convenient handle. The circumference of the ring is concave. A purse-string suture of silk or catgut is run around the cut ends of the bowel, as in using the Murphy button. The ends of the bowel are then slipped over the ring and the purse-string sutures firmly tied in the groove. Lembert, or Halsted's mattress, sutures are then placed to approximate the peritoneal surfaces of the gut. The handle is then unscrewed and withdrawn and a little firm pressure separates the ring at once into its four sections, · which are small and easily passed by the bowel, thus having the advantages of the crushable cylinders of potato, turnip, etc., without their disadvantages. This ring has some of the good points of the Murphy button and the Laplace forceps, and is without their objections. It is much simpler and less expensive. The segments do not cause pouching of the intestine, as they weigh only from 10 to 25 grains, while the Murphy button weighs over half an ounce. The lumen is much larger than that of the button, and it does not depend upon sloughing for its liberation. It is quickly applied, as the handle greatly facilitates manipulation. The ring has been used in a number

were upon the inside of the bowel, with the exception of those closing the longitudinal slit upon the con- . vexity of the intestine, through which the cut ends, were inverted while being sutured. It must be apparent that if we could find a way of placing all the sutures and knots upon the inside of the bowel, and at the same time do away with the longitudinal incision, which is necessary to enable us to place the sutures in the Maunsell operation, we would surely be approaching very close to the ideal. This is what is made possible by the Connell suture.

The resection of bowel having been made in the ordinary manner, the first stitch is placed at the mesenteric attachment of the cut ends. The needle : is passed clear through the intestinal walls of both cut ends on one side of the mesenteric attachment and is returned through the walls in a like manner on the other side and is tied as is shown in figure 1, A. The ends of the suture are left long so as to make convenient stays for the assistant to hold.

The next stitch is passed in a similar manner, but at a point about one-third of the circumference cf.

of cases of intestinal anastomosis with excellent results.

The second method of which I wish to speak is known as the "Connell Suture," and belongs to the class of operation in which no mechanical aid is employed. This ingenious method was invented by Dr. F. Gregory Connell of Chicago, and was first published in the Philadelphia Monthly Medical Journal for January, 1899. It was first employed in June, 1900, by Martin of Chicago, and was presented in an improved form with a report of nineteen cases and fifteen recoveries, before the American Medical Association in the summer of 1901, by Dr. Connell. This paper appeared in the Journal of the American Medical Association for October 12, 1901, under the title of "The Knot within the Lumen in Intestinal Surgery." Of all the methods belonging to this class of operation, it, theoretically at least, more nearly approaches the ideal than any other yet devised.

We have mentioned the great success of Maunsell's method, and noted that the success of that method was due largely to the firm union obtained by the sutures passing through the entire intestinal wall, and to the fact that all of the sutures and knots

the bowel away from the first stitch (see figure 1, B). The ends of this stitch are also left long and the assistant now holds the bowel by the two stitches (see figure 2, A and B). Next, stitches are now placed in the space between suture A and B, and are tied and cut short, thus completing one-third of the anastomosis (see figure 2). In inserting these sutures, the needle penetrates both cut ends of the bowel at once, thus saving considerable time.

The second third of the circumference is closed in precisely the same manner as the first third (see figure 3).

The closure of the last third must be done in a somewhat different manner. While the stitches are placed and tied in exactly the same position, the needle must penetrate each wall of the gut separately as shown in figure 4.

It is apparent that no difficulty in tying the stitches on the inside of the lumen will be encountered until we come to the last stitch, as they are tied through the opening in the bowel not yet closed. But after the last stitch has been placed, comes the problem of tying it with the knot inside the bowel, and herein lies the trick of the Connell method.

The last stitch having been placed in position ready

to be tied, a threaded needle is passed, eye end first, between the approximated walls of the bowel, at a point nearly opposite the last stitch in the space between two sutures (see figure 5, a). The eye end of the needle, with its thread, is brought out of the aperture remaining to be closed by the last stitch (see b, figure 5). The ends of the last stitch are then passed through the loop of the threaded needle (see b, figure 5), and are drawn into the bowel, and out of it through the space in the walls at which the eye end of the needle first entered (see figure 6).

The ends of the last stitch are now drawn tight, closing the final opening, and bringing the opposite sides of the bowel in contact with each other, while the stitch is tied and cut (see figure 7). The knot is then slipped into the lumen of the bowel through the space between the stitches, and the seemingly impossible has been accomplished (see figure 8).

