ON THE INFLUENCE 
OF THE 
CERVICAL PORTIONS OF THE SYMPATHETIC 
NERVE AND SPINAL CORD 
UPON 
THE EYE 
AND ITS APPENDAGES, 
ILLUSTRATED BY CLINICAL CASES, WITH OBSERVATIONS. 
BY t 
JOHN W. OGLE, M.D., 
ASSISTANT-PHYSICIAN TO ST. GEORGE’S HOSPITAL. 
[From Volume XLI of the * Medico-Chirurgical Transactions,* 
published by the Royal Medical and Chirurgical Society of 
London.] 
LONDON: 
PRINTED BY 
J. E. ADLARD, BARTHOLOMEW CLOSE, 
1858, ON THE INFLUENCE 
OF the 
CERVICAL PORTIONS OF THE SYMPATHETIC 
NERVE AND SPINAL CORD 
UPON THE 
EYE AND ITS APPENDAGES, 
ILLUSTRATED BY CLINICAL CASES, WITH OBSERVATIONS. 
BY 
JOHN W. OGLE, M.D., 
FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS; ASSISTANT PHYSICIAN 
to st. george’s hospital. 
lleceived June 17tli.—Head June 22d, 1858. 
Of late years direct and rigorous experiment has done 
much in placing us in possession of more correct ideas 
respecting many parts of the human frame, and especially 
of the nervous system. Objections, however, have been 
entertained against the conclusiveness of experiments upon 
healthy animals as illustrative of morbid actions in man; 
and these objections may be reduced to three in number. 
First, the supposed essential difference between results 
obtained experimentally and those consequent upon disease 
in man; secondly, the great and almost insuperable liability 
to implicate numerous and important parts in the attempt 
to arrive by operation at any given structure, thus compli- 
cating the very subject which we are striving to render clear; 
and thirdly, the modification of results obtained, owing to 
unavoidable haemorrhage and the exhaustion of sensibility. 
It is as regards the comparative freedom from the last two 
objections that experiments upon the sympathetic nerve in 
the region of the neck, the properties and anatomical con- 2 
THE INFLUENCE OF TIIE SYMPATHETIC 
stitution of which have ever divided the opinions of phy- 
siologists, may be most favorably considered, and their results 
accepted as trustworthy. The large size of the vessels and 
nerves of this region, the ease with which they may for the 
occasion be dislocated without injury or danger to the 
animal, rendering the sympathetic, as it were, quite super- 
ficial and accessible, the simple arrangement and the ready 
dissection of the parts, all these particulars have caused 
our knowledge of the influence exerted by the cervical sym- 
pathetic upon the heart, lungs, and eye, to be much added 
to of late. 
The main points which I propose to bring before the 
notice of the Society in the following paper, may be summed 
up as follows: 
In the first place, I shall commence with certain pre- 
fatory observations and a short historical review of the most 
important results obtained as regards the eye and its ap- 
pendages, by experiments which have from time to time been 
performed upon the cervical parts of the sympathetic, and 
the spinal cord with which it is connected. I shall then 
proceed to relate the histories of clinical cases, old and new, 
in which a contracted state of the pupil had become a sub- 
ject of interest, induced apparently by the pressure of 
thoracic aneurisms, equivalent in degree to the experimental 
■aetion of the sympathetic in animals. 
In the second place, I shall bring forward clinical cases in 
which a similar result had been observed in connexion 
with aneurism of other arterial branches than those within 
the thorax. 
In the third place, I shall adduce instances in which 
pressure upon the sympathetic (but from other causes than 
aneurism) had produced a like effect, as in the case of en- 
larged glands, carcinomatous and other deposits, &c. 
In the fourth place, bearing in view the intimate con- 
nexion between the sympathetic main branches in the neck 
and the cervical part of the spinal cord, I shall draw atten- 
tion to certain cases in which a contracted pupil had been 
observed in injuries of the spinal cord itself. ON THE EYE AND ITS APPENDAGES. 
3 
In the fifth place, I shall bring forward clinical cases in 
which a dilated state of the pupil was apparently produced 
by pressure, from various causes, upon the sympathetic, the 
pressure being so slight or transient as merely to act as a 
stimulus to the dilator fibres of the pupil, enabling them to 
overbalance the resisting contractors. 
In the sixth place, and lastly, calling to mind one or two 
points in the anatomy of the sympathetic in the neck and 
within the cranium, I shall relate cases in which symptoms 
arose from pressure upon the sympathetic or certain nervous 
structures with which it is connected, such as might, in 
addition to these effects upon the iris already alluded to, 
have been anticipated from anatomical considerations. These 
symptoms are strictly analogous to the various phenomena 
produced in the lower animals by section of, or extreme 
pressure upon, the sympathetic. 
The influence of the “ sympathetic” portion of the nervous 
system on the modifications of sensibility and vascularity, 
and of the temperature of external parts supplied by it, has 
been within the last few years abundantly proved experi- 
mentally by Brown-Sequard,1 Claude Bernard,2 Schiff,3 
A. Kussmaul, and A. Tenner,4 &c., although these authors 
differ in some important respects as to their interpretation of 
several phenomena witnessed by them. Moreover, Bernard8 
ascertained that, in addition to alterations of the tempera- 
ture of external parts, division of the cervical part of the 
sympathetic induced a much increased temperature within 
the cerebral hemisphere on the side upon which section of 
the nerve had been made ;6 and also that the blood in the 
jugular vein was rendered warmer on the side operated upon 
1 ‘Memoire lu a l’Academie des Sciences,’ Janvier 16, 1854. 
2 ‘ Comptes rendus de l’Academie des Sciences,’ Mars 29, 1852. 
3 ‘ Untersuchung. z. Physiologie des Nervensystems,’ Von Moritz 
Schiff, Frankfurt, 1855. 
4 J. Moleschott’s ‘Untersuchung. z. Naturlehre d. Mensch. u. d. Thiere,’ 
i, 90, 1857. 
5 ‘Memoires lus a la Societe de Biologie,’ 1853, p. 94.. 
6 See also Henle’s and Pfeuffer’s * Zeitschrift,’ vii, p. 206, 1855. 4 
THE INFLUENCE OE THE SYMPATHETIC 
than on the opposite one. But, in addition to modifications 
of vascularity and temperature, experiment shows that an 
altered state of muscular parts may be effected by inter- 
ference with those branches of the sympathetic system 
which are distributed to them. For instance, Valentin and 
Henle, and, still later, Budge,1 have demonstrated that con- 
tractions of the heart and larger blood-vessels are producible 
by stimulation of the sympathetic branches derived to them. 
E. H. Weber,2 of Leipzig, Arnspc^gcj^3 and others, made 
many observations on the decided effects of the pneumo- 
gastric (a nerve considered, I believe, by Brown-Sequard 
and others as being to a great extent a sympathetic one) 
upon the movements of the heart; and E. P. Pfliiger4 
shows that arrest of the movements of the small intestine 
follows galvanic irritation of the splanchnic nerves. 
Now, although it is only in quite recent times that the 
physiological relation between the sympathetic and the 
various vessels and muscular parts to which it is extensively 
distributed has become at all adequately appreciated, yet for 
a number of years many observers have at times instituted 
experiments tending to show the effects of the sympathetic 
upon the eye. I will here- pass in very brief review some 
of the most interesting results which have been arrived at 
by various observers in this direction, so far only as they 
have relation to the present communication, a passing con- 
sideration of which will best lead to a full understanding of 
the cases which I now present to the notice of the Society. 
The first experimenter who appears to have recognised, 
amongst other effects of injury to the sympathetic nerve in 
the cervical region, those upon the pupils of the eyes, was 
Pourfour du Petit. Experimenting as he did between the 
years 1712 and 1727, upon animals in which the sympathetic 
nerve in the neck and the pneumogastric are so intimately 
connected as to be incapable of separation, as in the dog, for 
example (unlike the rabbit or tbe cat, in which these 
1 Frerich’s ‘ Tages-bericht,’ 1852, No. 441. 
Wagner’s ‘ Handworterb. d. Physiol,’ 1846, Bd. iii, Abtli. ii, p. 45. 
Virchow’s ‘Archiv.,’ vol. ix, 1856. 
Quoted in Schmidt’s ‘ Jahrbiicher,’ vol. lxxxix, No. 1, p. 15, 1856. ON THE EYE AND ITS APPENDAGES. 
5 
two nerves lie together in one sheath, hut are disjoined), 
he found1 that when the united cord of the vagus and 
sympathetic was divided, the following phenomena were 
observable2 In many animals he noticed on the side 
operated upon a most marked contraction of the pupil, 
partial closing of the eyelids, with protrusion of the car- 
tilaginous third eyelid at the inner angle of the eye, and 
also a redness and apparent swelling of the eye, with, sub- 
sequently, the secretion of pus from its surface. It is at 
once obvious that these effects are very similar to those of 
section of the fifth pair of cranial nerves, when divided near 
the Gasserian ganglion, as they were first described by 
Fodera3, Herbert Mavo4, Majendie5, and Sir C. Bell. They 
however differ materially in the following particulars, viz., in 
their accession at a much earlier period after injury of the 
nerve, and in their greater limitation, inasmuch as the cornea 
very seldom indeed becomes ulcerated, and the inflamma- 
tion appears to be confined to the conjunctiva, whilst in 
section of the fifth pair within the cranium, as described by 
Valentin,6 the iris, after profuse suppuration of the surface 
of the eyeball, becomes distended with blood, the chambers 
of the eve and the pupil become filled with exudations, and 
the cornea ulcerated. Petit, aware of the anatomical con- 
nexion between the sympathetic in the neck and the pneu- 
mogastric, sagaciously perceived that it was in regard of the 
section of the sympathetic alone that these phenomena were 
1 ‘ Memoirs on the influence of the so-called Intercostal Nerve on the 
Eye,’ 1727 (‘Ilistoire de l’Academie Roy ale,’ avec les ‘Memoires,’ &c.) 
2 Emmert (‘ Archiv. f. d. Physiolog. Yon Reil und Autenreith,’Bd- 
xl, p. 117), who experimented much upon the necks of animals, found 
that in the dog, wolf, and foumart, this connexion between the vagus and 
the sympathetic in one sheath was most intimate, whilst, on the other 
hand, in the cat, goat, sheep, bull, horse, ass, and pig, he found that it 
was only very slight, although it did exist. In the hare, rabbit, and guinea- 
pig, the two nerves are quite separate, as in man. 
3 ‘ Journ. de Physiologie experimentale,’ tome iii, p. 227, 1823. 
4 ‘Anatomical and Physiological Commentaries,’ No. 2. 
5 ‘Journal de Physiologie experimentale,’ tom. iv, p. 178, 1824. 
