CARMALT': Changes in -Refraction from a Blow.
57g
CHANGES IN REFRACTION RESULTING FROM A BLOW. By W. H. CARMALT, M.D., NEW HAVEN, CONN.
R. A. S., aged twenty, a student in the sophomore class of Yale College, New Haven, myopic since twelve years of age, consulted me on October 23, I882, reporting that while practising in the gymnasium the day before, he had fallen violently forward, striking his right eye upon a bolt projecting from the floor. The blow was quite severe, sufficient to shake him up so that he kept quite still the remainder of the day and evening, neither going about nor studying, but at the time of his visit he felt quite well again, except as to his eye. Wearing his glasses habitually for all purposes of vision, near or far, he now felt an uncomfortable sensation in looking through his right glass, and could see much better at distance without it-better, indeed, than he remembered ever to have seen before without glasses; but for all that, he had a very confused sensation when looking with both eyes either with or without glasses. During the summer of i88i his eyes had been examined in Paris-he could not remember by whom-and his present glasses were then given him, and he had seen perfectly well with either eye with them until the day before. I found them to be for the R. E., - 4.5 and L. E., - 5.5. The time at his disposal was short on that day and my examination necessarily somewhat hasty. So far as I could determine, however, I found the refraction of his R. E. to be M.- J.5(V.O. 5)- 2. cyl. ax. I65', V. = o.8-, and of his L. E., M. = -6. V.'- 0.7. I have no note as to the actual condition of his accomnioda-
580
CARMALT: Chaniges in Refraction
tion on that day, but reading with that eye, with or without glasses, was painful to him and he declined it. I detected nothing abnormal about the movements of his iris, the pupil was round and clear and the lens gave no reflection by oblique illumination. The ophthalmoscopic examination was quite painful, but I examined the fundus by both direct and indirect methods and detected nothing abnormal, though, for the reasons already given, the observation was necessarily not exhaustive. I deferred further examination until I could get data as to his previous condition and wrote to his father, a surgeon of eminence in New York, and of very considerable ophthalmological knowledge, for the previous history of his son's refraction, and received answer, that in I878 his eyes 4.5, and L. E. bad been examined and recorded: R. E. - 5.5, V. I in each eye; again in i88o, R. E. = - 4., L. E. = - 5.5, V. I, and these were the only recorded observations as to his previous condition, but he knew of nothing unusual from ordinary cases of M. Owing to a misunderstanding, I was not consulted again until February 24, I883 (four months), when I made the R. E., without atropia, to be Asm. i. cyl. ax. horiz., V. = wit/i 0.7; L. E., also without atropia, M.- 7, V.-, V normal accommodation in each. I then instilled a one per cent. solution of atropia into the R. E. several times in the course of about two hours and obtained Asm.- 0.75, cyl. ax. horiz., V. =0.7, with total paralysis of accommodation. On ophthalmoscopic examination at this time there was no conus at the nerve, nor other evidence of retino-choroidal trouble-not so much as I expected to find with the degree of previous M. as reported. By oblique illumination no opacity of the lens was detected. At my request for a consultation, he called, the day following, upon Dr. Loring, of New York, who, giving a more careful examination, made the refraction of R. E., M. = -0.75 s. + I.5, cyl. ax. 8o0, V. I; L. E., M. -6. s._-o-75, cyl. ax. 450, V. = I, subject, however, he stated, to revision. Subsequently, on March 4th, after the effect of the atropia -
Resulting from a Blow.
