KOLLER: Cocaine in Eye Operations.
42 r
I have lately interested myself in the matter and made a series of experiments with the view of studying the corneal nerves. At the same time I was searching for a fixative that would allow the use of alcohol for the proper hardening and further treatment of the preparations. For the question of the te-minals of the sensitive nerves can only be solved by very thin sections. For this purpose, I have, in the last few weeks, sacrificed a number of rabbits and about three dozen cats, injecting them with methyleneblue. The technique of these experiments is by no means an easy one. I think I have succeeded in finding, a method of fixing that answers the requirements mentioned, and although it is not yet fully developed, I am confident that it will be very useful not only to study the nerves in the cornea, but may serve also for the retina and other organs. I do not care to give you the details of a proceeding that still requires finishing, but invite you to inspect two of my cornea preparations. In looking at the ramification of the nerves you will see that it does not agree by any means with the usual description of a plexus. The more complete and distinct a preparation is, the less it makes the impression of a plexus. Although anastomoses are present, the type of ramification is that of a tree, and this may be a general law for the distribution of sensitive nerves. I intend to further develop my method, and may at some later time give you the results attained by it.
THE SUBCONJUNCTIVAL APPLICATION OF COCAINE IN EYE OPERATIONS. BY DR. CARL KOLLER, NEW YORK CITY.
It is now eight years since I published my first experiments about the anaesthetic properties of cocaine and its application in eye-surgery. My suggestion to use instillations of a cocaine solution to produce anaesthesia for operations on the eyeball met with general approbation, and consequently the usefulness of cocaine in other branches of surgery was explored by other investigators.
422
KOLLER: Cocaine in Eye Operations.
While in general surgery the hypodermic application of cocaine for production of local anoesthesia became very extensive, in eye-surgery the original method of instilling was generally retained, as the organ seems particularly suited for this method of application. In my very first experiments with animals, and later in eye operations, I noticed the fact, that by insiil/ations of cocaine we were sure to achieve an anaesthesia of the superficial tissues only. I could scratch, or burn, or cauterize the cornea without the slightest pain, but in the moment the iris prolapsed or was touched with an instrument, animals and humans gave brisk signs of pain. In a great number of cases I succeeded in making the iris anaEsthetic by beginning the instillations half an hour before the operation, but I did not succeed every -time. In my visits to eye-clinics of different countries I found that only in a very few of them instillations were begun in sufficient time before the operation to achieve this end. This circumstance, in my eyes, detracts from the value of cocaine-anesthesia in a great number of eye operations. The patient does not care which tissue hurts him. He siys he has pain and calls cocaine-anaesthesia a beautiful but delusive dream. The pain in touching the iris is especially troublesome in cataract operations. The patient who has been promised a painless extraction and experienced no pain in cutting the cornea is suddenly thrown out of his illusions of a painless operation, makes sometimes a sudden jerk, and may thus endanger the success of the operation. In squint operations one can notice every time that the patient does not feel the conjunctival cut, but does react quickly when the tendon is seized with the hook or forceps and divided. Very soon after my first communication I began using subconjunctival injections in squint operations, and during my time of assistantship to Professor Snellen I performed many tenotomies and advancements of muscles all with subconjunctival applications of cocaine. If the latter is applied in this way the operation can be made perfectly painless, and we have the double advantage of sparing the pain to the patient and not bringing discredit on a good drug. I proceed in the following way: After having rpgdered the conjunctiva anaesthetic by
KOLLER: Cocaine in Eye Operations.
423
instillation of a 4 per cent. solution, I insert the speculum and by means of a mouse-toothed forceps seize a fold of the conjunctiva over the tendon to be operated upon. The needle of a hypodermic syringe is inserted through this fold into the subconjunctival tissue as deep as possible, and a few drops of a two to four per cent. solution of cocaine are injected. I consider 0.05 (i of a grain) as the utmost limit for adults that can safely be applied as an injection, if the locality of injection is on the head, while on the limbs double that amount may be allowed if applied gradually. But I am careful to keep a good way within this limit. With a solution of 2 per cent., and even of i per cent., an entirely satisfactory an=esthesia can be produced if the solution is well distributed over the field of operation, and I attribute to this use of weak solutions the fact that I have not encountered yet any alarming accident from the use of cocaine. After the injection the speculum is removed from the eye and the eye is closed so that the artificial oedema of the conjunctiva may be given time to disappear, which it does in about five minutes. The disappearance may be helped by a little rubbing. If you have prepared a patient in this way you can perform the operation without the slightest pain, whether it be tenotomy or advancement. In iridectomies and cataract operations I have been inr the habit of instilling- a 4 per cent. solution every 5 minutes, beginning 20 to 30 minutes before the operations. During this time I keep the eye closed to prevent evaporation with subsequent haziness and desquamation of epithelium. In most cases I succeed fairly well in making the iris anaesthetic. But I do not succeed every time, and especially the hard eyes of subacute or chronic glaucoma will withstand the action of the drug, as in this class of eyes it is not absorbed by the cornea in sufficient quantity to penetrate into the anterior chamber. In the beginning of this year Prof. Snellen of Utrecht communicated to me in a private letter that he was using cocaine in form of subconjunctival injections for cataract operations.* He writes: "In cataract operations we inject the * Prof. Snellen has also described his way of proceeding in a communication concerning cataract operations in the Annales d' Oculisti4ue, January, 1892, page 75.
