OBSERVATIONS ON COCAINE ANÆSTHESIA

J. Jackson Clarke
1896 The Lancet  
159 or encrustration on the lids in cataractous subjects, it is most important that a healthy tone should be restored before operating. Pagenstecher destroys the lacrymal sac when there is purulent discharge, and Haab also recommends the .obliteration of the puncta by the galvanic cautery. I have, however, found myself that probing (without slitting up the .caniculus) and the use of astringents and antiseptics, 'especially that most potent of all, nitrate of silver, are sufficient to enable us
more » ... o extract with safety. When it is necessary to excise the iris for any reason during extraction without a general anaesthetic, it may be rendered insensible in from one to two minutes by merely dropping a solution of -cocaine on to the surface of the wound. Mr. Critchett, to whom we are indebted for the suggestion, conducts 'the solution into the anterior chamber by means of .a grooved curette ; but I have not found this necessary, -and have always deprecated the injection of fluids into the anterior chamber. When, in spite of all efforts to -extrude cortex, the pupil remains obstructed, grey, and sombre, the hyaloid fossa may on occasion be punctured, dn which case the patient is much in the position of one whose lens and capsule have both been removed at one co!/p with a spoon. Of course, the most serious drawback to ;simple extraction is the possible occurrence of prolapse of the iris; as Pagenstecher says : " The operation is completed beautifully, and just as beautifully next day you find that 'the iris is prolapsed." This accident is caused by abnormal 'tension of the eyeball, by sudden outgushes of the aqueous humour, by faulty placement of the incision, by swelling up of retained cortex, and by spasm of the lids. Kalt of Paris -endeavours to prevent prolapse by suturing the cornea, 'tralezowski by sealing the wound with an antiseptic wafer, Snellen of Utrecht by closing it with a conjunctival nap, and Knapp of New York by subjecting his patients to a series of tests immediately after extraction, .performing iridectomy in those cases in which the iris shows a tendency to protrude. For my own part, I am satisfied if the edges of the wound are accurately in apposition, if the flap fits like a watch-glass, and the pupil promptly contracts ; in these cases the anterior chamber is Teformed at once, there is no gushing of aqueous or prolapse of iris, and, barring accidents, there will be none. But .accidents will happen: "Against stupidity the gods themselves are powerless " ; hence we are compelled to reckon 'upon a certain percentage of cases in which prolapse will occur; and, of course, if prolapse were a very serious acci-,dent its possible occurrence would be a fatal objection to simple extraction, but it is not a very serious accident. The .great majority of the subjects of prolapse are no worse off than if iridectomy had been performed in the first instance, while, if the operation succeeds, then, indeed, the surgeon *has something like success-the success which leaves nothing to be desired, which has nothing to fear for the future, and which restores the patient to society, not only with excellent vision, but with eyes which show no trace wf operative interference. I presented patients, the subjects 'of double extraction by this method, to the notice of members of the Clinical Society of London in 1875, to the Medical Society and to the staff at the Royal London 'Ophthalmic Hospital and again to the members of the Ophthalmological Section at the jubilee meeting of the British Medical Association. Such eyes, according to ,my experience, bear the wear and tear of life much better than eyes operated on by the combined method, and of course sight is better (one patient on whom I operated for senile cataract twenty-six years ago is still alive and has -excellent sight), and, Helmholtz and Donders to the contrary notwithstanding, accommodation is not abolished. I have had patients able to read small print without glasses after -extraction, and many more who can do so by a slight change in the position of their distance glasses, and all i trace of operative interference is so conspicuously absent I that patients of mine who have afterwards consulted -eminent ophthalmic surgeons have quite naturally escaped -detection. Of course, in this operation there is only one wound ; in extraction with iridectomy there are two ; hence in the latter case the traumatism and liability to infection are greater. Otto Becker's researches (post mortem) have shown that when iridectomy is done there is always prolapse at the angles of the wound,2 and the lens capsule, as Mr. Swanzy warns us, is very apt to be trapped in the wound 1 See Foerster's Researches. 2 See his Pathological Anatomy of the Eye. with the combined operation, an accident which never happens with simple extraction. The central and movable pupil, too, of course fulfils its natural function of regulating and excluding rays of light much better than one that has been deprived of a portion of its sphincter, and, as in aphakial animals, compensates for the absence of the lens. If suppuration should threaten after extraction, internal antisepsis, after the method of Vopelius, should be at once adopted. The first is because I am convinced that in many cases the solutions, whether used for superficial application or for hypodermic injection, are insufficiently diluted, and the second because, of late, improvements in the composition of solutions for hypodermic use have been suggested. The scope of the ?netlwd. -As examples of the kind of operations to which my observations relate I may mention the removal of cutaneous tumours, such as rodent ulcer and sebaceous cysts of the scalp ; circumcision ; the excision of simple ganglia about the wrist and the ankle; the opening of deep abscesses, such as ischio-rectal and perineal abscesses, in cases where the skin is free from cedema and redness ; tenotomies ; the excision of tuberculous glands when free from deep adhesions ; and also as a superficial application for the removal of tonsils and adenoids in adolescents and adults. The more serious operations are, in my opinion, unsuited to the method on account of unforeseen difficulties and complications which may arise and demand prompt and energetic measures, but in emergencies and exceptional cases-e.g., tracheotomy-cocaine may be used. As an example of the use of the drug in an emergency the case related by Mr. Hartley is of interest; that surgeon successfully tied the external iliac artery after injecting a 2 per cent. solution. In parts to which the elastic band can be applied more latitude for the drug is obtained ; thus Bryson,2 using a 4 per cent. solution, performed double castration after surrounding the base of the scrotum with an elastic ligature. Irliosynerasy.-The smallest hypodermic dose which I have observed to produce faintness and nausea was one-tenth of a grain ; this was in the case of a man aged sixty-five. I have found that old people are especially susceptible, and it is advisable in every case to have brandy and amyl nitrite at hand. Probably, as is the case with chloroform, degeneration of the heart is the condition most to be feared. The application of cocaine to mucous surfaces has given rise to fatal accidents. It must, however, be borne in mind that many cases attributed to idiosyncrasy have been due to the use of injudiciously strong solutions or to the injection of the drug directly into veins. With proper care, even in regions rich in veins, such as the lower part of the rectum, the method may be safely practised; thus Ricard 3 has operated for hsemorrhoids after producing ansesthesia by a 1 per cent. solution, the needle being plunged deeply into the tissues and gradually withdrawn as the injection was made. Strengtlz of solittions.-For some years I have employed a 1 per cent. solution for hypodermic injection and a 2 per cent. solution for mucous surfaces, but latterly, influenced by the experience of Schleich,4 I have diminished the strength of the hypodermic injections. Schleich recommends a solution made up of cocaine hydrochlorate and sodium chloride, of each three grains ; morphia hydrochloride, onethird of a grain ; distilled water to three ounces-equivalent to a 0'25 per cent. solution. The sodium chloride was added, since it was found to diminish the pain caused by the 1
doi:10.1016/s0140-6736(02)00211-8 fatcat:zk5sylm3zjcmfajh52mymza6eq