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, Critchett127 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.
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 Kuhnt129).
128 Untersuchungen am d. Physiol. Institut. d. Univ. Heidelberg, Bd. ii. Heft 2.
129 Ueber Erkrankung der Sehnerven bei Gehirnleiden, 1879.
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. Marson130 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;" Coccius131 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 states132 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 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 Benedict135 also bears testimony to the great diminution in the intensity of variolous ophthalmia after the introduction of vaccination.
130 London Med. Gazette, 1838-39, pp. 204-207.
131 De Morbis Oculi humani que e Variolis exedi, etc., Leipzig, 1871.