COMPLIMENTS OF AUTHOR. 
Reprinted from the Transactions of the Medical and Chirurgical Faculty of Maryland, 1883. 
RELATION OP EYE AND SPINAL DISEASES. 
B T 
E N A 
PROFESSOR OF DISEASES OF THE EVE AND EAR COLDBGE OF PHYSICIANS ANI) 
SUROEONS, BALTIMORE. Reprinted from the transactions of the Medical and Chirurgical Faculty 
of the State of Maryland, 1883. 
Section on Ophthalmology. Otology and Laryn- 
gology 
By A. Friedenwald, M. D. 
Professor of Diseases of the Eye and Ear, College of Physicians and Surgeons, Baltimore. 
When ophthalmology had first succeeded in establishing itself as a 
specialty, it was feared by many that it would gradually alienate it- 
self completely from general medicine and surgery. The many new 
terms which it introduced and the intricate methods of exploration 
which it taught, made the communications which issued from those 
who had devoted themselves so zealously to it, contribute much to the 
apprehension that had from the first been entertained. The general 
advancement which had been effected in this department of science 
soon suggested what might he accomplished in other departments by 
similar work, and for a while it appeared that a general disintegration 
would ensue, as one new specialty after another, with its host of earnest 
devotees, presented itself so prominently to the consideration of the 
general profession. The result, however, has been different from what 
was anticipated, and ophthalmology was in the van in showing alle- 
giance to the general science. Whatever manifested itself in the eye 
during general disturbances, or whatever injurious influence reached 
it from diseased conditions of distant organs, or whatever trouble it 
became involved in from having a suffering neighbor, was carefully 
studied; the relations indicated so that the symptomatology of the 
general clinician was increased thereby, and it has often occurred 
that a careful exploration of the eye has revealed serious disease of 
other parts, which, in the absence of other symptoms, would have, at 
least for a time, been entirely overlooked. 
It has been satisfactorily demonstrated that the many wonderful 
links by which the various parts of the system are so intimately 
bound to each other, will not permit the complete isolation of any 2 
specialty. More than this—the various specialties, in exploring dis- 
tant regions, often meet each other and mutually extend the helping 
hand. Very close alliances have thus been formed, particularly be- 
tween ophthalmology and neurology, in defining the relations of 
brain and eye diseases on the one hand, and spinal and eye diseases on 
the other. It is the latter subject which has been chosen as the sub- 
ject of this report. 
It has long since been realized that spinal diseases not unfrequently 
involve the eye. Especially has this fact been pointed to in connection 
with Tabes dorsalis, but it has also been found that other lesions of 
the cord must be charged with a share in producing the eye troubles 
under consideration. 
With regard to the percentage of eye troubles in affections of the 
spinal cord, there have not been furnished sufficiently large statistics 
upon which a correct estimate could be based. Von Graefe estimated 
that in all cases of progressive atrophy of the optic nerve, thirty per cent. 
(30%) would have to be placed to the account of spinal diseases. 
Leber, in 87 cases of optic nerve atrophy which came under his ob- 
servation in a given time, found 23 cases which exhibited spinal symp- 
toms; that is, in 26 per cent, of the cases. In consulting the state- 
ments concerning the frequency with which optic nerve disease oc- 
curs as a consequence of spinal lesions, we must not be unmindful 
of the fact that it not seldom happens that the optic nerve presents 
the first symptoms occurring in the disease. Indeed, in some cases the 
eye symptoms may precede by many years the characteristic signs of 
spinal lesions. If we take this in consideration, it becomes extremely 
probable that in the statistics that have been tabulated by various 
authors, many cases of optic nerve atrophy have been excluded from 
the series that have been accompanied by spinal symptoms, which, 
however, in their future development proved to have owed their 
origin to the same distant cause. According to Charcot, the amaur- 
osis may be the first, and for a long time the only symptom mani- 
fested, and a period of time as long as ten years may elapse before 
the pains and characteristic motor disturbances become established. 
We must still further consider that the optic nerve is not the only 
part of the eye which is assailed in spinal affections, but that there 
are quite a number of cases in which contracted or dilated pupils are 
observed, and, furthermore, cases in which disturbances in the external 
muscles of the eye occur. 
