Some Cases Illustrating the Safety of Cocaine as an Anaesthetic in Cataract Extractions. BY GEO. E. FROTHINGHAM, M.D., PROFESSOR OF OPHTHALMOLOGY W THB UNIVERSITY OF MICHIGAN. Read in the Section on Ophthalmology and Otology, at the Thirty- Seventh Annual Meeting of the American Medical Association. Reprinted from the journal of the American Medical Association, August ar, 1886. CHICAGO: Printed at the Office of the American Medical Association. 1886. Some Cases Illustrating the Safety of Cocaine as an Anaesthetic in Cataract Extractions. / GEO. E. FROTH INGHAM, MDrT PROFESSOR OF OPHTH ALm6lj8^'T*TW TflifirNIVERSITY OF MICHIGAN. Read in the Section on Ophthalmology and Otology, at the Thirty- Seventh Annual Meeting of the American Medical Association. Reprinted from the Journal of the American Medical Association, August 21, 1886. CHICAGO:' Printed at the Office of the American Medical Association. x886. SOME CASES ILLUSTRATING THE SAFETY OF CO- CAINE AS AN ANESTHETIC IN CATARACT EXTRACTIONS. During the past year several experienced opera- tors have published cases and experiences that would seem to condemn cocaine as one of the most unsafe anaesthetics to use in the extraction of cataract. Notable among these we may mention the observa- tions of Nettleship, McHardy, and Browne*1 who have cited their experiences to show that the use of cocaine has a great tendency to produce panophthalmi- tis in eyes operated on for the extraction of cataract under its influence. Pfliiger charges it with produc- ing neuro-paralytic keratitis as a sequel to opera- tions of this kind made under its influence. Dobro- bolski, in a quite large per cent, of his cases, had prolonged nausea and vomiting follow as a result of using a four per cent, solution. Traumatic keratitis, tardy and imperfect healing of the wound made in the extractions, were noticed also as a complication in his cases, and ascribed to the cocaine. Bunge reports three complications apparently caused by its use in the clinic of Graefe, at Halle. These were: destruction of corneal epithelium; vesicular erup- tion on the »cornea; and parenchymatous corneal opacity. By this opacity it destroyed the eye in some of the cases, and impaired vision seriously in six cases out of a total of 150.2 Many other observ- ers have attributed bad results to the action of co- caine. 1 British Medical Journal, Nov. 21, 1885. 2 Ophthalmic Review, Nov., 1885, p. 338. 4 With a view of contributing to a settlement of the question as to whether any of these results may be fairly charged to the action of cocaine, I have thought it worth while to contribute my experience with it in the extraction of cataract, which I present in the form of a table prepared for me by E. B. Patterson, clerk of the ophthalmic clinic under my charge. (See table on pages 6 and 7.) A smooth operation was obtained in every case but one (No. 21). In this case a slight escape of vitreous occurred before the irridectomy was com- pleted. The lens was drawn out in its capsule by means of a sharp hook, without further loss of vit- reous, and a good result was obtained. V. = There was entire freedom from nausea and vomiting in all the cases in which cocaine was employed as an anaesthetic. Only fresh solutions of cocaine were used. These constitute all the cases of cataract extrac- tion performed by me at the public clinic from Oc- tober, 1885, to May, 1886. Although alone insuffi- cient to establish or contradict any of these claimed dangers from the effect of cocaine, they will serve to add to the great mass of statistics by which the questions referred to must ultimately be settled, and which will require the united reports of numerous operators. By reference to the table it will be seen that in thirty-nine extractions made since October 10, 1885, cocaine has been the anaesthetic used in thirty-one of the cases. In thirty of these a four per cent, solution was used. In one case, a feeble lady of 80, a two per cent, solution was substituted. Co- caine failed to act as an anaesthetic in three of the thirty-nine cases, and ether was selected on account of the timidity of the patient in four of the cases. The result was good in thirty-six of the thirty-nine cases, improved in two of the cases, and in the other case, in which the patient died of diabetic coma or. the 7th day, the result of the extraction was perfect. 