frequently associated with the menopause. The writer recalls a case
where for years there was headache with intense congestion of the
palpebral and bulbar conjunctiva, with a fulness and pressure on the
orbits at each menstrual period, all these symptoms disappearing with
the cessation of the menses. The most striking examples of the
influence of the menses on the eyesight are those where the flow has
been suddenly checked. Rejecting examples from the older authors, where
the want of exact helps to diagnosis might leave room for a different
interpretation of the symptoms, we will content ourselves with two
examples where the testing of the eyesight and the ophthalmoscopic
examination were made by skilled observers. Thus, Mooren--to whom we
are indebted for a careful discussion of the relations between uterine
disease and disturbances of sight--recites[109] the case of a
peasant-woman aged twenty-three years who had complete stoppage of the
menstrual flow from exposure to wet during the catamenial period: this
was accompanied by high fever and delirium, with pain in the region of
the right ovary. When these symptoms subsided, she noticed that there
was absolute loss of sight in the right eye, and so great a diminution
of it on the left that she could only distinguish movements of the
hand. The ophthalmoscope showed in the right side a multiple detachment
of the retina, and on the left an intense neuro-retinitis. Rest in bed,
inunctions of mercurial ointment, and cataplasms over the region of the
ovaries, with leeches to the septum of the nose and the neck of the
uterus, gradually brought about amelioration of the symptoms, with
restoration of the eyesight in the left eye. As might be expected, the
retinal detachment and consequent loss of vision in the right eye
remained permanent. In confirmation of this case, but in contrast with
it as regards the retinal symptoms, is the one related by
Samelsohn.[110] The patient (a peasant-girl) by standing in a cold
running brook while at work had her menses suddenly stopped. There was
no marked uterine or abdominal pain. The patient complained of a
feeling of pressure on the orbits, and experienced a gradual failure of
sight with contraction of the field of vision. In five days there was
absolute amaurosis of both eyes (no sensation of light and no
phosphenes to be obtained by pressure). The sight gradually returned in
each eye, this being preceded by a copious flow of tears, so that in
sixteen days the patient could read small print fluently. In seven
weeks the menses returned. There were no ophthalmoscopic symptoms: each
eye, both during the attack and subsequent to it, showed only striation
of the retina and tortuosity of its veins, the calibre of the retinal
arteries being unchanged. Unfortunately, any pupillary changes that
might have been recognized were annihilated by previous instillation of
atropine into the eye. In the first case there was every probability in
favor of a serous effusion into the subarachnoidal and the intravaginal
spaces. The latter case is more difficult to explain: if it were due to
orbital or intracranial neuritis, why should there not have been some
ophthalmoscopic changes during the {757} time that the patient was
under observation? If to effusion within the cranium or to local
circulatory disturbances in either the corpora quadrigemina or the
occipital lobes, why were there not other symptoms of intracranial
disturbance?
[Footnote 109: _Arch. f. Augenheilkunde_, Bd. x., 1881.]
[Footnote 110: _Berliner klin. Wochenschrift_, Jan., 1878, pp. 27-30.]
In further illustration of the effects of a stoppage of menstruation,
Mooren[111] cites the case of a peasant-woman aged thirty-one who had
complete suppression of the menses after the birth of her fourth child,
and where subsequently an almost continuous headache, dimness of
vision, and eventually epileptiform attacks, followed. The
ophthalmoscope showed a double neuritis so intense as to lead to the
supposition of a possible cerebral tumor. Mercurial inunctions with
seton to the back of the neck were resorted to without result.
Emmenagogues also failed to give relief. An examination of the uterus
was now made, which showed great enlargement and hyperplasia,
especially of its mouth and neck, for which scarifications and
sitz-baths were employed with good result. The headache and epileptoid
attacks disappeared, and the vision improved so far that the patient
(who when admitted to the hospital could only decipher Jaeger No.
xviii.) could read fluently Jaeger No. iii.
[Footnote 111: _Loc. cit._, p. 551.]
DISPLACEMENTS OF THE UTERUS.--Anteflexion and retroversion of the
uterus are frequent causes of retinal hyperæsthesia. In this connection
we may quote from the same author two cases, as showing how slight
mechanical irritations of the uterus may cause eye disturbance--one
where a patient had an episcleritis and a chronic metritis with
malposition of the uterus, in whom there was an exacerbation of the
ciliary neuralgia and of the local eye inflammation every time that the
ulcerated os uteri was cauterized or a pessary introduced; and a second
with an adhesive kolpitis, in whom the introduction of a pessary caused
unpleasant feelings about the head and oppression in the cardiac
region, accompanied on two separate occasions by capillary hemorrhages
into the retina, all of these symptoms disappearing rapidly after the
removal of the pessary. Mooren[112] has also seen a double
neuro-retinitis caused by retroversion of the uterus. The sight was so
much impaired that the patient could with difficulty decipher Jr. No.
xx.; but it was entirely regained within a few months after the uterus
had been replaced in its proper position. No other treatment was
employed.
