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					                  THE CANADIAN MEDICAL ASSOCIATION JOURNAL                                              903

                               THE OCULAR MALINGERER*
                                           A. G. McAuLEY, M.D.

                   Ophthalmnological Department, Royal Victoria Hospital, Montreal

THE frequency of malingering varies in dif-              photophobia, dizziness, dazzling, spasm of eye-
                                                         lids, etc.: (7) of contraction of the visual field,
      ferent countries, and, in any country, it
bears a pretty direct ratio to the liberality of         and scotomata.
its compensation laws and industrial insurance              We are led to suspect simulation by the lack
acts. As a rule the beneficiaries of these acts          of agreement between the results of the func-
feel that they are not liberally dealt with in           tional testing and of the objective examinations,
matters of compensation, and in many cases,              or, the inidividual functions give contrary re-
they are prone to make as much as possible of            sults, inasmuch as the visual acuity, the field
any accident or disability be it ever so trivial,        of vision, the color sense, etc., do not stand in
and to exaggerate symptoms or even manufac-              right relation with each other, and with the
ture them.                                               result of the objective examination.
   It may be that a person had an amblyopic                 In making the examination, it is fortunate if
eye preceding an injury, as, from difference in          we can impart to the person being examined
refractive condition of the two eyes and failure         the impression that he has our sympathy in
to develop binocular vision, or from disease.            his trouble, rather than have him harbour the
It is also possible that he was unaware of this          impression that he is being examined by one
amblyopia prior to his accident, and in such             who does not believe his statements, and is
case, he most certainly is likely to attribute the       endeavouring to trap him. This is much easier
condition to his accident. If he were unaware            of accomplishment with the person who is re-
of his amblyopia prior to his accident, he, of           ferred to the oculist for special examination
course, cannot be classified as a malingerer, as         and report for the firsttime, than with him who
he is merely labouring under a misapprehen-              has already been referred by a defending com-
sion of what his eye condition really was pre-           pany or party to several oculists, as his pre-
vious to his accident.                                   vious experience may have excited his sus-
   The chief objects of malingering are: (1)             picion, and developed his ability in being on
To secure damages; (2) To obtain pensions and            his guard.
insurance compensations; (3) To avoid military              The procedure should consist of a thorough
duty; (4) To gain admittance to a charitable             examination of the eyes externally and with
institution; (5) To secure alms; (6) Children            the ophthalmoscope. His refraction should be
sometimes pretend defective vision to avoid              accurately estimated, and most of the tests
school duties. Children living in rural parts            should be made with the person wearing the
have been known to gratify their desire to see           correction of. any refractive error he may
the city by declaring defect of vision, thereby          possess.
securing a trip to the city to see a specialist.            The objective tests of blindness depend main-
   The type of malingering may assume any of             ly upon two points: (1) Reaction of the pupil;
the following forms: (1) Simulation of total             (2) Direction of the visual axis. In testing
blindness; (2) of monocular blindness; (3) of            the reaction of the pupil by ordinary diffuse
an exaggeration of diminished vision; (4) of             daylight, have the person directly facing the
diminished vision where none exists; (5) of              window, and have him gaze at a distant object
paralyzed muscles of eye or eyelids; (6) of an           while he holds his hand across the eye that is
inability to use the eye on account of weakness,         not being examined, in order to exclude the
                                                         light therefrom. Note the size of the pupil in
   *Read before the Eye, Ear, Nose and Throat Section    the eye that is being tested, and then exclude
at the Annual Meeting of the Canadian Medical Associa-
tion, Montreal, June, 1923.                              the light therefrom by holding a hand across
it for five or six seconds. On removing your            (3) Sometimes blindness may be present in
hand, in the case of the light reflex being nor-     disease of the optic nerve itself, and still have
mal, you will find that the pupil has enlarged       light reflex of the pupil. This can be explained
considerably. The enlargement or dilatation rC-      only on the hypothesis that the fibres for the
mains about half a second, and then is followed      conduction of the light reflex are more resis-
by a very decided contraction, according to the      tant than those conveying visual impressionis.
intensity of the illumination. This contraction         (4) Sometimes in retinal degeneration and
is followed by a dilatation, and that by a still     blindness a very slow reaction to light takes
more moderate contraction, until at last the         place (Leber), the pupil dilating very grad-
pupil becomes stationary in a condition of more      ually in the dark, and contracting very
or less moderate contraction. By the rapidity        gradually again on return to light, and this in
and amplitude of these pupillary excursions          the absence of light perception.
