THE EYE SYMPTOMS OF EARLY PARESIS. BY NEIL JAMESON HEPBURN, M. D., The attention of the writer was specially directed to the ocular disturbances in the early period of general paresis by the observations made in the case of one who was a personal acquaintance, and hence afforded, perhaps, more than ordinary opportunities for observation. G. Z., æt. 38, asked for advice regarding the care of his eyes, which troubled him when reading, particularly at night. This was in December, 1884. He claimed that his vision was as good as ever, but that his eyes. tired easily. He was a theatrical manager, a man of exemplary habits, used neither liquor nor tobacco in any form, and was especially happy in his family relations. His family consisted of his wife and one child, three years old and healthy. He was very ambitious and a hard worker. No constitutional taint could be elicited, and he was especially reticent on the subject of his parents and early life. On physical examination his vision was found to be nearly normal, but the field cut off, on the temporal side in each eye, slightly and to the same extent. (See Chart No. I.) He accepted no glass for distance, but was able to read with comfort only with over each eye. He continued to do very well till December 12, 1885, when he began to complain again of the same indefinite discomfort. An examination at that time disclosed -0.75 in each eye, and he was more comfortable with that correction. He also had an insufficiency of the internal recti of from two to three degrees at twenty feet. The optic-nerve entrance at this time disclosed no marked deviation from the normal, except that it was too pale, perhaps, with a slightly bluish tint. The vessels in and about the disc were normal in appearance and color, except that they appeared to stand out in bolder relief, which was supposed to be due to the marked contrast they presented to the bluish-white background. Glasses were orderd, which corrected the error, both visual and muscular. On March 28, 1886, he complained that the discomfort still existed, and another examination was made. Nerve bluer tint, vessels still prominent, but beginning to show signs of atrophy in the narrowing of their caliber; not marked, however. Field more narrowed on temporal side (Chart No. II) and V-20- Refraction unchanged and tension normal. Examinations made on April 11th and May 2d of the same year gave similar results, except that the signs of atrophy became more marked and his vision was reduced to 8. On the advice of friends he then consulted Dr. David Webster, who made a diagnosis of optic-nerve atrophy, and ordered iodide of potassium in increasing doses. V. No improvement resulting, on June 5th Doctor Webster ordered the hypodermic use of strychnia. A curious feature of the case was that at this time, when the test showed vision to be steadily deteriorating, the patient was positive that he was improving, and insisted that he could see as well as ever; but would sometimes refuse to make the trial when requested. In the latter part of June he became restless and irritable, did not sleep well, and was somewhat changed from his usual quiet demeanor, but his friends laid it to a press of business matters, and urged him to take a rest. None of the toxic effects of strychnia were apparent at any time. From July 1st to 4th his wife states that he scarcely slept at all, was continually on the move, and acted so strangely that she was afraid for herself and the child. On July 5th could not be controlled or kept at home. Owned all the street-car lines, etc., and threatened to shoot conductor who refused to obey his commands. Was arrested, examined by the late Dr. W. R. Birdsall, found to be a paretic, and confined in Bloomingdale, where he grew more quiet, but died July 9, 1886. The apparent correspondence between the eye symptoms and the progress of the general affection, with the knowledge of the frequency of optic-nerve atrophy in old cases of general paresis, suggested the idea that perhaps cases presenting the appearances seen in the early history of this case might, if kept under observation, give some light as to the relation of the eye symptoms to the cerebral condition. With this object in view all the eye cases coming under observation since that time have been carefully examined, and where found to present similar appearances, or so nearly so as to excite suspicion, they have been followed up as thoroughly as it was possible to do without exciting the suspicion of the patient. As a result nine cases have been observed from an early stage of the disease, and most of them followed to their final termination. Of these I propose to offer a short account, and draw from the conclusions which have suggested themselves, with the hope that in the wider and Page 88 For Mbs R. B Date Page April 12:1871 Date Jany 10.1894 Page 88 more fertile field occupied by this society they may be further corroborated or shown to be only incidental. Com Case I.