IRIDO-CHOROIDITIS 
IN THE 
PUERPERAL STATE, 
BY 
. 
Thomas R. Pooley, M.D., 
NEW YORK. 
[Extracted from the Transactions of the New York Imitate Medical Society.| 
ALBANY, N. Y. : 
VAN BENTHUYSEN PRINTING HOUSE. 
1877. IRI DO-CHOROIDITIS 
IN THE 
PUERPERAL STA SfE 
4* 
The inflammation of the uveal tract which occurs in the'course 
of certain putrid, infectious diseases, especially in pyaemie and 
puerperal processes, supposed to be caused by embolus or embolic 
infarction, as a result of metastatis, has but rarely attracted the 
attention of oculists, on account of the rarity of its occurrence, and 
of the importance of the grave, general morbid phenomena which 
usually accompany it, and threaten the life of the patient. My 
interest in this subject has lately been excited by a case which has 
been under my observation, which I will now proceed to report. 
In order to make the history of the case interesting to the general 
practitioner, as well as to put together the relation between the 
puerperal condition and the eye disease, I shall take the liberty of 
reporting the case somewhat in detail. I am indebted to Dr. 
Colin Mackenzie, of New York, for the notes of the case, as well 
as for the opportunity of observing it. The doctor’s notes are as 
follows, except the description of the eye disease, which I have 
inserted myself: 
I was called Friday, the 23d of March, at 1 a. m., to attend 
Mrs. P., set. 21, primipara. On examination, I found a left 
oceipito anterior presentation, and the os slightly dilated, pains 
regular, and labor proceeding normally. The second stage of 
labor was entered about 7 a. m., and terminated at 9g, with the 
birth of the child,—placenta expelled by Crede’s method. Imme- 
diately after its removal the patient complained of feeling sick and 4 
faint, and continued to pass from one fainting fit to another, with 
nausea and vomiting ; loss of pulse at the wrist, and quite a pro- 
fuse flow of blood, although the uterus had contracted to about 
five inches in diameter. Brandy by the mouth, a large enema of 
the same with milk, and a tablespoonful of Squibb’s fluid extract of 
ergot were given. The cause of this sudden collapse was consid- 
ered to be due to the occurrence of a superficial rupture of the 
uterus. Dr. Noeggerath, who saw the case in consultation with 
me, found the heart’s action decidedly feeble on auscultation, with 
an almost imperceptible pulse. 
In about an hour she had rallied somewhat, the pulse was felt 
to be growing stronger, and at the end of two hours she seemed 
to have recovered entirely from the attack. She continued to 
improve until Monday evening, when she complained of slight 
pain on pressure in the lower part of the left side of the pelvis. 
Nothing abnormal could be detected by vaginal examination. 
The pain was relieved by quinine and carbolic acid internally, and 
by Tuesday evening had entirely disappeared. 
On Wednesday, the 28th, she seemed quite well, with tempera- 
ture 101° and pulse 100. No tenderness on pressure, although 
the lochia was diminished, but odorless. During the rest of the 
week pulse ranged from 92-96, and temperature from 99-101°. 
The bowels and bladder acted naturally. She slept and ate well. 
She did not nurse the child, and the milk secretion was checked 
by the application of belladonna. 
On Thursday, April 5th, 14 days after confinement, she had a 
severe attack of neuralgia of the right side of the face and head, 
which was relieved by quinine internally and chloroform exter- 
nally. The pulse had risen to 106 and temperature to 102°; but 
the following day she seemed quite well again, free from pain, with 
pulse 92 and temperature 100°. On Saturday, the 7th, at 4 a. m., 
she was seized with excruciating pain in the left eyeball. When 
Dr. Mackenzie saw her at 11 a. m. she could see quite well, and 
the only abnormal appearance of the eye was a congestion of the 
conjunctiva, which was attributed to the application of chloroform 
and vinegar made by the nurse. Cold applications were ordered, 
and quinine and a hypodermic injection of morphine, given at 5 p. m. 
There was slight protrusion of the eyeball, corneal opacity and 
total loss of sight. Pulse 102 and temperature 103°. At this 5 
time I was called in consultation, and made an examination of 
the eye. The lids were somewhat swollen, there was a slight 
frothy, muco-purulent discharge—serous chemosis—the cornea 
diffusely opaque. A few lines from its margin there was a circle 
of purulent infiltration, which extended quite round its circum- 
ference. The centre of this ring was also opaque, infiltrated, hut 
not purulent. Moreover, the entire cornea was anaesthetic. Upon 
touching it with a roll of paper, the patient did not make the 
slightest movement of the lids. Through the central part of the 
cornea, an indistinct view of the anterior chamber could be obtained, 
and it appeared to be tilled with pus. There seemed to be some 
increase of tension of the globe, but the eye was so exquisitely ten- 
der to pressure, that it was difficult to determine this point accu- 
rately. Perception of light existed in all parts of the visual field. 