5 There was no complication whatever as far as the healing process was concerned. The vision was clear at the first opening of the eye, and remained so up to the time of the patient's becoming unconscious, a few hours before her death. The other two cases were congenital cataract, which had been neglected beyond the period which permits of good results. In these cases degenerative changes called for extrac- tion. In one, operated on under cocaine, vision was much improved, and no complication occurred during the healing process. In the other ether had to be resorted to; slight iritis followed the operation. The patient improved, and is still gaining in visual power. No inflammatory complications occurred in thirty- four of the thirty-nine cases. Iritis occurred in four of the cases, in two of which ether was the anaesthetic used. In about seven hundred cataract extractions I do not remember so large a number of consecutive cases that presented so great freedom from inflammatory trouble, either of the cornea or deeper structures, though I have had a larger number of consecutive cases in which perfect results were ultimately ob- tained, and also with better average of vision. Nor have I had so remarkable freedom from nausea and vomiting after the extractions as when ether or chlo- roform were used, saying nothing of the embarrass- ment from this cause that so often occurred during the operation when made under these anesthetics, and which has deterred some operators from resort- ing to them. By using cocaine we also avoid that agitation of the patient which results from excessive bronchial secretion, so often produced when ether is used. Indeed, in my experience, so often is the pa- tient unpleasantly affected from this action of ether, and the obtaining a smooth operation endangered by it, that I have been in the habit for years of substi- tuting chloroform in all such cases, believing that 6 Z Date. Name and Residence. 3SV Eye Operat- ed on. Anaesthetic. Complication During Healing Process. Dis- charg'd. Result. Remarks. i 1885. Oct. 10. E. F., Fargo, Mich. 28 R Cocaine, 4pr. ct. Oct. 27 a small vesicle which Nov. 30 Good. Cataract soft; secondary opera- 2 " IO. E. C., Signet, Ohio. 64 L zz had formed at inner angle of wound was punctured and compress applied; no further trouble. Had iritis controlled by atro- Nov. 27 zz tion on Nov. 27, by needle. V= 20-30 +. Secondary operation upon opaque 3 Thos. McD., Hillsdale, Mich. 68 R Cl pine. None. Nov. 9 ll membrane, needle, Nov. n. V. = 20-100. V. = 20-40. 4 " II. H. S. A., Bay City, Mich. 66 L Slight iritis, controlled by Dec. 12 Needle operation on capsule. V. 5 " 14- Kath. McM., Camden, Ont. <>5 L atropine. None. Nov. 13 zz = 20-40. Patient has imbedded in iris a particle of Steele; has been there 45 years; was not disturbed. Some soft lens matter remains 6 if 16. Jas. L., Medina, Mich. 78 R cc None. Nov. 23 CC which obstructs vision; is now undergoing absorption. V. = 20-50. Some soft lens matter remained. 7 " 16. Mrs. G. F. C., Adrian, Mich. 4° R Cocaine failed. None. Nov. 7 Cl V. = 20-100. V. = 2O-ICO. 8 " 3i- G. W. C. Stanton, Mich. 62 L Ether used. Ether. Had iritis on third day; pu- Jan. 25, CC V. = 20-40. Patient lost R. E. 9 Nov. 4. M. B., Bloomdale, Mich. 50 R Cocaine, 4 pr. ct. pil drawn upward Jan. 13; membrane formed after oper- ation incised and central pu- pil made. None. 1886 Dec. 8 zz from inflammation after cataract extraction last year. V. = 20-40. IO " 4- E. S. G., Albion. Mich. H. J., Wayne Co. House, 68 R None. Nov. 23 V. - 20-40. ii " II. 5i L None. Dec. 14 V. = 20-70. 12 " 21. Mich. Mrs. C. R., Allendale, Mich. 57 R « None. Dec. 29 « Dec. 19 secondary operation (nee- 13 " 21. A. McA., Alpena, Mich. 28 R Ether. Had iritis, not severe, but Dec. 29 « die). V. = 20-40. Patient has had trouble with eyes 14 Dec. 2. M. W., Swartz Creek, Mich. 34 R Cocaine, 4 pr. ct. left a membrane. None. Dec. 19 for several years. L. E. was lost 8 yrs. ago after an operation; R. E. has had two iridectomies; Dec. 19 opaque capsule lacera- ted, resulting V. = 20-40. Some soft lens matter remains, 15 <r 2* E. T., Sherwood, Mich. 53 R CC None. Dec. 31 CC soft cataract. V.= 20-70 and im- proving. V. = 20-20. 16 " 26. Jas. C., Bowling Green, O. 55 R Cocaine failed. None. Jan. 6, ' * V. = 20-40. Cataract had un- 17 " 14- E. G., Mt. Pleasant, Mich. 54 L Ether used. Cocaine, 4 pr. ct. None. 1886 cc dergone degeneration, and was extracted V. - 20-40. 18 1886. Jan. 14. " 16. O. D., Duplaines, Mich. 63 R << None. 1886 Feb. 1 V. = 20-40. * 19 M. F., Battle Creek, Mich. 26 R Died on 7th day from dia- Vision good as determined by 20 " 23- J. A. McO., Stanley, Ohio. 45 R Cocaine failed. betic coma; no inflammatory complications of eye. None. Feb. 13 cc usual trial on opening eye. See special reference in summary. V. = 20-40. 21 " 20. J. B., Medina, Mich. 54 L Ether used. Cocaine, 4 pr. ct. None. Feb. 20 Vitreous escaped, lens extracted 22 Feb. 6. H. A., Schoolcraft, Mich. 70 R « None. Feb. 27 CC with sharp hook, resulting V. = 20-40. V. = 20-70. Has opaque and 23 " 27- P. G., Flint, Mich. 80 L u Iritis on 4th day. April 1 cc crinkled capsule left; can be im- proved by secondary operation. V. = 20-200. Secondary opera- 24 Mar. 6. E. R., Clayton, Mich. 60 R cc None. cc tion for membrane left by iritis made Mar. 17-needle. V. = 20-70. Cataract over-ma- 25 Feb. D. P. 58 L « None. « ture and shrunken. V. - 20-40. 