Chapter XLVI: Introduction: The object of the following essay is to give, as far as (2)

DISEASES OF THE KIDNEYS.--As has been abundantly proved by careful autopsies, inflammation of the retina may be developed during any form of _Bright's disease_, either with the enlarged mottled kidney of acute parenchymatous nephritis, the large white kidney, the amyloid kidney, or the cirrhotic kidney of chronic disease. In the vast majority of cases the retinal inflammation appears during the later stages of the last-named form of disease, and seems to be in some way dependent upon blood-poisoning, which has been caused by the degenerating kidney.

The retinitis presents various aspects, not only in different cases, but also in the different stages of its development in the same case, and distinguishes itself mainly from other forms of inflammation of the retina by its marked tendency to fatty degeneration. As seen at an eye hospital the disease usually presents a type quite different to that which predominates in the wards of a general hospital. In the former class of cases the blood-poisoning seems to fall with peculiar intensity on the nervous system, and the patients come complaining of headache, dizziness, and dim vision, these being the only marked symptoms of the malady, while the anæmia, dropsy, and other symptoms are either absent or present in so slight a degree that the patients have not supposed themselves to be suffering from any constitutional malady or to need any medical advice. In the walking cases the retinal changes are usually very extensive (and those in the cerebrum would possibly be found equally developed if we {753} had only as accurate a method of investigating them), whilst among hospital inmates we often see only a few white splotches in the retina, either with or without hemorrhages, and occasionally only a slight atrophy of the optic disc due to a previous retinitis. In the wards of a general hospital we have a much better opportunity to study the early development of the retinitis, and it is there most frequently encountered among those suffering from dropsy and dyspnoea--patients whose waxy skin and general appearance indicate at a glance how seriously their nutrition has been impaired by the ravages of the disease. When the individual lives and is not markedly relieved by the rest and treatment adopted, we frequently have an opportunity of seeing the development to a greater or less degree of the typical form of the affection.

In typical cases the retinal changes commence with slight oedema of the disc and surrounding retina, associated with a few irregular white splotches and striated hemorrhages in the fibre-layer. These white patches multiply and extend, but are usually confined within an area of two or three disc-diameters from the optic entrance. In high grades of the affection they coalesce and form a broad zone around the disc, which is itself swollen and prominent, its outlines being hidden by the opaque nerve-fibres which diverge from it. From time to time fresh hemorrhages occur, which are striated when in the fibre-layer, and of irregularly rounded outline when they invade the deeper portions of the retina. These were formerly supposed to be absolutely characteristic of the disease, but it is now asserted by several good observers that similar appearances have been seen in the neuro-retinitis caused by brain tumor or by basilar meningitis where there was no accompanying disease of the kidney. Graefe,[99] Schmidt and Wegner,[100] Magnus,[101] Leber,[102] Carter,[103] and Eales[104] have each reported such cases. The hemorrhages are usually either entirely absorbed or leave behind them a fatty clot, which adds an additional white patch to the splotches already existing in the retina. In many cases occurring in the last stages of the disease, a remarkably yellowish tint of the fundus is observed, together with decided alteration in the color of the blood-columns in the retinal blood-vessels, the blood in the arteries being too yellow, and that in the veins presenting too little of its usually pronounced red-purple tint. In short, there is a state of affairs approximating in some degree to that which we find in cases of pernicious anæmia.

[Footnote 99: _A f. O._, xii. 2.]

[Footnote 100: _Ibid._, xv. 3.]

[Footnote 101: _Ophth. Atlas_, Taf. vi. Fig. 2.]

[Footnote 102: _Graefe und Saemisch_, Bd. v. p. 581.]

[Footnote 103: _Diseases of the Eye_ (Am. ed.), p. 382.]

[Footnote 104: H. Eales, _Birmingham Med. Review_, Jan., 1880, p. 47.]

Exceptional forms of albuminuric retinitis have been recorded where the only change seen in the fundus oculi was a pronounced choking of the disc similar to that with which we are familiar in cases of brain tumor. The writer has seen cases which at the start could not be diagnosticated by the ophthalmoscope from cases of retinal hemorrhage due to other causes. Magnus has published similar cases.

