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to give one or two hints, without claiming any originality for them, that may be useful in some cases. No reference shall be here made to pain producing cases of eye disease, presenting perfectly clear pathological lesions-conjunctivitis, keratitis, iritis, choroiditis, etc., or to affections of the eyes produced by and dependent upon morbid conditions of the general system-syphilis, rheumatism, kidney disease, or organic affections of the brain. If the derangement is due eye strain there will be found a well defined cause for it in the eyes or the ocular muscles. There will be found either an anomaly of refraction, or an anomaly in the muscle balance. It matters little what form of anomaly this may be, or how great the degree, for the purpose of making a diagnosis by exclusion; the main object is to ascertain whether an anomaly exists. The importance of the anomaly is entirely a different matter, and it is for the oculist to determine the extent and the importance-not such an easy task at times.

It is, of course, a very easy matter to refer the patient to a competent oculist to make the examination, and the oculist certainly will raise no objection to such a procedure; but the patient sometimes does raise an objection to being examined at so much per by different specialists for the sake of finding out what the matter is, and he entertains the opinion that his doctor should decide beforehand the person to whom he should be sent for relief of his troubles. We shall not here discuss how much justice there is in this claim. But we will ask the rather pertinent question, is the general practitioner competent to decide the matter? I claim that he is, and if he is not he may become so with very little trouble. It is claimed that ophthalmology is the most exclusive of the specialties. It is, and profound are its mysteries. The average student of medicine gets through this department of his work with just enough to pass, and then shudders at the thought of what might have been. In practice, unless hard pushed, he will have none of it, and he is right. But, after all, it is the details that are difficult, not the fundamental propositions. The writer is a firm believer in specialties, and he would not yield an inch of his territory to the general practitioner, nor would he encroach an inch into the general practitioner's field, but it is not our object to claim that the practitioner should treat diseases of the eye, but that in certain given cases he should be able to recognize certain anomalies of these organs that may be the cause of the disturbances for which his patient seeks relief.

It may be stated that, with few exceptions, all symptoms producing disorders of the visual organs (pathological conditions in

cluded, but not here referred to) recognize some more or less well defined anomaly in the formation of the eye, or in the action of its muscles. And the question before us may be thus stated: Is there a simple method by which these anomalies may be detected by one who is not an expert in ophthalmological technique?

The ophthalmoscope, in the hands of any one moderately expert, is of great service-first, because by its aid he will be able to ascertain whether any pathology exists, and secondly, because he can detect errors of refraction. The ability to measure refraction with the ophthalmoscope is not a very common accomplishment, and the detection of small errors of a half diopter is most difficult even for experts; and these slight errors, especially when of the astigmatic form, frequently cause most distressing asthenopic symptoms. For the second purpose, therefore, the practitioner can not rely upon this instrument. The test card and box of lenses remain. The objection to this procedure is that it is complicated and difficult, and the outfit is expensive. This objection is valid when the purpose is to refract a case, but when the object is simply to ascertain whether there is an error of refraction or not, or whether there is muscle balance or imbalance, the matter is comparatively simple. The initial step in testing a case is done with four lenses and a Maddox rod, and with this small outfit and a test card the practitioner may determine what for him is the main object-whether his patient's eyes are normal. The outfit for such a test is very simple and inexpensive. In place of the large test case, a small one containing five* pieces is all that is required, and a test card, either of the ordinary size or one having letters to be read at thirty, twenty and fifteen feet. For the muscle test, a lighted candle, or ordinary gaslight turned down to a small flame, is all that is necessary. The technique is as follows:

Placing the patient with both eyes open at twenty feet from the light, and in such a position that the eyes will be on a level with it, the Maddox rod is placed before one eye, first with the axis of the rod perpendicular. The patient will then see with this eye a long line of dispersion colors-running horizontally-and with the other eye the light will be seen. If the line of dispersion colors runs through the light, there is no manifest imbalance of the superior and inferior recti muscles of the two eyes. If it does not run through, manifest imbalance exists-hyperphoria.

*These test cases may be obtained of F. A. Hardy & Co., 131 Wabash avenue, Chicago.

