[Extracted from the American Journal of the Medical Sciences for July, 1874.] 
RETINAL HEMORRHAGE AND ITS CONNECTION WITH 
CEREBRAL, CARDIAC, AND RENAL LESIONS. 
By CHARLES S. BULL, A.M., M.D., 
ASSISTANT SURGEON TO THE NEW YORK EYE AND EAR INFIRMARY; MICROSOOPI3T TO THE 
MANHATTAN EYE AND EAR HOSPITAL. 
Retinal hemorrhage, or apoplexy of the retina, is an affection doubly 
interesting to the ophthalmologist and pathologist, not only intrinsically, 
but also from its connection with other affections, local as well as general. 
It is by no means a rare lesion, and offers an interesting field for observa- 
tion and study, in respect of its causation and pathology. 
Its causation is of a twofold nature; that is, the hemorrhage may have 
an intrinsic and an extrinsic origin. It may arise from disease within the 
eye, as neuro-retinitis, retinitis, or glaucoma, and is then said to be intrinsic 
in its origin ; or it may originate in cardiac disease, chronic renal disease, 
or general disease of the vascular walls throughout the body. We oc- 
casionally meet with retinal hemorrhage in that obscure class of cases 
which we group under the head of the hemorrhagic diathesis, where there 
does not seem to be any particular disease of the vessels, and yet the 
patients suffer loss of blood from repeated hemorrhages from the mucous 
membranes and occasionally from the cutaneous surface. A sudden hemor- 
rhage into the retina or vitreous humor, from the rupture of aTetinal or 
choroidal vessel, may arise from some disease of the heart, or from au 
atheromatous condition of the coats of the vessels, or from chronic disease 
of the kidneys, and also, though rarely, from suppressed menstruation. 
When the hemorrhagic diathesis seems to be the predisposing cause, it 
almost always occurs in young persons, and there are generally multiple 
extravasations in the retina and vitreous humor. By the aid of the oph- 
thalmoscope we can distinguish three varieties of hemorrhage, and some 
authorities say four. The first variety consists of small round spots or 
points, circumscribed or scattered over the whole fundus, though generally 
in the neighbourhood of a vessel. Secondly, we meet with longitudinal 
streaks or bands, and these are in the nerve-fibre layer. Thirdly, there 
occur larger, irregular masses, situated always near the large veins. The 2 
fourth variety is a complete suffusion of the retina, a continuous extrava- 
sation of blood. These hemorrhages may be confined entirely to the 
retina, and this is usually the case; but it is by no means rare to meet 
with patients who complain of having lost their sight suddenly, and on 
examining the eye with the ophthalmoscope we get no reflex, and find the 
whole vitreous humor infiltrated with blood. It does not necessarily 
follow that this is the worst form of the disease, for the blood is generally 
absorbed, and some amount of vision at least restored. But in such ex- 
tensive extravasations the blood generally comes from a ruptured choroidal 
vessel, showing that the trouble is not confined to the retina, but involves 
also the vascular tissue of the eye. Where the source of the hemorrhage 
is a retinal vessel, the extravasation always seems to show a greater 
tendency to extend outwards to the choroid than inwards towards the 
vitreous humor. 
Apoplexy of the retina, having once occurred, shows a great tendency 
to recur, and where the recurrences are frequent, they may increase 
markedly the intraocular tension and give rise to hemorrhagic glaucoma. 
As an independent lesion, without any accompanying lesion of the tissue 
of the retina, apoplexy of the retina rarely occurs except in advanced life, 
most frequently after the fiftieth year, though it may accompany any form 
of retinitis at any age. Occasionally, though very rarely, it occurs coiuci- 
dently with purpura hemorrhagica. 
M. Rue, in the “ Union Medicale” for 1870, cites a case of retinal 
hemorrhage accompanying an attack of purpura hemorrhagica in a 
labourer, fifty years of age, who was an excessive drinker. Besides 
numerous spots of purpura upon the skin and mucous membrane of the 
mouth, the man had hematemesis, bloody stools, and numerous large 
hemorrhages into the retina, with marked disturbance of vision. In the 
right eye there was a hemorrhage into the macula lutea. Eight days 
later the spots of extravasation were darker, and in some there appeared 
small white spots. There was no albuminuria. The autopsy did not 
show any special changes in the organs, except the hemorrhages, and 
there was no change in the bloodvessels, as shown by the microscope. 