58I
had passed entirely off and his range of accommodation was found to be normal, I found that the combination for the R.E.of + i. cyl.ax. 900 fgave V. =i. +; L. E., M. - 6.5 s. - 0.5, cyl. ax. 300, V. = I.-; and that he had an insufficiency of the int. recti muscles 5= . On May 30th I examined the left (the uninjured) eye under full paralysis of A. and found M. - 6.5 00. 5, cyl. ax. 250, V. I. . There was, therefore, a sp. of acc. of this eye of &t.5 D. The A. of R. E. was perfect, with crossed cyl. glass could read No. i Sn. at 4". To summarize the facts of this, to my knowledge, unique case, it seems established that in a case of myopia of very considerable and nearly equal degrees in the two eyes, one was reduced by the impact of a blow to a condition of astigmatic myopia which resolved itself finally into a mixedastigmatism, without any loss of acuity of vision or range of accommodation. In endeavoring to account for the mechanism of this change, five possibilities present themselves: First, a change in the shape of the cornea; second, a diminution or shortening of the axis of the globe; third, a displacement or dislocation of the lens backward; fourth, a pre-existing spasm of accommodation, the tonicity of which had been released by the paralytic effect of the blow; fifth, a change in the relative positions or arrangement of the lenticular fibres. My first thought, after examining the patient the day following the receipt of the injury, was that there had been such a concussion of the lenticular fibres that the alteration in the refractive media was there, and I felt strongly that it was but the preliminary stage to the formation of a cataract. My mind was so impressed with this idea that I did not at that time advise a change in the glass of that eye, but impressed upon the patient the importance of noticing any failure in vision of that eye and to report. He did not notice anything of the kind and failed to report until four months had elapsed, when the myopia had entirely disappeared, leaving apparently the myopic astigmatism of - i, axis horizontal.
5 8:
8CARMALT: Changes in Refraction
When Dr. Loring examined him the following day, he measured the corneal image (reflection) with a keratometer and found it " the same as the other eye and normal." And I accept his statement as conclusive. Without giving his grounds therefor he further states: " I exclude a change in the length of the ball." I had arrived at the same conclusion, from the absence of any apparent changes in the fundus in the examination made on the day after the injury, as also any trace of it in the subsequent examination on February 24th. I could not conceive so great a disturbance in the sclera and choroid, and occurring so suddenly, without some structural changes sufficient to be detected by the ophthalnoscope, and I examined very carefully by both the direct and indirect methods. Dr. Loring examined him by the catoptric test and wrote: I get all these images in their proper places, and what appears to the naked eye of their proper size. Still I did think the image from the anterior surface of the lens was smaller than in the other eye. This, however, may not be so," and in another place in his letter, after discussing the case with much interest, he says, " I make the cause to be a change in the position of the lens and in its curvature; " also, " Another thing which makes me think it, the trouble, is in the lens and its position is that the pupil does not dilate evenly." On the following day, February 26th, while the pupil was still dilated with atropine, I examined his eyes, for the catoptric images, without, to be sure, the aid of any measuring apparatus, but could detect neither a difference in the relative positions of these images, as compared with the other eye, nor a recognizable difference in their respective sizes. If there was a dislocation of the lens backward it might reduce, or nullify the myopia entirely, but it could only be by a rupture of the suspensory ligament of the lens either totally or in part, either of which would have shown itself also in the characteristic oscillation of the iris, in the recession of the plane of the iris, or in an interference with the accommodation; none of these were observed. As to the irregularity of the pupil referred to by Dr. Loring, while under atropia, I
Resulting from a Bloze.
