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(the \dependence of ^

ABNORMAL EYE CONDITIONS

UPON

UTEUINE DISEASES.

T. JOHNSON-ALLO'WA.Y, Mi. D.,

Instructor in Gynaecology, McGill University, Montret^y

AND

, m. BTJIL.IL.ER, M. r>..

Professor of Ophthalmology and Otology, McGill University, Montreal.

{Reprinted from the Montbbal Mqdical Jouknal, November, 1892.)

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Surgeon to the Montreal General MospttaL

We are induced to lay before the profession a few practical
data which will shew how closely related certain conditions of
the eye, and perhaps of the nose and throat, are to diseased
conditions of the sexual system in women. When we consider
how seriously the whole general health of women is affected
by slight retrograde change in the sexual organs, we can easily
understand how the organs of sight will participate in the
general enfeebleraent estnblished. It is this participatiop
which is the real cause of the distressing ocular condi-
tions we so often see in young women who have for their
occupation teaching or some other such laborious work.
In the majority of instances the ages of these patients range
from n to 30, and a large number of thom are young girls
budding into womanhood. And as it is considered by the sex
generally that every woman suffers from head and back ache
as a normal condition from the time she matures until the
menopause, little attention is p:iid to such symptoms. When,
however, her anxiety becomes awakened by distress or serious
discomfort in the use of the eyes, the oculist is immediately
consulted. He often fails to find sufficient cause for the eye
trouble after a careful investigation of all the ocular functions.
He then directs his attention to reflex disturbances emanating
from other organs. Thus it happens that a considerable por-
tion of these cases are referred to the gynsecologist, but to
establish and demonstrate a direct communication of morbid-
ity between the pelvic organs and those of special sense would
be a somewhat difficult task. Nevertheless, with the aid of

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' THE DBPENDENCK OF ABNORMAL EYE CONDITIONS

... UPON UTERINE Disfc: AS lis. : y <\\ ^^ -i;-;*^-'.

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T. Johnson-Allow AY, M.D., * , /.• . -

Instructor in Gynasoology, MoGill University, Montreal, \'. ' '• ','

'■ ''V ■'■'; ■ ' AND " . ■

F. BULLBR, M.D.,

Professor of Ophthalmology and Otology, MoGill tlniversity ; Ophthalmio and Aural

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clinical observation, it can, wo believe, be approximately done,
and is in every way deserving of our most serious thought.
Physiologists and Neurologists can give us very little aid in
the matter. They tell us that the organs in question arc pro-
sided over by the spinal cord, the nerve force of which is con-
trolled or inhibited by the brain. Congestion of the spinal
cord may and does produce congestion of the pelvic organs
and increased glandular activity. But here our chain is
broken in regard to making connection with the trouble
located in the organs of special sense. We are not as yet in
the position to trace the path of morbid influence so widely
distributed. We have therefore to a great extent to fall back
upon the associated condition as a hystero-neurosis, and whilst
we know that patients aflflictod with chronic pelvic disease
usually complain of asthenopia or impairment of the ocular
functions, the direct relationship of those conditions to each
other is by no means well established. ,:•.,.

Although a large proportion of asthenopes may bo relieved
morb or lees completely by correcting errors of refraction,
faults in accommodation or muscular anomalies, there re-
mains a considerable number who cannot be successfully dealt
with in this way. The ophthalmic surgeon may search in
vain for any defect in the mechanism of vision. In many cases
the correction of slight errors of rofi-action utterly fails to give
relief, indeed it may happen that the use of glasses over so
accurately adapted rather augments the patient's distress.

In the last few years considerable advance has beep made
in our knowledge of reflex disturbances originating in morbid
conditions of other parts or organs, but finding expression in
visual disturbances of various kinds, more particularly in the
assemblage of symptoms commonly classed as asthenopia. A
conjunctivitis which resists all treatment but suddenly sub-
sides after the removal of a diseased tooth, or the correction
of some abnormality in the nose, or vault of pharynx, is ob-
viously an ey-e disease of reflex origin. Such an event hap-
pening occasionally might justly be regarded a coincidence,
but since hundreds of these oases are on record the existence
of reflex conjunctivitis is no longer a matter of conjecture.

When pronounced asthenopic symptoms without local signs
of disease are relieved in the same same way, the reflex nature

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of the asthenopia is equally obvious, That asthenopia fre-
quently originates from faulty conditi*)ns in the nasal passages
will be conceded by most opthalmologists of the present day.

It is not our purpose to discuss, or oven to mention all the
morbid conditions which give rise to roflex asthenopia.