In the course of Bright's disease uræmic amaurosis is much more rarely encountered than albuminuric retinitis. It is, however, occasionally developed in cases in which albuminuric retinitis already exists. It is rapid in its development, and in its subsidence is without retinal changes, the blindness being evidently due to some transient affection of the cerebral centres.

{754} DISEASES OF THE SKIN.--The _eczema_ of the lower lid, nose, angle of the mouth, and external meatus of the ear which so frequently accompanies the phlyctenular conjunctivitis of scrofulous children is probably the most common example of coincident skin and eye disease. Lepra is a frequent cause of severe affections of the eye in localities where it is endemic. Bull and Hansen[105] assert that the cornea is frequently attacked. They divide the manifestations of the disease upon this membrane into two varieties--the one in which there is a diffuse infiltration of the tissue, and the other where there is a formation of tubers. The first variety is a gray opacity limited to the border of the cornea, not separated from its circumference by any such clear area as is found in arcus senilis. This opacity becomes vascularized, and may remain quiet for years till another attack of hyperæmia occurs, which, also in time receding, leaves the tissue more opaque than before. In the second there are nodes which appear to start at the margin of the cornea and to accompany either its superficial or its deep layer of vessel-loops: this latter form is more dangerous to vision. The paralysis of the orbicularis muscle which is a frequent attendant upon the smooth form of the disease allows an exposure of the membrane to irritants which often produce a third form of inflammation. The iris also exhibits the smooth and the tuberous forms of the disease. Iritis occurring in lepra is, however, by no means pathognomonic; 50 per cent. of all cases exhibiting synechiæ are the result of extensions of corneal inflammations due to orbicular paralysis. The superciliæ and the eyelashes are said to be frequent seats of leprous tubercules. In the lids the first symptom is the falling of the eyelashes, which is dependent upon the formation of the tubers before they become manifest to sight and touch. Mooren[106] maintains that chronic skin eruptions favor the development of cataract by causing creeping inflammatory processes which alter the character of the exudations into the vitreous humor, and moreover claims that when such skin eruptions have their seat in the scalp they favor the occurrence of retinitis by maintaining a constant hyperæmia of the meninges. He further cites a case where he observed a decrease in the acuity of vision corresponding with the breaking out of a skin eruption, and an increase in the power of vision coincident with the disappearance of the eruption. Foerster[107] agrees with Mooren in the statement that cataract may be formed in cases where chronic skin affections favor the development of marasmus. Rothmund[108] reports a noteworthy curiosity to the effect that cataract followed a peculiar degeneration of the skin in three families living in separate villages in the Urarlberg. The skin of these patients showed a fatty degeneration of the rete Malpighii and of the papillæ, with consecutive thinning and atrophy of the epidermis: this was most marked on the cheeks, chin, and the outer surfaces of the arms and legs. In the individuals thus affected the skin disease commenced between the third and sixth months of life, whilst the cataract appeared in both eyes between the third and sixth years. Rothmund thinks that the same congenital predisposition to disease exists in both organs, because the lens is developed out of an unfolding of the external skin.

[Footnote 105: _The Leprous Diseases of the Eye_, Christiana, 1873.]

[Footnote 106: _Ophthalmologische Mittheilungen_, 1874, p. 93.]

[Footnote 107: _Graefe und Saemisch's Handb._, vol. vii. p. 152.]

[Footnote 108: _A. f. O._, xiv., 1, p. 159.]

{755} Disturbances of Vision caused by Disease of the Sexual Organs.