6 ‘De functionibus Nervorum Cerebralium, &c,, pp. 109-114, Bernae et 
Sangalli, Helvetiorum, 1852. 6 
THE INFLUENCE OF THE SYMPATHETIC 
called forth. After Petit, a number of experimenters 
more or less confirmed bis observations. The chief of these 
were Peter Mollinelli,1 who has recorded five observations 
describing the results of ligation and section of the sympa- 
thetic and par vagum, as united in the neck of the dog, 
Justus Arnemann,2 Cruikshank,8 Dupuv,4 Cammerer,5 Mayer 
of Bonn/’ Bracket,7 Reid,8 and Valentin.9 But on reading 
their productions, several discrepancies are manifest, and it 
is evident that they experimented with very different powers 
and with very varied intentions of observation. 
Dupuy, Professor of Veterinary Surgery at the College 
of Alfort, made a number of experiments along with 
Breschet, and under the eye of Dupuvtren, upon the cer- 
vical sympathetic in the horse. 
Like Petit, he also noticed that division of the nerve 
was followed by contraction of the pupil, descent of the upper 
eyelid, and redness of the conjunctiva, &c. In addition, he 
observed a peculiar dryness and adherence of the skin, 
swellings of the eyelids, and general emaciation; moreover, 
he noticed an increased temperature of the ears, with aug- 
mented perspiration and eruptions upon the skin, thus an- 
ticipating in a remarkable manner much that has more 
recently been brought forward as regards the influence of 
the sympathetic upon the capillaries of the skin and other 
parts. Brachet also found section of the sympathetic cer- 
vical nerves to be followed by cerebral congestion, agitation, 
somnolence, and stupidity. 
] ‘Commentarii Academic Bononiensis,’ tom. v, pp. 280-297, 1755. 
2 4 Versuche iiber d. Regeneration der Nerven,’ Gottingen, 1787. 
3 ‘Philosophical Transactions,’ part i, 1795, but written in 1776. 
4 4 Observations and Experiments communicated to the Medical Society 
of Emulation,’ and published in the ‘Journal de Medecine Chirurg. et 
Pharm.,’ p. 840, December, 1816. 
5 ‘ Yersuche iiber d. Natur der Krankhaften Magen-erweichung,’ 1828. 
fi ‘Journal der Chirurg. ii. Augen-lieilkunde,’ Yon Griife and P. von 
Walther, Bd. x, S. 418, 1827. 
7 4 Recherches experimentales sur les functions du Systcme Nerveux 
Ganglionnaire,’ 1830 and 1837. 
s 4 Edinburgh Med. and Surgical Journal,’ Jan. 1838, and Aug. 1839. 
Op. cit. 7 
ON THE EYE AND ITS APPENDAGES. 
1 need not in this place proceed with any minuteness to 
detail the various phenomena connected with the eye, or 
other parts, as called forth by the experiments of the above- 
mentioned observers on the sympathetic. It suffices to 
state that the following wrere the most prominent aggregate 
results so obtained, which I will notice as having special 
relation to the object of this paper;—a contracted condition 
of the pupil, an inward rolling of the eyeball (convergent 
strabismus), and a lowering of the upper eyelid to a greater 
or less degree (partial ptosis). The various experimenters 
differed in their observations, but although most interesting, 
it would here be out of place to tarry and show in what 
particulars they differed or agreed, or upon what circum- 
stances their discrepancies depended. 
These various effects (as well as others which I will not 
now particularise) followed division of the cervical part of 
the sympathetic in the middle of the neck of the dog, in 
which animal, as well as in the horse, it is found that the 
motor fibres of the iris contained in the cervical cords of 
the sympathetic, and (following Valentin) the vagus, are 
not confined to the upper ganglia, but pass through a larger 
extent of the trunks of the sympathetic cords. Reid, how- 
ever, found that in the case of rabbits operated upon at 
the same part of the neck, neither did decided redness of 
the conjunctiva, nor yet any alteration in the state of the 
pupil, take place at all; and this fact has since been con- 
firmed by others. But if, in the case of the rabbit, 
instead of dividing the sympathetic at the middle part of the 
neck, we remove the superior cervical ganglion, or its com- 
munications with the cervical nerves, or its branches as- 
cending to form the plexus around the carotid artery; or if, 
again, we remove the ganglion of the pneumogastric or the 
communications between the cervical nerves and this gan- 
glion, then these results do follow, the pupil becoming small, 
oblong, and angular. These phenomena are to be explained, 
according to Reid, by the difference in the distribution and 
connexion of the nerves in the region of the neck in dif- 
ferent animals. For instance, whilst the nervous filaments 
which in the rabbit pass from the spinal cord into the sym- 8 
THE INFLUENCE OF THE SYMPATHETIC 
pathetic, and thence into the iris, come from the superior 
cervical nerves only, they are found, on dissection, in the 
case of the dog and horse, to come from the lower cer- 
vical nerves in addition. Other differences also in the dis- 
tribution and connexions of the sympathetic fibres in the 
neck are found to exist in mammals. It will be remem- 
bered that in man the communicating branches between the 
cervical nerves and the sympathetic pass from all the cervical 
nerves, and join the sympathetic at their ganglia as well as 
in the course of their prolongations, and branches also pass 
from the cervical nerves to the ganglion of the pneumo- 
gastric. 
Valentin, considering the effects of these and ex- 
periments not here mentioned, as well as the acknowledged 
influence of the third pair of cranial nerves upon the iris, in 
the lenticular ganglion, came to the following conclusion. 
He determined that the movements of the membranous iris 
were under the control of a double nerve-force, emanating 
from two distinct portions of the nervous system. He de- 
monstrated that that branch of the inferior division of the 
third pair which is distributed to the inferior, and probably in- 
voluntary, oblique, or rotating muscle of the eye, and which 
contains sensory as well as motor fibres, presides, by means 
of its connexion with the lenticular ganglion through its 
short root, over the actions of the circular muscular fibres, 
viz., those drawing the veil towards a central point; whilst 
the pupil-dilating fibres, viz., those radiating from the margin 
of the pupil towards the attached or circumferential edge of 
the iris, were under the dominion of the sympathetic branch or 
branches passing from the cavernous plexus which also con- 
tain motor as well as sensory fibres.1 These latter branches 
are derived secondarily from one or more of the cervical 
sympathetic, and (according to Valentin) from the vagus- 
nerve ganglia, but primarily and essentially from the cervical 
1 Tills proposition of Valentin’s as to the part played by a double 
nerve-force in the movements of the iris, so far as the subject of this 
paper is concerned, is not affected by the views of Schiff, who thinks that 
the dilator-fibres of the pupil, enjoy both a cerebral and a spinal source 
of nerve influence. 9 
ON THE EYE AND ITS AFPENDAGES. 
nerves and spinal cord by branches of junction between 
them. Thus the iris enjoys a double innervation ; the one 
cerebral, the other spinal; each antagonising and balancing 
the other. This counterpoise of the opposing fibres of the iris 
is well illustrated by the dilatation of the pupil which, as a 
general rule, occurs along with ptosis and abducent squint, 
when the third cranial nerve is divided experimentally, or 
much pressed upon by an cranial tumour, &c., the iris- 
dilating or extensor fibres being then unopposed by the 
sphincter or flexor fibres. It is also well exemplified by the 
following circumstances. When a longitudinal opening is 
made into the iris of a rabbit, the artificial pupil becomes 
shorter and rounds, so long as the eye is healthy and the 
opposing flexors and extensors of the iris are not prevented 
from duly balancing each other; but if in the same animal 
the “ nervi molles” be divided, or, as Valentin terms it, 
the “ fons spinalis” be destroyed, then the artificial orifice, 
formerly round in form, becomes no longer so, but greatly 
elongated and arched, assuming a direction more or less 
parallel with the margin of the natural pupil. 
Such being the state of our knowledge in regard to this 
matter. Budge and Waller, confirmed by experiments,1 in 
1811, the fact that those branches of the sympathetic which 
control certain motions of the iris have not their real origin 
from the main trunk or the ganglia of the cord in the neck, 
but that they arise from the spinal cord, passing through the 
spinal nerves to the cervical sympathetic; and in those con- 
clusions Wagner and Buiter3 agreed. 
By following the nerves step by step until they found a 
place where irritation produced no effect, and by gradually 
removing portions of the cervical cord and watching the 
results on the pupils, they went on to prove, as it appeared 
to them, that in certain animals those branches which con- 
trol these movements of the iris were connected solely with 
that portion of the spinal marrow itself as a centre which 
1 Vierordt’s ‘ Archiv fiir Physiol. Heilkunde,’ 1852; Ergiinz. Heft. 
2 ‘De actione Belladonnas inlridem,’ Dissert. Traj. ad Rhenum, 1849. 10 
THE INFLUENCE OF THE SYMPATHETIC 
reaches from the sixth cervical to the fourth dorsal or tho- 
racic vertebra. 
Within the above limit any stimulus, chemical, galvanic, 
or mechanical, applied to the cord, if not too great, produces 
dilatation of the pupil, just indeed as if applied to the cer- 
vical branches of the sympathetic or to the branches passing 
to the sympathetic from this portion of the spinal cord. To 
this part, therefore, of the spinal cord, they gave the name 
of “ regio cilio-spinalis.” It should be stated, that Majendie 
had previously mentioned disorganization of the eyeball as 
following division of the cervical part of the spinal cord, 
although he did not bring forward any explanation of it. 
Budge determined that the anterior and middle columns 
of the spinal cord are to be considered as the truest seat of 
influence to the iris, the influence of the motor roots of the 
nerves on the iris being infinitely greater than that of the 
sensory. He experimented largely upon mammalia, fishes, 
and frogs, as to the movements of the iris, and found that 
the latter animals were most useful as regards many experi- 
ments, partly because they bore a larger amount of chloro- 
form than the others, and partly because in their case the 
influence of the sympathetic upon the eye was most clearly 
shown. In addition to the above-named centre of nervous 
influence to the iris from the lower part of the cervical cord, 
which the “ untere central-stelle,” that ob- 
server1 has lately described a second one, called by him the 
“ obere central-stelle,” situated high up in the neighbour- 
hood of the so-called hypoglossal, or ninth pair of cranial 
nerves, the branch or branches anastomosing between this 
nerve and the upper cervical ganglion of the sympathetic 
being the medium of the influence or communication.2 
1 ‘Ueber die Bewegung der Iris fur Physiologen und Arzte,’ Braun- 
schweig, 1855, p. 109. 
2 Dr. Brown-Sequard has lately informed me that, in his belief, injury 
of almost any portion of the spinal cord will to a certain extent affect the 
pupil corresponding to the side injured. It seems, however, that if this 
be so, the influence of such an injury upon the pupil diminishes in pro- ON THE EYE AND ITS APPENDAGES. 
11 
Bidder and Yolkmann found that in frogs1 that part of the 
cord from which the iris-influencing nerves proceed corres- 
ponds to the second and third cervical nerves. 
Budge, and, to a certain extent, Ruiter also, conclude that 
the first division of the fifth cranial nerve has specific 
branches of motion to the iris, but that the vagus nerve 
and the communicating branches of the upper cervical with 
the sympathetic have no possible influence upon the iris. 
