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wish to leave the wound open.

Dr. J. B. Bullitt: In regard to 1
diagnosis of foreign bodies in the
passages, I would call attention to t
fact that the ^-ray is an almost iufa
ble guide to diagnosis. Where the f
eign body is a bone or metal or wood
is very easy to detect. If it is a hi
or grain of corn it is more difficult, 1
the X-ray should not be overlooked.

Dr. Ap M. Vance: I have seen thi
cases. One where a child 5 years
age inhaled a nail. It remained t
years and a half and the boy \
thought to be dying, and in a sudc
fit of coughing it was expelled. I
twenty-seven years he went on,
healthy young man, later practiced m
icine. At the end of that time he 1
pneumonia. In August I saw him i
desperate condition and immediat
excised the eighth rib and opened u
gangrenous abscess of the right It
which discharged an immense amoi



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of foul material. He gradnally recov-
ered after an extensive sloagbing. He
went South that fall and abscess re-
curred and the wound was opened. He
came back with the wound closed. He
had a cough and examination revealed
the presence of tubercle bacilli. He
went to Colorado and abscess again
occurred and the wound was opened.
He has now been well for about two
years.

The other case was that of a large
St. Bernard dog, which had been sick
for two weeks. I was convinced it had
a foreign body in the trachea and did a
tracheotomy, and in a few minutes a
cough came on and he coughed up an
ordinary marble. The dog got well.

The third case I saw with Dr. Cheat-
ham, who will probably report it.



The essay of the evening was read
by Dr. S. G. Dabney, entitled, Ap-
pendicitis from the Standpoint of the
Patient. (See page 129.)

DISCUSSION.

Db. Ap M. Vance: Dr. Dabney has
given us a very valuable paper, and one
which will make us more sympathetic
with these backaches, the terrible thirst
and other discomforts following abdom-
inal operations. It is a perfect descrip-
tion, and it will do a great deal of good.
We have been trying to laugh oflf these
aches and pains heretofore. In trying
to find out the cause of this terrific
backache, I have thought that it is
largely due to the fact that patients are
put upon the table and kept in that po-
sition for so long. 1 have noticed that
those who are longest on the table suf-
fer the most. Patients with fractures,
and others who are kept in bed for a
long time, complain of the same ache
in a less degree. I believe we could
prepare our table in such a way, and
bolster up the small of the back, and
relieve a great deal of this strain. The
thirst is a very troublesome feature.
It is often dangerous for vomiting to
occur, and the least bit of water fre-
quently excites it. Sponging the face,



washing out the mouth and the use of
rectal injections will modify this to
some extent. We are learning to do
away with many of these troublesome
symptoms. The thirst and the back-
ache are the things that wear the patient
out.

Dr. Tubnsb Andbbson: I listened to
the paper with great pleasure. I have
long felt that we carried our rules a lit-
tle too far when we proscribed the use
of opium for these disturbances. I
was interested in hearing of the selec-
tion of a twelfth of a grain of heroin.
I have always used morphine in twelfth
of a grain doses. Since the heroin has
acted so nicely, I shall try it next time
instead of morphine. I congratulate
Dr. Dabney and also his surgeons.

Db. John A. Ouohtbblony: lam ex-
tremely glad to see Dr. Dabney on his
feet again and that the operation ter-
minated so happily as it did. I congrat-
ulate the surgeons with equal hearti-
ness, for if it is a pleasure to save life,
it is ten-fold more pleasure to rescue a
professional brother from the grave.

Db. a. M. Caetlbdge: I think Dr.
Dabney 's paper is of great scientific
value. It just about covers the ground
of most of these cases, and a physician
who has gone through it can give so
much better description of it. I think
Dr. Dabney can thank heaven he was
not operated on eight or ten years ago,
so far as the pain and thirst are con-
cerned. Lawson Tait was the father of
modern abdominal surgery, and we all
followed him for years and stuck to his
rules, and especially to that which said
no water should be given for hours
afterward. Now we know that people
differ greatly in their susceptibility to
nausea, and it is a great hardship to
deny water in every case of operation
on the peritoneum, when they might
not have nausea anyway. I make it a
rule to give a little water early and
then a little more. If there is marked
nausea beforehand I do not begin it.
For the last three or four years I have
been giving an entire glass, and if they
throw it up it washes out the stomach.