424
KOLLER: Cocaine in Eye Operations.
cocaine under the conjunctiva on the upper part of the eye, and the artificial chemosis makes it easy to form a conjunctival flap, which latter proceeding I have adopted since. I operate always without iridectomy." Following this suggestion I have used the subconjunctival application of cocaine in a number of cases, where I had to perform the operation of iridectomy or cataract extraction, and I am very well satisfied with the results attained. The anaesthesia was complete; there were no disadvantages. I proceed in the following way: First 1 instill a 4 per cent. solution of cocaine, wait a few minutes, and then the instillation is repeated. Now I insert the speculum, and by means of a sterilized hypodermic syringe inject a few drops of a 2 per cent. solution of cocaine under the conjunctiva next to that part of the cornea where I intend to make the section -this will be in most cases the upper part. The solution has been sterilized previously by boiling it and the hypodermic syringe by rinsing with alcohol and then 2 per cent. carbolic acid. After the injection the speculum is removed again, and one has to wait from 5 to IO minutes for the artificial oedema at the place of injection to subside, as it possibly would be in the way of the knife. If it is slow to disappear gentle rubbing will hasten it. The anesthesia thus attained is complete and will contribute to diminish that percentage of prolapses of the iris that still adheres to our statistics of cataract extraction. My experience with the subconjunctival application of cocaine in iridectomies and cataract extractions is so far a limited one, comprising- two cases of cataract, one case of chronic glaucoma, and two cases of iridectomy for other causes. Nevertheless, I venture to consider this method a safe one, having to my knowledge no disadvantages, and therefore recommend it to you for a trial. DISCUSSION. DR. J. A. LIPPINCOTT, Pittsburgh. - I have employed this method of using cocaine in operations of various kinds, especially in tenotomies and pterygium operations, for about a year and a half, and always with great satisfaction. I have never used it however in cataract extraction.
42 r
I have lately interested myself in the matter and made a series of experiments with the view of studying the corneal nerves. At the same time I was searching for a fixative that would allow the use of alcohol for the proper hardening and further treatment of the preparations. For the question of the te-minals of the sensitive nerves can only be solved by very thin sections. For this purpose, I have, in the last few weeks, sacrificed a number of rabbits and about three dozen cats, injecting them with methyleneblue. The technique of these experiments is by no means an easy one. I think I have succeeded in finding, a method of fixing that answers the requirements mentioned, and although it is not yet fully developed, I am confident that it will be very useful not only to study the nerves in the cornea, but may serve also for the retina and other organs. I do not care to give you the details of a proceeding that still requires finishing, but invite you to inspect two of my cornea preparations. In looking at the ramification of the nerves you will see that it does not agree by any means with the usual description of a plexus. The more complete and distinct a preparation is, the less it makes the impression of a plexus. Although anastomoses are present, the type of ramification is that of a tree, and this may be a general law for the distribution of sensitive nerves. I intend to further develop my method, and may at some later time give you the results attained by it.
THE SUBCONJUNCTIVAL APPLICATION OF COCAINE IN EYE OPERATIONS. BY DR. CARL KOLLER, NEW YORK CITY.
It is now eight years since I published my first experiments about the anaesthetic properties of cocaine and its application in eye-surgery. My suggestion to use instillations of a cocaine solution to produce anaesthesia for operations on the eyeball met with general approbation, and consequently the usefulness of cocaine in other branches of surgery was explored by other investigators.
422
KOLLER: Cocaine in Eye Operations.
