EYE PARALYSES. 
HY / 
JOHN AMOKV JEFFRIES, M. I). 
Reprinted from the Boston Medical and Surgical Journal 
of October 20 and 27, i8q2. 
BOSTON: 
DAMRELL & UPHAM, Publishers, 
283 Washington Strest. 
1892. //, //,///,,,/' ■ w. /'y/'"' 
S. J. PARKHILL A CO., PRINTERS 
BOSTON BY JOHN AMORY JRKFKIK8, M.D. 
EYE PARALYSES* 
[Tliis paper, which Dr. Jeffries had nearly finished at the time 
of his death, has been put in my hands to prepare for publica- 
tion. Although 1 knew something of his intentions in regard to 
it, a study of tlie paper itself and of the mass of material which 
lie had collected on the subject has convinced me of the diffi- 
culty of completing the task as he would have done it. With 
the exception of a few verbal changes, I have done little ex- 
cept to prepare a bibliography from the notes which Dr. Jeffries 
left, and to indicate in brackets the references to illustrative 
cases. Not having the original articles at hand and depending 
almost wholly upon these notes 1 fear that the classification of 
the cases, which I have tried to make, is not always erred, and 
that it might not agree with Dr. .Jeffries’ greater knowledge. I 
have added Bleuler's diagram, which Dr. Jeffries had copied, 
probably with the intention of inserting it. — p. c. K.] 
Probably every practitioner has at times been in 
<lonbl as to the nature of a case of eye-paralysis. The 
whole question is involved in practical difficulties. A 
patient complains of double vision ; and it is evident, 
unless the case be one of monocular diplopia, that at 
least one of the twelve extrinsic muscles of the eyes 
is paretic. In theory, the changes in the relative posi- 
tion of the images in different parts of the visual field 
should lead to an accurate diagnosis ; in practice, owing 
to the complex results produced when a number of 
muscles are affected, and to the stupidity of patients, 
the result is often far from satisfactory. Even when 
the eye distinctly lags in following an object, it may 
be dillicult to determine the condition of the oblique 
muscles. When, as sometimes happens, the patient 
fixes with the paretic eye, there is danger that the 
trouble may be assigned to the wrong eye. The pare- 
* Head before the Uobtou Medico-Psychological Society, March 17, 
18U.'. 2 
tic eye is used for fixation when it has the best sight 
or when it is specially trained, as in the case of the 
right eye in surveyors. It is therefore desirable to 
make a systematic study of every case of eye-paralysis 
with all the methods at our command. 
For this purpose it is necessary to have a pair of 
spectacles carrying plane glasses, one colorless, the 
other red, so that the color of the image may indicate 
to which eye it belongs. After assuring one’s self that 
the diplopia is not of monocular origin, by having the 
patient look first with one eye and then with the other, 
the whole field should be tested with some bright ob- 
ject, as a candle-light, and the result noted in a chart- 
like manner. The relative position of the images, 
their parallelism or obliquity, the distance between 
them, and which is red, should be determined for at 
least three points directly in front of the patient, 
and for two tiers on each side representing half-way 
and full lateral vision. When, as is often the case, 
vision is impaired as well as the motions of the eye- 
ball, care must be taken lest monocular vision due to 
lack of vision in the peripheral portion of one retina 
be mistaken for proof of parallel vision. After this, 
near vision should be tested in the same way. 
The double images had better be studied first, since 
they require close attention on the part of the patient 
and error is not easily recognized by the examiner. 
It must be borne in mind that lack of double vision 
does not prove the absence of paralysis. One of the 
images may be disregarded, lost, or there may be but 
one, as in cases of conjugate paralysis, where there is 
constant parallelism of vision even though motion to 
one side is absolutely lost. 
This is hardly the place to go into the details of the 
position of the images. They have been so fully 
worked out and figured in the various works on the 
eye and nervous system as to be familiar to all. Those 3 
interested in the difficult subject of double paralysis 
of the superior obliques will find the subject elabo- 
rated in a recent article by l’fliiger.'14 This paralysis 
is probably best recognized by the perimelic method. 
Next the motions of the eyes should be observed 
when following some object, as a finger, a piece of 
paper, or the like. With practice very slight devi- 
ations from the normal can lie recognized in this way. 
Not only the parallelism of vision, but the range of 
motion should be noted ; also the position of the lid, 
and whether it follows the pupil in looking down or 
not. Very good motor charts can be made by Lan- 
dolt’s method in cases where the defect of motion is 
considerable. This consists simply in substituting a 
card with letters on it for the plain moving card of a 
perimeter, and after having instructed the patient to 
follow it as long as he can and still read the letters, 
slowly move the card from the centre to the periphery. 
The point where distinct vision ceases should be noted 
on any of the charts used in plotting out the field of 
vision. A muscular defect shows itself as a limitation 
in the part of the field towards which the weak mus- 
cle should have moved the eye. The method is based 
on the fact that the letters cannot be read unless their 
images fall on or very near the visual axis of the eye. 
Those who have not used this method, might think 
that it was entirely dependent on the promptness and 
accuracy of the patient’s replies. This is not the case, 
as the reflections from the cornea render it very easy 
for the physician to recognize the faintest motion of 
tho eye. Of course, this method fails entirely in those 
relatively rare cases where the paralysis is dependent 
upon binocular vision. 
Several other factors remain to be determined which 
are more physiological in their nature ; thus, it should 
be noted if there is any difference in the motion of the 
eye when its mate is covered. A quite marked or 4 
even complete paralysis may vanish at once if the other 
eye be covered, while in others the paralysis is only 
apparent after the other eye is closed. Secondary devi- 
ation of the sound eye should be noted by placing a 
screen between the eye to be tested and the object 
gazed upon, and then removing it; if the deviation 
exists, the eye will be seen to fly back a few degrees 
as the object comes into view. It is due to the corre- 
lated muscles of the sound eye rotating the eye beyond 
the line of parallel vision, from sympathy in the effort 
required to fix the object with the paretic one. Hence, 
the direction of the motion is that in which the other 
eye is weak. 
In making this test the screen should be held suffi- 
ciently near the eye to prevent fixation being performed 
by it and yet in such a way that the eye can be seen 
by the observer. The readjustment of vision is at 
times very quick, and the process may be finished be- 
fore it can be noted. 
False projection, if well developed, is also a factor 
of considerable value. This —the failure properly to 
locate objects in space — is held to be due to our judg- 
ing of the relation of objects to ourselves not prima- 
rily by the position of their images on our retina?, but 
by the state of construction of the extrinsic muscles of 
the eye. We first determine the direction of the 
objects falling in the line of distinct vision by the eye 
muscles and then locate the rest of the field by means 
of the relation of the peripheral images to the centre 
of the field. As a result of this, if a small object — 
say a pin stuck into a table — is fixed with the paretic 
eye, and the patient be instructed to pick it up quickly 
the hand will miss the object and go too far in the 
direction towards which the motion of the eye is weak. 
Of course, in making this test, the other eye should 
be closed, the motion made rapidly, and the pin placed 
so as to involve the use of the affected muscles. When 5 
the paretic eye is closed, no false projection occurs, 
and the hand goes straight to the object. When both 
eves are open, false projections in the opposite direc- 
tion may result from overaction of the muscles of the 
healthy eye. When both eyes are affected, the last 
two tests often give most perplexing results. 
Besides the above, the reaction of the pupil to light, 
near vision, and sensations from the skin should be 
noted as well as the action of the ciliary muscles. At 
the time of, or shortly after, the occurrence of a pa- 
ralysis, the eye is apt to deviate in the opposite direc- 
tion owing to the contraction of the antagonists, the 
same as in other parts of the body. But, in spite of 
this, the eye is often able to move in the direction of 
the paralyzed muscles as far as the mid-point. 