The eyes and their appendages frequently exhibit the effects of perverted function or diseased conditions of the sexual organs. As might be expected, these ocular effects are most marked in the female, whose generative apparatus is so much more complex and extensive. While it is true that there are thousands of women with grave disease or derangement of these organs who are free from any uncomfortable eye symptoms, still, clinical experience shows that there are crowds of others who present eye lesions due entirely to such causes. Still more frequently do we see some slight optical defect (previously scarcely noticed) become so unbearable that the patient is unfitted for any useful employment. In fact, at most eye hospitals, and still more markedly in private practice, we find an excess of female over male patients. This excess becomes more palpable when we throw out of consideration the large number of male patients who are under treatment for injuries of all sorts the result of mechanical occupations not pursued by females, and the inflammations due to direct exposure to storm, cold, and intense heat.

MENSTRUATION.--When menstruation is profuse its effects are with difficulty distinguished from those of anæmia and loss of blood, but where it is retarded, irregular, or scanty the effects are more readily traced. All surgeons of experience are agreed that it is undesirable to perform operations for cataract or to make iridectomy at the menstrual period, and it is well known that eyes which have been progressing favorably after operations become congested and irritable during the monthly period. In trachomatous eyes retardation of the catamenia often causes the eruption of a fresh crop of granules, while in cases of phlyctenular and interstitial keratitis there are still more frequently relapse and exacerbation of the disease. Vaso-motor disturbances connected with the period of puberty and with that of cessation of the menses are of daily occurrence: we constantly see cases at these epochs where some slight astigmatism or hypermetropia, which has previously given no practical annoyance to the patient, becomes absolutely unbearable. The eyes become watery and sensitive to light; there is marked congestion of the retina with tortuosity of its veins, together with serous infiltration and swelling often sufficient to obscure the margins of the disc. These symptoms frequently entirely disappear when the menses have either become established or have permanently ceased. In some rare cases the symptoms are anomalous and striking: thus the writer has seen vicarious menstruation from the lachrymal caruncle, and a case of pemphigus of the upper lid occurring regularly at each menstrual period for some months. In another patient menstruation came on during the thirteenth year with intense headache, epistaxis, and photophobia, and for a long time afterward there was utter inability to use the eyes for school-work even during the catamenial interval. At almost every menstrual epoch during a period of eight years there has been a recurrence of these symptoms, although they subside sufficiently in the interval to allow the patient to use her eyes for a very limited amount of near work. At the first examination the ophthalmoscope showed that the retinal fibres were swollen and oedematous, hiding the outlines of the discs, while the lymph-sheaths of the retinal vessels at {756} their point of emergence from the disc presented an almost snow-white appearance. The discs and the retinæ have never quite resumed a normal appearance.

Disturbances in the circulation of the eye and its appendages are 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.]

RUBEOLA.--Preceding the outbreak of the skin eruption, or coincident with it, every case of measles presents a greater or less degree of catarrhal conjunctivitis, often accompanied by lachrymation, itching, and burning of the lids, slight pain, and photophobia. In from two to three weeks the catarrh usually disappears of itself, but in many cases leaves behind it an asthenopia and sensitiveness to light which often lasts for months. In some fortunately rare cases the catarrh increases, and we have a severe muco-purulent inflammation of the eyes, causing partial or total sloughing of the cornea, and thus leading either to the formation of a staphyloma or to the total loss of the eye. Moreover, we often have the development of phlyctenular keratitis as one of the sequelæ, especially among the weak and badly nourished. Some authors (Rilliet and Barthez, Mason, Schmidt-Rempler, De Schweinitz, etc.) relate cases where diphtheritic conjunctivitis, with all of its well-known symptoms--yellow, ropy-like secretion, great bulbar chemosis, and hard board-like infiltration of the lids--set in during the course of the disease. Kerato-malacia (a rapid sloughing of the cornea with marked anæsthesia of the ball, without swelling of the lids) was probably first observed as a consequence of measles by Fischer.[139] He had seen three cases, each accompanied by suppression of the skin eruption, severe fever, and delirium. The corneæ were entirely destroyed in twenty-four to forty-eight hours, and the children died soon after the development of the eye affection. Beger and Begold (Leber) have each reported similar cases. Sometimes in the course of this disease, amaurosis, either permanent or transient, is doubtful. Graefe[140] gives a case where failure of sight came on during convalescence, and where for a week there was absolute loss of perception of light, without any other ophthalmoscopic appearances than a slight neuritis, the patient gradually recovering his eyesight. In an epidemic of measles with severe cerebral symptoms, Nagel[141] records a case of a child where on the third day sopor, convulsions, opisthotonos, and dilatation of the pupils set in. The patient remained soporose for ten days, and then, on regaining consciousness, was found to be entirely blind. On the twenty-fifth day from the setting in of the convulsions, perception of light was dubious, and the pupils, which remained insensitive to the reflection from the ophthalmoscopic mirror, contracted slightly on exposure to the full glare of daylight. There was eventually complete recovery both of health and eyesight, the return of the latter being apparently hastened by the use of strychnia. The same author relates two other cases, in one of which the ophthalmoscope showed neuritis. One of them was fatal, the other terminated in recovery, and in neither was there any return of eyesight. In some cases of measles where Bright's disease of the kidneys is pre-existent or sets in during the {764} attack, there may be the development of the characteristic form of retinitis albuminuria.

