THE RELATIONS OF THE OPHTHALMOSCOPE TO LEGAL MEDICINE, PARTICULARLY AS REGARDS THE DETECTION OP SIMULATED MYOPIA OR, AMAUROSIS IN THE CASE OF PERSONS DRAFTED FOR MILITARY SERVICE.
BOSTON MEDICAL AND SURGICAL JOURNAL. Vol. Lxvi. Thursday, July 31, 1862. No. 26.
"Translated from Dr. A. Zander's "Ophthalmoscope, its Forms and Use," for the Boston Medical and Surgical Journal. By Hasket Derby, M.D.
The ophthalmoscope may be used with decided advantage in those cases in which the physician must give an opinion as to injuries of the eye, and especially as regards the question of their doing permanent damage. Are these injuries of so palpable a nature that the sclerotic and cornea are ruptured, and the aqueous and vitreous humors evacuated; or does a so-called traumatic cataract ensue a few hours after the injury, then the ophthalmoscope would certainly be of no avail. But cases arise in which, after a blow received on the eye or its neighborhood, a sudden partial or total loss of vision occurs; and in these cases an ophthalmoscopic examination is of great value in determining the nature of the injury. It may give a positive result, by detecting effusions of blood, retinal separation, <fcc.; or negative, by showing that no alterations or abnormities are to be observed in the eye itself, and thus proving that the injury in question has affected the brain. And, in this connection, the physician would further be secured from deception, when a person thus injured pretends that a loss of sight has resulted from the injury; or when a defect of vision had previously existed, and the discovery was made after and believed to be owing to the injury. For if, under such circumstances, the physician finds the traces of old disease, old exudations in the choroid, maceration of pigment, posterior staphyloma, <fec, his examination with the ophthalmoscope will place him in a position to deny most authoritatively any connection between the derangement of vision and the injury.
The advantage arising from the use of the ophthalmoscope under such circumstances might perhaps appear less great, owing to the fact that the number of these cases is relatively small. Much more frequent, however, arc the instances in which an ophthalmoscopic examination is indispensable to the physician who is called upon to give an opinion concerning the simulation of myopia or amaurosis by those drafted for military service.
Wellmarked short-sightedness has always been accounted a sufficient reason for release from military duty; and, as is well known, may be imitated by accustoming the eyes to the use of strong concave glasses. In spite of this, the existence of short-sightedness has generally been considered amply proved, when the person could read a short distance off with the glasses employed as tests. But who, from such external and functional symptoms, could form an opinion as to whether this was short-sightedness depending on a defect in the power of accommodation, on a derangement of the media of refraction, or on other anomalies in the interior of the bulb ? An examination with the ophthalmoscope can alone, up to a certain point, render us absolutely sure.
If we now, in a given case, have to determine whether the alleged short-sightedness is true or simulated, the following facts are to guide us (supposing always that the observer himself possesses a normal eye).
The suspicion that the myopia has been artificially produced by the use of too powerful concave glasses, would be further strengthened by the fact that the ordinary external evidences of short-sightedness are wanting in the eye in question, and that the result of the ophthalmoscopic examination does not harmonize with what here follows.
If, on examination of the eye with the mirror alone, the retinal vessels are seen as clearly and readily as in an entirely normal eye with the help of a convex lens (inverted image), a strong reason exists for acknowledging the existence of a real myopia.
A further reason lies in the fact, that, on examining the upright image, the observer is obliged to draw largely on his power of accommodation and to use strong concave glasses, in order to see the retina distinctly; for, the greater the degree of myopia in the observed eye, the greater accommodative effort and the stronger concave glasses are necessary on the part of the observer in order to clearly distinguish the details of the fundus of the eye. If the observer, having firmly impressed on his mind the appearances of a normal eye, examines a short-sighted eye (in the upright image), the surface that comes into view will appear less extensive; and, the greater the amount of short-sightedness, the nearer the image seems to approach his own eye. This image seems less illuminated, and less highly colored ; while, on the other hand, it is more magnified, its different details being less clearly defined. The size of the pupil being relatively the same, the eye of the observer is unable to take in the whole of the optic nerve at a glance, as it generally can in a normal eye and in the case of a moderately wide pupil. To obtain a distinct view of the fundus it is further necessary to employ concave glasses of a depth increasing with the degree of the short-sightedness, and to approach the eye of the observer nearer and nearer that of the observed.
In an over-sighted (hypermetropic) eye, on the contrary, a much larger surface comes into view; the image i3 formed at a much greater distance from the eye of the observer, is brighter and more highly colored, but much reduced in size; its details are more distinct, and the whole image better defined. In extreme over-sightedness, 'when the pupil is large, the observer takes in at a glance not only the optic nerve, but as much more of the fundus on either side; the whole effect being, in respect to size, similar to the real inverted image obtained by interposing a convex glass. Quite as remarkable is the difference in the choice of a corrective glass. The observer who is accustomed to examine the imago of a normal eye ■without the assistance of a lens (behind the mirror), is forced to use, for an over-sighted eye, a correspondingly strong convex corrective glass, or must supply its place by accommodating his own eye for the near. And, finally, his distance from the observed eye, during the examination, is greater, often considerable.
