OPHTHALMOSCOPIC STUDIES OF ACUTE 
MANIA, WITH NOTES OF CASES.* 
By LOUIS J. LAUTENBACH, M.D. 
(ASSISTANT SURGEON, EYE AND EAR DEPARTMENT, PHILADELPHIA DISPENSARY.) 
HISTORIES OF PATIENTS. 
By Dr. ALICE BENNETT, 
(resident physician, female department, STATE INSANE HOSPITAL, NORRISTOWN.) 
CONSIDERING the intimate relations of the eye to the 
brain ; its near proximity to this important centre ; 
the short distance between the origin and the termination 
of the optic nerve ; the fact of its venous system termina- 
ting in that of the brain ; and that the arterial supply 
is derived directly from the same main vessel as that of the 
brain ; that the subvaginal (inter-sheath) space is but an ex- 
tension of the subarachnoid space ; and that perhaps there 
is a canal system in the cribriform fascia which is in com- 
munication with the same space ; considering also that in 
the last twenty years ophthalmology has advanced with 
such rapidity, it certainly seems remarkable that more atten- 
has not been bestowed upon the ophthalmoscopic examina- 
tion of the mentally diseased—the subjects of insanity. 
The pathology of insanity is certainly very important, and 
yet of it but little is known. The eye offers a means by 
which we may perhaps, even in the living subject, obtain 
some suggestion of the diseased condition ; perhaps be a 
guide-post which, in a path involved in the mist of uncer- 
tainty, may with a gleam of light here and there serve to 
give a suggestion of the way. 
* Read before the Phila. Neurological Society, April 26, 1886. 
Reprinted from the Journal of Nervous and Mental Disease, Vol. xiii , 
No. 6, June, 1886. 2 
Z. 7. LAUTENBACH AND ALICE BENNETT. 
In acute mania the pathology is very uncertain, both by 
reason of the infrequency of deaths as well as by virtue of 
the fact that in the majority of cases when death occurs lit- 
tle or no change is found. This absence of any marked 
lesion is not conclusive that there are no lesions during life ; 
disturbances of the vascular supply of the brain are evanes- 
cent, and when present are not striking, and are therefore 
either not observed or are passed by without remark. 
These ophthalmoscopic examinations were undertaken, 
despite considerable discouragement both from ophthalmol- 
ogists and alienists, with the view of determining whether 
the study of eye conditions might not be of service in 
the pathological study of insanity, and after three years 
work, examining some eight hundred insane patients, it 
would appear that its value would soon be evident. 
It is surprising that of the many text-books and treatises 
on diseases of the eye, of which twenty-five were examined, 
but two have any reference to eye conditions in insanity. 
Of the sixteen text-books on insanity examined (all pub- 
lished since 1865) several had no reference to the subject 
whatever, while the rest had but a few lines or at most 
a page or two devoted to it. 
The apathy displayed is certainly, remarkable and scarcely 
in keeping with that spirit of investigation with which man 
is supposed to be blessed. There are no unusual difficulties 
to be encountered in the prosecution of these investigations; 
time and patience are the requisities; in fact there are pe- 
culiar advantages offered—the patients are not scattered 
here, there, and everywhere, but are collected together, 
many similar cases can be examined in succession, or again 
dissimilar cases can be immediately contrasted. A question 
which here presents itself is as to the reason why the medi- 
cal residents at the institutions do not prosecute the work. 
Their excuse must be the multiplicity of their duties 
preventing their devoting sufficient time to become expert. 
While believing that it requires constant daily work for 
years to be able thoroughly to recognize changes in nerve 
structure, as well as minute vascular changes, yet, with six 
months’ daily work, the eye can become sufficiently trained 
to allow of the recognition of ordinary conditions. ACUTE MANIA. 
3 
That the eyes of the insane should be systematically ex- 
amined, seems to be self-evident. That all patients should, 
if possible, be examined at least once by an experienced 
ophthalmologist, goes without saying; that many cases 
should be kept under observation, appears to be a necessity. 
The amount of time this would take in a large institution 
would be considerable—more, perhaps, than one actively 
engaged in his specialty could afford. What, then, is the 
remedy ? To have the resident or assistant-resident study 
up all cases after the initial examination: such cases as are 
worthy to be frequently examined by the resident, and as 
soon as the least change is observed, the case to be again 
examined by the expert. Of course, unusually interesting 
cases would be kept under the direct observation of the 
expert. 
