HOLT: Removal of Metal from the Vitreous.
435
DR. C. H. WILLIAMS of Boston. - In this connection I would like to show a specimen made by Dr. Wilder of Chicago, hardened in formalin, and mounted after the Priestly Smith method. It brings out beautifully the short distance between the lens and retina, and the natural hypermetropia of the sheep's eye. Some years ago I did some work upon fishes; their lens is more spherical in shape, and the distance between lens and retina is huite short. In the land animals the lens has more of the ordinary form of the human lens.
REPORT OF EIGHT CASES OF REMOVAL OF METAL FROM THE VITREOUS BY THE ELECTRO MAGNET, WITH A REVIEW OF NINE CASES PREVIOUSLY REPORTED. By E. E. HOLT, M.D., PORTLAND, ME.
One of the most serious conditions of the eye the ophthalmic surgeon is called upon to treat is an injury which has lodged a foreign body in the vitreous. Whether the sight has been immediately obscured or slightly affected, its presence still involves the integrity of the organ and may lead to sympathetic inflammation of the fellow eye. So long as there is a difference of opinion as to the best method of treating these injuries, it is the duty of everyone to accurately record his cases and report his experience to the end that there may be ultimately more uniformity in their treatment. With this object in view, the records of eight more cases are presented to the Society with a review of nine cases published in the TRANSACTIONS of the Society of I89I and I893. Case I. D. A. P. (IO,261), aged 36, consulted me November 29, I893, stating that six days previous to this time, while driving up a hoop on a flour barrel, using a broad file and a hammer, he felt something strike his right eye. He consulted physicians who could see nothing in the eye, and therefore were of the opinion that nothing serious had happened to it. With good sight and with the absence of external inflammation
436
HOLT: Removal of Metal from the Vitreous.
he went till the fifth day, when on testing the sight he found that he was nearly blind. Examination of the eye showed an indistinct scar in the cornea, just below the center of the pupil. There was circumcorneal injection with irritability of the eye. When he realized his condition his chagrin was unbounded, as he was a physician himself, and had been lulled into this condition against his better judgment. My advice was to remove the eye at once, if he wished to get well in. the easiest, quickest, and safest way, but there was a possibility of removing the steel by the electro-magnet and of saving the form of the eye with perhaps sight,. if he chose this course with its long tedious convalescence. He decided to have the steel removed by the electro-magnet if possible; if not successful in this attempt the eye was to be removed before he recovered from the ether. Under ether the operation was performed similar to those described in the previous cases reported. The long, straight point of Bradford's magnet was introduced several times, but nothing came out except something that might have been a drop of pus. Finally, after nearly an hour's search a whitish membrane presented in which was a dark spot. With the aid of the scissors and magnet this proved to be a bit of steel. It had evidently been drawn to the incision in the eye by the magnet. The conjunctival wound was closed by catgut, the eye dressed, and the patient put to bed. He made a good recovery, the lens became absorbed so that he had vision equal to about o. I. One day expressing how pleased he was with the result and how well he felt, another patient jokingly said he had no strength. This challenge was accepted, and in the scuffle he received a severe blow on the eye. It became inflamed and painful; phthisis bulbi developed and, finally, it was removed. Case II. F. B. (10,4IO), aged 23, was sent to me by Dr. E. M. Fuller of Bath. He stated that while chiseling out a set-screw a piece flew and struck his right eye. Examination of the eye showed a wound in the inferior temporal quadrant of the cornea, a notch in the iris, and the lens fractured so that no view of the fundus could be obtained. After the usual statement in such cases he desired to have the attempt made
HOLT: Removal of Meta/ from the Vitreous.