583
did not detect it, either before or after my attention had been called to it by him. Assuming, however, that there was a dislocation backward of the lens with consequent reduction of the myopia, that would in all probability have reduced it regularly, not by changing a simple myopia into acompound condition of myopia and myopic astigmatism, to be followed by a mixed astigmatism. For these reasons I am unable to accept the view of a dislocation of the lens as a cause of the change in the refraction. Dr. Loring, in a subsequent verbal communication, stated that on further consideration he doubted very much if a displacement of the lens was the true explanation of the change. Had there previously been, a spasm of accommodation.?, Was his myopia of - 4.5 functional ? He had put on glasses when about twelve years of age, because he was beginning to stoop at his lessons, and soon-I cannot state more exactly the period of time-accustomed himself to wear them for everything, reading and study, as well as for distance. There is no record of the number of the glasses he first wore, but for the last three years they have not varied from - 4.5 and - 5.5 R. and L. respectively. He has never had any pain or weariness in his eyes, the vision has never varied from time to time; there has been nothing but at first (presumably) a gradual increase of his myopia up to three years before the accident, then a steady persistence at the same degree with normal functional activity. This is certainly not what we are accustomed to see in spasm of accommodation, nor is it as we are taught in the literature of the subject. Spasm of accommodation is usually a variable quantity, and pain either in eves or head an almost universal accompaniment. It is not, however, an absolutely constant accompaniment, and in order to eliminate this factor from the problem, so far as analogy would allow us to judge, at the suggestion of Dr. Roosa I paralyzed the ciliary muscle of the fellow-eye by a one per cent. solution of sulphate of atropia, but obtained a reduction of the myopia of not more than half of, a dioptry. I cannot think that there has been a monocular spasm of accommodation all these years, conVert-
584
CARMALT: Changes in Refraction
ing a mixqd astigmatism into a simple myopia without giving him any annoyance in the years of study preparatory to and after entering college, but which had been at last released by the blow. The remaining alternative cannot be urged from any knowledge we have of such a condition ever having been positively determined, it is urged rather as a refuge, all the other explanations having been disproved or not being satisfactory. We know that cataract, i.e., a liquefaction or fatty degeneration of the lenticular fibres is occasionally produced from a simple concussion without rupture of the suspensory ligament or capsule. There must be all grades of disturbances of the fibres, from actual solution of their continuity from violence to the simple displacement of their relations to one another which takes place in the act of accommodation. This latter is so slight and the construction of the fibres such that they become immediatelv restored when the pressure of the capsule is removed. Is it not possible that a sudden and violent impulse should have so shaken and displaced the denticulate articulations of the lens fibres that they became fastened in the position to correspond to (or cause) the error of refraction indicated above ? I acknowledge there are no observations in the literature to justify this theory, but, so far as I know, the case itself is unique, and the other possible explanations have been either disproved or are more unsatisfactory even than the one here suggested, which I make for what it is worth, hoping to bring out discussion on the part of members whose experience has been larger than my own, or who have other views.
REMARKS.
DR. KNAPP said he thought similar observations had been
published, and for the greater part they were compiled in
Professor Arlt's monograph. on injuries of the eye (translated by C. S. Turnbull). In these cases we find lenticular astigmatism. The ophthalmoscope shows a pear-shaped condition of the optic nerve, the side opposite to the injury gives, in the inverted
Resulting from, a Blow.
585
image, the large side of a pear, which is evidence that that part of the lens is the flatter. That the astigmatism does not proceed from the cornea can be made out by the- reflex images. These cases may last for a long time, but certainly, if not capable of cure, are capable of improvement. It is possible that in these cases the zonula Zinnii or the ciliary ligament ruptures or is paralyzed in a small area, as we notice frequently in the iris-irido-dialysis. In that area the elastic force of the lens is not counterbalanced by the traction from its suspensory ligament, and a greater convexity, confined to that area, is the result. Dr. Knapp thought that a partial paralysis of the ciliary ligament, i.e., one limited to a circumscribed part of its fibres, need not interfere, as had been supposed, with the mechanism of accommodation. THE PRESIDENT said that it was difficult to account for the phenomenon upon the supposition of laceration of fibres of the ciliary ligament in the zonula of Zinn. The changes were not all produced immediately, but continued to take place for four months after the reception of the injury. DR. KNAPP said he thought that it was possible to conceive that there was ho laceration, and that paralysis might be the cause, lasting weeks or months and then disappearing. DR. SEELY said that the special point of interest was not in the engrafting of myopia upon astigmatism, but in the diminution of the previous myopia, which was great. If he understood Dr. Knapp, the case he reported was that of production of astigmatism by injury of a myopic eye, while in the case reported by Dr. Carmalt the point of interest was the reduction of the myopia to nothing by the injury, an entirely differ,ent matter. DR. KNAPP said he spoke only of the production of traumatic astigmatism. DR. SEELY thought the assumption of the existence of preceding spasm of accommodation was the most reasonable explanation of Dr. Carmalt's case. DR. CARMALT said that was a good supposition, except it must have been monocular, because he had shown no spasm in the other eye by instilling atropia. DR. SEELY thought that fact had been previously noticed, namely, spasm absolutely relieved in one eye but not in the other at all, even after using a mydriatic for months. DR. WEBSTER asked how it was determined that in those cases the myopia was not real. DR. SEELY said he thought it was in one eye.