In all probability opthuimologists still have much to learn
in this direction, and in order to learn they must enjoy the
intelligent co-operation of other workers in the wide field of
medical research. / > ' ' '

Among these the gynecologists certainly have to deal with
many cases that first are led to seek relief on account of their
visual troubles. *

Diseased states of the genital organs have long been known .
to bear a certain relation to various functional and organic
diseases of the eyes.

The admirable essay on the relation between diseases of the
genital oi-gans and the oi-gans of vision by Forster, in the
" Handbuch der Gesammten Augonheilkundo " of Grilfe &
Seemisch is a classical contribution to this subject, and though
often referred to by writers in othei languages has, we be-
lieve, never been translated into English. Wo therefore
insert a translation of this valuable article as far as it refers
directly to the subject we are now discussing. :

"The labours of A. Von Grafo and Bonders have thrown so
much light upon the group of cases hitherto included in the
chapter on hobotudo visus or kopiopia, that only a small con-
tingent remains for further investigation. Among these last,
a considerable number may be set down as belonging to a
class in which the visual disturbances are due to anatomical
changes in the cellular tissue around the uterus (parametrium),
well-known to be so richly supplied with nerves, and secondarily
to changes in the uterus itself. In these the visual disturbances
are to be regarded as hyperfesthesise of reflex origin involving
the 5th and optic nerves, and the group of symptoms they
present may be designated Kopiopia Hysterica.

The description these patients give of their eye troubles is
very similar to the complaints of those who suffer from mus-
cular or from accommodative asthenopia. In some parti-
culars, however, there is an important difference.

In Kopiopia Hysterica the chief complaint is of painful sen-

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sations of the mo.it varied deBcription, whilst in Muscular or
Accommodative Asthenopia the most prominent symptom is
indistinctness of vision.

In the former the painful sensations occur around the eye-
ball, on the top of the eye, or in the eyeball itself, or thoy may
be behind the eye or more rarely in the malar bone, bridge of
the nose, or in the upper jaw. These pains are variously des-
cribed as drawing or stretching, dull weight, or more rarely as
burning sensations. ' . ,. ,; -,

Very often there is a feeling of soreness over the eyeball or
burning or pricking sensations ou tl e surface of the eyeball or
at the edges of the eyelid, sometimes there is a painful heavi-
ness of the eyes or a feeling as if a foreign body o;* an eyelash
were ir. the conjunctival sac.

These sensations are often .increased by work, reading,
sewing, etc., and also by the bright light ; they come on, how-
ever, quite independently of an accommodative effort and often
last for many hours or for a whole day with some variation in
their intensity. Thoy are furthermore apt to be increased by
anything which causes physical or mental depression such as.
bodily fatigue, prolonged or loud conversation, anger or g,-ief.
They are diminished by rest, sleep, pleasant associations,
travel, etc. -. ', , :; '•'„ ' . ;. ■;• ,::; ■/ ;-, •* '■ ;.'; ''.v-,; ;,■

The pain has not the typical character of supra-orbital neu-
ralgia in which there are intervals of freedom from pain with
daily or more or less regular exacerbations.

In Kopiopia hysterica too, painful points are seldom pre-
sent. The pains of this reflex hypersBSthesia are also entirely
different from those of the so called ciliary neurosis, such as
occur in corneal ulcers, iritis and glaucomatous affections, in all
of which the pain resembles that of supra-neuralgia. ,

In the reflex affection both sides of the head are nearly
always affected. The pain is of longer duration, irritating and
annoying rather than intense, and never worse at night, whilst
that of a ciliaiy neurosis is altogether more severe with boring
sensations in the bony structures, often the entire side of the
head is affected and there are nocturnal exacerbations with
remissions during the daytime.

In the reflex affection these pains are often described as
terrible, but the patient never groans or becomes indifferent to

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all surroundings. There is no injection of the conjunctiva, no
swelling x)f the lids and no lachiymation, and nothing to ac-
count foi" the severity of the pain, signs which are often pre-
sent in typical forms of trigeminal neuralgia. There is no
evidence of heroic efforts to siippresn manifestations of pain
among a class of patients who arc peculiarly wanting in self
control. -11 I . . '

An examination of the eyes reveals either nothing at all to
account for the pain or the local manifestations are nothing
more than a slight conjunctivitis, a muscular insufficiency,
some hyperopia, or pi-esbyopia without error of refraction.
Further observations and treatment show, however, that these
local conditions wei-e only incidental and have, in rea ity no-
thing to do with the sensat'ions the patient complains of, since
the removal of these complications does not get rid of the
pains or at most affords but slight relief

The heaviness of the eyelids continues us before, even when
the conjunctival catarrh has been cured.