437
to remove the steel by the electro-magnet. Under ether the incision was made as usual between the external and inferior recti muscles, and upon introducing the magnet the second time I was gratified to find the steel upon its point, when it was withdrawn. There was marked reaction due largely to swelling of the lens. The pupil cleared, leaving a membrane, vision being equal to 0.2 when he went home. Discission would markedly improve the vision. Case III. G. C. C. (II,09I), aged 28, consulted me Sept. 7, I894, stating that while he was holding a cold-chisel, and another man was striking it to cut a car-rail, he felt something strike his right eye. The wound was large, and in the nasal side of the sclerotic, extending into the cornea. Under ether the wound was enlarged a little, and the long point of the electro-magnet introduced, but no steel was found. After searching half an hour with the magnet and probe, it was evident that the steel was concealed by tissue or had gone through the eye. The eye was removed, and the steel was found imbedded in the wall of the eye opposite the wound, so that it was not felt by the magnet or probe. Case IV. E. W. B. (I I,3o6), aged 54, was referred to me by Dr. Smith of Bangor, Me., Nov. i9, I894. He stated that while chiseling out a set-screw he felt something strike his right eye. Examination showed a large wound in the temporal side of the eye, about ten millimeters long, one-third of which extended into the cornea. Under ether the wound was enlarged backward, and the steel was felt in doing it. The magnet would draw the steel toward the wound, but it was so entangled with the tissue that I was obliged to use forceps to assist in extracting it. There was no marked reaction or pain, but with such an extensive lesion, the whole eye being involved, phthisis bulbi developed, and the eye was removed. Case V. C. B. (I 1,368), aged 38, was brought to me December I0, I894, by Dr. H. T. Clough, who found him being treated for a cold. He stated that twelve days before this time, while driving out a bolt with a steel punch, he felt something strike his right eye, but neither his friend-s nor his family physician could see any wound of the eye, and it was thought that
438
HOLT: Removal of Metalfrom the Vitreous.
he was suffering from the external injury accompanied with a cold. Vision had been reduced to discerning the outline of objects. The wound was a peculiar one. The man was looking up, and the steel entered the eye four or five millimeters below the cornea, on a line of its vertical diameter without wounding the lens, so that when he looked off on a horizontal or downward, it was completely covered by the lid, hence the inference that the eye was suffering from an external injury and cold. By looking into the eye with the ophthalmoscope from the extreme temporal side of the pupil the steel could be seen on the nasal side, lodged on the ciliary body. Under ether the wound in the sclerotic was enlarged backward, and the long point of the Bradford's magnet was introduced. After introducing the point of the magnet many times, I could, with the opthalmoscope, still see the steel, but little removed from its former place. Renewing my efforts, I succeeded in removing it after several more attempts. There was only moderate reaction, and he made a fair recovery, though of course the eye was seriously affected before the operation, vision being reduced to quantitative. Case VI. J. C. G. (I1,759), aged 20, consulted me April 30, I895, stating that while holding a drill for another man to strike with a twelve-pound hammer he felt something strike his left eye. Examination showed a wound in the inferior temporal quadrant, four millimeters long, crossing the sclero-corneal margin obliquely. The lens was fractured, and no view of the fundus could be obtained. The eye was in a state of active suppuration, so much so that I questioned him closely about having gonorrhcea, but he denied ever having the disease. I, however, applied a 2 per cent. solution of nitrate of silver after cleansing the eye thoroughly with a saturated solution of boric acid. Under ether I dissected down the conjunctiva on the inferior nasal quadrant, and made an opening in the sclerotic, striking the steel as my knife passed into the vitreous. The magnet point was introduced several times, but the steel could not be brought out. As the suppurative conj unctivitis was very active I desisted from further attempts to remove the steel by the magnet or forceps, for I felt that the eye would be rap-
.1IdOLT: Removal of Metal from thte Vitreous.
