REPORT OF OPHTHALMIC PRACTICE IN THE COWASJEE JEHANGHIER HOSPITAL, BOMBAY, DURING THE MONTH OF AUGUST, 1870. By Assistant Surgeon George Waters, Bombay Army. The total number of operations performed in this hospital the month of August amounted to 40, being the miniOf these seven were as follows :?Two cases mum of the year. of excision of vascular tumour (noevus), each growing immediately above the caruncula lachrymalis: operation for the dilaceration of opaque capsule remaining after the extraction of cataract, by the double needle method; Bowman's operation for fistula lachrymalis; Borelli's operation for staphyloma; extraction of foreign body, and Critckett's operation for the abscission of staphyloma; all of which are of such a nature as to require little comment?suffice it to say that each answered the purpose for which it was undertaken. I would merely add, with reference to Borelli's and Critchett's operation respectively, that the former is adopted when there is but part of the corAea involved, and a chance of procuring vision by artificial pupil after recovery ; whereas the latter need only be had recourse to when all hope of vision is lost, and the whole cornea involved. Paracentesis cornea) was performed nine times. This is another operation of which little can be said further than that it was performed with the usual objects, namely, evacuation of pus, and to afford more or less permanent immunity from pain, according to the nature of the case, by the diminution of intraocular pressure resulting from withdrawal of the aqueous humour. Three patients presented themselves, each having a sebaceous cyst in the upper eyelid; the smallest the size of a case an incision was pea, the largest that of a walnut. In each made through the skin horizontally across the tumour and the The out. resulting wounds healed cyst; then carefully dissected by first intention. Dissection of cilia of lower lid. This, so to speak, cruel little operation is now rarely had recourse to in this hospital. In this single instance, however, no other operation could be substituted with equal advantage to the patient. The tarsal margin, was completely covered with short cilia, and these being imperceptible at a little distance from the patient, no additional disfigurement resulted from their removal; on the contrary, the corneal irritation quickly subsiding, his appearance was improved. Canthoplasty was performed four times. Two of these opera| tions were performed on the same patient iu combination with
during
1
Febkuaky 1, 1871.]
A MIRROR OF
HOSPITAL PRACTICE.
Haynes Walton's operation for the cure of entropium, and succeeded admirably, considerably increasing the palpebral aperture, the entropium, and greatly diminishing the corneal irritation, consequent on the previously inverted lids. The other two canthoplasty operations were undertaken with a view to the cure of superficial keratitis due to the unusual pressure exerted upon the eye, by the unyielding, shortened and thickened state of the upper eyelid, occasioned by granular conjunctivitis of long standing. Here also the palpebral aperture was much narrowed; this was obviated, and the other symptoms of both cases markedly mitigated by the operation. The plan of inserting the armed needles, pulling them through, and leaving the threads ready for ligature prior to using the knife, is that now most frequently adopted in this hospital. It greatly facilitates the operation, by doing away with the of engaging the mucous membrane with the needle, when much bleeding happens to be present, which is not unfrequently the case. Haynes "Walton's operation for entropium was performed four times with good effect. In one ease of very aggravated entropium, the cartilage was grooved in combination with this opera-
lessening
difficulty
tion. Artificial pupil was made four times during the month. Case I.?0. V. Pupil contracted, and pupillary area closed
^ith
Iris not affected
lymph.
by atropine.
Artificial
the fourth day following had preception of light, but
the vitreous syphilitic in
diminished.
being origin
pupil.
On
no
more, very hazy, the result of irido-choroiditis, ; the tension of the globe was also much
Case II.?H. N.
had a large albugo completely overand intercepting the entrance of light. Artificial pupil. Result, excellent vision. Case III.?R. H. formerly suffered from suppurative keratitis with penetrating ulcer terminating in prolapse of the iris and recovery, with anterior synechia, and obliteration of the pupil. This took place in both eyes at different periods. Artificial pupil was made in each eye opposite the clearest portion of the cornea, six days being allowed to elapse between each operation. Result, tolerably good vision in both eyes. Iridectomy was performed four times.