Among those who have labored in this field maybe men- 
tioned Kostl and Niemetschek,1 who examined 223 eyes of 
134 insane patients ; Kostl,3 later, made a special study of 
epileptics; Sebaldi,3 who examined 170 patients; Voisin 
and Galezowski4 made examinations of 40 cases of general 
paralysis ; Graf6 and Westphal6 examined 14 similar cases ; 
Billod 6 is popularly supposed to have examined the fundus 
of paralytic patients, but only tested the acuteness of 
vision (finding total blindness in 3 out of 400 cases); Allbutt7 
reports examinations of 214 patients, of whom 51 were the 
subjects of mania; Jehn8 reports examinations of 153 
patients (36 of whom were examined by Prof. Saemisch 
and Dr. Mandelstaum), of which 17 were mania cases ; 
Bouchut,9 among his ophthalmoscopic examinations of 234 
cases of cerebral disorders, includes epilepsy and idiocy, 
but reports no cases of mania; Bouchut and Dubuc10 
report 31 epileptic cases; Noyes 11 reports a total of 60 
patients examined; Aldridge13 reports examinations of 
cases of epilepsy, of general paralysis, and acute dementia ; 
Klein 13 reports examinations of 134 patients; Dolbeau 14 
reports 2 cases of general paralysis ; Monti’s 15 paper has 
been inaccessible; Schmidt-Rempler16 examined 128 cases 
of insanity, in whom he found changes in but 13; Boy 17 
examined 80 cases of general paralysis ; Nettleship 18 ex- 4 
L. y. LAUTENBACH AND ALICE BENNETT. 
amined several general paralytics ; in the cases examined by 
Gowers,'* he found changes in the eye-ground infrequently ; 
Sebaldi,* in his examinations of idiopathic acute mania, 
found no decided change in the background of the eye, but 
yet found disturbances of the circulation in 75 per cent, of the 
cases; Allbutt’ examined 51 cases of mania, and found in 
“ 25 symptoms of intracranial disease; in 13 cases it was of 
doubtful meaning, and in 13 no change at all was found, or 
only local changes, such as glaucoma, myopia, etc.” 
Among his 51 mania cases examined there are 21 cases 
of acute mania, and, from his description of the ocular con- 
dition, I have made the following table : 
ALLBUTT.—ACUTE MANIA. 
1 
r 
2 
Ret. Hyper. 
r 
o 
i 
1 
< 
M 
-3 
SL Atrophy. 
K 
< 
* 
Acute mania, 1st attack. . . 
I 
4 
2 
I (during 
2 
2 
I 
13 
Acute mania, 2d or subsequent at* 
paroxysm) 
tacks 
2 
I 
O 
i 
I 
I 
2 
8 
Totals 
3 
5 
2 
2 
3 
3 
3 
21 
As the result of his investigation, he concludes: 
1st. That symptomatic changes in the eye are to be 
found in a large proportion of cases of mania. 
2d. That if cases known to be functional only, or incor- 
rectly named (such as erotomania, transient mania, hysteria, 
etc.), be omitted, the proportion of cases presenting perma- 
nent changes in or near the optic disc is still larger. 
3d. That both in mania depending on organic causes and 
in functional mania, the back of the eye, if observed within a 
few days after a paroxysm, presents a vascular suffusion or 
pinkness so great after severe paroxysms as to obscure the 
disc. No exudation is seen in these cases unless there ex- 
ists some permanent mischief. 
4th. That during a paroxysm, on the contrary, the disc 
is anaemic, perhaps from spasm of the vessels. ACUTE MANIA. 
5 
5th. That the permanent changes in the disc are due either 
to stasis from obstruction to the intracranial circulation with 
consecutive atrophy, or to ramollissement ending in simple 
white atrophy, or they may present changes of a mixed 
character. 
Jehn8 reported ophthalmoscopic examinations of seventeen 
cases of mania, but gives the condition of the fundus in but 
two or three cases. 
Noyes11 reports nineteen cases of acute mania, of which he 
places thirteen as accompanied by retinal hyperaemia, and 
six as being either normal or having an anaemic retina. 
Upon analyzing his cases I formed the following table: 
Nearly 
Normal. 
Ret. 
Hyper. 
Ret. 
Cong. 
Papillitis. 
SI. 
Atrophy. 
Atrophy, j 
Total. 
Acute mania .... 
2 
6 
8 
I 
2 
0 
19 
NOYES.—ACUTE MANIA. 
Among Klein’s13 nineteen cases of mania he found four 
cases of retinitis paralytica, and one case of diffuse retinitis. 
In the other fourteen, while he found no special lesions, he 
yet found unusual circulatory disturbances, but in how many 
of these cases it occurred is not mentioned. 
