The Treatment of Functional Nervous Diseases by the Relief of Eye-Strain. BY AMBROSE L. RANNEY, A.M., M.D., PROFESSOR OF ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM IN THE NEW YORK POST-GRADU- ATE MEDICAL SCHOOL AND HOSPITAL J PRO- FESSOR OF NERVOUS AND MENTAL DIS- EASES IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF VERMONT. SEFBINTBD FROM Neto ¥orfc JHetiical .Journal for January 7 and 1£, 1888. Rejorinted from the New York Medical Journal for January 7 and If 1888. THE TREATMENT OF FUNCTIONAL NERVOUS DISEASES BY THE RELIEF OF EYE-STRAIN* By AMBROSE L. RANNEY, A. M., M. D., PROFESSOR OF THE ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM IN THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL ; PROFESSOR OF NERVOUS AND MENTAL DISEASES IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF VERMONT. Within the past year the attention of the medical pro- fession has been drawn, more forcibly perhaps than ever before, to the fact that eye-strain may constitute an impor- tant element in the causation of nervous disturbances of the so-called "functional " type. In the light shed upon this subject chiefly by recent con- tributions to medical literature,! the view is gradually being * A lecture delivered by the author before the class of the New York Post-graduate Medical School and Hospital. f The reader is referred to the articles by Dr. George T. Stevens on "Chorea" ("Medical Record," 1876); on "Anomalies of the Ocular Muscles"("Arch, of Ophthalmology," June, 1877); and on "Ocular Irritations and Nervous Diseases" ("New York Medical Journal," April, 1877); also to his work on " Functional Nervous Diseases " (D. Appleton & Co., N. Y., 1887); also to a contribution by Dr. H. D. Noyes, on " Tests for Muscular Asthenopia and Insufficiency of the External Recti," read by him before the International Medical Congress, Copen- hagen, 1884 ; also to papers by the author on " The Eye as a Factor in 1 2 TREATMENT OF FUNCTIONAL NERVOUS DISEASES accepted by many in the profession that certain nervous diseases (whose pathology, to say the least, is still indoubt) are possibly not dependent in every case upon an unrecog- nized organic lesion ; and they are being led to coincide with the statement that the term " functional " nervous dis- ease may be properly applied, in some instances at least, to the graver nervous conditions-such, for example, as epi- lepsy, chorea, hysteria, or other manifestations of nervous exhaustion, and insanity. In other words, the professional mind seems more willing now than in the past to discard an apparently fruitless search for a pathognomonic lesion for each intractable nervous condition, and to look more calmly upon tangible clinical facts, even if they are radically opposed to pre-existing views. If the view that eye-strain is a frequent cause of func- tional nervous derangements proves to be the correct one, beyond the possibility of doubt or cavil, it is not difficult to see that a hope of marked relief or of ultimate recovery is practically extended to many hopeless sufferers upon whom drugs have exerted little or no benefit. In anticipation of the general acceptance of such a view (which I feel assured must in time prevail), I have consent- ed to discuss from a clinical and physiological standpoint some of the points involved in this theory. In doing so I shall call your attention to a few illustrative cases, with running commentaries upon such of them as present, to my the Causation of some Common Nervous Symptoms " (" New York Medi- cal Journal,"February 27 and March 15, 1886); on "Eye-strain in Neu- rology " (" New York Medical Journal," April 16, 1887); on "Eye-strain in its Relations to Functional Nervous Diseases " (" Medical Bulletin," September, 1887); and an abstract of an essay read before the Interna- tional Medical Congress at Washington, entitled " Does a Relationship exist between Anomalies of the Visual Apparatus and the so-called 'Neuropathic Predisposition?'" ("Medical Register," November 19, 1887). BY THE RELIEF OF EYE-STRAIN. 3 mind, any points of special interest. All of these cases have been encountered in my own practical office work, and most of them have been seen frequently by physicians of re*pute in our city, and by some physicians of note from neighboring States. In order that those of my audience who have possibly not given much attention to the views which these cases are particularly selected to illustrate may properly understand the train of reasoning that offered a solution to my mind of the symptoms here recorded, I take the liberty of quot- ing a few paragraphs from a paper which I lately read be- fore the International Medical Congress at Washington, en- titled "Does a Relationship exist between Anomalies of the Visual Apparatus and the so-called 1 Neuropathic ' Predis- position?" * This paper was based upon a carefully tabu- lated analysis of the records of one hundred consecutive cases of typical neuroses taken from my private case-book. In this paper I say : Until there is a uniformity in the methods employed for testing the eye-muscles,t and of terms for the recording of anomalies so detected, the profession must unfortunately con- tinue to be more or less embarrassed in this line of research. I do not feel justified in personally discussing this subject here, as it has only an indirect relationship with this paper; but I can not refrain from saying, in this connection, that to defect- ive methods of examination, made venerable chiefly by their antiquity, we owe to-day, in my opinion, much of our ignorance of anomalies of the ocular muscles. Some time ago I was struck, on looking over a children's magazine, with an illustration designed to teach the reader the dependence of the various organs of the body upon the brain. * An abstract of this paper was published in the " Medical Regis- ter," November 19, 1887. f See article by Dr. G. T. Stevens in the " Archives of Ophthal- mology," June, 1887. 4 . TREATMENT OF FUNCTIONAL NERVOUS DISEASES It represented the brain as the head of a manufacturing estab- lishment sitting at his desk, and around him were the various departments-as, for example, the liver-department, the stom- ach-department, the eye-department, etc. These departments were connected with the head of the establishment (the brain) by telegraph-wires, through which each could make its wants known and receive information regarding them. Probably the designer of this sketch (made for the purpose of illustrating to the child the dependence of the organs upon the brain for their successful operation, as well as their act- ual support) built "better than he knew." He embodied in his drawing a graphic representation of certain fundamental principles of physiology which are not clearly understood even by many adult minds in their bearings upon the general health. The lungs do not make us breathe; except in an indirect way, by asking the brain to start the necessary muscles into ac- tion. The stomach does not perform its functions until after the brain has been requested by it to turn on the blood-supply in sufficient quantities to produce the requisite quantity of gas- tric juice. The intestine performs its incessant worm-like movements by no inherent power of its own. The heart keeps up its rhythmical beating only when permitted to do so by the great center of nerve force. Now, is it at all inconsistent with physiological princi- ples to advance the view that any excess of nervous ex- penditure to one organ over the normal amount which should be furnished is done at the expense of the others sooner or later ? No one can draw incessantly upon his reserve capital of nerve-force without incurring a risk of ultimately exhaust- ing it. A bankruptcy in the reserve capital of nerve-force en- tails untold ills to the individual. The day of reckoning is postponed in any given case in direct proportion to the drafts made upon the reserve and the amount of the reserve. This may help us to explain BY TI1E RELIEF OF EYE-STRAIN. 