If individuals, liable to be drafted, simulate partial derangement of vision or complete amaurosis of an eye,* the ophthalmoscope is almost the only means we possess of deciding with certainty whether such affections really exist or are only simulated; inasmuch as ■we are unable, through external symptoms alone, to either affirm or deny their presence.
Strabismus of the affected eye, mydriasis, a smoky reflex from the bottom of the eye, immobility of the iris, are in fact symptoms that may point to a total loss of sight. But these aids to diagnosis fail in cases of amaurosis in which the retina is still slightly sensitive to light; or they may exist, entirely independent of amaurosis, in cases of paralysis of the third pair, or in idiopathic mydriasis. It is well known that the artificial mydriasis, produced by belladonna, is a favorite method of deception.
The pupil has almost always been found regular, and of normal or nearly normal mobility in cases of amaurosis that commence with hemiopia, or almost total loss of vision, or that depend on detachment of the retina, effusion of blood in the neighborhood of the macula lutca, small scattered retinal apoplexies, or serous effusions. Who, however, could diagnosticate these troubles with certainty •without the aid of the ophthalmoscope ?
In many other cases the pupil retains its size and mobility, although amaurosis really exists, caused, it may be, by extensive atrophy of the optic nerve, or by a disease of its substance. In such cases the ophthalmoscope proves that the retina or the optic nerve is incapable of performing its functions, by showing concavity of the papilla, a mother-of-pearl-like color of its surface, obliteration or atrophy of the retinal vessels, &c.
* In cases where there was reason to suspect that the amaurosis was simulated, I have seen von Graefe employ the following test. A prism, with the base upwards or downwards, is held before the sound eye, and the patient is told to regard some such object as a pencil or ruler held horizontally some Inches off. If he is asked how many objects he sees, and replies two, one of the images must be seen by the eye which haa been stated to be blind. Cover this eye, and one of the images disappears.—U. D.
Whether the ophthalmoscope will ever aid the medical expert in forming a just opinion of mental disease, must be determined at a later period; inasmuch as the data in our possession arc yet too deficient. We venture, however, to express a general hope, that what we have advanced may show that the ophthalmoscope will be no inconsiderable ally to the medical expert in such cases as those stated; as well as that it merits, as such, a more general appreciation than it has yet received.
See in this collection: The Ophthalmoscope: Its varieties and its use (1864), by Adolf Zander, M.D., U. S. Army Hospital Department issue
Citations of the use of an ophthalmoscope in the Medical and Surgical History of the Civil War:
CASE.--Private Francis H. Kirker, Co. E, 160th Pennsylvania Volunteers, aged 20 years, was wounded at Bull Run, August 29th, 1862, by a small rifle ball, which entered on the left side of the nose, at the junction of the nasal bore with its cartilage, and, passing obliquely across and slightly backward, emerged one inch above the angle of the lower jaw, on a vertical line with the external meatus, tearing away a part of the lobe of the car. He was conveyed to Washington, entering Georgetown College Hospital on September 6th; on February 4th, 1863, he was transferred to Broad and Cherry Streets Hospital. He stated that the wound bled freely at intervals for several days, and that several small pieces of bone had been removed. On admission the wound of entrance and exit had healed. There was partial paralysis of the muscles of the right cheek and some deafness on that side from injury to the nerves. There was slight ptosis of upper lid and partial loss of vision in the right eye. The ophthalmoscope revealed a congested stale of the retina. He was discharged from service on March 19th, 1863, and pensioned. Pension Examiner A. R. McClure reports, April 6th, 1867, that there is necrosis of the superior maxilla, and that the pensioner is unable to perform any labor without causing pain.
CASE.--Private John McNalley, Co. H, 81st Pennsylvania, aged 23 years, was wounded at Fredericksburg, Virginia, December 13th, 1862, by a round musket ball, which entered on the left side of the nose, on a line with the internal canthus of eye, fractured the nasal bone, and, passing obliquely across, fractured the right superior maxillary bone and penetrated the cheek opposite the second molar tooth, in its course giving rise to a fistula lachrymalis on the right side. He was at once admitted to the hospital of the 1st division, Second Corps, and, on December 20th, sent to Catharine Street Hospital, Philadelphia, whence he was transferred, on February 2d, 1863, to Broad and Cherry Streets Hospital. When admitted, both wounds had closed, with little depression at the wound of entrance. The right cheek was considerably swollen. The fistula had almost healed, and closed a few days after admission. The patient stated that the wounds bled very freely, at intervals, for the first twelve hours, and that several small pieces of bone were removed on admission to Catharine Street Hospital. He complained of partial loss of vision. The ball of the eye was slightly atrophied, and its pupil considerably larger than the other, and irregular and slow in action. An examination with the ophthalmoscope showed the vessels of the retina to be in a congested condition. He was discharged from service on March 31st, 1863. He is not a pensioner.
