Ophthalmoscopic Examination 
Of Sixty Insane Patients in the State Asylum at Utica. 
BY HENRY D. NOYES, M. D. 
[ From the American Journal of Insanity for January, 1872.] Ophthalmoscopic Examination 
OF SIXTY INSANE PATIENTS IN THE STATE 
ASYLUM AT UTICA. 
V. 
By the request of Dr. Gray, I examined witli the 
ophthalmoscope 60 patients taken from the wards of 
the asylum. Of the nature of their diseases I was 
quite ignorant, and often did not know whether the 
persons examined were insane. I had no preconceived 
notions of what lesions to expect, and simply de- 
scribed in brief notes the appearances which I saw. 
In most cases the pupils were dilated with atropia, 
and in almost all cases the examination was made by 
the upright image. Minute retinal changes can only 
be seen by this method, and the region of the yellow 
spot can be well seen only with dilated pupil. I am in 
the habit of looking with relaxed accommodation, and 
only require such a corrective glass as the patient’s re- 
fraction may demand. When any glass is needed, the 
fact is stated in the notes. 
I have endeavored to describe the facts just as they 
were, and have inserted statements which are not im- 
portant to the question of diagnosis, viz: the existence 
of physiological excavation, the accidental pigmentation 
of the choroidal border of the disc and other points 
which an ophthalmoscopist would at once know to be- 
long to the variations consistent with health. 
In the retina I speak in many cases of the occurrence 
of minute specks sometimes called pin points—usually 
found near the yellow spot. They may be in it, directly 
around it, or between it and the nerve. They are so 2 
fine as only to be seen with the greater magnifying 
power of the upright image. They are bright in color, 
whitish or yellowish, but are not the lesions seen in 
retinitis from Bright’s disease, nor in any recognized 
disease. I have seen the same specks in other eyes, 
and have not found that they produce any impairment 
of sight; but I can not assert that they are not precur- 
sors of lesions which may injure sight. They certainly 
appear most often in states of retinal congestion, and 
they are found in cases of asthenopia. If they are to 
have any value attached to them, it would be that they 
indicate hypersemia. The advancement of the small 
vessels nearer than normal to the macula, is an un- 
doubted sign of hypersemia. So, too, striation of 
the edge of the optic nerve and of the adjacent retina 
is due to oedema of the tissue. But I do not forget 
that there is striation wdiich is wholly physiological, 
even when not amounting to the degree recognized as 
due to opaque or double outlined nerve fibres (marie- 
haltige nervfa-sern.) In most cases the striation de- 
scribed is of the pathological variety. As to hyper- 
semia of the nerve, I am quite aware of the great dif- 
ferences which characterize the healthy state of the 
nerve in different persons, and I am accustomed to look 
quite as much for change in transparency and texture 
as for modification in hue. The significance to be given 
to pulsation of the veins upon the disc is yet a moot 
question. It has been regarded as a sign of arterial and 
intra ocular tension. It habitually occurs with quicken- 
ing of the respiration, and that may have induced it in 
some of the timid and excitable patients. It has been 
taken as a sign of cerebral anemia, and made much of 
in epileptic cases to determine the vascular state of the 
brain. We are not yet clear on this subject. 
The number of cases which are here tabulated are 3 
wholly insufficient for a basis of general deductions. 
These are but a handful to what must be collected be- 
fore such generalizations can be made. I have not, 
however, hesitated to point out facts which appear, 
on scrutiny of the cases, to be noteworthy. Small 
though the material is, it may do something to help us 
understand better a most intricate subject. For an 
account of similar cases, I would refer to All butt’s 
recent work on the ophthalmoscope in brain disease. 
GENERAL PARESIS, 11 cases. 
In all tliese cases, with the exception of two, there is 
hyperasmia and infiltration of the nerve and retina. 
The striation of the retina, near the nerve, is often ex- 
tremely pronounced, and may render the edge of the 
nerve hazy and indistinct. The nerve is often opaque 
in texture, or may be of a slatey hue. In one instance 
(5,) the nerve is found pallid, and doubt is expressed 
whether this may not correctly be called a sign of 
atrophy. It would not be easy to decide the point 
without testing the sharpness of sight, which wms not 
done. The hue of the opposite nerve and its ill-defined 
edge would favor this opinion, because its congestion 
would be likely to issue in just such pallor as is describ- 
ed in the left eye. Case 11 also presents these tokens, 
as if it were now in a secondary stage following con- 
gestion. The uniformity in the aspect of the fundus 
oculi was so considerable that I soon learned to suspect 
from ophthalmoscopic appearances what was the nature 
of the patient’s malady. I am not to be understood as 
saying, that I could thus diagnosticate general paresis. 
But the value of this observation will appear when, in 
inspecting other forms of brain disease, considerable 
discrepancies are noticed. 4 
1. Man—Admitted August 8, 1871, aged 40. Gen- 
eral Paresis, duration one year. (Used atropine to 
dilate pupil). 