5 why some escape it indefinitely, while others are precipitated into indescribable distress when life is hardly begun. In case the bearing of eye-strain upon the problem of nervous expenditure is not very clear to some of my hear- ers, I deem it wise to quote here some extracts from a late brochure of mine upon this subject (" N. Y. Med. Jour.," Feb. 27 and March 13, 1886). Speaking of hyperopia, I say : Fortunately for our nervous system, the normal eye takes pictures of surrounding objects without any muscular effort when the object is more than twenty feet away; hence, during the larger part of each day, the normal eye is passive, and is practically at rest, although performing its functions. How different is the condition of the far-sighted or 'hyperopic' eye, however, from the normal! For this eye (since it is too short in its antero-posterior axis) all objects have to be focused by muscular effort, irrespective of their distance from the eye- Such an eye is never passive. It has no rest while the body is awake. It is always straining more or less intensely to bring properly upon the retina the images of objects seen. The "hyperopic" condition of the eye, or "far-sightedness," as it is called, is a very common defect. It is especially frequent in persons of tubercular parentage. It is well, therefore, to suspect the existence of this defect in children or adults whose ancestors have died of " consumption." Again, speaking of muscular anomalies, I use the follow- ing illustration : A high-couraged horse feels the will, as well as the sup- port, of his driver through the reins by means of the bit. Al- though Lis course and rate of speed are changed from time to time at the will of the driver, the reins are never slackened. The horse becomes acquainted with the desires of his master by a sense of increased or diminished tension upon the reins. He is guided to either side by a difference in the tension of the two, although the driver does not entirely relax his hold upon the 6 TREATMENT OF FUNCTIONAL NERVOUS DISEASES opposing rein while he uses the guiding one, and the difference in tension may be very slight. So it is with the normal eye. It is both controlled and supported while performing its movements within the orbit by the eye-muscles (which are its reins). The brain is the driver. At its command the eye revolves, or remains stationary at any desired point. The. tension of muscles, opposed to any move- ment of the eye required, is so modified by the brain as to insure the requisite support to the eyeball, and to steady it as it moves. Thus, a perfect equipoise is constantly established between op- posing forces, adjusted with the nicest care to meet the full requirements of the organ under all possible circumstances. The normal eye does not tremble or wabble when it moves or the attempt is made to hold it in any fixed attitude. It is a piece of machinery, perfect in all its parts, reliable in its movements, perfectly controlled by its master. The eye with " muscular insufficiency " is like a horse with an inexperienced and incompetent driver; the proper tension upon the reins is not maintained at all times, as it should be; there is no equilibrium between antagonistic muscles ; fixed at- titudes are maintained with difficulty for any length of time; the brain becomes more or less disturbed by its inability to properly control the eye-movements, and exhausted by the con- tinual strain imposed upon it by the efforts required to do so even imperfectly. A point may now be raised concerning which some mis- apprehension seems to exist among medical men (judging from remarks which I occasionally hear expressed). I refer to the relationship of actual squint to nervous disturbances. No one can deny that people frequently live for long periods of time in houses impregnated with sewer-gas and in the most malarious regions without apparently suffering in consequence. Yet no intelligent man would attempt to prove to-day that sewer-gas poisoning and malarial infection were delusions simply because some people had escaped their influence. BY THE RELIEF OF EYE-STRAIN. 7 The argument lias been advanced that, because some cross-eyed people have escaped epilepsy, chorea, insanity, and functional neuroses of the milder types, it is erroneous to maintain that eye-strain has anything to do with these conditions. This is absurd upon its face. The hint might, perhaps, be pertinently dropped in this connection that cross-eyed people practically suffer but little from their mus- cular error, simply because they have habitual double vision, which no effort on their part can correct. These subjects learn very quickly to practically discard one image (the one seen by the crossed-eye) and to use one eye only for ordi- nary vision. In other words, they never try to blend the images of the two eyes, except in certain attitudes of the head which result in a single visual image, without an effort on the part of the patient. It is only in those cases where (in spite of a muscular error) the images of the two eyes can be blended by a great effort that the patient begins to experience the deleterious physical influences of abnormal muscular tension in the orbit. If we admit the proposition that eye defects, or anoma- lies of the ocular muscles, are liable to become causes of impaired nervous energy (because they demand an excess of nervous expenditure), we are forced to the conclusion that the earlier this source of physical depression is re- moved the better are the prospects of the person so relieved of escaping diseases which impaired nervous energy neces- sarily tends to hasten or develop. We are naturally led to question if the so-called " neuropathic predisposition " is not dependent (in a certain proportion of cases, to say the least) upon " eye-strain." We might possibly also be led to think that the so-called "tubercular tendency" (which is present, as far as my observation goes, in nearly 50 per cent, of all cases of marked functional nervous disease) might, in 8 TREATMENT OF FUNCTIONAL NERVOUS DISEASES some cases, be modified, controlled, or perhaps arrested be- fore its physical results become apparent by taking from the life of such subjects a load which their small reserve capital of nervous energy particularly unfits them to endure. It is hard to give up the view, so universally conceded, that a predisposition to disease means a " constitutional taint." Yet, in many cases, we are absolutely unable to demonstrate that any evidence of physical weakness or dis- ease has appeared until sufficient time had elapsed from the date of birth for the development of a serious impairment of nervous energy. What has caused it ? Has it been de- ficient nourishment, a lack of maternal care or solicitude during childhood, gross violations of the rules of hygiene, or a lack of prudence on the part of the individual when of matured experience? The history of case after case answers " no " to such surmises. These, then, are not the all-im- portant factors in every case. Phthisis, epilepsy, chorea, headaches, neuralgias, hysteria, dyspepsia, obstinate consti- pation, nervous prostration, inebriety, and many other evi- dences of the neurasthenic state are markedly hereditary. What is the load (if any) which many sufferers of this type are carrying through life ? Have they a congenital burden -which is, perhaps, too often unrecognized ? I leave these questions for future research to solve. In this lecture I will call your attention to a few cases selected from my own case-book where the relief of ocular defects produced remarkable and unexpected benefit after all hope of recovery had practically been abandoned by the patient. I bring these cases prominently before you in the inter- est of science only; because the improvement made by these patients is attributable not to drugs, but solely to Nature, when a burden of which she could not rid herself was taken away and recuperation became possible, BY THE RELIEF OF EYE-STRAIN. 9 Did you ever see a tired horse fall prostrate under an excessive burden ? How long would he remain so were the burden not removed ? Case I. Chronic Epilepsy.-Male, aged forty-three, mer- chant. Began to have severe epileptic fits when seventeen years of age. Had masturbated when a boy and had been ad- dicted in later years to excessive venery. Family History.-One brother is a confirmed dipsomaniac; the father died of paralysis; one sister is a victim to sick head- aches; no phthisis has existed in the family, so far as could be ascertained. The epileptic seizures of this patient varied in frequency from two or three a week to one in three months. He came under my care in 1871 (when twenty-eight years old), and was treated by me for many years with enormous doses of the bro- mides of potassium and sodium. These salts reduced the at- tacks to about four a year. Stopping the bromides invariably increased the frequency of the attacks. Eye defects*-In January, 1886, his eyes were examined after his return from an extended residence in the South. He showed under atropine a latent hyperopia of 2'50 D., and also a manifest esophoria of 4°. Subsequently several degrees of " latent " esophoria also manifested itself. Partial tenotomies were performed upon both interni, and hyperopic glasses were given him. Since the first operation (January, 1886) he has taken no bromides and has not had a convulsion. He has twice been "at death's door" with fevers, but he has shown at no time any epileptic tendencies. Case II. Excruciating Headaches, Chronic Diarrhoea, and Neuralgic Paroxysms.-Female, aged twelve. Family History.-The father is somewhat eccentric and in- temperate; pulmonary consumption was extremely common among the paternal ancestry ; one brother is an epileptic and is * For the meaning of terms employed in connection with muscular anomalies of the orbit, the reader is referred to the "New York Medi- cal Journal" for December 4, 1886, 10 TREATMENT OF FUNCTIONAL NERVOUS DISEASES partly idiotic; all the paternal side of the family are very ex- citable and nervous people. This little patient was a great sufferer. Whenever attempts were made by her parents to send her to school, she would "break down" at once with peculiar attacks characterized by obstinate vomiting, chronic diarrhoea, intractable headache, and neuralgic pains in the spine, limbs, and chest. All medical treatment had proved of no permanent benefit. So long as study was not attempted, the child suffered only at intervals with these severe attacks, but she remained weak and delicate. Eye-defects.