one decides as to whether the light reflex is           The absence of the physiological stimulus
normal or abnormal.                                  of binocular fixation of vision allows a blind,
   Reaction of the pupil to light may not take       or partially blind eye, to assume the anatomical
place even when sight exists, as when synechiae      position of rest, which is upward and outward,
are present, or in paralytic mydriasis. The          and we find in the case of an eye that is par-
pupils should be very thoroughly examined for        tially or totally blind, that it generally fails
posterior synechiae, and if necessary, a mydri-      to maintain proper fixation. When, therefore,
atic used to establish their condition. If the       perfect parallelism exists under all conditions,
patient has a dilated pupil when first seen, it      it is good evidence of the presence of sight, and
may have been artificially produced by a             of sight sufficiently good to produce single
mydriatic. Usually such cases may be detected        binocular vision.
by the mydriasis, as a rule, being nearly or            Additional tests of simulation of bilateral
quite ad maximum, in contra distinction to the       amaurosis:
more moderate mydriasis generally present in            Schmidt-Rimpler test.-The examiner directs the
the genuinely blind eye. Shrewd malingerers          patient to look at his own hand. A malingerer,
often use a weak solution of the drug, or delay      especially if ignorant, will now and then purposely look
                                                     elsewhere than at his hand, whereas, a person blind for
their appearance for examination until the pu-       either a short or a long time, experiences no difficulty
pillary dilatation has somewhat subsided. Dila-      whatever in fixing either of his hands with his visual
tation of the pupil being an almost constant           Burghardt 's test.-This is a modification of the
resuilt in amaurosis, the absence of this symp-      Schmidt-Rimpler test, the person being requested to
                                                     put out the forefinger of one hand, and then touch the
tom is exceedingly significant. Also, contrac-       tip of it with the forefinger of the other hand. People
tion of the pupil to light, or consensual reaction   actually blind experience no difficulty in doing this, but
                                                     the malingerer is unlikely to accomplish it.
(i.e. reaction of the pupil of the other eye when       Attitude Test.-The amaurotic person has a staring,
the light is applied to the alleged blind one)       fixed, unmeaning look of the eyes, which is very soon
                                                     acquired by those who are really blind, and which is
forms strong ground for suspecting simulation.       familiar to the oculist.
                                                        Of some importance also is the short stepping of the
   There are rare cases, however, in which, in       really blind, together with the upward turning of the
the presence of actual blindness, the pupillary      face, and a generally "listening" expression. Threat-
reflex for light is still maintained. Such are:      ening movements towards the person will occasionally
                                                     throw him off his guard, care being taken to make no
   (1) When the lesion is situated high up in        noise, or set current of air in motion, as these often
the optic pathway above where the fibres of          alarm persons truly blind. Sometimes an individual 's
                                                     ability to see has been elicited by suddenly bringing a live
the reflex arc branch off to the centre for the      mouse before his face. Observation of these cases, when
pupillary movements.                                 they are unaware that they are being observed, often
                                                     reveals undoubted evidence of their ability to see.
   (2) When the lesion is in the visual area in
the occipital cortex. The lesion in both cases         Detection of malingering of monocular
would need to be bilateral, otherwise, hemian-       blindness.
opsia, and not total blindness of an eye would          1-farlan 's test.-Place a pair of trial frames on the
                                                     patient. Before the seeing eye place a 10 dioptre con-
result. This is therefore very rare. It may          vex lens. Have patient read while both eyes are open-;
occur in uraemia, but is temporary, or other         if he succeed, it is with the eye he claimed to be defective,
                                                     and his answer indicates approximately the degree of
severe symptoms develop.                             his visual acuity.
                     THE CANADIAN MEDICAL ASSOCIATION JOURNAL                                                         905
    Prism and Maddox rod test.-Begin by covering the              Test with 6 dioptre- convex spherical lens.-The normal
 supposed blind eye, and by placing the prism so that it       eye is rendered myopic with the 6 dioptre convex
 only partially covers the pupil, show him that he can         spherical lens placed before it. The test type is placed
 see two lights with the one eye only. Then expose both        very close to the eyes and the patient requested to read.
 eyes and introduce the Maddox rod. If he see both the         Gradually move the test card away from the eyes until
 red streak and the light, he must be seeing with both         it is beyond the focus of the seeing eye. If the person
 eyes.                                                         continues to read, he is reading with the alleged blind
     Double prism test.-Place double prism with bases          eye, and the degree of vision is approximately measured
 together in, such a way as to produce monocular diplopia.     thereby.