Cyon, who has collected the record of 203 cases of locomotor ataxy, 
finds the various eye disturbances manifested in 105. 3 
Erb,* in referring to the muscular anomalies, makes the statement 
that if we embrace them all in the estimate, including the slight and 
transitory disturbances, differences in the pupils, spinal myosis, we 
have them in more than one-half the cases; more prolonged and per- 
manent disturbances, on the contrary, may probably not arise in more 
than one-third or one-fifth of all cases. 
Tropinard found in 102 cases, visual disturbances in 49. 
As has already been stated, it was through the study of the varied 
symptoms of locomotor ataxy that the revelation came to ns that 
spinal disease not unfrequently involved the visual apparatus. And 
while this form of spinal lesion still furnishes the largest number of 
cases in which visual disturbances are observed, they are also quite 
frequently met with in multiple sclerosis of the brain and spinal cord, 
in chronic myelitis, in slow compression of the cord, in injuries of 
the spinal cord, and in recent times we have been furnished with the 
evidence that cases of acute myelitis are not entirely free from this 
complication. 
When Erb wrote upon nervous disorders in Ziemsen’s Encyclopedia 
he was not yet aware that acute myelitis could involve the eye, for he 
states that “ disorders of the optic nerve, of the nerves supplying the 
muscles of the eye and other cerebral nerves, which play such a prom- 
inent role in chronic myelitis, are unknown in acute myelitis.” 
Allbutt found five cases of acute myelitis which presented visual 
disturbances, but it is not mentioned whether these depended upon 
atrophy of the optic nerve. Steffan first led the way to the investiga- 
tion of optic nerve degeneration due to acute myelitis.f He has been 
followed by very important observations in this direction by Seguin, 
Noyes, Rumpf, and quite recently by Nieden. 
The large field for the study of the connection of eye and spinal af- 
fections which these varied etiological sources have furnished has still 
further been extended by the valuable conjoined researches of Rieger 
and von Forster. J These investigators have been enabled to show by 
an extensive study of the symptoms of insane paralytics, and by sat- 
isfactory post mortem examinations, that the optic nerve degeneration 
which accompanied these cases was not due to the cerebral lesions, 
* Vol. 13, p. 580, Ziemsen’s Eneycl. 
f Versammlung der ophthalmologischen Gesellschaft, Heidelberg, 1879. 
X Auge und Riickenmark, von Dr. Rieger in Wurzburg und Dr. von Forster in 
Nurnburg, Grade’s Archiv f. Ophthal., Vol. 27, part 3. 4 
but had to be referred to the disease of the spinal cord that was con- 
comitant in these cases. 
The relations of eye diseases and brain affections had of late years 
been made so clear, that any case that was accompanied by the 
slightest brain symptoms was attributed to an intracranial cause; no 
matter what spinal symptoms might have coexisted, they were 
generally ignored, so far as any connection between them and the 
eye disturbance was concerned. They reached these conclusions by 
observing, that although meningitis and atrophy of the cortical sub- 
stance of the brain had existed, the eye symptoms were always want- 
ing, unless disease of the spinal cord had also been found. 
How a disease of the spinal cord could involve the eye has long 
been an unsolved problem. A glance at the different course which 
the optic nerve affection pursues, in the two most prominent spinal 
diseases, locomotor ataxy and multiple cerebro-spinal sclerosis, 
leads at once to the recognition of the fact that the eye is not assailed 
in these two diseases in the same way. In ataxy, when the optic 
nerve becomes implicated, we encounter a diseased condition which 
is of a progressive character. We do not observe in these cases any 
arrest of its development; the amblyopia which first manifests itself 
is observed gradually to become more and more marked, until finally, 
total amaurosis is established. In multiple sclerosis, on the contrary, 
the optic nerve has seldom been observed to have undergone complete 
atrophy, and, consequently, while persons suffering with an eye com- 
plication in this disease will have impaired vision, they will extremely 
seldom be found to have been rendered completely blind. 
