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The Eyes in Brain Localization
426
J. H E Y W A R D GIBBES
constantly on guard in order to avoid such confusion. Disseminated sclerosis and epidemic encephalitis are among the central nervous system diseases which pro duce their characteristic eye changes. In multiple sclerosis nystagmus and optic atrophy are of equal rank with scanning speech and intention tremor in leading to a correct diagnosis. The initial symptom of epidemic encephali tis is frequently diplopia, so much so that any complaint of double vision should immediately arouse the suspi cion of this disease. Leaving syphilis out of considera tion, it has been my experience that iritis, choroiditis, and neuroretinitis have been found most frequently in connection with definite focal infec tions in the teeth, tonsils, and para
nasal sinuses. The specific relationship of cause and effect has seemed to be clearly demonstrated in repeated in stances, by the rapid subsidence of the ocular inflammations after the re moval or drainage of the focal infec tions. Instructions for first aid, that are put into the hands of lay people, give directions for emergency measures, and then emphasize the propriety of calling a doctor. The relation of the internist to the ophthalmologist might be expressed in somewhat the same terms. After he has equipped himself to do all that I have intimated that he must, he should be anxious to submit his findings and seek more detailed in formation and guidance from those who are doing special work on the eye. 1431 Marion St.
T H E EYES IN BRAIN LOCALIZATION. F R A N K
E.
BRAWLEY,
CHICAGO,
M.D.
ILL.
The ophthalmologist helps to determine the position of brain lesions, by studies of the field of vision revealing scotomas, hemianopsias, and sector defects. The ophthalmoscope shows papilledema and optic atrophy. Unilateral blindness and abnormalities of the pupil, associated with other symptoms, give important information. Read before a joint meeting of the Chicago Medical and Chicago Ophthalmological Societies, February, 1927. See p. 447.
Of perhaps greatest importance are visual fields and these should be stud ied in every instance when in our office routine we encounter lowered vision for which we are unable to account. The presence of severe headaches, pro jectile vomiting, vertigo, uncertain gait, mind blindness, inability to see well to right or left, all indicate the need for careful field studies. Scoto mata, relative or absolute, hemianop sia, homonymous, heteronymous or altitudinal quadrant or sector defects and blind spot anomalies are the important findings. In the relative scotoma the colors employed are correctly recognized but are dull or altered. If the scotoma is absolute the colors are not recognized. Lesions in the optic nerve, chiasm, optic tracts and calcarine fissure area afliect green first and only later are red and blue affected. The scotoma usu ally found in pituitary disease begins as an upper temporal defect reaching toward and finally including the blind
spot. Ring scotoma is occasionally found in multiple sclerosis, lowgrade syphilis and encephalitis lethargica but retinitis pigmentosa in which it is most frequently found must be ex cluded. Optic nerve atrophy is found in two types, one with the typical disc pallor accompanied by very much narrowed vessels and contracted fields and the other with good fields and normal vessels but very low central vision. Pituitary disease produces the pri mary type of optic atrophy. Suppres sion of the sex function, acromegaly, headache and difficulty in reading and walking suggest pituitary involve ment. The fields may show, according to Gushing and Walker, bitemporal hem ianopsia 25 per cent; one blind eye and heminaopsia in the other in 43 per cent; homonymous hemianopsia in 12 per cent and in 19 per cent no changes in the fields. While in pituitary dis ease bitemporal hemianopsia has been
EYES IN B R A I N LOCALIZATION
considered the classic visual field pic ture, evidence is accumulating which tends to show that homonymous hem ianopsias are more frequent than has been supposed. Gushing states that homonymous defects occur half as fre quently as the bitemporal type. De Schweinitz found homonymous defects in six per cent of his material. Lillie reports his studies in fifty cases of acromegaly. 26 per cent had nor mal sellae turcicae and chiasmal find ings. 42 per cent showed enlargement of the sella, with erosion of the pos terior clinoids in the x-ray studies, but with no chiasmal or optic nerve in volvement. Only 38 per cent of his patients had definite ocular changes characteristic of chiasmal involvement, associated with enlargement of the sella and erosion of the posterior clinoids. The classic picture of a tabetic atrophy is a slowly contracting field in which the color fields are the first to be affected. Exceptionally, sector defects occur due to vascular disease. The picture of tabetic disease would not be complete without reference to the vestibular reactions found in this class of cases. Known cases of tabes were studied by John Richards and the author as a research problem, while on duty at the Medical Research Laboratory of the Air Service. The outstanding result in all cases studied by complete vestibular tests was, that tabes produces irritative effects upon the brain stem as shown by markedly increased duration and violence of the nystagmus, as well as the other ves tibular reactions induced by the turn ing and douching tests. Syphilis usually produces a retro bulbar neuritis with good fields and a central scotoma with low central \'ision. If, however, it involves the chiasm or optic tracts the typical anopsias will result depending on the location of the lesion. Multiple sclero sis is seen usually as atrophy of the temporal half of the discs accompanied by nystagmus on extreme outward rotation of the eyes. With these signs transient ocular muscle paralyses are occasionally seen, tho without in volvement of the pupil.
