Billeder på siden

toneum was extensively ruptured transversely. We found a large quantity of urine in the abdominal cavity, which was sponged out as thoroughly as possible and then flushed with sterilized boric solution. The ureters and abdominal viscera were not injured.

The peritoneum was sutured with cat-gut, but we were unable to repair the muscles or fascia because of their crushed condition, some loose portions necessitating removal. The bladder was stitched to the lower angle of the abdominal incision, which was then closed and dressed antiseptically. A free incision was

then made on either side of the one closed at divergent angles, in which deep drainage tubes were inserted. A syphon was arranged to carry the urine from the lower segment of the bladder to a receptacle. The patient reacted favorably from the operation, but died three days later from septic peritonitis.

Cases of this nature should impress us with the necessity of making early and thorough exploration, even though we have no abrasions or external evidence to guide us. There is no doubt but what the bladder was full and tense in this case which caused it to rupture more easily, but it hardly seems possible that the abdominal walls and muscles could have been torn and crushed as they were without the integument showing some evidence of injury.


Dr. A. Craig, of Columbia, Pa.: I merely rise to report a somewhat similar case that fell under my care some years ago. It was not exactly a case of rupture of the bladder, but of the urethra and sphincters of the rectum, accompanied with a fracture and overlapping of the pelvic arch. The case cited by Dr. Wooster has reminded me of it because he states that there was no external injury visible in his case. In my case the only external evidence of injury was the depression of the innominate bones, one toward the other. There was a rupture of the sphincter of the rectum which permitted some blood to ooze. This case, I am happy to say, terminated more favorably than the one reported by Dr. Wooster. The patient is still living after seven years. An operation was done by Dr. Deaver of Philadelphia, who made a new urethra through the prostrate region, it being impossible to connect the posterior and the anterior part of the urethra. A bougie

would pass out at the anus without effort. The urine passed through the anus. Dr. Deaver made a secondary operation in this case five years ago, which was similar to the first one. If the doctor is here he will probably take pleasure in giving an account of this case, which I know would be of interest to the Association.

I might say here, because I think it is a question of interest, that for six years this man was deprived of sexual relations, but after the operation was performed by Dr. Deaver the sexual desire returned. He is now married and is connected with the Pennsylvania Railroad.

Dr. P. Daugherty, of Junction City, Kan.: I look upon this as an unique case-something I have never heard of before. The unique part is not the rupture of the bladder, but the rupture of the abdominal muscles and crushing of the tissues without any discoloration or external signs of injury. It is very remarkable, and I do not think I have ever read or heard of anything of the kind before. It is easy enough to rupture the bladder if it is full, by compression, but rupture of the muscles of the abdomen, as the doctor found in this case, is a very remarkable thing.

Dr. W. B. Outten of St. Louis, Mo.: These cases bring to mind others that I have seen. There is one symptom, provided that we get a history of the case, which I think invariably points to rupture of the bladder or of the urethra itself or both. You will find very frequently that where a man's pelvis has been brought in contact with some strong force and where it has been pressed in, that the triangular ligament cuts directly through the urethra, and ruptures directly into the bladder. There is one symptom that has been taught me by experience in these cases, and that is, an unusual ecchymosis which usually extends from the seat of injury backward toward the anus and forward involving the scrotum. With this one symptom I would not hesitate to say that we had rupture of the urethra, and rupture of the bladder, and would straightway perform an operation for the purpose of correcting the trouble. I could relate to you some eight or ten cases of this kind. At one time there was an absolute dread among surgeons to do an external urethrotomy, particularly where there was much lacerated tissue, but now we are working intelligently upon this part of the economy without any dread of fear. At that

time these cases were followed by extravasation of urine and abscess and finally by death. There are very few instances in which we are competent to effect a cure, because in addition to having a ruptured bladder to contend with, and likewise a torn urethra, we have a fractured pelvis. I have seen cases where there has been a fracture of the pubes and ischium, where the pelvis was so twisted that all the relations were changed and the sacro-iliac synchondrosis was movable, and yet there was no indication of injury except beneath the scrotum. There, however, there was an extensive ecchymosis. When you get a perfect history of these cases the symptom of ecchymosis alone will lead you in the right direction.

Dr. A. J. Best, Centralia Kan.: I had a little experience last summer in one of these cases. A young man, while cutting grain fodder, slipped and fell, and one of the sharp points of the machine penetrated his anus. The sphincters were cut and the bladder torn to the extent of two and one-half inches. I saw the man several hours after the injury, at which time he was in a state of collapse. I tried to pass a catheter, but could not do so. I then washed out the rectum and put him on opiates, and he got along very nicely. It occurs to me that in these operations for bladder trouble that the rectum is the best place to operate sometimes.

