We constantly see cases of hyperemia of the conjunctiva with or without discharge. Paresis of accommodation is frequent, though less severe than that following diphtheria, although it seems to take longer to recover. Cases of embolism of the arteria centralis retinæ are recorded by Hosch and Coppez. Pronounced optic neuritis and neuro-retinitis, single and double, have been reported by Cross, Hartridge, Snell, and many others, including myself. The fundus presents varied appearances, in many cases seeming like an ordinary optic neuritis, in others presenting small brilliant white dots between the optio disc and the macula. These dots will sometimes disappear. The defect of vision varies, but in some cases the patient becomes totally blind.

Before going further I should like to dwell a little upon the importance of the ophthalmoscope as a means of diagnosis. The great charm, at least to my mind, of ophthalmic practice is the precise and definite nature of the work. We can, in the great majority of cases coming before us, give a definite diagnosis, a definite line of treatment, and a definite prognosis. This is undoubtedly due in a large measure to the proper and skillful use of the ophthalmoscope. Unfortunately, I fear that many practitioners do not keep up the use of this instrument. All must have some knowledge of its use, for nowadays a student cannot present himself for examination, even for the Membership of the Royal College of Surgeons, without a certificate of having done ophthalmic work. Still, there is a holding back in the use of this most helpful instrument, although to my mind nothing is so simple and easy. By retinoscopy, or the shadow test, we can in a few minutes find out not only the quality of an error of refraction, but we can estimate its quantity with the greatest accuracy. By the direct method of ophthalmoscopic examination we can scan the retina, the optic nerve, and the choroid. A few drops of homatropine hydro-bromate instilled into the palpebral sac about half an hour before the examination renders this quite a simple matter, which can be learned from any modern text-book.

One of the best instances of its use is, I think, in the detection of malingerers. Although the conscription is not in force in the British empire at the present time, yet we find many persons who believe or pretend that they cannot see. They generally complain of one eye only. Many of this class of patients

belong to the school-girl type, between the ages of 10 and 18 years. We frequently see them both in hospital and in private practice. A girl is brought by her anxious mother, who states that the girl cannot see with one eye. We examine the pupils and find them both equal, active to light, and normal in size. By retinoscopy we find there is no ametropia such as would cause blindness. By the direct ophthalmoscopic examination we find the fundus absolutely normal. The room has been darkened for this examination and the patient cannot very well see what we are manipulating. An empty spectacle frame capable of holding lenses is placed upon the patient's face, and she is told to read illuminated test-type in the corner of this dark room; then, both eyes being open, a strong convex lens is placed in front of one of the eyes so as to obscure its vision, and she is told to read again; then the other eye is treated in the same way. She does not know at the time that this glass obscures the vision. This is generally sufficient to confuse the patient to such a degree that she will read all the letters with either eye, not being quite sure with which eye she is actually reading. Having thus proved to our own satisfaction, that the patient can read with either eye, we resort to Snellen's colored test-types, which are red and green. We also place a red and green glass in front of each eye respectively, and this isolates the eyes so that one eye can only read red and the other only green letters. Now she is told to read and she will at once read both the red and the green letters, showing that both eyes are working and that she has been mistaken about her sight.

see.

In these young people there seems to be no definite motive for malingering, and they really seem to think that they cannot I never accuse them of untruthfulness, nor do I think that it well to tell even the parent that the young lady is untruthful. The parent is greatly distressed, and often not a little indignant. It is, I think, better to be silent and to advise the parent to withdraw all apparent sympathy. The condition is, no doubt, an early phase of hysteria, although very different from actual hysterical amblyopia.

Older women come with the same kind of a complaint. In men the motive is often more apparent, but even then they fall into the same trap by the mystifying treatment I have just described, and by the time we come to the colored types, they will read the red and green letters indiscriminately. I have

recently had several cases where by the use of the ophthalmoscope and the colored types just mentioned, I easily proved to my own satisfaction that I was dealing with a malingerer, and I could mention many instances showing the great value of the ophthalmoscope in forming a correct diagnosis where it would have been difficult to do so without a knowledge of its use. If the instrument is so useful in this trivial subject of malingering how much more valuable must it be in the detection of actual disease.

Take, for instance, renal disease. Nothing is more common in either hospital or private practice than the discovery of albuminuric retinitis. The patient may be quite unaware of any trouble beyond defective sight, and the ophthalmoscope demonstrates the existence of slight optic neuritis, white spots around the macula and hemorrhages scattered over the fundus of one or both eyes. The urine is examined and found to contain albumin and casts galore. These albuminuric affec tions of the retina are occasionally found in all forms of nephritis. They are most frequent in the later stages of contracted kidney, and when found in such cases they indicate not only a loss of vision, but also a probable loss of life in the near future.