586
GRUENING: A Case of Blepharop/asty
DR. CARMALT remarked that these patients came complaining of asthenopic symptoms. DR. SEELY said certainly. DR. BULLER asked, Why say changes in the lens? DR. SEELY replied, because he knew of no other explanation. THE PRESIDENT remarked that the discussion was upon Dr. Carmalt's paper. DR. F. B. LORING asked Dr. Carmalt if there existed the peculiar blur described by Dr.. Knapp. DR. CARMALT said nothing of that kind was seen. DR. KNAPP remarked that he did not say blur, he only said an elliptical appearance of the disi.
A CASE OF BLEPHAROPLASTY ACCORDING TO THE BRITISH METHOD. BY E. GRUENING, M.D., NEW YORK.
IN planning the operation for the case here related, I could only follow one of two methods-either the Italian (Tagliacozza's), or the British (Wolfe's). I chose -the latter. This method of transplanting skin without a pedicle has hitherto yielded both good and bad results, and has received praise and censure accordingly. But as positive always outweigh negative observations, I am of opinion that the cultivation of this excellent method will lead to a full knowledge of the conditions of success, and will insure for this operation its well-merited place in plastic surgery. A young man, seventeen years of age, applied to me to be relieved of an ectropion of the right upper lid. He stated that when three years old he had sustained a severe injury of the face by the explosion of a petroleum lamp. As a result of this accident I found the integument of almost the whole forehead, of the right temple, the right cheek, and the corresponding half of the nose, changed into a dense cicatricial tissue, the upper lid everted, and its well-preserved free bor-
57g
CHANGES IN REFRACTION RESULTING FROM A BLOW. By W. H. CARMALT, M.D., NEW HAVEN, CONN.
R. A. S., aged twenty, a student in the sophomore class of Yale College, New Haven, myopic since twelve years of age, consulted me on October 23, I882, reporting that while practising in the gymnasium the day before, he had fallen violently forward, striking his right eye upon a bolt projecting from the floor. The blow was quite severe, sufficient to shake him up so that he kept quite still the remainder of the day and evening, neither going about nor studying, but at the time of his visit he felt quite well again, except as to his eye. Wearing his glasses habitually for all purposes of vision, near or far, he now felt an uncomfortable sensation in looking through his right glass, and could see much better at distance without it-better, indeed, than he remembered ever to have seen before without glasses; but for all that, he had a very confused sensation when looking with both eyes either with or without glasses. During the summer of i88i his eyes had been examined in Paris-he could not remember by whom-and his present glasses were then given him, and he had seen perfectly well with either eye with them until the day before. I found them to be for the R. E., - 4.5 and L. E., - 5.5. The time at his disposal was short on that day and my examination necessarily somewhat hasty. So far as I could determine, however, I found the refraction of his R. E. to be M.- J.5(V.O. 5)- 2. cyl. ax. I65', V. = o.8-, and of his L. E., M. = -6. V.'- 0.7. I have no note as to the actual condition of his accomnioda-
580
CARMALT: Chaniges in Refraction