shadowing
the
pupil
had sub-acute keratitis of nearly two years' hazy and vision almost nil. Iridectomy was followed by a steady clearing of the cornea; so that in ten days vision was much improved. Case II.?S. M. iritis with descemetitis before serous admission, resulting in synechia posterior and hazy cornea. Iridectomy in this instance was not productive of much benefit. The anterior chamber became filled with blood, which was tardily absorbed, and even after absorption the cornea was not clearer than before operation. Case III.?0. V. Yery obstinate chronic pannijs. Iridectomy was followed by marked clearing of the cornea, and consequent improvement in vision. Extraction of cataract. Five cataracts were extracted during the month, four being by Yon Graefe's method, and the fifth scoop extraction. As cataract operations are always interesting, and the results important, I shall relate one or two in detail. Case I.?This was an old man of spare body and extremelv emaciated. On admission, in addition to cataract, he was suffering from chronic ophthalmia with much tumefaction and excoriation of the lids, mucous discharge, and the arcus senilis was well marked. After being treated for nearly a fortnight with mild stimulants applied to the eye, and ammonia and bark administered internally, the tumefaction of the lids disappeared, and the mucous discharge stopped. Both lenses were cataractous, one said to be of seven years' duration. Von Graefe's operation was performed in the left eye by downward and outward flap, and the mode of performing it adopted in this hospital being somewhat different from the plan at present advocated, a little detail of the same is rendered necessary. The patient being laid upon the table, the eyelids widely separated by a stop speculum, and steadied eyeball by grasping the conjunctiva close beneath the centre of the cornea, Von Graefe's long narrow knife is thrust through the sclerotic at the very periphery of the anterior chamber, at first obliquely upwards and inwards ; the handle is then raised towards the outer angle of the orbit, which causcs the knife's point to swing round in the anterior chamber, and a counter puncture is made through the sclerotic on the opposite side, the knife being thrust through almost to its hilt. The cut Out is then made, and in doing this the knife is made to revolve to the extent of a quarter circle, so that at the time of its exit? Case I.?D. D.
duration;
cornea
very
35
the edge is directed to the operator's face?the conjunctiva espeit is loose) now hangs in a fold cially in old persons (in whom which is turned downwards towards over the edge of the knife, the patient's chin, thus describing another quarter circle, and by the conjunctiva is formed into a flap; a o-entle sawing motion,
the incision is wholly in the sclerotic. The iris was then drawn out and a sufficient iridectomy perand the capsule lacerated, after formed, the cystotome introduced which the cataractous lens made its exit by gentle pressure from a tortoise-shell curette. Solution of atropine gr. ii?5i was instilled, and a compress and bandage applied. 2nd day.?Patient has pulled off the bandage. The eye however seems to have sustained no injury. 3rd day.?As a restless old man, removes the bandage almost Continue atropine and bandage. as soon as it is applied. 4th day.?Bandage again interfered with. Eye very clear. Continue treatment. 7th.?No redness ; no pain; a large opaque piece of capsule in the lower part of the papillary area: it is fast shrivelling. 12th.?With cataract spectacles counts No. 8, Jaeger. Dis-
charged.
Case II.?N. N. , of a sickly constitution, admitted with hard cataract in both eyes. That of right 5, and left 2 years' Both eyes had slight perception of light; iride3 duration. sluggish. The cataract of longest duration was extracted by Yon Graefe's method performed as described in case 1, with this difference, an upward instead of an outward and downward flap, this being the right eye. (The ambidextrous operator is able to make an upward flap in the left eye also, which has the advantage of being followed by less disfigurement, owing to the caloboma consequent on iridectomy being hidden by the upper eyelid.) Extraction being accomplished, atropine was instilled, and a compress and bandage applied. 2nd day.?No pain; no swelling; eyo clear ; atropine and
bandage. 3rd day.?No pain; oil at once. Continue
atropine
no
and
swelling;
bowels
constipated.
Castor
bandage.
7th day.?Slight pain around orbit.
