THE LIBRARY 
 
 OF 
 THE UNIVERSITY 
 
 OF CALIFORNIA 
 LOS ANGELES
 
 GEORGE W. JEAN, SANTA BARBARA, CALIF,
 
 THE EYE 
 
 GENERAL DIAGNOSIS, 
 
 A 
 
 HAND-BOOK 
 FOR THE USE OF 
 
 Students and General Practitioners. 
 
 BY 
 
 E. H. LINNELL, M. D. 
 
 PHILADELPHIA: 
 THE EDWARDS & DOCKER CO., 
 
 1897.
 
 COPYRIGHT, 1897, 
 
 By K. H. LINNELL.
 
 k/W 
 HI 
 
 T17 
 
 Dedicated to 
 
 J. E. LINNELL, Nl. D., 
 
 my FATHER, my PHYSICIAN, 
 
 and my FRIEND.

 
 TABLE OF CONTENTS. 
 
 Introduction. 7 
 
 PART FIRST. 
 
 The Eye Symptoms of Nervous and Constitu- 
 tional Diseases. 9 
 
 CHAPTER I. 
 
 Affections of the Eyelids, Conjunctiva, Orbit, 
 
 Globe, Sclera and Cornea. n 
 
 CHAPTER II. 
 Affections of the External Ocular Muscles. 27 
 
 CHAPTER III. 
 
 Affections of the Lens and Iris. Behavior of 
 
 Pupil and of the Accommodation. - - 54 
 
 CHAPTER IV. 
 
 Ophthalmoscopic Appearances of the Fundus 
 Oculi, Including Affections of the Choroid, 
 Retina and Optic Nerve. - 80 
 
 CHAPTER V. 
 
 The Sight and the Field of Vision. The Signi- 
 ficance of Visual Disorders Due to Le- 
 sions Implicating the Intra-Cranial Course 
 of the Optic Nerve Fibres, Including 
 Affections of the Chiasm, Tract, the 
 Optic Ganglia and the Cortical Visual 
 Centres and Psychic Visual Disorders. - 108 
 
 CHAPTER VI. 
 
 A Tabulated Statement of Diseases with More 
 
 or Less Characteristic Eye Symptoms. - 127 
 
 PART SECOND. 
 
 Reflex Neuroses. - - - - 141 
 
 (5)
 
 6 TABLE OF CONTENTS. 
 
 CHAPTER VII. 
 
 The Relation of Ocular Affections to Functional 
 
 Nervous Diseases. - 143 
 
 CHAPTER VIII. 
 
 The Relation of Affections of Remote Organs to 
 
 Ocular Neuroses. 174 
 
 PART THIRD. 
 
 Ocular Affections of Toxic Origin. - 187 
 
 CHAPTER IX. 
 
 Toxic Amblyopia, Chronic Retrobulbar Neuritis : 
 
 (a) Tobacco and Alcoholic Amblyopia ; 
 
 (b) Retrobulbar Neuritis Due to Other 
 Poisons. - 1 89 
 
 CHAPTER X. 
 
 Ocular Affections Caused by Various Therapeu- 
 tic Agents : (a) Disorders of Vision ; (b) 
 Pupillary Phenomena, Disturbances of 
 Accommodation and Other Ocular Symp- 
 toms Caused by Therapeutic Agents. 200 
 
 CHAPTER XI. 
 
 Ocular Affections Resulting from Poisonous Sub- 
 stances Not Medicinal, Administered Ac- 
 cidentally or by Design, or Connected 
 with Certain Avocations. - 214 
 
 CHAPTER XII. 
 
 Ocular Affections Due to Toxic Substances Con- 
 tained in Certain Articles of Food and 
 Drink ; (a) Fungus Poisoning ; (b) Pto- 
 maine Poisoning. Ocular Symptoms At- 
 tending and Following Anaesthesia. 221 
 
 Bibliography. 227 
 
 Index. - 234
 
 INTRODUCTION. 
 
 EXAMINATION of the eyes affords valuable aid not 
 only in the diagnosis of diseases of the central 
 nervous system, but also of constitutional affections and 
 diseases of other organs. 
 
 It has long seemed to the writer that this sub- 
 ject was too much neglected by the general practitioner. 
 The record of the pulse, temperature and respiration, uri- 
 nary analysis, etc., are among the every day routine meth- 
 ods of diagnosis, but the indications furnished by the 
 eye are too little understood, and too often overlooked. 
 
 When this treatise was commenced, it was with 
 the conviction that such a work was demanded, as 
 there was then no similar treatise in the English lan- 
 guage. Much of it was completed before the appear- 
 ance of the encyclopaedic work of Knies entitled " Re- 
 lations of Diseases of the Eye to General Diseases," and 
 I have freely availed myself of any information con- 
 tained therein, which had not previously come to my 
 knowledge. 
 
 It has not been my purpose to enumerate all the 
 eye symptoms which may be associated with the various 
 constitutional and local diseases, but rather to emphasize 
 such as are of direct importance in the way of diagno- 
 sis, and to present such data so as to be of ready refer- 
 ence and practical value. 
 
 (7)
 
 8 INTRODUCTION. 
 
 The book has been written from the standpoint 
 of the specialist for the student and general practitioner. 
 It embodies the personal experience of the writer dur- 
 ing a general practice of twenty years, and fifteen 
 years experience in the treatment of ocular diseases, in 
 addition to extensive reading. 
 
 I have not endeavored to go into the symptoma- 
 tology or differential diagnosis of the various ocular af- 
 fections which are discussed, further than the purpose of 
 the work demanded, or into the treatment of such affec- 
 tions. To do otherwise, would be to write a treatise 
 upon Ophthalmology. The book is simply what its 
 title indicates, namely, a Handbook of Diagnosis, and 
 as such I hope it may find a place among the reference 
 volumes of the student and the busy family physician 
 who aims to keep abreast of the times. 
 
 E. H. LINNELL, M. D. 
 
 Norwich, Connecticut, April, 1897.
 
 PART FIRST. 
 
 THE EYE SYMPTOMS OF NERVOUS 
 
 AND 
 
 CONSTITUTIONAL DISEASES.
 
 CHAPTER I. 
 
 AFFECTIONS OF THE EYELIDS, CONJUNCTIVA, ORBIT, 
 EYE-BALLS, SCLERA, AND CORNEA. 
 
 EYE LIDS. 
 
 In examining the lids for indications of general 
 disease, it is important to notice the color of the skin, 
 the presence or absence of thickening or oedema, of 
 inflammation of the ciliary margins, of neoplasms, the 
 movements of the lids, the existence of dilatation or 
 contraction of the palpebral fissure. 
 
 More or less anaesthesia of the skin of the lids, 
 with false localization of sensation is a symptom of 
 locomotor ataxia. 
 
 A pigmentation of the skin of the lids accompa- 
 nies Addison's disease of the supra-renal capsules. In 
 other cases it is symptomatic of uterine or hepatic dis- 
 ease. It is sometimes associated with abdominal growths. 
 Blue rings around the eyes may accompany menstrua- 
 tion in debilitated individuals. When they disappear 
 with the cessation of the menstrual flow, the symptom 
 is of no special importance, and does not indicate 
 organic disease. 
 
 A swollen oedematous non-inflammatory condition 
 is indicative of nephritis and should lead one to examine 
 
 1 (11)
 
 12 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 the urine, even in the absence of anaemia, debility and 
 other concomitants of renal affections. It is also present 
 in general hydraemia and in heart disease. It accom- 
 panies suppuration within the orbit, but in the latter 
 condition, it is sharply circumscribed by the bony edge, 
 and this circumstance will at once distinguish this form 
 of oedema, from that accompanying the affections pre- 
 viously mentioned, in which it is not distinctly circum- 
 scribed, but gradually merges into the healthy skin of 
 the eye-brow or the cheek. 
 
 Oedema of the lids is also suggestive of trichi- 
 nosis. It frequently accompanies that disease, and may 
 be one of its very early manifestations. 
 
 Thickening and swelling of the lids may be an 
 initial manifestation of myxoedema. 
 
 Eczema of the skin of the eyelids, especially of 
 the ciliary border, is frequently dependent upon a scrofu- 
 lous diathesis, but in many cases it is caused by eye 
 strain due to refractive errors, and is cured by the pre- 
 scription of suitable glasses. When neither of the above 
 causes exists, the presence of an obstinate eczema of 
 the margins of the lids should lead to an examination 
 of the urine, for this is a not infrequent accompaniment 
 of diabetes. 
 
 Styes, it is well-known, are frequently associated 
 with disorders of digestion, and with menstrual irregu- 
 larities, but they are often, also, the result of eye strain, 
 and are cured by correcting errors of refraction. I have
 
 EYE LIDS. 13 
 
 a patient who had a succession of styes for many 
 months. She was not conscious of any imperfection of 
 her vision, but a weak cylindrical glass before each eye 
 cured the styes, and also a headache from which she 
 had frequently suffered. 
 
 A tubercular nodule sometimes develops in the 
 tissue of the eyelid, simulating a large inflamed chala- 
 zion (a retention cyst of the Meibomian gland). A 
 knowledge of this fact may be of advantage in treat- 
 ment. 
 
 It should also be remembered that the initial le- 
 sion of leprosy may develop in the lid in the form of 
 nodules, which are hard and insensitive, of a whitish or 
 pale yellow or reddish color, accompanied with more or 
 less infiltration of the sub-cutaneous tissue. Anaesthetic, 
 whitish patches may also appear. 
 
 In studying the muscular conditions of the lids, 
 both paralytic and spasmodic conditions are of diagnos- 
 tic importance. I will consider these conditions sep- 
 arately as affecting the orbicularis and the levator of 
 the upper lid. 
 
 General debility, especially in old age, frequently 
 produces a laxity of the skin of the eyelids, with a de- 
 ficient innervation of the orbicularis, causing, second- 
 arily, eversion of the eyelids, and epiphora from malpo- 
 sition of the puncta, and a chronic conjunctivitis. Hence 
 such conditions suggest a lowered vitality and a need 
 for constitutional treatment, and careful diet to promote 
 nutrition.
 
 14 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 A true paralysis of the orbicularis produces the 
 condition known as lagophthalmus, in which the patient 
 is unable to close the eyes. It is associated with pa- 
 ralysis of the muscles of the face, owing to their com- 
 mon innervation by the facial nerve, and indicates the 
 peripheral nature of such a paralysis, for in 90 per cent 
 of facial paralyses of central origin the orbicularis and 
 frontalis muscles escape. An explanation of such ex- 
 emption is found in the assumption that the fibres of 
 the nerve which supply these muscles arise from a sep- 
 arate nucleus from that of the res of the nerve. The 
 possibility of ear disease and of syphilis should be borne 
 in mind. A paresis of the orbicularis, causing imperfect 
 closure of the lids, sometimes occurs in posterior spinal 
 sclerosis locomotor ataxia and should awaken suspi- 
 cion of this disease. Sometimes, in very ill persons, a 
 paralysis of the eyelids is simulated by a lack of sensi- 
 bility of the cornea and conjunctiva, so that the natu- 
 ral stimulus to close the eyes is lost. 
 
 Diminished frequency of winking from the same 
 cause also occurs in Basedow's disease, or exophthalmic 
 goitre, and is known as Stallwag's sign, or Dalrymple's 
 symptom. 
 
 A spasmodic action of the levator of the upper 
 lid (Abadie's sign) is another of the symptoms of 
 Basedow's disease, and Von Graefe first called atten- 
 tion to another characteristic feature of the affection, 
 viz. : a spasm of Mueller's muscle. This consists of a
 
 EYE LIDS. 15 
 
 few unstriped muscular fibres in the cellular tissue of 
 the orbit, innervated by the sympathetic. Its contrac- 
 tion causes a widening of the palpebral fissure, and in- 
 terferes with the associated movements of the eyeball 
 and the lid. This is noticed in looking downward, when 
 the lid lags behind, so that a white stripe of exposed 
 sclera is seen between the edge of the cornea and the 
 lid. This is a characteristic symptom of exophthalmic 
 goitre, and, together with Stelwag's sign, gives the pe- 
 culiar staring expression to such patients, and renders 
 the exophthalmus more noticeable. Starkey found Von 
 Graefe's sign present in all but 12 of 613 cases of ex- 
 ophthalmic goitre. It is an early symptom, and may, 
 for a considerable time, be the only feature of the case. 
 It may affect only one eye, or may be more marked on 
 one side. In testing for this sign it is best to have 
 the patient lying upon his back. His gaze should be 
 directed at some object, first held directly above his face, 
 then slowly moved downward toward his chest, when the 
 deficient movement of the upper lid becomes apparent. 
 
 The opposite condition, that of narrowing of the 
 palpebral fissure, was described by Jackson as a symp- 
 tom of posterior spinal sclerosis, and is caused also by 
 an opposite lesion, viz. : a paralysis instead of an irrita- 
 tion of the sympathetic. It is sometimes designated a 
 "sympathetic ptosis." 
 
 A tremulous action of the lids accompanies pa- 
 ralysis agitans.
 
 16 THE BYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 A spasm of the orbicularis is, in the majority of 
 cases, an expression of photophobia. The lids are 
 closed to shut out the light which is painful, owing to 
 inflammation or hyperaesthesia. When no inflammation 
 exists, a cause of the hyperaesthesia and its resultant 
 spasm may sometimes be found in eye strain from re- 
 fractive or muscular anomalies, especially the former. 
 It may also result as a reflex neurosis dependent upon a 
 a sexual or intestinal irritation. 
 
 Spasmodic winking, or nictitation of the lids, is 
 also a nervous manifestation, which likewise may result 
 from errors of refraction, may accompany or precede 
 general chorea or, by reflex action, may be associated 
 with disorders of the nose, teeth, or digestive organs. 
 
 We distinguish various forms of ptosis or inabil- 
 ity to raise the lids. There is a congenital form, us- 
 ually associated with diminished power of raising the 
 globe, and supposed to be due to a " congenital, central 
 defect." In other cases there is a lack of development 
 of the levator muscle. The writer is acquainted with a 
 Swedish family where all the children exhibit this pe- 
 culiarity. In such cases there is an overaction of the 
 frontalis muscle which gives the individual a peculiar 
 anxious expression. There is a form designated as 
 "morning ptosis," which occurs after sleep in debilita- 
 ted individuals. The levator is relaxed during sleep, 
 and in these cases a few minutes are requisite to enable 
 the person to recover the voluntary contraction of the 
 muscle.
 
 EYE LIDS. 17 
 
 There is, also, an hysterical ptosis. The latter 
 may be unilateral or bilateral, and is associated with 
 spasm of the orbicularis, which latter is particularly 
 marked when the patient is told to look upward. A 
 transient ptosis has been known to accompany an irrita- 
 tion of the fifth nerve, from the extraction of a tooth. 
 
 These various forms of ptosis are to be distin- 
 guished from true paralysis of the levator muscle. The 
 latter may result either from a peripheral neuritis, such 
 as occasionally occurs after exposure to cold, and from 
 alcoholism, or from a lesion of the third nerve any- 
 where in its course from its nucleus of origin to the 
 orbit. An isolated paralysis of the third nerve is us- 
 ually of nuclear origin, but it may be caused also by 
 a circumscribed lesion of the cortex of the frontal lobe 
 of the cerebrum, just in front of the fissure of Rolando. 
 The fibres of the third nerve decussate in their intra- 
 cerebral course, so that destruction of this centre causes 
 ptosis of the opposite side. The cortical centres for the 
 motor nerves of the eyeball are at a considerable dis- 
 tance from this point, and hence it is not strange that 
 ptosis sometimes occurs as an isolated paralysis, and 
 such an occurrence is a valuable point in the location 
 of cerebral symptoms having this association. 
 
 Ptosis is sometimes an accompaniment of paraly- 
 sis agitans and not infrequently is present in tabes, so 
 that its association with these affections needs no other 
 
 explanation. 
 2
 
 18 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 The significance of ptosis when occurring with 
 loss of function of the other motor nerves of the eye- 
 ball, does not need separate discussion here. It is hardly 
 necessary to mention the simulated ptosis due to cica- 
 trices caused by erysipelas, or to cellulitis orbitae, peri- 
 ostitis, and adhesions between the lid and eyeball. Such 
 a condition could hardly deceive the most careless and 
 superficial observer. 
 
 CONJUNCT1VAL AFFECTIONS. 
 
 In considering affections of the conjunctiva as af- 
 fording suggestive hints in general diagnosis, both that 
 of the lids and of the eyeball is understood. 
 
 It is desirable to note especially the presence of 
 inflammation, swelling general and circumscribed, and 
 of new growths. 
 
 The various forms of conjunctivitis, both palpe- 
 bral and ocular, are frequently idiopathic, from exposure 
 to cold, dust, strong light, etc., but very often they are 
 an indication of a scrofulous diathesis, or of indigestion, 
 and many cases only yield to treatment after careful 
 prescription of glasses. Conjunctivitis also is frequently 
 dependent upon nasal catarrh. Hence, when it does not 
 readily yield to suitable treatment, it will often be of 
 advantage to carefully examine the nose for the excit- 
 ing cause. 
 
 The phlyctenular form, characterized by the for- 
 mation of small vesicles and pustules, is very frequently
 
 CONJUNCTIVAL AFFECTIONS. 19 
 
 caused by nasal disease. These phlyctaenae develop very 
 frequently along the margin of the cornea, or some- 
 times on the cornea itself. Knies says nearly 90 per 
 cent, of such cases in children are from such a cause. 
 
 It is hardly necessary for me to mention the ob- 
 vious causal relations of severe purulent conjunctivitis, 
 and the poison of gonorrhoea, or other infectious secre- 
 tions. I have known an eye to be lost from panoph- 
 thalmitis resulting from infection with pus from an ul- 
 cerated tooth. 
 
 Conjunctival catarrh, as is well-known, accompan- 
 ies the prodromal stage of measles, and it is a frequent 
 manifestation in the early stage of epidemic cerebro- 
 spinal meningitis. 
 
 It is important to recognize the diphtheritic and 
 croupous forms of conjunctivitis. In both we have the 
 development of a pseudo-membrane, and the same dis- 
 tinction is to be made here, as in the throat, in the dif- 
 ferential diagnosis of the two affections. In the latter 
 the membrane is superficial and can be removed, leav- 
 ing a raw, bleeding surface, while in the former it is in- 
 terstitial, infiltrating the whole thickness of the mucous- 
 membrane which is pale and bloodless, owing to ob- 
 struction of the circulation by the pressure of the 
 exudate. A microscopic examination would be decisive. 
 In diphtheria of the conjunctiva, the constitutional 
 symptoms are often severe, and the swelling and indura- 
 tion of the whole lid is much more extensive and firmer 
 than in conjunctival croup.
 
 20 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 Spontaneous conjunctival hemorrhages are indica- 
 tive of an atheromatous condition of the arteries, and, 
 especially in elderly people, should lead us to appreciate 
 the danger of cerebral hemorrhage, and to adopt precau- 
 tionary measures. 
 
 Such hemorrhages are not infrequent in diabetes, 
 owing to the vascular degeneration which occurs in that 
 disease. Hemorrhage into the conjunctiva has been ob- 
 served in persons suffering with cholera, and is consid- 
 ered of serious import. 
 
 Oedema of the conjunctiva. A uniform swelling 
 of various degrees of tension, with or without inflamma- 
 tion, frequently accompanies meningitis. The exudation 
 may reach the orbit through the optic foramen, or it 
 may produce a venous stasis and subsequent exudation 
 by pressure upon the ophthalmic vein. It is an import- 
 ant indication of exudation in the cranial cavity. It is 
 frequently an early manifestation in both the epidemic 
 cerebro-spinal form, and in purulent basilar meningitis. 
 
 When there is an abrasion of the conjunctiva it 
 may become inoculated with the bacilli of tuberculosis. 
 This may occur through infection from the nose, skin 
 (lupus is now classed as a tuberculous affection), or 
 lungs; or the initial affection may be thus caused in a 
 healthy individual exposed to infection. It then be- 
 comes important to recognize it, so that prompt destruc- 
 tion of the nodule may prevent constitutional infection. 
 An ulcer develops at the point of inoculation, with a
 
 ORBIT-EYEBALL. 21 
 
 hard base often covered with granulations. Yellowish- 
 red nodules develop in the vicinity, giving a granular 
 appearance somewhat similar to trachoma, within which 
 the microscope reveals the tubercle bacilli. Later the 
 lymphatic glands of the face and neck become involved. 
 According to Eklund, leprosy may also originate 
 in the conjunctiva through the use of towels, etc. In 
 view of the increasing prevalence of that disease in this, 
 country, a knowledge of the fact may possibly be of 
 service. It is said to be caused by a micro-organism 
 similar in appearance to that of tuberculosis. The pri- 
 mary nodules, pale, yellowish or reddish, insensitive and 
 hard, increase in size and invade the other structures of 
 the eye. 
 
 ORBIT. 
 
 A periostitis or caries of the orbit, when not trau- 
 matic, should awaken suspicion of either tuberculosis or 
 syphilis, as it is usually caused by one or the other. 
 Michael says that " many cases of spontaneous cellulitis 
 orbitae in children and young people may be attributed 
 to a tuberculous infection of the cellular tissue." 
 
 EYEBALL. 
 
 The general expression of the eye will rarely es- 
 cape notice. The bright, lustrous, staring eye in febrile 
 conditions and in mental excitement is familiar to all. 
 So, also, is the dull, expressionless stare of mental hebe-
 
 22 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 tilde or actual dementia, and, less markedly, of typhoid 
 conditions, et cetera. 
 
 A protrusion of the eyeball, exophthalmus, is one 
 of the cardinal symptoms of Basedow's disease. It is 
 usually bilateral, but not invariably, or it may be of 
 unequal extent in the two eyes. It may be due to or- 
 bital growths, to suppuration within the orbit, or to- 
 aneurism of an orbital artery or of the internal carotid. 
 In the latter case the pulsation of the aneurism will be 
 communicated to the eye, and be perceptible to the ex- 
 aminer's fingers. Sometimes also a bntit can be detected 
 by the aid of the stethoscope. Pressure on the cavern- 
 ous sinus or the ophthalmic vein may cause sufficient 
 venous stasis to produce protrusion of the eye, in which 
 case the eye can be readily replaced by gentle pres- 
 sure. An exophthalmus developed in a patient of the 
 writer after using atropin for the examination of re- 
 refraction, and subsided under application of gentle pres- 
 sure. Exophthalmus in the new-born is sometimes 
 caused by retro-ocular hemorrhage. Such a case came 
 under my observation. The child was seen the day 
 after its birth, and presented a marked proptosis, which 
 disappeared in a few days under gentle pressure, and 
 treatment prescribed for .a co-existent conjunctivitis. 
 
 Every tissue of the eye at times affords points of 
 diagnostic importance. After a brief consideration of 
 the sclera and cornea I will discuss disorders of motil- 
 ity at some length, inasmuch as spasmodic and paralytic
 
 CORNEA. 23 
 
 affections of the ocular muscles are of extreme import- 
 ance in cerebral localization. 
 
 The icteroid coloration of the sclera is too well 
 recognized to need comment, but when occurring inde- 
 pendently of hepatic affections, it is suggestive of Addi- 
 son's disease of the supra-renal capsules. Idiopathic 
 scleritis is a rare affection. Rheumatism and syphilis 
 are the most frequent causes of inflammation of the 
 sclera and of the episcleral tissue. Syphilitic gummata 
 may develop primarily in the sclera, but they usually 
 invade this tissue from the uvea. A knowledge of the 
 cause of such affections will suggest a suitable line of 
 treatment. Tuberculous nodules also occasionally occur 
 
 in the sclera. In doubtful cases the sclerotic may at 
 
 i/ 
 
 times afford conclusive evidence of death by the exist- 
 ence of a desiccated patch within the palpebral fissure, 
 either at the inner or outer side and below the cornea. 
 
 CORNEA. 
 
 The cornea reveals a constitutional dyscrasia very 
 readily. The occurrence of phlyctaenulae at the edges 
 of the cornea in scrofulous children has been already 
 alluded to in speaking of conjunctivitis. Ulcers and ab- 
 scesses of the cornea are also frequently seen in stru- 
 mous subjects. 
 
 A parenchymatous inflammation of the cornea, 
 characterized by a diffuse infiltration into the deeper 
 layers of the membrane, giving an appearance of ground
 
 24 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 glass, which might be mistaken for a cataract by a 
 careless or inexperienced observer, is very characteristic 
 of inherited syphilis. It is rare in the acquired form 
 of the disease. It most frequently appears between the 
 sixth and fourteenth years. Mauthner estimates that 
 of the cases of interstitial keratitis are syphilitic. It 
 may accompany infectious diseases, and it has been 
 ascribed to rheumatism. Where corneal affections de- 
 velop in children who are free from scrofulous or syphi- 
 litic taint, the teeth should be examined, as there seems 
 sometimes to be a relation of cause and effect between 
 dental ' caries and such affections. Tuberculous nodules 
 may develop primarily in the marginal zone of the cor- 
 nea, and later in the cornea itself. Ulceration of the 
 cornea is not of infrequent occurrence in diabetes, and 
 is an indication of debility, and it should be remem- 
 bered that slight injuries in elderly and feeble individu- 
 als, which readily heal in persons in good health, are 
 very apt to break down into necrotic supptirative pro- 
 cesses, and hence demand especial care. 
 
 In anaesthesia of the trigeminus, accompanying 
 facial paralysis, or in conditions of profound depression, 
 as in cholera, typhoid, etc., a condition known as neuro- 
 paralytic keratitis develops. An ulceration occurs which 
 spreads rapidly and leads to destruction of the mem- 
 brane and irreparable blindness. This is due to injury 
 to the cornea, in consequence of its lack of sensibility. 
 Because of this lack of sensibility, particles of dust, etc.,
 
 CORNEA. 25 
 
 are not felt, and the cornea is not protected and kept 
 moist by the natural frequent closure of the lids. The 
 occurrence of such cases gave rise to the theory that 
 there existed special trophic fibres in the trigeminus 
 which presided over the nutrition of the cornea, but 
 this was disproved when Snellen demonstrated that sim- 
 ple protection of the eye was all that was necessary to 
 prevent such traumatic and infectious ulcerations. This 
 condition is somewhat analagous, but is to be differenti- 
 ated from, the excessive dryness and loss of transparency 
 of the cornea known as xerosis or desiccative keratitis, 
 which occurs after excessive loss of fluids, as in cholera, 
 childbed, etc. 
 
 Anaesthesia of the cornea occurs in locomotor 
 ataxia, so that in some instances the membrane may be 
 touched without producing winking of the eyelids. 
 Sometimes also there is a false localization of sensation, 
 so that a touch upon the cornea is referred to the ex- 
 ternal or internal canthus. 
 
 A malarial cachexia may manifest itself by an 
 inflammation of the cornea. Noyes says, in an editorial 
 note in Knies ' " The Eye in General Diseases : " 
 
 " Keratitis, as the result of malaria, is not infre- 
 quent, and presents features which are more or less 
 typical. It attacks, by preference, the epithelium and 
 superficial layers, is non-suppurative ; ulcerations are 
 superficial. It is chronic in duration. There is often 
 anaesthesia of the surface. The opacity is apt to run
 
 26 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 in streaks, yet may present itself in patches. One wilt 
 find marked tenderness of the supra-orbital nerves as 
 they pass out of the orbit, which is the most valuable 
 pathognomonic sign, and when occurring with the con- 
 ditions described, indicates the absolute necessity of qui- 
 nine in effective doses as an adjunct to local treat- 
 ment." 
 
 Leprous nodules occasionally develop in the cor- 
 neal tissues. 
 
 An opacity and insensibility of the cornea is an 
 evidence of death which might be of service in a 
 doubtful case.
 
 CHAPTER II. 
 
 AFFECTIONS OF THE EXTERNAL OCULAR MUSCLES. 
 
 Paralytic and spasmodic affections of the external 
 eye muscles occur with various intra-cranial and spinal 
 diseases, and while they are usually associated with 
 other symptoms which indicate with more or less pre- 
 cision the situation and nature of the lesion, the eye 
 symptoms alone will often furnish valuable diagnostic 
 indications. 
 
 A spasm of a given muscle, or group of muscles > 
 is produced by an irritation of a locality whose destruc- 
 tion causes a paralysis of the same part. It is self- 
 evident that a nerve may be excited or depressed in 
 any portion of its course from its ultimate distribution 
 to its termination in the cells of the cerebral cortex. 
 Hence an accurate knowledge of the minute anatomy of 
 the ocular motor nerves is a necessary preliminary to a 
 discussion of this branch of the subject. Therefore for 
 the sake of clearness, I will repeat here what may be 
 familiar. 
 
 The third, fourth, sixth, facial and sympathetic, 
 it will be remembered, are the motor nerves of the eye. 
 With the exception of the sympathetic, they can all be 
 
 traced to the gray matter of the aqueduct of Sylvius, 
 
 (27)
 
 28 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 and to that of the fourth ventricle. The nuclei of ori- 
 gin of both third nerves anastomose freely, and that of 
 the abducens communicates with the third and the ad- 
 jacent nuclei of the seventh and ninth. From here the 
 fibres of the third, or motor-oculi-communis, pass 
 through the cms cerebri and emerge at its inner side 
 just in front of the pons. Those of the fourth wind 
 around the cms and emerge at its outer edge, and those 
 of the sixth pass downward through the pyramids of 
 the medulla and appear at the lower posterior edge of 
 the pons. Thence these three nerve tracks extend 
 along the base of the brain, pass through the cavernous 
 sinus, where the third and sixth receive communicating 
 filaments from the carotid plexus, and enter the orbit 
 through the supra-orbital fissure. The terminal fibres 
 of the third nerve are distributed to the superior, infe- 
 rior and internal recti muscles, the inferior oblique, the 
 levator palpebrae superioris, the ciliary muscle, and the 
 sphincter iridis. The individual bundles of fibres inner- 
 vating these various muscles have been traced to a 
 series of centres in the aqueduct of Sylvius, which are 
 arranged in the following order from before backward, 
 viz. : 
 
 1. Ciliary muscle. . 
 
 2. Sphincter iridis. 
 
 3. Levator palpebrae. 
 
 4. Rectus internus and superior. 
 
 5. Rectus inferior and obliquus inferior.
 
 AFFECTIONS OF THE EXTERNAL OCULAR MUSCLES. 29 
 
 These several nuclei of origin may be simulta- 
 neously or individually diseased, as will be mentioned 
 later in detail. 
 
 The fourth nerve, or patheticus, is distributed to 
 the superior oblique, and the fibres of the sixth pass to 
 the external rectus. 
 
 The facial nerve arises from the floor of the 
 fourth ventricle, and it emerges at the posterior border 
 of the pons, passes through the Fallopian canal of 
 the petrous bone, and makes its exit through the sty- 
 loid foramen, from which point it spreads out over the 
 face, and, among other muscles, is distributed to the 
 frontalis and the orbicularis palpebrarum. 
 
 The motor fibres of the sympathetic arise from 
 the lowermost portion of the cervical cord, and, in their 
 course to the eye, pass through the superior cervical 
 ganglion and the carotid plexus, and are distributed to 
 the unstriped fibres in the orbit constituting Miiller's 
 muscle, whose contraction dilates the palpebral fissure, 
 and to the dilator fibres of the iris. 
 
 From these contiguous nuclei of origin fibres 
 pass to the higher centres in the cerebral cortex, gov- 
 erning the voluntary and associated movements of the 
 eyes. Bearing thus in mind the origin and course of 
 the fibres of the different motor nerves of the eyeball, a 
 study of the variety and relations of the ocular motor 
 disorders enables one to arrive at a more accurate diag- 
 nosis of the situation of a lesion than would be possible 
 without such knowledge.
 
 
 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 It is important to remember, in making a diag- 
 nosis of a cerebral affection from ocular symptoms, that 
 
 FIG. i. Diagram of Base of the Brain and Cranial Nerves, Pons and Medujla 
 taken from "Diseases of the Eye," by H. D. Noyes, M. D. I to XII, The Cranial 
 Nerves ; Th. optic thalamus ; k. pituitary body ; tc . tuber-cinereum ; a. corpora albi- 
 cantia (mammillaria) ; P. pes pedunculi ; i. internal geniculate body ; e. external 
 geniculate body ; PV. pons Varolii ; /a. anterior pyramid of medulla ; a. olive ; d. 
 decussation of anterior pyramids; ca. anterior column of spinal cord; cl. lateral 
 column of spinal cord ; Ce. cerebellum \Jt. flocculus of cerebellum ; X locus perfo- 
 ratus posticus ; + (on the left side), ganglion of Gasser ; + (on the right side), 
 motor root of trigeminus. 
 
 parts remote from the primary lesion frequently suffer 
 temporarily. This is especially true of apoplectic and
 
 PARALYTIC AFFECTIONS. 31 
 
 inflammatory conditions. The permanent symptoms, 
 therefore, are the only ones upon which an accurate 
 localization may be based. 
 
 PARALYTIC AFFECTIONS. 
 
 I will first consider the significance of paralytic 
 affections of the extrinsic eye muscles, leaving for future 
 discussion paralysis of accommodation and of the iris. 
 The diagnosis of a total paralysis of an ocular muscle 
 presents no difficulty. It is at once evident, by the in- 
 ability to turn the eye in the direction of the paralyzed 
 muscle, and by the squint caused by the unopposed action 
 of its opponent. It is otherwise when there is incom- 
 plete loss of function. Often there is no apparent loss 
 of motion, and the paresis is only manifested by the 
 resulting diplopia. That is only noticed when the eye 
 is turned in the direction of the weak muscle and 
 results from inharmonious action with its fellow of the 
 opposite eye, so that there is inaccurate binocular fixa- 
 tion of an object. In consequence, the retinal images 
 are not formed upon corresponding portions of each ret- 
 ina, and the aerial projection of the images are not 
 identical, and so an apparent doubling of the object re- 
 sults. The following directions for detecting a paresis 
 of the ocular muscles are so admirably expressed that I 
 cannot do better than to quote them, although I regret 
 that I cannot state the name of the author who formu- 
 lated them:
 
 32 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 " In determining which rectus muscle is affected, 
 there are two things to be determined. First, the part 
 of the field in which the doubling occurs ; secondly, the 
 eye which sees the furthest removed object. The affected 
 muscle is always on that side of its eye towards which 
 the doubling takes place, and it belongs to the eye that 
 sees the furthest removed object. To illustrate : Sup- 
 pose that the patient has single vision immediately in 
 front and to the right, but, on moving the candle in 
 the horizontal plane to the left, doubling takes place. 
 At once we are able to say that the affected muscle is 
 either the external rectus of the left, or the internal 
 rectus of the right eye. Since the affected muscle be- 
 longs to the eye that sees the object furthest removed, 
 it only remains for us to cover one eye or the other, 
 and learn from the patient which object disappears. 
 On covering the right eye, if the object furthest re- 
 moved is blotted out, then the affected muscle is the 
 internal rectus of the right ; if the contrary, then the 
 paretic muscle is the external rectus of the left. 
 
 "If the doubling takes place in the vertical 
 plane, single vision being below and immediately in 
 front, but doubling taking place as the candle is raised 
 above the horizontal plane, the affected muscle is the 
 superior rectus of one eye or the other. It belongs to 
 the eye that sees the higher object. If, on covering 
 the right eye, the higher object disappears, then it is
 
 PARALYTIC AFFECTIONS. 33 
 
 the superior of the right ; if the contrary, it is the 
 superior rectus of the left. 
 
 " Paralysis and paresis of an oblique muscle re- 
 quires a more careful study, and yet it is comparatively 
 easy to locate the affected muscle. If a candle be held 
 vertically before such a pair of eyes there would be 
 doubling, one image being vertical and the other lean- 
 ing, the vertical candle being seen by the non-affected 
 eye, while the leaning candle is seen by the eye to 
 which is attached the affected muscle. If the left eye 
 sees the leaning candle, and the inclination is towards 
 the right, the affected muscle is the superior oblique of 
 that eye. If it leans toward the left, the affected mus- 
 cle is the inferior oblique of that eye. The vertical 
 meridian of the eye affected is always turned in the op- 
 posite direction to the leaning of the candle." 
 
 It is desirable to make a distinction between 
 paralysis of one or several eye muscles and ophthalmo- 
 plegia. By the latter term is understood the simulta- 
 neous paralysis of those muscles of both eyes which are 
 concerned in conjugate movements, for instance, the ex- 
 ternal rectus of the right and the internal rectus of the 
 left eye, by the aid of which both eyes are simulta- 
 neously directed upon an object on the right side. 
 Such conjugate paralyses are of necessity of intra-cere- 
 bral or cortical origin, and a distinction should be 
 drawn between associate and conjugate paralyses, as 
 
 will be referred to later. 
 3
 
 34 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 The existence of conjugate contraction of the eyes 
 is also of diagnostic significance. This is reserved for 
 future discussion in connection with spasmodic affect- 
 ions. 
 
 In a given case of external ocular paralysis, our 
 
 first endeavor is to ascertain whether it is peripheral, 
 that is located within the orbit, basilar, that is in the 
 path of the nerve along the base of the skull, or intra- 
 cerebral (fascicular, nuclear or cortical). 
 
 I. PERIPHERAL PARALYSES. 
 
 An ocular paralysis due to a disease of the orbit 
 such as tumor, periostitis, cellulitis, etc., will be unilat- 
 eral and associated with other symptoms such as pain, 
 inflammation of lids and conjunctiva, exophthalmus, etc., 
 and there will be an absence of evidence of intra-cran- 
 ial and cerebral or spinal disease, such as implication of 
 other nerves, vertigo, drowsiness, pupillary phenomena, 
 headache or mental aberration. In cases of traumatic 
 origin, the evidence of injury, or the history of the case 
 will be decisive. Sometimes the association of the mus- 
 cles affected will settle the diagnosis of its peripheral 
 nature, as for instance, if the inferior oblique and the 
 internal ocular muscles (iris and ciliary) are affected 
 without implication of the other external muscles. This 
 is evident if we remember that the iris and ciliary mus- 
 cles are supplied by the short ciliary nerves, coming 
 from the ciliary ganglion situated in the back of the
 
 EXTERNAL OCULAR PARALYSES OF BASILAR ORIGIN^ 35 
 
 orbit, between the optic nerve and the external rectus, 
 and that the motor fibres of the ciliary ganglion are de- 
 rived from the branch of the motor-oculi which supplies 
 the inferior oblique, after its division from the main 
 trunk. Diphtheria is a cause of ocular paralysis which 
 is often due to a peripheral neuritis. 
 
 EXTERNAL OCULAR PARALYSES OF BASILAR ORIGIN. 
 
 A lesion at the base of the brain producing ocu- 
 lar paralysis would almost of necessity affect other 
 nerves the fifth, seventh, optic and olfactory, either 
 simultaneously or successively so that the diagnosis 
 would rest upon the association of other symptoms, es- 
 pecially of hemianopic visual disturbances from compres- 
 sion of one optic tract. The absence of such symptoms 
 would afford negative evidence against the basilar situa- 
 tion of the causative lesion. When the trigeminus is 
 paralyzed by a basilar affection, it is preceded by neu- 
 ralgia, which is not the case when it is of cortical 
 origin. An isolated paralysis of the third nerve due to 
 an intra-cranial basilar lesion is possible, but it affords 
 no data for a positive diagnosis. The absence of impli- 
 cation of the iris and ciliary muscle would counter-indi- 
 cate a basilar origin, as all the fibres from the separate 
 nuclei of origin are united when the nerve emerges 
 from the crus. 
 
 Simultaneous paralysis of both third nerves 
 might result from the pressure of a tumor, a syphilitic
 
 86 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 gumma for instance, between the cerebral peduncles 
 (cmra cerebri), or from an aneurism of the posterior 
 cerebral artery. A thrombosis of one cavernous sinus, 
 or an aneurism of one internal carotid might cause total 
 paralysis of the muscles of one eye, but as the ophthal- 
 mic division of the fifth nerve also passes through the 
 cavernous sinus, anaesthesia of the parts supplied by this 
 nerve, lids, conjunctiva, nasal fossae and integument of 
 the eyebrows, forehead and nose, would accompany the 
 motor disorder. 
 
 INTRA-CEREBRAL PARALYSES, INCLUDING AFFECTIONS 
 
 OF THE CRURA (FASCICULAR PARALYSIS), OF 
 
 THE PONS, NUCLEI AND CORTEX. 
 
 ALTERNATING PARALYSES. 
 
 The fibres of the motor nerves of the extremities 
 decussate in the medulla, those originating in the right 
 hemisphere being distributed to the left side of the body 
 and vice versa. The motor nerves to the ocular muscles 
 decussate higher up. Hence the existence of "alternate 
 paralysis," by which is meant paralysis of one or both 
 eyes on one side, and of the extremities on the other 
 side, indicates that the lesion is between the medulla 
 and the point of decussation of the ocular motor nerves, 
 viz. : either in the cms or the pons. 
 
 The ocular symptoms may be limited to one eye 
 or affect both. A lesion (hemorrhage, abscess, tumor), 
 limited to one crus or to the base of the brain imine-
 
 INTRA-CEREBRAL PARALYSES, ETC. 37 
 
 diately beneath it is extremely rare. It would occasion 
 paralysis of the motor-oculi on the side opposite the 
 hemiplegia. If the iris and ciliary muscle were not im- 
 plicated, the lesion could be definitely located within 
 the crus, because the fibres from the anterior nucleus 
 are, in that location, still considerably separated from 
 the others. 
 
 A paralysis of one external rectus and of the ex- 
 tremities on the opposite side indicates a lesion at the 
 posterior edge of the pons. So, also, an isolated lesion 
 of one sixth nerve, must be referred to a lesion in one 
 side of the pons. Since the sixth and facial have a 
 common origin in the gray matter in the floor of the 
 fourth ventricle, a nuclear lesion must affect both nerves. 
 
 An alternating paralysis caused by a lateral le- 
 sion of the pons is manifested by ophthalmoplegia, or 
 loss of the conjugate movement of both eyes toward the 
 sound side of the body. The eyes would deviate toward 
 the paralyzed side from unrestrained action of the oppo- 
 site muscles, and therefore the lesion is on the oppo- 
 site side of the pons from that toward which the e.yes 
 deviate. Conjugate deviation of the eyes also occurs as 
 a temporary symptom in most cases of apoplexy, but 
 when the hemorrhage is in one of the cerebral hemi- 
 spheres, the paralysis is not alternate, because the lesion 
 is above the decussation of the oculo motor nerves, and 
 therefore the eyes and the extremities are paralyzed on 
 the same side. Therefore, the inclination of the eyes is
 
 38 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 of diagnostic importance in locating the situation of an 
 apoplexy. 
 
