RE 48 G7 1918 OPTO UC-NRLF B ^ 4DD IfiM C BERKELEY LIBRARIES coasM^bsii '^N OPTOMETRY LIBRARY AQr\.fiA'tnr^r Uoll 642-1020 ^R MANUAL No. 3 |DI( ithorized by the Secretary of War • the Supervision of the Surgeon-General \i the Council of National Defense |:ary Ophthalmic Surgery [LLEN greenwood; m:B. jlErT.-COLONEL, MKIHCAL CORPS, U. S. A. ARY LIEUT.-COLONEL, HARVARD SURGICAL UNIT WITH THE Y MEDICAL CORPS, BRITISH EXPEDITIONARY FORCE Chapter on Trachoma, Other Contagious |cTiv.\L Diseases and Gas Conjunctivitis G. E. DE SCHWEINITZ, M.D. -lEUT. -COLONEL, MEDICAL CORPS, U. S. A. AND A IChapter on Ocular Malingering WALTER R. PARKER, M.D. COLONEL, MEDICAL CORPS, U. S. A. \d edition, thoroughly revised llluatrateO LEA & FEBIGER LADELPHIA AND NEW YORK 1918 €R 7 DAYS Y PHONE w RNIA, BERKELEY 94720 ^1^ *|^V»*A V* ^« V'*- -* ?r« *..*:!. »#^*»%i^% l#^^ mM* MEDICAL WAR MANUAL No. 3 Authorized by the Secretary of War and under the Supervision of the Surgeon-General and the Council of National Defense Military Ophthalmic Surgery By ALLEN GREENWOOD,' M.d. ' lieut.-coloneL, medical corps, u. s. a. recently honorary lieut.-colonel, harvard surgical i'nit with the royal army medical corps. british expeditionary force Including a Chapter on Tr.\choma, Other Contagious Conjunctival Diseases and Gas Conjunctivitis By G. E. de SCHWEINITZ, M.D. LIEUT.-COLONEL, MEDICAL CORPS, U. S. A. AND A Chapter on Ocular Malingering By WALTER R. PARKER, M.D. COLONEL, MEDICAL CORPS, U. S. A. SECOND EDITION, THOROUGHLY REVISED TllluettateO LEA & FEBIGER PHILADELPHIA AND NEW YORK 1918 (^1 BIOLOGY UBRAR^f G COPYRIGHT LEA & FEBIGER 1918 PREFACE TO THE SECOND EDITION. Owing to the absence of Lieut. -Colonel Greenwood on overseas duty, it has not been possible to secure the achantage of his revision of the section devoted to Military Ophthalmic Surgery. The Editor has added a few paragraphs, suggested by his experi- ence abroad, distinguished by being placed within brackets, the most important of which are: Con- tusions Hypotony; Cartilage Prosthesis; Implanta- tion after Remote Enucleation; Technic of Extrac- tion of Intra-ocular Metallic Foreign Bodies in British "Eye Centers" in France. The chapter on Trachoma has been revised by its author and an additional operative procedure, the one recommended by the trachoma experts of the Public Health Service, has been included. The chapter on Examination of Malingerers has also been re\'ised by its author and the tests for detecting simulated l)ihiU'ral blindness have been added. The authors express their high appreciation of iIk' cordial reception which has been accorded to this small manual and trust the new edition may find fa^'or among those for whom it was written. LlEUT.-COLONEL DE SCHWEINITZ, i«4:^iii (iii) Editor. PREFACE TO THE FIRST EDITION. This hand-book has been compiled with the idea of providing, in condensed form, suggestions that may be helpful to medical officers who have to deal with the special ophthalmic problems which arise in the daily routine of active army medical work, especially in the dressing stations and hospitals throughout the war zone. The surgical methods described have proven their worth in hos- pitals in the British Army. The book is in no sense a complete treatise on ophthalmic surgery. For the multitude of ophthalmic operations and procedures which are common to civilian as well as army life a reference to the well-recognized text-books is suggested. The many operations, therefore, such as plastics, which will be required for later army and civilian reconstruction work, have not been included or described here. Realizing the danger of trachoma and its spread in an army and understanding the tendency of recruits to malinger, the author appreciates to the fullest extent the great advantage of the chapters on Trachoma and Malingering so kindly con- (iv) PREFACE TO THE FIRST EDITION v t ril)u U'd by Drs. George E, de Schweinitz and Walter R. Parker, and extends his thanks accord- ingly. These chapters should be of especial value to the officers conducting cantonment examinations. A. G. Washington, 1917. CONTENTS. Military Ophthalmic Surgery .... 7 By Allen Greenwood, M.D. Trachoma and Common Forms of Conjunc- tivitis; Gas Conjunctivitis .... 61 By G. E. de Schweinitz, M.D. Examination OF Malingerers . . . .113 By Walter R. Parker, M.D. (vi) MILITARY OPHTHALMIC SURGERY. By Allen Greenwood, M.D., LIEUT.-COLONEL, M. C, U. 3. A. No previous war has afforded an opportunity for the work of the ophthalmologist such as the present conflict presents. Therefore a chapter on military ojihthalmic work will, of necessity, be largely a record of recent personal experiences. Many Eng- lish ophthalmologists have had a much wider exi)eriencc than the author, but during two seasons with the Harvard Surgical Unit, British Expedi- tionary Force, General Hospital No. 22, in France and consulting in the surrounding Base Hospitals an opportunity was afforded for observing and carrying out many varieties of ophthalmic technic. Of the sick and wounded soldiers who come into Base Hospitals, about 10 j)or cent, require some immediate examination or treatment of the eyes or surrounding structures, or subsequent examination and treatment. Of the cases requir- ing later examination the largest percentage are (7) 8 MILITARY OPHTHALMIC SURGERY furnished by those where fundus or visual field examinations are asked for by the internist and the brain surgeon. Many soldiers who have severe devastating body injuries may subsequently show signs of an apparently minor eye injury which has been masked by the graver illness, but which later proves lauch more serious. It is important that the general surgeon., as well as the ophthalmologist, shoald be alive to the po'^sibility of such occurrences. It is not a credit to the ophthalmic surgeons to have a soldier return to his home to convalesce following the loss of an arm or leg and have an iridocyclitis develop in one eye, as a result of an overlooked intra-ocular foreign body, and then to lose the other eye from sympathetic ophthalmitis. It is also important for the ophthalmic surgeon to care- fully inspect and watch the good eye while treating an injured one and it is equally important that any wounded soldier should have available for the examination and treatment of his eye injuries an experienced ophthalmologist. For still graver and more complicated eye conditions there should be also available for him an ophthalmic surgeon of even wider experience as a consultant. In the majority of late disco\'ered cases of intra-ocular foreign bodies the wound of entrance has healed and often cannot be found. The foreign body may have passed through the upper lid and the sclera into the vitreous, leaving no visible conjunctival wound. CONTUSIONS OF THE EYEBALL 9 and as the majority of men who enter the hospital liave been wounded or exposed to wounds the ophthalmic surgeon should always be on the look- out for undiagnosed intra-ocular foreign bodies. Any soldier who complains of a recent blurring of \ision of either eye should have a careful inspec- tion and ophthalmoscopic examination under mydri- asis, and if there is no circumcorneal injection, the pupil dilates readily and the vitreous appears clear, the presence of a foreign body is unlikely and the blurred vision due to some other cause, such as the amblyopia that is found in so-called cases of shell shock; but a suffused eye, with circumcorneal injec- tion and signs of uveal congestion or beginning iridocyclitis, should be viewed with grave suspicion and be subject to a careful x-ray examination. Small fragments of aluminum may not show by the .v-rays, but all other metallic bits will unless too minute. The author saw one patient where the track of a foreign body could be followed through the eye to its lodgment in the sclera above the macula. It was half a disk diameter in size, looked like silver, but on repeated trials gave no shadow with the .v-rays. There was no reaction and no attempts were made toward its removal. [It is important that every eye on which there is only a small patch of redness, which may conceal the entrance of a minute metallic foreign body, should be tested: "put up to the magnet," as the procedure is usiialK' called.] 10 MILITARY OPHTHALMIC SURGERY CONTUSIONS OF THE EYEBALL. Contusions of the eyeball are among the com- mon injuries seen and may vary from the slightest contusion, which results in a rapidly disappearing commotio retinae, to the severe hopeless case with a rupture of all the tunics of the eye, causing a gaping wound and extrusion of the globe contents. Between these two extremes will be found many grades, including single or multiple ruptures of the retina and choroid, with or without vitreous hemor- rhage; tears of the iris sphincter with hyphemia and permanent loss of reaction; iridodialysis, par- tial and complete lens dislocations, even to subcon- junctival luxations. These varying grades of con- tusions may be produced in many ways, such as direct blows on the anterior portion of the eye by spent or grazing missiles; sudden air expansions by nearby explosions or passing high-velocity bullets. Equatorial contusions are often produced by some portion of the surrounding bones being driven against the eye, or the vibratory effect of their being struck, the malar bone and the outer ridge of the orbit being particularly vulnerable. Posterior contusions may be produced by bullets, shrapnel balls and pieces of shell casing entering the pos- terior part of the orbit. One soldier was obser^'ed who had a bullet which had entered behind the left ear and finally penetrated the left eye, so that the point could be seen with the ophthalmoscope V ^ coyrusiONS of the eyeball ii (Plate I). I'or the large anterior ruptures, involv- ing all the tunics, with extrusion of most of the globe contents, enucleation is necessary. For smaller anterior ruptures, with iris or ciliary prolapse, the treatment by conjunctival keratojDlasty as described later is applicable. Treatment of the dislocated lenses is described in the paragraph devoted to traumatic cataracts. For other cases of contusion \ery little immediate special treatment is necessary. Rest and the application of compresses wrung out of ice-water are extremely useful in most cases for the first twenty-four hours or longer. One should always be on the watch in cases of partial lens dislocation for the secondary glaucoma which occa- sionally occurs, and for this reason the routine use of atropin is to be avoided. Unless the outer coat is ruptured bandaging is inadvisable. For the after- treatment of eyes that show vitreous blood-clot, massage, dionin and subconjunctival injections may help in the clearing, though often the blood-clots organize and a proliferating condition with subse- i quent shrinking results. [Contusion Hypotony. — The statement that reduced intra-ocular tension is an important sign of perforating scleral wounds, and especially of valuable diagnostic import, where, for example, a small penetrating wound of the sclera is covered with tumid and swollen conjunctiva, must not be accei)tc'd unreservedly in view of many observa- 2 12 MILITARY OPHTHALMIC SURGERY tions during the present war. In other words, reduced intra-ocular tension of the eyeball after injury and with only the slightest external mani- festations does not necessarily mean wound or rupture of the globe. The contusion caused in the manner already described may create a hypotony of short or long duration and be associated with grave internal lesions — vitreous hemorrhage, vitre- ous infiltrations, rupture of the choroid, etc. The lowered tension may be due to increased rate of excretion of intra-ocular fluid through expanded channels of exit, to paresis of intra-ocular nerves, to rupture of the pectinate ligament or to detach- ment of the pars ciliaris retinae.] WOUNDS OF THE EYEBALL. Most of these wounds are produced by flying fragments of shell casing, bits of exploding hand grenades, unburned cordite or sand and gravel thrown into the eyes by the explosion of shells among the sandbags of the trench parapets. Burns of the lids, conjunctivae and cornese from liquid fire or nearby explosions are frequent. Bullets and shrapnel balls cause many of the most destructive injuries, especially the former. Of the superficial wounds the majority consist of foreign bodies in the cornea, conjunctiva and sclera, and these are usually multiple. Many cases are seen in which the corneae are peppered by fine CONTUSIONS OF THE EYEBALL 13 metallic dust which mostly remains on or in the cornea, though occasionally some may be driven with sufficient force to pass into the iris and lens, when they have to be treated as intra-ocular for- eign bodies. The corneal foreign bodies can be remo\cd by using a spud or broad cataract needle. A well -sharpened gouge is very useful, or the point of a Beer knife and much time and patience and a steady hand are required for these procedures, llie point of the knife or gouge can be carefully worked beneath the foreign body and then by a slight lever movement the particle may be lifted out. Care must be taken not to push the particle through into the anterior chamber. Sometimes after a piece of steel, deeply embedded, has been loosened by the knife it can be drawn out by using the magnet. Soldiers are often brought in who ha\'e had one or both eyes peppered by unburnt cordite, leaving pasty yellowish masses embedded in the conjunctiva and cornea and in many cases in the iris and lens. The corneal masses may be largely remo\'ed, always exercising great care not to harm healthy tissue or penetrate the anterior chaml)er. The deeper and finer particles will grad- ually be thrown off and then the healing is usual!}' prompt. For good-sized pieces embedded in the iris an iridectomy with irrigation of the anterior chamber is usually advisable and attempts may be made to pick off the pieces lying on the iris which 14 MILITARY OPHTHALMIC SURGERY do not wash out with the irrigation. This particu- lar class of eye cases calls for a judgment and skill only to be acquired by actual experience. The lenticular cases will be considered under the para- graph devoted to traumatic cataracts. For the prevention of ulceration following the remo^•al of the foreign bodies one may use argyrol, White's ointment. Hydrarg. chloridi corrosivi ... . . gr. i .0081 Sodii chloridi gr. v .324 Petrolati 5v 155.52 nosophen ointment, Nosophen 3ij 8. Petrolati 5J 4- or simple boric acid flushings. For the prevention of pain nothing serves the purpose better than i per cent, solution of holocain, and in most cases atropin is advisable. Many cases of simple abra- sions of the cornese are seen and most of these present some ulceration. Fortunately the ser- piginous type of ulcer is almost never seen, but hypopyon keratitis is common. These abrasions yield readily to the holocain, argyrol and atropin medication. If the abrasion is fairly deep and a large ulcerated area left this may be made to heal much more quickly by covering it with a conjunc- tival flap. For lid burns, ice-water compresses and boric ointment are best, and for conjunctival and PENETRATING AND PERFORATING WOUNDS OF EYE 15 corneal burns the atropin and cocain alkaloid solution in castor oil. For finding small ulcers and abrasions and outlining them and to outline small corneal foreign bodies a solution of fluorescein is of great help and should always be at hand. The following is the formula for the solution: Fluorescein gr. viij .123 Liq. potassae 5ss 2. Aquae dest 5j 20.. '^i PENETRATING AND PERFORATING WOUNDS OF THE EYE. Such wounds of the eye will test the skill of the ophthalmologist more than any other line of work done in the Army Hospital, and it is here that the greatest good can be accomplished in the preven- tion of blindness. The most difficult problems are those w^here a penetrating foreign body remains in the eye instead of perforating and passing into the orbit or beyond. The method of treating these penetrating wounds with the presence in the globe of one or more foreign particles depends largely on the size and shape of the pieces and whether or not magnetic. When the penetrating foreign body is quite large the eye is usually so badly lacerated and so much vitreous lost that any attempt to remove the large and jagged piece would result in still more laceration and loss, so that such eyes should be enucleated, or if in a condition of well- established panophthalmitis, eviscerated. On enu- 16 MILITARY OPHTHALMIC SURGERY cleating these eyes it is usually found that the vitreous has been replaced by a large clot of blood and the extreme softness of such eyes with an absolute loss of vision constitutes an indication for early enucleation. Enucleation and Metallic or Glass Pros- thesis. — This brings up the whole question of the proper methods of enucleation, and the author wishes to urge at this time that soldiers so injured should have an operation that will provide for them a socket for the wearing of an artificial eye that will give the best cosmetic results. A man who has given his eye for his country deserves certainly no less than this. If it is thought desirable to do a simple enucleation the least that the ophthalmic surgeon can do is to sew the four recti muscles together; but, better still, some form of implantation operation is a much more advisable procedure, and every soldier should have the benefit of such when possible. In the ordinary Base Hospital, where much infection is always present, an additional wound of the body to obtain fat for implantation in Tenon's capsule is contra-indicated. During the summer of 1916 the author had the opportunity of implanting over thirty glass globes where it was necessary to do an ordinary enucleation. A glass ball of at least 18 to 20 mm. diameter was always used, for the use of this large size rendered the possibility of extrusion of the globe less likely, and PEXi:rRATI\G A.Wn perforating wounds of eve 17 this assertion was borne out by the fact that of those mentioned above as having been implanted all remained in. Gold balls are, of course, expen- sive, so that the implantation of the glass ball is surely the operation of election, and if carefully inserted with proper suturing of Tenon's capsule over the ball always before the suturing together of the muscles the likelihood of extrusion is largely eliminated. For the suturing of Tenon's capsule and the muscles as well as the conjunctiva, the author uses fairly fine twisted silk and the smallest full-curved needles. The silk thus buried beneath the conjunctiva is almost never seen again. In a pre\ious article^ the author has drawn attention to the great advantage of placing the sutures verti- cally in the conjunctiva in order to retain as long a palpable fissure as possible and thus avoid the dragging of the external canthus toward the center which results from a purse-string suture of the conjuncti\a. By the use of the above-mentioned size of globes, following the method outlined, one is able to pre\'ent permanently any sinking in of the upper lid such as will follow any other method. With a prosthesis in place and the lids closed there should be no difference in the appearance and level of the two up{)er lids. Any soldier who obtains ' Enucleation wilh Implantation of Hollow Gold or Glass Ball; A Plea for its More General Adoption, Archives of Ophthalmology, 1914, vol. xliii. 