Of the several cases examined by Gowers,19 in only one 
was there a pathological appearance—undue and uniform 
redness of the disc, with a distinctly softened edge. 
It may be well to indicate here the method of work, and 
also the terms used to express the conditions found. 
The eye-examinations have been made without a knowl- 
edge of the mental condition, which was, in fact, ignored. 
The examination included the taking of remote vision, test- 
ing the accommodation in about one half the cases. The 
lids, conjunctiva, cornea, sclera, iris, and lens were examined, 
and the tension taken. The ophthalmoscopic examination 
of the vitreous, nerve, retina, and choroid, with the measure- 
ment of the refraction, was usually made without a mydri- 
atic, although in about one hundred and fifty cases an ex- 6 
L. J. LAUTENBACH AND ALICE BENNETT. 
ception to this rule was made. All other facts concerning 
the ocular conditions present were noted. In the early part 
of the study the examination was now complete, but soon 
the value of an examination of the ear and throat became 
apparent, and for the last sixteen months has always been 
included. 
In the tables the terms nearly normal, cataracts, iritic de- 
posits, retinal hyperaemia, retinal congestion, papillitis and 
slight papillitis, slight atrophy, atrophy, choroiditis, retini- 
tis hemorrhagica, retinitis albuminurica, retinal anaemia, and 
glaucoma, are all that are used. Each case is recorded but 
once, the two eyes not being recorded separately. 
As nearly normal have been recorded all cases which did 
not present any noticeable feature in either eye. 
Cataracts and iritic deposits are only recorded where a 
satisfactory ophthalmoscopic view could not be obtained. 
Retinal hypercemia expresses the presence of an increased 
amount of blood, with little or no effusion, while retinal 
congestion is limited to a very marked increase of redness 
and marked enlargement of the vessels, with effusion, with 
sometimes a peculiar irregular, perhaps to be termed gran- 
ular, appearance (the retinitis paralytic of Klein is here 
included) of the retina. 
The term papillitis is used only when the optic disc is 
swollen and hazy, where the outlines are indistinct, or where 
the disc, while but slightly raised or swollen, has an indis- 
tinct edge or is congested, the porus being more or less 
obliterated. 
Slight papillitis sufficiently expresses itself. 
Slight atrophy is but a convenience to express minor grades 
of atrophy, in many cases of which the vision is near normal; 
the color and margin of the disc, with the appearance of the 
vesselsand of the porus, being sufficient to make the diagnosis. 
Atrophy includes all cases not placed under the previous 
headings, in which we had degeneration of the nerve, with 
frequently a sharpness of outline or an increase in the extent 
of the porus and diminution in the size of the vessels. 
The other terms used have their ordinary acceptation, 
and therefore need no explanation. ACUTE MANIA. 
7 
Up to April 12, 1886, 707 insane patients were examined 
at the Norristown and Philadelphia hospitals, of these 130 
were males and 57.7 females. 
The condensed table will serve roughly to indicate the 
class of patients examined and the results. 
EYE EXAMINATIONS BY DR. LAUTENBACH AT INSANE DEPART- 
MENT PHILADELPHIA HOSPITAL AND AT NORRISTOWN INSANE 
HOSPITAL. 
j Nearly Normal. 
j Cats, and Iritic Deps. 
Ret. Hyper. 
Ret. Cong. 
' Papillitis. 
SI. Atrophy. 
Atrophy. 
Choroiditis. 
Hemor. Ret. 
Album. Ret. 
Anaemic Ret. 
Glaucoma. 
No. of Cases. 
Mania (including mono- 
mania) 
41 
II 
42 
41 
30 
38 
63 
9 
I 
O 
I 
I 
278 
Melancholia .... 
40 
I 
30 
19 
9 
II 
21 
2 
2 
2 
2 
O 
139 
Dementia .... 
33 
9 
12 
I 
5 
30 
93 
4 
I 
O 
O 
O 
120 
All other cases, including 
epilepsy, general paresis, 
cerebral syphilis, imbecility, 
opium and alcoholic habits, 
moral insanity and cranks, 
22 
1 
20 
14 
12 
8 
22 
2 
I 
O 
O 
0 
102 
Totals .... 
136 
22 
IO4 
75 
56 
87 
199 
17 
5 
2 
3 
I 
707 
Of the 278 mania cases 105 were of the acute type; two 
cases have, however, been omitted, as no histories could be 
obtained. 
The following table will serve to show the ocular con- 
ditions present in these 103 cases. 
Nearly 
normal. 
Cataracts. 
Ret. 
Hyper. 
Ret. 
Cong. 
