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Methods of Diagnosis
OPHTHALMIC YEAR BOOK M E T H O D S O F DIAGNOSIS. EDWARD JACKSON, M.
D.
DENVER.
This section reviews the literature of 1918, on ophthalmic diagnosis in general. Papers referring to the diagnosis of any particular disease will be found mentioned under the heading of that disease or the class to which it belongs. BIBLIOGRAPHY.
Abbott, W. A. Records of Visual Acuity. Amer. Jour. Ophth., v. 1, p. 71. ATTolter, A. Ophthalmoscopic Examination with Red-free Light. Graefe's Arch. f. Ophth., v. 94, Sept., 1917. Abst. Brit. Jour. Ophth., v. 2, p. 248. A,ex nder " > G - F- Recording Visual Acuity. U 111.) Brit. Jour. Ophth., v. 2, p. 277. . t E" M- Malingering from Standpoint «f Eye. New York State Jour. Med., v. 18, P. 487. Bachstez, E. Estimation of "Sellaer" Length m Roentgen Image. (1 ill.) Zeit. f. Augenh., v. 36, p. 62. Beaumont, w . M. Malingering in Relation to the Eye. London: W. Heinemann, 1917. Beck, E. G., and Smith, E. L. Stereoscopic Hoentgenograms. Amer. Jour. Roent, v. 6. P. 369. Bernstein, E. J. Diagnosis of Cerebellar Abscess. Ann. Otol., Rhin. and Laryngol., v. 26, p. 804. Bourdler, F. Determination of Visual AcuIty. Arch. d'Opht., v. 36, p. 294. 7J.""' H l D> M e thods of Diagnosis in Ophthalmology. New Orleans Med. and Surg. Jour., v. 71, p. 145. Chapman, V. A. Records of Visual Acuity. Amer. Jour. Ophth., v. 1, p. 288. cl8 PP. C. A. Tuberculin in Diagnosis of Eye Lesions. Arch, of Diag., v. 10, p. 399. cp '«P, W. H. Malingering. (Dls.) Colo. Ophth. Soc, Jan., 1918. Amer. Jour. Ophth., v. 1, p. 344. Du nn, P. Detection of Simulated Blindness. .Med. Press, v. 105, pp. 317 and 334. E 'llot, R. H. A Scotometer. Brit. Jour, of Ophth., v. 2, p. 168. E Ppenstein, A. Study of Field of Vision and Blind Spot with Prism Apparatus. Klin. Monatsbl. f. Augenh., v. 60, p. 620. Exell, H. Detection of Feigned Blindness. Jour. Tenn. State Med. Assn., v. 11, p. 150. Fellows, C. G. Malingering of Eye. Jour. Amer. Inst. Homeop., v. 11, p. 424. Fleischer, B, Campimetry after Bjerrum. Klin. Monatsbl. f. Augenh., v. 60, p. 265. G'elchen, A. Theory of Acuteness of Vision. (17 ill.) Graefe's Arch. f. Ophth., T - 93, p. 303. Gonzalez, J. Frequent Errors in Ophthalmic Practice. Arch, de Oft., v. 18, p. 196.
Gullstrand, A. Macula in Red^free Light. Klin. Monatsbl. f. Augenh., v. 60, p. 289. Gumblner, A. Defective Vision, Pathologic Significance. New York Med. Jour., v. 107, p. 1214. Hudson, A. C. Reversible Screen Stereoscope. (6 ill.) Brit. Jour. Ophth., v. 2, p. 427. Icard, 3. Signs of Death. Jour. Amer. Med. Assn., v. 70, p. 1964. Jellett, J. W. H. Detection of Simulated Blindness. Med. Press, May 29, p. 413. Klauber. Simulation and Aggravation of Central Scotoma. Wien. kl. Woch., 1917, p. 1170. Abst. Klin. M. f. Augenh., v. 60, p. 405. Kleljn, A. de, and Stenvers, H. W. Localization of Fracture of Optic Foramen with Radiography. (2 ill., 2 pi.) Graefe's Arch. f. Ophth., v. 91, p. 431. Koeppe, L. Observations with Nernst Lamp and Oorneal Microscope. (Bibl.) Graefe's Arch. f. Ophth., v. 95, p. 282; v. 97, p. 1. Koyanagl. An Anguloscope (Modified Orthoscope). (2 ill.) Nippon Gank. Zasshi, Oct., 1917. Lagrange, F. Atlas of War Ophthalmoscopy. Paris, Masson et Cie. Amer. Jour. Ophth., v. 1, p. 613. Lecha-Marzo, A. Tear Sign of Death. Abst. Jour. A. M. A., v. 71, p. 1009. Lloyd, R. I. Perimetry and Campimetry. Jour. Amer. Inst. Homeop., v. 10, p. 1284. Masuda. Change in Eye Grounds in Wassermann Reaction. Nippon Gank. Zasshi, Oct., 1917. Morax, V. Atypical Subacute Glaucoma. Ann. d'Oculist, v. 155, p. 100. Amer. Jour. Ophth., v. 1, p. 736. Moxon, F. H. Illuminated Test Types for Estimating Light Sense and Night Blindness. Roy. Soc. Med., Sec. on Ophth., June 12. Lancet, June 22, 1918, p. 874. Parker, W. R. Examination of Malingerers. Med. War Manual, No. 3. Philadelphia, Lea and Feblger. Peter, L. C. Artificial Daylight Illumination for Perimetric Study and General Office Use. Amer. Jour. Ophth., v. 1, p. 189. Plchler, A. Simulated Contraction of Field. Graefe's Arch. f. Ophth., v. 94, p. 227. Rasquin, E. Determination and Evaluation of Visual Acuity in Military Service. (7 ill., Bibl.) Ann. d'Ocul., v. 155, p. 117.
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METHODS OP DIAGNOSIS
Report of Committee on Standardization of Illumination of Test-Cards and Perimeters. Amer. Ophth. Soc, v. 15, p. 324. Ring, Q. O. Variable Findings in Ocular X-ray Localization. (Dis.) Amer. Jour. Ophth., v. 1, p. 506. Robertson, C. M. Examination of Men Entering Aviation Service. Jour. Amer. Med. Assn., v. 71, p. 813. Roelofs, C. O. Tests for Visual Acuity. Nederl. Tijdsc'hr. v. Geneesk, 1917, p. 836. The Minimum Separabile and the Minimum Visible. Abet. Klin. M. f. Augenh., v. 60, p.- 655. RBnne, H . Anamnesis with Eye Disease. Hospltalstldende, v. 61, p. 403. Abst. Jour. Amer. Med. Assn., v. 70, p. 1987. 8alzer. Roentgen Rays in Ophthalmology. Abst. K. M. f. Augenh., v. 60, p. 831. 8alzman, M. Ophtbalmoscopy of Anterior Chamber. Zeit. f. Ophth., v. 34, p. 160. Schwarz. Exophthalmometer. Munch, med. Woch., 1917, p. 1414. Abst. Klin. M. f. Augenh., v. 60, p. 404. Snellen. Visual Acuity as Gage for Retinal Function. Nederl. Tijdsch. v. Geneesk, July 20, 1918, p. 240. Standards of Vision for Recruits, Ophth. Soc, United Kingdom, May 2, 1918. Abst. Lancet, May 11, p. 676. Stargardt. Simple Portable Adaptometer. Zeit. f. Augenh., v. 39, pt. 3. Abst. Klin. M. f. Augenh., v. 60, p. 830. Stenvers, H. W. Roentgenologic Remarks on Work of van der Hoeve and de Kleijn (5 ill.) Graefe's Arch. f. Ophth., v. 95, p. 95. Terrion, F. Factitious Diplopia. Paris Med., v. 8, p. 462. Abst. Jour. A. M. A., v. 71, p. 859.
