An Abstract of a Lecture on the 
Significance and Value of 
Pupillary Phenomena in 
Nervous Disease. 
Delivered at the Hew York Post-graduate 
Medical School and Hospital', 
November 31, 1887. 
by 
WILLIAM M. LESZYNSKY, M.D., 
INSTRUCTOR IN MENTAL AND NERVOUS DISEASES AT 
THE NEW YORK POST-GRADUATE MEDICAL SCHOOL 
AND HOSPITAL J ATTENDING NEUROLOGIST TO 
THE DBMILT DISPENSARY, ETC. 
(Reported by Louise Fiske-Bryson, M. D.) 
REPRINTED FROM 
Neto Yorlt ifHetucal $ourtial 
for March 31, 1888. Reprinted from the New York Medical Journal 
for March 31, 1888. 
AN ABSTRACT OF A LECTURE ON THE 
SIGNIFICANCE AND VALUE OF 
PUPILLARY PHENOMENA IN NERVOUS DISEASE. 
Delivered at the New York Post-graduate Medical School and Hospital, 
November SI, 1887. / 
By WILLIAM M. LESZYNSKY, M. D., 
INSTRUCTOR IN MENTAL AND NERVOUS DISEASES AT THE NEW YORK 
POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL ; ATTENDING 
NEUROLOGIST TO THE DEMILT DISPENSARY, ETC. 
(Reported by Louise Fiske-Bryson, M. D.) 
Pupillary phenomena in nervous troubles possess a dis- 
tinct value as corroborative evidence. In certain affections 
they appear early and with decided regularity. Taken 
alone, and separated from other signs, it would be unwar- 
rantable to consider them indicative of any pathological 
condition of the nervous system. Yet in connection with 
other symptoms they are valuable aids to diagnosis. Their 
importance lies in the fact that an intelligent comprehen- 
sion of their real significance enables us in many instances 
to distinguish between organic and functional nervous dis- 
ease. 
A word about the nerve and blood supply to the iris. 
“ The pupil may be considered to be under the dominion 
of two antagonistic mechanisms ; one a contracting mech- 
anism, reflex in nature, the third nerve serving as the effer- 2 
THE SIGNIFICANCE AND VALUE OF 
ent, and the optic as the afferent tract; the other a dilating 
mechanism, apparently tonic in nature, but subject to aug- 
mentation from various causes, and of this the cervical sym- 
pathetic is the efferent channel. Hence, when the optic or 
the third nerve is divided, not only does contraction of the 
pupil cease to be manifest, but active dilatation occurs on 
account of the tonic dilating influence of the sympathetic 
being left free to work. When, on the other hand, the 
sympathetic is divided, this tonic influence falls away and 
contraction results. When the optic or the third nerve is 
stimulated, the dilating effect of the sympathetic is over- 
come and contraction results; and when the sympathetic is 
stimulated, any contracting influence of the third nerve 
which may be present is overcome and dilatation ensues.” 
(M. Foster.) 
The blood-supply is remotely from the internal carotid 
artery, and immediately from the ophthalmic and its 
branches. The circulation in the pia mater has the same 
remote source, yet only in an anastomotic sense can it be 
considered the same as that of the iris. Abnormities of 
cerebral circulation may exist without evidence of such dis- 
turbance in the eye. On the other hand, changes in the 
pupil may point to pathological conditions of the brain or 
spinal cord. Relatively, eye-symptoms offer confirmation 
or negation of previous provisional diagnoses. 
All local diseases of the eye must be excluded before 
we think of some central nervous lesion or functional disor- 
der to account for any abnormal condition that may be 
present. The practitioner should familiarize himself with 
the preliminary methods of examination for acuteness of 
vision and errors of refraction. A visual power of twenty 
twentieths excludes but one condition only—myopia. Op- 
tic •neuritis or other trouble may be present. The next 
step is to examine the pupils carefully. They should be PUPILLARY PHENOMENA IN NERVOUS DISEASE. 