The use of prisms or of convex glasses, or tenotomy of the
external rectus affords but little aid to vision, indeed it fre-
quently happens that although glasses make vision more dis-
tinct they rather increase the patient's discomfort ; the glasses
are too strong or they make the sight too distinct, or the '
frames press uncomfortably upon the nose or temples and in-
crease the pain or cause distress in the head. The reflections
from the glasses aie also a constant source of annoyance.
Even blue glasses cause the same discomfort although in some
respects they afford partial relief.

The hypersesthesia thus depicted, is seldom confined to the
fifth nerve, but almost always affects the optic nerve too.
This finds expression as an intolerance of light or undue
sensitiveness to bright light. Ordinary diffuse light is, how-
ever, less distressing to the patient than artificial light. Such
patients complain much more of artificial than they do of day-
light, although the latter is infinitely the stronger. They are
much less incommoded by the light of a cloudy sky or even by
bright sunlight, than by that of a lamp in a darkened room.

Daring the daytime they go about without blue glasses, but
in the evening with the lamp lighted upon the table they can-
not endure the white tablecloth. It must be covered with

.1 ,11

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some ^ai'k mii(erial or at least with a printed no^^spaper. The
whito bcdquilt, the brftss lamp pedestal, or the opaque glass
globe dazzle and cause pain in tho eyes, conuequontiy must be
covered. The ianip must be removed to some out-of-the-way
place in order that the room may be sufficiently darlc, or the
patient retires to an unoccupied and darker room.

I believe this peculiar intolerance of light, which by the
way, is novex associated with lachrymation, may be regarded
as an intolerance of contrast between light and shadow in the
visual field which is far more striking in artificial than in day-
light for it is not at all likely that the artificial light in itself
possesses any upecial quality which causes it to irritate such
eyes* " '. • ;:\ ' : '■ .' . ■' • ' •' ' , ;■ '■'.-'■.■'■:'' y^.'

It is also worthy of note that these patients have their good
days and bad days without apparent cause for the variations.
During the good days they are almost free from pain, bear the
light bolter and can sometimes even read for hours at a time ;
but on their bad days all the symptoms are pronounced even
when the eyes are kept perfectly at I'est. The pain never
interferes with sloop and the patient is never awakened by
severe pains ir or about the eyes. If awakened from any
other cause, the only discomfort is a feeling of dryness or .
heaviness of the eyes.

In the morning, perhaps for several hours, they get on fair,
ly well, later on the labors of the day induce fatigue or loss of ,
tone, and with this their pains begin. It may be that the.-e
nocturnal remissions are due to the recumbent posture rather
than to the removal of external impressions. For example —
a young woman has an abortion with great loss of blood and-
on this account remains in bed for several weeks. During
this time she is free from all her eye troubles, can read, etc., ■
but 80 soon as she is up and about again they all con'e on
again. Shortly before and after menstruation the symptoms
are generally more pronounced. '> * ,. - "'^ '

These patients are for the most part exceedingly verbose,
describe their pains in hyperbolic phraseology and talk of . "^
them incessantly, but the entire absence of objective symptoms
and a behaviour inconsistent with any severe disease arouse a ;,
suspicion of simulation ; or at least of exaggeration.

The morbid visual sensations which these patients some-.

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times describe and the ciroumstances which seem to aronse
them are simply innumerable. Nevertheless, vision is very
frequently not in the least impaired, in fact it is apt to be re-
ma. KaMy acute. If there happens to be a slight amblyopia it
presents no special characteristic either soojoctive or objec-
tive; indeed, it is difficult as a rule to determine with ^r-
tainty whether the somewhat diminished visual acuteness
occasionally met with is not an habitual condicion existing
prior to the occurrence of pain and intolerance of light. In
only two cases out of several hundred the pupils were 5 m.m.
in width and unaffectetl by light. This symptom is therefore
of rare occurrence, though probably in some >"'ay dependent
upon the same conditions as the other phenomena. This class
of cases is rarely met with among men, although nervous men
are common enough. The malady in question may therefore
be justly regarded as a prerogative of the female sex I de-
sire, however, to emphasize the fact that I have met with a
small number of men who suffer in precisely the same way.

The vast majority of cases, however, are elderly spinsters,
sterile or prematurely rterile married women and widows.

