MEDICAL literature of all ages is full of recorded cases of ocular reflex neuroses. In former times they were recorded more as peculiar and not understood phenomena; as curiosities, rather than in a scientific sense admitting of explanation. Each year as conducted experiment and investigation is carried on, and as the nervous physical and psychical functions and their intricate relationship are gradually unravelled, and become better understood, the curious gives way to the matter of fact, and the former phenomena to natural and fairly well understood laws.
The subject is very extensive and far-reaching. We have neither time nor space to attempt exhaustive treatment. Ours a duty to schedule and classify; to record action and reaction; to collect authentic cases, of every possible variety, and from this maze and aggregation endeavor to deduce, in the future, some general and well established laws.
DEFINITION.-Nerve reflex is a direct transference of centripetal excitations to centrifugal paths, or vice versa, without the cooperation of the will.
All animal activity and functional force depend upon and is the result of physiological reflex action, whose general laws and pathways are understood.
The reflex is physiological as long as it is in harmony with normal functions and activities.
When the reflex excitations result either in over or under activity, it then becomes an abnormal reflex, or a neurosis.
Physiological reflex action, as well as reflex neurosis, may be manifested either as motor, sensor, or functional phenomena.
The contraction of the pupil to light is an example of physiological reflex; here impression is conveyed by the nerves of special sense (retina and optic nerve) to the brain centres, and then reflected back through a motor nerve (third nerve) producing contraction of the pupil. Or the sight of a disgusting object may produce nausea; here the pathway of the nervous reflex is through the same nerve of special sense to the pneumogastric, and hence the consequent nausea, a neurosis. Or the fluttering, increased rapidity of the heart beat; or the blanching of the checks, in the presence of great danger, will again represent the functional features of a reflex neurosis.
The fact that these nerve impulses, originating in one system of nerves, may be transmitted to another system and reflected back again, from sensor to motor or functional, presupposes a close connection and intimate correlation between the cerebro-spinal and the sympathetic systems of nerves. Such intimate relationship and blending are anatomical and physiological facts.
The great sympathetic system of nerves is a series of closely connected ganglia, extending along each side of the spinal column, from the head to the coccyx, communicating with itself from side to side, as well as with both roots of the spinal cord as they emerge. It communicates likewise with al the other nerves of the body, uniting with the fourth and sixth nerves, in the cavernous sinus; and with the olfactory and auditory at their ultimate expansion, as well as being in close connection with all the other cranial nerves, through its cranial ganglia; forming thus the great blending and binding pathway and influence.
While at the summit of the spinal cord is the medulla oblongata, a congregation of ganglionic centres, and series of sensory ganglia from which arise the seventh, eighth, ninth, tenth, eleventh and twelfth nerves; and also gives root to fibres of all the remaining six cranial nerves in its centre, the fourth ventricle. In addition to this, it is united by commissural hands in all parts of the brain proper, and contains most of the fibres, which are distributed to the other parts of the encephalon; and hence it transmits both the motor and sensory impulses, as they pass from and enter the cerebrum.
In the light of this intimate blending and interpenetration of the cerebro-spinal and sympathetic systems of nerves, their mutual influence, one upon the other, would seem to be, not phenomenal, but almost an anatomical and physiological necessity.
Since the normal processes and pathways of the reflection are so numerous and complex, it is easily intelligible how numerous and complicated the disturbances of motility, sensation and function may be, and from how many different points abnormal influence may be excited and reflected, in motor, sensor and functional, as well as in psychic, centres. The form and character of the neurosis may thus be extremely numerous, and hence the recognition of the primary cause may be not only difficult, but at times impossible to locate.
Starting out with the above statements clearly in mind, this discussion of ocular neuroses resolves itself into a simple statement of observed and recorded facts, without the necessity of delay for extended and elucidating argument.
Ocular reflex neuroses may be considered under two general headings:.
I.-Reflex-neuroses from the eyes to and implicating other parts and organs.
II.-Reflex-neuroses from other parts and organs, affecting the eyes.
These reflex activities may be variously manifested, for the same cause may result either in sensory, motor, functional or organic disturbances, and there is no known fixed law to determine which it will be; in fact, these groups often present no sharp lines of demarcation, but frequently overlap each other at many points, so that, in certain cases, we meet with symptoms characteristic of two or more groups.
Under the first heading, or reflexes from the eyes producing disturbances in other parts and organs, the most important and the most frequently met with, are resulting from optical anomalies, viz., myopia, hyperopia, astigmatism.
Various and distinctly different results may follow from the same apparent cause, such as pains in and about the eyes, headache, neuralgia, photophobia, nictitation, diplopia, nausea, vertigo, dizziness, restlessness, insomnia and mental aberrations.