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151



This is a great advance on the old treat-
ment.

The backache is one of the most an-
noying things, especially to patients
who have been np on their feet. If
they have been in bed for some time
they do not suflfer so mach. I am sat-
fied that the cause is complex, and
while the long continuance on the table
causes the greater suffering, yet the
anesthetic has much to do with it. I
think it is a very serious thing to take
an anesthetic. Numbers of people who
have been under its influence for a long
time get well, but 1 have had four or
five in which I have afterwards found
casts in the urine where I least expect-
ed them. 1 believe that this terrific
backache is in the kidney region and
after an anesthetic we have acute con-
gestion of the kidneys. We expect to
see a marked diminution in the secre-
tion of urine, even where a great deal
of water has been taken beforehand. I
think the acute congestion from the anes-
thetic causes most of the backache. I
have nothing to suggest as to its re-
lief.

I would like to call attention, from
the surgeon^s standpoint, to the fact
that Dr. Dabney walked into the oper-
ating room with this appendix ready to
fall to pieces. That is why the little
drain was used. I think the cause of
the indigestion and flatulence was this
appendix, and that he will have no fur-
ther trouble in that regard.

Dr. Hugh N. Leavell: I was Dr.
Dabney' 8 attending physician at this
time. I believe that possibly some of
this flatulence might have been due to
the condition of the appendix, but
whether that was the cause of the ap-
pendicitis, or vice versa, I do not know.
I have noticed for several years that he
suffered from tenderness and flatulence,
and frequently these attacks were se-
vere, and I have been called up to know
if I could suggest something to relieve
him. Knowing the vagaries of ap-
pendicitis, I would every time go to his
bedside rather than use the telephone.
At no time was there any marked ten-



derness over the region of the appen-
dix. The condition that presented
itself on the morning of the operation
was this: temperature normal; rectal
temperature 99-}-; tenderness over the
appendix not marked, except upon deep
pressure, and that below McBurney's
point. While the pulse was accel-
erated, it was also intermittent, and
that is a point I have noticed about
these gangrenous appendices. I have
verified this in a number of cases, one
quite recently. I have felt Dr. Dab-
ney' s pulse often, and never observed
any intermittency before.

As to the use of heroin, it did act
very nicely. Quite recently I have
verified that result by the use of a
tenth of a grain after abdominal sec-
tion. It does not seem to produce any
after effects at all.

I think the point about this flatulence
is exceedingly important in its relation
to the appendicitis.

Dr. J. M. Ray: I congratulate the
doctor on his paper and his personal ap-
pearance. In regard to the backache,
I believe that something else beside the
anesthetic plays a part, for we eye men
see so much of this backache following
cataract operations where anesthetics
are not used. It is the most annoying
thing we have to deal with. They near-
ly always have it. They have to keep
quiet in a prone position and are warned
not to turn on the side. 1 have been
able to relieve many of these patients
by a method of making the bed softer
or by putting something under them.
The best method is to place a pillow un-
der the small of the back.

Dr. T. H. Baker: I want to add my
congratulations and also express my
appreciation of the excellent and inter-
esting paper. Some weeks ago Dr.
Dabney edified us with some personal
experience with erysipelas and now he
has given us the same with appendici-
tis. I think this considerate thought-
fulness entitles him to the thanks of this
Society.

Dr. W. O. Roberts: I congratulate
the doctor on his recovery and also on



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the excellent paper. As to the back-
ache, in addition to the measures al-
ready spoken of, I have found great
benefit in the application of cold water
bags to the back. I think it is chiefly
-caused by the strain on the small of the
back, since the cases following cataract
would seem to do away with the idea
that it is due to the anesthetic. There
is a great strain on patients who lie per-
fectly still for a long time.

As to the heroin, I have used it in a
number of cases, but in larger doses.
I give from an eighth to a quarter of a
grain with excellent results, though oc-
casionally I get none at all. I agree
with Dr. Cartledge that we have been
keeping water from these patients too
long. It is well to give them a little
hot water, especially if they have lost
much blood. Cold water and ice will
bring on nausea.