18 MILITARY OPHTHALMIC SURGERY less than this after enucleation is not receiving the best results possible. [Cartilage Prosthesis. — The implantation of glass or gold balls in the manner described in the previous paragraph does not meet the favor it has received from American surgeons among English and French ophthalmic surgeons. Mayard, for example, places himself on record that plastic surgeons are a unit as to the superiority of natural tissues in contrast to metallic or glass prosthesis. He is satisfied that transferred cartilage establishes fresh communications with the bloodvessels in its vicinity, and becomes fixed to the capsule in recent enucleations. Even if the cartilage after implan- tation is transformed into a species of fibrous tissue, it is believed by many surgeons that the cosmetic result is not disturbed. For the purpose of making cartilage implantation, generally the eighth rib is selected and the globe of cartilage removed with a trephine of such size as is suited to the conditions. The cartilage having been introduced within Tenon's capsule it is sutured to the inside or, if possible, the four straight muscles are attached by means of sutures to this cartilage sphere; the rest of the oper- ation proceeds as has already been described. It has been stated that such grafts may be used even in the presence of septic eyes or septic sockets. Such use of cartilage implantation, that is, in the presence of septic sockets, the editor did not witness during PEXErRATI^'G AXD PERFORATING WOUNDS OF EYE 19 his senicein France, and therefore cannot personally state whether the procedure would be wise or not. In place of human cartilage it is the practice of some surgeons, notably INIagitot, to use formalized cartilage taken from a calf- or lamb-rib. This is l^laced in formol, lo per cent., for three days, and afterward freed from the formol by successive washings in sterile water. It is most important that there shall be a thorough remo\'al of all traces of the formol before the cartilage is implanted, w hich can be shaped to any size that is rec^uired for the purpose of the implantation. Terrien recommends a graft of cartilage, generally rib cartilage, 1.5 cm. in length, to which the tendons of the rectus muscles are sutured. In default of the graft prosthesis he greatly improved the appear- ances by using artificial stumps of hard ebonite shell in an envelope of soft India rubber, which was molded to the bottom of the conjunctival sac, or molds of wax were placed behind the artificial eye. It is perfectly possible to improve badly formed sockets after primary enucleation by the implanta- tion of a glass or gold ball into the orbit, an opera- tion to which Webster Fox gave the name "implan- tation after remote enucleation of an eyeball." Should this operation be undertaken, for example, on the right orbit, after the eyelids are separated by means of a speculum, the conjunctiva is grasped up and in above the inner canthus and the tissues 20 MILITARY OPHTHALMIC SURGERY are well pulled out. Next, a Beer knife or curved keratome is passed through the tissues somewhat obliquely and well down into the orbit and an opening made large enough for the insertion of the globe behind the tissues. This opening may be enlarged with curved scissors to the desired size. When ready a gold ball is inserted through the opening, which is closed with stitches, and over which a shell is placed, modelled after an artificial eye. The eyelids are then closed over this shell, which is left in place for twenty-four hours. The stitches are taken out on the third day. If the operation is to be performed on the left orbit the incision is made up and out, above the external rectus muscle, and the dissection carried out as previously described. In place of the implantation of a glass or gold ball a cartilage sphere or graft may be used and stitched into place, with the result of much improv- ing the appearances of the artificial eye, and pre- venting, or rather obviating, the unsightly or sunken appearance which only too often follows badly per- formed enucleations.] In the torn eyes that present a panophthalmitis, with or without an orbital cellulitis, the ordinary enucleation should have substituted for it an evis- ceration. The simplest method of doing this is to make a circular cut just back of the ciliary body and in front of the recti muscle attachments. The PENETRATING AND PERFORATING WOUNDS OF EVE 21 contents of the globe can then be scrubbed out with pledgets of gauze until nothing is left but the white sclera, which may then be cauterized lightly with crude carbolic acid. The dusting in of iodo- form powder helps to lessen infection and subse- quent purulent discharge. The pocket may then be filled with White's ointment. It is necessary to suture the conjunctiva or sclera, for the healing takes place \-ery rapidly with the formation of the customary quadrilateral shaped stump w^hich forms a fair substitute for the larger stump resulting from the glass-ball implantation. This is a very simple method of evisceration, and the after-results from the performance of a great many were in\a- riably good. The principal ad\antage of this pro- cedure lies in its not opening the optic nerve sheath and not disturbing the muscle attachments. For a torn and badly infected eye w^hich often has associated an orbital cellulitis the above method commends itself by its simplicity, ease of execu- tion and excellent results. In fact, healing after this method takes little longer than that after a simple enucleation and without special discomfort to the patient. [Colonel Lister, of the B. E. F., has advocated and practised the enucleation of a septic eye with this modification, namely, that a fringe of sclera, about lo mm. in width, is allowed to remain and surround the optic nerve entrance, avoiding, there- 22 MILITARY OPHTHALMIC SURGERV fore, opening of the optic nerve sheath and the danger of conveying infection through this route.] For the very large number of penetrating wounds showing by direct inspection, or the x-rays, the presence of one or more foreign bodies in the globe, the question of the method to be adopted for the early remo\'al of the foreign particles must be considered. About two-fifths of these intra-ocular foreign bodies are magnetic and, if such be the case, removal of these by some form of magnet is usually the desirable method. Most of these magnetic particles lie in the vitreous chamber and some operators will prefer to attempt the removal of these by what is called the anterior and some by the posterior method, through a scleral incision, while some may remove them by way of the original wound. The choice of these three routes- will depend largely on the size, shape and location of the foreign body. If one is to use the anterior route, which is only applicable to fragments of small size, a giant mag- net, or what the author calls "the arm magnet," of nearly equivalent strength, is necessary to give sufficient power to draw the foreign body carefully from the vitreous, through the zonule, and thence around the lens into the anterior chamber. When the foreign body has thus been drawn into the anterior chamber it may be removed through a corneal opening by further application of the large PKMETRATIXG A.XD FI^RFORATI XG WOUNDS OF EYE 23 mai2:nct, or the hand magnet may be substituted for the large magnet in order to complete the operation. In order to start the foreign body on its passage through the vitreous a repeated turning on and off of the magnet current may coax the particle for- ward, but the moment a bulging of the iris indicates Fig. I. — Arm magnet. its presence in the posterior aqueous chamber the current must be turned off and the direction of the e\e changed so that the pull of the magnet when the current is turned on may be parallel to the surface of the lens. I'or larger foreign bodies in the \itreous, and for such operators as prefer it for the smaller also, the posterior route may be chosen, and for this class a very careful .v-ray localization is especially essen- tial. In operating a conjunctival flap is laid back 24 MILITARY OPHTHALMIC SURGERY from over the selected point in the sclera, then a puncture is made in the latter and the rounded tip of the hand magnet applied to this opening, or the pointed tip may be passed into the vitreous to the Fig. 2 vicinity of the foreign body, the current applied and the particle withdrawn. The incision in the sclera should always be made meridionally to avoid, so far as possible, cutting vessels, and may be held open by one of the little non-magnetic scleral PEXETRATIXG AND PERFORATING WOUNDS OF EYE 25 retractors de\'ised for this purpose. When the tip of the hand magnet is applied to the opening in the sclera the foreign body may be slow in coming forward and patience and persistence in the appH- cation of the magnet may be rewarded by seeing Fig. 3. — Illustrating pull from below. the foreign IhhW appear. There will also be a cer- tain number of cases in which the foreign body and the wound of entrance are of considerable size and the latter open. Here it may be most advisable to draw the foreign body out through its wound of 26 MILITARY OPHTHALMIC SURGERY entrance, especially in cases in which the lens has already been damaged. When using the magnet Fig. 4. — Illustrating pull from above. in this way care must be taken to turn the current on and approach the eye to the magnet slowly, so as to avoid too sudden a jump of the foreign body. PENETRATIXG A XI) PRRFORATING WOUNDS OF EYE 27 One would not like to see the whole of a patient's iris on the magnet tip. As complete a dilatation of the pupil as is possible is advisable before any magnet operation. The postoperative treatment and bandaging is the same as after any intra- ocular operation. The author's therapeutic prefer- ence being atropin, argyrol, iodoform and White's ointment, as indicated. The most fa\-orable cases are those in which the magnetic foreign body lies anterior to the vitreous, either in the anterior cham- ber, iris or lens. Those in the anterior chamber can be readily removed through a small corneal incision by the use of the hand magnet. If it is entangled in the iris an effort should be made to disentangle it by careful use of the hand magnet or forceps, and if this is unsuccessful an iridectomy should be done and the foreign body brought out with its surrounding iris. If it is embedded in the anterior portion of the lens it may be possible to draw it out with the magnet into the anterior chanibcT. from whirh it can l)c remoxed. If it is deeply embedded it is advisable to wait until the lens becomes opaque, when both can be removed at the same time. A large particle anterior to the \ itreous is more likely to be followed by permanent good results than a smaller posterior one, [The technic almost universally employed by British ophthalmic surgeons in the B. E. K. for the 28 MILITARY OPHTHALMIC SURGERY extraction of intra-ocular foreign bodies includes the use of a giant magnet, for example, of the Haab type, or one of equal drawing power, and a small magnet for the removal of the body after it has been drawn into the anterior chamber. As Whiting and Goulden record the general principles of the method adopted, they are these: The wound of entrance is disregarded from the point of view of extraction unless there is a large, unhealed wound in the cornea or sclera, which would be strongly suggestive of the presence of a large foreign body in the vitreous, which it would be hazardous to remove by any other path. Almost universally the foreign body is drawn forward through the suspensory ligament of the lens into the posterior chamber and next through the pupil into the ante- rior chamber. From the latter chamber, through a suitable corneal incision, the foreign body is removed by means of a small magnet. Referring to the x-rays and localization of the foreign bodies, so universally practised in our country, these authors state that its assistance is by no means essential to successful treatment, and if localization is likely to involve several hours' delay it should be omitted. The editor noted how much attention was paid to pain as a sign of the presence or not of the foreign body while watching the work in British hospitals in France, some magnets being supplied with a PENETRATING AND PERFORATING WOUNDS OF EYE 29 special extension point for exploring the surface of the sclera in order to detect the spot of pain. The foreign body having been drawn into the anterior chamber, if the eye is red and tender it is usually recommended that the final stage of the operation shall be done under the influence of general anesthesia. The corneal incision is made above, about 3 mm. below the limbus, the point of the knife being directed straight toward the foreign body and the incision completed without any lat- eral movement. So successfully is this done that very little aqueous is lost. The extension point of llic magnet is next directed outside of the cornea immediately over the foreign body and the foreign body is gradually coaxed along the posterior surface of the cornea into the corneal incision, through which it is withdrawn. This method, briefly summa- rized, meets with the approval of Colonel Lister and is the outcome of a very great experience; but until the end-result of these magnet extractions are carefully tabulated it will be impossible to state with accuracy how they compare with those which follow careful localization and removal of the body by the scleral route. After the removal of foreign l)odies a treatment with atropin ointment and iced compresses is advisable.] In cases that present themselves with a posterior intra-ocular foreign body which is non-magnetic 30 MILITARY OPHTHALMIC SURGERY there is usually very little that can be done. Occa- sionally one will see a case in which the vitreous is still clear and the particle can be easily seen with the ophthalmoscope. \Mth a properly placed scleral cut the operator may with the electric ophthalmoscope see to guide a special pair of foreign body forceps within the eye, and in this way be able to seize and withdraw the particle. Occasion- ally, also, the x-rays may show the foreign body, by very careful localization, as lying in or on the sclera, and if so it may be possible to cut down directly onto and remove it. In the majority of these cases, however, enucleation becomes neces- sary, and in one eye removed by the author for multiple intra-ocular foreign bodies five were found in the vitreous, of which only one was magnetic. In some cases, particularly when a foreign body like aluminum is embedded and there is no reac- tion, it is much better surgery to leave the eye alone. It is a well-known fact that frequently an eye tolerates an encysted or embedded foreign body indefinitely, and therefore before removing such eyes the surgeon should give nature all the opportunity consistent with safety and comfort. The operator must never consider that having removed a foreign body from the eye his work is done, for it has in reality only begun. He is still confronted by the danger of severe iridocyclitis, I'EXETRAriXG AND PERFORATING WOUNDS OF EYE 31 vitreous disturbances or retinal separation. For the two latter conditions very little can be done, but for the former much may be accomplished. The moment an iridocyclitis appears likely the atropin used should be increased in strength and instilled more frequently. The effect of atropin may be made more potent by the use of 5 to 10 per cent, solution of dionin, and this result can also be accomplished l)y the frequent use of hot fomentations. Whenever available leeches should be apj^lied to the temple, and the ophthalmic surgeon should ncxer forget that the eyes he is treating are a i)ari of the body and their welfare is strongly infhi- ciiced by the general physical conditions. Soldiers who have been forced from their active life to C()mi)lete rest are likely to become constipated, and this should be carefully looked out for. In the beginning of the iridocyclitis the author has l)laced great reliance on the use of calomel in two- or three-grain doses, followed by a saline. Inunc- tions of mercury ha\e seemed