Affections of the Eye 
FROM 
SMALL-POX, 
BY CHARLES J. KIPP, M.D., 
OF 
Newark, N. J. 
Reprinted from Transactions oj Medical Society of New Jersey, 1874. 
NEWARK. N. J.; 
Jennings & Hardham, Steam Printers and Bookbinders, 153 & 155 Market Street. 
1 8 7 '1 . Affections of the Eye 
FROM 
SMALL-POX, 
BY CHARLES J. KIPP, M. D., 
OF 
Newark, N. J. 
Reprinted from Transactions of Medical Society of New Jersey, 1874. 
NEWARK, N. J.: 
Jennings & Hardham, Steam Printers and Bookbinders, 153 & 153 Market Street. 
18 74. AFFECTIONS OF THE EYE FROM SMALL-POX. 
The parts of the eye most frequently affected in Small-pox 
are the lids, the conjunctiva, and the cornea. The lachrymal 
passages, the vascular tunic, and the retina are comparatively 
seldom involved in Variola. For the sake of convenience, I 
shall treat, first, of the disease of the lids; second, of the 
lachrymal passages; third, of the conjunctiva; fourth, of the 
cornea; fifth, of the uveal tract and the retina. 
The formation of pustules on the upper surface of the lids 
is always attended by more or less oedema, but is never 
followed by unpleasant consequences, unless a number of the 
pustules coalesce. In this case, the subsequent contraction of 
the cicatrix may produce a slight ectropion. If pustules are 
developed at the free edge of the lid, or in the intermarginal 
space, they not unfrequently cause disease or total destruction 
of the hair-bulbs. Distichiasis, trichiasis and permanent loss 
of the eye-lashes may be thus produced. The cicatrices left 
by pustules in this situation are very unsightly, and a constant 
source of irritation to the eye. 
Hirschberg* is of opinion that true pustules are never seen 
at the intermarginal portion of the lid, and that the infiltra- 
tions observed there are of a diphtheritic nature, similar to 
those occurring in the mouth and uares in this disease. 
Various means have, at different times, been employed 
* Berliner Klinisclie Woclicnsclirift, No. 24,1871. 4 
with a view to prevent the development of pustules on the 
lids, but as they all failed to accomplish this object, it would 
be useless to give a detailed description of the same. If 
pustules have formed in this situation, it is best to open them 
and to evacuate their contents. The edges of the lids should 
be bathed with warm water, so as to remove the crusts from 
the lashes, and some simple ointment may be applied to pre- 
vent the new formation of crusts. If the ulcers are slow in 
healing, they should be painted over with a weak solution of 
nitrate of silver, every day, and, in very obstinate cases, they 
may be touched with a finely-pointed crayon of the sulphate 
of copper, or the mitigated nitrate of silver. 
The tear-conducting apparatus is only seldom affected in 
small-pox. The disease most frequently produced under 
these circumstances is Blennorrhoea of the lachrymal sac. 
The only case of this affection that has come under my 
observation, occurred in a boy three years of age, whom I 
first saw about three months after he had had an attack of 
variola. His parents were positive that his eyes had been 
perfectly healthy previous to the attack, and that his present 
disease first manifested itself during convalescence from the 
variola. There can be no doubt that in this case the blen- 
norrhoea supervened Upon a severe inflammation of the lining 
membrane of the respiratory tract, from which he suffer- 
ed during this attack. The symptoms differed in no 
respect from those observed in cases of lachrymal blen- 
norrhoea produced by other causes. The usual treatment 
of slitting up the upper canaliculus, followed by the daily 
introduction of Bowman’s probes and frequent syringing of 
the nasal cavity with warm salt water, caused the disappear- 
ance of the disease in about three months. 
Hypersemia of the conjunctiva, or conjunctivitis, more or 
less severe, occurs in nearly all cases of small-pox. The 
conjunctivitis usually commences during the first days of the 5 
eruption, and may assume either a catarrhal, blennorrhoic 
or phlyctenular character. In the majority of the cases it 
presents itself in the phlyctenular form. The symptoms of 
this affection are so well known that I shall not describe them 
here. Previously healthy eyes are very seldom seriously 
injured by the conjunctivitis of variola, but if the conjunc- 
tivitis occurs in eyes already suffering from an affection of 
the conjunctiva or cornea, it usually greatly aggravates such 
affections, and not unfrequently causes loss of vision. 