[Footnote 112: _Ophthalmologische Mittheilungen_, 1878, p. 97.]
PELVIC CELLULITIS.--Still more frequently are the reflex eye
disturbances caused by parametritis and the various forms of pelvic
cellulitis. Every practitioner has had abundant opportunity of studying
the easy fatigue of the eye, the burning and stinging conjunctival
sensations, the orbital and periorbital pains, the retinal
hyperæsthesia and sensitiveness to artificial light, which characterize
the early stages of the affection, accompanied later on by symptoms of
retinal anæsthesia. Inasmuch as the cause of these symptoms is
irremediable, we find in the majority of cases that it is impossible to
relieve the sufferings of the patient; this cause consisting in the
cicatricial shrinking of the parametrium and the pelvic connective
tissue. Sleep gives relief only so long as it lasts, and the patients
upon awakening, instead of feeling rested, often experience their
greatest pain and discomfort. Foerster[113] and Freund, who were the
first to demonstrate this {758} form of parametritis, call special
attention to the fact that the patients have their good and bad days
entirely independent of any use of the eyes. In many of the milder
cases, however, we find that the sufferings of the patients are
enhanced and aggravated by the presence of some defect, such as
astigmatism, hypermetropia, or insufficiency. Although the careful
correction of such defects will give considerable relief and enable the
patients to use their eyes for near work for a much longer period,
nevertheless the pain and discomfort are out of all proportion to the
amount of error. Of course, we are very far from having converted such
eyes into useful instruments for every-day work or for long-continued
labor, but we have removed an appreciable source of irritation from an
oversensitive nervous system, and done much to relieve the toedium vitæ
in cases which perhaps for months previously have been unable to amuse
or occupy themselves by the use of their eyes in either reading,
writing, or sewing.
[Footnote 113: "Allgemein-Leiden und Veränderungen des Sehorgans," in
_Graefe und Saemisch_, vol. vii. pp. 88-96.]
MASTURBATION is also an occasional cause of reflex eye disturbances.
Mooren[114] relates two aggravated cases in women who for years had
been excessively addicted to the vice. In both of these there were
accommodative asthenopia and tenderness in the ciliary region, dread
even of moderate illumination, which increased from year to year. In
both cases there were attacks of dyspnoea and other disturbance of
innervation of the pneumogastric nerve. Cohn has also published a
number of cases of eye disease in the male sex due to the same cause.
The main symptoms were a feeling of pressure on the eyes, bright dots
moving before them, and a sensation as if the air between the patient
and the object looked at was wavy and trembling. In some of the
individuals a discontinuance of onanism and a moderate indulgence in
sexual intercourse effected a complete cure. Travers[115] gives a case
of loss of sight from excessive venery, and another from masturbation.
Mackenzie[116] quotes Dupuytren as relating the case of a man who lost
his sight on the day after his wedding, but where it was promptly
restored by the use of a cold bath with stimulants and the application
of counter-irritation to the skin of the lumbar region. Foerster[117]
has recorded a case of kopiopia hysterica in a man where, from the eye
symptoms alone, he diagnosticated disease of the genital organs, and
where it was afterward proved that there was inability to copulate, the
patient having extremely small testicles and there being a thin
whey-like discharge from the urethra.
[Footnote 114: _Loc. cit._]
[Footnote 115: _Synopsis of Diseases of the Eye_, 1820, p. 145.]
[Footnote 116: _Diseases of the Eye_, 1854, p. 1075.]
[Footnote 117: _G. u. S. Handb._, vol. vii. p. 95.]