Dr. Buchanan of Pittsburg, Pa.: When we are called upon to make a diagnosis of suspected rupture of the bladder, we should, of course, at first endeavor to exclude rupture of the urethra, and, as far as my experience goes, the best means for determining whether there be a rupture of the urethra or not, is to pass a stiff catheter. If we have a rupture of the urethra we will very likely find a rough place in the canal. If the catheter passes smoothly into the bladder, there is probably no rupture of the urethra. Having gotten into the bladder and drawn some of the bloody urine, it becomes necessary to find whether this is due to a ruptured bladder or not, and the best test is that known as Weir's. He passes in a measured amount of aseptic fluid and determines whether he gets it all back or whether there more or less. If, after emptying the bladder and introducing a certain amount of aseptic fluid, we find only a small amount returns, we have good reason to suspect intra-peritoneal rupture of

the bladder. If we have found there is no rupture of the bladder, and we have reason to suppose there is rupture of the urethra, I think it is our duty at once to open the perineum in the median line, and explore the urethra directly through the opening. If we have unfortunately been unable to pass an instrument into the bladder, and have opened the urethra and are still unable to reach the bladder through the urethra, it becomes our duty to open the bladder above the pubes and we will find in most cases that this is a very easy matter. We can then perform retrograde catheterization, passing a catheter through from above down and either through the entire course of the urethra, or out through the perineum, and in this way save our patient from all the dangers of extravasation. If we have found that there is a rupture of the bladder, of course laparotomy is our only resource, and coming from Pittsburg, I do not want to let this opportunity go by without saying that the first operation for rupture of the bladder was done by Dr. A. G. Walter of Pittsburg, in 1862, and was not reported for seventeen years. I believe that this was the first abdominal section that was ever deliber

ately made for a traumatism.

Dr. Wooster (closing): Cases of this nature are not of frequent occurrence, and I have my doubts whether any treatment would have saved the life of this man. The abdominal cavity was largely infiltrated with urine. I removed it as well as I could. My main object in reporting the case was to show the extensive injury to the muscles and to the abdominal

walls. While we have heard of rupture of the bladder, yet none of us have seen or ever heard of anything so extensive as in this case, without the patient being almost instantly killed. As I have previously remarked, there was no abrasion or discoloration of the skin.

Dr. Daugherty: Was there any fracture of the pelvic bones?

Dr. Wooster: Not any; and the ureters were intact. The urine was deposited in the lower segment of the bladder.

Dr. Daugherty: How long did he live?
Dr. Wooster: Three days.

It is best to leave nature to her course; she is the sovereign physician in most diseases.-Sir W. Temple.



As my place of residence makes it impossible for me to enjoy the privileges of membership in this society, I feel much honored in being invited to address you, and I am particularly pleased that the subject chosen for me should be the use of the ophthalmoscope in general medicine, for it is a subject in which I am much interested.

Growers, in his excellent work on Medical Ophthalmoscopy, begins his introduction as follows:

"The ophthalmoscope is of use to the physician because it gives information, often not otherwise obtainable, regarding the existence or nature of diseases elsewhere than in the eye. This information depends upon the circumstance that we have under observation. I. The termination of an artery and the commencement of a vein, with the blood circulating in each. 2. The termination of a nerve, which, from its close proximity to the brain, and from other circumstances, undergoes significant changes in various diseases of the brain, and in affections of other parts of the nervous system. 3. A nervous structure, the retina, and a vascular structure, the choroid, which also suffer in a peculiar way in many general diseases."

functional disease of the nervous system, including insanity; diabetes; nephritis; disease of the heart and of the blood; syphilis; tuberculosis; rheumatism; pyæmia and septicæmia; typhoid and many other fevers, etc., etc.

I know of no better way in which to interest you in this instrument than to show you how easily its use may be acquired and that without a teacher. I must, however, take you back to first principles and I hope that those of you who use the ophthalmoscope and are familiar with the optical principles upon which its use depends will bear with me while I explain these principles somewhat in detail for the benefit of those who have not given the matter their attention.

Of course no one will deny the utility of being able to find within the eye corroborative, and sometimes the only positive evidence of serious disease in other organs, especially if such information can be obtained quickly and easily. When most of us were students, however, the use of the ophthalmoscope was not systematically taught as a part of the undergraduate work, and in the medical school with which I am connected, one of the leading colleges of the West, this is only the second year in which such a practical course has been a requirement, and I regret to say that it has been rather difficult to excite the proper degree of enthusiasm in the students for the reason, no doubt, that the value of ophthalmoscopy in general diagnosis is not sufficiently impressed by teachers and writers on general medicine and surgery. Under these circumstances it is not surprising that comparatively few physicians are using the ophthalmoscope as a matter of routine, even though it may give us valuable aid in the study of cases of injury and disease of the brain and its membranes, especially cerebral tumor and abscesses; disease and injury of the spinal cord; so-called *Read by invitation before the Section of Pathology of the hicago Academy of Sciences, Dec. 23, 1895.

