NOTES ON THE USE OF N[TROUS OXIDE AS AN ANIESTHETIC IN STRABIS,IUS OPERATIONS. By DR. ARTHUR MATHEWSON, Brooklyn.
THE use of nitrous oxide as an anesthetic for other operationis than those of dentistry has been the subject of frequent discussion in medical societies and journals, and especially of late, since the apparatus for its adlministration has been so much inmproved; but, so far as I am aware, no cases in which it has been employed in ophthalmiic surgery have been retorted, with the exception of one referred to by Dr. Jeffries, in a paper read before this Society, in I871, in which he employed it for doing Passavant's operation. He com. mends it highly, his patient suffering none of the disagreeable consequences which had been caused by previous admninistration of ether. My friends, Drs. Giberson and Rushmiore, of Brooklyn, lhad each recently used it in cases of amputation, where the patients were so feeble that they hardly dared to administer the other anesthetics, and had found that, after being kept under its influence for from twenty-five to thirty minutes, they recovered consciousness almost immiediately, had no trouble from vomitino, and were left in a very satisfactory condition. Learning from these cases within imiy own l)ersonal knowledge, and from others of which I had read, how easily and with what apparent safety the full anaesthetic effect of nitrous oxide could be kept up for a period miiore than long enough for any ordinary strabismus operation, and how speedily the effect passed away, it occurred to me that this agent would offer special advantages as an anaesthetic in strabotomy over chloroformii or ether. As we all know, the effect of -these latter is often slow in passing away, and it may be a long time before the patient is in a condition to enable us to satisfactorily test the effect of .the operation, so as to decide whether it is best to operate on the other eye, to dissect more freely, or to use sutures to increase or dimiiinish the effect of the dissection-a most desirable thing, as every operator nmust concede. The sense of suffocation caused by ether, too, with the attendant resistaince, struggling, and other dis-
38I
agreeable symptoms, are not to be too lightly thotught of, especially in case of delicate, nervous children with excitable parents. These were the a priori considerations which led me to think favorably of nitrous oxide as an anesthetic in strabotomy; and the following cases show my experience with it: CASE I.-Miss A. Mc., st. 23, the subject of convergent strabismus, had been operated on for its relief by another surgeon previous to coming under my care, and by miyself on January 2, I878. rhe:e was still a slight degree of convergence remaining; and to correct this she was put under the influence of nitrous oxide, February 12, 1878, by Dr. George F. Brush, an expert in its use, and tenotomy of the internal rectus of the right eye performiied. The patient was fully anxsthetized in two minutes, and the operation finished in two minutes more-the matted condition of the tissues resuilting from previous operations rendering it difficult to comiiplete the dissection more quickly. The inhalation of the nitrous oxide was kept up dturing the whole time, thus occupying four minutes. The uniconsciousness passed off at once, so that the effect of the operation could be fully tested, and within five minutes from the tinme she began the inhalation the patient rose from the operating-chair and was rea'dy to walk home without assistance. She felt no pain during the operation, and there were no unpleasant after-effects, as on previous occasions, when the ether had made her sick for two or three davs. The ether had also produced very disagreeable sensations of suiffocation; wlhile the sensations caused by the nitrous oxide were, according to her statenient, rather agreeable than otherwise. CASE I1.