Papil. 
SI. 
Atrophy. 
Atrophy. 
Choroidi- 
tis. 
Ret. 
Anaem. 
No. of 
Cases. 
Mania, acute, first attack. 
3 
i 
8 
13 
IO 
IO 
3 
i 
i 
50 
Second or subsequent at- 
tacks 
9 
i 
9 
IX 
8 
3 
9 
3 
o 
53 
Totals .... 
12 
2 
17 
24 
iS 
13 
12 
4 
i 
103 
LAUTENBACH.—ACUTE MANIA. 8 
L. 7. LAUTENBACH AND ALICE BENNETT. 
The following table will serve to compare these results 
with those of Allbutt and Noyes. 
n 
Cataracts. 
4 
Ret. 
Cong. 
Papil. 
SI. 
Atrophy. 
Atrophy. 
Chor. 
Ret. 
Anxm. 
No. of 
Cases. 
Examined by Noyes . . 
3 
o 
5 
2 
3 
3 
3 
o 
2 
21 
” “ Allbutt. . 
a 
o 
6 
8 
I 
2 
o 
o 
O 
“ Lautenbach 
12 
2 
17 
24 
18 
13 
12 
4 
I 
103 
Totals .... 
17 
2 
28 
34 
22 
18 
■» 
« 
3 
*43 
MANIA, ACUTE. 
It will be observed that in my observations on ioi cases 
of acute mania (excluding the two cases of cataract, as in 
these the background could not be satisfactorily examined) 
11.82 per cent, were nearly normal, 16.83 per cent, had 
retinal hyperaemia, 23.76 per cent, retinal congestion, 17.82 
papillitis, 24.75 atrophy, either slight or marked. These 
results are rather striking, but they are not markedly differ- 
ent from the results of Allbutt and Noyes, among whose 
cases 12.5 per cent were nearly normal. 
As noted in the table, of these 103 patients 50 were first 
attacks. Not to occupy too much of your time, short his- 
tories of only these primary attacks will be presented. Be- 
fore doing so it may be here noted that but two of our 103 
patients have died; in neither has death resulted from the 
mental condition; in one a post-mortem was refused, in the 
other it revealed some fulness of the cerebral capillaries. 
ACUTE MANIA CASES EXAMINED DURING THE FIRST ATTACK. 
Case i. Female, aged twenty-eight years, married, in good 
health up to three weeks before admission, when, after three 
days of inflammation of the hand (said to be erysipelas, fol- 
lowed by palmar abscess), accompanied with intense pain, loss 
of sleep, and general debility, she developed acute mania. 
Symptoms in early weeks were active, but soon subsided into a 
condition of comparative quiet with moderate degree of intellec- 
tual derangement, from which she slowly recovered. Discharged 
one year and eight months after admission. 
Ophththalm. exam, in eighth month of attack showed a condi- 
tion of retinal congestion of both eyes with a large lymph deposit 
on the right nerve. ACUTE MANIA. 
9 
Case 2. Female, nineteen, married. Has one child, born 
three weeks before admission. Previous health had been good. 
On the eighth day after labor, which was without complications, 
she had a chill, followed by fever, and on the ninth day developed 
maniacal symptoms of the most violent form. Admitted to the 
hospital on the sixteenth day of mania. Much reduced in flesh 
and strength ; flesh bruised by throwing herself about. Vaginal 
examination revealed pelvic cellulitis. Kept in bed partially un- 
der influence of anodynes, with appropriate local treatment. All 
symptoms began to abate in two weeks. Discharged entirely well 
in three months. 
Ophthalm. exam, in fourth week of attack showed an anaemic 
retina in both eyes. 
Case 3. Female, nineteen, single. Worked in factory, often did 
overwork, and had not always nutritious food. The physical ex- 
haustion consequent upon this mode of life was assigned by her 
friends as the cause of the insanity. Admitted to the hospital on 
the third day of an attack of violent mania, which, after running 
a course of three months, terminated in recovery. 
Ophthalm. exam, during the third month, when she was conva- 
lescing, and the mental symptoms had in great measure subsided, 
revealed retinal congestion and retained nerve-sheath of both 
eyes. 
Case 7. Female, forty-two years, single. Has lived without 
regular occupation ; belongs to a family considered eccentric 
and highly excitable, but with no history of insanity. 
At the time of admission was in a state of wild excitement. 
Insanity had existed for three months, beginning with melancho- 
lia and passing into mania, which had become uncontrollable only 
during the preceding week. After repeated exacerbations and re- 
missions, the patient appeared to recover at the end of ten months 
and was discharged, but the disease has since recurred. 
