Reprinted from the New York Medical Journal 
for December 3, 1892. 
EYE-STRAIN 
AND ITS RELATIONS TO “CEREBRAL HYPEREMIA,” ETC* 
v/' 
By E. C. SEGUIN, M. I). 
Eye-strain, more especially that due to paresis or origi- 
nal weakness of the third and sixth cerebral nerves, pro- 
duces many symptoms besides cephalalgia and migraine 
which have lately received so much intelligent attention. 
The symptoms to which I refer are fully as important as 
cephalalgia and migraine, but have been generally, if not 
universally, misunderstood because practitioners have blind- 
ly followed the theoretical teachings of certain authorities. 
The chief of these symptoms are : Occipital, suboc- 
cipital, and occipito-cervical pain and distress; a sense of 
stiffness in the occipito-cervical region (“ at the base of the 
brain,” as is commonly said) ; feelings of fullness, pressure, 
or lightness in the head ; sensations of numbness or of 
formication in the scalp; varying degrees and forms of diz- 
ziness (but not true vertigo f) ; inability to read, write, sew, 
* A supplement to Lectures on some Points in the Treatment and 
Management of Neuroses, which appeared in the Journal in April and 
May, 1890. Lecture I. Written at Florence in January, 1890, for a 
German edition of the Lectures (G. Thieme, Leipsic, 1892). 
f Aural or labyrinthine vertigo and vertigo from evident or latent 
diplopia are, of course, excluded. In such cases true vertigo (subject- 
ive whirling or turning) exists, and often no other cerebral symptoms 
are present 
Copyright, 1892, by D. Appleton and Company. 2 
EYE-STRAIN. 
converse, sit at table, to go on the street or into rooms, and 
even to “ think,” without supervention or aggravation of 
symptoms; fear of certain places; insomnia; emotional at- 
tacks ; pains (differing from migraine) in various parts of 
the head ; and, later, also the multiple symptoms termed 
neurasthenia. Individual patients describe these subjective 
symptoms somewhat differently, according to their ability 
of observation and their facility of expression. 
The above-mentioned symptoms, variously grouped and 
sometimes combined with others, have been appropriated 
by the advocates of a fanciful vaso-motor pathology ; and 
such wholly theoretical “ diseases ” as “ cerebral hypercemia ” 
(Hammond) and “ congestion of the base of the brain ” 
(Brown-Sequard) have been accepted by the profession with 
but too little open criticism, and multitudes of patients have 
been treated by remedies deductively considered as useful, 
such as the actual cautery, cups, and blisters to the neck, 
the ice-bag to the head and spine; internally, ergot, the 
bromides in full doses, belladonna, and (contrary to the 
theory, but found useful in practice) strychnine. Such 
cases have never been cured, I believe, by these means alone, 
though often relief has been obtained by the analgesic 
effects of the remedies and by the suggestion of the confi- 
dent specialist.1 
I have never recognized these so-called “ diseases,” but 
have always recorded and spoken of the symptoms as par- 
sesthesiae of the head {cephalic par cesthesice), awaiting the time 
when experience might lead to their more correct interpre- 
tation. 
To be brief, I now believe that I can offer a preliminary 
partial grouping of these symptoms according to their patho- 
genesis, not by any means a perfect scheme, but one which 
may serve as a basis for further and more minute observa- 
tion and better classification. EYE-STRAIN. 
3 
1. The majority of cases presenting such symptoms are, 
I think, cases of eye-strain : exhaustion and hypersesthesia 
resulting from the persistent use of weak neuro-muscular 
organs, more especially the third and sixth nerve appara- 
tuses. Errors of refraction seem to play but a secondary 
part in the genesis of the symptoms, whereas they are very 
important in cases of cephalalgia and migraine. Most of 
all, suboccipital pain and distress (the chief symptoms of 
“ congestion of the base of the brain ”) are due to defect- 
ive power of convergence and accommodation. Not rarely, 
in all categories, the symptoms appear within a short time 
or suddenly, after years of apparently easy use of the eyes. 
This sudden onset may often be traced to the action of 
some debilitating influence, such as an attack of acute dis- 
ease, to over-use of the eyes, etc. ; and it often coincides 
with the “ failure of accommodation,” normal or premature. 
In other words, the strain and fatigue resulting from the 
use of weak eyes are often long compensated or rendered 
latent by perfect health. 
2. Some cases (my experience does not enable me to 
state a proportion) of cephalic parsesthesicß are due to dys- 
crasic conditions, more especially lithaemia, oxaluria, latent 
gout—in general terms, to conditions of suboxidation. The 
early stage of cirrhosis of the kidneys is sometimes charac- 
terized by these symptoms and obstinate headache, and in 
these cases the arterial tension is persistently high, the urine 
is overabundant, of low gravity, contains hyaline casts with 
or without albumin; attacks of convulsions and of slight 
hemiplegia are not rare. 
3. Such symptoms as lightness in the head, pressure in 
any direction (I do not believe that the direction of the 
pressure, a purely subjective interpretation by the patient, 
has any meaning in the present state of our knowledge), and 
deficiency in power of attention, memory, etc., may un- 4 
EYE-STRAIN. 
doubtedly be caused by anaemia of the brain from general 
anaemia or through valvular cardiac disease, feeble heart, etc. 
