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Clinical diagnosis, case examination and the analysis of symptoms online

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fering with reading) of atropine, which may be reserved for the

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treatment of iritis after it has been duly diagnosed. The adhesions
of iritis should not be confounded with the threads of a congenitally
persisting pupillary membrane ; the latter do not start from the mar-
gin of the pupil, but from the anterior surface of the iris.

Mydriasis and Myosis. — Where uni- or bi-lateral myosis is pres-
ent, one must exclude : The use of a myotic, some disease of the
nervous system (tabes, etc.), paralysis of the cervical sympathetic
[disease in the cervical region (enlarged glands) or in the medias-
tinum should be looked for] with slight ptosis, and intoxication by
opium, morphine, etc.

Where there is mydriasis, one must exclude: The use of a
mydriatic (sometimes surreptitious), oculomotor paralysis, paral-
ysis of the iris and ciliary muscle (diphtheria, syphilis, etc.), cere-
brospinal diseases, lesions of the orbit, and certain intoxications

Fig. 677. — Synechiae in iritis.

(belladonna, spoiled meat, etc.). The physician should think of
incipient general paralysis where the pupils are markedly unequal
and insensitive to light.

An indispensable proceeding is to ascertain the mobility or
IMMOBILITY of the pupil to light and accommodation, and then to
test the consensual reflex.

The Argyll-Robertson pupil {lack of response to light coupled
with response to fixation and convergence) is a sign of nervous
syphilis (tabes, general paralysis, etc.), hut very many syphilitics do
not show it.

Finally, there are cases in which :

1. When light is thrown into one eye, its pupil fails to contract,
but the opposite pupil responds, through the consensual reflex; the
condition then present is a paralytic mydriasis with peripheral in-
volvement of the ciliary and pupillary nerves due, e.g., to syphilis.
If light is thrown in the opposite eye, the pupil responds, but the
pupil of the first eye remains motionless.

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2. Light is thrown in a single eye and both pupils remain
motionless. If now light is thrown in the other eye alone, both
pupils respond. This condition is the result of a complete blindness
of the first eye due to local (peripheral) disease of the retina and
optic nerve.

In so-called "hysteric" blindness and in blindness of cortical
origin the reflexes are retained, as a general rule.

Pupillary Area. — ^The pupillary opening overlies the anterior
surface of the lens. The observer should ascertain whether there
is not some exudate, with partial or total occlusion of the pupil
(Fig. 678) and pigment deposits (former iritis).

Fig. 678. - Complete, urn- Fig. 679.— Opacities in the lens (partial

hilicoid occlusion of the cataract), contrasting as black spots in the

Qupil. pupil illuminated with the ophthalmoscopic


The condition of the lens should be investigated — ^whether it is
clear or opaque (cataract, partial or total, acquired or congenital,
and of many possible varieties).

The observation of a grayish hue of the pupil, very commonly
present in old persons, yet unaccompanied by opacity, should not
lead to the conclusion that cataract exists. The pupil does not seem
to be of a clear black when looked at by daylight; yet the lens is
found to be clear on closer examination.

Aside from the cases in which there is advanced, intense, and
unquestionable opacity, as seen on lateral illumination with a lamp
and by use of the hand lens, the physician should not commit him-
self until after he has illuminated the interior of the eye with the
ophthalmoscopic mirror, which, after dilatation of the pupil with 2
per cent, cocaine (and waiting 20 minutes), will reveal, contrasting
in black against the red background of the eye, the slightest lens

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opacities (Fig. 679) of incipient cataract — ^not yet sufficiently
marked to prevent reading and writing.

Without being trained in examining the retina and optic nerve,
the practitioner may employ for this purpose the mirror and any
available source of light, the patient being meanwhile shaded by a
screen (Fig. 664).

The patient should be requested to move his eye about while
the light is being directed at him with the mirror; very often the
pupillary area will appear filled with moving objects, floating
particles, detached retina bobbing about a dislocated and mov-
able lens, crystals, etc.

Som« eyes that prove unilluminable, the pupil continuing to
exhibit an ebony black appearance, are the seat of tumor, hemor-
rhage, black cataract, etc.

Limiinous Pupil. — Where, in a child, the pupil presents a
glowing, illuminated (cat's eye) appearance, there is frequently
present a glioma of the retina, a tumor which destroys the eye
and is generally fated in spite of enucleation.