This method is difficult to describe, but is simple to grasp when once seen.

The chief advantages of this method over others of this type are, in the very firm union of the serous surfaces of the bowel, that practically none of the suture material is exposed on the peritoneal surface, therefore obviating the danger of capillarity, that the suture material eventually works its way into the lumen of the intestine and is thus entirely gotten rid of, and that no incision in the wall of the bowel is necessary to accomplish it, as is required in the Maunsell method.

In the Maunsell operation the anastomosis is made with an overhand stitch, and there is always a possibility that the cut ends may slip by each other, so that the serous surfaces are not in perfect apposition. In Connell's method this is impossible. It is a decided advantage to have no sutures on the peritoneal surface, as they sometimes cause irritation and may eventually be the cause of a fecal fistula. The avoidance of an incision in the bowel is a decided improvement, of course. Furthermore, Connell demonstrated in his article on "The Knot within the Lumen" that it is practically impossible to place a Lembert, or Halsted mattress, suture without perforating the entire intestinal wall. Halsted showed that, in order to get a firm union, it was necessary to penetrate the tough and strong submucous coat, and all operators recognize that fact to-day. In his article he illustrated the relative thickness of the various coats of the intestine by a picture which magnified the wall of the bowel about thirty-two times (see figure 9), but as Connell rightly points out, he failed to magnify the needle in the same proportion as the rest of the illustration. In figure 9 is shown the size of a No. 8 needle magnified the same number of times as the intestinal wall in this picture, and it must be readily apparent to all that the task of picking up the submucous coat with any surety of not penetrating the mucosa is a practical impossibility. The submucous coat is estimated as being

inch in thickness, while the No. 8 needle has a diameter of inch. Also, it is important to remember that in the duodenum, Brunner's glands, which, of course, are in direct communication with the intestinal lumen, are situated in the submucosa.

Therefore there would seem to be no advantage to be derived by using Lembert or Halsted sutures, as they, in practice, do not avoid penetration of the bowel and the dangers of capillarity.

Over a year ago the Connell suture had been employed nineteen times with fifteen recoveries, and it must have been used many times since. Its further employment will, undoubtedly, become popular as its merits are known and its technique mastered.

The third method that I wish to present is that of O'Hara forceps, which belongs to the class in which mechanical aids are used. This instrument was first presented by Dr. M. O'Hara, Jr., of Philadelphia, in April, 1900. It consists of two slender clamp forceps held together by a serre-fine (see figure 14).

The technique of the method is extremely simple. Each forceps is clamped on the gut at the exact points where the intestine is to be resected (see figure 10). The intestine is cut away close to each forceps (see figure 11), and the two forceps are then approximated and fastened together with the serrefine clamp. Halsted mattress sutures are then placed so as to bring the walls of the intestine together over the forceps (see figure 12), and when one side has been completed both pair of forceps are turned over and the other side is sutured in the same manner. The sutures being all tied, the forceps are therefore completely buried (see figure 13). The forceps are then unlocked, and each one is withdrawn through the small opening left, which is closed by a stitch.

The advantages of this instrument are, that they are rapid of application and simple in construction; that one pair of forceps will answer for any size of intestines, thus doing away with the necessity of various sizes of Murphy buttons and Laplace forceps; that no preliminary clamping or ligating of the bowel is necessary, and last but not least, that they avoid contamination with the interior of the gut, as all the manipulation is exterior to its lumen. This last is an advantage which no other method possesses. With the foregoing recent methods, I have had personal experience with the O'Hara forceps only.