There was slight exophthalmos. Instillations of atropine and the 
constant application of hot compresses were ordered, and hypo- 
dermic injection of morphine to relieve the supra-orbital neuralgia, 
which was very severe. The diagnosis of purulent irido-choroidi- 
tis was made, and taken in connection with the severe constitu- 
tional disturbance, and its sudden development, both Dr. Macken- 
zie and myself had no hesitation in the opinion, that the patient 
was suffering from purulent infection. 
A thorough vaginal and uterine examination was made by Drs. 
Noe£<»;eratli and Mackenzie. There was no laceration of the os 
or perineum, no heat of the vagina, no phlebitis discoverable. 
Dr. N., however, thought he could detect a deep-seated abscess of 
the vulvo-vaginal gland, of the left side. Pulse, 120; tempera- 
ture, 103.5°. Quinine increased to live grains every two hours, 
combined with two grains of carbolic acid. Her temperature, 
however, continued to rise until 10 p. m. It had reached 104.5°, 
when Dr. Thomas was added to the counsel of the case. He could 
find no satisfactory explanation for her condition. While he was 
present, she was taken with intense pain in the left elbow joint. 
He advised the cold bath for about ten minutes, to be repeated 
every three hours. After the first bath temperature fell to 102°, 
pulse to 116. They were repeated regularly until six had been 
taken, but after the third hey temperature and pulse rose to 
104.5° and 120 respectively. In spite of all treatment her con- 
dition continued to grow worse and worse, and the temperature 6 
and pulse to go higher and more frequent. Diarrhoea and hic- 
cough set in ; her memory began to fail, and mind to wander. 
On Sunday a. m. her pulse fluctuated between 148 and 1G0, 
temperature 105.2°, and continued about the same until Monday 
morning, when the pulse was so rapid that it could not be counted ; 
temperature was 107.2°, and she died at p. m. No post- 
mortem could be obtained. I had the opportunity of watching 
the eye through the progress of the disease. The swelling of the 
lids and conjunctiva slowly subsided, and never increased after the 
first observation. 
The entire cornea became infiltrated with pus. Pain subsided 
after about forty-eight hours, after which she did not complain, 
unless the eyeball was touched. In four or five days the sensibility 
of the eye returned, and sloughing of the cornea began, but per- 
foration of the globe did not ensue. 
Without venturing any remarks upon the puerperal complica- 
tion, which was, however, clearly enough one of pyaemia, I will 
offer a few remarks upon the eye affection. In the first place, the 
course of the disease is in some respects different to that usual 
in panophthalmitis or purulent choroiditis. The inflammatory 
symptoms are not so severe ; there is not so much swelling of 
the lids and ocular chemosis, as occurs in other forms of pan- 
ophthalmitis. Another peculiarity in the case just related, is the 
involving of the cornea in the purulent process. I was at first 
thrown off my guard in the diagnosis by this symptom, and was 
inclined to think that I had to deal with a suppurative process in 
the cornea. But the quite sudden loss of sight, and the grave 
constitutional symptoms were against such a supposition. The 
severe pain, and the anaesthesia of the cornea, were most likely 
caused by a temporary increase in the tension of the globe, although 
it was difficult to determine any increase of hardness on account 
of the excessive tenderness of the eye. It has been recog- 
nized, for some time, that suppuration of the iris, choroid, and, 
indeed, all the tissues of the eye may occur in many forms of 
pyaemia, from many different causes, such as inflammation of the 
umbilical cord in the new born, in grave typhous affections after 
scarlet fever, small-pox, malignant pustule, phlegmonous erysipe- 
las and affections of the skin. Middlemore says, that he saw it after 
cholera ; H. Schmidt after acute rheumatism, without heart dis- 7 
ease, and in cases of extensive tuberculosis. Its occurrence in the 
puerperal state must, however, be very rare. This is the first case 
of the kind which has come under my own observation ; and Dr. 
Thomas, whose opportunities for seeing all complications of the 
puerperal state, are especially good, told me that this was only 
the second case of the kind which had come under his observe 
tion. The other one he saw twenty-five years ago, in the Dublin 
Lying-in Asylum. Most of the cases which have come under my 
notice, have occurred in the course of cerebro-spinal meningitis. 
The generally accepted view in regard to the way in which the 
eye disease occurs in metastatic choroiditis, is that it is caused by 
embolus or embolic infarction of some vessel or vessels within 
the eye. 
It is an established fact, proved conclusively by Knapp in his 
excellent work (on Metastatic Irido-Choroiditis, Clinically and 
Anatomically Explained, Archiv. fiir Ophth., Bd. XII, 1, p. 127), 
that there is a large accumulation of pus with cellular tissue pro- 
liferation between the choroid and retina, which occurs at the 
expense of the choroid and iris, causing a considerable thicken- 
ing of the same. By this means the retina, vitreous, and even the 
lens may be infiltrated with pus. But search was made in vain 
for an embolus in the vessels of the uveal tract. 
