BULL: Gunshot Wound of the Eyeball.
275
GUNSHOT WOUND OF THE EYEBALL. BY CHARLES STEDMAN BULL, M.D., NEW YORK CITY.
Gunshot Wound of Right Eye. On November 9, I895, a gentleman, aged 37, came to my office with the following story: Four days before, while shooting quail with a party of friends, he was shot in the neck, face, and right eye by one of the party, from a distance of about sixty feet. He received three shots in the neck, one just over the parotid gland, one in the temple, and at least one in the eye. He lost the sight of the right eye at once, and everything appeared of a red color with this eye. The shot in the neck and tenmple were removed within half an hour after the accident, and he was carried home and cold applications made to the eye. When I saw him there was an excoriation involving the external canthus, a laceration of the conjunctiva of the globe in the infero-temporal quadrant, and a perforation at the sclero-corneal margin in the same region. The anterior chamber was filled with blood, tension was increased, and he complained of constant pain in the eyeball. There was but little chemosis of the conjunctiva and no swelling of the lids. There was a moderate amount of subconjunctival hemorrhage. He was placed on his back in bed, a mixture of atropine and cocaine was instilled, and cold compresses were ordered to be applied and constantly changed. In the course of twenty-four hours the pain was much relieved, and on the second day the absorption of the blood in the anterior chamber began. On the fifth day the blood was entirely absorbed, the iris was widely dilated, and adherent to the wound at the sclero-corneal margin, and at the bottom of the anterior chamber was a small black body, which was thought to be the shot. On the tenth day all signs of irritation had subsided, and I decided to attempt the removal of the shot. The original
276
BULL: Gunshot Wound of the Eyeball.
wound was reopened and enlarged in the direction of the foreign body. A probe was passed and the latter discovered to be metallic. A small platinum probe was then hammered out thin and flat at the end, carefully introduced through the wound and passed behind and beyond the shot, and then by pressing the end of the flattened probe against the cornea and slowly withdrawing it, the shot was removed without the slightest difficulty. An attempt was then made to replace the prolapsed iris, but this proved impossible, and it was carefully excised, leaving a coloboma downwards and outwards. There was no reaction following the operation, the wound healed promptly under atropine and a bandage, and two weeks later the vision on being tested proved to be 20/30. The patient has been seen a number of times since, the last occasion being about four months ago, when the vision was the same and the lens was perfectly intact. Guntshot Wounid of Left Eye. Mr. H., aged 5I, was first seen November I2, I896, and gave the following history: Two days before he was accidentally shot obliquely in the face by a charge of No. I2 shot, at a distance of about thirty feet. Two shot struck him on the left side of the forehead, one at the outer angle of the left upper lid, and one about the middle of the left upper lid, which did not penetrate the thickness of the lid. These shot were all removed from beneath the skin at the time. He immediately complained of severe pain in the eye, which has continued ever since. When I saw him there was a very extensive subcutaneous and subconjunctival hemorrhage with bruising of the conjunctiva and eyeball, there was a clot in the anterior chamber, the iris was discolored, the pupil was distorted, and the vitreous was full of blood. There was no reflex from the fundus, tension + i, there was perception of light, intense photophobia, and severe pain. Owing to the extensive subconjunctival hemorrhage, it was impossible to tell whether a shot had entered the eyeball, and any prolonged ex-
BULL: Gunshot Wound of the Eyeball.
