April 15, 1906. Child has had no vomiting, has steadily increased in weight and has learned to read. Prescribed her full correction, one diopter, axis 90 degrees. She has since remained well except on one occasion, when she had an attack of vomiting caused by the breaking of her glasses; vomiting occurred before the prescription for glasses could be refilled.

CASE III-Miss Mary E., aged twenty-four. Referred to me for treatment by Dr. Weisser, with the following history: External and ophthalmoscopic examination of eyes normal. Muscle balance shows one-half degree of exophoria at six meters, with two degrees of esophoria at reading distance. Atropine retinoscopy and test case show compound hypermetropic astigmatism. Prescribed for constant use: Right eye, 0.75 of a diopter, left eye, 0.75 of a diopter, with 0.75 of hypermetropic astigmatism, axis 60. Physical examination showed tenderness in the epigastrium and tenderness opposite, and, to the left of the twelfth dorsal vertebra, pain immediately following the ingestion of food. Diagnosis, gastric ulcer.

She was given the rest cure, following which the symptoms, tenderness, pain, and discomfort after meals, were relieved, glasses worn during rest in bed.

CASE IV.-Miss G. Gives a history of having had stomach trouble for four years; has almost constant eructation of gas, which is her principal symptom; complains of pain in the right side, for which she has been treated, or rather massaged, by a so-called osteopath for some months; both this and medicinal measures have failed to haye any effect upon the symptoms. On inquiry it was found that she had been examined by an ophthalmologist seven years ago, wore glasses for three years, when they were discontinued; from about this time we have a history of stomach trouble. Suspecting, or rather to eliminate any eye strain, I referred her for examination to Dr. Weisser, who makes the following report:

"External and ophthalmoscopic examination show eyes normal, muscle balance three degrees of esophoria at six meters. Homatropine retinoscopy and test case show compound hypermetropic astigmatism. Prescribed for constant use: Right eye, sph. plus 0.50 of a diopter, cyl. plus 0.87 of hypermetropic astigmatism, axis 90 degrees. Left eye: Sph. plus 0.50 of a diopter, cyl. plus 87 of a hypermetropic astigmatism, axis 90 degrees."

general health, she says, is as good or better than it has 'ever been.

CONCLUSIONS.

1. That neurasthenia gastrica, or nervous dyspepsia, is frequently due to, or complicated by, eye strain.

2. That other gastric disturbances are sometimes aggravated by eye strain.

3. That along with other points in the examination of gastric cases this should not be neglected.

4. That when eye strain is the cause of gastric symptoms the relief by proper refraction is prompt and satisfactory.

DISCUSSION.

DR. R. D. CLIPPINGER, Bellefontaine, O.: I am sorry I did not get to hear the first part of the paper. I am very much interested in this subject, because I have found great relief to follow the correcting of eye-strain. My experience has been very decided in telling me that eye-strain often produces all the symptoms of an old so-called chronic gastritis, and I am glad that another man saw fit to bring this to our attention. It has seemed to me the general practitioner is apt to ignore the eyes. Perhaps the eye specialists have talked so much in times past that we have become rather disgusted. But I think it would be well for us to remember that the eyes, which are used every moment in the day, which keep up a constant strain and waste of energy, produce some very marked nervous manifestations.

DR. MARK D. STEVENSON, Akron, O.: To an ophthalmologist it is indeed gratifying to hear such a report from a specialist in internal medicine. About six years ago I prepared a paper on the relation, as to cause and effect, between eye-strain and gastric disturbances, and some of the claims there made, which many observers have since substantiated, were ridiculed.

Many times symptoms that are said to arise from the stomach do not do so. Experience proves that very many patients are relieved of nausea and vomiting by wearing the proper lenses, and that these patients, on laying aside, losing or breaking their lenses, again develop the same symptoms. I have patients now who, if they break their lenses or lay them aside for half a day, experience much nausea and sometimes attacks of vomiting. The much-abused stomach is undoubtedly blamed for many symptoms of which it is not the source, simply because the patient refers his symptoms to the stomach. Frequently these same symptoms undoubtedly arise from a disordered condition of the alimentary canal, so that ophthalmologists

and others should be very careful about overdoing the old, laughed-at "nerve-leak" and other explanations of reflex phenomena. Although men have become very tired of hearing about "wastes of energy," etc., it is something that needs reiteration, as shown by the fact that many do not consider reflex causes, but attach the blame to the organ in which the symptoms are experienced. Reflex symptoms from the eyes arise not only from astigmatism and hyperphoria, but also from imbalance of the twelve external muscles which move and direct the eyes. Vertical imbalance is an especially common cause of many distressing symptoms. Even if defects in eyes are properly corrected by lenses, they must accommodate, make a muscular effort, in order to see close objects, and quite an amount of effort of the external muscles must be made to direct the eyes to a point close to them. By looking at an object a few inches distant anyone may experience the strain it causes the eye muscles. Very improperly fitting lenses placed before even normal eyes, which would make conditions similar to defective eyes, will soon produce much distress. In giving the rest cure the patient should be prohibited from reading. Atropine locally will make eyework impossible.