The result of the examinations gives us a knowl- 
edge of the muscles paralyzed, the degree of paralysis, 
and the conditions under which it occurs. These facts 
have still to be correlated with what we know of the 
physiology of the eye, both normal and pathological, 
as well as with the results of clinical observation and 
the post-mortem examination before a full diagnosis 
can be made, and the physician be truly said to under- 
stand the case. A full diagnosis calls for a determi- 
nation not only of the parts paralyzed, but also of the 
portions of the nervous system affected, and the nature 
of the affecting process. Fortunately for the patient, 
the second part of the diagnosis has little to do with 
treatment; only in surgical cases is an exact knowl- 
edge of the seat of disease called for by therapy. 
The physiology of the muscles of the eye is by no 
means a simple problem ; not only do we have to ex- 
plain how the muscles bring the eyes into the proper 
position, but also to trace out the track through the 
nervous system by which this is effected. In the nor- 
mal inactive state, where vision may be said to be in 
abeyance, the eyes rest in a mid-position and with 6 
nearly parallel visual axes. I say nearly, because on 
several occasions I have thought that the eye did not 
correspond by a few degrees, the same as is cormnou 
in the blind. Now, if an object to one side of the axis 
attract attention, the eyes are at once turned so that 
their axes are brought to bear upon it. This is done 
by the equal and synchronous action of the internal 
rectus of one eye and the external rectus of the other, 
and if the object is not on a level with the eyes, by 
the action of the muscles turning the eye up or down 
(superior rectus and inferior oblique or the reverse). 
Tliis process, lateral conjugate deviation, has attracted 
much attention, and yet we do not know how it is 
brought about. Starting with the experiments of 
Mott and Schaefer 95 96 130 and others, we know that 
this motion is produced by stimulation of the middle 
portion of the frontal lobe just in front of the head 
area, the eye turning to the opposite side. Again, 
stimulation in the visual field in the occipital lobe 
causes the same motion, but in an opposite direction — 
that is, the eyes turn to the side stimulated. Lastly, 
if the seat in the occipital region where the eyes are 
turned to one side and that in the frontal region where 
the eves are turned to the other are stimulated syn- 
chronously with the same current, the motion induced 
by the frontal area prevails over that of the occipital. 
Over and above this, conjugate motion is liable to 
be induced by stimulation almost anywhere in the cor- 
tex. Such conjugate paralysis or deviation has been 
well recognized since the thesis of Prevost 118 and is 
one of the most constant early symptoms following 
almost any sudden gross lesion of the cerebrum. Dur- 
ing the comatose period, if there be any, the eyes will 
be found turned as if looking to the sound side. When 
consciousness returns, the eyes may still continue in 
their former position, or assume the normal one. If 
still turned to one side, a true paralysis may exist, or 7 
the position may simply be one of selection, the eyes 
being able to follow an object well to the opposite side. 
In either case the trouble usually vanishes in the 
course of a few hours or weeltH. and the eyes return to 
a normal state. Since in pontine trouble the paralysis 
is crossed with that of the limbs, the symptom is at 
times of value in locating the lesion. 
In a small proportion of the cases the deviation re- 
mains constant, as a permanent paralysis, indicating 
that the motor region or fibres have been actually in- 
jured and not simply disturbed in their functions. 
Efforts have been made to use this symptom for 
purposes of localization, but so far with poor success. 
Thus Wernicke 164 holds that such a paralysis coming 
on with a shock without loss of consciousness points to 
disease of the lower temporal region of the opposite 
side, and cites a few cases besides his own. They are, 
however, far from satisfactory. 
There is a small number of cases where disease of 
the frontal convolutions lias been accompanied by dis- 
turbance of paralysis of the eyes of such nature as to 
suggest some close connection with the lesiou, but they 
are far too few and vatiue to justify any conclusions, 
though seeming to tally well with experiments on 
animals. 
As we do not know whence the motions of the eyes 
spring, it goes without saying that we do not know 
the course of the fibres conveying the impulse to the 
nuclei at the base of the brain. They probably pass 
down in the anterior part of the internal capsule and 
thence, via the pyramidal tracts, to near the nuclei of 
the third nerve where they cross. Perlia 111 describes 
a set of fibres which, coming from the crus, turn and 
pass back along the raphe and then enter the nuclei 
from their free surface; these seem to be best ex- 
plained as being the lower end of the cerebral fibres. 
The fibres to the sixth nuclei also probably cross some- 8 
where in the same regicm, since in pontine trouble pa- 
ralysis of the sixth nerve is always on the same side 
as the lesion. The sixth nucleus is placed under the 
eminentia teres in the angle formed by the knee of 
the facial nerve. Its root fibres pass down and out; 
the course of its cerebral fibres is not known. 
• Conjugate deviation in cases of pontine disease is of 
far more diagnostic value then when springing from 
disease higher up, and has, since Foville38 first called 
attention to the subject, offered material for much dis- 
cussion and many theories. In 1885 Bleuler8 collected 
the cases and made a very material contribution to our 
knowledge of the subject; recently I have been at 
some pains to go over the literature and have been 
able nearly to double the number of cases with autopsy 
collected by Bleuler. Even a brief citation of these 
would swell this article far beyond all limits, nor in 
view of Bleuler’s article is it necessary; but as they 
show several points of importance, a close summary is 
required. Owing to the internal recti being supplied 
by the third nerves, while the external recti receive 
their fibres from the sixth pair, lesions in the pons are 
liable to split up conjugate motion into its separate 
elements. 
The following different states are found to exist: 
(1) Complete paralysis of one external rectus and 
the crossed internal rectus, so that neither muscle is 
capable of any motion, the eyes looking forward or to 
the other side according to the state of the opposite 
pair of muscles. In these cases the eyes turn readily 
to the opposite side, up or down, but stop at the mid- 
line as if transfixed. 
(2) Precisely the same state as in the first condition 
except that the internal rectus acts perfectly for near 
or convergent vision. 
(3) When both eyes are open, the eye with the 
paralyzed internal rectus will not turn in for objects 9 
on the other side of the nose, hut will if the other eye 
he covered. 
(4) The internal rectus will not act in conjugate, 
but will in near vision : the external rectus being 
normal. 
(5) Though devoid of any signs of conjugate pa- 
ralysis we must consider simple nuclear sixth nerve 
paralysis as an element of conjugate paralysis. 
[I)r. .JelTries told me that he hail omitted to speak 
fully of the cases in this lirst class, iu which the con- 
jugate paralysis was complete. I find in his notes 
references to eleven cases, which seem to belong here : 
those of Leyden,74 Bernhardt,5 Ballet.1 Broadbent.18 
Desnos,20 Mejer,84 Folville,83 Garel,89 Wernicke,185 
Mills,88 and Webber.161] 
In all these cases there were destructive lesions 
which, as far as can be judged from the report, in- 
volved either a considerable area in the [ions above 
the nucleus of the sixth nerve or involved the pons 
immediately below or in front of the sixth nucleus 
on the paralyzed side. 
In the second group of ten cases [Kahler and Pick.87 
Fereol,81 Vinantiis,159 Mills,89 Ilotstetter,81 Grasset,47 
Poubin,117 Blocq and Guinon,9 Finny,87 Graux,48] eight 
showed a lesion just below or at the eminentia teres. 
It was in most cases small or at least did not affect 
much tissue in this region. In the other two, those 
of JVIills60 and Hofstetter,*1 the lesion was a good-sized 
tumor in the upper quarter of the pons. The symp- 
toms in the lirst case do not appear to have been in 
any way peculiar. Iu Ilofstetter’s case there was sim- 
ply a paresis of conjugate motion and no deviation to 
the opposite sitle. 