Ophthalm. exam, made in seventh month revealed atrophy of 
both nerves. 
Case 9.—Female, thirty-three years ; married. Cause: ill-health. 
Admitted in sixth month of attack, of mild type. Still in hospital; 
has not recovered (twenty-seventh month). Prognosis unfavorble. 
Ophthalmoscopic examination in sixth month, nearly normal; in 
twenty-seventh month', slight atrophy. 
Case 10.—Female, fifty years ; widow. Cause : family troubles. 
Admitted in third week, mild type. Still in hospital (thirty-eighth 
month) ; now partially demented. 
Ophthalmoscopic examination in eighth month, nearly normal ; 
in thirty-eighth month, slight atrophy of both eyes. 
Case- 12.—Female, thirty-two years ; married. Insanity de- 
veloped in third month of pregnancy ; admitted in third month 
of attack, of mild type. Discharged, recovered (eighth month 
of attack) ; six weeks after labor. 
Ophthalmoscopic examination in fourth month showed slight 
(syphilitic ?) atrophy of both eyes. 10 
L. J. LAUTENBACH AND ALICE BENNETT. 
Case 13—Female, twenty-seven years ; single. Cause : over- 
work. Admitted in third week. Recovered in one year, and no 
relapse since (three years). 
Ophthalmoscopic examination in eleventh month showed reti- 
nal hyperaemia of both eyes. 
Case 14.—Female, nineteen years ; single. Cause : change of 
country. Admitted in second week. Recovered in six months. 
Ophthalmoscopic examination in seventh week, retinal conges- 
tion of both eyes ; in sixth month, same condition, but less marked. 
Case 15.—Female, nineteen years; single. Cause: measles. 
Admitted in fourth month. Recovered in seven months. 
Ophthalmoscopic examination in tenth month, showed retinal 
congestion of both eyes. Re-examined five months after her dis- 
charge, when the same condition, but less marked, was observed. 
Case 17.—Female, twenty-four years; single. Cause: ill- 
health. Admitted in third week. Recovered in five months. 
Ophthalmoscopic examination in eighth week of attack ; showed 
retinal hyperaemia of both eyes. 
Case 18.—Female, eighteen years; single. Cause: ill-health. 
Admitted in fourth month. Recovered in ten months. 
Ophthalmoscopic examination in tenth month : retinal conges- 
tion of both eyes. 
Case 19.—Female, nineteen years; single. No apparent 
cause. Mania of the hysterical type. Admitted in third week. 
Recovered in eight months. 
Ophthalmoscopic examination in seventh month : retinal hyper- 
aemia of both eyes ; slight papillitis, right eye. 
Case 20.—Female, twenty-eight years ; married. Melancholia, 
followed in three days by mania, came on eight days after labor. 
Recovered in five months. 
Ophthalmoscopic examination in sixth week : slight atrophy of 
both eyes. 
Case 21.—Female, thirty-two years ; married. Father was in- 
sane before her birth. Recovered in six months. 
Ophthalmoscopic examination in third month ; slight atrophy 
of both eyes. 
Case 23.—Female, nineteen years ; single. Cause : change of 
country. Admitted in fifth week. Great excitement with partial 
remissions. Recovered in nine months. 
Ophthalmoscopic examination in seventh month (convalescent) : 
retinal hyperaemia of both eyes. 
Case 24.—Female, twenty-six years ; single. Cause : disap- 
pointment in love. Recovered in one year. 
Ophthalmoscopic examination in seventh month : retinal hyper- 
aemia of left eye. Re-examined four month after her discharge, 
and the same condition, slightly less marked, was observed. 
Case 26.—Female, seventeen years ; single. No known cause. 
Active manifestations of mania. Recovered in seven months. 
Ophthalmoscopic examination in fourth week : papillitis, right 
eye. ACUTE MANIA. 
11 
Case 27.—Female, twenty-one years ; single. Cause : over- 
work. Admitted in third month. Now in hospital (seventh 
month) ; recovery doubtful. 
Ophthalmoscopic examination in sixth month ; papillitis, both 
eyes. 
Case 28.—Female, twenty-eight years ; single. No known 
cause. Admitted in third week. Recovered in seven months. 
Ophthalmoscopic examination in second month : slight atrophy 
of both eyes. 
Case 29.—Female, twenty-eight years ; widow. Cause : over- 
work and anxiety. Admitted in third week. Recovered in six 
months. 
Ophthalmoscopic examination in fifth month : retinal conges- 
tion of both eyes. 