 If the eyes turn toward the paralyzed side, we 
 have an alternating paralysis, and the lesion is in the 
 pons on the opposite side. If the eyes turn toward the 
 sound side, the hemorrhage is in one or other hemi- 
 sphere above the pons, and on the same side toward 
 which the eyes turn. 
 
 A deviation of the eyes from the side of a cere- 
 bral lesion may exist from simple conjugate spasm of 
 the ocular muscles, owing to an irritation in the vicin- 
 ity of the visual sphere in the occipital cortex of the 
 opposite side, thus simulating the condition found in 
 diseases of the pons. The unimpared ability to move 
 the eyes in the opposite direction will demonstrate the 
 absence of paralysis, and the limbs on the side toward 
 which the eyes are turned will also be in a rigid, spas- 
 modic condition, in contrast with the flaccid paralyzed 
 state. 
 
 Another indication of disease of pons is an 
 associate paralysis of the eyes. This differs from the 
 conjugate paralysis just referred to in that the paralysis 
 of the affected muscles is not complete. In conjugate 
 paralysis toward the left, for instance, both eyes are 
 turned to the right, and cannot be moved at all in the 
 opposite direction. In associate paralysis, on the other 
 hand, they can be turned to the left as far as the mid- 
 dle line, but no farther. Such cases have been occa-
 
 INTRA-CEREBRAL PARALYSES, ETC. 39 
 
 sionally observed, but no satisfactory explanation of 
 their cause was offered until, in 1879 or I 88o, Duval 
 discovered a bundle of fibres proceeding from the nu- 
 cleus of origin of the abducens to the oculo-motorius of 
 the opposite side. Later, a case of associate paralysis 
 was reported by Ferreol, in which an autopsy disclosed 
 a small tumor in the immediate vicinity of origin of 
 the sixth nerve. Stellwag saw this peculiar condition 
 in a case of Basedow's disease. Gowers locates a lesion 
 causing such associate paralysis in the tegmental region 
 of the pons on one side, above and adjacent to the nu- 
 cleus of the sixth nerve. If the nucleus of the sixth 
 nerve were involved, the palsy of the external rectus 
 would be complete, so that that eye could not be turned 
 outward at all, even as far as the middle line. Inas- 
 much also as the internal rectus receives special direct 
 innervation from the third nucleus, it is not incompati- 
 ble with associate paralysis, that contraction of the im- 
 paired internal rectus should be retained in convergence 
 of the visual axes, or that this eye should turn in con- 
 nection with its fellow, whose external rectus is im- 
 paired, as far as the middle line in the direction of the 
 associate paralysis. 
 
 Two other varieties of this associate paralysis in 
 horizontal movement have been described, the one by 
 M. Parinaud, in which spasm of the internal rectus ex- 
 ists, and the other by Sauvineau, in which spasm of the 
 external rectus exists. These differences are explained
 
 40 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 by a slight variation in the situation of the lesion, so 
 that with the paralysis for lateral associated movement 
 there is an irritation of one or the other nerve. Thus 
 both associate and conjugate paralysis point to a lesion 
 in the corresponding side of the pons. There is some 
 reason to believe that the pons also contains centres 
 which preside over the associated lateral and vertical 
 movements of the eyes. 
 
 " Paralysis of both upward and downward move- 
 ments of the eyes, bilateral and accompanied with pto- 
 sis, has been observed with disease of the corpus stri- 
 atum and optic thalamus. Loss of conjugate movement 
 upwards has been caused by a lesion of the tubercula 
 quadrigemina." (Gowers). 
 
 Verray reported such a case accompanied with 
 tendency to deviate toward the left when walking. The 
 affection came on suddenly and was attributed to a 
 small hemorrhage in the tubercula quadrigemina. See 
 "Revue Med. de la Suisse Romande" March, 1893. 
 
 " Beckheim believed that the superior olive 
 (which extends the whole length of the pons) acted as 
 a reflex centre for correlating movements of the head 
 and eyes with auditory impressions, and its lesion 
 might therefore be expected to interfere with such cor- 
 relations, causing a lack of response by the head and 
 eyes to sounds coming from various directions." (Chas. 
 K. Mills in " International Clinics," October, 1895). 
 Such a centre for reflex movements of the head and
 
 NUCLEAR PARALYSES. 41 
 
 eyes in connection with auditory impressions has been 
 referred to the internal geniculate body. 
 
 NUCLEAR PARALYSES. 
 
 A nuclear paralysis may affect one or both eyes, 
 but, owing to the free communication between the nu- 
 clei of the opposite sides, the latter is more frequent. 
 As has been previously mentioned, the motor-oculi 
 arises from separate nuclei in the aqueduct of Sylvius. 
 Hence an isolated paralysis of one or more of the 
 branches of the nerve, or their successive implication, 
 points unmistakably to a nuclear lesion. Not infre- 
 quently, the intra-ocular muscles escape, because their 
 motor fibres receive a separate vascular supply. A total 
 paralysis of all the muscles of both eyes is, in all prob- 
 ability, of nuclear origin. The only other explanation 
 is a separate lesion involving each cavernous sinus or 
 each optic foramen. 
 
 CORTICAL OCULAR PARALYSES. 
 
 The course of the nerve fibres between their nu- 
 clei of origin and the cortical visual centres has not 
 been anatomically demonstrated, and we have no data 
 for differentiating ocular paralyses due to lesions in 
 these two localities, i. e., cortical or fascicular. They are 
 always binocular and conjugate. Each visual area not 
 only receives impressions from the opposite half fields of
 
 42 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 vision of the two eyes, but also presides over the volun- 
 tary, conjugate movements in the same direction. An 
 irritation at a given point of the occipital cortex, as has 
 been mentioned, causes deviation of both eyes toward 
 the particular part of the opposite visual field which is 
 in anatomical relation with that spot (conjugate spasm), 
 'and a circumscribed lesion results in hemianopic visual 
 defects and corresponding loss of conjugate movement. 
 The visual centre on the right side is associated with 
 the left half fields of vision and with conjugute move- 
 ments toward that side, and vice versa. Therefore the 
 lesion is always on the side opposite the paralysis, and 
 the eyes deviate toward the side of the lesion. 
 
 There are two features which are characteristic 
 of cortical ophthalmoplegias, and which serve to distin- 
 guish them from similar motor defects due to lesions of 
 the pons. 
 
 First, involuntary and reflex movements are pre- 
 served. If a strong light is thrown into one or both 
 eyes from the paralyzed side, they will turn in the di- 
 rection of the light, that is, in the direction in which 
 voluntary movement is lost. The same occurs under 
 the impulse of a sudden command or a loud noise. 
 Such involuntary movements are absent in all cases 
 where the lesion is at or below the nuclei. 
 
 Second, cortical paralyes are associated with vis- 
 ual disturbances and pupillary conditions which are of 
 great value in locating the causative lesion, but a dis-
 
 CORTICAL OCULAR PARALYSES. 43 
 
 cussion of such symptoms will be reserved for a subse- 
 quent chapter. 
 
 Dissociate paralyses, that is, of individual muscles 
 not concerned in associate movements, are also of cen- 
 tral origin. 
 
 In muscular affections due to central disease there 
 is very great difficulty in overcoming the resulting di- 
 plopia. Even with carefully selected prisms, the patient 
 finds it almost impossible to unite the double images. 
 
 Having said so much in regard to the localiza- 
 tion of a lesion, let us now inquire whether the eye 
 symptoms furnish any evidence of the nature of the dis- 
 eased process. We cannot state from the presence of 
 ocular palsy alone that there exists hemorrhage, embo- 
 lism, thrombosis, meningitis, turner, neuritis, effusion of 
 lymph serum or pus, softening or sclerosis, any one of 
 which may be the cause of the existing symptoms, but 
 still these same ocular palsies do often point toward the 
 nature as well as the location of the central lesion. 
 
 A sudden lesion, developing immediately or with- 
 in a few hours and causing paralysis, is always a vas- 
 cular one, either a hemorrhage or an occlusion. An 
 acute lesion, developing in a few days or weeks, is 
 probably inflammatory. A chronic one indicates degen- 
 erative processes or gradual pressure from a neoplasm. 
 
 Ocular paralyses in children, without obvious 
 cause, is to be regarded as a very serious premonition 
 of tubercular meningitis. Such a case occurred not
 
 44 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 long since in my practice. I was consulted simply for 
 the secondary squint I declined to operate, and gave a 
 guarded prognosis, and within a few months the child 
 died with unmistakable signs of this affection. Such 
 symptoms are much less frequently associated with sim- 
 ple meningitis. 
 
 In adults ocular paralyses are very suggestive of 
 cerebral syphilis. Von Graefe says that one-third of all 
 ocular paralyses are due to syphilis. The proportion 
 has been estimated as high as one-half. They occur 
 usually in the later stages of the disease. The third 
 nerve is affected in three-quarters of such cases and the 
 sixth in one-quarter. It may be a nuclear lesion, a 
 neuritis of the trunk or root of the nerve, or it may be 
 compressed in its course along the base of the brain by 
 a gumma. Such a paralysis may be the initial symp- 
 tom of cerebral syphilis. One variety, where several 
 muscles of both eyes are affected successively and trans- 
 iently, varying in degree and duration, is considered al- 
 most pathognomonic of the cerebral form of this dis- 
 ease. Anaesthesia or dysaesthesia of the skin of the face 
 frequently accompanies syphilitic ocular palsies. 
 
 Ocular palsies with similar manifestations are 
 also very frequent in locomotor ataxia, or tabes dorsalis. 
 They may be an early or late feature of the case. Fre- 
 quently, as in one case coming under my observation, 
 they preceded for some time the other developments of 
 the disease. Mott in " International Clinics," 1895, Vol.
 
 CORTICAL OCULAR PARALYSES. 45 
 
 I, page 127, says that 25 per cent, of the cases com- 
 mence with ocular paralysis. Two varieties are consid- 
 ered suspicious, viz., " insignificant paresis which easily 
 recovers, but soon reappears in one or the other eye. 
 In other cases there quickly becomes associated with 
 a perhaps trifling paresis of the abducens, a contraction 
 of the internal rectus." (Mauthner's " Gehirn und 
 Auge "). Such cases are very obstinate to treatment. 
 
 It is estimated that from 20 to 40 per cent, of 
 the cases of tabes are accompanied with ocular palsies, 
 which are of sudden development and of transient dura- 
 tion with frequent relapses. One or both eyes may be 
 affected. Thus we see that the symptoms resemble very 
 closely those resulting from syphilis, and it should be 
 remembered that most tabetic patients have at some 
 time been syphilitic. 
 
 Authorities differ as to the order of frequency of 
 the involvement of the muscles. In 100 cases of tabes, 
 Dillman found paresis of one or more of the muscles 
 supplied by the third nerve 26 times ; abducens paresis 
 12 times; trochlearis paresis 3 times. Kahler, on the 
 contrary, considers paralysis of the external rectus of 
 most frequent occurrence and of the levator palpebrae 
 next in frequency. 
 
 Associate paralysis of convergence has been 
 noticed. Knies says : " Every paralysis of an ocular 
 muscle which occurs suddenly in a healthy person 
 (without injury, apoplexy, or other brain symptoms,
 
 46 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 diabetes, mellitus or insipidus, syphilis, albuminuria, 
 etc.) arouses the suspicion of a beginning tabes, especially 
 if it recovers in a comparatively short time or subse- 
 quently relapses." 
 
 Thus in the majority of ocular paralyses, espe- 
 cially in adults, we shall find the exciting cause to be 
 either syphilis or tabes, and the following points of dif- 
 ferential diagnosis between these two affections as for- 
 mulated by Fournier in the " Bull, de Med." 1887, is 
 of value, although not of universal application : 
 
 Tabes. Syphilis. 
 
 Often only a single muscle Larger number of muscles 
 involved (nerve roots chief- involved and accompanied 
 ly). with headache, vertigo, epi- 
 
 leptic attacks, aphasia, men- 
 tal disorders, etc. 
 
 Accommodation intact for Accommodation suffers ear- 
 a long time. ly. 
 
 Often temporary, sometimes More permanent and devel- 
 lasting but a few hours. op more gradually. 
 
 Galezowski, on the other hand, says that uni- 
 lateral paralysis of accommodation without mydriasis is 
 often the first sign of beginning tabes, and is associa- 
 ted with anaesthesia of patches of skin in the temporal 
 region. Those which occur early in the disease more 
 frequently recover than those developing later.
 
 CORTICAL OCULAR PARALYSES. 47 
 
 Multiple sclerosis and general paresis also give 
 rise to ocular paralyses of similar character. Other 
 symptoms will be present to establish a differential 
 diagnosis. A paralysis of both external recti has been 
 noticed as an early manifestation of the latter affection. 
 
 Disease of the cerebral vessels, resulting from 
 diabetes and renal affections, may be the cause of ocular 
 paralysis, and hence an examination of the urine should 
 not be neglected when a satisfactory explanation has 
 not been reached. 
 
 Ocular paralyses may be rheumatic and may 
 affect a single muscle or several. Usually one or more 
 contiguous branches of the nerve are involved, the 
 superior rectus and the levator palpebrae for instance. 
 They follow exposure, are associated with other rheu- 
 matic affections, remote or present, and are, as a rule, 
 limited to one eye, whereas ocular paralyses from cen- 
 tral disease are usually bilateral. Such cases are gener- 
 ally regarded as of nuclear origin. Diphtheria rarely 
 causes paralysis of the external eye muscles. Such 
 cases, when they do occur, are usually peripheral, and 
 are the sequence of hemorrhages or neuritis, but some- 
 times they are nuclear. They occur later in the disease 
 and usually slowly recover. An ocular paralysis, due to 
 peripheral neuritis, is most frequently caused by alcohol, 
 and we should expect to find associated symptoms of 
 peripheral neuritis in other localities.
 
 48 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 PATHOLOGY OF NUCLEAR PARALYSES. 
 
 It has been remarked previously that progressive 
 paralysis of the different branches of the third nerve, or 
 a total paralysis of all the muscles of both eyes, is al- 
 most conclusive evidence of a nuclear lesion. This les- 
 ion may be of varied nature ; for instance, a tubercular 
 formation, or a cyst might exist in this situation and 
 produce the symptoms by pressure. A syphilitic athero- 
 matous degeneration, or an embolism of one of the 
 branches of the basilar artery would explain such a 
 condition. 
 
 Certain toxic substances, notably lead, alcohol 
 sulphuric acid, and the fumes of charcoal, have pro- 
 duced nuclear ocular paralysis, but more frequently the 
 resulting eye symptoms in such cases of poisoning are 
 due to peripheral neuritis. 
 
 Acute and chronic infectious diseases are also oc- 
 casionally associated with nuclear ocular palsies. They 
 may complicate divers affections, notably bulbar paraly- 
 sis, progressive muscular atrophy, tabes and disseminate 
 sclerosis. 
 
 There is an acute and a chronic form of nuclear 
 paralysis. An acute form develops in intemperate per- 
 sons and is usually fatal. 
 
 Knies says : " Progressive paralysis of the ocular 
 muscles is an essential feature of polio-encephalitis 
 superior, or inflammation of the floor of the fourth ven-
 
 PATHOLOGY OF NUCLEAR PARALYSES. 49 
 
 tricle. (Wernicke was the first to differentiate it). The 
 acute hemoirhagic form is usually due to alcohol. The 
 chronic form is the more frequent. The symptoms are 
 generally bilateral, are irregular in development, and af- 
 fect both the external and internal muscles. The loss 
 of function may be complete or partial. It is rarely an 
 independent disease. Somnolence is an' early and char- 
 acteristic feature which serves as a diagnostic point in 
 distinction from simple nuclear paralyses." 
 
 SPASMODIC AFFECTIONS OF THE EXTERNAL OCULAR 
 MUSCLES. 
 
 It has been previously remarked that spasm of 
 one or more of the ocular muscles is caused by an irri- 
 tation of the same locality whose destruction causes 
 paralysis. Hence no further discussion of the localiza- 
 tion of cerebral affections, as indicated by ocular spas- 
 modic affections, is necessary. A single muscle or a 
 group of muscles may be affected by irritation of a 
 nerve at its nucleus, or at its cerebral termination. Cor- 
 tical spasms are always binocular and conjugate. As 
 has been remarked in discussing paralytic affections, the 
 secondary deviation of the eyes in cases of cerebral ap- 
 oplexy, indicates the side of the brain affected. The 
 eyes point toward the side of the lesion unless the 
 hemorrhage is in the pons or crus, when the eyes and 
 extremities are paralyzed on opposite sides, and the eyes 
 
 deviate toward the unaffected side of the brain. 
 
 4
 
 50 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 Since muscular spasms are the expression of 
 cerebral irritation, we should expect to meet with them 
 in hyperaernic and inflammatory affections of the brain 
 and meninges. Strabismus is frequent in cerebro-spinal 
 and basilar meningitis. It is not infrequently caused by 
 reflex irritation from the teeth and digestive organs. 
 This will be more specifically considered in the chapter 
 on reflex neuroses. There is one form of spasm which 
 is worthy of special mention. I refer to nystagmus, an 
 oscillating, to and fro movement of the eyeballs, usually 
 in the horizontal plane, and caused by alternate contrac- 
 tion and relaxation of the external and internal recti. 
 This condition may be congenital or developed in early 
 childhood. It then indicates simply a lack of voluntary 
 control of the muscles, which is acquired by the child 
 simultaneously with intelligent vision. As soon as he 
 recognizes objects, he directs the eyes toward them, 
 thereby acquiring the faculty of accurate fixation. It is 
 easy to understand that this faculty will be imperfectly 
 developed if vision is too indistinct to create cortical 
 perceptions definite and strong enough to excite the im- 
 pulse of adjustment. Hence opacities of the cornea due 
 to ophthalmia neonatorum, and congenital cataract, colo- 
 boma of the iris and choroid, microphthalmus and high 
 degrees of refractive errors are among the recognized 
 causes of congenital or infantile nystagmus. If both eyes 
 are imperfect, the nystagmus is constant, but if one eye 
 only suffers, the tremor is only noticed when an effort
 
 EXTERNAL OCULAR MUSCLES. 51 
 
 is made to fix an object with this eye, but then it is 
 bilateral. It may also result from arrested development 
 of the nerve trunks or cortical centres, so that the mo- 
 tor stimulus is wanting though visual impressions are 
 accurately received and interpreted. 
 
 Nystagmus also develops in persons who use 
 their eyes for long periods with insufficient light, as the 
 so-called " Miner's Nystagmus." The confinement in 
 dark, ill-ventilated, underground chambers, and the 
 breathing of poisonous gasses, added to the strain upon 
 the eyes, consequent upon working with insufficient 
 light and keeping the eyes fixed in an unnatural posi- 
 tion many hours a day, which the nature of the work 
 necessitates, are the causes of this affection. Night 
 blindness often develops simultaneously. 
 
 When nystagmus develops in adults, who are not 
 engaged in such occupations, it is a valuable diagnostic 
 sign indicating the existence of serious organic disease. 
 But it affords no evidence of the location or the nature 
 of the disease, for it has been found associated with 
 meningeal and subdural hemorrhage, pachy-meningitis- 
 hemorrhagica, in tubercular basilar meningitis, cerebral 
 hemorrhage, thrombosis in the sinuses, tumor, softening, 
 disease of the optic thalamus, lesions of the cerebellum, 
 in disease of one side of the pons, and in degenerative 
 diseases of the cord. Gowers, in the last edition of his 
 " Diseases of the Nervous System," says : " The practi- 
 cal significance of nystagmus is extremely great, not
 
 52 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 from any distinct indication of the seat, or precise na- 
 ture of the disease, but because it shows the presence of 
 more than functional disturbance. It is often marked in 
 the early stage of degenerative disease when other 
 symptoms are equivocal, and a search for it should 
 never be omitted, and should include always the up- 
 ward movement of the eyes. It may be trusted without 
 hesitation, and in a large number of cases prevents a 
 mistake in diagnosis." 
 
 It occurs very frequently with multiple sclerosis 
 and is a characteristic symptom and a valuable diagnostic 
 sign. It is said to occur in 12 per cent, of all cases 
 of this disease. When tremor of the eyes on fixing an 
 object is associated with true nystagmus, we have an 
 additional indication of multiple sclerosis. According to 
 Knies, the symptom is caused by sclerotic foci in the 
 vicinity of the muscle nuclei, whereby the conduction 
 is interfered with, but not abolished. In other cases it 
 indicates incomplete motor paralysis of the cerebral cor- 
 tex. It rarely occurs in tabes and paralysis agitans. 
 
 " Charcot regards nystagmus-like twitching of the 
 eyes, that is, irregular movements when an object is 
 fixed, as a valuable diagnostic sign of Friedreich's dis- 
 ease or hereditary ataxia, which begins generally at the 
 period of puberty." (Knies). 
 
 In opposition to the views of Gowers, above ex- 
 pressed, that the presence of nystagmus always indicates 
 an organic nervous disease, Dr. Sabrazes, in " Semaine
 
 EXTERNAL OCULAR MUSCLES. 53 
 
 Medic" for September 26, 1894, and quoted in the Eng- 
 lish edition of "Annal d'oculistique," says : 
 
 "Is acquired nystagmus, the diagnostic value of 
 which I am about to sketch, always produced by a per- 
 manent organic lesion? May there not be cases in 
 which the successive elimination of the many causes 
 cited to explain nystagmus, lead the observer to suspect 
 the possibility of a purely functional disturbance arising 
 from hysterical phenomena? 
 
 " This is not the opinion of neurologists, and par- 
 ticularly of Charcot, who said, in 1892, in the course of 
 a lecture on multiple sclerosis and its ocular phenom- 
 ena : ' Nystagmus is never found in hysteria or in 
 tabes.' 
 
 " But the existence of a single indisputable case, 
 carefully observed, suffices to controvert this too strong 
 assertion and to show that an hysterical nystagmus may 
 really exist. 
 
 " The author confirms his assertion by reporting 
 a case of manifest hysteria where the nystagmus was 
 independent of any lesion of the visual apparatus. Fur- 
 thermore, hypnotic suggestion caused the disappearance 
 of all symptoms of disease as soon as it was practiced. 
 
 " Nystagmus should not, then, be taken as an 
 absolute proof of multiple sclerosis without considering 
 the possibility of hysteria." (Valude).
 
 CHAPTER III. 
 
 AFFECTIONS OF THE LENS AND IRIS. BEHAVIOR OF 
 THE PUPIL AND OF THE ACCOMMODATION. 
 
 AFFECTIONS OF THE LENS. 
 
 The lens derives its nourishment from the arteries 
 of the ciliary processes. A lenticular opacity is always 
 an evidence of impaired nutrition and there are two var- 
 ieties of cataract which are of special diagnostic signif- 
 icance. 
 
 I. A laminated cataract sometimes occurs in young 
 children in consequence of convulsions, and the latter 
 may be caused by rachitis. An explanation has been 
 offered upon the supposition that a spasm of the ciliary 
 muscle accompanies the general convulsions, and thus 
 interferes with the circulation in the arteries of the 
 ciliary processes. The development and growth of the 
 lens continues up to the sixth year, and those parts 
 which have been completely formed previous to the oc- 
 currence of the convulsions remain transparent, while 
 the nutrition of the portion which is still in a forma- 
 tive stage suffers and hence is more or less cloudy. 
 The opacity does not develop immediately, but within a 
 few days or weeks subsequent to the convulsion. There- 
 
 (54)
 
 AFFECTIONS OF THE IRIS. 55 
 
 fore the occurrence of a laminated cataract indicates the 
 necessity for constitutional treatment, especially with ref- 
 erence to rachitis. 
 
 II. A soft or cortical cataract in older children 
 or young adults is frequently caused by diabetes, owing 
 to the absorption of water and to the presence of glu- 
 cose. Both eyes are usually affected. Therefore the 
 urine should always be examined in such cases. 
 
 La Grange ("Arch. d'Ophthal.," 1887, Jan.) found 
 13 cases of cataract among 52 diabetics, and Galezowski 
 ("Jahr.J, Aug.," 1883, P- 2 97) found 46 cases of cata- 
 ract in 144 diabetics. 
 
 AFFECTIONS OF THE IRIS. 
 
 Inflammation of the iris (iritis) always arouses a 
 suspicion of syphilis, and there is one form of the affection 
 which warrants a positive diagnosis of this disease. The 
 proportion of cases of iritis which are of specific nature 
 has been estimated by various writers at from one-fourth, 
 (Arlt), to three-quarters. Probably fifty per cent, is a 
 safe estimate. Not all of them, however, manifest the 
 characteristic feature giving rise to the classification of 
 " guminous," " condylomatous " or " papulous " iritis. 
 This consists in the development of " yellow or dirty 
 orange colored nodules, surrounded by a narrow red 
 zone two or three millimetres in diameter, more often 
 toward the pupillary margin and below." The reddish 
 color of the nodules distinguishes the syphilitic iritis
 
 56 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 from the tubercular and leprous iritis, in which there 
 also occurs a formation of tubercles or nodules. The 
 former are grayish red or yellowish white in color, and 
 are not much larger than a pin's head. There are 
 usually several, and they may appear and disappear for 
 a considerable length of time. Ludwig Bach makes the 
 assertion in Knapp's Archives, Jan., 1895, that iritis is 
 just as often of tuberculous as of syphilitic origin, but 
 this is probably an exaggeration. He states also that the 
 ciliary portion of the iris is the part most often 
 affected by tuberculosis. The leprous nodules are gray- 
 ish in color and are situated towards the outer edge of 
 the iris, and usually grow until they fill the anterior 
 chamber and induce secondary cyclitis and irido-cyclitis, 
 and destruction of the eye. Leprosy is a rare disease in 
 this country, while tuberculosis is common. Probably 
 iritis is never a primary manifestation of either disease, 
 and there will be coexistent symptoms which will ren- 
 der a diagnosis unequivocal. 
 
 Syphilitic iritis is most frequently observed in the 
 secondary stage of the acquired form. It has been ob- 
 served within three weeks after the appearance of the 
 initial lesion. When iritis develops in children, espe- 
 cially in infants, it is usually a manifestation of heredi- 
 tary lues. 
 
 Sarcoma, also, sometimes develops in the iris, 
 producing symptoms somewhat analagous to those of 
 syphilis and leprosy. The color of the growths and the
 
 AFFECTIONS OF THE IRIS. 57 
 
 course of development, the history and concomitant 
 symptoms will decide the diagnosis. 
 
 Diabetes is occasionally associated with a form of 
 iritis, with a significant symptom of an unusually exten- 
 sive exudation, purulent or fibrinous, into the anterior 
 chamber. 
 
 Iritis may be idiopathic, and caused by exposure 
 to cold, especially in rheumatic subjects, and it is fre- 
 quently associated with gonorrhoea. Certain conditions 
 frequently, though not invariably, accompany both of 
 these varieties, and render their differential diagnosis 
 difficult without the aid of other symptoms. Both are 
 prone to relapse, and are accompanied with pain and in- 
 flammation of the joints, and both are attended with a 
 thick, fibrinous, easily coagulating exudation, with a 
 tendency to firm adhesion to the lens and to occlusion 
 of the pupil. 
 
 Distinguishing features of the rheumatic form are 
 the greater severity of the pain, the aggravation from 
 moving the eye, and the rarity of suppuration. 
 
 It is stated that iritis often complicates relapsing 
 fever, and, while of no diagnostic importance, the fact 
 should be borne in mind that the affection may be 
 promptly recognized and correctly treated. 
 
 Finally, in cases of iritis without obvious cause, 
 the urine should be examined, for it has been ascribed 
 to albuminuria.
 
 58 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 BEHAVIOR OF THE PUPIL AND OF THE ACCOMMODATION. 
 
 Before discussing the significance of pathological 
 conditions of the pupil, a few words regarding its natu- 
 ral form and size, and the methods of examination are 
 desirable. 
 
 The pupil is the nearly round opening in the 
 muscular curtain of the iris. It appears black under 
 ordinary circumstances because the part of the retina 
 presenting through it is not illuminated. The iris is 
 composed of both radiating fibres whose contraction en- 
 larges the opening, and of constrictor fibres by means 
 of which the opening is made smaller. The size of the 
 pupil therefore varies considerably under physiological 
 conditions. It contracts under the stimulus of light, 
 upon efforts of accommodation, and with convergence, 
 and it dilates under feeble illumination, and upon irri- 
 tation of the skin, especially of the face and of the back 
 of the neck. It is larger in children and smaller in old 
 age than in adult life. It is also slightly larger in my- 
 opia and smaller in hyperrnetropia than in emmetropia. 
 The diminution of accommodation in the former con- 
 dition, and its increase in the latter is the explanation 
 of the varying size. 
 
 Its diameter, under ordinary illumination, is from 
 2.5 mm.-5.8 mm., with an average of about 4 mm., and 
 a constant departure from this standard is usually an indi- 
 cation of disease. The pupils of the two eyes should be
 
 BEHAVIOR OF PUPIL AND ACCOMMODATION. 59 
 
 of uniform size, although very careful examination fre- 
 quently demonstrates trifling variations not apparent 
 upon ordinary inspection, and they should react con- 
 sensually and equally to stimuli applied to either eye 
 singly, or to both together. When only one pupil is il- 
 luminated, for instance, both should contract to the same 
 extent. If any inequality is noticed, the one showing 
 the lesser reaction is usually the pathological one, but 
 this is not invariable. 
 
 The behavior of the pupils is of very great prac- 
 tical significance in the diagnosis both of the location 
 and nature of nervous diseases, and therefore its exami- 
 nation should be conducted systematically and with 
 great care. The following method is recommended : It 
 is assumed that any inflammation of the iris or posterior 
 synechiae is absent, and that the media are clear. The 
 patient being seated before a window with moderate 
 illumination, the size and form of each pupil should 
 be separately measured with a rule or, preferably, with 
 a pupillometer constructed especially for this purpose, 
 while he is gazing straight before him at a distance. 
 The observation should be made when both eyes are 
 open, and when they are alternately closed or shaded, 
 carefully noting any movement of contraction or dilata- 
 tion, and any lack of uniformity in such movements in 
 the two eyes. The reaction upon convergence and ac- 
 commodation is now studied by fixing the patient's gaze 
 upon the examiner's finger, which is gradually ap-
 
 60 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 proached along the middle line to about 8 inches in 
 front of the patient's eyes. To study the accommoda- 
 tive reaction independently of convergence, each eye 
 should be examined separately. The one under observa- 
 tion should be directed straight forward and the other 
 one closed. After a few seconds he is made to suddenly 
 fix his gaze upon some near object, without altering the 
 direction of his vision. The pupil should immediately 
 contract, and dilate again as soon as the object is re- 
 moved. 
 
 The light reflex is best observed by concentrating 
 a pencil of light, preferably from an artificial source of 
 illumination, upon the pupil by means of a convex lens, 
 and watching the resulting contraction of each pupil. 
 The eyes are to be separately tested, the one not under ob- 
 servation being shielded from direct exposure to the light, 
 but not closed. The light should be thrown into the eye 
 from different directions, and its intensity varied to test the 
 sensibility of different portions of the retina and the de- 
 gree of such sensibility. These tests should be several 
 times repeated in obscure cases, when the result of the 
 first examination is not conclusive, and it is often ad- 
 visable to place the patient in a darkened room for 
 some minutes previously. 
 
 Having discussed the methods of examination, 
 I pass to what may be learned from the results so ob- 
 tained.
 
 BEHAVIOR OF PUPIL AND ACCOMMODATION. 61 
 
 Dilatation and contraction of the pupils may be 
 due to direct stimulation of the motor nerves, but they 
 are usually reflex acts. The light reflex, the skin 
 reflex, and the contraction attending efforts of accommo- 
 dation and convergence have been already mentioned. 
 
 Mydriasis and myosis have no special significance 
 as isolated symptoms, but, taken in connection with 
 other symptoms, they are sometimes an index of the 
 nature and location of a morbid process, and the differ- 
 ent forms of paralysis of the iris muscles are very sug- 
 gestive diagnostic indications,, as will be apparent in a 
 later discussion. 
 
 If we recall the paths which the afferent and 
 efferent impulses traverse in each instance of reflex and 
 associated action, we shall more clearly understand the 
 morbid processes which abolish these acts. 
 
 i. CONTRACTION OF THE PUPIL Contraction of 
 the pupil under the stimulus of light (the light reflex) is 
 accomplished by an afferent impulse passing from the 
 retina along the optic nerve and optic tract to the 
 thalamus, and by way of the habenular ganglion to the 
 pineal gland. From each of these localities (the habenu- 
 lar ganglion and the pineal gland) fibres pass to the 
 oculo-motor nucleus in the aqueduct of Sylvius, and 
 from thence the motor impulse travels along the third 
 nerve to the ciliary ganglion, and through the ciliary 
 nerves to the constrictor fibres of the iris.
 
 62 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 The consensual reaction of the pupils is ex- 
 plained by the existence of communicating branches be- 
 tween the habenular ganglia in either hemisphere of the 
 brain, the communication taking place through the pos- 
 terior commissure, and also by the decussation of the 
 optic nerve fibres in the chiasm, so that stimulation 
 transmitted from the retina of one eye reaches the 
 visual centres through the medium of both optic tracts. 
 (Some writers locate the reflex centre from the iris in 
 the anterior corpora quadrigemina instead of the haben- 
 ular ganglion). 
 
 It is evident that the pupillary light reflex will 
 be lost whenever the conduction fails either in the optic 
 or the third nerve. 
 
 Accommodation, or the adjustment of the vision 
 for near objects, is effected by contraction of the ciliary 
 muscle, which, as well as the iris, is under control of 
 the third nerve. An act of accommodation is usually 
 associated with contraction of the pupil. It should be 
 remembered that this is, to some extent, a mechanical 
 result of the contraction of the ciliary muscle whereby 
 a larger amount of blood is forced into the iris. Both 
 the reflex and associated contraction fail simultaneously, 
 as a rule, but it is possible for the latter to be pre- 
 served, when the light reflex fails, constituting the so- 
 called "Argyll-Robertson pupil," the significance of 
 which will be referred to later.
 
 BEHAVIOR OF PUPIL AND ACCOMMODATION. 63 
 
 The reflex arc by which the pupillary reaction 
 attending convergence of the visual axes is accomplished 
 is probably completed by fibres which pass from the 
 optic tract to the corpora quadrigemina, and from 
 thence to the third nucleus. The function of the cor- 
 pora quadrigemina is not yet positively determined, but 
 it seems almost certain that they preside over " ocular 
 movements in their relation to visual impressions." 
 (Gowers). 
 
 2. DILATATION OF THE PUPIL. Dilatation of the 
 pupil results passively from relaxation of the sphincter 
 pupillae, and actively from the contraction of the dilator 
 fibres, through stimulation of the sympathetic nerves 
 which govern them. In this manner direct excitation 
 of the cilio-spinal centre in the upper dorsal portion of 
 the cord produces mydriasis, and irritation of the skin 
 has also this effect, by reflex action. In the latter case, 
 the afferent impulse reaches the corpora quadrigemina 
 through the spinal cord, and the motor impulse is 
 thence transmitted again through the upper cervical 
 cord by way of the seventh and eighth cervical and 
 first dorsal nerve roots, to the cervical sympathetic, 
 thence to the cavernous plexus, ciliary ganglion and 
 ciliary nerves. Some of the sympathetic fibres reach 
 the iris by a different path, as is proven by the fact 
 that irritation of the trunk of the sympathetic in the 
 neck produces dilatation of the pupil after removal of 
 the ciliary ganglion. The ophthalmic division of the
 
 64 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 fifth nerve is one of the channels for such sympathetic 
 influence. 
 
 Thus the skin reflex will be lost whenever the 
 conduction fails in either direction, in consequence of a 
 lesion in the upper cervical region of the cord, in the 
 cervical sympathetic, or along the path between the lat- 
 ter and the ciliary ganglion. When the light reflex is 
 lost in diseased conditions, the skin reflex generally fails 
 also, but not always. The skin reflex may be preserved 
 when the light reflex is lost. 
 
 As of diagnostic significance in connection with 
 nervous affections, we recognize a spastic and a paretic 
 variety of both mydriasis and myosis, and, in a given 
 case, it is desirable to inquire which variety exists. 
 
 MYDRIASIS The spastic variety of mydriasis is 
 caused by contraction of the radiating fibres of the iris 
 through stimulation of the sympathetic motor nerves. 
 The widely dilated pupil, in such conditions, still con- 
 tracts with efforts of accommodation and upon the stimu- 
 lus of light, showing that the constrictor fibres and the 
 path of the light reflex are unaffected, but there is di- 
 minished or absent contraction from the use of myotics 
 such as eserine and pilocarpine. 
 
 Other signs of sympathetic irritation are also 
 present, such as dilatation of the palpebral fissure with 
 impaired power of closing the lid. Often, also, careful 
 observation shows slight protrusion of the eye, and lack 
 of uniformity in the downward movement of the lid and
 
 BEHAVIOR OF PUPIL AND ACCOMMODATION. 65 
 
 eyeball. Those points will enable one to differentiate 
 the spastic from the paretic variety of mydriasis. 
 
 The characteristic feature of the latter condition 
 is absence of contraction of the sphincter muscle, mani- 
 fested especially by loss of the light reflex. It presents 
 a moderately dilated and immobile pupil in contrast to 
 the widely dilated and sensitive pupil of spastic mydri- 
 asis. Another feature of paretic mydriasis is that it can 
 be increased by atropin, which, when dropped into the 
 conjunctival sac, has the two-fold action of paralyzing 
 the terminal fibres of the third nerve and of stimulating 
 the sympathetic. 
 
 It has been previously stated that the light reflex 
 will be wanting when the conduction fails either in the 
 optic or the third nerve, hence we might subdivide 
 paretic mydriasis into (a) sensory or centripetal, and (b) 
 motor or centrifugal paresis. With the former, the 
 mydriasis is always bilateral and associated with more 
 or less loss of sight, so that the visual perception is too 
 faint to excite the motor impulse. The latter form is 
 usually associated with loss of function of one or more 
 of the extrinsic eye muscles, and indicates an interrup- 
 tion of the motor impulse at some point. It may exist 
 with unimpaired sight. 
 
 Having determined in a given case which variety 
 of mydriasis is present, we are prepared to inquire next, 
 what deductions can logically be drawn therefrom?
 
 66 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 I. Spastic mydriasis may affect one or both eyes, 
 and indicates, as has been mentioned, an irritation of 
 the cilio-spinal centre situated in the lower cervical and 
 upper dorsal region of the cord, or of the cervical sym- 
 pathetic. This irritation may be direct or reflex. 
 
 Direct irritation exists in the early stages of all 
 inflammatory diseases of the spinal cord and its mem- 
 branes in this locality, such as spinal congestion, menin- 
 gitis, and neoplasms, and in the so-called "spinal irrita- 
 tion," which is frequently met with in nervous and 
 chlorotic young women. It is also a premonitory sign 
 of tabes. 
 
 Reflex irritation results from irritation of the 
 skin (the so-called skin reflex) already referred to. It 
 accompanies extensive cutaneous burns and severe urti- 
 caria. Pinching the skin at the back of the neck 
 causes mydriasis in certain cases of meningitis, and is 
 known as Parrot's sign. Intestinal worms cause spastic 
 mydriasis by reflex action ; also disease of the apex of 
 the lung, and anuerisms of the aorta and arteria innom- 
 mata. 
 
 In the latter cases the mydriasis is on the side 
 of the lesion. Cerebral affections with increased intra- 
 cranial pressure, and certain mental states, fright, acute 
 mania and melancholia, for instance, are, at times, asso- 
 ciated with this form of mydriasis, the explanation of 
 which must be a reflex irritation communicated to the 
 dilating centre.
 
 LOSS OF THE LIGHT REFLEX. 67 
 
 Spastic mydriasis, then, indicates the locality of 
 the casual affection, but furnishes no definite informa- 
 tion as to its nature. Sometimes dilatation of one pupil 
 with preserved reaction to light, simulating spastic 
 mydriasis, is observed, which is due to some peculiar 
 condition of the iris. Such a condition is not of serious 
 import, and may persist for years. 
 
 PARETIC MYDRIASIS. LOSS OF THE LIGHT REFLEX. 
 
 As was observed when discussing paralysis of 
 the ocular muscles, the third nerve may be implicated 
 anywhere between the globe and its cortical termina- 
 tion, and the same is equally true of the optic nerve, so 
 that both the motor and sensory varieties of paretic 
 mydriasis may be advantageously classified in the same 
 manner that was adopted with paralysis of the external 
 muscles, namely ; ist, Peripheral ; 2d, Intra-cranial (a, 
 Basilar ; b, Nuclear) ; 3d, Cortical. 
 
 With the first classification, that is, cases of peri- 
 pheral origin, whether motor or sensory, the present 
 discussion does not concern itself, as they have no 
 relation to the diagnosis of nervous diseases. Care 
 should be taken, however, not to confound the symp- 
 toms caused by the use of mydriatics, such as atropin, 
 duboisine, cocaine, hyoscyarnine, etc., with similar ac- 
 companiments of cerebral affections. It is important to 
 remember that all drugs which dilate the pupil also 
 impair the power of accommodation and vice-versa. The
 
 68 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 same is true of myotics and spasm of the ciliary muscle. 
 
 Reflex iiidoplegia (it has been previously stated 
 that the pupillary functions are usually reflex) is ordi- 
 narily bilateral. 
 
 Loss of the light reflex, when monocular, may 
 be either peripheral, basilar or nuclear, and of itself 
 does not furnish data for exact localization. It is 
 always motor. Otherwise contraction would follow light 
 stimulus transmitted from the other eye. 
 
 Monocular mydriasis is sometimes idiopathic, 
 caused by exposure to cold, although in suspected dis- 
 ease of the nerve centres, monocular mydriasis and pa- 
 ralysis of accommodation is to be regarded with suspi- 
 cion, as suggesting the approach of general paralysis or 
 of insanity. 
 
 Wernicke r s sign, or " hemianopic pupillary inac- 
 tion," is a trustworthy guide in the diagnosis of the sit- 
 uation of a lesion causing hemianopic visual disorders. 
 If light thrown upon the blind portion of the retina 
 causes contraction of the pupils, it demonstrates that 
 the cause of the lesion is above the reflex path for the 
 pupillary response to light stimulus. The converse, 
 namely, lack of contraction of the pupils, is conclusive 
 evidence that the lesion is at the optic thalamus, or be- 
 tween it and the optic nerve stem. 
 