The motor influence of the fifth upon the iris is thought by 
Budge to be proved by the contraction of the pupil, which 
is seen to follow division of the fifth, even although the third 
pair be divided so as to remove the possibility of any reflex 
action through that channel. 
Valentin, moreover, thinks he proves that in the rabbit 
an antagonism between various parts of the spinal nervous 
origin itself exists, and that the innervation supplied through 
the vagus ganglion (which this observer looks upon as 
having an influence upon the movements of the iris) con- 
trols the muscular fibres nearest to the lower end of the 
pupil, whilst that from the upper cervical ganglion presides 
over the muscular fibres nearest the upper end. It appears 
to him to be so from the fact that, on dividing the ganglion 
of the vagus and its roots, the margin of the pupil, which 
is rendered oblong, becomes sharp and angular above, and 
the inferior margin rounded; but if the tapper cervical 
ganglion of the sympathetic be divided, the sharp margin of 
the pupil is below and the rounded one above. 
In addition, Budge and Waller found that any injury to 
the whole or half of the central parts of the spinal cord, 
alluded to above, or to the entire nerves issuing thence, or 
to the anterior branches only of these nerves, removed all 
power of action from the extensor or dilator muscles of 
the pupil, leaving the pupil-contracting fibres to the active 
and unfettered influence of such fibres of the third cerebral 
portion to its distance from the cervical region ; and for practical pur- 
poses, the “cilio-spinal regions” of the neck must be considered to exist. 
1 ‘ Die Selbstandigkeit des Sympatk. Nerven-Systems/ Leipzig, 
1842. 12 
THE INFLUENCE OF THE SYMPATHETIC 
nerve as preside over them, and (as they think) to the motor 
influence of the ophthalmic division of the fifth. 
Brown-Sequard and Bernard came to the same conclusion 
as to the general details of these experiments mentioned by 
Budge. In addition to other phenomena, they found1 that in 
cases where contraction of the pupil and vascularity of the 
conjunctiva, &c., had resulted from division of the sympathetic 
in the neck, galvanism of the upper end of the divided nerves 
produced a dilatation of the pupil and opening of the eyelids, 
as also cessation of the conjunctival vascularity, and diminu- 
tion of the increased temperature, &c. These effects are in 
some particulars not so strongly marked when they follow 
galvanism of the sympathetic nerve, which has not been pre- 
viously divided. Schiff2 agrees with Bernard and It. 
Wagner in stating that this galvanizing induces positive 
protrusion of the eyeballs. 
H. Miiller3 has also described dilatation of the pupil as 
following galvanism of the cervical sympathetic after decapi- 
tation at the sixth cervical vertebra (less, however, than that 
produced by belladonna), and its continuance so long as the 
stimulus was applied, the pupil of the side opposite that on 
which galvanism was used being at the same time not at all 
affected. 
Corroborations of the above-made statement as to the 
effects of section and galvanism of the sympathetic, &c., 
are to be found in the writings of Schiff (loc. cit.) of 
Callenfels, and others.4 It is worthy of remark that Ruiter6 
found the size of the pupil on the side operated upon, to be, 
in comparison with that of the opposite eye, exactly as two 
to three in the rabbit, and in the dog as one to three. In 
accordance with this statement, another of Valentines is in- 
teresting, viz., that in the dog the cerebral influence upon 
the iris, exercised through the third cranial nerve, as op- 
1 See Brown-Sequard’s 'Memoir,’ 1854; also Gaz. Medicale, 1854. 
2 Op. cit., p. 148. 
3 Verhandlung. d. Wurzburg Gesellschaft. 
4 Henle’s and Pfeuffer’s ‘ Zeitschrift,’ vii, 1855, p. 157. 
4 ‘ De actione Belladonnse in Iridem,’ Op. cit. ON THE EYE AND ITS APPENDAGES. 
13 
posed to the spinal which acts through the channels of the 
sympathetic, is greater than in the rabbit. 
It ought to be added, that Professor Reid found that 
pressure also upon the cervical part of the sympathetic pro- 
duced contraction of the pupil, which, on the removal of the 
pressure, completely regained its natural size. 
The above particulars comprehend, as I believe, the sum 
of our present information with regard to the peculiar de- 
pendency of the movements of the iris on certain branches 
of the sympathetic and that portion of the spinal cord from 
which they emanate, as shown by experiment. 
The question is naturally suggested as regards the con- 
tracted state of the pupil in connexion with the ptosis and 
strabismus which in so many cases followed division of the cer- 
vical sympathetic,—What is the signification or physiological 
purpose, of these changes in the eye and its appendages ? 
I believe these phenomena may be looked upon as having 
some final reference to the condition of the retina, just as 
we find that in early life the pupil is generally contracted, 
and thus adapted as a screen to the delicacy of this tender 
nervous expansion; or again, as in old age, when, as Bichat 
observes, the pupil is generally dilated in proportion to the 
insensibility of the retina or to the opacity of the originally 
transparent refracting media, by which the entrance of light 
is hindered. And why in these experiments the retina 
should require such careful protection, such a tendency to 
contraction of the pupil and closure of the eyelids in order to 
exclude a superabundance of light, may easily be conjectured 
when we call to remembrance the anatomical constitution of 
that structure, a most delicate nervous sheet, the integrity 
of whose capillary vessels as to tone, &c., is of the very 
utmost necessity to that of its function; and when we also 
bear in mind the numerous examples which we possess of 
disturbance to the capillary circulation produced by injury 
to the sympathetic, whose ultimate branches are distributed 
along with the vessels. 
A better instance of this capillary disturbance, by wray of 
illustration, we cannot have than * the distension of the 14 
THE INFLUENCE OF THE SYMPATHETIC 
pericardial blood-vessels and the exudations pouredxJi’om 
them out around the heart after injury to the thoracic 
ganglia of the sympathetic, as shown by Bernard and Scliiff. 
"We may not then injudiciously or unreasonably suppose 
that in the matter of the retina the very numerous and 
closely packed capillary vessels of this membrane become 
affected, whenever, by experiment or disease, the sympathetic 
nerves from which they are supplied become seriously injured, 
and that a distinct relation exists between the unnatural 
condition so produced and the experimental phenomena 
above mentioned, which are, as regards the retina, protective 
in their aim. Pathological instances of this kind of confede- 
rate or consensual action for conservative purposes might, 
if needful, be quoted in abundance. A case in point, which 
I have lately fallen in with, is so notable that I will briefly 
describe it. 
A man, set. 45, experienced the effects, during the night, 
of a very vivid flash of lightning.1 He Avas at once struck 
down and unable to rise for some seconds, but wras not at 
all deprived of consciousness. At the time he felt great pain 
in the eyes, but this soon went off, leaving him blind and 
unable to open them. He continued blind for seven months, 
at the end of which time the form of the eyes was found to 
be good and the cornese clear, but the pupils were exceed- 
ingly contracted. The moment the eyelids were forcibly 
raised from before the pupil the patient cried out in ecstasy 
that he saw the light, but added that it gave him such acute 
pain that it could be no longer borne, and begged that the 
eyelids might be allowed to close. In the course of time 
the patient regained his sight, the retina, as it is observed, 
still retaining excessive sensibility. It appears to me that 
in the above case the firm spasmodic closure of the eyelids 
and the contracted pupil possessed a definite relation to each 
other, and had special reference to some particular condition 
of the bloodvessels of the exquisitely sensitive retina, in- 
duced by the impress of the over-strong light. 
1 ‘ Memoirs of the Medical Society of London,’ vol. ii, p. 503. ON THE EYE AND ITS APPENDAGES. 
15 
The above-mentioned phenomena may be concomitant 
only with the unwonted condition of the retinal capillaries,1 
but it is also possible that they may stand in relation to that 
condition as reflex movements, according to the suggestion 
of my friend Dr. Baly. 
As a summary of the various particulars contained in the 
previous part of this communication, I would say that there 
seem to exist anatomical and experimental grounds for the 
subjoined statements.—That certain movements of the iris 
(the contraction and dilatation of the pupil) are under the 
control of certain fibres of the sympathetic nerve emanating 
from the carotid and cavernous plexus, as are also frequently 
to some degree, at least in lower animals, the movements of 
the levator of the upper eyelid and the external rectus 
muscle of the eyeball.2 That these sympathetic nervous 
twigs are derived secondarily from the great sympathetic 
trunks in the neck, but primarily from certain parts of the 
spinal cord, by communication between these grand trunks 
and the spinal nerves. That consequently, the same effects 
produced upon the iris, the levator palpebra, and external 
rectus, by interference with the sympathetic in the neck, 
will follow if the communications passing between it and the 
cervical part of the spinal cord, or the cord itself, be similarly 
affected. That, as a rule, paralysis of the dilator fibres of 
the iris (permitting contraction of the pupil), and, in many 
animals, partial paralysis of the levator palpebrse and external 
rectus muscle, follow section of, or extreme pressure upon these 
1 In connexion with this supposition, I would allude to the experi- 
ments, before quoted, of Brachet, who found cerebral congestion and 
somnolence to follow division of the sympathetic in the neck—phenomena 
doubtless resulting from some unnatural capillary condition ; and to those 
of Bernard and Callenfells, who determined by actual experiment that the 
temperature of the brain, and of the blood returning from it, and the 
size of the meningeal vessels, was increased by the experiment. 
2 It may here be stated, that it is not in all the experiments that con- 
traction of the pupil, or even elevation of superficial temperature, follows 
division of the sympathetic; and much more variable appears to be the 
influence of the sympathetic upon the upper eyelid and external rectus 
muscle. Upon what this difference depends is not known. THE INFLUENCE OF THE SYMPATHETIC 
parts of tlie nervous system, whilst mere irritation by elec- 
tricity, and stimulating, chemical, and mechanical agents, 
induce a dilatation of the pupil. 
Bearing in mind the results of the above-mentioned ex- 
periments upon healthy animals, it is to be expected that 
under disease any pressure or lesion of the cervical sympa- 
thetic or its ganglia, or its connexions with the spinal cord, 
wrould tend to produce effects on the iris similar in kind at 
least to those arrived at by experiment. 
With the beautiful physiology of this subject in view, it 
was that Dr. Gairdner, of Edinburgh,1 shrewdly interpreted 
the rationale of contraction of the pupil, which he found to 
occur in certain cases of thoracic aneurism in which the 
enlarged vessel pressed upon some parts of the ganglia or 
branches of the sympathetic. He has brought before the 
Medical and Chirurgical Society of Edinburgh, cases in 
which the contracted state of the pupil existed, apparently 
owing to interference with the sympathetic in the upper 
part of the thorax. These cases of his I will briefly allude 
to along with those placed on record by others, numbering 
them so as to include in a series those which I shall myself 
bring forward in which the pupil of the eye only had become 
affected, or in which, in addition to this symptom, other 
symptoms also appeared, apparently arising from interference 
with the sympathetic nervous supply. In Dr. Gairdner’s 
cases the only symptom dwelt upon by him as being pro- 
duced by such interference is the contraction of the pupil. 