Among childbearing v,'onion the affection is rare [indicative
of freedom from disease of the reproduction organs], and when
present is always ameliorated durin" pregnancy.

We hear the same complaints f girls between 15 and 25
years of age. Alter the age of CO tno affection is almost un-
known. Among 56 typical cases chosen from a large number
on account of having been more accurately observed, two were
between 15 and 20 years of age, 23 between 20 and 30, 12
between 30 and 40, 15 between 40 and 50, and 4 between 50
and 60. -■ '' -^^ ■^•'^•-- ■ ■ ■ ■ ^. .• . / •"«..-— V-" ■'"'>;■ '■

The disease is more common among the well-to-do than the
poorer classes. In 1000 cases only 8 or 10 belonged to the
latter.

The general health as a rule is conspicuously defective,
sleeplessness, nervous irritability, palpitation of the heart, low
spirits, pains in the abdomen and small of the back, and con-
stipation are commonly present. Pains in the arms and fin-
gers are often experienced. The entire array of nervous mani-
fep.tations known under the name of hysteria and often asso-
ciated with a certain perversity of behaviour is now and then
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observed, although the tj'picnl hysterical phenomena such as
" an uncontrollable tendency to laugh or cry, globus hystericus^
convulsions, paralysis of sensory or motor nerves, arthro-
pathia hysterica, arc seldom met with among these .patients.

In some cases hysterical sj'mptoms are entirely wanting,
an^ indeed, kopiopia hystei-ica may be associated with an
appearance of robust health.

The group of symptom ; described, and which are extremely
characteristic so far as they concern the eyes, are always
associated with and caused by a peculiar chronic inflammation
of the cellular tissue surrounding the uterus or atrophic pai'a-
raetritis chronica.

Professor Freund of Breslau was the first to recognize this
affection of the genital organs and in the course of 14 yeai-s
has met with it in a large number of patients suffering from
the above described visual disturbances.

The connection between this affection of the eyes and
disease of the genital organs is so constant that whenever
the former is met with the latter may with certainty be
assumed to exist. Since Freund has proved the existence of
this disease of the genital app&ratus by numerous autopsies
and preparations I shall give here a brief description of the
morbid conditions in his own words as follows : —

•* That part of the pelvic cellular tissue which immediately
surrounds the cervical portion of the uterus is called the para-
metrium. This structui'e presents several peculiarities which
distinguish it from other pelvic cellular tissue.

It is destitute of fat and of closer texture becoming more
and more dense as the uterus is approached. The portion
which immediately surrounds the uterus shows in horizontal
sections a stellate arrangement and carries the principal blood
and lymph vessels as well as the nerves which supply the
uterus and to some extent the ovaries also. Traced down-
wards it will be seen that this dense connective tissue en-
velope of the uteras arises from that part of the fascia pelvica
interna which surrounds the vagina. The great ganglionic
apparatus of the uterus lies imbedded in the parts surrounding
the lateral portion of the Laquear vaginae but above the level
of the Laquear.

From this part of the Parametrium which immediately sur-

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rounds the cervix uteri proceed certain pathological changes
of a chronic inflammatary character analogous to nimilur
aftcctions mot with in other ,oi'gftns (such as the liver, kidneys
and lungs) not only in progress i^nd results of the disease but
also in the phenomena they give I'ise to during life. The
chi-onic infiammatoiy process begins insiduously and ^'arries
first a hyperplasia, then acioatiica! contraction of the affected
connective tissue and spi'eaUs in every direction, m )ie
especially along the base of the broad ligaments as far as the
walls of the pelvis, spreading from this to the cellular tissue
surrounding the rectum and bladder. It spreads upwards
very often to the round ligaments which rest in the anterior
leaf of the broad ligaments but seldom to the Fallopian tube;
lastly it extends downwards as far as the upper third of the
vagina. The broad ligaments are thickened by hyperplastic
prolifera' ion of connective tissue, especially in their, lower
parts these two surfaces are, so to 8j)eak, glued together and
cannot be made to slide over each other as in the normal con-
dition. The ureters are drawn towai js the cervix uteri, and
their lumen contracted just where ihey are most closely sur-
rounded by the shrinking connective tissue.

Blood-vessels coursing through this tissue participate in the
same process and nerve fibres running through this hard
scar tissue are often found more or less destroyed by it.

