EXPULSIVE HEMORRHAGE AFTER CATARACT EXTRACTION.

By S. K. GANGULY, m.b., Calcutta.

Mrs. D., aged seventy-three, a patient of Dr. V. K. Chatter jee, was brought to me by her son for the treatment of dim vision.

Right Eye had vision = finger count at four feet. Left Eye had vision = finger count at six inches. Both eyes had shallow anterior cham- bers, well reacting pupils,

' black ' cataracts and

a normal tension. But the large lens and shallow anterior chamber suggested a tendency to glau- coma. She had no other ocular or constitutional symptoms or signs. Accordingly I advised ex- traction of the left lens and told her son that there was a reasonable chance of recovery of some useful sight, although the cataract was bad in type.

After a good clearing of the bowels of the patient the previous day, under cocaine and adren- alin her left cataract was extracted with a large incision, and iridectomy, and capsulotomy. About five minutes after the operation, on the table, her left hand began to shiver and a little pain was felt in the eye. She was put to bed and kept warm, when the shivering and the pain abated but presently she started vomiting and cry- ing out

"

my heart ! " The pulse was all right but the part of the bandage on the left side of the nose was tinged with blood. About three hours after the operation she had a violent pain in the eye and 'felt as if her eye was coming out and the bandage was now soaked with blood. Bromides and ice did her little good. The

bleeding stopped by evening, although the vomit- ing and sickness continued for three days more.

Previous to .this operation, I used to give a

hypodermic injection of morphia to every patient before the operation and all of them used to feel sick afterwards. One of the patients who was eighty-five years old vomited for two days after the injection although he did well afterwards and had good sight. This effect of morphia prevented its use in the case of the lady in question. The eye was dressed 24 hours after the opera-

tion. The signs of expulsive haemorrhage were present except the bleeding. The protruding vitreous, iris, etc., were cut off and the conjunc- tiva was replaced. The wound healed in seven

days. There being no haemorrhage, nor pain, nor willingness on the part of the relatives of the

patient, enucleation was not performed.^ Unfortunately in private practice this is my

fourth case of intraocular and third case of ex-

pulsive haemorrhage {vide Calcutta Medical

Journal, December 1922). Maddox says expulsive

L Feb., 1923.] TREATMENT OF CHRONIC GONORRHOEA : PILLAY. 71

haemorrhage "occurs scarcely more than once

or twice in an average ophthalmic surgeons's life time." {A. J. 0. Series 3, Vol. 3, p. 23),

"

Soon after the operation, it may be before the patient is removed from the couch, great pain sets in. On removal of the dressings they are found to be saturated with blood, while the cor- neal flap is turned downwards, the wound is

gaping, and through it blood clot, vitreous and fris protrude. The haemorrhage is from the reti-' nal or choroidal blood vessels which are atheroma- tous. The accident, which is rare, cannot be foreseen and the eye is always lost." {Swansy).

Vomiting as a sign of expulsive haemorrhage is not mentioned in the ordinary text-books. Maddox had to extract a cataract from the

second eye of a patient " after the fellow eye had

been lost by expulsive haemorrhage "

having been operated on "by one of the ablest and most

esteemed London surgeons, due of course to no surgical fault on his part" because the latter

surgeon "could not be persuaded to touch " the second eye. His method, which resulted in suc- cess, was as follows:

I. Preliminary iridectomy (at least one week before the extraction.)

II. Preparation of the patient, (a) By suitable constitutional treatment for some time beforehand. (b) By mercurial purging, milk diet, and calcium lactate the previous night.

III. Administration of bromide and morphia on the morning of the operation.

IV. Just before the extraction :?(a) Cutting a large vein in front of the same side as the eye to make it bleed profusely, (b) Pricking the episcleral veins of the same eye.

V. During the extraction :?(a) Performing the operation on the patient's bed. (b) Raising the head of the. patient, (c) Keeping the feet

sedulously warm, (d) Application of hot tur-

pentine stupes on the abdomen to draw the blood thitherwards.

VI. After the extraction :?(a) Suturing of the corneal wound, (b) Gentle compressive^ bandage.