277
amination was to be avoided at this time on account of the severe pain. Cold applications were constantly made, and a solution of atropine and cocaine was instilled every hour. In twentyfour hours the blood was absorbed from the anterior chamber, the iris dilated ad maxinmum, and he could distinguish the movements of the hand in the temporal half of the field. The pain had diminished, but there was considerable conjunctival chemosis. November I4, '96. No severe pain. Swelling of lids and conjunctiva less. Subjective photopsia still present. Nasal half of field absent. V. = 1/200 in temporal half of field. Nasal half of fundus visible. Floating clots in vitreous. Globe very sensitive to the touch. November I5, '96. Vitreous still clearer, but no reflex from fundus on temporal side, general bruised sensation much less marked. November I7th. Vitreous more cloudy. On outer aspect of eyeball, just above upper margin of the external rectus, near the equatorial region, was a slight elevation, as of a small shot embedded in the sclera. T. -I. November Igth. Vitreous still more opaque with reflex only from extreme nasal periphery of fundus. Probably a fresh hemorrhage. November 2Ist. Conjunctival chemosis increased. Appearance of a shot on external aspect almost certain. An attempt was made to remove it under cocaine, by a meridional incision through the conjunctiva. As soon as the conjunctiva was incised, a bead of black vitreous protruded, but no shot was found. One shot had evidently penetrated the eyeball, and no attempt was made to find it. From this time the unfavorable symptoms rapidly subsided, and by December 7th there was no external evidence of the injury. The left eye became perfectly quiet, with no superficial or deep injection, and clear media. There were at times attacks of very severe tri-facial neuralgia, always beginning in the eye. The tension was normal. Vision was reduced to counting OPH.-3
278
BULL: Gunshot Wound of the Eyeball.
fingers in the infero-temporal quadrant of the field. On January I5, '97, all local applications were discontinued, but quinine and strychnine were given for the neuralgic attacks. The retina was detached outwards and downwards, and slightly upwards, over about three-fifths of its extent. After the effects of the atropia had passed away, the iris reacted to the stimuli of light and convergence, but remained somewhat discolored. All photophobia disappeared. He was enabled to use the other eye for all purposes by February 4th, without any evidence of fatigue or subjective photopsia. The eye remained unchanged until October 20th, when on examining him for distance and reading glasses, the lens of the left eye was seen to be growing opaque. At the last examination, made June IO, '98, the lens was entirely opaque and presented the usual milky appearance of a soft cataract. The right eye has remained intact throughout.
Gunshot Wound of Left Eye. Mr. J. M., aged 38, was first seen by me on December I3, I896, and gave the following history: About two weeks before, while shooting in a patch of woods with two friends, he was shot in the left eye by one of his friends, at a distance of about forty feet, and lost the sight of this eye immediately. Four small shot, of the size of No. I2, were picked out of the skin of the face, and two from the scalp just above the line of the hair. There were three wounds of the lids, one in the upper lid and two in the lower lid. The eyeball was bloodshot, and there was a small hole in the sclera on the temporal aspect of the globe. When I saw him the lids were somewhat swollen, and the upper lid drooped. The subconjunctival hemorrhage had -nearly disappeared, being most marked at the line of insertion of the external rectus muscle, where there was a slight cicatricial projection. There were two shot in the lower lid, just beneath the skin, which were readily removed. One shot could be felt embedded in the upper lid, and on everting the lid it was found just beneath the conjunctiva, 4near the upper margin of the tarsus, and was readily
BULL: Gunshot Wound of the Eyeball.
279
removed through a slight transverse incision. The cornea was uninjured and transparent and the aqueous humor clear. The iris was discolored, was moderately dilated and did not respond to the stimulus of light. There was no sign of injury to the globe except the cicatrix over the insertion of the external rectus. There was no reflex from the fundus and no detail of the vitreous could be made out, but the lens was clear. The scar at the point of entrance of the shot was very thin and at the center was so black as to simulate the appearance of the shot. It was reopened by a slight incision, but no shot was found, and the vitreous and black pigment immediately presented. The wound was closed with a single scleral suture under all antiseptic precautions, a solution of atropine was instilled, and the eye was bandaged. There was no reaction. After a week had elapsed the bandage was permanently removed, and the eye treated simply by cold bathing and atropine. All swelling soon disappeared from the lids, the partial ptosis receded, and the eyeball became white like the other. In about five weeks after the injury, the patient could count fingers in the temporal half of the field, the infiltration in the vitreous became gradually absorbed and some of the details of the fundus could be distinguished. At the end of the tenth week after the accident, the vitreous had become entirely clear, and every detail of the fundus could be seen. There was no sign of the shot, but at a point on the nasal side of the fundus, very near the margin of the disc, was an atrophic patch, about half of the diameter of the disc, with a depression through the sclera, where the shot had probably passed through the posterior wall of the eye into the orbit. The disc was very pale, but otherwise normal. The retina was detached downwards and outwards, but firmly adherent apparently at the site of the external wound on the temporal side. The lens was entirely clear, and there was an eccentric vision of I0/70. The right eye was normal and has remained so ever since. This patient has been seen at intervals of about a month ever -since, and at the last visit, on June i6th, the vision of the left eye was I0/50 - eccentrically, and the appearance of the fundus was
28o
BULL: Gunshot Wound of the Eyeball.