 When hemianopic pupillary inaction exists with- 
 out concomitant hemianopic visual defect, it indicates 
 that the lesion is between the nucleus of the third
 
 LOSS OF THE LIGHT REFLEX. 69 
 
 nerve and the optic tract. This symptom is known as 
 Knies' sign, and when observed is of definite value in 
 localization. 
 
 In case of sudden blindness also the presence or 
 absence of the light reflex is of service in determining 
 the location of the lesion causing it, for, as we have 
 seen in the case of hemianopia, if it is due to a corti- 
 cal disease affecting the higher centres beyond the 
 "belt-line," so to speak, the light reflex will be pre- 
 served, while it will be lost in affections of the retina, 
 optic nerve or tract. There are exceptions to this rule, 
 however, for cases are on record where there was sud- 
 den blindness from a lesion affecting the nerve trunks 
 in front of the chiasm, in which the pupillary reflex 
 was preserved. Such cases simply indicate that a 
 slighter stimulus suffices for the production of reflex 
 contraction of the constrictor fibres of the iris, than for 
 the perception of light. 
 
 An isolated paralysis of the constrictor fibres of 
 the iris without other signs, points to a circumscribed 
 lesion, probably syphilitic, in the anterior part of the 
 floor of the fourth ventricle, affecting only that part of 
 third nucleus from which arise the fibres supplying the 
 iris. It is possible for such a lesion to be manifested 
 by monocular mydriasis, but from the anastomosis 
 which exists between the nuclei of the two sides, such 
 a condition is extremely unlikely.
 
 70 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 Cortical paretic mydriasis is bilateral. It occurs 
 with cerebral anemia, in apoplexy and in meningeal 
 hemorrhage, and in alcoholism. When mydriasis suc- 
 ceeds a primary myosis in apoplexy, it is an unfavor- 
 able symptom, showing paralysis of the third nerve 
 from increasing pressure. The presence of dilatation or 
 contraction is a valuable point of differential diagnosis 
 between apoplexy and embolism, as the pupils are un- 
 altered in the latter. It is of frequent occurrence dur- 
 ing epileptic seizures, and is associated with conditions 
 of increased intra-cranial pressure which compresses the 
 third nerve, such as tumors and hydrocephalus. It fre- 
 quently attends the later stages of tubercular meningitis, 
 but is rare in the epidemic cerebro-spinal variety. This 
 fact may be of value in a differential diagnosis. It oc- 
 curs also in diseases of the cerebellum. In concussion 
 of the brain we find a sluggish action of the pupils 
 without marked dilatation or contraction. In coma from 
 compression, we find one or both pupils dilated and 
 sluggish. 
 
 Care should be exercised to discriminate between 
 loss of vision from cerebral affections and the indistinct- 
 ness resulting from impaired accommodation, or because 
 of the circles of diffusion formed on the retina in con- 
 sequence of the dilated pupil. In the latter case, near 
 vision will be restored by a suitable convex lens when 
 the accommodation is at fault, and the circles of diffu- 
 sion may be obviated by limiting the amount of light
 
 LOSS OF THE LIGHT REFLEX. 71 
 
 entering the eye, by looking through a small opening 
 in a card or similar device, thus improving vision for 
 all distances. 
 
 Paretic mydriasis is an early symptom of general 
 paralysis and a late manifestation of paralysis of the in- 
 sane. 
 
 Von Graefe called attention to an ephemeral 
 variety of mydriasis, which occurs transiently, at short 
 intervals, and which he regarded as a premonitory 
 symptom of insanity, more especially of "ambitious 
 monomania." It may, however, be of the spastic variety 
 due to spinal irritation. The pupillary phenomena of 
 this disease will be referred to again. 
 
 The condition of the pupil is of service in dis- 
 tinguishing an atrophy of the optic nerve resulting 
 from inflammation or caused by cerebral disease, from 
 that form known as spinal atrophy. In the two former 
 cases it is, as a rule, dilated through loss of the light 
 reflex, but in the latter it is contracted, in consequence 
 of paralysis of the sympathetic. 
 
 Mydriasis may be a premonition of uraernic in- 
 toxication, hence the condition of the pupils should be 
 carefully watched in cases of nephritis when this con- 
 dition threatens. 
 
 Mydriasis with loss of power of accommodation 
 should awaken a suspicion of syphilis, for Alexander 
 states that three-fourths of such cases are of syphilitic
 
 72 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 origin, while Uhthoff estimates the proportion due to 
 this cause at one-fourth the whole number. 
 
 In cholera, loss of the light reflex is a bad prog- 
 nostic omen. In the " Deutsch. Med. Woch." for Jan- 
 uary 23, 1891, Corte states that where the reaction to 
 light fails, a fatal termination is certain, even in an ap- 
 parently mild case, and, on the other hand, the progno- 
 sis is favorable even in very severe cases if the light 
 reflex is preserved, and this he considers true without 
 regard to the existence of a dilated or contracted pupil. 
 
 THE ARGYLL ROBERTSON PUPIL. 
 
 Usually the reflex contraction of the iris attending 
 efforts of accommodation and convergence is lost simul- 
 taneously with failure of the light reflex. It is possible 
 for the associated contraction to be preserved when 
 there is no response to the stimulus of light, and this 
 variety of reflex iridoplegia is known as the " Argyll 
 Robertson pupil," and is a very valuable diagnostic in- 
 dication in two forms of nervous disease. 
 
 The method of testing the accommodative and 
 convergent reaction has already been mentioned on page 
 59, and need not be repeated here. Noyes maintains 
 that convergence and not accommodation is the factor 
 inducing contraction in the Robertson pupil, and sup- 
 ports his statement by eliminating all accommodation. 
 This he did by placing a strong concave lens before the 
 patient's eye during the examination, and found the re-
 
 THE ARGYLL ROBERTSON PUPIL. 73 
 
 suit to be the same. (" Diseases of the Eye," last edi- 
 tion, page 436). 
 
 The pupil may be of normal size, dilated or con- 
 tracted, but usually there is more or less myosis. For 
 this reason it would seem that a consideration of this 
 pupillary condition in connection with mydriasis. was 
 inappropriate. But inasmuch as the myosis is only an 
 association, and not an essential feature of the " Argyll 
 Robertson pupil," and since the characteristic of the 
 latter is a paresis of the sphincter iridis, it seems advis- 
 able to discuss it here. 
 
 Its presence demonstrates a lesion affecting the 
 fibres extending from the tubercula quadrigemina to 
 the third nucleus. Since there is no impairment of 
 vision and no loss of voluntary motion, it is evident 
 that the primary optic ganglia and the third nucleus 
 are unaffected. It is found in locomotor ataxia, or tabes 
 dorsalis, and paresis, or progressive paralysis of the in- 
 sane, as a characteristic symptom and is very rare in 
 other diseases. Hence it becomes a very valuable aid 
 in diagnosis, especially as it often occurs very early in 
 these two affections. The peculiar mental condition 
 and the disorder of speech in paresis will enable one to 
 make a differential diagnosis. These two diseases may 
 exist simultaneously. 
 
 Dillman says that the " Argyll Robertson pupil " 
 is found in 70 per cent, of the cases of tabes, and in 25
 
 74 THE EVE AS AN AID IN GENERAL DIAGNOSIS. 
 
 per cent, it is a very early symptom. It is estimated 
 that this symptom occurs in half the cases of paresis. 
 
 MYOSIS. 
 
 With myosis also we recognize a spastic and a 
 paretic variety. The former is the expresssion of irrita- 
 tion of the oculo-motor nerve, and is accompanied by 
 spasm of accommodation. Atropia will cause full dila- 
 tation and relaxation of accommodation. It commonly 
 attends hyperaemia of the brain and the early inflam- 
 matory period of cerebral affections, and of tubercular 
 and cerebro-spinal meningitis, the irritable premonitory 
 stage of apoplexy and of nacrosis, and the excitement of 
 intoxication from alcohol and chloroform. 
 
 We find it with hemorrhage into the cerebral 
 ventricles and into the pons Varolii, in which situations 
 an irritation of the adjacent oculo-motor nucleus results. 
 A neoplasm near the origin or along the course of the 
 third nerve, would, in its early stages, cause spastic 
 myosis, and it accompanies hysterical and epileptic at- 
 tacks. It may be due to the influence of nicotine, and 
 it occurs in reflex irritation from affections of the fifth 
 nerve. 
 
 PARETIC MYOSIS. 
 
 The paretic is a much more common form of 
 myosis, and is characterized by failure of the skin re- 
 flex, and, when uncomplicated, the pupil is of medium
 
 PARETIC MYOSIS. 75 
 
 size and responds both to light and convergence. It is 
 an evidence of paralysis of the sympathetic, which may 
 be due to direct injury of the cervical sympathetic, or to 
 its compression by an anuerism, a tumor, enlarged glands, 
 etc. It is then monocular and is associated with other 
 evidences of sympathetic paralysis, such as slight ptosis 
 and flushing of the corresponding side of the face, with 
 local increase of temperature amounting sometimes to 
 1.5 F., measured in the nostril or external auditory 
 canal. Such a condition may last for years. 
 
 Paretic myosis is generally caused by a chronic 
 disease of the spinal cord. It does not occur, however, 
 when the disease is situated below the upper dorsal re- 
 gion. In this variety of myosis, both pupils are affected, 
 the accommodation is normal, and the pupil can be 
 dilated with atropin, although rather feebly. Atropin 
 has a two-fold action in producing dilatation. It causes 
 paralysis of the terminal fibres of the third nerve dis- 
 tributed to the sphincter-pupillae and ciliary muscle, and 
 at the same time it stimulates the sympathetic which in- 
 nervates the dilator fibres. This explains the more en- 
 ergetic action of the drug in spasmodic than in the 
 paretic form of myosis. The latter is more especially 
 met with in tabes and progressive paralysis of the in- 
 sane. Dillman says that it is present in 23 per cent, of 
 the cases of tabes. 
 
 We have seen that in these two diseases the 
 "Argyll Robertson pupil " is also usually present, so
 
 76 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 that we find the characteristic feature to be that of re- 
 flex iridoplegia in the full meaning of the term, that 
 is, a failure of all pupillary reflexes, and this condition 
 serves as a valuable point in differential diagnosis be- 
 tween true tabes and the multiple neuritis (of alcoholic 
 origin, usually) which so closely simulates it, for in the 
 latter there is an absence of myosis and reflex irido- 
 plegia. 
 
 In tabes, the reaction to light generally fails 
 first. Knies says: "Absence of pupillary reaction to 
 light, which is followed by loss of reaction to accom- 
 modation and to convergence and to cutaneous irritants, 
 is one of the most characteristic signs of impending or 
 beginning tabes, and forms an integral part of the fur- 
 ther clinical history of the disease." 
 
 " The presence of oculo-pupillary and vaso-motor 
 symptoms of paresis or irritation are important in an 
 accurate local diagnosis in injuries of the spine. Almost 
 every severe spinal injury is attended with vaso-motor 
 paralysis and rise of temperature upon the side of the 
 motor paralysis." 
 
 The presence of myosis and iridoplegia with 
 coma of syphilitic origin, enables us to differentiate it 
 from a similar condition due to uraemia or alcoholism 
 in which there is mydriasis. It is hardly necessary to 
 mention the extreme myosis which occurs in opium 
 poisoning. The absence of myosis would be a counter- 
 indication in suspected acute poisoning, but it is
 
 ANISOCOREA. 77 
 
 worthy of remark that mydriasis is not uncommon in 
 chronic opium habitues. 
 
 ANISOCOREA. 
 
 By this term is understood an inequality in the 
 size of the two pupils, or an irregular and unequal re- 
 sponse to the various stimuli. 
 
 Knies says that difference in size of the pupils 
 points to the path between the optic ganglia and 
 the nuclei of the third nerve, as the location of the le- 
 sion causing it. " It may be an irritative lesion or a 
 commencing paralysis, according as one pupil is too 
 small or too large. The one which reacts most freely 
 and readily to light, convergence, etc., is to be consid- 
 ered the normal one." 
 
 Dillman says that this condition occurs in 34 per 
 cent, of the cases of tabes, and therefore it furnishes 
 still another oculo-pupillary sign of that disease in addi- 
 tion to those already mentioned. In common with my- 
 osis and reflex iridoplegia, anisocorea is characteristic 
 also of the early stage of general paralysis of the in- 
 sane. 
 
 Oliver, of Philadelphia, in discussing the pupill- 
 ary phenomena met with in this disease (in the " Med. 
 News" of November n, 1893), mentions "Irregularities 
 in size and reaction of the pupils with myosis. Dimin- 
 ished action of mydriatics, marked temporary asymmet- 
 ries, one pupil being quite small and irregular for sev-
 
 78 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 eral examinations, while its fellow was large and ovoid 
 or oval." 
 
 HIPPUS. 
 
 There is a condition of the iris known as " hip- 
 pus," characterized by alternate contraction and dilata- 
 tion of the pupil, which often accompanies nystagmus, 
 and is of similar significance. It must not be con- 
 founded with that tremor of the iris that accompanies 
 movements of the eye in dislocation or absence of the 
 lens. Hippus occurs frequently in multiple sclerosis, 
 and in connection with hysterical and epileptic seizures. 
 
 Rhythmical contractions of the iris have been 
 noticed in typhoid fever during the stage of cerebral 
 manifestations. 
 
 " Rapid alteration of myosis and mydriasis has 
 also been observed in tubercular meningitis." (Knies). 
 
 DISORDERS OF ACCOMMODATION. 
 
 The ciliary muscle and the iris, being both in- 
 nervated by the third nerve, usually act together. Spasm 
 of accommodation, as a rule, is accompanied with myo- 
 sis, and paralysis of accommodation with mydriasis. 
 Remembering, however, that the fibres which supply the 
 ciliary muscle arise from a separate nucleus, we can un- 
 derstand how the accommodation may be lost alone by a 
 circumscribed nuclear lesion in the vicinity of the floor 
 of the fourth ventricle (the aqueduct). Loss of accom- 
 modation (associated or not with mydriasis, or paralysis
 
 DISORDERS OF ACCOMMODATION. 79 
 
 of the extrinsic eye muscles) is the most frequent form 
 of post-diphtheritic paralysis, which is generally of nu- 
 clear origin, though sometimes it is due to a peripheral 
 neuritis. This is frequently the only manifestation of 
 post-diphtheritic paralysis, and readily yields to appro- 
 priate treatment, while, if unrecognized, it may seriously 
 alarm both physician and patient. It may occur very 
 soon or at a considerable time after disappearance of 
 the throat symptoms. It affects both eyes and occurs more 
 often in children than in adults. Frequently the pupil is 
 unaffected. It may be a valuable diagnostic indication in 
 doubtful cases, for the presence of paralysis of accommo- 
 dation following a sore throat or a membranous inflamma- 
 tion of the conjunctiva, of the vulva, or on a wound, de- 
 cides definitely the diphtheritic nature of the case. Bilat- 
 eral cycloplegia, as an isolated symptom, occurs also in 
 certain diseases of the cord, and may be explained by 
 an extension upward of the disease to the third nucleus. 
 Noyes enumerates the following diseases which 
 may be complicated with paralysis, more or less com- 
 plete, of the faculty of adjustment of near vision, viz. : 
 diabetes, trichinosis, cerebro-spinal sclerosis, essential 
 anaemia, masturbation and excessive venery, alcoholism, 
 uterine and syphilitic affections, neuralgia of the dental 
 and other branches of the fifth nerve. While of no spe- 
 cial value as a means of diagnosis in these affections, a 
 recognition of the cause of the visual disorder is desir- 
 able, as influencing the treatment.
 
 CHAPTER IV. 
 
 THE OPHTHALMOSCOPIC APPEARANCES OF THE FUNDUS 
 
 OCULI, INCLUDING AFFECTIONS OF THE CHOROlD, 
 
 RETINA AND OPTIC NERVE. 
 
 For the diagnosis of pathological changes in the 
 interior of the eye, behind the crystalline lens, the aid 
 of the ophthalmoscope is necessary. This instrument is 
 of very great value in the diagnosis of cerebral and 
 spinal affections, as well as of certain constitutional dis- 
 orders, and every progressive physician should be famil- 
 iar with its use. The instrument consists essentially of 
 a mirror perforated in its centre, and having a series 
 of lenses, any one of which can be brought directly 
 behind the perforation. The pupil of the patient is 
 illuminated by light reflected from a gas jet by the mir- 
 ror, and on looking through the aperture, directly in 
 the line of the illuminating rays, the observer is en- 
 abled to examine the interior of the patient's eye. Many 
 different patterns of the instrument are to be obtained, 
 but for the use of the general practitioner there is 
 none better than Loring's Student's Ophthalmoscope, a 
 cut of which is given below. 
 
 The optic nerve is but an off-shoot from the 
 brain, and the retina but an expansion of the former, so 
 
 (80)
 
 AFFECTIONS OF THE RETINA AND OPTIC NERVE. 81 
 
 that we have here a continuity of nervous structure sub- 
 ject to identical morbid processes. Moreover, the optic 
 nerve sheaths enter into the structure of the tunics of 
 the eyeballs on the one side, and are continuous with 
 
 the cerebral meninges on the other ; and the sub-vagi- 
 nal spaces are tubular prolongations of the cranial sub- 
 arachnoid and sub-dural spaces. It is easy to under- 
 stand, therefore, how meningitis may be complicated 
 with peri- or insterstitial neuritis, and how watery or 
 purulent exudations in the cranial cavity may cause dis- 
 tention of the nerve sheaths and induce inflammatory 
 changes in the papilla and retina. Again, derangement 
 of the cerebral circulation is accompanied with simulta- 
 neous changes in the retinal vessels, and the ophthal- 
 moscope enables one to recognize hyperaemia and anae- 
 mia of the retina, hemorrhage, embolism of the arteria 
 centralis, and the varieties of intra-ocular inflammation 
 which are symptomatic of constitutional affections. Fre- 
 quently before the sight begins to suffer, the ophthal- 
 6
 
 82 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 moscope reveals changes at the optic disc, and in a 
 doubtful case we are often enabled by its aid to con- 
 firm a diagnosis of disease of the brain, heart, kidneys, 
 etc., and to interpret the true meaning of various ner- 
 vous symptoms not otherwise of definite signification. 
 
 In these pages it is not my intention to discuss 
 the differential diagnosis of the various forms of disease 
 at the fundus of the eye. Such a diagnosis requires 
 special training and skill not possessed by the majority 
 of general practitioners. In pursuing the general plan 
 of this treatise, I shall endeavor simply to point out the 
 significance of certain pathological conditions as deter- 
 mined by ophthalmoscopic examination, assuming the 
 reader to be familiar with the use of the instrument, or 
 that, not possessing the requisite skill and knowledge, 
 he appreciates the importance and value of such a pro- 
 cedure, and will call in the aid of a specialist. 
 
 AFFECTIONS OF THE CHOROID. 
 
 As with iritis, so also with choroiditis, the most 
 frequent cause is syphilis, so that the presence of either 
 the diffuse or the disseminate variety awakens a strong 
 suspicion of a specific origin, but there are no charac- 
 teristic features which warrant an absolute diagnosis of 
 syphilis. It occurs in both the acquired and the inher- 
 ited form of the disease, but is most often met with 
 in the second, third or fourth years of the acquired 
 form. When syphilis can be excluded as the exciting
 
 AFFECTIONS OF THE CHOROID. 83 
 
 cause, disorders of nutrition, such as anaemia, chlorosis 
 and scrofula, are to be sought for. 
 
 We also recognize a metastatic suppurative cho- 
 roiditis, which is a manifestation of pyaemia, and occurs 
 most frequently as a complication of puerperal fever. It 
 may be the first or the only indication of pyaemia, and 
 hence may lead to the recognition of a hitherto unsus- 
 pected suppurative condition. 
 
 Knies says that a " sero-plastic purulent " cho- 
 roiditis occurs frequently as a complication or a sequence 
 of cerebral meningitis, especially in children. In such 
 cases it is usually monocular, and caused primarily by 
 phlebitis of the ophthalmic vein, although there may be 
 "a coincident deposit of morbific material in the pia 
 mater and the choroid." 
 
 A septic choroiditis has been noticed after ty- 
 phoid and intermittent fevers. Tuberculosis of the cho- 
 roid occurs with or without tubercular meningitis in the 
 form of " single or multiple whitish yellow or rosy yel- 
 low round masses over which the retinal vessels pass. 
 Their outlines are rather hazy. They are very rarely 
 surrounded by a striking pigmented zone, and this is 
 important in making a differential diagnosis. The indi- 
 vidual nodules usually grow, coalesce and project more 
 and more into the vitreous. Usually they belong to the 
 terminal stage of tuberculosis, and develop shortly be- 
 fore death." Therefore they possess but little diagnostic 
 value as a rule, but their recognition is important, be-
 
 84 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 cause sometimes, as Hangg says in " Dis. Strasbourg," 
 1890, "they may apparently constitute the sole manifes- 
 tation of tuberculosis for a long time." 
 
 AFFECTIONS OF THE RETINA AND OPTIC NERVE. 
 
 We can draw no fast lines of differentiation be- 
 tween the diagnostic significance of neuritis and retinitis, 
 as they so frequently coexist and merge the one into 
 the other. In general terms it may be stated that in 
 constitutional disorders pathological changes are more 
 pronounced in the tissues of the retina, while the intra- 
 ocular extremity of the optic nerve is first and most 
 predominantly affected by intra-cranial and spinal affec- 
 tions. It is deemed advisable, therefore, to consider sep- 
 arately the ophthalmoscopic appearances of the back 
 ground of the eye as they relate to systemic and ner- 
 vous diseases, and first let us inquire what data may 
 thus be obtained for the diagnosis of constitutional dis- 
 eases and those of remote organs. 
 
 Retinitis and neuro-retinitis are found in connec- 
 tion with many and diverse constitutional disorders. 
 Often they are of no special diagnostic importance, oc- 
 curring simply as complications in the course of well 
 pronounced and universally recognized diseases. As ex- 
 amples may be mentioned their occurrence in typhus 
 and typhoid fever, measles, small-pox, diphtheria, pneu- 
 monia and intermittent fever ; in disturbances of nutri- 
 tion such as scrofula, scurvy, purpura and oxaluria, and
 
 CHANGES IN THE CIRCULATION OF THE RETINA. 85 
 
 in acute anaemia, especially after hemorrhage from the 
 uterus or stomach. Sometimes they occur as a rheu- 
 matic manifestation and in menstrual disturbances. 
 
 In other instances, affections of the optic nerve 
 and retina are of great value in the diagnosis of consti- 
 tutional maladies and disorders of remote organs. In 
 general, it may be stated that morbid appearances in 
 these tissues, when not connected with nervous diseases, 
 or indicative of them, point to lesions of the heart and 
 blood vessels, to syphilis or to renal disease. 
 
 CHANGES IN THE CIRCULATION OF THE RETINA. 
 
 Venous hyperaemia of the retina accompanies 
 cardiac affections in which the return of the blood to- 
 ward the heart is impeded, as in valvular lesions and in 
 fatty heart. Associated with the above, there may be 
 pulsation of the retinal arteries. This association of 
 arterial pulsation and fulness of the retinal veins almost 
 always exists in aortic insufficiency. The explanation of 
 the former consists in a hypertrophy of the left ventri- 
 cle, whereby the blood pressure is increased during its 
 contraction, and the venous hyperaemia results from the 
 regurgitation which accompanies the ventricular diastole. 
 The same conditions also explain the alternate redden- 
 ing and pallor of the disc observed in aortic insuffi- 
 ciency. Retinal pulsation sometimes occurs with aneu- 
 rism of the aorta and arteria innominata.
 
 86 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 An embolism of the central retinal artery may 
 be the first indication of an insidious endocarditis, as 
 was the case in a patient of the writer. Thus the oph- 
 thalmoscope may afford the first evidence of heart dis- 
 ease, and aid in the differential diagnosis of its varied 
 forms. 
 
 Hemorrhage into the retina, without accompany- 
 ing inflammation, indicates (a) increased blood pressure, 
 such as occurs in hypertrophy of the heart, and in val- 
 vular lesions and in suppresio mensuum ; (b) disease of 
 the retinal vessels ; (c) morbid states of the blood. 
 
 Arterio-sclerosis and an atheromatous condition of 
 the retinal arteries not infrequently cause hemorrhage. 
 With the ophthalmoscope the arteries appear narrower 
 than usual, and this narrowing is often more con- 
 spicuous at certain portions of the vessel, giving it 
 an irregular wavy outline. These changes are more 
 marked in the region of the macula, because the nutri- 
 tion of this part of the retina is not equal to that of 
 the other portions. Such a condition of the retinal ves- 
 sels is of importance as an indication of a similar con- 
 dition existing in other portions of the body, especially 
 in the brain. When observed, with or without retinal 
 hemorrhages, it is a warning signal of impending cere- 
 bral apoplexy, and should lead the physician to adopt 
 precautionary measures to prevent such a catastrophy. 
 
 Such vascular degeneration often results from 
 syphilis. It is frequent with renal affections, and it
 
 CHANGES IN THE CIRCULATION OP THE RETINA. 87 
 
 should also arouse a suspicion of diabetes, for retinal 
 hemorrhages due to vascular degeneration are not infre- 
 quent in this condition. They appear, as a rule, in the 
 form of small, roundish spots (not striated). Hirshberg 
 says they always occur when the disease has lasted more 
 than ten or twelve years, and he regards them as of 
 unfavorable prognostic significance. The association of 
 nephritis with the late stages of the diabetes should not 
 be forgotten, and the possibility of the dependence of 
 the retinal hemorrhages upon the latter. With nephritis 
 the hemorrhages are more frequently striated. 
 
 Retinal hemorrhages, due to a diseased condition 
 of the blood, occur in infectious diseases, in pyaemia 
 and septicaemia, in profound anaemia, in malaria, in ex- 
 tensive burns of the skin, in poisoning by phosphorus 
 and lead, and after the bites of venomous snakes. Some 
 of these varieties of hemorrhage demand special consid- 
 eration. 
 
 While the diagnosis of infectious diseases is not 
 in any degree dependent upon the existence of reti- 
 nal hemorrhages, they are not of infrequent occurrence, 
 and are of prognostic importance. They may occur at 
 all stages, and are an unfavorable complication, espe- 
 cially where occurring early, indicating, as they do, a 
 condition of "profound toxaemia." The same may be 
 said of pyaemia and septicaemia. When they occur 
 early in acute septicaemia, a fatal termination may be 
 expected within a very few days. When they are .found
 
 88 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 after cutaneous burns, they indicate a condition similar 
 to septicaemia, resulting from the absorption of decom- 
 posing material. 
 
 The presence of retinal hemorrhages affords valu- 
 able evidence in the differential diagnosis between chlo- 
 rosis and pernicious anaemia, for they frequently occur 
 with the latter, but never in pure chlorosis. The 
 hemorrhages are unaccompanied with retinitis, and have 
 frequently a grayish red centre which is considered 
 quite characteristic. The fact that retinal hemorrhages 
 rarely occur in cachectic conditions resembling anaemia 
 is another useful diagnostic point, and emphasizes the 
 importance of ophthalmoscopic examinations in the dif- 
 ferential diagnosis of such conditions, especially in se- 
 vere and chronic cases. 
 
 Hemorrhages very frequently attend the various 
 forms of retinitis in which they form an integral factor, 
 and to which we will next devote our attention. For 
 the purpose of general diagnosis we recognize the fol- 
 lowing varieties of retinitis, viz. : 
 
 1. Retinitis albuminurica or nephritica, accom- 
 panying different varieties of renal disease, including 
 the retinitis albuminurica of pregnancy. 
 
 2. Retinitis syphilitica. 
 
 3. Retinitis diabetica. 
 
 4. Retinitis leukaemica. 
 
 5. Retinitis of gouty origin. 
 
 . With all varieties the optic nerve is, as a rule,
 
 CHANGES IN THE CIRCULATION OF THE RETINA. 89 
 
 involved to a greater or less degree, so that the desig- 
 nation neuro-retinitis would define the condition more 
 accurately. 
 
 As previously remarked, the differential diagnosis 
 of these varieties of retinitis requires expert skill and 
 experience, and is beyond the scope of this work. The 
 reader is referred to treatises upon ophthalmology for 
 such discussions. The features common to all varieties, 
 but differing in degree and in distribution, are changes 
 in the retinal vessels, congestion, haziness and indis- 
 tinctness of the outlines of the optic disc, hemorrhages 
 and exudation (serous or plastic) into the retina, sclero- 
 sis and fatty degeneration of the vascular and nervous 
 elements, and hyperplasia of the connective tissue. The 
 stellate appearance of the exudation distributed around 
 the macular region in the early stages of the disease is 
 quite characteristic of the nephritic variety of retinitis, 
 although it is, at times, closely simulated by the dia- 
 betic, anaemic and leukaemic retinitis. Thus, while 
 there are special features which are more frequently 
 found in certain special varieties of retinitis, there is no 
 variety which is absolutely pathognomonic. It is the 
 presence of retinitis or neuro-retinitis in one of its 
 phases, rather than the special and peculiar features 
 which it presents, that is of special importance to the 
 general practitioner. 
 
 Retinitis occurs most often in connection with 
 albuminuria, next with syphilis, and diabetes is consid-
 
 90 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 ered the third most frequent cause. We will consider 
 these associations in the order enumerated : 
 
 THE RELATION OF RETINITIS AND NEURORETINITIS TO 
 ALBUMINURIA. 
 
 The ophthalmoscope affords very great assistance 
 in the diagnosis of nephritis. Every oculist of experi- 
 ence is familiar with the fact that retinitis albuminu- 
 rica is often one of the earliest symptoms of inflamma- 
 tion of the kidneys. Failure of vision, without apparent 
 cause, should lead without delay to an ophthalmoscopic 
 examination, which may disclose the evidence of nephri- 
 tis, or, in a doubtful case, such an examination, even 
 before there is any impairment of vision, may demon- 
 strate the cause of constitutional symptoms, which pre- 
 viously had not been rightly interpreted. 
 
 It has been variously estimated that from 20-33 
 per cent, of all cases of nephritis are associated with 
 retinitis. It occurs with various forms of chronic kid- 
 ney disease, but most frequently with the contracted or 
 atrophic kidney. It is rare in the waxy form and in 
 the large white kidney. Next in frequency is the ne- 
 phritis of pregnancy, and last the post-scarlatinal va- 
 riety. 
 
 Chronic nephritis in all forms is a serious mal- 
 ady, coming on gradually and insidiously. When in an 
 advanced stage it is beyond the curative reach of medi- 
 cal skill, although much may be done to prolong life
 
 RELATION OP RETINITIS, ETC. 91 
 
 and to mitigate suffering. In its early stages it can fre- 
 quently be arrested and sometimes radically cured. No 
 aids to diagnosis are to be neglected in these conditions, 
 and no warning eye symptom should be misunderstood 
 or disregarded, and I cannot too strongly emphasize the 
 fact that there are changes in the background of the 
 eye, which are almost pathognomonic of disease of the 
 kidneys, and there are others which are highly suggest- 
 ive of such conditions. 
 
 Usually, both eyes are affected, but often in varying 
 degrees. Marple, in the " N. Y. Med. Record " for March 
 n, 1893, remarks that "According to the testimony of 
 most observers, unilateral neuro-retinitis of Bright's dis- 
 ease, even where it remains unilateral for only a short 
 time, is of rare occurrence. Cases which remain for 
 month or years with only one eye involved are exces- 
 sively rare. When the affection comes on in a few 
 hours, as after an injury, or remains limited to one eye 
 for months or years, as in chronic renal disease, the or- 
 dinarily accepted theories as to its causation seem inade- 
 quate. A satisfactory explanation of such cases seems 
 difficult if not impossible." 
 
 The ophthalmoscopic appearances bear no definite 
 ratio to the degree of impairment of vision, for preser- 
 vation of useful sight is not incompatible with pro- 
 nounced changes in the retina. It is rare that com- 
 plete blindness results. 
 
 The existence of retinitis is not only of diag-
 
 92 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 nostic, but of prognostic importance with renal affec- 
 tions. The eye complication may recover, while the 
 nephritis continues. It has been stated upon good 
 authority that "life is rarely prolonged more than one, 
 or, at most, more than two, years," after the develop- 
 ment of retinitis. 
 
 Bull gives in the "Trans. Am. Oph. So.," a re- 
 port of the history of 103 cases of chronic renal disease 
 with retinitis. Of these more than 50 per cent died 
 during the first year, and the majority within six 
 months; 17 per cent, died during the second year. 
 
 Those cases associated with retinal hemorrhages 
 are more unfavorable than those without. It has been 
 remarked that the ophthalmoscopic appearances which 
 are so frequently found with renal affections as to con- 
 stitute a distinct variety, designated as retinitis albumi- 
 nurica, are also occasionally found in diabetes and leu- 
 kaemia and pernicious anaemia. They may be present 
 without any assignable cause. Nevertheless, the ab- 
 sence of albuminuria must not be allowed without 
 repeated and careful examinations. 
 
 RETINITIS ALBUMINURICA OF PREGNANCY. 
 
 Retinitis has been observed as early as the third 
 month, but it is more frequent in the later stages the 
 seventh or eighth month and more often in primparae. 
 Since, as has already been remarked, vision is not al- 
 ways affected early in the disease, systematic ophthalmo-
 
 RETINITIS ALBUMINURICA OF PREGNANCY. 93 
 
 scopic examinations should be made during pregnancy 
 whenever albuminuria exists. 
 
 The principal interest which attaches to it is as 
 regards the question of the advisability of the induction 
 of premature labor. Howe, Pooley and Moore have re- 
 ported cases where this procedure restored the sight. 
 
 Howe says ("Amer. Journal Ophthal.," Vol. II, pp. 
 5, 6, 1885), " The induction of labor is warrantable 
 where retinitis occurs in the early stage of pregnancy, 
 and persists in spite of proper treatment, but is not war- 
 rantable in the last few weeks, in spite of the greater 
 ease with which it is accomplished." 
 
 Randolph, of Baltimore, concludes from his per- 
 sonal experience that "visual disturbances showing 
 themselves in the last seven weeks of pregnancy, while 
 indicating the same retinal lesion, are of less grave im- 
 port in so far as sight is concerned, and unless very 
 pronounced and associated with wide-spread ophthalmo- 
 scopic changes, should not in themselves call for the 
 induction of premature labor, for literature shows that, 
 in such cases, the sight is completely restored after 
 labor. This is especially true when the retinitis shows 
 itself in the last two weeks of pregnancy." (" Johns Hop- 
 kins Hospital Bulletin," Baltimore, June and July, 1894). 
 
 The following abstract of a discussion of the sub- 
 ject before the Medical Society of Berlin, January 23, 
 1895, by Dr. Silex is worthy of record. The report is 
 taken from the "Annals' d' Occulistique"
 
 94 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 " All the peculiarities of albuminuric retinitis in 
 pregnancy are not yet well known. Dr. Silex is in pos- 
 session of preparations which show the vessels intact. 
 
 " Its symptomatology and prognosis are very in- 
 exactly treated in literature, and its therapeutics have 
 been much neglected. The author has given much at- 
 tention to this special pathological subject for many 
 years, and has arrived at definite conclusions in regard 
 to the affection. 
 
 "To form a judgment of a case, it is necessary 
 first to make a critical ophthalmoscopic examination of 
 the retinal arteries. In the first stages of the disease, 
 the central artery is often seen with the erect image 
 transformed into a large white cord. This is produced 
 by dilatation of the peri-vascular lymphatic space. This 
 change may disappear, but hyaline degeneration of the 
 arteries threatens the canals of the vessels, which may 
 compromise the function of the internal layers of the 
 retina and produce atrophy of this membrane and of the 
 optic nerve. If the vessels are normal, albuminuric 
 retinitis presents little danger. This form of retinitis 
 may arise from an affection of the kidneys during preg- 
 nancy, an acute or chronic nephritis, the general symp- 
 toms of which are early developed. The visual distur- 
 bances develop slowly, most frequently in the second 
 period of pregnancy, especially in primiparae. If they 
 develop rapidly, chronic nephritis must be assumed.
 
 RETINITIS ALBUMINUR.ICA OF PREGNANCY. 95 
 
 After delivery, vision is established more or less com- 
 pletely. 
 
 " In 22 patients examined during a considerable 
 period, n recoverd vision more than ^, 10 others re- 
 mained with a lesser degree of acuity, and five of them 
 were almost blind. This unfortunate result was due to 
 atrophy of the optic nerve, to retino-choroiditis, and to 
 detachment of the retina, which occurred at a later 
 stage in both eyes. These figures are so important, 
 from a social point of view, that Silex advises interfer- 
 ence with pregnancy in all cases where retinitis is 
 found. Its prognosis is indeed uncertain ; the women 
 are frequently attacked with eclampsia, and the hope of 
 a living child is but faint. In chronic nephritis, dan- 
 ger to the life of the mother and child settles the ques- 
 tion of interference ; in case of nephritis of pregnancy, 
 premature delivery is not advocated, as in several cases 
 good vision has returned after expectant treatment. 
 
 "The condition of the retinal vessels should de- 
 cide the question of interference. For example, in two 
 pregnant women, at the commencement of the eighth 
 month, one having an acuity of ^-, and the other of 
 3^, one might be authorized to perform premature de- 
 livery in the first case on account of the vascular 
 changes, while one should wait in the second. It is in- 
 teresting that Dr. Silex has been able to find large 
 quantities of albumin in the urine during one or two 
 years without development of chronic nephritis in sev-
 
 96 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 eral women in whom the retinal lesion had disappeared 
 and the general health had remained good. The long 
 duration of albuminuria has not always a bad progno- 
 sis when it can be attributed to a renal affection of 
 pregnancy." 
 
 It should be remembered, as Noyes remarks, that 
 " the arnaurosis of pregnancy may be independent of 
 uraemia and without changes in the eye grounds, but 
 with a tendency to atrophy of the optic nerve." 
 
 RETINITIS SYPHILITICA. 
 
 Syphilis is the cause of many cases of retinitis. 
 It occurs in the hereditary as well as the acquired form. 
 It is usually among the secondary symptoms, more 
 rarely a tertiary development. It may occur as a prim- 
 ary affection, or it may accompany iritis or choroiditis 
 or cerebral syphilis. 
 
 It presents no distinguishing or pathognomonic 
 features. It usually exhibits the ophthalmoscopic pic- 
 ture of a simple retinitis without marked exudation or 
 hemorrhage. There may be an unusual tendency to the 
 development of connective tissue in the retina and in 
 the vitreous, constituting the so-called retinitis prolifer- 
 ans. A marked tendency to relapse is a somewhat 
 characteristic feature of syphilitic retinitis. A more fre- 
 quent localization in the central portions of the retina, 
 and a more frequent sequence of optic nerve atrophy are 
 also indicative of a syphilitic origin.
 
 RETINITIS DIABETICA. 97 
 
 RETINITIS DIABETICA. 
 
 Diabetic retinitis is of rare occurrence and indi- 
 cates a severe type of the disease. It presents many 
 points of similarity to nephritic retinitis, but there are 
 also some peculiarities which the specialist will recog- 
 nize. In brief, the following points may be mentioned : 
 irregular distribution of the exudation, less frequent im- 
 plication of the macula, and when in this location, lack- 
 ing the stellate arrangement, absence of neuritis, and 
 the punctate form of the hemorrhages, which are also 
 of more frequent occurrence. The vascular changes are 
 more marked in the smaller vessels, while the larger 
 ones suffer equally or to a greater extent in albuminuric 
 retinitis. The latter is almost always binocular, while 
 the diabetic form is frequently confined to one eye. 
 
 " Every diabetic disease of the retina is of serious 
 diagnostic import, showing degeneration of the vessels, 
 and showing liability to cerebral hemorrhage which is 
 more frequent than in the eye." 
 
 RETINITIS LEUKAEMICA. 
 
 Retinitis with leucocythemia is not common, and 
 is of no special diagnostic importance. The fundus 
 sometimes presents a peculiar orange hue. As has been 
 previously remarked, it may closely simulate the picture 
 of retinitis albuminurica, and the same is true of the 
 7
 
 98 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 retinitis which sometimes develops in the course of per- 
 nicious anaemia. 
 
 GOUTY RETINITIS. 
 
 Dr. Bull, of New York, in the " N. Y. Medical 
 Journal " for August, 1893, describes the features of this 
 form of retinitis. He says : 
 
 "An arterio- and phlebo-sclerosis of the retina is 
 noticed by ophthalmoscopic examination, and the micro- 
 scope shows degeneration in the vessels of the choroid 
 and optic nerve as well. A pathognomonic symptom is 
 a peculiar yellowish granular exudation in the retina 
 around the posterior pole of the eye, usually leaving 
 the macula intact, and situated mainly in the nerve fibre 
 layer, although found to some extent in all the layers 
 except the rods and cones. The changes in the fundus 
 are always bilateral, though rarely symmetrical in both 
 eyes. There is marked impairment of central vision, 
 but there is little or no loss of peripheral vision. The 
 loss of central visual perception is progressive up to a 
 certain point, but blindness never results. Hemorrhages 
 are rare, except in the early stages. In the later stages 
 the walls are strengthened by the deposits." 
 
 AFFECTIONS OF THE OPTIC NERVE. 
 
 In describing the relation of neuritis and atrophy 
 of the optic nerve to intra-cranial and spinal affections, 
 it is proper to remark by way of introduction, that coin-
 
 CHOKED DISC. 99 
 
 cident cerebral or spinal diseases and ocular affections 
 do not always or necessarily stand in the relation of 
 cause and effect. A certain condition of the optic nerve 
 revealed by the ophthalmoscope may be idiopathic, or, 
 as we have seen, it may occur as a secondary result of 
 various general and local diseases. Again, habitual or 
 severe headache associated with progressive failure of 
 sight, is not always a sign of brain trouble, but may be 
 due simply to the effort to see distinctly, where the vis- 
 ion is defective from strictly ocular disorders. 
 
 Neuritis is very frequently caused by brain 
 disease, especially by tumor, meningitis and abscess. 
 Different authors estimate the proportion of cases of 
 brain tumor in which neuritis exists as from 70 to 90 
 per cent. Hence, in doubtful cases, a knowledge of its 
 presence or absence is of great value. It usually takes 
 the form of 
 
 CHOKED DISC. 
 