Detection of False Diplopia. Arch. d'Opht., v. 36, p. 45. Trantas. Detection of Unilateral Blindness. Abstract in Jour. Amer. Med. Assn., v. 71, p. 17. Ophthalmoscopy of the Corneo-iridic Angle. (5 ill.) Arch. d'Opht., v. 36, p. 257. Urlbe-Troncoso, M. Wider Use of the Tonmeter. Amer. Jour. Ophth., v. 1, p. 799. Vogt, A. Color of Macula. Klin. Monatsbl. f. Augenh., v. 60, p. 449. Illumination of Eye ground with Light Devoid of Red Rays. Ann. d'Ocul., v. 155, p. 58. Vertical Linear Pigmentation Observed in Retina of Young in Red-free Light. (1 col. pi.) Klin. M. f. Augenh., v. 60, p. 47. Von der Heydt, R. Corneal Loupe. (1 ill.) Amer. Jour. Ophth., v. 1, p. 339. Walker, C. B. Quantitative Perimetry. (9 Fig., 3 pi.) Trans. Amer. Ophth. Soc, v. 15, p. 166. Arch, of Ophth., v. 46, p. 537. Neurologic Perimetry. Ophth. Rec, v. 26, p. 600. Wells, D. W. Adaptability of Phoro-Optometer Stereoscope for Hattz and Bissell Charts. Amer. Jour. Ophth., v. 46, p. 537. Wescott, C. D. Visual Examinations. Railway Surg. Jour., v. 24, p. 1. Wolffberg. Theory and Practice of TestB for Acuteness of Vision. Woch. f. Therapla and Hyg. d. Auges, Oct., 1917. Nofl. 1 and 2. Wolfe, C. T. The Eye as Index of Certain Diseases. Kentucky Med. Jour., v. 16. p. 110.
DIGEST OF T H L L I T E R A T U R E
Ol'HTHALMOSCOI'Y WITH RED-FREE L I G H T . — Ophthalmoscopists generally are familiar w i t h the c h a n g e s in t h e color of the ocular fundus produced by variations in the color of the source of the light employed. Fifteen years ago M a y o u ( O . Y. B„ v. 1, p. 196) called attention to the very striking changes of color produced by the mercury vapor l a m p . S o m e five y e a r s a g o V o g t ( O . Y. B., v. 10, p. 271) r e p o r t e d upon the a p p e a r a n c e of t h e fundus a s seen w i t h yellow-blue light, o b t a i n e d t h r u a filter t h a t c u t o u t all t h e red r a y s . V o g t has continued his i n v e s t i g a t i o n s b r i n g ing o u t facts of practical i m p o r t a n c e in diagnosis, which will m a k e this m e t h o d of e x a m i n a t i o n o n e of o u r r e c o g n i z e d diagnostic r e s o u r c e s . T h e l i g h t is o b t a i n e d from a small arc l a m p , a n d filtered t h r u t w o screens
each b e i n g a layer of fluid 8 m m . in t h i c k n e s s . O n e is a 30 p e r c e n t solution of c o p p e r s u l p h a t a n d the o t h e r a solution of erioviridin 0.78 p a r t s to 10,000 of distilled w a t e r . T h e s e screens cut o u t t h e red a n d o r a n g e l i g h t t o bey o n d t h e line D of t h e s p e c t r u m . T h e y also e l i m i n a t e t h e short w a v e end of the s p e c t r u m , leaving only the yellowg r e e n - b l u e portion. T h e light is usedw i t h an o r d i n a r y o p h t h a l m o s c o p e , by t h e direct m e t h o d . B u t t h e p a t i e n t ' s retina should not be subjected to it for m o r e t h a n one-half m i n u t e a t a time, a l t h o n o evidence of h a r m from it, either objective o r subjective, has been noted. B y m e a n s of s u c h light V o g t has proven the yellow color of the living r e t i n a in t h e m a c u l a ; a n d b y experim e n t he has s h o w n t h a t such yellow
DIGEST OF THE LITERATURE
color is not perceptible under ordinary ophthalmoscopic illumination because of the red background. The general appearance presented by the normal Hindus under such illumination is shown in Plate IV, Fig. 1. Tfc C ° P ^ C d' s c *s white or greenish. 1he small vessels appear black, and are therefore, more clearly visible than under ordinary illumination. The macula is distinctly greenish-yellow, the retinal reflexes are especially abundant, and the nerve fibre layer is visible tnruout the fundus. The fibers may be seen curving from the disc to the macula. The retinal reflexes, seen ordU narily in young persons, by this light become visible at all ages. The retina 1S AIS t r a n s P a r e n t than by red light, and hence more visible. In many young eyes a pre-retinal t r i a * l o n w a s seen; supposed to be due to folds in the hyaloid membrane. This had been occasionally noted by earlier observers with the ordinary light. In the eyes of two albinos no macula could be found; and by cutting down the illumination with ground glass the yellow color seen in normal eyes disappeared, and left only a depressed spot. tn pathologic eyes the most minute hemorrhages became strikingly visible. *n retinitis and chorioretinitis the curving nerve fibers became concealed by edema. Disease of the retina or optip nerve, resulting in atrophy, causes disappearance of the nerve fiber layer of the retina, as shown in Fig. 2 and B Fig. 3. Affolter reports a series of cases with plates contrasting the appearances as seen by ordinary and red-free light. In a Cas c . °* recurring hemorrhage into the vitreous, from disease of the retinal vessels, the ordinary illumination showed very dimly the optic disc and largest vessels and a cloud in the vitreous. But by red-free light the diffuse vitreous haze seemed to disappear, rendering the details of the fundus and the yellow macula distinctly visible. In a case of exudation into the retina the red-free light revealed strongly glistening spheres in the vitreous, in front of the affected region, which were not seen at all otherwise. In reti-
nitis punctata albescens the white spots were more clearly seen, much more numerous, and more widely distributed tnruout the retina by red-free light than by ordinary illumination. In another case of retinitis followed thruout its course, the changes were much more striking as seen by the red-free light. In a case of neuroretinitis the macnlar lesions gave a more characteristic appearance by the new method of examination, and the same was true of another case of macular lesion. In optic neuritis the minute hemorrhages which dotted the region of swelling were strikingly brought out. On the other hand certain lesions, especially of the choroid, and the star figure of white retinal exudate in renal retinitis, are better differentiated by the ordinary illumination. In a controversial article of thirtyfive pages Gull&trand supports the view he advanced twelve years before, in opposition to Dimmer, that the yellow color of the retina at the macula does not exist during life. The spot of yellow seen with the red-free light he explains as due to the intense illumination reflected from the sclera thru the choroid and the thinnest portion of the retina. But this explanation is disproved by Vogt, who has examined four cases of hole in the macula, three traumatic, one of unknown origin, with red-free light; and found the area where the retina was absent not at all yellow, but blackish.