Case 1 was that of a quarryman, set. 40,2 affected by 
aneurism of the arch of the aorta, involving the sympathetic 
1 Since writing the above, Dr. Gairdner has sent me a pamphlet written 
by Dr. Robert MacDonnell, of Montreal, and reprinted from the 4 Mont- 
real Medical Chronicle/ June, 1858, entitled, “ On Contraction of the 
Pupil, a symptom of Intra-thoracic Tumours,” containing the history of 
a case observed by him as early as 1850, in which pressure on the sympa- 
thetic at the root of the neck had produced contraction of the pupil, and 
also ptosis. To this case I shall refer further on, at p. 432. 
2 ‘Edinburgh Monthly Journal,’ August, 1855, p. 143. ON THE EYE AND ITS APPENDAGES. 
nerve, as shown by post-mortem examination, and in all 
probability the lower cervical ganglion, as also the various 
spinal nerves and the vertebral artery. During six weeks 
of observation the left pupil was seen to be much smaller 
than the right one, but both of them acted under the influ- 
ence of light. It is stated that “for a good many weeks 
before death the difference in the size of the pupils had 
become scarcely recognisable.” This case terminated fatally 
by haemorrhage into the oesophagus. 
Case 2 was one recorded by Dr. Walshe1 of aneurism of 
the aorta, greatly compressing the innominate artery, and 
causing the right radial pulse to be almost imperceptible. 
In Dr. Walshe’s account I find it stated that “the left 
pupil during life was observed to be one eighth of an inch 
in diameter; the right one was not more than half the size, 
and both round and moderately brisk. After death both 
were larger than during life; the right one, that which 
during life was so notably the smaller, was very distinctly 
larger than the left one.” 
Case 3 was one described by Dr. Gairdner, of a journey- 
man shoemaker, who, along with signs either of thoracic 
aneurism or disease of the aortic valves, with hypertrophied 
heart, had contraction of the left pupil. He acquainted 
me with the particulars of this case in December, 1856, and 
I have lately heard from him that in this patient, who is 
still in improved health (May, 1858), there exists a “ re- 
markable irregularity of temperature,—cold sweats followed 
by flushing, accurately limited to that half of the face on 
which the pupil is affected.” Dr. Gairdner also tells me 
that recently he has had the opportunity of seeing “ another 
case of unilateral sweating in connexion with contraction 
of the pupil on the same side and signs of heart disease 
or aneurism.”3 
1 ‘Diseases of the Lungs, Heart, and A.orta,’ 2d edit., p. 759. 
2 Since writing the above, Dr. Gairdner has informed me that the first 
of these two patients affected with unilateral sweating, has lately died, 18 
THE INFLUENCE OF THE SYMPATHETIC 
Case 4 was under Dr. Gairdner’s own treatment, and 
Avas one in which a contraction of the pupil was associated 
with thoracic aneurism. 
Case 5 was also under Gairdner’s observation, and was a 
“ well-marked case of innominate aneurism.” The right 
pupil was contracted as compared with the left. The 
patient, a woman, is probably still alive. 
Case 6 is published at large1 by Dr. Williamson, of Leith. 
In this the contracted pupil (a symptom which continued to 
exist even after death) along with certain neuralgic symptoms 
was considered during life to be the means of diagnosis 
between an aneurism and aortic valve disease. After death, 
intra-thoracie aneurism was found on the same side as the 
contracted pupil. This case has lately been alluded to in 
connexion with the subject of contracted pupil as conse- 
quent upon aneurismal pressure, at p. 482 of the f Archives 
generates/ April, 1858. 
Case 7, published by Dr. Banks, of Dublin, King’s Pro- 
fessor of Physic,3 was that of a woman, set. 24, who had a con- 
tracted pupil in connexion with a supposed aneurism in the 
upper and left part of the chest. The sight of the affected eye 
was good, and the contraction of the pupil, though constant as 
compared with the pupil of the other eye, was susceptible of 
change, like its fellow, according to the amount of light per- 
mitted to fall upon the eye. The patient left the hospital 
in the same condition, and from a letter kindly sent to me, 
April 23d, 1857, I learnt from Dr. Banks that he had seen 
nothing of the patient since her dismissal from the hospital. 
but that a post-moi’tem examination could not be obtained. He also 
states that in this case the peculiar symptoms were at the last in abeyance, 
the pupils being equally small. 
1 ‘Edinburgh Monthly Journal,’ January, 1857, p. 614. 
2 ‘Dublin Hospital Gazette,’ January 15th, 1856. This case has been 
quoted in the ‘ Dublin Quarterly Journal of Medical Science,’ vol. xxv, 
p. 438. ON THE EYE AND ITS APPENDAGES. 
19 
Case 8 is one related by Dr. 'Wiltshire,1 of a supposed 
enormous dilatation of the ascending aorta and arch, with 
the vessels arising therefrom, occurring in a woman, mt. 60. 
The right pupil was always more contracted than the left 
one, but it quickly dilated on the application of atropine to 
the eye. 
Case 9 is that of a man, set. 58, related by Dr. Hope,2 
who was affected by aneurism of the ascending aorta, of the 
size of a cocoa-nut, with general dilatation of the aorta, and 
who died of pneumonia. He had had headaches for about 
six weeks, and, in addition to other symptoms, complete 
blindness of the right eye and incomplete blindness of the 
left one. Both of the pupils were contracted. No special 
brain symptoms existed, and after death the brain was found 
healthy, but there was thought to be slight dwindling of 
the left optic nerve. 
The above-named cases are the only ones, excepting one 
quoted by Dr. Reid (here numbered as Case 25), which are, 
so far as I yet know, placed upon record, or privately noticed 
by others, wherein an alteration had been observed as a 
presumable result of interference with the sympathetic 
branches supplied to the iris, by pressure from intra-thoracic 
aneurisms.3 It will be remembered that the only symptom 
1 ‘Lancet/ 1856, vol. i, p. 678. 
2 ‘Diseases of the Heart and Great Vessels/ 3d edit., 1839, p. 608. 
3 In a letter quite recently received, and since the writing of the above, 
Dr. Gah’dner informs me that he has met with four other cases in which 
a contracted state of the pupil was connected with intra-thoracic aneurism. 
In the first the symptoms- were “ clear.” This case was seen with Dr. 
Simpson. In the second a small aneurism pressed towards, but did not 
directly involve the sympathetic on the right side. On the same side the 
pupil was contracted. In the third case Dr. Gairdner was called to the 
patient the night before he died suddenly. Both the pupils were re- 
markably contracted, and on this phenomenon, combined with other 
symptoms, a diagnosis of aneurism was founded. On post-mortem 
examination a large aneurism was discovered encroaching on both sides 
of the vertebral column all the way down the thorax. In the fourth case, 20 
THE INFLUENCE OF THE SYMPATHETIC 
of interest in connexion with these aneurisms, which are all 
of the thoracic aorta, was a contracted state of the pupil. 
It occurred to me that aneurisms of other arteries than 
those in the thorax might, by exercising similar pressure, 
produce similar results as regards the pupils of the eyes. 
I thought it might be so with the subclavian or the carotid 
in the neck; and I was fortunate enough to find one or two 
instances recorded in which alteration of the pupil was pro- 
duced by aneurism of the carotid. 
The following forms a very striking instance : 
Case 10.—A man, set. 41, had an aneurism of the left 
carotid artery measuring five and a half inches by four. 
Headache, cough, dyspuoea, and dysphagia were induced. 
The pupil of the left eye was particularly noticed by his 
attendants as being contracted, and vision of the left eye 
was impaired. Mr. Coates, of Salisbury,1 tied the artery, 
and on the eighth day after the operation the pupil, which 
had been contracted, was observed, according to the pub- 
lished notes, as “ having almost recovered its natural state 
of dilatation and sensibility.” 
The above case, although meagre as to particulars, seems 
to me to afford a remarkable illustration of the connexion 
between injury of the sympathetic in the neck by aneurismal 
pressure, and altered conditions of the iris; the latter re- 
covering its natural state in proportion as the aneurism les- 
sened after the operation, thus relieving the nerve of the 
unwonted pressure. 
It also suggested itself tliat probably pressure from other 
one seen with a pupil of St. Andrew’s, at the Dispensary, the signs were 
“ all pretty clear.” The patient died, but no post-mortem examination 
could be obtained. He also mentions two or three other cases in which 
a contracted pupil was found and a thoracic aneurism guessed at, but not 
proved to exist; and also several other cases in which, along with this 
modification of the pupil, there was “no reasonable ground to suspect 
pressure on the sympathetic.” 
1 Johnson’s ‘Medical Journal,’ vol. ii, 870, March, 1822. ON THE EYE AND ITS APPENDAGES. 
21 
sources than aneurisms might in a similar way affect the 
pupil. This might be so in certain cases where the 
lymphatic glands were greatly enlarged and indurated by 
inflammatory processes or occupied by specific products, as 
the scrofulous or carcinomatous; or where the general 
tissues about the main course of the sympathetic in the 
cervical or upper thoracic region were similarly affected ; or 
again, it might he the case where abnormal bony growths 
existed in certain parts of the thorax or neck, or even of the 
cranium, as of the basi-cranial bones, involving the neigh- 
bourhood of the cavernous sinuses. 
Here I am bound to mention, that in my hopes of finding 
such cases I was in a degree anticipated by Dr. Reid, who 
mentions a case (one which I shall insert as my 25th) 
in which a contraction of the pupil was produced by pres- 
sure from malignant deposit in the neck. 
Whilst on the watch for cases such as I have just alluded 
to, one presented itself to my notice in St. George’s Hos- 
pital in the course of the year 1856. It was as follows: 
Case 11.—A man, set. 22, was admitted with a great 
enlargement of the cervical lymphatic glands on the left 
side, forming a painful tumour of the size of a small orange. 
There was cough, with occasional stridulous breathing, and, 
subsequently, great dyspnoea and bloody expectoration. 
Extensive disease also of the axillary glands came on. The 
pupils of both eyes were noticed as being dilated and equal 
in size, but on the twenty-first day after his admission the 
cervical glands had enormously increased, and the pupils 
were seen to be very unequal, that of the left eye being 
much the smallest. Both pupils contracted when the eyes 
were directed either inwards or outwards, and only after a 
short space of time did the right pupil regain its compara- 
tively large size. On the twenty-third day the tumour was 
of the size of a swan's egg. There was no difference as 
detected by the hand (the thermometer unfortunately was 
not used) in the temperature of the ear or side of the head, 
&c. As before, the left pupil was much smaller than the 22 
TIIE INFLUENCE OF THE SYMPATHETIC 
right one, but both pupils contracted when the eyes were 
turned outwards or inwards, and this was the case inde- 
pendently of the varied access of light. Oftentimes they 
were seen to become equal when the eyes were kept very 
widely open, and when suddenly turned to the bright light 
of a window. 
On the patient’s looking about or withdrawing the eyes 
from the light, the right pupil would again become dilated, 
and thus the twro pupils again became unequal. After death 
I found the left lung, and the mediastinal, cervical, and 
axillary glands, all occupied by firm carcinomatous deposit, 
effecting considerable pressure upon the sympathetic and its 
connecting branches, the trachea and oesophagus being 
greatly pushed to the right side. 