439
idly destroyed by the active inflammation present, if the steel were removed, and it would be better to remove the eye, which was done. The steel was found so entangled in tissue that it could not have been removed by the magnet. Case VII. C. M. C. (i i,8o6), aged 28, consulted me May i6, 1895, stating, that he felt something, strike his eye yesterday while he was using a planer. Sight was obliterated at once. There was a wound in the upper temporal quadrant of the eye, extending into the cornea sufficiently to divide the iris throughout its width and crossing- the sclero-corneal marg,n to an extent of two or three millimeters. The lenis was broken up so that there was no red reflex. Under ether I opcned the eye between the external and inferior recti muscles and made a careful search for the steel. I felt quite sure I came in contact with it once. I finally decided to remove the eye and did so, during which operation there was some loss of its contents. I speak of this because upon a pretty careful examination of the eye afterwards 1 failed to find the steel. Case VIII. G. C. 0. (' I,884), aged 26, consulted me June I4, I895, at the instance of Dr. Griffin of Pittsfield, stating that six days previous to this time he felt something strike his left eye while he was hammering an iron pin. Sight was immediately obscured. Examination of the eye showed a dilated pupil (from atropine, wlhich had been applied) several dark spots just behind the lens in the vitreous, one of which had rather an indistinct reflex, like metal, so that it was decided that this one was the piece of steel. In searching for the wound of the eye, through which this penetrated, I found after some time an indistinct scar at the lowest portion of the cornea, close to the sclerocorneal margin. The pupil being dilated, the wound in the iris was obscured. It would seem that the steel had been projected into the vitreous to a point above the center of the pupil, taking in some blood with it which had become absorbed, leaving dark spots and streaks, and that it had gradually sunk down and back as could be readily demonstrated by a parallax of the spots, which moved about, indicating that the vitreous had become liquefied at this point. Under ether I opened the eye between the external and inferior recti muscles. I introduced OPH.-I3
440
HOLT: Removal of AMetal from the Vitreotus.
the long, straight point of Bradford's magnet, and as I knew the exact location of the steel, and could readily see the point of thc magnet through the pupil as I manipulated it, I did not expect to be long in removing the steel, but I was doomed to disappointment. I introduced the magnet many times, but practically in the same direction, and at last saw the steel at the edge of the wound on the magnet. There was but little haemorrhage and no loss of vitreous. The conjunctival wound was closed by two catgut sutures, and the eyes covered with cotton, held in place by silk isinglass plaster. The operation lasted about an hour. The patient's pulse became feeble, and the breathing bad, so that the feet were elevated and he was given a hypodermic of strychnia. The patient was put to bed. He has made an excellent recovery, vision being equal to 0.5. In reviewing, these cases and those previously reported, we have a series of seventeen which, although small, is nevertheless interesting and instructive. The one case in the first series, in which prima'ry enucleation was performed, there was no expectation of saving the eye; it was introduced into that series to show how accurately the estimation of the location of the steel was made, and how the eye might have been saved had not the folly of waiting two weeks been adopted. It should not be considered in the results. In case one of this series the eye might have been saved had not an accident occurred during convalescence, although a week had elapsed before the operation was performed, during which time the lens became opaque, and no view of the fundus could be obtained. In cases three and four the nature of the injury was such as not to expect any better results than were obtained. In case six the eye was infected and active suppuration existed, so that if I had persisted, and had been successful in removing the steel, the eye would have been destroyed by suppuration. In case seven I was disappointed in not obtaining the steel. I felt sure it was in the eye, but could not find it even after enucleation. It probably escaped during the process of enucleation, as some of the contents of the eye was lost. We, therefore, have three primary and two secondary enucleations in this series. Case eight was an ideal one for the removal of steel by the electro-
HOLT: Removal of Affetal from the Vitreous.
44I
magnet, though a week had elapsed before the operation. The results thus far have been all that could be expected, namely, the preservation of the eye with good vision. As long as medicine is not an exact science, the true physician or surgeon must constantly be on the alert lest his remedies do more harm than good. With these facts in view, we must in every case of injury of the eye, in which a foreign body has been lodged in the vitreous, advise the patient either to have the foreign body removed or the eye, or else let them alone, and treat the eye expectantly. We must do one of these three things, and which it shall be must be determined in each individual case after the accident has occurred. There are some ophthalmic surgeons, however, who question the propriety of removing steel from the vitreous, claiming that if successfully done the eye sooner or later is doomed to destruction. This has not been my experience. The results of thcse three series of cases are as follows: One had vision of 0.7; three had vision of 0-5 ; two had vision of 0.2; four had vision of O.I; one had quantitative vision. I have heard from those operated upon any length of time, and they are all doing as well or better than when they left me. I feel sure I should hear from them if they had any trouble with their eyes. Discission in five or six of these cases would improve vision, but they were satisfied with the results obtained, and discission was not urged upon them, for I think it best to keep the eye as quiet as possible after an accident and operation of this kind. I have now practiced the removal of steel from the vitreous by the electro-magnet for ten years, and the results are very much better than those obtained in the ten years previous to that time when I did not use the magnet. I feel sure from my former experience and from the observation of neglected cases of those treated on the let-alone plan, that the sight in nearly all of the eyes here recorded would have been destroyed had not the steel in the vitreous been removed. With the certainty that in a large number of cases the eye will be destroyed if the steel is left in the eye, is it not our duty to make an attempt to remove it and thus give the patient
:442
RISLEY: Vaso-motor Atazia.