Local inflammations may follow same cause, as conjunctivitis, blepharitis, styes, corneal inflammation or ulceration, retinal hyperaemia or optic-nerve congestion, etc. These are all the direct results of irritation produced by eye- strain, transmitted through the optic nerve to and though the cerebro-spinal and sympathetic systems of nerves, finding outlet either as a perverted sensation, a motor impulse, or causing functional disturbance, and, may be, organic changes in various parts.
Under this heading we must also place heterophoria and its disturbing consequences, for it is not the deviation in direction of the eyes themselves directly which causes such unpleasant results, which are almost identical with those caused by optical anomalies, but it is through the resulting lack of visual equilibrium, and the difficulty or impossibility of forming retinal images and impression on the necessary “identical points,” which is the prime cause of the long list of troubles which may follow in the wake of this lack of muscular equilibrium of the eyes.
If we ask why the same apparent condition may produce such widely different results, we should remember, as before remarked, that the laws of reflex action are not universal. The same irritation, functional or organic, may produce radically different reflexes in different subjective, or in the same subject at different times. While in other cases the same apparent optical or muscular error does not seem to be attended by the least irritating reflex results. There must be some nervous predisposition existing in the subject afflicted aside from the local points of irritation. This would seem to be proved by the fact that they in whom reflex troubles are most common are usually of a neurasthenic temperament.
To illustrate this variety of susceptibility coming, under my personal observation, a few brief cases, which are familiar and numerous, may be given:.
A scholarly minister, about 50, had, for years, suffered with neuralgic pains in and about the eyes, frequent nausea, nervous prostration, etc., the familiar picture. A + .25 Dc. ax. 90 degree, brought perfect relief and restored health.
In another case, a neurotic boy, age 15, had frequent epileptoid attacks, which a -.5 Dc. ax. horizontal removed, thus showing the small amount of error producing aggravated results in predisposed neurasthenic subjects.
A typical case, showing on utter lack of susceptibility, may now be examined. A gentleman, age 30, applied to me for aid in defective vision. he had never seen as well as other people. Had never been subject to headaches, neuralgia, nor other signs of reflex irritation; only “could not see well.”.
Examination showed V=15/30. With + 6 Ds. + 1.25 Dc. ax. 45 degree in the R. eye, and same combination, with ax. 135 degree in L. eye, gave him v=15/15. He continues to wear this glass with great physical comfort and personal satisfaction. Under ordinary circumstances we would have expected much nerve reflex irritation to be associated with such an optical condition.
Again, a young lady, 18 years old, wore a + 2 D. for six or eight years, with great relief to former suffering. As the end of this time she again began to have reflex irritation symptoms to a very annoying degree. The addition of a. 25 Dc., ax. 90 degree brought instant and permanent relief, thus showing that the neurasthenic predisposition may be different in the same individual at different times, influenced, no doubt, by other general conditions and nerve irritations, originating at parts other than the eyes.
Under peculiar reflex symptoms may here be mentioned the case of a lady with myopic astigmatism who felt a severe pain run down her right leg every time she tried to read more than a few minutes.
In the above consideration of the resulting sensory neuroses, above given, as pain, neuralgia, headache, etc., we should remember, as Erb well states it, that pain is a common sensation that belongs, not to a peculiar kind, but only to a certain degree of sensation, and it thus has no specific quality. It is only a question of intensity; hence pain is only the aggravation of normal sensations, and this is the chief difference between a physiological reflex and an abnormal or reflex neuroses. The sensation of pain depends upon two factor, its intensity and individual susceptibility.
The various forms of reflex neuroses, which may result from optical anomalies, will illustrate the different reflex pathways through which perverted nerve may be exhibited.
While the attention of the ophthalmologist is principally directed to the various forms of reflex neurosis originating in the eyes, he should carefully keep in mind that, in keeping with the laws of reflex nerve action, irritation of any character, having origin in my organ or at any part of the body remote or near the eyes, may be transmitted back to and affect the eyes through the same pathways which the first-mentioned efferent neurosis travelled. Indeed, many of the most obstinate and annoying cases of eye trouble we meet can only be remedied by the discovery and mastery of the remote causes which produce them. The eye is in a state of responsive sympathy with every organ and region of the body.
Tabes dorsalis or allied diseases are accompanied by contracted pupils and at times by paralysis of the eye muscles. Paresis of the occulo motorius and abducens occur in the early stages of locomotor ataxia.
In seventy cases of locomotor ataxia reported by Graniger Stewart (ef. Med. W., 1882) there were 20 cases of squint; 3 of ptosis; 4 diplopia, without manifest squint; 7 of myosis; 4 difference in papillary diameter; 8 with Argyll-Robertson pupil, etc.
