similar to the provisions recommended by the special committtee on ophthalmia neonatorum appointed by the American Medical Association.

These in substance are as follows:

1. The enactment of laws in each state or territory requiring the supervisory control and licensure of mid-wives by the board of health.

2. The distributions by health boards of circulars of advice to mid-wives and mothers, giving instructions as to the dangers, methods of infection and prophylaxis of ophthalmia neonatorum.

3. The preparation and distribution by health boards of ampoules or tubes containing the chosen prophylactic with specific instructions for its use.

4. To insist on the proper maintenance of proper records in all maternity institutions and other hospitals in which children are born.

5. Periodic reports to Boards of Health by all physicians engaged in obstetrics of the number of cases of ophthalmia neonatorum that has occurred in their practice within a specified time, whether or not a prophylactic was used-if so, what-together with the result.

6. Organized effort throughout the states.

A full discussion of ophthalmia neonatorum would be both profitable and interesting, but it would take us into too wide a field for the purpose of this paper. Our object at present is only to point out in a general way the various preventable causes of blindness and to briefly discuss the means by which they may be lessened or prevented. Moreover, it should be borne in mind at the very inception of the movement for the suppression of blindness, that ophthalmia neonatorum is not the only preventable cause that should receive consideration. Wherever any form of neglect or abuse exists that results in unnecessary impairment or loss of sight it should be thoroughly investigated and completely eliminated.

One notable fault that lies with our own profession is the placing of ophthalmology by common consent among the distinctive specialties, and not giving its students the adequate training which the importance of this branch of medicine demands.

It is because of this lack of training that the refractive work of the country is largely in the hands of jewelers and

graduates of schools of optometry, whose knowledge of the eye is of the most primitive sort, and not in the hands of the profession to which it rightfully belongs. Not only is refraction a practical part of medicine but it is a potent factor in the conservation of eyesight as well.

A forward step was made toward the correction of this defect in medical training when, in 1909, pursuant to the recommendation of the committee of the American Medical Association, the Nebraska State Board of Registration established the requirement of a working knowledge of simple refraction as a condition for license. This requirement, if universally adopted, will be the means of adequate provision being instiuted by all medical schools for teaching refraction, not as optional special courses now in common vogue, but as a part of the general medical curriculum. Thereby will the optical evil be solved, general medicine enriched, and the best interests of the public subserved.

For a century or more it has been known that the requirements of school life resulted in injury to the eyes of many of the children. From numerous and exhaustive investigations, myopia has been proven beyond contradiction, to be, to an alarming extent, the direct result of the strain of school life. While much has been written upon this subject and some advance has been made in the correction of the evil in recent years, the public has not yet been awakened to its full signifi

cance.

Every means possible should be taken to safeguard the pupil against this tendency to impairment of vision. These safeguards should be instituted with the laying of the foundation of the school house and should be continued throughout the school life. In spite of the known importance of the proper lighting of the school room, this phase of the students welfare is not given the attention that it deserves as is evidenced by examples too numerous to mention. The proud boast of the city of Omaha is the efficiency of its public school system and yet with but two or three exceptions the lighting of the ward school building has not been provided according to scientific and established hygienic principles; and I am credibly informed that this defect is universal.

Not less important is the proper seating of the child. The school desks and seats of today as a rule meet the physiological requirements of children as a class, but this goes for naught unless the seat and desk exactly meet the requirements of the

individual. A child whose seat is too high or too low for his requirements must assume a faulty position which adds greatly to the strain of accommodation and convergence and aids in the production of myopia. The teachers are doing what they can to correct this, with the limited means at their disposal but either through false ideas of economy, or an insufficient knowledge of the physiological and mechanical laws underlying upright sitting, the bodies of men who are responsible for our school systems have too often ignored this important question. The need of every school room is a seat and desk adjustable to the individual.

The time at my disposal prevents me from discussing many of the defects that exist in the hygiene of vision in the schools, but before dismissing this subject I must mention the importance of the adoption of some systematic and periodical method of inspection by our school boards, which would be effective in detecting diseases of the eye and anomalies of vision, in order that parents may be warned of the existence of such diseases and defects and of the necessity of instituting proper measures for their relief.

These inspectors could also act in the capacity of advisory boards to which questions of sanitation, the lighting of school rooms, the proper seating of pupils, and all things pertaining to hygiene of vision could be referred. The cost of such inspection and supervision would be returned to the commonwealth fiftyfold by the good that would accrue. It is needless to add that the inspection should be in charge of competent medical men.

Every one who has treated certain diseases of the eye, particularly phlyctenular and interstitial keratitis, knows how almost futile his efforts are when the treatment must be carried out in households in which sanitary surroundings and good food are wanting. We have not as yet in our state, large hospitals like the Massachusetts Charitable Eye and Ear Infirmary that can afford a social service work providing for salaried nurses whose duties, in part, are to visit homes and instruct . the parents in the hygiene of the home, so important in diseases of the eye. But we have at our command in this city the services of a Charitable organization, which can do what might be called medical social extension service for all who may need it. Mrs. W. R. Adams, the superintendent of the Visiting Nurses Association, has offered to send a competent nurse at the request of any physician to parents, where instructions in hygiene of the home and the proper interpretation of the doctor's ad

vice are needed. Doubtless a similar arrangement could be managed in other places, and, if taken advantage of, it will be a potent factor in the campaign for prevention of blindness and the conservation of eye sight.