-An examination of her eyes showed a latent hyperopia of nearly 3 D. and esophoria of 8°. Prior to the use of atropine she had normal vision (|~&). The wearing of spheric- al glasses (2 D.) and prisms (4° over each eye with the bases out) caused all her distressing symptoms to disappear within two weeks. A letter, lately received from her mother by me, says: "I thank you next to the dear Lord for removing this burden of anxiety about my child, which was becoming unbearable." Prisms were ordered in this case because the parents de- cided to postpone a radical correction of the muscular error. This step I expect to undertake very soon. Case III. Chronic Epilepsy.-Female, aged twenty, unmar- ried. Family History.-The father died of apoplexy. No heredi- tary tendency to nervous disease or phthisis could be discov- ered. The epileptic seizures had existed for five years and devel- oped after an excessive use of the eyes in sewing upon a black material. Menstruation was regular. The epileptic fits were, however, more frequent during the week prior to and follow- ing the menstrual epoch. Under large doses of bromides and ergot she had once in her history passed six weeks without an attack; but she averaged, when I first saw her, about six at- tacks each month. An epileptic attack could usually be induced \)y fixing the eyes for a few minutes intently upon some near ob- ject. She had at one time as high as thirty severe fits in twenty- four hours. When the bromides were withdrawn from this BY THE RELIEF OF EYE-STRAIN. 11 patient, the fits increased to several each day (often as high as ten severe seizures). She had for years suffered from obstinate constipation and pain during her menses. Eye-defects.-This patient was found to be absolutely em- metropic both before and after the use of atropine. She showed, however, an esophoria of 5° and a very low power of abduction. Subsequently, a large amount of latent esophoria developed. Several partial tenotomies were performed upon the interni of this patient during an interval of some four months until all latent esophoria was apparently overcome. After the first op- eration, the lacrymal secretion, which was singularly defective, became normal, her mental despondency disappeared, and her attacks rapidly diminished in frequency. Since June 10, 1886, she has had no fits to my knowledge, nor to that of her physi- cian so far as I can ascertain. The case was lost sight of by both of us some months ago, much to my regret. When I last tested her eyes, she showed no defect and was apparently in perfect health. She had passed several menstrual epochs with- out any epileptic seizures. In this case I would call attention (1) to the fact that emmetropia existed; (2) to the fact that the eye was the apparent exciting cause of her attacks; (3) to the fact that epileptic seizures could be induced by excessive use of the internal muscles of the eye; and (4) that the esophoria was " latent " to a very marked degree. In addition to these points of interest, another fact is worthy of passing remark-viz., that the relief of the " eye- strain " was followed in this case by a total disappearance of the habitual constipation that previously had existed, and that menstruation ceased to be accompanied by pain up to my last notes on the case. This experience, although ap- parently a coincidence, is not by any means infrequent with female patients in my experience, after a partial tenotomy of an eye-muscle for the relief of an abnormal tension with- in the orbit. It is probably to be attributed to the fact 12 TREATMENT OF FUNCTIONAL NERVOUS DISEASES that the nerve-power of the patient improves rapidly after the excessive expenditure of nerve-force demanded by abnormal eye-tension is arrested, thus allowing of an im- provement in the functions of the other viscera. My in- troductory remarks will, I trust, make this explanation clear to the audience and bring this statement more into apparent harmony with physiological laws. Case IV. Melancholia, Morbid Impulses, Cerebral Con- fusion and Distress, and an Intractable Prostatic Neuralgia.- Male, aged twenty-three, unmarried. Family History.-The mother of the patient suffers from neuralgia and headache. The paternal grandfather had paraly- sis. The paternal grandmother was " extremely delicate." One brother suffers from headaches. Another brother is very ex- citable and of a highly nervous temperament. No case of con- sumption has ever occurred in any branch of the family. Eye-defects.-Hyperopia (latent) of 2'50 D. Esophoria (mani- fest) 4°. Subsequently, 12° were elicited prior to any operative procedure. This patient had been under medical care for many months for a prostatic neuralgia, and had derived no benefit from local or general treatment. He developed melancholia, and would frequently retrace his steps for several blocks, during a stroll, in order to touch some object which he felt he should have touched when he passed it. The use of his eyes intensified his mental symptoms markedly. He also suffered from morbid fears. He had never had venereal disease. After partial tenotomies were performed upon his interni, and his hypermetropia was corrected by +1'50 spherical glasses, his recovery was very rapid and com- plete. He has had no abnormal mental symptoms or neuralgia of his prostate since the first operation (now nearly two years). His father, one brother, and a sister have since been examined by me, and all had very marked eye-defect. In some respects this is one of the most remarkable cases I have yet observed. The mental condition of the patient, prior to the relief of eye-tension, was such as to BY THE RELIEF OF EYE-STRAIN. 13 justify the worst forebodings. Neither he nor his family had ever suspected any eye-defect in spite of the fact that his " latent" hyperopia was of a very high degree (nearly 3 D.), and his " latent " esophoria was of an equally high degree. His prostatic neuralgia was of a severe and intractable type, and its cause could not be discovered; yet it disappeared at once after a free operation upon the interni. Case V. Cerebral Neurasthenia, Pseudo-ataxia, and Chronic Headache.-Male, married, aged forty-three. Family History.-Two brothers died of phthisis, one uncle of paralysis; maternal ancestors are nervously predisposed; two children of the patient suffer from nervous disturbances. Eye-defects.-Hyperopia (latent) of 2 D. Esophoria of 7° (manifest). This gentleman was a great sufferer. Had been forced to give up his business from constant distress in the head, which was aggravated by any mental labor. He walked with difficulty on account of a feeling of great insecurity, and closely simu- lated the gait of an ataxic. He ate poorly and slept badly. No organic disease could be found, and electrical treatment was thoroughly tried, and proved of little benefit. Within twenty- four hours after a tenotomy of his internal rectus was per- formed he ceased to have pain in his head, walked with greater ease than for many months, and left for his distant home with- in a week, provided with + 1 D. spherical glasses. The last report from him noted a slight tendency toward a return of his bad feelings, and he was advised to have his eyes again exam- ined to ascertain if any latent esophoria remained to be cor- rected. In his last letter he says: "I have not had a sick-headache since leaving New York, and much less of the neuralgic pain in the neck and other parts." Cases VI and VII. Asthenopia and Sick-headaches.-Males, unmarried, aged twenty-one and twenty-two. Both were col- lege students. Family History.-Headaches were common in their imme- 14 - TREATMENT OF FUNCTIONAL NERVOUS DISEASES diate relatives and ancestors, and in one phthisis was found to have affected the ancestry. Eye-defects.-Both had slight latent hyperopia and esophoria (manifest) of a moderate degree. These were typical cases of asthenopia and sick-headache. Both wore prisms for a while with benefit, but they found that a latent esophoria showed itself, and required a change of the strength of the prisms. The stronger prisms caused them some distress in walking. They both underwent an operation for the radical correction of the defect, and have remained entirely free from asthenopic symptoms and headache up to the present time. The necessity of wearing glasses, which was thus dis- pensed with, is a matter of delight to both. In one of these cases a marked tendency to dyspepsia and chronic constipation has apparently been entirely overcome. This fact was also noted in Case III. The last tests made of the eyes of these patients showed an entire absence of muscular defect in the orbits. Case VIII. Cerebral Neurasthenia, Constant Pain in the Head of Five Years' Duration, Asthenopia, etc.-Female, unmar- ried, aged twenty-one years. Family History.-Maternal aunt and five paternal relatives died of phthisis; two cousins had chronic chorea. Eye-defects.