B. Disorders Unattended with External Lesions, thoagh some-
times Attended with Internal Lesions, Visible only by Endoscopy.
— Pain. — Pain in or near the eye, without any visible pathologic
condition, must be differentiated from headache and migraine —
though these are often present in addition.

After having carefully investigated (by palpation, etc.) whether
the pain is not the result of some inflammatory condition which is
not yet superficially manifest (beginning stye, keratitis, iritis^ over-
looked foreign body beneath the lid or in the cornea) or of increased
intraocular tension {glaucoma), the physician should proceed to
eliminate simple migraine and especially ophthalmic migraine with
scintillating scotoma and images of luminous bands, sometimes with
transient hemianopia.

He should next think of facial neuralgia (making pressure over
the points of emergence of the trifacial branches about the orbit)
and tic douloureux ; a prospective eruption {herpes zoster) should
be kept in mind. Neurasthenic and hypochondriac patients some-
times experience for years paroxysms of ocular neuralgia (delayed
recurrent keratalgia) in eyes that have previously been subjected

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to some form of traumatism, often of trifling degree (erosion from
contact with the finger nail or with a house plant, etc.). Very care-
ful examination is necessary in such cases.

Pain after Close Work. — Refractive disorders {astigmatism,
hyperopia, presbyopia, and sometimes marked myopia) should be
excluded. Headache of this type, which is very common, demands
the wearing of glasses, in conjunction with general treatment of
coexisting disturbances (neurosis, anemia, intoxication, etc.).
Latent strabismus and insufficiency of and excessive strain in con-
vergence, as well as slight forms of diplopia, may likewise be the
cause of the pain.

Miscellaneous Visual Disturbances. — ^Impaired Vision on One
or Both Sides. — The patient complains of blurred vision with
one or both eyes ; or he may be unable to see anything, not even
light ; yet the eyes seem normal.

Where the patient is still able to see a few objects he should be
placed 5 meters away from the test card (Fig. 650), with the latter
well illuminated and the patient's back to the light, and his ability
to distinguish some of the letters ascertained.

The observer may hold the perforated disc (stenopeic open-
ing) in front of each eye in turn, the other eye being meanwhile
covered; or a card with a pinhole may be substituted. If vision
is improved thereby, some error of refraction (myopia, hyper-
opia, or astigmatism) is present, with or without disease of the
fundus, and the patient will derive more or less benefit from the
use of concave, convex, or cylindric lenses, which the practi-
tioner may try to select if they are available, but accurate pre-
scription of which requires the intervention of the eye specialist.

Where, on the other hand, the stenopeic opening reduces
vision, some disease of the fundus exists, or an amblyopia due to
a post-ocular cerebral or neuropathic disorder.

Here again an examination by the specialist is necessary to
settle the question and determine which, among the numerous
possible disorders, has been the cause of the blindness or visual
impairment in one or both eyes.

Nyctalopia. — Improvement of vision as the light of day dimin-
ishes, occurring in subjects who are dazzled in broad daylight (alco-

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holic amblyopia, some cases of cataract, certain diseases of the fun-
dus, etc.).

Hesperanopia. — This term, proposed by the writer, and more
accurate than the old term hemeralopia (which is etymologic-
ally nonsensical), refers to a sudden reduction of vision as the
light of day declines. The subject then becomes nearly blind. There
are cases of transitory hesperanopijsi (in overworked or poisoned in-
dividuals and disorders of the liver and kidneys) and cases of per-
manent hesperanopia, already present in childhood (retinitis pig-
mentosa chronica). It is essential to have the eye-grounds ex-
amined in such cases, particularly where the subject is a child who
seems helpless and has difficulty in getting about towards evening
(crepuscular amblyopia).

Phosphenes. — This symptom is an evidence of retinal irrita-
tion, which is sometimes of serious degree in myopic subjects; it
may be a forerunner of detachment of the retina. It is also
present in a variety of affections of the retina and choroid. There
are even blind subjects who continue to be inconvenienced by
luminous visions. The condition should not be confounded with
the paroxysm of ophthalmic migraine with scintillating scotoma.

