84 "Sehstörungen bei der Pneumonie," Deutsches Klinik, 1862, No. 27.
Affections of the Eye caused by Diseases of the Digestive Organs.
TEETH.—Ophthalmic literature furnishes many instances of diseases of 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 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.
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.
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 Laurence87 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 attention88 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.)
87 Amer. ed. by Hays, 1847, p. 554.
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 Buchwald91 have all recorded cases of retinal hemorrhage in cases of grave disease of the liver. Litten92 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 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?]. Foerster93 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.
89 Heinrich Müller's Gesammelte Schriften, pp. 331-335.