CHAPTER XX
Psychical Symptoms Associated with the Sense of Vision.. 467
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DIAGNOSIS FROM OCULAR SYMPTOMS
INTRODUCTION
Many of the troubles that lead patients to visit us at our offices are self limited and will get well of themselves if let alone, but others, which perhaps resemble them closely, are not so obliging, and, if not rightly treated, will go on to impairment of the vision, destruction of the eye, or possibly loss of life. Right treatment must be based on a correct diagnosis. This is plain to the patient himself, who is justified in asking us if we know just what is the matter with him before he begins to follow our directions. Snap diagnoses are bril- liant sometimes, but they are quite as apt to be wrong, and are hazardous even when they are based on resemblances to previous cases that have been carefully studied. The most experienced diag- nosticians are the least prone to make snap diagnoses, and are the most apt to study symptoms closely. These are truisms that apply to every branch of medicine. The specialist meets with some of the diseases of the eye every day, others he has never seen, and the more experienced he is the more constantly is he on the qui vive lest he should make a mistake. The danger of error increases with the lack of studious experience and is greatest among practitioners whose patients have yet to arrive, and those who meet with only a small percentage of eye cases. These find it extremely difficult to ar- range the symptoms presented by a patient so as to arrive at a diag- nosis by exclusion. It is not uncommon for a serious condition in the eye or orbit to be overlooked by a physician whose attention has been caught and held by some other, perhaps less important, lesion or symptom elsewhere in the body, as when a case of glaucoma is mistaken for one of trigeminal neuralgia. Literature abounds in excellent descriptions of individual diseases which we study in the hope that we shall recognize them when they appear before us, but their number is so great, and the resemblances some bear to others
1
2 DIAGNOSIS FROM OCULAR SYMPTOMS
are so close, that memory cannot be relied upon to differentiate one from another. We cannot make a diagnosis by exclusion through calling up mental pictures of every possible disease which may pre- sent certain symptoms, and then eliminating all that do not corre- spond in every particular to the clinical picture presented by the individual patient. We must gather together all of the symptoms that can be obtained, select the prominent ones which indicate the group of diseases to which this one belongs, and narrow the group more and more by an orderly consideration of the remaining symp- toms until but one disease is left. Then we have made a diagnosis by exclusion, but the process is not as easy as it sounds.
Ever since entering upon the study of ophthalmology I have wished that some bright mind would analyze the symptoms that appertain to or appear in the eye, select certain ones for points of departure, and arrange the others into syndromes, showing how those which re- semble each other differ, and how exclusion is to be made. A colossal dream perhaps, certainly a stupendous task, yet one well worth under- taking, if only to make a single step toward rendering accurate diag- nosis easier to the unskilled. Many books have been written, many beautiful plates published that are of immense help in diagnosis, but all seem to illustrate individuals, to introduce them as it were, with- out pointing out with sufficient clearness the distinguishing marks by which each could be differentiated from all others. Finally I undertook the task, but with many misgivings, for I have no claim to be possessed of surpassing ability as a diagnostician. The com- pleted work falls far short of my ideal. I can only hope that it contains a suggestion as to presentation which will be developed better in the future.
The system adopted is to try to utilize the symptom or condition that predominates in the mind of the examiner as the central figure from which to work outward toward the diagnosis, to collate about this the possibilities with the characteristics of each, and then to dis- cuss individual diseases sufficiently to make each picture clear. No attempt is made to fill in all of the details, because a multiplicity of symptoms that are adventitious rather than diagnostic seems to me to be confusing. Once the diagnosis has been reached the details can be filled in and the result compared with the complete and beauti- ful delineations that abound. Brevity is employed for the sake of clearness, not to save space, and the omission of any important diag- nostic points must be attributed to my lack of appreciation of their
INTRODUCTION 3
importance. At the same time omissions and errors have been found and corrected even on the last reading of the manuscript. Prob- ably some remain, but it is hoped that the number is not large. AXti- ology and course frequently are valuable diagnostic aids, and are included as such. Frequent reference is made to the inestimable assistance furnished by pathology, bacteriology, and biological re- search, but the details of the methods by which such help is obtained are omitted, because to deal with them would carry us far afield of our subject. Treatment is outside of the scope of this work. Numer- ous repetitions and cross references have been made necessary by the realization that when a patient is examined by two or more physi- cians a different symptom may be the more strongly impressed on the mind of each, so that each will have a different point of departure from which to construct his diagnosis, and also by the fact that a symptom which predominates in one case may appear to be subor- dinate in another. The symptomatology of diseases of other parts of the organism is gone into only in so far as it seemed necessary for the understanding of the associated ocular symptoms. My only reply to a critic who claims that this is not a system, but an unscien- tific lack of one, is that if he can devise anything better suited to meet the needs of physicians who are intent on finding out what is the matter with their patients, he should do so at once and relegate this poor attempt to the background. The great question is whether this book will enable students to diagnose diseases in which the eye is affected more readily and correctly than others which they have at command, or not, and the answer can come only from the students themselves.
Wherever I have consciously appropriated the ideas of some one else, I have tried to give credit for them, but in many cases the source of the ideas has been forgotten. Probably I am indebted to Roemer more than to any other one author, because of my familiarity with his textbook, but I am under obligation to a very large number of writers, the names of many of whom will be found scattered through the volume.
The absence of illustrations deserves an explanation, as the pub- lisher has very kindly put a large number of plates at my disposal and urged their acceptance, but after a long period of consideration I have decided not to avail myself of the courtesy. My endeavor is to present pen pictures that bring out strongly the points through which differentiation is made, and it is practically impossible to pre-
4 DIAGNOSIS FROM OCULAR SYMPTOMS
sent these points in a plate so as to make clear the differentiation | between two conditions that closely resemble each other. Ilustra- tions in black and white are little more than suggestive; we are not apt to recognize them unless we know what they are intended to represent, and then our memories and imaginations supply the de- ficiencies. No one can admire more than I do the perfection of repro- duction to be seen in the best colored plates, but these seem to me to place too strong an emphasis on what is simply visible, and they necessarily portray the details which are peculiar to the one individual case as distinctly as those from which aid is obtained in making the diagnosis. They seem to be easier to study than pen pictures, yet if anyone doubts the correctness that they place too great emphasis on certain of the diagnostic symptoms, let him take an atlas of the very best, with which he is not acquainted, cover up the titles, and try to diagnose the conditions portrayed; his surprise when the titles are uncovered may be illuminating. From such a plate we can perceive that the lids are swollen, that the conjunctiva is inflamed, there is an ulcer of the cornea, that one eye deviates or protrudes, or that there are certain gross lesions in the fundus, but these are only steps toward the diagnosis. We need to learn the cause of the swollen lid, and of the conjunctivitis. No one can differentiate through such a picture a pneumococcal from a diplococcal ulcer of the cornea, a strabismus from a muscular paresis, the cause of an exophthalmos, or an albuminuric from one of many other forms of retinitis, yet these are the important things to be determined in each individual case. Furthermore, such plates seem to me to distract attention from the text, and to lead the beginner to look for duplicates in his practice, which are seldom to be found. For these reasons I have decided to do without such illustrations, although I appreciate their beauty and attractiveness.