its normal rosy tint, owing to the disappearance of the capillary vessels. The retinal arteries and veins are generally smaller than normal. I. The atrophy is secondary to optic neuritis, which may be shown either by an earlier ophthalmoscopic observation or by the presence of exudate in the nerve head, concealing the lamina cribrosa and giving a 'filled in' appearance to the disc and sometimes extending outward along the retinal vessels. <Callout type='important' title='Important'>The appearance of the disc alone is not always sufficient to distinguish post-neuritic atrophy from simple atrophy.</Callout> Diagnosis to be made as in Optic Neuritis, q, v.
II. The atrophy is non-neuritic, or simple, which may be shown by the absence of an earlier observation of neuritis and the absence of exudate in the nerve head and along the retinal vessels. The lamina cribrosa is more exposed than normal. A. The atrophy is almost always unilateral and is caused by hemorrhage, inflammation or new growth within the orbit. B. The atrophy is almost always bilateral and is not caused by disease within the orbits.
<Callout type='risk' title='Risk'>Confirmatory signs of the existence of organic dis- ease of the central nervous system (such as paralysis of the ocular muscles, face, tongue or one side of the larynx, paralysis of the limbs that cannot be ex- plained as functional, Jacksonian epilepsy, typical ankle clonus, absence of knee-jerk, Argyll-Robertson pupil, coincident mental impairment, etc.) are absent.</Callout> Although only rarely found apart from other evidence OPTIC ATROPHY, e, the atrophy mae effect of a systemic condition ;re neuralgia, or migraine, ivmptom of an organic disease, is very greatly impoverished as in se- pernicious anemia or leuco- iystemic infection, as in variol; lalaria, diphtheria, typhus syphilis. is a condition of severe toxemia, as in uremia, gout, diabetes, alcoholism, plumbism, hydrargyrisni, chorea or poisoning by tobacco or carbon disulphidc.
<Callout type='tip' title='Tip'>d. The atrophy follows long-continued and severe ophthalmic neuralgia or migraine. Very rare.</Callout>
- Confirmatory signs of the existence of organic dis- ease of the central nervous system are present. a. The cranium is injured or diseased in such a way as to interrupt fibers of the optic nerves or optic tracts, as in fracture at the base or chronic thicken- ing of the bones.
b. There is no evidence that the cranium is primarily affected ; the lesion is intracranial or spinal. i. The disease is congenital or develops grad- ually in infancy. There is globular enlarge- ment of the cranium. Hydrocephalus, ii. The onset of the disease which causes the atrophy is sudden and — § Coincident with a blow on the head and loss of consciousness. Cerebral Concussion, §§ Without external violence. Hemiplegia occurs as consciousness is lost. ! Age usually less than 40. There is a septic endocarditis or a pulmonary ab- scess. Cerebral Embolism, !! Age usually more than 40. The arteries are degenerated. There may be evi- dence of increased blood pressure at the time of onset. Cerebral Hemorrhage,
<Callout type='warning' title='Warning'>3. The joint disease is secondary to paraplegia which is accompanied by loss of control of the bladder and rectum and more or less sensory loss, indicating some form of myelitis.</Callout> Myelitic Arthropathy.
The disturbance is in the skin and subcutaneous tissue without marked involvement of the bones. A. Sloughing occurs in a parnljzed p:art, especially where the skin is subjected to pressure or the irritation of heat or a blister. Diagnosis as in Paralysis. B. A painless, indolent ulcer appears in the sole of the foot or, very rarely, in the hand. It resists treatment and tends to penetrate deeply. Absence of knee-jerk and various other symptoms indicate the existence of tabes. Perforating Ulcer in Tabes,
<Callout type='important' title='Important'>H. There are destructive trophic changes in the fingers, especially in the terminal phalanges, like those of a felon, but painless.</Callout> Neuralgic pains may occur independent of the trophic changes. Sensibility to temperature and pain is lost in areas where touch is retained. Various other cord symptoms, especially paralysis of the type found in amyotrophic lateral sclerosis, may confirm the diagnosis of syringomyelia. Morvan's Disease, a special form of syringomyelia.
I. There are symmetrical fatty tumors in the subcutaneous tissue which are tender and painful. Patients usually alcoholic or syphilitic. Adiposis Dolorosa (Dereum).
J. There are subcutaneous and perluips submucous swell- ings affecting principally the face, lips, tongue, pharynx, genitals and limbs. The swelling is well defined, tense, not tender, does not pit on pressure and may be either white or pink. It comes on rapidly, in a few minutes to a few hours and after lasting bours or days may rapidly disappear, recurring at regular or irregular in- tervals. Gastro-intestinal pains are common. Neuro- pathy is very marked in many of the cases. Angioneurotic Edema,
K. There is pain in one foot, very rarely in both feet or in a hand, associated w^ith redness and often with swelling and increased local temperature, sometimes with hyperhidrosis and local hemorrhages. All the symptoms tend to subside when the patient reclines and rests the foot in an elevated position ; they are also relieved by cold and aggravated by warmth. Standing and letting the foot hang brings on a paroxysm of pain accom- panied by a rose-red flush and arterial throbbing ; there is no cyanosis or gangrene. Occurs almost exclusively in men, either alone or in association with various other nervous affections. Erythromelalgia,
L. There is an edematous swelling of a limb which is hysterically paralyzed, or contractured, or exhibits the hysterical simulation of joint disease. The swelling does not pit on pressure and is greatest in the morning. The part may be unchanged in color and temperature, or may be red and warm, but is mostly cyanotic and cold. Hysterical Edema . V. There is a general vaso-motor dilatation with rapid heart ac- tion and, in most cases, goitre and protrusion of the eye- balls. The carotids pulsate strongly, there is a character- istic thrill and murmur in the enlarged thyroid and the heart is often dilated. The skin is moist and diarrhea is common. A fine, rapid tremor of the hands is almost al- ways to be observed. Mental changes (irritability, mania, melancholia) may occur. Far more common in women than in men. The disease is apparently dependent upon excessive function of the thyroid gland, so it may be re- garded as the opposite of myxedema. Exophthalmic Goitre,
THE PAIXS OF NERVOUS DISEASE. I73 THE PAIXS OF NERVOUS DISEASE. I. Pain definhelv referred to the distribution of one or more nerves. A. Accompanied by signs of organic disease of the ner' e, such as a tumor or tumors on the nerve trunk or ner'e endings, atrophic paralysis, loss of tendon reflexes or of faradic irritability', tenderness of the ner'e and the mus- cles supplied by it, sensory loss in the distribution of the ner'e, glossy skin, etc. Pain of a peculiar stinging or burning character and usually persistent in the interval between exacerbations.