Last summer I resected seven inches of ileum with their aid, in a patient who came into my service at the Post-Graduate Hospital, with the following history: Mrs. A. S., age twenty-six years, married seven years, perfectly healthy until the birth of her only child five years ago. Her labor was difficult, requiring forceps, and was followed by puerperal sepsis, which resulted in the formation of a tuboovarian abscess on the right side. This abscess eventually pointed in the right inguinal region above Poupart's ligament, and although it was opened and curetted by her physician, it had resulted in a sinus, which was discharging pus freely at the time I first saw her. Her general condition was one of misery, as she suffered constant pain. At times she had a profuse discharge of pus from the rectum. Examination disclosed a subinvoluted retroverted uterus, firmly bound with adhesions, and a mass in the right side, the size of a duck's egg. A probe passed into the inguinal sinus entered directly into this mass. Before opening the abdomen, the inguinal sinus was sealed with gauze and collodion to prevent contamination. Extensive omental adhesions were encountered, and the tuboovarian abscess was exposed with considerable difficulty. The vermiform appendix with the caput coli and two loops of ileum were densely adherent to the wall of the abscess. An appendectomy was next done, and the head of the colon released. One loop of intestine communicated directly with the abscess cavity by an opening one inch in diameter, and this was closed with mattress sutures. The other loop of bowel was constricted, and had several perforations, so that I deemed it unwise to leave it. This loop, seven inches in length, I resected with the aid of the O'Hara forceps. The walls of the abscess were dissected out and the opening into the inguinal sinus was closed. Vaginal drainage was made. The patient made a rapid and uncomplicated re

covery, and is entirely well to-day, having gained fifteen pounds. The ease with which I was able to make the resection with this instrument and the satisfactory result obtained fully confirm the claims that have been made for it.

These recent methods are certainly worthy of attention, and as they overcome the recognized disadvantages of the standard operations, they must be looked upon as a decided advance. Doubtless each operator will prefer the method to which he is most accustomed, but it is not wise to depend on one method alone, as the circumstances under which we are called upon to make an anastomosis are very variable

The surgeon surely has a variety to choose from in these three methods, but whether he prefers the crushable ring or the O'Hara forceps, he should certainly include the Connell suture in h s repertoire, as it is necessary that he have one method at his command when only a needle and silk are needed to accomplish an anastomosis, as the emergency may unexpectedly arise when no mechanical aids are at hand.

230 WEST FIFTY-NINTH STREET.

THE PHYSICIAN AND THE OPHTHALMOSCOPE.

BY FRANCIS VALK, M.D.,

NEW YORK.

Ar the last meeting of the State Medical Society held in Albany, our retiring President, Dr. Henry L. Elsner, in his closing address, "A Modern Diagnosis,' used these words, "An instrument of precision too little employed by the general practitioners is the ophthalmoscope, for the introduction of which the memory of Von Helmholz will always be revered."—"It gives information regarding the existence and nature of pathological conditions elsewhere than in the eye which is often obtainable in no other way." As I listened to his argument on the use of the ophthalmoscope I asked myself the question, How many physicians know how to use this extremely valuable instrument? Why do they not useit? Can its use be so demonstrated to them that they may use it? These are questions to be answered partly by the physicians themselves, but the last must be answered by one somewhat familiar with the use of the ophthalmoscope and with the advantages it may present to the physician in the diagnosis of many conditions that arise in general practice, either that it may elucidate some unexplained phenomena or confirm some previously suspected conditions.

It goes without saying that every physician should make himself as fully competent as possible in the diagnosis of all general diseases, with their complications and their sequela. In the use of all other instrumental aids, as the stethoscope, etc., the physician does inform himself as thoroughly as possible, yet in the use of this instrument, one of the best for objective diagnosis of disease, he seems to have left it in the hands of the specialist; depending possibly on a consultation or passing the matter to one side depending solely on his other objective and subjective signs.

There are few instruments in the hands of the physicians that can give as useful information in the diagnosis and prognosis of disease as that of the ophthalmoscope, nor is there one that can be relied upon so implicitly. The findings of the ophthalmoscope are so obvious and correct that they leave no doubt as to the condition of the fundus and the systemic conditions that these findings may indicate. Furthermore, as Gowers well says, "We examine the artery to its termination and the

commencement of a vein with the blood circulating in each; the termination of a most important nerve which, from its close proximity to the brain, undergoes significant changes in various disease conditions of the brain and in affections of all other parts of the nervous system; and a nervous structure, the retina and a vascular structure, the choroid, which also suffer in a peculiar way in many general diseases." Is not this matter important enough for a careful consideration?