DR. GEO. P. SPRAGUE, Lexington, Ky.: As bearing upon the subject under discussion, I think of two points not yet brought out. One is that the so-called gastric disturbances in neurasthenia are very often really reflex disturbances due to vertigo; in one case a lack of equilibrium due to a visual defect; in some other cases dependent upon middle-ear congestion or disease. Another point that I find very commonly in sending neurasthenics to oculists for correction of eye-strain, is that until the attention of the oculist, who may be a man of great renown or superior ability, is called to the possible psychic connection between the pa

tient's condition and the visual defect, he very often fails to give the full correction, which he can do and does do after that matter has been called to his attention.

DR. JONES (closing): I am very glad to have this question discussed as it has been. There are one or two points that I would mention. First, that in giving the name to this condition of neurasthenia gastrica due to eye-strain, I took into consideration that the cause was not a stomach disturbance per se, but was a reflex condition, a nerve irritation due to eye-strain. Now, one doctor to my left here referred to the secretion of gastric juice, which secretion is largely influenced by nerve stimulation, and nerve strain would be just as likely to increase the gastric secretion as it would be to cause a muscular contraction and vomiting and the other symptoms of gastric neurasthenia. These other exciting causes, such as irritation of the female sexual organs, and shock, and so on. and great excitement, are really more common, it seems to me, than eye-strain. Those who are familiar with the history of dark days in Wall Street will probably know that many men, when the market goes against them, if they have been out to lunch recently will go out and vomit the lunch they have just had, simply because of the nerve strain due to losses or the turn in the market. So that any of the causes that excite the nervous system is likely to bring about gastric symptoms. They also influence other parts of the body, and one of the points I wanted to bring out in the paper was, in these particular cases the stomach is the point of least resistance, and gives way under the strain produced by the condition of the eye. It was interesting to me to see that the cases that need glasses are the ones that have far-sighted eye trouble. The near-sighted person does not make an effort to accommodate and the far-sighted person does.

plain the springing up of the various isms and faith cures of recent times? Said a prominent lawyer to me only a little while ago when called to see him professionally, "I have no faith in medicine." Why is this? Who is to blame for it?

The clamor for a higher standard of training of those who aspire to enter our ranks is both loud and long, and rightfully so, and yet by our attitude we distrust the very thing for which we are contending, viz., a more accurate and scientific method of the treatment of disease. Surely there is no honest reason for this. When we look back over the past and review the rapid progress the purely medical side of our profession has made in five and twenty years, we have every reason for congratulation. We speak in the most enthusiastic terms of the improvements in modern surgery, unmindful of the fact that the advancement in internal medicine has been infinitely greater, and we have every reason to believe the future will keep pace with the past. Not only has the deathrate of all acute infectious diseases been materially decreased, but longevity, as shown by mortuary statistics, markedly augmented.

By reason of this distrust we are missing the fundamental idea of a medical education. Potentially the whole medical fabric has the cure of disease as its culminating purpose. The reasons for this lack of confidence are numerous and not far to seek. In the first place, I think the medical colleges are largely to blame for this unfortunate state of affairs. There has been such a multiplicity of specialties introduced into the medical curriculum in the last few years, and each teacher demanding more time for his particular study because of its vital importance, that something must be crowded into the background. Nor is the end yet. Circulars are being sent to the deans of the various medical colleges from different interests asking for the establishment of a chair in some new specialty or line of investigation. As an illustration, only recently, as you will remember, circulars were sent out by the organization of life insurance examiners asking that to a separate teacher be assigned the duty of teaching the proper method of making life insurance examinations. Another is wanted on dietetics, another on hydrotherapeutics, and lastly on medical economics. These are all commendable, and probably desirable, but where the time is to come from is quite an

other thing. With all these diversified interests clamoring for recognition, is it any wonder that therapeutics and pharmacology, the most important of them all, should be neglected?

