SELECTIONS
FROM OPHTHALMIC PRACTICE IN THE COWASJEE JEHANGHEER HOSPITAL, BOMBAY.
By Assistant Surgeon
Geokge
Watebs, Bombay Army. were treated this hospital. Diseases of the
During the month of September, 72 patients
in the in-door cornea
department
of
furnished the greatest number of
in order
cases, next
affections of the conjunctiva ; of the lens and capsule ; of the choroid and retina; of the iris ; and of the lachrymal OP' paratus?there being only one instance of each of the following diseases, viz., affections of the eyelids, of the sclera, general affections of the eye, diseases within the orhit, and various defects of sight. The classification adopted is that contained in of the authorised nomenclature prepared by the Royal College Physicians of London. Amongst the operations performed during the month, the most important were,?cataract extractions, and as the circumcame
stances
Graefe's
i
fou^cajies augured" onty',in('Tifferent success, Von mol?i?ro'f'opei,ating was adopted in order to test its
of
suitability in sill conditions, where I shall consequently relate each of Case I.?S. II. aged 60,
justified.
extraction is at all these four cases in detail.
health below the average, , admitted with hard cataract in both eyes ; that of right eye two and half years, and of left, three months' duration. Very little difference, however, was observed in their appearance. Eight eye, pupil freely dilated by atropine instilled 21 hours previously, nucleus faintly marked. Slight increase of tension
I
palpebral aperture
narrow.
Yon Graefe's method of
|
extraction, without chloroform; patient slightly unsteady. The lens escaped slowly, being coaxed out by gentle pressure on the lower edge of sclerotic by a tortoise-shell curette. Atropine was instilled and a compress and bandage applied. Made an uninterrupted recovery, and was well in fourteen days. Hazy vision resulted owing to the entire posterior capsule remaining and becoming opaque. Three weeks after the operation the opaque capsule was dilacerated by Bowman's double needle method. A good deal of debris still remained blocking up the pupil to a considerable extent, and materially marring vision, but afterwards these pieces of capsule commenced to shrivel, while the patient's sight gradually improved, and in a few days good vision will be the result. In this case however, even when the capsule shall have shrivelled sufficiently to leave a tolerably large pupil, we must not confidently expect perfect vision, for the increased tension above noted, though not sufficient to contrainduate extraction of the cataractous lens, has been presumably caused by some pathological condition of the deeper seated structures, which does not admit of direct treatment, and much improvement in vision from constitutional remedies can never be relied upon, especially when increased tension is
symptoms.
is
now
patient; she will
The
soon
woman
occasionally attending
as
implicitly
one
an
of the
out-door
be re-admitted with a view to undergoing the extraction of the cataract of the other eye. Case II.?T. M. had cataract in both eyes, but the one in left eye is miniature, only giving the pupil a greenish look, and not impairing vision to any great extent; while the cataract of right eye was fully formed, of an amber colour, and two and a half years' duration. Gums bore marked evidence of scorbutus. Von Graefe's operation, w ithout anaesthesia. Excellent recovery, patient having perfect vision eight days after the operation. This operation was undertaken with much uncertainty as to the propriety of interfering, and the benefit which might accrue. Notwithstanding the very unequivocal evidence which the patient exhibited of having had scorbutus?indeed, so marked was the latter that Dr. Sylvester on first seeing the case almost pronounced against operating?there still being a slight chance of restoring vision, he resolved to give the patient the benefit of the same. The happy result above mentioned is therefore all the more gratifying. Case III.?S. F. ?, aged 60, had a pale, puffy, anaemic nppearance, suggestive of Bright's disease of the kidneys, but no positive evidence of the latter was obtained from a careful examination of the urine, which merely contained a small amount of biliary acids. Had slight vision, pupils only half dilated by atropine. These symptoms augured no very brilliant success.
Extraction
by
Von Graefe's
method,
without chloroformnot at all in
The vitreous showed during the operation, but
Maech 1, 1871.]