I have only found five cases [Bleuler 8 (two), Spitz- 
ku,144 Quioc,119 Samelsohn,128] where it is clearly stated 
that the eye with the paralyzed internal rectus turned, 
as in conjugate motion, to the other side when the 10 
other eye was covered. The question is how this 
comes about. To all appearance the suppression of 
the eye with the paralyzed external rectus restores 
power in the other, as if its weakness were due to 
sympathy and not to actual paralysis; but such an ex- 
planation not only fails to explain, but stands in 
marked contrast to peripheral paralysis of the sixth 
nerve where this action does not occur. There is 
nothing peculiar in the autopsies; in two there were 
tumors of moderate size below the sixth nucleus. In 
Bleuler’s 8 two cases the tubercles, through diffuse, 
especially attacked the sixth nucleus. In Spitka’s144 
the tumor, though extensive, apparently spared the 
floor of the ventricle along the raphe. 
The only way out of the difficulty is to assume that 
the apparent conjugate motiou in monocular vision is 
in reality a convergent motion substituted in its place. 
In this case we might expect the covered eye also to 
turn in and the pupils to contract. If either occurred, 
it would be fair to hold the point demonstrated. Un- 
fortunately, in none of the cases has either been noted. 
But there are cases without autopsy, evidently of the 
same nature, in which this has been found to be the 
case. Also the obverse is known to occur in paralysis 
of convergence. If this view be correct, this group is 
really identical with the preceding. 
There are three cases which apparently belong to 
the fourth group. Ivochlin71 reports the case of a boy 
three years old who after a month’s sickuess developed 
a decided deviation of the right eye to the right, and 
left facial paralysis. The tongue was projected 
straight; the pupils were equal ; the limbs normal and 
the mind clear; pulse 112. After the paralysis had 
existed for a mouth, meningeal symptoms developed, 
and the child died. At the autopsy the only possible 
cause found for the paralysis was a tubercle adhering 
by its base to the floor of the fourth ventricle on the 11 
left side at the level of the angle formed by cerebellar 
peduncles. The region of the third nerve nuclei was 
normal. 
Hunnius 82 reports the case of a man forty years old 
who had apoplexy. Two days later, up and down 
motion of the eyes was normal. There was absolute 
loss of power in the left external rectus, and the two 
internal recti ; convergence and binocular vision could 
only be executed with difficulty (!) ; left conjugate 
motion lost; left eve in mid-position ; right turned out 
forty degrees. Spinal rayosis; marked dysarthria; 
right hemiplegia. Paralysis of right facial, the upper 
branch being least affected, and right hypoglossus. 
Head carried turned to the right, but can be turned 
anywhere. Mind clear, vision good, no nystagmus. 
Bv the fifth day the left eye had turned in a little, 
ami the right was not turned so far out, only parallel 
to left. No other change. Death from pneumonia 
on the twelfth day. All the cranial nerves normal ; 
softening in the left half of the pons beginning back 
of its anterior limit and most extensive in the middle. 
Part of the sixth root apparently implicated, but not 
the nucleus. Pyramidal tract entirely destroyed. 
In the third case rep irted by Schutz 132 a woman 
forty-eight years old, after two weeks of weakness, 
was suddenly seized with paralysis and difficulty of 
speech, without loss of consciousness. On the fourth 
day there was diffuse headache, stertorous respiration, 
rapid pulse, and no oedema. She understood well, but 
spoke with difficulty. The head was freely moved, 
there was ptosis on the right, and the left eye did not 
turn in and down with the right ; otherwise, motions 
of eyes normal. The pupils were small, the left angle 
of the mouth paretic, the tongue turned to the left. 
There was slight rigidity of all four limbs, and the 
right was paralyzed. At autopsy the vessels were 
found contorted, the ventricles enlarged, the epeu- 12 
dyma thickened, and a pair of small cysts the size of 
peas in the thalami. Also in the upper half of the 
pons an irregular haemorrhage, larger than a hazel- 
nut, in the region of the left seventh nucleus, which 
spared the lower parts on the left and part of the 
right half of the pons. 
In the first case Gubler50 has already given the in- 
terpretation accepted by me; the second case belongs, 
as far as loss of left conjugate motion is concerned, to 
the second group. It is only the internal rectus of 
the left eye which is here of interest. This acted in 
convergence and not in conjugate motion. The pre- 
sumption is that the fibres of the third nerve system, 
affected in association with the system of the sixth 
nerve in conjugate motion, were here affected alone ; 
but the autopsies are too vague to aid in plotting out 
the position of the fibres. 
There is one case (Eichhorst20) of simple deviation 
of the eyes and no paralysis due to a lesiou in the pons. 
A man forty-seven years old and a syphilitic, fell in 
coma after a few hours of moderate pain in the head. 
On return of consciousness there was right hemiplegia, 
motor aphasia, relaxation of right side of palate, right 
facial paralysis, dysphagia. The face and eyes were 
both turned to the right, but could be moved freely in 
any direction. There was also a tendency to lie on 
the right side. The pupils were much contracted and 
the light reflexes lost. Sensorium free. Death oc- 
curred on the eighth A clot was found in the 
anterior part of the basilar artery, and the pons was 
very soft in the anterior part of the left half. The 
softening extending nearly to the floor of the fourth 
ventricle. The cerebellar peduncles were normal. A 
figure of the basal surface of the pons shows that the 
spfteuing involved the lower half of the left crus. 
To my mind, this is not a case of conjugate paraly- 
sis but one of forced rotation to the right, a symptom 13 
frequently associated with conjugate paralysis. There 
was no paralysis of the eyes. All the cranial nerves 
uifected were on the same side as the hemiplegia, and 
the figure in spite of the text shows the lesions to be 
in the crus. 
Since a central paralysis of the sixth nerve is an 
essential part of a conjugate paralysis, they are best 
considered in this connection. Bleuler 8 has classed a 
case reported bv Grasset47 among those of conjugate 
paralysis, which to my mind belongs to this group. 
The head, eyes, and body turned to the right, but the 
right eye could be turned to the left, while the left 
could not. Autopsy showed several small sarcomas, 
two of these being in the left half of the pons. This 
case seems to be in reality one of conjugate deviation 
of the eyes to the right and paralysis of the left sixth 
nerve. 
My collection of simple paralyses of the sixth nerve 
dependent upon injury in the pons offers nothing 
peculiar in their character. There does not seem to be 
any point of distinction in action between the different 
parts of this system. In all, if not from the first, 
there have been before long other symptoms pointing 
to the pons. Some cases have begun as conjugate 
paralysis, and then become simple sixth paralysis; in 
others the obverse has been the case. In the first 
group the lesion has been a haemorrhage at the em- 
inentia teres. 1 have myself seen the two states 
alternate from time to time. Though there is no 
autopsy, a brief summary is given, as the case is of 
some interest.* 
Considerable ingenuity has been spent upon the ex- 
planation of the mechanism of conjugate paralysis, and 
various theories evolved. Most of these involve either 
the existence of a special nucleus besides the sixth 
nucleus for conjugate motiou or fibres arising from the 
* No record of thin caae 1» jjiven. 14 15 
sixth nucleus and ending somewhere in the line for the 
internal rectus, either in the nucleus of the third nerve 
or (he nerve itself. No one has pointed out the nucleus 
barring Gowers,48 who suggests the olivary body, but 
as this is healthy in many of the cases it needs no con- 
sideration. The various fibre tracts have been pointed 
out by one or another, but not in such a wav as to 
convince the doubter. None of these hypotheses stand 
in harmony with the facts. 
