eye from paralysis of the trophic fibers of the fifth pair of 
cranial nerves. While the form of inflammation is noted in the 
title of the paper as “neuro-paralytic,” this term is used in the 
limited sense just considered. It was not a case of neuro-paralytic 
destruction of the eye-ball, i. e. disease brought about by paraly- 
sis of all the fibers of the ciliary nerves. The elements in favor 
of these opinions are discussed in the paper. 
If this form of eye disease be accepted as due to paralysis of the 
trophic nerves the case may be regarded as offering a further argu- 
ment in favor of the pathological conditions, which give rise to 
“Basedow’s disease,” being seated in the glands of the cervical 
sympathetic. 
Some additions have been made to the article in reprinting it 
in pamphlet form. These are enclosed in brackets, [—]. 
181 East State Street. C. A Case oe Basedow’s Disease, Terminating in 
Total Loss of Sight from [Neuro-Paralytic] 
Inflammation of the Cornea. 
Miss C. J.,a?t. 20, born in Scotland; delicate complexion, and 
light auburn hair; ana*inic, very nervous, and with enfeebled intel- 
lect, came under the observation of one of the surgeons of the 
Brooklyn Eye and Ear Hospital (Dr. Arthur Mathewson. by whose 
kind permission I report the case), May 3, 1877. She was accom- 
panied by a female friend from whom the following brief antece- 
dent history of the patient, which I copy from my note-book, was 
obtained : 
'‘She has always been nervous and weak minded; is easily fright- 
ened, and starts at loud and sudden noises. Her eyeballs have pro- 
truded from the orbits as long a time as can be remembered. One 
night about four weeks before the date of this visit to the hospital, 
some of her companions at a charitable institution in Brooklyn, N. 
Y., put something into her bed, which caused her to be badly 
frightened. The next morning the eyeballs were found protruding 
from their socket to a much greater extent than they were before. 
The exophthalmos continued to increase within the succeeding two 
weeks. Some days it was noticed that tae protrusion was not so 
great as on others. On the first of May the left eye became in- 
flamed, and to-day, May 3d, she appears at the hospital.” 
The eyeballs were found to protrude to such an extent from the 
orbits that the lids would not cover the cornea? at all. The cornea 
of the left eye was slightly cloudy over its entire surface. There 
was also some swelling and oedema of the ocular conjunctiva. 
Both of these membranes were dry and very sensitive. Vision 
(left eye)=ability to count fingers at 120 c. m. (4 feet); (right eye) 
slight chemosis, cornea clear. No ophthalmoscopic ex- 
amination was made of either eye. No enlargement of the thyroid 
gland. Rapidity of the heart’s action not observed at this time. 
As local remedies vaseline was directed to be used in both eyes, 
together with a solution of atropiae sulphas (.24 c. g. aqua 32 
grm.), and a borax and camphor bath; she was directed to return 
on the following day, but. 6he did not put in an appearance until 
May <ith, two days after her prescribed time, when the chemosis of 
the left eye was very tense. The conjunctiva was dry and scaly 
in appearance, and so sensitive that when it was touched with a 
feather the patient would cry from the severity of tTie pain. The 
lower half of the cornea was yellow and horn-like; the upper half 
was cloudy as before. Vision=perception of light: the cornea of 
the left eye was at this time markedly cloudy; the chemosis tense, 
and the same dry condition of the cornea and conjunctiva mani- 
fested itself as in the fellow eye. Vision=ability to count fingers 
at 150 c. m. (5 feet). A more careful examination of her general 4 
CORNWELL. 
condition was made at this time. Her nervous symptoms were 
more marked than when previously seen; she was hysterical, man- 
ifesting this condition in laughing and crying most of the time. 
Her circulation was 130, which became rapidly increased after the 
least excitement. Temperature 102°. No swelling of the thyroid 
gland, and no organic disease of the heart could be detected. 
She was admitted into the hospital, and the continuous use of 
hot water and the instillation of the atropia solution (for which 
eseriti sulph.—.06 c. g. aqua 32 grm.—was substituted later), were 
ordered, together with tonics of iron and quinia, egg-nogg and nu- 
tritious diet. On May 8th the entire cornea of the left eye was 
yellow, dry and shrivelled, and the cornea of the right eye was rap- 
idly undergoing the same changes, and by the following morning 
(May 9th) the white cloud in the center of the cornea was surround- 
ed by a dry yellow ring about 3 mm. in width. Vision=perception 
of light. The globes underneath the lids were perfectly normal in 
appearance, not the slightest infiamation of the ocular conjuctiva 
existed posterior to the margins of the upper and the lower lids. 