3 
mobile and of the same size and shape. Place the patient 
in a position facing a window. Do not allow the sun to 
shine upon his face. Never attempt an examination of the 
pupils while the patient sits or stands with his back to the 
light, as under such circumstances the pupils are usually 
dilated. It is unadvisable to examine the pupils directly 
in front of a gas flame. The patient is likely to and gen- 
erally does “fix” upon the flame, thereby causing contrac- 
tion of the pupils in accommodation, which may mislead 
the examiner. Direct him to gaze upon some object at 
least twenty feet distant in order to relax accommodation. 
Sufficient knowledge of ophthalmology to recognize or ex- 
clude local diseases of the eye that may affect the pupil is 
an essential feature in the examination we are now consid- 
ering. The following method of observation should be 
systematically adhered to: 
1. As to the size of the pupils. 
2. As to their, shape. 
3. As to their equality. 
4. As to their mobility. 
Contracted pupils are generally seen when the eyes are 
exposed to a bright light and in persons over fifty years of 
age. The existence of myosis in any one under fifty years 
of age is almost always pathological. Contracted pupils are 
found in cerebral hypersemia or congestion, and in the 
early stages of meningitis. They may also be due to hy- 
perinetropia or to the effect of some drug, such as eserine, 
morphine, pilocarpine, etc. Irritation of the third nerve at 
its nucleus or in any part of its course, or paralysis of the 
sympathetic or its branches, produces contraction of the 
pupil on the same side as the lesion. Myosis is frequently 
seen in cases of locomotor ataxia and in paretic dementia, 
and occasionally in cervical myelitis. 
Dilated pupils exist as a normal condition in darkness 4 
THE SIGNIFICANCE AND VALUE OF 
or subdued light. Unless due to local disease of the eye, 
their presence in an old person is always pathological, and 
may indicate some disturbance in the nervous system. In 
children the pupils are often dilated, as well as in grown 
persons of exaggerated reflex irritability. It is frequently 
an expression of increased excitability in cases of <k nervous- 
ness,” hysteria, etc. Mydriasis may result from the effect 
of drugs—such as atropine, duboisine, hyoscyamine, etc- 
In high degrees of myopia, the pupils are usually found 
dilated. This condition may also be due to cerebral or 
general anaemia. Paralysis of the third nerve, or irritation 
of the cervical sympathetic, produces dilatation of the pupil 
on the same side as the lesion. Dilatation of the pupils 
takes place during epileptic coma, in amaurosis, and in high 
grades of optic neuritis. It is also a manifestation of ex- 
cessive intracranial pressure. 
The shape of the pupils may vary, being distinctly dif- 
ferent in each eye at times, or both may be alike, yet irregu- 
lar. Sometimes one is round and the other pear-shaped, or 
triangular, or somewhat vertical or horizontal. An irregular 
pupil may result from the adhesive bands of a former iritis. 
The condition known as coloboma may be congenital, or 
acquired through surgery. It is a deformity in which the 
symmetry of the iris is destroyed by an elongated gap or 
cleft. Irregularity of the pupil may occasionally be observed 
in cases of paretic dementia without a pre-existing iritis. 
Unequal pupils never occur in health, but are observed 
where there is marked difference in the degree of refraction 
in the two eyes. They are present in paretic dementia, and, 
if not found at one examination, will be discovered subse- 
quently. Unless the inequality is pronounced, it is fre- 
quently difficult to determine whether one pupil should be 
considered dilated or the other contracted. Unilateral dila- 
tation may be due to some local disease of the eye; to in- PUPILLARY PHENOMENA IN NERVOUS DISEASE. 
5 
stillation of atropine or other mydriatic ; to paralysis of the 
motor oculi, or to irritation of the cervical sympathetic on 
the same side; or to blindness on the affected side. Uni- 
lateral myosis may be dne to an existing or a former iritis; 
to irritation of the third nerve, or paralysis of the sympa- 
thetic on the same side; or to the instillation of drugs. 
Either phenomenon may be present during an attack of 
migraine. 
The mobility of the pupils should next be considered. 