IJleuler * has advanced a theory which was compati- 
ble with the facts up to his time of writing, and it 
holds good for the more recent cases. According to 
this, the fibres run direct from the cortex to their re- 
spective root nuclei, but there are two sets of fibres for 
the internal rectus, one for conjugate vision and one 
for near vision ; the fibres run down as separate bun- 
dles below their nucleus close to the sixth nucleus, and 
then turn hack and cross to their nucleus. There is 
no physiological objection to this theory, and it coin- 
cides well with the results of pathological investiga- 
tions — indeed, it was built up from the best summary 
there is on the subject. It does demand the two sets 
of fibres, something not held to exist in any other part. 
O O', Optic tracts. 
K K', Cortical centres. 
a a1, Abducens nuclei. 
»*'. Internal rectus nuclei. 
S S', Point where the internal rectus fibres bend. 
1, Lesion producing Provost’s symptom. 
2, 3, Lesions producing paralysis of one abducens and the opposite 
internal rectus for all movements. 
4, Lesion producing paralysis of one abducens and weakness of the 
opposite internal rectus for all movements. 
6, Paralysis of leti abducens, absolute defect of right internal rectus 
for associated lateral movements, weakness of both internal 
recti for convergence. 
U, Paralysis of abducens and inactivity of opposite internal rectus 
for lateral movements only. 
7, Total paralysis of opposite internal rectus. 
Explanation ok Figure (from Bleuler). 
a, Double HbUuoeim paralysis. 
0, Paralysis of convergence. 16 
On the whole I believe it to be the best working 
theory we have. The only other wav of looking at it 
seems to be that there is but one set of fibres, these 
going close to the sixth nucleus, but that the impulses 
descending from above in conjugate and near vision 
are different, and that the conjugate impulse is more 
easily interrupted than the near vision impulse ; the 
nearest analogy being the different results obtained by 
the stimulation of a nerve as shown by Hooper and 
Bowditch, and the selection of the extensor muscles in 
most hemiplegias. Any such theory of course ignores 
the idea that each muscle is represented by certain 
nerve fibres, cells and areas, which transmit the force 
after the style of a complex system of bell cords,— 
an idea which seems in silence to be creeping into 
neurology, but does not tally well with complete re- 
covery after resection of a nerve. One can hardly 
imagine that in these cases the cells in the cord estab- 
lish their old relations with the muscles. If not, 
and the pull cord theory be correct, utter confusion 
should result when any motion is attempted. 
Whatever the theory may he, the practical point re- 
mains that all cases of partial conjugate paralysis so 
far reported have depended upon lesions of the pons. 
A few cases with autopsy have been reported in 
which conjugate paralysis of up or down, but not of 
lateral motion existed [Thomsen,154 Niedeu,98 Hoppe,69 
Henoch,54 Gee 43J. Of these I have collected a few 
cases and have been unable to procure the records of 
several others. Some are cases of pure paralysis of 
up »r down motion, others are complicated by other 
pareses but nevertheless this form of conjugate paraly- 
sis was the leading factor in the case. In all of these 
a lesion has been found at the level of the nuclei of the 
third pair, and in all but Thomsen’s 164 case thedisease 
has been central. As this case is of extreme interest 
it is given in detail : 17 
A man, forty-eight years old, slowly developed the 
following state : Viscera normal, mind feeble ; pupils 
small, riiflit larger than left a trace of the light reac- 
tion in the left, hut none in the right. Lids drop in 
rest, hut can he well opened, llolh eyes moved to a 
normal extent to the right, to the left or dowu, hut 
always with nystagmus. A marked paralysis on look- 
ing up, the eyes turning scarcely above the horizontal 
plane. Monocular vision the same, except that the 
right eye is less movable than the left. No changes 
in the state of the eyes to death one month later. The 
arms were weak and tremulous, the legs weak and 
slightly spastic with normal knee-jerks, hut ankle clo- 
nus. The urine escaped at times, and the gait was 
unsteady and spastic. Autopsy revealed a moderate 
amount of chronic meningitis, thickening of the epen- 
dyma, a few sclerotic patches in the cord, and a partial 
degeneration of both the anterior and posterior roots. 
Also a gumma at the point of exit of the third nerves 
between the corpora mammillaria and the crura. In 
the left only a small portion of the crus and substantia 
nigra were affected, while on the right the growth in- 
volved the lower portion of the red nucleus, the median 
third of the substantia nigra, and less of the crus. The 
right third uerve was extensively degenerated, the left 
hut slightly. The uuclei of the third uerve were nor- 
mal. 
Thomsen classes the case as one of peripheral par- 
alysis, which to my mind is a mistake. Though the 
lesion was peripheral to the nuclei, it was still in the 
brain. The substantia nigra, and red nucleus cau 
hardly be called peripheral structures. It seems clear 
that the lesion involved the nerve libres destined for 
the superior and inferior recti. 
The only other associated motion of the eyes it that 
of convergence in near vision. In this motion the eyes 
both bring their axes to bear on the subject, and ow- 18 
ing to its nearness the axes converge. Contraction of 
the pupil and accommodation are normally associated 
with it. Commonly the object looked at in near vision 
is in front of the face, and hence the contraction of 
the internal recti are approximately symmetrical ; but 
even in running the eye across a page this symmetry 
is broken. The extent to which lateral near vision 
can be practised appears to be very variable. In some 
cases as soon as the object is passed but a slight dis- 
dance to either side of the nose, the pupil dilates, vi- 
sion is poor, and the eyes become parallel, indicating 
the substitution of conjugate for convergent vision. In 
other cases the object can be carried so far to one side 
that one eye looks at the nose and the other is well 
turned out before the break comes. In all whom I 
have examined, even with the other eye covered, near 
vision does not occur when the object is far to one 
side. 
A good many cases of paralysis of near vision have 
been reported, but unfortunately as vet there are no 
autopsies. [Cases by Barel,8 Earles,25 Parinau,1(>8 110 
Peters,112 Stoltiug,160 Grafe,45 Pilz,115 De Watteville,21 
and Binsler.7] Some of the cases are suggestive of an 
hysterical state, but the mass of them point to gross 
disease. A centre of convergence has been assumed 
to exist in the anterior part of the third nuclei, but as 
yet nothing definite has been shown. Hensen and 
Vbickers’55 experiments—which do not tally with 
others — at the most do not demonstrate a centre : irri- 
tation at a point of crossing of fibres would produce 
the same effect. Thus, if, as suggested above, the fibres 
governing convergence come down to near the sixth 
nucleus, ascend and cross to their nuclei, stimulation 
at this crossing would produce convergence. What- 
ever the mechanism this paralysis is just the obverse 
of lateral conjugate paralysis. With both eyes open, 
neither will turn in, but cover one and the other comes 19 
in at once, while the covered turns out to a parallel 
position. The case reported by Rinsler7 may betaken 
as a typical example. A hind man, previously well, 
ran to an appointment, and while blowing on the horn, 
suddenly lo>t sight of the music and had to stop play- 
ing. Careful examination showed that distant vision 
was good, but near vision poor and accompanied by 
crossed diplopia. When one eye was covered, the 
other turned in well for near vision, the covered eye 
turning out at the saute time. The right pupil reacted 
to light, but did not to accommodation. Sense of cold 
less distinct on the right side than on the left. No 
other symptoms, no change in six mouths. 