I do not expect that the general practitioner will ever become so far proficient as to readily detect all the most delicate changes that are sometimes presented by this beautiful system of vessels, nerves, and tissues of the eyeball, yet I do believe that with reasonable experience in the use of this instrument the physician may so perfect himself as to recognize the most important changes in these delicate structures of the eyeball indicative of or associated with some systemic disease. What can be more useful than the picture presented by the appearance of the termination of the optic nerve in any obscure disease of the brain or that of the retinal vessels and the retina itself in diseases of the kidney? Do we not know of cases of Bright's disease in which the first correct diagnosis has been made when the eyes have been examined with the ophthalmoscope? Tuberculosis may be diagnosed, or at least confirmed, with the ophthalmoscope by the appearance of the fundus, as it shows the characteristic tubercles in the choroid, and in doubtful cases of acute miliary tuberculosis may confirm the diagnosis. It is not always possible to refer these cases to those who are engaged in this special field of medicine and one who can use this instrument-even in a comparatively limited manner

will be much more than compensated from the instruction and the information it will give him. The brief time it may require to learn the method of its use in a practical way is not very great.

How often have I heard the answer to the question, Have you an ophthalmoscope? Yes, but I never use it; but why? Why does the physician possess this instrument and yet not use it? I think I can answer this question in this way: Because when he commenced the study of ophthalmoscopy in the textbooks he found it presented so many details and so many complications that the instru ment was soon laid aside, simply to be remembered in the possession of its owner, but not to be used. It is my hope that this subject may be presented in a very simple manner, by one partially familiar with its uses and advantages, which is the object of this paper, and I would present it by the common-sense method, so that it will be useful to the physician, and leave the more complicated uses. of the instrument to the specialist.

Before proceeding further let me describe the instrument. What is it? It is simply an apparatus by which we may place the examiner's eye in the path of the rays of light as they come from the background of the examined eye when illuminated by reflected light.

To see an object we must have the rays of light pass into our eyes in certain directions, either parallel or divergent. Now the rays coming from an examined eye are either parallel, divergent, or convergent. To the second condition-divergent rays-our eyes are readily adjusted and we have a perfect image on the retina of the examiner, the fundus being easily seen. The parallel and convergent rays cannot be focussed on the retinaand here is one of the trials of the beginnerexcept under special conditions, but they can be

easily made divergent and so become useful for the vision of the examiner. Then our instrument is a mirror to illuminate the examined eye and a disk of lenses to so bend the emerging rays that they may focus on the retina of the examiner.

To illuminate the eye we require a good steady light-the Argand burner with oil or gas is the best-a slightly concave mirror to concentrate and reflect the light and a handle to direct the reflected rays, within the eyeball, directly through the pupillary space. If we now place the examiner's eye in the center of the rays coming from the examined eye-that is, behind the aperture as the retina is illuminated, he will be able to see the details of the fundus if the outcoming rays are divergent. If not divergent we cannot see the fundus clearly, and we must make them so by placing suitable glasses behind the aperture. It can be readily understood that if the examiner's eye receives these rays and can focus them on the retina, they must there form a picture that will correspond with the object from which they proceed. In other simple words, the ophthalmoscope enables us to look into the eyes of our patients and to see the condition of the eye-ground, either in health or disease. Such is the simple purpose of the ophthalmoscope, seemingly very easy, but I will point out the difficulty that may arise and then show the usefulness of the instrument.

It has been fifty years or more since the ophthalmoscope was first used to see the interior of the eye, but to Von Helmholz we owe all reverence for his introduction of this instrument in 1851, and those of to-day are the same in principle, only differing in the mechanical parts, as when the instument was first used. I do not propose to enter into the subject of the estimation of the refraction of the eye, but only how to see the background or retinal field; what it looks like and what are the essential changes that we should be able to see, to know, and to appreciate. Now the textbooks tell us to look through the aperture of the ophthalmoscope as if we were looking toward infinity or in the distance with the accommodation at rest, etc. This is all very true, but it requires a vast amount of practice to master just that; no beginner can do it, nor is it essential, and moreover it is only useful to the specialist. I shall then try to inform you as to the use of the instrument as needed in the hands of the general practitioner. Let us accept the statement that one is utterly ignorant of the method of using the ophthalmoscope, but wishes to understand its use in the diagnosis and prognosis of certain diseases of the general system. How then shall he use the ophthalmoscope so that he may gain this practical knowledge? Place the light-let me say at once that too bright a light is not necessary for the appreciation of the most delicate changes at the fundus-behind the patient, about one foot distant from the eye, on a level with it and to the right or left according to the eye to be examined; seated now on the side of the eye to be examined, the ophthalmoscope is placed before the corresponding eye of the examiner and he looks through the small