A solution of muriate of quinia was substituted for the eserine. 
The use of the vaseline was continued, and an oiled-silk mask or- 
dered to be worn, which gave her so much relief from the pain 
which the exposure of the eyes to the air occasioned that she cried 
when it was removed for any length of time. Fluid extract of 
ergot was substituted for the tinct. valerian and Hoffmann’s 
anodyne. The ergot (Squibb’s) was given in 4 grm. doses every 
two hours, which had the effect of reducing the cardiac pulsa- 
tions from 130 to less than 100 a minute. The temperature 
fell from 102° to 100». Whenever the use of the drug was omitted 
the temperature again rose to its original height (102°) with cor- 
responding increase in the rapidity of the heart’s action. G-lycerite 
of starch was tried as a local remedy, but the vaseline was found to 
be better. On the following day the cornea of the left eye was dry 
and yellow. Same treatment continued. Two days later (May 
12th) the appearance of the patient at this time was frightful. The 
lids of both eyes were forced widely apart by the protruding eye- 
balls. The lower ones twitched with great rapidity most of the 
time. The ocular conjunctiva of both eyes was dry and scaly; the 
chemosis was so great that an abrupt dark-colored mound was formed 
around the cornea, overlapping its edge to quite a marked extent. 
She was very irritable. Her face and neck were red from the con- 
gested state of the vessels, [the pulsations of the carotids was 
noticablemt a distance of some feet,] and she perspired profusely 
most of the time. 
One week later she was discharged. The globes were now 
[noticably shrunken and] softened. The lids could be closed to such 
an extent that but a narrow space intervened between their edges; 
the intra-ocular tension was much lowered (T——2). Her nervous 
irritability had by this time chiefly subsided. Circulation 130, 
temperature 101°. 
Blindness from disease of the cornea as a sequel of Basedow’s dis_ 
ease is a very rare occurrence. Most authorities in ophthalmology 
make but a passing reference to the few cases that have been re- BASEDOW’S DISEASE. 
5 
ported, and regard the opinion advanced by Von .Graefe, viz., that 
the diseased condition of the cornea is brought about by a paralysis 
of the “trophic” fibres of the ophthalmic division of the trifacial 
nerve as (with our present knowledge, which it must be confessed 
is yet vague of the nervous agency governing the nutrition of the 
eye,) most worthy of acceptance. Soelberg Wells, in his “Treatise 
on the Eye,” records but a single instance of blindness occurring 
in this disease coming under his observation, the patient being a 
young woman. Graefe, according to the same author, records 
fourteen cases, ten men and four women, in the Berliner Klin. 
Wocltenschr., 18G7. VonDusch gives in his Lehrl. d. HerzJchtn., 
Leipzig, 1808, an analysis of fifty-six cases of the disease coming un- 
der his observation, in all of which there was diminution of the 
normal sensibility of the cornea only. 
The experiments of Meissner (Hcnle and Pfeujfer's Zeitscrhift, 
xxix.), and subsequently those of Schiff (loq. cit.) on rabbits have 
obtained as a result the belief that certain (the innermost) 
“trophic” fibres enter into the structure of the fifth nerve. On 
these experiments the opinion has been based (0. Wyss, Valentine, 
and others) that on account of the division of these (innermost) fibres 
the eye is less able to resist those changes which are brought about 
by its exposure to external irritants, the air, dust, etc,, after com- 
plete division of the nerve by which the sensibility of the organ is 
lost. Graefe, after these experiments, believed that disease of the 
cornea as a sequel of Basedow’s disease was due to paralysis of 
these “trophic” fibres of the ophthalmic branch of the trifacial 
nerve. The character of the destructive changes which take place 
in the cornea are described by Eulenberg in a paragraph which I 
reproduce from a paper on Basedow’s disease under the head of 
“Vaso-Motor Neuroses” in Ziemssen’s Cyclopwdia, vol. xiv. p- 88:— 
“Another and a rarer group of symptoms must, perhaps.be regarded in some cases as sec - 
ondary, as a sequel of the exophthalmos and thedefectire power to depress the upper lids. 