We have left to consider the great mass of eye par- 
alyses, which simply affect one or more muscles and 
do not tend to select associated functions. In these 
Cases we are deprived of a most valuable guide in local- 
ization, ami are obliged to fall back on what other 
symptoms iu»j he present, and a few isolated points 
of value. As is now well known, the nuclei of the 
fourth nerves lie just behind those of the third nerves, 
and practically form a unit with them. The nerves 
themselves, however, instead of passing down from the 
nuclei to the lower surface of the pons, go up and 
above the aqueduct before issuing from the brain. As 
a result, the crossing gives an occasion for double fourth 
nerve paralysis, without involvement of the other 
nerves ; which the peripheral course of the nerves does 
not readily lend itself to. Though no cases of the 
isolated paralysis of the superior obliques have been 
reported, there are those of Christ’s n and others in 
which this symptom has been used with good success. 
There are few other factors of importance in the 
distribution of the paralysis. Mauthner*1 ami others 
have held that a peripheral paralysis of the nerve trunk 
was complete or practically evenly distributed among 
the various muscles supplied by the nerve, while a 20 
paralysis due to disease in the base of the brain was 
commonly incomplete or irregularly distributed. Thus 
the intrinsic or extrinsic muscles of the eye alone might 
be affected or some of the muscles of the third and not 
the others; the reason being that while the nerve is 
compact and small and therefore not easily partly af- 
fected, the nuclei of the third nerves are strung along 
the floor of the aqueduct and the posterior part of the 
third ventricle in the form of several sub-nuclei. Vari- 
ous efforts have been made to determine the functions 
of these sub-nuclei, but so far little, if anything, be- 
yond speculative results has been obtained. Anatomy 
shows that there is a median nucleus common to both 
third nerves, and that the posterior dorsal nucleus 
sends fibres across the raphe to the opposite third nerve. 
As a general axiom Mauthner’s position is undoubtedly 
true ; but, as the case of Thomsen already cited 154 and 
the following show, it is not absolute. Oppenlieim102 
has reported two cases of brain tumor which appear 
probably to belong here. In the one there was paresis 
of the right third and sixth nerves, aud of the left in- 
ternal rectus from a tumor the size of an apple chiefly 
in the basal part of the right frontal lobe, but extend- 
ing some to the left frontal lobe. In the other there 
was complete paralysis of right internal rectus with 
a tumor in the right temporal lobe which pressed 
upon the lower parts of the brain and third nerve. 
Meyer’s 84 cases of multiple neuritis also bear on this 
point. 
Another symptom of value is the variableness of the 
paralysis. Most true peripheral paralyses tend to run 
a definite course, and do not change rapidly, indeed 
from minute to minute, as is not uncommon in central 
cases. This is naturally explained by the nerves being 
little more than conductors, acting when isolated from 
the body, while the centres discharge and generate 
force. As a result of this it is not rare to see a slight 21 
paresis grow during the course of an examination into 
a paralysis, and new paresis develop. From the same 
cause the paresis is apt to show itself at night or even- 
ing and not in the mornm". 
Hut the above characteristics are of use in only a 
small part of the cases : in the majority we must rely 
on the general symptoms and etiology for our diag- 
nosis. There are a number of diseases which from 
their importance require consideration. 
In tabes, as has long been known, there is frequently 
a history of transitory diplopia during the prodromal 
period. A patient sees double on and off, just for a 
moment, particularly at night. The time is fixed partly 
by the causes already referred to, and partly bv the 
fact that lamps afford a close test of the eyes. When 
the eyes are tested no signs of paralysis are detected. 
In another group, usually more advanced, a positive 
paralysis exists, an external rectus is weak, convergence 
is poor, or they see double in the upper stories of the 
houses as they pass along the street. These paralyses 
may in their turn pass off in a few days, give place to 
others, or remain fixed. The origin of these fugacious 
paralyses is not known, but their significance when 
combined with previous syphilitic infection is gravely 
suggestive of tabes to follow. The more fixed paraly- 
ses are apparently due to a mixture of causes, the most 
common being a thickening of the ependyma and an 
extension of the process into the nuclei and fibre 
tracts ; another is syphilitic infiltration about the roots 
of the nerves before they are combined into a compact 
bundle. Endarteritis and its results do not apparently 
play an important part in these early paralyses. 
The latter ami general paralyses of the eye occur- 
ring in tabes are usually classed as cases of ophthal- 
moplegia. These are characterized by their irregular 
distributions, extent and persistency. 
Paralysis of the eye muscles is by no means rare in 22 
cases of multiple sclerosis. Upthoff 157 found seventeen 
cases in a hundred. These cases are classed as follows: 
Two of double sixth paralysis, four of single sixth, 
three of third nerve, all partial; two of lateral con- 
jugate, one of up conjugate, three of convergence, and 
two of ophthalmoplegia externa. It will be noticed 
that the paralyses are all limited, do not tend to in- 
clude the whole of the third nerve, bat only alfect one 
or two muscles, as an associated motion. They tend 
to be more closely limited than in tabes. 
Tumors involving the corpora quadrigeroina, the 
pineal or pituitary gland are very apt to cause paraly- 
sis in the branches of the third, together with a pecu- 
liar form of ataxia and impairment of sight, but there 
is nothing in the paralysis itself to indicate the nature 
of the lesion, except perhaps in cases of paralysis of 
up-and down motion. The diagnosis of the nature of 
the lesion must be based on the general symptoms 
of tumor and the fact that other lesions are rare in this 
locality. In a summary of 29 cases Christ17 found 
paralysis of the third nerve in 22, of the fourth in six, 
and of the sixth in nine cases. 
The so-called cases of ophthalmoplegia externa re- 
quire notice. In 1879 Hutchinson 64 called attention 
to a group of cases in which a progressive fairly sym- 
metrical paralysis of the muscles of the e-balls formed 
a predominant symptom among a group of scattered 
bulbar paralyses and general cerebral symptoms. 
Since then the limits of this group have been extended 
so as to cover all general eye paralyses apparently of 
central origin and thus any value which may have at- 
tached to the name has been lost. To-day a diagnosis 
of ophthalmoplegia is about as significant as one of 
stomach ache. The twenty odd cases in which there 
are fairly good autopsy reports, some being monuments 
of labor, skill ami knowledge, show a great variety of 
processes. 23 
A few groups, however, can be separated out, with 
a fair decree of accuracy : 
First, there are the cases of polio-encephalitis of 
Wernicke, represented by Gavet's case,40 Wernicke’s187 
three cases, and Thomsen’s151 two cases. In these 
cases there are but little paralysis except of the eyes, 
but in all mental disturbance, active delirium or somno- 
lence, a staggering ataxic gait, tremor and the general 
signs of severe brain disease. At the autopsy a marked 
injection of the vessels, and numerous miliary haemor- 
rhages throughout the central gray matter of the third 
ventricle, aqueduct, and fourth ventricle have been the 
principal trouble. The process has also iu some cases 
been diffused through the whole of this region. In 
others, more or less extensive degeneration of the nu- 
clei has also been present. 
In Hutchinson’s caseM the process is given as a 
nuclear degeneration, the same as in muscular atrophy, 
a pathology with which the symptoms well accorded. 
Some of the cases of diphtheritic paralysis also appear 
to partake of the same nature though peripheral trou- 
ble is present. These cases are slower than those of 
Wernicke’s group, and lack the high degree of vascu- 
lar change and acute symptoms, but seem to be allied 
to them by a certain amount of vascular change and 
the nuclear degeneration. 
A second class is represented bv the cases of 
Duboys,2* Eiseulohr,2* and Bristowe,12 in which careful 
microscopic examination gave negative results. In 
character they all differ: the first was a recurrent 
trouble, the second like a bulbar case, while iu the 
third there were signs of Graves’ disease and much 
suggesting hysteria. 
The rest of the cases depend on all sorts of gross 
lesions, as Etter’s81 with myelitis, Sutter’s161 with 
tumor, Buzzard’s18 with syphilitic endarteritis (?), 
while the changes occurring iu company with tabes, 24 
multiple sclerosis, and general paralysis make up the 
rest. 