Case 30.—Female, twenty-eight years ; married. Cause : lacta- 
tion. Admitted in sixth week. Now in hospitalj prognosis 
doubtful. 
Ophthalmoscopic examination in eighth week ; slight atrophy of 
both eyes. Re-examination in seventh month (mental symptoms 
aggravated) : slight atrophy with retinal congestion of both eyes. 
Case 32.—Female, seventy-five years ; widow. Cause : family 
trouble. Recovered in six months. 
Eye examination revealed cataracts of both eyes. 
Case 33.—Female, twenty-four years ; married. Came on 
three weeks after labor, six months before her admission ; and 
recovered one year later. 
Ophthalmoscopic examination in sixth month : slight atrophy 
of both eyes. 
Case 37.—Female, twenty-seven years ; married. Cause : ill- 
health. Developed melancholia four months previous to her ad- 
mission and mania one month after admission. Now in hospitalj 
prognosis favorable. 
Ophthalmoscopic examination in fourth month, nearly nor- 
mal ; in fifth month, papillitis ; in seventh month, papillitis less 
marked. 
Case 38.—Female, twenty-eight years ; single. No known 
cause. Violent mania developed eight days before admission. 
Recovered in five months. 
Ophthalmoscopic examination in first month, retinal hyper- 
semia of both eyes ; re-examined ten months after recovery, same 
condition present. 
Case 39.—Female, twenty-three years ; single. Cause : ill- 
health. Admitted in third month ; recovered in eight months. 
Ophthalmoscopic examination in eighth month (convalescent), 
retinal congestion of both eyes ; re-examination twenty-eight 
months after recovery, retinal hypersemia (both eyes) present. 
Case 41.—Female, twenty-five years ; single. Cause : ill-health. 
Admitted in second month, recovered in three and a half months ; 
but recurred one and a half years later, and died from the effect 
of hemorrhage (uterine). 12 
L. 7. LAUTENBACH AND ALICE BENNETT. 
Ophthalmoscopic examination in fifth week : papillitis of both 
eyes. 
Case 42. —Female, twenty-five years ; single. Cause : over- 
work. A pronounced case of mania ; now in fourth year, and 
has passed into a state of dementia. Still in hospital. 
Ophthalmoscopic examination in eleventh month, slight atro- 
phy of both eyes ; subsequent examinations showed the atrophic 
condition more marked. 
Case 43.—Female, forty years ; married. Developed four months 
after labor ; now in twelfth month, and is still in hospital; progno- 
sis is unfavorable. 
Ophthalmoscopic examination in first month, papillitis of both 
eyes ; in twelfth month, commencing atrophy of both eyes. 
Case 44.—Female, twenty-seven years ; married. Came on five 
weeks after labor ; now in fourth month of attack ; still in hospi- 
tal ; prognosis favorable. 
Ophthalmoscopic examination in fifth week, retinal hyperaemia 
of both eyes ; in fourth month, same condition, less marked. 
Case 45.—Female, thirty years ; married. Cause : overwork 
and anxiety. Still in hospital (tenth month of attack) ; prognosis 
unfavorable. 
Ophthalmoscopic examination in fourth month, papillitis of both 
eyes ; in tenth month, same condition, but less marked. 
Case 46.—Female, twenty-nine years ; single. Cause : over- 
work. Remained in hospital for eight months without much 
change; then left, and has not been heard from. 
Ophthalmoscopic examination in third week, papillitis of both 
eyes. 
Case 47.—Female, twenty-eight years ; married. No known 
cause. Still in hospital (fourth month) ; prognosis unfavorable. 
Ophthalmoscopic examination in third month : slight atrophy 
of both eyes. 
Case 48.—Female, twenty-five years ; single. No known cause. 
Recovered in sixteen months. 
Ophthalmoscopic examination in eleventh month : nearly nor- 
mal, both eyes. 
Case 50.—Female, twenty-six years ; single. Cause : phthisis. 
Recovered in seven months.* 
Ophthalmoscopic examination in first month : choroiditis, left 
eye. 
Case 51.—Female, twenty years; single. No known cause. 
Still in hospital (in tenth month of attack); prognosis unfavor- 
able. 
Ophthalmoscopic examination in second month, retinal con- 
gestion of both eyes ; in tenth month, atrophy of both eyes. 
Case 52.—Female, twenty years ; single. Cause : ill-health 
and family trouble. Recovered in five months. 
Ophthalmoscopic examination in second month, papillitis, both 
eyes. 
Case 54.—Female, thirty-six years ; married. Regan on the ACUTE MANIA. 
13 
twelfth day after labor. Still in hospitalj now, in third year of at- 
tack, in condition of chronic mania. 