While in general surgery the hypodermic application of cocaine for production of local anoesthesia became very extensive, in eye-surgery the original method of instilling was generally retained, as the organ seems particularly suited for this method of application. In my very first experiments with animals, and later in eye operations, I noticed the fact, that by insiil/ations of cocaine we were sure to achieve an anaesthesia of the superficial tissues only. I could scratch, or burn, or cauterize the cornea without the slightest pain, but in the moment the iris prolapsed or was touched with an instrument, animals and humans gave brisk signs of pain. In a great number of cases I succeeded in making the iris anaEsthetic by beginning the instillations half an hour before the operation, but I did not succeed every -time. In my visits to eye-clinics of different countries I found that only in a very few of them instillations were begun in sufficient time before the operation to achieve this end. This circumstance, in my eyes, detracts from the value of cocaine-anesthesia in a great number of eye operations. The patient does not care which tissue hurts him. He siys he has pain and calls cocaine-anaesthesia a beautiful but delusive dream. The pain in touching the iris is especially troublesome in cataract operations. The patient who has been promised a painless extraction and experienced no pain in cutting the cornea is suddenly thrown out of his illusions of a painless operation, makes sometimes a sudden jerk, and may thus endanger the success of the operation. In squint operations one can notice every time that the patient does not feel the conjunctival cut, but does react quickly when the tendon is seized with the hook or forceps and divided. Very soon after my first communication I began using subconjunctival injections in squint operations, and during my time of assistantship to Professor Snellen I performed many tenotomies and advancements of muscles all with subconjunctival applications of cocaine. If the latter is applied in this way the operation can be made perfectly painless, and we have the double advantage of sparing the pain to the patient and not bringing discredit on a good drug. I proceed in the following way: After having rpgdered the conjunctiva anaesthetic by
KOLLER: Cocaine in Eye Operations.
423
instillation of a 4 per cent. solution, I insert the speculum and by means of a mouse-toothed forceps seize a fold of the conjunctiva over the tendon to be operated upon. The needle of a hypodermic syringe is inserted through this fold into the subconjunctival tissue as deep as possible, and a few drops of a two to four per cent. solution of cocaine are injected. I consider 0.05 (i of a grain) as the utmost limit for adults that can safely be applied as an injection, if the locality of injection is on the head, while on the limbs double that amount may be allowed if applied gradually. But I am careful to keep a good way within this limit. With a solution of 2 per cent., and even of i per cent., an entirely satisfactory an=esthesia can be produced if the solution is well distributed over the field of operation, and I attribute to this use of weak solutions the fact that I have not encountered yet any alarming accident from the use of cocaine. After the injection the speculum is removed from the eye and the eye is closed so that the artificial oedema of the conjunctiva may be given time to disappear, which it does in about five minutes. The disappearance may be helped by a little rubbing. If you have prepared a patient in this way you can perform the operation without the slightest pain, whether it be tenotomy or advancement. In iridectomies and cataract operations I have been inr the habit of instilling- a 4 per cent. solution every 5 minutes, beginning 20 to 30 minutes before the operations. During this time I keep the eye closed to prevent evaporation with subsequent haziness and desquamation of epithelium. In most cases I succeed fairly well in making the iris anaesthetic. But I do not succeed every time, and especially the hard eyes of subacute or chronic glaucoma will withstand the action of the drug, as in this class of eyes it is not absorbed by the cornea in sufficient quantity to penetrate into the anterior chamber. In the beginning of this year Prof. Snellen of Utrecht communicated to me in a private letter that he was using cocaine in form of subconjunctival injections for cataract operations.* He writes: "In cataract operations we inject the * Prof. Snellen has also described his way of proceeding in a communication concerning cataract operations in the Annales d' Oculisti4ue, January, 1892, page 75.
424
KOLLER: Cocaine in Eye Operations.
cocaine under the conjunctiva on the upper part of the eye, and the artificial chemosis makes it easy to form a conjunctival flap, which latter proceeding I have adopted since. I operate always without iridectomy." Following this suggestion I have used the subconjunctival application of cocaine in a number of cases, where I had to perform the operation of iridectomy or cataract extraction, and I am very well satisfied with the results attained. The anaesthesia was complete; there were no disadvantages. I proceed in the following way: First 1 instill a 4 per cent. solution of cocaine, wait a few minutes, and then the instillation is repeated. Now I insert the speculum, and by means of a sterilized hypodermic syringe inject a few drops of a 2 per cent. solution of cocaine under the conjunctiva next to that part of the cornea where I intend to make the section -this will be in most cases the upper part. The solution has been sterilized previously by boiling it and the hypodermic syringe by rinsing with alcohol and then 2 per cent. carbolic acid. After the injection the speculum is removed again, and one has to wait from 5 to IO minutes for the artificial oedema at the place of injection to subside, as it possibly would be in the way of the knife. If it is slow to disappear gentle rubbing will hasten it. The anesthesia thus attained is complete and will contribute to diminish that percentage of prolapses of the iris that still adheres to our statistics of cataract extraction. My experience with the subconjunctival application of cocaine in iridectomies and cataract extractions is so far a limited one, comprising- two cases of cataract, one case of chronic glaucoma, and two cases of iridectomy for other causes. Nevertheless, I venture to consider this method a safe one, having to my knowledge no disadvantages, and therefore recommend it to you for a trial. DISCUSSION. DR. J. A. LIPPINCOTT, Pittsburgh. - I have employed this method of using cocaine in operations of various kinds, especially in tenotomies and pterygium operations, for about a year and a half, and always with great satisfaction. I have never used it however in cataract extraction.
