INTRAOCULAR WAR INJURIES.

R. D. SLEIGHT, M.D., Late Captain M. C. WILFRID HAUGHEY, Late Major, M.C.

BATTLE CREEK, MICH.

War wounds and injuries to the head, the result of the war just past, have caused frequent eye involvements even when the external appearance of the eye was normal. The explosion of shells, the discharge of big guns, the explosion of grenades and the jar due to direct hits, intense commotion of the air, fractures of the skull, or the maxillae, the malar or orbital arch, such are the injuries which may and have produced lesions of the eye which are of interest to the Army Ophthalmologist. LaGrange in a large service has found that eye lesions produced as a result of the injuries or the conditions mentioned, follow a certain definite manner; that laws may be written, as positive as any clinical law, which govern these ophthalmic changes, by which if certain parts of the head or face are injured, certain types of eye injuries will follow and the severity of the eye change will be more or less in direct relation to the severity of the injury or the violence of the contusion. In this paper we shall outline the laws 'proposed by LaGrange and make a few comments upon them.

FIRST LAW. Injuries to the inner coats of the eye may be caused through commotion of the air from the explosion of a shell at some distance. There are also well authenticated cases of luxation and subluxation of the lens, and of traumatic cataract, caused in this way. The fundus lesion usually seen is a rupture of the choroid or retina or both at the posterior pole.

This law governs a group of injuries caused by a commotion of the air. The eye ball is shaken in the same manner as the air commotion will shake a building, the violence depending upon the severity of the air commotion or the nearness of the source of the disturbance. The lesions are chiefly at the posterior pole of the eye, are variable in extent but are chiefly located in the macular or the paramacular region. The uveal tract being the more delicate structure is the first to be injured, therefore, we find that in this group of eye injuries produced by commotion, macular choroidal rupture is most frequently found. We occasionally also have retinal hemorrhage and may even have the vitreous more or less tinged with blood.

SECOND LAW. Injury to the orbit by traumatisms of the frontal region and radiating fracture of the orbital vault, usually involve the optic foramin or sphenoidal fissure and cause lesions of the sensory, motor, and optic nerves, the eyeball itself being uninjured.

The second group of injuries produces a different type of visual disturbances, which may be explained by functional disturbances of the nerves supplying the eye and adnexia, also by injury to the optic nerve itself. These injuries being the result of radiating fractures of the orbital vault and direct extension to the nerve. It is also possible to have injuries, as a result of these same disturbances, of the second, third, fourth, fifth, sixth and seventh Cranial nerves. One or more or all of these nerves may be in

jured and we may have an atrophy of the optic nerve or a loss of motility and sensation or separation of the eye from its trophic nerve supply.

THIRD LAW. Injury to the facial bony structures, but not involving the orbit, produces lesion of the eye, by concussion, at the macular region. This was found to be the commonest cause of impairment or loss of central vision, but the type of fundus lesion is not cônstant.

This is a type of cases where the disturbance is produced by concussion. The injury to the bony facial structure produces a vibratory wave which is transmitted to the orbit through the pterygomaxillary fossa and fissure. The eye is shaken just as a building is shaken by an earthquake. This type of injury is frequently located in the macula or macular region and may be explained as follows. The macular region being the most delicate and sensitive portion of the eye, is more liable to injury and secondly the posterior wall of the eye has attached to it the optic nerve which forms a sort of drag when the eye is shaken. The twitching or jerking motion produced by injury in this region produces ruptures or hemorrhages. In a small number of facial injuries there is produced a loss of central vision for which the ophthalmoscope shows no direct cause.

FOURTH LAW. Injury to the facial bony structures producing fracture of the orbit, with more or less depression of its walls, without striking the eyeball, produces two types of fundus lesion: macular and paramacular changes

by concussion, and peripheral fundus lesions at site nearest the injury to the orbital wall.

This is a group of injuries in which we have macular changes as described under group three but there also exists chorio-retinal lesions of varying extent resulting directly from the impact, and the extent and severity of the lesions is in proportion to the extent of the injury. This chorio-retinal lesion is always situated interior to the orbital fracture. A wave starting from the fractured region shakes the soft tissues of the orbit and suddenly and violently strikes the eye rupturing the membranes at the point of contact. The rupture is chiefly of the choroid and with hemorrhage; the blood detaching and rupturing the retina sometimes producing a proliferating chorioretinitis. It is evident, then, that this group contains two types of injuries: Macular injury, and choroidal or chorioretina changes. These injuries were of quite frequent occurrence.

FIFTH LAW. When the missile passes through the orbit without direct injury to the eyeball, it produces the same disorders as in group four, but with the addition of lesions resulting from laceration of structures of orbital cavity. Very often, the optic nerve is cut through, in which event the disc is lacerated, as if it had been pulled out.

This type contains the injuries of type four with the addition of direct injury to intraorbital tissues, and the type of injuries in addition to those described under group four can of course vary with the part or region of the orbit injured.

