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his pulse, as before the operation, was 155 a minute; his respirations 40. The following day I irrigated with a 2 per cent. solution of carbolic acid and substituted a drainage tube for the gauze. The change in his condition the next week was phenomenal; his temperature became normal; his pulse was reduced to 110, stronger and fuller; his appetite was inordinate, eating or asking to be fed whenever awake; his respirations from 24 to 28 a minute. He had been taking a tonic of iron and quinine, and when constipated a little sulphate of magnesia was given. Each day I irrigated the cavity with the carbolized solution, after which I injected peroxide of hydrogen, followed by iodoform and glycerine (3iv to žvi). On April 15 I went to pay my daily visit. I found my patient in a very gratifying state; he complained a little of his cough, but so confident did I feel in a future recovery that I promised to let him sit up in ten days. He was prepared to be dressed by the nurse in attendance, the patient assisting himself in the preparation. As soon as I introduced the nozzle of the syringe into the wound he began to cough; this was nothing unusual, as I experienced the same difficulty every day. I stopped for a moment, which gave him relief, and began very gently to remove the pus. This time the cough became violent; my patient became cyanotic; I immediately grasped his pulse; it could not be felt; I tried every means possible to revive him, with no result; he was dead. I was unable to hold an autopsy, and can account for his death by shock only, produced by a rupture of liver attachments, with a flow of pus and water into the abdominal cavity, superinduced by the cough.

The points of interest in this case, gentlemen, must be very apparent to you. Death might have ensued from several factors; firstly, from asphyxia or drowning the patient by irrigation; secondly, from shock resulting from a rupture of adhesions between the liver, abdominal wall and diaphragm. Another cardinal point. is the danger of delay in making an early incision to prevent a communication with the bronchial tube. Once this communication is formed the graver does the condition of our patient become. The constant passage of septic material through a lung, no matter how healthy, must leave destruction in its wake, and should we succeed in effecting a cure of the primary and graver trouble, we

leave a suitable nidus for the propagation of the tubercle bacillus. I feel confident that my patient suffered from some such trouble.

The conclusion I draw from this case is: All suspected cases of liver abscesses should be explored early; a negative result will not increase the danger of the patient, a positive one will surely be of inestimable benefit. If pus is located an early incision should be made and the cavity thoroughly evacuated. If a communication has already formed with the bronchial tube irrigation should never be practiced, but in its place the cavity should be constantly packed with iodoform gauze. The latter will absorb the pus and disinfect the cavity, and the patient will be spared the danger from which my patient died.

For discussion see page 343.

WHAT THE GENERAL PRACTITIONER SHOULD KNOW ABOUT DISEASES OF THE EYE.*

BY FRANK TRESTER SMITH, A. M., M. D.,
Professor of Diseases of the Eye, Chattanooga Medical College,
CHATTANOOGA, TENN.

That there is a lack of knowledge in the profession regarding the elementary principles of ophthalmology will hardly be denied by any one who is at all familiar with the facts. Our crowded college courses, and the feeling among students that they are not required in actual practice to know anything of the eye, owing to the multiplication of specialists, are largely responsible for this. Again, the subject is so extensive that it is difficult to decide where to leave off the study, and instead of mastering a few general princi ples with the more important facts, too often the matter is skimmed over and a superficial knowledge of much is obtained instead of a thorough acquaintance with what is most necessary. It will be the object of this paper to define the minimum amount of knowledge *Read before the Tennessee State Medical Society.

of this subject which one should have before entering the practice of medicine. If he understands these things well he will find it much better for his reputation, his pocketbook and for his patient; for if he makes a mistake elsewhere the kindly earth will cover it up, but here an error will be a walking advertisement to his want of skill or lack of knowledge.

