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nerves as well as the large number of association fibres which are stimulated during ocular activity gives us a rational basis for tracing certain of the general subjective symptoms.
It is not necessary to go into detail concerning the less frequent and obscure symptoms of beginning eye strain and we shall only consider those which are practically always observed.
In hyperopia, or far sight: the symptoms are many and various but foremost is headache or "brow ache:" it is usually frontal, frontotemporal, or may extend to the occipital region or all over the head. If headache be due to the eyes diagnosis is simple owing to the fact that it arises during periods of ocular activity and diminishes or disappears during ocular rest. Socalled "sick headache" is most frequently of ocular origin. Inflammation of the lid margins, styes, cysts of the Meibomian glands, and conjunctival irritations are very frequently present. An abnormal desire to sleep after close application is good evidence. Print
blurs and becomes dimmed after short periods of activity or the lines of printed matter "run together." The eye in hyperopia is small, with short interpupillary distance. A convergent squint in children usually indicates hyperopia. Distant vision is good but for close work there occurs a narrowing of the palpebral fissure and the act of reading is accomplished very slowly. There is an inability for long continued reading or close work, a necessity for greater illumination and a marked variation in the distance at which the work is held from the eyes.
In Myopia or near sight, there is not as a rule severe or annoying headache. An inability to to see distant objects clearly is the primary and often the only symptom complained of by the patient. The eyeball is usually prominent, there is a long interpupillary distance, and a divergent squint usually indicates Myopia. The two cardinal points are the poor distant vision and the good near vision. The pupils are sometimes dilated and the irides slug
gish to stimuli. Near work is performed in deficient light, the shoulders may be stooped, and there may be a lateral movement of the head during close work.
In Astigmatism there are but few reliable objective signs. There sometimes is seen frowning, head turned. to one side, narrowed palpebral fissure in myopic astigmatism and widened. fissure in hyperopic astigmatism. None of these are dependable but since astigmatic errors are observed as complications the diagnosis can safely be left to such methods as retinoscopy.
Heterophoric asthenopia, the eye strain arising from faulty muscle balance, is occasionally seen alone but. more often in combination with some form of ametropia and constitutes a comparatively large percentage of patients. Reflex neuroses are very frequent accompaniments of muscular imbalance. Vertigo, migraine, mental confusion and consequent depressed mental activity, and various gastric disturbances are often the symptoms presented by patients who are not even aware of any ocular disorder. Continued over a period of time these neuroses affect the general system and this reduction in general physical tone in turn augments the condition of eye strain. Thus a vicious circle is established which, if not properly diagnosed and treated, means great physical suffering and actual pathologic changes in the structures of the eye. The migraine found in these cases has been described as "an explosive paroxysmal psychoneurosis, comparable to an epileptic seizure in that the manifestations are sensory rather than motor." Its usual site is occipital, nuchal, and cervical and in some cases extending even to the dorsal areas. "Church" and "Opera" headaches, car sickness, confusion and nausea from observing rapidly moving objects and the more recent "Moving Picture" headache are all most frequently dependent upon ocular irregularities.
It is not necessary to consider the other forms of asthenopia in this article
for they are usually, if not always associated with one or more of the forms described, presenting merged symptom groupings and can be diagnosticated only by the special methods employed by the trained ophthalmologists.
The experience of any ophthalmologist will warrant the statement that there are a great many cases of eye strain treated symptomatically, unrecognized by the physician, and allowed to go uncorrected until such changes have occurred as render the ocular structures irretreivably damaged. And there are some physicians who do not realize the importance and scope of a thorough examination and consider their obligation to the patient discharged when they send him to the optician for an "Eyes Tested Free" fiasco.
It has truthfully been said that the greatest judgment and the utmost skill are necessary in the prescribing of lenses for any pair of eyes. So much is to be taken into consideration, and such slight modifications are so productive of such harmful results that a medical education and a thorough training in this special form of work are obligatory.
The sooner we come to a full realization of the serious secondary disorders and the very harmful functional disarrangements that may arise from the eyes in a state of strain, just so soon will we see a decrease in the distressing neuroses and in the harmful and unwarranted therapy now so frequently. 217 Newton Claypool Building.
A CASE OF INANITION FROM OVERFEEDING.
BY DR. G. B. JACKSON, OF INDIANAPOLIS.
August 1, 1908. Baby II. Female; age four months; weight 834 pounds; weighed 71⁄2 pounds at birth; fed artificially; never gained very well, lately losing weight. Bowels always loose and move six to ten times a day with great volume of semi solid con
sistency with white flakes, slight mucuos and rerely greenish streaks. Examination shows no blood nor pus. Urinates every 2 Oto 40 minutes and perspires freely and constantly. Vomits only rarely but cries very much. and sleeps poorly.
On inquiry as to the feeding, the mother said that "several physicians. had tried everything" and that for the last two weeks it had been getting as follows: Cream, 71⁄2 oz., milk, 11 oz., milk sugar, 2 oz., lime water, 2 oz., water, 191⁄2 oz. This is a total of 40 oz. in 24 hours, besides a small drink of water "between meals." The meals were 5 oz. of the above formula every two hours. Thus, the infant received about 50 oz. of fluids in the 24 hours.