Some of the hemorrhages were in the choroid. There were some few 
fat granules in the tissue of the retina, but none in the walls of the 
vessels. 
When these hemorrhages occur without any inflammatory action in the 
retina, they must be regarded as a sign of an anomalous state of the cir- 
culation, and an unfavourable prognosis is to be given. 
Retinal apoplexy is ordinarily accompanied by a slight serous transuda- 
tion into the tissue of the retina, which gives the latter an oedematous ap- 
pearance. The prognosis is always more or less unfavourable, not so 
much on account of possible injury to the vision, as on account of its 
being a symptom of profound trouble elsewhere. 
It often occurs simultaneously with lesion of the heart, and advanced 
general atheromatous degeneration of the walls of the bloodvessels, which 3 
two morbid conditions are frequently the source of grave cerebral affections. 
The prognosis becomes still more unfavourable if it is a second or third 
attack. 
When the retina itself is inflamed, then the walls of the vessels are in- 
volved. The extravasations in a retinitis are usually slight, but often 
very numerous. They are generally situated in the inner layers of the 
retina, but under the pressure of the blood they not uufrequently press 
into the meshes of its connective tissue framework. In this situation they 
appear columnar in shape, but near the papilla they are elongated. The 
frequent occurrence of extravasations in inflammation of the retina finds 
another cause in the swelling of the optic disk, from the nerve being in- 
volved, and the consequent venous congestion. Stellwag tells us that 
retinal hemorrhages occur not uncommonly in old people, particularly in 
those having a tendency to capillary hemorrhage of the brain. It is 
generally conceded that hypertrophy of the left ventricle of the heart in- 
creases the tendency to these hemorrhages. 
And now, what are the subjective symptoms of a retinal apoplexy ? 
Sometimes, though not very often, the patient may have some premonitory 
warnings of a faulty circulation, particularly if he is advanced in years. 
There may be attacks of vertigo and amblyopia, transient in duration, but 
recurring. But usually the hemorrhage occurs suddenly, and this is one 
of the most characteristic symptoms. The patient may wake in the 
morning and find that he is blind in one or both eyes, though usually the 
disease is confined to one eye, at least in the beginning. It may occur 
while he is pursuing his ordinary avocations, appearing as a dark red or 
black spot or ball before the eye, which rapidly extends and obscures the 
entire field of vision. Of course the impairment of sight produced by the 
hemorrhage depends on the extent of the effusion and its locality. There 
may be a single large clot, or a number of small ones. If the clot is a 
large one, the hyaloid membrane is usually ruptured, and the vitreous 
humor becomes filled with blood, and this is generally the case when the 
extravasation comes from a choroidal vessel. 
Whether constitutional syphilis exerts any predisposition to retinal 
hemorrhage is by no means certain. Though inflammation of the retina 
is a not uncommon symptom in general syphilis, hemorrhages in this 
form of retinitis are not often seen, and though some authorities assert 
that syphilitic patients are very predisposed to what is usually called 
“ retinitis apoplectica,” their assertions are not sufficiently fortified by 
actual cases to be of very great value. The form of retinitis observed in 
constitutional syphilis is not usually of the exudative variety. The retina 
is swollen and oedematous and soon loses its transparency, but there is 
rarely anything more than a serous exudation. In a published account of 
clinical observations made at Wiesbaden for the years 1863 to 1866, Dr. 
Mandelstamm reports that among nine cases of syphilitic retinitis, there 4 
were four of them accompanied by hemorrhagic extravasations, thus 
proving the assertion of some observers to be wrong, that apoplexy of the 
retina never occurs in syphilitic retinitis. 
Retinal hemorrhages occur by far more frequently in men than in women, 
and also much oftener in patients over fifty years of age than under it. 