427
The visual fields in multiple sclero sis show marked contraction for white and colors and a central scotoma. Sud den blindness in one eye, accompanied bv such a visual field picture in the other, suggests a multiple sclerosis. Areas of sclerosis in the brain stem involve different levels of the posterior longitudinal bundles composed of the nerve fibers supplying the ocular muscles. These lesions may be lo cated by vestibular tests which show absence, perversion or reversal of the normal nystagmus. The mechanism of choked disc and its exact significance is still a subject for discussion. Generally speaking the neurologists seem committed to the explanation, that the fluid in the vagi nal sheath of the optic nerve is cere brospinal fluid forced there by increas ing intracranial pressure. Many oph thalmologists on the other hand be lieve that the papilledema is caused by pressure downward from the dilated third ventricle upon the chiasm, inter fering with the return venous and lymphatic circulation. Where the pressure is sufficient, retinal edema with exudates results, a picture indis tinguishable from an inflammatory process. It seems probable that either of these hypotheses may be correct in certain cases. The stage of progress of brain tumor at which papilledema appears depends upon the location of the lesion. The early cases of choked disc result from tumors of the pons and anterior por tions of the cerebellum, lying close to the third ventricle, while in the cases where the papilledema appears late, the lesion is more centrally lo cated. Sharp's production of artificial papilledema in young puppies, perhaps favors the theory that the papilledema is caused by the forcing of cerebro spinal fluid into the optic nerve sheath. He inserted a gelatin capsule filled with cotton into the aqueduct of Silvius. Disc changes occurred in six hours and definite elevation in from 12 to 24 hours. Decompression then relieved the pressure and the discs re turned to normal. Reports from various observers who had opportunity to study head injuries
428
P. Β. B R A W L E Y
during the late war indicate the value the opposite eye is usually present. of papilledema as a diagnostic sign. Fixed pupils have been noted, in cases These findings have been analyzed and where the growth involves the corpora the following summary arranged by quadrigemina. James Patton. Transient processes of the ocular I. The presence of papilledema es muscles, and even a transient Argyll pecially when associated with recent Robertson pupil, have been found in intracranial injuries is positive evi cases where great pressure occurred. Tumors of the corpora quadrigemina dence of intracranial injury. occur early in life and are secondary to II. In cases where an extensive tumors of the pineal gland. There is traumatic decompression is present, usually great pressure on the third should the disc become progressively ventricle with resultant choked disc blurred, further relief of pressure of high degree. Sudden blindness from should be secured. pressure on the optic tract is fre III. In milder cases the symptoms quently found, early in the case. above referred to may be relieved by In an outline such as this, mention spinal puncture. should be made of that other "window IV. Even tho there may be an of the brain," the vestibular apparatus. extensive fracture, providing there is This is especially appropriate, as the no great destruction of brain tissue, ocular apparatus plays such an import the absence of papilledema is of very ant role in the vestibular studies. favorable prognostic significance. After the stimuli produced by the turn A somewhat rare symptom complex ing and douching tests, nystagmus is is the association of complete unilat produced, which indicates the integ eral blindness with hemiplegia of the rity, or otherwise, of the Deiter's nu opposite side of the body. The blind cleus and the longitudinal fasciculus ness is sudden and occurs simultan in the brain stem. Stimulation of the horizontal semicircular canal produces eously with the hemiplegia and loss of consciousness. The condition is as horizontal nystagmus, with the quick sociated with thrombosis or embolism component toward the ear opposite of the central retinal artery and the that stimulated. This is a normal re middle cerebral artery. This picture sponse while its absence proves that occurs in individuals with evident there is a block in the medulla. Stimu cardiovascular disease and has been lation of the vertical canals produces a confirmed by autopsy. Tumors of the rotary nystagmus, away from the ear The presence of this temporal lobe, due to the latency of being tested. this region, are difficult to recognize. type of nystagmus shows a norma! Eye findings are frequently useful in pons, in the region of the longitudinal the diagnosis of such lesions. Appari bundle, and its absence a block at this tions of odd people often in unusual point. dress may appear. Hemianopsia of 30 North Michigan Avenue.