about the same, the retinal detachment not having increased in extent, and the lens still remained clear.
Pistol-Shot Wound of Left Eye. Mr. D. W., aged 43, was accidentally shot in the left eye on April I7, I897, and I saw him within a few hours after the injury. The weapon used was a small Smith & Wesson revolver, and was fired at a distance of eight feet from the patient and to the left side. The bullet struck him just at the outer canthus, passed through the sclera and cornea almost tangentially, smashed both nasal bones and passed out on the other side, and was subsequently found on the floor of the room. When I saw him there was extensive laceration of both lids at the external canthus, laceration of the ocular conjunctiva, a groove entirely through the sclera from the equatorial region to the corneal margin in the temporal quadrant, and nearly the entire cornea was torn away, leaving only a small portion above still attached to the sclera. The iris was in shreds and the vitreous full of blood. After careful cleansing of the parts with bichloride solution, the lens was found dislocated downwards and backwards into the vitreous, which protruded from the open anterior segment of the eye. The patient was still suffering from the shock of the accident, and after removing some fragments of the fractured nasal bones, the parts were bandaged and the patient made comfortable. The family was told that the eye was destroyed, and enucleation was advised as soon as the patient was able to bear it. This was done on the third day, and in the usual manner, and at the same time the nasal bones were elevated, all small fragments removed, and a small plastic operation done to bring the skin over the bridge of the nose in place, and also at the external canthus. The patient did very well, and all the wounds healed with satisfactory rapidity. An excellent cavity for the insertion of an artificial eye resulted. The patient was very carefully watched for several months, but the right eye remained intact throughout in all its functions, and may now be considered entirely out of danger.
BULL: Tumors of the Orbit and Eyelids.
28I
On examining the enucleated globe, the wound of the bullet was found to involve the sclera, choroid, ciliary body and ora serrata, and zonule. The lens though dislocated was not ruptured, and the capsule was not injured. DISCUSSION.
DR. EMIL GRUENING. - The cases reported by Dr. Bull are not gunshot wounds, but wounds of the eye by shot; the only gunshot wound of the eye that he had really behaved quite differently from the others, and removal of the stump became necessary. I was very much interested in his method of procedure. Dr. Bull thought it necessary to incise in two cases in which he did not find the shot. I think that in the search for the shot an incision through the sclera is not necessary. We do not gain much by it, and do not find the shot, especially when the vitreous is not transparent; the cicatrix is generally black, and we imagine we shall find the shot there, which is usually not the case. At any rate, the shot is aseptic and eyes are very rarely infected. DR. BULL. - There was no search made for the shot in either case; we thought the shot presented and the conjunctiva was incised, but there was no incision through the sclera in either case. DR. GRUENING. -I understood Dr. Bull to say that the vitreous presented. DR. BULL. - I did, but the sclera had been injured by the wound, and when the conjunctiva was incised the vitreous presented, but the sclera was not opened by the operator.
SOME UNUSUAL TUMORS OF THE ORBIT, EYELIDS, AND VICINITY. BY CHARLES STEDMAN BULL, M.D., NEW YORK CITY.