-Patient had hyperopia (latent) of l-25 D. and exophoria (manifest) of 2°. A latent hyperphoria of 2° was subsequently discovered. This young lady was brought into my office by two assist- ants, who were obliged to carry her from the carriage. For several years she had been carried daily from her room to the library of her father's house, and, after reclining in a chair for a few hours, she would be again carried to her bedroom. She could manage with difficulty to walk slowly across a room. She had not been able to write, read, sew, or see her most inti- mate friends for five years on account of a constant pain in her head, which was rendered intolerable by any use of the eyes or excitement. Her symptoms began while at boarding-school, from which she was removed to her home in a recumbent post- ure and by easy stages. BY THE RELIEF OF EYE-STRAIN. 15 I used static electricity upon this patient for some weeks with a slight improvement in her power of walking, but no re- lief to her head. I then persuaded her to consent to a relief (by partial tenotomies) of her abnormal eye-tension. Tenoto- mies were then performed upon her left superior rectus and both extern! within the space of two weeks. From that date her improvement was very rapid. She was sent home a few weeks later practically cured. A letter from her physician, lately received by me, says: "Your patient is the wonder of this region. She rivals the 'Jersey Lily' in her feats of walking." Before this patient was sent home she ascended and de- scended five flights of stairs daily, and averaged over a mile's walk each day without a companion to assist her. Case IX. Spinal Neurasthenia ; Gastralgic Attacks; At- tacks of Laryngeal Spasm; Persistent Tremor.-Female, mar- ried, aged forty-two. Family History.-Several blood-relatives died of phthisis; father and brother died of phthisis. Eye-defects.-The patient was found to be emmetropic (when under atropine). Esophoria (manifest) of 3° existed. This is quite as striking a case as the one last narrated, al- though of a different character. The patient had been for six- teen years a chronic invalid. She was unable to bear the least excitement. Even the companionship of her family for an evening was at times too great a strain upon her nervous sys- tem. She was at times a great sufferer from severe paroxysms of neuralgia of the stomach, and frequent attacks of alarming shortness of breath and a sense of impending suffocation would occur. I personally witnessed one of these attacks in my office, and it was entirely free from a trace even of hysteria. It was of much shorter duration than an asthmatic attack, and seemed to be due to a spasm of the larynx. She became markedly cya- notic, and suffered alarming shortness of breath. In addition to these symptoms, this patient suffered from an uncontrollable trembling of the facial muscles and limbs when at all startled or excited. She had been for years unable to attend places of amusement or to bear physical exertion. 16 TREATMENT OF FUNCTIONAL NERVOUS DISEASES Much to my surprise (as she had a marked phthisical his- tory), an examination of her eyes showed no refractive error (even when under the influence of atropine). She showed, however, a very high degree of esophoria, and a partial tenoto- my was performed upon both of her interni. The effect was magical. She recovered her health completely within two months, and is to-day able to endure as much as when a young girl. The last report from her, some weeks ago, states that she had "shopped all day and attended the theatre in the evening." An old friend of the family lately alluded to the case, in ray presence, as one "not of cure, but of resurrection." Case X. Chronic Chorea of Thirty-one Years1 Duration, affecting the Head, Face, and all the Extremities.-Female, aged thirty-three, unmarried. Family History.-The father had pulmonary haemorrhages for many years. One paternal aunt died of " hasty consump- tion." Sick-headaches are very common among both paternal and maternal ancestors. Neuralgia is a frequent complaint among the paternal ancestors. When two years of age this girl developed chorea. The spasmodic twitchings steadily grew worse, in spite of the fact that her father was a physician, and that she had the services of the most skillful medical men from time to time. The twitchings began on the right side; but they subsequently in- volved the left side, and also the head and face. She has suffered some from sick-headaches, as has also her sister. The hands have gradually become so contractured that all attempts to use them are more or less distressing. Her fin- gers could not be extended farther than would suffice to grasp small objects. When I first saw this patient she was unable to write except by grasping the pencil with all the fingers and the palm of the left hand, and holding the left hand with the right hand as the spasmodic movements of writing were made. She walked with a peculiar unsteady and crab like gait, ate with difficulty, and suffered great pain between the shoulder-blades and over the first lumbar vertebra (two points, by the way, which are very frequently attacked, in my experience, when eye-strain is pres- BY THE RELIEF OF EYE-STRAIN. 17 ent). She had never written with ink. Prior to menstrua- tion (which occurred at seventeen years of age) the patient had experienced attacks (probably epileptic) which she describes as " those of numbness, followed by a loss of consciousness." She has had chronic constipation all her life. The memory and mental faculties are perfect. When I first saw this patient the spasms were very violent, especially about the face and neck. The limbs were jerked about, the fingers too tightly clinched at times to grasp any- thing, and the speech was rendered peculiarly spasmodic and al- most unintelligible at times. She sputtered, and at times ejected drops of saliva, when endeavoring to converse. At the first examination she exhibited no refractive error; but, under atropine, a high degree of hyperopia (1 -75 D.) was detected, and proper spherical glasses (4-1 D.) were at once pro- vided. In order to test her eye-muscles, the services of Pro- fessor J. Williston Wright, of this city, who saw her with me by invitation, were invoked to hold her head. This he did with no small effort by clasping the head on either side, and firmly pressing her head against his body as he stood behind her chair. During this examination she whistled shrill notes on two occa- sions, and underwent the most violent facial and body contortions. The results of this imperfect examination (necessarily so under such conditions) indicated to me that a high degree of hyperphoria existed ; and, as I could not again see the patient for some months, I decided to perform a free division of the left inferior rectus muscle. I then instructed the patient to try and get a photograph taken, if possible, before she saw me again. She laughingly said that she "had never been able to have a picture taken, but that she would do so if she could." She then departed for her home with instructions to return to me for treatment in the autumn. The first picture of this case is one that she was able to have taken three weeks after the operation, when her head and shoulders had become comparatively calm, as a result of the relief afforded by it. This photograph was deemed at that time a great success by herself and friends. You can see in it the blurred outlines which indicate that the move- ments were still somewhat active. 18 TREATMENT OF FUNCTIONAL NERVOUS DISEASES During the past autumn this patient has been under my care for some eight weeks. I have partially divided the right superior rectus and both externi in order to overcome a high degree of left hyperphoria and exophoria, and I have administered static sparks daily to the spine and limbs. The second picture will give, better than words can describe it, an idea of the wonder- ful improvement which has taken place. Prior to her depart- ure for her home (some weeks since) she could thread the finest cambric-needle, and pass her fare to the conductor of a street- car without attracting the notice of passengers, or throwing it out of the window, as she certainly would have been apt to do two months previously. She can fully extend her fingers, walk several miles a day, write with far greater certainty and ease, and eat at a boarding-house table without exciting comment. Her limbs still twitch somewhat immediately before going to sleep, and, in the presence of .strangers or when unduly excited, she still shows some spasmodic movements of the face and shoulders. When calm she is, however, perfectly composed, and almost entirely free from convulsive movements. She considers herself as practically cured; but I suspect that time and some further operative work upon the eye-muscles will be demanded before complete restoration to health is effected. As I regard this case as one of the most distressing and typical cases of chronic chorea ever reported, it may be well to state that the patient is well known to Professor A. M. Phelps and Professor J. AV. Wright, of this city, and Pro- fessor Woodward, of Burlington, Vt., and that she has been seen by many members of the profession both from this city and distant States during her treatment in my office. During the whole treatment of this patient no drugs have been employed, and the photographs are from un- touched negatives. I attribute to the static applications the rapid relief of the contractured state of the fingers and the improvement in her general strength ; but, from many facts observed during my treatment of her, I am convinced that BY THE RELIEF OF EYE-STRAIN. 