Muscae volitantes. — These are most commonly present in
myopia, in overworked individuals, and in neurasthenia. They
may sometimes be present for years, or even indefinitely, irre-
spective of normal vision. Examination of the fundus will show
whether the lens, vitreous body, and internal membranes remain
in a normal condition and will permit of making a more accurate

Disturbances of Color Vision. — These may be temporary, as in
alcoholic and tobacco amblyopia, affections of the retina and choroid,
diabetes, etc., or congenital, as in Daltonism (color blindness; to
be excluded by special tests).

Colored Vision. — Erythropsia (red vision) in neuroses, after
cataract extraction, etc. Various phenomena of colored audition.

Iridescent Vision. — When a patient sees the colors of the rain-
bow when looking at an open flame (candle), the intraocular ten-
sion should always be tested, this symptom being often an accom-
paniment of glaucoma.

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Photophobia. — Where, in the presence of photophobia, the cor-
nea and iris are both found normal, a disorder of the retina or of
the lens (cataract) is to be feared. Some neurasthenics, however,
are subject to paroxysms of photophobia although vision and the
eye are and remain normal.

Vertigo. — One should first of all determine whether the patient
is not suffering from double vision; the writer's advice has fre-
quently been sought on account of vertigo attributed to the stomach,
previously treated by diet and antidyspeptic remedies, where the
actual cause was paralysb of a nerve or muscle of the eye.

JVhen a patient complains of vertigo, the physician should close
one of the patient's eyes, which will cause the vertigo to disappear
at once if some form of ocular paralysis is responsible.

Vertigo also occurs in connection with deep-seated disorders of
the eye, with unsuitable glasses, with overstrong lenses, and with
general disorders.

Diplopia and Polyopia. — One should at once ascertain, by
having the patient close one eye, whether he is not seeing double
with a single eye; in some neuroses, indeed, and especially in in-
cipient cataract, there occurs a monocular diplopia or polyopia, the
patient seeing, e.g., seven or eight gas jets where there is but one,
with one of his eyes.

Where the subject has to use both eyes to see double, paralysis
or contracture of some muscle exists, or there may be a mechanical
deviation of the eye on account of orbital disease (tumor or

A person suffering with diplopia generally shows a faulty posi-
tion of the eye, due to loss of power of one muscle and attraction
of the eye by the normally antagonistic muscle. Ordinary strabis-
mus, or squint, does not cause diplopia, and in spite of the faulty
position, each eye, when examined independently, is capable of
rotating in all directions; paralysis is not present under these cir-
cumstances. Faulty position and diplopia are the result of the
physiologic peculiarities of the nerves and muscles of the eye (Fig.
680). In paresis with but slight muscular weakness, however, or
where a single muscle, such as the inferior oblique or inferior rec-
tus, is weak, the faulty position is almost imperceptible, and the
localizing diagnosis is based on the diplopia alone.

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It is well to place a red glass before an eye in order to find out
with which eye the fed image is seen (crossed diplopia— or hotnony-
mous when on the same side), and to hold a lighted candle 2 meters
in front of the patient.

Objective and Subjective Signs of Paralyses. — Complete
paralysis of the oculomotor nerve (3d pair) which supplies both
the superior, inferior, and internal recti, the inferior oblique, and
the constrictor of the pupil and levator palpebral superioris,
results in :

Ptosis, mydriasis, paralysis of accommodation {reading being
impossible except with a strong convex lens), divergent strabismus,
and horizontal crossed diplopia, i.e., a condition in which the
false image is projected to the side opposite that of the paralyzed

] Sup. rectus
Sup. oblique

Int. recttiil^. ^' ■■^iw Ext. rectni

Inf. oblique

Inf. rectus

Fig. 680.— Muscles of the Ufi eye, with their respective distances
from the cornea and functions.

Internal rectus, adductor ; external rectus, abductor ; inferior rec-
tus, depressor, inward rotator, and adductor; superior rectus, elevator,
inward rotator, and adductor; superior oblique, with its pulley, depres-
sor, inward rotator, and abductor; inferior obuque, elevator, outward
rotator, and abductcM*.

Paraljrsis of the abducens (6th pair), which supplies the ex-
ternal rectus or abductor muscle, results in convergent strabismus,
with the false image on the same side (horizontal homonymous

Paralysis of the patfaeticus (4th pair), which supplies the
superior obUque or inward rotator, depressor, and abductor
muscle, results in vertical homonymous diplopia, with deviation
upward and toward the unaffected side.