4. It is also possible that occasionally these symptoms 
indicate the beginning of organic cerebral disease, but at 
present we can not feel sure of this in a given case. 
5. Probably cephalic paraesthesiae are developed by the 
action of peripheral—i. e., extra-cerebral—lesions, as in 
some cases of “ spinal irritation,” etc. 
The chief purpose of this note is, however, to endeavor 
to advance the problem, as presented in group 1, one step 
further, and to state (from observed facts only) which of 
the above-mentioned symptoms may be caused by paresis 
of the third nerves and their muscles, and which by paresis 
of the sixth nerves and their muscles, apart from the ele- 
ment of refraction, which is also important. 
The necessity of stating my views in so small a compass 
must be the excuse for the following condensed summary of 
two symptom-groups which deserve more ample treatment: 
A. Symptoms of Paresis [lnsufficiency) of the Third Cere- 
bral Nerves and Attached Muscles.—Occipito-cervical pain 
and “ distress ” are the characteristic symptoms, sometimes 
the only ones. The pain, diurnal as a rule, and often not 
appearing until the patient has used his eyes in dressing, 
eating, or reading, is usually greatest between the occipital 
bone and the second vertebra, though it often extends from 
the upper part of the occiput to the fourth or even the sixth 
vertebra. It is sometimes more a “ distress ” than a true 
pain, and is often accompanied by sensations of stiffness 
and tightness (“ as if a hand grasped the neck ”). There is 
never, strictly speaking, neuralgia of the occipital nerves, or 
objective rigidity as in beginning caries. Tenderness is 
rarely found, though in women spinal hypersesthesia (so- 
called spinal irritation) often coincides. Frequently there 
Is a sensation of weight or downward pressure on the back EYE-STRAIN. 
5 
part of the head, with (usually) intermittent numbness (a 
“ dead ”or “ wooden ” feeling-) and formication. In some 
cases the fullness or tightness (cincture or cap feeling) ex- 
tends to the whole head. 
Apparent loss of power of attention and concentration 
(volition) is much complained of, even to a degree simulat- 
ing mental failure.* Reading, writing, sewing, piano prac- 
tice, conversation, even eating, are painful or unbearable; 
in other words, the symptoms are increased by any act re- 
quiring convergence and accommodation. It is sometimes 
said by patients, in objection to the suggestion of eye- 
strain, that the symptoms appear or are increased by 
“ simply thinking ” ; but this statement involves ignorance 
of the psychological fact (or law) that in thinking, giving 
attention, concentrating our mind, and in willing—in all 
such apparently purely psychic acts—we unconsciously send 
out motor impulses to the ocular apparatus chiefly, but also 
to many other muscular groups. Any one can, by a few 
moments’ study of himself, verify the truth of this state- 
ment that giving attention or willing usually includes ex- 
ternal muscular activity (unconscious, as a rule). Thus eye- 
strain occurs in persons who do not mean to use their de- 
fective eyes. 
The prolonged duration of these symptoms, or rather of 
the strain, may lead to neurasthenia, insomnia, and a curi- 
ous mixture of hysteria and hypochondria, so that the diag- 
nosis becomes more obscure. 
Headache is not rare, but in such cases there are also 
usually faults in refraction or other factors. Simple asthen- 
opia, sense of fatigue, or pain in the eyes, orbits, brow, or 
temples, is only occasional, and seldom a prominent symp- 
tom. Usually the patient pretends to have strong eyes. 
* Some cases of “breaking down” at school from “overwork” be- 
long to this category. EYE-STRAIN. 
B. Symptoms of Paresis [lnsufficiency) of the Sixth 
Cerebral Nerves ayid Attached Muscles.—In contrast with 
the symptoms of insufficiency of the third nerve apparatus, 
the symptoms of this condition are diffused, variable, and 
less definite. Perhaps the most prominent is dizziness, or 
“ vertigo,” as stated by the patient. But close questioning- 
shows that this is not a true vertigo, but a sense of un- 
steadiness, of uncertainty of equilibrium, of confusion, 
clearly referred to the head. Allied to this is nearly always 
a sense of indefinite fear. At times the dizziness is so 
great as to oblige the patient to keep his room and to give 
up all ordinary duties and relations. Going out upon the 
street or entering rooms filled with people intensifies the 
feeling to an insupportable degree, and the patient needs 
the moral or physical support of another person. 
Various and peculiar sensations are felt in the head— 
such as a sense of fullness, “as if the head would burst” ; 
a downward pressure on the head, diffused or localized, 
“asif a stone or a sharp stick ” pressed on it; a sense of 
constriction, general or cincture-like; pain in various areas 
of the scalp ; occasional feelings of numbness (a “ dead ” 
or “ wooden ” feeling), or of formication or wormlike 
crawling, also variously distributed; a quasi tinnitus or 
noise in the head (not in the ears) is not rare. 
