- Email: [email protected]
THE TONIC PUPIL
689 "
THE TONIC PUPIL
"
iridoplegia," ophthalmoplegia interna " or whose origin is obscure, are of the same nature as the disorder known as tonic pupil. In the past there may have been too great a tendency to suspect a syphilitic taint in such conditions. Dr. ADIE believes that the disorder of which they are signs is one in the production of which no known hereditary or acquired morbid factor plays a part. It runs a benign course without the incidence of further symptoms, and is compatible with long
THE Argyll Robertson phenomenon, in which both pupils are either totally inactive or very nearly so to light, but react briskly on stimulation to convergence, is a familiar sign of tabes, and is only found in syphilitic patients. There are, however, other pupillary conditions more or less simulating the Argyll Robertson pupil to which Dr. W. J. ADIim draws attention in an enlightening contribution to our knowledge of the tonic pupil life. reaction.! It is important to distinguish these conditions, since they appear to have no connexion
with syphilis
nor
any grave
significance. They
have been described by various observers during recent years under the names of tonic pupillary reaction, myotonic reaction, tonic convergence reaction of pupils apparently inactive to light, non-luetic Argyll Robertson pupil, or pseudoArgyll Robertson pupil. Confusion is the more apt to occur since this reaction also may be associated with absence or diminution of one or more of the tendon reflexes. The essential feature of the true tonic pupil, according to Dr. ADIE, is its behaviour during and after convergence. " While the patient gazes at a near object the pupil, often after some delay, contracts slowly and with increasing
slowness through a range sometimes greatly in excess of the normal, often down to pinhead size ; having been larger, it almost always becomes much smaller than its normal fellow. After the effort to converge is relaxed one of several things may happen: the pupil continues to contract (rare), or remains fixed for several or many seconds (the rule), or begins to dilate at once (common); dilatation once begun proceeds at a rate even slower than that of the preceding contraction, and many seconds, or even minutes, elapse before it regains its usual resting size."
The reaction to light appears to be absent on casual testing, but after a long sojourn in a dark room the tonic pupil can usually be made to contract through a normal range. It is almost always larger than its normal fellow. This contrasts with the behaviour of the Argyll Robertson pupil. Where the contraction of the pupil to convergence and its return to its usual state are rapid, other points of difference are that the tonic reaction is unilateral in about 80 per cent. of the cases, whereas in the Argyll Robertson it is unilateral only in about 5 per cent. The tonic pupil is hardly ever small, and dilates to its full size with mydriatics ; the Argyll Robertson pupil is small, the diameter being less than 3 mm. in 80 per cent. of cases, and dilates with difficulty to mydriatics. A large proportion of the patients with tonic pupils are healthy young females. There is no evidence of any but an accidental connexion with either syphilitic or any other disease of the nervous system. When the tonic pupil is associated with diminution or absence of one or more reflexes, loss of one ankle-jerk is the most common abnormality. Asymmetry is indeed not unusual; either knee- or ankle-jerk may be absent on one side only. The symptomatology of the condition appears to be extremely variable. Difficulty of accommodation is the only venience to the occur.
to cause inconand not always it does patient, In Dr. ADIE’S view many cases of so-called
symptom likely
1 Brit. Jour. Ophth., August, 1932, p. 449.
HOSPITAL SWEEPSTAKES THE voluntary hospitals do not wish their needs to be made a pretext for the legalisation of lotteries, but on the other hand they are not opposed to legislation, and would be willing to accept money derived from properly legalised sources. This, in brief, is the message conveyed Sir ARTHUR STANLEY in his evidence before the by Royal Commission on Betting and Lotteries on Sept. 16th. Only a statistician would complain that the importance of this pronouncement is lessened by the fact that he actually submitted his statement of evidence to only a small number of hospitals (72, of which 52 replied, 40 agreeing with his views). Sir ARTHUR is president of the British Hospitals Association, and his long and intimate connexion with the work of the voluntary hospitals gives him a title to be their spokesman. His evidence may, therefore, be considered as authoritative. He holds that lotteries could best be managed and safeguarded from fraud by the appointment of a statutory body on the lines of the British Broadcasting Corporation. A percentage of the proceeds of public lotteries and sweepstakes would be set aside as a general fund, out of which grants would be made to national organisations for charity; grants to voluntary hospitals, for example, would be made through the British Hospitals Association. He believes that if large sums were given out of the proceeds of lotteries to individual hospitals there would be a tendency for charitable contributions, which now amount to £8,000,000 a year, to diminish seriously. A considerable part of that sum is given by people who oppose lotteries on principle, and who would withdraw their while many others would feel that their support, contributions were no longer needed. Although Sir ARTHUR believes that the funds for maintenance of hospitals will continue to be contributed by the charitable public, the decline in large fortunes makes it inevitable, in his view, that large sums for capital purposes will be increasingly difficult to obtain. It is this need which he contemplates being met out of a lottery fund without danger of alienating subscribers ; and the large sums of money which are at present going to Ireland would be kept in this country and spent on deserving objects at home. Sir ARTHUR’S evidence shows an interesting modification of the views he expressed in our columns in May of last year. In a letter written at that time he was
