beginnings have been made as in Boston where Harvard will from this time on control all appointments to the Massachusetts Eye and Ear Infirmary, but the process will be a slow one.

con

Conditions of private practice have changed greatly in the last two decades and adjustments to these conditions are by no means complete. For instance, glaucoma was sidered to call for immediate operation and most of it does still, but much of it is secondary to iritis, the cause of which is now more easy to locate and eradicate. Many cases of squint are now relieved by glasses. Fewer eyes are injured, fewer eyes have to be enucleated because of gonorrheal ophthalmia at birth and because of sympathetic ophthalmia. So eye work has gradually become less a surgical specialty and more a medical one.

Another matter which is influencing private practice is the growth of optometry. It has been recognized by nearly all state legislatures, despite our objection, and courses in optometry are now given in various universities including Columbia, Ohio, Illinois and South Dakota. The optician has come to stay. And when his training has been brought up to a good standard and his practice properly safeguarded he will undoubtedly get a considerable portion of the present income of the eye doctor. This will be because his education is less expensive and because he will be able to serve patients with simple presbyopia and a considerable number of patients with other conditions, adequately, at a lesser cost to the patient than can the eye doctor. The more severe and complicated cases, including most eye

headaches, will continue to be much better cared for by the eye doctor who alone can use cycloplegics.

But these matters of education and practice concern largely the profession itself in its immediate social activity. What of the more strictly social aspects of ophthalmic medicine as commonly understood? How is eye work relating itself to the schools, to preventive medicine and sanitation, to loss of eyesight in the industries, to workmen's compensation, to alleviation of suffering from eye disease and blindness in general?

First the schools. Eye doctors the country over have urged school inspection for years, in season and out; yet inspection has not become general. The most hopeful aspect of this situation is a movement under way for an approach along a different line. Inspection has heretofore been a function of the local departments of health and it is proposed to transfer this function to the Boards of Education. Legislation will be necessary but the obvious advantages in the shape of greater freedom from politics and better financing will make a strong appeal. It is contended that the right and duty of the school board to be assured that the pupil can see, hear, sit up straight and is not a moron, is just as obvious as is its right and duty to provide the proper books, desks, and a penny lunch, free if necessary, and that inspection should be defined as a function of educational bodies, leaving of course vaccination, quarantine, isolation and exclusion from school for contagious diseases still in the hands of the health department. One very great advantage too, will

lie in the fact that the people who have confessedly looked askance at medical inspection in the hands of health departments doctors, doctors, doctors will trust their school board more fully; in fact they think better of the school board and know more about it in the smaller communities than they do of any of the rest of the administrative bodies.

Another type of school work in which eye doctors are much concerned is the formation of what are called "Conservation of Vision Classes," for want of a better term. Heretofore if vision could not be improved to 3/10 or 20/70 the pupil had only one place to go and that was to the school for the blind. A Mr. Irwin in Cleveland conceived the idea of printing text books with large letters (half inch or so high) and providing desks with wheels so that they can easily be rolled to a window or blackboard. Not more than 10 or 12 pupils can be so accomodated in a single room, under one teacher, and while they prepare their work in this room they recite in the regular class rooms with pupils of their own age and who are in possession of good sight. The work was started in 1913 only but has spread with marvelous rapidity over the country until now there are 155 classes in 12 states-Ohio, New York, Minnesota, California, Connecticut, Illinois, Massachusetts, Michigan, Pennsylvania, Wisconsin, Washington and Louisiana. Canada has 2, Italy 1. The work of the eye doctor in determining what constitutes the loss of useful vision for purposes of compensation to the injured is going on apace, but much remains to be done.

On the side of research we still do not know the cause of trachoma or the cause of sympathetic ophthalmia, and we have only a very inadequate knowledge of the cause and nature of glaucoma. Comparatively few people now stay blind because of cataract formation, but, as long as the cause and nature of the other three eye scourges remain unknown, we have great and continuing need for close coöperation between those specially trained and the laity in high spirited organizations for the prevention of blindness and the care of the blind. The same need is, of course, present in every other field of medicine and no specially trained man can better relate himself to the civic needs of his community and discharge his duty as a citizen of the state or nation than to use his special knowledge and spare time in helping along such work. The growth of such organizations is phenomenal, and whereas those who started them felt that the need would be short-lived, that the community could be soon awakened to the situation and the state be shouldered with what is properly its duty in these matters of prevention and relief, everyone now realizes they are to be needed for a long time to come. National associations have been formed and are necessary, but state organizations to meet the peculiar needs of commonwealths are just as necessary. This is true of Illinois and Missouri, for instance, because in these states trachoma is such problem. We have in these states organizations in which the degree of coöperation between the laity and the medical profession is a matter of just pride. Through the country-wide ac

tivity of the National Committee for the Prevention of Blindness and the local influence of such organizations as the Missouri and Illinois State Societies there is now a uniform law in nearly all states making it a misdemeanor not to report a case of baby's sore eyes to the local health officer within six hours. Prosecutions of doctors and midwives have been numerous, and along with the general decrease of ophthalmia neonatorum, it has come about that the year 1922 did not claim one blind baby in Chicago, and indeed not one in the whole state of Massachusetts! Such organizations have made trachoma a reportable contagious disease along with smallpox. In others the use of wood alcohol in shellacs and varnishes, in the millinery trade and in hair tonics has been prohibited by law and controlled by proper labelling.

Proper lighting of school rooms with not less than one-quarter window area to floor space has been secured. Safety first protecting glasses and proper guards for revolving machinery have been urged along with correct street and automobile lighting. The roller towel has been abolished.