A MIRROR OF HOSPITAL PRACTICE.
quantity, and extraction was completed without any appreciable ?loss of that medium. This, however, required manipulation of the highest delicacy, for the vitreous was unmistakably fluid, and therefore very liable to escape. Slight ciliary pain followed the operation, but soon subsided, and the eye completely recovered within a fortnight, without the occurrence of another bad symptom. Fair vision resulted, which was more than we Ventured to expect as may easily be understood from the abovementioned condition of the patient. Case IV.?H. S. , aged 62, very healthy. Had senile cataract in left eye, the duration of which could not be ascertained owing to the patient's want of intelligence ; pupil well dilated, but anterior chamber shallow. Operation by Yon Graefe's method. The shallowness of the anterior chamber rendered great caution necessary when making ?he section of the sclera, in order to avoid injuring the iris, lhe lena refused to exit by pressure on the cornea, but its removal was accomplished by traction with the scoop. A thin piece of capsule remained in the pupillary area. Recovered in fourteen days. The capsule having undergone considerable shrivelling, a good pupil resulted, and the patient was discharged, able to read No 2 Jaeger. The general health of these four patients, be it remembered, was below par, and promised only indifferent benefit from operation. The good results which, nevertheless, followed must therefore be considered as strongly recommendatory of Yon Graefe's method of extraction through the sclerotic. The other operations were very varied in their nature, but I shall merely relate a few, with their results, which struck me as interesting. Case I.?II. P. was admitted with a tumour in the outer angle of the orbit, connected with the lachrymal gland, peculiar inasmuch as its shape, size and position gave the patient very much the appearance of having a horn in an early stage of growth. Operation.?An incision having been made horizontally across the tumour through the skin with an ordinary scalpel, and its edges separated, a cyst was-discovered, which on being carefully dissected out and incised was seen to be composed of coagulated blood. A good deal of bleeding occurred during the operation, but was easily controlled by pressure afterwards. Silk sutures were used to unite the edges of the wound, and a union took place, and compress and bandage applied. Rapid the patient's appearance was much improved. was admitted with synechia posterior in Case II.?N. M. both eyes, the pupil of left eye occluded by organised lymph, the result of syphilitic iritis consequent on syphilis contracted four years previously. Stated that shortly after contracting it, he was seized with severe pain in the eyes, accompanied with redness and followed by much deterioration of vision. This evidently must have been an attack of irido-choroiditis, and as syphilitic iritis generally does not give rise to much pain, we presume that the inflammation, having begun in the iris, extended backwards, and thus arose the pain experienced by the patient at the outset of his disease. Operation.?Artificial pupil was made at the lower and inner portion of the iris of left eye, and though a good pupil remained, the lens capsule was revealed white and semi-opaque. Atropine solution grs. ii to ?i having been instilled, a compress and bandage "was applied. Treatment:?Mist. Ferri. et Potass. Iodidi, gi, three times a day. 2nd day.?Pupil partially closed, but there is still an ?opening, the size of No. 8 shot. Vision very little improved, no irritation. Continue treatment. 6th day.?Slight effusion of blood in the new pupil. 7th day.? Slight redness. Continue treatment. 12th day.?Can distinguish colours, and has a good perception of light. Continue. 16tli day.?Pupil filled with blood. Continue treatment. 20th day.?Blood disappearing, but still only bare perception of light and colour. Slight redness of globe continues. 28th day.?Pupil very distinct, but vision is still scarcely more than a qualitative perception of light. Fundus cannot be illuminated owing to haziness of the vitreous. Discharged. The treatment of this case, though negative in its result, is not altogether wanting in importance. Had constitutional treatment been had recourse to during the active symptoms of irido-choroiditis, or very shortly afterwards, its effect would have been manifest, for then the lymph effused, not having assumed such permanent organization, would have yielded readily to the action of absorbefacients. So far as wo can learn no treatment was adopted in this case, hence the state of the vitreous. The soouer then after syphilis unequivocally
53
manifests itself in the eye, we administer anti-syphilitic agents, the less appreciably will the disease interfere witli the'function of vision. And we doubt not since affections of the eye are not among the very earliest of secondary syphilitic manifestations, that the effect of mercury and iodide of potassium, single or combined, administered, let us say, on implication of the glands if not prophylactic is at least decidedly mitigatory of syphilitic ocular lesions when they occur. In such cases, therefore, the first object in treatment is to arrest the depredations of constitutional syphilis, and thus prevent the condition which unfortunately has obtained in the eyes of N. M., viz., diffused opacity of vitreous and loss of transparency in the lens capsule. had staphyloma of right cornea, Case III.?T. M. with a large central penetrating ulcer, through which the iris protruded. The ulcer was surrounded by a zone of healing cornea. Pupil obliterated, no vision. The left eye also had a penetrating ulcer on the upper third of the cornea, with prolapsed iris. Pupil pretty clear. Slight redness of the globe. Treatment :?Atropine and belladonna applied to the eye and orbit, aloes and iron administered internally. After a few days the cornea having sufficiently recovered, artificial pupil by excision was made with the double object of procuring vision arid arresting staphyloma. An excellent pupil was obtained, but the staphyloma not materially affected. Treatment after operation :?Local atropine compress and band;igo ; constitutional, ammonia and bark.
(To
be
continued.)
