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when it becomes the last and only chance for the patient.
I have refrained from using the terms exploratory and diagnostic incisions, believing that they not infrequently serve as a shield to cover a lack of diagnostic ability. It is a moral obligation resting upon every physician and surgeon to develop to the utmost of his ability the highest diagnostic attainments.
Aseptic surgery has, undoubtedly, been one of the greatest boons to humanity that the nineteenth century has brought forth; but to me it seems that it offers a great temptation to men who have not had surgical training, and who, therefore, lack the requisite skill, to do operations which are not always necessary for their patient's good.
TRAUMATISMS OF THE EYEBALL.*
BY CASSIUS D. WESCOTT, M. D., CHICAGO. Instructor in Ophthalmology at Rush Medical College.
I am sorry, indeed, that I have nothing to offer in regard to traumatisms of the eye which is new to the ophthalmologist, but I hope we may find it profitable to talk over some of the old things and perhaps put them in a new light. As we discussed the subject of foreign bodies in the eye at our meeting in Chicago, last year, I will confine myself at this time to a consideration of perforating wounds of different parts of the globe. I will not weary you with a report of cases, but will try to present, without being dogmatic, the principles which should guide us in the care of these important injuries.
Perforating wounds of the cornea usually heal promptly, if they are not infected, but are always followed by opacities which obscure the sight if they are at all central. If they become infected, but finally heal, the amount of scar tissue and opacity is much greater, and vision is often permanently and totally lost as the result of a wound of the cornea, which would have been insignificant but for its infection.
There is always great danger, too, that such a wound will lead to infection of the interior of the eye and destruction of the entire globe. Again, when the aqueous humor escapes after such an injury the iris is very apt to prolapse
*Read at the ninth annual meeting of the National Association of Railway Surgeons, at St. Louis, April 30, 1896.
and become entangled in the wound, especially if the latter is large.
In eye injuries we are obviously limited in our antiseptic measures because of the delicacy of the tissue involved; therefore, the greater importance of absolute and invariable cleanliness. Sterilized water is as useful here as elsewhere and I believe that the addition of 3 per cent of boric acid or 2 per cent of borax makes it better and such solutions are always more efficacious and agreeable if used warm. After scrubbing the patient's face with soap and water the injured eye should be thoroughly but very gently irrigated or repeatedly flooded with hot water or one of the solutions above mentioned. If the iris is involved in the wound and the injury is not more than six hours old we should endeavor to replace it by gentle manipulation with a small, smooth spatula or other suitable instrument. If unsuccessful we should seize the protruding portion, draw it out gently and cut it off. We will usually find, after such an iridectomy, that the wound is clear, but if not we can usually make it so by careful use of the spatula. A few drops of a 1 per cent solution of atropine solution should then be instilled, to guard against iritis and closure of the pupil, the wound dusted with finely powdered iodoform, a bandage applied and the patient put to bed. I do not believe that we should touch a prolapsed iris that is more than six hours old unless the injury has been properly dressed at once and we are reasonably sure that the wound has remained aseptic; under such circumstances we may safely open the wound in some cases, even after twelve or twenty-four hours.
Penetrating wounds of the sclera are always serious because of the great liability of infection of the interior of the eye. We may usually know that an eye has been perforated by the loss of the tension or normal hardness of the globe as compared with that of the fellow eye, even if the wound is obscured by swelling and ecchymosis of the conjunctiva. If the perforation has opened the anterior chamber the latter will be shallow or obliterated from the escape of the aqueous humor. In the case of large wounds of the sclera the darkly pigmented uvea frequently protrudes, the prolapsed portion belonging to the choroid, the ciliary body or the iris, according to the location of the wound. If the uvea is also rup
tured the vitreous will present in the opening or may hang out of the wound. Rupture of the sclera and the uveal tract may occur in consequence of a blow upon the eye without injury to the conjunctiva. In such a case the lens is sometimes found lying beneath the unbroken conjunctiva or the prolapsed uvea and vitreous may form the contents of the bulging tumor.
When infection occurs in consequence of a penetrating injury of the eye the globe may be lost in either of two ways. We may have an acute, suppurative inflammation of all the tissues (panophthalmitis) or a less violent plastic inflammation chiefly of the iris and ciliary body (irido-cyclitis), the exudate becoming organized and the globe gradually shrinking.