The action of this disease upon the pelvic organs is mani-
fested at first in a considerable disturbance of the circulation
which occasions a venous hyperamia of the genital tube with
chronic inflammatory swelling (Metritis Chronica htomorr-
hoidalis) waich is associated with similar changes in the rec-
tum and bladder, catarrh of the genital mucous membrane,
irregular and often profuse menstruation. In the Iftter stages
of advanced atrophy, there is atrophy of the pelvio cellular
tiissue generally, involving even parts which are not directly
connected with the cicatrizing process, atrophy of the genital
canal, especially of the uterus, which frequently acquires an
uneven surface, partly caused by varicose nodules and partly
by the irregular pressure of cicatrizing areas upon the adjacent
uterine substance.

The analogy between this dis ase and cirrhosis of the liver,
fibroid degeneration of the lungs and granular degeneration of
the kidneys is most striking.

12f

The disease is not a rare one, it occurs in women who have
borne children as well as in those who have not. Clinically
most cases may be traced to undue excitation of the genital
organs complicated with excessive secretion. The course of
the disease is essentially chronic, the prognoses in respect to
a restitutio in intogiura is unfavorable ; although the organic
changes are permanent the nervous phenomena ultimately
subside. ,■'.>.'•■>:. ,;>■,.•■..•, v^..- .^.'.. ,.

Kopiopia hysterica is not curable. It alwaj's diirappears in
time, though often not until the patient bus spent years and
years of suffering. I have never observed that it tends to
induce any other disease of the eyes either inflammatory or
non-iaflammatory.

According to my experience, there are not many remedies
that can be relied upon to relieve the symptoms, such as pain
and intolerance of light, but a certain degree of improvement
may be confidently expected after the patient has taken, in
the course of four days, castoieum Canadense 2.0 and Ext.
Valeriana 4.0. The improvement lasts at the most some four
weeks. Acdate of zmc takes second rank as a remedy in this
affection, quinine, narcotic."*, and cold eye douches are either
■useless or of problematic value. '

Protective glasses are always indispensable, only care must
be taken to avoid the darker tints. Un no account should
the patient be permitted to remain in darkened rooms, such a
course never succeeds in diminishing the intolerance of light'
On the conti-ary protracted seclusion in a darkened room in-
variably augm'-nts the functional irritability.

Measures should be chiefly directed to the cure of the para-
metritis chronica; this, however, is unfortunately not very
amenable to treatment when the restoration has become
complete.

At or about sixty years the hypereesthesiBB are likely to sub-
side entirely, at least in so far as the optic and fifth nerves are
concerned."

It will be observed from the foregoing that the kopiopia
hysterica so well described by Forster is attributed by him to a
form of wasting parametritis chronica.

It will be our object to show that other morbid conditions
affecting the uterus and pelvic organs are also capable of giv-

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ing rise to poraistent foims of asthenopia, and we believe the
oplhalmologist and gynecologist will have confeiTed a mutual
benefit upon each other, and assisted the progress of medical
scien'je when they have succeeded in defining more accurately
the various morbid conditions in and about the uterus which
give rise to i ' perpetuate asthenopia. Physiology has not
yet been able to disclose the several links in the chain of nerve
perturbation which associates functional weakness of the
visual organs with parametritis chronica and although path-
ology may discover wide deviation?? from the normal condition
at one end of the chain there is often nothing at all to ucoount
for symptomatic disturbance at the other.

We have seen severe and obstinate cases of asthenopia re-
lieved by the removal of morbid conditions in other parts sup-
plied by the fifth nerve, and we have observed certain inflam-
matory affections of the eyes relieved in the same way, but in
those the reflex area is all within the domain of the same
nerves.

When however, the primary lesion is in parts so remote as
the genital organs it is far more difficult to un<lerstand the
complex relationship which must exist between parts so wide-
ly separated from each other, in order to account for this reflex
form of asthenopia. It cannot be explained by assuming more
loss of tone or debility of the system generally, since extreme
debility often exists without the least visual disturbance, and
on the other hand disturbance of the uterine functions asso-
ciated with asthenopia is quite consistent with robust general
health. That this should be exceptional may be granted with-
out diminishing the importance of the fact, indeed it is all the
more reason for further investigation of such cases. When
the opthalmologist and gynecologist shall have compared
notes sufficiently often we may perhaps be in a position to
understand these Hystero-neuroses better than our predeces-
sors have done.

