OCULAR SYMPTOMS IN DISEASES OF THE 
SPINAL CORD* 
By WILLIAM OLIVER MOORE, M.D. 
PROFESSOR OF THE DISEASES OF THE EYE AND EAR IN THE NEW YORK POST-GRADUATE MEDICAL 
SCHOOL AND HOSPITAL, ETC., ETC. 
OF Nature’s minute wonders the human eye is the 
paragon. But it is not the apparatus which the delicate 
knife of the anatomist reveals, the retina and lenses, 
or even their combined arrangement, that most strikingly 
indicates the subtile workmanship involved in the little 
fleshy globule we call the eye ; it is the effects they pro- 
duce, the purposes they subserve, the results they accom- 
plish. Far greater are these than the. careless crowd dream 
of, or the imaginative fully realize. The phenomena of 
sight is indeed sufficiently extraordinary ; not less so are 
the minor missions which the visual organ fulfils. The eye 
speaks with an eloquence and truthfulness surpassing speech. 
It is the window out of which the winged thoughts often fly 
unwittingly. It is the tiny magic mirror on whose crystal 
surface the moods of feeling fitfully play, like the sunlight 
and shadow on a stream. How aptly has the eye been 
called the “window of the soul” ; instinctively it is raised 
in devotion, and bent downward in shame. When enthusi- 
asm lends fire to the soul the eye flashes ; when pleasure stirs 
the heart the eye sparkles : when deep sorrow darkens the 
bosom the eye dispels hot tears ; when confidence stays the 
mind, the eye looks forth proudly ; when insanity desolates 
the brain, the eye roves wildly ; and 
“ O’er the eye Death most exerts his might, 
And hurls the spirit from its throne of light. ’ ’ 
® Read before the Section on Neurology, N. Y. Academy of Medicine, 
March 9, 1888. WILLIAM OLIVER MOORE. 
2 
Eye language is thus a part of our study in medicine, and 
should be more generally understood than it is, not in dis- 
eases of the brain and cord, but in general affections. The 
unfortunate know a friend and are reassured ; the timid 
recognize a master spirit and are strengthened ; the guilty 
know their accuser, and quail. Beware of the man whose 
eye you can never meet. 
That the eye should show changes in the diseases affect- 
ing the brain, with which it is so closely connected, is clear, 
but why, in those situated in the spinal cord, it is not quite 
so easy to comprehend. Ever since the diseases of the 
“golden bowl” have been the subject of close study, ocular 
symptoms have been noticed, and of late years these same 
symptoms, associated with affections of the “ silver cord,” 
have claimed much attention and enquiry. 
I regret that I am unable to make any new contribution to 
our knowledge of the pathological anatomy of these dis- 
eases, but hope that in the discussion it may be evoked. 
In entering this vast and interesting field one must be very 
careful to make minute and accurate observations, especially 
in reference to pupillary signs, as Iwano has found that 
out of 134 young persons examined, 131 had assymetry of 
the face, and that the pupils were irregular in 122 : and that 
the largest pupil occurred most frequently on the left side, 
which was usually the smaller side of the face. 
We shall not attempt to cover the above field, which the 
title of the paper indicates, but only take up certain points 
that have always interested us. 
Your attention will be more particularly called to atrophy 
of the optic nerve, and ophthalmoplegia interna, with but 
only a passing notice to ophthalmoplegia externa, and 
nystagmus. 
Atrophy of the optic nerve comes chiefly under the notice 
of the ophthalmologist, while the affections of the iris more 
commonly under the observation of the physician. 
The ocular symptoms in spinal cord disease are to be 
looked upon as associations and not as effects ; and that 
they are also always the result of degenerative processes in 
the cord. DISEASES OF THE SPINAL CORD. 
The usually slow progress of the spinal symptoms is evi- 
dence of this fact. 
Among the many degenerative diseases of the cord it is 
strange that most of the eye symptoms should be with one 
of them alone, with tabes dorsalis. The fact that they are 
associations and not effects is clearly stated by Gowers in 
the following manner : 
1. “That disease of any nature may exist in any part of 
the spinal cord without the occurrence of ocular symptoms, 
if we except the very rare paralysis of the dilators of the 
pupil in disease of the sympathetic tract in the cervical 
region. 
2. “The ocular symptoms which may be absent when 
the cord disease is advanced may exist in extreme degree 
when such disease is in a very early stage. 
3. “ With the single exception of the sympathetic symp- 
toms just mentioned, we know of no anatomical connection 
or functional mechanism by which the spinal cord disease 
can produce the ocular symptoms.” 
INJURIES TO THE SPINE. 