to be of ser\ace in combating this condition, and for pain the use of fairly large doses of aspirin or salicylate of sodium. If in spite of treatment the iridocyclitis persists and the vision is lost it is necessary that the eye shuld be enucleated to prevent the possibility of sympathetic inilammation in the sound eye. >i 32 MILITARY OPHTHALMIC SURGERY Conjunctival Keratoplasty. — When the re •moved foreign body is of considerable size it ofter becomes necessary to adopt some method of seal ing the wound to minimize the danger of infection and such cases come under the same category as the penetrating wounds of the anterior portion of the eye, which occur in considerable numbers, without foreign-body inclusion. These wounds occur of all sizes and in all locations, from the small perfora- tion near the limbus, with its protruding knuckle of iris, to the one that splits the cornea from limbus to limbus with iris prolapse at each end and a traumatic cataract presenting in the center. These wounds are mostly made as a result of a piece of shell casing striking some part of the bony ridge, which stops it, but not before some edge or corner of the flying missile has cut the eye; or a flying piece may pass across the front of the face, cutting lids and eyeball, to embed itself finally in the base of the nose or even in the other eye, making it impera- tive that everything possible be done to save the cut globe. Many cases are seen in which one eye has been torn out or into shreds and the other eye cut by the same missile. It is for such cases that the greatest skill of the ophthalmic surgeon is enlisted, and the author has come to have the greatest con- fidence in a well-performed conjunctival kerato- plasty as giving by far the best results. It is advis- PENETRATING AND PERFORATING WOUNDS OF EYE 33 able to make the conjunctival flap and have the Biitures inserted before clearing up the wound or cutting off the iris prolapse, thus lessening the risk 3f vitreous loss. In removing the prolapsed iris it is always best to grasp the protruding bit and tease it out before cutting, so as to make the resulting coloboma larger than the wound and thus prevent adhesion to the edges. Where the lens is injured, so much as possible of the swollen sub- stance should be removed by suction, irrigation, or both. When the wound is peripheral it is sufficient to cut the conjunctiva from the limbus along half the circumference of the cornea, with the center of the conjunctival cut opposite the corneal or limbus ^vound. After undermining the conjunctiva it will be found possible to draw it nearly to the middle of the cornea. The subconjuncti\al tissue, with its rich blood supply and abundant adhesi\'e exudate, ^vlll seal the wound quickly and allow the anterior rhamber to fill and atropin exert its influence. For :omeal wounds more centrally placed or for wounds extending across the cornea a second curved cut in :he conjunctiva, about 7 or 8 mm. from the circum- :orneal one, is required so as to fashion a bridge of :onjunctival tissue, which, by a suture above and Delow, can be drawn across the center of the cornea. In three or four days the bridge can be sutured 3ack onto its original position, lea\ing enough 3 34 MILITARY OPHTHALMIC SURGERY subconjunctival tissue In the wound to seal It per- manently and prevent staphyloma. By the above Fig. 5. — By passing the suture through a fold in flap and then through a fold above a firmer hold can be obtained and the anchoring hold should include episcleral tissue. (After Kuhnt.) Fig. 6. — Flap in place. (After Kuhnt.) method It Is possible to save many eyes that appear to be irreparably injured and frequently to save a PENETRATIXG AND PERFORATING WOUNDS OF EYE 35 useful amount of vision; and the author would make a plea at this time that some such attempt Fig. 7. — Bridge. (After Kuhnt ) s^L^^% Fig. 8. — Bridge in place. (After Kuhnt.) be made to save these apparently hopeless eyes, even if the cut passes through the ciliary body, for 36 MILITARY OPHTHALMIC SURGERY if good healing takes place under the conjunctival flap, without any iridocyclitis resulting, the danger of sympathetic ophthalmitis is practically elimi- nated. If, after such an attempt at conservative surgery, there does appear infection and iridocyclitis, then the eye can be removed, with only a few days lost, and long before the danger of sympathetic ophthalmitis. The author saw no patients with this justly dreaded complication during his service and in no case did severe iridocyclitis follow a well- executed conjunctival keratoplasty, performed on eyes showing no signs of infection at the time of operation. Two things to be remembered are first, the advisability of getting flaps ready and the sutures in place before cutting off the prolapse, and thus possibly exposing the vitreous and causing loss of the latter by the manipulations and second, making sure that the entire wound is covered by the flap of conjunctiva. For cases where the wound extends a long way into the sclera, suturing of this may be necessary, followed by modified flaps to conform to the condition. Here a double flap may be crossed over the wound. Even in cases where there is a large prolapse of iris or ciliary body that has been left several days and is very adherent the above method is still applicable and far better than using the cautery which the author never approves of. Touching the edges of the scleral and conjunctival cuts with tincture of TRAUMATIC CATARACTS, 37 iodin has been advocated and is a very useful procedure, and for the same purpose the author rubs in hnel\- powdered iodoform. TRAUMATIC CATARACTS. The treatment of traumatic cataracts, seen so fre- quentl}-, forms an important part of the work, and cases may be divided, for convenience of discus- sion, into those due to concussion and to those more frequently seen due to a perforating wound. The hitter may occur with, or without, the presence of an intra-ocular foreign body and after the rcmo\al of tlie foreign body these cases may all be consid- ered under the second of the above-mentioned di\isions. Several factors should guide one in the treatment of cataracts due to non-perforating inju- ries. One of the principal guides being the tension of the eye, for if this be low an attempt to remove the opaque lens is inadvisable. If, however, the tension is increased, showing a glaucoma secondary to the swelling of the lens, operative interference is a(l\isable rather than depending on myotics, unless the latter very speedily relieve the tension. The danger of iritic adhesions in such cases would ordinarily make one doubtful about using myotics, so that it has been the custom of the author to remove as much as possible of the swollen lens substance, leaving the remainder for future absorp- tion under the use of atropin and dionin. Where 38 MILITARY OPHTHALMIC SURGERY there is no pus tension and the opacity is not com- plete, it would be advisable to leave the lens alone unless the other eye has previously been lost; in which case operative interference may be demanded for the mental effect upon the patient produced by the restoration of vision. For these cases the ordinary combined extraction is advised without any extensive attempts to remove all of the cortical material, for these patients are mostly young and experience has shown that absorption of such remaining lens substance proceeds very rapidly. A dislocated lens should be removed if possible. When located in the anterior chamber the pupil should be contracted with eserine or pilocarpine prior to attempts at removal and at the time of removal a needle may be passed behind the lens to prevent its being pushed into the vitreous chamber. When the lens is located in the vitreous the ordinary cataract incision, preferably with a conjunctival flap and an iridectomy, may permit the operator to lift out the lens by using the vectis, with only a slight loss of vitreous. Where there is only a par- tial dislocation it would be better surgery to let the lens alone unless the advent of complications demands its removal. In the rare cases where the sclera has ruptured and the lens has been forced out of the wound and under the conjunctiva it is better to remove it and bring the scleral wound together either by scleral stitches or by anchoring TRAUMATIC CATARACTS 39 the conjuncti\a in such a way as to pull the wound together. This seems much better than leaving the lens until the scleral wound has healed. In the cases of cataracts due to perforating injuries, as a rule the treatment may be carried out at the time of the reparative work on the injured eye, especially if the lens is considerably broken up. For operating on eyes showing a swollen traumatic cataract the following procedure is advisable: Through the original wound if it still be open or through a corneal incision made with the keratome or Graefe knife the tip of the suction apparatus can be placed inside and a goodly portion of the swollen lens substance withdrawn. In doing this one must make sure that the anterior capsule is well open and retracted. Otherwise the suction apparatus will not take up the lens substance. The removal of the middle of the anterior lens capsule by means of capsule forceps is advised. The remaining portions of the lens substance can be washed out with the irrigator or the irrigator may be used for the whole operation by those not wishing to use the suction apparatus. In some cases it may be possible to remove the greater portion of the lens substance by massage of the cornea, though the author much prefers one of the foregoing methods. After the removal of the lens substance the iris, which has been displaced or extruded during the procedure, must be put back 40 MILITARY OPHTHALMIC SURGERY either with the stream of water from the irrigator or a repositor, and if it does not go back readily and smoothly an iridectomy should be performed. Atropin both before and after the operation will help to prevent adhesions between the iris and the strands of lens capsule. Where a very minute fragment has passed through the lens and been removed by the magnet either by the anterior or the posterior method the lens injury may safely be disregarded, for in some cases the lenticular opacity will be permanently confined to the part of the lens through which the fragment has passed. PENETRATING WOUNDS OF THE ORBIT. Here again the treatment will depend largely on the presence or absence of a foreign body. Many of the bullet wounds involving the orbit are through and through, and several were seen by the author where the bullet had passed through the apex of both orbits from side to side, cutting the optic nerves. Except for the direct injury produced and the consequent filling of the orbit with blood such through-and-through bullet wounds are usually not attended by complications in healing, unless too great a degree of proptosis results. This may also be true of the round lead shrapnel bullet, which may enter the orbit without causing much damage and be removed, leaving the important orbital struc- tures intact (Plate II). All this, however, is not ^ PLATE II X-ray of shrapnel ball which entered the orbit between the eyeball and the lacrimal bone. It passed just behind the eyeball and was removed, leaving the latter uninjured. ; PLATE III X-ray of piece of brass shell timer located in right frontal sinus, having passed through the left eye and left frontal sinus. J PENETK.\.TING WOUNDS OF THE ORBIT 41 true of other forms of missile, especially the jagged l)ieces of shell casing which are very likely to pro- duce an orbital cellulitis that may be caused by the Bacillus aerogenes capsulatus. The author has seen 5 cases of such gas-bacillus infection of the orbit, with one death. Removal of the offending foreign substance from the orbit and free drainage, with the use in the most severe cases of Carrell's tubes, will usually take care of orbital cellulitis. Careful localization by means of the .T-ray is of first importance before making attempts to remove intra-ocular foreign bodies, to determine whether they have passed outside of the orbit, or may be intra-orbital. In many cases It will be found that they have passed into the brain cavity, requiring a craniectomy for their removal. For such cases a specially devised brain tip for the arm magnet may be of signal service. Such a brain tip has been previously suggested by the author for the Lancaster arm magnet and is about the size and shape of the ordinary blackboard crayon. P^oreign bodies which have passed through the orbit may also be located in the frontal sinus or ethmoid and after .v-ray localization be removed (Plate III). Experi- ence has shown that if such foreign bodies have passed through both the orbit and ethmoid into the brain cavity there usually results a fatal meningitis. Two of the author's cases, however, where the foreign body had (lri\en the superior orbital plate y 42 MILITARY OPHTHALMIC SURGERY upward into the brain cavity were followed by recovery. In the case of small fragments that have passed into the apex of the orbit where attempts at removal might endanger the muscles and nerves it is wiser to refrain from interference unless subse- quently an orbital cellulitis develops, though it is not usual for small fragments to penetrate so deeply. One complication deserves especial mention here, for prompt treatment may result in saving an eye, or possibly an only eye. This refers to the neuro- paralytic corneal disturbances resulting from an injury to the orbital nerves and the corneal disturb- ances due to exposure where an orbital hemor- rhage or injury has caused excessive proptosis. These two conditions usually occur together and there should be added to them at this time the cases of corneal exposures from lagophthalmos due to an injury that has cut the facial nerve. The moment the cornea shows signs of loss of luster or beginning ulceration, and in selected cases even before the signs appear, the outer two-thirds of the lids should be sutured together. As the cases may be of long duration, especially those with lagoph- thalmus, it is best to pare the outer two-thirds of both lid edges, avoiding the lashes, prior to suturing, so that they may remain united as long as desired. This procedure leaves a small lid aperture through which the eye condition may be observed and treated and the patient see. If considerable ulcer- PENETRATING WOUNDS OF THE ORBIT 43 ation of the cornea has already appeared at the usual position, just above the lower limbus, better and quicker healing for this may be brought about by covering the lower half of the cornea with a conjunctival flap after curetting the ulcer and rub- bing in iodoform or tincture of iodin. Subsequent iri-atment depends on conditions as they arise, Tiie following case illustrates the above very well. Sergeant H. Entered the hospital after having been hit on the left side of the face by a large piece of shell which fractured both the upper and lower jaw, with multiple cuts in the parotid region extend- ing from the zygoma down to the angle of the man- dible. There was a good deal of loss of tissue in this region and the ear was badly torn. The injury was three days old and as a result of a complete lagophthalmus and exposure of the eye there was a deep corneal ulcer involving the lower quarter of the cornea. There was a hypopyon occupying the lower third of the anterior chamber which shifted on the patient lying on his side. The patient was in a semiconscious condition, but it was thought i)cst to make an attempt to save the eye. The usual conjunctival flap for such a condition was l^rcpared and the outer two-thirds of the lid edges were pared off, then the ulcer scraped, the anterior chamber opened and the pus allowed to escape, iodoform was rubbed in and the conjunctival flap drawn up over the lower half of the cornea. The 44 MILITARY OPHTHALMIC SURGERY prepared portion of the lids were then sutured together, White's ointment appHed and the eye bandaged. Twice daily after this the conjunctival sac was washed out through the aperture left between the lids near the inner canthus and atropin and argyrol instilled. After a few days of this the conjunctival flap pulled back, showing a perfect healing of the corneal ulcer. The patient left the hospital about six weeks later with the lids still held together and with excellent vision through the unsutured portion, the pupil fully dilated with atropin and the cornea showing a slight hazy cica- trix where the former ulcer had been. This expe- rience was repeated a number of times, so that this procedure can certainly be recommended in these desperate cases, [The danger of injudicious exploration of the orbital tissues and the tolerance by the orbit of foreign bodies have been described. Sometimes deeply situated foreign bodies may be secured, after x-ray localization, by resection of the temporal wall of the orbit: in one case examined by the editor the body — a piece of shrapnel — being situ- ated just at the apex of the orbit in contact with the optic nerve.] WOUNDS OF THE EYELIDS. WOUNDS OF THE EYELIDS In this war sc\ere wounds of tlie face ha\'e been extremely common and many of these have involved the eyelids, with or without some of the ocular wounds described abo\e. In some cases the lids are actually torn away and completely destroyed, so that subsequently careful plastic surgery becomes necessary. Pedicled fiaps may be used provided there, has not been a large destruction of surround- ing skin tissue. Otherwise, Thiersch grafts may be employed. No definite rules of procedure can l)e laid down because the cases vary so much and each indixidual case must be treated according to the conditions and along the lines that have proved best for the individual operator. Cuts and tears of the lids where the loss