the benefit of a chance to save the eye with useful vision ? There is no excuse for not attempting to remove the steel because the lens has been injured, and we cannot see it with the ophthalmoscope. There were only five of these cases where the steel could be seen and located. In the other twelve cases its position had to be estimated from the position and nature of the external wound of the eye and the probable position of the person and the eye at the time of the accident. This estimation was so accurate that in nine of the twelve cases the Graefe knife came in contact with the metal when the incision was made through the sclerotic. There is no reason why we should not attempt the removal of a foreign body from the vitreous when it cannot be seen or definitely located, provided the injury is such as to necessitate its removal.or the eye itself. If successfully done, uinder aseptic methods, there is a chance of saving the form of the eye with useful vision, which is one of the greatest triumphs of the ophthalmic surgeon.
A CASE OF VASO-MOTOR ATAXIA, WITH EYE SYMPTOMS SIMULATING MONOCULAR EXOPH-
THALMIC-GOITRE. By S. D. RISLEY, M.D., OF PHIILADELPHIA.
The clinical picture presented by exophthalmic goitre is, unfortunately, a very familiar one to the ophthalmic surgeon. Notwithstanding the frequent opportunities for its study, the ultimate cause, or exact nature of the characteristic phenomena are still very far from a satisfactory solution. Although as a rule both eyes are involved, cases of monocular exophthalmos are not rare in literature; no case has, however, come under my own observation, unless indeed, the case here reported is to be so regarded. On June I 2th last, Mrs. B., aged 42, came to the Wills Eye Hospital, complaining that for the past three months she had been annoyed by a peculiar "staring " appearance in the right
435
DR. C. H. WILLIAMS of Boston. - In this connection I would like to show a specimen made by Dr. Wilder of Chicago, hardened in formalin, and mounted after the Priestly Smith method. It brings out beautifully the short distance between the lens and retina, and the natural hypermetropia of the sheep's eye. Some years ago I did some work upon fishes; their lens is more spherical in shape, and the distance between lens and retina is huite short. In the land animals the lens has more of the ordinary form of the human lens.
REPORT OF EIGHT CASES OF REMOVAL OF METAL FROM THE VITREOUS BY THE ELECTRO MAGNET, WITH A REVIEW OF NINE CASES PREVIOUSLY REPORTED. By E. E. HOLT, M.D., PORTLAND, ME.
One of the most serious conditions of the eye the ophthalmic surgeon is called upon to treat is an injury which has lodged a foreign body in the vitreous. Whether the sight has been immediately obscured or slightly affected, its presence still involves the integrity of the organ and may lead to sympathetic inflammation of the fellow eye. So long as there is a difference of opinion as to the best method of treating these injuries, it is the duty of everyone to accurately record his cases and report his experience to the end that there may be ultimately more uniformity in their treatment. With this object in view, the records of eight more cases are presented to the Society with a review of nine cases published in the TRANSACTIONS of the Society of I89I and I893. Case I. D. A. P. (IO,261), aged 36, consulted me November 29, I893, stating that six days previous to this time, while driving up a hoop on a flour barrel, using a broad file and a hammer, he felt something strike his right eye. He consulted physicians who could see nothing in the eye, and therefore were of the opinion that nothing serious had happened to it. With good sight and with the absence of external inflammation
436
HOLT: Removal of Metal from the Vitreous.