FROM OPHTHALMIC PRACTICE IN THE COWASJEE JEHANGHEER HOSPITAL, BOMBAY.
By Assistant Surgeon
Geokge
Watebs, Bombay Army. were treated this hospital. Diseases of the
During the month of September, 72 patients
in the in-door cornea
department
of
furnished the greatest number of
in order
cases, next
affections of the conjunctiva ; of the lens and capsule ; of the choroid and retina; of the iris ; and of the lachrymal OP' paratus?there being only one instance of each of the following diseases, viz., affections of the eyelids, of the sclera, general affections of the eye, diseases within the orhit, and various defects of sight. The classification adopted is that contained in of the authorised nomenclature prepared by the Royal College Physicians of London. Amongst the operations performed during the month, the most important were,?cataract extractions, and as the circumcame
stances
Graefe's
i
fou^cajies augured" onty',in('Tifferent success, Von mol?i?ro'f'opei,ating was adopted in order to test its
of
suitability in sill conditions, where I shall consequently relate each of Case I.?S. II. aged 60,
justified.
extraction is at all these four cases in detail.
health below the average, , admitted with hard cataract in both eyes ; that of right eye two and half years, and of left, three months' duration. Very little difference, however, was observed in their appearance. Eight eye, pupil freely dilated by atropine instilled 21 hours previously, nucleus faintly marked. Slight increase of tension
I
palpebral aperture
narrow.
Yon Graefe's method of
|
extraction, without chloroform; patient slightly unsteady. The lens escaped slowly, being coaxed out by gentle pressure on the lower edge of sclerotic by a tortoise-shell curette. Atropine was instilled and a compress and bandage applied. Made an uninterrupted recovery, and was well in fourteen days. Hazy vision resulted owing to the entire posterior capsule remaining and becoming opaque. Three weeks after the operation the opaque capsule was dilacerated by Bowman's double needle method. A good deal of debris still remained blocking up the pupil to a considerable extent, and materially marring vision, but afterwards these pieces of capsule commenced to shrivel, while the patient's sight gradually improved, and in a few days good vision will be the result. In this case however, even when the capsule shall have shrivelled sufficiently to leave a tolerably large pupil, we must not confidently expect perfect vision, for the increased tension above noted, though not sufficient to contrainduate extraction of the cataractous lens, has been presumably caused by some pathological condition of the deeper seated structures, which does not admit of direct treatment, and much improvement in vision from constitutional remedies can never be relied upon, especially when increased tension is
symptoms.
is
now
patient; she will
The
soon
woman
occasionally attending
as
implicitly
one
an
of the
out-door
be re-admitted with a view to undergoing the extraction of the cataract of the other eye. Case II.?T. M. had cataract in both eyes, but the one in left eye is miniature, only giving the pupil a greenish look, and not impairing vision to any great extent; while the cataract of right eye was fully formed, of an amber colour, and two and a half years' duration. Gums bore marked evidence of scorbutus. Von Graefe's operation, w ithout anaesthesia. Excellent recovery, patient having perfect vision eight days after the operation. This operation was undertaken with much uncertainty as to the propriety of interfering, and the benefit which might accrue. Notwithstanding the very unequivocal evidence which the patient exhibited of having had scorbutus?indeed, so marked was the latter that Dr. Sylvester on first seeing the case almost pronounced against operating?there still being a slight chance of restoring vision, he resolved to give the patient the benefit of the same. The happy result above mentioned is therefore all the more gratifying. Case III.?S. F. ?, aged 60, had a pale, puffy, anaemic nppearance, suggestive of Bright's disease of the kidneys, but no positive evidence of the latter was obtained from a careful examination of the urine, which merely contained a small amount of biliary acids. Had slight vision, pupils only half dilated by atropine. These symptoms augured no very brilliant success.
Extraction
by
Von Graefe's
method,
without chloroformnot at all in
The vitreous showed during the operation, but
Maech 1, 1871.]