19 the relief of the eye-strain is alone deserving of whatever credit may be claimed for her recovery. Four weeks before she was dismissed from my care she read and sewed con- tinuously for several days, and was immediately precipi- tated into a relapse, which as rapidly subsided when the cause was ascertained and its recurrence prevented. Case XI. Chronic Epilepsy.-Male, unmarried, aged twen- ty years. Family History.-No consumption among the ancestors or immediate family. Several members of the family suffer from headaches. Eye-defects.-Hyperopic astigmatism (0'75 De. and 0'50 De.) ; esophoria (manifest) of 6° ; and latent hyperphoria of a very high degree. The latter has proved very persistent, and has only lately been satisfactorily corrected. The progress of the case has also demonstrated that a high degree of latent eso- phoria had to be corrected in excess of what he at first mani- fested. This patient was a victim to the severest type of chronic epilepsy. His attacks were extremely frequent and severe. Going from light into darkness would invariably cause an attack and a total loss of consciousness. I personally attended him, in connection with Dr. G. W. Leonard, of New York, when he had fifty-two epileptic seizures in eight hours, each fit lasting exactly three minutes. All medicinal treatment had proved inoperative. His attacks began while he was at school as a child, and were preceded by a difficulty for months of keeping his place on a page while reading. lie used to hold his finger on the line to aid him in reading. His improvement, after repeated tenotomies upon both in- terni and the left superior rectus, has been most remarkable. His attacks have been decreased over 75 per cent. He is still under observation, with a prospect of still greater improvement, if not of a permanent cure. He has taken no bromides or medi- cine of any kind save an occasional diuretic (tincture of iron) for sluggish kidneys. 20 TREATMENT OF FUNCTIONAL NERVOUS DISEASES The photographs of this patient, which I now exhibit to you, hardly show the happy change which has occurred since the last was taken, in spite of the complete cessation of the bromides for about eighteen months. In place of the dull, apathetic, and sluggish features which indicate the impaired mental state of the patient from the bromides, you can see in the second photograph the animated expression and the shortening of the face, which are much more apparent to-day even than when it was taken. The change in his general health and physical strength has been even more marked than his facial changes. Case XII. Chronic Epilepsy. - Female, unmarried, aged nineteen years. Family History.-Paternal grandmother died of phthisis. The mother has migraine. The brother has migraine. A pa- ternal aunt was insane. Eye-defects.-A high degree of myopia (S'TS D.) and myopic astigmatism (1*50 D.). Esophoria (manifest) of 9°. A high degree of latent hyperphoria was also discovered later. Prior to my first examination this young lady was consid- ered a hopeless epileptic. She had been for years under the care of several of our most noted neurologists and oculists. After a partial relief of her abnormal eye-tension by tenotomies, she went over seven months without an attack, and regained her mental faculties, which had been somewhat impaired by bromides. Within the past four months she has had six attacks of epilepsy, two of which followed fright, one an imprudence in eating salads very late and immediately before going to bed, and the fourth after the excitement attending a departure for a pleasure excursion. She has lately manifested a latent muscu- lar defect which I have yet to overcome. From a letter ad- dressed me by her father not long since I quote the following paragraphs: " Nothing but an inability on my part to pay for your ser- vices would persuade me to remove my daughtei1 from your BY THE RELIEF OF EYE-STRAIN. 21 care, and if I could not pay, I would ask you for charity to keep her. " Her whole being has been altered, and her physical condi- tion is better than for eight years." The photographs of this patient, which I now exhibit, show a very marked alteration in her physical and mental states, as a result of the relief of the muscular errors de- tected in the orbits. She is now allowed to enjoy privi- leges which were considered impracticable prior to this treatment, such as an unrestricted diet, horseback exercise, visits to the city unattended, attendance at social gather- ings, etc. As this case is well known to some prominent medical men of this city, it may be proper for me to state that since October 10, 1886 (some fifteen months), this patient has had but eight epileptic seizures. Prior to that date my records go to show that, even when under bromides, from one to six fits a day often occurred, and that the nocturnal attacks (which were very frequent) were not always noted. It is safe, therefore, to say that, had she received no medicinal treatment or correction of her eye-defects during the past fifteen months, the total number of seizures would probably have been more than a hundred times this number. She had been known to have as high as seventeen epileptic seiz- ures during one night. Her attendant has assured me that since my treatment was commenced all nocturnal attacks have ceased. The point may be raised that a report of any epileptic case, until the full limit of three years has been passed without an attack and without the employment of any medicine which would control the epileptic tendency, must be considered as somewhat premature. In reply, I would say that the cases I have brought forward are not repre- sented as cases of radical cure. They are adduced simply TREATMENT OF FUNCTIONAL NERVOUS DISEASES 22 as a clinical evidence that the frequency of such attacks has been greatly modified, and in two instances completely con- trolled for long periods of time without the aid of drugs. On the other hand, there are now to my knowledge several cases of chronic epilepsy similarly treated that might be brought forward (did I deem it necessary to quote from the experience of another) which have fulfilled all the require- ments which would justify the belief in a radical cure of chronic epilepsy. One of these patients lias passed over seven years without a fit, and several have exceeded the three-year limit. We all admit, I think, that epilepsy is certainly the gravest of all the functional nervous maladies, and that it is, as a rule, incurable by drugs; hence, as I have remarked in a previous discussion concerning this subject, " one radi- cal cure of epilepsy without the aid of drugs offsets a thou- sand failures as a scientific proof of a discovery." It is impossible for any one not familiar with the diffi- culties encountered in the treatment of these subjects (al- ready discussed) to appreciate the fact that, in some cases of epilepsy, eye-defects may exist which can not be thor- oughly rectified; and that, even in favorable cases, time and patience are important factors in the treatment. Epileptics usually present, in my experience, in addition to errors of refraction, anomalies in both the lateral and vertical movements of the eyes ; and in some cases the oblique movements are probably at fault. Moreover, ex- perience with these subjects demonstrates clearly to my mind that the muscular anomalies which exist are generally " latent " to a marked degree. It should be remembered also that a victim to chronic epilepsy who is rendered by any treatment as free from at- tacks without the bromides as he was when under their dele- terious influence, has been very markedly benefited ; again, BY THE RELIEF OF EYE-STRAIN. 23 that if a marked diminution of the attacks has been effect- ed, the patient has double cause for gratitude ; finally, that if the attacks are arrested in toto without drugs, it is to-day one of the most remarkable facts recorded in medical litera- ture. There is a point where opposition to carefully made clinical statistics respecting new views ceases to be con- servatism. True conservatism is the brake upon the engine of progress. It is to be used in checking its speed when going too fast, but not in preventing its advance, even if the country is an unexplored field. Too often in medicine the term conservatism has become a favorite synonym for bigotry and intolerance. Respecting the relationship of chorea to anomalies of the visual apparatus I would make the following suggestions: 1. Choreic subjects belong to one of two classes: (1) Those who tend to get well under almost any treatment or even without treatment, and (2) those who fail to get re- lief from any medicinal aid. The latter tend to run a chronic course, usually one of unfavorable progression. 