Left eye—Small choroidal atrophy, nasal side. Veins 
rather large. Arteries medium. In region of macula 
are minute specks, pin points, dusky red. Physiologi- 
cal excavation of disc. 
Right eye—Similar. Venous pulsation distinct. Ar- 
teries and veins more equal in size. Pin points, specks 
about the macula. Retina yellowish. 
2. Man—Admitted June 29, 1869, aged 35, married, 
good habits, demented. General Paresis, duration two 
years. (Used atropine.) 
Left eye—Nerve oblong vertically, slightly pale and 
small, vessels on temporal side few. Veins large and 
tortuous. Arteries thin. Pulsation distinct. Stria- 
tion in retina. No physiological excavation. Pin 
points visible at macula. 
Right eye—Nerve more circular. Tissue clear. 
Veins large. Retina more transparent. Arteries small, 
some striation above and below. Entire edge of nerve 
pigmented. Pin points between nerve and macula dis- 
tinct. Vessels nearly meet at macula. 
3. Man—Admitted January 12, 1871, aged 55, mar- 
ried, good habits. General Paresis. Ill health. Dura- 
tion nine months. (Used atropine.) 
Left eye—Nerve transparent, hypersemic. Vessels 
tortuous and very numerous. Retina oedematous. Stri- 
ation decided in upper part of nerve, visible all round it. 
Right eye—Same as left, except that there are pin 
points between disc and macula. Nerve hyperaemic. 
Striated around edge. Tissue transparent. 
4. Man—Admitted April 10,1871, aged 30, married, 
smokes. General Paresis. Demented. Duration four 
weeks. (Used atropine.) 5 
Left eye—Deep hypersemia of nerve, borders indis- 
tinct. Striated. Vessels numerous and tortuous. 
Veins enlarged and pulsating. Tissue opaque. Slatey 
hue. Few points. Macula distinct, few vessels ap- 
proaching it. 
Right eye—Nerve extremely hyperamiic. Border of 
lens hazy. Venous pulsation. Central excavation. 
5. Man—Admitted April 6,1871, aged 48. Dement- 
ed. General Paresis. 
Left eye—Nerve pallid. Vessels small and few. Ar- 
teries small. Vessels full. Some striation between 
nerve and retina. Nothing about macula. Nerve 
anaemic, or it may be incipient atrophy. 
Right eye—Nerve of a more pink hue. Edges ill- 
defined. Tissue not clear. Veins rather full. Nothing 
about macula. 
6. Man—Admitted November 5, 1868, aged 45, mar- 
ried, good habits. General Paresis. (Used atropine.) 
Right eye—Intense hypersemia of nerve. Physio- 
logical excavation. Vessels wriggle out of nerve like 
worms. Tissue of retina clear. Nothing at macula. 
Left eye—Same as right. 
7. Man—Admitted April 27, 1871, aged 32 years, 
single, has used tobacco. Demented. General Paresis. 
Duration three months. (Used atropine.) 
Right eye—Nerve slightly liyperaBmic. Edges hazy. 
Veins full and pulsating. Arteries normal. Slight 
striation. Tissues not clear. Vessels in retina tortu- 
ous. Some specks close to macula. 
Left eye—Nerve hypersemic. Edges not clear. No 
decided striation. Veins full. Can see macula. One 
or two specks. 
8. Man—Admitted June 7, 1871, aged 38, single, has 
used tobacco and liquor. General Paresis. Demented. 
Duration six and a-half months. (Used atropine.) 6 
Right eye—Nerve semi-transparent, hyperaemic. Edg- 
es not clear. Slight injection of nerve. Nerve looks 
foggy without decided opacity. 
9. Woman—Admitted March 22, 1870, aged 51, 
single, good habits. General Paresis. Demented. 
Duration six months. 
Left eye—Capillary hyperaemia. Vessels full. Edges 
sharp. No oedema of retina. No striation. Can not 
see macula. 
Right eye—Deep capillary hyperaemia. Veins pul- 
sating and full. Substance round retina normal. Edg- 
es clean. Can not see macula. 
10. Woman—Admitted August 30, 1871, aged 40, 
married, good habits. General Paresis. Sub-acute ma- 
nia. (Used atropine.) 
Right eye—Pupil very small. Veins indistinct. Ca- 
pillary hyperaemia. Edge of nerve apparently clear. 
Veins large. 
Left eye—Pupil small. Deep capillary hyperaemia. 
Vessels tortuous. 
11. Man—Admitted July 11,1871, aged 27, married, 
good habits. General Paresis. Demented. (Used 
atropine.) 
Right eye—Tissue of nerve somewhat opaque or 
white. Edges indistinct. Arteries and veins normal. 
Some specks near macula. 
Left eye—Nerve tissue whitish opaque. Floating 
body in vitreous, attached to end of nerve. Vitreous 
clear. One or two specks on macula. Edges indistinct. 
DEMENTIA, 18 cases. 