When the vision becomes impaired in locomotor ataxy, certain 
alterations in the appearance of the optic nerve will be revealed from 
the first, showing that a certain degree of atrophy has occurred. In 
multiple sclerosis, according to Steffan,* a considerable amblyopia 
may present itself, and the optic nerve may not reveal anything 
abnormal in its appearance. And even when a certain degree of 
atrophy has been discovered, the impaired vision which has been 
found to co-exist, may be found in the further observation of the case 
to have become considerably improved. When the optic nerve has 
been assailed in locomotor ataxy, we will not observe a similar 
fluctuation in the vision, nor will even a temporary cessation in 
the danger which threatens be noticed. 
* Loc. cit. 5 
We must conclude from these important differences in the clinical 
aspect which these cases present, that the pathological anatomy of 
the diseased nerves must vary greatly. Indeed, from the general 
pathology of the disease, we may assume that in multiple cerebro- 
spinal sclerosis, the optic nerve affection does not depend upon any direct 
influence of the diseased cord, but that from the diffused character of 
the disease, both the cord and the eye are independently attacked. 
We can readily understand that a pathological process, that travels 
ovei; so extended a ground as does multiple sclerosis, can in its full 
development also reach the optic nerve, without regarding the disease 
of the latter as due directly to the disturbance in the part originally 
affected. And in this sense, multiple sclerosis is to be excluded from 
the category of diseases of the spinal cord which have a direct in- 
fluence in establishing changes in the eye. 
But how are we to regard the relations between the eye trouble and 
the spinal disease when the former appears as the undoubted con- 
sequence, of the latter ? The simplest explanation that suggests itself 
is, that an inflammation, having reached the spinal meninges, has 
ultimately extended to the meninges at the base of the brain, and 
finally to the optic nerves. While this theory must be left uncontro- 
verted as a possibility in the acute cases that have ended in resolu- 
tion, it cannot be accepted as an explanation of the chronic forms, 
for it is neither sustained by the symptoms nor by the autopsy. 
That a diseased condition of the spinal cord can induce changes in 
the distantly situated optic nerves, as a direct consequence, we are 
forced to accept as a fact, by the history of acute cases, especially 
those due to traumatic lesions, and furthermore by the result of phy- 
siological experiments, to which we will hereafter refer; and we are 
forced to assume, in the absence of any apparent continuity of disease 
in the parts situated between the diseased cord and the affected eye, 
that the injury is transmitted by a vaso-motor disturbance, conveyed 
in the tract of the sympathetic nerve. 
In studying the method of transmission of a pernicious influence 
from a diseased cord to the optic nerve, we must not overlook a way- 
station between the affected parts, which (Stilling’s investigations, in 
tracing the roots of the optic nerve in the medulla oblongata, have 
brought to our notice. If we grant that a spinal lesion might first 
assail that part of the medulla from which the optic nerve roots are 
said to arise, no extra messenger would be required to explain how 
the disease was conveyed to the optic nerve, provided that the optic 6 
nerve degeneration showed a centrifugal development; but on the 
contrary, the anatomical investigations that have been made have 
proved that the disease in the nerve begins at its terminal part and 
spreads in a centripetal direction. Besides this, we would still have 
to search for the method by which the disease is carried from the 
cord to the medulla, the parts intervening remaining intact. If 
future investigations will demonstrate that the medulla may be 
implicated, we will still require the theory which has been men- 
tioned, namely, a vasomotor disturbance, to indicate the journey of a 
diseased influence from the cord to the optic nerve, with the modi- 
fication that that influence has made two instead of one leap, but in 
the same direction ; in either event the eye trouble must be regarded 
as equally dependent upon the spinal lesion. 
The most conclusive testimony regarding the optic nerve degener- 
ation being due to the direct influence of spinal disease, is furnished 
by those cases which have had a traumatic origin. Allbutt* found in 
thirty cases of well-marked spinal injuries, eight cases in which eye 
disturbances occurred; they accompanied those which followed a 
chronic course, that is to say, the cases which had sustained a less 
severe injury, of which there were thirteen; in the other seventeen, 
which terminated in death in a few weeks, no alteration in the 
eye appeared. 