Strangely enough, migratory ophthalmitis, so-called sympathetic inflammation, rarely follows the more violent panophthalmitis, in which the eye is often full of pus, but very frequently destroys the uninjured eye in cases of irido-cyclitis.
The prognosis is grave in all cases of penetrating wounds for the reason that the prick of a needle or of a hat pin may carry a fatal infection to the interior of the eye and the vitreous humor is an ideal culture medium. Wounds of the ciliary region are particularly dangerous, not only in leading to destruction of the injured eye, but in being followed by migratory trouble.
Before describing the treatment of wounds of the sclera a word in regard to foreign bodies is almost necessary. It is very seldom that an eye will tolerate the presence of a foreign body, although such bodies do sometimes become encysted and give no trouble for years. I therefore make it an invariable rule to enucleate every eye known to contain a foreign body which can not be removed. If the patient will not consent he must bear the responsibility. He should at least present himself frequently for examination and submit to excision at the first sign of inflammation. If we know that an injured eye does not contain a foreign body we must then consider the possibility of saving the organ to useful vision. Large wounds with extensive prolapse of the inner coats of the eye are always followed by shrinking and loss of sight and the ever present danger of sympathetic trouble should guide us in advising immediate removal or at least abscission and evis
ceration of the globe, which gives a better and more movable stump for a glass eye. I would also advise the immediate excision of an eye in which the ciliary body has been injured, even if some sight remained, unless the fellow eye was useless or had been removed.
When migratory inflammation has once involved the uninjured eye it is best to retain the injured one if there be any sight in it, for ultimately it may be the better of the two.
Any adult eye which is blind and remains continually tender is a source of peril and, being useless, should be removed, but if such an eye in a patient under twenty years can be kept quiet by treatment it is desirable to retain it, because the loss of an eye in youth retards the growth of the orbit and the corresponding side of the face.
If we decide that an eye which has sustained a penetrating injury can be saved, our first duty is to secure and maintain perfect cleanliness, as already described. Small wounds quickly close if kept clean and the patient maintains quiet. The eye should be carefully irrigated and dressed once a day with borated cotton and a snug bandage, best made of white mosquito netting and applied wet. Atropine, in I per cent solution, is the best local anodyne and usually all that is needed, but if there is much reaction and great pain, iced compresses, applied every five minutes by aseptic fingers, afford great comfort and check inflammation.
Larger wounds should be closed by sutures. carefully taken through the conjunctiva and episcleral connective tissue. I cannot advise stitching through the sclera for the tissue is so hard that the needle often breaks out or goes through with a jerk which causes hemorrhage and otherwise disturbs the interior of the eye.
If the ciliary body or choroid presents in the wound it must be gently replaced, not cut off, and the scleral wound carefully closed over it with stitches. For suture material I have used for several years kangaroo tendon, furnished me by Dr. Marcey of Boston, which I can split to any desired size, easily sterilize in an aqueous solution of the bichloride and preserve indefinitely in alcohol.
DISCUSSION OF DR. WESCOTT'S PAPER.
Dr. D. Emmett Welsh, Grand Rapids: I do not think I can add anything to the remarks made by Dr. Wescott. They are all pertinent and I agree with him in every particular.
There is one point, however, that I would make and that is with reference to the use of eserine to contract the pupil instead of atropia to dilate it. This would depend upon the location of the wound in the cornea. In some instances it is preferable to use' eserine to get the iris out from the edges of the wound. If any portion of the pupillary edge of the iris becomes attached in a wound in the margin of the cornea eserine, by its contracting power, will act better than atropia.
Dr. James M. Ball, St. Louis, Mo.: It may be I have misunderstood Dr. Wescott, but if I caught what he said correctly, he does not believe in replacement of the prolapsed iris after six hours. Is that right, Doctor?
Dr. Wescott: Yes, under the conditions stated.