In the same report of Dr. Mandelstamm, just quoted, out of 26 cases of 
retinal apoplexy, 22 occurred in patients from fifty to eighty years of age, 
and 24 of the 26 cases were in men. Dr. Mandelstamm calls particular 
attention to the fact that the hemorrhages most frequently occurred in 
persons between seventy and eighty years of age, and thinks it by no means 
hypothetical to conclude that they are caused by atheromatous changes in 
the walls of the bloodvessels. In a report of the same institution at 
Wiesbaden for the years 1861 and 1862, Dr. Pagenstecher reports 19 cases 
of retinal apoplexy in two years, and calls attention to the fact that in 
many of these cases the amount of functional disturbance was compara- 
tively slight, and by no means commensurate with the pathological 
changes as seen with the ophthalmoscope. 
One of the cases was a robust man, thirty-three years of age, who had 
extensive hemorrhagic extravasations all over the surface of the retina, 
except at the macula lutea, and yet he read Jaeger No. 4 type, and had a 
normal field of vision. Five months later the hemorrhages were all ab- 
sorbed and the patient read Jaeger No. 1 type. In this case there was no 
organic affection diagnosticated. 
The connection of retinal hemorrhage with lesions of the brain, heart, 
and kidneys is one of very great interest, and at the same time is still some- 
what obscure. Perhaps the greatest doubt has been thrown upon the 
statements of some writers, that the hemorrhages into the retina occurring 
in elderly people are to be regarded as a premonitory or precursory sign 
of cerebral apoplexy. Of course, the only way to confirm the statement 
is to tabulate a sufficient number of casgs in which extravasations into the 
retina have been followed at a varying interval by cerebral hemorrhage. 
This has not been done, and from the nature of things would be difficult 
of accomplishment. As a rule, we are unable to keep our patients under 
observation for any great length of time; yet, with some care I am con- 
vinced we might, in time, collect some valuable statistics on this point. 
I have seen three cases in which retinal apoplexy was followed by cerebral 
apoplexy, and I have now under observation a fourth case, which I expect 
will follow the same course. The history of these cases will be given sub- 
sequently in detail. Dr. Allbutt, in his valuable work on the ophthalmo- 
scope, says that in cases of large cerebral hemorrhage, where there has been 
retinal disease and chronic disease of the kidneys, there were usually seen 
small hemorrhagic extravasations about the optic disks, but considers that 
these may occur in patients without the danger of an attack of cerebral 
hemorrhage, and even when the patients do not complain of their vision. 5 
Hemorrhage into the retina has been recorded in a number of cases of 
encephalic apoplexy, but Dr. Allbutt is not disposed to think that any 
pressure upon the recurrent vessels could cause a rupture of the retinal 
vessels unless they were diseased. But we know as an established fact 
that in all cases of cerebral apoplexy occurring in old people, there is 
always atheromatous degeneration of the walls of the vessels generally 
throughout the body, and of course the retinal vessels do not escape. 
Dr. Berthold, in the Klinische Monatsblatter fur AugenheilJcunde for 
April, 1870, relates a case of a woman, between thirty-five and forty years 
of age, who came to him with the complaint of sudden loss of vision in 
the right eye, and on examination with the ophthalmoscope he found a 
hemorrhage into the macula lutea. As he was on the point of dropping 
in some atropia to dilate the pupil, so that he might examine the whole 
fundus more carefully, she suddenly complained of feeling unwell, fell back, 
and died in three-quarters of an hour with all the signs of cerebral apoplexy. 
Unfortunately there was no autopsy. Dr. Heymann, in the year 1864, in 
the same journal, relates a case of retinal apoplexy occurring two months 
after the vision commenced to fail; the hemorrhages were situated near 
the optic disk, were from the veins, and rapidly increased in size and 
number. One month after their first appearance came the first attack of 
unconsciousness and paralysis. Before this the eye had given signs of 
neuritis and progressive atrophy of the optic nerve fibres. The hemor- 
rhages occurred in both eyes to about the same extent. 
There were probably in this last case cerebral lesions at the base of the 
brain near the left ventricle. The first ophthalmoscopic sign visible was 
the engorgement of the retinal veins, due to some hindrance to the flow 
of venous blood. Subsequently the pressure became greater, as was proved 
by a double sign, narrowing of the arterial calibre and rupture of the veins. 