Further on I shall adduce, as Case 19th, an instance of 
scarlet fever in which the pupil was affected by pressure 
from enlarged glands in the neck. 
I may here mention that I have notes of a case in which 
there was extensive inflammation of the pleural membranes 
and mediastina passing up the neck, and involving all the 
deeply placed tissues about the vessels and nerves, with 
great effusion of firm inflammatory products as high as the 
base of the cranium, in which the pupils became remarkably 
contracted. This condition appeared to be owing to inter- 
ference with the sympathetic; but as the patient was taking 
calomel and opium, which might have affected the pupils, 
I am constrained to have some doubts about it, and there- 
fore will not include it amongst this set of cases. 
Judging from our knowledge of the connexions between 
the sympathetic and the spinal cord, and from the various 
experiments upon the consequences of injury to the spinal 
cord itself in animals, to which at an earlier part of this 
communication I alluded, I thought it probable that similar 
symptoms to those which we have seen to follow mechanical 
interference with the sympathetic in animals, might arise 
when the upper part of the spinal cord was suffering from 
disease or injury in man. I have not been disappointed in 
my search for cases related, in which exactly such symptoms ON THE EYE AN1) ITS APPENDAGES. 
23 
as I anticipated were exhibited. One or two such cases I 
will quote, as follows, merely selecting such details as bear 
on the point in question : 
Case 12 was that of a man who was the subject of ex- 
travasation of blood into the substance of the spinal cord 
corresponding to the fifth and sixth cervical vertebrte. 
Both the pupils were noticed as becoming greatly con- 
tracted. The patient died in forty-eight hours after the 
attack, remaining quite sensible to the last, and showing no 
cerebral symptoms whatever. This case is related by Sir 
B. C. Brodie.1 
Case 13 was one of fracture and dislocation of some of 
the lower cervical and dorsal vertebrse, owing to a fall from 
a haystack, and is also related as under the care of Sir B. C. 
Brodie.3 The patient, mt. 71, had oppressed breathing and 
noticeable contraction of both pupils. His senses were entire 
and collected, and he remained quite conscious to the last, 
gradually sinking. After death the centre of the medulla 
spinalis opposite to the injury was remarkable as being of a 
brownish-red colour, and highly congested. 
It is not expressly said that the spinal cord was softened, 
but such a change in colour would most probably not have 
taken place without some amount of disorganization. 
Case 14 was that of a man, set. 45, the subject of frac- 
ture of the fourth and fifth cervical vertebrae, related by 
Mr. Vincent, of St. Bartholomew’s Hospital.3 Diminished 
sensibility and power of motion existed in all the limbs, and 
there was priapism. The respiration was mainly dia- 
phragmatic. Both of the pupils were noticed as being 
contracted. On post-mortem examination the spinal cord 
at the affected part was found much swollen and softened, 
and blood was extravasated outside the theca vertebralis. 
Case 15 was that of a man, set. 39, who by a fall had 
1 ‘ Transactions of the Royal Medical and Chirurg. Society,’ vol. xx, 
p. 149. 
2 Johnson’s ‘Medical Journal,’ 1828, vol. ix, p. 477. 
3 Johnson’s ‘ Medical Journal,’ vol. viii, p. 452. 24 
THE INFLUENCE OF THE SYMPATHETIC 
fractured one or two cervical vertebrae, and was brought 
into St. George’s Hospital in 1849. On the day after ad- 
mission he was found to have lost power in the right leg, 
and partially also in the left leg; and on this day it was 
noticed that both pupils were contracted, but especially the 
right one. No other mention is made of the eyeballs or 
pupils. The spinal cord, after death, was found to be con- 
siderably encroached upon and softened, both as to its 
anterior and posterior columns, the central part being very 
vascular. The brain was quite healthy. 
Case 16 was that of a man, set. 48, who was ad- 
mitted into St. George’s Hospital in June, 1849, having 
fallen from a considerable height against a piece of timber. 
There was loss of sensibility and power of motion in the 
lower limbs, with numbness of the arms and diaphragmatic 
breathing. 
In the evening of the day of admission it was noticed that 
the patient moved his arms less easily, and that the pupils 
of both eyes had become contracted. Two days after ad- 
mission his pupils were observed as being very highly con- 
tracted, and great pain and numbness were complained of by 
the patient. No brain symptoms came on, and on the day 
of his death, which was the fourth after the accident, the 
patient spoke quite rationally to the nurse. After death, 
fracture of the lower cervical and upper dorsal vertebrae 
with displacement, was found, and much blood was seen 
extravasated within and around the cervical cord of the 
part; the entire circumference of the cord, from a point 
corresponding to the fifth cervical as far as the second 
dorsal vertebrae—almost exactly coinciding with Budge’s 
“regio cilio-spinalis” (see reference at former part of the 
paper, p. 406)—being greatly softened. The cranium and 
its contents were quite natural. 
In all the above cases quoted from other authorities, or 
newly related, the special symptom brought prominently 
forward, as resulting from a certain degree of intei’ference 
with the sympathetic and its branches in the neck, or that ON THE EYE AND ITS APPENDAGES. 
25 
part of the spinal cord with which it is connected, was a 
contracted state of the pupil. (See Note A in Appendix.) 
This pathological phenomenon in the human body quite 
accords with the contraction of the pupil produced by divi- 
sion, ligation, or extreme pressure of these parts of the nervous 
system, in experiments upon the lower animals. 
But in the description of many of the experiments to 
whichlhave alluded (p.408) it was stated that a certain amount 
of stimulus, mechanical, chemical, or galvanic, applied to the 
cervical sympathetic, would produce not a contraction, but a 
dilatation of the pupil, and moreover, that when contrac- 
tion of the pupil and other symptoms had been already 
produced by section or extreme pressure of the nervous 
structures before described, they could be reversed, as it 
were, on the application of galvanism to that part of the 
nerve or spinal cord still holding unbroken connexion 
with the iris; and in the place of contraction, a dilated 
state of the pupil could be at once established. Galvanism, 
also, of the upper part of the spinal cord, which was other- 
wise whole and untouched, would produce the same dilated 
state of the pupil. 
The knowledge of these facts helped me to account for 
certain pathological instances in which, under apparently 
similar circumstances to many of the cases which I have 
already enumerated, not a contracted state of the pupil was 
produced, as in them, but, on the contrary, a dilated state. 
This dilatation of the pupil in the human subject is ana- 
logous in its causation, I believe, to the dilatation produced 
in experiment by the application of certain stimuli to the 
sympathetic nerve. We know that if a stimulus applied to 
a motor nerve be carried only to a certain pitch, the nerve is 
irritated, and we have, as a result-, contraction of the muscle 
to which the nerve is distributed; but if the stimulation be 
carried to an extreme, then, on the contrary, it produces 
paralysis of that muscle. (See Appendix, Note B.) In 
like manner, in the cases which I am about to describe, I 
would seekto explain the dilatation of the pupil, on the suppo- 
sition that the pressure upon the sympathetic trunks and fila- 26 
THE INFLUENCE OF THE SYMPATHETIC 
merits and tire interference with the spinal cord were so slight, 
comparatively, that it merely acted as an irritant, just as 
gentle galvanism might have done, the sympathetic fibres to 
the dilator pupillse being stimulated. Should the pressure 
in such cases remain in so slight a degree, the dilatation of 
the pupil would also continue, hut should it increase so as 
to paralyse the sympathetic or spinal fibres, then the action 
of the sphincter of the pupil would preponderate and con- 
traction of the pupil ensue. The quickness with which 
contraction will follow dilatation of the pupil in such cases 
will depend most likely, in part, upon the general character 
as to susceptibility of the nervous system in any given 
person but chiefly upon the exact position at which the 
pressure may be exercised, whether if be of an aneurism or 
other tumour; and also upon the rapidity of increase in size 
of the object effecting the pressure and its consistency. For 
example, it appears likely that the same growth situated low 
down in the thorax (as, for example, an aneurism in the lower 
part of the arch of the aorta) would not be nearly so 
harmful to the sympathetic as if it were close to the upper 
outlet of the chest, where the grand sympathetic trunks on 
either side are large, more prominent, and confined within 
a narrow bony circle, and where also they are more elaborate 
in their connexions. 
Again, modifications as to interference with the sym- 
pathetic by aneurism or tumour, &c., might well he expected, 
according to the number and anatomical arrangement of the 
sympathetic fibres around the part affected, which may vary 
considerably in man, as we know they do in animals. 
I will now proceed to give one or two cases which seem 
to illustrate the occurrence of dilatation of the pupil, 
owing to a slight amount only of pressure upon the synapa- 
1 In connexion with the susceptibility of external impressions made 
upon portions of the nervous system, the fact ascertained experimentally 
by It. Miquel (‘ Archiv d. Yereinsf. Gemeins. Arbeiten,’ &c., 1853, Hgt. iii. 
p. 386) is interesting, that the results of pressure upon the sciatic and 
median nerve are more decided and persistent in proportion to the general 
exhaustion of the nervous system. ON THE EYE AND ITS APPENDAGES. 
27 
thetic, or to some slight change in the spinal cord, serving to 
stimulate and not to paralyse such fibres as pass eventually 
through the spinal nerves and sympathetic to the iris. 
Case 17 was that of a woman, set. 40, whom I watched 
closely in the wards of St. George’s Hospital, in the year 
1856. She was admitted with a pulsating tumour, of the 
size of a hen’s egg, situated at the third intercostal space on 
the right side. There was a sharp diastolic click audible 
over both scapulse behind, and specially at the middle of the 
right one; and subsequently a systolic murmur was 
heard over the tumour, and dyspnoea, with cough, came on. 
Afterwards, the tumour was found to have appeared on the 
left of the sternum, and stridulous breathing occasionally 
occurred. The pupils were noticed as having become 
slightly dilated. Later on in the history of the case the 
“ right pupil became still more increased in size, so as to 
contrast notably with the left one.” Heath took place 
shortly afterwards. On post-mortem examination, an aneu- 
rism of the size of a cocoa-nut was found destroying a part 
of the right side of the sternum, and the contiguous por- 
tion of the third rib, and arising from the upper part of the 
ascending aorta, this vessel itself being also greatly dilated. 
Case 18 was that of a man, set. 57, who was brought 
into St. George’s Hospital with extensive occupation of the 
left side of the neck by “ scirrhous infiltration,” the skin 
being tuberculated, indurated, and discoloured. He lay in 
a state of indifference, and it was noticed that the pupil of 
the left eye was dilated, that of the right one being natural. 
He sank, owing to dysphagia. In addition to the skin, 
most of the structures of the entire depth of the left side 
of the neck were found after death to be affected by the de- 
posit, and there can be no doubt that the sympathetic fila- 
ments would fall in for their share of pressure, although 
but slight in degree. 