A MIRROR OF HOSPITAL PRACTICE.
quantity, and extraction was completed without any appreciable ?loss of that medium. This, however, required manipulation of the highest delicacy, for the vitreous was unmistakably fluid, and therefore very liable to escape. Slight ciliary pain followed the operation, but soon subsided, and the eye completely recovered within a fortnight, without the occurrence of another bad symptom. Fair vision resulted, which was more than we Ventured to expect as may easily be understood from the abovementioned condition of the patient. Case IV.?H. S. , aged 62, very healthy. Had senile cataract in left eye, the duration of which could not be ascertained owing to the patient's want of intelligence ; pupil well dilated, but anterior chamber shallow. Operation by Yon Graefe's method. The shallowness of the anterior chamber rendered great caution necessary when making ?he section of the sclera, in order to avoid injuring the iris, lhe lena refused to exit by pressure on the cornea, but its removal was accomplished by traction with the scoop. A thin piece of capsule remained in the pupillary area. Recovered in fourteen days. The capsule having undergone considerable shrivelling, a good pupil resulted, and the patient was discharged, able to read No 2 Jaeger. The general health of these four patients, be it remembered, was below par, and promised only indifferent benefit from operation. The good results which, nevertheless, followed must therefore be considered as strongly recommendatory of Yon Graefe's method of extraction through the sclerotic. The other operations were very varied in their nature, but I shall merely relate a few, with their results, which struck me as interesting. Case I.?II. P. was admitted with a tumour in the outer angle of the orbit, connected with the lachrymal gland, peculiar inasmuch as its shape, size and position gave the patient very much the appearance of having a horn in an early stage of growth. Operation.?An incision having been made horizontally across the tumour through the skin with an ordinary scalpel, and its edges separated, a cyst was-discovered, which on being carefully dissected out and incised was seen to be composed of coagulated blood. A good deal of bleeding occurred during the operation, but was easily controlled by pressure afterwards. Silk sutures were used to unite the edges of the wound, and a union took place, and compress and bandage applied. Rapid the patient's appearance was much improved. was admitted with synechia posterior in Case II.?N. M. both eyes, the pupil of left eye occluded by organised lymph, the result of syphilitic iritis consequent on syphilis contracted four years previously. Stated that shortly after contracting it, he was seized with severe pain in the eyes, accompanied with redness and followed by much deterioration of vision. This evidently must have been an attack of irido-choroiditis, and as syphilitic iritis generally does not give rise to much pain, we presume that the inflammation, having begun in the iris, extended backwards, and thus arose the pain experienced by the patient at the outset of his disease. Operation.?Artificial pupil was made at the lower and inner portion of the iris of left eye, and though a good pupil remained, the lens capsule was revealed white and semi-opaque. Atropine solution grs. ii to ?i having been instilled, a compress and bandage "was applied. Treatment:?Mist. Ferri. et Potass. Iodidi, gi, three times a day. 2nd day.?Pupil partially closed, but there is still an ?opening, the size of No. 8 shot. Vision very little improved, no irritation. Continue treatment. 6th day.?Slight effusion of blood in the new pupil. 7th day.? Slight redness. Continue treatment. 12th day.?Can distinguish colours, and has a good perception of light. Continue. 16tli day.?Pupil filled with blood. Continue treatment. 20th day.?Blood disappearing, but still only bare perception of light and colour. Slight redness of globe continues. 28th day.?Pupil very distinct, but vision is still scarcely more than a qualitative perception of light. Fundus cannot be illuminated owing to haziness of the vitreous. Discharged. The treatment of this case, though negative in its result, is not altogether wanting in importance. Had constitutional treatment been had recourse to during the active symptoms of irido-choroiditis, or very shortly afterwards, its effect would have been manifest, for then the lymph effused, not having assumed such permanent organization, would have yielded readily to the action of absorbefacients. So far as wo can learn no treatment was adopted in this case, hence the state of the vitreous. The soouer then after syphilis unequivocally
53
manifests itself in the eye, we administer anti-syphilitic agents, the less appreciably will the disease interfere witli the'function of vision. And we doubt not since affections of the eye are not among the very earliest of secondary syphilitic manifestations, that the effect of mercury and iodide of potassium, single or combined, administered, let us say, on implication of the glands if not prophylactic is at least decidedly mitigatory of syphilitic ocular lesions when they occur. In such cases, therefore, the first object in treatment is to arrest the depredations of constitutional syphilis, and thus prevent the condition which unfortunately has obtained in the eyes of N. M., viz., diffused opacity of vitreous and loss of transparency in the lens capsule. had staphyloma of right cornea, Case III.?T. M. with a large central penetrating ulcer, through which the iris protruded. The ulcer was surrounded by a zone of healing cornea. Pupil obliterated, no vision. The left eye also had a penetrating ulcer on the upper third of the cornea, with prolapsed iris. Pupil pretty clear. Slight redness of the globe. Treatment :?Atropine and belladonna applied to the eye and orbit, aloes and iron administered internally. After a few days the cornea having sufficiently recovered, artificial pupil by excision was made with the double object of procuring vision arid arresting staphyloma. An excellent pupil was obtained, but the staphyloma not materially affected. Treatment after operation :?Local atropine compress and band;igo ; constitutional, ammonia and bark.
(To
be
continued.)