Physiological pupillary reactions are the following : 
1. Contraction to light, or direct reflex action. 
2. Consensual contraction, or indirect reflex action. 
3. Associated contraction in accommodation. 
1. Contraction of the pupils to light, or direct reflex ac- 
tion, is thus investigated : Instruct the patient to gaze upon 
some large object at least twenty feet distant, and to keep 
both eyes open. The eyes are then covered or shaded. In 
a few moments one is suddenly uncovered and exposed to 
light, when, in the normal state, the pupil (which always 
dilates in darkness or subdued light) immediately contracts. 
The other eye is then tested in the same manner. 
2. For consensual contraction, or indirect reflex action, 
the examination is conducted in the same manner as before, 
only both eyes are at first left uncovered. One eye is then 
covered, and in a moment or two is sudde-nly exposed, when 
it will be noticed that a simultaneous contraction occurs in 
the opposite pupil. This consensual pupillary reaction to 
light is owing to bilateral association of the reflex mech- 
anism. 
3. Associated contraction to accommodation is obtained 
with the patient in the same position. Direct him to look 
at some small object held within one foot of the eyes, 
when, in the normal state, synchronous contraction of both 
pupils will take place. In health the pupils dilate upon 6 
THE SIGNIFICANCE AND VALUE OF 
pinching, scratching, or irritating the skin over the neck or 
elsewhere. This is supposed to be due to excitation of the 
sympathetic nerve-fibers in connection with the so-called 
cilio-spinal center. Abnormal conditions of the pupils are 
not difficult to discover if their physiological action is thor- 
oughly understood and constantly borne in mind. Reflex 
action to light is lost when the eyes are blind from disease 
of the optic nerves or retina}. If only one eye is blind, the 
direct action of its pupil will be lost, but (unless there is 
disease of its third nerve also) the indirect or consensual 
action will be preserved, or may be much greater than in 
health. Loss of reaction to light during the epileptic parox- 
ysm is a positive diagnostic symptom in excluding simula- 
tion. 
In the condition known as the “ Argyll-Robertson pupil ” 
there is abolition of reflex action upon exposure to light, 
but the associated pupillary contraction in accommodation 
is preserved. This symptom is occasionally accompanied 
by mvosis or inequality of the pupils, afid is a valuable aid 
to diagnosis. It occurs in locomotor ataxia, in paretic de- 
mentia, and in some cases of disseminated sclerosis. The 
presence of the Argyll-Robertson pupil in conjunction with 
the absence of knee-jerk may be considered presumptive 
evidence of degeneration affecting the posterior columns of 
the spinal cord. 
In this connection it is interesting to note that in eyes 
that are totally blind the pupils are generally found dilated, 
and fail to react upon sudden exposure to light; but at 
times associated pupillary contraction occurs when the pa- 
tient is instructed to make an effort and act as though he 
were looking at an object within a few inches—by encour- 
aging him, as it were, to indulge in a (somewhat modified) 
visual hallucination. 
In the condition known as cycloplegia, or paralysis of PUPILLARY PHENOMENA IN NERVOUS DISEASE. 
7 
the ciliary muscle—an occasional complication or sequel of 
diphtheria—the contraction of the pupils to light is pre- 
served ; but, as the sufferer has become temporarily presby- 
opic (if the expression may be allowed) and the mechanism 
controlling accommodation is interfered with, the pupils fail 
to react for the near point. This, you perceive, is the re- 
verse of the Argyll-Robertson pupil. When the pupil is 
dilated by atropine, it fails to react either to light or in ac- 
commodation, as both the ciliary muscle and the fibers of 
the motor oculi supplying the iris are paralyzed. This fail- 
ure to respond to light is from peripheral causes. 
It has been my earnest endeavor in this lecture to im- 
press upon you, and outline for your benefit, as concisely as 
is consistent with lucidity, the advantages of a methodical 
examination of the pupils and the significance of any ab- 
normities they may present. The study of this too often 
neglected field of investigation will amply repay you for all 
the time, thought, and care bestowed upon it. It is one of 
the clinical features of many otherwise obscure conditions. 
As before stated, pupillary phenomena serve as corroborative 
evidence, affording confirmation or negation of a provisional 
diagnosis. I have purposely refrained from referring at 
length to the various local diseases of the eye which influ- 
ence the pupil. This subject belongs to the broad domain 
of ophthalmology. REASONS WHY 
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