 The development of a neoplasm in an unyielding 
 skull necessarily causes an increase of the intra-cranial 
 pressure. One result of this increased pressure is a 
 serous and lympathic stasis in the optic nerve with 
 congestion, oedema and swelling of the optic papil- 
 la visible with the ophthalmoscope, and constituting 
 choked disc. Another result of increased intra-cranial 
 pressure is a displacement of the fluid contained in the 
 sub-arachnoid and sub-dural spaces. Some of the fluid
 
 100 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 would escape through the foramen magnum into the 
 lymph spaces of the cord, while a portion would distend 
 the sheaths of the optic nerve, which, as we have seen, 
 are tubular prolongations of these cavities. Thus the 
 congestion and oedema of the papilla would be in- 
 creased, and inflammation and exudation and, perhaps, 
 hemorrhage would develop, and the choked disc become 
 a choked neuritis. Both of these conditions indicate, 
 with very few exceptions, an increase of the intra-cra- 
 nial pressure. 
 
 The intensity of the symptoms bears a pretty 
 constant, though not invariable, ratio to the amount of 
 the increased pressure, and as brain tumors cause a 
 greater increase of pressure than any other morbid pro- 
 cess, choked disc has come to be considered as almost 
 pathognomonic of the existence of a tumor. It is evi- 
 dent that mechanical distention of the nerve sheaths is 
 not the only factor in causing the neuritis, from the fact 
 that all cases of brain tumor are not associated with it, 
 and also that very small tumors produce it, while occa- 
 sionally very large tumors exist without it With 
 chronic hydrocephalus also, in which the intra-cranial 
 pressure is markedly increased, we find as a rule sim- 
 ple atrophy of the optic nerve and no inflammatory 
 changes. " The propagation of tissue irritation " is a 
 recent rather ambiguous expression to explain the modus 
 operandi of such an associated condition. It is less fre- 
 quent with neoplasms of the frontal lobes than with
 
 CHOKED DISC. 101 
 
 those situated more posteriorly, especially in the cerebel- 
 lum. When in one frontal lobe, a unilateral choked 
 disc might be caused, but whenever any variety of neu- 
 ritis is due to an intra-cranial affection of whatever 
 kind, it is, with few exceptions, bilateral. Hence, we 
 may lay down the rule that a unilateral neuritis is 
 probably not dependent upon cerebral disease. 
 
 Choked disc is not an early symptom of a cere- 
 bral tumor, indeed, a tumor may exist for a long time 
 without causing choked disc. This happens when the 
 tumor is of slow growth. On the other hand, it may 
 occur suddenly in connection with a chronic neoplasm. 
 A rapidly growing tumor never causes a slowly develop- 
 ing neuritis, although the reverse may be true ; that ' is, 
 a slowly developing tumor may take on a sudden growth 
 with rapid development of neuritis as mentioned above. 
 
 A cerebral abscess frequently induces optic neu- 
 ritis, but there are no reliable ophthalmoscopic data for 
 arriving at a differential diagnosis between the latter 
 affection and a brain tumor, although we usually find 
 " less swelling and more pronounced inflammation " in 
 cerebral abscess. 
 
 Other diseases which cause marked increase of 
 intra-cranial pressure rarely cause true choked disc. 
 Such diseases are tubercular meningitis, chronic hydro- 
 cephalus, extensive cerebral hemorrhages and pachy- 
 meningitis hemorrhagica. It has also occasionally been 
 found with tumors of the spinal cord, with albuminuria, 
 diabetes, leukaemia and after profuse hemorrhages,
 
 102 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 In conclusion it may be remarked that the diag- 
 nostic significance of choked disc is extremely valuable, 
 indicating marked increase of intra-cranial pressure, and 
 affording strong presumptive evidence of a tumor as the 
 cause of the increased pressure. 
 
 SIMPLE NEURITIS. 
 
 The distinction between choked disc and simple 
 neuritis is rather one of degree than of kind, and a 
 brain tumor may be accompanied with a simple neuri- 
 tis without strong swelling or prominence of the papilla. 
 This is more apt to be the case when the tumor is in 
 the frontal lobe not far distant from the optic nerve. 
 Thus a unilateral neuritis acquires additional diagnostic 
 importance. A true choked disc could hardly develop 
 idiopathically, but simple neuritis sometimes does, after 
 exposure to cold for example, so that we cannot say pos- 
 itively that such a condition necessarily implies the ex- 
 istence of cerebral disease, but it affords strong presump- 
 tive evidence of an "irritative process within the 
 skull." A considerable degree of inflammation may ex- 
 ist without impairment of sight, and may be an early 
 symptom before headache, etc., appears. Hence the im- 
 portance of ophthalmoscopic examination in all doubtful 
 cases is apparent, and in obscure cases without marked 
 mental symptoms, pain or other pronounced indication 
 of cerebral disease, the ophthalmoscope may establish 
 the diagnosis.
 
 SIMPLE NEURITIS, 103 
 
 With the exception of intra-cranial neoplasms, 
 chronic meningitis is the most frequent cause of neuri- 
 tis, and it is easy to understand how the inflammation 
 extends in such cases by continuity of structure, so that 
 here we more frequently find an interstitial or a peri- 
 neuritis. It is found in the majority of cases, and 
 hence is an important aid in differential diagnosis. It 
 does not often occur early in the disease. Acute men- 
 ingitis, either tuberculous or non-tuberculous, is seldom 
 accompanied with marked ophthalmoscopic changes, nor 
 do we often find them with cerebro-spinal meningitis. 
 Knies, on the contrary, asserts that neuritis is quite fre- 
 quent in the latter disease. 
 
 It has been observed that choked disc may re- 
 sult in consequence of cerebral gummata, but syphilis 
 may attack the nerve of one or both eyes directly, giv- 
 ing rise to simple neuritis, either as an isolated mani- 
 festation, or in connection with affections of the cerebral 
 nerves. 
 
 Affections of the optic nerve are of vahie in in- 
 juries to the skull, enabling one occasionally to locate a 
 fracture at the orbital foramen or in the immediate 
 vicinity of the optic chiasm. 
 
 Similarly, neuritis developing after an injury to 
 the spine, concussion, " railway spine," etc., points to 
 the cilio-spinal region as the seat of the lesion. 
 
 Neuritis is sometimes of malarial origin, in which 
 case it is usually bilateral, and it occasionally develops
 
 104 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 in the course of typhoid and other infectious diseases. 
 
 Dr. White, of Richmond, Va., reports in the 
 "Medical News" for July 15, 1893, a case of optic neu- 
 ritis occurring in the third week of typhoid, and a second 
 case where optic atrophy was noted four months after 
 an attack of typhoid fever, during the course of which 
 vision had begun to fail, and had continued, notwith- 
 standing the improvement in the general health. He 
 also cited a case of blindness after malarial intermittent. 
 
 Gowers says "optic neuritis may follow scar- 
 let fever without any organic change in the brain to 
 cause it, hence the inference that scarlet fever poison 
 has a special action on the nervous system/' 
 
 Neuritis and retinitis are, at times, complications 
 of dementia paralytica and multiple sclerosis. Multiple 
 neuritis, or pseudo tabes, sometimes occasions an axial 
 neuritis with central scotoma, simulating toxic ambly- 
 opia. This is a valuable diagnostic sign between true 
 and false tabes, in the former of which we meet with 
 simple atrophy of the nerve without inflammation. 
 Similar symptoms occasionally result from the influence 
 of gout. 
 
 In such cases there may be also chalky deposits 
 along the vessels of the conjunctiva. 
 
 ATROPHY OF THE OPTIC NERVE. 
 
 The secondary result of neuritis, and especially 
 of choked neuritis, is atrophy, from compression of the
 
 ATROPHY OF THE OPTIC NERVE. 105 
 
 nervous elements by the vascular engorgement and in- 
 flammatory exudation. This is called consecutive or 
 secondary atrophy, in distinction from simple atrophy 
 which is not a result of inflammation. The two forms 
 can be differentiated by ophthalmoscopic examination, 
 but a discussion of the points of difference is not within 
 the scope of this treatise. If, in the course of a brain 
 tumor, we have the picture of inflammatory atrophy of 
 the optic nerve, it demonstrates the previous existence 
 of choked disc, and also that the tumor is a chronic 
 condition, because atrophy requires considerable length 
 of time for its development. Thus we see that the con- 
 dition of the optic nerve is of prognostic as well as 
 diagnostic importance. In exceptional cases a brain tu- 
 mor causes simple atrophy by direct pressure upon the 
 optic tract, chiasm or nerve. When only one tract suf- 
 fers compression, corresponding portions of each nerve 
 will show atrophic changes while the remaining halves 
 will be uninjured. When one nerve, between the chiasm 
 and the globe suffers, monocular atrophy ensues. Sim- 
 ple atrophy may result from cerebral meningitis, and it 
 is often an accompaniment of multiple sclerosis, but in 
 the latter disease it is usually incomplete in its develop- 
 ment. It occurs late in the course of progressive 
 paralysis, but sometimes it is an early manifestation. 
 
 It may also be associated with dementia and 
 idiocy. The most frequent cause of simple optic nerve 
 atrophy is tabes dorsalis, in which disease the atrophy
 
 106 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 begins in the outer temporal side. In its fully de- 
 veloped stage it resembles a glaucomatous excavation. 
 It is often an early symptom, and is ordinarily asso- 
 ciated with "Argyll-Robertson pupil " and spinal myosis, 
 to each of which reference has been previously made. 
 It may be many years before the essential features of 
 tabes develop. It may occur in any stage of the dis- 
 ease, and the rapid or slow development of the optic 
 nerve affection is in inverse ratio to the motor symp- 
 toms, so that it becomes of prognostic as well as diag- 
 nostic significance. When the loss of sight is rapid, the 
 locomotor ataxia is usually of slow development and 
 vice versa. Sometimes when the atrophy does not appear 
 until the tabetic symptoms are well developed, a tem- 
 porary arrest of the latter follows the appearance of the 
 visual symptoms. Berger considers the association of 
 diminished sensibility of the conjunctiva and cornea, and 
 false localization of sensation with optic atrophy "a 
 strong presumptive evidence in favor of a tabetic origin 
 of this atrophy." 
 
 Both eyes are affected, but not always simultane- 
 ously. There may be a considerable interval, perhaps 
 several years, before the second eye is affected. Knies 
 says the "proportion of atrophy with tabes is variously 
 estimated at from 10-35 P er cent." Galezowski says, 
 " two-thirds of all optic nerve atrophies are tabetic. 
 Every genuine gray atrophy raises suspicion of tabes." 
 The length of time that elapses between the commence-
 
 ATROPHY OF THE OPTIC NERVE. 107 
 
 ment of the process and complete blindness varies from 
 two months to seventeen years. The average time is 
 three years. 
 
 Knies says that in pseudo tabes we find a "gray- 
 ish-red opacity and obliterated borders of the nasal half 
 of the papilla, with atropic discoloration of the outer 
 halves." 
 
 A similar condition is seen in toxic amblyopia. 
 
 Acute and chronic myelitis cause neuritis or sim- 
 ple atrophy. The appearance of the optic nerve and 
 retina affords no reliable indication of the amount of 
 vision. Marked deviation from a normal standard may 
 exist for a long time before the sight is noticeably 
 affected ; hence the importance of an early ophthalmo- 
 scopic examination.
 
 CHAPTER V. 
 
 THE SIGHT AND THE FIELD OF VISION. THE SIGNIFI- 
 CANCE OF VISUAL DISORDERS DUE TO LESIONS IM- 
 PLICATING THE INTRA-CRANIAL COURSE OF 
 THE OPTIC NERVE FIBRES, INCLUDING AF- 
 FECTIONS OF THE CHIASM, THE 
 TRACT, THE OPTIC GANGLIA, 
 AND THE CORTICAL 
 VISUAL CENTRES, 
 AND 
 
 'PSYCHIC VISUAL DISORDERS. 
 
 In the preceding chapters we have discussed the 
 significance of pathological conditions of the various tis- 
 sues of the eye and its adnexa. We have now to con- 
 sider certain subjective disorders of vision, irrespective 
 of any ophthalmoscopic changes which may or may not 
 accompany* them. Such conditions are of extreme value 
 in the localization of intra-cranial affections, and occa- 
 sionally in the elucidation of obscure constitutional dis- 
 eases. 
 
 Three methods of estimating the visual acuity are 
 commonly employed. First by the use of test type of 
 different sizes, each of which is seen by a normal eye 
 at a given distance. The amount of vision is then ex- 
 
 (108)
 
 THE SIGHT AND THE FIELD OF VISION. 109 
 
 pressed by a fraction, the numerator of which indicates 
 the distance at which the patient reads the type, and 
 the denominator the distance at which the same type 
 should be read. V =%$, for instance, indicates that at 
 a distance of twenty feet, the patient cannot read print 
 smaller than that which is normally read at fifty feet 
 His vision is then -- of the normal standard. 
 
 When the sight is too defective to be tested in 
 that way, we ascertain at what distance he can count 
 the fingers of the examiner, and lastly whether he can 
 still distinguish light from darkness. 
 
 Blindness, partial or complete, sudden or gradual, 
 temporary or permanent, occurs very frequently in the 
 course of intra-cranial and spinal diseases, and while the 
 mere subjective sensation of failing sight, without oph- 
 thalmoscopic findings, affords by itself no basis for the 
 diagnosis of the nature of the causative lesion, it does 
 afford very valuable data for determining the situation 
 of such a lesion. When it affects both eyes, the pre- 
 sumption is warrantable that the cause lies at or be- 
 hind the chiasm, if we except a simultaneous lesion of 
 both optic nerves, which, though possible, is extremely 
 rare. (Double retro-bulbar neuritis). 
 
 One sided blindness, when not dependent upon 
 an ocular affection, must be referred to the optic nerve 
 between the globe and the chiasm, constituting a retro- 
 bulbar neuritis. A discussion of this condition is not 
 relevant in this connection. (See the chapter on toxic
 
 110 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 amblyopia). A central scotoma, that is, a dark spot in 
 the centre of the visual field, which is one of the char- 
 acteristic features of retro-bulbar neuritis, does not, there- 
 fore, necessarily indicate a central lesion. It is other- 
 wise with bilateral and symmetrical defects affecting 
 corresponding portions of both visual fields. Such dis- 
 orders indicate a lesion involving the intra-cranial 
 course of the optic nerve fibres, and a clear understand- 
 ing of the anatomical path of these fibres is essential 
 for an appreciation of the diagnostic significance of the 
 various forms of hemianopia. It will be profitable, 
 therefore, at this point, to review the course and ulti- 
 mate termination of the optic nerve fibres, and to -en- 
 quire into the function of the primary optic ganglia and 
 the cortical visual centres. 
 
 The optic tracts from either side unite at the 
 chiasm where they undergo a semi-decussation. The 
 fibres of the right tract are distributed to the right half 
 of each retina, and those of the left tract to the left 
 half of each retina. Each optic nerve thus contains 
 both crossed and uncrossed fibres. The right nerve, for 
 instance, contains uncrossed fibres from the right tract, 
 which are distributed to the right, or temporal side, of 
 the retina, and also crossed fibres from the left optic 
 tract, which are distributed to the nasal half of the right 
 retina. Each optic tract contains the fibres coming from 
 the corresponding halves of the retinae of the two eyes, 
 the right tract those from the right halves, and the left
 
 PLATE I.
 
 THE SIGHT AND THE FIELD OF VISION. Ill 
 
 tract those from the left halves. The uncrossed bundle 
 of fibres lies at the outer edge of the chiasm on either 
 side. 
 
 Plate I illustrates the course of the fibres from 
 either tract to the eye. 
 
 Passing backward along the base of the brain, 
 some of the fibres enter the optic thalamus, particularly 
 the posterior portion known as the pulvinar, but the 
 larger part enter the external geniculate body. In both 
 of these bodies the optic nerve fibres are augmented by 
 axis cylinders from their ganglion cells, and then pass 
 upwards to the cortex of the occipital lobe by way of 
 the internal capsule, constituting the optic radiation of 
 Gratiolet. 
 
 Thus both the optic thalamus and the external 
 corpus geniculatum are directly concerned with con- 
 scious vision, and a lesion of either interrupts the direct 
 line of conduction from the eye to the visual centres. 
 Fibres also pass from the thalamus to the third nu- 
 cleus, and are concerned with the reflex movements of 
 the iris. A few fibres of the optic tract pass to the an- 
 terior corpora quadrigemina, which bodies have no 
 relation to conscious vision, but preside over invol- 
 untary conjugate and associated ocular movements de- 
 pendent upon visual impressions, " and transmit to the 
 visual sphere a knowledge of involuntary movements 
 which follow light stimuli."
 
 112 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 Still other fibres pass downward to the posterior 
 columns of the cord and subserve the involuntary re- 
 flexes of the general muscular system due to visual im- 
 pressions from the opposite half of the visual field. By 
 means of these fibres is explained the visual symptoms 
 which occur in the course of locomotor ataxia. A few 
 'fibres also pass from the tract to the internal geniculate 
 body and from thence to the posterior corpora quadri- 
 gemina, but they are unimportant for our consideration, 
 as these two bodies have no relation with the function 
 of sight. It has been asserted that fibres pass directly 
 from the tract to the visual centres without entering 
 the thalamus or geniculate body, but this has not been 
 positively demonstrated. 
 
 Knies considers it probable that a "union of the 
 binocular visual impressions of corresponding halves of 
 the fields of vision into a harmonious single impression 
 takes place in the primary optic ganglia." The harmo- 
 nious single impression thus formed is thence transmit- 
 ted to the cortical centre, and thus is exemplified the 
 function of all the basal ganglia, which is to receive, 
 regulate and control impressions from all outside sta- 
 tions, and to transmit them to their respective cerebral 
 centres. 
 
 But the optic ganglia have other important func- 
 tions in presiding over the involuntary movements of 
 the head, neck and extremities, dependent upon visual 
 impressions received from the opposite half of the vis-
 
 THE SIGHT AND THE FIELD OF VISION. 113 
 
 ual field, as well as those ocular reflex movements asso- 
 ciated with sensory impressions derived from the ear, 
 the face and distant portions of the body. 
 
 It is at the visual centre in the cortex of the 
 occipital lobe that visual impressions first awaken con- 
 scious perceptions. From this position originate im- 
 pulses for conscious ocular movements toward the oppo- 
 site side, and here memory pictures are stored, by virtue 
 of which an object once seen is recognized. The whole 
 area of the occipital cortex is regarded as directly re- 
 lated to the faculty of vision, but the cuneus is the 
 most important portion, and lesions here produce the 
 most pronounced and serious impairment of sight. 
 
 The researches of Henschen (see " Klinische und 
 Anatomische Beitrdge zur Pathologic des Gehirns" Upsala, 
 1892), seem to indicate that the immediate vicinity of 
 the calcarine fissure is the locality where a lesion caus- 
 ing permanent hemianopia is found. 
 
 By means of commissural fibres between the vis- 
 ual centres and the higher intellectual centres visual 
 impressions excite mental processes. 
 
 We are now in a position to discuss intelligently 
 the data for the localization of intra-cranial affections 
 which are furnished by lesions involving the path of 
 the optic nerve fibres posterior to the orbit. 
 
 Such binocular subjective symptoms may be con- 
 veniently classified under two heads, viz. :
 
 114 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 1. Changes in the form and extent of the visual 
 fields constituting the various forms of hernianopsia. 
 
 2. Amaurosis and amblyopia (or, more correctly, 
 cortical blindness), and the varied forms of psychic vis- 
 ual disorders. 
 
 A knowledge of the normal boundaries of the 
 visual fields for form and color is essential for a recog- 
 nition of pathological defects in its dimensions or out- 
 line. When the eyes are fixed upon a given object 
 its retinal image is formed upon the macula lutea 
 of each eye, the most sensitive portion of the retina, 
 and at the same time rays of light emanating from 
 objects on all sides of the object of fixation enter the 
 pupil, and form more or less distinct images upon 
 peripheral parts of the retina. It is evident that the 
 farther such visual images are projected into space, 
 the larger the resulting visual field will be, but it will 
 always represent a certain number of degrees of the cir- 
 cumference of a circle, however large or small such a 
 circle may be. It is evident also that the vision will 
 be more extensive on the temporal side than in other 
 directions, because the outlines of the orbit and the 
 bridge of the nose will obstruct the course of peripheral 
 rays in other directions, and that the limits in individ- 
 ual cases will vary slightly according to the conforma- 
 tion of the face. The physiological limits of the visual 
 field for form are, approximately, 90 outward, 60 
 above, 50 on the nasal side, and 65 below. The field
 
 PLATE II. 
 
 LEFT VISUAL FIELD. RIGHT VISUAL FIELD. 
 Fixation Point. 
 
 L. Genicu/afc Bocty 
 L Int Capsule 
 
 - Of. ' * * 
 
 **&*& fart?*
 
 THE SIGHT AND THE FIELD OF VISION. 
 
 115 
 
 for color is not coextensive with that for form, and dif- 
 fers with the different colors, that for blue being the 
 largest, and that for green the smallest. The accompa- 
 nying chart illustrates the physiological limits of the 
 visual fields. 
 
 The examination of the visual field is best made 
 by means of the perimeter. There are various patterns 
 of this instrument in the market. The latest and best 
 design is made by E. B. Meyrowitz, of new York, a cut 
 of which is appended. The special feature of this in- 
 strument is that it is self-recording, a desideratum which
 
 116 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 has long been sought but never practically attained be- 
 fore. 
 
 A perimeter will hardly be found in the office of 
 the general practitioner, and, in its absence, an approxi- 
 
 mate estimate of any pathological change in the visual 
 field can be gained in the following way : 
 
 The patient, seated directly in front of the physi- 
 cian and about two feet distant, fixes with his left eye, 
 for instance, the right eye of the examiner, or vice versa, 
 the other eye of both physician and patient being 
 closed. Then the farthest point in all directions, at
 
 HEMIANOPSIA. 117 
 
 which the movement of the physician's hand (held mid- 
 way between their two faces,) can be seen by the pa- 
 tient while the position of his eye is unchanged, gives 
 the outline of his visual field. By comparing this with 
 the physician's field, simultaneously delineated, any de- 
 cided abnormality is detected. 
 
 HEMIANOPSIA. 
 
 By this term is understood a complete or partial 
 loss of sight, affecting one-half of each visual field. 
 Care is to be exercised not to confound it with blind- 
 ness of one eye. 
 
 Hemianopsia may be classified as heteronymous 
 or homonymous. In the former, unsymmetrical parts of 
 the visual field are involved, and it may again be desig- 
 nated as heteronymous medial hemianopsia when the 
 nasal half of each field is defective, or heteronymous 
 temporal hemianopsia when the loss of vision is con- 
 fined to the temporal half of each retina. The dividing 
 line between the seeing and the non-seeing areas may 
 or may not pass through the fixation point, and the 
 blindness may be partial or absolute that is, the hemi- 
 anopsia may be complete or incomplete. Since the 
 fields of vision are projected from the opposite sides of 
 the retina, it is evident that medial hemianopsia signi- 
 fies blindness of the temporal half of each retina, and 
 temporal hemianopsia, blindness of the nasal half. 
 Either variety of heteronymous hemianopsia indicates
 
 118 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 an affection of the chiasm, and is strongly suggestive of 
 a syphilitic gumma, for gummous meningitis at the base 
 of the brain is, next to endarteritis, the most common 
 form of brain syphilis, and the most frequent situation 
 of the affection is in the immediate vicinity of the 
 chiasm. Temporal hemianopsia, as a result of syphilis, 
 occurs, it is estimated, twice as frequently as homony- 
 mous hemianopsia from the same cause. 
 
 In medial hemianopsia the uncrossed bundles 
 of fibres of each tract are affected, and therefore the le- 
 sion is to be located at the outer edge of the chiasm 
 on either side. In temporal hemianopsia the lesion in- 
 volves the crossed bundles of each tract, and it can only 
 result from a morbid process affecting the central part 
 of the chiasm from before backward, or at its anterior 
 or posterior angle. Accumulation of fluid in the third 
 ventricle with hydrops of the infundibulum would 
 exert transverse pressure on the chiasm, with such vis- 
 ual manifestations. 
 
 HOMONYMOUS HEMIANOPSIA, that is, a loss, more 
 or less complete, of functionally associated and corre- 
 sponding portions of each visual field, right or left, can 
 only be explained by a lesion affecting the fibres of one 
 optic tract, and this may be situated at any point be- 
 tween the chiasm and the cortex. The designation of 
 right or left homonymous hemianopsia, it will be under- 
 stood, refers to field and not to retina. The pres- 
 ence or absence of the light reflex and of visual hallu-
 
 HEMIANOPSIA. 119 
 
 cinations (photopsia, etc.) is of importance in more ex- 
 actly locating the lesion. The optic tract may be com- 
 pressed by the exudation attending basilar meningitis, 
 by a syphilitic gumma (the most frequent cause) or 
 other neoplasm, or by a hemorrhage. It is evident that 
 since visual impressions are interrupted in the affected 
 tract, sensory reflex iridoplegia will necessarily result. 
 There will be no contraction of the pupils when light 
 is thrown upon the blind halves of the retinae, but the 
 light reflex will be preserved when the light is thrown 
 on the seeing part of either retina, transmission being 
 uninterrupted along the uninjured tract. 
 
 The same condition, viz., " hemianopic pupillary 
 inaction " is present in homonymous hemianopsia due 
 to a lesion of the pulvinar, and in the absence of 
 involvement of the nerves supplying the ocular muscles, 
 and other phenomena which would almost of necessity 
 accompany a lesion of one tract, this symptom warrants 
 a diagnosis of a lesion at this point. When hemianopic 
 visual disorders are caused by disease in the course of 
 the optic radiation, or in the cortical visual area, the 
 pupillary light reaction is preserved, and this is true 
 whether the blind or the seeing portion of the retina is 
 illuminated, and irrespective of any conscious sensation 
 of light. Homonymous hemianopsia may occur suddenly 
 as the sole manifestation of a cerebral hemorrhage. If, 
 under such circumstances, the pupillary light reflex is 
 preserved, the presence or absence of visual hallucina-
 
 120 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 tions may enable one to decide whether the hemorrhage 
 is cortical, or situated in the path of the optic radiation. 
 If the visual area in the occipital cortex is destroyed, 
 there can be no photopsia or visual hallucinations. 
 Hence, if they exist in the affected half of the visual 
 field the lesion is not cortical, but when they are want- 
 ing, we possess no data for exact localization in one or 
 other of these circumscribed areas. 
 
 Vialet, of Paris, in " Annales d' Oculistique" Paris, 
 April, 1894, thus defines the boundaries of the cortical 
 visual area. It "occupies the entire extent of the in- 
 ternal surface of the occipital lobe, embracing the 
 cuneus and the fusiform lobes, being bounded anteriorly 
 by the internal perpendicular fissure (parieto-occipital ?), 
 above by the superior edge of the hemisphere, below by 
 the inferior edge of the third occipital convolution, and 
 behind by the occipital lobe.'' 
 
 Different portions of this area are in relation 
 with distinct parts of the field of the opposite eye. 
 " The macular region corresponds to the cuneus and, 
 perhaps, to the first occipital convolution. In the re- 
 mainder of the occipital cortex known as ' NothnagePs 
 memory centre for visual impressions,' the anterior part 
 corresponds to the inferior part of the opposite field, the 
 lateral part to the outer, the posterior parts to the up- 
 per portions of the field. Hence in partial destruction 
 of the occipital cortex, the visual disturbance varies
 
 CROSSED AMBLYOPIA. 121 
 
 greatly according to the location of the diseased focus." 
 (Knies). 
 
 There seems to be a separate centre for the per- 
 ception of color, for hemianopsia for color sometimes 
 exists without other defect. The apex of the occipital 
 lobe is the spot where a lesion produces most complete 
 and pronounced hemianopsia, but injuries to the outer 
 and medial surfaces also produce this defect to a lesser 
 degree, manifested as " hemianopic peripheral scotomata 
 with practically no subjective sensations, and not de- 
 tected with the perimeter without great care." It should 
 be borne in mind that cortical lesions are always ho- 
 monymous, and this feature will aid in a differential 
 diagnosis between such disorders and scotomata and 
 contractions of the fields due to affections of the retina 
 and optic nerve, which occur in the course of cerebral 
 tumors, dementia paralytica, tabes, etc. 
 
 Defects of the visual field without ophthalmo- 
 scopic findings also occur in hysteria and uraemia, and 
 the reader is referred to the chapter on reflex neuroses 
 for a discussion of such disorders. 
 
 CROSSED AMBLYOPIA. 
 
 It would seem from the occurrence of crossed 
 amblyopia, that is, dimness of sight in the opposite eye, 
 generally with concentric diminution of the field, and 
 with some restriction of the field on the same side, that 
 there is a higher visual centre where impressions from
 
 J 22 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 both fields are united. There have been a few recorded 
 autopsies of cases presenting crossed amblyopia during 
 life, in which the posterior and inferior part of the 
 parietal lobe known as the " angular gyrus " was dis- 
 eased. Thus pathological evidence would seem to point 
 to this locality as the seat of a higher visual centre, 
 "and Ferrier has demonstrated the existence of such a 
 centre at this spot in animals. The theory of crossed 
 amblyopia was first advanced by Charcot, and it is sup- 
 ported by Gowers but discredited by others. 
 
 There are various forms of transient amblyopia 
 which can only be explained by temporary disorders of 
 the circulation in the visual centres. Such transient 
 amblyopia may be manifested as hemianopic defects, 
 symmetrical scotomata, central or peripheral, or as more 
 or less complete blindness associated or not with scin- 
 tillation, or the appearance of sparks or flashes of light. 
 Such attacks appear more frequently in females, and in 
 persons of neurotic temperament. They are explained 
 by a vaso-motor disturbance in the visual areas, and it 
 is important to understand that they are not, as a rule, 
 of serious import. Occasionally they are the precursors 
 of an epileptic attack. More frequently they are asso- 
 ciated with cephalalgia and vertigo. 
 
 AMAUROSIS AND AMBLYOPIA. PSYCHIC VISUAL 
 DISORDERS. 
 
 Sudden blindness of both eyes may result from a 
 simultaneous affection of both visual areas. Monocular
 
 PSYCHIC VISUAL DISORDERS. 123 
 
 blindness points to an affection of the optic nerve in 
 front of the chiasm, or to an intra-ocular affection. Cor- 
 tical disorders, it will be remembered, are always binoc- 
 ular, and are attended with preserved pupillary reaction. 
 Meningitis of the convexity of the brain with exudation 
 may occasion such loss of vision. It may result from 
 extreme loss of blood, producing anaemia and loss of 
 sensibility of the visual centres. In such cases the vis- 
 ion will be recovered with the returning circulation. It 
 may be due to malaria. It may be of toxaemic origin, 
 especially in uraemia. It may be due to reflex irrita- 
 tion or be a manifestation of hysteria. The visual dis- 
 orders associated with these affections are discussed in 
 the chapter on reflex neuroses. 
 
 The opposite condition, viz., undue excitability 
 of the visual centres manifested by photophobia and 
 hyperaesthesia of the retina, phosphenes, etc., unaccom- 
 panied with inflammatory conditions of the eye may be 
 a part of a general nervous excitability, or may be an 
 early symptom of meningitis or encephalitis. 
 
 There will be no difficulty in diagnosing a case 
 of sudden blindness due to uraemic intoxication, for it 
 is always associated with other symptoms, such as head- 
 ache, vomiting, stupor and convulsions. It is caused by 
 an affection of the visual centres either from a toxic 
 element in the blood, or, perhaps, as has been sug- 
 gested, by an anaemia consecutive to an extensive effu- 
 sion into the cerebral ventricles. The exact pathology
 
 124 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 is undetermined. The pupillary reaction to light is or- 
 dinarily preserved, and unless complicated with a pre- 
 vious albuininuric retinitis, there are no ophthalmoscopic 
 changes, and the sight returns with the subsidence of 
 the other uraemic manifestations. Uraemic amaurosis is 
 said to occur most frequently with post-scarlatinal neph- 
 ritis, and next with the contracted kidney, and it is 
 sometimes met with in the nephritis of pregnancy. 
 Similar visual disturbances occasionally appear in the 
 later stages of diabetes. 
 
 It remains to discuss certain psychic visual dis- 
 orders. 
 
 HALLUCINATIONS OF SIGHT, that is, "false inter- 
 pretations and judgments of real sensorial phenomena," 
 are an indication of mental disorders. The pupils dilate 
 or contract as the fancied object apparently recedes or 
 approaches. This circumstance may be of use in the 
 treatment of delirium or insanity. Such symptoms are 
 also sometimes of toxic origin. See chapter on toxic 
 amblyopia. 
 
 A peculiar and interesting form of visual defect 
 styled by Fuchs "soul blindness," sometimes results 
 from a diseased focus situated in the vicinity of the 
 localities implicated in cases of hemianopsia and crossed 
 amblyopia, but distinctly separated therefrom. The pa- 
 tient sees, but he has lost all memory of visual impres- 
 sions, and, therefore, objects are unrecognized. He cannot 
 read because he has lost all memory of the meaning of
 
 PSYCHIC VISUAL DISORDERS. 125 
 
 the characters (alexia). Or he may recognize objects, 
 but cannot recall their names, a condition constituting 
 word blindness. 
 
 Soul blindness is usually a transient symptom 
 associated with disease of another portion of the brain. 
 Knies says that it is very rare as an isolated symptom, 
 that it occurs quite often with progressive paralysis 
 of the insane, but is always temporary. 
 
 An interruption in the course of the commissural 
 fibres uniting the visual areas with the higher intellect- 
 ual centres explains another interesting class of psychic 
 visual disorders which may be briefly mentioned, viz. : 
 
 MOTOR ALEXIA. This is very similar to soul 
 blindness and word blindness, but differs from those 
 conditions in that the names of objects seen cannot be 
 spoken, although remembered. 
 
 DYSLEXIA. " He can read aloud, but after utter- 
 ing a few words, a peculiar uncomfortable feeling is 
 experienced which compels him to stop. This condi- 
 tion is temporary, but often followed by severe cerebral 
 symptoms." 
 
 PAR ALEXIA. A condition in which " single let- 
 ters, syllables or words are omitted in reading or con- 
 fused with others having a similar sound." 
 
 AGRAPHIA. ' In which he cannot copy, although 
 the movements of the hand and arm are unimpaired 
 and he can write from dictation."
 
 126 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 PARAGRAPHIA. In which there is a "confusion 
 or omission of letters, syllables and words in writing." 
 
 Such conditions as the above are usually transi- 
 tory. The precise location of lesions causing them can- 
 not be definitely determined, but it may be stated that 
 if the motor or visual symptoms are the more pro- 
 nounced, the disease is located nearer the motor or the 
 visual centres respectively.
 
 CHAPTER VI. 
 
 A TABULATED STATEMENT OF DISEASES WITH MORE OR 
 LESS CHARACTERISTIC EYE SYMPTOMS. 
 
 ABDOMINAL GROWTHS. 
 
 More or less pigmentation of the skin of the eye- 
 lids. 
 
 ADDISON'S DISEASE OF THE SUPRA RENAL CAPSULES. 
 
 Pigmentation of the skin of the lids and of the 
 sclera. 
 
 ALBUMINURIA. 
 
 Retinitis, and neuro-retinitis. 
 
 ALCOHOLISM. 
 
 Paretic mydriasis. Paralysis of accommodation, 
 or spastic myosis in the early excitable stage. 
 Paralysis of the external ocular muscles. Ptosis. 
 
 ANAEMIA (CEREBRAL). 
 
 Paretic mydriasis 
 
 ANAEMIA (CONSTITUTIONAL). 
 
 Paralysis of accommodation, choroiditis, retinitis 
 and retinal hemorrhages. 
 
 ANEURISM OF ORBITAL ARTERY, OR INTERNAL CAROTID. 
 
 Exophthalmus. 
 
 AORTA AND ARTERIA INNOMINATA, ANEURISM OF. 
 
 Reflex spastic mydriasis on the side of the lesion. 
 Retinal pulsation. 
 
 (127)
 
 128 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 APOPLEXY. 
 
 Dilatation or contraction of the pupils distin- 
 guishes it from embolism, in which the pupils 
 are unaffected. Spastic myosis in premonitory 
 stage. When, during a seizure, mydriasis occurs 
 after a previous myosis it is an unfavorable 
 symptom, signifying increasing pressure. Nystag- 
 mus. Homonymous hemianopsia. 
 
 APOPLEXY OF CORTEX OR CORONA EADIATA. 
 
 Eyes and extremities paralyzed on the same side. 
 Eyes deviate toward the side of the lesion. 
 
 APOPLEXY OF THE CBUS OR PONS VAEOLII. 
 
 Eyes and extremities paralyzed on opposite sides. 
 Eyes deviate away from the side on which the 
 lesion exists. 
 
 APOPLEXY OF THE PONS. 
 
 Spastic myosis. 
 
 APOPLEXY OF VENTBICLES. 
 
 Spastic myosis. 
 
 ATHEBOMA. 
 
 Conjunctival hemorrhage. Intra-ocular hemor- 
 rhages. 
 
 ATBOPHY, PROGRESSIVE. MUSCULAR. 
 
 Ocular paralyses. 
 
 BASEDOWS DISEASE OB EXOPHTHALMIC GOITRE. 
 
 Diminished frequency of winking. Spasm of the 
 levator of the upper lid. (Abadie's sign). Widen- 
 ing of the palpebral fissure, owing to contraction 
 of Mueller's muscle. (Stellwag's or Dalrymple's
 
 A TABULATED STATEMENT OF EYE SYMPTOMS. 129 
 
 sign). Loss of associated movement of the upper 
 lid and the eye-ball. (Von Graefe's sign). Ex- 
 ophthalmus. 
 
 BRAIN, ABSCESS OF. 
 
 Neuritis. 
 
 " BASILAR AFFECTIONS OF. 
 
 Loss of pupillary reflexes. Homonymous 
 hemianopsia. Paralyses of ocular muscles. 
 
 " CEREBRAL CORTICAL AFFECTIONS. 
 
 Conjugate ocular paralyses, (or ophthalmo- 
 plegias.) Loss of voluntary movements of 
 the eyes, with preservation of involuntary or 
 reflex movements of pupil and eye-ball. 
 Eyes paralyzed on side opposite the cerebral 
 lesion. Eyes deviate towards side of lesion. 
 Psychic visual disorders. 
 
 " CEREBRAL AFFECTIONS WITH INCREASED INTRA-CRANIAL 
 PRESSURE. 
 
 Paretic mydriasis ordinarily. Sometimes 
 reflex spastic mydriasis. 
 
 " CEREBELLUM, AFFECTIONS OF. 
 
 Nystagmus. 
 
 " CONCUSSION OF. 
 
 Sluggish action of pupils without marked 
 dilatation or contraction. 
 
 " HYPERAEMIA OF. 
 
 Spastic myosis. 
 
 " TUMOR OF. 
 
 Nystagmus. Paretic mydriasis. Choked disc. 
 Choked neuritis. Atrophy of optic nerve.
 
 130 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 Homonymous hemianopsia, when pressure 
 is exerted upon fibres of one tract. 
 
 CHOLERA. 
 
 Conjunctival hemorrhage. Anesthesia of cornea. 
 Neuro-paralytic keratitis. Loss of the light reflex 
 indicates a fatal termination even in apparently 
 mild cases. Preservation of the light reflex war- 
 rants a favorable prognosis, even in severe cases. 
 Black patches appear in the sclerotic below the 
 cornea in severe cases. They are of irregular 
 form and size and tend to coalesce. Their pres- 
 ence is of very unfavorable significance. 
 
 COMA, ALCOHOLIC OR URAEMIC. 
 
 Mydriasis. 
 
 COMA, SYPHILITIC. 
 
 Myosis and reflex iridoplegia. 
 
 DEATH, SIGNS OF. 
 
 Opacity and insensibility of the cornea. Desicca- 
 tion of the sclera. Abolition of pupillary reflexes. 
 Absence of the red reflex from the fundus. 
 
 DENTAL AFFECTIONS. 
 
 Various forms of inflammation of the cornea. 
 Nictitation. 
 
 DIABETES. 
 
 Eczema of the eyelids. Conjunctival hemorrhage. 
 Ulceration of the cornea. Paralysis of the exter- 
 nal ocular muscles and of the accommodation. 
 Cortical cataract. Retinitis and neuro-retinitis.
 
 A TABULATED STATEMENT OF EYE SYMPTOMS. 131 
 
 Attophy of the optic nerve. Degeneration of the 
 retinal vessels and hemorrhages. Lagrange found, 
 in 52 cases of diabetes, 13 of intra-ocular hemor- 
 rhage and the same number of cases of cataract. 
 (See "Arch. tfOphth.," Jan., 1887). Galezowski 
 found in 144 cases of diabetes, 5 of paresis of 
 accommodation, 4 of keratitis, 7 of iritis, 4 of 
 glaucoma, 46 of cataract, 27 of retinitis, 31 of 
 amblyopia, 3 of amotio retinae, and 3 of atrophy 
 of the optic nerve. (See "Jahr. /. Aug." 1883, p. 
 297). 
 
 DIGESTION, DISORDERS OF. 
 
 Styes. Nictitation. 
 
 DIPHTHERIA. 
 
 Diphtheritic conjunctivitis. Paralysis of the ex- 
 ternal eye muscles rare; of accommodation more 
 frequent. 
 
 EMBOLISM, CEREBRAL. 
 
 No pupillary symptoms ; in contradistinction from 
 apoplexy. 
 
 EPILEPSY. 
 
 Paretic mydriasis during the seizure or spastic 
 myosis. Hippus as consciousness returns and fre- 
 quently during the intervals. Spasms of the ocu- 
 lar muscles. 
 
 FEVER, PUERPERAL AND TYPHOID. 
 
 Metastatic suppurative choroiditis. 
 
 FEVER, RELAPSING. 
 
 Iritis.
 
 132 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 FIFTH NERVE, AFFECTIONS OF. 
 
 Reflex spastic myosis. 
 
 FOUBTH VENTRICLE, LESIONS IN. 
 
 Nuclear ocular paralyses affecting separate nuclei 
 of the third nerve, or successive implication of 
 its various branches. Also total paralysis of all 
 the muscles of both eyes. 
 
 FBIEDREICH'S DISEASE (HEREDITART ATAXIA). 
 