OPHTHALMOSCOI'Y OF THE ANGLE OF TIIF. ANTKRJOR CHAMBER.—More than
ten years ago Trantas described the appearances of the iridocorneal angle in a case of marked keratoglobus. Since the publication of Salzmann's papers (O. Y. B., v. 11, p. 18; vol. 13, p. 17), Trantas has given systematic study to the subject, and proposes to designate this form of ophthalmoscopy by the single word "gonioscopy." In the main his observations agree closely with those of Salzmann. This region is most easily explored in highly myopic eyes or those which present keratoglobus. From his study of such eyes he recognizes, passing from before backward
4
METHODS OP DIAGNOSIS
or from without inward in the region of inspection, a white zone, the sclera, distinctly separated from a "whitish" zone, as tho a little pigment had been mixed with the white. The line or band separating them apparently contains still more pigment. The whitish zone he believes to be the pectinate ligament; the darker band the canal of Schlemm. Behind the whitish zone appears a band extremely white which may be crossed by black lines approximately perpendicular to it which he thinks are prolongations from the iris. Inside of this are seen the iris crypts; and, still farther in, the wavy folds of the iris periphery. In one case by rubing the eyeball for a few minutes, or pressing upon it with the finger, the band marking the canal of Schlemm, one and a half or two millimeters wide, became very red; and this color remained for many minutes. H e believes that this demonstrates that the canal of Schlemm usually contains lymph, but that blood may be forced into it by obstruction of the venous outflow. In some eyes this region presents small isolated scarlet vessels, either against the sclera or the anterior surface of the iris. In the first case he described Trantas noticed a regular plexus of these vessels which he thought might be compensatory for an obliterated canal of Schlemm. The pigmented projections he has noticed and the general appearances closely resemble those described by Salzmann. In response to Trantas article Salzmann publishes a short note regarding priority, and the independence of his own work. Both these writers comment upon the remarkable similarity of the observations thus independently made. OPHTHALMOSCOPY. — Ap microscopy of the living eye-ground, with strong magnification in the focal light of the Gullstrand Nernst slit lamp, Koeppe discusses the conditions of this kind of examination and describes the apparatus he has employed to extend the illumination from the surface to the ocular fundus. He places on the cornea a contact lens, with a flattened anterior
surface. This is, in a way, the opposite of the nearly hemispheric contact lens used by Salzmann, in the examinations referred to above. The illumination is effected thru one portion of the pupil, while another part transmits the emergent rays by which the details of the deep vitreous, retina, choroid, etc., are seen. A prism system, such as is used in the binocular microscope, permits the binocular study of the parts. The Atlas of War Ophthalmoscopy of Lagrange contains a collection of 100 plates, 20 of them in colors, which will assist in the diagnosis of certain conditions of the fundus; particularly that of proliferating chorioretinitis, and other injuries produced by concussion and the appearances following avulsion of the optic nerve. Masuda has found that syphilitic appearances of the ocular fundus shown by direct ophthalmoscopy, especially dust-like opacities of the vitreous, have a diagnostic significance that is confirmed in five-sixths of the cases by the results of the Wassermann reaction. EXTERNAL EXAMINATIONS.—For
the
examination of the cornea, iris, anterior chamber, and crystalline lens a self illuminating corneal loupe has been arranged by Von der Heydt. The light from an electric bulb is concentrated by a condensing lens at the field focussed by a three-quarters aplanatic objective. A form of the hydroophthalmoscope is proposed by Koyanagi, for the examination of the angle of the anterior chamber. He calls it an anguloscope. It consists of the usual water container with a glass front. It is to be applied to the margin of the orbit. Koeppe has continued his studies with the corneal microscope aided by illumination with the Nernst slit lamp, by an investigation of the arrangement of the lymph vessels in the bulbar conjunctiva and episclera. This has been carried on with normal eyes, and also with eyes of persons of advanced age, and on eyes with pigment specks in or under the conjunctiva with melanosis, pathologic pigmentation, argyrosis, tattooing, siderosis and hemorrhage in or under the conjunctiva; and in the
DIGEST OF THE LITERATURE
choking of the vessels connected with glaucoma, and in lymphangiectasia. He finds that the blood vessels of the conjunctiva and episclera, apparently even the finest capillaries, are surrounded by lymph sheaths. The perivascular lymph sheaths of th e'veins are almost twice as thick and numerous as those of the arteries. The capillaries of the marginal plexus of vessels show such perivascular lymph spaces. No transition of the lymph spaces in the cornea to the perivascular lymph spaces of the limbus was discernible. Among simple ophthalmic implements Schwarz describes, beside an apparatus ior taking the visual field, one for measuring the position of the puP»ls and that of the apex of the cornea. He also describes a binocular loupe formed by joining the parts of two 15 D. convex lenses at an inclination of 160 degrees. TONOMETRV.—No modification of the
tonometer, and no extended investigations with it have been published in the past year. Morax has advocated its use in connection with the symptoms of increased lacrimation without lesions of the tear passages and obscure pain in the face and orbit. Uribeironcoso urges that the tonometer will make clear the diagnosis in many obscure cases. RADIOGRAPHIC
D I A G N O S I S . — By
slightly modifying the method suggested by Rhese for examination of the ethmoid and sphenoid cells de Kleijn ana Stenvers have been able to secure A-ray evidence of fractures of the base °» the skull, implicating the optic foramen The deposit of callus and a break in the normal outline in the bone were both perceptible in the case which tJ iey publish. The unreliability of X-ray localization is illustrated in a case reported by ** ln g. One X-ray plate indicated the foreign body well behind the eyeball near the optic nerve. Ophthalmoscope evidence having been secured of its presence in the fundus, the picture taken by another operator showed it within the eyeball, near the nerve entrance. The mistake of locating a foreign body outside the eye, which is
S
really within it, has been made so frequently that there would appear to be a general tendency in that direction. This may be due to failure to allow properly for the divergence of the rays casting the shadow. The diagrams are made the size of the eyeball, but the shadow cast by diverging rays is necessarily larger. Attention is called to a still more serious error of X-ray diagnosis by a case reported by Bachstez. In this case there was much evidence pointing to a tumor of the hypophysis, and the X-ray picture showed very marked enlargement of the sella turcica. On the support of such evidence a radical operation was done, and the patient died of basilar meningitis. Post mortem examination showed brain tumors, angiosarcomas, chronic internal hydrocephalus, atrophy of the hypophysis with marked widening and deepening of the sella turcica, and atrophy of its walls. Beck and Smith have published a paper upon stereoscopic roentgenograms. Salzer has described a method worked out at Gullstrand's clinic for combining plates taken simultaneously by two X-ray tubes at comparatively widely separated angles for the localization of foreign bodies. VISUAL ACUITY.—It is pointed
out
by Roelofs that we should not regard measurement of the "minimum separab l e " as the measurement of visual acuity. He thinks that both resolving power and optical space sense should be considered; and makes a sharp distinction between the smallest observable breadth and the smallest observable difference in direction. Two dots not sufficiently separated to be seen as separate dots may give the impression of a short bar, the direction of which can be recognized. Using rods of different lengths and breadths as the best object he found that a line 80 second's long could be recognized with great probability, and that one 110 seconds long could be recognized with certainty. The shortest rod recognizable was twice as long as its breadth, which was 17 seconds. Long lines, however, could be recog-
6
METHODS OP DIAGNOSIS
nized when much narrower, say from 2.5 seconds to 3 seconds. If narrower than this no line was recognized. Roelof s believes that the examination of visual acuity should include, becide the use of such rods or lines, testing with Snellen's letters, or similar optotypes based on the minimum separabile. In estimating visual acuity by the minimum separabile Alexander points out that for parallel rays it does not matter whether the angle separating distinct points, or subtended by a letter, be measured at the anterior focus of the eye, or at the nodal point, since in both cases the angle is the same. Wolffberg writes on the theory and practice of tests for acuteness of vision. The mathematic optics involved in the theory of visual acuity based upon determination of the perception of optotypes, or minimum separation of two points, is discussed by Gleichen. He discusses distinct and indistinct vision, vision with diffusion circles, within
uu Fig. 4.
Optotype of Rasquin.