CONGESTION AND INFLAMMATION OF THE OVARIES.--Disease of the ovaries is
frequently associated with retinal oedema and hyperæsthesia. In women
complaining of weak and painful eyes pressure in the ovarian region
often causes pain. Where only one ovary is tender to the touch, we
often notice that the patient complains more of the corresponding eye,
although there may be no difference or abnormality in the
ophthalmoscopic appearance of the two eyes. Under this head may be
appropriately mentioned the eye symptoms of patients affected with
hystero-epilepsy, a disease which is always associated with ovarian
trouble, of which Charcot has given us so graphic a picture. He says
that previous to the attack the patient experiences an aura which
starts from the abdomen. The convulsion is ushered in by a loud cry,
which {759} is accompanied by pallor of the face and loss of
consciousness. These symptoms are succeeded by twitching and rigidity
of the face-muscles, with foaming at the mouth, followed by contortions
of the muscles of the trunk, abdomen, and lower limbs, the paroxysm
terminating with sobbing, weeping, and laughing. Landolt has given us a
careful description of the eye symptoms in such cases, and groups them
into four stages. In the first, the outer and inner tunics of the eye
appear healthy and the acuity of vision is normal, but there is a
contraction of the form- and color-folds, always more marked on the
affected side. In the second group the acuity of vision begins to fail,
and the symptoms become more marked on the hitherto sound side. In the
third with the more affected eye fingers can scarcely be counted, while
the field of vision is limited to a few degrees from the fixation
point; at this stage the ophthalmoscope shows a serous swelling of the
retina, with fulness and tortuosity of its veins. In the fourth stage
there is a partial atrophy of the optic nerve on both sides.
PREGNANCY.--Cases of amaurosis occurring during pregnancy, in which the
vision was impaired after delivery, are recorded by Beer,
Ramsbotham,[118] and other writers of the preophthalmoscopic period.
Some of them, at least, may probably be accounted for by the occurrence
of albuminuric retinitis in the puerperal state, but no such
interpretation can be put on the more recent cases reported by
Lawson[119] and Eastlake,[120] which in their main features strongly
recall the amaurosis after loss of blood, although there is no history
of any similar hemorrhages. In Lawson's case, we have an amaurosis
which commenced during the gestation of the eighth child, and recurred
during the ninth and tenth pregnancies. After the eighth labor the
patient recovered sufficient sight to be able to sew; the amount of
vision being gradually lessened after each gestation until finally
complete atrophy of the optic nerve ensued. In Eastlake's case, the
patient (æt. thirty-four) had borne nine children at full time. The
labors were normal in character, and the amount of blood lost was not
excessive. On the second or third days after the second and each
subsequent delivery, sudden loss of vision occurred, and the woman
became insensible. On recovering her consciousness, her sight did not
at once return, the amaurosis remaining from three to five weeks. After
the last labor there was complete and permanent loss of sight in both
eyes: Z. Laurence examined this case with the ophthalmoscope, and
reports only a slight contraction of the retinal arteries, without
other positive lesion. Zehender,[121] in treating of the subject,
remarks that "almost every busy eye-surgeon has encountered similar sad
cases."
[Footnote 118: _Med. Times and Gazette_, March 7, 1834.]
[Footnote 119: _R. L. O. Hos. Rep._, vol. iv. pp. 65, 66.]
[Footnote 120: _Obstet. Trans._, vol. v. p. 79 (1864).]
[Footnote 121: _Handbuch der Augenheilkunde_, vol. ii. p. 180.]
PUERPERAL PHLEBITIC OPHTHALMITIS.--According to Mackenzie, this dread
malady, which, as a rule, causes the death of the patient, may develop
at any time from the third to the thirtieth day after delivery. It
frequently attacks both eyes, and in those cases which do not terminate
fatally eyesight is usually lost. Hall and Higginsbottom,[122]
Mackenzie,[123] Fischer,[124] {760} Arlt,[125] and Hirschberg[126] have
all given good clinical descriptions of the disease, with careful
autopsies. As in other forms of metastasis, it is ushered in with a
chill. Soon after, transient darting pains are felt in the eye, which
are sometimes associated with photopsies and followed by serous
infiltration of the conjunctiva bulbi. Later, owing to effusion in the
capsule of Tenon and to the swelling of the orbital tissues, the eye
projects forward and its motility is impaired, these symptoms being
accompanied by a clouding of the cornea and the formation of pus in the
anterior chamber. If the patient lives, we may have either discharge of
pus through the cornea or sclera, or its gradual absorption: in either
case, the eyeball shrinks to a small stump. Anatomical examination
shows that the starting-point of these symptoms is a septic embolism of
either the choroidal or central retinal blood-vessels. According to
Hirschberg, "In other pyæmic affections in which the eye is attacked
with septic embolism life is dangerously threatened, but there is a
larger percentage of recovery with permanent blindness (single or
double) than in the puerperal form."
[Footnote 122: _Medico-Chirurgical Transactions_, 1829, vol. xv. p.
120.]
[Footnote 123: _Treatise on Diseases of the Eye_, London, 1854.]