 Nystagmus. 
 
 GOUT. 
 
 Retinitis. 
 
 HEART, AORTIC INSUFFICIENCY. 
 
 Alternate reddening and pallor of the optic disc. 
 
 HEART, ENDOCARDITIS. 
 
 Embolism of the arteria centralis retinae. 
 
 HEART, ORGANIC AFFECTIONS OF. 
 
 Oedema of lids. Venous hyperaemia of retina 
 and pulsation of retinal arteries. Seen with val- 
 vular affections, fatty heart and aortic insuffi- 
 ciency. 
 
 HEART, HYPERTROPHY OF LEFT VENTRICLE. 
 
 Retinal hemorrhages. 
 
 HEART, VALVULAR LESIONS OF. 
 
 Retinal hemorrhages. 
 
 HELMINTHIASIS. 
 
 Reflex spastic mydriasis. 
 
 HEPATIC AFFECTIONS. 
 
 Pigmentation of the skin of the lids. Coloration 
 of sclera.
 
 A TUBULATED STATEMENT OF EYE SYMPTOMS. 133 
 
 HYDRAEMIA. 
 
 Oedema of lids. 
 
 HYDBOCEPHALTJS. 
 
 Paretic mydriasis. Neuritis and atrophy of optic 
 nerve. 
 
 HYSTERIA. 
 
 Chromidrosis. Epiphora. Ptosis. Spastic myosis 
 (during a hysterical convulsion). Hippus. Hyper- 
 aesthesia of the retina. Spasm of accommodation. 
 Amblyopia. Contraction of the visual field. Sud- 
 den onset, erratic course, sudden disappearance. 
 
 INSANITY. 
 
 Monocular mydriasis and paralysis of accommoda- 
 tion are suspicious premonitory signs, as is also 
 transient recurrent mydriasis. 
 
 KIDNEY, DISEASES OF. 
 
 Degeneration of the retinal vessels with or with- 
 out hemorrhages. Retinitis and neuro-retinitis. 
 Amblyopia. Oedema of lids. 
 
 LEPROSY. 
 
 Leprous nodules in eyelids, conjunctiva, cornea 
 and iris. Anaesthetic spots and white patches in 
 the lids. According to Lopez ("Archiv. f. Aug.," 
 XXII, 2 and 3) "the eye is affected in half the 
 cases, the eye with its appendages in all cases." 
 Knies. 
 
 LUNG, DISEASE OF APEX. 
 
 Reflex spastic mydriasis.
 
 134 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 MALARIA. 
 
 Chronic superficial non-suppurative keratitis. Sen- 
 sitiveness of supra-orbital nerves. Retinal hemor- 
 rhages. Choroiditis. 
 MANIA. 
 
 Reflex spastic mydriasis. 
 
 MASTURBATION. 
 
 Paralysis of accommodation. Hyperaesthesia of 
 the retina. 
 
 MELANCHOLIA. 
 
 Reflex spastic mydriasis. 
 
 MENINGITIS, CEREBRAL 
 " ACUTE. 
 
 Mydriasis or myosis. Photophobia. Injec- 
 tion of conjunctiva. 
 
 CHRONIC. 
 
 Interstitial and peri-neuritis. Atrophy of the 
 optic nerve. 
 
 " OF THE CONVEXITY. 
 
 Cortical blindness or hemianopsia with pre- 
 served pupillary light reflex. Hyperaesthesia 
 of the retina. Photophobia, phosphenes, etc. 
 
 CEREBRO-SPINAL. 
 
 Eye symptoms frequent. Conjunctivitis in 
 early stages. Later oedema of conjunctiva, 
 denoting exudation in cranial cavity. Stra- 
 bismus. Nystagmus. Spastic myosis in early 
 stages. Reflex spastic mydriasis from pinch- 
 ing the skin at the back of the neck.
 
 A TUBULATED STATEMENT OF EYE SYMPTOMS. 135 
 
 (Parrot's sign). Hippus. Choroiditis. Photo- 
 phobia. Neuritis. 
 
 MENINGITIS, SPINAL. 
 
 Spastic mydriasis in the early stage. 
 
 TUBERCULAR. 
 
 Strabismus. Nystagmus. Ocular paralyses. 
 Spastic myosis in early stage. Rapid alter- 
 nation of myosis and mydriasis. Paretic 
 mydriasis in later stages in centra-distinction 
 from cerebro-spinal meningitis, in which it 
 is rare. Tuberculosis of the choroid. Homo- 
 nymous hemianopsia. 
 
 MENINGEAL HEMORRHAGE. 
 
 Nystagmus. Hemianopsia. 
 
 MENSTRUATION, DISORDERS OF. 
 
 Styes. 
 
 MYELITIS, ACUTE AND CHRONIC. 
 
 Neuritis or simple atrophy of the optic nerve. 
 
 MYXOEDEMA. 
 
 Thickening and swelling of the lids. 
 
 NEPHRITIS. 
 
 See diseases of the kidney. 
 
 NEURALGIA OF THE FIFTH NERVE. 
 
 Paralysis of accommodation. 
 
 NEURITIS, MULTIPLE OR PSEUDO-TABES. 
 
 Axial neuritis with central scotoma. Absence of 
 pupillary symptoms, in centra-distinction from 
 true tabes.
 
 136 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 NICOTINE POISONING. 
 
 Spastic myosis. Retro-bulbar neuritis with central 
 scotoma. 
 
 PARALYSIS. 
 
 " AGITANS. 
 
 Tremor of the lids. Ptosis. 
 
 " GENERAL (PARALYSIS OF INSANE. PARESIS). 
 
 Monocular mydriasis and paralysis of the 
 accommodation and transient recurrent myd- 
 riasis are suspicious premonitory symptoms. 
 Paretic mydriasis is an early symptom. The 
 "Argyll-Robertson pupil " is found in fifty 
 per cent, of the cases. Anisocorea. Paretic 
 myosis. Optic neuritis. Atrophy of optic 
 nerve. Soul blindness. Sudden development 
 and transient duration of ocular symptoms, 
 similar to multiple sclerosis and tabes. 
 
 POLIO ENCEPHALITIS SUPERIOR (INFLAMMATION OF THE FLOOR 
 OF THE FOURTH VENTRICLE). 
 
 Progressive paralysis of the ocular muscles is the 
 essential feature. 
 
 PONS VAROLII. LESIONS OF. 
 
 Nystagmus. Associate ocular paralyses in hori- 
 zontal lines. Spastic myosis. An isolated lesion 
 of one side produces paralysis of the external 
 rectus on the same side. 
 
 PYAEMIA. 
 
 Metastatic suppurative choroiditis. Retinal hemor- 
 rhages.
 
 A TUBULATED STATEMENT OF EYE SYMPTOMS. 137 
 
 RACHITIS. 
 
 Cortical or laminated cataract. 
 
 EHEUMATISM. 
 
 Paralysis of external ocular muscles, usually of 
 one eye, and affecting one or more contiguous 
 branches of the nerve, such as the superior rectus 
 and levator palpebrae superioris. Iritis with gela- 
 tinous exudation. 
 
 SCLEEOSIS, MULTIPLE. 
 
 Nystagmus, a frequent and valuable diagnostic 
 sign. Ocular paralyses characterized by sudden 
 development, transient duration and variable 
 course, similar to syphilis and tabes. Hippus. 
 Paralysis of accommodation. Impairment of vis- 
 ion, but rarely complete blindness. Central sco- 
 torna. Irregular or concentric contraction of the 
 visual field. Neuritis. 
 
 SCROFULA. 
 
 Eczema of lids. Styes. Ciliary blepharitis. Con- 
 junctivitis. Pustules and abscesses of the cornea. 
 
 
 
 Phlyctenular conjunctivitis and keratitis. Choroi- 
 ditis. 
 
 SNAKE POISONING. 
 
 Retinal hemorrhages. 
 
 SKIN, EXTENSIVE BURNS OF. 
 
 Reflex .spastic mydriasis (skin reflex). 
 
 SPINAL CORD. 
 
 " INFLAMMATION AND CONGESTION OF. SPINAL IRRITATION. 
 
 Spastic mydriasis occurs in the early stages.
 
 138 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 SPINAL CORD. DEGENERATIVE DISEASE OF. 
 
 Nystagmus. 
 
 SYPHILIS. 
 
 Every tissue of the eye, except the lens, is af- 
 fected. Inflammations of the lids, orbit and ly- 
 chrymal passages. Arrest of development, such 
 as microphthalmus, etc., in the congenital form. 
 Periostitis and caries of the orbit. Paralytic af- 
 fections of the lids and external ocular muscles. 
 Various muscles are suddenly, successively and 
 transiently involved. Parenchymatous keratitis. 
 Inflammation of the sclera with gummata. Myd- 
 riasis with loss of accommodation. Gummous 
 iritis. Choroiditis. Degeneration of the retinal 
 vessels with or without hemorrhages. Retinitis 
 and neuro-retinitis. Atrophy of the optic nerve. 
 Heteronymous and homonymous hemianopsia. 
 Zimmerman, of Milwaukee, says, in u Knapp's 
 Archives," Jan., 1895, that only about 15 per 
 cent, of the cases of brain syphilis are without 
 
 
 
 ocular symptoms. 
 
 TABES. 
 
 Anaesthesia of the skin of the lids of the con- 
 junctiva and cornea, with false localization of 
 sensation. Paresis of orbicularis palpebrarum. 
 Narrowing of the palpebral fissure. Ptosis. Pa- 
 ralysis of the ocular muscles, sudden in develop- 
 ment and transient in duration, similar to syphi-
 
 A TUBULATED STATEMENT OP EYE SYMPTOMS. 139 
 
 letic paralyses and to those which occur in mul- 
 tiple sclerosis. 
 
 Spastic mydriasis may be a premonitory symptom. 
 Paretic myosis occurs in 23 per cent, of the cases. 
 The "Argyll-Robertson pupil " is a very character- 
 istic symptom and occurs in 70 per cent, of the 
 cases. In 25 per cent, it is an early symptom. 
 Reflex iridoplegia, or failure of all the pupillary 
 reflexes. The reaction to light fails first, followed 
 by loss of reaction with accommodation and con- 
 vergence, and lastly the skin reflex is lost. 
 Anisocorea occurs in 34 per cent, of the cases. 
 Reflex iridoplegia is a valuable diagnostic point 
 between true and false tabes, or multiple neuritis. 
 In the latter, myosis and reflex iridoplegia are 
 wanting. Atrophy of the optic nerve. 
 Ocular symptoms may appear very early, even 
 many years before the ataxic symptoms. Gowers 
 relates a case where twenty years elapsed between 
 blindness optic nerve atrophy, etc., and the onset 
 of ataxia. 
 
 Wtien spinal symptoms are well marked ocular symp- 
 toms are often latent or absent, and the reverse is also 
 true, viz., when ocular symptoms are marked the 
 spinal symptoms are slight or absent and may be long 
 delayed. 
 
 TRICHINOSIS. 
 
 Oedema of the lids and paralysis of accommoda- 
 tion.
 
 140 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 TUBERCULOSIS. 
 
 Periostitis and caries of the orbit. Tubercular 
 nodules in eyelids, conjunctiva, iris and choroid. 
 Iritis with grayish-red nodules. 
 
 TYPHOID FEVER. 
 
 Anaesthesia of the cornea, neuro-paralytic kerati- 
 tis. Hippus in stage of cerebral manifestations. 
 Metastatic suppurative choroiditis. Intra-ocular 
 hemorrhages. 
 
 URAEMIA. 
 
 Mydriasis is a premonitory sign. Sudden failure 
 of vision. 
 
 UTERINE AFFECTIONS. 
 
 Pigmentation of the skin of the lids. Paralysis 
 of accommodation. 
 
 URTICARIA. 
 
 Reflex spastic mydriasis.
 
 PART SECOND. 
 
 REFLEX NEUROSES 
 
 (141)
 
 CHAPTER VII. 
 
 THE RELATION OF OCULAR AFFECTIONS TO FUNCTIONAL 
 NERVOUS DISEASES. 
 
 The term neurosis may be used synonymously 
 with a functional nervous affection. By either expres- 
 sion we understand a disorder of the nerves, or nerve 
 centres, of a purely functional nature, and unassociated 
 with known organic structural changes. It is not as- 
 serted that such changes may not exist, but that they 
 have not been recognized. A functional nervous disease 
 may originate in some irritation or lesion in a part dis- 
 tant from that in which the symptoms are manifested. 
 In such a case the disease is designated as a reflex neu- 
 rosis, and the reflex influence of affections of the eye in 
 causing functional nervous diseases is the theme of the 
 present chapter. The converse of this, viz. : the discus- 
 sion of reflex neuroses, as they are manifested by func- 
 tional eye diseases dependent upon distant foci of irri- 
 tations, will be reserved for subsequent consideration. 
 
 Functional nervous diseases may be conveniently 
 classified as general and local. In the former class be- 
 long epilepsy, chorea, neurasthenia and hysteria. Very 
 much has been written during the past few years upon 
 the relation of eye-strain to such affections, and the ten- 
 
 (143)
 
 144 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 dency of specialism in medicine to beget narrowness of 
 view, and of enthusiastic study in one direction to dis- 
 tort the judgment is nowhere more clearly exemplified. 
 Mere coincidence has been many times mistaken for 
 cause and effect. The origin of almost all nervous af- 
 fections has been assigned by some over-zealous ophthal- 
 'mologists to ocular disorders, and the exaggerated im- 
 portance thus given them has been denied by others, 
 some of whom undoubtedly underrate their influence in 
 such directions. The truth, as I shall endeavor to show, 
 lies between these two extreme views. 
 
 The study of neuroses is one of great import- 
 ance, and whatever promises to extend our knowledge 
 of their causes, and thus to teach us how to prevent 
 their development, or on the other hand, offers additional 
 means of cure is of direct value and merits careful con- 
 sideration. The recorded observation and experience of 
 multitude of skilled and trustworthy physicians seem 
 to demonstrate that ocular affections are both a cause 
 and an effect of functional nervous diseases. 
 
 The wear and tear of modern life consequent 
 upon the competition of business, the feverish excite- 
 ment and anxiety of speculation, the demands of social 
 and fashionable life with its mental and physical ex- 
 haustion, the excitement of modern fiction and the 
 drama, are some of the universally recognized exciting 
 causes of such diseases. Thus an inherited neurotic 
 temperament transmitted from parent to child is a fre-
 
 FUNCTIONAL NERVOUS DISEASES. 145 
 
 quent predisposing cause, and the extreme and increas- 
 ing prevalence of nervous disorders is thus readily un- 
 derstood. When a person of this neurotic temperament, 
 hereditary or acquired, is subjected to any special source 
 of nervous exhaustion the effect of such strain is inten- 
 sified, and is followed, in many instances, by pronounced 
 and far-reaching effects. The fact that such overwork, 
 anxiety, loss of sleep, and so forth is often well borne 
 without obvious injury by persons in robust health is 
 no proof of the incorrectness of this statement. Simi- 
 larly, any organ, although somewhat crippled by reason 
 of structural weakness or difficult or painful exercise 
 of function, may do its work without apparent detriment 
 when the body as a whole is in a condition of perfect 
 health, but when the vital powers are enfeebled from 
 any cause, such as lack of nutrition, overwork bodily 
 or mental, or from actual disease, the weak organ is the 
 first to suffer and the slowest to recover. 
 
 We recognize in certain functional eye-diseases 
 both the cause and the effect of general neuroses such 
 as those enumerated. The faculty of vision is a most 
 complex one, demanding the exercise of various and in- 
 tricate nervous activities. The first requisite for binocu- 
 lar single vision is that an image of the object shall 
 be formed upon corresponding portions of each retina. 
 Otherwise, the two retinal impressions cannot be blend- 
 ed into a harmonious single perception, and diplopia 
 
 results. In order that the images may fall upon cor- 
 10
 
 146 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 responding retinal points, the functional integrity of 
 the four recti and the two oblique muscles, by which 
 the harmonious associated movements of the two eyes 
 are obtained, is essential. This means uninterrupted 
 and harmonious innervation along the lines of the 
 third, fourth and sixth nerves, proceeding from physio- 
 logically intact centres, which preside over and regulate 
 the ocular movements. The normal exercise of the 
 faculty of accommodation is also essential to perfect 
 vision, as well as the movements of the iris, calling for 
 exercise of other fibres of the third and of the sympa- 
 thetic nerves. Supposing these factors to be physiologi- 
 cally and anatomically perfect, and the dioptric media 
 to be transparent and of proper refractive power, the 
 conduction of visual impressions through the optic 
 nerve must be unimpaired, and the visual centres must 
 be in healthy condition, in order that the impressions 
 thus received may be converted into intelligent percep- 
 tions of form, size and color, and that accurate concept- 
 ions of the nature, distance and position of objects may 
 be obtained. When we remember that during all our 
 waking hours the eyes are in constant use in both dis- 
 tant and near vision, and when we consider the close ap- 
 plication required of the student, the artist, the profes- 
 sional man, the book-keeper and the skilled mechanic, we 
 are in a position to realize the amount of nervous energy 
 which is thus called for, and to appreciate the strain 
 resulting from any abnormality of structure or function
 
 FUNCTIONAL NERVOUS DISEASES. 147 
 
 in the visual apparatus, and the influence which such a 
 strain exerts in the development and maintainance of 
 functional neuroses in persons of neurotic temperament. 
 In all such cases, it should be remembered that eye- 
 strain is an important factor to be considered. 
 
 OCULAR AFFECTIONS AS A CAUSATIVE 
 INFLUENCE IN EPILEPSY. 
 
 The literature of the past few years contains fre- 
 quent references to the subject, and many cases have 
 been reported in which cures have followed correction 
 of refractive or muscular anomalies of the eyes. Doubt- 
 less errors in diagnosis have sometimes been made, and 
 in other instances sufficient proof of recovery has not 
 been offered; nevertheless the testimony of so many in- 
 vestigators, many of them men of recognized ability and 
 trustworthiness, is deserving of careful consideration. 
 Leaving out of the question those cases of epilepsy con- 
 secutive to injuries of the skull, or associated with or- 
 ganic brain disease, there remain many others of so- 
 called " idiopathic epilepsy " in which no pathological 
 changes have been discovered. These cases occur in 
 persons of a strongly neurotic temperament, with whom 
 there is often a family history of previous epilepsy or 
 insanity. Inherited syphilis often exists in these individ- 
 uals with defective development of the brain. The latter 
 however may exist without syphilis, and be the result 
 of other influences. The remote cause, viz., the constitu-
 
 148 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 tional predisposition thus induced, is of vastly more im- 
 portance than the exciting cause. The latter is often 
 apparently insignificant and frequently overlooked. It 
 may be dental irritation, helminthiasis or other intesti- 
 nal disorder, or a reflex influence from sexual or other 
 nervous excitation. Frequently it is some strong men- 
 tal impression, such as fright, excitement or sudden 
 grief. These conditions alone are incapable of originat- 
 ing true epilepsy, but they are all recognized as ade- 
 quate exciting causes of the disease when added to a 
 pronounced predisposition to epilepsy. Any one of them 
 may on an appropriate occasion serve as a match to 
 fire an explosion of nervous energy resulting in a con- 
 vulsive seizure. A repetition may occur from the same 
 or a similar cause, and the susceptibility of the individ- 
 ual increases with each attack until they recur without 
 assignable cause, and thus true idiopathetic epilepsy is 
 developed. A single convulsive seizure directly due to 
 a reflex irritation, as in children during dentition, or 
 with acute indigestion, may strongly resemble true epi- 
 lepsy, but in the absence of repetition could hardly be 
 so diagnosed. If a transient condition such as those 
 mentioned, or a violent fit of anger or fear may thus 
 become the exciting cause of convulsive attacks which 
 continue to recur without the repetition of the initial 
 cause, it seems much more plausible to assign a causa- 
 tive influence to a permanently active source of nerve 
 waste such as is found in eye-strain, and it is a signifi-
 
 FUNCTIONAL NERVOUS DISEASES. 149 
 
 cant fact that Semeling (" Charite Annal." XI, p. 389) 
 asserts that anomalies of the eye occur in 20 per cent, 
 of all epileptics. 
 
 Another argument in support of the influence of 
 eye-strain is afforded by the fact that visual aurae pre- 
 cede an attack in a large number of cases of epilepsy. 
 Gowers says, (" Diseases of the Nervous System," Vol. 
 2, p. 739) : "A visual warning is twice as frequent 
 as all the other special sense aurae together. It may 
 be a sudden loss of sight, but is more frequently a 
 visual sensation, a flash of light or sparks, or flashes of 
 color. Usually many colors are seen, red and blue most 
 frequently. It may be an elaborate sensation, a vague 
 beautiful vision, or a definite image of some object, for 
 instance, an old woman with a dress of some certain 
 color, ugly faces, animals, etc." 
 
 An aura, either sensory or motor, "gives us in- 
 formation of the functional region of the brain where 
 the process of the fit begins," and such visual aurae 
 as enumerated clearly indicate that in many cases the 
 visual centre is the locality where the "discharge" com- 
 mences. Aural warnings associated with the sense of 
 vision, or of varied nature and location are more common 
 in epilepsy associated with organic cerebral lesions than 
 in the idiopathic variety, and they do not usually indi- 
 cate an ascending irritation from the part where the pe- 
 culiar sensation is felt, but are rather the expression of a 
 central irritation referred to the extremity first affected.
 
 150 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 Clinical experience teaches that the converse may be 
 true viz., that peripheral ascending irritation is some- 
 times the cause of the attack. Gowers mentions a case 
 which illustrates this fact. A boy received a severe cut 
 on one of the fingers of the right hand which was fol- 
 lowed by epilepsy. The spasms always commenced in 
 the hand and were arrested by amputation of the in- 
 jured finger. 
 
 Visual aurae may be indirectly dependent upon 
 eye-strain, and the cure of epilepsy by correction of oc- 
 ular anomalies is explained, as in the above case, by 
 the removal of the cause of peripheral irritation. The 
 path by which such influence travels from the eye to 
 the brain is uncertain, but the hypothesis that anae- 
 mia of the brain, due to vaso-motor spasm, is the im- 
 mediate cause of the explosion of nervous energy mani- 
 festing itself by the epileptic crisis, would afford, if 
 proved, a probable explanation of the path of the ocular 
 reflex through the intimate connection of the cerebral 
 and sympathetic nerves which exists in and around the 
 eye, and their mutual physiological and pathological rela- 
 tions. 
 
 Much time and space might be occupied in quot- 
 ing from various authors reports of cases of epilepsy 
 dependent upon eye-strain and cured by removal of the 
 same. D'Abundo claims to have cured it by correction 
 of astigmatism. Elliot, Colburn and Frothingham by 
 convex glasses, and Stevens by operative measures in
 
 FUNCTIONAL NERVOUS DISEASES. 151 
 
 heterophoria. Wood says in a discussion of the " Treat- 
 ment of Epilepsy by Tenotomy of the Ocular Muscles," 
 in the " New York Med. Journal " of July 7 and 14, 1894: 
 "Anomalies of the muscles alone may produce epilepsy 
 by acting as a reflex irritant. It is true that some 
 cases of epilepsy are cured by muscular treatment when 
 there is true heterophoria. In cases in which epilepsy 
 is to be attributed to loss of ocular equilibrium, other 
 symptoms of the latter are not wanting". Pechdo, 
 Fumagalli and Galezowski report cures by enucleation. 
 It is proper to remark in this connection that cases of 
 epilepsy have been cured by a variety of trivial opera- 
 tive measures where the results must be attributed to 
 the influence of suggestion. After making due allow- 
 ance for such influence and for too enthusiastic opin- 
 ions, and for errors of judgment and of diagnosis, many 
 cases remain too well authenticated to admit of doubt. 
 
 If the preceding arguments are worthy of consid- 
 eration, a single case will carry as much weight as 
 many in establishing the possibility of such a cause for 
 epilepsy, and of emphasizing the importance of exam- 
 ining the eyes in all cases where the cause and the 
 remedy are not apparent. If this most serious and fre- 
 quently incurable disease can thus be relieved even oc- 
 casionally we shall be guilty of criminal neglect if we 
 omit such examination. Dr. F. Park Lewis, in the 
 " Eye, Ear and Throat Journal " for January, 1895, 
 reports the following case of epilepsy dependent upon
 
 152 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 eye-strain : " A bright young man of eighteen or there- 
 abouts, was sent about two years ago to a military school 
 where he was successful in his examinations and greatly 
 interested in his work. The amount of mental work 
 required was rather unsual, however, and the discipline 
 rigid. Without any warning, he was one day taken 
 with a genuine epileptic seizure. This was shortly fol- 
 lowed by another and again another, so that it was 
 necessary for him to return home. He was placed 
 under the care of a prominent neurologist and treated 
 generously with bromides. In spite of care and treat- 
 ment, the attacks decreased neither in frequency nor 
 severity, until his parents, having heard of eye-strain as 
 a possible cause of convulsions of this character, brought 
 him to me that he might have a comprehensive ocular 
 examination. Tests under atropine showed a small de- 
 gree of hypermetropia with a quarter of a dioptre of 
 vertical astigmatism. He had, however, marked esopho- 
 ria with weakness of the external recti. He was given 
 appropriate prisms, operative measures being held in re- 
 serve. Surgical interference has never been resorted to, 
 and from the time of wearing glasses until now about 
 a year ago he has never had an attack." 
 
 Dr. Lewis remarks: "Other cases of like charac- 
 ter might be given in which high degrees of exophoria 
 and also astigmatism have been the exciting causes of 
 epilepsy. In one instance, whenever the accommodation 
 was relaxed with atropine, all convulsive tendency im-
 
 FUNCTIONAL NERVOUS DISEASES. 153 
 
 mediately disappeared and did not return while the my- 
 
 driasis was maintained To fail to 
 
 recognize the reflex nature of these cases is to shut our 
 eyes in the only direction from which we may confi- 
 dently look for relief. The fact that all epilepsies have 
 not a reflex origin, or the equally palpable truth that 
 muscular insufficiencies and other nerve strains exist 
 without causing disturbances, either epileptic or other- 
 wise, is no argument against the conclusion that I have 
 drawn, and only leads to a plea for a more careful dif- 
 ferentiation of symptoms and their probable cause in 
 diagnosis, and a greater hesitancy in resorting to bro- 
 mides or any palliative measures which may be of 
 doubtful efficacy in the one set of cases, and must be of 
 positive injury in another more complicated, and less 
 easy to diagnose epileptic group." 
 
 Various eye symptoms have been noticed during 
 an epileptic attack, such as spasm of the orbicularis 
 and deviation of both eyes toward one side, and roll- 
 ing movements. The lids may be open or closed, 
 and the conjunctiva is insensitive. The pupils may be 
 contracted at the beginning of the attack, but this is 
 not invariable. Dilatation with inaction to light comes 
 on simultaneously with the cyanosis, and continues until 
 signs of consciousness begin to be manifested, when the 
 mydriasis ceases. Afterwards there is alternate contrac- 
 tion and dilatation, changing every few seconds during 
 an interval of several minutes. Frequently in the in-
 
 154 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 terim between attacks there occur variations in the size 
 of the pupils without apparent cause. 
 
 CHOREA. 
 
 Although pathological changes in the brain and 
 spinal cord have been found in many cases of chorea, 
 they vary so much in situation and character and are 
 so frequently absent, that no definite conclusion can be 
 drawn from them as to the cause of the affection. 
 Hence it is classed among the neuroses. An hereditary 
 neuropathic temperament usually underlies the disease, 
 other members of the family frequently suffering from 
 insanity, epilepsy or hysteria. It is much more frequent 
 in the female sex, and during the impressionable age of 
 childhood. Fright is the most frequent exciting cause 
 where the predisposition exists. Cases have been attri- 
 buted to intestinal worms, and to irritation of a periph- 
 eral nerve. 
 
 Eye-strain should be remembered as a possible 
 factor, although the evidence of such an influence rests 
 upon a much more slender basis than with epilepsy. 
 Ranney, of New York, reports in the " Medical Record " 
 for May 12, 1894, a series of cases of chorea all of 
 which were cured or much benefitted by graduated ten- 
 otomies. Stevens attaches much importance to errors of 
 refraction as a cause of chorea, and Gould claims to 
 have cured one case by the use of convex glasses. This 
 view is strongly opposed by other oculists of eminence.
 
 NEURASTHENIA AND HYSTERIA. 155 
 
 The committee of the N. Y. Neurological Society, who 
 were appointed some years ago to investigate Dr. Stev- 
 ens' claims, came to the conclusion that they were not 
 supported by facts. 
 
 De Schweinitz, of Philadelphia, analyzed 227 
 cases of chorea, in which he found either hypermetropia 
 or hypermetropic astigmatism to exist in 76 per cent, 
 and myopia and mixed astigmatism in a few of the re- 
 mainder. At first sight this would seem to afford strong 
 corroborative testimony in favor of the relation of cause 
 and effect between chorea and refractive errors. When, 
 however, we recall the fact that exactly the same, viz., 76 
 per cent, of all children in the elementary schools have 
 hypermetropic refraction, the evidence seems as strong 
 that chorea causes hypermetropia as the reverse. 
 
 Although the facial muscles are affected in nearly 
 all cases, the ocular muscles are rarely involved. 
 
 Lifting of the eyebrows, closure of the lids and 
 rolling of the eyes increasing on excitement and ceas- 
 ing during sleep have been observed in this disease. 
 Dilatation and inequality of the pupils may be present. 
 Nystagmus occurs rarely, and points to a cerebral lesion 
 as the cause both of the nystagmus and of the chorea. 
 Thus its presence would be of diagnostic importance as 
 indicating that the latter was not a simple neurosis. 
 
 NEURASTHENIA AND HYSTERIA. 
 
 Eye-strain is a direct cause of neurasthenia and 
 an indirect cause of hysteria. The former is not a dis-
 
 156 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 tinct disease, but a condition of nervous exhaustion 
 which may be due to a variety of conditions both men- 
 tal and physical, or it may be a direct sequence of defi- 
 nite diseases both functional and structural. It is not 
 necessary to repeat in this connection what has been 
 said in reference to the large expenditure of nervous 
 energy required in physiological vision, and it needs no 
 additional argument to emphasize the depressing influ- 
 ence of conditions demanding unusual nervous effort 
 such as necessarily attends the visual act when errors 
 of refraction or weakness of the external or internal 
 eye-muscles exist. Here again we recognize the " vic- 
 ious circle " of cause and effect, and will expect to 
 find, as we do, all forms of asthenopia developed and 
 intensified in neurasthenia. There is easy fatigue of the 
 eyes and of the visual centres and anaesthesia of the 
 retina ; accommodation and convergence are also weak. 
 These conditions explain the indistinctness of near vis- 
 ion and the pain attending it, and the necessity for 
 convex glasses in those who have not previously re- 
 quired them, as well as the frequent change of glasses 
 which those already dependent upon them require. The 
 retinal and central exhaustion produces impairment of 
 distant vision, frequent alterations of the visual fields 
 and dilated and changeable pupils. Romberg called 
 attention to an unusual symptom which he considered 
 peculiar to neurasthenic individuals, viz., an inability 
 to close the eyes completely when standing with the
 
 HYSTERIA. 157 
 
 feet close together, because of weakness of the accom- 
 modation and spasm of the sympathetic. L,oenwerg 
 states that this symptom occurs on standing, without re- 
 gard to the position of the feet. 
 
 Certain peculiar visual disorders occur in neuras- 
 thenia, but are more frequent in hysteria, and, therefore, 
 they will not be separately discussed here. There is an 
 intimate relation between neurasthenia and hysteria, for 
 the former underlies a large proportion of functional 
 nervous diseases, including hysteria, and is often the 
 direct cause of them. 
 
 HYSTERIA. 
 
 As with epilepsy and chorea, we recognize in 
 hysteria also an hereditary neurotic tendency which is 
 intensified by poor health, anaemia and any depressing 
 influence such as eye-strain, which thus may be enum- 
 erated among the causes of hysteria. Therefore the cor- 
 rection of muscular and refractive errors is an import- 
 ant factor in the treatment of hysterical affections. 
 
 To reverse the subject, we recognize many func- 
 tional ocular affections manifested in the domain of 
 both the cerebral and the sympathetic nerves as a re- 
 sult of hysteria. A general characteristic of such dis- 
 orders is suddenness of onset, erratic course, often a 
 sudden disappearance, and the absence of apparent ade- 
 quate cause of ophthalmoscopic changes or other evidence
 
 158 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 of pathological basis for the symptoms exhibited. Such 
 affections may, for convenience, be classified as : 
 
 a. Muscular disorders. 
 
 b. Disorders of sensation. 
 
 c. Disorders of secretion. 
 
 d. Visual disorders. 
 
 a. MUSCULAR DISORDERS. Under this head may 
 be mentioned twitching and spasmodic closure of the 
 lids and spasm of accommodation. The latter produces 
 apparent near-sightedness, indicated by more or less in- 
 distinctness of distant vision and an inclination to hold 
 objects nearer the eye in reading, writing, etc. Spasm 
 of accommodation is not at all characteristic of func- 
 tional nervous troubles, for it occurs frequently in con- 
 nection with errors of refraction, but hysteria and neu- 
 rasthenia increase the liability to it when refractive 
 errors exist. 
 
 Paralytic affections occasionally occur, among 
 which hysterical ptosis is the most common form. The 
 expression " hysterical ptosis " is rather misleading, 
 however, for most cases are due rather to a slight spasm 
 of the orbicularis than to a real weakness of the levator 
 palpebrae. This is demonstrated by the circumstance 
 that when the patient is told to look up she bends her 
 head backward, and if the head is held, the spasmodic 
 contraction of the lids is manifestly increased. In other 
 cases paralysis of the sympathetic supplying the un-
 
 HYSTERIA. 159 
 
 striped muscular fibres of Mueller may explain the 
 slight drooping of the lids. 
 
 It was positively asserted by Charcot in 1892 
 that " nystagmus is never found in hysteria," and Gow- 
 ers, in the latest edition of his treatise on nervous dis- 
 eases, lays special stress on the importance of nystag- 
 mus as a diagnostic sign, indicating the existence of 
 "more than a functional disturbance of the brain or 
 cord." 
 
 A case reported by Dr. Sabrazes in the " Semaine 
 Medic.," September 26, 1894, seems to prove that these 
 statements of Charcot and Gowers are not to be ac- 
 cepted without reservation. The patient had nystagmus 
 without indication of any lesion of the visual apparatus, 
 associated with manifest indications of hysteria. Hyp- 
 notic suggestion caused the immediate disappearance of 
 all symptoms of disease. 
 
 Frequent variations in the size of the pupil with- 
 out apparent cause was mentioned as a manifestation 
 of neurasthenia, and it is also one of the recorded 
 symptoms of hysteria. 
 
 b. DISORDERS OF SENSATION in and around the 
 eyes as a manifestation of hysteria are frequent and 
 varied. Pain occurs either spontaneously or with efforts 
 of accommodation. Tenderness in the ciliary region 
 and anaesthesia of the skin of the lids and of the con- 
 junctiva and cornea are common.
 
 160 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 c. VASO-MOTOR and other SYMPATHETIC DISTUR- 
 BANCES in the eye are evidenced by disorders of secre- 
 tion such as epiphora without irritation or emotion, and 
 chromidrosis, or a coloration of the skin of the lids in 
 consequence of an abnormal formation of pigment by 
 the sweat glands. 
 
 d. VISUAL DISORDERS have been frequently no- 
 ticed in hysteria. There may be slight impairment of 
 vision or total blindness. Hysterical amblyopia, as it is 
 called, is of sudden onset and unaccompanied with oph- 
 thalmoscopic changes or evidences of cerebral lesions. 
 It may affect both eyes, but more frequently it is 
 monocular. The reaction of the pupil to light may be 
 retained or lost. If retained it indicates a cortical af- 
 fection, probably a vaso-motor disturbance of the circu- 
 lation. Hysterical amblyopia is usually of transient 
 duration and sudden in its disappearance. It is often 
 surprisingly improved by lenses of various sorts, convex, 
 concave or prismatic. The explanation of such im- 
 provement must be an increased innervation caused by 
 the use of the lenses. 
 
 Monocular amblyopia with retained pupillary re- 
 flex is strongly suggestive of simulation, and the differ- 
 ential diagnosis between simulation and hysteria is dif- 
 ficult. Apart from other hysterical manifestations, the 
 test for diplopia by means of the stereoscope and prisms 
 will afford valuable aid if carefully conducted. Binocu- 
 lar vision is essential for uniting the two pictures of
 
 HYSTERIA. 161 
 
 the stereoscope into a harmonious single image. Hence 
 if the patient with alleged monocular amblyopia sees 
 clearly with the stereoscope, the simulation of blindness 
 of one eye is exposed. A prism of 6 or more held 
 with its apex upward before one eye will produce a 
 double image (one above the other) of a candle or gas- 
 flame across the room if both eyes are used in seeing. 
 The effect of prisms upon the visual lines can also be 
 noted where it is not desirable to trust the statements 
 of the patient. If a prism of 6 to 10 is placed before 
 one eye with its base out, while the patient's gaze is 
 directed towards an object a few feet distant, the eye be- 
 hind the prism will make a movement inward (in the 
 direction of the apex of the prism) to avoid the diplopia 
 caused by the prism, unless that eye is blind or nearly 
 so. The detection of the fraud is more difficult when the 
 patient asserts that the sight of one eye is deficient, but 
 not entirely lost. We must then in conducting the test 
 endeavor to deceive him as to which eye is being 
 tested. If he is able to read fine print with the ambly- 
 opic eye while he imagines he is using the sound eye, 
 the simulation is apparent. Such a test may be con- 
 ducted in the following manner : 
 
 By the aid of Snellen's or Jaeger's test-types we 
 ascertain the smallest print he can read with the sound 
 eye. Then, handing him a spectacle frame having a 
 plain glass before the sound eye and a strong convex 
 
 glass before the supposed amblyopic eye, we ask him to 
 11
 
 162 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 read again. Later, under pretext of having neglected to 
 note the size of the print previously read, or for other 
 plausible reason, we repeat the test, this time reversing 
 the lenses so as to bring the convex glass before the 
 sound eye. If he now reads the same print at the 
 former distance, the diagnosis is established. 
 
 Monocular diplopia is sometimes an hysterical 
 manifestation and is usually caused by a spasm of ac- 
 commodation, as is evidenced by the fact that the di- 
 plopia disappears under the use of atropin for the re- 
 laxation of accommodation. Dr. Lagrange reported to 
 the " Medical and Surgical Society of Bordeaux," in 
 November, 1894, a case of hysterical monocular diplopia 
 which was unusual, in that it was evidently due to a 
 cerebral condition, and in which the diplopia was cured 
 by hypnotic suggestion. In this case the diplopia was 
 uninfluenced by the use df atropin. 
 
 There is a peculiar form of the visual field which 
 Charcot considers characteristic of hysteria, especially 
 when it is unilateral. Excentric vision gives us the 
 faculty of orientation, as it is called, which is of exceed- 
 ing value. If, in walking, for instance, we were uncon- 
 scious of all objects save those directly before us, we 
 would not only lose much of the pleasure of seeing, but 
 would be continually exposed to danger, for we would 
 not notice the approach of objects on either side; 
 neither could we appreciate the relative position and 
 direction of objects. This is well illustrated in the case
 
 HYSTERIA. 163 
 
 of retinitis pigmentosa, where, although central vision 
 in a limited area may still be preserved to such an 
 extent that the patient is able to read fine print, yet 
 be incapable of guiding himself alone. 
 
 Certain diseases produce characteristic alterations 
 in the form and outline of the visual field. For in- 
 stance, retro-bulbar neuritis causes a central scotoma, or 
 a loss of vision characterized by a black spot in the 
 centre of the field. In atrophy of the optic nerve there 
 is a concentric narrowing advancing very irregularly 
 from the periphery, often commencing from the tem- 
 poral side. Sometimes the field is quite uniformly re- 
 stricted on all sides, and, again, large gaps appear in 
 one direction while the boundaries may be nearly nor- 
 mal in all others. Glaucoma produces a narrowing, 
 usually manifested first on the nasal side. Hysteria 
 sometimes produces a concentric contraction with a 
 nearly uniform outline in all directions. This peculiar 
 form of the visual field, existing without ophthalmo- 
 scopic findings, is very characteristic of hysteria, and 
 hence is worthy of remembrance as affording a valuable 
 diagnostic point in certain cases when a suspicion of 
 cerebral disease exists. It may be associated with more 
 or less impairment of central vision, and more or less 
 loss of the color sense. 
 
 The following case is cited by way of illustra- 
 tion.
 
 164 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 Addie C., a sensitive, nervous child, fourteen years 
 old consulted me in February, 1896, complaining of 
 headache, indistinctness of vision, restless dreamful sleep, 
 and a variety of nervous symptoms which were appar- 
 ently associated with the approach of puberty. She had 
 never menstruated. Two years previously I had ex- 
 amined her and found slight hyperopic astigmatism in 
 each eye with some amblyopia of the left. With glasses 
 prescribed at that time the vision of the right eye was 
 jf, and that of the left f 
 
 These glasses she had worn constantly and satis- 
 factorily until shortly before consulting me in Febru- 
 ary, 1896. At that time v.o.d.=$ and v.o.s.=$, and 
 could not be improved by glasses. She could not read 
 print finer than Sn. No. i. After paralyzing the ac- 
 commodation with atropin distant vision was the same, 
 and all lenses were again refused. Ophthalmoscopic ex- 
 amination showed nothing abnormal. The visual fields 
 were concentrically contracted, with somewhat irregular 
 outlines. 
 
 Under treatment for her general health, rest of 
 the eyes and outdoor exercise, there was gradual im- 
 provement both in central vision and in the outline of 
 the fields until August 5, when there was a slightly in- 
 creased contraction of the latter. This was only tem- 
 porary, however, and, on the second of September, she 
 again accepted the lenses which corrected the slight as- 
 tigmatism previously demonstrated, and vision of the
 
 PLATE III 
 
 ,,w 
 
 > 
 
 ff , ///' 
 
 A;//-" 
 
 March 7* '96 
 June 5* '96 
 AIKJ. 5'h '96
 
 PLATE IV 
 
 March 
 June 
 Any. 
 Sept. 
 
 f 96 
 t> '96 
 96 
 ?^ '96
 
 HYSTERIA. 165 
 
 right eye was again |J- and that of the left ^f, the vis- 
 ual fields were practically normal as is shown by the 
 appended charts (Plates III and IV), and she read .5 
 easily. 
 