Then came the sclerosis of the connective tissue of the nerve and retina, 
and finally the signs of apoplexy. 
Dr. Reynolds considers that clots in the retina are to be regarded as 
warning symptoms of a cerebral lesion, and after the age of forty, they 
point at least frequently to the danger of the patient dying of cerebral 
hemorrhage. Dr. Tanner also considers them as warnings of cerebral 
lesions, classing them with the sudden transient attacks of blindness and 
diplopia which are met with. Dr. Hammond says, in speaking of cerebral 
hemorrhage, that defects of sight may occur, usually characterized by the 
presence of dark spots in the axis of vision. These are due to minute 
extravasations of blood into the retina, and are always of most serious 
importance. He says he has known retinal hemorrhages to precede by 
more than a year the occurrence of a more severe lesion. 
Dr. Colsman, of Barmen, has reported a number of cases of retinal 
hemorrhage in the Berliner Klinische Wochenschrift for February, 1870, 
some of which were followed by cerebral apoplexy. He draws particular 
attention to the fact that the retina is peculiarly liable to disturbances in 
its circulation, owing to its anatomical connections and anastomoses with 6 
the vessels of the cranial cavity and jugular veins. This may either result 
in anaemia from hindrance to the arterial current, or in congestive hyper- 
aemia due to pressure on the venous circulation from some cause within 
or without the cranium. Instances of the latter condition are by no means 
rare, such as swelling of the tissue of the optic nerve and retina from the 
pressure caused by tumours within the cranium or orbit, giving us the 
“ stauungs-papille” of Yon Graefe, in which hemorrhagic extravasations 
into the retina are very common. Dr. Colsman considers that in a general 
fatty .or atheromatous degeneration of the vessels, retinal hemorrhages are 
to be regarded as preceding or accompanying cerebral apoplexy. In those 
cases where there is no perceptible disease of the arteries, he thinks that 
an increased blood pressure in the cranial veins from whatever cause, is 
readily propagated to the retinal veins owing to the rich anastomosis of 
the ophthalmic vein with the cavernous sinus. We no doubt sometimes 
meet with cases in which there is apparently no cause for the retinal hemor- 
rhages, and these are just the ones which require most minute and care- 
ful scrutiny. A rigid examination will usually establish some etiological 
connection between the state of the retina and some other organ or tissue 
in the body. 
One of Dr. Colsman’s cases was a very corpulent woman, without any 
organic lesion, who had suffered from repeated attacks of retinal apoplexy. 
His ninth reported case was one of repeated hemorrhages into the retina 
in a woman, sixty-two years of age. There were a number of small, 
bandlike hemorrhages all over the retinae of both eyes, some recent, others 
which had undergone retrogressive metamorphosis. There was no other 
disease of the eyes, nor of any organ in the body which might cause these 
extravasations. The sight improved somewhat as the hemorrhages became 
absorbed, but the patient soon after died of cerebral apoplexy. His eleventh 
reported case occurred in a perfectly healthy man, forty-two years of age, 
who complained of periodically recurring and transient redness of the 
conjunctiva and dimness of vision of one eye. There was oedema of the 
retina and papilla of this eye and some delicate hemorrhages. The patient 
complained of severe headache, particularly after any bodily exertion. 
About three months later he died suddenly from cerebral apoplexy. All 
these symptoms pointed to an abnormal state of the cerebral circulation. 
The following four cases were under the writer’s own observation for a 
time, and as the various symptoms point to an intimate connection be- 
tween lesions of the retina and lesions of the brain, the histories will be 
given somewhat in detail :— 
Case I.—A. P., aged sixty-three, English, married, a book-keeper, 
applied to me in 1871 for an affection of the right eye, of some fourteen 
months’ standing. He complained of a suddenly occurring dimness of 
vision, coming on at irregular periods, lasting a varying length of time, 
though never more than a few hours, and always being more intense when 
it first appeared, and gradually growing better. He said he had always 
led an exceptionally temperate life, and was apparently in excellent health. 
On examining the eye there was nothing abnormal externally, but with the 
ophthalmoscope there were seen a number of small, punctate hemorrhages 7 
all over the retina, and some two or three upon the optic disk itself. 