opening or aperture. If possible, it is best to keep both eyes open, but for the purpose we have in view, one may close the eye not used if by so doing it will assist him in the examination. Now reflect the light from the lamp or gas-burner into the patient's eye and we find the pupil changes from its natural blackness to that of a bright orange red. If not so, we must proceed to a more detailed examination of the anterior part of the eye, as the cornea and lens. To do this, we place the lens

marked 6. in the disk, at the aperture and we move nearer the patient until we are within the focal distance of the lens-about five or six inches— when we will see the anterior part of the eye mangified and can readily detect any opacity or changes that may appear on the cornea or lens, showing generally as black spots on the bright orange red color of the pupillary space. This examination may indicate incipient cataract, iritic deposits on the capsule or, if there is complete absence of the pupillary reflex, some very serious condition of the interior of the eye-ball. To resume, if this portion of the eye is found to be perfectly clear, we now proceed to examine the deeper parts or fundus. Removing the convex lens and again looking through the aperture, with the reflected light directed into the pupillary space, we now attempt to see the background or fundus of the eye-in other words, But just

the nerve, retina, vessels, the choroid, etc. here comes the great difficulty which all examiners meet in their first attempts to examine the eye. This is due to the direction of the rays of light coming out from the examined eye and the inability of the examiner to control the action of his own accommodation. We make an effort to look at us on account of the

something very close to proximity of the patient's eye and so we exert a certain amount of accommodative power, preventing the formation of a distinct image on our own retina. To obviate this difficulty, so common to beginners, we must place at the aperture one of the concave lenses marked with red figures on the disk. This will neutralize the action of our own accommodation, will make the rays of light divergent and then the details of the fundus will rapidly come to view. Now, having mastered this instrument to the point where you can begin to see the fundus, you must know what you see and what to look for, both in health and disease, so that you recognize such pathological conditions of the fundus that may point to some systemic condition. If you will attempt to make this examination on the eyes of your patients that have no eye troubles, young people with large pupils, you will soon appreciate what is the appearance of the normal fundus, with the arteries, veins, and nerves. this mental picture before us we can readily see any pathological changes that may have taken place. Before proceeding further, let me state, inasmuch as the pupillary area is not always the same in every eye, and when very small it is very difficult even for an expert to see anything except the red reflex, then you are justified in using a weak mydriatic to dilate the pupil. Atropine will not do for this purpose, as it impairs the sight too long. Cocaine, 4 per cent., or homatropine, one-fifth of one per cent., will be the best dropped in the eye about twenty minutes before we are ready to begin the examination. Either one of these drugs will dilate the pupil in a short time and will make your examination much easier, while the effects of the mydriatic will pass off in about twenty-four hours.

With

All these conditions now being at our command, the next question arises, What is the normal eye? and in the words of Haab, "I cannot too appearance of the fundus or background of the strongly advise the beginner to study the normal eye as often and as thoroughly as possible."

We first note the color of the eye-ground; this will appear very different even in perfect health, according to the individual, as blonde or brunette. Brunettes generally present a much darker eyeground than blondes. This difference is chiefly due to the amount of pigment in the retinal layer,

the pigment epithelium. This pigment is also in the choroidal layer showing as dark spaces between the choroidal vessels, and in the negro the dark spaces and the numerous choroidal vessels are very often seen, while in the albino, with little or no pigment, the vessels of the choroid will appear red on an almost white background. In the region of the macula or yellow spot-the position of most acute vision—always found outward toward the temples from the nerve entrance, we find the pigment color darker and in many cases a small spot in the center. This pigment is also seen about the entrance of the optic nerve, forming the choroidal ring, dark masses irregularly placed, but seldom, if ever, extending completely around the nerve. The nerve entrance is quickly seen, being so prominent as a large round space, apparently in the center of the eye-ground. It presents a grayish-white color, seemingly semi-transparent, and the central part whiter from the dipping inward of the central nerve fibers. If the central part is very large and deep, the lamina cribrisa may be seen as a large, white network in the nerve entrance. This nerve entrance or papilla may be round or slightly oval in any direction, and in a condition of health its surface does not extend beyond the plane of the retina. The retina itself in health cannot be seen except in some cases by the most practised eye. The general appearance of this eye-ground presents to the examiner's eye a peculiar appearance, as of a very small irregularly figured carpet, somewhat like a mosaic of small light and dark spots; this is called the stippling of the retina. This is very important and should be carefully studied, as its presence or absence must indicate the condition of the retina. The slightest changes are shown by the blurring of this delicate network of pigment, which indicates some pathological condition either in the eye itself or the parts behind it. The arteries of the eye-ground consist of the branches of the central artery of the retina, which pass out from the nerve and dividing into smaller arteries extend outward over the entire retinal field to the anterior part of the eye-ball; similarly, the veins. of the eye-ground have the same arrangement, are darker in color and empty into the central vein of the retina. We can recognize the arteries by their lighter color and the white line that runs along the center of each vessel, while the veins present a much darker color, the line along the center not being so prominent. All these vessels have a straight course, being slightly curved, and they can be distinctly traced to the periphery of the retina. Any irregularity in their course or blurring of their outlines is probably due to some retinal changes. Pulsation in the veins on or near the nerve entrance, may be readily seen and has no special significance, but if seen in the arteries is serious. The diagnosis of this condition is very difficult and would carry us beyond the scope of this paper. For a more complete description of the normal eye-ground I must refer you to the many textbooks on this subject, but I have described the most important details of the appearance of the normal fundus as seen with the ophthalmoscope, in order that we may become familiar with this picture from the examination of the eye in health so as to appreciate the changes that take place in disease as shown by the retina nerve and vessels.