Dr. R. L. Ireland: I congratulate
Dr. Dabney on his recovery and thank
him for the privilege of being present
to-night. The only part I had was that
of administering the anesthetic, and he
has described that fully in the paper.
He did just like we always want them
to do — came in quietly and gave him-
self over to the physician and did as re-
•quested. There was no stage of ex-
citement at all. We started with chlo-
roform and carried him to the stage of
unconsciousness and then changed to
•ether. He had a pulse of 120, which
would intermit about every twenty-fifth
beat. It took a larg^ quantity of ether
to keep him under. During the opera-
tion his pulse seemed to lose a part of
its volume, so we gave him 1-30 of a
grain of strychnia and 1-100 of nitro-
glycerine, which brought the pulse up
but did not do away with the missing
beat.

Concerning the backache, it stands
to reason that it is due to both the anes-
thetic and the strained position. We
frequently get it without the anesthetic
as a result of strain. I believe the dis-
tress is greater when the anesthetic has
been administered for a long time. The
kidney secretion is materially dimin-



ished by the anesthetic. Tp overcome
the pain in the back a pillow is excel-
lent, applied also under the knees to
change the position. The pillow under
the back should be rather firm. I be-
lieve the administration of saline per
rectum, for it relieves the intense thirst
to a great extent, helps the kidney se-
cretion and is also a heart stimulant.

De. Louis Fbank: I feel Dr. Dab-
ney is to be congratulated on his beau-
tiful and perfect recovery. As to the
backache, I believe the various points
mentioned have a great deal to do with
this pain, but I do not believe that it is
entirely due to the anesthetic. I use
very little ether, and I do not believe
the position on the table has a great
deal to do with it. Some of these cases
have no backache at all. I think most
of it is due to the rigidity of the mus-
cles of the back in the effort to keep
perfectly still. If the patients are al-
lowed to turn over it is relieved in a
very short time. If this backache were
due to congestion of the kidneys, I be-
lieve we would get other symptoms,
and I have never seen any blood or
albumen following one of these cases.
It seems to me the pressure within the
vessels in acute congestion would cause
something to appear in the urine.

As to the nausea and thirst, we are
coming to change our methods in
all abdominal work. We cannot treat
any two cases alike. The symp-
tom of thirst differs a great deal
in different people, in propor-
tion to the amount of fluid taken be-
fore the operation, the amount of blood
lost and the length of time the abdo-
men is open. I instruct my patients to
drink ail the water they can a day or
two before the operation. There are
times when this does not have any ef-
fect at all, and I have also given saline
in great quantities without any effect.
In some cases, however, there is marked
diminution in thirst.

Cases differ also as to nausea, some
having none at all. In other cases
where I felt like I could give them
nothing by the mouth, I have seen the



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nausea cease at ODce after giving a glass
of water. I make it a role to give
vicliy or carbonated water in small
quantities as early as possible after op-
eration. If they vomit, I give it again.

As to the point made by Dr. Leavell,
I do not believe that flatnlence has
anything to do with appendicitis, but
that it was the latter that caused all the
digestive disturbances. I do not be-
lieve functional disturbances occur near-
ly so often as many of us have thought.
I also believe that an appendix such as
this, has been subjected to previous at-
tacks. I do not believe that any pri-
mary attack of appendicitis will result
in gangrene, unless there has been a
twisting of the appendix.

Dr. S. 6. Dabnby: 1 thank the mem-
bers of the Society for their congrat-
ulations and kind expressions as to the
paper.

[Reported by B. A. Forbes.]

THE LOUISVILLE MEDICO-CHI-

RURGICAL SOCIETY.

Stxited Meeting, June 26, 1903.

The essay of the evening, entitled
''Glaucoma," was read by Dr. T. C.
Evans. (See page 125).

DISCUSSION.

Dr. S. G. Dabney: Glaucoma is a
very broad subject, and I will speak
only of a few points in my own expe-
rience. I have seen two or three cases
that were brought on by the use of
mydriatics. One was a young Hebrew
whom I saw shortly after I began to
practice, with a history that his mother
had had glaucoma. He made a perfect
recovery under the administration of
eserine. That form generally gets well
without operation. The other case was
that of a lady past 70, living in an in-
terior town. I had operated on one eye
for glaucoma five or six years previous-
ly. She had another attack after the
physician used a mydriatic, but eserine
was used immediately and I was called
in. I found it necessary to do an iri-
dectomy and she made a recovery.