Lastly, eye symptoms of the greatest possible value in the diagnosis of diseases of the nervous system, intra-cranial and otherwise; but, alas, my time has expired and I should require a longer period for the development of this aspect of ophthalmology.

Gentlemen, I hope I have not wearied you, and before I finish this expiring effort of my year of office, let me thank you for the honor of having been elected to act as your president for the past year.

THE death rate of Dublin has reached such an excessive figure (49 per 1,000) that the Lord-Lieutenant of Ireland has ordered an official inquiry into its causes.-Med. Record.

NEARLY 8,000,000 persons in Germany belong to the Krankenkassen, or, in other words, are insured against illness. Onethird of these reported illness in 1898, the average duration being seventeen days, which, taking the average of wages at only fifty cents a day, means a loss of nearly $24,000,000 a year. -Med. Times.

Sections.

PSYCHOLOGICAL MEDICINE.

Under charge of ANTRIM EDGAR OSBORNE, M. D., PH. D., Superintendent California (State) Home for the Feeble-Minded, Eldridge; Professor of Diseases of the Mind and Nervous System, College of Physicians and Surgeons of San Francisco.

The Sensation of Pain.-Experiments in psychology have demonstrated: Women are more sensitive to pain than men, but this must not be confounded with the ability to bear pain, which is greater in the former than in the latter sex. American professional men are more sensitive to pain than their professional English and German colleagues, and American business men are less sensitive than either. The left hand is more sensitive to pain than the right.

Thyroid Extract in Insanity.-Mabon and Babcock, in the American Journal of Insanity, offer the following conclusions:

First. The dose depends entirely on the individual. In some cases 25 grains per day will be necessary to bring about circulatory or temperature reaction. In others the same results will be had with 5 grains t. i. d. Each case is a law unto itself.

Second.-Essential for the best results that the patient be put to bed and kept there, not only during the whole treatment, but for a week at least after.

Third. The treatment should be continued for at least thirty days.

Fourth.-Must not be discouraged by failure in first adminis tration, but resort to many subsequent trials. The digestive tract is not always tolerant of large doses. Early in the treatment nausea is often present, and later vomiting occurs in about one-fourth of the cases. Diarrhoea and pronounced gastrointestinal irritability sometimes follow.

Fifth.-Best results are obtained in cases of acute manis, melancholia, puerperal and “climacteric” insanities, stuporous states and primary dementia, particularly where they have failed to respond to the ordinary lines of treatment.

Sixth.-High temperature reaction is not necessary; the average among recorded cases (men) was 99.6°

Seventh.-Physical improvement is to be expected, whether mental improvement takes place or not.

Eighth.-Proportion of relapses less then in any other line of

treatment.

As to the specific action of the thyroid extract, it is claimed that in its action on the nervous system, the variable symptoms it gives rise to are dependent upon the idiosyncrasies of the case in hand. Many observers confirm the opinion of Bruce, that it is a direct cerebral stimulant. It is probable that it supplies some substance demanded by brain cell nutrition, accounting for its specific action in myxedema. A recent theory of its action is that thyroidism is the direct result of toxins produced in the manufacture or extraction, and that mental improvement may be classed with such as occasionally follows typhoid, erysipelas, and other infectious diseases.

Anthropometry and Abnormality.-Delicate, slender people are more subject to typhoid fever than to consumption (Hildebrand), and are also more inclined to nervous diseases than other people.

The relation of the size of the heart and the circumference of the arteries is gradually changed during the growth of the body, causing a consequent variation in blood pressure. This is specially true at puberty when the heart increases very fast in volume, for the arteries increasing much in length with the increase in length of the body, but little in diameter, demand greater work from the heart. Thus there is a direct and important relation between the growth of the body and the growth of the heart. Should this growth be irregular or abnormally fast, serious difficulties may arise, and Beneke has endeavored to show that herein lies the cause of the development of consumption at puberty.

Dolichocephaly (long-headedness) increases in children as ability decreases. A high percentage seems to be a concomitant of mental dullness.

As circumference of the head increases mental ability increases, race for race; children of the non-laboring classes having heads larger in circumference than children of the laboring classes.

Among the whites head circumference of the boys is larger than of girls, but among the colored children, girls excel the boys slightly, and at all ages excel white girls.

For a certain period before and after puberty, girls are taller and heavier than boys, but at no other time.

Bright boys are, as a rule, heavier and taller than dull boys.

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