 If he see three lights he is seeing with the alleged blind       Test with colored letters.-The transparent coloured
 .eye.                                                         letters (red and green) alternating, and on black back-
     Cuignet test.-A lighted candle is brought before the      ground, are much used in this test. With the red glass
 good eye, and is slowly carried towards the blind eye.        placed before the sound eye, if he be then able to read
 Patient is detected if he still declares he sees the candle   the green letters, he must be seeing with the eye sup-
 when it has reached a position where it is concealed from     posed to be blind, as the green letters are not transmitted
 the sound eye by the nose.                                    through the red glass, green being the complementary
     Bar-reading test.-Direct the person to read from a         colour of red.
 book, holding quite still both the head and the book.             Letters are written on white paper with a black and
 Insert a pencil or narrow ruler vertically between the         a red pencil alternately. The person is told to read the
 eyes and the book. If he continue to read uninterrup-          letters rapidly while a red glass is placed before the
 tedly, he is undoubtedly seeing with both eyes, because,       sound eye. If he read the whole of the letters, it is
 did he not see with one eye, such letters 'as were quite       proof that he is able to read with' the eye he claims to
 invisible to the other (on account of the pencil inter-        be blind, for the sound eye, looking through the red
 vening between that other eye and those letters), he           glass, cannot see the red letters, since these now offer
 .could not read them. Words unrelated in sense are best        no contrast to the background which also appears red.
 for this test, as there is less liklihood of the obstructed    The acuity of vision in the supposed blind eye can also
 words being guessed.                                           be estimated by this test.
     Alfred Graefe test.-Have the person hold the pro-             Detection of simulation of bilateral amblyopia.-It is
  fessedly bad eye closed. Then set before the sound eye        always ground for suspicion when the person in reading
 a prism in such a position that the thick edge thereof         aloud the test type, declares that he can read no further,
 extends horizontally across the pupil. The person, of          although, thus far, he has made no mistake in identi-
 course, sees double, a fact that he will readily admit,        fying all the letters. A truly honest reader will almost
 because, so far, the professedly unseeing eye has not          invariably miscall the most difficult letters (for in-
 been called in question. Then have him uncover the             stance B or S) in one line, before declaring his inability
 "unseeing" eye, the examiner at the same time moving           to read any of the letters of the next. Again, if he
the prism so that it completely covers the pupil. If he         miscall only certain letters in a line and these are the
 still see double, he is seeing with the alleged blind eye.     easiest letters in that line (for instance T and L), this
-This test has an especial advantage in that, unknown           is ground for some suspicion.
 to the person the visual acuity of each eye can be ac-            Repeated tests made with test cards ending with lines
 curately estimated. This is accomplished by having             of different sized type on different days or occasions of
'him read first one, and then the other of the twin images.     testing (as Snellen 40 on one occasion, Snellen 20 or 10
    In simpler form this test may be carried out by plac-       on another), will now and then suffice to expose the
 ing a 10 dioptre prism before the sound eye. If he             simulation of bilateral amblyopia, the malingerer believ-
 admit seeing double he is seeing with both eyes. Here,         ing that on each occasion, he should, to be consistent,
however, when the alleged blind eye is manifestly under         leave off reading at exactly the same number of lines
 examination he will not invariably confess to seeing           from the bottom of the card.
 double.                                                           Unsuspected observation from a neighbouring apart-
    Crossed diplopia test.-Place a prism (8 or 10               ment is sometimes resorted to, and occasion-ally from
*dioptre) before the alleged blind eye. If that is a see-       such a coign of vantage, the person will be observed to
 ing eye it will make an excursion inward, involuntarily,      take up books and papers and examine them critically.
 for the sake of single vision.                                    In simulated amblyopia, the presence or absence of
    Vieusse test.- On a plain stereoscopic card are placed     mydriasis, and the presence or absence of the pupillary
two wafers of different colours, one red for instance, and     light reflex, are, of course, very much less to be depended
the other blue, at a distance in the case of each wafer        upon as tests for malingering than in eases of simulated
of ½2 cm. from a vertical line dividing the card in            amaurosis. In fact, simulated, bilateral, moderate
halves. When so small a distance separates the wafers,         amblyopia is the most difficult variety of important
viz 1 cm., the wafer on the right side of the card             ocular malingering to expose.
 appears to be on the left, and the wafer which is on the         Mirror test.-If the person is pretending to have only
-left side of the card appears to be on the right. The         a slight defect of vision, the test with the mirror in
 card is placed in a sterescope, and the person requested      one of the various ways is of value. Use a chart with
to look at the card through the instrument. If he admit        letters like H or 0, which appear the same both ways,
 that he sees both wafers, then of course he is seeing         or two -charts, one with reverse letters. Place the per-
 with both eyes. If, on the other hand, he confess to          son midway between a mirror and a chart at which he
seeing one wafer only, he is asked to state the colour of      looks, then have him read the smallest he can. Now
that wafer. He will almost certainly, if malingering,          have him turn halfway round and read them in the
name the colour of the wafer which appears to be on            mirror. The distance by the mirror is three times as
the- side of the sound eye, which unmasks him, as this         great and his visual acuity is measured accordingly.