THE TONIC PUPIL
"
iridoplegia," ophthalmoplegia interna " or whose origin is obscure, are of the same nature as the disorder known as tonic pupil. In the past there may have been too great a tendency to suspect a syphilitic taint in such conditions. Dr. ADIE believes that the disorder of which they are signs is one in the production of which no known hereditary or acquired morbid factor plays a part. It runs a benign course without the incidence of further symptoms, and is compatible with long
THE Argyll Robertson phenomenon, in which both pupils are either totally inactive or very nearly so to light, but react briskly on stimulation to convergence, is a familiar sign of tabes, and is only found in syphilitic patients. There are, however, other pupillary conditions more or less simulating the Argyll Robertson pupil to which Dr. W. J. ADIim draws attention in an enlightening contribution to our knowledge of the tonic pupil life. reaction.! It is important to distinguish these conditions, since they appear to have no connexion
with syphilis
nor
any grave
significance. They
have been described by various observers during recent years under the names of tonic pupillary reaction, myotonic reaction, tonic convergence reaction of pupils apparently inactive to light, non-luetic Argyll Robertson pupil, or pseudoArgyll Robertson pupil. Confusion is the more apt to occur since this reaction also may be associated with absence or diminution of one or more of the tendon reflexes. The essential feature of the true tonic pupil, according to Dr. ADIE, is its behaviour during and after convergence. " While the patient gazes at a near object the pupil, often after some delay, contracts slowly and with increasing
slowness through a range sometimes greatly in excess of the normal, often down to pinhead size ; having been larger, it almost always becomes much smaller than its normal fellow. After the effort to converge is relaxed one of several things may happen: the pupil continues to contract (rare), or remains fixed for several or many seconds (the rule), or begins to dilate at once (common); dilatation once begun proceeds at a rate even slower than that of the preceding contraction, and many seconds, or even minutes, elapse before it regains its usual resting size."
The reaction to light appears to be absent on casual testing, but after a long sojourn in a dark room the tonic pupil can usually be made to contract through a normal range. It is almost always larger than its normal fellow. This contrasts with the behaviour of the Argyll Robertson pupil. Where the contraction of the pupil to convergence and its return to its usual state are rapid, other points of difference are that the tonic reaction is unilateral in about 80 per cent. of the cases, whereas in the Argyll Robertson it is unilateral only in about 5 per cent. The tonic pupil is hardly ever small, and dilates to its full size with mydriatics ; the Argyll Robertson pupil is small, the diameter being less than 3 mm. in 80 per cent. of cases, and dilates with difficulty to mydriatics. A large proportion of the patients with tonic pupils are healthy young females. There is no evidence of any but an accidental connexion with either syphilitic or any other disease of the nervous system. When the tonic pupil is associated with diminution or absence of one or more reflexes, loss of one ankle-jerk is the most common abnormality. Asymmetry is indeed not unusual; either knee- or ankle-jerk may be absent on one side only. The symptomatology of the condition appears to be extremely variable. Difficulty of accommodation is the only venience to the occur.
to cause inconand not always it does patient, In Dr. ADIE’S view many cases of so-called
symptom likely
1 Brit. Jour. Ophth., August, 1932, p. 449.
HOSPITAL SWEEPSTAKES THE voluntary hospitals do not wish their needs to be made a pretext for the legalisation of lotteries, but on the other hand they are not opposed to legislation, and would be willing to accept money derived from properly legalised sources. This, in brief, is the message conveyed Sir ARTHUR STANLEY in his evidence before the by Royal Commission on Betting and Lotteries on Sept. 16th. Only a statistician would complain that the importance of this pronouncement is lessened by the fact that he actually submitted his statement of evidence to only a small number of hospitals (72, of which 52 replied, 40 agreeing with his views). Sir ARTHUR is president of the British Hospitals Association, and his long and intimate connexion with the work of the voluntary hospitals gives him a title to be their spokesman. His evidence may, therefore, be considered as authoritative. He holds that lotteries could best be managed and safeguarded from fraud by the appointment of a statutory body on the lines of the British Broadcasting Corporation. A percentage of the proceeds of public lotteries and sweepstakes would be set aside as a general fund, out of which grants would be made to national organisations for charity; grants to voluntary hospitals, for example, would be made through the British Hospitals Association. He believes that if large sums were given out of the proceeds of lotteries to individual hospitals there would be a tendency for charitable contributions, which now amount to £8,000,000 a year, to diminish seriously. A considerable part of that sum is given by people who oppose lotteries on principle, and who would withdraw their while many others would feel that their support, contributions were no longer needed. Although Sir ARTHUR believes that the funds for maintenance of hospitals will continue to be contributed by the charitable public, the decline in large fortunes makes it inevitable, in his view, that large sums for capital purposes will be increasingly difficult to obtain. It is this need which he contemplates being met out of a lottery fund without danger of alienating subscribers ; and the large sums of money which are at present going to Ireland would be kept in this country and spent on deserving objects at home. Sir ARTHUR’S evidence shows an interesting modification of the views he expressed in our columns in May of last year. In a letter written at that time he was