1901 Journal of the American Medical Association (JAMA)  
external rectus muscle, the duration of the paresis varying from a few weeks to about three months. 2. Thé retention, during almost the entire period of observation, of the knee-jerks. 3. The existence of various foci of degeneration, as especially illustrated in the comparatively early involvement of the sacral cord and the consequent loss of the deep reflexes of the lower extremities ; the paretie ocular muscle, the numbness, the laryngeal crises. 4. Although a specific history was thought to
more » ... tory was thought to be present, the antisyphilitic treatment was quite nugatory or possibly damaging, for the reason previously stated. 5. The therapy, aside from the stomach and intestinal requirements, that gave the best, although but palliative result, was chlorid of gold and sodium. DISCUSSION. Dr. S. D. Risley, Philadelphia-Dr. Ring has honored me with a request to open the discussion on this very important topic, but I can not, in the very few moments allowed, enter into any extensive general consideration of tabes. A few years ago, through the courtesy of friends, I went through several general hospitals in Philadelphia and studied the ocular conditions in every case of tabes I could find. The result of those studies, I am sorry to say now, were never published, but left a very pronounced impression upon my own mind. In the first place, a very large proportion showed a greyness of the outer halves of the optic nerves, but in many instances this was not present until late in the disease. Another point that impressed itself on my mind was the abnormalities of ocular motility, which often came on very early in the disease. It is generally said that these ocular paralyses are transient. That is certainly so in a large number of cases, but there is a group like the one presented to-day in which it is not transient. I have never seen a case in which the external recti were involved that the paresis proved to be transient. The transient cases of paralysis were always of one of the vertically acting muscles or of the internal recti. The paralysis is often quite transient, lasting but a few hours or days. In this connection I recall the ease of an eloquent clergyman who was to have been one of the speakers at the dedication of the Bartholdi fountain at the Centennial Exposition in Philadelphia, in 1876. He was sitting on the platform awaiting his turn to speak, when he suddenly became nauseated and giddy, and was compelled to leave the platform. He thought it was due to the heat, but from his lucid statement it appeared to be a plain case of diplopia due to a transient palsy of the internal rectus. The symptoms disappeared after a few hours, but occasionally, afterward, he was annoyed by brief periods of disturbed vision which he learned to know were due to impaired muscular balance. I did not see him until 1881, when he was sent to me by the late Dr. William Pepper, because of this disturbance of vision. He then had, in the left eye, an absolute macular scotoma with a contracted field, and a distinctly grey outer half of the nerve. The patellar reflexes were impaired, but station was good. The disease slowly progressed until there was total atrophy of the optic nerve, and no perception of light. The right eye was healthy and vision normal ; no contraction of the field and no scotoma. Perhaps six years later he came complaining of trouble with the other eye. I found here also a macular scotoma with the same appearances about the disc, and this also passed to complete blindness. His gait was now ataxic and he died a few years ago, twenty years after the transient attack of diplopia and fifteen after the commencing atrophy of the optic nerve on the left side, having been confined to his room for many years. The initial symptom in this case occurred in 1876, and for ten years afterward he pursued his professional calling and was called on for many public addresses besides, while during those ten years he could not be made to believe he was in any sense ill. I wish to allude to one other point concerning the treatment. For many years I have been using bichlorid of mercury in these cases. I have one man who has .been under my care since 1884, a novelist who has followed his calling without interruption, and is now, in addition, the editor of a literary publica-tion, and has for sixteen years taken biebJorid of mercury internally, in doses anywhere from 1/100 gr. three or four times a day to 1/24 or'even 1/12 gr., he regulating the doses himself up to the point of relief from the lightning pains. His reflexes are absent, his station impaired but variable, but at no time has he manifested any disturbances of ocular motility. He came under observation in 1884 for impaired vision. There was a central scotoma for red and some concentric contraction of the fields. He was an excessive smoker and the victim of irregular habits culminating in an occasional spree. When made to comprehend his danger, he corrected his habits in great measure, but the tabetic symptoms slowly advanced. The relief from pain secured by the corrosive sublimate is of great interest. The etiology, as we know, is obscure, but most observers regard it as due to syphilis. In one case under my care for about ten years, with paralysis of the externus, the patient believed that his disease was due to excessive venery. How correct his own view in this case was I do not know, but it was his firm conviction. Dr. John E. Weeks, New York City-I would like to suggest that in all probability this particular salt of mercury is not necessarily the only one that will produce amelioration of the painful symptoms in tabes, but that mercury in ointment, the simple metallic mercury, is sufficient in many cases. I have reference particularly to a ease recently under observation, in which inunctions were used very f rely, the patient being kept at the point of saturation for some time; the relief of pain, as well as the improvement in his general condition was extremely marked. The idea that tabes is a disease due to an affection of the peripheral neurons is perhaps completely established at the present time; the atrophy of the optic nerve is secondary to degeneration of the ganglion cells in the retina. Dr. L. Webster Fox, Philadelphia-A man I had under observation some time ago, who had gone the rounds of the hospitals, told me the only relief he got was from excessive doses of whisky. I do not wish to encourage the drinking of whisky in such cases, but onh' mention this as one of the many remedies that have been applied to these cases. Dr. Ring-Dr. Fox's suggestion confirms my opinion that some of these cases, even though they are specific, do not get relief from the use of antisyphilitic treatment, the lesion being rather a degenerative sequence of syphilis. It may be of interest, in closing, to note, from a letter I received from this patient the day before I left Philadelphia, that the patient has had another recurrence of_the diplopia following a severe voyage and desperate seasickness. Despite the hundreds of reported cases, great uncertainty still remains as to the exact optical effect produced by removing the clear crystalline lens from a highly myopic eye. The great mass of these cases are so reported as not to throw any definite light on the optical questions involved. To point out what is our present knowledge of the subject, and to urge the reporting of more exact data regarding future cases are the purposes of this paper. Myopia due to Excessive Corneal Curvature.\p=m-\Ifa high myopia were due solely to excessive curvature of the cornea\p=m-\the anteroposterior length of the eyeball and the refractive power of the lens being no greater than in the average emmetropic eye\p=m-\the removal of the crystalline lens would cause substantially the same optical effect as it would in the emmetropic eye; that is, about 11 D. of change as measured at the cornea; or 12 to 13 D. as measured by a concave lens placed in the usual position for spectacle lenses. Myopia due to Excessive Refractive Influence of Lens.-With a myopia due solely to the excessive refrae-
doi:10.1001/jama.1901.52470110009002a fatcat:lm7gsyw44vcqvasmsc52yh2m3i