26 Mar. 13. A. W. 52 R * ' None. •• V. - 20-70. Has opaque and 27 " 13- C. C., Howell, Mich. 56 R Ether. None. cc wrinkled capsule, and can be im- proved by secondary operation. V. = 20-20. Cocaine not tried, 28 " 24. A. S., Paw Paw, Mich. 75 R Cocaine, 4 pr. ct. None. Cl as patient was too nervous. V. = 20-70. Slight membrane 29 " 21. H. C., Homer, Mich. 67 L Cl None. cc from capsulitis; April 13 memb. lacerated; April 26 V. = 20-40. V. = 20-40. 3° April 3. J. M., Calumet, Mich. 65 R cc None. Cl V. = 20-30. 31 Mar. 31. E. L., Alpena, Mich. 24 L None. c 1 V. - 20-40. Soft cataract. 32 April 3. J. S., Peru, Ind. 7° R None. April 26 cc Case was complicated by glau- 33 " 10. A. G., Hamilton, Ont. 14 R Ether. None, except slight iritis. cc comatous condition. See special reference in summary. Metamorphosed soft cataract; 34 " 14. J. L. H., Plainwell, Mich. J. R., Britton, Dakota. 70 L Cocaine, 4 pr. ct. None. needle operation made Dec. 9, '85, but as no absorption had ta- ken place it was necessary to ex- tract it. V. = 20-40 +. 35 " 14. t6 L Ether. None. cc Degenerated congenital cataract 36 " 14- Mrs.M. A.H., Eaton Rapids, 80 R Cocaine, 2 pr. ct. None. CC requiring extraction. Patient much improved. V. = 20-70 ♦. 37 " 14- Mich. N. P., Chatham, Ont. 57 L " 4 pr. ct. None. ic V. = 20-30. 38 " 17- C. S., Fayette, Ohio. 68 R None. Test made May 12th. V. = 39 " 34 E. F., Fargo, Mich. 28 L None. « 20-40 ♦. Vision tested May io, = 20-40. 8 the increased risk to the life of the patient arising from this substitution is warranted in view of the greater certainty of obtaining a smooth operation, and thus increasing the chances of restoring sight. From my own experience, I am inclined to regard cocaine as the safest anaesthetic we possess for use in cataract extractions, so far as subsequent compli- cations are concerned. While it may, by its vaso- motor constriction, or paralytic action, temporarily diminish the nutrition of the cornea, I believe that impairment to be only brief, except in rare cases. I believe it is no more likely to interfere with the heal- ing of the wound in this way, than the general de- pression arising from the effect of chloroform. From what we, at present, know concerning the action of each of these anaesthetics, it is rational to suppose that there is far less disturbance of the interior circu- lation of the eye produced by cocaine than by either of the other two, and consequently less liability of panophthalmitis following its use in these opera- tions. So far as its effect to produce shedding of the corneal epithelium is concerned, in most of the cases I have seen reported, antiseptic solutions had also been used, and I am inclined to ascribe this corneal complication to some carelessness ip the use of these solutions, rather than to the effect of cocaine. At any rate, it has never been observed by me to follow the use of cocaine when resorted to for this or any other purpose. Solutions of cocaine, when kept for more than a few days, or gelatine tablets con- taining cocaine (as they are hygroscopic and liable to change), may be attended with danger when used in operations upon the eye. In reviewing these cases, cases nineteen and thirty- two are worthy of brief special consideration. Case nineteen illustrates how guarded must be our prognosis in all cases of diabetic cataract. This patient had not been aware of her condition, and was made acquainted with it only through the investiga- 9 tions I insist upon as preliminary to cataract extrac- tions. Among these preliminary examinations I insist upon an analysis of the urine. This has been my custom for many years. For the past few years I have been especially urgent upon this point by reason of an unfortunate result that occurred in a case in which I had neglected it, and was thus un- prepared to expect misfortune. A lady about 60 years of age presented herself at my clinic having the appearance of a person in good health, and claimed to be perfectly well. She was blind from senile cataract, both lenses presenting the peculiar amber hue, and there was apparently no complication. She was very urgent for an immediate operation, and presented reasons that induced me to yield to her request, and without waiting for the usual urine anal- ysis I operated, using ether as the anaesthetic. The patient suffered from prolonged nausea and vomiting and seemed not fully to recover from the effect of the anaesthetic, and died of coma about ten days after the operation was performed. The wound had healed nicely and the eye presented no sign of com- plication. Examination of the