On the other hand, irritation of the cilio-spinal region will often associated with partial mydriasis and optic nerve congestion, while paresis or paralysis off the cervical sympathetic will produce myosis as well as partial ptosis. This is through the sympathetic system of nerves. According to Hensen and Volckers, the papillary fibres of the sympathetic have the cord at the upper dorsal and lower cervical vertebrae, going through the superior cervical ganglion and entering the carotid plexus.
They then pass through the ciliary ganglion in the orbit. The whole of the fibres do not take this course, because it is found that when the ciliary ganglion is extirpated, irritation of the trunk of the sympathetic will still dilate the pupil. The ophthalmic branch of the fifth nerve, and probably other nerves connecting with the inner eye, also furnish channels of access for other sympathetic fibres. The partial ptosis is caused by paresis or paralysis of the sympathetic, which sends motor fibres to the musculi palpebrales. This form of partial ptosis is not uncommon in women, and is frequently associated with reflexes from the uterine or ovarian system.
Hystero-neuroses form a special and frequently met with group. It is noteworthy, however, that the severity of the uterine disease does not predicate the presence or absence, the severity or the mildness of the reflex. Authority tells us that structural diseases of the uterus and its appendages are not so apt to be followed by reflex phenomena, as functional troubles.
In this very interesting discussion of “Visual Disturbances and Uterine Disease,” A Mooren (A. f. A. vol. x.) declares, from his large experience, that there is no part of the eye which (either from a physiological or pathological point of view) is beyond the influence of the uterine system. He assigns the reflex theory as the direct cause.
The suppression of menstruation has frequently produced eye complications. McKay (Jour. Med. Sciences, 1882,) gives twelve cases of ocular affections from suppressed menstruation, numbering among them choked disc, diplopia, asthenopia, defective vision in some, etc.; while M.F. Comes (Am. Med. Herald. Oct., 1882,) gives four cases of menstrual amblyopia, varying from slight loss of vision to almost total blindness, deep seated pains in eyes, with burning stinging, etc.-all of which were restored after menstruation had been re-established.
Sexual excesses, especially masturbation, are frequent causes of reflex ocular trouble. The latter is a prolific cause of much irritation, and it it generally very difficult to trace, especially in females. It is frequent cause of spasm of the accommodation, hyperaemia of the funds and optic disc, obstinate neuralgic pains in and about the eyes, and in some cases paresis of the accommodation.
Connected with hysteria, that general neurosis of the whole nervous system, there are frequent and various forms of eye complications, embracing partial or complete amblyopia, hemiopia, scotoma, phosphenes, floating clouds, myosis, mydriasis, ptosis, photophobia, spasm or paresis of the accommodation, neuralgic pains, etc., all of which are purely reflex ocular neuroses, a part of the general neurosis.
Orificial irritation are frequent causes of reflex troubles. This includes haemorrhoidal and other and diseases, phymosis, stricture of the urethra, or cervix uteri-all of which are, without question, frequent causes. Recent current medical literature is filled with cases fully illustrating this.
Intestinal irritation, either from inflammation or from worms, has been followed by ocular reactions. Both of these conditions may produce similar eye reflexes, such as temporary strabismus, diplopia, myosis or mydriasis, ptosis or wide-open eyelids. Many remarkable cases have been reported from time to time. Lawrence (Am Ed., 1854, p. 607,) gives case of a child, seven years old, who had intolerable paroxysms of pain in left eye, which was entirely relieved by purgatives, bringing away a coral bead, which had been swallowed.
M. Wishart gives a case of complete amaurosis of the left eye, in a boy nine years old, of four months’ duration, who made immediate recovery after free purgative.
Another case is given of a boy, eight years old, who could not see large print, who was rapidly restored after turpentine enemata brought away quantities of worms.
In a recent case of my own, a young man of twenty-six, who had a very persistent and annoying diplopia, causing vertigo and disagreeable head symptoms, recovered promptly after pressing several years of tape-worm.
There are many cases, similar to those related, on record.
The great trifacial nerve is very intimately connected with all parts of the visual apparatus, both directly and indirectly through the sympathetic nerves and the ciliary ganglion. From this we might expect that all the necessary conditions to favor frequent and varied forms of ocular reflex neuroses were present- and such is the case.
Many authentic cases of defective vision following irritation of the fifth nerve, have been reported. McKenzie (Am. Ed., 1855, p. 997,) gives a case of a man who had a small tumor on the crown of the head, which had been ten years coming. It was not painful or sensitive to touch. He had much headache, and quite a defective vision. it proved to be a cartilaginous cyst, filled with a yellowish fluid. Its removal restored his vision and remedied his headaches.