As a conclusion it may be said that not only is ophthalmic medicine a very limited specialty but that it has suffered further limitation in its surgical side and in the development of optometry, yet in its more strictly social aspects it has a rich relationship to established medical institutions, to other branches of medicine, to medical education and to research; that along with its unique opportunity for service in the schools, in industry and in other broad civic problems it is assured of an important place in the future social scheme.

T

HE intention of this brief paper is to bring out a few of the clinical phases of this disease, which were observed in 17 cases seen in private and consultation practice since 1908. I do not propose to discuss the Streptococcus viridans as found in the many rather harmless conditions, but rather to discuss the special endocarditis in which it plays such an important and disastrous part.

February 22, 1908, Miss C., aged seventeen, a high school pupil, with a history of previous early infection of rheumatic fever, leaving a mitral valve lesion, when returning home from a party, got wet feet in slushy snow. She began that night having a tonsillitis of the usual type, returned to school in a few days, but felt weak, had slight fever and was unable to concentrate, although she kept up with her studies. Later she remained home, appetite poor, feeling exhausted, and with a remittent fever. Several consultations were held, and malaria, typhoid fever, tuberculosis and anemia were suggested. In such manner the case dragged along until August, when pains of a peculiar type were complained of in the right popliteal space, and with impaired circulation and later complete obstruction at the bifurcation of the popliteal artery, with dry gangrene of the

1 Presented before the American Congress on Internal Medicine, St. Louis, Mo., February 18 to 23, 1924.

foot and leg. In September partial occlusion of the right bracheal at bifurcation was observed; and in October, in the right carotid, a marked thickening was noted. In a few days, hemiplegia of the left side resulted. The patient lived until November 23 of that year. The undertaker secured a small portion of the carotid artery for me (the parents objecting to an autopsy), and I was able to observe a clot in this artery.

In 1912, Mrs. G., aged forty-one, who had a well compensated mitral lesion and whom I had attended for many years, complained of weakness, anorexia and anginoid pains. She was sent to the hospital with a newly acquired heart lesion of an uncertain type. In a short while she had pain in the left popliteal space, with later gangrene of the foot and leg. In a short period, the right popliteal artery became partially occluded, with marked mottling and cyanosis of the foot. Death occurred shortly after this complication (about four months after the onset of the symptoms).

In December, 1919, a boy, aged sixteen, was received at the Missouri Baptist Sanitarium, with a history of rheumatic fever. Evidence of a mitral lesion had been observed before his last illness. I judge that he had had the milder phase of the streptococcic infection for some time previous to his admission to the Hospital, and was now in the embolic period. At any rate, about mid-January he showed evidences of occlusion and gangrene of the right leg and foot. He lived until April of the following year. Dr. Ives found the Streptococcus viridans in the blood culture.

I should like to mention here, incidentally, that the latter patient's mother, aged thirty-eight, had a chronic mitral lesion, and in 1922, after several months of invalidism, died. The Streptococcus viridans was found in the blood by Dr. Ives previous to death. In this very rare infection, it is especially unusual to observe two members of the same family similarly afflicted.

In July, 1923, Mr. S., aged sixty-four, was admitted to the Missouri Baptist Sanitarium and operated on by Dr. Burford for a large obstructive prostate. On admission the patient was suffering from arthralgia, myalgia, weakness and a mild fever. There was a history of acute inflammatory rheumatism fifteen years previously, leaving him with a mitral and aortic roughening. Immediately after the second stage of the prostatic operation, the patient had several severe chills, high fever and ran a septic course until mid-August, when evidences of a rather diffuse pneumonic process (probably embolic) were observed; almost clear blood was expectorated. At this time the patient was running a varying temperature, continuing for several weeks, with progressive weakness, with all signs and symptoms of a mild degree of sepsis. The cause of these clinical observations, the Streptococcus viridans infection, was thought of, and blood cultures were requested. Numerous colonies of the Streptococcus viridans were found on many occasions by Dr. Ives. Because of homesickness, with a remission of the more severe symptoms, the patient was permitted to return to his home. He was re-admitted to the Hospital late in November with fever, anorexia, vomiting at times, either constipation or diarrhea alternating, and evidences of septicemia. In December he complained of severe rheumatic pains in the left knee. Examination revealed a marked tenderness limited to the popliteal space. The nurse called my attention to the dorsum of his foot, and the several bruised-like plaques over this area which gradually became darker and ulcerated, leaving several granular areas. During that month he complained of severe left side pains about the left hypochondrium, also radiating pains towards the left groin,

with dyspnea and mild delirium. These symptoms persisted for several weeks. Death occurred in January, 1924.

In brief, the autopsy showed infarctions of the spleen, enlarged kidneys, with myriads of petechiae. The heart was of the cor bovinum type, with large friable vegetations on the mitral valve. The tibial and popliteal arteries contained thrombi.

These 4 cases demonstrate the results of the severer forms that occur, fortunately rarely, in this type of streptococcus infection. While from a bacteriological standpoint, I cannot say positively that the first 2 cases were of the green coccus type, clinically I feel justified in grouping them among those of that type found later, when the knowledge and culture of the Streptococcus viridans became better understood by ourselves and the bacteriologists.

Although Schottmueller, Lenhartz and others described the peculiarities of this coccus in the early days of 1900, it seems that very little was written or done by the bacteriologists in this country for several years to bring the condition to the notice of American clinicians.

E. C. Rosenow, in 1913, at the Minneapolis meeting of the American Medical Association, demonstrated the selective affinity of the several cocci; and in September of that year, addressed the St. Louis Medical Society on the peculiarities of streptococci. To him is due the credit for stimulating our local profession to observe more carefully subacute inflammatory heart lesions.

My 13 other cases have not been as spectacular as those described, yet they were interesting in many respects, bringing out points that