-T. H., æt. 55. First seen December 24, 1888. plains indefinitely of discomfort in vision. V-28-- in right eye; 0 in left, with correction. All the intrinsic ocular muscles are weaker than normal, internal recti more than the rest. Abduction four degrees. Adduction five degrees, but no apparent insufficiency. Optic discs creamy pink, with vessels too prominent on the surface. Retina and choroid apparently normal. Field slightly contracted on temporal side, and perception of blue poor in right eye, with micropsia in the same eye. January 18, 1891.-Patient has consulted other physicians without obtaining any relief from his disagreeable symptoms. Now he has periodic dilatation of the right pupil, migraine, and some photopsia in same eye. V-8 R. E., and 8 L. E. Fields narrowed ten degrees on temporal side. Muscular conditions about the same. Optic discs white, tending to blue. Vessels still prominent, and no marked change in caliber. Facies changing, naso-labial fold not so sharp and signs of echo speech. Says business worries him. January 20, 1892.-Informed by a friend of Mr. H. that he had gone abroad in the preceding autumn for the purpose of getting rid of his nervousness, and that a physician whom he had consulted in Germany had said that his brain was affected. Case II.-O. E. F., æt. 50. Pilot. First seen on December 26, 1889. He had been complaining of his eyesight for some time previous. Has V=28-- R. E., -L. E., with correction, and no accommodation. Esophoria two degrees at twenty feet. Discs whitish-blue, vessels prominent, slight atrophic crescent on temporal side of disc. Field cut off fifteen degrees on temporal side in each. Pupils normal. This case was seen at intervals of two or three months till January, 1890, when he was removed from the city for his health, having developed some signs of mental disturbance, the nature of which was not easily made out from the account furnished by his friends, except that he had developed extravagant habits. He died in March of the same year from injury. On the last two visits he had exhibited marked paretic tendencies in articulation when he became excited. Case III.-G. B. B., æt. 47. First seen March 11, 1890. Paresis external rectus right eye twenty-six degrees at twenty feet. V=R. E. -; L. E. 8. Discs leathery white, with pinkish center. Vessels stand out on surface of disc, no change in caliber. Fields cut off temporarily, more in left. Ordered potassium iodide in increasing doses. March 24th, same year, paresis of external rectus only twenty degrees at twenty feet. Vision unchanged. Objects to medicine. April 20th.-Fields and vision same as on previous visit. Has stopped taking his medicine and refused further treatment; said he could see as well as ever. Lost sight of till heard from in the Butler Hospital, where he was admitted March, 1893, and I am informed was discharged July, 1893, improved. Case IV.-W. J. S., æt. 53. First seen October 2, 1890, with paresis of external rectus of right eye, five degrees at twenty feet. Occasional diplopia. Previous history good. Fundus oculi apparently normal, but discs white and vessels prominent. V-R. E.; L. E. 8, with correction, paresis of accommodation. Fields cut off fifteen degrees temporarily in each eye. Suggested an alterative course of treatment, and that he be watched. In the spring of 1891 he was supposed to be suffering from neurasthenia, and was taken abroad for his health. 60 Case V.-Mrs. R. B., æt. 55. First seen on April 12, 1891. Had a good family. Had brought up a large family, and had had much care. She complained of vertical headache, for which I was consulted. No pain in eyes. V-8 o. u. with correction ; and read Jäger No.1 at 9" w. -- 5.00, o. u. No apparent heterophoria. Discs show shallow cup, creamy or leathery white, vessels of normal caliber and prominent, giving pronounced parallax on motion. Tension normal. No disturbance of vision. Fields cut off as per chart. Occasional disturbances of speech. Since that time the patient has been seen occasionally, and now exhibits a typical case of so-called general paralysis of the insane, with acute attacks, interspersed with gradually lengthening quiet intervals, with intelligence disappearing and bodily strength much reduced. On January 10, 1894: V=8; fields cut off as per chart No. IV. Discs blue, and vessels considerably diminished in caliber and slightly tortuous. Case VI.-Mr. F. P., æt. 47. First seen on July 14, 1891, complaining of impaired vision. No history of constitutional disease. V-8-o. u., discs leathery, vessels prominent, and of normal caliber. Fields cut off as per chart No. V. Hesitating and echo speech, and flabby naso-labial line, slight bilateral ptosis. On suggesting the possible outcome of the disease to the friend who accompanied him, he was very indignant; insisted that he could see and do business as well as ever, and refused treatment. He was |