2. The chronic form of chorea is one of the most serious and hopeless of nervous maladies. It is not infrequently associated with epilepsy or with mental impairment. 3. Both forms of chorea are based, as a rule, upon a well-marked neuropathic or tubercular predisposition. 4. The pathology of chorea is not known. No one has ever proved that it was a " constitutional disease," in the sense that an organic lesion was essential to its develop- ment. Now, the remarkable case which I report belonged, without question, to the class which I think is generally regarded by neurologists as incurable, and as offering but little hope of marked improvement under any form of medi- cation. In this girl, at least, all such attempts at relief had 24 TREATMENT OF FUNCTIONAL NERVOUS DISEASES proved of no benefit. The convulsive movements had per- sisted for over thirty years, and the condition of the patient has steadily grown worse in spite of the best medical care. She had probably had a few epileptic seizures in girlhood, but her mind had remained unimpaired. When Dr. G. T. Stevens read his paper on the relation- ship between refractive errors and chorea in 1876, he ad- vanced views that were new to the profession. Within a year a paper on the same subject was published by an- other,* in which the view of Dr. Stevens, that hyperopia constituted an important element in most cases of chorea, was very stongly combated. The latter paper has been quite extensively quoted. It may not be inappropriate for me, therefore, to carefully analyze the paper referred to in this connection, as I feel that the conclusions of the critical reviewer are misleading, and certainly not in accord with my own observations. This observer drew his conclusions from an examination of thirty-one cases of chorea, most of which, if not all, were taken from dispensaries. It is safe to infer, therefore, that the patients were not well educated. They may not have even known their letters sufficiently well to be regarded as accurate in reading test-type. In the second place, the ages of the thirty-one patients reported show that twenty-two were less than twelve years of age. Four were six years of age, and one was only three and a half; one was seven, three were eight, three were nine, four were ten, and six were eleven years old. The question naturally arises whether (at these ages) the tests of vision usually made by the aid of test-types when the patient is well under atropine are reliable in children that are pre- sumably ignorant. In the third place, seventeen out of the thirty-one pa- * Dr. 0. S. Bull, "Med. Record," June, 1877. BY THE RELIEF OF EYE-STRAIN. 25 tients were found to be emmetropic in one eye or both when atropine was used by this observer. This is certainly a very remarkable fact, as it is a proportion which is contradicted by statistics gathered by equally competent observers from the examination of children's eyes under atropine.* In the fourth place, the percentage of hyperopia and hyperopic astigmatism combined constitutes, according to this observer, about 55 per cent, of the total number. No myopia or myopic astigmatism was detected in any of the thirty-one cases. The latter fact is remarkable, and seems to cast further doubt upon the cases reported as " emme- tropic." Again, nineteen of the thirty-one patients are reported as having had " insufficiency of the interni." Now, I have examined within the last three years the eyes of a very large number of patients who were afflicted- with various nervous disorders, and I have given special attention to the state of the eye-muscles detected by appropriate tests in these cases. I have found the condition of "insufficiency of the interni" to be a comparatively rare one when Graefe's test was employed with the test-object (preferably a candle- flame) at twenty feet from the eye. It is reasonable to infer, therefore, that the tests made by this observer were such as to require accommodative efforts (probably the line- and-dot test at fourteen inches). Such tests, if made under atropine, are certainly open to criticism and probable cor- rection. Even if not made under atropine, this form of test is only of value in connection with the other. * Cohn shows that, in 299 eyes under atropine, no case of absolute emmetropia was detected. Hausen found but 26 emmetropic eyes in 1,610, and Durr but 30 in 414. A. Randall states, in his article on " The Refraction of the Human Eye, a Critical Study of the Examina- nations of the Refraction, especially among School-children" (''Am. Jour, of the Med. Sci.," July, 1885), that only per cent, of 1,834 eyes of infants and school-children were found to be emmetropic. 26 TREATMENT OF FUNCTIONAL NERVOUS DISEASES The critical reviewer mentions a certain "Martin fami- ly " as a proof to his mind that a " neurotic taint " exists in choreic subjects. Now, the four choreics of this family were all hyperopic, while five who were not so had no chorea. This fact would seem to confirm Dr. Stevens's view. No one disputes the fact that a " neurotic predisposition " is present in most choreic subjects; but the view that eye- defect tends to create this tendency seems to be less gen- erally accepted. Finally, the paper here referred to notes a failure to re- lieve the chorea by the use of glasses, in a few cases where the patients were able to purchase them. If other serious defects existed besides the hyperopia (to the extent shown in the examinations reported by this observer), this is not to be wondered at. Hyperopic glasses will not relieve "in- sufficiency of the interni" (frequently noted by this ob- server in his choreic subjects) ; and the latter is certainly a well-accepted cause of reflex disturbances when it exists, as well as the latent hyperopia that was alone corrected. In preparing this lecture I have looked carefully over the records of all cases of chorea which I have personally tested for anomalies of the visual apparatus. I have not found a single case where either "manifest" or "latent" hyperopia did not exist. I do not mean to assert that this statement proves anything-but it certainly seems a very strange co- incidence, if such it is. Respecting the "neurotic taint" to which this reviewer attributes the origin of chorea, I would respectfully refer my hearers to a study of this question and its dependency upon anomalies of the visual apparatus in a paper previous- ly quoted from,* and also to tables of a similar purport published (since that article was read at the International * " Med. Register," November 19, 1887. BY THE RELIEF OF EYE-STRAIN. 27 Medical Congress) by Dr. George T. Stevens, in his work on " Functional Nervous Diseases." * I feel that I must add one statement in reference to the dependence of typical sick headaches and intractable neu- ralgias upon eye-strain. For ten years past I have stated in my lectures that I had yet to encounter a case of typical and periodical sick- headache in which the eyes themselves or the eye-muscles were not at fault. I have never seen any occasion to modify or retract this apparently sweeping assertion. Respecting chronic neuralgia, my experience teaches me that eye-strain is its cause in a very large percentage of such cases. I would state, however, that I do not regard ophthal- moscopic tests for latent refractive errors as conclusive,! because I have too often found such examinations (even when made by those most skilled in that special line of work) to be in error. I have detected this error by means of the full effects of atropine upon the accommodation of the pa- tient and the employment of Snellen's test-types. In very young children, and in the ignorant classes who can not read test-type, the ophthalmoscope unavoidably becomes the only means of determining refractive errors with an approach to accuracy. * D. Appleton & Co., 1887. ■f There are two sources of error which are possible in all ophthal- moscopic examinations as a step toward the determination of refrac- tion. The first of these is that the observer may not be able to per- fectly relax his own accommodation while using the instrument. Most oculists of large experience believe that they can do this with certainty -a belief which is perhaps not always well founded. The second source of error lies in the accommodation of the patient. This can not always be relaxed by instructing the patient to look at an object twenty or more feet distant from the eye. I am satisfied that mistakes in the determination of refractive errors by the ophthalmoscope are far more frequent than are generally supposed. For the past three years I have 28 TREATMENT OF FUNCTIONAL NERVOUS DISEASES The muscular apparatus of the organ of vision is too in- timately associated with sight-perceptions (because such examined the eyes of almost every patient intrusted to my care by the aid of test-type after the pupils have been fully dilated by atropine. I am not aware that I have ever lost a patient by the use of this drug. In my experience, intelligent persons are always willing to submit to a temporary inconvenience for the purpose of obtaining positive in- formation respecting any point that