There was no oedema of the retina, and no large extravasation anywhere. 
The retinal veins were perhaps a trifle engorged. The other eye was 
perfectly normal. His heart was examined and found healthy, as were 
also the liver and kidneys, the urine having been repeatedly examined and 
nothing abnormal found. A closer investigation showed disease of the 
radial and temporal arteries. The patient said that he frequently felt a 
fulness in the head after a meal or after stooping, but that the feeling 
soon passed off. Being sure of the connection between the repeated reti- 
nal lesions and the cerebral circulation, I cautioned the patient to lead a 
very quiet life, avoid all undue muscular and mental exertion, and report 
himself from time to time. He was seen three or four times and then 
disappeared, and on going to inquire about him, I was informed that he 
had died from cerebral apoplexy, following a recurrence of the dimness of 
vision. The death took place about eighteen months after the first ap- 
pearance of the retinal lesion. 
Case II.—R. H., aged fifty-four, Irish, married, a gardener, applied 
to me for a sudden loss of sight in the left eye, which had come on two 
days before, while working at his business. The patient was short and 
stout, of full habit, and had in former years been a hard drinker. He had 
suffered from vague rheumatic pains for years, but had never had any 
distinct attack of rheumatism. He said he had always considered himself 
a healthy man until this failure of his sight. On testing his vision, I 
found he could count fingers at about ten feet, and could just make out 
Snellen CC at three feet; the vision in the other eye was normal. With 
the ophthalmoscope there were seen three large hemorrhages in the retina, 
two in the course of the ascending vein, and one along the main branch 
of the descending vein. There was no oedema and no pulsation, and the 
other eye was normal. His heart was examined and found healthy, though 
it was beating much more rapidly than was normal, but this, he said, had 
been the case for years. The urine was repeatedly examined, but nothing 
could be found that pointed to renal disease. His arteries were slightly 
atheromatous, but not markedly so. The patient was seen from time to 
time, and occasionally some small fresh hemorrhages made their appear- 
ance in the retina. He died suddenly one night after running rapidly 
some distance, with all the signs of cerebral hemorrhage. 
Case III.—W. H. B., American, aged fifty-two, single, a lumberman, 
complained of a sudden attack of blindness in both eyes, which had come 
on about a month before. Since then the vision had improved somewhat, 
though it was still very dim. The patient had been a man of violent 
passions, a hard drinker, and, while in the army, had contracted a severe 
type of malarial fever in some of the swamps of the Southwest, from which 
he had never entirely recovered. The liver was considerably enlarged, 
occasionally painful, and he suffered habitually from dyspeptic symptoms. 
There was a loud, blowing murmur over the base of the heart, synchro- 
nous with the first sound. I could detect no disease of the kidneys, though 
there was occasionally some pain in the lumbar region. On examining his 
20 
eyes the vision was found reduced to and the ophthalmoscope showed 
numerous hemorrhages in the retina of variable size and shape, most of 
them undergoing retrogressive metamorphosis. The extravasations were 
so numerous as to give a general brownish colour to the whole fundus. The 
patient was told plainly the condition of affairs and the danger in which 8 
he stood, and was advised to return to his home in Wisconsin and lead a 
quiet life. This he promised to do, but I afterwards heard that he had 
become paralyzed, and died unconscious, probably from cerebral hemor- 
rhage. 
Case IV.—Mrs. T. C. S., aged sixty-four, applied to me in February 
of this year for a failure of vision which had come on suddenly in both 
eyes, and which had gradually grown worse. On examination, vision with 
10 20 
th» right eye was qq, and with the left With the ophthalmoscope 
there were seen numerous large hemorrhages in the right retina, and in- 
cipient cataract. The extravasations were all in the course of the large 
retinal veins. In the left eye there were not nearly so many clots, and 
they were smaller than in the right eye. There was also an incipient 
cataract in this eye. The patient is of very full habit, short and stout, 
with chronic valvular disease of the heart, and a marked arcus senilis. 
She also suffers from chronic cystic catarrh and a femoral hernia of the 
right side. The urine has been examined carefully, and neither albumen 
nor casts have been found. The patient is still under observation, but I 
expect to hear of her death by cerebral hemorrhage, which may occur at 
any time. 
