David Lewis
1854 The Lancet  
SURGEON TO THE ROYAL LONDON OPHTHALMIC HOSPITAL; SENIOR ASSISTANT-SURGEON TO THE LONDON HOSPITAL, ETC. As the following case is, I believe, the first example of the employment of Dr. Arnott's ingenious suggestion in operations upon the eye, and as it presents some other points of interest, I am anxious to bring it before the notice of the profession. -I was requested by my friend, Mr. Hovell, of Clapton, to ineet him in consultation, together with my friend and colleague, Mr. Dixon, in the case
more » ... Dixon, in the case of a gentleman, somewhat past the middle period of life, who had recently come up from the country to place himself under Mr. Hovell's care, on account of severe, painful, and protracted disease of the right globe. It appeared, from the history of the case, that the disease had commenced very insidiously about two years ago, attacking first the inner surface of the cornea, spreading to the iris, and then by degrees involving the choroid, retina, and humours, producing secondary cataract, and entirely destroying vision. All these serious results took place without any acute symptoms, and with very slight pain, and in spite of mercury and other active measures. Things remained in this condition for several months, without any obvious change, when suddenly, about six weeks previous to our seeing him, he was attacked with symptoms of acute inflammation of the globe, attended with intense pain of a paroxysmal and intermittent character, and radiating from its source along the branches of the fifth pair of nerves. Our patient described this pain as being almost unbearable when at its acmé, as resisting all ordinary means of relief, and as subsiding only to renew itself with increased force. On examining the globe, the vessels were found to be in a state of extreme congestion, the pupil was widely dilated, and a hard cataract could be seen thrust forward, pressing upon the iris, and nearly in contact with the cornea; the globe felt very hard, and was extremely tender to the touch. It was quite evident that these symptoms were due to tension of the globe, caused by abnormal accumulation of fluid within its dense, unyielding, fibrous case, pressing the hard lens against the nerves of the iris, and thus involving the entire fifth pair of nerves. It was one of those cases which, if unrelieved, must either exhaust the powers of the patient, or find vent in the giving way of the cornea and sclerotic, and the occurrence of staphyloma. Seeing, then, that the eye was lost, that the lens was acting as a foreign body, that the globe was suffering from tension, and that no relief could be expected while this state of things lasted, the obvious suggestion that occurred to us was to make a section of the cornea, allow the lens and some of the vitreous humour to escape, and thus get rid of the cause of the suffering. There were, however, some serious and wellgrounded objections to this proceeding; the highly inflamed state of the globe would render such an operation intensely and almost unbearably painful, and the lengthened period during which the eye had been diseased, the enlarged state of the bloodvessels, and the extreme spasm of the muscles, would almost inevitably cause the humours to be suddenly forced out, and the vessels to give way, distending the globe with blood, occasioning hæmorrhage to a serious extent, and probably rousing up the old pain with increased severity. It is true that some of these objections might have been obviated by the use of chloroform, but it was deemed quite inexpedient to have recourse to general anæsthesia, because our patient had recently suffered from hemiplegia. It was suggested that it would be more desirable to wait until the eye subsided into n quiet state; but as this would have necessitated inconvenient delay, and as there was a liability at any moment to a severe relapse, our patient, when the " pros" and " cons" were fairly laid before him, determined to have the operation performed without loss of time. It then occurred to me that it would be a favourable case for the employment of local anæsthesia, with the threefold object of destroying the sensibility of the part, constringing the vessels to prevent hæmorrhage, and diminishing the liability to subsequent inflammation. With this view some pounded ice was put into a bladder, mixed with salt, and placed over the right eye, temple, cheek, and brow, and kept there for about twenty minutes. At the end of that time, all sensation being lost, I made a rapid section of the cornea, which was immediately followed by the cataract and some portion of vitreous humour. Some slight hæmorrhage occurred, but slowly, and not to an extent beyond half an ounce. As sensation returned, our patient complained of extreme soreness and discomfort about the eye, and some of the old pains, taking the course of the fifth pair of nerves, came on. All this, however, speedily subsided, and ive had the satisfaction of seeing him in a few days quite free from pain, the section of the cornea gradually approximating, and with every prospect of a speedy and complete recovery, without fear of relapse, now that the cause of all the suffering was removed. It seems to me that the application of cold fulfilled, in this case, all the indications that were desired, and from the slight hæmorrhage that occurred, and from my previous experience of somewhat similar cases, I am of opinion that if the operation had been performed without local anoesthesia, there would' have been very severe pain at the time, extensive bleeding, consequent painful distention of the globe, and a tedious recovery. Finsbury-square, Sept. 1854.
doi:10.1016/s0140-6736(02)54623-7 fatcat:mnvi7ec5kfhohpxjj4vqugphqm