[Footnote 124: _Lehrbuch der Entzündungen und Organischen Krankheiten
des Menschlichen Auges_, 1866, p. 285.]
[Footnote 125: _Die Krankheiten des Auges_, 1863, Bd. ii. pp. 167,
269.]
[Footnote 126: _Archives of Ophthalmology_, 1880, vol. ix. p. 177.]
Influence of Lactation.--The asthenopia, feeble accommodation,
photophobia, and obstinate phlyctenular inflammations of the
conjunctiva and cornea which occur during prolonged lactation are
subjects of daily observation to every ophthalmic surgeon. They
unfrequently fail to yield to appropriate remedies so long as the
patients continue to nurse their children. Besides these symptoms,
Critchett[127] has called attention to the sudden unilateral affection
of sight which occurs during lactation, and is due to hemorrhage
situated either in or behind the retina. This author has frequently
seen such cases coming on without pain.
[Footnote 127: _Medical Times and Gazette_, 1858, p. 118.]
PATHOLOGY.--As regards the pathology of these affections we are still
very much in the dark. Mooren in his elaborate paper (previously
quoted) considers that the reflex disturbances of the retina and optic
nerve may either be transmitted directly, or may cause primarily a
spinal myelitis, which in its turn affects the eyes. He points out that
the subperitoneal connective tissue of the pelvis and the uterus is so
rich in blood-vessels, lymphatics, and nerves that Rouget has likened
it to cavernous tissue. He asserts that the uterine and pelvic nerves
re-enter the lumbar cord, while the veins anastomose freely with the
veins of the spinal column; and quotes Röhrig to show that electric
stimulation of the ovary causes a rise in the general blood-pressure
and a diminution of the heart's action--effects which he attributes to
irritation of the vagus. He further maintains that any long-standing or
often-repeated congestion of the visual centres, of the optic nerve, or
of the retina would cause increase of connective tissue and a
subsequent tendency to contraction, while the lymph which is poured
out, acting on the cylinder axis of the nerves, causes them first to
swell, and finally to absorb (Rumpf,[128] Kuhnt[129]).
[Footnote 128: _Untersuchungen am d. Physiol. Institut. d. Univ.
Heidelberg_, Bd. ii. Heft 2.]
[Footnote 129: _Ueber Erkrankung der Sehnerven bei Gehirnleiden_,
1879.]
{761} Febrile and Post-febrile Ophthalmitis.
VARIOLA.--Various affections of the eye which at times impair its
functions, and at others destroy vision, frequently arise during the
course as well as during the subsidence of smallpox. When pocks form in
the skin of the eyelids, they cause the lids to swell to such an extent
as to completely close the eye: many patients so affected relate how,
after being blind for a week or ten days, they again recovered their
eyesight. The cicatricial processes which ensue often produce falling
of the eyelashes with incurvation of the tarsus, which changes the
direction of the ciliæ and causes the lashes to rub against the
eyeball. During the first stage of the disease there is always flushing
and congestion of the conjunctiva, frequently associated with increased
flow of tears and sensitiveness to strong light. In some cases we find
small elevated yellowish spots, often in groups of two or three,
surmounted by an area of vascularization on the edges of the lids and
in the tarsal conjunctiva. Similar efflorescences are at times seen in
the conjunctiva bulbi and on the limbus corneæ. These coincide in the
time of their appearance with the eruption on the skin, and are
probably of the same nature, although from the difference in the
anatomical structures they do not present the same appearance as the
pocks in the skin. Hebra, who has observed and analyzed twelve thousand
cases, says that 1 per cent. of the total number presented
efflorescences in the conjunctiva. Neumann, Knecht, Schely, Buck, and
other German authorities describe them; and Adler in his able monograph
(_On Eye Diseases during and after Variola_) gives an accurate account
of them. In opposition to the above statement it should be mentioned
that Gregory maintains that no mucous membranes except those of the
fauces, larynx, and trachea are capable of taking on variolous
inflammation. Marson[130] also, who from his position at the London
Smallpox Hospital had unusual opportunities for witnessing the disease,
maintains "that pustules never form on the conjunctiva;" Coccius[131]
is also of the same opinion. These authors call attention to the fact
that the well-known abscesses of the cornea which occur during the
drying and desquamation of the eruption, and which have frequently been
described as pocks by the older authors, cannot in any sense be
considered as pocks. Beer, however, while calling these formations
pocks, distinctly states[132] that they occur during the suppurative or
drying stage. There seems to be no good reason why the above-described
conjunctival efflorescences, which come on simultaneously with the
