neys calls for immediate relief, that we are for a time obliged to partly ignore the underlying trouble to save the life of the patient; but we should not forget that there is an underlying trouble. The usual remedies for nephritis are demanded. In those instanceswhich by the way are quite common-where the left heart is hypertrophied and there is much cardiac perturbation, the demand is well met by the barium salts, particularly the idodide. Arteriosclerosis is essentially a connective tissue disease; at least there is where the chief lesion lies. As I have been watching the action of barium for the past twenty-five years I have become more and more impressed with its control of connective tissue change, even extending to ectodermic glia tissue. The cardiac symptoms of barium are well known by all homoeopathic physicians. The property just mentioned makes it a valuable substitute for potassium iodide. To those who insist on giving strychnia in every case of over three weeks standing, let me beg such to hold their enthusiasm until the patient is well and strong enough to live through it. I honestly believe I have seen more people live in spite of strychnia than on account of it. A case such as was presented in the first part of the paper reminds one of opium, and there are stuperous and mentally weak cases where it does much good if given in minute doses; it helps to improve metabolism and overcome constipation. Some patients notwithstanding dulness and a sort of mental mist are very irritable and unreasonable, quick to show wrath; a few doses of anacardium will often work a very gratifying change. Electricity is rapidly coming to the fore and some remarkable results are being reported from use of high tension currents; it has the advantage of not interfering with other treatment. I often suspect that if we took as much pains to measure results after using medicines as after using electricity, our confidence in remedies would be considerably enhanced.

In concluding an already too long paper I would say: whenever a case presents of a person past fifty with persistent, or often recurring vertigo, mental slowness, and inconsistent neurasthenic. symptoms, and a careful examination shows no marked error in organs of special sense, and no organic error in renal or hepatic regions, examine very closely for signs of sclerosis in the arteries, inquire minutely if the habits of life would be productive of such. One word in correction: in sclerosis in the very young it has been claimed that heredity is an important factor. Our resources are medicine, electricity, and hygiene, but the greatest of these is hygiene.

Discussion by Dr. Edw. E. Allen.

"There is just one point that I should like to emphasize in the treatment of this disease, and it seems to me that it is plainly to be reasoned out when we take into consideration that it is an inflammation in the spinal cord, with a great amount of congestion there, and that right here the thing to do is to rest the patient. I mean by that to rest the patient and make him rest, put him on a Bradford frame, if necessary, and bind

him down for a certain number of hours each day, and keep the spine as rigid as it can be made, preventing it from bending.

"Supplementing that, of course, the thing for us to do as homœopaths is to get as good a remedy as we can, and I want to recommend gelsemium as the one that I have received the best results from."

Dr. N. M. Wood said that nutrition is one of the main elements in the after-treatment of this disease, and said that fifteen of twenty minutes' use of the electric baker is very beneficial because it brings the blood supply to the surface and nourishes the muscles.

Dr. Allen said that he had used the electric baker but found that wherever it was used too frequently furuncles appeared on the skin, especially around the hair follicles, and for that reason he had to stop using it.

Discussion by Dr. J. P. Sutherland.

"The treatment of arteriosclerosis embraces everything in the way of hygiene, sanitation, diet, pharmacotherapeutics and electrotherapeutics. No two cases are alike, and each case has to be treated on its own individual merits.

"I have devoted a little time within the past two or three days to thinking about this subject, and thought I would like very much to look up some of our text-books to find out what they had to say about it, and was surprised to find they had so little to say on the treatment of arteriosclerosis.

"In thinking of arteriosclerosis it has occurred to me to classify it in one of the three divisions of disease that I not infrequently make use of. One class consists of the cases that tend inevitably to recovery, the socalled infectious and self-limited diseases. Another class tends just as certainly to dissolution, such as pernicious anemia and malignant diseases. There is still another class which is very numerous which does not tend either to spontaneous recovery or certain death. It rather tends to dissolution, and unless arrested in some way it may lead to the death of the patient. I look upon arteriosclerosis as belonging to this class of diseases. It is more or less curable, certainly preventable, and I think much can be done for it if taken hold of in time."

