The Argyll Robertson pupil
In 1869 Douglas Moray Cooper Lamb Argyll Robertson described his famous pupillary sign in two papers:
Argyll Robertson was one of the first surgeons to specialise in ophthalmology. Pupillary miosis, inequality, and irregularity, without reaction to light, had been known in cases of tabes dorsalis and dementia paralytica (GPI) since the end of the 18th century.
Ernst Julius Remak had shown the pupillary signs of tabes to Argyll Robertson,3 whose later famous reports of 1869 acknowledged Remak’s observation of the miotic pupil, its defective reaction to light, and preserved contraction on accommodation. Romberg (1839) also gave an earlier description.3
The Argyll Robertson pupil soon became a “pathognomonic sign” in tabes dorsalis, dementia paralytica, and meningovascular syphilis. However, the role of syphilis in causing these disorders was hotly debated. Jean Alfred Fournier and Sir Jonathan Hutchinson (1828–1913) favoured a syphilitic aetiology, but not until the 20th century was it generally accepted as the cause. Crucial to this were the discoveries by Schaudinn and Hoffmann of the treponema pallidum in 1905 and the serologic test in 1906 of August Paul von Wassermann(1866–1925).
The abnormal pupil is probably caused by damage to cells in the pretectal region of the midbrain. As a result, signals carried from the retina are not relayed via the pretectal nucleus on the affected side to the Edinger–Westphal nuclei. This causes a loss of both the direct and consensual pupillary light reflexes. Since the accommodation reflex pathway is separate from the light reflex it is unaffected. Pupillary inequality, irregularity, and iris atrophy without reaction to light are the hallmarks, clinically distinguishable from the Holmes–Adie myotonic pupil. Walshe stated4 that “these components though varying from case to case are never found together apart from neurosyphilis”. Others claim it occurs rarely in Wernicke’s encephalopathy and diabetes.
Argyll Robertson was born in 1837 in Edinburgh,5 where his father, John, was a general surgeon, who concentrated on eye surgery. He graduated at St Andrews, in 1857, returned as a house surgeon to the Edinburgh Royal Infirmary, then studied in Berlin under the leading ophthalmologist Albrecht von Graefe (1828–1870). He became lecturer in diseases of the eye at the Edinburgh Medical School in 1862. In 1863, he published an important article6 on the Calabar bean (Physostigmin venosum), the seed of a leguminous plant found in Calabar, Nigeria. Argyll Robertson instilled an extract into his own eye noting that physostigmine constricts the pupil. He predicted it would become “most valuable in the ophthalmic pharmacopoeia”.
In 1867 he was appointed assistant ophthalmic surgeon, and in 1870 full ophthalmic surgeon to the Royal Infirmary, where he stayed until retirement in 1897.
Physostigmine from the calabar beam was to be important in the treatment of glaucoma. Argyll Robertson was also the first to describe a trepanning method of operation for certain cases of glaucoma. He became chairman of the ophthalmologic society of England, 1886, held office in the Royal College of Surgeons of Edinburgh, and was honorary eye physician to Queen Victoria and King Edward VII. In 1904, for health reasons, he moved to the Jersey. While on holiday in India in 1908 he became ill in Gondal near Bombay, and died.
His biographer noted
“His handsome features and his tall, athletic frame made him the cynosure of all female eyes in his youth and in his later
years, clad in a grey frock-coat and top hat, his dignified manner combined with his genial old-world courtesy made him conspicuous
in any assembly and a magnificent ambassador of Scotland.” 7
A keen golfer, he won the gold medal of the Royal and Ancient Club, St Andrews, five times.