LaGrange observed several cases where the same bullet passed through both orbits and cut both optic nerves behind the eye ball. When the nerve has been cut or violently contused, we find marked injury at the posterior wall of the eye ball, the result of traction by the shock which the nerve suffered. The nerve when thus injured is naturally pulled by the missile, apparently, the missile trying to pull the nerve out of the eye ball and LaGrange has observed cases in which this actually happened. other cases there is serious chorio-retinal injuries often of proliferating type resulting from laceration of the optic nerve. In other cases the trophic nerves, the motor nerves or even the oculo-motor muscles themselves may be cut.

In

SIXTH LAW. Mediate or immediate contusion of the eyeball by a missile grazing the globe tangentially without rupturing it, produces immediate disorders of the 'fundus at site of the impact, and the macular region is also the seat of lesions due to concussion. However, the peripheral and central lesions encroach upon each other; the eye is distorted, the area of destruction goes from the posterior pole to the peripheral region corresponding to site of impact.

When the eyeball is contused but not ruptured by a missile grazing it, we always find fundus changes at the point corresponding with the point of impact represented by the rupture of the choroid and usually by rupture of the retina also. These lesions are extensive and usually radiate toward the macula. Thus the macular region is secondarily involved in these

cases.

All visual changes resulting from war injuries can be explained by one or the other or by two or more of these laws.

To LaGrange's rules we would add a seventh as follows:

SEVENTH LAW. Accompanying or following infectious diseases which have been prevalent in the army, we may have suppurative choroiditis, papillitis or nerve atrophy.

Under this group are to be classed the various intraocular changes that we have noticed in the Military Service. Suppurative choroiditis. occurs in meningitis cases and also occasionally in septic pneumonia. We have also seen nerve atrophy in meningitis. Under this heading would come albumenuric retinitis cases accompanying scarlet fever.

Among the twenty-five cases of meningitis which were under treatment at Field Hospital 33, there were six cases of suppurative choroiditis following or during meningitis, developing at no particular period of the disease. The patients complained of very little pain, chiefly only of loss of vision. On examination we found haziness of cornea, dilated pupil and in a few hours pus in the anterior chamber. In four of the cases only one of the eyes was affected and in the other two cases both eyes. In all of the cases except one an evisceration was performed with good results. In the case in which no operation was performed the eye was becoming soft when I left the hospital.

DISCUSSION.

DR. WALTER R. PARKER (Detroit): I had the privilege of seeing practically all the cases that returned and were sent to the Walter Reid Hospital, and Fort McHenry. In addition to this I was at the Walter Reid Hospital, so had indirectly some responsibility in these cases. Fortunately, we were early in possession, through Government channels, with the classification made by Lagrange. It may sound fanciful as you hear it read in this way, but as a matter of fact it was very practical. We amused ourselves finally by looking at the eye and then predicting the character of the wound and the location, and it was astonishing how near we could make our diagnosis. In a case where there was a point of contact a chorioretinitis will start from a point opposite that of the bony wall and extend anteriorly from that point. That is so constant that not infrequently choroidal disturbances would be missed because they were so far forward. But the general picture of these cases is one of the most striking things I have seen. It is the best atlas imaginable. In most of the cases the vitreous was entirely clear, or at least to such a degree that it did not appear in the detailed fundus examination. In addition to the simple macular disturbances, not infrequently there would be a pigment disturbance throughout the entire posterior fundus, making a picture like a long-standing choroiditis.

Without going into the detail of the different classes I want to emphasize the things that seem the most striking. I had never before with any certainty made a diagnosis of hemorrhage of the sheath—with a brownish-black ring, looking like

a choroidal ring except that it is smooth and well rounded. When once seen it never can be mistaken for anything else, and could not be forgotten. The other thing that impressed me is the short time that is necessary for pigment changes in the fundus to simulate the changes in an old choroiditis. We have all of us been called on to testify in court cases as to the probable length of time that elapsed in a choroidal lesion. Personally, I have been willing to say in most cases that the lesion has existed a year or perhaps two. As a matter of fact, we saw many cases that looked like old choroidal cases, and we were positive they had existed not more than from three to six months. It was a complete revelation to me. We will all see these cases, and I thought you would be interested to look up this classification and see how nearly you can bring the cases under this classification that Lagrange has given us.

I also want to speak of those cases where the optic nerve is torn out. They are comparatively common. I never had seen a case of that kind. The cases present the appearance of a very exaggerated glaucoma involving the entire nerve head. In some cases the whole posterior pole will be torn off. You will get good fundus reflexes until you get to the posterior pole, and then it is simply a mass or webb. But the partial tearing out of the optic nerve, like hemorrhage of the sheath, when once seen will be remembered without difficulty. But they are lesions with which we have not been familiar previous to war experience. There was no hemorrhage in the cases I saw. There may have been hemorrhage earlier, but not when I saw them.

STUDY AND TREATMENT OF THE INSANE.

Over 50 per cent. of the patients in the state hospitals of Illinois-or of any other state, for that matter-are cases of dementia praecox. The salient feature of this type of mental disorder is a loss of interest in the things that serve as spurs to normal activity-desire to get on in the world, love of home and family, outside social interests, etc. Fantastic ideas and bizarre activities take the place of these sane interests, and the affected individual ceases to make the adjustments necessary to retain his place as a member of the family and of society at large. He gets out of step with the mass of his fellows; depends more and more upon his own delusional resources; contents himself with poorer and poorer way of doing things; and in the end, if allowed to go his own gait, suffers a more or less profound deterioration.