Mooren f reports a case in which a blow with the flat of the hand, 
causing syncope which lasted half an hour, was followed by heavi- 
ness of the lower extremities, and in the further course, by progressive 
optic nerve atrophy, terminating in blindness and accompanied by 
other spinal symptoms. 
Bruce Clarce J reports four cases, three of simple concussion of the 
spinal cord, and one of fracture of the vertebra. In these, “ early 
transient changes of the optic disk were observed. They could not 
have been even suspected without periodical ophthalmoscopic exami- 
nations. The appearances noticed consisted of hyperaemia and some- 
times odcema of the optic disk.” 
Bull,§ in examinations which he conducted in cases of Potts’ 
disease, found that while the optic nerve was free from any destruc- 
* On the Ophthalmoscopic Signs of Spinal Disease, Lancet, Vol. 1, p. 76, 1870. 
t Ophthalmologische Mitth., 1874, p. 95. 
t London Medical Record, 1881, p. 166, April 15th. 
§ Eye Lesions in Affections of the Spinal Cord, American Journal Medical 
Sciences, July, 1875, p. 70. 7 
tive alteration, the branches of the vena centralis retinae were large 
and tortuous, the minute nutrient vessels of the nerve increased in 
number and size, the enlargement being occasionally also noticed in 
the arteria centralis retinae. 
In the cases of Allbutt, quoted above, hyperaemic conditions of the 
fundus oculi were found associated with the amblyopia. 
The discovery of vascular disturbances in the above-mentioned 
cases has a very important significance. Von Graefe rejected the idea 
that an optic nerve atrophy could directly be due to spinal disease, 
for the reason that he had never observed the atrophy of the nerve in 
these cases preceded by hyperaemic conditions, pointing to an optic 
neuritis as the beginning of the eye disease, as is commonly the case in 
atrophy following intra-cranial causes. He viewed the optic nerve 
complication and the spinal lesions due to a common cause, affecting 
different parts of the nervous system independently of each other. 
In addition to the hyperaemic conditions that have been found in 
the traumatic cases, we have the complete symptoms of optic neuritis 
found in association with the acute cases that have already been men- 
tioned, to show that it is very probable that the atrophy which has 
been regarded as the starting point of the eye disease, is but the con- 
secutive expression of a previously existing inflammation. 
Wharton Jones,* as far back as 1869, first announced the theory 
that the disease of the optic nerve in spinal lesions was in general due 
to disturbance of the sympathetic nerve, leading first to paralysis of 
the vasomotor nerves and to hyperaemic conditions, and later to atrophy 
of the optic nerve. 
The objection which Von Graefe first offered, namely, the absence 
of hyperaemic conditions previous to the atrophy, greatly retarded its 
acceptance. The force of this objection has been greatly shattered, 
not only by the hyperaemic conditions which the ophthalmoscope has 
revealed in connection with acute and traumatic myelitis, but also by 
the investigations of Hiegerand von Forster,f who have been able to 
report two cases of spinal disease of chronic form in which well- 
marked intercurrent hyperaemic conditions were observed. 
It has been claimed that the eye disturbance often taking place 
long in advance of the spinal symptoms, deprives the theory of 
Wharton Jones of plausibility. Indeed, this circumstance has been 
* On the Occurrence of Amaurotic Amblyopia, long after the injury, in cases of 
Concussion of the Spinal Cord, Brit. Med. Jour., July 2, 1809. 
t Loc. cit., pp. 117, 118. 8 
adduced as evidence to prove that the eye-trouble is entirely inde- 
pendent of the spinal lesion. It must be borne in mind, however, 
that these opinions were proclaimed before the importance of the 
tendon reflex, as a means of diagnosis in spinal affections when other 
phenomena might still be in abeyance, was discovered. Rieger and 
von Forster, in a number of cases of optic nerve atrophy, were 
enabled, principally through the absence of the tendon reflex, to 
detect that the cord had simultaneously been affected. It may safely 
be assumed that the atrophy of the nerve which is generally dis- 
covered as soon as disturbance of the vision is complained of, has 
been preceded by vascular disturbances; for in connection with 
choked disk, we have long since learnt that this may exist, and that 
too, to a very high degree, as is often discovered by the neurologist, 
long before any impaired vision follows. 