tion on that day, but reading with that eye, with or without glasses, was painful to him and he declined it. I detected nothing abnormal about the movements of his iris, the pupil was round and clear and the lens gave no reflection by oblique illumination. The ophthalmoscopic examination was quite painful, but I examined the fundus by both direct and indirect methods and detected nothing abnormal, though, for the reasons already given, the observation was necessarily not exhaustive. I deferred further examination until I could get data as to his previous condition and wrote to his father, a surgeon of eminence in New York, and of very considerable ophthalmological knowledge, for the previous history of his son's refraction, and received answer, that in I878 his eyes 4.5, and L. E. bad been examined and recorded: R. E. - 5.5, V. I in each eye; again in i88o, R. E. = - 4., L. E. = - 5.5, V. I, and these were the only recorded observations as to his previous condition, but he knew of nothing unusual from ordinary cases of M. Owing to a misunderstanding, I was not consulted again until February 24, I883 (four months), when I made the R. E., without atropia, to be Asm. i. cyl. ax. horiz., V. = wit/i 0.7; L. E., also without atropia, M.- 7, V.-, V normal accommodation in each. I then instilled a one per cent. solution of atropia into the R. E. several times in the course of about two hours and obtained Asm.- 0.75, cyl. ax. horiz., V. =0.7, with total paralysis of accommodation. On ophthalmoscopic examination at this time there was no conus at the nerve, nor other evidence of retino-choroidal trouble-not so much as I expected to find with the degree of previous M. as reported. By oblique illumination no opacity of the lens was detected. At my request for a consultation, he called, the day following, upon Dr. Loring, of New York, who, giving a more careful examination, made the refraction of R. E., M. = -0.75 s. + I.5, cyl. ax. 8o0, V. I; L. E., M. -6. s._-o-75, cyl. ax. 450, V. = I, subject, however, he stated, to revision. Subsequently, on March 4th, after the effect of the atropia -
Resulting from a Blow.
58I
had passed entirely off and his range of accommodation was found to be normal, I found that the combination for the R.E.of + i. cyl.ax. 900 fgave V. =i. +; L. E., M. - 6.5 s. - 0.5, cyl. ax. 300, V. = I.-; and that he had an insufficiency of the int. recti muscles 5= . On May 30th I examined the left (the uninjured) eye under full paralysis of A. and found M. - 6.5 00. 5, cyl. ax. 250, V. I. . There was, therefore, a sp. of acc. of this eye of &t.5 D. The A. of R. E. was perfect, with crossed cyl. glass could read No. i Sn. at 4". To summarize the facts of this, to my knowledge, unique case, it seems established that in a case of myopia of very considerable and nearly equal degrees in the two eyes, one was reduced by the impact of a blow to a condition of astigmatic myopia which resolved itself finally into a mixedastigmatism, without any loss of acuity of vision or range of accommodation. In endeavoring to account for the mechanism of this change, five possibilities present themselves: First, a change in the shape of the cornea; second, a diminution or shortening of the axis of the globe; third, a displacement or dislocation of the lens backward; fourth, a pre-existing spasm of accommodation, the tonicity of which had been released by the paralytic effect of the blow; fifth, a change in the relative positions or arrangement of the lenticular fibres. My first thought, after examining the patient the day following the receipt of the injury, was that there had been such a concussion of the lenticular fibres that the alteration in the refractive media was there, and I felt strongly that it was but the preliminary stage to the formation of a cataract. My mind was so impressed with this idea that I did not at that time advise a change in the glass of that eye, but impressed upon the patient the importance of noticing any failure in vision of that eye and to report. He did not notice anything of the kind and failed to report until four months had elapsed, when the myopia had entirely disappeared, leaving apparently the myopic astigmatism of - i, axis horizontal.
