(_a_) _Argyll-Robertson Phenomenon, without Other Evidence of Disease._
CASE X.—A. L., aged thirty-three, the subject of slight hypermetropic
astigmatism. Pupils small, not quite circular, with Argyll-Robertson
phenomenon; no other ocular defect, and no evidence of a spinal lesion.
No history of syphilis.
CASE XI.—K. S., aged forty-three. Pupils rather small, unequal, quite
destitute of light response, though moving freely in convergence; no
other ocular defect except some presbyopia; no evidence of spinal
disease, though left knee-jerk not easily obtained. Unmarried; syphilis
seems highly improbable.
CASE XII.—G. G., aged sixty. Pupils small, with distinct
Argyll-Robertson phenomenon. Knee-jerks, not easily obtained, but not
definitely abnormal, and no other evidence of spinal disease. Patient
suffers from defective vision, probably from tobacco poisoning (central
scotoma for red); no history or evidence of syphilis.
(_b_) _Argyll-Robertson Phenomenon, with Other Ocular Disturbance
Suggestive of Locomotor Ataxia._
CASE XIII.—D. T., aged forty-two. Pupils below medium size, destitute of
light response, with free movement in convergence; had for seven days
suffered from diplopia, and under observation gradual development of
complete paralysis of right external rectus; no other ocular defect.
Knee-jerks distinct, and no suggestion of spinal disease; chancre of lip
and secondary syphilis nine years before.
(_c_) _Argyll-Robertson Pupils, with More or Less Evidence of Spinal
Disease._
CASE XIV.—T. F., aged fifty-five. Right pupil 2mm., left 3 mm., each
with Argyll-Robertson phenomenon; no other ocular defect except
presbyopia. Ten years ago had difficulty in passing urine, and since
then occasionally voids it involuntarily, and for eighteen years has
been liable to seizures of pain in calves, insteps, and heels;
knee-jerks normal, and no objective signs of spinal disease. Venereal
sore when aged twenty, but no secondary symptoms, and father of six
healthy children.
CASE XV.—H. W., aged thirty-eight, is the subject of hypermetropia, 4.5
D. Pupils very small, especially left; neither moves under light, but
distinct contraction during convergence. Admits recent difficulty in
descending stairs, saying he “frequently misses the bottom step,” and
has suffered from “sciatica” for two years. No objective evidence of
spinal disease, and urinary and sexual functions undisturbed. Admits
gonorrhea, but denies syphilis. Wife miscarried eight months after
marriage; no further pregnancies.
CASE XVI.—R. S., aged forty-three. Hypermetropic and presbyopic. Pupils
small, unequal, not quite circular, and with definite Argyll-Robertson
phenomenon. Knee-jerks cannot be obtained (confirmed on three different
dates), but no other sign or symptom of tabes dorsalis, unless
“rheumatic pains” in lower limbs for several years. Unmarried; no
history of syphilis. Four years ago had, after “catching cold,” to have
urine withdrawn by a catheter, but no subsequent disturbance of bladder
function.
CASE XVII.—E. W., aged forty-eight. Myosis with Argyll-Robertson
phenomenon; right ptosis and crossed diplopia (one month), without
obvious ocular paresis; absence of right knee-jerk (confirmed on two
occasions), and failure in retention power of bladder (six months), but
no other evidence of spinal disease; vulvar sores and skin eruption six
years before.
III.—CASES IN WHICH AN OCULAR PARALYSIS IS THE EARLIEST OR DOMINATING
SYMPTOM.
(a) _Ocular Paralysis, without Other Evidence of Disease._
CASE XVIII.—(By permission of Mr. J. T. James, F. R. C. S.) F. D., aged
thirty-seven. Dilated and immobile pupils, without any other ocular
defect. No evidence of spinal disease; syphilis nine years ago; no
change while under observation for three years.
CASE XIX.—K. K., aged twenty-eight. Iridoplegia, double, followed by
paralysis of left external rectus, the condition being under observation
for nearly a year, but without the discovery of any satisfactory
explanation. No evidence of spinal disease. Married, four healthy
children, no miscarriage; during one pregnancy very free loss of hair
(now grown again), but no other occurrence to suggest syphilis. No
family or personal history of gout or rheumatism.
