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The Chairman: The American Medical Society, I believe, has appointed a committee to consider this subject, and that committee has made some reports. I believe I left some copies of the last report of that national committee in the hands of Dr. Wishard and the secretary. Dr. Jaeger, have you anything to say in closing the discussion?

Dr. A. S. Jaeger, of Indianapolis: Mr. President, I wish to thank the gentlemen for the kindly manner in which they have accepted my paper. I would like to remark, in speaking about the treatment of acute gonorrhea, when I appeared before the local society naturally in a paper of this kind I took up the treatment of all these various conditions, and it took so long they turned the lights out on me, and I have attempted to shorten the paper for this occasion. We do not see acute gonorrhea so much. The respectable woman does not know she has gonorrhea. She thinks she has an aggravated case of leucorrhea, and she lets it go on, lets it run until there is excoriations, etc.; and by that time. the infection has traveled up into the cavity of the uterus. Then again this infection travels so rapidly that in two or three weeks we have a typical case of pyosalpinx. I had a case sent to me from Kokomo, and I had to operate upon her. Another case was the wife of a young man I treated four or five years ago for acute gonorrhea. He was one of these smart ones that is, he thought as soon as the discharge was stopped he was cured. Two or three years afterwards he decided upon marriage. I took an interest in the young man; he was something more than a patient, he was a friend; and I went to him, and I said, "Are you thoroughly cured?" "Oh, yes," he replied, "I am all right." Don't you have any discharge at all?" I asked. "Oh, well, once in a while I have a drop, just a little drop of milky stuff; it goes away in a day or so, and that is the end of it." I begged him not to marry; I put it before him in the strongest terms I could; but he married a very estimable young lady, and they went off on the wedding trip. Four days afterwards they had to bring her home in a private I examined the cervix discharges, and there was the gonococci. I put it to him pretty plainly. The girl's mother and

car.

15-Ind. Med. Assn.

father insisted on knowing what the trouble was. Of course, I did not tell them what the trouble was, but I told them I believed an operation was necessary, and they took me by the nape of the neck and threw me out of the case. Another surgeon was called in, and he made a similar diagnosis, and he was thrown out of the case and somebody else brought in. They removed the young lady to Cleveland, and the last I heard of her was the notice of a funeral. The parents simply could not believe that an operation was necessary, that it could be necessary, in a young girl only two or three weeks after marriage. It seemed to them impossible that it could be so.

As I say, we do not often have acute vaginitis. Of all the cases of gonorrhea in women, scarcely ten per cent. are vaginitis. Nature has taken care of that. We only have the primary acute vaginitis in women who have not been deflowered, or women recently deflowered; for after the vagina has been accustomed to coition the cells are able to resist infection. The only time we get vaginitis is when the discharges have developed in severity to such an extent that even the highest resistance has to give way. We have most acute gonorrhea in women in the urethra and in the cervix.

THE EYESIGHT OF SCHOOL CHILDREN AND THEIR FUNCTIONAL REFLEXES DUE TO EYESTRAIN.

BY WALTER N. SHARP, M. D., INDIANAPOLIS, IND.

This subject has been presented to the profession and the public many times by able men as a matter of education to those who have the care of children either in the home or in the school, and it may not be amiss to again present a few facts to further enhance the interest in the subject.

The proper care and treatment of a child's eyes influence, to a great degree, its general health and its future possibilities. Much depends, then, on a knowledge of this fact, and of some of the conditions requiring correction.

Many cases of refractive error become physical wrecks because of the reflex conditions brought to bear upon the nervous system through unconscious accommodation. Not infrequently, children are obliged to remain at home a day or two at regular intervals during the term, with severe headache, while during the vacation months, when they are romping in the open air and the eyes are relieved from near work, these headaches seldom or never For lack of interest or ambition, many children leave school at adolescence, when, if the effort to see normally were relieved by proper refraction, there is no doubt that some of them would continue their studies with pleasure to themselves and honor to their citizenship.

occur.