5 8:
8CARMALT: Changes in Refraction
When Dr. Loring examined him the following day, he measured the corneal image (reflection) with a keratometer and found it " the same as the other eye and normal." And I accept his statement as conclusive. Without giving his grounds therefor he further states: " I exclude a change in the length of the ball." I had arrived at the same conclusion, from the absence of any apparent changes in the fundus in the examination made on the day after the injury, as also any trace of it in the subsequent examination on February 24th. I could not conceive so great a disturbance in the sclera and choroid, and occurring so suddenly, without some structural changes sufficient to be detected by the ophthalnoscope, and I examined very carefully by both the direct and indirect methods. Dr. Loring examined him by the catoptric test and wrote: I get all these images in their proper places, and what appears to the naked eye of their proper size. Still I did think the image from the anterior surface of the lens was smaller than in the other eye. This, however, may not be so," and in another place in his letter, after discussing the case with much interest, he says, " I make the cause to be a change in the position of the lens and in its curvature; " also, " Another thing which makes me think it, the trouble, is in the lens and its position is that the pupil does not dilate evenly." On the following day, February 26th, while the pupil was still dilated with atropine, I examined his eyes, for the catoptric images, without, to be sure, the aid of any measuring apparatus, but could detect neither a difference in the relative positions of these images, as compared with the other eye, nor a recognizable difference in their respective sizes. If there was a dislocation of the lens backward it might reduce, or nullify the myopia entirely, but it could only be by a rupture of the suspensory ligament of the lens either totally or in part, either of which would have shown itself also in the characteristic oscillation of the iris, in the recession of the plane of the iris, or in an interference with the accommodation; none of these were observed. As to the irregularity of the pupil referred to by Dr. Loring, while under atropia, I
Resulting from a Bloze.
583
did not detect it, either before or after my attention had been called to it by him. Assuming, however, that there was a dislocation backward of the lens with consequent reduction of the myopia, that would in all probability have reduced it regularly, not by changing a simple myopia into acompound condition of myopia and myopic astigmatism, to be followed by a mixed astigmatism. For these reasons I am unable to accept the view of a dislocation of the lens as a cause of the change in the refraction. Dr. Loring, in a subsequent verbal communication, stated that on further consideration he doubted very much if a displacement of the lens was the true explanation of the change. Had there previously been, a spasm of accommodation.?, Was his myopia of - 4.5 functional ? He had put on glasses when about twelve years of age, because he was beginning to stoop at his lessons, and soon-I cannot state more exactly the period of time-accustomed himself to wear them for everything, reading and study, as well as for distance. There is no record of the number of the glasses he first wore, but for the last three years they have not varied from - 4.5 and - 5.5 R. and L. respectively. He has never had any pain or weariness in his eyes, the vision has never varied from time to time; there has been nothing but at first (presumably) a gradual increase of his myopia up to three years before the accident, then a steady persistence at the same degree with normal functional activity. This is certainly not what we are accustomed to see in spasm of accommodation, nor is it as we are taught in the literature of the subject. Spasm of accommodation is usually a variable quantity, and pain either in eves or head an almost universal accompaniment. It is not, however, an absolutely constant accompaniment, and in order to eliminate this factor from the problem, so far as analogy would allow us to judge, at the suggestion of Dr. Roosa I paralyzed the ciliary muscle of the fellow-eye by a one per cent. solution of sulphate of atropia, but obtained a reduction of the myopia of not more than half of, a dioptry. I cannot think that there has been a monocular spasm of accommodation all these years, conVert-
584
CARMALT: Changes in Refraction
ing a mixqd astigmatism into a simple myopia without giving him any annoyance in the years of study preparatory to and after entering college, but which had been at last released by the blow. The remaining alternative cannot be urged from any knowledge we have of such a condition ever having been positively determined, it is urged rather as a refuge, all the other explanations having been disproved or not being satisfactory. We know that cataract, i.e., a liquefaction or fatty degeneration of the lenticular fibres is occasionally produced from a simple concussion without rupture of the suspensory ligament or capsule. There must be all grades of disturbances of the fibres, from actual solution of their continuity from violence to the simple displacement of their relations to one another which takes place in the act of accommodation. This latter is so slight and the construction of the fibres such that they become immediatelv restored when the pressure of the capsule is removed. Is it not possible that a sudden and violent impulse should have so shaken and displaced the denticulate articulations of the lens fibres that they became fastened in the position to correspond to (or cause) the error of refraction indicated above ? I acknowledge there are no observations in the literature to justify this theory, but, so far as I know, the case itself is unique, and the other possible explanations have been either disproved or are more unsatisfactory even than the one here suggested, which I make for what it is worth, hoping to bring out discussion on the part of members whose experience has been larger than my own, or who have other views.