J. H E Y W A R D GIBBES
constantly on guard in order to avoid such confusion. Disseminated sclerosis and epidemic encephalitis are among the central nervous system diseases which pro duce their characteristic eye changes. In multiple sclerosis nystagmus and optic atrophy are of equal rank with scanning speech and intention tremor in leading to a correct diagnosis. The initial symptom of epidemic encephali tis is frequently diplopia, so much so that any complaint of double vision should immediately arouse the suspi cion of this disease. Leaving syphilis out of considera tion, it has been my experience that iritis, choroiditis, and neuroretinitis have been found most frequently in connection with definite focal infec tions in the teeth, tonsils, and para
nasal sinuses. The specific relationship of cause and effect has seemed to be clearly demonstrated in repeated in stances, by the rapid subsidence of the ocular inflammations after the re moval or drainage of the focal infec tions. Instructions for first aid, that are put into the hands of lay people, give directions for emergency measures, and then emphasize the propriety of calling a doctor. The relation of the internist to the ophthalmologist might be expressed in somewhat the same terms. After he has equipped himself to do all that I have intimated that he must, he should be anxious to submit his findings and seek more detailed in formation and guidance from those who are doing special work on the eye. 1431 Marion St.
T H E EYES IN BRAIN LOCALIZATION. F R A N K
E.
BRAWLEY,
CHICAGO,
M.D.
ILL.
The ophthalmologist helps to determine the position of brain lesions, by studies of the field of vision revealing scotomas, hemianopsias, and sector defects. The ophthalmoscope shows papilledema and optic atrophy. Unilateral blindness and abnormalities of the pupil, associated with other symptoms, give important information. Read before a joint meeting of the Chicago Medical and Chicago Ophthalmological Societies, February, 1927. See p. 447.
Of perhaps greatest importance are visual fields and these should be stud ied in every instance when in our office routine we encounter lowered vision for which we are unable to account. The presence of severe headaches, pro jectile vomiting, vertigo, uncertain gait, mind blindness, inability to see well to right or left, all indicate the need for careful field studies. Scoto mata, relative or absolute, hemianop sia, homonymous, heteronymous or altitudinal quadrant or sector defects and blind spot anomalies are the important findings. In the relative scotoma the colors employed are correctly recognized but are dull or altered. If the scotoma is absolute the colors are not recognized. Lesions in the optic nerve, chiasm, optic tracts and calcarine fissure area afliect green first and only later are red and blue affected. The scotoma usu ally found in pituitary disease begins as an upper temporal defect reaching toward and finally including the blind
spot. Ring scotoma is occasionally found in multiple sclerosis, lowgrade syphilis and encephalitis lethargica but retinitis pigmentosa in which it is most frequently found must be ex cluded. Optic nerve atrophy is found in two types, one with the typical disc pallor accompanied by very much narrowed vessels and contracted fields and the other with good fields and normal vessels but very low central vision. Pituitary disease produces the pri mary type of optic atrophy. Suppres sion of the sex function, acromegaly, headache and difficulty in reading and walking suggest pituitary involve ment. The fields may show, according to Gushing and Walker, bitemporal hem ianopsia 25 per cent; one blind eye and heminaopsia in the other in 43 per cent; homonymous hemianopsia in 12 per cent and in 19 per cent no changes in the fields. While in pituitary dis ease bitemporal hemianopsia has been
EYES IN B R A I N LOCALIZATION
considered the classic visual field pic ture, evidence is accumulating which tends to show that homonymous hem ianopsias are more frequent than has been supposed. Gushing states that homonymous defects occur half as fre quently as the bitemporal type. De Schweinitz found homonymous defects in six per cent of his material. Lillie reports his studies in fifty cases of acromegaly. 26 per cent had nor mal sellae turcicae and chiasmal find ings. 42 per cent showed enlargement of the sella, with erosion of the pos terior clinoids in the x-ray studies, but with no chiasmal or optic nerve in volvement. Only 38 per cent of his patients had definite ocular changes characteristic of chiasmal involvement, associated with enlargement of the sella and erosion of the posterior clinoids. The classic picture of a tabetic atrophy is a slowly contracting field in which the color fields are the first to be affected. Exceptionally, sector defects occur due to vascular disease. The picture of tabetic disease would not be complete without reference to the vestibular reactions found in this class of cases. Known cases of tabes were studied by John Richards and the author as a research problem, while on duty at the Medical Research Laboratory of the Air Service. The outstanding result in all cases studied by complete vestibular tests was, that tabes produces irritative effects upon the brain stem as shown by markedly increased duration and violence of the nystagmus, as well as the other ves tibular reactions induced by the turn ing and douching tests. Syphilis usually produces a retro bulbar neuritis with good fields and a central scotoma with low central \'ision. If, however, it involves the chiasm or optic tracts the typical anopsias will result depending on the location of the lesion. Multiple sclero sis is seen usually as atrophy of the temporal half of the discs accompanied by nystagmus on extreme outward rotation of the eyes. With these signs transient ocular muscle paralyses are occasionally seen, tho without in volvement of the pupil.