2. Placing the Maddox rod so that the axis runs horizontally, a line of dispersion colors will be seen extending perpendicularly. If the line runs through the light there is lateral balance, externi and interni. If it does not, there is lateral imbalance. If the dispersion line is deviated to the side of the eye over which the Maddox rod is placed, there is inturning of the eyes-esophoria. If the dispersion line is deviated to opposite side of the light, there is outturningexophoria. Example: If the Maddox rod is placed over the right eye and the line of dispersion is seen to the right of the light there is esophoria. If to the left of the light, there is exophoria. Deviations of this nature are fruitful sources of nervous disturbances; but it should be borne in mind that they very frequently are caused by errors of refraction. The second test is with the card. With good illumination, normal eyes should easily read the line marked 20 at twenty feet; that marked 15 at fifteen feet. This test should always be made for each eye separately. Inability to read them signifies that vision is not normal. The test may here cease. If the line is readily deciphered, there is normal vision. This excludes any perceptible amount of myopia, but leaves a possibility of hypermetropia and slight degrees of astigmatism. Place before the eye the lens marked 0.50 spherical. If it blurs the line, there is no manifest hyperopia. If no change is noticed, or there is improvement, hyperopia exists. If +0.50 spherical blurs the line, place before the eye +0.50 cylindrical, with the axis perpendicular. If it clears the line there is astigmatism. If this blurs, try the axis horizontally, then obliquely midway between the two. If improvement is noted there is hyperopic astigmatism. If in one direction it blurs and in another no change is noted, there is astigmatism. If nothing satisfactory has been accomplished with these lenses, try -0.50 cylindrical. Place it before the eye with the axis horizontal, then perpendicular, then in the oblique position. If in any of these positions there is improvement in vision there is manifest myopic astigmatism. The word manifest is used in all these cases advisedly, because the manifest error is not necessarily the true error; but for the purpose in hand, the question whether an error exists or not 13. solved.

I have purposely left the fourth glass in the case for the last, because its findings are frequently untrustworthy. The elements that contribute to make this test uncertain need not here be discussed, but the fact should be borne in mind. If the letters are rather indistinct, and this lens clears them up, there is manifest myopia, but we

should not lose sight of the fact that many young emmetropes and hypermetropes accept a negative glass. A red glass has been added to the case, I confess, more for the sake of symmetry than for any other reason. It is used for detecting latent diplopia-double vision. In some cases, when ordinarily one object is seen with both eyes, when tested with a red glass over one eye there will be double images. The significance of this phenomenon it is not our purpose to discuss -suffice it to state that the Maddox rod will, for the object in view, answer the purpose of detecting muscle anomalies.

Resuming Test the case for muscle balance. If there is imbalance, you have found a datum. Test with card: First-If the patient can not readily decipher 20/20, vision is not normal. You need not pursue the investigation any further. Second-If the patient can read 20/20, use the lenses as detailed above. If he accepts any of them, there is an anomaly, and bear in mind that small anomalies frequently give rise to large disturbances. Indeed, at times it would seem that they are in inverse proportion one to the other. By the use of these simple tests you will be enabled either to eliminate the eyes from the problem, or you will be furnished with certain definite data concerning them. In both cases the tests will assist you to determine whether it shall be neurologist or ophthaimologist.

36 WASHINGTON STREET.

EYE SIGNS IN MIGRAINE.

BY DR. CHARLES H. BEARD, CHICAGO.

In the brief space of ten minutes allowed for the discussion of this subject, viz., the eye signs in migraine, let us set aside the subjective visual phenomena, which are aften associated with the disorder in question, and the errors of refraction, which are so dominant a factor in its etiology, and which have been so voluminously commented upon, and let us, rather, look for an ophthalmoscopic picture that we may consider instead. For there is such a picture and replicas of it are by no means uncommon.

In this connection, then, I would call your attention to a subtle, anomalous condition of the choroid, frequently met with, less frequently recognized, and most frequently ignored or overlooked. I refer to a choroid that is meager and thin; that is, one whose chief elements-blood vessels and pigment crystals, or granules-are not only too sparse but also too small. The relative absence of these ele

ments constitutes the more striking features of the picture in question. I will attempt, with the aid of a drawing made from life, to describe it (Fig. 1).

As you all know, the outer layers of the retina depend for their nourishment upon the choroidal circulation, and, in great measure, for their proper function upon the choroidal pigment, in the sense that the polygonal cells belong to the choroid. It must be remembered that a fully developed, or normally appearing retinal vascular system, and a retina otherwise without visible defect does not neces

Fundus of left eye in case of a six year old girl, showing most of the features referred to in the accompanying text.

sarily mean a healthy retina, for the essential outer layers or epithelial portion depend for their sanity upon a healthy or well developed choroid. It is here, then, that we are to look for the signs referred to and, as before intimated, these are easily overlooked.

The condition is distinguished by the clearness with which the veins and arteries of the choroid can be seen, and the splotchy and stippled coloring of brown, which is the choroidal pigment. Where