 There are certain well-determined areas in which 
 the various colors are perceived. The outlines of the 
 color fields differ from those for form, and vary with 
 the individual colors (see chart p. 115). 
 
 The same incongruity of manifestation which has 
 been found in other hysterical affections is noticeable 
 in the outlines of the various color fields. There may 
 be complete loss of color perception, or the form of 
 the fields may exhibit entire lack of uniformity as com- 
 pared with the normal standard. With organic affec- 
 tions we notice irregular contractions of the field for 
 form, and regular contractions of the color fields, while 
 the reverse, viz. : uniform concentric narrowing of the 
 field for form, and irregular, unsymmetrical contraction 
 of the color fields occurs in hysterical affections. 
 
 Certain ocular symptoms have been recorded in 
 connection with other functional nervous diseases, but, 
 as they possess no diagnostic significance, they are not 
 pertinent to the objects of this discussion. 
 
 LOCAL OCULAR REFLEX NEUROSES. 
 
 In the introduction to this chapter functional 
 nervous diseases were divided into general or systemic, 
 and local. It remains to consider the relation of oculai 
 affections to local neuroses.
 
 166 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 No argument is needed to convince the ophthal- 
 mologist, or the general practitioner, who is conversant 
 with current medical literature, of the frequent depend- 
 ence of headache of various sorts upon eye-strain. The 
 cure of headache, often of long standing, by the correc- 
 tion of errors of refraction or of heterophoria is a mat- 
 ter of every day experience with the specialist. These 
 two sources of eye-strain are so often associated that it 
 is difficult to determine their relative importance, some 
 writers attributing the greater influence to difficulty of 
 accommodation and weakness of the extrinsic muscles, 
 and others to refractive anomalies. To one or all of 
 these conditions very many cases of headache are due. 
 This fact should be borne in mind, and a thorough ex- 
 amination of the eyes should be made in all cases of 
 frequent or continuous headache where the cause for 
 the same is not evident, or where ordinary treatment is 
 not satisfactory. It has been the experience of the 
 writer that in these cases the patient frequently has 
 not been conscious of any visual defect or asthenopic 
 symptoms, yet examination has disclosed a muscular or 
 refractive error, which has been demonstrated to be the 
 cause of the headache, because correction of the former 
 has been followed by disappearance of the latter. Such 
 cases emphasize the importance of ocular investigation, 
 even in the absence of eye symptoms. 
 
 Headaches from eye-strain present a variety of 
 forms. Sub-occipital pain, suggestive of congestion of
 
 LOCAL OCULAR REFLEX NEUROSES. 167 
 
 the base of the brain, and symptoms of general cerebral 
 hyperaetnia are common ; also dull pain over the eyes 
 or behind them, or extending from the eyes to the ver- 
 tex or occiput, and neuralgic pains in and about the 
 eyes. 
 
 Hemicrania or migraine, popularly called " sick 
 headache," frequently follows over-use of the eyes. It 
 is probably an expression of general nervous exhaustion 
 from over-exertion of weak organs, and the numerous 
 visual phenomena, such as amblyopia, scotoma, hemia- 
 nopic defects, phosphenes, muscae volitantes, etc., point to 
 an irritation of the cortical visual centre. These visual 
 symptoms are so pronounced in many cases as to give 
 rise to the special classification of " ophthalmic mi- 
 graine," or " scintillating scotoma." It is characterized 
 by dazzling, luminous vibrations occurring in the right 
 or left visual field of both eyes, with more or less com- 
 plete homonymous hemianopia on the same side. The 
 reactions of the pupil are preserved, affording another 
 evidence of the cortical situation of the disturbance. 
 The attack may or may not be accompanied with pain 
 and nausea, but the absence of pain is the exception. 
 It admits of but one explanation, viz. : a vaso-motor 
 disturbance of the visual area of the cortex of the occi- 
 pital lobe on the side opposite to the affected visual 
 field. It may be a reflex ocular neurosis, but it fre- 
 quently results from other causes, and is sometimes a 
 manifestation of hysteria. Pure scintilating scotoma,
 
 168 THE EYE AS AX AID IN GENERAL DIAGNOSIS. 
 
 without fully-developed migraine, is comparatively of 
 frequent occurrence in brain workers, and is not of 
 serious import. 
 
 Visual symptoms occur in fully one-half of the 
 cases of migraine, and their existence is of importance 
 in making a differential diagnosis between the latter 
 affection and supra or infra orbital neuralgia. Photo- 
 phobia, lacrymation and conjunctivitis occur with both 
 disorders. We may have either contracted or moderately 
 dilated pupils with migraine, showing either spasm or 
 paralysis of the sympathetic. These phenomena are ab- 
 sant in pure neuralgia, and in the latter, pressure upon 
 the nerve is painful. 
 
 A severe case of migraine cured by correction of 
 compound myopic astigmatism was reported by Noyes. 
 
 Dr. O. Landman in a recent journal " attempts 
 to determine the character and behavior of headaches 
 dependent upon an uncorrected error of refraction. Ac- 
 cording to him, migraine is only rarely caused by error 
 of refraction, even when it is accompanied by this. It 
 is especially uninterrupted headache which is caused by 
 some ocular defect. It is more frequent in women than 
 in men, and may generally be localized. Uninterrupted 
 diffuse headache is usually caused by a general distur- 
 bance. If the patient complains of headache in the 
 eyes, or of pain extending from the eye-balls to the 
 head, or surrounding the eyes after work, or situated 
 behind the eye-balls, or of exasperated attacks in the
 
 LOCAL OCULAR REFLEX NEUROSES. 169 
 
 evening in general, of painful symptoms yielding to re- 
 pose, it is probable that the cause resides in the eyes. 
 The author thinks that it is refraction and not a lack 
 of equilibrium of the motor muscles of the eye which 
 produces headache. Two hundred cases of ocular head- 
 ache present the following subdivisions of localization : 
 eye-brows, 41 per cent. ; top of head, 20 per cent. ; oc- 
 cipital, 12 per cent. ; occipital frontal, 8 per cent. ; 
 temporal, 8 per cent. In a single case, the headache 
 was general. The forehead and the vertex, and the oc- 
 ciput and the vertex were each thirteen times the seat 
 of pain ; occipital headache was frequently accompanied 
 with stiffness of the nape of the neck." 
 
 Ocular vertigo may be mentioned in this connec- 
 tion, although we are discussing especially neuroses re- 
 sulting from functional ocular diseases. It is not of 
 frequent occurrence, but sometimes it is met with as a 
 reflex nervous manifestation dependent upon paralysis 
 of one or or more of the ocular muscles. When the 
 effort is made to move the eye in the direction of the 
 paralyzed muscle, diplopia and erroneous projection of 
 the visual field results, the proper relation of ob- 
 jects is lost, and vertigo occurs. The trouble is usually 
 of transient duration, for the sensorium soon learns to 
 correct the false impressions received, but its recognition 
 is important to prevent errors in prognosis, and useless 
 and perhaps injurious treatment.
 
 170 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 Insomnia and even mental aberration have been 
 ascribed to eye-strain. Baker, of San Diego, Cal., re- 
 ports in " Southern Cal. Prac." for January, 1893, a 
 case of mental derangement in a woman 46 years of 
 age which was promptly relieved by correction of 
 mixed astigmatism. Baker, of Utica, reports in " Amer- 
 ican Journal of Insanity," April, 1893, several cases of 
 " psychalgia " relieved by correcting errors of refrac- 
 tion. 
 
 Herren, of Jackson, in " Ophthalmic Record," 
 January, 1893, reports recurring attacks of sneezing 
 cured by correcting ametropia. Miles reports in the 
 " Weekly Medical Review," 1884, 107 cases of func- 
 tional nervous diseases in which there were frequent 
 sneezing, nose-bleeding, catarrhal symptoms and itching 
 and tickling sensations, which were either much re- 
 lieved or entirely cured by the wearing of suitable 
 glasses'. 
 
 Nausea is not infrequently caused by using the 
 eyes where there exists an uncorrected ametropia or 
 muscular weakness. Neuschueler reports a cure of 
 toothache by prisms. (Knies). Pains in the teeth fre- 
 quently accompany the ciliary pains of keratitis, iritis 
 and cyclitis. Cases of ocular reflexes to distant parts 
 might be multiplied, but sufficient evidence has been 
 offered to emphasize the fact, the remembrance of 
 which may be of service occasionally to the intelligent 
 and progressive physician.
 
 LOCAL OCULAR REFLEX NEUROSKS. 171 
 
 Organic affections of the eye are not without in- 
 fluence as sources of reflex phenomena, but such influ- 
 ence usually is readily recognized and does not need 
 special discussion. It is, for the most part, explained 
 by the depression, mental and physical, which is en- 
 tailed by pain and loss of sight. 
 
 One practical deduction from the preceding dis- 
 cussion is that many functional nervous affections are 
 undoubtedly dependent to a greater or less degree upon 
 eye-strain, and are relieved or radically cured by cor- 
 rection of errors of refraction and of heterophoria. Er- 
 rors of not more than .25 D. frequently cause annoy- 
 ance in persons of a sensitive nervous temperament, 
 and their correction is followed by a disappearance of 
 the symptoms. Apparently stupid and backward child- 
 ren often appear so because of defective vision. 
 
 On one occasion the writer witnessed relief fol- 
 lowing the prescription of as weak a glass as .12 D. 
 The fact that such small errors are frequently endured 
 without detriment, is no reason for always ignoring 
 them, nor does it invalidate the teaching of clinical ex- 
 perience in other cases. The same conclusions have 
 been reached in regard to sources of nerve strain in 
 other organs, considerable departure from a normal 
 standard being often endured without noticeable effect, 
 and, on the other hand, apparently insignificant disor- 
 ders being attended with serious reflex manifestations.
 
 172 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 
 
 What has been demonstrated in regard to errors 
 of refraction is also true of muscular defects. " Latent 
 exophoria or esophoria of 2 to 4 is often physiologi- 
 cal, and requires no treatment." (Maddox on Ophthalmo- 
 logical use of Prisms). Higher degrees frequently 
 diminish after wearing corrective lenses. When they 
 occasion annoyance they demand treatment either by 
 exercise, tenotomy, or by the wearing of prisms or the 
 decentration of lenses. Slight vertical deviations more 
 frequently cause neurotic symptoms than do lateral ones 
 of the same degree. I have repeatedly had gratifying 
 results from the use of a vertical prism of one-half a 
 degree. 
 
 If it could be positively determined in a given 
 case that nervous affections were caused or aggravated 
 by such ocular disorders as have been mentioned, it 
 would be of inestimable value. Such data for an abso- 
 lute diagnosis do not always exist, when pronounced 
 subjective symptoms connected with the use of the eyes 
 are not manifested. In doubtful cases rest of the eyes, 
 with or without temporary paralysis of accommoda- 
 tion or temporary use of prisms, will solve the problem 
 either by affording relief to the symptoms, or by de- 
 monstrating the existence of such pronounced errors 
 as unhesitatingly demand correction, or that even slight 
 errors are not well borne. Relief may be immediate or 
 gradual following treatment of ocular disorders, and 
 much judgment and experience is required to decide
 
 LOCAL OCULAR REFLEX NEUROSES. 173 
 
 the question of the influence of eye-strain in many ob- 
 scure cases. This factor in the aetiology and perpet- 
 uation of functional nervous affections should ever be 
 borne in mind by the ophthalmologist, the neurologist 
 and the general practitioner. 
 
 Another deduction from this discussion is that 
 examination of the eyes is of great value in the differ- 
 ential diagnosis between functional and organic nervous 
 diseases.
 
 CHAPTER VIII. 
 
 THE RELATION OF AFFECTIONS OF REMOTE ORGANS TO 
 OCULAR NEUROSES. 
 
 Functional ocular disorders due to distant and cir- 
 cumscribed foci of irritation, either functional or organic, 
 will now be considered. An inquiry into the mechan- 
 ism and paths of reflex action, both physiological and 
 pathological, will enable us to understand the subject 
 more clearly and to appreciate its discussion. 
 
 For the production of reflex action three factors 
 are necessary : first, an afferent impulse starting from 
 the periphery, second, a reflex centre, and third, an 
 efferent impulse starting from this centre and extending 
 to the part where the reflex action is manifested. Two 
 varieties of physiological reflex action are familiar, un- 
 der the designation of the skin reflex and the tendon 
 reflex. Irritation of the skin of the foot, for instance, 
 produces flexion, and a sharp blow on the patella ten- 
 don extension of the leg. In these cases the path is 
 through the cerebro-spinal nervous system to and from 
 the reflex centre of the cord. 
 
 An afferent impulse may travel upward to the 
 brain producing a sensation which again is reflected to 
 a distant part or organ. In the feeling of faintness or 
 
 (174)
 
 RELATION OF AFFECTIONS OF REMOTE ORGANS. 175 
 
 nausea from an unpleasant sight, for instance the effer- 
 ent influence is transmitted through the pneumo-gastric, 
 and in blushing, a vaso-motor influence is directed to 
 the capillaries of the face. A sensation of pain may be 
 felt in a remote locality by reflex influence emanating 
 from a diseased part, or by simple suggestion, as by con- 
 centrating the attention upon a given portion of the 
 body. 
 
 The functions of organic life are maintained 
 through the agency of the unstriped muscular fibres in 
 the viscera and blood-vessels under the control of the 
 sympathetic system. Respiration, circulation, secretion, 
 etc., are reflex acts which, as well as the general nutri- 
 tion of the body, are regulated and dominated by the 
 reflex centres in the medulla and the higher cere- 
 bral centres. While the sympathetic nerves contain 
 motor fibres in large proportion, they also transmit af- 
 ferent sensory impressions from the viscera, and the in- 
 timate connection between the cerebro-spinal and the 
 sympathetic or, as Foster calls it, the splanchnic systems 
 of nerves, permits ready transmission of impressions 
 from one system to the other. The vaso-motor nerves, 
 by which the calibre of the vessels is controlled, and 
 the blood supply regulated according to the physiologi- 
 cal requirements of nutrition, secretion and general 
 functional activity, are controlled by the vaso-motor 
 centres in the cord, and by the higher centre in the 
 medulla.
 
 176 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 Thus we see that reflex action may take place 
 through the medium of either the cerebro-spinal or the 
 sympathetic systems, singly or jointly, and may be 
 manifested as psychic, sensory, motor, vaso-motor and 
 trophic phenomena. The effect depends upon the 
 strength of the initial impression and the condition of 
 excitability of the centre. There are well-defined chan- 
 nels for the conduction of the ordinary physiological re- 
 flexes, but the structure of the central nervous system 
 permits of the transmission of the efferent impulse 
 along various paths, and we find pathological reflex ac- 
 tion to be either a diminution or increase of physiologi- 
 cal action, or a perversion of the same. There are re- 
 flex centres situated all along the spinal cord which 
 receive and transmit sensory and motor influences 
 throughout the areas supplied by the corresponding 
 spinal nerves. Similarly, there are sympathetic ganglia 
 on either side of the spine, along its whole extent, an- 
 astomosing freely with all the spinal nerves. The 
 spinal reflex centres communicate freely by anastomos- 
 ing fibres, and, as has been mentioned, are connected 
 with the higher reflex centre of the medulla, and con- 
 trolled by it. The latter probably is influenced by still 
 higher cerebral centres, the exact location of which has 
 not been definitely determined. This is rendered prob- 
 able by the reflex disturbances following psychical im- 
 pressions of fear, surprise, disgust, pain, etc. The spinal 
 sympathetic ganglia are continued upwards into the
 
 RELATION OP AFFECTIONS OF REMOTE ORGANS. 177 
 
 cranial cavity, and through the cervical, carotid, Gas- 
 serian, ophthalmic, otic, and spheno-palatine ganglia, are 
 in communication with the cranial nerves. 
 
 Thus we find an unbroken nervous chain extend- 
 ing all over the body to its remotest parts, with free 
 anastomoses between the different systems of nerves. 
 Any sensitive surface, under pathological conditions, 
 may give rise to reflex action of the most diverse 
 kinds, and the location and nature of such disturbances 
 is determined by the strength of the initial impression 
 and by the condition of the reflex centres, the direction 
 of the efferent impulse being along the " lines of least 
 resistance." Suppose, for instance, an impression is re- 
 ceived from a diseased point at a given spinal centre. 
 The latter has numerous communicating lines in the 
 direction of the sympathetic and also in the direction 
 of other spinal centres. If the first centre is in normal 
 condition, no efferent influence is excited to be transmit- 
 ted along the nerves with which it is in special relation. 
 The sensory influence is continued along one of the 
 many anastomosing branches, and from centre to centre. 
 Sooner or later, an unusually excitable centre is reached, 
 or one having organs or tissues under its control which 
 are in a condition of lowered vitality, or are morbidly 
 impressionable. The deleterious influence is then mani- 
 fested in one of the ways referred to, when under 
 strictly physiological conditions it would still be inop- 
 erative. A lessened or exaggerated vaso-motor control 
 12
 
 178 THE EYE AS AN AID IX GENERAL DIAGNOSIS. 
 
 by the central ganglia may be the determining factor, 
 and vaso-motor paralysis or spasm in the part finally 
 reached will cause hyperaemia or anaemia, developing, 
 if unchecked, into inflammation with exudation and 
 perhaps a neoplastic growth, or causing exaggerated, di- 
 minished or perverted function. Reflex neuroses usually 
 are vascular at first, and due to vaso-motor disturbances 
 which induce, secondarily, functional and organic 
 changes. 
 
 On the other hand, spasm or paralysis of volun- 
 tary muscular fibre may result through transmission of 
 the impulse along a motor nerve of the cerebro-spinal 
 system, or only a painful sensation may be experienced 
 in consequence of a remote excitation. 
 
 Thus we understand how peripheral irritation 
 from almost any point may reach the eye, and a knowl- 
 edge of this fact may sometimes enable us to unravel a 
 difficult case, and to find a remedy for a functional eye 
 trouble through treatment intelligently directed to the 
 original cause of the disorder. Here great care and dis- 
 crimination is necessary to avoid confounding mere coin- 
 cidence with cause and effect. The eye symptoms and 
 the symptoms of the distant parts may both result 
 directly from the same cause. Let us first examine 
 some of the physiological ocular reflexes, and then inquire 
 what are some of the functional disturbances of the eye 
 which are recognized as due to reflex influences, and 
 what pathological conditions have been demonstrated 
 to occasion them.
 
 RELATION OF AFFECTIONS OF REMOTE ORGANS. 179 
 
 PHYSIOLOGICAL OCULAR REFLEXES. 
 
 The contraction of the pupil upon the stimulus 
 of the light and its dilatation following irritation of 
 the skin are examples of physiological reflex action. 
 In the former case the stimulation of the retina is con- 
 veyed to the habenular ganglion or the anterior tuber- 
 cula quadrigemina, and thence an efferent motor influ- 
 ence is sent along the motor oculi. In the latter the 
 peripheral sensory nerves convey the impression through 
 the spinal cord to the corpora quadrigemina, and thence 
 the motor influence travels down the upper cervical 
 cord and along the cervical sympathetic to the carotid, 
 the cavernous and the ophthalmic ganglia, and through 
 the ciliary nerves to the iris. Winking and lachryma- 
 tion from irritation of the conjunctiva or cornea are 
 also reflex acts for the protection of the eye. 
 
 Pathological reflexes, or ocular neuroses, are very 
 numerous and varied, and are of similar nature to those 
 already enumerated in the discussion of general func- 
 tional nervous diseases. 
 
 Numerous organic diseases are sometimes of re- 
 flex origin, but in the present discussion our attention 
 will be confined to purely functional disturbances. It 
 is not desirable to consider these various neuroses in 
 detail, but a brief enumeration of the more frequent 
 manifestations of reflex irritation may be helpful in pre- 
 venting errors in diagnosis.
 
 180 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 Where neurasthenia and hysteria could be ex- 
 cluded, the following conditions have been recorded 
 by trustworthy observers, as caused directly by reflex 
 influences emanating from distant foci of irritatiom 
 and cured by their removal : pain of various kinds 
 in and about the eye, photophobia, lachrymation, nicti- 
 tation, ptosis, lagophthalinus, temporary strabismus, my- 
 osis, mydriasis, anaemia and hyperaemia of the fundus 
 from vaso-motor spasm or paresis, muscae volitantes, 
 diplopia, amblyopia, scotomata and concentric contraction 
 of the visual fields. 
 
 Nasal and dental reflexes are the most frequent, 
 and when we consider the intimate nervous anastomoses 
 between the nose and teeth and the eye, we are not 
 surprised that such is the case. "The spheno-palatine 
 ganglion sends branches to the nasal mucosa, and is in 
 direct communication with the Gasserian ganglion at 
 the sensory root of the trigeminus. The otic, ophthal- 
 mic, maxillary and superior and inferior dental ganglia 
 are united in common through the sympathetic, giving 
 a rich field of nervous network, in any part of which, 
 transmission of any irritation sufficient to disturb its 
 normal physiological functions could produce neurotic 
 phenomena." 
 
 The intimate relation between the eye and the 
 nose is shown by the physiological reflex actions of lach- 
 rymation following irritation of the nose, and of sneez- 
 ing attending irritation of the retina by strong light.
 
 RELATION OF AFFECTIONS OP REMOTE ORGANS. 181 
 
 Various nasal conditions have caused ocular neuroses by 
 reflex action. A distinction must be made between 
 such functional neuroses and affections due to extension 
 of inflammation, or to the absorption of septic material 
 by the blood vessels or lympathics. Certain inflamma- 
 tory conditions of the structure of the eye are also at 
 times of reflex origin from nasal diseases, but the defini- 
 tion of the term neuroses, as accepted in this treatise, 
 precludes their discussion. 
 
 Various authors have reported ocular affections, 
 such as those enumerated, associated with the following 
 nasal disorders, viz. : polypi, hypertrophy of the turbi- 
 nateds, abnormalities of the septum, and inflammation of 
 the maxillary, sphenoidal and ethmoidal sinuses, which 
 were cured by treatment of such conditions by galvano- 
 cautery and operations with the saw and snare. 
 
 The following cases reported by Dr. T. M. Stew- 
 art, of Cincinnati, in the " Eye, Ear and Throat Jour- 
 nal," are cited by way of illustration : 
 
 CASE FIRST. " Mrs. B. applied for treatment, 
 giving a history of constant dull aching in the left eye, 
 gradually growing worse during the past three years. 
 Glasses had been worn without relief. Aching in eye 
 made worse during each attack of rhinitis, which at- 
 tacks were frequent and caused by the least exposure. 
 The left inferior meatus was quite patulous, but the 
 middle turbinated body was swollen to the extent of 
 touching the septum, and proved to be a genuine hy-
 
 182 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 pertrophy. Reduction of the enlarged turbinated \vas 
 followed by some relief, but not of sufficient amount to 
 call the case cured. At a later visit upon deep explor- 
 ation with a probe, we found an osseous spur on the 
 septum pressing against the middle turbinated body. 
 This growth was unsuspected and entirely hidden until 
 after reduction of the enlarged middle turbinated. The 
 growth was operated with the trephine, and no return 
 of the headache and eyeache was noted for a period of 
 three months. Re-examination showed a fibrous band 
 of union between the cut surface on the septum and 
 the middle turbinated. This was cut away and a dress- 
 ing of borated gauze placed between the opposing sur- 
 faces. After it was removed and the parts healed, we 
 again had the satisfaction of noting the disappearance 
 of the head pains. Later the case presented itself at 
 the clinic, with the report that for five months no 
 return had been noted of the head pains. Previously 
 to reporting the case here, inquiry was made by mail, 
 and now sixteen months have passed with no return of 
 the trouble." 
 
 CASE SECOND. " Deep seated pain in the eyes 
 on reading or sewing for even a few moments in a wo- 
 man aged thirty-five years. Complains of pressure over 
 the bridge of the nose and on top of the head. Catch- 
 ing cold would send streaks of pain from the bridge of 
 the nose to the seat of the steady pressure on top of 
 the head. Condition had existed for over two years.
 
 RELATION OF AFFECTIONS OF REMOTE ORGANS. 183 
 
 " We found comparatively free breathing space, 
 but both middle turbinateds were enlarged anteriorly, 
 crowding the outer walls and the septum. Removal of 
 the enlarged turbinateds by the forceps stopped the pres- 
 sure on top of the head, but some pain on use of the 
 eyes continued. Deep exploration revealed an osseous 
 growth on the septum, and an adhesion to it of the 
 posterior part of the middle turbinated. Removal of the 
 growth and division of the adhesion cured the case, in 
 that ten months have elapsed with no return of the 
 symptoms." 
 
 Browne, in " Diseases of the Nose and Throat," 
 reports a case of glaucoma cured by removal of a nasal 
 polypus after iridectomy had failed to relieve. Goitre 
 and Basedow's disease have been cured by the same 
 means. 
 
 It is also worthy of note, both as confirming the 
 causal relation of nasal and ocular affections, and as a 
 warning to inexperienced operators, that similar ocular 
 affections have followed operations on the nose. 
 
 A case in point occurred recently in my own 
 practice. I removed an enchondroma from the right 
 side of the septum. Vision in the eye on the same side 
 declined from yf to |^, without ophthalmoscopic changes 
 in the interior of the eye, and with no other apparent 
 cause. The impairment of vision lasted for two months 
 and again became normal.
 
 184 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 Musehold cured a case of exophthalmic goitre by 
 removal of a hyperplastic growth of the inferior turbi- 
 nated, and he reports five similar cases from the 
 " Deutsche Medicinische Wochenschrift" Feb., 1892. He 
 considers the disease a vaso-dilator neurosis. (Dr. White, 
 of Richmond, in the discussion of nasal neuroses in 
 Burnett's " Treatise on Diseases of Ear, Nose and 
 Throat "). 
 
 Trousseau claims to have cured two cases of 
 blepharospasm, one of obstinate scotoma scintallans, one 
 of mydriasis and three obstinate asthenopias by treatment 
 of the nasal mucus membrane. Ziern reports a case of 
 contraction of the visual field cured by restoring the 
 outflow from the antrum of Highmore. 
 
 There seems to be some evidence that glaucoma 
 is, at least in some instances, of reflex origin through 
 the sympathetic nerves. Irritation of the sympathetic 
 causes increased ocular tension, while its section causes 
 diminished tension. The same results follow irritation 
 or paralysis of the fifth nerve by communication with 
 the sympathetic through the ciliary ganglion. On first 
 thought one would expect to find minus tension fol- 
 lowing stimulation of the sympathetic, and the reverse 
 when it is paralyzed. The explanation lies probably in 
 a stimulation of the vaso-dilator fibres which attends re- 
 flex action. Noyes remarks that " neuralgia of the fifth 
 nerve is potential, and nervous strain is a provocation 
 of glaucoma." Ziem claims to have secured temporary
 
 RELATION OF AFFECTIONS OF REMOTE ORGANS. 185 
 
 enlargement of the field in chronic glaucoma by gal- 
 vano-cautery of the nasal mucous membrane, and Len- 
 nox Browne reports a case of glaucoma rapidly cured 
 by removal of a nasal polypus. 
 
 The relation of dental affections, especially caries, 
 to ocular neuroses is substantiated by the record of 
 more numerous cures following treatment of the teeth 
 than in the case of nasal reflexes. Amblyopia and 
 amaiirosis have been reported several times in such 
 connection. Neuralgic toothache is sometimes a pro- 
 dromal stage of glaucoma. Sous, in the " Journal de 
 Medicine de Bordeaux" Nov. 20, 1893, reports the follow- 
 ing case : "A young woman, twenty-one years of age, 
 of a lymphatic constitution, but in perfect health, 
 had vision reduced to y 1 ^ and amplitude of accommoda- 
 tion much reduced. Both conditions returned to nor- 
 mal after a dental condition was cared for. He ex- 
 plained the case by reflex action of the superior max- 
 illary division of the fifth nerve upon the ophthalmic 
 branch of Willis." 
 
 Reflexes from the outer and middle ear to the 
 eye are occasionally noted. Blepharospasm is the most 
 frequent variety. 
 
 The influence of helminthiasis and sexual disor- 
 ders in both males and females is frequent and needs 
 no comment. Androgsky, of St. Petersburg, reports in 
 Zehender's " Klinische Monats blatter fur Augenheilkunde" 
 Stuttgart, Vol. 32, p. 263, 1894, two cases of chronic
 
 186 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 spasm of the orbictilaris muscle produced by the pres- 
 ence of tape-worm in the alimentary canal. Functional 
 uterine affections are more influential in this direction 
 than organic. 
 
 The foregoing discussion emphasizes the depend- 
 ence of certain functional eye troubles upon reflex ac- 
 "tion emanating from distant sources of irritation. In 
 the absence of functional or organic constitutional dis- 
 ease which would offer a probable explanation of such 
 existing eye symptoms, and when no satisfactory cause 
 for them is found in the eye or its appendages, and yet 
 they do not yield to appropriate treatment, then a reflex 
 origin is to be sought in the nose, the teeth, the ear, 
 or in the digestive and sexual systems.
 
 PART THIRD. 
 
 OCULAR AFFECTIONS OF TOXIC ORIGIN. 
 
 (187)
 
 CHAPTER IX. 
 
 TOXIC AMBLYOPIA. CHRONIC RETRO-BULBAR NEURITIS. 
 
 Certain drugs, when administered internally, ex- 
 ternally or hypodermically, are capable of causing ocu- 
 lar symptoms which may or may not be of serious im- 
 port, but which it is important to recognize. They 
 advise the observant physician that a remedy is not 
 well borne, or that the patient possesses a peculiar sus- 
 ceptibility to it. A knowledge of these occasional 
 occurrences is a check upon the injudicious and careless 
 employment of such remedies, or when such drug effects 
 are simply annoying and not dangerous, their recogni- 
 tion enables the physician to quiet unnecessary appre- 
 hension on the part of the patient or friends. Many 
 poisons produce characteristic eye symptoms which are 
 an important aid in the diagnosis of the substance 
 which has been administered by accident or design, 
 and thus may be not only a guide to treatment, but 
 of prime importance in a medico-legal aspect. Again 
 the existence of certain eye symptoms sometimes affords 
 an explanation of obscure conditions in other parts of 
 the body due to toxic influences hitherto unsuspected. 
 Certain articles of food and drink, if improperly pre- 
 pared, or when taken immoderately, or where a per- 
 
 (189)
 
 190 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 sonal idiosyncracy exists, cause a condition of toxaemia 
 which gives rise to ocular symptoms, the explanation 
 of which is important, both as regards diagnosis and 
 treatment. The same may be said of ptomaine poison- 
 ing. Certain avocations require the use of noxious sub- 
 stances which affect the eye or the vision, and their 
 recognition is also important. It is not my purpose in 
 the present discussion to enumerate every recorded toxic 
 symptom that has been observed in the department of 
 ophthalmology, but only those of diagnostic importance 
 either as determining the cause and nature of the ocu- 
 lar manifestations, or as an aid in the diagnosis of 
 constitutional disorders. Only those affections which 
 are directly of toxic origin will be considered Those 
 due to uraemia or occurring in the course of diabetes, 
 although in reality of a toxic nature, or those which 
 are the indirect result of poisons which induce vascular 
 changes, such as occur in chronic alcoholism or those 
 consecutive to cerebral or spinal or cardiac lesions will 
 not be discussed here. The reader is referred to other 
 portions of this work for a consideration of such affect- 
 ions. The present topic may be classified as follows : 
 
 I. Toxic AMBLYOPIA. By this term is ordinarily 
 understood the disturbances of vision caused by the in- 
 ordinate use of tobacco and alcohol. I shall also con- 
 sider under this head similar disturbances of vision 
 caused by various other substances.
 
 TOXIC AMBLYOPIA. 191 
 
 II. OCULAR AFFECTIONS FOLLOWING THE EM- 
 PLOYMENT OF VARIOUS THERAPEUTIC AGENTS. 
 
 III. THE EFFECTS OF NON-MEDICINAL POISON- 
 OUS SUBSTANCES AND THOSE ATTENDING CERTAIN 
 AVOCATIONS. 
 
 IV. OCULAR AFFECTIONS DUE TO Toxic SUB- 
 STANCES CONTAINED IN CERTAIN ARTICLES OF FOOD 
 AND DRINK: a. FUNGUS POISONING; b. PTOMAINE 
 POISONING. 
 
 V. OCULAR CONDITIONS DURING AND FOLLOW- 
 ING ANAESTHESIA. 
 
 I. Toxic AMBLYOPIA. 
 
 A. TOBACCO AND ALCOHOL AMBLYOPIA. 
 
 Each of these agents causes a disturbance of 
 vision with nearly identical symptoms and they are, 
 therefore, mentioned together. As will be indicated 
 later there are slight differences in their manifestations, 
 but the essential phenomena from which the diagnosis 
 of the affection is made are the same. Usually both 
 agents are factors in producing the disease, but either 
 alone has occasioned it. Long continued and excessive 
 indulgence in either alcohol or tobacco is necessary for 
 its development. It seldom occurs in persons under 
 thirty-five years of age, and it is usually older individ- 
 uals with impaired nutrition who are thus affected. 
 Much depends also upon the quality of the liquor and 
 the tobacco used. There is more fusel oil in poor
 
 192 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 whiskey, and more nicotine in the inferior and cheaper 
 grades of tobacco, than in the more expensive varieties. 
 Hence we find more cases of toxic amblyopia among 
 the poorer classes. 
 
 Berry in " Trans. Oph. Soc. United Kingdom," 
 Vol. VII, p. 91, estimates the amount of tobacco which 
 causes amblyopia as from one ounce to half a pound or 
 more weekly. The effect depends somewhat upon the 
 manner of using tobacco. Smoking when the stomach 
 is empty, and inhaling the smoke whereby it comes in 
 contact with a large absorbing mucous surface, is espe- 
 cially injurious. Personal idiosyncrasy is also a very 
 important factor influencing the development of toxic 
 symptoms. 
 
 As most habitual drinkers also use tobacco it is 
 difficult in most cases to determine the relative import- 
 ance of each. In France the greater influence is 
 assigned by many writers to alcohol, but most authori- 
 ties consider tobacco as responsible for the larger num- 
 ber of cases of toxic amblyopia. 
 
 Among Orientals, where the use of the weed is 
 almost universal, visual disturbance as a result is very 
 infrequent. This immunity is ascribed to the mildness 
 of the tobacco and to the way in which it is used. 
 De Schweinitz says (' ; Toxic Ainblyopias," 1896) " Turks 
 while smoking cigarettes, are particular that no tobacco 
 shall come in contact with the buccal mucous mem- 
 brane, and, although they inhale the smoke vigorously,
 
 TOXIC AMBLYOPIA. 193 
 
 they are not poisoned, because, according to Von Milli- 
 gen, tobacco poisoning (and hence amblyopia) is possible 
 only when nicotine in solution is brought in contact 
 with the mucous membrane of the mouth and swal- 
 lowed." 
 
 Smoking is more harmful than chewing, but 
 Noyes, in his " Diseases of the Eye," p. 683, asserts 
 that he has observed the disease as a result of chewing 
 alone. Cases are also on record where it has been 
 caused by the practice of "dipping" or rubbing snuff 
 upon the gums. 
 
 In a tabulated report of 204 cases of retro-bulbar 
 neuritis (the pathological condition which obtains in 
 toxic amblyopia) he found 64 to be the result of alco- 
 hol, 23 the result of tobacco, and 45 were attributed to 
 the combined influence of the two, so that more than 
 one-half of the whole number resulted from one or both 
 of these agents. 
 
 Uhthoff (see Graefe's Archive, Bd. XXXII, et al.) 
 examined 1000 cases of alcoholic excess, in which he 
 found 6 per cent, of amblyopia, and other 6.5 per cent, 
 exhibiting the lesion of the optic nerve which is char- 
 acteristic of toxic amblyopia, but in which the visual 
 symptoms had not developed. 
 
 In the " Quarterly Journal of Inebriety," for 
 
 Jan., 1893, Dowling, of Cincinnati, publishes a report of 
 
 an examination of 150 employees in a tobacco factory, 
 
 among whom 45 exhibited more or less evidence of 
 
 13
 
 194 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 tobacco amblyopia. He thinks the inhalation of tobacco 
 dust is capable of producing the disease. 
 
 It does not require expert skill or long experi- 
 ence to diagnose the affection. The ophthalmoscopic 
 symptoms are absent or trivial until a late stage, hence 
 the diagnosis is made from the subjective symptoms. 
 
 There is an acute, non-toxic form of retro-bulbar 
 neuritis resulting from severe exertion, sudden chilling 
 of the body, suppression of menstruation, rheumatism, 
 syphilis or lead poisoning, or sometimes accompanying 
 infectious diseases, especially measles, angina and influ- 
 enza. In these cases it is evident that a condition of 
 toxaemia underlies and causes the amblyopia, but not in 
 the sense of the present discussion. These cases are 
 sudden in development, and are accompanied with more 
 or less pain in and around the eyes. The loss of vis- 
 ion may be complete, while this has very rarely been 
 recorded in the case of tobacco or alcohol amblyopia. 
 The acute form is more often unilateral, while the 
 chronic toxic form is very rarely limited to one eye. 
 
 Dr. d'Oench, of New York, reported a case of 
 toxic amblyopia due apparently to the abuse of alcohol 
 and tobacco, in which within the short space of twelve 
 hours, vision was reduced from the normal standard to 
 the ability only to count fingers at two feet distance 
 from the eye. (See "N. Y. Med. Record," July 14, 
 1894).
 
 TOXIC AMBLYOPIA. 195 
 
 The patient usually exhibits a gradual failure of 
 central vision constituting a central scotoma, a hiatus 
 or black spot in the centre of the visual field, while the 
 peripheral vision remains unimpaired. At first the vis- 
 ion for color fails, red and green are not as bright as 
 formerly, and later are not recognized at all. Soon the 
 perception of blue and yellow fails, and later, not even 
 the form of objects is recognized, and a perfect blank 
 in the centre of the visual field is left. The patient 
 sees nothing directly in the line of vision, although ob- 
 jects at one side are seen with the usual distinctness. 
 He, therefore, cannot see to read or write, or if the 
 scotoma is not too large, the middle of a sentence or, 
 perhaps, of a word is lost, while the two ends of the 
 line are seen imperfectly. It is very rare for periph- 
 eral vision to be lost, so that complete blindness is not 
 to be feared. Usually both eyes are equally affected. 
 Patients often complain of an annoying sense of daz- 
 zling when in a bright light, and this may be the first 
 symptom for which the individual consults the physi- 
 cian. Owing to this circumstance, the patient declares 
 that he sees better in a dim light, and in some in- 
 stances this is true to a limited extent, although, as a 
 rule, the improvement is more imaginary than real. 
 
 PATHOLOGY. The pathological basis of this con- 
 dition is an atrophy of the bundle of fibres in the optic 
 nerve which supplies the macula lutea and its imme- 
 diate vicinity. This atrophy is the result of a slow and
 
 196 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 slight interstitial neuritis, but the acute variety of re- 
 tro-bulbar neuritis is designated as inflammatory, in dis- 
 tinction from the chronic toxic form in which there is 
 no pain or other manifest signs of inflammation. 
 
 The situation of this atrophy is at first in the 
 portion of the nerve lying in the optic canal, that is, 
 behind the eyeball and in front of the chiasrn, as its 
 name implies. As the disease progresses, the atrophic 
 process extends downward until it becomes evident at 
 the optic disc, by ophthalmoscopic examination, at its 
 lower temporal side, for it is at this point that the 
 bundle of fibres designated enters the eyeball. The 
 selection of this special bundle of fibres by these poi- 
 sonous agents is an interesting and hitherto unexplained 
 fact. It is not invariable, for cases have been reported 
 where the peripheral fibres were affected, leaving the 
 macular bundles intact, in which case, of course, the 
 peripheral vision would be lost and central vision be 
 retained. This, however, is of very exceptional occur- 
 rence, and is not pathognomonic of tobacco or alcohol 
 amblyopia. There is no noticeable change in the ap- 
 pearance of the vessels of the disc or retina. 
 
 DIFFERENTIAL DIAGNOSIS BETWEEN TOBACCO AND 
 ALCOHOL AMBLVOPIA. 
 
 In alcohol poisoning the scotoma is central and 
 always includes the point of fixation, but with tobacco 
 the scotoma is very near but not at the point of fixa- 
 tion. This is probably not invariably the case. In
 
 TOXIC AMBLYOPIA. 
 
 197 
 
 tobacco amblyopia the scotoma is usually of an oval 
 shape, with the long horizontal diameter extending be- 
 tween the point of fixation and the blind spot. 
 
 The following charts of tobacco and alcohol sco- 
 tomas are taken from de Schweinitz's " Toxic Ambly- 
 opia." 
 
 Tobacco Amblyopia ; absolute central scotomas ; peripheral 
 boundaries of field normal in extent. 
 
 Typical oval scotomas from a case of tobacco amblyopia. 
 The patient, aged sixty, had smoked five pipes of tobacco daily and 
 an occasional cigar since he was nineteen ; a moderate beer drinker.
 
 198 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 With tobacco the amblyopia is oftener unilateral 
 or differing in degree in the two eyes. With alcohol 
 the pupil is dilated and the accommodation weak, while 
 with tobacco we find a contracted pupil and spasm of 
 accommodation. Paresis of accommodation may be one 
 of the first disorders of vision of chronic inebriety, and 
 should serve as a warning not to be disregarded. 
 
 The alcoholic form of the disease develops rather 
 more rapidly than that due to tobacco, and the latter is 
 less amenable to treatment. 
 
 In this connection certain other ocular phenom- 
 ena accompanying intoxication with alcohol are worthy 
 of mention, viz. : 
 
 Marked concentric narrowing of the visual field 
 and diplopia. 
 
 Sudden blindness with merely quantitative per- 
 ception of light, associated with dilated and irresponsive 
 pupils, and with absence of any abnormal conditions of 
 the fundus as seen with the ophthalmoscope, has been 
 observed in acute alcoholism. 
 
 The differential diagnosis between true tabes 
 and the simulation of that disease resulting from chronic 
 alcoholism is aided by remembering that myosis is ab- 
 sent in the latter condition. Other symptoms of the 
 real affection are also absent, but it is not the province 
 of this treatise to discuss them.
 