Examination revealed a thin, pale infant without signs of rachitis and with a soft abdomen, normal temperature. The integument was somewhat loose, easily lifted into folds and very moist.
Diagnosis. Overfeeding with consequent indigestion and inanition.
Upon calculating the caloric worth. of the 24 hours' food it was found to be about 750 Ca.-enough for an infant weighing 17 pounds-in other words about twice the amount necessary to support the case before us.
Treatment-Give no water between meals. Feed milk, whole and pasteurized 16 oz., barley water, 16 oz., milk sugar, 11⁄2 oz. Allow 5 oz. every three hours and increase the milk proportion servation. very gradually under physician's ob
This prescription was based upon the calorimetric principle in infant feeding (see article by writer in Indiana Medical Journal, 1907), and upon the evident fact of overwork of the urinary, circulatory, respiratory and digestive systems by the too great quantity of fluid ingestion. The writer. always uses uses simple simple milk dilutions. when borne well by the infant.
Results: August 3d. Bowel moved. Results: August 3d. Bowels moved four times in last 24 hours and less volume. There is less urination and
sweating and the child is more restful. August 14th. Bowels moving twice; one-half as many micturitions as formerly. Weight 934 pounds and the child has a much more contented general appearance.
This case tells its own story. It was selected from my records because its history spoke so emphatically and typically upon one of the points of greatest danger in artificial feeding, i. e., overfeeding.
340 Newton Claypool Building.
BY FREDERICK C. SHATTUCK, M. D.
Jackson Professor of Clinical Medicine in Harvard Medical School, Boston.
The subject of my remarks this evening is not of my choice. It was assigned me by the higher powers for reasons I do not presume fully to understand. I cannot believe that you are peculiarly in need of instruction in medical ethics, and I know that I am not specially qualified to give it; but having from my youth been brought up in habits of obedience I cannot break away from early and long training, and-you must take the consequences.
Of several definitions of ethics in the Century Dictionary, I have selected the following as perhaps best meeting our requirements of the evening as I conceive them. "Ethics is the doctrine of man's duty in respect of himself and of the rights of others." Ethics thus formulates right conduct. and o aids us to see the light; but we must constantly strive to be led by it. Intellect and character are very different qualities, too rarely coexistent in their higher degrees in the same person. One or the other may be highly developed, or less or more atrophied, congenitally, from disuse, or both. He
*An address to the students of Western Reserve University Medical College and the Academy of Medicine of Cleveland, April 25, 1908. From The Cleveland Medical Journal, August, 1908.
whose unclouded vision sees things just as they are, including the right and wrong of almost any and every question may, allowing himself to be dominated by love, ambition, avarice or some other passion, with open eyes choose a low course. Per contra, he whose intellect, which may be acute though narrom, fails to grasp the true relation of things, may, subduing all passion and apparent self-interest, act nobly, even if, with a mind more logical than clear, false premises lead to false conclusions. History affords examples of either extreme, as well as a few of that harmonious balance of intellect and character, which, in General Washington, has so impressed the world, and as long as man works upward must remain a living force.
Standards of ethical conduct-that is, conduct which not only tends to the development of individual character but also to that of the well-being of the race-have undergone considerable evolution, the most potent single influence which has been brought to bear upon them being Christianity. "An eye for an eye and a tooth for a tooth" of the Judiac, is supplanted by the offering of the other cheek to the smiter, of the Christian dispensation. Taking the world as a whole, even today, external standards vary enormously with the degree and kind of civilization-and its lack-with the reli
gion and organization of society, the physical peculiarities of a country, the density of population, means of com
munication and a thousand other things. With us a state of relative fixity has been reached.
The more complex society becomes, the closer knit by applied science, the more organization gains on individual action, the more numerous are the restrictions which must be placed on the individual for the benefit of society as a whole. That which may be perfectly right and proper for the savage, or even for the civilized man in the wilderness, may be highly reprehensible under other conditions.
We are all agreed that as men we should so live as to cultivate our intellects, to enlighten our consciences, to strengthen and elevate our characters, and, in as far as in us lies, to promote the well-being of mankind. This is practical ethics. What, then, is medical ethics? Has an adjective any place in ethics? If so, why? Cannot all practical ethics be summed up in the Golden Rule? Yes and no. It can be so summed up, but rules based on analysis are useful as short-cuts, promoting the rapidity of decision as to right conduct in concrete cases which may seem, or really be, complex. Every calling involves some peculiarities of relation to other persons, which adds to or modifies the restrictions imposed by general ethics. The peculiarly intimate relations, especially with female patients, involved in the practice of medicine necessitate a very strict standard, lapses from which are less pardonable to the doctor than to men of any other calling save the priesthood. This has been recognized from very early times as we shall see
observation and experiment, the care of the soul and of the body cannot remain in the same hands.