skin, should not be considered as analogous in their natures, although
from the absence of the corium in the conjunctiva they cannot assume
the well-known form of the skin eruption. At times the conjunctivitis
becomes catarrhal, and even purulent, leaving in some cases an acute
dacryo-cystitis (Adler), and more frequently a low grade of blenorrhoea
of the lachrymal duct. Beer states that "those authorities may be right
who suppose that there is a real eruption of pocks in the mucous
membrane of the tear-sac, because no other sort of inflammation of it
is so apt to cause complete closure in its entire length."[133] The
cornea may present either diffuse or interstitial keratitis. Malacia or
abscesses are more {762} frequent in the severe cases, where there are
evidences of metastases to other organs. They usually form in the outer
quadrant of the cornea, and are accompanied by marked ciliary
injection, the patients complaining of stitches in the ball with
frontal and temporal neuralgia. Prolapse of the iris and often the
formation of a staphyloma are produced by the perforation of resultant
ulcers; sometimes the entire cornea is swept away. Marson declares that
he has seen this last condition occur within forty-eight hours from the
time of the commencement of the corneal affection. Iritis is a less
frequent complication. It is of the seroplastic variety, and, according
to Adler, comes on only after the twelfth day and in cases where the
progress of the disease is slow and insidious. It is always accompanied
by some degree of cyclitis and by vitreous opacities. Four cases of
glaucoma are on record as occurring during variola; and one (that of
Adler) is noteworthy from the fact that the prodroma of glaucoma
coincided with those of the smallpox. It was successfully operated on,
notwithstanding the fact that the incision was made difficult by the
necessity of avoiding a pock on the limbus of the cornea. Fortunately,
the present generation has rarely an opportunity of seeing great
numbers of eye affections from smallpox, and when they do occur, the
partial protection from previous vaccination often modifies their
severity. In these days of antivaccination societies, it is interesting
to turn back to the accounts of the disease given by those who were in
active practice at the time of Jenner's great discovery, and to see how
serious the matter appeared when viewed through their spectacles. Thus,
Andreæ says, "No disease is so dangerous to the eyesight as the
smallpox, and before the introduction of vaccination it caused as much
blindness as all other eye inflammations put together."[134]
Benedict[135] also bears testimony to the great diminution in the
intensity of variolous ophthalmia after the introduction of
vaccination.
[Footnote 130: _London Med. Gazette_, 1838-39, pp. 204-207.]
[Footnote 131: _De Morbis Oculi humani que e Variolis exedi, etc._,
Leipzig, 1871.]
[Footnote 132: _Lehre von den Augenkrankheiten_, vol. i. p. 527.]
[Footnote 133: _Op. cit._, p. 525.]
[Footnote 134: August Andreæ, _Grundriss der Gesammten Augenheilkunde_,
vol. ii. p. 260.]
[Footnote 135: P. W. G. Benedict, _De Morbis Oculi humani
inflammatorii_, lib. iii. p. 367.]
Writing later, Himly[136] says: "Smallpox, formerly a rich source of
all eye diseases by which the doctor was most busied, is at present
only feebly represented by the varioloids (_i.e._ smallpox modified by
cowpox)." Mackenzie[137] states that "in former times smallpox proved
but too often the cause of serious injury to the eyes, and even of
entire loss of sight. It was by far the most frequent cause of partial
and total staphyloma." Dumont in his work on blindness, the result of
his own observations at the Hospice des Quinze-Vingts at Paris, and
from its extensive statistics in previous years, records that out of a
total of 2056 blind, 262 were blind from variola (or 12.64 per cent.);
and, further, that the old records of the hospice showed 17.9 per
cent., whilst at present (1856) it was 12 per cent. amongst the older
inmates, and but 7 per cent. amongst the more recently admitted. He
quotes Carron du Villars as giving the ratio before Jenner at 35 per
cent. From immunity we become careless, so that when an epidemic breaks
out (as that in Mayence in 1871) we have a state of suffering which
forcibly brings back our remembrance of old times. Thus, Manz asserts
that "the pestilences of the last (Franco-German) war have revived the
remembrance of a disease which in the {763} beginning of this century
was a terror to humanity, but which in the last decade was so rare that
many now living physicians know it only by the writings of the older
authors: the late epidemics, however, have enlarged their experience,
and added a new contingent to the almost extinct army of the
smallpox-scarred blind."[138]
[Footnote 136: _Krankheiten u. Missbildungen des Auges_, Berlin, 1843,
p. 481.]
[Footnote 137: _Diseases of the Eye_, p. 500.]
[Footnote 138: _Jahresbericht f. Ophth._, 1873, pp. 178-183.]