is the one that would be seen by the alleged blind eye.           Tests for the simulation of the concentric contraction
    Perhaps a better way is to have a horizontal line on       of the viswl field, and scotomata.-This form of simu-
one of the halves of the card, a vertical line on the other,   lation is rare. Feigning concentric contraction of the
these lines occupying such positions that when seen            visual field is more common than feigning scotomata,
tlirough a stereoscope by a pair of sound eyes, they form      and generally the contraction feigned is of high degree,
a cross. If, then, a person really blind in one eyef looks     as moderate contraction would not constitite good ground
at this card through the instrument, he will see either        for heavy damages. The person should be examined on
the horizontal line only, or else the vertical line only.      various days, and the separate results written down and
1f he admit seeing a cross he is malingering.                  carefully compared. By taking the size of the field as
a whole, and also the size of the various scotomata             Actual detective work in such cases is sometimes
different distances, almost any malingerer can be            valuable, and at times such persons have been found
exposed.                                                     to spend a considerable number of hours in writing and
   lTests for the simulation of weakness and fatigue of      reading. Such a person may at times, for an attrac-
vision.-As genuine symptoms, weakness and fatigue are        tive wagfle, consent to copy fine print for many hours
almost always due to errors of refraction, to paresis or     daily or nightly, especially if he believe that he will not
paralysis of the ciliary muscles, to various affections of   be subject to damaging observation.
the extrinsic muscles, to or neurasthenia or hysteria.          Though much apparatus has been devised to detect
The physical signs of these various disorders will be        the malingerer, much of it ingenious, and some of it
present. Sometimes rapid exhaustion of the eyes does
really occur as an isolated symptom, and then the ques-      complicated, the tests herein referred to have been con-
tion of malingering or no malingering is very difficult      fined to those that may be carried out with the equip-
to answer. Repeated testing is unlikely to develop much.     ment that is common to every oculist's office.

                                        A. A. BRAMLEY-MOORE, B.A., M.D.


INJURIES,      or   at least   severe   injuries,   to the   came to an unexpected stop while he was riding
    eyes from broken spectaeles or eyeglasses                behind it. One eye was so severely lacerated
are fortunately of very rare occurrence, al-                 by a fragment of his broken spectacles that it
though it is possible many minor injuries                    had to be removed.
of this nature are never placed on record.                     One day early in December, 1915, while pre-
In 1914, Hans Lauber reckoned the frequency                  scribing glasses for a little boy, the mother
of this form of injuiry as one in thirty thousand            asked me, as mothers often do, if there was not
patients. Some writers incline to a very much                danger to the child's eyes from the spectacles
lower figure.                                                getting broken. I replied that I had' never seen
   I consider that minor injuries to the eyelids             a case of a child getting injured in that way.
from broken glasses are fairly common; that                  By a curious coincidence, before the end of that
injuries to the eyeball itself, while much less              month three cases of injury to the eyes by
frequent than injuries to the lids, are neverthe-            broken glasses came under my care, and one of
less- more common than a perusal of the jour-                the cases was that of a child. In the last eleven
nals devoted to ophthalmology would lead one                 years in Montreal I have had only eight cases
to suppose. The reason of this is that in the                of injury to the eye from broken glasses. In
great majority of cases they are slight super-               only one case was the injury so severe that the
ficial wounds of the cornea and selera, and are              eyeball had to be removed.
treated by the general practitioner, or if they                 In two cases the eyeball was so severely dam-
go to the outdoor department of a general hos-               aged that an operation for prolapse of iris had
pital are treated by the house surgeon on duty               to be performed, but in each case vision equal
in the out-door department, and recover so                   to one-half of normal was finally obtained.
quickly that they never come under the care
of an eye specialist; the slight injury to the eye              In two cases the injury was severe, but the
being often cloaked under a more obvious in-                 eyeball was not penetrated, and normal sight
jury to the lids and face, many of these cases               was obtained.
being the results of assaults or brawls.                         In three cases the injury was not dangerous.
   The first case of this nature that came under             In the case of the child the injury was received
my observation was in 1909 when acting as as-                while trying to spin a top.
sistant to Mr. Stephen Mayou at the Central                     In two cases the injury was received in a
'London Ophthalmic Hospital. A bicyclist                     fight, and one of these lost his eye which had
wearing spectacles crashed into a cart that                  to be removed.

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