THE RELATIONSHIP 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."
<ms_p3v2_739>
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