Cases have been reported by MacKenzie, Yon Griife, Meyer,
and others, which shew a certain connection between diseases
of the eye and the organs of generation, but which are not of
a reflex character; they are not neuroses, but cases of actual
amblyopia, in connection with amenorrhoea and dysmenorrhoea,
caused by extravasation of blood into the retina during intense

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cerebral congestion depending upon the retention of the men-
^trual flow. Oculists have informed mo that the majority of
cases of asthenopia consulting them, except those due to over-
use of the eyes, errors of refraction, or muscular anomalies,
are found in females, many of whom suffer from menstrual
irregularities or other evidence of uteiane disturbances. These
patients are carefully treated with tonics to invigoi-ate the
debilitated system ; the eye condition is attended to, but it is
found that they do not improve, and will not until the uterine
lesion has been cured. Decrease in the power of vision, dim-
ness of sight as if a cloud was passing befoj-e the eyes, occur
both as menstrual and pathological neui-oses, and are relieved
by treatment of the uterine disease. Meyer relates the case
of a maiden lady, aged 40, in whom the «ienstrual flow was
ushered in by an amaurosis of several hours' duration, which
disappeared as suddenly as it came on, but was never accom-
panied by symptoms of cerebral congestion — evidently a men-
strual reflex which would have juelded to proper uterine
treatment. Engelmann nays: " Jn all cases of true reflex
neurosis no structural changes exist in the early stages at
least, and the ophthalmoscope wi reveal an absolutely
healthy condition of the fundus of the ve, but after a dura-
tion of years the disease, heretofore simulated, may develop
in place of the phantom. In no organ is the persistent con-
tinuance of a reflex so liable to result in actual changes as in
the eye." Cases are reported by Di-. Fordyce Barker where
Drs. Agnew and Noyes failed to find any pathological changes
in the eye, and after proper treatment of the uterine lesion
the patient lost all morbid affections of the eyes. The more
trivial forms of ophthalmic disease yield but slowly with im-
provement of the uterine affection, if treatment has not been
begun early, and it is only the more violent and rapidly
developing symptoms which respond as readily to utei'ine
treatment as do the other reflex neuroses. In fact, experience
seems to show that ophthalmic reflex neuroses are more per-
sistent and yield more slowly to treatment than those of any
other organ, and if they have existed for years they are liable
to result in structural changes or disease proper of the eye,
which is not the case with other reflexes. Although this view
may not be accepted by many ophthalmologists, all will con-

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cede the fact that asthenopia, as a hysterp-neui'OseH, may per-
sist for an indefinite period, defying all measures for its relief
until the uterine defect has been corrected. According to
Rampoldi,* there are five groups of sexual diseases which
affect the eve, as follows :

(1.) Hysteria and chronic metritis are causative of asthen-
opia and retinal hypersesthesia.

(2.) Menstrual disordei-s. Amenorrhcea is causative of con-
junctivitis, keratitis, iritis and phlyctonulee. To suppression of
the menses he refers diseases of the choroid, with neuritis and
retinitis. The tendency to glaucoma is known to accompany
a sudden suppression.

(3.) Inflammatoiy diseases occur in hypersesthesia and neu-
ralgias of the trigeminus.

(4.) Pregnancy causes the difficulty accompanying the albu-
minuria of tbftt state. Amblyopia and amaurosis have been
common from thren to fourteen days after hemorrhage.

(5.) During lactat:on and the puorperium the following have
been observed : Panophthalmitis, ulcers of the cornea, retin-
itis, photophobia, disturbances of accommodation and other
morbid conditions resulting from debility.

These views are held by Rampoldi in regard to eye affec-
tions associated with pelvic disease, but it is difficult to trace
any positive relationship of individual ophthalmic affections
to such pelvic disease; few indeed of them are reflex neuroses.
We believe however, that there are many cases of asthen-
opia which are undoubtedly of a reflex nature, and will now
relate a few examples.

Case I. — Aged 19, unmarried. Consulted me Dec. 7th, 1891.
Menstruation began at 15. She has suffered severe pain at hfir
periods ever since. The pain has been gradually increasing
to the present time. Periodicity shortened to three weeks.
Great premenstrual exhaustion. Duration of flow 5 to 7 days.
Quantity large. Pi'ofuso leucorrhoeij. Constant backache.
Constant headache. Distressing asthenopia. Supraorbital
pain. "Wears glasses. Irritation of bladder. Nocturnal fre-
quency 5 to 20 times each night.

Examination. — Uterus retrovertod 2°. Pelvic floor painful
to touch. Cervix eroded, catarrhal endometritis. Profuse
glairy m'^.coid discharge issuing from cervical canal.

*Ann'' TIniv. de Med., Sept., 1888.

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Operation. — Divulsion of cervix with sleel dilator. Endome-
trium curetted. Eemcfved catarrhal patch. lodofoi-m gauze
drain. Shortened round ligaments, using buried sutures. Con-
valescence perfect. Uterus antoverted when loft for home.

