Fox: Clinical Observations.
149
CLINICAL OBSERVATIONS. BY L. WEBSTER FOX, M.D., PHILADELPHIA.
OBS. I.-Congenital cataracts successfully removed in a patient sixty years of age. , negress, presented On February 4, I884, Harriet H of the Germantown Hospital, sufferthe Clinic Eye herself at with well-marked ing with cataracts. The lenses were opaque, deposits of calcareous concretions situated in the anterior or visible portions of the lenses. Upon examination, good projection of light obtained. The history elicited was that since birth the vision had not changed, she simply.being able to distinguish day from night, or the light of a lamp, or the shadow of a dark object when brought directly in front of her face. Feeling assured of the sensibility of the retina, an operation for cataract in one eye was suggested, and was performed. The lens was successfully removed in its capsule with a Critchett's spoon. There was a small loss of vitreous, which was fluid. The eye was closed immediately, and the wound healed without reaction; the eye was bathed daily with a mild astringent lotion, but the eyelid was not disturbed. At the end of eight days the bandages were removed, when it was found that the wound was closed and a key-hole iridectomy existed, which was perfect in outline and showed clear media. The patient was astonished; she could see objects several feet distant, but was quite at a loss to understand the visual phenomena. She was quite nervous from the effect of the shock, and started violently and closed her eyes as if with fear. She was unable to name any object placed before her, but readily distinguished it when her hand was placed upon it. A few moments afterward she readily distinguished a watch 20
150
Fox: Clinical Observations.
which was shown her. This was distinguished not by its form, but by its ticking. At this time, wools of different colors were placed before her, and a certain one given to be matched, which was done without confusion, proving the accurate sensibility of the retina to the most delicate tints, although not a name was known to the patient. After several days the object and wool tests were again made with the same results. When looking at a distance-for she could recognize objects at a distance, the refraction of the eye before the operation being myopic to eleven dioptrics-she tried to grasp the objects, and a flock of sparrows were supposed to be tea-cups. Owing to her first impression of distances she was for quite a time afraid to walk with her eyes open, the floor appearing at a great distance; a red and black color producing pain in the eyeball, while green and white were soothing. After the bandages were removed from her eyes, she was allowed the freedom of a moderately lighted room to become accustomed to the objects about her, as well as to learn to measure distances; she repeatedly refused to walk, although the nurse assured her that no dang-er would befall her in the effort. The patient was soon able to associate the name with the object, and at the end of some weeks, in the meantime using her eye constantly, she was able to mention all the objects in the ward of the hospital, but at times would make mistakes quite as ludicrous as confounding the birds with the tea-cups. Her vision without glasses is equivalent to ;2, and with sph. + i. she is able to see fine stitches, which would be equal to J. i at IO". In January, I885, the right eye was operated on; no reaction followed, and she is now able to see perfectly with both eyes. Her color fields were accurately measured at different times, and found to correspond to Landolt's measurements. The fundus oculi presents a peculiar picture. The optic nerves are oval in shape-not due to astigmatism-while the vessels are few in number, and do not extend beyond the equator bulbi, and merge into capillaries. The lenses were found to be only two-thirds the size of an ordinary adult lens.
Fox: Clinical Observations.
V
I5I1
Instead of being convex in shape, they were found to be spheroidal. The patient is now employed as a general servant in the hospital. OBS. II.-R. L., a woman of twenty-seven years. At three years of ag-e was injured in the left eye; two years subsequently sympathetic ophthalmia developed, leaving the right eye with qualitative perception of light only. At various times she had operations performed on right eye by distinguished surgeons, with negative results. On June 2 1, I884, at the Germantown Hospital, an iridotomy was performed on the right eye; a large ovoidal-shaped pupil with clear media was the result of this operation. This patient, who had had good vision at one time, was annoyed at the "confused look" of surrounding objects. Erythropsia was also annoying. After three months this retinal irritation disappeared and objects assumed a natural color. Colored glasses were worn for this defect. After repeated examination the following formula was prescribed: sph. + io. D. 2 cyl. + 3. D., axis I80o cyl. +2. D., axis 50°; V=F.' For reading, sph. + I4. D. 2 cyl. + 1.50. D., axis 50o, J. I at I0". The patient (educated at a blind asylum) has presented me, in writing, with her first mental impressions, after the restoration of vision, of the living and inanimate objects surrounding her; and her mental conception of objects conveyed through the medium of touch, was as unlike that received through the now restored organ of vision as day from
night. DISCUSSION.