to pay the cost of a

In the first place, it is not to be expected that every doctor should become a specialist or in any sense competent to deal with all eye affections, but he should know enough to know his ignorance. Secondly, it is not necessary for him to understand how to fit glasses, but he should know the main indications for the use of spectacles, e. g., presbyopia, diminished vision, asthenopia, headache, functional nervous disorders. In the third place, he should not attempt to use the ophthalmoscope for several reasons. First, it will not pay. He will not realize enough out of these cases good instrument. Then there is the cost and time of learning. It would be cheaper for him to pay a fee out of his own pocket to a competent specialist. He could not keep in practice for this work. Most books on diseases of the eye have a chapter on the ophthalmoscope which always seemed to me as worse than useless. We can divide the cases under consideration into four classes: 1, Those with impaired vision; 2, those complaining of pain referred to the eye; 3, the inflammatory cases; 4, the miscellaneous Your patrons have a right to demand that you know something of these and not depend entirely on the oculist. You will be compelled to give advice in all these cases, and you should know how to advise and when it is necessary to call in a specialist. You should know that every case of impaired vision and any clear cornea should have the benefit of an expert examination, provided that there is any perception of light. The doctor should be able to test for perception of light. He should know that where there is no perception of light, or where the cornea is opaque, that it is not worth while to subject your patron to any expense for an examination. He should know that where spectacles are supposed to be required that the oculist, and not the traveling charlatan nor the optician, is the proper person to whom these cases should be referred. He should be able to diagnose between glaucoma and

cases.

cataract as a cause for the poor vision, and not advise the former to wait until it gets ripe, with the result that a specialist is consulted when it is too late to preserve any vision.

In our second class of cases, in which pain is the prominent symptom, glaucoma is at once suggested. With the diagnosis of this disease every practitioner should be familiar. It does not require any skill to diagnose increased tension (hardness) of the eyeball in a well-marked case, and the other points of the diagnosis should be well understood. Pain in the eye without inflammatory symptoms is more often glaucoma than neuralgia. In some cases of glaucoma the reflex symptoms have predominated so that cases have been treated for biliousness. You should know enough to prescribe myotics until an operation can be performed.

best to use it, as

But the doctor

The general practitioner will be most often consulted in reference to our third class of cases, the inflammations. In all inflammations of the eye atropine is indicated, with the exception of the inflammations of the conjunctiva. Even here it will, as a rule, do no harm, so that in a case of doubt it would be the neglect of this agent may result disastrously. should know that it is to be used with caution in all cases over forty years, and that it is positively contraindicated in cases where there is any tendency to glaucoma. While many inflammations of the eye tend to spontaneous cure, and others would get well if treated on the above general principles, still it would be better to consult a specialist early and carry out a line of treatment laid down by him than to send him the case after all other resources are exhausted. The doctor should know the indications and the contraindications of atropine and also of aserine.

In some cases it is difficult to diagnose between glaucoma and serous iritis. If it were iritis and aserine or pilocarpine used to contract the pupil, the case would be made worse. If it were glaucoma and atropine or other mydriatic used, the result would be disastrous.

Under the fourth head are included all cases of functional nervous disorders, reflex and otherwise, which may be benefited by wearing glasses, or by some treatment, operative or otherwise, of the eyes. This includes cases of asthenopia, headache, chorea,

epilepsy and all obscure nervous troubles.

It is sufficient for you

to remember that many of these cases have been relieved and some cured by treating their eyes.

Injuries of the eyeball should, as a rule, be referred to a specialist at an early date, and especially if there is a suspicion of a foreign body, on account of the danger of sympathetic ophthalmia.

An endeavor has here been made to briefly outline the minimum knowledge of this branch which a general practitioner should have. More might be useful. For instance, the size and motility of the pupil will often aid in diagnosing cerebral affections or general diseases.

What has been given seems to be indispensable to any one who wants to practice medicine conscientiously.

SOCIETY REPORTS.

ORLEANS PARISH MEDICAL SOCIETY.

NEW ORLEANS, LA., April 29, 1893.

DR. A. J. BLOCH read a paper on

A CLINICAL REPORT OF A CASE OF HEPATIC ABSCESS.

(See page 337.)

DISCUSSION.

DR. DE ROALDES asked concerning the size of the cavity and the prognosis. Dr. Bloch said that the cavity was very large; the patient was getting rapidly worse, and when first seen death seemed to be but a question of a few days. An operation was imperatively demanded.

DR. CHASSAIGNAC said that the thanks of the society were due to Dr. Bloch for a graphic report of his case. It was highly interesting, not only on account of its clinical features, but it possessed the rather unusual merit of reporting a fatal termination. Many

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