These symptoms are disturbances (tfthe nutrition of the bulb, especially in the outer coats 
of the eye, the conjunctiva and cornea. The impairment of the power of moving the lids 
prevents the eye from receiving its due share of moisture, whence comes dryness in the 
conjunctival sac, distension of the conjunctival veins and conjunctivitis. The lachrymal 
secretion is often increased. In the majority of cases nothin# worse occurs; but in 
bad cases severe disturbance of nutrition of the cornea occurs, closely resembling 
what occurs in neuroparalytic ophthalmia, and perhapr explicable in the same 
way. The cornea first loses its sensibility; on its surface dry yellow spots appear, which 
gradully enlarge, and the final result is the formation of an eschar, followed by diffuse 
desiccation or even perforation. In other cases infiltrations occur at several points of 
the cornea at once, and ulceration or even perforation occurs. It is remarkable that 
these disturbances in the nutrition of the globe are common in men (Hasedow. Prael, 
Nauman, Von (iraefe), although in a few instances also observed in women (Lawrence, 
Tatum, Teissier).” 
[Here the author regards the most important factor in the 
etiology of these disturbances in the nutrition of the cornea to be the 
want of protection of this membrane, together with the dryness oc- 
casioned by the exophthalmos. These, it seems to mo from my 6 
CORNWELL. 
study of this case’ are to be regarded as secondary factors only. 
This I will endeavor to show before I conclude the paper.] 
It will be observed that the patient, whose history I have re- 
corded, suffered very much from the sensitive condition of the eyes. 
She cried when they were exposed to the air for any length of time, 
or when they were touched with a feather. The inflamation was 
not of a violent character, but a drying or shrivelling up of these- 
membranes—an acute xerosis—[in the treatment of which 
the constant application of vaseline, glycerite of starch, hot 
fomentations, etc., was absolutely without good effect.] There 
was no loss of corneal tissue. In this particular it will be noticed 
that it differs from that form of inflamation of the eye which or- 
dinarily follows its exposure to external irritants, as after facial 
paralysis with consequent drooping of the lower lid, or retraction of 
one or both lids from cicatrices the result of burns, or from 
exophthalmos due to tumors or aneurisms of the orbit. In these 
latter instances acute keratitis is developed with photophobia and 
profuse lachrymation, followed by sloughing of cornea oftentimes, 
or dense pannus.* Here the corneae were dry and yellow; no loss 
of tissue was perceptible, and no sloughing. The. membranes (the 
corneae) were at first white, resembling ground glass, becoming 
subsequently dry and yellow. There was no anaesthesia of the eye- 
balls due to stretching of the ciliary nerves, and no paralysis of the 
extra-ocular muscles. No mention is made in my notes of the case 
of dilatation of the pupil, or loss of accommodation in the right 
eye before it became affected by the disease. If such changes 
were present, they would have been observed doubtless, and re- 
corded, and yet the globes protruded from between the lids to such 
an extent as to be (in profile view) half way out of the orbits. 
Posterior to the margins of the lids the globes were perfectly healthy 
in apperance, not the slightest congestion of the ocular conjunctiva 
was present so long as the case was under observation. The ocular 
conjunctiva was chemotic and cedematous, the latter condition to a 
slight extent at the margins of the lids. Lachrymation was but 
slight; flake3 of mucous adhering to the convexity of the swelling. 
[The globes finally became very soft. Tension—2.] 
We read at times of instances where after paralysis of the fifth 
nerve the cornea became affected, although the eye was protected 
* [A case of neuro-paralytic ophthalmia has come under my observation since the first 
appearance of this paper in which the cornea of the affected eye underwent pricisely the 
the same changes as were exhibited in the right eye of this patient. I had operated on the 
patient for the removal of a multilocular cyst of the orbit. The resulting inflammation 
caused such swelling of the orbital structures that the pressure interfered with the 
vitality of the ciliary nerves and necrosis of the cornea was the result. The history of this 
case will appear in a future article.] BASEDOW'S DISEASE. 