CASE XX.—G. H., aged thirty-three. Dilated and immobile pupils, with
incomplete ptosis and divergence of eyeball on each side. Present
condition of four years’ duration, and separated by an interval of three
years from venereal sore and skin eruption. No other ocular defect; no
evidence of spinal disease, and general health good throughout. No
change while under observation for three months.
(b) _Ocular Paralysis, with Other Ocular Evidence Suggestive of
Locomotor Ataxia._
CASE XXI.—E. S., aged forty-three. Diplopia from paralysis right
external rectus, pupils small, each with Argyll-Robertson phenomenon;
visual left acuity only 6/12, and small but distinct central scotoma,
with some contraction of the peripheral field; knee-jerks distinct, and
no ataxia or other evidence of spinal disease. Three early miscarriages,
no full-time child. No change while under observation for nine months,
but on two occasions severe attack of vomiting and abdominal pain,
extending over several days and without recognized cause (? gastric
crises).
CASE XXII.—A. M., aged fifty-five. Left ptosis and paralysis of external
ocular muscles supplied by third nerve in 1887, the pupils being normal,
followed by incomplete recovery. In 1897 development of identical
condition on the right side, and pupils found to be small and with
Argyll-Robertson phenomenon; knee-jerks very slight and with great
difficulty, but no other evidence of spinal disease. No history of
syphilis.
CASE XXIII.—H. F., aged thirty-seven. Right ptosis with diplopia (seven
days) and defective inward excursion of right eyeball; pupils very
small, not quite equal, and with Argyll-Robertson phenomenon; optic
disks pale and marked contraction of visual fields, but normal central
vision; knee-jerks scarcely to be obtained, but no other evidence of
spinal disease. No history of syphilis. Father of four healthy children.
Seen after a month’s interval, paralysis of all external right ocular
muscles supplied by third nerve, and knee-jerks absent.
(c) _Ocular Paralysis, with More or Less Evidence of Spinal Disease._
CASE XXIV.—G. S., aged forty-one. Ptosis and complete ophthalmoplegia
externa on left side, with dilated and immobile pupils and some degree
of right ptosis, these conditions or some of them having been present
for five years. Knee-jerks distinct, and no ataxic phenomenon, but
imperfect control over bladder, and failure of sexual power during last
six months. No admitted syphilis.
CASE XXV.—J. L., aged forty-two. Diplopia and drooping left upper eyelid
for four years. Ptosis left side, and marked defect of ocular movements
in each eye; left pupil dilated and immobile; right small, contracts
during convergence, but no light response; no other ocular defect.
Knee-jerk scarcely obtained on either side; no ataxia, but attacks of
“twitching pains” in lower limbs, and for some time difficulty in
starting the flow of urine. Venereal sore in 1882, and subsequent loss
of hair, but no other secondary symptoms. Patient watched for twelve
months without appreciable change.
CASE XXVI.—L. D., aged forty-four. Crossed diplopia (one month), without
obvious ocular paralysis, and pupils small with Argyll-Robertson
phenomenon. Knee-jerks absent; no ataxia to usual test, but has noticed
tendency to stagger in the dark; is troubled with pains in the knees,
has difficulty in commencing the act of micturition, and recent marked
failure of sexual power; venereal sore at twenty years, and subsequent
sore throat, but no skin eruption or loss of hair. Father of three
healthy children.
CASE XXVII.—J. H., aged forty-seven. Double vision of two months’
duration; similar attack three years ago, with complete recovery.
Paralysis of right external rectus; pupils, visual acuity, and visual
fields normal. Knee-jerks absent, but no other evidence of spinal
disease. Patient the subject of albuminuria, and presents physical
evidence of an aneurism of the ascending aortic arch. Youngest child has
marked evidence of inherited syphilis.
CASE XXVIII.—W. M., aged thirty-five. Paralysis of left third nerve,
without iridoplegia or cycloplegia; pupils normal. Knee-jerks absent,
but no ataxia or other evidence of spinal disease. Several venereal
sores ten years ago, but no recognized secondary syphilis. There is,
however, evidence of a former iritis.