Ophthalmoscopic examination in sixth month, atrophy of both 
eyes ; in third year, same condition. 
Case 55.—Female, twenty-five years ; single. No known 
cause. Recovered in nine months. 
Ophthalmoscopic examination in second week : retinal conges- 
tion of both eyes. 
Case 56.—Female, thirty-three years ; married. Cause : men- 
tal shock. Now in second month of attack. Still in hospital ; 
prognosis favorable. 
Ophthalmoscopic examination on twelfth day : slight atrophy 
with choroidal congestion of both eyes. 
Case 57.—Female, thirty-five years ; married. No known 
cause. Recovered in eleven months. 
Ophthalmoscopic examination in third month : retinal hyperse- 
mia of both eyes. 
Case 58.—Female, twenty-seven years ; married. Began three 
weeks after labor. Recovered in three months. 
Ophthalmoscopic examination in first month : retinal conges- 
tion of both eyes. 
Case 59.—Female, thirty-five years ; single. Cause : over- 
work. Now in twenty-third month of attack ; still in hospital ; 
prognosis unfavorable. 
Ophthalmoscopic examination in second month, retinal con- 
gestion of both eyes ; in twenty-third month, slight papillitis of 
both eyes. 
Case 60.—Female, twenty-seven years ; single. Cause : over- 
work. Still in hospital (thirteenth month of attack) ; prognosis 
favorable. 
Ophthalmoscopic examination in eighth month, retinal hyper- 
semia of both eyes ; in thirteenth month, same condition, but less 
marked. 
Case 93.—Male, twenty-five years ; married. Cause : ill-health. 
Recovered in seven months, but has since recurred several times. 
Ophth. examination in fifth month : papillitis, right eye. 
Case 94.—Male, forty years ; single. Cause, intemperance. 
Now in thirty-fourth month of attack ; still in hospitalj in a con- 
dition of dementia. 
Ophth. examination in twentieth month : slight atrophy, both 
eyes. 
Case 95.—Male, thirty-three years ; married. Cause : irregu- 
lar life. Attack came on twenty-eight months ago. He is still 
in hospital, the present diagnosis being general paresis. 
Ophth. examination in eleventh month : retinal hypersemia, 
both eyes, with atrophy of left eye. 
Case 96.—Male, twenty-seven years ; married. Cause un- 
known. Recovered in fifteen months. 
Ophth. examination in fourth month : retinal congestion, both 
eyes. 14 
L. y. LAUTENBACH AND ALICE BENNETT. 
Case 97.—Male, twenty-six years ; single. Cause : intemper- 
ance. He is still in hospital (thirty-five months since commence- 
ment of attack), in a condition of dementia. 
Ophth. examination in twenty-second month : retinal conges- 
tion, both eyes. 
It will be observed that of the fifty cases twenty-eight 
recovered, and, so far as known, have not recurred ; the termi- 
nation of one case (46) is unknown. Three cases recurred, 
and of the eighteen still in the hospital the prognosis of 
four is favorable, of two doubtful, and of twelve unfavora- 
ble. Of the three patients in whom the disease recurred, 
two (41 and 93) presented papillitis, and one (7) a condi- 
tion of atrophy. In the four cases with favorable progno- 
ses we have retinal hyperaemia in two cases, in one (44) the 
disease is of four months’ standing, and the retinal hyper- 
aemia has lessened considerably during the course of the 
disease. The other case (60) is of thirteen months’ stand- 
ing, and the retinal hyperaemia has also moderated. Of the 
other two cases, one (37) is a case of papillitis which has 
become less marked, and the other (56) is a case of slight 
atrophy. Of the two cases of doubtful prognoses one, (27) 
is a case of papillitis, and the other (30) of slight atrophy. 
Of the twelve unfavorable cases, two (9 and 10) were nearly 
normal, but soon became slightly atrophic; three were 
accompanied with retinal congestion, one (51) becoming a 
case of atrophy, one (59) a case of slight papillitis, and one 
(97) remaining in the condition of retinal congestion ; two 
(43 and 45) were accompanied with papillitis, three (42, 
47, and 94) with slight atrophy, and two (54 and 95) with 
atrophy. 
Among these twenty-one cases slight atrophies appeared 
eight times during the course of the disease, atrophies four 
times, and papillitis seven times. 
Of the twenty-eight cases which recovered, one (48) was 
nearly normal; one (32) was a cataract case; six (13, 17, 
23, 24, 38, and 57) were cases of retinal hyperaemia, while 
ten (1, 3, 14, 15, 18, 29. 39, 55, 58, and 96) were cases of 
retinal congestion; three (19, 26, and 52) were cases of 
papillitis (case 19 being classified as slight); five (12, 20, 21, ACUTE MANIA. 