Within the past year a patient of mine had a tumor, size of a filbert, about one-half an inch above the supra-orbital foramen of the left eye. It had been gradually developing for some years, and the vision of that eye had been as gradually growing less and less. The removal of this growth perfectly restored the sight.
Many cases of partial or nearly total loss of vision, caused by diseased teeth, have been published. I discussed this topic in a contribution, “The Eye-tooth and the Eye,” in the Chicago Medical Investigator (July, 1875), and gave then the accepted explanation for it, which is that it is a reflex-neurosis through the ciliary ganglion and the other sympathetic connections of the great trifacial nerve. Since then a number of interesting cases have come under my observation. One case is well worthy of comment.
A lady had a large cavity in the left upper bicuspid tooth. The diseased contents were thoroughly excavated and removed, and the nerve was killed by a dentist. The tooth was filled with gold. A month or two afterward, the vision of the left eye began to fail, growing less and less as the weeks went by. The tooth was not sensitive, but the gum at one side of it seemed painful to pressure.
The tooth was extracted, and the sight was rapidly restored. Examination of the tooth showed that in the filling of it the thin side wall had been perforated at one point, and a little plug of gold had been forced through it, extending about one-tenth of an inch outside, and pressed against the wall of the socket; and this had set up the reflex-neurosis, through the well known pathways, to the seeing-nerve.
In the above brief examples of various forms of ocular reflex neuroses, no attempt has been made to explain why the reflexes should be so varied in their nature; why the phenomenon is at one time sensor, at another motor, than functional and again organic; for, as mentioned before, there does not seem to be any known law regulating the direction which the reflex may take. They may thus be manifested as.
I.-Sensor. II.-Motor. III.-Functional. IV.-Organic.
Under sensor reflex neuroses may be grouped all forms of abnormal or perverted sensations-hyperaesthesia-anaesthesia.
Under motor reflexes will be included all forms of spasmodic action (tonic, clonic, spastic), paralysis or paresis.
Under functional reflex ocular neuroses, will be numbered all interference with the proper nutrition of the eye, or its vaso-motor supply, affecting as a result either the seeing nerve, retina, dioptric media, accommodation apparatus; or the proper support of any of the other eye tissues.
Closely related to this last heading is the reflex neuroses, which may result in organic changes; anaemia, hyperaemia, inflammation tissue or anatomical changes, hyperplasia, neoplastic formations, degenerative processes, hypertrophy or atrophy. Eye literature is full of examples of the above statements.
McKenzie relates a case of a man, aged 45, with an old discharging ulcer on his leg, which was suppressed by his getting wet. This was followed by blindness, in fourteen days afterward. The ulcer was restored and vision then returned. The same authority tells us that Beer claimed to have cured twenty such amaurotic patients, by restoring suppressed ulcerations. Such conditions can only be explained by reflex sympathy from the sentient surfaces to the cerebro-spinal centre, transferred to the sympathetic system, and through this to the optic nerves and retinal expansion, or their brain centres.
A. Moore has discussed this question in his paper, “Influence of the Skin and its Diseases upon the Eye.”.
An important additional heading should be likewise mentioned, which while distinct from the others, is very markedly influenced by any one or all of the above subdivisions given. It may be introduced under the term psychic, or the influence of ocular neuroses upon the brain centres proper, which may result in illusions, aberrations, chorea, epileptoid seizures, vertigo and even insanity. Both optical anomalies and heterophoria have been followed by such results.
Experiment has demonstrated, that section or paralysis of the cervical sympathetic will be followed by hypotony, and that irritation of the same nerve will produce the reverse effect, hypertony; thus proving conclusively, that tension of the eye is largely influenced, if not entirely regulated by the sympathetic nerve. The well-known fact that the irritation of the fifth nerve may cause increased T. and its paralysis a reduced T., does not disprove it, for the is latter effect may be explained by the intimate relationship and reflex blending of these nerves, brought about thoroughly the ciliary ganglion.
Hence, since it is thus proved that T. of the eyes may be increased by irritation of the sympathetic nerves, and decreased by its partial or total paralysis, and since the nutrition of the eye itself is largely influenced by the same sympathetic; and finally, since the sympathetic may be irritated by reflex action, from other nerves, it would seem reasonable to assume that glaucoma is merely a reflex neurosis, arising from a continued irritation of the sympathetic nerves, it would seem reasonable to assume that glaucoma is merely a reflex neurosis, arising from a continued irritation of the sympathetic nerves, connected with the eye, which irritation, as we have seen, may have origin in any part of the body near or remote from the eyes.