Extract belladonnoe if necessary. atropine and bandage. 8th day,?Eye slightly painful; iris widely dilated ; pupil clear. One small speck of opaque capsule visible in pupillary area. Vision dull, probably chorvidal congestion. Two leeches. Jalap and Calomel. Continue extract belladonna) and instillation of atropine. 9th day.?Freely purged ; pain gone. Vision still dull. Mist, quinoe 31, 3 times a day. Extract belladonna). 10th day.?Counts No. 20, Jaeger. Continue mist, and extract belladonnoe. 14th day.?No pain; vision increasing; vitreous almost clear ; fundus hyperamic, disc scarcely distinguishable. Continue treatment. 17th day.?Conjunctival and sub-conjunctival redness; slight pain, cornea hazy ; stroma of iris clear. 2 leeches. Extract belladonna) around orbit, instil atropine frequently. 19th day,?Improving. Belladonna) and Potass bicarb, daily. Continue
20th day.?Redness less ; no pain. Continue treatment. 21st day.?Progressing favorably; no injection, 23rd day.?Counts No. 1, Jaeger, with 2^ inch spectacles.
Discharged.
Case III.?B. S. -, 50 years of age, admitted with hard cataThat of left eye ten, and right six months' ract in both eyes. duration. Right eye, was operated upon by Von Graefe's method. In this instance the lens refused to exit, after laceration of the " capsule, nor could it bo coaxed" out by exerting gentle pressure on the lower portion of the cornea, with a small spatula of tortoise shell. The latter proceeding was not persevered in, lest escape of vitreous might follow, and as the patient became very unsteady, there was dangor of the lens sinking into the vitreous. Consequently, Critchett's scoop was had recourse to, and by inserting this behind the lens and exerting gentle tracThis case progressed tion, the operation was completed. favorably to recovery without a single bad symptom. On the 12th day after the operation vision was perfect. Case IV.?This was the loft eye of the same patient, namely Von Graefe's method, scoop, again B. S. necessitated, and extraction therewith readily accomplished. Recovered with uninterrupted progress. On the 10th day after the operation counted No. 1 brilliant. Case V. was a case of traumatic cataract following a wound of the eyeball. There being extensive adhesion of the iris to the anterior capsule of the lens, the old scoop operation
THE INDIAN MEDICAL GAZETTE.
36
deemed most suitable, and accordingly performed. The made a very excellent recovery. The number of new cases treated in hospital during the month, not requiring operative interference, amounted to 48. The majority of diseases were classed under diseases of the cornea, diseases of the iris, and diseases of the conjunctiva, in the order mentioned. Many of these cases Were interesting, but none very peculiar, so that separate notice is unnecessary. The number of patients attending the out-door department during the month was 601. Granular conjunctivitis, keratitis, acute, and chronic, together with impaired vision from disease of the fundus oculi, furnished the largest number of cases. Remarks.?1. We generally find that in cases of hazy cornea arising from chronic interstitial keratitis, nothing marks the commencement of recovery so decidedly as an iridectomy. 2. The percentage of iritis following cataract extraction in this hospital though always small, has been rendered still smaller by making a large iridectomy before removing the lens; indeed, an iridectomy is positively necessary when extracting through the sclerotic. 3. "With reference to the method of extracting cataract generally adopted in this hospital, I beg to offer a few remarks for the consideration of those who take an interest in ophthalmic surgery. The plan of making the flap entirely in the sclerotic i3 not that which is most accepted by the leading ophthalmologists of the present day; still, I think it has some strong arguments in its favour, especially for the people of this country. Let us consider the matter pro and con. What are its recommendations ? 1st, a wound in the vascular sclerotic heals much more quickly than a wound in the non-vascular cornea ; 2nd, whilst the patient is supine, the scleral wound being on the same plane with the lens, extraction is accomplished with less manipulation than when the incision is higher up, namely, in the And most assuredly, the less an eye is " fiddled" with cornea. during an operation, the more likely is the result of that operation to be successful; 3rd, except in very healthy eyes, the cicatrix after extraction the cornea invariably travels onwards towards its centre, and the more remote the primary cicatrix lies, the longer must it take in becoming perceptible on the cornea : indeed, the cicatrix leaves no track in the sclerotic. Let us now glance at the objections to the method of operating entirely in the sclera, (so far as the flap is concerned.) What are they ? It is said cyclitis is more liable to follow when the incision is entirely in the sclera, which, theoretically, is very plausible; but it has not been borne out in the practice of this hospital, whicb is not inconsiderable; there having been a3 many as 35 operations for extraction of cataract performed in one month during tbe cold season. Again it is urged that escape of the vitreous i3 not uncommon in such operations. Touching this point, one very important fact must not bo overlooked; it is this. In Europe cataract is rarely extracted without the aid of chloroform, whereas natives of Hindostan, from the general torpor of their nervous sensibilities, will bear the same operation, whilst perfectly conscious, in many instances without even a groan. Taking advantage of this fact, we generally dispense with the use of chloroform. In Europe, while the bad effects of chloroform in extraction of cataract have long been recognised, its use cannot be altogether dispensed with, for the nervous endowment of Euroit is utterly impossible for them to bear peans being so very high, such an operation unaided by chloroform and remain absolutely quiet?a condition peculiarly essential in order to succeed. The most serious objection to chloroform is the liability to escape of the vitreous, consequent on the sickness and vomiting so frequently entailed by its use. In short, it would appear that without chloroform, the flap being formed entirely in the sclera, the vitreous is as little or even less likely to escape as when the aperture is made in the cornea and chloroform administered, while the former has the great advantage of a more rapid union of the wound. Thus it will be seen that the necessity or not for the administration of choloroform ought chiefly to decide the mode of operation to be adopted.