-Miss M. G., set. 22, was put under the influence of nitrous oxide for operation for correction of convergent strabismus, by Dr. Brush, at his office, February i6, I878. Drs. Giberson and Hesse assisted me, and the former took accurate note of the timie. She was fully anresthetized in one nminute ; tenotomiiy of the left internal rectus was done in one minute miore; and forty-five seconds after removal of inhaling apparatus (which had only covered the mo'ith, not the nose, during a part of the time) she had conmpletely recovered consciousness, so that the effect of the operation could be tested. T'here was no vomiiiting or other unpleasant after-effects. CASE III.-MIiss A. C., set. 8-convergent strabismus; May 30, I878-was completely anesthetized by nitrous oxide, admiinistered by Dr. Brush, in one aud a half minutes ; tenotonmy of internus of 0. D. perfornmed in one and a half minutes. Recovery of conscious-
382 ness almost instantaneous, so that effect of operation could be tested. This patient had dined just previous to the operation, and there was some vomiting afterward. A few weeks later tenotomy of the left internuis was performed. The- nitrous oxide was given on this occasion more slowly, i. e., Imixed with more air, and the patient was anesthetized in three minutes. The operation, including introduction of stuture, occuipied one minute and fifty seconids. There was some vomiting afterward. CASE IV.-Jamiies D., aet. 22-convergent strabismtus-operated on May 28, I878. Anasthetized in two minutes. Tenotomy of right internus in one and a half imiinutes; interval of one and a half minuites; tenotomy of left internus one nminute; no vomiting or other unpleasant after-effects. CASE V. -E. C., boy of 6 years-strabismus convergens. Anaesthesia obtained in one and a half minutes; tenotomiiy of both interni occupied three minutes. Consciousness restored at once, and effect of operation tested after a mlinute or two. No unpleasant aftereffects except a very little vomiting. In all these cases the patient was seated in a dentist's operatingchair, tipped back as far as possible, and the gas drawn from the apparatus of Johnston Bros. (1260 Broadway, New York) for the use of the liquid nitrous oxide. This has an inhaler fitted with a valve, so that atmospheric air can easily be admitted, and a cupshaped cover to go over MLoth and nose. Johnston Bros. make also a very convenient portable apparatus. The patient in each case went quietly under the influence of the anxsthetic withoutt any of the suffocating sensations caused by ether, and, with the exception of the vomiting in two of the cases, there were no unpleasant after-effects. In some of the cases a blue and livid color of the face camiie on, as it will somnetimiies during the admiiinistration of ether; but this passed off at once on admiiission of air, and had no disagreeable conisequences. It was noticed that while this lividity of the face continued there was scarcely any bleeding fromii the dissection, gnd that the blood was very dark; but on admission of air the blood became bright at once and flowed freely. Full muscular relaxation did not accompany anesthesia in all these cases; but this was not an inconvenience, as it might prove in cataract and other operations.
383 The minimum and maximum quantities of gas consumed in these cases were seven anid twenty gallons, at a maxinmum cost of one
dollar. Previous to the date of these cases my colleague, Dr. Rushmore, had employed nitrous oxide in a strabisim.us operation at the Brooklyn Eye and Ear Hospital, with very satisfactory results.
OPHTHALMIC CONTRIBUTIONS. By GEORGE STRAWBRIDGE, M.D., of Philadelphia. I. TUMOR OF THE OPTIC NERVE-ITS REMOVAL WITHOUT ENUCLEATION OF THE EYEBALL.