DR. DENNETT.-I understand that two cylinders were used in this case. I am not mathematician enough to say why, but I think that two cylinders, with their axes inclined to each other, might be replaced by one cylinder. DR. KNAPP.-That is so. DR. RISLEY.-I recall one instance in which, with a spherocylindrical lens, I was able to improve vision by adding a prism I
Formula ground in one glass by Borsch, 1324 Walnut St.,
Philadelphia, Pa.
I52
WEBSTER: Enucleation for Glaucoma
with the base downwards. I think that the improvement was due to the bending of the light toward the macula. DR. ROOSA.-I want to express my interest in this first case. I had one case, that of a boy, fourteen years old, who passed through some of these stages, but not in such a marked manner as detailed by Dr. Fox. There is one poiilt that I wish to call the attention of the Society to. I have heard some of the members to-day.express vision by a number of words which are unnecessary. One said, g2 "barely," and Dr. Fox said, "nearly" 21. I think that if a patient can see all the letters of 2o and a few of the letters of 0, we should say V. = J +. If he can see all of 20 and more than half of 20, we can say V. = tj. DR. Fox.-I use that method in my case-book. DR. DENNETT.-I was in the habit of indicating this same thing with crescendo and diminuendo signs, as in algebra, at one time, but I grew out of the habit of doing this because it was not always understood. DR. KNAPP.-I think that the method of Dr. Roosa should be adopted. It is short and perfectly scientific.
A CASE IN WHICH THE ENUCLEATION OF AN EYE FOR. GLAUCOMA ABSOLUTUM WAS FOLLOWED WITHIN THIRTY-SIX HOURS BY AN ATTACK OF ACUTE GLAUCOMA IN THE FELLOW EYE. BY DAVID WEBSTER, M.D., NEW YORK.
THOMAS B., aged fifty-four, a native of England and a cutter by occupation, came to me at the suggestion of my friend, Dr. Thomas H. Hlolgate, of New York, on September 23, I884. He recollected that, upon more than one occasion, in early life, he had received blows, more or less severe, upon his right eye. He was not aware of any impairment of vision, however, until the year I874, during which he lost the sight of his right eye from successive attacks of what appears, from the history, to have been inflammatory glaucoma. From that time the eye has been sightless and frequently bloodshot and painful.
149
CLINICAL OBSERVATIONS. BY L. WEBSTER FOX, M.D., PHILADELPHIA.
OBS. I.-Congenital cataracts successfully removed in a patient sixty years of age. , negress, presented On February 4, I884, Harriet H of the Germantown Hospital, sufferthe Clinic Eye herself at with well-marked ing with cataracts. The lenses were opaque, deposits of calcareous concretions situated in the anterior or visible portions of the lenses. Upon examination, good projection of light obtained. The history elicited was that since birth the vision had not changed, she simply.being able to distinguish day from night, or the light of a lamp, or the shadow of a dark object when brought directly in front of her face. Feeling assured of the sensibility of the retina, an operation for cataract in one eye was suggested, and was performed. The lens was successfully removed in its capsule with a Critchett's spoon. There was a small loss of vitreous, which was fluid. The eye was closed immediately, and the wound healed without reaction; the eye was bathed daily with a mild astringent lotion, but the eyelid was not disturbed. At the end of eight days the bandages were removed, when it was found that the wound was closed and a key-hole iridectomy existed, which was perfect in outline and showed clear media. The patient was astonished; she could see objects several feet distant, but was quite at a loss to understand the visual phenomena. She was quite nervous from the effect of the shock, and started violently and closed her eyes as if with fear. She was unable to name any object placed before her, but readily distinguished it when her hand was placed upon it. A few moments afterward she readily distinguished a watch 20
150
Fox: Clinical Observations.