Dr. Sutherland then read extracts from various authoritative books on the practice of medicine in regard to the treatment of this condition to show how little help was to be obtained from them in this particular case.

He laid particular stress on the abstinence from meat, giving reasons for his opinion. In conclusion he demonstrated to the Society a "Tycos" sphygmomanometer as the latest improvement in these now commonly used instruments.

THE TREATMENT OF PNEUMONIA.-During the past few months two articles have appeared of importance in the treatment of pneumonia. The first of these was one by Floyd and Lucas, giving their results obtained from the use of leucocytic extract in which they followed the method introduced by Hiss.

The second paper by Dr. Leary, of Tufts College, describes his success in treating pneumonia by vaccines.

The former paper gives a mortality of 12 per cent., the latter of 17 per cent. Of course, at the present time the number of cases treated each month has been so small as to render the statistics of uncertain value. If, however, as may well be the case, the results in future prove as satisfactory as those already obtained, our ideas concerning the therapeutics of this unfortunately common and much-feared disease will be subjected to decided alteration, as at present the mortality given is 40 per cent. In both of these new methods of treatment, in addition to the lowered mortality, the advantages of a less severe toxemia and a more early crisis are advanced. Certainly the results thus far obtained justify a much more extended test, which they will undoubtedly receive.

THE VALUE OF CYCLOPLEGICS IN REFRACTION*

BY A. B. NORTON, M. D., NEW YORK.

Your Chairman's invitation to present a paper before this Society was forwarded to me during my summer vacation, and, while the honor was appreciated, I am free to confess it was the attractive subject assigned me that caused my acceptance. I was at first tempted to change the title to "The Necessity of Cycloplegics in Refraction," for I may acknowledge at once that after twentyeight years of experience in refraction work I am convinced of its absolute necessity in many cases and its great value in nearly all cases. The longer one works with cycloplegics the more satisfied he becomes with his own work and the more he sees the errors of his associates. The oculist, like the physician, always sees the mistakes of his fellows because, as a rule, it is only the dissatisfied patient who seeks another doctor.

My records will show that a very large proportion of my patients who had been previously and unsatisfactorily fitted with glasses by other oculists had been examined without the use of cycloplegics. So far as I have been able to watch the results in my own practice, the failures in refraction work have been far less when fitted after cycloplegics than when none were used. In exclusive ophthalmic practice when patients as a rule are seen but a few times at most, fitted with glasses which if correct will require no change for two years at least, and in children may remain correct for thirty or more years, it is almost impossible to know if one's work is satisfactory to the patient, or what proportion are dissatis,fied and are seeking other oculists. I am sure, however, so far as I can trace my results, that I am holding a very much larger proportion of my patients fitted after cycloplegics than those fitted. without its use.

In considering our topic, "The Value of Cycloplegics in Refraction," let us for a moment consider a few elementary facts.

Vision, or the sense of sight, requires for its perfect performance a normal, or, as it is called, an emmetropic eye. A normal eye is so constructed that rays proceeding from a distant object are focused exactly upon the retina without any voluntary or involuntary effort. Refraction means the bending of rays from a distant object to focus upon the retina, and in normal eyes this is done without effort. In hyperopic, myopic, or astigmatic eyes there must be some expenditure of force in some of the structures involved in the function of focusing, or a bending of the rays to focus upon the retina. To illustrate, a hyperopic eye is too short, or there is too little focusing material with the result that rays would theoretically come to a focus behind the retina and all vision *Read before the Massachusetts Homeopathic Medical Society. Worcester.

October 13, 1909.

in a hyperope would be blurred and hazy were it not for the action of the ciliary muscle pressing upon the crystalline lens and forcing it into a condition of increased convexity. This involuntary effort of the ciliary muscle when retained within the bounds of physiological limit does no harm, but a constant and excessive effort becomes pathological. The result of this perpetual over-exertion is rebellion, just as it would be if any other muscle, nerve or function in the body were abused. This rebellion may come on early or not for years, may cause asthenopic symptoms, headaches, neuralgia, etc., or simply blurred vision. The constant effort of the ciliary muscle is apt to excite a spasm of the accommodation which alters or masks the true refractive state of the eye, and in order to overcome this spasm a cycloplegic is demanded.