An isolated accumulation of pus mixed with blood corpuscles, 
which Knapp found under a retina infiltrated by pus, was taken 
to be an hemorrhagic purulent infarction, because the adjacent 
vessels were overloaded with blood. Wccker, in his article on 
this subject (in Graefe Saemisch Hand Buch Der Gesammten 
Augenheilkunde), questions the correctness of Knapp’s conclu- 
sions. He says, the assumption, however, that the noxious 
substance taken into the circulation is capable of producing a 
plugging up of the vessels of the chorio-capillaris, and the subse- 
quent hypenemia, hemorrhage, and suppuration which then 
appear in the stroma of the adjacent larger blood vessels, remains 
only an hypothesis. It is still less proven that a hemorrhagic or 
metastatic focus suffices to produce parenchymatous inflammation 
in the remaining portions of the choroid, at first, and later also in 
the other membranes of the eye, in other words, to cause a true 
purulent panophthalantis. Wecker holds, that there is a tendency 
of the white blood corpuscles to transude through the blood 8 
vessels, caused by the effect of the infectious substances, which 
are taken into the circulation, upon their walls. 
H. Schmidt also (Anatomical Investigations of a case of Metas- 
tatic Irido-Choroiditis) maintains that in the blood vessels neither 
emboli nor purulent thrombi could be found, although Vir- 
chow, Otto, Weber, and other experimenters have shown that this 
form of choroiditis occurs in artificially induced emboli; still the 
direct connection of the rapidly occuring metastatic suppuration 
with the process of embolism has not been positively proven. 
A case has quite lately been published by L. Weiss, which he 
reported at the Ophthalmological Congress in Heidelberg, in 1875 
(Klin. Monatsblatter fur Augenheilkunde, 1875, p%397), of metas- 
tatic irido-choroiditis of both eyes, occurring in pyaemia after a 
complicated fracture, in which the microscopic examination de- 
monstrated a thrombosis in one of the affected eyes. While, so 
far as I am aware, this is the only case in which the obliteration 
of a vessel in the eye has really been observed, this theory seems 
to us to be the more tenable of the two—and quite as free from 
mere hypothesis as that offered by Wecker, unless he will 
demonstrate in what manner the walls of the blood vessels are 
affected by the toxic condition of the blood, or even demonstrate 
that they are altered at all. It seems to us that he is unnecessarily 
severe in his strictures upon the other theory, which, to say the 
least, is just as good as the one he offers. 
There is a form of metastatic irido-choroiditis, which has been 
described by a number of observers—especially Schmidt, Knapp 
and Wecker—which must be entirely separated from that occur- 
ring simultaneously with pyaemia and other infectious diseases, and 
which is based on the communication of the sub-choroidal space 
with the inter-vaginal sheath of the optic nerve, and the cavity of 
the skull (sub-dural space). It is observed principally as occur- 
ring in cerebro-spinal meningitis, typhoid fever, tuberculosis, etc., 
and differs materially in its clinical features from the septic form. 
It is generally less acute. It never causes such extensive suppura- 
tion, especially of the retina, and we often have the opportunity 
to observe it terminate in partial phthisis bulbi. Often, especially 
in cerebro-spinal meningitis, the origin of the disease passes unno- 
ticed, since the grave general symptoms absorb the attention of 
those surrounding the patient. In the beginning of the disease, 9 
if opportunity l>e afforded to see it at that stage, we find consider- 
able chemosis, with slight protrusion of the eye, which can be 
explained by the assumption of an overfilling of the lymph spaces 
of the eye (Michel.) Numerous synechiae are formed, which bind 
the lens more or less firmly to the somewhat dilated pupil. Lens 
and iris are soon pushed forward so that the anterior chamber 
almost entirely disappears. From the beginning of the disease of 
the eye, a whitish reflex is noticeable, which we receive from the 
pupil, even if it should be extensively covered by exudation, the 
visual power suffers very rapidly and materially, so that even per- 
ception of light is wanting. If the patient survives the general 
disease, tne irritation rapidly decreases, and a very marked atrophy 
of the tissue of the iris takes place, so that often, both through the 
membrane covering the pupil and the atrophic iris, which lies 
close to the posterior surface of the cornea, we see the white fundus 
of the eye shining through. The just described course is that 
which we have always observed, and the pushing forward of the 
iris, with the whitish reflex from the vitreous, is such a character- 
istic picture that we do not hesitate, in children who are brought 
to us with it, to diagnose a passed meningitis, which is usually 
cerebro-spinal. 
This form of disease commonly only affects one eye. I have 
only seen one case myself in which both eyes were affected, and 
the patient became absolutely blind ; but in a small percentage of 
cases it occurs in both. The other form of the disease, occurring 
in pyaemia and septicaemia, is said to more often affect both eyes, 
either simultaneously or at different periods ot the disease. In the 
case which we have reported, it seems plausible to suppose that 
the severe pain which was felt first on the right side might have 
been caused by the same morbid condition of that eye, which, 
however, did not go far enough to produce actual suppurative 
inflammation.