Case 19 was one wliicli lately I observed at St. 28 
THE INFLUENCE OF THE SYMPATHETIC 
George's Hospital, of a young man affected by scarlet 
fever. He had ulcerated sore throat, and extensive enlarge- 
ment of both sides of the neck, but particularly of the 
left side. The pupils of both eyes ivere fixed, but very 
dilated, the left one being much the more so. After death, 
the cervical lymphatic glands were found to be very greatly 
enlarged, and in one or two places suppurating ; and most 
of the deep tissues, with vessels and nerves at the sides of 
the neck, were indurated, and matted together by inflamma- 
tory products. These changes were especially observable on 
the left side of the neck. 
Case 20 was one which, by Dr. Sibson's courtesy, I 
saw under his care at St. Mary's Hospital. An abstract of 
the notes which he gave me is as follows:—Rosetta James, 
set. 42, was admitted Oct. 18th, 1857, with swelled and con- 
gested face and neck, distended jugular vein on the right 
side, and pulsation at the second intercostal space on the right 
side of the chest, with fulness and dulness of this region, 
extending from the edge of the sternum about one inch 
outwards. Other symptoms existed, leading to the diag- 
nosis of an intra-thoracic aneurism. No mention exists of 
any peculiarity in the appearance of the pupil until December 
11th, when it is stated that the left pupil was more dilated 
than the right. On the 12th February, it is stated that the 
impulse of the aneurism was stronger, and felt over an area 
of three inches from the second to the fourth costal cartilages ; 
and that both pupils were dilated, but the left one much 
the most so. On exposing the eyes to the light of a 
candle, u both pupils contracted, but the left one still re- 
mained the largest." Attacks of giddiness wrere also com- 
plained of, and the patient felt at times “ as if she were 
going out of her mind." On March 8th, it is recorded 
that “ whilst asleep, the pupils were contracted, but the left 
one was the largest." “ Both of them speedily dilated 
when she awoke." 
Case 21 was one under the care of Dr. Cockle, wlio ON THE EYE AND ITS APPENDAGES. 
29 
kindly gave me the following abstract of it1:—The 
patient suffered from a very large aneurism of the ascend- 
ing and transverse part of the aorta, as was found after 
death; and on dissection it was ascertained that, besides 
other structures, the sympathetic nerve on the left side was 
involved to a considerable extent. During life, it was ob- 
served that, in addition to pain, cough, dysphagia and dysp- 
noea, one of the pupils (unfortunately it is not particularised) 
was much larger than the other, the vision being at the 
same time dimmed. Moreover, before death a peculiar 
state of mortification was set up in the side of the nose, 
corresponding to the side chiefly affected by the aneurism. 
In the early part of the history, the pupils are described as 
being found contracted, and no difference between them was 
observed. It may therefore be concluded that one of them 
became altered during the course of the disease, and whilst 
the patient was under notice. The aneurism, still showing 
distinctly the implication of the main sympathetic branch, 
is now in the museum of St. Mary's Hospital, where I had 
the opportunity of inspecting it. 
Case 22 was that of J. M—, set. 57, who was brought 
into St. George’s Hospital May 30th, 1849, with infiltration 
of most of the textures of the left side of the neck, and the 
cervical glands with carcinoma. On admission he was in a 
state of half stupor, caused, as it was thought at the time, 
by pressure upon the cervical blood-vessels. It was noticed, 
that the pupil of the left eye was considerably dilated, whilst 
that of the other one was natural. Pressure by the hand on 
the right side of the neck induced syncope. 
On post-mortem examination the external jugular vein 
was found to be obliterated by coagulum, and the carotid 
artery, internal jugular vein, and pneumogastric nerve, on 
the left side, were found surrounded by the cancerous 
growth, so that it can hardly be conceived that the sympa- 
1 This case will be seen related in vol. ix of the ‘ Pathological Society’s 
Transactions.5 30 
THE INFLUENCE OF THE SYMPATHETIC 
thetic trunk behind could altogether escape some pressure 
which might yet not suffice to paralyse it. 
Case 23 was that of P. O. II—, set. 61, who was 
brought into St. George's Hospital September 21st, 1857, 
having fallen down backwards in the act of lifting a heavy 
load of hay. He was at the time collapsed, and suffering 
pain at the upper part of the dorsal region, where the 
spinous processes appeared more than usually prominent. He 
had lost all power of movement in both lower and upper 
limbs ; and it was noticed, when he was admitted, that both 
pupils were unusually dilated, but that the pupil of the 
right eye was more dilated than the left. On a further ob- 
servation, the same state of the pupil was noticed. The 
patient died in eight days, and, on post-mortem examination, 
“ minute points of ecchymosis were seen in the substance of 
the spinal cord, at the lower part of the cervical region, 
which was also softer than in other parts," and it was 
noticed that the “ white matter had, in parts, a pinkish hue." 
The last five cases show simply a dilated state of the 
pupil, owing, I believe, to a comparatively slight inter- 
ference with the cervical sympathetic, or that part of the 
spinal cord with which it is connected, no further change 
in the pupil being observed. It is presumable, that this 
dilation, should the pressure have been increased, would 
have been exchanged for contraction, on the supposition 
which I have previously advanced. 
The next case which I will adduce is a very remarkable 
one, inasmuch as a dilatation and contraction of the pupil 
were noticed as succeeding each other in a rapid and some- 
what inexplicable manner. The phenomena were, I think, 
clearly traceable to the extraordinary condition of the sub- 
fascial tissues of the neck. 
Case 24 was that of a German lady in Dublin, set. 
25, who, in August, 1856, suffered from phlegmonous in- ON THE EYE AN1) ITS APPENDAGES 
31 
flammation in the neck. In consequence, a tumour formed 
on the right side of the neck, extending from the ear to the 
lower border of the thyroid cartilage, and seated beneath 
the cervical fascia. Great pain existed, and suppuration 
came on, marked by repeated rigors. It was now ob- 
served that the pupil of the right eye was greatly dilated, 
so much so, indeed, that but a very little of the iris was to 
be seen. Soon after this dilatation of the pupil was no- 
ticed, the patient got relief from the pain and slept, and, on 
awaking, the pupil hitherto so much dilated, was found to 
be of the natural size. In the evening a rigor again came on, 
and the pupil was now contracted ; a paroxysm of pain followed 
the rigor, and the pupil became dilated as before. These 
alterations in the size of the pupil were observed several 
times; and, moreover, during this time, the iris, which na- 
turally was of a gray colour, acquired a dark brown tinge} 
The abscess in the neck was now opened, the rigors ceased, 
and the pupil remained dilated, but would contract under 
the stimulus of light, the power of vision being apparently 
entire. As the state of the neck improved, the affected 
pupil returned to its natural size. In the summer of 1857, 
whilst in London, this lady again suffered from an abscess 
in the same region, and is reported to have had a similar 
return of the affection of the pupil. In 1858 another 
abscess formed on the same side of the neck, but at a lower 
part. The pupil became again dilated, and so continued 
until the abscess was nearly healed. The dilatation was 
not, however, nearly so extreme as in the earlier attack. 
For the history of the above case I have to thank Dr. Kidd, 
of Great Brunswick Street, Dublin, who, in a most generous 
way, has placed it, hitherto unrecorded, at my service. 
For the general effect of dilatation of the pupil, as result- 
ing from the stimulus of a moderate pressure, analogous to 
that produced by galvanism, we are in a measure prepared 
1 This change of colour was no doubt the result of an alteration in the 
amount of blood in the capillary vessels of the iris, and was due to inter- 
ference with the vaso-motor nerves of these capillaries. THE INFLUENCE OF THE SYMPATHETIC 
by a knowledge of the frequency of similar dilatation in 
cases of mere irritation, as by worms, of the intestinal tract 
whose innervation is from the sympathetic as also by the 
frequency of such dilatation in cases of burns, scalds, lacera- 
tions, and other mechanical injuries, physiologically compa- 
rable to the influence of the sympathetic on the heart 
causing palpitation, &c., as in certain diseases of the abdo- 
minal viscera; as also in cases of general debility, when we 
know the cerebral influences to be impaired, and, by com- 
parison, the sympathetic and spinal ones to be intensified. 
Hitherto, all the cases and observations brought forward 
have had reference simply to some altered state, a dilata- 
tion or contraction of the pupil, phenomena parallel to 
similar ones, induced in the eyes of the lower animals by 
direct experiment. This altered condition of the pupil in 
disease resembles that established in animals by section of 
the sympathetic, See., inasmuch as the dilatation or contrac- 
tion is not absolute and complete, but may still be modified 
by the action of light, atropine, &c. Thus, in Case 20 
the pupils are mentioned as both of them contracting, 
although the left one remained still the largest, and, in the 
same case they were contracted whilst the patient was 
asleep, but dilated on her awaking. Again, the same 
response to the impression of light was exhibited in Cases 7 
and 24 and to that of atropine in Case 8; and the same 
effect will be seen hereafter, as in Case 25, to have followed 
the application of belladonna. 
So also in the lower animals. Dr. Reid observed that in a 
dog, whose sympathetic and vagus nerves he had completely 
divided (second experiment), the contracted pupil still con- 
tinued to be affected by light; and when the dog was dying, 
poisoned by prussic acid, the pupils of both eyes became 
equal,and very much dilated. Mollinelli3 also, iu his third ob- 
servation, speaks of thepupil beingmadetocontractstill further, 
even when already contracted by division of the sympathetic. 
1 Dr. Waterfield has lately informed me of a case in which almost total 
blindness was apparently produced by the presence of a tape-worm> 
and at once remedied by its expulsion. 
Op. cit. ON THE EYE AND ITS APTENDAGES. 
33 
In one or two of the cases which I have watched, I have 
found that the contraction or dilatation of the pupil varied 
in a remarkable and unaccountable way at various times; and it 
is interesting, in connexion with this fact, to remember, that in 
certain cases of disease of the brain, rapid and well-marked 
variations in the size of the pupils are wont to occur at 
times most unexpectedly. It may here be called to mind, 
that in dilatation of the pupil from paralysis of the oculo- 
motor nerve, as by a tumour pressing upon it, and conse- 
quent want of contractile power of the sphincter of the iris, 
there is, of course, no change in the pupil on the increased 
admission of light upon the eye; and this is the case also, 
I believe, in complete dilatation of the pupil from the 
use of belladonna, as resorted to for the. purposes of 
couching. 
It will be remembered, that I pointed out other symptoms 
besides the contracted pupil, as following experimental inter- 
ference with the cervical sympathetic or spinal cord in 
animals, and these were chiefly ptosis and convergent strabis- 
mus. These phenomena I believe may be accounted for 
rationally, and on anatomical grounds. (See Appendix,noteC.) 
I thought it, therefore, probable, and was very wishful, that I 
should find instances in which either of these symptoms had 
been associated and noticed in man, along with a contraction 
of the pupil, owing to interference with the sympathetic. Such 
a combination of circumstances I find in the case which I 
before mentioned, page 415, as being alluded to by Professor 
Reid, and more fully described by Mr. Hare, house-surgeon 
at the general infirmary at Stafford.1 This was not a 
case in which the sympathetic nerve was affected by an 
aneurism, but by a malignant tumour; and, as Reid 
only spoke of it as respects the contracted pupil, I will 
here give a general summary of the particulars. 