 TOXIC AMBLYOPIA. 199 
 
 B. RETRO-BULBAR NEURITIS DUE TO OTHER POISONS. 
 
 Toxic amblyopia with central scotoma has also 
 been caused by the following substances, viz. : 
 
 STRAMONIUM. Fuchs reports a case caused by 
 smoking stramonium leaves for the relief of asthma. See 
 Fuchs' " Text-book of Ophthalmology," p. 441. 
 
 BISULPHIDE OF CARBON, SULPHUR CHLORIDE, 
 LEAD, AND PERHAPS CHLORAL. Juler asserts that ex- 
 cessive TEA drinkers are predisposed to this disease and 
 OPIUM, it is alleged, has also caused it. 
 
 ARSENIC has produced a form of retro-bulbar 
 neuritis, and so has CANNABIS INDICA. 
 
 Hirschberg reported a typical case of toxic am- 
 blyopia with central scotoma and without ophthalmo- 
 scopic changes occurring in a girl of sixteen, upon whom 
 IODOFORM was being used locally after a resection of 
 the hip. A similar result was observed by Hutchinson 
 during the internal administration of the drug in com- 
 bination with CREOSOTE. This fact should be borne in 
 mind, that the first indication of such poisonous influ- 
 ence may be recognized, in view of the extensive use 
 of this drug as a topical application.
 
 CHAPTER X. 
 
 OCULAR AFFECTIONS CAUSED BY VARIOUS THERAPEUTIC 
 
 AGENTS. 
 
 Various drugs in addition to those already men- 
 tioned sometimes produce toxic symptoms, such as im- 
 paired vision, pupillary phenomena, disturbances of ac- 
 commodation and of motility, and even organic lesions 
 of various structures of the eye which it is desirable to 
 consider. 
 
 A. DISORDERS OF VISION. 
 
 QUININE AMAUROSIS. Quinine produces a dis- 
 turbance of vision exactly the reverse of that which 
 has been described as due to the influence of tobacco 
 and alcohol, viz. : a condition sometimes designated as 
 telescopic vision. The periphery of the visual field is 
 lost, and vision is restricted to a very narrow area in 
 the centre, frequently of an elliptical shape with the 
 long axis horizontal. The following charts illustrate 
 the condition. They are taken from de Schweinitz. 
 The shaded areas represent the limits of the field. 
 
 Usually there is, at first, more or less loss of 
 central vision which sometimes amounts to complete 
 blindness. Therefore we speak of quinine amaurosis in- 
 
 (200)
 
 OCULAR AFFECTIONS CAUSED BY DRUGS. 
 
 201 
 
 stead of amblyopia, by which latter expression we desig- 
 nate the slighter impairment of sight which results 
 from the influence of tobacco and alcohol. 
 
 The amaurosis lasts from a few hours to several 
 weeks. Many cases completely recover. In many others 
 the peripheral vision remains permanently impaired, and 
 in a few there is but slight improvement of central 
 vision. This was true in a case that came under my 
 
 E.E. 
 
 Visual fields in a case of quinine amaurosis three months after 
 recovery from complete blindness. 
 
 own observation. In addition to the visual symptoms 
 mentioned there may be hallucinations of sight, mydri- 
 asis, impaired accommodation, anaesthesia of the cornea, 
 nystagmus, divergent strabismus and slight exophthal- 
 mus. 
 
 The amblyopia develops suddenly. Noyes says 
 that it is always the result of large doses, and usually 
 of repeated large doses, and that no cases have been
 
 202 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 recorded where it resulted from small or even moderate 
 doses. He does not define what he means by small or 
 moderate but mentions one case that developed after 
 taking four hundred and eighty grains in the course 
 of twenty-four hours. 
 
 The inaccuracy of his assertion is demonstrated 
 by a case reported by Pischl, of San Francisco, in the 
 "Medical News" for July 20, 1893. Only thirty grains 
 were taken during twenty-four hours. While central 
 vision was but slightly affected, the fields were con- 
 tracted to 5. It will be remembered that the natural 
 limits are from 45to 90, varying in different direc- 
 tions, being limited upward and toward the median side 
 by the projection of the brows and the bridge of the 
 nose (see chart of normal field, p. 115). After five 
 weeks' treatment there was only partial recovery. 
 
 Cases of amblyopia have also been reported fol- 
 lowing the exhibition of fifteen, twelve, and even a 
 fewer number of grains in twenty-four hours. The 
 effect depends largely upon individual idiosyncrasy, and 
 persons of a neurotic temperament are more susceptible 
 to its toxic influence. Such cases as those to which al- 
 lusion has been made ought certainly to teach caution 
 in the use of the remedy, and it is important to remem- 
 ber that a person who has once suffered from quinine 
 amaurosis is afterward much more susceptible to the 
 toxic influence of the drug. Other alkaloids of cin- 
 chona, especially cinchonine and cinchonidine, occasion-
 
 OCULAR AFFECTIONS CAUSED BY DRUGS. 203 
 
 ally have the same effect upon vision, and it has fol- 
 lowed the use of the tincture. 
 
 Claiborne, of New York, in the " Medical Rec- 
 ord " for August 14, 1894, formulates his conclusions in 
 regard to quinine amaurosis as follows : 
 
 " i. Quinine in toxic doses may produce blind- 
 ness. 
 
 2. The duration of the amaurosis varies greatly. 
 
 3. The toxic dose is distinctly indeterminate. 
 
 4. The field of vision remains contracted. 
 
 5. Central vision usually returns to normal. 
 
 6. There is color blindness at first, color percep- 
 tion being ultimately restored in the central field. 
 
 7. The ophthalmological picture is that of white 
 atrophy. 
 
 8. Experiments upon dogs show that there is 
 atrophy of the entire optic tract. 
 
 9. The same experiments show that the cells of 
 the cuneus are probably not affected. 
 
 10. Treatment is of no avail." 
 
 PATHOLOGY. The ophthalmoscope shows a con- 
 dition of ischaernia of the retina, which affords an ex- 
 planation of the visual symptoms by the occurrence of 
 sudden arterial spasm. Both veins and arteries are very 
 much contracted. There are, as a rule, no ophthalmo- 
 scopic evidences of inflammation or exudation. Knies 
 says that a slight exudation may occur in the macula 
 lutea producing a cherry-red spot, very similar to the
 
 204 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 appearance found in embolism of the central retinal 
 artery. The optic discs appear paler, but their outlines 
 are sharply defined. 
 
 De Schweinitz in the " Transactions of the Amer- 
 ican Ophthalmological Society," for 1891, p. 23, says : 
 " The original effect is upon the vaso-motor centres, pro- 
 ducing constriction of the vessels ; finally changes in 
 the vessels themselves are set up, owing perhaps to 
 endo-vasculitis. Thrombosis may occur, and the result 
 of all these is an extensive atrophy of the visual tract." 
 
 The amblyopia from quinine is usually associated 
 with sudden deafness, but curiously enough, the latter 
 effect has usually been attributed to hyperaemia instead 
 of anaemia. In this connection the remarks of the edi- 
 tor of the translation of Gruber's work on diseases of 
 the ear in the second American edition are worthy of 
 mention. He says : 
 
 " Brunner calls attention to the contradiction ex- 
 isting between the statements of aural and ophthalmic 
 surgeons concerning the effects of quinine. According 
 to Kirchner and Roosa, large doses produce hyperaemia 
 and extravasation of blood ; while ophthalmologists state 
 that it produces marked anaemia of all the retinal ves- 
 sels. It must, however, be mentioned that in the expe- 
 riments made by Gruber under Weber Liel's supervision, 
 the temperature in the external auditory canal dimin- 
 ished after its employment, and hyperaemia of the canal 
 or of the vessels of the malleus was never observed.
 
 OCULAR AFFECTIONS CAUSED BY DRUGS. 205 
 
 Similar results were obtained with salicylate of soda. 
 The mitigation of auditory vertigo following its admin- 
 istration would in this way be explained by ischaemia 
 of the labyrinthine vessels." 
 
 SALICYLATE OF SODA is said to produce visual 
 symptoms similar to those which have been mentioned 
 as a result of quinine. Complete blindness has been 
 observed after taking eight grammes within a space of 
 ten hours. It was associated with marked mydriasis and 
 with normal ophthalmoscopic appearances. The retinal 
 veins were well filled. After ten hours the patient 
 could count fingers, and vision was completely restored 
 in twenty-four hours. (E. Gatti in u Gaz. degli Ospital" 
 1880-1, p. 4). 
 
 CAFFEIN. Hutchinson (in the " Centralblatt fur 
 Augenheilkunde" Aug., 1887, p. 240) claims to have seen 
 amblyopia closely resembling quinine amblyopia result- 
 ing from caffein. 
 
 ERGOTINE also produces ischaemia of the retina 
 with consequent impairment of vision, by reason of its 
 well-known effect upon the blood vessels. The possibil- 
 ity of such a result should be remembered when pre- 
 scribing this drug for the cure of uterine neyomata, 
 etc., especially when a disposition to such a condition 
 already exists. 
 
 Among other drugs which produce more or less 
 impairment of vision may be mentioned the following :
 
 206 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 OSMIC ACID causes great and sudden but tempo- 
 rary amblyopia, with loss of the faculty of accommoda- 
 tion, and with no ophthalmoscopic changes in the retina 
 or optic nerve. 
 
 ANTIPYRIN. Blindness lasting one minute was 
 reported after a dose of 15 grains. De Schweinitz re- 
 ports the following visual disturbances noted by himself 
 after taking large doses of the drug, viz. : " undulations 
 in the atmosphere, something like those caused by the 
 ascent of heated air, followed by an apparent shower of 
 sparkling points of light ; phenomena, in other words, 
 which are the frequent prodromes of migraine." 
 
 BROMIDE OF POTASH has produced sudden loss 
 of sight with pallor of the optic disc and narrow ves- 
 sels. 
 
 CANNABIS INDICA, or hashish, frequently causes 
 toxic amblyopia with symptoms resembling those occa- 
 sioned by tobacco and alcohol. Unlike those substances, 
 its effects are often unilateral, and there may be simply 
 a scotoma without color disturbance. The visual symp- 
 toms may be associated with mydriasis or myosis, and 
 disturbance of the accommodation. 
 
 CARBOLIC ACID produced complete blindness last- 
 ing two days in a man, after washing out the pleural 
 sac with 100 grammes of a 3 per cent, solution (see 
 "Berlin-Klin. Wochensehr." 1882, XIX, p. 748). It 
 causes also sluggish pupils which may be either dilated 
 or contracted, and without ophthalmoscopic changes.
 
 OCULAR AFFECTIONS CAUSED BY DRUGS. 207 
 
 COCAINE has produced amblyopia. Glaucoma has 
 resulted from its protracted application to the nasal 
 mucous membrane. Hence it should be remembered 
 that such use of the drug is not entirely unattended 
 with danger. 
 
 CREOLIN is said to occasion sometimes more or 
 less impairment of vision. 
 
 CHLORAL HYDRATE has caused temporary amau- 
 rosis. Other visual disturbances similar to those ob- 
 served in hysteria, dependent presumably upon paresis 
 of the accommodation, are attributed to its influence. 
 
 DIGITALIS produces sometimes more or less cloud- 
 iness of vision, due principally to the mydriasis which 
 it occasions. This knowledge may enable one to differ- 
 entiate the drug influence from a direct sequence of a 
 cardiac lesion. 
 
 ESERINE. Complete blindness, of short duration, 
 has been observed after its instillation into the conjunc- 
 tival sac. 
 
 FELIX MAS. When administering this drug as 
 a taenicide, it should be borne in mind that several 
 cases of blindness have been attributed to it. It 
 produces complete loss of vision of both eyes, coming 
 on within twenty-four hours, or after several days. At 
 first there are no ophthalmoscopic changes, but subse- 
 quently atrophy of the optic nerves develops. This cir- 
 cumstance demonstrates that the visual disturbance is 
 not a result of an influence exerted upon the visual
 
 208 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 centres, but an affection of the optic nerve stem, a form 
 of retro-bulbar neuritis. There are no characteristic 
 symptoms which admit of a diagnosis of the cause of 
 blindness, without the previous history and attendant 
 symptoms. 
 
 MORPHINE. Complete blindness of both eyes 
 "was observed in a patient who had taken two grammes 
 of morphine subcutaneously within five days. The 
 papillae were cloudy and the arteries narrow. 
 
 RESORCIN causes disturbance of vision in poison- 
 ous doses. 
 
 VISUAL HALLUCINATIONS result from the influ- 
 ence of BELLADONNA and ATROPIN, especially in the 
 dark. They are also very prominent in the intoxica- 
 tion from CANNABIS INDICA. COCAINE, AESCULUS, SAN- 
 TONINE and STRAMONIUM also occasion them. With 
 AESCULUS the visions are distressing, and with STRA- 
 MONIUM they frequently take the shape of bugs, snakes, 
 etc., resembling the hallucinations of mania a potu. 
 
 COLORED VISION has been noticed after various 
 remedies, especially the following : 
 
 VIOLET VISION is sometimes caused by CANNA- 
 BIS INDICA. 
 
 YELLOW VISION is characteristic of SANTONINE. 
 This results within ten or fifteen minutes after the ad- 
 ministration of the drug, and it may be associated with 
 mydriasis and inequality of the pupils. The yellow 
 vision is preceded transiently by violet vision. All
 
 OCULAR AFFECTIONS CAUSED BY DRUGS. 209 
 
 shadows appear in the complementary color, which fact 
 demonstrates that the peculiar visual disturbance is 
 caused by a peripheral irritation, and that the central 
 visual sense is intact. 
 
 YELLOW VISION also results from CHROMIC ACID, 
 DIGITALIS, NITRITE OF AMYL and PICRIC ACID. With 
 the last named drug this phenomenon has been noticed 
 after a small dose taken internally, too small to produce 
 coloration of the media, and lasting an hour. This cir- 
 cumstance would indicate that the xanthopsia was 
 caused by an action upon the visual centre. It was not 
 followed by blue or violet vision. 
 
 IODOFORM occasionally causes RED or BLUE VIS- 
 ION, and COLORED VISION has been caused by COCAINE. 
 
 COLOR BLINDNESS, of a greater or less degree, 
 may be caused by QUININE and those other drugs which 
 have been mentioned as producing visual disorders simi- 
 lar to quinine amblyopia, viz. : SALICYLATE OF SODA, 
 ERGOT and CAFFEIN. 
 
 PHOSPHORUS. SPARKS and FLASHES of light re- 
 sult characteristically from this drug, and from BELLA- 
 DONNA and SANTONINE. 
 
 MICROPSIA and DIPLOPIA have also resulted from 
 the use of COCAINE. 
 
 HEMIANOPSIA has been recorded as a symptom 
 following the inhalation of dilute HYDROCYANIC ACID, 
 and after poisoning with CARBONIC OXIDE. In the lat- 
 
 14
 
 210 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 ter case the loss of vision was in the lower part of the 
 visual fields. 
 
 B. PUPILLARY PHENOMENA, DISTURBANCES OF ACCOMMO- 
 DATION AND OTHER OCULAR SYMPTOMS CAUSED 
 BY THERAPEUTIC AGENTS. 
 
 MYDRIASIS is caused by BELLADONNA and its al- 
 kaloid ATROPIN, by DATURINE, DUBOISINE, ERGOTINE, 
 
 HOMATROPINE, COCAINE, ACONITE, DIGITALIS, HYDRO- 
 CYANIC ACID and CYANIDE OF POTASH, HYOSCYAMUS 
 and its alkaloids HYOSCYAMINE and HYOSCINE, by 
 STRAMONIUM, GELSEMIUM and CONIUM. CALABAR BEAN 
 in poisonous doses sometimes causes mydriasis, although 
 marked myosis is its usual effect. This circumstance 
 might possibly prevent a mistake in diagnosis. QUI- 
 NINE produces mydriasis preceded by transient myosis. 
 AESCULUS HIPPOCASTINUM, much used in the form of a 
 cerate as an application to hemorrhoids, produces great 
 dilatation of the pupils in connection with the distress- 
 ing visions already alluded to. This may aid in the 
 diagnosis of poisoning from eating horse-chestnuts, 
 which sometimes occurs in children. Although myosis 
 is considered pathognomonic of OPIUM or MORPHINE 
 narcosis, the opposite effect, viz. : mydriasis, is observed 
 quite frequently in those habituated to its use. It 
 should be mentioned, however, that myosis is never ab- 
 sent in acute opium poisoning, and rarely in the chronic 
 form.
 
 OCULAR AFFECTIONS CAUSED BY DRUGS. 211 
 
 MYOSIS results as a prominent symptom from the 
 internal administration of the following drugs, viz. : 
 CHLORAL (perhaps preceded by transient mydriasis); 
 CALABAR BEAN and its alkaloid ESERINE, PILOCARPINE, 
 JABORANDI, MORPHINE and OPIUM in its various forms 
 and SALICYLATE OF SODA. QUININE produces a tran- 
 sient myosis which is soon followed by mydriasis. 
 
 Spasm of accommodation is usually associated 
 with contraction of the pupil, and paresis of accommoda- 
 tion with dilatation, hence it is unnecessary to repeat 
 the drugs which cause these conditions. It is worthy 
 of remark in this connection that in chronic morphine 
 habitues the paradoxical condition of spasm of accommo- 
 dation associated with mydriasis sometimes occurs. 
 
 Among other ocular conditions following the em- 
 ployment of various therapeutic substances may be men- 
 tioned the following : 
 
 PTOSIS lasting two weeks has been produced by 
 SULFONAL, which has become a favorite remedy for in- 
 somnia. A knowledge of this fact may prove valuable. 
 Partial ptosis has followed the use of IODOFORM. 
 
 TWITCHING OF THE LIDS is caused by CALABAR 
 BEAN, ESERINE and JABORANDI. 
 
 SWELLING OF THE LIDS occasionally occurs as an 
 effect of CHLORAL. 
 
 CONJUNCTIVITIS sometimes follows the use of 
 ATROPIN and BROMIDE OF POTASH. Pustules may ap- 
 pear on the conjunctiva during the employment of the
 
 212 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 latter drug, even when there are none upon the skin. 
 Conjunctivitis with irritation of the lids has also been 
 reported as a result of CHLORAL. 
 
 CHRYSAROBIN OINTMENT, when applied to the 
 skin, may produce conjunctivitis without secretion. 
 When it enters the conjunctival sac, the inflammation 
 which follows is attended with profuse secretion. 
 
 RESORCIN also causes conjunctivitis. 
 
 YELLOWNESS of the CONJUNCTIVA is sometimes 
 caused by PICRIC ACID. 
 
 EPIPHORA results from the use of IODINE and 
 IODIDE OF POTASH. 
 
 CORNEAL ANAESTHESIA has resulted from the use 
 of SULFONAL, QUININE and APOMORPHIA. The latter 
 produces also cloudiness of the cornea. 
 
 CORNEAL SOFTENING has been observed in OPIUM 
 smokers, as a part of the general marasmus thus 
 caused. 
 
 KERATITIS has been reported as an apparent 
 result of large doses of BROMIDE OF POTASH. 
 
 CATARACT has been caused by ERGOTINE and 
 PILOCARPINE. The rapid development of cataract no- 
 ticed during the jaborandi or pilocarpine treatment, 
 should teach caution in their employment with elderly 
 persons or those with incipient cataract. Opacity of the 
 crystalline lens has been produced in rabbits by the 
 injection of NAPHTHALIN, and MENTHOL in lethal doses 
 is said to have a similar effect.
 
 OCULAR AFFECTIONS CAUSED BY DRUGS. 213 
 
 GLAUCOMA sometimes develops after the use of 
 mydriatics, especially ATROPIN, hence the tension should 
 first be tested, and any tendency to a glaucomatous con- 
 dition be carefully investigated before employing such 
 agents. COCAINE applied persistently to the nasal 
 mucous membrane has apparently precipitated an attack 
 of glaucoma, and several cases following its instillation 
 into the conjunctival sac have been reported.
 
 CHAPTER XL 
 
 OCULAR AFFECTIONS RESULTING FROM POISONOUS SUB- 
 STANCES NOT MEDICINAL, ADMINISTERED ACCIDENT- 
 ALLY OR BY DESIGN, OR CONNECTED WITH 
 CERTAIN EMPLOYMENTS. 
 
 More or less impairment of vision results from 
 the following substances : 
 
 ANILINE. " MISTY VISION " has been recorded 
 as an effect of poisoning with this substance, together 
 with mydriasis and pigmentation of the cornea and con- 
 junctiva. 
 
 ARSENIC. Persons employed in the manufacture 
 of wall paper, Paris green, cosmetics and pigments often 
 suffer from arsenical poisoning. The RETRO-BULB AR 
 NEURITIS which it apparently causes, and to which 
 reference was made in discussing toxic amblyopia, is 
 characterized by a distinct paracentral scotoma for red 
 and green, and great diminution of central vision with 
 preservation of the normal limits of the periphery of 
 the visual field. The ophthalmoscope shows sector- 
 shaped decoloration of the temporal portion of the optic 
 nerve. Very few cases of the sort have been reported, 
 and the fact that retro-bulbar neuritis does not seem to 
 exist among the arsenic eaters of Styria leads one to 
 
 (214)
 
 AFFECTIONS RESULTING FROM POISONS. 215 
 
 question whether arsenic was the sole cause of the vis- 
 ual disturbances attributed to it. 
 
 LEAD. Chronic lead poisoning gives rise to a 
 variety of visual defects. Some are only indirectly 
 caused by the poison, being a sequence of vascular 
 changes in the cerebral vessels, such as sclerosis and 
 peri-arteritis, of hemorrhages, spots of softening, etc., or 
 of the kidney lesions which lead causes. 
 
 Other visual phenomena are the direct result of 
 the poison upon the eye and the optic nerve, or upon 
 the visual centre. The indirect influences alluded to 
 will not be discussed here. The reader is referred to 
 other portions of this work for their consideration. 
 
 As direct result of chronic lead poisoning we 
 note : 
 
 1. Temporary dimness of vision, and also RETRO-BUL- 
 
 BAR NEURITIS with its characteristic symptom of 
 cerebral scotoma. Both the acute and chronic 
 forms have been recorded as due to chronic lead 
 poisoning. The amblyopia occurring with acute 
 lead poisoning is usually of uraemic origin in 
 consequence of a kidney lesion. 
 
 2. NEURITIS with a diffusely reddened and cloudy pa- 
 
 pilla, sometimes with hemorrhages and leading 
 later to 
 
 3. ATROPHY of the optic nerve and complete blindness. 
 
 4. HEMIANOPSIA, CONCENTRIC NARROWING of the VISUAL 
 
 FIELDS, COLOR DISORDERS, HALLUCINATIONS and
 
 216 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 HYSTERICAL VISUAL DISTURBANCES occasionally 
 
 develop. 
 
 Other symptoms of lead poisoning will usually be 
 present to establish the diagnosis, such as colic, wrist- 
 drop, headache, etc. 
 
 Saturnine poisoning may result from the inges- 
 tion of food or drink impregnated with lead, by hand- 
 ling paint, etc., by the use of hair dyes and cosmetics ; 
 and De Schweinitz says : " Not a few cases occur in 
 tailors and seamstresses who bite instead of break the 
 threads they are using. These threads are weighted 
 with sugar of lead, which is thus gradually introduced 
 into the system. I have seen one such case, in which, 
 in addition to the general lead toxaemia, there was op- 
 tic neuritis." 
 
 NITROBENZOL is used in the manufacture of 
 dyes. It has an odor and taste very much like that of 
 the oil of bitter almonds, and is sometimes used as a 
 substitute for the latter in the manufacture of confec- 
 tionery and in the preparation of perfumery. It pro- 
 duces DIMINUTION of VISION and CONCENTRIC NARROW- 
 ING OF THE VISUAL FIELD resembling quinine amauro- 
 sis. A characteristic ophthalrnoscopic appearance ac- 
 companying the amblyopia, described by L/itten, is a 
 darkening of the background of the eye "as if stained 
 with ink" (see u Centralbl. fur prakt. Augenheilk" 1891, 
 XV, p. 118). Sometimes it produces a central scotoma. 
 Identical visual disturbances are caused by Di-NiTRO-
 
 AFFECTIONS RESULTING FROM POISONS. 217 
 
 BENZOL, which is used in the manufacture of explosives, 
 especially "robarite" and " sicherheit." 
 
 BISULPHIDE OF CARBON AND SULPHUR CHLO- 
 RIDE, employed in the manufacture of rubber, cause 
 RETRO-BULBAR NEURITIS, as has been already mentioned. 
 The former is the more poisonous. It is stated that 40 
 per cent, of the cases of chronic poisoning from this 
 substance have amblyopia. The patient complains of 
 an indistinctness of vision as if he were looking through 
 a fog. This increases and a central scotoma with 
 intact boundaries of the field develops, reminding one of 
 tobacco amblyopia. The scotoma is most marked for 
 red or green, and in mild cases there may be color 
 blindness or contraction of the color fields without 
 scotoma. MONOCULAR POLYOPIA, MACROPSIA, MICROPSIA, 
 
 HEMERALOPIA, NYCTALOPIA and ANAESTHESIA of the 
 
 CONJUNCTIVA and CORNEA have also been attributed to 
 the influence of this poison. 
 
 Exposure to the vapor of dilute HYDROCYANIC 
 ACID is reported to have caused temporary AMAUROSIS 
 and HEMIANOPSIA. 
 
 SNAKE POISON causes an acute hemorrhagic dia- 
 thesis, and either temporary or permanent IMPAIRMENT 
 of VISION may result in consequence of hemorrhage in 
 the retina or optic nerve, or in the visual centres. 
 Amaurosis after snake bites is said to be of common 
 occurrence in Brazil.
 
 218 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 METHYL ALCOHOL, obtained by the destructive 
 distillation of wood, a by-product in the manufacture 
 of charcoal, and used as a solvent for resins and in the 
 manufacture of aniline dyes, has caused BLINDNESS 
 within twenty-four hours of its administration, according 
 to Mengin. ("Rec. d'Ophth.," 1879, p. 663). 
 
 MERCURY causes LOSS OF VISION due to hemor- 
 rhages, fatty degeneration and inflammation of the 
 retina and optic nerve, resembling retinitis albuminu- 
 rica. 
 
 PHOSPHORUS, used in the manufacture of matches, 
 etc., causes very similar pathological conditions to those 
 resulting from mercury, and with corresponding visual 
 disorders. 
 
 LIDS. OEDEMA AND ECZEMA of the lids is 
 caused by ARSENIC. The skin is often dry and scaly. 
 
 A BLUISH COLOR of the skin of the lids is caused 
 by NITRATE OF SILVER. 
 
 CONJUNCTIVA. INFLAMMATION and ULCERATION 
 of the conjunctiva is also caused by ARSENIC. It occa- 
 sions a BROWNISH-RED COLORATION of that membrane, 
 especially noticeable in workers in artificial flowers. 
 The bluish hue noticed upon the skin of the lids in 
 nitrate of silver poisoning, is also seen upon their inner 
 surfaces. ANILINE causes a BROWNISH color of the con- 
 junctiva and cornea, and a JAUNDICED appearance results 
 from PHOSPHORUS.
 
 AFFECTIONS RESULTING FROM POISONS. 219 
 
 PARALYSIS of one or more of the external eye 
 muscles, of the iris and ciliary muscle, and of the lid 
 may be an accompaniment of L,EAD poisoning. The fol- 
 lowing case reported by Bach, of Wurzburg, in the 
 " Archiv fur AugenJtielkunde," April, 1893, is interesting 
 and suggestive. The patient had exhibited symptoms 
 of lead poisoning for some time, and the ocular condi- 
 tion was regarded as another manifestation of the same 
 toxaemia. The pupils were irregular, and there was 
 absence of the usual reflex contraction with convergence 
 and accommodation and upon the stimulus of light. 
 The reflex dilatation attending stimulation of the sym- 
 pathetic was preserved. The visual field for white was 
 normal, but was contracted for red and green. There 
 was some protrusion of the right eye suggestive of 
 Basedow's disease. There was paralysis, more or less 
 complete, of the rectus internus, superior and inferior, 
 and of the levator of the upper lid of the fight eye, 
 and slight paresis of the external rectus of the ieft eye. 
 De Schweinitz asserts that the external rectus W more 
 frequently affected than any other of the ocular mus- 
 cles. 
 
 NYSTAGMUS sometimes accompanies poisoning by 
 ARSENIC, LEAD and BENZINE. 
 
 PUPIL. CYANIDE OF POTASH (used in photog- 
 raphy) and HYDROCYANIC ACID cause enormous DILATA- 
 TION and immobility of the pupils, associated with 
 slight exophthahnus, swelling of the upper lid, and a
 
 220 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 peculiar staring expression. Mydriasis also results from 
 ANILINE, BISULPHIDE OF CARBON, NITROBENZOL and 
 
 Dl-NITROBENZOL. 
 
 IRITIS has been caused by FUCHSIN and ANI- 
 LINE. 
 
 VITREOUS OPACITIES occur in ARSENICAL POISON- 
 ING, and according to Wolfe (see " British Medical 
 Journal," 1879, II, p. 328) from excessive TEA drinking. 
 
 RETINAL HEMORRHAGES are caused by ANILINE, 
 PHOSPHORUS, CARBONIC ACID GAS, LEAD, MERCURY, 
 NITROBENZOL and SNAKE POISONING. With aniline 
 and nitrobenzol the blood is very dark. With the for- 
 mer the fundus appears as if filled with ink.
 
 CHAPTER XII. 
 
 OCULAR AFFECTIONS DUE TO POISONOUS SUBSTANCES 
 CONTAINED IN CERTAIN ARTICLES OF FOOD AND 
 DRINK. A : FUNGUS POISONING. B : PTO- 
 MAINE POISONING. OCULAR SYMP- 
 TOMS ATTENDING AND FOL- 
 LOWING ANAESTHESIA. 
 
 A. FUNGUS POISONING. Certain varieties of mush- 
 rooms are poisonous, and, in addition to the gastro-in- 
 testinal disturbances and other toxic manifestations, give 
 rise to the following eye symptoms which may occasion- 
 ally serve as an aid to an understanding of the systemic 
 affection, and of the species of fungus which is the 
 exciting cause. 
 
 PUPILLARY phenomena are among the most fre- 
 quent of such symptoms. 
 
 MYDRIASIS follows the ingestion of some varieties 
 of fungi belonging to the genus MORCHELLA, and it is 
 usually accompanied with paresis of accommodation. 
 
 MYOSIS AND SPASM OF ACCOMMODATION attend 
 
 poisoning with certain varieties of AGARICUS, a genus 
 of mushroom embracing over a thousand species, many 
 of which are edible. The poisonous varieties contain 
 muscarine which occasions the ocular symptoms. 
 
 (221)
 
 222 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 VISUAL HALLUCINATIONS are also symptomatic of 
 fungus poisoning and AMBLYOPIA without organic 
 changes in the fundus has been observed. 
 
 HEMORRHAGES AND FATTY DEGENERATION of 
 the RETINA are occasional manifestations of the same 
 toxaemia. 
 
 B. PTOMAINE POISONING. By this term is under- 
 stood the effects produced by the ingestion of toxic sub- 
 stances developed in animal tissues and secretions dur- 
 ing the process of decomposition. Ptomaines are pro- 
 duced through the agency of micro-organisms. They 
 are the virus of the bacteria of putrefaction, and are 
 found in the early stages of decomposition, sometimes 
 before such a condition is perceptible to the senses. 
 They develop notably in mussels, oysters, eels and other 
 varieties of fish, also in sausage, ham, mutton, veal, 
 beef, canned meats, and in milk and articles made from 
 milk, as cheese, custard and ice-cream. However caused, 
 the phenomena of ptomaine poisoning are very similar. 
 Such poisoning is often serious and sometimes fatal. 
 Typhoid fever is sometimes closely simulated. 
 
 The ocular symptoms of ptomaine poisoning are 
 similar to those mentioned under fungus poisoning. 
 
 Congestion of the conjunctiva attends acute pto- 
 maine poisoning. 
 
 Paralysis and paresis of the levator of the upper 
 lid (ptosis), and of the external ocular muscles some-
 
 OCULAR AFFECTIONS DUE TO POISONOUS SUBSTANCES. 223 
 
 times occur. Such symptoms are usually of nuclear 
 origin and suggest hemorrhage or meningitis. 
 
 Mydriasis and paresis of accommodation usually 
 attend ptomaine poisoning, and thus are of diagnostic 
 importance. They are among the typical symptoms of 
 poisoning by bad meat. They may be the only symp- 
 toms in mild cases, and are frequently overlooked. The 
 mydriasis is always bilateral. Paresis of accommodation 
 may occur without dilatation of the pupil. 
 
 Myosis and spasm of accommodation attend poi- 
 soning from neurine, a ptomaine found in putrefying 
 fish. 
 
 Vision is not disturbed as a rule, although am- 
 blyopia has been noticed. 
 
 Some fishes are poisonous only at certain times 
 and under certain conditions, when they may give rise 
 to symptoms of ptomaine poisoning. The toxic element 
 may reside only in special organs, as the liver and sex- 
 ual glands, or may be dependent upon the kind of food 
 which they have eaten. Decomposing haddock contains 
 muscarine, and causes symptoms identical with those at- 
 tending agaricus poisoning. De Schweinitz "explains 
 many of the symptoms of ptomaine poisoning by the 
 statement that " many ptomaines are basic compounds, 
 closely simulating the vegetable alkaloids, such as nico- 
 tine, atropin, veratrine and strychnine," and he adds, 
 "consequently the ocular symptoms which may arise
 
 224 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 under their influence are similar to those which the al- 
 kaloids themselves produce." 
 
 OCULAR CONDITIONS ATTENDING AND FOLLOWING 
 ANAESTHESIA. 
 
 The behaviour of the pupil during anaesthesia 
 from chloroform is important, and should be understood 
 and carefully noticed, as it affords a valuable indication 
 of approaching danger. 
 
 During the early stage, before narcosis is com- 
 plete, the pupil is dilated and responsive to light. In 
 the stage of complete insensibility, the pupils are con- 
 tracted and the eyeballs are fixed. Dilatation with re- 
 action to light returns with returning consciousness. 
 Dilatation during narcoses indicates a necessity for cau- 
 tion. 
 
 Sudden dilatation during complete anaesthesia is an 
 indication of impending asphyxia. The inhalations should 
 be at once discontinued and every effort made to stimu- 
 late respiration and to avert imminent death. The con- 
 comitants of this form of dilatation serve to differentiate 
 it from that previously mentioned, and to emphasize the 
 danger attending it. They are : i, profound narcosis in 
 distinction from commencing narcosis or recovery from it ; 
 2, absence of conjunctival and all other reflexes, instead 
 of the presence of contraction upon the stimulus of 
 light and of other reflexes ; 3, stertorous respiration in
 
 OCULAR AFFECTIONS DUE TO POISONOUS SUBSTANCES. 225 
 
 distinction from shallow respiration and efforts at vom- 
 iting; 4, fixed, immovable eyeballs, instead of mobile. 
 
 Arthur Ward, in the " London Lancet," for July 
 28, 1896, offers the following explanation of the pupil- 
 lary phenomena : He considers the primary dilatation 
 due to reflex inhibition of the unaffected third nerve 
 centre induced by mental, sensory or sympathetic in- 
 fluences acting upon the semi-narcotized cerebrum. 
 Dilatation he considers due to reflex inhibition. In 
 complete narcosis, the cerebrum is no longer capable of 
 receiving or transmitting peripheral impressions, but the 
 third nerve centre still controls the pupil. In profound 
 and dangerous narcosis, the third nerve centre is also 
 narcotized and no longer controls the pupil which di- 
 lates and grows insensitive to light, and the globe be- 
 comes fixed. When the narcosis is not very profound, 
 the contracted pupils will dilate after cutaneous irrita- 
 tion or when the patient is loudly called. 
 
 ETHER. Contraction is the rule during ether narco- 
 sis. In 1 200 inhalations Jacob (Jahrbuch fur Augenheil- 
 kunde, 1879, p. 229) observed mydriasis only six times. 
 
 ETHYL CHLORIDE has produced long-continued 
 dense corneal opacities due solely to oedema. 
 
 ETHYL BICHLORIDE. Acute glaucoma has fol- 
 lowed anaesthesia from this agent, associated with opac- 
 ity of the cornea, but with slight external signs of in- 
 flammation. 
 
 15
 
 226 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 ETHYL NITRITE produces dilatation and immo- 
 bility of the pupils. 
 
 NITROUS OXIDE. Extreme myosis attends the 
 coma caused by inhalation of this gas. It also causes 
 agreeable visual hallucinations. Dilatation of the reti- 
 nal arteries and extreme redness of the papilla has been 
 observed.
 
 CHAPTER XIII. 
 
 BIBLIOGRAPHY. 
 
 The following is a partial list of authors and 
 publications consulted in the preparation of this treatise. 
 
 "AMERICAN JOURNAL OF OPHTHALMOLOGY." 
 "ANNALES D'OCULISTIQUE." 
 ANTONELLI : 
 
 "Archives de Neurologia." Paris, Nov., 1893. 
 
 "ARCHIVES OF OPHTHALMOLOGY." (KNAPP & SCHWEIGGER). 
 ANDROGSKY, OF ST. PETERSBURG : 
 
 Zehender's " Klinische Monatsblatter fur Augen- 
 heilkunde." Stuttgart, Vol. 32, p. 263, 1894. 
 
 ARNDT : 
 
 " System of Medicine." 
 
 BULL: 
 
 " Trans. American Oph. Soc." and N. Y. "Medical 
 Journal," August, 1893. 
 
 BACH, LUDWIG : 
 
 Knapp's " Archives," January, 1895. 
 
 BERRY : 
 
 " Trans. Oph. Soc." United Kingdom, Vol. VII, p. 
 91. 
 
 " BERLINER KLIN WOCHENSCHR." 
 BACH, OF WURTZBURG : 
 
 "Archiv fur Augenheilkunde," April, 1893. 
 
 (227)
 
 228 THE EYE AS AN AID IN GENERAL DIAGNOSIS. 
 
 BERGER. E. : 
 
 " La Medecine Moderne," Nov. 21, 1895. 
 
 BAKER, OF SAN DIEGO : 
 
 "Southern Cal. Prac.," January, 1893. 
 
 BAKER, OF UTICA : 
 
 "American Journal of Insanity," April, 1893. 
 
 BROWNE, LENNOX : 
 
 "Diseases of the Nose and Throat." 
 
 BURNETT : 
 
 " System of Diseases of the Eye, Nose and 
 Throat." 
 
 CORTE : 
 
 " Deutsche Med. Woch.," January 23, 1891. 
 
 CLAIBOBNE : 
 
 "Medical Record," August 14, 1894. 
 
 DE SCHWEINITZ : 
 
 " Toxic Amblyopias," 1896. 
 
 " " Transactions of the American Ophthalmological 
 Society " for 1891, p. 23. 
 
 BOWLING : 
 
 "Quarterly Journal of Inebriety" for January, 1893. 
 
 "EYE, EAE AND THROAT JOURNAL." 
 EL8ELING, OF GBATZ: 
 
 " Fortschritt. der Medicin." Berlin, Dec., 1892. 
 
 FUCHS: 
 
 " Text-book of Ophthalmology." 
 
 FOX, WEBSTER: 
 
 "Medical Bulletin."
 
 BIBLIOGRAPHY. 229 
 
 FOSTER : 
 
 "Text-book of Physiology." 
 
 GOWERS : 
 
 " Diseases of the Nervous System." 
 
 GALEZOWSKI : 
 
 "Jahrb. f. Aug.,'' 1883, p. 297. 
 On Hereditary Ocular Syphilis. "Transactions 
 of Dermatology and Syphilography." Paris, Nov. 
 15, 1895. 
 
 GRUBER : 
 
 "Diseases of the Ear." Translation. 2nd Amer- 
 ican Edition. 
 
 GATTI, E. : 
 
 "Gaz. degli Ospital," 1880, I, p. 4. 
 
 GRAY: 
 
 " Anatomy." 
 
 GOODNO : 
 
 " Practice of Medicine." 
 
 HOWE: 
 
 "American Journal Ophthal.," Vol. II, 5-6, 1885. 
 
 HANGG : 
 
 "Dis." Strasbourg, 1890. 
 
 HENSCHEN : 
 
 " Klinische und Anatomische Beitrage zur Patho- 
 logic des Gehirns." Upsala, 1892. 
 
 HUTCHINSON : 
 
 " Centralblatt fiir Augenheilkunde," August, 1887, 
 p. 240.
 
 230 THE EYE AS AN AID IX GENERAL DIAGNOSIS. 
 
 HULANICKI. OF ST. PETEKSBURG : 
 
 " Medicinische Wochenschrift.," June, 1893. 
 
 HERREN, OF JACKSON : 
 
 "Ophthalmic Record," January, 1893. 
 
 HAMMOND : 
 
 " Diseases of the Nervous System." 
 
 "JOHN HOPKINS HOSPITAL BULLETIN," Baltimore. 
 JACOB : 
 
 "Jahrbuch fiir Augenheilkunde," 1879, p. 229. 
 
 JENNINGS : 
 
 " Color Vision and Color Blindness." 
 
 "JOURNAL OF OPHTHALMOLOGY, OTOLOGY AND LARYNGOLOGY." 
 JULER : 
 
 " Ophthalmic Science and Therapeutics." 
 
 KNIES : 
 
 " The Eye in General Diseases." 
 
 LA GRANGE: 
 
 "Arch. d'Ophthalm.," January, 1887. 
 " " Medical and Surgical So.," Bordeaux, Novem- 
 ber, 1894. 
 
 LETTIN : 
 
 "Centralbl. for prakt. Augenheilk.," 1891, XII, 
 p. 118. 
 
 LEWIS, E. PARK: 
 
 "Eye, Ear and Throat Journal," January, 1895. 
 
 LOPEZ : 
 
 "Archiv. f. Aug.," XXII, 2 and 3. 
 
 LORING : 
 
 "Text-book of Ophthalmoscopy."
 
 BIBLIOGRAPHY. 231 
 
 MARPLE: 
 
 "New York Medical Record," March n, 1893. 
 
 MILLS, CHAS. K. : 
 
 "International Clinics," October, 1895. 
 
 MOTT: 
 
 "International Clinics, 1 ' 1895, Vol. I, p. 127. 
 
 MENGIN: 
 
 "Rec. d'Ophth.," 1879, p. 663. 
 
 MILES : 
 
 "Weekly Medical Review," 1884. 
 
 MADDOX : 
 
 '"' Ophthalmological use of Prisms." 
 