Experimentally in laboratories, injuries to the spinal 
cord of animals have shown ocular symptoms, and these 
naturally lead us to expect similar results in man, where 
injuries of the spinal column have inflicted pressure on the 
cord. 
Mr. Erichsen,* of London, has done much to bring this 
to notice, and all but considered it sufficiently frequent to 
establish a causal relation between the two events. 
It is stated on authority, that Alexander the Great was 
in danger of losing his eyesight from the blow of a heavy 
stone on the back of the neck. Thirty-six per cent, of 
Erichsen’s cases showed undoubted eye symptoms. 
These are more commonly : difficulty of seeing in poor 
light to read, blurring of the type, floating bodies before the 
eyes, occasionally diplopia, with photophobia. The oph- 
thalmoscopic appearances are usually negative. 
Wharton Jonesf considers the eye symptoms in these 
3 
* Erichsen, “Concussion of the Spine,” London, 1875. 
J “ Failure of Sight after Railway and other Injuries of the Spine and Head,” 
London, 1869. 4 
WILLIAM OLIVER MOORE. 
cases due to the disturbance in the cilio-spinal centre, and 
the sympathetic filaments springing from the dorsal and 
cervical cord. 
Other authors have reported severe eye symptoms from 
comparatively slight injuries of the spine. 
I have seen but two cases of concussion of the spine, and 
in each of these eye symptoms were present in the shape of 
asthenopia. The fundus in each case was normal, and dis- 
tant vision good, yet difficulty was experienced on reading ; 
both were females, and each had loss of accommodation, 
that is to say, they could not use the ciliary muscle long 
without fatigue, and a convex glass had to be given to 
rectify this difficulty. In neither case was muscular dis- 
turbance of the extrinsic muscles of the eye found. 
In Caries of the Vertebrae, when of traumatic origin we 
frequently find intra-ocular symptoms, and the ophthalmo- 
scope usually shows a condition of engorgement of the 
vessels of the optic disc and surrounding parts. 
Dr. Chas. S. Bull* reports the histories of eleven cases 
of traumatic caries of the spine, mostly occurring in the 
cervical, but some also in the dorsal and lumbar regions. 
Seven had engorgement of retinal veins, with no changes 
in the arteries : in two choked disc was noticed, and in two 
anaemia seemed to be present, although the veins were 
enlarged. 
I have examined fifteen cases of ocular disturbance in 
vertebral caries of traumatic origin, and found the following 
conditions: In two, optic neuiitis, with swelling: three, 
hyperaemia of the disc, with blurred outline, but no oedema ; 
eight had enlarged veins, and arteries normal in size or only 
slightly enlarged, the changes were symmetrical in each 
eye ; two had floating bodies in the vitreous, with enlarged 
retinal veins ; these changes are probably due to the sym- 
pathetic filaments springing from the dorsal and cervical 
cord. 
LOCOMOTOR ATAXIA. 
The frequency with which optic nerve atrophy occurs in 
tabes is differently stated ; Leber found it present in 26 per 
ss Trans. American Ophthal. Society, vol. ii. DISEASES OF THE SPINAL CORD. 
5 
cent., Gowers, in 20 per cent., and Nettleship, in 50 per 
cent. 
During the past ten years we have made notes of 80 
cases of atrophy of the optic nerve, where no other history 
could be obtained, and of this number 32 had the signs of 
tabes as shown by the absence of the knee-jerk ; 18 had 
ataxic symptoms when first seen. In examining the re- 
ports of many of the ophthalmic hospitals of this country, 
we are unable to tell the proportion of optic nerve diseases 
due to locomotor ataxia, owing to the method of recording 
diagnoses. Erb found only 12% per cent, of his cases to 
have atrophy of the optic nerve ; so that, although it is ad- 
mitted by all writers as a frequent association, the percentage 
is at great variance. It has been said that the percentage 
given by the ophthalmologist is too high : I do not think 
so, but rather that it is due to the fact that the patient seeks 
advice for failing vision, when no signs of ataxia are yet 
present, and that the observers being on the alert for a cause 
of the optic atrophy, enter into an examination of the gen- 
eral condition of the patient and discover tabetic symptoms. 
I know this has been my personal experience in this direc- 
tion. Atrophy of the optic nerve belongs to the more 
frequent of the complications of tabes ; it commonly arises 
in the initial stage, and may be the first manifestation ; the 
amblyopia produced by it may last for as many as ten years, 
before other symptoms of tabes appear, as in the case re- 
ported by Charcot. Gowers has also reported similar cases ; 
in one the optic atrophy preceded the locomotor symptoms 
twenty and in another fifteen years. That optic atrophy 
ever occurs before the loss of the knee jerk, I am not satis- 
fied ; in all the cases under my observation it was absent— 
and I believe it is well recognized that the loss of the 
knee jerk may precede for a long time other locomotor 
symptoms. 