Cysticercus Cyst of the Lower Lid. The patient was a boy, aged six years, by name Joseph Gavino, born in New York of Italian parents, and was first seen by me at
275
GUNSHOT WOUND OF THE EYEBALL. BY CHARLES STEDMAN BULL, M.D., NEW YORK CITY.
Gunshot Wound of Right Eye. On November 9, I895, a gentleman, aged 37, came to my office with the following story: Four days before, while shooting quail with a party of friends, he was shot in the neck, face, and right eye by one of the party, from a distance of about sixty feet. He received three shots in the neck, one just over the parotid gland, one in the temple, and at least one in the eye. He lost the sight of the right eye at once, and everything appeared of a red color with this eye. The shot in the neck and tenmple were removed within half an hour after the accident, and he was carried home and cold applications made to the eye. When I saw him there was an excoriation involving the external canthus, a laceration of the conjunctiva of the globe in the infero-temporal quadrant, and a perforation at the sclero-corneal margin in the same region. The anterior chamber was filled with blood, tension was increased, and he complained of constant pain in the eyeball. There was but little chemosis of the conjunctiva and no swelling of the lids. There was a moderate amount of subconjunctival hemorrhage. He was placed on his back in bed, a mixture of atropine and cocaine was instilled, and cold compresses were ordered to be applied and constantly changed. In the course of twenty-four hours the pain was much relieved, and on the second day the absorption of the blood in the anterior chamber began. On the fifth day the blood was entirely absorbed, the iris was widely dilated, and adherent to the wound at the sclero-corneal margin, and at the bottom of the anterior chamber was a small black body, which was thought to be the shot. On the tenth day all signs of irritation had subsided, and I decided to attempt the removal of the shot. The original
276
BULL: Gunshot Wound of the Eyeball.
wound was reopened and enlarged in the direction of the foreign body. A probe was passed and the latter discovered to be metallic. A small platinum probe was then hammered out thin and flat at the end, carefully introduced through the wound and passed behind and beyond the shot, and then by pressing the end of the flattened probe against the cornea and slowly withdrawing it, the shot was removed without the slightest difficulty. An attempt was then made to replace the prolapsed iris, but this proved impossible, and it was carefully excised, leaving a coloboma downwards and outwards. There was no reaction following the operation, the wound healed promptly under atropine and a bandage, and two weeks later the vision on being tested proved to be 20/30. The patient has been seen a number of times since, the last occasion being about four months ago, when the vision was the same and the lens was perfectly intact. Guntshot Wounid of Left Eye. Mr. H., aged 5I, was first seen November I2, I896, and gave the following history: Two days before he was accidentally shot obliquely in the face by a charge of No. I2 shot, at a distance of about thirty feet. Two shot struck him on the left side of the forehead, one at the outer angle of the left upper lid, and one about the middle of the left upper lid, which did not penetrate the thickness of the lid. These shot were all removed from beneath the skin at the time. He immediately complained of severe pain in the eye, which has continued ever since. When I saw him there was a very extensive subcutaneous and subconjunctival hemorrhage with bruising of the conjunctiva and eyeball, there was a clot in the anterior chamber, the iris was discolored, the pupil was distorted, and the vitreous was full of blood. There was no reflex from the fundus, tension + i, there was perception of light, intense photophobia, and severe pain. Owing to the extensive subconjunctival hemorrhage, it was impossible to tell whether a shot had entered the eyeball, and any prolonged ex-
BULL: Gunshot Wound of the Eyeball.