the limits of accommodation, beyond those limits, acuteness of vision in astigmatic eyes, and vision diminished by imperfect correction, and by looking obliquely through correcting lenses. With reference to the standard illumination of test type a committee appointed by the American Ophthalmological Society points out; that with the usual intervals between successive lines of test letters, the results are so loosely approximate that an increase of illumination of 30 to 60 per cent would make no perceptible difference in the results obtained. Great excess of brightness in the surroundings tends to reduce visual acuity; but it may be also reduced by perfectly dark surroundings. The choice is an order of brightness, not greater than that of a moderate light gray ground, illuminated like the test card. For the testing of visual acuity Ras-
quin has suggested an optotype consisting of a square the side of which is five times as long as the width of the line composing it. See Fig. 4. On one side of this a part is cut out of the middle, making a break having the same length as the breadth of the line. The test is to recognize which side of the square is thus interrupted. He thinks the visual acuity, estimated by test type, should be recorded in decimal fractions. The optotypes should be graded in geometric progression and the corresponding visual acuity follow an arithmetric progression. Many papers have been written regarding the visual acuity needed for military service, and the standards adopted in different countries have been the subject of much criticism. In general these papers show a disposition to recognize greater impairment of vision as admissible for special and limited branches of service. Bourdier carries this same thought into his conclusions regarding what should be called blindness. He would recognize as "absolute blindness" complete suppression of all vision of both eyes. But he would call "professional blindness" such vision as fell below the standard required for the exercise of one's profession; the amount varying of course with each profession or occupation. "Practical blindness" he would term an impairment of vision that prevented its utilization in any occupation or profession. A self luminous test-type, obtained by use of a radio-active substance, has been proposed by Moxon for the purpose of estimating light sense or the degree of night blindness. Stargardt has suggested a simple portable box photometer, sufficiently exact for measuring the power of light adaptation in ordinary clinical diagnosis. With regard to records of visual acuity Abbott points out the increased labor and confusion that arise from designating vision by all sorts of fractions, and enters a plea for the use of decimals exclusively. Chapman would designate as 0. not the complete absence of vision, but vision of 20/220. By the allotting of 10 per cent increase in
DIGEST OF THE LITERATURE
vision for every decrease of 20 feet in the distance that the 20-foot letters are recognized he would reach standard vision of 2 0 / 2 0 = 1 . at 20 feet. He thinks that the fractions based on the Snellen system of estimating visual acuity have been taken too seriously. The pathologic significance of diminished visual acuity and that of its importance as an indication for treatment are urged by Gumbiner. PERIMETRY.—The report of the Committee of the American Ophthalmological Society considering standardization of the illumination of perimeters points out that plans for illumination must take into account: (1) The rapid adaptation of the peripheral retina by which a sensation loses characteristic quality under a continued stimulus. (2) The susceptibility of the peripheral retina to contrast, the same test surface, giving different results with different backgrounds. (3) The totally different results obtained with different sizes of color spots. , It is pointed out that beside variations in instruments, test colors, and technic, the comparison of perimetric findings loses much of its value because inadequate attention is paid to the illumination of the test spot. The patient is usually placed so that his shadow falls upon the arc of the perimeter in certain positions, while the maximum light falls about the middle of the lower quadrant, and a minimum at the middle of the quadrant above. They propose an investigation of these effects of the usual daylight illumination of the perimeter when taking different parts of the field, and also of the color tests used. The obtaining of an artificial illumination for pcrimetry, which shall closely resemble daylight in regard to its color values, has been the subject of a paper by Peter. He finds that the Mazda lamp covered by the socalled daylite" screen, of the Corning Glass Works, furnishes a satisfactory illumination. He thinks that from a scientific standpoint no objection can be raised to such an artificial illumination, which will stand the test of spectrum analysis. The papers of Walker upon
7
this subject were noted last year (v. 14, p. 5). The scotometer of Priestley Smith CO. Y. B., v. 4, p. 193) has been modified by Elliot, who uses the black velvet screen a little over one meter in diameter, mounted on a wheel so that it rotates around the central axis, which carries a sheet of paper on which the observations are recorded. Fixation in the axis is secured by a 3 mm. white ivory disc, having a 1 mm. black center. The distance of the patient's eyes is maintained by a chin and forehead rest. The screen is marked along one meridian into 5 degrees and 1 degree spaces, by stitches of black silk. The test objects are discs of white blotting paper, which adhere readily to the velvet surface. The chart revolving with the disc indicates the meridian in which the observation is being taken. The adaptability of the phoro-optometer stereoscope for mapping the blind spot, in using the Haitz and Bissell charts, has been the subject of a communication by Wells. He points out that the nodal point of the eye examined should be the center from which the field is measured, exactness being more important with the smaller dimensions of the stereoscopic fields. Eppenstein has used the universal prism apparatus of Bielschowsky which is modelled after some of the American phorometers, for mapping defects of the central visual field, especially enlargement of the blind spot. Fleischer has published tables of tangents for marking off the Bjerrum campimeter screen, for use at 100, 1200, 2000 or 2270 mm. The 1200 mm. tangents are given because this is the multiple of 300 mm., the usual radius of the perimeter arc; and 2270 mm. because at that distance one degree corresponds to 40 mm. removal from the fixation point. Lloyd has written on the general aspects of pcrimetry and campimetry. BINOCULAR VISION TESTS.—In
1912
(O. Y. B., V. 9, p. 86), Hudson described a very simple form of amblyoscopc for the treatment of convergent squint, which is equally useful in diagnosis. He has modified this by mak-
8
METHODS OP DIAGNOSIS
ing a screen that can have an opening in the middle for both eyes to look t h r u ; or can be shut off in the middle, compelling the eyes to look on the two sides of the screen. Beside its use in the diagnosis of binocular vision and movements, it is an excellent instrument for detecting malingering. Even the closing of one eye by the malingerer can quickly be nullified by shiftin or reversal of the test pictures. DETECTION OF SIMULATION AND M A -
LINGERING.—The large number of papers regarding this subject published in the past year contain but little that is new to the ophthalmologist. Alger points out the importance of a real— that is, thoro—examination of the person in all respects; and the necessity for the ophthalmologist to divest himself of mental bias. After this an understanding of the mental attitude of the person examined is important; and the handling of the case in a way to disarm antagonism. The stupid patients, who do not respond in any way, are usually the most difficult to unmask. In using a colored glass test for alleged monocular blindness he suggests that it should be placed before the good eye long enough to make the psychologic impression that this eye sees red; and then, getting the examinee to read rapidly a card on which there are red letters, he will be likely to read these, altho they are not visible to the eye with the red glass. Terrien suggests to unmask pretended diplopia, the use of two colored glasses one of which is transparent and the other ground, or opaque. The person tested having been allowed to read thru the former glass with both eyes open, the latter is then substituted before the good eye. Trantas to detect simulation of monocular blindness brings black shades gradually before both pupils. This causes a black vertical band to appear in the field with a diffusion border at each edge if vision is binocular. Pichler recommends taking of the visual field as a means of detecting simulation; and reports several cases, in one of which the field for white was smaller than the field for blue. In
others the fields showed a spiral narrowing. Testing of the fields can at least be made to prove the unreliability of the patient's answers; and where impairment of the field does not correspond to any organic condition it should always be a subject for suspicion. In discussing the paper of Alger, Snell told of a man who had a normal visual field in his good eye, but claimed inability to see the test object until it was brought to the middle line, when the alleged blind eye was also left open. Central scotoma, as Klauber points out, is not commonly understood by the laity, so that its simulation is rare. He has, however, met with three cases, one hysteric and readily cured by electricity ; the other two in intelligent soldiers, one of whom had some lowering of central vision. In this case it was demonstrated by use of a prism of 10 degrees, base out, which would induce the turning in of the eye for central fixation. Stereoscopic tests may also be used for the purpose. General reviews of the tests for malingering have been published by Parker, Beaumont, Dunn, Ezell, Fellows, and Jellett. Crisp reports the case of a child claiming monocular blindness after slight injury, who would permit the lashes to be touched by the hand projected toward the eye, before there was any blinking; but she was readily unmasked by the ordinary convex lens test. OCULAR
SIGNS OF DEATH.—Lecha-
Marzo believes that actual can be distinguished from apparent death by the change in the reaction of the tears. In life this is always alkaline, as he has invariably found it in more than 1000 healthy persons, and about the same number of hospital patients. But soon after death the reaction becomes acid. It is easily tested by placing a little piece of litmus paper under the lids for a moment. Icard depends on the green colora- . tion of the ocular media which follows injection of fluorescein during life. If, two hours after such an injection, no green coloration is noticeable, the patient is certainly dead. The presence
DIGEST OF THE LITERATURE
of a conjunctival reaction to irritants is also of value, but he warns against the use of ether for this purpose, as dangerous to the cornea. Ethylmorphinhydrochlorid (dionin) is effective and less dangerous. GENERAL PAPERS. — The common points in the patient's history of his case and his account of his sensations are. discussed by Ronne. He finds intolerance of tobacco smoke the most constant symptom of conjunctivitis. The amount of epiphora may be estimated by asking if the patient has to carry his handkerchief in his hand in
9
the street, or in the house. The sensation of a foreign body, if intermittent, is probably due to some other cause. Other practical points of this kind are mentioned. Common mistakes with reference to ocular disease is the subject of a paper by Gonzalez. The eye symptoms of cerebellar abscess are discussed by Bernstein. Clapp has written on tuberculin in the diagnosis of eye lesions; and Wolfe upon the eye as an index of certain diseases. Visual examinations from the point of view of railway men have been discussed by Wescott.