[Footnote 139: J. N. Fischer, _Lehrbuch der Entzündungen und Organischen Krankheiten des Menschlichen Auges_, Prag, 1846, p. 275.]

[Footnote 140: _A. f. O._, xii., 2, p. 138.]

[Footnote 141: _Behandlung der Amaurosen_, pp. 24-30.]

SCARLATINA.--In scarlatina we have usually a hyperæmia of the conjunctiva coincident with the skin eruption. Inflammatory affections of this membrane and of the cornea are much less frequent than in measles. Martini[142] remarks that only in one case in twenty is there any inflammation of the eye. Beer[143] informs us that the tears are more irritating than in morbillous ophthalmia, and that the photophobia is more persistent. When ichorous ulcers form, they attack not only the cornea, but also the white of the eye, and spread much more rapidly in this situation than in the conjunctival leaflet of the cornea. Kerato-malacia occurs more frequently than in rubeola. Bonman[144] relates that in a severe epidemic of scarlet fever five boys in one family were taken sick, and that two of them lost their sight from sloughing of the cornea within a week of their seizure. Of these, one died, and the other was brought to him with a shrunken globe and without light-perception. The eyes of the other three children were not affected. Arlt in the first volume of his work on diseases of the eye[145] has given us a clinical description of this form of kerato-malacia. The patient, a boy of four and a half years, was first seen by him on the eighth day of the disease. The child was very pallid, with a burning-hot skin, hoarse voice, slight diarrhoea, and flat abdomen. The right cornea was evenly clouded throughout, swollen, and softened, while the left had lost its brilliancy and was slightly clouded, presenting the appearance of an eye thirty-six hours after death. The conjunctivæ of both eyes were white, with a few vessels and ecchymotic spots in their lower parts. On the tenth day, the right cornea was converted into a mass as soft as schmeer-käse, and was beginning to be thrown off on the centre, where there was a hernia of the hitherto unaffected membrane of Descemet. Both eyes eventually had the cornea completely destroyed, and the patient died on the seventeenth day. Iritis is more frequent than after measles.

[Footnote 142: _Von dem Einflusse des Secretions Flussigkeiten_, vol. ii. pp. 267, 268.]

[Footnote 143: _Lehre von dem Augenkrankheiten_, Bd. i. pp. 536, 537.]

[Footnote 144: _Lectures on the Parts concerned in the Operations in the Eye_, London, 1870, p. 110.]

[Footnote 145: _Krankheiten des Auges_, vol. i. pp. 211-213.]

Considering the frequency of acute nephritis in this disease, the retinal lesions are comparatively rare. Schreiber[146] gives two interesting plates of chorio-retinitis after scarlatina. Ebert[147] at a meeting of the Berlin Medical Society in 1867 called attention to some cases of transient blindness in the course of scarlatina without ophthalmoscopic changes; and Graefe, who presided at the meeting, remarked that in all these cases of absolute blindness there was still reaction of the pupil to the light, and that therefore there could be no neuritis or decided lesion between the corpora quadrigemina. He considered the prognosis favorable so long as there was pupillary reaction, and not necessarily bad where it was wanting. Although this is the rule, the prognosis is certainly more favorable when the pupil reacts promptly and to moderate light. Hirschberg[148] has recorded a case of blindness following meningitis, where light-perception failed to return, although the pupillary reaction lasted several weeks.