is deemed of scientific value in relation to themselves. I have personally come to regard the ophthal- moscope as an unreliable instrument for the determination of refrac- tion. Its use is rendered compulsory, however, in very young children, and in those who, from ignorance or feeble-mindedness, are unreliable in their reading of test-type. It is generally accepted, furthermore, among our best oculists that astigmatism (a recognized source of nervous perplexity) is always estimated more accurately with the pupil widely dilated by atropine than with the normal pupil. The reasons which I have already given must suffice to explain why the use of atropine con- stitutes a most important preliminary step to the detection and estima- tion of any error in the eye-muscles, although many other arguments might be brought forward to prove its advisability in some subjects. Again, the view is held that no examination for suspected muscular error in the orbit should be regarded as conclusive for diagnosis, or as a basis for any surgical procedure, until the eye has been proved to be free from refractive error, or rendered as nearly emmetropic as possible by properly selected glasses. It is, of course, advisable during the first interview with each patient to note and record any " manifest " defect in sight. If such exists, each eye should be provided with the glass which gives the best vision for each eye (the two eyes being always tested independently of each other). After such correction, the different tests employed to detect muscular anomalies should then be made, and the results of each test should be recorded as the " manifest muscular error." At the second interview, with the pupils fully dilated by atro- pine, the same steps should be repeated. We thus learn, in many cases, the existence of refractive conditions which the first interview did not reveal. We record such as " latent " refractive conditions. By the aid of suitable glasses any latent refractive error found is then to be cor- rected ; subsequent to this correction the muscular movements are to be tested with each eye temporarily adjusted to distant vision by suit- able glasses. BY THE RELIEF OF EYE-STRAIN. 29 perceptions serve to call the eye-muscles indirectly into ac- tion and to regulate eye-movements) to be physiologically considered as an independent piece of mechanism from the eye itself; hence in all cases it is vital to success in treat- ment that the nearest possible approach to emmetropia should be obtained in every patient before the muscles are examined for disturbances of equilibrium. Very marked disturbances in the proper adjustment and tension of the eye-muscles which apparently exist in some subjects may be modified or be totally corrected in some patients by the fitting of a proper glass to each eye. Now, I would call attention to a very important clini- cal fact-viz., that the amount of error detected in any given case, when the eye-muscles are tested, does not neces- sarily indicate the full amount of abnormal eye-tension that actually exists. The results of ordinary tests simply tell us how much eye-tension exists which the patient can not over- come by any effort of which he is capable. Upon this one point too great stress can not be laid, as it sheds much light upon the clinical history of many patients who suffer from eye-strain. All authorities recognize the fact to-day that a patient may have a very marked congenital shallowness of the eye, and apparently have normal vision, or possibly ap- pear to be even near-sighted prior to the use of atropine. Subsequently to its use, the same patient will, however, show a high degree of far-sightedness (hypermetropia), be- cause the ciliary muscle (temporarily paralyzed by the atro- pine) can not overcome or (to speak more technically) com- pensate for the abnormal shallowness of the eye. Unfortu- nately for science, we have as yet no drug which aids us in determining the existence of a " latent " muscular error in the orbit, as we are now able to do by the aid of atropine in case a latent refractive error is suspected to exist in a patient. Yet are we justified in concluding that latent muscular TREATMENT OF FUNCTIONAL NERVOUS DISEASES 30 anomalies do not exist? Most assuredly not. There is the strongest clinical evidence to the contrary. A few months ago I examined tlie eyes of a prominent physician on three consecutive days, and I was unable to detect (either before or after prismatic exercise of his eye-muscles) any change in his ocular condition from the one noted at the first ex- amination. His symptoms, however, led me to believe that a greater muscular error existed than he showed, although the anomaly detected was a very marked and important one. I therefore instructed him to wear a prism until the next examination, which fully corrected the error then de- tected. Less than two hours later I accidentally had the opportunity of again examining bis eyes. His muscular error was then, to my surprise, exactly double what it origi- nally appeared to be. He was again given a full prismatic correction for the defect detected. Twenty-four hours later he was examined for the fifth time, and he still showed an excess of two degrees over the record of the day previous. He was again given a full prismatic correction; but from that time he failed to exhibit any further alteration in his ocular tests. The relief afforded by prisms * was so instan- * Prismatic glasses are not only inadequate as satisfactory remedial agents in most cases, but they may be positively injurious to certain classes of patients. Few, if any, of our prominent oculists have per- haps ordered as many prismatic glasses as the chief advocate of the method now under discussion. Yet, in spite of this fact, strict limita- tions upon their field of usefulness (not generally taught) seem to be rendered probable by late investigations. A careful study of the dif- ferent movements of the eyeball, and of the combination of muscles required to produce some of them, must impress even the most casual reader with the idea that an agent (such, for example, as a strong prism) which tends to restrict the movements of any one muscle may do harm if persistently worn. Some patients are peculiarly susceptible to such influences. I have encountered a large number of patients whose eyes refused to tolerate a prismatic glass. Their symptoms were at once made worse whenever they attempted to correct an existing muscular BY THE BELIEF OF EYE-STRAIN. 31 taneous and permanent (while they were worn) as to prove conclusively that the prisms were wisely selected, and that anomaly by wearing a prismatic glass. On the other hand, many pa- tients are benefited at once by the use of prisms, and suffer no incon- venience of any kind from them. What are we to infer from this state- ment ? Are we to surmise that the prisms were either injudiciously selected or improperly placed, simply because the patient could not tolerate them ? I think not! Such might possibly be the case in the hands of a novice, but presumably it is not the case in the experience of one skilled in eye examinations. My own experience in several such instances has shown me that a tenotomy of the muscle exhibiting the greatest tension has been followed by a complete cessation of the nerv- ous symptoms for which the patient sought relief, in spite of the fact that prisms prescribed to correct the same error have proved intoler- able to the patient, and have markedly aggravated the symptoms. There is, however, a practical and important field for prismatic glasses. It is well to keep, as a part of a physician's office equipment, a large number of prisms of different angles. These can be slipped into a frame with the base inward, outward, upward, or downward, as the exigencies of any case seem to demand. They may be loaned from time to time to patients, for the purpose either of verifying a diagnosis or of developing a latent muscular error which the physician may be led (by repeated examinations of the patient) to suspect. When they are well tolerated, the physician may often learn a great deal by their protracted influence. When they are not well borne, it is advisable, as a rule, to discontinue their use at once. It is often wise to prescribe a prismatic glass, also, for a class of patients who are unable (for one reason or another) to submit at the time to tenotomy. Sooner or later, I find that such patients usually return. As a rule, they do so for one of the following reasons : (1) Because they have developed an additional "latent" muscular error, which the prisms naturally failed to correct; (2) because they do not tolerate them well, and are made decidedly worse by their use ; (8) because they prefer a tenotomy to the incon- venience of a glass which has to be constantly worn; and (4) because they suffer from eye-fatigue on account of the disturbance to co-ordi- nate movements of the eyeball. There is no doubt that very many per- sons with nervous diseases are materially helped (if not radically cured) by the aid of prismatic glasses ; but the question naturally arises to my mind in this connection, " Would they not have been more