In 12 tlie optic nerve and retina exhibited hyper- 
aemia or infiltration. In six they did not. The causes 
assigned to the mental state in the first cases were, 
epilepsy 2; intemperance 3 ; masturbation 3; exces- sive sexual indulgence 1; phthisis 1; ill-health 1; not 
given 1. 
Duration had been from six months to a year in 3; 
for one year in 2; for three years in 2; for five years in 
2; not stated 3. 
Of the six cases not liyperaeinic the causes of mental 
state were, epilepsy 1; hemiplegia 1; intemperance 1; 
not stated 3. 
Duration, one year and less, 3; not stated, 3. 
In searching for peculiarities among these cases, it 
may be stated that while there is nothing like uniform- 
ity in the ophthalmoscopic appearances, the preponder- 
ance of hyperaemic cases is to be noted. It is further 
notable that the degree of vascularity is very intense. 
This affects chiefly the capillary and venous circulation. 
See cases 12, 14, 15, 17, 18. The torpid condition of 
the cerebral nerve substance would appear to be re- 
flected in the intra-ocular circulation. 
12. Man—Admitted December 21, 1870, aged 50, 
single, good habits. Dementia. (Used atropine.) 
Right eye—Intensely hyperaemic. Veins large and 
extremely tortuous. Physiological excavation. Swell- 
ing on edge of nerve. Striation all round retina. Small 
veins toward macula numerous and tortuous. Bifurca- 
tion deep in nerve. Hypermetropic 1-24. Macula not 
seen on account of head being tremulous. 
Left eye—Extremely hyperaemic. Nerve striated. 
Veins large, both trunks and small branches numerous 
and tortous. Hyperaemia of retina around macula. 
Snakey veins across macula. Veins relaxed and tor- 
tuous. 
13. Man—Admitted February 3, 1870, aged 33, 
single. Dementia. Ill-health. 10 months. Choroidi- 
tis disseminata. (Used atropine.) 8 
Left eye—Nerve slightly hypersemic. Vessels nu- 
merous. Veins full. Arteries small. Pulsation dis- 
tinct. Edge and surrounding retina striated. Cho 
roidal epithelium marked. Macula very distinct. 
Vessels close to it. See foramen centrale: vessels 
come down on all sides to macula. At periphery vessels 
distinctly tortuous, hut not in all parts. 
Light eye—Nerve tissue opaque. Subretinal effu- 
sion. Transparent effusion behind retina at bottom of 
eye seen with —|—7; most anterior part with -[-5. Signs 
of old choroiditis. Vicinity of nerve edge is ragged 
on nasal side. White streaks run through choroid. 
14. Man—Admitted March 13,1861, aged 30, single. 
Dementia. Masturbation. 14 months. (Used an ex- 
tra quantity of atropine.) 
Left eye—Macula not visible. Pin points near it. 
Vessels traced to centre. Nerve deeply reddened. 
Central physiological excavation small. Temporal bor- 
der of nerve contains pigment. Striation adjoining 
retina. Tissue cedematous. Vessels tortuous, nerve 
slightly swollen, —]—1-48. 
15. Man—Admitted November 17, 1869, aged 23, 
single, has used tobacco. Dementia. Irregular habits. 
(Used atropine.) 
Light eye—Excessive liyperaomia, and vessels very 
numerous. Disc and edge strongly striated. Middle 
portion of retina white. Macula very red (scarlet.) 
Vessels close to it. Veins large. 
Left eye—Central excavation. Striation of disc and 
substance adjoining retina. Excessive hyperaemia. 
Venous pulsation. Veins large and opalescent. Mac- 
ula distinct and red. Retina greyish. Fovea very 
marked. Close to vessels a few pin points between 
macula and disc. 9 
16. Man—Admitted April 19,1871, aged 41, married, 
lias chewed tobacco to excess, intemperate. Dementia. 
Duration six months. (Used atropine.) 
Left eye—Physiological excavation. Vessels numer 
ous. Border of disc distinct. Substance surrounding 
retina appears as if marked by striae, or as if broken into 
radiating dotted lines. Veins and arteries about the 
same. Macula visible but not well defined, with dots 
indistinct but numerous. Nerve not specially hy- 
persemic. Tissue clear. 
Right eye—Nerve has central physiological excava- 
tion. Not very hypersemic. Vessels numerous and 
fairly proportioned. Same dots as in left eye. Specked 
uniformly. Bifurcation of artery a little covered by 
connective tissue, suggesting obliteration of central 
artery. Macula sufficiently marked and surrounding 
retina finely speckled. Nerve tissue transparent. 
Edge well defined. 
17. Man—Admitted August 27, 1870, aged 50, mar- 
ried, has used tobacco and liquor. Dementia. Ill 
health from injury. (Used atropine.) 
Right eye—Deep hypersemia of nerve. Edge ill-de- 
fined. Betina striated. Arteries small. Veins full. 