D.
DENVER.
This section reviews the literature of 1918, on ophthalmic diagnosis in general. Papers referring to the diagnosis of any particular disease will be found mentioned under the heading of that disease or the class to which it belongs. BIBLIOGRAPHY.
Abbott, W. A. Records of Visual Acuity. Amer. Jour. Ophth., v. 1, p. 71. ATTolter, A. Ophthalmoscopic Examination with Red-free Light. Graefe's Arch. f. Ophth., v. 94, Sept., 1917. Abst. Brit. Jour. Ophth., v. 2, p. 248. A,ex nder " > G - F- Recording Visual Acuity. U 111.) Brit. Jour. Ophth., v. 2, p. 277. . t E" M- Malingering from Standpoint «f Eye. New York State Jour. Med., v. 18, P. 487. Bachstez, E. Estimation of "Sellaer" Length m Roentgen Image. (1 ill.) Zeit. f. Augenh., v. 36, p. 62. Beaumont, w . M. Malingering in Relation to the Eye. London: W. Heinemann, 1917. Beck, E. G., and Smith, E. L. Stereoscopic Hoentgenograms. Amer. Jour. Roent, v. 6. P. 369. Bernstein, E. J. Diagnosis of Cerebellar Abscess. Ann. Otol., Rhin. and Laryngol., v. 26, p. 804. Bourdler, F. Determination of Visual AcuIty. Arch. d'Opht., v. 36, p. 294. 7J.""' H l D> M e thods of Diagnosis in Ophthalmology. New Orleans Med. and Surg. Jour., v. 71, p. 145. Chapman, V. A. Records of Visual Acuity. Amer. Jour. Ophth., v. 1, p. 288. cl8 PP. C. A. Tuberculin in Diagnosis of Eye Lesions. Arch, of Diag., v. 10, p. 399. cp '«P, W. H. Malingering. (Dls.) Colo. Ophth. Soc, Jan., 1918. Amer. Jour. Ophth., v. 1, p. 344. Du nn, P. Detection of Simulated Blindness. .Med. Press, v. 105, pp. 317 and 334. E 'llot, R. H. A Scotometer. Brit. Jour, of Ophth., v. 2, p. 168. E Ppenstein, A. Study of Field of Vision and Blind Spot with Prism Apparatus. Klin. Monatsbl. f. Augenh., v. 60, p. 620. Exell, H. Detection of Feigned Blindness. Jour. Tenn. State Med. Assn., v. 11, p. 150. Fellows, C. G. Malingering of Eye. Jour. Amer. Inst. Homeop., v. 11, p. 424. Fleischer, B, Campimetry after Bjerrum. Klin. Monatsbl. f. Augenh., v. 60, p. 265. G'elchen, A. Theory of Acuteness of Vision. (17 ill.) Graefe's Arch. f. Ophth., T - 93, p. 303. Gonzalez, J. Frequent Errors in Ophthalmic Practice. Arch, de Oft., v. 18, p. 196.
Gullstrand, A. Macula in Red^free Light. Klin. Monatsbl. f. Augenh., v. 60, p. 289. Gumblner, A. Defective Vision, Pathologic Significance. New York Med. Jour., v. 107, p. 1214. Hudson, A. C. Reversible Screen Stereoscope. (6 ill.) Brit. Jour. Ophth., v. 2, p. 427. Icard, 3. Signs of Death. Jour. Amer. Med. Assn., v. 70, p. 1964. Jellett, J. W. H. Detection of Simulated Blindness. Med. Press, May 29, p. 413. Klauber. Simulation and Aggravation of Central Scotoma. Wien. kl. Woch., 1917, p. 1170. Abst. Klin. M. f. Augenh., v. 60, p. 405. Kleljn, A. de, and Stenvers, H. W. Localization of Fracture of Optic Foramen with Radiography. (2 ill., 2 pi.) Graefe's Arch. f. Ophth., v. 91, p. 431. Koeppe, L. Observations with Nernst Lamp and Oorneal Microscope. (Bibl.) Graefe's Arch. f. Ophth., v. 95, p. 282; v. 97, p. 1. Koyanagl. An Anguloscope (Modified Orthoscope). (2 ill.) Nippon Gank. Zasshi, Oct., 1917. Lagrange, F. Atlas of War Ophthalmoscopy. Paris, Masson et Cie. Amer. Jour. Ophth., v. 1, p. 613. Lecha-Marzo, A. Tear Sign of Death. Abst. Jour. A. M. A., v. 71, p. 1009. Lloyd, R. I. Perimetry and Campimetry. Jour. Amer. Inst. Homeop., v. 10, p. 1284. Masuda. Change in Eye Grounds in Wassermann Reaction. Nippon Gank. Zasshi, Oct., 1917. Morax, V. Atypical Subacute Glaucoma. Ann. d'Oculist, v. 155, p. 100. Amer. Jour. Ophth., v. 1, p. 736. Moxon, F. H. Illuminated Test Types for Estimating Light Sense and Night Blindness. Roy. Soc. Med., Sec. on Ophth., June 12. Lancet, June 22, 1918, p. 874. Parker, W. R. Examination of Malingerers. Med. War Manual, No. 3. Philadelphia, Lea and Feblger. Peter, L. C. Artificial Daylight Illumination for Perimetric Study and General Office Use. Amer. Jour. Ophth., v. 1, p. 189. Plchler, A. Simulated Contraction of Field. Graefe's Arch. f. Ophth., v. 94, p. 227. Rasquin, E. Determination and Evaluation of Visual Acuity in Military Service. (7 ill., Bibl.) Ann. d'Ocul., v. 155, p. 117.
2
METHODS OP DIAGNOSIS
Report of Committee on Standardization of Illumination of Test-Cards and Perimeters. Amer. Ophth. Soc, v. 15, p. 324. Ring, Q. O. Variable Findings in Ocular X-ray Localization. (Dis.) Amer. Jour. Ophth., v. 1, p. 506. Robertson, C. M. Examination of Men Entering Aviation Service. Jour. Amer. Med. Assn., v. 71, p. 813. Roelofs, C. O. Tests for Visual Acuity. Nederl. Tijdsc'hr. v. Geneesk, 1917, p. 836. The Minimum Separabile and the Minimum Visible. Abet. Klin. M. f. Augenh., v. 60, p.- 655. RBnne, H . Anamnesis with Eye Disease. Hospltalstldende, v. 61, p. 403. Abst. Jour. Amer. Med. Assn., v. 70, p. 1987. 8alzer. Roentgen Rays in Ophthalmology. Abst. K. M. f. Augenh., v. 60, p. 831. 8alzman, M. Ophtbalmoscopy of Anterior Chamber. Zeit. f. Ophth., v. 34, p. 160. Schwarz. Exophthalmometer. Munch, med. Woch., 1917, p. 1414. Abst. Klin. M. f. Augenh., v. 60, p. 404. Snellen. Visual Acuity as Gage for Retinal Function. Nederl. Tijdsch. v. Geneesk, July 20, 1918, p. 240. Standards of Vision for Recruits, Ophth. Soc, United Kingdom, May 2, 1918. Abst. Lancet, May 11, p. 676. Stargardt. Simple Portable Adaptometer. Zeit. f. Augenh., v. 39, pt. 3. Abst. Klin. M. f. Augenh., v. 60, p. 830. Stenvers, H. W. Roentgenologic Remarks on Work of van der Hoeve and de Kleijn (5 ill.) Graefe's Arch. f. Ophth., v. 95, p. 95. Terrion, F. Factitious Diplopia. Paris Med., v. 8, p. 462. Abst. Jour. A. M. A., v. 71, p. 859.