Dufour 24 has summarized the mass of reported cases 
of ophthalmoplegia exterior or nuclear palsies, from 
which the following figures are taken. Males 122, 
females 41. Before the fifteenth year, 23; in the next 
fifteen 35; and from thence to the sixty-ninth year 67 
cases. Total, 125. Of 183 cases 31 had previous 
cerebrospinal disease, 74 syphilis, diphtheria, diabetes, 
or the like, and 78 were in health. 
Disease at the base of the skull often causes more 
or less paralysis of the eyes, as in tubercular menin- 
gitis and the so-called syphilitic meningitis. As a rule 
iu the first any eye paralysis is of late date, and accom- 
panied by affection of other nerves in a way suggest- 
ing a disease of the membranes, as well as by general 
constitutional symptoms. But this is no law, as the 
following case of Seitz135 proves. A man of forty 
years went to bed well and woke up in the morning 
with a complete paralysis of the right third nerve. He 
later developed the full signs of tubercular meningitis 
from which he died. The autopsy showed nothing re- 
markable to explain the early eye paralysis. Syphili- 
tic disease of the membranes is usually in reality a 
more or less diffuse gummatous or round cell growth, 
springing from the dura, and often lying between the 
dura and the skull. By creeping along the base of 
the skull and crowding the foramina such growths, 
though of small mass, can produce great mischief. It 
is equally true in these cases, as in others of syphilitic 
origin, that fever is conspicuous by its absence, while 
nocturnal pain and insomnia predominate. Uuverricht’s 
case 158 is a type of how a small amount of tumor can 
produce much mischief. In the other case the disease 
at the surface of the base is combined with central 
trouble depending on disease of the vessels or the neu- 
roglia, as iu the case carefully studied by Siemerling.140 25 
Other tumors in the some region produce the same 
effects, but tend by pressure to cause paralyses of 
the body as well as optic neuritis. They also tend 
to a unilateral distribution, to picked paralysis of the 
fifth nerve, with neuralgia, as well as to involve the 
nerves in series as they run along the base of the 
skull. 
There are still but few cases of recurrent paralysis 
of a third nerve with autopsy reported. (Richter,120 
Weiss,163 Fiedler 84 two.) in all of these, in spite of 
the various theories advanced, some form of local dis- 
ease of the nerve has been found as tubercle, lihroma, 
meningitis. These cases have not been true recurrent 
paralysis, since there has been a certain amount of 
paresis between the spells. They are cases of paresis 
of the third nerve with recurrent exacerbations. The 
spells are apt to he accompanied or preceded by pain, 
vomiting, und confusion. 
Until lately there has been more or less feeling that 
the eyes were exempt in cases of multiple neuritis, a 
position exploded bv the cases of Pal,107 as well as by 
that of Meyer.84 The last case is of special interest, 
as it partook of the character of an ophthalmoplegia. 
A man forty-two years, old suffering from chronic 
bronchitis and bronchiectasis developed a paralysis of 
all the muscles of the eye-halls and the levators of the 
lids, but with no paralysis of the pupils. Anaesthesia 
of the cornea, paraesthesia of the back and limbs, and 
dysphagia soon developed, shortly after which death 
occurred- A careful microscopic examination failed 
to show any disease of the brain, but did demonstrate 
an extensive multiple neuritis. The third, fourth, and 
sixth nerves were degenerated, while the facials, hyo- 
glossals, glossopharyngeals aiid many spinal nerves 
were partially degenerated. 
In disease of the orbit the paralysis may be general, 
according to accepted doctrine, or localized in certain branches of the third nerve ; hut our knowledge of the 
subject is very meagre. The foramina themselves 
offer opportunity for trouble by the growth of exosto- 
ses, while fracture is not a rare cause of trouble. With 
so-called rheumatic paralyses of the eye muscles, so 
commonly referred to, I have had little or no experi- 
ence. Of some fifty or sixty cases of which I have 
records, there is but one which can fairly be considered 
as belonging to this group if it exist. This case was 
seen but once, and was so classed from lack of any in- 
dications. It goes without saying that the probabilities 
of syphilis were great. The only autopsy made in the 
allied facial trouble (Minkowski90) revealed a general 
degeneration of the whole nerve, and no signs of rheu- 
matism. Had other nerves been affected, the case 
would have been one of multiple neuritis. 
There are a few other factors which require mention 
from the danger of their being overlooked, as congeni- 
tal imperfections of motion due to paralysis, as in the 
cases of conjugate paralysis reported by Giafe46and 
others, to imperfect insertion of the muscles or, to dis- 
ease in the muscles and tissue of the orbit. Of the 
latter I have seen one case (following influenza?) in 
which there was much limitation of motion of the eye- 
balls, intense pain, deep tenderness, fever, pupils not 
affected, which recovered in ten days. 
Ptosis, though not due to paralysis of a muscle of 
an eye-ball, is so closely connected with these as to re- 
quire notice. The lid is raised by two muscles, the 
levator palpebrae supplied by the third nerve .and un- 
striped fibres supplied by sympathetic fibres. Paraly- 
sis of the latter is not so very rare, judging from the 
slight dropping of the lid during a spell of hemicrania, 
and in tabetics. A slight congenital drooping of the 
upper lid is also by no means uncommon. This state 
is of importance chiefly from the possibility of its 
being mistaken for a true ptosis. The obverse con- 
26 27 
dition is seen in the failure of the lid to follow the 
pupil down and the wide palpebral fissure of Graves’ 
disease. 
True ptosis is a different affair and is a sign of im- 
portance as a danger signal rather than as a factor in 
diagnosis. It is commonly present in the early stages 
of hemiplegia from any cause, and has much the same 
significance as conjugate deviation of the eyes. Some 
writers have endeavored to localize a special centre 
for the lid in the temporal region, hut have failed to 
make out a strong case. Barring the cerebral cases, 
ptosis occurs with paralysis of the third nerve, from 
almost any cause, and is often the first sign. A patient 
wakes up with slight drooping of one lid, and in the 
course of a few hours to mouths the other {tarts sup- 
plied by the third nerve are involved. Either the 
nerve to the lid is more exposed to disease, or owing 
to its position and constant work defects in the muscle 
are more easily recognized. However this may he, a 
picked paralysis of one muscle supplied by the third 
nerve is very rare and quite surely will be followed by 
others. The danger is that the physician may over- 
look or slight the paralysis and thus receive a disagree- 
able surprise. 
No reference has been made to treatment, since, 
with 60 many different processes involved it would 
open up a wide field. The process causing the paraly- 
sis is the object to be aimed at, not the paralysis. M v 
own feeling is that where the cause is not apparent, 
an eye paralysis is very apt to be of syphilitic origin, 
and as such to suggest antisyphilitic treatment. 'There 
is little pathological evidence at hand, but this view 
seemed in accord with the growing sentiment of those 
who have paid most attention to the subject. Un- 
fortunately it does not follow that because an eye pa- 
ralysis has a syphilitic basis, treatment will do any 
good. 28 
To sum up: 
(1) All cases of lateral conjugate paralysis are of 
central origin. 
(2) When the paralysis is on the same side as other 
paralyses the lesion is on the opposite side of the brain. 
Such paralyses as a rule are transitory and follow al- 
most any sudden lesion, and often only show them- 
selves as a prevailing position of the eye, and not as 
a true paralysis or even paresis. 
(3) When the paralysis is crossed with the paraly- 
ses below, the lesion is in the pons-medulla region. 
The above three are equally true of spasms. 
(4) A gradual development of conjugate paralysis 
clearly points to the region of the sixth nucleus of the 
same side as affected. 