Tissue of nerve clouded. Macula perceptible but not 
pronounced. No abnormal specks. Can see choroidal 
epithelium. 
Left eye—Nerve oblong vertically. Hypersemic. 
Tissue clouded. Arteries small and tortuous. Veins 
full. Edge of nerve hazy. Betina striated and oedema- 
tous. A few glistening points around macula. 
18. Man—Admitted December 20, 1869, aged 25, 
single, good habits. Dementia. Masturbation. Dura- 
tion 5 years. (Used atropine.) 
Right eye—Numerous pin points in macula. Vessels 
deep in nerve. Hypersemia of surrounding retina. 10 
Very striated. Moderate temporal excavation. Stria- 
tion marked above and below and runs along emergent 
vessels. Pin points between macula and nerve, and be- 
yond. Vessels of moderate size. Macula specially 
noticeable for striation and pin points. Retina oede- 
matous. 
Left eye—Macula distinct. Pin points. Looks gran- 
ular. Nerve liyperaemic. Opalescent. Striation of 
border of retina distinct. Veins full. Arteries small. 
Pulsation evident. No excavation of any consequence. 
Retina near nerve appears striated. Not much infil- 
trated. 
19. Man—Admitted June 21, 1861, aged 41, single, 
has used tobacco. Dementia. 5 years. Phthisis. 
Left eye—Hypermetropic 1-10. Strabismus in early 
life. Veins tortuous. Nerve small. 
20. Man—Admitted May 6, 1871, aged 22, single. 
Dementia. Masturbation. (Used atropine.) 
Left eye—Nerve pink. Oblong vertically. Cen- 
tral physiological excavation. Edges not clear. Retina 
not striated. Tissue not clear. Venous pulsation. 
Nerve tissue clear. 
Right eye—Central physiological excavation. Nerve 
hypersemic. Distinct reflection from retina. Choroidal 
pigment deep. Iris brown. Eyes not regarded as 
abnormal. 
21. Man—Admitted February 14, 1870, aged 28, sin- 
gle, has used tobacco, very intemperate. Dementia. 6 
months. 
Left eye—Nerve hyperaemic. Tissue hazy. Retina 
striated. 
Right eye—Nerve hyperaemic. Faint striation. 
Marked pulsation. Macula not visible. 
22. Man—Admitted July 7,1870, aged 41, single, has 
used tobacco and liquor. Epileptic. Duration 3 years. 
Demented. 11 
Right eye—Faint hyperaemia of nerve. Central 
physiological excavation. Retina striated. Venous 
pulsation strongly pronounced. Macula normal. Re- 
tina transparent. Striation round nerve. 
Left eye—Slight hyperaemia of nerve. Physiological 
excavation deep. Venous pulsation not strong. Re- 
tina faintly striated around disc. One bright pin point 
on choroid. 
23. Man—Admitted March 11,1865, aged 30, single, 
good habits. Dementia. Epilepsy. Duration 1 year. 
(Used atropine.) 
Left eye—Nerve hyperaemic. Retina indistinct. Ar- 
teries normal. Venous pulsation. Some veins enlarged. 
Macula studded with spots, which are also scattered 
over adjoining retina. 
Right eye—Physiological excavation. No noticeable 
dilatation. Retina striated. Border of nerve heavily 
pigmented. Glistening points on macula but not so 
many as in left eye. 
24. Man—Admitted December 19, 1870, aged 16, 
single, good habits. Epileptic. Demented. 
Lieft eye—Nerve hyperaemic. Tissue transparent. 
Veins full and large. Striation above and below; else- 
where normal. Veins full. Arteries fair. Retina 
normal. Macula not visible. 
Right eye—Nerve tissue transparent. Faint redness. 
Veins full. No pulsation. Arteries normal. Region 
of macula normal. 
25. Man—Admitted April 1, 1862, aged 45, single, 
good habits. Dementia. Hemiplegia. Duration 8 
months. (Used atropine.) 
Lieft eye—Nerve tissue disposed to blue. Moderately 
transparent. Possibly capillary anaemia. Principal 
vessels normal. Macula not seen. 12 
Right eye—Atrophy from injury. No specific diffi- 
culty. 
26. Man—Admitted February 7, 1871, aged 23, sin- 
gle. Intemperance. Dementia. (Used atropine.) 
Left eye—Vessels numerous. Retina clear. Macula 
visible. Congenital striation. Nothing abnormal. 
Right eye—Nerve clear. Slight hyperaemia, Ves- 
sels numerous. Striation due to opaque nerve fibres. 
Nothing abnormal. 
27. Man—Admitted January 19,1871, aged 25, single, 
good health. Dementia. (Used atropine.) 
Right eye—Myopic 1-16. Vessels full. Pulsation 
not excessive. Nerve substance transparent. Edges 
clear. Vessels of retina tortuous. Macula visible. 
Normal. 
Left eye—Myopic 1-16. Veins full and pulsating. 
No infiltration. Macula visible. Nothing abnormal. 