Case 25, was that of a man, set. 40, who was attacked by 
1 ‘Medical Gazette,’ September 29, 1838, p. 16. 34 
THE INFLUENCE OF THE SYMPATHETIC 
pain down the left arm and shoulders, across, the chest, 
and up to the left eye and side of the face. A tumour was 
observed in the inferior triangular space of the left side of 
the neck, resembling an enlarged and scrofulous gland. The 
left pupil was contracted, and the left eye “partially closed 
but no inflammation of the conjunctiva seems to have been 
observed. 
After a time weakness, and eventually paralysis, of sen- 
sation and motion in the lower limbs came on, followed by 
trismus and dysphagia, and death by suffocation, the growth 
in the neck having become much larger, and very hard. 
The conti'acted pupil could be dilated on the application of 
belladonna around the orbit. After death the tumour was 
found to be ojf a scirrhous nature. It had implicated the large 
vessels and the spinal nerves with the great sympathetic at the 
lower part of the neck, the lower cervical ganglion of the 
sympathetic, the thoracic duct, and the recurrent laryngeal 
nerve. It was also found lying on the brachial plexus; and 
having penetrated the foramina, by which the last cervical 
and the first dorsal nerves escape from the spinal canal, it 
had become attached to the external surface of the spinal 
dura mater. The ptosis, the trismus, and the contracted 
pupil, caused the observers of this case to anticipate some 
disease of the central nervous structures ; but no disease 
whatever, either of the brain or spinal cord was found, and 
the above-mentioned symptoms were spoken of as having 
been essentially sympathetic in character. Whatever may 
be the interpretation of the trismus, dysphagia, &c., there is, 
in my mind, no doubt of the connexion between the ptosis, 
as well as the contracted pupil on the one hand, and the in- 
terference, by pressure, with the cervical nervous structures 
on the other hand. 
One or two more cases I will quote, illustrative of a more 
or less complete paralysis of the upper eyelid, along with 
some interference with the sympathetic nervous structures. 
Case 26. Was that of a man, set. 50, under Sir Astley 
Cooper’s care, affected by aneurism of the internal carotid 35 
ON TIIE EYE AND ITS APPENDAGES. 
artery, which, produced distressing throbbing pain in the 
left side of the head, and giddiness, with almost total loss 
of consciousness and sight, on stooping ; also cough, dyspnoea, 
and hoarseness.1 
It was noticed that ptosis of the eyelid on the affected 
side “gradually” came on until the eye was fully half 
closed, the sight of the eye remaining good, and no other 
special symptoms arising. 
The common carotid was tied, with absolute success, and 
the peculiar pain in the head was quickly relieved, but 
unfortunately no history of the state of the eyelids after 
the operation has been recorded, although I think we may 
very fairly and reasonably conclude that the eyelid resumed 
its natural position, as the patient is reported to have 
become in all respects perfectly well. 
Of course, the importance of the ptosis was not at the 
time recognised, or it would have received special attention. 
There is no mention of the condition of the eye-ball or 
pupil during the whole course of this case, but it was, 
however, noticed that the ear of the patient on the side 
implicated, was frequently affected by a feeling of coldness, 
succeeded by heat. 
I consider this case to be of special interest, as showing 
the gradual accession of paralysis of the levator of the 
eyelid, as the aneurism of the carotid increased. 
Case 27 related by Mr. Butcher, of Dublin,2 was that 
of a man, set. 56, affected by extensive carcinoma of tbe 
glands of tbe axilla, and of the neck, on the left side, dis- 
placing the trachea, and compressing the oesophagus. 
Dyspnoea and dysphagia came on, and by degrees, indeed 
almost imperceptibly, a drooping of the upper eyelid on the 
affected side, which Mr. Butcher states that he watched for 
many days. On being much roused or spoken to, the eye- 
lid was tardily raised and kept open. In a letter, dated 
December7th,1856, Mr. Butcher informed me that he had not 
1 ‘ Transactions of the Royal Medical and Chirurg. Society,’ vol. i, p. 22. 
2 ‘Dublin Medical Journal,’ November, 1856, p. 259. 36 
THE INFLUENCE OF THE SYMPATHETIC 
perceived that the action of the iris or the axis of the eye 
on the side affected had in any way differed in this case 
from those on the other side. 
With regard to this case, it might be asked how the 
ptosis can be explained, Avliilst, at the same time, no affec- 
tion of the pupil was recorded ? In reply, it might be 
stated that possibly the pupil was affected, although it 
might be so only to a slight extent. An amount of differ- 
ence in the pupils, even considerable, often passes unnoticed, 
unless specially looked for, whilst ptosis is very obvious. 
It is to be remarked that, in none of these cases 
have we any strabismus noted, such as existed in 
several of the experiments on animals, illustrating the 
effects of interference with the sympathetic, &c.: but the 
possibility of the occurrence of strabismus, as a clinical result 
of such interference, is well illustrated by the cases men- 
tioned by Sir C. Bell, in which1 squinting in children Avas 
produced by over-eating. This squint Avas at first tem- 
porary, and only observed on occasions of distended 
stomach ; but at times became confirmed. 
Such are some of the cases, in which, along with injury 
to the cervical sympathetic, or cervical part of the spinal 
cord in man, a more or less complete condition of ptosis has 
been noticed, suggesting a comparison with those experi- 
ments on animals, in which the same symptom was produced 
by section of or extreme pressure on, the sympathetic.3 
1 cThe Nervous System of the Body, -with an Appendix of Cases and 
Consultations,’ 1844, 3d edit., p. 389. 
2 In the case of carcinoma within the thorax and neck, before alluded 
to (p. 412), as being described by Dr. Robert MacDonnell, of Montreal, 
there was in addition to a contracted state of the pupil, ptosis of the 
upper eyelid and frequent epistaxis from the nostril on the side affected 
by the malignant growth. The contracted pupil (as in Case 20, and 
others before mentioned) nevertheless answered to the influence of light. 
In his remarks on this case, the author alludes to the connexion between 
the sympathetic and the third nerve as the probable cause of ptosis; and 
this conjecture, made so completely apart from, and independent of my 
own solution of the subject, I look upon as being of essential service in 
support of my view in question. 37 
ON THE EYE AND ITS APPENDAGES. 
I liave described, as briefly as I could, all the pathological 
facts which, at this opportunity, I have thought fitting or 
necessary to bring forward, as indicating the results upon 
the eye, and its appendages, of interference with the sympa- 
thetic thereto distributed, as occurring in the neck, or of 
injury to that part of the spinal cord with which the sympa- 
thetic branches or ganglia are connected. 
Of course I have been careful to exclude cases in which 
the pupils might become affected by other causes, and which 
we ought to estimate before deciding upon the clinical im- 
portance of a contracted or dilated pupil in any given case 
of supposed pressure upon the sympathetic or its tributaries. 
Setting aside those cases in which disease or injury of 
the brain, intra-cranial irritation or effusion, urremia and 
various poisonings are accompanied by an irregular condi- 
tion of the pupil, we must not overlook the effects of such 
remedies as are well known to influence the pupil, and by 
which one might easily be deceived. In some people, also, 
a contracted or dilated state of the pupil is habitual, but it 
is very rare, although such cases do exist, to find that the 
pupil of one eye is contracted or dilated without the other 
being likewise so, unless some previous disease or injury 
have caused this difference. 
We may also be misled by the fact of the pupil having 
been injured by mechanical or inflammatory lesions of the 
eye, or by alterations in its size, in adaptation to cataract, 
opacity of the lens, &c. Of course, all doubt of such com- 
plications becomes out of the question, almost to a cer- 
tainty, when the progress of alterations in the pupil is 
actually watched at the bed-side, as it was in several cases 
which I have just adduced. 
It is out of the scope of this paper to dwell at length upon 
the subject, but I cannot close it without alluding to the possi- 
bility of alterations in the size of the pupils as a result of 
injury to other and more distant parts of the sympathetic 
system than those immediately in the cervical or thoracic 
regions. This appears to be not improbable, from many 
facts. For instance, the temperature of the entire body 38 
THE INFLUENCE OF THE SYMPATHETIC 
was found by Bernard to be affected1 by injury to the sym- 
pathetic in the neck ; and Arnemann mentions persistent 
diarrhoea as a result of wounding of this nerve. More- 
over, Budge found that galvanism of the posterior part of 
the lower extremity of the spinal cord produced a very 
striking increase in the number of the heart’s contractions, 
a circumstance coinciding with those cases of disease in which 
pressure upon various parts of the back produces syncope 
and palpitation of the heart, &c. Bomberg speaks also of 
tabes dorsalis, an affection strictly of the spinal cord, and 
generally of its lumbar portion, as being accompanied at 
times by a contracted state of one or both pupils; and 
recently, also, Brown-Sequard has stated2 that injury and 
removal of the supra-renal capsules pretty often produce, 
amongst other effects, decided contraction of the pupil of 
the eye on the side corresponding to that on which the opera- 
tion is performed ; a fact no doubt due to implication of the 
sympathetic connected so freely with these small viscera. 
May it not be that the contraction of the pupil, accom- 
panying lesions of certain parts of the brain also, may 
exist by virtue of injury to such nervous strands as pass 
between those portions of the brain and such parts of the 
spinal cord as are (according to our knowledge obtained 
experimentally,) central points, as it were, to branches 
joining the cervical sympathetic. Some encouragement to 
this view is afforded by the fact, that diseases of cranial 
centres appear to induce disease of spinal centres, by 
depriving them, as it were, of a wonted impulse, thus throwing 
them more or less out of activity. And Tiirck3 has shown 
how secondary changes, as seen by the microscope, may be 
produced in the spinal cord, merely by intra-crauial causes, 
as in certain cases of hemiplegia. 
It may be, and this idea may here be suggested with pro- 
priety, that the pain in the head and eyes, the giddiness, 
unusual sensations, deafness, double sight, dimness of sight, 
1 ‘Memoires de la Societe de Biologie,” 1853. 
s ‘Archives generates,’ vol. ii, 1856, p. 587. 
8 * Weiner Zeitscb,’ vol. vi, 1850, p. 6, and vol. viii, 1852, Bd. ii., p. 511. ON THE EYE AND ITS APPENDAGES. 
39 
or even blindness, which are so very often coincident with 
thoracic aneurisms, most frequently existing on the same 
side, and which are independent of any visible cerebral change 
after death, are owing to some interference with sympathetic 
nerve-influence to the intra-cranial capillaries. In accord- 
ance with the above suggestions is the fact that, in case 26, 
that of Sir A. Cooper, the peculiar pain in the head, 
which had existed along with the carotid aneurism, was 
quickly relieved by the ligation of the vessel, and conse- 
quent diminution of the aneurism. The relief which fol- 
lowed the removal of the pressure upon the sympathetic, as 
it appears to me, yielded sufficient evidence that the cerebral 
distress was not dependent upon any inherent disease of the 
blood-vessels, apart from their connexion with the sympa- 
thetic, accredited to them, and to which they are subordinate. 