Juno 27th, six months following operation, this lady writes as
follows : " My eyes are very much better. J still wear glasses,
but with them 1 do not suffer pain, and the moving sensation
over my left eye, from which I have suffered so much, is also
removed."

Case IP. — aged 28, unmarried. Consulted me September,
1889. Menstruation fairly regular. Duration (> to 7 days;
rather profuse. Within the past six months has sufiered
severe menstrual pain, chie^y in back and hypo^astrium.
Has p.lso constant intermenstrual backache. A false step or
sudden jar greatly increases pain. Has severe headaches and
supraorbital neuralgia at times. Suffers from asthenopia, and
cannot read but for a short time.

Examination. — Uterus retro verted and fixed in well of pel-
vis. Both ovaries prolapsed into Douglas' pouch. They are
very tender to touch.

Operation. — Shortened the round ligaments after a few weeks'
preparatory treatment, chiefly rest. Jlosult very good. Uterus
in normal position four weeks afterward ■», and pelvic floor free
from tenderness.

June 24th, 1892 (three years), this young lady writes me as
follows: "1 can assure you ray eyesight has improved very
much indeed, and 1 was very fortunate to have undergone the
operation. I have become fleshy and strong, and can walk
miles ; in fact, 1 am a new creature. Patients similarly
affected can rest assured, with care for a year or so, they will
be as well as I am." These statements are made three years
after treatment.

Case III. — Aged 28, unmarried. Consulted mo January,
1889. She menstruated every third week; somewhat pro-
fuse; duration 5 to 6 days. Complains of great prostration,
constant backache and a beaiingdown pelvic sensation. There
is asthenopia and an inability to read or do needlework with-
out glasses. Pain in buck of eyeball.

Examination — Uterus retroverted, found low down, lying
in axis of outlet. Whole pelvic floor tender to pressure.
Cervix elongated and conoid in shape, glairy mucus issuing
from cervical canal. Chronic endometritis.

Operation. — After due preparatory treatment, I shortened
the round ligaments on September 23rd, 1889. I saw and
examined patient October 24th following. Found result very
perfect, uterus anteverted and fundus lying close to pubic

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bone. Pelvic contents free from tenderness. I hoard from
this patient two months ago. She has continued to work as
ealeswoman up to the present time. She is well ; her eye-
sight is good, and has not given her any trouble since tieat-
ment, now three years ago. - / .

Case IV. — Aged 42 ; married eleven years, five children,
youngest 3 years of age. Menstruation has been very pro-
fuse ; duration 8 to 9 days as a rule ; quantity very large.
Profuse leucorrhceal discharge. Constant back and side ache,
inci'eased on fatigue, but no special dysmenoirhceal pain. Suf-
fers from distressing headaches, especially post-menstrual.
Has great impairment of vision, granular lids, anc^even with
aid of glasses cannot read but a few minutes. Great impair-
ment also of general health.

Examination. — Perineum lacerated and pelvic floor destroyed.
Vaginal walls prolapsed. Cervix much congested and eroded,
but no evidence of laceration. Extensive ha)morrhagic en-
dometritis. Uterus enlarged and retroverted. Pelvic floor
excessively tender to pressure.

Operation.— After pro para toiy treatment, removed cervix,
curetted endometrium, restored perineum by flap-splitting
method and shortened round ligaments.

I received a letter dated June 24th, 1892 (one year after),
from this lady^ as follows: — *' I am happy to be able to eay
that it is many years since my eyes have been so well. The
sight is better, but the great improvement is in the lids and
strength of the eye. Before the treatment my eyes felt as if
they would burst, were much inflamed and were always glued
together in the morning. Now I do not know what it is to
have anything wrong with them."

Case V. — For many years a suflerer from uterine disease.
Is a great invUid and obliged to spend most of her time in
bed or on a couch. Suff'ers much from pain in the eyes and
asthenopia. No error of refraction or muscular fault. Ac-
commodation good. Eeferred to Dr. AUoway.

Sexual history. — This lady was in greatly i-educed health ;
suffered great pain during menstruation, with excessive flow
and intramenstrual leucorrhcea. Examination shows bilateral
laceration of cervix with eversion of the cervical segments ;
hyperplastic endometritis ; destruction of pelvic floor and
perineum ; uterus retroverted, no adhesions. Had borne two
full-term children. Wears glasses.