I think a mistake apt to be made in
diagnosis is in confounding a bilious at-
tack with an acute glaucoma. Both are
attended with pain on one side of the
head and both have vomiting. I have
seen two or three cases in which a di-
agnosis of a bilious attack might have
been made and it turned out to be glau-
coma.

I think the problem of operation is a
diflScult one. Broadly speaking, the
views of the essayist are generally ac-
cepted, that the sooner it is done the
better. Now and then there is an ex-
ception. I recall one case of a lady
past 82, whose symptoms had sub-
sided, she had a vision of about 20-40,
and was in feeble health; she had no
pain, the field of vision was tolerably
good, and I did not think operation was
wise. It may have been an error, but
my judgment still is that it was better
to use myotics. She went to the
springs, and later went to some dis-
tance. When she left 1 considered
her condition too good for operation,
and when she returned, too bad. Her
vision had become greatly impaired,
but she had good sight in the other
eye. She is now about 84 ^or 85.
Gases of that kind present a difficult
problem as to the advisability of opera-
tion.

Coming down to the question of the
operation itself, I have often been en-
couraged by a remark made by Dr.
Knapp, that he frequently fonnd it im-
possible to do a satisfactory iridectomy
in acute glaucoma. I have found it
one of the most difiicult operations.
Another great consolation is that an
imperfect operation may yield satisfac-
tory results. I remember one case of
a lady who had refused an operation in
the first eye until driven to it by the
pain. She recovered much better
sight than was expected, and when the
other eye was attacked she consented
to an immediate operation ; I was very
much dissatisfied with the operation
itself, but she got excellent results. It
must be remembered that some of these
cases recover from an acute attack with-



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out operation. The tendency at pres-
ent is to attribute the cause to gout and
rheumatism, and it is important that
the eliminative organs be kept active.

Db. J. M. Ray: As to the etiology
of glaucoma there is much difference of
opinion. I believe, as a result of ob-
servation, that glaucomatous eyes are
nearly always hypermetropic. I can-
not recall a single case in a myopic
eye. I believe also that there is a great
deal of difference between acute and
chronic glaucoma. Chronic glaucoma
almost invariably occurs in elderly peo-
ple who are the subjects of arterio-
sclerosis; the changes going on in the
walls of the blood vessels is the predis-
posing factor.

I believe that von Graefe, who in-
troduced iridectomy for glaucoma,
stated at the time that all that it did
was to relieve the tension. It does not
stop the inflammatory process from go-
ing on in the eye, but simply changes
the circulation of the eye so that there
is a re-establishment of equilibrium be-
tween secretion and excretion. When
none of the iris has been removed and
yet an eye gets along favorably, it
shakes our confidence in the belief that
we relieve cases by removal of a large
part of the iris. That was impressed on
me by a case I now have on hand. In
this case one eye was lost by operation
and an iridectomy in the other was a
failure. There are adhesions between
the iris and the cornea as a result, yet
the eye is practically as good as it was
several years ago.

I believe that all glaucomatous eyes
with marked tension are benefitted by
operation, though there are occasional
exceptions. As to glaucoma simplex,
with few symptoms present beyond
gradual failing of vision with little or
no tension, I have watched them close-
ly for months without detecting any ten-
sion, yet the clinical evidences in the
eye all pointed to glaucoma. I do not
see how we can expect any benefit from
an iridectomy in an eye of that kind, yet
many operators insist upon iridectomy
in all cases. I remember Dr. Knapp



said that glaucoma means iridectomy.
My observation is that this broad state-
ment does not hold true. I have seen
a number of cases of simple glaucoma
in which I operated on the first eye and
lost it, and operation on the second was
refused, and that eye went on for years
with good vision. I have an old gen.
tleman on band now on whom I op-
erated fourteen years ago in one eye.
In the other eye he has constantly used
a myotic, and he still has useful vision
in that eye.

Another point about simple glaucoma
is this: It has been my observation that
the disease spends its force on the pos-
terior segment of the eye. The anterior
chamber may be normal and the pupil
normal, yet the field of vision be very
much contracted and the optic nerve
atrophied, taking in the whole disc. I
have seen them with little tension, yet
pressure of the finger will bring on
pulsation of the central artery with
disc.