of tissue is slight or absent should be carefully sutured as early as possil)le. The greatest pains must be taken to see that the conjunctival portion is first accurately sutured and that the line of the lashes be restored before suturing the skin wound. Tin's is no less true when the e>e itself is destroyed, for in such a case the good appearance of an artificial eye may depend on the accuracy of lid suturing. When the cuts are multiple the usual condition, and especially through the inner canthus, a severe test is put on the operator's skill and patience. For the conjunc- ti\ al i)ortion of the cut, fine silk is the best suturing J }<. MILITARY OPHTHALMIC SURGERY material, and this is also used for the skin, though one may substitute horsehair, silkworm gut, or catgut. When the cut extends into skin beyond the lids silkworm gut affords the best material. Owing to the fact that many of these lid cases have been dealt with as open wounds until their arrival at the Base Hospital it is necessary that the wound edges be freshened before suturing. If subsequent infection takes place and the wound opens, plastic surgery becomes necessary later. It is not the purpose in this chapter to enter into a description of plastic work for restoration of lids and sockets, though of such work there will be plenty after the war. The present appeal is for the earliest possible suturing of lid wounds. PROPHYLAXIS. It is well to consider at this time the best method of preventing some of these severe eye injuries, and the author had worked out a tentative plan for a steel eye shield to be fastened to the soldier's helmet. On taking up the question with some of the author- ities in Washington it was found that Colonel W. H. Wilmer had, at the request of the Ordnance Department, devised a shield along similar lines and one that left very little, if anything, to be desired toward accomplishing its purpose. The author's shield had two stenopeic slits, one hori- PROPHYLAXIS 47 zontal and one vertical, while Dr. Wilmer's has a single horizontal stenopeic slit in front of each eye which allows for good vision, greatly enhances the strength of the shield and is by far the best. By extending the shield on each side it can be made to cover the temple region, thus including the outer ridge of the orbit and the malar bone. Such a shield if fastened to the helmet so that it can be swung up out of the way when not in use would, if the soldiers could be induced to wear them, lessen to a \ery great extent the number of eye injuries. A full description of Colonel Wilmer's ingenious device will probably be written by him. In devising such shields with a single stenopeic slit, the closer it can be brought to the eyes the better. The question of whether it is advisable to make the eye shield tight enough to keep out lachrymatory gases by careful f)adding and placing some transparent material behind the opening can only be decided by actual experience. Such a tight shield might cause a steaming of the transparent material and prevent its use. It might possibly be more advis- able to have the gas mask entirely separate from the shield and make no attempts to keep the latter air-tight. 48 MILITARY OPHTHALMIC SURGERY EYE CONDITIONS THAT ARE AN EXPRESSION OR DIAGNOSTIC SIGN OF DISEASE OR INJURIES ELSEWHERE. Retinal and optic nerve alterations may be found in the so-called trench nephritis. To see these signs at their height one must examine the nephritis cases as soon as they enter the hospital, for the slight optic neuritis and retinal edema seen in at least 75 per cent, of the severe cases is very ephem- eral and subsides as rapidly as the general edema. Rarely hemorrhages may be seen but no sign of vessel or retinal degeneration. One of the most important services of the ophthalmic surgeon lies in his examination for eye signs in all cranial injuries whether they are simple concussions, furrow wounds, fractures or penetrating wounds, and a load of responsibility rests upon him, for the general surgeon frequently bases his decision as to oper- ating on the report of his ophthalmic confrere. Most of the severe local head blows made by glancing bullets or shrapnel balls (the so-called furrow wounds), or an impinging but not penetrat- ing piece of shell casing, which have resulted in splintering of the inner table, or the brain destruc- tion which may occur without any splintering whatever, will sooner or later give rise to increased intracranial pressure, the first sign of which is a rapidly developing disk-edema which quickly in- creases to a choking of the disk. In these cases EYE CONDITIONS 49 the condition from the start is of the choked disk or intracranial pressure type, where the swelling is confined almost wholly to the nerve head even when it is raised several diopters above the sur- rounding retina. This type of optic nerve change can thus be differentiated from the inflammatory type which is seen in the cases that develop menin- gitis. Here besides the swollen nerve head there is an extension of inflammatory disturbance for some distance out into the retinal tissue, with fre- quently hemorrhages and exudates. Thus it is possible in some cases to differentiate between intracranial pressure and meningitis even in the early stages of these conditions. When the nerve change is due to increased intracranial pressure a trc'phining over the injured brain area, which allows for the removal of an extradural or intradural blood-clot or disorganized brain substance, results ill its raj^id disappearance. A recrudescence of these ner\e conditions would indicate a return of the intracranial pressure, demanding further inter- fiTence. When, howev^er, the inflammatory neu- ritis type is seen it usually indicates a purulent meningitis for which little can be done. For the injuries of the back of the head besides a fundus insjjection there should be a careful testing of the \isual fields. Such an examination will reveal many cases of varying types of hemianopsia from the complete homonymous hemianopsia to hemian- 4 50 MILITARY OPHTHALMIC SURGERY opic scotomata and quadrant defects. Frequently it will be found in the long furrow wounds across the occipital region that the brain lesion as shown by the hemianopsia is on the side not indicated by the most severe portion of the scalp injury. For a treatise on the very careful working out of such fields the reader is referred to an excellent one by Holmes and Lister {Proceedings Royal Society Med- icine, June, 1916). Some of the hemianopsias will recover following operative interference, but some will not. When the hemianopsia is not accom- panied by optic nerve changes and there are no other indications for operation and the bone unin- jured, operation is not advised. Various paralyses of the third and sixth ocular nerves may result from basal fractures and are interesting from the stand-point of localization, but have no special bearing on the question of prognosis or treat- ment. [Almost always a papillary swelling appearing soon after a cranial injury indicates a developing choked disk. Disk changes occurring at a later period may be papillo-edemas (choked disks) caused, for example, by a cyst, or papillitis (optic neuritis) in association with brain abscess in men- ingitis. Bilateral choked disks which arise weeks and months after cranial injury are of grave import in that they indicate a serious intracranial lesion which has escaped notice. Hence the impor- REFRACTION 51 tance, as has bccMi pointed out, of frequent ophthal- moscopic examination after all cranial injuries.] PSYCHONEUROSES. It is not within the scope of this book to enter into a lengthy discussion as to the various forms of psychoneuroses which often accompany the so- called shell shock. Many cases of amblyopia are obser\'ed and some of them have been proved to be similar to the hysterical amblyopia seen in civil life. Some soldiers with night-blindness come under the same category, though several seen showed typical retinitis pigmentosa and were evidently affected before entering the service. REFRACTION. Each Base Hospital should have a trial case and frames so that emergency refraction work can be done for officers and such of the personnel as may require it. It is, however, not the purpose of this book to go into the subject of refraction. When a Special Hospital is reasonably near the Base Hos- pital such work can be better done there. A full equipment is necessary in each Base Hospital for performing the various tests for detecting malin- gerers. The description of such tests by Colonel Walter R. Parker is given in Section III, and is very complete. 52 MILITARY OPHTHALMIC SURGERY From my experience and observations while doing the eye work for Base Hospitals aggregating nearly ten thousand beds I have become firmly convinced that with the large groups of Base Hospitals handy to them there should be established a Special Hos- pital so that men with seriously wounded eyes might have the care that is given to such cases in the many civilian Special Hospitals found so necessary in the industrial centers in this country. The more remote Base Hospitals are from the home country the greater the need of a Special Hospital in the war zone, as much for the beginning of reconstruction work as for the acute cases. Men in Field Hospitals whose principal injury is obvi- ously a severe one of the eye could be tagged and sent directly to the Special Hospital, while men in Base Hospitals requiring treatment best afforded by the Special Hospital could be transferred in a few hours, as shown by actual experience. Such a Special Hospital could have a much more extensive equipment than the average Base Hospital. There should be an operating building with at least two operating rooms, one for the infected cases and one for the non-infected. In the latter various types and strengths of magnets should be installed. An x-ray room should be provided and placed in charge of an Officer thoroughly familiar with intra- ocular foreign-body localization. The x-ray oper- ator in the average Base Hospital has not this REFRACTION 53 familiarity and as a rule has not the time to develop such. One American who has recently published nearly one thousand foreign-body records is recog- nized as one of the finest rontgenologists and for- eign-body localization experts in the world, and it would certainly seem wasteful to ask such a man to take care of the few cases requiring such experi- ence that would come to the average Base Hospital when in a Special Hospital so much greater use might be made of such unusual ability. A dark room in the operating building is necessary for fundus and retinoscopic work and some of the wards should be arranged so that they could be darkened. A long vision room with trial cases and all the equipment necessary for the best refraction work should be provided and one or more expert opticians with all the tools and supplies required to grind and cut out lenses and adjust frames. A good supply of already cut round cylinders and spherocylinders could be carried and the correct axes be obtained by simply turning them in the frames. Lastly, but by no means least, the nurses in such a hospital could be chosen from those hav- ing special training in some of the Eye and Ear Hospitals. Such a hospital might be made part of a Special Hospital for head, ear, face, and jaw injuries, there being, of course, great need for early reconstruction work along all these lines. Some such scheme for the employment of special men has 54 MILITARY OPHTHALMIC SURGERY for some time been followed by the Continental Army Medical Departments and it is becoming more evident every day that the best reconstruc- tion work begins as soon as possible after a soldier has been wounded, and in no line of surgery is early special work more necessary and productive of good results than ophthalmic surgery. It has been impossible in a condensed account of personal experiences like this to cover in detail all military eye work, but it is the hope of the author that helpful hints may be found in it for the oph- thalmic surgeons who go fresh from civilian practice into Army Hospital work, and that they may be stimulated by it to careful attempts to do conser- vative eye surgery for the soldiers who give so much. It is also hoped that, from the above, a realization of how frequently severe multiple eye injuries occur in trench warfare and how impor- tant the saving of sight is, both to the soldier and the country, may stimulate men of wide ophthalmic experience to serve, and the army heads entrusted with the lives and sight of soldiers may be induced to see that such experienced men are made a\ail- able for the wounded. The niceties of skill and judgment necessary to handle the multitude of severe cases can, however, only be acquired by actual experience, for the author cannot agree with those who consider that military ophthalmology differs from civilian only in degree but not in kind. AR^[Y CASE OF EYE INSTRUMENTS 55 How many civilian ophthalmic surgeons, if any, have treated gas-bacillus infections of the orbit and face, and how many have treated eye and orbital injuries due to high-velocity bullets? In reality there are many eye conditions seen which are entirely new even to men of large experience in industrial accidents. The following list 'of instruments necessary for a Base Hospital is here included: Army Case of Eye Instruments. Model of 191 7. (In Mahogany Case.) Quantity. Curette, chalazion (Mayhoefer), medium i Cystotome (Graefe) i Canahculus knife (Bowman), fle.xible shank 2 Forceps, advancement (Reese's) i Forceps, cilia, plain i Forceps, chalazion (Lambert's) i Forceps, entropion (Desmarres) i Forceps, fixation with catch 2 Forceps, iris, angular, mouse-toothed 2 Forceps, trachoma (Noyes's), i up and i down 2 Forceps, trachoma (Prince's) i Gouge, sharp-pointed, V-shaped i Iris hook, sharp (Tyrell's) i Iris scissors, full curved 2 Knives, cataract (Graef's), assorted sizes 3 Irrigator, anterior chamber i Knives, scalpel type, medium size 3 Knives, needle (Knapp's), medium size 3 Keratome, angular (Jaeger's), medium size 3 Lens, spoon, metal (Graefe's) i Lens, spoon, metal (Daviel's) i Lens, condensing, 2 inches broad, hard-rubber ring i Lid plate, hard rubber (Jaeger's) i 56 MILITARY OPHTHALMIC SURGERY Quantity. Needle-holding forceps (Stevens's) 2 Lens, spoon, wire loupe i Needles, paracentesis i Needles, full curved, plain eye, cutting edge 12 Needles, half curved, plain eye, cutting edge, assorted 12 Ophthalmoscope (Loring's) i Probes, lachrymal (Theobold's), double-ended (set) i Retinoscope i Auxiliary Case. Cautery handle. Cautery tips (corneal set). Lachrymal (canaliculus) dilator. Fixation forceps (without catch). Iris forceps (curved 2, straight i). Capsule forceps. Trachoma forceps (Knapp's). Advancement forceps (Prince's). Entropion forceps (right and left angular) . Lid elevator, i additional. Keratomes, straight. Knife, cataract (Graefe's), 3 additional. Knife (Beer's). Knife, scalpel type, 3 additional. Knife, needle (Hays-Ziegler). Needle holder. Additional needles, 2 dozen curved. Scissors, straight, sharp-pointed. Scissors, straight, dull-pointed. Scissors, half curved. I speculum, additional (Weeks's). I spud, protecting handle. Tenotomy hook (Smith's). Tonotomy hook (Graefe's) additional. Trephine (Elliot's). ADDITIONAL EQUIPMENT NOT TO GO IN CASE 57 Additional Equipment not to go in Case. 12 soft-rubber ear syringes. I DeZeng box, with electric ophthalmoscope and retinoscope. 1 hand perimeter (Schweigger's), with 12 dozen charts. 2 magnets (Lancaster models), Thomas Gleeson, Boston. 2 pocket flashlights, with extra batteries. 1 corneal loupe (Berger's). 3 irrigators (Xew York Eye and Ear Pattern). Suction apparatus. Glass balls (i8, 20, 22 mm., 12 each, lead free). Projection lamp for illumination in eye operating. Apparatus for localizing foreign bodies (Sweet). Holgrem's stick of colored worsteds. Tonometer (SchiOtz's). Treatment case. Set of non-magnetic instruments. Instrument rack. Undines, 12. 2 solution bottles. 2 condensing lenses. I wall cabinet. 7 APPENDIX. INDICATIONS FOR ENUCLEATION. ^ 1. An eye with a wound so situated as to invoKe the ciHary region, and so extensive as to destroy sight immediately or to make its ultimate destruc- tion by inflammation of the iris and ciliary body reasonably certain. 2. An eye with a wound in this region already complicated by severe inflammation of the iris or ciliary body, even if sight is not destroyed; or an eye containing a foreign body which judicious eft'orts have failed to extract, and in which severe iritis is present, even if sight is not destroyed. 3. An eye the vision of which has been destroyed by plastic iridocyclitis, or one which has atrophied or shrunken, provided there are tenderness on [)rt>>uri' ill the ciliary region and attacks of recurring irritation; or without waiting for signs of irritation. 