Dr. Moore (resuming): Then I must take issue with the doctor on that point, and in fortifying my position, I wish to state that about a year ago I made three cataract operations one afternoon, two of them being made without iridectomy. The next day my assistant had two cases of iris prolapse. Forty-eight hours after extraction I placed the patients under chloroform and instead of replacing the iris made an iridectomy in each case with excellent results. Vision was good. These two cases show that prolapse of the iris can be removed forty-eight hours after the prolapse has occurred without detriment. I am well aware that the position taken by Dr. Wescott is held by many ophthalmic surgeons; at the same time, all of us have met with cases which are directly at variance with the teaching of the books. The advice given by the author of the paper in regard to replacing the prolapsed iris is exceedingly dangerous. It might do, possibly, in the hands of an oculist, and the possibility of replacing the iris and having it stay in position would be increased if eserine were used, but, as a matter of fact, I have seen eyes lost by panophthalmitis because the attending physician tried to push back the prolapsed iris, and the operation of iridectomy, if made under aseptic conditions, is perfectly safe, and there is no danger of infection as compared with the danger of the iris prolapse returning. Of course, if you push the iris back you evacuate the aqueous, and in the course of thirty minutes it reaccumulates, the wound has to be reopened, and the iris has to be dealt with once
more. Many physicians seem to think that aseptic surgery applies almost to every place except the eye, and, as the essayist has said, one cannot be too careful about boiling his instruments, sterilizing them in every way possible. The oculist should pay particular attention to his own hands.
In making the statement that every eye which contains a foreign body which cannot be removed should be enucleated, I presume the doctor has overlooked that numerous class of cases in which the foreign body is lodged in the lens and remains there for many months, and in that class of cases we occasionally extract the cataract and secure a good result and give the patient a useful eye.
I am compelled to take issue with the doctor in another respect, namely, his advice for the immediate enucleation of an eye in cases of wounds of the ciliary body. A case in point: A man employed on the Illinois Central received an injury to his eye by a water gauge on a locomotive bursting, and as a result of which a piece of glass injured the cornea at the corneo-scleral junction and cut into the ciliary body. In this case there was prolapse of the iris. The attending physician, before I saw the case, had been using bichloride, but advised the man to consult an oculist. I saw him on the fourth day after the accident and immediately made an iridectomy, and I am glad to say that that man is now free from symptoms of irritation, and that he has useful vision in the eye.
Dr. Welsh spoke of the use of eserine in retaining the iris in situ after prolapse. Sometimes it will do it. I think a more efficient means is that which has been used for several years by Dr. Eugene Smith of Detroit, namely, the hypodermatic injection of small doses of morphia. About a year ago Dr. Smith published the results of one hundred cases of cataract extraction without iridectomy, and he generally makes use of the hypodermatic injection of morphia to prevent prolapse of the iris.
Dr. Wescott (closing): I am greatly indebted to Dr. Welsh for speaking of eserine, and also to Dr. Ball for his kindly criticisms. There are cases, unquestionably, where eserine seems to aid us in keeping the iris away from a wound of the cornea, which is more or less marginal. It frequently, however, as Dr Ball says, will fail. I have not tried hypo
dermatic injections of morphia to retain the iris in situ after prolapse, but am familiar with the report of Dr. Smith. The chief reason for not mentioning the subject of eserine in the paper was because I strove for simplicity from start to finish, and also because of the great danger of iritis and closure of the pupil in all of these cases of injury to the cornea. In the cases where eserine would fail, it would certainly be better to use atropine because of its influence in preventing iritis.
In regard to the criticism of Dr. Ball about interfering with prolapse of the iris after six hours, I will refer to the paper. (Here Dr. Wescott read extracts from his paper, which pertained to the point under discussion.) Dr. Ball was speaking of an operation wound which he had unquestionably made aseptically and preserved in an aseptic condition. It is very different, indeed, opening such a wound and opening one due to traumatism, which has not been dressed, and which undoubtedly has had an opportunity to become infected.
In regard to foreign bodies in the lens, I quite agree with Dr. Ball, and his criticism is an addition to the paper in that respect. We do have small foreign bodies embedded in the lens which do not necessitate the removal of the eye at once, unless we know that they are septic, and it may be impossible to know when they are in such a condition. These small foreign bodies in the lens frequently cause swelling of the lens and an injurious inflammation of the eye, which calls for immediate action. In such cases we can sometimes save the organ by prompt removal of the lens, while in others we cannot do so, and must subsequently enucleate the eye after an attempt has been made to save it. Of course, there are cases of wounds of the ciliary body which have not been followed by loss of the eye or by ophthalmitis. I cannot advise you to assume the entire responsibility in any of these eye injuries if you can call to your aid an ophthalmic surgeon, but we all realize that the first treatment of a surgical injury of any part of the body is very important. You are called upon in emergencies to act at once whether you continue in charge or not. In any of these injuries you will, because of your science, because of your loyalty to the best interests of your patient, consult an ophthalmic surgeon if you can. I have given what I
think to be the best advice if you must act upon your own resources and without aid.
The Hour for Capital Operations.