rapidly 32 TREATMENT OF FUNCTIONAL NERVOUS DISEASES the "latent" insufficiency which developed after their use more accurately represented his true condition than the original observations made at our first interview. I mention this case not because it is at all unique (for many such instances have been observed), but because it illustrates admirably the existence of "latent" insufficiency, which happened in this case to be developed by the tem- porary use of correcting prisms. In the second place, it is not at all uncommon to ob- serve the development of latent muscular anomalies in the orbit, sooner or later, after a partial tenotomy has been benefited and permanently relieved with far less inconvenience to the patient by tenotomy ? " The view is held that tenotomy is the only way of permanently relieving abnormal tension of a muscle in the orbit. There are only two ways of overcoming an abnormal tendency of the visual axes to deviate from parallelism whenever the eyes are di- rected upon an object more than twenty feet off. One of these is by the aid of a prism; the other is by tenotomy of the muscle which di- rectly aids in producing and perpetuating the deviating tendency. Whenever prisms are prescribed, they afford relief practically in the same way as a " rubber muscle" does in orthopasdic surgery; in other words, they compel the muscle which is opposed to the base of the prism worn by the patient to overcome the antagonistic muscle, and also to so adjust the eye as to compensate for the refractive effect of the prism. They practically act, therefore, as a " pulley-weight "-a mechanical device seen in all gymnasiums. Now, if the wearing of prisms had no deleterious action upon those particular muscles, which, in each case, are not at all at fault, and if they invariably exerted only beneficial effects, this principle of treatment could be more generally applied with benefit. Even then the existence of " latent " insufficiency might, unfortunately, remain unrecognized for a greater or less period of time, possibly to the serious detriment of the patient. On the other hand, if it is satisfactorily demonstrated that tenotomy has been ren- dered a safe and accurate method of correcting muscular anomalies in the orbit, a fact has certainly been noted that opens a new and shorter route to relief. Such a step enables us, moreover, to decide the ques- tion of "latent" muscular defects in any given case. BY THE RELIEF OF EYE-STRAIN. 33 satisfactorily and scientifically performed for the correction of a " manifest " muscular error. Sometimes quite a long interval elapses before latent insufficiency shows itself. Again, it shows itself almost immediately. An epileptic upon whom I operated for eye-defect,, who has now been free from attacks for over a year and a half, in spite of the cessation of all drugs, showed me originally only one degree of esophoria. This defect would, I think, have been heretofore regarded by most oculists as hardly worthy of correction, even by a prism. The subse- quent treatment of this case demanded repeated tenotomies upon both of the interni, and proves not only that I had a high degree of "latent " trouble to correct (which a one- degree prism would not have helped), but also that the at- tacks have thus far been totally arrested by the relief of ab- normal eye-tension. In the third place, it has been proved that systematic daily exercises of the various eye-muscles (accomplished by teaching the patient to fuse images which have been ren- dered momentarily double by a prism held before the eyes) will, in some cases, develop latent muscular anomalies of the orbit. In other words, patients, after a week's muscular drills will often show a greater flexibility of and control over the eye-muscles, and oftentimes the existence of a lack of equi- librium in the eye movements which they did not exhibit at the earlier examinations. I am aware that an injudicious use of such prismatic tests in the hands of a novice might cause " asthenopia,'' and seriously affect the muscular con- ditions of the orbit; but this fact can hardly be used, I think, by fair-minded critics to explain the phenomena, alluded to here. Finally, it may be stated in this connection that one ex- amination of the various eye movements is not, as a rule» 34 TREATMENT OF FUNCTIONAL NERVOUS DISEASES sufficient for a positive diagnosis respecting muscular anoma- lies. Repeated tests have often to be made before a com- plicated problem may be satisfactorily solved, even by an expert in this line of examination. Before I leave this subject it is but proper to say that the cases reported by me (while not a large number in the aggregate) were, without exception, well-marked cases of typical and intractable neuroses. The improvement noted in each case after well-directed treatment of the eyes or the eye-muscles tends to cast a doubt upon the existence of any organic disease. No. other causes of reflex nervous dis- turbances outside of the eyes were detected after a careful search in any of these cases ; otherwise it would have been my manifest duty to relieve all that were found in my efforts to benefit the symptoms manifested by each pa- tient. It is not to be expected, nor do I anticipate, that views so radically opposed to the ordinary methods of treatment by medication, now generally advocated for functional nerv- ous diseases, will be accepted at once by the profession at large, even if correct and satisfactorily demonstrated. No great advance in science has ever been made until time has tempered prejudice and modified the prevailing tendencies of thought. Of late years we, as a profession, have had our atten- tion drawn, however, more seriously than ever before to the clinical importance and the necessity of detection of re- mote sources of irritation to the nervous centers. We have already learned that the ovaries, the womb, the prepuce, the urethra, the rectum, the alimentary canal, etc., can, in some instances, induce serious nervous conditions which closely simulate the evidences of organic disease. Complete pa- ralysis of both legs has been known to be cured in a child by circumcision. The operation devised by Battey for the BY THE RELIEF OF EYE-STRAIN. 35 removal of the ovaries in subjects attacked with hystero- epilepsy is to-day sustained by the profession, and often performed with the view of removing a merely supposititious source of reflex disturbance. This supposition, in many cases, is based, unfortunately, upon data much less scientific and therefore less reliable than the tests employed to detect anomalies of the visual apparatus. It is safe to question, therefore, if the source of reflex irritation in many patients of this class has been carefully sought for, and if it does not lie more in the eyes than in healthy ovaries,* which are not infrequently sacrificed. Personally, I should not feel justified in taking so serious a step with any patient until every other possible cause of reflex disturbance had been carefully sought for in vain. There is no doubt that many physicians of prominence are devoting more attention to-day in their practical office work to the determination of latent refractive errors in the eye and disturbances of equilibrium in the eye-muscles than was their habit in years past. This long-neglected but important element in the "neu- ropathic tendency " (and perhaps also in the " tubercular predisposition") is now receiving from many sides the most thoughtful consideration. Sooner or later, in my opinion, our views,of the causes of functional nervous disease will no longer be those now advanced in most of the works de- voted to that field. We shall in time more clearly recog- nize the fact that drugs do more harm in functional neu- roses than good whenever any exciting cause of such a morbid condition persists and can be removed; just as we to-day rely, in case of a joint-disease, more upon mechanical separation of the surfaces of the inflamed joint than upon anodynes to relieve the pain. We shall learn to search more * Cysts in the ovary are seldom, if ever, wanting ; hence they can scarcely be pronounced (when small) an evidence of disease. 36 TREATMENT OF FUNCTIONAL NERVOUS DISEASES. carefully and intelligently for obscure causes of reflex dis- turbances, and to try the effect of their removal before we resort to drugs. Medication must eventually, in my opin- ion, become the dernier ressort of the physician, in this par- ticular class of nervous diseases, rather than the haven of refuge. J* J? REASONS WHY Physicians Should Subscribe FOR The New York Medical Journal, Edited by FRANK P. FOSTER, M. D., Published by D. APPLETON & CO., 1, 3, & 5 Bond St. 1. BECAUSE : It is the LEADING JOURNAL of America, and contains more reading-matter than any other journal of its class. 2. BECAUSE : It is the exponent of the most advanced scientific medical thought. 3. BECAUSE : Its contributors are among the most learned medical men of this country. 4. BECAUSE: Its "Original Articles" are the results of scientific observation and research, and are of infinite practical value to the general practitioner. 5. 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