Operation. — Curettement, excision of cervix, restoration of
perineum, and shortening of round ligaments. Last r* ji t

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from this patient said sh*^ was healthy ; had nursed her husband
through typhoid feve* one year aftor her operation, and is at
present (four years aUer operation) enjoying excellent health.

Case VI. — Seen shortly nfter recovering from Alexander's
operation for retroflaxion of uterus, lias suffered from weak-
ness of the eyes for several years. Vision normal ; no error
of refraction beyond a slight compound hyperopic astigma-
tism ; 180° + 0.25 4-0.50; V. =6/5 each eye; these prescribed
for. No muscular anomaly or lault in accommodation. When
last heard from was able to use the eyes comfortably without
glasses. No treatment other than the operation performed
by jr>r. Alloway (see Case I) was pursued.

Case VII. — Aged 34; a delicate-looking woman. Sent to
me on account of headache and pain in the eyes, always
aggravated by their use in any near work. Complains chiefly
of pain in top and back of the head much increased by use of
the eyes. The eyes appear normal and there is no lack of
accommodation. Not more than 050 of hyperopia. No ab-
normality in the muscular functions. V. =6/6, each eye.
Sent to Dr. Alloway on account of pain in the back and side,
leucorrhoea, etc.

Sexual history. — This case was a wretched, confirmed invalid,
in constant pelvic pain, and unable to follow her occupation of
seamstress. The uterus and appendages weie firmly fixed to
the bottom of the pelvis en wasse.

Operation. — Laparotomy ; found appendages densely adherent
to uterus and broad ligaments in Douglas' pouch. Removed
appendages with much difficulty (chronic purulent salpingitis).
Sutured uierus to anterior abdominal wall, Recovery perfect.
This patient reports herself (eighteen months after operation)
being in perfect health, works hard at her trade, and has good
eyesight. , .

Case VIII. — Aged 40. Eyes weak, and painful when used.
Often pain even when not used, and always intolerant of arti-
ficial light. No muscular anomaly beyond a general want of
power in the ocular muscles as tested by prisms. Ace. good.
Hyperopia=0.50D., but unable to use the eyes continuously —
either with or without glasses. Referred to Dr. Alloway on
account of supposed uterine trouble.

Sexual history. — Married 21 years ; four full-term children,
youngest 12 years of age. Has had many miscarriages. Last
pregnancy six years ago. Menstruation irregular ; duration
eight days. Severe dysmenorrhoea, increasing in severity of
late. Is a great sufferer from constant pelvic and abdominal
pain, and incessant vomiting for days at a time. Has had
cervical canal dilated upon several occasions by sponge tents.

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Examination. — Uterus antoflexed ; both broad lignments
seem thickened and fix uterus and appendagos to the side walls
of pelvis; whoh pelvic contents oxtiemely tender to touch;
cervical canal open and issuing glairy mucopurulent discharge.
Patient has been for years a confirmed invalid.

Operation. — Laparotomy. Removed appendages ; they were
BO adherent and encased in organized exudation that they had
to be removed piecemeal. Eecovery perfect.

This patient, when seen a year aftei:, operation, reported
that she had no attack of vomiting since operation. Her eye-
sight was much better, but, from a feeling of precaution, wore
glasses. Quite recently this patient reports that her health
has been quite restored. Has no pain whatever; has become
stout and strong. Her eyesight normal.

Case IX. — Has been a chronic invalid for years. For the
past twelve months subject to great weakness of the eyes,
which has taken the form of recurrent attacks of kerato-con-
junctivitis. The right cornea presents a central nebula, the
left a zone of fine blood-vessels encroaching on its upper third.
The conjunctiva of eyelids is very hypereemic and decidedly
i-oughened near their anterior margins ; the lids, too, pi-ess more
closely than is usual upon the eyeballs. This patient also pre-
sents a hypertrophic rhinitis and acne of the external integu-
ment of the nose. The irritability of the eyes may be due in
part to the nasal trouble. Pain and intolerance of light are
much complained of. These conditions have persisted, with
occasional remissions, since last autumn.

Sexual history (May, 1892). — Kxtensivo laceration of cervix
with eversion of segments. Pelvic floor destroyed and perineum
torn to sphinctei*. Hyperplastic endometritis. Pain and
menorrhagia. Intermenstrual leucorrhoea. Constant headache
and backache.

Operation. — Curettement ; excision of cervix ; restoration of
pelvic floor and perineum.

The husband of this lady writes, date October 24th, 1892;
"She is now enjoying very good health. Her eyes are much
better and stronger. I am hopeful the improvement will be
permanent."