As these paraesthesise are increased by the sight of mov- 
ing objects in a small or large space (on the street, where 
machinery is in motion, or where a number of people are 
moving), we often meet with conditions like those termed 
agorophobia and claustrophobia; and I am confident that 
many cases recorded under these titles have really been 
cases of eye-strain. However, I admit that there are such 
cases which depend upon more general pathological condi- 
tions. I should add that the movements necessary to make 
the examination of the eyes of these patients fatigue them EYE-S I’RAIN. 
very much, even the simplest test of the recti muscles by 
the index finger causing distress. Hence examinations 
should he made slowly and in several seances. 
Apparent loss of mental power is perhaps more marked 
a feature of these cases than of those of category A. The 
patient can do things fairly well all alone in the quietude 
of his room, but in his relations with the world he seems 
to lose all self-control and power of attention and concen- 
tration. In consequence of the distress attending going 
out upon the street and meeting other persons, such a de- 
gree of emotional disturbance (loss of self-control) is de- 
veloped that the patient is said to be hysterical. His 
symptoms absorb his attention so much that he often is 
called hypochondriacal as wel I. 
Insomnia and neurasthenia are results of long-continued 
■eye-strain in this category as in the first—perhaps more. 
It is in these later stages of the affection that the diagno- 
sis becomes obscure, and can only be determined by pro- 
longed observation and by trial of treatment. For it is 
not easy to say at once, in a case presenting symptoms of 
neurasthenia and hysteria (perhaps also “spinal irritation ”), 
together with defective eyes, which of the conditions is 
primary 7 and pathogenetic. The relation of cause and effect 
is doubtless in either direction in different cases, and it will 
be for future observation to give us the elements for judg- 
ing this important question more quickly and positively. 
In the few cases which I have seen in which all the ocu- 
lar muscles were paretic, the (multiple) symptoms were 
more like those of category B. 
It may be said that there is a certain overlapping of 
semeiology in this sketch of the two symptom groups. 
This is true, but I believe that further study will make the 
distinction more complete, though it must be remembered 
that these overlappings appear in nearly all symptom groups 8 
EYE-STRAIN. 
which we attempt to represent as “ diseases.” This note is 
suggestive only, and I do not pretend to state more than 
the main outlines of the question. 
It is probable that a special grouping of symptoms will 
be found to be due to “ spasm of accommodation,” which 
so often complicates errors of refraction. T have not the 
data for any suggestion in this direction, except to say that 
headache and migraine will be found prominent. 
Diagnosis by Manipulation.—lt is out of my province 
to speak of the ophthalmic examination necessary in all 
such cases ; but I desire to call attention to the facts that 
the simple test of convergence, by approximating a small 
object to the patient’s nose, increases the suffering of sub- 
jects of the first category, while those of the second cate- 
gory experience great distress when made to look out- 
ward or around without moving the head, or if a bright 
object is moved circularly, or a wheel rotated before 
them. Complete atropinization gives these last patients 
great relief. 
Diagnosis by Drugs.—ln the present state of medicine 
this is occasionally a final resort. We employ it in sup- 
posed malarious and syphilitic cases, even while remember- 
ing that quinine does cure some non-malarious conditions, 
and that mercury and iodide of potassium are occasionally 
efficacious where syphilis is out of the question. A trial 
by bromide treatment often enables us to correctly judge 
cases in which hysterical and epileptic symptoms are con- 
joined. In cases of eye-strain, experience has taught me 
that cases of the first category (third-nerve paresis) are 
relieved by nux vomica or strychnine, and are aggravated 
by belladonna and other mydriatics ; whereas, on the con- 
trary, the last-named remedies give relief to cases of the 
second category (sixth-nerve paresis), and strychnine makes 
them worse. In some uncomplicated cases of paresis o EYE-STRAIN. 
9 
the third nerves (insufficiency of the recti intend or of the 
ciliary muscle) an apparent cure is obtained by a progressive 
course of strychnine. 
T can not in this note refer in extenso to the treatment 
of all such cases, but will simply repeat what is stated in 
the text of the Lectures—viz., that, apart from the adapta- 
tion of proper glasses and prisms, in some cases the use of 
partial or total tenotomy or myotomy, which are all of the 
utmost importance, the scientific treatment consists in the 
internal use of nux vomica, strychnine, and nerve tonics 
generally in cases of category A, and of cannabis indica, 
belladonna, atropine, conium, the bromides, antipyrine, 
etc., for cases of category B. Of course, in cases of both 
categories, rest, much more complete than is usually pre- 
scribed (even ocular rest by prolonged atropinization), and 
a general restorative treatment, are necessary. Change of 
scene and travel are useful, but should never be prescribed 
until all the visual defects have been corrected and con- 
valescence is evident. Work should not be resumed ex- 
cept with the aid of the most appropriate optical correc- 
tion, and by degrees. It must be added that there are eyes 
which can not be “ corrected ” with our present appliances, 
and in such cases the prognosis is bad, although temporary 
improvement may be obtained by proper medicinal and hy- 
gienic treatment. I would, lastly, suggest that tobacco is 
particularly injurious to persons whose third nerves, are 
weak.