The most ancient statement on medical ethics of which I can get clear trace is the Hippocratic Oath, of about 460 B. C. This oath was taken on entering studies and runs as follows: "I swear by Apollo, the physician, by Aesculapius, by Hygeia, Panacea, and all the gods and goddesses, that according to my ability and judgment I will keep this oath and stipulation, to reckon him who teaches me this art equally dear to me as my parents, to share my substance with him and relieve his necessities if required, to look upon his offspring on the same footing as my own person, and to teach them this art if they shall wish to learn it without fee or stipulation, and that by precept, lecture and every other mode of instruction I will impart a knewledge of this art to my own sons, to those of my teachers and to disciples. bound by a stipulation and oath, according to the law of medicine, but to no others. I will offer that system of regimen, which, according to my ability and judgment. I consider for the benefit of my, patients, and abstain from whatever is deleterious and mischievious. I will give no deadly medicine to anyone if asked, nor suggest any such counsel, and in like manner I will not give a woman a pessary to produce an abortion. With purity and with holiness I will pass my life and practise my art. I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will
abstain from every voluntary act of mischief and corruption, and further,
from the seduction of females and
males, of freemen and slaves. Whatever in connection with my professional practice, or not in connection with. it, I see or hear, I will not divulge, as reckoning that all such things should be kept secret. While I continue to
keep this oath inviolate, may it be granted to me to enjoy life and the practice of my art, respected by all men at all times; but should I trespass and violate this oath, may the reverse be my lot."
"He should have all his senses perfect. "He should be disposed for solitude. "He should be free from haughtiness. "He should be of a thoughtful disposition. "He should be free from those faults which go by the name of Vyasana."
Then follow elaborate ceremonies which are gone through with, so interesting and curious that I wish we had time for them in full. And finally, the perceptor formulates, as it were, code, the acceptance of which is a prerequisite of pupilage.
Charaka, dating probably, as I am informed by Professor Lanman, from about 100 A. D., deals at some length with medical ethics and the mutual relations of pupil and teacher. It is too long to give in full, but I permit myself to make some extracts, calling your attention to the fact that this ancient Indian oath was administered to the pupil about to enter on the study always seek, whether standing or sitting, the
of medicine, not at the end of his pupilage. We note the stress which is laid on the physical perfection of the candidate, and remember that such, in a limited way, is a pre-requisite to admission to the Romish priesthood. After setting forth what constitutes a good treatise to select for minute study a list of the qualifications desirable in the preceptor, the pupil desirous of courting him should attend on him with heedfulness like one re vering one's sacrificial fire, or one's deity, or one's king, or one's father, or one's patron." A very proper attitude of pupil to teacher, not always observed at the present day.
Next come the qualities of the pupil:
"He should be of a mild disposition. "He should be noble by nature. "He should not be mean in acts. "His eyes, mouth and nasal line should be straight.
"His tongue should be thin, red and unslimy.
"His teeth and lips should have no deformity.
"He should not have a nasal voice.
"He should be endued with a large understanding.
"Hhe should have power of judgment and memory.
"He should have a liberal mind.
"He should belong to a family the members of which have studied the medical scriptures or followed medicine as a profession.
"He should have a devotion for truth. "He should not be defective in respect of any limb.
"If thou desirest to achieve success of areatment, earn wealth, acquire celebrity, and win Heaven thereafter, thou shouldst, reverencing kine and Brahmanas above all,
good of all living creatures. Thou shouldst. with thy whole heart, strive to bring about the cure of those that are ill.
Even for the sake of thy life thou shouldst not drain those that are ill of their substance.
Thou shouldst not, even in imagination, know another man's wife.
Thou shouldst not, similarly, appropriate other people's possessions.
Thou shouldst not keep any connection with publicans, or sinful men, or with those that are abettors of sinful behavior.
Thou shouldst speak words that are soft, unstained by impurity (obscenity), fraught with righteousness, incapable of giving pain to others, worthy of praise, truthful, beneficial and properly weighed or measured.
Thou shouldst always conduct thyself taking note of place and time.
While entering the family dwelling-house of the patient, thouldst do it with notice to the inmates and with their permission. Thou shouldst (at such times) be accompanied by some male member of the family. Thou shouldst cover thy person properly. Thou shouldst (while entering) keep thy face downwards. With thy wits about thee, thou shouldst, with understanding and mind properly fixed, observe all thoings. Duly conducting thyself in this way thou shouldst enter (the dwelling-house of the patient.)
Having entered, thou shouldst not devote thy words, mind, understanding, and the senses to anything else than what is calcu
*Certain habits and acts go by the name of "Vyasana." They arfe hunting, gambling with dice, sleep during day time, speaking ill of others, infatuation for women, excessive addiction to singing, dancing and instrumental music, purposeless sauntering, and others of a similar nature. The HinduScriptures abound with exhortations to avoid them. In the case, of a Brahmacharin (pupil living in the house of his preceptor), their avoidance is doubly incumbent.-T.