7 
by the fulling of the upper lid (associated ptosis).1 This is contrary 
to what usually occurs, as the experiments of Magendie and other 
vivisectionists, together with our subsequent clinical experience, 
have taught us. In rare cases we find no disease of the cornea, al- 
though this membrane was wholly insensitive from paralysis of the 
fifth nerve, and unprotected. 
We must look for the cause of the corneal disease in the case I 
report in these two directions, viz.: (1) It was due simply to the 
exposure of the eyeballs to the air, and wholly disassociated from 
an affection of the fifth nerve or the ganglion of Gasser; or (2) The 
“trophic” fibres of the nerve were alone affected, and on this ac- 
count the eye was unable to resist the injurious influences of the 
air, dust, etc. 
The obviously neurotic character of the disease in this patient to 
my mind is worthy of consideration in ofTering a theory as to the 
cause of the destructive changes in the cornea. The reader will note 
these points by turning to the history ot the case. The patient al- 
ways nervous, starting at loud and sudden noises; her feeble intel- 
lectual powers; the brusque development of the exophthalmos after 
a fright at a comparatively trivial circumstance, together with her 
subsequent irritable and hysterical condition. The character of the 
destructive process which took place in this case is not what we 
would naturally expect to follow exposure of the eye to irritants 
alone. [As the case progressed the globes became very soft. (T.-2.) 
I regard this fact as one of some importance. Irido-choroiditis and 
suppurative choroiditis (panophthalmitis) reduce the eye tension 
The former condition does not occur, however, in the progress of a 
form of inflammation which brings about necrosis of the cornea. 
Here one would expect in turn suppurative iritis, cyclitis and 
choroiditis going on to general destruction of the globe (or 
panophthalmitis,)—a violent inflammation, attended with swelling 
of the lids, severe circumorbital pain,marked constitutional disturb- 
ance, etc. Although the chemosis was marked in this case it was in 
part due to oedema, while underneath the lids there was no injec- 
tion of the vessels of the conjunctiva overlying the sclera. 
Basing my opinion on these facts I believe the disease to have 
been one affecting the gasserian ganglion resulting in protrusion 
and nutritive changes in the eyeballs.] Is it unreasonable to sup- 
pose that the primary exophthalmos was of neurotic origin, and 
that the protrusion of the eye balls developed itself to a much 
greater extent after this fright from further changes taking place 
1 Vide Paralysis of the Trigeminus, followed by Slouching oi the Cornea, by William 
F. Norris, M. D.; Amer. Joum. Med. Sci., Jan, 1872, p. 81). 8 
CORNWELL.—BASEDOW’S DISEASE. 
in the ganglion of Gasser (in this case the elements of the sympa- 
thetic perhaps being only affected) or in the fibres of the sympa- 
thetic nerve which are distributed to the eye, the “trophic” fibres 
of the fifth pair of nerves, as they are generally believed to be? The 
greater number (eight out of twelve) of the necropsies made in which 
changes were found in the cervical sympathetic [glands] forms 
a basis for such a theory, i Eulenburg suggest (loc. cit., 
p. 98.) that it is not impossible that this condition—[necrosis 
of the cornea]—should result from disturbances of inner 
vation on the part of those sympathetic fibres which enter 
into the structure of the ophthalmic division of the fifth nerve. 
Stretching of the ciliary nerves had manifestly nothing to with 
it, as the cofneae were sensitive, and morbidly so, as long as 
the patient was under observation. In Emmert’s (twenty) cases 
the reader will observe that the sensibility of the cornea and 
conjunctiva was much lowered. This, according to authorities, is 
not the rule but the exception. I regret that the menstrual func- 
tion of the patient was not made the subject of careful investiga- 
tion. If I remember rightly, she stated there was suppression of 
the menstrual flow, but I did not record it at the time; she had a 
markedly chlorotic appearance, which improved under the tonic 
course followed during her stay in the hospital. 
The case presented one other feature of interest, and that was 
the absence of enlargement of the thyroid gland. This was ob- 
served by Yon Dusch in three of fifty-six cases.2 
1 Observed by Troussean, Keith. Cruise, McDoneal, Traube, Biermier, Virchow and 
(Teiglei; not recognized by Recklinghausen, Paul, Fournier and Olliver. 
2 Accelerated action of heart, absent in 3 cases. 
Goitre 3 “ 
Exophthalmos . . . “ 4 “ 
In the order of their development—Lelirb, d. Herzhtn., 1888.