28. Man—Admitted April 19, 1867, aged 56, mar- 
ried, good habits. Dementia. Duration 7 years. 
(Used atropine.) 
Left eye—Color of nerve nearly normal. Edges a 
little indistinct. Choroidal specks near nerve. 
Right eye—Tissue of nerve nearly normal. Vessels 
normal. Edges indistinct. Choroidal epithelium thin, 
showing pigment. 
29. Man—Admitted May 12, 1871, aged 34, single, 
good habits. Dementia. 4 months duration. (Used 
atropine.) 
Right eye—Nerve pinkish. Arteries normal. 
Veins same. No striation of nerve. Macula distinct. 
No specks. 
Left eye—Nerve pink and transparent. Arteries and 
veins normal. Lower vessels larger than upper. Can 
see choroidal pigment about nerve. 13 
MANIA. Acute 15. Sub-acute 5. Chronic 6=26. 
The cases of acute and sub-acute mania may be con- 
sidered together. Among the 20 are found a portion 
with hyperaemia of the nerve and retina, viz.: 14; and 
another part in which these tissues are either normal 
or anaemic, viz.: 6. 
Of the hyperaemic, the causes were: meningitis 3, ep- 
ilepsy 3, masturbation 1, over work 1, intemperance and 
syphilis 1, typhoid fever 1, phthisis 1, ill health 1, no 
cause given 3. 
The duration of the disease was comparatively brief, 
viz.: from two weeks to seven months; with one excep- 
tion, in whom it had lasted seven years and was caused 
by an injury of the skull, (case 49.) 
Of the cases not hyperaemic, the causes were: intem- 
perance 4, masturbation 1, ill health 1. Their duration 
was in all less than three months; one was only 10 
days, (case 31.) 
It is true that the larger number of the cases show 
optic and retinal congestion, but in those which do not, 
the maniacal symptoms were severe. 
We would not assume that the vascularity of the 
nerve is always an index of the circulation in the hemi- 
spheres; but we may suggest that the variety found in 
the appearance of the optic nerve accords with the view 
that mania is the result of exhaustion of nerve force, as 
well as of over excitation. 
In the case of only ten days duration, the appearance 
of the nerve strongly suggests atrophy. 
The cases of meningitis all exhibit optic hyperaemia; 
and the case of old injury (49,) shows marked signs of 
chronic neuro-retinitis. 
30. Man—Admitted February 28, 1871, aged 27. 
Masturbation. Acute mania. Duration 1 month. 
(Used atropine.) 14 
Left eye—Nerve pallid. Condition of anaemia, not 
atrophy. Tissue transparent. Vessels small and few. 
Arteries diminished and a little thinned. Veins a 
little larger. 
Light eye—Pupil closed by iritis. Patient much 
excited. 
31. Woman—Admitted April 19,1871, aged 45, mar- 
ried, good habits. Acute mania. Ill health. Duration 
10 days. 
Light eye—Myopic 1-16. A bluish tint in nerve, 
suggests atrophy, and vessels tortuous. Retinal tissue 
normal. 
32. Man—Admitted January 20, 1871, aged 35, mar- 
ried, intemperate. Acute mania. Duration 2 months. 
(Used atropine.) 
Light eye—Nerve tissue transparent. Edges clear. 
Vessels numerous. Nerve tissue normal. 
Left eye—Tissue clear, perhaps anaemic. Same as 
right eye. 
33. Man—Admitted May 14, 1871, aged 50, married, 
smokes and drinks. Acute mania. Duration 2 months, 
(Used atropine.) 
Light eye—Nerve pallid. Oblong vertically. Ves- 
sels large and tortuous. Pulsation decided. Nerve 
substance not infiltrated. Slight striation of choroidal 
pigment of fundus. Glistening points on macula. Ero- 
sion of macula. Difference 1-16 between summit and 
bottom of nerve. 
Left eye—Macula discernible. No lesion. Points in 
its vicinity. Vessels close to it. Nerve hyperaemic. 
Vessels tortuous. Venous pulsation. Parallax great. 
Slight striation. (Edema surrounding vessels. Iris light 
blue. 
34. Man—Admitted July 7, 1871, aged 28, single, 
has used liquor to excess. Acute mania. Duration 10 
weeks. (Used atropine.) 15 
Left eye—Nerve bluisli white color. Somewhat stri- 
ated. Eetina not infiltrated. Vessels normal size. 
Venous pulsation. Macula distinct. No specks. 
Light eye—Nerve nearly of normal hue. Fine stri- 
ations. Vessels normal. Tissue of retina normal. 
35. Man—Admitted November 15, 1869, aged 38, 
married, has used tobacco to excess, intemperate and. 
has syphilis. Sub-acute mania. Duration 4 weeks. 
(Used atropine.) 
Left eye—Slight hyperseonia. Tissue almost clear. 