Because of their frequency and their importance in the diagnosis of disease, there are two conditions of the fundus of the eye that will always have special interest to the medical profession. I refer to retinitis in its many manifestations and what is commonly called "choked disk." Retinitis, inflammation of

the retina, covers a vast variety of changes in the back part of the eye, readily seen by the expert with the ophthalmoscope. The general practitioner cannot see all the minute changes, yet with reasonable care he can appreciate the important changes that may indicate some local or systemic disease if he becomes familiar with the appearance of the normal fundus. Now inflammation of the retina becomes the most important change, because it is frequently present in so many other systemic diseases that may be first noticed from the complaints of failing vision, as if there was a veil or blur over the page when reading. According to Jacobson (New York Mcdical Journal, July, 1901), inflammation of the retina occurs in 10 per cent. of the cases of Bright's disease, and is known as albuminuric retinitis. significance is very important, as it is well known that when these changes take place in the retina the possible duration of life is seldom more than two years.

Its

I made the diagnosis of Bright's disease with the ophthalmoscope in the case of supposed hysterical amblyopia and in three weeks from that time the patient, a young girl, passed away. The importance of this examination must be obvious to all, and if we have the pupil dilated with any brief mydriatic, and retinitis is present, then, as we look into the eye with the ophthalmoscope, we will see a great difference in the appearance of the retina from that of the normal. The edges of the disk will not be clearly seen; the veins will be dark, tortuous and dilated; the arteries, partly covered by the swollen retina, cannot be followed to the periphery and seem to be covered by white masses, like clouds, that are partly due to exudation and oedema of the retina. Then we find various dark, irregular spots, small and large, scattered about the retinal field, due to hemorrhages from rupture of some of the small vessels of the retina. In some cases these hemorrhages may be very large and in others very few or even entirely absent. White patches about the retina. are frequently seen, in which we note that the edges are not very clearly marked, but shade off into the retina and the small blood vessels seem to pass through them. Fatty degeneration of the retina is also present and shows itself as a peculiar stellate appearance in the region of the macula or yellow spot. These minute spots are arranged in rows, radiating outward from the center of the macular region, not always perfect, as they may be absent. on one or the other side, but when present with the other appearances are almost positive evidence of kidney disease. Knapp states that this degeneration of the retina may be seen in tumor of the brain, but I have not been able to see any cases yet that were not associated with albumin in the urine. The swelling of the retina may extend so as to involve the nerve-head or disk, with blurring of its outline and reddening of its surface; in advanced cases this swelling may resemble "choked disk" or papillitis, but the presence of the stellate figure in the region of the macula, the white patches and the hemorrhageswill confirm the diagnosis of Bright's disease. I do not know of any more important use of the ophthalmoscope to the practitioner of medicine than the diagnosis of the condition of albuminuric retinitis. The changes that may be shown in the early stages. of this disease may present a slight congestion and tortuosity of the vessels, with blurring of the retinal and the edges of the disk; this condition associated with diminished vision would lead us to suspect diseases of the kidneys and at a time when it may be amenable to treatment; but when we have the characteristic picture as presented, then we can only say that the prognosis is very grave, with probably