When the disease was supposed to be situated and limited 
in the posterior columns of the cord, the association with it 
of a peripheral degeneration of the optic nerve was an 
anomaly. But since the recent pathological researches of 
Pierret, who has shown that the degeneration of the optic 6 
WILLIAM OLIVER MOORE. 
nerve is not the only peripheral lesion, and that that in the 
cord is not the only central change. He has shown that 
there is often an independent degeneration in the cutaneous 
nerves, commencing in the extremities, and that the optic 
nerve change is strictly analogous ; that there may also 
exist a degeneration at the central termination of the optic 
as well as of other cranial nerves, similar to that existing in 
the posterior columns of the cord. From his standpoint 
tabes is considered a “wide sensory neurosis,” in the course 
of which the optic nerve atrophy occurs. Dejerine and 
Westphal have also enlarged our former narrow concep- 
tions of the tabetic process. During the period when there 
is no affection of the patient’s gait, and only the loss of the 
patellar reflex, unsteadiness on standing with bare feet close 
together, with closed eyes, and with lightning pains, there 
is no doubt that optic atrophy often commences and ad- 
vances to a considerable degree, and according to Gowers, 
it occurred during this period twice as frequently in this 
than the later stages of the affection. In my cases, 14 out 
of 32 had only loss of knee jerk and rheumatic pains in the 
legs. It is rare for it to occur when the ataxia is so great 
that the patient cannot walk. 
The atrophy usually begins in one eye before the other, 
and may reach a considerable degree before the fellow-eye 
suffers. The immediate cause of the amblyopia in tabes is 
the gray degeneration of the optic nerves—a degeneration 
similar in all respects with the changes in the spinal cord. 
One disease begins at the periphery of the trunk of the optic 
nerve, and gradually attacks the central fibres ; it always 
begins on the trunk of the nerve or the portion nearest the 
eye, and from thence toward the optic tract. The narrow- 
ing of the visual field would lead us to this conclusion, had 
not post-mortem changes already shown this condition. 
The disease of the optic nerve manifests itself by diminu- 
tion in the acuteness of vision ; the field which is at first 
normal becomes gradually narrower, the field being irregu- 
larly contracted. The color field is usually limited before 
the visual, the perception of green being lost first, then red, 
and then yellow and blue. Ophthalmoscopic examination DISEASES OF THE SPINAL CORD. 
7 
shows in the early stages a dirty-looking nerve, which is in- 
dicative of a low grade of neuritis, and this continuing pro- 
duces the final full marked appearances of white atrophy 
of the optic nerve, with narrow arteries and other parts of 
the fundus appearing normal. 
The optic nerve atrophy occurring in tabes is usually 
progressive, and leads to complete blindness, though I have 
seen two cases where vision was not completely destroyed. 
And one may observe no ophthalmoscopic change in the 
fundus, and yet amblyopia of a high grade present; in such 
cases doubtless degeneration is retro-bulbar. 
The next most frequent ocular symptom in tabes is the 
pupillary change. Of the four muscular actions, contraction 
of the pupil on stimulation of the optic nerve, contraction 
of the sphincter, in association with that of the ciliary and 
internal recti muscles, and contraction of the dilator fibres 
of the iris on stimulation of the skin, and contraction of 
the ciliary muscle on accommodation, some or all may be 
lost in association with spinal disease. These changes de- 
pend upon or leave three centres capable of separate action, 
all of which probably lie in the tract beneath the aqueduct 
of Sylvius. Experiments made by Hensen make it likely 
that the anterior portion of the tract governs accommoda- 
tion, and the centre next behind it the reflex contraction of the 
iris. On the outer side of the latter is a centre on which 
depends the reflex sensory dilatation of the pupil. The 
efferent path of the two former are through the third nerve. 
As yet we know little as to the centre for the contraction of 
the iris which is associated with accommodation, not know- 
ing whether the nucleus for the ciliary muscle is connected 
with the mechanism for contraction of the pupil at the 
centre, or in the lenticular ganglion, or in the ganglionic 
mechanism within the eye. It is more probable that the 
connection is in the lenticular ganglion. 
The path by which stimulation of the skin causes reflex 
dilitation of the iris is circuitous. The afferent impulse 
reaches the centre by the cervical part of the spinal cord 
when the skin of the neck is stimulated, and the efferent 
impulse descends the cervical cord thence to the superior 8 
WILLIAM OLIVER MOORE. 
thoracic ganglion of the sympathetic, and then ascends the 
sympathetic to the eye. 