427
The visual fields in multiple sclero sis show marked contraction for white and colors and a central scotoma. Sud den blindness in one eye, accompanied bv such a visual field picture in the other, suggests a multiple sclerosis. Areas of sclerosis in the brain stem involve different levels of the posterior longitudinal bundles composed of the nerve fibers supplying the ocular muscles. These lesions may be lo cated by vestibular tests which show absence, perversion or reversal of the normal nystagmus. The mechanism of choked disc and its exact significance is still a subject for discussion. Generally speaking the neurologists seem committed to the explanation, that the fluid in the vagi nal sheath of the optic nerve is cere brospinal fluid forced there by increas ing intracranial pressure. Many oph thalmologists on the other hand be lieve that the papilledema is caused by pressure downward from the dilated third ventricle upon the chiasm, inter fering with the return venous and lymphatic circulation. Where the pressure is sufficient, retinal edema with exudates results, a picture indis tinguishable from an inflammatory process. It seems probable that either of these hypotheses may be correct in certain cases. The stage of progress of brain tumor at which papilledema appears depends upon the location of the lesion. The early cases of choked disc result from tumors of the pons and anterior por tions of the cerebellum, lying close to the third ventricle, while in the cases where the papilledema appears late, the lesion is more centrally lo cated. Sharp's production of artificial papilledema in young puppies, perhaps favors the theory that the papilledema is caused by the forcing of cerebro spinal fluid into the optic nerve sheath. He inserted a gelatin capsule filled with cotton into the aqueduct of Silvius. Disc changes occurred in six hours and definite elevation in from 12 to 24 hours. Decompression then relieved the pressure and the discs re turned to normal. Reports from various observers who had opportunity to study head injuries
428
P. Β. B R A W L E Y
during the late war indicate the value the opposite eye is usually present. of papilledema as a diagnostic sign. Fixed pupils have been noted, in cases These findings have been analyzed and where the growth involves the corpora the following summary arranged by quadrigemina. James Patton. Transient processes of the ocular I. The presence of papilledema es muscles, and even a transient Argyll pecially when associated with recent Robertson pupil, have been found in intracranial injuries is positive evi cases where great pressure occurred. Tumors of the corpora quadrigemina dence of intracranial injury. occur early in life and are secondary to II. In cases where an extensive tumors of the pineal gland. There is traumatic decompression is present, usually great pressure on the third should the disc become progressively ventricle with resultant choked disc blurred, further relief of pressure of high degree. Sudden blindness from should be secured. pressure on the optic tract is fre III. In milder cases the symptoms quently found, early in the case. above referred to may be relieved by In an outline such as this, mention spinal puncture. should be made of that other "window IV. Even tho there may be an of the brain," the vestibular apparatus. extensive fracture, providing there is This is especially appropriate, as the no great destruction of brain tissue, ocular apparatus plays such an import the absence of papilledema is of very ant role in the vestibular studies. favorable prognostic significance. After the stimuli produced by the turn A somewhat rare symptom complex ing and douching tests, nystagmus is is the association of complete unilat produced, which indicates the integ eral blindness with hemiplegia of the rity, or otherwise, of the Deiter's nu opposite side of the body. The blind cleus and the longitudinal fasciculus ness is sudden and occurs simultan in the brain stem. Stimulation of the horizontal semicircular canal produces eously with the hemiplegia and loss of consciousness. The condition is as horizontal nystagmus, with the quick sociated with thrombosis or embolism component toward the ear opposite of the central retinal artery and the that stimulated. This is a normal re middle cerebral artery. This picture sponse while its absence proves that occurs in individuals with evident there is a block in the medulla. Stimu cardiovascular disease and has been lation of the vertical canals produces a confirmed by autopsy. Tumors of the rotary nystagmus, away from the ear The presence of this temporal lobe, due to the latency of being tested. this region, are difficult to recognize. type of nystagmus shows a norma! Eye findings are frequently useful in pons, in the region of the longitudinal the diagnosis of such lesions. Appari bundle, and its absence a block at this tions of odd people often in unusual point. dress may appear. Hemianopsia of 30 North Michigan Avenue.