CASE XXIX.—M. C., aged fifty-four. Paralysis of left external rectus,
with history of two previous attacks of diplopia during last four years;
no other ocular defect, unless some imperfect light response in left
pupil; knee-jerks absent, and complaint of “sciatica” for two years, but
no other evidence of spinal disease. Albuminuria distinct, and physical
signs of hypertrophy of left ventricle. No history of syphilis.
CASE XXX.—(By permission of Mr. N. M. MacLehose, M. B.) H. Y., aged
thirty. Homonymous diplopia observed over a period of six months without
appreciable ocular paralysis; pupils of medium size, with definite
Argyll-Robertson phenomenon; knee-jerks absent, and in later months
decided ataxia and sensory defects in lower limbs; visual acuity
unaffected to ordinary test, but gradual contraction of visual fields,
especially on right side; chancre and secondary syphilis four years
before.
There are in these series of cases many facts which might reasonably be
made the subject of remarks, and several of the cases are certainly of
great individual interest. But they are here displayed in the above
grouping for the purpose of illustrating the clinical order and sequence
in which, as a matter of actual experience, the ocular disturbances of
locomotor ataxia may manifest themselves in relation to the spinal
evidences of that disease. Of course, in those cases in which there
exists only a single ocular symptom unaccompanied by any sign of spinal
disease, it may be objected that it has yet to be demonstrated that such
cases are of the nature of locomotor ataxia. It is doubtless to be
desired that such cases should be under exact observation as long as the
opportunity for further developments exists—that is, for the entire life
of the patient. But to insist upon such a condition is a mere counsel of
perfection. One must make reasonable use of such evidence as the brevity
of life and the exigencies of practice permit. And the evidence here set
forth affords at least a very strong presumption, to say the least of
it, of the truth of the doctrines stated in the earlier paragraphs of
this paper. Probably the particular proposition which is most likely to
be contested is the one which places the Argyll-Robertson pupil equally
with optic-nerve atrophy, and an ocular paralysis, as a possible first
event in the eruption of the phenomena of locomotor ataxia. But on
turning to the records it will be found that the facts support this
suggestion almost as strongly as they support the corresponding
suggestion in reference to optic-nerve atrophy and ocular paralysis.
Attention in this respect may be particularly given to Case XIII. The
man complains of a quite recent diplopia, and he has undoubtedly had
syphilis; the pupils show the Argyll-Robertson phenomenon. It is in the
highest degree probable that, had the patient been under observation a
week or two earlier, the condition of the pupils would have been the
sole existing ocular abnormality. Yet in the light of the development of
an ocular paralysis, it can scarcely be doubted that, whether he develop
spinal symptoms or not, his nervous system is the site of diseased
processes of the locomotor ataxia order. When to these facts there are
added, as in Cases XIV. to XVII., illustrations of the various forms and
degrees of evidence of spinal disease that may be associated with the
Argyll-Robertson pupil, it seems impossible to resist the conclusions
that the condition of the pupil so named may be the first evidence of
locomotor ataxia; that it may precede by varying intervals other
evidences of the disease; and that at least very probably, in a certain
number of cases, the symptomatology of the disease may be permanently
restricted to this one event. In some examples of its spinal form
locomotor ataxia is undoubtedly an extremely chronic disease, with few
and imperfectly developed symptoms; and it is thus not unnatural to
expect that similar limitations may obtain in the ocular manifestations
of the disease. That evidences of grave nervous disease may be limited
to the pupil is well seen in Case XVIII., where a syphilitic patient was
under observation for three years without the discovery of any
abnormality other than paresis of each sphincter iridis. There is
certainly no obvious reason why a similar restriction should not
determine the Argyll-Robertson pupil as a purely isolated phenomenon
with, it must be added, the same unfortunate possibilities that are
undoubtedly attached to the patient whose case has just been quoted. The
conclusions above adopted in reference to the Argyll-Robertson pupil are
applicable, _mutatis mutandis_, to optic-nerve atrophy and to ocular
paralysis, as is abundantly demonstrated in the corresponding series of
the cases recorded in this paper.