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While in the intestinal canal the stone gradually increases in size by the formation of concentric layers of phosphate of ammonia and magnesia. I recall from an early experience the case of a woman, for several months a sufferer from severe abdominal pains, who passed three large enteroliths of a jagged appearance, followed by profuse and repeated hemorrhages from the bowels, thus reducing her vitality to a very low ebb. Had my familiarity with the symptoms of gall stones been sufficient to make a diagnosis, followed by prompt operation, I might have saved my patient much suffering and prevented perforation of the gall-bladder and escape of the gall stones into the alimentary canal, thus removing any possibility of the stones passing into the peritoneal cavity, exciting general peritonitis, a condition almost invariably, with or without immediate operation, producing death.

Among the indications demanding operation upon the gall-bladder I shall mention the following: Gall-stone colic, sepsis, empyema of the gall-bladder, jaundice or obstruction of the bile ducts, fistulous openings, and fat necrosis.

In carcinoma of the gall-bladder operation should not be attempted. The morphine habit is frequently acquired as the result of the surgeon's inability to recognize and operate upon these cases at the proper time. It is sometimes very difficult to examine the gall-bladder, even after the incision is made through which it is exposed, because of its atrophic and retracted condition.

Mayo, of Rochester, Minn., has perhaps done more gall-bladder work than any other American surgeon with the possible exception of Murphy, of Chicago. Of three hundred and twenty cases operated upon by Mayo, the gall stones were found outside of the gall-bladder and ducts in thirteen cases, due to perforation.

When there is occlusion of the cystic duct due to a firmly impacted stone, or when the mucous membrane of the gall-bladder is extensively diseased, the gall-bladder should be obliterated by thoroughly dissecting out the entire mucous membrane as far down into the cystic duct as possible, where it is ligated and cut off; or the peritoneum may be split along each side of the cystic duct and the duct ligated. There is practically very little danger of post-operative hemorrhage following dissection. Mayo, from his wide experience, reports one case with slight hemorrhage which continued for twelve days.

The recurrence of gall stones after operation is exceedingly rare; however, in some cases the pain continues, the cause of which is yet

unknown. Cases proving fatal from disease of the gall-bladder invariably present symptoms of kidney involvement at least twenty-four hours before death.

The presence of steapsin in the urine is proof of fat necrosis, which is conclusive evidence of the presence of gall stones. Patients with ecchymotic spots, extreme jaundice, or malignancy are poor subjects for operation, and it is from this class of cases that we derive our mortality. It is essential that the technique of gall-bladder operation and its after-treatment should be well understood. Following a thorough preparation of the patient, the field of operation is covered with the Murphy rubber dam, a piece of adhesive rubber tissue eight by ten inches in size. Through this dam an incision is carried down through the rectus muscle to the peritoneum; this is picked up and incised between two tissue forceps, and its cut edges are clamped with hemostatic forceps to prevent retraction. A search is now made for the gallbladder, and when found it is seized by its tip with a pair of gall-bladder forceps and brought out through the wound for an inch. The gallbladder is then stitched with a continuous catgut suture to the parietal peritoneum, beginning at the superior angle of the wound with a suture armed with two needles, one of which is carried around the outer half of the circumference of the gall-bladder, the other around the inner half to the inferior surface of the gall-bladder, where they are securely tied, anchoring the gall-bladder to the parietal peritoneum, completely closing off the peritoneal cavity. The tip of the gall-bladder is drawn well up by the forceps and a coffer-dam of iodoform gauze placed snugly around its free end, after which the tip of the gall-bladder is stitched with one silk suture on each side to the skin. This accomplished, the gall-bladder is then opened and its contents partially or completely evacuated. In the majority of cases, however, it is preferable to remove only a limited number of the stones at the primary operation, allowing the others to come away gradually as the drainage proceeds.

The dressing consists in leaving the rubber dam in place for the protection of the skin throughout the whole of the after-treatment, it never causing the slightest dermatitis, being prepared as is the oxide of zinc adhesive plaster. A rubber drainage-tube, large enough to snugly fill the opening in the gall-bladder, is passed to its bottom, secured by a safety-pin, and left for drainage. To the rubber drainagetube a few feet of rubber tubing is attached, to convey the bile and other debris into the waste bucket. Carefully placed around the drainage-tube

is packed the ordinary cotton and gauze dressings. The patient is placed in bed in a semi-reclining position, at an angle of forty-five degrees, to insure perfect drainage, and it is remarkable with how little inconvenience the convalescence is attended.

At the end of from three to five days the wound is inspected for the first time, and not infrequently with the withdrawal of the drainage-tube numerous stones come away and profuse discharge takes place. A search is then made for any stones that may have remained in the gall-bladder; when found, especially if impacted in the mouth of the cystic duct, they are often very difficult of extraction. In some cases it requires hours of the utmost patience upon the part of the surgeon to extract an impacted stone from the mouth of the cystic duct. This work is not accomplished by mere touch alone, but by inspection through the speculum. The stone may in this manner be brought as perfectly into view as if held in the palm of the hand. If after about twenty minutes' work the stone is not dislodged the drainage-tube is replaced and the patient is returned to bed, when the stone is left to nature until the next dressing, three or four days later, when another effort is made to dislodge and remove the stone. This procedure is continued with exceeding care until all of the stones have been extracted. In some cases many weeks are required to accomplish the desired result.