There is no defect aside from mental incapacity which will hinder a child's progress in school so much as defective vision. It is illogical and unreasonable to lay the majority of ills to eyestrain, as some of the more radical men are doing, but there is not the slightest doubt that not a few serious functional and psychological disturbances are due to visual error or muscular imbalance.

According to our best authorities, hypermetropia is almost universal at birth-92.4 per cent.; up to the fifth year it is 84 per cent.; while among children in the elementary schools it is 76 per cent.; and with the pupils of the higher grades it is 56 per cent. In three hundred cases examined during the second year of life, the hypermetropia averaged 2 D. This shows that a perfectly normal eye at birth is an exception; but that with gradual development of the body in general, and the use of the ciliary muscle, the eye develops in proportion, until the percentage of hypermetropia is reduced to about 50 per cent.

By hypermetropia or farsightedness, we do not mean that a child can see farther than the normal eye, as is understood to bethe case by many of the laity, and by some physicians, but if the error is not great, the child can see as well, and even so when the hypermetropia is of considerable degree.

Rays of light entering the eye should fall upon the retina. This they do in a normal eye, but in the case of a hypermetropiceye, which is shorter than the normal from before backward, the rays of light reach the retina before they focus; hence, in order to focus the rays sharply on the retina, a contraction of the ciliary muscle is necessary. The child realizes that, according to a natural law, objects brought near to the eye, apparently enlarge them, and as a child is only able to grasp one letter or a short word at a glance, it instinctively brings the book nearer to the eye to enlarge or make more distinct the letters or words looked at. This requires an extra accommodation, and if hypermetropia exists, coupled with the abnormal amount of accommodation required, and still a treble exertion, if the light and other conditions are not favorable, reacts disastrously upon the delicate nervous system.

Donders says that an error of less than a diopter is rarely disturbing to the vision; but the reverse of this is the case in my own experience, and in that of many of our best observers. Often a slight hypermetropia of a quarter to one diopter will cause greater reaction in a child of nervous temperament than a farsight of a much greater degree, because it is always corrected by strain from the time the child rises in the morning till it retires.

at night, while a high hypermetrope does not see normally, and will not try to overcome his error. Again, the ciliary muscle is developed to such a degree as to compensate for the extra accommodation. Some children pass through school without any untoward symptoms, but later they usually require assistance much earlier in life than a simple presbyope-usually between the ages of twenty-five and thirty-five years. Some high hypermetropes have normal, or nearly normal vision, but in order to reach it their full energy is expended. They frown and squint and bend the head and shoulders forward in their effort to shorten the distance, without any reflex symptoms except these. I recently refracted a child of eight years who was brought to me by reason of these symptoms. The vision was .5, while under full paralysis of accommodation his vision was 1/20, thereby accommodating from 1/20 to 10/20 vision. His error was 7 D.

It is during school life, then, that the eyes should receive attention in their development towards normal or abnormal conditions. By overstrain, by cramped conditions of light or position, and excessive use of the ciliary muscle, overdevelopment, by stretching the delicate plastic coats of the young organ, may ensue, and an acquired and progressive myopia may result. This is not as common among school children as might be supposed, however, as only under extreme conditions does the eye overdevelop. It is as natural for the eye to develop in childhood as for that of any other organ, and where there are no untoward symptoms it is not right to burden the child with glasses.

Headache in the child is not always caused by eyestrain or muscular imbalance. There are a hundred and one other causes which should be sought for by the family physician, but in the majority of cases where the functions of digestion and secretion are normal, eyestrain is at the bottom of the trouble and the. physician should not fail to have the child's eyes properly refracted by a competent oculist, even if the vision is apparently normal and the refractive error slight; for what parent cares to have his child's progress hampered by physical ailments which hinder his application in school. A refractive error often begets weakness of one or more of the extrinsic muscles and squint or

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