4. An eye the sight of which has been destroyed, even though sympathetic inflammation has begun ' From Manual of Opluhalmolog>', prepared by the Sub-section ' "glandular" lids and acute con- junctival catarrh. Indeed, an attack of acute :onjunctivitis may precede the development of tra- :homa, or the active or acute manifestations may be due to an infection with the Morax-Axenfeld bacillus, the Koch-Weeks bacillus and even the ^onococcus. This is especially true in Egypt. Moreover, trachoma is essentially a disease of exacerbation, during which the process may be so active that it simulates the primary acute disease. Chronic Trachoma. — Chronic trachoma as originally defined is conveniently classified into several varieties. I. Papillary trachoma is characterized in typical :ases by an infiltration of the adenoid layer, which rushes up the thickened epithelium and by hyper- :rophied and congested conjunctival papilUc which nake it difficult or impossible to detect the "swollen ollicles" (trachoma bodies). The appearances arc lot unlike a chronic conjunctivitis of the non- Tachomatous type, and the thickening and redness )f the tissue may be so great that it somewhat •esembles raw beef. To this form of the disease the :erni chronic trachoma is often specially applied. iVhere the follicles (trachoma bodies) can be ietected lying among the greatly hypertrophied md inflamed papillse the process is sometimes lescribed as diffuse or mixed trachoma. (Plate IV.) 72 , MILITARY OPHTHALMIC SURGERY 2. Follicular trachoma is characterized by con- spicuous development of grayish-white or yellowish- red follicles in the fornices, often in rows along the upper margin of the superior tarsus, or irregularly placed in the tarsal conjunctiva, and not infre- quently invading the ocular conjunctiva and even the caruncle and plica. From fancied resemblances they have been called "sage-grain" or "vesicular" granulation, and have sometimes been likened to the appearance of frog-spawn. (Plate V.) 3. Cicatricial trachoma is characterized by the formation of grayish-white scar lines, often inter- secting the remains of old granulations, and later by diffuse scar tissue, atrophy and fibroid induration of the mucous membrane. (Plate VI.) Symptoms and Course of Trachoma. — In gen- eral terms the course may be divided into the stage of evolution, the stage of elaboration and the stage of cicatrization. Important to remember is the fact that the lesions may develop, especially in the upper retrotarsal folds, without antecedent inflammation, and so insidiously that their real nature is for a long time unknown to the patient, and undetected unless the lids are carefully in- ; spected after thorough eversion. At this time I there may be little or no abnormal secretion. Later the palpebral mucous membrane, often yellowish red in color, becomes unevenly rough because the tissue is filled with the growing and developing PLATE V .^0^W: '^^^H Follicular Trachoma. J ^\ PLATE VI •i^ "t Cicatricial Trachoma and Pannus. ^ TRACHOMA 73 'follicles." Even in this period, if the orginal )rocess has not been an acutely active one, abnormal ccretion may not be conspicuous. Still later the follicular and cellular masses com- )ress the conjunctiva and its circulation and corneal ;hanges become manifest in the beginnings of the io-called pannus (see page 74). As time goes on /ascularit>' increases, the follicles grow in size and ncrease in number, their contents may be forced )ut by surrounding infiltration and the hypertro- phy of the so-called conjuncti\al papilke becomes 1 conspicuous feature. During this process of fatty degeneration and softening of the follicles, or of -etrogression without softening, fresh eruptions of 'ollicles are taking place, which in turn go through the same changes which their forerunners have experienced. The conjunctiva is swollen, the )apillcT greatly hypertrophied and the follicles ire hard to find; indeed, they may be fused with lapilla?. The mucous membrane assumes a fiesh- -ed appearance, photoj)hobia is active, muco- :)urulent or purulent secretion is abundant and orneal changes are consjMcuous. These \arious itages may last for months, but ultimately invari- ibly trachoma results in cicatrization as the result )f absorption of the contents of the follicles and proliferation of the connective tissue of the con- unctiva. Although it is con\ enicnt to di\i(le the course of 74 MILITARY OPHTHALMIC SURGERY this disease into stages, it is by no means always possible to separate sharply one from the other by symptoms or manifestations peculiar to itself. Exacerbations are frequent, and these have given rise to the description of acute trachoma, because the irritative phenomena become intense, with scalding tears, great dread of light, corneal vascularization, ulceration and later mucopurulent discharge. To one of the important complications of tra- choma a brief reference has already been made, namely, pannus. Usually stated to be the result of long-standing granular lids, in its earliest stages it is often found soon after the follicular infiltration begins. It is a form of vascular kera- titis, and while the rough upper lid is a predispos- ing factor, it is not the true cause of pannus, which is probably due to contiguity and represents a form of direct infection. Usually the upper half of the cornea becomes hazy and small vessels proceed inward from the corneal loop toward the center. At first they lie between the epithelium and Bow- man's membrane, but in the later stages this mem- brane breaks down and the anterior layers of the substantia propria are involved. Pannus does not always begin in the upper portion of the cornea. It has been noted, for example by White, as com- mencing at the outer half, and in severe types the entire cornea is invaded. (Plate VII.) PLATE VII m Typical Tiachoma. TRACHOMA 75 \Micn tlio true corneal tissue is attacked ulcer- ation occurs, and such ulcers may be extensive and deeply placed. Iritis may be a complicating cir- cumstance. Xot infretiuently the corneal ulcera- tion is followed by perforation, the cornea may become entirely oi^acjue or it may be distorted by staphylomatous bulging. Occasionally, in place of an acnixx' ulceration, the ulce'rated area is indolent in character, and there may appear just at the apex of the pannus a shallow central ulcer with a slightly turbid base, which heals and leaves a faintly opaque facet. The amount of vasculariza- tion in i:)annus varies considerably. Sometimes onl\ a few \essels are present and sometimes the vessels are so thickly produced that the appearance is fleshy in character. Other sequels of long-standing trachoma are trichiasis, in which the lashes are misplaced and turn inward against the eyeball, and districhiasis, in which incurved rows of suj^plementary cilia are (lc\ eloiDcd from the intermarginal part of the lids. With trichiasis entropion, or an inversion of the lid, is often associated, and occasionally the oj^po- site form of lid misplacement is observed, namely, ectropion. These deformities of the lid and its border arise because of the chronic induration and scar tissue which always ultimately develop. This tissue, firmly attached to the tarsus, which itself is softened by lymphoid intilt ration, contracts and _; 76 MILITARY OPHTHALMIC SURGERY bends the lid and its border from their normal posi- tion. As the result of the induration of the mucous membrane there may be a practical obliteration of the conjunctival sulcus, the membrane under- going a form of drying up, to which the name xerosis or xerophthalmos is applied. Patients with advanced trachoma, especially in the cicatricial stage, often have a curiously sleepy look. They peer uncertainly through their narrow palpebral fissures, and the droop of the lid suggests in its appearance a partial ptosis. If, as is the case in the stage of increased purulent secretion, the pus glues the eyelids together the discomforts of the subjects of this disease are greatly increased. Although for the most part trachoma is confined to the conjunctiva of the lids, and is especially pronounced in the retrotarsal folds, the bulbar conjunctiva does not always escape and the lesions of the disease may be found In many cases in the plica and the caruncles, a situation which is of diagnostic import. Furthermore, in many of its subjects inflammation of the lacrimal sac is present (dacryocystitis) and trachomatous changes may be detected in the walls of this sac and even in the mucous membrane of the nose. Recently, Gifford has called attention to the frequency with which the inner end of the canaliculus is occluded in trachomatous patients in whom the disease is of long standing. TRACHOMA 77 Cause. — The cause of trachoma is unknown, and while there is no proof that microorganisms of the bacterial group, or blastomycetes, are etiological factors, it is the impression of Treacher Collins that the disease depends upon an organism of ultra- microscopic dimensions. If the morbid material from a trachomatous conjunctiva is transferred to another eye a disease like the one from which it came is apt to originate, and in this sense tra- choma is specifically communicable; but it is a contact infection and cannot be transmitted through the air. The danger of the spread of trachoma is greatly increased if there is such morbid secretion, and therefore it is that where the hygienic surround- ings are unfavorable and where the inmates of insti- tutions, barracks, armies, camps, etc., dwell close together and are uncleanly and careless in their personal habits, using common utensils, handker- chiefs, bed-linen, etc., the facility with which the disease may spread is greatly increased. In the discharge and in the follicle content of fresh untreated trachoma, less easily in granulated lids of long standing, small granules resembling diplococci were discovered by Halberstadter and Prowazek. Surrounded by a zone, hence called chhnnydozoa, they occur either isolated or grouped together within the cell next to the nucleus. These "cell inclusions" are often accompanied by small bodies in the protoplasm of the cells and outside J 78 MILITARY OPHTHALMIC SURGERY of the cells, which are called Lindner's ''initial bodies." Because the Prowazek bodies are com- paratively rarely present in other conjunctival dis- ease their detection is significant even though their nature is unknown, but their absence does not exclude trachoma. Also, they have been found in some types of ophthalmia neonatorum and in cer- tain forms of chronic conjunctivitis, and it is said Fig. 9. — So-called trachoma bodies — epithelial inclusions. (Axenfeld.) in their early stage in normal conjunctivae. When hrst discovered they were believed to be the cause of trachoma, but later this belief was abandoned (Fig. 9). Pathological Histology. — If trachomatous tis- sue is examined microscopically the following cellular elements will be found in the follicles: Lymphocytes, chiefly in the peripheral zone; mononuclear leuko- TRACHOMA 79 cytes, of whicli the greater portion of the folHcles is coniposcci ; phagocytes and certain accessory ele- ments, for instance, multinuclear cells. Beneath these follicles dilated lymph vessels are conspicuous and bloodvessels may extend into the follicles. The lymphadenoid tissue which surrounds the follicles is often densely infiltrated with leukocytes. ^i- <■.- . / ^ •\ ' ^ V -•^^^^ Fig. 10. — Trachoma of the retrotarsal fold: a, follicle; b, difluse infiltration: c, Henlc's gland with goblet cells; d, lymph vessel filled with leukocytes (X 39). (Holden.) This scar tissue probably depends upon a prolifera- tion of the connective tissue of the conjunctiva (Fig. 10). Diagnosis. — When trachoma is well de\'cloped in any of the varieties which have been descril)ed there is comparatively little difificulty in making a diagnosis, and if microscopic investigation of the J 80 MILITARY OPHTHALMIC SURGERY tissue Stained with the Giemsa material should reveal the Prowazek granules, this discovery would be a factor of importance in any case of doubt, but it would not be pathognomonic. In point of fact, up to the present time we are obliged to depend upon clinical signs in making a diagnosis. Usually a chronic conjmiclivitis or a chronic blennorrhea with enlargement of the conjunctival papillae can be readily distinguished from trachoma by the greater hypertrophy in the latter disease, and particularly by the thickening and induration of the tarsus. Venial conjunctivitis may be distinguished from trachoma by the flattened appearance of the granu- lations, often covered with a delicate film, as if brushed over with a thin layer of milk, the absence of infiltration and of pannus and by the history of recurrences at special seasons of the year. Also, eosinophilcs are conspicuously present in the secre- tion of vernal catarrh. Parinaud's conjtmctivitis, a rare disease, has some resemblance to certain types of trachoma. It is associated with swelling of the preauricular glands, and sometimes of the lymph glands in the neck and of the parotid and submaxillary glands. Tuberculosis of the conjunctiva, also an infrequent disease, should be distinguished from trachoma by the associated swelling of the lymph glands, and if there is any doubt, by submitting the tissue to a TRACHOMA 81 microscopic and bacteriological examination. The tuberculin test, however, would not be satisfactory, as in a good many instances it would appear that the injection of tuberculin has been followed by a reaction in what would seem to be typically trachomatous tissue. The theory that all follicles in the conjuncti\'a represent trachoma has often been maintained, and therefore the well-known Jolliciilosis of the conjunc- tiva, sometimes called follicular conjunctivitis, and characterized by small pinkish prominences in the conjunctiva, for the most part in the retrotarsal folds, and usually arranged in parallel rows, has been regarded by some obserxers as a form of trachoma and called follicular trachoma. Now, while it may not be possible in the early stages of trachoma to distinguish the so-called trachoma bodies from large lymphatic follicles, there is a distinct difference in the nature of the two conditions. In the folliculosis referred to the foUicks are benign; tlu'\- are smaller by more than one-half than the follicles of trachoma; they are in large measure confined to the fornices; they are never seen on the plica or the bulbar conjunctiva; pannus is not associated with them; and finally they disappear without leaving any scar tissue. And yet between these benign follicles and what Parsons calls the serious form of follicle which belongs to trachoma, border-line cases occur which > 82 MILITARY OPHTHALMIC SURGERY are extremely difficult to classify and of which no one has ever yet succeeded in writing a descrip- tion upon which a satisfactory diagnosis could be made. Hence the importance of investigating carefully during the inspection, for example, of sol- diers and recruits, every case of reddened conjunc- tiva, with or without the presence of follicles. If the follicles are irregularly present, and not dis- posed in typical parallel rows, and especially if they are deeply set and beginning induration of the tarsus is evident, the presence of trachoma becomes more than a suspicion. Moreover, even in its very earliest stages, as has recently been pointed out by Stieren and Van Kirk, in their search for trachoma among mill workers, loupe investigation of the upper portion of the cornea will not infrequently detect a very delicate ingrowth of vessels, the first beginnings of a pannus, not discoverable by naked-eye examination. This sign is an important one, and is not present if the follicles are benign. While it is well-nigh axiomatic to state that any granular disease of the conjunctiva which results in cicatrization is trachoma, there are a few other affections of the conjunctiva which give rise to scar tissue, notably pemphigus. But in this dis- ease, a very rare one, ulcers covered with mem- branes are evident, which precede the cicatrizing process, and the lesions of pemphigus elsewhere on TRACHOMA 83 the 1)()(1\ are discoN'cred !)>■ the historv' or by actual ()l)ser\ation and ser\'c to establish the diagnosis. The scars following burns of the conjunctiva are totalK' unlike those of trachoma, and the history is axailable, and the same is true of moderate cicatrization of the conjunctiva which is occasion- all\' seen after purulent conjunctivitis, and more freiiuenil) in connection with chronic blepharitis and its accompanying ectropion. The pannus of phlyctenular disease is usually unevenly or irregu- larly distributed, and is not largely confined, as in I he majority of cases of trachoma, to the upper half of the cornea. (See also p. 74.) Also, the historN of the two affections is totally different, and this applies to the pannus which sometimes follows trichiasis produced by conditions other than granular lids, for example, burns. Trachoma is often spoken of as a disease of adult life. This is a mistake; severe cases are found in \ery young children, and this has been especially triir in tlu' iincstigations of IMcMullen, Stucky, White and other surgeons, who hax'e had large opportunities of observing trachoma, as it occurs in the western portion of our own country, and especially in the Appalachian region. Treatment. — The treatment of trachoma natu- rally divides itself into medicamenlal, mechanical, chemical and operative procedures. As medicamental measures to check infccti\'e 84 MILITARY OPHTHALMIC SURGERY secretion, the usual antiseptic and slightly astrin- gent lotions may be employed. Those which serve the best purpose are saturated solutions of boric acid, equal parts of boric acid and physiological salt solution, bichloride of mercury (i to 5000, i to 10,000) and cyanide of mercury (i to 1500). The irrigations should be liberal, preferably with warmed solutions, and frequently repeated. To control the purulent quality of the secretion a solution of nitrate of silver (2 per cent.), painted over the diseased conjunctiva after thorough eversion of the lid, and neutralized after the white film forms by irrigations with physiological salt solution, is strongly indicated. For the same purpose argyrol (25 per cent.) and protargol (10 per cent.) are much employed. None of the silver preparations should be used for long periods of time lest argyrosis of the conjunctiva be produced, and on this account these preparations, especially argyrol and protargol, silvol and the like should not be given to the patient for home use. Recently a 0.5 per cent, oily solution of dichlor- amin-T has been recommended in the treatment of trachoma and has been reported as a useful agent to control abnormal secretion. It does not seem to the author to have advantages in this regard over other remedies, but it is only right that it should have a full trial before deciding as to its value in this disease. Abnormal secretion being in control, and espe- TRACHOMA 85 cially when eruptions of new granulations are asso- ciated with beginning cicatricial changes, sulphate of copper, abandoned by some practitioners, is in the judgment of the author an admirable remedy. A smooth crystal of sulphate of copper is applied to all portions of the affected palpebral conjunctiva, and the surface after a few minutes flushed with cold sterile water. An excellent application, which may substitute the copper stick, is a 5 per cent, solution of this remedy in glycerin, applied with a cotton mop, the patient several times a day instill- ing into the conjunctival cul-de-sac a i per cent, solution of the same preparation. To hasten the absorption of the follicles and to prevent xerosis of the conjunctiva, applications of boroglyceride (30 to 50 per cent.) arc useful, as is also tannin and glycerin, 30 to 60 grains to the ounce (1.95 to 3.9 grams to 30 c.c). During acute exacerbations of trachoma, so-called acute trachoma, in addition to the usual collyria, if there is iritic involvement, mydriasis is indicated. This may be secured with atropin sulphate, 4 grains (0.26 gram) to the ounce (30 c.c), or preferably with scopolamin hydro- bromate, 2 grains (0.13 gram) to the ounce (30 c.c.) of distilled water. ^ A corneal ulcer, if infected, should be cauterized with trichloracetic acid or ' 0( the many astringent and antiseptic applications which have been tried and recommended, only those which the author has found useful are mentioned. J I L 86 MILITARY OPHTHALMIC SURGERY carbolic acid, and in these circumstances holocain (2 per cent.) and dionin (5 per cent.) are of value. AIechanical MEASURES.