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local physician said to me, as we left together, that there was no use paying any attention to him as he went around to all the doctors without benefit. Shortly afterward he called at my office, and I found he had refractive error and prescribed glasses. Lately I saw him, and he said he was about relieved of all his troubles and had gained thirty pounds in weight.
A young farmer twenty years of age, in the same neighborhood, had been in poor health for a year or two. In June last he came to me complaining of obstinate constipation, headache, sleeplessness, pain in the back and one hip. I examined his eyes and found refractive error, which was corrected. A month or so ago he called, wearing his glasses, and said he was entirely well and had gained fifteen pounds in weight.
Of the sixteen cases above mentioned only five were conscious of any trouble with their eyes.
If it were more generally known that such an exceedingly large per cent of mankind are ametropic or heterophoric there would, perhaps, be less difficulty in realizing the vast amount of ill health due to this cause.
In the large number of persons having hypermetropia, astigmatism, or muscle insufficiencies, there is a strain of the ciliary or external eye muscles in focusing and fusing images which is continuous while the eyes are open. This constant strain may be and often is a prime factor in the causation not only of many of the ordinary eye diseases themselves, but also of many of the functional nervous diseases, such as headache, vertigo, nausea, or nervous dyspepsia, insomnia, neurasthenia, chorea, epilepsy, insanity, chronic, gastric, and digestive derangements and various obscure nervous diseases.
In many of these reflex troubles the patients themselves do not know that they have any eye defect at all, yet many remarkable cures have been made by the proper adjustment of lenses combined with treatment of the external eye muscles in cases needing it.
While the general practitioner may not be able to do this work himself, he can in many cases satisfy himself of the cause of the trouble and give temporary relief by paralyzing the accommodation by the use of atropia. It should be used of the strength of four grains to the ounce in the young adults and half this strength in children.
One drop should be put into the outer corner of each eye three times a day after meals to prevent constitutional effects, and it sometimes requires to be continued from three to seven days to fully paralyze the ciliary
muscle. If there is no trouble with the external eye muscle this will usually mitigate or relieve the symptoms while the effects of it last, but it should be used with caution if at all in persons toward or past middle life, on account of the danger of glaucoma. Every physician using it should therefore familiarize himself with the more prominent symptoms of this disease in order to be able to recognize or .guard against it. It is said to be rare before the fortieth year. I generally use the gelatine discs of homatropine and cocaine in thirty to forty-five years of age.
Should the atropia test indicate eye-strain as a cause of the trouble, you can then send your patient to a competent refractionist for permanent relief, and if you have had no previous experience in this line you will often be surprised at the satisfactory results. It should be borne in mind, however, that the glasses must be worn.
In regard to refraction work, Noyes, in the preface to his work on diseases of the eye, says: “To the study and experience needed in general medicine must be added, for proper treatment of the eye, a considerable acquaintance with physics, mathematics, and physiological optics. The knowledge which they furnish finds its chief application in unraveling functional disorders of sight, viz., errors of refraction and accommodation and motility.”
Some natural mechanical talent also comes in well in fitting frames. With all these qualifications the refractionist must be fully equipped with the necessary instruments of precision. I do not think, from my own experience, that any one can get the best results in all cases without the use of the ophthalmometer and phorometer, yet I recently had in my office a young man who had lately been examined by several oculists in two of our large cities who said they had never before seen either. In his case an astigmatism in both eyes had been overlooked by the previous examiners, and also a slight muscle error, which disappeared after wearing the cylindrical lenses a while.
The shadow test is also very useful in some cases.
The ophthalmoscope is a necessary instrument for examining the interior of the eye, but is of very little use in accurate refraction work. While the above-mentioned instruments are useful and some of them necessary, a good set of test-lenses and atropia in proper cases are the main reliance.
With all these qualifications and equipments, it requires, including the time of waiting on the mydriatic, two to five hours in each case
and sometimes considerable patience to work out these cases properly, and even then in some cases repeated trials have to be made before the best results are obtained.
My experience, which is only that of an average practitioner who took up refraction work in connection with a general practice several years ago, seems to justify me in indorsing the views of a medical writer, who says of eye strain as a cause of disease and its treatment: “There are few medical truths that have been discovered fraught with more possible and incalculable good to mankind. . . It is a therapeutic measure that depends for its exercise upon an exactness of knowledge of delicate, mysterious, physiological and psychological functions that few possess, and upon a subtle discrimination and judgment with which by character and education few are endowed.”
THE INADEQUACY OF THE KIDNEY IN ITS RELATION TO MEDI
CINE AND SURGERY.*
BY WILLIAM BAILEY, A. M., M. D. Professor of Materia Medica, Therapeutics, and Public Hygiene in the University of Louisville.