REMARKS.
DR. KNAPP said he thought similar observations had been
published, and for the greater part they were compiled in
Professor Arlt's monograph. on injuries of the eye (translated by C. S. Turnbull). In these cases we find lenticular astigmatism. The ophthalmoscope shows a pear-shaped condition of the optic nerve, the side opposite to the injury gives, in the inverted
Resulting from, a Blow.
585
image, the large side of a pear, which is evidence that that part of the lens is the flatter. That the astigmatism does not proceed from the cornea can be made out by the- reflex images. These cases may last for a long time, but certainly, if not capable of cure, are capable of improvement. It is possible that in these cases the zonula Zinnii or the ciliary ligament ruptures or is paralyzed in a small area, as we notice frequently in the iris-irido-dialysis. In that area the elastic force of the lens is not counterbalanced by the traction from its suspensory ligament, and a greater convexity, confined to that area, is the result. Dr. Knapp thought that a partial paralysis of the ciliary ligament, i.e., one limited to a circumscribed part of its fibres, need not interfere, as had been supposed, with the mechanism of accommodation. THE PRESIDENT said that it was difficult to account for the phenomenon upon the supposition of laceration of fibres of the ciliary ligament in the zonula of Zinn. The changes were not all produced immediately, but continued to take place for four months after the reception of the injury. DR. KNAPP said he thought that it was possible to conceive that there was ho laceration, and that paralysis might be the cause, lasting weeks or months and then disappearing. DR. SEELY said that the special point of interest was not in the engrafting of myopia upon astigmatism, but in the diminution of the previous myopia, which was great. If he understood Dr. Knapp, the case he reported was that of production of astigmatism by injury of a myopic eye, while in the case reported by Dr. Carmalt the point of interest was the reduction of the myopia to nothing by the injury, an entirely differ,ent matter. DR. KNAPP said he spoke only of the production of traumatic astigmatism. DR. SEELY thought the assumption of the existence of preceding spasm of accommodation was the most reasonable explanation of Dr. Carmalt's case. DR. CARMALT said that was a good supposition, except it must have been monocular, because he had shown no spasm in the other eye by instilling atropia. DR. SEELY thought that fact had been previously noticed, namely, spasm absolutely relieved in one eye but not in the other at all, even after using a mydriatic for months. DR. WEBSTER asked how it was determined that in those cases the myopia was not real. DR. SEELY said he thought it was in one eye.
586
GRUENING: A Case of Blepharop/asty
DR. CARMALT remarked that these patients came complaining of asthenopic symptoms. DR. SEELY said certainly. DR. BULLER asked, Why say changes in the lens? DR. SEELY replied, because he knew of no other explanation. THE PRESIDENT remarked that the discussion was upon Dr. Carmalt's paper. DR. F. B. LORING asked Dr. Carmalt if there existed the peculiar blur described by Dr.. Knapp. DR. CARMALT said nothing of that kind was seen. DR. KNAPP remarked that he did not say blur, he only said an elliptical appearance of the disi.
A CASE OF BLEPHAROPLASTY ACCORDING TO THE BRITISH METHOD. BY E. GRUENING, M.D., NEW YORK.
IN planning the operation for the case here related, I could only follow one of two methods-either the Italian (Tagliacozza's), or the British (Wolfe's). I chose -the latter. This method of transplanting skin without a pedicle has hitherto yielded both good and bad results, and has received praise and censure accordingly. But as positive always outweigh negative observations, I am of opinion that the cultivation of this excellent method will lead to a full knowledge of the conditions of success, and will insure for this operation its well-merited place in plastic surgery. A young man, seventeen years of age, applied to me to be relieved of an ectropion of the right upper lid. He stated that when three years old he had sustained a severe injury of the face by the explosion of a petroleum lamp. As a result of this accident I found the integument of almost the whole forehead, of the right temple, the right cheek, and the corresponding half of the nose, changed into a dense cicatricial tissue, the upper lid everted, and its well-preserved free bor-