Retina round nerve granulated, not striated. Veins 
rather large. Vessels on temporal side, small and few 
in number. Eetina extremely speckled around the 
vicinity of the nerve as well as macula. Macula not 
well defined. Central portion of fundus equal to six 
diameters of optic disc across, sprinkled with faint yel- 
low spots, a few lustrous, most of them dim. 
Light eye—Nerve a little pallid. Small vessels few. 
Veins and arteries natural, but perhaps diminished. 
Eetina hazy. Intensely speckled over large region like 
an eruption of lichen. 
36. Man—Admitted February 12, 1870, aged 47, 
married, has used tobacco. Ill health. Acute mania. 
Duration 2 weeks. (Used atropine.) 
Left eye—Nerve pinkish, slightly hazy. Veins large 
as usual. Eetinal tissue normal. 
Light eye—Nerve tissue pinkish, not clear, faintly 
striated. Adjacent retina speckled, as if from absorbed 
exudation. Vessels not extra full. Macula visible. A 
few pin points near retina. 
37. Man—Admitted July 21, 1871, aged 25, single, 
intemperate. Acute mania. Meningitis. Duration 4 
weeks. 
Light eye—Great tortuous vessel on retina, may be 
congenital. Nerve moderately pink. Edges clear. 
Physiological excavation. 16 
Left eye—Nerve tissue transparent. Vessels fair size. 
Slightly tortuous on retina. Macula distinct. Retinal 
tissue slightly dotted. Probably healthy. Appearan- 
ces not decisive. 
38. Man—Admitted June 13, 1868, aged 31. Sub- 
acute mania. Overwork. 6 months. 
Light and left eye—Same. Nerve hypersemic. 
Physiological excavation. Veins large. Vitreous hazy. 
Myopic 1-8. Eye restless. Macula not seen. Patient 
much excited. 
39. Man—Admitted February 21, 1870, aged 22, sin- 
gle. Sub-acute mania. Irregular habits. Masturba- 
tion. 4 months. 
Light eye—No i)hysiological excavation. Marked 
hypersemia of disc. Striation of entire edge. Veins 
full—pulsating. Opalescence over veins and arteries as 
if due to connective tissue in retina. Hypersemia dis- 
tinct. Inverted image. 
Left eye—Similar. 
40. Man—Admitted April 22,1871, aged 52, married, 
smokes. Acute mania. (Used atropine.) 
Left eye—Great number of vessels. Tissues kyper- 
semic and not clear. Edge pigmented. Macula nor- 
mal. No excavation. 
Light eye—Old iritis. 
41. Man—Admitted January 7, 1869, aged 35, mar- 
ried, good habits. Dementia. Sub-acute mania when 
admitted. Aphasia complete. 
Light eye—Nerve hypersemic. Infiltration of its bor- 
der distinct. Veins largely dilated. Arteries small. 
No pulsation. Patient uneasy. 
42. Man—Admitted May 16, 1870, aged 41, single, 
good habits. Acute paroxysmal mania. Duration & 
weeks. (Used atropine.) 17 
Right eye—Vessels large. Deep capillary hyper- 
semia. Edges clear. Physiological excavation. No 
changes in retina. Myopic 1-16. 
Left eye—Myopic 1-8. Vessels upon nerve quite 
large. Man restless. Large frame and head. 
43. Woman—Admitted February 2, 1871, single, 
good habits. Acute mania following typhoid fever. 5 
months. 
Right eye—Central physiological excavation. Nerve 
tissue decidedly pink. Not perfectly clear. Vitreous 
hazy. Retina striated above and below. Macula visi- 
ble. Iris dark. The haziness of retina may be con- 
genital. 
Left eye—Central physiological excavation. Great 
parallax. Nerve hypersemic. Vessels full. Macula 
visible. No specks. 
44. Man—Admitted October 5,1870, aged 27, single, 
good habits. Acute mania. Phthisis. 2 months dura- 
tion. (Used atropine.) 
Right eye—Nerve moderately hypersemic. Veins 
large: very opalescent: pulsating. Nerve tissue not 
transparent: edges somewhat clear. Small vessels near 
macula tortuous and run to centre. Specks on macula. 
Left eye—Macula distinct. Small vessels tortuous 
approaching macula. Nerve tissue transparent. Cen- 
tral and temporal excavation. Edges clear and faintly 
striated. Veins large and pulsating. Retina near 
nerve looks infiltrated. Vessels wriggle on retina. 
45. Man—Admitted August 9, 1870, aged 17, single, 
good habits. Acute mania. Meningitis. Duration 2 
weeks. (Used atropine.) 
Right eye—Nerve hypersemic. Tissue striated. Ves- 
sels numerous. Veins large. Striation of all adjoin- 
ing retina decided. Venous pulsation emphatic. Cho- 
roidal spots. Macula very distinct. Surrounding 18 
macula are grayish spots. Some pin points between 
macula and disc. Beyond macula faint choroidal thin- 
ning. 
Left eye—Striation of nerve and adjoining retina. 