Through the electric or common speculum, with a good light, the mucous membrane of the gall-bladder, and even the mouth of the cystic duct, may be thoroughly inspected, and when relieved of all stones and disease the drainage-tube is removed along with the coffer-dam, and the wound permitted to close spontaneously, it not being good practice to attempt by surgical means to close the fistulous opening.

LOUISVILLE.

T

PHLYCTENULAR INFLAMMATION OF THE CORNEA.*

BY M. F. COOMES, A. M., M. D.

Professor of Physiology, Ophthalmology, Otology, and Laryngology in the Kentucky School of Medicine;
a Member of the American Medical Association, the Kentucky State Medical Society, and the Louis-
ville Clinical Society; Ophthalmic Surgeon to Louisville City Hospital and the Kentucky
School of Medicine Hospital; Consulting Ophthalmic Surgeon to

Sts. Mary and Elizabeth Hospital; Ophthalmic

Surgeon to St. Anthony's Hospital, etc.

This disease is confined almost exclusively to children from two to fifteen years of age; sometimes it is met with in adults.

Causes. The older practitioners in ophthalmology were inclined to believe that it was a blood discrasia, and they were not far from being correct. A micro-organism resembling the cocus flavus desidens has been found in connection with phlyctenular inflammation of the cornea, but while this is true I am of the opinion that the subject of this disease is always in a state of physical depravity when the disease manifests itself, therefore the soil must be in a proper condition before the germs develop and bring about the characteristic manifestations.

Symptoms. Congestion of the conjunctiva, either general or in localized areas, is always one of the conditions present in this disease; in fact, this is the last of the symptoms to disappear. The redness of the covering of the eyeball in many cases is very mild, while in the aggravated cases the congestion is violent, and along with this active congestion there is always photophobia (intolerance of light) and excessive lacrymation. In many of the typical cases the child, if it be only a few years old, will bury its head in the pillow at daylight and keep it there until twilight unless removed by force. This picture, no doubt, is familiar to most of you. In such cases the ulceration of the cornea is usually deep or near the center, or a large area of ulceration or a number of small ulcers will be found to exist in most cases of this kind. The depth of the ulceration and the surface area of tissue involved will always govern the severity of the symptoms; that is, the more tissue involved the more severe the symptoms. There is frequently an eczematous condition about the nose and face, which at times is extremely annoying to both patient and doctor, but which should be treated as an ordinary eczema.

Prognosis. The prognosis of the disease will depend altogether on the violence of the attack and the amount of corneal tissue involved,

* Read before the Brashear Medical Society, at Taylorsville, Ky., July 15, 1902.

and the manner in which the case is handled. With proper care and prompt, active treatment the most of these cases recover with good vision.

Treatment. This is necessarily local and constitutional. The local treatment should be directed to the relief of pain and the arrest of the progress of the disease; that is, of the destructive ulcerative processes that sometimes occur in connection with these cases. To determine the condition of the ulcer, cocaine the eye with a four-per-cent solution of cocaine and then drop a solution of methyl blue, five grains to the ounce of water, into the eye, when that portion of the corneal surface that is open will be stained a deep blue with the methyl.

The presence and size of the ulcer having been obtained by the staining, the next thing to be done is to touch the ulcer with pure liquid carbolic acid. This is best done by taking an ordinary dressingprobe and dipping the rounded end of it into the carbolic acid and then shake what can be shaken from the probe and finally touch the surface of the ulcer, which should become whitened by the acid. Then some bland oil, as albolene oil, should be dropped into the eye to insure against the excess of acid doing harm. It is very important to stain these ulcers each day, so as to note their progress. If the area of blue is decidedly lessened, then further use of the carbolic applications will not be necessary; but if there is no reduction in the stained area, or an increase in its size, then another application, and so until the healing process begins. Usually it is not necessary to make more than one, or at the most two, applications of the acid.

Atropine is recommended by nearly all authorities, but for what reason I am not prepared to say. It dilates the pupil and lets in an excessive amount of light upon an already highly sensitive retina. A solution of the sulphate of eserine, one grain to an ounce of water, dropped into the eyes every six hours is quite sufficient to maintain a very close pupil and thus cut out the light and stimulate the circulation in the sluggish vessels in the neighborhood of the ulcer, which is an all-important matter in such cases. In extreme cases a four-percent solution of cocaine may be used once in twenty-four hours. This, however, should only be done for the purpose of examining the eye Nurses and mothers should be warned of the great danger of cocaine solutions, as the continued influence of the drug will destroy the cornea in a few hours. I have recently witnessed the loss of an eye by the patient disobeying directions in regard to the use of cocaine. Where

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