[Footnote 146: _Veränderungen des Augenhinter-grundes_, Plates iii. and iv., Figs. 7 and 8.]

[Footnote 147: _Berliner klin. Wochenschrift_, Jan. 15, 1868, pp. 21-23.]

[Footnote 148: _Ibid._, 1869, p. 387.]

{765} Relapsing typhus fever is frequently followed by amblyopia and inflammation of one or both eyes. Considerable variety in the intensity and in the symptoms of the disease has been manifested in different epidemics, and the ratio of the percentage of eye cases has greatly varied. In most outbreaks of relapsing typhus fever amblyopia is followed by inflammation. This was the sequence of the symptoms in the epidemic in Dublin in 1826, in Glasgow in 1845, and in Finland in 1865, although in the last-mentioned the inflammatory symptoms were less prominent and severe than in the first two. The eye symptoms rarely develop during the first attack of the fever, but usually occur after a second or third attack or during convalescence. The earliest careful study of the eye symptoms in a severe epidemic is that of Wallace,[149] who tells us that "there is often that haggard and worn aspect, that sickly, mottled, pallid hue of skin, that sleepy, exhausted, and oppressed appearance of the eye, which is more easily observed than described. The patient only half opens the lids of the affected organ. They are of a purplish-red color and humid. Their subcutaneous vessels are preternaturally enlarged. The vascularity of the sclerotic and conjunctiva is greatly increased. The vessels of the former describe a reticulated zone round the cornea, and those of the latter run in a direction more or less straight to the edge of this membrane, and sometimes appear to pass on the edge. The hue of the redness is peculiar; it is a dark brick-red. The pupil is generally much contracted, and its edge thickened and irregular. The iris is altered in color, generally greenish, and incapable of motion. There exists dimness of the cornea, which may be compared to the appearance glass assumes when it has been breathed upon. There is often a turbidness of the aqueous humor, and a pearly appearance of the parts behind the iris may be observed by looking through the pupil. There is great intolerance of light, and a copious, hot lachrymal discharge. The vision will be found for the most part so extremely imperfect that the patient can merely distinguish light from darkness, and he is often tormented by flashes of light which shoot across his eye, and these occur more particularly in dark places; or he is troubled by brilliant spectres or by the constant presence of muscæ volitantes. There is very considerable pain, which returns in paroxysms, and these are almost always more severe at night. The pain is sometimes referred to the ball of the eye, sometimes to one of the lids, sometimes to the temple or to the circumference of the orbit." Mackenzie agrees in the main with the foregoing description: his cases were also accompanied by severe inflammation, with hypopyon and copious precipitates in the membrane of Descemet and on the anterior capsule of the lens. He also called attention to the diminution of the intraocular tension and the consequent flabbiness of the eyeball, and states that out of 1877 cases of fever admitted to the Glasgow Infirmary during the epidemic of 1843, 261 (one-seventh) were attacked by the disease of the eye. Anderson,[150] who describes the same epidemic later in the course, takes exception to Wallace's statement that there is always an amaurotic stage at the outset of the disease. He computes these cases at two-thirds of the entire number, and tabulates five cases of inflammation without {766} amaurosis. He also describes and gives plates which show opacities of the vitreous, posterior synechia, pigment on the anterior capsule, posterior polar cataract, and other forms of lenticular degeneration; these conditions ensuing not only in this disease, but in all other affections where the circulation in the ciliary body and the constitution of the vitreous are profoundly involved. Schweigger, in describing an epidemic in Berlin, says that in one-third of the cases of ophthalmia there was simple unilateral iritis, and that in a second third there was diffuse punctiform or flocculent vitreous opacities without any trace of iritis or external symptoms of disease; while in the remaining third there was iritis with vitreous opacities in common: when it ensues in its usual form the effects of annular synechiæ or detachment of the retina; rarely from suppuration of the corneæ. Although of late years the Russian writers have materially added to our knowledge of the affection, nevertheless in most essentials their observations agree with those above quoted. Thus, Blessig[151] gives an account of an epidemic in St. Petersburg, while Logetschnikow[152] describes an epidemic in Moscow in which he encountered over 700 cases of this form of ophthalmia. Larionow[153] relates the history of a mild epidemic in the Russian army of the Caucasus, and tabulates 767 cases of the fever, in which are also included a number of cases of exanthematic typhus and a few cases of typhoid fever. Exclusive of the ischæmia of the retina and feebleness of the accommodation which were present in every case during convalescence, there were 3 cases of serous retinitis, 2 of hemeralopia, and only 3 of iritis; while in 10 per cent. of these there were vitreous opacities. He did not see a single case of genuine irido-choroiditis in the entire number. Estlander[154] has given a masterly description of two epidemics which he observed at Helsingfors in Finland, both of which occurred after a failure of the crops and consequent famine. In the first of these epidemics, which was of a mild type, only 3 out of 222 patients died, and the concomitant eye affections were few in number; while in the latter, 18 out of 242 patients died, and extensive vitreous opacities with severe inflammation of the eyes were frequent. He agrees with Mackenzie that the fever attacks few children under ten years of age, and says that although the disease is much more liable to attack people between twenty and thirty years of age, here it is less frequent than it is in patients between ten and twenty years of age, where it exists in one half of the cases. Arlt[155] agrees with this, and says that it is due to the fact that hunger and malnutrition are in general much worse borne by adolescents than by adults. As regards the period of the disease at which the eye symptoms come on, Estlander says that out of 28 carefully observed cases it developed 6 times during the fever or a week after its cessation, 11 times between the second and fourth week, 5 times in the second month, and 6 times from the third to the fifth month. These figures agree well with those given by Mackenzie, and show that there is both a feeble state of constitution and a prolonged convalescence from {767} this severe fever. Pepper,[156] in a previous volume of this work, has given an interesting account of an epidemic in this city in which he states that eye affections were of rare occurrence.