I have been impressed for a long time with this question that I had proposed for you. To fully appreciate it I would say, perhaps first we ought to take into consideration the importance of the functions of the kidney. Of all the organs of elimination I presume that more labor and more responsibility are placed upon the kidney than all other organs of the body. It is an organ whose sole and chief object, so far as we know, is elimination, maintaining the purity and integrity of the blood. I believe, moreover, that many people are born with an inferior power so far as the kidney is concerned; that they are naturally handicapped by insufficient elimination. I believe that many of the well-defined diseases that we are called upon to treat are largely due to defective elimination.
I might say in this connection that the kidney indirectly performs an important part in nutrition, for I believe that the removal of waste products is as essentially requisite for good nutrition as the supply of new material can be, and oftentimes our purpose and work in the treatment of diseases not well defined is to increase the elimination. And I have been impressed for a long time that in such cases, where elimi
* Read before the Louisville Medico-chirurgical Society, April 8, 1898. Por discussion see p. 444.
nation if not defective is at least not active, that the patient when ill is handicapped by virtue of that fact. I have also been impressed that, in addition to this, defective elimination was a very important factor both in medicine and in surgery.
I simply want to bring out the points sufficiently to suggest a free discussion so that many of the points may be emphasized and other important ones brought out.
I believe it is on this account, with elimination already defective, that we get conditions that were discussed at the last meeting of this society, that condition which occurs during gestation, when by pressure or other influences this function is interfered with, and at the climax at its completion, or even before the accumulation of effete material in the blood, is so great as to bring about the conditions we discussed at that meeting, viz., puerperal eclampsia.
I think oftentimes in very many diseases characterized by excessive waste that this defective elimination is an important factor-in all of those where disintegration of material has been so great that elimination has not kept pace with the amount of products of disintegration that are thrown into the circulation-thus affecting the centers unfavorably. So it is in our work oftentimes, in the treatment of many diseases medically, that we have to use measures to increase this elimination, if possible, to make it keep pace with the additional waste that is going on, so that these products may not be accumulated in the blood. Then I am sure that when we come to the field of surgery that oftentimes an operation, capital it may be, that would otherwise be successful is handicapped by this very feature; that possibly the shock of the operation of itself will serve for the time being to lessen the integrity of this function on the part of the kidney. It is in this way too, no doubt, the kidney, perhaps being already disabled and with increased work required of it, that we get suppression of the urine and conditions like this that come up after severe surgical shock.
It is true that the kidney is responsible for normal elimination, and we know likewise that most of the remedies used are largely eliminated from the system by means of the kidney, and I believe that oftentimes we get a surcharge of the medication, we get a superabundance of the remedy in the system, because the kidney has not done its work as usual in eliminating the drug. With a kidney that is not operating, many of the drugs that ordinarily are rapidly eliminated by the kidney will not be so eliminated and we will get an accumula
tion of the drug in the system, and perhaps do harm rather than good. And it is true that the function is often materially interfered with because the kidney is required to eliminate the drug.
I think the kidney is responsible for elimination of many of the drugs that we give, and I would mention particularly the use of ether as an anesthetic. Under these conditions, unfavorable for elimination, the kidney is overstimulated it may be, or at least its function is materially lowered by the agent going to the kidney in such large quantities through the circulation, the kidney undertakes unusually rapid elimination of it, resulting in impairment of its function—the kidney is disabled by the action of the drug.
There are many questions along this line that have had my attention for a long time, and without additional argument I simply want to bring the question properly before the society and ask for its discussion so as to emphasize in the lines of work that the various members are doing their estimate of the importance of the functions of the kidney and how the difficulties may be overcome.
I simply submit these remarks for your discussion.
Reports of Societies.
LOUISVILLE MEDICO-CHIRURGICAL SOCIETY.*
Stated Meeting, April 8, 1898, the President, Frank C. Wilson, M. D., in the chair.
Operation for Femoral Hernia. Dr. Ap Morgan Vance showed a hernial sac with some omental contents, removed from a lady forty years of age who had had hernia for twelve years. It has been irreducible and occupied the right groin. The variety of hernia could not be made out at first, but at the operation it proved to be femoral. After opening the skin, which was very thin, the sac was separated and was found translucent; floating in it were a number of little yellow bodies. I opened the sac and many of these little bodies came out; they look something like hydatids, but are probably composed of fat. I have never before encountered any thing like these in a hernial sac. The major portion of the contents of the sac was water.
Stenographically reported for this journal by C. C. Mapes, Louisville, Kentucky.