These pupillary symptoms are as common in tabes as 
they are rare in other spinal diseases. 
The most common being the loss of reflex action to 
light, while the pupil still contracts to accommodation, the 
“ Argyll-Robertson ” pupil or reflex iridoplegia. 
Associated with this symptom is also a loss of the dilita- 
tion of the pupil on stimulation of the skin. Next in 
frequency, but very much less common, is paralysis of all 
the intrinsic muscles of the eye, the ophthalmoplegia interna 
of Hutchinson. 
The rarest is loss of accomriiodation, cycloplegia, with- 
out loss of reflex action. 
If we embrace all of the pupillary symptoms, both slight 
and transitory, and the more profound, we will find them 
present, according to Erb, in more than one-half of all 
tabetic cases. Gowers, in 72 cases of primary degenerative 
ataxia, found the internal muscles of the eye affected in 
92 per cent. 
The percentage of his cases with pupillary signs was in 
the first stage 84, in the second 93, and in the third 100. 
In forty-one of our own cases already spoken of, the 
“Argyll-Robertson” pupil was present. 
When the light reflex is lost the pupils are often small, 
but not necessarily so. 
When there is loss of accommodation they are rarely 
very small, less than 2mm., and are often 4 or 5 mm. in 
diameter. 
The reflex dilatation of the pupil when the skin is stimu- 
lated is a phenomenon closely allied to the contraction of 
arteries, which may be produced in animals by the stimulus 
of pain. The dilatation of the pupil may be obtained by 
irritating the skin of the face or the neck ; it is double, that 
is, the stimulation of one side causes dilatation of both 
pupils. 
The skin reflex is usually absent when the light reflex is 
lost ; the skin reflex may be retained when cycloplegia is 
present. DISEASES OF THE SPINAL CORD. 
9 
Dr. Hughlings Jackson has reported a case where vision 
was absolutely lost by optic atrophy, in whom the “ Argyll- 
Robertson ” pupil existed, and when the patient “made 
believe ” look at the clouds the pupil enlarged, and con- 
tracted when he made the effort to look at a near object. 
In examining the reflex dilatation which accompanies 
stimulation of the skin, precaution as follows should be ob- 
served : the eye should be shaded from a glare of light, 
voluntary movements on the part of the patient should be 
arrested during the test, as any movements being made the 
pupils being shaded will cause dilatation of the pupils. 
Urthoff* found reflex immobility of the pupil, combined 
with preservation of reaction on convergence, in 67 per cent, 
of all tabetic cases, and also the pupils were found to be un- 
equal in one-fourth of the cases ; one-sided cycloplegia was 
found in only five out of 166 cases. Reflex immobility of 
the pupil, without reaction on convergence, was found in 
thirty cases. 
We must not omit the paralysis of the externe muscles 
of the eye, that are so commonly seen in tabes, usually 
either the abducens or the motor oculi, and rarely the fourth 
nerve, which give rise to various symptoms of dizziness, 
diplopia and strabismus. Graefe has pointed out that tabetic 
patients show little disposition to fuse the images in binocu- 
lar vision, and this is taken as sign of the central origin of 
the affection. These muscular paralyses are frequent in the 
early stages of the disease ; they are transient often in char- 
acter, and this fact has not been very readily explained. 
Ptosis is also present when no other branch of the third 
nerve is involved. 
In 203 cases of tabes collected from various sources, par- 
alysis of ocular muscles occurred in 52, or over 25 per cent. 
GENERAL PARESIS OF THE INSANE. 
In this disease ocular symptoms are quite prevalent and in 
great variety. Mr. W. B. Lewis, of Wakefield, England, has 
collected the histories of sixty patients, with the following 
result: Loss of reaction of the pupil to light, 78 per cent.; 
* Berlin, “ Klinisch Woche.ischr.” 1886, No. 3. 10 
WILLIAM OLIVER MOORE. 
movements on accommodation, associated iridoplegia, 43 
per cent.; reflex dilatation to cutaneous stimulation was lost 
in 63 per cent.; complete fixity of the pupil, without impair- 
ment of accommodation, was found in 15 per cent.; in 7 per 
cent, of ophthalmoplegia interna occurred, although it was 
rarely complete as regards the ciliary muscle. 
He summarizes as follows : 
1. A loss of reflex dilatation to sensory stimulation occurs 
in a very large proportion of cases. 
2. Reflex iridoplegia (loss of action to light) next to the 
preceding is the most frequent accompaniment of the 
disease. 
