McGregor, M. D., Littleton. Discussion opened by J. Wallace Russell, M. D., Concord. Report. "On Medical Legislation." By James T. Greeley, M. D., Nashau. Discussion opened by A. P. Richardson, M. D., Walpole. Essay. "Disordered Digestions." By L. J. Frink, M. D., Bartlett. Discussion opened by I. G. Anthoine, M. D., Nashua.

Essay. "Altitude: Its Effects upon Different Individuals, with Report of Two Cases." By Geo. S. Gove, M. D., Whitefield. Discussion opened by G. P. Conn, M. D., Concord.

Report.-"On Variola." By Geo. Cook, M. D., Concord. Discussion opened by I. A. Watson, M. D., Concord.

The South Dakota Medical Assembly.

The "Medical Assembly" was organized at Sioux Falls, South Dakota, May 26, 1896.

The following is the scientific programme: "Address in Medicine," Dr. Robert E. Conniff, Sioux City, Iowa.

"Address in Surgery," Dr. J. N. Warren, Sioux City, Iowa.

"Address in Gynecology," Dr. Edward Hornibrook, Cherokee, Iowa.

"Address in Obstetrics," Dr. S. A. Brown, Sious Falls, South Dakota.

"Address in Anatomy," Dr. L. Phelan, Sioux City, Iowa.

"Address in Ophthalmology," Dr. R. E. Woodworth, Sioux Falls, South Dakota.

"Sparteine in Surgical Anaesthesia, Dr. G. G. Cottom, Rock Rapids, Iowa.

"Antitoxin in Diphtheria," Dr. W. H. Meyers, Sheldon, Iowa; Dr. Jos. Schwartz, Hartford, S. D.

"Injuries to the Eyeball," Dr. J. C. Dunlavy, Sioux City, Iowa.

"Bacteriology in Diagnosis, Dr. S. Olney, Sioux Falls, S. D.

"Pyonephrosis," Dr. William Jepson, Sioux City, Iowa.

"Lessons from 800 Confinements, Dr. F. J. Smith, Alton, Iowa.

"Hysterectomy: Its Uses and Abuses," Dr. V. B. Knott, Sioux City, Iowa.

"Afterbirths," Dr. T. S. Roberts, Sioux Falls, S. D.

"Extra-uterine Pregnancy," Dr. A. C. Bergen, Sioux City, Iowa.

"Proprietary Remedies," Dr. Geo. W. Bliss, Valley Springs, S. D.

"Obstetric Anesthesia," Dr. W. M. Richey, Le Mars, Iowa.

"Ulcers of the Cornea," Dr. George Park, Sioux City, Iowa.

The purse of the patient frequently protracts his cure.-Zimmermann.

Miscellany.

(154) Pathogenesis of Uræmia.

Ajello and Paraveandalo (Lo Sperim, an. 49, fasc 4), as the result of numerous experiments on animals, believe that uræmia is closely related to the presence or absence of an internal renal secretion. Just as other glands have internal secretions, so has the kidney. The authors found that animals, after unilateral nephrectomy and without any treatment, died in from eight days to eleven months with albuminuria and cachexia. On the other hand, animals, after unilateral nephrectomy, when inoculated with renal juice prepared after the method of Brown-Sequard and D'Arsonval (20 c.cm. injected daily in dogs, 10 c.cm. in rabbits), did not present any albuminuria or cachexia, and lived in good health until killed for other experiments. After double nephrectomy without treatment the animals died in four to fortyeight hours; if treated with renal juice they lived from forty-eight hours to four days and more. The implantation of kidneys, whether subcutaneously or in the peritoneal cavity, gave negative results.-British Medical Journal.

The four humors in man, according to the old physicians, were blood, choler, phlegm and melancholy.-R. C. Trench.

FOR SALE.

PRACTICE FOR SALE:-I offer for sale my practice in the County seat of one of the best counties in Iowa. Have been here for twelve years; am surgeon of the leading road entering the town; am medical examiner for six life insurance companies, etc. I simply require that my successor buy my office fixtures.-mostly new-worth $700. Purchaser must be reliable physician with few years' practice. Address "Z. V.," care RAILWAY SURGEON, Chicago.

Desiring to remove to the Pacific Coast, I offer my well-established practice of over 20 years to any physician who will purchase my real estate, situated in one of the most beautiful and thriving towns in Southern Michigan, and surrounded by a very rich farming country. The town is intersected by two important railroads, for one of which the subscriber is surgeon. The real estate consists of a fine brick house of eight rooms and two fine offices besides, attached to, and a part of, the residence. A fine well of the purest water, two cisterns, waterworks, etc. Fine garden filled with choice fruit in bearing, peaches, pears and apricots and small fruits, raspberries, currants, etc. Fine barn and other outbuildings, comparatively new and in the very best condition, all offered with the practice and goodwill at a very low figure for cash. Address "MACK, Surgeon," care RAILWAY SURGEON, Monadnock Block Chicago, Ill.

By reason of failing health, physician wishes to dispose of real estate and practice. Practice amounts to nearly $4.000 per year. No charges except for real estate. Address WM. D. B.. AINEY, Montrose, Pa.

Desiring to remove to a warmer climate, owing to poor health. I offer my well-established practice of 11 years to any physician who will purchase my real estate; situated in one of the most thriving towns in the Platte Valley, in Central Nebraska, on main line of Union Pacific R. R., on which road I am the assistant surgeon.

The real estate consists of 2 lots "on corner," on which there is a fine artistic "modern" frame house, 8 rooms; stable 20x30, wind mill, tower and 30-barrel tank: nice blue grass lawn, trees and fine garden (all new); and all offered with my $5,000 practice and good will, at a very low figure. A part cash, balance on time. A very thickly populated country. Address 'BOVINE," care RAILWAY SURGEON, Monadnock Block, Chicago, Ill

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.

DISCUSSION Of Dr. WoostER'S PAPER.

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

The

would pass out at the anus without effort. 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.

I

Dr. P. Daugherty, of Junction City, Kan.: 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.

The

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. 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 is 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 deliberately 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.

"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."

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.

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.

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.

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