It is a well-known fact that hemorrhage into the retina is a common 
accident in the advanced stages of chronic Bright’s disease. Dr. George 
Johnson, of King’s College Hospital, London, has advanced some inter- 
esting points explanatory of their causation, in the Medical Times and 
Gazette for July 2, 18T0. In this disease of the kidneys, he says, the 
muscular walls of the minute arteries in most of the tissues, are much 
hypertrophied, owing to long-continued overaction. Excessive contrac- 
tion of the minute systemic arteries impedes the onward movement of the 
blood, and calls for increased efforts on the part of the heart to carry on 
the circulation. Hence hypertrophy of the left ventricle. An obvious 
result of the struggle between the increased action of the heart and the 
increased arterial resistance is an increased strain and pressure on the 
arterial walls, and a consequent increased risk of hemorrhage from rup- 
ture of one or more minute arteries, such as we frequently meet with in a 
punctate cerebral hemorrhage. I)r.'Johnson has observed in cases of 
Bright’s disease with hypertrophy of the left ventricle, that, while as a 
rule the minute arteries in all the tissues have their muscular walls hy- 
pertrophied, the hypertrophy of the arteries of different tissues in the 
same subject is sometimes unequal. May not the hemorrhages into the 
retina and brain, that we meet with in these cases, be due to the fact that 
the increased propelling force of the hypertrophied left ventricle was not 
counterbalanced by an equivalent hypertrophy, and consequent resisting 
power in the minute cerebral and retinal vessels ? Of course we must 
depend upon the microscope for solving the question whether the retinal 
vessels are hypertrophied or not, in cases of chronic Bright’s disease, and, 
unfortunately, we are not very often able to get possession of the eyes of 
patients who have died from chronic renal disease. I was fortunate 9 
enough, during the past summer, to follow up a case of retinitis albumi- 
nurica with hemorrhages, which I had seen in consultation. I was present 
at the autopsy, and got possession of one kidney, the heart, and one eye. 
A careful microscopic examination showed a very marked hypertrophy of 
the renal capillaries and small vessels of the heart, but the retinal and 
choroidal vessels were not much hypertrophied, though their walls were 
somewhat thicker than normal. This one case seems to go to support Dr. 
Johnson’s views, but we need more cases. The situation of the hemor- 
rhages in the retina which accompany retinitis albuminurica is somewhat 
different from the situation of retinal clots occurring in other forms of 
retinitis, though not always so ; at least this is the conclusion I have 
drawn from my observations. We must recollect that in the class of cases 
now under consideration there is a pathological process going on in the 
eye, which if not always a strictly inflammatory one, yet always induces 
permanent destructive changes in the retina. We may say that there is 
always an inflammation of the retina present, the morbid process at first 
going on in the inner layers of the retina, anterior to and also involving 
the retinal vessels. There is always a degeneration of these vessels, and 
very soon the engorged and tortuous vessels rupture and extravasations of 
blood occur, partly in the form of fine, radiating streaks between the 
bundles of nerve fibres, partly in the form of larger oval or circular spots 
rendering it very difficult to recognize the smaller vessels. I have observed 
almost invariably that these hemorrhages occur around the posterior pole 
of the eye, or rather round the entrance of the optic nerve, and between 
the disk and the macula. They seem, as a rule, to have the form of the 
spokes of a wheel, radiating from the optic papilla as a centre. They 
occur most frequently in the advanced stages of the morbid process of the 
retina, after the outline of the papilla has become obscured, and the disk has 
become surrounded by a wall of brawny infiltration. On this wall small 
hemorrhages occur very frequently. There does not appear to be any par- 
ticular period in the course of the renal disease at which these hemorrhages 
occur, though we are far more likely to meet with them at the period when 
the excretion of urine is more and more interfered with, consequent upon 
the atrophy of the renal tissue. Here the general circulation becomes 
more and more impeded, and the tension of the vascular system, augmented 
by the increased action of the hypertrophied ventricle, finally reaches a 
point where rupture ensues and extravasations occur. The blood does not 
always come from the larger vessels, though it sometimes does. Hulke 
says that he does not recollect an instance among the cases which he sub- 
mitted to microscopic examination, in which the hemorrhage came from 
the larger vessels ; it was always from the capillaries. The hemorrhages 
are usually in the inner layers of the retina, next the vitreous humor, 
though sometimes they infiltrate the whole thickness of the retina, and are 
even met with between the choroid and retina. In the case mentioned 10 
above, in which I was fortunate enough to obtain the eye for examination, 
the extravasations in the retina were all in the nerve fibre and internal 
granule layers, but there were two or three clots in the swollen tissue of 
the optic disk, and quite a large one in the tissue of the nerve itself, just 
in the region of the lamina cribrosa. In this case the extravasations came 
from both large vessels and capillaries. Another point which I have ob- 
served in cases of retinitis albuminurica, is that retinal hemorrhages scarcely 
ever occur unless there is at the same time organic disease of the heart. 