No local cause of neuritis, such as wound or pres- sure. A tumor or tumors mav be felt on the ner'e trunk or ner'e endings. Neuroma,
A single ner'e is affected and a local cause of neuritis, such as pressure, stretching, a wound or local infection, is apparent. Localized Neuritis,
The areas affected are bilateral and symmetrical, especially in the distribution of the musculo-spiral and external prpiliteal nerves. A toxic cause, such as alcoholism, arsenical poisoning, general infection or exposure with extreme exertion is present. Multiple Neuritis,
B. No proof of organic disease of the nerve, although the skin supplied by it and certain definite points along its course may be tender. Pain paroxysmal, usually with inter- vals of complete freedom. Toxemia, anemia or general nervous depression and some local irritation the nn)st common causes. Ncurali^ia,
II. Headache. Pain in the head not definitely referred to the distribution of particular nerves.
A. There is organic disease of the brain or its membranes, 174 NERVOUS AND MENTAL DISEASES. shown, not merely by the severity and persistence of the headache, but also by the occurrence of some more positive sign, e, g,^ paralysis of ocular muscles, face, tongue or one side of larynx ; inequality of pupils or failure of light reaction ; optic neuritis or optic atrophy ; typical ankle clonus; Jacksonian epilepsy, etc. If delirium or stupor occurs headache still continues. Vomiting common.
Onset sudden or very rapid, in a fewr minutes to a day, following an injury or occurring in an aged or insane person, without fever or other evidence of in- fection. Rigidity, perhaps convulsions, followed by paralysis, on the side opposite the headache. Sopor and coma with slowness of pulse supervene. Meningeal Hemorrhage,
Onset acute or subacute, in a few hours to a few weeks. Delirium, general or local convulsions and cranial nerve symptoms (such as ptosis, strabismus, inequality or immobility of pupils, paralysis or twitching of face, etc.) common. Optic neuritis oc- casional, rarely intense.
a. Patient, more commonly a child or an old person, depressed by an exhausting disease. Tempera- ture normal or slightly elevated. Venous disten- sion and edema of the forehead and sides of the head or of the eyelids and temple. Marantic Sinus Thrombosis, {May be as- sociated with meningitis or abscess, ) Onset rapid or slow, in a few days to weeks or months. Source of purulent infection present, e. g,^ otitis media, empyema, abscess in any part of the body, infected wound of the head. Rigors, followed by fever and sweating common. Temperature irregular, usually elevated but sometimes depressed. Optic neuritis frequent but rarely intense. In comparison with meningitis focal cerebral symptoms are common and cranial nerve symptoms uncommon. Duration may be short or it may be very long with a period
Key Takeaways
- Optic atrophy can result from various causes, including neuritis and systemic diseases.
- Trophic symptoms often indicate underlying neurological or systemic issues.
- Diagnosis of optic atrophy requires careful examination and consideration of associated signs.
Practical Tips
- Be vigilant for any changes in vision that could indicate optic atrophy, especially if accompanied by other neurological symptoms.
- Consider the patient's overall health and potential systemic conditions when diagnosing optic atrophy or trophic symptoms.
- Look for specific signs such as exudate in the nerve head to distinguish between neuritic and non-neuritic atrophy.
Warnings & Risks
- Do not overlook the possibility of systemic diseases, especially in cases where no clear local cause is found.
- Be cautious with patients showing signs of myelitis or other serious neurological conditions.
- Avoid misdiagnosis by thoroughly examining all possible causes and ruling out functional or hysterical symptoms.
Modern Application
While the techniques for diagnosing optic atrophy and trophic symptoms have advanced, understanding these historical methods can still be valuable in recognizing early signs of neurological issues. Modern tools like MRI and CT scans provide more precise imaging, but a thorough clinical examination remains crucial.
Frequently Asked Questions
Q: What are the common causes of optic atrophy mentioned in this chapter?
The chapter mentions several causes of optic atrophy, including neuritis, systemic conditions (such as pernicious anemia or leprosy), and local factors like hemorrhage or inflammation within the orbit.
Q: How can one differentiate between neuritic and non-neuritic optic atrophy?
The chapter states that neuritic optic atrophy is often associated with exudate in the nerve head, while non-neuritic atrophy shows a more exposed lamina cribrosa without such exudate.
Q: What are some signs of systemic diseases that can cause optic atrophy?
The chapter lists several systemic conditions as potential causes, including pernicious anemia, leprosy, syphilis, and various infections like malaria or typhus. These conditions often present with additional neurological symptoms.