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Lastly, there occur instances of independent paralysis of a
nerve-branch supplying but one of the muscles innervated by the
oculomotor, either in one eye or in both, and in which determina-
tion of the exact type of involvement is a complex matter. There
being no distinct defect of position, the diagn'osis is gradually elab-
orated through analysis of the existing diplopia. By moving the
candle about before the eyes, at first horizontally and then vertically,
the head meanwhile being kept motionless, a progressive widening
of the distance between the images is noted (in the direction of the
paralyzed muscle).

Puech and Fromaget clearly summarize the significance of dip-
lopia in the table reproduced below. Examination shows, indeed :

1. In //i^ direction in which the function. o/ the affected muscle
is normally exerted:

False image, increase of the diplopia and progressive increase
of the distance between the images, limitation of movement, an
altered direction, of the face and the inclination of the head,

2. In the direction opposite to the physiologic function of
the affected muscle:

Faulty position of the eye and diminution of the diplopia.
Later, after having precisely determined whether the diplopia is
of the HOMONYMOUS or CROSSED variety, the following:

A. — Homonjrmous Diplopia. |


Affected Eye.

1. In the horizontal direc-


The distance between the

tion :


images steadily increases
on the paralyzed side.

f above:


The upper image corre-

2. In the vertical 1


sponds to the affected



I below:


The lower image corre-


sponds to the affected eye.


—Crossed Dip


1. In the horizontal direc-


The distance between the



images increases in the
direction of the motor
action of the paralyzed
muscle, and, hence toward
the normal eye.

2. In the vertical f ^^^^^•
direction: ( below:


The upper image is that of
the affected eye.


The lower image is that of


the affected eye.

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The general practitioner scarcely needs to undertake such in-
vestigations : He may Hmit himself to the immediate diagnosis of
the more easily recognizable forms of paralysis with obvious devia-
tion and muscular weakness — those involving the oculomotor and
abducens — and to blind-folding one eye to abolish diplopia and ver-
tigo ; in any kind of paralysis he should then, without further ado,
proceed with an investigation of the cause and with causal

A consultation with the specialfst later will determine the fur-
ther details of the condition, and will also, if the occasion exists,
differentiate paralysis from contracture, which is much less

Ophthalmoplegia. — Diffuse forms of paralysis, congenital or
acquired, inherited and familial, oi the neri'es and muscles of the
eye. "

Where all the centers (progressive nuclear ophthalmoplegia)
of the motor nerves to the eye fail\in succession, the patient,
with his drooped lids, with difficulty raised by wrinkling the
forehead, and his eyeballs fixed in their orbits, is said to present
the ophthalmoplegic Hutchinson's facies.

Ophthalmoplegic migraine (with sudden and recurrent failure
of all the muscles) is frequently a benign condition, from which
recovery occurs withifi a fe%v days-; in some instances, however, it
is attended with dangerous intracranial disturbances, infectious or

Paralysis of Associated Movements. — Cases occur in which,
in both eyes, whereas other movements of the eyes can still be made,
there exists a paralysis of the associated movements, vertical
(paralysis of ele7'ation or of depression of the eyeball) or lateral,
owing to disease of the association fibers connecting the centers and
convolutions. An ophthalmo-neurologic consultation should be held,
as in any other form of paralysis, to determine the cause and seat
of the lesion. A complete examination of the patient should be
made, with determination of any co-existing syndromes, such as
that of Millard-Gubler (pontine lesion with paralysis of the ab-
ducens and. facial on the same side and hemiplegia on the opposite
side) and that of Weber (peduncular lesion with oculomotor paral-

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ysis and opposite paralyses of the face and extremities) — syndromes
to be referred to again later in this work.

Abnormalities of the Visual Field. — (a) Peripheral con-
traction. — ^This may be concentric or excentric and monocular or

In glaucoma, the patient presents, if the disease is of long
standing, an excentric and internal contraction of the visual field.

Fig. 681. — Course of the optic nerve-paths (with their direct and
crossed fasciculi) from the eye to the brain; c, c', cuneus; a, b, decussa-
tion of the optic tracts (chiasm).

He is unable to see an object placed in front of his eye, and sees it
only when it is moved toward the temporal region.

An extreme degree of concentric contraction (some fieMs
are only of the size of a dime) may be observed in retinitis
pigmentosa, in optic atrophy — e.g., in tabes — and in various in-
stances of amblyopia unattended with ophthalmoscopic lesions
(hystero-pithiatism, etc.).