15 
28, and 33) were cases of slight atrophy, while one (2) was 
a case of anaemic retina, and one (50) of choroiditis. 
The case (46) of which the result was not known was a 
case of papillitis. 
It will perhaps be interesting to contrast the eye condi- 
ditions in the recovered cases with the changes in the re- 
curred and in those who have not recovered. 
Nearly 
Normal. 
Cataracts. 
Ret. Hyp. 
Ret. Cong. 
Papil. 
SI. Atr. 
Atrophy. 
s' 
H 
c 
< 
Ret. Chor. 
No. of 
Cases. 
Recovered cases . 
i 
I 
6 
IO 
3(1 of si. pap.) 
5 
0 
I 
1 
28 
Recurred and not 
recovered cases 
2 
o 
2 
3 
6 
5 
3 
O 
0 
21 
Result unknown 
1 
1 
The frequency of hyperaemia and congestion in the favor- 
able and recovered cases is rather striking, so also is the ab- 
sence of marked atrophy. In the other cases :—those which 
either recurred or are unfavorable, present rather a large 
number of cases of papillitis and atrophy. 
We accepted the facts, refrained from drawing conclu- 
sions, have hoped that as our cases grew in number our 
knowledge would become broader, and that conclusions 
might develop unconsciously. In endeavoring to draw con- 
clusions we have a difficulty with which to contend :—the 
undoubtedly various bases of the symptoms of mania ; per- 
haps in one case due to an abnormality of structure, a want 
of development ; perhaps, again, a localized congestion, or 
even a degeneration, or perhaps an irritation nucleus occa- 
sioning vascular disturbances by reflex action ; or, again, a 
general vascular engorgement, or one of various diseases 
acting through some change in blood pressure or in the 
constitution of the blood or by reflex action. 
A few facts have developed :—for instance, we feel that if 
in acute mania hyperaemias or congestions only are present, 
the case is apt to terminate favorably ; that if papillitis 
be present, the chances are decidedly lessened ; that this is 
also the case if marked atrophy be present ; that if a condi- 
tion of retinal hyperaemia be present, in addition to a slight 16 
L. J. LA UTENBACH AND ALICE BENNETT. 
atrophy, the chances of recovery are decidedly more favor- 
able than would be the case were the latter alone present. 
These general truths we believe to be evident to all who 
will consult our last table. That, in addition, many infer- 
ences have been unconsciously suggested during the course 
of this work, must be evident to all; but it is better to wait 
until the work is older, and the list of cases longer, and 
allow the inferences or theories to develop into truths be- 
fore presenting them. 
I Prager Viertelj, 1867, Bd. 95, p. 134. 
* Prager Viertelj, 1870, Bd. 106 and 107. 
* Revista Clinica, 1870. Nagels Jahresbericht fur Ophthal., 1870, p. 374. 
Archiv fur Psyehiatrie, 1871, iii., p. 228. 
4 L'Union m/d., vol. xxxi., 1866, p. 404. Schmidts yahrbiichtr, 1869, Bd. 
*4*. P- 79- 
4 Archiv fiir Pschiatrie u. Nervenkr., 1868, i., p. 44. 
* Annales m/d.-psychol., 1863, ii., p. 317. 
T “ Use of the Ophthalmoscope in Diseases of the Nervous System and of 
the Kidneys,” 1871, p. 371. 
4 Allgemeine Zeitschrift far Psychiatric u. s. w., vol. xxx., 1873-4, p. 519. 
* *• Du diagn. des malad. du syst. nerveux par l'ophthalm.,” 1866, Paris.” 
H Prager Viertelj, 1865, Bd. 85, p. 102. 
II Amer. Joum. of Insanity, 1872, vol. xxviii., p. 410. 
" West Riding Lunatic Asylum Reports, vol. i., p. 71 ; vol. ii., p. 223 ; vol. 
ix., p. 291. 
** Wiener nud. Presse, 1877, p. 89. 
14 Archiv far Ophthalm., Bd. ii., p. I. Gas. des Mpitaux, 1866, No. 48. 
M “ De l’ophthalm. dans les malad. mentales.” 
14 Annales <Toculistique, 1875, vol. Ixxiv., p. 267, 
17 These de Paris, 1879. 
14 Ophthalm. Hosp. Reports, vol. ix. p. 178. 
14 “ Medical Ophthalmoscopy,” 1882, p. 176.