Before closing this communication, I would draw atten- 
tion to a point which, connected as the subject is with 
several of the experiments before quoted, naturally presents 
itself on consideration of the cases which 1 have just 
detailed. The question might well be put, whether, during ob- 
servation of any of those clinical cases, any undue heat or sensi- 
bility of the skin, or any visible altered vascular action in 
the eye or elsewhere, ensued from pressure exercised upon 
the sympathetic? The only clear indication of this 
appears in case 3, in which it will be remembered 
that flushings following cold sweats were noticed, exactly 
limited to that half of the face on which the altered state 
of the pupil existed. We have, however, something of the 
kind also, I think, in the 21st case, in which an unaccount- 
able “ mortification ” of the integument of the nose took place 
on the side corresponding to that of the aneurism, an effect 
no doubt due to the interception of such nervous influence 
as presides over the capillaries of this portion of the face.1 
Just as in the experiments on the lower animals, the vessels 
1 In Case 26, also, that in which ptosis was noticed in connexion with 
a carotid aneurism, it. is stated that, on the side affected, the patient’s ear 
was frequently affected by a feeling of coldness succeeded by heat, phe- 
nomena most likely due to sympathetic disturbance. 40 
THE INFLUENCE OF THE SYMPATHETIC 
of the ear become affected, do I infer that the vessels of the 
retina become influenced; its tolerance of light being sub- 
verted in those cases of sympathetic interference wherein 
a contraction of the pupil is caused in man. But of this I 
have no distinct proof, as the parts are so removed from view. 
In all observations laying claim to accuracy, upon such 
cases as have been alluded to in the foregoing pages, it will 
in future, be necessary to notice, as carefully as possible, by 
instrumental means, the temperature of the various parts of 
the body, especially the face and head; but, although we 
may anticipate deviations from the natural state of tempera- 
ture in many cases, if very fine and delicate instru- 
ments be used, yet it must not be expected that such 
alterations will be in all cases manifested, especially if any 
considerable time have elapsed since the commencement of 
sympathetic interference. Of course we may well foresee, 
that in this respect, the effect of suddenly cutting off the 
influence of the sympathetic by section, in the lower animals, 
would differ strikingly from the results obtained by such 
gradual pressure as would generally be exercised by an 
aneurism or growing tumour in man. Moreover, in a much 
higher degree would anatomical differences between man and 
the lower animals be likely to account for variety in results; 
but this variety in results naigUt exist without at all 
affecting the validity of parallelism between the class of 
pathological phenomena above examined, and the experi- 
ments quoted. Even in dogs experimented upon, Valentin 
found that the effects upon the iris of dividing the sympa- 
thetic, varied considerably in extent according to the colour 
of this muscular curtain. Schiff also states, that in the 
rabbit, a manifest difference regarding the modifications of 
temperature in the ears, as produced by sections of the sym- 
pathetic exists, according as the rabbit be of the long or 
short-eared variety. 
Such are the applications theoretical and practical, which 
I have ventured to make of the experiments entered upon 
by several observers, with the view of determining the ON THE EYE AND ITS APPENDAGES. 
41 
effects of injury to the sympathetic upon the pupil and 
certain appendages of the eye. I have not sought to 
establish the dictum, that either contraction or dilatation of 
the pupil is to be considered as 'pathognomonic, or as a 
test of intra-thoracic aneurism, cancer, or other tumour, or 
of any specified disease whatever. On the contrary, I 
have carefully examined several cases both of aneurism and 
other causes of pressure in the thorax and in the neclc, and 
I confess that I have found several in which no unnatural 
condition whatever of the pupil was to be noticed. All I have 
desired to do, is to establish the fact, that alterations in the 
movements of the iris and other phenomena connected with 
the eye may be produced by, and become symptoms of 
pressure, exercised in various ways on certain parts of 
the sympathetic, or by pressure upon, or structural altera- 
tions of those portions of the spinal cord with which the 
sympathetic is connected. That these changes do not 
always accompany the various phenomena above alluded to, 
is only to say, that they are not invariable criteria, just as 
vomiting, for instance, or pain in the head, are not the 
necessary attendants of cerebral disease ; but yet they are so 
frequent as to merit the character and denomination of 
symptoms thereof, and to have become a means of diagnosis. 
I will not now occupy time by inquiring why these pupil 
symptoms are variable, appearing in some cases, and not in 
others. Most likely the solution is to be met with in the 
anatomical connexions of the nerves about the cause of 
pressure, the character of the growth, and the rate of rapidity 
of its formation, and in the stage of the disease,1 as well as 
upon other circumstances yet to be made out. 
In these observations, it has been my endeavour to render 
experimental physiology subservient to practical medicine, 
to give what assistance was in my power, towards the edi- 
fication of pathological science upon such a foundation as 
alone is legitimate and truly scientific. If it shall be 
1 It will be remembered that in tbe history of one or two of the cases 
before detailed, the amount of alteration in the pupil varied at different 
periods of observation. 42 
THE INFLUENCE OF THE SYMAATHETIC 
thought that I have in any degree succeeded in enrich- 
ing or enlarging the boundaries of a field which the labours 
of others had in their degree cleared, I shall have reason 
to congratulate myself, in that my efforts will not have 
been fruitless. 
APPENDIX. 
Note A. (See page 421.)—I have no doubt, that if I 
had had the requisite time to scrutinise all the cases re- 
corded in the various periodicals, or, if it had been desir- 
able to multiply examples, I should have found several other 
cases in which some affection of the pupil had been noted, 
though, at the time, not understood, in connexion with 
aneurisms, tumours, injuries, &c., about the neck, so situ- 
ated as to interfere with the sympathetic and the cervical 
region of the spinal cord. I do not, however, think that a 
very great number of cases would be so met with, having 
this implication of the pupil, seeing, indeed, how little 
attention is ordinarily paid at the bed-side to the exact 
state of the eye, except in cases of disease of the brain. 
Unless specially looked for, the condition of the pupil has 
been, hitherto, in a marvellous manner disregarded in disease, 
even in disease of the brain itself, and, in support of this 
observation, I cannot resist stating, that it was not until the 
year 1818 that any positive notice was taken by the profes- 
sion of the poisoning by opium being attended by any 
alteration of the pupil.1 The first distinct report of this 
fact was by Dr. Kinnis, who spoke of the pupils “ being 
fixed” “ and contracted to the size of a head,” when 
relating a case of recovery from the effects of opium.2 
Now, considering how many observers, long before that 
period, must have watched the results of poisonous doses of 
opium, is it not a little curious that none had described 
either contraction, or what sometimes occurs, dilatation of 
the pupil in connexion therewith ? I have looked in vain 
1 See the statements by Dr. Sibson in the ‘Medical Gazette,’ 1848, 
p. 268. 
3 ‘Edinburgh Medical Journal,’ 1818, p. 603. ON THE EYE AND ITS APPENDAGES. 
43 
through the writings of several authors who wrote before 
the period above mentioned, for evidence of any knowledge 
of a relationship between the phenomenon in question and 
opium-poisoning; and even for some years subsequent to the 
case related by Dr. Kinnis, I find no mention of the fact in 
the writings of various medical men who wrote on practical 
subjects. 
Note B. (See page 421.)—The fact of spasms of a 
muscle preceding a condition of paralysis, or vice versa, is 
often illustrated in cases of disease where pressure is exerted 
on the nerves of the extremities. We also have experience 
of it in the pupils of the eyes, as when a contracted 
pupil precedes dilatation, consequent upon pressure, as by a 
tumour upon the third cranial nerve. And a notable instance 
exists in the spasm of the facial muscles, which not in- 
frequently precedes facial paralysis of the same side—a 
state which may also folloiv the paralysis, when the muscles 
and nerves are returning to their natural condition. 
Note C. (See page 429.)—It will be remembered, 
that in man the cervical sympathetic trunks on both 
sides, whose connexion with the spinal nerves has been 
previously alluded to, send up processes (varying in num- 
ber, according to the statement of Weber, even in the 
same animals) which, surrounding the internal carotid 
artery whilst in the carotid canal of the temporal bone 
and before its division within the cranium, form a 
large network, the carotid and cavernous plexus. From 
this plexus, besides sundry branches to other parts, which 
are not to my present purpose, we find communications 
joining the third and the sixth pair of cranial nerves, as 
well as the ophthalmic or lenticular ganglion. The branch 
to the ganglion is of course the medium of innervation to 
the dilator of the pupil. The communications between the 
plexus and the sixth pair of nerves in man has been found 
by Valentin, to be effected by several important branches. 
Cuvier, who made observations on the calf, sheep, wolf, and 
porcupine, speaks of this communication as consisting of 
‘ a number of filaments but, in some animals, accord- 44 
INFLUENCE OF SYMPATHETIC ON THE EYE, ETC. 
ing to Weber, the branches to the sixth pair are entirely 
absent, and this may be the case at times in marfa^so. 
Tn man, the communication between the sympathetic 
plexus and the third cranial pair, is ordinarily effected by 
two or three branches which join thi3 nerve just before its 
division into its two major branches, and consequently before 
the subdivision is given off, destined to the elevator of 
the upper eyelid and superior rectus. 
All these branches, i. e., the one to the lenticular gan- 
glion, that to the external rectus or abducent muscle, and 
that to the third pair, will be no doubt affected in a similar 
manner, though possibly in a different degree, by section of, 
or extreme pressure upon the sympathetic main branches or 
trunks in the neck, &c. Just as we get paralysis of the 
dilator of the pupil, and consequently contracted pupil, pro- 
duced by virtue of the branch of the carotid plexus, given 
off to the ophthalmic ganglion, so have we more or less 
paralysis of the abducent muscle, by virtue of the twigs fur- 
nished to the sixth pair, which supplies that muscle, allow- 
ing thus of convergent squint; and more or less paralysis 
of the elevator of the upper eyelid by virtue of the twigs to 
the third pair, producing ptosis, the orbicularis palpebrarum 
still acting and overcoming that muscle. Possibly, in 
some cases, more or less of the strabismus may also be 
caused by virtue of an implication of sympathetic twigs 
distributed to other branches of the third and the fourth 
pairs, from which nerves the oblique muscles are supplied. 
We have other instances in the human body, besides the 
external rectus and levator palpebrse, of a single muscle 
being supplied by different nerves, of which good illustra- 
tions are found in the buccinator, the muscles at the angles 
of the mouth, and the sterno-cleido-mastoid muscles; and, 
since in such a case both sets of nervous branches must 
operate upon the muscular fibre, it cannot be doubted, that 
in proportion as either nervous source becomes weakened, 
the muscle loses power, and so becomes overbalanced in 
action by any antagonising muscles. It is most probable 
also that the sympathetic twigs distributed to the muscle, 
or joining the nerves of the eyeball, are only concerned in 
involuntary and consensual movements.