THE case occurred in a woman aet. 24, housekeeper by occupation, married. Both eyeballs were prominent from birth. For a number of years the woman had suffered from neuralgic attacks (right hemicrania) and slow loss of vision of right eye. Four years ago the eye became entirely blind. One year later, after a difficult confinement, a marked increase of exophthalmos of the right eye was observed. This has continued to time of operation. Status praesens.-Right eyeball has an exophthalmos of 12 Mnm., and is pushed upward and toward the nasal side of the orbit by the tumor, which can be felt by the finger pressed between the inferior and external recti-miiuscular interspace. Motions of the eyeball are moderately good; tension not altered; some conjunctival injection; entire loss of vision. Ophthalmoscopic Examination.-Refraction hypermetropic; media entirely clear; papilla, white, outline somewhat undefined, as if neuritis had previously existed Diagnosis.-Atrophy of optic nerve after neuritis, caused probably b) an optic nerve tumnor. Method of Operation.-The outer lid commissuire was divided to increase the available room. The inferior and external recti-muscles were then divided at their eyeball attachment, and the interspace cleared sufficiently to allow a finger, entrance. The tumor could be distinictly felt, and to a certain extent could be separated from the surrounding tissue by the finger; the optic nerve could be felt
THE use of nitrous oxide as an anesthetic for other operationis than those of dentistry has been the subject of frequent discussion in medical societies and journals, and especially of late, since the apparatus for its adlministration has been so much inmproved; but, so far as I am aware, no cases in which it has been employed in ophthalmiic surgery have been retorted, with the exception of one referred to by Dr. Jeffries, in a paper read before this Society, in I871, in which he employed it for doing Passavant's operation. He com. mends it highly, his patient suffering none of the disagreeable consequences which had been caused by previous admninistration of ether. My friends, Drs. Giberson and Rushmiore, of Brooklyn, lhad each recently used it in cases of amputation, where the patients were so feeble that they hardly dared to administer the other anesthetics, and had found that, after being kept under its influence for from twenty-five to thirty minutes, they recovered consciousness almost immiediately, had no trouble from vomitino, and were left in a very satisfactory condition. Learning from these cases within imiy own l)ersonal knowledge, and from others of which I had read, how easily and with what apparent safety the full anaesthetic effect of nitrous oxide could be kept up for a period miiore than long enough for any ordinary strabismus operation, and how speedily the effect passed away, it occurred to me that this agent would offer special advantages as an anaesthetic in strabotomy over chloroformii or ether. As we all know, the effect of -these latter is often slow in passing away, and it may be a long time before the patient is in a condition to enable us to satisfactorily test the effect of .the operation, so as to decide whether it is best to operate on the other eye, to dissect more freely, or to use sutures to increase or dimiiinish the effect of the dissection-a most desirable thing, as every operator nmust concede. The sense of suffocation caused by ether, too, with the attendant resistaince, struggling, and other dis-
38I
agreeable symptoms, are not to be too lightly thotught of, especially in case of delicate, nervous children with excitable parents. These were the a priori considerations which led me to think favorably of nitrous oxide as an anesthetic in strabotomy; and the following cases show my experience with it: CASE I.-Miss A. Mc., st. 23, the subject of convergent strabismus, had been operated on for its relief by another surgeon previous to coming under my care, and by miyself on January 2, I878. rhe:e was still a slight degree of convergence remaining; and to correct this she was put under the influence of nitrous oxide, February 12, 1878, by Dr. George F. Brush, an expert in its use, and tenotomy of the internal rectus of the right eye performiied. The patient was fully anxsthetized in two minutes, and the operation finished in two minutes more-the matted condition of the tissues resuilting from previous operations rendering it difficult to comiiplete the dissection more quickly. The inhalation of the nitrous oxide was kept up dturing the whole time, thus occupying four minutes. The uniconsciousness passed off at once, so that the effect of the operation could be fully tested, and within five minutes from the tinme she began the inhalation the patient rose from the operating-chair and was rea'dy to walk home without assistance. She felt no pain during the operation, and there were no unpleasant after-effects, as on previous occasions, when the ether had made her sick for two or three davs. The ether had also produced very disagreeable sensations of suiffocation; wlhile the sensations caused by the nitrous oxide were, according to her statenient, rather agreeable than otherwise. CASE I1.