In arriving at this conclusion we need not simply be governed by 
the experience that vascular disturbances play so prominent a role in 
the initiatory stages of those conditions which lead to atrophy of the 
optic nerve in intracranial disease. In the frequent occurrence of 
changes in the pupil in spinal affections we have very strong evidence 
of the complicity of the sympathetic nerve, and physiological experi- 
ments have long ago taught us that its innervation is accompanied 
by hyperaemic conditions. It is true that the vascular disturbances 
referred to were observed in the integument of the face and neck, on 
the side upon which the cervical sympathetic had been operated on; 
and it is of great interest to know in what manner the retinal circu- 
lation would be affected under these circumstances. 
Rieger and von Forster report the following experiments : Irrita- 
tion of the exposed cervical sympathetic in rabbits, with a strong in- 
ductive current, at a point 5mm. below the superior cervical ganglion, 
up to the ganglion itself, caused, in the case of two rabbits, very con- 
siderable contraction of the retinal vessels, which, after the interrup- 
tion of the current, disappeared in one and a half minutes ; the 
contraction of the vessels being always accompanied by wide dilatation 
of the pupil. 
After the cervical sympathetic had been cut and the ganglion 
removed, in four cases no immediate effect was observed; but on the 
next day, and for several days after, until the animal died, the retinal 
vessels on the side of the operation remained dilated. 
With regard to the simple irritation of the exposed nerve, the result 
corresponds with what we have previously known, namely, that it 9 
would cause contraction of the radiating fibres of the iris; and the 
contraction of the muscular coat of the vessels, which was also found, 
is in perfect harmony with this condition of the pupil. That, how- 
ever, there should be no immediate result following when the nerve 
was severed and the ganglion removed, is rather a surprise; for the 
experiments of Claude Bernard and others have taught that among 
other phenomena, contraction of the pupil would invariably be pro- 
duced. The dilatation of the retinal vessels, which took place the 
day after the operation, indicates how vascular disturbance may 
precede optic nerve atrophy, through the influence of the sympa- 
thetic, and suggests further how it possibly may be called forth in 
spinal disease. 
Three clinical observations, which Rieger and von Forster report, 
are exceedingly interesting as showing the complicity of the sympa- 
thetic in assaults upon the eye, in which, however, the spinal cord 
was not involved. Time will not permit me to give these cases in 
full. The first of the group exhibits optic nerve degeneration, with 
unmistakable symptoms of vaso-motor disturbances about the face. 
In the second we are shown that a double struma, exerting pressure 
upon the cervical sympathetic, caused a peculiar discoloration of the 
face, and hyperaemia and swelling of the optic disk with impaired 
vision. In the third there was exhibited the external manifestation 
of disturbance of the sympathetic, and the symptoms of a very 
destructive form of inflammation, of which a plastic iritis and 
increased tension were the prominent features. In the study of 
exophthalmic goitre, which, it is conceded, depends upon a disturbed 
condition of the sympathetic, we have been made acquainted with 
the hyperaemic conditions by which this disease is attended, but in 
these observations neither inflammation nor atrophy has been 
observed. The cases just cited have therefore an important signifi- 
cance, showing as they do that under certain conditions the 
hyperaemia, which was heretofore known to occur in disturbances of 
the sympathetic, may go one step farther and assume the full 
character of an inflammation, and finally result in degenerative 
changes. 
The experiments which Rieger and von Forster made upon the cord, 
in supplementing those previously made upon the cervical sympa- 
thetic, are exceedingly interesting. A strong induced current with 
sharp electrodes was sent through the lumbar vertebrae, being so 
directed that it had to pass through the cord. Tonic spasm of all 10 
the muscles supervened. After one minute the current was inter- 
rupted, the retinal vessels were slightly contracted, and the pupils 
were dilated ad maximum and remained in this condition for some 
time. At first the animal was unable to move, and the patella reflex, 
which had been readily induced before, was now found to be entirely 
wanting. 