w
as
ca se
through
[Eebbttaey 1, 187L
during
1
Febkuaky 1, 1871.]
A MIRROR OF
HOSPITAL PRACTICE.
Haynes Walton's operation for the cure of entropium, and succeeded admirably, considerably increasing the palpebral aperture, the entropium, and greatly diminishing the corneal irritation, consequent on the previously inverted lids. The other two canthoplasty operations were undertaken with a view to the cure of superficial keratitis due to the unusual pressure exerted upon the eye, by the unyielding, shortened and thickened state of the upper eyelid, occasioned by granular conjunctivitis of long standing. Here also the palpebral aperture was much narrowed; this was obviated, and the other symptoms of both cases markedly mitigated by the operation. The plan of inserting the armed needles, pulling them through, and leaving the threads ready for ligature prior to using the knife, is that now most frequently adopted in this hospital. It greatly facilitates the operation, by doing away with the of engaging the mucous membrane with the needle, when much bleeding happens to be present, which is not unfrequently the case. Haynes "Walton's operation for entropium was performed four times with good effect. In one ease of very aggravated entropium, the cartilage was grooved in combination with this opera-
lessening
difficulty
tion. Artificial pupil was made four times during the month. Case I.?0. V. Pupil contracted, and pupillary area closed
^ith
Iris not affected
lymph.
by atropine.
Artificial
the fourth day following had preception of light, but
the vitreous syphilitic in
diminished.
being origin
pupil.
On
no
more, very hazy, the result of irido-choroiditis, ; the tension of the globe was also much
Case II.?H. N.
had a large albugo completely overand intercepting the entrance of light. Artificial pupil. Result, excellent vision. Case III.?R. H. formerly suffered from suppurative keratitis with penetrating ulcer terminating in prolapse of the iris and recovery, with anterior synechia, and obliteration of the pupil. This took place in both eyes at different periods. Artificial pupil was made in each eye opposite the clearest portion of the cornea, six days being allowed to elapse between each operation. Result, tolerably good vision in both eyes. Iridectomy was performed four times.
shadowing
the
pupil
had sub-acute keratitis of nearly two years' hazy and vision almost nil. Iridectomy was followed by a steady clearing of the cornea; so that in ten days vision was much improved. Case II.?S. M. iritis with descemetitis before serous admission, resulting in synechia posterior and hazy cornea. Iridectomy in this instance was not productive of much benefit. The anterior chamber became filled with blood, which was tardily absorbed, and even after absorption the cornea was not clearer than before operation. Case III.?0. V. Yery obstinate chronic pannijs. Iridectomy was followed by marked clearing of the cornea, and consequent improvement in vision. Extraction of cataract. Five cataracts were extracted during the month, four being by Yon Graefe's method, and the fifth scoop extraction. As cataract operations are always interesting, and the results important, I shall relate one or two in detail. Case I.?This was an old man of spare body and extremelv emaciated. On admission, in addition to cataract, he was suffering from chronic ophthalmia with much tumefaction and excoriation of the lids, mucous discharge, and the arcus senilis was well marked. After being treated for nearly a fortnight with mild stimulants applied to the eye, and ammonia and bark administered internally, the tumefaction of the lids disappeared, and the mucous discharge stopped. Both lenses were cataractous, one said to be of seven years' duration. Von Graefe's operation was performed in the left eye by downward and outward flap, and the mode of performing it adopted in this hospital being somewhat different from the plan at present advocated, a little detail of the same is rendered necessary. The patient being laid upon the table, the eyelids widely separated by a stop speculum, and steadied eyeball by grasping the conjunctiva close beneath the centre of the cornea, Von Graefe's long narrow knife is thrust through the sclerotic at the very periphery of the anterior chamber, at first obliquely upwards and inwards ; the handle is then raised towards the outer angle of the orbit, which causcs the knife's point to swing round in the anterior chamber, and a counter puncture is made through the sclerotic on the opposite side, the knife being thrust through almost to its hilt. The cut Out is then made, and in doing this the knife is made to revolve to the extent of a quarter circle, so that at the time of its exit? Case I.?D. D.