he went till the fifth day, when on testing the sight he found that he was nearly blind. Examination of the eye showed an indistinct scar in the cornea, just below the center of the pupil. There was circumcorneal injection with irritability of the eye. When he realized his condition his chagrin was unbounded, as he was a physician himself, and had been lulled into this condition against his better judgment. My advice was to remove the eye at once, if he wished to get well in. the easiest, quickest, and safest way, but there was a possibility of removing the steel by the electro-magnet and of saving the form of the eye with perhaps sight,. if he chose this course with its long tedious convalescence. He decided to have the steel removed by the electro-magnet if possible; if not successful in this attempt the eye was to be removed before he recovered from the ether. Under ether the operation was performed similar to those described in the previous cases reported. The long, straight point of Bradford's magnet was introduced several times, but nothing came out except something that might have been a drop of pus. Finally, after nearly an hour's search a whitish membrane presented in which was a dark spot. With the aid of the scissors and magnet this proved to be a bit of steel. It had evidently been drawn to the incision in the eye by the magnet. The conjunctival wound was closed by catgut, the eye dressed, and the patient put to bed. He made a good recovery, the lens became absorbed so that he had vision equal to about o. I. One day expressing how pleased he was with the result and how well he felt, another patient jokingly said he had no strength. This challenge was accepted, and in the scuffle he received a severe blow on the eye. It became inflamed and painful; phthisis bulbi developed and, finally, it was removed. Case II. F. B. (10,4IO), aged 23, was sent to me by Dr. E. M. Fuller of Bath. He stated that while chiseling out a set-screw a piece flew and struck his right eye. Examination of the eye showed a wound in the inferior temporal quadrant of the cornea, a notch in the iris, and the lens fractured so that no view of the fundus could be obtained. After the usual statement in such cases he desired to have the attempt made
HOLT: Removal of Meta/ from the Vitreous.
437
to remove the steel by the electro-magnet. Under ether the incision was made as usual between the external and inferior recti muscles, and upon introducing the magnet the second time I was gratified to find the steel upon its point, when it was withdrawn. There was marked reaction due largely to swelling of the lens. The pupil cleared, leaving a membrane, vision being equal to 0.2 when he went home. Discission would markedly improve the vision. Case III. G. C. C. (II,09I), aged 28, consulted me Sept. 7, I894, stating that while he was holding a cold-chisel, and another man was striking it to cut a car-rail, he felt something strike his right eye. The wound was large, and in the nasal side of the sclerotic, extending into the cornea. Under ether the wound was enlarged a little, and the long point of the electro-magnet introduced, but no steel was found. After searching half an hour with the magnet and probe, it was evident that the steel was concealed by tissue or had gone through the eye. The eye was removed, and the steel was found imbedded in the wall of the eye opposite the wound, so that it was not felt by the magnet or probe. Case IV. E. W. B. (I I,3o6), aged 54, was referred to me by Dr. Smith of Bangor, Me., Nov. i9, I894. He stated that while chiseling out a set-screw he felt something strike his right eye. Examination showed a large wound in the temporal side of the eye, about ten millimeters long, one-third of which extended into the cornea. Under ether the wound was enlarged backward, and the steel was felt in doing it. The magnet would draw the steel toward the wound, but it was so entangled with the tissue that I was obliged to use forceps to assist in extracting it. There was no marked reaction or pain, but with such an extensive lesion, the whole eye being involved, phthisis bulbi developed, and the eye was removed. Case V. C. B. (I 1,368), aged 38, was brought to me December I0, I894, by Dr. H. T. Clough, who found him being treated for a cold. He stated that twelve days before this time, while driving out a bolt with a steel punch, he felt something strike his right eye, but neither his friend-s nor his family physician could see any wound of the eye, and it was thought that
438
HOLT: Removal of Metalfrom the Vitreous.