3. Complete loss of movements of accommodation oc- 
curred in 25 per cent. 
4. Cycloplegia associated with the latter in four of the 
60, (more or less complete) and was found only in the ad- 
vanced stages of the disease. 
And he concludes that the sequence of morbid phenomena 
occurring in the iris, is as follows : 
Paralysis of reflex dilitation to cutaneous stimulation, 
reflex iridoplegia probably shown at first by an initial con- 
traction, followed by dilitation under full focal light, and 
passing into a later stage of immobility, and occasionally 
complete, ophthalmoplegia interna. Optic nerve atrophy 
occurs, and in 22 cases examined by Dr. Lawford, London, 
Eng., three were found thus affected. 
Nystagmus is associated with tabes, but is a rare symptom 
in this affection, and is usually found in multiple-sclerosis ; 
it has been ably set forth by Friedreich, who states that it is 
always bi-lateral, and that the movements of the eyes are 
rotatory and irregular, as seen in the case presented to the 
Society this evening: 
Richard Purcell, aet. 42, watchman. Sent to me by Dr. 
A. C. Coombs, of Newtown, N. Y., Feb. 13, with the follow- 
ing history : That for the past fourteen months he has no- 
ticed a difficulty with his eyes ; that they “jump ” and annoy 
him very much by causing objects to move rapidly in front 
of him. Has no pain. In 1872 he was struck on the left 
shoulder by a falling telegraph pole ; this knocked him over DISEASES OF THE SPINAL CORD. 
11 
and caused a severe contusion of the arm and shoulder, so 
that he could not use it for many weeks, and he never has 
had freedom from pain in it since, although he has moderate 
use of the member. Has not used tobacco since 1886, but 
has used alcohol in moderation. 
Present condition, Feb. 13, 1888, well nourished and all the 
functions good. R.= ||, L.= Jjj—2.5 D,0—2.75 D, cy. ax. 30°. 
Abduction, 8° ; adduction, 150 ; no vertical deviation by 
the prism test, nor hyperphoria at 20 feet. With the cor- 
recting glasses in position the nystagmus is the same as 
without them. There is no contraction of the visual or color 
field as tested by the perimeter. 
Both eyes show a marked nystagmus both around a trans- 
verse as well as an antero-posterior axis, which gives the 
eye a peculiar, swimming appearance. When the patient 
looks downward the ocular movements cease, as they also 
do when he fixes the eyes on a given object, but as soon as 
they are removed the oscillations begin with marked vigor. 
Pressure on the nape of the neck by the fingers, or throw- 
ing the head back so that the neck impinges upon the collar, 
causes the motions of the eye to cease. When lying in bed 
the patient states the eyes are quiet. 
The fundus in each eye shows a dirty-looking optic nerve, 
but one which would not be considered abnormal by many ; 
yet I am inclined to consider the nerve in a state of neuritis 
of a low grade which will produce atrophy ; the ophthalmo- 
scopic examination is very difficult, owing to the rapid 
movements. The pupil responds to light and accommoda- 
tion. 
The knee-jerk is present so far as my testing has proved ; 
the patient complains of swaying while walking, and that 
his feet do not have the proper sensation on touching the 
floor. I present him as an example of nystagmus probably 
due to multiple sclerosis, from the injury of the shoulder 
years ago. 
It does not occur during rest, but always on an attempt 
to fix the eye. 
Frederich considers it due to a form of ataxy of the move- 
ments of the eye, and speaks of it as ataxic nystagmus, and the 12 
WILLIAM OLIVER MOORE. 
cause to be due to a disturbance of the co-ordinatory tracts, 
which lead from the centres of co-ordination to the nuclei of 
the nerves of the ocular muscles lying on the floor of the 
fourth ventricle, and that it does not occur in spinal disease 
until the medulla is involved. 
Pierret explains these movements on the ground of the 
primary disease of the sensitive root tracts of the trigeminus 
in the medulla. 
Nystagmus is a very common symptom of multiple scle- 
rosis, and it is increased by any effort of the will or any 
violent emotion ; according to Charcot it is met with in one- 
half of the cases. 
In multiple sclerosis of the cord, we have temporarily a 
permanent diplopia due to paralysis of the various ocular 
muscles ; amblyopia is also observed, but it rarely, as in 
tabes, leads to positive blindness, with optic nerve atrophy, 
although in rare cases it does ; the difficulty is probably due 
to nodules of sclerosis in the optic tracts and optic nerve. 
The paralyses of the external muscles of the eye due to 
spinal cord disease, we will reserve mention of till a future 
occasion, as the subject of ophthalmoplegia externa is of 
much scope and interest.