Veins opalescent; pulsate, are not enlarged. Arter- 
ies fair. Macula distinct. Surface of retina gray. 
Vessels run close to macula. No pin points. 
46. Man—Admitted September 27, 1870, aged 52, 
married, has used liquor and tobacco. Acute mania. 
Epilepsy. 7 months. (Used atropine.) 
Light eye—Nerve cloudy, hyperaemic; edges heavy. 
Vessels full. Macula not visible. 
Left eye —Pupil closed by iritis. 
47. Man—Admitted October 18, 1871, aged 33, mar- 
ried, good habits. Sub-acute mania. Meningitis. Du- 
ration 7 months. (Used atropine.) 
Right eye—Nerve moderately hyperaemic. Veins 
large. Arteries normal. Physiological excavation. 
Striation of edge of nerve and all adjacent retina. 
Veins opalescent and pulsating. Macula distinct. 
Choroidal atrophy as wrell as retinal specks. 
Left eye—Nerve hyperaemic. Tissue not clear; hazy; 
some swelling. Veins pinched at egress, dilated out- 
ward. Arteries small. Striation decided, reddened 
and slight oedema. Beyond nerve, arteries are slightly 
tortuous. Macula not clear. Specks near, and vessels 
run close to it. 
48. Man—Admitted May 3, 1870, aged 22, single, 
good habits. Acute maniacal attacks. Epilepsy. 2 
weeks. 
Left eye—(Used atropine.) Slight hypersemia of 
nerve. Slight physiological excavation. Veins some- 
what dilated and pulsating. Striation of adjacent reti- 
na. Some specks at macula. 19 
Right eye—(No atropine.) Hyperemia of nerve. 
Edge of nerve distinct. A little striated. Arteries 
and veins tortuous and pulsating. Macula not seen. 
Small pupil. 
49. Man—Admitted January 19, 1870, aged 42, mar- 
ried, used tobacco. Epilepsy. Injury to skull. Du- 
ration 7 years. Attacks of mania with epileptic seiz 
ures. (Used atropine.) 
Left eye—Hypersemia of nerve. Deep temporal 
physiological excavation. Venous trunks large; not 
tortuous. A white patch on nasal side of nerve. 
Nerve partially concealed by vessels. Glistening cob- 
web look. Small vessels on temporal side are tortuous. 
Faint striation of surrounding retina. Macula not seen. 
Vessels run toward it. 
Right eye—Nerve hypersemic. Temporal excavation. 
Veins numerous. Tissue not clear. Border indistinct. 
Betina hazy. Choroidal epithelium slightly granular. 
Veins covered with faint opalescence. 
CHRONIC MANIA, 6 cases. 
Of these 3 show signs of inflammatory action or hy- 
persemia in the optic and retina, and 3 show no lesions. 
50. Man—Admitted February 20, 1871, aged 49, 
married, good habits. Chronic mania. Duration 5 
years. (Used atropine.) 
Right eye—Neuro-choroido-retinitis. Nerve infiltra- 
ted, hazy. Patches of connective tissue in choroidal 
pigment. Vessels numerous and tortuous. Transpar- 
ent subretinal effusion. 
Left eye—Nerve tissue not perfectly transparent. 
Slightly pink. Slight exudation on retina at upper edge 
of nerve. Vessels rather full. Nothino; at macula. 
51. Man—Admitted July 27, 1870, aged 57, single, 
smokes and drinks. Chronic mania, Duration 2 years. 
Intemperance and vice. 20 
Right eye—Myopic 1-16. External physiological ex- 
cavation. Slight choroidal crescent temporal side. Tis- 
sue of nerve mottled. Lamina cribosa distinct. Yeins 
and arteries pinched. Hypersemia of nerve substance. 
No pulsation. 
Left eye—Physiological excavation very deep. My- 
opic 1-48. Hyperaemia of disc. No pulsation visible. 
Veins and arteries normal. Retina normal. 
52. Man—Admitted October 13, 1847, aged (at pres- 
ent) 64, single,' good habits. Chronic mania. Duration 
(before admission) 3 years. (Used atropine.) 
Right eye—Myopic 1-16. Vessels numerous not en- 
larged. Venous pulsation. Nerve hyperaemic. Cen- 
tral physiological excavation. Tissue not clear. Edge 
of nerve ill-defined. At macula decided erosion spots. 
No striation of retina about nerve. 
Left eye—Nerve slightly hyperaemic. Vessels re- 
duced in size. Tissue not clear. No pulsation. No 
striae. Myopic 1-48. Region of macula as if exuda- 
tion and absorption had taken place. 
53. Man—Admitted July 3, 1871, aged 27, single. 
Masturbation. Chronic mania. (Used atropine.) 
Left eye—Nothing abnormal. Iris dark. Macula 
distinct. Congenital opaque nerve fibres on retina. 
Nerve tissue transparent pink. Central physiological 
excavation. Nothing abnormal. 