he was suffering from the external injury accompanied with a cold. Vision had been reduced to discerning the outline of objects. The wound was a peculiar one. The man was looking up, and the steel entered the eye four or five millimeters below the cornea, on a line of its vertical diameter without wounding the lens, so that when he looked off on a horizontal or downward, it was completely covered by the lid, hence the inference that the eye was suffering from an external injury and cold. By looking into the eye with the ophthalmoscope from the extreme temporal side of the pupil the steel could be seen on the nasal side, lodged on the ciliary body. Under ether the wound in the sclerotic was enlarged backward, and the long point of the Bradford's magnet was introduced. After introducing the point of the magnet many times, I could, with the opthalmoscope, still see the steel, but little removed from its former place. Renewing my efforts, I succeeded in removing it after several more attempts. There was only moderate reaction, and he made a fair recovery, though of course the eye was seriously affected before the operation, vision being reduced to quantitative. Case VI. J. C. G. (I1,759), aged 20, consulted me April 30, I895, stating that while holding a drill for another man to strike with a twelve-pound hammer he felt something strike his left eye. Examination showed a wound in the inferior temporal quadrant, four millimeters long, crossing the sclero-corneal margin obliquely. The lens was fractured, and no view of the fundus could be obtained. The eye was in a state of active suppuration, so much so that I questioned him closely about having gonorrhcea, but he denied ever having the disease. I, however, applied a 2 per cent. solution of nitrate of silver after cleansing the eye thoroughly with a saturated solution of boric acid. Under ether I dissected down the conjunctiva on the inferior nasal quadrant, and made an opening in the sclerotic, striking the steel as my knife passed into the vitreous. The magnet point was introduced several times, but the steel could not be brought out. As the suppurative conj unctivitis was very active I desisted from further attempts to remove the steel by the magnet or forceps, for I felt that the eye would be rap-
.1IdOLT: Removal of Metal from thte Vitreous.
439
idly destroyed by the active inflammation present, if the steel were removed, and it would be better to remove the eye, which was done. The steel was found so entangled in tissue that it could not have been removed by the magnet. Case VII. C. M. C. (i i,8o6), aged 28, consulted me May i6, 1895, stating, that he felt something, strike his eye yesterday while he was using a planer. Sight was obliterated at once. There was a wound in the upper temporal quadrant of the eye, extending into the cornea sufficiently to divide the iris throughout its width and crossing- the sclero-corneal marg,n to an extent of two or three millimeters. The lenis was broken up so that there was no red reflex. Under ether I opcned the eye between the external and inferior recti muscles and made a careful search for the steel. I felt quite sure I came in contact with it once. I finally decided to remove the eye and did so, during which operation there was some loss of its contents. I speak of this because upon a pretty careful examination of the eye afterwards 1 failed to find the steel. Case VIII. G. C. 0. (' I,884), aged 26, consulted me June I4, I895, at the instance of Dr. Griffin of Pittsfield, stating that six days previous to this time he felt something strike his left eye while he was hammering an iron pin. Sight was immediately obscured. Examination of the eye showed a dilated pupil (from atropine, wlhich had been applied) several dark spots just behind the lens in the vitreous, one of which had rather an indistinct reflex, like metal, so that it was decided that this one was the piece of steel. In searching for the wound of the eye, through which this penetrated, I found after some time an indistinct scar at the lowest portion of the cornea, close to the sclerocorneal margin. The pupil being dilated, the wound in the iris was obscured. It would seem that the steel had been projected into the vitreous to a point above the center of the pupil, taking in some blood with it which had become absorbed, leaving dark spots and streaks, and that it had gradually sunk down and back as could be readily demonstrated by a parallax of the spots, which moved about, indicating that the vitreous had become liquefied at this point. Under ether I opened the eye between the external and inferior recti muscles. I introduced OPH.-I3
440
HOLT: Removal of AMetal from the Vitreotus.
the long, straight point of Bradford's magnet, and as I knew the exact location of the steel, and could readily see the point of thc magnet through the pupil as I manipulated it, I did not expect to be long in removing the steel, but I was doomed to disappointment. I introduced the magnet many times, but practically in the same direction, and at last saw the steel at the edge of the wound on the magnet. There was but little haemorrhage and no loss of vitreous. The conjunctival wound was closed by two catgut sutures, and the eyes covered with cotton, held in place by silk isinglass plaster. The operation lasted about an hour. The patient's pulse became feeble, and the breathing bad, so that the feet were elevated and he was given a hypodermic of strychnia. The patient was put to bed. He has made an excellent recovery, vision being equal to 0.5. In reviewing, these cases and those previously reported, we have a series of seventeen which, although small, is nevertheless interesting and instructive. The one case in the first series, in which prima'ry enucleation was performed, there was no expectation of saving the eye; it was introduced into that series to show how accurately the estimation of the location of the steel was made, and how the eye might have been saved had not the folly of waiting two weeks been adopted. It should not be considered in the results. In case one of this series the eye might have been saved had not an accident occurred during convalescence, although a week had elapsed before the operation was performed, during which time the lens became opaque, and no view of the fundus could be obtained. In cases three and four the nature of the injury was such as not to expect any better results than were obtained. In case six the eye was infected and active suppuration existed, so that if I had persisted, and had been successful in removing the steel, the eye would have been destroyed by suppuration. In case seven I was disappointed in not obtaining the steel. I felt sure it was in the eye, but could not find it even after enucleation. It probably escaped during the process of enucleation, as some of the contents of the eye was lost. We, therefore, have three primary and two secondary enucleations in this series. Case eight was an ideal one for the removal of steel by the electro-
HOLT: Removal of Affetal from the Vitreous.