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(ft) Bilateral contraction with obscuration of one-half
OF THE VISUAL FIELD: Hemianopia.^ — In hemianopia there is
complete normalcy of the eye-grounds and inspection of Fig. 681
will show what the homonymous or homolateral (on the same side)
and the heteronymous varieties of hemianopia consist of.

Central vision is retained and the patient is able to read.

Where hemianopia is suspected on account of the position of
the patient, who turns his head in such a manner as to direct toward
external objects that portion of the eye which is still functionally
available, and ot\ account of the absence of lateral vision of per-
sons, o£ dishes on the table (the patient sees his glass, but nothing

Fig. 682. — Right homonymous hemianopia the result of disease of the
left optic tract at d (Fig. 681) or of its cerebral origin, c.

which adjoins it), or of the word following that which he is read-
ing, it is easy to localize the intracranial situation of the lesion
responsible. This can be done by copying the accompanying dia-
gram and by interrupting the optic fibers, either between the brain
and the optic chiasm, at d, for example, showing that there is
homolateral homonjrmous hemianopia, right- or left- sided (Fig.
682), or in the region of the chiasm, at the crossed or non-crossed
fasciculi, heteronymous or heterolateral, binasal or bitemporal
hemianopia (Fig. 683). There also occur complicated cases, with
patch-like defects, atypical forms, double hemianopia, etc.

1 This condition has often been termed hemio^io or hemianopsia; the
writer prefers to substitute for these the term hemianopia, which expresses
the gap in the field of vision and conforms in its termination to the cus-
tomary, general nomenclature, as in diplopia, hy per mtir a pia, nyctalopia.

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For practical purposes, homonymous hemianopia (Fig. 682) is
nearly always the result of a cortical lesion in the occipital region
and cuneus (softening, syphilitic arteritis, hemorrhage, etc.). It is
generally accompanied by apoplectic strokes, hemiplegia, aphasia, or

Fig. 683. — Bi-temporal heteronymous hemianopia (in acromegaly) , due
to pressure on the optic chiasm (crossed fasciculi).

psychic blindness. Consultation with the ophthalmologist and the
neurologist is quite indispensable.

Cro.y.y^rf hemianopia of the bitemporal type (Fig. 683) is fre-
quently the result of acromegaly, the enlarged pituitary body

Fig. 684. — Central scotoma in an alcoholic subject.

exerting pressure on the optic chiasm (a, b) ; whence a characteris-
tic form of visual field (see Eye conditions met with in general

(c) ScoTOMATA. — The patient complains of spots or gaps in the
CENTRAL or PARACENTRAL PORTIONS of the visual field, and not at

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its periphery. Central scotomata (Fig. 684) indicate defective func-
tioning of the macular region of the retina and are the most annoy-
ing to the patient. In some cases they are due to disorders of the
fundus, in others to special disturbances, among others alcoholic
and tobacco areatment (tarsorrhaphy, etc.).

(&) Adrenal glands, — Asthenia of the eyes, etc.

(c) Pituitary body. — Exophthalmus, nystagmus, and paralyses
of ocular muscles in conjunction with the acromegalic facies. Pro-
gressive optic atrophy.

The fields of vision should always be tested — bitemporal hemi-
anopia with loss of the two outer halves of the visual fields on
account of pressure* on the two crossed fasciculi of the optic nerve
at the optic chiasm (see Fig. 683).

(rf) Testicles and ovaries. — Effects on the eyes may be of the
asthenic, hypersthenic, or toxic types, — ^to be determined with a
varying degree of probability in the individual case.

Diseases of the Reproductive System. — (a) Male. — Gonor-
rheal ophthalmia, direct or metastatic, with scleritis, iritis, optic
neuritis, or dacryoadenitis.

(fc) Female. — Iridochoroiditis and deep-seated infections of
metritic origin, following the menopause, etc. Menstrual asthen-
opia. Optic atrophy following profuse metrorrhagia.

Retinal hemorrhages and neuroretinitis during pregnancy, the
nephritis of pregnancy (sometimes necessitating induction of labor),
or lactation. Pulsating exophthalmus. Metastatic intraocular sup-

Online LibraryAlfred MartinetClinical diagnosis, case examination and the analysis of symptoms → online text (page 18 of 50)