277
amination was to be avoided at this time on account of the severe pain. Cold applications were constantly made, and a solution of atropine and cocaine was instilled every hour. In twentyfour hours the blood was absorbed from the anterior chamber, the iris dilated ad maxinmum, and he could distinguish the movements of the hand in the temporal half of the field. The pain had diminished, but there was considerable conjunctival chemosis. November I4, '96. No severe pain. Swelling of lids and conjunctiva less. Subjective photopsia still present. Nasal half of field absent. V. = 1/200 in temporal half of field. Nasal half of fundus visible. Floating clots in vitreous. Globe very sensitive to the touch. November I5, '96. Vitreous still clearer, but no reflex from fundus on temporal side, general bruised sensation much less marked. November I7th. Vitreous more cloudy. On outer aspect of eyeball, just above upper margin of the external rectus, near the equatorial region, was a slight elevation, as of a small shot embedded in the sclera. T. -I. November Igth. Vitreous still more opaque with reflex only from extreme nasal periphery of fundus. Probably a fresh hemorrhage. November 2Ist. Conjunctival chemosis increased. Appearance of a shot on external aspect almost certain. An attempt was made to remove it under cocaine, by a meridional incision through the conjunctiva. As soon as the conjunctiva was incised, a bead of black vitreous protruded, but no shot was found. One shot had evidently penetrated the eyeball, and no attempt was made to find it. From this time the unfavorable symptoms rapidly subsided, and by December 7th there was no external evidence of the injury. The left eye became perfectly quiet, with no superficial or deep injection, and clear media. There were at times attacks of very severe tri-facial neuralgia, always beginning in the eye. The tension was normal. Vision was reduced to counting OPH.-3
278
BULL: Gunshot Wound of the Eyeball.
fingers in the infero-temporal quadrant of the field. On January I5, '97, all local applications were discontinued, but quinine and strychnine were given for the neuralgic attacks. The retina was detached outwards and downwards, and slightly upwards, over about three-fifths of its extent. After the effects of the atropia had passed away, the iris reacted to the stimuli of light and convergence, but remained somewhat discolored. All photophobia disappeared. He was enabled to use the other eye for all purposes by February 4th, without any evidence of fatigue or subjective photopsia. The eye remained unchanged until October 20th, when on examining him for distance and reading glasses, the lens of the left eye was seen to be growing opaque. At the last examination, made June IO, '98, the lens was entirely opaque and presented the usual milky appearance of a soft cataract. The right eye has remained intact throughout.
Gunshot Wound of Left Eye. Mr. J. M., aged 38, was first seen by me on December I3, I896, and gave the following history: About two weeks before, while shooting in a patch of woods with two friends, he was shot in the left eye by one of his friends, at a distance of about forty feet, and lost the sight of this eye immediately. Four small shot, of the size of No. I2, were picked out of the skin of the face, and two from the scalp just above the line of the hair. There were three wounds of the lids, one in the upper lid and two in the lower lid. The eyeball was bloodshot, and there was a small hole in the sclera on the temporal aspect of the globe. When I saw him the lids were somewhat swollen, and the upper lid drooped. The subconjunctival hemorrhage had -nearly disappeared, being most marked at the line of insertion of the external rectus muscle, where there was a slight cicatricial projection. There were two shot in the lower lid, just beneath the skin, which were readily removed. One shot could be felt embedded in the upper lid, and on everting the lid it was found just beneath the conjunctiva, 4near the upper margin of the tarsus, and was readily
BULL: Gunshot Wound of the Eyeball.
279
removed through a slight transverse incision. The cornea was uninjured and transparent and the aqueous humor clear. The iris was discolored, was moderately dilated and did not respond to the stimulus of light. There was no sign of injury to the globe except the cicatrix over the insertion of the external rectus. There was no reflex from the fundus and no detail of the vitreous could be made out, but the lens was clear. The scar at the point of entrance of the shot was very thin and at the center was so black as to simulate the appearance of the shot. It was reopened by a slight incision, but no shot was found, and the vitreous and black pigment immediately presented. The wound was closed with a single scleral suture under all antiseptic precautions, a solution of atropine was instilled, and the eye was bandaged. There was no reaction. After a week had elapsed the bandage was permanently removed, and the eye treated simply by cold bathing and atropine. All swelling soon disappeared from the lids, the partial ptosis receded, and the eyeball became white like the other. In about five weeks after the injury, the patient could count fingers in the temporal half of the field, the infiltration in the vitreous became gradually absorbed and some of the details of the fundus could be distinguished. At the end of the tenth week after the accident, the vitreous had become entirely clear, and every detail of the fundus could be seen. There was no sign of the shot, but at a point on the nasal side of the fundus, very near the margin of the disc, was an atrophic patch, about half of the diameter of the disc, with a depression through the sclera, where the shot had probably passed through the posterior wall of the eye into the orbit. The disc was very pale, but otherwise normal. The retina was detached downwards and outwards, but firmly adherent apparently at the site of the external wound on the temporal side. The lens was entirely clear, and there was an eccentric vision of I0/70. The right eye was normal and has remained so ever since. This patient has been seen at intervals of about a month ever -since, and at the last visit, on June i6th, the vision of the left eye was I0/50 - eccentrically, and the appearance of the fundus was
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BULL: Gunshot Wound of the Eyeball.
