the eye said to be caused by affections of the teeth. These vary in
severity from slight conjunctivitis and photophobia, or temporary
failure of accommodation, to absolute amaurosis. It is natural to
suppose that affections of the dental division of the trigeminus might
readily give rise to reflex disorders in parts supplied by branches of
the same main trunk. Although the writer has been on the lookout for
such affections, he has seen very few cases of eye disease which could
be logically attributed to disease of the teeth, and has known at least
two sound teeth which were uselessly sacrificed to mistaken theories of
pathology. Perhaps the most noteworthy effort to assign dental
neuralgia as a cause of amaurosis is the well-known paper of Jonathan
Hutchinson in the _Royal London Ophthalmic Hospital Reports_ for 1865.
An attentive study of the interesting cases there recorded shows that
but few of them can be considered as affording convincing evidence of
the point which he desires to prove, and few are probably more keenly
aware of this fact than the distinguished surgeon himself when he
writes: "I am quite alive to some of the sources of mistake which
attend the attempt to prove the occurrence of paralysis from reflex
irritation consequent on a peripheral cause: chief among them we have,
of course, the possibility that the neuralgia itself may have been due
to central disease, and that the extension of the latter may have
complicated other nerves."[85] That amaurosis does, however, sometimes
follow dental irritation is proved by Hutchinson's first case in the
above-quoted paper, where neuralgia of the eyeball with great
intolerance of light was cured by extraction of a carious molar tooth.
Perhaps the most striking case on record is that of Galezowski,[86]
where a small fragment of wood which had entered the cavity of a
carious tooth (probably from picking the teeth with a wooden
toothpick), lodged at the extremity of one of the fangs, is said to
have caused absolute blindness of the eye, with dilatation of the pupil
on the same side. After a blindness of eleven months the tooth with the
foreign body was extracted, causing the evacuation of a few drops of
thin pus from the antrum; after which the patient improved and vision
gradually returned, so that on the ninth day after the operation he
could see with the affected eye as well as with the other. Schmidt,
after an examination of 96 patients with carious teeth, formulates the
following conclusions: "1. That we may have a more or less considerable
limitation of the accommodation {750} in consequence of pathological
irritation of the dental branches of the trigeminus. 2. This may occur
on both sides. Where the affection is one-sided, it is always on the
side of the affected tooth. 3. It is usually an affection of the young,
very seldom or never occurring in old age. 4. That the diminution of
the power of accommodation is due to increased intraocular pressure
caused by reflected irritation of the vaso-motor nerves of the eye."
These conclusions are interesting, but cannot be considered absolutely
correct, in consequence of the fact that there are no recorded tests
for astigmatism or insufficiency, and that accurate examination of the
state of refraction was impossible through want of a mydriatic which
may in measure have accounted for the existent diminution of
accommodation. More extended and minute investigations of the subject
are desirable.
[Footnote 85: "A Group of Cases illustrating the Occasional Connection
between Neuralgia of the Dental Nerves and Amaurosis," by Jonathan
Hutchinson, F.R.C.S., _R. L. O. H. Rep._, vol. iv. pp. 381-388.]
[Footnote 86: _Archives générales de Médecine_, t. xxiii. pp. 261-264.]
STOMACH, INTESTINES, AND LIVER.--Amblyopia and amaurosis with severe
gastric symptoms are not very uncommon, but, although such cases are
made much worse by the ingestion of indigestible substances,
constipation, etc., it has nevertheless always appeared to the writer
that the primary lesion lay in the nervous system. Galezowski, however,
lays stress on this subject, and discriminates between a true and false
locomotor ataxia; the latter being, according to this author,
symptomatic of stomachic and intestinal lesions. Many of the older
writers relate cases of amaurosis from worms in the intestines. Thus
Laurence[87] gives an instance of sluggishness and partial dilatation
of the pupils with dim vision which promptly disappeared after the
evacuation of seat-worms consequent on an enema of turpentine. Hays
calls attention[88] to a case recorded by Welsh of Massachusetts where
complete amaurosis in a child instantly ceased on a worm being puked
up. Many similar instances might be adduced which in modern books are
either passed over in silence or looked at with a shrug of incredulity.
Although the writer has had no personal experience with such cases, he
can readily understand that in children the irritation of worms might
easily give rise to enough reflex disorder of the spinal cord and brain
as to cause impairment of the accommodation and partial dilatation of
the pupils. (The effects of hæmatemesis and hemorrhage from the bowels
have been already discussed.)
[Footnote 87: Amer. ed. by Hays, 1847, p. 554.]
[Footnote 88: _Ibid._, 1847, p. 555.]
That jaundice shows readily in the conjunctiva is well known to all
practitioners, and yellow vision is described as an occasional symptom
of severe icterus, Jaeger calls attention to a light-yellow color of
the eye-ground and retinal vessels under these circumstances.