A man, thirty years of age, who had for some mouths been 
under my care for chronic blennorrhoic conjunctivitis and 
ulcer of cornea of left eye, and who was slowly recovering, 
was attacked by small-pox, for which he was treated in a 
hospital. The attack was quite a severe one. Immediately 
after his dismissal from the hospital, he returned to me for 
further treatment, and I then found the cornea of the left eye 
nearly destroyed, and the conjunctival disease much worse 
than at any time before the attack. His right eye was now 
also affected with the same disease as the left. The man is 
still under treatment, and there is some prospect that he will 
at least retain useful vision in his right eye. 
Beer, Conradi, and most of the older writers on diseases of 
the eye, were of the opinion that the diseases of the conjunctiva 
and cornea, seen in small-pox, were caused by the formation 
of pustules on the conjunctiva and cornea. More recent 
observations have, however, shown that variolous pustules are 
only very rarely developed in these structures. Dr. I. T. 
Marson,* who has had exceptional opportunities for studying 
this subject, says; “ Out of 1,500 cases, no instance had then 
or for some time afterwards come under his notice in which 
the pustules of small-pox formed on the eye. It does, how- 
ever, happen now and then. In nearly thirty years the number 
* Reynold’s System of Medicine, vol. 1, page 443. 6 
of cases of small-pox admitted into the hospital has exceeded 
15,000. Out of this number, twenty-six instances have been 
noticed in which the primary pustule has formed on the eye. 
It has not, however, in any one of these instances injured the 
eye in any way.” 
Of the more recent writers on this subject, Prof. Horner* 
is the only one who believes that the corneal affections occur- 
ring in variola are caused by the formation of pustules on the 
eye-ball. 
In nearly all of the cases in which a pustule was developed 
on the eye, it was situated in the inner or outer quadrant 
of the ocular conjunctiva. It has never been seen on the 
cornea. 
My own experience with regard to this point is limited to 
the following case: On the 30th of June, 1873, I was 
requested by Dr. Lehmacher to see a man, thirty years of age, 
who was suffering from a very mild attack of variola compli- 
cated with disease of right eye. The man had been vacci- 
nated in infancy, but had not been re-vaccinated. There 
were but few pustules visible. I examined his eye on the 
fourth day of the eruption and found great cedema of the 
lids, severe congestion and considerable swelling of the ocular 
conjunctiva, and in this membrane, nearly midway between 
the cornea and outer canthus, was seen a round white infil- 
tration of about the size of a split pea. The infiltration 
was in every respect like the so-called pustules present in the 
mouth and pharynx of the same man. The cornea was per- 
fectly transparent. Under the use of cold applications to the 
eyelids, the infiltration was soon thrown off, and the ulcer 
left by it healed without further treatment. Subsequently, 
after all the dried scabs had fallen off, an extensive and deep 
* Nagel, Jahresberiobt ueber die Leistungen und Fortscbritte im Gebiete der 
Opbtbalmologie. 2 Jahrgang, Seite 197. 7 
central infiltration was developed in tlie cornea of the same 
eye; of this I shall speak hereafter. 
Variolous conjunctivitis usually passes away with the 
eruption, and in most instances requires no treatment. 
Cold applications to the eyelids are, however, of service 
in relieving the burning and smarting, and should 
be used in every case in which the inflammation is at 
all marked. If the conjunctivitis continues after the 
primary disease has passed otf, it will be necessary to make 
topical applications of solutions of nitrate of silver or sul- 
phate of zinc, to the conjunctiva. 
The affection of the cornea may be said to be the most 
dangerous, so far as the sight is concerned, of all the various 
diseases of the eye, seen in small-pox. The lesion most fre- 
quently observed under these circumstances, is a circum- 
scribed infiltration in the substance of the cornea. It rarely 
manifests itself before the tenth day of the eruption, and is 
most commonly seen about the fourteenth day. In some 
cases it does not, however, commence till some weeks after 
all scabs have fallen off. To the latter form some authors 
have applied the name of Post-Variolous Keratitis. 