In a second experiment the sharp electrodes were applied to the 
previously intact integument between the fourth and sixth dorsal 
vertebrae, and pushed through in a direction that they reached the 
arch of the vertebra on either side. A medium induced current was 
employed for five seconds, by which dilatation of the retinal vessels 
was produced, and in a few seconds more very decided dilatation of 
the retinal vessels followed. The experiment was repeated five or six 
times with the same current, sometimes with negative results; but 
whenever the pupils dilated the dilatation of the vessels followed 
soon after. If the current was greatly increased, suddenly the vessels 
became anaemic, the papilla pale, the pupils contracted, and death of 
the animal supervened. The autopsy, which was undertaken immedi- 
ately after,showed that all the abdominal and thoracic organs, the brain 
and its meninges, were anaemic. A very large amount of bipod was 
found occupying the vertebral canal, from the first dorsal vertebra to 
the end of the canal and compressing the cord. The hyperaemia 
terminated abruptly at the seventh cervical vertebra, from which 
point upwards the canal was anaemic. 
In a third experiment the vertebral canal was opened at a point 
corresponding to the first dorsal vertebra, and the needle electrodes 
were introduced from behind without any special reference to what 
part of the cord was struck. A very weak current was used. Both 
the pupils and the vessels dilated, and as the experiment was pro- 
longed, convulsions supervened and the animal died, the vessels and 
pupils having contracted just before. The same result was found as 
in the previous autopsy. 
It will be observed that the irritation of the spinal cord was accom- 
panied by quite different results in the eye than when the experiment 
was directed to the cervical sympathetic; and furthermore, a differ- 
ence was observable in the direct irritation of the cord when different 
points were selected. When the cervical sympathetic was chosen for 
the experiment we find contraction of the pupil and contraction of 
the retinal vessels. When the lumbar portion of the cord was 
operated on there resulted dilatation of the pupils and contraction of 11 
the vessels, and when the dorsal portion of the cord was experimented 
on we find that both dilatation of the pupils and dilatation of the 
vessels occurred. 
One fact certainly has been satisfactorily established in these expe- 
riments, namely, that an irritation of the cord will set up hy- 
peraemic conditions of the optic nerve, although from the varied 
results of the different experiments it might be objected that the 
influence from the point of irritation in the cord is not carried to the 
optic nerve by way of the sympathetic. It cannot, however, be denied 
that the sympathetic nerve may, under certain circumstances, be the 
medium through which the eye is reached in spinal diseases, for, in 
addition to other evidence, we have the observation of Basch,* who 
has seen the dilatation of the retinal vessels as a result of irritation of 
the splanchnic nerve ; on the other hand, it cannot be claimed that 
when disease of the cord implicates the eye that it always travels in 
the same path. 
With regard to the differential diagnosis of optic nerve disease as a 
result of spinal lesions, the great expectations that have been in- 
dulged in in reference to the ophthalmoscope have as yet not been 
realized. And while there are those who speak of peculiarities in the 
hyperaemic stage, and of characteristic discolorations of the optic 
disk in* the stage of atrophy, there would hardly be one who would 
venture a diagnosis upon these alone. The examination of the func- 
tions of the eye may, however, yield very important data. Prominent 
among these are the red-green color-blindness, and the contracted 
field of vision, especially the sector-shaped defects that will frequently 
be manifested. Another very significant symptom in distinguishing 
this from other forms of atrophy is the increased sensibility to light. 
Not only will such patients see better in twilight, but sometimes 
when they are almost entirely blind they will still complain of the 
distressing effect of bright light. When spinal symptoms are already 
developed the diagnosis is comparatively easy; and in the absence of 
those ordinarily looked for, the examination of the tendon reflex will 
often lead to the detection of spinal disease, when other symptoms, 
by which this condition is more commonly attended, may not yet 
have made their appearance. Westphalf first called the attention of 
the ophthalmologists to the importance of the tendon reflex as a 
diagnostic aid in all cases of optic nerve atrophy, and urged its 
* Arbeiten d. Leipzigher Physiologischen Instituts, 1875. 
t Berliner Klin. Wochenschrift. January, 1878. 12 
employment with a view of determining whether it constitutes an 
early symptom of locomotor ataxy. 