44I
magnet, though a week had elapsed before the operation. The results thus far have been all that could be expected, namely, the preservation of the eye with good vision. As long as medicine is not an exact science, the true physician or surgeon must constantly be on the alert lest his remedies do more harm than good. With these facts in view, we must in every case of injury of the eye, in which a foreign body has been lodged in the vitreous, advise the patient either to have the foreign body removed or the eye, or else let them alone, and treat the eye expectantly. We must do one of these three things, and which it shall be must be determined in each individual case after the accident has occurred. There are some ophthalmic surgeons, however, who question the propriety of removing steel from the vitreous, claiming that if successfully done the eye sooner or later is doomed to destruction. This has not been my experience. The results of thcse three series of cases are as follows: One had vision of 0.7; three had vision of 0-5 ; two had vision of 0.2; four had vision of O.I; one had quantitative vision. I have heard from those operated upon any length of time, and they are all doing as well or better than when they left me. I feel sure I should hear from them if they had any trouble with their eyes. Discission in five or six of these cases would improve vision, but they were satisfied with the results obtained, and discission was not urged upon them, for I think it best to keep the eye as quiet as possible after an accident and operation of this kind. I have now practiced the removal of steel from the vitreous by the electro-magnet for ten years, and the results are very much better than those obtained in the ten years previous to that time when I did not use the magnet. I feel sure from my former experience and from the observation of neglected cases of those treated on the let-alone plan, that the sight in nearly all of the eyes here recorded would have been destroyed had not the steel in the vitreous been removed. With the certainty that in a large number of cases the eye will be destroyed if the steel is left in the eye, is it not our duty to make an attempt to remove it and thus give the patient
:442
RISLEY: Vaso-motor Atazia.
the benefit of a chance to save the eye with useful vision ? There is no excuse for not attempting to remove the steel because the lens has been injured, and we cannot see it with the ophthalmoscope. There were only five of these cases where the steel could be seen and located. In the other twelve cases its position had to be estimated from the position and nature of the external wound of the eye and the probable position of the person and the eye at the time of the accident. This estimation was so accurate that in nine of the twelve cases the Graefe knife came in contact with the metal when the incision was made through the sclerotic. There is no reason why we should not attempt the removal of a foreign body from the vitreous when it cannot be seen or definitely located, provided the injury is such as to necessitate its removal.or the eye itself. If successfully done, uinder aseptic methods, there is a chance of saving the form of the eye with useful vision, which is one of the greatest triumphs of the ophthalmic surgeon.
A CASE OF VASO-MOTOR ATAXIA, WITH EYE SYMPTOMS SIMULATING MONOCULAR EXOPH-
THALMIC-GOITRE. By S. D. RISLEY, M.D., OF PHIILADELPHIA.
The clinical picture presented by exophthalmic goitre is, unfortunately, a very familiar one to the ophthalmic surgeon. Notwithstanding the frequent opportunities for its study, the ultimate cause, or exact nature of the characteristic phenomena are still very far from a satisfactory solution. Although as a rule both eyes are involved, cases of monocular exophthalmos are not rare in literature; no case has, however, come under my own observation, unless indeed, the case here reported is to be so regarded. On June I 2th last, Mrs. B., aged 42, came to the Wills Eye Hospital, complaining that for the past three months she had been annoyed by a peculiar "staring " appearance in the right
