Some measure must be used to protect the tongue. A cork or a rubber pad between the teeth is the common practice. I am very favorably impressed with a handkerchief, used as a bit, holding the tongue down and out of the way.

The after-care of the patient is the care of a case with the symptoms of Bright's disease possibly in its pre-organic period, but the same as if she had not been pregnant, excepting that the anemia is more marked than in the early stage of Bright's disease in the non-pregnant.

LOUISVILLE.

A CONTRIBUTION TO THE STUDY OF EYE-STRAIN AS A CAUSE OF NERVOUS DISEASES.*

BY A. G. BLINCOE, A. M., M. D..

Two years ago I prepared a short paper on eye-strain, which was published in the Transactions of this society for the year 1896, in which I gave the results of treatment of sixty-one cases of headache by correcting refractive and muscle errors, about forty per cent being cured, and fifty per cent benefited, making ninety per cent cured or benefited. In looking over the notes of my cases for the past two years I find I have treated seventy-three cases of headache and various nervous troubles by the same methods, with fully as good results. Of these there were four cases of neurasthenia, two cured and two benefited; two cases of vertigo, both cured; one case of chronic chorea of a year or two's duration, and one case of cramping of the muscles bordering on same, both cured; one case of cerebral hyperemia, with mental derangement and delusion, cured; this case, however, had bromides and ergot in addition to the eye treatment; two cases of epilepsy, both of which seem to have been benefited-one has gone three or four months at a time without a spell and without medicine, though for years she averaged two or three a week; the other has had no spell for over three months, having previously had them every three or four weeks. Both of these cases have, in addition to their ametropia which has been corrected, a muscle error, and are still under treatment for the latter. The remainder of the cases treated were headache sufferers. One of these, a young man, had been going on crutches for two years prior to the time I fitted him with a pair of spectacles over a year and a

*Read at the May meeting of the Kentucky State Medical Society, 1898.

half ago. A few months ago he called to see me, saying his headache was entirely cured and that he had laid aside his crutches, having gained in weight, strength, and general health.

An old lady, sixty-eight years of age, came into my office last August, saying she wanted me to cure her headache with a pair of spectacles, as she knew of several whom I cured in that way. I told her that it was mostly younger persons whom I cured, but made an examination of her eyes and found she had, besides a refractive error, compound hypermetropic astigmatism, sixteen degrees of esophoria, an amount usually thought to require an operation. I, however, loaned her a pair of prisms to wear a week or so. She then reported them comfortable and beneficial, so I ordered her a pair of spherocylindrical lenses ground with prisms of required strength, base out, with a reading glass in the form of bifocals, for constant wear, and I am reliably informed by one of her neighbors, who came to me to get fitted with glasses for the same purpose, that she is entirely cured.

One of the cases of vertigo with occasional "blind headaches" had been paying monthly doctors' bills for years, but has had no trouble since putting on spectacles about four months ago. This case was peculiar in having near-sighted astigmatism in one eye and far-sighted in the other.

A clergyman, thirty-five years of age, single, has been a neurasthenic since boyhood, and has for years been troubled with profuse sweat ing of the feet, for which he had tried numerous remedies, including strychnia in full doses. Nearly four months ago I fitted him with a pair of glasses, and in a recent letter, in reply to one that I had written him, he says: "I find the glasses comfortable, and would find it uncomfortable without them. Have worn them constantly. My general health has improved considerably, and I can stand twice as much work as I could before I got the glasses. My feet do not perspire as much as before, and I am not troubled as often with my heart as formerly. I believe I am improving all the time and that the improvement is due to the glasses." I hope to hear, in the course of a few months, of still further improvement in this case.

Last summer I was called to an adjoining county in consultation, and before leaving the place a farmer of the neighborhood, twentyeight years old, married, who complained of dyspepsia, headache, vertigo, insomnia, and palpitation of the heart, asked me to prescribe for him. I suggested that he come to my office for examination. The

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 persons from 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."

BARDSTOWN, KY.

THE INADEQUACY OF THE KIDNEY IN ITS RELATION TO MEDICINE 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. For discussion see p. 444.