The eye, as you all know, is a camera in the form of a sphere. The cornea, the crystalline lens and the aqueous and vitreous humors constitute the refracting apparatus and correspond to the lenses of the photographer's camera. The iris is an automatic diaphragm and the inside of the globe is made black by the pigment of the uveal tract. The retina forms the most sensitive of plates upon which pictures are constantly formed, while the eyes are open, and conveyed to the brain as definite visual impressions through the fibers of the optic nerves and tracts. We are able, at will, to adapt the eye to vision at different distances by means of the accommodation, which, as you will remember, consists in changing the focus of the camera by altering the convexity of the crystalline lens.

optic nerves and tracts. significant

By the refraction of the eye we mean its power of focusing rays of light upon the retina. In emmetropia or normal refraction, parallel rays or those from a distance, are focused upon the retina without any effort of accommodation. It is evident that if we would see the fundus of an eye, we must throw light through the pupil and upon the retina and receive the light reflected therefrom into our own eye in such a way as to form a sharp image. Helmholtz first accomplished this in 1857 by placing obliquely before the eye a simple plate of glass. Rays from a convenient lamp, falling upon the glass plate, were, in part, reflected into the eye and illuminated the retina. The rays reflected back from the fundus arriving at the glass plate were again reflected, in part, back to the source of light, but some of the light passed through the glass plate into his own eye, enabling him to see the illuminated fundus. Much more light is obtained by using a piece of glass with a mirror coating, a round hole through the coating enabling the observer to see through it. Still more light is obtained by using a concave mirror, because the rays reflected from such a surface are rendered convergent.

An ophthalmoscope then consists essentially of a mirror with a hole in it, but our modern

instruments are provided with a concave mirror and a revolving disc containing a series of convex and concave lenses which can be rotated at will behind the perforation in the mirror.

Figure I represents the path of the rays when the ophthalmoscope is used in the direct method. In this method the observer sees the eye just as he would see an object through a convex glass or simple microscope. The


image of the eye-ground is a virtual one; that is, it seems to be behind the eye. It is magnified and erect.

From the candle L, the divergent rays falling on the mirror O, are rendered convergent. Passing through the refractive media of the eye, they are rendered still more convergent and come to a focus in the vitreous humor; diverging again, they form on the retina, the illuminated circle, whose diamter is a b. If this eye is emmetropic, rays from the points x and y will pass out of the eye into the eye of the observer. All the rays from the point x will be parallel. Rays from the point y will also be parallel. No image is formed, but the rays continue their course, and, entering the eye of the observer, come to a focus on his retina at the points x' and y.' Rays from the point x in the patient's eye unite at the point x' on the observer's retina. In a similar manner rays from the point y'in the patient's eye unite at the point y in the observer's eye. These rays, projected backward, seem to lie in their true position. Rays from the middle point m of the patient's eye unite on the middle point m of the observer's eye, and are projected backward to the point from which they originated. The point x, above m in the patient's eye, is represented by x in the observer's eye below the middle point m. The point y below m, in the patient's eye, is represented by y above m in the observer's eye. (The figure and explanation are from Dr. Schweinitz).

It is evident, from a study of the above diagram, that in order to see any details in the fundus of a patient's eye, the surgeon's eye must be in a condition to focus parallel rays of light upon its retina. In other words, it must

be emmetropic and he must be able to relax his accommodation as in distant vision; but we are all so thoroughly habituated to the use of the accommodation in looking at things close by that the first thing we have to learn in using the ophthalmoscope is to break this habit--to relax the accommodation at will, so that the eye of the surgeon, placed close in front of the patient's eye, is in a condition to receive parallel rays of light and to focus them upon the retina. In order to acquire this ability I have found it of service in approaching the patient or the eye-model in the dark room, to stare at the black wall as if looking into vacancy.

In my class work at Rush College, I have first given the students plain perforated mirrors and pill boxes with printing in the bottom and an aperture in the cover corresponding to the pupil of the eye, and they have practiced in the dark room, getting control of the light. They have also practiced the proper position in which the ophthalmoscope should be held-the handle held easily in the hand, the finger upon the side, and steadied by resting it against the nose and brow in such a way that whenever it is put up it comes naturally in position for the eye to see through the aperture. Then each student has taken his ophthalmoscope and gone through the same maneuvers with the pill box.