More time is required in the laboratory because new lines of investigation are constantly being required of the candidate for the medical degree, as though his entire energies in the future were to be devoted to this work rather than to an accurate and scientific application of remedies at the bedside. Utility and practicability, with broadness of view, is the goal for which he is striving. Do not, I pray you, misinterpret my meaning, and assume that I would in the least degree minimize the importance of laboratory work or laboratory methods. Far from it. On the contrary, their importance cannot be overestimated. Because a proper application of therapeutic methods presupposes not only a correct interpretation of the cause of disease, but equally as well, and of as much importance, the changes that cause produces, and in no way can this be learned except with the aid of the microscope and test-tube. Without this, an intelligent comprehension of what to do in a given case would be out of the question.

Seriously, however, are we not in danger of raising up a generation of laboratory doctors rather than of bedside physicians? While in school they become imbued with the idea that the laboratory training received is the sine qua non, and, possibly after being very lightly lacquered by a brief visit to a German medical center, they return more thoroughly convinced than ever with the idea of making a diagnosis and then letting the patient die to confirm it. What matters it to the man who is sick whether the number of red blood cells coursing through his arteries are a hundred thousand more or less, or that the hemoglobin is ninety or ninetyfive on a scale of a hundred, or that the number of white cells are a few score more or less than the normal standard, or, if you please, whether his opsonic index is in the positive or negative phase? All of this may be necesary in the concrete case, and a knowledge of how to determine it for the most part essential, but what the patient wants to know is, how soon can I be cured? This is the thought that is uppermost in his mind, because to him it is the most essential, and the physician cannot ignore it. The teachers of therapeutics as well as medicine are not

wholly blameless in this matter. The former will often not take that optimistic attitude that is essential to carry conviction, and leaves the impression, not intentional, of course, that there is nothing certain about this, while the latter will go over in the most minute detail the etiology, pathology and symptoms of a given disease and dismiss with a few glittering generalities the treament. In this way the spirit of Oslerism, which years ago ought to have been consigned to the medical junk heap, has practically taken hold of the profession.

In the clinics at the out-patient department, when it comes to the treatment, Mr. A. will be given four onces of No. 2, with directions to take a teaspoonful after each meal, and told to return in two weeks for further instructions, while Mr. B. will be given two ounces of No. 3, and told to come again. Now, what does all this lead to? What is the inevitable result? Step into the private office of many physicians who dispense their own medicines, and you will see a row of bottles, one marked "Uterine tonic," another "Uterine sedative," another "Rheumatic cure," and so on throughout the whole list of diseased conditions from baldness to bunions. Ask your druggist about the prescriptions on his files, and he will frankly admit that many of them are for proprietary medicines from which the label is to be removed before it is sent out to the one for whom it is prescribed. Educated in the way I have indicated, and I do not think the picture is overdrawn, and seeing those to whom the young graduate is to look for guidance prescribing in this haphazard manner, is it any wonder that he falls a victim to the bewitching smile and confident tone of the "sample man," who with his well-learned story tells the doctor how to prescribe for the sick. And if perchance the physician, young or old, meekly admits that he has not used his particular compound and "sure cure," he looks at you with amazement, as much as to say, "Surely, you have been in the mountains with Rip Van Winkle."

To my mind, this is one of the crying evils of the hour, and one that can only be remedied by greater and more assiduous attention being paid to therapeutics and pharmacology. What surgeon among you would listen with equanimity while. some nomadic vendor of surgical instruments told you the indications for, and the best method of, performing some difficult.

and dangerous surgical operation as well as the subsequent management of the case, and yet the purely medical man is told how he shall treat disease involving just as much responsibility as well as great skill in diagnosis and as high a degree of mental acumen in correct therapeutics, as the surgeon. We must not lose sight of the important fact that treating disease means something more than the mere giving of drugs. Often-very often, indeed-the advice the physician gives as to diet, hygiene, exercise or complete rest is of more value to the patient than the prescription he writes, and will have as much or more to do with restoring him to health, and is an integral part of therapeutics.

My plea, then, is not for less time in the laboratory, but for more time and attention to therapeutics and pharmacology; for more specific directions in the use and indication for different drugs, as well as what they are expected to do, and everything that enters into the treatment of discase, hygienic, dietetic and medicinal. would have the student and physician know more of the pharmacopeia, and less of the literature distributed by the ever-increasing army of retail men. I would have him know more about how to combine drugs in order that their highest efficacy and usefulness may be obtained, and less about Cactina pellets being good for heart disease. In short, I would have him know more about treating the patient, less about treating the disease.