This question is too extensive to permit a detailed examination and discussion of all the causes of preventable blindness. Industrial accidents, Fourth of July celebrations, hereditary blindness and syphilis supply their full quota and are questions demanding attention as well as those discussed in this paper. The time is ripe for the strongest aid possible to be brought to the support of this worthy cause-and that aid is the medical profession. It is not beyond the possibilities that, if the medical profession will lend the support to this movement for the suppression of blindness which it deserves, the day is not far distant when adequate safeguards will be placed about the eyesight of this nation and no more of its people will be doomed to life-long darkness through preventable causes.

DISCUSSION.

Dr. W. H. Wilson, Lincoln, Neb.:

I want to compliment the doctor on his very excellent and timely paper, but there is one point somewhat emphasized by the author that I would speak of briefly and that is where he refers to and urges the enactment of a law requiring the reporting of all cases of ophthalmia neonatorum. Possibly many of the physicians of the state do not know, although I think they should know for the subject has been brought to their attention through the contagious disease cards, that we have some such law on that subject at the present time. I am inclined to think that it is not so much a need of more law to deal with this disease as it is an observance of the law we now have. The State Board of Health, acting under the powers conferred upon it by law, made neonatorum one of the reportable infectious diseases and yet I am in position to say that physicians througout the state, and Omaha physicians are no exception to the rule, are not reporting to any considerable extent the existance of the disease. Either that or we do not have the disease in this state. I think there is quite a tendancy among physicians of this state and probably it will apply to physicians through the United States, to be quite derelict in duty in regard to the reporting of infectious and contagious diseases and it seems to me all must concede such a situation is not exactly creditable to the profession. It is true that in the matter of quarantinable diseases, our physicians report quite well to the local authorities and fairly well to the state department and in some of the infectious diseases a good showing of returns are made, but we are not getting nearly the returns we should. In all of the communicable diseases listed for reporting, it is very desirable to have as complete returns as possible made to the state board for statistical purposes, but that is not sufficient for the important, because practical, part is the prompt reporting to the local board to the end that preventive measures may at once be instituted.

Dr. Quincy, Ashland, Neb.:

I would like to ask Dr. Owen in his final discussion whether or not he thinks a four per cent solution of nitrate of silver is too strong to be used.

I have always used it and have never had any bad results and always excellent results. Where I have used it, at birth, I have never had any inflammation.

Dr. Edwards, Nebraska City, Neb.:

In regard to the method of lighting the school rooms. We all know that this is a cause of a great deal of trouble. The light so strikes on the black boards, that the eye of the child in a short time will become irritated. This can very easily be overcome by so arranging the seats that the light will come from the side or the back of the rooms. We should take hold of this matter. Dr. Owens has reported and shown us the enormous percentage of blindness whcih can be prevented by early and vigorous treatment. The majority of the people do not understand inflammation of eyes or gravity of pus and if they are taught that pus oozing from the eye and inflammation is a cause for grave fear, they will put their children into the hands of some competent physician, who will no doubt be able to relieve them from possible blindness for life.

Dr. Strong, Omaha:

One point. There is a very stringent law in this state regarding professional secrecy. Would not a doctor be likely to get into very serious trouble if he made a practice of reporting such cases as have been mentioned? I think we would be liable to get ourselves into hot water, very hot water in reporting a case as Gonorrheal ophthalmia.

Dr. F. S. Owen, Omaha, closing:

Regarding the use of nitrate of silver as a prophylactic, the 4% solution as employed by Dr. Quincy, is much too strong for its needs, and may be a postive source of danger if not skillfully applied. Crede recommended a 2% solution and this strength is still largely employed, but many now think a 1% solution is of sufficient strength to meet all requirements. Certainly the latter strength is to be preferred, when employed by nurses and unskilled hands.

The fear of trouble that Dr. Strong entertains should she report her cases of ophthalmia neonatorum, as required in the Howe law is imaginary and if such fear were universally entertained there can be no progress made in the prevention of this by far the greatest source of unnecessary blindness. The fact is when an infant's eyes become violently sore a day or two after its birth, the laity is so well informed on the subject today that the immediate friends of the family usually already know the real cause of the trouble and hence there would be no betrayal of professional secrets to report the case to the board of health. The report need not be open to general inspection, and hence in no way will it be publicly known. Such a report puts the child attended by unskilled midwives and the child in the homes of the poor, where there is no treatment, in the way of receiving proper treatment. That is the real object of such a law.

Practice of Medicine- Its Success and Failure.

*By F. A. BUTLER, M. D., Harvard, Neb.

There is no doubt but the average practitioner of medicine, when a student attending lectures in a medical college course, very poorly understood what these two words, success and failure, mean in his subsequent professional career, and just what per cent of practicing physicians in the great field of medicine

*Read before the Nebraska State Medical Association, Omaha, May 2, 3 and 4, 1911.