Accompanying this mental degradation there is no corresponding physical decay, and, as a result, the praecox patient who enters an institution at twenty may very well continue to exist there until he is seventy. At least 20 per cent. of all commitments belong to this group, and, since so few die and so few recover (possibly 10 per cent.), a balance between the incoming and outgoing is not struck until at least half of the entire hospital population consists of this type.

This sad statement, says The Modern Hospital in an article on the Chicago State Hospital, Dunning, Ill., is an admission of the fact that dementia praecox still remains very much in the realm of the unknown. Since its cause has not yet been discovered, it can be treated only by those methods which have empirically proved to be successful.

R. H. Nichols

W. H. Sawyer
J. D. Bruce

J. D. Riker ....

C. B. Fulkerson

F. B. Walker
Guy Johnson

Detroit

. Jackson .. Calumet .Holland

Hillsdale .Saginaw

Pontiac

.Kalamazoo

.Detroit

Traverse City

Appointment to committees is not an idle honor. Acceptance of an appointment implies a pledge that the acceptor will devote time, energy and thought to the work that is allotted to and within the province of his committee. Further, he agrees to carry through the activities of his committee so as to obtain results and accomplish definite ends for the benefit, influence and achievements of the Society and its members. In plain words it means work.

Each member of these Committees has been notified of his appointment and the chairman of each committee has been supplied with the names of those who comprise his committee. A list of the Committees will be found each month in the front advertising section of the Journal. President Baker has set out to make this Society year witness some definite advanced He organizational activity and achievement. cannot do this without the support and cooperation of his committees and our entire membership. We must, therefor, all rally to the support of our President; plan and undertake definite work; contribute our time and energy to the problems presenting. May he not receive this support from the very start? Will you not become active at once?

We would also request every member to read the "object" of our Society as given in the first sections of the Constitution. Are you, as a member, aiding your local Society and its of ficers to attain that object? We hope you will contribute your personal efforts to attain that end during the meetings of this winter.

EVENTUALLY. WHY NOT NOW?

We have stolen the slogan of one of the main ingredients of the staff of life that we have had drummed into us since we first sported pants, but it best illustrates our point and that is our only excuse for thus pilfering.

To get right down to business, though, from a careful investigation, we find that most of us who were in uniform are now back on the old job and trying to gather up the strings that were cast adrift in 1917 and 1918.

Our experiences in the army were varied and at times we almost thought that we had given in vain from the manifold duties that we were called upon to perform. Perform is the only word that really does our efforts justice, when our inexperience in the ways of the military is taken into consideration and the so-called redtape seemed useless energy expended but in all this maelstrom of humanity that was called to the defense of humanity, we doctors, if we did nothing more than issue the proverbial Iodine and C. C.'s, learned the value of organized effort, that wonderful achievement of really working together, where every man's bit added to another man's bit, got the desired results, no matter what they were.

Those of us who were not fortunate enough to get into the game for one reason or other, also observed the effect of concerted effort in the work that was carried on among the civilians.

Now, why not profit by this experience? Why not instill some of the result of our observation into our work, now that we are getting back into our stride again? There is nothing to be gained by one individual striving to do it all. There is nothing to be gained by two or three of us working to a common end while an equa number are pulling in the opposite direction. Realizing what would be ing that there is no time like the present while the germ of co-operation and team work that

An now

was inoculated in the service has still the power to assert itself and has not reached the dormant state, the council of the society has taken preliminary steps to bring the realization of the get-to-gether policy home to the medical profession of Michigan.

No man is so good that he can not learn from another and gain from his experience. Just because the other man is not your next door neighbo is no reason that you shou net benefit from his association. Get to know your coworkers in the profession. It means success and dollars and cents to you.

The cry is generally made among the county societies that they haven't time for the effort of widening their scope and increasing their membership. We realize that this akes considerable work and really more than the average doctor can give from his daily allotment of twenty-four hours but we also know that it must be done and done quickly. So

We have now secured the assistance of a man who will devote his entire time to engendering a fuller co-operation and work-together policy among us all.

He is here to render every assistance to the county societies and will work with you in every way to make your society a real working and producing factor.

His ideas are at your disposal, as well as his personal assistance at your meetings. Just drop us a line and tell us what your troubles are. We are here to help you.

Mr. Harold O. Gurney will in the course of the next three months call on the officers of County Societies and will review with these officers and members of these county societies plans for active society work and meetings. Personally we are intimately acquainted with Mr. Gurney, know his ability and we are certain he is going to be of assistance in a way that will reflect to the benefit of the entire profession. In the meantime, until he calls, we want you to write us your ideas of how we can help youtell us your needs.

We get back to our headline again. We all know that it is something that must be done before the medical fraternity of this state is really efficient, so why wait until tomorrow, it never comes. Eventually it must be. Why not now?