which was shown her. This was distinguished not by its form, but by its ticking. At this time, wools of different colors were placed before her, and a certain one given to be matched, which was done without confusion, proving the accurate sensibility of the retina to the most delicate tints, although not a name was known to the patient. After several days the object and wool tests were again made with the same results. When looking at a distance-for she could recognize objects at a distance, the refraction of the eye before the operation being myopic to eleven dioptrics-she tried to grasp the objects, and a flock of sparrows were supposed to be tea-cups. Owing to her first impression of distances she was for quite a time afraid to walk with her eyes open, the floor appearing at a great distance; a red and black color producing pain in the eyeball, while green and white were soothing. After the bandages were removed from her eyes, she was allowed the freedom of a moderately lighted room to become accustomed to the objects about her, as well as to learn to measure distances; she repeatedly refused to walk, although the nurse assured her that no dang-er would befall her in the effort. The patient was soon able to associate the name with the object, and at the end of some weeks, in the meantime using her eye constantly, she was able to mention all the objects in the ward of the hospital, but at times would make mistakes quite as ludicrous as confounding the birds with the tea-cups. Her vision without glasses is equivalent to ;2, and with sph. + i. she is able to see fine stitches, which would be equal to J. i at IO". In January, I885, the right eye was operated on; no reaction followed, and she is now able to see perfectly with both eyes. Her color fields were accurately measured at different times, and found to correspond to Landolt's measurements. The fundus oculi presents a peculiar picture. The optic nerves are oval in shape-not due to astigmatism-while the vessels are few in number, and do not extend beyond the equator bulbi, and merge into capillaries. The lenses were found to be only two-thirds the size of an ordinary adult lens.
Fox: Clinical Observations.
V
I5I1
Instead of being convex in shape, they were found to be spheroidal. The patient is now employed as a general servant in the hospital. OBS. II.-R. L., a woman of twenty-seven years. At three years of ag-e was injured in the left eye; two years subsequently sympathetic ophthalmia developed, leaving the right eye with qualitative perception of light only. At various times she had operations performed on right eye by distinguished surgeons, with negative results. On June 2 1, I884, at the Germantown Hospital, an iridotomy was performed on the right eye; a large ovoidal-shaped pupil with clear media was the result of this operation. This patient, who had had good vision at one time, was annoyed at the "confused look" of surrounding objects. Erythropsia was also annoying. After three months this retinal irritation disappeared and objects assumed a natural color. Colored glasses were worn for this defect. After repeated examination the following formula was prescribed: sph. + io. D. 2 cyl. + 3. D., axis I80o cyl. +2. D., axis 50°; V=F.' For reading, sph. + I4. D. 2 cyl. + 1.50. D., axis 50o, J. I at I0". The patient (educated at a blind asylum) has presented me, in writing, with her first mental impressions, after the restoration of vision, of the living and inanimate objects surrounding her; and her mental conception of objects conveyed through the medium of touch, was as unlike that received through the now restored organ of vision as day from
night. DISCUSSION.
DR. DENNETT.-I understand that two cylinders were used in this case. I am not mathematician enough to say why, but I think that two cylinders, with their axes inclined to each other, might be replaced by one cylinder. DR. KNAPP.-That is so. DR. RISLEY.-I recall one instance in which, with a spherocylindrical lens, I was able to improve vision by adding a prism I
Formula ground in one glass by Borsch, 1324 Walnut St.,
Philadelphia, Pa.
I52
WEBSTER: Enucleation for Glaucoma
with the base downwards. I think that the improvement was due to the bending of the light toward the macula. DR. ROOSA.-I want to express my interest in this first case. I had one case, that of a boy, fourteen years old, who passed through some of these stages, but not in such a marked manner as detailed by Dr. Fox. There is one poiilt that I wish to call the attention of the Society to. I have heard some of the members to-day.express vision by a number of words which are unnecessary. One said, g2 "barely," and Dr. Fox said, "nearly" 21. I think that if a patient can see all the letters of 2o and a few of the letters of 0, we should say V. = J +. If he can see all of 20 and more than half of 20, we can say V. = tj. DR. Fox.-I use that method in my case-book. DR. DENNETT.-I was in the habit of indicating this same thing with crescendo and diminuendo signs, as in algebra, at one time, but I grew out of the habit of doing this because it was not always understood. DR. KNAPP.-I think that the method of Dr. Roosa should be adopted. It is short and perfectly scientific.
A CASE IN WHICH THE ENUCLEATION OF AN EYE FOR. GLAUCOMA ABSOLUTUM WAS FOLLOWED WITHIN THIRTY-SIX HOURS BY AN ATTACK OF ACUTE GLAUCOMA IN THE FELLOW EYE. BY DAVID WEBSTER, M.D., NEW YORK.
THOMAS B., aged fifty-four, a native of England and a cutter by occupation, came to me at the suggestion of my friend, Dr. Thomas H. Hlolgate, of New York, on September 23, I884. He recollected that, upon more than one occasion, in early life, he had received blows, more or less severe, upon his right eye. He was not aware of any impairment of vision, however, until the year I874, during which he lost the sight of his right eye from successive attacks of what appears, from the history, to have been inflammatory glaucoma. From that time the eye has been sightless and frequently bloodshot and painful.
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