Junge,[89] Stricker,[90] and Buchwald[91] have all recorded cases of
retinal hemorrhage in cases of grave disease of the liver. Litten[92]
says that for ten years he has examined every case of liver disease
under his charge with the ophthalmoscope, and found retinal hemorrhages
only in fifteen cases. These occur only when icterus is present, but
are not due, as Traube assumes, to the action of the biliary acids on
the blood-corpuscles. If they were so, we should have blood-stained
lymphatic sheaths instead of corpuscular diapedesis and massing of the
exuded blood. Of these 15 cases, 4 were cases of congestive jaundice, 4
of carcinoma, 1 each of acute fatty {751} degeneration and
phosphorus-poisoning, 1 of abscess, 2 of cirrhosis, 1 of hydrops
cystides filleæ. The hemorrhages were usually in the nuclear layers,
and seldom presented white centres, as in leucocythæmia. In the case of
phosphorus-poisoning there were large white plaques with marginal
inflammation. Litten considers that the pigment-spots reported in the
retina in cases of liver disease (his own cases and Landolt's) are due
not to cirrhosis hepatis, but to a congenital or acquired disposition
to connective-tissue hyperplasia [syphilis?]. Foerster[93] has called
attention to a group of cases which he ascribes to hyperæmia of the
liver and plethora abdominalis, where we find discomfort in the use of
the eyes from the accompanying retinal hyperæmia and diminution of the
range of accommodation, and where the ophthalmoscope frequently shows
premature senile degeneration of the lens, manifested by striæ
occurring in the extreme periphery. Every careful observer will
doubtless agree to the accuracy of this description, and to the
advantages of proper hygiene, exercise, and the alterative mineral
waters (Karlsbad, Saratoga) in such cases.
[Footnote 89: _Heinrich Müller's Gesammelte Schriften_, pp. 331-335.]
[Footnote 90: _Berliner klin. Wochenschrift_.]
[Footnote 91: Foerster, _loc. cit._]
[Footnote 92: _Deutsche med. Wochenschrift_, 25 März, 1882, pp.
179-182.]
[Footnote 93: _G. u. S._, vol. vii. p. 74.]
SPLEEN.--The effect of disease of the spleen in causing disease of the
eye has already been alluded to in the discussion of leucæmic
retinitis.
Xanthopsia appears to be a very infrequent complication of liver
disease. Moxon,[94] who records seven cases of fatal obstructive
jaundice, has never seen it. He remarks that in these cases the
vitreous and lens remained perfectly clear, while the blood-serum was
saffron-yellow and the sclerotic deeply stained (yellow or
olive-green). Rose[95] gives the only case with which the writer is
familiar, in which it was carefully studied and demonstrated with the
spectroscope. Here the violet end of the spectrum was shortened as in
poisoning by santonin, and the blue blindness was so marked that a few
days before his admission to the hospital the patient had excited the
astonishment of his fellow-workmen by mistaking the color of a door
which had been freshly painted blue. The autopsy showed here also that
the vitreous and aqueous were colorless, but the cornea was clearly
yellow. This Rose thinks insufficient to have caused the xanthopsia,
and therefore attributes it to the effect of the jaundice in the
nerve-centres.
[Footnote 94: "Clinical Remarks on Xanthopsia and the Distribution of
Bile-Pigment in Jaundice," _Lancet_, Jan. 25, 1873. p. 130.]
[Footnote 95: "Die Gesichtsläuschungen im Icterus," _Virchow's Archiv_,
vol. xxx. pp. 442-447.]
HEMERALOPIA.--The curious affection hemeralopia, which we well know to
be a constant accompaniment of some forms of congenital nerve-atrophy
(retinitis pigmentosa), and also to affect, at times, considerable
numbers of persons exposed to the glare, overwork, and exposure of an
active campaign, is probably always due to some form of malnutrition or
disorder of the digestive apparatus, and in many cases it is associated
with jaundice and disease of the liver. That glare of light is not
necessary to its production is shown by its development in convalescent
hospitals. Reymond of Turin reports it as developing in an individual
affected by pellagra on whom he had operated for cataract, and who
during the four weeks subsequent had never been out of his room.
Cornillon[96] reports 5 cases of hemeralopia during jaundice, and of
these 4 came under his observation {752} in a single winter in the
hospital in Vichy. It never appeared early in the congestion of the
liver, but always after jaundice had existed for some time, and
disappeared without special treatment--often to recur when the disease
of the liver became more marked. Parinaud[97] has reported 4 such cases
in all, with jaundice, the conjunctiva being yellow, but the media not
tinged. There were no ophthalmoscopic changes. One of these cases was
malarial hepatitis, the other three probably cirrhosis. A curious
change in the ocular conjunctiva has been noted in many of these cases
of hemeralopia, and attention was first called to it by Bitot.[98] He
observed 29 cases at the Hospice des Enfants Assistés at Bordeaux. The
bulbar conjunctiva in the palpebral fissure, usually at the outside of
the cornea, becomes dry and anæsthetic (epithelial xerosis), and a
number of minute points form in it, and the little patch becomes like
mother-of-pearl, iridescent and silvery. They become paler before they
disappear, and come and go with the advent and cessation of the
hemeralopia. Pressing on the conjunctiva over the spot by rubbing the
lids over it often causes little fragments of the dry patch to crumble
off. The adjoining conjunctiva is dry and less pliant, more like
parchment. The extensive occurrence of hemeralopia during the severe
Easter fasts of the Greek Church has been noted by Blessig. There is
frequently diarrhoea associated with this condition. Teuscher also
speaks of conjunctival xerosis and hypopyon keratitis in the young
slave-children in the Brazilian coffee-plantations, associated with
gastric catarrh and diarrhoea.
[Footnote 96: _Le Progrès médicale_, No. 9, Fèvrier 26, 1881, pp.
157-159.]
[Footnote 97: _Archives générales de Médecine_, April, 1881, pp.
403-414.]
[Footnote 98: _Gaz. méd. de Paris_, No. 27, 4 Juillet, 1863.]
Diseases of the Kidneys and Skin.
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.