DISCUSSION.

DR. JOHN G. SPENZER, Cleveland: Pharmacology and therapeutics should go hand in hand. The former must be well known before one can hope to be a good therapeutist. The composition, preparation, active principle, tributary and untoward action of drugs, and means of assist ng such actions, are vital points with the doctor. It gives him a seeming amount of common sense and self-reliance in the treatment of disease. People nowaday want relief from their misfortunes and suffering, and this education and preventive medicine remove much unnecessary torture of mind and body.

DR. JOHN B. MCGEE, Cleveland: It is certainly necessary to place all possible stress upon the teaching of therapeutics; it has been rather overshadowed by other branches, gut we have enough of definite knowledge in a therapeutic way to warrant its assuming a prominent place in the curriculum; as it is a branch of daily use to the physician, it is one in which

he should feel confidence as to his ability, and as to its worth. The intimate interrelation of pharmacology and therapeutics is self evident, and a more thorough knowledge of both will lessen or remove the truth in the charge of therapeutic skepticism now SO frequently brought against the profession.

The more thoroughly conversant we are with the action and uses of our drugs, the better we shall be able to employ them, and the more satisfactory results shall we obtain. We look to the pharmacologist for a knowledge of the method of action, which renders us ready to appreciate and apply the therapeutic test. We should teach all considered of value concerning our remedies, and while such knowledge may be largely empirical, we recall the fact that, on the other hand, a great number of our recent remedies have come to us from a pharmacologic source. One method of gringing added emphasis to therapeutics in a general way is to have more time and papers devoted to the subject at our society meetings where such are usually relatively few in number.

While we recognize the value of physiologic therapeutics, much of our tretament still calls for drug medication. While disease does not necessarily call for medicine, yet when needed it should be given to produce its characteristic effects, as symptoms arise calling for interference or control. We should impress, too, the fact that any drug abused will do harm, and recognize the danger of overtreatment, and interference with the natural tendency to recovery. While our ultimate aim is to remove the

cause, we know that our specifics are few in number and impress the difference between specific and symptomatic treatment; as much relief and possibly aid can be given by judicious symptomatic medication, and the limitations of a drug uses should be remembered-what it cannot do as well as what it can.

It is advisable to pdace emphasis on filling the indications with as few remedies as possible, and to know thoroughly those recognized by the profession generally as standard in character. A few representative drugs well known, rather than a large number superficially. It is well for the student to know that digitalis is of great value when cardiac compensation begins to fail, but the details of the choice of preparation, its dose, the frequency with which to repeat it and which active principle to prefer, all contribute to its more successful use.

In conclusion, I believe that all the time we can possibly give should be devoted to therapcutics and pharmacology, including materia medica, although the relative subdivision of time in these variouse subjects might be left to the individual curriculum, while recognizing a minimum for all three related subjects. Placing special stress upon the mastery of the main drugs, as embodied in the Pharmacopeia, though recognizing many at present not official, and endeavor to impress the student with confidence in the action and results of our therapeutics whether drug or physiologic, believing that one's optimism or skepticism as to its value in disease is apt to bear an almost direct relation to one's therapeutic knowledge.

It is an undisputed fact that gonorrhea can be controlled more surely and quickly by the employment of the newer silver salts than by the older methods. It is also known that these preparations have the power of dialysis through animal membranes, but only when retained for a sufficiently long interval. This step in the technique is so important that it seems advisable to give more publicity to the matter. Ordinarily the patient is given a solution of the vitellin, proteid, or gelatose of silver, and told to retain a syringe ful for from five to ten minutes or longer. These directions are seldom carried out, either from lack of time or disinclination, or from cramping of fingers of patient or attendant. Not only are the directions wholly inadequate, as regards length of

time solution should be retained, but, fully as important and as often neglected, is to write for only small quantities of the injection fluid. jection fluid. Most prescriptions call for from five to eight ounces of these preparations. Experience has shown that chemical changes take place in as short a time as six hours to twice as many days, largely depending on the salt selected. This chemical change causes at first irritation of the tissues; later the solution becomes more or less inert. For these reasons only small amounts should be ordered at one time (not more than three ounces), preference being given to the proteid salt, which retains its efficacy longer. Therefore, the use of a satisfactory clamp and an absolutely fresh solution suggested themselves, in order that good results