Detection of False Diplopia. Arch. d'Opht., v. 36, p. 45. Trantas. Detection of Unilateral Blindness. Abstract in Jour. Amer. Med. Assn., v. 71, p. 17. Ophthalmoscopy of the Corneo-iridic Angle. (5 ill.) Arch. d'Opht., v. 36, p. 257. Urlbe-Troncoso, M. Wider Use of the Tonmeter. Amer. Jour. Ophth., v. 1, p. 799. Vogt, A. Color of Macula. Klin. Monatsbl. f. Augenh., v. 60, p. 449. Illumination of Eye ground with Light Devoid of Red Rays. Ann. d'Ocul., v. 155, p. 58. Vertical Linear Pigmentation Observed in Retina of Young in Red-free Light. (1 col. pi.) Klin. M. f. Augenh., v. 60, p. 47. Von der Heydt, R. Corneal Loupe. (1 ill.) Amer. Jour. Ophth., v. 1, p. 339. Walker, C. B. Quantitative Perimetry. (9 Fig., 3 pi.) Trans. Amer. Ophth. Soc, v. 15, p. 166. Arch, of Ophth., v. 46, p. 537. Neurologic Perimetry. Ophth. Rec, v. 26, p. 600. Wells, D. W. Adaptability of Phoro-Optometer Stereoscope for Hattz and Bissell Charts. Amer. Jour. Ophth., v. 46, p. 537. Wescott, C. D. Visual Examinations. Railway Surg. Jour., v. 24, p. 1. Wolffberg. Theory and Practice of TestB for Acuteness of Vision. Woch. f. Therapla and Hyg. d. Auges, Oct., 1917. Nofl. 1 and 2. Wolfe, C. T. The Eye as Index of Certain Diseases. Kentucky Med. Jour., v. 16. p. 110.
DIGEST OF T H L L I T E R A T U R E
Ol'HTHALMOSCOI'Y WITH RED-FREE L I G H T . — Ophthalmoscopists generally are familiar w i t h the c h a n g e s in t h e color of the ocular fundus produced by variations in the color of the source of the light employed. Fifteen years ago M a y o u ( O . Y. B„ v. 1, p. 196) called attention to the very striking changes of color produced by the mercury vapor l a m p . S o m e five y e a r s a g o V o g t ( O . Y. B., v. 10, p. 271) r e p o r t e d upon the a p p e a r a n c e of t h e fundus a s seen w i t h yellow-blue light, o b t a i n e d t h r u a filter t h a t c u t o u t all t h e red r a y s . V o g t has continued his i n v e s t i g a t i o n s b r i n g ing o u t facts of practical i m p o r t a n c e in diagnosis, which will m a k e this m e t h o d of e x a m i n a t i o n o n e of o u r r e c o g n i z e d diagnostic r e s o u r c e s . T h e l i g h t is o b t a i n e d from a small arc l a m p , a n d filtered t h r u t w o screens
each b e i n g a layer of fluid 8 m m . in t h i c k n e s s . O n e is a 30 p e r c e n t solution of c o p p e r s u l p h a t a n d the o t h e r a solution of erioviridin 0.78 p a r t s to 10,000 of distilled w a t e r . T h e s e screens cut o u t t h e red a n d o r a n g e l i g h t t o bey o n d t h e line D of t h e s p e c t r u m . T h e y also e l i m i n a t e t h e short w a v e end of the s p e c t r u m , leaving only the yellowg r e e n - b l u e portion. T h e light is usedw i t h an o r d i n a r y o p h t h a l m o s c o p e , by t h e direct m e t h o d . B u t t h e p a t i e n t ' s retina should not be subjected to it for m o r e t h a n one-half m i n u t e a t a time, a l t h o n o evidence of h a r m from it, either objective o r subjective, has been noted. B y m e a n s of s u c h light V o g t has proven the yellow color of the living r e t i n a in t h e m a c u l a ; a n d b y experim e n t he has s h o w n t h a t such yellow
DIGEST OF THE LITERATURE
color is not perceptible under ordinary ophthalmoscopic illumination because of the red background. The general appearance presented by the normal Hindus under such illumination is shown in Plate IV, Fig. 1. Tfc C ° P ^ C d' s c *s white or greenish. 1he small vessels appear black, and are therefore, more clearly visible than under ordinary illumination. The macula is distinctly greenish-yellow, the retinal reflexes are especially abundant, and the nerve fibre layer is visible tnruout the fundus. The fibers may be seen curving from the disc to the macula. The retinal reflexes, seen ordU narily in young persons, by this light become visible at all ages. The retina 1S AIS t r a n s P a r e n t than by red light, and hence more visible. In many young eyes a pre-retinal t r i a * l o n w a s seen; supposed to be due to folds in the hyaloid membrane. This had been occasionally noted by earlier observers with the ordinary light. In the eyes of two albinos no macula could be found; and by cutting down the illumination with ground glass the yellow color seen in normal eyes disappeared, and left only a depressed spot. tn pathologic eyes the most minute hemorrhages became strikingly visible. *n retinitis and chorioretinitis the curving nerve fibers became concealed by edema. Disease of the retina or optip nerve, resulting in atrophy, causes disappearance of the nerve fiber layer of the retina, as shown in Fig. 2 and B Fig. 3. Affolter reports a series of cases with plates contrasting the appearances as seen by ordinary and red-free light. In a Cas c . °* recurring hemorrhage into the vitreous, from disease of the retinal vessels, the ordinary illumination showed very dimly the optic disc and largest vessels and a cloud in the vitreous. But by red-free light the diffuse vitreous haze seemed to disappear, rendering the details of the fundus and the yellow macula distinctly visible. In a case of exudation into the retina the red-free light revealed strongly glistening spheres in the vitreous, in front of the affected region, which were not seen at all otherwise. In reti-
nitis punctata albescens the white spots were more clearly seen, much more numerous, and more widely distributed tnruout the retina by red-free light than by ordinary illumination. In another case of retinitis followed thruout its course, the changes were much more striking as seen by the red-free light. In a case of neuroretinitis the macnlar lesions gave a more characteristic appearance by the new method of examination, and the same was true of another case of macular lesion. In optic neuritis the minute hemorrhages which dotted the region of swelling were strikingly brought out. On the other hand certain lesions, especially of the choroid, and the star figure of white retinal exudate in renal retinitis, are better differentiated by the ordinary illumination. In a controversial article of thirtyfive pages Gull&trand supports the view he advanced twelve years before, in opposition to Dimmer, that the yellow color of the retina at the macula does not exist during life. The spot of yellow seen with the red-free light he explains as due to the intense illumination reflected from the sclera thru the choroid and the thinnest portion of the retina. But this explanation is disproved by Vogt, who has examined four cases of hole in the macula, three traumatic, one of unknown origin, with red-free light; and found the area where the retina was absent not at all yellow, but blackish.