about the same, the retinal detachment not having increased in extent, and the lens still remained clear.
Pistol-Shot Wound of Left Eye. Mr. D. W., aged 43, was accidentally shot in the left eye on April I7, I897, and I saw him within a few hours after the injury. The weapon used was a small Smith & Wesson revolver, and was fired at a distance of eight feet from the patient and to the left side. The bullet struck him just at the outer canthus, passed through the sclera and cornea almost tangentially, smashed both nasal bones and passed out on the other side, and was subsequently found on the floor of the room. When I saw him there was extensive laceration of both lids at the external canthus, laceration of the ocular conjunctiva, a groove entirely through the sclera from the equatorial region to the corneal margin in the temporal quadrant, and nearly the entire cornea was torn away, leaving only a small portion above still attached to the sclera. The iris was in shreds and the vitreous full of blood. After careful cleansing of the parts with bichloride solution, the lens was found dislocated downwards and backwards into the vitreous, which protruded from the open anterior segment of the eye. The patient was still suffering from the shock of the accident, and after removing some fragments of the fractured nasal bones, the parts were bandaged and the patient made comfortable. The family was told that the eye was destroyed, and enucleation was advised as soon as the patient was able to bear it. This was done on the third day, and in the usual manner, and at the same time the nasal bones were elevated, all small fragments removed, and a small plastic operation done to bring the skin over the bridge of the nose in place, and also at the external canthus. The patient did very well, and all the wounds healed with satisfactory rapidity. An excellent cavity for the insertion of an artificial eye resulted. The patient was very carefully watched for several months, but the right eye remained intact throughout in all its functions, and may now be considered entirely out of danger.
BULL: Tumors of the Orbit and Eyelids.
28I
On examining the enucleated globe, the wound of the bullet was found to involve the sclera, choroid, ciliary body and ora serrata, and zonule. The lens though dislocated was not ruptured, and the capsule was not injured. DISCUSSION.
DR. EMIL GRUENING. - The cases reported by Dr. Bull are not gunshot wounds, but wounds of the eye by shot; the only gunshot wound of the eye that he had really behaved quite differently from the others, and removal of the stump became necessary. I was very much interested in his method of procedure. Dr. Bull thought it necessary to incise in two cases in which he did not find the shot. I think that in the search for the shot an incision through the sclera is not necessary. We do not gain much by it, and do not find the shot, especially when the vitreous is not transparent; the cicatrix is generally black, and we imagine we shall find the shot there, which is usually not the case. At any rate, the shot is aseptic and eyes are very rarely infected. DR. BULL. - There was no search made for the shot in either case; we thought the shot presented and the conjunctiva was incised, but there was no incision through the sclera in either case. DR. GRUENING. -I understood Dr. Bull to say that the vitreous presented. DR. BULL. - I did, but the sclera had been injured by the wound, and when the conjunctiva was incised the vitreous presented, but the sclera was not opened by the operator.
SOME UNUSUAL TUMORS OF THE ORBIT, EYELIDS, AND VICINITY. BY CHARLES STEDMAN BULL, M.D., NEW YORK CITY.
Cysticercus Cyst of the Lower Lid. The patient was a boy, aged six years, by name Joseph Gavino, born in New York of Italian parents, and was first seen by me at