(5) Paralysis of up or down motions or both mo- 
tions indicate disease in the region of the corpora 
quadrigemina, but may be due to disease in the third 
nerves proper, at the point of exit. 
(6) Reasoning from analogy, paralysis of convergence 
points to disease in the central gray below the aque- 
duct, but as yet autopsies are lacking. 
(7) Picked paralysis of parts of a third nerve 
strongly suggests central disease, but is not proof of it. 
(8) A majority of the cases of eye paralysis' occur 
in the syphilitic. 
(9) A paralysis which changes rapidly, quickly 
showing fatigue, is probably central in origin. 
(10) Transitory paralysis in the syphilitic is strongly 
suggestive of future tapes. 
(11) An eye paralysis, however simple it may seem, 
is always a just cause for suspicion of trouble to come, 
and demands a prompt and thorough examination of 
the patient. 
(12) There is no evidence that there is any form of 
connection between the sixth nucleus and the third, 
except iu the cerebrum. 29 
1. Ballet. Le Progrcs Medical, p. 78G, 1880. 
2. Banliam. Lancet. p. 588, 1881. 
3. Barel. Archives d’Oplitlialmologle, vii, 503. 
4. Bennett and Saville. Brain, xii, 102. 
6. Bernhardt. Berliner klin. Wocheuschr., pp. 143, 157, 1881. 
0. Bernhardt. Berliner klin. Wocheuschr., p. 1009, 1889. 
7. Binsler. Deutsch. militiir-arzt. Zeitschr., xviii, .i0l. 
8. Blenler. Deutsches Archiv f. klin. Med., xxxvii, 527, 
xxxvii , 28. 
9. Blocq et tiuinon. Archives de med. exper., iii, 74. 
10. Bottiyer. Archiv f. Psych., xxi, 613. 
11. Bouveret et Curtillet. Lyon medical, Ixv, 35. 
12. Bristowe. Brain, viii, 313. 
13. Broadbent. Med. Times and Gazette, i, 554, 1872. 
14. Brims. Neuroloy. Centralblatt, p. 151. 
15. Buttersack. Archiv f. Psych., xvii, ti03. 
18. Buzzard. Brain, v, 34. 
17. Christ. Deutsches Archiv f. klin. Med., xlvi, 497. 
18. Claes. Berliner klin. Wocheuschr , No. 37, 1891. 
19. Debove. Bull, de la soc. anat., p. 422, 1874. 
20. Desnos. Bull, de la soc, med. des hop., x, 87. 
21. I>e Watteville. Neuroloy. Centralblatt, p. 217, 1887. 
22. Dittmann. Neuroloy. Centralblatt, p 428, 1889. 
23. Duboys. Bull. cliu. nat. ophtbalm., p. 121, 1882. 
24. Dufour. Les paralysies nucleaires des muscles des yeux. 
25. Karles. Trans. Ophtlialm Soc., iv, 300 
28. Eichhorst. Charite-Annalen., p. 208, 1874. 
27. Eichhorst. Corr.-hliitt. f. schweiz. Aerzt , xix, 432. 
28. Eichhorst. Charite-Annalen., p 224, 1874. 
•29. Eisenlohr. Neuroloy. Centralblatt, Nos. 15, 18, 1887. 
30. Essmarck und Jessen. Ally. Zeitschr. f. Psych., p. 20, 
1857. 
31. Etter. Corr.-bliitt. f. schweiz. Aerzt., xii, 789. 
32. Fereol. Gazette des hop., x, 98. 
33. Fereol. Bull, de la soc. mod. des hop., p. 125, 1873. 
34. Fiedler. Jahresberieht f. Ophthalmol., xviii, 583. 
35. Fiedler. Centralblatt f. Nervenheilk, p. 491, 1887. 
38. Finlayson. Glasgow Mod. Jour., April, 1888. 
37. Finny. Dublin Jour. Med. Sci., lxxxvii, 380. 
38. Foville. Quoted by Graux. 
39. Garel. Revue de med., p. 593, 1882. 
40. Gayet. Archives de physiol., vii, 341. 
41. Gayet. Gazette hehdom., p. 282, 1878. 
42. Gee. St. Barthol Hosp. Kep.,xxvi, 108. 
43. Gowers. Diseases of the Nervous System, ii, 178, 1st ed. 
44. Griife. Handbuch d. yesammt. Aiiyenheilk., vi, 1875. 
45. Griils. Verbandl. Iuternat. Ophthalmol. Congress, p. 30, 
1888. 
4o Griife. Archiv f. Ophthalmol., viii, 2te ab., p 74. 
BIBLIOGRAPHY. 30 
47. Grasset. Montpellier med., xl, 323. 
48. Graux. These de Paris, 1878. 
49. Gubler. Schmidt’s Jahvbiich., lvii, 299. 
50. Gubler. Gazette hebdorn., p. 721, 1858. 
51. Gull. Med. Times, xix, 371. 
52. Hallopeau. Archives de physiol., viii, 794. 
53. Hallopeau. Bull, de la soc. anat., 187b. 
54. Henoch. Berliner klin. Wochenschr. p. 125, 1804. 
55. Hensen und Vblckers. Arcliiv f. Ophthalmol., xxiv, 1. 
56. Heubner. Die luetische Erkrankungen der Hirnarterien. 
57. Heuser. Virchow’s Arcliiv, cx, 9. 
58. Hirsehberg Neurolog. Centralblatt, No. 24, 1882. 
59. Hoppe. Neurolog. Centralblatt, p. 628, 1888. 
i 0 Hiick. Klin. Monatsblatt. f. Augenheilk, July, 1879. 
61. Huguenin und Hofstetter. Zur Casuistik der Ponstumoren. 
62. Huunius. Zur Symptomatologie der Briickenerkraukun- 
gen. 
63. Husner. Prager med. Wochenschr.. p. 59, 1883. 
64. Hutchinson. Med. Cliir. Trans., lxii, 307. 
65. Hutchinson, Jr. Lancet, p. 115, 1887. 
66. Josephs. Zeitselir. f. klin med., xvi, 349. 
67. Kahler und Pick. Vierteljalirsclir f. d. prakt. Heilkunde, 
cxlii, 87. 
68. Kahler und Pick. Zeits-hr. f. Heilkunde, p. 301, 1881. 
69. Kahler und Pick. Arcliiv f. Psych , x, 334. 
70. Keen. Araer. Jour. Med. Sci , lxxxviii, 329. 
71. Kochlin. These de Paris, 1858. 
72. Lancereaux. Des affections nerveuses sypliilitiques. 
73. Leube. Deutsches Arcliiv f. klin. Med , xl, 217. 
74. Leyden. Klinik der Riickenmarkskrankheiten, ii, 65. 
75. Lichtheim. Corr.-blatt. f. schweiz. Aerzte, xii, 2. 
76. McAldowie. Brain, iii, 125. 
77. McGregor. Lancet, Dec. 11, 1886. 
78. Manz. Berliner klin. Wochenschr., p. 637, 1885. 
79. Marot. Bull, de la soc. anat., p. 189, 1875. 
80. Martin. Bull, de la soc. auat., p. 152, 1877. 
81. Mauthner. Die Lehre von der Augenmuskellahmungen. 
82. Mendel. Deutscli. med. Wochenschr., p. 124, 1885. 
83. Mendel. Neurolog. Centralblatt, p. 128, 1885. 
84. Meyer. Neurolog. Centralblatt, vii, 180. 
85. Meyer. Arcliiv f. Psych , xiii, 63. 
86. Mierzejewsky und Rosenbach. Neurolog. Centralblatt, p. 
361, 1885. 