OPHTHALMOSCOI'Y OF THE ANGLE OF TIIF. ANTKRJOR CHAMBER.—More than
ten years ago Trantas described the appearances of the iridocorneal angle in a case of marked keratoglobus. Since the publication of Salzmann's papers (O. Y. B., v. 11, p. 18; vol. 13, p. 17), Trantas has given systematic study to the subject, and proposes to designate this form of ophthalmoscopy by the single word "gonioscopy." In the main his observations agree closely with those of Salzmann. This region is most easily explored in highly myopic eyes or those which present keratoglobus. From his study of such eyes he recognizes, passing from before backward
4
METHODS OP DIAGNOSIS
or from without inward in the region of inspection, a white zone, the sclera, distinctly separated from a "whitish" zone, as tho a little pigment had been mixed with the white. The line or band separating them apparently contains still more pigment. The whitish zone he believes to be the pectinate ligament; the darker band the canal of Schlemm. Behind the whitish zone appears a band extremely white which may be crossed by black lines approximately perpendicular to it which he thinks are prolongations from the iris. Inside of this are seen the iris crypts; and, still farther in, the wavy folds of the iris periphery. In one case by rubing the eyeball for a few minutes, or pressing upon it with the finger, the band marking the canal of Schlemm, one and a half or two millimeters wide, became very red; and this color remained for many minutes. H e believes that this demonstrates that the canal of Schlemm usually contains lymph, but that blood may be forced into it by obstruction of the venous outflow. In some eyes this region presents small isolated scarlet vessels, either against the sclera or the anterior surface of the iris. In the first case he described Trantas noticed a regular plexus of these vessels which he thought might be compensatory for an obliterated canal of Schlemm. The pigmented projections he has noticed and the general appearances closely resemble those described by Salzmann. In response to Trantas article Salzmann publishes a short note regarding priority, and the independence of his own work. Both these writers comment upon the remarkable similarity of the observations thus independently made. OPHTHALMOSCOPY. — Ap microscopy of the living eye-ground, with strong magnification in the focal light of the Gullstrand Nernst slit lamp, Koeppe discusses the conditions of this kind of examination and describes the apparatus he has employed to extend the illumination from the surface to the ocular fundus. He places on the cornea a contact lens, with a flattened anterior
surface. This is, in a way, the opposite of the nearly hemispheric contact lens used by Salzmann, in the examinations referred to above. The illumination is effected thru one portion of the pupil, while another part transmits the emergent rays by which the details of the deep vitreous, retina, choroid, etc., are seen. A prism system, such as is used in the binocular microscope, permits the binocular study of the parts. The Atlas of War Ophthalmoscopy of Lagrange contains a collection of 100 plates, 20 of them in colors, which will assist in the diagnosis of certain conditions of the fundus; particularly that of proliferating chorioretinitis, and other injuries produced by concussion and the appearances following avulsion of the optic nerve. Masuda has found that syphilitic appearances of the ocular fundus shown by direct ophthalmoscopy, especially dust-like opacities of the vitreous, have a diagnostic significance that is confirmed in five-sixths of the cases by the results of the Wassermann reaction. EXTERNAL EXAMINATIONS.—For
the
examination of the cornea, iris, anterior chamber, and crystalline lens a self illuminating corneal loupe has been arranged by Von der Heydt. The light from an electric bulb is concentrated by a condensing lens at the field focussed by a three-quarters aplanatic objective. A form of the hydroophthalmoscope is proposed by Koyanagi, for the examination of the angle of the anterior chamber. He calls it an anguloscope. It consists of the usual water container with a glass front. It is to be applied to the margin of the orbit. Koeppe has continued his studies with the corneal microscope aided by illumination with the Nernst slit lamp, by an investigation of the arrangement of the lymph vessels in the bulbar conjunctiva and episclera. This has been carried on with normal eyes, and also with eyes of persons of advanced age, and on eyes with pigment specks in or under the conjunctiva with melanosis, pathologic pigmentation, argyrosis, tattooing, siderosis and hemorrhage in or under the conjunctiva; and in the
DIGEST OF THE LITERATURE
choking of the vessels connected with glaucoma, and in lymphangiectasia. He finds that the blood vessels of the conjunctiva and episclera, apparently even the finest capillaries, are surrounded by lymph sheaths. The perivascular lymph sheaths of th e'veins are almost twice as thick and numerous as those of the arteries. The capillaries of the marginal plexus of vessels show such perivascular lymph spaces. No transition of the lymph spaces in the cornea to the perivascular lymph spaces of the limbus was discernible. Among simple ophthalmic implements Schwarz describes, beside an apparatus ior taking the visual field, one for measuring the position of the puP»ls and that of the apex of the cornea. He also describes a binocular loupe formed by joining the parts of two 15 D. convex lenses at an inclination of 160 degrees. TONOMETRV.—No modification of the
tonometer, and no extended investigations with it have been published in the past year. Morax has advocated its use in connection with the symptoms of increased lacrimation without lesions of the tear passages and obscure pain in the face and orbit. Uribeironcoso urges that the tonometer will make clear the diagnosis in many obscure cases. RADIOGRAPHIC
D I A G N O S I S . — By
slightly modifying the method suggested by Rhese for examination of the ethmoid and sphenoid cells de Kleijn ana Stenvers have been able to secure A-ray evidence of fractures of the base °» the skull, implicating the optic foramen The deposit of callus and a break in the normal outline in the bone were both perceptible in the case which tJ iey publish. The unreliability of X-ray localization is illustrated in a case reported by ** ln g. One X-ray plate indicated the foreign body well behind the eyeball near the optic nerve. Ophthalmoscope evidence having been secured of its presence in the fundus, the picture taken by another operator showed it within the eyeball, near the nerve entrance. The mistake of locating a foreign body outside the eye, which is
S
really within it, has been made so frequently that there would appear to be a general tendency in that direction. This may be due to failure to allow properly for the divergence of the rays casting the shadow. The diagrams are made the size of the eyeball, but the shadow cast by diverging rays is necessarily larger. Attention is called to a still more serious error of X-ray diagnosis by a case reported by Bachstez. In this case there was much evidence pointing to a tumor of the hypophysis, and the X-ray picture showed very marked enlargement of the sella turcica. On the support of such evidence a radical operation was done, and the patient died of basilar meningitis. Post mortem examination showed brain tumors, angiosarcomas, chronic internal hydrocephalus, atrophy of the hypophysis with marked widening and deepening of the sella turcica, and atrophy of its walls. Beck and Smith have published a paper upon stereoscopic roentgenograms. Salzer has described a method worked out at Gullstrand's clinic for combining plates taken simultaneously by two X-ray tubes at comparatively widely separated angles for the localization of foreign bodies. VISUAL ACUITY.—It is pointed
out
by Roelofs that we should not regard measurement of the "minimum separab l e " as the measurement of visual acuity. He thinks that both resolving power and optical space sense should be considered; and makes a sharp distinction between the smallest observable breadth and the smallest observable difference in direction. Two dots not sufficiently separated to be seen as separate dots may give the impression of a short bar, the direction of which can be recognized. Using rods of different lengths and breadths as the best object he found that a line 80 second's long could be recognized with great probability, and that one 110 seconds long could be recognized with certainty. The shortest rod recognizable was twice as long as its breadth, which was 17 seconds. Long lines, however, could be recog-
6
METHODS OP DIAGNOSIS
nized when much narrower, say from 2.5 seconds to 3 seconds. If narrower than this no line was recognized. Roelof s believes that the examination of visual acuity should include, becide the use of such rods or lines, testing with Snellen's letters, or similar optotypes based on the minimum separabile. In estimating visual acuity by the minimum separabile Alexander points out that for parallel rays it does not matter whether the angle separating distinct points, or subtended by a letter, be measured at the anterior focus of the eye, or at the nodal point, since in both cases the angle is the same. Wolffberg writes on the theory and practice of tests for acuteness of vision. The mathematic optics involved in the theory of visual acuity based upon determination of the perception of optotypes, or minimum separation of two points, is discussed by Gleichen. He discusses distinct and indistinct vision, vision with diffusion circles, within
uu Fig. 4.
Optotype of Rasquin.