^From the very ear- liest days trachoma therapeusis has included mas- sage, scraping and scratching. Massage associated with medicaments is more efficacious than simple massage, for example, by introducing a small massage glass ball beneath the lid and making counter-pressure on the cutaneous palpebral sur- face. As the result of long experience the late Dr. Charles H. Beard highly recommended the follow- ing procedure: After instilling one drop of adrenalin solution (i to 2000), a tightly wound cotton mop, dipped in a solution of bichloride of mercury (i to 250) is after eversion of the lid rubbed firmly over the affected conjunctiva for two minutes, the cot- ton being kept moist with renewed applications of the sublimate solution. Next, the conjunctival surface is thoroughly irrigated with a hot boric acid solution, followed by a drop of a 4 per cent, solution of cocain. This procedure should be repeated at two-day intervals, and on the alternate days the same type of massage is employed, save only that for the bichloride solution argyrol (50 per cent.) is substituted. The author has found this procedure of value, using the bichloride in the strength of i to 300 or i to 500, especially during the stage of lymphoid infiltration and decided follicular eruption, unassociated with much abnor- TRACHOMA 87 null discharge. In place of the bichloride mixture a solution of cyanide of mercury (i to 500) may be used. A more xigorous procedure than massage is the operation called brassage or grattage, which is per- formed as follows: After the patient is anesthetized the conjunctival sur- face is exposed in the manner already described. The trachomatous tissue is then deeply scarified, the inci- sions running parallel to the margin of the lid. The surface is next rubbed with the back of the scalpel and the conjuncti\a vigoroush' scrubbed with an ordinary tooth-brush carrying a solution of bichloride of mer- cury, 1 to 2000. If the palpebral fissure is very narrow, canthotomy should precede the operation. The after- treatment consists in measures to prevent adhesions between the folds of the conjuncti\a and the conjuncti\al cul-de-sac and the daily application of a sublimate solu- tion of the same strength as that originally used for at least a week following grattage. The subsequent treat- ment comprises the usual antiseptic lotions and applica- tions until cure is effected. D. H. Coover recommends that grattage be per- formed with strips of sterilized sandpaper, and D. W. White has designed an instrimient for the pur- l)ose, called silica trachoma rasps, made by fixing sand on orange-wood sticks. With brossage, how- ever accomplished, the author has had little experi- ence. As the late Dr. Beard remarked, it is not an extremely bad measure, but it is far from being 88 MILITARY OPHTHALMIC SURGERY as good as some others, and it has never appealed to the author. A description of the operative procedure used by the PubHc Health Service has kindly been furnished by Surgeon John McMullen, and is as follows : The eyelid is everted by means of a special forceps. Next by the use of two scalpels, one in either hand, the conjunctiva is gradually raised and the full extent of the cul-de-sac is exposed and the granulations are scarified superficially, begin- ning from the bottom and extending forward toward the ciliary margin. Succeeding this, in some cases, it is well to use a moderately stiff brush with bichloride solution i to 2000. The next step is to use fine mesh gauze sponges, and these are rubbed over the entire afi'ected conjunctiva until the surface is smooth and the hypertrophy and granulations have been removed. This can be determined by the reappearance of the small bloodvessels to view. The operation is completed by again everting the eyelid and thoroughly wash- ing out of the conjunctiva all blood-clots, etc., with a boric acid solution, followed by the instillation of two drops of a 20 per cent, solution of argyrol. The after-treatment consists in cleansing the eyes, every three hours, with a boric solution and the instillation of a 20 per cent, argyrol solution. This is continued for several days or until all sloughs have disappeared. TRACHOMA 89 The amount of traumatism necessary depends entirely on the individual case in hand, and the operator is guided solely by the necessity of each case. If a radical operation has been performed the eyes should be examined carefully for the next twenty-four to forty-eight hours for adhesions, and these should be broken up immediately. At the end of about one week following operation, if granulations or rough surfaces are found, these should be lightly touched with a 2 per cent, solution of silver nitrate, repeated two, three, four or more times a week. Expression. — This procedure is usually performed according to the method of the late Dr. H. Knapp, and often known as Knapp's operation : After the patient is etherized, or a submucous injec- tion of cocain is made, the upper lid is everted, seized at the convex border of the tarsus with a pair of fixation forceps, and drawn away from the eye so as to expose thoroughly the whole palpebrobulbar conjunctiva. If the tissue is infiltrated it may be superficially scarified, preferably with a three-bladed scarifier. One blade of the roller forceps is pushed deeply between the ocular and palpebral conjunctiva and the other is applied to the e\erted surface of the tarsus. The forceps is com- pressed with some force, drawn forward, and the infil- trated soft substance squeezed out as the cylinders roll over the surfaces of the fold held between it. This maneuver is repeated until all the morbid material has been expressed — in other words, to use Knapp's expres- sion, until the conjunctiva has been thoroughly milked. 90 MILITARY OPHTHALMIC SURGERY The lower lid is treated in the same way. During the operation the surfaces should be frequently flooded with a tepid solution of bichloride of mercury, 1 to 8000, and after the operation cold compresses may be laid on the lid for twenty-four hours. The following day the lids should be everted, and usually a delicate grayish Fig. II. — Knapp's operation for trachoma. (Hansell and Sweet.) layer of lymph will be found covering the entire area of operation. This should be removed, the swollen mucous membrane exposed and touched in the ordinary way with a solution of nitrate of silver, 5 to 10 grains (0.324 to 0.65 gram) to the ounce (30 c.c). Each day this treatment should be repeated until the swelling has TRACHOMA 01 subsided, when the daily application of a crystal of sul- phate of copper is advisable (Fig. 11), This operation the author has employed exten- si\c'h' and always in suitable cases with satisfac- tion. It is especially valuable in cases of spawn- like granulations (follicular trachoma) and diffuse hyalin infiltration, and may be used in cicatricial trachoma associated with patches of hyaline degen- eration. It is contra-indicated during an acute process, or if there is much purulent discharge. According to Weeks its effectiveness is increased if after the expression a germicide, e. g., bichloride of mercury (i to 2000), is brushed into the tissues. In place of the Knapp roller forceps the Noyes or Prince forceps may be used, or the expressor of Kuhnt, made of two coapting perforated metal plates, which has the advantage that it causes less traction on conjunctiv^al membrane. The expression operation has been radically modified by D. \V. \\'hite and P. C. White, in that they expose the tarsus of the upper lid by dissect- ing back its conjunctival covering and making a number of vertical incisions in the tarsus. Each vertical strip being rolled in the manner described, and the roller may also include the affected con- junctiva, this membrane afterward being sutured again into place. This modified roller or expression operation has the evident advantage of getting rid of tarsal lymphoid infiltration, which is not so well J i 92 MILITARY OPHTHALMIC SURGERY or not at all accomplished in the simpler procedure. The author has had no experience with this method, which, next to certain radical measures presently to be described, its designer considers to be the most satisfactory procedure. Chemical Measures. — This term has been applied to those procedures which include cauterization with various caustics and with the actual or thermic cautery, and may also include scarification of the conjunctiva, followed by electrolysis. None of these procedures possesses any real advantage, and severe cauterization is definitely contra-indicated. The x-ray treatment of trachoma, as well as its treatment by radium, bid fair for a short time to supply a new therapeutic measure in the treatment of this intractable disease. The author's own experience with the x-rays, while a limited one, yielded results which were indifferent, and May's observ^ations indicate that the effect of radium is not as favorable as that of sulphate of copper. Carbon dioxide snow has been employed, and recently Tyrrell, in England, has maintained that this agent represents one of the most successful methods of treating trachoma when the follicles are over the tarsus. The author's experience with carbon dioxide is too limited to enable him to express an opinion as to its effectiveness. Operative Measures. — In addition to the opera- tion of expression already described in connection with the mechanical procedures, it remains to TRACHOMA 93 briefly describe curettage; excision of the retro tarsal fold, or of a strip of the infiltrated fornix; removal of a part of the tarsus at the same time that the strip of infiltrated fornix is excised (the so-called combined excision) ; and extirpation of the tarsus (Kuhnt's extirpation). 1. Curettage. — This procedure has a very limited application, although it at one time was much practised. It consists essentially in excising indi- vidual follicles and removing their contents with a small curette, a tedious procedure, which is utterly unsuitable should there be extensive infiltration, and if i)ractised at all, is applicable only to those condi- tions in which small islands of follicles exist, or ha\-e escaped some of the other procedures which have been described. 2. Simple Excision. — Following a suggestion of Romer, a subjunctival injection of cocain (4 per cent.) causes the diseased transition fold of the conjunctiva to bulge forward, and makes plain a line of demarcation between the diseased area and the healthy bulbar conjunctiva. The convex margin of the tarsus is brought within the grasp of two pairs of forceps, and an incision is made in the healthy scleral conjunctiva close to the line of demarcation from the outer to the inner canthus. Miiller's muscle, which has a l)luish look, is usually recognized when the wound separates and the bulbar conjunctixa retracts. Next, three sutures are intro- duced through the margin of the bulbar conjunctiva, which is undermined. The next incision is so placed as to separate the transitional fold from the tarsus; the dis- eased tissue King between these two incisions, being > 94 MILITARY OPHTHALMIC SURGERY seized at the inner canthus, is separated from the under- lying tissue with blunt scissors and removed. Finally, the needles attached to the sutures already in place are placed through the edge of the tarsus and tied. This operation is of some service if the trachoma- tous process is largely confined to the transition folds, and there are no indications of serious lym- phoid infiltration of the tarsus itself. It is some- times quite effective in checking a developing pannus, and is nearly always, if the indication as given is strictly attended to, followed by improve- ment. Should the lower fornix be selected for this type of incision, and Kuhnt is accustomed in large measure to restrict it to this area, the upper lid is held back and the patient is required to look upward. Next, the surgeon everts the lower lid and excises the required strip of conjunctiva, begin- ning usually upon the outer side. In these lower fornix excisions sutures are rarely necessary. In both instances the operation should be followed by free irrigation, the operated area dusted over with finely powdered iodoform, and the lids bandaged. This bandage may be removed at the end of a couple of days, and the usual antiseptic irrigations employed. 3. Combined Excision. — This operation is a muco- tarsal excision whereby the affected transitional folds and the infiltrated part of the tarsus are removed. It may be performed as follows: 77\MC7/O.U.l After free eoeainizatioii of the eonjiinctix'a, the eye l)eing rotated downward, the upper Hd is doubly everted and held in position by means of two fixation forceps, Fig. 12.— Combined excision. First stage. (Wuotton, Arch of Ophthal.) in such a manner that the bulbar cT)njunctiva is drawn upward upon the surface of the tarsus. The first inci- sion, which should penetrate the conjunctiva alone, is made transversely at the juncture of the palpebral and r 96 MILITARY OPHTHALMIC SURGERY bulbar conjunctiva (Fig. 12), thus separating the dis- eased and healthy tissue. Injury of Miiller's muscle, Fig. 13. — Combined excision. Second stage. Ophthal.) (Wootton, Arch, of Tlie In 01 which lies directly beneath, must be avoided. The retracted bulbar conjunctiva is next separated from the jdliji, subjacent tissue for a distance of 4 mm. Three sutures TRACHOMA 97 armed with a needle at each end are inserted through the lower lid of the w^ound. I'^ollowing this dissection the lid is allowxxl to take the position of single eversion, and a horn or Jaeger plate is placed beneath the skin surface of the eyelid, the margin of which is pressed firmly u})on it (Fig. 13). Next an incision is made for the entire length of the lid 2.5 mm. from its inner mar- gin and exactly parallel to it. The lateral horns of the two incisions are joined by a short vertical cut at their external and internal extremities. Thus the boundaries Di the diseased conjunctiva and tarsus are fixed. The next step consists in dissecting up this area, care being taken not to injure the orbicularis or M tiller's muscle. How much of the diseased tarsus shall be removed lepends upon the severity of the condition and the dis- tribution of the lesions; usually the piece removed is about 2.5 cm. long and 1 cm. broad. Hemorrhage hav- ing been checked, the operation is completed by stitch- ing the margin of the bulbar conjunctiva to the rim of tarsus which remains, and it is important that the :onjunctiva shall be united exactly to corresponding points of the tarsal cartilage. The eye is closed, and the surgeon makes gentle traction on the middle suture in 1 direction vertical to the lid margin. The point where Lhe suture crosses the upper margin of the tarsal rim is grasped with toothed forceps, one blade being passed aeneath the lid, which is then everted. The suture is next passed through the upper margin of the tarsal car- tilage at the point designated by the teeth of the forceps, rhe other sutures are treated in like manner (Fig. 14). (n order to avoid pressure on the cornea the sutures nay be placed thus, following the method of von 31acowicz: The sutures are armed with two needles, yhich are passed entirely through the lid, the anterior 7 98 MILITARY OPHTHALMIC SURGERY one transfixing the upper margin of the cartilage, the posterior one the aponeurosis muscle and skin in close Fig. 14. — Placing of sutures. (Wootton, Arch, of Ophthal.) proximity. The sutures are tied over a roll of gauze, and may be removed on the fifth day.