duration;
cornea
very
35
the edge is directed to the operator's face?the conjunctiva espeit is loose) now hangs in a fold cially in old persons (in whom which is turned downwards towards over the edge of the knife, the patient's chin, thus describing another quarter circle, and by the conjunctiva is formed into a flap; a o-entle sawing motion,
the incision is wholly in the sclerotic. The iris was then drawn out and a sufficient iridectomy perand the capsule lacerated, after formed, the cystotome introduced which the cataractous lens made its exit by gentle pressure from a tortoise-shell curette. Solution of atropine gr. ii?5i was instilled, and a compress and bandage applied. 2nd day.?Patient has pulled off the bandage. The eye however seems to have sustained no injury. 3rd day.?As a restless old man, removes the bandage almost Continue atropine and bandage. as soon as it is applied. 4th day.?Bandage again interfered with. Eye very clear. Continue treatment. 7th.?No redness ; no pain; a large opaque piece of capsule in the lower part of the papillary area: it is fast shrivelling. 12th.?With cataract spectacles counts No. 8, Jaeger. Dis-
charged.
Case II.?N. N. , of a sickly constitution, admitted with hard cataract in both eyes. That of right 5, and left 2 years' Both eyes had slight perception of light; iride3 duration. sluggish. The cataract of longest duration was extracted by Yon Graefe's method performed as described in case 1, with this difference, an upward instead of an outward and downward flap, this being the right eye. (The ambidextrous operator is able to make an upward flap in the left eye also, which has the advantage of being followed by less disfigurement, owing to the caloboma consequent on iridectomy being hidden by the upper eyelid.) Extraction being accomplished, atropine was instilled, and a compress and bandage applied. 2nd day.?No pain; no swelling; eyo clear ; atropine and
bandage. 3rd day.?No pain; oil at once. Continue
atropine
no
and
swelling;
bowels
constipated.
Castor
bandage.
7th day.?Slight pain around orbit.
Extract belladonnoe if necessary. atropine and bandage. 8th day,?Eye slightly painful; iris widely dilated ; pupil clear. One small speck of opaque capsule visible in pupillary area. Vision dull, probably chorvidal congestion. Two leeches. Jalap and Calomel. Continue extract belladonna) and instillation of atropine. 9th day.?Freely purged ; pain gone. Vision still dull. Mist, quinoe 31, 3 times a day. Extract belladonna). 10th day.?Counts No. 20, Jaeger. Continue mist, and extract belladonnoe. 14th day.?No pain; vision increasing; vitreous almost clear ; fundus hyperamic, disc scarcely distinguishable. Continue treatment. 17th day.?Conjunctival and sub-conjunctival redness; slight pain, cornea hazy ; stroma of iris clear. 2 leeches. Extract belladonna) around orbit, instil atropine frequently. 19th day,?Improving. Belladonna) and Potass bicarb, daily. Continue
20th day.?Redness less ; no pain. Continue treatment. 21st day.?Progressing favorably; no injection, 23rd day.?Counts No. 1, Jaeger, with 2^ inch spectacles.
Discharged.