Uthoff’s* investigations incline to this conclusion, and in his cases, 
in which spinal symptoms were present, the patella reflex was almost 
invariably absent. In only two of his fifteen cases could the patella 
reflex be demonstrated, and in these the spinal symptoms were very 
well marked. In twenty-four cases of progressive optic nerve atrophy, 
there were seven in which the patella reflex was absent. In these 
cases there was nothing to indicate that they were due to diseases of 
the cord, but there was one among them in which, after three months, 
spinal symptoms became developed. Probably if the others could 
have been followed, similar results would have been observed. In 
sixteen cases of atrophy of the optic nerve, due to cerebral diseases, 
eight of nine in adults showed that the tendon reflex was maintained; 
in the others the patients were too young for satisfactory examinations. 
With regard to the changes noticed in the pupil in spinal diseases, 
there is nothing that can be pointed out as peculiar when the pupils 
are dilated; but when the pupils are contracted we find a condition 
that seems to be quite characteristic. .The peculiarity alluded to 
consists in the phenomenon that this contracted pupil undergoes no 
alteration whether the patient be brought into a dark chamber or be 
exposed to the most intense light, but still exhibiting changes with 
the efforts of accommodation. With regard to the frequency of spinal 
myosis, Uthoff found it present in nine cases of fifteen. To Argyle 
Robertson is due the credit of having first pointed out the character- 
istic features of spinal myosis.f His observations were soon fully 
verified by Knapp,| Leber,§ Hempel,|| and others, and it may be re- 
garded as one of the principal symptoms in the differential diagnosis 
of optic nerve atrophy due to spinal diseases. 
We now arrive at a point in our studies where we must turn our 
attention to another form of eye symptom in spinal affection, namely, 
the disturbances of the muscles of the eyeball; and here we approach 
the most obscure part of our subject. Both the alterations found in 
the optic nerve and in the pupil can be explained by disturbance of 
the sympathetic. There is nothing in the nature of the affection of 
* Beitrag zur Sehnervenatrophie, Graefe’s Archiv fur Ophthal. 
t Edinb. Med. Journal, 1809. 
t Archiv fur Augen und Ohrenheilkunde, 1872. 
$ Virchow-IIirsch’s Jahresb. 1872. 
|| Ueber die Spinalmyosis, Graefe’s Archiv, 22 a. 13 
the muscles of the eyeball, however, which points to a similar origin. 
It has been found that the paralysis of the muscles of the eyeball 
appears as a very early symptom in the spinal disease; sometimes 
assuming a very transitory character, at others persisting obstinately. 
The muscles supplied by the fourth pair of nerves seem to enjoy 
almost entire immunity in these conditions; those supplied by the 
third and sixth pairs are attacked with almost equal frequency. 
Sometimes the motor oculi of one eye will be involved, while the 
abduceus of the other alone has suffered. 
The paralysis of the muscles of the eyeball occurring in syphilis 
bears a great resemblance to that met with in spinal lesions, pre- 
senting the difference, however, that complete paralysis of the motor 
oculi is more frequently observed in the former. Rieger and von 
Forster have so frequently been able to trace syphilis antedating the 
symptoms of spinal disease that came under their notice, especially 
in those cases that were attended by such paralysis, that they were 
forced to infer that the paralysis had an independent origin in these 
cases. It might be said, in opposition to this opinion, that in 
excluding this group of symptoms from the general influence that 
passes from the cord to the eye, the whole theory of the dependence 
of the eye complication upon the diseased cord is seriously assailed. 
It must not be overlooked, however, that the principal support which 
the theory that the eye symptoms are produced by the spinal lesion, 
and are not a simple coincidence with it, has been received from what 
has been observed in acute cases of myelitis, in traumatic lesions, and 
in the physiological experiments to which the cord has been sub- 
jected, and in these cases the oeulo-pupilar symptoms alone were 
manifested. It is to be hoped that further investigation will fully 
clear up the discrepancy which is noticed in this regard between the 
acute and chronic forms of spinal lesions.