^ j 1 Many modifications of this operd,tion have been described. The ' one recorded here is condensed and somewhat modified from H. W. Wootton's description (Archives of Ophthahnology, vol. xxxix). D. W. White and P. C. White have evolved an elaborate technic, fully described (Ophthalmology', October, 1015), and are enthusiastic advo- cates of the removal of the tarsal cartilage and palpebral conjunctiva in the treatment of chronic trachoma. TRACHOMA 99 This operation, originally designed by Heisrath, and modified and improved by Kuhnt and other surgeons is suited to chronic trachoma with tarsal infiltration, to chronic trachoma with pannus inde- pendently of the tarsal condition, and in the so- called gelatinous trachoma of retro tarsal folds and with thickening of the tarsus. Excision of the Tarsus. — This operation is recom- mended by Kuhnt in some cases of chronic tra- choma with great thickening of the tarsus in the cicatricial stage. The structure is exposed through an incision running the whole length of the tarsal cartilage, 22 mm. from the free border. After exposure the tarsus is dissected from its position and detached from the levator tendon. Treatment op^ Pannus. — Ordinarily pannus sub- sides when the various measures which have been described succeed in dissipating the granulated sur- face of the palpebral conjunctiva. Formerly invet- erate pannus was often treated by means of the de W'ecker jeqiiirity method, to wit, producing a violent conjunctivitis with a 3 per cent, solution of this drug — a technic which has been abandoned. Jequiritol and jequiritol serum, introduced by Romer, have also ceased to claim attention. Not infrequently stubborn pannus is materially benefited by peritomy, or more properly, peridcc- toniy, which consists in excising a strip of the bul- bar conjunctiva about 3 mm. in width, surrounding 100 MILITARY OPHTHALMIC SURGERY the cornea, followed by scarification of the vessels at the Hmbus. In certain cases of advanced and old pannus remarkable results follow the dissec- tion from the cornea of the opaque and vascular tissue. It has to be done with skill and care lest the cornea be perforated, and is a method of pro- cedure recommended by the late Dr. Gruening many years ago. Should there be intense blepharo- spasm, and on this account dangerous compression of the cornea, or should the palpebral fissure be greatly contracted, the operation of canthoplasty is indicated. It is performed as follows: One blade of a pair of probe-pointed scissors is intro- duced behind the external commissure, and the entire thickness of the tissues is divided, making the wound in the skin a little longer than that in the conjunctiva. The wound margins are next separated, and the surgeon loosens the conjunctiva at the apex of the incision and frees it from the underlying tissue. Three sutures are passed, one uniting the extremity of the conjunctival flap to the center of the skin incision, and one suture above and one below, near the angles of the wound (Fig. 15). Division of the external canthus without sub- sequent introduction of sutures is known as cantJwtomy. If stenosis of the lachrymonasal duct is present, it must be rendered patulous, and chronic dacryo- cystitis treated by excision of the lachrymal sac. Prognosis. — Always a tedious disease and sub- ject to relapses and exacerbations, trachoma is curable if properly managed, and the improvement TRACHOMA 101 in prognosis has been evident since carefully applied mechanical measures and well-considered operative procedures have given place to, or been associated with, medicamental applications. This is no.tably true in the work of Dr. John McMullen, Dr. Siuck\- and many others in Kentucky and the Fig. 15. — Canthoplasty. The stitches ready to be tied. (Haab.) neighboring regions, and of the Drs. White and others in further Western States. The impor- tance of the early detection of trachoma before decided corneal complications and pronounced lid disturbance ha\-e arisen cannot be too strongly emphasized. 102 MILITARY OPHTHALMIC SURGERY Prophylaxis. — In camps, cantonments and bar- racks there should be systematic and repeated inspection of the soldiers' eyes after thorough ever- sion of the lids, and all suspects promptly isolated and kept from mingling with their fellows until the conjunctivse are entirely restored to a normal con- dition. It is well known that trachoma is often carried into armies from the outside; thus in trouble in this regard in the Allied Armies abroad it was largely through alien laborers that the infec- tion was introduced. It is of paramount impor- tance that the eyes of all recruits should be inspected before they are assigned to duty in the various camps and cantonments. This is particularly true where in our National Army recruits and drafted men come from those regions in which the preva- lence of trachoma among the civil population is conspicuous (p. 64). The ease with which the infection can spread, especially if in the eyes of the carriers purulent secretion is present, is well known, and the careless use of towels, linen, hand- kerchiefs and common utensils cannot be too strongly condemned. Civilian visitors and work- men coming from areas where trachoma is known to exist should not escape inspection, and if any of them have eyes which are not above suspicion, he or she should be forbidden to enter the military zone. ACUTE CONJUNCTIVITIS 103 ACUTE CONJUNCTIVITIS. A mild variety of this affection, l^nown usually as simple catarrhal conjunctivitis, in which only a moderate amount of mucopurulent secretion, con- taining generally only the ordinary pus-producing organisms, gathers, and which is contagious but not actively so, is readily managed. The eyes should be frequently irrigated with a saturated boric acid solution and the conjunctiva of the c\crted lid brushed with a i per cent, solution of nitrate of silver, or a 25 per cent, solution of argyrol should be dropped into the conjunctival sac se\eral times a day. This sufifices to dissipate the afTection in a few days. A more active manifestation of this disease, which on account of certain characteristic features may be regarded as a distinct affection, is acute contagious conjunctivitis, commonly known as "pink eye." In addition to marked edema of the lids, very free purulent secretion, often gathered into long strings, and subconjunctival hemorrhages are evident. In typical cases the affection is caused by the Koch-Weeks bacillus; but an almost exactly similar condition is due to the pneumococcus. Intensely contagious, this infection spreads rap- idly from one person to another, and where indi- \ i(Iuals are closely associated, as in schools, camps, etc., can speedily develop into an epidemic. The duration of the disease is usually from sLx to ten 104 MILITARY OPHTHALMIC SURGERY days. The prognosis is entirely favorable. (See Plate VIII.) The treatment does not differ from that already detailed, except that it should be more vigorous. In addition to the usual collyria, bichloride of mercury may be tried, i to lo,ooo. A mixture of sulphate of zinc, i grain (0.13 gram) to the ounce of sterile water (30 c.c), is valuable; iced compresses afford relief at the height of the affection. Argyrol is commonly prescribed, but it should not be too long continued. Brushing the everted lids with a I per cent, solution of nitrate of silver is useful, the excess to be neutralized with physiological salt solution. GONORRHEAL CONJUNCTIVITIS OF ADULTS. This can usually be traced to its source of con- tagion from an acute gonorrhea or a gleet, by contact with soiled fingers or linen or from an eye affected with this type of conjunctivitis, and like urethral gonorrhea is due to the activities of the gonococcus, which is readily detected in the pus after staining smears with the ordinary reagents, for example, methylene blue. (See Plate \'1 1 1.) Usually appearing within twenty-four to forty-eight hours after inoculation, its symptoms develop with great activity; rapid and tense edema of the lids; thick, greenish-yellow pus; chemosis of the bulbar conjunc- tiva, and unless the violence of the inflammation is quickly subdued, haziness of the cornea; ulceration PLATE VIII .-«a fra.F Fia.m Fig. I. — Discharge from right eye in a ease of purulent con- junctivitis ; gonococci numerous in cells (Stephenson). Fig, II. — Bacillus of ^A'^eeks in pure culture (from a photo- graph) (Weeks). Fig. III. — Conjunctival secretion from acute contagious conjunctivitis; polynuclear leukocytes with the bacillus of "Weeks; P, phagocyte containing bacillus of Weeks; immers. i\., oc. lii (Morax). Fig. IV. — Secretion from a ease of conjunctivitis, showing pneumoeocci ; immers. j'j, oe. iii (Morax). GOXORRIir.AL COXJUXCTIVITIS OF ADULTS 105 »f this membrane, which may quickly be perforated; )roIapse of the iris with all its evil consequences nay occur. Loss of the eye from the formation )f staphyloma, or sloughing of the entire cornea ind phthisis bulbi, is always iminent. The prog- losis is grave, and fully developed gonorrheal )phthalmia almost always eventuates in corneal ilceration. The follo\. ing method of treatment the author las found efficacious in a very large experience in :he wards of the Philadelphia General Hospital: i) The constant application of iced compresses, vhich in the earlier stages should be continuous, Dut as the inflammatory process subsides may be employed for periods of twenty minutes to half an lour every three or four hours. (2) The conjunc- :ival sac should be irrigated with sufficient fre- ijuency to wash away the rapidly accumulating 3US, using either the bichloride of mercury, i to ^000, or cyanide of mercury, i to 5000, or a satu- -ated solution of boric acid. (3) Into the conjunc- tival sac a 25 per cent, solution of argyrol should 36 instilled with sufficient frequency to keep the nflamed mucous membrane immersed in the fluid. The argyrol has absolutely no germicidal effect, but it is detergent, sinks to the bottom of the :ul-de-sac, and floats to the surface pus and mucus, kvhich can thus be readily removed. In place of irgyrol, protargol is advised, in 10 per cent, solu- 106 MILITARY OPHTHALMIC SURGERY tion, by many surgeons, but in the experience of the author neither the argyrol nor the protargol is usually sufficient, and certainly in addition to the argyrol once a day the lid should be everted and painted with a 2 per cent, solution of nitrate of silver, the excess to be neutralized with physiological salt solution until the white film which accumulates after the silver application has been thoroughly washed away. The lids are then returned into place and anointed with vaselin, some of which is per- mitted to enter the sac. The cornea must be watched with great care for signs of haziness or ulceration, and practically always it is necessary to keep the iris under the influence of a mydriatic, for example, a drop of a i per cent, solution of sulphate of atropin, two or three times a day. If there is great chemosis of the bulbar conjunctiva, and therefore great danger of corneal sloughing, incisions of this hard rim relieve the pressure. Occasionally in stubborn cases Kalt's method of using copiously, a pint at a time in continuous irrigation, a solution of permanganate of potas- sium, I to 2000 to 5000, once a day, acts most favorably. Naturally, the vigor of these applica- tions must be lessened as the inflammatory symp- toms subside. The spread of a corneal ulcer may sometimes be checked by touching it with trichloracetic acid, or liquid carbolic acid, care being taken to touch COXORRHEAL CONJUNCTIVITIS OF ADULTS 107 only the sloughing area. If one eye alone is affected, the other eye should be carefully protected by cov- ering it with a Buller's shield, made from a watch crystal carefully put in place with strips of plaster or gauze and collodion (Fig. i6). Much of the suc- FiG. i6. — Application of Buller's shield, (de Schweinitz.) cess of the treatment of this disease consists in constant attention, and a special nurse or a skilled orderly should be detailed for this purpose. Great care must be taken to destroy all cotton, cloths, etc., which come in contact with the inflamed eye. The patient should be isolated, and have his own set of treatment bottles, etc. 108 MILITARY OPHTHALMIC SURGERY DIPLOBACILLUS CONJUNCTIVITIS. This is a troublesome form of conjunctivitis, usually subacute in character, but sometimes so active that it assumes acute proportions. In the subacute types there is generally a moderate dis- charge, an irritability of the conjunctiva, and fre- quently a soreness of the commissural angles, so that the disease is sometimes called angular con- junctivitis. Many of the types of so-called sub- acute conjunctivitis, and even chronic conjuncti- vitis, are of this character. The diplobacillus of Morax and Axenfeld is most readily detected by smears, examined under the microscope stained for the bacteriological content. In these cases the ordinary collyria are of little value, and nitrate of silver is not of much use; in fact, of practically no use. The specific is zinc, and the lids should be everted once a day and touched with a i per cent, solution of sulphate of zinc, the excess being flushed off with boric acid, and the patient given a collyrium of sulphate of zinc, 2 grains to the ounce, to be used frequently. This is practically a specific. Other preparations of zinc are equally valuable, especially the sozoiodolate (i or 2 per cent.). GAS CONJUNCTIVITIS 109 OCULAR PHENOMENA OF "GASSING" (GAS CONJUNCTIVITIS). In the earlier periods of the war, drift- or cloud- gas attacks were delivered from compressed cylin- ders and carried over by means of pii)es, the gas being composed of chlorin mixed with phosgene. This type of gas caused, in addition to great irrita- tion of the respiratory tract, a smarting and prick- ing sensation of the eyes, followed by blepharo- spasm, photophobia, intense chemosis of the con- junctiva and well-defined and often violent conjunc- ti\"itis. In the majority of instances severe corneal lesions did not arise, but if the cornea was examined carefully by means of a loupe, small infiltrations were noted, especially in the periphery, and a kera- titis characterized by vesicle formation has been obser\-ed, as has been described by Major George Derby and other surgeons. It is probable tha^ the corneal changes were more frequent than the records seem to show and were not detected, owing to insufficiency of investigation. Occasionally eyes were lost as the result of severe and purulent types of keratitis, but this was a very rare complication. At the present time drift-gas attacks have been abandoned and their place taken by shell gas, the projectile being filled with liquid which is converted into gas by the explosion of the shell. Systematic writers have classified shell gas according to the effects into lachrymal or tear gas, of which benzyl bromide is the type; eye and lung irritants, for J no MILITARY OPHTHALMIC SURGERY example, chlorin ; lung irritants and asphyxiants, for instance, phosgene; eye and skin irritants charac- teristic of mustard gas. Lachrymal gas produces excessive epiphora, pho- tophobia and palpebral spasm. Its ocular effects are evanescent and serious results from the oph- thalmic stand-point are rare. Although it has been stated that phosgene has little effect on the eyes, it has - also been noticed that this agent may be responsible for a mucopurulent conjunctivitis, and sometimes phosgene and mustard gas appear to have been combined. Mustard gas produces extensive burns of the skin, particularly along the inner sides of the thighs, on the genitalia and where the skin is thin and moist. A large percentage of soldiers subjected to mustard-gas attacks present ocular lesions. The lids are swollen and may be covered with blisters or bullae; photophobia and lacrimation are intense and the conjunctival lesions vary from moderate hyperemia to pronounced injection, extensive white chemosis and edema, the affected conjunctiva somewhat resembling a mucous membrane which has been brushed with a strong solution of nitrate of silver. In the majority of these cases there is corneal involvement, roughening of the epithelium and sometimes well-marked band-like opacity of the cornea. Occasionally there are severe ulcers and even hypopyon-keratitis, but these dire results GAS CONJUNCTIVITIS 111 are comparatively rare. Occasionally temporary loss of vision has been noted. Whether this is due to the violence of the local reaction or to intra- ocular changes has not been satisfactorily deter- mined. Some French observers have described a form of retinitis. Many of the soldiers with mustard-gas conjunc- tivitis arc able to return to their Units at the expiration of three or four weeks, ultimate recovery being the rule. Occasionally, however, the con- valescence is much prolonged ; a few eyes have been totally lost. To give some idea of the fre- quency of the corneal complications, it may be stated that in an analysis made by Teulieres of 1500 men who had been gassed, there were only 23 with severe eye lesions, 3 corneal ulcers and I panophthalmitis. Sometimes nebulous cornea? result. Occasionally the leukomas are marginal, the central vision not being disturbed. The most satisfactory treatment consists in a lotion of a I per cent, solution of sodium bicar- bonate. Liquid albolene or paraffin is employed with benefit, especially if later irrigation with an ordinary saline solution is used. Apparently an ordinary oil, for example, castor oil, does not act as satisfactorily as the albolene or paraffin. Dionin has been recommended for the corneal complica- tions, but there is much difference of opinion with reference to its efficiency. As the pupils are apt J 112 MILITARY OPHTHALMIC SURGERY to be contracted and ciliary irritation is frequent, atropin is advisable. The eyes should be protected during the earlier stages with a shade or dark glasses, but the patients should be encouraged to to be up and about as soon as possible lest they pass into a stage characterized by photophobia and asthenopia, when really there are no local ocular lesions remaining to account for them. EXAMINATION OF MALINGERERS. By Walter R. Parker, M.D., COLONEL, M. C, U. S. A. Malingerers who wish to evade military service through feigning faulty visual acuity may be divided into three classes as follows: "A" — Those who claim total loss of vision in one eye. "B" — Those who claim partial loss of vision in one or both eyes. "C" — Those who claim total blindness in both eyes. Representatixes of any group may ha\e a normal acuity of \ision or may exaggerate a defect actually pre:^cnt. The visual rcciuirement for recruits l)cing for unlimited military service 20/100 in each eye correctable to 20/40 in one eye and for limited military service 20/200 in each eye correctable to 20 '40 in one eye, it is only necessary to prove that at least this amount is present, leaving the deter- 8 (113) 114 MILITARY OPHTHALMIC SURGERY mination of the actual acuity of vision for future examinations. In testing for malingering the medical examiner should bear in mind that detection is more likely to result when the man is allowed to believe that his case is regarded from the first as genuine and that his story is not discredited. There is something indefinable in the bearing of the malingerer w4iich experience alone can detect. He may be self- assertive and overconfident; he may be hesitating and evasive. Careful observation should be made of his conduct and every movement noted. The nature of the man's answer should be taken into account and considered in the light of the kind of reply that is given when a genuine refraction case is being dealt with. Equipment. 