Case III.?B. S. -, 50 years of age, admitted with hard cataThat of left eye ten, and right six months' ract in both eyes. duration. Right eye, was operated upon by Von Graefe's method. In this instance the lens refused to exit, after laceration of the " capsule, nor could it bo coaxed" out by exerting gentle pressure on the lower portion of the cornea, with a small spatula of tortoise shell. The latter proceeding was not persevered in, lest escape of vitreous might follow, and as the patient became very unsteady, there was dangor of the lens sinking into the vitreous. Consequently, Critchett's scoop was had recourse to, and by inserting this behind the lens and exerting gentle tracThis case progressed tion, the operation was completed. favorably to recovery without a single bad symptom. On the 12th day after the operation vision was perfect. Case IV.?This was the loft eye of the same patient, namely Von Graefe's method, scoop, again B. S. necessitated, and extraction therewith readily accomplished. Recovered with uninterrupted progress. On the 10th day after the operation counted No. 1 brilliant. Case V. was a case of traumatic cataract following a wound of the eyeball. There being extensive adhesion of the iris to the anterior capsule of the lens, the old scoop operation
THE INDIAN MEDICAL GAZETTE.
36
deemed most suitable, and accordingly performed. The made a very excellent recovery. The number of new cases treated in hospital during the month, not requiring operative interference, amounted to 48. The majority of diseases were classed under diseases of the cornea, diseases of the iris, and diseases of the conjunctiva, in the order mentioned. Many of these cases Were interesting, but none very peculiar, so that separate notice is unnecessary. The number of patients attending the out-door department during the month was 601. Granular conjunctivitis, keratitis, acute, and chronic, together with impaired vision from disease of the fundus oculi, furnished the largest number of cases. Remarks.?1. We generally find that in cases of hazy cornea arising from chronic interstitial keratitis, nothing marks the commencement of recovery so decidedly as an iridectomy. 2. The percentage of iritis following cataract extraction in this hospital though always small, has been rendered still smaller by making a large iridectomy before removing the lens; indeed, an iridectomy is positively necessary when extracting through the sclerotic. 3. "With reference to the method of extracting cataract generally adopted in this hospital, I beg to offer a few remarks for the consideration of those who take an interest in ophthalmic surgery. The plan of making the flap entirely in the sclerotic i3 not that which is most accepted by the leading ophthalmologists of the present day; still, I think it has some strong arguments in its favour, especially for the people of this country. Let us consider the matter pro and con. What are its recommendations ? 1st, a wound in the vascular sclerotic heals much more quickly than a wound in the non-vascular cornea ; 2nd, whilst the patient is supine, the scleral wound being on the same plane with the lens, extraction is accomplished with less manipulation than when the incision is higher up, namely, in the And most assuredly, the less an eye is " fiddled" with cornea. during an operation, the more likely is the result of that operation to be successful; 3rd, except in very healthy eyes, the cicatrix after extraction the cornea invariably travels onwards towards its centre, and the more remote the primary cicatrix lies, the longer must it take in becoming perceptible on the cornea : indeed, the cicatrix leaves no track in the sclerotic. Let us now glance at the objections to the method of operating entirely in the sclera, (so far as the flap is concerned.) What are they ? It is said cyclitis is more liable to follow when the incision is entirely in the sclera, which, theoretically, is very plausible; but it has not been borne out in the practice of this hospital, whicb is not inconsiderable; there having been a3 many as 35 operations for extraction of cataract performed in one month during tbe cold season. Again it is urged that escape of the vitreous i3 not uncommon in such operations. Touching this point, one very important fact must not bo overlooked; it is this. In Europe cataract is rarely extracted without the aid of chloroform, whereas natives of Hindostan, from the general torpor of their nervous sensibilities, will bear the same operation, whilst perfectly conscious, in many instances without even a groan. Taking advantage of this fact, we generally dispense with the use of chloroform. In Europe, while the bad effects of chloroform in extraction of cataract have long been recognised, its use cannot be altogether dispensed with, for the nervous endowment of Euroit is utterly impossible for them to bear peans being so very high, such an operation unaided by chloroform and remain absolutely quiet?a condition peculiarly essential in order to succeed. The most serious objection to chloroform is the liability to escape of the vitreous, consequent on the sickness and vomiting so frequently entailed by its use. In short, it would appear that without chloroform, the flap being formed entirely in the sclera, the vitreous is as little or even less likely to escape as when the aperture is made in the cornea and chloroform administered, while the former has the great advantage of a more rapid union of the wound. Thus it will be seen that the necessity or not for the administration of choloroform ought chiefly to decide the mode of operation to be adopted.
w
as
ca se
through
[Eebbttaey 1, 187L