Of the many questions that present themselves for solution in regard to operative cases, a by no means unimportant one is that of the hour for operating. A good deal may be said for almost any time that may be selected, and for this reason: It may be generally assumed that the hour selected is the one that suits the
surgeon best. For many reasons we cannot find fault with the operator for taking such a time as seems best to accord with his other engagements. It has long been a recognized right of the patient not to be disappointed, if by any possibility this can be avoided, after the hour has been named and the preparations made for the operation.
In following the course of operative cases and various operators for a number of years in the hospitals of a large city, it has seemed to us that the early morning operation had a great many claims which entitled it to serious consideration by operators. A good night's rest, attained artificially if necessary, an empty stomach, the patient all ready for anæsthesia upon awakening, the fear and dread of what is coming being crowded into the fewest possible moments, the whole day with active attendants constantly moving about and alive to every demand of the patient, the ability to run in and see for one's self how the case is doing during the first 12 to 18 hours, without encroaching upon the practitioner's allotted time for sleep, are a few of the points which seem to recommend an early hour. On the other hand, it cannot be denied that it may be a source of greater task upon the surgeon's powers, especially if he be concerned and anxious, as always conscientious men must be in regard to capital operations, and if this anxiety interferes with the operator's sleep. Even with this disadvantage we still believe the operator capable of doing better work before he has become tired and annoyed by the various demands upon him during the early hours. of the day. It would be impossible to compare the results, because we have no data with which to make a comparison, but we believe that the men who have operated extensively in the early morning hours have never returned to afternoon operations as a matter of choice. -Gaillard's Medical Journal.
Strange Record-I remembered having seen the heart of one that was bowelled as suffering for high treason, that being cast into the fire, leaped at first at least a foot and a half in height, and after by degrees lower and lower for the space (as I remember) of seven or eight minutes.-Bacon on Life and Death.
It can be safely asserted that the great bulk of the ills of life arise from ignorance and vice, and this is particularly true regarding disease. It has been repeatedly said, and with truth, that the best and greatest wealth is health; that health is the foundation of all temporal enjoyment; that it is the one supreme blessing accorded to man and that without it all else is without value. Yet modern life, with all its vaunted progress, takes less heed of the health of man than it does of his finances. Hundreds upon hundreds of volumes delve deeply into the realms of thought regarding financial problems, every nook and corner of the brain is made to exhaust itself in explanation of some gilded theory, while the study of health is viewed with seeming commendation, but without the the intense teeming and pertinacious thought bestowed upon money. That Godgiven boon, health, is viewed as a secondary consideration until disease takes its place, and then, and not until then, is the bounteous richness of health appreciated. Colton says: "There is this difference between these two temporal blessings, health and money; money is the most coveted, but the least enjoyed;
health is the most enjoyed but the least coveted; and the superiority of the latter is still most obvious when we reflect that the poorest man would not part with health for money, but that the richest would gladly part with all his money for health." This may be true upon general principles; it may be true as a naked proposition, but in modern life the unbiased observer would, we think, come to the conclusion that health appears to be the least valued possession of man. System, application and intensity from first to last, mark the study of the acquirement of wealth, while there are only isolated instances of the study of health. We have prime ministers and secretaries of finance in the interest of money, but none for health. Money is eternally and zealously guarded, while health is viewed as not precious enough to foster study, not important enough to be guarded by sustenance of government and continuous employment of intellect.
In this electric age of ours, tension, extreme tension, is our constant condition; the grinding wear and tear of intellect, the exhausting, ceaseless labor of mind, the continued neglect of muscular exercise, the faults of living, the emotional excitement of political and business interests, all are tending to cause diseased mental conditions. Health is only thought of when we are menaced by epidemics or when disease manifests itself with the rulers of a realm. Were but half of the thought given to a consideration of the health of man individually and en masse that is given to the acquirement of riches, the result would be a far-reaching benefit in the prosperity of nations. As Voltaire has said: "The fate of a nation has often depended upon the good or bad digestion of a prime minister," and it is likewise true that a nation must depend upon the healthful function of its citizens' brains and bodies for its perpetuity. It is a deep and unknown quantity but yet a readily imagined one, how fertile a cause unhealthy mentality is in the production of violence, discontent and revolution. There can be no doubt that faulty environment, unhealthy habits and the by-play of degenerate minds are potent factors in the production of emotionalism and when once this is created it readily leads to discontent of the masses, violence and revolution.
We believe that a judicious study of the