54. Man—Admitted February 20,1871, aged 45, sin- 
gle, has used tobacco. Chronic mania. 
Right eye—Nerve tissue not clear. Macula visible. 
Retinal tissue clear. No specks. 
Left eye—No deviation from normal. Nerve trans- 
parent. 
55. Man—Admitted October 14,1870, aged 43, mar- 
ried, good habits. Chronic mania. (Used atropine.) 21 
Left eye—Nerve nearly normal tint. Vessels rather 
small. Striation round nerve. Pigment on choroidal 
edge. Retina slightly granular. Unable to find mac- 
ula. Veins pointed at nerve. 
Right eye—Nerve pink. Arteries small. Veins not 
enlarged. Edge of nerve rather hazy. Retina not stri- 
ated. Nothing noticeable about macula. 
MELANCHOLIA, 5 cases. 
In only one case could any evidence of abnormal con- 
dition be detected within the eye. 
In the remaining 4 the ocular tissues were healthy. 
56. Man—Admitted December 21, 1870, aged 39, 
married, good habits. Melancholia. Overwork and 
heat. Duration 5 months. 
Left eye—(Used atropine.) Nerve moderately hy- 
peraemic. Central and temporal excavation. Striation 
on border of and surrounding retina. Veins moder- 
ately large and surrounded by opalescence. Arteries of 
fair size. Connective tissue around them abundant. 
Most abundant below. Striation distinct. Arterial 
sheath of connective tissue. Macula red and distinct. 
Retina hazy. Veins near macula. One large pin point 
above horizontal meridian. None near macula. Opaque 
nerve fibres above and below. 
Right eye—(No atropine.) Not looked at. 
57. illan—Admitted June 20, 1871, aged 25, single, 
good habits. Imbecile. 
Left eye—Nerve transparent and pinkish. Vessels 
numerous. Some striation in retina. Tissue transpa- 
rent and normal. 
58. Man—Admitted December, 14, 1861, now aged 
39, has smoked. Melancholia. Masturbation. Dura- 
tion 6 weeks. 22 
Left 1-12. Nerve normal hue. 
Edges distinct. Arteries and veins normal. 
59. Man—Admitted March 25, 1871, aged 43, mar- 
ried, has used tobacco. Melancholia. Duration 2 years. 
Light eye—Nerve normal color and texture. Vessels 
small. No distinct striation of edges. Some specks 
about macula. 
60. Man—Admitted February 3,1871, aged 50, mar- 
ried, good habits. Melancholia. 
Light eye—Central excavation. Nerve tissue healthy. 
Faintly anaemic. Veins normal. Arteries small. Tis- 
sue of retina transparent. Macula not visible on ac- 
count of having no atropine. Myopic 1-16. Nerve 
pinkish. Central excavation. Arteries small. Veins 
usual size. No striation. Edges well defined. Can 
not see macula. 
The number of cases above described are too few to 
justify dogmatic generalizations. But one can not help 
being struck with the dissimilarity of the appearances 
in cases classified as belonging to the same category. 
The putting of a certain number of patients together, 
under one head, whose violent mental manifestations 
deserve the name of mania, is a convenience in certain 
respects; but no one pretends that this is a classifica- 
tion based on pathological distinctions. The actual 
state of the brain in these cases is widely unlike in dif- 
ferent individuals. Hence there is no wonder dis- 
crepancies in ophthalmoscojDic appearances. In classify- 
ing insanity, mental manifestations have been made the 
basis of distinction, because indeed we have been una- 
ble to determine the physical state of the brain, which 
was the real disease. The ophthalmoscope may help 
us during life to arrive at some knowledge on this vital 
subject. But the necessary limitations of its power of 
penetration must be borne in mind. First, that it 23 
shows only one of the prolongations of the brain, which 
may not be involved in the brain lesion. Secondly, the 
magnifying power yet obtainable is too small to show 
the intimate texture of the optic nerve and retina. As 
in the brain, it is impossible often to see the true lesions 
without the higher power of the microscope; so for the 
optic nerve, we need much greater power than we yet 
have in the ophthalmoscope. But, despite these re- 
straints upon its capability, it shows us often important 
facts. For example, atrophy of the optic nerve not infre- 
quently precedes disorders of the brain and spinal cord; 
and sclerosis may be the pathological change at the 
foundation of all the lesions. Again, retinal hemor- 
rhage may be the precursor of cerebral hemorrhage. 
It is also true that serious lesion may exist in the 
optic nerve and retina without any damage to sight. 
In the case of the insane, it is important to question them 
closely as regards the degree of sight, and make them 
fulfill the proper test by test letters, such as those of 
Snellen. If practicable, the field of vision should be 
determined so as to discover defects in the peripheral 
part of the retina. Certainly the inspection of the 
optic nerve by the ophthalmoscope should never be 
neglected. 
It is hoped that opportunity may be afforded for con- 
tinuing the above investigations, and many more cases 
be added to to the above list. 
New York, December 15, 1871.