I think the subject is one on which
no two of us can absolutely agree, but
it is wise to follow out the idea that all
cases of glaucoma with increased ten-
sion of the eye should be operated on,
unless the physical conditions preclude.
On the other hand, I believe simple

flaucoma, in which we are unable to
etect any tension in the eye, are not
often benefitted by the operation, and
that if treated with eserine, strychnine
and the salicylates they will retain
their sight as long as when an iridec-
tomy has been done.

Db. Wm. Cheatham: Dr. Evans has
so well covered the literature of this
subject that there is not much left to
say except to give personal experience.
The subject of glaucoma is to the ocu-
list what appendicitis \a to the general
surgeon. Acute glaucoma is easily di-
agnosticated, and its treatment is clear-
ly defined. It is the sub-acute and
chronic cases which give us so much
trouble. I have a case on hand in
point now, in the person of a prominent
lady in town. I found she had incipi-
ent glaucoma of right eye, with well



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155



established chronic glaucoma of left.
She had had a sensation of something
behind the eyes pushing them out.
Eserine relieves this symptom. The
question is as to whether to operate or
depend upon feeding, hygiene and lo-
cal medication. She is aged, feeble,
and is improving under the above treat-
ment. In glaucoma simplex the base
of the iris is often found adherent to
the sclera. The symptoms of acute
glaucoma and iritis are quite similar
except as to the condition of the pupil;
the mistake in such a differential diag-
nosis is quite a serious one, and is often
made by the inexperienced.

Dr. Evans referred to errors of re-
fraction. In one of Gould's year books,
be will find a statement made that a
majority of cases of glaucoma in the
early stages can be cured by the cor-
rection oi an existing error of refrac-
tion. I believe in the refraction theory
as a cause of glaucoma. We speak of
the iris being pushed forward, and a
closure of the angle of filtration caus-
ing increased tension and glaucoma,
yet we have cases in which the iris is
tied down, and the angle completely
obliterated, with no glaucoma. It is an
error to look upon cases of hemorrhagic
glaucoma as a. local disease; it is circu-
latory and general. In aortic regurgi-
tation we get an arterial pulsation with-
in the eye, which simulates some the
pulsation seen in glaucoma. We have
three forms of cupping the optic
nerve: the physiological, atrophic and
glaucomatous. Between the latter two
there is some difficulty at times in dif-
ferentiating. Iridectomy is the treat-
ment in all forms. At times when to
operate, and whether to operate, and
whether or not to operate on both
eyes, with only one involved, is a diffi-
cult question to settle. I regard a
good iridectomy, with a clear lens pres-
ent, the capital on the eyeball. There
is much to be said on this subject, but
the time is limited.

Db. Wm. Bailey: I cannot discuss
the disease, but I want to ask a ques-
tion. There is a general opinion that



atropine is a very potent factor in the
causation of the disease. That being
the most common of the mydriatics
used, if it were a very potent factor, it
seems to me the results would be more
common. I think that if a person has
one glaucomatous eye, and atropine
should be used in the other, and glau-
coma follow, it is not necessarily pro-
duced by the mydriatic. I think the
importance of atropine as a factor in
glaucoma is exaggerated. Even where
it has been attributed to the atropine,
if a close examination had been made,
perhaps some of the symptoms of glau-
coma might have been recognized. It
may be that the drug would have some
influence in increasing the liability to
glaucoma, but that it is liable to pro-
duce the disease in a healthy eye, I
must express a doubt.



Current Literature.



Cooke, Jos. Brown, New York: The Roentgen
Ray in Obstetrics.— (JVl Y. State Jour,
Medicine,)

While it is true the pelvis of the non-
pregnant woman can be studied by
means of the rays, and deformities,
exostoses, and contractions recognized,
this work requires skill which can only
belong to one of great experience in
reading the negative or print. Photo-
graphs of the gravid uterus are not of
any practical aid in diagnosis. The
uterus and fetus up to the end of the
fifth month of pregnancy, in living
women, is no more than a filmy veil on
the plate. Careful palpation, ausculta-
tion and ballottment will yield equally
good results at this time. A rough
idea of presentation, but none of posi-
tion, may be made out when the fetus



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