They do occur sometimes where there is no cardiac complication, but this 
is not often the case. During the past three years I have had the oppor- 
tunity of observing eighteen cases of retinitis associated with renal disease, 
and from these cases I have drawn the above conclusion. 
The first case was a man, 30 years of age, who had all the symptoms of 
chronic Bright’s disease, with affected vision in both eyes. The ophthal- 
moscope showed infiltration of the retina at the macula lutea, round the 
optic nerve, and between the nerve and the macula, and at the periphery 
near the ora serrata, there were patches of choroidal atrophy. Between 
the nerve and the macula in each eye were a number of longitudinal 
hemorrhages, always more superficial to the peculiar yellowish-white, 
glistening exudations. This man had hypertrophy of the left ventricle of 
the heart, with chronic valvular disease. He had moderate oedema of 
the face and extremities, frequent attacks of uraemic amblyopia, and marked 
dyspnoea. The urine contained albumen and fatty casts. 
Case second was a man, 32 years of age, who had, when first seen, the 
peculiar stellate exudation round the macula and a brawny infiltration of 
the optic papilla, with a few small thread-like hemorrhages round the 
nerve entrance and upon the disk. Three weeks later he complained of 
being entirely blind in the left eye, and on examining him with the 
ophthalmoscope, the whole vitreous humor was found opaque, probably 
from a large hemorrhage, which completely concealed the fundus. This 
man had a tremendous rough, blowing sound at the apex of the heart, 
synchronous with the first sound, with marked hypertrophy. His urine 
contained albumen and granular casts. 
Case third was a woman, 60 years of age, with oedema of the legs and 
feet, marked ascites, pale waxy complexion, and some dyspnoea. There 
was a mitral regurgitant murmur, hypertrophy of the heart, and constant 
palpitation. The retinae of both eyes were strewn with hemorrhages, but 
there was very little exudation into the tissue of the retina. The urine 
contained albumen, but no casts. 
Case fourth was a man, 23 years of age, and was an exceptional one, 
in that, though the retinal hemorrhages were very abundant, and the renal 
symptoms most marked, he had no cardiac lesion. 
Case fifth was a man, 55 years of age, in whom the hemorrhages were 
confined to the right eye, though both retinae were involved in the fatty 
degeneration. He had both valvular disease and hypertrophy of the heart. 
The urine contained albumen and casts. 
Case sixth was a man, 43 years of age, with hemorrhage in both eyes, 
fatty degeneration of the retinae, and hypertrophy of the heart, but no 
valvular lesion. He had uraemic convulsions, and his urine was loaded 
with albumen and casts. 11 
Case seventh was a boy, aged 15 years, with fatty infiltration of the 
retina in each eye, but no hemorrhages. He had no heart disease, and 
no very pronounced signs of chronic renal disorder except frequent mic- 
turition, though there was a history of convulsions and his urine contained 
albumen. 
Case eighth was a woman, 18 years of age, with very marked retinitis 
albuminurica in both eyes, but no hemorrhages. She had no cardiac 
disease, but a great deal of general anasarca. Urine albuminous. 
Case ninth was also a woman, 19 years of age, with retinitis albuminu- 
rica in both eyes, though most developed in the right eye, but there were 
a large number of hemorrhages on and around the optic papilla. She 
had had acute articular rheumatism three years before, and had both 
valvular disease and hypertrophy of the heart. The urine contained neither 
albumen nor casts. 