The number of cases of circumscribed corneal infiltration 
from variola that has lately been under my care, and of which 
I have notes, is twelve. In three of these the infiltrations 
were situated in the superficial layers, and in the remaining 
nine, in the middle and posterior layers of the cornea. Of 
the superficial infiltrations, two were located in the centre, and 
one was situated in the periphery of the cornea. The peripheric 
infiltration was formed during the suppurative fever, the 
central infiltrations during convalescence. In each of the 
three cases, the infiltration presented itself as a round, flat, 
greyish-white spot, of about the size of a lentil. The infil- 
tration was soon thrown otf, leaving an open ulcer which 
spread in circumference but not much in depth. In the case 8 
in which the infiltration was situated at the margin, the ulcer 
extended over the entire lower half of the cornea, and 
involved about one-half of its thickness. The subjective 
symptoms consisted of pain in and around the eye, photopho- 
bia and lachrymation. More or less congestion of the epi- 
scleral vessels was present in each of the cases. They all 
did well, the sight being now nearly as good as before the 
attack. 
Infiltrations in the deeper layers of the cornea were observed 
in nine cases. In two of these, several infiltrations appeared 
at the opposite margins of the cornea, during the secondary 
fever. At the time these patients came under my charge the 
entire cornese were yellow and shriveled, and were shortly 
afterwards exfoliated. Total staphyloma was the result in 
both cases. In the remaining seven cases the infiltrations were 
situated in the centre of the cornea, and were developed either 
during the stage of desiccation or during convalescence. The 
symptoms of irritation were well marked in all of these cases. 
The infiltration which at first presented itself as a bluish- 
white cloud in the posterior layers, soon increased in size 
and assumed a yellowish tinge. The layers immediately in 
front of the infiltration, were at first lustrous and transparent, 
but soon became dull and opaque, and were afterward 
exfoliated. In three of the cases hypopion was developed? 
and spontaneous perforation would, in all probability, have 
occurred in these same cases if this accident had not been 
averted by paracentesis of the cornea. Two of the cases 
were of more than ordinary interest. The first derives its 
interest from the fact that both eyes became affected,—an 
occurrence which is but seldom observed. In the left eye, 
deep-seated marginal infiltrations were developed during the 
suppurative fever, and caused destruction of the entire cornea 
and the formation of a total staphyloma. The cornea of the 
right eye showed no signs of disease till the primary disease 9 
had passed off, when a deep-seated central infiltration formed 
which, fortunately, left but a faint macula. The second 
is the case already mentioned, in which a pustule was 
seen in the ocular conjunctiva, on the fourth day of 
the eruption. On the eleventh day, the skin being at the 
time free from scabs, and the ulcer left by the pustule on the 
conjunctiva having healed, a deep-seated infiltration made 
its appearance in the centre of the cornea. Extensive ulcera- 
tion of the cornea and hypopion threatened destruction of 
the eye, but, after a very protracted convalescence, he was 
discharged, with a dense central leucoma of moderate size. 
The results obtained in the nine cases of deep-seated infil- 
tration were as follows: In five a moderate central opacity 
remains; in two the sight is much impaired by a dense cen- 
tral leucoma, but may be greatly improved by the formation 
of an artificial pupil; and in the remaining two, total staphy- 
loma of the cornea followed the destruction of this structure. 
A feature common to all the cases above referred to, was the 
extreme slowness of the process of repair, the length of time 
required for the complete cicatrization of the ulcer being in 
most of the cases from four to six months, and in a few, more 
than a year. 
An examination of my notes, with reference to the severity 
of the primary disease in the above cases, shows that the 
gravity of the corneal affection by no means corresponded to 
the quantity or character of the eruption. Both mild and 
severe corneal diseases were observed in bad cases of variola, 
and one of the worst of the cases of eye disease above men- 
tioned occurred in a patient who had only a few pustules on 
his face and neck. Ten of my patients had never been vac- 
cinated. Total destruction of the cornea occurred in two of 
these; in one the disease left a dense leucoma, and in the 
remaining seven, a slight macula. Two had been vaccinated 
in infancy, but had not been re-vaccinated. Both were over 10 
fifteen years of age. In one a dense central leucoma remains, 
and in the other the disease left a macula in lower half of 
cornea. 
With regard to the causes of this disease of the cornea, we 
have as yet no positive knowledge. It is generally supposed 
to be due to a lowered vitality, resulting from the small-pox 
poison, but that such is not always the case, is apparent, I 
think, from the fact, that one of the largest corneal infiltra- 
tions observed by me occurred in a person who did not feel 
sufficiently sick to remain in his room till the eruption had 
disappeared. 
The treatment pursued in these cases varied somewhat, 
according to the degree of the irritation present in each case. 