87. Miles. Archives of Med., vi, 196. 
88. Mills Archives of Med , viii, 60. 
89. Mills. Jour. Nerv. and Ment. Dis., viii, 470. 
90. Minkowski. Berliner klin. Wochenschr., p. 665, 1891. 
91. Mobius Munch, med. Wochenschr., p. 91, 1888. 
92. Mobius. Centralblatt f. Nervenheilk., p. 449, 1887. 
93. Mobius. Berliner klin. Wochenschr., p. 604, 1884. 
94. Moeli. Archiv f. Psych., xviii, 1. 31 
95. Mott and Schaefer. Brain, p. 164, 1890. 
96. Mott and Schaefer. Brain, p. 174, 1890. 
97. Neumann. Berliner klin. Wochenschr., p. 403, 1890. 
98. Nleden. Centralblatt f. Angenheilk., iv, 209. 
99. Nnthnagel. Wien. med. Blatter, No. 19, 1X84. 
100. Nothnagel. Topische Piagnostik der Uehirnkrankheiten. 
101. Nothnagel. Zeitschr. f. klin. med., xvi, 424. 
102. Oppenheim. Areliiv f. Psych., xvi, 707. 
103. Oppenheim. Archiv f. Psych., xx, 131. 
104. Oppenheim. Charittf-Annalen., x. 334. 
105. Onnerod. Trans. Path. Soc., Loud., xi,21. 
100. Ormerod. Lancet, i, 504, 18.84. 
107. Pal. Ueber multiple Neuritis. 
108. Parinaud. Trans. Brain, ix, 330 
109. Parinaud. (iazette hebdom., p. 727, 1887. 
110. Parinaud. Archives de neurol., v, 145. 
111. Perlia. Archiv f. Ophthalmol., xxxv, 287. 
112. Peters. Centralblatt f. prakt. Angenheilk., xii, 225. 
113. Petrina. Prag. Vierteljahschr. f. prakt. Heilk., 1877. 
114. Pfliiger. Archiv. f. Ophthalmol., xxxvii. 71. 
115. Pilz Jahrbuch. f. Kinderbeilk., u. f., iii, 133. 
llti. Poltko. Archiv f. Psych., x, 205. 
117. l’oubin. Le progrcs med., p. 180, 1880. 
118. Prdvost. Thfese de Paris 1808. 
119. Quioc. Lyon mW., p 313, 1881. 
120. Kichter. Archiv f. Psych., xviii, 259. 
121. Rickards. Lancet, i. 774, 1888. 
122. Romberg. Casper’s Wochenschr., p. 6, 1842. 
123. Ross. Brain, vii, 501. 
124. Roussel. Le progrfes med , Ixxxvi, 593. 
125. Sanger. Archiv f. Psych , x, 158. 
126. Samelsohn. Verhandl. Internat. Ophthalmol. Congress, 
p. 39, 1888. 
127. Samelsohn. Deutsche med. Wochenschr., No. 46, 1888. 
128. Sand by. Lancet, ii. 345, 1882. 
129. Saundby. Birmingham Med. Review, p. 222, 1885. 
130. Schaefer. Brain, x, 362. 
131. Schapringer. N. Y. med. Monatsheft. p. 621, 1889. 
132. Schntz Prag. med. Wochenschr., p. 361, 1881. 
133. Schwartz. Zeitschr f. klin med , xiv. 293. 
134. Seguin. Jour. Nerv. and Ment. I)is., xv, 317. 
136. Seitz. Die Meningitis tuberculosa der Erwachsenen. 
136. Senator. Archiv f. Psych., xiv. 643. 
137. Sharkey. Trans Ophthalmol. Soc., iv, 276 
138 Sharkey Trans. Ophthalmol. Soc., viii, 314. 
139. Shaw. Brain, v, 251 
140. Siemerling. Archiv f. Psych., xix, 401. 
141. Simou. Brit. Med. Jour., Jan. 2. 1886. 
142. Smith, Priestley. Ophthalmol, llosp. Rep., viii, 185. 
143. Snell. Lancet, i, 138, 1885. 
144. Spitzka. Jour. Nerv. and Ment. Pis., xiii, 193. 32 
145. Spitzka. Jour. Nerv. and Ment. Dis., xiii, -113. 
146. Starr. Jour. Nerv. and Ment. Dis.. xv, 301. 
147. Steffen. Berliner klin. Woehensohr., p. 108, 1864. 
148. Sticker. Munch, nied. Wochenschr , p. 087, 1887. 
140. Stiehel. Paralvseos hfemorrhagieie nervi oeulo-motorii in 
infante oliservatus casus rarissimus. 
150. Stolting mid Bruns Archiv f. Ophthalmol., xxxiv, 02. 
151. Sutter. Casuistisclier Beitrag zur Lehre tier Ophtlialmo- 
plegien. 
152. Swanzy. Wien med. Presse, p. 1(>04, 1889. 
153. Tassi. Rivista sper. di freniatria, xii, 72. 
154. Thomsen. Archiv f. Psych., xviii, (516. 
155. Thomsen. Archiv f. Psych., xix, 185. 
15(5. Thomsen. Centralblatt f. Nervenheilk., p. 531, 1884. 
157. Uhthoff. Archiv f. Psych., xxi, 55. 377. 
158. Unverricht. Fortschr d. Med , p. 701. 1887. 
159. Vinantiis. Annali di Oftalmol., xiii, 274. 
180. Warner. Med. Chir. Trans., lxvi. 107. 
1(51. Webber. Boston Med. and Surg. Jour., 8 March, 1883. 
1(52. Weher. Med. Chir Trans., xlvi, 121. 
1(53. Weiss. Wiener med. Wocheuschr., p. 522, 1885. 
164. Wernicke. Archiv f. Psych., xx, 243. 
165. Wernicke. Archiv f. Psych., vii, 513. 
166. Wernicke. Berliner klin. Wochenschr., p. 304, 1876. 
167. Wernicke. Lehrbuch der Gehirnkrankheiten, ii, 233. 
168. Westphal. Archiv f. Psych., xviii, 84(5. 
169. Westphal und Siemerling. Archiv f. Psych., xxii, Supp. 
Heft. 
170. Willcocks. Brit. Med. Jour., p. 272, 1881. 
171. Wollenberg. Archiv f. Psych., xxi, 778. Two Volumes yearly, beginning with the first Nos. in January and July. But 
Subscriptions may begin at any time. 
This Journal has been published for more than sixty years as a weekly journal under its present title. 
Still it is incumbent upon th s Journal, no less than upon others to assure its patrons from time to 
time, as the occasion arises, of its desire, ability, and determination to meet all the requirements of the most 
activ-* roedlea journalism of the day, without sacrificing any of that enviable reputation which is an inheri- 
tance rrom the past. 
It is under the editorial Management of I)r. George B. Shattuck, assisted by a large 6talT of competent 
coadjutors. 
Communications from all quarters of the country are acceptable. Liberal arrangements are made for 
repriuts of original articles, aud for such illustrations as serve to tucrease their value or interest. 
All editorial count nnioations, and books for review, should be addressed to the Editor. 
Subscriptions and advertisements received by the undersigned, to whom remittances should be sent by 
money-order, draft, or registered letter. 
Terms of Subscription : In the United States, and to Canada and Mexico, $5.00 a year in advance. 
To Foreign Countries embraced in the Universal Postal Union, $1.56 a year additional. Single numbers, 15c. 
Ten consecutive numbers free by mail on receipt of $1.00. 
Sample copies sent free on application. 
Published by DAMRELL & UPHAM, 
Washington St., I loston. 
MedicalandSurgical Journal 
A FIRST-CLASS WEEKLY MEDICAL NEWSPAPER. PUBLISHED EVERY THURSDAY. 
THE BOSTON