1. Trial frame, i blank, i green glass, i red glass. Spherical lens, +i6, -f-6, +3, +0.25, —3, -2, -I, -0.25. 2. Two lO-degree prisms. 3. Ophthalmoscope. Electric. 4. Condensing lens. 5. One loupe. 6. Snellen's malingering test glass (FRIEND) in red and green letters on glass. 7. Special test card. Instead of the single top letter representing 20/200, the scale should be rearranged so that it begins with the top letter EXAMINATION OF MALINGERF-RS 115 20/100 followed by two 20/70, three 20/50, etc., in imitation of the standard types. Thus the man who has been coached to read but four lines and reads them has passed the standard without being aware that he has committed himself. 8. Test card, with letters reversed for use in mirror. 9. Test cards, one line of type on each card and three cards for each size of letters. These cards are to be exposed to view at a distance of twenty feet, one card at a time. Thus the recruits do not know to which line the letter corresponds on the regular test card. 10. One stereoscope and cards. 1 1 . Retinoscope, electric and reflecting mirror. 12. Drugs. Euphthalmin hydrochlorate (disks if pos- sible;. Homatropin (disks if possible). Cocain hydrochlorate (tabloid if possible). Eserine salicylate (disks if possible). Methods of Examination. — CLASS "yl." — (Total loss of vision in one eye.) (a) A prism, base downward, is placed before the admittedly sound eye while the man looks at a distant point of light or candle flame. If he sees two lights, binocular xision is proved. The examiner may \ary the test by placing the prism before the "blind" eye, either base up or base down. ^ 116 MILITARY OPHTHALMIC SURGERY (b) A prism of lo degrees with base outward is placed before the ''bHnd" eye. If there is any sight in this eye, double vision will be produced and the eye will be seen to move inward to correct it and fuse the two images. (c) The "blind" eye is covered. A prism of lo degrees with the apex up is placed before the sound eye in such a position that its edge lies hori- zontally across the center of the pupil. This pro- duces monocular diplopia. The prism is then moved upward so as to be completely in front of the sound eye, and at the same time the "blind" eye uncovered. If diplopia is produced or admitted, there is sight in the "blind" eye. (d) Test with Colored Glasses and Letters. — This consists in directing the individual to read a row of red and green letters through a red and green glass. The red letters will be invisible to the eye that has the green glass before it and vice versa, but if all the letters are correctly read irrespective of their color, there must be sight in the "blind" eye. Further, the smallest letters correspond with the 20/40 test letters and if read at twenty feet indicate vision up to standard. To determine this, reverse the glasses and direct the letters to be read. As these letters are seen by transmitted light, the proper illumination back of the chart must be observed. EXAMINATION OF MALINGERERS 117 (e) Tests ivith Trial Glasses. — A high phis glass is placed before the sound eye and a low plus or minus before the "blind" eye. If the distant type is read, the vision in the "blind" eye is good. Or a plus 6 diopter lens is placed before the sound eye and the test type placed very close to the eyes and the patient allowed to read. Gradually increase the distance until the card is beyond the focus of the sound eye. If the patient continues to read, he is seeing with the alleged "blind" eye, if) The Stereoscopic Test. — This may be made with the ordinary stereoscope, the printed matter so arranged that certain portions of it are not present before one or the other eye. If the patient reads consecutively, he is reading with both eyes. This test may be greatly varied by using different symbols or figures, only a portion of which is present on each side so that it requires binocular vision to see the complete figure. {g) The action of the pupil must be carefully tested, there usually being no movement to light stimulation when the eye is blind. If the examiner is not satisfied the following examinations should be made: Oblique Examination. — A careful examination of the cornea should be made with the aid of a con- densing lens and a loupe. Ophthalmoscopic E.xamination. — A searching ex- amination with the ophthalmoscope should be made 118 MILITARY OPHTHALMIC SURGERY together with an estimation of the refractive error. The pupil should be dilated if necessary. CLASS "5."— Partial loss of vision in one or both eyes. The most common manifestation of malingering takes the form of a statement that one eye is imperfect, and men pleading this disability may be divided into two classes: (a) Those who pretend to have an optical defect. (b) Those who know they have an optical defect and exaggerate its effect. No hard-and-fast tests can be prescribed for the detection of these cases. Much depends on the alertness and ingenuity of the medical examiner. The tests with prisms are not applicable here, for there is not pretended blindness in one eye, but simply an alleged diminution of the visual acuity. Methods of Examination. — CLASS "B." (a) Special test card. (See equipment No. 7.) (b) Single line test cards. (See equipment No. 8.) (c) Trial frame test. Place a trial frame upon the man's face and put before the sound eye a high convex lens (-|-i6D), and before the blind eye a plain or weak lens (0.25) which will not interfere with vision. If letters placed at distance of twenty feet are read, the fraud is at once exposed. EXAMINATION OF MALINGERERS 119 (d) Mirror Tests with Special Test Cards. (See cquii:)ment No. 7.) — Test cards are used which are identical, except one has the letters reversed. The recruit is directed to read the letters on the chart across the room, and then in a mirror beside it, which reflects letters that are placed over his head. The letters seen in the mirror are located double the distance of the direct letters from the man being examined. The malingerer is apt to read in the mirror the line which he read on the first card, showing that his vision is twice as good as he pretends. (e) Obliciue examination with condensing lens and loupe. (/) Ophthalmoscopic Examination. — It is prob- able that the malingerer will resist the ophthalmo- scopic examination by frequent winking or rolling of the eyes. In this event, it is best to caution the man that a report of his vision must be made, and then to postpone further examination until after the next few recruits have been examined. Estimate the refractive error with the use of the ophthalmoscope. If no error of marked degree exists and the media and fundi are normal, the rela- tion between the alleged vision and the refractive condition furnishes an important clue. If the error is about +4.00 or —2.00 the visual acuity could l)c about 20/100, but when the defect cannot be accounted for objectively and the vision is 120 MILITARY OPHTHALMIC SURGERY brought from 20/100 to 20/50 or 20/30 by means of a low plus or minus glass, the man is malingering. (g) Retinoscopy. CLASS " C". — Total Blindness in both Eyes. — Total blindness in both eyes is rarely claimed. It is almost impossible for a man to deceive those who see him daily, and there will usually be found some acquaintance who is ready to testify against him. Every case of total blindness, the cause of which cannot be determined, should be regarded with suspicion. If an applicant is actually blind in both eyes and there exists no adhesion of the iris, the pupils are as a rule well dilated and react slightly, if at all, to light stimulation. A test pretending to discover the applicant's ability to determine direction may be made in the hope of catching him off his guard. The examiner may go to one side of the room and ask the patient to approach him. In his way may be placed some articles of furniture, though care must be taken that the patient may not injure himself. Observa- tion should be made as to whether or not the patient avoids the objects so placed. A patient who complains of sudden total loss of vision must assume the attitude and gait of a blind man, walking stiffly and hesitatingly, with hands KXAMIXATION OF MALINGERERS 121 outstretched, face imjiassu'e, expression dull; eyes turned ui)ward, eyelids immovable even when flaslu's of lii;ht or objects are quickly brought toward his eyes. The occlusion bandage may be applied for a day to ascertain if the patient can maintain the role of the blind patient as well as when both eyes are uncovered. Schmidt-Rimpler suggests that the patient be told to look at his own hand, which he holds a short distance from his eyes. A blind man will easily succeed in casting his eyes In the direction of his own hand while a pretender may afTect to look in a different direction, believing that he is thereby deceiving the examiner. The examiner may use the prism test described on p. Ii6 (b). Occupation. — The man's occupation in ci\il life may ha\e been such that it could not have been followed without more vision than he claims. In the absence of ocular defects, continuous and persistent blepharospasm, the use of colored glasses, eye shades or e>-e l)andages should be regarded with suspicion. Diplopia, — Cases of malingering arc occasion- ally met with in which the man complains that he sees double. These must be investigated with the application of the ordinary tests as if they were genuine, with every precaution taken to guard against a serious ners'ous lesion being o\'erlooked. : ^ IL'2 MILITARY OPHTHALMIC SURGERY CojNUNCTiviTis. — Inflammation of the lids is sometimes produced by introducing irritating sub- stances in the conjunctival sac, ipecacuanha powder, soap, particles of sand or other foreign matter being used for such purposes. The characteristics of this form of conjunctivitis are its sudden onset, usually in one eye alone, the marked irritation and swelling of the lower conjunc- tival sac, with a moderate amount of secretion. Sometimes the lids have an erysipelatous appear- ance, and great difficulty is experienced in opening them. Corneal ulcers have been observed. DISEASES OF EYE AND ADNEXA.^ Abscess of lid Amaurosis Amblyopia exanopsia hysterical nocturnal toxic Ankyloblepharon Aphakia Astigmatism Blepharitis Blepharospasm Cataract Cellulitis of lids Chalazion Choked disk Choroidal tumor Choroiditis suppurating choroiditis Color-blindness Conical cornea Conjuncti%-itis acute catarrhal chemical chronic follicular granular (trachoma) phlyctenular purulent traumatic vernal Cyclitis Dacryoadenitis Dacryocystitis Detachment of choroid of retina Ectropion Entropion Epiphora Exophthalmos Fistula of lacrimal sac Glaucoma acute chronic secondary Hemianopsia Hemorrhage into retina subconjvnictival into vitreous Herpes zoster ophthalmicus Hordeolum Hyperemia of conjunctiva Hyphemia Hypopyon Iridocyclitis Iritis acute chronic syphilitic Keratitis herpetic non-ulcerative parenchymatous phlyctenular ' Lists furnished for the Surgeon-General's GfTice by the Section of Ophthalmology. (123) 124 MILITARY OPHTHALMIC SURGERY Keratoiritis Keratomalacia Leukoma adherens Lacrimal obstruction Lagophthalmos M yopia Neuritis (optic) Neuroretinitis albuminurica Nystagmus Obstrtiction of retinal arteries Opacity of vitreous Ophthalmoplegia externa interna Orbital cellulitis Panophthalmitis Paralysis of ocular muscle Presbyopia Proptosis Pterygium Ptosis Retinitis albuminurica diabetic hemorrhagic syphilitic Retrobulbar neuritis Scleritis Snow-blindness Staphyloma of cornea Symblepharon Sympathetic ophthalmitis Synechia Thrombosis of retinal veins Ulcer of cornea Uveitis Xerosis EYE INJURIES. Burns of conjunctiva Concussion of eye Contusion of eye Ecchvmoses of conjunctiva of lids Foreign bodies in anterior chamber choroid conjunctiva cornea iris lens lids orbit sclera vitreous Injury to optic nerve Iridodialysis Penetrating wounds of ciliary body Penetrating wounds of cornea lens lids orbit sclera Perforating wounds of cornea globe orbit Prolapse of ciliary body of iris Ruptures of choroid and retina of cornea of globe Tears of lids multiple simple Traumatic cataract EYE OPERATIONS. Advancement of eye muscle Blepharoplasty Canthoplasty Canthotomy Cataract extraction Chalazion operation Conjunctival keratoplasty Dilation of lacrimal duct Discision for cataract Ectropion operation Entropion operation Enucleation, simple with implantation Epilation Evisceration Excision of tarsus Exenteration Extirpation of lacrimal sac Foreign bodies, removal from anterior chamber conjunctiva cornea lens lids magnet, extraction of Foreign bodies, removal from orbit sclera vitreous Incision of abscess of lacrimal sac Iridectomy Iridotomy Kronlein's operation Paracentesis of cornea Plastic on lids Probing of lacrimal duct Pterygium Ptosis operation Saemisch operation Sclerocorncal trephining Sclerotomy Staphyloma operation Suction for traumatic cataract S\Tnblepharon operation Tarsorrhaphy Tenotomy of eye muscle Trachoma, expression for Trichiasis operation (125) INDEX. A Amblyopia, hysterical 51 nocturnal 51 Anatomy of eyelids ; .... 66 to 69 Army lists of eye diseases and operations 123 B Burns of lids 12 treatment of 14 C C.\TARACT, traumatic 37 to 40 treatment of 39 to 40 Choked disk 49 Ciliary body prolapse 36 Commotio retinae 10 Concussion of eyeball 37 treatment of 38 Conjunctival keratoplasty 31 description of 32 to 37 Conjunctivitis 103 acute simple (catarrhal) 103 treatment of 104 chronic (diplobacillus) 108 treatment of 108 follicular 81 gas 109 gonorrheal 104 treatment of 105 to 107 Parinaud's 80 tubercular 80 vernal 80 (127) INDEX Contusion of eyeball . treatment of hypotony Corneal abrasions treatment of ulcers treatment of 43 Cranial injuries 48 D DiSTICHIASIS 43 to 44 to 51 75 E Ectropion 75 Entropion 75 Enucleation 16 to 18 indication for 5p with implantations 16 Evisceration 20 to 21 indication for 60 Eye, penetrating wounds of 15 Eyelids, wounds of 45 F Fluorescein solution 15 Foreign bodies in anterior chamber 15 to 27 in cornea ..... 12 treatment of 12 to 13 in globe 22 treatment of 22 to 23 in iris 14. 27 treatment of 14. 27 in lens 27 magnetic 22 to 29 non-magnetic 29 in orbit 41 in vitreous 22 to 29 G Gas bacillus in orbit 41 conjunctivitis 109 Glaucoma (secondary) 37 INDEX 129 H Hemianopsias 50 Hemorrhage, orbit 40 retina 48 vitreous 10 Hyphemia 10 Hypotony, contusion 11 I Increased intracranial pressure 49 Instruments 55 to 57 IridocycHtis 31. 36 Iridodialysis 10 Iris (prolapse of) 32, 36 Irrigation 33, 39 K Ker.-\titis (neuroparalytic) 42 L Lagophthalmos 42 Lens, dislocation of 10, 38 in vitreous 3*^ Lid wounds 12, 45 to 46 M Magnets 23 to 27 Malingerers 113 blindness feigned by 120 classes of 113 colored glasses and letters for 116 conjunctivitis in 121 diplopia in 121 equipment for examination 114 examinations of 113 methods of examination for 115 to 121 mirror tests 119 occupation tests 121 ophthalmoscope tests 119 prism tests 119 stereoscope test 115 trial glasses test 115 Meningitis 49-50 J N NosopHEN ointment 14 O Optic neuritis 49, 50 Orbit, injudicious exploration of 44 penetrating wounds of 40 perforating wounds of 40 Orbital cellulitis 20, 21, 41 P Pannus 74 treatment of 99, 100 Panophthalmitis 20 Paralyses of ocular molar nerves 50 Penetrating wounds of eye 15 to 37 of orbit 40 Perforating wounds of eye 15 to 37 of orbit 40 Prophylaxis (against eye injuries) 46, 47 Proptosis 42 Prosthesis, cartilage 18 glass 16 metallic 16 Psychoneuroses 51 R Refraction 51 Retinal edema 48 separation 30 Retinitis pigmentosa 51 Rupture of choroid 10 of globe 10, II of retina 10 S Scotomas 50 Suction 39 Sympathetic ophthalmitis 36 131 T Trachoma 6i acute 74 brossaRe in 87 causes of 76 to 78 chemical treatment of 76 chronic 71 cicatricial . 72 curettage for 93 definition of 69 diagnosis of 79 distribution of 62 to 66 excision for 93 combined 94 to 99 follicular 72 grattage in 87 papillary 71 pathology of 78 predispositions to 65 prognosis of 100, loi prophylaxis 102 symptoms and course of 72 to 76 treatment of 83 mechanical 86 to 92 Trench nephritis 42 Trichiasis 75 W White's ointment 14 X X-RAY localization 23, 41 \^6wmi ? 3 4 5 6 ALL BOOKS MAY BE RECALLED Al RENEWALS MAY BE REQUESTED DUE AS STAMPED BEL( FORM NO. DD 23, 2.5nn, UNIVERSITY OF CAI 12780 BERKELE