-Miss M. G., set. 22, was put under the influence of nitrous oxide for operation for correction of convergent strabismus, by Dr. Brush, at his office, February i6, I878. Drs. Giberson and Hesse assisted me, and the former took accurate note of the timie. She was fully anresthetized in one nminute ; tenotomiiy of the left internal rectus was done in one minute miore; and forty-five seconds after removal of inhaling apparatus (which had only covered the mo'ith, not the nose, during a part of the time) she had conmpletely recovered consciousness, so that the effect of the operation could be tested. T'here was no vomiiiting or other unpleasant after-effects. CASE III.-MIiss A. C., set. 8-convergent strabismus; May 30, I878-was completely anesthetized by nitrous oxide, admiinistered by Dr. Brush, in one aud a half minutes ; tenotonmy of internus of 0. D. perfornmed in one and a half minutes. Recovery of conscious-
382 ness almost instantaneous, so that effect of operation could be tested. This patient had dined just previous to the operation, and there was some vomiting afterward. A few weeks later tenotomy of the left internuis was performed. The- nitrous oxide was given on this occasion more slowly, i. e., Imixed with more air, and the patient was anesthetized in three minutes. The operation, including introduction of stuture, occuipied one minute and fifty seconids. There was some vomiting afterward. CASE IV.-Jamiies D., aet. 22-convergent strabismtus-operated on May 28, I878. Anasthetized in two minutes. Tenotomy of right internus in one and a half imiinutes; interval of one and a half minuites; tenotomy of left internus one nminute; no vomiting or other unpleasant after-effects. CASE V. -E. C., boy of 6 years-strabismus convergens. Anaesthesia obtained in one and a half minutes; tenotomiiy of both interni occupied three minutes. Consciousness restored at once, and effect of operation tested after a mlinute or two. No unpleasant aftereffects except a very little vomiting. In all these cases the patient was seated in a dentist's operatingchair, tipped back as far as possible, and the gas drawn from the apparatus of Johnston Bros. (1260 Broadway, New York) for the use of the liquid nitrous oxide. This has an inhaler fitted with a valve, so that atmospheric air can easily be admitted, and a cupshaped cover to go over MLoth and nose. Johnston Bros. make also a very convenient portable apparatus. The patient in each case went quietly under the influence of the anxsthetic withoutt any of the suffocating sensations caused by ether, and, with the exception of the vomiting in two of the cases, there were no unpleasant after-effects. In some of the cases a blue and livid color of the face camiie on, as it will somnetimiies during the admiiinistration of ether; but this passed off at once on admiiission of air, and had no disagreeable conisequences. It was noticed that while this lividity of the face continued there was scarcely any bleeding fromii the dissection, gnd that the blood was very dark; but on admission of air the blood became bright at once and flowed freely. Full muscular relaxation did not accompany anesthesia in all these cases; but this was not an inconvenience, as it might prove in cataract and other operations.
383 The minimum and maximum quantities of gas consumed in these cases were seven anid twenty gallons, at a maxinmum cost of one
dollar. Previous to the date of these cases my colleague, Dr. Rushmore, had employed nitrous oxide in a strabisim.us operation at the Brooklyn Eye and Ear Hospital, with very satisfactory results.
OPHTHALMIC CONTRIBUTIONS. By GEORGE STRAWBRIDGE, M.D., of Philadelphia. I. TUMOR OF THE OPTIC NERVE-ITS REMOVAL WITHOUT ENUCLEATION OF THE EYEBALL.
THE case occurred in a woman aet. 24, housekeeper by occupation, married. Both eyeballs were prominent from birth. For a number of years the woman had suffered from neuralgic attacks (right hemicrania) and slow loss of vision of right eye. Four years ago the eye became entirely blind. One year later, after a difficult confinement, a marked increase of exophthalmos of the right eye was observed. This has continued to time of operation. Status praesens.-Right eyeball has an exophthalmos of 12 Mnm., and is pushed upward and toward the nasal side of the orbit by the tumor, which can be felt by the finger pressed between the inferior and external recti-miiuscular interspace. Motions of the eyeball are moderately good; tension not altered; some conjunctival injection; entire loss of vision. Ophthalmoscopic Examination.-Refraction hypermetropic; media entirely clear; papilla, white, outline somewhat undefined, as if neuritis had previously existed Diagnosis.-Atrophy of optic nerve after neuritis, caused probably b) an optic nerve tumnor. Method of Operation.-The outer lid commissuire was divided to increase the available room. The inferior and external recti-muscles were then divided at their eyeball attachment, and the interspace cleared sufficiently to allow a finger, entrance. The tumor could be distinictly felt, and to a certain extent could be separated from the surrounding tissue by the finger; the optic nerve could be felt