A cycloplegic might be called a paralyzer of the accommodation, as by it is meant a drug which produces a temporary paralysis of the ciliary muscle, and for the time of its action places at rest the accommodation.

Spasm of the accommodation may exist in either a hyperopic, myopic or astigmatic eye. If present in a hyperopic eye it will decrease the degree of the hyperopia or may convert it into an apparent myopia. Ciliary spasm will always increase myopia and will usually change or mask an astigmatism. Where there is present a spasm of the accommodation there is no way by which the true total refractive error can be determined except by the use of a cycloplegic, and while it is only in exceptional cases that one corrects the total refractive error, yet for scientific work it is always of advantage to know the full amount. While spasm of the accommodation is an infrequent condition at the most, and when found is usually in young people, yet it may occur, as already pointed out, at any time of life. The diagnosis of spasm of the accommodation can only be made, in many instances, by the use of cycloplegics. There are, to be sure, in certain cases positive symptoms of spasm, but the extent of the spasm can never be determined without a cycloplegic, and the most dangerous case is apt to be the hidden one where the condition is overlooked. Given then a refractive error of any kind complicated by spasm of the accommodation, a cycloplegic must be used for accurate work.

All oculists recognize the necessity of cycloplegics where spasm of the accommodation is present. but many never use them in patients after forty years of age, because at this age spasm is less frequent and also from fear of causing glaucoma. It is generally conceded that cycloplegics may cause glaucoma in people over forty years of age, and I have seen one instance in my own practice, but owing to prompt treatment no ultimate harm resulted in this case. I have used atropin to examine the refraction in thousands of eyes of adults both before and since this one unfortunate experience, with no evil effects whatever, and I am positive the advantages gained by its use far offset the slight percentage of danger. Before using cycloplegics in adults it is now always my rule to examine

the range of accommodation, the tension, and any predisposing history of glaucoma. It seems therefore to me that every case where spasm of the accommodation is present or even suspected cycloplegics should be used.

Astigmatism, which you will bear in mind is where the refraction in one axis of the eye is different from that of the opposite axis, and which as a rule is due to an irregular curvature of the cornea, but may be due to the lens, is frequently corrected or compensated for in part or in whole by the action of the ciliary muscle upon the lens. While this compensatory action of the accommodation may be kept up in some cases for an indefinite period without effort or strain, it is very apt to cause disturbance sooner or later. It may cover or mask to subjective examinations, that is, retinoscopy, ophthalmometer, etc., the true amount, or apparently alter the axis of the astigmatism and only the use of cycloplegics would disclose the true condition. In the lower degrees of astigmatism it is frequently impossible for the patient to recognize with the correcting lens the true axis of the astigmatism. They are very frequently unable to distinguish the difference between two positions fifteen to thirty degrees apart. They are often unable to detect the difference in vision through lenses of from 50 to 75 dioptres difference in strength. The patient's uncertainty as to the axis and strength of the best lens is never as great with the eye under a cycloplegic as without. If then we are depending upon the test lenses alone in refractive work we can certainly do more accurate work by using cycloplegics.

While ophthalmometers, keratometers, retinoscopy, etc., are undoubtedly of great help in determining the axis and degree of the astigmatism, yet we are constantly finding cases that will not accept and wear with comfort the theoretical glass shown by these methods. I have for twenty years used ophthalmometers, and in that time four or five different makes. At the present writing, in addition to the ophthalmometer, I have by its side the new Sutcliffe keratometer, both instruments being used in every case to determine if possible which is the more accurate. As every one of experience must then admit that no method is infallible we must for correct work use them all, and at the same time admit that the most scientific, accurate and reliable method is the examination under cycloplegics.

We also must admit that the most practical and satisfactory test to the patient is that with the test lenses.

We have thus far referred to cases of astigmatism and to cases where spasm of the accommodation was present. Now a word as to the other refractive errors. I believe that every case of myopia, or nearsightedness, in children should be examined under cycloplegics. Myopia is to me the most serious of all refractive errors to the child, because least apt to cause headaches, nervousness or general asthenopic symptoms, calling the parents' attention to the eyes, and because it comes on so insidiously and progresses so