[Footnote 149: "An Essay on a Peculiar Inflammatory Disease of the Eye, and its Mode of Treatment," _Trans. Med.-Chir. Soc. of London_ (read Dec. 11, 1827).]

[Footnote 150: "Post-febrile Ophthalmitis," _Monthly Journ. Med. Sci._, 1845, pp. 723-729.]

[Footnote 151: _Congrès internationale d'Ophthalmologie_, Paris, 1868, pp. 114-117.]

[Footnote 152: "Entzündung der Vorderen Abschnitten der Choroidea als Nachkrankheit der Febris Recurrens," _A. f. O._, Bd. xvi., 1, S. 352-363.]

[Footnote 153: _Klinische Monatsblätter f. Augenheilkunde_, 1878, pp. 487-497.]

[Footnote 154: _A. f. O._, xv. 2, pp. 108-143.]

[Footnote 155: _Klin. Darstellung der Krankheiten des Auges_, 1881, pp. 289-291.]

[Footnote 156: Vol. I. p. 399.]

Exanthematous typhus fever is occasionally followed by the same train of symptoms as pointed out in discussing Larionow's statistics, who gives vitreous opacities as the most frequent forms of the eye affection. Out of a total of 57 fever patients with typhus exanthematicus, he found 1 case each of iritis, keratitis, and neuro-retinitis, 2 cases of contraction of the field of vision, 5 of subconjunctival ecchymosis, and 2 of conjunctival catarrh.

Abdominal Typhoid Fever.--Severe eye complications are less frequent in this disease than in either of the foregoing affections. During convalescence from this, as from all other exhausting diseases, there is usually feebleness of the accommodation, and occasionally the development of vitreous opacities, with or without the formation of cataract. The most common eye affections show as an optic neuritis or paralysis of some of the muscles supplied by the third pair of nerves, and are due to a complicating meningitis.