urine made during the illness showed both albumen and sugar, and an autopsy revealed that the patient suffered from that somewhat rare combination of Bright's disease and diabetes mellitus. Recognizing the injurious effect of ether in Bright's disease, I blamed myself for ad- ministering it in this case without knowing the con- dition and warning the friends of the increased danger. In case 19, however, we had the diagnosis clear before the operation. As cocaine relieved us of the constitutional disturbance incident to a general anaes- thetic, and the patient was courageous, urgently soliciting the operation, and cheerful during its per- formance, there was no reason for expecting that the extraction might hasten the fatal issue of the disease All this was duly considered in my discussion of the 10 case before the class, and I had also stated the un- certainty of life in any of these cases. I was not, however, prepared to expect a fatal termination of the disease in this case so soon. The result shows us how careful must be our prognosis as to life in such cases, though it should have no effect to deter us from operating when a person is blind from dia- betic cataract and presents no evidence of immediate danger from the constitutional disease. If the pa- tient lives but a few weeks, the blessings of sight will be a sufficient reward for all he endures, and with cocaine we may expect to perform the operation on courageous and hopeful patients with no fear of has- tening the fatal issue. Neither can cocaine or the operation be charged with the result in this case. Case 32 ilustrates the favorable results that some- times come from apparently hopeless operations, and shows that cocaine may be used safely even when there is increased tension. He began to notice dim- ness of sight about three years ago, the sight failing slowly but constantly. There was no pain until about three months preceding his appearance at my clinic. During these three months he has had slight pain in eyes, and headache. The left eye was en- tirely blind; he could not perceive the brightest light, pupil dilated and would not respond to brightest light, lens opaque and pressing against the cornea, T + 2, no pain at present. Right eye perceives bright light, pupil dilated and responds slightly and slowly to bright light, lens opaque and bulging into anterior chamber, which is almost completely obliterated, T+ 1, no pain at present, a few enlarged anastomos- ing veins in ciliary region. This patient was told that there was no prospect of a successful operation, but at his urgent request it was undertaken on right eye, thinking it possible to preserve perceution of light for awhile longer and perhaps enable him to see large objects. On March 20 a large iridectomy was made, using cocaine as the anaesthetic. The ante- 11 rior chamber was so nearly obliterated that only by careful use of Graefe's knife could a small incision into the anterior chamber be made, and this had to be enlarged greatly by the scissors to allow a suffi- ciently large piece of the iris to be seized and excised. April 3.-The patient has very completely recov- ered from former operation. Tension normal, and anterior chamber nearly of normal depth. Cocaine was used and lens extracted. Operation smooth, and no after complications occurred. April 26.-Eye tested, and with + £ S. V = sharp. Ophthalmoscopic examination showed results of serous choroiditis and there was choroidal atrophy about the disc, but no excavation of disc itself. As regards the action of cocaine, the results in these cases would tend to establish the following proposi- tions : 1. Cocaine relieves the operator from the embar- rassments during the operation for cataract that arise from vomiting; also from the agitation of his patient which results from excessive bronchial secretion, or stertorous breathing. These are often very trouble- some when ether or chloroform is used. 2. The danger to the result which often arises from nausea and vomiting after the extraction, when other anaesthetics are employed, is very surely avoided when cocaine is selected as the anaesthetic agent and is properly used. 3. The danger arising from the depressing effect of cocaine upon the nutrition of the cornea is no greater than in cases where ether or chloroform are used. The depression of the circulation, which often arises from either of them, may affect very injuriously the corneal nutrition. 4. The disturbance of the circulation of the inte- rior of the eye, and consequent danger of panoph- thalmitis from this cause, is probably less in using cocaine for this operation, than in resorting to gen- eral anaesthesia. 12 5. The danger of sepsis and consequent panoph- thalmitis from the use of cocaine may be avoided by using only fresh solutions.