WOUNDS OF THE NOSE.--The few cases reported in detail of wounds of the nasal region were those in which some attempt at reparation or restoration had been made. On page 322 several cases of sabre cuts of the nose are enumerated, and illustrations of gunshot wounds of the nose are given on page 358. In incised and lacerated wounds of
(*) The ophthalmoscope was not used in the field hospitals of the Union or Southern armies, so far as can be learned. But in the recent Prussian-French War, we learn from Dr. L. VASLIN'S Études sur les Plaies par Armes ŕ Feu, Paris, 1872, p. 203, et seq., that Dr. Galegowski was able to determine the existence of subchoroidean effusions and of lacerations of the choroid by contrecoup. These refinements, like that of detecting a cherry-stone in the œsophagus by percussion, are not of practical utility.
The number of recorded cases of wounds of nerves of special sense caused by missiles is small. The following case of shot wound of the neck is interesting, and is regarded as a case of injury of the sympathetic nerve:(1)
CASE 1077.--Edward Mooney, aged 24 years, enlisted July, 1861, Co. C, 110th Pennsylvania. He was perfectly healthy before and after enlisting, until wounded at Chancellorsville, May 3, 1863. He was standing erect and was looking toward the left side, when a ball entered his right neck one and a half inches behind the ramus of the jaw, at the anterior edge of the sterno-cleido mastoid muscle. The ball passed across the neck, rising a little, and emerged immediately below and a half inch in front of the angle of the jaw on the left side. He fell senseless, and, judging from the movements of his regiment, may have so remained during half an hour. On awaking, he found his mouth full of clotted blood, which he pulled out. The bleeding did not continue. After a short rest he was able to walk nearly three miles to the rear, where his wounds were dressed with cold water. On his way he discovered that his speech had become hoarse, difficult, and painful, and that deglutition gave rise
(1) MITCHELL, MOREHOUSE, and KEEN (loc. cit., p. 44) are of the opinion that this is a "case of injury of the sympathetic nerve, and if so, that it is the only one on record."
to great uneasiness and to burning pains. He says the sensation of pain was felt as though behind the pomum adami. After five days of great suffering and utter inability to swallow, he obtained some relief, but, for a month or more, was forced to swallow a mouthful of water after every mouthful of solid food. The power to swallow gradually improved, and is now as good as it ever was. A week after he was wounded he became able to articulate without pain, although still hoarsely. This difficulty also lessened by small degrees. At present, July, 1863, his voice is still a little hoarse. During his recovery, which was rapid, the wounds healing within six weeks, he had a good deal of pain in the back of the neck. He says that he had headache whenever, after the injury, He attempted to walk far or exert himself; but he describes the headache as chiefly behind the ear and in the back of the head, with some frontal pain. About one month after he was hurt a comrade noticed the peculiar appearance of his right eye and
called his attention to it. A little later it began to be troublesome in bright lights, and has remained so ever since, with of late some change for the better. July 15, 1863: The pupil of the right eye is very small, that of the left eye unusually large. There is slight but very distinct ptosis of the right eye, and its outer angle appears as though it were dropped a little lower than the inner angle. The ball of the right eye looks smaller than that of the left. These appearances existed whether the eye was opened or closed, and gave to that organ the look of being tilted out of the usual position. The conjunctiva of the right eye is somewhat redder than that of the left, and the pupil of the right eye is a little deformed, oval rather than round. In a dark place, or in half-lights, the difference in the pupils was best seen; but in very bright light, as sunlight, the two pupils became nearly of equal size. The left eye waters a good deal, but has the better vision, the right eye having become myopic. In sunlight he sees well at first, but, after a lime, observes red flashes of light in the right eye, and finally, after long exposure, sees the same appearances with the left eye also. He complains a good deal of frontal headache at present, and thinks that since the injury his memory has been failing, although of late it has improved. Has lost flesh and strength since he was wounded. About the 30th of August the patient rode to the office of Dr. Dyer, who examined his eyes with the ophthalmoscope, but found no abnormal retinal appearances.
Mooney walked from Dr. Dyer's office to the hospital, an unusual exertion, as he was weak, and avoided exercise on account of the headache it caused. An orderly who was with him on this occasion remarked to one of the hospital staff upon the singular appearance which his face presented after walking in the heat. It became distinctly flushed on the right side only, and pale on the left. This fact was afterward observed anew by one of us. The patient had used exercise and had just come in. The right half of the face was very red. The flush extended to the middle line, but was less definite as to its limit on the chin and lips than above these points. He complained of pain over the right eye and of red flashes in that organ. A careful thermometric examination, made during repose, showed no difference in the heat of the two sides within the mouth or the ear. We regret that it did not occur to us to repeat this when the face was flushed by exertion. Under a tonic course of treatment he gained ground rapidly. The eyes became less sensitive, the pupils more nearly alike, the line of the lid straighter. He had several attacks of fainting after exposure to the sun, and these, with occasional diarrhœa, retarded l,is recovery. He was at last able to return to duty, and left for that purpose in October, 1863, nearly all of his peculiar symptoms having disappeared and his general health having been altogether recovered
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