Case tenth was a man, 23 years of age, with retinitis albuminurica but 
no hemorrhages. There was no cardiac disease, but the liver was very 
much enlarged, and there was considerable abdominal dropsy. The urine 
contained albumen, but no casts. 
Case eleventh was a woman, 35 years of age, with retinitis nephritica, 
and enormous hemorrhages in both retinae. There was chronic valvular 
disease of the heart and some hypertrophy. The urine was albuminous, 
but contained no casts. 
Case twelfth was also a woman, 47 years of age, with hemorrhages in 
each eye, punctate in character, and a general cedematous appearance of 
the retinas. She had both hypertrophy and valvular disease of the heart. 
The urine contained albumen and casts. 
Case thirteenth was a woman, 25 years of age, with typical retinitis 
albuminurica, but no hemorrhages, and this patient had no cardiac com- 
plication. 
Case fourteenth was a woman, 50 years of age, with incipient cataract 
and posterior staphyloma in the left eye, and retinitis nephritica with 
many hemorrhages in the right eye. She had chronic valvular disease and 
hypertrophy of the heart. 
Case fifteenth was a woman, 43 years of age, with both eyes affected by 
the peculiar exudation accompanying chronic Bright’s disease, and numer- 
ous small hemorrhages in both eyes. Chronic valvular disease and very 
marked hypertrophy of the heart. Urine loaded with albumen and casts. 
Case sixteenth was a woman, 20 years of age, who had for several 
months suffered from general anasarca and occasional convulsions, epilepti- 
form in character. There was no history of rheumatism, and on examin- 
ing her chest no cardiac disease was detected. Her urine was nearly half 
solid with albumen, and contained casts of all kinds. With the ophthal- 
moscope the retina of each eye was seen to be the seat of the peculiar 
changes accompanying Bright’s disease, but there were no hemorrhages. 
This case I had an opportunity of observing from time to time for more 
than a year, and at no time was there any extravasation of blood seen. 
Case seventeenth was a woman, 25 years of age, in whom the renal 
trouble was consequent upon a gravid uterus. It was her first pregnancy, 
and during the sixth month she had some swelling of the feet and ankles, 
and shortly afterwards a series of convulsions, which lasted till evening, 
when she aborted. Immediately after this her eyesight began to fail, and 
she complained of dyspnoea and palpitation. On examining her eyes, I 
saw a neuro-retinitis in both, with enormous exudation into the disk aud 12 
retina and upon the disk two considerable hemorrhages in the left eye, and 
a number of smaller ones in the rigiit eye. An examination of the chest 
revealed hypertrophy and valvular disease of the heart. A few days later, 
an examination showed several fresh hemorrhages from the horizontal 
vessels in both eyes. This patient afterwards died from what was prob- 
ably cerebral hemorrhage, as she was paralyzed on the left side and died 
comatose. 
Case eighteenth was one of monocular retinitis albuminurica in a woman, 
39 years of age. In the right eye there was a general haziness of the 
fundus, and the veins were engorged and tortuous. In the left eye, below 
and between the nerve and the macula, was a yellowish mass of exudation 
in the deeper layers of the retina, from which radiated streaks or lines of 
the same colour. Just above the main mass of exudation were several 
hemorrhagic spots of varying size, and one or two small, punctate extra- 
vasations upon the optic disk. This woman had both hypertrophy and 
valvular disease of the heart, and her uriue contained both albumen and 
casts. 
In going over these eighteen cases hastily, we see that in eleven cases of 
retinal hemorrhage there was valvular disease and hypertrophy of the 
heart. In one case of hemorrhage, there was hypertrophy of the heart, 
but no valvular disease. In five cases there were no hemorrhages in the 
retina, and no cardiac disease of any kind. And finally in only one case 
was there retinal hemorrhage without at the same time cardiac lesion. 
These results, though taken from a small number of cases, seem to bear 
out the opinion already expressed, that retinal hemorrhages rarely accom- 
pany retinitis albuminurica, unless the renal disease is complicated by dis- 
ease of the heart. 
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