the limits of accommodation, beyond those limits, acuteness of vision in astigmatic eyes, and vision diminished by imperfect correction, and by looking obliquely through correcting lenses. With reference to the standard illumination of test type a committee appointed by the American Ophthalmological Society points out; that with the usual intervals between successive lines of test letters, the results are so loosely approximate that an increase of illumination of 30 to 60 per cent would make no perceptible difference in the results obtained. Great excess of brightness in the surroundings tends to reduce visual acuity; but it may be also reduced by perfectly dark surroundings. The choice is an order of brightness, not greater than that of a moderate light gray ground, illuminated like the test card. For the testing of visual acuity Ras-
quin has suggested an optotype consisting of a square the side of which is five times as long as the width of the line composing it. See Fig. 4. On one side of this a part is cut out of the middle, making a break having the same length as the breadth of the line. The test is to recognize which side of the square is thus interrupted. He thinks the visual acuity, estimated by test type, should be recorded in decimal fractions. The optotypes should be graded in geometric progression and the corresponding visual acuity follow an arithmetric progression. Many papers have been written regarding the visual acuity needed for military service, and the standards adopted in different countries have been the subject of much criticism. In general these papers show a disposition to recognize greater impairment of vision as admissible for special and limited branches of service. Bourdier carries this same thought into his conclusions regarding what should be called blindness. He would recognize as "absolute blindness" complete suppression of all vision of both eyes. But he would call "professional blindness" such vision as fell below the standard required for the exercise of one's profession; the amount varying of course with each profession or occupation. "Practical blindness" he would term an impairment of vision that prevented its utilization in any occupation or profession. A self luminous test-type, obtained by use of a radio-active substance, has been proposed by Moxon for the purpose of estimating light sense or the degree of night blindness. Stargardt has suggested a simple portable box photometer, sufficiently exact for measuring the power of light adaptation in ordinary clinical diagnosis. With regard to records of visual acuity Abbott points out the increased labor and confusion that arise from designating vision by all sorts of fractions, and enters a plea for the use of decimals exclusively. Chapman would designate as 0. not the complete absence of vision, but vision of 20/220. By the allotting of 10 per cent increase in
DIGEST OF THE LITERATURE
vision for every decrease of 20 feet in the distance that the 20-foot letters are recognized he would reach standard vision of 2 0 / 2 0 = 1 . at 20 feet. He thinks that the fractions based on the Snellen system of estimating visual acuity have been taken too seriously. The pathologic significance of diminished visual acuity and that of its importance as an indication for treatment are urged by Gumbiner. PERIMETRY.—The report of the Committee of the American Ophthalmological Society considering standardization of the illumination of perimeters points out that plans for illumination must take into account: (1) The rapid adaptation of the peripheral retina by which a sensation loses characteristic quality under a continued stimulus. (2) The susceptibility of the peripheral retina to contrast, the same test surface, giving different results with different backgrounds. (3) The totally different results obtained with different sizes of color spots. , It is pointed out that beside variations in instruments, test colors, and technic, the comparison of perimetric findings loses much of its value because inadequate attention is paid to the illumination of the test spot. The patient is usually placed so that his shadow falls upon the arc of the perimeter in certain positions, while the maximum light falls about the middle of the lower quadrant, and a minimum at the middle of the quadrant above. They propose an investigation of these effects of the usual daylight illumination of the perimeter when taking different parts of the field, and also of the color tests used. The obtaining of an artificial illumination for pcrimetry, which shall closely resemble daylight in regard to its color values, has been the subject of a paper by Peter. He finds that the Mazda lamp covered by the socalled daylite" screen, of the Corning Glass Works, furnishes a satisfactory illumination. He thinks that from a scientific standpoint no objection can be raised to such an artificial illumination, which will stand the test of spectrum analysis. The papers of Walker upon
7
this subject were noted last year (v. 14, p. 5). The scotometer of Priestley Smith CO. Y. B., v. 4, p. 193) has been modified by Elliot, who uses the black velvet screen a little over one meter in diameter, mounted on a wheel so that it rotates around the central axis, which carries a sheet of paper on which the observations are recorded. Fixation in the axis is secured by a 3 mm. white ivory disc, having a 1 mm. black center. The distance of the patient's eyes is maintained by a chin and forehead rest. The screen is marked along one meridian into 5 degrees and 1 degree spaces, by stitches of black silk. The test objects are discs of white blotting paper, which adhere readily to the velvet surface. The chart revolving with the disc indicates the meridian in which the observation is being taken. The adaptability of the phoro-optometer stereoscope for mapping the blind spot, in using the Haitz and Bissell charts, has been the subject of a communication by Wells. He points out that the nodal point of the eye examined should be the center from which the field is measured, exactness being more important with the smaller dimensions of the stereoscopic fields. Eppenstein has used the universal prism apparatus of Bielschowsky which is modelled after some of the American phorometers, for mapping defects of the central visual field, especially enlargement of the blind spot. Fleischer has published tables of tangents for marking off the Bjerrum campimeter screen, for use at 100, 1200, 2000 or 2270 mm. The 1200 mm. tangents are given because this is the multiple of 300 mm., the usual radius of the perimeter arc; and 2270 mm. because at that distance one degree corresponds to 40 mm. removal from the fixation point. Lloyd has written on the general aspects of pcrimetry and campimetry. BINOCULAR VISION TESTS.—In
1912
(O. Y. B., V. 9, p. 86), Hudson described a very simple form of amblyoscopc for the treatment of convergent squint, which is equally useful in diagnosis. He has modified this by mak-
8
METHODS OP DIAGNOSIS
ing a screen that can have an opening in the middle for both eyes to look t h r u ; or can be shut off in the middle, compelling the eyes to look on the two sides of the screen. Beside its use in the diagnosis of binocular vision and movements, it is an excellent instrument for detecting malingering. Even the closing of one eye by the malingerer can quickly be nullified by shiftin or reversal of the test pictures. DETECTION OF SIMULATION AND M A -
LINGERING.—The large number of papers regarding this subject published in the past year contain but little that is new to the ophthalmologist. Alger points out the importance of a real— that is, thoro—examination of the person in all respects; and the necessity for the ophthalmologist to divest himself of mental bias. After this an understanding of the mental attitude of the person examined is important; and the handling of the case in a way to disarm antagonism. The stupid patients, who do not respond in any way, are usually the most difficult to unmask. In using a colored glass test for alleged monocular blindness he suggests that it should be placed before the good eye long enough to make the psychologic impression that this eye sees red; and then, getting the examinee to read rapidly a card on which there are red letters, he will be likely to read these, altho they are not visible to the eye with the red glass. Terrien suggests to unmask pretended diplopia, the use of two colored glasses one of which is transparent and the other ground, or opaque. The person tested having been allowed to read thru the former glass with both eyes open, the latter is then substituted before the good eye. Trantas to detect simulation of monocular blindness brings black shades gradually before both pupils. This causes a black vertical band to appear in the field with a diffusion border at each edge if vision is binocular. Pichler recommends taking of the visual field as a means of detecting simulation; and reports several cases, in one of which the field for white was smaller than the field for blue. In
others the fields showed a spiral narrowing. Testing of the fields can at least be made to prove the unreliability of the patient's answers; and where impairment of the field does not correspond to any organic condition it should always be a subject for suspicion. In discussing the paper of Alger, Snell told of a man who had a normal visual field in his good eye, but claimed inability to see the test object until it was brought to the middle line, when the alleged blind eye was also left open. Central scotoma, as Klauber points out, is not commonly understood by the laity, so that its simulation is rare. He has, however, met with three cases, one hysteric and readily cured by electricity ; the other two in intelligent soldiers, one of whom had some lowering of central vision. In this case it was demonstrated by use of a prism of 10 degrees, base out, which would induce the turning in of the eye for central fixation. Stereoscopic tests may also be used for the purpose. General reviews of the tests for malingering have been published by Parker, Beaumont, Dunn, Ezell, Fellows, and Jellett. Crisp reports the case of a child claiming monocular blindness after slight injury, who would permit the lashes to be touched by the hand projected toward the eye, before there was any blinking; but she was readily unmasked by the ordinary convex lens test. OCULAR
SIGNS OF DEATH.—Lecha-
Marzo believes that actual can be distinguished from apparent death by the change in the reaction of the tears. In life this is always alkaline, as he has invariably found it in more than 1000 healthy persons, and about the same number of hospital patients. But soon after death the reaction becomes acid. It is easily tested by placing a little piece of litmus paper under the lids for a moment. Icard depends on the green colora- . tion of the ocular media which follows injection of fluorescein during life. If, two hours after such an injection, no green coloration is noticeable, the patient is certainly dead. The presence
DIGEST OF THE LITERATURE
of a conjunctival reaction to irritants is also of value, but he warns against the use of ether for this purpose, as dangerous to the cornea. Ethylmorphinhydrochlorid (dionin) is effective and less dangerous. GENERAL PAPERS. — The common points in the patient's history of his case and his account of his sensations are. discussed by Ronne. He finds intolerance of tobacco smoke the most constant symptom of conjunctivitis. The amount of epiphora may be estimated by asking if the patient has to carry his handkerchief in his hand in
9
the street, or in the house. The sensation of a foreign body, if intermittent, is probably due to some other cause. Other practical points of this kind are mentioned. Common mistakes with reference to ocular disease is the subject of a paper by Gonzalez. The eye symptoms of cerebellar abscess are discussed by Bernstein. Clapp has written on tuberculin in the diagnosis of eye lesions; and Wolfe upon the eye as an index of certain diseases. Visual examinations from the point of view of railway men have been discussed by Wescott.