Instillations of a solution of the Sulphate of Atropine were 
used in all. The strength of the solution ranged from /two 
to four grains of the alkaloid to the ounce of water, and the 
instillations were made three to six times daily. In cases in 
which there was a marked congestion of the episcleral and 
conjunctival vessels, tepid water fomentations were applied 
to the eye for half an hour to an hour at the time, three or 
four times daily; but if the symptoms of irritation were not 
very pronounced, warm water was substituted for the tepid. 
The fomentations were continued till the process of repair 
was well under way. In all cases the eye was protected by a 
bandage in the intervals between the fomentations, and for 
some time after their use had been stopped. The pressure 
bandage was applied only in cases in which the ulcer threat- 
ened to perforate. In two of the cases it became necessary 
to puncture repeatedly the bulged-out floor of the ulcer to 
prevent spontaneous perforation with all its serious conse- 
quences. To relieve the ciliary neuralgia, subcutaneous 
injections of sulphate of morphia were made in the temple. 
The swelling of the conjunctiva, especially of the retrotarsal 
fold, which was developed in several of the cases after the 11 
protracted use of the bandage, required for its removal daily 
applications of a solution of the nitrate of silver (five grains 
to the ounce of water). To expedite the clearing-up of the 
opacities of the cornea, finely powdered calomel, or a weak 
salve of the yellow oxide of mercury (one grain to the drachm 
of lard) was applied to the conjunctival sac. In addition to a 
nutritious diet, some preparation of iron or sulphate of quinia 
was prescribed in every ease. 
Besides the circumscribed infiltrations of the cornea, other 
observers have met in small-pox with cases of parenchyma- 
tous keratitis, and neuro-paralytic ulceration of the cornea. 
As the symptoms of these affections are so well known, and 
the treatment is the same whether they are a complication of 
small-pox or not, it will be unnecessary to make further 
reference to either. 
Of the diseases of the uveal tract which occasionally com- 
plicate small-pox, Iritis has been most frequently observed, 
v. Graefe* says that it is mostly of a mixed sero-plastic char- 
acter, and that it appears to be always combined with serous 
choroiditis. Such, at least, was the case in more than thirty 
cases of variolous iritis which came under his observation. 
From this it would seem that simple iritis is never or, at all 
events, very rarely seen in the course of small-pox. The 
accompanying affection of the vitreous body may also induce 
posterior polar and cortical cataract, which will remain after 
the complete disappearance of the other anomalies. 
Hagelf has also met with several cases of post-variolous 
iritis, in each of which the iritis was of a serous character, 
and accompanied by opacities of the vitreous. The course of 
the disease was favorable, although somewhat protracted. 
According to Bouchard| the variolous iritis commonly 
* ArcMv f. Ophthalmologic, xv. 3, p. 194. 
f % Nagel op. eit. p. 250. 12 
attacks but one eye, and commences during the stage of des- 
iccation. It is not preceded by an eruption of pustules on 
the lids or on the conjunctiva, nor by keratitis. Its symp- 
toms are pain in and around the eye, impairment of sight, 
injection of episcleral vessels, and sometimes discoloration 
of iris and sluggishness of pupil. Its course is on the whole 
favorable, and atropine produces speedy relief. Bouchard 
compares post-variolous iritis to the inflammation of the iris, 
which is sometimes observed simultaneously with rheumatism 
in gonorrhoea. 
The iritis of small-pox rarely manifests itself till after the 
scabs have fallen off, and is therefore not inappropriately 
called post-variolous iritis. 
Leeches to the temple, frequent instillations of a strong 
solution of sulphate of atropine, and application of cold to 
the eye, are the means usually employed in this disease. 
Hypodermic injections of sulphate of morphine are some- 
times needed to relieve the pain, and in severe cases it may 
become necessary to administer some form of mercury. 
Von G-raefe* makes mention also of a case of glaucoma 
supervening upon hemorrhagic choroiditis, occurring in a 
patient suffering from hemorrhagic small-pox. 
Variolous Retinitis is apparently very seldom met with, as 
I can find the record of only two cases of this diseasef in the 
literature of this subject at my disposal. As nothing to the 
contrary appears in the record, it is to be presumed that the 
symptoms and the treatment of this form of retinitis do 
not differ materially from those of idiopathic retinitis. 
* Archiv. f. Ophthalmologic, xv. 3,193. 
+ Nagel, Op. Cit. page 180.