 MUSEHOLD : 
 
 " Deutsche Medicinische Wochenschrift," Febru- 
 ary, 1892. 
 
 MAUTHNER : 
 
 " Sympathetic Diseases of the Eye." 
 " "Gehrin und Auge." 
 
 " NEW YORK MEDICAL JOURNAL," 1893. 
 NOYES : 
 
 Editorial note in Knies' " The Eye in General 
 Diseases." 
 " " Diseases of the Eye," p. 683. 
 
 NORRIS AND OLIVER : 
 
 "Text-book of Ophthalmology." 
 
 NORTON : 
 
 " Ophthalmic Diseases and Therapeutics." 
 
 OLIVER : 
 
 "Medical News," November n, 1893.
 
 232 THE EYE AS AX AID IX GEXERAL DIAGXOH- 
 
 D'OENCH: 
 
 "N. Y. Medical Record," July 14, 1894. 
 " "Ophthalmic Review." 
 
 OSLEB : 
 
 " Practice of Medicine." 
 
 OLIVER, CHAS A. 
 
 "Ophthalmic Methods for the recognition of 
 Nerve Disease." 
 
 PISCHL . 
 
 u Medical News," July 20, 1893. 
 
 RANDOLPH : 
 
 "Johns Hopkins Hospital Bulletin," June and 
 July, 1893. 
 
 RANNEY, OF NEW YORK : 
 
 "Medical Record," May 12, 1894. 
 
 ROOSA, ST. JOHN: 
 
 "Treatise on the Diseases of the Eye." 
 
 SABRAZES : 
 
 " Semaine Medic.," September 26, 1894. 
 
 SEMELING : 
 
 "Charite Annal.," XI, p. 389. 
 
 STEWART, OF CINCINNATI : 
 
 " Eye, Ear and Throat Journal." 
 
 SOUS: 
 
 "Journal de Medecine de Bordeaux," Nov., 1893. 
 SILEX : 
 
 At Medical Society of Berlin, January 23, 1895, 
 reported in " Annales d'Oculistique."
 
 BIBLIOGRAPHY. 233 
 
 TJHTOFF : 
 
 Graefe's " Archives," Bd. XXXII, et. al, (p. 3, p. 
 
 6b). 
 
 VIALET: 
 
 " Annales d'Oculistique." Paris, April, 1894. 
 
 VERRAY : 
 
 " Rev. Med. de la Suisse Romande." 
 WOLFE : 
 
 "British Medical Journal," 1879, H> P- 3 2 8- 
 
 WARD, ARTHUR : 
 
 "London Lancet," July 28, 1896. 
 WHITE : 
 
 " Medical News," July 15, 1893. 
 
 WOOD; 
 
 "N. Y. Medical Journal," July 7 and 14, 1894. 
 
 WHITE, OF RICHMOND : 
 
 " Burnett's Treatise on Diseases of Ear, Nose and 
 Throat." 
 
 WHITE, JOSEPH: 
 
 " London Medical Press and Circular," March, 
 1894. 
 
 ZIMMERMANN, OF MILWAUKEE: 
 
 Knapp's " Archives," January, 1895.
 
 INDEX. 
 
 ABADIE'S Sign, .... 14 
 
 Abdominal Growths, . . . . . . . . n 
 
 Abscess of Brain, 99, TOI 
 
 Accommodation, Behavior of, ........ 58 
 
 Accommodation, Disorders of, ... 78, 156, 211, 221, 223 
 Accommodation, Spasm of, ........ 158 
 
 Addison's Disease, n, 23 
 
 Agraphia, 125 
 
 Albuminuria, 57, 89, 90, 101 
 
 Albuminuric Retinitis, ......... 90 
 
 Alcoholism, ........ 70, 74, 76, 79, 198 
 
 Alexia, 125 
 
 Alternating Paralysis, ........ 36, 37 
 
 Amaurosis, 122, 123, 124, 185, 200, 217 
 
 Amblyopia, ........ 122, 185 
 
 Amblyopia, Alcoholic 191-198 
 
 Amblyopia, Crossed, . . . . . . . . .121 
 
 Amblyopia, Drug Effects, ....... 200-210 
 
 Amblyopia Due to Poisons, ....... 214-218 
 
 Amblyopia, Hysterical, ....... 160-165, 216 
 
 Amblyopia, Monocular, 160, 162 
 
 Amblyopia, Tobacco, ........ 191-198 
 
 Amblyopia, Tobacco, Differential Diagnosis of, . . 196, 197, 198 
 
 Amblyopia, Toxic, 107, 189-199 
 
 Amblyopia, Toxic, Pathology of, 195, 196 
 
 Amblyopia, Toxic, Symptoms of, . . . . . . .195 
 
 Amblyopia, Transient, . . . . . . . . .122 
 
 Anaemia, ......... 83, 87, 123 
 
 Anaemia of Brain, 150 
 
 Anaemia, Pernicious, . . . . ... 88, 92 
 
 Anaesthesia of Conjunctiva, 106, 153, 159, 217 
 
 Anaesthesia of Cornea, 25, 159, 212, 217 
 
 Anaesthesia of Lids, . . . . n> I3> J 59 
 
 (235)
 
 236 INDEX. 
 
 Anaesthesia, Ocular Conditions Attending and Following, . . 224 
 
 Aneurism of Aorta and Art. Innoni., 66, 85 
 
 Aneurism of Internal Carotid, 22 
 
 Aneurism of Orbital Artery, 
 
 Angular Gyrus, Affections of, I22 
 
 Angina I94 
 
 Anisocorea, 
 
 Aorta, Aneurism of, ....... 66 8s 
 
 Aortic Insufficiency, 85 
 
 Apoplexy 37| 3 8, 70, 74 , 101, 119 
 
 Apoplexy Cerebral, Deviation of eyes in, .... 37, 38 
 
 Argyll-Robertson Pupil .62, 72, 105 
 
 Arsenic, ' Ig9 
 
 Art. Innom. Aneurism of 66 85 
 
 Arterio-Sclerosis, g 
 
 Associate Paralysis, ""8 30 
 
 Ataxia, Hereditary (Friedreich's Disease) 52 
 
 Atheroma, 20, 86 
 
 Atrophy of Optic Nerve, . . . 104, 105, 106, 107, 195, 196, 215 
 Aural Ocular Reflexes, !ge 
 
 DASALAR Paralysis, 35 
 
 Basedow's Disease, ...... . 14 22 30 
 
 Base of Brain, Diagram of, 30 
 
 Binocular Vision, Requisites for I 45 > ^5 
 
 Bisulphide of Carbon, ...... joq 
 
 Blindness, Monocular, 109, 123, 160 
 
 Blindness, Significance of, .... . NX), igg 
 
 Blindness, Simulated, Method of Detecting, .... 160-162 
 
 Blue Color of Lids, 218 
 
 Brain, Abscess of, 99 i IOI 
 
 Brain, Anaemia of J-Q 
 
 Brain, Compression of 70 
 
 Brain, Concussion of, 70 
 
 Brain, Hyperaemia of, 74 
 
 Brain, Tumor of, 70, 99, 100, 101, 102, 105 
 
 Bright's Disease, oj 
 
 Burns of Skin 87, 88 
 
 PALCARINE Fissure, II3 
 
 Cannabis Indica 199
 
 INDEX. 237 
 
 Carbon Bisulphide, 199 
 
 Caries of Orbit, 21 
 
 Carotid, Internal, Anuerism of, 22 
 
 Cataract, . . 54, 55, 212 
 
 Catarrh, Nasal 18 
 
 Cerebellum, Disease of, . . . . . . . 7 
 
 Cerebral Embolism, .......... 70 
 
 Cerebro-spinal Meningitis, . . . . . . 50, 70 74, 102 
 
 Chiasm, Affections of . . 118 
 
 Chiasm, Optic, . . no 
 
 Chloral, 199 
 
 Chloroform, -74 
 
 Chlorosis, 83, 88 
 
 Cholera, ... 20, 24, 25, 71 
 
 Choked Disc, 99, lo > ii> i 2 > 103, 105 
 
 Choked Neuritis, 100 
 
 Chorea, 16, 154, 155 
 
 Chorea, Hypermetropia, Frequency with, 155 
 
 Choroid, Affections of, .82 
 
 Choroiditis, Metastatic Suppurative, 83 
 
 Cilio-Spinal Centre 63, 66 
 
 Color Blindness, 209 
 
 Color Fields, Chart of, H5 
 
 Colored Vision, 208, 209 
 
 Coma, Syphilitic 7 6 
 
 Compression of Brain, 7<> 
 
 Concussion of Brain, 7 
 
 Concussion of Spine, IO 3 
 
 Congestion, Spinal 66 
 
 Conjugate Paralysis, 37, 3 8 41 
 
 Conjunctiva, Affections of, l8 i4> 218 
 
 Conjunctiva, Anaesthesia of, IQ 6, i53> I 59> 2I 7 
 
 Conjunctiva, Hemorrhage of, 2O 
 
 Conjunctiva, Leprosy of, . . 21 
 
 Conjunctiva, Oedema of, 
 
 Conjunctiva, Tuberculosis of 2O 
 
 Conjunctiva, Xerosis of, . 
 
 Conjunctivitis, .....' 2II > 2I2 2l8 > 222 
 
 Conjunctivitis, Croupous, 
 
 Conjunctivitis, Diphtheritic, .... 
 
 Conjunctivitis, Phlyctenular, l8 > J 9 
 
 Convulsions, Infantile, 54
 
 238 INDEX. 
 
 Cornea, Affections of, 23, 212, 218 
 
 Cornea, Anaesthesia of, 25, 159, 212, 217 
 
 Cornea, Leprosy of, 26 
 
 Corpora Quadrigemina, Affections of 40 
 
 Corpora Quadrigemina, Function of, in 
 
 Corpus Striatum, Affections of, 40 
 
 Cortical Paralysis, 36, 41, 42, 43 
 
 Cortical Visual Disorders, 38, 42, 113, 119, 120, 121, 122, 123, 126, 167 
 
 Creosote 199 
 
 Crossed Amblyopia, .......... 121 
 
 Crura Cerebri, Affections of, 36, 37 
 
 Cuneus, 113, 120 
 
 QALRYMPLE'S Sign, 14 
 
 Death, Signs of, 23, 26 
 
 Dementia, ............ 105 
 
 Dementia Paralytica, ... 68, 71, 73, 75, 77, 104, 105, 125 
 
 Dental Ocular Reflexes 180, 185 
 
 Diabetes, . .12, 19, 24, 47, 55, 57, 79, 87, 89. 9 2 . 97, 99, xoi, 124 
 
 Diabetic Conjunctivitis 19 
 
 Diabetic Iritis, ........... 57 
 
 Diabetic Retinitis, 99 
 
 Digestion, Disorders of, 12, 16 
 
 Diphtheria, . . . .19, 35, 47, 79 
 
 Diplopia, ............ 209 
 
 Diplopia, Monocular, 162 
 
 Diseases, A Tabulated Statement of, with Characteristic Eye 
 
 Symptoms, ......... 127-140 
 
 Dissociate Paralysis, 43 
 
 Drugs, Disorders of Vision due to, ..... 200 to 210 
 
 Drugs, Effects in Amblyopia, ... . . 200 to 210 
 
 Drugs, Pupillary Phenomena due to, 210, 211 
 
 Dyslexia, ............ 125 
 
 CCZEMA of Lids, 12, 218 
 
 Embolism, Cerebral, 70 
 
 Embolism of Central Retinal Artery, 86 
 
 Eucephalitis, 123 
 
 Endocarditis 86 
 
 Epilepsy, . 78, 122, 147-1 54 
 Epilepsy, Behavior of Pupil in, 153
 
 INDEX. 239 
 
 Epilepsy, Eye Symptoms During Attack, 153 
 
 Epilepsy, Influence of Eye-Strain in Causing, . . . 147-152 
 
 Epilepsy, Visual Aurae in I49 f i$ o 
 
 Exophthalmic Goitre 14, 15 
 
 Eye, Nervous Anastomoses Between Nose and Teeth and, . . 180 
 
 Eye-ball, Protrusion of, ........ 22, 219 
 
 Eyes, Deviation of, in Cerebral Apoplexy, Etc 37, 38 
 
 Eye-strain a Cause of Headache 166-169 
 
 CEVER, Intermittent, 83 
 
 Fever, Puerperal, ......... 83 
 
 Fever, Scarlet, 104 
 
 Fever, Typhoid, 83, 104 
 
 Field of Vision for Color, . . . . . . . .115 
 
 Field of Vision, Method of Examination, .... 116, 117 
 
 Field of Vision, Normal Boundaries of, 114 
 
 Fifth Nerve, Irritation of, . . . . . . . 17, 184 
 
 Friedreich's Disease (Hereditary Ataxia), 52 
 
 Fundus, Ophthalmoscopic Appearance of, ..... 80 
 
 Fungus Poisoning, 221, 222 
 
 /^ENICULATE Bodies, External, . ... in 
 
 ^ Glaucoma, 184, 185, 213, 225 
 
 Goitre, Exophthalmic, . . . . . . . . 14, 15 
 
 Gonorrhoea, 57 
 
 Gonorrhoeal Iritis, .......... 57 
 
 Gout 98 
 
 Gouty Retinitis, 98 
 
 Gratiolet, Optic Radiation of, ill, 119, 120 
 
 OALLUCINATIONS, Visual, . . 118, 119, 124, 208, 215, 222 
 
 Headache Caused by Eye-Strain, 166-169 
 
 Heart Disease, 12, 85, 86 
 
 Hemeralopia, 217 
 
 Hemianopsia, 42, 68, 113, 117, 209, 215, 217 
 
 Hemianopsia, Homomymous, . . . . . . . . 118 
 
 Hemianopic Pupillary Inaction (Wernicke's Sign), ... 68 
 
 Hemorrhage, Cerebral, 37, 38, 70, 74, loi, 119, 
 
 Hemorrhage of Conjunctiva, 20 
 
 Hemorrhage of Retina, ....... 86, 220, 222 
 
 Hemorrhages, Sequence of 101
 
 240 INDEX. 
 
 Hepatic Disease, n, 23 
 
 Hippus 77 
 
 Hydraemia, 12 
 
 Hydrocephalus, . . 70, 100, 101 
 
 Hyperaemia of Brain, . . 74 
 
 Hyperaemia of Retina, ......... 85 
 
 Hypennetropia, Frequency with Chorea, 155 
 
 Hypertrophy of Left Ventricle, 83 
 
 Hysteria 53, 78, 123, 157, 159 
 
 "Hysteria, Behavior of Pupil in 159 
 
 Hysteria, Disorders of Sensation in, ... . 159 
 
 Hysteria, Muscular Disorders in, . . . . . . 17, 158 
 
 Hysteria, Vaso-Motor Disorders in, . . . . . 160 
 
 Hysteria, Visual Fields in, 162, 165 
 
 Hysterical Amblyopia, 160-165. 216 
 
 Hysterical Eye Symptoms, General Features of, . . . . 157 
 
 Hysterical Paralysis, ......... 158 
 
 Hysterical Ptosis, . 17, 158 
 
 IDIOCY 105 
 
 Infantile Convulsions, . 54 
 
 Infectious Diseases, 87, 194 
 
 Inflammation of Optic Nerve, 102, 103 
 
 Influenza, 194 
 
 Inherited Syphilis, 24, 96, 147 
 
 Insanity 68, 71, 73, 75, 77, 114, 124, 125, 169 
 
 Insomnia, 170 
 
 Intermittent Fever, 83 
 
 Intra-Cerebral Paralysis 36 
 
 lodoform, ............ 199 
 
 Iris, Affections of, 55. 219, 220 
 
 Iritis, Diabetic, 57 
 
 Iritis, Gonorrhoeal, 57 
 
 Iritis, Leprous 56 
 
 Iritis, Rheumatic, 57 
 
 Iritis, Syphilitic 55. 56 
 
 Iritis, Tuberculous, 56 
 
 Irritation, Spinal, 66 
 
 Malarial, 25 
 
 Keratitis, Neuro-paralytic, ....... 24
 
 INDEX. 241 
 
 Keratitis, Parenchymatous, ........ 23 
 
 Kidney, Diseases of, . . . . n, 47, 86, 89, 90, 92, 124 
 
 Knies' Sign, ........... 69 
 
 T ABOR, Premature, Indications for Induction of, ... 93 
 Lagophthalmus, . ......... 14 
 
 Lead, Poisoning by, . 87, 194, 199 
 
 Leprosy of Conjunctiva, 21 
 
 Leprosy of Cornea, 26 
 
 Leprosy of Iris, 56 
 
 Leprosy of Lids, .......... 13 
 
 Leukaemia, ......... 92, 97, 101 
 
 Leukaemic Retinkis, ......... 97 
 
 Lids, Affections of II, 15, 16, 17, 158, 219 
 
 Lids, Anaethesia of, . . . . . . . . n, 13, 159 
 
 Lids, Blue Color of, 218 
 
 Lids, Eczema of, 12, 218 
 
 Lids Leprosy of . . . . . 13 
 
 Lids, Oedema of, n, 12, 218 
 
 Lids, Paralysis of, .... . .... 17 
 
 Lids, Pigmentation of Skin of, H 
 
 Lids, Swelling of, 211, 219 
 
 Lids, Tremor of, 15, 211 
 
 Lids, Tuberculosis of, 13 
 
 Light Reflex, 61, 69, 118 
 
 Locomotor Ataxia (Tabes), n, 14, 17, 25, 44, 45, 46, 66, 71, 73, 
 
 75> 76, 77, 104, 105, 106, 112, 198 
 Local Ocular Reflex Neuroses, ' . . 165 
 
 M 
 
 ACROPSIA, 217 
 
 Malaria, ....... 25, 87, 103, 104, 123 
 
 Malarial Keratitis 25 
 
 Measles, *94 
 
 Memory Centre, Nothnagel's 120 
 
 Meningitis, 20, 83, 99, 103, 105, 123 
 
 Meningitis, Cerebro-spinal, SO, 70, 74, 102 
 
 Meningitis, Pachy-hemorrhagica, . . . 101 
 
 Meningitis, Spinal, 
 
 Meningitis, Tubercular, . . 43, 5, 7o, 7 1, 7 8 , 8 3, IO1 , i 2 > 11 9 
 
 Menstruation, Disorders of, n, 12, 86, 194 
 
 Metastatic Suppurative Choroiditis, 8 3 
 
 16
 
 242 INDEX. 
 
 Methods of Estimating Acuity of Vision, .... 108, 109 
 
 Micropsia 209, 217 
 
 Migraine, 167, 168 
 
 Migraine Ophthalmic 167 
 
 Monocular Blindness, 109, 123, 160 
 
 Monocular Diplopia, 162 
 
 Monocular Mydriasis, . . . . . , 68, 69 
 
 Monocular Polyopia, 217 
 
 Morning Ptosis, 16 
 
 Multiple Sclerosis 47, 52, 7 8 , 79, 104, 105 
 
 Muscles, External Ocular, Affections of, . 27, 158, 159, 172, 219 
 Muscles, Spasmodic Affections of, . . . . 14, 38, 42, 49-53 
 
 Muscular Disorders in Hysteria, ...... 17, 158 
 
 Mydriasis, 210, 219, 220, 221, 223 
 
 Mydriasis, Monocular, 68, 69 
 
 Mydriasis, Paretic 65, 67 
 
 Mydriasis, Spastic, . 64, 66, 67 
 
 Myelitis, % 107 
 
 Myosis, 74, 198, 211, 221, 223 
 
 Myosis, Paretic 74, IO 5 
 
 Myosis, Spastic, 74 
 
 MARCOSIS, ... 74 
 
 Nasal Catarrh, . . 18 
 
 Nasal Ocular Reflexes, 180-185 
 
 Nausea, 170 
 
 Nephritis-, n, 89, 90, 92, 124 
 
 Nerves, Motor of Eye, Origin and Course of, .... 27 
 Nerve, Third, Nuclei of Origin of, ...'.. 28 
 
 Neurasthenia, i55-*57, 158, I7 1 
 
 Neurasthenia, Eye Symptoms in, 156 
 
 Neuritis, Choked, 100 
 
 Neuritis, Multiple. (Pseudo-Tabes), ... 76, 104, 105, 107 
 Neuritis, Retro-bulbar, . . . 109, Ho, 189-199, 214, 215, 217 
 
 Neuritis, Retro-bulbar Acute, 19; 
 
 Neuritis, Simple of Optic Nerve, . . . 102, 103, 104, 107, 215 
 
 Neuro-Paralytic Keratitis, . . 24 
 
 Nuclear Paralysis 36, 49 
 
 Neuroses, . 143 
 
 Neuroses, Ocular, 174 
 
 Nose, Affections of, 16, 18, 170
 
 INDEX. 243 
 
 Nose-bleed, I70 
 
 Nose and Teeth, Nervous Anastomoses between Eye and, . 180 
 
 Nothnagel's Memory Centre, I2O 
 
 Nyctalopia, 2I - 
 
 Nystagmus, 50, 53, 159, 219 
 
 Affections a Cause of Functional Nervous Diseases, 
 How to Determine, ....... 172 
 
 Ocular Affections caused by Poisons, 214-221 
 
 Ocular Affections due to Poisonous Substances in Food and 
 
 Drink, 221, 224 
 
 Ocular Affections caused by Therapeutic Agents, . . . 200 
 Ocular Conditions Attending and Following Anaesthesia, . .224 
 
 Ocular Neuroses, .174 
 
 Ocular Vertigo, .... 169 
 
 Oedema of Conjunctiva, . . 24 
 
 Oedema of Lids n, 12, 218 
 
 Olivary Body (Superior), Function of, 40 
 
 Ophthalmic Migraine, ......... 167 
 
 Ophthalmic Vein, Phlebitis of, 83 
 
 Ophthalmoscopic Appearance of Fundus, 80 
 
 Opium 199 
 
 Opium Poisoning, .76 
 
 Optic Chiasm, .... ....... no 
 
 Optic Ganglia. Functions of, 112 
 
 Optic Nerve, Affections of, ...... 84, 98, 103 
 
 Optic Nerve, Atrophy of, . . 104, 105, 106, 107, 195, 196, 215 
 Optic Nerve, Course and Termination of Fibres of, . no, in, us 
 Optic Nerve, Inflammation of, ...... 102, 103 
 
 Optic Radiation of Gratiolet, in, 119, 120 
 
 Optic Thalmus, Affections of, 40, 68, III 
 
 Optic Tract, no, m, n8, 119 
 
 Ophthalmoplegia, 33, 37, 42 
 
 Orbicularis, Spasm of, 16, 153 
 
 Orbit, Caries of, 21 
 
 Orbit, Suppuration within, ....... 12, 22 
 
 Orbital Artery, Aneurism of, 22 
 
 pACHY-MENINGlTlS-Hemorrhagica, . 101 
 Paragraphia, 126
 
 244 INDEX. 
 
 Paralexia, 125 
 
 Paralysis Agitans 15, 17 
 
 Paralysis, Alternating, 36, 37 
 
 Paralysis, Associate, . . 38, 39 
 
 Paralysis, Basilar, .... 35 
 
 Paralysis, Conjugate, . . -37, 38. 41 
 
 Paralysis, Cortical, 36, 41, 42, 43 
 
 Paralysis, Dissociate, 43 
 
 Paralysis, Hysterical, 158 
 
 Paralysis of Insane, . . 68, 71, 73, 75, 77, 104, 105, 114, 125 
 
 Paralysis, Intracerebral 36 
 
 Paralysis of Levator of Upper Lid, . . .... 17 
 
 Paralysis, Nuclear, . 36, 37, 41 
 
 Paralysis, Nuclear, Pathology of, ... . 48, 49 
 
 Paralysis, Peripheral, .... ... 34 
 
 Paralysis, Post- Diphtheritic, 79 
 
 Paralysis, Progressive, ... 68, 71, 73, 75, 77, 104, 105. 125 
 Paralytic Affections of External Ocular Muscles, 31, 44, 45 f 47, 
 
 158, 219, 222 
 
 Parenchymatous Keratitis, 23 
 
 Paresis, General, . . 47, 68, 71, 73, 75, 77, 104, 105, 114, 125 
 
 Paretic Mydnasis, 65, 67 
 
 Paretic Myosis, . 74. 105 
 
 Parrot's Sign 65 
 
 Perimeter, Diagram of 116 
 
 Peripheral Paralysis, ... . . 34 
 
 Pernicious Anaemia, . . 88, 92 
 
 Phlyctenular Conjunctivitis, ... 18, 19 
 
 Phlebitis of Ophthalmic Vein 83 
 
 Pigmentation of Skin of Lids, 1 1 
 
 Phosphorus, Poisoning by, . . . . 87 
 
 Poisoning, Fungus, ... 221, 222 
 
 Poisoning by Lead, . .87, 194, 199 
 
 Poisoning, Ptomaine, 222, 223 
 
 Poisoning by Opium, . . . 76 
 
 Poisons a Cause of Ocular Affections, 214-224 
 
 Poisons, Disorders of Vision due to, .... 214-218 
 
 Polyopia, Monocular, 217 
 
 Pons, Affections of, . . 36, 37, 3 s , 39- 4, 4 2 , 74 
 Post-Diphtheritic Paralysis, 76 
 
 Posterior Spinal Sclerosis, I4i *5
 
 INDEX. 245 
 
 Pregnancy, Retinitis of, 92, 124 
 
 Progressive Paralysis, ... 68, 71, 73, 75, 77, 104, 105,' 125 
 
 Protrusion of Eye-ball, 22, 219 
 
 Ptomaine Poisoning, 222, 223 
 
 Ptosis, 16, 211, 221 
 
 Ptosis, Hysterical !7 ( 1$$ 
 
 Ptosis, Morning, 16 
 
 Ptosis, Sympathetic, . . 15 
 
 Puerperal Fever 83 
 
 Pulsation of Retinal Arteries, 85 
 
 Pulvinar, . , in, 119 
 
 Pupil, Behavior of 58 
 
 Pupil, Behavior during Anaesthesia, 224 
 
 Pupil, Behavior in Epilepsy, ... ..... 153 
 
 Pupil, Behavior in Hysteria, . . . . . . . .159 
 
 Pupillary Phenomena due to Drugs 210, 211 
 
 Pyaemia, 83, 87 
 
 DACHITIS, . . .... 54, 55 
 
 ^ Railway Spine, 103 
 
 Reflex Action, Mechanism of Production, . . .174, 175, 176 
 
 Reflex Action, Pathological, 177, 178 
 
 Reflex, Light, , 61, 69, 118 
 
 Reflex Neuroses, Local Ocular, . 165 
 
 Reflex, Skin, .-.-.. . . . . . . 63, 66, 74 
 
 Reflexes, Aural Ocular, . 185 
 
 Reflexes, Dental Ocular, . . . , . . . 180, 185 
 
 Reflexes, Nasal Ocular, ........ 180, 185 
 
 Reflexes, Pathological Ocular, .180 
 
 Reflexes, Physiological Ocular, Examples of, . . . .179 
 
 Refraction, Errors of, A Cause of Headache, . 166, 167, 168, 169 
 Refraction, Errors of, A Cause of Neurasthenia, . . . 156, 171 
 Retina, Affections of, ......... 84 
 
 Retina, Hyperaemia of, ......... 85 
 
 Retinal Artery, Central, Embolism of, ...... 86 
 
 Retinal Arteries, Hemorrhage from, .... 86, 2:0, 222 
 
 Retinal Arteries, Pulsation of, ....... 85 
 
 Retinitis 83, 104 
 
 Retinitis Albuminurica, 90 
 
 Retinitis Diabetica -99 
 
 Retinitis, Gouty, 98
 
 246 INDI-X. 
 
 Retinitis Leukaemica, 97 
 
 Retinitis, Nephritic, 89, 90 
 
 Retinitis of Pregnancy, ........ 92, 124 
 
 Retinitis Syphilitica, 96 
 
 Retro-bulbar Neuritis, . . . 109, no, 189-199, 214, 215, 217 
 
 Rheumatism, 23, 24, 47, 57, 191. 
 
 Rheumatic Iritis 57 
 
 Romberg's SmyptOm, 156 
 
 CARCOMA, ... 56 
 
 Scarlet Fever, 104 
 
 Sclera. Tuberculosis of, 23 
 
 Scleritis, ... . . 23 
 
 Sclerosis, Multiple, 47, 52, 78, 79, 104, 105 
 
 Sclerosis, Post Spinal, . ... 14, 15 
 
 Scotoma, Scintillating, 167 
 
 Scrofula, 12, rS, 23, 83 
 
 Sensation, False Localization of n, 25, 106 
 
 Sensation, Disorders of in Hysteria 159 
 
 Septicaemia, ... 87 
 
 Sequence of Hemorrhages, . . . 101 
 
 Simulated Blindness, Detection of, 160-162 
 
 Skin, Burns of, ... 87, 88 
 
 Skin Reflex, 63, 66, 74 
 
 Skull, Fracture of, ... 103 
 
 Snake Bites, 87 
 
 Sneezing 170 
 
 Soul Blindness, . . 124, 125 
 
 Spasm of Accommodation, 158 
 
 Spasm, Conjugate of Eye Muscles, . ... 38, 42, 49 
 
 Spasm of External Ocular Muscles, 49~53 
 
 Spasm of Leva tor of Upper Lid, 14 
 
 Spasm of Mueller's Muscle, .... ... 14 
 
 Spasm of Orbicularis, 16, 153 
 
 Spasm, Vaso-motor, a Cause of Epilepsy, 150 
 
 Spastic Mydriasis, . . . . 64, 66, 67 
 
 Spastic Myosis, .... 74 
 
 Spinal Congestion, ... 66 
 
 Spinal Cord, Disease of, 75, 76 
 
 Spinal Cord, Tumor of, . . .... 101 
 
 Spinal Irritation, 66
 
 INDEX. 247 
 
 Spinal Meningitis, 66 
 
 Spine, Concussion of, . ........ 103 
 
 Stell wag's Sign 14 
 
 Strabismus, ........... 50 
 
 Stramonium, . . . . . . . . j . . 199 
 
 Sulphur Chloride . . 199 
 
 Swelling of Lids . 211, 219 
 
 Sympathetic, Influence of upon Tension of Eye, . . . 184 
 
 Sympathetic Ptosis, 14 
 
 Syphilis, . 21, 23, 44, 46, 55, 56, 71, 79, 82, 86, 89, 96, 103, 
 
 118, 119, 194 
 
 Syphilis, Inherited, 24, 96, 147 
 
 Syphilitic Coma, 76 
 
 Syphilitic Iritis, 55, 56 
 
 Syphilitic Retinitis, 96 
 
 "FABES, (Locomotor Ataxia), n, 14, 17, 25, 44, 45, 46, 66, 71, 
 
 73, 75, 76, 77, 104, 105, 106, 112, 198 
 Tabes, Pseudo, (Multiple Neuritis), ... 76, 104, 105, 107 
 
 Tape-worm, ... 185 
 
 Tea, .199 
 
 Teeth, Disorders . of, . 16, 170 
 
 Teeth and Eye, Nervous Anastomoses between, . . . .180 
 
 Thalamus, Optic, ........ .in 
 
 Thalamus Opticus, Affections of, ...... 40, 68 
 
 Therapeutic Agents a Cause of Ocular Affections, . . . 200 
 
 Tobacco Amblyopia., ........ 191-198 
 
 Toxic Amblyopia, 107, 189-199 
 
 Tracts, Optic, no, m, 118, 119 
 
 Transient Amblyopia, 122 
 
 Tremor of Lids, , 15, 211 
 
 Trichinosis, X 2, 79 
 
 Tubercula Quadrigemina, : . 4 
 
 Tubercular Meningitis, . . 40, 50, 70, 74, 78, 83, 101, 102, 119 
 
 Tuberculosis, 21, 23, 83 
 
 Tuberculosis of Conjunctiva, . . -- . 20 
 
 Tuberculosis of Iris, . - . ' . 56 
 
 Tuberculosis of Lids, . J 3 
 
 Tuberculosis of Sclera, ... 23 
 
 Tumor of Brain, ..... 7, 99, 100, 101, 102, 105 
 Tumor of Spinal Cord, I01
 
 248 INDEX. 
 
 Typhoid Conditions, 24, 83, 104 
 
 I 1RAEMIA, .... ... 71, 76, 123, 124 
 
 Urticaria, ........... 66 
 
 Uterine Disease "-79. 185 
 
 WASO-MOTOR Disturbances in Hysteria, 160 
 
 Vaso-motor Spasm a Cause of Epilepsy, . . . .150 
 
 Ventricle, Hypertrophy of Left, 83 
 
 Ventricle, Third, Accumulation of Fluid in, . . . .118 
 
 Vertigo, Ocular, 169 
 
 Vision, Binocular, Requisites for, ...... 145, 146 
 
 Vision, Colored, 208, 209 
 
 Vision, Disorders of due to Drugs, ..... 200-210 
 
 Vision, Disorders of due to Poisons, ..... 214-218 
 
 Vision, Methods of Estimating Acuity of, . . . 108, 109 
 
 Visual Aurae in Epilepsy, ....... 149, 150 
 
 Visual Centres, . , . . 113, 119, 120, 121, 122, 123, 126 
 
 Visual Centre, Affections of, 38, 42, 167 
 
 Visual Disorders, Cortical, 38, 42, 113, 119. 120, 121, 122, 123, 126, 127 
 
 Visual Field for Color, 115 
 
 Visual Field in Hysteria, 162, 165 
 
 Visual Field, Method of Examination, . . . . 116, 117 
 
 Visual Fields, Normal Boundaries of, 114 
 
 Visual Hallucinations, .... 118, 119, 124, 208, 215, 222 
 
 Vitreous, Opacities of 220 
 
 Von Graefe's Sigu ..15 
 
 \X7ERNICKE'S Sign, (Hemianopic Pupillary Inact; . 68 
 
 Winking, Diminished Frequency of, 14 
 
 Winking, Spasmodic, 16 
 
 Xerosis of Conjunctiva, .25
 
 O 
 
 *, 
 
 mee, $1.00. 
 
 on 
 
 By Clarence A. Veasey, A. M., M. D, 
 
 Adjunct Professor of Diseases of the Eye, Philadelphia Polyclinic ; Chief Clinical Assistant to the Oph- 
 thalmological Department Jefferson Medical College Hospital ; Consulting 
 Ophthalmologist, Philadelphia Lying-in Charity, etc. 
 
 "Dr. Veasey in the compilation of this book has filled a void 
 in ophthalmic literature, and has given to the student of ophthal- 
 mology an aid that has long been wanted. Atlantic Medical Re- 
 view. 
 
 "' Ophthalmic Operations ' is so full of practical information 
 so concisely stated, that every practitioner, as well as student, 
 should possess it." Bi-Monthly Bulletin of the University College of 
 Medicine, Richmond, Va. 
 
 **** The reviewer having found it useful among his own 
 students, cordially recommends ^."International Med. Magazine. 
 
 Fif iy-Six Illustrations, many of mem Entirely New and Prepared Especially for mis work. 
 
 THE object of this work has been to present to the student and 
 practitioner entering the field of operative ophthalmology a re- 
 liable guide to the various operations that can be practiced on 
 animals' eyes, to enable him to possess a greater experience and a lar- 
 ger amount of confidence in himself when attempting operative work 
 on the human eye. The various operations are taken up and the meth- 
 ods and technique of 
 performing them fully 
 described and illustra- 
 ted, so that one may 
 become thoroughly fa- 
 miliar with any opera- 
 tive procedure, prac- 
 ticing it as many times 
 as he chooses. 
 
 So far as can be as- 
 certained this is the 
 first time this matter 
 has appeared in book 
 form. Heretofore, the 
 only way in which the 
 information contained therein could be obtained was through personal 
 instruction or through some operative course in a public institution. 
 This little work is intended not only to assist those who are able to 
 avail themselves of such courses of instructions, but also those who are 
 less fortunate in being remote from the medical centres where such 
 courses can be obtained. 
 
 "It was a happy 
 thoughtwhich inspir- 
 ed Dr. Veasey to pre- 
 pare this book." The 
 Medical Bulletin. 
 
 OPINIONS 
 OF THE PRESS. 
 
 It is cheerfully 
 recommended for the 
 purpose it is intend- 
 ed to fulfill." Phila- 
 delphia Polyclinic. 
 
 "This little manual has a distinct place in ophthalmic work. 
 * * * * we commend it to the teachers of Ophthalmology. 1 ' Colo- 
 rado Medical Journal. 
 
 There is certainly room for a book of this kind * * * * Dr. 
 book ought to have a wide circulation." Annals ej 
 Ophthalmology 
 
 Veasey's little book ought tc 
 
 We believe that this little book meets a real need of both 
 teacher and student." The Ophthalmic Review. 
 
 " The little volume fulfills its purpose." Archives of Ophthal- 
 mology. 
 
 The Edwards & Docker Co., 
 
 518=520 ninor Street, = Philadelphia. 
 
 HORACE BINDER, Manager.
 
 $1.OO Postpaid. 
 
 and its Practical Application 
 to the Study of Refraction. 
 
 BY EDWARD JACKSON, A. M-, M. D. 
 Professor of Diseases of the Eye In the Philadelphia Polyclinlc, Surgeon to Wills' Eye Hospital, Etc., Etc. 
 
 Skiascopy is the most accurate objective method of measuring re- 
 fraction, and the one with which it is easiest to obtain a practical work- 
 ing acquaintance. This book gives the clearest, most complete, and 
 most practical account of it yet published. 
 
 "Bears the stamp ot personal experience and original observation, and cannot be too highly rec- 
 ommended to t very oculist and physician desirous of btcoming thoroughly familiar with the theory 
 and practice ot skiascopic examination." Journal of the American Medical Association. 
 
 "All Ophthalmologist* will welcome Dr. Jackson's little manual. It is an authoritative and excel- 
 lent exposition of the subject with which it deals." Medical News. 
 
 " This is an excellent book. No ophthalmologist can consider himself abreast of the times unless 
 he understands skiascopy, and a better text book on the subject cannot be found." N. Y. Med. Journal. 
 
 " This little book gives a very complete and serviceable presentation of the theory of the shadow- 
 test, and its practical applications. To many it will seem too diffuse ; but, in reality, it contains but lit- 
 tle superfluous matter at least for those who have but an imperfect previous knowledge of this useful 
 method of examination Even one who has somewhat extensive experience iti the latter will find in- 
 formation and maiiv useful hints." Archives of Ophthalmology. 
 
 " The work as a whole is very ci editable j and the practitioner who takes the trouble to master its 
 contents will know all that can be said of this very excellent, speedy and satisfactory mode of deter- 
 mining the nature and degree of both common and uncommon errors of refraction." The Lancet. 
 
 stud 
 
 "Altogether this little book of 109 paues is one so full of practical information that it should be 
 lied by every one who is not a thorough master of the subject treated." -Ophthalmic Record. 
 
 I0 Pages with 21 Illustrations. 
 
 (j* BOUND IN CLOTH, $I.OO. 
 
 
 
 The u. Examination of the Eye 
 
 By J. HERBERT CliAIBORJME. Jr., JH. D-, 
 
 Adjunct Professor of Ophthalmology in the N. Y. Polyclinic ; Instructor in Ophthalmology, College ot 
 
 Physicians and Surgeons, N. Y.; Assistant Surgeon to the New Amsterdam Eye and Ear 
 
 Hospital; Author of " Theory and Practice of Ophthalmoscope." 
 
 " Without making any claims for originality, except in his treatment of the subject, which is simple 
 and attractive, the author has presented a book on refractive errors and their correction which is ad- 
 mirably adapted to the use of students and beginners. The book contains in addition chapters on the 
 propertie of lenses, vision and mydriatics. It is neatly gotten up and appropriately illustrated. "Ho- 
 maofathic Eye, Ear and Throat Journal, N. Y. 
 
 " Contains the facts necessary for the examination of the eye as pertaining to refraction expressed 
 in a simple, clear and attractive manner a fit companion for the author's pievious work on the oph- 
 thalmoscope. The type and binding are also excellent" The Canadian Medical Review. 
 
 "This book consists of a number of lectures or lessons on the subject of fitting glasses delivered to 
 the graduating classes of the College of Physicians and Surgeons, New York. The method of properly 
 adjusting glasses in cases of hypermetropia, myopia, astigmatism and presbyopia is described in an at- 
 tractive way, and is made so clear that the book undoubtedly will prove a valuable aid to students and 
 beginners. The chapter on Presbyopia is unusually full, and contains the substance of all that has gone 
 before. The important subject of Mydriatics is discussed in the last chapter ; formnlte are given and 
 suggestions made as to the cases in which they are indicated." Medical and Surgical Journal, St. Louis. 
 
 The Eduuards & Docker Co., 
 
 518-2O MINOR STREET, ~ 
 HORACE BINDER, Manager.
 
 p 
 
 Fospeetus fot* 1897. 
 
 The A 
 
 metucan 
 
 35 Cts. per Copy. 
 $4.00 per Year. 
 $4.60 per year, Foreign. 
 
 1867 
 3 I St 1897 
 
 YEAR 
 
 A Monthly Journal Devoted to 
 
 The Natural Sciences 
 
 in their widest sense. 
 
 THE AMERICAN NATURALIST differs 
 from most other Journals in the extent 
 and efficiency ot its editorial corps, 
 which embraces eleven men, mostly profes- 
 sors in well-known Universities in Maine, 
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 phia, Baltimore and Washington ; and Lin- 
 coln, Nebraska. This editorial supervision 
 secures competent criticism on the subject 
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 NATURALIST the presentation to the public 
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 As heretofore, THE NATURALIST endeavors 
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 In performing this service, it bespeaks the 
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 THE AMERICAN NATURALIST was com- 
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 MANAGING EDITORS: 
 
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 Philadelphia, Pa. 
 
 Dr. F. C. KENYON, 
 
 Washington, D. C. 
 
 ASSOCIATE EDITORS: 
 
 Department of Petrography 
 
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 Colby University, Waterville, Me. 
 
 Department of Mineralogy 
 
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 Ithaca, N. Y. 
 
 Department of Botany 
 
 Dr. C. E. BESSEY, 
 The University of Nebraska, Lincoln, Neb. 
 
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 ERWIN F. SMITH, 
 
 Washington, D. C. 
 
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 College of New Hampshire, Durham, N. H. 
 
 Department of Embryology, 
 
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 Johns Hopkins University, Baltimore, Md. 
 
 Department of Anthropology 
 
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 University of Pennsylvania. 
 
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 Princeton, N. J. 
 
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