We also use a schematic eye, made by Queen & Co., constructed upon suggestions made by Dr. Wm. Thomson of Philadelphia several years ago. It is in accordance with strict mathematical formulæ, and consists essentially of two pasteboard tubes, one sliding

[graphic][merged small][subsumed][merged small]

into the other, the first one containing in the front part a convex lens of 20 diopters. At the back of the sliding tube there is a picture representing the retina, which can be brought nearer to or farther from the lens representing the refractive media of the eye. By this movement all refractive states of axial ametrophia up to 6 D. hypermetropia and 6 D. myopia can be exactly reproduced, and are read off by means of a scale on the sliding tube.

Each student has been asked to provide himself with one of these models to practice upon at home, as well as in the dark room in the college laboratory. There we have standards.


upon the top of which are three of these schematic eyes; one is emmetropic, one is hyperopic and the other is myopic. Students have been advised to practice first, the examination of the hyperopic eye, because it is easy to see the details of the fundus without complete relaxation of the accommodation. When they are able to partially relax the accommodation and see the fundus of the hyperopic eye easily, they are advised to practice upon the emmetropic eye, first approaching from a distance, staring at the blank wall behind the model and gradually relaxing the accommodation. Suddenly they see the details of the painted fundus. When one is once able to do this, subsequent efforts are rendered very easy. Then we have them practice upon the myopic eye, and they very soon discover that it is quite impossible, to see the details of the retina without employing the concave lenses which are contained in the ophthalmoscope. This is readily understood when we consider the path of the rays of light coming out from the myopic eye.

They come to the surgeon's eye convergent and must be made parallel or divergent by passing. through a concave lens before they can be made to focus upon his retina. For this reason we have in the revolving disc of the ophthalmoscope a series of concave lenses which can be rotated at will behind the aperture of the mirror. Likewise, if the surgeon is myopic he must, in using the ophthalmoscope, either wear his correcting glasses, or what is more convenient, turn into the aperture of his instrument a lens equal in strength to the degree of his myopia. If the surgeon be hypermetropic he may first render his eye emmetropic by turning into the instrument a convex lens of proper strength.

If we desire to estimate the degree of myopia with the ophthalmoscope we may do so by finding the weakest convex lens, through which we may see the details of the eye ground clearly, after allowing for error in our own eye and completely relaxing the accommodation. Likewise we may estimate the amount of hypermetropia in an eye under the influence of a mydriatic by finding the strongest convex lens with which we can see the fundus clearly. Unless we have perfect control of our accommodation at all times, it is evident that the measurements cannot be depended upon, and the surgeon must also know the refraction of his defect. own eyes and allow for any

In using the ophthalmoscope by the indirect method we interpose between the instrument and the patient's eye a convex lens of about 3 inches focus and turn into the aperture of the ophthalmoscope a convex lens of 10 inches focus. A real, inverted image of the interior of the eye is formed and the method is similar in principle to that of the compound microscope.

The ophthalmoscope mirror O (Fig 3) is held at a considerably greater distance from the patient than in the direct method. The rays from the candle come to a focus before reaching the eye or object-lens. They then diverge, and, passing through the object-lens 1, are rendered convergent. After traversing the dioptric media of the eye, their convergence is increased, and once more they unite somewhere in the vitreous humor, from which point they diverge and form a circle of illumination on the retina. Their course, in passing from the candle until they reach the retina, is shown by the arrow-heads in the figure.

A portion of the retina, a to b, represented by the arrow, forms an image, b' a', between the lens and the observer's eye, represented by the inverted arrow. Rays from the point a, on the upper part of the retina, pass out of the eye parallel to each other. After passing through the object-lens 1, they are rendered

[blocks in formation]

convergent and some to a focus at the point a' In in the lower part of the inverted arrow. the same way rays from the point b on the lower part of the retina are parallel on passing out of the eye, but are rendered convergent by the lens 1,and come to a focus at a point b' in It is this the upper part of the inverted arrow. æreal image that the observer sees, and not the eye ground of the patient. Rays from this image are focused on the observer's eye, just as rays from the retina are focused in the direct method, i. e., the rays from the point a' are focused on a higher portion of the observer's retina, and rays from the point b' are focused on a lower portion. They are likewise projected back to the points in the image from which they originated. (De Schweinitz.)

By the direct method the objects seen are magnified about 15 diameters, but in the indirect method we obtain a view of a much larger portion of the retina at one time, magnified about 4 diameters. As in microscopy, it is best to examine specimens first with low power, so in ophthalmoscopy it is best to use first the indirect and then the direct method in every examination.

In the choice of instruments I give my

« ForrigeFortsæt »